TY 2011 Form 990

(A) Name and Title	(B) Average hours per week (describe hours for related organizations in Schedule O)	(C) Position (do not check more than one box, unless person is both an officer and a director/trustee)	(E) Reportable compensation from related organizations (W- 2/1099-MISC)
(1) WILLIAM BERRY PHD FORMER DIRECTOR	1.0	X			0
(2) BROTHER JAMES GAFFNEY FSC FORMER DIRECTOR	1.0	X			0
(3) AIDA GIACHELLO PHD FORMER DIRECTOR	1.0	X			0
(4) MARK HANSON DIRECTOR/FORMER CHAIRPERSON	1.0	X	X		0
(5) SISTER LINDA HATTON SSCM FORMER SECRETARY	1.0	X	X		0
(6) THOMAS HUBERTY MD DIRECTOR/FORMER VICE CHAIR	1.0	X	X		0
(7) SISTER MARY ELIZABETH IMLER FORMER DIRECTOR	1.0	X	X		0
(8) BETTINA JOHNSON FORMER TREASURER	1.0	X			0
(9) LUCIA JONES FORMER DIRECTOR	1.0	X			0
(10) MARSHA LADENBURGER DIRECTOR	1.0	X			0
(11) SISTER TERRY MALTBY DIRECTOR	1.0	X			0
(12) BECKY MEGGESIN FORMER DIRECTOR	1.0	X			0
(13) DANIEL RUSSEL FORMER VICE CHAIRPERSON	1.0	X	X		0
(14) KENT RUSSELL DIRECTOR	1.0	X			0
(15) GUY WIEBKING CHAIRPERSON/ FORMER PRES & CEO	40.0	X	X	798,058	0
(16) SANDRA BRUCE DIRECTOR/ PRESIDENT & CEO	40.0	X	X	1,564,401	33,589
(17) HAVEN COCKERHAM DIRECTOR	1.0	X			0

(A) Name and business address	(B) Description of services	(C) Compensation
FELMLEY-DICKERSON PO BOX 1550 BLOOMINGTON,IL617021550	CONTRACTOR	2,469,360
SHALES MCNUTT CONSTRUCTION 749 N STATE STREET ELGIN,IL60123	CONSTRUCTION	2,557,150
MADISON AVENUE ANESTHESIA PLACEMENT 19627 S LAGRANGE RD MOKENA,IL60448	ANESTHESIA SERVICES	4,100,004
CHRISTIE CLINIC LLC 101 W UNIVERSITY AVENUE CHAMPAIGN,IL61820	HOSPITALIST SERVICES	1,043,818
ANESTHESIA ASSOC 2540 HANFORD LANE AURORA,IL60502	ANESTHESIA SERVICES	1,740,163
2 Total number of independent contractors (including but not limited to those listed above) who received more than $100,000 of compensation from the organization 70

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 United States. See Part IV, line 21	0	0
2	Grants and other assistance to individuals in the United States. See Part IV, line 22	73,650	73,650
3	Grants and other assistance to governments, organizations, and individuals outside the United States. 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 ....	5,363,002		5,363,002
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	355,193,847	338,602,931	14,967,129	1,623,787
8	Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) ....	0
9	Other employee benefits .......	77,359,021	75,514,625	1,773,011	71,385
10	Payroll taxes ...........	24,498,721	24,498,721
11	Fees for services (non-employees):
a	Management ......	0
b	Legal .........	1,526,416	12,690	1,513,726
c	Accounting ...........	1,066,503	27,058	1,039,445
d	Lobbying ...........	0
e	Professional fundraising. See Part IV, line 17..	139,507			139,507
f	Investment management fees ......	0
g	Other ..........	2,428,947	353,731	2,027,053	48,163
12	Advertising and promotion ....	4,625,919	255,967	4,312,812	57,140
13	Office expenses .......	161,930,677	158,280,146	3,435,146	215,385
14	Information technology ......	36,395,016	14,024,908	22,351,583	18,525
15	Royalties ..	0
16	Occupancy ...........	17,487,164	15,989,382	1,490,001	7,781
17	Travel ............	384,057	208,443	167,118	8,496
18	Payments of travel or entertainment expenses for any federal, state, or local public officials ......	0
19	Conferences, conventions, and meetings ....	553,795	292,855	238,267	22,673
20	Interest ...........	30,069,958		30,069,958
21	Payments to affiliates .......	0
22	Depreciation, depletion, and amortization .....	54,303,763	54,165,590	138,013	160
23	Insurance ..............	19,753,170	10,525,338	9,227,832
24	Other expenses. Itemize expenses not covered above (List miscellaneous expenses in line 24f. If line 24f amount exceeds 10% of line 25, column (A) amount, list line 24f expenses on Schedule O.)
a	OTHER PURCHASED SERVICES	97,538,621	90,391,634	6,681,647	465,340
b	INTERNAL PURCHASED SERVICES	46,974,370	11,151,768	35,822,602
c	TAXES	37,187,928	910,422	36,277,506
d	FOOD	6,391,357	6,207,222	142,526	41,609
e
f	All other expenses	27,731,959	20,630,205	6,706,179	395,575
25	Total functional expenses. Add lines 1 through 24f	1,008,977,368	822,117,286	183,744,556	3,115,526
26	Joint costs. Complete this line only if the organization reported in column (B) joint costs from a combined educational campaign and fundraising solicitation. Check here if following SOP 98-2 (ASC 958-720).

Part X Balance Sheet
	1	Cashnon-interest-bearing ..........	0	1	0
2	Savings and temporary cash investments .......	42,301,204	2	37,306,915
3	Pledges and grants receivable, net .........	0	3	0
4	Accounts receivable, net .........	160,016,149	4	175,864,260
5	Receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of
	Schedule L ..........	0	5	0
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 ..........	0	6	0
7	Notes and loans receivable, net .............	0	7	0
8	Inventories for sale or use ..............	23,132,697	8	23,621,593
9	Prepaid expenses and deferred charges ............	23,408,845	9	24,863,725
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	1,034,046,352
b	Less: accumulated depreciation. .....	10b	528,126,142	574,654,482	10c	505,920,210
11	Investments—publicly traded securities ..........	0	11	0
12	Investments—other securities. See Part IV, line 11 ......	0	12	0
13	Investments—program-related. See Part IV, line 11 ..	0	13	0
14	Intangible assets .........	0	14	0
15	Other assets. See Part IV, line 11 ...........	27,278,437	15	29,158,202
16	Total assets. Add lines 1 through 15 (must equal line 34)...	850,791,814	16	796,734,905
	17	Accounts payable and accrued expenses .	84,431,743	17	76,670,085
18	Grants payable ..........	0	18	0
19	Deferred revenue ..........	0	19	0
20	Tax-exempt bond liabilities ..........	0	20	0
21	Escrow or custodial account liability. Complete Part IV of Schedule D..	0	21	0
22	Payables to current and former officers, directors, trustees, key employees, highest compensated employees, and disqualified
	persons. Complete Part II of Schedule L..........	0	22	0
23	Secured mortgages and notes payable to unrelated third parties ..	0	23	0
24	Unsecured notes and loans payable to unrelated third parties ....	0	24	0
25	Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17-24). Complete Part X of Schedule D.....	141,723,111	25	154,118,283
26	Total liabilities. Add lines 17 through 25.....	226,154,854	26	230,788,368
		Organizations that follow SFAS 117, check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets .....	616,558,786	27	557,750,919
28	Temporarily restricted net assets .....	6,666,863	28	6,739,739
29	Permanently restricted net assets .....	1,411,309	29	1,455,879
	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 .....	624,636,958	33	565,946,537
34	Total liabilities and net assets/fund balances .....	850,791,814	34	796,734,905

- TIN:

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

2011

Open to Public
Inspection

Name of the organization

PROVENA HOSPITALS

Employer identification number

36-4195126

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) 2011

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) 2007	(b) 2008	(c) 2009	(d) 2010	(e) 2011	(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) 2007	(b) 2008	(c) 2009	(d) 2010	(e) 2011	(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—2011. 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—2010. 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—2011. 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—2010. 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) 2011

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) 2007	(b) 2008	(c) 2009	(d) 2010	(e) 2011	(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) 2007	(b) 2008	(c) 2009	(d) 2010	(e) 2011	(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 2011 (line 8 column (f) divided by line 13 column (f)) .........

Public support percentage from 2010 Schedule A, Part III, line 15 ...............

Section D. Computation of Investment Income Percentage

Investment income percentage for 2011 (line 10c column (f) divided by line 13 column (f)) ......

Investment income percentage from 2010 Schedule A, Part III, line 17 .............

19a

33 1/3% support tests—2011. 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—2010. 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) 2011

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) 2011

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

2011

Name of organization

PROVENA HOSPITALS

Employer identification number

36-4195126

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, total 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 total 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 on line H of its
Form 990-EZ or on Part I, 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) (2011)

Page 2

Name of organization PROVENA HOSPITALS
Schedule B (Form 990, 990-EZ, or 990-PF) (2011)
Part I	Contributors (see Instructions). Use duplicate copies of Part I if additional space is needed.
(a) No.	(b) Name, address, and ZIP + 4	(c) Total 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) Total 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) Total 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) Total 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) Total 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) Total 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) (2011)

Page 3

Name of organization PROVENA HOSPITALS
Schedule B (Form 990, 990-EZ, or 990-PF) (2011)
Part II	Noncash Property (see Instructions). Use duplicate copies of Part II if additional space is needed.
(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) (2011)

Page 4

Schedule B (Form 990, 990-EZ, or 990-PF) (2011)

Name of organization
PROVENA HOSPITALS

Employer identification number

36-4195126

Part III

Exclusively religious, charitable, etc., individual contributions to section 501(c)(7), (8), or (10) organizations
that total 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

$
Use duplicate copies of Part III if additional space is needed

(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) (2011)

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, 11a, 11b, 11c, 11d, 11e, 11f, 12a, or 12b
SchDMd Bullet

Attach to Form 990. SchDMd Bullet

See separate instructions.

OMB No. 1545-0047

2011

Open to Public Inspection

Name of the organization

PROVENA HOSPITALS

Employer identification number

36-4195126

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 can 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 education) Preservation of an historically important land area

Protection of natural habitat Preservation of a certified historic structure

Preservation of open space

Complete lines 2a through 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, and not on a historic structure listed in the National Register ....................	2d

Number of conservation easements modified, transferred, released, extinguished, or terminated by the organization during
the tax 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 (ASC 958), 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 (ASC 958), 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 (ASC 958), 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) 2011

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
1a	Beginning of year balance ....	1,823,675	1,671,727	1,569,474	1,071,590
b	Contributions ........	61,758	104,516	26,655	489,327
c	Net investment earnings, gains, and losses ...	43,217	83,936	-2,254	11,557
d	Grants or scholarships .....	-26,673	12,960	0	3,000
e	Other expenditures for facilities and programs ........	-16,425	19,544	-81,988	0
f	Administrative expenses ....	-311	4,000	4,136	0
g	End of year balance ......	1,885,241	1,823,675	1,671,727	1,569,474

Provide the estimated percentage of the year end balance (line 1g) held as:

Board designated or quasi-endowment SchDMd Bullet

20.000 %

Permanent endowment SchDMd Bullet

80.000 %

Temporarily restricted endowment SchDMd Bullet

The percentages in lines 2a, 2b, and 2c should equal 100%.

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)

Yes

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

3a(ii)

Yes

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

Yes

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

Part VI

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

Description of property		(b)Cost or other basis (other)	(c) Accumulated depreciation	(d) Book value
1a	Land .................	22,487,057		22,487,057
b	Buildings ................	652,967,132	294,533,421	358,433,711
c	Leasehold improvements ............	1,602,816	497,876	1,104,940
d	Equipment ................	315,257,133	216,949,900	98,307,233
e	Other .................	41,732,214	16,144,945	25,587,269
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).).......				505,920,210

Schedule D (Form 990) 2011

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
Other








Total. (Column (b) must equal Form 990, Part X, col. (B) line 12.)

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) must 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) must 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) Book value
Federal Income Taxes		0
DUE TO THIRD PARTY PAYORS		86,960,741
DUE TO AFFILIATES		15,530,698
OTHER CURRENT LIABILITIES		34,918,828
OTHER LONG TERM LIABILITIES		16,708,016





Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)		154,118,283
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) 2011

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 through 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 must 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 must 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
Supplemental Information		On January 1, 2008, Provena adopted ASC Subtopic 740-10 Income Taxes- Overall, which addresses the determination of how tax benefits claimed or expected to be claimed on a tax return should be recorded in the consolidated financial statements. Under ASC Subtopic 740-10, Provena may recognize the tax benefit from an uncertain tax position only if it is more likely than not that the tax position will be sustained on examination by the taxing authorities, based on the technical merits of the position. The tax benefits recognized in the consolidated financial statements from such a position are measured based on the largest benefit that has a greater than 50% likelihood of being realized upon ultimate settlement. ASC Subtopic 740-10 also provides guidance on derecognition, classification, interest and penalties on income taxes, and accounting in interim periods and requires increased disclosures. At the date of adoption, and as of December 31, 2011, Provena does not have any liabilities for any unrecognized tax benefits.

Schedule D (Form 990) 2011

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE G (Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service

Supplemental Information Regarding
Fundraising or Gaming Activities

Complete if the organization answered "Yes" to Form 990, Part IV, lines 17, 18, or 19,or if the organization entered more than $15,000 on Form 990-EZ, line 6a. right arrow

Attach to Form 990 or Form 990-EZ. right arrow

See separate instructions.

OMB No. 1545-0047

2011

Open to Public Inspection

Name of the organization
PROVENA HOSPITALS

Employer identification number

36-4195126

Part I

Fundraising Activities. Complete if the organization answered "Yes" to Form 990, Part IV, line 17.

Indicate whether the organization raised funds through any of the following activities. Check all that apply.

a	Mail solicitations	e	Solicitation of non-government grants
b	Internet and e-mail solicitations	f	Solicitation of government grants
c	Phone solicitations	g	Special fundraising events
d	In-person solicitations

Did the organization have a written or oral agreement with any individual (including officers, directors, trustees

or key employees listed in Form 990, Part VII) or entity in connection with professional fundraising services?

Yes

If “Yes,” list the ten highest paid individuals or entities (fundraisers) pursuant to agreements under which the fundraiser is
to be compensated at least $5,000 by the organization. Form 990-EZ filers are not required to complete this table.

(i) Name and address of individual or entity (fundraiser)	(ii) Activity	(iii) Did fundraiser have custody or control of contributions?		(iv) Gross receipts from activity	(v) Amount paid to (or retained by) fundraiser listed in col. (i)	(vi) Amount paid to (or retained by) organization
	(ii) Activity	Yes	No	(iv) Gross receipts from activity		(vi) Amount paid to (or retained by) organization
SR MARGARET MARY KNITTEL	GRANT WRITING	Yes		228,081	32,222	195,859
NMASQUERADE JEWELRY	$5.00 SALE		No	8,809	7,189	1,620
SCRUBS TO YOU	UNIFORM SALE	Yes		11,690	9,863	1,827
CENTRAL ILLINOIS BOOKS	BOOK FAIR		No	14,377	11,732	2,645
BOUTIQUE TO YOU	PURSE SALE		No	6,120	4,995	1,125
Total .................				269,077	66,001	203,076

List all states in which the organization is registered or licensed to solicit funds or has been notified it is exempt from registration or licensing.

IL, IN

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

Cat. No. 50083H

Schedule G (Form 990 or 990-EZ) 2011

Page 2

Part II

Fundraising Events. Complete if the organization answered "Yes" to Form 990, Part IV, line 18, or reported more than $15,000 on Form 990-EZ, line 6a. List events with gross receipts greater than $5,000.

		(a) Event #1 FESTIVAL OF TRE (event type)	(b) Event #2 GALA (event type)	(c) Other Events 10 (total number)	(d) Total Events (Add col. (a) through col. (c))
1	Gross receipts . . .	463,833	275,987	936,030	1,675,850
2	Less: Charitable contributions . . .	463,833		195,370	659,203
3	Gross income (line 1 minus line 2) . . .		275,987	740,660	1,016,647
4	Cash prizes . . .			8,000	8,000
5	Non-cash prizes . .
6	Rent/facility costs . .	16,000		92,857	108,857
7	Food and beverages . .
8	Entertainment . . .
9	Other direct expenses .	149,330	251,196	294,741	695,267
10	Direct expense summary. Add lines 4 through 9 in column (d) ...........				812,124
11	Net income summary. Combine lines 3 and 10 in column (d)............				204,523

Part III

Gaming. Complete if the organization answered "Yes" to Form 990, Part IV, line 19, or reported more than $15,000 on Form 990-EZ, line 6a.

(a) Bingo

(b) Pull tabs/Instant
bingo/progressive bingo

(c) Other gaming

(d) Total gaming (Add col. (a) through col. (c))

Gross revenue . . . .

Cash prizes . . . .

Non-cash prizes . . .

Rent/facility costs . . .

Other direct expenses . .

Volunteer labor . . .

	Yes
	No

	Yes
	No

	Yes
	No

Direct expense summary. Add lines 2 through 5 in column (d) ........... right arrow

Net gaming income summary. Combine lines 1 and 7 in column (d) .......... right arrow

Enter the state(s) in which the organization operates gaming activities:

Is the organization licensed to operate gaming activities in each of these states? ............

YesNo

If "No," Explain:

10a

Were any of the organization's gaming licenses revoked, suspended or terminated during the tax year? .....

YesNo

If "Yes," Explain:

Does the organization operate gaming activities with nonmembers? .................

YesNo

Is the organization a grantor, beneficiary or trustee of a trust or a member of a partnership or other entity

formed to administer charitable gaming? ..........................

YesNo

Schedule G (Form 990 or 990-EZ) 2011

Page 3

Indicate the percentage of gaming activity operated in:

The organization's facility ......................

13a

An outside facility ........................

13b

Provide the name and address of the person who prepares the organization's gaming/special events books and records:

Name

Address

1400 W PARK
URBANA,IL61801

15a

Does the organization have a contract with a third party from whom the organization receives gaming

revenue? ......................................

YesNo

If "Yes," enter the amount of gaming revenue received by the organization right arrow

$ and the

amount of gaming revenue retained by the third party right arrow

$ .

If "Yes," enter name and address:

Name

Address

Gaming manager information:

Name

Gaming manager compensation right arrow

Description of services provided right arrow

Director/officer Employee Independent contractor

Mandatory distributions:

Is the organization required under state law to make charitable distributions from the gaming proceeds to

retain the state gaming license? ............................

YesNo

Enter the amount of distributions required under state law distributed to other exempt organizations or spent

in the organization's own exempt activities during the tax year right arrow

Part IV

Complete this part to provide additional information for responses to quuestion on Schedule G (see instructions.)

Identifier	ReturnReference	Explanation
Schedule G, Part I Line 2(b)		Sr Margaret Mary Knittel Is a grant writer that specializes in fund raising activities with private foundations that promote the ministry.

Schedule G (Form 990 or 990-EZ) 2011

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

2011

Open to Public Inspection

Name of the organization

PROVENA HOSPITALS

Employer identification number

36-4195126

Part I

Charity Care and Certain Other Community Benefits at Cost

Yes

Did the organization have a financial assistance policy during the tax year? If "No," skip to question 6a....

Yes

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

Yes

If the organization had multiple hospital facilities, indicate which of the following best describes application of the financial assistance policy to its various hospital facilities during the tax year.

Applied uniformly to all hospital facilities Applied uniformly to most hospital facilities Generally tailored to individual hospital facilities

Answer the following based on the financial assistance eligibility criteria that applied to the largest number of the organization's patients during the tax year.

Did the organization use Federal Poverty Guidelines (FPG) to determine eligibility for providing free care?

If "Yes," indicate which of the following was the FPG family income limit for eligibility for free care:

Yes

100% 150% 200% Other

Did the organization use FPG to determine eligibility for providing discounted care? If "Yes," indicate which of the

following was the family income limit for eligibility for discounted care: ............

Yes

200% 250% 300% 350% 400% Other 600 %

If the organization did 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 used an asset test or other threshold, regardless of income, to determine eligibility for free or discounted care.

Did the organization's financial assistance policy that applied to the largest number of its patients during the tax year provide for free or discounted care to the "medically indigent"? ..............

Yes

Did the organization budget amounts for free or discounted care provided under its financial assistance policy during the tax year? ............................

Yes

If "Yes," did the organization's financial assistance 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 discountedcare to a patient who was eligibile for free or discounted care?...............

Did the organization prepare a community benefit report during the tax year?...........

Yes

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

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

Financial Assistance 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 Financial Assistance at cost (from Worksheet 1) ..		13,643	34,081,846		34,081,846	3.380 %
b Medicaid (from Worksheet 3, column a) .....		149,210	157,434,373	120,066,134	37,368,239	3.700 %
c Costs of other means-tested government programs (from Worksheet 3, column b) .
dTotal Financial Assistance and Means-Tested Government Programs .....		162,853	191,516,219	120,066,134	71,450,085	7.080 %
Other Benefits e Community health improvement services and community benefit operations (from (Worksheet 4) ....	151	93,574	3,460,077	278,617	3,181,460	0.320 %
f Health professions education (from Worksheet 5) ..	20	4,030	5,298,190	601,501	4,696,689	0.470 %
g Subsidized health services (from Worksheet 6) ..	2		26,016,470	23,935,255	2,081,215	0.200 %
h Research (from Worksheet 7)	6	638	193,337		193,337	0.020 %
i Cash and in-kind contributions for community benefit (from Worksheet 8) ....	38	5,423	973,035	11	973,024	0.090 %
jTotal Other Benefits ...	217	103,665	35,941,109	24,815,384	11,125,725	1.100 %
kTotal. Add lines 7d and 7j. ..	217	266,518	227,457,328	144,881,518	82,575,810	8.180 %

For Paperwork Reduction Act Notice, see the Instructions for Form 990. Cat. No. 50192T Schedule H (Form 990) 2011

Schedule H (Form 990) 2011

Page

Part II

Community Building Activities Complete this table if the organization conducted any community building activities during the tax year, and describe in Part VI how its community building activities promoted the health of the communities it serves.

		(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	2	1,703		1,703
2	Economic development
3	Community support	23	14,638	439,982	33,559	406,423	0.040 %
4	Environmental improvements	5	2	34,970		34,970
5	Leadership development and training for community members
6	Coalition building	2	119	2,190		2,190
7	Community health improvement advocacy
8	Workforce development	1		425		425
9	Other
10	Total	33	14,761	479,270	33,559	445,711	0.040 %

Part III

Bad Debt, Medicare, & Collection Practices

Section A. Bad Debt Expense

Yes

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

Yes

Enter the amount of the organization's bad debt expense........

117,627,189

Enter the estimated amount of the organization's bad debt expense attributable to patients eligible under the organization's financial assistance 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).....

510,936,260

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

459,433,891

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

51,502,369

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

Did the organization have a written debt collection policy during the tax year? ..........

Yes

If "Yes," did the organization’s collection policy that applied to the largest number of its patients during the tax year contain provisions on the collection practices to be followed for patients who are known to qualify for financial assistance? Describe in Part VI.......................

Yes

Part IV

Management Companies and Joint Ventures

(see instructions)

(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 %
1Alliance PHO	Physician Hospital Org.	50.000 %	0 %	50.000 %
2KANKAKEE VALLEY DLY	Dialysis Center	50.000 %	0 %	50.000 %
3Kendail PT Surgery	Surgery Center	15.000 %	0 %	50.000 %
4Dreyer Provena Amb	Ambulatory Care Center	40.000 %	0 %	60.000 %
5Provena Service Corp	Physicians Practices	100.000 %	0 %	0 %
6Ctr Digestive Dis	Digestive Health Center	10.000 %	0 %	80.000 %
7
8
9
10
11
12
13

Schedule H (Form 990) 2011

Page

Part VFacility Information

Section A. Hospital Facilities (list in order of size from largest to smallest) How many hospital facilities did the organization operate during the tax year?6 Name and address		Other (Describe)
1	PROVENA ST JOSEPH Medical Center 333 N Madison Street Joilet,IL60435	X	X	X
2	Provena Mercy Medical Center 1325 N Highland Aurora,IL60506	X	X	X
3	Provena Covenant Medical Center 1400 Park Street Urbana,IL61801	X	X	X
4	Provena St Joseph Hospital 77 North Airlite Avenue Elgin,IL60123	X	X	X
5	Provena St Mary's Hospital 500 West Court Street Kankakee,IL60901	X	X	X
6	Provena United Samaritans Medical Center 812 N Logan Danville,IL61832	X	X	X

Schedule H (Form 990) 2011

Page

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)

PROVENA ST JOSEPH Medical Center

Name of Hospital Facility:

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 2011)
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 the community health 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 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	Participation in the development of a community-wide community benefit plan
	d	Participation in the execution of a 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 Needs Assessment
	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 and 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	Explained eligibility criteria for financial assistance, and whether such assistance includes free or discounted care?		8	Yes
9	Used federal poverty guidelines (FPG) to determine eligibility for providing free care?...........		9	Yes
	If "Yes," indicate the FPG family income limit for eligibility for free care: 200.% If "No," explain in Part VI the criteria the hospital facility used.

Schedule H (Form 990) 2011

Page

Part VFacility Information (continued)

				Yes	No
10	Used FPG to determine eligibility for providing discounted care?.................		10	Yes
	If “Yes,” indicate the FPG family income limit for eligibility for discounted care: 600.% If "No," explain in Part VI the criteria the hospital facility used.
11	Explained the basis for calculating amounts charged to patients?.................		11	Yes
	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	Yes
13	Included measures to publicize the policy within the community served by the hospital facility?.......		13	Yes
	If “Yes,” indicate how the hospital facility publicized the policy (check all that apply):
	a	The policy was posted 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 (FAP) that explained actions the hospital facility may take upon non-payment?.......		14	Yes
15	Check all of the following collection actions against an individual that were permitted under the hospital facility's policies during the tax year before making reasonable efforts to determine the patient’s eligibility under the facility’s FAP:
	a	Reporting to credit agency
	b	Lawsuits
	c	Liens on residences
	d	Body attachments
	e	Other similar actions (describe in Part VI)
16	Did the hospital facility or an authorized third party perform any of the following actions during the tax year before making reasonable efforts to determine the patient’s eligibility under the facility’s FAP?..........		16	Yes
	If “Yes,” check all actions in which the hospital facility or a third party engaged:
	a	Reporting to credit agency
	b	Lawsuits
	c	Liens on residences
	d	Body attachments
	e	Other similar actions (describe in Part VI)
17	Indicate which efforts the hospital facility made before initiating any of the actions checked in line 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 patients were eligible for financial assistance under the hospital facility’s financial assistance policy
	e	Other (describe in Part VI)

Schedule H (Form 990) 2011

Page

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	Yes
	If “No,” indicate why:
	a	The hospital facility did not provide care for any emergency medical conditions
	b	The hospital facility’s policy was not in writing
	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)
Individuals Eligible for Financial Assistance
19	Indicate how the hospital facility determined, during the tax year, the maximum amounts that can be charged to FAP-eligible individuals for emergency or other medically necessary care.
	a	The hospital facility used its lowest negotiated commercial insurance rate when calculating the maximum amounts that can be charged
	b	The hospital facility used the average of it's three lowest negotiated commercial insurance rates when calculating the maximum amounts that can be charged
	c	The hospital facility used the Medicare rates when calculating the maximum amounts that can be charged
	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		No
	If “Yes,” explain in Part VI.
21	Did the hospital facility charge any of its FAP-eligible patients an amount equal to the gross charge for any services provided to that patient?...............................		21		No
	If “Yes,” explain in Part VI.

Schedule H (Form 990) 2011

Page

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)

Provena Mercy Medical Center

Name of Hospital Facility:

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 2011)
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 the community health 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 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	Participation in the development of a community-wide community benefit plan
	d	Participation in the execution of a 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 Needs Assessment
	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 and 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	Explained eligibility criteria for financial assistance, and whether such assistance includes free or discounted care?		8	Yes
9	Used federal poverty guidelines (FPG) to determine eligibility for providing free care?...........		9	Yes
	If "Yes," indicate the FPG family income limit for eligibility for free care: 200.% If "No," explain in Part VI the criteria the hospital facility used.

Schedule H (Form 990) 2011

Page

Part VFacility Information (continued)

				Yes	No
10	Used FPG to determine eligibility for providing discounted care?.................		10	Yes
	If “Yes,” indicate the FPG family income limit for eligibility for discounted care: 600.% If "No," explain in Part VI the criteria the hospital facility used.
11	Explained the basis for calculating amounts charged to patients?.................		11	Yes
	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	Yes
13	Included measures to publicize the policy within the community served by the hospital facility?.......		13	Yes
	If “Yes,” indicate how the hospital facility publicized the policy (check all that apply):
	a	The policy was posted 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 (FAP) that explained actions the hospital facility may take upon non-payment?.......		14	Yes
15	Check all of the following collection actions against an individual that were permitted under the hospital facility's policies during the tax year before making reasonable efforts to determine the patient’s eligibility under the facility’s FAP:
	a	Reporting to credit agency
	b	Lawsuits
	c	Liens on residences
	d	Body attachments
	e	Other similar actions (describe in Part VI)
16	Did the hospital facility or an authorized third party perform any of the following actions during the tax year before making reasonable efforts to determine the patient’s eligibility under the facility’s FAP?..........		16	Yes
	If “Yes,” check all actions in which the hospital facility or a third party engaged:
	a	Reporting to credit agency
	b	Lawsuits
	c	Liens on residences
	d	Body attachments
	e	Other similar actions (describe in Part VI)
17	Indicate which efforts the hospital facility made before initiating any of the actions checked in line 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 patients were eligible for financial assistance under the hospital facility’s financial assistance policy
	e	Other (describe in Part VI)

Schedule H (Form 990) 2011

Page

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	Yes
	If “No,” indicate why:
	a	The hospital facility did not provide care for any emergency medical conditions
	b	The hospital facility’s policy was not in writing
	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)
Individuals Eligible for Financial Assistance
19	Indicate how the hospital facility determined, during the tax year, the maximum amounts that can be charged to FAP-eligible individuals for emergency or other medically necessary care.
	a	The hospital facility used its lowest negotiated commercial insurance rate when calculating the maximum amounts that can be charged
	b	The hospital facility used the average of it's three lowest negotiated commercial insurance rates when calculating the maximum amounts that can be charged
	c	The hospital facility used the Medicare rates when calculating the maximum amounts that can be charged
	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		No
	If “Yes,” explain in Part VI.
21	Did the hospital facility charge any of its FAP-eligible patients an amount equal to the gross charge for any services provided to that patient?...............................		21		No
	If “Yes,” explain in Part VI.

Schedule H (Form 990) 2011

Page

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)

Provena Covenant Medical Center

Name of Hospital Facility:

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 2011)
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 the community health 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 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	Participation in the development of a community-wide community benefit plan
	d	Participation in the execution of a 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 Needs Assessment
	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 and 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	Explained eligibility criteria for financial assistance, and whether such assistance includes free or discounted care?		8	Yes
9	Used federal poverty guidelines (FPG) to determine eligibility for providing free care?...........		9	Yes
	If "Yes," indicate the FPG family income limit for eligibility for free care: 200.% If "No," explain in Part VI the criteria the hospital facility used.

Schedule H (Form 990) 2011

Page

Part VFacility Information (continued)

				Yes	No
10	Used FPG to determine eligibility for providing discounted care?.................		10	Yes
	If “Yes,” indicate the FPG family income limit for eligibility for discounted care: 600.% If "No," explain in Part VI the criteria the hospital facility used.
11	Explained the basis for calculating amounts charged to patients?.................		11	Yes
	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	Yes
13	Included measures to publicize the policy within the community served by the hospital facility?.......		13	Yes
	If “Yes,” indicate how the hospital facility publicized the policy (check all that apply):
	a	The policy was posted 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 (FAP) that explained actions the hospital facility may take upon non-payment?.......		14	Yes
15	Check all of the following collection actions against an individual that were permitted under the hospital facility's policies during the tax year before making reasonable efforts to determine the patient’s eligibility under the facility’s FAP:
	a	Reporting to credit agency
	b	Lawsuits
	c	Liens on residences
	d	Body attachments
	e	Other similar actions (describe in Part VI)
16	Did the hospital facility or an authorized third party perform any of the following actions during the tax year before making reasonable efforts to determine the patient’s eligibility under the facility’s FAP?..........		16	Yes
	If “Yes,” check all actions in which the hospital facility or a third party engaged:
	a	Reporting to credit agency
	b	Lawsuits
	c	Liens on residences
	d	Body attachments
	e	Other similar actions (describe in Part VI)
17	Indicate which efforts the hospital facility made before initiating any of the actions checked in line 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 patients were eligible for financial assistance under the hospital facility’s financial assistance policy
	e	Other (describe in Part VI)

Schedule H (Form 990) 2011

Page

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	Yes
	If “No,” indicate why:
	a	The hospital facility did not provide care for any emergency medical conditions
	b	The hospital facility’s policy was not in writing
	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)
Individuals Eligible for Financial Assistance
19	Indicate how the hospital facility determined, during the tax year, the maximum amounts that can be charged to FAP-eligible individuals for emergency or other medically necessary care.
	a	The hospital facility used its lowest negotiated commercial insurance rate when calculating the maximum amounts that can be charged
	b	The hospital facility used the average of it's three lowest negotiated commercial insurance rates when calculating the maximum amounts that can be charged
	c	The hospital facility used the Medicare rates when calculating the maximum amounts that can be charged
	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		No
	If “Yes,” explain in Part VI.
21	Did the hospital facility charge any of its FAP-eligible patients an amount equal to the gross charge for any services provided to that patient?...............................		21		No
	If “Yes,” explain in Part VI.

Schedule H (Form 990) 2011

Page

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)

Provena St Joseph Hospital

Name of Hospital Facility:

Line Number of Hospital Facility (from Schedule H, Part V, Section A):4

				Yes	No
Community Health Needs Assessment (Lines 1 through 7 are optional for 2011)
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 the community health 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 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	Participation in the development of a community-wide community benefit plan
	d	Participation in the execution of a 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 Needs Assessment
	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 and 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	Explained eligibility criteria for financial assistance, and whether such assistance includes free or discounted care?		8	Yes
9	Used federal poverty guidelines (FPG) to determine eligibility for providing free care?...........		9	Yes
	If "Yes," indicate the FPG family income limit for eligibility for free care: 200.% If "No," explain in Part VI the criteria the hospital facility used.

Schedule H (Form 990) 2011

Page

Part VFacility Information (continued)

				Yes	No
10	Used FPG to determine eligibility for providing discounted care?.................		10	Yes
	If “Yes,” indicate the FPG family income limit for eligibility for discounted care: 600.% If "No," explain in Part VI the criteria the hospital facility used.
11	Explained the basis for calculating amounts charged to patients?.................		11	Yes
	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	Yes
13	Included measures to publicize the policy within the community served by the hospital facility?.......		13	Yes
	If “Yes,” indicate how the hospital facility publicized the policy (check all that apply):
	a	The policy was posted 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 (FAP) that explained actions the hospital facility may take upon non-payment?.......		14	Yes
15	Check all of the following collection actions against an individual that were permitted under the hospital facility's policies during the tax year before making reasonable efforts to determine the patient’s eligibility under the facility’s FAP:
	a	Reporting to credit agency
	b	Lawsuits
	c	Liens on residences
	d	Body attachments
	e	Other similar actions (describe in Part VI)
16	Did the hospital facility or an authorized third party perform any of the following actions during the tax year before making reasonable efforts to determine the patient’s eligibility under the facility’s FAP?..........		16	Yes
	If “Yes,” check all actions in which the hospital facility or a third party engaged:
	a	Reporting to credit agency
	b	Lawsuits
	c	Liens on residences
	d	Body attachments
	e	Other similar actions (describe in Part VI)
17	Indicate which efforts the hospital facility made before initiating any of the actions checked in line 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 patients were eligible for financial assistance under the hospital facility’s financial assistance policy
	e	Other (describe in Part VI)

Schedule H (Form 990) 2011

Page

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	Yes
	If “No,” indicate why:
	a	The hospital facility did not provide care for any emergency medical conditions
	b	The hospital facility’s policy was not in writing
	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)
Individuals Eligible for Financial Assistance
19	Indicate how the hospital facility determined, during the tax year, the maximum amounts that can be charged to FAP-eligible individuals for emergency or other medically necessary care.
	a	The hospital facility used its lowest negotiated commercial insurance rate when calculating the maximum amounts that can be charged
	b	The hospital facility used the average of it's three lowest negotiated commercial insurance rates when calculating the maximum amounts that can be charged
	c	The hospital facility used the Medicare rates when calculating the maximum amounts that can be charged
	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		No
	If “Yes,” explain in Part VI.
21	Did the hospital facility charge any of its FAP-eligible patients an amount equal to the gross charge for any services provided to that patient?...............................		21		No
	If “Yes,” explain in Part VI.

Schedule H (Form 990) 2011

Page

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)

Provena St Mary's Hospital

Name of Hospital Facility:

Line Number of Hospital Facility (from Schedule H, Part V, Section A):5

				Yes	No
Community Health Needs Assessment (Lines 1 through 7 are optional for 2011)
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 the community health 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 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	Participation in the development of a community-wide community benefit plan
	d	Participation in the execution of a 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 Needs Assessment
	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 and 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	Explained eligibility criteria for financial assistance, and whether such assistance includes free or discounted care?		8	Yes
9	Used federal poverty guidelines (FPG) to determine eligibility for providing free care?...........		9	Yes
	If "Yes," indicate the FPG family income limit for eligibility for free care: 200.% If "No," explain in Part VI the criteria the hospital facility used.

Schedule H (Form 990) 2011

Page

Part VFacility Information (continued)

				Yes	No
10	Used FPG to determine eligibility for providing discounted care?.................		10	Yes
	If “Yes,” indicate the FPG family income limit for eligibility for discounted care: 600.% If "No," explain in Part VI the criteria the hospital facility used.
11	Explained the basis for calculating amounts charged to patients?.................		11	Yes
	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	Yes
13	Included measures to publicize the policy within the community served by the hospital facility?.......		13	Yes
	If “Yes,” indicate how the hospital facility publicized the policy (check all that apply):
	a	The policy was posted 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 (FAP) that explained actions the hospital facility may take upon non-payment?.......		14	Yes
15	Check all of the following collection actions against an individual that were permitted under the hospital facility's policies during the tax year before making reasonable efforts to determine the patient’s eligibility under the facility’s FAP:
	a	Reporting to credit agency
	b	Lawsuits
	c	Liens on residences
	d	Body attachments
	e	Other similar actions (describe in Part VI)
16	Did the hospital facility or an authorized third party perform any of the following actions during the tax year before making reasonable efforts to determine the patient’s eligibility under the facility’s FAP?..........		16	Yes
	If “Yes,” check all actions in which the hospital facility or a third party engaged:
	a	Reporting to credit agency
	b	Lawsuits
	c	Liens on residences
	d	Body attachments
	e	Other similar actions (describe in Part VI)
17	Indicate which efforts the hospital facility made before initiating any of the actions checked in line 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 patients were eligible for financial assistance under the hospital facility’s financial assistance policy
	e	Other (describe in Part VI)

Schedule H (Form 990) 2011

Page

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	Yes
	If “No,” indicate why:
	a	The hospital facility did not provide care for any emergency medical conditions
	b	The hospital facility’s policy was not in writing
	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)
Individuals Eligible for Financial Assistance
19	Indicate how the hospital facility determined, during the tax year, the maximum amounts that can be charged to FAP-eligible individuals for emergency or other medically necessary care.
	a	The hospital facility used its lowest negotiated commercial insurance rate when calculating the maximum amounts that can be charged
	b	The hospital facility used the average of it's three lowest negotiated commercial insurance rates when calculating the maximum amounts that can be charged
	c	The hospital facility used the Medicare rates when calculating the maximum amounts that can be charged
	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		No
	If “Yes,” explain in Part VI.
21	Did the hospital facility charge any of its FAP-eligible patients an amount equal to the gross charge for any services provided to that patient?...............................		21		No
	If “Yes,” explain in Part VI.

Schedule H (Form 990) 2011

Page

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)

Provena United Samaritans Medical Center

Name of Hospital Facility:

Line Number of Hospital Facility (from Schedule H, Part V, Section A):6

				Yes	No
Community Health Needs Assessment (Lines 1 through 7 are optional for 2011)
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 the community health 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 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	Participation in the development of a community-wide community benefit plan
	d	Participation in the execution of a 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 Needs Assessment
	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 and 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	Explained eligibility criteria for financial assistance, and whether such assistance includes free or discounted care?		8	Yes
9	Used federal poverty guidelines (FPG) to determine eligibility for providing free care?...........		9	Yes
	If "Yes," indicate the FPG family income limit for eligibility for free care: 200.% If "No," explain in Part VI the criteria the hospital facility used.

Schedule H (Form 990) 2011

Page

Part VFacility Information (continued)

				Yes	No
10	Used FPG to determine eligibility for providing discounted care?.................		10	Yes
	If “Yes,” indicate the FPG family income limit for eligibility for discounted care: 600.% If "No," explain in Part VI the criteria the hospital facility used.
11	Explained the basis for calculating amounts charged to patients?.................		11	Yes
	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	Yes
13	Included measures to publicize the policy within the community served by the hospital facility?.......		13	Yes
	If “Yes,” indicate how the hospital facility publicized the policy (check all that apply):
	a	The policy was posted 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 (FAP) that explained actions the hospital facility may take upon non-payment?.......		14	Yes
15	Check all of the following collection actions against an individual that were permitted under the hospital facility's policies during the tax year before making reasonable efforts to determine the patient’s eligibility under the facility’s FAP:
	a	Reporting to credit agency
	b	Lawsuits
	c	Liens on residences
	d	Body attachments
	e	Other similar actions (describe in Part VI)
16	Did the hospital facility or an authorized third party perform any of the following actions during the tax year before making reasonable efforts to determine the patient’s eligibility under the facility’s FAP?..........		16	Yes
	If “Yes,” check all actions in which the hospital facility or a third party engaged:
	a	Reporting to credit agency
	b	Lawsuits
	c	Liens on residences
	d	Body attachments
	e	Other similar actions (describe in Part VI)
17	Indicate which efforts the hospital facility made before initiating any of the actions checked in line 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 patients were eligible for financial assistance under the hospital facility’s financial assistance policy
	e	Other (describe in Part VI)

Schedule H (Form 990) 2011

Page

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	Yes
	If “No,” indicate why:
	a	The hospital facility did not provide care for any emergency medical conditions
	b	The hospital facility’s policy was not in writing
	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)
Individuals Eligible for Financial Assistance
19	Indicate how the hospital facility determined, during the tax year, the maximum amounts that can be charged to FAP-eligible individuals for emergency or other medically necessary care.
	a	The hospital facility used its lowest negotiated commercial insurance rate when calculating the maximum amounts that can be charged
	b	The hospital facility used the average of it's three lowest negotiated commercial insurance rates when calculating the maximum amounts that can be charged
	c	The hospital facility used the Medicare rates when calculating the maximum amounts that can be charged
	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		No
	If “Yes,” explain in Part VI.
21	Did the hospital facility charge any of its FAP-eligible patients an amount equal to the gross charge for any services provided to that patient?...............................		21		No
	If “Yes,” explain in Part VI.

Schedule H (Form 990) 2011

Page

Part VFacility Information (continued)

Section C. Other Health Care Facilities That Are Not Licensed, Registered, or Similarly Recognized as a Hospital Facility (list in order of size, from largest to smallest) How many non-hospital health care facilities did the organization operate during the tax year?36
Name and address		Type of Facility (describe)
1	Provena Caton Farm Immediate Care 7000 Caton Farm Road Plainfield,IL60586	Immediate Care Ctr
2	Provena Caton Farm Imaging Center 7000 Caton Farm Road Plainfield,IL60586	Imaging Center
3	Provena Physical Therapy 3000 W Jefferson St Joliet,IL60435	Physical Therapy
4	Provena Physical Therapy Services 1280 Windham Parkway Romeoville,IL60446	Physical Therapy
5	Provena Center for Wound Care 301 North Madison St Joliet,IL60435	Wound Care Center
6	Provena Physical TherapyIndustrial Reha 852 Sharp Avenue Shorewood,IL60404	physical therapy
7	Provena Health Ctr-Diagnostic Imaging 1416 South Randall Road Geneva,IL60134	Imaging Center
8	Provena Occupational HealthDiabetes Ctr 87 North Airlite Street Suite 130 Elgin,IL60123	Occupational Health
9	Provena Outpatient Rehab Services 87 North Airlite Street Elgin,IL60123	Rehabilitation Services
10	Provena Occupational Health 1320 N Highland Suite B Aurora,IL60506	Occupational Med.
11	Provena Physical Therapy 1975 Melissa Lane Aurora,IL60506	Physical Therapy
12	Provena Health Institute 1975 Melissa Lane Aurora,IL60506	outpatient clinic
13	Mercy Professional Building Pharmacy 1315 N Highland Aurora,IL60506	Outpatient Pharmacy
14	Provena Physical Rehab & Sport Injury 2132 Jefferson Street Joliet,IL60435	Physical Therapy
15	Provena Physical Therapy Services 1812 Lincoln Highway New Lenox,IL60451	Physical Therapy
16	Provena Physical Therapy Services 15120 Wallin Drive Plainfield,IL60544	Physical Therapy
17	Provena Sleep Disorder Center 2132 Jefferson Street Joliet,IL60435	Sleep Disorder Center
18	Provena Physical Therapy Services 7000 Caton Farm Road Plainfield,IL60586	Physical Therapy
19	Medcare 24 hour Acute Care 2250 West Algonquin Road Lake in the Hills,IL60156	Immediate Care Center
20	Provena Sleep Lab 412 Sheridan Danville,IL61832	Sleep Disorder Center
21	Provena United Samaratins Open MRI 412 Sheridan Danville,IL61832	Imaging Center
22	Provena United Samartins Med Ctr Fndtn 801 W Fairchild Danville,IL61832	Foundation Office
23	Provena United Samaratins Oncology Ctr 806 North Logan Avenue Danville,IL61832	Oncology Center
24	Provena Yorkville Medical Office Bldg 1500 Sycamore Road Yorkville,IL60560	Medical Office Building
25	Provena Manteno Medcentre 501 S Locust Street Manteno,IL60950	Medical Office Building
26	Provena Medcentre East 455 West Court Street Kankakee,IL60901	Medical Office Building
27	Provena Medcentre West 555 West Court Street Kankakee,IL60901	Medical Office Building
28	Provena Momence Medcentre 739 North Dixie Highway Momence,IL60954	Medical Office Building
29	Provena Peotone Medcentre 117 South Harlem Avenue Peotone,IL60468	Medical Office Building
30	Provena St Mary's Regional Cancer Center 100 Provena Way Bourbonnais,IL60914	Regional Oncology Center
31	Provena St Mary's Imaging Center 100 Provena Way Bourbonnais,IL60914	Imaging Center
32	Provena St Mary's Occupational Health 230 W John Casey Road Bourbonnais,IL60914	Occupational Medicine
33	Provena Wellness Center 21 Heritage Drive Bourbonnais,IL60914	Health And Fitness Center
34	Provena Center For Healthy Aging 401 East University Suite 102 Champaign,IL61820	Senior Health Center
35	Provena Regional EMS 408 S Neil Street Champaign,IL61820	EMS Paramedic Services
36	Pro Ambulance Services 408 S Neil Street Champaign,IL61820	Ambulance Services

Schedule H (Form 990) 2011

Page

Part VI

Supplemental Information

Complete this part to provide the following information.

1	Required descriptions. Provide the descriptions 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, 3, 4, 5c, 6i, 7, 9, 10, 11h, 13g, 15e, 16e, 17e, 18d, 19d, 20, and 21.
2	Needs assessment. Describe how the organization assesses the health care needs of the communities it serves, in addition to any 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
Schedule H, Part I		Part I, Line 6a Provena Health, the corporate sponsor of Provena Hospitals, traditionally publishes an annual Report to Our Communities, which details the combined charitable impact our ministries have within the communities we serve. However, in 2011 due to the merger of Resurrection Health Care and Provena Health this communication was not published. We did submit our annual Community Benefit Plan to the state which is available to any community member upon request from the IL Attorney General Office. Part I, Line 7g Costs from physician clinics are not included in subsidized service totals. Part I, Line 7, Column (F) COSTS INCLUDED IN PART I, LINE 7 WERE CALCULATED USING A COMBINATION OF COST TO CHARGE RATIO, MEDICARE AND MEDICAID COST REPORTS, A COST ACCOUNTING SYSTEM INCLUDING ALL PATIENT SEGMENTS AND COMMUNITY BENEFIT SOFTWARE. WORKSHEET 2 WAS USED FOR CALCULATING THE COST TO CHARGE RATIO.
Schedule H, Part II		Community Building Activities include programs that address the root causes of health problems, such as poverty, homelessness and environmental problems. They support community assets by offering the expertise and resources of the health care organization. Provena Hospital ministries engage in a variety of community building activities which although are not specifically health activities ultimately improve the health and well-being of the communities we are privileged to serve. Examples of community building activities include: - The work of all of our hospitals in support of disaster readiness and emergency preparedness. This work goes above and beyond any licensure requirements to proactively ensure that our communities are safe and prepared if a disaster should present itself. This work assures the safety and health of the community if a disaster presents itself. - Ongoing partnership with Hospital Sisters Mission Outreach whose mission is the recovery and responsible redistribution of healthcare equipment and supplies to developing countries. The commitment attributes to local community health by being good stewards of our community resources and not contributing to the landfills within our communities. In addition, this activity promotes the health of the community that receives the equipment and supplies by giving them the tools that they need to better meet the health needs of their community.
Schedule H, Part III		Part III, Line 4 The Financial Assistance Policy allows for accounts in bad debt to be approved for Financial Assistance if the patient meets the criteria. There are possible financial assistance accounts in bad debt and we did not record an amount due to the fact we do not have a methodology to determine the dollar amounts. Part III, Line 8 The organization computes the Medicare shortfall/surplus based on a modified ratio of cost to charges. Part III, Line 9b The collection process consists of using a predictive dialer to contact the patient after discharge along with a series of 4 notifications/statements and a series of collection letters. A patient may apply for financial assistance at any time during the revenue cycle as outlined in the Provena Health Provision for Financial Assistance Policy. A patient balance may be referred to a 3rd party collection agency if one of the following criteria are met: 1) Patient has defaulted on an installment plan agreement and has missed a minimum of two (2) consecutive payments. 2) A minimum of four (4) notifications which may include statements or letters have been sent to the patient with no payments or agreement to pay. 3) The patient has failed to cooperate with the Medical Assistance Application for Public Aid. 4) There has been an inability to locate the patient via phone or mail. (e.g. mail returned with no forwarding address). 5) Account is greater than the small balance write off threshold. Patients with an approved financial assistance for 100% will not be referred to a 3rd party collection agency. Patients with partial financial assistance will follow the self-pay process. Patients in bad debt may apply for charity care/financial assistance at any time during the revenue cycle process. Our Financial Counselors, Central Billing Office and outside agencies assists patients with the financial assistance process. As stated in the Debt Collection Policy, "Agencies must follow the Provena Health Provision for Financial Assistance Policy, at any point in the collection process. If the patient requests this as an option, the account will be placed on hold with the agency and referred back to the hospital so that proper follow up can occur. The agency will not pursue the collection process until they are notified to continue activities." For more information about Provena's Financial Assistance Program visit www.Provena.org/FinancialAssistance.
NEEDS ASSESSMENT		Part VI, 2 Provena Hospital ministries join forces with local community organizations to assess the health needs of the community. Community needs assessments are completed for the individual counties we serve with community partners every 3-5 years depending on the community needs and available resources. To supplement the community needs assessment Provena Hospitals also review and analyze Inpatient and Emergency Department utilization on an annual basis to uncover any new community health trends. In addition to assessing the health needs, Provena Hospital ministries also complete medical staff development plans. The plans are conducted by external consultants, who provide an independent assessment of the need for physicians by specialty within the hospital's primary service area as defined by Stark regulations. Identifying community needs is just one step in the needs assessment process. The most critical step is prioritizing and aligning expertise to make an impact on the identified needs. To facilitate this process, each hospital ministry has a Mission Committee of the Board that is ultimately responsible for the oversight and direction of the community benefit initiatives. On an annual basis this board committee, which is made up of community and board members, recommends approval to the hospital Board of Directors the hospital's community benefit plan. This plan identifies the priorities and action that will take place over the next year. PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCE Provena hospital ministries proactively communicate the availability of our financial assistance programs with bilingual signage and brochures displayed prominently throughout high traffic areas of our ministries, as well as within our inpatient and outpatient registration/patient admitting areas and emergency departments. Comprehensive information about our financial assistance programs - including eligibility criteria, application details, and contact information - is also presented on our consumer Web site (www.provena.org/financialassistance). Financial counselors are also available to meet with patients during their stay if they have questions about their ability to pay for services and our financial assistance programs. Additionally, Provena hospital ministries participate with an outside vendor to assure eligible patients are also receiving benefits from the Medicaid entitlement programs. The vendor works with patients to complete appropriate applications. All self-pay or Medicaid pending patient statements contain information regarding our financial assistance programs and appropriate contact information in a bilingual format. Finally, to ensure the integrity of our financial assistance programs, our financial assistance policy and practices are audited by our internal auditors, CHAN, Health Care Auditors, to assure consistent application of policy and practice across all Provena Hospitals. COMMUNITY INFORMATION Provena Hospital ministries provide services at 43 sites, including six acute care hospitals with a total of 1,317 staffed beds and 39 health centers. These ministries offer a broad range of services from highly specialized tertiary services to an extended network of primary and ambulatory care. Provena Hospital ministries have identified a separate service area for each of its acute care hospitals utilizing a consistent methodology and reflecting a combination of geographic location and market share criteria. The total service area of each ministry represents approximately 80% to 90% of the total inpatient discharges from that facility. The primary service area (the "Primary Service Area") of each facility represents approximately 65 to 75% of such discharges and the secondary service area (the "Secondary Service Area") of each facility represents approximately 15 to 25% of such discharges. The Primary Service Areas and Secondary Service Areas have been determined by utilizing a patient origin analysis to identify those zip codes that represent inpatient discharges. These zip codes are then mapped to identify geographic coverage of the Primary Service Areas and Secondary Service Areas. None of the Provena Hospital ministries share a common Primary Service Area. They are located in adjacent geographies, complementing the services provided by each facility and providing an opportunity for additional synergies throughout the System. Many of the Provena Hospital ministries facilities are located in population growth areas. Based upon population estimates and projections obtained from Claritas, Inc., the population of the Hospitals combined service area is expected to grow at a rate of 1.7% annually between 2010 and 2015, compared with a growth rate of 0.4% and 0.3% per year in the Chicago MSA (defined below) and in Illinois, respectively. Ten percent of Provena's service area population is over the age of 65, compared to 11% and 13% in the Chicago MSA and in Illinois, respectively. Information related to each ministry is noted below.
Schedule H, Part VI cont'd		Provena Covenant Medical Center, Champaign, IL (PCMC): Champaign County is the sixth largest county in the state of Illinois with estimated 2009 population of 184,402 in PCMC's primary service area and 109,226 in the secondary service area. In the primary service area 10% of the population is over the age 65 and the average household income is $64,446. The primary demographic make-up of Champaign County is as follows: 78.8% white, 11.2% black or African American, 6.5% Asian, 2.9% Hispanic/Latino. 6.9% of families in Champaign County live below the poverty level. The PCMC service area is defined by zip code below. Approximately 63% and 17% of total inpatient discharges to the PCMC-Urbana facility originate from this Primary Service Area and Secondary Service Area. Service Area: Primary Market -61821 Champaign, 61801 Urbana, 61820 Champaign, 61866 Rantoul, 61802 Urbana, 61953 Tuscola, 61880 Tolono, 61873 Saint Joseph, 61956 Villa Grove, 61874 Savoy, 61849 Horner, 61878 Thomasboro, 61822 Champaign, 61847 Gifford, 61877 Sidney, 61943 Oakland, 61851 Ivesdale, 61884 White Heath, 61839 De Land, 61931 Humboldt, 61844 Fithian, 61862 Penfield, 61882 Weldon, 61773 Sibley, 61930 Hindsboro, 61812 Armstrong, 60933 Elliott, 61932 Hume, 61871 Royal, 60926 Claytonville, 61845 Foosland, 61941 Murdock Service Area: Secondary Market - 60948 Loda, 60957 Paxton, 61856 Monticello, 61853 Mahomet, 61938 Mattoon, 61910 Arcola, 60936 Gibson City, 61920 Charleston, 61942 Newman, 61813 Bement Identified Community Needs The Champaign County Health Plan 2011-2015 identified four IPLAN (Illinois Plan for Local Assessment of Need) Priorities: Access to Care (Health, Dental and Mental), Accidents (Automobile, Alcohol, In-Home), Obesity, (Nutrition, Diet & Exercise, risk factors and complications), and Violence (Domestic violence, relationship between drug, alcohol abuse and violence) Provena United Samaritans Medical Center (PUSMC), Danville, IL: PUSMC's primary and secondary service areas have an estimated population of 110,000 residents. In the primary service area 17% of the population is over the age 65 and the average household income is $46,467. The primary demographic make-up of Vermillion County is as follows: 86% white, 11% black or African American, 3.0% Hispanic/Latino. 9.7% of families in Vermillion County live below the poverty level. The PUSMC service area is defined by zip code below. Approximately 78% and 20% of total inpatient discharges to the PUSMC-Danville facility originate from this Primary Service Area and Secondary Service Area, respectively. Service Area: Primary Market -61832 Danville, 61834 Danville, 61846 Georgetown, 61883 Westville, 61833 Tilton Service Area: Secondary Market - 47932 Covington, IN, 60942 Hoopeston, 61817 Catlin, 61858 Oakwood, 61870 Ridge Farm, 61924 Chrisman, 60963 Rossville, 47987 Veedersburg, IN, 61841 Fairmont, 47974 Perrysville, IN, 47993 Williamsport, IN, 61814 Bismark, 61865 Potomac, 47928 Cayuga, IN, 47952 Kingman, IN, 61876 Sidell, 61811 Alvin, 61844 Fithian, 61850 Indianola, 47991 West Lebanon, IN, 61848 Henning, 47982 State Line, IN, 60960 Rankin, 47918 Attica, IN, 61812 Armstrong, 60973 Wellington, 61940 Metcalf, 61831 Collision Identified Community Needs In 2006, PUSMC conducted a community needs assessment to identify the top three health care needs in the community. The report concluded that the top unmet health care needs in our service area are: Access to Healthcare, Community Health Education/Outreach, Affordability of Healthcare and Teen Pregnancy. Provena Saint Joseph Medical Center (PSJMC), Joliet, IL PSJMC's primary service has an estimated population of 262,946 and 369,243 in the secondary service area. In the primary service area 9% of the population is over the age 65 and the average household income is $79,175. Approximately, 7.7% of the population in Joliet lives below the poverty level. The racial makeup of the city is 79.3% White, 8.9% African American, 2.5% Asian. The 2010 population also estimates that 16.2% are Hispanic or Latino, while 83.8% are non-Hispanic. The Provena Saint Joseph Medical Center service area is defined by zip code below. Approximately 69% and 24% of total inpatient discharges to the PSJMC-Joliet facility originate from this Primary Service Area and Secondary Service Area, respectively. Service Area: Primary Market - 60435 Joliet, 60436 Joliet, 60544 Plainfield, 60433 Joliet, 60431 Joliet, 60432 Joliet, 60434 Joliet, 60585 Plainfield, 60586 Plainfield, 60403 Crest Hill, 60404 Shorewood Service Area: Secondary Market - 60451 New Lenox, 60481 Wilmington, 60450 Morris, 60410 Channahon, 60446 Romeoville, 60447 Minooka, 60416 Coal City, 60408 Braidwood, 60421 Elwood, 60441 Lockport , 60448 Mokena, 60442 Manhattan, 60423 Frankfort, 60440 Bolingbrook, 60424 Gardner, 60439 Lemont, 60407 Braceville, 60474 South Wilmington, 60491 Homer Glen Identified Community Needs - Provena Saint Joseph Medical Center co-facilitated the Will County MAPP Needs Assessment from 2009 through 2010 to be actively engaged in the current county assessment to fully understand the health needs of county residents. the following priorities were identified at the MAPP Strategic Planning Session held in May 2010: Access to care (primary, specialty, behavioral health, substance use disorders), Awareness of services and how to access them, Collaboration and linkage within systems, Prevention and management of chronic care issues Provena St. Mary's Hospital (PSMH), Kankakee, IL: PSMH's primary service has an estimated population of 93,102 and 67,029 in the secondary service area. In the primary service area 13% of the population is over the age 65 and the average household income is $59,101. 8% of the population in Kankakee lives below the poverty level. The racial makeup of the city is 76% White, 15% African American, 6.4% Hispanic. The PSMH service area is defined by zip code below. Approximately 75% and 20% of total inpatient discharges to the PSMH-Kankakee facility originate from this Primary Service Area and Secondary Service Area, respectively. Service Area: Primary Market - 60901 Kankakee, 60914 Bourbonnais, 60915 Bradley, 60954 Momence, 60950 Manteno Service Area: Secondary Market - 60964 Saint Anne, 60927 Clifton, 60922 Chebanse, 60940 Grant Park, 60970 Watseka, 60941 Herscher, 60913 Bonfield, 60938 Gilman, 60911 Ashkum, 60955 Onarga, 60944 Hopkins Park, 60951 Martinton, 60930 Danforth, 60910 Aroma Park, 60912 Beaverville, 60919 Cabery, 60961 Reddick, 60917 Buckingham, 60935 Essex, 60928 Cresent City, 60481 Wilmington, 60468 Peotone, 60420 Dwight, 60958 Pembroke Township
Schedule H, Part VI cont'd		Identified Community Needs PSMH partnered with the Kankakee County Health Department and others to assess the needs of the community through a comprehensive needs assessment, developed by Health Systems Research at the University of Illinois College of Medicine in Rockford. The top conditions reported in Kankakee County were: High Cholesterol, High Blood Pressure, Arthritis, Asthma, and Diabetes. The Community Health Needs assessment also stated that almost two in three (64.5%) Kankakee County adults consider themselves to be overweight or obese compared to 59.0% statewide. In 2011, PSMH focused on 1) Obesity, 2) Pulmonary conditions and 3) Access to care. Note that the needs of diabetes, high blood pressure, high cholesterol and cardiac related assessment were addressed in our obesity focus. Provena Mercy Medical Center (PMMC), Aurora, IL: Aurora, where PMMC resides, is the second largest city in Illinois and accounts for most of the hospital's primary service area. PMMC's primary service has an estimated population of 225,504 and 277,564 in the secondary service area. In the primary service area 7% of the population is over the age 65 and the average household income is $82,440. Within the primary service area (Aurora), approximately 35,000 individuals (21.3%) reside in medically underserved areas (MUAs). Of that population, about 30% fall 200% below the federal poverty level. Within the MUA, 68% of the population is Hispanic and 11% is African American. Fifty-three per cent are underinsured and 47% are Medicaid recipients. Within the community at large, 27% of households report English as a second language. 11% of children in Kane County live in poverty. PMMC's service area is defined by zip code below. Approximately 68% and 19% of total inpatient discharges to the PMMC-Aurora facility originate from this Primary Service Area and Secondary Service Area, respectively. Service Area: Primary Market - 60506 Aurora, 60505 Aurora, 60542 North Aurora, 60538 Montgomery, 60504 Aurora, 60507 Aurora, 60502 Aurora Service Area: Secondary Market - 60510 Batavia, 60543 Oswego, 60560 Yorkville, 60548 Sandwich, 60545 Plano, 60174 Saint Charles, 60554 Sugar Grove, 60134 Geneva, 60552 Somonauk, 60503 Aurora, 60511 Big Rock, 60520 Hinckley, 60119 Elburn, 60115 DeKalb, 60541 Newark, 60512 Bristol, 60531 Leland, 60556 Waterman, 60539 Mooseheart Identified Community Needs In 2006, the hospital engaged with community stakeholders in the Kane County Community Assessment - IPLAN (Illinois Plan for Local Assessment of Need). The assessment process engaged over 90 organizational and community leaders as part of the Kane County Community Health Committee. Staff from Provena Mercy actively participated on this committee. As a result of the IPLAN, 3 priority areas were identified by the Health Department and its partners: Access Health Care (emphasis on specialty care), , Infant Mortality, Chronic Disease (with an emphasis on cardiovascular disease, obesity). Provena Saint Joseph Hospital (PSJH), Elgin, IL: PSJH's primary service has an estimated population of 210,893 and 462,013 in the secondary service area. In the primary service area 8% of the population is over the age 65 and the average household income is $85,837. 6.4% of families in Elgin live below the poverty level. 11% of children in Kane County live in poverty. The racial makeup of the city is 70.49% White, 6.80% African American, 0.40% Native American, 3.88% Asian, 0.06% Pacific Islander, 15.39% from other races, and 2.98% from two or more races. 34.32% of the populations are Hispanic or Latino of any race. A significant portion of Elgin's Asian population is of Laotian origin. The PSJH's service area is defined by zip code below. Approximately 65% and 24% of total inpatient discharges to the PSJH-Elgin facility originate from this Primary Service Area and Secondary Service Area, respectively. Service Area: Primary Market -60123 Elgin, 60120 Elgin, 60124 Elgin, 60121 Elgin, 60110 Carpentersville, 60177 South Elgin, 60140 Hampshire, 60118 Dundee Service Area: Secondary Market- 60102 Algonquin, 60103 Bartlett, 60174 Saint Charles, 60014 Crystal Lake, 60107 Streamwood, 60142 Huntley, 60098 Woodstock, 60050 McHenry, 60051 McHenry, 60156 Lake in the Hills, 60175 Saint Charles, 60136 Gilberts, 60134 Geneva, 60013 Cary, 60152 Marengo, 60135 Genoa, 60109 Burlington, 60012 Crystal Lake, 60180 Union Identified Community Needs In 2006, PSJH engaged with community stakeholders in the Kane County Community Assessment - IPLAN (Illinois Plan for Local Assessment of Need). The assessment process engaged over 90 organizational and community leaders as part of the Kane County Community Health Committee. Staff from PSJH actively participated on this committee. As a result of the IPLAN, 3 priority areas were identified by the Health Department and its partners: Access Health Care (emphasis on specialty care), , Infant Mortality, Chronic Disease (with an emphasis on cardiovascular disease, obesity). Promotion of community health Provena Hospitals are faith based ministries that provide services based upon the ethical and religious directives of the Catholic Church. Provena Hospitals operates six hospitals. Provena hospitals enhance the public health of our communities by: 1. Ensuring our medical staff is open to all qualified physician, 2. All of our hospitals are accredited and in good standing with the Joint Commission Accreditation of Healthcare Organizations (JCAHO). 3. Ensuring our board of directors is diverse and able to provide expertise, and made up of independent members of the communities we serve. Our board members must follow a conflict of interest policy. 4. Surplus funds are reinvested into the organization to improve patient care though new programs and technology. 5. Provide financial assistance and sliding scale discounts and have collection practices that are in compliance with state and federal guideline. In addition, we follow the financial assistance and charity guidelines of the Catholic Health Association. 6. We participate in all government sponsored health care programs, Medicare, Medicaid, CHAMPUS, Tricare, SCHIP and others. 7. We provide emergency room services in all of our communities and provide training to local fire departments and ambulances. Our emergency room participates with local police and fire departments in disaster drills. 8. Our emergency room services and urgent care services are staffed by Board Certified Emergency Room Physicians and treat patients according to EMTALA guidelines and serve all patients regardless of ability to pay. 9. Five of our hospitals qualified for disproportionate share. In addition, we are committed to determining the needs of our communities and creating ways to meet those needs. The obligation to reach out to those in need and improve health flows directly from our Catholic identity and the heritage of our founding congregations. Below are a few examples of how each of our hospitals promote the health of our communities. Provena Covenant Medical Center, Champaign, IL (PCMC) 2011 Community Benefit Highlights: SMILEHEALTHY Partnership A community wide dental initiative resulted in the opening of the Frances Nelson Dental Center (FNDC) in Champaign on October 10th. PCMC donated $62,000 toward start up costs. This initiative includes PCMC, Carle Foundation Hospital, SmileHealthy (a local non-profit), Parkland College, Lincoln Legal and United Way. PCMC donated $10,500 for seven mobile dental clinics at local food pantries and a homeless shelter. Dental exams, hygiene services, restoration and extractions were provided to over 100 uninsured clients. Nutritional and dental education was offered to every ED patient with dental issues. Classes were offered twice a month. Some were referred to the mobile dental clinic, Parkland College or FNDC. Provena Bucher Farm Project PCMC partnered with WILL and Eastern Illinois Food Bank to increase the distribution of fresh produce to the patrons of food pantries. PCMC also partnered with Lincoln Legal and the Lumpkin Foundation to provide a SNAP card recipient "double dollars" in the purchase of produce at the North First Street Farmers Market. Faith in Action Volunteers from fifteen congregations provided assistance to seniors through transportation, home and phone visits, and chores and small home repairs. Provena Covenant's Center for Healthy Aging provided reimbursement for travel expenses and coordinated the program.
Schedule H, Part VI cont'd		Crisis Nursery Support Crisis Nursery provides short-term, nurturing care 24 hours a day, 365 days a year to children ages birth through five, when no other resources are available to help. Each family has their own unique crisis and story. The nursery is committed to prevent child abuse and neglect. Provena Covenant Medical Center has a long standing relationship with the Crisis Nursery Center and leases the land for $1. PCMC provided linens and meals every day as well as paid the utilities, ground maintenance and security for a total of $44,000 in 2010. The total for 2011 is expected to be similar. Provena United Samaritans Medical Center (PUSMC), Danville, IL 2011 Community Benefit Highlights: The HALO Project coordinates the efforts of the community in partnering and participating in healthy community initiatives and is committed to building a community culture that supports healthy life choices and a high quality of life. During 2011, HALO Project made a concentrated effort in impacting children's dental care through the Smiling Faces Dental Days program. Four area dentists along with five of their dental staff provided free screenings, x-rays, cleanings, fluoride treatments, sealants, fillings, extractions, and two root canals to fifty-seven low-income children. Three-hundred and twenty-four children took advantage of the Smiling Faces Dental Days program with one-hundred and ninety-three of the children receiving a free cleaning, fluoride treatment, or sealants. The screenings and treatments were provided in the Colgate Dental Van by Orland Park Dental Services staff of Peoria. Four area dentists were also at the Children's Health, Safety, & Activity Fair providing free dental screenings to one-hundred twenty-seven children. Each child at every dental event received education on proper brushing and flossing technique as well as a goody bag full of dental hygiene products to use at home. Faith in Action (FIA) and Faith in Action South (FIAS) are interfaith ministries that assist health-impaired, homebound senior adults with transportation, home and phone visits, shopping, home maintenance, temporary relief for caregivers, chores and wheelchair ramps. Target populations include seniors age 60 and older. I Sing the Body Electric (ISBE) educates Vermilion County (VC) youth through promotion of health and disease prevention initiatives. This three-phase program works to close the gap between the lack of prevention programs and the prevalence of adolescent health risk behaviors in the County. Young Men/Young Women Aware are leadership development programs that focus on Education, Health Awareness, and Leadership with three objectives: high school completion, college obtainment, and teenage pregnancy/fatherhood prevention with a focus on abstinence. Since the programs' inception, 99% of Young Women Aware participants have remained pregnancy-free; 0% of participating young men self report they have not become teenaged fathers; and both programs have had a 100% high school graduation rate. The vast majority move on to colleges, trade schools, and the armed services. Provena Saint Joseph Medical Center (PSJMC), Joliet, IL 2011 Community Benefit Highlights: Partnership with Will-Grundy Medical Clinic (WGMC) PSJMC provided $35,000 to the Will-Grundy Medical Clinic in 2011. In addition, PSJMC has been a significant supporter of the Will-Grundy Medical Clinic since its inception, providing funding, volunteer hours from clinical staff, and contributing free services and leadership through service on WGMC's board of directors. In 2011, that support was clearly evident: 38 WGMC patients for surgical procedures and related services totaling $3,172,501. PSJMC also donated over 1,560 related services (radiology, diagnostic tests and treatments). These services are quantified at cost. Joliet Partners for Healthy Families (JPHF) Provena Saint Joseph Medical Center formed the JPHF coalition in 2007 to combat the childhood obesity epidemic in vulnerable populations within Will County. The partnership includes the Joliet Public Schools District 86, the Joliet Park District, Greater Joliet Area YMCA, Harvey Brooks Foundation, University of St.Francis, the University of Illinois Extension and the Will County Health Department. The overall goal of JPHF is to create a healthier community through increased access to balanced nutrition and physical activity. The JPHF coalition developed three unique, successful after-school programs under its Healthy Kids Club initiative but is now looking to address the root causes of childhood obesity through impacting policy, systems and environmental change. JPHF has now expanded into all sectors within the community and has engaged local community leaders to support its initiative and goals. Provena St. Mary's Hospital (PSMH), Kankakee, IL 2011 Community Benefit Highlights: Dr. Arocha's Asthma Camp - Camp Aire was conducted for the 18th year. We provided 47 children with asthma nutritional education, physical education, crafts and entertainment. During 2011 we conducted 2 "mini-camps" or days, so that we could measure how our children were doing. Our metrics included peak flows, which remain the same or increased by 10 to 30 points, endurance (children continued to enjoy physical activity such as soccer, basketball, cheerleading and dance), missed schools days (there were on average 2-6 days missed for 4th quarter 2011), and ED usage (most children were cared for by their pediatricians, however one child had several ED visits this year, and is being treated more aggressively at this time by his pediatrician). Children have continued to be instructed to do peak flow maneuvers weekly so that they can track changes in peak flows due to their growth. Fit "N" Healthy was created to target obesity and educate adults about healthier lifestyles in underserved communities. In 2011, there were a total of 278 participants in 4 ten week sessions. The average weight loss was 5.2 lbs. The glucose numbers dropped an average of 21 points; many brought their A1C levels to within normal range. The average blood pressure dropped low enough that all together since 2008 we have 11 members of the program no longer needing medication to control their blood pressure. The average BMI level in a ten week period was between 2-5%. The cholesterol numbers dropped an average of 14-17 points. Provena Mercy Medical Center (PMMC), Aurora, IL 2011 Community Benefit Highlights: Language Access to Healthcare (LAH) is PMMC's community-based interpreting program that provides interpreting services to community-based organizations and limited-English proficient individuals. It is widely recognized that a patient's ability to communicate presenting concerns, participate in his/her medical care regimen and provide compliant self care and follow up after discharge is dependent upon his/her ability to communicate and understand effectively. Persons who do not speak English as their primary language and who have a limited ability to read, speak, write, or understand English are known as limited-English proficient (LEP). The percentage of individuals who speak English less than "very well" in Aurora is 44% which highlights the need for LAH in the Aurora market. A1C Achiever Program "Life with Diabetes" is a 2-3 month program that combines diabetes self-management education and medical nutrition therapy concurrently. Patients are referred by their primary healthcare provider to meet with a diabetes educator for an individual initial assessment to determine the plan of care. Patients attend six 1.5 hour sessions and two individual medical nutrition therapy sessions. Healthy behavior goals are selected by the patient and diabetes educator to be re-evaluated midway through the program and upon program completion or as needed. All patients that achieve an A1C of less than 7% become part of the "A1C Achiever" program which is a patient recognition program that rewards patients for achieving glycemic control. The target population is all individuals with Type 1 or Type 2 Diabetes. The emphasis of the program is on providing access to care for the underserved in the hospitals primary service area which includes 8 federally designated medically underserved areas (MUAs). The program aim is to provide diabetes services so that program participants can attain glycemic control and improve current health status Faith Community Nursing program continues to bring health, wellness and prevention into the faith communities. The nurses assess prisoners for the presence of medical homes and provide a wide array of educational opportunities. Toolkits have also been developed and implemented for risk assessments and screenings in the areas of: hypertension, stroke, acute coronary syndrome, osteoporosis, cholesterol/lipids, diabetes, colon, prostate, breast and skin cancer.
Schedule H, Part VI cont'd		The Community Wellness Program provides community education and screening programs on a variety of health and wellness topics both in the community and main hospital location. Components of the program include: blood pressure, blood glucose, blood lipid, body fat and body mass index (BMI) screenings. Health education topics on chronic disease include hypertension, stroke, diabetes, obesity and heart disease. The target population is underserved adults in the hospitals primary service area which includes 8 federally designated medically underserved areas (MUA). The overall program aim is to provide early detection and health education on chronic disease. Provena Saint Joseph Hospital (PSJH), Elgin, IL 2011 Community Benefit Highlights: The Community Wellness Program provides community education and screening programs on a variety of health and wellness topics both in the community and main hospital location. Components of the program include: blood pressure, blood glucose, blood lipid, body fat and body mass index (BMI) screenings. Health education topics on chronic disease include hypertension, stroke, diabetes, obesity and heart disease. The target population is underserved adults in the hospitals primary service area which includes 8 federally designated medically underserved areas (MUA). The program aim is to provide early detection and health education on chronic disease. Engaged Partner in Activate Elgin which is a city-wide initiative to engage all sectors of the community to work in harmony providing all residents with opportunities to improve their health, well-being, and overall quality of life. Through this initiative, local YMCAs are serving as "connectors," bringing together high-level representatives from the government, public health and private sectors to drive meaningful change. Activate Elgin involves community partnerships, as this challenging work requires the collaboration of many organizations working together toward the common goal of reducing obesity and related health conditions in the Elgin area. Affiliated health care system Effective November 30, 1997, The Franciscan Sisters of the Sacred Heart, The Servants of the Holy Heart of Mary - holy Family Province, and the Sisters of Mercy of the Americas Regional Community of Chicago created a new equally sponsored Catholic healthcare system called Provena Health in order to assure the provision of ongoing quality healthcare services to the communities served by the sponsors. Provena Health is the sole corporate sponsor of Provena Hospitals, Provena Senior Services, Provena Home Health, Provena Care @ Home, and Provena Health Assurance SPC, and owns 100% of Provena Ventures, Inc. These organizations include all of the healthcare operations of the Sponsors. Provena provides healthcare and long-term care services to communities primarily located in northern and central Illinois. As was the case from our very beginnings, Provena Health is called to be much more than a just a provider of health services. Provena Health has instilled within all of its ministries that are committed to responding to the needs of these we are privileged to serve; delivering high quality care that is accessible to all. It is this culture of caring and giving that drives our diligent efforts to ensure we return the optimal value of our charitable assets to our local communities. To ensure the commitment to the health of our communities was a top priority for all Provena Health ministries, the Provena Health Board of Directors adopted a Board Philosophy Statement in December 2007. The Community Benefit Board Philosophy Statement provides guidance for policies, practices and community benefit programs. The philosophy ensures that Provena Ministries pay special attention to the poor, vulnerable and underserved as well as continuing to effectively collaborate with the communities we serve on identified community needs. State filing of community benefit report Illinois

Schedule H (Form 990) 2011

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

2011

Open to Public
Inspection

Name of the organization
PROVENA HOSPITALS

Employer identification number
36-4195126

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	(e) Amount of non-cash assistance	(f) Method of valuation (book, FMV, appraisal, other)	(g) Description of non-cash assistance	(h) Purpose of grant or assistance

Enter total number of section 501(c)(3) and government organizations listed in the line 1 table ................. Bullet Image

Enter total number of other organizations listed in the line 1 table ......................... . Bullet Image

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

Cat. No. 50055P

Schedule I (Form 990) 2011

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
(1) scholarships	49	73,650

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
form 990 schedule I, PART I LINE 2		THE FOLLOWING THREE HOSPITALS AWARDED GRANTS AND ASSISTANCE AND USED THE FOLLOWING PROCEDURES FOR MONITORING THE USE OF THE FUNDS DISTRIBUTED: Provena Covenant Medical Center Checks for authorized students are sent directly to their respective universitIES (and made payable to the universitIES) for disbursement to the studentS for appropriate expenses such as tuition. In the case of Parkland College where a good number of nursing scholarships are given, Parkland bills THE MEDICAL CENTER at the conclusion of each semester. THE MEDICAL CENTER IS billed for only the dollars used and if a student does not utilize all of the funds made available for HIS OR HER scholarship award, the Auxiliary is not billed and does not incur the expense. They also notify THE MEDICAL CENTER if A student drops out or changes curriculums therefore no longer being eligible for the funds given in their healthcare studies. Most of the universities have auditing practices which requires them to oversee the distribution of scholarship funds to their students. THE MEDICAL CENTER placeS ITS confidence in their practices to ensure that monies given to the students are monitored appropriately. Provena Mercy Medical Center Scholarships are handled through THE MEDICAL CENTER'S Foundation. The Foundation office receives the applications and distributes the applications to a committee. The committee reviews the applications, determines which candidates to interview in person, conducts the interviews, and selects the recipients. The Foundation receives the tuition bills and makes the tuition payments directly to the schools (up to the amount of the scholarship award). Some grants are handled through THE Foundation. When grant funds are to be expended, a "Disbursement of Foundation Funds" form is completed by the clinical director responsible for handling the grant. The Foundation reviews and approves the form, and the funds are expended. The Foundation notifies Finance that the funds can be released from restriction. The clinical director and Foundation office work together to submit the necessary grant reports to the grantor. Federal grants are not handled through the Foundation. The clinical director responsible for the grant works with Finance to track the expenses for the grant. The clinical director prepares and submits the necessary reports to the grantor. PROVENA UNITED SAMARITANS MEDICAL CENTER THE MEDICAL CENTER insureS that the young man or young woman awarded a scholarship through Young Men Aware or Young Women Aware actually enroll in an institution of higher learning and pay the scholarship (generally only $500 or $1,000) directly to the institution. Thus, eliminating any chance that the SCHOLARSHIP will not actually go towards education.

Schedule I (Form 990) 2011

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

2011

Open to Public Inspection

Name of the organization

PROVENA HOSPITALS

Employer identification number

36-4195126

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 or provision 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. Do not check any boxes for methods
used by a related organization to establish compensation of the CEO/Executive Director, but explain in Part III.

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? ........

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

Yes

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

Yes

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 Regulations 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) 2011

Page 2

Part II

Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees. Use duplicate copies if additional space is 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) for each listed individual must equal the total amount of Form 990, Part VII, Section A, line 1a, applicable column (D) and column (E) for that individual.

(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 as deferred in prior Form 990
(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)	(F) Compensation reported as deferred in prior Form 990
(1) GUY WIEBKING	(i) (ii)	0 726,939	0 0	0 71,119	0 0	0 0	0 798,058	0 51,088
(2) SANDRA BRUCE	(i) (ii)	0 967,144	0 597,257	0 0	0 12,250	0 21,339	0 1,597,990	0 0
(3) MICHAEL BROWN	(i) (ii)	327,069	14,135	67,258	31,125	20,744	460,331	0
(4) EUGENE MCMAHON	(i) (ii)	237,049	25,000	58,305	37,850	30,966	389,170	0
(5) PAUL BELTER	(i) (ii)	266,230	0	53,259	22,822	30,059	372,370	0
(6) WILLIAM BROWN	(i) (ii)	0	0	254,726	0	25,240	279,966	0
(7) GARY GASBARRA	(i) (ii)	282,138	14,150	87,140	37,220	34,323	454,971	18,305
(8) JOMEL LABAYOG	(i) (ii)	571,744	16,762	49,408	0	21,713	659,627	0
(9) VICTOR ROSTAPSHOV	(i) (ii)	321,490	0	23,032	0	13,896	358,418	0
(10) MICHAEL PANUSKA	(i) (ii)	229,843	27,000	17,461	0	12,896	287,200	0
(11) JINJENG ZHU	(i) (ii)	217,193	0	29,439	0	20,367	266,999	0
(12) ANNE LI	(i) (ii)	152,995	0	22,552	0	17,803	193,350	0
(13) ANIL GOPINATH	(i) (ii)	185,655	14,711	64,926	16,630	28,659	310,581	0
(14) MOLLY NICHOLSON	(i) (ii)	126,582	8,338	25,688	11,139	21,451	193,198	0
(15) PAMELA URBANSKI	(i) (ii)	141,880		106,108	1,872	6,167	256,027	0
(16) LAURENCE DRY	(i) (ii)	173,123		41,352	15,597	30,829	260,901	0
(17) LISA DIMARCO	(i) (ii)	176,712		25,157	14,661	18,482	235,012	0
(18) JOHN BACCHETTI	(i) (ii)	135,402	0	42,227	0	11,020	188,649	42,101
(19) JARED ROGERS	(i) (ii)	108,132	15,540	73,055	10,485	16,908	224,120	0
(20) PAUL DONOHUE	(i) (ii)	129,615	0	26,141	11,175	25,686	192,617	0
(21) BABAK PAZOOKI	(i) (ii)	212,819	0	24,629	18,953	31,636	288,037	0
(22) AMY LAFINE	(i) (ii)	161,178	0	67,792	15,803	25,568	270,341	0
(23) ELIZABETH HUGHES	(i) (ii)	339,502	151,131	57,492	15,329	30,439	593,893	0
(24) GARY PLUNDO	(i) (ii)	264,970	22,555	69,806	24,481	24,136	405,948	0
(25) AMY STEVENS	(i) (ii)	243,182	9,515	31,864	18,720	1,103	304,384	0
(26) JACQUELINE MEDLAND	(i) (ii)	182,591	15,789	40,564	17,306	27,445	283,695	0
(27) JANICE NEMRI	(i) (ii)	158,894	12,874	53,195	15,522	18,237	258,722	0
(28) ELIZABETH GARROW	(i) (ii)	165,952	14,372	34,354	15,600	18,274	248,552	0
(29) DANIEL HATCHER	(i) (ii)	169,191	0	39,703	11,969	12,427	233,290	15,230
(30) SUZETTE MAHNEKE	(i) (ii)	182,430	0	13,441	15,244	18,289	229,404	0
(31) DAVID MCNARY	(i) (ii)	129,093	0	52,791	0	2,186	184,070	0
(32) JEFFREY BRICKMAN	(i) (ii)	435,991	40,272	129,244	41,815	21,792	669,114	110,744
(33) INDRANIL BOB SARKAR	(i) (ii)	40,217	0	139,776	3,218	18,350	201,561	0
(34) MICHAEL ARNO	(i) (ii)	255,590	0	249,066	25,585	32,696	562,937	55,529

Schedule J (Form 990) 2011

Page 3

Part III

Supplemental Information

Complete this part to provide the information, explanation, or descriptions required for Part I, lines 1a, 1b, 3, 4c, 5a, 5b, 6a, 6b, 7, and 8. Also complete this part for any additional information.

Identifier	Return Reference	Explanation
FORM 990 SCHEDULE J SUPPLEMENTAL INFORMATION		PART I, QUESTION 4A THE FOLLOWING RECEIVED SEVERANCE PAYMENTS: Indranil Bob Sarkar $83,210

Schedule J (Form 990) 2011

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE M
(Form 990)

Department of the Treasury

Internal Revenue Service

NonCash Contributions

Complete if the organization answered "Yes" on Form 990, Part IV, lines 29 or 30.
Right pointing arrow large image

Attach to Form 990.

OMB No. 1545-0047

2011

Open to Public Inspection

Name of the organization

PROVENA HOSPITALS

Employer identification number

36-4195126

Part I

Types of Property

	(a) Check if applicable	(b) Number of Contributions or items contributed	(c) Noncash contribution amounts reported on Form 990, Part VIII, line 1g	(d) Method of determining noncash contribution amounts
1 Art—Works of art ....
2 Art—Historical treasures .
3 Art—Fractional interests ..
4 Books and publications ..
5 Clothing and household goods .......
6 Cars and other vehicles ..
7 Boats and planes ....
8 Intellectual property ...
9 Securities—Publicly traded .
10 Securities—Closely held stock .
11 Securities—Partnership, LLC, or trust interests ....
12 Securities—Miscellaneous ..
13 Qualified conservation contribution—Historic structures .....
14 Qualified conservation contribution—Other ...
15 Real estate—Residential .
16 Real estate—Commercial ..
17 Real estate—Other ...
18 Collectibles .....
19 Food inventory ...
20 Drugs and medical supplies .
21 Taxidermy ......
22 Historical artifacts ....
23 Scientific specimens ..
24 Archeological artifacts ...
25 Other ( Printing )	X	0	5,582	Cost
26 Other ( accounting services )	X	0	11,000	COST
27 Other ( advertising )	X	0	8,000	cost
28 Other ( remodeling of Cancer center )	X	0	6,493	Cost
Other ( sound system )	X	0	11,387	cost
Other ( radio/mc for event )	X	0	7,800	cost
Other ( food for event )	X	0	5,750	cost
Other ( certificates/meeting room/raffle items )	X	0	5,000	cost
Other ( mink coat )	X	0	7,500	cost
Other ( creative equipment and labor )	X	0	20,000	cost
Other ( microscope )	X	0	19,500	cost
Other ( medical equipment )	X	0	43,423	cost
Other ( medical equipment )	X	0	79,587	cost

Number of Forms 8283 received by the organization during the tax year for contributions
for which the organization completed Form 8283, Part IV, Donee Acknowledgement ...

Yes

30a

During the year, did the organization receive by contribution any property reported in Part I, lines 1-28 that it

must hold for at least three years from the date of the initial contribution, and which is not required to be used

for exempt purposes for the entire holding period? ..................

30a

If "Yes," describe the arrangement in Part II.

Does the organization have a gift acceptance policy that requires the review of any non-standard contributions?

32a

Does the organization hire or use third parties or related organizations to solicit, process, or sell noncash

contributions? ............................

32a

If "Yes," describe in Part II.

If the organization did not report revenues in column (c) for a type of property for which column (a) is checked,

describe in Part II.

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

Cat. No. 51227J

Schedule M (Form 990) 2011

Page 2

Part II

Supplemental Information. Complete this part to provide the information required by Part I, lines 30b,
32b, and 33 and whether the organization is reporting in Part I, column (b) the number of contributions, the number of items received, or a combination of both. Also complete this part for any additional information.

Identifier	Return Reference	Explanation

Schedule M (Form 990) 2011

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

2011

Open to Public
Inspection

Name of the organization

PROVENA HOSPITALS

Employer identification number

36-4195126

Identifier	Return Reference	Explanation
FORM 990 PART VI SECTION A, QUESTION 4		On November 1, 2011, Provena Health and its affiliates ("Provena") and Resurrection Health ("RHC") completed a system merger to form Provena-Resurrection Health Network (d/b/a Presence Health). Pursuant to the merger, the two sponsoring congregations of RHC and the three sponsoring congregations of Provena agreed to jointly sponsor a new system composed of all entities comprising both systems, including Provena Hospitals. The system merger was accomplished through the establishment of a new system parent corporation as the sole member of the former parent corporations of each system (i.e., Resurrection Health Care Corporation and Provena Health, respectively). The parent corporation of the newly merged health care system, Provena-Resurrection Health Network (d/b/a Presence Health) (referred to as Presence Health, herein), is a not_for_profit, tax_exempt corporation. The merger was effected to preserve and strengthen Catholic health care, furthering Provena's and RHC's charitable missions. Presence Health created the largest Catholic healthcare network in the State of Illinois, spanning 12 hospitals, 28 long_term care and senior residential facilities, more than 50 primary and specialty care clinics, and 6 home health agencies. The combined health system has hospital operations throughout Chicago, Des Plaines, Evanston, Aurora, Elgin, Joliet, Kankakee, Urbana, and Danville. Concurrent with the merger, directors of both Provena and RHC resigned at the effective date of the transaction, and a new Board of Directors was formed. The merger of Provena and RHC was approved by the Sponsors of both organizations to improve access to care in the communities served.
FORM 990 PART VI SECTION A, QUESTIONS 7A & 7B		The corporate member consisting of 2 members appointed by the leadership teams of each of the five sponsoring congregations of religious women has the authority to appoint Board members and approve the recommendations of the Board.
FORM 990 PART VI SECTION B, QUESTION 11B		THE DATA AND INFORMATION NECESSARY TO PREPARE THE FORM 990 WAS COMPILED BY PROVENA HEALTH'S ACCOUNTING GROUP. KPMG, AS EXTERNAL TAX PREPARERS, USED THIS INFORMATION TO PREPARE THE FORM 990. THE FINAL FORM 990 IS PROVIDED TO THE CORPORATION'S BOARD OF DIRECTORS FOR REVIEW PRIOR TO FILING.
FORM 990 PART VI SECTION B, QUESTIONS 12A, 12B, & 12C		THE ORGANIZATION HAS ADOPTED A POLICY THAT REQUIRES BOARD MEMBERS TO COMPLETE A STATEMENT THAT DISCLOSES ALL ACTIVITIES AND PROHIBITS VOTING ON ANY MATTERS INVOLVING ANY CONFLICTS. EVERY AGENDA HAS A STATEMENT THAT PROHIBITS VOTING ON AGENDA ITEMS WHERE BOARD MEMBERS HAVE CONFLICTS. VENDOR FILES ARE MATCHED WITH COMPANIES BOARD MEMBERS THAT HAVE AFFILIATIONS WITH TO DETERMINE IF CONFLICTS EXIST.
FORM 990 PART VI SECTION B, QUESTIONS 15A & 15B		AN INDEPENDENT HUMAN RESOURCES COMPANY REVIEWS SALARY SURVEYS FOR CEO'S AND KEY EMPLOYEES DURING THE YEAR AND MAKES RECOMMENDATIONS TO THE BOARD OF DIRECTORS or a designated board committee.
FORM 990 PART VI SECTION C, QUESTION 19		GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICIES, AND FINANCIAL STATEMENTS ARE AVAILABLE TO THE PUBLIC UPON REQUEST AND ARE ON THE ORGANIZATION'S WEBSITE.
FORM 990 PART XI	Line 5, Other Change in Net Asset or Fund Balance	Unrealized loss on securities (380,000) Transfers from Affiliates 14,998,000 Impairment Loss (70,000,000) Net Assets Released from Restrictions 2,366,000 Contributions pledged but not yet received (3,823,003) Donations received with temporary restrictions 72,876 Donations received with permanent restrictions 44,570 Other changes in net assets, net (9,000) Net Assets released from restriction 1,009,511 Book/Tax Income Difference with Joint Ventures (746,084) Net Income from Special Events (204,523) Volunteer Hours 906,389 ------------ Other Changes in Net Assets or Fund Balances(Ln 5) (55,765,264)

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

Cat. No. 51056K

Schedule O (Form 990 or 990-EZ) 2011

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

2011

Open to Public Inspection

Name of the organization

PROVENA HOSPITALS

Employer identification number

36-4195126

Part I

Identification of Disregarded Entities (Complete if the organization answered "Yes" on Form 990, Part IV, line 33.)

(a) Name, address, and EIN of disregarded entity	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Total income	(e) End-of-year assets	(f) Direct controlling entity

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) RESURRECTION HEALTH CARE CORPORATION 7435 WEST TALCOTT AVENUE CHICAGO,IL60631 36-2235165	SENIOR LIVING	IL	501(C) (3)	3	na
(2) RESURRECTION MEDICAL CENTER 7435 WEST TALCOTT AVENUE CHICAGO,IL60631 36-3330926	HEALTH CARE	IL	501(C) (3)	3	NA
(3) OUR LADY OF THE RESURRECTION MEDICAL CTR 5645 WEST ADDISON STREET CHICAGO,IL60634 36-2644178	HEALTH CARE	IL	501(C) (3)	3	NA
(4) Provena-Resurrection Health Network 7435 WEST TALCOTT AVENUE CHICAGO,IL60631 36-1649520	HEALTH CARE	IL	501(c )(3)	3	NA
(5) SAINT FRANCIS HOSPITAL 355 RIDGE AVENUE EVANSTON,IL60202 36-2167800	HEALTH CARE	IL	501(C) (3)	3	NA
(6) SAINTS MARY AND ELIZABETH MEDICAL CENTER 2233 WEST DIVISION STREET CHICAGO,IL60622 36-2171079	HEALTH CARE	IL	501(C) (3)	3	NA
(7) HOLY FAMILY MEDICAL CENTER 100 n RIVER ROAD DES PLAINES,IL60016 36-2439318	HEALTH CARE	IL	501(C) (3)	3	NA
(8) Holy Family Health Care System Inc 100 N River Road Des Plaines,IL60016 36-3495969	health care	IL	501 (c )(3)	3	NA
(9) Saint Joseph Hospital 2900 North Lake Shore Drive chicago,IL60657 36-3200170	health care	IL	501 (c )(3)	3	NA
(10) Resurrection University 7435 West Talcott Avenue chicago,IL60631 36-2182170	health care	IL	501 (c )(3)	3	NA
(11) Resurrection Ambulatory Services 7435 West Talcott Avenue Chicago,IL60631 36-4286236	health care	IL	501 (c )(3)	3	NA
(12) Resurrection Senior Services 7435 West Talcott Avenue chicago,IL60631 23-7061646	senior living	IL	501 (c )(3)	3	na
(13) Resurrection Services 7447 West Talcott Avenue chicago,IL60631 36-3330928	health care	IL	501 (c )(3)	3	na
(14) Proviso Family Services 1820 South 25th Avenue broadview,IL60155 36-2709982	health care	IL	501 (c )(3)	3	na
(15) Resurrection Home Health Services 5747 West Dempster morton grove,IL60053 36-2893936	home care	IL	501 (c )(3)	3	Resur Health
(16) Resurrection Development Foundation 150 N River Road des plaines,IL60016 36-3330929	fundraising	IL	501 (c )(3)	7	Resur Health
(17) Resurrection Ministries of New York 90 N Main Street castelton,NY12033 14-1720818	parent corp	NY	501 (c )(3)	3	Resur Health
(18) Resurrection Nursing Home Inc 90 N Main Street castelton,NY12033 14-1348691	senior living	NY	501 (c )(3)	3	Resur Min NY
(19) Mount Loretto Nursing Home Inc 302 Swart Hill Road amsterdam,NY12010 14-1363014	senior living	NY	501 (c )(3)	3	Resur Min NY
(20) Resurrection Medical Center Auxiliary 7435 West Talcott Avenue chicago,IL60631 36-6109825	fundraising	IL	501 (c )(3)	7	Resur MedCtr
(21) Saint Francis Hospital Auxiliary 355 Ridge Avenue evanston,IL60202 36-6143349	fundraising	IL	501 (c )(3)	7	St Fran Hosp
(22) provena health 9223 w st francis road frankfort,IL60423 36-3366652	healthcare	IL	501(c)(3)	11	na
(23) provena senior services 19065 hickory creek drive mokena,IL60448 37-1127787	healthcare	IL	501(c)(3)	7	prov health
(24) provena care home 19065 hickory creek drive mokena,IL60448 46-0483587	healthcare	IL	501(c)(3)	9	prov health
(25) provena home health inc 19065 hickory creek drive mokena,IL60448 46-0483581	healthcare	IL	501(c)(3)	9	prov health
(26) provena self-insurance trust 9223 west st st francis road frankfort,IL60423 36-2987310	healthcare	IL	501(c)(3)	9	prov health
(27) provena laverna terrace 19065 hickory creek drive mokena,IL60448 36-3438977	healthcare	IL	501(c)(3)	9	prov health

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

Cat. No. 50135Y

Schedule R (Form 990) 2011

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	(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?
(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

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) PROVENA SERVICES CORPORATION 9223 W ST FRANCIS ROAD FRANKFORT,IL60423 36-4314354	medical	IL	Prov Hosp	c corp	-13,024,585	7,036,598	100.000 %
(2) PROVENA VENTURES 9223 west st francis road frankfort,IL60423 37-1168085	medical	IL	provena health	c corp
(3) provena properties 9223 west st francis road frankfort,IL60423 36-3520630	medical	IL	provena health	c corp
(4) Provena Assurance Corporation 9223 west st francis road frankfort,IL60423 98-0420054	medical	IL	provena health	c corp
(5) PROVENA SELF-INSURANCE TRUST 9223 WEST ST FRANCIS ROAD FRANKFORT,IL60423 36-2987310	INSURANCE	IL	PROVENA HEALTH	TRUST
(6) L Gilbraith Insurance SPC Ltd 9223 West St Francis Road Frankfort,IL60423 98-0420054	medical	IL	na	c corp
(7) resurrection health care preferred 100 N River Road Des Plaines,IL60016 36-3974620	Mgd Care Contract		RHCC	C Corp

Schedule R (Form 990) 2011

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

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

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

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

Yes

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

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

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

h Exchange of assets with related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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

Yes

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

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

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

m Sharing of facilities, equipment, mailing lists, or other assets with related organization(s) . . . . . . . . . . . . . . . . . . . . .

n Sharing of paid employees with related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

o Reimbursement paid to related organization(s) for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

p Reimbursement paid by related organization(s) for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

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

r Other transfer of cash or property from related 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) PROVENA SERVICE CORPORATION	P	68,067
(1)
(2)
(3)
(4)
(5)
(6)

Schedule R (Form 990) 2011

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)	(e) Are all partners section 501(c)(3) organizations?		(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?
(a) Name, address, and EIN of entity	(b) Primary activity	(c) Legal domicile (state or foreign country)	Yes	No	(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

Schedule R (Form 990) 2011

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: THE ORGANIZATION STRIVES TO MAINTAIN AND IMPROVE THE HEALTH OF THE COMMUNITIES IT SERVES BY PROVIDING SERVICES THAT EMPHASIZE AVOIDING ILLNESS THROUGH PREVENTIVE CARE AND STATE-OF-THE-ART TECHNOLOGIES.
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	14
5	Total number of individuals employed in calendar year 2011 (Part V, line 2a) ...	5	8,566
6	Total number of volunteers (estimate if necessary) ....	6	2,131
7a	Total unrelated business revenue from Part VIII, column (C), line 12 ..	7a	2,891,940
b	Net unrelated business taxable income from Form 990-T, line 34 ..	7b	169,140

		Prior Year	Current Year
8	Contributions and grants (Part VIII, line 1h) .........	3,897,876	4,464,417
9	Program service revenue (Part VIII, line 2g) .........	1,099,490,773	990,095,600
10	Investment income (Part VIII, column (A), lines 3, 4, and 7d ) ....	2,331,917	-1,493,050
11	Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e)	12,139,052	12,985,244
12	Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)...................	1,117,859,618	1,006,052,211
13	Grants and similar amounts paid (Part IX, column (A), lines 1–3 )...	108,667	73,650
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)	455,649,344	462,414,591
16a	Professional fundraising fees (Part IX, column (A), line 11e).....	36,015	139,507
b	Total fundraising expenses (Part IX, column (D), line 25) 3,115,526
17	Other expenses (Part IX, column (A), lines 11a–11d, 11f–24f)....	651,770,742	546,349,620
18	Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25)	1,107,564,768	1,008,977,368
19	Revenue less expenses. Subtract line 18 from line 12.......	10,294,850	-2,925,157
		Beginning of Current Year	End of Year
20	Total assets (Part X, line 16).............	850,791,814	796,734,905
21	Total liabilities (Part X, line 26).............	226,154,854	230,788,368
22	Net assets or fund balances. Subtract line 21 from line 20.....	624,636,960	565,946,537

Sign Here

	Signature of officer	Date

	Type or print name and title.


4a	(Code: ) (Expenses $ 822,117,286 including grants of $ 73,650 ) (Revenue $ 990,095,600 )
	THE HOSPITALS PROVIDED INPATIENT MEDICAL CARE, MATERNITY SERVICES AND CHARITY CARE. THE HOSPITALS SERVED BOTH THE AGED AND THE POOR BY PARTICIPATION IN THE MEDICARE AND MEDICAID PROGRAMS. THE HOSPITALS PROVIDED OUTPATIENT SERVICES TO MEMBERS OF THE COMMUNITY REGARDLESS OF ABILITY TO PAY.

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$ 822,117,286

(A) Name and Title	(B) Average hours per week (describe hours for related organizations in Schedule O)	(C) Position (do not check more than one box, unless person is both an officer and a director/trustee)					(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) SISTER PATRICIA KOSCHALKE CSFN DIRECTOR	1.0	X					0		0
(19) SISTER CLARA FRANCES KUSEK CR DIRECTOR	1.0	X					0		0
(20) SUSAN MCDONOUGH DIRECTOR	1.0	X					0		0
(21) VICTOR ORLER DIRECTOR	1.0	X					0		0
(22) SISTER MARY SHINNICK OSF DIRECTOR	1.0	X					0		0
(23) THOMAS SETTLES DIRECTOR	1.0	X					0		0
(24) SISTER EVELYN VARBONCOEUR SSCM DIRECTOR	1.0	X					0		0
(25) JAMES WINIKATES DIRECTOR	1.0	X					0		0
(26) MICHAEL BROWN PRES & CEO PUSMC	40.0		X					408,462	50,955
(27) EUGENE MCMAHON PRESIDENT & CEO PSJH	40.0		X					320,354	67,903
(28) PAUL BELTER REGIONAL VP FINANCE/ CEO	40.0		X					319,489	51,967
(29) GARY GASBARRA REGIONAL VP FINANCE/ CFO	40.0		X					383,428	70,629
(30) ANIL GOPINATH CMO	40.0			X			265,292		44,203
(31) MOLLY NICHOLSON VP PATIENT CARE SRVS	40.0			X			160,608		26,552
(32) PAMELA URBANSKI VP PATIENT CARE SRVS	40.0			X			247,988		7,868
(33) LAURENCE DRY VP STRATEGY & OPS	40.0			X			214,475		45,665
(34) LISA DIMARCO VP PATIENT CARE SRVS	40.0			X			201,869		32,416
(35) JOHN BACCHETTI REG VP STRATEGIC PLG & BUS DEV	40.0			X			177,629		10,573
(36) JARED ROGERS CMO	40.0			X			196,727		26,480
(37) PAUL DONOHUE VP FOUNDATION	40.0			X			155,756		36,103
(38) BABAK PAZOOKI CMO	40.0			X			237,448		49,477
(39) AMY LAFINE PRESIDENT & CEO ~ PSMH	40.0			X			228,970		40,601
(40) ELIZABETH HUGHES PRESIDENT & CEO ~ PSJMC	40.0			X			548,125		44,656
(41) GARY PLUNDO CMO	40.0			X			357,331		47,704
(42) AMY STEVENS COO	40.0			X			284,561		18,720
(43) JACQUELINE MEDLAND VP PATIENT CARE SRVS	40.0			X			238,944		43,713
(44) JANICE NEMRI CAO	40.0			X			224,963		32,803
(45) ELIZABETH GARROW VP FOUNDATION	40.0			X			214,678		32,914
(46) DANIEL HATCHER CMO	40.0			X			208,894		23,388
(47) SUZETTE MAHNEKE VP PATIENT CARE SRVS	40.0			X			195,871		32,589
(48) DAVID MCNARY VP AMBULATORY SRVS	40.0			X			181,884		1,546
(49) JEFFREY BRICKMAN SYS SR VP/ PRES & CEO PSJMC	40.0			X				605,507	62,998
(50) INDRANIL BOB SARKAR VP STRATEGIC PLG & BUS DEV	40.0			X			179,993		20,939
(51) MICHAEL ARNO PRESIDENT & CEO PSMH	40.0			X				504,656	57,368
(52) JOMEL LABAYOG PHYSICIAN	40.0				X		637,914		20,800
(53) VICTOR ROSTAPSHOV PHYSICIAN	40.0				X		344,522		12,784
(54) MICHAEL PANUSKA MEDICAL DIRECTOR	40.0				X		274,304		11,784
(55) JINJENG ZHU PHYSICIST	40.0				X		246,632		19,271
(56) ANNE LI PHYSICIAN	40.0				X		175,547		16,885
(57) WILLIAM BROWN SYS SR VP/ PRES & CEO PSJH	40.0					X		254,726	24,912

1b	Sub-Total................
c	Total from continuation sheets to Part VII, Section A....
d	Total (add lines 1b and 1c)............	6,400,925	5,159,081	1,120,755

				(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		659,203
d	Related organizations...1d
e	Government grants (contributions)1e		147,804

f	All other contributions, gifts, grants, and similar amounts not included above1f		3,657,410
g	Noncash contributions included in lines 1a-1f:$ 231,022
h	Total. Add lines 1a-1f.......			4,464,417
			Business Code
2a	NET PATIENT REVENUE		900,099	990,095,600	990,095,600
b
c
d
e
f	All other program service revenue .
g	Total. Add lines 2a–2f........			990,095,600
3	Investment income (including dividends, interest
	and other similar amounts).....			2,467,272		867,184	1,600,088
4	Income from investment of tax-exempt bond proceeds..			0
5	Royalties............			0
		(i) Real	(ii) Personal
6a	Gross rents	2,054,276
b	Less: rental expenses
c	Rental income or (loss)	2,054,276
d	Net rental income or (loss).......			2,054,276		286,636	1,767,640
		(i) Securities	(ii) Other
7a	Gross amount from sales of assets other than inventory
b	Less: cost or other basis and sales expenses		3,960,322
c	Gain or (loss)		-3,960,322
d	Net gain or (loss)..........			-3,960,322			-3,960,322
8a	Gross income from fundraising events (not including $ 659,201 of contributions reported on line 1c). See Part IV, line 18 ...
	a		1,016,647
b	Less: direct expenses ...b		812,124
c	Net income or (loss) from fundraising events..			204,523			204,523
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	CAFETERIA SALES		722,100	4,422,292			4,422,292
b	PHARMACY APOTHECARY		446,110	1,244,503			1,244,503
c	PHARMACY REVENUE		446,110	1,636,539		1,146,011	490,528
d	All other revenue ....			3,423,111	6,580	592,109	2,824,422
e	Total. Add lines 11a–11d ......			10,726,445
12	Total revenue. See Instructions....			1,006,052,211	990,102,180	2,891,940	8,593,674


				(A) Beginning of year		(B) End of year
1	Cashnon-interest-bearing ..........			0	1	0
2	Savings and temporary cash investments .......			42,301,204	2	37,306,915
3	Pledges and grants receivable, net .........			0	3	0
4	Accounts receivable, net .........			160,016,149	4	175,864,260
5	Receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of
	Schedule L ..........			0	5	0
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 ..........			0	6	0
7	Notes and loans receivable, net .............			0	7	0
8	Inventories for sale or use ..............			23,132,697	8	23,621,593
9	Prepaid expenses and deferred charges ............			23,408,845	9	24,863,725
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	1,034,046,352
b	Less: accumulated depreciation. .....	10b	528,126,142	574,654,482	10c	505,920,210
11	Investments—publicly traded securities ..........			0	11	0
12	Investments—other securities. See Part IV, line 11 ......			0	12	0
13	Investments—program-related. See Part IV, line 11 ..			0	13	0
14	Intangible assets .........			0	14	0
15	Other assets. See Part IV, line 11 ...........			27,278,437	15	29,158,202
16	Total assets. Add lines 1 through 15 (must equal line 34)...			850,791,814	16	796,734,905
17	Accounts payable and accrued expenses .			84,431,743	17	76,670,085
18	Grants payable ..........			0	18	0
19	Deferred revenue ..........			0	19	0
20	Tax-exempt bond liabilities ..........			0	20	0
21	Escrow or custodial account liability. Complete Part IV of Schedule D..			0	21	0
22	Payables to current and former officers, directors, trustees, key employees, highest compensated employees, and disqualified
	persons. Complete Part II of Schedule L..........			0	22	0
23	Secured mortgages and notes payable to unrelated third parties ..			0	23	0
24	Unsecured notes and loans payable to unrelated third parties ....			0	24	0
25	Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17-24). Complete Part X of Schedule D.....			141,723,111	25	154,118,283
26	Total liabilities. Add lines 17 through 25.....			226,154,854	26	230,788,368
	Organizations that follow SFAS 117, check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets .....			616,558,786	27	557,750,919
28	Temporarily restricted net assets .....			6,666,863	28	6,739,739
29	Permanently restricted net assets .....			1,411,309	29	1,455,879
	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 .....			624,636,958	33	565,946,537
34	Total liabilities and net assets/fund balances .....			850,791,814	34	796,734,905