2012-05-10T13:17:31-05:00 2011-06-30 BKD LLP 312 WALNUT STREET SUITE 3000 CINCINNATI OH 45202 990 2010-07-01 310537486 THE GOOD SAMARITAN HOSPITAL OF CINCINNATI OHIO GOOD 5135696575 619 OAK STREET - ACCOUNTING 3 WEST CINCINNATI OH 45206 MICHAEL CROFTON 5135696575 2012-05-10 1 5136218300 2010 2016-02-24 21:20:13Z JOHN PROUT 619 OAK STREET - ACCOUNTING 3 WEST CINCINNATI OH 45206 519094931 0 0928 X WWW.TRIHEALTH.COM X 1852 OH THE ORGANIZATION'S MISSION IS TO IMPROVE THE HEALTH STATUS OF THE COMMUNITY IT SERVES. 11 7 3893 1093 599620 -356418 2011657 1819755 452506006 477423089 17517998 26589936 7757833 12262151 479793494 518094931 565970 571927 0 0 209583482 221197407 0 0 0 225744205 238726565 435893657 460495899 43899837 57599032 587586475 696050814 236475946 233617196 351110529 462433618 X SEE SCHEDULE O 0 0 393386491 571927 486942795 SEE SCHEDULE H 393386491 1 1 0 1 0 0 0 0 1 1 1 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 0 1 274 0 1 3893 1 1 1 0 0 0 0 0 0 0 0 0 X 11 7 1 0 0 0 1 1 1 1 1 0 0 0 1 1 1 1 1 1 1 0 X MICHAEL CROFTON 5135695677 619 OAK STREET - ACCOUNTING 3 WEST CINCINNATI OH 45206 ROBERT WALKER 1.00 X X 0 0 0 JAMES SCHWAB 1.00 X X 0 0 0 STEPHEN SCHRANTZ 1.00 X X 0 0 0 MICHAEL MCGRAW 1.00 X X 0 0 0 PAUL EDGETT III 1.00 X 0 596461 78607 MICHAEL HAVERKAMP 1.00 X 0 0 0 THOMAS FINN 1.00 X 0 0 0 MYRTIS POWELL 1.00 X 0 0 0 SR MARY ELLEN MURPHY 1.00 X 0 0 0 EDWARD HARNESS JR 1.00 X 0 0 0 SILVANIA NG MD 1.00 X 0 45000 0 MARC ALEXANDER MD 1.00 X 45000 0 0 JOHN PROUT 1.00 X X 0 1216064 299811 DONNA NIENABER ESQ 1.00 X 0 480976 138646 CRAIG RUCKER 1.00 X 0 492908 115752 DAVE DORNHEGGEN 60.00 X 0 347377 109208 WILLIAM GRONEMAN 1.00 X 0 511263 166581 GERALD OLIPHANT 1.00 X 0 547879 117654 GEORGES FEGHALI MD 1.00 X 0 493357 137101 ROBERT ROHS MD 40.00 X 341719 0 40185 MICHAEL HOLBERT MD 40.00 X 265559 0 22576 MICHAEL MARCOTTE MD 40.00 X 200367 0 42394 HELEN KOSELKA MD 40.00 X 200630 0 47826 SAMATHA MAST MD 40.00 X 155921 0 23245 MICHAEL CROFTON 0.00 X 0 261091 67993 1209196 4992376 1407579 59 1 1 0 TRI-STATE HEALTHCARE LAUNDRY INC 551 S LOOP ROAD EDGEWOOD KY 41017 LAUNDRY 1610272 AMERICAN NURSING CARE INC 1700 EDISON DRIVE SUITE 300 MILFORD OH 45150 NURSING 1244326 PHYSICIANS ANESTHESIA SERVICES INC 20 MEDICAL VILLAGE DRIVE EDGEWOOD KY 41017 ANESTHESIA 970250 MORRISON MANAGEMENT SPECIALISTS PO BOX 102289 ATLANTA GA 30368 FOOD SERVICE 763142 ESKRIBE INC 6770 COMMERCE COURT BLACKLICK OH 43004 MEDICAL TRANSCRIPTION 655719 43 1818228 1527 1819755 PATIENT SERVICES 621990 475555556 475030106 525450 JOA REVENUE 990009 7810951 7810951 AFFILIATED ORG. RENTAL 532000 1331214 1331214 EQUITY CHANGE IN ORGS. 990009 -7274632 -7274632 477423089 9875083 22635 9852448 906290 906290 906290 906290 16671903 1042950 1000000 16671903 42950 16714853 16714853 CAFETERIA 722100 2184090 2184090 PHARMACY 446110 1836155 1836155 RESEARCH 900099 1204201 1204201 6131415 6079880 51535 11355861 518094931 484181720 599620 31493836 565806 565806 6121 6121 171569260 145152760 26416500 11149602 8749035 2400567 25809528 19911744 5897784 12669017 10953863 1715154 1453717 1389819 63898 2410753 2410753 212408 212408 1207057 1207057 17343631 14620535 2723096 2151799 305613 1846186 6771462 4602206 2169256 7749403 648223 7101180 8688500 7428785 1259715 627767 270614 357153 6789964 6789964 5885160 5885160 21089197 17546156 3543041 4392315 4238662 153653 MEDICAL/DIETARY SUPPLIE 101032584 100735403 297181 BAD DEBTS 36897918 36897918 REPAIRS AND MAINTENANCE 6610824 6177489 433335 OHIO HOSPITAL FEE 3810209 3810209 O&M COST TRACK FEES 678411 678411 2923486 1907155 1016331 460495899 393386491 67109408 0 18384195 24981720 28099105 49421712 298360 99690 1449355 3005214 177600 167400 519461641 335646159 173571630 183815482 44927953 41516113 309592250 366526724 11086027 26516759 587586475 696050814 44394290 52467167 47034 91310 134295401 147851989 57739221 33206730 236475946 233617196 X 345900651 457130498 5209878 5303120 351110529 462433618 587586475 696050814 X 57599032 53724057 X X 0 1 1 X 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 1 91955 0 0 1 8555 100510 0 EXPLANATION OF OTHER LOBBYING ACTIVITIES: PART II-B, LINE 1I: DURING THE TAX YEAR, THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO ("HOSPITAL") PAID ANNUAL MEMBERSHIP DUES TO VARIOUS NATIONAL, STATE AND LOCAL ORGANIZATIONS, A PORTION ($1,762) OF WHICH RELATED TO LOBBYING ACTIVITIES. IN ADDITION, TRIHEALTH, INC., A RELATED ORGANIZATION OF HOSPITAL, WHICH PROVIDES ADMINISTRATIVE SUPPORT SERVICES TO HOSPITAL, PAID ANNUAL MEMBERSHIP DUES TO VARIOUS NATIONAL, STATE AND LOCAL ORGANIZATIONS A PORTION OF WHICH RELATED TO LOBBYING ACTIVITIES. A PORTION OF THE AFOREMENTIONED ADMINISTRATIVE SUPPORT SERVICES ARE ALLOCATED TO HOSPITAL AND $3,430 OF THE AMOUNT SHOWN ON LINE 1I REPRESENTS HOSPITAL'S SHARE OF THESE LOBBYING EXPENSES. FINALLY, HOSPITAL'S CONTROLLING ORGANIZATION, CATHOLIC HEALTH INITIATIVES, PAYS ANNUAL DUES TO THE AMERICAN HOSPITAL ASSOCIATION ("AHA") AND CATHOLIC HOSPITAL ASSOCIATION ("CHA"), A PORTION OF WHICH IS ALLOCATED TO LOBBYING ACTIVITIES. FOR THE TAX YEAR, THE AMOUNT SHOWN ON LINE 1I ABOVE REPRESENTS HOSPITAL'S SHARE OF ALLOCATED LOBBYING EXPENSES: AHA $839; CHA $2,524. PART IV, SUPPLEMENTAL INFORMATION: PART II-B, LINE 1(F), GRANTS TO OTHER ORGANIZATIONS FOR LOBBYING: TRIHEALTH, INC., A RELATED ORGANIZATION OF HOSPITAL, WHICH PROVIDES ADMINISTRATIVE SUPPORT SERVICES TO HOSPITAL, PAID FEES TO CASSIDY AND ASSOCIATES, A LEADER IN THE GOVERNMENT RELATIONS INDUSTRY FOR OVER THIRTY YEARS, FOR PROFESSIONAL SERVICES. A PORTION OF THE AFOREMENTIONED ADMINISTRATIVE SUPPORT SERVICES ARE ALLOCATED TO HOSPITAL AND THE AMOUNT SHOWN ON LINE 1F REPRESENTS HOSPITAL'S SHARE OF THESE EXPENSES. 12221795 66487 12288282 12018000 203795 12221795 11923322 94678 12018000 1.00000 0 1 1 10489392 10489392 297768906 183848022 113920884 7698256 3882026 3816230 187094074 147916111 39177963 16411013 16411013 183815482 CHI OPERATING INVESTMENT PROGRAM 366526724 F 366526724 RETIREMENT PLAN LIABILITY 22799269 LEASE PAYMENT LIABILITY 8357447 ENVIRONMENTAL REMEDIATION LIABILITY 1502422 UNCLAIMED PROPERTY 547592 33206730 518094931 460495899 57599032 33042181 20681876 53724057 111323089 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: THE FINANCIAL STATEMENTS OF THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO ("HOSPITAL") ARE AUDITED WITH ITS SUBSIDIARIES. FOLLOWING IS THE TEXT OF THE FOOTNOTE TO HOSPITAL'S AUDITED FINANCIAL STATEMENTS THAT REPORTS ITS AND ITS SUBSIDIARY'S LIABILITY, IF APPLICABLE, FOR UNCERTAIN TAX POSITIONS UNDER ASC 740-10-25: THE COMPANY COMPLETED AN ANALYSIS OF UNCERTAIN TAX POSITIONS IN ACCORDANCE WITH APPLICABLE ACCOUNTING GUIDANCE AT JUNE 30, 2011 AND 2010, AND DETERMINED NO AMOUNTS WERE REQUIRED TO BE RECOGNIZED IN THE CONSOLIDATED FINANCIAL STATEMENTS AT JUNE 30, 2011 AND 2010. IN ADDITION, HOSPITAL'S FINANCIAL INFORMATION IS INCLUDED IN THE CONSOLIDATED AUDITED FINANCIAL STATEMENTS OF CATHOLIC HEALTH INITIATIVES ("CHI"), A RELATED ORGANIZATION. CHI IS A TAX-EXEMPT COLORADO CORPORATION AND HAS BEEN GRANTED AN EXEMPTION FROM FEDERAL INCOME TAX UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. CHI OWNS CERTAIN TAXABLE SUBSIDIARIES AND ENGAGES IN CERTAIN ACTIVITIES THAT ARE UNRELATED TO ITS EXEMPT PURPOSE AND THEREFORE SUBJECT TO INCOME TAX. AS OF JUNE 30, 2011, CHI HAS NET DEFERRED TAX ASSETS OF $2.1 MILLION AND A NONCURRENT NET DEFERRED TAX LIABILITY OF $5.4 MILLION RELATED TO THESE TAXABLE ACTIVITIES. MANAGEMENT ANNUALLY REVIEWS ITS POSITIONS AND HAS DETERMINED THAT THERE ARE NO MATERIAL UNCERTAIN TAX POSITIONS THAT REQUIRE RECOGNITION IN THE CONSOLIDATED FINANCIAL STATEMENTS. PART XI, LINE 8 - OTHER ADJUSTMENTS: CHANGE PENSION PLAN/SERP FUNDED STATUS 24,738,916. TRANSFER TO CHI CAPITAL RESOURCE POOL -4,024,236. MISCELLANEOUS ADJUSTMENT -32,804. 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 1 1 X 1 X 1 X 1 1 0 1 1 19548484 6414967 13133517 0.03100 71710690 54792091 16918599 0.03990 91259174 61207058 30052116 0.07090 1530924 37149 1493775 0.00350 21016731 10034128 10982603 0.02590 5101366 4080746 1020620 0.00240 2565642 2565642 0.00610 112285 112285 0.00030 30326948 14152023 16174925 0.03820 121586122 75359081 46227041 0.10910 356750 356750 0.00080 2136 2136 0.00000 358886 358886 0.00080 1 9250997 96578589 96576469 2120 X 1 1 1 1 GOOD SAMARITAN HOSPITAL

375 DIXMYTH AVENUE CINCINNATI OH 45220

X X X X X NA 1 5 GOOD SAMARITAN MEDICAL CENTER

6949 GOOD SAMARITAN DRIVE CINCINNATI OH 45247

EMERGENCY DEPARTMENT/OUTPATIENT SERVICES GOOD SAMARITAN PHYSICAL THERAPY

8748 UNION CENTRE DRIVE WEST CHESTER OH 45069

PHYSICAL THERAPY GOOD SAMARITAN HOSPITAL OUTPATIENT CTR

6350 GLENWAY AVENUE CINCINNATI OH 45211

OUTPATIENT PHYSICIAN CLINIC GOOD SAMARITAN HOSPITAL WEIGHT MGMT CTR

3219 CLIFTON AVENUE SUITE 225 CINCINNATI OH 45220

WEIGHT MANAGEMENT SERVICES GOOD SAMARITAN HOSPITAL WOMEN'S CENTER

3219 CLIFTON AVENUE SUITE 100 CINCINNATI OH 45220

WOMEN'S HEALTH SERVICES PART I, LINE 3C: THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO UTILIZES THE FEDERAL POVERTY GUIDELINES ("FPG") IN DETERMINING CHARITY CARE ELIGIBILITY. SEE THE RESPONSES TO PART I, LINE 3A AND 3B.AN INDIVIDUAL'S INCOME UNDER FPG IS A SIGNIFICANT FACTOR IN DETERMINING ELIGIBILITY FOR CHARITY CARE. HOWEVER, IN DETERMINING WHETHER TO EXTEND DISCOUNTED OR FREE CARE TO A PATIENT, THE PATIENT'S ASSETS MAY ALSO BE TAKEN INTO CONSIDERATION. FOR EXAMPLE, A PATIENT SUFFERING A CATASTROPHIC ILLNESS MAY HAVE A REASONABLE LEVEL OF INCOME, BUT A LOW LEVEL OF LIQUID ASSETS SUCH THAT A PAYMENT OF MEDICAL BILLS WOULD BE SERIOUSLY DETRIMENTAL TO THE PATIENT'S FINANCIAL (AND ULTIMATELY PHYSICAL) WELL-BEING AND SURVIVAL. SUCH A PATIENT MAY BE EXTENDED DISCOUNTED OR FREE CARE BASED UPON THE FACTS AND CIRCUMSTANCES. PART I, LINE 6A: IN 1995, THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO AND BETHESDA HOSPITAL, INC. FORMED A PARTNERSHIP CALLED TRIHEALTH, INC. TO CREATE AN INTEGRATED HEALTH DELIVERY SYSTEM WHOSE MISSION IS TO IMPROVE THE HEALTH OF THE PEOPLE THEY SERVE, WITH AN EMPHASIS ON PREVENTION, WELLNESS AND EDUCATION. THE COMMUNITY BENEFIT PROVIDED BY THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO IS TRACKED ON A STANDALONE BASIS, HOWEVER ITS COMMUNITY BENEFIT IS REPORTED IN COMBINATION WITH BETHESDA HOSPITAL, INC.'S COMMUNITY BENEFIT IN A REPORT PREPARED BY TRIHEALTH, INC. PART I, LINE 7: FOR THE AMOUNTS REPORTED AT COST IN PART I, LINE 7, THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO UTILIZED WORKSHEET 2 - RATIO OF PATIENT CARE COST-TO-CHARGES, WHICH WAS PROVIDED IN THE INSTRUCTIONS TO SCHEDULE H, TO CALCULATE THE COST-TO-CHARGE RATIO. PART I, LINE 7G: THE SUBSIDIZED HEALTH SERVICES COMMUNITY BENEFIT AMOUNT REPORTED IN PART I, LINE 7(G) DOES NOT INCLUDE COSTS ATTRIBUTABLE TO PHYSICIAN CLINICS. PART I, L7 COL(F): $36,897,918 OF BAD DEBT EXPENSES THAT WAS INCLUDED IN FORM 990, PART IX, LINE 25, COLUMN (A) HAS BEEN REMOVED FOR PURPOSES OF CALCULATING THE PERCENTAGE OF TOTAL EXPENSES IN SCHEDULE H, PART I, LINE 7, COLUMN (F). PART II: THE UPTOWN CONSORTIUM ("CONSORTIUM") IS RECOGNIZED BY THE INTERNAL REVENUE SERVICE AS EXEMPT FROM INCOME TAX UNDER INTERNAL REVENUE CODE SECTION 501(A) AS AN ORGANIZATION DESCRIBED IN INTERNAL REVENUE CODE SECTION 501(C)(3). IT IS MADE UP OF THE FIVE LARGEST EMPLOYERS OF CINCINNATI'S "UPTOWN" INCLUDING THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO. "UPTOWN" GENERALLY INCLUDES THE NEIGHBORHOODS OF AVONDALE, CLIFTON, CLIFTON HEIGHTS, CORRYVILLE, FAIRVIEW, MT. AUBURN AND UNIVERSITY HEIGHTS. THE CONSORTIUM IS DEDICATED TO BUILDING THE HUMAN, SOCIAL AND PHYSICAL IMPROVEMENT OF UPTOWN CINCINNATI. IT WILL UNDERTAKE A VARIETY OF INVESTMENT AND PROGRAM ACTIVITIES IN UPTOWN TO HELP PROVIDE HOUSING, HEALTH CARE AND JOB OPPORTUNITIES.IN ADDITION, THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO ASSISTS, THROUGH VOLUNTEERING, VARIOUS ORGANIZATIONS INCLUDING THE WORK RESOURCE CENTER OF CINCINNATI WHICH PROVIDES SKILLS TRAINING FOR INDIVIDUALS WITH DISABILITIES AND DISADVANTAGES TO INCREASE THEIR INDEPENDENCE THROUGH EMPLOYMENT. PART III, LINE 4: NET PATIENT ACCOUNTS RECEIVABLE (PART OF FOOTNOTE A)NET PATIENT ACCOUNTS RECEIVABLE AND NET PATIENT SERVICE REVENUE HAVE BEEN ADJUSTED TO THE ESTIMATED AMOUNTS EXPECTED TO BE COLLECTED. THESE ESTIMATED AMOUNTS ARE SUBJECT TO FURTHER ADJUSTMENTS UPON REVIEW BY THIRD-PARTY PAYORS.THE PROVISION FOR BAD DEBTS IS BASED UPON MANAGEMENT'S ASSESSMENT OF HISTORICAL AND EXPECTED NET COLLECTIONS CONSIDERING HISTORICAL BUSINESS AND ECONOMIC CONDITIONS, TRENDS IN HEALTH CARE COVERAGE, AND OTHER COLLECTION INDICATORS. MANAGEMENT PERIODICALLY ASSESSES THE ADEQUACY OF THE ALLOWANCES FOR UNCOLLECTIBLE ACCOUNTS BASED UPON HISTORICAL WRITE-OFF EXPERIENCE. THE RESULTS OF THESE REVIEWS ARE USED TO MODIFY AS NECESSARY THE PROVISIONS FOR BAD DEBTS AND TO ESTABLISH APPROPRIATE ALLOWANCES FOR UNCOLLECTIBLE NET PATIENT ACCOUNTS RECEIVABLE. AFTER SATISFACTION OF AMOUNTS DUE FROM INSURANCE, THE COMPANY FOLLOWS ESTABLISHED GUIDELINES FOR PLACING CERTAIN PATIENT BALANCES WITH COLLECTION AGENCIES, SUBJECT TO THE TERMS OF CERTAIN RESTRICTIONS ON COLLECTION EFFORTS AS DETERMINED BY EACH THE COMPANY. FINANCIAL INSTRUMENTS THAT POTENTIALLY SUBJECT THE COMPANY TO CONCENTRATIONS OF CREDIT RISK CONSIST PRIMARILY OF NON-GOVERNMENTAL PATIENT ACCOUNTS RECEIVABLE. THE COMPANY GRANTS CREDIT WITHOUT COLLATERAL TO ITS PATIENTS, MOST OF WHOM ARE INSURED UNDER THIRD-PARTY PAYOR AGREEMENTS. THE PERCENTAGES OF GROSS PATIENT ACCOUNTS RECEIVABLE FROM PATIENTS AND THIRD-PARTY PAYORS AT JUNE 30 APPROXIMATED THE FOLLOWING: 2011 - MEDICARE 18%, MEDICAID 3%, MANAGED CARE 21%, SELF PAY 22%, COMMERCIAL AND OTHER 36%2010 - MEDICARE 18%, MEDICAID 4%, MANAGED CARE 19%, SELF PAY 23%, COMMERCIAL AND OTHER 36%AS FOR THE AMOUNT OF BAD DEBT THAT REASONABLY COULD BE ATTRIBUTABLE TO PATIENTS WHO LIKELY WOULD QUALIFY FOR FINANCIAL ASSISTANCE UNDER THE ORGANIZATION'S CHARITY CARE POLICY, THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO DOES NOT REPORT ACTUAL BAD DEBT EXPENSE AS COMMUNITY BENEFIT. IF UPON FURTHER RESEARCH, IT IS ULTIMATELY DETERMINED THAT A PORTION OF BAD DEBT EXPENSE IS ATTRIBUTABLE TO PATIENTS WHO WOULD LIKELY QUALIFY FOR FINANCIAL ASSISTANCE UNDER TRIHEALTH'S CHARITY CARE POLICY, THOSE COSTS WOULD BE RECLASSIFIED, AS APPROPRIATE, TO COMMUNITY BENEFIT AT THAT TIME. PART III, LINE 8: THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO USES THE "STEPDOWN METHODOLOGY" IN DETERMINING THE MEDICARE ALLOWABLE COSTS REPORTED ON THE MEDICARE COST REPORT. THIS METHOD OF COST FINDING PROVIDES FOR THE ALLOCATION OF THE COST OF SERVICES RENDERED BY EACH GENERAL SERVICE COST CENTER TO OTHER COST CENTERS WHICH UTILIZE SUCH SERVICES. ONCE THE COSTS OF A GENERAL SERVICE COST CENTER HAVE BEEN ALLOCATED, THAT COST CENTER IS CONSIDERED CLOSED. ONCE CLOSED, IT DOES NOT RECEIVE ANY OF THE COSTS SUBSEQUENTLY ALLOCATED FROM THE REMAINING GENERAL SERVICE COST CENTERS. THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO DID NOT REPORT ANY MEDICARE SHORTFALL AS COMMUNITY BENEFIT IN PART III, LINE 7 OF THIS SCHEDULE. PART III, LINE 9B: AS OF THE FILING OF THIS RETURN, THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO, AS PART OF TRIHEALTH, INC., MAINTAINS A WRITTEN DEBT COLLECTION POLICY. TRIHEALTH, INC., WHO PERFORMS THE BILLING SERVICES FOR ALL AFFILIATED HOSPITALS, WILL NOT INITIATE COLLECTION PRACTICES ON PATIENTS WHO ARE KNOWN TO QUALIFY FOR CHARITY CARE OR FINANCIAL ASSISTANCE. BEFORE COLLECTION ACTIONS ARE TAKEN, TRIHEALTH, INC. WILL MAKE REASONABLE EFFORTS, GENERALLY AS EARLIER IN THE BILLING PROCESS AS POSSIBLE, TO DETERMINE WHETHER A PATIENT IS ELIGIBLE FOR FINANCIAL ASSISTANCE. AFTER SUCH EFFORTS HAVE BEEN MADE AND A BALANCE REMAINS THAT IS THE RESPONSIBILITY OF THE PATIENT OR GUARANTOR, TRIHEALTH, INC. MAY PURSUE, IN ITS SOLE DISCRETION, WHATEVER ACTIONS IT MAY BE ENTITLED TO TAKE UNDER LAW. PART VI, LINE 2: IN 1852, THE SISTERS OF CHARITY ESTABLISHED GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO ("GSH") IN AN EFFORT TO ADDRESS THE NEEDS OF THE GROWING CITY OF CINCINNATI. IN 1995, GSH & BETHESDA HOSPITAL, INC. ("BETHESDA") FORMED A PARTNERSHIP TO CREATE A LOCAL HEALTH SYSTEM: TRIHEALTH, INC. ("TRIHEALTH"). TRIHEALTH'S MISSION IS TO IMPROVE THE HEALTH STATUS OF THE COMMUNITY THROUGH A FULL RANGE OF HEALTH RELATED SERVICES (E.G. PREVENTION, WELLNESS & EDUCATION)THE SERVICES DESCRIBED BELOW, & OTHERS NOT LISTED, PROMOTE A HEALTHY COMMUNITY. PROGRAMS SEEK TO REDUCE THE BURDENS ON THE GOVERNMENT. FOR EXAMPLE, IF GSH DID NOT ADDRESS THE ROOT CAUSES OF LOW BIRTH WEIGHT & PREMATURITY, THE BURDEN TO GOVERNMENT MEDICAL PROGRAMS SUCH AS MEDICAID WOULD BE EVEN GREATER.CURRENTLY, GSH, AS PART OF TRIHEALTH, IS INVOLVED IN THE PLANNING & IMPLEMENTATION OF A COLLABORATIVE COMMUNITY HEALTH NEEDS ASSESSMENT WITH AN ANTICIPATED COMPLETION TIMELINE OF 2012. THE ASSESSMENT REPORT WILL ASSIST PARTNER HOSPITALS & AGENCIES IN ADDRESSING UNMET HEALTH NEEDS, WITH AN OVERALL AIM OF IMPROVING POPULATION HEALTH. COMMUNITY HEALTH NEEDS, AS ASSESSED IN PRIOR YEARS BY INDEPENDENT GROUPS SUCH AS THE GREATER CINCINNATI UNITED WAY AS WELL AS THE HEALTH FOUNDATION OF GREATER CINCINNATI, HAVE SHOWN SIGNIFICANT HEALTH NEEDS FOR THE GREATER CINCINNATI AREA IN INFANT MORTALITY, OBESITY, DEPRESSION, HYPERTENSION & DIABETES. TWO MAJOR STRATEGIES ARE IN PLACE TO ADDRESS INFANT MORTALITY & DIABETES. THE REMAINING COMMUNITY HEALTH NEEDS RECEIVE TRIHEALTH'S EXPERTISE & FOCUS THROUGH ONGOING HOSPITAL & PHYSICIAN PRACTICE INITIATIVES.FREE & DISCOUNTED SERVICES ARE PROVIDED FOR THOSE UNABLE TO PAY & MEETING ELIGIBILITY CRITERIA. THROUGH THE HOSPITAL CARE ASSURANCE PROGRAM (HCAP), GSH SERVES PATIENTS MEETING CRITERIA SET FORTH BY THE STATE OF OHIO. GSH POLICY IS TO PROVIDE CHARITY CARE ON A SLIDING SCALE DISCOUNTING WHEN THE FAMILY INCOME IS UP TO 400 % OF THE ANNUALLY ESTABLISHED FEDERAL POVERTY GUIDELINE. IT OFFERS AN UNINSURED DISCOUNT FOR MEDICALLY NECESSARY SERVICES FOR THOSE WHO HAVE NO INSURANCE & WHO DO NOT QUALIFY FOR OTHER FINANCIAL ASSISTANCE OPTIONS. FINANCIAL COUNSELORS ASSIST PATIENTS IN COMPLETING THE FINANCIAL ASSISTANCE APPLICATION WHICH IS AVAILABLE ON TRIHEALTHS WEBSITE & BROCHURES ABOUT FINANCIAL ASSISTANCE ARE VISIBLE & AVAILABLE IN HOSPITAL REGISTRATION & ADMITTING AREAS.GSH PROVIDED $46.2 MILLION IN TOTAL COMMUNITY BENEFIT FOR FISCAL YEAR 2011. OF THAT TOTAL, $30.1 MILLION REPRESENTED UNCOMPENSATED CARE. THE UNPAID COST OF MEDICARE IS NOT INCLUDED IN COMMUNITY BENEFIT.GSH FUNDS THE PARISH NURSE MINISTRY & COMMUNITY HEALTH WORKER PROGRAMS. THESE PROGRAMS PROVIDE, AT NO CHARGE, HOME VISITS TO LOW INCOME CLIENTS IN 9 NEIGHBORHOODS. CLIENTS INCLUDE SENIORS & FRAIL ELDERLY IN THEIR HOMES OR IN CONGREGATE SUBSIDIZED HOUSING, THE MENTALLY & PHYSICALLY HANDICAPPED LIVING ALONE OR IN GROUP HOMES, & MOTHERS WHO ARE PREGNANT OR WHO HAVE RECENTLY DELIVERED A BABY. REFERRALS COME FROM HOSPITAL CARE COORDINATORS, OTHER HOSPITALS & AGENCIES. THE TEAM PROVIDES HEALTH SCREENINGS, EDUCATION ON MANAGING CHRONIC ILLNESSES, & CONNECTIONS TO ASSISTANCE. THE NEWLY DEVELOPED PURPLE (PREVENTING REPEAT PERINATAL LOSS) PROJECT CONNECTS MOTHERS WHO HAVE EXPERIENCED THE LOSS OF A PREGNANCY GREATER THAN 20 WEEKS GESTATION WITH A PARISH NURSE WHO PROVIDES EMOTIONAL & SPIRITUAL SUPPORT, NUTRITION INFORMATION & EDUCATION ON INTER-CONCEPTION HEALTH.THE INPATIENT BEHAVIORAL HEALTH UNITS AT GSH ARE AMONG THE FEW SUCH UNITS IN THE GREATER CINCINNATI COMMUNITY. THE ADULT BEHAVIORAL HEALTH INPATIENT UNIT IS A 19-BED COMPREHENSIVE PSYCHIATRIC UNIT FOR ADULT PATIENTS REQUIRING ACUTE INPATIENT CARE. THE TEAM CONSISTS OF PSYCHIATRISTS, NURSING STAFF, SOCIAL WORKERS, OCCUPATIONAL THERAPISTS, THERAPEUTIC RECREATION SPECIALISTS, & ART THERAPISTS. THE FULL SERVICES OF THE HOSPITAL ARE AVAILABLE AS REQUIRED FOR THE PATIENT'S CARE. TREATMENT FOCUSES ON SYMPTOM & MEDICATION MANAGEMENT & EDUCATION, & SAFE DISCHARGE DISPOSITION WITH A LINK TO COMMUNITY RESOURCES. THE SENIOR BEHAVIORAL HEALTH INPATIENT UNIT IS A SPECIALTY BEHAVIORAL HEALTH INPATIENT UNIT ADDRESSING THE PSYCHOLOGICAL, MEDICAL, EMOTIONAL & SPIRITUAL NEEDS OF GREATER CINCINNATI'S OLDER ADULTS. THE TEAM OF PSYCHIATRISTS, PSYCHIATRIC NURSES, SOCIAL WORKERS, & ACTIVITY & OCCUPATIONAL THERAPISTS PROVIDES INDIVIDUALIZED TREATMENT FOR OLDER ADULTS WITH PHYSICAL & MENTAL HEALTH PROBLEMS.HEALTHY WOMEN HEALTHY LIVES IS A PROGRAM BASED ON THE PREMISE THAT PREVENTION, EARLY DETECTION, TREATMENT & ACCESS TO HEALTH CARE SERVICES IMPROVE INDIVIDUAL & COMMUNITY HEALTH OUTCOMES. THE FOCUS IS ON HEALTH RISKS ASSOCIATED WITH THE ONSET OF MENOPAUSE. WELL ORGANIZED SCREENING & EDUCATION EVENTS BRING THE SERVICES TO AT RISK POPULATIONS OF AFRICAN AMERICAN, APPALACHIAN, HISPANIC, UNINSURED & UNDERINSURED WOMEN FORTY YEARS OF AGE OR OLDER. SCREENING INCLUDES OSTEOPOROSIS, MAMMOGRAPHY, CHOLESTEROL, HYPERTENSION, & OBESITY. EVERY WOMAN RECEIVES A NURSE CONSULTATION, A COPY OF THEIR RESULTS & A WRITTEN PRIMARY CARE REFERRAL. WOMEN WITH ABNORMAL RESULTS ARE CONTACTED & ASSISTED IN ACCESSING PRIMARY CARE. IN FISCAL YEAR 2011 OVER 500 WOMEN WERE SERVED BY THIS PROGRAM. HAMILTON COUNTY'S INFANT MORTALITY RATE OF 19%, THE HIGHEST IN OHIO HAS LED GSH TO FOCUS ON MATERNAL & INFANT HEALTH PROGRAMS. STRATEGIES INCLUDE INVESTIGATING THE ROOT CAUSES OF PREMATURITY & LOW BIRTH WEIGHT.GSH HAD 6385 DELIVERIES IN FISCAL YEAR 2011. OF THESE BIRTHS, THE PERCENTAGE OF MOTHERS WITH PRETERM LABOR WAS 15% (A 2% INCREASE OVER FY10). THE PERCENTAGE OF BABIES BORN WEIGHING LESS THAN 2500 GRAMS WAS 14% (A SLIGHT DECREASE FROM FY10). THIS DECREASE MAY BE ATTRIBUTED IN PART TO GSH'S COLLABORATIVE EFFORTS TO REDUCE ELECTIVE DELIVERIES BEFORE THE 39TH WEEK. ADDITIONALLY, THE CARE MANAGEMENT PROVIDED TO MOTHERS BY GSH PERINATAL SOCIAL WORKERS & CARE COORDINATORS INCLUDES SPECIAL PROGRAMS IN CHEMICAL DEPENDENCY & OTHER PREGNANCY HIGH-RISK ISSUES. THE GSH PARISH NURSES & COMMUNITY HEALTH WORKERS VISIT REFERRED MOTHERS IN THEIR HOMES & WORK WITH THEM TO PROBLEM-SOLVE THE FREQUENT CHALLENGES FACED SUCH AS SAFE HOUSING & CARE OF CHILDREN, AS WELL AS HEALTHY MANAGEMENT OF THE PREGNANCY.PERINATAL CARE COORDINATION NURSES & SOCIAL WORKERS FROM GSH ASSIST MOTHERS IN THE GSH FACULTY MEDICAL CENTER. THEY ALSO TRAVEL TO CLINICS IN ORDER TO REACH OUT & HELP UNINSURED & UNDERINSURED MOTHERS ACCESS PUBLIC PROGRAMS, REFERRALS, EDUCATION, ASSESSMENT & RESOURCES.GSH CONTINUES A COMMITMENT TO EDUCATING THE NEXT GENERATION OF HEALTH CARE PROVIDERS--PHYSICIANS & ALLIED HEALTH PROFESSIONALS. GSH, AS PART OF TRIHEALTH, INC., SPONSORS MEDICAL RESIDENCIES. THERE WERE 28 RESIDENTS IN INTERNAL MEDICINE & 23 GENERAL SURGERY RESIDENTS AT GSH IN FISCAL YEAR 2011. 2 FELLOWS IN VASCULAR SURGERY RECEIVED EXTENDED LEARNING & PREPARATION IN THEIR FELLOWSHIP AT GSH. 32 TOTAL RESIDENTS IN OBSTETRICS & GYNECOLOGY LEARNED IN A JOINT RESIDENCY AT BOTH BETHESDA & GSH.IN THE GSH FACULTY MEDICAL CENTER ("FMC"), A MULTI-SPECIALTY CENTER, MEDICAL RESIDENTS PROVIDE CARE TO PATIENTS UNDER THE GUIDANCE OF ATTENDING PHYSICIANS. FMC SERVICES INCLUDE OBSTETRICS & GYNECOLOGY, INTERNAL MEDICINE, VASCULAR & GENERAL SURGERY, DYSPLASIA, HIGH-RISK PREGNANCY, URO-GYNECOLOGY & GASTRO-INTESTINAL. THE FMC PHARMACIST HELPS ELIGIBLE CLIENTS COMPLETE THE MEDICATION ASSISTANCE PROGRAMS APPLICATIONS. THE GSH ON-SITE PHARMACY PROVIDES PRESCRIPTIONS FOR THOSE IN NEED, AT REDUCED OR NO COST.GSH COLLABORATES WITH LOCAL & REGIONAL COLLEGES, UNIVERSITIES & TRAINING CENTERS TO PROVIDE MENTORING, INTERNSHIPS, CLERKSHIPS, SUPERVISED EDUCATION & CLINICAL ROTATIONS TO STUDENTS IN HEALTH FIELDS. THESE PARTNERSHIPS HELP STUDENTS LEARN ABOUT & PREPARE FOR PROFESSIONS IN NURSE PRACTITIONER, RESPIRATORY THERAPY, RADIOLOGY TECHNOLOGY, STERILE PROCESSING, PHLEBOTOMY, MEDICAL LABORATORY, CLINICAL DIETETICS, PHARMACY, SPEECH, AUDIOLOGY, PHYSICAL THERAPY, OCCUPATIONAL THERAPY, NURSE MIDWIFERY, & NEONATAL NURSE PRACTITIONER. PASTORAL CARE OFFERS A CLINICAL PASTORAL EDUCATION PROGRAM EDUCATING CLERGY & OTHERS IN PASTORAL SKILLS TO MINISTER EFFECTIVELY TO THE SICK & THE DYING.GSH'S RESEARCH PROGRAM MANAGES BASIC & APPLIED SCIENTIFIC STUDIES & SPONSORED CLINICAL TRIALS. IT ALSO SUPPORTS THE EDUCATION ACTIVITIES OF STAFF PHYSICIANS & SURGEONS, TEACHING FACULTY, RESIDENTS, & ALLIED HEALTH PROFESSIONALS. WHAT IS LEARNED THROUGH THE RESEARCH & EDUCATION PROGRAMS IS SHARED WITH THE LARGER COMMUNITY. THE RESEARCH PROGRAM HELPED RESEARCHERS GIVE 65 PROFESSIONAL PRESENTATIONS AT REGIONAL & NATIONAL MEETINGS. AN ESTIMATED 45 STUDIES & ARTICLES WERE PUBLISHED IN PEER-REVIEWED MEDICAL JOURNALS.THROUGH THESE PROGRAMS, GSH CONTINUES ITS SPECIAL CONCERN FOR THE VULNERABLE. EMPLOYEES, PHYSICIANS & LEADERS PROVIDING & GUIDING THESE PROGRAMS FOR COMMUNITY HEALTH ARE LIVING THE CORE VALUES OF STEWARDSHIP & RESPONSE TO COMMUNITY NEEDS. PART VI, LINE 3: TRIHEALTH, INC. ("TRIHEALTH") PERFORMS THE BILLING SERVICES FOR ALL AFFILIATED HOSPITALS INCLUDING THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO. BROCHURES/APPLICATIONS, PROVIDED IN MULTIPLE LANGUAGES, ARE VISIBLE AND AVAILABLE IN THE REGISTRATION AND ADMITTING AREAS OF ALL TRIHEALTH AFFILIATED HOSPITALS. IN ADDITION, THE APPLICATION IS PRINTED ON THE REVERSE SIDE OF A PATIENT'S BILL WITH INSTRUCTIONS ON HOW TO COMPLETE THE APPLICATION AS WELL AS HOW TO RETURN IT. FINANCIAL COUNSELORS ASSIST PATIENTS IN COMPLETING THE FINANCIAL ASSISTANCE APPLICATION. FINALLY, TRIHEALTH INC.'S WEBSITE CONTAINS INFORMATION REGARDING ITS CHARITY CARE AND FINANCIAL ASSISTANCE PROGRAMS WITH DIRECTIONS ON HOW TO CONTACT THE APPROPRIATE PERSONNEL TO INITIATE AN APPLICATION OR ASK QUESTIONS ABOUT THE PROCESS. PART VI, LINE 4: LOCATED IN CINCINNATI, OHIO, GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO AND THE TRIHEALTH SYSTEM SERVE HAMILTON, BUTLER, WARREN AND CLERMONT COUNTIES, AS WELL AS PERSONS FROM INDIANA AND KENTUCKY. OHIO'S THIRD LARGEST CITY, CINCINNATI HAS AN ESTIMATED POPULATION OF 296,943. THE POPULATION WITHIN THE FOUR OHIO COUNTIES SERVED BY TRIHEALTH IS ESTIMATED TO BE 1,580,560 AND 12% PERCENT OF THIS POPULATION IS UNINSURED. THE GEOGRAPHIC AREA SERVED BY THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO IS PREDOMINANTLY URBAN WITH A LARGE SEGMENT OF ITS PATIENTS UNINSURED, UNDERINSURED OR MEDICAID RECIPIENTS. PART VI, LINE 6: THE ONGOING PURPOSE OF THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO ("GSH") IS TO PROVIDE CARE WITH COMPASSION. ITS MISSION IS TO IMPROVE THE HEALTH STATUS OF THE COMMUNITY THROUGH HEALTH RELATED SERVICES--PREVENTION, WELLNESS AND EDUCATION. ITS BOARD OF DIRECTORS IS COMPRISED OF INDEPENDENT COMMUNITY REPRESENTATIVES. GSH IS AN ACUTE TERTIARY TEACHING HOSPITAL. AS PART OF TRIHEALTH A SYSTEM OF SERVICES SPANNING ACUTE CARE TO HOME CARE, BABIES TO SENIORS. IT PROVIDES A 24-HOUR EMERGENCY ROOM, FOUR INTENSIVE CARE UNITS FOR NEONATES AND ADULTS, ADULT AND GERIATRIC INPATIENT PSYCHIATRIC CARE, AND AN ACCREDITED REHABILITATION MEDICINE PROGRAM. SERVICES ARE OPEN TO ALL INDIVIDUALS REGARDLESS OF ABILITY TO PAY. GSH HAS AN OPEN MEDICAL STAFF AND A HISTORY OF TRAINING AND EDUCATING MEDICAL RESIDENTS AND HEALTH CARE PROFESSIONALS. ITS MEDICAL AND SCIENTIFIC RESEARCH PROGRAMS INCLUDE STUDIES THAT ARE NOT COMMERCIALLY SPONSORED. GSH PARTICIPATES IN MEDICARE AND MEDICAID AND OTHER GOVERNMENT-SPONSORED HEALTH CARE PROGRAMS, AND HAS AN ACTIVE CHARITY CARE PROGRAM.SEE RESPONSE TO PART VI, LINE 2 FOR ADDITIONAL INFORMATION. PART VI, LINE 7: IN 1995, THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO AND BETHESDA HOSPITAL, INC. FORMED A PARTNERSHIP CALLED TRIHEALTH, INC. TO CREATE AN INTEGRATED HEALTH DELIVERY SYSTEM WHOSE MISSION IS TO IMPROVE THE HEALTH OF THE PEOPLE THEY SERVE, WITH AN EMPHASIS ON PREVENTION, WELLNESS AND EDUCATION. TRIHEALTH, INC.'S SITES INCLUDE TWO HOSPITAL LOCATIONS AND VARIOUS PHYSICIAN OFFICE BUILDINGS THROUGHOUT THE GREATER CINCINNATI AREA IN ADDITION TO FITNESS, REHABILITATION, OCCUPATIONAL HEALTH, PALLIATIVE CARE SERVICES AND OUTPATIENT CENTERS. IT ALSO PROVIDES SERVICES IN HOMES AND WORKPLACES AND DELIVERS CARE AND EDUCATION COOPERATIVELY THROUGH COMMUNITY-BASED ORGANIZATIONS, SUCH AS CHURCHES, SCHOOLS, CLINICS AND SOCIAL AGENCIES. 1 HEALTHY BEGINNINGS INC 47 E HOLLISTER STE 201 CINCINNATI OH 45219 311380939 501(C)(3) 70000 RESIDENCY SUPPORT HEALTHY MOM AND BABIES INC 2270 BANNING ROAD CINCINNATI OH 45239 311155292 501(C)(3) 103500 CHARITY CARE HARMONY GARDEN 1776 MENTOR AVE BOX 221 CINCINNATI OH 45212 205461244 501(C)(3) 10000 VIOLENCE PREVENTION GRANT UPTOWN CONSORTIUM INC 629 OAK STREET SUITE 306 CINCINNATI OH 45206 200688727 501(C)(3) 147900 GENERAL PURPOSE VOLUNTEERS IN MEDICAL MISSIONS PO BOX 756 SENECA SC 29679 621361564 501(C)(3) 6250 MEDICAL SERVICE TRIP THE CENTER FOR CLOSING THE HEALTH GAP IN GREATER CINCINNATI 3120 BURNET AVENUE SUITE 201 CINCINNATI OH 45229 200902286 501(C)(3) 107865 GENERAL PURPOSE BETHESDA FOUNDATION 619 OAK STREET CINCINNATI OH 45206 237374129 501(C)(3) 34300 GENERAL PURPOSE CENTER FOR RESPITE CARE INC PO BOX 141301 CINCINNATI OH 45229 202544994 501(C)(3) 25500 GENERAL PURPOSE GOOD SAMARITAN HOSPITAL FOUNDATION OF CINCINNATI INC 619 OAK STREET CINCINNATI OH 45206 311206047 501(C)(3) 6120 GENERAL PURPOSE HEALTH IMPROVEMENT COLLABORATIVE OF GREATER CINCINNATI INC 2100 SHERMAN AVE NO 100 CINCINNATI OH 45212 311449807 501(C)(3) 23945 GENERAL PURPOSE COLLEGE OF MOUNT SAINT JOSEPH 5701 DELHI ROAD CINCINNATI OH 45233 237179567 501(C)(3) 10200 GENERAL PURPOSE 11 EDUCATIONAL ASSISTANCE (I.E. TUITION PAYMENT, INTERPRETER SERVICES, ETC.) 1 6121 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO ("HOSPITAL") PROVIDES GRANTS TO OTHER ORGANIZATIONS AND INDIVIDUALS ON A VERY LIMITED BASIS. IN THOSE INSTANCES, THE DEPARTMENT GRANTING THE FUNDS IS RESPONSIBLE FOR OBTAINING AND STORING ALL NECESSARY INFORMATION FROM THE OTHER ORGANIZATION AND INDIVIDUALS RELATIVE TO HOW THE FUNDS WILL BE SPENT. GENERALLY, GRANTS ARE PROVIDED, ON BEHALF OF HOSPITAL THOUGH TRIHEALTH, INC. ("TRIHEALTH"), A SUPPORTING ORGANIZATION OF HOSPITAL, WHICH PROVIDES ADMINISTRATIVE SUPPORT SERVICES TO HOSPITAL. AS SUCH, TRIHEALTH IS RESPONSIBLE FOR MONITORING THE USE OF HOW THE FUNDS WILL BE SPENT. 0 1 0 0 0 0 0 1 0 PAUL EDGETT III 0 384470 0 112138 0 99853 0 59749 0 18858 0 675068 0 77989 JOHN PROUT 0 826309 0 325512 0 64243 0 290415 0 9396 0 1515875 0 0 DONNA NIENABER ESQ 0 285693 0 112845 0 82438 0 122081 0 16565 0 619622 0 0 CRAIG RUCKER 0 356895 0 119103 0 16910 0 108173 0 7579 0 608660 0 0 DAVE DORNHEGGEN 0 255360 0 71524 0 20493 0 95545 0 13663 0 456585 0 0 WILLIAM GRONEMAN 0 340571 0 112569 0 58123 0 143853 0 22728 0 677844 0 15009 GERALD OLIPHANT 0 394187 0 128877 0 24815 0 96037 0 21617 0 665533 0 0 GEORGES FEGHALI MD 0 345269 0 124696 0 23392 0 114648 0 22453 0 630458 0 0 ROBERT ROHS MD 338496 0 0 0 3223 0 39472 0 713 0 381904 0 0 0 MICHAEL HOLBERT MD 265102 0 0 0 457 0 22012 0 564 0 288135 0 0 0 MICHAEL MARCOTTE MD 200367 0 0 0 0 0 23063 0 19331 0 242761 0 0 0 HELEN KOSELKA MD 199148 0 870 0 612 0 40963 0 6863 0 248456 0 0 0 SAMATHA MAST MD 155681 0 0 0 240 0 11108 0 12137 0 179166 0 0 0 MICHAEL CROFTON 0 191909 0 48549 0 20633 0 45715 0 22278 0 329084 0 0 PART I, LINE 4B PART I, LINE 4B - NON-QUALIFIED DEFERRED COMPENSATION PLAN ELIGIBLE EXECUTIVES (GENERALLY VICE PRESIDENTS AND ABOVE) PARTICIPATE IN A PROGRAM THAT PROVIDES FOR SUPPLEMENTAL RETIREMENT BENEFITS. THE PAYMENT OF BENEFITS UNDER THE PROGRAM, IF ANY, IS ENTIRELY DEPENDENT UPON THE FACTS AND CIRCUMSTANCES UNDER WHICH THE EXECUTIVE TERMINATES EMPLOYMENT WITH THE ORGANIZATION. BENEFITS UNDER THE PROGRAM ARE UNFUNDED AND NON-VESTED. DUE TO THE SUBSTANTIAL RISK OF FORFEITURE PROVISION, THERE IS NO GUARANTEE THAT THESE EXECUTIVES WILL EVER RECEIVE ANY BENEFIT UNDER THE PROGRAM. ANY AMOUNT ULTIMATELY PAID UNDER THE PROGRAM TO THE EXECUTIVE IS REPORTED AS COMPENSATION ON FORM 990, SCHEDULE J, PART II, COLUMN B IN THE YEAR PAID. TRIHEALTH, INC., THE RELATED ORGANIZATION THAT PAID THE SALARIES OF THE FOLLOWING INDIVIDUALS LISTED IN SCHEDULE J, PART II, CONTRIBUTED, ON BEHALF OF THE FOLLOWING INDIVIDUALS, TO A SUPPLEMENTAL NONQUALIFIED RETIREMENT PLAN IN THE AMOUNTS AS NOTED: JOHN PROUT - $240,770 DONNA NIENABER, ESQ. - $67,368 CRAIG RUCKER - $63,874 MICHAEL CROFTON - $14,108 GERALD OLIPHANT - $73,468 DAVE DORNHEGGEN - $39,203 WILLIAM GRONEMAN - $75,052 GEORGES FEGHALI, MD - $72,079. IN ADDITION, THE FOLLOWING INDIVIDUALS LISTED IN SCHEDULE J, PART II, RECEIVED A PAYMENT FROM A SUPPLEMENTAL NONQUALIFIED RETIREMENT PLAN WHICH WAS TREATED AS TAXABLE COMPENSATION BY THEIR RESPECTIVE EMPLOYERS: WILLIAM GRONEMAN - $15,009 (TRIHEALTH, INC.) PAUL EDGETT III - $77,989 (CATHOLIC HEALTH INITIATIVES) PART I, LINE 7 PART I, LINE 7: A PHYSICIAN HAS A BASE SALARY BUT IS ALSO ELIGIBLE FOR A BONUS. THE BONUS IS CONTINGENT ON THE PROFITABILITY OF HIS OR HER PRACTICE. ESSENTIALLY, THE PROFITABILITY OF HIS OR HER PRACTICE GETS PAID TO THE PHYSICIAN AS A BONUS UP TO A MAXIMUM OF $100,000. SUPPLEMENTAL INFORMATION PART III PART I, LINE 3 - METHODS USED TO ESTABLISH CEO COMPENSATION TRIHEALTH, INC., A RELATED ORGANIZATION OF THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO, WHO PAID THE INDIVIDUAL, USES THE FOLLOWING TO ESTABLISH THE COMPENSATION OF THE FILING ORGANIZATION'S CEO/EXECUTIVE DIRECTOR: * COMPENSATION COMMITTEE; * INDEPENDENT COMPENSATION CONSULTANT; * COMPENSATION SURVEY OR STUDY; AND * APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE. PART I, LINE 4A - SEVERANCE PAYMENTS: THE REPORTABLE INDIVIDUALS OF THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO ARE PAID BY TRIHEALTH, INC., A RELATED ORGANIZATION, RECOGNIZED BY THE INTERNAL REVENUE SERVICE AS EXEMPT FROM FEDERAL INCOME TAX UNDER INTERNAL REVENUE CODE SECTION 501(A) AS AN ORGANIZATION DESCRIBED IN INTERNAL REVENUE CODE SECTION 501(C)(3). THESE INDIVIDUALS DO NOT HAVE EMPLOYMENT AGREEMENTS SO NO SPECIAL ARRANGEMENTS EXIST BEYOND TRIHEALTH, INC.'S STANDARD EMPLOYEE SEVERANCE PACKAGE. SEVERANCE PAY IS BASED ON LENGTH OF SERVICE. THE AMOUNT OF NOTICE PAY WILL BE DETERMINED BY HUMAN RESOURCES IN ACCORDANCE WITH TRIHEALTH, INC. POLICY. PAYMENTS OF SEVERANCE ARE CONDITIONED UPON SIGNING A SEPARATION AND RELEASE AGREEMENT. NO REPORTABLE INDIVIDUALS RECEIVED SEVERANCE PAYMENTS FROM TRIHEALTH, INC. DURING THE 2010 CALENDAR YEAR. DESCRIPTION OF THE ORGANIZATION'S MISSION FORM 990, PART III, LINE 1 THE ORGANIZATION'S MISSION IS TO NURTURE THE HEALING MINISTRY OF THE CHURCH BY BRINGING IT NEW LIFE, ENERGY AND VIABILITY IN THE 21ST CENTURY. FIDELITY TO THE GOSPEL URGES US TO EMPHASIZE HUMAN DIGNITY AND SOCIAL JUSTICE AS WE MOVE TOWARD THE CREATION OF HEALTHIER COMMUNITIES. FORM 990, PART VI, SECTION A, LINE 2 THE OFFICERS, DIRECTORS AND TRUSTEES OF THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO LISTED IN PART VII, SECTION A HAVE A "BUSINESS RELATIONSHIP" WITH EACH OTHER BY VIRTUE OF SITTING ON THE BOARDS OF BETHESDA HOSPITAL, INC. AND TRIHEALTH, INC., BOTH AFFILIATED ENTITIES OF TRIHEALTH, INC. SYLVANIA NG, MD, EDWARD HARNESS, ROBERT L. WALKER, MICHAEL HAVERKAMP, AND MYRTIS POWELL HAVE A "BUSINESS RELATIONSHIP" WITH EACH OTHER BY VIRTUE OF SITTING ON THE BOARD OF BETHESDA, INC., THE SINGLE CORPORATE MEMBER OF BETHESDA HOSPITAL, INC. JOHN PROUT, DONNA NIENABER, ESQ., CRAIG RUCKER, WILLIAM GRONEMAN, GERALD OLIPHANT, GEORGES FEGHALI, MD AND DAVE DORNHEGGEN HAVE A "BUSINESS RELATIONSHIP" WITH EACH OTHER BY VIRTUE OF SITTING ON RELATED ENTITY BOARDS OF TRIHEALTH, INC. AND ITS SUBSIDIARIES AND AFFILIATES AS WELL AS BEING EMPLOYED BY TRIHEALTH, INC. OR ITS AFFILIATES/SUBSIDIARIES. FORM 990, PART VI, SECTION A, LINE 6 THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO HAS TWO (2) CORPORATE MEMBERS. CATHOLIC HEALTH INITIATIVES, A COLORADO NON-PROFIT CORPORATION, IS THE SOLE VOTING MEMBER AND TRIHEALTH, INC., AN OHIO NON-PROFIT CORPORATION, IS THE SOLE NON-VOTING MEMBER. FORM 990, PART VI, SECTION A, LINE 7A IN ACCORDANCE WITH THE CORPORATE BYLAWS OF THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO ("HOSPITAL"), THE TRUSTEES OF THE HOSPITAL (OTHER THAN THE CHIEF EXECUTIVE OFFICER AND THE PRESIDENTS OF THE MEDICAL STAFFS OF GOOD SAMARITAN HOSPITAL AND BETHESDA NORTH HOSPITAL WHO SERVE BY VIRTUE OF THEIR OFFICES) SHALL BE NOMINATED AND ELECTED BY THE VOTING MEMBER NO LATER THAN JUNE 30 OF EACH YEAR IN THE MANNER PROVIDED IN THE NETWORK AFFILIATION AGREEMENT. FORM 990, PART VI, SECTION A, LINE 7B CATHOLIC HEALTH INITIATIVES ("CHI") IS THE SOLE CORPORATE VOTING MEMBER OF THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO ("HOSPITAL"). PURSUANT TO SECTION 5.4.2 OF THE HOSPITAL'S BYLAWS AND THE NETWORK AFFILIATION AGREEMENT, THE VOTING MEMBER SHALL HAVE THE SPECIFIC RIGHTS SET FORTH IN THE GOVERANCE MATRIX. PURSUANT TO THE GOVERNANCE MATRIX, THE FOLLOWING RIGHTS ARE RESERVED TO THE CHI BOARD DIRECTLY OR THROUGH POWERS DELEGATED TO THE CHI CHIEF EXECUTIVE OFFICER: * SUBSTANTIAL CHANGE IN THE MISSION OR PHILOSOPHY OF THE HOSPITAL, * AMENDMENT OF THE CORPORATE DOCUMENTS OF THE HOSPITAL, * APPROVAL OF MEMBERS OF THE HOSPITAL'S BOARD, * REMOVAL OF A MEMBER OF THE GOVERNING BODY OF THE HOSPITAL, * APPROVAL OF ISSUANCE OF DEBT BY THE HOSPITAL, * APPROVAL OF PARTICIPATION OF THE HOSPITAL IN A JOINT VENTURE, * APPROVAL OF FORMATION OF A NEW CORPORATION BY THE HOSPITAL, * APPROVAL OF A MERGER INVOLVING THE HOSPITAL, * APPROVAL OF THE SALE OF ALL OR SUBSTANTIALLY ALL OF THE ASSETS OF THE HOSPITAL, * AUTHORITY TO REQUIRE THE TRANSFER OF ASSETS BY THE HOSPITAL TO CHI TO ACCOMPLISH CHI'S GOALS AND OBJECTIVES, AND TO SATISFY CHI DEBTS, AND * ADOPTION OF LONG RANGE AND STRATEGIC PLANS FOR THE HOSPITAL. PURSUANT TO SECTION 5.5.2 OF THE HOSPITAL'S BYLAWS AND THE NETWORK AFFILATION AGREEMENT, CHI MAY, IN EXERCISE OF ITS APPROVAL POWERS, GRANT OR WITHHOLD APPROVAL IN WHOLE OR IN PART, OR MAY, IN ITS COMPLETE DISCRETION, AFTER CONSULTATION WITH THE BOARD AND THE PRESIDENT AND CHIEF EXECUTIVE OFFICER OF THE HOSPITAL, RECOMMEND SUCH OTHER OR DIFFERENT ACTIONS AS IT DEEMS APPROPRIATE. FORM 990, PART VI, SECTION B, LINE 11 MEMBERS OF THE BOARD ARE PROVIDED AN ELECTRONIC COPY OF THIS FORM 990 PRIOR TO FILING. HOWEVER, FOR THE PROTECTION OF DONOR PRIVACY, SCHEDULE B - SCHEDULE OF CONTRIBUTORS WAS REMOVED FROM THE COPY PROVIDED TO THE BOARD. SUBSEQUENT TO PRESENTATION TO THE BOARD, THE ORGANIZATION FILES THE RETURN MAKING ANY NON-SUBSTANTIVE CHANGES NECESSARY TO EFFECT E-FILING. ANY SUCH CHANGES ARE NOT RE-SUBMITTED TO THE BOARD. FORM 990, PART VI, SECTION B, LINE 12C ALL BOARD MEMBERS ARE REQUIRED TO ANNUALLY DISCLOSE CERTAIN FINANCIAL INTERESTS AND FIDUCIARY RELATIONSHIPS. THE EXECUTIVE COMMITTEE AND CORPORATE COUNSEL REVIEW RESPONSES, CONDUCT FURTHER INVESTIGATION, IF NECESSARY, AND DETERMINE WHEN A CONFLICT EXISTS WITH RESPECT TO A CERTAIN TRANSACTION. IF A CONFLICT EXISTS, THE TRANSACTION IS NOT TO BE ENTERED INTO UNLESS ALTERNATIVES ARE FULLY INVESTIGATED AND, IN THEIR ABSENCE, THE BOARD, WITHOUT PARTICIPATION OF THE INTERESTED MEMBER(S), DETERMINES THAT THE TRANSACTION IS IN THE BEST INTEREST OF THE ORGANIZATION. PLANS TO MANAGE THE CONFLICT DURING THE RELATIONSHIP ARE IMPLEMENTED. ALL DISCUSSIONS ARE APPROPRIATELY DOCUMENTED. FORM 990, PART VI, SECTION B, LINE 15 IN DETERMINING COMPENSATION OF THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO'S OFFICERS AND DIRECTORS, THE ANNUAL PROCESS PERFORMED BY TRIHEALTH, INC. (A RELATED ORGANIZATION WHO PAID THE INDIVIDUALS) INCLUDED: * COMPENSATION COMMITTEE; * INDEPENDENT COMPENSATION CONSULTANT; * COMPENSATION SURVEY OR STUDY; AND * APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE. ADDITIONALLY, ALL DISCUSSIONS AND DECISIONS ARE CONTEMPORANEOUSLY DOCUMENTED. FORM 990, PART VI, SECTION C, LINE 19 THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO'S GOVERNING DOCUMENTS, CONFLICTS OF INTEREST POLICY AND FINANCIAL STATEMENTS ARE AVAILABLE UPON REQUEST. IN ADDITION, THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO'S FINANCIAL STATEMENTS ARE INCLUDED IN THE CATHOLIC HEALTH INITIATIVES' CONSOLIDATED AUDITED FINANCIAL STATEMENTS THAT ARE AVAILABLE AT WWW.CATHOLICHEALTHINT.ORG OR AT HTTP://WWW.DACBOND.COM. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED GAINS ON INVESTMENTS: 33,042,181. CHANGE PENSION PLAN/SERP FUNDED STATUS 24,738,916. TRANSFER TO CHI CAPITAL RESOURCE POOL -4,024,236. MISCELLANEOUS ADJUSTMENT -32,804. TOTAL TO FORM 990, PART XI, LINE 5: 53,724,057. VOLUNTEER INFORMATION FORM 990, PART I, LINE 6 DURING THE TAX YEAR, THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO WAS ASSISTED BY 1,093 VOLUNTEERS WHO DONATED 100,605 HOURS. EXECUTIVE COMMUNITY COMPOSITION AND AUTHORITY FORM 990, PART VI, LINE 1 PURSUANT TO ARTICLE SECTION 8.1.1 OF THE BYLAWS OF THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO ("HOSPITAL"), THE BOARD OF TRUSTEES MAY ESTABLISH AN THE EXECUTIVE COMMITTEE WHICH MAY EXERCISE SUCH POWER AND AUTHORITY OF THE BOARD OF TRUSTEES IN INTERVALS BETWEEN MEETINGS OF THE BOARD AS AUTHORIZED BY THE BOARD. THE EXECUTIVE COMMITTEE IS COMPOSED OF THE BOARD CHAIR, THE BOARD VICE CHAIR, THE PRESIDENT AND THE CHIEF EXECUTIVE OFFICER, THE SECRETARY AND TWO OTHER BOARD MEMBERS IN ACCORDANCE WITH THE NETWORK AFFILIATION AGREEMENT. PURSUANT TO SECTION 8.1.5 OF THE HOSPITAL'S BYLAWS, COMMITTEES, SUCH AS THE EXECUTIVE COMMITTEE, THAT ARE GRANTED THE AUTHORITY TO ACT ON BEHALF OF THE BOARD OF DIRECTORS SHALL CONSIST OF AT LEAST THREE MEMBERS OF THE BOARD OF TRUSTEES. FURTHER, PURSUANT TO SECTION 8.1.1 OF THE HOSPITAL'S BYLAWS, FOUR MEMBERS OF THE EXECUTIVE COMMITTEE SHALL CONSTITUTE A QUORUM FOR THE TRANSACTIONS OF BUSINESS AND THE ACT OF THE FOUR OF THEM SHALL CONSTITUTE THE ACT OF THE COMMITTEE. ESTIMATE OF HOURS DEVOTED TO RELATED ORGANIZATIONS FORM 990, PART VII, SECTION A OFFICERS AND DIRECTORS (AS NOTED WITH A "SCH O" REFERENCE) FOR THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO PROVIDE SERVICES TO TRIHEALTH, INC. (A RELATED ORGANIZATION WHO THE INDIVIDUALS) AND ITS SUBSIDIARIES/AFFILIATES ("TRIHEALTH"). HOURS WORKED ARE NOT TRACKED ON AN ENTITY BY ENTITY BASIS. THE COMPENSATION REPORTED ON THE FORM 990, PART VII, SECTION A WAS PAID TO THESE INDIVIDUALS IN FULFILLMENT OF THEIR DUTIES AS FULL-TIME, 60 HOURS-PER-WEEK EMPLOYEES OF TRIHEALTH. CHANGE IN PROCESS OF AUDIT OVERSIGHT OR SELECTION OF INDEPENDENT AUDITOR FORM 990, PART XI, LINE 2C THE FINANCIAL STATEMENTS OF THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO ("HOSPITAL") ARE AUDITED WITH ITS SUBSIDIARIES. HOSPITAL HAS A COMMITTEE THAT ASSUMES THE RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT OF BOTH ITS AND ITS SUBSIDIARIES FINANCIAL STATEMENTS AS WELL AS THE SELECTION OF THE INDEPENDENT AUDITOR. DURING THE TAX YEAR, THERE WAS NOT A CHANGE IN THE PROCESS OF AUDIT OVERSIGHT AND/OR SELECTION OF AN INDEPENDENT AUDITOR BY HOSPITAL. 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