2011-05-13T13:02:48-05:00 2010-06-30 Pleus and Company LLC 14323 S Outer Forty Ste 310N Chesterfield MO 63017 990 2009-07-01 730579285 MERCY HEALTH CENTER INC MERC 4057523655 4300 WEST MEMORIAL ROAD OKLAHOMA CITY OK 73120 Jon Vitiello 4057523724 2011-05-10 1 3143179916 2009 2016-02-24 21:20:13Z Diana Smalley 4300 WEST MEMORIAL ROAD OKLAHOMA CITY OK 73120 314531922 0 0928 X www.mercyok.net X 1992 OK TO CARRY OUT THE HEALING MINISTRY OF JESUS BY PROMOTING HEALTH AND WELLNESS THROUGH OUR COMMUNITIES, TO PROVIDE QUALITY HEALTH SERVICES THROUGH A WISE USE OF RESOURCES AND EXCEPTIONAL MERCY SERVICE. 17 13 3543 313 13870721 -186857 1645038 627287 258013887 286482348 382590 166746 21861790 25666162 281903305 312942543 396612 433938 0 130437504 132422711 0 0 131510503 163961721 262344619 296818370 19558686 16124173 180204734 165291354 35387540 27573380 144817194 137717974 MERCY HEALTH CENTER IS ROOTED IN THE MISSION OF JESUS AND THE HEALING MINISTRY OF THE CHURCH. THIS TRADITION IS MARKED BY VALUES OF JUSTICE, EXCELLENCE, STEWARDSHIP AND RESPECT FOR THE DIGNITY OF EACH PERSON.MERCY MEMORIAL HEALTH CENTER IMPLEMENTS AND ADVOCATES FOR INNOVATIVE HEALTH AND SOCIAL SERVICES TO IMPROVE THE HEALTH AND QUALITY OF LIFE OF COMMUNITIES SERVED, WITH PARTICULAR CONCERN FOR PEOPLE WHO ARE ECONOMICALLY POOR.IN SERVING OTHERS WE MAKE A DIFFERENCE BY TOUCHING THEIR LIVES WITH COMPASSION AND EXCEPTIONAL MERCY SERVICE. 0 0 219446723 433938 293665171 Mercy Health Center, Inc. ("Mercy") provides quality medical health care regardless of race, creed, sex, national origin, handicap, age, or ability to pay. During FY2010, Mercy provided services to 19,380 inpatients, 48,775 emergency department patients, and 248,436 outpatients. Services are provided through a community-based, acute care hospital, and a rehabilitation center. Our outpatient services include a home health agency, outpatient surgery and diagnostics and various primary physician clinics/services. The institution continues to focus on the provision of primary health services through the purchase of primary clinics and education to the community, regardless of their means to pay for these services. Mercy recognizes that not all individuals possess the ability to purchase essential medical services and, further, that part of our mission is to provide health care services and health care education to the communities in which our facilities are located. In keeping with Mercy's commitment to serve all members of the community, Mercy provides; (i) free care and/or subsidized care, (ii) care to persons covered by governmental programs at below cost, (iii) health activities and programs to support the community, (iv) health education programs, and (v) a variety of broad community support activities. Among the community support activities offered by Mercy are the following:1) community education and Wellness programs 2) support group meetings3) health fairs, screenings, and free clinics 4) subsidized health services including hospice, home health services, and disaster readiness, and community health research5) Cash and in-kind donations for events and fund-raising6) Community building activities, in partnership with other community organizations7) Pre-natal and well baby care to the poor Mercy provides care to patients who lack financial resources and are deemed to be medically indigent and does not pursue collection of amounts determined to qualify as charity care. In addition, Mercy provides services to other patients under the Medicare Program and various state Medicaid programs. Such programs pay providers amounts that are less than billed charges of the services provided to the recipients. Care is provided to those with limited or no ability to pay. Relief for the financial burden of health care services rendered to the indigent totaled $9,171,425 in FY2010.Mercy continues to be a strong leader and partner in community collaborations in Oklahoma. These include health education programs/classes, support groups, clinical services, in-kind donations, conferences, and many community building activities. Some of the highlights include "Project Early Detection" which provides breast health services for uninsured women and "Diabetes Wellness Project" which serves diabetic clients who attend a free clinic. This project offers diabetes education, foot care, blood glucose monitoring skills and supplies, healthy lunches, grocery shopping tips, exercise activities, and journaling. Mercy has also adopted a low-income elementary school and provides weekly tutors, an annual health fair, and other support. A wide variety of support groups is offered each month. Lab services are provided for three free clinics in the community. 219446723 1 1 0 1 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 1 1 1 1 0 0 0 0 0 0 0 1 0 0 0 0 1 1 1 0 0 1 0 0 3543 1 1 1 0 0 0 0 0 0 0 0 17 13 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 0 0 OK X Jon Vitiello 4057523724 4300 WEST MEMORIAL ROAD OKLAHOMA CITY OK 73120 DIANA SMALLEY 6.00 X X 0 541413 166553 DIANNE B GASBARRA MD 1.00 X 0 27188 0 SISTER REBECCA ANN HENDRICKS RSM 1.00 X 0 0 0 LINDA P LAMBERT 1.00 X 0 0 0 SISTER MARY JEANETTE NOONAN RSM 1.00 X 0 0 0 DONALD K RAHHAL MD 1.00 X 0 0 0 BROOK D SCOTT MD 1.00 X 0 0 0 RICHARD V SMITH MD 40.00 X 94971 0 13763 SISTER CABRINI KOELSCH RSM 1.00 X 0 0 0 SISTER ROSEMARY WELSH RSM 1.00 X 0 0 0 JANE JAYROE GAMBLE 1.00 X 0 0 0 MIKE E O'NEAL 1.00 X 0 0 0 STEVEN A BURNER MD 1.00 X 0 251828 36255 CINDY CARMICHAEL 1.00 X X 167063 50635 9733 John Harkess MD 1.00 X 0 0 0 James M Hartsuck MD 1.00 X 0 0 0 Kenneth Hieke MD 1.00 X 0 0 0 JAMES NEWMAN 16.00 X 0 337999 87400 MARK JOHNSON 40.00 X 391750 0 101199 JULIA AKINS 40.00 X 40460 203233 29531 LINDA FANNING 40.00 X 185485 0 15392 LOREN FJONE 40.00 X 231055 0 26818 PAUL FOSTER 40.00 X 202008 0 19794 BECKY PAYTON 40.00 X 228528 0 28878 JERRY BAUMEISTER 40.00 X 194941 0 37778 JAMES DIXSON 40.00 X 250324 133885 72116 THOMAS EDELSTEIN 40.00 X 117350 49572 24748 JIM GEBHART 40.00 X 0 226833 10046 AARON STEFFENS 40.00 X 161774 0 15256 RALPH C THOMAS 40.00 X 231449 0 11207 ALAN HOLLINGSWORTH 40.00 X 195100 0 13354 GABRIEL PARDO 40.00 X 297030 0 26438 BRENT HOLLIMAN 40.00 X 163525 0 16282 KEITH MADISON 40.00 X 158126 0 14243 HOWARD YOUNG 40.00 X 159282 0 22154 JEFF JOHNSTON X 0 549160 75791 3470221 2371746 874729 69 1 1 0 GK FINANCING 4 EMBARDCADERO CTR STE 3700 SAN FRANCISCO CA 94111 MEDICAL AND FINANCING SVCS 1273482 OK HEART HOSPITAL 4050 WEST MEMORIAL ROAD OKLAHOMA CITY OK 73120 MEDICAL SERVICES 1236372 HEALTHCARE FINANCIAL RESOURCES 830 N MEACHUM RD SCHAUMBURG IL 60173 A/R RECOVERY 852600 AFFILIATED ANESTHESIOLOGISTS 4200 W MEMORIAL RD STE 703 OKLAHOMA CITY OK 73120 MEDICAL SERVICES 833500 LINEN KING 14780 S MEMORIAL BIXBY OK 74008 LINEN SERVICES 786150 60 627287 627287 PATIENT SERVICE REVENU 621300 286482348 286482348 286482348 157821 157821 4548663 1589379 2959284 2959284 2959284 8925 8925 8925 8925 MDT LABORATORY SVC 621500 10214370 10214370 PHARMACY 446110 8073014 5247381 2825633 CAFETERIA 722210 1611969 1611969 2807525 1935442 830718 41365 22706878 312942543 293665171 13870721 4779364 239938 239938 194000 194000 2666926 2666926 104132108 76287182 27844926 4271169 3129058 1142111 14467337 10598771 3868566 6885171 5044077 1841094 25963924 25963924 28777 21082 7695 1658 1658 17975543 13168883 4806660 106265 77850 28415 595942 436587 159355 120006 87916 32090 7745778 5674557 2071221 483362 354111 129251 11367512 8327839 3039673 2245487 1645044 600443 MEDICAL SUPPLIES 43748873 43748873 BAD DEBT 22257478 22257478 PHARMACEUTICALS 19475046 19475046 EQUIPMENT RENTAL & MAIN 2775896 2033621 742275 9070174 6644810 2425364 296818370 219446723 77371647 0 26534342 12956047 45593862 44055396 1163161 179982 3857065 4755247 619267 549621 327231594 225551571 101826641 101680023 70396 755038 540000 360000 180204734 165291354 26146764 26897146 226176 226176 9014600 450058 35387540 27573380 X 144817194 137717974 144817194 137717974 180204734 165291354 X 0 1 1 X 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 1 6873 0 0 0 6873 0 Part II-B, Line 1i: Explanation of Other Lobbying Activities: The filing organization is a member of and pays dues to the Oklahoma Hospital Association. For the year ended June 30, 2010, dues were $74,421. Approximately 9.49% of Oklahoma Hospital Association dues were attributable to lobbying activities performed by this association. 1602629 16170270 17772899 74319998 39947864 34372134 425639 146623 279016 225721265 180960374 44760891 8991793 4496710 4495083 101680023 MEDICARE SETTLEMENTS 450058 450058 Part X: Description of Uncertain Tax Positions Under FIN 48: The consolidated audited financial statements of the Sisters of Mercy Health System, Inc. and Subsidiaries do not include a footnote to report the organization's liability for uncertain tax provisions under FIN 48, as they are deemed immaterial for disclosure. 1 1 X 1 X 1 X 1 1 1 0 1 1 6937303 6937303 0.02530 2234122 2234122 0.00810 9171425 9171425 0.03340 6 4446 2034531 2034531 0.00740 2 60 208340 208340 0.00080 4 75 2432917 2432917 0.00890 2 463 349351 349351 0.00130 14 5044 5025139 5025139 0.01840 14 5044 14196564 14196564 0.05180 1 4994 80035 80035 0.00030 1 0 23748 23748 0.00010 1 0 1825 1825 0.00000 1 0 55938 55938 0.00020 1 600 22873 22873 0.00010 5 5594 184419 184419 0.00070 1 7368805 0 79657969 110395358 -30737389 X 1 1 MERCY HEALTH CENTERINC

4300 WEST MEMORIAL ROAD OKLAHOMA CITY OK 73120

X X X Part III, Line 4: The text of the footnote that is included in the Sisters of Mercy Health System, Inc. and Subsidiaries audited financial statements that describes bad debt expense follows: "Patient accounts that are uncollected, including those placed with collection agencies, are initially charged against the allowance for uncollectible accounts in accordance with collections policies of the Health System and, in certain cases, are reclassified to charity care if deemed to otherwise meet the health system's charity care policy. The provision for uncollectible receivables is based on management's assessment of historical and expected net collections considering business and economic conditions, trends in healthcare coverage, and other collection indicators. Periodically throughout the year, management assess the adequacy of the allowance for uncollectible receivables based upon the payor composition and aging of receivables as of the reporting date with consideration of the historical payment and write-off experience by payor category. The results of these reviews are then used to make any modifications to the provision for uncollectible receivables to establish an appropriate allowance for uncollectible receivables. After satisfaction of amounts due from insurance, the health system follows established guidelines for placing past-due balances with collection agencies."To determine the amount of bad debt expense, at cost, bad debt expense attributable to patient accounts was multiplied by a ratio of cost to charges. The ratio of cost to charges used was based on detailed cost accounting, where available. Where cost accounting is not available, cost report cost to charge ratios were utilized.The filing organization determined that the estimated amount of bad debt expense (at cost) attributable to patients eligible under the organization's charity care policy is $0. Although the charity care policy requires the participation of the patient requesting assistance, we have a process under presumptive charity (refer to disclosure for Part III, #9b) to address accounts for patients who do not provide the information. We believe that our charity policy is comprehensive enough to capture almost all patients who qualify for charity care. Part III, Line 8: The Medicare shortfall was computed using the annual Medicare cost report (CMS Form 2552-96). It is the position of Mercy Health Center, Inc. that 100% of the shortfall should be treated as community benefit. This amount represents the costs of providing services that remain uncompensated to the provider. Part III, Line 9b: Mercy will exhaust all other payment options and avenues to obtain financial assistance and third party payments including, but not limited to, local, state, and federal assistance programs before considering an applicant for Charity/Medical Indigence. Charity/Medical Indigence will only apply to the remaining balance after all third party payments are applied. Applicants are identified as potentially eligible for Medicaid benefits must first make application to Medicaid. Financially Indigent means an uninsured or underinsured patient who is accepted for care with no obligation, or with a discounted obligation, to pay for the services rendered based on a demonstrated inability by, income and family size, to meet their financial obligations. A patient is Medically Indigent when his/her financial responsibility is so significant in relation to their total income and/or assets that payment in full is not likely or equitable. Generally no patient's financial responsibility shall be greater than 20% of the household income, subject to an asset test. Mercy will use financial counseling and point of service activities to identify Charity/Medical Indigence as soon as practical in the intake process toincrease customer satisfaction and reduce costs of operations. In addition to financial counseling, Mercy will provide patient financial services and financial assistance options through signage and brochures at all patient access points and explanations of financial assistance on patient statements. Part VI, Line 2: Community Roundtable meetings were held in Oklahoma City and El Reno, which are located in the Mercy Health Center, Inc. service area. Participants shared their views on both the current and future state of health in their communities.A second step in the needs assessment process included review of the Oklahoma Health Improvement Plan (OHIP). This is a comprehensive plan of the Oklahoma State Health Department and its partners to identify health problems in the state.Additional information was received and assessed from the City/County Health Department Wellness scores and the community Health Status Report for 2008. Part VI, Line 3: The filing organization has printed material available at each point of registration in our facility, in addition to electronically availability at our web site. Specific information provided: Financial Assistance Information As a part of our healing ministry, the filing organization is committed to providing quality healthcare services to patients regardless of their financial situation. We offer payment assistance for those who do not have insurance or who are in financial need. Uninsured Patient Discounts A discount from the hospital's regular billed charges will be provided to patients who do not have insurance. This includes patients whose financial situation normally would not otherwise qualify them for charity care discounts. Patients without insurance whose financial situation qualifies them for charity care discounts (see Eligibility Guidelines below) must first find out if they are eligible for Medicaid before applying for financial assistance. Patients denied Medicaid eligibility then must provide certain information to show financial need. Applications for charity care discounts will be reviewed for eligibility based on the applicant's income, family size, amount of payment due and availability of other assets or resources. Please note that care must be medically necessary to be considered eligible for uninsured patient discounts. Eligibility Guidelines for Charity Care Discounts The Federal Poverty Guidelines for income are the basis for determining eligibility for charity care discounts. For example, individuals with incomes below 100% of the Federal Poverty Guidelines will be eligible for free care. Individuals with incomes greater than 100% of the Federal Poverty Guidelines may be eligible for care at discounted rates depending on their income level and/or the amount due to the hospital. Additional Financial Assistance After appropriate discounts have been applied, arrangements may be made for an interest-free monthly payment plan. Generally, no patient's financial responsibility will be greater than 10% of annual household income, adjusted to consider availability of other assets that could be used toward making payments. Part VI, Line 4: Mercy Health Center, Inc. is located in northwest Oklahoma City. Mercy Health Center, Inc. primarily serves those in urban/suburban Oklahoma City and a six-county area with a 1.09 million population; Oklahoma, Canadian, Cleveland, Kingfisher, Lincoln and Logan counties.- OKC Summary: 16% of population are uninsured, 16% Medicaid, and 14% Medicare- Higher death rate than the US rate- Oklahoma County compares unfavorably to counties of similar population composition and demographic make-up on 16 of 22 community health indicators.- Leading cause of death attributed to injuries for residents under age 45 with cancer and heart disease for those age 45+.- Risk factors that contribute to premature death are high blood pressure, smoking, and adult obesity.- Identified health needs: school health initiative, access to health services, prevention, tobacco, obesity Part VI, Line 5: Mercy Health Center, Inc. (MHC) community building activities promote the health of the communities in which they serve. Through active participation in community boards, neighborhood/community meetings and involvement in community-based events, MHC demonstrates its ongoing commitment to the community. Community building activities serve as a link to engage Mercy coworkers to look beyond the walls of the facilities in which they serve. Some of the community building activities in which MHC serves are:- Diabetes Wellness Project (DWP) provides diabetes education, foot care, blood glucose monitoring skills and supplies to uninsured diabetics.- Mercy Mentors provide weekly tutoring to Linwood Elementary, an inner-city, low- income elementary school.- Project Early Detection (PED) provides breast care services for uninsured women in Oklahoma.- Active participation on community boards.- Community events include: Elder Law Day, Caregiver Survival Skills Conference, Oklahoma Turning Point Council, Linwood Neighborhood Health Fair, annual flu shots for the underserved, - Ongoing collaboration with community partners/agencies to meet the needs of the poor and uninsured.- Mercy Health Center was a founding partner of the Health Alliance for the Uninsured (HAU), which was formed to improve access of healthcare for the uninsured. There are 16 clinics affiliated with the HAU. Part VI, Line 6: Mercy Health Center, Inc. (MHC) is a Catholic health care corporation that, pursuant to the organizational core belief that health care services are a vital and integral part of the Church's healing mission, engages in a ministry which provides general acute care, ambulatory, long-term and home care health services to individuals and families in its service communities. In keeping with MHC's commitment to serve all members of the communities it serves, MHC provides care to patients regardless of ability to pay. As defined by the institution's charity policy, MHC does not pursue collection of amounts determined toqualify for charity care. In addition, MHC provides services to other patients under the Medicare Program and various state Medicaid programs. Such programs pay providers amounts that are substantially less thanbilled charges, and frequently less than the cost, of the services provided to the recipients.MHC is governed by a Board of Directors which includes representation from community leaders in the organization's primary service areas. All board members are required to complete an annual Conflict of Interestsurvey. Any potential conflicts of interest disclosed by board members are screened by general counsel and reviewed by the board chairperson and CEO. This process ensures that public, rather than private, interests areserved by MHC.Surplus funds and unrestricted assets held by MHC are reinvested in patient care, medical education and research initiatives which support the organization's mission to deliver compassionate care and exceptionalhealth care services to the communities it serves. Examples include the following: - Expansion of Emergency Room facilities at Mercy Health Center in Oklahoma City to further meet the health care needs of this community. - Renovation and upgrade of the Intensive Care Unit at Mercy Health Center in Oklahoma City to provide the highest quality care of this community.- Conversion to the EPIC Electronic Health Record system. This platform allows continuity of patient medical record access by providers throughout the Mercy system and also allows the patient to access information from their own records, allowing more complete and meaningful communication, information and health education for the community. - Renovation and upgrades to the Operating Room suites to meet the technological and clinical advances, continuing to provide the highest quality of care to support the needs of the population served my MHC and its staff physicians.- Purchase and installation of key diagnostic imaging equipment to aid in the accurate and timely diagnosis of disease. Part VI, Line 7: The filing organization is part of the Sisters of Mercy Health System ("Mercy"). Mercy is a Missouri non-profit corporation with its headquarters ("ministry office") in St. Louis, Missouri. Mercy provides health care services in four states - Arkansas, Kansas, Missouri, and Oklahoma - and has outreach ministries located in Louisiana, Mississippi, and Texas. Mercy's mission is "As the Sisters of Mercy before us, we bring life to the healing ministry of Jesus through our compassionate care and exceptional service." As of June 30, 2010, Mercy facilities included 28 hospitals with 3,718 acute licensed beds (3,300 acute available beds). For the fiscal year ended June 30, 2010, Mercy had more than 6.3 million outpatient visits, more than 1,200 employed physicians, and approximately 28,000 employees, making Mercy the eighth largest Catholic health system in the United States based on net patient service revenue. Mercy is sponsored by Mercy Health Ministry, which is governed by members that include Sisters of Mercy.Many services that are essential to fulfilling Mercy's mission are centralized at the Ministry Office. Such centralized services include Treasury, Information Technology, Clinical Quality Management, Legal and Compliance Counsel, Compensation and Benefits, Consulting, Performance Management, Revenue Management, Capital Management, Clinical Engineering, and Clinical Safety. The centralization of such support services enables Mercy to ensure that each of its communities, whether large or small, has the services it needs. OK 1 ALLIED ARTS ONE N HUDSON STE 140 Oklahoma City OK 73102 730804291 501(c)(3) 15000 Community enrichment Edmund Area CHAMBER OF COMMERCE 825 E 2nd St Suite 100 Edmund OK 73034 730544087 501(c)(6) 13750 Economic development MARCH OF DIMES 5100 BROOKLINE STE 270 Oklahoma City OK 73102 131846366 501(c)(3) 40000 NICU family support MOUNT ST MARY HIGH SCHOOL 2801 S SHARTEL AVE oklahoma City OK 73109 730605969 501(c)(3) 10000 Educational endowment UNITED WAY OF CENTRAL OKLAHOMA PO BOX 837 oklahoma City OK 73105 730589829 501(c)(3) 21500 Community campaign Pros for Africa 211 NOrth Robinson Oklahoma City OK 73102 271674673 501(c)(3) 5000 charitable donation World Neighbors Inc 4127 MW 122nd Street Oklahoma City OK 73120 730707328 501(c)(3) 5000 Sponsorship donation 6 1 TUITION SCHOLARSHIPS 69 194000 Procedure for Monitoring Grants in the U.S.: Part I, Line 2: Schedule I, Part I, Line 2: The organization uses an approval process to determine which organizations will receive grants during the fiscal year. The funds are then given directly to the nonprofit organization. 1 1 0 0 0 0 0 1 0 DIANA SMALLEY 0 397309 0 115774 0 28330 0 151301 0 15252 0 707966 0 0 STEVEN A BURNER MD 0 236484 0 0 0 15344 0 21664 0 14591 0 288083 0 0 CINDY CARMICHAEL 125529 49623 27642 0 13892 1012 4626 0 3482 1625 175171 52260 0 0 JAMES NEWMAN 0 258143 0 60157 0 19699 0 72747 0 14653 0 425399 0 0 MARK JOHNSON 313024 0 45751 0 32975 0 88915 0 12284 0 492949 0 0 0 JULIA AKINS 35753 109224 0 32993 4707 61016 0 22858 1642 5031 42102 231122 0 0 LINDA FANNING 153522 0 23666 0 8297 0 13882 0 1510 0 200877 0 0 0 LOREN FJONE 176012 0 30329 0 24714 0 19974 0 6844 0 257873 0 0 0 PAUL FOSTER 161921 0 23337 0 16750 0 5988 0 13806 0 221802 0 0 0 BECKY PAYTON 176141 0 28617 0 23770 0 17788 0 11090 0 257406 0 0 0 JERRY BAUMEISTER 118793 0 24642 0 51506 0 31287 0 6491 0 232719 0 0 0 JAMES DIXSON 197197 129750 38815 0 14312 4135 59804 0 8003 4309 318131 138194 0 0 THOMAS EDELSTEIN 89666 5388 7112 0 20572 44184 15285 0 9463 0 142098 49572 0 0 JIM GEBHART 0 135222 0 50000 0 41611 0 4567 0 5479 0 236879 0 0 AARON STEFFENS 137421 0 21527 0 2826 0 7228 0 8028 0 177030 0 0 0 RALPH C THOMAS 226732 0 0 0 4717 0 4577 0 6630 0 242656 0 0 0 ALAN HOLLINGSWORTH 173510 0 11142 0 10448 0 2201 0 11153 0 208454 0 0 0 GABRIEL PARDO 268595 0 0 0 28435 0 11498 0 14940 0 323468 0 0 0 BRENT HOLLIMAN 125461 0 31076 0 6988 0 3419 0 12863 0 179807 0 0 0 KEITH MADISON 118624 0 9635 0 29867 0 7899 0 6344 0 172369 0 0 0 HOWARD YOUNG 125872 0 0 0 33410 0 8443 0 13711 0 181436 0 0 0 JEFF JOHNSTON 0 328696 0 123469 0 96995 0 61229 0 14562 0 624951 0 0 Part I, Line 4a Thomas Edelstein received $38,848 in severance pay from St. Johns Mercy Health Care in St. Louis, a related entity. Schedule J, Part I, Question 4b Sisters of Mercy Health System, the Parent Company, offers supplemental retirement plans to certain executives which provide benefits upon retirement based on compensation, age at the time of benefit commencement, length of service with the company and/or its affiliates, and length of tenure in the plan. The individuals reportable on this return who participate in the supplemental executive retirement plans include: Diana Smalley Jeffrey Johnston The following individuals participated in a supplemental management retirement plan: James Dixson Linda Fanning Mark Johnson Jeffrey Johnston James Newman Becky Payton The amount of all accrued benefits is included in compensation amounts provided in Schedule J, Part II, Column (C). No persons listed on this return received payment under the plans during the tax year. Part I, Line 7 The filing organization provides a non-fixed bonus plan for which certain tiers of its employees are eligible. For fiscal year 2009 (July 1, 2008-June 30, 2009), payment of all or part of the bonus is contingent upon percentage attainment of (I) personal goals and (II) certain financial targets. For fiscal year 2010 (July 1, 2009-June 30, 2010), payment of all or part of the bonus is contingent upon attainment of certain financial targets. Payments are made annually in October following (I) the conclusion of the fiscal year and (II) determination of goal achievement (applicable only for fiscal year 2009). Bonus opportunities are tiered percentages and are dependent upon the leadership level and attainment percentage. Mercy's attainment of financial goals are validated by an external consulting firm and are then taken into account by the executive compensation committee of Mercy when analyzing executive compensation for reasonableness. Supplemental Information Part III PART I, LINE 3: The filing organization relies on a related organization; refer to Schedule O, Part VI, question 15a and 15b for the process the related organization follows. OKLAHOMA HEART HOSPITAL LLC SEE SCHEDULE O 1236372 INDEPENDENT CONTRACTOR 0 OKLAHOMA CARDIO VASCULAR ASSOCIATION SEE SCHEDULE O 213019 INDEPENDENT CONTRACTOR 0 Form 990, Part VI, Section A, line 6 Mercy Health Center Inc. has a sole Corporate member, Mercy Health System, Inc. Form 990, Part VI, Section A, line 7a Mercy Health System, Inc. may APPOINT AND REMOVE MEMBERS OF THE BOARD. Form 990, Part VI, Section A, line 7b THE FOLLOWING CORPORATE POWERS AND RESPONSIBILITIES SHALL BE RESERVED SOLELY UNTO Mercy Health System, Inc.: - Adopt or amend the mission and philosophy of the Corporation and any organization controlled by the Corporation; - Adopt or amend the strategic plans, goals, and objectives of the Corporation and any organization controlled by the Corporation; - Adopt or amend the operating and capital budgets of the Corporation and any organization controlled by the Corporation and any changes in such budgets in excess of an amount established from time to time by the Member; - Review and approve any capital expenditures or recommendations not previously approved as part of the Corporation's budgets; - Authorize or approve the assignment, transfer, sale or lease of any of the assets of the Corporation or any organization controlled by the Corporation or interest therein in excess of an amount established from time to time by the Member; - Authorize or approve the grant of any pledge, lien, encumbrance, mortgage, deed of trust or other security interest in any or all of the assets of the Corporation and any organization controlled by the Corporation; - Authorize or approve the incurrence of debt (other than debt incurred for the acquisition of goods that are acquired in the ordinary course of business) by the Corporation or any organization controlled by the Corporation and the grant any security interests, the placement of any encumbrances, the entering into any covenants, and the execution of any documents and the taking of any actions necessary or appropriate in connection with the incurrence of such debt; - Merge, dissolve or abandon the Corporation or any organization controlled by the Corporation; - Amend the Certificate of Incorporation and Bylaws of the Corporation and any organization controlled by the Corporation; - Establish all compensation and benefit terms for physicians and other medical professionals employed or otherwise retained by the Corporation; - Approve the creation, ownership or acquisition of, or affiliation with, any other organization controlled by the Corporation; - Approve contracts in which the Corporation assumes financial risk, including but not limited to managed care contracts, subject to consultation with the Managed Care Contracting Committee of the Member; - Approve the Clinic's manpower plan; - Through the sole action of the President of the Member (with the approval of the President of Mercy, appoint and remove the President of the Corporation; and - Authorize and amend the Charity Care Policy of the Clinic. Form 990, Part VI, Section B, line 11 The Form 990 is prepared by an independent accounting firm, using information provided by the filing organization. A draft Form 990 is reviewed by the filing organization's finance team. The draft Form 990 is also reviewed by the Sisters of Mercy Health System's Tax department, to ensure accuracy and consistency with other related organizations' Form 990s. After questions arising from the various reviews are addressed and incorporated into the Form 990, a revised draft is provided to the filing organization's leadership team for review. Once reviewed and approved by the filing organization's leadership team, the Form 990 is provided to the Board of Directors for review; it is then signed and filed with the IRS. Form 990, Part VI, Section B, line 12c THE BOARD ANNUALLY RECEIVES A CONFLICT OF INTEREST QUESTIONAIRE. THE ORGANIZATION HAS A COMPLIANCE DEPARTMENT TO MONITOR AND ENFORCE COMPLIANCE WITH THE CONFLICT OF INTEREST POLICY. Form 990, Part VI, Section B, line 15a For those classified as officers (and thus disqualified persons), the organization uses the following to establish compensation: external market salary surveys, external market salary studies, engagement of an independent compensation consultant, and review/approval of compensation by the executive compensation committee of the Board of the Sister of Mercy Health System. For those classified as key employees, the organization uses the following to establish the compensation: external market salary surveys, external market salary studies, and review/approval of executive management. Compensation reviews are completed on an annual basis, and a review was completed during the reporting year. Form 990, Part VI, Section C, line 19 Governing documents, conflict of interest policy, and financial statements have been made available from time to time but are not published publicly. Part XI, Line 2 Audited Financial Statements The filing organization's financial statements were included in the Sisters of Mercy Health System, Inc. and Subsidiaries annual financial statement audit. The Sisters of Mercy Health System, Inc. and Subsidiaries received an unqualified opinion from the external auditors for fiscal 2010 (the tax year currently being reported). However, no separate audit opinion is issued on the financial statements of the filing organization. The ultimate responsibility for oversight of the financial statement audit and selection of the external auditor lies with the Finance, Audit, and Compliance Committee of the Sisters of Mercy Health System Board of Directors. Audit results are communicated to this committee. Part XI, Line 3 Single Audit Act and OMB Circular A-133 The Consolidated Group of Sisters of Mercy Health System is required to undergo an audit as set forth in the single audit act and OMB Circular A-133. The single audit was conducted on a consolidated basis. FORM 990, SCHedule L, PART IV Relationship between interested person and organization DIANA SMALLEY, BOARD MEMBER, AND JAMES NEWMAN AND MARK JOHNSON, OFFICERS OF THE ORGANIZATION, ARE ALL BOARD MEMBERS OF OKLAHOMA HEART HOSPITAL, LLC BROOK D. SCOTT, MD, IS A BOARD MEMBER OF THE ORGANIZATION AND OKLAHOMA CARDIOVASCULAR ASSOCIATION FORM 990, SCHEDULE R, PART II ST JOHNS MERCY HEALTH SYSTEM ST. JOHN'S MERCY HEALTH SYSTEM CONSISTS OF ST. JOHN'S MERCY MEDICAL CENTER, EIN 43-065393, AND ST. JOHN'S MERCY HOSPITAL, EIN 43-1066883. Form 990, Schedule R Lawson ERP software is the primary accounting software used by Sisters of Mercy Health System, Inc. and Subsidiaries. The majority of the intercompany/related organization transactions are processed through Lawson via intercompany journal entries. With the current design of the ERP system, there are various limitations on the related organization information that can be extracted from Lawson. Due to these limitations, most of the related organization activity for the filing organization has been classified on Schedule R, Part V, in lines O and P. FORM 990, PART VII STEVEN BURNER DEVOTED AN AVERAGE OF 40 HOURS PER WEEK TO RELATED ORGANIZATIONS. JAMES NEWMAN DEVOTED AN AVERAGE OF 45 HOURS PER WEEK TO RELATED ORGANIZATIONS. DIANA SMALLEY DEVOTED AN AVERAGE OF 34 HOURS PER WEEK TO RELATED ORGANIZATIONS. CINDY CARMICHAEL DEVOTED AN AVERAGE OF 39 HOURS PER WEEK TO RELATED ORGANIZATIONS. THOMAS EDELSTEIN DEVOTED AN AVERAGE OF 10 HOURS PER WEEK TO RELATED ORGANIZATIONS. Form 990, Part V, Question 2a THE SALARIES AND WAGES REPORTED ON FORM 990, PART IX, LINE 7 REPRESENT AN ALLOCATION OF SALARIES AND WAGES FROM A RELATED ORGANIZATION. Employees are paid by a related organization under a common paymaster arrangement. As such, all required payroll filing (including W-2 and W-3's) was reported under the related organization's EIN. Form 990, Part V, Question 1a Independent contractors for the filing organization are paid by the Sisters of Mercy Health System (EIN 43-1423050). As such, all required Form 1099 and Form 1096 reporting is made for the entire Health System (with limited exceptions) under the SMHS EIN. NEUROSCIENCE INSTITUTE SERVICES ORGANIZATION LLC 4300 W MEMORIAL ROAD OKLAHOMA CITY OK 73120 300487934 MGD CARE SERVICES OK 0 4127956 MERCY HEALTH CENTER INC Advance Care Hospital 300 Werner St 3rd Floor Hot Springs AR 71913 710816634 Long term acute-care hospital AR 501c3 3 SMHS Breech Regional Med Ctr 100 Hospital Drive Lebanon MO 65536 431767432 Hospital MO 501c3 3 ST JOHn's Health System Inc Carroll Health Foundation 214 Carter Street Berryville AR 72616 710759301 Foundation AR 501c3 11-I Ozark Regions Health Systems Casa de Misericordia 1602 McClelland Street Laredo TX 78044 742912461 Women's domestic violence shelter TX 501c3 9 Mercy Ministries of Laredo Healdton Mercy Hosp Corp 918 South Street Healdton OK 73438 263173902 hospital OK 501c3 3 Mercy Memorial Health Ctr Inc Laredo Medical Group 14528 S Outer Forty St 100 Chesterfield MO 63017 742764726 Inactive TX 501c3 9 MHSystem of Texas Inc McAuley Portfolio Mgmt Co 14528 S Outer Forty St 100 Chesterfield MO 63017 261708048 Portfolio management. MO 501c3 11-II SMHS Mercy El Reno Hosp Corporation 2115 Parkview Drive El Reno OK 73036 736617948 Operating co for leased hosp OK 501c3 3 SMHS Mercy Emergency Med Srvs 4300 W Memorial Road Oklahoma City OK 73120 810627035 Inactive OK 501c3 9 Mercy Health Center Inc Mercy Fdtn Health Innov 14528 S Outer Forty St 100 Chesterfield MO 63017 200901499 Foundation MO 501c3 11-II SMHS Mercy Health Ctr Fdtn 401 Woodland Hills Blvd Fort Scott KS 66701 481077073 Foundation KS 501c3 11-III MHS of Kansas Inc Mercy Health Ctr Fdtn Inc 4300 W Memorial Road Oklahoma City OK 73120 731593024 Foundation OK 501c3 11-I Mercy Health Center Inc Mercy Health MNMCH Inc 220 Pennsylvania Avenue Columbus KS 66725 270842031 Critical Access Hospital MO 501c3 9 Mercy Health System-Joplin Inc Mercy Health of Joplin Found 2727 McClelland Blvd Joplin MO 64804 270906136 Foundation MO 501c3 11-I Mercy Health System-Joplin Inc Mercy Health of Joplin Inc 2727 McClelland Blvd Joplin MO 64804 270814858 Hospital MO 501c3 9 Mercy Health System-Joplin Inc Mercy Health Services 4300 W Memorial Road Oklahoma City OK 73120 141838609 dissolved 6/30/10 OK 501c3 3 Mercy Health Center Inc Mercy Health System Joplin Inc 2727 McClelland Blvd Joplin MO 64804 300584463 Health System MO 501c3 11-II SMHS Mercy Health System KS 401 Woodland Hills Blvd Ft Scott KS 66701 480956045 Hospital;rural health clinics KS 501c3 3 SMHS Mercy Health System NW Ark Inc 2710 Rife Medical Ln Rogers AR 72758 621684203 Physician Group AR 501c3 11-II SMHS Mercy Health System TX 14528 S Outer Forty St 100 Chesterfield MO 63017 742764727 Inactive TX 501c3 11-II SMHS Mercy Health System Inc 4300 W Memorial Road Oklahoma City OK 73120 731453048 Holding company OK 501c3 11-II SMHS Mercy Hospital Fdtn Indep 800 W Myrtle Independence KS 67301 481079981 Foundation KS 501c3 11-I MHS of Kansas Inc Mercy Hospital of Laredo 14528 S Outer Forty St 100 Chesterfield MO 63017 741189682 Inactive TX 501c3 3 MHSystem of Texas Inc Mercy Medical Group 645 Maryville Ctr Dr Ste 100 St Louis MO 63141 431771217 Physician Group MO 501c3 9 St John's Mercy Health Care Mercy Memorial Health Ctr Fdtn 1011 14th Avenue NW Ardmore OK 73401 710962525 Foundation OK 501c3 11-I Mercy Memorial Health Ctr Inc Mercy Memorial Health Ctr Inc 1011 14th Avenue NW Ardmore OK 73401 731500629 Hospital OK 501c3 3 Mercy Health System Inc Mercy Ministries of Laredo 2500 Zacatecas Laredo TX 78043 200198462 healthcare, outreach,food pantry. TX 501c3 3 SMHS Mercy Physicians Ok 4300 W Memorial Road Oklahoma City OK 73120 270473057 Physician Group/Clinic OK 501c3 9 Mercy Health System Inc MHM Support Services 14528 S Outer Forty St 100 Chesterfield MO 63017 202553101 Centralized Health System Functions MO 501c3 11-II SMHS Mission Clinical Services 300 Werner Street Hot Springs AR 71913 134239691 Physician Clinics AR 501c3 11-II St Joseph's MHS Inc Ozarks Regions HS 214 Carter Street Berryville AR 72616 710759299 Hospital AR 501c3 3 St John's Health System Inc Sisters of Mercy Hlth Sys 14528 S Outer Forty St 100 Chesterfield MO 63017 431423050 Health System - Corporate Office MO 501c3 11-II N/A Sisters of Mercy Ministries 14528 S Outer Forty St 100 Chesterfield MO 63017 721069468 Family counseling;social justice advocacy MO 501c3 9 SMHS St Edward Health Frank Cty 801 W River Street Ozark AR 72949 710689680 Hospital AR 501c3 3 St Edward Mercy Medical Ctr St Edward Health Log Cty 500 E Academy Paris AR 72855 710655753 Hospital AR 501c3 3 St Edward Mercy Medical Ctr St Edward Health Scott Cty 1341 W 6th Street Waldron AR 72958 710557895 Hospital AR 501c3 3 St Edward Mercy Medical Ctr St Edward Mercy Clin 7301 Rogers Avenue Fort Smith AR 72917 261318597 Physician Clinic AR 501c3 3 St Edward MHS Inc St Edward Mercy Foundation PO Box 17000 Fort Smith AR 72917 237330425 Foundation AR 501c3 3 St Edward Mercy Medical Ctr St Edward Mercy HS Inc 7301 Rogers Avenue Fort Smith AR 72917 261318515 Holding Company AR 501c3 11-II SMHS St Edward Mercy Med Ctr 7301 Rogers Avenue Fort Smith AR 72917 710240352 Hospital AR 501c3 3 St Edward MHS Inc St Francis Hosp MtView MO 100 W Highway 60 Mountain View MO 65548 440607149 Hospital MO 501c3 3 ST John's Health System Inc St Johns Aurora Inc 500 Porter Avenue Aurora MO 65605 431936696 Operating co for leased hosp MO 501c3 3 St John's Health System Inc St Johns Cassville Inc 94 Main Street Cassville MO 65625 431936699 Operating co for leased hosp MO 501c3 3 St John's Health System Inc St Johns Childrens Hosp 1235 E Cherokee Street Springfield MO 65804 INactive MO 501c3 3 ST JOhn's Health System Inc St Johns Clinic Inc 1965 Fremont Street Suite 2950 Springfield MO 65804 431560263 Physician Group MO 501c3 3 St John's Health System Inc St Johns Fdtn Comm Hlth 1235 E Cherokee Street Springfield MO 65804 320195818 Foundation MO 501c3 11-II St John's Health System Inc St Johns Health System In 1235 E Cherokee Street Springfield MO 65804 431856028 Holding Company MO 501c3 11-II SMHS St Johns Home Care Berryville 214 Carter Street Berryville AR 72616 870781247 Home Health and Hospice operations. AR 501c3 11-III St John's Regional Health Ctr St Johns Medical Rsch Inst 1235 E Cherokee Street Springfield MO 65804 870796305 Research - Clinical Trials MO 501c3 3 St John's Health System Inc St Johns Mercy Fdtn 645 Maryville Ctr Dr Ste 100 St Louis MO 63141 562410020 Foundation MO 501c3 11-II St John's Mercy Health Care St Johns Mercy Health Care 645 Maryville Ctr Dr Ste 100 St Louis MO 63141 431718408 Health System MO 501c3 11-II SMHS St Johns Mercy Health System 645 Maryville Ctr Dr Ste 100 St Louis MO 63141 430653493 Hospital MO 501c3 3 St John's Mercy Health Care St Johns Mercy Hospital Fdtn 901 E Fifth Street Washington MO 63090 562410022 Foundation MO 501c3 11-II St John's Mercy Health Care St Johns Mercy Supp Srv 615 S New Ballas Road St Louis MO 63141 431677952 Inactive MO 501c3 11-III St John's Mercy Health System St Johns Reg Hlth Ctr 1235 E Cherokee Street Springfield MO 65804 440552485 Hospital MO 501c3 3 St John's Health System Inc St Josephs Mercy Clin 1 Mercy Lane Hot Springs AR 71913 261125131 Physician Clinic AR 501c3 9 St Joseph's MHS Inc St Josephs Mercy Health Center 300 Werner Street Hot Springs AR 71913 710236913 Hospital AR 501c3 3 St Joseph's MHS Inc St Josephs Mercy Health Fdtn 300 Werner Street Hot Springs AR 71913 710804718 Foundation AR 501c3 11-II St Joseph's Mercy Health Ctr St Josephs Mercy Health Sys 300 Werner Street Hot Springs AR 71913 261125064 Holding Company AR 501c3 11-II SMHS St Mary-Rogers Mem Hos 2710 Rife Medical Ln Rogers AR 72758 710294390 Hospital AR 501c3 3 MH S NW Arkansas Inc St Marys Hospital Foundation 2710 Rife Medical Ln Rogers AR 72858 710601687 Foundation AR 501c3 11-III St Mary-Rogers Mem Hosp Inc St Marys Hosp Enid Ok 14528 S Outer Forty St 100 Chesterfield MO 63017 730614655 Inactive OK 501c3 3 Mercy Health System Inc The Sr M Cornelia Blasko Fn 100 W Highway 60 Mountain View MO 65548 431873914 Foundation MO 501c3 11-I St Francis Hosp Mount View MO Unity Ambulatory Care 645 Maryville Ctr Dr Ste 100 St Louis MO 63141 431861745 Inactive MO 501c3 11-III St John's Mercy Health Care Southern Oklahoma Diag Ctr LLC 1011 Fourteenth Avenue NW ARDMORE OK 73401 431971232 MRI Services OK N/A N/A 0 0 Resource Optimiz & InnovLLC 645 Maryville Ctr DrSte 200 ST LOUIS MO 63141 460468368 Central Distribution Center MO N/A N/A 0 0 Mercy Ambulatory Surgery Center LLC 7301 Rogers Avenue FORT SMITH AR 72917 710827721 Ambulatory Surgery Center AR N/A N/A 0 0 Hot Springs Equip Leasing LLC 300 Werner Street HOT SPRINGS AR 71913 204340915 Inactive, dissolved 9/30/09 AR N/A N/A 0 0 Hot Springs MRI Partnership 100 Ridgeway Place HOT SPRINGS AR 72901 710675196 Inactive, dissolved 8/5/09 AR N/A N/A 0 0 FORT SMITH EMERGENCY MEDICAL SERVICES 1701 SOUTH GREENWOOD FORT SMITH AR 72901 710416615 Emergency medical services AR N/A N/A 0 0 Southern Oklahoma PHO LLC 1011 Fourteenth Avenue NW ARDMORE OK 73401 731462104 Inactive, dissolved 12/31/09 OK N/A N/A 0 0 St Edward Mercy MC M-P Office Bldg 7301 Rogers Avenue FORT SMITH AR 72903 710554050 Office Building AR N/A N/A 0 0 St Edward Medical Services Inc 7301 Rogers Avenue Fort Smith AR 72903 202965518 Inactive dissolved 5/5/10 AR N/A C Consolidated Logistics Inc 2710 Rife Medical Lane Rogers AR 72758 710474406 Inactive dissolved 8/4/09 AR N/A C Mercy Comm Services Inc 401 Woodland Hills Blvd Fort Scott KS 66701 481078101 Catering operations KS N/A C Frontenac Properties Inc 14528 S Outer Forty Suite 100 Chesterfield MO 63017 521914421 Holds ancillary assets & owns aircraft DE N/A C MHP Inc 14528 S Outer Forty Suite 300 Chesterfield MO 63017 431697084 Holding company sold 10/1/10 DE N/A C Mercy Medical Services Inc 14528 S Outer Forty Suite 100 Chesterfield MO 63017 710641246 Inactive dissolved 7/1/09 MO N/A C Inveno Health Inc 1235 E Cherokee Street Springfield MO 65804 264509571 Technology transfer company MO N/A C Unity Support Services Inc 645 Maryville Centre Drive Suite 10 St Louis MO 63141 431797042 Inactive MO N/A C UH L Corp Inc 645 Maryville Centre Drive Suite 10 St Louis MO 63141 742499535 Holding company MO N/A C MHN of the Southern Region Inc 1011 14th Avenue NW Ardmore OK 73401 731580607 Employed physicians, physician assistants, and nurse practitioners OK N/A C Mercy Health Center Condominium Inc 4300 W Memorial Rd Oklahoma City OK 73120 680640970 Administrator of certain real property and improvements OK MERCY HEALTH CENTERINC C 793293 1899005 0.88000 Mercy Managed Care Corporation 4300 W Memorial Road Oklahoma City OK 73120 731441665 Holding company OK N/A C Mercy Health Network Inc 4300 W Memorial Road Oklahoma City OK 73120 731381689 Employed physicians, physician assistants, and nurse practitioners OK N/A C 0 0 1 0 0 0 0 0 1 0 0 0 1 1 1 1 0 0 Healdton Mercy Hospital Corporation O 5407082 Healdton Mercy Hospital Corporation P 276373 Mercy Health Ctr Fdtn Inc O 74111 Mercy Health Network of the Southern Region Inc O 6408956 Mercy Health Network of the Southern Region Inc P 351073 Mercy Health Network Inc N 785637 Mercy Health Network Inc O 36237227 Mercy Health Network Inc P 3581016 Mercy Health Services Inc O 850352 Mercy Health Services Inc P 415883 Mercy Health System Inc O 91043 Mercy Memorial Health Center Foundation O 58422 Mercy Memorial Health Center Inc O 116450882 Mercy Memorial Health Center Inc P 10380376 Mercy Physicians of Oklahoma Inc O 1281567 Mercy Physicians of Oklahoma Inc P 185299 MHM Support Services O 33328937 MHP Inc P 4664659 Resource Optimization & Innovation LLC O 15714849 Sisters of Mercy Health System O 1694444 St John's Mercy Health Care O 80436 St John's Mercy Health System O 356274 Mercy Health Ctr Fdtn Inc C 627287