2013-11-15T15:43:39-06:00 2012-12-31 911194016 Clark Nuber PS 10900 NE 4th Suite 1700 Bellevue WA 98004 990 2012-01-01 930863097 PROVIDENCE HEALTH PLAN PROV 5035746330 4400 NE Halsey Bldg 2 Portland OR 97213 Jeffrey Butcher 5035746330 2013-11-15 1 Sara Elizabeth J Hyre CPA P00235495 4254544919 2012 2016-03-07 17:11:31Z Jack A Friedman 4400 NE Halsey Bldg 2 Portland OR 97213 1760326964 0 X www.providence.org/healthplans X 1998 OR Healthcare Service Contractor. 16 16 0 0 0 0 1138390 0 1080483203 1100676071 25584901 22713007 72891 2476096 1107279385 1125865174 2424914 3970620 0 0 49854060 58624734 0 0 0 1041249189 1018491530 1093528163 1081086884 13751222 44778290 601828582 663428937 138629036 159197886 463199546 504231051 X As People of Providence, we reveal God's love for all, especially the poor and vulnerable, through our compassionate service.Healthcare Service Contractor. 0 0 572194361 546899 613671648 Commercial group is offered to employers who provide access to health coverage to their employees. Products include Personal Option and Open Option plans. For the Individual and Family plans offered to those who are not eligible for Medicare and Medicaid, PHP served approximately 13,700 members. This product is health underwritten to manage risk appropriately with targets to reach the more than 650,000 uninsured Oregonians. 415802488 420864 444250527 Providence Medicare Plans are solutions for people who are eligible for Medicare, supporting affordable access and easier administration for members. PHP advocates for evidence-based and cost effective treatments for patients and appropriate payment levels to providers to keep access to health care available to people who are eligible for Medicare. This program served approximately 41,000 members in 2012. 27864454 2857 43814495 Providence offers Providence Administrative Services Only (ASO) for large groups capable of self-funding the risk experience of the group, but want claims administration and often skilled medical management; and consumer choice plans which offer qualified Health Savings Account (HSA) options. This program served approximately 182,000 members in 2012. 1270733 0 1347892 Providence Medicare Supplement plans (Medi-Gap) are no longer open plans, but we have membership that continue to be enrolled in these closed-to-new-member plans. 3000000 3000000 0 Developing innovative methods of providing health care services in Oregon. 4270733 3000000 1347892 1020132036 0 0 0 0 0 0 0 0 0 1 0 0 1 1 1 1 1 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 1 X 13753 0 1 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 OR X Jeff Butcher CFO 5035746390 4400 NE Halsey Bldg 2 Portland OR 97213 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 Jeffrey W Rogers 0.20 49.80 X 0 623631 319793 Jack Friedman 50.00 2.00 X 0 679882 227031 Alison S Schrupp 53.00 2.00 X 0 665713 203813 Barbara L Christensen 43.00 2.00 X 0 370289 119698 Michael G White 48.00 2.00 X 0 344957 69217 Bruce W Wilkinson 43.00 2.00 X 0 631976 170482 Robert A Gluckman 48.00 2.00 X 0 416221 168859 Jeffrey Butcher 48.00 2.00 X 0 289621 31075 Gregory Van Pelt 0.00 60.00 X 0 1193691 434439 Shelly M Handkins 0.00 50.00 X 0 483207 304166 James H Mackay 50.00 0.00 X 0 306857 98902 Gerald R Corn 50.00 0.00 X 0 248280 30290 Stephanie C Dreyfuss 40.00 0.00 X 0 257787 29013 Susan Abate 40.00 0.00 X 0 215716 74553 Katherine L Powell 50.00 0.00 X 0 235937 35046 Kevin W Keck MD 0.00 0.00 X 0 104249 0 0 7310014 2316377 0 1 1 0 PH&S-OR dba Prov Portland Medical Cente PO BOX 3395 Portland OR 97208 Hospital and Healthcare Services 123573457 PH&S-OR dba Prov St Vincent Medical Ce PO BOX 3178 Portland OR 97208 Hospital and Healthcare Services 109870863 Salem Hospital 890 Oak Street SE Salem OR 97301 Hospital and Healthcare Services 59223574 Oregon Health Sciences University PO BOX 575 Portland OR 97207 Healthcare 49036689 PH&S-OR dba Prov Medical Group - North PO BOX 3158 Portland OR 97208 Physician Services 47043907 1033 EPO Premiums 900099 612334380 612334380 Medicare Payments 900099 443278155 443278155 ASO Fees 900099 43718594 43718594 Medicare Supp. Premium 900099 1344942 1344942 1100676071 14071178 14071178 5437860 5588399 -150539 -150539 -150539 637515220 628873391 8641829 8641829 8641829 ACO Reimbursement 900099 2172281 2172281 Litigation Settlement 900099 212199 212199 Capital Usage Fee 900099 185528 185528 56627 50682 5945 2626635 1125865174 1103084562 0 22780612 3970620 3970620 4264571 564125 3700446 38630822 28669598 9961224 15729341 10483775 5245566 456450 335373 121077 990285 990285 12994743 6984132 6010611 5834 5834 3051700 1655808 1395892 6349121 3923479 2425642 4738233 3525632 1212601 536556 159954 376602 162811 80377 82434 15159313 6376773 8782540 1887689 1266547 621142 170180 126628 43552 Medical Claims 942249650 942249650 Commission Fees 12785328 12785328 OR & WA High Risk Pool 8288846 4558865 3729981 Premium Tax 6566468 3611557 2954911 2098323 1583309 515014 1081086884 1020132036 60954848 0 7405953 13716262 12392145 3012405 3868812 316 95700 95700 113059128 35797327 81995187 77261801 452338663 522960821 8277721 10399526 34986375 36450132 601828582 663428937 292166 3338891 13622288 12420166 124714582 143438829 138629036 159197886 X 0 0 73716441 73716441 389483105 430514610 463199546 504231051 601828582 663428937 X 44778290 -3746786 1 X 0 1 X 1 0 79730868 8592614 71138254 4857475 1883228 2974247 28018227 25321485 2696742 452558 452558 77261801 Pharmacy Rebate Receivable 2357534 Receivable from ASO Clients 4675546 Due from Affiliates 1694390 Investment Income Accruals 2942333 Due from CMS 7151881 Land Trustee Funds 14371717 Alternate Funding Arrangement 1320420 Reinsurance Receivable 380347 Overpayment recoveries outstanding 244032 Receivable from State of Oregon - Children's Reinsurance Pool 1311932 36450132 Unpaid Claims & Withholdings 102176179 Due to OR. Public Employees Retirement System 1534317 Due to Affiliates 12560284 Due to Medicare Part D 7409184 Due to CMS - Medical 406888 Miscellaneous Payables 1926763 Deposits Insured Grp. Alternative Arrangements 2608604 Claim Refunds in Process 996321 Pre-funding of ASO Claims 5586150 ASO Client Health Improvement Fund 1197857 Premium deficiency reserve 3724660 Unpaid Claims Liability for Administrative expenses 2489593 Broker commission accrual 822029 143438829 X 1077739692 -3746786 2687991 -1058795 1078798487 990285 46076402 47066687 1125865174 1031625800 605604 605604 1031020196 990285 49076403 50066688 1081086884 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. Part XI, Line 2d - Other Adjustments: Ceded - Reinsurance Premiums -2,816,892. Gross-up Medicare Part D Reserve 3,422,496. Accrual of Straight-line Lease amount 2,082,387. Part XI, Line 4b - Other Adjustments: Capital Usage Fee from PPP & PHA 185,528. ASO Fees 43,718,594. Reimbursement for Accountable Care expenses 2,172,281. Rounding -1. Part XII, Line 2d - Other Adjustments: Ceded Reinsurance Premiums -2,816,892. Gross-up Medicare Part D Reserve 3,422,496. Part XII, Line 4b - Other Adjustments: Capital Usage Fee 185,528. Reimbursement for Accountable expenses 2,172,281. ASO Fees 43,718,594. Affiliates Transfer 3,000,000. 1 Shriners Hospitals for Children 2900 Rocky Point Drive Tampa FL 33607 362193608 501(c)(3) 300000 Medical care for children in Oregon PH&S - Oregon (Patient Assistance Fund) 4400 NE Halsey Bldg 1 Portland OR 97213 510216587 501(c)(3) 200000 Assistance with medical bills for the needy Virginia Garcia 85 N 12th Ave Cornelius OR 97113 930717997 501(c)(3) 60000 Health care assistance for migrant workers Stand for Children 516 SE Morrison Street Suite 420 Portland OR 97214 521957214 501(c)(3) 50000 2012 Donation for ongoing support Iron Tribe Inc 16641 SE 82nd Drive Clackamas OR 97015 010935371 501(c)(3) 25000 Assistance for people in recovery and former incarcerated individuals. George Fox University 414 N Noridian Newberg OR 97132 930386839 501(c)(3) 25000 PCGC 2012 Funding Community Health Partnership 315 SW Fifth Avenue Suite 202 Portland OR 97204 931259522 501(c)(3) 25000 2012 OHIPP Membership & Supporting Level Sponsorship Coalition of Community Health Clinics (CCHC) 619 SW 11th Avenue Suite 225 Portland OR 97205 911829239 501(c)(3) 25000 Assistance for healthcare needs for the needy Center for Family Development Inc 1258 High Street Eugene OR 97401 931071248 501(c)(3) 25000 Assisting families in developing better working relationships Bradley Angle House 4548 N Albina Avenue Portland OR 97217 510188664 501(c)(3) 25000 Assisting people effected by domestic violence Clatsop Behavioral Healthcare 2120 Exchange Street Suite 301 Astoria OR 97103 930513669 501(c)(3) 24880 Mental health assistance for those in need Transition Projects 665 NW Hoyt Street Portland OR 97209 930591582 501(c)(3) 16702 Operational support Rose Haven PO BOX 11620 Portland OR 97211 205922682 501(c)(3) 15000 Assistance for women and children at risk Meals on Wheels People 7710 SW 31st Avenue Portland OR 97219 930584318 501(c)(3) 15000 Food for disabled Community Action Organization 1001 SW Baseline Street Hillsboro OR 97123 930554941 501(c)(3) 15000 Eliminate conditions of poverty and assist with opportunities for the poor. Central City Concern 232 NW Sixth Avenue Portland OR 97209 930728816 501(c)(3) 14687 Operational support Center Against Rape and Domestic Violence 4786 SW Philomath Blvd Corvallis OR 97339 930792125 501(c)(3) 14687 Operational support Wallace Medical Concern PO Box 3506 Gresham OR 97030 930853709 501(c)(3) 10000 Primary and urgent healthcare to patients in need Upstream Public Health 240 N Broadway Suite 215 Portland OR 97227 421579435 501(c)(3) 10000 Assistance with seeking broad-based health solutions Human Solutions Inc 12350 SE Powell Blvd Portland OR 97212 930977166 501(c)(3) 10000 Assistance for homeless and low-income families Clackamas Service Center 8800 SE 80th Ave Clackamas OR 97206 930626175 501(c)(3) 10000 Essential services to the needy Chehalem Youth & Family Services PO Box 636 Newberg OR 97132 930764541 501(c)(3) 10000 Essential services to the needy American College of Cardiology Ed Fdn PO Box 55424 Portland OR 97238 205915188 501(c)(3) 6149 Education program for treatment of heart disease Sunshine Pantry 7795 SW Cirrus Drive Bldg 26 Beaverton OR 97005 203834167 501(c)(3) 5000 Assistance for families at risk in Beaverton, Oregon Northwest Pilot Project 1430 SW Broadway Street Ste 200 Portland OR 97201 930635871 501(c)(3) 5000 Housing services for those 55+ who are homeless or at risk National Multiple Sclerosis Society 104 SW Clay Street Portland OR 97204 930551147 501(c)(3) 5000 Funding for research and assistance for those with MS Folktime 4837 NE Coach Street Portland OR 97213 931222522 501(c)(3) 5000 Counseling and mental health for the needy Providence Portland Medical Foundation 4805 NE Glisan Street Portland OR 97213 931231494 501(c)(3) 3000000 Innovative methods for delivering health care in Oregon 28 0 Procedure for Monitoring Grants in the U.S.: Part I, Line 2: Schedule I, Part I, Line 2: We request and condition grants upon each of the following: 1) The program summary and budget; 2) Verification of malpractice and liability coverage; 3) Updates provided every six months; 4) Documentation evidencing tax-exempt or municipal status; 5) Documentation showing that they serve the low income and uninsured regardless of ability to pay for services; 6) Provide upon request, financial reporting of the budgeted use of grant funds. 1 1 0 0 0 0 0 0 0 Jeffrey W Rogers 0 444646 0 178408 0 577 0 300735 0 19058 0 943424 0 48099 Jack Friedman 0 464884 0 197421 0 17577 0 201491 0 25540 0 906913 0 50985 Alison S Schrupp 0 271507 0 380590 0 13616 0 183613 0 20200 0 869526 0 0 Barbara L Christensen 0 248845 0 91481 0 29963 0 105420 0 14278 0 489987 0 0 Michael G White 0 279637 0 48320 0 17000 0 64912 0 4305 0 414174 0 0 Bruce W Wilkinson 0 230796 0 384180 0 17000 0 151098 0 19384 0 802458 0 0 Robert A Gluckman 0 358275 0 57946 0 0 0 147904 0 20955 0 585080 0 0 Jeffrey Butcher 0 256311 0 33310 0 0 0 11473 0 19602 0 320696 0 0 Gregory Van Pelt 0 717021 0 458901 0 17769 0 411729 0 22710 0 1628130 0 292233 Shelly M Handkins 0 381343 0 101287 0 577 0 281371 0 22795 0 787373 0 0 James H Mackay 0 292281 0 14576 0 0 0 84415 0 14487 0 405759 0 0 Gerald R Corn 0 222719 0 8561 0 17000 0 21665 0 8625 0 278570 0 0 Stephanie C Dreyfuss 0 221487 0 36300 0 0 0 10531 0 18482 0 286800 0 0 Susan Abate 0 193386 0 22330 0 0 0 66842 0 7711 0 290269 0 0 Katherine L Powell 0 217287 0 18650 0 0 0 16173 0 18873 0 270983 0 0 Kevin W Keck MD 0 0 0 0 0 104249 0 0 0 0 0 104249 0 0 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: 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. 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 1) Jack Friedman a) Taxable SERP Earned but not Paid - $47,618 b) SERP Interest Credit - $139,595 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) Alison Schrupp a) Taxable SERP Earned but not Paid- $333,981 b) SERP Interest Credit - $129,551 c) Taxable CBRP Earned but not Paid - $2,359 d) ESP Interest Credit - $23,315 4) Gregory Van Pelt a) Taxable SERP Earned but not Paid - $183,330 b) ESP Interest Credit - $96,202 c) SERP Interest Credit - $240,115 5) Barbara L. Christensen a) SERP Interest Credit - $18,401 b) Taxable SERP Earned but not Paid - $48,701 c) ESP Interest Credit - $31,193 6) Robert A. Gluckman a) SERP Interest Credit - $54,530 b) SERP Earned but not Vested - $58,022 c) Taxable CBRP Earned but not Paid - $196 7) Shelly M. Handkins a) SERP Interest Credit - $35,757 b) SERP Earned but not Vested - $207,834 8) James Mackay a) Taxable CBRP Earned but not Paid - $7,663 b) Non-Taxable CBRP Earned - $2,367 9) Gerald Corn a) Taxable CBRP Earned but not Paid - $1,084 b) Non-Taxable CBRP Earned - $290 10) Michael White a) SERP Earned but not Vested - $17,251 b) SERP Interest Credit - $18,470 11) Bruce Wilkinson a) Taxable SERP Earned but not Paid - $345,840 b) Non-Taxable SERP Earned - $375 c) SERP Interest Credit - $124,281 12) Jeff Butcher a) SERP Earned but not Vested - $8,231 Part I, Lines 4a-b SEVERANCE 1) Kevin W. Keck - $104,249 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 The sole Corporate Member is Providence Plan Partners. Form 990, Part VI, Section A, line 7a The powers of the Corporate Member include the provision to appoint the number of Directors, appoint the Board of Directors and to remove such Directors at any time with or without cause. Form 990, Part VI, Section A, line 7b The following powers reside with the Member: * To adopt or change the mission, philosophy, and values of the Corporation. * To amend or repeal the Articles of Incorporation and the Bylaws of the Corporation. * To approve the acquisition of assets, the incurrence of indebtedness or the lease, sale, transfer, assignment or encumbering of the assets, in excess of a specified amount. * To approve the dissolution and/or liquidation or the consolidation or merger of the Corporation. * To approve the annual operating and capital budget and approval any deviations from the budget exceeding a specified amount. * To appoint the Corporation's certified public accountants after receiving recommendation of the Board of Directors. * To approve the lending of Corporate funds, other than the purchase of publicly traded securities, to unaffiliated organizations. * To approve the closure of any institution or major ministry or work within this Corporation. 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 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 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. 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. Mary Corita Heid, RSM - 1801 Lind Avenue SW, #9016, Renton, WA 98057. Michael A. Stein - 1801 Lind Avenue SW, #9016, Renton, WA 98057. Michael Holcomb - 1801 Lind Avenue SW, #9016, Renton, WA 98057. Dana A. Rasmussen - 1801 Lind Avenue SW, #9016, Renton, WA 98057. James S. Roberts, MD - 1801 Lind Avenue SW, #9016, Renton, WA 98057. Peter J. Snow - 1801 Lind Avenue SW, #9016, Renton, WA 98057. Jeffrey B. Clode, MD -Thru 6/12 - 1801 Lind Avenue SW, #9016, Renton, WA 98057. Sallye Liner - 1801 Lind Avenue SW, #9016, Renton, WA 98057. Owen B. Robinson - 1801 Lind Avenue SW, #9016, Renton, WA 98057. Cheryl M. Scott - 1801 Lind Avenue SW, #9016, Renton, WA 98057. Ellen L. Wolf - 1801 Lind Avenue SW, #9016, Renton, WA 98057. Isiaah Crawford - 1801 Lind Avenue SW, #9016, Renton, WA 98057. Martha Diaz Aszkenazy - 1801 Lind Avenue SW, #9016, Renton, WA 98057. Kirby McDonald - 1801 Lind Avenue SW, #9016, Renton, WA 98057. Dave Olsen - 1801 Lind Avenue SW, #9016, Renton, WA 98057. Charles (Chuck) Watts - 1801 Lind Avenue SW, #9016, Renton, WA 98057. John Nordstrom - Thru 7/12 - 1801 Lind Avenue SW, #9016, Renton, WA 98057. Jeffrey W. Rogers - 1801 Lind Avenue SW, #9016, Renton, WA 98057. Changes in Net Assets or Fund Balances: Form 990, Part XI, line 9: Rounding 1. AUDITED FINANCIAL STATEMENTS FORM 990, PART IV, LINE 12 The audited financial statements of Providence Health Plan are prepared on a statutory basis in conformity with insurance accounting practices prescribed or permitted by the National Association of Insurance Commissioners and the Insurance Division of the Oregon Department of Consumer and Business Services. EMPLOYEE COMPENSATION FORM 990, PART II, LINE 5 & PART V, LINE 2A The employees working at Providence Health Plan are paid by Providence Health & Services - Oregon EIN# 51-0216587 or Providence Health & Services - WA. dba Health System Office EIN# 91-0725998. 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 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 AGREEMENTS 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. Effective July 1, 2012, Providence Health System - Southern California entered into an affiliation agreement with Facey Medical Foundation and Facey Medical Group. The Facey Medical Foundation is a nonprofit medical foundation, which operates ten clinics in the North San Fernando, Santa Clarita, San Gabriel and Simi Valleys. These sites are staffed by the Facey Medical Group physicians pursuant to a professional services agreement. 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 Assurance 4400 NE Halsey Bldg 2 Portland OR 97213 550828701 Medicaid Healthcare Provider OR 501( c)(4) N/A Providence Health Plan 1 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 - 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 - 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