2014-02-04T19:04:39-07:00 2013-03-31 990 2012-04-01 362448028 JACKSON PARK HOSPITAL FOUNDATION JACK 7739477989 7531 Stony Island Avenue Chicago IL 60649 William Dorsey MD 7739477989 2014-01-24 2012 2015-11-30 17:44:51Z William Dorsey MD 7531 Stony Island Avenue Chicago IL 60649 99196469 0 X www.jacksonparkhospital.org X 1960 IL The mission of the physicians, staff, and Board of Directors of the organization is to provide compassionate and high quality healthcare services to meet the needs of the patients and communities we serve. 10 3 926 0 0 0 30000 13622330 122172577 63089919 5545 6038 5898274 22478182 128106396 99196469 0 0 0 0 42366604 41507450 0 0 0 78512906 48455243 120879510 89962693 7226886 9233776 115743843 123963251 32602855 31575135 83140988 92388116 The mission of the physicians, staff and Board of Directors of the organization is to provide compassionate and high quality healthcare services to meet the needs of the patients and communities we serve. 0 0 85565059 63089919 Jackson Park Hospital Foundation provides inpatient and outpatient medical care and behavioral medicine services to Chicago's south side communities regardless of the patients ability to pay. Jackson Park Hospital serves a economically challenged community with high rates of foreclosures, unemployment, violence and some of the worst health indices in the City of Chicago. Jackson Park Hospital itself is challenged to stay viable in such a poorly resourced area. However, Jackson Park Hospital works to deploy its limited resources in ways that most appropriately meets the needs of our community. 0 0 0 85565059 1 1 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 1 0 0 0 0 0 0 1 0 1 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 926 0 1 926 1 0 0 0 0 0 0 X 10 3 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 IL X Nelson Vasquez 7739477989 7531 Stony Island Chicago IL 60649 X Dr Erma Brooks Williams 2 X 0 0 0 James Clark III 2 0 X 0 0 0 Dr Arol Augsburger 2 0 X 0 0 0 William Dorsey MD 40 0 X X 581030 0 8173 Lakshmi Dodda MD 40 0 X 205040 94818 5329 Harshad Mehta MD 40 0 X 122739 0 2957 Bangalore Murthy MD 40 0 X 148924 148359 4774 Haroon Olomi MD 40 0 X 92579 195724 5329 Carryn Carranza MD 40 0 X 0 396020 0 James Nunn MD 40 0 X 65191 333360 15237 Merritt Hasbrouck 40 0 X 497859 0 104 G Randall Smith 40 0 X 485665 0 18237 Nelson Vasquez 40 0 X 199550 0 18237 Barry Mandell 40 0 X 143660 0 17237 Patricia Simon 40 0 X 141282 0 3433 Thodur Ranganathan MD 40 0 X 261572 0 15229 Rose Ette RN 60 0 X 188558 0 4774 Naveed Muhammad MD 40 X 142330 0 14891 Sahr Ngombu RN 50 0 X 121784 0 4986 Georgia Lubben MD 40 0 X 128664 32831 0 3526427 1201112 138927 34 0 1 1 NICL Laboratories 306 ERA Drive BNorthbrook IL 60062 Laboratory Services 1589201 Rush Nursing Services 7501 Stony Island Chicago IL 60649 Temporary Nurse Staff 1396742 Cardinal Health 7000 Cardinal Place Dublin OH 43017 Medical Supplies 944797 EMCARE INC 7032 Collection Center Chicago IL 60693 Provides Emergency Room Physicians 922094 Radiology Imaging Consultants 71 W 156th Street Harvey IL 60426 Provides on site Radiologist 825000 25 0 0 30000 0 0 13592330 0 13622330 The provision of inpatient and outpatient hospital services 622110 63089919 63089919 0 0 0 0 0 0 63089919 6038 0 0 6038 0 0 0 0 0 0 0 0 123650 0 0 0 123650 0 123650 123650 0 0 0 0 0 0 0 0 0 0 0 0 0 30000 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 22354532 22354532 0 0 22354532 99196469 85568101 0 6038 X 3343114 3343114 30729586 30729586 343107 343107 4432689 4432689 2658954 2658954 438822 438822 530758 530758 84940 84940 26214980 26214980 574309 574309 434672 434672 2368354 2368354 268147 268147 Bad Debt 10378910 10378910 0 0 Provider Tax Expense 7161351 7161351 0 0 89962693 85565059 4397634 0 2919609 2706969 0 0 0 0 83622210 92690513 0 0 0 0 0 0 1038425 984524 2075623 2079164 78580494 53714743 25451708 24865751 0 0 0 0 0 0 0 0 636268 636330 115743843 123963251 12281117 11448602 0 0 4179238 4556966 0 0 0 0 0 0 9661827 9089057 0 6480673 6480510 32602855 31575135 X 83140988 92388116 0 0 0 0 83140988 92388116 115743843 123963251 X 9233776 13352 0 0 0 0 X 0 1 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 2482024 0 2482024 46720603 0 33208425 13512178 349716 0 254898 94818 24315181 0 20251420 4063761 4712970 0 0 4712970 24865751 Self Insurance Liability 5769068 Pension Liability 711442 6480510 99196469 0 0 0 0 0 99196469 0 0 0 99196469 89962693 0 0 0 0 0 89962693 0 0 0 89962693 Annual Gala 147781 0 147781 0 0 66759 27280 9000 18537 0 0 147781 0 147781 0 0 66759 27280 9000 18537 121576 26205 1 1 X 1 X 1 X 1 1 1 0 1 1 5553923 5553923 0.0617 0 0 5553923 0 5553923 0.0617 112438 112438 0.0013 3241810 3241810 0.036 7132531 7132531 0.0793 0 0 10486779 0 10486779 0.1166 0 0 16040702 0 16040702 0.1783 1 16430535 12136780 23180084 23059211 120873 X 0 1 1 Jackson Park Hospital Foundation

7531 Stony Island Chicago IL 60649

www.jacksonparkhospital.org X X X X Behavioral Medicine Jackson Park Hospital Foundation 1 1 X X X X X X 13 1 0 0 X 1 0 1 1 200 1 200 1 X X X X X X X 1 1 X X X 0 X 1 X X X 1 0 0 SchH_P01_S00_L07 Schedule H, Part I, Line 7 The costing methodology used to calculate financial assistance at cost is the cost-to-charge ratio derived from the hospitals Medicare cost report. SchH_P01_S00_L072f Schedule H, Part I, Line 7, Column f The hospital reported a total of $39,716,062 in Bad Debt. SchH_P03_S0A_L04 Schedule H, Part III, Section A, Line 4 In July 2011, the FASB issued ASU 2011-07, Presentation and Disclosure of Patient Service Revenue, Provision for Bad Debt, and the Allowance for Doubtful Accounts for Certain Health Care Entities. ASU 2011-07 amends Accounting Standards Codification 954, Health Care Entities, to provide financial statement users with greater transparency about a health care entity's net patient service revenue, which is sometimes grossed up and recognized at the time the services are rendered regardless of whether the entity expects to collect that amount, and the related allowance for doubtful accounts. ASU 2011-07 provides information to assist financial statement users in assessing an entity's sources of net patient service revenue and related changes in its allowance for doubtful accounts. It requires health care entities that recognize significant amounts of patient service revenue at the time the services are rendered, even though they do not assess the patient's ability to pay, to present the provision for bad debts related to patient service revenue as a deduction from patient service revenue (net of contractual allowances and discounts) on their statement of operations. For non-public entities, ASU 2011-07 is effective for the first annual period ending after December 15, 2012, and interim and annual periods thereafter, with early adoption permitted. The Corporation adopted this new standard in fiscal year 2013. SchH_P03_S0B_L08 Schedule H, Part III, Section B, Line 8 The cost of providing care to Medicare patients was based on completion of the Medicare cost report. SchH_P06_S00_L02 Schedule H, Part VI, Line 2 Jackson Park Hospital Foundation begins outreach and assessment of its community health by evaluating which health conditions and diseases are prevalent among its inpatient and outpatients. The hospital has also purchased community health information services from the Metropolitan Chicago Healthcare Council. Together, they confirm the need for education and other interventions for diabetes, asthma and behavioral medicine. The hospital has responded to these needs through the development of several community education programs and specialty clinics. SchH_P06_S00_L03 Schedule H, Part VI, Line 3 The hospital has contracted with a third party that assist any patient through the application process of Medicaid or Medicare. This company will also assist the patient and or the family through the hospitals charity application process. SchH_P06_S00_L04 Schedule H, Part VI, Line 4 Jackson Park Hospital's primary service area is 60649, 60619, 60620,60617 and 60628. Our primary service area for our behavioral patients is much broader and encompass the City of Chicago. The average income in the hospitals primary service area is approximately 46% of the State of Illinois average. SchH_P06_S00_L07 Schedule H, Part VI, Line 7 Jackson Park Hospital Foundation prepared an annual Community Benefit Report which is submitted to the Attorney General of the State of Illinois. X X X X 0 0 0 0 0 0 0 0 0 Dr Erma Brooks Williams 0 0 0 0 0 0 0 0 0 0 0 0 0 Dr Arol Augsburger 0 0 0 0 0 0 0 0 0 0 0 0 0 James Clark III 0 0 0 0 0 0 0 0 0 0 0 0 0 0 William Dorsey MD 581030 0 0 0 0 0 0 0 8173 0 589203 0 223283 Lakshmi Dodda MD 205040 94818 0 0 0 0 0 0 5329 0 210369 94818 188091 91878 Harshad Mehta MD 122739 0 0 0 0 0 0 0 2957 0 125696 0 120308 0 Bangalore Murthy MD 148924 148359 0 0 0 0 0 0 4774 0 153698 148359 130193 Haroon Olomi MD 92579 195724 0 0 0 0 0 0 5329 0 97908 195724 0 175655 Carryn Carranza MD 0 396020 0 0 0 0 0 0 0 0 0 396020 0 377817 James Nunn MD 65191 333360 0 0 0 0 0 0 15237 0 80428 333360 0 0 Merritt Hasbrouck 497859 0 0 0 0 0 0 0 104 0 497963 0 480132 0 G Randall Smith 485665 0 0 0 0 0 0 0 18237 0 503902 0 489830 0 Nelson Vasquez 199550 0 0 0 0 0 0 0 18237 0 217787 0 222084 0 Barry Mandell 143660 0 0 0 0 0 0 0 17237 0 160897 0 163755 0 Patricia Simon 141282 0 0 0 0 0 0 0 3433 0 144715 0 152144 0 Thodur Ranganathan MD 261572 0 0 0 0 0 0 0 15229 0 276801 0 307372 0 Rose Ette RN 188558 0 0 0 0 0 0 0 4774 0 193332 0 199879 0 Naveed Muhammad MD 142330 0 0 0 0 0 0 0 14891 0 157221 0 183886 0 Sahr Ngombu RN 121784 0 0 0 0 0 0 0 4986 0 126770 0 0 0 Georgia Lubben MD 128664 32831 0 0 0 0 0 0 0 0 128664 32831 0 0 F990_P06_S0B_L11b Form 990, Part VI, Section B, Line 11b The management and members of the audit committee review the return prior to its release. F990_P06_S0B_L12c Form 990, Part VI, Section B, Line 12c All officers, directors or trustees, and key employees are required to complete a conflict of interest disclosure form every three years. Jackson Park Hospital Foundation is scheduled to complete this procedure in its fiscal year 2014. F990_P06_S0B_L15 Form 990, Part VI, Section B, Line 15 Jackson Park Hospital Foundation has a compensation committee. The Chairman of The Board reviews the compensation of senior management and key employees on an annual basis. F990_P06_S0C_L19 Form 990, Part VI, Section C, Line 19 Jackson Park Hospital Foundation makes its 990, Conflict of Interest policy, Community Benefit Report and financial statements available to the public by appointment with its Vice President Finance. F990_P07_S0B_L01A Form 990, Part VII, Section B, Line 1(A) Description of services NICL Laboratories - hospital laboratory testing. Rush Nursing Services - temporary registered nurse staffing. Cardinal Health - patient medical supplies. EMCARE - Emergency physician staffing. Radiology Imaging Consultants - Radiology physician staffing. F990_P09_S00_L11g Form 990, Part IX, Line 11g Other direct expenses related to patient care. F990_P11_S00_L05 Form 990, Part XI, Line 5 Net unrealized gains (losses) on investments as reported by the hospitals pension trustee. The Friedell Clinic SC 7531 Stony Island Avenue Chicago IL 60649 363290656 Primary Health Care IL C 100 100 1 0 The Foundation For Jackson Park Hospital 7531 Stony Island Ave Chicago IL 60649 270029181 Raise funds for the hospital's charitable purpose. IL C 100 100 1 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 The Foundation For Jackson Park Hospital c 30000 Actual receipt