2011-11-08T12:26:11-06:00 2010-12-31 CROWE HORWATH LLP 330 E JEFFERSON BLVD PO BOX 7 SOUTH BEND IN 466240007 990 2010-01-01 352064353 PARKVIEW OCCUPATIONAL HEALTH CENTERS INC PARK 2603738407 2200 RANDALLIA DRIVE FORT WAYNE IN 46805 MICHAEL P BROWNING 2603738407 2011-11-08 1 KENNETH J KEBER 5742323992 2010 2016-02-24 21:20:13Z MICHAEL PACKNETT 10501 CORPORATE DRIVE FORT WAYNE IN 46845 7970662 0 X WWW.PARKVIEW.COM X 1998 IN DELIVER OCCUPATIONAL HEALTH CARE SERVICES AND PROMOTE GENERAL HEALTH OF COMMUNITY. 3 2 117 0 0 0 0 522 7616245 7969840 -6819 -472 0 0 7609426 7969890 0 0 0 0 5449886 5002384 0 0 0 2811950 2557353 8261836 7559737 -652410 410153 1176690 1439243 487807 340207 688883 1099036 X DELIVER OCCUPATIONAL HEALTH CARE SERVICES IN A TIMELY, EFFICIENT, COST-EFFECTIVE MANNER AND PROMOTE THE GENERAL HEALTH OF THE COMMUNITY BY PROVIDING EDUCATIONAL AND WELLNESS PROGRAMS TO EMPLOYEE PATIENTS AND EMPLOYER CLIENTS. 0 0 7021851 7969840 PARKVIEW OCCUPATIONAL HEALTH CENTERS, INC. (POHCI) PROVIDES A FULL RANGE OF OCCUPATIONAL HEALTH SERVICES IN PREVENTION, TREATMENT, AND REHABILITATION. EMPLOYEE ASSISTANCE PROGRAMS (EAP) AND WELLNESS SITE CLINIC SERVICES ARE ALSO AVAILABLE.POHCI PERFORMS A WIDE VARIETY OF PRE-PLACEMENT PHYSICAL EXAMINATIONS FOR A WIDE CROSS SECTION OF THE FORT WAYNE AREA BUSINESS COMMUNITY. THESE EXAMINATIONS ARE SPECIFIC TO THE JOB FOR WHICH THE INDIVIDUAL IS BEING CONSIDERED, AND WITH THE ADVENT OF THE AMERICANS WITH DISABILITIES ACT (ADA), ARE MATCHING POTENTIAL JOB APPLICANTS WITH THE ESSENTIAL FUNCTIONS OF THEIR JOBS. THIS ASSISTANCE IS CRITICAL TO EMPLOYERS AS THEY COMPLY WITH ADA. THE ORGANIZATION ALSO OFFERS A NATIONALLY CERTIFIED DRUG SCREEN PROGRAM, WHICH IS OPERATED IN COMPLIANCE WITH GUIDELINES ESTABLISHED BY THE NATIONAL INSTITUTE FOR DRUG ABUSE. FURTHER, THE ORGANIZATION PROVIDES ON-SITE MEDICAL MONITORING EXAMINATION PROTOCOL DEVELOPMENT, E. G., ASSISTING COMPANIES WITH THEIR COMPLIANCE UNDER OCCUPATIONAL SAFETY AND HEALTH ADMINISTRATION GUIDELINES, ERGONOMIC COMPLIANCE ASSISTANCE, AND ASSISTANCE IN COMPLIANCE WITH THE AMERICANS WITH DISABILITIES ACT REASONABLE ACCOMMODATION GUIDELINES. ADDITIONALLY, THE ORGANIZATION PROVIDES INDUSTRIAL HYGIENE SERVICES TO ASSIST IN ANALYZING NOISE LEVELS, INDOOR AIR QUALITY, AND OTHER MANDATED SURVEILLANCE PROGRAMS UNDER THE AUTHORIZATION OF THE OCCUPATIONAL SAFETY AND HEALTH ADMINISTRATION.POHCI SPECIALIZES IN THE TREATMENT OF WORKERS' COMPENSATION INJURIES AND OFFERS SERVICES COMPLIMENTARY TO THE BASIC TREATMENT OF AN INJURY, SUCH AS HAND SURGERY, NEUROLOGY, AND OPHTHALMOLOGY, AS WELL AS IN-HOUSE PHARMACY SERVICES. THE CONCEPT OF THE ORGANIZATION'S TREATMENT PLAN IS CENTERED AROUND THE EARLY INTERVENTION/EARLY TO WORK CONCEPT. THROUGH EARLY INTERVENTION AND A VARIETY OF TREATMENT AND REHABILITATIVE MODALITIES, PATIENTS ARE ASSURED THE MOST EXPEDITIOUS RETURN TO WORK, THUS SAVING THE EMPLOYERS TREMENDOUS EXPENSE IN LOST PRODUCTIVITY, OVERTIME, TRAINING COSTS, ETC.POHCI PROVIDES BOTH PHYSICAL AND OCCUPATIONAL THERAPY ON-SITE AT EACH LOCATION. THE THERAPISTS ARE TRAINED IN REHABILITATION OF WORK RELATED INJURIES AND ARE SUPERVISED BY THE ORGANIZATION'S OCCUPATIONAL HEALTH PHYSICIANS. THE FOCUS OF THE THERAPIST IS TO RETURN THE INJURED WORKER TO THE JOB. DURING PHYSICAL THERAPY REHABILITATION, THE INJURED WORKER IS TAUGHT PROPER LIFTING TECHNIQUES TO AVOID RE-INJURY. THE OCCUPATIONAL THERAPY DEPARTMENT SPECIALIZES IN HAND REHABILITATION, UTILIZING VARIOUS EXERCISES AND SPLINTS THAT ASSIST IN EXPEDITING THE RECOVERY PROCESS.POHCI ALSO PROVIDES A COMPREHENSIVE WORK HARDENING PROGRAM, WHICH OPERATES WITHIN A WORK SIMULATION ENVIRONMENT, THUS ASSISTING THE INDIVIDUAL WITH BUILDING A PHYSICAL TOLERANCE LEVEL IN ORDER TO RETURN TO WORK IN A FULLY REHABILITATED CONDITION, IF AT ALL POSSIBLE.POHCI MEETS THE OCCUPATIONAL HEALTH CARE NEEDS OF FORT WAYNE AREA EMPLOYERS IN THE AREAS OF PREVENTION, TREATMENT, AND REHABILITATION. THESE SERVICES ARE DELIVERED WITH AN EMPHASIS ON COST CONTAINMENT THROUGH EARLY INTERVENTION AND EXPERT CASE MANAGEMENT.POHCI'S CLINICS ARE EQUIPPED TO CONDUCT BASIC INJURY CARE, PHYSICAL EXAMINATIONS, AND THE FOLLOWING ANCILLARY SERVICES: X-RAY, COLLECTION OF SPECIMENS FOR LABORATORY ANALYSIS, PULMONARY FUNCTION TESTING, AUDIOMETRY, ELECTROCARDIOGRAMS (EKG), AND VISION SCREENING.CERTAIN SERVICES ARE CONTRACTED IN THE TREATMENT COMPONENTS. HAND SURGERY, NEUROLOGY, PHYSIATRY, AND OPHTHALMOLOGY ARE ALL CONTRACTED WITH INDIVIDUAL PHYSICIANS AND/OR SPECIALTY GROUPS WHO PROVIDE THEIR SERVICES ON POHCI PREMISES TO ASSURE STREAMLINED COMMUNICATION WITH THE PHYSICIAN AND THE EMPLOYER/INSURANCE CARRIER. THESE CONTRACTS REMUNERATE THESE SPECIALISTS ON A FEE FOR SERVICE BASIS.POHCI IS COMMITTED TO COST CONTAINMENT FOR ITS EMPLOYER CLIENTS AND/OR THEIR INSURANCE CARRIERS. SINCE THE ORGANIZATION SPECIALIZES IN OCCUPATIONAL HEALTH, APPROXIMATELY NINETY-NINE PERCENT (99%) OF THE FEES FOR ALL CASES ARE PAID EITHER THROUGH THE EMPLOYERS' WORKERS' COMPENSATION INSURANCE OR DIRECTLY BY THE EMPLOYERS.EMPLOYEE ASSISTANCE PROGRAM (EAP) AND WELLNESS SERVICES ARE ALSO AVAILABLE TO ITS EMPLOYER CLIENTS. BOTH EAP AND WELLNESS SERVICES CAN BE CUSTOM DESIGNED TO FIT CLIENT'S NEEDS. EAP COUNSELING SERVICES ARE PROVIDED BY LICENSED PROFESSIONALS. WELLNESS SERVICES AVAILABLE INCLUDE STRESS MANAGEMENT, DIET MANAGEMENT AND PERSONAL WELLNESS PROFILES. 7021851 1 0 0 0 0 0 0 0 0 1 0 0 1 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 X 4 0 1 117 1 0 0 0 0 0 0 0 0 0 0 X 3 2 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 IN X MICHAEL P BROWNING 2603738407 10501 CORPORATE DRIVE FORT WAYNE IN 46845 X LISA SCHANBACHER 20.00 X 61477 67714 32933 PETER BACHINI 1.00 X 0 243445 42905 MARJORIE HINER 1.00 X 250 3750 0 DENISE LEMMON 1.00 X 250 6250 0 MICHAEL PACKNETT 1.00 X 0 912103 158919 MICHAEL BROWNING 1.00 X 0 80871 5343 JEFFREY FRANCIS 1.00 X 0 206802 15269 STANTON RISSER 1.00 X 0 138872 24814 MARK O'BRIEN 40.00 X 220058 0 37815 GREGORY KNISS 40.00 X 155217 0 27854 DIANE CASEY 40.00 X 109522 0 6956 CHARLES MASON 0.00 X 0 448413 0 546774 2108220 352808 3 1 1 0 0 522 522 PATIENT SERVICE 621400 7416830 7416830 EMPLOYEE ASSISTANCE 900099 553010 553010 7969840 300 772 -472 -472 -472 7969890 7969840 0 -472 77649 77649 3819651 3509367 310284 1105084 1018896 86188 1341867 1341867 1080 1080 639297 623368 15929 1195 1195 383175 382472 703 50891 45644 5247 11363 6035 5328 45264 45264 58795 25836 32959 DUES & SUBSCRIPTIONS 11215 8233 2982 BAD DEBT 8055 8055 MISCELLANEOUS 5156 4539 617 7559737 7021851 537886 0 125 200 -43587 -40904 1035167 1055274 7646 6178 1127285 913672 177339 213613 0 204882 1176690 1439243 321720 340207 166087 0 487807 340207 X 688883 1099036 688883 1099036 1176690 1439243 410153 0 X 0 1 1 X 0 X SCHEDULE A, PART IV, SUPPLEMENTAL INFORMATION: FORM 990, SCHEDULE A, PART 1, LINE 3: EXPLANATION OF CHARITY STATUS PURSUANT TO THE IRS DETERMINATION LETTER DATED SEPTEMBER 1, 1999, THE ORGANIZATION IS RECOGNIZED AS EXEMPT UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. THE ORGANIZATION IS DESCRIBED IN SECTION(S) 509(A)(1) AND 170(B(1)(A)(III) AS A HOSPITAL OR A COOPERATIVE HOSPITAL SERVICE ORGANIZATION. PARKVIEW OCCUPATIONAL HEALTH CENTER, INC.'S ORIGINAL APPLICATION FOR RECOGNITION OF EXEMPTION (FORM 1023) STATES THE FOLLOWING: "THE CORPORATION WILL NOT BE A HOSPITAL BUT WILL OPERATE OUTPATIENT CLINICS. THE CORPORATION OPERATES FOR THE PURPOSE OF TREATING WORKERS' COMPENSATION INJURIES AND ILLNESSES IN THE FORT WAYNE METROPOLITAN AREA. IT WILL NOT BE AN EMERGENCY ROOM AS FORMALLY DEFINED. IT WILL BE DESIGNED TO TREAT MINOR EMERGENCIES THAT OCCUR IN THE WORK PLACE THAT ARE COVERED UNDER WORKERS' COMPENSATION LAWS. AS AN AFFILIATE OF PARKVIEW HEALTH SYSTEMS, INC., ALL CHARITY PATIENTS WILL BE REFERRED AND TREATED WITHIN THE PARKVIEW SYSTEM IF SUCH PATIENTS SO CHOOSE." 25232 3886 21346 402700 384121 18579 694149 523670 170479 5204 1995 3209 213613 DUE TO/FROM INTERUNIT 204882 204882 X X X X X 0 1 0 0 0 0 0 1 0 LISA SCHANBACHER 61323 61883 0 5595 154 236 6888 7587 8784 9674 77149 84975 0 0 PETER BACHINI 0 155134 0 30744 0 57567 0 20700 0 22205 0 286350 0 0 MICHAEL PACKNETT 0 638622 0 270643 0 2838 0 145546 0 13373 0 1071022 0 0 JEFFREY FRANCIS 0 103936 0 56980 0 45886 0 5960 0 9309 0 222071 0 8835 STANTON RISSER 0 106781 0 31911 0 180 0 7098 0 17716 0 163686 0 0 MARK O'BRIEN 182040 0 20000 0 18018 0 13690 0 24125 0 257873 0 0 0 GREGORY KNISS 153081 0 0 0 2136 0 16223 0 11631 0 183071 0 0 0 CHARLES MASON 0 0 0 0 0 448413 0 0 0 0 0 448413 0 448413 PART I, LINE 4B SUPPLEMENTAL NONQUALIFIED RETIREMENT PLAN PAYMENTS TAXABLE - JEFFREY FRANCIS $8,835; CHARLES MASON $448,413 PARTICIPANTS DEFERRED - PETER BACHINI $20,700; MICHAEL BROWNING $3,835; MICHAEL PACKNETT $133,296; LISA SCHANBACHER $2,655 PART I, LINE 7 MANAGEMENT INCENTIVE COMPENSATION PLAN (MICP) IS AN ANNUAL INCENTIVE PROGRAM. SYSTEM GOALS ARE APPROVED BY THE BOARD IN ADVANCE OF THE PLAN YEAR. AT CONCLUSION OF THE PLAN YEAR, RESULTS ARE SHARED WITH THE BOARD AND THE BOARD APPROVES FINAL PAYMENT. FORM 990, PART VI, SECTION A, LINE 6 THE ORGANIZATION IS ORGANIZED AS A NOT-FOR-PROFIT CORPORATION. PURSUANT TO THE ORGANIZATION'S GOVERNING DOCUMENTS, PARKVIEW HEALTH SYSTEM, INC. EIN 35-1972384 IS THE SOLE MEMBER OF PARKVIEW OCCUPATIONAL HEALTH CENTERS, INC. WITH CERTAIN RESERVED POWERS. FORM 990, PART VI, SECTION A, LINE 7A THE CORPORATE MEMBER, PARKVIEW HEALTH SYSTEM, INC. EIN 35-1972384 SHALL HAVE THE FOLLOWING RESERVED POWERS AS DEFINED IN THE NETWORK AGREEMENT: 1. THE BOARD OF DIRECTORS SHALL BE COMPRISED OF THREE (3) DIRECTORS. EACH DIRECTOR SHALL BE ELECTED BY THE SOLE MEMBER OF THE CORPORATION AT THE ANNUAL MEETING OF THE MEMBERSHIP. 2. THE CONFLICT OF INTEREST POLICY OF THE SOLE MEMBER OF THE CORPORATION, WHICH HAS BEEN APPROVED BY THE SYSTEM-WIDE CORPORATE COMPLIANCE COMMITTEE AND APPROVED BY THE SOLE MEMBER OF THE CORPORATION, SHALL APPLY TO THE CORPORATION. THIS CONFLICT OF INTEREST POLICY CAN ONLY BE AMENDED UPON THE APPROVAL OF THE BOARD OF DIRECTORS OF THE SOLE MEMBER OF THE CORPORATION. 3. IT SHALL BE THE GENERAL RULE THAT THE EMPLOYMENT OF IMMEDIATE FAMILY MEMBERS (MOTHER, FATHER, SISTER, BROTHER, SON, DAUGHTER OR SPOUSE) OF DIRECTORS AND EXECUTIVE MANAGEMENT STAFF SHALL BE PERMITTED AS AUTHORIZED BY THE PERSONNEL POLICIES OF THE CORPORATION AND THE SOLE MEMBER OF THE CORPORATION. FORM 990, PART VI, SECTION A, LINE 7B SEE SCHEDULE O EXPLANATION FOR FORM 990, PART VI, SECTION A, LINE 7A FORM 990, PART VI, SECTION B, LINE 11 PURSUANT TO PARKVIEW HEALTH SYSTEM INC.'S BYLAWS, THE SYSTEM AUDIT COMMITTEE MAY ACT ON BEHALF OF THE CORPORATION TO PROVIDE REVIEW OF THE CORPORATION AND ITS SUBSIDIARY CORPORATIONS' FORM 990 FILINGS. PARKVIEW OCCUPATIONAL HEALTH CENTERS, INC. IS A SUBSIDIARY CORPORATION OF PARKVIEW HEALTH SYSTEM, INC. AN ELECTRONIC COPY OF THE ORGANIZATION'S FINAL FORM 990 (INCLUDING REQUIRED SCHEDULES) WAS PROVIDED TO EACH VOTING MEMBER OF THE ORGANIZATION'S GOVERNING BODY, PRIOR TO FILING WITH THE IRS. ON OCTOBER 12, 2011, THE SYSTEM AUDIT COMMITTEE REVIEWED THE FORM 990 AS ULTIMATELY FILED WITH THE IRS. THIS REVIEW INCLUDED A PRESENTATION BY THE ORGANIZATION'S TAX PREPARER TO HIGHLIGHT THE SIGNIFICANT AREAS ON THE REDESIGNED FORM 990 AND SUPPLEMENTAL SCHEDULES. FORM 990, PART VI, SECTION B, LINE 12C AS DESCRIBED IN ARTICLE IX SECTION 6, OF THE PARKVIEW HEALTH SYSTEM, INC. (PH) BYLAWS, PH ADOPTED PH'S COMPLIANCE POLICY FOR THE ORGANIZATION AND ITS NOT-FOR-PROFIT RELATED ORGANIZATIONS (AND AS LIKEWISE NOTED IN THEIR BYLAWS) WHEN ADDRESSING CONFLICTS OR POTENTIAL CONFLICTS OF INTEREST. THIS COMPLIANCE POLICY (COMPLIANCE POLICY #14) REQUIRES THAT EACH BOARD MEMBER, BOARD COMMITTEE MEMBER, AND KEY MANAGEMENT PERSONNEL MUST ANNUALLY COMPLETE A CONFLICT OF INTEREST FORM. THIS INFORMATION IS PROVIDED TO THE CHAIRMAN OF THE BOARD (FOR BOARD AND BOARD COMMITTEE MEMBERS) AND TO SENIOR MANAGEMENT (FOR KEY MANAGEMENT PERSONNEL). IN ADDITION, AS TO THE CONDUCT OF BOARD MEETINGS, THE FOLLOWING PROCESS IS FOLLOWED: "WHENEVER A PH OR PH AFFILIATE BOARD OR BOARD COMMITTEE IS CONSIDERING A TRANSACTION OR ARRANGEMENT WITH AN ORGANIZATION, ENTITY OR INDIVIDUAL IN WHICH A PERSON COVERED BY THIS POLICY HAS A FINANCIAL OR CONFLICTING INTEREST, THE FOLLOWING SHALL OCCUR: 1. THE INTERESTED PERSON MUST DISCLOSE THE FINANCIAL OR CONFLICTING INTEREST AND ALL MATERIAL FACTS TO THE PH OR PH AFFILIATE BOARD OR BOARD COMMITTEE; 2. THE INTERESTED PERSON WITH THAT FINANCIAL OR CONFLICTING INTEREST MAY MAKE A PRESENTATION AT THE BOARD OR BOARD COMMITTEE MEETING REGARDING THE TRANSACTION OR ARRANGEMENT HOWEVER, HE/SHE SHALL LEAVE THE MEETING DURING THE DISCUSSION OF, AND THE VOTE ON, THE TRANSACTION OR ARRANGEMENT THAT RESULTS IN THE FINANCIAL OR CONFLICTING INTEREST; AND 3. THE PH OR PH AFFILIATE BOARD OR BOARD COMMITTEE MUST APPROVE THE TRANSACTION OR ARRANGEMENT BY A MAJORITY VOTE OF THE BOARD MEMBERS PRESENT AT A MEETING THAT HAS A QUORUM, NOT INCLUDING THE VOTE OF THE INTERESTED PERSON. IN ADDITION, THE FOLLOWING CONSIDERATIONS SHOULD BE MADE: 4. IF APPROPRIATE, THE PH OR PH AFFILIATE BOARD OR BOARD COMMITTEE MAY APPOINT A DISINTERESTED PERSON OR COMMITTEE TO INVESTIGATE ALTERNATIVES TO THE PROPOSED TRANSACTION OR ARRANGEMENT; AND 5. IN ORDER TO APPROVE THE TRANSACTION, THE PH OR PH AFFILIATE BOARD OR BOARD COMMITTEE MUST FIRST FIND, BY A MAJORITY VOTE OF THE DISINTERESTED BOARD MEMBERS, THAT THE PROPOSED TRANSACTION OR ARRANGEMENT IS IN THE BEST INTERESTS OF AND FOR THE BENEFIT OF PH AND/OR PH AFFILIATES AND THE PROPOSED TRANSACTION IS FAIR AND REASONABLE TO PH AND/OR PH AFFILIATES AND, AFTER REASONABLE INVESTIGATION, THAT THE PH AND/OR PH AFFILIATES CANNOT OBTAIN A MORE ADVANTAGEOUS TRANSACTION OR ARRANGEMENT WITH REASONABLE EFFORTS UNDER THE CIRCUMSTANCES." FORM 990, PART VI, SECTION B, LINE 15 THE ORGANIZATION USED A PROCESS FOR DETERMINING COMPENSATION OF THE CEO, OFFICERS, AND KEY EMPLOYEES. THE PROCESS INCLUDES CONSULTATIONS WITH AN INDEPENDENT COMPENSATION ADVISOR; REVIEW, AND APPROVAL BY THE GOVERNING BODY; AND CONTEMPORANEOUS DOCUMENTATION AND RECORDKEEPING WITH RESPECT TO DELIBERATIONS AND DECISIONS REGARDING THE COMPENSATION ARRANGEMENTS. THE BOARD EXECUTIVE COMMITTEE OF PARKVIEW HEALTH SYSTEM, INC. SERVED AS THE EXECUTIVE COMPENSATION COMMITTEE IN 2010, PURSUANT TO THE ORGANIZATION'S BYLAWS, FOR PURPOSES OF REVIEWING AND APPROVING ALL EXECUTIVE COMPENSATION, BENEFITS AND PERQUISITES FOR THE 2010 COMPENSATION PACKAGE. THE COMPENSATION PACKAGE WAS APPROVED BY A MAJORITY OF INDEPENDENT BOARD EXECUTIVE COMMITTEE MEMBERS. PARKVIEW'S INDEPENDENT CONSULTANT PREPARES A COMPETITIVE COMPENSATION ANALYSIS USING DATA FROM MULTIPLE PUBLISHED SURVEYS PREPARED BY INDEPENDENT FIRMS FOR POSITIONS THAT ARE FUNCTIONALLY COMPARABLE IN SIMILAR-SIZED HEALTH SYSTEMS AND HOSPITAL ORGANIZATIONS ON BOTH A REGIONAL AND NATIONAL BASIS. THE INDEPENDENT CONSULTANT PROVIDES A STATEMENT OF REASONABLENESS OF THE COMPENSATION PROVIDED TO THE CEO AS WELL AS ALL EXECUTIVES AT THE VICE PRESIDENT LEVEL AND ABOVE. ALL DATA IS SHARED WITH THE BOARD OF DIRECTORS EXECUTIVE COMMITTEE. THE BOARD APPROVES ANY CHANGES IN COMPENSATION FOR THE CEO AND HIS DIRECT REPORTS. APPROVAL IS ALSO PROVIDED FOR THE MERIT BUDGET FOR THE ENTIRE ORGANIZATION. THE BOARD REVIEWS AND APPROVES THE MANAGEMENT INCENTIVE COMPENSATION PLAN (MICP). OFFICES OR POSITIONS REVIEWED AT THE 2010 MEETING: PRESIDENT AND CEO PH EXECUTIVE VICE PRESIDENT STRATEGIC DIRECTION AND BUSINESS DEVELOPMENT EXECUTIVE VICE PRESIDENT PARKVIEW HEALTH/COO PARKVIEW HOSPITAL EXECUTIVE VICE PRESIDENT AND COO PARKVIEW HEALTH MEDICAL DIRECTOR COMMUNITY HOSPITALS SENIOR VICE PRESIDENT OPERATIONS / SERVICE EXCELLENCE SENIOR VICE PRESIDENT HUMAN RESOURCES SENIOR VICE PRESIDENT AND GENERAL COUNSEL SENIOR VICE PRESIDENT HEALTH PLAN SERVICES SENIOR VICE PRESIDENT PATIENT CARE SENIOR VICE PRESIDENT AND CHIEF QUALITY OFFICER / PATIENT SAFETY OFFICER SENIOR VICE PRESIDENT OPERATIONS SENIOR VICE PRESIDENT AND CHIEF INFORMATION OFFICER SENIOR VICE PRESIDENT/COO ORTHOPEDIC HOSPITAL SENIOR VICE PRESIDENT/COO COMMUNITY HOSPITALS - HUNTINGTON SENIOR VICE PRESIDENT/COO COMMUNITY HOSPITALS - NOBLE SENIOR VICE PRESIDENT/COO COMMUNITY HOSPITALS - WHITLEY SENIOR VICE PRESIDENT/COO COMMUNITY HOSPITALS - LAGRANGE SENIOR VICE PRESIDENT/COO PHYSICIAN PRACTICES SENIOR VICE PRESIDENT AND CHIEF FINANCIAL OFFICER SENIOR VICE PRESIDENT REVENUE CYCLE MANAGEMENT MEDICAL DIRECTOR PARKVIEW PHYSICIAN GROUP SENIOR VICE PRESIDENT FACILITY DESIGN AND OVERSIGHT EXECUTIVE DIRECTOR WOMEN AND CHILDREN'S SERVICES VICE PRESIDENT - PATIENT CARE - NOBLE VICE PRESIDENT - PATIENT CARE - WHITLEY VICE PRESIDENT - PATIENT CARE - LAGRANGE CORPORATE DIRECTOR MARKETING, COMMUNICATIONS, COMMUNITY RELATIONS VICE PRESIDENT/ADMINISTRATOR PRIMARY CARE PRACTICE GROUP EXECUTIVE DIRECTOR CANCER SERVICES VICE PRESIDENT CHANGING SPACES CONSTRUCTION/PROJECT MANAGEMENT MEDICAL DIRECTOR HEALTH PLAN SERVICES CORPORATE DIRECTOR DIETETICS/FOOD SERVICES VICE PRESIDENT PLANNING AND DECISION SUPPORT VICE PRESIDENT STRATEGIC AND BUSINESS PLANNING VICE PRESIDENT HEALTH INFORMATION MANAGEMENT EXECUTIVE DIRECTOR PKV OUTPATIENT ENTERPRISE VICE PRESIDENT/ADMINISTRATOR SPECIALTY PRACTICE GROUP VP SPECIAL PROJECTS VP PPG FINANCE VP SUPPLY CHAIN COO PARKVIEW HEART INSTITUTE FORM 990, PART VI, SECTION C, LINE 19 COPIES OF THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE AVAILABLE UPON REQUEST. COMMON PAYING AGENT FOR FILING ORGANIZATION FORM 990, PART V, LINE 1A, 2A AND PART VII, SECTION B, LINE 2: PARKVIEW HEALTH SYSTEM, INC. (PH), EIN 35-1972384, IS THE COMMON PAYING AGENT FOR THE FILING ORGANIZATION, PARKVIEW OCCUPATIONAL HEALTH CENTERS, INC., EIN 35-2064353. THEREFORE, ALL APPLICABLE IRS TAX FILINGS, INCLUDING FORMS 1099, 1096, W-2 AND W-3 ARE REPORTED AND FILED BY PH. THE TOTAL NUMBER REPORTED IN BOX 3 OF FORM 1096 AND FILED BY THE COMMON PAYING AGENT, PH, FOR THE YEAR ENDED DECEMBER 31, 2010 WAS 510. THE TOTAL NUMBER OF EMPLOYEES REPORTED ON FORM W-3 AND FILED BY THE COMMON PAYING AGENT, PH, FOR THE YEAR ENDED DECEMBER 31, 2010 WAS 7,707. FOR PURPOSES OF COMPLETING FORM 990, PART V, LINE 1A AND 2A, THE NUMBER REPORTED FOR THE PARKVIEW OCCUPATIONAL HEALTH CENTERS, INC. WAS 4 AND 117 RESPECTIVELY. AS REFLECTED IN PART VII, SECTION B, NO INDEPENDENT CONTRACTORS RECEIVED MORE THAN $100,000 IN COMPENSATION FOR SERVICES FROM PARKVIEW OCCUPATIONAL HEALTH CENTERS, INC. AVERAGE HOURS PER WEEK DEVOTED TO RELATED ORGANIZATIONS FORM 990, PART VII, SECTION A, COLUMN B: MICHAEL PACKNETT (PH CEO), MICHAEL BROWNING (CURRENT PH SVP & CFO), JEFFREY FRANCIS (PH SVP & CFO), AND STANTON RISSER (INTERIM PH CFO) DEVOTED APPROXIMATELY 40 HOURS PER WEEK TO PARKVIEW HEALTH SYSTEM, INC. (PH), AND ONE HOUR PER WEEK TO EACH OF THE FOLLOWING TAX-EXEMPT AND TAXABLE ORGANIZATIONS RELATED TO PH: PARKVIEW HOSPITAL, INC. (PVHOS) PARKVIEW OCCUPATIONAL HEALTH CENTERS, INC. (POHCI) - FILING ORGANIZATION HUNTINGTON MEMORIAL HOSPITAL, INC. (HMHOS) COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. (LGHOS) COMMUNITY HOSPITAL OF NOBLE COUNTY, INC. (NBHOS) WHITLEY MEMORIAL HOSPITAL, INC. (WMHOS) PARKVIEW FOUNDATION, INC. (PVFND) PARKVIEW HUNTINGTON HOSPITAL FOUNDATION, INC. (HMFND) COMMUNITY HOSPITAL OF NOBLE COUNTY FOUNDATION, INC. (NBFND) WHITLEY MEMORIAL HOSPITAL FOUNDATION, INC. (WMFND) PARKVIEW PROFESSIONAL PROGRAMS, INC. (PPP) MIDWEST COMMUNITY HEALTH ASSOCIATES, INC. (MCHA) ORTHOPAEDIC HOSPITAL AT PARKVIEW NORTH, LLC (ORTHO) MANAGED CARE SERVICES, LLC (MCS) FOUNDATION SURGERY AFFILIATE OF FORT WAYNE, LLC (ISCLC) PARKVIEW IMAGING HUNTINGTON, LLC (PIHLC) LISA SCHANBACHER (DIRECTOR/POHCI EXECUTIVE DIRECTOR) DEVOTED APPROXIMATELY 20 HOURS PER WEEK TO POHCI AND 20 HOURS PER WEEK TO PH. PETER BACHINI (DIRECTOR-PARTIAL YEAR/PH SVP) DEVOTED APPROXIMATELY ONE HOUR PER WEEK TO POHCI AND 40 HOURS PER WEEK TO PH. MARJORIE HINER (DIRECTOR) DEVOTED APPROXIMATELY ONE HOUR PER WEEK TO POHCI, ONE HOUR PER WEEK TO PH AND ONE HOUR PER WEEK TO HMHOS. DENISE LEMMON (DIRECTOR) DEVOTED APPROXIMATELY ONE HOUR PER WEEK TO POHCI, ONE HOUR PER WEEK TO PH AND ONE HOUR PER WEEK TO NBHOS. SALARIES AND WAGES, OTHER EMPLOYEE BENEFITS AND PAYROLL TAXES FORM 990, PART IX, LINES 5-10: PARKVIEW HEALTH SYSTEM, INC., EIN 35-1972384, SERVES AS THE COMMON PAYING AGENT FOR ALL TAX-EXEMPT ORGANIZATIONS OF THE SYSTEM. SALARIES AND WAGES OF EMPLOYEES WORKING FOR THESE ORGANIZATIONS ARE CHARGED DIRECTLY TO THE ORGANIZATIONS IN WHICH THEY WORK. THE ACTUAL EXPENSES FOR PAYROLL TAXES, EMPLOYEE BENEFITS, AND PENSION PLAN CONTRIBUTIONS ARE REFLECTED ON THE BOOKS OF PARKVIEW HEALTH SYSTEM, INC. FOR FINANCIAL REPORTING PURPOSES. TO ACCOUNT FOR BENEFIT COSTS ON THE BOOKS OF THE OTHER TAX EXEMPT ORGANIZATIONS, AN ALLOCATION METHODOLOGY IS UTILIZED TO CHARGE THESE ORGANIZATIONS WITH AN ESTIMATE OF THE OVERALL COSTS, REFERRED TO AS A "BENEFIT ALLOCATION" FROM PARKVIEW HEALTH SYSTEM, INC. THE ALLOCATION DOES NOT DISTINGUISH BETWEEN THE COSTS OF THE VARIOUS COMPONENTS (I.E. PAYROLL TAXES, EMPLOYEE BENEFITS, AND PENSION PLAN CONTRIBUTIONS). THEREFORE, FOR PURPOSES OF THE FORM 990, PART IX, THE TOTAL BENEFIT ALLOCATION FOR THE EMPLOYEES' SALARIES AND WAGES REPORTED ON LINE 7 IS REFLECTED ON LINE 9 AND NOT ALLOCATED BETWEEN LINES 8 OR 10. FOR PURPOSES OF THE FORM 990, PART IX, LINES 5 AND 6 REFLECT COMPENSATION AND BENEFIT AMOUNTS REPORTED IN PART VII. PARKVIEW HEALTH SYSTEM INC 10501 CORPORATE DRIVE FORT WAYNE IN 46845 351972384 HEALTH CARE IN 501(C)(3) LINE 11C, III-FI N/A 0 PARKVIEW HOSPITAL INC 2200 RANDALLIA DRIVE FORT WAYNE IN 46805 350868085 HOSPITAL CARE IN 501(C)(3) LINE 3 PARKVIEW HEALTH SYSTEM INC 0 COMMUNITY HOSPITAL OF LAGRANGE COUNTY INC 207 N TOWNLINE ROAD LAGRANGE IN 46761 202401676 HOSPITAL CARE IN 501(C)(3) LINE 3 PARKVIEW HEALTH SYSTEM INC 0 COMMUNITY HOSPITAL OF NOBLE COUNTY INC 401 SAWYER ROAD KENDALLVILLE IN 46755 352087092 HOSPITAL CARE IN 501(C)(3) LINE 3 PARKVIEW HEALTH SYSTEM INC 0 WHITLEY MEMORIAL HOSPITAL INC 353 N OAK STREET COLUMBIA CITY IN 46725 351967665 HOSPITAL CARE IN 501(C)(3) LINE 3 PARKVIEW HEALTH SYSTEM INC 0 HUNTINGTON MEMORIAL HOSPITAL INC 2001 STULTS ROAD HUNTINGTON IN 46750 351970706 HOSPITAL CARE IN 501(C)(3) LINE 3 PARKVIEW HEALTH SYSTEM INC 0 0 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0