Form990
Click to see attachment
Department of the Treasury
Internal Revenue Service
Return of Organization Exempt From Income Tax
Under section 501(c), 527, or 4947(a)(1) of the Internal Revenue Code (except black lung benefit trust or private foundation)

MediumBullet The organization may have to use a copy of this return to satisfy state reporting requirements.
OMB No. 1545-0047
2010
Open to Public Inspection
A For the calendar year, or tax year beginning 01-01-2010 and ending 12-31-2010
BCheck if applicable:
CName of organization
EXEMPLA INC FKA LUTHERAN HOSPITAL
 
Doing Business As
 
 
Number and street (or P.O. box if mail is not delivered to street address)
2420 West 26th Ave Suite 100D
 
Room/suite
City or town, state or country, and ZIP + 4
Denver, CO80211
D Employer identification number

84-1103606
E Telephone number

G Gross receipts $ 652,465,674
F Name and address of principal officer:
Robert Ladenburger
 
 
I
Tax-exempt status: (   ) LeftBullet (insert no.) or
J
Website:MediumBullet
WWW.EXEMPLA.ORG
H(a)
Is this a group return for
affiliates?
H(b)
Are all affiliates included?
If "No," attach a list. (see instructions)
H(c)
Group exemption number MediumBullet  
K Form of organization:
 
L Year of formation: 1905
M State of legal domicile: CO
Part I
Summary
Activities & Governance 1 Briefly describe the organization’s mission or most significant activities: THE MISSION OF EXEMPLA, INC. IS TO FOSTER HEALING AND HEALTH FOR THE GREATER DENVER, COLORADO METROPOLITAN SERVICE AREA.
2 Check this box MediumBullet
3 Number of voting members of the governing body (Part VI, line 1a) .... 3 10
4 Number of independent voting members of the governing body (Part VI, line 1b) .... 4 9
5 Total number of individuals employed in calendar year 2010 (Part V, line 2a) ... 5 8,497
6 Total number of volunteers (estimate if necessary) .... 6 1,285
7a Total unrelated business revenue from Part VIII, column (C), line 12 .. 7a 335,389
b Net unrelated business taxable income from Form 990-T, line 34 .. 7b 0
Revenues; Prior Year Current Year
8 Contributions and grants (Part VIII, line 1h) ......... 262,181 670,723
9 Program service revenue (Part VIII, line 2g) ......... 592,795,194 623,180,351
10 Investment income (Part VIII, column (A), lines 3, 4, and 7d ) .... 4,064,089 12,605,253
11 Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e) 667,219 13,396,221
12 Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)................... 597,788,683 649,852,548
Expenses; 13 Grants and similar amounts paid (Part IX, column (A), lines 1–3 )... 332,701 264,747
14 Benefits paid to or for members (Part IX, column (A), line 4) .... 0 0
15 Salaries, other compensation, employee benefits (Part IX, column (A), lines 5–10) 304,137,398 305,103,899
16a Professional fundraising fees (Part IX, column (A), line 11e).... 0 0
b Total fundraising expenses (Part IX, column (D), line 25) MediumBullet0    
17 Other expenses (Part IX, column (A), lines 11a–11d, 11f–24f).... 285,482,498 324,297,104
18 Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25) 589,952,597 629,665,750
19 Revenue less expenses. Subtract line 18 from line 12...... 7,836,086 20,186,798
Net Assets or Fund Balances; Beginning of Current Year End of Year
20 Total assets (Part X, line 16)............ 881,617,835 917,736,341
21 Total liabilities (Part X, line 26)............ 521,585,247 533,685,454
22 Net assets or fund balances. Subtract line 21 from line 20 ..... 360,032,588 384,050,887
Part II
Signature Block
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete. Declaration of preparer (other than officer) is based on all information of which preparer has any knowledge.
Sign Here
JumboBullet
Signature of officer Date
JumboBullet
Type or print name and title.
Paid Preparer's Use Only Preparer's
signatureBig Right Arrow 		Date
right pointing bullet image Preparer’s taxpayer identification number
(see instructions)
Firm’s name (or yours
if self-employed),
address, and ZIP + 4Big Right Arrow




 		EIN right pointing bullet image
Phone no. right pointing bullet image
May the IRS discuss this return with the preparer shown above? (see instructions) .........
For Privacy Act and Paperwork Reduction Act Notice, see the separate instructions.
Cat. No. 11282Y
Form 990 (2010)
Form 990 (2010)
Page 2
Part III
Statement of Program Service Accomplishments
Check if Schedule O contains a response to any question in this Part III . . . . . . . . . .
1
Briefly describe the organization’s mission: THE MISSION OF EXEMPLA, INC. IS TO FOSTER HEALING AND HEALTH FOR THE GREATER DENVER, COLORADO METROPOLITAN SERVICE AREA.
2
Did the organization undertake any significant program services during the year which were not listed on
the prior Form 990 or 990-EZ? ....................
If “Yes,” describe these new services on Schedule O.
3
Did the organization cease conducting, or make significant changes in how it conducts, any program services? ..........................
If “Yes,” describe these changes on Schedule O.
4
Describe the exempt purpose achievements for each of the organization’s three largest program services by expenses.
Section 501(c)(3) and 501(c)(4) organizations and section 4947(a)(1) trusts are required to report the amount of grants and allocations to others, the total expenses, and revenue, if any, for each program service reported.
4a (Code:   ) (Expenses $ 450,109,610 including grants of $ 0 ) (Revenue $ 573,764,304 )
Provision of hospital based healthcare services, including charity care and unreimbursed Medicaid - see description in Schedule O
4b (Code:   ) (Expenses $ 34,913,503 including grants of $ 0 ) (Revenue $ 27,021,324 )
Physician clinics - See detailed descriptions in Schedule O
4c (Code:   ) (Expenses $ 14,523,192 including grants of $ 0 ) (Revenue $ 17,310,576 )
West Pines Behavioral Health - See detailed description in Schedule O
4d Other program services. (Describe in Schedule O.)
(Expenses $ 16,630,216 including grants of $ 264,747 ) (Revenue $ 18,043,391 )
4e Total program service expensesMediumBullet$ 516,176,521
Form 990 (2010)
Form 990 (2010)
Page 3
Part IV
Checklist of Required Schedules
Yes
No
1
Is the organization described in section 501(c)(3) or 4947(a)(1) (other than a private foundation)? If “Yes,” complete Schedule AClick to see attachment.....................
1
Yes
 
2
Is the organization required to complete Schedule B, Schedule of Contributors? Click to see attachment........
2
Yes
 
3
Did the organization engage in direct or indirect political campaign activities on behalf of or in opposition to candidates for public office? If “Yes,” complete Schedule C, Part IClick to see attachment..........
3
 
No
4
Section 501(c)(3) organizations. Did the organization engage in lobbying activities? If “Yes,” complete Schedule C,
Part IIClick to see attachment.........................
4
Yes
 
5
Is the organization a section 501(c)(4), 501(c)(5), or 501(c)(6) organization that receives membership dues, assessments, or similar amounts as defined in Revenue Procedure 98-19? If “Yes,” complete Schedule C, Part III........................
5
 
 
6
Did the organization maintain any donor advised funds or any similar funds or accounts where donors have the right to provide advice on the distribution or investment of amounts in such funds or accounts? If “Yes,” complete
Schedule D, Part IClick to see attachment.......................
6
 
No
7
Did the organization receive or hold a conservation easement, including easements to preserve open space,
the environment, historic land areas or historic structures? If “Yes,” complete Schedule D, Part IIClick to see attachment...
7
 
No
8
Did the organization maintain collections of works of art, historical treasures, or other similar assets? If “Yes,” complete Schedule D, Part III Click to see attachment....................
8
 
No
9
Did the organization report an amount in Part X, line 21; serve as a custodian for amounts not listed in Part X; or provide credit counseling, debt management, credit repair, or debt negotiation services? If “Yes,”
complete Schedule D, Part IVClick to see attachment...................
9
 
No
10
Did the organization, directly or through a related organization, hold assets in term, permanent,or quasi-endowments? If “Yes,” complete Schedule D, Part VClick to see attachment
10
 
No
11
If the organization’s answer to any of the following questions is ‘Yes,’ then complete Schedule D, Parts VI, VII, VIII, IX, or X as applicable:
a
Did the organization report an amount for land, buildings, and equipment in Part X, line10? If “Yes,” complete Schedule D, Part VI.Click to see attachment
11a
Yes
 
b
Did the organization report an amount for investments—other securities in Part X, line 12 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part VII.Click to see attachment
11b
 
No
c
Did the organization report an amount for investments—program related in Part X, line 13 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part VIII.Click to see attachment
11c
 
No
d
Did the organization report an amount for other assets in Part X, line 15 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part IX.Click to see attachment
11d
 
No
e
Did the organization report an amount for other liabilities in Part X, line 25? If “Yes,” complete Schedule D, Part X.Click to see attachment
11e
Yes
 
f
Did the organization’s separate or consolidated financial statements for the tax year include a footnote that addresses the organization’s liability for uncertain tax positions under FIN 48 (ASC 740)? If “Yes,” complete Schedule D, Part X.Click to see attachment
11f
Yes
 
12a
Did the organization obtain separate, independent audited financial statements for the tax year? If “Yes,” complete Schedule D, Parts XI, XII, and XIII Click to see attachment
12a
 
No
b
Was the organization included in consolidated, independent audited financial statements for the tax year? If “Yes,” and if the organization answered ‘No’ to line 12a, then completing Schedule D, Parts XI, XII, and XIII is optional Click to see attachment
12b
Yes
 
13
Is the organization a school described in section 170(b)(1)(A)(ii)? If “Yes,” complete Schedule E
13
 
No
14a
Did the organization maintain an office, employees, or agents outside of the United States?....
14a
 
No
b
Did the organization have aggregate revenues or expenses of more than $10,000 from grantmaking, fundraising, business, and program service activities outside the United States? If “Yes,” complete Schedule F, Part I......... Click to see attachment
14b
Yes
 
15
Did the organization report on Part IX, column (A), line 3, more than $5,000 of grants or assistance to any organization or entity located outside the U.S.? If “Yes,” complete Schedule F, Part II.. Click to see attachment
15
Yes
 
16
Did the organization report on Part IX, column (A), line 3, more than $5,000 of aggregate grants or assistance to individuals located outside the U.S.? If “Yes,” complete Schedule F, Part III.. Click to see attachment
16
 
No
17
Did the organization report a total of more than $15,000, of expenses for professional fundraising services on Part IX, column (A), lines 6 and 11e? If “Yes,” complete Schedule G, Part I
17
 
No
18
Did the organization report more than $15,000 total of fundraising event gross income and contributions on Part VIII, lines 1c and 8a? If “Yes,” complete Schedule G, Part II..........
18
 
No
19
Did the organization report more than $15,000 of gross income from gaming activities on Part VIII, line 9a? If “Yes,” complete Schedule G, Part III...................
19
 
No
Form 990 (2010)
Form 990 (2010)
Page 4
Part IV
Checklist of Required Schedules (continued)
20a
Did the organization operate one or more hospitals? If “Yes,” complete Schedule H..... Click to see attachment
20a
Yes
 
b
Did the organization attach its audited financial statement to this return? Note: All Form 990 filers that operate one or more hospitals must attach audited financial statements. ..... Click to see attachment
20b
 
No
21
Did the organization report more than $5,000 of grants and other assistance to governments and organizations in the United States on Part IX, column (A), line 1? If “Yes,” complete Schedule I, Parts I and II.. Click to see attachment
21
Yes
 
22
Did the organization report more than $5,000 of grants and other assistance to individuals in the United States on Part IX, column (A), line 2? If “Yes,” complete Schedule I, Parts I and III..... Click to see attachment
22
 
No
23
Did the organization answer “Yes” to Part VII, Section A, questions 3, 4, or 5, about compensation of the organization’s current and former officers, directors, trustees, key employees, and highest compensated employees? If “Yes,” complete Schedule J................ Click to see attachment
23
Yes
 
24a
Did the organization have a tax-exempt bond issue with an outstanding principal amount of more than $100,000 as of the last day of the year, that was issued after December 31, 2002? If “Yes,” answer questions 24b–24d and complete Schedule K. If “No,” go to line 25................
24a
 
No
b
Did the organization invest any proceeds of tax-exempt bonds beyond a temporary period exception?...
24b
 
 
c
Did the organization maintain an escrow account other than a refunding escrow at any time during the year
to defease any tax-exempt bonds?......................
24c
 
 
d
Did the organization act as an “on behalf of” issuer for bonds outstanding at any time during the year?...
24d
 
 
25a
Section 501(c)(3) and 501(c)(4) organizations. Did the organization engage in an excess benefit transaction with a disqualified person during the year? If “Yes,” complete Schedule L, Part I...... Click to see attachment
25a
 
No
b
Is the organization aware that it engaged in an excess benefit transaction with a disqualified person in a prior year, and that the transaction has not been reported on any of the organization’s prior Forms 990 or 990-EZ? If “Yes,” complete Schedule L, Part I................ Click to see attachment
25b
 
No
26
Was a loan to or by a current or former officer, director, trustee, key employee, highly compensated employee, or disqualified person outstanding as of the end of the organization’s tax year? If “Yes,” complete Schedule L,
Part II........................... Click to see attachment
26
 
No
27
Did the organization provide a grant or other assistance to an officer, director, trustee, key employee, substantial contributor, or a grant selection committee member, or to a person related to such an individual? If “Yes,” complete Schedule L, Part III............... Click to see attachment
27
 
No
28
Was the organization a party to a business transaction with one of the following parties? (see Schedule L, Part IV instructions for applicable filing thresholds, conditions, and exceptions):
a
A current or former officer, director, trustee, or key employee? If “Yes,” complete Schedule L, Part IV ......................... Click to see attachment
28a
 
No
b
A family member of a current or former officer, director, trustee, or key employee? If “Yes,”
complete Schedule L, Part IV................... Click to see attachment
28b
 
No
c
An entity of which a current or former officer, director, trustee, or key employee (or a family member thereof) was an officer, director, trustee, or owner? If “Yes,” complete Schedule L, Part IV.. Click to see attachment
28c
Yes
 
29
Did the organization receive more than $25,000 in non-cash contributions? If “Yes,” complete Schedule M
29
 
No
30
Did the organization receive contributions of art, historical treasures, or other similar assets, or qualified conservation contributions? If “Yes,” complete Schedule M............
30
 
No
31
Did the organization liquidate, terminate, or dissolve and cease operations? If “Yes,” complete Schedule N,
Part I...........................
31
 
No
32
Did the organization sell, exchange, dispose of, or transfer more than 25% of its net assets? If “Yes,” complete Schedule N, Part II.......................
32
 
No
33
Did the organization own 100% of an entity disregarded as separate from the organization under Regulations sections 301.7701-2 and 301.7701-3? If “Yes,” complete Schedule R, Part I........ Click to see attachment
33
Yes
 
34
Was the organization related to any tax-exempt or taxable entity? If “Yes,” complete Schedule R, Parts II, III, IV, and V, line 1..................... Click to see attachment
34
Yes
 
35
Is any related organization a controlled entity within the meaning of section 512(b)(13)? .....
35
Yes
 
a
Did the organization receive any payment from or engage in any transaction with a controlled entity within the meaning of section 512(b)(13)? If “Yes,” complete Schedule R, Part V, line 2... Click to see attachment
36
Section 501(c)(3) organizations. Did the organization make any transfers to an exempt non-charitable related organization? If “Yes,” complete Schedule R, Part V, line 2........... Click to see attachment
36
 
No
37
Did the organization conduct more than 5% of its activities through an entity that is not a related organization and that is treated as a partnership for federal income tax purposes? If “Yes,” complete Schedule R, Part VIClick to see attachment
37
 
No
38
Did the organization complete Schedule O and provide explanations in Schedule O for Part VI, lines 11 and 19? Note. All Form 990 filers are required to complete Schedule O. ............
38
Yes
 
Form 990 (2010)
Form 990 (2010)
Page 5
Part V
Statements Regarding Other IRS Filings and Tax Compliance
Check if Schedule O contains a response to any question in this Part V . . . . . . . . . .
Yes
No
1a
Enter the number reported in Box 3 of Form 1096. Enter -0- if not applicable. .......
1a
627
b
Enter the number of Forms W-2G included in line 1a. Enter -0- if not applicable.
1b
0
c
Did the organization comply with backup withholding rules for reportable payments to vendors and reportable gaming (gambling) winnings to prize winners? ..................
1c
Yes
 
2a
Enter the number of employees reported on Form W-3, Transmittal of Wage and Tax Statements filed for the calendar year ending with or within the year covered by this return .....................
2a
8,497
b
If at least one is reported on line 2a, did the organization file all required federal employment tax returns?

Note. If the sum of lines 1a and 2a is greater than 250, you may be required to e-file. (see instructions)
2b
Yes
 
3a
Did the organization have unrelated business gross income of $1,000 or more during the year?.............................
3a
Yes
 
b
If “Yes,” has it filed a Form 990-T for this year? If “No,” provide an explanation in Schedule O.....
3b
Yes
 
4a
At any time during the calendar year, did the organization have an interest in, or a signature or other authority over, a financial account in a foreign country (such as a bank account or securities account)?.......................
4a
 
No
b
If "Yes," enter the name of the foreign country: MediumBullet
See instructions for filing requirements for Form TD F 90-22.1, Report of Foreign Bank and Financial Accounts.
5a
Was the organization a party to a prohibited tax shelter transaction at any time during the tax year?..
5a
 
No
b
Did any taxable party notify the organization that it was or is a party to a prohibited tax shelter transaction?
5b
 
No
c
If “Yes” to line 5a or 5b, did the organization file Form 8886-T? ........
5c
 
 
6a
Does the organization have annual gross receipts that are normally greater than $100,000, and did the organization solicit any contributions that were not tax deductible?..........
6a
 
No
b
If “Yes,” did the organization include with every solicitation an express statement that such contributions or gifts were not tax deductible?........................
6b
 
 
7
Organizations that may receive deductible contributions under section 170(c).
a
Did the organization receive a payment in excess of $75 made partly as a contribution and partly for goods and services provided to the payor?....................
7a
 
No
b
If “Yes,” did the organization notify the donor of the value of the goods or services provided?.....
7b
 
 
c
Did the organization sell, exchange, or otherwise dispose of tangible personal property for which it was required to file Form 8282?...........................
7c
 
No
d
If “Yes,” indicate the number of Forms 8282 filed during the year ....
7d
 
e
Did the organization receive any funds, directly or indirectly, to pay premiums on a personal benefit contract?..........................
7e
 
No
f
Did the organization, during the year, pay premiums, directly or indirectly, on a personal benefit contract?..
7f
 
No
g
If the organization received a contribution of qualified intellectual property, did the organization file Form 8899 as required?...................
7g
 
 
h
If the organization received a contribution of cars, boats, airplanes, or other vehicles, did the organization file a Form 1098-C?...............
7h
 
 
8
Sponsoring organizations maintaining donor advised funds and section 509(a)(3) supporting organizations. Did the supporting organization, or a donor advised fund maintained by a sponsoring organization, have excess business holdings at any time during the year?................
8
 
 
9
Sponsoring organizations maintaining donor advised funds.
a
Did the organization make any taxable distributions under section 4966?.........
9a
 
 
b
Did the organization make a distribution to a donor, donor advisor, or related person?......
9b
 
 
10
Section 501(c)(7) organizations. Enter:
a
Initiation fees and capital contributions included on Part VIII, line 12 ...
10a
 
b
Gross receipts, included on Form 990, Part VIII, line 12, for public use of club facilities
10b
 
11
Section 501(c)(12) organizations. Enter:
a
Gross income from members or shareholders .........
11a
 
b
Gross income from other sources (Do not net amounts due or paid to other sources against amounts due or received from them.) ........
11b
 
12a
Section 4947(a)(1) non-exempt charitable trusts. Is the organization filing Form 990 in lieu of Form 1041?
12a
 
 
b
If “Yes,” enter the amount of tax-exempt interest received or accrued during the year.
12b
 
13
Section 501(c)(29) qualified nonprofit health insurance issuers.
a
Is the organization licensed to issue qualified health plans in more than one state?
Note. All 501(c)(29) organizations must list in Schedule O each state in which they are licensed to issue qualified health plans, the amount of reserves required by each state, and the amount of reserves the organization allocated to each state.
13a
 
 
b
Enter the aggregate amount of reserves the organization is required to maintain by the states in which the organization is licensed to issue qualified health plans.
13b
 
c
Enter the aggregate amount of reserves on hand.
13c
 
14a
Did the organization receive any payments for indoor tanning services during the tax year?.....
14a
 
 
b
If "Yes," has it filed a Form 720 to report these payments? If “No,” provide an explanation in Schedule O..
14b
 
 
Form 990 (2010)
Form 990 (2010)
Page 6
Part VI
Governance, Management, and Disclosure For each “Yes” response to lines 2 through 7b below, and for a “No” response to lines 8a, 8b, or 10b below, describe the circumstances, processes, or changes in Schedule O. See instructions.
Check if Schedule O contains a response to any question in this Part VI . . . . . . . . . .
Section A. Governing Body and Management
Yes
No
1a
Enter the number of voting members of the governing body at the end of the tax year ..............
1a
10
b
Enter the number of voting members included in line 1a, above, who are independent .................
1b
9
2
Did any officer, director, trustee, or key employee have a family relationship or a business relationship with any other officer, director, trustee, or key employee? .................
2
 
No
3
Did the organization delegate control over management duties customarily performed by or under the direct supervision of officers, directors or trustees, or key employees to a management company or other person? ..
3
Yes
 
4
Did the organization make any significant changes to its governing documents since the prior Form 990 was filed?
4
Yes
 
5
Did the organization become aware during the year of a significant diversion of the organization’s assets? .
5
 
No
6
Does the organization have members or stockholders? ................
6
Yes
 
7a
Does the organization have members, stockholders, or other persons who may elect one or more members of the governing body? .........................
7a
Yes
 
b
Are any decisions of the governing body subject to approval by members, stockholders, or other persons? ..
7b
Yes
 
8
Did the organization contemporaneously document the meetings held or written actions undertaken during the year by the following:
a
The governing body? .........................
8a
Yes
 
b
Each committee with authority to act on behalf of the governing body? ............
8b
Yes
 
9
Is there any officer, director, trustee, or key employee listed in Part VII, Section A, who cannot be reached at the organization’s mailing address? If “Yes,” provide the names and addresses in Schedule O .....
9
 
No
Section B. Policies (This Section B requests information about policies not required by the Internal
Revenue Code.)
Yes
No
10a
Does the organization have local chapters, branches, or affiliates? ............
10a
Yes
 
b
If “Yes,” does the organization have written policies and procedures governing the activities of such chapters, affiliates, and branches to ensure their operations are consistent with those of the organization? ....
10b
Yes
 
11a
Has the organization provided a copy of this Form 990 to all members of its governing body before filing the form?
11a
Yes
 
b
Describe in Schedule O the process, if any, used by the organization to review the Form 990. .....
12a
Does the organization have a written conflict of interest policy? If “No,” go to line 13.......
12a
Yes
 
b
Are officers, directors or trustees, and key employees required to disclose annually interests that could give rise to conflicts? ...........................
12b
Yes
 
c
Does the organization regularly and consistently monitor and enforce compliance with the policy? If “Yes,” describe in Schedule O how this is done ....................
12c
Yes
 
13
Does the organization have a written whistleblower policy? ...............
13
Yes
 
14
Does the organization have a written document retention and destruction policy? .........
14
Yes
 
15
Did the process for determining compensation of the following persons include a review and approval by independent persons, comparability data, and contemporaneous substantiation of the deliberation and decision?
a
The organization’s CEO, Executive Director, or top management official ...........
15a
Yes
 
b
Other officers or key employees of the organization ................
15b
Yes
 
If "Yes" to line a or b, describe the process in Schedule O. (See instructions.)
16a
Did the organization invest in, contribute assets to, or participate in a joint venture or similar arrangement with a taxable entity during the year? ......................
16a
Yes
 
b
If “Yes,” has the organization adopted a written policy or procedure requiring the organization to evaluate its participation in joint venture arrangements under applicable federal tax law, and taken steps to safeguard the organization’s exempt status with respect to such arrangements? ............
16b
Yes
 
Section C. Disclosure
17
List the States with which a copy of this Form 990 is required to be filedMediumBullet
18
Section 6104 requires an organization to make its Form 1023 (or 1024 if applicable), 990, and 990-T (501(c)(3)s only) available for public inspection. Indicate how you make these available. Check all that apply.
19
Describe in Schedule O whether (and if so, how), the organization makes its governing documents, conflict of interest policy, and financial statements available to the public.
20
State the name, physical address, and telephone number of the person who possesses the books and records of the organization: MediumBullet
BRENDA CHILMAN
2480 W 26TH AVENUE STE 360B
Denver,CO80211
(303) 467-4430
Form 990 (2010)
Form 990 (2010)
Page 7
Part VII
Compensation of Officers, Directors,Trustees, Key Employees, Highest Compensated Employees, and Independent Contractors
Check if Schedule O contains a response to any question in this Part VII . . . . . . . . . .
Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees
1a Complete this table for all persons required to be listed. Report compensation for the calendar year ending with or within the organization’s tax year.
RoundBullet List all of the organization’s current officers, directors, trustees (whether individuals or organizations), regardless of amount
of compensation, and current key employees. Enter -0- in columns (D), (E), and (F) if no compensation was paid.

RoundBullet List all of the organization’s current key employees, if any. See instructions for definition of "key employee."
RoundBullet List the organization’s five current highest compensated employees (other than an officer, director, trustee or key employee)
who received reportable compensation (Box 5 of Form W-2 and/or Box 7 of Form 1099-MISC) of more than $100,000 from the
organization and any related organizations.

RoundBullet List all of the organization’s former officers, key employees, or highest compensated employees who received more than $100,000
of reportable compensation from the organization and any related organizations.

RoundBullet List all of the organization’s former directors or trustees that received, in the capacity as a former director or trustee of the
organization, more than $10,000 of reportable compensation from the organization and any related organizations.

List persons in the following order: individual trustees or directors; institutional trustees; officers; key employees; highest
compensated employees; and former such persons.
Check this box if neither the organization nor any related organizations compensated any current or former officer, director, or trustee.
(A)
Name and Title 		(B)
Average hours per week (describe hours for related organizations in Schedule O) 		(C)
Position (check all that apply) 		(D)
Reportable compensation from the organization (W- 2/1099-MISC) 		(E)
Reportable compensation from related organizations (W- 2/1099-MISC) 		(F)
Estimated amount of other compensation from the organization and related organizations
Individual Trustee or Director; Institutional Trustee; Officer; Key Employee; Highest compensated employee; Former;
(1) WILLIAM M MURRAY
CHAIRMAN
 2.0 X           0 1,706,457 169,086
(2) KOGER PROPST
DIRECTOR
 2.0 X           0 0 0
(3) FELIX W COOK SR
DIRECTOR
 2.0 X           0 0 0
(4) MICHAEL CHASE MD
DIRECTOR
 2.0 X           0 0 0
(5) KENNETH W EGGEMAN PHD
DIRECTOR
 2.0 X           0 0 0
(6) JOHN V MCDERMOTT
DIRECTOR
 2.0 X           0 0 0
(7) KATHRYN A PAUL
DIRECTOR
 2.0 X           0 0 0
(8) DAVID ROLL
DIRECTOR
 2.0 X           0 0 0
(9) BRUCE WARING MD
DIRECTOR
 2.0 X           0 0 0
(10) SISTER AMY WILLCOTT
DIRECTOR
 2.0 X           0 0 0
(11) JEFFREY D SELBERG
PRESIDENT & CEO, PARTIAL YEAR
 50.0     X       3,728,704 0 22,356
(12) ROBERT ALAN MINKIN
PRESIDENT & CEO-ESJH, PART YR
 50.0     X       0 1,215,312 13,481
(13) ROBERT H MALTE
PRESIDENT & CEO-ELMC, PART YR
 50.0     X       1,137,188 0 19,002
(14) JUDY A MITCHELL
SVP-STRAT&ORG EFFECT, PART YR
 50.0     X       825,403 0 25,237
(15) DAVID HAMM
PRESIDENT & CEO-EGSMC
 50.0     X       732,786 0 46,529
(16) DAVID C PECORARO
SVP & CIO
 25.0     X       332,998 79,343 31,024
(17) KATHRYN LOUISE BALLINGER
VP&GENERAL COUNSEL, SECRETARY
 50.0     X       404,500 0 37,801
Form 990 (2010)
Form 990 (2010)
Page 8
Part VII
Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees (continued)
(A)
Name and Title 		(B)
Average hours per week (describe hours for related organizations in Schedule O) 		(C)
Position (check all that apply) 		(D)
Reportable compensation from the organization (W- 2/1099-MISC) 		(E)
Reportable compensation from related organizations (W- 2/1099-MISC) 		(F)
Estimated amount of other compensation from the organization and related organizations
Individual Trustee or Director; Institutional Trustee; Officer; Key Employee; Highest compensated employee; Former;
(18) TODD A CONKLIN
SVP & CFO, TREASURER
 50.0     X       612,506 0 37,987
(19) LISA S KETTERING
SR VP-CMO (SYSTEM)
 50.0     X       357,303 0 38,806
(20) BAIN FARRIS
PRESIDENT & CEO-ESJH, PART YR
 50.0     X       0 525,916 73,804
(21) GRANT WICKLUND
PRESIDENT & CEO-ELMC, PART YR
 50.0     X       0 424,675 54,600
(22) ROBERT LADENBURGER
PRESIDENT & CEO, PARTIAL YEAR
 50.0     X       0 1,224,099 63,373
(23) ROBERT G BILLERBECK
VP-CHIEF MEDICAL OFFICER
 50.0       X     351,845 0 36,005
(24) ELISA WETHERBEE
CHIEF OPERATING OFFICER EPN
 50.0       X     269,085 0 46,576
(25) S ANN EVANS
VP-CHIEF NURSING OFFICER(ELMC)
 50.0       X     255,823 0 22,317
(26) BETH C FORSYTH
VP-CLIN & SUPPORT SVCS (EGSMC)
 50.0       X     238,728 0 35,738
(27) MARGARET CAIN PRICE
VP-OPERATIONS (ELMC)
 50.0       X     315,767 0 29,782
(28) DEBORAH L WELLE POWELL
VP-PAYER STRAT & LEG AFFAIRS
 50.0       X     264,029 0 27,885
(29) KAREN TAYLOR
VP-COMMUNICATIONS & MARKETING
 50.0       X     291,918 0 11,813
(30) KAREN M SCREMIN
VP-FINANCE (ELMC)
 50.0       X     228,714 0 27,221
(31) EVERETT A DAVIS
VP-FACILITIES DEVELOPMENT
 50.0       X     208,917 0 41,861
(32) BRENDA S CHILMAN
VP-CONTROLLER
 50.0       X     249,684 0 20,987
(33) SANDRA R CAVANAUGH
VP-COMMUNITY DEVELOPMENT
 50.0       X     191,522 0 22,660
(34) SUSAN E KERSCHEN
VP-CHIEF NURSING OFFCR (EGSMC)
 50.0       X     247,934 0 20,177
(35) ADILBERTO TORRES JR
VP-HUMAN RESOURCES SYSTEM
 50.0       X     183,287 0 29,130
(36) JOHN D HIGGINS
VP FINANCE (EGSMC)
 50.0       X     181,118 0 31,249
(37) CAROL J SALZMAN
VP-EXEC DIR FOUNDTN & COMM DEV
 50.0       X     173,972 0 33,746
(38) LAURA L FOLSOM
VP-DEV & EXEC DIR FOUNDATION
 50.0       X     175,311 0 20,095
(39) SCOTT A BARTUSEK DAY
VP-HUMAN RESOURCES (ELMC)
 50.0       X     164,327 0 22,202
(40) BARBARA HELEN DAVIS
VP-PERFORMANCE EXCELLENCE
 50.0       X     151,712 0 16,309
(41) BARRY K PLATNICK
PHYSICIAN
 50.0         X   385,125 0 39,824
(42) ROBERT E SWANEY III
PHYSICIAN
 50.0         X   389,705 0 37,981
(43) RODERICK G LAMOND
PHYSICIAN
 50.0         X   882,488 0 21,428
(44) WILLIAM L SABER
PHYSICIAN
 50.0         X   381,069 0 26,238
(45) ANDREW W MCBRIDE
PHYSICIAN
 50.0         X   347,128   45,457
(46) MARTIN CARROLL HELLDORFER
SVP-MISSION, FORMER
 0.0           X 132,630 0 9,126
1b Sub-Total................MediumBullet
c Total from continuation sheets to Part VII, Section A....MediumBullet
d Total (add lines 1b and 1c)............MediumBullet 14,793,226 5,175,802 1,308,893
2
Total number of individuals (including but not limited to those listed above) who received more than $100,000 in reportable compensation from the organizationMediumBullet422
Yes
No
3
Did the organization list any former officer, director or trustee, key employee, or highest compensated employee on line 1a? If “Yes,” complete Schedule J for such individual .............
3
Yes
 
4
For any individual listed on line 1a, is the sum of reportable compensation and other compensation from the organization and related organizations greater than $150,000? If “Yes,” complete Schedule J for such individual...........................
4
Yes
 
5
Did any person listed on line 1a receive or accrue compensation from any unrelated organization or individual for services rendered to the organization? If “Yes,” complete Schedule J for such person .....
5
 
No
Section B. Independent Contractors
1
Complete this table for your five highest compensated independent contractors that received more than $100,000 of compensation from the organization.
(A)
Name and business address 		(B)
Description of services 		(C)
Compensation
M A MORTENSON COMPANY
1621 18th Street Ste 400
DENVER,CO80202 		CONSTRUCTION 34,606,848
ROCKY MOUNTAIN CARDIOVASCULAR INSTI
1835 FRANKLIN ST SUITE 4000
DENVER,CO80218 		CARDIOVASCULAR 16,878,392
SAUNDERS CONTRUCTION INC
6950 S JORDAN RD
ENGLEWOOD,CO80112 		CONSTRUCTION 5,164,656
SXC HEALTH SOLUTIONS
38920 EAGLE WAY
CHICAGO,IL606871389 		PRESCRIPTION BENEFIT 5,104,640
MIDTOWN INPATIENT MEDICINE LLC
1721 E 19TH AVE UNIT 366
DENVER,CO80218 		HOSPITALIST 4,530,479
2
Total number of independent contractors (including but not limited to those listed above) who received more than $100,000 in compensation from the organization MediumBullet224
Form 990 (2010)
Form 990 (2010)
Page 9
Part VIII
Statement of Revenue
(A)
Total revenue 		(B)
Related or
exempt
function
revenue 		(C)
Unrelated
business
revenue 		(D)
Revenue
excluded from
tax under sections
512, 513, or 514
Contributions, gifts, grants and other similar amounts 1a Federated campaigns..1a  
b Membership dues....1b  
c Fundraising events....1c  
d Related organizations...1d 559,918
e Government grants (contributions)1e 110,805
f All other contributions, gifts, grants, and
similar amounts not included above1f 		 
g Noncash contributions included in lines 1a-1f:$  
h Total. Add lines 1a-1f.......MediumBullet 670,723
Program Service Revenue Business Code
2a NET PATIENT REVENUE 622,110 618,329,196 617,993,807 335,389  
b OTHER AFFILIATED RENT INCOME 531,120 1,301,828 1,301,828    
c PHARMACY SALES 446,110 142,321 142,321    
d EDUCATION & OTHER 611,600 159,390 159,390    
e ADMIN MISC INCOME 900,099 152,033 152,033    
f All other program service revenue . 3,095,583 3,095,583    
g Total. Add lines 2a–2f........MediumBullet 623,180,351
Other Revenue 3 Investment income (including dividends, interest
and other similar amounts).....MediumBullet 4,815,697     4,815,697
4 Income from investment of tax-exempt bond proceeds..MediumBullet 543,683     543,683
5 Royalties............MediumBullet 0      
(i) Real (ii) Personal
6a Gross Rents 751,619  
b Less: rental expenses 610,374  
c Rental income or (loss) 141,245  
d Net rental income or (loss).......MediumBullet 141,245     141,245
(i) Securities (ii) Other
7a Gross amount from sales of assets other than inventory 7,160,761 114,550
b Less: cost or other basis and sales expenses   29,438
c Gain or (loss) 7,160,761 85,112
d Net gain or (loss)..........MediumBullet 7,245,873     7,245,873
8a Gross income from fundraising events (not including
$  
of contributions reported on line 1c). See Part IV, line 18 ...
a  
b Less: direct expenses ...b  
c Net income or (loss) from fundraising events..MediumBullet 0    
9a Gross income from gaming activities.
See Part IV, line 19 ...
a  
b Less: direct expenses ...b  
c Net income or (loss) from gaming activities...MediumBullet 0      
10a Gross sales of inventory, less
returns and allowances .
a 2,269,046
b Less: cost of goods sold ..b 1,973,314
c Net income or (loss) from sales of inventory..MediumBullet 295,732     295,732
Miscellaneous Revenue Business Code
11a OTHER RENTAL REVENUE 900,099 175,491 175,491    
b EQUALIZATON 900,099 12,783,753 12,783,753    
c            
d All other revenue ....        
e Total. Add lines 11a–11d ......MediumBullet 12,959,244
12 Total revenue. See Instructions....MediumBullet 649,852,548 635,804,206 335,389 13,042,230
Form 990 (2010)
Form 990 (2010)
Page 10
Part IX
Statement of Functional Expenses
Section 501(c)(3) and 501(c)(4) organizations must complete all columns. All other organizations must complete column (A) but are not required to complete columns (B), (C), and (D).
Do not include amounts reported on lines 6b,
7b, 8b, 9b, and 10b of Part VIII. 		(A)
Total expenses 		(B)
Program service expenses 		(C)
Management and general expenses 		(D)
Fundraising expenses
1 Grants and other assistance to governments and organizations in the U.S. See Part IV, line 21 224,747 224,747
2 Grants and other assistance to individuals in the U.S. See Part IV, line 22 0  
3 Grants and other assistance to governments, organizations, and individuals outside the U.S. See Part IV, lines 15 and 16 40,000 40,000
4 Benefits paid to or for members 0  
5 Compensation of current officers, directors, trustees, and key employees .... 9,430,458 8,193,691 1,236,767  
6 Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) .... 0      
7 Other salaries and wages 231,570,971 201,201,361 30,369,610  
8 Pension plan contributions (include section 401(k) and section 403(b) employer contributions) .... 13,264,140 11,423,602 1,840,538  
9 Other employee benefits ....... 34,056,854 29,331,109 4,725,745  
10 Payroll taxes ........... 16,781,476 14,452,871 2,328,605  
11 Fees for services (non-employees):        
a Management ...... 1,132,802 1,132,785 17  
b Legal ......... 831,783 0 831,783  
c Accounting ........... 289,959 0 289,959  
d Lobbying ........... 0      
e Professional fundraising. See Part IV, line 17.. 0  
f Investment management fees ...... 467,803 0 467,803  
g Other .......... 33,902,267 27,132,769 6,769,498  
12 Advertising and promotion .... 1,835,858 0 1,835,858  
13 Office expenses ....... 8,869,737 5,569,328 3,300,409  
14 Information technology ...... 6,933,718 202,146 6,731,572  
15 Royalties .. 0      
16 Occupancy ........... 8,126,934 6,247,137 1,879,797  
17 Travel ............ 545,777 224,854 320,923  
18 Payments of travel or entertainment expenses for any federal, state, or local public officials ...... 0      
19 Conferences, conventions, and meetings .... 394,676 272,344 122,332  
20 Interest ........... 14,185,356 0 14,185,356  
21 Payments to affiliates ....... 0      
22 Depreciation, depletion, and amortization ..... 51,459,339 39,282,832 12,176,507  
23 Insurance .............. 3,711,674 657,454 3,054,220  
24 Other expenses. Itemize expenses not covered above. (Expenses grouped together and labeled miscellaneous may not exceed 5% of total expenses shown on line 25 below.)
a MEDICAL SUPPLIES 90,370,930 89,655,522 715,408  
b BAD DEBTS 34,994,430 34,994,430 0  
c EQUIP RENTAL & MAINTENANCE 11,624,300 11,313,048 311,252  
d MEDICAID PROVIDER FEE 30,333,059 30,333,059 0  
e LOSS ON BOND DEFEASANCE 17,361,317 0 17,361,317  
f All other expenses 6,925,385 4,291,432 2,633,953  
25 Total functional expenses. Add lines 1 through 24f 629,665,750 516,176,521 113,489,229 0
26 Joint costs. Check here MediumBullet if following
SOP 98-2 (ASC 958-720). Complete this line only if the organization reported in column (B) joint costs from a combined educational campaign and fundraising solicitation 		       
Form 990 (2010)
Form 990 (2010)
Page 11
Part X Balance Sheet
(A)
Beginning of year 		(B)
End of year
Assets 1 Cash—non-interest-bearing .......... -2,473,264 1 696,240
2 Savings and temporary cash investments ....... 55,927,723 2 19,903,673
3 Pledges and grants receivable, net .........   3  
4 Accounts receivable, net ......... 89,165,095 4 81,073,318
5 Receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of
Schedule L ..........   5  
6 Receivables from other disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B). Complete Part II of
Schedule L ..........   6  
7 Notes and loans receivable, net ............. 14,611,353 7 4,038,962
8 Inventories for sale or use .............. 9,130,765 8 9,333,216
9 Prepaid expenses and deferred charges ............ 5,489,779 9 4,983,886
10a Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D 10a 989,947,878
b Less: accumulated depreciation. ..... 10b 440,205,478 531,899,678 10c 549,742,400
11 Investments—publicly traded securities .......... 172,157,192 11 244,208,951
12 Investments—other securities. See Part IV, line 11 ...... 470,313 12 419,118
13 Investments—program-related. See Part IV, line 11 ..   13  
14 Intangible assets .........   14  
15 Other assets. See Part IV, line 11 ........... 5,239,201 15 3,336,577
16 Total assets. Add lines 1 through 15 (must equal line 34)... 881,617,835 16 917,736,341
Liabilities 17 Accounts payable and accrued expenses . 100,373,135 17 90,288,503
18 Grants payable ..........   18  
19 Deferred revenue .......... 864,891 19 1,203,411
20 Tax-exempt bond liabilities .......... 272,072,517 20 1,601,494
21 Escrow or custodial account liability. Complete Part IV of Schedule D..   21  
22 Payables to current and former officers, directors, trustees, key
employees, highest compensated employees, and disqualified
persons. Complete Part II of Schedule L..........   22  
23 Secured mortgages and notes payable to unrelated third parties ..   23  
24 Unsecured notes and loans payable to unrelated third parties .... 22,578,499 24 22,608,307
25 Other liabilities. Complete Part X of Schedule D..... 125,696,205 25 417,983,739
26 Total liabilities. Add lines 17 through 25..... 521,585,247 26 533,685,454
Net Assets or Fund Balance Organizations that follow SFAS 117, check here MediumBullet and complete lines 27 through 29, and lines 33 and 34.
27 Unrestricted net assets ..... 359,973,373 27 383,992,351
28 Temporarily restricted net assets ..... 59,215 28 58,536
29 Permanently restricted net assets .....   29  
Organizations that do not follow SFAS 117, check here MediumBullet and complete lines 30 through 34.
30 Capital stock or trust principal, or current funds .....   30  
31 Paid-in or capital surplus, or land, building or equipment fund .....   31  
32 Retained earnings, endowment, accumulated income, or other funds   32  
33 Total net assets or fund balances ..... 360,032,588 33 384,050,887
34 Total liabilities and net assets/fund balances ..... 881,617,835 34 917,736,341
Form 990 (2010)
Form 990 (2010)
Page 12
Part XI
Reconcilliation of Net Assets
Check if Schedule O contains a response to any question in this Part XI . . . . . . . . . .
1
Total revenue (must equal Part VIII, column (A), line 12) . . .
1
649,852,548
2
Total expenses (must equal Part IX, column (A), line 25) . . . . .
2
629,665,750
3
Revenue less expenses. Subtract line 2 from line 1 . . . .
3
20,186,798
4
Net assets or fund balances at beginning of year (must equal Part X, line 33, column (A)) . .
4
360,032,588
5
Other changes in net assets or fund balances (explain in Schedule O) . . . .
5
3,831,501
6
Net assets or fund balances at end of year. Combine lines 3, 4, and 5 (must equal Part X, line 33, column (B)) . . . . . .
6
384,050,887
Part XII
Financial Statements and Reporting
Check if Schedule O contains a response to any question in this Part XII . . . . . . . . . .
Yes
No
1
Accounting method used to prepare the Form 990:  
If the organization changed its method of accounting from a prior year or checked "Other," explain in
Schedule O.
2a
Were the organization’s financial statements compiled or reviewed by an independent accountant?..
2a
 
No
b
Were the organization’s financial statements audited by an independent accountant?........
2b
Yes
 
c
If “Yes,” to 2a or 2b, does the organization have a committee that assumes responsibility for oversight of the audit, review, or compilation of its financial statements and selection of an independent accountant?
If the organization changed either its oversight process or selection process during the tax year, explain in Schedule O............................
2c
Yes
 
d
If “Yes” to line 2a or 2b, check a box below to indicate whether the financial statements for the year were issued on a separate basis, consolidated basis, or both:
3a
As a result of a federal award, was the organization required to undergo an audit or audits as set forth in the Single Audit Act and OMB Circular A-133? ................
3a
 
No
b
If “Yes,” did the organization undergo the required audit or audits? If the organization did not undergo the required audit or audits, explain why in Schedule O and describe any steps taken to undergo such audits. ..
3b
 
 
Form 990 (2010)
Additional Data


Software ID:  
Software Version:  
Form 990, Special Condition Description:
Special Condition Description
SCHEDULE A
(Form 990 or 990EZ)

Department of the Treasury
Internal Revenue Service
Public Charity Status and Public Support

Complete if the organization is a section 501(c)(3) organization or a section
4947(a)(1) nonexempt charitable trust.
right arrow Attach to Form 990 or Form 990-EZ. right arrow See separate instructions.
OMB No. 1545-0047
2010
Open to Public
Inspection
Name of the organization
EXEMPLA INC FKA LUTHERAN HOSPITAL
 
Employer identification number

84-1103606
Part I
Reason for Public Charity Status (All organizations must complete this part.) See instructions
The organization is not a private foundation because it is: (For lines 1 through 11, check only one box.)
1
2
3
4
5
section 170(b)(1)(A)(iv). (Complete Part II.)
6
7
8
9
receipts from activities related to its exempt functions—subject to certain exceptions, and (2) no more than 331/3% of
its support from gross investment income and unrelated business taxable income (less section 511 tax) from businesses
acquired by the organization after June 30, 1975. See section 509(a)(2). (Complete Part III.)
10
11
e
f
g
(i) a person who directly or indirectly controls, either alone or together with persons described in (ii)
Yes
No
and (iii) below, the governing body of the the supported organization? ................
11g(i)
 
 
(ii) a family member of a person described in (i) above? ......................
11g(ii)
 
 
(iii) a 35% controlled entity of a person described in (i) or (ii) above? ................
11g(iii)
 
 
h
(i)
Name of supported organization 		(ii)
EIN 		(iii)
Type of organization (described on lines 1- 9 above or IRC section (see instructions)) 		(iv)
Is the organization in col. (i) listed in your governing document? 		(v)
Did you notify the organization in col. (i) of your support? 		(vi)
Is the organization in col. (i) organized in the U.S.? 		(vii)
Amount of support?
Yes No Yes No Yes No
Total                  

For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 11285F
Schedule A (Form 990 or 990-EZ) 2010
Schedule A (Form 990 or 990-EZ) 2010
Page 2
Part II
Support Schedule for Organizations Described in IRC 170(b)(1)(A)(iv) and 170(b)(1)(A)(vi)
(Complete only if you checked the box on line 5, 7, or 8 of Part I or if the organization failed to qualify under Part III. If the organization fails to qualify under the tests listed below, please complete Part III.)
Section A. Public Support
Calendar year(or fiscal year beginning in) (a) 2006 (b) 2007 (c) 2008 (d) 2009 (e) 2010 (f) Total
1 Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") ....            
2 Tax revenues levied for the organization's benefit and either paid to or expended on its behalf.......            
3 The value of services or facilities furnished by a governmental unit to the organization without charge..            
4 Total. Add lines 1 through 3..            
5 The portion of total contributions by each person (other than a governmental unit or publicly supported organization) included on line 1 that exceeds 2% of the amount shown on line 11, column (f)..            
6 Public Support. Subtract line 5 from line 4.            
Section B. Total Support
Calendar year(or fiscal year beginning in) (a) 2006 (b) 2007 (c) 2008 (d) 2009 (e) 2010 (f) Total
7 Amounts from line 4..            
8 Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..            
9 Net income from unrelated business activities, whether or not the business is regularly carried on..            
10 Other income. (Explain in Part IV.) Do not include gain or loss from the sale of capital assets..            
11 Total support (Add lines 7 through 10).            
12
12
 
13
Section C. Computation of Public Support Percentage
14
14
 
15
15
 
16a
b
17a
b
18
Schedule A (Form 990 or 990-EZ) 2010
Schedule A (Form 990 or 990-EZ) 2010
Page 3
Part III
Support Schedule for Organizations Described in IRC 509(a)(2)
(Complete only if you checked the box on line 9 of Part I or if the organization failed to qualify under Part II. If the organization fails to qualify under the tests listed below, please complete Part II.)
Section A. Public Support
Calendar year(or fiscal year beginning in) (a) 2006 (b) 2007 (c) 2008 (d) 2009 (e) 2010 (f) Total
1 Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") .            
2 Gross receipts from admissions, merchandise sold or services performed, or facilities furnished in any activity that is related to the organization's tax-exempt purpose......            
3 Gross receipts from activities that are not an unrelated trade or business under section 513..            
4 Tax revenues levied for the organization's benefit and either paid to or expended on its behalf...            
5 The value of services or facilities furnished by a governmental unit to the organization without charge..            
6 Total. Add lines 1 through 5.            
7a Amounts included on lines 1, 2, and 3 received from disqualified persons...            
b Amounts included on lines 2 and 3 received from other than disqualified persons that exceed the greater of $5,000 or 1% of the amount on line 13 for the year.            
c Add lines 7a and 7b..            
8 Public Support (Subtract line 7c from line 6.)            
Section B. Total Support
Calendar year (or fiscal year beginning in) (a) 2006 (b) 2007 (c) 2008 (d) 2009 (e) 2010 (f) Total
9 Amounts from line 6...            
10a Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..            
b Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.            
c Add lines 10a and 10b.            
11 Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on.            
12 Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)            
13 Total support (Add lines 9, 10c, 11 and 12.).            
14
Section C. Computation of Public Support Percentage
15
15
 
16
16
 
Section D. Computation of Investment Income Percentage
17
17
 
18
18
 
19a
b
20
Schedule A (Form 990 or 990-EZ) 2010
Schedule A (Form 990 or 990-EZ) 2010
Page 4
Part IV
Supplemental Information. Supplemental Information. Complete this part to provide the explanation required by Part II, line 10; Part II, line 17a or 17b; or Part III, line 12. Also complete this part for any additional information. (See instructions).
Facts And Circumstances Test
 
Explanation
 
 
 
 
Schedule A (Form 990 or 990-EZ) 2010

Additional Data


Software ID:  
Software Version:  
Schedule B
(Form 990, 990-EZ,
or 990-PF)
Department of the Treasury
Internal Revenue Service
Schedule of Contributors
Arrow Bullet Attach to Form 990, 990-EZ, or 990-PF.
OMB No. 1545-0047
2010
Name of organization
EXEMPLA INC FKA LUTHERAN HOSPITAL
 
Employer identification number

84-1103606
Organization type (check one):
Filers of:
Section:
Form 990 or 990-EZ





Form 990-PF




Check if your organization is covered by the General Rule or a Special Rule.  
Note. Only a section 501(c)(7), (8), or (10) organization can check boxes for both the General Rule and a Special Rule. See instructions.
General Rule—
Special Rules
......................... Arrow Bullet   $    
Caution. An Organization that is not covered by the General Rule and/or the Special Rules does not file Schedule B (Form 990,
990-EZ, or 990-PF), but it must answer “No” on Part IV, line 2 of its Form 990, or check the box in the heading of its
Form 990-EZ, or on line 2 of its Form 990-PF, to certify that it does not meet the filing requirements of Schedule B (Form 990,
990-EZ, or 990-PF).
For Paperwork Reduction Act Notice, see the Instructions
for Form 990, 990-EZ, or 990-PF.
Cat. No. 30613XSchedule B (Form 990, 990-EZ, or 990-PF) (2010)

Schedule B (Form 990, 990-EZ, or 990-PF) (2010)
Page 1 of 1 of Part I
Name of organization
EXEMPLA INC FKA LUTHERAN HOSPITAL
  		Employer identification number

84-1103606
Part I
Contributors (see Instructions)
     
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Aggregate contributions		 (d)
Type of contribution
RESTRICTED
RESTRICTED
 

     
RESTRICTED
RESTRICTED  
RESTRICTED, RESTRICTED   RESTRICTED

$RESTRICTED




(Complete Part II if there is
a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Aggregate contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  




(Complete Part II if there is
a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Aggregate contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  




(Complete Part II if there is
a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Aggregate contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  




(Complete Part II if there is
a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Aggregate contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  




(Complete Part II if there is
a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Aggregate contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  




(Complete Part II if there is
a noncash contribution.)
Schedule B (Form 990, 990-EZ, or 990-PF) (2010)

Schedule B (Form 990, 990-EZ, or 990-PF) (2010)
Page 1 of 1 of Part II
Name of organization
EXEMPLA INC FKA LUTHERAN HOSPITAL
  		Employer identification number

84-1103606
Part II
Noncash Property (see Instructions)
     
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
Schedule B (Form 990, 990-EZ, or 990-PF) (2010)

Schedule B (Form 990, 990-EZ, or 990-PF) (2010)
Page 1 of 1 of Part III
Name of organization
EXEMPLA INC FKA LUTHERAN HOSPITAL
  		Employer identification number

84-1103606
Part III
Exclusively religious, charitable, etc., individual contributions to section 501(c)(7), (8), or (10) organizations
aggregating more than $1,000 for the year. (Complete columns (a) through (e) and the following line entry.)
For organizations completing Part III, enter the total of exclusively religious, charitable, etc.,
contributions of $1,000 or less for the year. (Enter this information once. See instructions.) Arrow Bullet $  
(a) No.
from
Part I		 (b)
Purpose of gift		 (c)
Use of gift		 (d)
Description of how gift is held
 
(e)
Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
       
 
(a) No.
from
Part I		 (b)
Purpose of gift		 (c)
Use of gift		 (d)
Description of how gift is held
 
(e)
Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
       
 
(a) No.
from
Part I		 (b)
Purpose of gift		 (c)
Use of gift		 (d)
Description of how gift is held
 
(e)
Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
       
 
(a) No.
from
Part I		 (b)
Purpose of gift		 (c)
Use of gift		 (d)
Description of how gift is held
 
(e)
Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
       
 
Schedule B (Form 990, 990-EZ, or 990-PF) (2010)

Additional Data


Software ID:  
Software Version:  
SCHEDULE C
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service
Political Campaign and Lobbying Activities

For Organizations Exempt From Income Tax Under section 501(c) and section 527
SchCMd Bullet Complete if the organization is described below.
SchCMd Bullet Attach to Form 990 or Form 990-EZ. SchCMd Bullet See separate instructions.
OMB No. 1545-0047
2010
Open to Public
Inspection
If the organization answered “Yes,” to Form 990, Part IV, Line 3, or Form 990-EZ, Part V, line 46 (Political Campaign Activities), then
Round Bullet Section 501(c)(3) organizations: Complete Parts I-A and B. Do not complete Part I-C.
Round Bullet Section 501(c) (other than section 501(c)(3)) organizations: Complete Parts I-A and C below. Do not complete Part I-B.
Round Bullet Section 527 organizations: Complete Part I-A only.
If the organization answered “Yes,” to Form 990, Part IV, Line 4, or Form 990-EZ, Part VI, line 47 (Lobbying Activities), then
Round Bullet Section 501(c)(3) organizations that have filed Form 5768 (election under section 501(h)) Complete Part II-A. Do not complete Part II-B.
Round Bullet Section 501(c)(3) organizations that have NOT filed Form 5768 (election under section 501(h)): Complete Part II-B. Do not complete Part II-A.
If the organization answered “Yes,” to Form 990, Part IV, Line 5 (Proxy Tax) or Form 990-EZ, Part V, line 35a (Proxy Tax), then
Round Bullet Section 501(c)(4), (5), or (6) organizations: Complete Part III.
Name of the organization
EXEMPLA INC FKA LUTHERAN HOSPITAL
 
Employer identification number

84-1103606
Part I-A
Complete if the organization is exempt under section 501(c) or is a section 527 organization.

1
Provide a description of the organization's direct and indirect political campaign activities on behalf of or in opposition to candidates for public office in Part IV.
2
Political expenditures ....................................SchCMd Bullet
$  
3
Volunteer hours ........................................
 

Part I-B
Complete if the organization is exempt under section 501(c)(3).
1
Enter the amount of any excise tax incurred by the organization under section 4955 .........SchCMd Bullet
$  
2
Enter the amount of any excise tax incurred by organization managers under section 4955 ......SchCMd Bullet
$  
3
If the organization incurred a section 4955 tax, did it file Form 4720 for this year? ..............
4a
Was a correction made? .........................................
b
If "Yes," describe in Part IV.
Part I-C
Complete if the organization is exempt under section 501(c) except section 501(c)(3).
1
Enter the amount directly expended by the filing organization for section 527 exempt function activities SchCMd Bullet
$  
2
Enter the amount of the filing organization's funds contributed to other organizations for section 527 exempt funtion activities ....................................SchCMd Bullet

$  
3
Total exempt function expenditures. Add lines 1 and 2. Enter here and on Form 1120-POL, line 17b..SchCMd Bullet

$  
4
Did the filing organization file Form 1120-POL for this year? ..........................
5
Enter the names, addresses and employer identification number (EIN) of all section 527 political organizations to which the filing
organization made payments. For each organization listed, enter the amount paid from the filing organization’s funds. Also enter the amount of political contributions received that were promptly and directly delivered to a separate political organization, such as a separate segregated fund or a political action committee (PAC). If additional space is needed, provide information in Part IV.
(a) Name (b) Address (c) EIN (d) Amount paid from filing organization's funds. If none, enter -0-. (e) Amount of political contributions received and promptly and directly delivered to a separate political organization. If none, enter -0-.










For Privacy Act and Paperwork Reduction Act Notice, see the instructions for Form 990.
Cat. No. 50084S
Schedule C (Form 990 or 990-EZ) 2010

Schedule C (Form 990 or 990-EZ) 2010
Page 2
Part II-A
Complete if the organization is exempt under section 501(c)(3) and filed Form 5768 (election under section 501(h)).
A Check
B Check
Limits on Lobbying Expenditures
(The term "expenditures" means amounts paid or incurred.) 		(a) Filing
Organization's
Totals 		(b) Affiliated Group
Totals
1a Total lobbying expenditures to influence public opinion (grass roots lobbying) ......    
b Total lobbying expenditures to influence a legislative body (direct lobbying) .......    
c Total lobbying expenditures (add lines 1a and 1b) ...................    
d Other exempt purpose expenditures ........................    
e Total exempt purpose expenditures (add lines 1c and 1d) ...............    
f Lobbying nontaxable amount. Enter the amount from the following table in both
columns.		    
  If the amount on line 1e, column (a) or (b) is:The lobbying nontaxable amount is:    
  Not over $500,00020% of the amount on line 1e.    
  Over $500,000 but not over $1,000,000$100,000 plus 15% of the excess over $500,000.    
  Over $1,000,000 but not over $1,500,000$175,000 plus 10% of the excess over $1,000,000.    
  Over $1,500,000 but not over $17,000,000$225,000 plus 5% of the excess over $1,500,000.    
  Over $17,000,000$1,000,000.    
       
g Grassroots nontaxable amount (enter 25% of line 1f) .................    
h Subtract line 1g from line 1a. If zero or less, enter -0-. ................    
i Subtract line 1f from line 1c. If zero or less, enter -0-. ................    
j If there is an amount other than zero on either line 1h or line 1i, did the organization file Form 4720 reporting
section 4911 tax for this year? ......................................

4-Year Averaging Period Under Section 501(h)
(Some organizations that made a section 501(h) election do not have to complete all of the five
columns below. See the instructions for lines 2a through 2f on page 4.)
Lobbying Expenditures During 4-Year Averaging Period
  Calendar year (or fiscal year
beginning in) 		(a) 2007 (b) 2008 (c) 2009 (d) 2010 (e) Total
             
2a Lobbying non-taxable amount          
             
b Lobbying ceiling amount
(150% of line 2a, column(e)) 		         
             
c Total lobbying expenditures          
             
d Grassroots non-taxable amount          
             
e Grassroots ceiling amount
(150% of line 2d, column (e))		          
             
f Grassroots lobbying expenditures          
Schedule C (Form 990 or 990-EZ) 2010


Schedule C (Form 990 or 990-EZ) 2010
Page 3
Part II-B
Complete if the organization is exempt under section 501(c)(3) and has NOT filed Form 5768 (election under section 501(h)).
(a)
Yes
No
(b)
Amount
1
During the year, did the filing organization attempt to influence foreign, national, state or local legislation, including any attempt to influence public opinion on a legislative matter or referendum, through the use of:
a
Volunteers? .........................................
 
No
b
Paid staff or management (include compensation in expenses reported on lines 1c through 1i)? ....
 
No
c
Media advertisements? ....................................
 
No
 
d
Mailings to members, legislators, or the public? .........................
 
No
 
e
Publications, or published or broadcast statements? .......................
 
No
 
f
Grants to other organizations for lobbying purposes? .......................
Yes
 
50,000
g
Direct contact with legislators, their staffs, government officials, or a legislative body? ........
 
No
 
h
Rallies, demonstrations, seminars, conventions, speeches, lectures, or any similar means? ......
 
No
 
i
Other activities? If "Yes," describe in Part IV ..........................
Yes
 
53,533
j
Total. lines 1c through 1i ...................................
103,533
2a
Did the activities in line 1 cause the organization to be not described in section 501(c)(3)? .....
 
No
b
If "Yes," enter the amount of any tax incurred under section 4912 .................
 
c
If "Yes," enter the amount of any tax incurred by organization managers under section 4912 .....
 
d
If the filing organization incurred a section 4912 tax, did it file Form 4720 for this year? .......
 
 
Part III-A
Complete if the organization is exempt under section 501(c)(4), section 501(c)(5), or section 501(c)(6).
Yes
No
1
Were substantially all (90% or more) dues received nondeductible by members? ................
1
 
 
2
Did the organization make only in-house lobbying expenditures of $2,000 or less? ................
2
 
 
3
Did the organization agree to carryover lobbying and political expenditures from the prior year? ..........
3
 
 
Part III-B
Complete if the organization is exempt under section 501(c)(4), section 501(c)(5), or section 501(c)(6) if BOTH Part III-A, lines 1 and 2 are answered “No” OR if Part III-A, line 3 is answered “Yes”.
1
Dues, assessments and similar amounts from members .....................
1
 
2
Section 162(e) non-deductible lobbying and political expenditures (do not include amounts of political
expenses for which the section 527(f) tax was paid).
a
Current year .........................................
2a
 
b
Carryover from last year ....................................
2b
 
c
Total ...........................................
2c
 
3
Aggregate amount reported in section 6033(e)(1)(A) notices of nondeductible section 162(e) dues .
3
 
4
If notices were sent and the amount on line 2c exceeds the amount on line 3, what portion of the excess does the organization agree to carryover to the reasonable estimate of nondeductible lobbying and political expenditure next year? ................................
4
 
5
Taxable amount of lobbying and political expenditures (see instructions) ..............
5
 
Part IV
Supplemental Information
Complete this part to provide the descriptions required for Part l-A, line 1; Part l-B, line 4; Part l-C, line 5; and Part ll-B, line 1i.
Also, complete this part for any additional information.
Identifier Return Reference Explanation
LOBBYING EXPENDITURES SCHEDULE C, PART II-B, QUESTION 1I $53,533 OF OTHER LOBBYING EXPENDITURES INCLUDES PORTIONS OF VARIOUS MEMBERSHIP DUES THAT ARE DESIGNATED AS LOBBYING EXPENSE BY THOSE ORGANIZATIONS IN WHICH EXEMPLA OR EXEMPLA ENTITIES ARE MEMBERS.
Schedule C (Form 990 or 990EZ) 2010

Additional Data


Software ID:  
Software Version:  

SCHEDULE D
(Form 990)
Department of the Treasury
Internal Revenue Service
Supplemental Financial Statements
SchDMd Bullet Complete if the organization answered "Yes," to Form 990,
Part IV, line 6, 7, 8, 9, 10, 11, or 12.
SchDMd Bullet Attach to Form 990. SchDMd Bullet See separate instructions.
OMB No. 1545-0047
2010
Open to Public Inspection
Name of the organization
EXEMPLA INC FKA LUTHERAN HOSPITAL
 
Employer identification number

84-1103606
Part I
Organizations Maintaining Donor Advised Funds or Other Similar Funds or Accounts. Complete if the organization answered "Yes" to Form 990, Part IV, line 6.
(a) Donor advised funds (b) Funds and other accounts
1 Total number at end of year .......    
2 Aggregate contributions to (during year) ...    
3 Aggregate grants from (during year) ...    
4 Aggregate value at end of year .......    
5
Did the organization inform all donors and donor advisors in writing that the assets held in donor advised
funds are the organization's property, subject to the organization's exclusive legal control? ............
6
Did the organization inform all grantees, donors, and donor advisors in writing that grant funds may be
used only for charitable purposes and not for the benefit of the donor or donor advisor, or for any other purpose conferring impermissible private benefit. ...................................
Part II
Conservation Easements. Complete if the organization answered "Yes" to Form 990, Part IV, line 7.
1
Purpose(s) of conservation easements held by the organization (check all that apply).
2
Complete lines 2a–2d if the organization held a qualified conservation contribution in the form of a conservation easement on the last day of the tax year.
Held at the End of the Year
a Total number of conservation easements ....................... 2a  
b Total acreage restricted by conservation easements .................. 2b  
c Number of conservation easements on a certified historic structure included in (a) ..... 2c  
d Number of conservation easements included in (c) acquired after 8/17/06 ........ 2d  
3
Number of conservation easements modified, transferred, released, extinguished, or terminated by the organization during
the taxable year SchDMd Bullet  
4
Number of states where property subject to conservation easement is located SchDMd Bullet  
5
Does the organization have a written policy regarding the periodic monitoring, inspection, handling of violations, and
enforcement of the conservation easements it holds? .............................
6
Staff and volunteer hours devoted to monitoring, inspecting and enforcing conservation easements during the year SchDMd Bullet  
7
Amount of expenses incurred in monitoring, inspecting, and enforcing conservation easements during the year SchDMd Bullet $  
8
Does each conservation easement reported on line 2(d) above satisfy the requirements of section
170(h)(4)(B)(i) and 170(h)(4)(B)(ii)? ....................................
9
In Part XIV, describe how the organization reports conservation easements in its revenue and expense statement, and
balance sheet, and include, if applicable, the text of the footnote to the organization’s financial statements that describes
the organization’s accounting for conservation easements.
Part III
Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets.
Complete if the organization answered "Yes" to Form 990, Part IV, line 8.
1a
If the organization elected, as permitted under SFAS 116, not to report in its revenue statement and balance sheet works of
art, historical treasures, or other similar assets held for public exhibition, education or research in furtherance of public service,
provide, in Part XIV, the text of the footnote to its financial statements that describes these items.
b
If the organization elected, as permitted under SFAS 116, to report in its revenue statement and balance sheet works of art,
historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service,
provide the following amounts relating to these items:
(i)
Revenues included in Form 990, Part VIII, line 1 ........................SchDMd Bullet $  
(ii)
Assets included in Form 990, Part X ..............................SchDMd Bullet $  
2
If the organization received or held works of art, historical treasures, or other similar assets for financial gain, provide the
following amounts required to be reported under SFAS 116 relating to these items:
a
Revenues included in Form 990, Part VIII, line 1 ..........................SchDMd Bullet $  
b
Assets included in Form 990, Part X ...............................SchDMd Bullet $  
For Privacy Act and Paperwork Reduction Act Notice, see the Intructions for Form 990
Cat. No. 52283D
Schedule D (Form 990) 2010

Schedule D (Form 990) 2010
Page 2
Part III
Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets (continued)
3
Using the organization’s accession and other records, check any of the following that are a significant use of its collection
items (check all that apply):
a
d
b
e
 
c
4
Provide a description of the organization’s collections and explain how they further the organization’s exempt purpose in
Part XIV.
5
During the year, did the organization solicit or receive donations of art, historical treasures or other similar
assets to be sold to raise funds rather than to be maintained as part of the organization’s collection?........
Part IV
Escrow and Custodial Arrangements. Complete if the organization answered "Yes" to Form 990,
Part IV, line 9, or reported an amount on Form 990, Part X, line 21.
1a
Is the organization an agent, trustee, custodian or other intermediary for contributions or other assets not
included on Form 990, Part X? ....................................
b
If "Yes," explain the arrangement in Part XIV and complete the following table:
Amount
c Beginning balance ................................. 1c  
d Additions during the year .............................. 1d  
e Distributions during the year ............................. 1e  
f Ending balance ................................... 1f  
2a
Did the organization include an amount on Form 990, Part X, line 21? .....................
b
If “Yes,” explain the arrangement in Part XIV.
Part V
Endowment Funds. Complete if the organization answered "Yes" to Form 990, Part IV, line 10.
(a)Current Year (b)Prior Year (c)Two Years Back (d)Three Years Back (e)Four Years Back
1a Beginning of year balance ....      
b Contributions ........      
c Investment earnings or losses ...      
d Grants or scholarships .....      
e Other expenditures for facilities
and programs ........ 		     
f Administrative expenses ....      
g End of year balance ......      
2
Provide the estimated percentage of the year end balance held as:
a
Board designated or quasi-endowment: SchDMd Bullet  
b
Permanent endowment: SchDMd Bullet  
c
Term endowment: SchDMd Bullet  
3a
Are there endowment funds not in the possession of the organization that are held and administered for the
organization by:

Yes
No
(i) unrelated organizations ........................
3a(i)
 
 
(ii) related organizations ........................
3a(ii)
 
 
b
If "Yes" to 3a(ii), are the related organizations listed as required on Schedule R? .........
3b
 
 
4
Describe in Part XIV the intended uses of the organization's endowment funds.
Part VI
Investments—Land, Buildings, and Equipment. See Form 990, Part X, line 10.
Description of investment (a) Cost or other basis (investment) (b)Cost or other basis (other) (c) Accumulated depreciation (d) Book value
1a Land .................   25,464,714 25,464,714
b Buildings ................   467,645,247 46,687,521 420,957,726
c Leasehold improvements ............   6,658,413 4,484,501 2,173,912
d Equipment ................   444,895,446 384,780,087 60,115,359
e Other .................   45,284,058 4,253,369 41,030,689
Total. Add lines 1a-1e. (Column (d) should equal Form 990, Part X, column (B), line 10(c).)........SchDMdBullet 549,742,400
Schedule D (Form 990) 2010

Schedule D (Form 990) 2010
Page 3
Part VII
Investments—Other Securities. See Form 990, Part X, line 12.
(a) Description of security or category
(including name of security)		 (b)Book value (c) Method of valuation:
Cost or end-of-year market value
(1)Financial derivatives    
(2)Closely-held equity interests    
Other








Total. (Column (b) should equal Form 990, Part X, col.(B) line 12.)Small Bullet  
Part VIII
Investments—Program Related. See Form 990, Part X, line 13.
(a) Description of investment type (b) Book value (c) Method of valuation:
Cost or end-of-year market value








Total. (Column (b) should equal Form 990, Part X, col.(B) line 13.)Small Bullet  
Part IX
Other Assets. See Form 990, Part X, line 15.
(a) Description (b) Book value








Total. (Column (b) should equal Form 990, Part X, col.(B) line 15.)...........Small Bullet  
Part X
Other Liabilities. See Form 990, Part X, line 25.
1.(a) Description of Liability (b) Amount
Federal Income Taxes 0
DUE TO 3RD PARTY PAYORS 7,334,906
ACCRUED INTEREST PAYABLE 2,864,680
OTHER CURRENT LIABILITIES 51,451
MALPRACTICE LIABILITY 10,627,918
OTHER LIABILITIES 2,899,661
PENSION LIABILITIES 17,959,850
B NOTE PAYABLE TO ESJH 60,000,000
NOTES PAYABLE TO SCLHS 277,365,000
ACCRUED INTEREST PAYABLE TO SCLHS 6,413,419
ACCRUED INTEREST PAYABLE TO ESJH 23,305,316
CURRENT PAYABLES TO RELATED ORGANIZATIONS 9,161,538
Total. (Column (b) should equal Form 990, Part X, col.(B) line 25.)Small Bullet 417,983,739
2. Fin 48 (ASC 740) Footnote. In Part XIV, provide the text of the footnote to the organization's financial statements that reports the organization's liability for uncertain tax positions under FIN 48 (ASC740).
Schedule D (Form 990) 2010

Schedule D (Form 990) 2010
Page 4
Part XI Reconciliation of Change in Net Assets from Form 990 to Financial Statements
1 Total revenue (Form 990, Part VIII, column (A), line 12) .................... 1  
2 Total expenses (Form 990, Part IX, column (A), line 25) ..................... 2  
3 Excess or (deficit) for the year. Subtract line 2 from line 1 ............. 3  
4 Net unrealized gains (losses) on investments .......................... 4  
5 Donated services and use of facilities ............................. 5  
6 Investment expenses ................................... 6  
7 Prior period adjustments .................................. 7  
8 Other (Describe in Part XIV) ................................. 8  
9 Total adjustments (net). Add lines 4 - 8 ............................. 9  
10 Excess or (deficit) for the year per financial statements. Combine lines 3 and 9 ......... 10  
Part XII Reconciliation of Revenue per Audited Financial Statements With Revenue per Return
1 Total revenue, gains, and other support per audited financial statements ....... 1  
2 Amounts included on line 1 but not on Form 990, Part VIII, line 12:
a Net unrealized gains on investments .......... 2a  
b Donated services and use of facilities ......... 2b  
c Recoveries of prior year grants ........... 2c  
d Other (Describe in Part XIV): ............ 2d  
e Add lines 2a through 2d ..................... 2e  
3 Subtract line 2e from line 1..................... 3  
4 Amounts included on Form 990, Part VIII, line 12, but not on line 1:
a Investment expenses not included on Form 990, Part VIII, line 7b . 4a  
b Other (Describe in Part XIV): ........... 4b  
c Add lines 4a and 4b....................... 4c  
5 Total Revenue. Add lines 3 and 4c. (This should equal Form 990, Part I, line 12.) ...... 5  
Part XIII Reconciliation of Expenses per Audited Financial Statements With Expenses per Return
1 Total expenses and losses per audited financial statements ............. 1  
2 Amounts included on line 1 but not on Form 990, Part IX, line 25:
a Donated services and use of facilities .......... 2a  
b Prior year adjustments .............. 2b  
c Other losses ................ 2c  
d Other (Describe in Part XIV): ............ 2d  
e Add lines 2a through 2d...................... 2e  
3 Subtract line 2e from line 1..................... 3  
4 Amounts included on Form 990, Part IX, line 25, but not on line 1:
a Investment expenses not included on Form 990, Part VIII, line 7b .. 4a  
b Other (Describe in Part XIV): ............ 4b  
c Add lines 4a and 4b....................... 4c  
5 Total expenses. Add lines 3 and 4c. (This should equal Form 990, Part I, line 18.) ...... 5  
Part XIV
Supplemental Information
Complete this part to provide the descriptions required for Part II, lines 3, 5, and 9; Part III, lines 1a and 4; Part lV, lines 1b and 2b;
Part V, line 4; Part X; Part XI, line 8; Part XII, lines 2d and 4b; and Part XIII, lines 2d and 4b. Also complete this part to provide any additional information.
Identifier Return Reference Explanation
Schedule D Part X LIABILITY FOR UNCERTAIN TAX POSITONS EXEMPLA ACCOUNTS FOR UNCERTAINTY IN TAX POSITIONS IN ACCORDANCE WITH THE ACCOUNTING STANDARDS CODIFICATION (ASC) 740, INCOME TAXES, WHICH PRESCRIBES CRITERIA FOR THE FINANCIAL STATEMENT RECOGNITION AND MEASUREMENT OF A TAX POSITION TAKEN OR EXPECTED TO BE TAKEN IN A TAX RETURN. ASC 740 ALSO PROVIDES GUIDANCE ON DERECOGNITION, CLASSIFICATION, INTEREST AND PENALTIES, ACCOUNTING IN INTERIM PERIODS, DISCLOSURE, AND TRANSITION. MANAGEMENT HAS DETERMINED THAT THERE ARE NO MATERIAL UNCERTAIN TAX POSITIONS AS OF DECEMBER 31, 2010 AND 2009. TAX YEARS 2007 THROUGH 2009 REMAIN SUBJECT TO EXAMINATION BY FEDERAL AND STATE JURISDICTIONS.
Schedule D (Form 990) 2010

Additional Data


Software ID:  
Software Version:  




SCHEDULE F
(Form 990)

Department of the Treasury
Internal Revenue Service
Statement of Activities Outside the United States
Right pointing arrow large image Complete if the organization answered "Yes" to Form 990,
Part IV, line 14b, 15, or 16.
Right pointing arrow large image Attach to Form 990. Right pointing arrow large image See separate instructions.
OMB No. 1545-0047
2010
Open to Public Inspection
Name of the organization
EXEMPLA INC FKA LUTHERAN HOSPITAL
 
Employer identification number

84-1103606
Part I
General Information on Activities Outside the United States. Complete if the organization answered
“Yes” to Form 990, Part IV, line 14b.
1
For grantmakers. Does the organization maintain records to substantiate the amount of the grants or
assistance, the grantees' eligibility for the grants or assistance, and the selection criteria used to award
the grants or assistance? ...................................
2
For grantmakers. Describe in Part V the organization’s procedures for monitoring the use of grant funds outside the
United States.
3
Activites per Region. (Use Part V if additional space is needed.)
(a) Region (b) Number of offices in the region (c) Number of employees or agents in region or independent contractors (d) Activities conducted in region (by type) (e.g., fundraising, program services, investments, grants to recipients located in the region) (e) If activity listed in (d) is a program service, describe specific type of
service(s) in region		 (f) Total
expenditures for region/investments
in region
Sub-Saharan Africa     Program Services HOSPITAL 40,000
           
           
           
           
           
           
           
           
           
           
           
           
           
           
           
           
3a Sub-total .....     40,000
b Total from continuation sheets to Part I ...      
c Totals (add lines 3a and 3b)     40,000
For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990.Cat. No. 50082W Schedule F (Form 990) 2010
Schedule F (Form 990) 2010
Page 2
Part II
Grants and Other Assistance to Organizations or Entities Outside the United States. Complete if the organization answered "Yes" to Form 990,
Part IV, line 15, for any recipient who received more than $5,000. Check this box if no one recipient received more than $5,000 ........ MediumBullet
Use Part V if additional space is needed.
1 (a) Name of organization (b) IRS code section
and EIN (if applicable)		 (c) Region (d) Purpose of
grant 		(e) Amount of
cash grant 		(f) Manner of
cash
disbursement 		(g) Amount of
of non-cash
assistance 		(h) Description
of non-cash
assistance 		(i) Method of
valuation
(book, FMV,
appraisal, other)
             
Sub-Saharan Africa SUPPORT ARUSHA LUTHERAN MEDICAL CENTRE 40,000 WIRE TRANSFE      
             
             
             
             
             
             
             
             
             
             
             
             
             
             
2
Enter total number of recipient organizations listed above that are recognized as charities by the foreign country, recognized as tax-exempt by the IRS, or for which the grantee or counsel has provided a section 501(c)(3) equivalency letter .....MediumBullet
0
3
Enter total number of other organizations or entities ........................MediumBullet
1
Schedule F (Form 990) 2010
Schedule F (Form 990) 2010Page 3
Part III
Grants and Other Assistance to Individuals Outside the United States. Complete if the organization answered "Yes" to Form 990, Part IV, line 16.
Use Part V if additional space is needed.
(a) Type of grant or assistance (b) Region (c) Number of recipients (d) Amount of
cash grant 		(e) Manner of cash
disbursement 		(f) Amount of
non-cash
assistance 		(g) Description
of non-cash
assistance 		(h) Method of
valuation
(book, FMV,
appraisal, other)
               
               
               
               
               
               
               
               
               
               
               
               
               
               
               
               
               
               
Schedule F (Form 990) 2010
Schedule F (Form 990) 2010
Page 4
Part IV
Foreign Forms
1 Was the organization a U.S. transferor of property to a foreign corporation during the tax year? If "Yes," the organization may be required to file Form 926 (see instructions for Form 926).................
2 Did the organization have an interest in a foreign trust during the tax year? If " Yes," the organization may be required to file Form 3520 and/or Form 3520-A. (see instructions for Forms 3520 and 3520-A)..........
3 Did the organization have an ownership interest in a foreign corporation during the tax year? If "Yes," the organization may be required to file Form 5471, Information Return of U.S. Persons with respect to Certain Foreign Corporations. (see instructions for Form 5471)..............................
4 Was the organization a direct or indirect shareholder of a passive foreign investment company or a qualified electing fund during the tax year? If "Yes," the organization may be required to file Form 8621, Return by a Shareholder of a Passive Foreign Investment Company or Qualified Electing Fund. (see instructions for Form 8621)
5 Did the organization have an ownership interest in a foreign partnership during the tax year? If "Yes," the organization may be required to file Form 8865, Return of U.S. Persons with respect to Certain Foreign Partnerships. (see instructions for Form 8865)....................................
6 Did the organization have any operations in or related to any boycotting countries during the tax year? If "Yes," the organization may be required to file Form 5713, International Boycott Report (see instructions for Form 5713)................................................
Schedule F (Form 990) 2010
Schedule F (Form 990) 2010
Page 5
Part V
Supplemental Information
Complete this part to provide the information (see instructions) required in Part I, line 2, and any additional information.
Identifier ReturnReference Explanation
MONITORING OF FUNDS PART I, LINE 2 EXEMPLA PROVIDES ASSISTANCE TO ONLY ONE ORGANIZATION OUTSIDE THE U.S. EXEMPLA OBTAINED AN INITIAL NEEDS ASSESSMENT REPORT FROM THE ORGANIZATION, WHICH ALSO OUTLINED THE COMMITMENT OF EXEMPLA TO PROVIDE SUPPORT TO THE ORGANIZATION BASED ON AN INITIAL SITE VISIT. EXEMPLA MAINTAINS REGULAR CONTACT WITH THE ORGANIZATION, SENDS A TEAM OF CLINICIANS FOR SITE VISITS TO THE ORGANIZASTION EVERY YEAR AND RECEIVES AND REVIEWS THE ORGANIZATION'S ANNUAL REPORT.
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
Schedule F (Form 990) 2010
Additional Data


Software ID:  
Software Version:  



SCHEDULE H
(Form 990)
Department of the Treasury
Internal Revenue Service
Hospitals
MediumBullet Complete if the organization answered "Yes" to Form 990, Part IV, question 20.
MediumBullet Attach to Form 990. MediumBullet See separate instructions.
OMB No. 1545-0047
2010
Open to Public Inspection
Name of the organization
EXEMPLA INC FKA LUTHERAN HOSPITAL
 
Employer identification number

84-1103606
Part I
Charity Care and Certain Other Community Benefits at Cost
Yes
No
1a
Does the organization have a charity care policy? If "No," skip to question 6a...........
1a
Yes
 
b
If "Yes," is it a written policy? .......................
1b
Yes
 
2
If the organization has multiple hospitals, indicate which of the following best describes application of the charity care policy to the various hospitals.
3
Answer the following based on the charity care eligibility criteria that applies to the largest number of the organization's patients.
a
Does the organization use Federal Poverty Guidelines (FPG) to determine eligibility for providing free care to low
income individuals? If "Yes," indicate which of the following is the FPG family income limit for eligibility for free care:
3a
Yes
 
b
Does the organization use FPG to determine eligibility for providing discounted care to low income individuals? If
"Yes," indicate which of the following is the family income limit for eligibility for discounted care: .....
3b
Yes
 
c
If the organization does not use FPG to determine eligibility, describe in Part VI the income based criteria for determining eligibility for free or discounted care. Include in the description whether the organization uses an asset test or other threshold, regardless of income, to determine eligibility for free or discounted care.
4
Does the organization's policy provide free or discounted care to the "medically indigent"? ......
4
Yes
 
5a
Does the organization budget amounts for free or discounted care provided under its charity care policy? ...
5a
Yes
 
b
If "Yes," did the organization's charity care expenses exceed the budgeted amount?.........
5b
Yes
 
c
If "Yes" to line 5b, as a result of budget considerations, was the organization unable to provide free or discounted
care to a patient who was eligibile for free or discounted care?...............
5c
 
No
6a
Does the organization prepare an annual community benefit report?.............
6a
Yes
 
6b
If "Yes," does the organization make it available to the public? ..............
6b
Yes
 
Complete the following table using the worksheets provided in the Schedule H instructions. Do not submit these worksheets with the Schedule H.
7
Charity Care and Certain Other Community Benefits at Cost
Charity Care and
Means-Tested Government Programs		 (a) Number of activities or programs (optional) (b) Persons served (optional) (c) Total community benefit expense (d) Direct offsetting revenue (e) Net community benefit expense (f) Percent of total expense
a Charity care at cost (from
Worksheets 1 and 2) .. 		1   11,655,997   11,655,997 1.960 %
b Unreimbursed Medicaid (from
Worksheet 3, column a) . 		1   32,079,156 21,346,843 10,732,313 1.800 %
c Unreimbursed costs—other means-tested government programs (from Worksheet 3, column b) ....            
dTotal Charity Care and
Means-Tested Government Programs ..... 		2   43,735,153 21,346,843 22,388,310 3.760 %
Other Benefits
e Community health improvement
services and community
benefit operations (from
(Worksheet 4) .... 		19   615,901   615,901 0.100 %
f Health professions education
(from Worksheet 5) .. 		10   1,583,616   1,583,616 0.270 %
g Subsidized health services
(from Worksheet 6) .. 		5   77,472,655 50,583,830 26,888,825 4.520 %
h Research (from Worksheet 7) 1   43,646   43,646 0.010 %
i Cash and in-kind contributions
to community groups
(from Worksheet 8) .. 		27   790,976   790,976 0.130 %
jTotal Other Benefits ... 62   80,506,794 50,583,830 29,922,964 5.030 %
kTotal. Add lines 7d and 7j. .. 64   124,241,947 71,930,673 52,311,274 8.790 %
For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990. Cat. No. 50192T Schedule H (Form 990) 2010
Schedule H (Form 990) 2010
Page 2
Part II
Community Building Activities Complete this table if the organization conducted any community building activities.
(a) Number of activities or programs (optional) (b) Persons served (optional) (c) Total community building expense (d) Direct offsetting
revenue 		(e) Net community building expense (f) Percent of total expense
1 Physical improvements and housing            
2 Economic development 6   10,310   10,310 0 %
3 Community support 1   22,069   22,069 0.010 %
4 Environmental improvements            
5 Leadership development and training for community members            
6 Coalition building            
7 Community health improvement advocacy 1   4,100   4,100 0 %
8 Workforce development 3   295,782   295,782 0.050 %
9 Other 1   2,312   2,312 0 %
10 Total 12   334,573   334,573 0.060 %
Part III
Bad Debt, Medicare, & Collection Practices
Section A. Bad Debt Expense
Yes
No
1
Does the organization report bad debt expense in accordance with Heathcare Financial Management Association Statement No. 15? ..........................
1
Yes
 
2
Enter the amount of the organization's bad debt expense (at cost).....
2
7,812,567
3
Enter the estimated amount of the organization's bad debt expense (at cost) attributable to patients eligible under the organization's charity care policy ..
3
0
4
Provide in Part VI the text of the footnote to the organization's financial statements that describes bad debt expense. In addition, describe the costing methodology used in determining the amounts reported on lines 2 and 3, and rationale for including a portion of bad debt amounts as community benefit.
Section B. Medicare
5
Enter total revenue received from Medicare (including DSH and IME).....
5
68,256,072
6
Enter Medicare allowable costs of care relating to payments on line 5.....
6
85,601,430
7
Subtract line 6 from line 5. This is the surplus or (shortfall)........
7
-17,345,358
8
Describe in Part VI the extent to which any shortfall reported in line 7 should be treated as community benefit.
Also describe in Part VI the costing methodology or source used to determine the amount reported on line 6.
Check the box that describes the method used:
Section C. Collection Practices
9a
Does the organization have a written debt collection policy? ...............
9a
Yes
 
b
If "Yes," does the organization's collection policy contain provisions on the collection practices to be followed for patients who are known to qualify for charity care or financial assistance? Describe in Part VI......
9b
Yes
 
Part IV
Management Companies and Joint Ventures
(a) Name of entity (b) Description of primary
activity of entity 		(c) Organization's
profit % or stock
ownership % 		(d) Officers, directors,
trustees, or key
employees' profit %
or stock ownership% 		(e) Physicians'
profit % or stock
ownership %
1e PET Imaging X LP
  		Outpatient Imaging 42.857 %    
2RT Therapy Ctr of Th
  		Outpatient Radiation 33.000 %   33.500 %
3Lutheran ASC LLC
  		Outpatient Surgery 53.970 %   44.000 %
4
5
6
7
8
9
10
11
12
13
Schedule H (Form 990) 2010
Schedule H (Form 990) 2010
Page 3
Part VFacility Information
Section A. Hospital Facilities
(list in order of size, measured by total revenue per facility, from largest to smallest)
How many hospital facilities did the organization operate during the tax year?2
Name and address 		Licensed Hospital General-Medical-Surgical Children's Hospital Teaching Hospital Critical Hospital Research Facility ER-24Hours ER-Other Other (Describe)
1 EXEMPLA LUTHERAN MEDICAL CENTER
8300 W 38TH AVE
WHEAT RIDGE,CO80211 		X                
2 EXEMPLA GOOD SAMARITAN MEDICAL CENTER
200 EXEMPLA CIRCLE
LAFAYETTE,CO80026 		X                
Schedule H (Form 990) 2010
Schedule H (Form 990) 2010
Page 4
Part VFacility Information (continued)

Section B. Facility Policies and Practices.

(Complete a separate Section B for each of the hospital facilities listed in Part V, Section A)
Name of Hospital Facility:EXEMPLA LUTHERAN MEDICAL CENTER
Line Number of Hospital Facility (from Schedule H, Part V, Section A):1

Yes No
Community Health Needs Assessment (Lines 1 through 7 are optional for 2010)
1 During the tax year or any prior tax year, did the hospital facility conduct a community health needs assessment (“Needs Assessment”)? If “No,” skip to question 8. ..................... 1    
If “Yes,” indicate what the Needs Assessment describes (check all that apply):
a A definition of the community served by the hospital facility
b Demographics of the community
c Existing health care facilities and resources within the community that are available to respond to the health needs of the community
d How data was obtained
e The health needs of the community
f Primary and chronic disease needs and other health issues of uninsured persons, low-income persons, and minority groups
g The process for identifying and prioritizing community health needs and services to meet those needs
h The process for consulting with persons representing the community’s interests
i Information gaps that limit the hospital facility’s ability to assess all of the community’s health needs
j Other (describe in Part VI)
2 Indicate the tax year the hospital facility last conducted a Needs Assessment: 20  
3 In conducting its most recent Needs Assessment, did the hospital facility take into account input from persons who represent the community served by the hospital facility? If “Yes,” describe in Part VI how the hospital facility took into account input from persons who represent the community, and identify the persons the hospital facility consulted. 3    
4 Was the hospital facility’s Needs Assessment conducted with one or more other hospital facilities? If “Yes,” list the other hospital facilities in Part VI............................ 4    
5 Did the hospital facility make its Needs Assessment widely available to the public? ........... 5    
If “Yes,” indicate how the Needs Assessment was made widely available (check all that apply):
a Hospital facility’s website
b Available upon request from the hospital facility
c Other (describe in Part VI)
6 If the hospital facility addressed needs identified in its most recently conducted Needs Assessment, indicate how (check all that apply):
a Adoption of an implementation strategy to address the health needs of the hospital facility’s community
b Execution of the implementation strategy
c Development of a community benefit plan for the facility
d Participation in community-wide community benefit plan
e Inclusion of a community benefit section in operational plans
f Adoption of a budget for provision of services that address the needs identified in the CHNA
g Prioritization of health needs in the community
h Prioritization of services that the hospital facility will undertake to meet health needs in its community
i Other (describe in Part VI)
7 Did the hospital facility address all of the needs identified in its most recently conducted Needs Assessment? If “No,” explain in Part VI which needs it has not addressed together with the reasons why it has not addressed such needs. 7    
Financial Assistance Policy
Did the hospital facility have in place during the tax year a written financial assistance policy that:
8 Explains eligibility criteria for financial assistance, and whether such assistance includes free or discounted care? 8    
9 Used federal poverty guidelines (FPG) to determine eligibility for providing free care to low incomeindividuals?.. 9    
If “Yes,” indicate the FPG family income limit for eligibility for free care:   %
Schedule H (Form 990) 2010
Schedule H (Form 990) 2010
Page 5
Part VFacility Information (continued)

Yes No
10 Used FPG to determine eligibility for providing discounted care to low income individuals?......... 10    
If “Yes,” indicate the FPG family income limit for eligibility for discounted care:   %
11 Explained the basis for calculating amounts charged to patients?................. 11    
If “Yes,” indicate the factors used in determining such amounts (check all that apply):
a Income level
b Asset level
c Medical indigency
d Insurance status
e Uninsured discount
f Medicaid/Medicare
g State regulation
h Other (describe in Part VI)
12 Explained the method for applying for financial assistance?................... 12    
13 Included measures to publicize the policy within the community served by the hospital facility?....... 13    
If “Yes,” indicate how the hospital facility publicized the policy (check all that apply):
a The policy was posted at all times on the hospital facility’s web site
b The policy was attached to all billing invoices
c The policy was posted in the hospital facility’s emergency rooms or waiting rooms
d The policy was posted in the hospital facility’s admissions offices
e The policy was provided, in writing, to patients upon admission to the hospital facility
f The policy was available upon request
g Other (describe in Part VI)
Billing and Collections
14 Did the hospital facility have in place during the tax year a separate billing and collections policy, or a written financial assistance policy that explained actions the hospital facility may take upon non-payment?........ 14    
15 Check all of the following collection actions against a patient that were permitted under the hospital facility's policies at any time during the tax year:
a Reporting to credit agency
b Lawsuits
c Liens on residences
d Body attachments or arrests
e Other (describe in Part VI)
16 Did the hospital facility engage in or authorize a third party to engage in any of the following collection actions during the tax year?................................... 16    
If “Yes,” check all collection actions in which the hospital facility or a third party engaged (check all that apply):
a Reporting to credit agency
b Lawsuits
c Liens on residences
d Body attachments
e Other (describe in Part VI)
17 Indicate which actions the hospital facility took before initiating any of the collection actions checked in question 16 (check all that apply):
a Notified patients of the financial assistance policy upon admission
b Notified patients of the financial assistance policy prior to discharge
c Notified patients of the financial assistance policy in communications with the patients regarding the patients’ bills
d Documented its determination of whether a patient who applied for financial assistance under the financial assistance policy qualified for financial assistance
e Other (describe in Part VI)
Schedule H (Form 990) 2010
Schedule H (Form 990) 2010
Page 6
Part VFacility Information (continued)

Policy Relating to Emergency Medical Care
Yes No
18 Did the hospital facility have in place during the tax year a written policy relating to emergency medical care that requires the hospital facility to provide, without discrimination, care for emergency medical conditions to individuals regardless of their eligibility under the hospital facility’s financial assistance policy?.......... 18    
If “No,” indicate the reasons why (check all that apply):
a The hospital facility did not provide care for any emergency medical conditions
b The hospital facility did not have a policy relating to emergency medical care
c The hospital facility limited who was eligible to receive care for emergency medical conditions (describe in Part VI)
d Other (describe in Part VI)
Charges for Medical Care
19 Indicate how the hospital facility determined the amounts generally billed to individuals who had insurance covering emergency or other medically necessary care (check all that apply):
a The hospital facility used the lowest negotiated commercial insurance rate for those services at the hospital facility
b The hospital facility used the average of the three lowest negotiated commercial insurance rates for those services at the hospital facility
c The hospital facility used the Medicare rate for those services
d Other (describe in Part VI)
20 Did the hospital facility charge any of its patients who were eligible for assistance under the hospital facility’s financial assistance policy, and to whom the hospital facility provided emergency or other medically necessary services, more than the amounts generally billed to individuals who had insurance covering such care?......... 20    
If “Yes,” explain in Part VI.
21 Did the hospital facility charge any of its patients an amount equal to the gross charge for services provided to that patient?................................... 21    
If “Yes,” explain in Part VI.
Schedule H (Form 990) 2010
Schedule H (Form 990) 2010
Page 4
Part VFacility Information (continued)

Section B. Facility Policies and Practices.

(Complete a separate Section B for each of the hospital facilities listed in Part V, Section A)
Name of Hospital Facility:EXEMPLA GOOD SAMARITAN MEDICAL CENTER
Line Number of Hospital Facility (from Schedule H, Part V, Section A):2

Yes No
Community Health Needs Assessment (Lines 1 through 7 are optional for 2010)
1 During the tax year or any prior tax year, did the hospital facility conduct a community health needs assessment (“Needs Assessment”)? If “No,” skip to question 8. ..................... 1    
If “Yes,” indicate what the Needs Assessment describes (check all that apply):
a A definition of the community served by the hospital facility
b Demographics of the community
c Existing health care facilities and resources within the community that are available to respond to the health needs of the community
d How data was obtained
e The health needs of the community
f Primary and chronic disease needs and other health issues of uninsured persons, low-income persons, and minority groups
g The process for identifying and prioritizing community health needs and services to meet those needs
h The process for consulting with persons representing the community’s interests
i Information gaps that limit the hospital facility’s ability to assess all of the community’s health needs
j Other (describe in Part VI)
2 Indicate the tax year the hospital facility last conducted a Needs Assessment: 20  
3 In conducting its most recent Needs Assessment, did the hospital facility take into account input from persons who represent the community served by the hospital facility? If “Yes,” describe in Part VI how the hospital facility took into account input from persons who represent the community, and identify the persons the hospital facility consulted. 3    
4 Was the hospital facility’s Needs Assessment conducted with one or more other hospital facilities? If “Yes,” list the other hospital facilities in Part VI............................ 4    
5 Did the hospital facility make its Needs Assessment widely available to the public? ........... 5    
If “Yes,” indicate how the Needs Assessment was made widely available (check all that apply):
a Hospital facility’s website
b Available upon request from the hospital facility
c Other (describe in Part VI)
6 If the hospital facility addressed needs identified in its most recently conducted Needs Assessment, indicate how (check all that apply):
a Adoption of an implementation strategy to address the health needs of the hospital facility’s community
b Execution of the implementation strategy
c Development of a community benefit plan for the facility
d Participation in community-wide community benefit plan
e Inclusion of a community benefit section in operational plans
f Adoption of a budget for provision of services that address the needs identified in the CHNA
g Prioritization of health needs in the community
h Prioritization of services that the hospital facility will undertake to meet health needs in its community
i Other (describe in Part VI)
7 Did the hospital facility address all of the needs identified in its most recently conducted Needs Assessment? If “No,” explain in Part VI which needs it has not addressed together with the reasons why it has not addressed such needs. 7    
Financial Assistance Policy
Did the hospital facility have in place during the tax year a written financial assistance policy that:
8 Explains eligibility criteria for financial assistance, and whether such assistance includes free or discounted care? 8    
9 Used federal poverty guidelines (FPG) to determine eligibility for providing free care to low incomeindividuals?.. 9    
If “Yes,” indicate the FPG family income limit for eligibility for free care:   %
Schedule H (Form 990) 2010
Schedule H (Form 990) 2010
Page 5
Part VFacility Information (continued)

Yes No
10 Used FPG to determine eligibility for providing discounted care to low income individuals?......... 10    
If “Yes,” indicate the FPG family income limit for eligibility for discounted care:   %
11 Explained the basis for calculating amounts charged to patients?................. 11    
If “Yes,” indicate the factors used in determining such amounts (check all that apply):
a Income level
b Asset level
c Medical indigency
d Insurance status
e Uninsured discount
f Medicaid/Medicare
g State regulation
h Other (describe in Part VI)
12 Explained the method for applying for financial assistance?................... 12    
13 Included measures to publicize the policy within the community served by the hospital facility?....... 13    
If “Yes,” indicate how the hospital facility publicized the policy (check all that apply):
a The policy was posted at all times on the hospital facility’s web site
b The policy was attached to all billing invoices
c The policy was posted in the hospital facility’s emergency rooms or waiting rooms
d The policy was posted in the hospital facility’s admissions offices
e The policy was provided, in writing, to patients upon admission to the hospital facility
f The policy was available upon request
g Other (describe in Part VI)
Billing and Collections
14 Did the hospital facility have in place during the tax year a separate billing and collections policy, or a written financial assistance policy that explained actions the hospital facility may take upon non-payment?........ 14    
15 Check all of the following collection actions against a patient that were permitted under the hospital facility's policies at any time during the tax year:
a Reporting to credit agency
b Lawsuits
c Liens on residences
d Body attachments or arrests
e Other (describe in Part VI)
16 Did the hospital facility engage in or authorize a third party to engage in any of the following collection actions during the tax year?................................... 16    
If “Yes,” check all collection actions in which the hospital facility or a third party engaged (check all that apply):
a Reporting to credit agency
b Lawsuits
c Liens on residences
d Body attachments
e Other (describe in Part VI)
17 Indicate which actions the hospital facility took before initiating any of the collection actions checked in question 16 (check all that apply):
a Notified patients of the financial assistance policy upon admission
b Notified patients of the financial assistance policy prior to discharge
c Notified patients of the financial assistance policy in communications with the patients regarding the patients’ bills
d Documented its determination of whether a patient who applied for financial assistance under the financial assistance policy qualified for financial assistance
e Other (describe in Part VI)
Schedule H (Form 990) 2010
Schedule H (Form 990) 2010
Page 6
Part VFacility Information (continued)

Policy Relating to Emergency Medical Care
Yes No
18 Did the hospital facility have in place during the tax year a written policy relating to emergency medical care that requires the hospital facility to provide, without discrimination, care for emergency medical conditions to individuals regardless of their eligibility under the hospital facility’s financial assistance policy?.......... 18    
If “No,” indicate the reasons why (check all that apply):
a The hospital facility did not provide care for any emergency medical conditions
b The hospital facility did not have a policy relating to emergency medical care
c The hospital facility limited who was eligible to receive care for emergency medical conditions (describe in Part VI)
d Other (describe in Part VI)
Charges for Medical Care
19 Indicate how the hospital facility determined the amounts generally billed to individuals who had insurance covering emergency or other medically necessary care (check all that apply):
a The hospital facility used the lowest negotiated commercial insurance rate for those services at the hospital facility
b The hospital facility used the average of the three lowest negotiated commercial insurance rates for those services at the hospital facility
c The hospital facility used the Medicare rate for those services
d Other (describe in Part VI)
20 Did the hospital facility charge any of its patients who were eligible for assistance under the hospital facility’s financial assistance policy, and to whom the hospital facility provided emergency or other medically necessary services, more than the amounts generally billed to individuals who had insurance covering such care?......... 20    
If “Yes,” explain in Part VI.
21 Did the hospital facility charge any of its patients an amount equal to the gross charge for services provided to that patient?................................... 21    
If “Yes,” explain in Part VI.
Schedule H (Form 990) 2010
Schedule H (Form 990) 2010
Page 7
Part VFacility Information (continued)

Section C. Other Facilities That Are Not Licensed, Registered, or Similarly Recognized as a Hospital Facility
(list in order of size, measured by total revenue per facility, from largest to smallest)
How many non-hospital facilities did the organization operate during the tax year?41
Name and address Type of Facility (Describe)
1 EXEMPLA COLORADO LUTHERAN HOME
7991 W 71ST AVE
ARVADA,CO80004 		NURSING HOME
2 EXEMPLA COLORADO LUTHERAN HOME
7991 W 71ST AVE
ARVADA,CO80004 		NURSING HOME
3 EXEMPLA COLORADO LUTHERAN HOME
7991 W 71ST AVE
ARVADA,CO80004 		NURSING HOME
4 EXEMPLA COLORADO LUTHERAN HOME
7991 W 71ST AVE
ARVADA,CO80004 		NURSING HOME
5 EXEMPLA COLORADO LUTHERAN HOME
7991 W 71ST AVE
ARVADA,CO80004 		NURSING HOME
6 EXEMPLA COLORADO LUTHERAN HOME
7991 W 71ST AVE
ARVADA,CO80004 		NURSING HOME
7 EXEMPLA COLORADO LUTHERAN HOME
7991 W 71ST AVE
ARVADA,CO80004 		NURSING HOME
8 EXEMPLA COLORADO LUTHERAN HOME
7991 W 71ST AVE
ARVADA,CO80004 		NURSING HOME
9 EXEMPLA COLORADO LUTHERAN HOME
7991 W 71ST AVE
ARVADA,CO80004 		NURSING HOME
10 EXEMPLA COLORADO LUTHERAN HOME
7991 W 71ST AVE
ARVADA,CO80004 		NURSING HOME
11 EXEMPLA COLORADO LUTHERAN HOME
7991 W 71ST AVE
ARVADA,CO80004 		NURSING HOME
12 EXEMPLA COLORADO LUTHERAN HOME
7991 W 71ST AVE
ARVADA,CO80004 		NURSING HOME
13 EXEMPLA COLORADO LUTHERAN HOME
7991 W 71ST AVE
ARVADA,CO80004 		NURSING HOME
14 EXEMPLA COLORADO LUTHERAN HOME
7991 W 71ST AVE
ARVADA,CO80004 		NURSING HOME
15 EXEMPLA COLORADO LUTHERAN HOME
7991 W 71ST AVE
ARVADA,CO80004 		NURSING HOME
16 EXEMPLA COLORADO LUTHERAN HOME
7991 W 71ST AVE
ARVADA,CO80004 		NURSING HOME
17 EXEMPLA COLORADO LUTHERAN HOME
7991 W 71ST AVE
ARVADA,CO80004 		NURSING HOME
18 EXEMPLA COLORADO LUTHERAN HOME
7991 W 71ST AVE
ARVADA,CO80004 		NURSING HOME
19 EXEMPLA COLORADO LUTHERAN HOME
7991 W 71ST AVE
ARVADA,CO80004 		NURSING HOME
20 EXEMPLA COLORADO LUTHERAN HOME
7991 W 71ST AVE
ARVADA,CO80004 		NURSING HOME
21 EXEMPLA COLORADO LUTHERAN HOME
7991 W 71ST AVE
ARVADA,CO80004 		NURSING HOME
22 EXEMPLA COLORADO LUTHERAN HOME
7991 W 71ST AVE
ARVADA,CO80004 		NURSING HOME
23 EXEMPLA COLORADO LUTHERAN HOME
7991 W 71ST AVE
ARVADA,CO80004 		NURSING HOME
24 EXEMPLA COLORADO LUTHERAN HOME
7991 W 71ST AVE
ARVADA,CO80004 		NURSING HOME
25 EXEMPLA COLORADO LUTHERAN HOME
7991 W 71ST AVE
ARVADA,CO80004 		NURSING HOME
26 EXEMPLA COLORADO LUTHERAN HOME
7991 W 71ST AVE
ARVADA,CO80004 		NURSING HOME
27 EXEMPLA COLORADO LUTHERAN HOME
7991 W 71ST AVE
ARVADA,CO80004 		NURSING HOME
28 EXEMPLA COLORADO LUTHERAN HOME
7991 W 71ST AVE
ARVADA,CO80004 		NURSING HOME
29 EXEMPLA COLORADO LUTHERAN HOME
7991 W 71ST AVE
ARVADA,CO80004 		NURSING HOME
30 EXEMPLA COLORADO LUTHERAN HOME
7991 W 71ST AVE
ARVADA,CO80004 		NURSING HOME
31 EXEMPLA COLORADO LUTHERAN HOME
7991 W 71ST AVE
ARVADA,CO80004 		NURSING HOME
32 EXEMPLA COLORADO LUTHERAN HOME
7991 W 71ST AVE
ARVADA,CO80004 		NURSING HOME
33 EXEMPLA COLORADO LUTHERAN HOME
7991 W 71ST AVE
ARVADA,CO80004 		NURSING HOME
34 EXEMPLA COLORADO LUTHERAN HOME
7991 W 71ST AVE
ARVADA,CO80004 		NURSING HOME
35 EXEMPLA COLORADO LUTHERAN HOME
7991 W 71ST AVE
ARVADA,CO80004 		NURSING HOME
36 EXEMPLA COLORADO LUTHERAN HOME
7991 W 71ST AVE
ARVADA,CO80004 		NURSING HOME
37 EXEMPLA COLORADO LUTHERAN HOME
7991 W 71ST AVE
ARVADA,CO80004 		NURSING HOME
38 EXEMPLA COLORADO LUTHERAN HOME
7991 W 71ST AVE
ARVADA,CO80004 		NURSING HOME
39 EXEMPLA COLORADO LUTHERAN HOME
7991 W 71ST AVE
ARVADA,CO80004 		NURSING HOME
40 EXEMPLA COLORADO LUTHERAN HOME
7991 W 71ST AVE
ARVADA,CO80004 		NURSING HOME
41 EXEMPLA COLORADO LUTHERAN HOME
7991 W 71ST AVE
ARVADA,CO80004 		NURSING HOME
Schedule H (Form 990) 2010
Schedule H (Form 990) 2010
Page 8
Part VI
Supplemental Information
Complete this part to provide the following information.
1 Required descriptions. Provide the description required for Part I, lines 3c, 6a, and 7; Part II; Part III, lines 4, 8, and 9b; and Part V, Section B, lines 1j, 2, 4c, 6i, 7, 11i, 13i, 17l, 18l, 19e, 21d, 25, and 26.
2 Community health needs assessment. Describe how the organization assesses the health care needs of the communities it serves, in addition to any community health needs assessments reported in Part V, Section B.
3 Patient education of eligibility for assistance. Describe how the organization informs and educates patients and persons who may be billed for patient care about their eligibility for assistance under federal, state, or local government programs or under the organization’s financial assistance policy.
4 Community information. Describe the community the organization serves, taking into account the geographic area and demographic constituents it serves.
5 Promotion of community health. Provide any other information important to describing how the organization’s hospital facilities or other health care facilities further its exempt purpose by promoting the health of the community (e.g., open medical staff, community board, use of surplus funds, etc.).
6 Affiliated health care system. If the organization is part of an affiliated health care system, describe the respective roles of the organization and its affiliates in promoting the health of the communities served.
7 State filing of community benefit report. If applicable, identify all states with which the organization, or a related organization, files a community benefit report.
Identifier ReturnReference Explanation
COMMUNITY BENEFIT REPORT PART I, LINE 6A COMMUNITY BENEFITS ARE INCLUDED IN A REPORT PREPARED BY EXEMPLA HEALTHCARE.
COSTS ATTRIBUTABLE TO PHYSICIAN CLINICS PART I, LINE 7G THE ORGANIZATION INCLUDED AS SUBSIDIZED HEALTH SERVICES $7,771,518 IN LOSSES ATTRIBUTABLE TO PHYSICIAN CLINICS.
BAD DEBT EXPENSE PART I, LINE 7, COLUMN(F) BAD DEBT EXPENSE INCLUDED ON PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE OF TOTAL EXPENSES IN SCHEDULE H PART I, LINE 7, COLUMN (H) IS $31,273,076.
COSTING METHODOLOGY PART I, LINE 7 THE COST ACCOUNTING SYSTEM WAS USED AS THE BASIS TO CALCULATE THE AMOUNTS REPORTED AS CHARITY CARE AND MEANS-TESTED GOVERNMENT PROGRAMS. THE COST ACCOUNTING SYSTEM ADDRESSES ALL PATIENT SEGMENTS. THE COST OF SUBSIDIZED SERVICES WAS CALCULATED AS THE NET LOSS OF THE RELEVANT DEPARTMENT USING THE DEPARTMENTAL EXPENSES AND ALLOCATED OVERHEAD EXPENSES, AND THE DEDUCTION RATIO PER THE COST ACCOUNTING SYSTEM. FOR SUBSIDIZED SERVICES, THE COST OF CHARITY, MEDICAID, AND SELF PAY PATIENTS WERE REMOVED IN THE CALCULATION.
COMMUNITY BUILDING ACTIVITIES PART II THE COMMUNITY BUILDING ACTIVITIES FOR EXEMPLA GOOD SAMARITAN MEDICAL CENTER (EGSMC) WERE FOCUSED ON "WORKFORCE DEVELOPMENT" AND "COMMUNITY SUPPORT." RECRUITMENT OF PHYSICIANS TO MEDICAL SHORTAGE AREAS WITHIN OUR PRIMARY SERVICE AREA (PSA) CONTRIBUTED TO THE IMPROVEMENT OF HEALTH IN OUR COMMUNITY. WE USE A STANDARD PROCESS FOR DETERMINING THE COMMUNITY NEED OF EACH PHYSICIAN SPECIALTY. SEVERAL CURRENT DATA ELEMENTS AND CONDITIONS ARE CONSIDERED. THE LARGEST PORTION OF OUR COMMUNITY BUILDING FUNDS WAS DESIGNATED FOR THIS PURPOSE SINCE WE DETERMINED A SHORTAGE OF SEVERAL SPECIALTIES WITHIN OUR PSA. "DISASTER READINESS AND PUBLIC HEALTH EMERGENCY TRAININGS" WERE ADDITIONAL FOCUS AREAS WITHIN COMMUNITY BUILDING ACTIVITIES. EXEMPLA GOOD SAMARITAN MEDICAL CENTER (EGSMC) IS TAKING A LEADERSHIP ROLE IN BOULDER COUNTY FOR READINESS TRAINING BEYOND THE REQUIREMENTS OF ACCREDITING BODIES OR GOVERNMENT ENTITIES. FOUR (4) HOSPITALS WITHIN BOULDER COUNTY PARTICIPATE ON A REGULAR BASIS AND BOULDER COUNTY HAS BEEN RECOGNIZED AS ONE OF THE LEADERS IN THE STATE OF COLORADO. THE STAFF FROM EGSMC CONTRIBUTES SIGNIFICANT TIME AND RESOURCES EACH YEAR TO LEAD THE DISASTER READINESS AND PUBLIC HEALTH EMERGENCY ACTIVITIES FOR THE COUNTY AND THE REGION. IN ADDITION TO "WORKFORCE DEVELOPMENT" AND "DISASTER READINESS," EGSMC AND EXEMPLA LUTHERAN MEDICAL CENTER (ELMC) ACTIVELY PARTICIPATE IN "ECONOMIC DEVELOPMENT" IN THE FORM OF DONATIONS TO LOCAL CHAMBERS OF COMMERCE (E.G. LAFAYETTE CHAMBER, BROOMFIELD ECONOMIC DEVELOPMENT COUNCIL, JEFFERSON COUNTY ECONOMIC COUNCIL, BOULDER CHAMBER OF COMMERCE, AND OTHERS) AND "COMMUNITY HEALTH IMPROVEMENT ADVOCACY" FOR OUR COMMUNITY. THE COMMUNITY BUILDING ACTIVITIES SELECTED BY BOTH EXEMPLA GOOD SAMARITAN MEDICAL CENTER AND EXEMPLA LUTHERAN MEDICAL CENTER EACH YEAR PROMOTE THE HEALTH OF THE COMMUNITY IN SIGNIFICANT WAYS.
BAD DEBT EXPENSE COSTING METHODOLOGY AND OTHER INFO PART III, LINE 4 A COST TO CHARGE RATIO IS USED AS THE METHODOLOGY FOR DETERMINING THE AMOUNTS REPORTED AS COST OF BAD DEBT EXPENSE. FOR ALL SELF-PAY ACCOUNTS, A STANDARD 40% DISCOUNT IS FIRST APPLIED TO CHARGES AS A DEDUCTION OF REVENUE. BAD DEBT EXPENSE IS REFLECTED NET OF DISCOUNTS APPLIED AND PAYMENTS RECEIVED. THE ORGANIZATION DOES NOT INCLUDE IN BAD DEBT EXPENSE ANY AMOUNT THAT COULD REASONABLY BE ATTRIBUTABLE TO PATIENTS WHO LIKELY WOULD QUALIFY FOR FINANCIAL ASSISTANCE UNDER THE HOSPITALS' CHARITY CARE POLICY. THE FOLLOWING ARE THE RELEVANT PORTIONS OF THE COMPANY'S FOOTNOTE TO THE FINANCIAL STATEMENTS RELATED TO BAD DEBT: INCLUDED IN NET RECEIVABLES IS THE ALLOWANCE FOR UNCOLLECTIBLE RECEIVABLES. THE ALLOWANCE FOR UNCOLLECTIBLE RECEIVABLES IS BASED UPON MANAGEMENT'S ASSESSMENT OF HISTORICAL AND EXPECTED NET COLLECTIONS AND TAKES INTO CONSIDERATION HISTORICAL BUSINESS AND ECONOMIC CONDITIONS, TRENDS IN HEALTHCARE COVERAGE, AND OTHER COLLECTION INDICATORS. MANAGEMENT PERIODICALLY ASSESSES THE ADEQUACY OF THE ALLOWANCES FOR UNCOLLECTIBLE ACCOUNTS BASED UPON HISTORICAL WRITE-OFF EXPERIENCE BY PAYOR CATEGORY. THE RESULTS OF THESE ASSESSMENTS ARE USED TO MODIFY, AS NECESSARY, THE PROVISION FOR BAD DEBTS AND TO ESTABLISH APPROPRIATE ALLOWANCES FOR UNCOLLECTIBLE NET PATIENT ACCOUNTS RECEIVABLE.
COSTING METHODOLOGY FOR MEDICARE COSTS PART III, LINE 8 INPATIENT AND OUTPATIENT MEDICARE COSTS ARE CALCULATED ON THE COST REPORT. INPATIENT COSTS ARE A PRODUCT OF ROUTINE SERVICE COSTS BASED ON PER DIEMS AND ANCILLARY COSTS BASED ON INPATIENT MEDICARE CHARGES FACTORED BY INPATIENT COST TO CHARGE RATIOS. OUTPATIENT COSTS ARE BASED ON MEDICARE OUTPATIENT CHARGES FACTORED BY OUTPATIENT COST TO CHARGE RATIOS. EXEMPLA, INC. DOES NOT RECOGNIZE THE MEDICARE SHORTFALL AS A COMMUNITY BENEFIT.
DEBT COLLECTION POLICY PART III, LINE 9B AN INTEGRAL COMPONENT OF OUR MISSION IS TO BE GOOD FINANCIAL STEWARDS. THIS REQUIRES US TO DETERMINE WHICH PATIENTS ARE IN NEED OF CHARITY CARE AND WHICH ARE ABLE TO CONTRIBUTE SOME PAYMENT FOR CARE RECEIVED. WE MAINTAIN A BALANCE THAT ENABLES US TO CONTINUE TO PROVIDE CHARITY CARE TO THOSE WHO NEED IT MOST, AND TO ENSURE THAT WE MANAGE OUR RESOURCES SO THAT WE CAN CONTINUE TO BE HERE WHEN PEOPLE NEED US MOST. EXEMPLA, INC NOTIFIES PATIENTS OF FINANCIAL ASSISTANCE POLICY UPON ADMISSION, DISCHARGE AND IN COMMUNICATION REGARDING PATIENT BILLS. PATIENTS ARE CONTACTED MULTIPLE TIMES ABOUT UNPAID BALANCES PRIOR TO INITIATING ANY COLLECTION ACTION. IF A PATIENT IS DETERMINED TO BE ELIGIBLE FOR FINANCIAL ASSISTANCE AT ANY TIME DURING THE COLLECTION PROCESS, THE ACCOUNT IS RECLASSIFIED AS FINANCIAL ASSISTANCE AND DEBT COLLECTION EFFORTS ARE CEASED.
NEEDS ASSESSMENT PART VI, LINE 2 AS PART OF OUR CORE VALUE OF RESPONSE TO NEED, WE TAKE STEPS TO DETERMINE WHERE THERE IS THE MOST NEED IN ORDER TO PROVIDE THE GREATEST GOOD. EXEMPLA GOOD SAMARITAN MEDICAL CENTER AND EXEMPLA LUTHERAN MEDICAL CENTER HAVE REGULARLY PARTICIPATED IN NEEDS ASSESSMENTS TO IDENTIFY THE ONGOING AND CHANGING NEEDS OF THE COMMUNITY. THE MOST RECENT SURVEY WAS CONDUCTED IN 2009, AND OTHER SURVEYS WILL BE CONDUCTED ON A REGULAR BASIS. THIS ASSESSMENT STUDIES A DEFINED COMMUNITY SERVED BY THSE HOSPITALS AND IS DONE BY PARTNERING WITH LOCAL GOVERNMENT AND SOCIAL AGENCIES; COMBINING EFFORTS WITH OTHER LOCAL HOSPITALS AND HEALTH CARE ORGANIZATIONS; AND CONDUCTING SURVEYS AND ASSESSMENTS WITH THE ASSISTANCE OF OUTSIDE CONSULTANTS. WE ALSO CONTINUOUSLY ASSESS THE NEEDS OF THE COMMUNITY THROUGH CLOSE WORKING RELATIONSHIPS AND PARTNERSHIPS WITH SERVICE AGENCIES IN THE COMMUNITY, AND BY EVALUATING STATE AND COUNTY HEALTH STATISTICS. TO ADDRESS RATES OF ILLNESS IN THE COMMUNITY, BOTH EXEMPLA GOOD SAMARITAN MEDICAL CENTER AND EXEMPLA LUTHERAN MEDICAL CENTER HAVE A MULTITUDE OF PROGRAMS IN PLACE THROUGH ITS DIABETES CENTER, CANCER CENTER AND NEUROVASCULAR CENTER AT ELMC AND THROUGH COMMUNITY OUTREACH. A VARIETY OF CLASSES ARE OFFERED ON WEIGHT MANAGEMENT AND SUPPORT GROUPS FOR CANCER PATIENTS. WE ALSO ROUTINELY OFFER COMMUNITY HEALTH AND SAFETY CLINICS, SKIN CANCER SCREENINGS, BREAST CANCER SURVIVORSHIP PROGRAMS, CLASSES FOR PROSPECTIVE PARENTS AND DIABETES MANAGEMENT CLASSES, TO NAME A FEW. EXEMPLA GOOD SAMARITAN MEDICAL CENTER AND EXEMPLA LUTHERAN MEDICAL CENTER ALSO RECOGNIZE THE ESSENTIAL NEED TO ENHANCE AND IMPROVE MEDICAL OUTCOMES, QUALITY AND SERVICES. IN RESPONSE, A BEST IN THE NATION STRATEGY AND PROGRAM WAS IMPLEMENTED. THE OBJECTIVES OF THE PROGRAM ARE TO BE THE BEST IN THE NATION IN PREDEFINED QUALITY, SERVICE AND COST INDICATORS. THE QUALITY INDICATORS ARE IN ALIGNMENT WITH MAJOR PUBLICLY COMPARABLE DATABASES INCLUDING THE COLORADO HEALTH AND HOSPITAL ASSOCIATION AND CENTERS FOR MEDICARE AND MEDICAID SERVICES. COLLECTIVELY WITH ITS 634 LICENSED BEDS AT ELMC AND EGSMC, EXEMPLA SERVED THE COMMUNITY WITH 27,448 INPATIENT ADMISSIONS AND 109,176 EMERGENCY ROOM (ER) VISITS. COMPREHENSIVE MEDICAL SERVICES INCLUDE, BUT ARE NOT LIMITED TO, CARDIOLOGY, ONCOLOGY, ORTHOPEDIC, WOMEN AND FAMILY, PEDIATRICS, EMERGENCY AND TRAUMA, NEONATAL INTENSIVE CARE, NEUROLOGY, NEUROSURGERY, OB/GYN, GENERAL SURGICAL AND MEDICAL, PRIMARY CARE, INTERNAL MEDICINE, BEHAVIORAL HEALTH, HOSPICE CARE AND INTEGRATIVE HEALTH SERVICES.
PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCE PART VI, LINE 3 EXEMPLA, INC TREATS PATIENTS WITH RESPECT AND DIGNITY REGARDLESS OF THEIR ABILITY TO PAY. EXEMPLA, INC HAS A WRITTEN FINANCIAL ASSISTANCE POLICY THAT EXPLAINS ELIGIBILITY CRITERIA FOR FINANCIAL ASSISTANCE AT VARIOUS LEVELS, INCLUDING A 100% DISCOUNT, AND IS BASED ON FEDERAL POVERTY GUIDELINES. WE WORK WITH PATIENTS TO HELP THEM UNDERSTAND THEIR FINANCIAL RESPONSIBILITY FOR CARE RECEIVED, FINANCIAL ASSISTANCE AVAILABLE TO THEM, AND TO ESTABLISH PAYMENT PROGRAMS IN DEMONSTRATION OF OUR CORE VALUE OF RESPECT. AS PART OF OUR RESPONSIBILITY TO EDUCATE, WE INFORM OUR PATIENTS AND THEIR FAMILIES OF THE AVAILABILITY OF ASSISTANCE, INCLUDING GOVERNMENT PROGRAMS. WE COMMUNICATE THIS IN A VARIETY OF WAYS TO ENSURE THAT MESSAGES REACH MULTIPLE AUDIENCES. BEFORE, DURING AND/OR AFTER ADMISSION, WE ENCOURAGE OUR SELF PAY PATIENTS TO VISIT WITH A FINANCIAL COUNSELOR TO DISCUSS QUALIFICATIONS FOR FINANCIAL ASSISTANCE. THE FINANCIAL COUNSELOR WORKS WITH THE PATIENT TO COMPLETE A FINANCIAL ASSISTANCE FORM TO DETERMINE THE LEVEL OF DISCOUNT FOR WHICH THE PATIENT MAY BE ELIGIBLE. WE POST FINANCIAL ASSISTANCE INFORMATION IN EMERGENCY AND ADMISSIONS AREAS, ON BILLINGS INVOICES, IN VARIOUS AREAS AROUND THE HOSPITAL AND CLINIC SITES AND ON THE HOSPITAL WEBSITE. WE PROVIDE WRITTEN MATERIALS TO PATIENTS THAT DETAIL OUR FINANCIAL ASSISTANCE POLICY AND HOW IT IS ADMINISTERED. THIS COVERS ELIGIBILITY, STEPS TO FOLLOW TO DETERMINE IF A PATIENT QUALIFIES FOR ASSISTANCE, TYPICAL CHARGES A PATIENT MAY EXPECT FOR ROUTINE PROCEDURES, AND ASSISTANCE AVAILABLE BASED ON A PATIENT'S INCOME LEVEL. WE PROVIDE MATERIALS AND EDUCATION WHEN PATIENTS ARE DISCHARGED, AND INCLUDE INFORMATION IN BILLING STATEMENTS, INCLUDING PHONE NUMBERS AND OTHER METHODS TO CONTACT US WITH QUESTIONS. WE ENSURE THAT OUR FINANCIAL COUNSELORS, ADMISSION EMPLOYEES, SOCIAL WORKERS AND OTHER EMPLOYEES UNDERSTAND OUR POLICIES TO BE ABLE TO ASSIST PATIENTS IN THE MOST APPROPRIATE WAY. WE ALSO PROVIDE PAYMENT PLAN OPTIONS TO OUR PATIENTS. THIS HELPS PATIENTS MEET THEIR FINANCIAL OBLIGATIONS IN A REASONABLE AND DIGNIFIED MANNER BASED ON THEIR ABILITY TO PAY, AND ALLOWS THEM TO CONTINUE TO ENSURE THE ONGOING WELFARE OF THEIR FAMILIES. THIS IS DONE IN ACCORDANCE WITH OUR CORE VALUE OF RESPECT.
COMMUNITY INFORMATION PART VI, LINE 4 THE COMMUNITY SERVED BY EXEMPLA, INC. IS A CONTINUUM OF MUNICIPALITIES AND SECTIONS OF MUNICIPALITIES WITHIN THE GREATER DENVER METRO AREA, EXTENDING FROM THE CENTRAL WEST METRO DENVER CITIES OF LAKEWOOD AND EVERGREEN TO LONGMONT, THE MOST NORTHWEST MUNICIPALITY IN THE METRO DENVER AREA (EXCLUDING THE CITY OF BOULDER PROPER). WHILE THERE ARE SOME MOUNTAIN AND RURAL AREAS OVER THIS COMMUNITY EXPANSE, MOST OF THE COMMUNITY SERVED IS SUBURBAN AND URBAN AREAS. THE POPULATION OF THE ENTIRE COMMUNITY SERVED IS 1,066,000 AS OF YEAR 2010. THIS AREA REPRESENTS A LITTLE LESS THAN 40% OF THE WHOLE DENVER METRO AREA. HOWEVER THE COMMUNITY SERVED CAN BE SEPARATED INTO THREE MORE HOMOGENEOUS AREAS OF WEST CENTRAL METRO DENVER (LAKEWOOD, EVERGREEN, WHEAT RIDGE, GOLDEN, ARVADA AND A NORTHWEST PORTION OF THE CITY OF DENVER), NORTHWEST ADAMS COUNTY (WESTMINSTER-EAST, THORNTON, NORTHGLENN, FEDERAL HEIGHTS AND BRIGHTON), AND EAST BOULDER COUNTY (LOUISVILLE, LAFAYETTE, BROOMFIELD, WESTMINSTER-WEST, AND LONGMONT). THE WEST CENTRAL METRO DENVER AREA IS THE MOST POPULATED AREA. IT IS THE OLDEST AREA WITH LESS PERCENTAGE OF CHILDREN, A HIGHER PERCENTAGE OF SENIORS, AND HIGHER MEDIAN AGE. IT IS ALSO THE AREA WITH THE HIGHEST PERCENTAGE OF HOUSEHOLDS BELOW THE POVERTY LEVEL INFLUENCED IN PART BY THE HIGH PERCENTAGE OF SENIORS. - AVERAGE INCOME IS $78,000 AND 14% OF HOUSEHOLDS ARE BELOW THE POVERTY LEVEL. - UNEMPLOYED IN THIS AREA ACCOUNTS FOR 8.6% OF THE POPULATION AND 14% OF THE POPULATION IS AGE 65 OR OLDER. MORBIDITY (PERCENT OF ADULTS REPORTING FAIR OR POOR HEALTH) IS 10% OF THE POPULATION IN THIS COUNTY. ADULT SMOKING IS 18% OF THE POPULATION; ADULT OBESITY (PERCENT OF ADULTS THAT REPORTED A BMI OF GREATER THAN OR EQUAL TO 30) IS 18%; EXCESSIVE DRINKING (INCLUDING BINGE DRINKING) IS 19% OF THE POPULATION IN THIS COUNTY. THIS COUNTY REPORTS 66% OF THE POPULATION RECEIVING A MAMMOGRAPHY SCREENING (PERCENT OF FEMALE MEDICARE ENROLLEES). THE NORTHWEST ADAMS COUNTY IS A YOUNGER AREA WITH A HIGHER PERCENTAGE OF CHILDREN, A LOWER PERCENTAGE OF SENIORS AND A LOWER MEDIAN AGE. THE AREA HAS THE LOWEST AVERAGE INCOME AND THE HIGHEST UNEMPLOYMENT, PERCENTAGE THAT ARE NOT HIGH SCHOOL GRADUATES, AND HISPANIC PERCENTAGE. - AVERAGE INCOME IS $75,000 AND 11% OF HOUSEHOLDS ARE BELOW THE POVERTY LEVEL. - UNEMPLOYED IN THIS AREA ACCOUNTS FOR 11% OF THE POPULATION AND 8% OF THE POPULATION IS AGE 65 OR OLDER. MORBIDITY (PERCENT OF ADULTS REPORTING FAIR OR POOR HEALTH) IS 18% OF THE POPULATION IN THIS COUNTY, HIGHER THAN THE OTHER COUNTIES LISTED HERE. ADULT SMOKING IS 22% OF THE POPULATION; ADULT OBESITY (PERCENT OF ADULTS THAT REPORTED A BMI OF GREATER THAN OR EQUAL TO 30) IS 24%; EXCESSIVE DRINKING (INCLUDING BINGE DRINKING) IS 19% OF THE POPULATION IN THIS COUNTY. THESE HEALTH FACTORS ARE ALL HIGHER THAN THE OTHER COUNTIES REPORTED HERE. THIS COUNTY REPORTS 58% OF THE POPULATION RECEIVING A MAMMOGRAPHY SCREENING (PERCENT OF FEMALE MEDICARE ENROLLEES). THE EAST BOULDER COUNTY AND ASSOCIATED AREAS HAS AN AGE BREAKOUT MOST SIMILAR TO THE DENVER METRO AREA AS A WHOLE (MEDIAN AGE 37). IT HAS THE HIGHEST AVERAGE INCOME, LOWEST UNEMPLOYMENT, HIGHEST EDUCATION LEVELS AND LOWEST PERCENTAGE OF MINORITIES. - AVERAGE INCOME IS $93,000 AND 11% OF HOUSEHOLDS ARE BELOW THE POVERTY LEVEL. - UNEMPLOYED IN THIS AREA ACCOUNTS FOR 7.1% OF THE POPULATION AND 9% OF THE POPULATION IS AGE 65 OR OLDER. MORBIDITY (PERCENT OF ADULTS REPORTING FAIR OR POOR HEALTH) IS 9% OF THE POPULATION IN THIS COUNTY. ADULT SMOKING IS 13% OF THE POPULATION; ADULT OBESITY (PERCENT OF ADULTS THAT REPORTED A BMI OF GREATER THAN OR EQUAL TO 30) IS 13%; EXCESSIVE DRINKING (INCLUDING BINGE DRINKING) IS 18% OF THE POPULATION IN THIS COUNTY. THIS COUNTY REPORTS A HIGHER MAMMOGRAPHY SCREENING THAN THE OTHER COUNTIES, WITH 70% OF THE POPULATION RECEIVING A MAMMOGRAPHY SCREENING (PERENT OF FEMAL MEDICARE ENROLLEES). BESIDES THE EXEMPLA INC. HOSPITALS, EXEMPLA LUTHERAN MEDICAL CENTER, WHEAT RIDGE AND EXEMPLA GOOD SAMARITAN, LAFAYETTE THERE ARE THREE OTHER NOT-FOR-PROFIT HOSPITALS IN THE COMMUNITY: " ST. ANTHONY NORTH HOSPITAL-CENTURA HEALTH, WESTMINSTER " AVISTA ADVENTIST HOSPITAL-CENTURA HEALTH, LOUISVILLE " LONGMONT UNITED HOSPITAL, LONGMONT THERE IS ALSO ONE FOR-PROFIT HOSPITAL, NORTH SUBURBAN MEDICAL CENTER-HEALTHONE, THORNTON.
PROMOTION OF COMMUNITY HEALTH PART VI, LINE 5 WE EXTEND OUR CARE BEYOND OUR HOSPITALS' WALLS IN ORDER TO IMPROVE THE HEALTH OF OUR COMMUNITY. OUR COMMUNITY ACTIVITIES DEMONSTRATE THIS COMMITMENT. OUR COMMUNITY ACTIVITIES AT EXEMPLA LUTHERAN MEDICAL CENTER INCLUDE A VARIETY OF CLASSES ON WEIGHT MANAGEMENT AND SUPPORT GROUPS FOR CANCER PATIENTS. ELMC ALSO ROUTINELY OFFERS COMMUNITY HEALTH AND SAFETY CLINICS, SKIN CANCER SCREENINGS, BREAST CANCER SURVIVORSHIP PROGRAMS, CLASSES FOR PROSPECTIVE PARENTS AND DIABETES MANAGEMENT CLASSES, TO NAME A FEW. EXEMPLA GOOD SAMARITAN MEDICAL CENTER'S HEALTH & HEALING CENTER CONDUCTS HEART HEALTH SCREENINGS IN THE COMMUNITY INCLUDING CHOLESTEROL SCREENING AND BLOOD PRESSURE SCREENINGS SEVERAL TIMES THROUGHOUT THE YEAR. WE ALSO PROMOTE HEALTH AND WELLNESS FOR OUR EMPLOYEES THROUGH PROGRAMS SUCH AS POUND POUNDERS TO PROMOTE WEIGHT LOSS. WE ALSO PROVIDE PRESENTATIONS TO COMMUNITY GROUPS ON SUBJECTS SUCH AS BALANCE, EXERCISE AND STRETCHING. WELLNESS QUEST CLASSES LED BY EGSMC PHYSICIANS ARE HELD IN THE COMMUNITY FOR PREVENTIVE-CARE EDUCATION AND INDIVIDUAL RESPONSIBILITY FOR HEALTH PROMOTION. WE HAVE PARTNERED WITH SUCH ORGANIZATIONS AS THE LAFAYETTE SENIOR CENTER, THE LAFAYETTE RECREATION CENTER AND OTHER COMMUNITY ORGANIZATIONS PROVIDING SERVICES TO OUR COMMUNITY. EGSMC ALSO PROVIDES HEALTH SCREENINGS FOR EMPLOYEES OF BOULDER VALLEY SCHOOL DISTRICT AND SCREENINGS AT EVENTS SEVERAL TIMES THROUGHOUT THE YEAR TO RESIDENTS OF BROOMFIELD, LAFAYETTE AND OTHERS IN THE SURROUNDING AREAS. WE ARE AN IMPORTANT PART OF OUR COMMUNITY AND SERVE IN MANY WAYS, FROM DELIVERING CORE HEALTH CARE TO PREVENTIVE CARE TO SUPPORT OF OTHER CIVIC GROUPS. IN 2010, WE PROVIDED COMMUNITY BENEFIT TOTALING $52,645,847, INCLUDING TRADITIONAL CHARITY CARE AND THE UNPAID COST OF MEDICAID. OUR BOARD OF DIRECTORS REPRESENTS MEDICAL AND BUSINESS PROFESSIONALS, AND ALL PROVIDE HOURS OF SERVICE IN SUPPORT OF OUR HOSPITAL. THEY ARE DEEPLY INVOLVED IN OUR NEEDS ASSESSMENT PROCESS, BUILDING PROGRAMS AND SERVICES, AND COMMUNITY OUTREACH TO ENSURE THAT PEOPLE KNOW ABOUT SERVICES AVAILABLE TO THEM THROUGH OUR HOSPITAL. WHEN EXEMPLA, INC. HAS EXCESS REVENUE OVER OPERATING EXPENSES, WE USE THOSE FUNDS TO OBTAIN CURRENT HEALTH CARE TECHNOLOGIES AND EQUIPMENT, IMPROVE PATIENT CARE, PROVIDE MEDICAL TRAINING EDUCATION AND RESEARCH, AND TO EXPAND ACCESS TO POINTS OF CARE. THESE INVESTMENTS ENSURE WE'LL BE HERE TO CARE FOR FUTURE GENERATIONS. WE ALSO SUPPORT OUR EMPLOYEES IN VOLUNTEERING FOR COMMUNITY ORGANIZATIONS, INCLUDING SERVING ON COMMUNITY BOARDS, AND PROVIDE OPPORTUNITIES FOR THEM TO SUPPORT CAUSES THROUGH HOSPITAL EVENTS SUCH AS CANCER, HEART DISEASE, AMERICAN HEART ASSOCIATION, RACE FOR THE CURE, MARCH OF DIMES AND EPILEPSY FUNDRAISING DRIVES. WE ARE GOOD CITIZENS AND PARTNER WITH OTHER ORGANIZATIONS AND AGENCIES TO SUPPORT A THRIVING COMMUNITY, SUCH AS THE JEFFERSON COUNTY HEALTH DEPARTMENT, LIVEWELL COLORADO, THE METRO COMMUNITY PROVIDER NETWORK, MENTAL HEALTH PARTNERS OF BOULDER, MEALS ON WHEELS (BROOMFIELD & BOULDER COUNTIES), BROOMFIELD HEALTH & HUMAN SERVICES AND OTHER AGENCIES IN A SIX-COUNTY AREA. COMMUNITY BENEFITS PROVIDED IN 2010 THROUGHOUT SISTERS OF CHARITY OF LEAVENWORTH HEALTH SYSTEM (SCLHS) TOTALED $52.6 MILLION. AS PART OF SCLHS, WE PROMOTE THE SHARED MISSION THAT "WE WILL, IN THE SPIRIT OF THE SISTERS OF CHARITY, REVEAL GOD'S HEALING LOVE BY IMPROVING THE HEALTH OF THE INDIVIDUALS AND COMMUNITIES WE SERVE, ESPECIALLY THOSE WHO ARE POOR OR VULNERABLE." WE ARE COMMITTED TO LIVING AND DEMONSTRATING OUR CORE VALUES OF EXCELLENCE, RESPECT, RESPONSE TO NEED, STEWARDSHIP AND WHOLENESS. SCLHS SUPPORTS ITS HOSPITALS BY PROVIDING GUIDANCE, OVERSIGHT, AND RESOURCES TO HELP THEM ACCOMPLISH INITIATIVES THAT IMPROVE HEALTH IN ALL OUR COMMUNITIES. THIS INCLUDES COORDINATING COMMUNITY BENEFIT PROCESSES, PROVIDING GUIDANCE WITH COMMUNITY NEEDS ASSESSMENTS, AND ESTABLISHING CONSISTENT FINANCIAL ASSISTANCE AND CHARITY CARE POLICIES AND PROCEDURES. OTHER WAYS SCLHS BENEFITS ITS HOSPITALS INCLUDE QUALITY IMPROVEMENT AND PERFORMANCE EXCELLENCE INITIATIVES; SYSTEM-WIDE IT IMPLEMENTATION AND INFRASTRUCTURE; STRATEGIC AND OPERATIONS DIRECTION AND OVERSIGHT; SUPPLY CHAIN MANAGEMENT AND PURCHASING; BENEFITS ADMINISTRATION (INCLUDING A WELLNESS PROGRAM FREE TO EMPLOYEES THAT PROMOTES THEIR HEALTH AND WELL-BEING); RISK MANAGEMENT; DISASTER PLANNING AND CRISIS ASSISTANCE. BY SHARING THE WORK ACROSS OUR SYSTEM WE ARE ABLE TO LIGHTEN THE BURDEN FOR ALL IN ORDER TO FULFILL OUR MISSION OF IMPROVING HEALTH IN OUR COMMUNITIES. SCLHS IMPROVES OVERALL HEALTH IN OUR COMMUNITIES BY PROVIDING INFRASTRUCTURE TO SUPPORT AND SUSTAIN FOUR CLINICS FOR THE UNINSURED IN KANSAS AND COLORADO. THE SCLHS CLINICS FOR THE UNINSURED ARE OFTEN THE ONLY SAFETY NET CLINIC IN THEIR COMMUNITY AND PROVIDE VALUABLE SERVICES FOR THOSE WHO ARE MOST VULNERABLE. EACH HOSPITAL IS SUPPORTED BY A FOUNDATION TO ACCESS AND OPTIMIZE LOCAL PHILANTHROPIC ORGANIZATIONS AND INDIVIDUALS. THESE FOUNDATIONS RAISE FUNDS THROUGH OUTREACH, SPECIAL EVENTS, AND BUILDING DONOR RELATIONS THROUGHOUT THEIR COMMUNITY TO SUPPORT THE NEEDS OF THE HOSPITAL.
AFFILIATED HEALTH CARE SYSTEM PART VI, LINE 7 EXEMPLA, INC. IS A CONTROLLED ENTITY OF THE SISTERS OF CHARITY OF LEAVENWORTH HEALTH SYSTEM, INC. (SCLHS). SCLHS AND ITS AFFILIATED ENTITIES HAVE A COMMON CALLING AND MISSION "TO REVEAL GOD'S HEALING LOVE BY IMPROVING THE HEALTH OF THE INDIVIDUALS AND COMMUNITIES IT SERVES, ESPECIALLY THOSE WHO ARE POOR OR VULNERABLE." EXEMPLA, INC. PROMOTES THE HEALTH OF THE COMMUNITY BY DELIVERING DIRECT HIGH QUALITY HEALTHCARE SERVICES THAT ARE RESPONSIVE TO THE NEEDS OF ITS PATIENTS AND THEIR FAMILIES. SCLHS SUPPORTS THE EFFORTS OF THE HOSPITAL THROUGH STRATEGIC DIRECTION AND OPERATING OVERSIGHT. SCLHS SUPPLIES OVERHEAD SUPPORT SERVICES TO EXEMPLA, INC. INCLUDING INFORMATION TECHNOLOGY SERVICES, CENTRAL CASH MANAGEMENT AND INVESTMENT, RISK MANAGEMENT AND INSURANCE AND QUALITY IMPROVEMENT LEADERSHIP.
STATE FILING OF COMMUNITY BENEFIT REPORT PART VI, LINE 8 THE SISTERS OF CHARITY OF LEAVENWORTH HEALTH SYSTEM FILES A COMMUNITY BENEFIT REPORT IN FOUR STATES: CALIFORNIA, COLORADO, KANSAS AND MONTANA.
Schedule H (Form 990) 2010
Additional Data


Software ID:  
Software Version:  
Schedule I
(Form 990)
Department of the Treasury
Internal Revenue Service
Grants and Other Assistance to Organizations,
Governments and Individuals in the United States
Complete if the organization answered "Yes," to Form 990, Part IV, line 21 or 22.
lBullet Attach to Form 990
OMB No. 1545-0047
2010
Open to Public
Inspection
Name of the organization
EXEMPLA INC FKA LUTHERAN HOSPITAL
 
Employer identification number
84-1103606
Part I
General Information on Grants and Assistance
1
Does the organization maintain records to substantiate the amount of the grants or assistance, the grantees' eligibility for the grants or assistance, and
the selection criteria used to award the grants or assistance? ....................................
2
Describe in Part IV the organization's procedures for monitoring the use of grant funds in the United States.
Part II
Grants and Other Assistance to Governments and Organizations in the United States. Complete if the organization answered "Yes" to
Form 990, Part IV, line 21 for any recipient that received more than $5,000. Check this box if no one recipient received more than $5,000. Use
Part IV and Schedule I-1 (Form 990) if additional space is needed ......................... lBullet
(a) Name and address of organization
or government		 (b) EIN (c) IRC Code section
if applicable		 (d) Amount of cash grant (e) Amount of non-cash
assistance		 (f) Method of valuation
(book, FMV, appraisal,
other)		 (g) Description of
non-cash assistance		 (h) Purpose of grant
or assistance
(1) YOUNG AMERICANS CENTER FOR FINANCIAL EDU3555 E FIRST AVE
DENVER,CO80206 		74-2477108 501(c)(3) 10,000       SCHOOL YEAR SUPPORT
(2) COLORADO CENTER FOR NURSING EXCELLENCE5290 East Yale Cir Ste 102
DENVER,CO80222 		32-0022295 501(c)(3) 50,000       OPERATING AND PROGRAM SUPPORT
(3) DENVER HEALTH FOUNDATION655 BROADWAY SUITE 750
DENVER,CO80203 		84-1085196 501(c)(3) 35,000       OPERATING AND PROGRAM SUPPORT
(4) DENVER PUBLIC SCHOOL FOUNDATION900 GRANT STREET SUITE 503
DENVER,CO80203 		84-1224325 501(C)(3) 20,000       OPERATING AND PROGRAM SUPPORT
(5) SPECIAL TRANSIT4880 PEARL STREET
BOULDER,CO80301 		84-0777296 501(C)(3) 17,500       CAPITAL CAMPAIGN BUILDING PROJECT
(6) SISTER CARMEN COMMUNITY CENTER701 W BASELINE ROAD
LAFAYETTE,CO80026 		84-0820308 501(c)(3) 15,000       OPERATING AND PROGRAM SUPPORT
(7) FOOD BANK OF THE ROCKIES10700 E 45TH AVENUE
DENVER,CO80239 		84-0772672 501(c)(3) 10,000       COLORADO CAN DO CAMPAIGN
(8) MENDING FACES422 HUMBOLDT STREET
DENVER,CO80214 		27-2151804 501(C)(3) 9,000       INTERNATIONAL MISSION








2
Enter total number of section 501(c)(3) and government organizations ......................... Bullet Image
8
3
Enter total number of other organizations ................................ . Bullet Image
0
For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50055P
Schedule I (Form 990) 2010

Schedule I (Form 990) 2010
Page 2
Part III
Grants and Other Assistance to Individuals in the United States. Complete if the organization answered "Yes" to Form 990, Part IV, line 22.
Use Schedule I-1 (Form 990) if additional space is needed.
(a)Type of grant or assistance (b)Number of
recipients		 (c)Amount of
cash grant		 (d)Amount of
non-cash assistance		 (e)Method of valuation (book,
FMV, appraisal, other)		 (f)Description of non-cash assistance













Part IV
Supplemental Information. Complete this part to provide the information required in Part I, line 2, and any other additional information.
Identifier Return Reference Explanation
DESCRIPTION OF ORGANIZATION'S PROCEDURES FOR MONITORING THE USE OF GRANTS PART 1, QUESTION 2 THE ORGANIZATION KEEPS RECORDS TO SUPPORT THE AMOUNTS PROVIDED OR REASONS FOR SUCH SUPPORT. SUPPORT IS NOT CONSIDERED GRANTS, BUT RATHER MISCELLANEOUS DONATIONS AND SPONSORSHIPS. ELIGIBILITY FOR FUNDING IS DETERMINED ON AN INDIVIDUAL BASIS, CONSIDERING THE USE OF THE FUNDS AND HOW THE USE RELATES TO EXEMPLA'S MISSION.
Schedule I (Form 990) 2010


Additional Data


Software ID:  
Software Version:  


Schedule J
(Form 990)
Department of the Treasury
Internal Revenue Service
Compensation Information
For certain Officers, Directors, Trustees, Key Employees, and Highest
Compensated Employees
SchJMediumBullet Complete if the organization answered "Yes" to Form 990,
Part IV, question 23.
SchJMediumBullet Attach to Form 990. SchJMediumBullet See separate instructions.
OMB No. 1545-0047
2010
Open to Public Inspection
Name of the organization
EXEMPLA INC FKA LUTHERAN HOSPITAL
 
Employer identification number

84-1103606
Part I
Questions Regarding Compensation
Yes
No
1a
Check the appropiate box(es) if the organization provided any of the following to or for a person listed in Form
990, Part VII, Section A, line 1a. Complete Part III to provide any relevant information regarding these items.
b
If any of the boxes in line 1a are checked, did the organization follow a written policy regarding payment or reimbursement orprovision of all the expenses described above? If "No," complete Part III to explain....
1b
Yes
 
2
Did the organization require substantiation prior to reimbursing or allowing expenses incurred by all
officers, directors, trustees, and the CEO/Executive Director, regarding the items checked in line 1a? ....
2
Yes
 
3
Indicate which, if any, of the following the organization uses to establish the compensation of the
organization's CEO/Executive Director. Check all that apply.
4
During the year, did any person listed in Form 990, Part VII, Section A, line 1a with respect to the filing organization or a related organization:
a
Receive a severance payment or change-of-control payment? ...............
4a
Yes
 
b
Participate in, or receive payment from, a supplemental nonqualified retirement plan? ........
4b
Yes
 
c
Participate in, or receive payment from, an equity-based compensation arrangement? ........
4c
 
No
If "Yes" to any of lines 4a-c, list the persons and provide the applicable amounts for each item in Part III.
Only 501(c)(3) and 501(c)(4) organizations only must complete lines 5-9.
5
For persons listed in form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the revenues of:
a
The organization? ...........................
5a
 
No
b
Any related organization? .........................
5b
 
No
If "Yes," to line 5a or 5b, describe in Part III.
6
For persons listed in form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the net earnings of:
a
The organization? ...........................
6a
 
No
b
Any related organization? .........................
6b
 
No
If "Yes," to line 6a or 6b, describe in Part III.
7
For persons listed in Form 990, Part VII, Section A, line 1a, did the organization provide any non-fixed
payments not described in lines 5 and 6? If "Yes," describe in Part III ............
7
 
No
8
Were any amounts reported in Form 990, Part VII, paid or accured pursuant to a contract that was
subject to the initial contract exception described in Regs. section 53.4958-4(a)(3)? If "Yes," describe
in Part III .............................
8
Yes
 
9
If "Yes" to line 8, did the organization also follow the rebuttable presumption procedure described in Regulations section 53.4958-6(c)? .........................
9
Yes
 
For Privacy Act and Paperwork Reduction Act Notice, see the Intructions for Form 990
Cat. No. 50053T
Schedule J (Form 990) 2010

Schedule J (Form 990) 2010
Page 2
Part II
Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees. Use Schedule J-1 if additional space needed.
For each individual whose compensation must be reported in Schedule J, report compensation from the organization on row (i) and from related organizations, described in the
instructions on row (ii). Do not list any individuals that are not listed on Form 990, Part VII.

Note. The sum of columns (B)(i)-(iii) must equal the applicable column (D) or column (E) amounts on Form 990, Part VII, line 1a.
(A) Name (B) Breakdown of W-2 and/or 1099-MISC compensation (C) Retirement and other deferred compensation (D) Nontaxable
benefits		 (E) Total of columns
(B)(i)-(D) 		(F) Compensation
reported in prior
Form 990 or
Form 990-EZ
(i) Base compensation (ii) Bonus & incentive compensation (iii) Other reportable compensation
(1) JEFFREY D SELBERG (i)
(ii)		 174,329
0 		798,246
0 		2,756,129
0 		20,006
0 		2,350
0 		3,751,060
0 		1,327,697
0
(2) ROBERT ALAN MINKIN (i)
(ii)		 0
104,739 		0
0 		0
1,110,573 		0
11,496 		0
1,985 		0
1,228,793 		0
130,884
(3) ROBERT H MALTE (i)
(ii)		 107,148
0 		80,921
0 		949,119
0 		16,040
0 		2,962
0 		1,156,190
0 		146,152
0
(4) JUDY A MITCHELL (i)
(ii)		 135,951
0 		70,975
0 		618,477
0 		19,736
0 		5,501
0 		850,640
0 		95,312
0
(5) DAVID HAMM (i)
(ii)		 337,971
0 		80,993
0 		313,822
0 		27,892
0 		18,637
0 		779,315
0 		275,300
0
(6) DAVID C PECORARO (i)
(ii)		 229,547
76,450 		83,044
0 		20,407
2,893 		16,105
0 		12,909
2,010 		362,012
81,353 		0
0
(7) KATHRYN LOUISE BALLINGER (i)
(ii)		 311,320
0 		54,643
0 		38,537
0 		24,060
0 		13,741
0 		442,301
0 		0
0
(8) ROBERT G BILLERBECK (i)
(ii)		 293,589
0 		38,654
0 		19,602
0 		16,396
0 		19,609
0 		387,850
0 		0
0
(9) ELISA WETHERBEE (i)
(ii)		 225,913
0 		6,666
0 		36,506
0 		21,485
0 		25,091
0 		315,661
0 		0
0
(10) S ANN EVANS (i)
(ii)		 203,911
0 		29,912
0 		22,000
0 		13,317
0 		9,000
0 		278,140
0 		0
0
(11) MARTIN CARROLL HELLDORFER (i)
(ii)		 40
0 		2,000
0 		130,590
0 		0
0 		9,126
0 		141,756
0 		0
0
(12) BETH C FORSYTH (i)
(ii)		 194,255
0 		19,851
0 		24,622
0 		20,758
0 		14,980
0 		274,466
0 		0
0
(13) MARGARET CAIN PRICE (i)
(ii)		 208,769
0 		68,498
0 		38,500
0 		13,661
0 		16,121
0 		345,549
0 		0
0
(14) DEBORAH L WELLE POWELL (i)
(ii)		 208,282
0 		33,710
0 		22,037
0 		18,273
0 		9,612
0 		291,914
0 		0
0
(15) KAREN TAYLOR (i)
(ii)		 9,498
0 		0
0 		282,420
0 		10,640
0 		1,173
0 		303,731
0 		0
0
(16) KAREN M SCREMIN (i)
(ii)		 185,799
0 		29,970
0 		12,945
0 		11,859
0 		15,362
0 		255,935
0 		0
0
(17) EVERETT A DAVIS (i)
(ii)		 169,334
0 		29,446
0 		10,137
0 		19,248
0 		22,613
0 		250,778
0 		0
0
(18) BRENDA S CHILMAN (i)
(ii)		 187,146
0 		33,001
0 		29,537
0 		12,809
0 		8,178
0 		270,671
0 		0
0
(19) TODD A CONKLIN (i)
(ii)		 360,063
0 		207,291
0 		45,152
0 		16,396
0 		21,591
0 		650,493
0 		0
0
(20) SANDRA R CAVANAUGH (i)
(ii)		 158,523
0 		15,180
0 		17,819
0 		15,296
0 		7,364
0 		214,182
0 		0
0
(21) BARRY K PLATNICK (i)
(ii)		 352,056
0 		 
0 		33,069
0 		16,396
0 		23,428
0 		424,949
0 		0
0
(22) SUSAN E KERSCHEN (i)
(ii)		 198,606
0 		21,465
0 		27,863
0 		3,502
0 		16,675
0 		268,111
0 		0
0
(23) LISA S KETTERING (i)
(ii)		 320,810
0 		15,656
0 		20,837
0 		15,028
0 		23,778
0 		396,109
0 		0
0
(24) ROBERT E SWANEY III (i)
(ii)		 373,136
0 		0
0 		16,569
0 		16,396
0 		21,585
0 		427,686
0 		0
0
(25) WILLIAM M MURRAY (i)
(ii)		 0
910,180 		0
489,328 		0
306,949 		0
157,816 		0
11,270 		0
1,875,543 		0
0
(26) RODERICK G LAMOND (i)
(ii)		 860,423
0 		0
0 		22,065
0 		0
0 		21,428
0 		903,916
0 		0
0
(27) WILLIAM L SABER (i)
(ii)		 342,000
0 		500
0 		38,569
0 		16,396
0 		9,842
0 		407,307
0 		0
0
(28) ADILBERTO TORRES JR (i)
(ii)		 139,825
0 		23,067
0 		20,395
0 		13,790
0 		15,340
0 		212,417
0 		0
0
(29) JOHN D HIGGINS (i)
(ii)		 146,773
0 		24,061
0 		10,284
0 		10,431
0 		20,818
0 		212,367
0 		0
0
(30) CAROL J SALZMAN (i)
(ii)		 136,993
0 		14,979
0 		22,000
0 		12,984
0 		20,762
0 		207,718
0 		0
0
(31) LAURA L FOLSOM (i)
(ii)		 150,273
0 		12,039
0 		12,999
0 		10,282
0 		9,813
0 		195,406
0 		0
0
(32) SCOTT A BARTUSEK DAY (i)
(ii)		 124,434
0 		15,566
0 		24,327
0 		10,826
0 		11,376
0 		186,529
0 		0
0
(33) BARBARA HELEN DAVIS (i)
(ii)		 119,745
0 		9,545
0 		22,422
0 		8,047
0 		8,262
0 		168,021
0 		0
0
(34) BAIN FARRIS (i)
(ii)		 0
425,155 		0
83,164 		0
17,597 		0
63,105 		0
10,699 		0
599,720 		0
0
(35) GRANT WICKLUND (i)
(ii)		 0
379,170 		0
0 		0
45,505 		0
40,226 		0
14,374 		0
479,275 		0
0
(36) ROBERT LADENBURGER (i)
(ii)		 0
576,595 		0
268,750 		0
378,754 		0
52,613 		0
10,760 		0
1,287,472 		0
0
(37) ANDREW W MCBRIDE (i)
(ii)		 222,081
  		74,739
  		50,308
  		20,228
  		25,229
  		392,585
  		0
 
Schedule J (Form 990) 2010

Schedule J (Form 990) 2010
Page 3
Part III
Supplemental Information
Complete this part to provide the information, explanation, or descriptions required for Part I, lines 1a, 1b, 4c, 5a, 5b, 6a, 6b, 7, and 8. Also complete this part for any additional information.
Identifier Return Reference Explanation
TAX INDEMNIFICATION AND GROSS UP PAYMENTS SCH J, PART I, QUESTION 1A 21 INDIVIDUALS RECEIVED GROSS UP PAYMENTS FOR GIFTS OR OTHER ITEMS THAT WERE TAXABLE TO THE INDIVIDUAL IN THEIR W-2'S. THESE TOTALED $919 IN THE AGGREGATE.
SOCIAL CLUB DUES SCH J, PART I, QUESTION 1A SOCIAL CLUB DUES WERE PAID BY EXEMPLA ON BEHALF OF JEFFREY D. SELBERG ($280), ROBERT ALAN MINKIN ($559), AND TODD A CONKLIN ($1,580) DURING 2010.
SEVERANCE AND CHANGE OF CONTROL PAYMENTS SCHEDULE J, PART I, QUESTION 4A SEVERANCE PAYMENTS WERE MADE TO THE FOLLOWING INDIVIDUALS IN THE FOLLOWING AMOUNTS DURING 2010: JEFFREY D SELBERG - $1,330,420 ROBERT ALAN MINKIN - $960,372 ROBERT H MALTE - $750,132 JUDY A MITCHELL - $485,702 MARTIN CARROLL HELLDORFER - $130,590 KAREN TAYLOR - $264,599 CHANGE OF CONTROL PAYMENTS WERE MADE TO THE FOLLOWING INDIVIDUALS DURING 2010 AS PAYOUTS OF THE FORMER 457(F) PLAN IN CONJUNCTION WITH THE CHANGE OF CONTROL PROVISIONS OF THAT PLAN: JEFFREY D SELBERG - $1,327,697 ROBERT ALAN MINKIN - $130,884 ROBERT H MALTE - $146,152 JUDY A MITCHELL - $95,312 DAVID HAMM - $275,300
SUPPLEMENTAL NONQUALIFIED RETIREMENT PLANS SCHEDULE J, PART I QUESTION 4B EXEMPLA HAD A 457(F) SUPPLEMENTAL NONQUALIFIED DEFERRED COMPENSATION PLAN, IN WHICH CERTAIN KEY OFFICERS PARTICIPATED UNTIL A CHANGE OF CONTROL OF THE ORGANIZATION IN 2009. THE FOLLOWING OFFICERS RECEIVED CHANGE OF CONTROL DISTRIBUTIONS FROM THE 457(F) PLAN IN 2010 IN ACCORDANCE WITH THE PROVISIONS OF THAT PLAN: JEFFREY D SELBERG - $1,327,697 ROBERT ALAN MINKIN - $130,884 ROBERT H MALTE - $146,152 JUDY A MITCHELL - $95,312 DAVID HAMM - $275,300 FURTHER, OTHER REPORTABLE COMPENSATION SHOWN IN SCHEDULE J PART II COLUMN (B) (III) CONTAINS AN ANNUAL REPORTING ADJUSTMENT FOR CERTAIN EMPLOYEES WHO PARTICIPATE IN THE SUPPLEMENTAL NONQUALIFIED RETIREMENT PLANS. SISTERS OF CHARITY OF LEAVENWORTH HEALTH SYSTEM (SCLHS) PROVIDES NONQUALIFIED RETIREMENT PLANS FOR EXECUTIVES TO COMPENSATE FOR IRS IMPOSED LIMITATIONS IN QUALIFIED RETIREMENT PLANS AND TO PROVIDE A BENEFIT CONSISTENT WITH OTHER NOT FOR PROFIT HEALTH SYSTEMS. THESE PLANS ENABLE THE EXECUTIVE TO EARN BENEFITS DURING EACH YEAR THAT THEY PARTICIPATE. ON THE ADVICE OF COUNSEL, SCLHS HAS DETERMINED THAT THESE BENEFITS SHOULD BE SUBJECT TO TAXATION AS THEY ARE EARNED AND VESTED RATHER THAN WHEN THEY ARE RECEIVED. AS A RESULT, THE TOTAL NONQUALIFIED RETIREMENT PLAN BENEFITS, WHICH WERE ACCRUED AND VESTED IN THE CURRENT YEAR, ARE NOW CONSIDERED TAXABLE AND THUS WERE TAXED TO THE PARTICIPANTS. AN AMOUNT EQUAL TO THE PARTICIPANT'S EXPECTED INCOME TAX LIABILITY WAS WITHDRAWN FROM THE PARTICIPANT'S ACCOUNT AND REMITTED TO THE IRS AS WITHHOLDING ON THE TAXABLE BENEFIT. THE AMOUNTS WITHDRAWN FROM THE PLAN FOR TAXES IN 2010 WERE: ROBERT W. LADENBURGER - $120,631 WILLIAM M. MURRAY - $113,244
INCENTIVE PLANS SCHEDULE J, PART I, QUESTION 6A THE MANAGEMENT INCENTIVE PLANS ARE BASED ON A COMBINATION OF MEASURES, AND ARE TAILORED TO INDIVIDUAL PARTICIPANTS. SENIOR LEADERSHIP IS ELIGIBLE FOR THE SENIOR MANAGEMENT INCENTIVE PLAN (SMIP). PERFORMANCE CATEGORIES FOR THE SMIP ARE LIVES SAVED, MEDICARE CORE MEASURES, PATIENT SAFETY COMPOSITE, INPATIENT SATISFACTION, LEVEL OF INPATIENTS THAT WOULD RECOMMEND, EMPLOYEE ENGAGEMENT, BEST PLACE TO PRACTICE RESULTS FOR PHYSICIANS, ADJUSTED ADMISSIONS, EMERGENCY AVAILABILITY, FLEX BUDGET COMPLIANCE, AND OPERATING CASH FLOW MARGIN. THE FINAL TWO CATEGORIES ARE GENERALLY RELATED TO THE NET EARNINGS OF THE DIVISION IN WHICH THE INDIVIDUAL WORKS, OR IN THE CASE OF SYSTEM SERVICES SENIOR MANAGEMENT, THE NET EARNINGS OF THE COMPANY. THE RELATIVE WEIGHT OF EACH CATEGORY IS TAILORED TO THE INDIVIDUAL PARTICIPANT. DESIGNATED MANAGERS AND DIRECTORS ARE ELIGIBLE FOR THE MANAGEMENT INCENTIVE PLAN (MIP). PERFORMANCE CATEGORIES FOR THE MIP ARE HOSPITAL OPERATING MARGIN, HOSPITAL PATIENT SATISFACTION, CLINICAL AND OPERATIONAL EXCELLENCE, FINANCIAL PERFORMANCE, SERVICE EXCELLENCE, EMPLOYEE ENGAGEMENT, AND PHYSICIAN ENGAGEMENT. THE RELATIVE WEIGHT OF EACH CATEGORY IS TAILORED TO THE INDIVIDUAL PARTICIPANT.
INITIAL CONTRACT EXCEPTION SCHEDULE J, PART I, QUESTION 8 ROBERT MINKIN WAS HIRED IN JUNE 2006, AND WAS PAID PURSUANT TO A CONTRACT THAT WAS SUBJECT TO THE INITIAL CONTRACT EXCEPTION DESCRIBED IN REGS. SECTION 53.4958-4(A)(3).
COMPENSATION OF BOARD MEMBER SCHEDULE J, PART II THE SISTERS OF CHARITY OF LEAVENWORTH HEALTH SYSTEM, INC. (SCLHS) CONSISTS OF ELEVEN HOSPITALS AND THREE CLINICS (AFFILIATES) IN FOUR STATES INCLUDING SAINT JOHN'S HOSPITAL AND HEALTH CENTER (SAINT JOHN'S) IN SANTA MONICA, CALIFORNIA. SCLHS AND ITS AFFILIATES ADHERE TO GOVERNANCE EXCELLENCE STANDARDS INCLUDING TRANSPARENCY AND ACCOUNTABILITY. WILLIAM M. MURRAY IS PRESIDENT & CHIEF EXECUTIVE OFFICER FOR SISTERS OF CHARITY OF LEAVENWORTH HEALTH SYSTEM (SCLHS). HE ALSO SERVES AS A MEMBER OF THE EXEMPLA, INC.'S (EXEMPLA) BOARD. THE COMPENSATION REFLECTED IS THAT OF MR. MURRAY'S POSITION AS AN SCLHS EXECUTIVE AND NOT AS A MEMBER OF EXEMPLA'S BOARD. IN KEEPING WITH SCLHS' CORE VALUE OF STEWARDSHIP, NO BOARD MEMBER SERVING ON SCLHS OR AFFILIATE BOARDS IS COMPENSATED FOR THAT SERVICE.
Schedule J (Form 990) 2010

Additional Data


Software ID:  
Software Version:  
Schedule L
(Form 990 or 990-EZ)
Department of the Treasury
Internal Revenue Service
Transactions with Interested Persons
MediumBullet Complete if the organization answered
"Yes" on Form 990, Part IV, lines 25a, 25b, 26, 27, 28a, 28b, or 28c,
or Form 990-EZ, Part V lines 38a or 40b.
MediumBullet Attach to Form 990 or Form 990-EZ. MediumBulletSee separate instructions.
OMB No. 1545-0047
2010
Open to Public Inspection
Name of the organization
EXEMPLA INC FKA LUTHERAN HOSPITAL
 
Employer identification number

84-1103606
Part I
Excess Benefit Transactions (section 501(c)(3) and section 501 (c)(4) organizations only).
Complete if the organization answered "Yes" on Form 990, Part IV, line 25a or 25b, or Form 990-EZ, Part V, line 40b.
1(a) Name of disqualified person (b) Description of transaction (c) Corrected?
Yes No





2
Enter the amount of tax imposed on the organization managers or disqualified persons during the year under section 4958. ......................... Bullet Image$
 
3
Enter the amount of tax, if any, on line 2, above, reimbursed by the organization ....... Bullet Image$
 

Part II
Loans to and/or From Interested Persons.
Complete if the organization answered "Yes" on Form 990, Part IV, line 26, or Form 990-EZ, Part V, line 38a.
(a) Name of interested person and purpose (b) Loan to or from the organization? (c)Original principal amount (d)Balance due (e) In default? (f) Approved by board or committee? (g)Written agreement?
To From Yes No Yes No Yes No
Total ...............Small Bullet $  
Part III
Grants or Assistance Benefitting Interested Persons.
Complete if the organization answered "Yes" on Form 990, Part IV, line 27.
(a) Name of interested person (b)Relationship between interested person and the organization (c)Amount of grant or type of assistance
For Privacy Act and Paperwork Reduction Act Notice, see the
Instructions for Form 990 or 990-EZ.
Cat. No. 50056A
Schedule L (Form 990 or 990-EZ) 2010
Schedule L (Form 990 or 990-EZ) 2010
Page 2
Part IV
Business Transactions Involving Interested Persons.
Complete if the organization answered "Yes" on Form 990, Part IV, line 28a, 28b, or 28c.
(a) Name of interested person (b) Relationship between interested person and the organization (c) Amount of transaction (d) Description of transaction (e) Sharing of organization's revenues?
Yes No
(1) MIDTOWN INPATIENT MEDICINE LLC PARTNER / KEY EMPLOYEE 4,530,479 HOSPITALIST SVCS AGREEMENT   No
Part V
Supplemental Information
Complete this part to provide additional information for responses to questions on Schedule L (see instructions).
Identifier Return Reference Explanation
BUSINESS TRANSACTION RELATIONSHIPS PART IV LISA KETTERING, A KEY EMPLOYEE, IS A PARTNER IN MIDTOWN INPATIENT MEDICINE.
Schedule L (Form 990 or 990-EZ) 2010

Additional Data


Software ID:  
Software Version:  




SCHEDULE O
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service
Supplemental Information to Form 990 or 990-EZ

Complete to provide information for responses to specific questions on
Form 990 or to provide any additional information.
MediumBullet Attach to Form 990 or 990-EZ.
OMB No. 1545-0047
2010
Open to Public
Inspection
Name of the organization
EXEMPLA INC FKA LUTHERAN HOSPITAL
 
Employer identification number

84-1103606
Identifier Return Reference Explanation
EXEMPT PURPOSE ACHIEVEMENTS FORM 990, PART III, QUESTION 4A - 4D EXEMPLA INC. (EXEMPLA) OPERATES EXEMPLA LUTHERAN MEDICAL CENTER (ELMC), SERVING PRIMARILY WESTERN AND SOUTHERN SUBURBAN AREAS OF METRO DENVER, EXEMPLA GOOD SAMARITAN MEDICAL CENTER (EGSMC), SERVING PRIMARILY BOULDER AND NORTHWEST COUNTIES OF METRO DENVER, AND OTHER AFFILIATED MEDICAL SERVICES. THE SYSTEM'S COLLECTIVE PROGRAM SERVICES ACCOMPLISHMENTS INCLUDE BUT ARE NOT LIMITED TO THE FOLLOWING: MEDICAL SERVICES ARE PROVIDED TO ALL WHO SEEK SERVICE REGARDLESS OF RACE, CREED, SEX, NATIONAL ORIGIN, HANDICAP, AGE, OR ABILITY TO PAY. ALTHOUGH REIMBURSEMENT FOR SERVICES IS CRITICAL FOR THE OPERATION AND STABILITY OF EXEMPLA, IT IS RECOGNIZED THAT NOT ALL INDIVIDUALS POSSESS THE ABILITY TO PURCHASE ESSENTIAL MEDICAL SERVICES. THEREFORE, IN KEEPING WITH EXEMPLA'S COMMITMENT TO SERVE ALL MEMBERS OF ITS COMMUNITY, FREE CARE AND/OR SUBSIDIZED CARE WILL BE CONSIDERED AND PROVIDED WHERE THE NEED AND/OR AN INDIVIDUAL'S INABILITY TO PAY EXIST. IN ADDITION, EXEMPLA RECOGNIZES THE ESSENTIAL NEED TO BE EXCEPTIONAL STEWARDS OF MEDICARE, MEDICAID AND COMMUNITY/PRIVATE FUNDING DOLLARS. FOR 2010, EXEMPLA PROVIDED BENEFIT TO THE COMMUNITY AT A COST OF $52,645,847, INCLUDING CHARITY CARE, UNREIMBURSED MEDICAID, OTHER SUBSIDIZED HEALTH SERVICES AND EDUCATION. EXEMPLA ALSO RECOGNIZES THE ESSENTIAL NEED TO ENHANCE AND IMPROVE MEDICAL OUTCOMES, QUALITY AND SERVICES. IN RESPONSE, A BEST IN THE NATION STRATEGY AND PROGRAM WAS IMPLEMENTED. THE OBJECTIVES OF THE PROGRAM ARE TO BE THE BEST IN THE NATION IN PREDEFINED QUALITY, SERVICE AND COST INDICATORS. THE QUALITY INDICATORS ARE IN ALIGNMENT WITH MAJOR PUBLICLY COMPARABLE DATABASES INCLUDING THE COLORADO HEALTH AND HOSPITAL ASSOCIATION AND CENTERS FOR MEDICARE AND MEDICAID SERVICES. RECOGNIZED 2010 QUALITY ACHIEVEMENTS INCLUDE, BUT ARE NOT LIMITED TO THE FOLLOWING: " EXEMPLA HEALTHCARE - SELECTED BY THOMPSON REUTERS AS ONE THE TOP 50 HOSPITAL SYSTEMS IN THE COUNTRY FOR CLINICAL QUALITY AND EFFICIENCY. " EXEMPLA HEALTHCARE IS NATIONALLY RECOGNIZED IN A CASE STUDY BY GE HEALTHCARE FOR OUR USE OF THE CENTRICITY PERINATAL CLINICAL INFORMATION SYSTEM FOR OB NURSING DOCUMENTATION FOR GREATER EFFICIENCY AND ACCURACY IN PATIENT SAFETY. " ELMC - THE HEART AND NEUROVASCULAR CENTER RECEIVED CYCLE II RE-ACCREDITATION FROM THE SOCIETY OF CHEST PAIN CENTERS (SCPS) WHICH IS GRANTED TO FACILITIES THAT MEET ESTABLISHED PROTOCOLS IN CARING FOR PATIENTS WITH ACUTE CORONARY SYMPTOMS AND OTHER RELATED ILLNESSES. THIS DESIGNATION ASSURES QUALITY CARE FROM THE TIME A PATIENT ENTERS THE HOSPITAL TO THE TIME OF DISCHARGE. " ELMC - NATIONAL EXCELLENCE IN HEALTHCARE FOUR STAR AWARD IN PATHOLOGY SERVICES, RADIOLOGY SERVICES AND OVERALL QUALITY OF CARE. " ELMC - RECEIVED APPLICATION APPROVAL FOR GET WITH THE GUIDELINES STROKE GOLD BY THE AMERICAN HEART ASSOCIATION/AMERICAN STROKE ASSOCIATION. ELMC EARNED THE GOLD PERFORMANCE ACHIEVEMENT AWARD FOR MAKING 85 PERCENT OR BETTER COMPLIANCE IN ALL OF THE METRICS BEING EVALUATED OVER THE PREVIOUS THREE YEARS. " EGSMC - CYCLE II RE-ACCREDITATION FROM THE SOCIETY OF CHEST PAIN CENTERS WHICH IS GRANTED TO FACILITIES THAT MEET ESTABLISHED PROTOCOLS IN CARING FOR PATIENTS WITH ACUTE CORONARY SYMPTOMS AND OTHER RELATED ILLNESSES. THIS DESIGNATION ASSURES QUALITY CARE FROM THE TIME A PATIENT ENTERS THE HOSPITAL TO THE TIME OF DISCHARGE. " EGSMC - CONSUMER REPORTS.ORG CAPTURED DATA FOR THE TOP HOSPITAL IN THE STATE OF COLORADO WITH THE LOWEST RATES OF INFECTION. AMONG THE 28 HOSPITALS REPORTING THIS DATA, EGSMC WAS RECOGNIZED AS THE SECOND ON THIS LIST FOR HAVING NO CENTRAL LINE INFECTIONS IN ITS CRITICAL CARE UNIT. " EGSMC - RECEIVED THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION'S NCDR ACTION REGISTRY - GWTG GOLD PERFORMANCE ACHIEVEMENT AWARD FOR 2009 - ONE OF ONLY 21 HOSPITALS NATIONWIDE TO DO SO. THIS AWARD RECOGNIZES THE COMMITMENT AND SUCCESS IN IMPLEMENTING A HIGHER STANDARD OF CARE FOR HEART ATTACK PATIENTS. COLLECTIVELY WITH ITS 634 LICENSED BEDS AT ELMC AND EGSMC, EXEMPLA SERVED THE COMMUNITY WITH 27,448 INPATIENT ADMISSIONS, 109,176 EMERGENCY ROOM (ER) VISITS AND 227,498 EXEMPLA PHYSICIAN NETWORK (OUTPATIENT CLINICS) ENCOUNTERS. COMPREHENSIVE MEDICAL SERVICES INCLUDE, BUT ARE NOT LIMITED TO, CARDIOLOGY, ONCOLOGY, ORTHOPEDIC, WOMEN AND FAMILY, PEDIATRICS, EMERGENCY AND TRAUMA, NEONATAL INTENSIVE CARE, NEUROLOGY, NEUROSURGERY, OB/GYN, GENERAL SURGICAL AND MEDICAL, PRIMARY CARE, INTERNAL MEDICINE, BEHAVIORAL HEALTH, HOSPICE CARE AND INTEGRATIVE HEALTH SERVICES. A STRONG COMMITMENT TO THE HEALTH OF THE COMMUNITY IS FURTHER EXEMPLIFIED, BUT NOT LIMITED TO, THE FOLLOWING PROGRAMS: EXEMPLA LUTHERAN MEDICAL CENTER WITH ITS 400 LICENSED BEDS, ELMC SERVED THE COMMUNITY WITH 15,764 INPATIENT ADMISSIONS AND 71,042 EMERGENCY ROOM VISITS.
SERVICES AND PROGRAMS o THE CANCER CENTER AT ELMC INCLUDES ALL STAGES OF CARE INCLUDING INITIAL DIAGNOSIS; GIVING, MONITORING AND MANAGING MEDICATIONS; PATIENT AND FAMILY EDUCATION. THE CENTER INCLUDES STATE-OF-THE-ART RADIATION ONCOLOGY CENTER, THE INFUSION CENTER, INTERNAL MEDICINE/ONCOLOGY UNIT, REHABILITATION, EDUCATION AND SUPPORT SERVICES. o AT THE HEART AND NEUROVASCULAR CENTER, PATIENTS ARE TREATED BY AN INTERDISCIPLINARY TEAM FOR CARDIAC AND NEUROLOGICAL CARE. PATIENTS DO NOT NEED TO BE TRANSFERRED TO ANOTHER FACILITY. THE CENTER FEATURES ADVANCED IMAGING EQUIPMENT AND NEUROLOGICAL SUITES TO SPEED PATIENTS' CARE. o THE BREAST CARE CENTER ACCREDITED BY THE AMERICAN COLLEGE OF RADIOLOGY, PROVIDES A FULL RANGE OF HIGH-TECH BREAST CARE SERVICES IN ITS NEW SCREENING AND DIAGNOSTIC SUITES INCLUDING DIGITAL MAMMOGRAPHY SCREENINGS AND DIAGNOSTIC SERVICES ULTRASOUND, STEREOTACTIC BIOPSIES, MEDICAL CONSULTATION, EDUCATION, AS WELL AS AN ALTERNATIVE HEALTH CENTER AND EMOTIONAL SUPPORT. o THE WOMEN AND FAMILY CENTER INCLUDES A LEVEL III NEONATAL INTENSIVE CARE UNIT AND COMPREHENSIVE PRENATAL AND PARENTING EDUCATION. THE ANTEPARTUM FAMILY UNIT HELPS PREGNANT WOMEN WHO NEED SPECIALIZED CARE FOR THEMSELVES AND/OR THEIR UNBORN BABIES. SUPPORT FOR THE NEW UNIT HELPS US REACH OUR GOAL TO HELP WOMEN HAVE HEALTHY PREGNANCIES, BIRTHS AND BABIES. o THE DIAGNOSTIC IMAGING CENTER IS ONE OF DENVER'S MOST ADVANCED IMAGING CENTER FEATURING COMPREHENSIVE STATE-OF-THE-ART DIAGNOSTIC IMAGING SERVICES COVERING FOUR BASIC MODALITIES: 40 SLICE CT SCANNER; 3.0 TELSA MRI SYSTEM; ULTRASOUND ROOMS WITH ADJOINED CHANGING ROOMS AND RESTROOMS; AND DIAGNOSTIC (X-RAY) TECHNOLOGY IN ALL-DIGITAL ENVIRONMENT. o THE HUMAN MOTION INSTITUTE (HMI) OFFERS STATE-OF-THE-ART MUSCULOSKELETAL CARE. HMI COMBINES THE MOST ADVANCED MEDICAL TECHNOLOGY WITH A DEDICATED TEAM OF PHYSICIANS AND MEDICAL PROFESSIONALS. THE FOCUS IS ON PREVENTION, ASSESSMENT, TREATMENT AND REHABILITATION OF MUSCULOSKELETAL INJURIES. o THE DIABETES CENTER PROVIDES CERTIFIED DIABETES EDUCATORS THAT OFFER INFORMATION AND COUNSELING SERVICES AS WELL AS MULTIPLE PROGRAMS TO HELP PATIENTS MANAGE DIABETES. o THE EMERGENCY DEPARTMENT IS A 52 BED, FULL SERVICE DEPARTMENT WITH A LEVEL 3 TRAUMA DESIGNATION. SERVICES ARE AVAILABLE 24 HOURS A DAY / 7 DAYS A WEEK AND STAFF IS EQUIPPED TO HANDLE ANY EMERGENCY OR URGENT CARE SITUATION. SERVICES INCLUDED MEDICAL SCREENING, MEDICAL TREATMENT AND REFERRALS FOR PEOPLE OF ALL AGES. o COLLIER HOSPICE CENTER PROVIDES COMPASSIONATE, COMPREHENSIVE, INTERDISCIPLINARY END-OF-LIFE CARE FOR TERMINALLY ILL PATIENTS AND SUPPORT FOR THEIR FAMILIES. PATIENTS ARE SERVED IN THEIR HOMES, IN NURSING HOMES AND IN THE HOSPICE INPATIENT UNIT LOCATED ON ELMC'S CAMPUS. FREE COMMUNITY SERVICES: VOLUNTEER-BASED PRE-HOSPICE SUPPORT, GRIEF SUPPORT GROUPS, GRIEF EDUCATION WORKSHOPS, CAREGIVER SUPPORT GROUPS AND GRIEF SUPPORT FOR YOUNG PEOPLE. o EXEMPLA COLORADO LUTHERAN HOME (CLH) PROVIDES INDEPENDENT AND ASSISTED-LIVING ACCOMMODATIONS FOR OLDER ADULTS AND IS RECOGNIZED AS AN EDEN ALTERNATIVE FACILITY. IT IS AN ELDER-CENTERED COMMUNITY THAT IMBUES DAILY LIFE WITH VARIETY AND SPONTANEITY. CLH IS A SKILLED NURSING FACILITY THAT INCLUDES A SECURED ALZHEIMER'S UNITS FOR PATIENTS NEEDING 24/7 CARE. o EXEMPLA WEST PINES IS A BEHAVIORAL HEALTH FACILITY THAT PROVIDES INPATIENT AND OUTPATIENT PSYCHIATRIC AND RECOVERY SERVICES TO ADULTS AND ADOLESCENTS. THE WEST PINES RECOVERY CENTER OFFERS AN INNOVATIVE TWO-WEEK ADDICTION RECOVERY PROGRAM TO CLIENTS AND THEIR FAMILIES WHO STRUGGLE WITH ADDICTION, OR ADDICTION PLUS MENTAL ILLNESS. AFTER THE TWO-WEEK STAY, CLIENTS RECEIVE INTENSIVE OUTPATIENT ASSISTANCE AND OPTIONAL MEDICATION MANAGEMENT. THE PROGRAM PROVIDES SHORTER STAYS AND LOWER COSTS. o BRIDGES INTEGRATIVE HEALTH AND WELLNESS OFFERS INTEGRATIVE CARE (ACUPUNCTURE, MASSAGE, HEALING TOUCH, PULMONARY REHABILITATION, PHYSICAL THERAPY AND CARDIAC REHABILITATION). o THE EXEMPLA LUTHERAN MEDICAL CENTER FOUNDATION WAS ESTABLISHED IN 2007, IN RESPONSE TO DONOR DEMAND FOR A FOUNDATION EXCLUSIVELY DEDICATED TO THE CURRENT AND FUTURE NEEDS OF ELMC. AT ITS CORE, THE FOUNDATION HAS A COMMITMENT AND DEDICATION TO PROVIDING FOR THE EVOLVING HEALTH CARE NEEDS OF OUR COMMUNITY, WHETHER THAT IS UPDATING FACILITIES, ADDING NEW TECHNOLOGIES, OR DEVELOPING INNOVATIVE NEW PARTNERSHIPS AND SERVICES. o ESTES STREET COMMUNITY CLINIC IS A PARTNERSHIP BETWEEN ELMC, THE JEFFCO ACTION CENTER AND METRO COMMUNITY PROVIDER NETWORK. THE CLINIC SERVES HOMELESS AND LOW-INCOME CHILDREN AND ADULTS WITHOUT INSURANCE. IT PROVIDES ACUTE AND PREVENTIVE CARE, IMMUNIZATIONS AND WELL-CHILD AND WELL-WOMEN CHECKUPS. o ELMC PROVIDES COMPREHENSIVE EDUCATION PROGRAMS WITH OPPORTUNITIES FOR ALL AGES. THROUGH EDUCATION, RELIABLE HEALTH INFORMATION AND SUPPORT, THE PROGRAM PARTNERS WITH DOCTORS AND OTHER HEALTH CARE EXPERTS TO IMPROVE COMMUNITY HEALTH. EXEMPLA GOOD SAMARITAN MEDICAL CENTER WITH ITS 234 LICENSED BEDS, EGSMC SERVED THE COMMUNITY WITH 11,684 INPATIENT ADMISSIONS AND 38,134 EMERGENCY ROOM VISITS. SERVICES AND PROGRAMS o CARDIAC AND VASCULAR SERVICES INCLUDES THE CARDIAC CALCIUM SCORE FOR DETECTING HEART DISEASE RISK. o EMERGENCY AND TRAUMA SERVICES INCLUDES A LEVEL III TRAUMA CENTER, INCLUDING STROKE AND TELEMEDICINE. o BONE AND JOINT INSTITUTE INCLUDES A COMPREHENSIVE TREATMENT OF ALL JOINT INJURIES AND REPLACEMENT. FULL SERVICE PHYSICAL THERAPY IS ALSO AVAILABLE. o NEUROSCIENCES: IN 2009, GOOD SAMARITAN MEDICAL CENTER ADDED TWO BREAKTHROUGH NEUROSCIENCE TECHNOLOGIES - THE INFRARED 800TM AND THE OPMI PENTERO - FOR TREATMENT OF STROKES, ANEURYSMS, BRAIN TUMORS AND OTHER CONDITIONS. IN 2010, THE HOSPITAL EMPLOYED A STROKE FELLOWSHIP-TRAINED PHYSICIAN AND HAS CREATED A STROKE CENTER. o OTOLARYNGOLOGY INCLUDES BALLOON SINUPLASTY. o WOMEN AND FAMILY CENTER INCLUDES A LEVEL II NEONATAL INTENSIVE CARE AND COMPREHENSIVE PRENATAL AND PARENTING EDUCATION. SUPPORT FOR THE UNIT HELPS US REACH OUR GOAL TO HELP WOMEN HAVE HEALTHY PREGNANCIES, BIRTHS AND BABIES. EGSMC ALSO IS THE FIRST HOSPITAL TO RECEIVE THE BABY-FRIENDLY DESIGNATION IN COLORADO. o INPATIENT AND OUTPATIENT SURGICAL SERVICES INCLUDES A BONE & JOINT INSTITUTE. o NEUROSURGERY, INCLUDING O-ARM TECHNOLOGY FOR COMPLEX NEUROSURGICAL CASES AND THE OPMI PENTEROMICROSCOPE, A STATE OF THE ART IMPROVEMENT IN INTRA-OPERATIVE VISUALIZATION FOR BRAIN TUMORS AND ANEURYSMS, THE ONLY ONE OF ITS KIND IN THE REGION. o INTERVENTIONAL AND DIAGNOSTIC RADIOLOGY INCLUDING A 64-SLICE CT SCANNER. OTHER SERVICES INCLUDE MRI, ULTRASOUND AND DIAGNOSTIC IMAGING. o EGSMC'S HEALTH & HEALING CENTER OFFERS INPATIENT AND OUTPATIENT INTEGRATIVE CARE (ACUPUNCTURE, MASSAGE, HEALING TOUCH, PULMONARY REHABILITATION, PHYSICAL THERAPY AND CARDIAC REHABILITATION). o THE EXEMPLA GOOD SAMARIAN MEDICAL CENTER FOUNDATION WAS ESTABLISHED IN 2005 TO FUND THE CURRENT AND FUTURE NEEDS OF EGSMC. AT ITS CORE, THE FOUNDATION HAS A COMMITMENT AND DEDICATION TO PROVIDING FOR THE EVOLVING HEALTH CARE NEEDS OF OUR COMMUNITY, WHETHER IT IS UPDATING FACILITIES, ADDING NEW TECHNOLOGIES, OR DEVELOPING INNOVATIVE NEW PARTNERSHIPS AND SERVICES. o EGSMC PROVIDES WELLNESS QUEST, A COMPREHENSIVE EDUCATION PROGRAM WITH OPPORTUNITIES FOR ALL AGES. THROUGH EDUCATION, RELIABLE HEALTH INFORMATION AND SUPPORT, THE PROGRAM PARTNERS WITH DOCTORS, OTHER HEALTH CARE EXPERTS AND SCHOOLS TO IMPROVE COMMUNITY HEALTH. o EGSMC WORKS CLOSELY WITH CLINICA CAMPESINA, A LAFAYETTE-BASED, FEDERALLY-QUALIFIED CLINIC FOR INDIGENT AND LOW INCOME INDIVIDUALS IN BOULDER COUNTY, PROVIDING ASSISTANCE TO FAMILIES IN NEED. o EGSMC PARTICIPATES IN THE CRAYONS TO CALCULATORS PROGRAM ANNUALLY TO ASSIST FAMILIES IN NEED WITH NECESSARY SCHOOL SUPPLIES, INCLUDING BACKPACKS. o EGSMC'S BABY'S FIRST RIDE PROGRAM IS A SERVICE OFFERED TO ALL FAMILIES DELIVERING AT OUR HOSPITAL. PARENTS ARE TAUGHT THE PROPER WAY TO INSTALL AND USE A CAR SEAT TO ENSURE THEIR BABY'S FIRST RIDE IS A SAFE ONE. o THE EGSMC FOUNDATION STRIVES TO BE THE OPEN DOOR FOR THOSE IN OUR COMMUNITY WHO ARE AS PASSIONATELY COMMITTED TO THE EXEMPLA GOOD SAMARITAN MEDICAL CENTER'S VISION AS WE ARE. THROUGH THE FOUNDATION, DONORS WILL BE ABLE TO HELP EXEMPLA GOOD SAMARITAN MEDICAL CENTER REMAIN A UNIQUE HEALING ENVIRONMENT IN THIS COMMUNITY, USE THE MOST ADVANCED MEDICAL TECHNOLOGY, USE THE BEST PRACTICES IN CLINICAL CARE ANYWHERE, AND BE A GOOD SAMARITAN TO THOSE WHO NEED US MOST. EXEMPLA PHYSICIAN NETWORK 2010 VOLUME - 227,498 VISITS SERVICES o 17 FAMILY PRACTICE, OCCUPATIONAL MEDICINE AND PHYSICAL THERAPY CLINICS PROVIDE TOP-QUALITY PRIMARY CARE AND THE BEST TREATMENT OPTIONS FOR PHYSICAL AND WORKPLACE INJURIES. o 18 SPECIALTY CLINICS INCLUDE CARDIOLOGY, CARDIOVASCULAR SURGERY, JOINT AND SPORTS MEDICINE, NEUROLOGY AND NEUROSURGERY, MATERNAL FETAL MEDICINE, OB/GYN, UROGYNECOLOGY, DIABETES AND ENDOCRINE CARE, AND PLASTIC RECONSTRUCTIVE AND AESTHETIC SURGERY. o 2 URGENT CARE CLINICS - EXEMPLA LUTHERAN SOUTHWEST AND EXEMPLA WESTMINSTER PROVIDE CARE FOR MINOR INJURIES AND ILLNESSES.
DELEGATION OF CONTROL OVER MANAGEMENT DUTIES FORM 990, PART VI, QUESTION 3 IN JUNE 2008, EXEMPLA, INC., AS MANAGER OF EXEMPLA SAINT JOSEPH HOSPITAL, ENTERED INTO A MANAGEMENT AGREEMENT WITH INSIGHT ONCOLOGY FOR THE MANAGEMENT OF THE HOSPITAL'S COMPREHENSIVE CANCER CENTER SERVICES. IN DECEMBER 2008, LUTHERAN CAMPUS ASC, LLC, LOCATED ON THE ELMC CAMPUS, OF WHICH EXEMPLA PARTNERS, LLC IS A MEMBER, ENTERED INTO AN AGREEMENT WITH PINNACLE III, LLC FOR THE MANAGEMENT OF THE COMPANY. IN DECEMBER 2008, LUTHERAN CAMPUS ASC, LLC, LOCATED ON THE ELMC CAMPUS, OF WHICH EXEMPLA PARTNERS, LLC IS A MEMBER, ENTERED INTO AN AGREEMENT WITH PINNACLE III, LLC FOR THE MANAGEMENT OF THE COMPANY. CHANGES TO ORGANIZATIONAL DOCUMENTS FORM 990, Part VI, A, 4 EFFECTIVE APRIL 14, 2010, THE MEMBERS OF EXEMPLA AGREED TO AN AMENDMENT OF THE JOINT OPERATING AGREEMENT (JOA) THAT STATES THAT ON JUNE 30, 2014, OR EARLIER UNDER CERTAIN CIRCUMSTANCES, COMMUNITY FIRST FOUNDATION'S INTEREST IN THE JOA AND OTHER RIGHTS RELATING TO EXEMPLA WOULD BE TERMINATED AT A PRICE NOT TO EXCEED $280 MILLION.
MEMBERS OR STOCKHOLDERS FORM 990, PART VI, QUESTION 6 THE ORGANIZATION HAS TWO MEMBERS: COMMUNITY FIRST FOUNDATION (CFF) AND SISTERS OF CHARITY OF LEAVENWORTH HEALTH SYSTEM (SCLHS)
ELECTION OF MEMBERS OF GOVERNING BODY FORM 990, PART VI, QUESTION 7A CFF APPOINTS 5 OF THE DIRECTORS AND SCLHS APPOINTS 5.
DECISIONS OF GOVERNING BODY SUBJECT TO APPROVAL FORM 990, PART VI, QUESTION 7B BOTH MEMBERS (COMMUNITY FIRST FOUNDATION AND SISTERS OF CHARITY OF LEAVENWORTH HEALTH SYSTEM, SCLHS) HAVE CERTAIN RESERVE POWERS TO APPROVE CHANGES TO THE BYLAWS REGARDING APPOINTMENT OF BOARD MEMBERS. SCLHS ALSO HAS EXTENSIVE RESERVE POWERS OVER ANY CHANGE IN MISSION, CHANGES TO THE ARTICLES OF INCORPORATION OR BYLAWS, ACQUISITION OF ASSETS, INCURRENCE OF DEBT, MERGER OR DISSOLUTION, APPROVAL OF STRATEGIC PLANS AND BUDGETS, AND APPOINTMENT OF AUDITORS.
990 REVIEW PROCESS FORM 990, PART VI, QUESTION 11A ALL 990 REPORTING WAS REVIEWED INTERNALLY WITH SENIOR MANAGEMENT. ALL QUESTIONS AND CHANGES PROPOSED WERE ADDRESSED PRIOR TO FILING FORM 990. A DRAFT 990 WAS PROVIDED TO THE MEMBERS OF THE AUDIT COMMITTEE AND OF THE BOARD FOR REVIEW. A COMPLETE COPY OF THE FINAL FORM 990 WAS THEN PROVIDED ELECTRONICALLY TO EACH VOTING MEMBER OF THE EXEMPLA BOARD OF DIRECTORS PRIOR TO ITS SUBMISSION TO THE INTERNAL REVENUE SERVICE.
MONITORING COMPLIANCE WITH CONFLICT OF INTEREST POLICY FORM 990, PART VI, QUESTION 12C THE ORGANIZATION REGULARLY AND CONSISTENTLY MONITORS AND ENFORCES ITS CONFLICT OF INTEREST POLICY BY PROVIDING EDUCATION AND TRAINING FOR EACH OF ITS EMPLOYEES, STAFF, OFFICERS AND DIRECTORS, AS WELL AS HAVING EACH OF THESE INDIVIDUALS COMPLETE A CONFLICT OF INTEREST STATEMENT ON AN ANNUAL BASIS TO DISCLOSE ANY POTENTIAL CONFLICT ISSUES. THESE STATEMENTS ARE CAREFULLY REVIEWED BY THE LEGAL DEPARTMENT. WHEN A CONFLICT IS IDENTIFIED, THE LEGAL DEPARTMENT COMPILES ALL REPORTED CONFLICTS, AND EVALUATES THE DISCLOSURES FOR ACTUAL CONFLICTS. A REPORT IS PROVIDED TO ORGANIZATION'S PRESIDENT/CEO REGARDING EMPLOYEES AND OFFICERS, AND TO THE CHAIR OF THE BOARD AND CHAIR OF THE GOVERNANCE COMMITTEE REGARDING BOARD MEMBERS. THOSE WITH IDENTIFIED CONFLICTS OF INTEREST MUST RECUSE THEMSELVES FROM ANY MEETING DURING THE DISCUSSION AND VOTE THEREOF.
PROCESS FOR DETERMINING COMPENSATION OF CEO, OFFICERS, OR KEY EMPLOYEES FORM 990, PART VI, QUESTION 15A & 15B WHEN REVIEWING AND SETTING COMPENSATION FOR "DISQUALIFIED PERSONS", EXEMPLA'S PROCESS INCLUDES: THE COMPENSATION COMMITTEE OF THE BOARD IS CHARGED WITH THE RESPONSIBILITY FOR SETTING THE OVERALL COMPENSATION PHILOSOPHY AND FOR EVALUATING THE TOTAL COMPENSATION PROGRAMS FOR DISQUALIFIED PERSONS. THE BOARD MEMBERS ARE INDEPENDENT MEMBERS AND IN THESE DISCUSSIONS THE CEO RECUSES HIMSELF FROM THE DISCUSSIONS AROUND HIS OWN COMPENSATION. THE COMMITTEE OBTAINS VALID, COMPARABLE MARKET DATA (FROM INDEPENDENTLY PUBLISHED SOURCES) FOR COMPARABLE POSITIONS AND FROM 990 FILINGS. THIS COMMITTEE ENGAGES THE SERVICES OF AN INDEPENDENT EXPERT IN EXECUTIVE COMPENSATION TO REVIEW THE MARKET DATA AND PROVIDE AN OPINION AS TO THE REASONABLENESS OF THE TOTAL COMPENSATION PROGRAM. FOR THE PAST SEVERAL YEARS, THE INDEPENDENT FIRM HAS BEEN WATSON WYATT. WATSON WYATT VALIDATES THE PROCESS USED BY MANAGEMENT FOR IDENTIFYING "DISQUALIFIED PERSONS' AND THEN CONDUCTS A COMPARABILITY STUDY/ANALYSIS OF PAY AT SIMILAR TYPES AND SIZES OF ORGANIZATIONS AND REVIEWS BASE SALARY, INCENTIVE (OR OVER-BASE PROGRAMS), BENEFITS, RETIREMENT PLANS AND PERQUISITES. WATSON WYATT REVIEWS THE FINDINGS WITH THE BOARD COMMITTEE AND MINUTES ARE PREPARED AND SHARED WITH ALL THE VOTING BOARD MEMBERS EACH YEAR THAT DOCUMENTS THE DISCUSSION AND ANY ACTIONS THAT MAY HAVE BEEN TAKEN. A COPY OF A FORMAL OPINION LETTER PREPARED BY WATSON WYATT FOLLOWING THE DISCUSSION WITH THE COMPENSATION COMMITTEE IS PROVIDED TO THE BOARD CHAIR AND SHARED WITH THE FULL BOARD. THIS PROCESS IS UNDERTAKEN EACH YEAR. SISTERS OF CHARITY OF LEAVENWORTH HEALTH SYSTEM (SCLHS) EMPLOYS THE EXECUTIVE TEAM AT EACH OF ITS HOSPITAL AFFILIATES, INCLUDING EXEMPLA. AS PART OF ITS ANNUAL REVIEW PROCESS, SCLHS USES THE FOLLOWING IN ESTABLISHING THE COMPENSATION OF THOSE IN THESE POSITIONS: -COMPENSATION COMMITTEE -INDEPENDENT COMPENSATION CONSULTANT -FORM 990 OF OTHER ORGANIZATIONS -WRITTEN EMPLOYMENT CONTRACTS -COMPENSATION SURVEYS AND STUDIES -APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE THE ABOVE SUPPORT THE COMPENSATION COMMITTEE'S EFFORTS TO ENSURE THAT THE LEVEL OF COMPENSATION PROVIDED TO ITS EXECUTIVES (OFFICERS, KEY EMPLOYEES, ETC.) IS CONSISTENT WITH MARKET VALUE AND THE PAY PHILOSOPHY SET BY THE BOARD. THE PAY PHILOSOPHY SET BY THE BOARD IS TO PAY AT THE MIDDLE OF THE MARKET FOR EXECUTIVES OF SIMILAR SIZED ORGANIZATIONS OVERALL. SCLHS' EXECUTIVE COMPENSATION IS COMPARABLE TO THAT PROVIDED IN SIMILAR, NOT-FOR-PROFIT HEALTHCARE SYSTEMS AND HOSPITALS.
AVAILABILITY OF GOVERNING DOCS, CONFLICT OF INTEREST POLICY, FINANCIALS FORM 990, PART VI, QUESTION 19 GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, FINANCIAL STATEMENTS, AND RELATED DOCUMENTS ARE PROVIDED UPON REQUEST AS DEEMED APPROPRIATE.
BOND ISSUANCES PART IV, QUESTION 24 THE PROJECT FINANCED WITH SERIES 2009A BONDS WAS NOT PLACED INTO SERVICE UNTIL 2010. DURING 2010, THE 2009A BONDS WERE TRANSFERRED TO THE SISTERS OF CHARITY OF LEAVENWORTH HEALTH SYSTEM'S (SCLHS) MASTER TRUST INDENTURE. FURTHER, ALL EXISTING FIXED RATE DEBT OF EXEMPLA, INC. WAS REFINANCED UNDER THE SCLHS MASTER TRUST INDENTURE DURING 2010. BECAUSE EXEMPLA HAS NO DIRECTLY OUTSTANDING BOND ISSUANCES, EXEMPLA HAS NOT COMPLETED SCHEDULE K. ALL DISCLOSURES FOR THE BONDS THAT ARE WITHIN THE SCLHS MASTER TRUST INDENTURE ARE INCLUDED IN THE SCLHS FORM 990.
INDEPENDENT CONTRACTORS PART VII, SECTION B, QUESTION 2 EXEMPLA, INC., AS THE PARENT COMPANY/MANAGER OF OTHER ENTITIES, INCLUDING ST JOSEPH HOSPITAL, MAKES ALL VENDOR PAYMENTS FOR THOSE ENTITIES. THE DOLLAR AMOUNTS AND TOTAL NUMBER OF PAYMENTS TO INDEPENDENT CONTRACTORS REFLECTED IN THIS RETURN ARE THE COMBINED PAYMENTS FOR EXPENDITURES OF ALL SUCH ENTITIES.
OTHER CHANGES IN NET ASSETS PART XI, Line 5 OTHER CHANGES IN NET ASSETS: CONTRIBUTIONS TO RELATED ORGANIZATIONS (984,429) UNREALIZED GAIN - NET 7,462,581 CHANGE IN FUNDED STATUS OF PENSION (132,235) CHANGE IN INVESTMENT IN SYSTEM (5,060,785) CHANGE IN PROF AND GEN LIABILITY TRUST 2,743,190 OTHER (196,821) TOTAL 3,831,501
HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:WILLIAM M MURRAY TITLE:CHAIRMAN HOURS:50
HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:DAVID C PECORARO TITLE:SVP & CIO HOURS:25
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.
Cat. No. 51056K
Schedule O (Form 990 or 990-EZ) 2010

Additional Data


Software ID:  
Software Version:  
SCHEDULE R
(Form 990)
Department of the Treasury
Internal Revenue Service
Related Organizations and Unrelated Partnerships
MediumBulletComplete if the organization answered "Yes" to Form 990, Part IV, line 33, 34, 35, 36, or 37.
MediumBulletAttach to Form 990. MediumBullet See separate instructions.

OMB No. 1545-0047
2010
Open to Public Inspection
Name of the organization
EXEMPLA INC FKA LUTHERAN HOSPITAL
 
Employer identification number

84-1103606
Part I
Identification of Disregarded Entities (Complete if the organization answered "Yes" on Form 990, Part IV, line 33.)
(a)
Name, address, and EIN of disregarded entity


(b)
Primary activity


 		(c)
Legal domicile (state
or foreign country)

 		(d)
Total income
(e)
End-of-year assets


 		(f)
Direct controlling
entity







(1) EXEMPLA PARTNERS LLC
8300 W 38TH AVE
WHEAT RIDGE,CO80033
02-0749530 		JT VENTURE IN CO 8,019 657,291 EXEMPLA INC
 
(2) Lutheran Health Partners LLC
8300 W 38TH AVE
WHEAT RIDGE,CO80033
84-1103606 		HC IMPROVEMEN CO 120,000 596,111 EXEMPLA PART
 
(3) EXEMPLA GOOD SAMARITAN MEDICAL CENTER L
200 EXEMPLA CIRCLE
LAFAYETTE,CO80026
43-1982139 		HEALTHCARE CO 228,863,275 345,858,556 EXEMPLA INC
 






Part II
Identification of Related Tax-Exempt Organizations (Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related tax-exempt organizations during the tax year.)
(a)
Name, address, and EIN of related organization


(b)
Primary activity


 		(c)
Legal domicile (state
or foreign country)

 		(d)
Exempt Code section
(e)
Public charity status
(if section 501(c)(3))

 		(f)
Direct controlling
entity

 		(g)
Section 512(b)(13) controlled organization
Yes No
(1) SISTERS OF CHARITY LEAVENWORTH HLTH SYST

9801 RENNER BLVD STE 100

LENEXA,KS66219
23-7379161 		SUPPORT MMBRS KS 501(C)(3) 11B-TYPE II NA
 
 
 
(2) CARITAS CLINICS INC

818 NORTH 7TH STREET

LEAVENWORTH,KS66048
48-1009910 		CLINIC SVCS KS 501(C)(3) 3 NA
 
 
 
(3) MARIAN CLINIC INC

1001 SW GARFIELD

TOPEKA,KS66604
48-1046905 		CLINIC SVCS KS 501(C)(3) 3 NA
 
 
 
(4) MARILLAC CLINIC INC

2333 N 6TH STREET

GRAND JUNCTION,CO81501
84-1085822 		CLINIC SVCS CO 501(C)(3) 3 NA
 
 
 
(5) PROVIDENCE MEDICAL CENTER

8929 PARALLEL PARKWAY

KANSAS CITY,KS66112
48-0784446 		HEALTHCARE KS 501(C)(3) 3 NA
 
 
 
(6) ST JOHN HOSPITAL INC

3500 SOUTH FOURTH STREET

LEAVENWORTH,KS66048
48-0543768 		HEALTHCARE KS 501(C)(3) 3 NA
 
 
 
(7) BETHANY COMMUNITY PLAZA INC

15 NORTH 12TH STREET

KANSAS CITY,KS66102
48-1207407 		HEALTHCARE KS 501(C)(3) 3 NA
 
 
 
(8) PROVIDENCEST JOHN FOUNDATION INC

8929 PARALLEL PARKWAY

KANSAS CITY,KS661121689
48-0925688 		SUPPORT 501C3 KS 501(C)(3) 7 NA
 
 
 
(9) ST FRANCIS HEALTH CENTER INC

1700 SW 7TH STREET

TOPEKA,KS66606
48-0547719 		HEALTHCARE KS 501(C)(3) 3 NA
 
 
 
(10) ST FRANCIS HEALTH CENTER FOUNDATION

1700 SW 7TH STREET

TOPEKA,KS66606
48-1092520 		SUPPORT 501C3 KS 501(C)(3) 11A-TYPE I NA
 
 
 
(11) ST MARYS HOSPITAL & MEDICAL CENTER INC

2635 N 7TH STREET

GRAND JUNCTION,CO81502
84-0425720 		HEALTHCARE CO 501(C)(3) 3 NA
 
 
 
(12) ST MARYS HOSPITAL FOUNDATION

2635 N 7TH STREET

GRAND JUNCTION,CO81502
23-7001007 		SUPPORT 501C3 CO 501(C)(3) 11A-TYPE I NA
 
 
 
(13) SAINT JOSEPH HOSPITAL FOUNDATION

1835 FRANKLIN STREET

DENVER,CO80218
84-0735096 		SUPPORT 501C3 CO 501(C)(3) 11A-TYPE I NA
 
 
 
(14) HOLY ROSARY HEALTHCARE

2600 WILSON

MILES CITY,MT59301
81-0231792 		HEALTHCARE MT 501(C)(3) 3 NA
 
 
 
(15) HOLY ROSARY HEALTHCARE FOUNDATION INC

2600 WILSON

MILES CITY,MT59301
20-2270238 		SUPPORT 501C3 MT 501(C)(3) 11A-TYPE I NA
 
 
 
(16) ST VINCENT HEALTHCARE

1233 NORTH 30TH

BILLINGS,MT59101
81-0232124 		HEALTHCARE MT 501(C)(3) 3 NA
 
 
 
(17) ST VINCENT HEALTHCARE FOUNDATION

PO BOX 35200

BILLINGS,MT591075200
81-0468034 		SUPPORT 501C3 MT 501(C)(3) 7 NA
 
 
 
(18) NORTHWEST RESEARCH & EDUCATION INSTITUTE

315 NORTH 25TH STREET

BILLINGS,MT59101
20-1343024 		COMM HLTH RES MT 501(C)(3) 9 NA
 
 
 
(19) ST JAMES HEALTHCARE

400 SOUTH CLARK STREET

BUTTE,MT597012328
81-0231785 		HEALTHCARE MT 501(C)(3) 3 NA
 
 
 
(20) ST JAMES HEALTHCARE FOUNDATION

400 SOUTH CLARK STREET

BUTTE,MT59701
65-1202190 		SUPPORT 501C3 MT 501(C)(3) 11A-TYPE I NA
 
 
 
(21) SAINT JOHNS HOSPITAL AND HEALTH CENTER

1328 22ND STREET

SANTA MONICA,CA90404
95-1684082 		HEALTHCARE CA 501(C)(3) 3 NA
 
 
 
(22) JOHN WAYNE CANCER INSTITUTE

2000 SANTA MONICA BLVD

SANTA MONICA,CA90404
95-4291515 		CANCER R&D CA 501(C)(3) 4 NA
 
 
 
(23) SAINT JOHNS HOSPITAL & HLTH CENTER FNDTN

1328 22ND STREET

SANTA MONICA,CA904042091
95-6100079 		SUPPORT 501C3 CA 501(C)(3) 11A-TYPE I NA
 
 
 
(24) EXEMPLA LUTHERAN MEDICAL CENTER FNDTN

2480 W 26TH AVESUITE 360B

DENVER,CO80211
20-8846152 		SUPPORT 501C3 CO 501(C)(3) 7 NA
 
 
 
(25) EXEMPLA GOOD SAMARITAN MEDICAL CTR FNDTN

200 EXEMPLA CIRCLE

LAFAYETTE,CO80026
84-1649162 		SUPPORT 501C3 CO 501(C)(3) 7 NA
 
 
 
(26) LUTH MED CNTR PRO&GEN LIAB SELF-INS TRST

2480 W 26TH AVE SUITE 360B

DENVER,CO80211
74-2571584 		INSURANCE CO 501(C)(3) 11A-TYPE I NA
 
 
 
(27) MEDPARK INC

2480 W 26TH AVESUITE 360B

DENVER,CO80211
84-1490379 		PARKING CO 501(C)(3) 7 NA
 
 
 
(28) SAINT JOSEPH HOSPITAL

1835 FRANKLIN STREET

DENVER,CO80218
84-0417134 		HEALTHCARE CO 501(C)(3) 3 NA
 
 
 
For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50135Y
Schedule R (Form 990) 2010
Schedule R (Form 990) 2010
Page 2
Part III
Identification of Related Organizations Taxable as a Partnership (Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related organizations treated as a partnership during the tax year.)
(a)
Name, address, and EIN of
related organization



 		(b)
Primary activity




 		(c)
Legal
domicile
(state or foreign
country)


 		(d)
Direct controlling
entity



 		(e)
Predominant income(related, unrelated, excluded from tax under sections 512-514)

(f)
Share of total income




 		(g)
Share of end-of-year
assets



 		(h)
Disproprtionate allocations?




 		(i)
Code V—UBI
amount in box 20 of
Schedule K-1
(Form 1065)
 		(j)
General or
managing
partner?



 		(k)
Percentage
ownership
Yes No Yes No
(1) PAVILION IMAGING LLC

750 WELLINGTON
GRAND JUNCTION,CO81501
03-0516198 		RADIOLOGY CO NA
  		N/A 0 0   No 0   No  
(2) GRAND VALLEY SURGICAL CENTER LLC

710 WELLINGTON
GRAND JUNCTION,CO81501
84-1505075 		OP SURGERY CO NA
  		N/A 0 0   No 0   No  
(3) SAN JUAN CANCER CENTER LLC

600 SOUTH 5TH STREET
MONTROSE,CO81401
20-2856331 		OP CANCER CO NA
  		N/A 0 0   No 0   No  
(4) BILLINGS MRI CENTER LLC

1041 NORTH 29TH STREET
BILLINGS,MT59101
81-0450943 		MRI-PET SCAN MT NA
  		N/A 0 0   No 0   No  
(5) LUTHERAN CAMPUS ASC LLC

3455 LUTHRN PKW SUITE 150
WHEATRIDGE,CO800336028
02-0749532 		OP SURGERY CO EXEMPLA PTNRS
  		RELATED 503,873 3,035,937   No 0   No 54.564 %
(6) COLORADO SURGICAL VENTURES LLC

30 S WACKER DR SUITE 2302
CHICAGO,IL60605
20-8038915 		OP SURGERY CO NA
  		N/A 0 0   No 0   No  
(7) COLORADO SURGICAL HOSPITAL LLC

30 S WACKER DR SUITE 2302
CHICAGO,IL60605
20-8038977 		OP SURGERY CO NA
  		N/A 0 0   No 0   No  
Part IV
Identification of Related Organizations Taxable as a Corporation or Trust (Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related organizations treated as a corporation or trust during the tax year.)
(a)
Name, address, and EIN of related organization



 		(b)
Primary activity



 		(c)
Legal domicile
(state or
foreign
country)
 		(d)
Direct controlling
entity


 		(e)
Type of entity
(C corp, S corp,
or trust)

 		(f)
Share of total income



 		(g)
Share of
end-of-year
assets

 		(h)
Percentage
ownership
(1) CARITAS INC AND SUBSIDIARIES
9801 RENNER BOULEVARD SUITE 100
LENEXA,KS66219
48-0941069 		OTHER MEDICAL KS N/A
 C CORP 0 0 0 %
(2) LEAVEN INSURANCE COMPANY LTD
23 LIME TREE BAY AVE PO BOX 1051
GEORGETOWN,GRAND CAYMANKY1-1102
CJ
98-0370522 		INSURANCE CJ N/A
   0 0 0 %










Schedule R (Form 990) 2010
Schedule R (Form 990) 2010
Page 3
Part V
Transactions With Related Organizations (Complete if the organization answered "Yes" on Form 990, Part IV, line 34, 35, 35A, or 36.)
Note. Complete line 1 if any entity is listed in Parts II, III or IV.
Yes
No
1 During the tax year, did the orgranization engage in any of the following transactions with one or more related organizations listed in Parts II-IV?
a Receipt of (i) interest (ii) annuities (iii) royalties (iv) rent from a controlled entity . . . . . . . . . . . . . . . . . . . . . . .
1a
 
No
b Gift, grant, or capital contribution to other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1b
Yes
 
c Gift, grant, or capital contribution from other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1c
Yes
 
d Loans or loan guarantees to or for other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1d
Yes
 
e Loans or loan guarantees by other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1e
Yes
 
f Sale of assets to other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1f
 
No
g Purchase of assets from other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1g
 
No
h Exchange of assets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1h
 
No
i Lease of facilities, equipment, or other assets to other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1i
Yes
 
j Lease of facilities, equipment, or other assets from other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . .
1j
 
No
k Performance of services or membership or fundraising solicitations for other organization(s) . . . . . . . . . . . . . . . . . . . . . .
1k
Yes
 
l Performance of services or membership or fundraising solicitations by other organization(s) . . . . . . . . . . . . . . . . . . . . . .
1l
 
No
m Sharing of facilities, equipment, mailing lists, or other assets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1m
Yes
 
n Sharing of paid employees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1n
Yes
 
o Reimbursement paid to other organization for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1o
Yes
 
p Reimbursement paid by other organization for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1p
Yes
 
q Other transfer of cash or property to other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1q
 
No
r Other transfer of cash or property from other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1r
Yes
 
2
If the answer to any of the above is "Yes," see the instructions for information on who must complete this line, including covered relationships and transaction thresholds.
(a)
Name of other organization 		(b)
Transaction
type(a-r) 		(c)
Amount involved 		(d)
Method of determining amount involved
(1) SAINT JOSEPH HOSPITAL

 N 172,002,825  
(2) SAINT JOSEPH HOSPITAL

 M 5,060,785  
(3) SAINT JOSEPH HOSPITAL

 K 34,256,326  
(4) SAINT JOSEPH HOSPITAL

 R 12,783,753  
(5) SAINT JOSEPH HOSPITAL

 E 60,000,000  
(6) EXEMPLA LUTHERAN MEDICAL CENTER FOUNDATION

 N 216,776  
(7) EXEMPLA LUTHERAN MEDICAL CENTER FOUNDATION

 O 45,280  
(8) EXEMPLA LUTHERAN MEDICAL CENTER FOUNDATION

 C 394,775  
(9) EXEMPLA GOOD SAMARITAN MEDICAL CTR FOUNDATION

 N 239,216  
(10) EXEMPLA GOOD SAMARITAN MEDICAL CTR FOUNDATION

 O 229,627  
(11) EXEMPLA GOOD SAMARITAN MEDICAL CTR FOUNDATION

 C 165,231  
(12) LUTHERAN CAMPUS ASC LLC

 D 3,313,178  
(13) SAINT JOSEPH HOSPITAL

 P 119,680,137  
(14) LUTH MED CNTR PROF & GEN LIAB SELF-INS TRUST

 P 2,743,190  
(15) LUTH MED CNTR PROF & GEN LIAB SELF-INS TRUST

 D 264,804  
(16) EXEMPLA LUTHERAN MEDICAL CENTER FOUNDATION

 D 415,488  
(17) EXEMPLA GOOD SAMARITAN MEDICAL CTR FOUNDATION

 E 9,664  
(18) SAINT JOSEPH HOSPITAL

 E 9,151,965  
(19) SAINT JOSEPH HOSPITAL

 O 7,562,103  
Schedule R (Form 990) 2010
Schedule R (Form 990) 2010
Page 4
Part VI
Unrelated Organizations Taxable as a Partnership (Complete if the organization answered "Yes" on Form 990, Part IV, line 37.)
Provide the following information for each entity taxed as a partnership through which the organization conducted more than five percent of its activities (measured by total assets or gross revenue) that was not a related organization. See instructions regarding exclusion for certain investment partnerships.
(a)
Name, address, and EIN of entity 		(b)
Primary activity 		(c)
Legal domicile
(state or foreign
country) 		(d)
Are all
partners
section
501(c)(3)
organizations? 		(e)
Share of
end-of-year
assets 		(f)
Disproprtionate allocations? 		(g)
Code V—UBI
amount in box
20 of Schedule K-1
(Form 1065) 		(h)
General or
managing
partner?
Yes No Yes No Yes No






























Schedule R (Form 990) 2010
Schedule R (Form 990) 2010
Page 5
Part VII
Supplemental Information
Complete this part to provide additional information for responses to questions on Schedule R (see instructions).
Identifier Return Reference Explanation
METHOD TO DETERMINE VALUE OF SCHEDULE R TRANSACTIONS SCHEDULE R, PART V, LINE 2 COLUMN C THE ORGANIZATION USED THE AMOUNT RECONGIZED ON THE BOOKS AND RECORDS OF THE ORGANIZATION OF CASH RECEIVED OR PROVIDED, ADJUSTED TO THE ACCRUAL BASIS, TO DETERMINE THE VALUE OF SCHEDULE R TRANSACTIONS, WHICH APPROXIMATES FAIR VALUE.
Additional Data


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