2012-07-26T10:13:51-05:00 2011-12-31 911194016 Clark Nuber PS 10900 NE 4th Suite 1700 Bellevue WA 98004 990 2011-01-01 930575982 PROVIDENCE ST VINCENT MEDICAL FOUNDATION PROV 5038936460 9205 SW BARNES ROAD PORTLAND OR 97225 Eli Morgan 5038936460 2012-07-26 1 Sara Elizabeth J Hyre CPA P00235495 4254544919 2011 2016-02-24 21:20:13Z Richard Clark 9205 SW BARNES ROAD PORTLAND OR 97225 117871907 0 X www.providencefoundations.org/foundations/pages/ X 1969 OR To support Providence St. Vincent Medical Center. 26 25 0 85 0 0 7586764 5300462 0 0 9158800 10265480 292990 333786 17038554 15899728 7699261 14713626 0 0 346983 351610 352 0 388996 473643 457151 8520239 15522387 8518315 377341 148802707 140104098 4635844 8564703 144166863 131539395 X As People of Providence, we reveal God's love for all, especially the poor and vulnerable, through our compassionate service.Support the ministries of Providence St. Vincent Medical Center. 0 0 12101585 12101585 0 Funding of operations at Providence St Vincent Medical Center and PH&S-Oregon.This includes $3.5 million for an IMRI Surgical suite, $1.8 million for the hospital Heart and Vascular Center, and $2.8 million to medical research, in addition to helping support the day-to-day operations of the St Vincent Medical Center. 2467413 2467413 0 Nursing scholarships and loans. The Foundation has entered into student loan agreements with nursing students at a local university. Under these agreements, the Foundation pays for nursing student tuition. If the nursing student is subsequently employed by Providence Health & Services (PH & S),the student loan agreements are forgiven over a three-year period by the Foundation. In the event the nursing students are not employed by PH & S, the student loan agreements become due.Since it began, the nursing scholarship program has helped over 400 students become nurses. 126216 126216 0 The Foundation provided $126,216 in assistance to Catholic Charities for its administration of the Helping Hand fund, which provided living assistance to employees within the PH & S - Oregon corporation. 10000 10000 0 Scholarships for medical education for four students. 8412 8412 0 Donation to YMCA to support community programs. 18412 18412 14713626 1 1 0 0 0 0 0 0 0 1 1 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 1 0 0 0 0 1 0 0 0 0 1 X 28 0 1 0 0 0 0 0 0 0 0 0 0 0 X 26 25 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 OR X Steve Cassell 5032154773 1235 NE 47th St 260 Portland OR 97213 X Eli Morgan 2.00 X X 0 0 0 Kevin Kelly 2.00 X X 0 0 0 Paul Rosenbaum 2.00 X X 0 0 0 Patricia Karamanos 2.00 X X 0 0 0 Marty Brantley 2.00 X X 0 48000 0 Sandy Andersen 2.00 X 0 0 0 Chris Anderson 2.00 X 0 0 0 Henry Ashforth 2.00 X 0 0 0 Molly Bordonaro 2.00 X 0 0 0 Timothy Boyle 2.00 X 0 0 0 Peter Brix 1.00 X 0 0 0 Andy Bryant 1.00 X 0 0 0 Storm Floten 1.00 X 0 0 0 Ed Jensen 1.00 X 0 0 0 Lynn Johnson 1.00 X 0 0 0 Bruce Korter 1.00 X 0 0 0 Paul Linnman 1.00 X 0 0 0 John Miner 1.00 X 0 0 0 Susan Paulsell 1.00 X 0 0 0 Norma Paulus 1.00 X 0 0 0 Bill Reiersgaard 1.00 X 0 0 0 Steve Shepard 1.00 X 0 0 0 Laura Spear 1.00 X 0 0 0 Donald Vollum 1.00 X 0 0 0 Rick Waller MD 1.00 X 0 0 0 Donald Washburn 1.00 X 0 0 0 Dick Clark 40.00 X 0 152186 25964 0 200186 25964 0 0 1 0 0 5546 2229285 3065631 451404 5300462 350343 350343 111381958 101466821 9915137 9915137 9915137 839144 505358 333786 333786 15899728 0 0 10599266 14713626 14713626 161636 48491 113145 114789 34431 80358 75185 22555 52630 400 400 260608 260608 56476 16943 39533 7564 7564 82686 24806 57880 510 153 357 31812 9544 22268 Donor Recognition 13784 13784 Dues & Subscriptions 1959 588 1371 State of OR Annual Fee 1200 1200 Miscellaneous 152 46 106 15522387 14713626 419765 388996 4926807 1460929 3242659 2248172 6821390 5527596 40664 48496 3565664 2521940 3565664 125100641 119719586 6148606 7533655 148802707 140104098 9711 17100 1853046 2561202 2773087 5986401 4635844 8564703 X 105165238 96942137 28152403 23580841 10849222 11016417 144166863 131539395 148802707 140104098 X 377341 -13004809 X X 0 1 1 X 0 X 10324270 6848030 9236104 7586764 5300462 39295630 10324270 6848030 9236104 7586764 5300462 39295630 3173716 36121914 3198293 632186 524064 527512 350343 5232398 44528028 3700890 0.81120 0.80850 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 13557000 217345 -372498 437681 12964166 12178000 6000 1691000 318000 13557000 11098000 15000 1217000 152000 12178000 10863000 241000 -1000 5000 11098000 0.00000 0.85000 0.15000 0 0 3565664 3565664 3565664 Cash Surrender Value - Life Insurance 137821 Artwork and Paintings 264878 Cemetery Plots 3600 Gift Annuities & Trusts 7127356 7533655 Gift Annuity and Trust Liabilities 5144516 Due to Affiliates 841885 5986401 Description of Intended Use of Endowment Funds: Part V, Line 4: The endowment funds provide for medical research, patient care and capital needs of Providence St Vincent Medical Center. 2011 funds were used for the Laser Lab, Medical Research and the Department of Medicine. Description of Uncertain Tax Positions Under FIN 48: Part X: Accounting principles generally accepted in the United States of America require the Foundations' management to evaluate tax positions taken by the Foundations and recognize a tax liability (or asset) if the Foundation has taken an uncertain position that more likely than not be sustained upon examination by the IRS. Management has analyzed tax positions taken by the Foundations and has concluded that as of June 30, 2011, there are no uncertain positions taken or expected to be taken that would require recognition of a liability (or asset) or disclosure in the combined financial statements. 1 PH&S-OR dba Providence St Vincent Medical Center 9205 SW Barnes Rd Portland OR 97225 930575982 501 (c)(3) 11248585 general support PH&S-OR dba Providence Shared Services PO Box 13993 Portland OR 97213 930823489 501 (c)(3) 853000 general support University of Portland 5000 N Willamette Blvd Portland OR 97203 930401259 501 (c)(3) 2467413 Nursing Loans Catholic Charities 231 SE 12th Ave Portland OR 97214 930386801 501 (c)(3) 126216 Employee Assistance Program George Fox University 414 N Meridian St Newberg OR 97132 930386839 501 (c)(3) 5000 Scholarships YMCA of Columbia - Willamette 955 SW Barbur Blvd 240 Portland OR 97219 930386981 501 (c)(3) 8412 Annual Fund Program Support 5 0 Procedure for Monitoring Grants in the U.S.: Part I, Line 2: Schedule I, Part I, Line 2: As most grants go to an affiliated company, the Foundation has access to the Financial reports of Providence St. Vincent Medical Center and can review these records for appropriate use of funds. Providence's regional nursing manager works with all educational institutions to monitor the nursing education funds provided to each school. The Foundation has worked closely with Catholic Charities in establishing an Employee Assistance Program. Financial records are provided as requested by the Foundation. 0 0 0 0 0 0 0 0 0 Dick Clark 0 147741 0 4445 0 0 0 9449 0 16515 0 178150 0 0 X 15 451404 Average High/Low 0 0 1 0 Method for Determining Number of Contributors: Part I, Column (b): The amounts shown on Part I, Col. B reflect the number of donations received of the specific type of item. Form 990, Part VI, Section A, line 6 The Corporate Member of the Foundation is Providence Health & Services - Oregon, a not-for-profit corporation. Form 990, Part VI, Section A, line 7a The Corporate Member has the power to approve the number of Directors, appoint the Board of Directors of the Foundation and remove such Directors at any time with or without cause. Form 990, Part VI, Section A, line 7b The following powers are reserved exclusively to the Corporate Member: * Adopt and amend the Articles of Incorporation and the Bylaws of the Foundation after consultation with the Foundation's Board of Directors. * Approve the merger, consolidation, or affiliation of the Foundation with another corporation, organization or program, or the dissolution of the Foundation. * Approve any strategic plan of the Foundation. * Approve the annual fundraising plan including special events, annual, capital and planned giving activities. * Approve the acceptance of any gift that carries conditions or limitations or any gift restricted to services, programs or facilities not currently offered or approved to be offered by the Corporate Member's Board. * Develop and implement investment policies and/or guidelines that will be used by the Foundation in determining appropriate investments. Form 990, Part VI, Section B, line 11 The Form 990 is prepared internally by experienced staff and reviewed by the internal Director of Taxes and external tax advisors. The Foundation Director and signing Board Officer will review the Form 990 in detail. Once approved, an electronic copy of the Form 990 is emailed to the Board prior to filing with the IRS. Form 990, Part VI, Section B, line 12c Providence Health & Services maintains a conflict of interest policy that applies to board members and management of all Providence-related organizations. The purpose of the policy is to guide and direct those serving the Providence Health & Services' corporations and other legal entities so they can (1) fulfill their fiduciary responsibilities and exercise stewardship in ways that promote and protect the best interests of Providence and, (2) avoid situations that create a conflict, or the appearance of a conflict, between the interests of an individual associated with Providence and Providence. On an annual basis, each board member and management level employee must complete and submit an updated conflict of interest statement. Conflict of interest disclosures are reviewed by the System Integrity Department working in conjunction with the Department of Legal Affairs. If it is determined that an actual conflict exists, appropriate follow-up action is taken with the individual to rectify the conflict. Form 990, Part VI, Section B, line 15 It is Providence's intention to make financial information accessible and transparent. Although the filing of Form 990 provides insight into how Providence achieves its Mission, delivers its programs and stewards its finances, deciphering the information directly from Form 990 can be challenging. The following paragraphs provide further information about the process we use to determine compensation for top management, officers and key employees. Providence has a single fiduciary Board, with responsibility for financial oversight associated with fulfillment of the Providence Mission, developing system policies, protecting the assets entrusted to the organization and overseeing the strategic and operational affairs of Providence's legal entities. Providence also maintains a network of community ministry boards with responsibility for quality of care oversight, community relations, advocacy and community needs assessments. Providence has a consistent compensation philosophy for all of its employees, including our senior executives. Salaries for senior executives are determined by the Providence 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 consultants role is to review an extensive array of compensation surveys of large, not-for-profit health care systems in the United States. Providence is one of the larger health systems in the country, and as such, the Board benchmarks executive compensation against other large, not-for-profit health systems whose revenue is similar to that of Providence. Base salaries for Providence executives are set at the median level of the market, as identified by the independent consultant and reviewed with the Human Resources Committee. Performance incentives allow executives to earn additional compensation if they achieve specific organizational and individual goals for furthering Providence operating principles - advancing the Providence Mission and core values, meeting benchmarks for charity care, achieving quality targets, delivering top-rated customer satisfaction, meeting employee satisfaction goals and reaching financial performance objectives. The Board of Directors conducts a thorough process to ensure performance incentives are aligned with appropriate practices for not-for-profit health care systems. The Board's process for executive compensation fully complies with IRS standards and mirrors the best practices recommended in the "Report to Congress and the Nonprofit Sector on Governance, Transparency, and Accountability" submitted to the Senate Finance Committee by the Panel on the Nonprofit Sector. The Foundation Executive Director is compensated by a related organization which uses a market based compensation program utilizing several independent third party compensation market surveys to establish pay ranges for the position. The related organization then establishes the individual rate of pay within the range based on relevant experience, skills and competencies. The rate offered to the Executive Director at the time of hire was determined through discussion between the Regional CEO, Regional Director of HR and the Administrative Director of HR. The ranges and rate of pay are reviewed on an annual basis by Regional HR. Form 990, Part VI, Section C, line 19 Public disclosure of governing documents, conflict of interest policy and 990 filings are made available to the public upon written request. The consolidated Health System financial statements are available on our public Internet site www2.providence.org. All governing policies including the conflict of interest policy, as well as 990 filings are available to employees on the Intranet site. Changes in Net Assets or Fund Balances: Form 990, Part XI, line 5: Net unrealized losses on investments: -13,004,810. Rounding 1. Total to Form 990, Part XI, Line 5: -13,004,809. VOLUNTEERS FORM 990, PART I, LINE 6 Our Foundation volunteers are crucial for the successful operation of our two gift shops, which provide net proceeds for important Foundation-funded hospital projects. Additionally, we have several community volunteer leaders who actively participate as ambassadors on our Advisory Boards for the Institutes for Heart and Vascular, Cancer, Brain, Ethics and Breast Center. Lastly, we have two volunteers who offer clerical support for the Foundation office. 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. EMPLOYEE COMPENSATION Form 990, PART I, LINE 5 & Part V, Line 2a The employees working at the Foundation are paid by Providence Health & Services - Oregon EIN# 51-0216587. Therefore, no W-2s are issued by the reporting organization. TRUSTEE COMPENSATION REPORTED FORM 990, PART VII Marty Brantley, Immediate Past President, was paid by Providence Health & Services - Oregon for consulting services provided to the Medical Center. 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 1067 Everett WA 982061067 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 3601 SW Murray Blvd 10 Beaverton OR 97005 911861964 Healthcare Services OR 501( c)(4) N/A PH & S - Oregon 0 Providence Health Plan 3601 SW Murray Blvd 10 Beaverton OR 97005 930863097 Health Service Contractor OR 501( c)(4) N/A Providence Plan Partners 0 Providence Health Assurance 3601 SW Murray Blvd 10 Beaverton OR 97005 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 - 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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 Willamette Falls Hospital dba Providence Willamette Falls Medical Center 1500 Division Street Oregon City OR 97045 930426018 Healthcare OR 501(c )(3) Line 3 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 & Activities 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 & Activities of SMMC WA 501(c )(3) Line 7 PH & S - Washington 0 Providence Imaging Center 3340 Providence Drive Anchorage AK 99508 920118807 Medical Imaging AK N/A Providence Surgery Centers LLC PO Box 233889 Anchorage AK 99523 203567411 Surgery AK N/A Mountainstar Clinical Laboratories LLC 611 N Perry Spokane WA 99202 261345983 Outpatient Lab MT N/A Broadway Imaging LLC 500 W Broadway Missoula MT 59802 522405971 Medical Imaging MT N/A Ctr for MedImaging-Tanasbourne LLC 1235 NE 47th Ave Portland OR 97213 200477972 Imaging - Diagnostics OR N/A Ctr for Med Imaging-Bridgeport LLC 1235 NE 47th Ave Portland OR 97213 260796953 Imaging - Diagnostics OR N/A Center for Specialty Surgery LLC 11782 SW Barnes Rd Portland OR 97225 263638838 Ambulatory Surgery Center OR N/A Clackamas Radiation Oncology Center LLC 1235 NE 47th Ave 288 Portland OR 97213 260381897 Radiation Oncology OR N/A Oregon Outpatient Surgery Center 7300 SW Childs Rd Tigard OR 97224 223883387 Ambulatory Surgery Center OR N/A Surgery Ctr at Tanasbourne LLC 1235 NE 47th Ave 260 Portland OR 97213 208187971 Ambulatory Surgery Center OR N/A ProvidenceSilverton Rehab LLC 1235 NE 47th Ave 260 Portland OR 97213 481287267 Rehab Services OR N/A Portland Medical Imaging LLC 10538 SE Washington St Portland OR 97216 201054971 Imaging - Diagnostics OR N/A Prov Radiation Oncology Develop Assn LLC 1235 NE 47th Ave Portland OR 97213 260682491 Real Estate - MOB OR N/A Central Point MRI LLC 870 S Front St Central Point OR 97502 261975164 MRI Services OR N/A Greater Valley Medical Building LP 501 S Buena Vista St Burbank CA 91505 954570858 Real Estate - MOB CA N/A Pathology Associates Medical Laboratories LLC 611 N Perry Spokane WA 99202 270943279 Outpatient Lab WA 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 Alpha Medical Laboratory LLC 611 N Perry Spokane WA 99202 912017347 Outpatient Lab ID N/A PacLab LLC 611 N Perry Spokane WA 99202 911743952 Outpatient Lab WA N/A HealthServicesNW LLC PO Box 389672 Seattle WA 98138 311750915 Medical Billing WA N/A Medalia Healthcare LLC 1801 Lind Ave SW 9016 Renton WA 98057 911660459 Physician Benefits WA N/A Distribution Operations Center LLC 1801 Lind Ave SW 9016 Renton WA 98057 271054858 Supplies Purchasing Agent WA N/A Oregon Advanced Imaging LLC 881 OHare Parkway Medford OR 97504 450471748 Medical Imaging OR N/A ProvidenceUSP Surgery Ctrs LLC 11550 Indian Hills Road 160 Mission Hills CA 91345 200905938 Ambulatory Surgery Center CA N/A California Laboratory Associates LLC 501 Buena Vista Burbank CA 91505 273888692 Outpatient Lab CA N/A Canby Medical Center I LLC 2747 Pence Loop SE Salem OR 97302 205470937 Real Estate - MOB OR N/A ProvidenceUSP Santa Clarita GP LLC 11550 Indian Hills Road 160 Mission Hills CA 91345 202829660 Ambulatory Surgery Center CA N/A Providence Health Ventures Inc 4101 Torrance Blvd Torrance CA 90503 330122216 Investment CA N/A C Caron Health Corporation 510 West Front Street Missoula MT 59802 810486082 Medical Physician Service MT N/A C Providence Health Care Ventures Inc 101 West 8th Ave TAF C-9 Spokane WA 99204 900155714 Clinical/Medical Lab WA N/A C Providence Physician Services Co 101 West 8th Ave TAF C-9 Spokane WA 99208 911216033 Clinical/Medical Lab WA N/A C Yakima Medical Arts Inc 611 N Perry Suite 100 Spokane WA 99202 910787963 Rental Real Estate WA N/A C Bourget Health Services Inc PO Box 2687 Spokane WA 99220 911354431 Clinical/Medical Lab WA N/A C Charitable Remainder Trusts (4) OR T 1.00000 Charitable Remainder Trusts (1) OR T 0.66000 0 1 1 0 0 0 0 1 0 0 0 0 1 1 1 1 1 1