2011-08-04T19:06:09-05:00 2010-09-30 RSM MCGLADREY INC ONE SOUTH WACKER DRIVE SUITE 800 CHICAGO IL 606063392 990 2009-10-01 361564290 NORWEGIAN AMERICAN HOSPITAL Inc NORW 7732928200 1044 NORTH FRANCISCO AVENUE CHICAGO IL 60622 ANTHONY EVERS 7732928200 2011-08-04 1 3126343400 2009 2016-02-24 21:20:13Z JOSE R SANCHEZ 1044 NORTH FRANCISCO AVENUE CHICAGO IL 60622 109881399 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. 14 13 1069 54 88159 -202492 247999 627714 117581925 109076880 284724 80646 34887 7797 118149535 109793037 0 0 51233931 51472391 0 0 66084050 60157014 117317981 111629405 831554 -1836368 90102907 94745926 53313710 61138493 36789197 33607433 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 73284299 108766256 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, 2010, Norwegian American Hospital forgone $15,582,964 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 2010, Norwegian American Hospital served 9,580 patients admitted who received 39,862 days of healthcare services. These patient days can be attributed to the following programs -Medical Surgical 15,046 -Obstetrics 3,959 -Intensive Care 2,938 -Detoxification 5,348 -Special Care Nursery 1,438 -Pediatric 4,44 -Psychiatric Adult 7,338 -Psychiatric Geriatric 3,351 -Emergency Department visits provided during fiscal year 2010 were 25,890 -Other Outpatient Serves services were Healthworks visits 2,830. 73284299 1 0 0 1 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 1 110 0 1 1069 1 1 1 0 0 0 0 0 0 0 0 14 13 0 1 0 0 0 0 0 1 1 0 1 1 0 1 1 1 1 0 1 1 0 IL X ANTHONY EVERS Cfo CIA 7732928200 1044 NORTH FRANCISCO AVE CHICAGO IL 606222743 MICHAEL J O'GRADY JR 40.00 X X 435323 0 45466 PATRICK DRISCOLL 10.00 X X 0 0 0 HENRY MUNEZ 4.00 X X 0 0 0 EZEQUIEL MONTES 8.00 X X 0 0 0 MARCO REATEGUI 8.00 X X 0 0 0 RAFAEL CAMPANINI 2.00 X 0 0 0 MARTA CERDA 3.00 X 0 0 0 PERRY J GULBRANDSEN 2.00 X 0 0 0 EDUARDO LADLAD 2.00 X 0 0 0 DUKE MIGLIN 2.00 X 0 0 0 TOCHUKWU O ONYEKWULUJE 2.00 X 0 0 0 MYRNA E PEDERSEN 2.00 X 0 0 0 HECTOR J RODRIGUEZ 2.00 X 0 0 0 RAFAELA MUNOZ-ULRICH 2.00 X 0 0 0 MURALI K VINTA 63.00 X 249785 0 972 ROSALLY V STARR 48.00 X 241510 0 16000 MAUREEN E TART LEE 47.00 X 237505 0 23500 CARRIE L SMITH 46.00 X 218982 0 15174 JOSE DE LEON 39.00 X 196561 0 0 1579666 0 101112 55 0 1 0 TSG 903 COMMERCE DRIVE SUITE 160 OAK BROOK IL 60523 CONSULTING 3093882 SODEXHO INC & AFFILIATES 4880 PAYSPHERE CIRCLE CHICAGO IL 60674 MANAGEMENT SERVICES 2848395 KRAHL CONSTRUCTION 322 SOUTH GREEN STREET CHICAGO IL 60607 CONSTRUCTION 1951956 SHIFTWISE (US BANK CORPORATE TRUST) 2501 SW 1ST AVE SUITE 200 PORTLAND OR 97201 NURSING AGENCY 1540491 MIDWEST CLINICAL IMAGING 8600 BYRNMAWR AVE STE 850N CHICAGO IL 60631 MEDICAL 1401339 16 361020 266694 627714 medicare/medicaid paym 621110 73029867 73029867 MEDICAID ASSESSMENT RE 621110 17997156 17997156 net PATIENT SERVICES 621110 17130463 17130463 MISCELLANEOUS 621110 608770 608770 DIETARY CAFE SALES 900099 284958 284958 25666 25666 109076880 80646 80646 31700 88362 -56662 -56662 23700 -80362 INFO SYS USER FEES 532420 64459 64459 64459 109793037 108766256 88159 310908 902660 902660 42691727 31591878 11099849 4818587 3565754 1252833 3059417 2325157 734260 3803642 2890768 912874 408343 310341 98002 134000 134000 207029 207029 6563834 4988514 1575320 313743 238445 75298 138963 105612 33351 4412279 3353332 1058947 1767105 1459499 307606 2578 1959 619 104929 79746 25183 1595000 1595000 3184666 2420346 764320 3473386 2639773 833613 PROVISION FOR BAD DEBT 10965974 10965974 MEDICAL SUPPLIES 8296888 8296888 IL MEDICAID TAX ASSESSM 6433044 6433044 REPAIRS AND MAINTENANCE 1986586 1509805 476781 dietary 892530 678323 214207 5472495 4159073 1313422 111629405 73284299 38345106 0 4802828 1269974 11300480 18439457 16855728 12521073 1252671 1177411 1723461 4527530 107824292 74776172 31285633 33048120 13948421 10167862 593688 455648 8339997 13138851 90102907 94745926 12749635 8452438 9299602 23059316 22459854 1140654 526358 16364105 20400241 53313710 61138493 X 34677260 31591582 2111937 2015851 36789197 33607433 90102907 94745926 X 0 1 1 X 0 X 0 0 0 0 0 0 1 205833 1 1146 0 206979 0 4529913 4529913 40926342 27532174 13394168 3112770 2983410 129360 55049928 41627690 13422238 4205339 2632898 1572441 33048120 PROPERTY HELD FOR FUTURE USE 1189446 INVESTMENT IN JOINT VENTURE 5457340 due from affiliates 59932 BENeFICIAL INTEREST IN NET ASSETS OF FOUNDATION 1884197 DUE FROM THIRD-PARTY PROGRAMS 4547936 13138851 accrued malpractice liability 7212486 CONDITIONAL ASSET RETIREMENT OBLIGATION 3111374 NET PENSION LIABILITY 8604558 SODEXHO CAPITAL LEASE 53073 due to third party programs 1418750 20400241 Part X: Description of Uncertain Tax Positions Under FIN 48: The Hospital and Foundation are tax-exempt organizations 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 adopted accounting guidance related to the accounting for uncertainty in income taxes on October 1, 2007. The Hospital and Foundation file a Form 990 (Return of Organization Exempt from Income Taxes) and Centennial files a Form 1120 annually. When these returns are 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 hospitals and foundations include such matters as the following: tax-exempt status of each entity, the continued tax-exempt status of bonds issued by the organizations, 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 Internal Revenue Service Form 990-T, as appropriate. The benefit of a tax position is recognized in the financial statements in the period during which, based on all available evidence, management believes it is more likely than not the tax 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% likely to be realized on settlement with the applicable taxing authority. The portion of the benefits associated with the tax positions taken that exceeds the amount measured as described above is reflected as a liability for unrecognized tax benefits in the balance sheet along with any associated interest and penalties that would be payable to the taxing authorities upon examination. At September 30, 2010 and 2009, there were no unrecognized tax benefits identified or recorded as liabilities. 1 1 1 X 1 X 600.000000000000 1 1 1 0 1 1 4412606 4412606 0.03950 49639765 56019350 -6379585 0.00000 54052371 56019350 -1966979 0.03950 349620 266694 82926 0.00070 558513 75049 483464 0.00430 908133 341743 566390 0.00500 54960504 56361093 -1400589 0.04450 1 3582583 1194433 25066281 23663493 1402788 X 1 1 CENTURY PHO INC TO OBTAIN AND MANAGE CONTRACTS WITH HEALTH MAINTENANCE ORGANIZATIONS, PREFE 0.50000 0.50000 FAMILY HEALTH NETWORK INC PROVIDER OF MANAGED HEALTH CARE SERVICES FOR THE INDIGENT UNDER CONTRACT WI 0.20000 NORWEGIAN AMERICAN HOSPITAL

1044 N FRANCISCO CHICAGO IL 60660

X X Part I, Line 6a: NORWEGIAN AMERICAN HOSPITAL FILES ANNUAL COMMUNITY BENEFIT REPORT WITH THE ILLINOIS ATTORNEY GENERAL'S OFFICE. Part I, Line 7: COST TO CHARGE RATIO WAS CALCULATED USING THE IRS'S SCHEDULE H WORKSHEET 2. Part I, Line 7f: BAD DEBT EXPENSE IS $10,965,974 Part III, Line 4: 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. 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 2010 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% Part VI, Line 5: 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. IL X X X X 1 0 0 0 0 0 0 0 0 MICHAEL J O'GRADY JR 435323 0 0 0 0 0 43270 0 2196 0 480789 0 0 0 MURALI K VINTA 249785 0 0 0 0 0 0 0 972 0 250757 0 0 0 ROSALLY V STARR 241510 0 0 0 0 0 16000 0 0 0 257510 0 0 0 MAUREEN E TART LEE 237505 0 0 0 0 0 16500 0 7000 0 261005 0 0 0 CARRIE L SMITH 218982 0 0 0 0 0 15174 0 0 0 234156 0 0 0 JOSE DE LEON 196561 0 0 0 0 0 0 0 0 0 196561 0 0 0 Part I, Line 4a Michael J. O'Grady, Jr. received a severance payment in the amount of $23,700. ILLINOIS FINANCE AUTHORITY REVENUE BONDS SERIES 2008 861091967 45200FMQ9 2008-08-15 4500000 SEE SCHEDULE O 0 0 ILLINOIS FINANCE AUTHORITY REVENUE BONDS SERIES 2008 861091967 45200FMS5 2008-08-15 5000000 SEE SCHEDULE O 0 0 ILLINOIS FINANCE AUTHORITY REVENUE BONDS SERIES 2008 861091967 45200FMT3 2008-08-15 14450000 SEE SCHEDULE O 0 0 4500000 798333 1159612 157619 2384436 1 0 1 1 5000000 798334 1159612 157619 2884435 1 0 1 1 14450000 798333 1159611 157620 12334436 1 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Form 990, Part VI, Section A, line 3 THE ORGANIZATION DELEGATED CONTROL OVER MANAGEMENT DUTIES TO THE SIBERY GROUP. Form 990, Part VI, Section B, line 11 The Form 990 is reviewed by the Accounting Manager and the Director of Fiscal Services. The Form 990 is then provided to the governing body after it has been filed. Form 990, Part VI, Section B, line 12c Board of Trustees and Senior Management is required to disclose potential conflicts of interest. 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. SCHEDULE K, PART I,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 COSTS 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. NORWEGIAN AMERICAN HOSPITAL FOUNDATION 1044 NORTH FRANCISCO CHICAGO IL 60622 363257131 SUPPORTING FOUNDATION IL 501(C)(3) 11A N/A CENTENNIAL MEDICAL MANAGMENT CORPORATION 1044 NORTH FRANCISCO AVENUE CHICAGO IL 60622 363394548 outPATIENT PHARMACY IL N/A C 290474 547377 1.00000 CENTURY PHO INC 1029 N SACRAMENTO CHICAGO IL 60622 363935696 HEALTH CARE SERVICES IL N/A C 637670 896406 0.50000 0 0 1 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 CENTURY PHO INC N 111229