2013-11-15T15:21:04-06:00 2012-12-31 930418710 DELAP LLP 5885 MEADOWS ROAD NO 200 LAKE OSWEGO OR 97035 990 2012-01-01 930415219 SANTIAM MEMORIAL HOSPITAL SANT 5037692175 1401 N 10TH AVENUE STAYTON OR 973831311 TERRY FLETCHALL 5037692175 2013-11-14 1 WESLEY B HANSEN P00226581 5036974118 2012 2016-03-07 17:11:31Z TERRY FLETCHALL 1401 N 10TH AVENUE STAYTON OR 973831311 35729827 0 X WWW.SANTIAMHOSPITAL.ORG X 1950 OR GENERAL ACUTE HEALTH CARE HOSPITAL SERVING SANTIAM COMMUNITIES 9 9 311 0 0 0 66857 22101 35230773 35408269 24316 43213 164450 154434 35486396 35628017 0 0 0 0 17036990 18959075 0 0 0 14091724 14143943 31128714 33103018 4357682 2524999 45595331 57094687 18993495 28227538 26601836 28867149 SANTIAM MEMORIAL HOSPITAL'S MISSION IS TO PROVIDE QUALITY HEALTH CARE TO PERSONS SUFFERING FROM ILLNESS, INJURIES, OR DISABILITIES AND TO PROMOTE THE GENERAL HEALTH AND WELFARE OF THE COMMUNITY THROUGH EDUCATION, SUPPORT, AND MEDICAL SERVICES. 0 0 28640109 35410398 ACUTE HOSPITAL CARE: PATIENT DAYS 2,468, NURSERY DAYS 279, SWING BED DAYS 96, AMBULANCE TRIPS 1,659, OUTPATIENT DAYS 34,995, REFERENCE LABORATORY 132,362. 28640109 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 77 0 1 311 1 0 0 0 0 0 0 0 0 0 0 0 0 X 9 9 0 0 0 0 1 1 0 1 1 0 0 1 1 1 1 1 1 1 1 0 OR X TERRY FLETCHALL 5037692175 1401 N TENTH AVENUE STAYTON OR 97383 RON ETZEL 3.00 X 0 0 0 ELAINE HANSEN 3.00 X 0 0 0 VICTOR KINTZ 3.00 X 0 0 0 MARYANN MEREDITH 3.00 X 0 0 0 MIKE ODENTHAL 3.00 X 0 0 0 RANDY MICKEY 3.00 X 0 0 0 GEORGE LONG 3.00 X 0 0 0 LAWRENCE FISHER 3.00 X 0 0 0 FRANCIS HENDRICKS 3.00 X 0 0 0 TERRY FLETCHALL 50.00 X 240317 0 32613 MAGGIE HUDSON 50.00 X 183363 0 24742 GENNY BALDWIN 50.00 X 177995 0 29613 ERIC VON BORSTEL 32.00 X 227651 0 17565 JOHN HOFFMAN 40.00 X 385507 0 22579 SUSAN TAYLOR 50.00 X 299191 0 21976 LORI BORELLA 32.00 X 289021 0 12663 FREDRICK CARLOCK 32.00 X 257389 0 21976 2060434 0 183727 8 1 1 0 CHARLES H STRINGHAM MD 1401 N 10TH AVE STAYTON OR 973831311 EMERGENCY ROOM PHYSICIAN 449706 ROBERT L JACQUES MD 1401 N 10TH AVE STAYTON OR 973831311 EMERGENCY ROOM PHYSICIAN 341638 HEINZ MECHANICAL 2615 NW ST HELENS PORTLAND OR 97210 CONSTRUCTION SERVICES 242069 CONSTRUCTION SYSTEMS MANAGEMENT LLC 810 TUKWILA DRIVE WOODBURN OR 97071 CONSTRUCTION MANAGEMENT SERVICES 161040 DANNY SPARKS MD 1401 N 10TH AVE STAYTON OR 973831311 EMERGENCY ROOM PHYSICIAN 158308 5 16511 5590 22101 ACUTE HOSPITAL CARE 900099 30459765 30459765 MEDICARE/MEDICAID PMTS 900099 29641758 29641758 ELECTRONIC HLTH RECORDS 990009 1067585 1067585 PROVISION FOR CHARITY 900099 -1475656 -1475656 CONTRACTUAL ALLOWANCES 900099 -24596269 -24596269 311086 311086 35408269 30094 4 30090 94800 98292 -3492 -3492 -3492 11601 5036 0 3518 11601 1518 13119 13119 CAFETERIA REVENUE 900099 157926 157926 157926 35628017 35404781 0 201135 688642 688642 13559196 12620080 939116 342795 298092 44703 3342879 2048566 1294313 1025563 837749 187814 80730 80730 117862 117862 1856309 1759270 97039 125272 125272 73500 55125 18375 133022 107102 25920 285731 274302 11429 222 222 1420 1420 1349369 1221638 127731 163865 112215 51650 SUPPLIES 4553351 4465212 88139 BAD DEBTS 3187046 3187046 EQUIPMENT RENTAL & MAIN 571067 493812 77255 CLINIC EXPENSE 521918 521918 1123259 636562 486697 33103018 28640109 4462909 0 240 240 8159869 11609952 6426645 5920388 15063 19132 1103455 1142548 574610 460618 48752760 13612473 26998937 35140287 501339 554404 531172 539574 1284001 1707544 45595331 57094687 8658762 5358787 10334733 22868751 18993495 28227538 X 26601836 28867149 26601836 28867149 45595331 57094687 X 2524999 38285 -297971 X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 232930 1091087 1324017 1289643 9728416 5758997 5259062 616390 451903 164487 10176986 7401573 2775413 25617308 25617308 35140287 32181285 38285 -3187046 -3148761 35330046 297971 297971 35628017 29915972 0 29915972 3187046 3187046 33103018 PART XI, LINE 2D - OTHER ADJUSTMENTS: BAD DEBT EXPENSE -3,187,046. PART XI, LINE 4B - OTHER ADJUSTMENTS: REVENUE FROM WILLAMETTE VALLEY COMMUNITY HEALTH, LLC 297,967. REVENUE FROM DISPROPORTIONATE SHARE HOSPITAL 3 TRUST 4. PART XII, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT EXPENSE 3,187,046. 1 1 1 X 1 X 1 1 1 0 0 1 708 731925 731925 0.02210 1 25800 4257499 3656946 600553 0.01810 2 26508 4989424 3656946 1332478 0.04020 8 2834 76750 9046 67704 0.00200 8 2834 76750 9046 67704 0.00200 10 29342 5066174 3665992 1400182 0.04220 1 3187046 2549637 8512145 11082735 -2570590 X 1 1 1 1 SANTIAM MEMORIAL HOSPITAL

1401 N 10TH AVENUE STAYTON OR 973831311

X X X SANTIAM MEMORIAL HOSPITAL 1 1 X X X X X X X X X 11 1 1 1 X 1 0 1 1 150.000000000000 1 250.000000000000 1 X X X X X 1 1 X X X X 1 X 0 1 X 0 1 5 SUBLIMITY MEDICAL CLINIC

114 SE CHURCH ST SUBLIMITY OR 97325

PHYSICIAN CLINIC AUMSVILLE MEDICAL CLINIC

205 MAIN ST AUMSVILLE OR 97325

PHYSICIAN CLINIC CASCADE MEDICAL CLINIC

1375 N 10TH AVENUE STE B STAYTON OR 97383

PHYSICIAN CLINIC SANTIAM MEDICAL CLINIC

280 S FIRST AVENUE MILL CITY OR 97360

PHYSICIAN CLINIC SANTIAM WOMEN'S CLINIC

1373 N 10TH AVENUE STAYTON OR 97383

PHYSICIAN CLINIC PART III, LINE 4: THE COSTING METHODOLOGY USED TO DETERMINE THE AMOUNT ON LINE 2: THE GROSS BAD DEBT CHARGES, $3,187,046, WERE APPLIED TO THE PATIENT CARE COST TO CHARGES RATIO ESTABLISHED IN WORKSHEET 2. BAD DEBTS ARE DETERMINED AFTER THE PATIENT RECEIVED 4 STATEMENTS AFTER DATE OF SERVICE OR DATE OF PAYMENT BY INSURANCE. AFTER THE 4TH STATEMENT, THE PATIENT RECEIVES A LETTER EXPLAINING THAT THEIR ACCOUNT WILL BE TURNED OVER TO A COLLECTION AGENCY IF PAYMENT IS NOT RECEIVED BY THE END OF THE MONTH.THE COSTING METHODOLOGY USED TO DETERMINE THE AMOUNT ON LINE 3: THROUGH OBSERVATION OF CHARITY CARE COORDINATOR, 80% OF BAD DEBTS MAY HAVE QUALIFIED FOR CHARITY CARE BECAUSE OF 1) INCORRECT CONTRACT INFORMATION GIVEN TO HOSPITAL, 2) UNABLE OR UNWILLINGNESS TO FILL OUT AND COMPLETE CHARITY CARE FORMS AND SUPPORTING DOCUMENTATION AND 3) THE STIGMA ASSOCIATED WITH THE ACCEPTANCE OF CHARITY CARE. PART III, LINE 9B: FINANCIAL ASSISTANCE IS GRANTED ON A SLIDING SCALE. IF AMOUNT DEEMED TO BE PAYABLE BY THE PATIENT IS DELINQUENT, THE PATIENT IS SENT TO COLLECTION AGENCY FOR THE PORTION OUTSTANDING. SANTIAM MEMORIAL HOSPITAL PART V, SECTION B, LINE 3: CONSULTED WITH MARION COUNTY DEPARTMENT OF HEALTH AND OTHER COMMUNITY MEMBERS REGARDING THE NEEDS OF STAYTON AND SURROUNDING AREAS SERVED. SANTIAM MEMORIAL HOSPITAL PART V, SECTION B, LINE 4: SALEM HEALTH SYSTEM, SILVERTON HOSPITAL NETWORK SANTIAM MEMORIAL HOSPITAL PART V, SECTION B, LINE 7: CHIP PLANNING IMPLEMENTED IN 2012 SANTIAM MEMORIAL HOSPITAL PART V, SECTION B, LINE 20D: ALL PATIENTS ARE CHARGED AT THE SAME GROSS CHARGES. SANTIAM MEMORIAL HOSPITAL PART V, SECTION B, LINE 22: ALL PATIENTS ARE BILLED THE SAME GROSS CHARGES REGARDLESS OF INSURANCE STATUS. ALL PATIENTS ARE GIVEN A 10% DISCOUNT FOR PAYMENT OVER $ 500. REPORTS FILED WITH STATES PART VI, LINE 7 OR X X X 0 0 0 1 0 0 0 0 0 TERRY FLETCHALL 168720 0 49097 0 22500 0 19500 0 13113 0 272930 0 0 0 MAGGIE HUDSON 151879 0 25097 0 6387 0 10613 0 14129 0 208105 0 0 0 GENNY BALDWIN 152398 0 25097 0 500 0 16500 0 13113 0 207608 0 0 0 ERIC VON BORSTEL 226554 0 1097 0 0 0 6891 0 10674 0 245216 0 0 0 JOHN HOFFMAN 384410 0 1097 0 0 0 7500 0 15079 0 408086 0 0 0 SUSAN TAYLOR 298094 0 1097 0 0 0 7500 0 14476 0 321167 0 0 0 LORI BORELLA 287924 0 1097 0 0 0 7500 0 5163 0 301684 0 0 0 FREDRICK CARLOCK 256292 0 1097 0 0 0 7500 0 14476 0 279365 0 0 0 FORM 990, PART VI, SECTION A, LINE 6 THE HOSPITAL HAS APPROXIMATELY 400 MEMBERS WHO VOTE ON SELECTING BROAD OF DIRECTORS. FORM 990, PART VI, SECTION A, LINE 7A THE HOSPITAL HAS APPROXIMATELY 400 MEMBERS WHO VOTE ON SELECTING BROAD OF DIRECTORS. FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 IS REVIEWED BY THE DIRECTORS AND OFFICERS. FORM 990, PART VI, SECTION B, LINE 12C THE BOARD OF DIRECTORS, KEY EMPLOYEES AND CHIEF OF STAFF IS REQUIRED TO SIGN AN ANNUAL CONFLICT OF INTEREST STATEMENT ATTESTING TO THEIR COMPLIANCE. FORM 990, PART VI, SECTION B, LINE 15 SMH USES A THIRD PARTY COMPENSATION AND BENEFIT SERVICE: OLNEY & ASSOCIATES. THE SURVEY PROVIDES DATA ON HOSPITAL KEY EMPLOYEE COMPENSATION AND BENEFITS BASED ON BED SIZE, GEOGRAPHIC REGION, ADMISSIONS AND GROSS REVENUE. THE BOARD OF DIRECTORS REVIEW COMPENSATION AND BENEFITS FOR THE CEO (TERRY FLETCHALL), COO/CFO(MAGGIE HUDSON) AND CHIEF NURSING OFFICER(GENNY BALDWIN). THE CEO'S CONTRACT IS THROUGH THE HOSPITAL APPROVED BY THE BOARD AND THE CHIEF NURSING OFFICER AND COO/CFO CONTRACTS ARE WITH THE HOSPITAL APPROVED BY THE CEO. FORM 990, PART VI, SECTION C, LINE 19 SANTIAM MEMORIAL HOSPITAL MAKES COPIES OF ITS GOVERNING DOCUMENTS AND AUDITED FINANCIAL STATEMENTS AVAILABLE UPON REQUEST. THE AUDITED FINANCIAL STATEMENTS ARE ALSO AVAILABLE BY CONTACTING THE STATE OF OREGON DEPARTMENT OF JUSTICE. THE CONFLICT OF INTEREST POLICY IS NOT AVAILABLE TO THE PUBLIC. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 9: TAXABLE INCOME FROM WILLAMETTE VALLEY COMMUNITY HEALTH, LLC -297,967. TAXABLE INCOME FROM DSH3 TRUST -4. SANTIAM MEMORIAL HOSPITAL AUXILIARY 1401 N 10TH AVENUE STAYTON OR 97383 237399406 OPERATION OF GIFT SHOP AT THE HOSPITAL OR 501(C)(3) LINE 3 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 SANTIAM MEMORIAL HOSPITAL AUXILIARY N