2012-11-14T07:35:24-06:00 2011-12-31 990 2011-01-01 362739299 TRINITY MEDICAL CENTER TRIN 3097795000 2701 17TH ST ROCK ISLAND IL 61201 GREG PAGLIUZZA JR 3097792218 2012-10-24 2011 2016-02-24 21:20:13Z RICHARD SEIDLER 2701 17TH ST ROCK ISLAND IL 61201 410573249 0 X WWW.TRINITYQC.COM X 1969 IL IMPROVE THE HEALTH OF THE PEOPLE AND COMMUNITIES WE SERVE. 19 12 3162 490 98398 1959 4557383 3124407 327767972 326497284 9729087 6208675 2704090 3293825 344758532 339124191 2856454 2361256 0 0 136467919 156553893 0 0 0 187923285 168463077 327247658 327378226 17510874 11745965 346938374 364192128 177254174 188506032 169684200 175686096 X THE MISSION OF TRINITY MEDICAL CENTER IS TO IMPROVE THE HEALTH OF THE PEOPLE AND COMMUNITIES WE SERVE. 0 0 257451104 1979196 329523224 HEALTH-CARE SERVICESTRINITY MEDICAL CENTER IS AN IMPORTANT ELEMENT OF THE HEALTH-CARE DELIVERY SYSTEM THAT THE QUAD CITY COMMUNITIES RELY ON EVERY DAY. IT IS COMMITTED TO PROVIDING QUALITY HEALTH CARE AND TO USING ITS RESOURCES TO THE GREATEST COMMUNITY BENEFIT. TRINITY MEDICAL CENTER PROVIDES INPATIENT AND OUTPATIENT MEDICAL SERVICES TO TREAT INDIVIDUALS WITH DISEASES, ILLNESS AND INJURIES WITH VARYING COMPLEXITIES. IT PROVIDES SERVICES TO IMPROVE THE HEALTH OF PATIENTS AND TO BETTER THEIR QUALITY OF LIFE. ALL SERVICES ARE PROVIDED REGARDLESS OF AN INDIVIDUAL'S RACE, CREED, SEX, NATIONALITY, HANDICAP, AGE OR ABILITY TO COMPENSATE FOR SERVICES RENDERED. THESE INCLUDE, BUT ARE NOT LIMITED TO GENERAL ACUTE CARE, SURGERIES, INTENSIVE CARE AND CRITICAL CARE, CARDIOLOGY, ONCOLOGY, REHABILITATION, SKILLED NURSING, MATERNAL/CHILD CARE, LABORATORY, PHARMACEUTICAL DRUGS, EMERGENCY SERVICES, OUTPATIENT CLINICS, AND RADIOLOGY. SOME OF THE SERVICES PROVIDED DO NOT GENERATE ENOUGH INCOME TO OFFSET THEIR COST. IN THE FISCAL PERIOD ENDED DECEMBER 31, 2011, TRINITY MEDICAL CENTER ADMITTED 18,994 PATIENTS RESULTING IN A TOTAL OF 80,447 PATIENT DAYS. TOTAL OUTPATIENT SURGERY REGISTRATIONS FOR THE SAME PERIOD WERE 9,338. THERE WERE ALSO 77,732 EMERGENCY ROOM VISITS AND 1,926 BABIES DELIVERED. 25854200 382060 COMMUNITY BENEFIT, INCLUDING CHARITY CARECHARITY CARE AND MEANS-TESTED PROGRAMS: TRINITY MEDICAL CENTER PROVIDES CHARITY CARE AND OTHER MEANS-TESTED PROGRAMS WITH THE GOAL TO IMPROVE THE COMMUNITY'S OVERALL HEALTH AND ACCESS TO CARE. THIS INCLUDES HEALTH-CARE SERVICES REGARDLESS OF THE PATIENT'S INSURANCE COVERAGE OR FINANCIAL STATUS. CHARITY CARE AND PARTIAL TO FULL FINANCIAL ASSISTANCE IS PROVIDED TO PATIENTS ON A CASE-BY-CASE BASIS. CHARITY CARE WAS MADE AVAILABLE TO 19,977 PEOPLE AT A VALUE OF $7,190,321 IN 2011. OFTENTIMES, TRINITY MEDICAL CENTER RECEIVES PAYMENTS FROM PAYORS OR PATIENTS THAT ARE LESS THAN IT CHARGES FOR SERVICES. TRINITY MEDICAL CENTER PARTICIPATES IN MEDICAID AND OTHER GOVERNMENT-SPONSORED HEALTH-CARE PROGRAMS. TRINITY MEDICAL CENTER'S NET COST OF PROVIDING CARE FOR WHICH IT RECEIVES PAYMENT BELOW ITS COST IS $13,279,244 FOR 2011. TOTAL CHARITY CARE AND MEANS-TESTED PROGRAMS REPORTED VALUE: $20,469,565.OTHER BENEFITS: TRINITY MEDICAL CENTER PROVIDES SEVERAL OTHER BENEFITS THAT ASSIST THE COMMUNITY. PROGRAMS INCLUDE, BUT ARE NOT LIMITED TO COMMUNITY HEALTH IMPROVEMENT SERVICES AND COMMUNITY BENEFIT OPERATIONS SUCH AS PREVENTION AND HEALTH SCREENINGS; HEALTH PROFESSIONAL'S EDUCATION; SUBSIDIZED HEALTH SERVICES; RESEARCH; AND CASH AND IN-KIND CONTRIBUTIONS TO COMMUNITY GROUPS. TRINITY MEDICAL CENTER COLLABORATES WITH OTHER HOSPITALS, CHURCHES, SCHOOLS, CHAMBERS OF COMMERCE AND DAYCARE CENTERS TO IMPROVE COMMUNITY HEALTH AND EXPAND ACCESS TO HEALTH CARE. TRINITY MEDICAL CENTER HAS DEDICATED STAFF TO ASSIST COMMUNITY BENEFIT EFFORTS. APPROXIMATELY 144,376 PERSONS WERE SERVED THROUGH THESE PROGRAMS. TOTAL OTHER BENEFITS REPORTED VALUE: $5,384,635. 283305304 1 1 0 1 0 0 0 0 0 1 1 0 0 0 1 1 0 1 0 0 0 0 0 0 1 0 1 1 1 0 1 0 0 0 0 0 0 1 1 0 0 0 0 0 1 0 0 0 0 1 290 0 1 3162 1 1 1 0 0 0 0 0 0 0 0 0 X 19 12 1 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 1 1 IL IA X X SUSAN M KAISER DIR OF FINANCE 3097792895 2701 17TH ST ROCK ISLAND IL 61201 STEPHANIE ACRI 1.00 X X 0 0 0 KIM ARMSTRONG 1.00 X 0 0 0 DUNCAN CAMERON 1.00 X 0 0 0 DR RAJENDRA DAHAL 1.00 X 0 0 0 JAMES HASS 1.00 X 0 0 0 KEN KOUPAL 1.00 X 0 0 0 DR FARAZ MANAZIR 1.00 X 0 0 0 KENNY MASSEY 1.00 X 0 0 0 PETER MCLAUGHLIN 1.00 X 0 14855 0 LINDA NEWBORN 1.00 X 0 14437 0 DR AHMED OKBA 1.00 X 0 0 0 DR WILLIAM OLSON FR 911 40.00 X 711517 0 39391 DR ALEX PAREIGIS 1.00 X 0 0 0 KATHY PULLEY 1.00 X 0 0 0 MARK SCHWIEBERT 1.00 X 0 0 0 RICK SEIDLER 40.00 X X 727601 0 95987 KARLA STEELE 1.00 X X 0 0 0 HEIDI STORL 1.00 X 0 0 0 KAI SWANSON TO 211 1.00 X 0 0 0 DR MATTHEW WILBER 1.00 X 0 0 0 TAMARA BYRAM 40.00 X 187286 0 33053 DAVID DEOPERE 1.00 X 291100 0 31908 MYKL GARRETT TO 1111 40.00 X 304989 0 33387 DR PAUL MCLOONE 40.00 X 96671 165459 33408 GREG PAGLIUZZA JR 40.00 X 343298 0 58672 JAY WILLSHER FR 1111 40.00 X 279425 0 89547 DR PAUL BOLGER 40.00 X 514762 0 44913 KATHLEEN CUNNINGHAM TO 511 40.00 X 141715 134211 27745 JON HONSEY TO 611 40.00 X 178585 0 23608 RICHARD MURPHY 40.00 X 150217 0 32873 BOBETTE PATTERSON 40.00 X 155846 0 27012 MICHAEL PATTERSON 40.00 X 355244 0 39353 KATHERINE PEARSON 40.00 X 215096 0 34827 JEFFREY STOLZE 40.00 X 274609 0 86854 DR RANDALL BAY 40.00 X 466570 0 42222 DR GREGORY BOHN 40.00 X 596387 0 39052 DR MARK BUETTNER 40.00 X 540627 0 45617 DR KEVIN KURTH 40.00 X 474960 66875 38436 DR CHAD VANDERLINDEN 40.00 X 464371 0 40111 ANDREA COLEMAN TO 1109 0.00 X 123903 0 8049 WILLIAM LEAVER TO 1207 0.00 X 0 1341336 307059 TOM TIBBITTS TO 610 0.00 X 0 758496 24275 KEVIN VERMEER TO 509 0.00 X 0 672385 194916 7594779 3168054 1472275 141 1 1 0 METROPOLITAN MEDICAL LAB 1814 E LOCUST ST DAVENPORT IA 52803 LAB SERVICES 8541868 MISSIPPI VALLEY REGIONAL PO BOX 3655 DAVENPORT IA 52808 BLOOD CENTER 2167416 TAG COMMUNICATIONS 230 E SECOND ST DAVENPORT IA 52801 HEALTHCARE MARKETING 1402824 METRO MRI CENTER LIMITED PART 615 VALLEY VIEW DR MOLINE IL 61265 ADVANCED RADIOLOGY 1223451 DIVERSIFIED CLINICAL SERVICES PO BOX 636981 CINCINNATI OH 452636981 WOUND CARE SERVICES 1158690 68 24890 2886903 48519 164095 5595 3124407 NET PATIENT REVENUE 900099 317588206 317588206 EDUCATION & RESEARCH 900099 2783073 2783073 RENTAL REVENUE 531100 2058949 2058949 MGMT & SUPPORT SVCS 561000 1402472 1309202 93270 MISCELLANEOUS REVENUE 900099 1382467 1377339 5128 1282117 1282117 326497284 2909917 2909917 74327054 61429 71045432 44293 3281622 17136 3298758 3298758 14137 24890 17935 -3798 -3798 613081 341398 271683 271683 CAFETERIA/FOOD SVCS 722210 1576450 1576450 MISCELLANEOUS REVENUE 900099 1449490 1449490 3025940 339124191 329424826 98398 6476560 2361256 2361256 4134526 4134526 156956 156956 120766548 110666428 10100120 5391271 4940380 450891 18663535 17102640 1560895 7441057 6818736 622321 3815149 1287728 2527421 1750 1750 25000 25000 592486 1669 590817 30863303 27646470 3216833 103930 47494 56436 10816088 10064974 751114 13831930 11727730 2104200 6294834 6150008 144826 362423 303465 58958 536005 302085 233920 6968664 6968664 14845508 5331365 9514143 286202 -570650 856852 MEDICAL SUPPLIES 67647679 67589943 57736 MISCELLANEOUS EXPENSE 11455152 11533583 -78431 INCOME TAXES 16974 16974 327378226 283305304 44072922 0 15304 13582026 34436245 42454498 38016303 43576214 12666600 13294650 8306448 7654536 1248670 1386933 306022909 176203884 132402000 129819025 109467727 102081001 8798316 8821284 1580761 1521961 346938374 364192128 25153133 29382527 385567 -96455 7139000 7285611 144576474 151934349 177254174 188506032 X 166128273 172005553 2229989 2324364 1325938 1356179 169684200 175686096 346938374 364192128 X 11745965 -5744069 X 0 1 1 X 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 1 25000 0 0 25000 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: DENNY JACOBS AND ASSOCIATES ACTS ON TMC'S BEHALF TO PROMOTE AND EDUCATE LEGISLATORS AND STATE GOVERNMENT ABOUT TMC'S POSITION RELATING TO LAWS, BILLS, POLICIES, PROCEDURES AND ETC. 111608387 342481 -7619436 610604 103720828 98763528 368566 13589944 1113651 111608387 73344833 6436324 19425565 443195 98763528 98982185 582339 -26903952 446486 -1130747 73344833 0.96530 0.01310 0.02160 0 1 1 6322281 6322281 199986646 107449566 92537080 90600952 64117570 26483382 9113030 4636748 4476282 129819025 DUE TO AFFILIATES 454328 ASBESTOS REMOVAL LIABILITY 1093219 MISCELLANEOUS LIABILITY 165409 SELF-INSURANCE RESERVE 12705892 LONG-TERM RETENTION INCENTIVES 1573049 HEALTH AND WELFARE BENEFITS RESERVE 1614506 IOWA HEALTH SYSTEM NOTE PAYABLE 134327946 151934349 339124191 327378226 11745965 -5648543 -95526 -5744069 6001896 349068000 -5648543 17383006 11734463 337333537 397694 1392960 1790654 339124191 338339000 17388495 17388495 320950505 397694 6030027 6427721 327378226 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: THE ORGANIZATION RETAINS FUNDS FOR INTENDED FUTURE USES, INCLUDING PURCHASE OF EQUIPMENT, INDIGENT CARE, FUNDING OF MISSION RELATED OPERATIONS, AND HEALTH EDUCATION. IN ADDITION, SOME FUNDS ARE HELD FOR INVESTMENT IN PERPETUITY. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: IOWA HEALTH SYSTEM AND MOST OF ITS SUBSIDIARIES ARE CLASSIFIED AS TAX-EXEMPT ORGANIZATIONS AS DESCRIBED IN SECTIONS 501(C)(3) AND 501(C)(2) OF THE INTERNAL REVENUE CODE (THE CODE). TAX-EXEMPT ORGANIZATIONS ARE NOT SUBJECT TO FEDERAL AND STATE INCOME TAXES ON RELATED INCOME, PURSUANT TO SECTION 501(A) OF THE CODE. THESE ORGANIZATIONS ARE SUBJECT TO FEDERAL AND STATE INCOME TAXES TO THE EXTENT THEY HAVE UNRELATED BUSINESS INCOME AS DESCRIBED UNDER PROVISIONS OF SECTION 511 OF THE CODE. THE HEALTH SYSTEM FILES FORM 990 FOR SUBSTANTIALLY ALL OF ITS OPERATING ENTITIES IN THE U.S. FEDERAL JURISDICTION AND IS NO LONGER SUBJECT TO EXAMINATION BY TAX AUTHORITIES FOR THE YEARS BEFORE 2008. THE HEALTH SYSTEM HAS NO MATERIAL UNCERTAIN TAX POSITIONS. CERTAIN SUBSIDIARIES ARE SUBJECT TO FEDERAL AND STATE INCOME TAXES. SOME OF THESE CORPORATIONS HAVE ACCUMULATED NET OPERATING LOSS CARRYFORWARDS THAT ARE AVAILABLE TO OFFSET FUTURE TAXABLE INCOME DURING THE CARRYFORWARD PERIOD. NO INCOME TAX BENEFIT HAS BEEN RECOGNIZED FOR THE NET OPERATING LOSS CARRYFORWARDS OR OTHER POTENTIAL DEFERRED TAX ASSETS IN THE CONSOLIDATED FINANCIAL STATEMENTS BECAUSE THE HEALTH SYSTEM BELIEVES REALIZATION OF THESE BENEFITS IS UNLIKELY. PART XI, LINE 8 - OTHER ADJUSTMENTS: CHANGE IN BENEFICIAL INTEREST IN TRINITY HEALTH FOUNDATION 149,564. CHANGES IN PENSION LIABILITY -245,090. TOTAL TO SCHEDULE D, PART XI, LINE 8: -95,526. PART XII, LINE 2D - OTHER ADJUSTMENTS: SPECIAL EVENT EXPENSES 17,935. SUBSIDIARY ELIMINATING ENTRIES (PRECEDENCE) 506,534. SUBSIDIARY ELIMINATING ENTRIES (RYC) 16,517,139. COST OF GOODS SOLD 341,398. PART XII, LINE 4B - OTHER ADJUSTMENTS: REVENUES IN TEMPORARILY RESTRICTED FUND BALANCE 178. IOWA HEALTH SYSTEM CONTRACTING SERVICES, LC PURCHASE REBATES 1,301,907. ROUNDING 365. ELIMINATING ENTRIES 90,510. PART XIII, LINE 2D - OTHER ADJUSTMENTS: SUBSIDIARY ELIMINATING ENTRIES (PRECEDENCE) 512,023. SPECIAL EVENT EXPENSES 17,935. SUBSIDIARY ELIMINATING ENTRIES (RYC) 16,517,139. COST OF GOODS SOLD 341,398. PART XIII, LINE 4B - OTHER ADJUSTMENTS: EXPENSES IN UNRESTRICTED FUND BALANCE 4,632,017. IOWA HEALTH SYSTEM CONTRACTING SERVICES, LC PURCHASE REBATES 1,301,907. ROUNDING 103. ELIMINATING ENTRIES 96,000. STYLE SHOW 37537 21075 16462 16520 GARDEN PARTY 1490 3815 -2325 1415 39027 24890 14137 17935 17935 -3798 1 1 X 1 X 1 X 1 1 0 1 1 19977 7190321 7190321 0.02200 29285 27562888 14238644 13324244 0.04070 49262 34753209 14238644 20514565 0.06270 103096 1629944 1629944 0.00500 1062 823490 823490 0.00250 17448 2035801 2035801 0.00620 378 476397 476397 0.00150 22392 838542 419539 419003 0.00130 144376 5804174 419539 5384635 0.01650 193638 40557383 14658183 25899200 0.07920 34737 278987 278987 0.00090 34737 278987 278987 0.00090 0 8696324 22861000 109849345 120934942 -11085597 X 1 1 1 QUAD CITY AMBULATORY SURGERY CENTER LLC AMBULATORY SURGERY CENTER 0.50000 0.50000 2 TRINITY PHYSICIAN HOSPITAL ORGANIZATION LTD LICENSED PPO PROVIDING HEALTH MGMT SERVICES TO PEOPLE IN IL & IA 0.49900 0.40370 3 TRINITY BETTENDORF ORTHOPEDIC CO-MANAGEMENT COMPANY LLC ADMINISTRATION OF ORTHOPEDIC SERVICE LINES 0.50000 0.50000 3 1 TRINITY MEDICAL CENTER - ROCK ISLAND

2701 17TH ST ROCK ISLAND IL 61201

X X X 2 TRINITY MEDICAL CENTER - MOLINE

500 JOHN DEERE RD MOLINE IL 61265

X X X 3 TRINITY MEDICAL CENTER - BETTENDORF

4500 UTICA RIDGE RD BETTENDORF IA 52722

X X X TRINITY MEDICAL CENTER - ROCK ISLAND 1 1 X X X X X X X 11 1 1 1 X X X X X X 1 1 1 200.000000000000 1 400.000000000000 1 X X X 1 1 X X X 1 X X X X 1 X X X X X X X 1 X 0 1 TRINITY MEDICAL CENTER - MOLINE 2 1 1 200.000000000000 1 400.000000000000 1 X X X 1 1 X X X 1 X X X X 1 X X X X X X X 1 X 0 1 TRINITY MEDICAL CENTER - BETTENDORF 3 1 1 200.000000000000 1 400.000000000000 1 X X X 1 1 X X X 1 X X X X 1 X X X X X X X 1 X 0 1 3 TRINITY CENTER FOR WOUND CARE

4480 UTICA RIDGE ROAD SUITE 110 BETTENDORF IA 52722

OUTPATIENT ONLY TRINITY OUTPATIENT REHABILITATION SERVIC

4480 UTICA RIDGE ROAD SUITE 102 BETTENDORF IA 52722

OUTPATIENT ONLY QUAD CITY AMBULATORY SURGERY CENTER

520 VALLEY VIEW DRIVE SUITE 300 MOLINE IL 61265

AMBULATORY SURGERY CENTER PART I, LINE 6A: TRINITY MEDICAL CENTER'S COMMUNITY BENEFIT REPORT IS CONTAINED WITHIN THE IOWA HEALTH SYSTEM CONSOLIDATED COMMUNITY BENEFIT REPORT WHICH IS POSTED ON ITS WEBSITE AT WWW.IHS.ORG.IN ADDITION, THE HOSPITAL AND ITS REGIONAL AFFILIATES PUBLISHES AN ANNUAL COMMUNITY BENEFIT REPORT. THIS REPORT IS POSTED ON ITS WEBSITE AT WWW.TRINITYQC.COM. PART I, LINE 7G: THE NET COMMUNITY BENEFIT COST OF SUBSIDIZED HEALTH SERVICES OF $2,035,801 IS ATTRIBUTED TO TRINITY AMBULANCE SERVICE. PART II: COMMUNITY BUILDING ACTIVITIES ARE ESSENTIAL ROLES FOR HEALTH-CARE ORGANIZATIONS IN THAT THEY ADDRESS MANY OF THE UNDERLYING DETERMINANTS OF HEALTH. RESEARCH HAS CONTINUALLY SHOWN THAT WHEN THE FACTORS INFLUENCING HEALTH ARE EXPLORED, HEALTH CARE ACTUALLY PLAYS THE SMALLEST ROLE PROPORTIONATELY. A REPORT IN THE JOURNAL OF AMERICAN MEDICAL ASSOCIATION AND THE CENTER FOR DISEASE CONTROL (MCGINNIS, 1996) SUGGESTS THAT THE FACTORS IMPACTING HEALTH ARE AS FOLLOWS: LIFESTYLE AND BEHAVIORS, 50%, ENVIRONMENT (HUMAN AND NATURAL), 20%, GENETICS AND HUMAN BIOLOGY, 20%, AND HEALTH CARE, 10%. COMMUNITY BUILDING ACTIVITIES HELP TO ADDRESS THE OTHER INDICATORS OUTSIDE OF THE ROLE TRADITIONALLY PLAYED BY HEALTH-CARE ORGANIZATIONS. THESE ACTIVITIES ARE ALMOST EXCLUSIVELY DONE IN SOME FORM OF PARTNERSHIP IN WHICH THE COMMUNITY OR OTHER ORGANIZATIONS ARE BETTER SUITED TO ADDRESS. HEALTH-CARE ORGANIZATIONS GENERALLY PROVIDE TIMELY AND SPECIFIC RESOURCES TO HELP THESE ISSUES. HEALTH-CARE ORGANIZATIONS CAN BE A RICH AND VALUABLE COMMUNITY RESOURCE IN WAYS NOT TYPICALLY CONSIDERED. OFTEN THE MOST EFFECTIVE WAY TO HELP IMPACT AND IMPROVE THE COMMUNITY HEALTH STATUS IS TO SUPPORT OTHER AGENCIES AND ORGANIZATIONS IN A VARIETY OF WAYS OUTSIDE OF HEALTH SERVICES. THIS IS OFTEN DONE THROUGH CASH OR IN-KIND SERVICES TO SUPPORT OTHER NON-PROFITS, DONATIONS OF DURABLE MEDICAL EQUIPMENT AND SUPPLIES TO CERTAIN AGENCIES, OR THROUGH LEADERSHIP AND EDUCATIONAL EXPERTISE. TRINITY MEDICAL CENTER CONTRIBUTES FINANCIALLY TO A WIDE VARIETY OF COMMUNITY ORGANIZATIONS THAT ADDRESS THE BROADER NEEDS OF THE COMMUNITY. THESE DONATIONS ALLOW OTHER NON-PROFIT ORGANIZATIONS TO FULFILL THEIR MISSIONS TO IMPROVE THE WELL BEING OF THE COMMUNITY AND CONTRIBUTE TO ITS OVERALL HEALTH STATUS IN WAYS THAT MAY DIFFER FROM THE DIRECT SERVICES OF THE HOSPITAL ORGANIZATION AND MAXIMIZE THE RESOURCES THEY HAVE TO WORK WITH. TRINITY MEDICAL CENTER EMPLOYEES ARE ACTIVE IN EDUCATING PARTNERS ON A WIDE VARIETY OF HEALTH SUBJECTS THAT ADVANCE THEIR WORK. FURTHER, TRINITY MEDICAL CENTER EMPLOYEES ARE MEMBERS OF MANY NON-PROFIT BOARDS TO PROVIDE LEADERSHIP OR COLLABORATE TO ADDRESS COMPLEX HEALTH ISSUES. THESE TYPES OF ACTIVITIES SPEAK TO THE BREADTH AND CAPACITY THAT THE HOSPITAL HAS IN IMPACTING THE HEALTH STATUS OF THE COMMUNITY IN A COMPREHENSIVE AND INTENTIONAL APPROACH. PART III, LINE 4: THE HEALTH SYSTEM PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS BASED UPON A REVIEW OF OUTSTANDING RECEIVABLES, HISTORICAL COLLECTION INFORMATION AND EXISTING ECONOMIC CONDITIONS. AS A SERVICE TO THE PATIENT, THE HEALTH SYSTEM BILLS THIRD-PARTY PAYERS DIRECTLY AND BILLS THE PATIENT WHEN THE PATIENT'S LIABILITY IS DETERMINED. PATIENT ACCOUNTS RECEIVABLE ARE DUE IN FULL WHEN BILLED. ACCOUNTS ARE CONSIDERED DELINQUENT AND SUBSEQUENTLY WRITTEN OFF AS BAD DEBTS BASED ON INDIVIDUAL CREDIT EVALUATION AND SPECIFIC CIRCUMSTANCES OF THE ACCOUNT.THE AMOUNT REPORTED ON LINE 2 WAS CALCULATED USING IRS WORKSHEET 2 'RATIO OF PATIENT CARE COST TO CHARGES' TO CALCULATE THE COST TO CHARGE RATIO FOR TRINITY MEDICAL CENTER. THIS RATIO WAS THEN APPLIED AGAINST THE BAD DEBT ATTRIBUTABLE TO PATIENT ACCOUNTS USING IRS WORKSHEET A TO ARRIVE AT THE BAD DEBT EXPENSE AT COST REPORTED ON LINE 2. PART III, LINE 8: AMOUNTS ON LINE 6 WERE CALCULATED USING IRS WORKSHEET B 'TOTAL MEDICARE ALLOWABLE COSTS.' THE MEDICARE ALLOWABLE COSTS WERE OBTAINED FROM THE MEDICARE COST REPORTS AND THEN REDUCED BY ANY AMOUNTS ALREADY CAPTURED IN COMMUNITY BENEFIT EXPENSE IN PART I ABOVE.THE HOSPITAL BELIEVES THE ENTIRE AMOUNT OF THE MEDICARE SHORTFALL SHOULD BE TREATED AS COMMUNITY BENEFIT, MORE SPECIFICALLY, AS CHARITY CARE. THE ELDERLY CONSTITUTE A CLEARLY-RECOGNIZED CHARITABLE CLASS, AND MANY MEDICARE BENEFICIARIES, LIKE THEIR MEDICAID COUNTERPARTS, ARE POOR AND THUS WOULD HAVE QUALIFIED FOR THE HOSPITAL'S CHARITY CARE PROGRAM, MEDICAID OR OTHER NEEDS-BASED GOVERNMENT PROGRAMS ABSENT THE MEDICARE PROGRAM. BY ACCEPTING PAYMENT BELOW COST TO TREAT THESE INDIVIDUALS, THE BURDENS OF GOVERNMENT ARE RELIEVED WITH RESPECT TO THESE INDIVIDUALS. ADDITIONALLY, THERE IS A SIGNIFICANT POSSIBILITY THAT CONTINUED REDUCTION IN REIMBURSEMENT MAY ACTUALLY CREATE DIFFICULTIES IN ACCESS FOR THESE INDIVIDUALS. FINALLY, THE AMOUNT SPENT TO COVER THE MEDICARE SHORTFALL IS MONEY NOT AVAILABLE TO COVER CHARITY CARE AND OTHER COMMUNITY BENEFIT NEEDS. PART III, LINE 9B: AFTER THE PATIENT MEETS THE QUALIFICATIONS FOR FINANCIAL ASSISTANCE, THE ACCOUNT BALANCE IS PARTIALLY OR ENTIRELY WRITTEN OFF, AS APPROPRIATE. ANY REMAINING BALANCE, IF ANY, WOULD BE COLLECTED UNDER THE NORMAL DEBT COLLECTION POLICY. TRINITY MEDICAL CENTER - ROCK ISLAND PART V, SECTION B, LINE 3: A COMPREHENSIVE AND REPRESENTATIVE COMMUNITY WIDE PHONE SURVEY WAS CONDUCTED AND FOCUS GROUPS WERE CONVENED WITH KEY INFORMANTS OF WHOM SOME WERE USERS. TRINITY MEDICAL CENTER - ROCK ISLAND PART V, SECTION B, LINE 4: GENESIS HEALTH SYSTEM, THE ROCK ISLAND COUNTY HEALTH DEPARTMENT, THE SCOTT COUNTY HEALTH DEPARTMENT, TRINITY MUSCATINE PUBLIC HEALTH, AND THE COMMUNITY HEALTH CARE CENTER. TRINITY MEDICAL CENTER - ROCK ISLAND PART V, SECTION B, LINE 5C: THE HEALTH NEEDS ASSESSMENT WAS RECENTLY COMPLETED. IT WAS POSTED ON OUR HOSPITAL WEBSITE MARCH 21, 2012 AND WILL BE AVAILABLE ON THE WEBSITES OF THE OTHER COMMUNITY HEALTH NEEDS ASSESSMENT PARTNERS. TRINITY MEDICAL CENTER - ROCK ISLAND PART V, SECTION B, LINE 15E: GUARANTORS RECEIVE A CYCLE BILL EERY 30 DAYS FOR THE LIFE OF THE ACCOUNT ON A/R. ON DAY 41, 11 DAYS AFTER THE SECOND BILLING CYCLE, A FIRST COLLECTION ATTEMPT IS MADE FROM THE TELEVOX DIALER. THE SECOND COLLECTION ATTEMPT IS MADE BY THE DIALER ON DAY 71, 11 DAYS AFTER THE THIRD AND FINAL BILLING CYCLE. THE THIRD COLLECTION ATTEMPT IS MADE BY THE DIALER ON DAY 87, E DAYS BEFORE THE ACCOUNT IS REVIEWED FOR COLLECTIONS. ACCOUNTS WITH SATISFACTORY PAYMENTS OR PREARRANGED PAYMENT ARRANGEMENTS THAT ARE CURRENT ARE NOT SENT TO THE DIALER. ACCOUNTS WITH A MENTAL HEALTH DIAGNOSIS, WORKERS COMPENSATION ACCOUNTS, ACCOUNTS WITH SKILLED NURSING FACILITIES, AND ACCOUNTS WITH NO PHONE NUMBER ARE ALSO NOT SENT TO THE DIALER. THESE ACCOUNTS ARE ON A MANUAL LIST WHICH THE COLLECTION TEAM REVIEWS AND MAKES CALLS MANUALLY AS DEEMED APPROPRIATE. WHEN THE ACCOUNTS ARE GREATER THAN OR EQUAL TO $5,000, THE COLLECTION TEAM WILL SEND A FINANCIAL ASSISTANCE APPLICATION IF THEY CANNOT MAKE CONTACT WITH THE GUARANTOR AND 10 BUSINESS DAYS LATER, A PAST LETTER. THEY WILL ALSO CHECK FOR MEDICAID ELIGIBILITY FOR THEIR STATE OF RESIDENCE. TRINITY MEDICAL CENTER - MOLINE PART V, SECTION B, LINE 15E: GUARANTORS RECEIVE A CYCLE BILL EERY 30 DAYS FOR THE LIFE OF THE ACCOUNT ON A/R. ON DAY 41, 11 DAYS AFTER THE SECOND BILLING CYCLE, A FIRST COLLECTION ATTEMPT IS MADE FROM THE TELEVOX DIALER. THE SECOND COLLECTION ATTEMPT IS MADE BY THE DIALER ON DAY 71, 11 DAYS AFTER THE THIRD AND FINAL BILLING CYCLE. THE THIRD COLLECTION ATTEMPT IS MADE BY THE DIALER ON DAY 87, E DAYS BEFORE THE ACCOUNT IS REVIEWED FOR COLLECTIONS. ACCOUNTS WITH SATISFACTORY PAYMENTS OR PREARRANGED PAYMENT ARRANGEMENTS THAT ARE CURRENT ARE NOT SENT TO THE DIALER. ACCOUNTS WITH A MENTAL HEALTH DIAGNOSIS, WORKERS COMPENSATION ACCOUNTS, ACCOUNTS WITH SKILLED NURSING FACILITIES, AND ACCOUNTS WITH NO PHONE NUMBER ARE ALSO NOT SENT TO THE DIALER. THESE ACCOUNTS ARE ON A MANUAL LIST WHICH THE COLLECTION TEAM REVIEWS AND MAKES CALLS MANUALLY AS DEEMED APPROPRIATE. WHEN THE ACCOUNTS ARE GREATER THAN OR EQUAL TO $5,000, THE COLLECTION TEAM WILL SEND A FINANCIAL ASSISTANCE APPLICATION IF THEY CANNOT MAKE CONTACT WITH THE GUARANTOR AND 10 BUSINESS DAYS LATER, A PAST LETTER. THEY WILL ALSO CHECK FOR MEDICAID ELIGIBILITY FOR THEIR STATE OF RESIDENCE. TRINITY MEDICAL CENTER - BETTENDORF PART V, SECTION B, LINE 15E: GUARANTORS RECEIVE A CYCLE BILL EERY 30 DAYS FOR THE LIFE OF THE ACCOUNT ON A/R. ON DAY 41, 11 DAYS AFTER THE SECOND BILLING CYCLE, A FIRST COLLECTION ATTEMPT IS MADE FROM THE TELEVOX DIALER. THE SECOND COLLECTION ATTEMPT IS MADE BY THE DIALER ON DAY 71, 11 DAYS AFTER THE THIRD AND FINAL BILLING CYCLE. THE THIRD COLLECTION ATTEMPT IS MADE BY THE DIALER ON DAY 87, E DAYS BEFORE THE ACCOUNT IS REVIEWED FOR COLLECTIONS. ACCOUNTS WITH SATISFACTORY PAYMENTS OR PREARRANGED PAYMENT ARRANGEMENTS THAT ARE CURRENT ARE NOT SENT TO THE DIALER. ACCOUNTS WITH A MENTAL HEALTH DIAGNOSIS, WORKERS COMPENSATION ACCOUNTS, ACCOUNTS WITH SKILLED NURSING FACILITIES, AND ACCOUNTS WITH NO PHONE NUMBER ARE ALSO NOT SENT TO THE DIALER. THESE ACCOUNTS ARE ON A MANUAL LIST WHICH THE COLLECTION TEAM REVIEWS AND MAKES CALLS MANUALLY AS DEEMED APPROPRIATE. WHEN THE ACCOUNTS ARE GREATER THAN OR EQUAL TO $5,000, THE COLLECTION TEAM WILL SEND A FINANCIAL ASSISTANCE APPLICATION IF THEY CANNOT MAKE CONTACT WITH THE GUARANTOR AND 10 BUSINESS DAYS LATER, A PAST LETTER. THEY WILL ALSO CHECK FOR MEDICAID ELIGIBILITY FOR THEIR STATE OF RESIDENCE. TRINITY MEDICAL CENTER - ROCK ISLAND PART V, SECTION B, LINE 19D: IF THE INDIVIDUAL APPLIES AND QUALIFIES FOR FINANCIAL ASSISTANCE UNDER THE FACILITY'S FINANCIAL ASSISTANCE POLICY, THE HOSPITAL FACILITY USES THE AVERAGE OF THE THREE LOWEST NEGOTIATED COMMERCIAL INSURANCE RATES FOR THOSE SERVICES AT THE HOSPITAL FACILITY TO DETERMINE THE AMOUNTS BILLED FOR ALL SERVICES, INCLUDING EMERGENCY OR MEDICALLY NECESSARY CARE. THIS OCCURS REGARDLESS WHETHER THE INDIVIDUAL HAS INSURANCE COVERAGE. ALSO, IF THE INDIVIDUAL HAS INSURANCE COVERAGE AND DOES NOT APPLY OR QUALIFY FOR FINANCIAL ASSISTANCE UNDER THE FACILITY'S FINANCIAL ASSISTANCE POLICY, THE HOSPITAL FACILITY USES THE INSURER'S NEGOTIATED RATE FOR THOSE SERVICES AT THE HOSPITAL FACILITY. HOWEVER, IF THE INDIVIDUAL DOES NOT HAVE INSURANCE COVERAGE AND EITHER DOES NOT APPLY OR DOES NOT QUALIFY FOR FINANCIAL ASSISTANCE UNDER THE FACILITY'S FINANCIAL ASSISTANCE POLICY, THE HOSPITAL FACILITY USES THE GROSS RATES FOR THOSE SERVICES TO DETERMINE THE AMOUNTS BILLED. IF THE UNINSURED INDIVIDUAL AGREES TO PAY THE BILL IN FULL, THE HOSPITAL FACILITY WILL PROVIDE A 20%-30% DISCOUNT FROM THE GROSS RATES FOR THOSE INDIVIDUALS. TRINITY MEDICAL CENTER - MOLINE PART V, SECTION B, LINE 19D: IF THE INDIVIDUAL APPLIES AND QUALIFIES FOR FINANCIAL ASSISTANCE UNDER THE FACILITY'S FINANCIAL ASSISTANCE POLICY, THE HOSPITAL FACILITY USES THE AVERAGE OF THE THREE LOWEST NEGOTIATED COMMERCIAL INSURANCE RATES FOR THOSE SERVICES AT THE HOSPITAL FACILITY TO DETERMINE THE AMOUNTS BILLED FOR ALL SERVICES, INCLUDING EMERGENCY OR MEDICALLY NECESSARY CARE. THIS OCCURS REGARDLESS WHETHER THE INDIVIDUAL HAS INSURANCE COVERAGE. ALSO, IF THE INDIVIDUAL HAS INSURANCE COVERAGE AND DOES NOT APPLY OR QUALIFY FOR FINANCIAL ASSISTANCE UNDER THE FACILITY'S FINANCIAL ASSISTANCE POLICY, THE HOSPITAL FACILITY USES THE INSURER'S NEGOTIATED RATE FOR THOSE SERVICES AT THE HOSPITAL FACILITY. HOWEVER, IF THE INDIVIDUAL DOES NOT HAVE INSURANCE COVERAGE AND EITHER DOES NOT APPLY OR DOES NOT QUALIFY FOR FINANCIAL ASSISTANCE UNDER THE FACILITY'S FINANCIAL ASSISTANCE POLICY, THE HOSPITAL FACILITY USES THE GROSS RATES FOR THOSE SERVICES TO DETERMINE THE AMOUNTS BILLED. IF THE UNINSURED INDIVIDUAL AGREES TO PAY THE BILL IN FULL, THE HOSPITAL FACILITY WILL PROVIDE A 20%-30% DISCOUNT FROM THE GROSS RATES FOR THOSE INDIVIDUALS. TRINITY MEDICAL CENTER - BETTENDORF PART V, SECTION B, LINE 19D: IF THE INDIVIDUAL APPLIES AND QUALIFIES FOR FINANCIAL ASSISTANCE UNDER THE FACILITY'S FINANCIAL ASSISTANCE POLICY, THE HOSPITAL FACILITY USES THE AVERAGE OF THE THREE LOWEST NEGOTIATED COMMERCIAL INSURANCE RATES FOR THOSE SERVICES AT THE HOSPITAL FACILITY TO DETERMINE THE AMOUNTS BILLED FOR ALL SERVICES, INCLUDING EMERGENCY OR MEDICALLY NECESSARY CARE. THIS OCCURS REGARDLESS WHETHER THE INDIVIDUAL HAS INSURANCE COVERAGE. ALSO, IF THE INDIVIDUAL HAS INSURANCE COVERAGE AND DOES NOT APPLY OR QUALIFY FOR FINANCIAL ASSISTANCE UNDER THE FACILITY'S FINANCIAL ASSISTANCE POLICY, THE HOSPITAL FACILITY USES THE INSURER'S NEGOTIATED RATE FOR THOSE SERVICES AT THE HOSPITAL FACILITY. HOWEVER, IF THE INDIVIDUAL DOES NOT HAVE INSURANCE COVERAGE AND EITHER DOES NOT APPLY OR DOES NOT QUALIFY FOR FINANCIAL ASSISTANCE UNDER THE FACILITY'S FINANCIAL ASSISTANCE POLICY, THE HOSPITAL FACILITY USES THE GROSS RATES FOR THOSE SERVICES TO DETERMINE THE AMOUNTS BILLED. IF THE UNINSURED INDIVIDUAL AGREES TO PAY THE BILL IN FULL, THE HOSPITAL FACILITY WILL PROVIDE A 20%-30% DISCOUNT FROM THE GROSS RATES FOR THOSE INDIVIDUALS. TRINITY MEDICAL CENTER - ROCK ISLAND PART V, SECTION B, LINE 21: AS DESCRIBED IN SCHEDULE H, PART V, LINE 19, IF THE PATIENT DOES NOT APPLY OR QUALIFY FOR FINANCIAL ASSISTANCE AND ALSO IS UNINSURED OR RECEIVES NO BENEFIT FROM THEIR INSURANCE ON A SERVICE PROVIDED BY THE HOSPITAL FACILITY, THEY WOULD BE CHARGED AMOUNTS EQUAL TO GROSS CHARGES FOR THE SERVICES PROVIDED TO THE PATIENT. HOWEVER, IF THE PATIENT AGREES TO PAY IN FULL, THEY WILL RECEIVE A 20%-30% DISCOUNT FROM THE GROSS CHARGES. TRINITY MEDICAL CENTER - MOLINE PART V, SECTION B, LINE 21: AS DESCRIBED IN SCHEDULE H, PART V, LINE 19, IF THE PATIENT DOES NOT APPLY OR QUALIFY FOR FINANCIAL ASSISTANCE AND ALSO IS UNINSURED OR RECEIVES NO BENEFIT FROM THEIR INSURANCE ON A SERVICE PROVIDED BY THE HOSPITAL FACILITY, THEY WOULD BE CHARGED AMOUNTS EQUAL TO GROSS CHARGES FOR THE SERVICES PROVIDED TO THE PATIENT. HOWEVER, IF THE PATIENT AGREES TO PAY IN FULL, THEY WILL RECEIVE A 20%-30% DISCOUNT FROM THE GROSS CHARGES. TRINITY MEDICAL CENTER - BETTENDORF PART V, SECTION B, LINE 21: AS DESCRIBED IN SCHEDULE H, PART V, LINE 19, IF THE PATIENT DOES NOT APPLY OR QUALIFY FOR FINANCIAL ASSISTANCE AND ALSO IS UNINSURED OR RECEIVES NO BENEFIT FROM THEIR INSURANCE ON A SERVICE PROVIDED BY THE HOSPITAL FACILITY, THEY WOULD BE CHARGED AMOUNTS EQUAL TO GROSS CHARGES FOR THE SERVICES PROVIDED TO THE PATIENT. HOWEVER, IF THE PATIENT AGREES TO PAY IN FULL, THEY WILL RECEIVE A 20%-30% DISCOUNT FROM THE GROSS CHARGES. PART VI, LINE 2: TRINITY MEDICAL CENTER CONTINUALLY WORKS WITH COMMUNITY PARTNERS IN THE QUAD CITY AREA OF IOWA AND ILLINOIS TO ASSESS THE HEALTH NEEDS OF THE COMMUNITY. IT'S PRIMARY "COMMUNITY HEALTH ASSESSMENT" PARTNERS ARE THE SCOTT COUNTY PUBLIC HEALTH DEPARTMENT, THE ROCK ISLAND COUNTY HEALTH DEPARTMENT, THE COMMUNITY HEALTH CARE CENTER (AN FAQC), GENESIS MEDICAL CENTER AND THE QUAD CITY HEALTH INIITIATIVE. (THE QUAD CITY HEALTH INITIATIVE IS JOINTLY SPONSORED BY TRINITY MEDICAL CENTER AND GENESIS MEDICAL CENTER). THIS COLLABORATION CONTINUES AND EXISTS TO FACILITATE COORDINATION AND NON-DUPLICATION OF EFFORT AMONG THE PARTNERS AS WE ALL DEVELOP PROGRAMS AND SERVICES DESIGNED TO RESPOND TO THE NEEDS IDENTIFIED IN THE ASSESSMENT. AS NOTED EARLIER, TRINITY MEDICAL CENTER AND GENESIS HEALTH SYSTEM ARE THE SPONSORING PARTNERS OF THE QUAD CITY HEALTH INITIATIVE (QCHI). QCHI IS A COMMUNITY PARTNERSHIP WORKING TO CREATE A HEALTHY COMMUNITY. IT CONSISTS OF OVER 200 VOLUNTEERS FROM ALL WALKS OF LIFE, AS WELL AS A BOARD OF DIRECTORS WHOSE MEMBERS ARE REPRESENTATIVE OF THE COMMUNITY IN TERMS OF SOCIO-ECONOMIC VARIABLES AND COMMUNITY LEADERSHIP. THE BOARD MEETS QUARTERLY. QCHI IS ONE OF THE RESOURCES THAT TRINITY UTILIZES.WHEN ADDRESSING THE COMMUNIITY'S HEALTH NEEDS. TRINITY'S MISSION EFFECTIVENESS COMMITTEE WHICH CONSISTS OF AREA CLERGY, PHYSICIANS, REPRESENTATIVES OF THE BUSINESS AND SOCIAL SERVICE COMMUNITIES AND TRINITY SENIOR LEADERSHIP IS ANOTHER INVALUABLE RESOURCE UTILIZED TO DEVELOP AND MONITOR TRINITY'S COMMUNITY BENEFITS PLAN. THE PLAN IDENTIFIES SPECIFIC HEALTH PRIORITIES, STRATEGIES AND PLANS OF ACTION TO ADDRESS THOSE NEEDS WHICH ARE CONSISTENT WITH ITS MISSION AND CAPACITY. TRINITY'S EFFORTS TO "IMPROVE THE HEALTH OF THE COMMUNITIES WE SERVE" ARE MONITORED IN PART BY THE OTHER PARTNER AGENCIES CITED EARLIER I.E. SCOTT COUNTY PUBLIC HEALTH DEPARTMENT, COMMUNITY HEALTH CARE CENTER, ROCK ISLAND COUNTY PUBLIC HEALTH DEPARTMENT AND GENESIS MEDICAL CENTER AS WELL AS BY THE MISSION EFFECTIVENESS COMMITTEE. THE LATTER IS A STANDING COMMITTEE OF TRINITY REGIONAL HEALTH SYSTEM'S BOARD AND MEETS A MINIMUM OF FOUR TIMES A YEAR. ADDITIONALLY, THE QUAD CITY HEALTH INITIATIVE MONITORS AND REPORTS SPECIFIC INDICATORS TO AID IN THE DEVELOPMENT OF NEW PLANS OR REFINING EXISTING ONES. TRINITY MEDICAL CENTER ALSO PARTICIPATES AS PART OF THE UNITED WAY COMMUNITY IMPACT COMMITTEE. THIS GROUP ACTIVELY ADDRESSES NEED AND STRATEGIES ASSOCIATED WITH HEALTH. MORE SPECIFICALLY, THIS GROUP OFTEN FOCUSES ON THE SOCIAL DETERMINANTS OF HEALTH AND HOW TO IMPACT THEM IN THE EFFORT TO RAISE THE COMMUNITY HEALTH STATUS. THIS WIDE BASED COLLABORATIVE PROVIDES OPPORTUNITIES FOR TRINITY MEDICAL CENTER TO ENGAGE IN VARIOUS AREAS OF SERVICE TO THE COMMUNITY THAT MAY BE OUTSIDE OF ITS TYPICAL EXPERTISE BUT WITHIN ITS EXISTING RESOURCES. IN ADDITION TO THESE ORGANIZED COMMUNITY EFFORTS, TRINITY MEDICAL CENTER CONTINUALLY MONITORS COMMUNITY NEEDS SPECIFIC TO ITS SERVICE LINES AND THE RESOURCES IT CAN LEVERAGE TO ADDRESS THEM. INDIVIDUAL DEPARTMENTS OFTEN WORK TO IDENTIFY SPECIFIC NEEDS RELATED TO THEIR SERVICES AND THE POPULATION THEY IMPACT. PART VI, LINE 3: TRINITY MEDICAL CENTER PERFORMS THE FOLLOWING ACTIVITIES TO COMMUNICATE THE AVAILABILITY OF CHARITY CARE AND FINANCIAL ASSISTANCE TO ALL PATIENTS: 1) PLACES SIGNAGE, INFORMATION, AND/OR BROCHURES IN APPROPRIATE AREAS OF THE PROVIDER (E.G., THE EMERGENCY DEPARTMENT, AND REGISTRATION AND CHECK-OUT/CASHIER AREAS) STATING THE PROVIDER/PHYSICIAN PRACTICE OFFERS CHARITY CARE AND DESCRIBES HOW TO OBTAIN MORE INFORMATION ABOUT FINANCIAL ASSISTANCE, 2) PLACES A NOTE ON THE HEALTH-CARE BILL AND STATEMENTS REGARDING HOW TO REQUEST INFORMATION ABOUT FINANCIAL ASSISTANCE, 3) DESIGNATES INDIVIDUALS WHO CAN EXPLAIN THE PROVIDER'S CHARITY CARE POLICY, AND 4) INSTRUCTS STAFF WHO INTERACT WITH PATIENTS TO DIRECT QUESTIONS REGARDING THE CHARITY CARE POLICY TO THE PROPER PROVIDER REPRESENTATIVE. PART VI, LINE 4: TRINITY MEDICAL CENTER IS A 515-BED COMMUNITY HOSPITAL SERVING EASTERN IOWA AND WESTERN ILLINOIS. TRINITY MEDICAL CENTER IS NONDENOMINATIONAL AND SERVES ALL WHO COME HERE, REGARDLESS OF REASON OR CIRCUMSTANCE.80% OF TRINITY MEDICAL CENTER'S MARKET RESIDENTS LIVE WITHIN THE IOWA COUNTIES OF ROCK ISLAND (IL) AND SCOTT (IA). TRINITY MEDICAL CENTER ADMITS APPROXIMATELY 22,000 INPATIENTS AND CARES FOR 86,000 EMERGENCY PATIENTS PER YEAR. MEDIAN HOUSEHOLD INCOMES RANGE FROM 46,226 TO 49,964 AND THE AVERAGE POVERTY RATE IS 12%. 62% OF TRINITY MEDICAL CENTER INPATIENTS ARE ELIGIBLE FOR MEDICARE OR MEDICAID. ROCK ISLAND AND SCOTT COUNTIES BOTH HAVE SIGNIFICANT MINORITY POPULATION. ROCK ISLAND IS 82% CAUCASION, 9% AFRICAN AMERICAN, 12% HISPANIC, AND 2% ASIAN. SCOTT IS 86% CAUCASION, 7% AFRICAN AMERICAN, AND 6% HISPANIC. PART VI, LINE 5: THE HOSPITAL IS ORGANIZED AND OPERATED EXCLUSIVELY FOR CHARITABLE PURPOSES WITH THE GOAL OF PROMOTING THE HEALTH OF THE COMMUNITIES IT SERVES. THE HOSPITAL SUPPORTS THIS MISSION WITH A COMMUNITY BOARD, OPEN MEDICAL STAFF, AND AN EMERGENCY ROOM AVAILABLE TO PATIENTS REGARDLESS OF ABILITY TO PAY. THE BOARD OF DIRECTORS OF THE HOSPITAL IS COMPOSED OF CIVIC LEADERS WHO RESIDE IN THE SERVICE AREA OF THE HOSPITAL. THE BOARD ACTIVELY DEBATES AND SETS POLICY AND STRATEGIC DIRECTION FOR THE HOSPITAL BUT DOES NOT GET INVOLVED IN ISSUES RELATED TO THE DIRECT OPERATIONS OF THE HOSPITAL. THE BOARD TAKES A BALANCED APPROACH WHEN ADDRESSING COMMUNITY AND BUSINESS/FINANCIAL CONCERNS. THE BOARD IS ALSO THE PRIMARY GROUP FOR DETERMINING THE USE OF HOSPITAL SURPLUS FUNDS, WHICH ARE ALL USED TO FURTHER OUR CHARITABLE PURPOSE. PART VI, LINE 6: THE HOSPITAL IS PART OF IOWA HEALTH SYSTEM. INITIALLY FORMED IN 1995, IOWA HEALTH SYSTEM IS THE STATE'S FIRST AND LARGEST INTEGRATED HEALTH SYSTEM, SERVING NEARLY ONE OF EVERY THREE PATIENTS IN IOWA. THROUGH RELATIONSHIPS WITH 27 HOSPITALS IN METROPOLITAN AND RURAL COMMUNITIES AND MORE THAN 200 PHYSICIAN CLINICS, IOWA HEALTH SYSTEM PROVIDES CARE THROUGHOUT IOWA AND ILLINOIS.IOWA HEALTH SYSTEM ENTITIES EMPLOY THE STATE'S LARGEST NONPROFIT WORKFORCE, WITH MORE THAN 24,000 EMPLOYEES WORKING TOWARD INNOVATIVE ADVANCEMENTS TO DELIVER THE BEST OUTCOME FOR EVERY PATIENT EVERY TIME. EACH YEAR, THROUGH MORE THAN 3.1 MILLION PATIENT VISITS, IOWA HEALTH SYSTEM HOSPITALS AND CLINICS PROVIDE A FULL RANGE OF CARE TO PATIENTS AND FAMILIES. WITH ANNUAL REVENUES OF $2.8 BILLION, IOWA HEALTH SYSTEM IS THE FIFTH LARGEST NONDENOMINATIONAL HEALTH SYSTEM IN AMERICA AND PROVIDES COMMUNITY BENEFIT PROGRAMS AND SERVICES TO IMPROVE THE HEALTH OF PEOPLE IN ITS COMMUNITIES. IOWA HEALTH SYSTEM AND ITS AFFILIATES ENGAGE IN COMMUNITY HEALTH PROGRAMS AND SERVICES THROUGHOUT IOWA, AND WORK WITH VOLUNTEER AND CIVIC ORGANIZATIONS, SCHOOLS, BUSINESSES, INSURERS AND INDIVIDUALS TO SUPPORT ACTIVITIES THAT BENEFIT PEOPLE THROUGHOUT THE STATE. IN 2011, IOWA HEALTH SYSTEM AND ITS AFFILIATES PROVIDED MORE THAN $387 MILLION OF COMMUNITY BENEFIT. THE CONTRIBUTIONS TO THEIR COMMUNITIES BY IOWA HEALTH SYSTEM AND ITS AFFILIATES ARE REPORTED IN DETAIL IN STATEMENT OF PROGRAM SERVICE ACCOMPLISHMENTS (PART III) OF THE IRS FORM 990 OF THOSE AFFILIATES. REPORTS FILED WITH STATES PART VI, LINE 7 IL,IA 0 ILLINOIS HOSPITAL ASSOCIATION 37092 EAGLE WAY CHICAGO IL 60679 362352486 501(C)(3) 131490 PROGRAM SUPPORT IOWA HEALTH SYSTEM 1200 PLEASANT ST DES MOINES IA 50309 421435199 501(C)(3) 2155583 PROGRAM SUPPORT 2 0 X 1 1 1 1 0 0 0 0 0 0 0 DR WILLIAM OLSON FR 911 646580 0 0 0 64937 0 16224 0 23167 0 750908 0 0 0 RICK SEIDLER 433126 0 166284 0 128191 0 83659 0 12328 0 823588 0 0 0 TAMARA BYRAM 135915 0 36087 0 15284 0 12629 0 20424 0 220339 0 0 0 DAVID DEOPERE 197279 0 53444 0 40377 0 12781 0 19127 0 323008 0 0 0 MYKL GARRETT TO 1111 248996 0 0 0 55993 0 33276 0 111 0 338376 0 0 0 DR PAUL MCLOONE 68463 164779 24746 605 3462 75 3590 9900 2991 16927 103252 192286 0 0 GREG PAGLIUZZA JR 277559 0 39750 0 25989 0 43062 0 15610 0 401970 0 0 0 JAY WILLSHER FR 1111 199974 0 50635 0 28816 0 63222 0 26325 0 368972 0 0 0 DR PAUL BOLGER 451696 0 0 0 63066 0 18846 0 26067 0 559675 0 0 0 KATHLEEN CUNNINGHAM TO 511 64461 113153 48116 17500 29138 3558 8995 5660 5261 7829 155971 147700 0 0 JON HONSEY TO 611 87205 0 52241 0 39139 0 12489 0 11119 0 202193 0 0 0 RICHARD MURPHY 130284 0 15142 0 4791 0 10780 0 22093 0 183090 0 0 0 BOBETTE PATTERSON 123865 0 18677 0 13304 0 11134 0 15878 0 182858 0 0 0 MICHAEL PATTERSON 233316 0 65988 0 55940 0 18846 0 20507 0 394597 0 0 0 KATHERINE PEARSON 154132 0 41243 0 19721 0 15075 0 19752 0 249923 0 0 0 JEFFREY STOLZE 200686 0 55042 0 18881 0 61604 0 25250 0 361463 0 0 0 DR RANDALL BAY 420869 0 0 0 45701 0 18846 0 23376 0 508792 0 0 0 DR GREGORY BOHN 583473 0 0 0 12914 0 18846 0 20206 0 635439 0 0 0 DR MARK BUETTNER 530108 0 0 0 10519 0 18846 0 26771 0 586244 0 0 0 DR KEVIN KURTH 371976 54391 0 0 102984 12484 17123 2692 16788 1833 508871 71400 0 0 DR CHAD VANDERLINDEN 453061 0 0 0 11310 0 18846 0 21265 0 504482 0 0 0 ANDREA COLEMAN TO 1109 0 0 0 0 123903 0 0 0 8049 0 131952 0 0 0 WILLIAM LEAVER TO 1207 0 938718 0 335170 0 67448 0 253072 0 53987 0 1648395 0 0 TOM TIBBITTS TO 610 0 197906 0 50000 0 510590 0 12250 0 12025 0 782771 0 456583 KEVIN VERMEER TO 509 0 485743 0 135017 0 51625 0 169053 0 25863 0 867301 0 0 PART I, LINE 1A DISCRETIONARY SPENDING ACCOUNTS: CERTAIN OFFICERS AND/OR DIRECTORS WERE PROVIDED AN EXECUTIVE ALLOWANCE. THE ALLOWANCES ARE REQUIRED TO BE USED TO COVER CERTAIN TRAVEL, MEALS, HEALTH OR SOCIAL CLUB DUES, ENTERTAINMENT, ETC. EXPENSES INSTEAD OF RECEIVING TAX-EXEMPT REIMBURSEMENT. THE ALLOWANCE IS INCLUDED IN TAXABLE COMPENSATION AND REPORTED ON FORM W-2. THE ALLOWANCE GUIDELINES ARE ADDRESSED IN A WRITTEN POLICY. PART I, LINES 4A-B SEVERANCE PAYMENT: THE FOLLOWING INDIVIDUALS RECEIVED A SEVERANCE PAYMENT DURING THE YEAR THAT WAS INCLUDED IN THEIR TAXABLE INCOME: ANDREA COLEMAN $125,462 AND MYKL GARRETT $23,810. SUPPLEMENTAL NON-QUALIFIED RETIREMENT PLAN: THE FOLLOWING INDIVIDUALS PARTICIPATED IN A NON-QUALIFIED RETIREMENT PLAN WITH THE FOLLOWING CHANGES TO THEIR ACCOUNTS: DAVID DEOPERE $-6,065, MYKL GARRETT $14,588, WILLIAM LEAVER $243,630, GREG PAGLIUZZA JR. $26,948, RICHARD SEIDLER $66,665, JEFFREY STOLZE $42,758, KEVIN VERMEER $157,312 AND JAY WILLSHER $44,376. AMANDA CROWELL FAMILY MEMBER OF BOARD MEMBER DUNCAN CAMERON 129191 EMPLOYMENT 0 BOBETTE PATTERSON FAMILY MEMBER OF KEY EMPLOYEE MICHAEL PATTERSON 182859 EMPLOYMENT 0 CARDIOVASCULAR MEDICINE PC COMMON BOARD MEMBER/OFFICER 173901 MEDICAL SERVICES 0 MARSHA ROMAN FAMILY MEMBER OF KEY EMPLOYEE MICHAEL PATTERSON 102779 EMPLOYMENT 0 MEDICAL ARTS ASSOCIATES LTD PC COMMON BOARD MEMBER/OFFICER 791000 RENT AND MEDICAL SERVICES 0 METRO MRI CENTER LIMITED PARTNERSHIP COMMON BOARD MEMBER/OFFICER 2092000 INVESTMENT AND PATIENT SERVICE REVENUE 0 MICHAEL PATTERSON FAMILY MEMBER OF KEY EMPLOYEE BOBETTE PATTERSON 394596 EMPLOYMENT 0 QUAD CITY AMBULATORY SURGERY CENTER LLC COMMON BOARD MEMBER/OFFICER 3451000 INVESTMENT 0 SNYDER PARK NELSON & SCHWIEBERT PC COMMON BOARD MEMBER/OFFICER 178967 ATTORNEY FEES 0 TRINITY BETTENDORF ORTHOPEDIC CO-MANAGEMENT COMPANY LLC COMMON BOARD MEMBER/OFFICER 150000 MEDICAL SERVICES 0 TRINITY PHYSICIAN HOSPITAL ORGANIZATION LTD COMMON BOARD MEMBER/OFFICER 487000 INVESTMENT, RENT, ADMINISTRATIVE FEES, SALARIES/BENEFITS, CREDENTIALING FEES, OTHER PROFESSIONAL FEES 0 FORM 990, PART VI, SECTION A, LINE 2 ALEX PAREIGIS, MD; AHMED OKBA, MD; BUSINESS RELATIONSHIP FORM 990, PART VI, SECTION A, LINE 2 MICHAEL PATTERSON; BOBETTE PATERSON; FAMILY RELATIONSHIP FORM 990, PART VI, SECTION A, LINE 6 TRINITY REGIONAL HEALTH SYSTEM, A TAX-EXEMPT ILLINOIS NOT-FOR-PROFIT CORPORATION, IS THE SOLE MEMBER. FORM 990, PART VI, SECTION A, LINE 7A TRINITY REGIONAL HEALTH SYSTEM'S MAY APPOINT ONE BOARD MEMBER AND APPROVES ALL OTHERS. FORM 990, PART VI, SECTION A, LINE 7B TRINITY REGIONAL HEALTH SYSTEM, AS SOLE MEMBER, APPROVES AMENDMENTS TO ARTICLES, BYLAWS AND MISSION, MAY REMOVE ANY TRUSTEE WITH OR WITHOUT CAUSE, APPOINTS CEO AND VICE PRESIDENT, APPROVES MERGERS, CREATION OF SUBSIDIARY OR AFFILIATE ORGANIZATIONS, AND APPROVES BUDGETS AND LONG-RANGE STRATEGY. TRINITY REGIONAL HEALTH SYSTEM AND IOWA HEALTH SYSTEM MUST APPROVE DISSOLUTION. FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 IS PREPARED INTERNALLY BY THE IOWA HEALTH SYSTEM TAX DEPARTMENT USING INFORMATION GATHERED FROM VARIOUS FUNCTIONAL AREAS OF THE ORGANIZATION. EACH SECTION OF THE RETURN IS REVIEWED BY THE RESPONSIBLE FUNCTIONAL AREA ALONG WITH THE TAX DEPARTMENT. A DRAFT COPY OF THE RETURN IS PROVIDED TO THE CFO FOR REVIEW. A FULL COPY OF THE FORM 990 IS PROVIDED TO THE BOARD OF DIRECTORS PRIOR TO FILING WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C THE ORGANIZATION HAS A CONFLICT OF INTEREST POLICY. ANNUALLY ALL OFFICERS, DIRECTORS, KEY EMPLOYEES AND REPORTING PHYSICIANS ARE REQUESTED TO COMPLETE A QUESTIONNAIRE TO REPORT POTENTIAL CONFLICTS OF INTEREST. PERSONS WHO HAVE NOT RETURNED QUESTIONNAIRES ARE CONTACTED ADDITIONAL TIMES IN AN EFFORT TO RECEIVE COMPLETE AND ACCURATE RESPONSES FROM ALL PERSONS. THE ANNUAL QUESTIONNAIRES INCLUDE AN ACKNOWLEDGEMENT THAT THE OFFICER, DIRECTOR, KEY EMPLOYEE OR REPORTING PHYSICIAN: 1) HAS ACCESS TO A COPY OF THE CONFLICT OF INTEREST POLICY; 2) HAS READ AND UNDERSTANDS THE POLICY; 3) AGREES TO COMPLY WITH THE POLICY; 4) UNDERSTANDS THAT THE POLICY APPLIES TO ALL COMMITTEES AND SUBCOMMITTEES HAVING BOARD-DELEGATED POWERS; AND 5) UNDERSTANDS THAT THE ORGANIZATION IS A CHARITABLE ORGANIZATION AND THAT IN ORDER TO MAINTAIN ITS TAX-EXEMPT STATUS, IT MUST CONTINUOUSLY ENGAGE PRIMARILY IN ACTIVITIES WHICH ACCOMPLISH ONE OR MORE OF ITS TAX-EXEMPT PURPOSES. SENIOR ADMINISTRATIVE STAFF AT ALL RELATED ORGANIZATIONS PROVIDE INFORMATION TO A CENTRAL COORDINATOR RELATED TO THE IDENTIFICATION OF WHICH INDIVIDUALS SHOULD RECEIVE THE QUESTIONNAIRE FOR COMPLETION. THE RESULTS ARE COMPILED CENTRALLY AND REVIEWED BY THE IOWA HEALTH SYSTEM COMPLIANCE OFFICER AND DIRECTOR OF INTERNAL AUDIT. THE DETAIL RESULTS ARE REPORTED TO A COMMITTEE OF THE SYSTEM BOARD. THE RESULTS RELATED TO SPECIFIC REGIONAL PARENT COMPANIES, THEIR HOSPITALS AND RELATED ORGANIZATIONS, ARE DISTRIBUTED IN DETAIL TO THE CHAIRPERSON OF THE REGIONAL PARENT ORGANIZATION, THE CHIEF EXECUTIVE OFFICER, CHIEF FINANCIAL OFFICER AND COMPLIANCE MANAGER. THESE INDIVIDUALS ARE ALSO REMINDED OF THE APPROPRIATE PROCESS TO BE FOLLOWED DURING THE YEAR TO ADDRESS POTENTIAL CONFLICTS OF INTEREST THAT RELATE TO MATTERS THAT ARE BROUGHT TO THE BOARD OF DIRECTORS FOR ACTION. THE INFORMATION DISCLOSED IS USED TO IDENTIFY POTENTIAL CONFLICTS OF INTEREST AND TO ASSIST IN COMPLETING IRS AND MEDICAID QUESTIONNAIRES. ANY DUALITY OF INTEREST OR POSSIBLE CONFLICT OF INTEREST ON THE PART OF ANY ORGANIZATIONAL OFFICER, DIRECTOR, KEY EMPLOYEE OR REPORTING PHYSICIAN TOGETHER WITH ALL MATERIAL FACTS, SHOULD BE DISCLOSED TO THE BOARD OF DIRECTORS AND MADE A MATTER OF RECORD, EITHER THROUGH AN ANNUAL PROCEDURE OR WHEN THE INTEREST OCCURS OR BECOMES A MATTER OF BOARD ACTION. ANY ORGANIZATIONAL OFFICER, DIRECTOR, KEY EMPLOYEE OR REPORTING PHYSICIAN HAVING A CONFLICT OF INTEREST IN ANY MATTER SHOULD NOT BE PRESENT DURING GENERAL DISCUSSION NOR VOTE OR USE HIS OR HER PERSONAL INFLUENCE ON THE MATTER, AND HE OR SHE SHOULD NOT BE COUNTED IN DETERMINING THE EXISTENCE OF A QUORUM FOR PURPOSES OF THE MATTER OR ITEM AS TO WHICH A CONFLICT EXISTS. THE BOARD SHOULD EXCLUDE THE INDIVIDUAL FROM ANY DISCUSSION OR VOTE IN WHICH THE BOARD DECIDES WHETHER OR NOT A CONFLICT OF INTEREST EXISTS. IN CASES IN WHICH AN OFFICER, DIRECTOR, KEY EMPLOYEE, REPORTING PHYSICIAN OR THE INDIVIDUAL'S HOUSEHOLD MEMBER HAS A CONFLICT OF INTEREST IN AN ARRANGEMENT OR TRANSACTION, THE FOLLOWING ADDITIONAL STEPS MAY BE TAKEN AT THE DIRECTION OF THE BOARD OF DIRECTORS: 1) AFTER DISCLOSURE OF THE FINANCIAL INTEREST AND ALL MATERIAL FACTS, AND AFTER ANY DISCUSSION WITH THE INTERESTED PERSON, HE OR SHE SHALL LEAVE THE BOARD OR COMMITTEE MEETING WHILE THE DETERMINATION OF A CONFLICT OF INTEREST IS DISCUSSED AND VOTED UPON. THE REMAINING BOARD OR COMMITTEE MEMBERS SHALL 1) DECIDE IF A CONFLICT OF INTEREST EXISTS, 2) A DISINTERESTED PERSON OR COMMITTEE MAY BE APPOINTED TO INVESTIGATE ALTERNATIVES TO THE PROPOSED ARRANGEMENT OR TRANSACTION; 3) IN ORDER TO APPROVE THE ARRANGEMENT OR TRANSACTION, THE BOARD MUST FIRST FIND, BY MAJORITY VOTE OF DISINTERESTED MEMBERS, THAT THE ARRANGEMENT OR TRANSACTION IS IN THE ORGANIZATION'S BEST INTEREST, IS FAIR AND REASONABLE TO THE ORGANIZATION, AND, AFTER REASONABLE INVESTIGATION, THE DISINTERESTED MEMBERS HAVE DETERMINED THAT A MORE ADVANTAGEOUS TRANSACTION OR ARRANGEMENT CANNOT BE OBTAINED WITH REASONABLE EFFORTS UNDER THE CIRCUMSTANCES; THE MINUTES OF THE BOARD AND ALL COMMITTEES WITH BOARD-DELEGATED POWERS SHALL CONTAIN: 1) THE NAMES OF THE PERSONS WHO DISCLOSED OR OTHERWISE WERE FOUND TO HAVE A FINANCIAL INTEREST IN CONNECTION WITH AN ACTUAL OR POSSIBLE CONFLICT OF INTEREST, THE NATURE OF THE FINANCIAL INTEREST, ANY ACTION TAKEN TO DETERMINE WHETHER A CONFLICT OF INTEREST WAS PRESENT, AND THE BOARD'S OR COMMITTEE'S DECISION AS TO WHETHER A CONFLICT OF INTEREST IN FACT EXISTED; 2) THE NAMES OF THE PERSONS WHO WERE PRESENT FOR DISCUSSIONS AND VOTES RELATING TO THE TRANSACTION OR ARRANGEMENT, THE CONTENT OF THE DISCUSSION, INCLUDING ANY ALTERNATIVES TO THE PROPOSED TRANSACTION OR ARRANGEMENT, AND A RECORD OF ANY VOTES TAKEN IN CONNECTION THEREWITH; IN ORDER TO PROTECT THE ORGANIZATION'S BEST INTERESTS, APPROPRIATE DISCIPLINARY ACTION MAY BE TAKEN WITH RESPECT TO AN OFFICER, DIRECTOR, KEY EMPLOYEE OR REPORTING PHYSICIAN WHO VIOLATES THE CONFLICT OF INTEREST POLICY. FORM 990, PART VI, SECTION B, LINE 15 THE EXECUTIVE COMMITTEE OF THE IOWA HEALTH SYSTEM BOARD OF DIRECTORS ("COMMITTEE") CONDUCTS A COMPREHENSIVE ANNUAL REVIEW OF ALL COMPENSATION AND BENEFITS PROVIDED TO THE ORGANIZATION'S OFFICERS AND KEY EMPLOYEES, INCLUDING THE IHS CHIEF EXECUTIVE OFFICER (THE "CEO"). THIS ANNUAL REVIEW COMPARES THE TOTAL COMPENSATION AND VALUE OF BENEFITS PROVIDED TO EACH EXECUTIVE, ON A POSITION BY POSITION BASIS, TO THAT PROVIDED TO FUNCTIONALLY SIMILAR POSITIONS IN SIMILARLY SITUATED ORGANIZATIONS. THIS REVIEW IS CONDUCTED BY THE COMMITTEE WITH THE ASSISTANCE OF A NATIONAL, INDEPENDENT COMPENSATION CONSULTANT REPORTING DIRECTLY TO THE COMMITTEE. THE COMMITTEE HAS BEEN DELEGATED THE RESPONSIBILITY FOR OVERSIGHT OF EXECUTIVE COMPENSATION AND IS MADE UP ENTIRELY OF INDEPENDENT DIRECTORS WITHIN THE MEANING OF THE "REBUTTABLE PRESUMPTION OF REASONABLENESS" UNDER THE FEDERAL INCOME TAX INTERMEDIATE SANCTIONS RULES. THE COMPENSATION CONSULTANT HOLDS ITSELF OUT TO THE PUBLIC AS A COMPENSATION CONSULTANT, PERFORMS THESE VALUATIONS ON A REGULAR BASIS, IS QUALIFIED TO MAKE THE VALUATIONS OF THE SERVICES INVOLVED, AND HAS SO INDICATED IN A WRITTEN CERTIFICATION TO THE COMMITTEE. BASED UPON THE ADVICE OF THE COMPENSATION CONSULTANT, AND APPLYING THE BOARD'S COMPENSATION PHILOSOPHY, THE COMMITTEE ESTABLISHES THE OVERALL ADJUSTMENT IN COMPENSATION AND BENEFITS FOR APPROXIMATELY THE TOP FIFTY EXECUTIVES IN THE ENTIRE HEALTH SYSTEM (SEVERAL OF WHICH ARE EMPLOYEES OF THE FILING ORGANIZATION) AND DELEGATES TO THE CEO THE AUTHORITY TO MAKE ADJUSTMENTS, CONSISTENT WITH THE COMMITTEE'S DIRECTION, FOR THE OTHER EXECUTIVES. THE COMMITTEE DETERMINES ALL ASPECTS OF THE COMPENSATION AND BENEFITS OF THE CEO. THE COMMITTEE INTENTIONALLY TAKES ALL THE STEPS NECESSARY TO QUALIFY FOR THE REBUTTABLE PRESUMPTION OF REASONABLENESS UNDER THE FEDERAL INCOME TAX LAW INTERMEDIATE SANCTIONS RULES, INCLUDING CONTEMPORANEOUS SUBSTANTIATION OF ALL COMMITTEE MEETINGS AND ACTIONS. THE ORGANIZATION BELIEVES IT IS IN FULL COMPLIANCE WITH SECTION 4958 OF THE IRC, PROVIDES NO MORE THAN REASONABLE AND FAIR MARKET VALUE COMPENSATION AND BENEFITS FOR ITS EMPLOYEES AND DOES NOT PROVIDE ANY EXCESS COMPENSATION OR BENEFITS AS PROHIBITED BY SECTION 4958. THE ANNUAL REVIEW OF COMPENSATION AND BENEFITS WAS LAST PERFORMED IN DECEMBER 2011 FOR THE FOLLOWING INDIVIDUALS: DAVID DEOPERE, MYKL GARRETT, WILLIAM LEAVER, GREG PAGLIUZZA, JR., RICHARD SEIDLER, JEFFREY STOLZE, KEVIN VERMEER, AND JAY WILLSHER. THE COMPENSATION AND BENEFITS OF THE OTHER PERSONS LISTED ON FORM 990, PART VII WAS ESTABLISHED BY AN INDEPENDENT PERSON/COMMITTEE USING AN INDEPENDENT COMPENSATION CONSULTANT AND/OR COMPENSATION SURVEY OR STUDY FOR SIMILARLY QUALIFED PERSONS IN FUNCTIONALLY COMPARABLE POSITIONS AT SIMILARLY SITUATED ORGANIZATIONS. COMPENSATION AND BENEFITS ARE BASED ON THE FAIR MARKET VALUE OF THE SERVICES PROVIDED TO THE ORGANIZATION. FORM 990, PART VI, SECTION C, LINE 19 IOWA HEALTH SYSTEM, OUR PARENT ORGANIZATION, HAS VOLUNTARILY ADOPTED MANY OF OUR INDUSTRY'S GOVERNANCE "BEST PRACTICES." IOWA HEALTH SYSTEM HAS DONE SO TO FURTHER ASSURE OUR STAKEHOLDERS THAT OUR GOVERNANCE AND MANAGEMENT IS CONDUCTED RESPONSIBLY AND WARRANTS THE TRUST YOU PLACE IN US. IN SEPTEMBER 2003, THE IOWA HEALTH SYSTEM BOARD OF DIRECTORS VOLUNTARILY ADOPTED OVER 40 CHANGES TO ITS GOVERNANCE STRUCTURE TO BETTER COMPLY WITH GOVERNANCE BEST PRACTICES AND THE INTENT AND APPLICABLE REQUIREMENTS OF THE SARBANES-OXLEY ACT OF 2003. IN ADDITION, GOVERNANCE POLICIES AND RELATED INFORMATION HAS BEEN ADDED TO THE IOWA HEALTH SYSTEM WEBSITE, WWW.IHS.ORG, INCLUDING BUT NOT LIMITED TO: OVER 130 CORPORATE COMPLIANCE POLICIES, INCLUDING CHARITY CARE AND CONFLICTS OF INTEREST POLICIES; GOVERNANCE BEST PRACTICE POLICIES; THE IDENTIFICATION OF BOARD MEMBERS AND BOARD COMMITTEES; COMPENSATION FOR HOSPITAL CEO'S; AND FINANCIAL INFORMATION FOR THE PAST SEVEN YEARS. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED LOSSES ON INVESTMENTS: -5,648,543. CHANGE IN BENEFICIAL INTEREST IN TRINITY HEALTH FOUNDATION 149,564. CHANGES IN PENSION LIABILITY -245,090. TOTAL TO FORM 990, PART XI, LINE 5: -5,744,069. ALLEN COLLEGE 1825 LOGAN AVENUE WATERLOO IA 50703 421351526 EDUCATE AND DEVELOP HEALTHCARE PROFESSIONALS IA 501(C)(3) 170(B)(1) (A)(II) ALLEN HEALTH SYSTEMS INC 1 ALLEN HEALTH SYSTEMS INC 1825 LOGAN AVENUE WATERLOO IA 50703 421201924 SUPPORT AFFILIATES' MISSION TO IMPROVE HEALTH CARE IA 501(C)(3) 509(A)(3), TYPE II IOWA HEALTH SYSTEM 1 ALLEN MEMORIAL HOSPITAL CORPORATION 1825 LOGAN AVENUE WATERLOO IA 50703 420698265 HOSPITAL IA 501(C)(3) 170(B)(1) (A)(III) ALLEN HEALTH SYSTEMS INC 1 ANAMOSA AREA AMBULANCE SERVICE 101 GRANT WOOD DRIVE ANAMOSA IA 52205 421466284 PROVIDE AMBULANCE SERVICES IA 501(C)(3) 509(A)(2) ST LUKE'SJONES REGIONAL MEDICAL CENTER 1 CENTRAL IOWA HEALTH PROPERTIES CORPORATION 1200 PLEASANT STREET DES MOINES IA 50309 421233759 PROPERTY HOLDING COMPANY IA 501(C)(2) CENTRAL IOWA HEALTH SYSTEM 1 CENTRAL IOWA HEALTH SYSTEM 1200 PLEASANT STREET DES MOINES IA 50309 421189791 SUPPORT AFFILIATES' MISSION TO IMPROVE HEALTH CARE IA 501(C)(3) 509(A)(3), TYPE II IOWA HEALTH SYSTEM 1 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FOR ENTITIES THAT ARE PART OF THE CONSOLIDATED HEALTH SYSTEM (WITH COMMON CONTROL) THE ATTRIBUTION RULES OF IRC SECTION 318 APPLY; MEANING THAT ALL ORGANIZATIONS ARE DEEMED TO HAVE CONTROL OF THE ORGANIZATIONS OWNED BY THE CONTROLLING ORGANIZATION. AS SUCH, WE ARE REPORTING ALL RELATED ORGANIZATIONS OF THE HEALTH SYSTEM IN PARTS II, III & IV. FOR PART V REPORTING, THE TRANSACTIONS DISCLOSED ARE THOSE BETWEEN THE DIRECTLY CONTROLLED PARENT-SUBSIDIARY ONLY.