2021-08-16T10:09:18-05:00 2020-09-30 381357951 PLANTE & MORAN PLLC 10 S RIVERSIDE PLAZA 9TH FLOOR CHICAGO IL 60606 990 2019-10-01 361564290 HUMBOLDT PARK HEALTH HUMB 7732928200 1044 NORTH FRANCISCO AVENUE CHICAGO IL 60622 JAMES PORTER CFO 7732928200 2021-08-11 1 DAVID LOWENTHAL P00378651 3122071040 2021-08-11 2019 2022-09-23 18:48:47Z JOSE R SANCHEZ 1044 NORTH FRANCISCO AVENUE CHICAGO IL 60622 131696040 0 X WWW.HPH.CARE X 1935 IL HUMBOLDT PARK HEALTH PROVIDES QUALITY AND COMPASSIONATE HEALTH CARE SERVICES BY PARTNERING WITH PATIENTS AND THEIR FAMILIES, OUR EMPLOYEES, PHYSICIANS AND THE COMMUNITIES WE SERVE. 12 9 1140 0 0 0 2074533 10327955 114480136 120161689 972544 751260 18120 455136 117545333 131696040 0 0 0 0 67199156 67848432 0 0 0 56931665 60900967 124130821 128749399 -6585488 2946641 100099980 144081504 66877504 109522409 33222476 34559095 X HUMBOLDT PARK HEALTH PROVIDES QUALITY AND COMPASSIONATE HEALTH CARE SERVICES BY PARTNERING WITH PATIENTS AND THEIR FAMILIES, OUR EMPLOYEES, PHYSICIANS AND THE COMMUNITIES WE SERVE. 0 0 88749233 120601070 HUMBOLDT PARK HEALTH (HOSPITAL) IS A PREMIER HEALTH CARE PROVIDER WHERE THE PATIENT COMES FIRST. AS AN ORGANIZATION OF CAREGIVERS, HUMBOLDT PARK HEALTH INSPIRES TO CONSISTENTLY HIGH STANDARDS OF QUALITY, FAMILY-CENTERED HEALTH CARE SERVICES AND COST EFFECTIVENESS. HUMBOLDT PARK HEALTH SEEKS TO PROMOTE WELLNESS WITHIN THE FAMILY AND TO BE DYNAMIC PARTNERS IN HEALTH WITH THE COMMUNITIES IT SERVES. FOR THE FISCAL YEAR ENDED SEPTEMBER 30, 2020, HUMBOLDT PARK HEALTH ESTIMATES IT PROVIDED $5,854,044 IN CHARITY CARE COST FOR HEALTHCARE SERVICES AND SUPPLIES PROVIDED TO MEMBERS OF THE COMMUNITIES SERVED UNDER ITS CHARITY CARE POLICY. THESE MEMBERS DID NOT HAVE THE ABILITY TO PAY FOR SERVICES RECEIVED. HUMBOLDT PARK HEALTH ALSO PROVIDED CARE TO PATIENTS WHO ARE BENEFICIARIES OF MEDICARE, MEDICAID, BLUE CROSS AND MANAGED CARE REIMBURSEMENT PROGRAMS. REIMBURSEMENT AMOUNTS FOR THESE PROGRAMS ARE LESS THAN CHARGES AND IN SOME CASES LESS THAN COST. FOR FISCAL YEAR 2020, HUMBOLDT PARK HEALTH SERVED 5,587 PATIENTS ADMITTED WHO RECEIVED 34,446 DAYS OF HEALTHCARE SERVICES. 88749233 1 1 0 1 0 0 0 0 0 0 1 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 1 1 1 0 0 1 110 0 1 1140 1 0 0 0 0 0 0 0 0 0 0 1 0 X 12 9 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 1 1 IL X JAMES PORTER CFO 7732928200 1044 NORTH FRANCISCO AVENUE CHICAGO IL 60622 JOSE R SANCHEZ PRESIDENT & CEO 40.00 0.00 X 1141258 0 482290 RAMON BARAJAS PHYSICIAN OB/GYN 40.00 0.00 X 493516 0 18971 MAX IZBICKI PHYSICIAN OB/GYN 40.00 0.00 X 466387 0 9069 DAGOBERTO CAMACHO INTERIM CHIEF MEDICAL OFFICER 40.00 0.00 X 410191 0 26390 NATASHA T JENKINS HOSPITALIST OB/GYN 40.00 0.00 X 406977 0 26329 SAMIR N SHAHEN CHIEF HOSPITALIST 40.00 0.00 X 390699 0 14140 QAISER JAMAL CHIEF HOSPITALIST 40.00 0.00 X 366673 0 26400 JAGDEEP SINGH CHIEF MEDICAL OFFICER 40.00 0.00 X 365812 0 19442 MICHELLE Y BLAKELY PHD CHIEF OPERATING OFFICER 40.00 0.00 X 215636 0 6695 GARY KRUGEL CHIEF FINANCIAL OFFICER (THRU 10/19) 40.00 0.00 X 308815 0 13090 ALI KUTOM BOARD TRUSTEE 2.00 0.00 X 151823 0 0 ANGELES VALDES PRESIDENT OF MEDICAL STAFF 2.00 0.00 X 103487 0 0 ANTHONY RAJKUMAR CHIEF OPERATING OFFICER 40.00 0.00 X 57578 0 0 GREGORY PAGLIUZZA JR CHIEF FINANCIAL OFFICER (11/19-4/20) 40.00 0.00 X 26442 0 0 SEAN GALLAGHER CHIEF FINANCIAL OFFICER (03/20-1/21) 40.00 0.00 X 0 0 0 BILLY OCASIO CHAIRMAN 5.00 0.00 X X 0 0 0 WILMI SCHMIDT VICE-CHAIRWOMAN 4.00 0.00 X X 0 0 0 JOHN MONTEVERDE SECRETARY 8.00 0.00 X X 0 0 0 MIGUEL TOVAR TREASURER 8.00 0.00 X X 0 0 0 RICHARD A BLABOLIL BOARD TRUSTEE 2.00 0.00 X 0 0 0 ADAM A BORIS BOARD TRUSTEE 2.00 1.00 X 0 0 0 KEVIN CMUNT BOARD TRUSTEE 4.00 0.00 X 0 0 0 MICHAEL E REED BOARD TRUSTEE 2.00 0.00 X 0 0 0 DAN YUNKER BOARD TRUSTEE 2.00 0.00 X 0 0 0 ANTONIO GUILLEN BOARD TRUSTEE 2.00 0.00 X 0 0 0 4905294 0 642816 147 0 1 0 QUEST DIAGNOSTICS 12989 COLLECTIONS CTR DR CHICAGO IL 60693 LAB SERVICE CONTRACT 4551011 NORTH AMERICAN PARTNERS 68 S SERVICE RD 350 MELVILLE NY 11747 PROFESSIONAL MEDICAL SERVICES 2389023 SODEXO INC & AFFILIATES 4880 PAYSPHERE CIRCLE CHICAGO IL 60674 DIETARY & FACILITIES MANAGEMENT SERVICES 2301872 FH PASCHEN SN NIELSEN & ASSOC 5515 N EAST RIVER RD CHICAGO IL 60656 CONSTRUCTION 1623375 STAFFENCY LLC 221 W COLLEGE AVE 2ND FLR APPLETON WI 54911 NURSING STAFFING AGENCY 1356149 14 979130 9348825 10327955 MEDICARE/MEDICAID PAYMENTS 621110 64927066 64927066 MEDICAID ASSESSMENT REVENUE 621110 37494461 37494461 NET PATIENT SERVICE REVENUE 621110 12146078 12146078 OPERATING REVENUE 621110 3651831 3651831 ACA ACCESS PAYMENTS 621110 1942253 1942253 120161689 751260 751260 455136 0 455136 455136 439381 15755 131696040 120601070 0 767015 X 2476296 2476296 55023004 42521708 12501296 405538 405538 6238975 378550 5860425 3704619 2766957 937662 182699 128 182571 159999 159999 214268 214268 6417 6417 16865813 13732561 3133252 116389 43623 72766 10015825 9944303 71522 5382194 1198993 4183201 10924 763 10161 64915 23934 40981 1625678 1625678 3940032 1724109 2215923 3830384 42820 3787564 IL MEDICAID AND ACA TAX 7710750 7710750 PROVISION FOR BAD DEBT 7041599 7041599 LAUNDRY LINEN CLEANING 578039 578039 LICENSE FEES 428130 257869 170261 2726912 782527 1944385 128749399 88749233 40000166 0 10521590 52940076 7259693 6819855 12704378 11247802 1501372 1900331 1172581 1022622 155489919 117541499 36193068 37948420 19136952 19627925 11610346 12574473 100099980 144081504 19391935 26235826 1500000 9600000 16793138 16365782 9533325 6933321 19659106 50387480 66877504 109522409 X 29418791 30056855 3803685 4502240 33222476 34559095 100099980 144081504 X 2946641 -149485 -1460537 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 1 0 0 0 0 1 190000 0 1 24268 214268 0 PART II-B, LINE 1: HOSPITAL REPRESENTATIVES HAVE DIRECT CONTACT WITH LEGISLATORS, THEIR STAFF, AND OFFICIALS WITHIN THE ADMINISTRATION REGARDING ISSUES RELATED TO THE PROVISION OF HEALTHCARE AND HEALTHCARE FINANCING. HOSPITAL REPRESENTATIVES HAVE ENGAGED IN DIRECT MEETINGS WITH LEGISLATORS, LEGISLATIVE STAFF, AND AGENCY STAFF. THEY HAVE ALSO HAD PHONE CONVERSATIONS AND CORRESPONDED BY EMAIL. WRITTEN COMMUNICATION IN THE FORM OF MEMOS AND LETTERS IS ALSO USED. ADDITIONALLY, A PORTION OF MEMBERSHIP DUES PAID TO THE ILLINOIS HOSPITAL ASSOCIATION AND THE METROPOLITAN HEALTHCARE COUNCIL ARE USED FOR LOBBYING PURPOSES. 0 0 4840913 4840913 79251293 57589234 21662059 3692772 3313586 379186 67704941 56638679 11066262 37948420 BENEFICIAL INTEREST IN NET ASSETS OF FOUNDATION 4402240 DUE FROM AFFILIATES 689157 INSURANCE RECOVERIES RECEIVABLE 4340561 INVESTMENT IN JOINT VENTURE 528480 INVESTMENT IN SUBSIDIARY 114243 OTHER ASSETS 1310346 PROPERTY HELD FOR FUTURE USE 1189446 12574473 ACCRUED MALPRACTICE LIABILITY 14444979 CONDITIONAL ASSET RETIREMENT OBLIGATION 2500682 DUE TO THIRD PARTY PROGRAMS 3140076 ACCRUED WAGES 1425012 PROVIDER RELIEF FUND 28876731 50387480 1 1 1 X 1 X 600.000000000000 1 1 1 0 1 1 5318607 0 5318607 0.04370 60725909 66932210 0 0.00000 66044516 66932210 5318607 0.04370 808967 572300 236667 0.00210 3342663 2027212 1315451 0.01150 4151630 2599512 1552118 0.01360 70196146 69531722 6870725 0.05730 1 7041598 0 17808291 18590571 -782280 X 1 1 1 CENTURY PHO INC TO OBTAIN AND MANAGE CONTRACTS WITH HEALTH MAINTENANCE ORGANIZATIONS. 0.50000 0.00000 0.50000 1 1 HUMBOLDT PARK HEALTH 1044 N FRANCISCO CHICAGO IL 60660 WWW.HPH.CARE X X X X HUMBOLDT PARK HEALTH 0 0 1 X X X X X X X X X 18 1 1 1 1 X TINYURL.COM/23RY2TDE 1 18 1 TINYURL.COM/23RY2TDE 0 1 X 200.000000000000 600.000000000000 X X X X 1 1 X X 1 X TINYURL.COM/YU5WYDV3 X TINYURL.COM/25A82D9T X TINYURL.COM/J4KU4VDJ X X X 1 X 0 X X X X 1 X 0 0 HUMBOLDT PARK HEALTH PART V, SECTION B, LINE 5: THE CHNA COMBINED ROBUST PUBLIC HEALTH DATA, COMMUNITY INPUT, EXISTING RESEARCH, EXISTING PLANS, AND EXISTING ASSESSMENTS TO DOCUMENT THE HEALTH STATUS OF COMMUNITIES WITHIN CHICAGO AND SUBURBAN COOK COUNTY AND TO HIGHLIGHT SYSTEMIC INEQUITIES THAT ARE NEGATIVELY IMPACTING HEALTH.PRIMARY AND SECONDARY DATA FROM A DIVERSE RANGE OF SOURCES WERE UTILIZED FOR ROBUST DATA ANALYSIS AND TO IDENTIFY COMMUNITY HEALTH NEEDS IN CHICAGO AND SUBURBAN COOK COUNTY. THE ILLINOIS PUBLIC HEALTH INSTITUTE (IPHI) WORKED WITH THE CHNA COMMITTEE AND STEERING COMMITTEE TO DESIGN AND FACILITATE A COLLABORATIVE, COMMUNITY-ENGAGED ASSESSMENT. THE CHNA PROCESS WAS ADAPTED FROM THE MOBILIZING FOR ACTION THROUGH PLANNING AND PARTNERSHIPS (MAPP) MODEL, A COMMUNITY-ENGAGED STRATEGIC PLANNING FRAMEWORK THAT WAS DEVELOPED BY THE NATIONAL ASSOCIATION FOR COUNTY AND CITY HEALTH OFFICIALS (NACCHO) AND THE CENTERS FOR DISEASE CONTROL AND PREVENTION (CDC). BOTH THE CHICAGO AND COOK COUNTY DEPARTMENTS OF PUBLIC HEALTH USE THE MAPP FRAMEWORK FOR COMMUNITY HEALTH ASSESSMENT AND PLANNING. THE MAPP FRAMEWORK PROMOTES A SYSTEM FOCUS, EMPHASIZING THE IMPORTANCE OF COMMUNITY ENGAGEMENT, PARTNERSHIP DEVELOPMENT, AND THREE TYPES OF DATA--SECONDARY DATA, COMMUNITY INPUT, AND SYSTEM ANALYSIS. AHE CHOSE THIS INCLUSIVE, COMMUNITY-DRIVEN PROCESS TO LEVERAGE AND ALIGN WITH HEALTH DEPARTMENT ASSESSMENTS AND TO ACTIVELY ENGAGE STAKEHOLDERS, INCLUDING COMMUNITY MEMBERS, IN IDENTIFYING AND ADDRESSING STRATEGIC PRIORITIES TO ADVANCE HEALTH EQUITY. PRIMARY DATA FOR THE CHNA WAS COLLECTED THROUGH FOUR METHODS:1. COMMUNITY INPUT SURVEY2. COMMUNITY RESIDENT FOCUS GROUPS AND LEARNING MAP SESSIONS3. HEALTH CARE AND SOCIAL SERVICE PROVIDER FOCUS GROUPS4. TWO STAKEHOLDER ASSESSMENTS LED BY PARTNER HEALTH DEPARTMENTS: FORCES OF CHANGE ASSESSMENT AND HEALTH EQUITY CAPACITY ASSESSMENT COMMUNITY INPUT SURVEY: THE COMMUNITY INPUT SURVEY WAS DESIGNED TO UNDERSTAND THE COMMUNITY HEALTH NEEDS AND ASSETS FROM COMMUNITY RESIDENTS. THE COMMUNITY INPUT SURVEY, ALONG WITH FOCUS GROUP DATA, INFORMED THE PRIORITY AREAS AND STRATEGIES FOR COMMUNITY HEALTH IMPROVEMENT IN CHICAGO AND SUBURBAN COOK COUNTY.COMMUNITY FOCUS GROUPS:BETWEEN AUGUST 2018 AND FEBRUARY 2019, ALLIANCE FOR HEALTH EQUITY PARTNERS COLLABORATED TO CONDUCT A TOTAL OF 57 FOCUS GROUPS WITH PRIORITY POPULATIONS SUCH AS VETERANS, INDIVIDUALS LIVING WITH MENTAL ILLNESS, COMMUNITIES OF COLOR, OLDER ADULTS, CAREGIVERS, TEENS AND YOUNG ADULTS, LGBTQ+ COMMUNITY MEMBERS, ADULTS AND TEENS EXPERIENCING HOMELESSNESS, FAMILIES WITH CHILDREN, FAITH COMMUNITIES, ADULTS WITH DISABILITIES, AND CHILDREN AND ADULTS LIVING WITH CHRONIC CONDITIONS SUCH AS DIABETES AND ASTHMA. IN ADDITION, THIRTY-SIX FOCUS GROUPS WERE CONDUCTED BY IPHI AND 21 LEARNING MAP SESSIONS WERE LED BY WEST SIDE UNITED WITH NOTETAKING BY IPHI.HEALTH CARE AND SOCIAL SERVICE PROVIDER FOCUS GROUPS:THERE WERE ALSO THREE FOCUS GROUPS WITH HEALTH CARE AND SOCIAL SERVICE PROVIDERS HOSTED BY SWEDISH COVENANT HOSPITAL, MACNEAL HOSPITAL, AND SOUTH SHORE HOSPITAL. FOCUS GROUP FACILITATORS ASKED PARTICIPANTS ABOUT THE UNDERLYING ROOT CAUSES OF HEALTH ISSUES THAT THEY SEE IN THEIR COMMUNITIES AND SPECIFIC STRATEGIES FOR ADDRESSING THOSE HEALTH NEEDS.STAKEHOLDER ASSESSMENTS LEAD BY PARTNER HEALTH DEPARTMENTS:THIS FORCES OF CHANGE ASSESSMENT COLLECTS INFORMATION ON THE TRENDS, FACTORS, AND EVENTS THAT ARE CURRENTLY AFFECTING AND/OR ANTICIPATED TO AFFECT THE PUBLIC HEALTH SYSTEM IN THE NEAR FUTURE (3-5 YEARS). CDPH LED THIS ASSESSMENT IN PARTNERSHIP WITH THEIR PARTNERSHIP FOR A HEALTHY CHICAGO, AND CCDPH. 122 RESPONDENTS REPRESENTING 86 ORGANIZATIONS IN CHICAGO AND SUBURBAN COOK COUNTY RESPONDED TO AN ONLINE SURVEY BETWEEN NOVEMBER 2018 AND JANUARY 2019. THE HEALTH EQUITY CAPACITY ASSESSMENT WAS LED BY CDPH, THE PARTNERSHIP FOR A HEALTHY CHICAGO, CCDPH, AND IPHI. CDPH, CCDPH, AND THE PARTNERSHIP WORKED WITH FACULTY FROM DEPAUL AND UIC SCHOOLS OF PUBLIC HEALTH TO DEVELOP A TOOL TO SCORE THE CAPACITY OF THE PUBLIC HEALTH SYSTEM TO ADVANCE HEALTH EQUITY. THE TOOL CONSISTS OF 5-6 QUESTIONS FOR EACH OF THE TEN ESSENTIAL PUBLIC HEALTH SERVICES RELATING TO FIVE COMPONENTS OF HEALTH EQUITY: COMMUNITY ENGAGEMENT/INVOLVEMENT, ORGANIZATIONAL PROCESSES, POWER/INFLUENCE, STRUCTURAL INEQUITIES, AND FUNDING. ON MARCH 5, 2019, 80 PEOPLE FROM ACROSS CHICAGO AND SUBURBAN COOK COUNTY CAME TOGETHER TO SCORE HOW WELL THE SYSTEM IS FUNCTIONING AROUND HEALTH EQUITY AND TO IDENTIFY CHALLENGES, STRENGTHS, AND OPPORTUNITIES TO MOVE FORWARD. HUMBOLDT PARK HEALTH PART V, SECTION B, LINE 6A: THE ALLIANCE FOR HEALTH EQUITY COMPLETED THE COLLABORATIVE CHNA BETWEEN MARCH 2018 AND MARCH 2019. THE ALLIANCE FOR HEALTH EQUITY IS A COLLABORATIVE OF 37 HOSPITALS WORKING WITH HEALTH DEPARTMENTS AND REGIONAL AND COMMUNITY-BASED ORGANIZATIONS TO IMPROVE HEALTH EQUITY, WELLNESS, AND QUALITY OF LIFE ACROSS CHICAGO AND SUBURBAN COOK COUNTY. A COMPLETE LIST OF COLLABORATING HOSPITALS CAN BE FOUND ON THE ALLIANCE FOR HEALTH EQUITY'S 2019 CHNA FOR CHICAGO AND SUBURBAN COOK COUNTY. HUMBOLDT PARK HEALTH PART V, SECTION B, LINE 6B: THE COLLABORATIVE CHNA WAS CONDUCTED WITH THE FOLLOWING HEALTH DEPARTMENTS AND COMMUNITY ORGANIZATIONS:- CHICAGO DEPARTMENT OF PUBLIC HEALTH- COOK COUNTY DEPARTMENT OF PUBLIC HEALTH AND COOK COUNTY HEALTH- ILLINOIS PUBLIC HEALTH INSTITUTE PART V, SECTION B, LINE 16I: PATIENTS WILL BE INFORMED OF FINANCIAL ASSISTANCE THROUGH VARIOUS METHODS. NOTICES INFORMING PATIENTS OF FINANCIAL ASSISTANCE WILL BE POSTED IN ADMISSION AND REGISTRATION AREAS. IT WILL ALSO BE PROVIDED TO PATIENTS, OR GUARANTORS, IN THEIR ADMISSION PACKET AND IN BILLING STATEMENTS. THIS INFORMATION, AND THE NOTICE POSTED IN HOSPITAL LOCATIONS, WILL BE IN ENGLISH, AND IN ANY OTHER LANGUAGE THAT IS THE PRIMARY LANGUAGE SPOKEN BY AT LEAST 5% OF THE RESIDENTS IN THE SERVICE AREA. TRANSLATIONS IN SPANISH AND POLISH CAN BE OBTAINED BY CALLING THE HOSPITAL'S PATIENT FINANCIAL SERVICES AND ARE CURRENTLY AVAILABLE ON THE HOSPITAL'S WEBSITE: HTTPS://WWW.HPH.CARE/PATIENT-FINANCIAL-SERVICES-3/ PART V, SECTION B, LINE 22D: THE HOSPITAL DETERMINES THE MAXIMUM AMOUNT THAT CAN BE CHARGED TO THE FAP-ELIGIBLE INDIVIDUALS BY CALCULATING THE UNINSURED PATIENT DISCOUNT AMOUNT AND APPLYING IT TO PATIENT ACCOUNT. THE DISCOUNT AMOUNT IS CALCULATED BY SUBTRACTING FROM 100% THE PRODUCT OF THE HOSPITAL'S COST TO CHARGE RATIO (FROM WORKSHEET C PART 1 FROM THE MEDICARE COST REPORT) AND 135% (MEDICARE COST ALLOWED TO CHARGE TO UNINSURED PATIENTS). HUMBOLDT PARK HEALTH'S UNINSURED DISCOUNT FOR FY 2020 IS 62% AS ROUNDED FROM THE CALCULATION AS SHOWN BELOW. 2019 COST TO CHARGE RATIO = 28.03%28.03% X 135% = 37.83%100% - 37.83% = 62.17%THE HOSPITAL PROVIDES A 72% DISCOUNT TO UNINSURED PATIENTS. NOTE, THE 72% UNINSURED DISCOUNT PROVIDED TO OUR PATIENTS EXCEEDS THE MINIMUM REQUIREMENT UNDER ILLINOIS LAW. PART I, LINE 3C: HUMBOLDT PARK HEALTH USES THE FPG TO DETERMINE FREE AND DISCOUNTED CARE. PATIENTS WITH ELIGIBLE ASSETS AND INCOME ABOVE THE 200%, BUT NOT EXCEEDING 600% OF FPG, ADJUSTED FOR FAMILY SIZE, WILL RECEIVE A DISCOUNT ON MEDICALLY NECESSARY SERVICES PROVIDED TO THEM, BASED UPON A SLIDING SCALE ESTABLISHED BY HOSPITAL POLICY. PART I, LINE 7: THE COSTING METHODOLOGY USED TO CALCULATE THE AMOUNTS REPORTED ON LINES 7A AND 7B IS THE COST-TO-CHARGE RATIO DERIVED FROM THE IRS'S SCHEDULE H, WORKSHEET 2 INSTRUCTIONS. HUMBOLDT PARK HEALTH USED ITS INTERNAL ACCOUNTING RECORDS TO CALCULATE THE AMOUNTS REPORTED IN LINES 7E AND 7F.MANAGEMENT DOES NOT CONCUR WITH WORKSHEET 3 INSTRUCTIONS IN REGARDS TO INCLUDING THE PROVIDER TAX EXPENSES IN WITH COLUMN (C) TOTAL COMMUNITY BENEFIT EXPENSE, AS WELL AS INCLUDING THE PROVIDER TAX REVENUE IN COLUMN (D) DIRECT OFFSETTING REVENUE. IF THESE WERE REMOVED FROM THE WORKSHEET 3 CALCULATION, NET COMMUNITY BENEFIT EXPENSE ON LINE 7B, COLUMN (E) WOULD HAVE BEEN $17,409,675 OR 14.65% OF TOTAL EXPENSE. THIS WOULD HAVE INCREASED THE TOTAL NET COMMUNITY BENEFIT EXPENSE ON LINE 7K, COLUMN (E) FROM $664,422 TO $24,280,399 OR 20.43% OF TOTAL EXPENSE. PART I, LINE 7G: HUMBOLDT PARK HEALTH DID NOT INCLUDE ANY COSTS ATTRIBUTABLE TO A PHYSICIAN CLINIC AS SUBSIDIZED HEALTH SERVICES. PART I, LINE 7, COLUMN (F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $ 7,041,598. PART III, LINE 2: THE BAD DEBT EXPENSE REPORTED ON PART III, LINE 2, IS THE BAD DEBT EXPENSE REPORTED ON FORM 990, PART IX. PART III, LINE 3: ALL OF THE HOSPITAL'S PATIENTS AUTOMATICALLY QUALIFY FOR FINANCIAL ASSISTANCE IF THEY DO NOT HAVE INSURANCE (THEY ARE CONSIDERED "SELF-PAY AND GIVEN 72% DISCOUNT). ONCE THE HOSPITAL DETERMINES THAT A PATIENT HAS NO INSURANCE, THEY AUTOMATICALLY DISCOUNT THE BILL BY 72%. SO THERE ARE NO INDIVIDUALS THAT MAY HAVE BEEN ELIGIBLE FOR FINANCIAL ASSISTANCE AND DID NOT RECEIVE ANY. BAD DEBT EXPENSE IS ATTRIBUTABLE TO PATIENTS WITH INSURANCE THAT MAY NOT HAVE PAID THEIR SHARE/CO-PAY OF THE BILL OR ATTRIBUTABLE TO PATIENTS THAT RECEIVED FINANCIAL ASSISTANCE (72% DISCOUNT) BUT DID NOT PAY THEIR 28%. THEREFORE, ZERO HAS BEEN REPORTED IN PART III, LINE 3. PART III, LINE 4: AUDITED FINANCIAL STATEMENTS FOOTNOTE REGARDING BAD DEBT EXPENSE: ACCOUNTS RECEIVABLE FOR PATIENTS, INSURANCE COMPANIES, AND GOVERNMENTAL AGENCIES ARE BASED ON GROSS CHARGES, REDUCED BY EXPLICIT PRICE CONCESSIONS PROVIDED TO THIRD PARTY PAYORS, DISCOUNTS PROVIDED TO QUALIFYING INDIVIDUALS AS PART OF OUR FINANCIAL ASSISTANCE POLICY, AND IMPLICIT PRICE CONCESSIONS PROVIDED PRIMARILY TO SELF-PAY PATIENTS. ESTIMATES FOR EXPLICIT PRICE CONCESSIONS ARE BASED ON PROVIDER CONTRACTS, PAYMENT TERMS FOR RELEVANT PROSPECTIVE PAYMENT SYSTEMS, AND HISTORICAL EXPERIENCE ADJUSTED FOR ECONOMIC CONDITIONS AND OTHER TRENDS AFFECTING THE HOSPITAL'S ABILITY TO COLLECT OUTSTANDING AMOUNTS.FOR RECEIVABLES ASSOCIATED WITH SELF-PAY PATIENTS (WHICH INCLUDES BOTH PATIENTS WITHOUT INSURANCE AND PATIENTS WITH DEDUCTIBLE AND COPAYMENT BALANCES DUE FOR WHICH THIRD-PARTY COVERAGE EXISTS FOR PART OF THE BILL), THE HOSPITAL RECORDS SIGNIFICANT IMPLICIT PRICE CONCESSIONS IN THE PERIOD OF SERVICE ON THE BASIS OF ITS PAST EXPERIENCE, WHICH INDICATES THAT MANY PATIENTS ARE UNABLE OR UNWILLING TO PAY THE PORTION OF THEIR BILL FOR WHICH THEY ARE FINANCIALLY RESPONSIBLE.PART III, LINE 6: MANAGEMENT DOES NOT CONCUR WITH PART III, SECTION B MEDICARE, LINE 6 REPORTING INSTRUCTIONS REGARDING UTILIZING ALLOWABLE COSTS FROM MEDICARE WORKSHEET B. IF MANAGEMENT USED THE ACTUAL AMOUNT OF COSTS TO CARE FOR MEDICARE PATIENTS, ALLOWABLE COSTS WOULD HAVE BEEN REPORTED AS $39,309,740 AND THE AMOUNT OF (SHORTFALL) WOULD HAVE BEEN ($21,501,448). PART III, LINE 8: COSTING METHODOLOGY USED IS THE MEDICARE COST REPORT WHICH UTILIZES A STEP-DOWN METHOD OF COST ALLOCATION. THIS ORDER OF ALLOCATION FOR OVERHEADS HAS BEEN PREDETERMINED BY MEDICARE AND IS PRINTED OUT ON THE COST REPORT. THE MOST COMMON OVERHEAD IS ALLOCATED FIRST TO ALL OTHER OVERHEADS AND THE PATIENT CARE COST CENTERS. THEN THAT COST CENTER IS CLOSED AND THE NEXT MOST COMMON OVERHEAD IS ALLOCATED. THIS IS CONTINUED UNTIL ALL THE OVERHEADS ARE ALLOCATED OUT. THE SEPTEMBER 30, 2020 COST REPORT DID NOT SHOW A SHORTFALL. PART III, LINE 9B: THE COLLECTION POLICIES CONTAIN PROVISIONS ON THE COLLECTIONS PRACTICES TO BE FOLLOWED FOR PATIENTS THAT QUALIFY FOR FINANCIAL ASSISTANCE. SUCH PRACTICES ARE: CHARITY - UPON APPROVAL OF PATIENT'S CHARITY APPLICATION THE COLLECTIONS ARE STOPPED, PATIENT'S BALANCE IS WRITTEN OFF ACCORDINGLY AND PATIENT IS NOTIFIED IN WRITING; UNINSURED PATIENT - UPON DETERMINATION THAT PATIENT HAS NO INSURANCE, 72% DISCOUNT IS APPLIED TO PATIENT ACCOUNT AND PATIENT IS NOTIFIED IN WRITING FOR THE OUTSTANDING BALANCE. PART VI, LINE 2: HUMBOLDT PARK HEALTH'S COMMUNITY BENEFIT PLAN WAS DEVELOPED TO ESTABLISH STRATEGIES FOR IMPROVING ACCESS TO CARE AND POSITIVELY AFFECTING THE HEALTH OF THE COMMUNITIES THAT IT SERVES. ADDITIONALLY, THE PLAN SETS THE COURSE FOR STRENGTHENING EXISTING PARTNERSHIPS AND BUILDING NEW ONES WITH INDIVIDUALS AND ORGANIZATIONS WITHIN HUMBOLDT PARK HEALTH'S PRIMARY SERVICE AREAS IN ORDER TO LEVERAGE AND MAXIMIZE THE IMPACT OF ITS PROGRAMS. DEVELOPMENT OF THE PLAN IS DERIVED THROUGH THE STRATEGIC PLANNING OF HUMBOLDT PARK HEALTH'S BOARD OF TRUSTEES AND THROUGH ORGANIZATIONAL INVOLVEMENT IN COMMUNITY PARTNERSHIPS. THE GOALS DEVELOPED FOR PLANNING COMMUNITY SERVICES INVOLVED MEETING WITH PHYSICIANS AND COMMUNITY PARTNERS TO DETERMINE WHERE THE GAPS OF CARE AND SERVICES COULD BE FILLED THROUGH HUMBOLDT PARK HEALTH INVOLVEMENT. IN DEVELOPING ITS COMMUNITY BENEFITS PLAN, HUMBOLDT PARK HEALTH SET THE FOLLOWING GOALS:1) SERVE AS A CATALYST/CONVENER FOR THE OBESITY AND DIABETES INITIATIVES IN HUMBOLDT PARK.2) PROMOTE INITIATIVES THAT ENHANCE ACCESS TO HEALTH CARE FOR THE UNINSURED AND UNDERINSURED.3) HUMBOLDT PARK HEALTH LEADERSHIP TO ASSUME AN ACTIVE ROLE IN COMMUNITY BASED ORGANIZATIONS BOARDS, TASK FORCES AND COMMUNITY EVENTS. PART VI, LINE 3: HUMBOLDT PARK HEALTH INFORMS AND EDUCATES PATIENTS AND PERSONS, WHO MAY BE BILLED FOR PATIENT CARE, ABOUT THEIR ELIGIBILITY FOR ASSISTANCE UNDER FEDERAL, STATE OR LOCAL GOVERNMENT PROGRAMS OR UNDER THE ORGANIZATION'S CHARITY CARE POLICY ON ITS INTRANET AND THROUGH FLYERS. PATIENTS ARE PROVIDED THESE POLICIES AT THE TIME OF REGISTRATION AND ARE ALSO AVAILABLE UPON REQUEST. PART VI, LINE 4: HUMBOLDT PARK HEALTH SERVES A PRIMARY COMMUNITY AREA AND A SECONDARY COMMUNITY AREA. THE FOLLOWING INFORMATION WAS OBTAINED FROM THE US CENSUS BUREAU, 2010 CENSUS.THE PRIMARY COMMUNITY AREA CONSISTS OF THE FOLLOWING AREAS, ZIP CODES AND POPULATION:- AUSTIN- BELMONT-CRAGIN- HERMOSA- HUMBOLDT PARK- LOGAN SQUARE- WEST TOWN- IRVING PARK- NORTH CENTER- EAST GARFIELD PARK- WEST GARFIELD PARK- NORTH LAWNDALE WHITE HISPANIC AFRICAN-AMERICANPRIMARY ZIP CODES POPULATION - PERCENTAGE 60618 46,754 51% 42,771 46% 2,559 3%60622 33,399 64% 15,289 29% 3,860 7%60624 958 3% 1,160 3% 35,987 94%60639 8,056 9% 68,639 76% 13,712 15%60647 34,357 39% 47,697 55% 5,237 6%60651 2,538 4% 21,756 34% 39,973 62%THE SECONDARY AREA CONSISTS OF THE FOLLOWING AREAS, ZIP CODES AND POPULATION:- ARCHER HEIGHTS- BRIGHTON PARK- CAGE PARK- GARFIELD RIDGE- WEST ELSDON- SOUTH LAWNDALE- PORTAGE PARK- PULLMAN WHITE HISPANIC AFRICAN-AMERICANPRIMARY ZIP CODES POPULATION - PERCENTAGE 60612 8,738 26% 4,319 13% 20,412 61%60623 2,301 2% 59,438 65% 30,369 33%60625 47,050 60% 28,304 36% 3,297 4%60632 12,939 14% 76,902 84% 1,485 2%60641 32,054 45% 38,057 53% 1,552 2%60644 1,506 3% 1,583 3% 45,559 94%60640 44,239 67% 9,923 15% 11,628 18%HUMBOLDT PARK HEALTH'S AGE FOR THE FISCAL YEAR WAS AS FOLLOWS:AGE PERCENTAGE0-14 2%15-44 44%45-64 37%65-74 9%75+ 8%HUMBOLDT PARK HEALTH'S RACE AND ETHNICITY FOR THE FISCAL YEAR WAS AS FOLLOWS:RACE PERCENTAGEASIAN 1%AMERICAN INDIAN OR NATIVE ALASKAN 0%BLACK OR AFRICAN-AMERICAN 43%WHITE 13%OTHER 43%ETHNICITY PERCENTAGEHISPANIC 41%NON-HISPANIC 59% PART VI, LINE 5: IN ADDITION TO PROVIDING QUALITY INPATIENT AND OUTPATIENT SERVICES, HUMBOLDT PARK HEALTH REACHES BEYOND ITS WALLS AND INTO COMMUNITIES THROUGH AN ARRAY OF ACTIVITIES AND PROGRAMS DESIGNED AND DELIVERED TO BENEFIT THE COMMUNITIES IT SERVES. THESE COMMUNITY BENEFITS INCLUDE: - CARE THAT IS PROVIDED FREE, SUBSIDIZED OR WITHOUT FULL REIMBURSEMENT FROM MEDICARE, MEDICAID OR OTHER GOVERNMENT INSURANCE PROGRAMS.- SERVICES RESPONDING TO UNIQUE COMMUNITY NEEDS, SUCH AS DIABETES SERVICES, EMERGENCY CARE, BEHAVIORAL HEALTH SERVICES, SUBSTANCE ABUSE, PEDIATRIC CARE-A-VAN; AS WELL AS HEALTH SCREENINGS, IMMUNIZATION PROGRAMS, SCHOOL-BASED HEALTH CARE AND OTHER COMMUNITY OUTREACH PROGRAMS.- EDUCATION TO TRAIN PHYSICIANS, NURSES, RADIOLOGY TECHNICIANS, AND OTHER HIGHLY SKILLED HEALTH CARE PROFESSIONALS.- VOLUNTEER SERVICES PROVIDED BY HOSPITAL EMPLOYEES WHO VOLUNTEER IN THEIR COMMUNITIES AND COMMUNITY MEMBERS WHO VOLUNTEER AT THE HOSPITAL. IN FYE 2018, THE HOSPITAL CONTRIBUTED TO HURRICANE MARIA RELIEF EFFORTS BY SENDING PHYSICIANS AND NURSES TO PUERTO RICO TO DIRECTLY ASSIST WITH CARE. ADDITIONALLY, EMPLOYEES CONTRIBUTED THEIR PTO AND THE HOSPITAL FOUNDATION CONTRIBUTED MONETARILY.- LANGUAGE-ASSISTANCE SERVICES, SUCH AS TRANSLATORS, SIGNAGE, FORMS, BROCHURES, PATIENT EDUCATION MATERIALS AND OTHER INFORMATION IN LANGUAGES OTHER THAN ENGLISH.- DONATIONS BY HUMBOLDT PARK HEALTH OF MEETING AND CLINIC SPACE, AS WELL AS OTHER ASSISTANCE TO COMMUNITY GROUPS. PART VI, LINE 6: HUMBOLDT PARK HEALTH IS NOT PART OF AN AFFILIATED HEALTHCARE SYSTEM. PART VI, LINE 7, REPORTS FILED WITH STATES IL X 1 1 X X 0 1 0 0 0 0 0 1 0 JOSE R SANCHEZ PRESIDENT & CEO 695758 0 423000 0 22500 0 479050 0 3240 0 1623548 0 0 0 RAMON BARAJAS PHYSICIAN OB/GYN 493165 0 0 0 351 0 5600 0 13371 0 512487 0 0 0 MAX IZBICKI PHYSICIAN OB/GYN 466214 0 0 0 173 0 0 0 9069 0 475456 0 0 0 DAGOBERTO CAMACHO INTERIM CHIEF MEDICAL OFFICER 410022 0 0 0 169 0 5600 0 20790 0 436581 0 0 0 NATASHA T JENKINS HOSPITALIST OB/GYN 381798 0 25000 0 179 0 5600 0 20729 0 433306 0 0 0 SAMIR N SHAHEN CHIEF HOSPITALIST 335594 0 54976 0 129 0 0 0 14140 0 404839 0 0 0 QAISER JAMAL CHIEF HOSPITALIST 350261 0 15976 0 436 0 5600 0 20800 0 393073 0 0 0 JAGDEEP SINGH CHIEF MEDICAL OFFICER 355308 0 10000 0 504 0 0 0 19442 0 385254 0 0 0 MICHELLE Y BLAKELY PHD CHIEF OPERATING OFFICER 214811 0 0 0 825 0 0 0 6695 0 222331 0 0 0 GARY KRUGEL CHIEF FINANCIAL OFFICER (THRU 10/19) 292162 0 15000 0 1653 0 0 0 13090 0 321905 0 0 0 ALI KUTOM BOARD TRUSTEE 151823 0 0 0 0 0 0 0 0 0 151823 0 0 0 PART I, LINE 1A HPH PAYS MEMBERSHIP DUES ON BEHALF OF JOSE R. SANCHEZ, PRESIDENT AND CEO, TO A SOCIAL CLUB. THE MEMBERSHIP IS USED EXCLUSIVELY FOR BUSINESS PURPOSES. PART I, LINE 4B JOSE R. SANCHEZ, PRESIDENT AND CEO, PARTICIPATED IN A SUPPLEMENTAL NONQUALIFIED RETIREMENT PLAN. THERE WERE NO DISTRIBUTIONS FROM THE PLAN IN CALENDAR YEAR 2019. PART I, LINE 7 AS INDICATED IN SCHEDULE J, PART II, SEVERAL OFFICERS AND HIGHEST COMPENSATED EMPLOYEES OF THE ORGANIZATION RECEIVED A BONUS BASED ON PERFORMANCE AND THE FINANCIAL RESULTS OF THE ORGANIZATION. THE BONUSES WERE APPROVED BY THE EXECUTIVE COMMITTEE OF THE BOARD. A ILLINOIS FINANCE AUTHORITY REVENUE BONDS SERIES 2008 861091967 45200FMS5 2008-08-15 5000000 SEE PART VI 0 0 0 B ILLINOIS FINANCE AUTHORITY REVENUE BONDS SERIES 2008 861091967 45200FMT3 2008-08-15 14450000 SEE PART VI 0 0 0 A 1920000 5000000 798334 1159612 157619 2884435 2008 1 0 1 1 B 785000 14450000 798333 1159612 157620 12334436 2008 1 0 1 1 A 0 0 0 0 0 0 1 B 0 0 0 0 0 0 1 A 0 0 0 0 0 0 0 0 0 B 0 0 0 0 0 0 0 0 0 A 0 B 0 SCHEDULE K SUPPLENTAL INFORMATION THE SERIES 2008 BOND PROCEEDS, TOGETHER WITH OTHER AVAILABLE FUNDS, WERE USED TO REFUND THE OUTSTANDING PRINCIPAL AMOUNTS OF CERTAIN BONDS IN THE AMOUNT OF $3,467,000, TO PAY OR REIMBURSE THE HOSPITAL FOR THE PAYMENT OF THE COST OF ACQUIRING, CONSTRUCTING AND EQUIPPING CERTAIN OF THE HOSPITAL'S HEALTH CARE FACILITIES, TO FUND A DEBT SERVICE RESERVE FUND FOR THE BENEFIT OF THE SERIES 2008 BONDS, AND TO PAY CERTAIN EXPENSES INCURRED IN CONNECTION WITH THE ISSUANCE OF THE SERIES 2008 BONDS. ST JOHN HEART CLINIC SC 100% CONTROLLED ENTITY OF TRUSTEE 173823 THE HOSPITAL PAID ST. JOHN HEART CLINIC S.C. FOR MEDICAL SERVICES. TRUSTEE JOHN MONTEVERDE OWNS 100% OF ST. JOHN HEART CLINIC. 0 FORM 990, PART VI, SECTION B, LINE 11B THE BOARD RETAINS THE SERVICES OF AN INDEPENDENT CPA FIRM TO PREPARE THE ORGANIZATION'S FORM 990. MEMBERS OF THE FISCAL SERVICES DEPARTMENT, THE CHIEF FINANCIAL OFFICER AND THE CHIEF EXECUTIVE OFFICER REVIEW THE COMPLETED FORM 990 AND PROVIDE A FULL COPY TO ALL MEMBERS OF THE FINANCE & AUDIT COMMITTEE. AFTER FORM 990 IS REVIEWED AND ACCEPTED BY THE FINANCE & AUDIT COMMITTEE, A COPY IS MADE AVAILABLE TO ALL VOTING MEMBERS OF THE GOVERNING BODY PRIOR TO FILING. THE GOVERNING BODY IS PROVIDED A REASONABLE AMOUNT OF TIME TO REVIEW THE RETURN AND ASK ANY QUESTIONS DIRECTLY TO ORGANIZATION MANAGEMENT OR THE CONTACT AT THE INDEPENDENT CPA FIRM PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C ALL TRUSTEES, OFFICERS, AND KEY EMPLOYEES AND KEY PHYSICIANS (AS DEFINED IN THE BOARD'S CONFLICT OF INTEREST POLICY) OF THE CORPORATION ARE SUBJECT TO THE CONFLICT OF INTEREST POLICY. IN ADDITION, ALL INDEPENDENT CONTRACTORS WHO PROVIDE SERVICES AND/OR MATERIALS TO THE CORPORATION IN EXCHANGE FOR $20,000 OR MORE IN PAYMENT DURING ANY FISCAL YEAR SHALL BE SUBJECT TO THESE PROVISIONS. ALL PERSONS SUBJECT HERETO SHALL BE HEREINAFTER REFERRED TO AS "COVERED PERSONS." THE CHIEF EXECUTIVE OFFICER OF THE CORPORATION IS RESPONSIBLE FOR PUBLICIZING THE PROVISIONS OF THIS ARTICLE TO THE PERSONS AFFECTED THEREBY. NO PERSON SHALL BECOME A TRUSTEE, OFFICER, OR EMPLOYEE OR MEDICAL DEPARTMENT DIRECTOR OF THE CORPORATION WITHOUT FIRST ACKNOWLEDGING IN WRITING TO THE CORPORATION THAT HE OR SHE HAS REVIEWED, FULLY UNDERSTANDS AND IS IN COMPLIANCE WITH THE PROVISIONS OF THE CONFLICT OF INTEREST POLICY. ALL COVERED PERSONS SHALL PROMPTLY DISCLOSE TO THE BOARD OF TRUSTEES OF THE CORPORATION ALL SUBSTANTIVE POTENTIAL CONFLICTS OF INTEREST WHICH SUCH PERSON DISCOVERS OR WHICH IS BROUGHT TO HIS OR HER ATTENTION. SUCH DISCLOSURE SHALL INCLUDE SUBMISSION TO THE BOARD OF A WRITTEN STATEMENT OF THE FACTS SURROUNDING THE CONFLICT OF INTEREST AND AN OPPORTUNITY TO MAKE A BRIEF ORAL STATEMENT TO THE BOARD WITH RESPECT TO THE MATTER IN QUESTION. AN ANNUAL DISCLOSURE STATEMENT SHALL BE CIRCULATED TO ALL COVERED PERSONS TO ASSIST THEM IN CONSIDERING SUCH DISCLOSURES. IN ADDITION, THE POLICY IS MONITORED PERIODICALLY THROUGHOUT THE YEAR FOR ANY CONFLICTS OF INTEREST. PROMPT DISCLOSURE NOTICES OF CONFLICT SHALL BE FILED WITH THE PRESIDENT OF THE CORPORATION OR ANY OTHER PERSON DESIGNATED BY HIM FROM TIME TO TIME TO RECEIVE SUCH NOTIFICATIONS. ALL DISCLOSURE NOTICES RECEIVED HEREUNDER SHALL BE NOTED FOR RECORD IN THE MINUTES OF A MEETING OF THE BOARD OF TRUSTEES. THE PRESENCE OF THE TRUSTEE WHO IS DIRECTLY OR INDIRECTLY A PARTY TO THE TRANSACTION IN QUESTION OR A TRUSTEE WHO IS OTHERWISE NOT DISINTERESTED MAY BE COUNTED IN DETERMINING WHETHER A QUORUM IS PRESENT FOR THE PURPOSE OF THE MEETING, BUT SHALL NOT BE PRESENT OR HAVE A VOTE WHEN THE BOARD OF TRUSTEES OR A COMMITTEE OF THE BOARD DISCUSSES AND TAKES ACTION ON THE TRANSACTION. FORM 990, PART VI, SECTION B, LINE 15 THE COMPENSATION OF THE CHIEF EXECUTIVE OFFICER, CHIEF OPERATING OFFICER/VICE PRESIDENT MEDICAL AFFAIRS AND CHIEF FINANCIAL OFFICER WERE REVIEWED BY AN EXTERNAL ORGANIZATION SPECIALIZING IN COMPENSATION MANAGEMENT. A COMPENSATION ANALYSIS IS PERFORMED EVERY THREE YEARS BY AN INDEPENDANT CONSULTING FIRM. THE RESULTS OF THAT REVIEW ARE DOCUMENTED IN WRITING AND PROVIDED TO THE EXECUTIVE COMMITTEE OF THE BOARD OF TRUSTEES. FORM 990, PART VI, SECTION C, LINE 19 HUMBOLDT PARK HEALTH MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART IX, LINE 11G PURCHASED MEDICAL PROCEDURES: PROGRAM SERVICE EXPENSES 3,346,495. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 3,346,495. PROFESSIONAL MEDICAL AND NON-MEDICAL SERVICES: PROGRAM SERVICE EXPENSES 10,386,066. MANAGEMENT AND GENERAL EXPENSES 3,133,252. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 13,519,318. FORM 990, PART XI, LINE 9: CHANGE IN NET ASSETS OF JOINT VENTURES -200,557. CHANGE IN MARK TO MARKET SWAP -61,081. CHANGE IN NET ASSETS OF HPH FOUNDATION 698,557. PENSION RELATED CHANGES, OTHER THAN NET PERIOD PENSION COST -1,721,578. OTHER PENSION COSTS -175,878. HUMBOLDT PARK HEALTH FOUNDATION 1044 NORTH FRANCISCO AVENUE CHICAGO IL 60622 363257131 SUPPORTING FOUNDATION IL 501(C)(3) LINE 12A, I HUMBOLDT PARK HEALTH 1 HUMBOLDT PARK HEALTH COMMUNITY PHARMACY 1044 NORTH FRANCISCO AVENUE CHICAGO IL 60622 363394548 OUTPATIENT PHARMACY IL HUMBOLDT PARK HEALTH C 174110 487994 1.00000 1 1 0 1 0 0 0 0 0 0 1 0 0 0 1 1 0 0 0 0 HUMBOLDT PARK HEALTH COMMUNITY PHARMACY A 9772 BOOK VALUE HUMBOLDT PARK HEALTH FOUNDATION A 4000 BOOK VALUE HUMBOLDT PARK HEALTH FOUNDATION C 979130 BOOK VALUE