2011-05-16T10:22:54-05:00 2010-06-30 DELOITTE TAX LLP 2500 ONE PPG PLACE PITTSBURGH PA 15222 990 2009-07-01 251801532 VALLEY MEDICAL FACILITIES INC VALL 4127416600 720 blackburn road sewickley PA 15143 BRYAN J RANDALL 4127416600 2011-05-16 1 Jeremy Hartzell 4123387200 2009 2016-02-24 21:20:13Z X SEE SCHEDULE O BRYAN J RANDALL 720 BLACKBURN ROAD SEWICKLEY PA 15143 594745557 0 X WWW.HERITAGEVALLEY.ORG X 1996 PA TO IMPROVE THE HEALTH AND WELL-BEING OF ALL PEOPLE IN THE COMMUNITIES WE SERVE. 22 17 3606 279 7525201 -129804 4738425 4110190 329459432 343058124 -22247555 13213187 16210805 15983501 328161107 376365002 68445 183518 0 188506683 195667147 0 0 155288880 159716610 343864008 355567275 -15702901 20797727 388467267 413937018 177925713 199266592 210541554 214670426 TO IMPROVE THE HEALTH AND WELL-BEING OF ALL PEOPLE IN THE COMMUNITIES WE SERVE. 0 0 346371059 341966330 THE HOSPITALS COMPRISING VALLEY MEDICAL FACILITIES PROVIDE ROUTINE AND AUXILLARY MEDICAL/SURGICAL, PSYCHIATRIC, AND REHABILITATION SERVICES TO THE COMMUNITIES SERVED BY THE HOSPITALS REGARDLESS OF PATIENT'S ABILITY TO PAY.DURING THE FISCAL YEAR, THE HOSPITALS HAD 25,906 INPATIENT ADMISSIONS, 1,846 NEWBORN ADMISSIONS, AND 119,966 INPATIENT DAYS. THE FACILITIES ALSO ENCOUNTER 97,089 EMERGENCY ROOM VISITS, 18,384 OUTPATIENT SURGERIES, 295 OPEN HEART PROCEDURES, 3,433 CARDIAC CATHETERIZATIONS AND 318,260 DIAGNOSTIC IMAGING PROCEDURES. 1403744 1091794 SCHOOL OF NURSING TO PROMOTE AND PROVIDE SUPPORT TO THE HOSPITALS. 347774803 1 0 0 1 0 0 0 0 1 1 1 1 0 0 0 0 0 0 0 0 1 1 1 1 0 0 0 0 0 1 1 1 0 0 0 0 0 1 0 0 0 1 144 0 1 3606 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 22 17 1 0 0 0 1 1 1 1 1 0 1 1 1 1 1 1 1 1 0 0 0 PA X FINANCE DEPT VALLEY MED FACILITIE 4127416600 420 rouser road moon township PA 15108 NORMAN F MITRY 40.00 X X X 499425 0 43946 RICHARD HOGAN MD 40.00 X 0 316238 24492 J zdunek do 40.00 X 0 259800 19995 JAMES SCIBILIA MD 40.00 X 0 392631 35443 ALEXANDAR VASILAKIS MD 40.00 X 0 470430 36601 LYNN GEORGE PHD 2.00 X 0 0 0 JOSEPH BECHERER 2.00 X X 0 0 0 A GARY CHACE 2.00 X X 0 0 0 GRORR III 2.00 X X 0 0 0 THOMAS JOHNSON ESQ 2.00 X 0 0 0 ALLEN WOLFERT MD 2.00 X 0 0 0 TIMOTHY W MERRILL JR 2.00 X 0 0 0 DANIEL J NADLER MD 2.00 X 0 0 0 DENNIS PEGDEN 2.00 X 0 0 0 DAVID M RAFALKO MD 2.00 X 0 0 0 JOHANNAH ROBB CPA 2.00 X X 0 0 0 Scott mElste 2.00 X 0 0 0 LAURA A VASSAMILLET 2.00 X X 0 0 0 Garry Hogan 2.00 X 0 0 0 Mary Kirsh 2.00 X 0 0 0 THOMAS ARBOGAST 2.00 X 0 0 0 DAVID ATCHESON DMD 2.00 X 0 0 0 BRYan j randall 40.00 X X 216059 0 35278 DANIEL BROOKS MD 40.00 X 278108 0 36013 ROSEMARY M NOLAN 40.00 X 280207 0 29533 BRUCE E EDWARDS 40.00 X 239549 0 35448 DAVID W CARLETON 40.00 X 193656 0 38509 RICHARD P BEAVER 40.00 X 190498 0 20507 JOHN CINICOLA 40.00 X 0 0 0 SHANON M LOFTUS ESQ 40.00 X 0 0 0 THOMAS PANGBURN MD 40.00 X 381979 0 42085 JOHN L LUELLEN MD 40.00 X 353327 0 41475 RONALD d LECKeY MD 40.00 X 330343 0 41033 EDWIN h PAGE MD 40.00 X 322621 0 39223 GAIL J SHUMWAY MD 40.00 X 282075 0 40357 JOHN CY WRIGHT MD 0.00 X 0 652740 39228 GEORGE BRETT III MD 0.00 X 0 396862 22382 JAMES MEDITCH MD 0.00 X 0 252340 33400 Peter manolukas do 0.00 X 0 285243 20770 3567847 3026284 675718 87 1 1 0 BEAVER ANESTHESIA ASSOC PO BOX 237 NEW BRIGHTON PA 15066 PROFESSIONAL SERVICES 2042960 WESTERN PA ANESTHESIA ASSOC PO BOX 643483 PITTSBURGH PA 15264 PROFESSIONAL SERVICES 1746917 OHIO VALLEY PERFUSION ASSOC 628 SCOTT RIDGE RD HARMONY PA 16037 PROFESSIONAL SERVICES 977325 ALLSCRIPTS 2297 PAYSHARE CIRCLE CHICAGO IL 60674 COMPUTER PROFESSIONAL SERVICES 641587 BUCHANAN INGERSOLL & ROONEY 301 GRANT STREET PITTSBURGH PA 15219 LEGAL 582255 34 3864619 245571 4110190 all OTHER PATIENT PAYM 900099 163430677 163128242 302435 MEDICAID HMO PAYMENTS 900099 101494684 101494684 MEDICARE/medicaid paym 900099 59631034 59631034 MEDICAID HMO PAYMENTS 900099 18501729 18501729 343058124 2848614 2848614 228745128 218146762 233793 10598366 -233793 10364573 10364573 SALE OF DRUGS 900099 7215266 7215266 NURSING TUITION 900099 743257 743257 SIX-SIGMA TRAINING 900099 7500 7500 8017478 1157472 6860006 15983501 376365002 344656418 7525201 20073193 32757 32757 150761 150761 4206964 4206964 148116380 145290333 2826047 11135408 11135408 21617562 21617562 10590833 10466085 124748 400136 280087 120049 258350 258350 18290 18290 148936 148936 1456324 1456324 3036852 3036852 3542781 3456770 86011 388055 362330 25725 90476 90476 3150073 3150073 24273042 24273042 MEDICAL AND OTHER SUPPL 52888306 52833236 55070 OTHER OUTSIDE SERVICES 24717933 24548396 169537 DRUGS 17877671 17877671 BAD DEBTS 12046418 12046418 EQUIPMENT RENTAL & MAIN 9460005 9459860 145 5962962 5803076 159886 355567275 347774803 7792472 0 2629349 3174118 4356991 4718717 347367 228679 35782540 32467840 6270765 6176996 7702952 12025117 394176739 230075375 152698663 164101364 153777208 177988881 36717567 689759 549412 388467267 413937018 42904376 40936672 83342 74400381 70886891 3650053 7638931 56887561 79804098 177925713 199266592 X 196969287 201534888 7791264 7054948 5781003 6080590 210541554 214670426 388467267 413937018 X 0 1 1 X 1 1 X 1 1 0 0 0 1 18290 1 60408 0 0 78698 0 Part IV, Supplemental Information: PART II-B, LINE 1(I), OTHER LOBBYING ACTIVITIES: A PORTION OF HOSPITAL and health system ASSOCIATION OF PA (HAP) DUES ARE LOBBYING EXPENSES. ADDITIONALLY, THE organization RETAINs THE LAW FIRM OF BUCHANAN INGERSOLL & ROONEY TO LOBBY ON THEIR BEHALF. 240777000 4160000 28999000 21000 13230000 1490000 259195000 284125000 846000 -38472000 -21000 -4884000 -817000 240777000 0.95000 0.02000 0.03000 1 1 1 2212779 2212779 133221232 71719532 61501700 1224773 283519 941254 244773714 155127258 89646456 12744241 2945066 9799175 164101364 INTEREST IN ASSETS HELD BY FOUNDATIONS 7710400 F OTHER INVESTMENTS 151948 F Commingled Funds 24844182 C Alternative investments 4011037 C 36717567 WORKERS COMP reserve - long term 2689746 ACCRUED PENSIONS AND OTHER LONG TERM LIABILITIES 77114352 79804098 376365002 355567275 20797727 5390005 2278444 -24337304 -16668855 4128872 381183358 5390005 5390005 375793353 571649 571649 376365002 355383755 0 355383755 183520 183520 355567275 Part V, Line 4: Description of Intended Use of Endowment Funds: SEE ADDITIONAL INFORMATION ON SCHEDULE O. Part XI, Line 8 - Other Adjustments: PENSION OBLIGATION ADJUSTMENT TRANSFER TO SEWICKLEY VALLEY MEDICAL GROUP, inc. FOR MEDCARE PURCHASE Part XII, Line 4b - Other Adjustments: RESTRICTED FUND INCOME Part XIII, Line 4b - Other Adjustments: RESTRICTED FUND EXPENSES PART X, LINE 2, fin 48 - VALLEY MEDICAL FACILITIES (VMF) HAS ADOPTED THE UNCERTAIN TAX PROVISIONS OF ASC 740 AS OF JULY 1, 2010. THERE WAS NO MATERIAL IMPACT AS A RESULT OF THE ADOPTION. VMF DOES NOT HAVE ANY MATERIAL UNCERTAIN TAX POSITIONS. VMF DOES NOT EXPECT A MATERIAL CHANGE IN THE ASC 740 UNCERTAIN TAX POSITIONS IN THE NEXT 12 MONTHS. 1 1 X 1 X 300.000000000000 1 X 450.000000000000 1 1 1 0 1 1 5064146 5064146 0.01420 34656031 21527809 13128222 0.03690 39720177 21527809 18192368 0.05110 204554 119986 84568 0.00020 1496027 926045 569982 0.00160 488309 349493 138816 0.00040 2188890 1395524 793366 0.00220 41909067 22923333 18985734 0.05330 3120 3120 0.00000 41552 41552 0.00010 109203 109203 0.00030 153875 153875 0.00040 0 4962096 2481048 158099638 162751037 -4651399 X 1 1 Heritage Valley BEAVER

1000 DUTCH RIDGE ROAD BEAVER PA 15009

X X X X HERITAGE VALLEY SEWICKLEY

720 BLACKBURN ROAD SEWICKLEY PA 15143

X X X Part I, Line 3c: PART I, LINE 3B: THE ORGANIZATION PROVIDES CHARITY CARE TO QUALIFYING INDIVIDUALS AND FAMILIES BASED ON A SLIDING SCALE, USING FEDERAL HEALTH & HUMAN SERVICES POVERTY GUIDELINES ACCOUNTING FOR FAMILY SIZE AT 300% OF THE POVERTY LEVEL FOR FREE CARE, A 75% DISCOUNT FOR FAMILIES AT 350%, A 50% DISCOUNT FOR FAMILIES AT 400%, AND A 25% DISCOUNT FOR FAMILIES AT 450%.PART I, LINE 6A: COMMUNITY BENEFIT REPORT AVAILABLE UPON REQUEST.PART 1, LINE 7G: FAMILY MEDICINE & FAMILY PLANNING CLINIC SUBSIDY. Part III, Line 4: THERE IS NO BAD DEBT FOOTNOTE REQUIRED FOR THE FINANCIAL STATEMENTS AUDITED BY DELOITTE & TOUCHE LLP. COST OF BAD DEBTS IN LINES 2 AND 3 IS BASED ON CALCULATIONS OF COST TO CHARGES APPLIED TO BAD DEBT CHArgES. Part III, Line 8: THE ORGANIZATION BELIEVES THE ENTIRE SHORTFALL OF REIMBURSEMENT VERSUS COST ($4,651,399) SHOULD BE CONSIDERED COMMUNITY BENEFIT SINCE IT RESULTS IN A LOSS THEREFORE LESSENING GOVERMENT BURDEN. COSTS ASSOCIATED WITH THE SHORTFALL WERE DETERMINED FROM THE ORGANIZATION'S COST ACCOUNTING SYSTEM. Part III, Line 9b: Within the organization's Bad Debt/Collection Policy, there is reference to the fact that patients are provided several options, one of which being the application for Charity Care in satisfying the outstanding balance of their account. If the patient pursues charity care, there is a separate policy detailing the steps required to qualify for charity care. Part VI, Line 2: THE ORGANIZATION ASSESSES COMMUNITY HEALTH CARE NEEDS IN SEVERAL WAYS. UTILIZATION OF SERVICES, ESPECIALLY INPATIENT AND EMERGENCY DEPARTMENT, ARE REVIEWED AT LEAST ANNUALLY TO DETERMINE THE TOP REASONS FOR ADMISSION/SEEKING CARE. AVAILABLE HEALTH STATISTICS DATA is REVIEWED AT LEAST ANNUALLY FROM THE PENNSYLVANIA DEPARTMENT OF HEALTH TO MEASURE THE STATUS OF HEALTH CONDITIONS IN BEAVER AND ALLEGHENY COUNTIES INCLUDING DATA ON PERFORMANCE COMPARED TO HEALTHY PEOPLE IN 2010. ADMINISTRATION IS IN CONTINUING DIALOGUE WITH ITS MEDICAL STAFF AND OTHER HEALTH PROFESSIONALS REGARDING COMMUNITY HEALTH NEEDS. PERIODICALLY THE ORGANIZATION HOLDS A STRATEGIC PLANNING PROCESS FOR SELECTED SERVICE LINES. PREVIOUS STRATEGIC CLINICAL PLANNING STUDY GROUPS HAVE INCLUDED THE TOPICS OF DIABETES CARE, BREAST HEALTH, EMERGENCY SERVICES AND CARDIOLOGY. IN 2009, THE ORGANIZATION COMPLETED A COMMUNITY HEALTH NEEDS ASSESSMENT. THE ASSESSMENT INCLUDED 600 HOUSEHOLD TELEPHONE SURVEYS CONDUCTED BY AN AREA MARKET RESEARCH FIRM WITH ADDITIONAL INPUT GATHERED FROM PATIENTS, EMPLOYEES, MEDICAL STAFF, CITIZENS AND MANAGEMENT. THE ASSESSMENT AFFIRMED THE ORGANIZATION'S CURRENT COMMUNITY HEALTH SERVICES AND INDICATED SOME ADDITIONAL AREAS TO CONSIDER FOR EXPANSION. Part VI, Line 3: The Organization is committed to assisting all self pay patients in applying for State Medicaid. Currently the Organization engages a third party service to interview and complete the Medicaid application on all patients admitted with no health insurance. During the application process, patients are made aware of the Charity Care Program in the event they are denied State Medicaid. The financial information obtained during this process is used in determining if the patients qualify for the Charity Care Program. If the patient is denied for Medicaid, they receive monthly statements reflecting the outstanding balance owed. The Organization makes the patients aware of the Charity Care Program on the back side of all self pay patient statements. The statement directs all inquiries regarding Charity Care to the Patient Accounting Department. The patients are provided with the guidelines of the program at the point they contact Patient Accounting. This phone call usually results in the application along with the current guidelines being mailed to the patient for completion. In addition, reference to the Charity Care Program is included in the "Patient Guide" which is provided to all patients admitted. Part VI, Line 4: Service Area & Population The Organization serves residents in the Western Pennsylvania counties of Allegheny, Beaver, Butler and Lawrence; Columbiana County in Eastern Ohio; and the panhandle of West Virginia. Our primary service area includes all of Beaver County, Northwestern Allegheny County, Southwestern Butler County, Southern Lawrence County, Eastern Columbiana County (Ohio), and Hancock and Brooke Counties (West Virginia). The population in our primary service area is approximately 458,000 people. The area is predominantly suburban although it includes towns, boroughs and rural areas. Selected Demographic Statistics Beaver County is emphasized as a plurality of The Organization's patients are residents of this county. The percentage of those 65 and older ranges from a low of 14.4% in Butler County to a high of 19.3% in Brooke County; Beaver County is 18.3%, substantially higher than the United states average of 12.6%. Median household income ranges from a low of $39,580 in Columbiana County to a high of $54,023 in Butler County; Beaver County is $44,817, substantially lower than the United states average of $50,740. The percentage of those below the poverty level ranges from a low of 8.8% in Butler County to a high of 15.1% in Columbiana County; Beaver County is 9.9%, substantially lower than the United states average of 13.0%. Uninsured adults range from a low of 9% in Allegheny and Butler counties to a high of 26% in Columbiana County; Beaver County is 12% In summary, the Organization'S service area is older and less affluent than the United States average but the percentage at or below the poverty level is lower as the national average includes inner cities In Fiscal 2009, Medicaid was 6.7 percent of net patient revenue at the Sewickley campus and 6.6 percent at the Beaver campus for a weighted average of 6.6 percent. This is typical for most suburban service areas. In our Community Health Needs Assessment survey, 9.3% of the adult respondents stated that they did not have health insurance coverage of some kind. In comparison, 13% of Pennsylvania adults reported no health insurance. However, the Pennsylvania result is for adults aged 18 to 64, while the needs assessment included some people over age 60, of whom only 4% reported not having health insurance of some kind. Rates of adults without health insurance are expected to climb until unemployment levels decrease when the current economic recession IS abateD. Medically Underserved Areas (MUAs) & Medically Underserved Populations (MUPs)MUAs in the Organization's primary service area include: Beaver Falls (part) Bridgewater Aliquippa (part) Coraopolis Mars MUPs in the Organization's service area include: Columbiana County-Medicaid eligible population Part VI, Line 5: EXECUTIVE SUMMARYDuring Fiscal 2010, the organization participated in over eighty activities providing community benefit. A selection of these activities included: Participated in six (6) major health fairs providing free screenings & health information. Presented health & wellness information, including mental health issues, at various school & community group events. Sponsored five (5) monthly support groups and working with six (6) other monthly support groups. Provided manikins to local first responder organizations for CPR certification activities. Day of Caring participants-value of donated time- $7,592. Participated in local school career days. Provided free clinical services or donating medical equipment to several community not-for-profit organizations. The organization also subsidizes various programs that benefit both the health and well being of the patients in the communities we serve and the students seeking to further their education in the health services field. Examples of these programs include: Family Practice and Family Planning Clinics School of Nursing Community Health Education & Outreach Maternal & Child Health staff at Heritage Valley, Sewickley-Conducted over fifteen (15) sessions of different prenatal education topics and also provided support groups for pregnancy loss and new mothers. Staff of the Community Health Services Department participated in twenty-eight (28) health fairs/education sessions. Car seats are rented at discounted rates to parents in need for safe transport of newborns. Family Medicine Residents provided free physicals and provided health education on smoking avoidance and sex education. The organization through its Ellwood Diagnostic Center provided Physicals for Twenty-five (25) Ellwood City Firemen. Women's Health Center staff performed approximately seven-hundred (700) osteoporosis health screenings at nineteen (19) community events or for patients and visitors at the Women's Health Center. The sterile processing department lends manikins to local fire departments, EMS units and police for CPR certification activities. Nutrition Services staff participated in twenty-two (22) community events, totaling approximately ninety-four (94) hours in staff time preparing for, traveling to and from, and attending these events. School of Nursing faculty and staff provided over seven hundred and fifty (750) hours of community service at thirty-seven (37) events. Management and staff from several departments participated in local school career days; the organization was a participant in the Ground Hog Job Shadow Day. Heritage Valley-Beaver laboratory services worked with high school students on science fair projects. Community groups use the conference center/education center at the hospitals for meetings; the pro-rated facility cost of these meetings was $16,515.Community-Based Clinical Services The Family Medicine Clinic (Beaver Falls) conducts free physicals for the foster grandparent program. The laboratory collected lab work for the physicals of twenty (20) firemen at an estimated value of $1,030.Healthcare Support Services The organization sponsors or works directly with five (5) support groups that meet monthly at an organization hospital or in the community; the organization is involved in another six (6) support groups that meet monthly in various community settings.Donations to Not-for-Profit Organizations Payments to local municipalities (in lieu of taxes) - $57,250 Donation of a parcel of land on the Beaver campus for the Brighton Township Volunteer Fire Department at a cost of $3,120. The organization sponsored events held by community not-for-profit organizations and donated $17,445 to these organizations (net of value received) Donation of four (4) Taser guns to Brighton Township Police Department at a cost of $7,000. Donation of beds, mattresses and other equipment and furnishings valued at $43,623, to global links, a 501(c)(3) not-for-profit which provides the assets to hospitals serving the poor in latin america and the caribbean. Donation of a chalkboard to headstart program at an estimated cost of $300. Part VI, Line 6: MEDICAL EDUCATION SCHOOL OF NURSING SUBSIDY - $505,692 The organization serves as a site for numerous health and administrative/professional internships and administrating nursing students from community college of beaver country, Robert morris university and kent state who use the organization as a site for clinical training with no tuition or monetary reimbursement. Coordination of these unpaid internships requires approximately 2,500 hours of staff time, valued at $64,290.Subsidized health services Family medicine clinic & family planning clinic (Beaver Falls) - $138,816 loss. (excluding estimated Medicaid & Medicare underpayments separately reported) Nutritional Counseling Serivces are subsidized - $84,568The organization is committed to offering a robust range of services to meet community needs; therefore some services such as emergency department services & maternal/child health services are operated with significant subsidies. Medical Staff Privileges Both the Beaver and Sewickley campuses have open medical staffs and privileges are granted to qualified physicians who meet established criteria. Only four departments have contractual arrangements so that physicians with privileges must belong to the contracting physician group: emergency department, radiology, pathology, and anesthesia. These are "hospital-based" physician specialties and such contractual arrangements are typical. All other departments are open to independent, qualified applicants. Improvements in Patient Care and Medical Education The Organization funds improvements in patient care and medical education in two ways: operating margin and grants from the two affiliated foundations. There are several means used by The Organization to improve patient care and support medical education: Qualified improvements for patient care, including Six Sigma/Lean Six Sigma methodology. Investment in facilities and equipment Support of medical education Support of community health servicesQuality Improvements in Patient Care The Organization has trained 118 people, including several physicians, in the Six Sigma/Lean Six Sigma quality improvement methodology and they have completed successful projects so they are now deemed "black belts" in this method. Some patient care performance highlights, as measured on the Organizations' Strategic Performance Index (balanced scorecard) include: high levels of compliance to national patient safety goals and CMS measures (97% and 96%, respectively). a patient fall rate of 1.8 per 1,000 patient days that has declined from 2.1 in 2008. a hospital acquired infection index of 1.0% which has decreased from 2.0% in fiscal year 2007.Investments in Facilities and Equipment The Organization has a significant capital budget, of approximately $30 million annually, primarily funded by operating margins. Recently, both hospital emergency departments have been renovated and expanded to meet patient volumes and improve service. Both foundations support facility enhancements and equipment in addition to the emergency department projects. The Sewickley Valley Hospital Foundation supports the purchase of maternity and infant care equipment and educational equipment for the School of Nursing. The Medical Center Foundation supports the purchase of cardiology and pediatric equipment.Medical Education The Organization has a family practice residency program in Beaver Falls, with an associated clinic, and a school of nursing in Moon Township. Both affiliated foundations offer nursing school scholarships.Community Health Services The Organization has a robust set of community health services which include: Pediatric asthma Diabetes Pregnancy health services The Community Advanced Illness Program (a palliative care program for people at the end of life) A pilot program in childhood obesity operated in partnership with the Quaker Valley School District and the Sewickley Valley YMCA.These services are supported through grants from the foundations. Also, nutritional services counseling is a program subsidized from operating funds. Part VI, Line 7: The Organization is a wholly owned subsidiary of Heritage Valley Health System, Inc. and provides inpatient and outpatient health care and related services to the residents of Beaver County, PA, and Northwestern Allegheny County, PA, and the surrounding areas through its two acute care hospitals: Heritage Valley, Beaver and Heritage Valley, Sewickley.The Organization is part of an independent, community-based health system, unaffiliated with any other health care system. The roles of the Organization and its affiliated foundations are documented elsewhere in this form. The contracted physician practices also participate in community health improvement efforts. Several physicians participated in the diabetes clinical program and several have met certain criteria to be identified under the NCQA's diabetes physician recognition program. Also, one of the senior pediatricians in Tri-State Pediatric Associates is a champion for the Organization's childhood obesity program. 1 FISHER HEALTHCARE 1225 N MICHAEL DRIVE WOOD DALE IL 60191 000000000 8560 FMV CONVERSION KIT DISASTER PREPAREDNESS VERATHON 20001 NORTH CREEK PARKWAY BOTHELL WA 98011 911248952 20775 FMV GLIDESCOPE DISASTER PREPAREDNESS 3 TUITION REIMBURSEMENT 104 150761 0 FMV N/A Other Information: Part IV: SCHEDULE I, PART I, LINE 2 - EDUCATIONAL ASSISTANCE IS GRANTED TO ACTIVE, ELIGIBLE FULL-TIME AND PART-TIME EMPLOYEES. CURRENT AND FUTURE EDUCATIONAL, TRAINING AND STAFFING NEEDS OF THE ORGANIZATION ARE TAKEN INTO CONSIDERATION WHEN GRANTING EDUCATIONAL ASSISTANCE. THE GRADE REPORT FOR EMPLOYEES RECEIVING EDUCATIONAL ASSISTANCE MUST SHOW A GRADE OF "C" OR BETTER FOR UNDERGRADUATE AND A "B" OR BETTER FOR GRADUATE LEVEL COURSES. X X X X X 0 0 0 0 0 0 0 0 0 NORMAN F MITRY 490002 0 0 0 9423 0 0 0 30088 0 529513 0 0 0 RICHARD HOGAN MD 0 304000 0 0 0 12238 0 0 0 13341 0 329579 0 0 J zdunek do 0 200000 0 0 0 59800 0 0 0 9608 0 269408 0 0 JAMES SCIBILIA MD 0 392131 0 0 0 500 0 0 0 23141 0 415772 0 0 ALEXANDAR VASILAKIS MD 0 470430 0 0 0 0 0 0 0 23141 0 493571 0 0 BRYan j randall 210001 0 0 0 6058 0 0 0 25555 0 241614 0 0 0 DANIEL BROOKS MD 275000 0 0 0 3108 0 0 0 25385 0 303493 0 0 0 ROSEMARY M NOLAN 275001 0 0 0 5206 0 0 0 18850 0 299057 0 0 0 BRUCE E EDWARDS 235000 0 0 0 4549 0 0 0 25380 0 264929 0 0 0 DAVID W CARLETON 190002 0 0 0 3654 0 0 0 29120 0 222776 0 0 0 RICHARD P BEAVER 185001 0 0 0 5497 0 0 0 11121 0 201619 0 0 0 THOMAS PANGBURN MD 341269 0 0 0 40710 0 0 0 29957 0 411936 0 0 0 JOHN L LUELLEN MD 334376 0 0 0 18951 0 0 0 29762 0 383089 0 0 0 RONALD d LECKeY MD 293021 0 0 0 37322 0 0 0 29680 0 360023 0 0 0 EDWIN h PAGE MD 286732 0 0 0 35889 0 0 0 27938 0 350559 0 0 0 GAIL J SHUMWAY MD 244220 0 0 0 37855 0 0 0 29680 0 311755 0 0 0 JOHN CY WRIGHT MD 0 639840 0 0 0 12900 0 0 0 23141 0 675881 0 0 GEORGE BRETT III MD 0 275989 0 0 0 120873 0 0 0 10016 0 406878 0 0 JAMES MEDITCH MD 0 251290 0 0 0 1050 0 0 0 23141 0 275481 0 0 Peter manolukas do 0 265243 0 0 0 20000 0 0 0 10016 0 295259 0 0 JAMES SCIBILIA MD BOARD DIRECTOR OF VALLEY MEDICAL FACILITIES 0 JAMES scibilia IS A BOARD MEMBER OF TRI-STATE PEDIATRIC ASSOCIATES, INC. - The listed amount for item C above represents payment by Valley Medical Facilities, inc. to TRI-STATE PEDIATRIC ASSOCiaTES, INC. for services rendered. 0 J ZDUNEK DO BOARD DIRECTOR OF VALLEY MEDICAL FACILITIES 115776 J. ZDUNEK IS A BOARD MEMBER OF TRI-STATE MEDICAL GROUP, INC. - The listed amount for item C above represents payment by Valley Medical Facilities, inc. to Tri-State Medical Group, inc. for services rendered. 0 RICHARD HOGAN MD BOARD DIRECTOR OF VALLEY MEDICAL FACILITIES 0 RICHARD hogan IS A BOARD MEMBER OF SEWICKLEY VALLEY MEDICAL GROUP, INC. - The listed amount for item C above represents payment by Valley Medical Facilities, inc. to SEWICKLEY VALLEY MEDICAL GROUP, INC. for services rendered. 0 GARRY HOGAN BOARD DIRECTOR OF VALLEY MEDICAL FACILITIES 115776 GARRY HOGAN IS A BOARD MEMBER OF TRI-STATE MEDICAL GROUP, INC. - The listed amount for item C above represents payment by Valley Medical Facilities, inc. to Tri-State Medical Group, inc. for services rendered. 0 GARRY HOGAN BOARD DIRECTOR OF VALLEY MEDICAL FACILITIES 0 GARRY HOGAN IS A BOARD MEMBER OF SEWICKLEY VALLEY MEDICAL GROUP, INC. - The listed amount for item C above represents payment by Valley Medical Facilities, inc. to SEWICKLEY VALLEY MEDICAL GROUP, INC. for services rendered. 0 NORMAN F MITRY BOARD DIRECTOR OF VALLEY MEDICAL FACILITIES 115776 NORMAN mitry IS A BOARD MEMBER OF TRI-STATE MEDICAL GROUP, INC. - The listed amount for item C above represents payment by Valley Medical Facilities, inc. to Tri-State Medical Group, inc. for services rendered. 0 NORMAN F MITRY BOARD DIRECTOR OF VALLEY MEDICAL FACILITIES 0 NORMAN mitry IS A BOARD MEMBER OF SEWICKLEY VALLEY MEDICAL GROUP, INC. - The listed amount for item C above represents payment by Valley Medical Facilities, inc. to SEWICKLEY VALLEY MEDICAL GROUP, INC. for services rendered. 0 NORMAN F MITRY BOARD DIRECTOR OF VALLEY MEDICAL FACILITIES 0 NORMAN mitry IS A BOARD MEMBER OF TRI-STATE PEDIATRIC ASSOCIATES, INC. - The listed amount for item C above represents payment by Valley Medical Facilities, inc. to TRI-STATE PEDIATRIC ASSOCiaTES, INC. for services rendered. 0 TIMOTHY W MERRILL BOARD DIRECTOR OF VALLEY MEDICAL FACILITIES 115776 TIMOTHY merrill IS A BOARD MEMBER OF TRI-STATE MEDICAL GROUP, INC. - The listed amount for item C above represents payment by Valley Medical Facilities, inc. to Tri-State Medical Group, inc. for services rendered. 0 TIMOTHY W MERRILL BOARD DIRECTOR OF VALLEY MEDICAL FACILITIES 0 TIMOTHY merrill IS A BOARD MEMBER OF SEWICKLEY VALLEY MEDICAL GROUP, INC. -The listed amount for item C above represents payment by Valley Medical Facilities, inc. to SEWICKLEY VALLEY MEDICAL GROUP, INC. for services rendered. 0 ALEXANDER VASILAKIS MD BOARD DIRECTOR OF VALLEY MEDICAL FACILITIES 115776 ALEXANDER vasilakis IS A BOARD MEMBER OF TRI-STATE MEDICAL GROUP, INC. - The listed amount for item C above represents payment by Valley Medical Facilities, inc. to Tri-State Medical Group, inc. for services rendered. 0 MARY KIRSCH CPA BOARD DIRECTOR OF VALLEY MEDICAL FACILITIES 0 MARY KIRSCH, CPA IS A SENIOR FINANCIAL MANAGER OF SIMIO, LLC OF WHICH DENNIS PEGDEN, ANOTHER BOARD MEMBER OF VALLEY MEDICAL FACILITIES OWNS MORE THAN 35%. 0 Form 990, Part I, Item C Doing Business As HERITAGE VALLEY, SEWICKLEY HERITAGE VALLEY, BEAVER Form 990, Part VI, Section A, line 2 (A) NAME OF INTERESTED PERSON (B) RELATIONSHIP BETWEEN INTERESTED PERSON AND ORGANIZATION (C) AMOUNT OF TRANSACTION (D) DESCRIPTION OF TRANSACTION (A) NAME OF PERSON: JAMES SCIBILIA, M.D. (B) RELATIONSHIP BETWEEN INTERESTED PERSON AND ORGANIZATION: BOARD DIRECTOR OF VALLEY MEDICAL FACILITIES (C) AMOUNT OF TRANSACTION $ 0. (D) DESCRIPTION OF TRANSACTION: JAMES SCIBILIA IS A BOARD MEMBER OF TRI-STATE PEDIATRIC ASSOCIATES, INC. - THE LISTED AMOUNT FOR ITEM C ABOVE REPRESENTS PAYMENT BY VALLEY MEDICAL FACILITIES, INC. TO TRI-STATE PEDIATRIC ASSOCIATES, INC. FOR SERVICES RENDERED. (A) NAME OF PERSON: J. ZDUNEK, D.O. (B) RELATIONSHIP BETWEEN INTERESTED PERSON AND ORGANIZATION: BOARD DIRECTOR OF VALLEY MEDICAL FACILITIES (C) AMOUNT OF TRANSACTION $ 115,776. (D) DESCRIPTION OF TRANSACTION: J. ZDUNEK IS A BOARD MEMBER OF TRI-STATE MEDICAL GROUP, INC. - THE LISTED AMOUNT FOR ITEM C ABOVE REPRESENTS PAYMENT BY VALLEY MEDICAL FACILITIES, INC. TO TRI-STATE MEDICAL GROUP, INC. FOR SERVICES RENDERED. (A) NAME OF PERSON: RICHARD HOGAN, M.D. (B) RELATIONSHIP BETWEEN INTERESTED PERSON AND ORGANIZATION: BOARD DIRECTOR OF VALLEY MEDICAL FACILITIES (C) AMOUNT OF TRANSACTION $ 0. (D) DESCRIPTION OF TRANSACTION: RICHARD hogan IS A BOARD MEMBER OF SEWICKLEY VALLEY MEDICAL GROUP, INC. - THE LISTED AMOUNT FOR ITEM C ABOVE REPRESENTS PAYMENT BY VALLEY MEDICAL FACILITIES, INC. TO SEWICKLEY VALLEY MEDICAL GROUP, INC. FOR SERVICES RENDERED. (A) NAME OF PERSON: GARRY HOGAN (B) RELATIONSHIP BETWEEN INTERESTED PERSON AND ORGANIZATION: BOARD DIRECTOR OF VALLEY MEDICAL FACILITIES (C) AMOUNT OF TRANSACTION $ 115,776. (D) DESCRIPTION OF TRANSACTION: GARRY HOGAN IS A BOARD MEMBER OF TRI-STATE MEDICAL GROUP, INC. - THE LISTED AMOUNT FOR ITEM C ABOVE REPRESENTS PAYMENT BY VALLEY MEDICAL FACILITIES, INC. TO TRI-STATE MEDICAL GROUP, INC. FOR SERVICES RENDERED. (A) NAME OF PERSON: GARRY HOGAN (B) RELATIONSHIP BETWEEN INTERESTED PERSON AND ORGANIZATION: BOARD DIRECTOR OF VALLEY MEDICAL FACILITIES (C) AMOUNT OF TRANSACTION $ 0. (D) DESCRIPTION OF TRANSACTION: GARRY HOGAN IS A BOARD MEMBER OF SEWICKLEY VALLEY MEDICAL GROUP, INC. - THE LISTED AMOUNT FOR ITEM C ABOVE REPRESENTS PAYMENT BY VALLEY MEDICAL FACILITIES, INC. TO SEWICKLEY VALLEY MEDICAL GROUP, INC. FOR SERVICES RENDERED. (A) NAME OF PERSON: NORMAN F. MITRY (B) RELATIONSHIP BETWEEN INTERESTED PERSON AND ORGANIZATION: BOARD DIRECTOR OF VALLEY MEDICAL FACILITIES (C) AMOUNT OF TRANSACTION $ 115,776. (D) DESCRIPTION OF TRANSACTION: NORMAN mitry IS A BOARD MEMBER OF TRI-STATE MEDICAL GROUP, INC. - THE LISTED AMOUNT FOR ITEM C ABOVE REPRESENTS PAYMENT BY VALLEY MEDICAL FACILITIES, INC. TO TRI-STATE MEDICAL GROUP, INC. FOR SERVICES RENDERED. (A) NAME OF PERSON: NORMAN F. MITRY (B) RELATIONSHIP BETWEEN INTERESTED PERSON AND ORGANIZATION: BOARD DIRECTOR OF VALLEY MEDICAL FACILITIES (C) AMOUNT OF TRANSACTION $ 0. (D) DESCRIPTION OF TRANSACTION: NORMAN mitry IS A BOARD MEMBER OF SEWICKLEY VALLEY MEDICAL GROUP, INC. - THE LISTED AMOUNT FOR ITEM C ABOVE REPRESENTS PAYMENT BY VALLEY MEDICAL FACILITIES, INC. TO SEWICKLEY VALLEY MEDICAL GROUP, INC. FOR SERVICES RENDERED. (A) NAME OF PERSON: NORMAN F. MITRY (B) RELATIONSHIP BETWEEN INTERESTED PERSON AND ORGANIZATION: BOARD DIRECTOR OF VALLEY MEDICAL FACILITIES (C) AMOUNT OF TRANSACTION $ 0. (D) DESCRIPTION OF TRANSACTION: NORMAN mitry IS A BOARD MEMBER OF TRI-STATE PEDIATRIC ASSOCIATES, INC. - THE LISTED AMOUNT FOR ITEM C ABOVE REPRESENTS PAYMENT BY VALLEY MEDICAL FACILITIES, INC. TO TRI-STATE PEDIATRIC ASSOCIATES, INC. FOR SERVICES RENDERED. (A) NAME OF PERSON: TIMOTHY W. MERRILL (B) RELATIONSHIP BETWEEN INTERESTED PERSON AND ORGANIZATION: BOARD DIRECTOR OF VALLEY MEDICAL FACILITIES (C) AMOUNT OF TRANSACTION $ 115,776. (D) DESCRIPTION OF TRANSACTION: TIMOTHY merrill IS A BOARD MEMBER OF TRI-STATE MEDICAL GROUP, INC. - THE LISTED AMOUNT FOR ITEM C ABOVE REPRESENTS PAYMENT BY VALLEY MEDICAL FACILITIES, INC. TO TRI-STATE MEDICAL GROUP, INC. FOR SERVICES RENDERED. (A) NAME OF PERSON: TIMOTHY W. MERRILL (B) RELATIONSHIP BETWEEN INTERESTED PERSON AND ORGANIZATION: BOARD DIRECTOR OF VALLEY MEDICAL FACILITIES (C) AMOUNT OF TRANSACTION $ 0. (D) DESCRIPTION OF TRANSACTION: TIMOTHY merrill IS A BOARD MEMBER OF SEWICKLEY VALLEY MEDICAL GROUP, INC. - THE LISTED AMOUNT FOR ITEM C ABOVE REPRESENTS PAYMENT BY VALLEY MEDICAL FACILITIES, INC. TO SEWICKLEY VALLEY MEDICAL GROUP, INC. FOR SERVICES RENDERED. (A) NAME OF PERSON: ALEXANDER VASILAKIS, M.D. (B) RELATIONSHIP BETWEEN INTERESTED PERSON AND ORGANIZATION: BOARD DIRECTOR OF VALLEY MEDICAL FACILITIES (C) AMOUNT OF TRANSACTION $ 115,776. (D) DESCRIPTION OF TRANSACTION: ALEXANDER vasilakis IS A BOARD MEMBER OF TRI-STATE MEDICAL GROUP, INC. - THE LISTED AMOUNT FOR ITEM C ABOVE REPRESENTS PAYMENT BY VALLEY MEDICAL FACILITIES, INC. TO TRI-STATE MEDICAL GROUP, INC. FOR SERVICES RENDERED. (A) NAME OF PERSON: MARY KIRSCH, CPA (B) RELATIONSHIP BETWEEN INTERESTED PERSON AND ORGANIZATION: BOARD DIRECTOR OF VALLEY MEDICAL FACILITIES (C) AMOUNT OF TRANSACTION $ 0. (D) DESCRIPTION OF TRANSACTION: MARY KIRSCH, CPA IS A SENIOR FINANCIAL MANAGER OF SIMIO, LLC OF WHICH DENNIS PEGDEN, ANOTHER BOARD MEMBER OF VALLEY MEDICAL FACILITIES, inc. OWNS MORE THAN 35%. Form 990, Part VI, Section A, line 6 VMF is owned 100% by Heritage Valley Health System (The System), its parent Company. The System has the right to participate in selected management decisions. Form 990, Part VI, Section A, line 7a VMF is owned 100% by Heritage Valley Health System (The System), its parent Company. The System has the right to participate in selected management decisions. Form 990, Part VI, Section A, line 7b VMF is owned 100% by Heritage Valley Health System (The System), its parent Company. The System has the right to participate in selected management decisions. Form 990, Part VI, Section B, line 11 A draft of the completed Form 990 and all associated forms is MADE AVAILABLE ELeCTRONICALLY to all Board of Directors Members and Senior Management for review and comment prior to filing with the Internal Revenue Service (IRS). The Board of Directors has delegated the responsibility for review and approval of the form 990 to the Finance Committee of the Board, which meets, reviews, and approves the Form 990 prior to filing. Form 990, Part VI, Section B, line 12c CERTAIN non-merit employees WITH JOB RESPONSIBILITIES THat PROVIDE AN OPPORTUNITY TO INFLUENCE BUSINESS DECISIONS ARE REQUIRED TO SIGN THE CONFLICT OF INTEREST FORM ANNUALLY. these Conflict of Interest statements are reviewed annually by the Department Director and System Director for Corporate Compliance to determine if a conflict exists. Any potential conflicts are referred to the appropriate Vice President and Human Resources to confirm and resolve the conflict. For merit employees, Conflict of interest statements are reviewed annually by the Department Manager, Vice President or CEO. Any potential conflicts are managed by the CEO. Other Potentially Interested Parties, such as Board Members, Officers and Highly Compensated employees sign a statement annually which affirms such person has received a copy of the Conflict of Interest Policy, has read and understands the policy, has agreed to comply with the policy, and understands that the Organization is a charitable organization and that in order to maintain its federal tax exemption it must engage primarily in activities which accomplish one or more of its tax exempt purposes. The Chairperson of the Board reviews annually a summary of the disclosure statements so that the Board members are familiar with potential conflicts. FORM 990, PART VI, LINE 14 THE ORGANIZATION HAS A RECORD RETENTION POLICY WHICH PROVIDES FOR THE RETENTION OF BUSINESS AND MEDICAL RECORDS, INCLUDING DESTRUCTION. FORM 990, PART VI, LINE 15 THERE WAS NO REVIEW CONDUCTED BY INDEPENDENT PERSONS AS NO INCREASES WERE PROVIDED DURING THIS TIME PERIOD. Form 990, Part VI, Section C, line 19 The organization publishes condensed financial statements for public use on its website www.heritagevalley.org. GOVERNING DOCUMENTS AND POLICIES, INCLUDING CONFLICTS OF INTEREST, ARE MADE AVAILABLE UPON REQUEST. Form 990, Part XI, Line 2c THE ORGANIZATION HAS A COMMITTEE THAT ASSUMES RESPONSIBILITY FOR OVERSIGHT OF AUDIT, REVIEW, OR COMPILATION OF ITS FINANCIAL STATEMENT AND SELECTION OF AN INDEPENDENT ACCOUNTANT. SCH. D. PART V LINE 4 Board Designated assets are unrestricted funds under the control of the Board of Directors. The majority of these funds are held in the Master Trust. The remaining funds are in the Checking and Money Market accounts. All interest, realized gains/losses, and unrealized gains/losses associated with these funds remain as Board Designated funds. Donor restricted specific purpose funds are composed of both Temporary and Permanent restricted funds. All funds earn interest, realized gains/losses, and unrealized gains/losses. Interest can be restricted by the donor, in which case it remains in the fund. The donor determines the interest classification at the time of the donation. The majority of the funds are held in the Master Trust with the remainder being in the Checking Account or Money Market accountS. Funds held by Heritage Valley Sewickley Foundation: Cardiology Fund - Restricted for cardiology/cardiac Rehab but otherwise unrestricted. Chaplain Fund - Restricted to use for the Chaplaincy program but otherwise unrestricted. Critical Care Fund - Restricted to Critical Care but otherwise unrestricted. Capital Project Fund - To be used to fund purchases of items designated through approved Heritage Valley Sewickley (HVS) capital budget. Margaret M. Dick Scholarship fund - Restricted endowment. Income only to be used to fund full-time first year students enrolled in HVS's School of Nursing. Emergency Department Fund - For Emergency Department use to benefit children at Medical Director's discretion; and for funding Emergency Department program & equipment needs. Irwin S. Terner Memorial Eye Glass fund - Restricted to purchase of eyeglasses for those that are unable to pay. Referrals to access this fund must be sent to Case management of HVS for evaluation of patient's needs. Ophthalmologists on staff provide glasses at cost. Eye Surgery Equipment fund - Equipment needs for Eye Department. Free Care Fund (CHARITY cARE) - To pay for prescription drugs for qualified needy patients to a maximum of $5,000 per year; and to pay for services for qualified needy as assessed by Case Management. (Currently transferring 10% per year for HVS charity care.) Thomas R. Havrilla School of Radiology Scholarship Fund - established by brighton radiology associates in memory of their friend and colleague to encourage individuals to pursue careers in radiology & employment at Valley Medical Facilities and Affiliates. Income Earned will be used annually to provide financial assistance to the top academic student completing their first year of training to assist them with their second year tuition costs. MacFarlane scholarship fund - restricted endowment. Annual interest is used for $1,500 scholarships for hvs school of nursing students who demonstrate financial need and superior clinical performance as determined by the administrator and faculty of the school. Hitchak scholarship - established with $11,000 gift from hitchak family members to endow a scholarship for graduate nursing studies. Maternal and infant child care fund - restricted for use of maternity and infant child care but otherwise unrestricted. E. Thorne Mckallip professional nursing development fund - restricted fund Income earned benefits members of hvs nursing staff in their professional development, excluding formal education preparation: Initial Nursing Certification fee Nursing recertification continuing education credits Fees for local continuing education Out-of-state continuing education (fees, transportation, accommodations) In-house education Oncology Fund - restricted for use for inpatient oncology services otherwise unrestricted. OR/Lab - restricted endowment. Restricted to use for the benefit of the operating rooms and the laboratory, but otherwise unrestricted. Rust foundation book loan - restricted for use for low interest loans for school of nursing students to provide financial assistance for books. School of nursing fund - Restricted to use for the capital and/or operating needs for the heritage valley school of nursing and financial assistance for its students but otherwise unrestricted. School of nursing alumni fund - balance of $1,000 for 10 years to provide an annual graduation gift of $100-$200, as determined by faculty of school. $500 to be set aside for 5 years for the re-establishment of an active alumnae association. After 2015, money will then be in the general fund for school of nursing. Money is utilized for speakers for students and graduates, as determined by director of school of nursing and one alumna. Dr. Sidney Selkovitz Endowed Fund - Permanently restricted endowed fund to benefit HVS. Principal will remain intact for perpetuity & interest income is used annually to further the work of HVS. The fund will be available for additional gifts for family, friends, & former patients who wish to pay tribute to Dr. Selkovitz. Speech Therapy Fund - Restricted to speech pathology but otherwise unrestricted. Elizabeth S. Standish Scholarship fund - Restricted Endowment. Income only to be used annually to provide scholarship for needy student of high scholastic standing enrolled in HVS's school of nursing and its faculty. (Currently provides $2,000 scholarship each year.) Staunton Clinic Fund - restricted to use for Staunton clinic but otherwise unrestricted. Temporary Restricted Fund - Temporary hold for Auxiliary donations until funds used for assigned projects; and formerly used to hold founders society donations (prior to 2000). Community Health Services Fund - Pediatric Asthma program; diabetes program; lifesmart program; pregnancy health services program; community advanced illness program; pediatric obesity program. Emergency department renovation fund - emergency department renovation project. Funds Held by Heritage Valley Beaver Foundation: Cardiology Fund - Restricted for cardiology/cardiac catheterization needs for Heritage Valley Beaver, but otherwise unrestricted. Center Civic Women's Club Fund - Restricted fund established in 1999 by Center Civic Women's Club to help cover expenses not reimbursed by insurance for cosmetic items (wigs, turbans, prostheses, etc.) for Beaver County women receiving cancer treatment through a heritage valley hospital heritage valley beaver or heritage valley Sewickley. Heritage Valley Beaver Foundation administers the fund. (includes criteria for eligibility). Cancer Treatment Center Benevolent Fund - To be used to assist patients who have exhausted their personal resources to battle cancer by assisting with transportation, medication or equipment needs. Allocations are based on recommendations from hospital case managers and cancer treatment center nursing. Restrictions: Pharmacy staff must be notified when prescription funding is required and the medication will be provided at cost with a separate bill sent to the foundation. Development Fund - Restricted for equipment and building (capital) needs for Heritage Valley Beaver. Community Health Services Fund - Pregnancy Health Services Program; diabetes program; lifesmart program; community advanced illness program; pediatric asthma program. Emergency Department Fund - To provide funding for equipment and program needs for Heritage Valley Beaver's Emergency Department. Emergency department renovation fund - emergency department renovation project. Equipment fund - to provide funding for equipment needs for heritage valley beaver. Free Care Fund - To reimburse heritage valley beaver for free care provided to patients treated; to assist with prescription drugs for qualified needy patients to a maximum of $5,000 per year or to pay for services for qualified needy as assessed by case management director. Labor & delivery fund - Restricted for use of heritage valley beaver maternity and infant child care. Honduras medical relief fund - reimbursement of expenses for heritage valley beaver physicians' medical missions to Honduras. Medical staff fund - funds are to be used for patient care purposes only, subject to the medical staff's endorsement. Pediatrics fund - restricted for use of heritage valley beaver pediatric unit for equipment and programs. Oncology Fund - To provide funding for equipment and program needs for Heritage Valley Beaver inpatient oncology, heritage valley beaver satellite facilities providing oncology services, and oncology services through the University of pittsburgh medical center / valley medical facilities, inc. cancer center, Beaver campus. Temporarily Restricted Fund - Auxiliary donations used for assigned projects. Endowment #2 - Permanently restricted endowments - Trust to be used exclusively for the rehabilitation of existing facilities, construction of new buildings, providing for special equipment and services and for expenses of deserving patients of Heritage Valley, Beaver. The trust is irrevocable but may be terminated at any time by the donor. Endowment #3939 - permanently restricted endowments - Established for Rochester General Hospital (predecessor hospital) to be used for the construction of new buildings, rehabilitation of existing facilities, provide for special equipment and services, and such other purposes as the Donor shall from time to time designate. Lida McHattie - Permanently Restricted Endowments - Beaver Foundation receives 1/6th share of the net income per quarter. Arthur E. Mayer - Permanently Restricted Endowments - Established in 1964. Martha Brown - Permanently Restricted Endowments - Established in 1973, Irrevocable Trust under Will. Mayer Society (Oncology) - Permanently Restricted Endowments - Cash gift to Beaver Foundation's endowment by Murray & Cecyl Thaw. In honor of their children Deborah & Robert. FUNDS HELD BY VALLEY MEDICAL FACILITIES Under Control of Heritage Valley Sewickley Foundation: Edith Oliver Rea Fund - Principal & income to be used by the President at his discretion for such purposes, as to help deserving individuals in need of financial assistance. Craig Family Memorial Fund - Restricted endowment. Income only to be used for Staunton Clinic. The Medical Director of the Clinic shall propose the use of such funds, and their expenditure will be made in accordance with the usual practices of the Hvs. Endowment - To be used at the discretion of the management/Board of valley medical facilities, inc. to support the mission of HVS. William m. Fitch Memorial Fund - Restricted endowment. Annual interest income to be used to encourage, stimulate and aid the governing board of hvs to maintain a position of being ever alert to changing opportunities for contributing to the health of the community served by HVS. Martha J. O'Rourke School of Nursing Scholarship - Restricted endowment. Income only to be used to provide financial assistance to a student of heritage valley sewickley's school of nursing. Van Kleeck Blood Bank Memorial Fund - restricted endowment - Income earned by the fund to benefit HVS blood bank by authorization of the president. Interest and principal invested in Vanguard GNMA funds with interest earnings reinvested until needed. Principal shall not be expended; however, should some extraordinary need arise in connection with the operation of the blood bank, it is understood that the hospital's board may authorize the expenditure of the principal to meet that need. SEWICKLEY VALLEY HOSPITAL FOUNDATION 420 ROUSER ROAD MOON TOWNSHIP PA 15108 251801533 FUNDRAISING PA 501(C)(3) 11C N/A THE MEDICAL CENTER FOUNDATION 420 ROUSER ROAD MOON TOWNSHIP PA 15108 251441516 FUNDRAISING PA 501(C)(3) 11C N/A HERITAGE VALLEY HEALTH SYSTEM INC 1000 dutch ridge road beaver PA 15009 251441518 PARENT SUPPORTING ORG PA 501(C)(3) 11C N/A VALLEY MEDICAL FACILITIES INC WORKERS COMPENSATION TRUST FUND 420 ROUSER ROAD MOON TOWNSHIP PA 15108 251463381 PROVIDE WORKER'S COMPENSATION BENEFITS PA 501(C)(3) 11C N/A TRI-STATE OBSTETRICS & GYNECOLOGY 1000 DUTCH RIDGE ROAD BEAVER PA 15009 251776052 PHYSICIAN PRACTICE PA C TRI-STATE PEDIATRIC ASSOCIATES INC 1000 DUTCH RIDGE ROAD BEAVER PA 15009 251775950 PHYSICIAN PRACTICE PA C SEWICKLEY VALLEY MEDICAL GROUP INC 1000 DUTCH RIDGE ROAD BEAVER PA 15009 251717258 PHYSICIAN PRACTICE PA C HERITAGE VALLEY INSURANCE COMPANY PO BOX 1051 GRAND CAYMAN CAYMAN ISLANDS CJ PROFESIONAL LIABILITY CAPTIVE CJ C TRI-STATE MEDICAL GROUP INC 1000 DUTCH RIDGE ROAD BEAVER PA 15009 251775949 PHYSICIAN PRACTICE PA C TRI-STATE GYNECOLOGY INC 1000 DUTCH RIDGE ROAD BEAVER PA 15009 841647473 PHYSICIAN PRACTICE PA C 0 0 1 0 0 0 0 0 1 0 0 1 1 1 1 1 1 0 SEWICKLEY VALLEY HOSPITAL FOUNDATION C 2473929 THE MEDICAL CENTER FOUNDATION C 1353642 VALLEY MEDICAL FACILITIES INC WORKERS COMPENSATION TRUST FUND Q 600000