2013-08-15T12:19:52-05:00 2012-12-31 911194016 Clark Nuber PS 10900 NE 4th Suite 1700 Bellevue WA 98004 990 2012-01-01 330844408 LITTLE COMPANY OF MARY ANCILLARY SERVICES CORPORATION LITT 8188473021 4101 TORRANCE BLVD TORRANCE CA 90503 Todd Hofheins 4255253985 2013-08-15 1 Sara Elizabeth J Hyre CPA P00235495 4254544919 2012 2016-02-24 21:20:13Z Elizabeth Zuanich 4101 TORRANCE BLVD TORRANCE CA 90503 5244286 0 X http://www2.providence.org/torrance/services/ X 1999 CA Outpatient Diagnostic Imaging Services. 16 16 0 0 0 0 0 0 5222090 4934205 863 551 262599 309530 5485552 5244286 0 0 0 0 2075575 1884813 0 0 0 3154762 3381544 5230337 5266357 255215 -22071 17688772 18387250 6957689 7807589 10731083 10579661 X As People of Providence, we reveal God's love for all, especially the poor and vulnerable, through our compassionate service.Outpatient Diagnostic Imaging Services. 0 0 4525564 0 4934205 LCMASC provides imaging services on an outpatient basis. Imaging services include bone density testing, mammograms, CT scans, MRI scans, and ultrasounds. Performed 29,945 diagnostic images during 2012.Providence Health System - Southern California, a non-profit public benefit corporation, is organized and operated exclusively for charitable purposes and, through its division Little Company of Mary Health Services (LCMHS) is the sole member of Little Company of Mary Ancillary Services Corporation (LCMASC). LCMHS has a mission statement dedicated to providing care to the people living within its service area. The Mission Statement is:"The mission of Little Company of Mary Health Services and its affiliates is a part of the larger mission of the Sisters of Little Company of Mary to make visible the healing presence of Jesus. Our mission embraces the care of the sick and dying through the Catholic health ministry and meeting the health needs of our community."The significance of this mission can be expressed as commitments to respect for the individual, quality of care, education for professionals and the community, and outreach to those in need. LCMASC will not turn away a patient because of inability to pay.LCMASC provides outpatient diagnostic imaging services and participates in the following charitable services, community benefit programs, community education programs and outreach programs:Mary Potter Program for Human Dignity - LCMASC provides charity care for those persons in need of financial assistance. Persons who are unable to pay for services receive their imaging/healthcare services for either no cost or at a reduced cost. Referrals for charitable services are received from referring physicians, from the radiologists, from the patients themselves, from the hospitals, etc.Cancer Education Programs - LCMASC and LCMHS provide numerous cancer education awareness, prevention and screening programs. These programs cover breast cancer, colon cancer, skin cancer, prostate cancer, lung cancer, brain cancer, etc. The programs address a better understanding and awareness of cancer, early detection, screening, diet, self-examinations, as well as other topics.Cancer Research - LCMASC participates with the Western Clinical Research lab to assist with the UCLA cancer research program. Bone scans, chest x-rays, CT scans and MRIs on cancer patients are performed at reduced costs.Tumor Registry - LCMASC, together with Little Company of Mary Hospital (LCMH) maintains a tumor registry program. All patients with cancer diagnosis are registered for long-term follow-up.Resource Library - LCMASC, together with LCMH, maintains a resource library where patients may obtain a great variety of information on specific cancer issues.As an affiliate of Providence Health & Services, LCMASC adheres to the System's policy of providing care to all persons who are ill regardless of their ability to pay. LCMASC also has a policy of providing community services through a variety of health related programs. 4525564 1 0 0 0 0 0 0 0 0 0 1 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 X 0 0 0 0 0 0 0 0 0 0 0 0 0 X 16 16 0 0 0 0 1 1 1 1 1 1 0 1 1 1 1 1 1 1 1 0 CA X Karl E Fritschel CPA 4255253339 1801 Lind Ave SW 9016 Renton WA 98057 X Lucille Dean SP 0.20 12.90 X X 0 0 0 M Adrian Davis LCM -Dcd 512 0.20 2.70 X 0 0 0 Mary Corita Heid RSM 0.20 5.40 X 0 0 0 Michael A Stein 0.20 6.10 X 0 18300 0 Michael Holcomb 0.20 7.50 X 0 19050 0 Dana A Rasmussen 0.20 5.80 X 0 18300 0 James S Roberts MD 0.20 8.90 X 0 20500 0 Peter J Snow 0.20 5.60 X 0 20500 0 Jeffrey B Clode MD -Thru 612 0.20 6.90 X 0 8750 0 Sallye Liner 0.20 4.00 X 0 15300 0 Owen B Robinson 0.20 5.30 X 0 15300 0 Cheryl M Scott 0.20 4.50 X 0 15000 0 Ellen L Wolf 0.20 7.60 X 0 15300 0 Isiaah Crawford 0.20 4.00 X 0 15000 0 Martha Diaz Aszkenazy 0.20 7.60 X 0 15175 0 Kirby McDonald 0.20 4.50 X 0 15175 0 Dave Olsen 0.20 5.40 X 0 15175 0 Charles Chuck Watts 0.20 6.00 X 0 15175 0 John Nordstrom -Thru 712 0.20 0.50 X 0 0 0 John F Koster MD 0.20 53.80 X 0 4069812 382715 Jeffrey W Rogers 0.20 49.80 X 0 623631 319793 Todd Hofheins 0.20 59.80 X 0 555725 40426 Michael L Butler 0.00 65.00 X 0 1406031 890844 Rod Hochman MD 0.00 65.00 X 0 1438710 332177 Gregory Van Pelt 0.00 60.00 X 0 1193691 434439 Arnold R Schaffer 0.00 60.00 X 0 1938273 209541 John V Fletcher 0.00 55.00 X 0 1575373 259253 Janice J Jones 0.00 55.00 X 0 1031256 204051 Myron Berdischewsky MD 0.00 60.00 X 0 2359308 166605 Michael Hunn 0.00 60.00 X 0 893036 67267 Cindra R Syverson 0.00 60.00 X 0 562260 220668 Terry L Smith 0.00 60.00 X 0 1012414 349119 Craig L Wright MD 0.00 60.00 X 0 773915 392058 Bruce Lamoureux 0.00 60.00 X 0 1519795 89010 Michael Wilson 0.00 55.00 X 0 794997 917 Ray Williams 0.00 55.00 X 0 1240435 162999 Kevin Brown 0.00 60.00 X 0 769772 154103 Jack Friedman 0.00 52.00 X 0 679882 227031 Cindy Strauss 0.00 55.00 X 0 621810 205922 Phil Jackson 0.00 55.00 X 0 609104 157689 David T Brooks 0.00 60.00 X 0 607017 245535 Medrice Coluccio 0.00 60.00 X 0 577022 433005 Eugene Al Parrish 0.00 0.00 X 0 485519 57205 John Kenagy 0.00 0.00 X 0 858674 14815 0 28439462 6017187 0 1 1 0 Advanced Imaging of South Bay 21143 Hawthorne Blvd 327 Torrance CA 90503 Diagnostic Imaging Service 1523820 GE Healthcare 101 Carnegie Center Princeton NJ 085406231 Equip Repair/Maintenance 188125 2 Primary Care 621500 4934205 4934205 4934205 551 551 107765 0 107765 107765 107765 Cost Recovery 900099 201765 201765 201765 5244286 4934205 0 310081 X 1756520 1673438 83082 500 500 127793 121822 5971 1033901 910020 123881 759 759 22278 10618 11660 5352 1571 3781 161684 123042 38642 4 4 1310202 997064 313138 612828 466362 146466 Medical Supplies 169360 169360 Non-Medical Supplies 41830 29236 12594 Licensing/Taxes 23346 21768 1578 5266357 4525564 740793 0 56252 25534 807764 1010313 23158 22500 19875 7911 16417080 13128200 5226802 3288880 11554921 14032112 17688772 18387250 364169 247484 6593520 7560105 6957689 7807589 X 10731083 10579661 10731083 10579661 17688772 18387250 X -22071 -129351 X X 0 1 X 1 1 1 X 5903907 6039494 6166387 5226237 4934205 28270230 145891 161219 131628 206124 201765 846627 6049798 6200713 6298015 5432361 5135970 29116857 0 0 0 29116857 52211 56668 54341 54054 108316 325590 52211 56668 54341 54054 108316 325590 6102009 6257381 6352356 5486415 5244286 29442447 0.98890 0.99070 0.01110 0.00930 X 1390000 1390000 3867981 2380051 1487930 372061 372061 0 10787038 10376088 410950 3288880 Due from Affiliates 14003713 Miscellaneous Receivables 28399 14032112 Due to Affiliates 7560105 7560105 X Description of Uncertain Tax Positions Under FIN 48: Part X, Line 2: The Health System recognizes the effect of income tax positions only if those positions are more likely than not of being sustained. Recognized income tax positions are measured at the largest amount that is greater than 50% likely of being realized. Changes in recognition or measurement are reflected in the period in which the change in judgment occurs. 1 1 0 0 0 0 0 0 0 John F Koster MD 0 1257618 0 2794425 0 17769 0 353700 0 29015 0 4452527 0 339126 Jeffrey W Rogers 0 444646 0 178408 0 577 0 300735 0 19058 0 943424 0 48099 Todd Hofheins 0 362360 0 175788 0 17577 0 18701 0 21725 0 596151 0 0 Michael L Butler 0 873495 0 516168 0 16368 0 863387 0 27457 0 2296875 0 435962 Rod Hochman MD 0 986310 0 250000 0 202400 0 307076 0 25101 0 1770887 0 0 Gregory Van Pelt 0 717021 0 458901 0 17769 0 411729 0 22710 0 1628130 0 292233 Arnold R Schaffer 0 741165 0 1189129 0 7979 0 185872 0 23669 0 2147814 0 630732 John V Fletcher 0 547460 0 1010144 0 17769 0 238549 0 20704 0 1834626 0 388497 Janice J Jones 0 593458 0 370591 0 67207 0 180325 0 23726 0 1235307 0 154703 Myron Berdischewsky MD 0 496463 0 1828076 0 34769 0 142532 0 24073 0 2525913 0 404844 Michael Hunn 0 511618 0 363649 0 17769 0 48572 0 18695 0 960303 0 216958 Cindra R Syverson 0 396975 0 164708 0 577 0 197231 0 23437 0 782928 0 130173 Terry L Smith 0 620095 0 326004 0 66315 0 326854 0 22265 0 1361533 0 69195 Craig L Wright MD 0 482963 0 290375 0 577 0 368118 0 23940 0 1165973 0 199302 Bruce Lamoureux 0 485693 0 1016299 0 17803 0 66061 0 22949 0 1608805 0 166650 Michael Wilson 0 794997 0 0 0 0 0 917 0 0 0 795914 0 0 Ray Williams 0 491804 0 452500 0 296131 0 137253 0 25746 0 1403434 0 0 Kevin Brown 0 460080 0 225000 0 84692 0 129502 0 24601 0 923875 0 0 Jack Friedman 0 464884 0 197421 0 17577 0 201491 0 25540 0 906913 0 50985 Cindy Strauss 0 376810 0 180000 0 65000 0 173813 0 32109 0 827732 0 0 Phil Jackson 0 393919 0 165118 0 50067 0 134924 0 22765 0 766793 0 0 David T Brooks 0 424982 0 181458 0 577 0 225451 0 20084 0 852552 0 149660 Medrice Coluccio 0 417956 0 141489 0 17577 0 419464 0 13541 0 1010027 0 344898 Eugene Al Parrish 0 83787 0 399842 0 1890 0 49393 0 7812 0 542724 0 56382 John Kenagy 0 75228 0 518535 0 264911 0 8047 0 6768 0 873489 0 115387 Part I, Line 1a The reporting organization did not provide any of the benefits listed in Part I, Line 1a. However, as part of Providence's philosophy of transparency, the narrative that follows relates to the compensation and benefits provided by the related organization. Providence Health & Services Expense Reimbursement Procedures include the following policies: First Class Travel or Charter Travel or Travel of Companions Air travel is reimbursable for tourist or economy class and should be at the least expensive airfare; which permits departures and arrivals at reasonable times and reasonable distance traveled. Employees are encouraged to plan in advance to get available discounts. Airline frequent flyer upgrades will never be reimbursed. First class air travel will only be reimbursed when tourist or economy class air travel is not available and business travel is mandated by a supervisor. In the rare circumstance that an executive must fly on a first class full fare ticket, their senior level supervisor must approve this expense. Companion travel will only be reimbursed by the organization for travel related to relocation, and should not exceed two relocation-related visits, unless approval by the SVP/Chief Human Resources Officer. During 2012, a total of one first-class ticket was purchased for disclosed personnel. Tax Indemnifications or Gross-Up Payments Providence Health & Services follows the federal and state taxation laws related to relocation expenses paid to the employee or to a third party on the employee's behalf. They are considered income and are therefore subject to payroll taxes. Based on the way Providence has chosen to pay the relocation expenses, Providence reports reimbursements and payments to vendors as income and these expense payments are reflected on the executive's Form W-2. Providence will gross-up the relocation benefits to offset the personal tax burden to the employee for IRS allowable expenses. During 2012, the following Key Employees received gross-up payments: Arnold R. Schaffer - Relocation Phil Jackson - Relocation Bruce Lamoureux - Gift Card The amounts reported for these gross-up payments are included on Schedule J, Part II, Column B (iii) - Other Reportable Compensation. Discretionary Spending Account Providence Health & Services provides an executive flex spending allowance per year (paid bi-weekly). This benefit is provided as discretionary spending because the organization does not reimburse for or provide additional executive benefits, such as a car allowance, additional executive life or disability insurance, or other market-based executive benefits practices. This benefit was discontinued for Calendar Year 2012. Housing Allowance or Residence for Personal Use Providence Health & Services provides housing allowances for purposes of relocation assistance only. Providence may pay temporary living expenses for the employee up to a maximum of 90 calendar days. Covered expenses are rent (excluding "rent" which may be paid in order to occupy a new permanent residence until the title clears) and utilities, including heat, electricity, gas, water, local internet and local telephone and garbage services. The SVP/Chief Human Resources Officer may approve temporary housing assistance for up to six months when family relocation is delayed to accommodate the school year or equivalent circumstances. Only in extenuating circumstances is housing extended beyond this six month period. During 2012, the following Key Employees received relocation/housing program payments: Arnold R. Schaffer Phil Jackson Terry L. Smith Ray Williams The amounts reported for these relocation payments are included on Schedule J, Part II, Column B (iii) - Other Reportable Compensation. Part I, Lines 4a-b NONQUALIFIED RETIREMENT PLANS A) SERP = Supplemental Executive Retirement Plan B) CBRP = Cash Balance Restoration Plan C) ESP = Elective Survivor Plan D) SOP = Share Option Plan E) NQ = Non-Qualified 409(a) Payout 1) John F. Koster, MD a) Taxable SERP Earned but not Paid- $1,872,867 b) SERP Interest Credit - $327,363 2) Jeffrey W. Rogers a) Taxable SERP Earned but not Paid - $44,273 b) ESP Interest Credit - $87,150 c) SERP Interest Credit - $136,048 3) Michael L. Butler a) SERP Interest Credit - $301,732 b) SERP Earned but not Vested - $527,516 4) Rod Hochman, MD a) NQ - $202,400 b) SERP Earned but not Vested - $284,676 5) Gregory Van Pelt a) Taxable SERP Earned but not Paid - $183,330 b) ESP Interest Credit - $96,202 c) SERP Interest Credit - $240,115 6) Arnold R. Schaffer a) Taxable SERP Earned but not Paid - $819,315 b) SERP Interest Credit - $157,753 7) John V. Fletcher a) Taxable SERP Earned but not Paid - $511,574 b) Taxable CBRP Earned but not Paid - $5,997 c) ESP Interest Credit - $50,355 d) SERP Interest Credit - $122,030 8) Janice J. Jones a) Taxable SERP Earned but not Paid - $147,676 b) Taxable CBRP Earned but not Paid - $264 c) Non-Taxable SERP Earned - $1 d) SERP Interest Credit - $144,057 9) Myron Berdischewsky, MD a) Taxable SERP Earned but not Paid - $1,522,140 b) Non-Taxable SERP Earned - $43,658 c) SERP Interest Credit - $82,406 10) Michael Hunn a) Taxable SERP Earned but not Paid - $222,462 b) SERP Interest Credit - $44,426 11) Cindra R. Syverson a) SERP Interest Credit - $33,544 b) SERP Earned but not Vested - $148,036 12) Terry L. Smith a) Taxable SERP Earned but not Paid - $68,857 b) Taxable CBRP Earned but not Paid - $673 c) ESP Interest Credit - $67,068 d) SERP Interest Credit - $164,038 13) Craig L. Wright, MD a) SERP Interest Credit - $95,974 b) SERP Earned but not Vested - $241,654 14) Bruce Lamoureux a) Taxable SERP Earned but not Paid - $895,277 b) Taxable CBRP Earned but not Paid - $970 c) Non-Taxable SERP Earned - $1 d) SERP Interest Credit - $47,391 15) Ray Williams a) SERP Earned but not Vested - $119,753 16) Kevin Brown a) NQ - $60,000 b) SERP Earned but not Vested - $114,573 17) Jack Friedman a) Taxable SERP Earned but not Paid - $47,618 b) SERP Interest Credit - $144,595 18) Cindy Strauss a) NQ - $48,000 b) SERP Earned but not Vested - $161,294 19) Phil Jackson a) SERP Interest Credit - $9,748 b) SERP Earned but not Vested - $85,986 20) David T. Brooks a) SERP Interest Credit - $44,009 b) SERP Earned but not Vested - $161,703 21) Medrice Coluccio a) SERP Interest Credit - $55,860 b) SERP Earned but not Vested - $341,617 22) Eugene "Al" Parrish a) Taxable SERP Earned but not Paid - $293,361 b) Non-Taxable SERP Earned - $39,762 23) John Kenagy a) Taxable SERP Earned but not Paid - $417,225 Part I, Lines 4a-b SEVERANCE 1) John Kenagy - $188,084 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. Form 990, Part VI, Section A, line 6 Providence Health System - Southern California is the Corporate Member. Form 990, Part VI, Section A, line 7a The Corporate Member has the power to: 1) Fix the number of Directors and appoint the Board of Directors. 2) Remove, with or without cause, any member of the Board of Directors. 3) Appoint the Chair of the Board of Directors. Form 990, Part VI, Section A, line 7b Reserved Powers of the Corporate Member: 1) Approve the mission and philosophy. 2) Adopt, amend or repeal the Articles of Incorporation or Bylaws. 3) Remove, with or without cause, the Chair of the Board. 4) Approve the annual budget and long-term capital and operational budgets and any changes exceeding 10% of the original budget. 5) Approve the acquisition of assets, the incurrence of indebtedness or the lease, sale, transfer, assignment or encumbering of assets exceeding $50,000. 6) Approve an agreement to affiliate, merge, restructure, liquidate or dissolve this Corporation. 7) Approve the Long-Range Consolidated Strategic and Financial Integrated Plan. 8) Approve the selection of the independent accountant as defined in Section 5013 of the California Corporations Code. 9) Organize or acquire any subsidiary nonprofit or for-profit corporations and any health care joint ventures. 10) Accept a legacy or gift that imposes a permanent or continuing obligation. 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 Board of Directors reviewed the Form 990 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 Boards 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 consultant's 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. Each year, the Board Chair conducts a formal performance evaluation of the President/CEO that considers input from the other directors and senior leaders reporting to the President. The evaluation is discussed with the Human Resources Committee and then a recommendation is made by the committee to the full Board. The Board Chair and the Chair of the Human Resources Committee also meet with an independent consultant to develop a salary recommendation; which is reviewed and approved first by the committee and then by the Board of Directors. Additionally, the President/CEO utilizes the market information provided by the consultant along with formal performance evaluations, to determine salary recommendations for other senior executives. This process includes a rigorous analysis of those recommendations with the Human Resources Committee as a part of the review and approval process. 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. 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 financial statements 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. Contact Addresses for Officers, Directors, Etc Form 990, Part VII Lucille Dean, SP - 1801 Lind Avenue SW, #9016, Renton, WA 98057-9016. Mary Corita Heid, RSM - 1801 Lind Avenue SW, #9016, Renton, WA 98057-9016. Michael A. Stein - 1801 Lind Avenue SW, #9016, Renton, WA 98057-9016. Michael Holcomb - 1801 Lind Avenue SW, #9016, Renton, WA 98057-9016. Dana A. Rasmussen - 1801 Lind Avenue SW, #9016, Renton, WA 98057-9016. James S. Roberts, MD - 1801 Lind Avenue SW, #9016, Renton, WA 98057-9016. Peter J. Snow - 1801 Lind Avenue SW, #9016, Renton, WA 98057-9016. Jeffrey B. Clode, MD -Thru 6/12 - 1801 Lind Avenue SW, #9016, Renton, WA 98057-9016. Sallye Liner - 1801 Lind Avenue SW, #9016, Renton, WA 98057-9016. Owen B. Robinson - 1801 Lind Avenue SW, #9016, Renton, WA 98057-9016. Cheryl M. Scott - 1801 Lind Avenue SW, #9016, Renton, WA 98057-9016. Ellen L. Wolf - 1801 Lind Avenue SW, #9016, Renton, WA 98057-9016. Isiaah Crawford - 1801 Lind Avenue SW, #9016, Renton, WA 98057-9016. Martha Diaz Aszkenazy - 1801 Lind Avenue SW, #9016, Renton, WA 98057-9016. Kirby McDonald - 1801 Lind Avenue SW, #9016, Renton, WA 98057-9016. Dave Olsen - 1801 Lind Avenue SW, #9016, Renton, WA 98057-9016. Charles (Chuck) Watts - 1801 Lind Avenue SW, #9016, Renton, WA 98057-9016. John Nordstrom -Thru 7/12 - 1801 Lind Avenue SW, #9016, Renton, WA 98057-9016. John F. Koster, MD - 1801 Lind Avenue SW, #9016, Renton, WA 98057-9016. Jeffrey W. Rogers - 1801 Lind Avenue SW, #9016, Renton, WA 98057-9016. Todd Hofheins - 1801 Lind Avenue SW, #9016, Renton, WA 98057-9016. Michael L. Butler - 1801 Lind Avenue SW, #9016, Renton, WA 98057-9016. Rod Hochman, MD - 1801 Lind Avenue SW, #9016, Renton, WA 98057-9016. Gregory Van Pelt - 1801 Lind Avenue SW, #9016, Renton, WA 98057-9016. Arnold R. Schaffer - 1801 Lind Avenue SW, #9016, Renton, WA 98057-9016. John V. Fletcher - 1801 Lind Avenue SW, #9016, Renton, WA 98057-9016. Janice J. Jones - 1801 Lind Avenue SW, #9016, Renton, WA 98057-9016. Myron Berdischewsky, MD - 1801 Lind Avenue SW, #9016, Renton, WA 98057-9016. Michael Hunn - 1801 Lind Avenue SW, #9016, Renton, WA 98057-9016. Cindra R. Syverson - 1801 Lind Avenue SW, #9016, Renton, WA 98057-9016. Terry L. Smith - 1801 Lind Avenue SW, #9016, Renton, WA 98057-9016. Craig L. Wright, MD - 1801 Lind Avenue SW, #9016, Renton, WA 98057-9016. Bruce Lamoureux - 1801 Lind Avenue SW, #9016, Renton, WA 98057-9016. Michael Wilson - 1801 Lind Avenue SW, #9016, Renton, WA 98057-9016. Ray Williams - 1801 Lind Avenue SW, #9016, Renton, WA 98057-9016. Kevin Brown - 1801 Lind Avenue SW, #9016, Renton, WA 98057-9016. Jack Friedman - 1801 Lind Avenue SW, #9016, Renton, WA 98057-9016. Cindy Strauss - 1801 Lind Avenue SW, #9016, Renton, WA 98057-9016. Phil Jackson - 1801 Lind Avenue SW, #9016, Renton, WA 98057-9016. David T. Brooks - 1801 Lind Avenue SW, #9016, Renton, WA 98057-9016. Medrice Coluccio - 1801 Lind Avenue SW, #9016, Renton, WA 98057-9016. Eugene "Al" Parrish - 1801 Lind Avenue SW, #9016, Renton, WA 98057-9016. John Kenagy - 1801 Lind Avenue SW, #9016, Renton, WA 98057-9016. Other Fees Form 990, Part IX, line 11g Purchased Services: Program service expenses 152,317. Management and general expenses 37,249. Fundraising expenses 0. Total expenses 189,566. MRI Repairs and Calibration: Program service expenses 550,378. Management and general expenses 0. Fundraising expenses 0. Total expenses 550,378. Records Storage: Program service expenses 207,325. Management and general expenses 0. Fundraising expenses 0. Total expenses 207,325. Janitorial/Pest Control: Program service expenses 0. Management and general expenses 86,632. Fundraising expenses 0. Total expenses 86,632. Changes in Net Assets or Fund Balances: Form 990, Part XI, line 9: Net Asset Transfer to Affiliate -129,351. EMPLOYEE COMPENSATION FORM 990, PART I, LINE 5 & PART V, LINE 2A The employees working at LCMASC are paid by Providence Health System - Southern California EIN# 51-0216589. Therefore, no W-2s are issued by the reporting organization. RELIGIOUS COMMUNITY MEMBERS FORM 990, PART VII As members of the Religious Community, each Sister has taken a vow of poverty as a compulsory part of her religious life. Any compensation for services of a Sister inures only for the benefit of the Community, not the individual members. All payments for services are made directly to the Religious Community. 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 System's financial statements and reporting, the audit process and the System's internal financial controls and policies; compliance with ethical, legal and regulatory standards and requirements; the independence, qualifications and performance of the System's internal and external auditors; the System's 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. 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 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 - Washington 0 Lundberg Association 5921 E Burnside Portland OR 97215 911562797 Housing OR 501( c)(3) Line 7 PH & S - Oregon 0 Providence St Francis Association 3415 12th Avenue NE Olympia WA 98506 943244854 Housing WA 501( c)(3) Line 7 PH & S - Washington 0 Providence Peter Claver Association 7101 38th Avenue South Seattle WA 98118 311629656 Housing WA 501( c)(3) Line 7 PH & S - Washington 0 Providence St Elizabeth House Association 3201 SW Graham St Seattle WA 98126 912171539 Housing WA 501( c)(3) Line 7 PH & S - Washington 0 Providence Gamelin House Association 4515 MLK Jr Way S Ste 200 Seattle WA 98108 311744654 Housing WA 501( c)(3) Line 7 PH & S - Washington 0 The Gamelin Association 312 North Fourth St Yakima WA 98901 911180824 Housing WA 501( c)(3) Line 7 PH & S - Washington 0 The Gamelin Oregon Association 5520 NE Glisan Portland OR 97213 911214491 Housing OR 501( c)(3) Line 9 PH & S - Oregon 0 The Gamelin California Association 540 23rd St Oakland CA 94612 911293869 Housing CA 501( c)(3) Line 9 PHS - 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 - Washington 0 Providence Newberg Health Foundation 1001 Providence Drive Newberg OR 97132 930889144 Support Providence Newberg Medical Center OR 501( c)(3) Line 7 PH & S - Oregon 0 Providence Seaside Hospital Foundation 725 S Wahanna Rd Seaside OR 97138 930927320 Support Providence Seaside Hospital OR 501( c)(3) Line 7 PH & S - Oregon 0 Providence Community Health Foundation 1111 Crater Lake Ave Medford OR 97504 930692907 Support Providence Medford Medical Center OR 501( c)(3) Line 7 PH & S - Oregon 0 Providence Benedictine Nursing Center Foundation 540 South Main St Mt Angel OR 973629532 911940286 Support Providence Benedictine Nursing Center OR 501( c)(3) Line 7 PH & S - Oregon 0 Providence Portland Medical Foundation 4805 NE Glisan St Portland OR 972132967 931231494 Support Providence Portland Medical Center OR 501( c)(3) Line 7 PH & S - Oregon 0 Providence St Vincent Medical Foundation 9205 SW Barnes Rd Portland OR 97225 930575982 Support Providence St. Vincent Medical Center OR 501( c)(3) Line 7 PH & S - Oregon 0 Providence Milwaukie Foundation 10150 SE 32nd Milwaukie OR 97222 943079515 Support Providence Milwaukie Hospital OR 501( c)(3) Line 7 PH & S - Oregon 0 Providence Child Center Foundation 830 NE 47th Portland OR 97213 930800140 Support Providence Child Center OR 501( c)(3) Line 7 PH & S - Oregon 0 Providence TrinityCare Hospice Foundation 5315 Torrance Blvd Suite B1 Torrance CA 90503 330261016 Support TrinityCare Hospice CA 501( c)(3) Line 7 PHS - So California 0 Providence Little Company of Mary Foundation 4101 Torrance Blvd Torrance CA 90503 510224944 Support Little Company of Mary Service Area CA 501( c)(3) Line 7 PHS - So California 0 PH&S FoundationSFVSA & SCVSA 501 S Buena Vista Street Burbank CA 91505 953544877 Support Program & Activities of SFVSA & SCVSA CA 501( c)(3) Line 7 PHS - So California 0 Providence Hospice of Seattle Foundation 425 Pontius Avenue North 300 Seattle WA 981095452 912077378 Support Hospice of Seattle WA 501( c)(3) Line 11/Type I PH & S - Washington 0 Providence Health & Services - Western Washington 1801 Lind Avenue SW 9016 Renton WA 980579016 911303277 Healthcare WA 501( c)(3) Line 3 Providence MinistriesWHC 0 Providence Health & Services 1801 Lind Avenue SW 9016 Renton WA 980579016 911549796 Shell Corporation WA 501( c)(3) Line 11/Type I N/A 0 Providence Health & Services - Montana 500 W Broadway PO Box 4587 Missoula MT 598064587 810231793 Healthcare MT 501( c)(3) Line 3 PH & S - Washington 0 Providence St Joseph Medical Center PO Box 1010 Polson MT 598601010 810463482 Healthcare MT 501( c)(3) Line 3 PH & S - Washington 0 St Thomas Child and Family Center 1710 Benefis Court Great Falls MT 59405 810233495 Early Childhood Education MT 501( c)(3) Line 1 PH & S - Washington 0 Sisters of Providence of Montana Corporation 1801 Lind Avenue SW 9016 Renton WA 980579016 262612415 Shell Corporation MT 501( c)(3) Line 1 PH & S - Washington 0 Providence Health Care Foundation - Eastern Washington 101 W 8th Ave Spokane WA 99204 320014330 Support PH&S-WA. 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. Montana MT 501( c)(3) Line 7 PH & S - Washington 0 University of Great Falls 1301 20th Street South Great Falls MT 59405 810231777 Post Secondary Education MT 501( c)(3) Line 2 PH & S - Washington 0 E WA & MT Unemployment Compensation Insurance Trust 1801 Lind Avenue SW 9016 Renton WA 980579016 911082119 Unemployment Benefits WA 501( c)(3) Line 11/Type I PH & S - Washington 0 Providence Willamette Falls Medical Foundation 1500 Division Street Oregon City OR 97045 931003750 Support Willamette Falls Hospital OR 501( c)(3) Line 11/Type I PH & S - Oregon 0 Providence Hood River Memorial Hospital Foundation Inc 811 13th St Hood River OR 97031 930921990 Support Providence Hood River Memorial Hospital OR 501( c)(3) Line 7 PH & S - Oregon 0 Providence Hospice and Home Care Foundation 2731 Wetmore Avenue Suite 500 Everett WA 98201 272552749 Support Program & Ministries of PHHC WA 501(c )(3) Line 7 PH & S - Washington 0 Providence St Mary Foundation 401 W Poplar St Walla Walla WA 99362 452841492 Support Program & Ministries of SMMC WA 501(c )(3) Line 7 PH & S - Washington 0 Facey Medical Foundation 15451 San Fernando Mission Blvd 200 Mission Hills CA 913451420 954322584 Support Facey Medical Group CA 501(c )(3) Line 7 PHS - So California 0 Swedish Health Services 747 Broadway Seattle WA 98122 910433740 Healthcare WA 501(c )(3) Line 3 Western HealthConnect 0 Swedish Edmonds 21601 76th Ave W Edmonds WA 98026 272305304 Healthcare WA 501(c )(3) Line 3 Western HealthConnect 0 Swedish Medical Center Foundation 747 Broadway Seattle WA 98122 910983214 Support Swedish Health Services WA 501(c )(3) Line 7 Swedish Health Services 0 Global To Local Health Initiative 747 Broadway Seattle WA 98122 273133200 Healthcare WA 501(c )(3) Line 7 Swedish Health Services 0 Swedish MJM Holdings 747 Broadway Seattle WA 98122 273139262 Holding Company WA 501(c )(3) Line 11/Type I Swedish Health Services 0 Marsha Rivkin Center for Ovarian Cancer Research 747 Broadway Seattle WA 98122 912054035 Ovarian Cancer Research WA 501(c )(3) Line 7 Swedish Health Services 0 Western HealthConnect 747 Broadway Seattle WA 98122 454171900 Shell Corporation WA 501(c )(3) Line 11/Type I Providence Ministries 0 Providence Imaging Center 3340 Providence Drive Anchorage AK 99508 920118807 Medical Imaging AK N/A Pathology Associates Medical Laboratories LLC 611 N Perry Spokane WA 99202 270943279 Outpatient Lab WA N/A California Laboratory Associates LLC 501 Buena Vista Burbank CA 91505 273888692 Outpatient Lab CA N/A Surgery Ctr at Tanasbourne LLC 1235 NE 47th Ave 260 Portland OR 97213 208187971 Ambulatory Surgery Center OR N/A Distribution Operations Center LLC 1801 Lind Ave SW 9016 Renton WA 98057 271054858 Supplies Purchasing Agent WA N/A Broadway Imaging LLC 500 W Broadway Missoula MT 59802 522405971 Medical Imaging MT N/A Ctr for Med Imaging-Bridgeport LLC 1235 NE 47th Ave Portland OR 97213 260796953 Imaging - 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 - MOB OR N/A Greater Valley Medical Building LP 501 S Buena Vista St Burbank CA 91505 954570858 Real Estate - MOB CA N/A Medalia Healthcare LLC 1801 Lind Ave SW 9016 Renton WA 98057 911660459 Physician Benefits WA N/A Prov Radiation Oncology Develop Assn LLC 1235 NE 47th Ave Portland OR 97213 260682491 Real Estate - MOB OR N/A ProvidenceSilverton Rehab LLC 1235 NE 47th Ave 260 Portland OR 97213 481287267 Rehab Services OR N/A Southern Idaho Regional Laboratory LLC 611 N Perry Spokane WA 99202 820511819 Outpatient Lab ID N/A Tri-Cities Laboratory LLC 611 N Perry Spokane WA 99202 911773986 Outpatient Lab WA N/A Providence Partners for Health LLC 501 S Buena Vista St Burbank CA 91505 454041798 Clinical Quality & Integration CA N/A Providence Health Ventures Inc 4101 Torrance Blvd Torrance CA 90503 330122216 Investment CA N/A C 0 Caron Health Corporation 510 W Front St Missoula MT 59802 810486082 Medical Physician Service MT N/A C 0 Providence Health Care Ventures Inc 101 W 8th Ave TAF C-9 Spokane WA 99204 900155714 Clinical/Medical Lab WA N/A C 0 Providence Physician Services Co 101 W 8th Ave TAF C-9 Spokane WA 99204 911216033 Clinical/Medical Lab WA N/A C 0 Yakima Medical Arts Inc 611 N Perry 100 Spokane WA 99202 910787963 Rental Real Estate WA N/A C 0 Bourget Health Services Inc PO Box 2687 Spokane WA 99220 911354431 Clinical/Medical Lab WA N/A C 0 1221 Madison Street Owners Assoc 747 Broadway Seattle WA 98122 201954319 Owners' Association WA N/A C 0 Washington Cancer Centers PC 1560 N 115th G-16 Seattle WA 98133 911792791 Cancer Treatment WA N/A C 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0