2012-08-14T15:00:59-05:00 2011-09-30 MCGLADREY LLP 1 S WACKER DRIVE STE 800 CHICAGO IL 60606 990 2010-10-01 361564290 Norwegian American Hospital Inc NORW 7732928200 1044 North Francisco Avenue Chicago IL 60622 Anthony Evers 7732928200 2012-08-14 1 David Faje 3126343400 2010 2016-02-24 21:20:13Z Jose R Sanchez 1044 North Francisco Avenue Chicago IL 60622 111718010 0 X www.nahospital.org X 1935 IL Norwegian American Hospital provides quality and compassionate health care services by partnering with patients, their families, our employees, physicians, and the communities we serve. 16 15 1274 54 84134 -64970 627714 7368620 109076880 104206058 80646 47198 7797 -17670 109793037 111604206 0 0 0 0 51472391 51560570 0 0 0 60157014 57667454 111629405 109228024 -1836368 2376182 94745926 95583955 61138493 65863584 33607433 29720371 X Norwegian American Hospital provides high quality and compassionate health care services by partnering with patients and their families, our employees, physicians and the communities we serve, "is a direct reflection of the organization's more than 116-year old tradition of caring for its neighbors - people and families who live in the surrounding communities. The mission statement is central to all organization planning. 0 0 87560858 104206058 Norwegian American Hospital is a premier health care provider where the patient comes first. As an organization of caregivers, Norwegian American inspires to consistently high standards of quality, family-centered health care services and cost effectiveness. Norwegian American Hospital seeks to promote wellness within the family and to be dynamic partners in health with the communities it serves. For the fiscal year ended September 30, 2011, Norwegian American Hospital forgone $14,556,719 worth of charges for healthcare services and supplies provided to members of the communities served under its charity care policy. These members did not have the ability to pay for services received. Norwegian American also provided care to patients who are beneficiaries of Medicare, Medicaid, blue cross and managed care reimbursement programs. Reimbursement amounts for these programs are less than charges and in some cases less than cost. For fiscal year 2011, Norwegian American Hospital served 8,705 patients admitted who received 37,177 days of healthcare services. 87560858 1 1 0 1 0 0 0 0 0 1 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 1 0 0 0 1 171 0 1 1274 1 1 1 0 0 0 0 0 0 0 0 0 X 16 15 0 0 0 0 0 0 0 1 1 0 1 1 0 1 1 1 1 1 1 1 0 IL X Anthony Evers CFO CIA 7732928200 1044 North Franscisco Ave Chicago IL 606222743 Marta Cerda 10.00 X X 0 0 0 Billy Ocasio 4.00 X X 0 0 0 Sandra Valenzuela 8.00 X X 0 0 0 Louis Tinajero 8.00 X X 0 0 0 Patrick Driscoll 2.00 X 0 0 0 Ibrahim A Majzoub MD 2.00 X 0 0 0 Duke Miglin 2.00 X 0 0 0 Tochukwu O Onyekwuluje 2.00 X 0 0 0 Hector J Rodriguez 2.00 X 0 0 0 Rafaela Munoz-Ulrich 2.00 X 0 0 0 Carmen C Hovanec 2.00 X 0 0 0 Enrique Lopez 2.00 X 0 0 0 Wilmi Schmidt 2.00 X 0 0 0 John Monteverde 2.00 X 0 0 0 Jose R Sanchez 40.00 X X 65817 0 0 Clare Ranalli Esq 2.00 X 0 0 0 Anthony Evers 40.00 X 0 0 0 Duane Fitch 40.00 X 0 0 0 Lucy R Hammerberg 40.00 X 308402 0 18617 Murali K Vinta 40.00 X 244808 0 3458 Maureen Tart Lee 40.00 X 243243 0 0 Helio Zapata 40.00 X 237115 0 5650 Rosally V Starr 40.00 X 234979 0 0 Michael J O'Grady Jr 0.00 X 310980 0 0 1645344 0 27725 56 1 1 0 Owens & Minor Inc 12199 Collection Center Drive Chicago IL 60693 Medical & Surgical Products 1891236 Amerisource Bergen Corp 21978 Network Place Chicago IL 60673 Pharmaceutical Distribution 1526870 Cleveland Dovington Partners PO Box 5940 Carol Stream IL 60197 Staffing Services 1476659 Krause Construction 3330 Edison Street Blue Island IL 60406 Construction 1309704 Humboldt Park Emergency Services 903 Commerice Drive Suite 160 Oak Brook IL 60523 Emergency Services 1112197 62 46940 7000000 321680 7368620 Medicare/Medicaid Paym 621110 68994128 68994128 Medicaid Assessment Re 621110 17997156 17997156 Net Patient Services 621110 14131328 14131328 Operating Revenue 621110 2839879 2839879 Dietary Cafe Sales 900099 243567 243567 104206058 47198 47198 33725 113804 -80079 -80079 21725 -101804 Info Sys User Fees 532420 62409 62409 62409 111604206 103962491 84134 188961 376797 376797 43062118 32144797 10917321 5096747 3771593 1325154 3024908 2298930 725978 5628776 4277870 1350906 485576 369038 116538 135996 135996 3998 3998 6428591 4885729 1542862 51521 39156 12365 169128 128537 40591 982907 747010 235897 1771607 1319108 452499 1779 1352 427 189123 143733 45390 1422445 1422445 3813276 2898090 915186 4059337 3085096 974241 Provision for Bad Debt 10941489 10941489 Medical Supplies 9109808 9109808 IL Medicaid Tax Assessm 6433044 6433044 Lease & Rental 1841381 1399450 441931 Repairs and Maintenance 1232751 936891 295860 2964921 2253340 711581 109228024 87560858 21667166 0 1269974 7463503 18439457 12090208 7000000 12521073 11985509 1177411 1141445 4527530 3049608 114184161 78597001 33048120 35587160 10167862 6354479 0 13594499 10912043 94745926 95583955 8452438 9553977 9299602 4746520 22459854 21825392 526358 234540 20400241 29503155 61138493 65863584 X 31591582 19942936 2015851 9777435 33607433 29720371 94745926 95583955 X 2376182 -6263244 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 1 191552 1 0 191552 0 4529913 4529913 43853973 28648462 15205511 3112770 3004501 108269 59200130 46944038 12256092 3487375 3487375 35587160 Property Held for Future Use 1189446 Investment in Joint Venture 5806312 Due from Affiliates 260737 Beneficial Interest in Net Assets of Foundation 2545781 Due from Third-Party Programs 326097 Investment in Subsidiary 783670 10912043 Accrued Malpractice Liability 9397530 Conditional Asset Retirement Obligation 3003625 Net Pension Liability 15823186 Sodexho Capital Lease 11118 Due to Third-Party Programs 1184197 Deferred Lease 83499 29503155 Description of Uncertain Tax Positions Under FIN 48: Part X: The Hospital is a tax-exempt organization under Internal Revenue Code Section 501(c)(3) and, accordingly, no income taxes are provided for in the accompanying consolidated financial statements relating to these organizations. The Hospital files Form 990 (Return of Organization Exempt from Income Tax. When this return is filed, it is highly certain that some positions taken would be sustained upon examination by the taxing authorities, while others are subject to uncertainty about the merits of the position taken or the amount of the position that would ultimately be sustained. Examples of tax positions common to health systems include such matters as the following: the tax-exempt status of each entity, the continued tax-exempt status of bonds issued by the obligated group, the nature, characterization and taxability of joint venture income and various positions relative to potential sources of unrelated business taxable income (UBIT). UBIT is reported on Form 990T, as appropriate. The benefit of a tax position is recognized in the consolidated financial statements in the period during which, based on all available evidence, management believes that it is more likely than not that the position will be sustained upon examination, including the resolution of appeals or litigation processes, if any. Tax positions are not offset or aggregated with other positions. Tax positions that meet the "more likely than not" recognition threshold are measured as the largest amount of tax benefit that is more than 50 percent likely to be realized on settlement with the applicable taxing authority. The portion of the benefits associated with tax positions taken that exceeds the amount measured as described above is reflected as a liability for unrecognized tax benefits in the accompanying consolidated balance sheets along with any associated interest and penalties that would be payable to the taxing authorities upon examination. Upon the adoption of the Financial Accounting Standards Board (FASB) - issued guidance at July 1, 2008, and as of each subsequent fiscal year-end, there were no unrecognized tax benefits identified and recorded as a liability. Form 990 filed by the Hospital is subject to examination up to three years from the extended due date of each return. 1 1 1 X 1 X 600.000000000000 1 1 1 0 1 1 4953806 4953806 0.04540 95256168 101122938 -5866770 0.00000 100209974 101122938 -912964 0.04540 304981 221789 83192 0.00080 957109 100927 856182 0.00780 1262090 322716 939374 0.00860 101472064 101445654 26410 0.05400 1 3003381 1001327 25721561 23876533 1845028 X 1 1 1 Century PHO Inc To obtain and manage contracts with health maintenance organizations 0.50000 0.50000 2 Family Health Network Inc Provider of managed health care services for the indigent under contract wi 0.20000 1 1 Norwegian American Hospital

1044 N Francisco Chicago IL 60660

X X NA 1 Part I, Line 3c: Norwegian American Hospital uses the FPG to determine free and discounted care. Patients with eligible assets and income above the 200%, but not exceeding 600% of FPG, adjusted for family size, will receive a discount on medically necessary services provided to them, based upon a sliding scale established by hospital policy. Part I, Line 6a: Norwegian American Hospital prepared an annual Community Benefit Report which is submitted to the Attorney General of the State of Illinois. Part I, Line 7: The costing methodology used to calculate the amounts reported in the table is the cost-to-charge ratio derived from the IRS's Schedule H, Worksheet 2. Part I, Line 7g: Norwegian American Hospital did not include any costs attributable to a physician clinic as Subsidized Health Services. Part I, L7 Col(f): There was a total of bad debt expense of $9,941,492 subtracted from total expenses. Part II: In addition to providing quality inpatient and outpatient services, Norwegian American Hospital reaches beyond its walls and into communities through an array of activities and programs designed and delivered to benefit the communities it serves. These community benefits include: - Care that is provided free, subsidized or without full reimbursement from Medicare, Medicaid or other government insurance programs. -Services responding to unique community needs, such as diabetes services, emergency care, behavioral health services, substance Abuse, Pediatric Care-A-Van; as well as health screenings, immunization programs, school-based health care and other community outreach programs. -Education to train physicians, nurses, radiology technicians, and other highly skilled health care professionals. -Volunteer services provided by hospital employees who volunteer in their communities and community members who volunteer at the hospital.-Language-assistance services, such as translators, signage, forms, brochures, patient education materials and other information in languages other than English. -Donations by Norwegian American Hospital of meeting and clinic space, as well as other assistance to community groups. Part III, Line 4: The cost methodology used to calculate the amount reported as Bad Debt Expense, at cost, is the cost-to-charge ratio derived from the IRS's Schedule H, worksheet 2.Audited Financial Statements footnote regarding bad debt expense:The collection of receivables from third-party payors and patients is the Hospital's primary source of cash for operations and is critical to its operating performance. The primary collection risks relate to uninsured patient accounts and patient accounts for which the primary insurance payor has paid, but patient responsibility amounts (deductibles and copayments) remain outstanding. Patient receivables from third-party payors are carried at a net amount determined by the original charge for the service provided, less an estimate made for contractual adjustments or discounts provided to third-party payors.Patient receivables due directly from patients are carried at the original charge for the service provided less discounts provided under the Hospital's charity care policy, less amounts covered by third-party payors and less an estimated allowance for doubtful receivables. Management determines the allowance for doubtful accounts by identifying troubled accounts and by historical experience applied to an aging of accounts. The Hospital considers accounts past due when they are outstanding beyond 45 days with no payment. The Hospital generally does not charge interest on past due accounts. Patient receivables are written off as uncollectible accounts expense when deemed uncollectible. Recoveries of receivables previously written off are recorded as a reduction of uncollectible accounts expense when received. Receivables or payables related to estimated settlements on various contracts in which the Hospital participates are reported as amounts due from or to third-party programs. Part III, Line 8: Costing Methodology used is the Medicare cost report which utilizes a step-down method of cost allocation.This order of allocation for overheads has been predetermined by Medicare and is printed out on the cost report.The most common overhead is allocated first to all other overheads and the patient care cost centers.Then that cost center is closed and the next most common overhead is allocated.This is continued until all the overheads are allocated out. Part VI, Line 2: Norwegian American Hospital's Community Benefit Plan was developed to establish strategies for improving access to care and positively affecting the health of the communities that it serves. Additionally, the Plan sets the course for strengthening existing partnerships and building new ones with individuals and organizations within Norwegian American Hospital's primary service areas in order to leverage and maximize the impact of its programs. Development of the plan is derived through the Strategic Planning of Norwegian American Hospital's Board of Trustees and through organizational involvement in community partnerships. The goals developed for planning community services involved meeting with physicians and community partners to determine where the gaps of care and services could be filled through Norwegian American Hospital involvement. In developing its Community Benefits Plan, Norwegian American Hospital set the following goals:1) Serve as a catalyst/convener for the Obesity and Diabetes initiatives in Humboldt Park2) Host community-based education events such as ESL, life skills training, job seeking skills, etc. 3)Promote initiatives that enhance access to health care for the uninsured and underinsured. 4)NAH Leadership to assume an active role in community based organizations Boards, Task Forces and Community Events Part VI, Line 3: Norwegian American Hospital informs and educates patients and persons, who may be billed for patient care, about their eligibility for assistance under federal, state or local government programs or under the organization's charity care policy on its intranet and through flyers. Part VI, Line 4: Norwegian American Hospital serves a Primary Community Area and a Secondary Community Area. The Primary Community Area consists the following areas, zip codes and population: -Austin-Belmont-Cragin-Hermosa-Humboldt Park-Logan Square-West Town-Avondale-Irving Park-North Center-East Garfield Park-West Garfield Park-North Lawndale Park White Hispanic African-AmericanPrimary Zip Codes Population - Perecentage60618 26,023 37% 42,597 60% 2,392 3%60622 15,379 40% 18,385 48% 4,634 12%60624 1,032 4% 244 1% 25,798 95% 60639 6,124 7% 60,432 74% 15,295 19%60647 14,923 21% 51,598 73% 4,173 6% 60651 2,703 14% 16,294 83% 708 4%The Primary Secondary Area consists the following areas, zip codes and population: -Archer Heights-Brighton Park-Gage Park-Garfield Ridge-West Elsdon-South Lawndale-Portage Park-Pullman White Hispanic African-AmericanSecondary Zip Codes Population - Perecentage60612 5,071 24% 2,800 13% 13,682 63%60623 1,175 1% 58,174 67% 27,111 31% 60628 2,252 3% 1,838 3% 66,955 94%60632 13,641 20% 49,881 75% 3,323 5%60641 28,875 54% 23,567 44% 1,025 2%60644 2,057 5% 598 1% 38,526 94%60804 10,122 17% 48,680 81% 1,245 2%Norwegian American Hospital's Age for fiscal year 2011 was as follows:Age %0 16%1-19 4%20-64 68%65-84 11%85-99 2%100+ 0%Norwegian American Hospital's Race and Ethnicity for fiscal year was as follows:Race %American Indian or Alaska 0%Asian 1%Black or African American 43%White 10%Other 46%EthnicityHispanic 47%Non-Hispanic 53% Reports Filed With States Part VI, Line 7 IL X X X X 1 0 0 0 0 0 0 0 0 Lucy R Hammerberg 308402 0 0 0 0 0 0 0 18617 0 327019 0 0 0 Murali K Vinta 244808 0 0 0 0 0 0 0 3458 0 248266 0 0 0 Maureen Tart Lee 243243 0 0 0 0 0 0 0 0 0 243243 0 0 0 Helio Zapata 237115 0 0 0 0 0 0 0 5650 0 242765 0 0 0 Rosally V Starr 234979 0 0 0 0 0 0 0 0 0 234979 0 0 0 Michael J O'Grady Jr 0 0 0 0 310980 0 0 0 0 0 310980 0 0 0 Part I, Line 4a Michael J. O'Grady, Jr. received a severance payment in the amount of $310,980 Illinois Finance Authority Revenue Bonds Series 2008 861091967 45200FMQ9 2008-08-15 4500000 See Part V 0 0 0 Illinois Finance Authority Revenue Bonds Series 2008 861091967 45200FMS5 2008-08-15 5000000 See Part V 0 0 0 Illinois Finance Authority Revenue Bonds Series 2008 861091967 45200FMT3 2008-08-15 14450000 See Part V 0 0 0 4500000 798333 1159612 157619 2384436 2008 1 0 1 1 5000000 798334 1159612 157619 2884435 2008 1 0 1 1 14450000 798333 1159311 157620 12334436 2008 1 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Schedule K, Part I, Line A, B, and C Column (f) - Description of Purpose: The Series 2008 bond proceeds, together with other available funds, were used to refund the outstanding principal amounts of certain bonds in the amount of $3,467,000, to pay or reimburse the Hospital for the payment of the cost of acquiring, constructing and equipping certain of the Hospital's health care facilities, to fund a debt service reserve fund for the benefit of the Series 2008 bonds, and to pay certain expenses incurred in connection with the issuance of the Series 2008 bonds. Sibery Group Duane Fitch, Interim CFO, is a member of the Sibery Group 1487062 Consulting Fee 0 Form 990, Part VI, Section B, line 11 The Form 990 is reviewed by members of the Fiscal Service department, followed by a review of the Chief Financial Officer and the Chief Executive Officer. Form 990, Part VI, Section B, line 12c All Trustees, Officers, and key employees and key physicians (as defined in the Board's Conflict of Interest Policy) of the Corporation are subject to the conflict of interest policy. In addition, all independent contractors who provide services and/or materials to the Corporation in exchange for $20,000 or more in payment during any fiscal year shall be subject to these provisions. All persons subject hereto shall be hereinafter referred to as "Covered Persons." The Chief Executive Officer of the Corporation is responsible for publicizing the provisions of this Article to the persons affected thereby. No person shall become a Trustee, Officer, or Employee or Medical Department Director of the Corporation without first acknowledging in writing to the Corporation that he or she has reviewed, fully understands and is in compliance with the provisions of the conflict of interest policy All Covered Persons shall promptly disclose to the Board of Trustees of the Corporation all substantive potential conflicts of interest which such person discovers or which is brought to his or her attention. Such disclosure shall include submission to the Board of a written statement of the facts surrounding the conflict of interest and an opportunity to make a brief oral statement to the Board with respect to the matter in question. An annual disclosure statement shall be circulated to all Covered Persons to assist them in considering such disclosures. Nevertheless, prompt disclosure notices of conflict shall be filed with the President of the Corporation or any other person designated by him from time to time to receive such notifications. All disclosure notices received hereunder shall be noted for record in the minutes of a meeting of the Board of Trustees. The presence of the Trustee who is directly or indirectly a party to the transaction in question or a Trustee who is otherwise not disinterested may be counted in determining whether a quorum is present for the purpose of the meeting, but shall not be present or have a vote when the Board of Trustees or a committee of the Board discusses and takes action on the transaction. Form 990, Part VI, Section B, line 15 In order to determine the pay level of an executive employee, Norwegian American Hospital utilizes wage data from a variety of sources including Metropolitan Chicago Health Care Council, Integrated Healthcare Services and Sullivan and Cotter. Compensation rates are determined based on the relevant experience and education of the candidate as compared to average survey ranges. Additional information on market conditions is obtained as needed via other published sources. Executive Recruitment firms, if engaged, can provide data regarding the market rates for executives with comparable experience and assist in establishing total compensation packages during the offer process. Form 990, Part VI, Section C, line 19 Norwegian American Hospital, Inc makes its governing documents, conflict of interest policy, and financial statements available to the public upon request. Changes in Net Assets or Fund Balances: Form 990, Part XI, line 5: Income from Centennial Medical Management Corp. 328,022. Income from investments in joint ventures 348,972. Pension related changes, other than net periodic pension cost -7,470,168. Foundation Net Income 661,584. Interfund Transfer -131,654. Total to Form 990, Part XI, Line 5: -6,263,244. Norwegian American Hospital Foundation 1044 North Francisco Ave Chicago IL 60622 363257131 Supporting Foundation IL 501(c)(3) Line 11a, I Norwegian American Hospital 1 Centennial Medical Management Corporation 1044 North Francisco Ave Chicago IL 60622 363394548 Outpatient Pharmacy IL N/A C 292747 1011002 1.00000 Century PHO Inc 1029 North Sacramento Ave Chicago IL 60622 363935696 Health Care Services IL N/A C 5379 1304416 0.50000 0 0 1 0 1 0 0 0 1 0 0 0 1 1 0 0 0 0 Century PHO Inc E 54991 Book Value