2013-05-10T11:38:06-05:00 2012-06-30 440160260 BKD LLP 312 WALNUT STREET SUITE 3000 CINCINNATI OH 45202 990 2011-07-01 310537486 THE GOOD SAMARITAN HOSPITAL OF CINCINNATI OHIO GOOD 5135696575 619 OAK STREET - ACCOUNTING 3 WEST CINCINNATI OH 45206 MICHAEL CROFTON 5135696575 2013-05-10 1 P00961884 5136218300 2011 2016-02-25 16:41:14Z JOHN PROUT 619 OAK STREET - ACCOUNTING 3 WEST CINCINNATI OH 45206 540031205 0 0928 X WWW.TRIHEALTH.COM X 1852 OH THE ORGANIZATION'S MISSION IS TO IMPROVE THE HEALTH STATUS OF THE COMMUNITY IT SERVES. 13 9 3880 1344 516609 -361321 1819755 1629240 477423089 518618062 26589936 9368293 12262151 9623333 518094931 539238928 571927 571823 0 0 221197407 229114192 0 0 0 238726565 265823926 460495899 495509941 57599032 43728987 696050814 723288138 233617196 252211328 462433618 471076810 X SEE SCHEDULE O 0 0 417736345 571823 523184293 SEE SCHEDULE H 417736345 1 1 0 1 0 0 0 0 0 1 1 1 0 1 1 1 0 1 0 0 0 0 0 0 0 0 1 1 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 1 296 0 1 3880 1 1 1 0 0 0 0 0 0 0 0 0 X 13 9 1 0 0 0 1 1 1 0 1 0 0 0 1 1 1 1 1 1 1 1 0 X MICHAEL CROFTON 5135695677 619 OAK STREET - ACCOUNTING 3 WEST CINCINNATI OH 45206 X ROBERT WALKER 1.00 X X 0 0 0 STEPHEN SCHRANTZ 1.00 X X 0 0 0 MICHAEL MCGRAW 1.00 X X 0 0 0 PAUL EDGETT III 1.00 X 0 590178 84389 MICHAEL HAVERKAMP 1.00 X 0 0 0 THOMAS FINN 1.00 X 0 0 0 MYRTIS POWELL 1.00 X 0 0 0 SR MARY ELLEN MURPHY 1.00 X 0 0 0 SILVANIA NG MD 1.00 X 0 45000 0 MARC ALEXANDER MD 1.00 X 45000 0 0 JOHN PROUT 1.00 X X 0 1226184 296426 STEPHEN BLATT MD 1.00 X 6000 123037 15131 STUART DONOVAN MD 1.00 X 0 12000 0 CRAIG EISENTROUT MD 1.00 X 0 0 0 WAYNE SHIRCLIFF 1.00 X 0 0 0 DONNA NIENABER ESQ 1.00 X 0 481624 151957 CRAIG RUCKER 1.00 X 0 543549 129732 DAVE DORNHEGGEN 60.00 X 0 360703 111194 WILLIAM GRONEMAN 1.00 X 0 548818 164974 GERALD OLIPHANT 1.00 X 0 598073 124115 GEORGES FEGHALI MD 1.00 X 0 513570 155997 ROBERT ROHS MD 40.00 X 336977 0 38855 DAVID DHANRAJ MD 40.00 X 239923 0 32900 MICHAEL HOLBET MD 40.00 X 237937 0 32147 HELEN KOSELKA MD 40.00 X 199135 0 49291 MICHAEL SMITH MD 40.00 X 168297 0 0 MICHAEL CROFTON 0.00 X 0 278995 75312 1233269 5321731 1462420 79 1 1 0 CATHOLIC HEALTH INITIATIVES 198 INVERNESS DRIVE WEST ENGLEWOOD CO 80112 CLINICAL ENGINEERING 5368511 TRI-STATE HEALTHCARE LAUNDRY INC 551 S LOOP ROAD EDGEWOOD KY 41017 LAUNDRY 1635481 AMERICAN NURSING CARE INC 1700 EDISON DRIVE SUITE 300 MILFORD OH 45150 NURSING 1345552 MORRISON MANAGEMENT SPECIALISTS PO BOX 102289 ATLANTA GA 30368 FOOD SERVICE 794380 PATIENT TRANSPORT SERVICES INC 1700 EDISON DRIVE SUITE 300 MILFORD OH 45150 PATIENT TRANSPORTATION 793336 44 1629240 1629240 PATIENT SERVICES 621990 524613418 524106812 506606 JOA REVENUE 990009 3765197 3765197 AFFILIATED ORG. RENTAL 532000 1459390 1459390 EQUITY CHANGE IN ORGS. 990009 -11219943 -11219943 518618062 10102870 10003 10092867 846932 0 846932 846932 846932 57700 758260 34017 -758260 23683 -734577 -734577 CAFETERIA 722100 2244174 2244174 PHARMACY 446110 2083042 2083042 RESEARCH 900099 1442985 1442985 3006200 3006200 8776401 539238928 523184293 516609 13908786 561723 561723 10100 10100 2757526 2757526 177715301 150307596 27407705 10761852 8106569 2655283 24735309 19253373 5481936 13144204 11229638 1914566 1659231 1596915 62316 2071619 2071619 146382 146382 1306807 1306807 19420724 14352694 5068030 3284878 299809 2985069 5769776 3061023 2708753 11636173 706159 10930014 10141057 8872546 1268511 468559 294072 174487 6462562 6462562 5538384 5538384 22142649 18741973 3400676 4169916 3777184 392732 MEDICAL/DIETARY SUPPLIE 109317565 109014563 303002 BAD DEBTS 44707741 44707741 OHIO HOSPITAL FEE 7516037 7516037 REPAIRS AND MAINTENANCE 6927345 6470900 456445 3136521 2393168 743353 495509941 417736345 77773596 0 24981720 18016875 49421712 49075276 99690 3005214 3195353 167400 44164 538366688 350035574 183815482 188331114 41516113 42391998 366526724 367126008 26516759 55107350 696050814 723288138 52467167 56371056 91310 68349 147851989 146120324 33206730 49651599 233617196 252211328 X 457130498 465440222 5303120 5636588 462433618 471076810 696050814 723288138 X 43728987 -35085795 X X 0 1 1 X 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 13505 13505 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: DURING THE TAX YEAR, THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO ("HOSPITAL") PAID ANNUAL MEMBERSHIP DUES TO VARIOUS NATIONAL, STATE AND LOCAL ORGANIZATIONS, A PORTION ($2,307) OF WHICH RELATED TO LOBBYING ACTIVITIES. IN ADDITION, TRIHEALTH, INC., A RELATED ORGANIZATION OF HOSPITAL, WHICH PROVIDES ADMINISTRATIVE SUPPORT SERVICES TO HOSPITAL, PAID ANNUAL MEMBERSHIP DUES TO VARIOUS NATIONAL, STATE AND LOCAL ORGANIZATIONS A PORTION OF WHICH RELATED TO LOBBYING ACTIVITIES. A PORTION OF THE AFOREMENTIONED ADMINISTRATIVE SUPPORT SERVICES ARE ALLOCATED TO HOSPITAL AND $6,402 OF THE AMOUNT SHOWN ON LINE 1I REPRESENTS HOSPITAL'S SHARE OF THESE LOBBYING EXPENSES. FINALLY, HOSPITAL'S CONTROLLING ORGANIZATION, CATHOLIC HEALTH INITIATIVES, PAYS ANNUAL DUES TO THE AMERICAN HOSPITAL ASSOCIATION ("AHA") AND CATHOLIC HOSPITAL ASSOCIATION ("CHA"), A PORTION OF WHICH IS ALLOCATED TO LOBBYING ACTIVITIES. FOR THE TAX YEAR, THE AMOUNT SHOWN ON LINE 1I ABOVE REPRESENTS HOSPITAL'S SHARE OF ALLOCATED LOBBYING EXPENSES: AHA $3,325; CHA $1,471. 12288282 339635 12627917 12221795 66487 12288282 12018000 203795 12221795 11923322 94678 12018000 1.00000 0 1 1 13520112 13520112 303308413 193868824 109439589 3735588 2693539 1042049 187795272 153473211 34322061 30007303 30007303 188331114 CHI OPERATING INVESTMENT PROGRAM 367126008 F 367126008 INVESTMENT IN UNCONSOLIDATED ORGANIZATIONS 34426619 CAPITAL LEASES 33551 MALPRACTICE INSURANCE/WORKERS COMPENSATION RECEIVABLE 20647180 55107350 RETIREMENT PLAN LIABILITY 31973942 ENVIRONMENTAL REMEDIATION LIABILITY 1453422 UNCLAIMED PROPERTY 547591 MALPRACTICE INSURANCE/WORKERS COMPENSATION LIABILITY 15676644 49651599 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: THE FINANCIAL STATEMENTS OF THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO ("COMPANY") ARE AUDITED WITH ITS SUBSIDIARIES. FOLLOWING IS THE TEXT OF THE FOOTNOTE TO THE COMPANY'S AUDITED FINANCIAL STATEMENTS THAT REPORTS ITS AND ITS SUBSIDIARY'S LIABILITY, IF APPLICABLE, FOR UNCERTAIN TAX POSITIONS UNDER ASC 740-10-25: THE COMPANY COMPLETED AN ANALYSIS OF UNCERTAIN TAX POSITIONS IN ACCORDANCE WITH APPLICABLE ACCOUNTING GUIDANCE AT JUNE 30, 2012 AND 2011, AND DETERMINED NO AMOUNTS WERE REQUIRED TO BE RECOGNIZED IN THE CONSOLIDATED FINANCIAL STATEMENTS AT JUNE 30, 2012 AND 2011. IN ADDITION, HOSPITAL'S FINANCIAL INFORMATION IS INCLUDED IN THE CONSOLIDATED AUDITED FINANCIAL STATEMENTS OF CATHOLIC HEALTH INITIATIVES ("CHI"), A RELATED ORGANIZATION. CHI'S FIN 48 (ASC 740) FOOTNOTE FOR THE YEAR ENDED JUNE 30, 2012 READS AS FOLLOWS: CHI IS A TAX-EXEMPT COLORADO CORPORATION AND HAS BEEN GRANTED AN EXEMPTION FROM FEDERAL INCOME TAX UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. CHI OWNS CERTAIN TAXABLE SUBSIDIARIES AND ENGAGES IN CERTAIN ACTIVITIES THAT ARE UNRELATED TO ITS EXEMPT PURPOSE AND THEREFORE SUBJECT TO INCOME TAX. MANAGEMENT ANNUALLY REVIEWS ITS TAX POSITIONS AND HAS DETERMINED THAT THERE ARE NO MATERIAL UNCERTAIN TAX POSITIONS THAT REQUIRE RECOGNITION IN THE ACCOMPANYING CONSOLIDATED FINANCIAL STATEMENTS. 1 1 X 1 X 1 X 1 1 0 1 1 18519785 6136102 12383683 0.02750 80281668 52483613 27798055 0.06170 98801453 58619715 40181738 0.08920 1348984 54008 1294976 0.00290 23001602 9898176 13103426 0.02910 4962024 3856825 1105199 0.00250 2703619 2703619 0.00600 319375 319375 0.00070 32335604 13809009 18526595 0.04120 131137057 72428724 58708333 0.13040 290000 290000 0.00060 290000 290000 0.00060 1 44707741 0 94414528 96363756 -1949228 X 1 1 1 1 GOOD SAMARITAN HOSPITAL

375 DIXMYTH AVENUE CINCINNATI OH 45220

X X X X X GOOD SAMARITAN HOSPITAL 1 1 1 100.000000000000 1 400.000000000000 1 X X X X X X 1 1 X X 1 0 1 X 0 0 5 GOOD SAMARITAN MEDICAL CENTER

6949 GOOD SAMARITAN DRIVE CINCINNATI OH 45247

EMERGENCY DEPARTMENT/OUTPATIENT SERVICES GOOD SAMARITAN PHYSICAL THERAPY

8748 UNION CENTRE DRIVE WEST CHESTER OH 45069

PHYSICAL THERAPY GOOD SAMARITAN HOSPITAL OUTPATIENT CTR

6350 GLENWAY AVENUE CINCINNATI OH 45211

OUTPATIENT PHYSICIAN CLINIC GOOD SAMARITAN HOSPITAL WEIGHT MGMT CTR

3219 CLIFTON AVENUE SUITE 225 CINCINNATI OH 45220

WEIGHT MANAGEMENT SERVICES GOOD SAMARITAN HOSPITAL WOMEN'S CENTER

3219 CLIFTON AVENUE SUITE 100 CINCINNATI OH 45220

WOMEN'S HEALTH SERVICES PART I, LINE 3C: THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO UTILIZES THE FEDERAL POVERTY GUIDELINES ("FPG") IN DETERMINING CHARITY CARE ELIGIBILITY. SEE THE RESPONSES TO PART I, LINE 3A AND 3B.AN INDIVIDUAL'S INCOME UNDER FPG IS A SIGNIFICANT FACTOR IN DETERMINING ELIGIBILITY FOR CHARITY CARE. HOWEVER, IN DETERMINING WHETHER TO EXTEND DISCOUNTED OR FREE CARE TO A PATIENT, THE PATIENT'S ASSETS MAY ALSO BE TAKEN INTO CONSIDERATION. FOR EXAMPLE, A PATIENT SUFFERING A CATASTROPHIC ILLNESS MAY HAVE A REASONABLE LEVEL OF INCOME, BUT A LOW LEVEL OF LIQUID ASSETS SUCH THAT A PAYMENT OF MEDICAL BILLS WOULD BE SERIOUSLY DETRIMENTAL TO THE PATIENT'S FINANCIAL (AND ULTIMATELY PHYSICAL) WELL-BEING AND SURVIVAL. SUCH A PATIENT MAY BE EXTENDED DISCOUNTED OR FREE CARE BASED UPON THE FACTS AND CIRCUMSTANCES. PART I, LINE 6A: IN 1995, THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO AND BETHESDA HOSPITAL, INC. FORMED A PARTNERSHIP CALLED TRIHEALTH, INC. TO CREATE AN INTEGRATED HEALTH DELIVERY SYSTEM WHOSE MISSION IS TO IMPROVE THE HEALTH OF THE PEOPLE THEY SERVE, WITH AN EMPHASIS ON PREVENTION, WELLNESS AND EDUCATION. THE COMMUNITY BENEFIT PROVIDED BY THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO IS TRACKED ON A STANDALONE BASIS, HOWEVER ITS COMMUNITY BENEFIT IS REPORTED IN COMBINATION WITH BETHESDA HOSPITAL, INC.'S COMMUNITY BENEFIT IN A REPORT PREPARED BY TRIHEALTH, INC. PART I, LINE 7: FOR THE AMOUNTS REPORTED AT COST IN PART I, LINE 7, THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO UTILIZED WORKSHEET 2 - RATIO OF PATIENT CARE COST-TO-CHARGES, WHICH WAS PROVIDED IN THE INSTRUCTIONS TO SCHEDULE H, TO CALCULATE THE COST-TO-CHARGE RATIO. PART I, LINE 7G: THE SUBSIDIZED HEALTH SERVICES COMMUNITY BENEFIT AMOUNT REPORTED IN PART I, LINE 7(G) DOES NOT INCLUDE COSTS ATTRIBUTABLE TO PHYSICIAN CLINICS. PART I, L7 COL(F): $44,707,741 OF BAD DEBT EXPENSES THAT WAS INCLUDED IN FORM 990, PART IX, LINE 25, COLUMN (A) HAS BEEN REMOVED FOR PURPOSES OF CALCULATING THE PERCENTAGE OF TOTAL EXPENSES IN SCHEDULE H, PART I, LINE 7, COLUMN (F). PART II: THE UPTOWN CONSORTIUM ("CONSORTIUM") IS RECOGNIZED BY THE INTERNAL REVENUE SERVICE AS EXEMPT FROM INCOME TAX UNDER INTERNAL REVENUE CODE SECTION 501(A) AS AN ORGANIZATION DESCRIBED IN INTERNAL REVENUE CODE SECTION 501(C)(3). IT IS MADE UP OF THE FIVE LARGEST EMPLOYERS OF CINCINNATI'S "UPTOWN" INCLUDING THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO. "UPTOWN" GENERALLY INCLUDES THE NEIGHBORHOODS OF AVONDALE, CLIFTON, CLIFTON HEIGHTS, CORRYVILLE, FAIRVIEW, MT. AUBURN AND UNIVERSITY HEIGHTS. THE CONSORTIUM IS DEDICATED TO BUILDING THE HUMAN, SOCIAL AND PHYSICAL IMPROVEMENT OF UPTOWN CINCINNATI. IT WILL UNDERTAKE A VARIETY OF INVESTMENT AND PROGRAM ACTIVITIES IN UPTOWN TO HELP PROVIDE HOUSING, HEALTH CARE AND JOB OPPORTUNITIES. PART III, LINE 4: NET PATIENT ACCOUNTS RECEIVABLE (PART OF FOOTNOTE A)NET PATIENT ACCOUNTS RECEIVABLE AND NET PATIENT SERVICE REVENUE HAVE BEEN ADJUSTED TO THE ESTIMATED AMOUNTS EXPECTED TO BE COLLECTED. THESE ESTIMATED AMOUNTS ARE SUBJECT TO FURTHER ADJUSTMENTS UPON REVIEW BY THIRD-PARTY PAYORS.THE PROVISION FOR BAD DEBTS IS BASED UPON MANAGEMENT'S ASSESSMENT OF HISTORICAL AND EXPECTED NET COLLECTIONS CONSIDERING HISTORICAL BUSINESS AND ECONOMIC CONDITIONS, TRENDS IN HEALTH CARE COVERAGE, AND OTHER COLLECTION INDICATORS. MANAGEMENT PERIODICALLY ASSESSES THE ADEQUACY OF THE ALLOWANCES FOR UNCOLLECTIBLE ACCOUNTS BASED UPON HISTORICAL WRITE-OFF EXPERIENCE. THE RESULTS OF THESE REVIEWS ARE USED TO MODIFY AS NECESSARY THE PROVISIONS FOR BAD DEBTS AND TO ESTABLISH APPROPRIATE ALLOWANCES FOR UNCOLLECTIBLE NET PATIENT ACCOUNTS RECEIVABLE. AFTER SATISFACTION OF AMOUNTS DUE FROM INSURANCE, THE COMPANY FOLLOWS ESTABLISHED GUIDELINES FOR PLACING CERTAIN PATIENT BALANCES WITH COLLECTION AGENCIES, SUBJECT TO THE TERMS OF CERTAIN RESTRICTIONS ON COLLECTION EFFORTS AS DETERMINED BY EACH THE COMPANY. FINANCIAL INSTRUMENTS THAT POTENTIALLY SUBJECT THE COMPANY TO CONCENTRATIONS OF CREDIT RISK CONSIST PRIMARILY OF NON-GOVERNMENTAL PATIENT ACCOUNTS RECEIVABLE. THE COMPANY GRANTS CREDIT WITHOUT COLLATERAL TO ITS PATIENTS, MOST OF WHOM ARE INSURED UNDER THIRD-PARTY PAYOR AGREEMENTS. THE PERCENTAGES OF GROSS PATIENT ACCOUNTS RECEIVABLE FROM PATIENTS AND THIRD-PARTY PAYORS AT JUNE 30 APPROXIMATED THE FOLLOWING: 2012 - MEDICARE 17%, MEDICAID 4%, MANAGED CARE 23%, SELF PAY 20%, COMMERCIAL AND OTHER 36%2011 - MEDICARE 18%, MEDICAID 3%, MANAGED CARE 21%, SELF PAY 22%, COMMERCIAL AND OTHER 36%AS FOR THE AMOUNT OF BAD DEBT THAT REASONABLY COULD BE ATTRIBUTABLE TO PATIENTS WHO LIKELY WOULD QUALIFY FOR FINANCIAL ASSISTANCE UNDER THE ORGANIZATION'S CHARITY CARE POLICY, THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO DOES NOT REPORT ACTUAL BAD DEBT EXPENSE AS COMMUNITY BENEFIT. IF UPON FURTHER RESEARCH, IT IS ULTIMATELY DETERMINED THAT A PORTION OF BAD DEBT EXPENSE IS ATTRIBUTABLE TO PATIENTS WHO WOULD LIKELY QUALIFY FOR FINANCIAL ASSISTANCE UNDER TRIHEALTH'S CHARITY CARE POLICY, THOSE COSTS WOULD BE RECLASSIFIED, AS APPROPRIATE, TO COMMUNITY BENEFIT AT THAT TIME. PART III, LINE 8: THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO USES THE "STEPDOWN METHODOLOGY" IN DETERMINING THE MEDICARE ALLOWABLE COSTS REPORTED ON THE MEDICARE COST REPORT. THIS METHOD OF COST FINDING PROVIDES FOR THE ALLOCATION OF THE COST OF SERVICES RENDERED BY EACH GENERAL SERVICE COST CENTER TO OTHER COST CENTERS WHICH UTILIZE SUCH SERVICES. ONCE THE COSTS OF A GENERAL SERVICE COST CENTER HAVE BEEN ALLOCATED, THAT COST CENTER IS CONSIDERED CLOSED. ONCE CLOSED, IT DOES NOT RECEIVE ANY OF THE COSTS SUBSEQUENTLY ALLOCATED FROM THE REMAINING GENERAL SERVICE COST CENTERS. THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO DID NOT REPORT ANY MEDICARE SHORTFALL AS COMMUNITY BENEFIT IN PART III, LINE 7 OF THIS SCHEDULE. PART III, LINE 9B: AS OF THE FILING OF THIS RETURN, THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO, AS PART OF TRIHEALTH, INC., MAINTAINS A WRITTEN DEBT COLLECTION POLICY. TRIHEALTH, INC., WHO PERFORMS THE BILLING SERVICES FOR ALL AFFILIATED HOSPITALS, WILL NOT INITIATE COLLECTION PRACTICES ON PATIENTS WHO ARE KNOWN TO QUALIFY FOR CHARITY CARE OR FINANCIAL ASSISTANCE. BEFORE COLLECTION ACTIONS ARE TAKEN, TRIHEALTH, INC. WILL MAKE REASONABLE EFFORTS, GENERALLY AS EARLIER IN THE BILLING PROCESS AS POSSIBLE, TO DETERMINE WHETHER A PATIENT IS ELIGIBLE FOR FINANCIAL ASSISTANCE. AFTER SUCH EFFORTS HAVE BEEN MADE AND A BALANCE REMAINS THAT IS THE RESPONSIBILITY OF THE PATIENT OR GUARANTOR, TRIHEALTH, INC. MAY PURSUE, IN ITS SOLE DISCRETION, WHATEVER ACTIONS IT MAY BE ENTITLED TO TAKE UNDER LAW. GOOD SAMARITAN HOSPITAL PART V, SECTION B, LINE 11H: SELECT CLINIC DISCOUNT - ELIGIBLE SERVICES RENDERED IN OR ORDERED BY PHYSICIANS AT SELECT CLINICS MAY BE DISCOUNTED IN AN AMOUNT NOT TO EXCEED 85%.O/B CLINIC DISCOUNT - O/B CLINIC PATIENTS RECEIVING ELIGIBLE SERVICES WHO DO NOT QUALIFY FOR FREE CARE AND FOR WHOM THE CHARITY CARE DISCOUNT IS NOT SUFFICIENT MAY RECEIVE A DISCOUNTED FLAT FEE PRICE FOR SUCH SERVICES.UNIQUE CIRCUMSTANCES ALLOWANCE - ALLOWANCES MAY BE GRANTED TO PATIENTS WITH UNIQUE CIRCUMSTANCES WHO DO NOT QUALIFY FOR ANY OTHER FINANCIAL ASSISTANCE. GOOD SAMARITAN HOSPITAL PART V, SECTION B, LINE 13G: GOOD SAMARITAN HOSPITAL DOES NOT PROVIDE A DETAILED COPY OF ITS FINANCIAL ASSISTANCE POLICY TO PATIENTS HOWEVER IT DOES PROVIDE A SUMMARY OF THE POLICY IN A MANNER LISTED IN LINES 13A-13E.IN ADDITION, SUCH INFORMATION SHALL BE PROVIDED IN LANGUAGES CONSIDERED TO BE COMMONLY SPOKEN BY THE POPULATION GOOD SAMARITAN HOSPITAL SERVES. IF TRANSLATION OR OTHER ASSISTANCE IS NEEDED TO FACILITATE COMPLETION AND/OR UNDERSTANDING OF THE FINANCIAL ASSISTANCE POLICY AND/OR APPLICATION TRANSLATION AND OTHER REASONABLE REQUESTS FOR ASSISTANCE WILL BE PROVIDED. GOOD SAMARITAN HOSPITAL PART V, SECTION B, LINE 19D: THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO ISSUES A BILLING STATEMENT TO ALL FAP ELIGIBLE INDIVIDUALS THAT STATES GROSS CHARGES FOR THE CARE RECEIVED AS THE STARTING POINT FOR APPLYING THE DISCOUNTS AND DEDUCTIONS THE FAP ELIGIBLE INDIVIDUAL IS ENTITLED TO UNDER ITS FAP, SUCH THAT THE AMOUNT THAT AN FAP ELIGIBLE INDIVIDUAL IS REQUIRED TO PAY IS (I) LESS THAN THE GROSS CHARGES FOR SUCH CARE, AND (II) TYPICALLY LESS THAN THE AMOUNTS GENERALLY BILLED TO PERSONS WITH INSURANCE. THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO'S ROBUST POLICY PROVIDES DISCOUNTS TO INDIVIDUALS WITH INCOME AT 400% OF THE FEDERAL POVERTY GUIDELINES BASED ON A SLIDING SCALE. ALTHOUGH IT IS POSSIBLE THAT THE LOWEST DISCOUNT ON SUCH SCALE MAY RESULT IN CHARGES THAT ARE MORE THAN THE AVERAGE GENERALLY BILLED TO INDIVIDUALS WITH INSURANCE, IT PREFERS TO EXTEND DISCOUNTS TO SUCH INDIVIDUALS RATHER THAN DENY THEM ELIGIBILITY UNDER THE POLICY SO THAT SUCH INDIVIDUALS RECEIVE SOME FINANCIAL ASSISTANCE RATHER THAN NONE. PART VI, LINE 2: IN 1852, THE SISTERS OF CHARITY ESTABLISHED GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO ("GSH") IN AN EFFORT TO ADDRESS THE NEEDS OF THE GROWING CITY OF CINCINNATI. IN 1995, GSH & BETHESDA HOSPITAL, INC. ("BETHESDA") FORMED A PARTNERSHIP TO CREATE A LOCAL HEALTH SYSTEM: TRIHEALTH, INC. ("TRIHEALTH"). TRIHEALTH'S MISSION IS TO IMPROVE THE HEALTH STATUS OF THE COMMUNITY THROUGH A FULL RANGE OF HEALTH RELATED SERVICES (E.G. PREVENTION, WELLNESS & EDUCATION)THE SERVICES DESCRIBED BELOW, & OTHERS NOT LISTED, PROMOTE A HEALTHY COMMUNITY AND SEEK TO REDUCE THE BURDENS ON THE GOVERNMENT. FOR EXAMPLE, IF GSH DID NOT ADDRESS THE ROOT CAUSES OF LOW BIRTH WEIGHT & PREMATURITY, THE BURDEN TO GOVERNMENT MEDICAL PROGRAMS SUCH AS MEDICAID WOULD BE EVEN GREATER.GSH, AS PART OF TRIHEALTH, PARTICIPATED IN AND WAS A FUNDER OF THE WORK OF A COLLABORATIVE, REGIONAL EFFORT, THE A.I.M. FOR BETTER HEALTH COMMUNITY HEALTH NEEDS ASSESSMENT (A.I.M). IN THE AREAS ASSESSED THE POPULATIONS SURVEYED WERE MORE OFTEN UNDERSERVED, INCLUDING THE UNINSURED, UNDERINSURED, LOW SOCIOECONOMIC STATUS, MINORITIES, AND OVER AGE SIXTY-FIVE, OR WITH A DIAGNOSIS OF MENTAL ILLNESS. THE A.I.M. PUBLISHED IN THE SPRING OF 2012, WILL BE THE BASIS FOR INCREASED ORGANIZATION AND COLLABORATION WITHIN AND AMONG HOSPITALS, HEALTH DEPARTMENTS AND SERVICE PROVIDERS TO BETTER ADDRESS THE HEALTH NEEDS AND DISPARITIES EXPERIENCED BY MANY PEOPLE AND FAMILIES IN THE REGION. FREE & DISCOUNTED SERVICES ARE PROVIDED FOR THOSE UNABLE TO PAY & MEETING ELIGIBILITY CRITERIA. THROUGH THE HOSPITAL CARE ASSURANCE PROGRAM (HCAP), GSH SERVES PATIENTS MEETING CRITERIA SET FORTH BY THE STATE OF OHIO. GSH POLICY IS TO PROVIDE CHARITY CARE ON A SLIDING SCALE DISCOUNTING WHEN THE FAMILY INCOME IS UP TO 400 % OF THE ANNUALLY ESTABLISHED FEDERAL POVERTY GUIDELINE. IT OFFERS AN UNINSURED DISCOUNT FOR MEDICALLY NECESSARY SERVICES FOR THOSE WHO HAVE NO INSURANCE & WHO DO NOT QUALIFY FOR OTHER FINANCIAL ASSISTANCE OPTIONS. FINANCIAL COUNSELORS ASSIST PATIENTS IN COMPLETING THE FINANCIAL ASSISTANCE APPLICATION WHICH IS AVAILABLE ON TRIHEALTH'S WEBSITE & BROCHURES ABOUT FINANCIAL ASSISTANCE ARE VISIBLE & AVAILABLE IN HOSPITAL REGISTRATION & ADMITTING AREAS.GSH FUNDS THE PARISH NURSE MINISTRY & COMMUNITY HEALTH WORKER PROGRAMS. THESE PROGRAMS PROVIDE, AT NO CHARGE, HOME VISITS TO LOW INCOME CLIENTS IN 9 NEIGHBORHOODS. CLIENTS INCLUDE SENIORS & FRAIL ELDERLY IN THEIR HOMES OR IN CONGREGATE SUBSIDIZED HOUSING, THE MENTALLY & PHYSICALLY HANDICAPPED LIVING ALONE OR IN GROUP HOMES, & MOTHERS WHO ARE PREGNANT OR WHO HAVE RECENTLY DELIVERED A BABY. REFERRALS COME FROM HOSPITAL CARE COORDINATORS, OTHER HOSPITALS & AGENCIES. THE TEAM PROVIDES HEALTH SCREENINGS, EDUCATION ON MANAGING CHRONIC ILLNESSES, & CONNECTIONS TO ASSISTANCE. THE PURPLE (PREVENTING REPEAT PERINATAL LOSS) PROJECT CONNECTS MOTHERS WHO HAVE EXPERIENCED THE LOSS OF A PREGNANCY GREATER THAN 20 WEEKS GESTATION WITH A PARISH NURSE WHO PROVIDES EMOTIONAL & SPIRITUAL SUPPORT, NUTRITION INFORMATION & EDUCATION ON INTER-CONCEPTION HEALTH.THE INPATIENT BEHAVIORAL HEALTH UNITS AT GSH ARE AMONG THE FEW SUCH UNITS IN THE CINCINNATI COMMUNITY. THE ADULT BEHAVIORAL HEALTH INPATIENT UNIT IS A 19-BED COMPREHENSIVE PSYCHIATRIC UNIT FOR ADULT PATIENTS REQUIRING ACUTE INPATIENT CARE. THE TEAM CONSISTS OF PSYCHIATRISTS, NURSING STAFF, SOCIAL WORKERS, OCCUPATIONAL THERAPISTS, THERAPEUTIC RECREATION SPECIALISTS, & ART THERAPISTS. THE FULL SERVICES OF THE HOSPITAL ARE AVAILABLE AS REQUIRED FOR THE PATIENT'S CARE. TREATMENT FOCUSES ON SYMPTOM & MEDICATION MANAGEMENT & EDUCATION, & SAFE DISCHARGE DISPOSITION WITH A LINK TO COMMUNITY RESOURCES. THE SENIOR BEHAVIORAL HEALTH INPATIENT UNIT IS A SPECIALTY BEHAVIORAL HEALTH INPATIENT UNIT ADDRESSING THE PSYCHOLOGICAL, MEDICAL, EMOTIONAL & SPIRITUAL NEEDS OF GREATER CINCINNATI'S OLDER ADULTS. THE TEAM OF PSYCHIATRISTS, PSYCHIATRIC NURSES, SOCIAL WORKERS, & ACTIVITY & OCCUPATIONAL THERAPISTS PROVIDES INDIVIDUALIZED TREATMENT FOR OLDER ADULTS WITH PHYSICAL & MENTAL HEALTH PROBLEMS.HEALTHY WOMEN HEALTHY LIVES IS A PROGRAM BASED ON THE PREMISE THAT PREVENTION, EARLY DETECTION, TREATMENT & ACCESS TO HEALTH CARE SERVICES IMPROVE INDIVIDUAL & COMMUNITY HEALTH OUTCOMES. THE FOCUS IS ON HEALTH RISKS ASSOCIATED WITH THE ONSET OF MENOPAUSE. WELL ORGANIZED SCREENING & EDUCATION EVENTS BRING THE SERVICES TO AT RISK POPULATIONS OF AFRICAN AMERICAN, APPALACHIAN, HISPANIC, UNINSURED & UNDERINSURED WOMEN FORTY YEARS OF AGE OR OLDER. SCREENING INCLUDES OSTEOPOROSIS, MAMMOGRAPHY, CHOLESTEROL, HYPERTENSION, & OBESITY. EVERY WOMAN RECEIVES A NURSE CONSULTATION, A COPY OF THEIR RESULTS & A WRITTEN PRIMARY CARE REFERRAL. WOMEN WITH ABNORMAL RESULTS ARE CONTACTED & ASSISTED IN ACCESSING PRIMARY CARE. THIS PROGRAM SERVES AS AN ENTRY POINT TO HEALTH CARE SERVICES FOR MANY WOMEN IN THE COMMUNITY.HAMILTON COUNTY'S INFANT MORTALITY RATE OF 19%, THE HIGHEST IN OHIO HAS LED GSH TO FOCUS ON MATERNAL & INFANT HEALTH PROGRAMS. STRATEGIES INCLUDE INVESTIGATING THE ROOT CAUSES OF PREMATURITY & LOW BIRTH WEIGHT.GSH HAD 6,257 DELIVERIES IN FISCAL YEAR 2012. OF THESE BIRTHS, THE PERCENTAGE OF MOTHERS WITH PRETERM LABOR WAS 13.5% (A 1.5% DECREASE OVER FY11). THE PERCENTAGE OF BABIES BORN WEIGHING LESS THAN 2,500 GRAMS WAS 14% (A SLIGHT DECREASE FROM FY11). THIS DECREASE MAY BE ATTRIBUTED IN PART TO GSH'S COLLABORATIVE EFFORTS TO REDUCE ELECTIVE DELIVERIES BEFORE THE 39TH WEEK. ADDITIONALLY, THE CARE MANAGEMENT PROVIDED TO MOTHERS BY GSH PERINATAL SOCIAL WORKERS & CARE COORDINATORS INCLUDES SPECIAL PROGRAMS IN CHEMICAL DEPENDENCY & OTHER PREGNANCY HIGH-RISK ISSUES. THE GSH PARISH NURSES & COMMUNITY HEALTH WORKERS VISIT REFERRED MOTHERS IN THEIR HOMES & WORK WITH THEM TO PROBLEM-SOLVE THE FREQUENT CHALLENGES FACED SUCH AS SAFE HOUSING & CARE OF CHILDREN, AS WELL AS HEALTHY MANAGEMENT OF THE PREGNANCY.PERINATAL CARE COORDINATION NURSES & SOCIAL WORKERS FROM GSH ASSIST MOTHERS IN THE GSH FACULTY MEDICAL CENTER. THEY ALSO TRAVEL TO CLINICS IN ORDER TO REACH OUT & HELP UNINSURED & UNDERINSURED MOTHERS ACCESS PUBLIC PROGRAMS, REFERRALS, EDUCATION, ASSESSMENT & RESOURCES.IN COLLABORATION WITH WINTON HILLS HEALTH CENTER, GSH FUNDS THE SALARIES OF TWO PHYSICIANS, SPECIALISTS IN OBSTETRICS AND GYNECOLOGY, AT THE CENTER. THIS AFFORDS HEALTH CARE ACCESS TO WOMEN IN THE AREAGSH CONTINUES A COMMITMENT TO EDUCATING THE NEXT GENERATION OF HEALTH CARE PROVIDERS, PHYSICIANS & ALLIED HEALTH PROFESSIONALS. GSH, AS PART OF TRIHEALTH, INC., SPONSORS MEDICAL RESIDENCIES. THERE WERE 28 RESIDENTS IN INTERNAL MEDICINE & 23 GENERAL SURGERY RESIDENTS AT GSH IN FISCAL YEAR 2012. 2 RESIDENTS/FELLOWS IN VASCULAR SURGERY RECEIVED EXTENDED LEARNING & PREPARATION AT GSH. 32 TOTAL RESIDENTS IN OBSTETRICS & GYNECOLOGY LEARNED IN A JOINT RESIDENCY AT BOTH BETHESDA & GSH.IN THE GSH FACULTY MEDICAL CENTER ("FMC"), A MULTI-SPECIALTY CENTER, MEDICAL RESIDENTS PROVIDE CARE TO PATIENTS UNDER THE GUIDANCE OF ATTENDING PHYSICIANS. FMC SERVICES INCLUDE OBSTETRICS & GYNECOLOGY, INTERNAL MEDICINE, VASCULAR & GENERAL SURGERY, DYSPLASIA, HIGH-RISK PREGNANCY, URO-GYNECOLOGY & GASTRO-INTESTINAL. THE FMC PHARMACIST HELPS ELIGIBLE CLIENTS COMPLETE THE MEDICATION ASSISTANCE PROGRAMS APPLICATIONS. THE GSH ON-SITE PHARMACY PROVIDES PRESCRIPTIONS FOR THOSE IN NEED, AT REDUCED OR NO COST.GSH COLLABORATES WITH LOCAL & REGIONAL COLLEGES, UNIVERSITIES & TRAINING CENTERS TO PROVIDE MENTORING, INTERNSHIPS, CLERKSHIPS, SUPERVISED EDUCATION & CLINICAL ROTATIONS TO STUDENTS IN HEALTH FIELDS. THESE PARTNERSHIPS HELP STUDENTS LEARN ABOUT & PREPARE FOR PROFESSIONS IN NURSE PRACTITIONER, RESPIRATORY THERAPY, RADIOLOGY TECHNOLOGY, STERILE PROCESSING, PHLEBOTOMY, MEDICAL LABORATORY, CLINICAL DIETETICS, PHARMACY, SPEECH, AUDIOLOGY, PHYSICAL THERAPY, OCCUPATIONAL THERAPY, NURSE MIDWIFERY, & NEONATAL NURSE PRACTITIONER. PASTORAL CARE OFFERS A CLINICAL PASTORAL EDUCATION PROGRAM EDUCATING CLERGY & OTHERS IN PASTORAL SKILLS TO MINISTER EFFECTIVELY TO THE SICK & THE DYING.GSH'S RESEARCH PROGRAM MANAGES BASIC & APPLIED SCIENTIFIC STUDIES & SPONSORED CLINICAL TRIALS. IT ALSO SUPPORTS THE EDUCATION ACTIVITIES OF STAFF PHYSICIANS & SURGEONS, TEACHING FACULTY, RESIDENTS, & ALLIED HEALTH PROFESSIONALS. WHAT IS LEARNED THROUGH THE RESEARCH & EDUCATION PROGRAMS IS SHARED WITH THE LARGER COMMUNITY. THE RESEARCH PROGRAM HELPS RESEARCHERS GIVE PROFESSIONAL PRESENTATIONS AT REGIONAL & NATIONAL MEETINGS AS HAVE STUDIES & ARTICLES PUBLISHED IN PEER-REVIEWED MEDICAL JOURNALS.THROUGH THESE PROGRAMS, GSH CONTINUES ITS SPECIAL CONCERN FOR THE VULNERABLE. EMPLOYEES, PHYSICIANS & LEADERS PROVIDING & GUIDING THESE PROGRAMS FOR COMMUNITY HEALTH ARE LIVING THE CORE VALUES OF STEWARDSHIP & RESPONSE TO COMMUNITY NEEDS. PART VI, LINE 3: TRIHEALTH, INC. ("TRIHEALTH") PERFORMS THE BILLING SERVICES FOR ALL AFFILIATED HOSPITALS INCLUDING THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO. BROCHURES/APPLICATIONS, PROVIDED IN MULTIPLE LANGUAGES, ARE VISIBLE AND AVAILABLE IN THE REGISTRATION AND ADMITTING AREAS OF ALL TRIHEALTH AFFILIATED HOSPITALS. IN ADDITION, THE APPLICATION IS PRINTED ON THE REVERSE SIDE OF A PATIENT'S BILL WITH INSTRUCTIONS ON HOW TO COMPLETE THE APPLICATION AS WELL AS HOW TO RETURN IT. FINANCIAL COUNSELORS ASSIST PATIENTS IN COMPLETING THE FINANCIAL ASSISTANCE APPLICATION. FINALLY, TRIHEALTH INC.'S WEBSITE CONTAINS INFORMATION REGARDING ITS CHARITY CARE AND FINANCIAL ASSISTANCE PROGRAMS WITH DIRECTIONS ON HOW TO CONTACT THE APPROPRIATE PERSONNEL TO INITIATE AN APPLICATION OR ASK QUESTIONS ABOUT THE PROCESS. PART VI, LINE 4: LOCATED IN CINCINNATI, OHIO, GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO AND THE TRIHEALTH SYSTEM SERVE HAMILTON, BUTLER, WARREN AND CLERMONT COUNTIES, AS WELL AS PERSONS FROM INDIANA AND KENTUCKY. OHIO'S THIRD LARGEST CITY, CINCINNATI HAS AN ESTIMATED POPULATION OF 290,270. THE POPULATION WITHIN THE FOUR OHIO COUNTIES SERVED BY TRIHEALTH IS ESTIMATED TO BE 1,500,000 AND 12% PERCENT OF THIS POPULATION IS UNINSURED. THE GEOGRAPHIC AREA SERVED BY THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO IS PREDOMINANTLY URBAN WITH A LARGE SEGMENT OF ITS PATIENTS UNINSURED, UNDERINSURED OR MEDICAID RECIPIENTS. PART VI, LINE 5: THE ONGOING PURPOSE OF THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO ("GSH") IS TO PROVIDE CARE WITH COMPASSION. ITS MISSION IS TO IMPROVE THE HEALTH STATUS OF THE COMMUNITY THROUGH HEALTH RELATED SERVICES--PREVENTION, WELLNESS AND EDUCATION. ITS BOARD OF DIRECTORS IS COMPRISED OF INDEPENDENT COMMUNITY REPRESENTATIVES. GSH IS AN ACUTE TERTIARY TEACHING HOSPITAL. AS PART OF TRIHEALTH A SYSTEM OF SERVICES SPANNING ACUTE CARE TO HOME CARE, BABIES TO SENIORS. IT PROVIDES A 24-HOUR EMERGENCY ROOM, FOUR INTENSIVE CARE UNITS FOR NEONATES AND ADULTS, ADULT AND GERIATRIC INPATIENT PSYCHIATRIC CARE, AND AN ACCREDITED REHABILITATION MEDICINE PROGRAM. SERVICES ARE OPEN TO ALL INDIVIDUALS REGARDLESS OF ABILITY TO PAY. GSH HAS AN OPEN MEDICAL STAFF AND A HISTORY OF TRAINING AND EDUCATING MEDICAL RESIDENTS AND HEALTH CARE PROFESSIONALS. ITS MEDICAL AND SCIENTIFIC RESEARCH PROGRAMS INCLUDE STUDIES THAT ARE NOT COMMERCIALLY SPONSORED. GSH PARTICIPATES IN MEDICARE AND MEDICAID AND OTHER GOVERNMENT-SPONSORED HEALTH CARE PROGRAMS, AND HAS AN ACTIVE CHARITY CARE PROGRAM.SEE RESPONSE TO PART VI, LINE 2 FOR ADDITIONAL INFORMATION. PART VI, LINE 6: IN 1995, THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO AND BETHESDA HOSPITAL, INC. FORMED A PARTNERSHIP CALLED TRIHEALTH, INC. TO CREATE AN INTEGRATED HEALTH DELIVERY SYSTEM WHOSE MISSION IS TO IMPROVE THE HEALTH OF THE PEOPLE THEY SERVE, WITH AN EMPHASIS ON PREVENTION, WELLNESS AND EDUCATION. TRIHEALTH, INC.'S SITES INCLUDE TWO HOSPITAL LOCATIONS AND VARIOUS PHYSICIAN OFFICE BUILDINGS THROUGHOUT THE GREATER CINCINNATI AREA IN ADDITION TO FITNESS, REHABILITATION, OCCUPATIONAL HEALTH, PALLIATIVE CARE SERVICES AND OUTPATIENT CENTERS. IT ALSO PROVIDES SERVICES IN HOMES AND WORKPLACES AND DELIVERS CARE AND EDUCATION COOPERATIVELY THROUGH COMMUNITY-BASED ORGANIZATIONS, SUCH AS CHURCHES, SCHOOLS, CLINICS AND SOCIAL AGENCIES. 1 HEALTHY BEGINNINGS INC 47 E HOLLISTER STE 201 CINCINNATI OH 45219 311380939 501(C)(3) 70000 SUPPORT FUNDING HEALTHY MOM AND BABIES INC 2270 BANNING ROAD CINCINNATI OH 45239 311155292 501(C)(3) 100000 CHARITY CARE ACADEMY OF MEDICINE OF CINCINNATI PROJECT ACCESS 2300 WALL STREET SUITE F CINCINNATI OH 45212 453029855 501(C)(3) 10000 GENERAL PURPOSE UPTOWN CONSORTIUM INC 629 OAK STREET SUITE 306 CINCINNATI OH 45206 200688727 501(C)(3) 147900 GENERAL PURPOSE COALITION TO PROTECT AMERICA'S HEALTH CARE PO BOX 30211 BETHESDA MD 20824 522253225 501(C)(4) 7650 COMMITMENT THE CENTER FOR CLOSING THE HEALTH GAP IN GREATER CINCINNATI 3120 BURNET AVENUE SUITE 201 CINCINNATI OH 45229 200902286 501(C)(3) 106335 GENERAL PURPOSE ARTHRITIS FOUNDATION INC 7124 MIAMI AVE CINCINNATI OH 45243 316043937 501(C)(3) 10200 SPONSORSHIP CENTER FOR RESPITE CARE INC PO BOX 141301 CINCINNATI OH 45229 202544994 501(C)(3) 25500 GENERAL PURPOSE GOOD SAMARITAN HOSPITAL FOUNDATION OF CINCINNATI INC 619 OAK STREET CINCINNATI OH 45206 311206047 501(C)(3) 11120 SPONSORSHIP AMERICAN HEART ASSOCIATION 5455 N HIGH STRET COLUMBUS OH 43214 135613797 501(C)(3) 38250 SPONSORSHIP MAYFIELD EDUCATION AND RESEARCH FUND 506 OAK STREET CINCINNATI OH 45219 310921099 501(C)(3) 10200 SPONSORSHIP 10 1 REFUGEE WOMEN'S SUPPORT GROUP 25 8292 INSTRUCTION IN ENGLISH AS A SECOND LANGUAGE AS WELL AS DISCUSSION RELATED TO VARIOUS HEALTH TOPICS. INFANT FUNERAL EXPENSE 1 100 840 FAIR MARKET VALUE PURCHASE OF INFANT CASKET MULTIVITAMINS 20 768 FAIR MARKET VALUE MULTIVITAMINS BOOKS 1 100 FAIR MARKET VALUE BOOKS PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO ("HOSPITAL") PROVIDES GRANTS TO OTHER ORGANIZATIONS AND INDIVIDUALS ON A VERY LIMITED BASIS. IN THOSE INSTANCES, THE DEPARTMENT GRANTING THE FUNDS IS RESPONSIBLE FOR OBTAINING AND STORING ALL NECESSARY INFORMATION FROM THE OTHER ORGANIZATION AND INDIVIDUALS RELATIVE TO HOW THE FUNDS WILL BE SPENT. GENERALLY, GRANTS ARE PROVIDED, ON BEHALF OF HOSPITAL THOUGH TRIHEALTH, INC. ("TRIHEALTH"), A SUPPORTING ORGANIZATION OF HOSPITAL, WHICH PROVIDES ADMINISTRATIVE SUPPORT SERVICES TO HOSPITAL. AS SUCH, TRIHEALTH IS RESPONSIBLE FOR MONITORING THE USE OF HOW THE FUNDS WILL BE SPENT. 0 1 0 0 0 0 0 1 0 PAUL EDGETT III 0 400709 0 167831 0 21638 0 62943 0 21446 0 674567 0 0 JOHN PROUT 0 859109 0 338532 0 28543 0 286218 0 10208 0 1522610 0 0 DONNA NIENABER ESQ 0 301071 0 139124 0 41429 0 135545 0 16412 0 633581 0 0 CRAIG RUCKER 0 395101 0 130118 0 18330 0 120190 0 9542 0 673281 0 0 DAVE DORNHEGGEN 0 267779 0 72608 0 20316 0 96667 0 14527 0 471897 0 0 WILLIAM GRONEMAN 0 360315 0 120587 0 67916 0 141510 0 23464 0 713792 0 16587 GERALD OLIPHANT 0 433802 0 145983 0 18288 0 102679 0 21436 0 722188 0 0 GEORGES FEGHALI MD 0 360606 0 122375 0 30589 0 133633 0 22364 0 669567 0 0 ROBERT ROHS MD 277418 0 56154 0 3405 0 38142 0 713 0 375832 0 0 0 DAVID DHANRAJ MD 209773 0 30000 0 150 0 19018 0 13882 0 272823 0 0 0 MICHAEL HOLBET MD 237343 0 0 0 594 0 31583 0 564 0 270084 0 0 0 HELEN KOSELKA MD 196648 0 1875 0 612 0 42293 0 6998 0 248426 0 0 0 MICHAEL SMITH MD 168297 0 0 0 0 0 0 0 0 0 168297 0 0 0 MICHAEL CROFTON 0 206505 0 50637 0 21853 0 53006 0 22306 0 354307 0 0 PART I, LINE 4B PART I, LINE 4B - NON-QUALIFIED DEFERRED COMPENSATION PLAN ELIGIBLE EXECUTIVES (GENERALLY VICE PRESIDENTS AND ABOVE) PARTICIPATE IN A PROGRAM THAT PROVIDES FOR SUPPLEMENTAL RETIREMENT BENEFITS. THE PAYMENT OF BENEFITS UNDER THE PROGRAM, IF ANY, IS ENTIRELY DEPENDENT UPON THE FACTS AND CIRCUMSTANCES UNDER WHICH THE EXECUTIVE TERMINATES EMPLOYMENT WITH THE ORGANIZATION. BENEFITS UNDER THE PROGRAM ARE UNFUNDED AND NON-VESTED. DUE TO THE SUBSTANTIAL RISK OF FORFEITURE PROVISION, THERE IS NO GUARANTEE THAT THESE EXECUTIVES WILL EVER RECEIVE ANY BENEFIT UNDER THE PROGRAM. ANY AMOUNT ULTIMATELY PAID UNDER THE PROGRAM TO THE EXECUTIVE IS REPORTED AS COMPENSATION ON FORM 990, SCHEDULE J, PART II, COLUMN B IN THE YEAR PAID. TRIHEALTH, INC., THE RELATED ORGANIZATION THAT PAID THE SALARIES OF THE FOLLOWING INDIVIDUALS LISTED IN SCHEDULE J, PART II, CONTRIBUTED, ON BEHALF OF THE FOLLOWING INDIVIDUALS, TO A SUPPLEMENTAL NONQUALIFIED RETIREMENT PLAN IN THE AMOUNTS AS NOTED: JOHN PROUT - $236,082 DONNA NIENABER, ESQ. - $68,563 CRAIG RUCKER - $78,831 MICHAEL CROFTON - $16,824 GERALD OLIPHANT - $82,817 DAVE DORNHEGGEN - $41,735 WILLIAM GRONEMAN - $80,979 GEORGES FEGHALI, MD - $76,814. IN ADDITION, THE FOLLOWING INDIVIDUALS LISTED IN SCHEDULE J, PART II, RECEIVED A PAYMENT FROM A SUPPLEMENTAL NONQUALIFIED RETIREMENT PLAN WHICH WAS TREATED AS TAXABLE COMPENSATION BY THEIR RESPECTIVE EMPLOYERS: WILLIAM GRONEMAN - $16,587 PART I, LINE 7 PART I, LINE 7: A PHYSICIAN HAS A BASE SALARY BUT IS ALSO ELIGIBLE FOR A BONUS. THE BONUS IS CONTINGENT ON THE PROFITABILITY OF HIS OR HER PRACTICE. ESSENTIALLY, THE PROFITABILITY OF HIS OR HER PRACTICE GETS PAID TO THE PHYSICIAN AS A BONUS UP TO A MAXIMUM OF $100,000. SUPPLEMENTAL INFORMATION PART III PART I, LINE 3 - METHODS USED TO ESTABLISH CEO COMPENSATION TRIHEALTH, INC., A RELATED ORGANIZATION OF THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO, WHO PAID THE INDIVIDUAL, USES THE FOLLOWING TO ESTABLISH THE COMPENSATION OF THE FILING ORGANIZATION'S CEO/EXECUTIVE DIRECTOR: * COMPENSATION COMMITTEE; * INDEPENDENT COMPENSATION CONSULTANT; * COMPENSATION SURVEY OR STUDY; AND * APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE. PART I, LINE 4A - SEVERANCE PAYMENTS: THE REPORTABLE INDIVIDUALS OF THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO ARE PAID BY TRIHEALTH, INC., A RELATED ORGANIZATION, RECOGNIZED BY THE INTERNAL REVENUE SERVICE AS EXEMPT FROM FEDERAL INCOME TAX UNDER INTERNAL REVENUE CODE SECTION 501(A) AS AN ORGANIZATION DESCRIBED IN INTERNAL REVENUE CODE SECTION 501(C)(3). THESE INDIVIDUALS DO NOT HAVE EMPLOYMENT AGREEMENTS SO NO SPECIAL ARRANGEMENTS EXIST BEYOND TRIHEALTH, INC.'S STANDARD EMPLOYEE SEVERANCE PACKAGE. GENERAL SEVERANCE PAY IS BASED ON LENGTH OF SERVICE. IN ADDITION, NOTICE PAY, IF APPLICABLE UNDER TRIHEALTH, INC. POLICY, MAY BE ADDED TO THE SEVERANCE PACKAGE AND THE AMOUNT OF NOTICE PAY WILL BE DETERMINED BY HUMAN RESOURCES IN ACCORDANCE WITH TRIHEALTH, INC. POLICY. PAYMENTS OF SEVERANCE ARE CONDITIONED UPON SIGNING A SEPARATION AND RELEASE AGREEMENT. NO REPORTABLE INDIVIDUALS RECEIVED SEVERANCE PAYMENTS FROM TRIHEALTH, INC. DURING THE 2011 CALENDAR YEAR. DESCRIPTION OF THE ORGANIZATION'S MISSION FORM 990, PART III, LINE 1 THE ORGANIZATION'S MISSION IS TO NURTURE THE HEALING MINISTRY OF THE CHURCH BY BRINGING IT NEW LIFE, ENERGY AND VIABILITY IN THE 21ST CENTURY. FIDELITY TO THE GOSPEL URGES US TO EMPHASIZE HUMAN DIGNITY AND SOCIAL JUSTICE AS WE MOVE TOWARD THE CREATION OF HEALTHIER COMMUNITIES. FORM 990, PART VI, SECTION A, LINE 2 THE OFFICERS, DIRECTORS AND TRUSTEES OF THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO LISTED IN PART VII, SECTION A HAVE A "BUSINESS RELATIONSHIP" WITH EACH OTHER BY VIRTUE OF SITTING ON THE BOARDS OF BETHESDA HOSPITAL, INC. AND TRIHEALTH, INC., ALL RELATED ENTITIES. SYLVANIA NG, MD, STUART DONOVAN, MD, ROBERT L. WALKER, MICHAEL HAVERKAMP, CRAIG EISENTROUT, MD AND MYRTIS POWELL HAVE A "BUSINESS RELATIONSHIP" WITH EACH OTHER BY VIRTUE OF SITTING ON THE BOARD OF BETHESDA, INC., THE SINGLE CORPORATE MEMBER OF BETHESDA HOSPITAL, INC. JOHN PROUT, DONNA NIENABER, ESQ., CRAIG RUCKER, WILLIAM GRONEMAN, GERALD OLIPHANT, GEORGES FEGHALI, MD, MARC ALEXANDER, MD, STEPHEN BLATT, MD, AND DAVE DORNHEGGEN HAVE A "BUSINESS RELATIONSHIP" WITH EACH OTHER BY VIRTUE OF SITTING ON RELATED ENTITY BOARDS OF TRIHEALTH, INC. AND ITS SUBSIDIARIES AND AFFILIATES AS WELL AS BEING EMPLOYED BY TRIHEALTH, INC. OR ITS AFFILIATES/SUBSIDIARIES. FORM 990, PART VI, SECTION A, LINE 6 THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO HAS TWO (2) CORPORATE MEMBERS. CATHOLIC HEALTH INITIATIVES, A COLORADO NON-PROFIT CORPORATION, IS THE SOLE VOTING MEMBER AND TRIHEALTH, INC., AN OHIO NON-PROFIT CORPORATION, IS THE SOLE NON-VOTING MEMBER. FORM 990, PART VI, SECTION A, LINE 7A IN ACCORDANCE WITH THE CORPORATE BYLAWS OF THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO ("HOSPITAL"), THE TRUSTEES OF THE HOSPITAL (OTHER THAN THE CHIEF EXECUTIVE OFFICER AND THE PRESIDENTS OF THE MEDICAL STAFFS OF GOOD SAMARITAN HOSPITAL AND BETHESDA NORTH HOSPITAL WHO SERVE BY VIRTUE OF THEIR OFFICES) SHALL BE NOMINATED AND ELECTED BY THE VOTING MEMBER NO LATER THAN JUNE 30 OF EACH YEAR IN THE MANNER PROVIDED IN THE NETWORK AFFILIATION AGREEMENT. FORM 990, PART VI, SECTION A, LINE 7B CATHOLIC HEALTH INITIATIVES ("CHI") IS THE SOLE CORPORATE VOTING MEMBER OF THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO ("HOSPITAL"). PURSUANT TO SECTION 5.4.2 OF THE HOSPITAL'S BYLAWS AND THE NETWORK AFFILIATION AGREEMENT, THE VOTING MEMBER SHALL HAVE THE SPECIFIC RIGHTS SET FORTH IN THE GOVERANCE MATRIX. PURSUANT TO THE GOVERNANCE MATRIX, THE FOLLOWING RIGHTS ARE RESERVED TO THE CHI BOARD DIRECTLY OR THROUGH POWERS DELEGATED TO THE CHI CHIEF EXECUTIVE OFFICER: * SUBSTANTIAL CHANGE IN THE MISSION OR PHILOSOPHY OF THE HOSPITAL, * AMENDMENT OF THE CORPORATE DOCUMENTS OF THE HOSPITAL, * APPROVAL OF MEMBERS OF THE HOSPITAL'S BOARD, * REMOVAL OF A MEMBER OF THE GOVERNING BODY OF THE HOSPITAL, * APPROVAL OF ISSUANCE OF DEBT BY THE HOSPITAL, * APPROVAL OF PARTICIPATION OF THE HOSPITAL IN A JOINT VENTURE, * APPROVAL OF FORMATION OF A NEW CORPORATION BY THE HOSPITAL, * APPROVAL OF A MERGER INVOLVING THE HOSPITAL, * APPROVAL OF THE SALE OF ALL OR SUBSTANTIALLY ALL OF THE ASSETS OF THE HOSPITAL, * AUTHORITY TO REQUIRE THE TRANSFER OF ASSETS BY THE HOSPITAL TO CHI TO ACCOMPLISH CHI'S GOALS AND OBJECTIVES, AND TO SATISFY CHI DEBTS, AND * ADOPTION OF LONG RANGE AND STRATEGIC PLANS FOR THE HOSPITAL. PURSUANT TO SECTION 5.5.2 OF THE HOSPITAL'S BYLAWS AND THE NETWORK AFFILATION AGREEMENT, CHI MAY, IN EXERCISE OF ITS APPROVAL POWERS, GRANT OR WITHHOLD APPROVAL IN WHOLE OR IN PART, OR MAY, IN ITS COMPLETE DISCRETION, AFTER CONSULTATION WITH THE BOARD AND THE PRESIDENT AND CHIEF EXECUTIVE OFFICER OF THE HOSPITAL, RECOMMEND SUCH OTHER OR DIFFERENT ACTIONS AS IT DEEMS APPROPRIATE. FORM 990, PART VI, SECTION A, LINE 8A IT IS THE COMMON PRACTICE OF THE ORGANIZATION TO DISSEMINATE A COPY OF THE PROPOSED MINUTES OF THE PREVIOUS MEETING TO THE BOARD OR COMMITTEE PRIOR TO THE NEXT MEETING AND TO DISCUSS AND APPROVE SUCH MINUTES AT THE NEXT MEETING. FOR 8 OF THE 9 MEETINGS OF THE BOARD AND EXECUTIVE COMMITTEE, THE MINUTES WERE CONTEMPORANEOUSLY DOCUMENTED. ON ONE OCCASION, HOWEVER, MINUTES FROM THE IMMEDIATELY PREVIOUS MEETING WERE NOT PUT ON THE AGENDA FOR A SPECIAL MEETING OF THE BOARD. SUCH MINUTES WERE REVIEWED AND APPROVED AT THE NEXT REGULAR MEETING OF THE BOARD, WHICH OCCURRED 91 DAYS AFTER THE PREVIOUS MEETING OCCURRED. FORM 990, PART VI, SECTION B, LINE 11 MEMBERS OF THE BOARD ARE PROVIDED AN ELECTRONIC COPY OF THIS FORM 990 PRIOR TO FILING. HOWEVER, FOR THE PROTECTION OF DONOR PRIVACY, SCHEDULE B - SCHEDULE OF CONTRIBUTORS WAS REMOVED FROM THE COPY PROVIDED TO THE BOARD. SUBSEQUENT TO PRESENTATION TO THE BOARD, THE ORGANIZATION FILES THE RETURN MAKING ANY NON-SUBSTANTIVE CHANGES NECESSARY TO EFFECT E-FILING. ANY SUCH CHANGES ARE NOT RE-SUBMITTED TO THE BOARD. FORM 990, PART VI, SECTION B, LINE 12C ALL BOARD MEMBERS ARE REQUIRED TO ANNUALLY DISCLOSE CERTAIN FINANCIAL INTERESTS AND FIDUCIARY RELATIONSHIPS. THE EXECUTIVE COMMITTEE AND CORPORATE COUNSEL REVIEW RESPONSES, CONDUCT FURTHER INVESTIGATION, IF NECESSARY, AND DETERMINE WHEN A CONFLICT EXISTS WITH RESPECT TO A CERTAIN TRANSACTION. IF A CONFLICT EXISTS, THE TRANSACTION IS NOT TO BE ENTERED INTO UNLESS ALTERNATIVES ARE FULLY INVESTIGATED AND, IN THEIR ABSENCE, THE BOARD, WITHOUT PARTICIPATION OF THE INTERESTED MEMBER(S), DETERMINES THAT THE TRANSACTION IS IN THE BEST INTEREST OF THE ORGANIZATION. PLANS TO MANAGE THE CONFLICT DURING THE RELATIONSHIP ARE IMPLEMENTED. ALL DISCUSSIONS ARE APPROPRIATELY DOCUMENTED. FORM 990, PART VI, SECTION B, LINE 15 IN DETERMINING COMPENSATION OF THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO'S OFFICERS AND DIRECTORS, THE ANNUAL PROCESS PERFORMED BY TRIHEALTH, INC. (A RELATED ORGANIZATION WHO PAID THE INDIVIDUALS) INCLUDED: * COMPENSATION COMMITTEE; * INDEPENDENT COMPENSATION CONSULTANT; * COMPENSATION SURVEY OR STUDY; AND * APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE. ADDITIONALLY, ALL DISCUSSIONS AND DECISIONS ARE CONTEMPORANEOUSLY DOCUMENTED. FORM 990, PART VI, SECTION C, LINE 19 THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO'S GOVERNING DOCUMENTS, CONFLICTS OF INTEREST POLICY AND FINANCIAL STATEMENTS ARE AVAILABLE UPON REQUEST. IN ADDITION, THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO'S FINANCIAL STATEMENTS ARE INCLUDED IN THE CATHOLIC HEALTH INITIATIVES' CONSOLIDATED AUDITED FINANCIAL STATEMENTS THAT ARE AVAILABLE AT WWW.CATHOLICHEALTHINT.ORG OR AT HTTP://WWW.DACBOND.COM. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED LOSSES ON INVESTMENTS: -10,121,036. CHANGE PENSION PLAN/SERP FUNDED STATUS -19,375,764. TRANSFER TO CHI CAPITAL RESOURCE POOL -5,755,356. MISCELLANEOUS ADJUSTMENT 166,361. TOTAL TO FORM 990, PART XI, LINE 5: -35,085,795. VOLUNTEER INFORMATION FORM 990, PART I, LINE 6 DURING THE TAX YEAR, THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO WAS ASSISTED BY 1,344 VOLUNTEERS WHO DONATED OVER 132,255 HOURS. EXECUTIVE COMMUNITY COMPOSITION AND AUTHORITY FORM 990, PART VI, LINE 1 PURSUANT TO ARTICLE SECTION 8.1.1 OF THE BYLAWS OF THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO ("HOSPITAL"), THE BOARD OF TRUSTEES MAY ESTABLISH AN THE EXECUTIVE COMMITTEE WHICH MAY EXERCISE SUCH POWER AND AUTHORITY OF THE BOARD OF TRUSTEES IN INTERVALS BETWEEN MEETINGS OF THE BOARD AS AUTHORIZED BY THE BOARD. THE EXECUTIVE COMMITTEE IS COMPOSED OF THE BOARD CHAIR, THE BOARD VICE CHAIR, THE PRESIDENT AND THE CHIEF EXECUTIVE OFFICER, THE SECRETARY AND TWO OTHER BOARD MEMBERS IN ACCORDANCE WITH THE NETWORK AFFILIATION AGREEMENT. PURSUANT TO SECTION 8.1.5 OF THE HOSPITAL'S BYLAWS, COMMITTEES, SUCH AS THE EXECUTIVE COMMITTEE, THAT ARE GRANTED THE AUTHORITY TO ACT ON BEHALF OF THE BOARD OF DIRECTORS SHALL CONSIST OF AT LEAST THREE MEMBERS OF THE BOARD OF TRUSTEES. FURTHER, PURSUANT TO SECTION 8.1.1 OF THE HOSPITAL'S BYLAWS, FOUR MEMBERS OF THE EXECUTIVE COMMITTEE SHALL CONSTITUTE A QUORUM FOR THE TRANSACTIONS OF BUSINESS AND THE ACT OF THE FOUR OF THEM SHALL CONSTITUTE THE ACT OF THE COMMITTEE. ESTIMATE OF HOURS DEVOTED TO RELATED ORGANIZATIONS FORM 990, PART VII, SECTION A OFFICERS AND DIRECTORS (AS NOTED WITH A "SCH O" REFERENCE) FOR THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO PROVIDE SERVICES TO TRIHEALTH, INC. (A RELATED ORGANIZATION WHO THE INDIVIDUALS) AND ITS SUBSIDIARIES/AFFILIATES ("TRIHEALTH"). HOURS WORKED ARE NOT TRACKED ON AN ENTITY BY ENTITY BASIS. THE COMPENSATION REPORTED ON THE FORM 990, PART VII, SECTION A WAS PAID TO THESE INDIVIDUALS IN FULFILLMENT OF THEIR DUTIES AS FULL-TIME, 60 HOURS-PER-WEEK EMPLOYEES OF TRIHEALTH. CHANGE IN PROCESS OF AUDIT OVERSIGHT OR SELECTION OF INDEPENDENT AUDITOR FORM 990, PART XII, LINE 2C THE FINANCIAL STATEMENTS OF THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO ("HOSPITAL") ARE AUDITED WITH ITS SUBSIDIARIES. HOSPITAL HAS A COMMITTEE THAT ASSUMES THE RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT OF BOTH ITS AND ITS SUBSIDIARIES FINANCIAL STATEMENTS AS WELL AS THE SELECTION OF THE INDEPENDENT AUDITOR. DURING THE TAX YEAR, THERE WAS NOT A CHANGE IN THE PROCESS OF AUDIT OVERSIGHT AND/OR SELECTION OF AN INDEPENDENT AUDITOR BY HOSPITAL. EVALUATION OF PARTICIPATION IN JOINT VENTURE AGREEMENTS FORM 990, PART VI, LINE 16B THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO HAS NOT FORMALLY ADOPTED A WRITTEN POLICY OR PROCEDURE REGARDING JOINT VENTURES. HOWEVER, CATHOLIC HEALTH INITIATIVES, A RELATED ORGANIZATION, HAS A SYSTEM-WIDE JOINT VENTURE MODEL OPERATING AGREEMENT WHICH INCORPORATES CONTROLS OVER THE VENTURE SUFFICIENT TO ENSURE THAT (1) THE EXEMPT ORGANIZATION AT ALL TIMES RETAINS CONTROL OVER THE VENTURE SUFFICIENT TO ENSURE THAT THE PARTNERSHIP FURTHERS THE EXEMPT PURPOSE OF THE ORGANIZATION; (2) IN ANY PARTNERSHIP IN WHICH THE EXEMPT ORGANIZATION IS A PARTNER, ACHIEVEMENT OF EXEMPT PURPOSES IS PRIORITIZED OVER MAXIMIZATION OF PROFITS FOR THE PARTNERS; (3) THE PARTNERSHIP DOES NOT ENGAGE IN ANY ACTIVITIES THAT WOULD JEOPARDIZE THE EXEMPT ORGANIZATION'S EXEMPTION; (4) RETURNS OF CAPITAL, ALLOCATIONS, AND DISTRIBUTIONS MUST BE MADE IN PROPORTION TO THE PARTNERS' RESPECTIVE OWNERSHIP INTERESTS; AND (5) ALL CONTRACTS ENTERED INTO BY THE PARTNERSHIP WITH THE EXEMPT ORGANIZATION MUST BE AT ARM'S-LENGTH, WITH PRICES SET AT FAIR MARKET VALUE. ANY JOINT VENTURE AGREEMENTS THAT DO NOT CONFORM TO THE MODEL AGREEMENT ARE GENERALLY REVIEWED BY COUNSEL. ALEGENT HEALTH - BERGAN MERCY HEALTH SYS 7500 MERCY ROAD OMAHA NE 68124 470484764 HEALTHCARE NE 501(C)(3) 3 CHI 1 ALEGENT HEALTH - MERCY HOSPITAL PO BOX 368 CORNING IA 50841 420782518 HEALTHCARE IA 501(C)(3) 3 AHBMHS 1 ALVERNA APARTMENTS 300 SE 8TH AVENUE LITTLE FALLS MN 56345 411351177 LTERM CARE MN 501(C)(3) 9 CHI 1 APPLETREE COURT 601 OAK STREET BRECKENRIDGE MN 56520 411850500 SENIOR HOMES MN 501(C)(3) 9 SFH 1 BISHOP DRUMM RETIREMENT CENTER 1111 6TH AVENUE DES MOINES IA 50314 420725196 LTERM CARE IA 501(C)(3) 9 CHI-IA CORP 1 BORNEMANN HEALTHCARE CORPORATION 2500 BERNVILLE ROAD PO BOX 316 READING PA 19603 232187242 HEALTHCARE PA 501(C)(3) 11A CHI 1 CARRINGTON HEALTH CENTER 800 NORTH 4TH STREET CARRINGTON ND 58421 450227311 HEALTHCARE ND 501(C)(3) 3 CHI 1 CATHOLIC HEALTH INITIATIVES 198 INVERNESS DRIVE WEST ENGLEWOOD CO 80112 470617373 HEALTHCARE CO 501(C)(3) 9 N/A 1 CATHOLIC HEALTH INITIATIVES COLORADO FOUNDATION 961 EAST COLORADO AVENUE COLORADO SPRINGS CO 80903 840902211 FUNDRAISING CO 501(C)(3) 7 CHI COLORADO 1 CENTENNIAL MEDICAL GROUP INC 2700 STEWART PARKWAY ROSEBURG OR 97470 900433062 PHYSICIANS OR 501(C)(3) 9 MMC 1 CHI COLORADO 188 INVERNESS DRIVE WEST ENGLEWOOD CO 80112 840405257 HEALTHCARE CO 501(C)(3) 3 CHI 1 CHI HEALTH CONNECT AT HOME - FARGO 4816 AMBER VALLEY PARKWAY FARGO ND 58104 271966847 HEALTHCARE ND 501(C)(3) 3 CHI 1 CHI INSTITUTE FOR RESEARCH AND INNOVATION 198 INVERNESS DRIVE WEST ENGLEWOOD CO 80112 271050565 HEALTHCARE CO 501(C)(3) 11A CHI 1 CHI KENTUCKY INC 3900 OLYMPIC BLVD SUITE 400 ERLANGER KY 41018 202741651 HEALTHCARE KY 501(C)(3) 11A CHI 1 CHI NATIONAL FOUNDATION 198 INVERNESS DRIVE WEST ENGLEWOOD CO 80112 270930004 FUNDRAISING CO 501(C)(3) 11A CHI 1 CHI NATIONAL HOME CARE 198 INVERNESS DRIVE WEST ENGLEWOOD CO 80112 451261716 HEALTHCARE CO 501(C)(3) 11A CHI NHC 1 CHI NATIONAL SERVICES 198 INVERNESS DRIVE WEST ENGLEWOOD CO 80112 452532084 HEALTHCARE CO 501(C)(3) 9 CHI 1 CHI NEBRASKA 555 SOUTH 70TH STREET LINCOLN NE 68510 363233121 HEALTHCARE NE 501(C)(3) 11A CHI 1 CHI-IOWA CORP 1111 6TH AVENUE DES MOINES IA 50314 420680448 HEALTHCARE IA 501(C)(3) 3 CHI 1 COMMUNITY LIMITED CARE DIALYSIS CENTER 619 OAK STREET ACCOUNTING-3 WEST CINCINNATI OH 45206 237419853 DIALYSIS OH 501(C)(2) GOOD SAM HOSPITAL 1 CONTINUING CARE HOSPITAL 150 NORTH EAGLE CREEK DRIVE LEXINGTON KY 40509 611400619 LTACH KY 501(C)(3) 3 SJHS 1 COVENANT HOME CARE 1223 POTTSVILLE PIKE SHOEMAKERSVILLE PA 19555 232018429 HOME HEALTH PA 501(C)(3) 11B N/A 1 ENUMCLAW REGIONAL HOSPITAL ASSOCIATION 1450 BATTERSBY AVENUE ENUMCLAW WA 98022 910715805 HEALTHCARE WA 501(C)(3) 3 FHS 1 FLAGET HEALTHCARE DBA FLAGET MEMORIAL HOSPITAL 4305 NEW SHEPHERDSVILLE ROAD BARDSTOWN KY 40004 611345363 HEALTHCARE KY 501(C)(3) 3 KOH 1 FLAGET MEMORIAL HOSPITAL FOUNDATION INC 4305 NEW SHEPHERDSVILLE ROAD BARDSTOWN KY 40004 562351341 FUNDRAISING KY 501(C)(3) 11A FH 1 FRANCISCAN FOUNDATION 1717 SOUTH J STREET TACOMA WA 98405 911145592 FUNDRAISING WA 501(C)(3) 9 FHS 1 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CARE MN 501(C)(3) 3 CHI 1 LINUS OAKES INC 2700 STEWART PARKWAY ROSEBURG OR 97470 930821381 SENIOR LIVING OR 501(C)(3) 9 MMC 1 LISBON AREA HEALTH SERVICES 905 MAIN STREET LISBON ND 58054 820558836 HEALTHCARE ND 501(C)(3) 3 CHI 1 MEMORIAL HEALTH CARE SYSTEM FOUNDATION 2525 DE SALES AVENUE CHATTANOOGA TN 37404 621839548 FUNDRAISING TN 501(C)(3) 7 MHCS 1 MEMORIAL HEALTH CARE SYSTEM INC 2525 DE SALES AVENUE CHATTANOOGA TN 37404 620532345 HEALTHCARE TN 501(C)(3) 3 CHI 1 MEMORIAL HEALTH PARTNERS FOUNDATION INC 6028 SHALLOWFORD ROAD CHATTANOOGA TN 37421 030417049 HEALTHCARE TN 501(C)(3) 9 MHCS 1 MERCY AUXILIARY OF CENTRAL IOWA 1111 6TH AVENUE DES MOINES IA 50314 426076069 AUXILIARY IA 501(C)(3) 11A CHI-IA CORP 1 MERCY CLINICS INC 1111 6TH AVENUE DES MOINES IA 50314 421193699 PHYSICIAN IA 501(C)(3) 9 CHI-IA CORP 1 MERCY COLLEGE OF HEALTH SCIENCES 1111 6TH AVENUE DES MOINES IA 50314 421511682 EDUCATION IA 501(C)(3) 2 CHI-IA CORP 1 MERCY FOUNDATION OF DES MOINES IA 1111 6TH AVENUE DES MOINES IA 50314 237358794 FUNDRAISING IA 501(C)(3) 7 CHI-IA CORP 1 MERCY FOUNDATION INC 2700 STEWART PARKWAY ROSEBURG OR 97470 936088946 FUNDRAISING OR 501(C)(3) 7 MMC 1 MERCY HEALTH CARE FOUNDATION PO BOX 368 CORNING IA 50841 421461064 FUNDRAISING NE 501(C)(3) 11A AHMH 1 MERCY HEALTHCARE FOUNDATION 570 CHAUTAUQUA BOULEVARD VALLEY CITY ND 58072 450226553 FUNDRAISING ND 501(C)(3) 11A MHVC 1 MERCY HOSPITAL FOUNDATION COUNCIL BLUFFS 800 MERCY DRIVE COUNCIL BLUFFS IA 51503 421178204 FUNDRAISING IA 501(C)(3) 11A AHBMHS 1 MERCY HOSPITAL OF DEVILS LAKE 1031 EAST SEVENTH STREET DEVILS LAKE ND 58301 450227012 HEALTHCARE ND 501(C)(3) 3 CHI 1 MERCY HOSPITAL OF VALLEY CITY 570 CHAUTAUQUA BOULEVARD VALLEY CITY ND 58072 450226553 HEALTHCARE ND 501(C)(3) 3 CHI 1 MERCY LIFECARE SYSTEMS 2727 MCCLELLAND BLVD JOPLIN MO 64804 431305163 PROPERTY MGMT MO 501(C)(3) 11A SJRMC 1 MERCY MEDICAL CENTER 1301 15TH AVENUE WEST WILLISTON ND 58801 450231183 HEALTHCARE ND 501(C)(3) 3 CHI 1 MERCY MEDICAL CENTER 2700 STEWART PARKWAY ROSEBURG OR 97470 930386868 HEALTHCARE OR 501(C)(3) 3 CHI 1 MERCY MEDICAL CENTER - CENTERVILLE 1 ST JOSEPHS DRIVE CENTERVILLE IA 52544 420680308 HEALTHCARE IA 501(C)(3) 3 CHI-IA CORP 1 MERCY MEDICAL FOUNDATION 1301 15TH AVENUE WEST WILLISTON ND 58801 450381803 FUNDRAISING ND 501(C)(3) 11A MMC 1 MERCY PROFESSIONAL PRACTICE ASSOCIATES INC 1111 6TH AVENUE DES MOINES IA 50314 421470935 PHYSICIAN IA 501(C)(3) 9 CHI-IA CORP 1 MNMCH INC 220 NORTH PENNSYLVANIA COLUMBUS KS 66725 481216238 HEALTHCARE KS 501(C)(3) 3 SJRMC 1 MT ST JOSEPH INC 3060 SE STARK STREET PORTLAND OR 97214 930386870 NURSING CARE OR 501(C)(3) 9 CHI 1 NEBRASKA HEART HOSPITAL 7500 SOUTH 91ST STREET LINCOLN NE 68526 392031968 HEALTHCARE NE 501(C)(3) 3 CHI NEBRASKA 1 OAKES COMMUNITY HOSPITAL 314 SOUTH 8TH STREET OAKES ND 58474 450231675 HEALTHCARE ND 501(C)(3) 3 CHI 1 OAKES COMMUNITY HOSPITAL FOUNDATION 314 SOUTH 8TH STREET OAKES ND 58474 710966606 FUNDRAISING ND 501(C)(3) 11A OCH 1 PUEBLO STEPUP 1925 EAST ORMAN AVENUE 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MEDICAL CENTER PO BOX 9804 GRAND ISLAND NE 68802 470376601 HEALTHCARE NE 501(C)(3) 3 CHI NEBRASKA 1 SAINT FRANCIS MEDICAL CENTER FOUNDATION PO BOX 9804 GRAND ISLAND NE 68802 470630267 FUNDRAISING NE 501(C)(3) 7 SFMC 1 SAINT JOSEPH BEREA HOSPITAL FOUNDATION INC 305 ESTILL STREET BEREA KY 40403 260152877 FUNDRAISING KY 501(C)(3) 7 SJHS 1 SAINT JOSEPH HEALTH SYSTEM INC 150 N EAGLE CREEK DR LEXINGTON KY 40509 611334601 HEALTHCARE KY 501(C)(3) 3 CHI 1 SAINT JOSEPH LONDON FOUNDATION INC 310 EAST NINTH STREET LONDON KY 40741 260438748 FUNDRAISING KY 501(C)(3) 11A SJHS 1 SAINT JOSEPH MOUNT STERLING FOUNDATION INC 50 STERLING AVENUE MOUNT STERLING KY 40353 272884584 FUNDRAISING KY 501(C)(3) 7 SJHS 1 SAINT JOSEPH'S HOSPITAL FOUNDATION 30 WEST 7TH STREET DICKINSON ND 58601 363418207 FUNDRAISING ND 501(C)(3) 11A SJHHC 1 SAMARITAN BEHAVIORAL HEALTH 601 S EDWIN C MOSES BLVD DAYTON OH 45408 020633634 HEALTHCARE OH 501(C)(3) 3 SHP 1 SAMARITAN HEALTH FOUNDATION 2222 PHILADELPHIA DRIVE DAYTON OH 45406 237296923 FUNDRAISING OH 501(C)(3) 7 SHP 1 SAMARITAN HEALTH PARTNERS 2222 PHILADELPHIA DRIVE DAYTON OH 45406 311107411 HEALTHCARE OH 501(C)(3) 11A CHI 1 ST JOSEPH HEALTH MINISTRIES 1929 LINCOLN HWY E STE 150 LANCASTER PA 17602 232342997 HEALTH PA 501(C)(3) 11A CHI 1 ST ANTHONY HOSPITAL 1601 SE COURT AVENUE PENDLETON OR 97801 930391614 HEALTHCARE OR 501(C)(3) 3 CHI 1 ST ANTHONY HOSPITAL FOUNDATION 1601 SE COURT AVENUE PENDLETON OR 97801 930992727 FUNDRAISING OR 501(C)(3) 11A SA HOSPITAL 1 ST ANTHONY'S HOSPITAL ASSOCIATION 4 HOSPITAL DRIVE MORRILTON AR 72110 710245507 HEALTHCARE AR 501(C)(3) 3 SVIMC 1 ST CATHERINE HOSPITAL 401 EAST SPRUCE STREET GARDEN CITY KS 67846 480543721 HEALTHCARE KS 501(C)(3) 3 CHI 1 ST CATHERINE HOSPITAL DEVELOPMENT FOUNDATION 401 EAST SPRUCE STREET GARDEN CITY KS 67846 200598702 FUNDRAISING KS 501(C)(3) 11A SCH 1 ST DOMINIC OF ONTARIO 351 SW 9TH STREET ONTARIO OR 97914 930433692 HEALTHCARE OR 501(C)(3) 3 CHI 1 ST FRANCIS HOME 2400 ST FRANCIS DRIVE BRECKENRIDGE MN 56520 410729978 LTERM CARE MN 501(C)(3) 9 CHI 1 ST FRANCIS LIFE CARE CORPORATION 19 POCONO ROAD DENVILLE NJ 07834 222536017 ELDERLY CARE NJ 501(C)(3) 9 SCHS 1 ST FRANCIS MEDICAL CENTER 2400 ST FRANCIS DRIVE BRECKENRIDGE MN 56520 410695598 HEALTHCARE MN 501(C)(3) 3 CHI 1 ST FRANCIS OF BAKER CITY 3325 POCAHONTAS ROAD BAKER CITY OR 97814 930412495 HEALTHCARE OR 501(C)(3) 3 CHI 1 ST JOHN'S MEDICAL GROUP 2727 MCCLELLAND BLVD JOPLIN MO 64804 431882377 PHYS PRACTICE MO 501(C)(3) 9 SJRMC 1 ST JOHN'S MERCY REGIONAL FOUNDATION 2727 MCCLELLAND BLVD JOPLIN MO 64804 431308084 FUNDRAISING MO 501(C)(3) 7 SJRMC 1 ST JOHN'S REGIONAL MEDICAL CENTER 2727 MCCLELLAND BLVD JOPLIN MO 64804 440545809 HEALTHCARE MO 501(C)(3) 3 CHI 1 ST JOSEPH COMMUNITY HEALTH SERVICES 300 CENTRAL AVE SW SUITE 3000W ALBUQUERQUE NM 87102 710897107 COMMUNITY NM 501(C)(3) 11A CHI 1 ST JOSEPH HOSPITAL FOUNDATION INC 305 ESTILL STREET LEXINGTON KY 40504 611159649 FUNDRAISING KY 501(C)(3) 11A SJHS 1 ST JOSEPH MEDICAL CENTER FOUNDATION 2500 BERNVILLE ROAD PO BOX 316 READING PA 19603 232649362 FUNDRAISING PA 501(C)(3) 11A SJRHN 1 ST JOSEPH MEDICAL CENTER FOUNDATION INC 7601 OSLER DRIVE TOWSON MD 21204 521681044 FUNDRAISING MD 501(C)(3) 7 SJMC 1 ST JOSEPH MEDICAL CENTER INC 7601 OSLER DRIVE TOWSON MD 21204 520591461 HEALTHCARE MD 501(C)(3) 3 CHI 1 ST JOSEPH MEDICAL FOUNDATION INC ONE ST JOSEPH DRIVE LEXINGTON KY 40504 311539059 PHY PRACTICES KY 501(C)(3) 3 SJHS 1 ST JOSEPH MEDICAL GROUP 2500 BERNVILLE ROAD PO BOX 316 READING PA 19603 208544021 HEALTHCARE PA 501(C)(3) 9 BHC 1 ST JOSEPH PHYSICIAN ENTERPRISES 7601 OSLER DRIVE TOWSON MD 21204 521311775 PHYSICIANS MD 501(C)(3) 11A SJMC 1 ST JOSEPH REGIONAL HEALTH NETWORK 2500 BERNVILLE ROAD PO BOX 316 READING PA 19603 231352211 HEALTHCARE PA 501(C)(3) 3 CHI 1 ST JOSEPH'S AREA HEALTH SERVICES 600 PLEASANT AVENUE PARK RAPIDS MN 56470 410695603 HEALTHCARE MN 501(C)(3) 3 CHI 1 ST JOSEPH'S HOSPITAL AND HEALTH CENTER 30 WEST 7TH STREET DICKINSON ND 58601 450226429 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