2013-05-09T14:08:51-05:00 2012-06-30 990 2011-07-01 362379649 GOTTLIEB MEMORIAL HOSPITAL GOTT 7084504966 701 W NORTH AVE MELROSE PARK IL 60160 AJAY SIAL 7084504966 2013-05-09 2011 2016-02-25 16:41:14Z LARRY GOLDBERG 701 W NORTH AVE MELROSE PARK IL 60160 132856482 0 X WWW.GOTTLIEBHOSPITAL.ORG X 1956 IL HEALTH CARE SERVICES 13 6 1308 217 2074173 -118266 134971 462838 120971380 129880571 4690 737218 8659161 1599005 129770202 132679632 0 0 0 0 70514206 67365807 0 0 0 60416550 65986470 130930756 133352277 -1160554 -672645 119134315 152695436 60244457 78193014 58889858 74502422 X HEALTH CARE SERVICES - SEE SCHEDULE H FOR MORE INFORMATION 0 0 115318744 128551091 GOTTLIEB MEMORIAL HOSPITAL (GOTTLIEB) IS AN ACUTE CARE NOT-FOR-PROFIT HOSPITAL WITH 255 LICENSED BEDS. OPERATING IN THE WESTERN SUBURBS OF ILLINOIS, GOTTLIEB PROVIDES VITAL HEALTH CARE SERVICES 24 HOURS A DAY, SEVEN DAYS A WEEK, TO PATIENTS IN VARIOUS SETTINGS, INCLUDING CARDIOVASCULAR/THORACIC, OBSTETRICS, ORTHOPAEDICS, MEDICAL IMAGING, GASTROENTEROLOGY, UROLOGY, HOME CARE AND HOSPICE SERVICES, TRANSITIONAL CARE, AND ADULT DAY CARE SERVICES.DURING FISCAL YEAR 2012 GOTTLIEB PROVIDED OVER 47,000 DAYS OF HEALTHCARE SERVICES AND OVER 77,000 OUTPATIENT VISITS TO THE COMMUNITY. GOTTLIEB MEMORIAL HOSPITAL IS DEDICATED TO PROVIDING SUPERIOR HEALTHCARE TO IMPROVE THE OVERALL HEALTH OF ALL WE SERVE. INDIVIDUALS WITHIN OUR COMMUNITY ARE PROVIDED ACCESS TO MEDICALLY NECESSARY CARE REGARDLESS OF THEIR ABILITY TO PAY. THE MISSION STATEMENT OF GOTTLIEB MEMORIAL HOSPITAL IS AS FOLLOWS:WE SERVE TOGETHER IN TRINITY HEALTHIN THE SPIRIT OF THE GOSPELTO HEAL BODY, MIND, AND SPIRITTO IMPROVE THE HEALTH OF OUR COMMUNITIESAND TO STEWARD THE RESOURCES ENTRUSTED TO US. 115318744 1 1 0 1 0 0 0 0 0 0 1 1 0 1 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 1 1 0 0 1 88 0 1 1308 1 1 1 0 0 0 0 1 1 0 0 0 0 X 13 6 0 1 1 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 1 1 IL NC X ELLYN CHIN 7084504534 701 W NORTH AVE MELROSE PARK IL 60160 X DANIEL HALE 2.00 X X 0 925954 106225 PATRICIA CASSIDY 20.00 X X 0 1885874 173667 LARRY GOLDBERG 10.00 X X 0 196650 12915 ROBERT FLANIGAN MD 2.00 X 0 408994 25796 RICHARD GAMELLI MD 2.00 X 0 890026 29194 P TERRENCE O'ROURKE 2.00 X 0 863581 50709 ROBERT SULO MD 2.00 X 0 333392 42076 DAVID WILBER 2.00 X 0 640268 26131 NANCY KNOWLES 2.00 X 0 0 0 HENRY LANG 2.00 X 0 0 0 WILLIAM REICHERT 2.00 X 0 0 0 MARC SCHWARTZ 2.00 X 0 0 0 SR JOAN MARIE STEADMAN CSC 2.00 X 0 0 0 JACK WEINBERG 2.00 X 0 0 0 AJAY SIAL 2.00 X 0 0 0 BENJAMIN CARTER 2.00 X 0 755014 102689 ELLYN CHIN 30.00 X 282497 0 62935 CHARLES REITER III 2.00 X 0 1588987 113850 JILL RAPPIS 2.00 X 0 288502 58102 DONNA HALINSKI 2.00 X 0 309741 48973 TOM HONAN NAVIGANT 10.00 X 0 1556520 0 KENNETH FISHBAIN 30.00 X 519217 0 69060 ALAN GOLDBERG 40.00 X 253087 0 128045 JOSEPH SWEDISH 2.00 X 0 5186660 576202 KEDRICK ADKINS 2.00 X 0 1405226 117120 J RICHARD O'CONNELL 2.00 X 0 943237 118221 MICHAEL MURPHY 2.00 X 0 474370 75538 BRETT WAKEFIELD 40.00 X 233997 0 202173 SILIA MIGLIO 40.00 X 157638 0 17486 MAURITA ADLER 40.00 X 150806 0 55342 ELIZABETH MCLAIN 40.00 X 145698 0 14675 JOHN ASTREIDES 40.00 X 141313 0 30796 PAUL WHELTON 0.00 X 0 3693100 1453069 CONSTANCE CLARK 0.00 X 182710 0 27851 2066963 22346096 3738840 54 1 1 1 GEORGE SOLLITT CONSTRUCTION COMPANY 790 N CENTRAL AVE WOODDALE IL 60191 CONSTRUCTION SERVICES 1692286 FRESENIUS MANAGEMENT SERVICES 16343 COLLECTION CTR DR CHICAGO IL 60693 HEALTHCARE SERVICES 379908 UBS GLOBAL ASSET MANAGEMENT 23387 NETWORK PLACE CHICAGO IL 60673 BANK SERVICES 324501 DIVERSIFIED CLINICAL SERVICES PO BOX 636981 CINCINNATI OH 45263 CLINICAL SERVICES 312090 QUEST DIAGNOSTICS PO BOX 12989 CHICAGO IL 60693 LABORATORY SERVICES 287614 22 4938 457900 462838 NET PATIENT SVC REV 900099 123649581 123649581 LABORATORY REV 621500 4348860 4156817 192043 PHARMACY REV 446110 1882130 1882130 129880571 426034 426034 342149 0 342149 342149 342149 309184 2000 0 0 309184 2000 311184 311184 197311 4938 104851 92460 92460 99846 71999 27847 27847 CAFETERIA 900099 391856 391856 744693 744693 1136549 132679632 128551091 2074173 1591530 2599571 2599571 50509620 46241521 4268099 2425802 2330034 95768 7891455 6980158 911297 3939359 3450266 489093 10 10 149114 149114 9056859 4711352 4345507 745504 745504 3680541 2867465 813076 997100 234296 762804 2932437 2793803 138634 70069 54781 15288 154362 71342 83020 100024 100024 6701022 6701022 4093083 4093083 MEDICAL SUPPLIES 20217445 19572901 644544 BAD DEBT 9123546 9123546 HOSPITAL PROVIDER TAX 3347110 3347110 UBI TAXES 30 30 4618214 2646040 1972174 133352277 115318744 18033533 0 37685910 10803190 58316 63107 12350498 16889292 315171 2759414 2874627 625540 415505 89913932 6998849 52086098 82915083 75000 5298857 447260 8645504 13046279 24475100 119134315 152695436 42195592 61487039 5554180 18048865 11151795 60244457 78193014 X 58814858 74502422 75000 0 58889858 74502422 119134315 152695436 X -672645 16285209 X X 0 1 1 X 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 1 11882 0 0 0 11882 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: GOTTLIEB MEMORIAL HOSPITAL HAS MADE GRANTS TO OTHER ORGANIZATIONS FOR LOBBYING PURPOSES. THESE GRANTS HAVE BEEN IN THE FORM OF MEMBERSHIP DUES PAID TO REGIONAL AND NATIONAL HEALTH CARE ORGANIZATIONS, WHERE THE ORGANIZATIONS HAVE PROVIDED GOTTLIEB MEMORIAL HOSPITAL WITH AN ESTIMATED PERCENTAGE OF DUES PAYMENTS WHICH ARE USED FOR LOBBYING ACTIVITIES. GOTTLIEB MEMORIAL HOSPITAL MADE NO CONTRIBUTIONS TO ANY LEGISLATORS OR CANDIDATES. 12500000 12500000 50613391 3262442 47350949 17465481 3629915 13835566 9335060 106492 9228568 82915083 COMMINGLED FUNDS DIRECTLY HOLDING SECURITIES 4880526 F EQUITY METHOD INVESTMENTS 3764978 C 8645504 NET DEFERRED TAX ASSET 146000 INTERCOMPANY RECEIVABLES 21553049 OTHER RECEIVABLES 2644732 INVESTMENT IN UNCONSOLIDATED AFFILIATES 101500 OTHER CURRENT ASSETS 29819 24475100 INTERCOMPANY PAYABLES 7541925 LONG-TERM ASSET RETIREMENT OBLIGATION (FIN 47) 441204 OTHER CURRENT LIABILITIES 1918666 OTHER LONG-TERM LIABILITIES 1250000 11151795 EMERALD BALL 202249 4938 197311 104851 202249 4938 197311 104851 104851 92460 1 1 X 1 X 1 X 600.000000000000 1 1 1 0 1 1 1 3062985 490600 2572385 0.02070 15659044 13435359 2223685 0.01790 1 18722029 13925959 4796070 0.03860 6 1666 55012 55012 0.00040 2 16 66900 66900 0.00050 1 3661 4004 4004 0.00000 0 1 8745 38514 38514 0.00030 10 14088 164430 164430 0.00120 11 14088 18886459 13925959 4960500 0.03980 1 40837 80729 80729 0.00060 1 40837 80729 80729 0.00060 0 1488106 446432 47392004 51824622 -4432618 X 1 1 1 1 GOTTLIEB MEMORIAL HOSPITAL

701 W NORTH AVE MELROSE PARK IL 60160

X X X INCLUDING OUTPATIENT SERVICES GOTTLIEB MEMORIAL HOSPITAL 1 1 1 200.000000000000 1 600.000000000000 1 X X X X X 1 1 X X X X 1 0 1 X 0 0 2 GOTTLIEB HOME HEALTH & HOSPICE

905 W NORTH AVE MELROSE PARK IL 60160

HOME HEALTH AND HOSPICE PROGRAM GOTTLIEB ADULT DAY CARE CENTER

555 W NORTH AVE MELROSE PARK IL 60160

ADULT DAY CARE CENTER PART I, LINE 6A: GOTTLIEB MEMORIAL HOSPITAL PREPARES AN ANNUAL COMMUNITY BENEFIT REPORT, WHICH IT SUBMITS TO THE STATE OF ILLINOIS. AS OF JULY 1, 2011, GOTTLIEB MEMORIAL HOSPITAL ALSO REPORTS ITS COMMUNITY BENEFIT INFORMATION AS PART OF THE CONSOLIDATED COMMUNITY BENEFIT INFORMATION REPORTED BY TRINITY HEALTH IN ITS ANNUAL REPORT, AVAILABLE AT WWW.TRINITY-HEALTH.ORG.IN ADDITION, GOTTLIEB MEMORIAL HOSPITAL WILL INCLUDE A COPY OF ITS MOST RECENTLY FILED SCHEDULE H ON BOTH ITS OWN WEBSITE AND TRINITY HEALTH'S WEBSITE. PART I, LINE 7: THE BEST AVAILABLE DATA WAS USED TO CALCULATE THE COST AMOUNTS REPORTED IN ITEM 7. FOR CERTAIN CATEGORIES, PRIMARILY TOTAL CHARITY CARE AND MEANS-TESTED GOVERNMENT PROGRAMS, SPECIFIC COST-TO-CHARGE RATIOS WERE CALCULATED AND APPLIED TO THOSE CATEGORIES. THE COST-TO-CHARGE RATIO WAS DERIVED FROM WORKSHEET 2, RATIO OF PATIENT CARE COST-TO-CHARGES. IN OTHER CATEGORIES, THE BEST AVAILABLE DATA WAS DERIVED FROM THE HOSPITAL'S COST ACCOUNTING SYSTEM. PART I, L7 COL(F): THE FOLLOWING NUMBER, $9,123,546, REPRESENTS THE AMOUNT OF BAD DEBT EXPENSE INCLUDED IN TOTAL FUNCTIONAL EXPENSES IN FORM 990, PART IX, LINE 25. PER IRS INSTRUCTIONS, THIS AMOUNT WAS EXCLUDED FROM THE DENOMINATOR WHEN CALCULATING THE PERCENT OF TOTAL EXPENSE FOR SCHEDULE H, PART I, LINE 7, COLUMN (F). PART II: COMMUNITY BUILDING ACTIVITIES - GOTTLIEB MEMORIAL HOSPITAL (GMH) PROVIDED A NUMBER OF COMMUNITY BUILDING ACTIVITIES IN FISCAL YEAR 2012 TO SUPPORT AND PROMOTE THE HEALTH OF THE COMMUNITIES IT SERVES. GMH AND ITS STAFF ALLERGIST PROVIDE GMH'S DAILY ALLERGY COUNT (FROM APRIL THROUGH OCTOBER) FOR THE ENTIRE CHICAGO AREA. THE COUNT IS PROVIDED, AT NO COST, TO NEWS OUTLETS AND ALL CHICAGO METEOROLOGISTS. THE COUNT ALSO IS AVAILABLE ON GMH'S WEB SITE, VIA TWITTER AND BY A TELEPHONE HOTLINE EACH WEEKDAY MORNING DURING ALLERGY SEASON. IT IS A RELIED-UPON RESOURCE BY PEOPLE IN THE CHICAGO AREA WHO NEED TO DETERMINE WHETHER TO TAKE ALLERGY MEDICATION BEFORE STEPPING OUT THE DOOR IN THE MORNING.IN ADDITION, GMH STAFF PILOTED A PEDIATRIC OBESITY PROGRAM TO HELP ADDRESS THE NEEDS OF OVERWEIGHT CHILDREN AND ADOLESCENTS, WHICH LATER DEVELOPED INTO A FULL PROGRAM. GMH STAFF ALSO PARTICIPATED ON A COMMITTEE OF AREA PROVIDERS AND AGENCIES TO HELP CONNECT SENIORS AND OTHERS WITH HEALTHCARE RESOURCES. FURTHERMORE, GMH PROVIDED LANGUAGE SUPPORT SERVICES FOR THOSE NEEDING ASSISTANCE AND HEALTH INFORMATION THROUGH A WIDELY-DISTRIBUTED COMMUNITY HEALTH NEWSLETTER. PART III, LINE 4: AS OF JULY 1, 2011, GOTTLIEB MEMORIAL HOSPITAL IS INCLUDED IN THE CONSOLIDATED FINANCIAL STATEMENTS OF TRINITY HEALTH. THE FOLLOWING IS THE TEXT OF THE ALLOWANCE FOR DOUBTFUL ACCOUNTS FOOTNOTE FROM THOSE STATEMENTS: "SUBSTANTIALLY ALL OF THE CORPORATION'S RECEIVABLES ARE RELATED TO PROVIDING HEALTHCARE SERVICES TO PATIENTS. ACCOUNTS RECEIVABLE ARE REDUCED BY AN ALLOWANCE FOR AMOUNTS THAT COULD BECOME UNCOLLECTIBLE IN THE FUTURE. THE CORPORATION'S ESTIMATE FOR ITS ALLOWANCE FOR DOUBTFUL ACCOUNTS IS BASED UPON MANAGEMENT'S ASSESSMENT OF HISTORICAL AND EXPECTED NET COLLECTIONS BY PAYOR."COSTING METHODOLOGY FOR LINES 2 AND 3: AMOUNTS ARE CALCULATED ON LINE 2 USING A COST TO CHARGE RATIO METHODOLOGY.ANY DISCOUNTS PROVIDED OR PAYMENTS MADE TO A PARTICULAR PATIENT ACCOUNT ARE APPLIED TO THAT PATIENT ACCOUNT PRIOR TO ANY BAD DEBT WRITE-OFF AND ARE THUS NOT INCLUDED IN BAD DEBT EXPENSE. AS A RESULT OF THE PAYMENT AND ADJUSTMENT ACTIVITY BEING POSTED TO BAD DEBT ACCOUNTS, WE ARE ABLE TO REPORT BAD DEBT EXPENSE NET OF THESE TRANSACTIONS.THE AMOUNT ON LINE 3 IS BASED ON THE ACCOUNTS WRITTEN OFF TO BAD DEBT AFTER THEY WENT TO COLLECTION AGENCY THAT HAD A CREDIT SCORE OF LESS THAN 500. BASED ON THE EXPERTISE OF THE COLLECTION AGENCY, THESE PATIENTS ARE UNABLE TO PAY AND MOST LIKELY WOULD HAVE QUALIFIED FOR CHARITY IF THEY HAD COMPLETED ALL PAPERWORK. PART III, LINE 8: GOTTLIEB MEMORIAL HOSPITAL DOES NOT BELIEVE ANY MEDICARE SHORTFALL SHOULD BE TREATED AS COMMUNITY BENEFIT. THIS IS SIMILAR TO CHA RECOMMENDATIONS, WHICH STATE THAT SERVING MEDICARE PATIENTS IS NOT A DIFFERENTIATING FEATURE OF TAX-EXEMPT HEALTHCARE ORGANIZATIONS AND THAT THE EXISTING COMMUNITY BENEFIT FRAMEWORK ALLOWS COMMUNITY BENEFIT PROGRAMS THAT SERVE THE MEDICARE POPULATION TO BE COUNTED IN OTHER COMMUNITY BENEFIT CATEGORIES.PART III, LINE 8: COSTING METHODOLOGY FOR LINE 6 - MEDICARE COSTS WERE OBTAINED FROM THE FILED MEDICARE COST REPORT. THE COSTS ARE BASED ON MEDICARE ALLOWABLE COSTS AS REPORTED ON WORKSHEET B, COLUMN 27, WHICH EXCLUDE DIRECT MEDICAL EDUCATION COSTS. INPATIENT MEDICARE COSTS ARE CALCULATED BASED ON A COMBINATION OF ALLOWABLE COST PER DAY TIMES MEDICARE DAYS FOR ROUTINE SERVICES AND COST TO CHARGE RATIO TIMES MEDICARE CHARGES FOR ANCILLARY SERVICES. OUTPATIENT MEDICARE COSTS ARE CALCULATED BASED ON COST TO CHARGE RATIO TIMES MEDICARE CHARGES BY ANCILLARY DEPARTMENT. PART III, LINE 9B: GOTTLIEB'S COLLECTION POLICY CONTAINS PROVISIONS ON THE COLLECTION PRACTICES TO BE FOLLOWED FOR PATIENTS WHO ARE KNOWN TO QUALIFY FOR CHARITY CARE FOR FINANCIAL ASSISTANCE. THERE ARE MANY INSTANCES WHEN A PATIENT DOES NOT FORMALLY COMPLETE A CHARITY/FINANCIAL APPLICATION, BUT WOULD QUALIFY FOR CHARITY OR FINANCIAL ASSISTANCE IF THE APPLICATION WERE COMPLETED. BEFORE AN ACCOUNT IS TURNED OVER TO A COLLECTION AGENCY, THE PATIENT ACCOUNTS STAFF FOLLOWS THE PROCESS OF EVALUATING WHETHER A PATIENT COULD MEET CHARITY OR FINANCIAL ASSISTANCE BY REVIEW OF THE FOLLOWING INFORMATION: PATIENT HISTORY, PATIENT DEMOGRAPHICS, EMPLOYMENT STATUS, FINANCIAL INFORMATION INCLUDING CREDIT CHECK, RETURNED MAIL, CITIZENSHIP, AND VALID IDENTIFICATION. GOTTLIEB MEMORIAL HOSPITAL PART V, SECTION B, LINE 19D: IN DETERMINING THE AMOUNTS BILLED TO INDIVIDUALS WHO DID NOT HAVE INSURANCE COVERING EMERGENCY OR OTHER MEDICALLY NECESSARY CARE, GOTTLIEB MEMORIAL HOSPITAL USED MEDICARE RECEIVED PER THE ILLINOIS UNINSURED PATIENT ACT. PART VI, LINE 2: NEEDS ASSESSMENT - GOTTLIEB MEMORIAL HOSPITAL PERFORMS COMMUNITY HEALTH NEEDS EVALUATIONS, WHICH ARE A POINT-IN-TIME EFFORT TO MEASURE THE HEALTH AND WELL-BEING OF THE COMMUNITY. IT SERVES AS THE BASIS FOR GOTTLIEB MEMORIAL HOSPITAL'S STRATEGIC AND SUBSEQUENT ACTION PLANNING TO DEVELOP HEALTH POLICY, ALLOCATE RESOURCES, IMPROVE OR EXPAND EXISTING SERVICES, IMPLEMENT NEW PROGRAMS AND COLLABORATE WITH OTHER COMMUNITY HEALTHCARE PROVIDERS. A COMMUNITY NEEDS ASSESSMENT ALSO SERVES AS A BENCHMARK FOR FUTURE ASSESSMENT OF RELATIVE PROGRESS TOWARD ESTABLISHED COMMUNITY HEALTH OBJECTIVES.THE GOTTLIEB MEMORIAL HOSPITAL COMMUNITY HEALTH NEEDS ASSESSMENT PROVIDES THE OPPORTUNITY TO:- GAIN INSIGHTS INTO THE NEEDS AND ASSETS OF THE COMMUNITIES SERVED - IDENTIFY AND ADDRESS THE NEEDS OF VULNERABLE POPULATIONS WITHIN THE COMMUNITY- ENHANCE HOSPITAL/COMMUNITY RELATIONSHIPS AND THE OPPORTUNITY FOR COLLABORATIVE COMMUNITY ACTION, INCLUDING INVOLVEMENT WITH COALITIONS, PARTNERSHIPS, BOARDS, COMMITTEES, COMMISSIONS, ADVISORY GROUPS AND PANELS- PROVIDE THE INFORMATION REQUIRED FOR COMMUNITY OUTREACH PLANNINGTHE GOTTLIEB MEMORIAL HOSPITAL COMMUNITY HEALTH NEEDS ASSESSMENT PROCESS INVOLVES THE GATHERING OF TWO TYPES OF DATA: QUANTITATIVE (DEMOGRAPHICS, HEALTH INDICATORS, ETC.) AND QUALITATIVE (PUBLIC SURVEYS, FORUMS, FOCUS GROUPS). THE DATA HELPS SUPPORT SHORT-TERM AND LONG-TERM DECISIONS ABOUT ALLOCATION OF COMMUNITY HUMAN AND CAPITAL RESOURCES. GOTTLIEB MEMORIAL HOSPITAL PLANS TO COMPLETE A MORE FORMAL COMMUNITY HEALTH NEEDS ASSESSMENT BY JUNE 30, 2013. PART VI, LINE 3: PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCE -GMH IS COMMITTED TO:- PROVIDING ACCESS TO QUALITY HEALTHCARE SERVICES WITH COMPASSION, DIGNITY AND RESPECT FOR THOSE WE SERVE, PARTICULARLY THOSE WHO ARE POOR AND UNDERSERVED IN OUR COMMUNITIES - CARING FOR ALL PERSONS, REGARDLESS OF THEIR ABILITY TO PAY FOR SERVICES- ASSISTING PATIENTS WHO CANNOT PAY FOR PART OR ALL OF THE CARE THEY RECEIVE; AND - BALANCING NEEDED FINANCIAL ASSISTANCE FOR SOME PATIENTS WITH BROADER FISCAL RESPONSIBILITIES IN ORDER TO SUSTAIN VIABILITY AND PROVIDE THE QUALITY AND QUANTITY OF SERVICES FOR ALL WHO MAY NEED CARE IN A COMMUNITYGMH HAS ADOPTED THE FOLLOWING GUIDING PRINCIPLES WHEN HANDLING THE BILLING, COLLECTION AND FINANCIAL SUPPORT FUNCTIONS FOR OUR PATIENTS: - PROVIDE EFFECTIVE COMMUNICATIONS WITH PATIENTS REGARDING HOSPITAL BILLS- MAKE AFFIRMATIVE EFFORTS TO HELP PATIENTS APPLY FOR PUBLIC AND PRIVATE FINANCIAL SUPPORT PROGRAMS- OFFER FINANCIAL SUPPORT TO PATIENTS WITH LIMITED MEANS- IMPLEMENT POLICIES FOR ASSISTING LOW-INCOME PATIENTS IN A CONSISTENT MANNER- IMPLEMENT FAIR AND CONSISTENT BILLING AND COLLECTION PRACTICES FOR ALL PATIENTS WITH PATIENT PAYMENT OBLIGATIONSGMH PROVIDES EFFECTIVE COMMUNICATION WITH PATIENTS REGARDING PATIENT PAYMENT OBLIGATIONS. FINANCIAL COUNSELING IS PROVIDED TO PATIENTS ABOUT THEIR PAYMENT OBLIGATIONS AND HOSPITAL BILLS. INFORMATION ON HOSPITAL-BASED FINANCIAL SUPPORT POLICIES AND EXTERNAL PROGRAMS THAT PROVIDE COVERAGE FOR SERVICES ARE MADE AVAILABLE TO PATIENTS DURING THE PRE-REGISTRATION AND REGISTRATION PROCESSES AND/OR THROUGH COMMUNICATIONS WITH PATIENTS SEEKING FINANCIAL ASSISTANCE. FINANCIAL COUNSELORS MAKE AFFIRMATIVE EFFORTS TO HELP PATIENTS APPLY FOR PUBLIC AND PRIVATE PROGRAMS FOR WHICH THEY MAY QUALIFY AND THAT MAY ASSIST THEM IN OBTAINING AND PAYING FOR HEALTHCARE SERVICES. EVERY EFFORT IS MADE TO DETERMINE A PATIENT'S ELIGIBILITY PRIOR TO - OR AT THE TIME OF - ADMISSION OR SERVICE. HOWEVER, DETERMINATION FOR FINANCIAL SUPPORT CAN BE MADE DURING ANY STAGE OF THE PATIENT'S STAY AFTER STABILIZATION OR COLLECTION CYCLE.GMH OFFERS FINANCIAL SUPPORT TO PATIENTS WITH LIMITED MEANS. THIS SUPPORT IS AVAILABLE TO UNINSURED AND UNDERINSURED PATIENTS WHO DO NOT QUALIFY FOR PUBLIC PROGRAMS OR OTHER ASSISTANCE. NOTIFICATION ABOUT FINANCIAL ASSISTANCE, INCLUDING CONTACT INFORMATION, IS AVAILABLE THROUGH A NUMBER OF MEANS, INCLUDING THE HOSPITAL'S WEBSITE. GMH HAS ESTABLISHED A WRITTEN POLICY FOR BILLING, COLLECTION AND SUPPORT FOR PATIENTS WITH PAYMENT OBLIGATIONS. GMH MAKES EVERY EFFORT TO ADHERE TO THE POLICY AND IS COMMITTED TO IMPLEMENTING AND APPLYING THE POLICY FOR ASSISTING PATIENTS WITH LIMITED MEANS IN A PROFESSIONAL, CONSISTENT MANNER. GMH EDUCATES STAFF MEMBERS WHO WORK CLOSELY WITH PATIENTS (INCLUDING THOSE WORKING IN PATIENT REGISTRATION AND ADMITTING, FINANCIAL ASSISTANCE, CUSTOMER SERVICE, AND BILLING AND COLLECTIONS) ABOUT THESE POLICIES WITH AN EMPHASIS ON TREATING ALL PATIENTS WITH DIGNITY AND RESPECT REGARDLESS OF THEIR INSURANCE STATUS OR THEIR ABILITY TO PAY FOR SERVICES. PART VI, LINE 4: COMMUNITY INFORMATION - OPERATING IN THE WESTERN SUBURBS OF CHICAGO, GMH IS AN ACUTE CARE, 255-LICENSED BED, NOT-FOR-PROFIT HOSPITAL; WITH A PROFESSIONAL OFFICE BUILDING, ADULT DAY CARE, GOTTLIEB CENTER FOR FITNESS, AND MARJORIE G. WEINBERG CANCER CARE CENTER ON ITS CAMPUS. GMH PROVIDES VITAL HEALTH CARE SERVICES TO PATIENTS IN VARIOUS CLINICAL AREAS, INCLUDING GENERAL MEDICINE, OBSTETRICS/GYNECOLOGY, CARDIOVASCULAR SERVICES, ORTHOPEDICS, NEUROSCIENCES, SPINE CARE, ONCOLOGY, AND ADULT CARE SERVICE. GMH'S AFFILIATION WITH LOYOLA UNIVERSITY HEALTH SYSTEM AND LOYOLA UNIVERSITY MEDICAL CENTER BRINGS A HIGH-QUALITY, FULL-SERVICE COMMUNITY-BASED INSTITUTION TOGETHER WITH A WORLD-CLASS TEACHING HOSPITAL AND MEDICAL SCHOOL. BOTH ORGANIZATIONS ARE NOT-FOR-PROFIT HEALTHCARE INSTITUTIONS AND BRING DIFFERENT STRENGTHS TO THIS RELATIONSHIP. THE COMMUNITIES SERVED BY THESE INSTITUTIONS BENEFIT FROM THE AFFILIATION BY ENHANCED HEALTHCARE PROVIDED LOCALLY AND THE IMPROVED FINANCIAL POSITIONS OF BOTH ORGANIZATIONS. GMH'S TOTAL SERVICE AREA, WHICH INCLUDES THE WESTERN SECTION OF CHICAGO, WESTERN COOK COUNTY AND THE EASTERN PART OF DUPAGE COUNTY, COVERS A POPULATION OF ABOUT ONE MILLION PEOPLE CHARACTERIZED BY A WIDE DEMOGRAPHIC MIX OF AGE, RACE AND ECONOMIC DIVERSITY. THE AREA HAS SUBSTANTIAL DISPARITIES IN SOCIOECONOMIC STATUS, UNEMPLOYMENT AND HEALTH STATUS. SPECIFICALLY, THE AREA HAS THE FOLLOWING CHARACTERISTICS: - 11 PERCENT OF THE POPULATION IS AGE 65 OR OLDER- AVERAGE HOUSEHOLD INCOME IS $65,266 WITH 17.2 PERCENT OF HOUSEHOLDS OVER $100,000 AND 22.8 PERCENT UNDER $25,000- HISPANICS ARE AMONG THE FASTEST-GROWING GROUP MAKING UP 33.7 PERCENT OF THE POPULATION PART VI, LINE 5: OTHER INFORMATION - IN FURTHERANCE OF LUHS' TRADITION OF TEACHING, GMH SUPPORTS HOSPITAL-BASED EDUCATION AND TRAINING OF FUTURE PROFESSIONALS. GMH PROVIDED HOME AND HOSPICE CARE TRAINING FOR STUDENT NURSES, SUPPLIED PRECEPTORS FOR PHARMACY STUDENTS, PROVIDED CLINICAL SUPERVISION OF PHYSICAL AND SPEECH THERAPY STUDENTS AND TRAINED MEDICAL STUDENTS TO EVALUATE PATIENTS' NEEDS THROUGH OUTREACH IN THE COMMUNITY. GMH ALSO PROVIDES SUBSIDIZED HEALTH PROGRAMS IN RESPONSE TO COMMUNITY NEEDS; THESE PROGRAMS OPERATE AT A FINANCIAL LOSS. PROGRAMS INCLUDE CLINICAL SERVICES, AS WELL AS COMMUNITY HEALTH AND EDUCATION PROGRAMS. SPECIFICALLY, GMH PROVIDED SUBSIDIZED SUPPORT FOR ITS ADULT DAY CARE CENTER. GMH BEGAN RUNNING THE CENTER AFTER A LOCAL CHURCH COULD NO LONGER AFFORD TO PROVIDE THIS COMMUNITY SERVICE. THE CENTER PROVIDES CARE FOR PERSONS WITH DIABETES, DEMENTIA, DEPRESSION AND OTHER MENTAL AND MEDICAL DIAGNOSES. IN ADDITION, DURING FISCAL YEAR 2012, GMH PROVIDED PRE-SCHOOL HEARING AND SPEECH SCREENINGS, AND ADMINISTERED 150 FREE VACCINATIONS AT ITS FLU SHOT FAIR. GMH ALSO MAINTAINS AND STAFFS A HEALTH INFORMATION RESOURCE CENTER TO GIVE PATIENTS, FAMILIES, THE GENERAL PUBLIC, EMPLOYEES AND OTHERS EASY ACCESS TO HEALTH INFORMATION. FURTHERMORE, GMH OFFERS OLDER ADULTS AN AARP SAFE DRIVING PROGRAM AND ITS YESTERDAY'S YOUTH CLUB, A SOCIAL CLUB WITH HEALTH AND LIFESTYLE EDUCATION AND ACTIVITIES FOR AN AVERAGE OF 900 SENIORS.GMH SUPPORTS OTHER NOT-FOR-PROFIT COMMUNITY ORGANIZATIONS THROUGH CASH AND IN-KIND CHARITABLE CONTRIBUTIONS. THIS CONTRIBUTION INCLUDES A SPONSORSHIP TO HISPANOCARE, A NOT-FOR-PROFIT ORGANIZATION WITH A MISSION TO PROVIDE QUALITY, COST-EFFECTIVE HEALTHCARE TO CHICAGO'S LATINO COMMUNITY IN A CULTURALLY SENSITIVE MANNER. HISPANOCARE COORDINATES COMMUNITY HEALTH FAIRS WHERE PREVENTIVE SERVICES AND SCREENINGS ARE OFFERED FREE OF CHARGE. IT EDUCATES THE LATINO COMMUNITY ABOUT GENERAL HEALTH, ILLNESS PREVENTION AND OTHER RELATED TOPICS THROUGH SPANISH RADIO TALK SHOWS, NEWSPAPER COLUMNS AND A MEMBER NEWSLETTER. HISPANOCARE ALSO ANNUALLY PROVIDES SEVERAL COLLEGE-LEVEL SCHOLARSHIPS TO STUDENTS ENROLLED IN HEALTHCARE-RELATED STUDIES. IN ADDITION, GMH AWARDED A GRANT TO A LOCAL ELEMENTARY SCHOOL IN THE 2012 FISCAL YEAR IN CONJUNCTION WITH THE PROJECT FIT AMERICA PROGRAM. THE GRANT WILL PAY FOR A SEVEN-STATION EXERCISE CIRCUIT INSTALLED ON THE SCHOOL GROUNDS AND A HEALTH-AND-FITNESS CLASSROOM COMPONENT, ALL DESIGNED TO HELP IMPROVE STUDENTS' FITNESS LEVELS AND MOTIVATE THEM TO ADOPT HEALTHY LIFESTYLES. SINCE THE PROGRAM WAS INITIATED, GMH HAS PROVIDED SPONSORSHIP GRANTS TO 14 SCHOOLS IN THIS HIGHLY EFFECTIVE NATIONAL PROGRAM. PART VI, LINE 6: GMH IS A MEMBER ORGANIZATION OF TRINITY HEALTH, ONE OF THE LARGEST CATHOLIC HEALTH CARE SYSTEMS IN THE COUNTRY. BASED IN LIVONIA, MICHIGAN, TRINITY HEALTH ANNUALLY REQUIRES THAT ALL MEMBER ORGANIZATIONS DEVELOP, AND ARE HELD ACCOUNTABLE FOR ACHIEVING, COMMUNITY BENEFIT GOALS THAT INCLUDE DEVELOPING NEEDED SERVICES OR EXPANDING ACCESS TO SERVICES FOR LOW-INCOME INDIVIDUALS. AS A NOT-FOR-PROFIT HEALTH SYSTEM, TRINITY HEALTH REINVESTS ITS PROFITS BACK INTO THE COMMUNITY THROUGH PROGRAMS TO SERVE THOSE WHO ARE POOR AND UNINSURED, MANAGE CHRONIC CONDITIONS LIKE DIABETES, HEALTH EDUCATION AND PROMOTION INITIATIVES, AND OUTREACH TO THE ELDERLY. IN FISCAL YEAR 2012, THIS INCLUDED OVER $615 MILLION IN SUCH COMMUNITY BENEFITS. THEREFORE, TRINITY HEALTH TAKES A SYSTEM APPROACH IN ITS COMMUNITY BENEFIT PLANNING AND IMPLEMENTATION, AND IS CONSEQUENTLY ABLE TO ENSURE THAT ITS MEMBER HOSPITALS AND OTHER ENTITIES/AFFILIATES ARE HELPING PROMOTE AND ADDRESS THE HEALTH NEEDS OF THEIR RESPECTIVE COMMUNITIES. FOR MORE INFORMATION ABOUT TRINITY HEALTH, VISIT WWW.TRINITY-HEALTH.ORG. REPORTS FILED WITH STATES PART VI, LINE 7 IL 1 1 0 0 0 0 0 0 0 DANIEL HALE 0 479340 0 186340 0 260274 0 87640 0 18585 0 1032179 0 155414 PATRICIA CASSIDY 0 490629 0 217040 0 1178205 0 158843 0 14824 0 2059541 0 0 LARRY GOLDBERG 0 126243 0 50000 0 20407 0 12003 0 912 0 209565 0 0 ROBERT FLANIGAN MD 0 321449 0 40579 0 46966 0 20982 0 4814 0 434790 0 0 RICHARD GAMELLI MD 0 308813 0 383422 0 197791 0 20982 0 8212 0 919220 0 0 P TERRENCE O'ROURKE 0 500415 0 209835 0 153331 0 22851 0 27858 0 914290 0 0 ROBERT SULO MD 0 331070 0 0 0 2322 0 20982 0 21094 0 375468 0 0 DAVID WILBER 0 567184 0 67500 0 5584 0 20982 0 5149 0 666399 0 0 BENJAMIN CARTER 0 509505 0 174420 0 71089 0 73824 0 28865 0 857703 0 0 ELLYN CHIN 246641 0 10856 0 25000 0 36904 0 26031 0 345432 0 0 0 CHARLES REITER III 0 262219 0 130098 0 1196670 0 98740 0 15110 0 1702837 0 0 JILL RAPPIS 0 237141 0 50152 0 1209 0 49455 0 8647 0 346604 0 0 DONNA HALINSKI 0 227291 0 72792 0 9658 0 33582 0 15391 0 358714 0 0 TOM HONAN NAVIGANT 0 1556520 0 0 0 0 0 0 0 0 0 1556520 0 0 KENNETH FISHBAIN 317784 0 6433 0 195000 0 57770 0 11290 0 588277 0 0 0 ALAN GOLDBERG 158266 0 3826 0 90995 0 102014 0 26031 0 381132 0 0 0 JOSEPH SWEDISH 0 1279458 0 677642 0 3229560 0 548602 0 27600 0 5762862 0 2698342 KEDRICK ADKINS 0 743978 0 316652 0 344596 0 103857 0 13263 0 1522346 0 143708 J RICHARD O'CONNELL 0 571942 0 230946 0 140349 0 85919 0 32302 0 1061458 0 0 MICHAEL MURPHY 0 402598 0 0 0 71772 0 48365 0 27173 0 549908 0 0 BRETT WAKEFIELD 69841 0 3272 0 160884 0 178142 0 24031 0 436170 0 0 0 SILIA MIGLIO 137314 0 4919 0 15405 0 14043 0 3443 0 175124 0 0 0 MAURITA ADLER 147615 0 3191 0 0 0 29311 0 26031 0 206148 0 0 0 ELIZABETH MCLAIN 145698 0 0 0 0 0 7520 0 7155 0 160373 0 0 0 JOHN ASTREIDES 138424 0 2889 0 0 0 21474 0 9322 0 172109 0 0 0 PAUL WHELTON 0 485635 0 251100 0 2956365 0 1438402 0 14667 0 5146169 0 0 CONSTANCE CLARK 98316 0 3723 0 80671 0 21657 0 6194 0 210561 0 0 0 PART I, LINE 3 AS OF JULY 1, 2011, GOTTLIEB MEMORIAL HOSPITAL IS A SUBSIDIARY IN THE TRINITY HEALTH SYSTEM. GOTTLIEB MEMORIAL HOSPITAL'S PRESIDENT IS PAID DIRECTLY BY THE SYSTEM'S PARENT ENTITY, TRINITY HEALTH CORPORATION. TRINITY HEALTH CORPORATION USED THE FOLLOWING METHODS TO ESTABLISH THE COMPENSATION OF GOTTLIEB MEMORIAL HOSPITAL'S PRESIDENT: - COMPENSATION COMMITTEE - INDEPENDENT COMPENSATION CONSULTANT - FORM 990 OF OTHER ORGANIZATIONS - WRITTEN EMPLOYMENT CONTRACT - COMPENSATION SURVEY OR STUDY, AND - APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE PART I, LINES 4A-B THE FOLLOWING INDIVIDUALS RECEIVED SEVERANCE PAYMENTS IN CALENDAR 2011. THESE AMOUNTS ARE INCLUDED IN COLUMN B(III): PATRICIA CASSIDY - $1,031,555 CHARLES REITER, III - $960,000 BRETT WAKEFIELD - $59,989 PAUL WHELTON - $432,802 IN ADDITION, COLUMN C OF SCHEDULE J, PART II INCLUDES THE FOLLOWING SEVERANCE AMOUNTS WHICH WERE UNPAID AS OF 12/31/11: PATRICIA CASSIDY - $121,005 ($60,503 PAID IN 2012 AND $60,502 TO BE PAID IN 2013) CHARLES REITER, III - $49,021 ($24,511 PAID IN 2012 AND $24,510 TO BE PAID IN 2013) BRETT WAKEFIELD - $81,803 (PAID IN 2012) PAUL WHELTON - $1,427,198 ($930,012 PAID IN 2012 AND $497,186 TO BE PAID IN 2013) PART I, LINE 4A: THE FOLLOWING INDIVIDUALS RECEIVED A CHANGE-OF-CONTROL PAYMENT IN CALENDAR 2011. THESE AMOUNTS WERE INCLUDED IN COLUMN B(III): CONSTANCE CLARK - $80,671 KENNETH FISHBAIN - $162,500 ALAN GOLDBERG - $82,895 BRETT WAKEFIELD - $70,895 PART II, LINE 4B: THE FOLLOWING ARE PARTICIPANTS IN THE TRINITY HEALTH PENSION RESTORATION PLAN, A NONQUALIFIED PLAN, WHICH PROVIDES RETIREMENT BENEFITS FOR CERTAIN ASSOCIATES WITH EARNINGS ABOVE THE IRS PAY CAP FOR QUALIFIED PLANS ($245,000 FOR 2011). THE FOLLOWING ACCRUALS FOR 2011 FOR THIS PLAN ARE INCLUDED IN COLUMN C OF SCHEDULE J, PART II: KEDRICK ADKINS - $91,607 BENJAMIN CARTER - $54,011 LARRY GOLDBERG - $5,686 DANIEL HALE - $42,034 MICHAEL MURPHY - $27,513 J. RICHARD O'CONNELL - $66,279 JOSEPH SWEDISH - $255,902 THE FOLLOWING ARE PARTICIPANTS IN THE LOYOLA UNIVERSITY MEDICAL CENTER RETIREMENT RESTORATION PLAN, A NONQUALIFIED PLAN, WHICH PROVIDES RETIREMENT BENEFITS FOR CERTAIN ASSOCIATES WITH EARNINGS ABOVE THE IRS PAY CAP FOR QUALIFIED PLANS ($245,000 FOR 2011). THE FOLLOWING TAXABLE AMOUNTS FOR 2011 FOR THIS PLAN ARE INCLUDED IN COLUMN B(III) OF SCHEDULE J, PART II: PATRICIA CASSIDY - $145,408 CHARLES RETIER, III - $152,173 THE FOLLOWING IS A PARTICIPANT IN A SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN (SERP). THE FOLLOWING SERP ACCRUAL FOR 2011 IS INCLUDED IN COLUMN C OF SCHEDULE J, PART II: JOSEPH SWEDISH - $265,000 PART II: THE FOLLOWING INDIVIDUALS BECAME VESTED IN A SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN (SERP) DURING CALENDAR 2011. AS A RESULT, THE VESTED AMOUNTS WERE INCLUDED IN THEIR 2011 TAXABLE INCOMES. THE FOLLOWING VESTED SERP AMOUNTS ARE INCLUDED IN COLUMN B(III) OF SCHEDULE J, PART II: KEDRICK ADKINS - $220,648 CHARLES REITER, III - $42,488 JOSEPH SWEDISH - $2,740,000 PAUL WHELTON - $2,362,626 COLUMN F OF SCHEDULE J INCLUDES THE PORTION OF THESE AMOUNTS THAT WERE REPORTED AS DEFERRED COMPENSATION IN PRIOR YEARS. SUPPLEMENTAL INFORMATION PART III PART II: TOM HONAN - THE AMOUNT LISTED IN COLUMN B(I) OF SCHEDULE J, PART II REPRESENTS THE AMOUNT PAID BY LOYOLA UNIVERSITY MEDICAL CENTER IN CALENDAR 2011 TO NAVIGANT FOR MR. HONAN'S SERVICES AS INTERIM CFO. GOTTLIEB MEMORIAL HOSPITAL DOES NOT KNOW HOW MUCH MR. HONAN RECEIVED AS WAGES FROM NAVIGANT IN CALENDAR 2011. FORM 990, PART VI, SECTION A, LINE 3 LOYOLA UNIVERSITY MEDICAL CENTER AND GOTTLIEB MEMORIAL HOSPITAL HAVE CONTRACTED WITH NAVIGANT FOR THE PROVISION OF INTERIM CFO SERVICES. SEE SCHEDULE J, PART III FOR ADDITIONAL INFORMATION. FORM 990, PART VI, SECTION A, LINE 4 EFFECTIVE JULY 1, 2011, GOTTLIEB MEMORIAL HOSPITAL AND ITS SOLE MEMBER, LOYOLA UNIVERSITY HEALTH SYSTEM, BECAME PART OF THE TRINITY HEALTH SYSTEM. GOTTLIEB MEMORIAL HOSPITAL'S ARTICLES AND BYLAWS WERE AMENDED TO REFLECT THIS OWNERSHIP CHANGE. FORM 990, PART VI, SECTION A, LINE 6 THE SOLE MEMBER OF GOTTLIEB MEMORIAL HOSPITAL IS LOYOLA UNIVERSITY HEALTH SYSTEM. SEE LINE 7 FOR ADDITIONAL INFORMATION. FORM 990, PART VI, SECTION A, LINE 7A LOYOLA UNIVERSITY HEALTH SYSTEM IS THE SOLE MEMBER OF GOTTLIEB MEMORIAL HOSPITAL. LOYOLA UNIVERSITY HEALTH SYSTEM HAS THE RIGHT TO APPOINT ALL PERSONS TO THE BOARD OF DIRECTORS OF GOTTLIEB MEMORIAL HOSPITAL. FORM 990, PART VI, SECTION A, LINE 7B AS SOLE MEMBER, LOYOLA UNIVERSITY HEALTH SYSTEM MUST APPROVE CERTAIN DECISIONS OF THE GOVERNING BODY, INCLUDING THE STRATEGIC PLAN, ANNUAL CAPITAL PLAN, AND ANNUAL OPERATING BUDGET. LOYOLA UNIVERSITY HEALTH SYSTEM MUST ALSO APPROVE SIGNIFICANT CHANGES SUCH AS A MERGER, DISSOLUTION, SALE OF ASSETS IN EXCESS OF CERTAIN LIMITS, A MATERIAL CHANGE IN MISSION, AND MODIFICATIONS TO GOVERNING DOCUMENTS. FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 IS PREPARED BY THE TRINITY HOME OFFICE TAX DEPARTMENT, BASED ON INFORMATION PROVIDED BY A MULTI-DISCIPLINARY TEAM OF LOYOLA AND GOTTLIEB STAFF. A DETAILED SUMMARY OF THE DRAFT FORM 990 IS PRESENTED TO THE ORGANIZATION'S BOARD FINANCE & PLANNING COMMITTEE AND THE ORGANIZATION'S OFFICERS ARE PROVIDED A COPY OF THE ORGANIZATION'S DRAFT FORM 990 (INCLUDING ALL KEY REQUIRED SCHEDULES). THE COMPLETE FORM 990 IS PROVIDED TO THE GOTTLIEB MEMORIAL HOSPITAL BOARD IN ELECTRONIC FORM, PRIOR TO FINALIZING AND FILING THE FORM. FORM 990, PART VI, SECTION B, LINE 12C GOTTLIEB MEMORIAL HOSPITAL HAS ADOPTED A CONFLICT OF INTEREST POLICY WHICH CONTAINS THE ELEMENTS IN THE MODEL CONFLICT OF INTEREST POLICY ISSUED BY THE IRS. IT APPLIES TO ALL "INTERESTED PERSONS" OF GOTTLIEB MEMORIAL HOSPITAL, WHICH INCLUDES DIRECTORS, PRINCIPAL OFFICERS AND EXECUTIVES, AND MEMBERS OF COMMITTEES WITH BOARD DESIGNATED POWERS. INTERESTED PERSONS ARE REQUIRED TO ACT AT ALL TIMES IN A MANNER CONSISTENT WITH GOTTLIEB MEMORIAL HOSPITAL'S CHARITABLE PURPOSE AND SERVICE TO THE COMMUNITY AND TO AVOID CONFLICTS OF INTEREST. INTERESTED PERSONS ARE REQUIRED TO MAKE FULL DISCLOSURE TO GOTTLIEB MEMORIAL HOSPITAL OF ANY FINANCIAL OR BUSINESS INTERESTS THAT MIGHT RESULT IN OR HAVE THE APPEARANCE OF A CONFLICT OF INTEREST. INTERESTED PERSONS ARE REQUIRED TO RECUSE THEMSELVES FROM DISCUSSION AND VOTING ON MATTERS INVOLVING A CONFLICT OF INTEREST. THE BOARD OF DIRECTORS OF GOTTLIEB MEMORIAL HOSPITAL IS RESPONSIBLE FOR THE REVIEW AND APPROVAL OF TRANSACTIONS WITH INTERESTED PERSONS, INCLUDING DETERMINING THAT SUCH TRANSACTIONS ARE FAIR AND REASONABLE TO GOTTLIEB MEMORIAL HOSPITAL. ON AN ANNUAL BASIS, INTERESTED PERSONS ARE REQUIRED TO COMPLETE A CONFLICT OF INTEREST DISCLOSURE STATEMENT AND TO AFFIRM THEIR RECEIPT OF THE CONFLICT OF INTEREST POLICY, COMPLIANCE WITH ITS REQUIREMENTS, AND AGREE TO NOTIFY THE ORGANIZATION OF CHANGES IMPACTING THEIR ANNUAL DISCLOSURE IN ACCORDANCE WITH THE POLICY. THE ANNUAL DISCLOSURES ARE REVIEWED WITH THE BOARD OF DIRECTORS OF GOTTLIEB MEMORIAL HOSPITAL ON AN ANNUAL BASIS. FORM 990, PART VI, SECTION B, LINE 15 TRINITY HEALTH FOLLOWS A PROCESS AND POLICY THAT IS INTENDED TO MIRROR THE IRC SECTION 4958 GUIDELINES FOR OBTAINING A "REBUTTABLE PRESUMPTION OF REASONABLENESS" WITH REGARD TO COMPENSATION AND BENEFITS. AS PART OF THAT PROCESS, THE COMPENSATION AND BENEFITS OF CERTAIN OFFICERS AND KEY MANAGEMENT OFFICIALS OF GOTTLIEB MEMORIAL HOSPITAL ARE REVIEWED AT LEAST ANNUALLY BY THE TRINITY HEALTH BOARD OR THE TRINITY HEALTH HUMAN RESOURCES AND COMPENSATION COMMITTEE (HRCC) OF THE BOARD, AUTHORIZED TO ACT ON BEHALF OF THE BOARD WITH RESPECT TO CERTAIN COMPENSATION MATTERS. AS PART OF ITS REVIEW PROCESS, THE HRCC RETAINS AN INDEPENDENT FIRM EXPERIENCED IN COMPENSATION AND BENEFIT MATTERS FOR NOT-FOR-PROFIT HEALTHCARE ORGANIZATIONS TO ADVISE IT IN THE DETERMINATIONS IT MAKES ON THE REASONABLENESS OF PROPOSED COMPENSATION AND BENEFITS ARRANGEMENTS. FORM 990, PART VI, SECTION C, LINE 19 EFFECTIVE JULY 1, 2011, GOTTLIEB MEMORIAL HOSPITAL IS A SUBSIDIARY ORGANIZATION IN THE TRINITY HEALTH SYSTEM. TRINITY HEALTH MAKES CERTAIN OF ITS KEY DOCUMENTS AVAILABLE TO THE PUBLIC ON ITS WEBSITE, WWW.TRINITY-HEALTH.ORG, IN THE "ABOUT US" SECTION. IN THIS SECTION, THE ANNUAL REPORT (WHICH INCLUDES COMMUNITY BENEFIT MINISTRY INFORMATION) AND CONSOLIDATED AUDITED FINANCIAL STATEMENTS ARE PUBLICLY AVAILABLE. IN ADDITION, GOTTLIEB MEMORIAL HOSPITAL WILL BE INCLUDING A COPY OF ITS MOST RECENTLY FILED SCHEDULE H ON BOTH ITS OWN WEBSITE AND TRINITY HEALTH'S WEBSITE. ESTIMATE OF THE AVERAGE HOURS PER WEEK DEVOTED TO RELATED ORGANIZATIONS: FORM 990, PART VII, SECTION A, LINE 1, COLUMN B: THE HOURS LISTED IN COLUMN B OF PART VII, SECTION A, LINE 1 REFLECT ONLY THE INDIVIDUALS' AVERAGE WEEKLY HOURS SPENT DIRECTLY ON THE ACTIVITIES OF THE REPORTING ORGANIZATION. IN ADDITION, THESE ARE THE AVERAGE HOURS PER WEEK DEVOTED TO RELATED ORGANIZATIONS: KEDRICK ADKINS - 53 HOURS BENJAMIN CARTER - 48 HOURS PATRICIA CASSIDY - 20 HOURS ELLYN CHIN - 10 HOURS KENNETH FISHBAIN - 10 HOURS ROBERT FLANIGAN, MD - 43 HOURS RICHARD GAMELLI, MD - 43 HOURS LARRY GOLDBERG - 35 HOURS DANIEL HALE - 48 HOURS DONNA HALINSKI - 43 HOURS TOM HONAN - 32 HOURS MICHAEL MURPHY - 53 HOURS J. RICHARD O'CONNELL - 53 HOURS P. TERRENCE O'ROURKE - 48 HOURS JILL RAPPIS - 45 HOURS CHARLES REITER, III - 43 HOURS AJAY SIAL - 43 HOURS ROBERT SULO, MD - 43 HOURS JOSEPH SWEDISH - 53 HOURS DAVID WILBER - 43 HOURS CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED LOSSES ON INVESTMENTS: -961,074. EQUITY TRANSFERS FROM AFFILIATES: 84,286,626. CHANGE IN DEFERRED RETIREMENT COST: -8,341,483. OTHER TRANSACTIONS: 115,998. PURCHASE ACCOUNTING ADJUSTMENTS DUE TO ACQUISITION BY TRINITY HEALTH CORP. -58,814,858. TOTAL TO FORM 990, PART XI, LINE 5: 16,285,209. FORM 990, PART XII, LINE 2 GOTTLIEB MEMORIAL HOSPITAL'S FINANCIAL STATEMENTS WERE INCLUDED IN THE FY12 CONSOLIDATED FINANCIAL STATEMENTS OF TRINITY HEALTH, WHICH WERE AUDITED BY AN INDEPENDENT PUBLIC ACCOUNTING FIRM. ADVANTAGE HEALTHSAINT MARY'S MEDICAL GROUP 245 STATE ST SE GRAND RAPIDS MI 49503 272491974 HEALTHCARE SERVICES MI 501(C)(3) 9 TRINITY HEALTH-MICHIGAN 0 AMICARE HOSPICE SERVICES INC 20555 VICTOR PARKWAY LIVONIA MI 48152 382949053 PROVIDE HOSPICE SERVICES MI 501(C)(3) 11, TYPE I TRINITY HOME HEALTH SERVICES INC 0 AUXILIARY OF HOLY ROSARY HOSPITAL 351 SW 9TH STREET ONTARIO OR 97914 943059469 SUPPORTS SERVICES OF RELATED HOSPITAL OR 501(C)(3) 9 SAINT ALPHONSUS MEDICAL CENTER-ONTARIO 0 BAUM HARMON MERCY HOSPITAL 255 NORTH WELCH AVENUE PRIMGHAR IA 51245 421500277 ACUTE/AMBULATORY HEALTHCARE SERVICES IA 501(C)(3) 3 MERCY HEALTH SERVICES-IOWA CORP 0 BAUM HARMON MERCY HOSPITAL & CLINICS FOUNDATION 255 NORTH WELCH AVENUE PRIMGHAR IA 51245 262973307 SUPPORT THE SERVICES OF RELATED HOSPITAL IA 501(C)(3) 11, TYPE I BAUM HARMON MERCY HOSPITAL 0 CATHERINE MCAULEY HEALTH SERVICES CORP PO BOX 995 ANN ARBOR MI 48106 382507173 FURTHER TRINITY HEALTH ACTIVITIES, ORGANIZE AND DEVELOP MEDICAL SERVICES MI 501(C)(3) 11, TYPE II TRINITY HEALTH-MICHIGAN 0 COMMUNITY HEALTH PARTNERS OF SOUTH BEND PO BOX 3998 SOUTH BEND IN 46619 263051440 HEALTHCARE SERVICES IN 501(C)(3) 3 SAINT JOSEPH REGIONAL MEDICAL CENTER INC 0 CRANBROOK HOSPICE CARE 281 ENTERPRISE COURT BLOOMFIELD HILLS MI 48302 383320699 PROVIDE HOSPICE HEALTH SERVICES MI 501(C)(3) 11, TYPE I TRINITY HOME HEALTH SERVICES INC 0 DILEY RIDGE MEDICAL CENTER 6150 EAST BROAD STREET COLUMBUS OH 43213 342032340 HOSPITAL CAMPUS IN FAIRFIELD COUNTY OHIO OH 501(C)(3) 3 MOUNT CARMEL HEALTH SYSTEM 0 DUBUQUE MERCY HEALTH FOUNDATION INC 250 MERCY DRIVE DUBUQUE IA 52001 262227941 SUPPORT THE SERVICES OF RELATED HOSPITAL IA 501(C)(3) 11, TYPE I MERCY HEALTH SERVICES-IOWA CORP 0 DYERSVILLE HEALTH FOUNDATION INC 1111 3RD STREET SW DYERSVILLE IA 52040 205383271 SUPPORT THE SERVICES OF RELATED HOSPITAL IA 501(C)(3) 11, TYPE I MERCY HEALTH SERVICES-IOWA CORP 0 GOTTLIEB COMMUNITY HEALTH SERVICES CORPORATION 701 W NORTH AVE MELROSE PARK IL 60160 363332852 SUPPORT THE SERVICES OF RELATED HOSPITAL IL 501(C)(3) 9 GOTTLIEB MEMORIAL HOSPITAL 1 GOTTLIEB MEMORIAL FOUNDATION 701 W NORTH AVE MELROSE PARK IL 60160 743260011 SUPPORT THE SERVICES OF RELATED HOSPITAL IL 501(C)(3) 11, TYPE III-FI N/A 0 GOTTLIEB MEMORIAL HOSPITAL 701 W NORTH AVE MELROSE PARK IL 60160 362379649 HEALTHCARE SERVICES IL 501(C)(3) 3 LOYOLA UNIVERSITY HEALTH SYSTEM 1 HACKLEY HOSPITAL 1700 CLINTON ST PO BOX 3302 MUSKEGON MI 494433302 381358196 HEALTHCARE SERVICES MI 501(C)(3) 3 MERCY HEALTH PARTNERS 0 HACKLEY HOSPITAL SELF INSURANCE PROFESSIONAL LIABILITY TRUST PO BOX 3302 MUSKEGON MI 494433302 382299878 SELF INSURANCE FOR GENERAL AND MALPRACTICE LIABILITY MI 501(C)(3) 11, TYPE III-FI MERCY HEALTH PARTNERS 0 HACKLEY LIFE COUNSELING 1352 TERRACE ST MUSKEGON MI 494423545 381386362 COUNSELING, EDUCATION, AND SUPPORT MI 501(C)(3) 9 MERCY HEALTH PARTNERS 0 HACKLEY VISITING NURSE SERVICES AND HOSPICE INC 888 TERRACE ST MUSKEGON MI 49440 381359598 PROVIDE HOME HEALTH CARE SERVICES MI 501(C)(3) 7 MERCY HEALTH PARTNERS 0 HOLY CROSS CARENET INC PO BOX 9184 FARMINGTON HILLS MI 48333 521945054 LONG-TERM CARE AND REHABILITATION FOR THE ELDERLY MD 501(C)(3) 9 TRINITY CONTINUING CARE SERVICES 0 HOLY CROSS HOSPITAL FOUNDATION INC 11801 TECH ROAD SILVER SPRING MD 20904 208428450 CHARITABLE FUNDRAISING MD 501(C)(3) 11, TYPE I HOLY CROSS HOSPITAL OF SILVER SPRING 0 HOLY CROSS HOSPITAL OF SILVER SPRING INC 1500 FOREST GLEN RD SILVER SPRING MD 209101484 520738041 HEALTHCARE SERVICES MD 501(C)(3) 3 TRINITY HEALTH CORPORATION 0 HOLY CROSS MEDICAL CENTER 20555 VICTOR PARKWAY LIVONIA MI 48152 951985442 HEALTHCARE SERVICES (FORMERLY) CA 501(C)(3) 3 TRINITY HEALTH CORPORATION 0 HOSPICE OF NORTH IOWA 232 SECOND STREET SE MASON CITY IA 504016208 421173708 HOSPICE HEALTH CARE SERVICES IA 501(C)(3) 7 MERCY HEALTH SERVICES-IOWA CORP 0 HOSPICE OF WASHTENAW II 806 AIRPORT BLVD ANN ARBOR MI 48108 383320707 HOSPICE HEALTH CARE SERVICES MI 501(C)(3) 11, TYPE I TRINITY HEALTH-MICHIGAN 0 HPCN 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SERVICES (FORMERLY) MI 501(C)(3) 3 CATHERINE MCAULEY HEALTH SERVICES CORP 0 MERCY AMICARE HOME HEALTHCARE OAKLAND 281 ENTERPRISE COURT BLOOMFIELD HILLS MI 483020312 383320698 PROVIDE HOME HEALTH CARE SERVICES MI 501(C)(3) 11, TYPE I TRINITY HOME HEALTH SERVICES INC 0 MERCY AMICARE HOME HEALTHCARE PORT HURON 505 HURON AVENUE PORT HURON MI 48060 383320701 PROVIDE HOME HEALTH CARE SERVICES MI 501(C)(3) 11, TYPE I TRINITY HOME HEALTH SERVICES INC 0 MERCY FOUNDATION INC 2525 SOUTH MICHIGAN AVENUE CHICAGO IL 60616 363227350 SUPPORTS THE SERVICES OF RELATED HEALTH CARE SYSTEM IL 501(C)(3) 11, TYPE I MERCY HEALTH SYSTEM OF CHICAGO 0 MERCY GENERAL HEALTH PARTNERS AMICARE HOMECARE 684 HARVEY STREET MUSKEGON MI 49442 383321856 PROVIDE HOME HEALTH CARE SERVICES MI 501(C)(3) 11, TYPE I TRINITY HOME HEALTH SERVICES INC 0 MERCY HEALTH PARTNERS 1415 LEAHY STREET MUSKEGON MI 49442 382589966 HEALTHCARE SYSTEM SUPPORT MI 501(C)(3) 11, TYPE I TRINITY HEALTH-MICHIGAN 0 MERCY HEALTH SERVICES - IOWA CORP 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