2014-05-14T12:36:16-05:00 2013-06-30 861065772 Deloitte Tax LLP 111 South Wacker Drive Chicago IL 60606 990 2012-07-01 362170840 Copley Memorial Hospital Inc c/o Rush-Copley Medical Ctr COPL 6309786200 2000 Ogden Avenue Aurora IL 605044206 Brenda VanWyhe 6309786200 2014-05-14 1 Laura Gillespie P00855604 3124861000 2012 2015-11-30 17:44:51Z Barry Finn 2000 Ogden Avenue Aurora IL 605044206 373333955 0 X www.rushcopley.com X 1886 IL To provide advanced medicine with quality outcomes and extraordinary care. 17 15 2027 250 0 0 1233078 893313 259634483 273284274 9412271 15780198 684692 6484366 270964524 296442151 20545 31010 0 0 116659646 125217858 0 0 0 117710952 128759262 234391143 254008130 36573381 42434021 367178403 423189731 213125243 233916155 154053160 189273576 X The mission of Rush-Copley is to provide advanced medicine with quality outcome and extraordinary care. 0 0 193476500 31010 278596449 Copley Memorial Hospital's mission is to provide advanced medicine with quality outcomes and extraordinary care. The focus on advanced medicine is concentrated in Copley Memorial Hospital's centers of excellence or "Institutes". Institutes represent the major service lines of the medical center: Cancer Care; Emergency Services; Heart & Vascular; Neuroscience; and Women's Health. The designation of Institutes allows the organization to prioritize among diverse opportunities and focus resources on these service lines. To that end, the medical center seeks to serve the community in ways that engage, educate and empower. In 2012, Copley Memorial Hospital proudly collaborated with dozens of civic and community groups to impact the knowledge, health and well being of the community. Copley Memorial Hospital offers free educational programs ranging from hand hygiene education aimed at preschool and primary grade school aged children to annual seminars educating adults about diabetes, heart health, cancer prevention, weight control, smoking cessation and more.A bimonthly newsletter is published and highlights health information and calendar of events info to 80,000+ households throughout the hospital service area. Free and reduced cost health screenings are regularly offered including free blood pressure monitoring on a walk-in basis.Highlighted Health Programming includes:During 2012, Copley Memorial Hospital ("The Hospital") sponsored, partnered or participated in over 600 community-based programs and events with special emphasis on improving the health and wellness of adults, children and underserved populations.Nutrition and Weight LossFour programs aimed at providing sound nutrition advice and weight loss strategies were held during the year. Topics included women and weight loss, strength training, and one pot meals. 54 people attended.Diabetes Presentations about diabetes and related screenings were conducted throughout the year at various community locations. Fasting glucose and blood pressure screenings were provided to over 560 community members.Smoking CessationThe Freedom from Smoking class was offered four times with a total of 19 participants. This free eight-week program provides support and the skills needed to quit smoking.Cancer Awareness and InformationFour classes and programs focusing on cancer were held in the community with over 300 participants. Programs offered included a course on survivorship, an ongoing yoga series and a special celebration of National Cancer Survivors Day.Latina Talks (Platicas Para Mujeres)Latina Talks (Platicas Para Mujeres) is an educational series geared toward the healthcare needs of Latina women. Latina Talks is offered nine times a year from September through May targeting Latina women in the Fox Valley area. Topics presented by professional healthcare providers include: A Healthy Weight, Breast Health, Layman's Guide to Mental Health, Over the Counter Medications, A Healthy Heart, Yoga & Meditation, Obesity: Causes & Consequences, Women's Health & Screenings and more. Typically, between 10 and 25 women attend the monthly sessions. In addition, Rush-Copley partners with Aurora University nursing students to provide daycare. Over 150 women have benefited from the presentations in the last year.Older Adult EducationEducational and interactive talks designed to provide seniors with health information and education are presented regularly at the Beecher Community Center in Yorkville. This program reaches approximately 300 seniors annually and provides healthcare presentations and with question and answer sessions.The Breakfast Club is a program offered to the senior community at large and takes place at Sunnymere, an assisted living facility. Bi-monthly presentations are attended by annually by 150 seniors.Pregnancy and ChildbirthPrenatal education classes are offered to couples who are pregnant or considering having a baby. Class topics include New Advances in Infertility, Thinking about Having a Baby, Breastfeeding, Bringing Home Baby and Child Safety. Tours of the Family Birth Center are also provided. Over 2,100 people participated in 2012.VascularSeveral PVD screenings took place through the year as well as programs that discussed healthy legs and veins. Over 200 people benefited from these activities. Movement DisordersFour community programs were offered to people who were experiencing or care for a person experiencing a movement disorder. 222 people attended these programs.WomenOver 200 women attended programs aimed specifically for them. Topics in the Women to Women series included mammography, heart, and breast and GI health. Other program topics included Financial Freedom and Continence. Physician Referral LineCopley Memorial Hospital offers a free physician and information referral telephone service to the community. This service allows community members to talk with a call advisor to match a person's health needs and preferences with the physician of their choice or link callers to services provided by the medical center. Over 13,500 people used this service in 2012.WebsiteCopley Memorial Hospital's website, www.rushcopley.com, with translation available into dozens of languages, offers access to free health information, a health encyclopedia, and a symptom checker. In 2012, there were over 890,000 visits to rushcopley.com. Copley Memorial Hospital provides a free speaker's bureau to community-based groups and routinely participates and sponsors health fairs aimed at minority populations including the yearly African American Health Fair and the annual Latina Health Festival.Together, these initiatives provided a positive influence for thousands of residents in the communities served by Copley Memorial Hospital.Charity Care - It is an inherent part of the Hospital's mission to provide necessary medical care free of charge, or at a discount, to individuals without insurance or other means of paying for such care. As the amounts determined to qualify for charity care are not pursued for collection, they are not reported as patient service revenue. The Hospital has an established charity care policy and maintains records to identify and monitor the level of charity care it provides. The Hospital provides free care to all patients who apply and support income and asset levels of less than 300% of the current-year poverty level and discounts balances to patients under 600% of the poverty level. Interest-free payment plans are also provided. These charity care records include the estimated cost of unreimbursed services provided and supplies furnished under its charity care policy and the excess of cost over reimbursement for Medicaid patients. The estimated cost of charity care provided is determined using a ratio of cost to gross charges and multiplying that ratio by the gross unreimbursed charges associated with providing care to charity patients. The Hospital also monitors the unreimbursed cost of patient bad debts. 193476500 1 1 0 1 0 0 0 0 0 1 1 0 0 1 1 0 1 1 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 174 0 1 2027 1 0 0 0 0 0 0 0 0 0 0 0 X 17 15 1 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 1 1 IL X Brenda VanWyhe 6309786200 2000 Ogden Avenue Aurora IL 60504 Mark Metzger 1.00 1.00 X 0 0 0 William Skoglund 1.00 1.00 X 0 0 0 Trish Anen 1.00 1.00 X 0 0 0 Cati Cederoth 1.00 1.00 X 0 0 0 Alice Daniele MD Beg 213 1.00 1.00 X 0 0 0 Bruce Dienst 1.00 1.00 X 0 0 0 Richard Edelman 1.00 1.00 X 0 0 0 Tom Fisher end 213 1.00 1.00 X 0 0 0 Santosh Gill MD end 213 40.00 1.00 X 580383 0 55452 Ronald Hem 1.00 1.00 X 0 0 0 Dennis Keane MD 1.00 1.00 X 15000 0 0 Herbert Knight 1.00 1.00 X 0 0 0 John Lies end 213 1.00 1.00 X 0 0 0 Maryanne Locklin 1.00 1.00 X 0 0 0 Dave Mead 1.00 1.00 X 0 0 0 Avery Miller 1.00 1.00 X 0 0 0 Jerome Roberts 1.00 1.00 X 0 0 0 Christine Sobek 1.00 1.00 X 0 0 0 Suresh Velagapudi MD 1.00 1.00 X 0 0 0 Barry Finn 40.00 3.00 X X 986985 0 385113 Brenda VanWyhe 40.00 3.00 X 373260 0 90053 Ryan Asmus 40.00 3.00 X 287071 0 72281 Lynn Scott 40.00 2.00 X 75262 0 16684 Steve Lowenthal MD 40.00 0.00 X 937151 0 44989 John Diederich 40.00 1.00 X 498899 0 126224 Diane Homan MD 40.00 0.00 X 434115 0 102459 Dennis DeMasie 40.00 0.00 X 314743 0 83842 Mary Shilkaitis 40.00 0.00 X 323779 0 82613 Gail Bumgarner 40.00 0.00 X 363371 0 68063 David Petasnick 40.00 0.00 X 197672 0 27267 Suzanne Sterchi 40.00 0.00 X 195702 0 31366 Sepehr Sani MD 40.00 0.00 X 1025874 0 25800 Dimitry Ruban MD 40.00 0.00 X 988873 0 47086 Todd Guynn MD 40.00 0.00 X 770915 0 59102 Teressa Alexander MD 40.00 0.00 X 623134 0 52396 Edward Lipman MD 40.00 0.00 X 608175 0 47121 Barbara Graham 0.00 0.00 X 156148 0 10398 9756512 0 1428309 182 1 1 0 Sodexo 4880 Paysphere Circle Chicago IL 60674 Food and Cleaning Service 3496152 Anthelio One Lincoln Center Suite 200 5400 Dallas TX 75240 Medical Records Management 2060000 Advocate Medical Group 1875 Dempster Suite 325 Park Ridge IL 60068 Medical Services 1131587 Fox Valley Acute Dialysis 1300 Waterford Drive Lower Level Aurora IL 60504 Dialysis 700185 Quest Diagnostics Inc PO Box 64922 Baltimore MD 21264 Laboratory Services 587559 24 893313 893313 Net Patient Revenue 621110 261577797 261577797 Medicaid Tax Revenue 621110 12995128 12995128 Other Program Revenue 900099 -1288651 -1288651 273284274 5588046 5588046 94485 94485 1375354 575212 800142 800142 800142 74334943 12079316 73091459 3225133 1243484 8854183 10097667 10097667 Outside Service Rev. 621990 5312175 5312175 Gift Shop Revenue 453220 211823 211823 Cafeteria Revenue 621990 147398 147398 12828 12828 5684224 296442151 278596449 0 16952389 31010 31010 6863384 6863384 93275427 69956570 23318857 3828332 2871249 957083 13196948 9897711 3299237 8053767 6040325 2013442 5415139 4061354 1353785 425660 425660 206801 206801 23353 17515 5838 4372731 3279548 1093183 1326812 1326812 57282175 42961631 14320544 7972901 5979676 1993225 6533131 4899848 1633283 156130 117098 39032 113279 84959 28320 7234141 7234141 16912316 16912316 10872940 8154705 2718235 Medicaid Provider Tax 7125304 7125304 Consulting 902159 902159 Laundry 837404 837404 1046886 785165 261721 254008130 193476500 60531630 0 32064640 201623 20000117 44464193 34476997 4474935 4710289 9839546 8183012 306493648 174997301 136065277 131496347 115889739 199247683 24380073 24873663 367178403 423189731 108752898 121151507 90552297 89816495 13820048 22948153 213125243 233916155 X 149675080 184865539 4378080 4408037 154053160 189273576 367178403 423189731 X 42434021 3894647 -11108252 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 41734 41734 0 Explanation of Lobbying Activities: Part II-B, Line 1: Copley Memorial Hospital is a member of various organizations that advocate on legal and policy issues that affect healthcare. A portion of the annual membership dues paid by Copley Memorial Hospital to these organizations is attributable to lobbying activities. 11131204 980802 712783 1663629 11161160 10648390 1409175 364134 1290495 11131204 9770170 878220 1349773 1349773 10648390 9053445 716725 613671 613671 9770170 8795988 257457 -747024 -747024 9053445 0.60510 0.39490 0 1 1 16906848 16906848 182061150 97661879 84399271 104320344 77335422 26984922 3205306 3205306 131496347 Long Term Malpractice AR Gross-Up 18121878 Intangible Assets 4834455 Unamortized Financing Costs 2186054 Invest Riverwest Oncology 1852754 Invest Home Health 462552 Invest Rush Copley Cardiovascular -2592030 Other 8000 24873663 Deferred Gain on Sale Long Term 11846421 Long Term Market Adjustment Swap Liability 7133363 Long Term SERP 3601664 Long Term Deferred Rent Obligation 366705 22948153 309634720 3894646 10191236 14085882 295548838 893313 893313 296442151 260872559 6864429 6864429 254008130 0 254008130 Description of Intended Use of Endowment Funds: Part V, Line 4: Rush Copley Foundation holds the Voris (income for CMH Cancer Care), Kobisk (Board restricted income to CMH), Copley (income unrestricted) and Dobbins (income for CMH Women's Health) Endowments. These funds are held for the benefit of Copley Memorial Hospital. Part XI, Line 2d - Other Adjustments: RCCC revenue to reconcile to CMH corporate not consolidated 4,156,447. RCCC revenue elimination to reconcile to CMH corporate not consolidated 2,150,770. Swap value adjustment 3,326,807. Rental expenses-2020 Ogden POB1 & 1100 W Veterans Pkwy Yorkville POB 557,212. Part XI, Line 4b - Other Adjustments: Contributions not reported on Line 1 included in income 893,313. Part XII, Line 2d - Other Adjustments: RCCC expenses to reconcile to CMH corporate not consolidated 6,307,217. Rental expenses-2020 Ogden POB1 & 1100 W Veterans Pkwy Yorkville POB 557,212. 1 1 X 1 X 300.000000000000 1 X 600.000000000000 1 1 1 0 1 1 7472927 7472927 0.02940 49861912 32946446 16915466 0.06660 57334839 32946446 24388393 0.09600 73054 73054 0.00030 6751984 565838 6186146 0.02430 41600 41600 0.00020 6866638 565838 6300800 0.02480 64201477 33512284 30689193 0.12080 1 29481332 2948133 70210060 76831644 -6621584 X 1 1 1 1 Copley Memorial Hospital

2000 Ogden Avenue Aurora IL 605044206

www.rushcopley.com X X X X Copley Memorial Hospital 1 1 X X X X X X X X X 12 1 1 1 X X X X X X X X X X 0 0 1 1 300.000000000000 1 600.000000000000 1 X X 1 1 X X 1 0 1 X 0 0 6 River West Radiation Center LLC

1221 N Highland Avenue Aurora IL 605044206

JV Oncology Community Alliance Home Health

4050 Healthway Drive Aurora IL 605044206

JV Home Health Rush-Copley Healthcare Center

1100 West Veterans Parkway Yorkville IL 60560

Convenient Care Rush-Copley Cardiovascular Consultants

2000 Ogden Avenue Aurora IL 605044206

Cardiovascular Services Midwest Center for Advanced Imaging

4355 Montgomery Road Naperville IL 60564

Radiology Services Midwest Center for Advanced Imaging

963 129th Infantry Dr Suite 140 Joliet IL 60431

Radiology Services Part I, Line 7: A cost accounting system was used to calculate the amounts reported in the table and a cost to charge ratio was utilized. The cost accounting system addresses all patient segments (Inpatient, Outpatient, Emergency Room, Private Insurance, Medicaid, Medicare, Uninsured and Self Pay). Part III, Line 4: Net patient service revenue is reported at the estimated net realizable amounts from third-party payors, patients, and others for services rendered. The Hospital has agreements with third-party payors that provide for payments at amounts different from established rates. Payment arrangements include prospectively determined rates per discharge, reimbursed costs, per diem payments, and discounted charges, including estimated retroactive settlements under payment agreements with third-party payors.The Hospital recognizes patient service revenue associated with services provided to patients who have third-party payor coverage on the basis of contractual rates for the services rendered. Provisions for adjustments to net patient service revenue are accrued on an estimated basis in the period the related services are rendered and adjusted in future periods as final settlements are determined. For uninsured patients that do not qualify for charity care, the Hospital recognizes revenue based on its discounted rates. On the basis of historical experience, a significant portion of the Hospital's uninsured patients will be unable or unwilling to pay for the services provided. Thus, the Hospital records a significant provision for uncollectible accounts related to uninsured patients in the period the services are provided. Patient service revenue, net of contractual allowances and discounts (but before the provision for uncollectible accounts), recognized in the period from these major payor sources, is as follows:Patient Service Revenue (Net of Contractual Allowances and Discounts) Third-Party PayorsFiscal year 2013 - $282,202 Fiscal year 2012 - $265,679 Self-Pay Fiscal year 2013 - $25,213Fiscal year 2012 - $22,180Total All PayorsFiscal year 2013 - $307,415Fiscal year 2012 - $287,859Patient accounts receivable are based on gross charges and stated at net realizable value. Accounts receivable are reduced by an allowance for contractual adjustments, based on expected payment rates from payors under current reimbursement methodologies, and also by an allowance for doubtful accounts. In evaluating the collectability of accounts receivable, the Hospital analyzes its past history and identifies trends for each of its major payor sources of revenue to estimate appropriate allowance for doubtful accounts and provision for uncollectible accounts based upon management's assessment of historical and expected net collections considering business and economic conditions, trends in health care coverage, and other collection indicators. Management regularly reviews data about these major payor sources of revenue in evaluating the sufficiency of the allowance for contractual adjustments and 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 uncollectible accounts (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 uncollectible accounts 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 discounted rates 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 uncollectible.The Hospital's allowance for doubtful accounts increased from 12.8% of gross accounts receivable less contractual allowances at June 30, 2012 to 14.5% of gross accounts receivable less contractual allowances at June 30, 2013. The increase in the allowance as a percentage of gross accounts receivable less contractual allowances was due to higher self-pay volumes and lower accounts receivable from third-party payors. Part III, Line 8: All of the shortfall reported in line 7 should be treated as community benefit because if we did not provide the service, the burden of the costs would fall on the government. Costs of treating Medicare patients are calculated using the IRS calculated percentage. Part III, Line 9b: It is our policy not to pursue collection practices against patients known to qualify for Charity Care or other financial assistance. In certain cases it may not be easily determined whether or not a patient qualifies for Charity Care or financial assistance. However, if after collection practices have begun, it later becomes known the patient qualifies, the collection efforts cease. Copley Memorial Hospital Part V, Section B, Line 3: In conducting the Community Health Needs Assessment, the hospital took into account input from persons who represent the broad interested the community served. This included community residents and experts in a range of areas including public health, minority populations, disparities in health care, social determinants of health, and health & social services.Persons who represent the broad interested the community served included:- Board of Directors- Hospital Administration- Community Health Needs Committee- Kane County Health Department- Kendall County Health Department- Communtiy Health Survey Participants- Focus Group Participants- Secondary Data SourcesFor complete details about how the hospital took into account input from persons who represent the broad interested the community served, the hospital's community health needs assessment can be accessed at:http://www.rushcopley.com/about/community-health-needs-assessment-report/ Copley Memorial Hospital Part V, Section B, Line 4: The Kane County Health Department, Rush-Copley Medical Center, Cadence Health Delnor Hospital, Presence Mercy Medical Center, Presence St. Joseph Hospital (Elgin), and Advocate Sherman Hospital worked together along with other community partners to develop the County's IPLAN (Illinois Project for Local Assessment of Needs). The IPLAN is a community health assessment and planning process that is conducted every five years by local health jurisdictions in Illinois. The collaborative participation in the planning process, plan development and identification of the health needs for the County served as a foundation for the development of each of the hospitals' respective Community Health Needs Assessments. Copley Memorial Hospital Part V, Section B, Line 7: The following identified communtiy health needs were not addressed:Infant MortalityRush-Copley Medical Center is already addressing this health need through a number of on-going initiatives, including:- Participation in the Perinatal Network with Rush University and providing Neonatal Intensive Care Services- Active participation in the Kane County Breastfeeding Coalition- Hired Breastfeeding Peer Counselors to support Lactation services- Monthly communication with The Circle of Wise Women - a group of African American community women committed to acting together to reduce infant mortality- Partner with Federally Qualified Health Care Centers to promote prenatal education classes- Preventing elective deliveries before 39 weeks gestation, without medical justification- In collaboration with IDOT, hosts car seat safety checks- "Text 4 Baby" initiative- Working closely with the Kane County Health Department's Perinatal Committee toward preventing infant mortality as well as reducing health disparitiesRush-Copley Medical Center will continue to focus on this need and be an active community partner in the development and implementation of new strategies and initiatives.Communicable DiseasesThe reduction of communicable diseases in the community is a public health issue for which the local health departments acknowledge primary responsibility and leadership oversight. Rush-Copley Medical Center continues to be a collaborative partner that provides on-going supportive services to the local health departments regarding this health issue.Mental and Behavioral HealthAs identified during the prioritization exercise, Rush-Copley does not provide mental or behavioral health services and it would not be feasible for the hospital to develop this type of program. Therefore, the hospital would not be able to have a measurable impact on this need. There are a great number of organizations in the community already addressing this need (as listed in the CHNA). The hospital currently works closely with area mental and behavioral health programs in the community in order to assist patients in accessing care.Housing ConditionsHousing conditions are societal factors that are outside the health care system, therefore the hospital is not in a position to directly impact these needs. However, the hospital will continue to collaborate with other agencies and support initiatives for these health issues, including working with the Kendall County Health Department to develop a distribution program for home radon detection kits through the medical group practice as well as through the hospital's car seat safety check program. Copley Memorial Hospital Part V, Section B, Line 14g: A summary of the FAP policy is available on the website and at the hospital emergency room and admissions areas.Part V, Section B, Line 20d: Self Pay discount of 30% applied to the sametotal charges billed to all patients. Part VI, Line 2: Community need is assessed through review of community and hospital data, periodic assessments with physician and clinicians, and reporting of information from hospital committees. Further input from the community arises from the community based board of directors, various forms of patient input, and hospital involvement with government, health industry, and community agencies. The hospital also actively participates in formal needs assessments conducted by government and community agencies. Part VI, Line 3: At the time of service, Copley Memorial Hospital patients are given a billing brochure, which describes the financial assistance/charity program availability. This information is also posted at the registration check-in desks, in an inpatient guide, and on the Rush Copley website. Financial counselors are available to explain the program in detail to patients who are seen without insurance coverage. All patient billing statements advise the patients to call and inquire on the details as needed. Part VI, Line 4: Copley Memorial Hospital's primary service area is approximately Kane County and Kendall County, Illinois located 45 to 55 miles southwest of Chicago. Kane County has a population of 512,000 people and is predominantly urban and suburban. Nearly 29% of the population is of Hispanic or Latino origin. Persons over the age of 65 comprise 8.6% of the population, and the poverty rate is 9.0%. Aurora, the second largest city in Illinois, dominates the county. Historically an industrial city, Aurora has experienced a considerable loss of manufacturing jobs and is transitioning its economy. Kendall County, to the south of Kane, has a population of 105,000. Persons over the age of 65 comprise 6.7% of the population and the poverty rate is 3.4%. The northwest section of the county is suburban while the remainder is rural. Part VI, Line 5: Copley Memorial Hospital's mission is to provide advanced medicine with quality outcomes and extraordinary care. To that end, the Medical Center seeks to serve the community in ways that engage, educate and empower. Copley Memorial Hospital serves all patients who present for care and serves the surrounding community along with a Board of Directors with a strong community base. The Board Members are independent community leaders and are selected based upon their expertise and experience in a variety of areas of benefit to the organization and their role as Board Members who direct and guide management in carrying out our mission. Board Members are not compensated for their service. As a charitable organization, all surplus funds are used to further our charitable purpose, mission and to serve the community. Some of our primary programs are: community health fairs, breastfeeding education classes, child care classes, etc. Copley Memorial Hospital provides access to physician, acute care, diagnostic, and rehabilitative services to people, regardless of ability to pay, through a number of facilities and services located throughout the service area. It provides programming relating to health education, prevention, and support targeted to specific populations. Medical education extends to clinical settings for nursing education and a family practice residency. Employees fill board and committee leadership positions for a number of economic development and social service agencies in communities throughout the service area. Part VI, Line 6: Copley Memorial Hospital has an affiliation with Rush University Medical Center that covers governance and other organizational relationships. Both organizations are parties to a master trust indenture that established an obligated group for purposes of issuing long-term debt. Reports Filed With States Part VI, Line 7 IL X 1 0 X X X X X 1 1 0 0 0 0 0 1 0 Santosh Gill MD end 213 344983 0 171062 0 64338 0 14197 0 41255 0 635835 0 0 0 Barry Finn 604554 0 367740 0 14691 0 344918 0 40195 0 1372098 0 0 0 Brenda VanWyhe 238620 0 127523 0 7117 0 57077 0 32976 0 463313 0 0 0 Ryan Asmus 183989 0 95565 0 7517 0 39923 0 32358 0 359352 0 0 0 Steve Lowenthal MD 379911 0 199923 0 357317 0 14197 0 30792 0 982140 0 230699 0 John Diederich 312424 0 177540 0 8935 0 92401 0 33823 0 625123 0 0 0 Diane Homan MD 274663 0 145753 0 13699 0 66489 0 35970 0 536574 0 0 0 Dennis DeMasie 212515 0 92022 0 10206 0 47233 0 36609 0 398585 0 0 0 Mary Shilkaitis 206791 0 107878 0 9110 0 48027 0 34586 0 406392 0 0 0 Gail Bumgarner 233669 0 122826 0 6876 0 53599 0 14464 0 431434 0 0 0 David Petasnick 157771 0 39768 0 133 0 7949 0 19318 0 224939 0 0 0 Suzanne Sterchi 153380 0 41739 0 583 0 8007 0 23359 0 227068 0 0 0 Sepehr Sani MD 724979 0 230200 0 70695 0 14197 0 11603 0 1051674 0 0 0 Dimitry Ruban MD 560387 0 382718 0 45768 0 14197 0 32889 0 1035959 0 0 0 Todd Guynn MD 683399 0 59600 0 27916 0 14197 0 44905 0 830017 0 0 0 Teressa Alexander MD 413526 0 175682 0 33926 0 14197 0 38199 0 675530 0 0 0 Edward Lipman MD 343983 0 255645 0 8547 0 14197 0 32924 0 655296 0 0 0 Barbara Graham 27672 0 0 0 128476 0 0 0 10398 0 166546 0 0 0 Part I, Line 1a The organization provides to all employees the use of an athletic facility that is owned and operated by a related tax exempt organization. Supplemental Information Part III Part I, Line 4a: Barbara Graham received a severance payment of $123,984 in calendar year 2012 from Copley Memorial Hospital pursuant to her severance agreement. Supplemental Information Part III Part I, Line 4b: SERP PLAN of CMH (Accruals): Barry Finn $330,721, Mary Shilkaitis $36,234, John Diederich $78,204, Steve Lowenthal $0, Dennis DeMasie $35,094, Diane Homan $52,292, Brenda VanWyhe $43,179, Gail Bumgarner $40,242 and Ryan Asmus $30,057. Please note that these amounts are included in the amounts listed on Schedule J, Part II, Column C. There is no constructive receipt of these amounts by the individuals until they are paid out as they are subject to a substantial risk of forfeiture. Any individual payouts would be included as reportable compensation on the recipient's annual Form W-2. Steve Lowenthal received payments in 2012 of $338,687. Supplemental Information Part III Part I, Line 7: Incentive bonus plan based on a series of approved strategic accomplishments. Supplemental Information Part III Part II, Column (B)(ii), Physician Bonus & incentive compensation: Physician bonuses were paid based on individual productivity goals A Illinois Finance Authority 861091967 45200FHN2 2008-05-28 34772005 See Part VI 0 0 0 B Illinois Finance Authority 861091967 45200FTZ2 2009-02-10 34075527 Construction of Replace Hosp & ICU addition 0 0 0 C Illinois Finance Authority 861091967 45200FYT0 2009-07-29 25912180 New Construction Hospital Campus 0 0 0 A 34772005 3085855 540878 34231127 1 0 1 1 B 34075527 3397043 498260 32745950 2009 0 0 1 1 C 25912180 2581171 401472 22919490 2009 0 0 1 1 B 0 0 0 0 0.00000 0.00000 0.00000 0 0 0 C 0 0 1 1 0 0.00000 0.00000 0.00000 0 0 0 A 0 0 0 1 0 0 0 0 0 B 0 1 0 0 0 0 0 0 0 C 0 1 0 0 0 0 0 0 0 A 0 B 0 C 0 Schedule K, Part I, Bond Issues: (a) Issuer Name: Illinois Finance Authority (f) Description of Purpose: Construction of Replace Hosp & ICU addition. Schedule K, Part I, line A, column (e):Issue Price of bonds of $34,772,005 does not tie to Form 8038 Part III Line 21(b) of $98,278,724. This is because the $34,772,005 is Copley Memorial Hospital's 35.38% prorata share of the $98,278,724 Obligated Group amount issued. Schedule K, Part I, line A, column (f): The Series 2006B Fixed Rate bonds currently refunded (as a reissuance) the Series 2006B Auction Rate bonds issued 8/17/2006, which were issued to refund pre-2003 bond issues. Schedule K, Part IV, Line 2c, Column A: The Series 2006B Fixed Rate bonds' rebate calculation that concluded that there was no liability (and hence no Form 8038-T to file) was completed on May 28, 2013. Form 990, Part VI, Section A, line 2 Many of the persons listed on Part VII have a "business relationship" with each other by virtue of sitting on related Rush-Copley Medical Center entity boards. Barry Finn, CMH President & CEO/Director, and William Skoglund, CMH Vice Chairman of the Board/Director, have a business relationship. Barry Finn is a board member at Old Second National Bank and William Skoglund is the Chairman and CEO at Old Second National Bank. Mr. Skoglund does not serve on Copley Memorial Hospital's compensation committee and has recused himself from any discussions or votes that involves Mr. Finn's salary. Form 990, Part VI, Section A, line 6 Rush-Copley Medical Center, Inc. ("RCMC") is the sole corporate member of Copley Memorial Hospital, Inc. ("CMH"), Rush-Copley Medical Group, NFP ("RCMG"), Copley Ventures, Inc. ("CV"), and Rush-Copley Foundation ("RCF"). Form 990, Part VI, Section A, line 7a CMH's Board of Directors includes at least nine (9) individuals elected by the sole corporate member, RCMC. Each of these elected directors is also a member of the Governing Board of CMH's sole corporate member, RCMC. The election and re-election of all CMH directors is at the direction of RCMC at the annual Governing Board meeting. Vacancies on the CMH Board of Directors are filled by CMH's sole corporate member, RCMC. In accordance with certain procedural requirements stated in the bylaws, elected directors may be removed by the affirmative vote of two-thirds of the board of directors of CMH's sole corporate member, RCMC. Form 990, Part VI, Section A, line 7b The Board of Directors of CMH's sole corporate member, RCMC, has the following exclusive powers over CMH: (1) the borrowing of any sum, the principal of which exceeds $500,000.00, or which has a stated term of greater than one year, or which is secured by a mortgage of all or any portion of CMH's real property or the creation of a security interest in CMH's assets, including personal property and revenues, for the benefit of the lender, lessor or vendor, or the defeasance, advance payment or cancellation of any outstanding debt of the category described herein; (2) any voluntary dissolution, merger, consolidation, sale or transfer of any of CMH's assets which exceeds one percent (1%) of CMH's total assets or any creation of a subsidiary or affiliate of CMH; (3) application to the Illinois Health Facilities Planning Board or any successor for a permit or certificate of need for a proposed activity, whether or not involving a capital expenditure; (4) approval of all annual and long-term capital and operational budgets; (5) any amendment to the Articles of Incorporation or Bylaws of CMH; (6) any agreement or transaction, either of which is of a material nature, with another corporation controlled by or affiliated with CMH's sole corporate member, RCMC, or which is a subsidiary of RCMC; (7) approval of any new or changes to existing long-term or master strategic plan; and (8) sale of any of CMH's real property or interest therein or purchases of any additional real estate. Form 990, Part VI, Section B, line 11 The Form 990 tax return is prepared by our external tax advisor with data provided by our organization. A draft of the Form 990 is provided to management for review and comment. The Board of Directors is provided with an approved copy of the Form 990 before it is filed. Form 990, Part VI, Section B, line 12c Annually, Officers, Directors, Key Employees, Management Team (Department Directors and Managers), and Billing Office personnel of Copley Memorial Hospital, Inc. are required to disclose interests that could give rise to conflicts. The conflict of interest statements are submitted and reviewed by the Chief Compliance Officer and the Audit and Corporate Integrity Committee of the Board. Those key personnel with conflicts are advised to recuse themselves from participating in decision-making related to the conflict. Form 990, Part VI, Section B, line 15 With respect to the CEO/VP's of the organization and key senior management, the organization follows a compensation approval procedure annually that involves approval of proposed and final compensation arragements by the organization's Compensation Committee and full board of Directors using comparability data, as well as contemporaneous documentation of compensation decisions in minutes. Form 990, Part VI, Section C, line 19 Form 990 available upon request. The organization does not make its governing documents or conflict of interest policy available to the public. Copies of the financial statements (whether or not audited) are provided upon reasonable request such as for a bank loan or to a bond rating agency. The financial statements are available on the Attorney General's website. Changes in Net Assets or Fund Balances: Form 990, Part XI, line 9: Transfer of assets to affiliates-net -14,055,883. Change in interest in net assets of Foundation -379,176. Swap value adjustment 3,326,807. Rush Copley Medical Center Inc 2000 Ogden Avenue Aurora IL 60504 363193787 Parent Company IL 501(c)(3) 11A N/A 0 Rush Copley Health Care System Inc 2000 Ogden Avenue Aurora IL 60504 363584043 Bridge Board RCMC & RUMC IL 501(c)(3) 11A N/A 0 Rush-Copley Foundation 2000 Ogden Avenue Aurora IL 60504 363093877 Grants to Charitable Organizations IL 501(c)(3) 7 Rush-Copley Medical Center Inc 1 Copley Ventures Inc 2000 Ogden Avenue Aurora IL 60504 363370216 Rental Prop., Infirmary Care, and Healthplex Fitness Center IL 501(c)(3) 3 Rush-Copley Medical Center Inc 1 Rush University Medical Center 1700 West Van Buren Street Chicago IL 60612 362174823 Hospitals IL 501(c)(3) 3 N/A 0 Yorkville Physical Therapy & Sports Medicine Center LLC 2000 Ogden Avenue Aurora IL 60504 364236345 Physical Therapy & Sports Medicine IL N/A Rush Copley Cardiovascular Consultants LLC 2000 Ogden Avenue Aurora IL 60504 273234201 Cardiovascular Medicine IL Copley Medical Center Inc Related -2166245 3248177 0 0 0.99000 Rush Copley Medical Group NFP 2000 Ogden Avenue Aurora IL 60504 363235315 Physician Practices IL N/A C 0 1 0 1 0 0 0 0 0 1 0 1 0 0 0 0 0 1 1 0 Rush Copley Medical Group NFP A 771828 Fair Market Value Rush Copley Foundation C 893313 Fair Market Value Rush Copley Foundation I 210704 Fair Market Value Rush Copley Foundation Q 682609 Fair Market Value Rush Copley Medical Center Inc I 14055883 Fair Market Value Copley Ventures Inc K 577435 Fair Market Value Copley Ventures Inc R 468000 Fair Market Value