2012-10-24T14:38:49-05:00 2011-12-31 911194016 Clark Nuber PS 10900 NE 4th Suite 1700 Bellevue WA 98004 990 2011-01-01 930863097 PROVIDENCE HEALTH PLAN PROV 5035746330 4400 NE Halsey Bldg 2 Portland OR 97213 Jeffrey W Rogers 4255253363 2012-10-24 1 Sara Elizabeth J Hyre CPA P00235495 4254544919 2011 2016-02-24 21:20:13Z Jack A Friedman 4400 NE Halsey Bldg 2 Portland OR 97213 1769696875 0 X www.providence.org/healthplans X 1998 OR Healthcare Service Contractor. 13 13 0 0 0 0 0 1138390 1024262145 1080483203 25344709 25584901 366161 72891 1049973015 1107279385 1850321 2424914 0 0 48754392 49854060 0 0 0 945670696 1041249189 996275409 1093528163 53697606 13751222 579258126 601828582 130137352 138629036 449120774 463199546 X As People of Providence, we reveal God's love for all, especially the poor and vulnerable, through our compassionate service.Healthcare Service Contractor. 0 0 572594390 288924 612993256 Commercial group is offered to employers who provide access to health coverage to their employees. Products include Personal Option and Open Option plans. For the Individual and Family plans offered to those who are not eligible for Medicare and Medicaid, PHP served approximately 11,500 members. This product is health underwritten to manage risk appropriately with targets to reach the more than 650,000 uninsured Oregonians. 384674714 1649173 424713880 Providence Medicare Plans are solutions for people who are eligible for Medicare, supporting affordable access and easier administration for members. PHP advocates for evidence-based and cost effective treatments for patients and appropriate payment levels to providers to keep access to health care available to people who are eligible for Medicare. This program served approximately 40,000 members in 2011. 25905526 449300 40820810 Providence offers Providence Administrative Services Only (ASO) for large groups capable of self-funding the risk experience of the group, but want claims administration and often skilled medical management; and consumer choice plans which offer qualified Health Savings Account (HSA) options. This program served approximately 185,000 members in 2011. 1476486 37517 2304218 Providence Medicare Supplement plans (Medi-Gap) are no longer open plans, but we have membership that continue to be enrolled in these closed-to-new-member plans. 1476486 37517 2304218 984651116 0 1 0 0 0 0 0 0 0 1 0 0 1 1 1 1 1 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 1 X 13584 0 1 0 0 0 0 0 0 0 X 13 13 0 0 0 0 1 1 1 1 1 1 0 1 1 1 1 1 1 1 1 0 OR X Jeff Butcher CFO 5035746390 4400 NE Halsey Bldg 2 Portland OR 97213 X Lucille Dean SP 16.70 X X 0 0 0 M Adrian Davis LCM 5.10 X 0 0 0 Mary Corita Heid RSM 4.70 X 0 0 0 Michael A Stein 6.40 X 0 19271 0 Michael Holcomb 6.50 X 0 16045 0 Dana A Rasmussen 5.50 X 0 16420 0 James S Roberts MD 6.00 X 0 21564 0 Peter J Snow 5.40 X 0 21643 0 Jeffrey B Clode MD 7.40 X 0 21545 0 Sallye Liner 2.60 X 0 19893 0 Owen B Robinson 5.50 X 0 16065 0 Cheryl M Scott 4.70 X 0 16143 0 Ellen L Wolf 9.00 X 0 16065 0 Jeffrey W Rogers 50.00 X 0 1614579 524852 Jack Friedman 50.00 X 0 3065815 364187 Alison S Schrupp 55.00 X 0 337452 65062 Barbara L Christensen 45.00 X 0 318127 76439 Michael G White 50.00 X 0 342180 29679 Bruce W Wilkinson 45.00 X 0 286141 27922 Robert A Gluckman 50.00 X 0 378466 46347 Jeffrey Butcher 50.00 X 0 218975 19942 Gregory Van Pelt 55.00 X 0 3311411 947178 Shelly M Handkins 50.00 X 0 476073 252920 James H Mackay 50.00 X 0 294111 80494 Gerald R Corn 50.00 X 0 257164 26610 Stephanie C Dreyfuss 40.00 X 0 231915 26769 Susan Abate 40.00 X 0 213446 33452 Carrie L Smith 40.00 X 0 198158 18501 Kevin W Keck MD 0.00 X 0 409472 10644 0 12138139 2550998 0 1 1 0 PH&S-OR dba Prov Portland Medical Cente PO BOX 3395 Portland OR 97208 Hospital and Healthcare Services 127043887 PH&S-OR dba Prov St Vincent Medical Ce PO BOX 3178 Portland OR 97208 Hospital and Healthcare Services 115093627 Salem Hospital 890 Oak Street SE Salem OR 97301 Hospital and Healthcare Services 67216167 PH&S-OR dba Prov Medical Group - North PO BOX 3158 Portland OR 97208 Physician Services 46455032 Oregon Health Sciences University PO BOX 575 Portland OR 97207 Healthcare 43767035 1068 1138390 1138390 EPO Premiums 900099 612578668 612578668 Medicare Payments 900099 424713880 424713880 ASO Fees 900099 40886437 40886437 Medicare Supp. Premium 900099 2304218 2304218 1080483203 15991423 15991423 5308599 5588399 -279800 -279800 -279800 666422569 656829091 9593478 9593478 9593478 Capital Usage Fee 900099 212129 212129 Depression Training 900099 60000 60000 Unclaimed Property 900099 56159 56159 24403 20673 3730 352691 1107279385 1080832164 0 25308831 2424914 2424914 5464796 407371 5057425 32733521 25471458 7262063 11655743 8162633 3493110 280287 224161 56126 918591 918591 9851190 5509205 4341985 62207 62207 3070480 1616447 1454033 5643668 3435602 2208066 4650025 3312328 1337697 426539 165348 261191 123415 65784 57631 67914454 5792609 62121845 2175538 1549947 625591 282896 201547 81349 Medical Claims 917319252 917319252 Commission Fees 13199240 13199240 OR & WA High Risk Pool 6758144 3716979 3041165 Premium Tax 6379394 3508667 2870727 2193869 1704657 489212 1093528163 984651116 108877047 0 1932903 7405953 13826393 13716262 2371013 3012405 316 95700 95700 115569393 33574206 86863175 81995187 435940757 452338663 7950170 8277721 30278015 34986375 579258126 601828582 370116 292166 15982700 13622288 113784536 124714582 130137352 138629036 X 0 0 73716441 73716441 375404333 389483105 449120774 463199546 579258126 601828582 X 13751222 327550 X X 0 1 1 X 0 RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 79730868 5036933 74693935 4857475 1650880 3206595 30841907 26886393 3955514 139143 139143 81995187 Pharmacy Rebate Receivable 1851846 Receivable from ASO Clients 3224019 Due from Affiliates 3439186 Investment Income Accruals 2665980 Due from CMS 7502180 Due from Providers 340275 Land Trustee Funds 14355000 Alternate Funding Arrangement 1065381 Reinsurance Receivable 542508 34986375 Unpaid Claims & Withholdings 99594913 Due to OR. Public Employees Retirement System 268953 Due to Affiliates 10852774 Due to Medicare Part D 1452418 Due to CMS - Medical 1156482 Miscellaneous Payables 1659223 Deposits Insured Grp. Alternative Arrangements 1964364 Claim Refunds in Process 1494883 Pre-funding of ASO Claims 5530800 ASO Client Health Improvement Fund 739772 124714582 1107279385 1093528163 13751222 327550 327550 14078772 1062707074 327550 -1809941 -1482391 1064189465 918591 42171329 43089920 1107279385 993423280 -45974163 -45974163 1039397443 918591 53212129 54130720 1093528163 Description of Uncertain Tax Positions Under FIN 48: Part X: The Health System recognizes the effect of income tax positions only if those positions are more likely than not of being sustained. Recognized income tax positions are measured at the largest amount that is greater than 50% likely of being realized. Changes in recognition or measurement are reflected in the period in which the change in judgment occurs. Part XII, Line 2d - Other Adjustments: SAP requirement - Reinsurance Premiums reduce Prem Rev & Med Claims -3,252,317. Medicare Part D Reserve -762,647. Averaging of Lease Revenue over life of lease 2,205,023. Part XII, Line 4b - Other Adjustments: Capital Usage Fee from PPP & PHA 212,129. ASO Fees offset against Admin. Exp. 40,820,810. Related Organization Expense Reimbursement 1,138,390. Part XIII, Line 2d - Other Adjustments: Reinsurance Premiums -3,252,317. ASO Fees offset against Admin Exp -40,820,810. Medicare Part D Reserve -762,647. Expense Reimbursement -1,138,390. Rounding 1. Part XIII, Line 4b - Other Adjustments: Capital Usage Fee 212,129. Net Asset Transfer - Payments to Affiliate 53,000,000. 1 Albertina Kerr Centers Foundation 424 NE 22nd Ave Portland OR 97232 931297104 501(c)(3) 25000 Essential services to the needy Benton County Health Department PO Box 579 Corvallis OR 97339 936002285 501(c)(3) 25000 Essential services to the needy Care to Share PO Box 397 Beaverton OR 97075 930900348 501(c)(3) 35000 Essential services to the needy Cascade AIDS Project 208 SW 5th Avenue Suite 800 Portland OR 97204 930903383 501(c)(3) 59224 Essential services to the needy Central City Concern 232 NW Sixth Avenue Portland OR 97209 930728816 501(c)(3) 20000 Essential services to the needy Chehalem Youth & Family Services PO Box 636 Newberg OR 97132 930764541 501(c)(3) 25000 Essential services to the needy Childrens Relief Nursery 8425 N Lombard Street Portland OR 97203 931260988 501(c)(3) 25000 Essential services to the needy Clackamas Service Center 8800 SE 80th Ave Portland OR 97206 930567549 501(c)(3) 25000 Essential services to the needy Community Health Partnership 315 SW Fifth Ave Ste 202 Portland OR 97204 931259522 501(c)(3) 25000 Community health awareness program De La Salle North Catholic High School 7528 N Fenwick Avenue Portland OR 97217 931287554 501(c)(3) 11000 Behavioral health Essential Health Clinic 266 West Main MS 68 Hillsboro OR 97123 383672046 501(c)(3) 45000 Essential services to the needy Gorge Ecumenical Ministries PO Box 25 Hood River OR 97031 237048820 501(c)(3) 30000 Essential services to the needy La Clinica Del Carino Family Health 849 Pacific Avenue Hood River OR 97031 930910794 501(c)(3) 25000 Access to health and dental care Loaves and Fishes Centers 7710 SW 31st Ave Portland OR 97219 930584318 501(c)(3) 60000 Meals for the needy Macdonald Center 605 SW Couch St Portland OR 97209 931060938 501(c)(3) 25000 Outreach and support svcs for needy Multicultural Integrated Kidney Ed Program 9155 SW Barnes Rd Suite 221 Portland OR 97225 930593858 501(c)(3) 25000 Kidney education program Neighbor Impact 2303 SW First St Redmond OR 97756 930884929 501(c)(3) 10000 Helping break the circle of poverty New Avenues for Youth 1220 SW Columbia Portland OR 97201 930910213 501(c)(3) 25000 Health for homeless and at-risk youth Northwest Mothers Milk Bank 3439 NE Sandy Blvd 130 Portland OR 97232 263458029 501(c)(3) 46000 Building a milk bank to serve the Northwest Oregon Food Bank PO Box 55370 Portland OR 97238 930785786 501(c)(3) 10731 Essential food and other essentials PH&S - Oregon 4400 NE Halsey Bldg 1 Portland OR 97213 510216587 501(c)(3) 200000 Healthcare support for needy Portland Homeless Family Solutions Metro 1838 SW Jefferson Portland OR 97201 263967833 501(c)(3) 20000 Essentials for homeless families Portland Reading Foundation PO Box 80516 Portland OR 97280 201760894 501(c)(3) 12500 At-risk, low-income children and youth Siskiyou Community Health Center 25647 Redwood Highway Cave Junction OR 97523 930628804 501(c)(3) 25000 Affordable healthcare solution Society of St Vincent De Paul PO Box 1189 Seaside OR 97138 930456525 501(c)(3) 25000 Essential services to the needy Southern Oregon Children and Family Council 1001 Beall Leane Central Point OR 97502 930564896 501(c)(3) 25000 Essential services to the needy St Vincent De Paul of Crook County 240 E First Street Prineville OR 97754 870747592 501(c)(3) 10000 Essential services to the needy Stand for Children 516 SE Morrison St Ste 420 Portland OR 97238 521957214 501(c)(3) 25000 Essential services to the needy Stand for Children Leadership Center 516 SE Morrison St Ste 420 Portland OR 97238 521957214 501(c)(3) 25000 Essential services to the needy Sunshine Pantry 6170 SW Cherry Hill Drive Beaverton OR 97008 203834167 501(c)(3) 25000 Basic needs/essential services The Dougy Center PO Box 86852 Portland OR 97286 930833241 501(c)(3) 32583 Support for grieving children, youth and families The Oregon Community Foundation 1221 SW Yamhill St Ste 100 Portland OR 97205 237315673 501(c)(3) 1220250 Community health initiative Tualatin Valley Gleaners 1316 NE 51st Ave Hillsboro OR 97124 300340412 501(c)(3) 7500 Food distibution to the poor and needy Urban Gleaners 4500 SW Humphrey Blvd Portland OR 97221 204641665 501(c)(3) 10000 Essential services to the needy Virginia Garcia Clinic 85 N 12th Ave Cornelius OR 97113 930717997 501(c)(3) 100000 Essential services to the needy Wallace Medical Concern PO Box 3506 Gresham OR 97030 930853709 501(c)(3) 20000 Healthcare services for the poor/needy White Bird Clinic 341 East 12th Avenue Eugene OR 97401 930585814 501(c)(3) 25000 Essential services for the poor/needy Willamette Family Medical Center 435 Lancaster Drive NE Salem OR 97301 931180397 501(c)(3) 24000 Healthcare svcs and education to poor/needy 38 0 Procedure for Monitoring Grants in the U.S.: Part I, Line 2: Schedule I, Part I, Line 2: We request and condition grants upon each of the following: 1) The program summary and budget; 2) Verification of malpractice and liability coverage; 3) Updates provided every six months; 4) Documentation evidencing tax-exempt or municipal status; 5) Documentation showing that they serve the low income and uninsured regardless of ability to pay for services; 6) Provide upon request, financial reporting of the budgeted use of grant funds. 1 1 0 0 0 0 0 0 0 Jeffrey W Rogers 0 428372 0 1171207 0 15000 0 505409 0 19443 0 2139431 0 0 Jack Friedman 0 447211 0 2587104 0 31500 0 339020 0 25167 0 3430002 0 0 Alison S Schrupp 0 274913 0 48908 0 13631 0 45433 0 19629 0 402514 0 0 Barbara L Christensen 0 243602 0 45410 0 29115 0 62313 0 14126 0 394566 0 0 Michael G White 0 275800 0 49880 0 16500 0 27392 0 2287 0 371859 0 0 Bruce W Wilkinson 0 225537 0 44104 0 16500 0 11284 0 16638 0 314063 0 0 Robert A Gluckman 0 350273 0 28149 0 44 0 28905 0 17442 0 424813 0 0 Jeffrey Butcher 0 201991 0 775 0 16209 0 3293 0 16649 0 238917 0 0 Gregory Van Pelt 0 690516 0 2584395 0 36500 0 925680 0 21498 0 4258589 0 0 Shelly M Handkins 0 344831 0 116242 0 15000 0 233358 0 19562 0 728993 0 0 James H Mackay 0 288008 0 5948 0 155 0 68398 0 12096 0 374605 0 0 Gerald R Corn 0 234444 0 6065 0 16655 0 14513 0 12097 0 283774 0 0 Stephanie C Dreyfuss 0 211915 0 20000 0 0 0 10084 0 16685 0 258684 0 0 Susan Abate 0 189386 0 24060 0 0 0 27548 0 5904 0 246898 0 0 Carrie L Smith 0 168583 0 29575 0 0 0 7355 0 11146 0 216659 0 0 Kevin W Keck MD 0 0 0 0 0 409472 0 0 0 10644 0 420116 0 0 Part I, Line 1a The reporting organization did not provide any of the benefits listed in Part I, Line 1a. However, as part of Providence's philosophy of transparency, the narrative that follows relates to the compensation and benefits provided by the related organization. Providence Health & Services Expense Reimbursement Procedures include the following policies: Discretionary Spending Account Providence Health & Services provides an executive flex spending allowance per year (paid bi-weekly). This benefit is provided as discretionary spending because the organization does not reimburse for or provide additional executive benefits, such as a car allowance, additional executive life or disability insurance, or other market-based executive benefits practices. Housing Allowance or Residence for Personal Use Providence Health & Services provides housing allowances for purposes of relocation assistance only. Providence may pay temporary living expenses for the employee up to a maximum of 90 calendar days. Covered expenses are rent (excluding "rent" which may be paid in order to occupy a new permanent residence until the title clears) and utilities, including heat, electricity, gas, water, local internet and local telephone and garbage services. The VP/Chief Human Resources Officer may approve temporary housing assistance for up to six months when family relocation is delayed to accommodate the school year or equivalent circumstances. Only in extenuating circumstances is housing extended beyond this six month period. During 2011, the following officer received relocation payments: Jeffrey Butcher Kevin Keck The amounts reported for these relocation payments are included on Schedule J, Part II, Column B (iii) - Other Reportable Compensation. Tax Indemnifications or Gross-Up Payments Providence Health & Services follows the federal and state taxation laws related to relocation expenses paid to the employee or to a third party on the employees behalf. They are considered income and are therefore subject to payroll taxes. Based on the way Providence has chosen to pay the relocation expenses, Providence reports reimbursements and payments to vendors as income and these expense payments are reflected on the executive's Form W-2. Providence will gross-up the relocation benefits to offset the personal tax burden to the employee for IRS allowable expenses. During 2011, the following Employees received gross-up payments: Alison Schrupp Robert Gluckman Jeffrey Butcher James Mackay Gerald Corn The amounts reported for these gross-up payments are included on Schedule J, Part II, Column B (iii) - Other Reportable Compensation. Part I, Lines 4a-b NONQUALIFIED RETIREMENT PLANS A) DBSERP = Defined Benefit Supplemental Executive Retirement Plan B) DCSERP = Defined Contribution Supplemental Executive Retirement Plan C) DBCBRP = Defined Benefit Cash Balance Restoration Plan D) DCRP = Defined Contribution Restoration Plan E) ESP = Elective Survivor Plan 1) Jack Friedman a) Taxable DBSERP Earned but not Paid - $2,382,870 b) Non-Taxable DBSERP Earned but not Paid - $59,332 c) DBSERP Interest Credit - $209,408 d) Taxable DCSERP Earned but not Paid - $45,262 e) Non-Taxable DCSERP Earned - $50,985 2) Jeffrey W. Rogers a) Taxable DBSERP Earned but not Paid - $1,005,741 b) Non-Taxable DBSERP Earned but not Paid - $135,144 c) Taxable DCSERP Earned but not Paid - $8,561 d) Non-Taxable DCSERP Earned - $48,099 e) ESP Interest Credit - $79,952 f) DBSERP Interest Credit - $202,199 3) Alison Schrupp a) Taxable DBCBRP Earned but not Paid - $1,258 b) ESP Interest Credit - $20,201 4) Gregory Van Pelt a) Taxable DBSERP Earned but not Paid - $ 2,008,828 b) Non-Taxable DBSERP Earned but not Paid - $185,993 c) Taxable DCSERP Earned but not Paid - $276,749 d) Non-Taxable DCSERP Earned - $292,233 e) ESP Interest Credit - $88,256 f) DBSERP Interest Credit - $319,032 5) Barbara L. Christensen a) ESP Interest Credit - $28,403 6) Robert A. Gluckman a) Taxable DCSERP Earned but not Paid - $7,999 7) Shelly M. Handkins a) Non-Taxable DCSERP Earned but not Paid - $204,337 8) James Mackay a) Taxable DBCBRP Earned but not Paid - $5,948 b) Non-Taxable DBCBRP Earned - $1,805 c) Non-Taxable DCRP Earned - $7,368 9) Gerald Corn a) Taxable DBCBRP Earned but not Paid - $50 b) Non-Taxable DBCBRP Earned - $155 c) Non-Taxable DCRP Earned - $1,034 Part I, Lines 4a-b SEVERANCE Kevin Keck - $395,878 Supplemental Information Part III FORM 990, SCHEDULE J, PART II - EXECUTIVE PERFORMANCE AWARDS PROGRAM The Providence Executive Performance Awards Program provides a lump sum award annually as a percent of the executive's base pay. Percent opportunities are aligned with our total compensation philosophy as outlined in Part VI, Section B, Line 15 (Process for determining compensation of top management, officers & key employees). The performance award is based on the level of accomplishment of annual system objectives and personal objectives. In 2011, 50 percent of the participant awards were based on pre-determined organizational goals consistent with Providences five strategic priorities of: mission driven, financially responsible, people centered, service oriented and quality focused. In 2011 the percent allocation for each of these strategic priorities was: Mission driven 10% Financially responsible 10% People centered 10% Service oriented 10% Quality focused 10%. To ensure affordability of the program, the organization (system, region or entity) must meet a threshold of 50 percent of budgeted net operating income. Form 990, Part VI, Section A, line 6 The sole Corporate Member is Providence Plan Partners. Form 990, Part VI, Section A, line 7a The powers of the Corporate Member include the provision to appoint the number of Directors, appoint the Board of Directors and to remove such Directors at any time with or without cause. Form 990, Part VI, Section A, line 7b The following powers reside with the Member: * To adopt or change the mission, philosophy, and values of the Corporation. * To amend or repeal the Articles of Incorporation and the Bylaws of the Corporation. * To approve the acquisition of assets, the incurrence of indebtedness or the lease, sale, transfer, assignment or encumbering of the assets, in excess of a specified amount. * To approve the dissolution and/or liquidation or the consolidation or merger of the Corporation. * To approve the annual operating and capital budget and approval any deviations from the budget exceeding a specified amount. * To appoint the Corporation's certified public accountants after receiving recommendation of the Board of Directors. * To approve the lending of Corporate funds, other than the purchase of publicly traded securities, to unaffiliated organizations. * To approve the closure of any institution or major ministry or work within this Corporation. Form 990, Part VI, Section B, line 11 The Form 990 is prepared internally by experienced staff and reviewed by the internal Director of Taxes and external tax advisors. The Board of Directors reviewed the Form 990 prior to filing with the IRS. Form 990, Part VI, Section B, line 12c Providence Health & Services maintains a conflict of interest policy that applies to board members and management of all Providence-related organizations. The purpose of the policy is to guide and direct those serving the Providence Health & Services' corporations and other legal entities so they can (1) fulfill their fiduciary responsibilities and exercise stewardship in ways that promote and protect the best interests of Providence and, (2) avoid situations that create a conflict, or the appearance of a conflict, between the interests of an individual associated with Providence and Providence. On an annual basis, each board member and management level employee must complete and submit an updated conflict of interest statement. Conflict of interest disclosures are reviewed by the System Integrity Department working in conjunction with the Department of Legal Affairs. If it is determined that an actual conflict exists, appropriate follow-up action is taken with the individual to rectify the conflict. Form 990, Part VI, Section B, line 15 It is Providence's intention to make financial information accessible and transparent. Although the filing of Form 990 provides insight into how Providence achieves its Mission, delivers its programs and stewards its finances, deciphering the information directly from Form 990 can be challenging. The following paragraphs provide further information about the process we use to determine compensation for top management, officers and key employees. Providence has a single fiduciary Board, with responsibility for financial oversight associated with fulfillment of the Providence Mission, developing system policies, protecting the assets entrusted to the organization and overseeing the strategic and operational affairs of Providence's legal entities. Providence also maintains a network of community ministry boards with responsibility for quality of care oversight, community relations, advocacy and community needs assessments. Providence has a consistent compensation philosophy for all of its employees, including our senior executives. Salaries for senior executives are determined by the Providence Board's Human Resources Committee and approved by the full Board of Directors, none of whom is a Providence employee. The Board retains an independent consultant each year to review salaries of those in the most significant leadership roles in the organization. Part of the consultant's role is to review an extensive array of compensation surveys of large, not-for-profit health care systems in the United States. Providence is one of the larger health systems in the country, and as such, the Board benchmarks executive compensation against other large, not-for-profit health systems whose revenue is similar to that of Providence. Base salaries for Providence executives are set at the median level of the market, as identified by the independent consultant and reviewed with the Human Resources Committee. Performance incentives allow executives to earn additional compensation if they achieve specific organizational and individual goals for furthering Providence operating principles - advancing the Providence Mission and core values, meeting benchmarks for charity care, achieving quality targets, delivering top-rated customer satisfaction, meeting employee satisfaction goals and reaching financial performance objectives. The Board of Directors conducts a thorough process to ensure performance incentives are aligned with appropriate practices for not-for-profit health care systems. The Board's process for executive compensation fully complies with IRS standards and mirrors the best practices recommended in the "Report to Congress and the Nonprofit Sector on Governance, Transparency, and Accountability" submitted to the Senate Finance Committee by the Panel on the Nonprofit Sector. Form 990, Part VI, Section C, line 19 Public disclosure of governing documents, conflict of interest policy and 990 filings are made available to the public upon written request. The consolidated financial statements are available on our public Internet site www2.providence.org. All governing policies including the conflict of interest policy, as well as 990 filings are available to employees on the Intranet site. Contact Addresses for Officers, Directors, Etc Form 990, Part VII Lucille Dean, SP - 1801 Lind Avenue SW, Renton, WA 98057. M. Adrian Davis, LCM - 1801 Lind Avenue SW, Renton, WA 98057. Mary Corita Heid, RSM - 1801 Lind Avenue SW, Renton, WA 98057. Michael A. Stein - 1801 Lind Avenue SW, Renton, WA 98057. Michael Holcomb - 1801 Lind Avenue SW, Renton, WA 98057. Dana A. Rasmussen - 1801 Lind Avenue SW, Renton, WA 98057. James S. Roberts, MD - 1801 Lind Avenue SW, Renton, WA 98057. Peter J. Snow - 1801 Lind Avenue SW, Renton, WA 98057. Jeffrey B. Clode, MD - 1801 Lind Avenue SW, Renton, WA 98057. Sallye Liner - 1801 Lind Avenue SW, Renton, WA 98057. Owen B. Robinson - 1801 Lind Avenue SW, Renton, WA 98057. Cheryl M. Scott - 1801 Lind Avenue SW, Renton, WA 98057. Ellen L. Wolf - 1801 Lind Avenue SW, Renton, WA 98057. Jeffrey W. Rogers - 1801 Lind Avenue SW, Renton, WA 98057. Changes in Net Assets or Fund Balances: Form 990, Part XI, line 5: Net unrealized gains on investments: 327,550. HOURS WORKED FORM 990, PART VII, SECTION A The average hours per week reflect hours worked for the entire Providence Health & Services healthcare system and are not allocated to the individual reporting entity. 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. AUDITED FINANCIAL STATEMENTS FORM 990, PART IV, LINE 12 The audited financial statements of Providence Health Plan are prepared on a statutory basis in conformity with insurance accounting practices prescribed or permitted by the National Association of Insurance Commissioners and the Insurance Division of the Oregon Department of Consumer and Business Services. RELIGIOUS COMMUNITY MEMBERS FORM 990, PART VII As members of the Religious Community, each Sister has taken a vow of poverty as a compulsory part of her religious life. Any compensation for services of a Sister inures only for the benefit of the Community, not the individual members. All payments for services are made directly to the Religious Community. EMPLOYEE COMPENSATION FORM 990, PART II, LINE 5 & PART V, LINE 2A The employees working at Providence Health Plan are paid by Providence Health & Services - Oregon EIN# 51-0216587 or Providence Health & Services - WA. dba Health System Office EIN# 91-0725998. Therefore, no W-2s are issued by the reporting organization. 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 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 - So California 0 Little Company of Mary Ancillary Services Corporation 4101 Torrance Blvd Torrance CA 90503 330844408 Imaging Services CA 501( c)(3) Line 9 PHS - So California 0 Providence TrinityCare Hospice 2601 Airport Drive 230 Torrance CA 90505 953264139 Hospice CA 501( c)(3) Line 9 PHS - So California 0 Providence Blanchet Association 1700 Providence Pl Centralia WA 98531 911789266 Housing WA 501( c)(3) Line 7 PH & S - Washington 0 St Luke Association 350 Washington Ave SE Chehalis WA 98352 943176618 Housing WA 501( c)(3) Line 7 PH & S - Washington 0 Providence Rossi Association 1700 Providence Pl Centralia WA 98531 311584166 Housing WA 501( c)(3) Line 9 PH & S - Washington 0 Lundberg Association 5921 E Burnside Portland OR 97215 911562797 Housing OR 501( c)(3) Line 7 PH & S - Oregon 0 Providence St Francis Association 3415 12th Avenue NE Olympia WA 98506 943244854 Housing WA 501( c)(3) Line 7 PH & S - Washington 0 Providence Peter Claver Association 7101 38th Avenue South Seattle WA 98118 311629656 Housing WA 501( c)(3) Line 7 PH & S - Washington 0 Providence St Elizabeth House Association 3201 SW Graham St Seattle WA 98126 912171539 Housing WA 501( c)(3) Line 7 PH & S - Washington 0 Providence Gamelin House Association 4515 MLK Jr Way S Ste 200 Seattle WA 98108 311744654 Housing WA 501( c)(3) Line 7 PH & S - Washington 0 The Gamelin Association 312 North Fourth St Yakima WA 98901 911180824 Housing WA 501( c)(3) Line 1 PH & S - Washington 0 The Gamelin Oregon Association 5520 NE Glisan Portland OR 97213 911214491 Housing OR 501( c)(3) Line 9 PH & S - Oregon 0 The Gamelin California Association 540 23rd St Oakland CA 94612 911293869 Housing CA 501( c)(3) Line 9 PHS - So California 0 Gamelin Washington Association 1423 First Avenue Seattle WA 98101 201910170 Housing WA 501( c)(3) Line 7 PH & S - Washington 0 Providence Foundation 1801 Lind Avenue SW 9016 Renton WA 980579016 943078543 Support PH&S Institutions WA 501( c)(3) Line 11/Type I PH & S - Washington 0 Providence Alaska Foundation 3300 Providence Drive - B Tower2 Anchorage AK 99508 920093565 Support PHS-Alaska AK 501( c)(3) Line 11/Type I PH & S - Washington 0 Providence St Peter Foundation 413 Lilly Road NE Olympia WA 985065166 911097056 Support Affiliated Tax-Exempt Organization WA 501( c)(3) Line 7 PH & S - Washington 0 Providence Health Care Foundation (Centralia) 914 S Scheuber Road Centralia WA 98531 911433382 Support Providence Centralia Hospital WA 501( c)(3) Line 7 PH & S - Washington 0 Providence Mount St Vincent Foundation 4831 - 35th Avenue SW Seattle WA 981262799 911188119 Support Providence Mount St.Vincent WA 501( c)(3) Line 7 PH & S - Washington 0 Providence Marianwood Foundation 3725 Providence Point Drive SE Issaquah WA 980297219 931554288 Support Providence Marianwood WA 501( c)(3) Line 11/Type I PH & S - Washington 0 Providence Newberg Health Foundation 1001 Providence Drive Newberg OR 97132 930889144 Support Providence Newberg Medical Center OR 501( c)(3) Line 7 PH & S - Oregon 0 Providence Seaside Hospital Foundation 725 S Wahanna Rd Seaside OR 97138 930927320 Support Providence Seaside Hospital OR 501( c)(3) Line 7 PH & S - Oregon 0 Providence Community Health Foundation 1111 Crater Lake Ave Medford OR 97504 930692907 Support Providence Medford Medical Center OR 501( c)(3) Line 7 PH & S - Oregon 0 Providence Benedictine Nursing Center Foundation 540 South Main St Mt Angel OR 973629532 911940286 Support Providence Benedictine Nursing Center OR 501( c)(3) Line 7 PH & S - Oregon 0 Providence Portland Medical Foundation 4805 NE Glisan St Portland OR 972132967 931231494 Support Providence Portland Medical Center OR 501( c)(3) Line 7 PH & S - Oregon 0 Providence St Vincent Medical Foundation 9205 SW Barnes Rd Portland OR 97225 930575982 Support Providence St. Vincent Medical Center OR 501( c)(3) Line 7 PH & S - Oregon 0 Providence Milwaukie Foundation 10150 SE 32nd Milwaukie OR 97222 943079515 Support Providence Milwaukie Hospital OR 501( c)(3) Line 7 PH & S - Oregon 0 Providence Child Center Foundation 830 NE 47th Portland OR 97213 930800140 Support Providence Child Center OR 501( c)(3) Line 7 PH & S - Oregon 0 Providence TrinityCare Hospice Foundation 2601 Airport Drive 230 Torrance CA 90505 330261016 Support TrinityCare Hospice CA 501( c)(3) Line 7 PHS - So California 0 Providence Little Company of Mary Foundation 4101 Torrance Blvd Torrance CA 90503 510224944 Support Little Company of Mary Service Area CA 501( c)(3) Line 7 PHS - So California 0 PH&S FoundationSFVSA & SCVSA 501 S Buena Vista Street Burbank CA 91505 953544877 Support Program & Activities of SFVSA & SCVSA CA 501( c)(3) Line 7 PHS - So California 0 Providence Hospice of Seattle Foundation 425 Pontius Avenue North 300 Seattle WA 981095452 912077378 Support Hospice of Seattle WA 501( c)(3) Line 11/Type I PH & S - Washington 0 The John Gabriel Ryan Association 1801 Lind Avenue SW 9016 Renton WA 980579016 911303277 Healthcare WA 501( c)(3) Line 3 PH & S - Washington 0 Providence Health & Services 1801 Lind Avenue SW 9016 Renton WA 980579016 911549796 Shell Corporation WA 501( c)(3) Line 11/Type I N/A 0 Providence Health & Services - Montana 500 W Broadway PO Box 4587 Missoula MT 598064587 810231793 Healthcare MT 501( c)(3) Line 3 PH & S - Washington 0 Providence St Joseph Medical Center PO Box 1010 Polson MT 598601010 810463482 Healthcare MT 501( c)(3) Line 3 PH & S - Washington 0 St Thomas Child and Family Center 1710 Benefis Court Great Falls MT 59405 810233495 Early Childhood Education MT 501( c)(3) Line 1 PH & S - Washington 0 Sisters of Providence of Montana Corporation 1801 Lind Avenue SW 9016 Renton WA 980579016 262612415 Shell Corporation MT 501( c)(3) Line 1 PH & S - Washington 0 Sacred Heart Children's Foundation PO Box 2555 Spokane WA 99220 320014330 Support Sacred Heart Children's Hospital WA 501( c)(3) Line 7 PH & S - Washington 0 St Patrick Hospital Foundation 500 West Broadway PO Box 4587 Missoula MT 598064587 237056976 Support Healthcare in W. 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 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 Providence Plan Partners O 119299599 Cost Providence Health Assurance P 2304426 Cost Providence Plan Partners P 212129 Cost Providence Health & Services - Washington Q 53000000 Cost