2018-05-14T12:00:31-05:00 2017-06-30 930623286 ALDRICH CPAS AND ADVISORS LLP 680 HAWTHORNE AVE SE 140 SALEM OR 97301 990 2016-07-01 930579722 SALEM HEALTH SALE 5038141938 890 OAK STREET SALEM OR 97301 JAMES PARR CFO 5038141938 2018-05-07 1 JOYLYN M ANKENEY CPA P00366587 5035857774 2018-05-07 2016 2022-09-23 18:48:47Z JAMES PARR 890 OAK STREET SALEM OR 97301 772378081 0 X WWW.SALEMHEALTH.ORG X 1970 OR TO IMPROVE THE HEALTH AND WELL BEING OF THE PEOPLE IN THE COMMUNITIES WE SERVE. 11 9 5102 514 2927275 182086 1078718 1293735 541672117 749790070 27090113 9717236 271919 3395065 570112867 764196106 359286 804612 0 0 276554506 386294442 0 0 0 235467985 316577436 512381777 703676490 57731090 60519616 1128037416 1211931939 416109738 391556988 711927678 820374951 TO IMPROVE THE HEALTH AND WELL-BEING OF THE PEOPLE AND COMMUNITIES WE SERVE. 0 0 126863753 348513552 SALEM HEALTH IS ONE OF THE LARGEST OF OREGON'S 59 ACUTE CARE HOSPITALS AND OPERATES THE BUSIEST EMERGENCY DEPARTMENT IN OREGON. THERE ARE 467 PRACTITIONERS, REPRESENTING 54 DIFFERENT SPECIALTIES. MORE THAN 514 VOLUNTEERS PROVIDE NON-MEDICAL SUPPORT FOR THE HOSPITAL.STATISTICS FOR THE 12 MONTH PERIOD ENDED 6/30/17: BIRTHS - 3,498, DIAGNOSTIC IMAGING PROCEDURES - 188,318, ED VISITS - 111,041, INPATIENT ADMISSIONS - 25,907, LABORATORY PROCEDURES - 1,369,633, SURGERIES - 13,378. THE PRIMARY SERVICE AREA IS MARION AND POLK COUNTIES WITH APPROXIMATELY 500,000 RESIDENTS. 473154181 386909587 SALEM HEALTH PROVIDES HEALTHCARE TO PEOPLE IN OUR COMMUNITY REGARDLESS OF THEIR ABILITY TO PAY. IN THE 12 MONTH PERIOD ENDED 6/30/17, THE COST OF SERVICES PROVIDED AS A COMMUNITY BENEFIT TOTALED $86.3 MILLION. THIS FIGURE CONSISTED OF $8.4 MILLION IN COSTS TO PROVIDE CHARITY CARE TO INDIVIDUALS WHO CANNOT AFFORD TO PAY; $39.1 MILLION IN UNDERPAYMENT BY MEDICAID AS THE AMOUNT PAID WAS LESS THAN THE COST TO PROVIDE THE SERVICES; AND $38.8 MILLION IN UNDERPAYMENT BY MEDICARE AS THE AMOUNT PAID WAS LESS THAN THE COST TO PROVIDE THE SERVICES. SALEM HEALTH DOES NOT PURSUE LEGAL ACTION FOR NON-PAYMENT OF BILLS AGAINST CHARITY CARE PATIENTS WHO HAVE DEMONSTRATED THAT THEY HAVE NEITHER SUFFICIENT INCOME NOR ASSETS TO MEET THEIR FINANCIAL OBLIGATIONS. 33253399 804612 16083680 SALEM HEALTH ACTIVELY PARTICIPATES IN COMMUNITY HEALTH IMPROVEMENT SERVICES. IN THE 12 MONTH PERIOD ENDED 6/30/17, SALEM HEALTH GAVE $11.9 MILLION FOR UNFUNDED OR UNDERFUNDED HEALTH SERVICES, INCLUDING IMPROVING ACCESS TO CARE THROUGH PHYSICIAN RECRUITING, COMMUNITY HEALTH EDUCATION AND PREVENTION PROGRAMS. THE HOSPITAL HAS AN ACTIVE SPEAKERS BUREAU PROVIDING FREE HEALTH LECTURES TO COMMUNITY GROUPS. HEALTH SCREENINGS, SUPPORT GROUPS AND EDUCATION CLASSES ARE OFFERED ON AN ON-GOING BASIS. IN FY 2017, SALEM HEALTH PROVIDED MORE THAN $1 MILLION IN CASH AND IN-KIND DONATIONS TO COMMUNITY HEALTH PROGRAMS SUCH AS MEDASSIST AND PROJECT ACCESS, PSYCHIATRIC CRISIS CENTER AND THE SALEM FREE CLINIC. 633271333 1 1 0 1 0 0 0 0 0 1 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 1 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 1 364 0 1 5102 1 1 1 0 0 0 0 0 0 0 0 0 X 11 9 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 OR X X SALEM HEALTH 5038141938 890 OAK STREET SE SALEM OR 97301 BONNIE DRIGGERS RN CHAIR 5.00 X X 0 0 0 KATHERINE L KEENE VICE CHAIR 4.25 X X 0 0 0 ALAN WYNN SECRETARY/TREASURER 5.25 X X 0 0 0 THERESA HASKINS TRUSTEE 3.50 X 0 0 0 KENNETH SHERMAN JR TRUSTEE 7.00 X 0 0 0 ROB KELLY MD TRUSTEE 5.00 X 0 0 0 LANE SHETTERLY TRUSTEE 7.00 X 0 0 0 ROBERT WELLS PAST-CHAIR 5.25 X 0 0 0 NANCY REYES-MOLYNEUX MD TRUSTEE 5.25 X 0 0 0 JOHN COMBES MD TRUSTEE 5.25 X 0 0 0 JOHN LATTIMER TRUSTEE 5.00 X 0 0 0 CHERYL NESTER WOLFE PRESIDENT AND CEO 30.00 10.00 X 730298 0 72614 JAMES PARR CHIEF FINANCIAL OFFICER 32.00 8.00 X 439053 0 81331 RALPH YATES CMO SALEM HEALTH AND SHMG 40.00 0.00 X 446271 0 70572 LAURIE BARR VP HUMAN RESOURCES 30.00 10.00 X 383267 0 75754 SARAH HORN CHIEF NURSING OFFICER 40.00 X 331092 0 73369 LEAH MITCHELL CIO - EFF 9/4/16 39.00 1.00 X 407289 0 61586 LORI JAMES-NIELSEN TERM 31717 SEE SCHEDULE J 10.00 30.00 X 376301 0 80661 ANDREW FURMAN VP MEDICAL AFFAIRS 40.00 0.00 X 366489 0 58718 BAHAA WANLY CHIEF OPERATING OFFICER 40.00 0.00 X 304241 0 63057 DENISE HOOVER VP SURGICAL SERVICES 40.00 X 205916 0 47789 SHEA CORUM VP IT OPERATIONS - EFF 10/16/16 40.00 X 156059 0 41808 LEILANI SLAMA VP COMMUNITY ENGAGEMENT 20.00 20.00 X 151389 0 41623 NORMAN GRUBER SEE SCHEDULE J - TERM 7/3/16 0.00 40.00 X 2254133 0 468570 JUAN OYARZUN - EFF 21917 DIRECTOR OF CARDIOTHORACIC MEDICINE 40.00 X 1240266 0 81273 JASWINDER KAUR ADULT HOSPITALIST PHYSICIAN 40.00 X 525447 0 53298 NERVIN FANOUS CARDIOTHORACIC SURGEON 40.00 X 782854 0 53274 NICOLE VANDERHEYDEN MD TRAUMA DIR/ ASSOC CMO SHMG 40.00 X 752460 0 89729 JAMES SAPIENZA FMR CAO OF SHWV 0.00 40.00 X 286100 0 17022 10138925 0 1532048 605 1 1 0 OHSU PO BOX 3595 PORTLAND OR 97208 CONTRACT LABOR 3057544 PEACEHEALTH LABORATORIES PO BOX 77003 SPRINGFIELD OR 97475 LABORATORY SERVICES 2460555 EPIC SYSTEMS CORP PO BOX 88314 MILWAUKEE WI 532880314 CONSULTING SERVICES 2326463 SALEM PULMONARY ASSOCIATES PC 801 MISSION ST SE SALEM OR 97302 CONTRACT LABOR 1643056 OREGON ANETHESIOLOGY GROUP 707 SW WASHINGTON ST SUITE 700 PORTLAND OR 972053536 CONTRACT LABOR 1518561 107 903927 389808 1293735 NET PATIENT REVENUE 621110 726998852 726998852 OTHER HOSPITAL SERVICES 900099 15103846 15013584 90262 PHARMACY 446110 6152630 4694113 1458517 REGIONAL LAB 621500 1512285 159518 1352767 NUTRITION SERVICES 722210 22457 22457 749790070 15719764 15719764 586854 1835813 -1248959 -1248959 -1248959 343634 6346162 -6002528 -6002528 -6002528 PASSTHROUGH INCOME 541900 4644024 4618295 25729 4644024 764196106 751506819 2927275 8468277 662342 662342 142270 142270 5215656 5215656 297475961 270260113 27215848 62520249 56278307 6241942 21082576 18850078 2232498 5601814 672477 4929337 1851961 108323 1743638 451375 412411 38964 89400 89400 26742895 23080556 3662339 157746 11543 146203 6751117 4028676 2722441 10464451 3967053 6497398 13278084 10677687 2600397 1096712 630116 466596 1240158 814753 425405 11351523 11351523 43574869 43574869 4244066 4244066 PATIENT SUPPLIES 102652141 102138345 513796 BAD DEBTS 36727074 36727074 PROVIDER TAX 34966256 34966256 OTHER PURCHASED SERVICE 10192133 8493337 1698796 5143661 1179158 3964503 703676490 633271333 70405157 0 612061 477445 2822703 5008688 76207991 86887594 1412894 545456 6493822 6386043 6277236 7051916 923453263 449075768 475097628 474377495 515710038 589144876 16176021 18742130 27227022 23310296 1128037416 1211931939 88404120 79929240 0 27940 296414854 284804178 295192 231968 30995572 26563662 416109738 391556988 X 708582568 817795213 3345110 2579738 711927678 820374951 1128037416 1211931939 X 60519616 43498493 4429164 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 135334 135334 703541156 703676490 1000000 250000 0 0 1000000 1000000 1000000 1000000 4000000 6000000 121166 173324 97242 135334 527066 250000 250000 250000 250000 1000000 1500000 SCHEDULE C, PART II-A SALEM HEALTH CONTRACTED WITH PUBLIC AFFAIRS COUNSEL TO KEEP THE HOSPITAL APPRISED OF BILLS IN THE STATE LEGISLATURE AND TO ENGAGE THE LEGISLATORS ON BEHALF OF THE HOSPITAL WHEN NECESSARY TO PROVIDE INFORMATION TO LEGISLATORS REGARDING THE IMPACT OF LEGISLATION ON THE HOSPITAL. ADDITIONALLY, THE HOSPITAL PAYS MEMBERSHIP DUES TO OAHHS AND AHA. A PORTION OF THE DUES TO THESE ORGANIZATIONS IS ALLOCATED TO LOBBYING ACTIVITY IN RELATION TO STATE AND NATIONAL HEALTHCARE ISSUES. 3345110 378374 -201146 937381 2584957 2619320 683999 655272 613481 3345110 2560192 318689 -66873 192688 2619320 2073328 674913 154704 342753 2560192 2120674 160956 379362 587664 2073328 1.00000 0 1 1 11668774 23124460 34793234 13495102 590851274 248566417 355779959 965187 274347490 200509351 74803326 9000976 9000976 474377495 FAIR VALUE INTEREST RATE SWAP AGREEMENT 12873617 ACCRUED POST RETIREMENT HEALTHCARE BENEFITS 4716526 ACCRUED MALPRACTICE INSURANCE 4027567 ESTIMATED LIABILITY TO MEDICARE 2070420 DUE TO SALEM HEALTH HOSPITALS & CLINICS 2759285 OTHER LONG-TERM LIABILITIES 116247 26563662 X 822516954 43498493 14822355 58320848 764196106 0 764196106 712089463 8868311 8868311 703221152 455338 455338 703676490 PART V, LINE 4: ENDOWMENT FUNDS ARE HELD BY SALEM HEALTH FOUNDATION FOR SALEM HEALTH SUPPORT. PART X, LINE 2: UNCERTAIN TAX POSITIONS FROM THE NOTES TO CONSOLIDATED FINANCIAL STATEMENTS ISSUED FOR SALEM HEALTH AND RELATED COMPANIES: THE CORPORATION (SALEM HEALTH HOSPITALS & CLINICS), SALEM HEALTH, SALEM HEALTH WEST VALLEY, SHF, WVHF, SHPS, AND WVIC ARE TAX-EXEMPT ORGANIZATIONS PURSUANT TO INTERNAL REVENUE CODE (IRC) SECTION 501(C)(3). AS SUCH, ONLY UNRELATED BUSINESS INCOME IS SUBJECT TO FEDERAL OR STATE INCOME TAXES. THE CORPORATION ACCOUNTS FOR UNCERTAINTY IN INCOME TAXES IN ACCORDANCE WITH FASB ASC 740-10, INCOME TAXES-IMPLEMENTATION GUIDANCE ON ACCOUNTING FOR UNCERTAINTY IN INCOME TAXES AND DISCLOSURE AMENDMENTS FOR NONPUBLIC ENTITIES. MANAGEMENT HAS NOT RECORDED A PROVISION AS UNRELATED BUSINESS INCOME, IF ANY, IS IMMATERIAL TO THE CONSOLIDATED FINANCIAL STATEMENTS. ACCOUNTING PRINCIPLES GENERALLY ACCEPTED IN THE UNITED STATES OF AMERICA REQUIRE THE CORPORATION TO EVALUATE TAX POSITIONS TAKEN BY THE CORPORATION AND RECOGNIZE A TAX LIABILITY (OR ASSET) IF THE CORPORATION HAS TAKEN AN UNCERTAIN POSITION THAT MORE LIKELY THAN NOT WOULD NOT BE SUSTAINED UPON EXAMINATION BY THE IRS. MANAGEMENT HAS ANALYZED TAX POSITIONS TAKEN BY THE CORPORATION AND HAS CONCLUDED THAT AS OF JUNE 30,2016 THERE ARE NO UNCERTAIN POSITIONS TAKEN OR EXPECTED TO BE TAKEN THAT WOULD REQUIRE RECOGNITION OF A LIABILITY (OR ASSET) OR DISCLOSURE IN THE CONSOLIDATED FINANCIAL STATEMENTS. THE CORPORATION IS SUBJECT TO ROUTINE AUDITS BY TAXING JURISDICTIONS; HOWEVER THERE ARE CURRENTLY NO AUDITS FOR ANY TAX PERIODS IN PROGRESS. THE CORPORATION MANAGEMENT BELIEVES IT IS NO LONGER SUBJECT TO INCOME TAX EXAMINATIONS FOR YEARS PRIOR TO FISCAL YEAR 2011. PART XI, LINE 2D - OTHER ADJUSTMENTS: REVENUE NETTED WITH EXPENSES 3,444,590. EXPENSE NETTED WITH REVENUE 11,377,765. PART XI, LINE 4B - OTHER ADJUSTMENTS: OTHER RELATED ORGANIZATION REVENUE NOT INCLUDED ON FINANCIAL STATEMENTS PART XII, LINE 2D - OTHER ADJUSTMENTS: REVENUE NETTED WITH EXPENSES 3,444,591. EXPENSES NETTED WITH REVENUE 11,377,765. CUMULATIVE EFFECT OF ADOPTION OF FAIR VALUE OPTION -5,954,045. PART XII, LINE 4B - OTHER ADJUSTMENTS: CHANGE IN BENEFICIAL INTEREST IN FOUNDATION -765,371. CHANGE IN POSTRETIREMENT BENEFIT OBLIGATION 1,220,709. 1 1 X 1 X 300.000000000000 1 X 1 1 1 0 1 1 31560 8372306 8372306 0.01260 153759 168081378 129011833 39069545 0.05860 185319 176453684 129011833 47441851 0.07120 123044 2733332 59865 2673467 0.00400 509 1366183 1366183 0.00200 28165597 16023815 12141782 0.01820 234061 234061 0.00040 23112 1021494 1021494 0.00150 146665 33520667 16083680 17436987 0.02610 331984 209974351 145095513 64878838 0.09730 213424 213424 0.00030 8047 8047 0.00000 22918 22918 0.00000 2724917 2724917 0.00410 2969306 2969306 0.00440 0 36727074 18314682 103595961 114046368 -10450407 X 1 1 1 1 SALEM HEALTH 890 OAK STREET SE SALEM OR 97301 14-1428 X X X SALEM HEALTH 1 0 0 1 X X X X X X X X X 15 1 1 1 1 X WWW.SALEMHEALTH.ORG X X 1 15 1 WWW.SALEMHEALTH.ORG/ABOUT/COMMUNITY/COMMUNITY-HEALTH-NEEDS-ASSESSMENT 0 1 X 300.000000000000 400.000000000000 X X X X X X 1 1 X X X X 1 X HTTP://WWW.SALEMHEALTH.ORG/ABOUT/CHARITY-CARE-AND-FINANCIAL-POLICY X HTTP://WWW.SALEMHEALTH.ORG/ABOUT/CHARITY-CARE-AND-FINANCIAL-POLICY X HTTP://WWW.SALEMHEALTH.ORG/ABOUT/CHARITY-CARE-AND-FINANCIAL-POLICY X X X X X X 1 X 0 X 1 X 0 0 SALEM HEALTH PART V, SECTION B, LINE 3J: A COMPREHENSIVE NEEDS ASSESSMENT WAS CONDUCTED IN TAX YEAR 2015. THE NEEDS ASSESSMENT DESCRIBES THE COMMUNITY SERVED BY THE HOSPITAL AND THE DEMOGRAPHICS OF THE COMMUNITY. THE MARION AND POLK COUNTY HEALTH CARE SYSTEM CAPACITY AND ACCESS ASSESSMENT CONTAINS HEALTH CARE FACILITY AND RESOURCE INFORMATION. THE CAPACITY AND ACCESS ASSESSMENT IS UPDATED ANNUALLY. THE LATEST CHNA AND HEALTH CARE SYSTEM CAPACITY AND ACCESS ASSESSMENTS ARE PUBLISHED TO THE SALEM HEALTH WEBSITE AT WWW.SALEMHEALTH.ORG. THE NATIONAL MODEL, MOBILIZATION FOR ACTION THROUGH PLANNING AND PARTNERSHIPS OR MAPP WAS USED AS THE FRAMEWORK FOR THE COMMUNITY HEALTH ASSESSMENT. THE FOUR ASSESSMENTS OF THE MAPP FRAMEWORK INCLUDE: COMMUNITY THEMES AND STRENGTHS, LOCAL PUBLIC HEALTH SYSTEM ASSESSMENT, COMMUNITY HEALTH STATUS ASSESSMENT AND THE FORCES OF CHANGE ASSESSMENT.THE COMMUNITY THEMES AND STRENGTHS ASSESSMENT WAS CONDUCTED BY SURVEYING COMMUNITY PARTNERS WORKING IN SOCIAL, HEALTH, COMMUNITY, EDUCATIONAL AND CORRECTIONAL HEALTH SETTINGS AND THE COMMUNITY-AT-LARGE. THE SURVEYS USED IN BOTH MARION AND POLK COUNTIES CONSISTED OF THE SAME QUESTIONS AND USED THE 2011 MARION COUNTY SURVEY AS A TEMPLATE. PAPER AND ELECTRONIC SURVEYS WERE ALLOCATED BASED ON POPULATION DISTRIBUTION THROUGHOUT OUR COMMUNITIES. THE COMMUNITY HEALTH STATUS ASSESSMENT WAS CONDUCTED BY COMPILING DATA FROM NATIONAL SURVEILLANCE SYSTEMS LIKE THE BEHAVIOR RISK FACTOR SURVEILLANCE SURVEY AND OREGON HEALTHY TEENS AS WELL AS STATE AND LOCAL DATA FROM BIRTH AND DEATH CERTIFICATES. IN ADDITION, AS SERIES OF COMMUNITY CAFES WERE CONDUCTED ACROSS MARION AND POLK COUNTY TO IDENTIFY HEALTH PRIORITIES.SALEM HEALTH HOSTED COMMUNITY CAFES AND REPRESENTATIVES FROM MARION AND POLK COUNTY PUBLIC HEALTH, PRESENTED CHNA FINDINGS TO THE SALEM HEALTH COMMUNITY BENEFIT COMMITTEE OF THE BOARD OF TRUSTEES IN NOVEMBER 2015. THE MARION AND POLK COUNTY HEALTH REPORTS WAS PUBLISHED IN DECEMBER 2015 AND CAN BE FOUND ON THE SALEM HEALTH WEBSITE. WWW.SALEMHEALTH.ORG. THE DOCUMENT INFORMED THE DEVELOPMENT OF THE COMMUNITY BENEFIT IMPLEMENTATION STRATEGY FOR REPORTING YEARS 2015 - 2017, ALSO AVAILABLE ON THE WEBSITE.THE IMPACT OF ACTIONS TAKEN TO ADDRESS THE SIGNIFICANT HEALTH NEEDS IDENTIFIED IN THE HOSPITAL FACILITIES PRIOR CHNAS CAN BE FOUND ON THE COMMUNITY HEALTH IMPROVEMENT PARTNERS (CHIP) ANNUALLY REPORT. THE CHIP IS COORDINATED BY THE MARION COUNTY PUBLIC HEALTH DEPARTMENT AND IS PUBLISHED ON THEIR WEBPAGE AT HTTP://WWW.CO.MARION.OR.US/HLT/CHIP/PAGES/DEFAULT.ASPX. SALEM HEALTH PART V, SECTION B, LINE 5: THE NATIONAL MODEL, MOBILIZATION FOR ACTION THROUGH PLANNING AND PARTNERSHIPS OR MAPP AS THE FRAMEWORK FOR THE COMMUNITY HEALTH ASSESSMENT. THE FOUR ASSESSMENTS OF THE MAPP FRAMEWORK INCLUDE: COMMUNITY THEMES AND STRENGTHS, LOCAL PUBLIC HEALTH SYSTEM ASSESSMENT, COMMUNITY HEALTH STATUS ASSESSMENT AND THE FORCES OF CHANGE ASSESSMENT.THE COMMUNITY THEMES AND STRENGTHS ASSESSMENT WAS CONDUCTED BY SURVEYING COMMUNITY PARTNERS WORKING IN SOCIAL, HEALTH, COMMUNITY, EDUCATIONAL AND CORRECTIONAL HEALTH SETTINGS AND THE COMMUNITY-AT-LARGE. THE SURVEYS USED IN BOTH MARION AND POLK COUNTIES CONSISTED OF THE SAME QUESTIONS AND USED THE 2011 MARION COUNTY SURVEY AS A TEMPLATE. PAPER AND ELECTRONIC SURVEYS WERE ALLOCATED BASED ON POPULATION DISTRIBUTION THROUGHOUT OUR COMMUNITIES. THE COMMUNITY HEALTH STATUS ASSESSMENT WAS CONDUCTED BY COMPILING DATA FROM NATIONAL SURVEILLANCE SYSTEMS LIKE THE BEHAVIOR RISK FACTOR SURVEILLANCE SURVEY AND OREGON HEALTHY TEENS AS WELL AS STATE AND LOCAL DATA FROM BIRTH AND DEATH CERTIFICATES. IN ADDITION, A SERIES OF COMMUNITY CAFES WERE CONDUCTED ACROSS MARION AND POLK COUNTY TO IDENTIFY HEALTH PRIORITIES.SALEM HEALTH HOSTED COMMUNITY CAFES AND REPRESENTATIVES FROM MARION AND POLK COUNTY PUBLIC HEALTH, PRESENTED CHNA FINDINGS TO THE SALEM HEALTH COMMUNITY BENEFIT COMMITTEE OF THE BOARD OF TRUSTEES IN NOVEMBER 2015. SALEM HEALTH PART V, SECTION B, LINE 6A: THE HOSPITAL FACILITY'S CHNA WAS CONDUCTED WITH SANTIAM HOSPITAL AND LEGACY HEALTH. SALEM HEALTH PART V, SECTION B, LINE 6B: THE HOSPITAL FACILITY'S CHNA WAS CONDUCTED WITH COMMUNITY ACTION AGENCY, THE EARLY LEARNING HUB, INC, MARION COUNTY HEALTH DEPARTMENT, POLK COUNTY HEALTH DEPARTMENT, OREGON STATE UNIVERSITY, COOPERATIVE EXTENSION, UNITED WAY, WVP HEALTH AUTHORITY, AND WILLAMETTE VALLEY COMMUNITY HEALTH. SALEM HEALTH PART V, SECTION B, LINE 7D: THE HOSPITAL MADE THE CHNA WIDELY AVAILABLE TO THE COMMUNITY. ALL PARTNERS DESCRIBED IN SECTION B, LINE 6B WERE PROVIDED WITH EXECUTIVE SUMMARY DOCUMENTS FOR DISTRIBUTION TO COMMUNITY MEMBERS FREE OF CHARGE. THE FULL ASSESSMENT ARE POSTED TO HOSPITAL AND COUNTY WEBSITES. SALEM HEALTH PART V, SECTION B, LINE 2: THE HOSPITAL WAS NOT ACQUIRED OR PLACED INTO SERVICE AS A TAX-EXEMPT HOSPITAL IN THE CURRENT TAX YEAR OR THE IMMEDIATELY PRECEDING TAX YEAR 2016. SALEM HEALTH PART V, SECTION B, LINE 11: PRIORITY AREAS ADDRESSED IN THE 2015 ASSESSMENT INCLUDE: EARLY PRENATAL CARE, DEPRESSION SCREENING, OBESITY AND TOBACCO USE.SALEM HEALTH IS AN ACTIVE MEMBER OF THE COMMUNITY HEALTH IMPROVEMENT PARTNERSHIP AND HAS REPRESENTATION ON THE PRENATAL CARE TASK FORCE ADDRESSING EARLY PRENATAL CARE. BABIES BORN TO MOTHERS WHO DO NOT RECEIVE PRENATAL CARE ARE THREE TIMES MORE LIKELY TO HAVE A LOW BIRTH WEIGHT AND FIVE TIMES MORE LIKELY TO DIE THAN THOSE BORN TO MOTHERS WHO DO GET CARE. EARLY PRENATAL CARE (I.E. CARE IN THE FIRST TRIMESTER OF A PREGNANCY) ALLOWS WOMEN AND THEIR HEALTH CARE PROVIDERS TO IDENTIFY AND, WHEN POSSIBLE, TREAT OR CORRECT HEALTH PROBLEMS AND HEALTH-COMPROMISING BEHAVIORS THAT CAN BE PARTICULARLY DAMAGING DURING THE INITIAL STAGES OF FETAL DEVELOPMENT. INCREASING THE NUMBER OF WOMEN WHO RECEIVE PRENATAL CARE, AND WHO DO SO EARLY IN THEIR PREGNANCIES, CAN IMPROVE BIRTH OUTCOMES AND LOWER HEALTH CARE COSTS BY REDUCING THE LIKELIHOOD OF COMPLICATIONS DURING PREGNANCY AND CHILDBIRTH.THE HEALTHY PEOPLE 2020 NATIONAL HEALTH TARGET IS TO INCREASE THE PROPORTION OF PREGNANT WOMEN WHO RECEIVE PRENATAL CARE IN THE FIRST TRIMESTER TO 77.9%. MARION COUNTY RATES ARE 75.1% AND POLK COUNTY MEETS THE TARGET AT 79.7%. TEEN AND LATINO MOTHERS DO NOT SEEK OR HAVE ACCESS TO EARLY PRENATAL CARE AT THE SAME RATES AS OLDER MOTHERS AND THOSE THAT IDENTIFY AS NON-HISPANIC, WHITE. TO ADDRESS THIS HEALTH PRIORITY, SALEM HEALTH COLLABORATES WITH THE SALEM KEIZER SCHOOL DISTRICT'S PROGRAM AT CHEMEKETA FOR PREGNANT AND PARENTING TEENS TO PROVIDE TEACHERS ON CHILDBIRTH TOPICS AND ALSO PROVIDE PRIVATE TOURS FOR THE TEENS THROUGH THEIR INSTRUCTOR. WE ATTEND HEALTH FAIRS AT CHEMEKETA FOR THIS GROUP A COUPLE OF TIMES A YEAR AND INCLUDE CAR SEAT DEMO AND INFORMATION. THE HOSPITAL COORDINATING OUTREACH TO TEENS. WE PUT OUT THE BROCHURES FOR THE OREGON MOTHERSCARE PROGRAM IN COOPERATION WITH THE MARION CO. HEALTH DEPT. THE HOSPITAL PROMOTES OREGON MOTHERSCARE. THE BOOT CAMP FOR NEW DADS REACHES THE TEEN DADS. WE POST ALL THESE CLASSES ON THE EARLY LEARNING HUB WEBSITE AND ALL THE AGENCIES ARE USING THIS WEB CALENDAR TO HELP PROMOTE THE CLASSES IN THE COMMUNITY. ADULT OBESITY RATES IN BOTH MARION AND POLK COUNTIES REMAIN ABOVE STATE AND NATIONAL AVERAGES AND ABOVE THE HP2020 GOAL OF 30.5%. LATEST RATES IN MARION COUNTY ARE REPORTED AT 32.7% AND POLK COUNTY 31.4%. SALEM HEALTH CONTINUES TO FOCUS ON OBESITY PREVENTION EFFORTS THROUGH HEALTH OUTREACH AND EDUCATION, SUPPORT OF PARTNERING AGENCIES WITH A SHARED GOAL TO DECREASE ADULT OBESITY, MEDICAL PROVIDER BMI SCREENING AND COMMUNITY HEALTH EDUCATION CENTER PROGRAMMING FOCUSING ON HEALTH PROMOTION AND PREVENTION OF CHRONIC DISEASE. OBESITY IS A PRIORITY FOR THE COMMUNITY HEALTH IMPROVEMENT PARTNERSHIP (CHIP). THE MARION COUNTY PUBLIC HEALTH DEPARTMENT CONVENES COMMUNITY STAKEHOLDER TO ADDRESS OBESITY USING A LOGIC MODEL AND COLLECTIVE IMPACT FRAMEWORK. PARTNERS ADDRESSING OBESITY SUBMIT ANNUAL ACTIVITIES AND REPORT RESULTS. SALEM HEALTH, AND OTHER COMMUNITY PARTNER'S COLLECTIVE IMPACT WORK, IS PUBLISHED ANNUALLY ON THE MARION COUNTY PUBLIC HEALTH WEBPAGE, CHIP REPORT.PSYCHOLOGICAL DISTRESS CAN AFFECT ALL ASPECTS OF OUR LIVES. OCCASIONAL DOWN DAYS ARE NORMAL, BUT PERSISTENT MENTAL/EMOTIONAL HEALTH PROBLEMS SHOULD BE EVALUATED AND TREATED BY A QUALIFIED PROFESSIONAL. FOR THIS REASON, SALEM HEALTH PROVIDES DEPRESSION SCREENING IN INPATIENT AND EMERGENCY ROOM SETTINGS. PRIMARY CARE CLINICS CONDUCT THE PHQ 9 AND THE COMMUNITY HEALTH EDUCATION CENTER ADDED THE PHQ2 TO SCREENING TO COMMUNITY HEALTH SCREENING PROGRAMS. MARION COUNTY RESIDENTS ON AVERAGE EXPERIENCE 4.1 POOR MENTAL HEALTH DAYS PER MONTH AND POLK COUNTY RESIDENTS ON AVERAGE EXPERIENCE 4.4 POOR MENTAL HEALTH DAYS PER MONTH, BOTH COUNTIES HAVE HIGHER THAN THE US AVERAGE VALUE OF 3.7 DAYS .TOBACCO IS THE AGENT MOST RESPONSIBLE FOR AVOIDABLE ILLNESS AND DEATH IN AMERICA TODAY. ACCORDING TO THE CENTERS FOR DISEASE CONTROL AND PREVENTION, TOBACCO USE BRINGS PREMATURE DEATH TO ALMOST HALF A MILLION AMERICANS EACH YEAR, AND IT CONTRIBUTES TO PROFOUND DISABILITY AND PAIN IN MANY OTHERS. THE WORLD HEALTH ORGANIZATION STATES THAT APPROXIMATELY ONE-THIRD OF ALL TOBACCO USERS IN THIS COUNTRY WILL DIE PREMATURELY BECAUSE OF THEIR DEPENDENCE ON TOBACCO. MARION AND POLK COUNTIES HAVE SEEN A SIGNIFICANT INCREASE IN TOBACCO USE FROM 2010 TO 2013. WITH A HIGH SMOKING PREVALENCE THERE IS ALSO A GREATER EXPOSURE TO SECONDHAND SMOKE FOR NON-SMOKERS, WHICH CAN CAUSE OR EXACERBATE A WIDE RANGE OF ADVERSE HEALTH EFFECTS SUCH AS CANCER, RESPIRATORY INFECTIONS, AND ASTHMA.THE HEALTHY PEOPLE 2020 NATIONAL HEALTH TARGET IS TO REDUCE THE PROPORTION OF ADULTS AGED 18 YEARS AND OLDER WHO SMOKE CIGARETTES TO 12.0%. LATEST POLK COUNTY DATA SHOWS A RATE OF 16.4% AND MARION COUNTY HAS 19% OF ITS RESIDENTS REPORTING TOBACCO USE. SALEM HEALTH IS A SMOKE FREE CAMPUS AND HAS WORK WITH CITY PLANNERS TO EXPAND SMOKE FREE ZONES TO NEIGHBORING SIDEWALKS AND CITY PARKS. THE HOSPITAL SCREENS 100% OF PATIENTS FOR TOBACCO USE AND PROVIDES ALL TOBACCO USERS WITH COMMUNITY CESSATION RESOURCE INFORMATION. THE AMERICAN LUNG ASSOCIATION, FREEDOM FROM SMOKING CURRICULUM IS OFFERED AT THE SALEM HEALTH COMMUNITY HEALTH EDUCATION CENTER AND THE HEALTH EDUCATION AND OUTREACH TEAM PROVIDES COMMUNITY BASED EDUCATION TO SCHOOLS RELATED TO TOBACCO PREVENTION. SALEM HEALTH PART V, SECTION B, LINE 13B: SALEM HEALTH FINANCIAL MATRIX IS BASED ON INCOME AS A PERCENT OF FEDERAL POVERTY LEVEL. SALEM HEALTH PART V, SECTION B, LINE 13H: CRITERIA CONSIDERED IN DETERMINING ELIGIBILITY INCLUDE, BUT ARE NOT LIMITED TO: 1. THE HOUSEHOLD'S GROSS INCOME. 2. HOUSEHOLD'S ASSETS OTHER THAN PRIMARY RESIDENCE -EQUITY IN A REAL ESTATE (OTHER THAN THE PATIENT/GUARANTOR'S PRIMARY RESIDENCE), SECURITIES OR OTHER ASSETS ARE CONSIDERED AVAILABLE TO PAY THE PATIENT'S MEDICAL EXPENSES AND SHOULD BE INCLUDED IN THE INCOME CALCULATION -THE INCOME FROM INCOME-PRODUCING REAL PROPERTY SHOULD BE USED IN THE CALCULATION RATHER THAN THE EQUITY. -INDIVIDUAL RETIREMENT ACCOUNTS (IRAS) OR OTHER RETIREMENT FUNDS WILL NOT BE INCLUDED IN HOUSEHOLD ASSETS; HOWEVER DISTRIBUTIONS FROM THOSE FUNDS WILL BE CONSIDERED INCOME. 3. FAMILY SIZE (PERSONS LEGALLY RESPONSIBLE FOR THE PATIENT BILL AND THEIR DEPENDENTS) 4. THE FAMILY'S MONTHLY OUT OF POCKET EXPENSES FOR MEDICAL SUPPLIES AND SERVICES. 5. ELIGIBILITY MAY BE CONTINGENT UPON PATIENT COOPERATION WITH THE APPLICATION PROCESS. *THE DEFINITION OF 'HOUSEHOLD'S GROSS INCOME' INCLUDES THE COMBINED GROSS MONTHLY INCOME OF ALL PERSONS LEGALLY RESPONSIBLE FOR PATIENT BILL OR BALANCE. HOUSEHOLD INCOMES UP TO 400% OF THE ANNUAL FEDERAL POVERTY GUIDELINES (FPG) WILL BE ELIGIBLE FOR FINANCIAL ASSISTANCE AS OUTLINED BELOW AND IN THE FPG FINANCIAL MATRIX: FINANCIAL MATRIX INCOME AS A PERCENTAGE OF FEDERAL POVERTY LEVEL PERCENTAGE DISCOUNT 0-300% 100% 301-400% 65% ALL OTHER UNINSURED SEE OTHER SELF-PAY DISCOUNT POLICY SALEM HEALTH PART V, SECTION B, LINE 15E: SUPPORTING DOCUMENTATION MAY INCLUDE THE FOLLOWING: PATIENT MUST PROVIDE TWO OF THE FOLLOWING DOCUMENTS TO SUPPORT THE INCOME CLAIMS ON THE APPLICATION. -THREE MONTHS INCOME VERIFICATION IN THE FORM OF PAY STUBS, BANK DEPOSITS, ETC. -SOCIAL SECURITY DETERMINATION LETTERS. -THE PRIOR YEAR'S TAX RETURNS OR 4506T-EZ -A "BASIC NEEDS" LETTER THAT INDICATES HOW PERSONS WITH NO INCOME ARE MEETING THEIR DAY TO DAY BASIC LIVING NEEDS. BASIC NEEDS" LETTER MUST ONLY BE CONSIDERED A SECONDARY SUPPORTING DOCUMENT AFTER THE FINANCIAL COUNSELOR OR CLERK VALIDATES THE INFORMATION. AS OUTLINED IN SALEM HEALTH'S CONDITION OF ADMISSION, A CREDIT BUREAU REPORT OR A CHARITY SCORING VENDOR MAY BE REQUESTED TO VALIDATE INFORMATION PROVIDED ON THE FINANCIAL ASSISTANCE APPLICATION. SALEM HEALTH MAY ACCEPT INFORMATION PROVIDED ON AN OHP APPLICATION, OHP ELIGIBILITY, PROBATE ESTATES DETERMINATION, DOCUMENTATION OF HOMELESS STATUS, OR RELIABLE THIRD PARTY CREDIT INFORMATION AS A SUBSTITUTE FOR THE FINANCIAL FORMS. OHP INFORMATION WILL BE CONSIDERED VALID 30 DAYS PRIOR TO ADMISSION AND 90 DAYS POST DISCHARGE. APPROVED SOURCES OF DOCUMENTATION FOR HOMELESS STATUS INCLUDE CHART NOTES, DISCHARGE PLANS, OR DISCHARGE SUMMARIES ENTERED INTO OUR HEALTH INFORMATION SYSTEM BY CARE PROVIDERS OR THE PATIENT INDICATING THEY ARE HOMELESS DURING THE REGISTRATION PROCESS. FINANCIAL ASSISTANCE GRANTED BASED ON THIRD PARTY INFORMATION RATHER THAN A FINANCIAL ASSISTANCE APPLICATION DOES NOT EXTEND TO FUTURE DATES OF SERVICE AND WOULD NEED TO BE REEVALUATED BASED ON INFORMATION AVAILABLE AT THAT TIME. APPLICATION PROCESS & ELIGIBILITY DETERMINATION A REQUEST FOR FINANCIAL ASSISTANCE MAY BE MADE BEFORE, DURING, OR AFTER THE PROVISION OF CARE. THE HOSPITAL HAS DEVELOPED AN APPLICATION PROCESS FOR DETERMINING INITIAL INTEREST IN AND QUALIFICATION FOR FINANCIAL ASSISTANCE. REQUESTS FOR FINANCIAL ASSISTANCE WILL BE ACCEPTED FROM THE PATIENT DIRECTLY, OR OTHERS ON THE PATIENT'S BEHALF. THIS COULD INCLUDE BUT IS NOT LIMITED TO, THE PATIENT'S REPRESENTATIVE, OR HOSPITAL STAFF. -FINANCIAL ASSISTANCE POLICY, PLAIN LANGUAGE SUMMARY AND APPLICATIONS MAY BE DOWNLOADED FROM OUR WEBSITE: HTTP://WWW.SALEMHEALTH.ORG/ABOUT/CHARITY-CARE-AND-FINANCIAL-POLICY -PAPER COPIES OF THE FINANCIAL ASSISTANCE POLICY, PLAIN LANGUAGE SUMMARY AND APPLICATIONS ARE AVAILABLE IN THE EMERGENCY DEPARTMENT, IN REGISTRATION AREAS AND AT PATIENT FINANCIAL SERVICES, 550 HAWTHORNE AVE SE, SUITE 200, SALEM OR 97301 -PAPER COPIES OF THE FINANCIAL ASSISTANCE POLICY, PLAIN LANGUAGE SUMMARY AND APPLICATIONS MAY BE REQUESTED BY MAIL FROM: FINANCIAL COUNSELING, SALEM HEALTH, PO BOX 14001, SALEM OR 97309-9976 OR VIA TELEPHONE BY CALLING 503-562-4357 SALEM HEALTH PART V, SECTION B, LINE 16J: INFORMATION ON THE HOSPITAL'S FINANCIAL ASSISTANCE IS BE MADE PUBLICLY AVAILABLE FREE OF CHARGE IN THE FOLLOWING MANNER: 1. NOTICES ARE POSTED IN KEY AREAS OF THE HOSPITAL, INCLUDING ADMITTING, THE EMERGENCY DEPARTMENT, OUTPATIENT DEPARTMENT REGISTRATION AREAS, AND PATIENT FINANCIAL SERVICES. 2. THE CONDITIONS OF ADMISSION FORM INFORMS THE PATIENT OF THEIR RIGHT TO APPLY FOR FINANCIAL ASSISTANCE. 3. WRITTEN INFORMATION IS AVAILABLE IN ENGLISH, SPANISH, RUSSIAN AND VIETNAMESE. THE HOSPITAL WILL PROVIDE THE APPROPRIATE INTERPRETATION SERVICES FOR PATIENTS/GUARANTORS WHO DO NOT SPEAK ENGLISH. 4. FRONT-LINE STAFF ARE TRAINED TO ANSWER FINANCIAL ASSISTANCE QUESTIONS EFFECTIVELY AND WILL DIRECT ANY THAT CANNOT BE ANSWERED TO FINANCIAL COUNSELOR'S IN A TIMELY MANNER. 5. THIS POLICY IS POSTED ON SALEM HEALTH'S WEB SITE. WRITTEN INFORMATION ABOUT THIS POLICY WILL BE MADE AVAILABLE UPON REQUEST. 6. ALL PATIENT BILLING STATEMENTS INCLUDES A NOTICE THAT FINANCIAL ASSISTANCE IS AVAILABLE AND CONTACT INFORMATION IF THEY WANT TO LEARN MORE. SALEM HEALTH PART V, SECTION B, LINE 18E: IT IS THE POLICY OF SALEM HEALTH TO PURSUE COLLECTION OF PATIENT BALANCES FROM PATIENTS WHO HAVE THE ABILITY TO PAY FOR SERVICES. SALEM HEALTH MAKES REASONABLE EFFORTS TO IDENTIFY PATIENTS WHO MAY BE ELIGIBLE FOR FINANCIAL ASSISTANCE. COLLECTION PROCEDURES ARE APPLIED CONSISTENTLY AND FAIRLY FOR ALL PATIENTS REGARDLESS OF INSURANCE STATUS. ALL COLLECTION PROCEDURES WILL COMPLY WITH APPLICABLE LAWS AND WITH SALEM HEALTH'S MISSION. FOR THOSE PATIENTS UNABLE TO PAY ALL OR A PORTION OF THEIR OPEN BALANCES, THE FINANCIAL ASSISTANCE POLICY WILL BE FOLLOWED. COLLECTION AGENCIES AND/OR LAW FIRMS MAY BE ENLISTED AFTER REASONABLE COLLECTION AND PAYMENT OPTIONS HAVE BEEN EXHAUSTED. AGENCIES MAY HELP RESOLVE ACCOUNTS WHERE PATIENTS ARE UNCOOPERATIVE IN MAKING PAYMENTS, HAVE NOT MADE APPROPRIATE PAYMENTS, OR HAVE BEEN UNWILLING TO PROVIDE REASONABLE FINANCIAL AND OTHER DATA TO SUPPORT THEIR REQUEST FOR FINANCIAL ASSISTANCE. COLLECTION AGENCY AND LAW FIRM STAFF WILL UPHOLD THE CONFIDENTIALITY AND INDIVIDUAL DIGNITY OF EACH PATIENT. ALL AGENCIES AND LAW FIRMS WILL COMPLY WITH ALL APPLICABLE LAWS INCLUDING HIPAA REQUIREMENTS FOR HANDLING PROTECTED HEALTH INFORMATION. SALEM HEALTH PART V, SECTION B, LINE 19E: SALEM HEALTH WILL NOTIFY INDIVIDUALS THAT FINANCIAL ASSISTANCE IS AVAILABLE TO ELIGIBLE INDIVIDUALS AT LEAST 30 DAYS PRIOR TO PURSUING EXTRAORDINARY COLLECTIONS ACTIONS (EAC) AS TO OBTAIN PAYMENT FOR THE CARE PROVIDED BY THE HOSPITAL. ECAS FOR HOSPITAL SERVICES WILL NOT COMMENCE FOR A PERIOD OF AT LEAST 240 DAYS AFTER THE DATE OF THE FIRST POST-DISCHARGE BILLING STATEMENT AND 30 DAYS AFTER THE HOSPITAL OR AUTHORIZED THIRD PARTY PROVIDES WRITTEN NOTICE OF ECAS THE HOSPITAL PLANS TO INITIATE FOR THE APPLICABLE MEDICALLY NECESSARY OR EMERGENCY MEDICAL CARE. SALEM HEALTH PART V, SECTION B, LINE 20E: SALEM HEALTH WILL NOTIFY INDIVIDUALS THAT FINANCIAL ASSISTANCE IS AVAILABLE TO ELIGIBLE INDIVIDUALS AT LEAST 30 DAYS PRIOR TO PURSUING EXTRAORDINARY COLLECTIONS ACTIONS AS TO OBTAIN PAYMENT FOR THE CARE PROVIDED BY THE HOSPITAL BY DOING THE FOLLOWING: 1. PROVIDE WRITTEN NOTICE TO THE INDIVIDUAL INDICATING THAT FINANCIAL ASSISTANCE IS AVAILABLE TO ELIGIBLE INDIVIDUALS, INDICATING THAT SALEM HEALTH INTENDS TO INITIATE OR HAVE A THIRD PARTY INITIATE TO OBTAIN PAYMENT FOR THE CARE, AND PROVIDES A DEADLINE AFTER WHICH ECAS MAY BE PURSUED AND WHICH IS NO LATER THAN 30 DAYS AFTER THE DATE OF THIS WRITTEN NOTICE 2. PROVIDE THE INDIVIDUAL A PLAIN LANGUAGE SUMMARY OF THE FINANCIAL ASSISTANCE POLICY WITH THE WRITTEN NOTICE 3. MAKE REASONABLE EFFORTS TO ORALLY NOTIFY INDIVIDUALS ABOUT THE SALEM HEALTH'S FINANCIAL ASSISTANCE POLICY. SALEM HEALTH PART V, SECTION B, LINE 21C: NOT APPLICABLE- SALEM HEALTH HAS A POLICY RELATIVE TO EMERGENCY MEDICAL CARE THAT REQUIRED THE HOSPITAL FACILITY TO PROVIDE, WITHOUT DISCRIMINATION, CARE FOR EMERGENCY MEDICAL CONDITIONS TO INDIVIDUALS REGARDLESS OF THEIR ELIGIBILITY UND THE HOSPITALS FINANCIAL ASSISTANCE POLICY. SALEM HEALTH PART V, SECTION B, LINE 21D: NOT APPLICABLE- SALEM HEALTH HAS A POLICY RELATIVE TO EMERGENCY MEDICAL CARE THAT REQUIRED THE HOSPITAL FACILITY TO PROVIDE, WITHOUT DISCRIMINATION, CARE FOR EMERGENCY MEDICAL CONDITIONS TO INDIVIDUALS REGARDLESS OF THEIR ELIGIBILITY UND THE HOSPITALS FINANCIAL ASSISTANCE POLICY. 8 1 - REHABILITATION CENTER 755 MISSION ST SE SALEM OR 97302 REHABILITATION 2 - LABORATORY PHLEBOTOMY SITE - HOPE 1600 STATE ST SALEM OR 97301 LABORATORY SERVICES 3 - COMPREHENSIVE PAIN CENTER 875 OAK STREET SALEM OR 97302 PAIN MANAGEMENT 4 - REGIONAL LABORATORY 3300 STATE ST SALEM OR 97301 LABORATORY SERVICES 5 - SALEM HEALTH MEDICAL CLINIC - KEIZER 550 DEITZ AVE NE KEIZER OR 97303 CLINIC 6 - SALEM HEALTH MEDICAL CLINIC - S SALEM 2925 RIVER RD S SALEM OR 97302 CLINIC 7 - SALEM HEALTH MEDICAL CLINIC - SALEM 966 12TH STREET SE SALEM OR 97301 CLINIC 8 - SALEM HEALTH MEDICAL CLINIC - W SALEM 1049 EDGEWATER ST NW SUITE 150 SALEM OR 97304 CLINIC PART I, LINE 3C: CRITERIA CONSIDERED IN DETERMINING ELIGIBILITY INCLUDE, BUT ARE NOT LIMITED TO: -THE HOUSEHOLD'S* GROSS INCOME. -HOUSEHOLD'S ASSETS OTHER THAN PRIMARY RESIDENCE ---EQUITY IN A REAL ESTATE (OTHER THAN THE PATIENT/GUARANTOR'S PRIMARY RESIDENCE), SECURITIES OR OTHER ASSETS ARE CONSIDERED AVAILABLE TO PAY THE PATIENT'S MEDICAL EXPENSES AND SHOULD BE INCLUDED IN THE INCOME CALCULATION ---THE INCOME FROM INCOME-PRODUCING REAL PROPERTY SHOULD BE USED IN THE CALCULATION RATHER THAN THE EQUITY. ---INDIVIDUAL RETIREMENT ACCOUNTS (IRAS) OR OTHER RETIREMENT FUNDS WILL NOT BE INCLUDED IN HOUSEHOLD ASSETS; HOWEVER DISTRIBUTIONS FROM THOSE FUNDS WILL BE CONSIDERED INCOME. -FAMILY SIZE (PERSONS LEGALLY RESPONSIBLE FOR THE PATIENT BILL AND THEIR DEPENDENTS) -THE FAMILY'S MONTHLY OUT OF POCKET EXPENSES FOR MEDICAL SUPPLIES AND SERVICES. -ELIGIBILITY MAY BE CONTINGENT UPON PATIENT COOPERATION WITH THE APPLICATION PROCESS. -THE DEFINITION OF 'HOUSEHOLD'S GROSS INCOME' INCLUDES THE COMBINED GROSS MONTHLY INCOME OF ALL PERSONS LEGALLY RESPONSIBLE FOR PATIENT BILL OR BALANCE.SUPPORTING DOCUMENTATION MAY INCLUDE THE FOLLOWING: PATIENT MUST PROVIDE TWO OF THE FOLLOWING DOCUMENTS TO SUPPORT THE INCOME CLAIMS ON THE APPLICATION. -THREE MONTHS INCOME VERIFICATION IN THE FORM OF PAY STUBS, BANK DEPOSITS, ETC. -SOCIAL SECURITY DETERMINATION LETTERS. -THE PRIOR YEAR'S TAX RETURNS OR 4506T-EZ -A "BASIC NEEDS" LETTER THAT INDICATES HOW PERSONS WITH NO INCOME ARE MEETING THEIR DAY TO DAY BASIC LIVING NEEDS. "BASIC NEEDS" LETTER MUST ONLY BE CONSIDERED A SECONDARY SUPPORTING DOCUMENT AFTER THE FINANCIAL COUNSELOR OR CLERK VALIDATES THE INFORMATION. AS OUTLINED IN SALEM HEALTH'S CONDITION OF ADMISSION, A CREDIT BUREAU REPORT OR A CHARITY SCORING VENDOR MAY BE REQUESTED TO VALIDATE INFORMATION PROVIDED ON THE FINANCIAL ASSISTANCE APPLICATION. SALEM HEALTH MAY ACCEPT INFORMATION PROVIDED ON AN OHP APPLICATION, OHP ELIGIBILITY, PROBATE ESTATES DETERMINATION, DOCUMENTATION OF HOMELESS STATUS, OR RELIABLE THIRD PARTY CREDIT INFORMATION AS A SUBSTITUTE FOR THE FINANCIAL FORMS. OHP INFORMATION WILL BE CONSIDERED VALID 30 DAYS PRIOR TO ADMISSION AND 90 DAYS POST DISCHARGE. APPROVED SOURCES OF DOCUMENTATION FOR HOMELESS STATUS INCLUDE CHART NOTES, DISCHARGE PLANS, OR DISCHARGE SUMMARIES ENTERED INTO OUR HEALTH INFORMATION SYSTEM BY CARE PROVIDERS OR THE PATIENT INDICATING THEY ARE HOMELESS DURING THE REGISTRATION PROCESS. FINANCIAL ASSISTANCE GRANTED BASED ON THIRD PARTY INFORMATION RATHER THAN A FINANCIAL ASSISTANCE APPLICATION DOES NOT EXTEND TO FUTURE DATES OF SERVICE AND WOULD NEED TO BE REEVALUATED BASED ON INFORMATION AVAILABLE AT THAT TIME. PART I, LINE 7: FINANCIAL ASSISTANCE, MEDICAID AND COSTS OF OTHER MEANS-TESTED GOVERNMENT PROGRAMS ACCOUNT FOR A LARGE PORTION OF SALEM HEALTH COMMUNITY BENEFIT CONTRIBUTION. ENSURING THAT COMMUNITY MEMBERS HAVE ACCESS TO EMERGENCY, PRIMARY CARE AND OTHER HEALTH SERVICES REGARDLESS OF ABILITY TO PAY, ALIGNS WITH THE HOSPITAL MISSION AND COMMITMENT TO SERVE THOSE LIVING IN MARION AND POLK COUNTIES. SALEM HEALTH IS DEEPLY EMBEDDED IN THE COMMUNITY AND HOSPITAL LEADERS WORK HAND IN HAND WITH REPRESENTATIVES FROM GOVERNMENT AGENCIES AND OTHER NON-PROFITS TO ASSESS AND ADDRESS COMMUNITY NEEDS. FOUR COMMUNITY WIDE TASK FORCES ARE IN PLACE TO ADDRESS THE FOUR HEALTH NEEDS DEEMED MOST CRITICAL IN MARION AND POLK COUNTY. THOSE ARE EARLY CHILDHOOD HEALTH INCLUDING PRENATAL CARE, TOBACCO AND SUBSTANCE ABUSE, DEPRESSION SCREENING AND OBESITY PREVENTION. THE HOSPITAL'S DIRECTOR OF COMMUNITY BENEFIT ATTENDS TASK FORCE MEETINGS AND LOOKS FOR WAYS TO LEVERAGE HOSPITAL RESOURCES TO IMPACT HEALTH OUTCOMES. HOSPITAL LEADERS VOLUNTEER TIME TO SERVE ON COMMUNITY NON-PROFIT BOARDS AND ATTEND REGIONAL COLLABORATIVE WORKGROUPS THAT ADDRESS SOCIAL DETERMINANTS OF HEALTH. EXAMPLES INCLUDE, BOARD POSITIONS ON THE EARLY LEARNING HUB, WITH A FOCUS ON KINDERGARTEN READINESS; THE MID-WILLAMETTE VALLEY HOMELESS INITIATIVE; AND SALEM KEIZER SPECIAL TRANSPORTATION ADVISORY GROUP.THE HOSPITAL PROVIDES COMMUNITY BASED HEALTH IMPROVEMENT SERVICES AS REQUESTED IN MARION AND POLK COUNTIES. IN 2016-2017 THESE INCLUDING HEALTH SCREENINGS, EDUCATION AND OUTREACH. THE EDUCATION CENTER OFFERS A LENDING LIBRARY, DROP IN NURSING CONSULTATION SERVICES, HEALTH SCREENINGS AND GROUP INSTRUCTION. IN ADDITION, THE CENTER PROVIDES SPACE FREE OF CHARGE TO COMMUNITY PARTNERS SEEKING TO IMPROVE HEALTH OUTCOMES. THE ROOMS HOST CLASSES, LECTURES, HEALTH FAIRS AND SUPPORT GROUPS THAT ARE COORDINATED IN PARTNERSHIP WITH COMMUNITY AGENCIES.SALEM HEALTH PROVIDED COMMUNITY PARTNERSHIP GRANTS IN 2016. THESE GRANTS SUPPORT THE WORK OF COMMUNITY PARTNERS THAT ARE ADDRESSING THE IDENTIFIED HEALTH NEEDS FROM THE 2015 COMMUNITY NEEDS ASSESSMENT. LASTLY, THE HOSPITAL PROVIDES TRAINING FOR NURSING STUDENTS AND EMERGING HEALTH CARE PROFESSIONS. IT HEALTH CAREER EXPLORATION PROGRAMS FOR HIGH SCHOOL STUDENTS IN DISTRICTS THAT FALL WITHIN THE HOSPITAL CATCHMENT AREA OF MARION AND POLK COUNTIES. PART I, LN 7 COL(F): THE AMOUNT OF BAD DEBT EXPENSE REMOVED FROM TOTAL EXPENSE THAT WAS INCLUDED IN FORM 990, PART IX, LINE 25, COLUMN (A), BUT REMOVED FROM THIS FIGURE FOR THE PURPOSES OF CALCULATING THE PERCENTAGE IN SCHEDULE H, PART I, LINE 7, COLUMN (F) WAS $36,727,074. PART I, LINE 6A A COMMUNITY BENEFIT REPORT WAS PREPARED DURING THE TAX YEAR AND CAN BE FOUND ON THE SALEM HEALTH WEBSITE AT WWW.SALEMHEALTH.ORG PART II, COMMUNITY BUILDING ACTIVITIES: SALEM HEALTH HAS MORE THAN 450 VOLUNTEERS AND A STAFF OF THREE THAT COORDINATE COMMUNITY BUILDING ACTIVITIES. VOLUNTEERS RAISE MONEY FOR COMMUNITY SCHOLARSHIPS, COORDINATE JOB SHADOW OPPORTUNITIES AND ARRANGE BLOOD DRIVES. LEADERS AT ALL LEVELS WITHIN SALEM HEALTH SERVE ON COMMUNITY BOARDS AND TASK FORCES THAT ADDRESS COMMUNITY NEEDS. THE HOSPITAL HAS BEEN ACTIVELY RECRUITING PRIMARY CARE PROVIDERS TO MARION AND POLK COUNTIES TO IMPROVE ACCESS TO CARE. SALEM HEALTH OFFERS PHYSICIAN LEADERSHIP TRAINING TO COMMUNITY PROVIDERS AND LEADERSHIP DEVELOPMENT COURSES THAT ARE MADE AVAILABLE TO LEADERS ACROSS THE SERVICE AREA. PART III, LINE 2: BAD DEBT EXPENSE IS PRIMARILY ESTIMATED BASED UPON THE HOSPITALS' HISTORICAL COLLECTION EXPERIENCE, THE AGE OF THE PATIENT'S ACCOUNT, THE PATIENT'S ECONOMIC ABILITY TO PAY, AND THE EFFECTIVENESS OF COLLECTION EFFORTS. PATIENT ACCOUNTS RECEIVABLE BALANCES ARE ROUTINELY REVIEWED IN CONJUNCTION WITH HISTORICAL COLLECTION RATES AND OTHER ECONOMIC CONDITIONS THAT MIGHT ULTIMATELY AFFECT THE COLLECTABILITY OF PATIENT ACCOUNTS WHEN CONSIDERING THE ADEQUACY OF THE AMOUNTS RECORDED IN THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. ACTUAL WRITE-OFFS HISTORICALLY HAVE APPROXIMATED MANAGEMENT'S EXPECTATIONS. PART III, LINE 3: BAD DEBT EXPENSE ATTRIBUTABLE TO PATIENTS WHO LIKELY WOULD QUALIFY FOR FINANCIAL ASSISTANCE UNDER SALEM HEALTH'S FINANCIAL ASSISTANCE POLICY, IS ESTIMATED BASED ON DATA FROM OUR PATIENT ACCOUNTING SYSTEM. THIS DATA IS THEN COMPARED AND MATCHED TO MEDIAN HOUSEHOLD INCOME CENSUS DATA BY ZIP CODE TO DETERMINE THE ESTIMATED BAD DEBT EXPENSE ATTRIBUTABLE TO PATIENTS WHO LIKELY WOULD QUALIFY FOR FINANCIAL ASSISTANCE PART II, LINE 8: SALEM HEALTH HAS BEEN ACTIVELY RECRUITING PRIMARY CARE PROVIDERS TO MARION AND POLK COUNTIES TO IMPROVE ACCESS TO CARE. PART II SALEM HEALTH HAS MORE THAN 450 VOLUNTEERS AND A STAFF OF THREE THAT COORDINATE COMMUNITY BUILDING ACTIVITIES. VOLUNTEERS RAISE MONEY FOR COMMUNITY SCHOLARSHIPS, COORDINATE JOB SHADOW OPPORTUNITIES AND ARRANGE BLOOD DRIVES.LEADERS AT ALL LEVELS WITHIN SALEM HEALTH SERVE ON COMMUNITY BOARDS AND TASK FORCES THAT ADDRESS COMMUNITY NEEDS.THE HOSPITAL HAS BEEN ACTIVELY RECRUITING PRIMARY CARE PROVIDERS TO MARION AND POLK COUNTIES TO IMPROVE ACCESS TO CARE. SALEM HEALTH OFFERS PHYSICIAN LEADERSHIP TRAINING TO COMMUNITY PROVIDERS AND LEADERSHIP DEVELOPMENT COURSES THAT ARE MADE AVAILABLE TO LEADERS ACROSS THE SERVICE AREA. PART III, LINE 4: EFFECTIVE OCTOBER 1, 2011, THE HOSPITALS ADOPTED FASB ISSUED ACCOUNTING STANDARDS UPDATE (ASU) NO. 2011-07, HEALTH CARE ENTITIES (TOPIC 954): PRESENTATION AND DISCLOSURE OF PATIENT SERVICE REVENUE, PROVISION FOR BAD DEBTS, AND THE ALLOWANCE FOR DOUBTFUL ACCOUNTS FOR CERTAIN HEALTHCARE ENTITIES. THE ADOPTION OF THIS ASU RESULTED IN A RECLASSIFICATION OF BAD DEBT EXPENSE FROM AN OPERATING EXPENSE TO BE A REDUCTION IN DERIVING NET PATIENT SERVICE REVENUE. THE ALLOWANCES FOR DOUBTFUL ACCOUNTS ARE PRIMARILY ESTIMATED BASED UPON THE HOSPITALS' HISTORICAL COLLECTION EXPERIENCE, THE AGE OF THE PATIENT'S ACCOUNT, THE PATIENT'S ECONOMIC ABILITY TO PAY, AND THE EFFECTIVENESS OF COLLECTION EFFORTS. PATIENT ACCOUNTS RECEIVABLE BALANCES ARE ROUTINELY REVIEWED IN CONJUNCTION WITH HISTORICAL COLLECTION RATES AND OTHER ECONOMIC CONDITIONS THAT MIGHT ULTIMATELY AFFECT THE COLLECTABILITY OF PATIENT ACCOUNTS WHEN CONSIDERING THE ADEQUACY OF THE AMOUNTS RECORDED IN THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. ACTUAL WRITE-OFFS HISTORICALLY HAVE APPROXIMATED MANAGEMENT'S EXPECTATIONS. PART III, LINE 8: MEDICARE PAYS A SIGNIFICANTLY REDUCED AMOUNT FOR MEDICAL SERVICES RENDERED TO THEIR ENROLLEES SUCH THAT THE NET REIMBURSEMENT DOES NOT COVER THE EXPENSES INCURRED TO PROVIDE THE SERVICES. SALEM HEALTH CONSIDERS THE DIFFERENCE BETWEEN THE COSTS TO PROVIDE THE SERVICES FOR MEDICARE ENROLLEES AND THE NET REIMBURSEMENT AS A BENEFIT TO THE COMMUNITY. MEDICARE FEE-FOR-SERVICE COSTS ARE DETERMINED FROM SALEM HEALTH'S FILED MEDICARE COST REPORT. THE CALCULATION OF NET BENEFIT IS EQUAL TO TOTAL MEDICARE PAYMENTS LESS MEDICARE COSTS.IN ADDITION TO TRADITIONAL MEDICARE FEE-FOR-SERVICE, SALEM HEALTH PROVIDES SUBSTANTIAL SERVICES TO OTHER MEDICARE POPULATIONS PARTICIPATING IN MEDICARE ADVANTAGE PLANS AT SIGNIFICANTLY REDUCED REIMBURSEMENT. THE NET REVENUES FOR THESE PLANS ARE LESS THAN THE COST TO PROVIDE CARE AND ARE NOT DISCLOSED IN PART III, LINE 8. SALEM HEALTH ALSO CONSIDERS THE DIFFERENCE BETWEEN THE NET COST TO PROVIDE CARE FOR MEDICARE ADVANTAGE ENROLLEES AND THE NET REIMBURSEMENT AS A BENEFIT TO THE COMMUNITY. THESE NET COSTS HAVE BEEN DETERMINED BY APPLYING THE RATIO OF COSTS TO CHARGES AS DETERMINED IN WORKSHEET 2 TO THE FULL BILLED CHARGES. THE CALCULATION OF NET BENEFIT IS EQUAL TO TOTAL MEDICARE ADVANTAGE PAYMENTS OF $154,301,793 LESS MEDICARE ADVANTAGE COSTS OF $182,654,129 FOR A TOTAL ADDITIONAL COMMUNITY BENEFIT IN THE AMOUNT OF $28,352,336. PART III, LINE 9B: THE BILLING AND COLLECTIONS ADMINISTRATIVE HOUSE-WIDE POLICY AND PROCEDURE STATES, "IF A PATIENT SUBMITS A COMPLETE APPLICATION FOR FINANCIAL ASSISTANCE AFTER AN ACCOUNT HAS BEEN REFERRED FOR COLLECTION ACTIVITY, SALEM HEALTH WILL SUSPEND THE ECAS UNTIL THE PATIENT'S APPLICATION HAS BEEN PROCESSED AND NOTIFY THE PATIENT OF DETERMINATION. IF AN INDIVIDUAL IS FOUND TO BE ELIGIBLE FOR FINANCIAL ASSISTANCE, ANY ECAS WILL BE REVERSED. PART VI, LINE 2: A COMPREHENSIVE NEEDS ASSESSMENT WAS CONDUCTED IN TAX YEAR 2015. THE NEEDS ASSESSMENT DESCRIBES THE COMMUNITY SERVED BY THE HOSPITAL AND THE DEMOGRAPHICS OF THE COMMUNITY. IT DOES NOT DESCRIBE THE EXISTING HEALTH CARE FACILITIES AND RESOURCES WITHIN THE COMMUNITY THAT ARE AVAILABLE TO RESPOND TO NEEDS. THE MARION AND POLK COUNTY HEALTH CARE SYSTEM CAPACITY AND ACCESS ASSESSMENT CONTAINS HEALTH CARE FACILITY AND RESOURCE INFORMATION. THE CAPACITY AND ACCESS ASSESSMENT IS UPDATED ANNUALLY. THE LATEST CHNA AND HEALTH CARE SYSTEM CAPACITY AND ACCESS ASSESSMENTS ARE PUBLISHED TO THE SALEM HEALTH WEBSITE AT WWW.SALEMHEALTH.ORG. THE NATIONAL MODEL, MOBILIZATION FOR ACTION THROUGH PLANNING AND PARTNERSHIPS OR MAPP WAS USED AS THE FRAMEWORK FOR THE COMMUNITY HEALTH ASSESSMENT. THE FOUR ASSESSMENTS OF THE MAPP FRAMEWORK INCLUDE: COMMUNITY THEMES AND STRENGTHS, LOCAL PUBLIC HEALTH SYSTEM ASSESSMENT, COMMUNITY HEALTH STATUS ASSESSMENT AND THE FORCES OF CHANGE ASSESSMENT.THE COMMUNITY THEMES AND STRENGTHS ASSESSMENT WAS CONDUCTED BY SURVEYING COMMUNITY PARTNERS WORKING IN SOCIAL, HEALTH, COMMUNITY, EDUCATIONAL AND CORRECTIONAL HEALTH SETTINGS AND THE COMMUNITY-AT-LARGE. THE SURVEYS USED IN BOTH MARION AND POLK COUNTIES CONSISTED OF THE SAME QUESTIONS AND USED THE 2011 MARION COUNTY SURVEY AS A TEMPLATE. PAPER AND ELECTRONIC SURVEYS WERE ALLOCATED BASED ON POPULATION DISTRIBUTION THROUGHOUT OUR COMMUNITIES. THE COMMUNITY HEALTH STATUS ASSESSMENT WAS CONDUCTED BY COMPILING DATA FROM NATIONAL SURVEILLANCE SYSTEMS LIKE THE BEHAVIOR RISK FACTOR SURVEILLANCE SURVEY AND OREGON HEALTHY TEENS AS WELL AS STATE AND LOCAL DATA FROM BIRTH AND DEATH CERTIFICATES. IN ADDITION, AS SERIES OF COMMUNITY CAF S WERE CONDUCTED ACROSS MARION AND POLK COUNTY TO IDENTIFY HEALTH PRIORITIES.SALEM HEALTH HOSTED COMMUNITY CAF S AND REPRESENTATIVES FROM MARION AND POLK COUNTY PUBLIC HEALTH, PRESENTED CHNA FINDINGS TO THE SALEM HEALTH COMMUNITY BENEFIT COMMITTEE OF THE BOARD OF TRUSTEES IN NOVEMBER 2015. THE MARION AND POLK COUNTY HEALTH REPORTS WAS PUBLISHED IN DECEMBER 2015 AND CAN BE FOUND ON THE SALEM HEALTH WEBSITE. WWW.SALEMHEALTH.ORG. THE DOCUMENT INFORMED THE DEVELOPMENT OF THE COMMUNITY BENEFIT IMPLEMENTATION STRATEGY FOR REPORTING YEARS 2015 - 2017, ALSO AVAILABLE ON THE WEBSITE.THE IMPACT OF ACTIONS TAKEN TO ADDRESS THE SIGNIFICANT HEALTH NEEDS IDENTIFIED IN THE HOSPITAL FACILITIES PRIOR CHNAS CAN BE FOUND ON THE COMMUNITY HEALTH IMPROVEMENT PARTNERS (CHIP) ANNUALLY REPORT. THE CHIP IS COORDINATED BY THE MARION COUNTY PUBLIC HEALTH DEPARTMENT AND IS PUBLISHED ON THEIR WEBPAGE AT HTTP://WWW.CO.MARION.OR.US/HLT/CHIP/PAGES/DEFAULT.ASPX. PART VI, LINE 3: PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCESALEM HEALTH SCREENS UNINSURED PATIENTS FOR ELIGIBILITY THROUGH THE OREGON HEALTH PLAN (OHP/MEDICAID), WORKERS COMPENSATION, THIRD PARTY LIABILITIES, CONSOLIDATED OMNIBUS BUDGET RECONCILIATION ACT (COBRA), OR ANY OTHER POTENTIAL FUNDING SOURCE AT THE POINT OF SCHEDULING, PATIENT REGISTRATION OR WHILE INPATIENT. THE HOSPITAL OR ITS REPRESENTATIVE WILL REVIEW THE PATIENT'S CURRENT RESOURCES AND WORK WITH HIM/HER TO GAIN ELIGIBILITY FOR ANY OF THESE PROGRAMS AS APPROPRIATE. PATIENTS THAT ARE NOT ELIGIBLE FOR OHP OR THE OTHER PROGRAMS LISTED ABOVE, AND HAVE FINANCIAL CONSTRAINTS THAT INHIBIT THEIR ABILITY TO PAY, WILL BE ASSESSED FOR A FINANCIAL ASSISTANCE. INFORMATION REGARDING THE HOSPITAL'S FINANCIAL ASSISTANCE IS MADE PUBLICLY AVAILABLE IN THE FOLLOWING MANNER: 1. NOTICES ARE POSTED IN KEY AREAS OF THE HOSPITAL, INCLUDING ADMITTING, THE EMERGENCY DEPARTMENT, OUTPATIENT DEPARTMENT REGISTRATION AREAS, AND PATIENT FINANCIAL SERVICES. 2. THE CONDITIONS OF ADMISSION FORM INFORMS THE PATIENT OF THEIR RIGHT TO APPLY FOR FINANCIAL ASSISTANCE. 3. WRITTEN INFORMATION SHALL BE AVAILABLE IN ENGLISH, SPANISH, RUSSIAN AND VIETNAMESE. THE HOSPITAL WILL PROVIDE THE APPROPRIATE INTERPRETATION SERVICES FOR PATIENTS/GUARANTORS WHO DO NOT SPEAK ENGLISH. 4. FRONT-LINE STAFF WILL BE TRAINED TO ANSWER FINANCIAL ASSISTANCE QUESTIONS EFFECTIVELY AND WILL DIRECT ANY THAT CANNOT BE ANSWERED TO FINANCIAL COUNSELOR'S IN A TIMELY MANNER. 5. THIS POLICY WILL BE POSTED ON SALEM HEALTH'S WEB SITE. WRITTEN INFORMATION ABOUT THIS POLICY WILL BE MADE AVAILABLE UPON REQUEST. 6. ALL PATIENT BILLING STATEMENTS WILL INCLUDE A NOTICE THAT FINANCIAL ASSISTANCE IS AVAILABLE AND CONTACT INFORMATION IF THEY WANT TO LEARN MORE PART VI, LINE 4: SALEM HEALTH SERVES MARION AND POLK COUNTIES.IN 2016, THERE WERE 79,291 PEOPLE AND 28,458 HOUSEHOLDS RESIDING IN THE POLK COUNTY. THE RURAL COMMUNITY HAD A POPULATION DENSITY OF 101.8 INHABITANTS PER SQUARE MILE (39.3/KM2). THERE WERE 31,166 HOUSING UNITS. THE RACIAL MAKEUP OF THE COUNTY WAS 90.7% WHITE, 2.6% AMERICAN INDIAN, 2.0% ASIAN, 0.9% BLACK OR AFRICAN AMERICAN, 0.4% PACIFIC ISLANDER AND 3.5% FROM TWO OR MORE RACES. THOSE OF HISPANIC OR LATINO ORIGIN MADE UP 13% OF THE POPULATION. 7.5% OF THE POPULATION IS FOREIGN BORN. THE AVERAGE HOUSEHOLD SIZE WAS 2.62. 5.9% OF THE POPULATION ARE UNDER THE AGE OF 5 YEARS, 23.5% ARE UNDER THE AGE OF 18 AND 16.4% ARE OVER THE AGE OF 65 YEARS. THE MEDIAN INCOME FOR A HOUSEHOLD IN POLK COUNTY IS $52,821. THE PER CAPITA INCOME FOR THE COUNTY WAS $23,967. ABOUT 13.7% OF THE POPULATION LIVE BELOW THE POVERTY LINE. ACCORDING TO THE U.S. CENSUS BUREAU, MARION COUNTY HAS A TOTAL AREA OF 744 SQUARE MILES (1,930 KM2), OF WHICH 741 SQUARE MILES (1,920 KM2) IS LAND AND 3.1 SQUARE MILES (8.0 KM2) (0.4%) IS WATER. THE MAJOR INDUSTRIES OF THE COUNTY ARE AGRICULTURE, FOREST PRODUCTS, MANUFACTURING, AND EDUCATION. POLK COUNTY HAS THE SECOND-LARGEST AREA DEVOTED TO VITICULTURE IN OREGON, AT 1,322 ACRES (5.35 KM2).IN 2016 THERE WERE 330,700 PEOPLE AND 113,996 HOUSEHOLDS RESIDING IN THE MARION COUNTY. THE COUNTY IS A BLEND OF URBAN AND RURAL WITH A POPULATION DENSITY OF 266.7 INHABITANTS PER SQUARE MILE (39.3/KM2). THERE WERE 123,467 HOUSING UNITS. THE RACIAL MAKEUP OF THE COUNTY WAS 89.4% WHITE, 2.6% AMERICAN INDIAN, 2.3% ASIAN, 1.4% BLACK OR AFRICAN AMERICAN, 1.0% PACIFIC ISLANDER AND 3.3% FROM TWO OR MORE RACES. THOSE OF HISPANIC OR LATINO ORIGIN MADE UP 26% OF THE POPULATION. 7.5% OF THE POPULATION IS FOREIGN BORN. THE AVERAGE HOUSEHOLD SIZE WAS 2.62. 5.9% OF THE POPULATION ARE UNDER THE AGE OF 5 YEARS, 23.5% ARE UNDER THE AGE OF 18 AND 16.4% ARE OVER THE AGE OF 65 YEARS. THE MEDIAN INCOME FOR A HOUSEHOLD IN MARION COUNTY IS $48,832. THE PER CAPITA INCOME FOR THE COUNTY WAS $22,490. ABOUT 16.8% OF THE POPULATION LIVE BELOW THE POVERTY LINE. ACCORDING TO THE U.S. CENSUS BUREAU, THE COUNTY HAS A TOTAL AREA OF 1,193 SQUARE MILES (3,090 KM2), OF WHICH 1,182 SQUARE MILES (3,060 KM2) IS LAND AND 10 SQUARE MILES (26 KM2) (0.9%) IS WATER. AGRICULTURE AND FOOD PROCESSING ARE IMPORTANT TO THE COUNTY'S ECONOMY, AS ARE LUMBER, MANUFACTURING, AND EDUCATION. MARION COUNTY IS THE LEADER IN AGRICULTURAL PRODUCTION AMONG ALL OTHER OREGON COUNTIES PART VI, LINE 5: SALEM HEALTH FUNDS A COMMUNITY HEALTH EDUCATION AND OUTREACH PROGRAM. THE CENTER IS STAFFED BY HEALTH EDUCATORS AND REGISTERED NURSES THAT PROVIDE EDUCATION SERVICES TO COMMUNITY MEMBERS ON A DROP IN BASIS. A MEDICAL PROFESSIONAL AND HEALTH CONSUMER LIBRARY ALLOWS PATRONS TO CHECK OUT HEALTH MATERIALS FREE OF CHARGE. THE LIBRARY SUPPORTS COMMUNITY PROVIDERS, HEALTH PROFESSIONAL AND STUDENTS THAT LIVE, WORK AND LEARN IN MARION AND POLK COUNTIES.MORE THAN 1500 CLASSES AND EVENTS ARE HELD AT THE CENTER AND IN THE COMMUNITY EACH YEAR TO PROMOTE HEALTH AND PREVENT CHRONIC CONDITIONS. THESE RANGE FROM PREVENTION AND EARLY DETECTION/SCREENING SERVICES TO CHRONIC DISEASE MANAGEMENT AND END OF LIFE DECISION SUPPORT. THE OUTREACH PRIORITIES SUPPORT THE CHNA AND STAFF WORK IN COLLABORATION WITH COMMUNITY PARTNERING AGENCIES TO IMPROVE THE HEALTH AND WELL-BEING OF THE COMMUNITIES AND INDIVIDUALS WITHIN MARION AND POLK COUNTIES. THE HOSPITAL EXECUTIVE TEAM MEMBERS INTENTIONALLY SERVE ON NON-PROFIT BOARDS THROUGHOUT MARION AND POLK COUNTIES. THESE INCLUDE THE UNITED WAY, MARION POLK FOOD SHARE, FAMILY BUILDING BLOCKS, LIBERTY HOUSE AND THE LOCAL COORDINATED CARE ORGANIZATION, AMONG OTHERS. THESE ORGANIZATIONS SERVE VULNERABLE POPULATIONS. OFTEN COMMUNITY BENEFIT ACTIVITIES, ESPECIALLY CASH AND IN-KIND DONATIONS,SUPPORT THE WORK OF PARTNERING ORGANIZATIONS TO MEET THE IDENTIFIED NEEDS OF THE UNDERSERVED IN OUR COMMUNITY. THE COMMUNITY PARTNERSHIP GRANT PROGRAM PROMOTES THE HEALTH AND WELL-BEING OF LOW-INCOME INDIVIDUALS AND FAMILIES IN MARION AND POLK COUNTIES THROUGH FUNDING PROJECTS THAT ADDRESS HEALTH RELATED PRIORITIES IDENTIFIED IN THE CHNA. IN 2016, NEARLY $300,000 WAS DISSEMINATED TO COMMUNITY PARTNERS TO ADDRESS EARLY CHILDHOOD HEALTH, DEPRESSION, SUBSTANCE USE DISORDER AND OBESITY. PART VI, LINE 6: SALEM HEALTH IS AN OREGON NONPROFIT CORPORATION AND A TAX-EXEMPT ORGANIZATION DESCRIBED IN SECTION 501(C)(3) OF THE CODE. SALEM HEALTH, HOSPITALS AND CLINICS IS THE "PARENT" CORPORATION AND SOLE CORPORATE MEMBER OF SALEM HEALTH, SALEM HEALTH FOUNDATION, SALEM HEALTH WEST VALLEY, WEST VALLEY HOSPITAL FOUNDATION, WILLAMETTE VALLEY INSURANCE CORPORATION, AND SALEM HEALTH PROFESSIONAL SERVICES. ALL ENTITIES WITHIN THE PARENT CORPORATION ARE SEPARATE NONPROFIT CORPORATIONS.SALEM HEALTH IS AN OREGON NONPROFIT CORPORATION AND A TAX-EXEMPT ORGANIZATION. THE CORPORATION ALSO DOES BUSINESS UNDER THE NAME "SALEM HEALTH, A PART OF SALEM HEALTH HOSPITALS AND CLINICS." SALEM HEALTH IS ONE OF THE LARGEST ACUTE CARE HOSPITALS IN OREGON. LICENSED FOR 494 BEDS, SALEM HEALTH OFFERS A BROAD RANGE OF INPATIENT AND OUTPATIENT SERVICES AN AREA OF OVER 500,000 PEOPLE, INCLUDING ALL OF MARION AND POLK AND PORTIONS OF LINN AND YAMHILL COUNTIES INCLUDING THE RESIDENTS OF THE CITY OF SALEM, THE STATE CAPITAL OF OREGON.SALEM HEALTH IS THE LARGEST PRIVATE EMPLOYER IN SALEM, OREGON, WITH APPROXIMATELY 4,189 FULL AND PART-TIME EMPLOYEES (AS OF JUNE 30, 2017). THE MEDICAL STAFF IS COMPRISED OF APPROXIMATELY 482 PHYSICIANS REPRESENTING MORE THAN 50 SPECIALTIES AND SUBSPECIALTIES, AND MORE THAN 300 VOLUNTEERS PROVIDE NON-MEDICAL SUPPORT FOR SALEM HEALTH.SALEM HEALTH, AS PART OF SALEM HEALTH HOSPITALS AND CLINICS IS GOVERNED BY AN ALL-VOLUNTEER COMMUNITY-BASED BOARD OF TRUSTEES (BOARD). THE BOARD HAS THE RESPONSIBILITY FOR THE DEVELOPMENT AND OVERSIGHT OF SALEM HEALTH VALUES, VISION, PURPOSE AND LONG-TERM STRATEGY. THROUGH THESE DOCUMENTS, THE COMMUNITY BENEFIT STEERING COMMITTEE ASSESSES AND REAFFIRMS SALEM HEALTH'S COMMUNITY BENEFIT COMMITMENTS AND CONNECTIONS WITH COMMUNITY NEEDS AND PRIMARY CONSTITUENCIES. THE COMMUNITY BENEFIT PLAN ASSURES MEASUREMENT AND COMPARISON OF SALEM HEALTH'S COMMUNITY ACTIVITIES TO EVOLVING NORMS AND OVERSEES THE CLEAR AND ACCURATE COMMUNICATION OF THESE ACTIVITIES TO KEY CONSTITUENCIES. PART VI, LINE 7, REPORTS FILED WITH STATES OR PART VI, LINE 6: AFFILIATED HEALTH CARE SYSTEMSALEM HEALTH, AS PART OF SALEM HEALTH HOSPITALS AND CLINICS, WAS AFFILIATED WITH OREGON HEALTH SCIENCE UNIVERSITY (OHSU). CHANGES IN PRIORITIES AND PROCESSES REQUIRING COURSE CORRECTIONS ARE COMMON IN THE FIRST YEARS OF AN AFFILIATION AND THE CONCLUSION WAS REACHED BY BOTH THE CORPORATION AND OHSU THAT THE JMA WAS NOT WORKING IN THE WAY ORIGINALLY INTENDED. THE PARTIES RECOGNIZED THE NEED FOR A TRANSITION. AS A RESULT, THE CORPORATION AND OHSU ENTERED IN TO A TRANSITION AGREEMENT THAT TERMINATED THE JMA EFFECTIVE MAY 4, 2017 WITH EACH PARTY REASSUMING OVERSIGHT AND FULL MANAGEMENT OF THEIR OWN CLINICAL ENTERPRISES AND THE CORPORATION TRANSFERRING ITS INTEREST IN OHSU PARTNERS TO OHSU. 1 MEDICAL FOUNDATION OF MARION & POLK COUNTIES 2995 RYAN DRIVE STE 100 SALEM OR 97301 931261633 501(C)(3) 17500 SPONSORSHIP OF ANNUAL BENEFIT FUNDRAISER/IMPROVE ACCESS TO HEALTHCARE AMERICAN CANCER SOCIETY 2120 1ST AV N SEATTLE WA 98121 841316555 501(C)(3) 5000 RELAY FOR LIFE SPONSORSHIP/IMPROVE SOCIAL DETERMINATE OF HEALTH MARCH OF DIMES 1220 SW MORRISON SUITE 510 PORTLAND OR 97205 131846366 501(C)(3) 10000 SPONSOR FOR SALEM MARCH FOR BABIES/IMPROVE SOCIAL DETERMINATE OF HEALTH SALEM HEALTH FOUNDATION PO BOX 14001 SALEM OR 97309 237002687 501(C)(3) 5000 CHARITABLE CONTRIBUTION GOLF TOURNAMENT SALEM KEIZER EDUCATION FOUNDATION 233 COMMERCIAL STREET NE SALEM OR 97301 930831467 501(C)(3) 25000 AWESOME 3000 SPONSORSHIP/DISEASE PREVENTION BOYS & GIRLS CLUB 1395 SUMMER ST NE SALEM OR 97301 930581470 501(C)(3) 37500 COMMUNITY PARTNER GRANT/IMPROVE SOCIAL DETERMINATE OF HEALTH LIBERTY HOUSE 2685 4TH ST NE SALEM OR 97301 931236936 501(C)(3) 5000 CHEFS FOR LIBERTY HOUSE SPONSORSHIP/CHAMPIONS FOR CHILDREN SPONSORSHIP SALVATION ARMY 1901 FRONT ST SALEM OR 97301 941156347 501(C)(3) 25000 COMMUNITY PARTNER GRANT UNITED WAY OF MID WILLAMETTE VALLEY 455 BLILER AVE NE SALEM OR 97303 930395586 501(C)(3) 7500 SPONSOR BINATIONAL HEALTH FAIR/PRESIDENT'S LEADERSHIP CIRCLE/IMPROVE SOCIAL DETERMINATE OF HEALTH SALEM FREE MEDICAL CLINIC 1300 BROADWAY ST NE STE 104 SALEM OR 97301 203549992 501(C)(3) 75000 ACCESS TO CARE (SALEM & DALLAS) SALEM INTERFAITH HOSPITALITY NETWORK 1055 EDGEWATER ST NW SALEM OR 97304 931234367 501(C)(3) 18250 COMMUNITY PARTNER GRANT POLK CO FAMILY & COMMUNITY OUTREACH 182 SW ACADEMY STREET 220 DALLAS OR 97338 936002310 MUNICIPAL 25000 COMMUNITY PARTNER GRANT MANO A MANO FAMILY CENTER 2921 SADDLE CLUB SE 1009 SALEM OR 97317 930992858 501(C)(3) 25000 COMMUNITY PARTNER GRANT AMERICAN DIABETES ASSOCIATION 4380 SW MACADAM AV210 PORTLAND OR 97239 131623888 501(C)(3) 24796 COMMUNITY PARTNER GRANT/IMPROVE SOCIAL DETERMINATE TO HEALTH FAMILY BUILDING BLOCKS 2425 LANCASTER DR NE SALEM OR 97305 931233373 501(C)(3) 46370 COMMUNITY PARTNER GRANT GILBERT HOUSE 116 MARION ST NE SALEM OR 97301 930948548 501(C)(3) 5000 EXHIBIT SPONSOR - ALL ABOUT ME MARION COUNTY PO BOX 14500 SALEM OR 97309 936002307 25000 COMMUNITY PARTNER GRANT/IMPROVE SOCIAL DETERMINATE TO HEALTH MARION POLK FOOD SHARE 1660 SALEM INDUSTRIAL DRIVE NE SALEM OR 97301 943034161 501(C)(3) 19971 COMMUNITY PARTNER GRANT/IMPROVE SOCIAL DETERMINATE TO HEALTH MWVCAA 2585 STATE ST SALEM OR 97301 237056987 501(C)(3) 12500 COMMUNITY PARTNER GRANT OHSU 3181 SW SAM JACKSON PARK RD PORTLAND OR 97239 237083114 5000 SPONSORSHIP OF GOLF TOURNAMENT PSYCHIATRIC CRISIS CENTER PO BOX 14500 SALEM OR 97309 936002307 16485 ACCESS TO MEDICAL SERVICES 22 CASH ASSISTANCE TO PATIENTS IN NEED FOR PRESCRIPTIONS, LIFELINE SUPPORT, REHABILITATION AND OTHER URGENT NEEDS. 98 20270 SCHOLARSHIPS FOR HEALTH PROFESSIONS EDUCATION 64 122000 PART I, LINE 2: GRANTS ARE ONLY MADE TO QUALIFIED EXEMPT ORGANIZATIONS. NO MONITORING IS REQUIRED. X X X X X 1 1 0 0 0 1 1 1 0 CHERYL NESTER WOLFE PRESIDENT AND CEO 579665 0 143292 0 7341 0 57385 0 15229 0 802912 0 0 0 JAMES PARR CHIEF FINANCIAL OFFICER 398813 0 38833 0 1407 0 45500 0 35831 0 520384 0 0 0 RALPH YATES CMO SALEM HEALTH AND SHMG 395536 0 37659 0 13076 0 42293 0 28279 0 516843 0 0 0 LAURIE BARR VP HUMAN RESOURCES 332579 0 49020 0 1668 0 41367 0 34387 0 459021 0 0 0 SARAH HORN CHIEF NURSING OFFICER 303412 0 26681 0 999 0 39435 0 33934 0 404461 0 0 0 LEAH MITCHELL CIO - EFF 9/4/16 362791 0 43386 0 1112 0 43756 0 17830 0 468875 0 0 0 LORI JAMES-NIELSEN TERM 31717 SEE SCHEDULE J 339834 0 33909 0 2558 0 46667 0 33994 0 456962 0 0 0 ANDREW FURMAN VP MEDICAL AFFAIRS 339040 0 26180 0 1269 0 24943 0 33775 0 425207 0 0 0 BAHAA WANLY CHIEF OPERATING OFFICER 273016 0 30295 0 930 0 30282 0 32775 0 367298 0 0 0 DENISE HOOVER VP SURGICAL SERVICES 186850 0 18722 0 344 0 26970 0 20819 0 253705 0 0 0 SHEA CORUM VP IT OPERATIONS - EFF 10/16/16 150901 0 5000 0 158 0 11060 0 30748 0 197867 0 0 0 LEILANI SLAMA VP COMMUNITY ENGAGEMENT 137445 0 13591 0 353 0 12359 0 29264 0 193012 0 0 0 NORMAN GRUBER SEE SCHEDULE J - TERM 7/3/16 523175 0 1722873 0 8085 0 419875 0 48695 0 2722703 0 0 0 JUAN OYARZUN - EFF 21917 DIRECTOR OF CARDIOTHORACIC MEDICINE 1235741 0 0 0 4525 0 41873 0 39400 0 1321539 0 0 0 JASWINDER KAUR ADULT HOSPITALIST PHYSICIAN 497808 0 26843 0 796 0 17225 0 36073 0 578745 0 0 0 NERVIN FANOUS CARDIOTHORACIC SURGEON 782005 0 0 0 849 0 22952 0 30322 0 836128 0 0 0 NICOLE VANDERHEYDEN MD TRAUMA DIR/ ASSOC CMO SHMG 715461 0 31022 0 5977 0 49205 0 40524 0 842189 0 0 0 JAMES SAPIENZA FMR CAO OF SHWV 37701 0 15762 0 232637 0 1951 0 15071 0 303122 0 0 0 PART I, LINES 4A-B SEVERANCE PAYMENTS WERE MADE TO JAMES SAPIENZA ($232,329) WHICH HAS BEEN INCLUDED IN 'OTHER REPORTABLE COMPENSATION'. SOME OF THE HOSPITAL'S EMPLOYEES RECEIVE DEFERRED COMPENSATION UNDER A 457(F) NONQUALIFIED PLAN. THIS COMPENSATION IS INCLUDED IN COMPENSATION REPORTED IN PART II. THE TOTAL NONQUALIFIED PORTION OF EACH PERSONS DEFERRED COMPENSATION IS: CHERYL NESTER WOLFE $79,653 ($39,493 INCLUDED IN BONUS & INCENTIVE COMPENSATION AND $40,160 INCLUDED IN DEFERRED COMPENSATION) JAMES PARR $28,275 (INCLUDED IN DEFERRED COMPENSATION) RALPH YATES $27,718 (INCLUDED IN DEFERRED COMPENSATION) LAURIE BARR $40,606 ($19,114 INCLUDED IN BONUS & INCENTIVE COMPENSATION AND $21,492 INCLUDED IN DEFERRED COMPENSATION) SARAH HORN $19,560 (INCLUDED IN DEFERRED COMPENSATION) LEAH MITCHELL $34,326 ($10,445 INCLUDED IN BONUS & INCENTIVE COMPENSATION AND $23,881 INCLUDED IN DEFERRED COMPENSATION) LORI JAMES-NEILSEN $24,142 (INCLUDED IN DEFERRED COMPENSATION) ANDREW FURMAN $24,174 (INCLUDED IN DEFERRED COMPENSATION) BAHAA WANLY $19,437 (INCLUDED IN DEFERRED COMPENSATION) DENISE HOOVER $11,418 (INCLUDED IN DEFERRED COMPENSATION) SHEA CORUM $2,558 (INCLUDED IN DEFERRED COMPENSATION) LEILANI SLAMA $3,681 (INCLUDED IN DEFERRED COMPENSATION) NORMAN GRUBER $2,122,873 (MULTIPLE YEARS OF NORMAN GRUBER'S ACCUMULATED 457(F)CONTRIBUTIONS VESTED UPON HIS RETIREMENT ON JULY 3, 2016 RESULTING IN $1,722,873 BEING REPORTED IN THE BONUS AND INCENTIVE COMPENSATION COLUMN, ADDITIONALLY $400,000 WAS INCLUDED IN DEFERRED COMPENSATION) JUAN OYARZUN $27,298 (INCLUDED IN DEFERRED COMPENSATION) NERVIN FANOUS $22,952 (INCLUDED IN DEFERRED COMPENSATION) NICOLE VANDERHEYDEN $60,352 ($31,022 INCLUDED IN BONUS & INCENTIVE COMPENSATION AND $29,330 INCLUDED IN DEFERRED COMPENSATION) JAMES SAPIENZA $17,713 ($15,762 INCLUDED IN BONUS & INCENTIVE COMPENSATION AND $1,951 INCLUDED IN DEFERRED COMPENSATION) PART I, LINE 6 CERTAIN PHYSICIANS RECEIVE INCENTIVE COMPENSATION IN ACCORDANCE WITH THEIR EMPLOYMENT AGREEMENTS WITH SALEM HEALTH. AMOUNTS NOTED ON SCHEDULE J PART II COLUMN (II) REFLECT PAYMENTS EARNED BY THESE PHYSICIAN EMPLOYEES IN SUCH AGREEMENTS. ADDITIONALLY, FOR KEY EMPLOYEES AND MANAGEMENT OF SALEM HEALTH THE BOARD OF TRUSTEES HAS APPROVED AN ANNUAL LEADERSHIP INCENTIVE PROGRAM THAT PROVIDES FOR INCENTIVE PAYMENTS BASED ON OBJECTIVE CRITERIA RELATED TO QUALITY AND SAFETY, ENGAGEMENT, PATIENT SATISFACTION AND FINANCIAL PERFORMANCE. JAMES SAPIENZA'S INCENTIVE PAYMENTS ARE BASED ON SALEM HEALTH WEST VALLEY'S BOARD APPROVED LEADERSHIP INCENTIVE PLAN. AMOUNTS NOTED ON SCHEDULE J PART II COLUMN (II) REFLECT PAYMENTS EARNED UNDER THE LEADERSHIP INCENTIVE PLAN. PART I, LINE 7 THE GOVERNANCE COMMITTEE OF THE BOARD OF TRUSTEES, IN CONSULTATION WITH INDEPENDENT COMPENSATION CONSULTANTS, REVIEWS CEO TOTAL COMPENSATION AND PERFORMANCE ANNUALLY. AS PART OF THE COMMITTEE'S ACTIONS, A NON-FIXED BONUS MAY BE AWARDED TO THE CEO. IN THIS YEAR THE NON-FIXED PAYMENT WAS PAID UNDER THE 457(F) NONQUALIFIED PLAN AND IS INCLUDED IN DEFERRED COMPENSATION REPORTED IN PART II. ADDITIONAL INFORMATION FOR EXECUTIVE TRANSITIONS NORMAN GRUBER, DURING THE 2016 CALENDAR YEAR UNTIL HIS RETIREMENT JULY 3, 2016, WAS A LOANED EXECUTIVE TO OHSU PARTNERS ACTING AS THE PRESIDENT OF OHSU PARTNERS. LORI JAMES-NIELSEN WAS CHIEF STRATEGY OFFICER UNTIL AUGUST 1, 2016. SUBSEQUENTLY SHE WAS A LOANED EXECUTIVE TO OHSU PARTNERS UNTIL MARCH 17, 2017. A THE HOSPITAL FACILITY AUTHORITY OF THE CITY OF SALEM OREGON REVENUE BONDS 521542796 794458CY3 2008-11-13 125000000 REFUND SERIES 2004AB AND 2006B. PATIENT TOWER CONSTRUCTION AND OTHER IMP. 0 0 0 B THE HOSPITAL FACILITY AUTHORITY OF THE CITY OF SALEM OREGON REVENUE BONDS 521542796 794458EL9 2016-11-01 215638877 REFUND SERIES 2013 AB AND 2008A. PAY COSTS OF ISSUANCE RELATING TO THE BONDS 0 0 0 A 50000000 125021764 633004 1153492 9260268 113975000 2009 1 0 1 1 B 4360000 216071523 33224410 1448654 181357045 41414 1 1 1 1 A 0 1 1 1 1 1 0.00400 0.00100 0.00500 0 0 1 B 0 1 1 1 1 1 0.00900 0.00200 0.01100 0 0 1 A 0 0 1 1 1 1 UBS AG 25.800000000000 0 0 0 0 1 B 0 1 1 0 0 0 0 0 1 A 1 B 1 SUPPLEMENTAL INFORMATION: COLUMN A: DIFFERENCE BETWEEN PART I(E) AND PART II, LINE 3 IS DUE TO INTEREST EARNINGS IN THE PROJECT FUND. PART I (F): PROCEEDS WERE USED TO REFUND SERIES 2004AB AND SERIES 2006B BONDS, FINANCE THE CONTRUCTION OF THE PATIENT TOWER AND OTHER IMPROVEMENTS. PART II, LINE 1: BONDS REFUNDING SERIES 2008C: SERIES 2013AB (ISSUED JUNE 27, 2013). PART III, LINE 7: AS PROVIDED IN TREASURY REGULATION SECTION 1.141-4(C)(2)(I)(B), THE AMOUNT OF PRIVATE PAYMENTS TAKEN INTO ACCOUNT UNDER THE PRIVATE PAYMENTS TEST MAY NOT EXCEED THE AMOUNT OF PRIVATE BUSINESS USE AND/OR UNRELATED TRADE OR BUSINESS USE. ACCORDINGLY, THE AMOUNT OF PRIVATE PAYMENTS FOR THE REPORTING PERIOD DOES NOT EXCEED THE AMOUNT STATED IN PART III,LINE 6, IS NOT IN EXCESS OF AMOUNTS PERMITTED UNDER SECTION 145 OF THE CODE. PART IV, LINE 2(B): THE REFUNDING AND NEW MONEY PORTIONS OF THE BONDS HAVE MET THE 6-MONTH EXCEPTION TO REBATE. PART IV, LINE 2(C): PROCEEDS OF THE BONDS MET A SPENDING EXCEPTION TO REBATE AND, THEREFORE, NO PAYMENT WILL EVER BE DUE ON THE BONDS. COLUMN B: DIFFERENCE BETWEEN PART I(E) AND PART II, LINE 3 IS DUE TO INTEREST EARNINGS ON BOND PROCEEDS. PART I (F): BONDS PROCEEDS WERE EXPENDED TO REFUND THE 2013AB BONDS (ISSUED ON JUNE27,2013), TO REFUND THE 2008A BONDS (ISSUED ON OCTOBER 8, 2008) TO REFUND THE 2006A BONDS (ISSUED ON NOVEMBER 15, 2006) AND TO PAY COSTS OF ISSUANCE RELATING TO THE BONDS. PART II, LINE 13: SINCE THE PROCEEDS OF THE BONDS WERE USED FOR REFUNDING PURPOSES, THE YEAR OF SUBSTANTIAL COMPLETION IS NOT APPLICABLE. PART III, LINE 7:AS PROVIDED IN TREASURY REGULATION SECTION 1.141-4(C)(2)(I)(B), THE AMOUNT OF PRIVATE PAYMENTS TAKEN INTO ACCOUNT UNDER THE PRIVATE PAYMENT TEST MAY NOT EXCEED THE AMOUNT OF PRIVATE BUSINESS USE AND/OR UNRELATED TRADE OR BUSINESS USE. ACCORDINGLY, THE AMOUNT OF PRIVATE PAYMENTS FOR THE REPORTING PERIOD DOES NOT EXCEED THE AMOUNT STATED IN PART III, LINE 6. THE ORGANIZATION HAS NOT UNDERTAKEN AN ANALYSIS OF THE PRIVATE SECURITY TEST WITH RESPECT TO THE BONDS, AS THE LEVEL OF PRIVATE BUSINESS USE AND/OR UNRELATED TRADE OR BUSINESS REPORTED IN PART III, LINE 6, IS NOT IN EXCESS OF AMOUNTS PERMITTED UNDER SECTION 145 OF THE CODE. PART IV, LINE 2(B): THE PORTION OF BOND PROCEEDS USED FOR CURRENT REFUNDING HAS MET THE 6-MONTH EXCEPTION TO REBATE. FORM 990, PART VI, SECTION B, LINE 11B THE GOVERNANCE COMMITTEE OF THE BOARD OF TRUSTEES REVIEWS THE 990. IT IS THEN FORWARDED TO THE ENTIRE BOARD OF TRUSTEES. FORM 990, PART VI, SECTION B, LINE 12C ON AN ANNUAL BASIS THE SECRETARY OF THE HOSPITAL SHALL SEND TO EACH PERSON WHO IS A TRUSTEE, OFFICER, OR MEMBER OF A COMMITTEE, AND TO THOSE EMPLOYEES OF THE HOSPITAL AS THE BOARD MAY DETERMINE, A COPY OF THE POLICY REGARDING CONFLICTS OF INTEREST, TOGETHER WITH A QUESTIONNAIRE INQUIRING AS TO CONFLICTS, TO BE COMPLETED A AND RETURNED TO THE SECRETARY BY THE TRUSTEE, OFFICER, COMMITTEE MEMBER OR EMPLOYEE PRIOR TO THE BEGINNING OF EACH CALENDAR YEAR. FORM 990, PART VI, SECTION B, LINE 15 EXECUTIVE COMPENSATION AT SALEM HEALTH IS DESIGNED TO ALLOW THE ORGANIZATION TO RECRUIT AND RETAIN QUALIFIED SENIOR LEADERS. THE GOVERNANCE COMMITTEE OF THE SALEM HEALTH BOARD OF TRUSTEES, NONE OF WHOM IS A SALEM HEALTH EMPLOYEE, ENGAGES ONE OR MORE INDEPENDENT CONSULTANTS TO PROVIDE A MARKET DATA ON EXECUTIVE COMPENSATION, INCLUDING BENEFITS, FOR THE CEO AND OTHER EXECUTIVES IN SIMILAR ROLES AT COMPARABLE ORGANIZATIONS. THIS INFORMATION IS USED BY THE GOVERNANCE COMMITTEE IN ITS DISCUSSIONS AND DECISIONS ON CEO COMPENSATION. THE CEO, IN CONJUNCTION WITH OTHER SALARY SURVEY OR PUBLIC INFORMATION AND THE INDEPENDENT CONSULTANT, ENSURES THAT EACH EXECUTIVE'S COMPENSATION IS COMPETITIVE IN THE MARKET FOR SIMILAR POSITIONS AT COMPARABLE ORGANIZATIONS. FORM 990, PART VI, SECTION C, LINE 19 THE CONFLICT OF INTEREST POLICY AND GOVERNING DOCUMENTS ARE AVAILABLE ON THE HOSPITAL WEBSITE. FORM 990, PART XI, LINE 9: CHANGE IN FAIR VALUE OF INTEREST RATE SWAP AGREEMENT 5,954,044. CHANGE IN NET BENEFIT COST 1,220,707. CHANGE IN BENEFICIAL INTEREST IN FOUNDATION -765,371. EQUITY TRANSFER BETWEEN RELATED ENTITIES -1,980,216. MWVP INC 570 LIBERTY ST SE STE 200 SALEM OR 97301 123456789 HOLDS LAND OR SALEM HEALTH HOSPITALS AND CLINICS SALEM HEALTH FOUNDATION 890 OAK STREET SE SALEM OR 97301 237002687 SUPPORTS SALEM HEALTH OR 501(C)(3) 7 SALEM HEALTH HOSPITALS AND CLINICS 0 SALEM HOSPITAL AUXILIARY 890 OAK STREET SE SALEM OR 97301 931081113 SUPPORTS SALEM HEALTH OR 501(C)(3) 9 N/A 0 SALEM HEALTH HOSPITALS & CLINICS 890 OAK STREET SE SALEM OR 97301 930823471 LEASES LAND TO SALEM HEALTH OR 501(C)(3) 11 TYPE 1 N/A 0 SALEM HEALTH WEST VALLEY 525 SOUTHEAST WASHINGTON STREET DALLAS OR 97338 431960221 HOSPITAL OR 501(C)(3) 3 SALEM HEALTH HOSPITALS AND CLINICS 0 WEST VALLEY HOSPITAL FOUNDATION 525 SOUTHEAST WASHINGTON STREET DALLAS OR 97338 931298564 SUPPORTS SALEM HEALTH WEST VALLEY OR 501(C)(3) 11 TYPE 1 SALEM HEALTH HOSPITALS AND CLINICS 0 WILLAMETTE VALLEY INSURANCE COMPANY 745 FORT STREET HONOLULU HI 96813 201836190 CAPTIVE INSURANCE HI 501(C)(3) 11 TYPE 1 SALEM HEALTH HOSPITALS AND CLINICS 0 SALEM HEALTH PROFESSIONAL SERVICES 890 OAK STREET SE SALEM OR 97301 753175249 BILLING SERVICE FOR PROFESSIONAL FEES OR 501(C)(3) 3 SALEM HEALTH HOSPITALS AND CLINICS 0 OREGON COMMUNITY IMAGING LLC 2925 RYAN DR SE SALEM OR 97301 202683062 MEDICAL IMAGING COOPERATIVE OR N/A OHSU PARTNERS 3303 SW BOND AVE STE 6100 PORTLAND OR 97239 475584608 HEALTHCARE SYSTEM MANAGEMENT OR N/A POPULATION HEALTH ALLIANCE OF OREGON LLC 601 SW 2ND AVE STE 1940 PORTLAND OR 97204 471546023 POPULATION HEALTH DATA MANAGEMENT OR N/A RELATED -1882700 951129 0 0 0.23860 WILLAMETTE VALLEY COMMUNITY HEALTH LLC 2995 RYAN DRIVE SE STE 200 SALEM OR 97301 455540852 COORDINATED CARE ORGANIZATION OR N/A RELATED 488963 1008771 0 0 0.09090 PREMIER HEALTHCARE ALLIANCE LP 13034 BALLANTYNE CORPORATE PLACE CHARLOTTE NC 28277 330387407 ENABLE HOSPITALS TO IMPROVE CLINICAL & FINANCIAL PERFORMANCE NC N/A RELATED 1144182 1625554 0 25729 1 0.00210 1 1 1 1 0 0 0 0 0 0 1 0 0 1 1 1 1 1 1