2013-08-07T12:22:48-05:00 2012-12-31 911194016 Clark Nuber PS 10900 NE 4th Suite 1700 Bellevue WA 98004 990 2012-01-01 930575982 PROVIDENCE ST VINCENT MEDICAL FOUNDATION PROV 5038936460 9205 SW BARNES ROAD PORTLAND OR 97225 Eli Morgan 5038936460 2013-08-07 1 Sara Elizabeth J Hyre CPA P00235495 4254544919 2012 2016-02-24 21:20:13Z Dick Clark 9205 SW BARNES ROAD PORTLAND OR 97225 117489452 0 X www.providencefoundations.org/foundations/pages/ X 1969 OR To support Providence St. Vincent Medical Center. 27 27 0 65 0 0 5300462 5177617 0 0 10265480 7599649 333786 436908 15899728 13214174 14713626 9819909 0 0 351610 378292 0 0 374482 457151 356014 15522387 10554215 377341 2659959 140104098 151282055 8564703 9246452 131539395 142035603 X As People of Providence, we reveal God's love for all, especially the poor and vulnerable, through our compassionate service.Support the ministries of Providence St. Vincent Medical Center. 0 0 7584431 7584431 0 Funding of operations and capital at Providence St Vincent Medical Center and PH&S-Oregon. This includes $1.75 million for the Electrophysiology Lab at the Heart and Vascular Center, and $1.15 million for a linear accelerator, in addition to helping support the day-to-day operations of the St Vincent Medical Center and expenses paid on the Medical Center's behalf. 1858300 1858300 0 Nursing scholarships and loans for future nurses working at Providence. Since it began, the nursing scholarship program has helped over 400 students become nurses. 164814 164814 0 Funds to Catholic Charities for its administration of the Helping Hand fund, which provided living assistance to employees within the PH & S-Oregon corporation. 136086 136086 0 Donation to Medical Teams International $6000, Donation to Oregon Health Sciences University $130,086 for laser lab research 14748 14748 0 Donation to YMCA of Columbia-Willamette for their child care program. 61530 61530 0 Medical tuition assistance and scholarships $61,425; Childrens backpacks donated to transitional school $105 212364 212364 9819909 1 1 0 0 0 0 0 0 0 1 1 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 1 0 0 0 0 1 0 0 0 1 X 25 0 1 0 0 0 0 0 0 0 0 0 0 0 X 27 27 1 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 OR X Steve Cassell 5032154773 1235 NE 47th St 260 Portland OR 97213 X Kevin Kelly 2.00 0.00 X X 0 0 0 Paul Rosenbaum 2.00 0.00 X X 0 0 0 Chris Anderson 2.00 0.00 X X 0 0 0 Peter Brix 2.00 0.00 X X 0 0 0 Eli Morgan 2.00 0.00 X X 0 0 0 Sandy Andersen 1.00 0.00 X 0 0 0 Henry Ashforth 1.00 0.00 X 0 0 0 Tim Boyle 1.00 0.00 X 0 0 0 Andy Bryant 1.00 0.00 X 0 0 0 Nancy Bryant 1.00 0.00 X 0 0 0 Chris Corrado 1.00 0.00 X 0 0 0 Gregory Goodman 1.00 0.00 X 0 0 0 Ed Jensen 1.00 0.00 X 0 0 0 Lynn Johnson 1.00 0.00 X 0 0 0 Pat Karamanos 1.00 0.00 X 0 0 0 Bruce Korter 1.00 0.00 X 0 0 0 Stefan Kurschner 1.00 0.00 X 0 0 0 Paul Linnman 1.00 0.00 X 0 0 0 William McCormick 1.00 0.00 X 0 0 0 John Miner 1.00 0.00 X 0 0 0 Susan Paulsell 1.00 0.00 X 0 0 0 Norma Paulus 1.00 0.00 X 0 0 0 Steve Plambeck 1.00 0.00 X 0 0 0 Steve Shepard 1.00 0.00 X 0 0 0 Don Vollum 1.00 0.00 X 0 0 0 Fredrick Waller MD 1.00 0.00 X 0 0 0 Don Washburn 1.00 0.00 X 0 0 0 Dick Clark 45.00 0.00 X 0 157115 30684 0 157115 30684 0 0 1 0 0 1202 696977 4479438 948170 5177617 371919 371919 95681 0 95681 95681 95681 110927104 103699374 7227730 7227730 7227730 917131 575904 341227 341227 13214174 0 0 8036557 9819484 9819484 425 425 168865 50660 118205 119405 35821 83584 90022 27006 63016 673 673 220401 220401 6692 2008 4684 51100 51100 45001 13860 31141 1147 344 803 23697 7109 16588 Donor Recognition 3630 3630 Miscellaneous 1500 450 1050 State of OR Annual Fee 1200 1200 Dues & Subscriptions 973 292 681 10554215 9819909 359824 374482 1460929 1554153 2248172 1717581 5527596 5282429 48496 74175 45081 3565664 45081 119719586 131716908 7533655 10891728 140104098 151282055 17100 79488 2561202 2693147 5986401 6473817 8564703 9246452 X 96942137 109661728 23580841 21354416 11016417 11019459 131539395 142035603 140104098 151282055 X 2659959 8152183 -315934 X X 0 1 X 1 0 X 6848030 9236104 7586764 5300462 5177617 34148977 6848030 9236104 7586764 5300462 5177617 34148977 2806076 31342901 632186 524064 527512 350343 467600 2501705 36650682 3841350 0.85520 0.81120 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 12964166 22120 1827274 461181 14352379 13557000 217345 -372498 437681 12964166 12178000 6000 1691000 318000 13557000 11098000 15000 1217000 152000 12178000 10863000 241000 -1000 5000 11098000 0.00000 0.77000 0.23000 0 0 25410 25410 19671 19671 45081 Cash Surrender Value - Life Insurance 137821 Artwork and Paintings 264878 Cemetery Plots 3600 Gift Annuities & Trusts 10422882 Due from Affiliates 62547 10891728 Gift Annuity and Trust Liabilities 4766879 Due to Affiliates 1706938 6473817 X Description of Intended Use of Endowment Funds: Part V, Line 4: The endowment funds provide for medical research, patient care and capital needs of Providence St Vincent Medical Center. 2012 funds were used for internal medicine medical education, medical ethics, and Camp Erin, which provides support for grieving children. Description of Uncertain Tax Positions Under FIN 48: Part X, Line 2: Accounting principles generally accepted in the United States of America require the Foundations' management to evaluate tax positions taken by the Foundations and recognize a tax liability (or asset) if the Foundation has taken an uncertain position that more likely than not would not be sustained upon examination by the IRS. Management has analyzed tax positions taken by the Foundations and has concluded that as of December 31, 2012, there are no uncertain positions taken or expected to be taken that would require recognition of a liability (or asset) or disclosure in the combined financial statements. 1 PH&S-OR dba Providence St Vincent Medical Center 9205 SW Barnes Rd Portland OR 97225 930575982 501 (c)(3) 6086910 Operational & Capital Support PH&S-OR dba Providence Shared Services PO Box 13993 Portland OR 97213 930823489 501 (c)(3) 1497521 Operational Support University of Portland 5000 N Willamette Blvd Portland OR 97203 930401259 501 (c)(3) 1909300 Nursing Loans Catholic Charities 231 SE 12th Ave Portland OR 97214 930386801 501 (c)(3) 164814 Employee Assistance Funds Medical Teams International PO Box 10 Portland OR 97207 930878944 501 (c)(3) 6000 Disaster Relief YMCA of Columbia - Willamette 955 SW Barbur Blvd 240 Portland OR 97219 930386981 501 (c)(3) 14748 Community Child Care Oregon Health & Science University 0690 SW Bancroft Portland OR 97239 931176109 501 (c)(3) 132086 Research $130,086, Scholarship $2,000 Northwestern University 1801 Hinman Evanston IL 60208 362167817 501 (c)(3) 5000 Scholarships 8 0 Procedure for Monitoring Grants in the U.S.: Part I, Line 2: Schedule I, Part I, Line 2: As most grants go to an affiliated company, the Foundation has access to the Financial reports of Providence St. Vincent Medical Center and can review these records for appropriate use of funds. Providence's regional nursing manager works with all educational institutions to monitor the nursing education funds provided to each school. The Foundation has worked closely with Catholic Charities in establishing an Employee Assistance Program. Financial records are provided as requested by the Foundation. 0 0 0 0 0 0 0 0 0 Dick Clark 0 152550 0 4565 0 0 0 11749 0 18935 0 187799 0 0 Supplemental Information Part III FORM 990, SCHEDULE J, PART II - EXECUTIVE PERFORMANCE AWARDS PROGRAM The Providence Executive Performance Awards Program provides a lump sum award annually as a percent of the executive's base pay. Percent opportunities are aligned with our total compensation philosophy as outlined in Part VI, Section B, Line 15 (Process for determining compensation of top management, officers & key employees). The performance award is based on the level of accomplishment of annual system objectives and personal objectives. In 2012, 50 percent of the participant awards were based on pre-determined organizational goals consistent with Providence's five strategic priorities of: mission driven, financially responsible, people centered, service oriented and quality focused. In 2012 the percent allocation for each of these strategic priorities was: Mission driven 10% Financially responsible 10% People centered 10% Service oriented 10% Quality focused 10%. To ensure affordability of the program, the organization (system, region or entity) must meet a threshold of 50 percent of budgeted net operating income. X 28 948170 Average High/Low 0 0 1 0 Method for Determining Number of Contributors: Part I, Column (b): The amounts shown on Part I, Col. B reflect the number of donations received of the specific type of item. Form 990, Part VI, Section A, line 2 Andy Bryant and Nancy Bryant have a family relationship. Form 990, Part VI, Section A, line 6 The Corporate Member of the Foundation is Providence Health & Services - Oregon, a not-for-profit corporation. Form 990, Part VI, Section A, line 7a The Corporate Member has the power to approve the number of Directors, appoint the Board of Directors of the Foundation and remove such Directors at any time with or without cause. Form 990, Part VI, Section A, line 7b The following powers are reserved exclusively to the Corporate Member: * Adopt and amend the Articles of Incorporation and the Bylaws of the Foundation after consultation with the Foundation's Board of Directors. * Approve the merger, consolidation, or affiliation of the Foundation with another corporation, organization or program, or the dissolution of the Foundation. * Approve any strategic plan of the Foundation. * Approve the annual fundraising plan including special events, annual, capital and planned giving activities. * Approve the acceptance of any gift that carries conditions or limitations or any gift restricted to services, programs or facilities not currently offered or approved to be offered by the Corporate Member's Board. * Develop and implement investment policies and/or guidelines that will be used by the Foundation in determining appropriate investments. Form 990, Part VI, Section B, line 11 The Form 990 is prepared internally by experienced staff and reviewed by the internal Director of Taxes and external tax advisors. The Foundation Director and signing Board Officer will review the Form 990 in detail. Once approved, an electronic copy of the Form 990 is emailed to the Board prior to filing with the IRS. Form 990, Part VI, Section B, line 12c Providence Health & Services maintains a conflict of interest policy that applies to board members and management of all Providence-related organizations. The purpose of the policy is to guide and direct those serving the Providence Health & Services' corporations and other legal entities so they can (1) fulfill their fiduciary responsibilities and exercise stewardship in ways that promote and protect the best interests of Providence and, (2) avoid situations that create a conflict, or the appearance of a conflict, between the interests of an individual associated with Providence and Providence. On an annual basis, each board member and management level employee must complete and submit an updated conflict of interest statement. Conflict of interest disclosures are reviewed by the System Integrity Department working in conjunction with the Department of Legal Affairs. If it is determined that an actual conflict exists, appropriate follow-up action is taken with the individual to rectify the conflict. Form 990, Part VI, Section B, line 15 It is Providence's intention to make financial information accessible and transparent. Although the filing of Form 990 provides insight into how Providence achieves its Mission, delivers its programs and stewards its finances, deciphering the information directly from Form 990 can be challenging. The following paragraphs provide further information about the process we use to determine compensation for top management, officers and key employees. Providence has a single fiduciary Board, with responsibility for financial oversight associated with fulfillment of the Providence Mission, developing system policies, protecting the assets entrusted to the organization and overseeing the strategic and operational affairs of Providence's legal entities. Providence also maintains a network of community ministry boards with responsibility for quality of care oversight, community relations, advocacy and community needs assessments. Providence has a consistent compensation philosophy for all of its employees, including our senior executives. Salaries for senior executives are determined by the Providence Board's Human Resources Committee and approved by the full Board of Directors, none of whom is a Providence employee. The Board retains an independent consultant each year to review salaries of those in the most significant leadership roles in the organization. Part of the consultants role is to review an extensive array of compensation surveys of large, not-for-profit health care systems in the United States. Providence is one of the larger health systems in the country, and as such, the Board benchmarks executive compensation against other large, not-for-profit health systems whose revenue is similar to that of Providence. Base salaries for Providence executives are set at the median level of the market, as identified by the independent consultant and reviewed with the Human Resources Committee. Performance incentives allow executives to earn additional compensation if they achieve specific organizational and individual goals for furthering Providence operating principles - advancing the Providence Mission and core values, meeting benchmarks for charity care, achieving quality targets, delivering top-rated customer satisfaction, meeting employee satisfaction goals and reaching financial performance objectives. The Board of Directors conducts a thorough process to ensure performance incentives are aligned with appropriate practices for not-for-profit health care systems. The Board's process for executive compensation fully complies with IRS standards and mirrors the best practices recommended in the "Report to Congress and the Nonprofit Sector on Governance, Transparency, and Accountability" submitted to the Senate Finance Committee by the Panel on the Nonprofit Sector. The Foundation Executive Director is compensated by a related organization which uses a market based compensation program utilizing several independent third party compensation market surveys to establish pay ranges for the position. The related organization then establishes the individual rate of pay within the range based on relevant experience, skills and competencies. The rate offered to the Executive Director at the time of hire was determined through discussion between the Regional CEO, Regional Director of HR and the Administrative Director of HR. The ranges and rate of pay are reviewed on an annual basis by Regional HR. Form 990, Part VI, Section C, line 19 Public disclosure of governing documents, conflict of interest policy and 990 filings are made available to the public upon written request. The consolidated Health System financial statements, including the Foundation, are available on our public Internet site www2.providence.org. All governing policies including the conflict of interest policy, as well as 990 filings are available to employees on the Intranet site. Changes in Net Assets or Fund Balances: Form 990, Part XI, line 9: Net Asset Transfer to Affiliate -315,933. Rounding -1. EMPLOYEE COMPENSATION Form 990, PART I, LINE 5 & Part V, Line 2a The employees working at the Foundation are paid by Providence Health & Services - Oregon EIN# 51-0216587. Therefore, no W-2s are issued by the reporting organization. VOLUNTEERS FORM 990, PART I, LINE 6 Volunteers assist in the gift shop with cashiering, assisting customers, and delivering flowers to patient rooms. AUDIT & COMPLIANCE Form 990, PART XII, LINE 2c The Providence Health & Services Audit and Compliance Committee assists the Board of Directors with the oversight of the integrity of the financial statements and reporting, the audit process and the internal financial controls and policies; compliance with ethical, legal and regulatory standards and requirements; the independence, qualifications and performance of the internal and external auditors; the investment committee; and informs the Board of Directors of critical risk areas and recommended mitigation. AFFILIATION AGREEMENT FORM 990, SCHEDULE R - RELATED ORGANIZATIONS On February 1, 2012, Providence Health & Services (the Health System) and Swedish Health Services (Swedish) effected an affiliation Agreement, which integrated the operations of the two health systems. The Health System and Swedish have affiliated to create a fully integrated, nonprofit, charitable health care system serving the communities throughout Western Washington. No cash or other purchase consideration was transferred to effect the affiliation. PSV Properties LLC 9205 SW Barnes Road Portland OR 97225 Real Estate OR 0 700000 Providence St Vincent Medical Foundation Providence Health & Services - Washington 1801 Lind Avenue SW 9016 Renton WA 980579016 510216586 Healthcare System WA 501( c)(3) Line 3 Providence Health & Services 0 Providence Health & Services - Oregon 1801 Lind Avenue SW 9016 Renton WA 980579016 510216587 Healthcare System OR 501( c)(3) Line 3 Providence Health & Services 0 Providence Health System - So California 1801 Lind Avenue SW 9016 Renton WA 980579016 510216589 Healthcare System CA 501( c)(3) Line 3 Providence Health & Services 0 Everett Transitional Care Services PO Box 5128 Everett WA 982065128 943264605 Transitional Care WA 501( c)(3) Line 9 N/A 0 Providence Oregon Management Corporation 1801 Lind Avenue SW 9016 Renton WA 980579016 930813977 Shell Corporation OR 501( c)(3) Line 1 PH & S - Oregon 0 Providence Plan Partners 4400 NE Halsey Bldg 2 Portland OR 97213 911861964 Healthcare Services OR 501( c)(4) N/A PH & S - Oregon 0 Providence Health Plan 4400 NE Halsey Bldg 2 Portland OR 97213 930863097 Health Service Contractor OR 501( c)(4) N/A Providence Plan Partners 0 Providence Health Assurance 4400 NE Halsey Bldg 2 Portland OR 97213 550828701 Medicaid Healthcare Provider OR 501( c)(4) N/A Providence Health Plan 0 Providence Medical Institute 4101 Torrance Blvd Torrance CA 90503 330283773 Healthcare CA 501( c)(3) Line 11/Type I PHS - So California 0 Little Company of Mary Ancillary Services Corporation 4101 Torrance Blvd Torrance CA 90503 330844408 Imaging Services CA 501( c)(3) Line 9 PHS - So California 0 Providence TrinityCare Hospice 5315 Torrance Blvd Suite B1 Torrance CA 90503 953264139 Hospice CA 501( c)(3) Line 9 PHS - So California 0 Providence Blanchet Association 1700 Providence Pl Centralia WA 98531 911789266 Housing WA 501( c)(3) Line 7 PH & S - Washington 0 St Luke Association 350 Washington Ave SE Chehalis WA 98352 943176618 Housing WA 501( c)(3) Line 7 PH & S - Washington 0 Providence Rossi Association 1700 Providence Pl Centralia WA 98531 311584166 Housing WA 501( c)(3) Line 9 PH & S - 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So California 0 Gamelin Washington Association 1423 First Avenue Seattle WA 98101 201910170 Housing WA 501( c)(3) Line 7 PH & S - Washington 0 Providence Foundation 1801 Lind Avenue SW 9016 Renton WA 980579016 943078543 Support PH&S Institutions WA 501( c)(3) Line 11/Type I PH & S - Washington 0 Providence Alaska Foundation 3300 Providence Drive - B Tower2 Anchorage AK 99508 920093565 Support PHS-Alaska AK 501( c)(3) Line 11/Type I PH & S - Washington 0 Providence St Peter Foundation 413 Lilly Road NE Olympia WA 985065166 911097056 Support Affiliated Tax-Exempt Organization WA 501( c)(3) Line 7 PH & S - Washington 0 Providence Health Care Foundation (Centralia) 914 S Scheuber Road Centralia WA 98531 911433382 Support Providence Centralia Hospital WA 501( c)(3) Line 7 PH & S - Washington 0 Providence Mount St Vincent Foundation 4831 - 35th Avenue SW Seattle WA 981262799 911188119 Support Providence Mount St.Vincent WA 501( c)(3) Line 7 PH & S - Washington 0 Providence Marianwood Foundation 3725 Providence Point Drive SE Issaquah WA 980297219 931554288 Support Providence Marianwood WA 501( c)(3) Line 11/Type I PH & S - 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Ministries in E. WA. WA 501( c)(3) Line 7 PH & S - Washington 0 St Patrick Hospital Foundation 500 West Broadway PO Box 4587 Missoula MT 598064587 237056976 Support Healthcare in W. 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Diagnostics OR N/A Ctr for MedImaging-Tanasbourne LLC 1235 NE 47th Ave Portland OR 97213 200477972 Imaging - Diagnostics OR N/A Portland Medical Imaging LLC 10538 SE Washington St Portland OR 97216 201054971 Imaging - Diagnostics OR N/A Oregon Advanced Imaging LLC 881 OHare Parkway Medford OR 97504 450471748 Medical Imaging OR N/A Minor & James Medical PLLC 515 Minor Avenue 200 Seattle WA 98104 911340223 Physician Clinic WA N/A Clackamas Radiation Oncology Center LLC 1235 NE 47th Ave 288 Portland OR 97213 260381897 Radiation Oncology OR N/A PETCT Imaging at Swedish Cancer Institute LLC 1221 Madison Street Seattle WA 98104 203132044 Medical Imaging WA N/A Mountainstar Clinical Laboratories LLC 611 N Perry Spokane WA 99202 261345983 Outpatient Lab MT N/A PacLab LLC 611 N Perry Spokane WA 99202 911743952 Outpatient Lab WA N/A Center for Specialty Surgery LLC 11782 SW Barnes Rd Portland OR 97225 263638838 Ambulatory Surgery Center OR N/A Oregon Outpatient Surgery Center 7300 SW Childs Rd Tigard OR 97224 223883387 Ambulatory Surgery Center OR N/A ProvidenceUSP Santa Clarita GP LLC 11550 Indian Hills Road 160 Mission Hills CA 91345 202829660 Ambulatory Surgery Center CA N/A ProvidenceUSP Surgery Ctrs LLC 11550 Indian Hills Road 160 Mission Hills CA 91345 200905938 Ambulatory Surgery Center CA N/A Alpha Medical Laboratory LLC 611 N Perry Spokane WA 99202 912017347 Outpatient Lab ID N/A Canby Medical Center I LLC 2747 Pence Loop SE Salem OR 97302 205470937 Real Estate - 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