2013-02-15T11:39:23-06:00 2012-03-31 450250958 EIDE BAILLY LLP 800 NICOLLET MALL STE 1300 MINNEAPOLIS MN 554027033 990 2011-04-01 810241755 ST JOHN'S LUTHERAN HOSPITAL INC STJO 4062837000 350 LOUISIANA AVENUE LIBBY MT 59923 BRUCE WHITFIELD 4062837000 2013-02-13 1 KIM C HUNWARDSEN P00484560 6122536500 2013-02-13 2011 2016-03-07 17:11:31Z BRUCE WHITFIELD 350 LOUISIANA AVENUE LIBBY MT 59923 29153818 0 X WWW.SJLH.ORG X 1952 MT HEALTHCARE SERVICES. 9 7 296 61 41729 0 387427 653219 26369502 28124276 79402 219827 65479 59815 26901810 29057137 10559 6990 0 0 15608257 16380605 0 0 214661 10673222 11789935 26292038 28177530 609772 879607 23988097 24457269 5067169 4470720 18920928 19986549 X TO PROVIDE EXCELLENT HEALTH CARE CLOSE TO HOME BY BEING A GREAT PLACE FOR EMPLOYEES TO WORK, PHYSICIANS TO PRACTICE MEDICINE, AND PATIENTS TO RECEIVE CARE. 1 0 22160808 6990 28124276 IN FISCAL YEAR 2012, ST. JOHN'S HOSPITAL PROVIDED SERVICE TO NEARLY 9,600 PATIENTS, MANY OF WHOM ARE UNINSURED/UNDERINSURED AND DO NOT HAVE AN ESTABLISHED PATIENT RELATIONSHIP WITH LOCAL PROVIDERS. THE TOTAL NUMBER OF ADJUSTED PATIENT DAYS AMOUNTED TO 12,442 FOR FISCAL YEAR 2012. THE PROGRAM SERVICES RANGE ANYWHERE FROM ROUTINE INPATIENT SERVICES TO HOME HEALTH TO CARDIAC REHAB, JUST TO NAME A FEW. ALL THESE SERVICES ARE PROVIDED TO A COMMUNITY THAT IS REMOTE IN LOCATION AND OFTEN CONSIDERED UNINSURED OR UNDERINSURED. IN ADDITION, SOME OF THE MAJOR PROGRAMS OFFERED BY THE HOSPITAL INCLUDE EMERGENCY SERVICES, SURGERY, AND PHYSICAL THERAPY. AS A SMALL CRITICAL ACCESS HOSPITAL MORE THAN 90 MILES AWAY FROM THE NEAREST EMERGENCY SERVICES, ST. JOHN'S LUTHERAN HOSPITAL RECOGNIZES THE NEED FOR AROUND THE CLOCK SERVICE AS IT RELATES TO EMERGENCY CARE. THAT IS WHY ST. JOHN'S OPERATES A 24/7 ER DEPARTMENT. DUE TO THE REMOTE LOCATION OF LINCOLN COUNTY, SURGERY IS A VERY IMPORTANT SERVICE FOR THE RESIDENTS OF LINCOLN COUNTY. IT IS NOT PRACTICAL OR ECONOMICAL TO EXPECT THAT PATIENTS MAKE THE 90-MILE TRIP TO KALISPELL FOR THIS SERVICE. THIS IS WHY ST. JOHN'S IS COMMITTED TO PROVIDING SURGICAL SERVICE FOR GENERAL, ORTHOPEDIC, OB/GYN, AND UROLOGY. NEARLY 1,100 SURGERIES WERE PERFORMED AS A RESULT OF THIS SERVICE.PHYSICAL THERAPY SERVICES OFFERED TO RESIDENTS OF LINCOLN COUNTY ENABLE PATIENTS TO RECEIVE SERVICE CLOSE TO HOME WHEN THEY ARE ALREADY STRUGGLING WITH PHYSICAL LIMITATIONS. OUR THERAPY STAFF ARE ABLE TO MAXIMIZE THE PATIENT'S LIMITATIONS FOR THERAPY AND ASSURE THAT THEY ARE ON A WELL-DESIGNED PROGRAM OF RECOVERY. OVER 1,900 PATIENTS WERE CARED FOR IN THIS PROGRAM DURING THE FISCAL YEAR 2012. 22160808 1 1 0 0 0 0 0 0 1 0 1 0 0 1 0 1 1 0 0 0 0 0 0 0 0 0 1 1 1 0 1 0 0 0 1 0 0 1 0 1 0 0 0 0 1 1 0 0 0 1 46 0 1 296 1 1 1 0 0 0 0 0 0 0 0 0 X 9 7 0 0 0 0 0 0 0 1 0 0 0 1 1 1 1 1 1 1 1 0 X GAYL SMITH CONTROLLER 4062837139 350 LOUISIANA AVENUE LIBBY MT 59923 KATHY NELSON 1.00 X X 0 0 0 JOHN KONZEN 1.00 X X 0 0 0 SARAH DINNING 1.00 X X 0 0 0 RUSS BARNES 1.00 X 0 0 0 KERRY BEASLEY 1.00 X 0 0 0 STEVE SORENSON OD 1.00 X 0 0 0 CHARI LUCAS 1.00 X 0 0 0 BOB CASTANEDA 1.00 X 0 0 0 JAY MALONEY MD 36.00 X 224339 0 17304 JOHN SCHWANTZ 40.00 X 0 0 0 STEVEN CHAVEZ 40.00 X 119067 0 12077 BILL PATTEN 40.00 X 199050 0 20371 JOSHUA URVATER 40.00 X 377739 0 11270 ANNE CAMBER 32.00 X 251049 0 23400 MARK SERRA 36.00 X 267557 0 12096 BRIAN BARSTAD 36.00 X 275374 0 13540 LOREN CLAUSEN 40.00 X 160385 0 11662 1874560 0 121720 17 0 1 0 CTA 1185 GROVE STREET BOISE ID 83702 ARCHITECTURE CONSULTANT 671580 KALISPELL REGIONAL HOSPITAL 310 SUNNYVIEW LANE KALISPELL MT 59901 TECHNOLOGY SERVICES 428428 XTEND HEALTHCARE LLC 500 WEST MAIN STREET SUITE 14 HENDERSONVILLE TN 37075 PER DIEM BUSINESS OFFICE STAFF 207840 PAML PO BOX 2720 SPOKANE WA 99220 LABORATORY SERVICES 107922 4 169600 65542 418077 165000 653219 NET PATIENT SERVICE RE 622110 27826306 27826306 OTHER REVENUE 900099 192274 150545 41729 CAFETERIA 722210 98043 98043 AUXILIARY REVENUE 900099 7653 7653 28124276 71084 71084 66660 6845 59815 59815 59815 52471 186108 35184 54652 17287 131456 148743 148743 29057137 28082547 41729 279642 6990 6990 342240 342240 120126 120126 12865072 10264267 2475424 125381 454037 364221 85418 4398 1693677 1372360 304938 16379 905453 677346 218809 9298 292074 292074 48645 48645 46750 46750 1771800 983711 779849 8240 66505 1385 65120 510301 415859 89399 5043 332852 178181 154671 279533 230360 46362 2811 27907 20669 7238 130948 130948 1251399 1251399 343564 343564 BAD DEBTS 2530900 2530900 MEDICAL SUPPLIES 1960937 1952619 8318 REPAIRS AND MAINTENANCE 1016926 724668 289871 2387 LICENSES AND TAXES 197690 23765 173925 981204 749908 190572 40724 28177530 22160808 5802061 214661 943413 1322522 5110980 4582442 4500 4861 661432 606414 500958 528886 21894698 12245601 9590823 9649097 4760504 4842388 23396 64482 2392091 2856177 23988097 24457269 3080042 2371747 33050 58988 1954077 2039985 5067169 4470720 X 16878060 17749152 1149377 1343906 893491 893491 18920928 19986549 23988097 24457269 X 879607 186014 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 1 11218 13146 15279 9085 0 372000 603017 975017 6819437 3914084 2905353 10411584 7793986 2617598 3688660 537531 3151129 9649097 INTEREST IN NET ASSETS OF FOUNDATION 2452616 ESTIMATED THIRD-PARTY PAYOR SETTLEMENTS 403561 2856177 29057137 28177530 879607 28362 157652 186014 1065621 29055884 11000 11000 29044884 12253 12253 29057137 28174144 0 28174144 3386 3386 28177530 PART IV, LINE 1B: THE ASSETS OF ST. JOHN'S HOSPITAL AUXILIARY ARE HELD BY ST. JOHN'S LUTHERAN HOSPITAL. THE AUXILIARY ACCOUNT BALANCES WERE NOT INCLUDED IN THE BALANCE SHEET AS THEY ARE NOT RECORDED FOR AUDIT PURPOSES. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: THE HOSPITAL IS A MONTANA NONPROFIT CORPORATION AND HAS BEEN RECOGNIZED BY THE INTERNAL REVENUE SERVICE (IRS) AS EXEMPT FROM FEDERAL INCOME TAXES UNDER SECTION 501(C)(3). THE HOSPITAL IS ANNUALLY REQUIRED TO FILE A RETURN OF ORGANIZATION EXEMPT FROM INCOME TAX (FORM 990) WITH THE IRS. IN ADDITION THE HOSPITAL IS SUBJECT TO INCOME TAX ON NET INCOME THAT IS DERIVED FROM BUSINESS ACTIVITIES THAT ARE UNRELATED TO ITS EXEMPT PURPOSE. THE ORAGANIZATION FILES AN EXEMPT ORGANIZATION BUSINESS INCOME TAX RETURN (FORM 990T) WITH THE IRS TO REPORT ITS UNRELATED BUSINESS TAXABLE INCOME. THE HOSPITAL BELIEVES THAT IT HAS APPROPRIATE SUPPORT FOR ANY TAX POSITIONS TAKEN AFFECTING ITS ANNUAL FILING REQUIREMENTS, AND AS SUCH, DOES NOT HAVE ANY UNCERTAIN TAX POSITIONS THAT ARE MATERIAL TO THE FINANCIAL STATEMENTS. THE HOSPITAL WOULD RECOGNIZE FUTURE ACCRUED INTEREST AND PENALTIES RELATED TO UNRECOGNIZED TAX BENEFITS AND LIABILITIES IN INCOME TAX EXPENSE IF SUCH INTEREST AND PENALTIES ARE INCURRED. THE HOSPITAL'S FEDERAL FORM 990T FILINGS ARE NO LONGER SUBJECT TO FEDERAL TAX EXAMINATIONS BY TAX AUTHORITIES FOR YEARS BEFORE 2009. PART XI, LINE 8 - OTHER ADJUSTMENTS: CHANGE IN UNRESTRICTED INVESTMENT IN NET ASSETS OF FOUNDATION -72,445. CHANGE IN TEMPORARILY RESTRICTED INVESTMENT IN FOUNDATION 227,970. ROUNDING -6. CHANGE IN ST. JOHN'S HOSPITAL AUXILIARY ASSETS 2,133. TOTAL TO SCHEDULE D, PART XI, LINE 8: 157,652. PART XII, LINE 2D - OTHER ADJUSTMENTS: DONATION FROM AUXILIARY ELIMINATED FOR TAX RETURN PURPOSES 11,000. PART XII, LINE 4B - OTHER ADJUSTMENTS: FUNDRAISING INCOME FROM AUXILIARY 4,600. REVENUE FROM AUXILIARY NOT RECORDED IN AUDITED FINANCIAL STATEMENTS 7,653. PART XIII, LINE 4B - OTHER ADJUSTMENTS: ST. JOHN'S HOSPITAL AUXILIARY EXPENSES INCLUDED ON FORM 990 3,386. 1 1 X 1 X 1 X 1 1 1 0 1 1 532000 0 532000 0.02070 2764659 1989845 774814 0.03020 3296659 1989845 1306814 0.05090 18 4139 88843 7060 81783 0.00320 2 159 303 303 0.00000 1 250 2804167 1414299 1389868 0.05420 2 0 14504 500 14004 0.00050 23 4548 2907817 1421859 1485958 0.05790 23 4548 6204476 3411704 2792772 0.10880 1 3040 3040 0.00010 1 871 871 0.00000 64675 64675 0.00250 2 68586 68586 0.00260 0 2530900 98000 7849158 7760550 88608 X 1 1 1 1 ST JOHN'S LUTHERAN HOSPITAL

350 LOUISIANA AVE LIBBY MT 59923

X X X X 2 REHAB, 1 OB/GYN, 1 HOME HEALTH,1 HOSPICE ST JOHN'S LUTHERAN HOSPITAL 1 1 1 100.000000000000 1 250.000000000000 1 X X X X 1 1 X X 1 0 1 X 1 1 PART I, LINE 7: CHARITY CARE EXPENSE WAS CONVERTED TO COST ON LINE 7A USING THE COST-TO-CHARGE RATIO DERIVED FROM WORKSHEET 2. UNREIMBURSED MEDICAID ON LINE 7B WAS CALCULATED USING THE COST-TO-CHARGE RATIO DERIVED FROM WORKSHEET 2. COMMUNITY HEALTH IMPROVEMENT SERVICES, LINE 7E, AND CASH AND IN-KIND CONTRIBUTIONS, LINE 7I, ARE REPORTED BASED ON THE AMOUNTS COMPILED IN THE CBISA REPORT. THE COST FOR SUBSIDIZED HEALTH SERVICES ON LINE 7G WAS DETERMINED USING THE MEDICARE COST REPORT. TOTAL COMMUNITY BENEFIT EXPENSE AS A PERCENTAGE OF TOTAL EXPENSE IS 10.88%. PART I, LINE 7G: COSTS OF $205,457 TO OPERATE A CLINIC WERE INCLUDED IN SUBSIDIZED HEALTH SERVICES REPORTED ON LINE G. PART I, L7 COL(F): THE AMOUNT OF BAD DEBT EXPENSE BACKED OUT OF TOTAL EXPENSES TO DETERMINE THE PERCENTAGE WAS $2,530,900. PART II: ST. JOHN'S LUTHERAN HOSPITAL IS OFFICIALLY DESIGNATED AS A HEALTH PROFESSIONS SHORTAGE AREA. THE COMMUNITY BUILDING WORKFORCE DEVELOPMENT COSTS OF $64,675 INCLUDE RECRUITING EXPENSES AND MOVING EXPENSES FOR THREE PHYSICIANS. PART III, LINE 4: THE ORGANIZATION'S BAD DEBT IS REPORTED AS CHARGES INCURRED DURING THE YEAR.BAD DEBT IS THE UNPAID OBLIGATION FOR CARE PROVIDED TO PATIENTS WHO MAY BE UNABLE OR UNWILLING TO PAY OR WHO DO NOT QUALIFY FOR CHARITY CARE. PRIOR TO ANY ACCOUNT BEING CLASSIFIED AS BAD DEBT, ALL PAYMENTS ARE APPLIED INCLUDING CONTRACTUAL ALLOWANCES AND DISCOUNTS FROM MEDICARE, MEDICAID, AND INSURANCE COMPANIES. ACCOUNTS FROM PATIENTS QUALIFYING FOR CHARITY CARE OR THE SHAREPAY SLIDING SCALE FINANCIAL ASSISTANCE PROGRAM ARE NOT WRITTEN OFF TO BAD DEBT. EVERY EFFORT IS MADE WITH THE PATIENT IN AN ATTEMPT TO COLLECT THE OUTSTANDING BALANCE. PAYMENTS ON ACCOUNTS THAT WERE WRITTEN OFF AS BAD DEBT REDUCES BAD DEBT EXPENSE.ST. JOHN'S LUTHERAN HOSPITAL BUDGETS FOR AND MONITORS THE LEVEL OF CHARITY CARE IT PROVIDES, AND DURING FY 2012 THE ORGANIZATION EXCEEDED ITS BUDGETED AMOUNT FOR CHARITY CARE. THE ORGANIZATION STILL PROVIDED FREE OR DISCOUNTED CARE TO PATIENTS WHO WERE ELIGIBLE. THE ESTIMATED AMOUNT OF THE ORGANIZATION'S BAD DEBT EXPENSE ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S CHARITY CARE POLICY IS CALCULATED BASED ON AN ESTIMATE OF CHARITY CARE TO GROSS CHARGES.FOOTNOTE TO FINANCIAL STATEMENTS:THE CARRYING AMOUNT OF PATIENT RECEIVABLES IS REDUCED BY A VALUATION ALLOWANCE THAT REFLECTS MANAGEMENT'S ESTIMATE OF THE AMOUNTS THAT WILL NOT BE COLLECTED FROM PATIENTS AND THIRD-PARTY PAYORS. MANAGEMENT REVIEWS ALL PATIENT RECEIVABLES BY PAYOR CLASS AND APPLIES PERCENTAGES TO DETERMINE ESTIMATED AMOUNTS THAT WILL NOT BE COLLECTED FROM THIRD PARTIES UNDER CONTRACTUAL AGREEMENTS AND AMOUNTS THAT WILL NOT BE COLLECTED FROM PATIENTS DUE TO BAD DEBTS. MANAGEMENT CONSIDERS HISTORICAL WRITE OFF AND RECOVERY INFORMATION IN DETERMINING THE ESTIMATED BAD DEBT PROVISION. PART III, LINE 8: TOTAL REVENUE RECEIVED FROM MEDICARE IS THE GROSS REIMBURSEMENT PLUS SETTLEMENT. BOTH TOTAL REVENUE RECEIVED FROM MEDICARE AND THE MEDICARE ALLOWABLE COSTS ARE REPORTED FROM THE MEDICARE COST REPORT. PART III, LINE 9B: THERE ARE NO COLLECTION EFFORTS FOR PATIENTS WHO ARE KNOWN TO QUALIFY FOR CHARITY CARE OR WHO QUALIFY FOR SHAREPAY, A SLIDING SCALE FINANCIAL ASSISTANCE PROGRAM DESIGNED TO MEET THE MEDICAL FINANCIAL OBLIGATIONS OF THE UNINSURED AND UNDERINSURED. ST. JOHN'S LUTHERAN HOSPITAL PART V, SECTION B, LINE 13G: A SUMMARY OF THE FINANCIAL ASSISTANCE POLICY IS PROVIDED WITH BILLING INVOICES AND IS POSTED IN THE FACILITY'S EMERGENCY ROOM AND WAITING ROOMS. ST. JOHN'S LUTHERAN HOSPITAL PART V, SECTION B, LINE 19D: ST. JOHN'S LUTHERAN HOSPITAL, INC. IS IN THE PROCESS OF REVISING THIS POLICY. ST. JOHN'S LUTHERAN HOSPITAL PART V, SECTION B, LINE 20: ST. JOHN'S LUTHERAN HOSPITAL, INC. IS IN THE PROCESS OF REVISING THIS POLICY. CURRENTLY THE FINANCIAL ASSISTANCE POLICY IS BEING APPLIED TO GROSS CHARGES. ST. JOHN'S LUTHERAN HOSPITAL PART V, SECTION B, LINE 21: ST. JOHN'S LUTHERAN HOSPITAL, INC. IS IN THE PROCESS OF REVISING THIS POLICY. PART VI, LINE 2: A COMPLETE COMMUNITY HEALTH NEEDS ASSESSMENT WAS CONDUCTED AND COMPLETED DURING THE 2011 FISCAL YEAR BY ST. JOHN'S LUTHERAN HOSPITAL IN COOPERATION WITH THE MONTANA OFFICE OF RURAL HEALTH AND THE NATIONAL RURAL HEALTH RESOURCE CENTER. ALL MAJOR MEDICAL ENTITIES IN THE COMMUNITY WERE INVOLVED WITH THE DEVELOPMENT OF THE SURVEY AND DISTRIBUTION OF THE RESULTS. ST. JOHN'S LUTHERAN HOSPITAL IS CURRENTLY WORKING ON A NEW COMMUNITY HEALTH NEEDS ASSESSMENT. PART VI, LINE 3: BROCHURES ARE AVAILABLE AT THE HOSPITAL IN WAITING AREAS. IN ADDITION, THE HOSPITAL EMPLOYS A FULL-TIME TRAINED PATIENT FINANCIAL SERVICES COUNSELOR TO ASSIST PATIENTS IN DETERMINING IF THEY QUALIFY FOR MEDICAID AS WELL AS FREE OR DISCOUNTED CARE. THE COUNSELOR ALSO PROVIDES HANDS-ON ASSISTANCE TO PATIENTS APPLYING FOR OTHER FINANICAL ASSISTANCE SUCH AS CHIP'S, HEATING ASSISTANCE, MEDICAID, AND WIC. APPLICATIONS FOR CHARITY CARE ARE ALSO DISCUSSED AT REGISTRATION AND DISCHARGE AND WITH PATIENTS WHO HAVE BILLS THAT ARE PAST DUE. PART VI, LINE 4: ST. JOHN'S LUTHERAN HOSPITAL IS LOCATED IN LIBBY IN NORTHWESTERN MONTANA, 72 MILES SOUTH OF THE CANADIAN BORDER, 89 MILES NORTHWEST OF KALISPELL, MONTANA, AND 35 MILES EAST OF THE IDAHO BORDER. LIBBY BECAME THE COUNTY SEAT FOR LINCOLN COUNTY IN 1909, THE COUNTY BEING NAMED AFTER PRESIDENT ABRAHAM LINCOLN. HELICOPTER TRANSPORT SERVICES ARE AVAILABLE TO PATIENTS REQUIRING SPECIALIZED CARE IN A LARGER HOSPITAL IN SPOKANE, KALISPELL OR MISSOULA. THE CLOSEST HOSPITAL IS BONNER GENERAL HOSPITAL ABOUT 47 MILES FROM LIBBY IN SANDPOINT, ID. RESIDENTS WITH INCOME BELOW POVERTY LEVEL IN 2011 WAS 16.3% COMPARED TO 14.6% IN THE STATE OF MONTANA. THE MEDIAN HOUSEHOLD INCOME WAS $30,107, WHICH IS SIGNIFICANTLY BELOW THE STATE AVERAGE. LINCOLN COUNTY IS THE LARGEST PRODUCER OF WOOD PRODUCTS IN MONTANA AND FIRST IN THE STATE IN COMMERCIAL FOREST LAND. UNEMPLOYMENT IN LIBBY WAS 15.1% IN 2011 WHICH IS ABOVE THE STATE AVERAGE. PART VI, LINE 5: ST. JOHN'S LUTHERAN HOSPITAL IS A NON-DENOMINATIONAL COMMUNITY HOSPITAL. IT IS A 25 BED FACILITY, 25 ACUTE CARE OF WHICH 3 ARE ICU BEDS, WITH A WIDE RANGE OF SURGICAL SERVICES AND EMERGENCY CARE. ST. JOHN'S LUTHERAN HOSPITAL IS ACTIVELY INVOLVED WITH MANY COMMUNITY PARTNERS TO PROMOTE HEALTH TO THE COMMUNITY. ORGANIZING AND FUNDING A COMMUNITY HEALTH FAIR, PROVIDING DISCOUNTED SERVICES FOR MAMMOGRAPHY, LABORATORY TESTS, AND X-RAYS, PROVIDING SPEAKERS FOR HEALTH LECTURES, AND PROVIDING SUPPORT FOR RECRUITING OF PHYSICIANS ARE JUST A FEW OF THE WAYS ST. JOHN'S HELPS THE COMMUNITY.OUR BOARD OF DIRECTORS IS COMPRISED ENTIRELY OF LOCAL RESIDENTS, NONE OF WHOM ARE EMPLOYEES OR CONTRACTORS. TO MEET THE NEEDS OF THE COMMUNITY, THE HOSPITAL EXTENDS MEDICAL STAFF PRIVILEGES TO ALL QUALIFIED, LICENSED PHYSICIANS IN THE COMMUNITY. SURPLUS FUNDS ARE REINVESTED FOR THE REPLACEMENT/ADDITION OF CAPITAL EQUIPMENT AND FACILITY UPKEEP. REPORTS FILED WITH STATES PART VI, LINE 7 MT 1 X 0 0 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: THE ORGANIZATION KEEPS ACCOUNTING RECORDS OF THE ORGANIZATIONS THAT RECEIVE ASSISTANCE DURING THE FISCAL YEAR. ORGANIZATIONS INCLUDE OTHER PUBLIC CHARITIES AND COMMUNITY ORGANIZATIONS. ONCE THE FUNDS ARE DISBURSED NO FURTHER MONITORING TAKES PLACE. X X 1 1 X X X X 0 0 0 1 0 0 0 0 0 JAY MALONEY MD 201203 0 0 0 23136 0 11317 0 5988 0 241644 0 0 0 BILL PATTEN 144150 0 0 0 54900 0 10259 0 10112 0 219421 0 0 0 JOSHUA URVATER 307576 0 0 0 70163 0 11270 0 0 0 389009 0 0 0 ANNE CAMBER 203049 0 0 0 48000 0 11413 0 11988 0 274450 0 0 0 MARK SERRA 225650 0 0 0 41907 0 8108 0 3988 0 279653 0 0 0 BRIAN BARSTAD 246434 0 0 0 28940 0 7037 0 6504 0 288915 0 0 0 LOREN CLAUSEN 141596 0 0 0 18789 0 7837 0 3824 0 172046 0 0 0 PART I, LINE 1A HEALTH CLUB MEMBERSHIP FEES AND SOCIAL CLUB MEMBERSHIP DUES WERE PAID ON BEHALF OF THE CEO AND CFO. AN AUTOMOBILE EXPENSE ALLOWANCE WAS PROVIDED TO THE CEO. ALL SUCH COMPENSATION IS REPORTED AS TAXABLE COMPENSATION. PART I, LINE 5 THE CEO RECEIVED COMPENSATION BASED ON A SET PERCENTAGE OF NET SERVICE REVENUE, LIMITED TO A MAXIMUM OF $5,000 PER YEAR. JOSHUA URVATER PHYSICIAN SIGN-ON AGREEMENT X 45000 0 0 1 1 MARK SERRA PHYSICIAN SIGN-ON AGREEMENT X 35000 4861 0 1 1 4861 FRANK LUCAS SPOUSE OF TRUSTEE 57964 SALARY AND BENEFITS AS AN EMPLOYEE 0 LAURIE MALONEY SPOUSE OF TRUSTEE 62162 SALARY AND BENEFITS AS AN EMPLOYEE 0 X 1 165000 LAND VALUATION 1 0 0 0 NEW PROGRAM SERVICES FORM 990, PART III, LINE 2 IN JUNE OF 2011, THE ORGANIZATION BEGAN OFFERING NUC MED AS AN ADDITIONAL SERVICE. FORM 990, PART VI, SECTION A, LINE 8B NO COMMITTEE HAS THE AUTHORITY TO ACT ON BEHALF OF THE GOVERNING BODY. FORM 990, PART VI, SECTION B, LINE 11 A DRAFT COPY OF THE FORM 990 AND FORM 990-T WILL BE REVIEWED IN DETAIL BY THE CFO. THE ENTIRE BOARD IS THEN PROVIDED A COPY FOR REVIEW PRIOR TO FILING OF THE FORM 990 AND FORM 990-T RETURNS. FORM 990, PART VI, SECTION B, LINE 12C THE ORGANIZATION REQUIRES ANNUAL CONFLICT OF INTEREST TRAINING FOR ALL OFFICERS, DIRECTORS, AND KEY EMPLOYEES ALONG WITH AN ANNUAL SUBMISSION OF A CONFLICT OF INTEREST FORM. THE BOARD OVERSEES THE PROCESS AND ANY POTENTIAL CONFLICTS ARE DISCUSSED BY THE BOARD. SHOULD A CONFLICT BE DETERMINED, THE CONFLICTED INDIVIDUAL ABSTAINS FROM VOTING ON THE CONFLICTED ISSUE. FORM 990, PART VI, SECTION B, LINE 15 THE BOARD REVIEWS INDEPENDENT SALARY SURVEYS AND OTHER COMPARABILITY DATA TO DETERMINE FAIR MARKET COMPENSATION AMOUNTS FOR OFFICERS AND KEY EMPLOYEES ON AN ANNUAL BASIS, AND THEN TAKES INTO ACCOUNT LOCAL ECONOMIC FACTORS AND SPECIFIC JOB RESPONSIBILITIES. THE PROCESS IS DOCUMENTED AND THE LAST REVIEW WAS PERFORMED IN 2012. FORM 990, PART VI, SECTION C, LINE 19 GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND ANNUAL FINANCIAL STATEMENTS ARE AVAILABLE TO THE PUBLIC UPON REQUEST. REQUESTS MAY BE IN PERSON, BY E-MAIL, IN WRITING, OR BY TELEPHONE. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED GAINS ON INVESTMENTS: 28,362. CHANGE IN UNRESTRICTED INVESTMENT IN NET ASSETS OF FOUNDATION -72,445. CHANGE IN TEMPORARILY RESTRICTED INVESTMENT IN FOUNDATION 227,970. ROUNDING -6. CHANGE IN ST. JOHN'S HOSPITAL AUXILIARY ASSETS 2,133. TOTAL TO FORM 990, PART XI, LINE 5: 186,014. FORM 990, PAGE 7, PART VII: THE FOLLOWING INDIVIDUAL DEVOTED TIME PROVIDING SERVICES TO ST. JOHN'S LUTHERAN HOSPITAL FOUNDATION, A RELATED ORGANIZATION. BILL PATTEN 2.00 HOURS PER WEEK AS DIRECTOR AND CEO ST JOHN'S LUTHERAN HOSPITAL FOUNDATION 350 LOUISIANA AVENUE LIBBY MT 59923 810425832 SUPPORT THE DEVELOPMENT OF ST. JOHN'S LUTHERAN HOSPITAL MT 501(C)(3) 11B N/A 0 ST JOHN'S REAL ESTATE CORPORATION 350 LOUISIANA AVENUE LIBBY MT 59923 201538952 SUPPORT THE DEVELOPMENT OF ST. JOHN'S LUTHERAN HOSPITAL MT 501(C)(2) N/A N/A 1 0 0 1 0 0 0 0 0 0 0 0 1 1 1 0 0 0 0 ST JOHN'S REAL ESTATE CORPORATION