2012-11-13T16:54:48-06:00 2011-12-31 930623286 AKT LLP 5665 SW MEADOWS RD SUITE 200 LAKE OSWEGO OR 97035 990 2011-01-01 930391573 GOOD SAMARITAN HOSPITAL CORVALLIS GOOD 5417684773 C/O SHS ACCOUNTING PO BOX 3000 CORVALLIS OR 973393000 DANIEL B SMITH 5417684773 2012-11-08 0 JOYLYN ANKENEY P00366587 5036204489 2011 2016-02-24 21:20:13Z GOOD SAMARITAN REGIONAL MEDICAL CTR STEVEN W JASPERSON 3600 NW SAMARITAN DR CORVALLIS OR 97330 331424632 0 X WWW.SAMHEALTH.ORG X 1948 OR GOOD SAMARITAN HOSPITAL, CORVALLIS (GSH) ACHIEVES ITS MISSION OF IMPROVING THE HEALTH AND WELL BEING OF THE COMMUNITY THROUGH ITS MEDICAL AND SURGICAL HOSPITAL AND HEALTHCARE CLINICS PROVIDING OUTPATIENT CARE SERVICES AT SEVERAL AREA LOCATIONS. 12 10 2099 251 1201837 -38471 1850641 475861 310274725 326487593 598535 598145 2368336 2707367 315092237 330268966 283825 279287 0 0 162291614 174410975 0 0 252344 145888204 154878894 308463643 329569156 6628594 699810 183573666 184278626 76799467 90912653 106774199 93365973 X GOOD SAMARITAN HOSPITAL, CORVALLIS (GSH) IS A MEMBER OF SAMARITAN HEALTH SERVICES (SHS), A REGIONAL NETWORK OF HOSPITALS, PHYSICIANS AND SENIOR CARE FACILITIES. THE NETWORK, FORMED IN THE LATE 1990'S, SERVES APPROXIMATELY 290,000 RESIDENTS IN LINN, BENTON, LINCOLN AND PORTIONS OF POLK AND MARION COUNTIES IN OREGON. IT IS LOCALLY OWNED, AND ITS BOARDS OF DIRECTORS INCLUDE HOSPITAL LEADERS, PHYSICIANS AND COMMUNITY REPRESENTATIVES. GSH PROVIDES HEALTHCARE SERVICES REGARDLESS OF RACE, COLOR, CREED, SEX, NATIONAL ORIGIN, DISABILITY OR AGE. THE MISSION OF GSH IS TO ENHANCE COMMUNITY HEALTH AND ACHIEVE HIGH VALUE THROUGH QUALITY SERVICES ACROSS A CONTINUUM OF CARE. THE COLLECTIVE VISION OF THE SHS SYSTEM IS TO BE A VALUES-DRIVEN ORGANIZATION GOVERNED BY COMMUNITY MEMBERS, PHYSICIANS AND OTHER HEALTH CARE PROVIDERS. SHS SEEKS TO BE THE FIRST CHOICE OF CONSUMERS IN THE REGION AND TO LEAD COLLABORATIVE EFFORTS AMONG THOSE WHO SHARE SIMILAR GOALS. 0 0 282087781 325642209 GOOD SAMARITAN HOSPITAL CORVALLIS (GSH), THE LARGEST HOSPITAL IN LINN, BENTON AND LINCOLN COUNTIES, OFFERS MORE THAN 22 MEDICAL SPECIALTIES INCLUDING COMPREHENSIVE CANCER CARE, A FULL-SERVICE CARDIOLOGY AND VASCULAR SURGERY PROGRAM, A SLEEP LAB, NEUROSURGERY AND OTHER REGIONAL SERVICES. GSH HAS MORE THAN 1,800 EMPLOYEES AND 200 VOLUNTEERS SERVING THE MEDICAL NEEDS OF THE COMMUNITY. IT IS LICENSED TO OPERATE 188 BEDS AND IS ONE OF ONLY THREE 'LEVEL 2' TRAUMA CENTERS IN THE STATE. DURING 2011, GSH SERVED 9,626 INPATIENTS, HAD 23,213 EMERGENCY DEPARTMENT VISITS, PERFORMED 10,873 SURGERIES AND DELIVERED 1,063 BABIES. IN ADDITION, GSH PERFORMED 71,529 IMAGING PROCEDURES, HAD 33,788 HOME HEALTH VISITS, AND HAD 175,611 PHYSICIAN CLINIC VISITS. 279287 279287 GRANTS AND ASSISTANCE PROVIDED BY GOOD SAMARITAN HOSPITAL CORVALLIS TO VARIOUS ORGANIZATIONS AND INDIVIDUALS TO BENEFIT THE COMMUNITY. SEE PART IX, LINES 1 AND 2 AND RELATED SCHEDULE I FOR MORE DETAILS. 282367068 1 1 0 0 0 0 0 0 0 1 1 0 0 0 1 0 0 1 0 0 0 0 0 0 0 0 1 1 1 1 1 0 0 0 0 0 0 1 0 0 0 0 0 0 1 1 1 1 0 1 7 0 1 2099 1 1 1 0 0 0 0 0 0 0 0 0 X 12 10 0 0 1 0 1 1 1 1 1 0 0 1 1 1 1 1 1 0 0 1 1 OR X X SAMARITAN HEALTH SERVICES 5417684773 PO BOX 3000 CORVALLIS OR 973393000 X BISHOP MICHAEL HANLEY 1.00 X 0 0 0 JAY MCHENRY 1.00 X 0 0 0 NANCY SEIFERT 1.00 X 0 0 0 GILBERT BECK 1.00 X X 0 0 0 CLIFFORD A HALL MD 8.00 X 18610 0 0 RICHARD CRONK MD 1.00 X X 0 0 0 REVEREND SIMON JUSTICE 1.00 X 0 0 0 CARLYN ROY 1.00 X X 0 0 0 SHIRLEY PETERSON 1.00 X X 0 0 0 JUDY LIST 1.00 X X 0 0 0 ERIC THOMPSON 1.00 X 0 0 0 FREDERICK WEISENSEE MD 40.00 X 306313 0 39193 TIM HENNESSY 1.00 X 0 0 0 STEVEN W JASPERSON 40.00 X 0 434923 65366 DANIEL B SMITH 8.00 X 0 320608 51431 KATHRYN M HALE 40.00 X 175948 0 44618 MICHAEL A MAY MD 40.00 X 296349 0 67382 SCOTT WILSON 40.00 X 160067 0 36598 STEVEN GOODWIN MD 40.00 X 632936 0 44030 DONALD PENNINGTON DO 40.00 X 852868 0 51642 TOSHIO NAGAMOTO MD 40.00 X 746778 0 49158 RANDALL V BREAM MD 40.00 X 611665 0 41169 LUIS VELA DO 40.00 X 764077 0 46675 4565611 755531 537262 240 0 1 0 0 453330 22531 475861 NET PATIENT REVENUE 900099 320166306 320166306 RETAIL PHARMACY 446110 6321287 5257233 1064054 326487593 483698 483698 723292 287484 435808 435808 435808 850356 2655 685548 53016 164808 -50361 114447 114447 238019 129618 108401 108401 CAFETERIA 722210 1915106 1915106 MISCELLANEOUS REVENUE 900099 187721 49938 137783 RELEASE OF INFORMATION 561000 50654 50654 9677 9677 2163158 330268966 325642209 1201837 2949059 211903 211903 67384 67384 1145078 948412 196666 130364560 125504874 4769498 90188 10511946 10123497 381240 7209 23336212 22473867 846341 16004 9053179 8718636 328334 6209 227478 227478 4275 4275 5301077 5193553 91206 16318 82114 37988 35887 8239 11117542 10663165 378621 75756 9415564 9415564 3929630 3921361 3851 4418 307093 298341 8752 1040274 944127 89868 6279 5278916 4962625 316291 11311928 11025636 285586 706 2975299 2970607 4692 MEDICAL SUPPLIES 52107654 52107654 PURCHASED SERVICES 41648997 12127185 29501380 20432 DUES, TAXES, & LICENSES 10131053 10066253 64214 586 329569156 282367068 46949744 252344 9434 11479 2169481 2030102 38052553 39678514 101427 441927 380498 5019356 4787976 2072746 2012409 229075285 111998939 119424458 117076346 12908435 12452050 407488 3373849 5441764 183573666 184278626 27279338 27472839 31037 21539 3708000 3708000 7872081 8549506 37909011 51160769 76799467 90912653 X 106774199 93365973 106774199 93365973 183573666 184278626 X 699810 -14108036 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 4975845 106549 -131912 191901 4758581 4582212 211952 443652 261971 4975845 3963225 107306 645769 134088 4582212 4989374 188135 -1015783 198501 3963225 0.20930 0.79070 0 1 1 2208871 2208871 140942257 58587826 82354431 2810337 418054 2392283 69441132 49181254 20259878 13672688 3811805 9860883 117076346 PROFESSIONAL LIABILITY RESERVE 1436000 OTHER LIABILITIES 367913 PAYABLE TO CONTRACTUAL AGENCIES 4356273 MINIMUM PENSION LIABILITY 40601911 ACCRUED INTEREST 1233198 TENANTS DEPOSITS 23583 ACCOUNTS PAYABLE-AFFILIATES 3141891 51160769 330268966 329569156 699810 -894525 -13213511 -14108036 -13408226 330327802 308133 308133 330019669 249297 249297 330268966 329877289 308133 308133 329569156 0 329569156 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: THE GOOD SAMARITAN HOSPITAL FOUNDATION (GSHF) HOLDS ENDOWMENT FUNDS THAT WILL ULTIMATELY BENEFIT THE HOSPITAL. GSHF'S BOARD-DESIGNATED AND GENERAL ENDOWMENTS ARE USED FOR GENERAL HOSPITAL SUPPORT. GSHF'S BERNIER ENDOWMENT IS USED FOR STAFF CONTINUING EDUCATION. GSHF'S ERKKILA ENDOWMENT IS USED FOR HEALTH AND HUMAN PERFORMANCE RESEARCH AND REHABILITATION. GSHF'S MULLINS SCHOLARSHIP ENDOWMENT SUPPORTS EDUCATIONAL SCHOLARSHIPS. GSHF'S PASTEGA HOUSE ENDOWMENT HELPS UNDERWRITE THE OPERATING COSTS OF THE MARIO PASTEGA GUEST HOUSE. GSHF'S VRTISKA ENDOWMENT SUPPORTS THE HOSPITAL'S LABORATORY FOR EDUCATIONAL PURPOSES. PART XI, LINE 8 - OTHER ADJUSTMENTS: DISTRIBUTIONS TO MINORITY INTEREST CONSOLIDATED JVS -1,360,146. INCREASE IN MINIMUM PENSION LIABILITY -11,856,043. OTHER CHANGES IN FUND BALANCE 2,678. TOTAL TO SCHEDULE D, PART XI, LINE 8: -13,213,511. PART XII, LINE 2D - OTHER ADJUSTMENTS: RENT EXP PER AFS NETTED WITH RENT REV PER TAX RETURN 177,954. RENT REV PER AFS NETTED WITH RENT EXP PER TAX RETURN 130,179. PART XII, LINE 4B - OTHER ADJUSTMENTS: CONTRIBUTION REVENUE - CHANGE IN NET ASSETS PER AFS 249,297. PART XIII, LINE 2D - OTHER ADJUSTMENTS: RENT EXP PER AFS NETTED WITH RENT REV PER TAX RETURN 177,954. RENT REV PER AFS NETTED WITH RENT EXP PER TAX RETURN 130,179. 1 1 X 1 X 1 X 1 1 0 1 1 20 8382 10908664 10908664 0.03310 8 55396 41749170 37037547 4711623 0.01430 28 63778 52657834 37037547 15620287 0.04740 24 5873 690592 6034 684558 0.00210 5 4791 7629498 3029989 4599509 0.01400 26 186489 73637280 35175333 38461947 0.11670 17 4367 781753 177954 603799 0.00180 72 201520 82739123 38389310 44349813 0.13460 100 265298 135396957 75426857 59970100 0.18200 2 838 5905 5905 0.00000 1 58 1819 1819 0.00000 3 896 7724 7724 0 4972196 265719 43698995 49515854 -5816859 X 1 1 1 CORVALLIS MED BLDGS LLC REAL PROPERTY RENTAL 0.54500 0.18500 2 HULL IMAGING LLC IMAGING SERVICES 0.60000 0.40000 3 SAMARITAN ENDOSCOPY CENTER MEDICAL SERVICES 0.66670 0.33330 4 CORVALLIS MRI A JV IMAGING SERVICES 0.50000 0.50000 5 CASCADE VIEW MEDICAL OFFICE BUILDING LLC REAL PROPERTY RENTAL 0.34000 0.31450 1 1 GOOD SAMARITAN HOSPITAL CORVALLIS

3600 NW SAMARITAN DRIVE CORVALLIS OR 97330

X X X X GOOD SAMARITAN HOSPITAL CORVALLIS 1 1 1 150.000000000000 1 200.000000000000 1 X X X X X X 1 1 X X X 1 0 1 X 0 0 28 SAMARITAN REGIONAL CANCER CENTER

501 NW ELKS DR CORVALLIS OR 97330

RADIATION ONCOLOGY SAMARITAN ORTHOPEDICS CLINIC

3620 NW SAMARITAN DR STE 202 CORVALLIS OR 97330

MEDICAL CLINIC - OUTPATIENT SAMARITAN HEART & VASC - VASC SURGERY

3615 NW SAMARITAN DR STE 201 CORVALLIS OR 97330

MEDICAL CLINIC - OUTPATIENT SAMARITAN SURGICAL SPECIALISTS

3615 NW SAMARITAN DR STE 201 CORVALLIS OR 97330

MEDICAL CLINIC - OUTPATIENT SAMARITAN GYN & SURGICAL ASSOCIATES

400 NW WALNUT BLVD STE 300 CORVALLIS OR 97330

MEDICAL CLINIC - OUTPATIENT SAMARITAN INTERNAL MEDICINE

3615 NW SAMARITAN DR STE 100 CORVALLIS OR 97330

MEDICAL CLINIC - OUTPATIENT SAMARITAN NEUROSURGERY - DR ROBERSON

3615 NW SAMARITAN DR STE 210 CORVALLIS OR 97330

MEDICAL CLINIC - OUTPATIENT SAMARITAN NEUROSURGERY - DR GOODWIN

3615 NW SAMARITAN DR STE 211 CORVALLIS OR 97330

MEDICAL CLINIC - OUTPATIENT SAMARITAN FAMILY MEDICINE

3517 NW SAMARITAN DR STE 201 CORVALLIS OR 97330

MEDICAL CLINIC - OUTPATIENT MAMMOGRAPHY CLINIC

444 NW ELKS DR CORVALLIS OR 97330

MAMMOGRAPHY CLINIC SAMARITAN KIDNEY SPECIALISTS

3615 NW SAMARITAN DR STE 203 CORVALLIS OR 97330

MEDICAL CLINIC - OUTPATIENT SAMARITAN PEDIATRICS

3517 NW SAMARITAN DR STE C CORVALLIS OR 97330

MEDICAL CLINIC - OUTPATIENT SAMARITAN URGENT CARE CENTER

5234 SW PHILOMATH BLVD CORVALLIS OR 97333

MEDICAL CLINIC - OUTPATIENT SAMARITAN DERMATOLOGY

2358 NW KINGS BLVD STE 100 CORVALLIS OR 97330

MEDICAL CLINIC - OUTPATIENT SAMARITAN ENDOSCOPY CENTER

3509 NW SAMARITAN DR STE 201 CORVALLIS OR 97330

ENDOSCOPY CENTER CORVALLIS MRI

3615 NW SAMARITAN DR STE 101 CORVALLIS OR 97330

IMAGING SERVICS CORVALLIS HEARTSPRING WELLNESS CENTER

990 NW CIRCLE BLVD STE 201 CORVALLIS OR 97330

MEDICAL CLINIC - OUTPATIENT SAMARITAN OBSTETRICS & GYN

3640 NW SAMARITAN DR STE 270 CORVALLIS OR 97330

MEDICAL CLINIC - OUTPATIENT SAMARITAN MENTAL HEALTH - CORVALLIS

3509 NW SAMARITAN DR CORVALLIS OR 97330

MENTAL HEALTH SERVICES SAMARITAN PLASTICRECON SURG - HAVARD

996 NW CIRCLE BLVD STE 103 CORVALLIS OR 97330

MEDICAL CLINIC - OUTPATIENT SAMARITAN HEMATOLOGY & ONCOLOGY

3640 NW SAMARITAN DR STE 161 CORVALLIS OR 97330

RADIATION ONCOLOGY SAMARITAN ORTHOPEDICS - DR VELA

3620 NW SAMARITAN DR STE 201 CORVALLIS OR 97330

MEDICAL CLINIC - OUTPATIENT SAMARITAN MENTAL HEALTH - ALBANY

1052 SW 29TH ST ALBANY OR 97321

MENTAL HEALTH SERVICES SAMARITAN INFECTIOUS DISEASE

3640 NW SAMARITAN DR STE 210 CORVALLIS OR 97330

MEDICAL CLINIC - OUTPATIENT SAMARITAN UROLOGY

990 NW CIRCLE BLVD STE 102 CORVALLIS OR 97330

MEDICAL CLINIC - OUTPATIENT SAMARITAN RHEUMATOLOGY

2358 NW KINGS BLVD STE 100 CORVALLIS OR 97330

MEDICAL CLINIC - OUTPATIENT SAMARITAN HAND THERAPY

3640 NW SAMARITAN DR CORVALLIS OR 97330

MEDICAL CLINIC - OUTPATIENT OUTPATIENT SURGERY

3620 NW SAMARITAN DR CORVALLIS OR 97330

AMBULATORY SURGERY PART I, LINE 6A: THE FILING ORGANIZATION SUBMITS AN ANNUAL COMMUNITY BENEFIT REPORT TO THE STATE OF OREGON. IN ADDITION, THE PARENT ORGANIZATION, SAMARITAN HEALTH SERVICES (SHS) PROVIDES AN ANNUAL REPORT TO THE COMMUNITY THAT INCLUDES COMMUNITY BENEFIT REPORTING FOR THE SYSTEM AS A WHOLE. PART I, LINE 7: THE COSTING METHODOLOGY USED TO CALCULATE THE AMOUNTS REPORTED IN SCHEDULE H, PART I, LINE 7A AND 7B IS A COST-TO-CHARGE RATIO DERIVED USING WORKSHEET 2, RATIO OF PATIENT CARE COST-TO-CHARGES FROM THE SCHEDULE H INSTRUCTIONS. FOR LINE 7G, A COMBINATION OF THE COST-TO-CHARGE RATIO AND COST ACCOUNTING SYSTEM CALCULATIONS IS USED SINCE NOT ALL SERVICES ARE TRACKED IN THE COST ACCOUNTING SYSTEM. PART I, LINE 7G: PHYSICIAN CLINICS MEETING THE DEFINITION OF SUBSIDIZED HEALTH SERVICES WERE INCLUDED IN THE REPORTING FOR LINE 7G. THE PORTION OF NET COMMUNITY BENEFIT EXPENSE RELATED TO THESE CLINICS IS $31,346,209. PART II: GSH PROVIDES SERVICES AND ACTIVITIES THAT ARE CLASSIFIED AS COMMUNITY BUILDING. THIS INCLUDES LEADING DISASTER PREPAREDNESS DRILLS WITH LOCAL AGENCIES AND STAFF PARTICIPATING IN ONE-ON-ONE MENTORING PROGRAMS AT A LOCAL SCHOOL. GSH ALSO PROVIDES OPPORTUNITIES FOR COMMUNITY MEMBERS TO OBTAIN TRAINING ON CIVIC AND CULTURAL ISSUES THAT IMPACT HEALTH. SOME OF THE TRAINING OPPORTUNITIES INCLUDED GRANT WRITING AND BOARD DEVELOPMENT. GSH STAFF SERVE ON MANY LOCAL COALITIONS AND BOARDS THAT PROMOTE THE HEALTH OF THE COMMUNITY. BOARD AFFILIATION INCLUDES, BUT IS NOT LIMITED TO COMMUNITY OUTREACH INC, THE GRACE CENTER, THE CENTER FOR HEALTHY AGING RESEARCH/SCIENTIFIC ADVISORY BOARD, AND THE CARING PLACE. ADDITIONALLY GSH STAFF SERVE ON THE OREGON HEALTH POLICY ADVISORY BOARD, THE OREGON HEALTH RESOURCES COMMISSION, THE MEDICAID ADVISORY COMMITTEE AND REGIONAL BOARDS THAT ADDRESS HEALTH CARE ISSUES. PART III, LINE 4: THE COSTING METHODOLOGY USED TO CALCULATE BAD DEBT EXPENSE (AT COST) ON LINE 2 OF PART III IS BASED ON THE FACILITY COST-TO-CHARGE RATIO, IN CONJUNCTION WITH WORKSHEET A FROM THE SCHEDULE H, PART III INSTRUCTIONS.LINE 3 REPRESENTS AN ESTIMATE OF THE AMOUNT OF COST INCLUDED IN LINE 2 (BAD DEBT EXPENSE AT COST) THAT REASONABLY COULD BE ATTRIBUTABLE TO PATIENTS WHO LIKELY WOULD QUALIFY FOR FINANCIAL ASSISTANCE UNDER THE ORGANIZATION'S CHARITY CARE POLICY, BUT FOR WHOM THE ORGANIZATION WAS NOT ABLE TO OBTAIN SUFFICIENT INFORMATION TO MAKE A DETERMINATION. THE METHODOLOGY USED TO ESTIMATE THIS POTENTIAL CHARITY CARE COST IS BASED ON FINANCIAL ASSISTANCE APPLICATIONS DENIED DUE TO INCOMPLETE DOCUMENTATION, MULTIPLIED BY THE AVERAGE CHARITY CARE WRITE-OFF FOR APPROVED APPLICATIONS.GOOD SAMARITAN HOSPITAL (GSH) IS THE LARGEST OF FIVE HOSPITALS OF SAMARITAN HEALTH SERVICES (SHS). AS A NETWORK, SHS PREPARES ITS FINANCIAL STATEMENTS ON A CONSOLIDATED BASIS. FOOTNOTE 1(O) FROM THE AUDITED CONSOLIDATED FINANCIAL STATEMENTS ENTITLED "PROVISION FOR BAD DEBTS AND ALLOWANCE FOR DOUBTFUL ACCOUNTS" DESCRIBES BAD DEBT EXPENSE AS FOLLOWS: "ACCOUNTS RECEIVABLE ARE REDUCED BY AN ALLOWANCE FOR DOUBTFUL ACCOUNTS. IN EVALUATING THE COLLECTABILITY OF ACCOUNTS RECEIVABLE, SHS ANALYZES ITS PAST HISTORY AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYOR SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND PROVISION FOR BAD DEBTS. MANAGEMENT REGULARLY REVIEWS DATA ABOUT THESE MAJOR PAYOR SOURCES OF REVENUE IN EVALUATING THE SUFFICIENCY OF THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. FOR RECEIVABLES ASSOCIATED WITH SELF-PAY PATIENTS (WHICH INCLUDE PATIENTS WITHOUT INSURANCE), SHS RECORDS A PROVISION FOR BAD DEBTS IN THE PERIOD OF SERVICE ON THE BASIS OF ITS PAST EXPERIENCE, WHICH INDICATES THAT MANY PATIENTS ARE UNABLE OR UNWILLING TO PAY THE PORTION OF THEIR BILL FOR WHICH THEY ARE FINANCIALLY RESPONSIBLE. FOR THIRD-PARTY RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRD-PARTY COVERAGE, SHS ANALYZES CONTRACTUALLY DUE AMOUNTS AND PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS AND A PROVISION FOR BAD DEBTS, WHICH PRIMARILY RELATES TO SELF-PAY PATIENT BALANCES THAT WILL REMAIN AFTER PAYMENTS FROM THE THIRD-PARTY PAYOR HAVE BEEN COLLECTED. THE DIFFERENCE BETWEEN THE STANDARD RATES (OR THE DISCOUNTED RATES IF NEGOTIATED) AND THE AMOUNTS ACTUALLY COLLECTED AFTER ALL REASONABLE COLLECTION EFFORTS HAVE BEEN EXHAUSTED IS CHARGED OFF AGAINST THE ALLOWANCE FOR DOUBTFUL ACCOUNTS." PART III, LINE 8: TOTAL MEDICARE ALLOWABLE COSTS REPORTED ON PART III, SECTION B, LINE 6 IS CALCULATED BY UTILIZING WORKSHEET B IN THE SCHEDULE H INSTRUCTIONS IN CONJUNCTION WITH AMOUNTS TAKEN DIRECTLY FROM THE FILING ORGANIZATION'S MEDICARE COST REPORT (CALCULATED BASED ON A COST-TO-CHARGE RATIO). CARING FOR MEDICARE PATIENTS FULFILLS A COMMUNITY NEED, AS THESE PATIENTS TYPICALLY HAVE LOW OR FIXED INCOMES AND GOVERNMENT REIMBURSEMENT IS NOT SUFFICIENT TO COVER THE COSTS OF PROVIDING CARE FOR THESE PATIENTS. MEDICARE PATIENTS ARE A GROWING SEGMENT OF THE LOCAL POPULATION, AND MANY ARE BECOMING INCREASINGLY DEPENDENT ON OUR HOSPITAL AND NON-PROFIT AFFILIATES TO PROVIDE FOR THEIR CARE, ESPECIALLY AS OTHER FOR-PROFIT HEALTHCARE PROVIDERS IN THE COMMUNITY DISCONTINUE ACCEPTING MEDICARE PATIENTS.THE AMOUNT OF MEDICARE SHORTFALL SHOWN ON LINE 7 OF PART III, SECTION B, IS UNDERSTATED. THIS IS PRIMARILY DUE TO THE FACT THAT THE MEDICARE COST REPORT INCLUDES ACTIVITY FOR MEDICARE FEE-FOR-SERVICE PATIENTS BUT NOT MEDICARE MANAGED CARE PATIENTS. MEDICARE MANAGED CARE ACCOUNTS FOR ROUGHLY HALF OF OUR MEDICARE ACTIVITY. IN ADDITION, CERTAIN COSTS OF PROVIDING HEALTHCARE SERVICES, SUCH AS PHYSICIAN COMPENSATION, ARE NOT ALLOWABLE ON THE MEDICARE COST REPORTS. THEREFORE, THE AMOUNT OF MEDICARE SHORTFALL SHOWN ON LINE 7 IS SMALLER THAN THE SHORTFALL CALCULATION USING REVENUE AND COST DATA FOR ALL MEDICARE PATIENT ACTIVITY, AS FOLLOWS:NET REV RECEIVED FROM MEDICARE (ALL MEDICARE PATIENT PROGRAMS):83,236,002MEDICARE COSTS (BASED ON A COST-TO-CHARGE RATIO): 100,898,872UNPAID COST OF PROVIDING SERVICES TO ALL MEDICARE PATIENTS: (17,662,870) PART III, LINE 9B: PER HOSPITAL GUIDELINES, IF A PATIENT IS DETERMINED TO QUALIFY FOR FINANCIAL ASSISTANCE PRIOR TO SENDING AN ACCOUNT TO COLLECTIONS, THE CHARITY WRITE-OFF IS PROCESSED AND NO COLLECTION ATTEMPT IS MADE. IF AN ACCOUNT IS ALREADY IN COLLECTIONS AND MEDICAID ELIGIBILITY IS DEEMED ACTIVE DURING THE ACCOUNT DATE OF SERVICE, NO FURTHER COLLECTION ATTEMPT WILL BE MADE. GOOD SAMARITAN HOSPITAL, CORVALLIS PART V, SECTION B, LINE 19D: THE MAXIMUM AMOUNT CHARGED BY THE HOSPITAL FACILITY TO FAP-ELIGIBLE INDIVIDUALS IS SET TO BE LESS THAN THE AVERAGE OF ALL NEGOTIATED COMMERCIAL INSURANCE RATES. PART VI, LINE 2: GOOD SAMARITAN HOSPITAL (GSH) ACTIVELY PARTICIPATES IN ASSESSING THE HEALTH NEEDS OF THE COMMUNITY. IN CONJUNCTION WITH THE UNITED WAY OF BENTON COUNTY, THE CITY OF CORVALLIS, BENTON COUNTY HEALTH DEPARTMENT, BENTON COUNTY FEDERALLY QUALIFIED HEALTH CENTER, OREGON STATE UNIVERSITY, THE BENTON COUNTY COMMISSION ON CHILDREN AND FAMILIES AND OTHER COMMUNITY PARTNERS, GSH EMPLOYEES AND OTHER SAMARITAN HEALTH SERVICES STAFF ACTIVELY PARTICIPATED IN A COMMUNITY NEEDS ASSESSMENT DURING 2010. THIS PROCESS INCLUDED EXAMINING PRIMARY DATA COLLECTED THROUGH FOCUS GROUPS, COMMUNITY FORUMS AND PERSONAL INTERVIEWS WITH SEVERAL COMMUNITY MEMBERS FROM THROUGHOUT BENTON COUNTY. SECONDARY DATA WAS GATHERED FROM STATE AND LOCAL AGENCIES THAT ADDRESS HEALTH NEEDS OF CHILDREN, YOUTH AND FAMILIES. AS A RESULT OF THE COMMUNITY NEEDS ASSESSMENT, GSH IS ABLE TO UPDATE THE ANNUAL COMMUNITY BENEFIT PLAN THAT OUTLINES GOALS, OBJECTIVES AND SERVICES THAT EXPAND ACROSS THE SAMARITAN HEALTH SERVICES SYSTEM RESPONDING TO COMMUNITY NEEDS. PART VI, LINE 3: GSH IS COMMITTED TO PROVIDING THE HIGHEST QUALITY HEALTH CARE SERVICES TO ALL, REGARDLESS OF THEIR ABILITY TO PAY. IF QUALIFICATIONS ARE MET, PATIENTS' CARE MAY BE PROVIDED FREE OR AT A REDUCED COST. THE DETERMINATION IS BASED IN PART ON POVERTY INCOME GUIDELINES ISSUED BY THE U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES. ONCE A COMPLETED FINANCIAL QUESTIONNAIRE HAS BEEN SUBMITTED, INDIVIDUALS/FAMILIES AT OR BELOW 200 PERCENT OF THE ESTABLISHED FEDERAL POVERTY LEVEL (FPL) COULD BE ELIGIBLE TO RECEIVE FREE OR DISCOUNTED CARE (CHARITY CARE).THE ORGANIZATION INFORMS AND EDUCATES PATIENTS AND COMMUNITY MEMBERS BY PUBLISHING INFORMATION REGARDING ALL FINANCIAL ASSISTANCE OPTIONS ON ITS WEBSITE, IN ADDITION TO IN PERSON AT THE REGISTRATION AREA, AND THROUGH CLEARLY IDENTIFIED MATERIALS LOCATED IN THE REGISTRATION AREA. PART VI, LINE 4: GSH PRIMARILY SERVES THE RESIDENTS OF BENTON COUNTY. HOWEVER, RESIDENTS FROM THE ADJOINING COMMUNITIES OF LINCOLN AND LINN COUNTIES ARE ALSO SEEN AT GSH. WITH A TOTAL POPULATION OF 85,579 (U.S. CENSUS 2010), BENTON COUNTY IS DESIGNATED AS AN URBAN COUNTY. THE COUNTY INCLUDES THE CITIES OF CORVALLIS AND PHILOMATH AS WELL AS THE SMALL INCORPORATED TOWNSHIPS OF MONROE AND ADAIR VILLAGE. APPROXIMATELY 21% OF BENTON COUNTY RESIDENTS LIVE IN RURAL AREAS OF THE COUNTY. THE MEDIAN HOUSEHOLD INCOME FOR BENTON COUNTY IS $71,800, AND 16.1% OF THE RESIDENTS LIVE BELOW THE FEDERAL POVERTY LEVEL. AS OF DECEMBER 2011, THE OREGON EMPLOYMENT DEPARTMENT REPORTED A 5.9% UNEMPLOYMENT RATE FOR BENTON COUNTY. ACCORDING TO THE 2012 COUNTY HEALTH RANKINGS, 17% OF BENTON COUNTY RESIDENTS ARE UNINSURED. PORTIONS OF BENTON COUNTY HAVE DESIGNATIONS OF MEDICALLY UNDERSERVED AREAS AND MEDICALLY UNDERSERVED POPULATIONS ACCORDING TO THE HEALTH RESOURCES AND SERVICES ADMINISTRATION, WITH GSH BEING THE ONLY HOSPITAL LOCATED IN BENTON COUNTY. PART VI, LINE 5: GSH'S GOVERNING BOARD IS COMPRISED OF LOCAL-AREA RESIDENTS. THE MAJORITY OF THE BOARD MEMBERS ARE INDEPENDENT, MEANING THEY AND THEIR FAMILY MEMBERS ARE NOT EMPLOYEES OF GSH NOR DO THEY HAVE ANY SIGNIFICANT BUSINESS RELATIONSHIPS WITH GSH. GSH EXTENDS ITS MEDICAL STAFF PRIVILEGES TO ALL QUALIFIED PHYSICIANS IN THE COMMUNITY. GSH APPLIES SURPLUS FUNDS TO IMPROVE PATIENT CARE, MEDICAL EDUCATION AND RESEARCH. GSH INVESTS IN UPDATING EQUIPMENT, TECHNOLOGY AND FACILITIES TO IMPROVE PATIENT CARE. GSH IS ACCREDITED FOR CONTINUING MEDICAL EDUCATION AND OFFERS WEEKLY PROGRAMS FOR AREA PHYSICIANS AND OTHER HEALTH PROFESSIONALS. THE CENTER FOR HEALTH RESEARCH AND QUALITY, A DEPARTMENT OF GSH'S PARENT COMPANY, SAMARITAN HEALTH SERVICES (SHS), PROVIDES ADMINISTRATIVE OVERSIGHT FOR HEALTH AND CLINICAL RESEARCH, QUALITY IMPROVEMENT PROJECTS AND STUDIES, AND OTHER SPONSORED ACTIVITIES FOR GSH AND ITS AFFILIATED HOSPITALS. GSH ALSO CONTRIBUTES FINANCIALLY TO THE LINN-BENTON COMMUNITY COLLEGE NURSING PROGRAM. PART VI, LINE 6: "BUILDING HEALTHIER COMMUNITIES TOGETHER" IS THE COMMITMENT OF, AND THE MOTIVATION FOR, SAMARITAN HEALTH SERVICES (SHS), A NETWORK OF OREGON HOSPITALS, PHYSICIANS, AND SENIOR CARE FACILITIES THAT SERVES THE HEALTH CARE NEEDS OF PEOPLE IN THE MID-WILLAMETTE VALLEY AND THE CENTRAL OREGON COAST.AS THE INDIVIDUAL ENTITIES OF SHS CAME TOGETHER TO BUILD HEALTHIER COMMUNITIES, THEY WERE DRAWN BY A SHARED MISSION "TO ENHANCE COMMUNITY HEALTH AND ACHIEVE HIGH VALUE THROUGH QUALITY SERVICES ACROSS THE CONTINUUM OF CARE." THAT MEANS SHS LOOKS CAREFULLY AT LOCAL HEALTH CARE NEEDS, AND IT GIVES THOUGHTFUL CONSIDERATION TO THE MOST EFFECTIVE WAYS TO MEET THOSE NEEDS. THE RESULT IS A RICH MIX OF LOCAL AND CENTRALIZED REGIONAL SERVICES WHICH PROVIDE HIGH VALUE AND EXCELLENT HEALTHCARE FOR PEOPLE AT ALL STAGES OF THEIR LIVES. SERVICES ARE PROVIDED TO ALL INDIVIDUALS, REGARDLESS OF THEIR ABILITY TO PAY. THE COLLECTIVE VISION OF SHS IS TO SUCCESSFULLY OPERATE AS A VALUES-DRIVEN, CHURCH-RELATED ORGANIZATION GOVERNED BY A PARTNERSHIP OF COMMUNITY MEMBERS, PHYSICIANS AND OTHER HEALTH CARE PROVIDERS. SHS SEEKS TO LEAD COLLABORATIVE EFFORTS AMONG PROVIDERS, EMPLOYERS, HEALTH PLANS AND CONSUMERS WHO SHARE SIMILAR GOALS AND VALUES TO MEET THE CHALLENGES OF THE FUTURE.GSH IS THE FLAGSHIP HOSPITAL OF SHS. IT PRIMARILY SERVES RESIDENTS OF BENTON COUNTY. OTHER AFFILIATED HOSPITALS ARE SAMARITAN ALBANY GENERAL HOSPITAL AND SAMARITAN LEBANON COMMUNITY HOSPITAL, SERVING RESIDENTS OF LINN COUNTY, AND SAMARITAN NORTH LINCOLN HOSPITAL AND SAMARITAN PACIFIC COMMUNITIES HOSPITAL, SERVING RESIDENTS OF LINCOLN COUNTY. REPORTS FILED WITH STATES PART VI, LINE 7 OR 1 COMMUNITY OUTREACH 865 REIMAN AVENUE CORVALLIS OR 97330 930602094 501(C)(3) 77148 MEDICAL, DENTAL, MENTAL HEALTH CLINICS OLD MILL CENTER 1650 SW 45TH PLACE CORVALLIS OR 97333 930722603 501(C)(3) 43750 SUPPORT FOR HIGH RISK INFANTS ALBANY HELPING HANDS PO BOX 2252 ALBANY OR 97321 931244271 501(C)(3) 7150 SUPPORT FOR HOMELESS PEOPLE CENTER AGAINST RAPE & DOMESTIC VIOLENCE PO BOX 914 CORVALLIS OR 97339 930792125 501(C)(3) 35000 TRANSITIONAL HOUSING SERVICES FOR DOMESTIC VIOLENCE SURVIVORS DIAL A BUS 605 NW 27TH STREET CORVALLIS OR 97330 264836268 501(C)(3) 5800 TRANSPORTATION SUBSIDIES FOR NEEDY PATIENTS ALSEA RURAL HEALTH CARE INC PO BOX 229 ALSEA OR 97324 930773246 501(C)(3) 15000 RURAL HEALTHCARE SUPPORT BENTON COUNTY HEALTH DEPARTMENT 530 NW 27TH ST CORVALLIS OR 97330 936002285 GOV'T 11040 ORAL HEALTH SUPPORT CORVALLIS DAYTIME DROP-IN CENTER 316 SW WASHINGTON AVE STE 410 CORVALLIS OR 97330 800019915 501(C)(3) 9100 SUPPORT FOR THE COMMUNICABLE DISEASE PREVENTION PROJECT 8 TRANSPORTATION 506 24627 MEDICAL ASSISTANCE 8 283 BOOK MEDICAL SUPPLIES SHELTER 21 576 MEALS FOR FAMILY MEMBERS OF PATIENTS 626 6261 BOOK MEALS ACCOMODATIONS - PASTEGA HOUSE 6493 35637 BOOK TEMPORARY HOUSING FOR HEALTH CARE RECIPIENTS PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: AGENCIES IN THE COMMUNITY ARE INVITED TO SUBMIT GRANT PROPOSALS THROUGH AN APPLICATION PROCESS. A COMMITTEE REVIEWS THE APPLICATIONS TO DETERMINE IF THE FUNDS REQUESTED WILL BE USED TO ADDRESS THE ORGANIZATION'S ESTABLISHED COMMUNITY HEALTH PRIORITIES, IDENTIFIED NEEDS, AND SUPPORTS THE ORGANIZATION'S MISSION. ONCE APPROVED AND FUNDED, AGENCIES MUST SUBMIT A COMPLETE ANNUAL REPORT DESCRIBING HOW THE FUNDS WERE USED, THE NUMBER OF CLIENTS SERVED, AND HOW OUTCOMES WERE ACHIEVED. X 1 1 X X X X 0 0 0 1 0 0 0 0 0 FREDERICK WEISENSEE MD 288599 0 2632 0 15082 0 23736 0 15457 0 345506 0 0 0 STEVEN W JASPERSON 0 375305 0 29000 0 30618 0 38497 0 26869 0 500289 0 0 DANIEL B SMITH 0 285276 0 28000 0 7332 0 20228 0 31203 0 372039 0 0 KATHRYN M HALE 163469 0 9665 0 2814 0 25290 0 19328 0 220566 0 0 0 MICHAEL A MAY MD 280513 0 10600 0 5236 0 36172 0 31210 0 363731 0 0 0 SCOTT WILSON 140093 0 7440 0 12534 0 11929 0 24669 0 196665 0 0 0 STEVEN GOODWIN MD 625653 0 6000 0 1283 0 20228 0 23802 0 676966 0 0 0 DONALD PENNINGTON DO 846558 0 5500 0 810 0 20228 0 31414 0 904510 0 0 0 TOSHIO NAGAMOTO MD 725968 0 3500 0 17310 0 20228 0 28930 0 795936 0 0 0 RANDALL V BREAM MD 590223 0 4800 0 16642 0 20228 0 20941 0 652834 0 0 0 LUIS VELA DO 748467 0 14800 0 810 0 20228 0 26447 0 810752 0 0 0 PART I, LINE 1A IN CONNECTION WITH ITS EMPLOYEE WELLNESS PROGRAM, THE ORGANIZATION HAS A GYM REIMBURSEMENT BENEFIT THAT IS AVAILABLE TO ALL EMPLOYEES WHO WORK AT LEAST 32 HOURS PER MONTH. THE EMPLOYEE MUST ATTEND THE GYM FOR 6 CONSECUTIVE MONTHS, AT LEAST 50 TIMES, IN ORDER TO QUALIFY FOR REIMBURSEMENT. THIS GYM REIMBURSEMENT BENEFIT IS INCLUDED IN THE EMPLOYEE'S TAXABLE WAGES AND IS SUBJECT TO STATE/FEDERAL WITHHOLDING TAX. ONE OFFICER AND TWO KEY EMPLOYEES RECEIVED THIS BENEFIT IN 2011. PART I, LINE 5 VARIOUS PHYSICIAN COMPENSATION METHODOLOGIES ARE UTILIZED AND, DEPENDING ON SPECIALTY, RELATIVE VALUE UNITS (RVU'S) MAY BE USED IN DETERMINING A PORTION OF OR ALL OF THEIR COMPENSATION. TANIA MAY FAM MBR, M. MAY 117886 EMP BY ORG 0 FORM 990, PART VI, SECTION A, LINE 4 SECTION 7.1.5 OF THE ORGANIZATION'S BYLAWS WERE AMENDED WHEREBY THE BOARD DEVELOPMENT COMMITTEE IS TO BE RESPONSIBLE FOR REVIEWING THE PERFORMANCE OF THE DIRECTORS. ALSO, THE RESTRICTION NOT ALLOWING BOARD DEVELOPMENT COMMITTEE MEMBERS TO ALSO SERVE AS OFFICERS OF THE BOARD WAS REMOVED. FORM 990, PART VI, SECTION A, LINE 6 GOOD SAMARITAN HOSPITAL CORVALLIS HAS A SOLE CORPORATE MEMBER, SAMARITAN HEALTH SERVICES, INC., WHICH IS A SECTION 501(C)(3) TAX-EXEMPT ORGANIZATION. FORM 990, PART VI, SECTION A, LINE 7A GOOD SAMARITAN HOSPITAL CORVALLIS ELECTS MEMBERS OF ITS BOARD OF DIRECTORS. THOSE ELECTED MEMBERS ARE THEN SUBMITTED TO THE SOLE CORPORATE MEMBER FOR APPROVAL. FORM 990, PART VI, SECTION A, LINE 7B THE SOLE CORPORATE MEMBER HAS SEVERAL RESERVED POWERS OVER THE ORGANIZATION. THESE RESERVED POWERS INCLUDE, BUT ARE NOT LIMITED TO, APPROVAL AT CERTAIN THRESHOLD LEVELS: THE BORROWING OF FUNDS, MERGERS AND ACQUISITIONS, AND SALES OR TRANSFERS OF ASSETS. IN ADDITION, THE SOLE CORPORATE MEMBER MUST APPROVE ANY CHANGE IN THE MISSION OF THE ORGANIZATION, THE ANNUAL BUDGET, AND ANY AMENDMENTS TO THE ARTICLES OF INCORPORATION OR BYLAWS. FORM 990, PART VI, SECTION B, LINE 11 A COPY OF THE ORGANIZATION'S FINAL FORM 990 (INCLUDING REQUIRED SCHEDULES), AS ULTIMATELY FILED WITH THE IRS, WAS PROVIDED TO EACH VOTING MEMBER OF THE SAMARITAN HEALTH SERVICES (SHS) AUDIT AND COMPLIANCE COMMITTEE PRIOR TO ITS FILING WITH THE IRS. SHS IS A 501(C)(3) CORPORATION AND IS THE SOLE MEMBER OF THE FILING ORGANIZATION. SHS'S CHIEF FINANCIAL OFFICER CONDUCTED THE FORM 990 REVIEW WITH THE COMMITTEE AND PROVIDED TIME FOR QUESTIONS FROM THE GROUP. A FORMAL REPORT OF THIS COMMITTEE HAS BEEN MADE TO THE FULL BOARD OF DIRECTORS OF SHS. FORM 990, PART VI, SECTION B, LINE 12C BOARD MEMBER CONFLICTS OF INTEREST: THE MEMBERS OF THE BOARD MUST ANNUALLY COMPLETE A CONFLICT OF INTEREST QUESTIONNAIRE, WHICH REQUIRES DISCLOSURE OF ANY CONFLICTS OR POTENTIAL CONFLICTS OF INTEREST. THE COMPLETED QUESTIONNAIRES ARE REVIEWED BY THE CHIEF FINANCIAL OFFICER AND CORPORATE COMPLIANCE OFFICER. IF A CONFLICT IS DISCLOSED THAT COULD PROHIBIT A MEMBER FROM SERVING ON THE BOARD, THIS IS EVALUATED BY THE AUDIT AND COMPLIANCE COMMITTEE OF THE SAMARITAN HEALTH SERVICES (SHS) BOARD OF DIRECTORS TO DETERMINE WHETHER THE MEMBER SHOULD CONTINUE TO SERVE ON THE BOARD. IF A CONFLICT IS DISCLOSED THAT DOES NOT PROHIBIT A MEMBER FROM SERVING ON THE BOARD, THE CONFLICT IS MANAGED THROUGH A PROCESS SET FORTH IN THE ORGANIZATION'S BYLAWS. THE BYLAWS PROHIBIT ANY BOARD MEMBER FROM VOTING ON AN ACTION WHERE AN INDIVIDUAL MEMBER HAS A CONFLICT OF INTEREST. EMPLOYEE CONFLICTS OF INTEREST: THE SHS CODE OF ETHICS AND CONDUCT POLICY REQUIRES THAT ALL SHS EMPLOYEES COMPLETE AN ANNUAL DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST. THROUGH THE HUMAN RESOURCES SOFTWARE, PERFORMANCE MANAGER, THE DISCLOSURE REQUIREMENT NOTICE IS ASSIGNED TO ALL EMPLOYEES AND BY YEAR END ALL TASKS ARE TO BE COMPLETED. IF THERE IS A PERCEIVED CONFLICT OF INTEREST IT IS REVIEWED BY THE CORPORATE COMPLIANCE OFFICER, LEGAL COUNSEL AND/OR SENIOR MANAGEMENT. ACTUAL CONFLICTS OF INTEREST ARE REVIEWED AND DISCUSSED BY THE AUDIT AND COMPLIANCE COMMITTEE OF THE SAMARITAN HEALTH SERVICES BOARD OF DIRECTORS. FORM 990, PART VI, SECTION C, LINE 19 FINANCIAL STATEMENTS ARE MADE AVAILABLE UPON REQUEST. SYSTEM-WIDE SUMMARIZED DATA IS ALSO PROVIDED IN THE ANNUAL REPORT TO THE COMMUNITY. THIS REPORT IS MADE AVAILABLE IN ALL KIOSKS AND HIGH-TRAFFIC AREAS OF ALL HOSPITALS AND PHYSICIAN CLINICS, AS WELL AS COMMUNITY PLACES SUCH AS THE PUBLIC LIBRARY. IT IS ALSO DISTRIBUTED TO THE BOARDS OF DIRECTORS AND DIRECTLY MAILED TO DONORS AND NEW RESIDENTS IN THE COMMUNITY. ADDITIONALLY, THE REPORT IS MADE AVAILABLE AT ALL EVENTS, COMMUNITY OUTREACH PROJECTS, AND SCREENINGS ATTENDED THROUGHOUT THE YEAR. GOVERNING DOCUMENTS ARE AVAILABLE TO THE PUBLIC UPON REQUEST. STEVEN W. JASPERSON FORM 990, PART VII - COMPENSATION EXPLANATION MR. JASPERSON'S COMPENSATION WAS PAID BY A RELATED ORGANIZATION FOR WORK DONE FOR THE FILING ORGANIZATION. DANIEL B. SMITH FORM 990, PART VII - COMPENSATION EXPLANATION MR. SMITH WORKED 40 HOURS PER WEEK FOR SEVERAL RELATED ORGANIZATIONS. HIS COMPENSATION WAS PAID BY A RELATED ORGANIZATION FOR WORK DONE FOR THE FILING ORGANIZATION AND SEVERAL RELATED ORGANIZATIONS. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED LOSSES ON INVESTMENTS: -894,525. DISTRIBUTIONS TO MINORITY INTEREST CONSOLIDATED JVS -1,360,146. INCREASE IN MINIMUM PENSION LIABILITY -11,856,043. OTHER CHANGES IN FUND BALANCE 2,678. TOTAL TO FORM 990, PART XI, LINE 5: -14,108,036. ALBANY GENERAL HOSPITAL PO BOX 3000 CORVALLIS OR 973393000 930110095 HOSPITAL SERVICES FOR THE COMMUNITY OR 501(C)(3) 3 SAMARITAN HEALTH SERVICES 0 ALBANY GENERAL HOSPITAL FOUNDATION 1046 SIXTH AVENUE SW ALBANY OR 97321 930712890 TO SUPPORT ALBANY GENERAL HOSPITAL OR 501(C)(3) 7 ALBANY GENERAL HOSPITAL 0 FIRSTCARE HEALTH FOUNDATION PO BOX 3000 CORVALLIS OR 973393000 930900124 TO SUPPORT AFFILIATED EXEMPT ENTITIES OR 501(C)(3) 11B, II SAMARITAN HEALTH SERVICES 0 FIRSTCARE MEDICAL FOUNDATION PO BOX 3000 CORVALLIS OR 973393000 930932697 PROVIDER OF MEDICAL SERVICES FOR THE COMMUNITY OR 501(C)(3) 9 SAMARITAN HEALTH SERVICES 0 GOOD SAMARITAN HOSPITAL AUXILIARY 3600 NW SAMARITAN DRIVE CORVALLIS OR 973393000 936024034 TO SUPPORT GOOD SAMARITAN HOSPITAL OR 501(C)(3) 11D, III-O N/A 1 GOOD SAMARITAN HOSPITAL FOUNDATION PO BOX 1068 CORVALLIS OR 97339 237252406 TO SUPPORT GOOD SAMARITAN HOSPITAL OR 501(C)(3) 7 GOOD SAMARITAN HOSPITAL 1 INTERCOMMUNITY HEALTH PLANS INC PO BOX 3000 CORVALLIS OR 973393000 931124326 SERVE OREGON HEALTH PLAN FOR MEDICAID OR 501(C)(4) N/A SAMARITAN HEALTH SERVICES 0 LEBANON COMMUNITY HOSPITAL FOUNDATION PO BOX 739 LEBANON OR 97355 931260080 TO SUPPORT LEBANON COMMUNITY HOSPITAL OR 501(C)(3) 7 MID-VALLEY HEALTHCARE INC 0 MID-VALLEY HEALTHCARE INC PO BOX 3000 CORVALLIS OR 973393000 930396847 HOSPITAL SERVICES FOR THE COMMUNITY OR 501(C)(3) 3 SAMARITAN HEALTH SERVICES 0 PARADIGM INDEMNITY CORPORATION PO BOX 3000 CORVALLIS OR 973393000 731668317 PURE NON-PROFIT CAPTIVE INSURANCE COMPANY HI 501(C)(3) 11A, I SAMARITAN HEALTH SERVICES 0 SAMARITAN HEALTH SERVICES INC PO BOX 3000 CORVALLIS OR 973393000 930951989 PROVIDE HEALTHCARE SUPPORT SERVICES OR 501(C)(3) 11C, III-FI N/A 0 SAMARITAN NORTH LINCOLN HOSPITAL 3043 NE 28TH STREET LINCOLN CITY OR 97367 931305493 HOSPITAL SERVICES FOR THE COMMUNITY OR 501(C)(3) 3 SAMARITAN HEALTH SERVICES 0 SAMARITAN PACIFIC HEALTH SERVICES 930 SW ABBEY STREET NEWPORT OR 97365 931329784 HOSPITAL SERVICES FOR THE COMMUNITY OR 501(C)(3) 3 SAMARITAN HEALTH SERVICES 0 SAMARITAN SENIOR CARE INC PO BOX 3000 CORVALLIS OR 973393000 931245534 PROVIDE HEALTHCARE FOR SENIORS OR 501(C)(3) 9 SAMARITAN HEALTH SERVICES 0 SAMARITAN ENDOSCOPY CENTER LLC 3600 NW SAMARITAN DR CORVALLIS OR 97330 202860067 MEDICAL SERVICES OR GOOD SAMARITAN HOSPITAL RELATED 478423 781103 0 1 0.66660 CORVALLIS MEDICAL BUILDINGS LLC 3600 NW SAMARITAN DRIVE CORVALLIS OH 97330 931257913 REAL ESTATE RENTAL OR GOOD SAMARITAN HOSPITAL EXCLUDED 139168 1471777 0 1 0.54500 EAST LINN MRI LLC 3600 NW SAMARITAN DRIVE CORVALLIS OR 97330 320229399 IMAGING OR MID-VALLEY HEALTHCARE INC N/A 0 0 HULL IMAGING LLC 3600 NW SAMARITAN DRIVE CORVALLIS OR 97330 203255479 IMAGING OR GOOD SAMARITAN HOSPITAL RELATED 744862 155129 0 1 0.60000 CBA-SAM LLC PO BOX 433 LINCOLN CITY OR 97367 931314523 REAL ESTATE RENTAL OR N/A N/A 0 0 CORVALLIS MRI A JOINT VENTURE 3615 NW SAMARITAN DRIVE CORVALLIS OR 97330 930949704 IMAGING OR GOOD SAMARITAN HOSPITAL RELATED 456705 459736 0 1 0.50000 MID-VALLEY MEDICAL PROPERTIES ASSOC LLC 1046 SIXTH AVE SW ALBANY OR 97321 300508747 REAL ESTATE RENTAL OR ALBANY GENERAL HOSPITAL N/A 0 0 MID-VALLEY MEDICAL BUILDINGS LLC PO BOX 557 LEBANON OR 97355 931126353 REAL ESTATE RENTAL OR N/A N/A 0 0 NORTHWEST MEDICAL ISOTOPES LLC 815 NW 9TH ST STE 256 CORVALLIS OR 97330 273007752 RESEARCH OR SAMARITAN HEALTH SERVICES N/A 0 0 2750 HARRISON BLVD LLC 413 SW 13TH AVE STE 300 PORTLAND OR 97205 274665571 REAL ESTATE RENTAL OR N/A N/A 0 0 CASCADE VIEW MEDICAL OFFICE BUILDING LLC PO BOX 3000 CORVALLIS OR 973393000 300658805 REAL ESTATE RENTAL OR GOOD SAMARITAN HOSPITAL EXCLUDED -2371 885058 0 1 0.34000 SAMARITAN HEALTH PLANS INC 3600 NW SAMARITAN DRIVE CORVALLIS OR 97330 930860860 HEALTH INSURANCE CARRIER FOR THE COMMUNITY OR SAMARITAN HEALTH SERVICES C 1 1 1 0 0 0 0 0 1 1 1 1 1 1 1 1 0 1 INTERCOMMUNITY HEALTH PLANS INC K 16272088 COST SAMARITAN ENDOSCOPY CENTER LLC A 344718 COST SAMARITAN ENDOSCOPY CENTER LLC N 144100 COST SAMARITAN ENDOSCOPY CENTER LLC O 144100 COST SAMARITAN ENDOSCOPY CENTER LLC R 444891 COST CORVALLIS MEDICAL BUILDINGS LLC A 47689 COST CORVALLIS MEDICAL BUILDINGS LLC R 76300 COST CORVALLIS MEDICAL BUILDINGS LLC J 427566 COST HULL IMAGING LLC A 168100 COST HULL IMAGING LLC N 638937 COST HULL IMAGING LLC R 858000 COST