TY 2010 Form 990

(A) Name and business address	(B) Description of services	(C) Compensation
ELLERBE BECKET INC 800 LASALLE AVE MINNEAPOLIS,MN55402	ARCHIT./CONTRACTOR	4,061,416
MCKAY CONSULTING 8590 BUSINESS PARK DR SHREVEPORT,LA71005	CONSULTANT	1,971,944
RODGERS HELICOPTER SERVICES 4965 AIRPORT ROAD KEARNEY,NE688473372	AIRCARE FLIGHT SVCS	1,548,728
SORENSEN GROUP INC 1400 WEST 22ND ST SUITE A KEARNEY,NE68845	CONTRACTOR	1,321,737
SENTINEL HEALTH CARE 2605 2ND AVE KEARNEY,NE68847	PHO	863,507
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 29

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	2,382,159	2,382,159
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	0
4	Benefits paid to or for members	0
5	Compensation of current officers, directors, trustees, and key employees ....	825,582	408,305	417,277
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	58,820,302	51,411,315	7,408,987
8	Pension plan contributions (include section 401(k) and section 403(b) employer contributions) ....	3,185,600	2,375,229	810,372
9	Other employee benefits .......	12,553,493	10,067,998	2,485,495
10	Payroll taxes ...........	4,291,006	3,633,464	657,542
11	Fees for services (non-employees):
a	Management ......	0
b	Legal .........	0
c	Accounting ...........	0
d	Lobbying ...........	0
e	Professional fundraising. See Part IV, line 17..	0
f	Investment management fees ......	0
g	Other ..........	29,628,377	19,793,913	9,834,464
12	Advertising and promotion ....	0
13	Office expenses .......	44,934,528	42,357,585	2,576,943
14	Information technology ......	0
15	Royalties ..	0
16	Occupancy ...........	2,310,822	1,746,494	564,328
17	Travel ............	622,572	423,560	199,012
18	Payments of travel or entertainment expenses for any federal, state, or local public officials ......	0
19	Conferences, conventions, and meetings ....	104,313	6,908	97,405
20	Interest ...........	1,329,403	1,329,403
21	Payments to affiliates .......	4,034,640	3,025,980	1,008,660
22	Depreciation, depletion, and amortization .....	11,401,462	8,964,286	2,437,176
23	Insurance ..............	609,237	487,389	121,847
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	Unrelated Business Taxes	11,648	11,648
b	Dues & subscriptions	373,817	209,703	164,114	0
c	Education	234,267	121,252	113,015
d	Bad debts	11,464,014	11,464,014
e	Recruitment and relocation	1,060,502	1,205	1,059,297
f	All other expenses	4,698,393	3,120,842	1,577,551	0
25	Total functional expenses. Add lines 1 through 24f	194,876,137	163,342,652	31,533,485	0
26	Joint costs. Check here 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

Part X Balance Sheet
	1	Cashnon-interest-bearing ..........	4,701	1	4,660
2	Savings and temporary cash investments .......	16,659,012	2	23,292,498
3	Pledges and grants receivable, net .........		3
4	Accounts receivable, net .........	32,966,891	4	31,321,539
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 .............	88,282	7	290,559
8	Inventories for sale or use ..............	7,631,058	8	7,411,778
9	Prepaid expenses and deferred charges ............	434,898	9	278,463
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	222,576,304
b	Less: accumulated depreciation. .....	10b	126,549,444	87,854,698	10c	96,026,860
11	Investments—publicly traded securities ..........	3,487	11	1,142
12	Investments—other securities. See Part IV, line 11 ......	133,693,001	12	170,545,706
13	Investments—program-related. See Part IV, line 11 ..		13
14	Intangible assets .........	2,301,156	14	2,301,156
15	Other assets. See Part IV, line 11 ...........	6,170,638	15	5,844,202
16	Total assets. Add lines 1 through 15 (must equal line 34)...	287,807,822	16	337,318,563
	17	Accounts payable and accrued expenses .	19,799,817	17	27,298,294
18	Grants payable ..........		18
19	Deferred revenue ..........		19
20	Tax-exempt bond liabilities ..........		20
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 ..	770,517	23	243,626
24	Unsecured notes and loans payable to unrelated third parties ....	35,061,693	24	29,807,013
25	Other liabilities. Complete Part X of Schedule D.....		25	209,836
26	Total liabilities. Add lines 17 through 25.....	55,632,027	26	57,558,769
		Organizations that follow SFAS 117, check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets .....	232,175,795	27	279,759,794
28	Temporarily restricted net assets .....		28
29	Permanently restricted net assets .....		29
	Organizations that do not follow SFAS 117, check here 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 .....	232,175,795	33	279,759,794
34	Total liabilities and net assets/fund balances .....	287,807,822	34	337,318,563

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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.

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

GOOD SAMARITAN HOSPITAL

Employer identification number

47-0379755

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.)

A church, convention of churches, or association of churches. section 170(b)(1)(A)(i).

A school described in section 170(b)(1)(A)(ii). (Attach Schedule E.)

A hospital or a cooperative hospital service organization described in section 170(b)(1)(A)(iii).

A medical research organization operated in conjunction with a hospital described in section 170(b)(1)(A)(iii). Enter the hospital's name, city, and state:

An organization operated for the benefit of a college or university owned or operated by a governmental unit described in

section 170(b)(1)(A)(iv). (Complete Part II.)

A federal, state, or local government or governmental unit described in section 170(b)(1)(A)(v).

An organization that normally receives a substantial part of its support from a governmental unit or from the general public described in

section 170(b)(1)(A)(vi). (Complete Part II.)

A community trust described in section 170(b)(1)(A)(vi). (Complete Part II.)

An organization that normally receives: (1) more than 331/3% of its support from contributions, membership fees, and gross

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.)

An organization organized and operated exclusively to test for public safety. Seesection 509(a)(4).

An organization organized and operated exclusively for the benefit of, to perform the functions of, or to carry out the purposes of one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2). See section 509(a)(3). Check the box that describes the type of supporting organization and complete lines 11e through 11h.

Type I

Type II

Type III - Functionally integrated

Type III - Other

By checking this box, I certify that the organization is not controlled directly or indirectly by one or more disqualified persons other than foundation managers and other than one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2).

If the organization received a written determination from the IRS that it is a Type I, Type II or Type III supporting organization, check this box ..................................................

Since August 17, 2006, has the organization accepted any gift or contribution from any of the
following persons?

(i) a person who directly or indirectly controls, either alone or together with persons described in (ii)

Yes

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)

Provide the following information about the supported organization(s).

(i) Name of supported organization	(ii) EIN	(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?
(i) Name of supported organization	(ii) EIN	Yes	No	Yes	No	Yes	No	(vii) Amount of support?


Total

For Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 11285F

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).

Gross receipts from related activities, etc. (See instructions.) ..................

First Five Years If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization,
check this box and stop here.......................................... right arrow

Section C. Computation of Public Support Percentage

Public Support Percentage for 2010 (line 6 column (f) divided by line 11 column (f)) .........

Public Support Percentage for 2009 Schedule A, Part II, line 14 ...............

16a

33 1/3% support test—2010. If the organization did not check the box on line 13, and line 14 is 33 1/3% or more, check this box
and stop here. The organization qualifies as a publicly supported organization ...................... right arrow

33 1/3% support test—2009. If the organization did not check the box on line 13 or 16a, and line 15 is 33 1/3% or more, check this
box and stop here. The organization qualifies as a publicly supported organization ..................... right arrow

17a

10%-facts-and-circumstances test—2010. If the organization did not check a box on line 13, 16a, or 16b and line 14
is 10% or more, and if the organization meets the "facts and circumstances" test, check this box and stop here. Explain
in Part IV how the organization meets the "facts and circumstances" test. The organization qualifies as a publicly supported
organization .................................................. right arrow

10%-facts-and-circumstances test—2009. If the organization did not check a box on line 13, 16a, 16b, or 17a and line
15 is 10% or more, and if the organization meets the "facts and circumstances" test, check this box and stop here.
Explain in Part IV how the organization meets the "facts and circumstances" test. The organization qualifies as a publicly
supported organization .............................................. right arrow

Private Foundation If the organization did not check a box on line 13, 16a, 16b, 17a or 17b, check this box and see
instructions ................................................... right arrow

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.).

Section C. Computation of Public Support Percentage

Public Support Percentage for 2010 (line 8 column (f) divided by line 13 column (f)) .........

Public support percentage from 2009 Schedule A, Part III, line 15 ...............

Section D. Computation of Investment Income Percentage

Investment income percentage for 2010 (line 10c column (f) divided by line 13 column (f)) ......

Investment income percentage from 2009 Schedule A, Part III, line 17 .............

19a

33 1/3% support tests—2010. If the organization did not check the box on line 14, and line 15 is more than 33 1/3% and line 17 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization .......... right arrow

33 1/3% support tests—2009. If the organization did not check a box on line 14 or line 19a, and line 16 is more than 33 1/3% and line 18 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization .... right arrow

Private Foundation If the organization did not check a box on line 14, 19a or 19b, check this box and see instructions ..... right arrow

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:

- TIN:

Schedule B
(Form 990, 990-EZ,
or 990-PF)

Department of the Treasury
Internal Revenue Service

Schedule of Contributors

Attach to Form 990, 990-EZ, or 990-PF.

OMB No. 1545-0047

2010

Name of organization

GOOD SAMARITAN HOSPITAL

Employer identification number

47-0379755

Organization type (check one):

Filers of:

Section:

Form 990 or 990-EZ

501(c)( ) (enter number) organization

4947(a)(1) nonexempt charitable trust not treated as a private foundation

527 political organization

Form 990-PF

501(c)(3) exempt private foundation

4947(a)(1) nonexempt charitable trust treated as a private foundation

501(c)(3) taxable private foundation

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

For an organization filing Form 990, 990-EZ, or 990-PF that received, during the year, $5,000 or more (in money or
property) from any one contributor. Complete Parts I and II.

Special Rules

For a section 501(c)(3) organization filing Form 990 or 990-EZ, that met the 33¹/3% support test of the regulations
under sections 509(a)(1) and 170(b)(1)(A)(vi), and received from any one contributor, during the year, a contribution of the
greater of (1) $5,000 or (2) 2% of the amount on (i) Form 990, Part VIII, line 1h, or (ii) Form 990-EZ, line 1. Complete Parts I and II.

For a section 501(c)(7), (8), or (10) organization filing Form 990, or 990-EZ, that received from any one contributor,
during the year, aggregate contributions of more than $1,000 for use exclusively for religious, charitable,
scientific, literary, or educational purposes, or the prevention of cruelty to children or animals. Complete Parts I, II, and
III.

For a section 501(c)(7), (8), or (10) organization filing Form 990, or 990-EZ, that received from any one contributor,
during the year, contributions for use exclusively for religious, charitable, etc., purposes, but these contributions did
not aggregate to more than $1,000. If this box is checked, enter here the total contributions that were received during
the year for an exclusively religious, charitable, etc., purpose. Do not complete any of the parts unless the General Rule
applies to this organization because it received nonexclusively religious, charitable, etc., contributions of $5,000 or more
during the year. ......................... 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)

Name of organization GOOD SAMARITAN HOSPITAL
Schedule B (Form 990, 990-EZ, or 990-PF) (2010) Page 1 of 1 of Part I
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	Person Payroll Noncash (Complete Part II if there is a noncash contribution.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Aggregate contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II if there is a noncash contribution.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Aggregate contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II if there is a noncash contribution.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Aggregate contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II if there is a noncash contribution.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Aggregate contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II if there is a noncash contribution.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Aggregate contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II if there is a noncash contribution.)
Schedule B (Form 990, 990-EZ, or 990-PF) (2010)

Name of organization GOOD SAMARITAN HOSPITAL
Schedule B (Form 990, 990-EZ, or 990-PF) (2010) Page 1 of 1 of Part II
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
GOOD SAMARITAN HOSPITAL

Employer identification number

47-0379755

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

(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

(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

(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

(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:

- TIN:

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

GOOD SAMARITAN HOSPITAL

Employer identification number

47-0379755

Part I-A

Complete if the organization is exempt under section 501(c) or is a section 527 organization.

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.

Political expenditures .................................... SchCMd Bullet

Volunteer hours ........................................

Part I-B

Complete if the organization is exempt under section 501(c)(3).

Enter the amount of any excise tax incurred by the organization under section 4955 ......... SchCMd Bullet

Enter the amount of any excise tax incurred by organization managers under section 4955 ...... SchCMd Bullet

If the organization incurred a section 4955 tax, did it file Form 4720 for this year? ..............

Yes No

Was a correction made? .........................................

Yes No

If "Yes," describe in Part IV.

Part I-C

Complete if the organization is exempt under section 501(c) except section 501(c)(3).

Enter the amount directly expended by the filing organization for section 527 exempt function activities SchCMd Bullet

Enter the amount of the filing organization's funds contributed to other organizations for section 527 exempt funtion activities .................................... SchCMd Bullet

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

Did the filing organization file Form 1120-POL for this year? ..........................

Yes No

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

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 if the filing organization belongs to an affiliated group.
B Check if the filing organization checked box A and "limited control" provisions apply.

Limits on Lobbying Expenditures (The term "expenditures" means amounts paid or incurred.)		(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? ......................................	Yes No

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

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

(b)

Amount

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:

Volunteers? .........................................

Paid staff or management (include compensation in expenses reported on lines 1c through 1i)? ....

Yes

Media advertisements? ....................................

Mailings to members, legislators, or the public? .........................

Publications, or published or broadcast statements? .......................

Grants to other organizations for lobbying purposes? .......................

Yes

7,020

Direct contact with legislators, their staffs, government officials, or a legislative body? ........

Yes

5,000

Rallies, demonstrations, seminars, conventions, speeches, lectures, or any similar means? ......

Other activities? If "Yes," describe in Part IV ..........................

Total. lines 1c through 1i ...................................

12,020

Did the activities in line 1 cause the organization to be not described in section 501(c)(3)? .....

If "Yes," enter the amount of any tax incurred under section 4912 .................

If "Yes," enter the amount of any tax incurred by organization managers under section 4912 .....

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

Were substantially all (90% or more) dues received nondeductible by members? ................

Did the organization make only in-house lobbying expenditures of $2,000 or less? ................

Did the organization agree to carryover lobbying and political expenditures from the prior year? ..........

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”.

Dues, assessments and similar amounts from members .....................

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).

Current year .........................................

Carryover from last year ....................................

Total ...........................................

Aggregate amount reported in section 6033(e)(1)(A) notices of nondeductible section 162(e) dues .

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? ................................

Taxable amount of lobbying and political expenditures (see instructions) ..............

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 Activities Explanation	Sch. C, Part II-B, Line 1F:	Line 1G: Good Samaritan Hospital has some staff who occasionally have cause to write elected officials on their behalf. In a few other instances the Good Samaritan Hospital staff have traveled to Lincoln or Washington, DC. and that time has included lobbying visits. Line 1f:THE PORTION OF ORGANIZATION DUES THAT ARE RELATED TO LOBBYING ARE AS FOLLOWS: Nebraska Hospital Association $4,638, CATHOLIC HOSPITAL ASSOCIATION $1,788 AND AMERICAN HOSPITAL ASSOCIATION $594.

Schedule C (Form 990 or 990EZ) 2010

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE D
(Form 990)

Department of the Treasury
Internal Revenue Service

Supplemental Financial Statements

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

GOOD SAMARITAN HOSPITAL

Employer identification number

47-0379755

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 .......

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? ............

Yes No

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. ...................................

Yes No

Part II

Conservation Easements. Complete if the organization answered "Yes" to Form 990, Part IV, line 7.

Purpose(s) of conservation easements held by the organization (check all that apply).

Preservation of land for public use (e.g., recreation or pleasure) Preservation of an historically importantly land area

Protection of natural habitat Preservation of a certified historic structure

Preservation of open space

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.


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

Number of conservation easements modified, transferred, released, extinguished, or terminated by the organization during
the taxable year SchDMd Bullet

Number of states where property subject to conservation easement is located SchDMd Bullet

Does the organization have a written policy regarding the periodic monitoring, inspection, handling of violations, and
enforcement of the conservation easements it holds? .............................

Yes No

Staff and volunteer hours devoted to monitoring, inspecting and enforcing conservation easements during the year SchDMd Bullet

Amount of expenses incurred in monitoring, inspecting, and enforcing conservation easements during the year SchDMd Bullet

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)? ....................................

Yes No

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.

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.

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

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:

Revenues included in Form 990, Part VIII, line 1 .......................... SchDMd Bullet

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

Page 2

Part III

Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets (continued)

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):

Public exhibition

Loan or exchange programs

Scholarly research

Other

Preservation for future generations

Provide a description of the organization’s collections and explain how they further the organization’s exempt purpose in
Part XIV.

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?........

Yes No

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.

Is the organization an agent, trustee, custodian or other intermediary for contributions or other assets not
included on Form 990, Part X? ....................................

Yes No

If "Yes," explain the arrangement in Part XIV and complete the following table:


c	Beginning balance .................................	1c
d	Additions during the year ..............................	1d
e	Distributions during the year .............................	1e
f	Ending balance ...................................	1f

Did the organization include an amount on Form 990, Part X, line 21? .....................

Yes No

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 ......

Provide the estimated percentage of the year end balance held as:

Board designated or quasi-endowment: SchDMd Bullet

Permanent endowment: SchDMd Bullet

Term endowment: SchDMd Bullet

Are there endowment funds not in the possession of the organization that are held and administered for the
organization by:

Yes

(i) unrelated organizations ........................

3a(i)

(ii) related organizations ........................

3a(ii)

If "Yes" to 3a(ii), are the related organizations listed as required on Schedule R? .........

Describe in Part XIV the intended uses of the organization's endowment funds.

Part VI

InvestmentsLand, Buildings, and Equipment. See Form 990, Part X, line 10.

Description of investment		(b)Cost or other basis (other)	(c) Accumulated depreciation	(d) Book value
1a	Land .................	8,098,717		8,098,717
b	Buildings ................	70,704,655	34,504,167	36,200,488
c	Leasehold improvements ............
d	Equipment ................	120,538,322	86,541,082	33,997,240
e	Other .................	23,234,610	5,504,195	17,730,415
Total. Add lines 1a-1e. (Column (d) should equal Form 990, Part X, column (B), line 10(c).)........				96,026,860

Schedule D (Form 990) 2010

Page 3

Part VII

InvestmentsOther 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
(3)Other (A) CHI OIP - Fixed Income	81,007,130	F
(B) CHI OIP - Equity Securities	89,538,576	F







Total. (Column (b) should equal Form 990, Part X, col.(B) line 12.)	170,545,706

Part VIII

InvestmentsProgram 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.)

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.)...........

Part X

Other Liabilities. See Form 990, Part X, line 25.

1.(a) Description of Liability		(b) Amount
Federal Income Taxes		0
PHYSICIAN MINIMUM REVENUE GUARANTEES		209,836








Total. (Column (b) should equal Form 990, Part X, col.(B) line 25.)		209,836
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

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
FIN 48 (ASC 740) FOOTNOTE	SCHEDULE D, PART X	GOOD SAMARITAN HOSPITAL'S financial information is included in the consolidated audited financial statements of Catholic Health Initiatives (CHI), a related organization. CHI's FIN 48 (ASC 740) footnote for the year ended June 30, 2011 reads as follows: "CHI is a tax-exempt Colorado corporation and has been granted an exemption from federal income tax under Section 501(c)(3) of the Internal Revenue Code. CHI owns certain taxable subsidiaries and engages in certain activities that are unrelated to its exempt purpose and therefore subject to income tax. As of June 30, 2011, CHI has current net deferred tax assets of $2.1 Million and a noncurrent net deferred tax liability of $5.4 million related to these taxable activities. Management reviews its tax positions annually and has determined that there are no material uncertain tax positions that require recognition in the consolidated financial statements."

Schedule D (Form 990) 2010

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE H
(Form 990)

Department of the Treasury
Internal Revenue Service

Hospitals

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

GOOD SAMARITAN HOSPITAL

Employer identification number

47-0379755

Part I

Charity Care and Certain Other Community Benefits at Cost

Yes

Does the organization have a charity care policy? If "No," skip to question 6a...........

Yes

If "Yes," is it a written policy? .......................

Yes

If the organization has multiple hospitals, indicate which of the following best describes application of the charity care policy to the various hospitals.

Applied uniformly to all hospitals Applied uniformly to most hospitals Generally tailored to individual hospitals

Answer the following based on the charity care eligibility criteria that applies to the largest number of the organization's patients.

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:

100% 150% 200% Other

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: .....

200% 250% 300% 350% 400% Other

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.

Does the organization's policy provide free or discounted care to the "medically indigent"? ......

Yes

Does the organization budget amounts for free or discounted care provided under its charity care policy? ...

Yes

If "Yes," did the organization's charity care expenses exceed the budgeted amount?.........

Yes

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?...............

Does the organization prepare an annual community benefit report?.............

Yes

If "Yes," does the organization make it available to the public? ..............

Yes

Complete the following table using the worksheets provided in the Schedule H instructions. Do not submit these worksheets with the Schedule H.

Charity Care and Certain Other Community Benefits at Cost

	(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) ..		3,372	4,941,201		4,941,201	2.690 %
b Unreimbursed Medicaid (from Worksheet 3, column a) .		10,141	16,584,429	5,513,624	11,070,805	6.040 %
c Unreimbursed costs—other means-tested government programs (from Worksheet 3, column b) ....
dTotal Charity Care and Means-Tested Government Programs .....		13,513	21,525,630	5,513,624	16,012,006	8.730 %
Other Benefits e Community health improvement services and community benefit operations (from (Worksheet 4) ....	61	344,534	1,846,023	209,703	1,636,320	0.890 %
f Health professions education (from Worksheet 5) ..	32	4,079	735,550	94,425	641,125	0.350 %
g Subsidized health services (from Worksheet 6) ..	1	391	3,325,333	3,179,383	145,950	0.080 %
h Research (from Worksheet 7)	3	645	393,191	73,496	319,695	0.170 %
i Cash and in-kind contributions to community groups (from Worksheet 8) ..	19	50,729	508,741		508,741	0.280 %
jTotal Other Benefits ...	116	400,378	6,808,838	3,557,007	3,251,831	1.770 %
kTotal. Add lines 7d and 7j. ..	116	413,891	28,334,468	9,070,631	19,263,837	10.500 %

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
3	Community support	1		19,053		19,053	0.010 %
4	Environmental improvements
5	Leadership development and training for community members
6	Coalition building
7	Community health improvement advocacy	1		7,289		7,289
8	Workforce development	1		774,480		774,480	0.400 %
9	Other	1	800	26,686	14,840	11,846	0.010 %
10	Total	4	800	827,508	14,840	812,668	0.420 %

Part III

Bad Debt, Medicare, & Collection Practices

Section A. Bad Debt Expense

Yes

Does the organization report bad debt expense in accordance with Heathcare Financial Management Association Statement No. 15? ..........................

Enter the amount of the organization's bad debt expense (at cost).....

4,922,535

Enter the estimated amount of the organization's bad debt expense (at cost) attributable to patients eligible under the organization's charity care policy ..

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

Enter total revenue received from Medicare (including DSH and IME).....

65,636,329

Enter Medicare allowable costs of care relating to payments on line 5.....

72,358,245

Subtract line 6 from line 5. This is the surplus or (shortfall)........

-6,721,916

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:

Cost accounting system Cost to charge ratio Other

Section C. Collection Practices

Does the organization have a written debt collection policy? ...............

Yes

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......

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 %
1
2
3
4
5
6
7
8
9
10
11
12
13

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?3 Name and address		Other (Describe)
1	GOOD SAMARITAN HOSPITAL 10 EAST 31ST STREET PO BOX 1990 KEARNEY,NE68848	X	X	ACUTE HOSPITAL
2	RICHARD H YOUNG HOSPITAL 1755 PRAIRIE VIEW PL KEARNEY,NE68847	X		PSYCHIATRIC HOSPITAL
3	GOOD SAMARITAN HOSPITAL LTC 10 EAST 31ST STREET PO BOX 1990 KEARNEY,NE68848	X		LONG TERM CARE

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:GOOD SAMARITAN HOSPITAL

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

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

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

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:RICHARD H YOUNG HOSPITAL

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

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

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

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:GOOD SAMARITAN HOSPITAL LTC

Line Number of Hospital Facility (from Schedule H, Part V, Section A):3

				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

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

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

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?
Name and address		Type of Facility (Describe)
1
2
3
4
5
6
7
8
9
10

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
Part I, Line 3c		If applicable, describe the income-based criteria for determining eligibility for free or discounted care under the organization's charity care policy. Also describe whether the organization uses the asset test or other threshold regardless of income to determine eligibility for free or discounted care. When Catholic Health Initiatives (the ultimate parent organization to Good Samaritan Hospital) established its charity care policy it was determined that establishing a household income scale based on the HUD very low income guidelines more accurately reflects the socioeconomic dispersions among the 69 urban and rural communities in 19 states served by CHI hospitals and health care facilities. In comparing HUD guidelines to the Federal Poverty Guidelines ("FPG"), we find that on average HUD guidelines compute to approximately 200% to 250% (and sometimes 300%) of FPG. Eligibility for charity care discounts shall be determined based on 130% of the annually updated HUD Geographic Very-Low Income Guidelines for the applicant's county of residence, referenced later in this document, available assets and any extenuating circumstances. Thus, the standards of eligibility for the application of charity discounts must consider assets, as well as income. In addition, the need for future services requiring financial assistance shall be assessed. Separate determinations of eligibility for charity care discounts shall be made for each date of service. Confirmation of continued eligibility shall be updated every 90 days for patients who require ongoing health care services. An individual's occupation may be indicative of eligibility for a charity care discount. Examples of low-paying jobs might include Day laborer, Farm worker, Migrant worker and Food service associate.
Part I, Line 6a		If the organization's community benefit report is contained in a report prepared by a related organization, rather than a separate report prepared by the organization, identify the related organization. GSH prepares its own annual written community benefit report. Its' community benefit report is not contained in that of a related organization.
Part I, Line 7g		To the extent that an organization includes any costs associated with physician clinics as subsidized health services in Part I, line 7g it must describe that it has done so and report in Part VI such costs included in part I, line 7g, line 1 There are no physician clinics included in subsidized health services.
Part I, Line 7, Column (f)		If applicable, state the bad debt expense included on Form 990 Part IX, line 25, column (A) but subtracted for purposes of calculating the percentage in this column. Total bad debt expense reported on Form 990 Part IX, line 25, Column A was $11,464,014.
PART I, LINE 7		Provide an explanation of the costing methodology used to calculate the amounts reported in the table. If a cost accounting system was used, indicate whether the cost accounting system addresses all patient segments (for example, inpatient, outpatient, emergency room, private insurance, Medicaid, Medicare, uninsured or self pay). Also indicate whether a cost-to-charge ratio was used for any of the figures reported in the table. Describe whether this cost-to-charge ratio was derived from Worksheet 2, and, if not, what kind of cost-to-charge ratio was used and how it was derived. If some other costing methodology was used besides a cost accounting system, cost-to-charge ratio, or a combination of the two, describe the method used. Costs in the table were computed using the organization's cost-to-charge ratio that covers all patient segments for Medicare, Medicaid and Charity. Each program's cost-to-charge ratio is calculated individually based on volume and reimbursement. The cost-to-charge ratio for the year ended 6/30/11 was computed using the following formula: Operating expense (before restructuring, impairment and other losses) divided by total operating revenue. Based on that formula: Charity: $5,957,321 / $10,059,795 = 59.22% Medicaid: $16,349,777 / $35,058,540 = 46.64% Medicare: $91,207,962 / $212,895,891 = 42.84%
PART III, SECTION A, LINE 4		Provide the rationale and the costing methodology used to determine the amount reported in Part III lines 2 and 3. Describe how the organization accounts for discounts and payments on patient accounts in determining bad debt expense. Also describe the method the organization uses to determine the amount that reasonably could be attributable to patients who likely would qualify for financial assistance under the hospital's charity care policy, if sufficient information has been available to make a determination as to their eligibility. Also, provide if applicable, the text of the footnote to the organization's financial statements that describes bad debt expense. If the organization's financial statements include a footnote on these issues that also includes other information, report only the relevant portions of the footnote. If the organization's financial statements do not contain such a footnote, state that the organization's financial statements do not include such a footnote and explain how the financial statements account for bad debt, if at all. Costing methodology for amounts reported on line 2 is determined using the organization's cost/charge ratio of 45.07%. When discounts are extended to self-pay patients, these patient account discounts are recorded as a reduction in revenue, not as bad debt expense. Good Samaritan Hospital does not believe that any portion of bad debt expense could reasonably be attributed to patients who qualify for financial assistance since amounts due from those individuals' accounts will be reclassified from bad debt expense to charity care within 30 days following the date that the patient is determined to qualify for charity care. Good Samaritan Hospital does not issue separate company audited financial statements. However, the organization is included in the consolidated financial statements of Catholic Health Initiatives. The consolidated footnote reads as follows: "The provision for bad debts is based upon management's assessment of historical and expected net collections considering historical business and economic conditions, trends in health care coverage, and other collection indicators. Management routinely assesses the adequacy of the allowances for uncollectible accounts based upon historical write-off experience by payor category. The results of these reviews are used to modify, as necessary, the provision for bad debts and to establish appropriate allowances for uncollectible net patient accounts receivable. After satisfaction of amounts due from insurance, CHI follows established guidelines for placing certain patient balances with collection agencies, subject to the terms of certain restrictions on collection efforts as determined by each facility.
PART III, SECTION B, LINE 8		Describe the costing methodology used to determine the Medicare allowable costs reported in the organization's Medicare Cost Report, as reflected in the amount reported in Part III, line 6. Describe, if applicable, the extent to which any shortfall reported in Part III, line 7 should be treated as a community benefit, and the rationale for the organization's position. Using essentially the same Medicare cost report principles as to the allocation of general services costs and "apportionment" methods, the "CHI Workbook" calculates a payers' gross allowable costs by service (so as to facilitate a corresponding comparison between gross allowable costs and ultimate payments received). The term "gross allowable costs" means costs before any deductibles or co-insurance are subtracted. Good Samaritan Hospital's ultimate reimbursement will be reduced by any applicable copayment/ deductible. Where Medicare is the secondary insurer, amounts due from the insured's primary payer were not subtracted from Medicare allowable costs because the amounts are typically immaterial. Although not presented on the Medicare cost report, in order to facilitate a more accurate understanding of the "true" cost of services (for "shortfall" purposes) the CHI Workbook allows a health care facility not to offset costs that Medicare considers to be non-allowable, but for which the facility can legitimately argue are related to the care of the facility's patients. In addition, although not reportable on the Medicare cost report, the CHI workbook includes the cost of services that are paid via a set fee-schedule rather than being reimbursed based on costs (e.g. outpatient clinical laboratory). Finally, the CHI Workbook allows a facility to include other health care services performed by a separate facility (such as a physician practice) that are maintained on separate books and records (as opposed to the main facility's books and records which has its costs of service included within a cost report). True costs of Medicare computed using this methodology: Total Medicare Revenue: $ 65,636,329 Total Medicare costs: $ 72,358,245 Surplus of Shortfall $(6,721,916) Good Samaritan Hospital believes that excluding Medicare losses from community benefit makes the overall community benefit report more credible for these reasons: Unlike subsidized areas such as burn units or behavioral-health services, Medicare is not a differentiating feature of tax-exempt health care organizations. In fact, for-profit hospitals focus on attracting patients with Medicare coverage, especially in the case of well-paid services that include cardiac and orthopedics. Significant effort and resources are devoted to ensuring that hospitals are reimbursed appropriately by the Medicare program. The Medicare Payment Advisory Commission (MedPAC), an independent Congressional agency, carefully studies Medicare payment and the access to care that Medicare beneficiaries receive. The commission recommends payment adjustments to Congress accordingly. Though Medicare losses are not included by Catholic hospitals as community benefit, the Catholic Health Association guidelines allow hospitals to count as community benefit some programs that specifically serve the Medicare population. For instance, if hospitals operate programs for patients with Medicare benefits that respond to identified community needs, generate losses for the hospital, and meet other criteria, these programs can be included in the CHA framework in Category C as "subsidized health services." Medicare losses are different from Medicaid losses, which are counted in the CHA community benefit framework, because Medicaid reimbursements generally do not receive the level of attention paid to Medicare reimbursement. Medicaid payment is largely driven by what states can afford to pay, and is typically substantially less than what Medicare pays
PART III, SECTION C, LINE 9B		If the organization has a written debt collection policy and answered "yes" to Part III, line 9b, describe the collection practices set forth in the policy that apply to patients who it knows qualify for charity care or financial assistance, whether or not such practices apply specifically to such patients or more broadly to also cover other types of patients. The Revenue Realization Center ensures that all patient and patient guarantor accounts are pursued fairly by reviewing all accounts prior to electronically transferring balances to Revenue Cycle Partners (RCP), which refers to the "early-out" collection agent used by GSH. gSH ensures that all collection activities consistently reflect the highest standards of ethics and integrity. GSH offers reasonable payment schedules and terms to each patient and patient guarantor with self-pay balances. GSH and Midland Professional Services performs a reasonable review of inpatient financial status by contacting the patient or patient guarantor prior to submission to RCP to assure that the patient and patient guarantor are not eligible for any public benefits (e.g., Medicaid) and do not qualify for financial assistance through the GSH Uninsured and Underinsured Patient Discounts policy. RCP immediately closes and returns any account that subsequently is determined to be eligible for Financial Assistance to GSH. GSH will process the identified accounts based on the Uninsured and Underinsured Patient Discounts policy.
PART V		List the number of each type of facility, other than those required to be licensed, registered or similarly recognized as a health care facility under state law (for example, 2 rehabilitation clinics, 4 diagnostic centers, 3 skilled nursing facilities, etc) Not applicable.
PART VI, ITEMS 2,4,5		Line 2: Describe how the organization assesses the health care needs of the communities it serves. Line 4: Describe the community the organization serves, taking into account the geographic area and demographic constituents it serves. Line 5: Describe how the organization's community building activities, as reported in Part II, promote the health of the communities the organization serves. Provide any other information important to describing how the organization's hospitals or other health care facilities further its exempt purpose by promoting health of the community (e.g. open medical staff, community board, use of surplus funds, etc). INTRODUCTION: I. Organization's Mission, Vision, and Tax-Exempt Purpose I. Mission - The mission of Good Samaritan Hospital and Catholic Health Initiatives is to nurture the healing ministry of the church by bringing it new life, energy and viability in the 21st century. Fidelity to the gospel urges us to emphasize human dignity and social justice as we move toward the creation of healthier communities. II. Vision - Honoring our Catholic heritage, Good Samaritan Hospital is recognized for excellence in regional healthcare through values-based leadership. III. Primary tax-exempt purpose - The Primary exempt purpose of Good Samaritan Hospital is to support the community by promoting and providing health care services in accordance with the needs of a community in the absence of private benefit. Good Samaritan Hospital serves both the underinsured and uninsured in Kearney, NE and the surrounding communities. Good Samaritan Hospital is listed within The Official Catholic Directory for 2011 and is organized and operated exclusively for religious, charitable, scientific and educational purposes within the meaning of Section 501(c)(3) of the Internal Revenue Code. Established by the Sisters of the Saint Francis in 1924, Good Samaritan Hospital is a 248-bed regional referral center in Kearney, Nebraska. Now a member of Catholic Health Initiatives, Good Samaritan provides specialty care to over 350,000 residents of central Nebraska and northern Kansas. Good Samaritan boasts Nebraska's first accredited Chest Pain Center, a Level II trauma center featuring AirCare emergency helicopter transport that is open to all persons regardless of ability to pay, advanced orthopedic care, comprehensive neurosurgery and a nationally accredited cancer center among its many unique tertiary care services. In the spirit of its founders, Good Samaritan serves not only as a medical facility, but also as a community partner. Good Samaritan is called by its core values of reverence, integrity, compassion and excellence to devote funding and resources to programs and services that benefit the health of the greater community. At Good Samaritan Hospital, providing outstanding medical care to the region is what we do best. Over the years, we've steadily worked to be the healthcare hub in central Nebraska, eliminating the need to travel to big cities to get the best care. Together with a personalized, home-town approach to care, our comprehensive services are great reasons to come to Good Samaritan Hospital when you need medical assistance. II. Community Benefit Approach Good Samaritan Hospital (GSH) is committed to the promotion of healthy communities. It is a critical role of leaders throughout GSH to identify the needs and assets of the community, respond directly and in collaboration with community partners, and report the significant benefits that it provides the community, including those who are economically underserved. To that end, it is the policy of GSH to collaborate with community partners to identify community needs and assets, and to plan, coordinate and implement responses to such needs. In addition, because it is important that the Community Benefit that GSH provides is documented and reported, GSH shall report on its Community Benefit activities in a manner consistent with other organizations that are a part of Catholic Health Initiatives (CHI). GSH endorses the process and principles outlined in the Catholic Health Association of the United States document titled A Guide for Planning and Reporting Community Benefit updated in May, 2006 and the CHI Community Benefit Handbook which is periodically updated. GSH shall integrate the community benefit budgeting and reporting requirements into its strategic financial planning, budgeting and reporting process. GSH shall develop and implement a plan to communicate the community benefit report on an annual basis to employees, volunteers, the medical staff, governing board, community and others, as appropriate. II. Uncompensated Care Charity Care As described in the Catholic Health Association's Guide for Planning and Reporting Community Benefit released in 2006, charity care is free or discounted health and health-related services provided to persons who cannot afford to pay and who meet the organization's criteria for financial assistance. Generally, a bill must be generated and recorded and the patient must meet the organization's criteria for charity care and demonstrate an inability to pay. Charity care is reported in terms of costs, not charges. Charity care does not include bad debt. Good SAMARITAN HOSPITAL PROVIDES A SIGNIFICANT LEVEL OF FREE CARE EACH YEAR. In Fiscal Year 2011, the cost of charity care provided was $4.9 million. Government-Sponsored Health Care Government-sponsored health care community benefit includes unpaid costs of public programs, the "shortfall" created when a facility receives payments that are less than costs for caring for public program beneficiaries. This "payment shortfall" is not the same as a contractual allowance, which is the full difference between charges and government payments. It does not include any shortfall that results from inefficiency or poor management. Good Samaritan Hospital incurred $11.1 million in unreimbursed costs for services provided to Medicaid patients and $13.3 million in unreimbursed costs for services provided to Medicare patients. Medicaid patients represented approximately 14.0 percent of the patients served by Good Samaritan Hospital in Fiscal Year 2011 and Medicare patients represented approximately 46.5 percent of the patients served. Frequently, the cost of providing services to Medicare and Medicaid patients is greater than the payment Good Samaritan Hospital receives from the government. QUALITATIVE DESCRIPTION OF COMMUNITY BENEFIT I. Community Outreach for the Poor In Fiscal Year 2011, Good Samaritan Hospital partnered with other community organizations to enhance the quality of life of the poor in our community. Such partnerships and services are described in this section. Community Health Access Team (CHAT) The Community Health Access Team is a team of individuals representing 14 different organizations and agencies whose mission is: Everyone with a point of entry to service in Buffalo County will have access to, regularly use, and be satisfied with comprehensive, cost effective, high quality, primary health services that support optimal quality of life. CHAT's goal is to reach 100 percent access to primary healthcare services for all with zero racial and ethnic disparity. Differences between people, such as culture, class, educational attainment, employment status and ability to pay, will no longer be associated with differential health outcomes. CHAT's primary target group is the uninsured and underinsured and their desired outcome is to create a new model to reach 100 percent health access and zero health disparities. Health Education Good Samaritan Hospital Provides funding for the Krames Patient Education system. The Krames Patient Education system is a web-based system that provides instant access to thousands of illustrated patient education topics that covers conditions, procedures, medications and wellness promotion. Health care providers have utilized over 16,000 health sheets for FY 2011. In addition, Good Samaritan Hospital has created Personal Health Managers for patients diagnosed with specific health conditions like Diabetes, Asthma and COPD. Good Samaritan Hsopital has provided approximately 250 Personal Health Managers to patients during FY 2011. Finally, Good Samaritan Hospital supports the distribution of the File for Life and POLST forms throughout the community Home Monitoring for Heart Failure Good Samaritan Hospital provides funding for patients with equipment to monitor their blood pressure, oxygenation level and weight. Patients are monitored by an RN Clinical Coordinator and any variances from acceptable levels are assessed by the nurse and then communicated with the patient's health care provider in order to reduce exacerbations of their condition. Good Samaritan Hospital provided monitoring services to patients over a wide geographic area from Norcator, KS to Stapleton and from Aurora to Brady. Patients also receive educational information about their Heart Failure co
PART VI, ITEMS 2,4,5 CONT'D		Midwest Telehealth Network The Midwest Telehealth Network became operational in 1995 with five rural sites and Good Samaritan Hospital as the hub facility. Since then, the telehealth network has grown to now include twenty-one rural sites from both Nebraska and Kansas. Activity over the network includes teleradiology, clinical encounters, teleemergency, administrative meetings and educational offerings. The program is coordinated by the TeleHealth Department, which is part of Outreach Services. The Network had received thirteen years of continuous funding through the Federal government, which makes it the longest federally funded program in the nation through the Office for the Advancement of Telehealth. The network sites include eighteen Nebraska sites and three Kansas sites. The program is recognized on a national level for the network's achievements. Program staff present on an annual basis at national and state conferences. The success of the Midwest Telehealth Network has been the catalyst for the creation of the Nebraska Statewide Telehealth Project. The Nebraska Statewide Telehealth Network is unique in that it brings together the hospitals across the state, the public health departments, state government and the bioterrorism labs at the state and regional level. The Network allows the sharing of information and services to many different users across the state. The Network also allows for increased access to medical consultation in our rural areas as well as provider and community education to the residents of those rural areas. In addition, it helps provide another communication tool for our homeland security effort in the case of an emergency or for educational purposes. This Network is an important part of the State of Nebraska's plan to ensure adequate behavioral medicine resources across the State. Richard H. Young Hospital provides professional support/consultation via Telemedicine for persons with psychiatric crisis WHO MAY PRESENT TO EMERGENCY ROOMS IN HOSPITALS THAT DO NOT HAVE THE RESOURCES TO MEET THIS NEED. Outreach Specialty Clinics Numerous outreach specialty clinics have been established to provide enhanced access to care in communities outside of Kearney. In concert with Good Samaritan Hospital, the medical staff has established clinics in several specialty areas allowing residents in rural communities to receive care close to home. These specialty areas include: Ear, Nose and Throat, Obstetrics and Gynecology, Hematology and Oncology, Sports Medicine, Ophthalmology, Urology, Neurosurgery, Cardiology, Podiatry, Spine and Orthopedics, Neurology, Nephrology, Pulmonology, Rheumatology and Vascular Surgery. Physician Recruitment Good Samaritan Hospital and members of the Medical Staff successfully recruited specialists to Kearney during Fiscal Year 2011. These include physicians specializing in the areas of: emergency medicine, interventional cardiology, pediatrics, obstetrics/gynecology, and internal medicine/hospitalist. The Good Samaritan Hospitalist Service program was launched in August of 2010. Programs for Families Good Samaritan Hospital has developed and implemented several collaborative projects to assist families. These projects have been developed from grant funds obtained by the Good Samaritan Hospital Foundation. They include: Early Development Network: The Early Development Network (EDN) provides Services Coordination to families who have children 0-3 years of age who have a verified disability per NE Rule 51 (Special Education law). This means that the program is an ongoing central access point for families to help connect them with services in their community that will help them care for their children and ensure the free and appropriate education guaranteed to all children ages birth to 21 in the State of Nebraska. Families are linked with developmental evaluations through their local school district, Nebraska Department of Health and Human Services programs, health resources, parent-to-parent support, and other supports and services as identified by the families' priorities. EDN Services Coordination through Good Samaritan Hospital covers Planning Region Teams 10 & 28. Counties located in these regions include: Buffalo, Dawson, Sherman, Valley, Loup, Garfield, Greeley, Blaine and Custer. In Fiscal Year 2011, the Early Development Network provided services coordination to an average of 157 families per month, which remained stable with the number served in 2010. The Early Development Network operates from the Richard Young Hospital GSH Campus in Kearney and a satellite office in Broken Bow. The program is currently staffed with six Services Coordinators. Injury Prevention - Trauma Department: Injury prevention efforts across the age continuum were successfully implemented with the partnerships of many community entities coming together for the health and safety of our neighbors. Separate programs are designed for children, teens and also adults/seniors. Safe Kids Platte Valley: Unintentional injury is the #1 killer of children in the United States. Safe Kids U.S.A. was launched in 1988 to address unintentional injuries to children ages 14 and under. Since that time, the rate has dropped 47%. Good Samaritan Hospital became part of Safe Kids in 1996 in partnership with other area hospitals. In 2004, Good Samaritan Hospital assumed a leadership role as the lead agency for Safe Kids Platte Valley. Safe Kids Platte Valley serves Buffalo, Dawson, Lincoln, and other south central and southwestern counties in Nebraska as a partner, educator, and resource in the mission of preventing accidental injuries to children. The major cause of deaths is traffic crashes; falls are the #1 cause of non-fatal injuries. Safe Kids addresses all areas of injury prevention including child passenger safety, fall prevention, bicycle and wheeled safety, water safety, pedestrian safety, farm safety, sports safety, home safety, playground safety, SIDS prevention, and more. Teen Net (Prenatal and Parenting Program for Teens): The objective of the Teen Net program is to instill healthy lifestyle choices in teens, which the program has been doing since its inception in school year 1992-93 at Kearney Public Schools. For pregnant and parenting teens this means teaching parenting skills and obtaining timely prenatal care, increasing graduation rates, prevention of child abuse and improving the feelings of self-worth. In previous fiscal years, the program has received grant funding through a variety of sources including Nebraska Health and Human Services Maternal and Child Health Division, Union Pacific Foundation and the Fraternal Order of Eagles. Funding through Good Samaritan Hospital and Kearney Public Schools was provided during Fiscal Year 2011. 100% of the seniors enrolled in the program this year graduated from High School and 50% are going on to further their education. Project SEARCH Project SEARCH is a one-year, high school transition program, which provides training and education leading to employment for individuals with disabilities. The Project SEARCH program occurs on-site at Good Samaritan Hospital. The cornerstone of Project SEARCH is total immersion in a large business. Each day, students report to the host business, learn employability skills in the classroom and job skills while participating in 3-4 internships/experiences during the year. Managers at the internship sites work with the Project SEARCH instructor and job coaches to support the students. For the 2010-11 school year as of 6/30/11, all five students have found competitive employment in the community. Richard Young/Emergency Support Program Richard H. Young Hospital offers inpatient and outpatient Behavioral Health services to individuals regardless of their ability to pay. Our free, no cost to the consumer or referral source, crisis psychiatric assessment service is offered 24 hours a day/7 days a week. Psychiatric assessments are provided to determine an individual's treatment needs and placed or referred to the appropriate level of care. We also offer at no cost tele-health psychiatric emergency assessment services to rural hospitals that do not have psychiatric services. RYH also offers free educational resources available upon request. Senior Services Network Senior Services provides information and support to area older adults and their families through a variety of services and programs. Lifeline personal emergency response service through Good Samaritan provides almost 400 older and disabled adults with the ability to signal for help with the push of a waterproof button worn around their neck or on their wrist. Last year Lifeline responded to more than 300 incident signals for assistance, arranging for help when subscribers were unable to dial 911. Sixty of these assists resulted in transport to the hospital. Currently twelve subscribers have the added protection of the security provided by the AutoAlert fall detection button. This life sa
PART VI, ITEM 3		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 charity care policy. Good Samaritan Hospital posts signage in English in admissions areas, the emergency department and other appropriate areas advising patients of the availability of financial assistance. Staff members will communicate the content of the signs to people who appear to be unable to read English. Sharing information about charity care is differentiated into two scenarios - one for an emergency patient and another for a non-emergency patient scheduling an admission or other procedure. Scenario - emergency patient: (i) Patients receiving emergency services shall be treated in accordance with Good Samaritan Hospital's emergency services policies, developed in accordance with EMTALA and other requirements. (ii) Good Samaritan Hospital engages in reasonable registration processes for individuals requiring examination or treatment: -Reasonable registration processes shall include asking whether an individual is insured and, if so, the name of the insurance program utilized, if such inquiry does not delay screening or treatment.- Reasonable registration processes shall not unduly discourage patients from remaining for further evaluation. Therefore, discussions regarding financial issues shall be deferred until after the patient has been screened and necessary stabilizing treatment has been initiated. Once EMTALA requirements are met, patients identified through the registration process as being without Medicare/Medicaid, other local health care financial assistance or adequate health insurance, will receive a packet of information that addresses the financial assistance policy and procedures, including an application. In the event that a patient does not receive the packet of information at the time of service, the packet will be mailed to the patient within ten days of the date of service to ensure that all self-pay patients are informed of financial assistance availability in a timely manner. Compliance is monitored through a Meditech NPR report. Scenario - non-emergency patient: Scheduling an admission or other procedure: (i) Patients without Medicare/Medicaid, other local health care financial assistance or adequate health insurance shall be mailed a packet of information that addresses the financial assistance policy and procedures, including an application within ten days of the date of service. This will ensure that all self-pay patients are informed of financial assistance availability in a timely manner. Compliance is monitored through a Meditech NPR report. Under either scenario, the Financial Assistance Application and accompanying instructions clearly indicate that Good Samaritan Hospital provides care, without regard to ability to pay, to individuals with limited financial resources, and explains how patients can apply for financial assistance. In addition, Good Samaritan Hospital's brochures on billing and payment guidelines address patient financial assistance. i. For assistance in which there are a significant number of patients not proficient in reading, writing or speaking English, additional information shall be provided (or assistance shall be made available) to complete necessary forms. ii. In the event that Good Samaritan Hospital's service area consists of 10% or more of the population who do not speak English, Good Samaritan Hospital will prepare informational notices in each of the languages that account for 10% or more of the total population. iii. To allow Good Samaritan Hospital to properly determine charity care eligibility, documents provided by patients to the Good Samaritan Hospital shall be written in English. iv. Records maintained by Good Samaritan Hospital to substantiate eligibility for charity care shall be completed in English. v. Good Samaritan Hospital will identify the availability of financial assistance in information booklets provided to patients and in general information provided on Good Samaritan Hospital's website. vi. Good Samaritan Hospital will begin the process of assessing financial ability during the pre-registration process or when they register as an emergency patient (subject to the EMTALA requirements discussed above).
PART VI, ITEM 7		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. Good Samaritan Hospital, along with its affiliated outpatient facilities are part of Catholic Health Initiatives. Catholic Health Initiatives (CHI) is a national faith-based nonprofit health care organization with headquarters in Englewood, Colorado. CHI's exempt purpose is to serve as an integral part of its national system of hospitals and other charitable entities, which are described as market-based organizations, or MBOs. An MBO is a direct provider of care or services within a defined market area that may be an integrated health system and/or a stand-alone hospital or other facility or service provider. CHI serves as the parent corporation of its MBOs which are comprised of 73 hospitals; 40 long-term care, assisted- and residential-living facilities; two community health-services organizations; two accredited nursing colleges; and home health agencies. Together, these facilities provided $612 million in charity care and community benefit in the 2011 fiscal year, including services for the poor, free clinics, education and research. CHI provides strategic planning and management services as well as centralized "shared services" for the MBOs. The provision of centralized management and shared services - including areas such as accounting, human resources, payroll and supply chain -- provides economies of scale and purchasing power to the MBOs. The cost savings achieved through CHI's centralization enable MBOs to dedicate additional resources to high-quality health care and community outreach services to the most vulnerable members of our society. Good Samaritan Hospital operates with its wholly owned affiliates and community partners, along with its fundraising arm, the Good Samaritan Hospital Foundation, to serve the health care needs of the Kearney, NE communities.
PART VI, ITEM 8		If applicable, identify all states with which the organization, or a related organization, files a community benefit report. Nebraska

Schedule H (Form 990) 2010

Additional Data

Software ID:
Software Version:

- TIN:

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
GOOD SAMARITAN HOSPITAL

Employer identification number
47-0379755

Part I

General Information on Grants and Assistance

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? ....................................

Yes No

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
(1) Buffalo County Community Partnership1755 Prairie View Place Kearney,NE68845	20-5852415	501(c)(3)	30,000
(2) St James Catholic Church3801 Ave A Kearney,NE68848	47-0380468	501(c)(3)	10,000
(3) Life Choices Pregnancy Resource2222 2nd Ave Kearney,NE68847	36-3756851	501(c)(3)	6,000
(4) Good Samaritan Hospital Foundation111 West 31st Street Kearney,NE68847	47-6059443	501(C)(3)	350,000
(5) CHI Nebraska555 S 70th Street Lincoln,NE68510	36-3233121	501(C)(3)	1,966,260

Enter total number of section 501(c)(3) and government organizations ......................... Bullet Image

Enter total number of other organizations ................................ . Bullet Image

For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 50055P

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
Schedule I Part I Q2	Procedures for monitoring the use of grants	In the case of a related party, a Restricted Fund Agreement is in place and, in other cases a Pledge Agreement may be in place. Donations are also made as solicited by various exempt organizations and Good Samaritan Hospital relies on those organizations to use the grants in accordance with each organization's exempt purpose.

Schedule I (Form 990) 2010

Additional Data

Software ID:
Software Version:

- TIN:

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

GOOD SAMARITAN HOSPITAL

Employer identification number

47-0379755

Part I

Questions Regarding Compensation

Yes

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.

First-class or charter travel Housing allowance or residence for personal use

Travel for companions Payments for business use of personal residence

Tax idemnification and gross-up payments Health or social club dues or initiation fees

Discretionary spending account Personal services (e.g., maid, chauffeur, chef)

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....

Yes

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? ....

Yes

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.

Compensation committee Written employment contract

Independent compensation consultant Compensation survey or study

Form 990 of other organizations Approval by the board or compensation committee

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:

Receive a severance payment or change-of-control payment? ...............

Yes

Participate in, or receive payment from, a supplemental nonqualified retirement plan? ........

Yes

Participate in, or receive payment from, an equity-based compensation arrangement? ........

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.

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:

The organization? ...........................

Any related organization? .........................

If "Yes," to line 5a or 5b, describe in Part III.

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:

The organization? ...........................

Any related organization? .........................

If "Yes," to line 6a or 6b, describe in Part III.

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 ............

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 .............................

If "Yes" to line 8, did the organization also follow the rebuttable presumption procedure described in Regulations section 53.4958-6(c)? .........................

For Privacy Act and Paperwork Reduction Act Notice, see the Intructions for Form 990

Cat. No. 50053T

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
(A) Name		(i) Base compensation	(ii) Bonus & incentive compensation	(iii) Other reportable compensation	(C) Retirement and other deferred compensation	(D) Nontaxable benefits	(E) Total of columns (B)(i)-(D)
(1) ROBERT LANIK	(i) (ii)	503,686	124,161	62,000	32,478	13,246	735,571
(2) MICHAEL SCHNIEDERS	(i) (ii)	181,221	2,700	35,356	15,525	7,857	242,659
(3) JOHN ALLEN	(i) (ii)	17,979		503,769	20,228	10,379	552,355	169,073
(4) STEPHEN LEURCK	(i) (ii)			70,620 70,552			70,620 70,552
(5) GEORGE HARMS	(i) (ii)	206,663	18,340	75,373	18,695	19,369	338,440
(6) ROBERT CUNNINGHAM	(i) (ii)	175,068	13,879	94,213	13,810	18,973	315,943	77,854
(7) LEIGH BERTHOLF	(i) (ii)	176,944	10,000	375	20,607	19,000	226,926
(8) TIMOTHY RANNEY	(i) (ii)	144,162		18,963	20,228	5,438	188,791
(9) CAROL WAHL	(i) (ii)	199,804	17,750	15,917	25,510	7,501	266,482	4,211
(10) FISHEL LIBERMAN	(i) (ii)	506,936	34,460	2,377	20,228	21,134	585,135
(11) PAMELA WESTERLING	(i) (ii)	416,919		37,527	20,228	17,297	491,971
(12) HUGO GONZALEZ NIETO	(i) (ii)	241,495	104,470	317	20,228	16,442	382,952
(13) STEVEN SCHULZ	(i) (ii)	315,634		13,335	25,128	16,442	370,539
(14) ROGER ALBIN	(i) (ii)	249,855	1,650	24,579	27,578	16,442	320,104
(15) STEVE LOVELESS	(i) (ii)	71,160		53,262	21,555	6,264	152,241	2,882

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
Relevant Information Regarding Listed Benefits	SCHEDULE J, PART I, Q. 1A	Good Samaritan Hospital provides for companion travel for its board members when deemed appropriate. THESE BENEFITS ARE PAID AND GROSSED-UP PURSUANT TO A WRITTEN POLICY. ALL SUCH BENEFITS ARE INCLUDED IN THE EMPLOYEE'S FORM W-2.
METHODS USED TO ESTABLISH CEO COMPENSATION	SCHEDULE J, PARTI, Q.3	Compensation for the top management official was established and paid by Catholic Health Initiatives (CHI), a related organization. CHI used the following to establish the top management official's compensation: (1) Compensation Committee; (2) Independent Compensation Consultant; (3) Written Employment Contracts; (4) Compensation Survey or Study; (5) Approval by the Board or Compensation Committee.
POST TERMINATION PAYMENTS	SCHEDULE J, PART I, LINE 4A	Post-termination payments are addressed in the executive employment agreements for Catholic Health Initiative's ("CHI") MBO CEOs. These employment agreements require that in order for the executive to receive post-termination payments, these individuals must execute a general release and settlement agreement. Post-termination payment arrangements are periodically reviewed for overall reasonableness in light of the executive's overall compensation package. The following reportable individuals received severance payments from Catholic Health Initiatives (a Related Organization) during the 2010 calendar year, and these severance payments were included in the individual's W-2 income and reportable compensation on Schedule J: JOHN ALLEN; $332,102.
DEFERRED COMPENSATION	SCHEDULE J, PART I, Q. 4B	During the 2010 calendar year Catholic Health Initiatives ("CHI"), a related organization, maintained a supplemental non-qualified deferred compensation plan for MBO CEOs and other CHI employees at the level of Senior Vice President and above. The following reportable individuals were eligible to participate in that plan: ROBERT LANIK, MICHAEL SCHNIEDERS During 2010 the following contributions were made by CHI to the deferred compensation plan: MICHAEL SCHNIEDERS $15,525 During 2010 the following distributions were made by CHI from the deferred compensation plan: JOHN ALLEN $169,073 Due to the "super" vesting rules under the CHI deferred compensation plan, participants who have met certain requirements such as termination, age, or years of service are eligible to receive their 2010 contributions in cash. These cash payouts are included in the participant's reportable compensation in column (iii) Other Reportable Compensation on Schedule J Part II. During 2010, the following contributions that would have been made by CHI to the deferred compensation plan were paid in cash: ROBERT LANIK $35,026 IN PRIOR YEARS GOOD SAMARITAN HOSPITAL MAINTAINED A SUPPLEMENTAL EMPLOYEE RETIREMENT PLAN FOR VICE PRESIDENTS AND ABOVE. THE PLAN WAS CLOSED IN 2010. THE FOLLOWING REPORTABLE INDIVIDUALS RECEIVED FINAL PAYOUTS THAT WERE INCLUDED IN SCHEDULE J: CAROL WAHL $7,018; STEVE LOVELESS $2,882; ROBERT CUNNINGHAM $83,044; GEORGE HARMS $67,240. during the calendar year 2010 good samaritan hospital instituted a call pay plan. the plan is a defined contribution, nonqualified deferred compensation plan that provides for contributioins to a participant's account, but does not promise any particular ultimate benefit to participants. the following reportable individuals were eligible to participate in the plan: dennis edwards and richard hranac. during the calendar year 2010 the following contributions were made to the call pay plan; dennis edwards, $21,777; richard hranac, $17,380.

Schedule J (Form 990) 2010

Additional Data

Software ID:
Software Version:

- TIN:

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

GOOD SAMARITAN HOSPITAL

Employer identification number

47-0379755

Identifier	Return Reference	Explanation
FORM 990, Part III, Q.3	CEASE CONDUCTING OR SIGNIFICANT PROGRAM SERVICE CHANGES	DURING THE FISCAL YEAR 2011 good SAMARITAN HOSPITAL TRANSFERRED THE FOLLOWING OPERATING DIVISIONS TO THE PHYSICIAN NETWORK, A RELATED TAX-EXEMPT ORGANIZATION: ANESTHESIA AND EMERGENCY.
FORM 990, PART VI, Q. 1A	Executive Committee composition and authority	PURSUANT TO SECTION 8.6 OF THE BYLAWS OF GOOD SAMARITAN HOSPITAL, THE EXECUTIVE COMMITTEE IS COMPOSED OF THE BOARD CHAIR, THE BOARD VICE CHAIR, THE PRESIDENT AND CEO, AND THE VICE PRESIDENT OF MEDICAL AFFAIRS, THE TREASURER, AND THE PRESIDENT OF THE MEDICAL STAFF EACH OF WHOM SERVES AS AN EX OFFICIO VOTING MEMBER OF THE EXECUTIVE COMMITTEE, AND AT LEAST THREE DIRECTORS APPOINTED BY THE BOARD. PURSUANT TO SECTION 8.1 OF THE CORPORATION'S BYLAWS, COMMITTEES, SUCH AS THE EXECUTIVE COMMITTEE, THAT ARE GRANTED THE AUTHORITY TO ACT ON BEHALF OF THE BOARD OF DIRECTORS MAY INCLUDE ONLY DIRECTORS OF THE CORPORATION. FURTHER, PURSUANT TO SECTION 8.6 OF THE CORPORATION'S BYLAWS, THE EXECUTIVE COMMITTEE HAS AND MAY EXERCISE SUCH POWERS AS MAY BE DELEGATED TO IT BY THE BOARD OF DIRECTORS. THE EXECUTIVE COMMITTEE ALSO POSSESSES THE POWER TO TRANSACT ROUTINE BUSINESS OF THE CORPORATION IN THE INTERIM PERIOD BETWEEN REGULARLY SCHEDULED MEETINGS OF THE BOARD OF DIRECTORS.
FORM 990, PART VI, Q.6	The Organization's Corporate Members/Stockholders	The sole member of the corporation is CHI Nebraska, A Nebraska nonprofit corporation.
FORM 990, PART VI, Q.7a	Members/Stockholders Electing Governing Body Members	CHI Nebraska has the power to appoint, remove or replace the members of the board of directors.
FORM 990, PART VI, Q. 7B	APPORVAL OF GOVERNING BODY DECISIONS BY MEMBERS\STOCKHOLDERS	The organization's corporate member is CHI Nebraska. Pursuant to Section 5.1 of the organization's bylaws, THE CORPORATE MEMBER SHALL HAVE THE SPECIFIC RIGHTS SET FORTH IN THE Governance matrix. Pursuant to the governance matrix the following rights are RESERVED TO THE CHI Nebraska BOARD DIRECTLY OR THROUGH POWERS DELEGATED TO THE CHI Nebraska CHIEF EXECUTIVE OFFICER: -Approve members of the Good Samaritan Hospital board -Amendment of the corporate documents of the Good Samaritan Hospital -Approve removal of a member of the governing body of the Good Samaritan Hospital -Adoption of long range and strategic plans for the Good Samaritan Hospital -Substantial change in the mission or philosophy of the Good Samaritan Hospital -Removal of a member of the governing body of the Good Samaritan Hospital -Approval of issuance of debt by Good Samaritan Hospital -Approval of participation of Good Samaritan Hospital in a joint venture -Approval of formation of a new corporation by Good Samaritan Hospital -Approval of a merger involving the Good Samaritan Hospital -Approval of the sale of all or substantially all of the assets of the Good Samaritan Hospital -To require the transfer of assets by the Good Samaritan Hospital to CHI to accomplish CHI's goals and objectives, and to satisfy CHI debts. Pursuant to Section 5.2 of the organization's bylaws, Good Samaritan Hospital or CHI Nebraska may, in exercise of their approval powers, grant or withhold approval in whole or in part, or may, in its complete discretion, after consultation with the Board and its President and the Chief Executive Officer of the organization, recommend such other or different actions as it deems appropriate.
FORM 990, PART VI, Q. 11b	Process the Organization uses to Review Form 990	Once the return is prepared, the return is reviewed by the Vice President of Finance. The Vice President of Finance provides a copy of the return to the Good Samaritan Hospital board either at a board meeting or electronically. Subsequent to providing a copy to the board the tax department files the return with the appropriate federal and state agencies, making any non-substantive changes necessary to effect e-filing. Any such changes are not re-submitted to the board.
FORM 990, PART VI, Q. 12C	Procedures for Monitoring and Enforcing the COI Policy	DISCLOSURE, REVIEW AND INITIAL DETERMINATION 1) GENERAL OBLIGATION. EACH DIRECTOR MUST PROMPTLY AND FULLY REPORT TO THE BOARD CHAIR SITUATIONS THAT MAY CREATE A CONFLICT OF INTEREST WHEN HE OR SHE BECOMES AWARE OF SUCH SITUATIONS. IN ANY SITUATION WHEN A DIRECTOR IS IN DOUBT, FULL DISCLOSURE SHOULD BE MADE SO AS TO PERMIT AN IMPARTIAL AND OBJECTIVE DETERMINATION. A WRITTEN RECORD OF THE DISCLOSURE WILL BE MADE. 2) ANNUAL DISCLOSURE STATEMENT. IN ADDITION TO THE ONGOING DISCLOSURE OBLIGATION, THE CORPORATION'S PRESIDENT AND CHIEF EXECUTIVE OFFICER SHALL ANNUALLY SEND TO ALL DIRECTORS A COPY OF THIS POLICY AND THE CONFLICT OF INTEREST DISCLOSURE STATEMENT. THE DIRECTOR MUST PROMPTLY COMPLETE, SIGN AND RETURN THE STATEMENT TO THE CORPORATION'S PRESIDENT AND CHIEF EXECUTIVE OFFICE. THE COMPLETED STATEMENT WILL BE REVIEWED BY THE PRESIDENT AND CHIEF EXECUTIVE OFFICER AND THE BOARD CHAIR. 3) REVIEW, EVALUATION AND INITIAL DETERMINATION. THE BOARD CHAIR OR DESIGNEE SHALL MAKE SUCH FURTHER INVESTIGATION OF ANY CONFLICT OF INTEREST DISCLOSURES AS HE OR SHE MAY DEEM APPROPRIATE. IF THE CONFLICT INVOLVES THE BOARD CHAIR, THE VICE CHAIR WILL ASSUME THE CHAIR'S ROLE OUTLINED IN THIS POLICY. BASED ON REVIEW AND EVALUATION OF THE RELEVANT FACTS AND CIRCUMSTANCES, THE BOARD CHAIR WILL MAKE AN INITIAL DETERMINATION AS TO WHETHER A CONFLICT OF INTEREST EXISTS AND WHETHER, PURSUANT TO THIS POLICY, REVIEW AND APPROVAL OR OTHER ACTION BY THE BOARD OF DIRECTORS IS REQUIRED. A WRITTEN RECORD OF THE BOARD CHAIR'S DETERMINATION, INCLUDING RELEVANT FACTS AND CIRCUMSTANCES, WILL BE MADE. THE BOARD CHAIR SHALL THEN MAKE AN APPROPRIATE REPORT TO THE EXECUTIVE COMMITTEE OF THE BOARD CONCERNING SUCH REVIEW, EVALUATION AND DETERMINATION. IF A DIFFERENCE OF OPINION EXISTS BETWEEN THE BOARD CHAIR AND ANOTHER DIRECTOR AS TO WHETHER THE FACTS AND CIRCUMSTANCES OF A GIVEN SITUATION CONSTITUTE A CONFLICT OF INTEREST OR WHETHER BOARD OF DIRECTORS REVIEW AND APPROVAL OR OTHER ACTION IS REQUIRED WITHIN THIS POLICY, THE MATTER SHALL BE SUBMITTED TO THE BOARD'S EXECUTIVE COMMITTEE, WHICH SHALL MAKE A FINAL DETERMINATION AS TO THE MATTER PRESENTED. SUCH DETERMINATION, INCLUDING RELEVANT FACTS AND CIRCUMSTANCES, WILL BE REFLECTED IN THE COMMITTEE MINUTES AND WILL BE REPORTED TO THE BOARD OF DIRECTORS. BOARD REVIEW: 1) TRANSACTIONAL CONFLICTS OF INTEREST. THE BOARD OF DIRECTORS SHALL CAREFULLY SCRUTINIZE AND MUST IN GOOD FAITH APPROVE OR DISAPPROVE ANY TRANSACTION IN WHICH THE CORPORATION AND/OR ANY OF ITS AFFILIATES IS A PARTY AND IN WHICH ONE OR MORE OF THE CORPORATION'S DIRECTORS EITHER: * HAS A MATERIAL FINANCIAL INTEREST; OR * IS A DIRECTOR OF THE OTHER PARTY (OTHER THAN THE CORPORATION'S OWN AFFILIATES). 2) THE BOARD OF DIRECTORS MUST APPROVE THE TRANSACTION BY A MAJORITY OF THE DIRECTORS ON THE BOARD, WITHOUT COUNTING THE VOTE OF ANY DIRECTOR WHO HAS AN INTEREST IN THE TRANSACTION. IN REVIEWING SUCH TRANSACTIONS BETWEEN THE CORPORATION AND VENDORS OR OTHER CONTRACTORS WHO ARE, OR ARE AFFILIATED WITH, DIRECTORS, THE BOARD SHALL ACT NO MORE OR LESS FAVORABLY THAN IT WOULD IN REVIEWING TRANSACTIONS WITH UNRELATED THIRD PARTIES. THE TRANSACTION WILL NOT BE APPROVED UNLESS THE BOARD DETERMINES THAT THE TRANSACTION IS FAIR TO THE CORPORATION. 3) OTHER CONFLICTS OF INTEREST. THE BOARD SHALL CAREFULLY REVIEW AND SCRUTINIZE ANY NON- TRANSACTIONAL CONFLICT OF INTEREST (E.G. DISCLOSURE OF NONPUBLIC INFORMATION, COMPETITION WITH THE CORPORATION, FAILURE TO DISCLOSE A CORPORATE OPPORTUNITY, EXCESSIVE GIFTS OR ENTERTAINMENT,ETC.) BY A MAJORITY VOTE OF THE DISINTERESTED DIRECTORS, THE BOARD SHALL TAKE WHATEVER ACTION IS DEEMED APPROPRIATE WITH RESPECT TO THE DIRECTOR UNDER THE CIRCUMSTANCES, INCLUDING POSSIBLE DISCIPLINARY OR CORRECTIVE ACTION, IN ORDER TO BEST PROTECT THE INTERESTS OF THE CORPORATION. THE BOARD SHOULD CONSULT WITH A MEMBER OF THE CHI LEGAL RESOURCE GROUP WHEN CONSIDERING DISCIPLINARY OR CORRECTIVE ACTION. 4) DISCLOSURE BY INTERESTED DIRECTOR. WHEN ANY CONFLICT OF INTEREST IS CONSIDERED BY THE BOARD, THE DIRECTOR MUST DISCLOSE ALL OF THE MATERIAL FACTS TO THE BOARD. THE DIRECTOR SHALL NOT VOTE OR USE HIS OR HER PERSONAL INFLUENCE ON THE MATTER. HOWEVER, IF REQUESTED, SUCH DIRECTOR IS NOT PREVENTED FROM BRIEFLY STATING HIS OR HER POSITION IN THE MATTER, NOR FROM ANSWERING PERTINENT QUESTIONS FROM BOARD MEMBERS, AS HIS OR HER KNOWLEDGE MAY BE OF SIGNFICIANT IMPORTANCE. THE DIRECTOR SHALL BE EXCUSED FROM THE MEETING DURING DISCUSSION AND VOTE ON THE CONFLICT OF INTEREST. 5) RECORD OF PROCEEDINGS. MINUTES OF THE BOARD OF DIRECTORS SHALL REFLECT THE FOLLOWING: THE INDIVIDUAL MAKING THE DISCLOSURE, THE NATURE OF THE DISCLOSURE, DISCUSSSION REGARDING ANY PROPOSED TRANSACTION, THE DECISION MADE BY THE BOARD, AND THAT THE INTERESTED DIRECTOR ABSTAINED FROM VOTING. 6) IMPLEMENTATION AND INTERPRETATION. QUESTIONS REGARDING THE IMPLEMENTATION AND INTERPRETATION OF THIS POLICY SHALL BE REFERRED TO A MEMBER OF THE CHI LEGAL RESOURCE GROUP. POLICY VIOLATIONS: IF THE BOARD REASONABLY BELIEVES THAT A DIRECTOR HAS FAILED TO DISCLOSE EITHER AN ACTUAL OR POTENTIAL CONFLICT OF INTEREST, OR ALL MATERIAL FACTS SURROUNDING AN ACTUAL OR POSSIBLE CONFLICT AS REQUIRED BY THIS POLICY, THE DIRECTOR WILL BE GIVEN AN OPPORTUNITY TO EXPLAIN SUCH ALLEGED FAILURE TO DISCLOSE. AFTER HEARING THE RESPONSE OF THE DIRECTOR, THE BOARD WILL CONDUCT SUCH ADDITIONAL INVESTIGATION AS MAY BE APPROPRIATE. IF THE BOARD DETERMINES THAT THE DIRECTOR HAS IN FACT FAILED TO DISCLOSE AS REQUIRED BY THIS POLICY, THE BOARD SHALL TAKE APPROPRIATE DISCIPLINARY OR CORRECTIVE ACTION. WHETHER BOARD OF DIRECTORS REVIEW AND APPROVAL OR OTHER ACTION IS REQUIRED WITHIN THIS POLICY, THE MATTER SHALL BE SUBMITTED TO THE BOARD'S EXECUTIVE COMMITTEE, WHICH SHALL MAKE A FINAL DETERMINATION AS TO THE MATTER PRESENTED. SUCH DETERMINATION, INCLUDING RELEVANT FACTS AND CIRCUMSTANCES, WILL BE REFLECTED IN THE COMMITTEE MINUTES AND WILL BE REPORTED TO THE BOARD OF DIRECTORS. It is essential that all employees of Good Samaritan Hospital avoid any situation or endeavor that could interfere with or create conflicts with personal interest. All management employees of Good Samaritan Hospital (GSH) will complete the "Agreement to Disclose Conflict of Interest and Maintain Confidentiality of Information" form upon assuming office or employment, and annually thereafter. If a potential conflict of interest arises between annual disclosure dates, the individual will immediately disclose relevant information to the CEO or VP, HR of GSH. Disclosure statements provide GSH with a method of resolving potential conflicts of interest. The guiding principles are fairness and reasonableness. It is not the intent to inhibit investment or conduct except when such investment or conduct may be harmful to GSH.
FORM 990, PART VI, Q. 15A	PROCESS FOR DETERMINING CEO'S COMPENSATION	the organization's CEO's compensation is paid by CHI. CHI has a defined compensation philosophy. Both the executive and non-executive compensation structures and ranges are reviewed annually in comparison to market data. CHI uses The Hay Group as the independent third party to assess executive compensation programs and to ensure the reasonableness of actual salaries and total compensation packages. Compensation of the senior most executives is reviewed annually. The Hay Group reviews both cash and total compensation for overall reasonableness, for adherence to CHI's compensation philosophy, and for comparability to the not-for-profit healthcare market. This independent review is delivered by Hay Group to the HR committee of the CHI Board of Stewardship Trustees annually at their September meeting and minutes are shared with the full board at the December meeting. The last review was September, 2011. In addition, in December 2009, Hay Group completed a comprehensive review of all positions at the level of vice president and above to determine and validate appropriate compensation levels.
FORM 990, PART VI, Q. 15B	PROCESS FOR DETERMINING COMPENSATION	HR Advantage has served as the independent compensation consultant for the Nebraska facilities in 2010. HR Advantage reviewed all Nebraska ministries' VP and Executive Directors compensation levels and provided a report with comparability data to CHI Nebraska HR Leaders to review with local CEOs, confirming the reasonableness of MBO Executive's compensation and philosophy. Compensation package and bonus potential for executive leaders is approved by each ministries local boards. The highest paid employees are Physicians. Their compensation was reviewed by an independent compensation consultant. There is a Physician Employment Agreement contract with each employed Physician. Contracts include a maximum compensation based upon an overall percentile national compensation per specialty as reported in the most recent version of the Physician Compensation and Production Survey as published by the MGMA.
FORM 990, PART VI, Q. 16B	Formal Policies Concerning Participation in Joint Ventures	Good Samaritan Hospital has not formally adopted a written policy or written procedure regarding joint ventures. However CHI's system-wide joint venture model operating agreement incorporates controls over the venture sufficient to ensure that (1) the exempt organization at all times retains control over the venture sufficient to ensure that the partnership furthers the exempt purpose of the organization; (2) in any partnership in which the exempt organization is a partner, achievement of exempt purposes is prioritized over maximization of profits for the partners; (3) the partnership does not engage in any activities that would jeopardize the exempt organization's exemption; (4) returns of capital, allocations, and distributions must be made in proportion to the partners' respective ownership interests; and (5) all contracts entered into by the partnership with the exempt organization must be at arm's-length, with prices set at fair market value. Any joint venture agreements that do not conform to the model agreement are generally reviewed by counsel.
FORM 990, PART VI, Q. 19	Public availability of Governing documents/COI Policy/Financial Statements	The organizing documents are available on the Nebraska Secretary of State website at http://www.sos.ne.gov. The Conflict of Interest Policy is available upon request. GOOD SAMARITAN HOSPITAL'S FINANCIAL STATEMENTS ARE INCLUDED IN THE CATHOLIC HEALTH INITIATIVES' CONSOLIDATED AUDITED FINANCIAL STATEMENTS THAT ARE AVAILABLE AT WWW.CATHOLICHEALTHINIT.ORG OR AT WWW.DACBOND.COM
FORM 990, PART VII	Estimate of Hours Devoted to Related Organizations	Compensation reported on Form 990, Part VII was paid to these individuals by related organizations in exchange for the fulfillment of their duties as full-time, 60 hour-per week employees.
FORM 990, PART XI, LINE 5	RECONCILIATION OF NET ASSETS	NET UNREALIZED GAINS/LOSSES $14,624,226 CHI CONNECT DEPRECIATION $485,169 CAPITAL POOL CONTRIBUTION ($2,510,400) -------------- NET CHANGE $12,598,995 ==============

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:

- TIN:

SCHEDULE R
(Form 990)

Department of the Treasury
Internal Revenue Service

Related Organizations and Unrelated Partnerships

Complete if the organization answered "Yes" to Form 990, Part IV, line 33, 34, 35, 36, or 37.
MediumBullet

Attach to Form 990. MediumBullet

See separate instructions.

OMB No. 1545-0047

2010

Open to Public Inspection

Name of the organization

GOOD SAMARITAN HOSPITAL

Employer identification number

47-0379755

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)	(f) Direct controlling entity
(1) KEARNEY IMAGING CENTER LLC PO BOX 2528 KEARNEY,NE68848 47-0831614	OP RADIOLOGY	NE	GSH

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
(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	Yes	No
(1) Catholic Health Initiatives 198 Inverness Drive West Englewood,CO80112 47-0617373	Healthcare	CO	501(c)(3)	9	CHI
(2) Bornemann Healthcare Corporation 2500 Bernville Road PO Box 316 Reading,PA19603 23-2187242	Healthcare	PA	501(c)(3)	11a	CHI
(3) CHI Institute For Research and Innovatio 198 Inverness Drive West Englewood,CO80112 27-1050565	Healthcare	CO	501(c)(3)	11a	CHI
(4) CHI National Foundation 198 Inverness Drive West Englewood,CO80112 27-0930004	Fundraising	CO	501(c)(3)	11a	CHI
(5) CHI National Services 198 Inverness Drive West Englewood,CO80112 45-2532084	Healthcare	CO	501(c)(3)	9	CHI
(6) CHI National Home Care 198 Inverness Drive West Englewood,CO80112 45-1261716	Healthcare	CO	501(c)(3)	11a	CHI
(7) Global Health Initiatives 198 Inverness Drive West Englewood,CO80112 20-1536108	Ministries	CO	501(c)(3)	11a	CHI
(8) St Joseph Physician Enterprises 7601 Osler Drive Towson,MD21204 52-1311775	Physicians	MD	501(c)(3)	11a	CHI
(9) St Vincent Infirmary Medical Center 2 St Vincent Circle Little Rock,AR72205 71-0236917	Healthcare	AR	501(c)(3)	3	CHI
(10) St Anthony's Hospital Association 4 Hospital Drive Morrilton,AR72110 71-0245507	Healthcare	AR	501(c)(3)	3	SVIMC
(11) St Vincent Foundation Two St Vincent Circle Little Rock,AR72205 51-0169537	Fundraising	AR	501(c)(3)	11a	SVIMC
(12) St Vincent Medical Group 2 St Vincent Circle Little Rock,AR72205 71-0830696	Healthcare	AR	501(c)(3)	9	SVIMC
(13) CHI Colorado 188 Inverness Drive West Englewood,CO80112 84-0405257	Healthcare	CO	501(c)(3)	3	CHI
(14) Mercy Regional Medical Center of Durango 1010 Three Springs Blvd Durango,CO81301 84-0405515	Healthcare	CO	501(c)(3)	3	CHI
(15) Catholic Health Initiatives Colorado Fou 961 East Colorado Avenue Colorado Springs,CO80903 84-0902211	Fundraising	CO	501(c)(3)	7	CHI Colorado
(16) Health SET 4200 West Conejos Place 436 Denver,CO80204 84-1102943	Low Inc.Care	CO	501(c)(3)	7	CHI Colorado
(17) Pueblo Stepup 1925 East Orman Avenue Suite G52 Pueblo,CO81004 84-1234295	Community	CO	501(c)(3)	7	CHI
(18) SET of Colorado Springs Inc 825 E Pikes Peak Avenue Bldg 29 Colorado Springs,CO80903 84-1183335	LTerm Care	CO	501(c)(3)	7	CHI Colorado
(19) Total Healthcare PO Box 7021 Colorado Springs,CO80933 84-0927232	Healthcare	CO	501(c)(3)	3	CHI Colorado
(20) CHI-Iowa Corp 1111 6th Avenue Des Moines,IA50314 42-0680448	Healthcare	IA	501(c)(3)	3	MHN
(21) Bishop Drumm Retirement Center 1111 6th Avenue Des Moines,IA50314 42-0725196	LTerm Care	IA	501(c)(3)	9	CHI-IA Corp
(22) House of Mercy 1111 6th Avenue Des Moines,IA50314 42-1323808	Shelter	IA	501(c)(3)	7	CHI-IA Corp
(23) Mercy Clinics Inc 1111 6th Avenue Des Moines,IA50314 42-1193699	Physician	IA	501(c)(3)	9	CHI-IA Corp
(24) Mercy College of Health Sciences 1111 6th Avenue Des Moines,IA50314 42-1511682	Education	IA	501(c)(3)	2	CHI-IA Corp
(25) Mercy Foundation of Des Moines IA 1111 6th Avenue Des Moines,IA50314 23-7358794	Fundraising	IA	501(c)(3)	7	CHI-IA Corp
(26) Mercy Auxiliary of Central Iowa 1111 6th Avenue Des Moines,IA50314 42-6076069	Auxiliary	IA	501(c)(3)	11a	CHI-IA Corp
(27) Mercy Professional Practice Associates 1111 6th Avenue Des Moines,IA50314 42-1470935	Physician	IA	501(c)(3)	9	CHI-IA Corp
(28) Mercy Medical Center - Centerville FKA 1 St Josephs Drive Centerville,IA52544 42-0680308	Healthcare	IA	501(c)(3)	3	CHI-IA Corp
(29) St Rose Ambulatory and Surgery Center F 3515 Broadway Great Bend,KS67530 48-0543724	Surgery Cntr	KS	501(c)(3)	3	CHI
(30) St Catherine Hospital 401 East Spruce Street Garden City,KS67846 48-0543721	Healthcare	KS	501(c)(3)	3	CHI
(31) St Catherine Hospital Development Found 401 East Spruce Street Garden City,KS67846 20-0598702	Fundraising	KS	501(c)(3)	11a	SCH
(32) CHI Kentucky Inc 3900 Olympic Blvd Suite 400 Erlanger,KY41018 20-2741651	Healthcare	KY	501(c)(3)	11a	CHI
(33) Saint Joseph Health System Inc 150 N Eagle Creek Dr Lexington,KY40509 61-1334601	Healthcare	KY	501(c)(3)	3	CHI
(34) Continuing Care Hospital 150 North Eagle Creek Drive Lexington,KY40509 61-1400619	LTACH	KY	501(c)(3)	3	SJHS
(35) Flaget Healthcare DBA Flaget Memorial 4305 New Shepherdsville Road Bardstown,KY40004 61-1345363	Healthcare	KY	501(c)(3)	3	CHI
(36) Flaget Memorial Hospital Foundation Inc 4305 New Shepherdsville Road Bardstown,KY40004 56-2351341	Fundraising	KY	501(c)(3)	11a	FH
(37) Saint Joseph London Foundation Inc 310 East Ninth Street London,KY40741 26-0438748	Fundraising	KY	501(c)(3)	11a	SJHS
(38) Saint Joseph Berea Hospital Foundation 305 Estill Street Berea,KY40403 26-0152877	Fundraising	KY	501(c)(3)	7	SJHS
(39) St Joseph Hospital Foundation Inc 305 Estill Street Lexington,KY40504 61-1159649	Fundraising	KY	501(c)(3)	11a	SJHS
(40) Saint Joseph Medical Foundation Inc One St Joseph Drive Lexington,KY40504 31-1539059	Phy Practices	KY	501(c)(3)	3	SJHS
(41) Saint Joseph Mount Sterling Foundation 50 Sterling Avenue Mount Sterling,KY40353 27-2884584	Fundraising	KY	501(c)(3)	7	SJHS
(42) St Joseph Medical Center Inc 7601 Osler Drive Towson,MD21204 52-0591461	Healthcare	MD	501(c)(3)	3	CHI
(43) St Joseph Medical Center Foundation In 7601 Osler Drive Towson,MD21204 52-1681044	Fundraising	MD	501(c)(3)	7	SJMC
(44) Alverna Apartments 300 SE 8th Avenue Little Falls,MN56345 41-1351177	Lterm Care	MN	501(c)(3)	9	CHI
(45) Lakewood Health Center 600 Main Avenue South Baudette,MN56623 41-0758434	LTerm Care	MN	501(c)(3)	3	CHI
(46) St Francis Home 2400 St Francis Drive Breckenridge,MN56520 41-0729978	LTerm Care	MN	501(c)(3)	9	CHI
(47) Appletree Court 601 Oak Street Breckenridge,MN56520 41-1850500	Senior Homes	MN	501(c)(3)	9	SFH
(48) St Francis Medical Center 2400 St Francis Drive Breckenridge,MN56520 41-0695598	Healthcare	MN	501(c)(3)	3	CHI
(49) Healthcare and Wellness Foundation 2400 St Francis Drive Breckenridge,MN56520 76-0761782	Fundraising	MN	501(c)(3)	11a	SFMC
(50) St Joseph's Area Health Services 600 Pleasant Avenue Park Rapids,MN56470 41-0695603	Healthcare	MN	501(c)(3)	3	CHI
(51) Unity Family Healthcare 815 2nd Street SE Little Falls,MN56345 41-0721642	Healthcare	MN	501(c)(3)	3	CHI
(52) St John's Regional Medical Center 2727 McClelland Blvd Joplin,MO64804 44-0545809	Healthcare	MO	501(c)(3)	3	CHI
(53) Mercy Lifecare Systems 2727 McClelland Blvd Joplin,MO64804 43-1305163	Property Mgmt	MO	501(c)(3)	11a	SJRMC
(54) MNMCH Inc 220 North Pennsylvania Columbus,KS66725 48-1216238	Healthcare	KS	501(c)(3)	3	SJRMC
(55) St John's Medical Group 2727 McClelland Blvd Joplin,MO64804 43-1882377	Phys Practice	MO	501(c)(3)	9	SJRMC
(56) St John's Mercy Regional Foundation 2727 McClelland Blvd Joplin,MO64804 43-1308084	Fundraising	MO	501(c)(3)	7	SJRMC
(57) Alegent Health - Bergan Mercy Health Sys 7500 Mercy Road Omaha,NE68124 47-0484764	Healthcare	NE	501(c)(3)	3	CHI
(58) Alegent Health - Mercy Hospital Corning PO Box 368 Corning,IA50841 42-0782518	Healthcare	IA	501(c)(3)	3	AHBMHS
(59) Mercy Health Care Foundation PO Box 368 Corning,IA50841 42-1461064	Fundraising	NE	501(c)(3)	11a	AHMH
(60) Mercy Hospital Foundation Council Bluff 800 Mercy Drive Council Bluffs,IA51503 42-1178204	Fundraising	IA	501(c)(3)	11a	AHBMHS
(61) CHI Nebraska 555 South 70th Street Lincoln,NE68510 36-3233121	Healthcare	NE	501(c)(3)	11a	CHI
(62) The Physician Network 8055 O Street Suite 300 Lincoln,NE68510 47-0780857	Phys Practice	NE	501(c)(3)	11a	CHI Nebraska
(63) Good Samaritan Hospital PO Box 1990 Kearney,NE68848 47-0379755	HealthCare	NE	501(c)(3)	3	CHI Nebraska
(64) Good Samaritan Hospital Foundation PO Box 1810 Kearney,NE68848 47-0659443	Fundraising	NE	501(c)(3)	7	GSH
(65) Catholic Health Care Federation 198 Inverness Drive West Englewood,CO80112 20-8473567	Jurdic Person	CO	501(c)(3)	11a	CHI
(66) Saint Elizabeth Regional Medical Center 555 South 70th Street Lincoln,NE68510 47-0379836	Healthcare	NE	501(c)(3)	3	CHI Nebraska
(67) Saint Elizabeth Foundation 555 South 70th Street Lincoln,NE68510 47-0625523	Fundraising	NE	501(c)(3)	7	SERMC
(68) Saint Elizabeth Health Services 555 South 70th Street Lincoln,NE68510 36-3233120	Healthcare	NE	501(c)(3)	3	SERMC
(69) Saint Francis Medical Center PO Box 9804 Grand Island,NE68802 47-0376601	HealthCare	NE	501(c)(3)	3	CHI Nebraska
(70) Saint Francis Medical Center Foundation PO Box 9804 Grand Island,NE68802 47-0630267	Fundraising	NE	501(c)(3)	7	SFMC
(71) St Mary's Hospital 1314 3rd Avenue Nebraska City,NE68410 47-0443636	Healthcare	NE	501(c)(3)	3	CHI Nebraska
(72) St Mary's Hospital Foundation 1314 3rd Avenue Nebraska City,NE68410 47-0707604	Fundraising	NE	501(c)(3)	7	SMH
(73) Saint Clare's Health Services Inc 25 Pocono Road Denville,NJ07834 22-3639733	Management	NJ	501(c)(3)	7	CHI
(74) Saint Clare's Community Care 66 Ford Road Denville,NJ07834 22-2876836	Healthcare	NJ	501(c)(3)	11b	SCHS
(75) Saint Clare's Foundation Inc 66 Ford Road Denville,NJ07834 22-2502997	Fundraising	NJ	501(c)(3)	7	SCHS
(76) Saint Clare's Hospital 66 Ford Road Denville,NJ07834 22-3319886	Healthcare	NJ	501(c)(3)	3	CHI
(77) St Francis Life Care Corporation 19 Pocono Road Denville,NJ07834 22-2536017	Elderly Care	NJ	501(c)(3)	9	SCHS
(78) Visiting Nurse Association of Saint Clar 191 Woodport Road Sparta,NJ07871 22-1768334	Home Health	NJ	501(c)(3)	9	SCHS
(79) St Joseph Community Health Services 300 Central Ave SW Suite 3000W Albuquerque,NM87102 71-0897107	Community	NM	501(c)(3)	11a	CHI
(80) CHI Health Connect at Home - Fargo 4816 Amber Valley Parkway Fargo,ND58104 27-1966847	Healthcare	ND	501(c)(3)	3	CHI
(81) Carrington Health Center 800 North 4th Street Carrington,ND58421 45-0227311	Healthcare	ND	501(c)(3)	3	CHI
(82) Lisbon Area Health Services 905 Main Street Lisbon,ND58054 82-0558836	Healthcare	ND	501(c)(3)	3	CHI
(83) Mercy Hospital of Devils Lake 1031 East Seventh Street Devils Lake,ND58301 45-0227012	Healthcare	ND	501(c)(3)	3	CHI
(84) The Mercy Hospital of Devils Lake Fdn 1031 East Seventh Street Devils Lake,ND58301 35-2367360	Fundraising	ND	501(c)(3)	11a	MHDL
(85) Mercy Hospital of Valley City 570 Chautauqua Boulevard Valley City,ND58072 45-0226553	Healthcare	ND	501(c)(3)	3	CHI
(86) Mercy Medical Center 1301 15th Avenue West Williston,ND58801 45-0231183	Healthcare	ND	501(c)(3)	3	CHI
(87) Mercy Medical Foundation 1301 15th Avenue West Williston,ND58801 45-0381803	Fundraising	ND	501(c)(3)	11a	MMC
(88) Oakes Community Hospital 314 South 8th Street Oakes,ND58474 45-0231675	Healthcare	ND	501(c)(3)	3	CHI
(89) Oakes Community Hospital Foundation 314 South 8th Street Oakes,ND58474 71-0966606	Fundraising	ND	501(c)(3)	11a	OCH
(90) St Joseph's Hospital and Health Center 30 West 7th Street Dickinson,ND58601 45-0226429	Healthcare	ND	501(c)(3)	3	CHI
(91) Saint Joseph's Hospital Foundation 30 West 7th Street Dickinson,ND58601 36-3418207	Fundraising	ND	501(c)(3)	11a	SJHHC
(92) Villa Nazareth Inc 801 Page Drive Fargo,ND58103 45-0226714	LT Care	ND	501(c)(3)	9	CHI
(93) Samaritan Health Partners 2222 Philadelphia Drive Dayton,OH45406 31-1107411	Healthcare	OH	501(c)(3)	11a	CHI
(94) Samaritan Behavioral Health 601 S Edwin C Moses Blvd Dayton,OH45408 02-0633634	Healthcare	OH	501(c)(3)	3	SHP
(95) Samaritan Health Foundation 2222 Philadelphia Drive Dayton,OH45406 23-7296923	Fundraising	OH	501(c)(3)	7	SHP
(96) The Good Samaritan Hospital of Cincinnat 619 Oak Street Accounting-3 West Cincinnati,OH45206 31-0537486	Healthcare	OH	501(c)(3)	3	TRI-HEALTH
(97) The Community Limited Care Dialysis Cent 619 Oak Street Accounting-3 West Cincinnati,OH45206 23-7419853	Dialysis	OH	501(c)(2)	none	GSH
(98) Good Samaritan College of Nursing & Heal 375 Dixmyth Ave Cincinnati,OH45220 31-1778403	Education	KY	501(c)(3)	2	GHS
(99) Good Samaritan Foundation of Cincinnati 619 Oak Street Accounting-3 West Cincinnati,OH45206 31-1206047	Fundraising	OH	501(c)(3)	11a	GSH
(100) Hospital Association for St Joseph Hosp 7601 Osler Drive Towson,MD21204 52-6050777	Healthcare	MD	501(c)(3)	9	SJMC
(101) Mercy Medical Center 2700 Stewart Parkway Roseburg,OR97470 93-0386868	Healthcare	OR	501(c)(3)	3	CHI
(102) Centennial Medical Group Inc 2700 Stewart Parkway Roseburg,OR97470 90-0433062	Physicians	OR	501(c)(3)	9	MMC
(103) Linus Oakes Inc 2700 Stewart Parkway Roseburg,OR97470 93-0821381	Senior Living	OR	501(c)(3)	9	MMC
(104) Mercy Foundation Inc 2700 Stewart Parkway Roseburg,OR97470 93-6088946	Fundraising	OR	501(c)(3)	7	MMC
(105) Mt St Joseph Inc 3060 SE Stark Street Portland,OR97214 93-0386870	Nursing Care	OR	501(c)(3)	9	CHI
(106) St Anthony Hospital 1601 SE Court Avenue Pendleton,OR97801 93-0391614	Healthcare	OR	501(c)(3)	3	CHI
(107) St Anthony Hospital Foundation 1601 SE Court Avenue Pendleton,OR97801 93-0992727	Fundraising	OR	501(c)(3)	11a	SA Hospital
(108) St Dominic at Ontario 351 SW 9th Street Ontario,OR97914 93-0433692	Healthcare	OR	501(c)(3)	3	CHI
(109) St Francis of Baker City 3325 Pocahontas Road Baker City,OR97814 93-0412495	Healthcare	OR	501(c)(3)	3	CHI
(110) St Joseph Health Ministries 1929 Lincoln Hwy E Ste 150 Lancaster,PA17602 23-2342997	Health	PA	501(c)(3)	11a	CHI
(111) St Joseph Health Ministries Foundation 1929 Lincoln Hwy E Ste 150 Lancaster,PA17602 23-2605579	Fundraising	PA	501(c)(3)	11a	SJHM
(112) St Joseph Health Services Inc 1929 Lincoln Hwy E Ste 150 Lancaster,PA17602 20-1425375	Dental care	PA	501(c)(3)	11a	SJHM
(113) St Joseph Regional Health Network 2500 Bernville Road PO Box 316 Reading,PA19603 23-1352211	Healthcare	PA	501(c)(3)	3	CHI
(114) St Joseph Medical Group 2500 Bernville Road PO Box 316 Reading,PA19603 20-8544021	Healthcare	PA	501(c)(3)	9	BHC
(115) St Joseph Medical Center Foundation 2500 Bernville Road PO Box 316 Reading,PA19603 23-2649362	Fundraising	PA	501(c)(3)	11a	SJRHN
(116) St Mary's Healthcare Center 801 East Sioux Avenue Pierre,SD57501 46-0230199	Healthcare	SD	501(c)(3)	3	CHI
(117) Gettysburg Medical Center 606 East Garfield Avenue Gettysburg,SD57442 46-0234354	Healthcare	SD	501(c)(3)	3	SMHC
(118) Memorial Health Care System Inc 2525 De Sales Avenue Chattanooga,TN37404 62-0532345	Healthcare	TN	501(c)(3)	3	CHI
(119) Memorial Health Care System Foundation 2525 De Sales Avenue Chattanooga,TN37404 62-1839548	Fundraising	TN	501(c)(3)	7	MHCS
(120) Memorial Health Partners Foundation Inc 6028 Shallowford Road Chattanooga,TN37421 03-0417049	Healthcare	TN	501(c)(3)	9	MHCS
(121) Franciscan Health System FKA Franciscan 1717 South J Street Tacoma,WA98405 91-0564491	Healthcare	WA	501(c)(3)	3	CHI
(122) Enumclaw Regional Hospital Association 1450 Battersby Avenue Enumclaw,WA98022 91-0715805	Healthcare	WA	501(c)(3)	3	FHS
(123) Franciscan Foundation 1717 South J Street Tacoma,WA98405 91-1145592	Fundraising	WA	501(c)(3)	9	FHS
(124) Franciscan Medical Group 1708 South Yakima Avenue Tacoma,WA98405 91-1939739	Healthcare	WA	501(c)(3)	9	FHS
(125) Franciscan Villa of South Milwaukee Inc 3601 South Chicago Avenue South Milwaukee,WI53172 39-1093829	Healthcare	WI	501(c)(3)	9	CHI

For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 50135Y

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 VUBI amount in box 20 of Schedule K-1 (Form 1065)	(j) General or managing partner?		(k) Percentage ownership
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity		(f) Share of total income	(g) Share of end-of-year assets	Yes	No	(i) Code VUBI amount in box 20 of Schedule K-1 (Form 1065)	Yes	No
(1) CHI Operating Investment Program LP 198 Inverness Drive West Englewood,CO80112 47-0727942	Investments	CO	CHI	Investment	139,679,805	2,069,974,790		No	371,292	Yes		100.000 %
(2) North River Surgery Center LLC 2209 Wildwood Avenue Sherwood,AR72120 71-0799771	Ambul Surg Ctr	AR	SVIMC	Related	198,313	1,758,688		No			No	57.450 %
(3) Audubon Land Company LLC 5390 N Academy Blvd Suite 300 Colorado Springs,CO80918 84-1513085	Real Estate	CO	THC	Related	-157,673	14,390,550		No			No	50.100 %
(4) OrthoColorado LLC 11650 West 2nd Place Lakewood,CO80255 37-1577105	Ortho Hospital	CO	THC	Related	-3,249,314	10,905,384		No			No	60.000 %
(5) Penrad Imaging 1390 Kelly Johnson Blvd Colorado Springs,CO80920 84-1072619	Medical Imaging	CO	THC	Related	1,857,228	5,457,224		No			No	70.000 %
(6) St Anthony Regional Mtn Cancer Center 4231 W 16th Avenue Denver,CO80112 37-1568013	Cancer Center	CO	THC	Related	-290,552			No			No	51.000 %
(7) St Francis Land Company 5390 N Academy Blvd Suite 300 Colorado Springs,CO80918 26-3134100	Real Estate	CO	THC	Related	-180,979	14,886,022		No			No	51.000 %
(8) Bluegrass Regional Imaging Center 1218 South Broadway Suite 310 Lexington,KY40504 61-1386736	Diagnostic	KY	SJ HospitalLex	Related				No			No	65.000 %
(9) St Joseph-PAML LLC 424 Lewis Hargett Circle Ste 160 Lexington,KY40503 45-2116736	Mgmt Svcs	KY	SJHS	Related				No		Yes		62.500 %
(10) Saint Joseph SCA Holdings LLC 424 Lewis Hargett Circle Ste 160 Lexington,KY40503 45-3801157	OP Surgery	DE	SJHS	Related				No		Yes		51.000 %
(11) Surgery Center of Lexington LLC 1451 Harrodsburg Road Lexington,KY40504 62-1179539	Surgery Center	DE	SJHS	Related	808,840	4,236,901		No		Yes		51.000 %
(12) Ruxton Surgicenter LLC 8322 Bellona Avenue Suite 201 Baltimore,MD21204 52-2095835	Surgery Center	MD	SJMC	Related				No		Yes		51.000 %
(13) Avantas LLC 1207 South 13 Street Omaha,NE68108 39-2045003	Healthcare	NE	AHMH	Unrelated				No			No	95.000 %
(14) Healthcare Support Services LLC PO Box 9804 Grand Island,NE68802 72-1546196	Laundry	NE	CHI	Related	196,124	3,913,481		No	-58,436		No	100.000 %
(15) Central Nebraska Home Care Services PO Box 1146-4510 Second Avenue Kearney,NE68848 47-0692112	Healthcare Srvc	NE	HSEINC	Related	-99,941	1,021,498		No	-48,712	Yes		100.000 %
(16) Superior Medical Imaging LLC 5000 North 26th Street Lincoln,NE68521 26-2884555	OP Diagnostics	NE	SERMC	Related				No			No	51.000 %
(17) Central Nebraska Rehab Services 3004 W Faidley Ave Grand Island,NE68802 81-0653461	Physical Therapy	NE	CHI	Related	1,857,991	2,262,775		No			No	51.000 %
(18) St Francis Medical Center Associates 1717 South J Street Tacoma,WA98405 91-1352698	Med. Office	WA	FHS	Related	116,948	1,652,280		No			No	54.210 %
(19) Peninsula Radiation Oncology 314 Martin Luther King Jr Way 11 Tacoma,WA98405 87-0808610	Healthcare Srvc	WA	FHS	Related	131,195	3,052,504		No			No	60.000 %
(20) Berywood Office Properties LLC 400 Berywood Trail Cleveland,TN37312 62-1875199	Phys Office	TN	MHCS	Related				No		Yes		63.000 %

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) Alternative Insurance Management Service 3900 Olympic Boulevard Suite 400 Erlanger,KY41018 84-1112049	Management Servic	CO	CHI	C Corp		3,267,441	100.000 %
(2) Captive Management Initiatives 6028D Shallowford Road Chattanooga,TN37422 98-0663022	Captive Managemen	CJ	CHI	C Corp			100.000 %
(3) Center for Translational Research 198 Inverness Drive West Englewood,CO80112 27-2269511	Healthcare	CO	CHI	C Corp	-2,247,962	1,668,589	100.000 %
(4) First Initiatives Insurance Ltd 1415 Southgate Pendleton,OR97801 98-0203038	Insurance	CJ	CHI	C Corp			100.000 %
(5) Franciscan Services Inc 198 Inverness Drive West Englewood,CO80112 23-2487967	Healthcare	CO	CHI	C Corp	-507,578	11,914,284	100.000 %
(6) SJH Services Corporation 198 Inverness Drive West Englewood,CO80112 23-2307408	Healthcare	CO	FSI	C Corp	-518,360	3,180,100	100.000 %
(7) St Joseph Development Company Inc 1717 South J Street Tacoma,WA98405 91-1480569	Rental	WA	FSI	C Corp	-36,395	12,168,022	100.000 %
(8) Towson Management Inc 7601 Osler Drive Towson,MD21204 52-1710750	Management Servic	MD	FSI	C Corp	-469,016	498,393	100.000 %
(9) Nazareth Assurance Company 76 St Paul Street Suite 500 Burlington,VT05401 03-0304831	Insurance	VT	CHI	C Corp	-379	123,535	100.000 %
(10) St Vincent Community Health Services In Two St Vincent Circle Little Rock,AR72205 71-0710785	Healthcare	AR	SVIMC	C Corp	2,309,129	14,049,375	100.000 %
(11) Comcare Services 4231 W 16th Avenue Denver,CO80204 84-0904813	Inactive	CO	CHIC	C Corp			100.000 %
(12) Des Moines Medical Center Inc 1111 6th Avenue Des Moines,IA50314 42-0837382	Real Estate	IA	CHI-IA Corp	C Corp		1,253,452	92.980 %
(13) Mercy Park Apartments Ltd 1111 6th Avenue Des Moines,IA50314 42-1202422	Housing	IA	CHI-IA Corp	C Corp	264,489	1,796,053	100.000 %
(14) Central Kansas Health Services Associati 3515 Broadway Great Bend,KS67530 48-1042853	MEDICAL EQUIPMENT	KS	CKMC	C Corp			100.000 %
(15) SJL Physician Management Services Inc 424 Lewis Hargett Cr 160 Lexington,KY40503 27-0164198	Management	KY	SJHS	C Corp			100.000 %
(16) St Joseph Office Park Association 1401 HarrodsBurg Road Bldg B70 Lexington,KY40504 61-1079899	Management	KY	SJHS	C Corp	16,644	882,139	85.000 %
(17) Mercy Health Services Corporation 2727 McClelland Blvd Joplin,MO64804 43-1457881	DME	MO	St John's RMC	C Corp	-1,533,371	1,369,083	100.000 %
(18) Good Samaritan Outreach Services PO BOX 1990 Kearney,NE68848 47-0659440	MEDICAL CLINIC	NE	CHI Nebraska	C Corp	-2,921,063	355,110	100.000 %
(19) Health Systems Enterprises Inc PO BOX 1990 Kearney,NE68848 47-0664558	MANAGEMENT	NE	GSH	C Corp	25,289	1,443,049	100.000 %
(20) Saint Clare's Primary Care Inc 66 Ford Road Denville,NJ07834 22-2441202	Billing Services	NJ	SCCC	C Corp	-342,970	2,177,166	100.000 %
(21) MedQuest 1301 15th Avenue West Williston,ND58801 45-0392137	Sale of DME	ND	MHof Williston	C Corp	9,852	962,554	100.000 %
(22) Consolidated Health Services 1700 Edison Drive Milford,OH45150 31-1378212	Home Health	OH	CHI	C Corp		11,595,125	100.000 %
(23) American Nursing Care 1700 Edison Drive Milford,OH45150 31-1085414	Home Health	OH	CHS	C Corp	1,778,617	44,470,358	100.000 %
(24) Amerimed Inc 1700 Edison Drive Milford,OH45150 31-1158699	Home Health	OH	ANC	C Corp	2,395,230	11,869,657	100.000 %
(25) Patient Transport Services Inc 1700 Edison Drive Milford,OH45150 31-1100798	Home Health	OH	ANC	C Corp	662,425	5,325,941	100.000 %
(26) Samaritan Family Care Inc 40 W Fourth St 1700 Dayton,OH45402 31-1299450	Healthcare	OH	SHP	C Corp			100.000 %
(27) Mercy Services Corp 2700 Stewart Parkway Roseburg,OR97470 93-0824308	Retail Sales	OR	MMC	C Corp	-690,267	954,798	100.000 %
(28) St Anthony Development Company 1415 Southgate Pendleton,OR97801 93-1216943	Athletic Club	OR	St Anthony H	C Corp	53,891	3,007,554	100.000 %
(29) CGH Realty Company Inc 215 N 12th St Reading,PA19603 23-2326801	Real Estate	PA	SJHM	C Corp	1,007	42,415	100.000 %
(30) Caduceus Medical Associates Inc 6028 Shallowford Road Suite D Chattanooga,TN37422 62-1570736	Healthcare	TN	MHCS	C Corp		1,008	100.000 %
(31) Mountain Management Services Inc 6028D Shallowford Road Chattanooga,TN37422 62-1570739	mgmt svc org	TN	MHCS	C Corp	-386,020	4,667,998	100.000 %
(32) Physician Health System Network 1149 Market St Tacoma,WA98402 91-1746721	Health Org.	WA	FHS	C Corp			100.000 %
(33) Healthcare Mgmt Services Org Inc 1149 Market St Tacoma,WA98402 91-1865474	Health Org.	WA	FHS	C Corp			100.000 %
(34) Harold W Rase 1995 Charitable Unittrust 30 West 7th Street Dickinson,ND58601 45-6090420	Investments	ND	SJHHC	Trust	1,240	21,533	100.000 %
(35) Harold W Rase 1996 Charitable Unittrust 30 West 7th Street Dickinson,ND58601 20-6037112	Investments	ND	SJHHC	Trust	900	15,495	100.000 %
(36) Harold W Rase 1997 Charitable Unittrust 30 West 7th Street Dickinson,ND58601 20-6037104	Investments	ND	SJHHC	Trust	1,025	20,261	100.000 %
(37) Harold W Rase 1999 Charitable Unittrust 30 West 7th Street Dickinson,ND58601 20-6037099	Investments	ND	SJHHC	Trust	1,313	25,027	100.000 %
(38) James & Henrietta Nistler Unitrust 30 West 7th Street Dickinson,ND58601 20-6021899	Investments	ND	SJHHC	Trust	-16,708	41,455	100.000 %
(39) Joseph A Schuster Annuity Trust #1 400 Univerity Avenue Des Moines,IA50314 42-1195122	Investments	IA	MFDM	Trust	18,924	441,488	100.000 %
(40) Ray & Shirley David 1999 Unitrust 30 West 7th Street Dickinson,ND58601 20-6037077	Investments	ND	SJHHC	Trust	1,250	24,194	100.000 %
(41) Tom Deyle Charitable Remainder Unitrust PO Box 1810 Kearney,NE68848 47-6192393	Investments	NE	GSHF	Trust	4,884	166,321	100.000 %
(42) David Deyle Charitable Remainder Unitrus PO Box 1810 Kearney,NE68848 47-6192395	Investments	NE	GSHF	Trust	4,880	166,425	100.000 %
(43) Jeanne Deyle Charitable Remainder Unitru PO Box 1810 Kearney,NE68848 47-6192398	Investments	NE	GSHF	Trust	4,880	166,320	100.000 %
(44) Lodesca Miller Charitable Remainder Unit PO Box 1810 Kearney,NE68848 47-6186933	Investments	NE	GSHF	Trust	3,387	86,367	100.000 %
(45) Robert & Wanda Charitable Remainder Unit PO Box 1810 Kearney,NE68848 26-6191916	Investments	NE	GSHF	Trust	13,030	537,775	100.000 %

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

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 . . . . . . . . . . . . . . . . . . . . . . .

Yes

b Gift, grant, or capital contribution to other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

c Gift, grant, or capital contribution from other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

d Loans or loan guarantees to or for other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

e Loans or loan guarantees by other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

f Sale of assets to other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

g Purchase of assets from other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

h Exchange of assets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

i Lease of facilities, equipment, or other assets to other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

j Lease of facilities, equipment, or other assets from other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . .

k Performance of services or membership or fundraising solicitations for other organization(s) . . . . . . . . . . . . . . . . . . . . . .

l Performance of services or membership or fundraising solicitations by other organization(s) . . . . . . . . . . . . . . . . . . . . . .

Yes

m Sharing of facilities, equipment, mailing lists, or other assets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

n Sharing of paid employees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

o Reimbursement paid to other organization for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

p Reimbursement paid by other organization for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

q Other transfer of cash or property to other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

r Other transfer of cash or property from other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

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
(1) Good Samaritan Hospital Foundation	c	1,000,676
(2) Catholic Health Initiatives	L	15,969,265
(3) Good Samaritan Hospital Foundation	B	350,000
(4) CHI Nebraska	B	1,966,260
(5) The Physician Network	L	1,800,487
(6) Good Samaritan Outreach Services	I	66,105
(7) Healthcare Support Services	L	523,232
(8) Central Nebraska Homecare	L	59,911
(9) CATHOLIC HEALTH INITIATIVES	Q	6,817,428

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 VUBI amount in box 20 of Schedule K-1 (Form 1065)	(h) General or managing partner?
(a) Name, address, and EIN of entity	(b) Primary activity	(c) Legal domicile (state or foreign country)	Yes	No	(e) Share of end-of-year assets	Yes	No	(g) Code VUBI amount in box 20 of Schedule K-1 (Form 1065)	Yes	No

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

Additional Data

Software ID:
Software Version:

1	Briefly describe the organization’s mission or most significant activities: To nuture the healing ministry of the church by bringing it new life, energy and viability. To promote and provide health care services to the needs of the community in the absence of private benefit.
2	Check this box
3	Number of voting members of the governing body (Part VI, line 1a) ....	3	16
4	Number of independent voting members of the governing body (Part VI, line 1b) ....	4	12
5	Total number of individuals employed in calendar year 2010 (Part V, line 2a) ...	5	1,712
6	Total number of volunteers (estimate if necessary) ....	6	848
7a	Total unrelated business revenue from Part VIII, column (C), line 12 ..	7a	99,376
b	Net unrelated business taxable income from Form 990-T, line 34 ..	7b	45,939

		Prior Year	Current Year
8	Contributions and grants (Part VIII, line 1h) .........	1,389,729	1,083,663
9	Program service revenue (Part VIII, line 2g) .........	197,774,999	214,592,483
10	Investment income (Part VIII, column (A), lines 3, 4, and 7d ) ....	6,184,766	10,920,883
11	Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e)	3,218,823	3,264,114
12	Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)...................	208,568,317	229,861,143
13	Grants and similar amounts paid (Part IX, column (A), lines 1–3 )...	592,265	2,382,159
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)	77,833,108	79,675,983
16a	Professional fundraising fees (Part IX, column (A), line 11e)....	0	0
b	Total fundraising expenses (Part IX, column (D), line 25) 0
17	Other expenses (Part IX, column (A), lines 11a–11d, 11f–24f)....	102,892,227	112,817,995
18	Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25)	181,317,600	194,876,137
19	Revenue less expenses. Subtract line 18 from line 12......	27,250,717	34,985,006
		Beginning of Current Year	End of Year
20	Total assets (Part X, line 16)............	287,807,822	337,318,563
21	Total liabilities (Part X, line 26)............	55,632,027	57,558,769
22	Net assets or fund balances. Subtract line 21 from line 20 .....	232,175,795	279,759,794

Sign Here

	Signature of officer	Date

	Type or print name and title.

Paid Preparer's Use Only	Preparer's signature	Date	Check if self- employed	Preparer’s taxpayer identification number (see instructions)
	Firm’s name (or yours if self-employed), address, and ZIP + 4			EIN
				Phone no.


4a	(Code: ) (Expenses $ 163,342,652 including grants of $ 2,382,159 ) (Revenue $ 214,622,754 )
	SEE SCHEDULE H

4b	(Code: ) (Expenses $ including grants of $ ) (Revenue $ )












4c	(Code: ) (Expenses $ including grants of $ ) (Revenue $ )












4d	Other program services. (Describe in Schedule O.)
	(Expenses $ including grants of $ ) (Revenue $ )
4e	Total program service expenses$ 163,342,652

(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
(A) Name and Title
(1) DAN BAHENSKY VICE CHAIRPERSON	4.0	X	X
(2) LARRY BUTLER BOARD MEMBER	2.0	X
(3) DENNIS EDWARDS VP MEDICAL AFFAIRS	10.0	X		11,250		21,777
(4) BEN HIRSCHFELD BOARD MEMBER	2.0	X
(5) MARY KALB BOARD MEMBER	5.0	X
(6) ROBERT LANIK BOARD MEMBER/CHI SVP	2.0	X			689,847	45,724
(7) RICHARD PILAKOWSKI BOARD MEMBER	3.0	X
(8) DALE POHLMANN CHAIR	4.0	X	X
(9) MICHAEL SCHNIEDERS PRESIDENT/CEO GSH	60.0	X	X		219,277	23,382
(10) GIL RUDE BOARD MEMBER	2.0	X
(11) THOMAS TYE II SECRETARY/TREASURER	3.0	X	X
(12) JANICE WIEBUSCH BOARD MEMBER	2.0	X
(13) WILLIAM VOSIK BOARD MEMBER	2.0	X
(14) MIKE MORGAN BOARD MEMBER	2.0	X
(15) RICHARD HRANAC PRESIDENT, MEDICAL STAFF	2.0	X				17,380
(16) BRIAN MAHER FOUNDATION BOARD CHAIR	2.0	X
(17) GEORGE HARMS VICE PRESIDENT OF FINANCE	60.0		X	300,376		38,064

(A) Name and Title	(B) Average hours per week (describe hours for related organizations in Schedule O)				(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
(A) Name and Title
(18) ROBERT CUNNINGHAM VP ANCILLARY SUPPORT	60.0	X			283,160		32,783
(19) TIMOTHY RANNEY VP MEDICAL AFFAIRS	60.0	X			163,125		25,666
(20) CAROL WAHL VP PATIENT SERVICES	60.0	X			233,471		33,011
(21) FISHEL LIBERMAN PHYSICIAN	65.0		X		543,773		41,362
(22) PAMELA WESTERLING PHYSICIAN	65.0		X		454,446		37,525
(23) HUGO GONZALEZ NIETO PHYSICIAN	65.0		X		346,282		36,670
(24) STEVEN SCHULZ PSYCHIATRIST	65.0		X		328,969		41,570
(25) ROGER ALBIN PHYSICIAN	65.0		X		276,084		44,020
(26) JOHN ALLEN PRESIDENT/CEO GSH	60.0			X		521,748	30,607
(27) STEPHEN LEURCK INTERIM CAO	60.0			X	70,620	70,552
(28) STEVE LOVELESS INTERIM PRESIDENT/CEO	60.0			X	124,422		27,819
(29) LEIGH BERTHOLF FORMER VICE PRESIDENT/CRO				X		187,319	39,607

1b	Sub-Total................
c	Total from continuation sheets to Part VII, Section A....
d	Total (add lines 1b and 1c)............	3,135,978	1,688,743	536,967

				(A) Total revenue	(B) Related or exempt function revenue	(C) Unrelated business revenue	(D) Revenue excluded from tax under sections 512, 513, or 514
1a	Federated campaigns..1a
b	Membership dues....1b
c	Fundraising events....1c
d	Related organizations...1d		1,000,676
e	Government grants (contributions)1e		82,630

f	All other contributions, gifts, grants, and similar amounts not included above1f		357
g	Noncash contributions included in lines 1a-1f:$
h	Total. Add lines 1a-1f.......			1,083,663
			Business Code
2a	Patient Services		900,099	212,513,852	212,513,852
b	Equity changes of unconsolidated orgs		900,099	959,645	989,916	-30,271
c	Rental Income		900,099	944,596	944,596
d	Program Service Revenue		900,099	125,655	125,655
e	Medical Services		900,099	48,735	48,735
f	All other program service revenue .
g	Total. Add lines 2a–2f........			214,592,483
3	Investment income (including dividends, interest
	and other similar amounts).....			3,356,090		10,190	3,345,900
4	Income from investment of tax-exempt bond proceeds..			0
5	Royalties............			0
		(i) Real	(ii) Personal
6a	Gross Rents
b	Less: rental expenses
c	Rental income or (loss)
d	Net rental income or (loss).......
		(i) Securities	(ii) Other
7a	Gross amount from sales of assets other than inventory	7,480,746	166,582
b	Less: cost or other basis and sales expenses		82,535
c	Gain or (loss)	7,480,746	84,047
d	Net gain or (loss)..........			7,564,793			7,564,793
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..			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...			0
10a	Gross sales of inventory, less returns and allowances .
	a
b	Less: cost of goods sold ..b
c	Net income or (loss) from sales of inventory..			0
Miscellaneous Revenue			Business Code
11a	Services Sold		900,099	1,207,742			1,207,742
b	Cafeteria		722,100	919,748		4,162	915,586
c	Child Care		624,410	447,101			447,101
d	All other revenue ....			689,523		115,295	574,228
e	Total. Add lines 11a–11d ......			3,264,114
12	Total revenue. See Instructions....			229,861,143	214,622,754	99,376	14,055,350


				(A) Beginning of year		(B) End of year
1	Cashnon-interest-bearing ..........			4,701	1	4,660
2	Savings and temporary cash investments .......			16,659,012	2	23,292,498
3	Pledges and grants receivable, net .........				3
4	Accounts receivable, net .........			32,966,891	4	31,321,539
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 .............			88,282	7	290,559
8	Inventories for sale or use ..............			7,631,058	8	7,411,778
9	Prepaid expenses and deferred charges ............			434,898	9	278,463
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	222,576,304
b	Less: accumulated depreciation. .....	10b	126,549,444	87,854,698	10c	96,026,860
11	Investments—publicly traded securities ..........			3,487	11	1,142
12	Investments—other securities. See Part IV, line 11 ......			133,693,001	12	170,545,706
13	Investments—program-related. See Part IV, line 11 ..				13
14	Intangible assets .........			2,301,156	14	2,301,156
15	Other assets. See Part IV, line 11 ...........			6,170,638	15	5,844,202
16	Total assets. Add lines 1 through 15 (must equal line 34)...			287,807,822	16	337,318,563
17	Accounts payable and accrued expenses .			19,799,817	17	27,298,294
18	Grants payable ..........				18
19	Deferred revenue ..........				19
20	Tax-exempt bond liabilities ..........				20
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 ..			770,517	23	243,626
24	Unsecured notes and loans payable to unrelated third parties ....			35,061,693	24	29,807,013
25	Other liabilities. Complete Part X of Schedule D.....				25	209,836
26	Total liabilities. Add lines 17 through 25.....			55,632,027	26	57,558,769
	Organizations that follow SFAS 117, check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets .....			232,175,795	27	279,759,794
28	Temporarily restricted net assets .....				28
29	Permanently restricted net assets .....				29
	Organizations that do not follow SFAS 117, check here 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 .....			232,175,795	33	279,759,794
34	Total liabilities and net assets/fund balances .....			287,807,822	34	337,318,563