2016-08-10T18:42:36-05:00 2015-09-30 381357951 PLANTE & MORAN PLLC 10 S RIVERSIDE PLAZA 9TH FLOOR CHICAGO IL 60606 990 2014-10-01 361564290 NORWEGIAN AMERICAN HOSPITAL INC NORW 7732928200 1044 NORTH FRANCISCO AVENUE CHICAGO IL 60622 GARY KRUGEL CFO 7732928200 2016-08-03 1 DAVID LOWENTHAL P00378651 3122071040 2016-08-03 2014 2016-12-15 16:53:06Z JOSE R SANCHEZ 1044 NORTH FRANCISCO AVENUE CHICAGO IL 60622 121197983 0 X WWW.NAHOSPITAL.ORG X 1935 IL NORWEGIAN AMERICAN HOSPITAL PROVIDES QUALITY AND COMPASSIONATE HEALTH CARE SERVICES BY PARTNERING WITH PATIENTS AND THEIR FAMILIES, OUR EMPLOYEES, PHYSICIANS AND THE COMMUNITIES WE SERVE. 12 10 1106 165 0 0 219946 517885 117016219 119473777 809660 99665 -42431 -51872 118003394 120039455 0 0 0 0 55475792 54165228 0 0 0 62010396 62965889 117486188 117131117 517206 2908338 104559133 107970510 67985841 74861725 36573292 33108785 X NORWEGIAN AMERICAN HOSPITAL PROVIDES QUALITY AND COMPASSIONATE HEALTH CARE SERVICES BY PARTNERING WITH PATIENTS AND THEIR FAMILIES, OUR EMPLOYEES, PHYSICIANS AND THE COMMUNITIES WE SERVE. 0 0 73568970 119473777 NORWEGIAN AMERICAN HOSPITAL IS A PREMIER HEALTH CARE PROVIDER WHERE THE PATIENT COMES FIRST. AS AN ORGANIZATION OF CAREGIVERS, NORWEGIAN AMERICAN INSPIRES TO CONSISTENTLY HIGH STANDARDS OF QUALITY, FAMILY-CENTERED HEALTH CARE SERVICES AND COST EFFECTIVENESS. NORWEGIAN AMERICAN HOSPITAL 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, 2015, NORWEGIAN AMERICAN HOSPITAL ESTIMATES IT PROVIDED $2,555,288 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. NORWEGIAN AMERICAN 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 2014, NORWEGIAN AMERICAN HOSPITAL SERVED 8,357 PATIENTS ADMITTED WHO RECEIVED 40,413 DAYS OF HEALTHCARE SERVICES. 73568970 1 1 0 1 0 0 0 0 0 0 1 0 0 1 1 1 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 92 0 1 1106 1 0 0 0 0 0 0 0 0 0 0 X 12 10 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 1 1 IL X GARY KRUGEL CFO 7732928200 1044 NORTH FRANCISCO AVENUE CHICAGO IL 60622 BILLY OCASIO CHAIRMAN 5.00 0.00 X X 0 0 0 WILMI SCHMIDT VICE-CHAIRMAN 4.00 0.00 X X 0 0 0 SANDRA VALENZULA SECRETARY 8.00 0.00 X X 0 0 0 LOUIS TINAJERO TREASURER 8.00 0.00 X X 0 0 0 ADAM BORIS TRUSTEE 2.00 0.90 X 0 0 0 RICHARD A BLABOLI TRUSTEE 2.00 0.00 X 0 0 0 CARMEN C HOVANEC TRUSTEE 2.00 0.00 X 0 0 0 LOUIS MANETTI TRUSTEE 2.00 0.00 X 0 0 0 MANUEL MARTINEZ MD TRUSTEE 2.00 0.00 X 0 0 0 JOHN MONTEVERDE MD TRUSTEE 2.00 0.00 X 0 0 0 OLGA SAAVEDRA MD TRUSTEE 2.00 0.00 X 0 0 0 RAFAEL CAMPANINI MD TRUSTEE 2.00 0.00 X 22000 0 0 SANCHEZ JOSE R PRESIDENT AND CEO (EX-OFFICIO) 40.00 0.00 X 552300 0 421475 ABHA AGRAWAL VP, MEDICAL AFFAIRS/COO 40.00 0.00 X 530094 0 22176 GARY KRUGEL CHIEF FINANCIAL OFFICER 40.00 0.00 X 222888 0 5004 NARAYAN RAVISHANKAR MD ANESTHESIOLOGIST 40.00 0.00 X 406323 0 15624 MAX IZBICKI MD PHYSICIAN, OB/GYN 40.00 0.00 X 326980 0 200 QAISER JAMAL MD CHIEF HOSPITALIST 40.00 0.00 X 246160 0 30925 JANA RICHARDS MD HOSPITALIST, OB/GYN 40.00 0.00 X 222838 0 2180 DAGOBERTO CAMACHO MD MEDICAL DIRECTOR 40.00 0.00 X 207282 0 9466 ANTHONY EVERS FORMER CHIEF FINANCIAL OFFICER 0.00 0.00 X 207733 0 6512 2944598 0 513562 59 1 1 0 SODEXO INC & AFFILIATES 4880 PAYSPHERE CIRCLE CHICAGO IL 60674 DIETARY & FACILITIES MANAGEMENT SERVICES 2194885 QUEST DIAGNOSTICS 12989 COLLECTIONS CENTER DRIVE CHICAGO IL 60693 LAB SERVICE CONTRACT 1845466 US BANK CORPORATE TRUST 2501 SW 1ST AVE SUITE 200 PORTLAND OR 97201 SHIFTWISE NURSING STAFFING AGENCY 1472676 CONTINENTAL ANESTHESIA 1301 W 22ND ST 610 OAKBROOK IL 60523 ANESTHESIA SERVICE CONTRACT 1323041 GE HEALTHCARE 5517 COLLECTIONS DRIVE CHICAGO IL 60693 RADIOLOGY BIOMEDICAL EQUIPMENT SERVICE 861355 39 517885 517885 MEDICARE/MEDICAID PAYMENTS 621110 69250118 69250118 MEDICAID ASSESSMENT REVENUE 621110 20798095 20798095 NET PATIENT SERVICES 621110 17312530 17312530 ACA ACCESS PAYMENTS 621110 6316430 6316430 OPERATING REVENUE 621110 5373155 5373155 423449 423449 119473777 102376 102376 13590 65462 -51872 -51872 -51872 1090105 250 1093066 0 -2961 250 -2711 -2711 120039455 119473777 0 47793 X 1251199 1251199 44974227 33644996 11329231 573499 6 573493 4356747 3589211 767536 3009556 2419442 590114 788308 422057 366251 109000 109000 103981 103981 247716 247716 73579 73579 14806799 11085952 3720847 164169 96891 67278 1784905 53367 1731538 1351382 234974 1116408 102092 59596 42496 1560119 2 1560117 5121307 2264303 2857004 4888422 121719 4766703 MEDICAL SUPPLIES 9222557 9257623 -35066 IL MEDICAID TAX ASSESSM 7512945 7512945 PROVISION FOR BAD DEBT 5460096 5460096 NON-MEDICAL SUPPLIES 1580745 1300507 280238 8087767 3558228 4529539 117131117 73568970 43562147 0 7793979 8080779 6683536 6492228 16998649 21869359 1027308 970432 2362379 1176713 129687218 96547767 35638364 33139451 17293461 17299833 16761457 18941715 104559133 107970510 12192063 14103129 2013014 129029 18882009 18567547 34898755 42062020 67985841 74861725 X 34271416 31181939 2301876 1926846 36573292 33108785 104559133 107970510 X 2908338 -124005 -6248840 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 57716 247716 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. 4529913 4529913 47253795 34208706 13045089 3602004 3082119 519885 73387224 59256942 14130282 914282 914282 33139451 INSURANCE RECOVERIES RECEIVABLE 5308230 PROPERTY HELD FOR FUTURE USE 1189446 INVESTMENT IN JOINT VENTURE 8359018 DUE FROM AFFILIATES 102946 BENEFICIAL INTEREST IN NET ASSETS OF FOUNDATION 1766846 INVESTMENT IN SUBSIDIARY 1178713 OTHER ASSETS 1036516 18941715 ACCRUED MALPRACTICE LIABILITY 21421366 CONDITIONAL ASSET RETIREMENT OBLIGATION 2757600 NET PENSION LIABILITY 15781697 DUE TO THIRD PARTY PROGRAMS 2086915 EQUIPMENT LOANS 14442 42062020 X PART X, LINE 2: ACCOUNTING PRINCIPLES GENERALLY ACCEPTED IN THE UNITED STATES OF AMERICA REQUIRE MANAGEMENT TO EVALUATE TAX POSITIONS TAKEN BY THE HOSPITAL AND RECOGNIZE A TAX LIABILITY IF THE HOSPITAL HAS TAKEN AN UNCERTAIN POSITION THAT MORE LIKELY THAN NOT WOULD NOT BE SUSTAINED UPON EXAMINATION BY THE IRS OR OTHER APPLICABLE TAXING AUTHORITIES. MANAGEMENT HAS ANALYZED THE TAX POSITIONS TAKEN BY THE HOSPITAL AND HAS CONCLUDED THAT AS OF SEPTEMBER 30, 2015, THERE ARE NO UNCERTAIN POSITIONS TAKEN OR EXPECTED TO BE TAKEN THAT WOULD REQUIRE RECOGNITION OF A LIABILITY OR DISCLOSURE IN THE CONSOLIDATED FINANCIAL STATEMENTS. THE HOSPITAL IS SUBJECT TO ROUTINE AUDITS BY TAXING JURISDICTIONS; HOWEVER, THERE ARE CURRENTLY NO AUDITS FOR ANY TAX PERIODS IN PROGRESS. MANAGEMENT BELIEVES IT IS NO LONGER SUBJECT TO INCOME TAX EXAMINATIONS FOR YEARS PRIOR TO SEPTEMBER 30, 2012. 1 1 X 1 X 1 X 600.000000000000 1 1 1 0 1 1 2555287 2555287 0.02290 59436635 63422313 -3985678 0.03500 61991922 63422313 -1430391 0.05790 479363 519743 -40380 0.00000 1331290 1890474 -559184 0.00500 1810653 2410217 -599564 0.00500 63802575 65832530 -2029955 0.06290 1 5460096 0 23001995 21161575 1840420 X 1 1 1 CENTURY PHO INC TO OBTAIN AND MANAGE CONTRACTS WITH HEALTH MAINTENANCE ORGANIZATIONS. 0.50000 0.00000 0.50000 1 1 NORWEGIAN AMERICAN HOSPITAL INC 1044 N FRANCISCO CHICAGO IL 60660 WWW.NAHOSPITAL.ORG X X NORWEGIAN AMERICAN HOSPITAL INC 0 0 1 X X X X X X X X X 14 1 0 0 1 X WWW.NAHOSPITAL.ORG/WP-CONTENT/UPLOADS/2016/01/CHNA-2014.PDF 1 14 1 WWW.NAHOSPITAL.ORG/WP-CONTENT/UPLOADS/2016/01/CHNA-2014.PDF 0 0 1 X 200.000000000000 600.000000000000 X X X X 1 1 1 X SEE PART V X SEE PART V X X 1 0 X X X X 1 X 0 0 NORWEGIAN AMERICAN HOSPITAL, INC. 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). NORWEGIAN AMERICAN HOSPITAL'S UNINSURED DISCOUNT FOR FY 2015 IS 60% AS ROUNDED UP FROM THE CALCULATION AS SHOWN BELOW. 2014 COST TO CHARGE RATIO = 29.27%29.27% X 135% = 39.51%100% - 39.51% = 60.49% PART V, LINE 16B, FAP WEBSITE: HTTP://WWW.NAHOSPITAL.ORG/WP-CONTENT/UPLOADS/2015/11/FB-300-FINANCIAL-ASSISTANCE.PDF PART V, LINE 16B, FAP APPLICATION WEBSITE: HTTP://WWW.NAHOSPITAL.ORG/WP-CONTENT/UPLOADS/2015/11/ASSISTANCE.PDF PART V, SECTION B, LINE 16 FINANCIAL ASSISTANCE POLICY WEBSITE AVAILABILITY NORWEGIAN AMERICAN HOSPITAL, INC. PART V, SECTION B, LINE 16A WEBSITE: SEE PART V NORWEGIAN AMERICAN HOSPITAL, INC. PART V, SECTION B, LINE 16B WEBSITE: SEE PART V PART I, LINE 3C: NORWEGIAN AMERICAN HOSPITAL 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. NORWEGIAN AMERICAN HOSPITAL 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 (B) WOULD HAVE BEEN $9,299,472 OR 8.33 PERCENT OF TOTAL EXPENSE. THIS WOULD HAVE INCREASED THE TOTAL NET COMMUNITY BENEFIT EXPENSE ON LINE 7K, COLUMN (E) FROM ($2,029,955) TO $11,255,195 OR 10.08 PERCENT OF TOTAL EXPENSE. PART I, LINE 7G: NORWEGIAN AMERICAN HOSPITAL DID NOT INCLUDE ANY COSTS ATTRIBUTABLE TO A PHYSICIAN CLINIC AS SUBSIDIZED HEALTH SERVICES. PART I, LN 7 COL(F): THERE WAS A TOTAL OF BAD DEBT EXPENSE OF $5,460,096 SUBTRACTED FROM TOTAL EXPENSES. 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. AN ALLOWANCE FOR CONTRACTUAL ADJUSTMENTS AND INTERIM PAYMENT ADVANCES IS BASED ON EXPECTED PAYMENT RATES FROM PAYORS BASED ON CURRENT REIMBURSEMENT METHODOLOGIES. THIS AMOUNT ALSO INCLUDES AMOUNTS RECEIVED AS INTERIM PAYMENTS AGAINST UNPAID CLAIMS BY CERTAIN PAYORS. IN EVALUATING THE COLLECTIBILITY OF ACCOUNTS RECEIVABLE, THE HOSPITAL ANALYZES ITS PAST HISTORY AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYOR SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND PROVISION FOR BAD DEBTS. MANAGEMENT REGULARLY REVIEWS DATA ABOUT THESE MAJOR PAYOR SOURCES OF REVENUE IN EVALUATING THE SUFFICIENCY OF THE ALLOWANCE FOR DOUBTFUL ACCOUNTS.FOR RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRD-PARTY COVERAGE, THE HOSPITAL ANALYZES CONTRACTUALLY DUE AMOUNTS AND PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS AND A PROVISION FOR BAD DEBTS, IF NECESSARY (FOR EXAMPLE, FOR EXPECTED UNCOLLECTIBLE DEDUCTIBLES AND COPAYMENTS ON ACCOUNTS FOR WHICH THE THIRD PARTY PAYOR HAS NOT YET PAID, OR FOR PAYORS WHO ARE KNOWN TO BE HAVING FINANCIAL DIFFICULTIES THAT MAKE THE REALIZATION OF AMOUNTS DUE UNLIKELY).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 A SIGNIFICANT PROVISION FOR BAD DEBTS 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. THE DIFFERENCE BETWEEN THE STANDARD RATES (OR THE DISCOUNTED RATES IF NEGOTIATED) AND THE AMOUNTS ACTUALLY COLLECTED AFTER ALL REASONABLE COLLECTION EFFORTS HAVE BEEN EXHAUSTED IS CHARGED OFF AGAINST THE ALLOWANCE FOR DOUBTFUL ACCOUNTS IN THE PERIOD THEY ARE DETERMINED TO BE UNCOLLECTIBLE.THE BAD DEBT EXPENSE REPORTED ON PART III, LINE 2, IS THE BAD DEBT EXPENSE REPORTED ON FORM 990, PART IX.ALL OF THE HOSPITAL'S PATIENTS AUTOMATICALLY QUALIFY FOR FINANCIAL ASSISTANCE IF THEY DO NOT HAVE INSURANCE (THEY ARE CONSIDERED "SELF-PAY AND GIVEN 60% DISCOUNT). ONCE THE HOSPITAL DETERMINES THAT A PATIENT HAS NO INSURANCE, THEY AUTOMATICALLY DISCOUNT THE BILL BY 60%. 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 (60% DISCOUNT) BUT DID NOT PAY THEIR 40%. THEREFORE, ZERO HAS BEEN REPORTED IN PART III, LINE 3.PART III, SECTION B: 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 $32,070,982 AND THE AMOUNT OF (SHORTFALL) WOULD HAVE BEEN ($9,068,987). 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, 2014 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, 60% DISCOUNT IS APPLIED TO PATIENT ACCOUNT AND PATIENT IS NOTIFIED IN WRITING FOR THE OUTSTANDING BALANCE. PART VI, LINE 2: NORWEGIAN AMERICAN HOSPITAL'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 NORWEGIAN AMERICAN HOSPITAL'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 NORWEGIAN AMERICAN HOSPITAL'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 NORWEGIAN AMERICAN HOSPITAL INVOLVEMENT. IN DEVELOPING ITS COMMUNITY BENEFITS PLAN, NORWEGIAN AMERICAN HOSPITAL SET THE FOLLOWING GOALS:1) SERVE AS A CATALYST/CONVENER FOR THE OBESITY AND DIABETES INITIATIVES IN HUMBOLDT PARK.2) HOST COMMUNITY-BASED EDUCATION EVENTS SUCH AS ESL, LIFE SKILLSTRAINING, JOB SEEKING SKILLS, ETC.3) PROMOTE INITIATIVES THAT ENHANCE ACCESS TO HEALTH CARE FOR THE UNINSURED AND UNDERINSURED.4) NORWEGIAN AMERICAN HOSPITAL LEADERSHIP TO ASSUME AN ACTIVE ROLE IN COMMUNITY BASED ORGANIZATIONS BOARDS, TASK FORCES AND COMMUNITY EVENTS. PART VI, LINE 3: NORWEGIAN AMERICAN HOSPITAL 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: NORWEGIAN AMERICAN HOSPITAL SERVES A PRIMARY COMMUNITY AREA AND A SECONDARY COMMUNITY AREA.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%NORWEGIAN AMERICAN HOSPITAL'S AGE FOR THE FISCAL YEAR WAS AS FOLLOWS:AGE PERCENTAGE0-14 2%15-44 44%45-64 37%65-74 9%75+ 8%NORWEGIAN AMERICAN HOSPITAL'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, NORWEGIAN AMERICAN HOSPITAL 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.-LANGUAGE-ASSISTANCE SERVICES, SUCH AS TRANSLATORS, SIGNAGE, FORMS, BROCHURES, PATIENT EDUCATION MATERIALS AND OTHER INFORMATION IN LANGUAGES OTHER THAN ENGLISH.-DONATIONS BY NORWEGIAN AMERICAN HOSPITAL OF MEETING AND CLINIC SPACE, AS WELL AS OTHER ASSISTANCE TO COMMUNITY GROUPS. PART VI, LINE 6: NOT AFFILIATED PART VI, LINE 7, REPORTS FILED WITH STATES IL X 1 1 X X 1 1 0 0 0 0 0 0 0 SANCHEZ JOSE R PRESIDENT AND CEO (EX-OFFICIO) 535500 0 0 0 16800 0 417165 0 4310 0 973775 0 0 0 ABHA AGRAWAL VP, MEDICAL AFFAIRS/COO 430094 0 100000 0 0 0 5200 0 16976 0 552270 0 0 0 GARY KRUGEL CHIEF FINANCIAL OFFICER 160000 0 62888 0 0 0 4458 0 546 0 227892 0 0 0 NARAYAN RAVISHANKAR MD ANESTHESIOLOGIST 406323 0 0 0 0 0 5200 0 10424 0 421947 0 0 0 MAX IZBICKI MD PHYSICIAN, OB/GYN 326980 0 0 0 0 0 0 0 200 0 327180 0 0 0 QAISER JAMAL MD CHIEF HOSPITALIST 245785 0 375 0 0 0 4457 0 26468 0 277085 0 0 0 JANA RICHARDS MD HOSPITALIST, OB/GYN 222838 0 0 0 0 0 0 0 2180 0 225018 0 0 0 DAGOBERTO CAMACHO MD MEDICAL DIRECTOR 207282 0 0 0 0 0 0 0 9466 0 216748 0 0 0 ANTHONY EVERS FORMER CHIEF FINANCIAL OFFICER 117565 0 0 0 90168 0 0 0 6512 0 214245 0 0 0 PART I, LINE 1A NAH PAYS MEMBERSHIP DUES ON BEHALF OF JOSE SANCHEZ TO A SOCIAL CLUB. THE MEMBERSHIP IS USED EXCLUSIVELY FOR BUSINESS PURPOSES. PART I, LINES 4A-B FORMER CFO ANTHONY EVERS RECEIVED A SEVERANCE PAYMENT OF $90,168 IN APRIL OF 2014. JOSE SANCHEZ PARTICIPATED IN A SUPPLEMENTAL NONQUALIFIED RETIREMENT PLAN. $417,165 WAS CREDITED TO HIS ACCOUNT IN THE FISCAL YEAR 2015. A ILLINOIS FINANCE AUTHORITY REVENUE BONDS SERIES 2008 861091967 45200FMQ9 2008-08-15 4500000 SEE PART VI 0 0 0 B ILLINOIS FINANCE AUTHORITY REVENUE BONDS SERIES 2008 861091967 45200FMS5 2008-08-15 5000000 SEE PART VI 0 0 0 C ILLINOIS FINANCE AUTHORITY REVENUE BONDS SERIES 2008 861091967 45200FMT3 2008-08-15 14450000 SEE PART VI 0 0 0 A 4500000 798333 1159612 157619 2384436 2008 1 0 1 1 B 5000000 798334 1159612 157619 2884435 2008 1 0 1 1 C 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 C 0 0 0 0 0 0 1 A 0 0 0 0 0 0 THE ARBITRAGE GROUP 0 0 0 0 0 B 0 0 0 0 0 0 THE ARBITRAGE GROUP 0 0 0 0 0 C 0 0 0 0 0 0 THE ARBITRAGE GROUP 0 0 0 0 0 A 0 B 0 C 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. JOHN MONTEVERDE MD TRUSTEE 192999 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 11 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. THE RESULTS OF THAT REVIEW WERE PROVIDED TO THE EXECUTIVE COMMITTEE OF THE BOARD OF TRUSTEES. FORM 990, PART VI, SECTION C, LINE 19 NORWEGIAN AMERICAN HOSPITAL INC. MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART IX, LINE 11G PROFESSIONAL FEES NONMEDICAL: PROGRAM SERVICE EXPENSES 1,386,478. MANAGEMENT AND GENERAL EXPENSES 1,663,810. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 3,050,288. OUTSOURCED SERVICES: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 512,551. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 512,551. TEMP AGENCY: PROGRAM SERVICE EXPENSES 4,372,317. MANAGEMENT AND GENERAL EXPENSES 404,751. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 4,777,068. PHYSICIAN FEES: PROGRAM SERVICE EXPENSES 5,304,373. MANAGEMENT AND GENERAL EXPENSES 893,018. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 6,197,391. CONSULTING FEES: PROGRAM SERVICE EXPENSES 4,439. MANAGEMENT AND GENERAL EXPENSES 246,717. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 251,156. LAB SERVICES FOR CLINICS: PROGRAM SERVICE EXPENSES 18,345. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 18,345. FORM 990, PART XI, LINE 9: INCOME (LOSS) FROM NORWEGIAN AMERICAN HOSPITAL FOUNDATION -633,026. INCOME (LOSS) FROM INVESTMENTS IN JOINT VENTURES 462,313. PENSION RELATED CHANGES, OTHER THAN NET PERIOD PENSION COST -6,048,049. NET ASSETS RELEASED FROM RESTRICTION -30,078. NORWEGIAN AMERICAN HOSPITAL FOUNDATION 1044 NORTH FRANCISCO AVENUE CHICAGO IL 60622 363257131 SUPPORTING FOUNDATION IL 501(C)(3) LINE 11A, I NORWEGIAN AMERICAN HOSPITAL INC 1 CENTENNIAL MEDICAL MANAGEMENT CORPORATION 1044 NORTH FRANCISCO AVENUE CHICAGO IL 60622 363394548 OUTPATIENT PHARMACY IL NORWEGIAN AMERICAN HOSPITAL INC C 599971 1210572 1.00000 1 1 0 1 0 0 0 0 0 0 1 0 0 0 1 1 0 0 0 0 NORWEGIAN AMERICAN HOSPITAL FOUNDATION A 4800 BOOK VALUE CENTENNIAL MEDICAL MANAGEMENT CORPORATION A 9722 BOOK VALUE NORWEGIAN AMERICAN HOSPITAL FOUNDATION C 517885 BOOK VALUE