TY 2012 Form 990

(A) Name and Title	(B) Average hours per week (list any hours for related organizations below dotted line)	(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)	(F) Estimated amount of other compensation from the organization and related organizations
(1) KOGER PROPST........................................................................ DIRECTOR, VICE CHAIR	2.0 .......................0.0	X			0	0	0
(2) FELIX W COOK SR........................................................................ DIRECTOR	2.0 .......................0.0	X			0	0	0
(3) BRUCE WARING MD........................................................................ DIRECTOR through 10/20/12	2.0 .......................0.0	X			0	0	0
(4) SISTER AMY WILLCOTT........................................................................ DIRECTOR	2.0 .......................0.0	X	X		0	0	0
(5) STEPHEN W COBB........................................................................ CHIEF MEDICAL OFFICER (EPN)	50.0 .......................0.0	X			0	272,196	60,439
(6) MICHAEL A SLUBOWSKI........................................................................ CHAIR,PRESIDENT AND CEO(SCLHS)	2.0 .......................50.0	X	X		0	1,513,703	36,584
(7) MARLA J WILLIAMS........................................................................ DIRECTOR	2.0 .......................0.0	X			0	0	0
(8) SALLY WOOLSEY........................................................................ DIRECTOR	2.0 .......................0.0	X			0	0	0
(9) LYDIA JUMONVILLE........................................................................ SVP FINANCE & CFO	50.0 .......................0.0	X	X		0	665,251	89,581
(10) RICK LOPES........................................................................ SVP Health Networks	50.0 .......................0.0	X			0	917,605	55,755
(11) TODD A CONKLIN........................................................................ SVP & CFO, TREASURER	25.0 .......................25.0		X		0	626,681	76,029
(12) BOB LADENBURGER........................................................................ PRESIDENT & CEO of EXEMPLA	25.0 .......................25.0		X		0	1,376,046	106,636
(13) DAVID HAMM........................................................................ PRESIDENT & CEO-EGSMC	50.0 .......................0.0			X	0	494,364	94,295
(14) ROBERT G BILLERBECK........................................................................ VP-CHIEF MEDICAL OFFICER	50.0 .......................0.0			X	0	357,486	61,013
(15) ELISA WETHERBEE........................................................................ CHIEF OPERATING OFFICER EPN	50.0 .......................0.0			X	0	305,534	56,790
(16) S ANN EVANS........................................................................ VP-CHIEF NURSING OFFICER(ELMC)	50.0 .......................0.0			X	195,861	0	5,322
(17) BETH C FORSYTH........................................................................ VP-CLIN & SUPPORT SVCS (EGSMC)	50.0 .......................0.0			X	0	271,869	50,387

(A) Name and business address	(B) Description of services	(C) Compensation
COLORADO DIAGNOSTIC LABS, PO BOX 840274DALLASTX75284	PROFESSIONAL SERVICE	4,488,752
MIDTOWN INPATIENT MEDICINE LLC, 1721 E 19TH AVE UNIT 366DENVERCO80218	PROFESSIONAL SERVICE	4,533,048
HL DAVISDAVIS A JOINT VENTURE, 1755 BLAKE ST SUITE 400DENVERCO80202	CONSTRUCTION DESIGN	12,849,427
WESTERN PARKING MAGEMENT, 682 S NILE WAYAURORACO80012	VALLEY SERVICES	2,906,546
HESKY-FISHER-LUKNIC COOK LLC, 7880 E 6TH AVEDENVERCO80230	PROFESSIONAL SERVICE	1,951,715
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 5

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	238,905	238,905
2	Grants and other assistance to individuals in the United States. See Part IV, line 22	465,195	465,195
3	Grants and other assistance to governments, organizations, and individuals outside the United States. See Part IV, lines 15 and 16	46,000	46,000
4	Benefits paid to or for members	0
5	Compensation of current officers, directors, trustees, and key employees ....	4,009,776	3,417,508	592,267
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	241,235,874	205,603,873	35,632,001
8	Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) ....	13,630,164	11,616,906	2,013,258
9	Other employee benefits .......	26,046,417	22,199,204	3,847,214
10	Payroll taxes ...........	16,199,058	13,806,358	2,392,699
11	Fees for services (non-employees):
a	Management ......	67,075,421	44,487,796	22,587,625
b	Legal .........	597,172		597,172
c	Accounting ...........	0
d	Lobbying ...........	15,235		15,235
e	Professional fundraising services. See Part IV, line 17	0
f	Investment management fees ......	0
g	Other (If line 11g amount exceeds 10% of line 25, column (A) amount, list line 11g expenses on Schedule O) ........	27,021,534	21,480,755	5,540,779
12	Advertising and promotion ....	1,732,761		1,732,761
13	Office expenses .......	8,677,069	5,426,987	3,250,082
14	Information technology ......	278,896	10,289	268,607
15	Royalties ..	0
16	Occupancy ...........	16,879,698	13,935,296	2,944,402
17	Travel ............	538,100	248,552	289,548
18	Payments of travel or entertainment expenses for any federal, state, or local public officials ......	0
19	Conferences, conventions, and meetings ....	701,954	507,910	194,044
20	Interest ...........	15,686,109		15,686,109
21	Payments to affiliates .......	0
22	Depreciation, depletion, and amortization .....	42,929,896	33,676,005	9,253,891
23	Insurance ..............	2,522,504	337,670	2,184,835
24	Other expenses. Itemize expenses not covered above (List miscellaneous expenses in line 24e. If line 24e amount exceeds 10% of line 25, column (A) amount, list line 24e expenses on Schedule O.)
a	MEDICAL SUPPLIES	93,703,749	93,544,509	159,240
b	BAD DEBTS	20,800,106	20,800,106
c	EQUIP RENTAL & MAINTENANCE	2,496,286	2,416,474	79,811
d	MEDICAID PROVIDER FEE	41,167,124	41,167,124
e	All other expenses	9,714,639	8,152,648	1,561,991
25	Total functional expenses. Add lines 1 through 24e	654,409,641	543,586,070	110,823,571	0
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 Check if Schedule O contains a response to any question in this Part X ...............
	1	Cashnon-interest-bearing .............	36,838,938	1	37,123,179
2	Savings and temporary cash investments .........	20,000,007	2	7
3	Pledges and grants receivable, net ...........	0	3	0
4	Accounts receivable, net .............	78,956,055	4	77,582,388
5	Loans and other receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of Schedule L ..................
		0	5	0
6	Loans and other receivables from other disqualified persons (as defined under section 4958(f)(1)), persons described in section 4958(c)(3)(B), and contributing employers and sponsoring organizations of section 501(c)(9) voluntary employees' beneficiary organizations (see instructions) Complete Part II of Schedule L
		0	6	0
7	Notes and loans receivable, net .............	15,755,574	7	18,619,696
8	Inventories for sale or use ..............	9,877,289	8	11,170,590
9	Prepaid expenses and deferred charges ..........	6,209,225	9	4,885,023
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	1,033,339,025
b	Less: accumulated depreciation .....	10b	550,394,462	518,658,820	10c	482,944,563
11	Investments—publicly traded securities ..........	235,899,311	11	319,620,389
12	Investments—other securities. See Part IV, line 11 .....	639,339	12	1,457,558
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 ...........	2,947,749	15	2,947,749
16	Total assets. Add lines 1 through 15 (must equal line 34)......	925,782,307	16	956,351,142
	17	Accounts payable and accrued expenses .........	85,436,196	17	76,973,827
18	Grants payable .................	0	18	0
19	Deferred revenue ................	1,203,012	19	943,340
20	Tax-exempt bond liabilities .............	1,601,494	20	1,601,494
21	Escrow or custodial account liability. Complete Part IV of Schedule D..	0	21	0
22	Loans and other 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 ....	21,077,752	24	19,594,147
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....................	412,213,092	25	415,223,168
26	Total liabilities. Add lines 17 through 25.........	521,531,546	26	514,335,976
		Organizations that follow SFAS 117 (ASC 958), check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets ..............	404,184,776	27	441,936,645
28	Temporarily restricted net assets ...........	65,985	28	78,521
29	Permanently restricted net assets ...........	0	29	0
	Organizations that do not follow SFAS 117 (ASC 958), 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 ...........	404,250,761	33	442,015,166
34	Total liabilities and net assets/fund balances ........	925,782,307	34	956,351,142

- 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

2012

Open to Public
Inspection

Name of the organization

EXEMPLA INC FKA LUTHERAN HOSPITAL

Employer identification number

84-1103606

Part I

Reason for Public Charity Status (All organizations must complete this part.) See instructions.

The organization is not a private foundation because it is: (For lines 1 through 11, check only one box.)

A church, convention of churches, or association of churches described in 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. See section 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 - Non-functionally integrated

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


Total

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

Cat. No. 11285F

Schedule A (Form 990 or 990-EZ) 2012

Page 2

Part II

Support Schedule for Organizations Described in Sections 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) 2008	(b) 2009	(c) 2010	(d) 2011	(e) 2012	(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) 2008	(b) 2009	(c) 2010	(d) 2011	(e) 2012	(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. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)..
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 2012 (line 6, column (f) divided by line 11, column (f)) .........

Public support percentage for 2011 Schedule A, Part II, line 14 ...............

16a

33 1/3% support test—2012. 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—2011. If the organization did not check a 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—2012. 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—2011. 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) 2012

Page 3

Part III

Support Schedule for Organizations Described in Section 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) 2008	(b) 2009	(c) 2010	(d) 2011	(e) 2012	(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) 2008	(b) 2009	(c) 2010	(d) 2011	(e) 2012	(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.)..

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 2012 (line 8, column (f) divided by line 13, column (f)) .........

Public support percentage from 2011 Schedule A, Part III, line 15 ...............

Section D. Computation of Investment Income Percentage

Investment income percentage for 2012 (line 10c, column (f) divided by line 13, column (f)) ......

Investment income percentage from 2011 Schedule A, Part III, line 17 .............

19a

33 1/3% support tests—2012. 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—2011. 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) 2012

Page 4

Part IV

Supplemental Information. Complete this part to provide the explanations required by Part II, line 10; Part II, line 17a or 17b; and 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) 2012

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

2012

Name of the organization

EXEMPLA INC FKA LUTHERAN HOSPITAL

Employer identification number

84-1103606

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) (2012)

Schedule B (Form 990, 990-EZ, or 990-PF) (2012)

Page 2

Name of organization EXEMPLA INC FKA LUTHERAN HOSPITAL

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) (2012)

Schedule B (Form 990, 990-EZ, or 990-PF) (2012)

Page 3

Name of organization EXEMPLA INC FKA LUTHERAN HOSPITAL

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) (2012)

Schedule B (Form 990, 990-EZ, or 990-PF) (2012)

Page 4

Name of organization
EXEMPLA INC FKA LUTHERAN HOSPITAL

Employer identification number

84-1103606

Part III

Exclusively religious, charitable, etc., individual contributions to section 501(c)(7), (8), or (10) organizations
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) (2012)

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE C
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service

Political Campaign and Lobbying Activities

For Organizations Exempt From Income Tax Under section 501(c) and section 527
SchCMd Bullet

Complete if the organization is described below. SchCMd Bullet

Attach to Form 990 or Form 990-EZ.
SchCMd Bullet

See separate instructions.

OMB No. 1545-0047

2012

Open to Public
Inspection

If the organization answered “Yes” to Form 990, Part IV, Line 3, or Form 990-EZ, Part V, line 46 (Political Campaign Activities), then
Round Bullet

Section 501(c)(3) organizations: Complete Parts I-A and B. Do not complete Part I-C.
Round Bullet

Section 501(c) (other than section 501(c)(3)) organizations: Complete Parts I-A and C below. Do not complete Part I-B.
Round Bullet

Section 527 organizations: Complete Part I-A only.
If the organization answered “Yes” to Form 990, Part IV, Line 4, or Form 990-EZ, Part VI, line 47 (Lobbying Activities), then
Round Bullet

Section 501(c)(3) organizations that have filed Form 5768 (election under section 501(h)): Complete Part II-A. Do not complete Part II-B.
Round Bullet

Section 501(c)(3) organizations that have NOT filed Form 5768 (election under section 501(h)): Complete Part II-B. Do not complete Part II-A.
If the organization answered “Yes” to Form 990, Part IV, Line 5 (Proxy Tax) or Form 990-EZ, Part V, line 35c (Proxy Tax), then
Round Bullet

Section 501(c)(4), (5), or (6) organizations: Complete Part III.

Name of the organization

EXEMPLA INC FKA LUTHERAN HOSPITAL

Employer identification number

84-1103606

Part I-A

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

Provide a description of the organization’s direct and indirect political campaign activities in Part IV.

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

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

Part I-B

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

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

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

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

Yes No

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

Yes No

If "Yes," describe in Part IV.

Part I-C

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

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

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

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

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

Yes No

Enter the names, addresses and employer identification number (EIN) of all section 527 political organizations to which the filing
organization made payments. For each organization listed, enter the amount paid from the filing organization’s funds. Also enter the amount of political contributions received that were promptly and directly delivered to a separate political organization, such as a separate segregated fund or a political action committee (PAC). If additional space is needed, provide information in Part IV.

(a) Name	(b) Address	(c) EIN	(d) Amount paid from filing organization's funds. If none, enter -0-.	(e) Amount of political contributions received and promptly and directly delivered to a separate political organization. If none, enter -0-.

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

Cat. No. 50084S

Schedule C (Form 990 or 990-EZ) 2012

Page 2

Part II-A

Complete if the organization is exempt under section 501(c)(3) and filed Form 5768 (election under section 501(h)).

A Check SchCMd Bullet

if the filing organization belongs to an affiliated group (and list in Part IV each affiliated group member's name, address, EIN, expenses, and share of excess lobbying expenditures).
B Check SchCMd Bullet

if the filing organization checked box A and "limited control" provisions apply.

Limits on Lobbying Expenditures (The term "expenditures" means amounts paid or incurred.)		(b) Affiliated group totals
1a	Total lobbying expenditures to influence public opinion (grass roots lobbying) ......
b	Total lobbying expenditures to influence a legislative body (direct lobbying) .......
c	Total lobbying expenditures (add lines 1a and 1b) ...................
d	Other exempt purpose expenditures ........................
e	Total exempt purpose expenditures (add lines 1c and 1d) ...............
f	Lobbying nontaxable amount. Enter the amount from the following table in both columns.
	If the amount on line 1e, column (a) or (b) is:The lobbying nontaxable amount is:
	Not over $500,00020% of the amount on line 1e.
	Over $500,000 but not over $1,000,000$100,000 plus 15% of the excess over $500,000.
	Over $1,000,000 but not over $1,500,000$175,000 plus 10% of the excess over $1,000,000.
	Over $1,500,000 but not over $17,000,000$225,000 plus 5% of the excess over $1,500,000.
	Over $17,000,000$1,000,000.

g	Grassroots nontaxable amount (enter 25% of line 1f) .................
h	Subtract line 1g from line 1a. If zero or less, enter -0-. ................
i	Subtract line 1f from line 1c. If zero or less, enter -0-. ................
j	If there is an amount other than zero on either line 1h or line 1i, did the organization file Form 4720 reporting section 4911 tax for this year? ......................................	Yes No

4-Year Averaging Period Under Section 501(h) (Some organizations that made a section 501(h) election do not have to complete all of the five columns below. See the instructions for lines 2a through 2f on page 4.)
Lobbying Expenditures During 4-Year Averaging Period
	Calendar year (or fiscal year beginning in)	(a) 2009	(b) 2010	(c) 2011	(d) 2012	(e) Total

2a	Lobbying nontaxable amount

b	Lobbying ceiling amount (150% of line 2a, column(e))

c	Total lobbying expenditures

d	Grassroots nontaxable amount

e	Grassroots ceiling amount (150% of line 2d, column (e))

f	Grassroots lobbying expenditures

Schedule C (Form 990 or 990-EZ) 2012

Page 3

Part II-B

Complete if the organization is exempt under section 501(c)(3) and has NOT filed Form 5768 (election under section 501(h)).

For each “Yes” response to lines 1a through 1i below, provide in Part IV a detailed description of the lobbying activity.

(a)

Yes

(b)

Amount

During the year, did the filing organization attempt to influence foreign, national, state or local legislation, including any attempt to influence public opinion on a legislative matter or referendum, through the use of:

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

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

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

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

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

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

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

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

Other activities? ..........................

Yes

15,235

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

15,235

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

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

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

If the filing organization incurred a section 4912 tax, did it file Form 4720 for this year? .......

Part III-A

Complete if the organization is exempt under section 501(c)(4), section 501(c)(5), or section 501(c)(6).

Yes

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

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

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

Part III-B

Complete if the organization is exempt under section 501(c)(4), section 501(c)(5), or section 501(c)(6) and if either (a) BOTH Part III-A, lines 1 and 2, are answered “No” OR (b) Part III-A, line 3, is answered “Yes."

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

Section 162(e) nondeductible lobbying and political expenditures (do not include amounts of political
expenses for which the section 527(f) tax was paid).

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

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

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

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

If notices were sent and the amount on line 2c exceeds the amount on line 3, what portion of the excess does the organization agree to carryover to the reasonable estimate of nondeductible lobbying and political expenditure next year? ................................

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

Part IV

Supplemental Information

Complete this part to provide the descriptions required for Part l-A, line 1; Part l-B, line 4; Part l-C, line 5; Part II-A (affiliated group list); Part II-A, line 2; and Part ll-B, line 1. Also, complete this part for any additional information.

Identifier	Return Reference	Explanation
LOBBYING EXPENDITURES	SCHEDULE C, PART II-B, QUESTION 1I	$15,235 OF OTHER LOBBYING EXPENDITURES INCLUDES PORTIONS OF VARIOUS MEMBERSHIP DUES THAT ARE DESIGNATED AS LOBBYING EXPENSE BY THOSE ORGANIZATIONS IN WHICH EXEMPLA OR EXEMPLA ENTITIES ARE MEMBERS.

Schedule C (Form 990 or 990EZ) 2012

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

2012

Open to Public Inspection

Name of the organization

EXEMPLA INC FKA LUTHERAN HOSPITAL

Employer identification number

84-1103606

Part I

Organizations Maintaining Donor Advised Funds or Other Similar Funds or Accounts. Complete if the organization answered "Yes" to Form 990, Part IV, line 6.

		(a) Donor advised funds	(b) Funds and other accounts
1	Total number at end of year .........
2	Aggregate contributions to (during year) ...
3	Aggregate grants from (during year) .....
4	Aggregate value at end of year ........

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 section 170(h)(4)(B)(ii)? .......................................

Yes No

In Part XIII, 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 XIII, 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 Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 52283D

Schedule D (Form 990) 2012

Page 2

Part III

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

Using the organization’s acquisition, 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 XIII.

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 XIII 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 XIII. Check here if the explanation has been provided in Part XIII ........

Part V

Endowment Funds. Complete if the organization answered "Yes" to Form 990, Part IV, line 10.

		(a)Current year	(b)Prior year	b (c)Two years back	(d)Three years back	(e)Four years back
1a	Beginning of year balance ....
b	Contributions ........
c	Net investment earnings, gains, and losses
d	Grants or scholarships .....
e	Other expenditures for facilities and programs ........
f	Administrative expenses ....
g	End of year balance ......

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

Board designated or quasi-endowment SchDMd Bullet

Permanent endowment SchDMd Bullet

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)

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

3a(ii)

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

Describe in Part XIII 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		(a) Cost or other basis (investment)	(b)Cost or other basis (other)	(c) Accumulated depreciation	(d) Book value
1a	Land .................	0	25,464,714		25,464,714
b	Buildings ................	0	567,500,014	233,395,140	334,104,874
c	Leasehold improvements ............	0	39,320,329	23,146,568	16,173,761
d	Equipment ................	0	390,647,076	293,572,618	97,074,458
e	Other .................	0	10,406,892	280,136	10,126,756
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).).......					482,944,563

Schedule D (Form 990) 2012

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 3RD PARTY PAYORS		3,745,503
ACCRUED INTEREST PAYABLE		8,169,254
OTHER CURRENT LIABILITIES		26,401
MALPRACTICE LIABILITY		11,217,265
OTHER LIABILITIES		2,503,717
PENSION LIABILITIES		24,073,020
NOTE PAYABLE TO ESJH		60,000,000
NOTES PAYABLE TO SCLHS		264,244,732
ACCRUED INTEREST PAYABLE TO SC		13,782,878
ACCRUED INTEREST PAYABLE TO ES		27,460,398
Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)		415,223,168
2. Fin 48 (ASC 740) Footnote. In Part XIII, 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 (ASC 740). Check here if the text of the footnote has been provided in Part XIII .....................................................

Schedule D (Form 990) 2012

Page 4

Part XI 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 XIII.) ............	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 XIII.) ...........	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 XII 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 XIII.) ............	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 XIII.) ............	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 XIII

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, line 2; Part XI, lines 2d and 4b; and Part XII, lines 2d and 4b. Also complete this part to provide any additional information.

Identifier	Return Reference	Explanation

Schedule D (Form 990) 2012

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE F(Form 990)

Department of the Treasury
Internal Revenue Service

Statement of Activities Outside the United States

Complete if the organization answered "Yes" to Form 990,Part IV, line 14b, 15, or 16. Right pointing arrow large image

Attach to Form 990. Right pointing arrow large image

See separate instructions.

OMB No. 1545-0047

2012

Open to Public Inspection

Name of the organization
EXEMPLA INC FKA LUTHERAN HOSPITAL

Employer identification number

84-1103606

Part I

General Information on Activities Outside the United States. Complete if the organization answered “Yes” to Form 990, Part IV, line 14b.

For grantmakers. Does the organization maintain records to substantiate the amount of the grants or

assistance, the grantees’ eligibility for the grants or assistance, and the selection criteria used to award

the grants or assistance? ...................................

Yes

For grantmakers. Describe in Part V the organization’s procedures for monitoring the use of grant funds outside
the United States.

Activites per Region. (The following Part I, line 3 table can be duplicated if additional space is needed.)

(a) Region		(d) Activities conducted in region (by type) (e.g., fundraising, program services, investments, grants to recipients located in the region)	(e) If activity listed in (d) is a program service, describe specific type of service(s) in region	(f) Total expenditures for and investments in region
	Sub-Saharan Africa	Program Services	HOSPITAL	46,000
















3a	Sub-total .....			46,000
b	Total from continuation sheets to Part I ...
c	Totals (add lines 3a and 3b)			46,000

For Paperwork Reduction Act Notice, see the Instructions for Form 990.Cat. No. 50082W Schedule F (Form 990) 2012

Schedule F (Form 990) 2012

Page 2

Part II

Grants and Other Assistance to Organizations or Entities Outside the United States. Complete if the organization answered “Yes” to Form 990, Part IV, line 15, for any recipient who received more than $5,000. Part II can be duplicated if additional space is needed.

(c) Region	(d) Purpose of grant	(e) Amount of cash grant	(f) Manner of cash disbursement
Sub-Saharan Africa	SUPPORT ARUSHA LUTHERAN MEDICAL CENTRE	46,000	WIRE TRANS

Enter total number of recipient organizations listed above that are recognized as charities by the foreign country, recognized as tax-exempt by the IRS, or for which the grantee or counsel has provided a section 501(c)(3) equivalency letter .... MediumBullet

Enter total number of other organizations or entities ....................... MediumBullet

Schedule F (Form 990) 2012

Schedule F (Form 990) 2012Page 3

Part III

Grants and Other Assistance to Individuals Outside the United States. Complete if the organization answered "Yes" to Form 990, Part IV, line 16.

Part III can be duplicated if additional space is needed.

(a) Type of grant or assistance		(b) Region	(c) Number of recipients	(d) Amount of cash grant	(e) Manner of cash disbursement	(f) Amount of non-cash assistance	(g) Description of non-cash assistance	(h) Method of valuation (book, FMV, appraisal, other)

Schedule F (Form 990) 2012

Page 4

Part IV

Foreign Forms

Schedule F (Form 990) 2012

Page 5

Part V

Supplemental Information
Complete this part to provide the information required by Part I, line 2 (monitoring of funds); Part I, line 3, column (f) (accounting method; amounts of investments vs. expenditures per region); Part II, line 1 (accounting method); Part III (accounting method); and Part III, column (c) (estimated number of recipients), as applicable. Also complete this part to provide any additional information (see instructions).

Identifier	ReturnReference	Explanation
MONITORING OF FUNDS	PART I, LINE 2	EXEMPLA PROVIDES ASSISTANCE TO ONLY ONE ORGANIZATION OUTSIDE THE U.S. EXEMPLA OBTAINED AN INITIAL NEEDS ASSESSMENT REPORT FROM THE ORGANIZATION, WHICH ALSO OUTLINED THE COMMITMENT OF EXEMPLA TO PROVIDE SUPPORT TO THE ORGANIZATION BASED ON AN INITIAL SITE VISIT. EXEMPLA MAINTAINS REGULAR CONTACT WITH THE ORGANIZATION, SENDS A TEAM OF CLINICIANS FOR SITE VISITS TO THE ORGANIZATION EVERY YEAR AND RECEIVES AND REVIEWS THE ORGANIZATION'S ANNUAL REPORT.

Schedule F (Form 990) 2012

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

2012

Open to Public Inspection

Name of the organization

EXEMPLA INC FKA LUTHERAN HOSPITAL

Employer identification number

84-1103606

Part I

Financial Assistance 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) as a factor in determining 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 as a factor in determining 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 %

If the organization used factors other than FPG in determining 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, as a factor in determining 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? ..............

Yes

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

Financial Assistance and Means-Tested Government Programs		(a) Number of activities or programs (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) ..	1	15,535,893		15,535,893	2.500 %
b	Medicaid (from Worksheet 3, column a) ....	1	42,804,409	22,925,449	19,878,960	3.100 %
c	Costs of other means-tested government programs (from Worksheet 3, column b) .
d	Total Financial Assistance and Means-Tested Government Programs .	2	58,340,302	22,925,449	35,414,853	5.600 %
Other Benefits		15	443,771		443,771	0.100 %
e	Community health improvement services and community benefit operations (from Worksheet 4) ..	15	443,771		443,771	0.100 %
f	Health professions education (from Worksheet 5) ..	8	1,815,900		1,815,900	0.300 %
g	Subsidized health services (from Worksheet 6) ..	17	8,317,499		8,317,499	1.300 %
h	Research (from Worksheet 7)	1	85,216		85,216
i	Cash and in-kind contributions for community benefit (from Worksheet 8)	24	1,453,763		1,453,763	0.200 %
j	Total. Other Benefits ..	65	12,116,149		12,116,149	1.900 %
k	Total. Add lines 7d and 7j .	67	70,456,451	22,925,449	47,531,002	7.500 %

For Paperwork Reduction Act Notice, see the Instructions for Form 990. Cat. No. 50192T Schedule H (Form 990) 2012

Schedule H (Form 990) 2012

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)	(c) Total community building expense	(e) Net community building expense
1	Physical improvements and housing
2	Economic development	5	7,908	7,908
3	Community support	1	14,332	14,332
4	Environmental improvements
5	Leadership development and training for community members
6	Coalition building
7	Community health improvement advocacy
8	Workforce development	1	406	406
9	Other
10	Total	7	22,646	22,646

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. Explain in Part VI the methodology used by the organization to estimate this amount. ......

9,244,694

Enter the estimated amount of the organization's bad debt expense attributable to patients eligible under the organization's financial assistance policy. Explain in Part VI the methodology used by the organization to estimate this amount and the rationale, if any, for including this portion of bad debt as community benefit. ......

1,153,000

Provide in Part VI the text of the footnote to the organization’s financial statements that describes bad debt expense or the page number on which this footnote is contained in the attached financial statements.

Section B. Medicare

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

59,424,470

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

66,759,719

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

-7,335,249

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(owned 10% or more by officers, directors, trustees, key employees, and physicians—see instructions)

(a) Name of entity	(b) Description of primary activity of entity	(c) Organization's profit % or stock ownership %	(e) Physicians' profit % or stock ownership %
1Lutheran ASC LLC	Outpatient Surgery	52.320 %	47.680 %
2
3
4
5
6
7
8
9
10
11
12
13

Schedule H (Form 990) 2012

Page

Part VFacility Information

Section A. Hospital Facilities (list in order of size from largest to smallest—see instructions) How many hospital facilities did the organization operate during the tax year?2 Name, address, and primary website address
1	Exempla Lutheran Medical Center 8300 W 38th Ave Wheat Ridge,CO80211	X
2	Exempla Good Samaritan Medical Center 200 Exempla Circle Lafayette,CO80026	X

Schedule H (Form 990) 2012

Page

Part VFacility Information (continued)

Section B. Facility Policies and Practices

(Complete a separate Section B for each of the hospital facilities or facility reporting groups listed in Part V, Section A)

	Exempla Lutheran Medical Center
Name of hospital facility or facility reporting group

For single facility filers only: line Number of Hospital Facility (from Schedule H, Part V, Section A)

Yes

Community Health Needs Assessment (Lines 1 through 8c are optional for tax years begining on or before March 23, 2012)

During the tax year or either of the two immediately preceding tax years, did the hospital facility conduct a community health needs assessment (CHNA)? If "No," skip to line 9....................

If “Yes,” indicate what the CHNA report describes (check all that apply):

A definition of the community served by the hospital facility

Demographics of the community

Existing health care facilities and resources within the community that are available to respond to the health needs of the community

How data was obtained

The health needs of the community

Primary and chronic disease needs and other health issues of uninsured persons, low-income persons, and minority groups

The process for identifying and prioritizing community health needs and services to meet the community health needs

The process for consulting with persons representing the community’s interests

Information gaps that limit the hospital facility’s ability to assess the community’s health needs

Other (describe in Part VI)

Indicate the tax year the hospital facility last conducted a CHNA: 20

In conducting its most recent CHNA, did the hospital facility take into account input from representatives of the community served by the hospital facility, including those with special knowledge of or expertise in public health? 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 ....................

Was the hospital facility’s CHNA conducted with one or more other hospital facilities? If “Yes,” list the other hospital facilities in Part VI................................

Did the hospital facility make its CHNA report widely available to the public? .............

If “Yes,” indicate how the CHNA report was made widely available (check all that apply):

Hospital facility’s website

Available upon request from the hospital facility

Other (describe in Part VI)

If the hospital facility addressed needs identified in its most recently conducted CHNA, indicate how (check all that apply to date):

Adoption of an implementation strategy that addresses each of the community health needs identified through the CHNA

Execution of the implementation strategy

Participation in the development of a community-wide plan

Participation in the execution of a community-wide plan

Inclusion of a community benefit section in operational plans

Adoption of a budget for provision of services that address the needs identified in the CHNA

Prioritization of health needs in its community

Prioritization of services that the hospital facility will undertake to meet health needs in its community

Other (describe in Part VI)

Did the hospital facility address all of the needs identified in its most recently conducted CHNA? If “No,” explain in Part VI which needs it has not addressed and the reasons why it has not addressed such needs ........

Did the organization incur an excise tax under section 4959 for the hospital facility's failure to conduct a CHNA as required by section 501(r)(3)? ...........................

If "Yes" to line 8a, did the organization file Form 4720 to report the section 4959 excise tax? ......

If "Yes" to line 8b, what is the total amount of section 4959 excise tax the organization reported on Form 4720 for all of its hospital facilities? $

Schedule H (Form 990) 2012

Page

Part VFacility Information (continued)

Financial Assistance Policy			Yes	No
9	Did the hospital facility have in place during the tax year a written financial assistance policy that:
	Explained eligibility criteria for financial assistance, and whether such assistance includes free or discounted care?	9	Yes
10	Used federal poverty guidelines (FPG) to determine eligibility for providing free care?...........	10	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.
11	Used FPG to determine eligibility for providing discounted care?.................	11	Yes
	If “Yes,” indicate the FPG family income limit for eligibility for discounted care: 400.% If "No," explain in Part VI the criteria the hospital facility used.
12	Explained the basis for calculating amounts charged to patients?.................	12	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)
13	Explained the method for applying for financial assistance?...................	13	Yes
14	Included measures to publicize the policy within the community served by the hospital facility?.......	14	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 website
b	The policy was attached to 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 on admission to the hospital facility
f	The policy was available upon request
g	Other (describe in Part VI)
Billing and Collections
15	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?.......	15	Yes
16	Check all of the following 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)
17	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?..........	17		No
	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)

Schedule H (Form 990) 2012

Page

Part VFacility Information (continued)

Indicate which efforts the hospital facility made before initiating any of the actions listed in line 17 (check all that apply):

Notified individuals of the financial assistance policy on admission

Notified individuals of the financial assistance policy prior to discharge

Notified individuals of the financial assistance policy in communications with the patients regarding the patients’ bills

Documented its determination of whether patients were eligible for financial assistance under the hospital facility’s financial assistance policy

Other (describe in Part VI)

Policy Relating to Emergency Medical Care

Yes

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?..........

Yes

If “No,” indicate why:

The hospital facility did not provide care for any emergency medical conditions

The hospital facility’s policy was not in writing

The hospital facility limited who was eligible to receive care for emergency medical conditions (describe in Part VI)

Other (describe in Part VI)

Charges to Individuals Eligible for Assistance under the FAP (FAP-Eligible Individuals)

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.

The hospital facility used its lowest negotiated commercial insurance rate when calculating the maximum amounts that can be charged

The hospital facility used the average of its three lowest negotiated commercial insurance rates when calculating the maximum amounts that can be charged

The hospital facility used the Medicare rates when calculating the maximum amounts that can be charged

Other (describe in Part VI)

During the tax year, did the hospital facility charge any FAP-eligible individuals 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? ............................

If “Yes,” explain in Part VI.

During the tax year, did the hospital facility charge any FAP-eligible individuals an amount equal to the gross charge for any service provided to that individual? .........................

If “Yes,” explain in Part VI.

Schedule H (Form 990) 2012

Page

Part VFacility Information (continued)

Section B. Facility Policies and Practices

(Complete a separate Section B for each of the hospital facilities or facility reporting groups listed in Part V, Section A)

	Exempla Good Samaritan Medical Center
Name of hospital facility or facility reporting group

For single facility filers only: line Number of Hospital Facility (from Schedule H, Part V, Section A)

Yes

Community Health Needs Assessment (Lines 1 through 8c are optional for tax years begining on or before March 23, 2012)

During the tax year or either of the two immediately preceding tax years, did the hospital facility conduct a community health needs assessment (CHNA)? If "No," skip to line 9....................

If “Yes,” indicate what the CHNA report describes (check all that apply):

A definition of the community served by the hospital facility

Demographics of the community

Existing health care facilities and resources within the community that are available to respond to the health needs of the community

How data was obtained

The health needs of the community

Primary and chronic disease needs and other health issues of uninsured persons, low-income persons, and minority groups

The process for identifying and prioritizing community health needs and services to meet the community health needs

The process for consulting with persons representing the community’s interests

Information gaps that limit the hospital facility’s ability to assess the community’s health needs

Other (describe in Part VI)

Indicate the tax year the hospital facility last conducted a CHNA: 20

Was the hospital facility’s CHNA conducted with one or more other hospital facilities? If “Yes,” list the other hospital facilities in Part VI................................

Did the hospital facility make its CHNA report widely available to the public? .............

If “Yes,” indicate how the CHNA report was made widely available (check all that apply):

Hospital facility’s website

Available upon request from the hospital facility

Other (describe in Part VI)

If the hospital facility addressed needs identified in its most recently conducted CHNA, indicate how (check all that apply to date):

Adoption of an implementation strategy that addresses each of the community health needs identified through the CHNA

Execution of the implementation strategy

Participation in the development of a community-wide plan

Participation in the execution of a community-wide plan

Inclusion of a community benefit section in operational plans

Adoption of a budget for provision of services that address the needs identified in the CHNA

Prioritization of health needs in its community

Prioritization of services that the hospital facility will undertake to meet health needs in its community

Other (describe in Part VI)

Did the organization incur an excise tax under section 4959 for the hospital facility's failure to conduct a CHNA as required by section 501(r)(3)? ...........................

If "Yes" to line 8a, did the organization file Form 4720 to report the section 4959 excise tax? ......

If "Yes" to line 8b, what is the total amount of section 4959 excise tax the organization reported on Form 4720 for all of its hospital facilities? $

Schedule H (Form 990) 2012

Page

Part VFacility Information (continued)

Financial Assistance Policy			Yes	No
9	Did the hospital facility have in place during the tax year a written financial assistance policy that:
	Explained eligibility criteria for financial assistance, and whether such assistance includes free or discounted care?	9	Yes
10	Used federal poverty guidelines (FPG) to determine eligibility for providing free care?...........	10	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.
11	Used FPG to determine eligibility for providing discounted care?.................	11	Yes
	If “Yes,” indicate the FPG family income limit for eligibility for discounted care: 400.% If "No," explain in Part VI the criteria the hospital facility used.
12	Explained the basis for calculating amounts charged to patients?.................	12	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)
13	Explained the method for applying for financial assistance?...................	13	Yes
14	Included measures to publicize the policy within the community served by the hospital facility?.......	14	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 website
b	The policy was attached to 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 on admission to the hospital facility
f	The policy was available upon request
g	Other (describe in Part VI)
Billing and Collections
15	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?.......	15	Yes
16	Check all of the following 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)
17	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?..........	17		No
	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)

Schedule H (Form 990) 2012

Page

Part VFacility Information (continued)

Indicate which efforts the hospital facility made before initiating any of the actions listed in line 17 (check all that apply):

Notified individuals of the financial assistance policy on admission

Notified individuals of the financial assistance policy prior to discharge

Notified individuals of the financial assistance policy in communications with the patients regarding the patients’ bills

Documented its determination of whether patients were eligible for financial assistance under the hospital facility’s financial assistance policy

Other (describe in Part VI)

Policy Relating to Emergency Medical Care

Yes

If “No,” indicate why:

The hospital facility did not provide care for any emergency medical conditions

The hospital facility’s policy was not in writing

The hospital facility limited who was eligible to receive care for emergency medical conditions (describe in Part VI)

Other (describe in Part VI)

Charges to Individuals Eligible for Assistance under the FAP (FAP-Eligible Individuals)

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.

The hospital facility used its lowest negotiated commercial insurance rate when calculating the maximum amounts that can be charged

The hospital facility used the average of its three lowest negotiated commercial insurance rates when calculating the maximum amounts that can be charged

The hospital facility used the Medicare rates when calculating the maximum amounts that can be charged

Other (describe in Part VI)

If “Yes,” explain in Part VI.

During the tax year, did the hospital facility charge any FAP-eligible individuals an amount equal to the gross charge for any service provided to that individual? .........................

If “Yes,” explain in Part VI.

Schedule H (Form 990) 2012

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?48
Name and address		Type of Facility (describe)
1	EXEMPLA COLORADO LUTHERAN HOME 7991 W 71st AVE ARVADA,CO80004	NURSING HOME
2	EXEMPLA LUTHERAN HOSPICE AT COLLIER HOSP 3210 LUTHERAN PARKWAY WHEAT RIDGE,CO80033	HOSPICE
3	LUTHERAN CAMPUS ASC 3455 LUTHERAN PKWY 150 WHEAT RIDGE,CO80033	AMBULATORY SURGERY CENTER
4	EXEMPLA THORNTON MEDICAL CENTER 3814 EAST 120TH AVENUE DENVER,CO80033	PHYSICIAN CLINIC
5	EXEMPLA DENVER MEDICAL ASSOCIATES 1960 OGDEN ST Suite 120 DENVER,CO80218	PHYSICIAN CLINIC
6	EXEMPLA FAMILY PRACTICE SPECIALISTS 3550 LUTEHRAN PARKWAY G-20 WHEAT RIDGE,CO80033	PHYSICIAN CLINIC
7	EXEMPLA FAMILY PEDIATRIC & INTERNAL MED 2600 CAMPUS DRIVE SUITE A LAFAYETTE,CO80026	PHYSICIAN CLINIC
8	EXEMPLA NW FAMILY & OCC MED & PHYS THER 12169 Sheridan BLVD Broomfield,CO80020	PHYSICIAN CLINIC
9	EXEMPLA GREEN MT FAM & OCC MED & PHYS TH 12790-A WEST ALAMEDA PARKWAY LAKEWOOD,CO80228	PHYSICIAN CLINIC
10	EXEMPLA COLORADO LUTHERAN APARTMENTS 8001 W 71ST AVE ARVADA,CO80004	ASSISTED LIVING RESIDENCE
11	EXEMPLA LUTHERAN MEDICAL CENTER TCU 8300 W 38TH AVE WHEAT RIDGE,CO80033	NURSING HOME
12	EXEMPLA LUTHERAN SOUTHWEST URGENT CARE 13402 WEST COAL MINE AVE SUITE 110 LITTLETON,CO80127	PHYSICIAN CLINIC
13	EXEMPLA WELLMORE FAMILY PRACTICE 7777 WEST 38TH AVE SUITE A-118 WHEAT RIDGE,CO80033	PHYSICIAN CLINIC
14	EXEMPLA WHEAT RIDGE OCC MED & PHYS THER 9830 I-70 FRONTAGE ROAD SOUTH WHEAT RIDGE,CO80033	PHYSICIAN CLINIC
15	EXEMPLA BLUESTONE ADVANCED SURGICAL CARE 300 EXEMPLA CIRCLE SUITE 360 LAFAYETTE,CO80026	PHYSICIAN CLINIC
16	EXEMPLA COLORADO PINNACLE ORTHO ASSOC 3455 LUTHERAN PARKWAY SUITE 210 WHEAT RIDGE,CO80033	PHYSICIAN CLINIC
17	EXEMPLA DENVER NEURO SURGERY & SPINE 1960 OGDEN ST SUITE 530 DENVER,CO80218	PHYSICIAN CLINIC
18	EXEMPLA MT STATES UROGYNECOLOGY - ESJH 1960 OGDEN ST SUITE 520 DENVER,CO80205	PHYSICIAN CLINIC
19	EXEMPLA LARKRIDGE FAMILY & OCC MED & PT 16570 WASHINGTON STREET THORNTON,CO80023	PHYSICIAN CLINIC
20	EXEMPLA STAPLETON FAMILY & OCC MED 2803 ROSLYN STREET DENVER,CO80238	PHYSICIAN CLINIC
21	EXEMPLA DIABETES & ENDOCRINE SERVICES 3555 LUTHERAN PARKWAY SUITE 180 WHEAT RIDGE,CO80033	PHYSICIAN CLINIC
22	EXEMPLA SURGICAL SPECIALISTS 1960 OGDEN ST SUITE 530 DENVER,CO80205	PHYSICIAN CLINIC
23	EXEMPLA LUTHERAN MATERNAL FETAL MEDICINE 3655 LUTHERAN PARKWAY SUITE 408 WHEAT RIDGE,CO80033	PHYSICIAN CLINIC
24	EXEMPLA PLASTIC RECONSTRUCT & AESTH SURG 3455 LUTHERAN PARKWAY SUITE 220 WHEAT RIDGE,CO80033	PHYSICIAN CLINIC
25	EXEMPLA DENVER NEURO SURGERY & SPINE 3455 LUTHERAN PARKWAY SUITE 280 WHEAT RIDGE,CO80033	PHYSICIAN CLINIC
26	EXEMPLA INTERNAL MEDICINE OF LAFAYETTE 300 EXEMPLA CIRCLE SUITE 300 LAFAYETTE,CO80026	PHYSICIAN CLINIC
27	EXEMPLA FRONT RANGE CARDIAC & THOR SURG 1960 OGDEN ST SUITE 540 DENVER,CO80205	PHYSICIAN CLINIC
28	EXEMPLA FIRESTONE FAMILY MEDICINE 8350 WCR 13 SUITE 160 FIRESTONE,CO80504	PHYSICIAN CLINIC
29	EXEMPLA URGENT CARE OF WESTMINSTER 7625 WEST 92ND AVENUE WESTMINSTER,CO80021	PHYSICIAN CLINIC
30	EXEMPLA MT STATES UROGYNECOLOGY - WEST 3555 Lutheran pkwy SUITE 406 WHEAT RIDGE,CO80033	PHYSICIAN CLINIC
31	EXEMPLA LUTHERAN SW URGENT CARE&OCC MED 13402 WEST COAL MINE AVENUE SUITE LITTLETON,CO80127	PHYSICIAN CLINIC
32	EXEMPLA FOOTHILLS NEUROLOGY ASSOCIATES 300 EXEMPLA CIRCLE SUITE 300 LAFAYETTE,CO80026	PHYSICIAN CLINIC
33	EXEMPLA LUTHERAN NEUROLOGY 3550 LUTHERAN PARKWAY WEST SUITE 2 WHEAT RIDGE,CO80033	PHYSICIAN CLINIC
34	EXEMPLA OASIS FAMILY MEDICINE 360 S GARFIELD ST Ste 500 DENVER,CO80209	PHYSICIAN CLINIC
35	EXEMPLA DIABETES EDUCATION CENTER 3555 LUTHERAN PKWY Suite 180 WHEAT RIDGE,CO80033	PHYSICIAN CLINIC
36	EXEMPLA ESSENTIAL WOMENS CARE 1960 OGDEN St SUITE 230 Denver,CO80218	PHYSICIAN CLINIC
37	ROCKY MOUNTAIN CV ASSOCIATES UNION 355 Union BLVD Suite 200 Lakewood,CO80228	PHYSICIAN CLINIC
38	ROCKY MOUNTAIN CV ASSOCIATES NORTH 8300 Alcott St Suite 300 Westminster,CO80031	PHYSICIAN CLINIC
39	ROCKY MOUNTAIN CV ASSOCIATES GSMC 300 EXEMPLA CIRCLE Suite 310 Lafayette,CO80026	PHYSICIAN CLINIC
40	ROCKY MOUNTAIN CV ASSOCIATES LMC 3655 Lutheran PKWY Suite 201 Wheat Ridge,CO80033	PHYSICIAN CLINIC
41	ROCKY MOUNTAIN CV ASSOCIATES SJD 1960 Ogden St Suite 110 Denver,CO80218	PHYSICIAN CLINIC
42	EXEMPLA CAPITOL HILL INTERNAL MEDICINE 1960 OGDEN ST SUITE 120 DENVER,CO80218	PHYSICIAN CLINIC
43	EXEMPLA STAPLETON OB-GYN 2807 ROSLYN ST DENVER,CO80238	PHYSICIAN CLINIC
44	EXEMPLA NEUROLOGY SERVICES OF DENVER 1960 Ogden Street Suite 120 Denver,CO80218	PHYSICIAN CLINIC
45	EXEMPLA MOUNTAIN STATES UROGYNECOLOGY - 300 EXEMPLA cIRCLE SUITE 250 LAFAYETTE,CO80026	PHYSICIAN CLINIC
46	EXEMPLA DIABETES&ENDOCRINE SERVICES 3555 LUTHERAN PKWY SUITE 180 WHEAT RIDGE,CO80033	PHYSICIAN CLINIC
47	EXEMPLA LUTHERAN HEMATOLOGY & ONCOLOGY 3550 LUTHERAN PARKWAY SUITE 100-a WHEAT RIDGE,CO80033	PHYSICIAN CLINIC
48	EXEMPLA UNION FAMILY MEDICINE 355 UNION BLVD SUITE 200 LAKEWOOD,CO80228	PHYSICIAN CLINIC

Schedule H (Form 990) 2012

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; Part V, Section A; and Part V, Section B, lines 1j, 3, 4, 5c, 6i, 7, 10, 11, 12h, 14g, 16e, 17e, 18e, 19c, 19d, 20d, 21, and 22.
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.
8	Facility reporting group(s). If applicable, for each hospital facility in a facility reporting group provide the descriptions required for Part V, Section B, lines 1j, 3, 4, 5c, 6i, 7, 10, 11, 12h, 14g, 16e, 17e, 18e, 19c, 19d, 20d, 21, and 22.

Identifier	ReturnReference	Explanation
COMMUNITY BENEFIT REPORT	PART I, LINE 6A	COMMUNITY BENEFITS ARE INCLUDED IN A REPORT PREPARED BY SCL HEALTH SYSTEM.
COSTS ATTRIBUTABLE TO PHYSICIAN CLINICS	PART I, LINE 7G	THE ORGANIZATION INCLUDED AS SUBSIDIZED HEALTH SERVICES $584,570.64 IN LOSSES ATTRIBUTABLE TO PHYSICIAN CLINICS.
BAD DEBT EXPENSE	PART I, LINE 7, COLUMN(F)	BAD DEBT EXPENSE INCLUDED ON PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE OF TOTAL EXPENSES IN SCHEDULE H PART I, LINE 7, COLUMN (H) IS $20,800,106.
COSTING METHODOLOGY	PART I, LINE 7	THE COST ACCOUNTING SYSTEM WAS USED AS THE BASIS TO CALCULATE THE AMOUNTS REPORTED AS CHARITY CARE AND MEANS-TESTED GOVERNMENT PROGRAMS. THE COST ACCOUNTING SYSTEM ADDRESSES ALL PATIENT SEGMENTS. THE COST OF SUBSIDIZED SERVICES WAS CALCULATED AS THE NET LOSS OF THE RELEVANT DEPARTMENT USING THE DEPARTMENTAL EXPENSES AND ALLOCATED OVERHEAD EXPENSES, AND THE DEDUCTION RATIO PER THE COST ACCOUNTING SYSTEM. FOR SUBSIDIZED SERVICES, THE COST OF CHARITY, MEDICAID, AND SELF PAY PATIENTS WERE REMOVED IN THE CALCULATION.
COMMUNITY BUILDING ACTIVITIES	PART II	THE COMMUNITY BUILDING ACTIVITIES FOR EXEMPLA GOOD SAMARITAN MEDICAL CENTER (EGSMC) WERE FOCUSED ON MENTAL HEALTH AND "COMMUNITY HEALTH ADVOCACY". Exempla Lutheran Medical Center (ELMC) FOCUSED ON "COMMUNITY HEALTH ADVOCACY" FOR TOBACCO CESSATION, EDUCATION AND PREVENTION AND REDUCING OVERWEIGHT AND OBESITY. ELMC AND EGSMC's RECRUITMENT OF PHYSICIANS TO MEDICAL SHORTAGE AREAS WITHIN OUR PRIMARY SERVICE AREA (PSA) CONTRIBUTED TO THE IMPROVEMENT OF HEALTH IN OUR COMMUNITY. WE USE A STANDARD PROCESS FOR DETERMINING THE COMMUNITY NEED OF EACH PHYSICIAN SPECIALTY. SEVERAL CURRENT DATA ELEMENTS AND CONDITIONS ARE CONSIDERED. THE LARGEST PORTION OF OUR COMMUNITY BUILDING FUNDS WAS DESIGNATED FOR THIS PURPOSE SINCE WE DETERMINED A SHORTAGE OF SEVERAL SPECIALTIES WITHIN OUR PSA. "DISASTER READINESS AND PUBLIC HEALTH EMERGENCY TRAININGS" WERE ADDITIONAL FOCUS AREAS WITHIN COMMUNITY BUILDING ACTIVITIES. EGSMC AND ELMC ARE TAKING A LEADERSHIP ROLE IN OUR RESPECTIVE COUNTIES FOR READINESS TRAINING BEYOND THE REQUIREMENTS OF ACCREDITING BODIES OR GOVERNMENT ENTITIES. FOUR (4) HOSPITALS WITHIN BOULDER COUNTY PARTICIPATE ON A REGULAR BASIS AND BOULDER COUNTY HAS BEEN RECOGNIZED AS ONE OF THE LEADERS IN THE STATE OF COLORADO. THE STAFF FROM EGSMC AND ELMC CONTRIBUTE SIGNIFICANT TIME AND RESOURCES EACH YEAR TO LEAD THE DISASTER READINESS AND PUBLIC HEALTH EMERGENCY ACTIVITIES FOR THE COUNTY AND THE REGION. IN ADDITION TO "COMMUNITY HEALTH ADVOCACY" AND "DISASTER READINESS," EGSMC AND ELMC ACTIVELY PARTICIPATE IN "ECONOMIC DEVELOPMENT" IN THE FORM OF DONATIONS TO LOCAL CHAMBERS OF COMMERCE (E.G. LAFAYETTE CHAMBER, BROOMFIELD ECONOMIC DEVELOPMENT COUNCIL, JEFFERSON COUNTY ECONOMIC COUNCIL, BOULDER CHAMBER OF COMMERCE, AND OTHERS) AND "COMMUNITY HEALTH IMPROVEMENT ADVOCACY" FOR OUR COMMUNITY. THE COMMUNITY BUILDING ACTIVITIES SELECTED BY EGSMC AND ELMC EACH YEAR PROMOTE THE HEALTH OF THE COMMUNITY IN SIGNIFICANT WAYS.
BAD DEBT EXPENSE COSTING METHODOLOGY AND OTHER INFO	PART III, LINE 4	A COST TO CHARGE RATIO IS USED AS THE METHODOLOGY FOR DETERMINING THE AMOUNTS REPORTED AS COST OF BAD DEBT EXPENSE. FOR ALL SELF-PAY ACCOUNTS, A STANDARD 40% DISCOUNT IS FIRST APPLIED TO CHARGES AS A DEDUCTION OF REVENUE. BAD DEBT EXPENSE IS REFLECTED NET OF DISCOUNTS APPLIED AND PAYMENTS RECEIVED. THE ORGANIZATION DOES NOT INCLUDE IN BAD DEBT EXPENSE ANY AMOUNT THAT COULD REASONABLY BE ATTRIBUTABLE TO PATIENTS WHO LIKELY WOULD QUALIFY FOR FINANCIAL ASSISTANCE UNDER THE HOSPITALS' CHARITY CARE POLICY. THE FOLLOWING ARE THE RELEVANT PORTIONS OF THE COMPANY'S FOOTNOTE TO THE FINANCIAL STATEMENTS RELATED TO BAD DEBT: INCLUDED IN NET RECEIVABLES IS THE ALLOWANCE FOR UNCOLLECTIBLE RECEIVABLES. THE ALLOWANCE FOR UNCOLLECTIBLE RECEIVABLES IS BASED UPON MANAGEMENT'S ASSESSMENT OF HISTORICAL AND EXPECTED NET COLLECTIONS AND TAKES INTO CONSIDERATION HISTORICAL BUSINESS AND ECONOMIC CONDITIONS, TRENDS IN HEALTHCARE COVERAGE, AND OTHER COLLECTION INDICATORS. MANAGEMENT PERIODICALLY ASSESSES THE ADEQUACY OF THE ALLOWANCES FOR UNCOLLECTIBLE ACCOUNTS BASED UPON HISTORICAL WRITE-OFF EXPERIENCE BY PAYOR CATEGORY. THE RESULTS OF THESE ASSESSMENTS ARE USED TO MODIFY, AS NECESSARY, THE PROVISION FOR BAD DEBTS AND TO ESTABLISH APPROPRIATE ALLOWANCES FOR UNCOLLECTIBLE NET PATIENT ACCOUNTS RECEIVABLE.
COSTING METHODOLOGY FOR MEDICARE COSTS	PART III, LINE 8	INPATIENT AND OUTPATIENT MEDICARE COSTS ARE CALCULATED ON THE COST REPORT. INPATIENT COSTS ARE A PRODUCT OF ROUTINE SERVICE COSTS BASED ON PER DIEMS AND ANCILLARY COSTS BASED ON INPATIENT MEDICARE CHARGES FACTORED BY INPATIENT COST TO CHARGE RATIOS. OUTPATIENT COSTS ARE BASED ON MEDICARE OUTPATIENT CHARGES FACTORED BY OUTPATIENT COST TO CHARGE RATIOS. EXEMPLA, INC. DOES NOT RECOGNIZE THE MEDICARE SHORTFALL AS A COMMUNITY BENEFIT. DEBT COLLECTION POLICY PART III, LINE 9B AN INTEGRAL COMPONENT OF OUR MISSION IS TO BE GOOD FINANCIAL STEWARDS. THIS REQUIRES US TO DETERMINE WHICH PATIENTS ARE IN NEED OF CHARITY CARE AND WHICH ARE ABLE TO CONTRIBUTE SOME PAYMENT FOR CARE RECEIVED. WE MAINTAIN A BALANCE THAT ENABLES US TO CONTINUE TO PROVIDE CHARITY CARE TO THOSE WHO NEED IT MOST, AND TO ENSURE THAT WE MANAGE OUR RESOURCES SO THAT WE CAN CONTINUE TO BE HERE WHEN PEOPLE NEED US MOST. EXEMPLA, INC NOTIFIES PATIENTS OF FINANCIAL ASSISTANCE POLICY UPON ADMISSION, DISCHARGE AND IN COMMUNICATION REGARDING PATIENT BILLS. PATIENTS ARE CONTACTED MULTIPLE TIMES ABOUT UNPAID BALANCES PRIOR TO INITIATING ANY COLLECTION ACTION. IF A PATIENT IS DETERMINED TO BE ELIGIBLE FOR FINANCIAL ASSISTANCE AT ANY TIME DURING THE COLLECTION PROCESS, THE ACCOUNT IS RECLASSIFIED AS FINANCIAL ASSISTANCE AND DEBT COLLECTION EFFORTS ARE CEASED.
PUBLICIZING THE FINANCIAL ASSISTANCE POLICY	PART V, LINE 13G	EXEMPLA, INC TREATS PATIENTS WITH RESPECT AND DIGNITY REGARDLESS OF THEIR ABILITY TO PAY. EXEMPLA, INC HAS A WRITTEN FINANCIAL ASSISTANCE POLICY THAT EXPLAINS ELIGIBILITY CRITERIA FOR FINANCIAL ASSISTANCE AT VARIOUS LEVELS, INCLUDING A 100% DISCOUNT, AND IS BASED ON FEDERAL POVERTY GUIDELINES. WE WORK WITH PATIENTS TO HELP THEM UNDERSTAND THEIR FINANCIAL RESPONSIBILITY FOR CARE RECEIVED, FINANCIAL ASSISTANCE AVAILABLE TO THEM, AND TO ESTABLISH PAYMENT PROGRAMS IN DEMONSTRATION OF OUR CORE VALUE OF RESPECT. AS PART OF OUR RESPONSIBILITY TO EDUCATE, WE INFORM OUR PATIENTS AND THEIR FAMILIES OF THE AVAILABILITY OF ASSISTANCE, INCLUDING GOVERNMENT PROGRAMS. WE COMMUNICATE THIS IN A VARIETY OF WAYS TO ENSURE THAT MESSAGES REACH MULTIPLE AUDIENCES. BEFORE, DURING AND/OR AFTER ADMISSION, WE ENCOURAGE OUR SELF PAY PATIENTS TO VISIT WITH A FINANCIAL COUNSELOR TO DISCUSS QUALIFICATIONS FOR FINANCIAL ASSISTANCE. WE POST FINANCIAL ASSISTANCE INFORMATION IN THE FORM OF A FINANCIAL ASSISTANCE BROCHURE IN EMERGENCY AND ADMISSIONS AREAS, ON BILLINGS INVOICES, IN VARIOUS AREAS AROUND THE HOSPITAL AND CLINIC SITES AND ON THE HOSPITAL WEBSITE. THE BROCHURE EXPLAINS OUR FINANCIAL ASSISTANCE POLICY AND HOW IT IS ADMINISTERED. THIS COVERS ELIGIBILITY, STEPS TO FOLLOW TO DETERMINE IF A PATIENT QUALIFIES FOR ASSISTANCE, TYPICAL CHARGES A PATIENT MAY EXPECT FOR ROUTINE PROCEDURES, AND ASSISTANCE AVAILABLE BASED ON A PATIENT'S INCOME LEVEL. WE PROVIDE THESE MATERIALS AND EDUCATION WHEN PATIENTS ARE DISCHARGED, AND INCLUDE INFORMATION IN BILLING STATEMENTS, INCLUDING PHONE NUMBERS AND OTHER METHODS TO CONTACT US WITH QUESTIONS. WE ENSURE THAT OUR FINANCIAL COUNSELORS, ADMISSION EMPLOYEES, SOCIAL WORKERS AND OTHER EMPLOYEES UNDERSTAND OUR POLICIES TO BE ABLE TO ASSIST PATIENTS IN THE MOST APPROPRIATE WAY. WE ALSO PROVIDE THE DETAILED FINANCIAL ASSISTANCE POLICY TO INDIVIDUALS UPON REQUEST AND POST THE POLICY TO OUR WEBSITE TO ENSURE THE ENTIRE COMMUNITY HAS ACCESS TO SUCH INFORMATION. AMOUNTS BILLED TO UNINSURED INDIVIDUALS PART V, LINE 20D EACH FACILITY (EXEMPLA GOOD SAMARITAN MEDICAL CENTER AND EXEMPLA LUTHERAN MEDICAL CENTER) AUTOMATICALLY APPLIES A 40% DISCOUNT FOR ANY PATIENT WITHOUT INSURANCE. IF AN INDIVIDUAL QUALIFIES FOR FINANCIAL ASSISTANCE AND HAS INCOME BELOW 200% OF THE FEDERAL POVERTY GUIDELINES, THE FULL ACCOUNT BALANCE IS ADJUSTED TO ZERO. IF INCOME IS BETWEEN 200% AND 400% OF THE FEDERAL POVERTY GUIDELINES OR IS DETERMINED TO BE MEDICALLY INDIGENT EVEN IF THEIR INCOME IS ABOVE 400% OF THE FEDERAL POVERTY GUIDELINES, A MODEST PATIENT FINANCIAL RESPONSIBILITY IS DETERMINED FOLLOWING A COPAY GRID. THE GRID TAKES INTO CONSIDERATION INCOME AND FAMILY SIZE, AND IS DESIGNED TO RESULT IN AN AMOUNT THAT IS LOWER THAN THE LOWEST COMMERCIAL PAYER RATES.
NEEDS ASSESSMENT	PART VI, LINE 2	AS PART OF OUR CORE VALUE OF RESPONSE TO NEED, WE TAKE STEPS TO DETERMINE WHERE THERE IS THE MOST NEED IN ORDER TO PROVIDE THE GREATEST GOOD. EXEMPLA GOOD SAMARITAN MEDICAL CENTER AND EXEMPLA LUTHERAN MEDICAL CENTER HAVE REGULARLY PARTICIPATED IN NEEDS ASSESSMENTS TO IDENTIFY THE ONGOING AND CHANGING NEEDS OF THE COMMUNITY. FOR 2012, THE PROCESS INCLUDED A THIRD HOSPITAL, EXEMPLA ST.JOSEPH HOSPITAL IN DENVER, COLORADO. THE MOST RECENT SURVEY WAS CONDUCTED IN 2012, AND OTHER SURVEYS WILL BE CONDUCTED ON A REGULAR BASIS. The final Community Health Needs Assessments (CHNA) for Exempla Good Samaritan Medical Center and Exempla Lutheran Medical Center was approved by the Exempla Board in June 2012. The CHNA was made widely to the public in 2013 after all community input was obtained and made available on the Exempla website, is available to the public upon request, and was provided to community organization who request funding or donations from the hospital. The Center for Health Administration at the University of Colorado Denver was retained to conduct data collection for the 2012 CHNA for Exempla per Internal Revenue Code requirements. As part of the Affordable Care Act of 2010 (ACA), each freestanding non-profit (501(c)3) hospital is required to conduct a CHNA every three years. This report is the first CHNA on behalf of the Exempla hospitals that comply with the IRS mandate. This CHNA describes the health status of each hospital's community and is to be used by the hospital and other collaborators when it develops an implementation plan that addresses the identified community needs. Data for the CHNA was predominantly collected from the Colorado Department of Public Health and Environment (CDPHE). Health professionals and the public have become increasingly aware of the role of such lifestyle factors as cigarette smoking, overweight, sedentary lifestyle, and the nonuse of seat belts in contributing to injury, illness and death. To measure such factors in adults, the Colorado Behavioral Risk Factor Surveillance System Survey (BRFSS) was used. BRFSS is a system of telephone surveys sponsored by the Centers for Disease Control (CDC). Since 1981, CDC has been using the Behavioral Risk Factor Surveillance System as a method of estimating the prevalence of high risk behaviors and lifestyle factors that contribute to death and disease. Colorado specific data was obtained via the CDPHE website and can be accessed at http://www.chd.dphe.state.co.us/topics.aspx?q=Adult_Health_Data . To measure risk factors in youth, the national Youth Risk Behavior Survey was included to determine behaviors that impact the health of students in 9th through 12th grades. The survey is conducted by select school systems across the nation and reported back to CDC. The CDC's Youth Risk Behavior Surveillance System (YRBSS) monitors six types of health-risk behaviors that contribute to the leading causes of death and disability among youth and adults, including unintentional injuries and violence, alcohol and other drug use, tobacco use, dietary behaviors, and inadequate physical activity. YRBSS also measures the prevalence of obesity and asthma among youth and young adults. Colorado specific data was obtained via the CDC website and can be accessed at http://apps.nccd.cdc.gov/youthonline/App/Results.aspx?LID=CO . The Exempla CHNA mirrors applicable parts of the CDPHE's 2012 Colorado's 10 Winnable Battles which identifies key health issues where progress can be made in the next five years. By aligning with the CDPHE, Exempla joins forces with an ally in efforts to make an impact on improving the health of its hospitals' communities. Through this process, Exempla also meets stipulations set by the ACA that requires hospitals to collaborate with their Public Health Departments to improve their communities' health. To ensure alignment with publically available CDPHE data, Exempla leaders decided which Colorado counties would make up the geographic area for the 2012 CHNA. Individual Exempla hospital facilities then examined their primary market areas and identified Colorado counties in which at least 10% of their patient population resided. The counties identified by each facility comprise the "Primary Service Area" used in the data reports. When county data was unavailable, Health Statistic Region data was substituted. The health indicators that were chosen for this report were selected based on publically available CDPHE data, and many were also identified as part of Colorado's 10 Winnable Battles. The health indicators are as follows: Overall Health Status; Access; Cancer; Diabetes; Heart Disease and Cerebrovascular Disease; HIV/AIDS; Communicable Disease; Injury; Mental Health; Obesity, Nutrition and Physical Activity; Oral Health; Sexual Health; Substance Abuse; and Tobacco. Exempla Good Samaritan Medical Center vetted the results of the CHNA and top health indicators by determining which indicators were below the Colorado state average for both Boulder and Broomfield Counties. The following indicators were selected: 1. Access, 2. Cancer 3. Communicable Diseases 4. Mental Health 5. Obesity, Nutrition and Physical Activity 6. Oral Health 7. Overall Health Status 8. Sexual Health and HIV / AIDS Community partners brought to the table for planning interventions were Centura Health System, Boulder County Health Department, Broomfield Health & Human Services, Mental Health Partners, West Pines, Exempla Physician Network, physicians from Ergentus, and numerous community organizations. The remainder of the needs identified in the CHNA is important to Exempla but due to limited expertise and the availability of community organizations, who are already addressing needs, Exempla Good Samaritan Medical Center will collaborate with community organizations to ensure all needs and health indicators are being addressed. Exempla Lutheran Medical Center vetted the results of the CHNA and top health indicators and selected the following indicators to be addressed: 1. Obesity 2. Nutrition and 3. Physical Activity. Community partners brought to the table for planning interventions were Jefferson County Health Department, West Pines, Wheat Ridge (WR) 2020, LiveWell WR, Enterprise WR, WR Business Association, City of WR, Weight Watchers, Sodexo, LiveLocal, Jefferson County Public Schools, and Pridemark EMS. The remainder of the needs identified in the CHNA is important to Exempla but due to limited expertise and the availability of community organizations in the community, who are already addressing needs, Lutheran will collaborate with community organization to ensure all needs and health indicators are being addressed. In support of the CHNA, Exempla has a defined COMMUNITY SERVED BY THE HOSPITALS. This is ACCOMPLISHED BY PARTNERING WITH LOCAL GOVERNMENT AND SOCIAL AGENCIES; COMBINING EFFORTS WITH OTHER LOCAL HOSPITALS AND HEALTH CARE ORGANIZATIONS; AND CONDUCTING SURVEYS AND ASSESSMENTS WITH THE ASSISTANCE OF OUTSIDE CONSULTANTS. WE ALSO CONTINUOUSLY ASSESS THE NEEDS OF THE COMMUNITY THROUGH CLOSE WORKING RELATIONSHIPS AND PARTNERSHIPS WITH SERVICE AGENCIES IN THE COMMUNITY, AND BY EVALUATING STATE AND COUNTY HEALTH STATISTICS. Exempla has A MULTITUDE OF PROGRAMS IN PLACE THROUGH ITS CANCER CENTER AND NEUROVASCULAR CENTER AND THROUGH COMMUNITY OUTREACH. A VARIETY OF CLASSES ARE OFFERED ON WEIGHT MANAGEMENT AND SUPPORT GROUPS FOR CANCER PATIENTS. WE ALSO ROUTINELY OFFER COMMUNITY HEALTH AND SAFETY CLINICS, SKIN CANCER SCREENINGS, BREAST CANCER SURVIVORSHIP PROGRAMS, CLASSES FOR PROSPECTIVE PARENTS AND DIABETES MANAGEMENT CLASSES, TO NAME A FEW. EXEMPLA ALSO RECOGNIZE THE ESSENTIAL NEED TO ENHANCE AND IMPROVE MEDICAL OUTCOMES, QUALITY AND SERVICES. IN RESPONSE, A BEST IN THE NATION STRATEGY AND PROGRAM WAS IMPLEMENTED. THE OBJECTIVES OF THE PROGRAM ARE TO BE THE BEST IN THE NATION IN PREDEFINED QUALITY, SERVICE AND COST INDICATORS. THE QUALITY INDICATORS ARE IN ALIGNMENT WITH MAJOR PUBLICLY COMPARABLE DATABASES INCLUDING THE COLORADO HEALTH AND HOSPITAL ASSOCIATION AND CENTERS FOR MEDICARE AND MEDICAID SERVICES. COLLECTIVELY WITH ITS 534 LICENSED BEDS AT ELMC AND EGSMC, EXEMPLA SERVED THE COMMUNITY WITH 28,705 INPATIENT ADMISSIONS AND 112,328 EMERGENCY ROOM (ER) VISITS. COMPREHENSIVE MEDICAL SERVICES INCLUDE, BUT ARE NOT LIMITED TO, CARDIOLOGY, ONCOLOGY, ORTHOPEDIC, WOMEN AND FAMILY, EMERGENCY AND TRAUMA, NEONATAL INTENSIVE CARE, NEUROLOGY, NEUROSURGERY,OB/GYN, GENERAL SURGICAL AND MEDICAL, PRIMARY CARE, INTERNAL MEDICINE, BEHAVIORAL HEALTH, HOSPICE CARE AND INTEGRATIVE HEALTH SERVICES.
PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCE	PART VI, LINE 3	EXEMPLA, INC TREATS PATIENTS WITH RESPECT AND DIGNITY REGARDLESS OF THEIR ABILITY TO PAY. EXEMPLA, INC HAS A WRITTEN FINANCIAL ASSISTANCE POLICY THAT EXPLAINS ELIGIBILITY CRITERIA FOR FINANCIAL ASSISTANCE AT VARIOUS LEVELS, INCLUDING A 100% DISCOUNT, AND IS BASED ON FEDERAL POVERTY GUIDELINES. WE WORK WITH PATIENTS TO HELP THEM UNDERSTAND THEIR FINANCIAL RESPONSIBILITY FOR CARE RECEIVED, FINANCIAL ASSISTANCE AVAILABLE TO THEM, AND TO ESTABLISH PAYMENT PROGRAMS IN DEMONSTRATION OF OUR CORE VALUE OF RESPECT. AS PART OF OUR RESPONSIBILITY TO EDUCATE, WE INFORM OUR PATIENTS AND THEIR FAMILIES OF THE AVAILABILITY OF ASSISTANCE, INCLUDING GOVERNMENT PROGRAMS. WE COMMUNICATE THIS IN A VARIETY OF WAYS TO ENSURE THAT MESSAGES REACH MULTIPLE AUDIENCES. BEFORE, DURING AND/OR AFTER ADMISSION, WE ENCOURAGE OUR SELF PAY PATIENTS TO VISIT WITH A FINANCIAL COUNSELOR TO DISCUSS QUALIFICATIONS FOR FINANCIAL ASSISTANCE. THE FINANCIAL COUNSELOR WORKS WITH THE PATIENT TO COMPLETE A FINANCIAL ASSISTANCE FORM TO DETERMINE THE LEVEL OF DISCOUNT FOR WHICH THE PATIENT MAY BE ELIGIBLE. WE POST FINANCIAL ASSISTANCE INFORMATION IN EMERGENCY AND ADMISSIONS AREAS, ON BILLINGS INVOICES, IN VARIOUS AREAS AROUND THE HOSPITAL AND CLINIC SITES AND ON THE HOSPITAL WEBSITE. WE PROVIDE WRITTEN MATERIALS TO PATIENTS THAT DETAIL OUR FINANCIAL ASSISTANCE POLICY AND HOW IT IS ADMINISTERED. THIS COVERS ELIGIBILITY, STEPS TO FOLLOW TO DETERMINE IF A PATIENT QUALIFIES FOR ASSISTANCE, TYPICAL CHARGES A PATIENT MAY EXPECT FOR ROUTINE PROCEDURES, AND ASSISTANCE AVAILABLE BASED ON A PATIENT'S INCOME LEVEL. WE PROVIDE MATERIALS AND EDUCATION WHEN PATIENTS ARE DISCHARGED, AND INCLUDE INFORMATION IN BILLING STATEMENTS, INCLUDING PHONE NUMBERS AND OTHER METHODS TO CONTACT US WITH QUESTIONS. WE ENSURE THAT OUR FINANCIAL COUNSELORS, ADMISSION EMPLOYEES, SOCIAL WORKERS AND OTHER EMPLOYEES UNDERSTAND OUR POLICIES TO BE ABLE TO ASSIST PATIENTS IN THE MOST APPROPRIATE WAY. WE ALSO PROVIDE PAYMENT PLAN OPTIONS TO OUR PATIENTS. THIS HELPS PATIENTS MEET THEIR FINANCIAL OBLIGATIONS IN A REASONABLE AND DIGNIFIED MANNER BASED ON THEIR ABILITY TO PAY, AND ALLOWS THEM TO CONTINUE TO ENSURE THE ONGOING WELFARE OF THEIR FAMILIES. THIS IS DONE IN ACCORDANCE WITH OUR CORE VALUE OF RESPECT.
COMMUNITY INFORMATION	PART VI, LINE 4	SCL Health System's acute care facility in the north Denver metropolitan area is Exempla Good Samaritan Medical Center ("EGSMC"). EGSMC is located in Lafayette, Colorado, and provides healthcare services to a wide array of communities in the north metropolitan area. The primary service area, which is based on the geographic area of contiguous zip codes from which the hospital draws approximately 75% of its inpatient discharges, is comprised of 23 standard zip codes located in Broomfield County (2 zip codes), Boulder County (5 zip codes), Adams County (10 zip codes), Jefferson County (4 zip codes) and Weld County (2 zip codes). The combined primary and secondary service area, which is based on the geographic area of contiguous zip codes from which the hospital draws approximately 90% of its inpatient discharges, is comprised of the 23 zip codes from the primary service area and 26 zip codes in the secondary service area located in the counties of Adams, Boulder, Gilpin, Jefferson, Larimer and Weld. EGSMC is the leading acute care provider in its primary service area and treats about one in five inpatients in that area, highest among hospitals in the market. The care site's highest concentration of patients originate from the corridor along US Highway 36 across to Interstate 70; comprised of the communities of Broomfield, Lafayette, Westminster, western Brighton and Thornton. EGSMC sees a substantial amount of patients enrolled with Kaiser Permanente and serves as Kaiser's main inpatient provider in the northern portion of the Denver metropolitan area. There are six acute care facilities located in EGMSC's primary service area, including, EGSMC, two Centura Health hospitals (not-for-profit) - Avista Adventist Hospital and Saint Anthony North Hospital, one HealthONE hospital (for-profit) - North Suburban Hospital, and two unaffiliated not-for-profit facilities, Platte Valley Medical Center and Longmont United Hospital. EGSMC's secondary service area includes four other acute care facilities, three of which are affiliated with local health systems (Exempla Lutheran Medical Center, McKee Medical Center - Banner Health, and Medical Center of the Rockies - University Health) and one independent hospital, Boulder Community Hospital. Exempla Lutheran Medical Center ("ELMC") is situated in the western portion of the Denver metropolitan area in the city of Wheat Ridge, Colorado. The care sites services many communities in the western metropolitan area including Wheat Ridge, Arvada, Golden, Lakewood, Westminster as well as communities in the foothills of the Front Range. ELMC's primary service area consists of 18 standard zip codes, mainly located in Jefferson County (13 zip codes), but also represented by zip codes in the counties of Denver (3 zip codes), Adams (1 zip code) and Gilpin (1 zip code). The secondary service area includes 20 zip codes and extends through Adams County, Broomfield County, Clear Creek County, Denver County and Jefferson County. The primary service area is defined as the geographic area of contiguous zip codes from which the hospital draws approximately 75% of its inpatient discharges and the combined primary and secondary service area is based on approximately 90% of discharges. ELMC's main concentration of care is provided to the communities of Wheat Ridge, Arvada and Golden. 50% of the care site's discharges come from eight zip codes within those cities. Additionally, ELMC services the most patients within its primary service area when compared to other hospitals furnishing close to 30% of the inpatient care. Up until 2010, ELMC had been the sole provider of acute care services within its primary service area until Saint Anthony Hospital, a Centura Health affiliate, re-located its facility from western Denver to an area in Lakewood closer to ELMC's campus. Currently, ELMC, Saint Anthony Hospital and Ortho Colorado Hospital at Saint Anthony Hospital, an orthopedic specialty hospital jointly owned by Centura Health and local physicians, are the acute care hospitals located in ELMC's primary service area. There are three acute care hospitals located in the secondary service area, Saint Anthony North Hospital (an affiliate of the not-for-profit Centura Health organization), North Suburban Medical Center (an affiliate of the for-profit HealthONE system) and Denver Health (government owned). THE COMMUNITY SERVED BY EXEMPLA, INC. IS A CONTINUUM OF MUNICIPALITIES AND SECTIONS OF MUNICIPALITIES WITHIN THE GREATER DENVER METRO AREA, EXTENDING FROM THE CENTRAL WEST METRO DENVER CITIES OF LAKEWOOD AND EVERGREEN TO LONGMONT, THE MOST NORTHWEST MUNICIPALITY IN THE METRO DENVER AREA (EXCLUDING THE CITY OF BOULDER PROPER). WHILE THERE ARE SOME MOUNTAIN AND RURAL AREAS OVER THIS COMMUNITY EXPANSE, MOST OF THE COMMUNITY SERVED IS SUBURBAN AND URBAN AREAS. THE POPULATION OF THE ENTIRE COMMUNITY SERVED IS 1,066,000 AS OF YEAR 2010. THIS AREA REPRESENTS A LITTLE LESS THAN 40% OF THE WHOLE DENVER METRO AREA. BESIDES THE EXEMPLA INC. HOSPITALS, EXEMPLA LUTHERAN MEDICAL CENTER, WHEAT RIDGE AND EXEMPLA GOOD SAMARITAN, LAFAYETTE THERE ARE five OTHER NOT-FOR-PROFIT HOSPITALS IN THE COMMUNITY: - ST. ANTHONY NORTH HOSPITAL-CENTURA HEALTH, WESTMINSTER - ST. ANTHONY WEST HOSPITAL-CENTURA HEALTH, LAKEWOOD - AVISTA ADVENTIST HOSPITAL-CENTURA HEALTH, LOUISVILLE - LONGMONT UNITED HOSPITAL, LONGMONT - Boulder Community Hospital, Boulder THERE IS ALSO ONE FOR-PROFIT HOSPITAL, NORTH SUBURBAN MEDICAL CENTER-HEALTHONE, THORNTON. The community served by EGSMC contains the following demographic information. POPULATION, RACE, ETHNICITY, AND GENDER In the Exempla Primary Service Areas/EGSMC, total population is 1,499,686, according to 2010 census data. Broomfield also has the highest percentage of all youth under 18 years of age, 26.1%, and Boulder County has 21.3%. Boulder County has 10% and Broomfield County 9.9% of their populations aged over 65. Both counties are predominantly white with Boulder at 87.2% and Broomfield at 86.1%, exceeding the state average of 81.3%. The next largest racial group is Asian with Broomfield at 6.1% and Boulder at 4.1%, again both exceeding the state average. Both Boulder & Broomfield have only small percentages of black residents and are lower than the state average. Persons of Hispanic or Latino origin make up 13.3% of Boulder County and 11.1% of Broomfield County. This is under the state average of about 21%. Broomfield County has slightly more females than males (50.4% vs 49.6%) and Boulder County has more males than females (49.8% female vs. 50.2% male) EDUCATION Both Boulder and Broomfield Counties exceed the state average for high school graduates and for those with bachelor's degrees or higher. Boulder has the highest education level in the state with 56.6% of the population with degrees. INCOME Boulder and Broomfield Counties have higher median income than the state average. Broomfield has the highest median income in the state at $77,606. Boulder meets the state average for persons below the poverty level and Broomfield has only 4.9% of population at poverty level. Boulder and Broomfield Counties are both under the state unemployment rate according to 2010 numbers. Broomfield was listed at 7.9% and Boulder at 7.1%. HEALTH STATUS Broomfield and Boulder Counties are well below the state average of 12% of persons who say their health is poor or fair. Boulder County has 8% and Broomfield County 7.3% of their populations self-identifying as such. Both Broomfield and Boulder Counties are below the state average of smokers in the population with Boulder at 12.8% and Broomfield at 13.9%. Both Boulder and Broomfield have population overweight percentages below the state average. Boulder's obesity rate is below the state average at 13.1%, but Broomfield at 20.8% is above the state average. Boulder is above the state average for high risk drinking at least once in the past month, while Broomfield is below state average. Both counties are below the state average for binge drinking at least once in the past month. The community served by ELMC contains the following demographic information. POPULATION, RACE, ETHNICITY, AND GENDER In the Exempla Primary Service Areas/ELMC, total population is 534,543, according to 2010 census data. Jefferson County also has the highest percentage of all youth under 18 years of age, 21.5%. Jefferson and Clear Creek Counties have the highest percentage of residents over age 65 and exceed the state average. Jefferson County has 12.6% and Clear Creek County 12.5% of their population ages over 65. Jefferson County is predominantly white, which includes Hispanics self-identifying, at 88.4%, exceeding the state average. The next largest racial group is Asian with Jefferson County at 2.6%, only a small percentage of black residents and are lower than the state average. Persons of Hispanic or Latino origin make up 14.3% of Jefferson County. This is below the state average. Jefferson County has more fema
PROMOTION OF COMMUNITY HEALTH	PART VI, LINE 5	WE EXTEND OUR CARE BEYOND OUR HOSPITALS' WALLS IN ORDER TO IMPROVE THE HEALTH OF OUR COMMUNITY. OUR COMMUNITY ACTIVITIES DEMONSTRATE THIS COMMITMENT. OUR COMMUNITY ACTIVITIES AT EXEMPLA LUTHERAN MEDICAL CENTER INCLUDE A VARIETY OF CLASSES ON WEIGHT MANAGEMENT AND SUPPORT GROUPS FOR CANCER PATIENTS. ELMC ALSO ROUTINELY OFFERS COMMUNITY HEALTH AND SAFETY CLINICS, SKIN CANCER SCREENINGS, BREAST CANCER SURVIVORSHIP PROGRAMS, CLASSES FOR PROSPECTIVE PARENTS AND DIABETES MANAGEMENT CLASSES, TO NAME A FEW. EXEMPLA GOOD SAMARITAN MEDICAL CENTER'S HEALTH & HEALING CENTER CONDUCTS HEART HEALTH SCREENINGS IN THE COMMUNITY INCLUDING CHOLESTEROL SCREENING AND BLOOD PRESSURE SCREENINGS SEVERAL TIMES THROUGHOUT THE YEAR. WE ALSO PROMOTE HEALTH AND WELLNESS FOR OUR EMPLOYEES THROUGH PROGRAMS SUCH AS POUND POUNDERS TO PROMOTE WEIGHT LOSS. WE ALSO PROVIDE PRESENTATIONS TO COMMUNITY GROUPS ON SUBJECTS SUCH AS BALANCE, EXERCISE AND STRETCHING. WELLNESS QUEST CLASSES LED BY EGSMC PHYSICIANS ARE HELD IN THE COMMUNITY FOR PREVENTIVE-CARE EDUCATION AND INDIVIDUAL RESPONSIBILITY FOR HEALTH PROMOTION. WE HAVE PARTNERED WITH SUCH ORGANIZATIONS AS THE LAFAYETTE SENIOR CENTER, THE LAFAYETTE RECREATION CENTER AND OTHER COMMUNITY ORGANIZATIONS PROVIDING SERVICES TO OUR COMMUNITY. EGSMC ALSO PROVIDES HEALTH SCREENINGS FOR EMPLOYEES OF BOULDER VALLEY SCHOOL DISTRICT AND SCREENINGS AT EVENTS SEVERAL TIMES THROUGHOUT THE YEAR TO RESIDENTS OF BROOMFIELD, LAFAYETTE AND OTHERS IN THE SURROUNDING AREAS. WE ARE AN IMPORTANT PART OF OUR COMMUNITY AND SERVE IN MANY WAYS, FROM DELIVERING CORE HEALTH CARE TO PREVENTIVE CARE TO SUPPORT OF OTHER CIVIC GROUPS. IN 2012, EXEMPLA INC PROVIDED COMMUNITY BENEFIT TO INCLUDE TRADITIONAL CHARITY CARE AND THE UNPAID COST OF MEDICAID. OUR BOARD OF DIRECTORS REPRESENTS MEDICAL AND BUSINESS PROFESSIONALS, AND ALL PROVIDE HOURS OF SERVICE IN SUPPORT OF OUR HOSPITAL. THEY ARE DEEPLY INVOLVED IN OUR NEEDS ASSESSMENT PROCESS, BUILDING PROGRAMS AND SERVICES, AND COMMUNITY OUTREACH TO ENSURE THAT PEOPLE KNOW ABOUT SERVICES AVAILABLE TO THEM THROUGH OUR HOSPITAL. WHEN EXEMPLA, INC. HAS EXCESS REVENUE OVER OPERATING EXPENSES, WE USE THOSE FUNDS TO OBTAIN CURRENT HEALTH CARE TECHNOLOGIES AND EQUIPMENT, IMPROVE PATIENT CARE, PROVIDE MEDICAL TRAINING EDUCATION AND RESEARCH, AND TO EXPAND ACCESS TO POINTS OF CARE. THESE INVESTMENTS ENSURE WE'LL BE HERE TO CARE FOR FUTURE GENERATIONS. WE ALSO SUPPORT OUR EMPLOYEES IN VOLUNTEERING FOR COMMUNITY ORGANIZATIONS, INCLUDING SERVING ON COMMUNITY BOARDS, AND PROVIDE OPPORTUNITIES FOR THEM TO SUPPORT CAUSES THROUGH HOSPITAL EVENTS SUCH AS CANCER, HEART DISEASE, AMERICAN HEART ASSOCIATION, RACE FOR THE CURE, AND MARCH OF DIMES. WE ARE GOOD CITIZENS AND PARTNER WITH OTHER ORGANIZATIONS AND AGENCIES TO SUPPORT A THRIVING COMMUNITY, SUCH AS THE JEFFERSON COUNTY AND BOULDER COUNTY HEALTH DEPARTMENT, LIVEWELL COLORADO, THE METRO COMMUNITY PROVIDER NETWORK, MENTAL HEALTH PARTNERS OF BOULDER, MEALS ON WHEELS (BROOMFIELD & BOULDER COUNTIES), BROOMFIELD HEALTH & HUMAN SERVICES AND OTHER AGENCIES IN A SIX-COUNTY AREA. AS PART OF SCL HEALTH SYSTEM (SCLHS), WE PROMOTE THE SHARED MISSION THAT "WE REVEAL AND FOSTER GOD'S HEALING LOVE BY IMPROVING THE HEALTH OF THE PEOPLE AND COMMUNITIES WE SERVE, ESPECIALLY THOSE WHO ARE POOR OR VULNERABLE." WE ARE COMMITTED TO LIVING AND DEMONSTRATING OUR CORE VALUES OF EXCELLENCE, CARING SPIRIT, INTEGRITY, STEWARDSHIP AND GOOD HUMOR. SCLHS SUPPORTS ITS HOSPITALS BYPROVIDING GUIDANCE, OVERSIGHT, AND RESOURCES TO HELP THEM ACCOMPLISH INITIATIVES THAT IMPROVE HEALTH IN ALL OUR COMMUNITIES. THIS INCLUDES COORDINATING COMMUNITY BENEFIT PROCESSES, PROVIDING GUIDANCE WITH COMMUNITY NEEDS ASSESSMENTS, AND ESTABLISHING CONSISTENT FINANCIAL ASSISTANCE AND CHARITY CARE POLICIES AND PROCEDURES. OTHER WAYS SCLHS BENEFITS ITS HOSPITALS INCLUDE QUALITY IMPROVEMENT AND PERFORMANCE EXCELLENCE INITIATIVES; SYSTEM-WIDE INFORMATION TECHNOLOGY IMPLEMENTATION AND INFRASTRUCTURE; STRATEGIC AND OPERATIONS DIRECTION AND OVERSIGHT; SUPPLY CHAIN MANAGEMENT AND PURCHASING; BENEFITS ADMINISTRATION (INCLUDING A WELLNESS PROGRAM FREE TO EMPLOYEES THAT PROMOTES THEIR HEALTH AND WELL-BEING); RISK MANAGEMENT; DISASTER PLANNING AND CRISIS ASSISTANCE. BY SHARING THE WORK ACROSS OUR SYSTEM WE ARE ABLE TO LIGHTEN THE BURDEN FOR ALL IN ORDER TO FULFILL OUR MISSION OF IMPROVING HEALTH IN OUR COMMUNITIES. SCLHS IMPROVES OVERALL HEALTH IN OUR COMMUNITIES BY PROVIDING INFRASTRUCTURE TO SUPPORT AND SUSTAIN THREE CLINICS FOR THE UNINSURED IN KANSAS AND COLORADO. THE SCLHS CLINICS FOR THE UNINSURED ARE OFTEN THE ONLY SAFETY NET CLINIC IN THEIR COMMUNITY AND PROVIDE VALUABLE SERVICES FOR THOSE WHO ARE MOST VULNERABLE. EACH HOSPITAL IS SUPPORTED BY A FOUNDATION TO ACCESS AND OPTIMIZE LOCAL PHILANTHROPIC ORGANIZATIONS AND INDIVIDUALS. THESE FOUNDATIONS RAISE FUNDS THROUGH OUTREACH, SPECIAL EVENTS, AND BUILDING DONOR RELATIONS THROUGHOUT THEIR COMMUNITY TO SUPPORT THE NEEDS OF THE HOSPITAL.
AFFILIATED HEALTH CARE SYSTEM	PART VI, LINE 6	SCL HEALTH SYSTEM IS A CONTROLLED ENTITY OF THE SISTERS OF CHARITY OF LEAVENWORTH HEALTH SYSTEM, INC. (SCLHS). SCLHS AND ITS AFFILIATED ENTITIES HAVE A COMMON CALLING AND MISSION "TO REVEAL GOD'S HEALING LOVE BY IMPROVING THE HEALTH OF THE INDIVIDUALS AND COMMUNITIES IT SERVES, ESPECIALLY THOSE WHO ARE POOR OR VULNERABLE." EXEMPLA, INC. PROMOTES THE HEALTH OF THE COMMUNITY BY DELIVERING DIRECT HIGH QUALITY HEALTHCARE SERVICES THAT ARE RESPONSIVE TO THE NEEDS OF ITS PATIENTS AND THEIR FAMILIES. SCLHS SUPPORTS THE EFFORTS OF THE HOSPITAL THROUGH STRATEGIC DIRECTION AND OPERATING OVERSIGHT. SCLHS SUPPLIES OVERHEAD SUPPORT SERVICES TO EXEMPLA, INC. INCLUDING INFORMATION TECHNOLOGY SERVICES, CENTRAL CASH MANAGEMENT AND INVESTMENT, RISK MANAGEMENT AND INSURANCE AND QUALITY IMPROVEMENT LEADERSHIP.
STATE FILING OF COMMUNITY BENEFIT REPORT	PART VI, LINE 7	THE SISTERS OF CHARITY OF LEAVENWORTH HEALTH SYSTEM FILES A COMMUNITY BENEFIT REPORT IN FOUR STATES: CALIFORNIA, COLORADO, KANSAS AND MONTANA.

Schedule H (Form 990) 2012

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

2012

Open to Public
Inspection

Name of the organization
EXEMPLA INC FKA LUTHERAN HOSPITAL

Employer identification number
84-1103606

Part I

General Information on Grants and Assistance

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. Part II can be duplicated if additional space is needed.

(a) Name and address of organization or government	(b) EIN	(c) IRC Code section if applicable	(d) Amount of cash grant	(h) Purpose of grant or assistance
(1) YOUNG AMERICANS CENTER 3550 E FIRST AVE DENVER,CO80206	84-1564926	501(c)(3)	10,000	Sponsor Medical Shop
(2) METRO COMMUNITY PROVIDER NETWORK 3701 S Broadway ENGLEWOOD,CO80113	74-2477108	501(C)(3)	50,000	SUPPORT FOR ESTES STREET COMMUNITY HEALTH CLINIC
(3) MOUNT SAINT VINCENT 4159 Lowell Blvd DENVER,CO80211	84-0405260	501(C)(3)	15,000	Golf for kids event.
(4) SISTER CARMEN COMMUNITY CENTER 655 ASPEN RIDGE DRIVE LAFAYETTE,CO80026	84-0820308	501(c)(3)	10,000	TO SUPPORT ACCESS TO HEALH CARE SERVICES
(5) MENTAL HEALTH FOUNDATION 1333 Iris Avenue Boulder,CO80304	84-0520493	501(C)(3)	25,000	To support mental health
(6) MEALS ON WHEELS OF BOULDER 909 ARAPAHOE AVE STE 121 BOULDER,CO80302	84-0594180	501(C)(3)	7,206	TO PROVIDE NUTRITIOUS MEALS TO RESIDENTS OF BOULDER

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

Cat. No. 50055P

Schedule I (Form 990) 2012

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.
Part III can be duplicated if additional space is needed.

(a)Type of grant or assistance	(d)Amount of non-cash assistance	(e)Method of valuation (book, FMV, appraisal, other)	(f)Description of non-cash assistance
(1) FREE PRESCRIPTION DRUGS FOR INDIGENT PATIENTS	465,195	BOOK	PRESCRIPTION DRUGS

Part IV

Supplemental Information.

Complete this part to provide the information required in Part I, line 2, Part III, column (b), and any other additional information.

Identifier	Return Reference	Explanation
DESCRIPTION OF ORGANIZATION'S PROCEDURES FOR MONITORING THE USE OF GRANTS	PART 1, QUESTION 2	THE ORGANIZATION KEEPS RECORDS TO SUPPORT THE AMOUNTS PROVIDED OR REASONS FOR SUCH SUPPORT. SUPPORT IS NOT CONSIDERED GRANTS, BUT RATHER MISCELLANEOUS DONATIONS AND SPONSORSHIPS. ELIGIBILITY FOR FUNDING IS DETERMINED ON AN INDIVIDUAL BASIS, CONSIDERING THE USE OF THE FUNDS AND HOW THE USE RELATES TO EXEMPLA'S MISSION.

Schedule I (Form 990) 2012

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

2012

Open to Public Inspection

Name of the organization

EXEMPLA INC FKA LUTHERAN HOSPITAL

Employer identification number

84-1103606

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 of 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 filing organization used 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? .........

Yes

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

If "Yes" to any of lines 4a-c, list the persons and provide the applicable amounts for each item in Part III.

Only 501(c)(3) and 501(c)(4) organizations only must complete lines 5-9.

For persons listed in Form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the revenues of:

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

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

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

For persons listed in Form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the net earnings of:

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

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

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

For persons listed in Form 990, Part VII, Section A, line 1a, did the organization provide any non-fixed
payments not described in lines 5 and 6? If "Yes," describe in Part III ............

Yes

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

Cat. No. 50053T

Schedule J (Form 990) 2012

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 (E) amounts for that individual.

(A) Name and Title		(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 and Title		(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)DAVID HAMMPRESIDENT & CEO-EGSMC	(i) (ii)	0 360,207	0 113,907	0 20,250	0 81,907	0 12,388	0 588,659	0 0
(2)ROBERT G BILLERBECKVP-CHIEF MEDICAL OFFICER	(i) (ii)	0 296,073	0 55,019	0 6,394	0 48,558	0 12,455	0 418,499	0 0
(3)ELISA WETHERBEECHIEF OPERATING OFFICER EPN	(i) (ii)	0 226,225	0 74,659	0 4,650	0 40,352	0 16,438	0 362,324	0 0
(4)S ANN EVANSVP-CHIEF NURSING OFFICER(ELMC)	(i) (ii)	0 0	0 0	195,861 0	0 0	5,322 0	201,183 0	0 0
(5)BETH C FORSYTHVP-CLIN & SUPPORT SVCS (EGSMC)	(i) (ii)	0 222,896	0 39,516	0 9,457	0 38,367	0 12,020	0 322,256	0 0
(6)MARGARET CAIN PRICEVP-OPERATIONS (ELMC)	(i) (ii)	0 224,920	0 39,483	0 3,700	0 39,141	0 12,317	0 319,561	0 0
(7)KAREN M SCREMINVP-FINANCE (ELMC)	(i) (ii)	0 195,692	0 34,819	0 808	0 35,497	0 6,834	0 273,650	0 0
(8)TODD A CONKLINSVP & CFO, TREASURER	(i) (ii)	0 377,511	0 236,016	0 13,154	0 59,483	0 16,546	0 702,710	0 0
(9)SUSAN E KERSCHENVP-CHIEF NURSING OFFCR (EGSMC)	(i) (ii)	0 191,630	0 35,605	0 3,551	0 35,074	0 12,062	0 277,922	0 0
(10)JOHN D HIGGINSVP FINANCE (EGSMC)	(i) (ii)	0 164,168	0 28,437	0 5,233	0 33,000	0 15,775	0 246,613	0 0
(11)GRANT WICKLUNDPRESIDENT & CEO-ELMC	(i) (ii)	0 394,762	0 104,652	0 23,789	0 54,760	0 16,663	0 594,626	0 0
(12)BOB LADENBURGERPRESIDENT & CEO of EXEMPLA	(i) (ii)	0 660,676	0 203,467	0 511,903	0 94,171	0 12,465	0 1,482,682	0 0
(13)MARK C WATTSPHYSICIAN	(i) (ii)	699,795 0	26,000 0	0 0	18,000 0	7,844 0	751,639 0	0 0
(14)KEVIN B MILLERPHYSICIAN	(i) (ii)	482,672 0	209,111 0	0 0	18,000 0	16,733 0	726,516 0	0 0
(15)STEPHEN W COBBCHIEF MEDICAL OFFICER (EPN)	(i) (ii)	0 238,645	0 24,557	0 8,994	0 46,845	0 13,594	0 332,635	0 0
(16)MICHAEL A SLUBOWSKICHAIR,PRESIDENT AND CEO(SCLHS)	(i) (ii)	0 993,061	0 398,970	0 121,672	0 24,119	0 12,465	0 1,550,287	0 0
(17)LYDIA JUMONVILLESVP FINANCE & CFO	(i) (ii)	0 499,288	0 152,073	0 13,890	0 73,035	0 16,546	0 754,832	0 0
(18)RICK LOPESSVP Health Networks	(i) (ii)	0 507,612	0 96,853	0 313,140	0 43,290	0 12,465	0 973,360	0 0
(19)TOWNDROWGERALDINE MVP-CHIEF NURSING OFFICER(ELMC)	(i) (ii)	231,600 0	0 0	0 0	6,948 0	432 0	238,980 0	0 0
(20)LAMONDRODERICK GPHYSICIAN	(i) (ii)	551,208 0	175,060 0	108,685 0	18,000 0	14,159 0	867,112 0	0 0
(21)LANKENAUJOHN EPHYSICIAN	(i) (ii)	776,709 0	27,622 0	0 0	18,000 0	16,599 0	838,930 0	0 0
(22)THOMPSONDONALD CPHYSICIAN	(i) (ii)	587,533 0	75,847 0	0 0	18,000 0	7,056 0	688,436 0	0 0

Schedule J (Form 990) 2012

Page 3

Part III

Supplemental Information

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

Identifier	Return Reference	Explanation
TAX INDEMNIFICATION AND GROSS UP PAYMENTS	SCH J, PART I, QUESTION 1A	26 INDIVIDUALS RECEIVED GROSS UP PAYMENTS FOR GIFTS OR OTHER ITEMS THAT WERE TAXABLE TO THE INDIVIDUAL IN THEIR W-2'S. THESE TOTALED $859.33 IN THE AGGREGATE.
SEVERANCE AND CHANGE OF CONTROL PAYMENTS	SCHEDULE J, PART I, QUESTION 4A	A CHANGE OF CONTROL PAYMENT WAS MADE TO KATHRYN BALLINGER IN THE AMOUNT OF $314,536.56 IN 2012. SISTERS OF CHARITY OF LEAVENWORTH HEALTH SYSTEM, INC. (SCLHS) PERIODICALLY INCURS SEVERANCE PAYMENTS RELATED TO FORMER EMPLOYEES. A SEVERANCE PAYMENT WAS MADE TO S. A. EVANS IN THE AMOUNT OF $198,013 IN 2012.
SUPPLEMENTAL NONQUALIFIED RETIREMENT PLANS	SCHEDULE J, PART I QUESTION 4B	EXEMPLA HAS A 457(F) SUPPLEMENTAL NONQUALIFIED DEFERED COMPENSATION PLAN, IN WHICH CERTAIN KEY OFFICERS PARTICIPATE. OTHER REPORTABLE COMPENSATION SHOWN IN SCHEDULE J PART II COLUMN (B) (III) CONTAINS AN ANNUAL REPORTING ADJUSTMENT FOR CERTAIN EMPLOYEES WHO PARTICIPATE IN THE SUPPLEMENTAL NONQUALIFIED RETIREMENT PLANS. SCLHS PROVIDES NONQUALIFIED RETIREMENT PLANS FOR EXECUTIVES TO COMPENSATE FOR IRS IMPOSED LIMITATIONS IN QUALIFIED RETIREMENT PLANS AND TO PROVIDE A BENEFIT CONSISTENT WITH OTHER NOT FOR PROFIT HEALTH SYSTEMS. THESE PLANS ENABLE THE EXECUTIVE TO EARN BENEFITS DURING EACH YEAR THAT THEY PARTICIPATE. ON THE ADVICE OF COUNSEL, SCLHS HAS DETERMINED THAT THESE BENEFITS SHOULD BE SUBJECT TO TAXATION AS THEY ARE EARNED AND VESTED RATHER THAN WHEN THEY ARE RECEIVED. AS A RESULT, THE TOTAL NONQUALIFIED RETIREMENT PLAN BENEFITS, WHICH WERE ACCRUED AND VESTED IN THE CURRENT YEAR, ARE NOW CONSIDERED TAXABLE AND THUS WERE TAXED TO THE PARTICIPANTS.
INCENTIVE PLANS	SCHEDULE J, PART I, QUESTION 7	THE MANAGEMENT INCENTIVE PLANS ARE BASED ON A COMBINATION OF MEASURES. MANAGEMENT AND SENIOR LEADERSHIP ARE ELIGIBLE FOR THE INCENTIVE COMPENSATION. PERFORMANCE CATEGORIES ARE MADE UP OF A COMBINATION OF CLINICAL QUALITY MEASURES AND OPERATING INCOME. THE OPERATING INCOME CATEGORY IS GENERALLY RELATED TO THE NET EARNINGS OF THE DIVISION IN WHICH THE INDIVIDUAL WORKS, OR IN THE CASE OF SYSTEM SERVICES SENIOR MANAGEMENT, THE NET EARNINGS OF THE COMPANY.
COMPENSATION OF BOARD MEMBER	SCHEDULE J, PART II	SCLHS CONSISTS OF ELEVEN HOSPITALS AND FOUR CLINICS (AFFILIATES) IN FOUR STATES INCLUDING EXEMPLA, INC. SCLHS AND ITS AFFILIATES ADHERE TO GOVERNANCE EXCELLENCE STANDARDS INCLUDING TRANSPARENCY AND ACCOUNTABILITY. MICHAEL A. SLUBOWSKI IS PRESIDENT & CHIEF EXECUTIVE OFFICER FOR SISTERS OF CHARITY OF LEAVENWORTH HEALTH SYSTEM (SCLHS). HE ALSO SERVES AS A MEMBER OF THE EXEMPLA, INC.'S (EXEMPLA) BOARD AND AS CHAIRMAN. THE COMPENSATION REFLECTED IS THAT OF MR. SLUBOWSKI'S POSITION AS AN SCLHS EXECUTIVE AND NOT AS A MEMBER OF EXEMPLA'S BOARD. IN KEEPING WITH SCLHS' CORE VALUE OF STEWARDSHIP, NO BOARD MEMBER SERVING ON SCLHS OR AFFILIATE BOARDS IS COMPENSATED FOR THAT SERVICE.

Schedule J (Form 990) 2012

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

2012

Open to Public
Inspection

Name of the organization

EXEMPLA INC FKA LUTHERAN HOSPITAL

Employer identification number

84-1103606

Identifier	Return Reference	Explanation
EXEMPT PURPOSE ACHIEVEMENTS	FORM 990, PART III, QUESTION 4A - 4D	EXEMPLA INC. (EXEMPLA) OPERATES EXEMPLA LUTHERAN MEDICAL CENTER (ELMC), SERVING PRIMARILY WESTERN AND SOUTHERN SUBURBAN AREAS OF METRO DENVER, EXEMPLA GOOD SAMARITAN MEDICAL CENTER (EGSMC), SERVING PRIMARILY BOULDER AND NORTHWEST COUNTIES OF METRO DENVER, AND OTHER AFFILIATED MEDICAL OPERATIONS. THE SYSTEM'S COLLECTIVE PROGRAM SERVICES ACCOMPLISHMENTS INCLUDE BUT ARE NOT LIMITED TO THE FOLLOWING: MEDICAL SERVICES ARE PROVIDED TO ALL WHO SEEK SERVICE REGARDLESS OF RACE, CREED, SEX, NATIONAL ORIGIN, HANDICAP, AGE, OR ABILITY TO PAY. ALTHOUGH REIMBURSEMENT FOR SERVICES IS CRITICAL FOR THE OPERATION AND STABILITY OF EXEMPLA, IT IS RECOGNIZED THAT NOT ALL INDIVIDUALS POSSESS THE ABILITY TO PURCHASE ESSENTIAL MEDICAL SERVICES. THEREFORE, IN KEEPING WITH EXEMPLA'S COMMITMENT TO SERVE ALL MEMBERS OF ITS COMMUNITY, FREE CARE AND/OR SUBSIDIZED CARE WILL BE CONSIDERED AND PROVIDED WHERE THE NEED AND/OR AN INDIVIDUAL'S INABILITY TO PAY EXIST. IN ADDITION, EXEMPLA RECOGNIZES THE ESSENTIAL NEED TO BE EXCEPTIONAL STEWARDS OF MEDICARE, MEDICAID AND COMMUNITY/PRIVATE FUNDING DOLLARS. FOR 2012, EXEMPLA PROVIDED BENEFIT TO THE COMMUNITY AT A COST OF $47,553,648, INCLUDING CHARITY CARE, UNREIMBURSED MEDICAID, OTHER SUBSIDIZED HEALTH SERVICES AND EDUCATION. EXEMPLA ALSO RECOGNIZES THE ESSENTIAL NEED TO ENHANCE AND IMPROVE MEDICAL OUTCOMES, QUALITY AND SERVICES. IN RESPONSE, A BEST IN THE NATION STRATEGY AND PROGRAM WAS IMPLEMENTED. THE OBJECTIVES OF THE PROGRAM ARE TO BE THE BEST IN THE NATION IN PREDEFINED QUALITY, SERVICE AND COST INDICATORS. THE QUALITY INDICATORS ARE IN ALIGNMENT WITH MAJOR PUBLICLY COMPARABLE DATABASES INCLUDING THE COLORADO HEALTH AND HOSPITAL ASSOCIATION AND CENTERS FOR MEDICARE AND MEDICAID SERVICES. COLLECTIVELY WITH ITS 572 LICENSED BEDS AT ELMC AND EGSMC, EXEMPLA SERVED THE COMMUNITY WITH 27,215 INPATIENT ADMISSIONS, 114,109 EMERGENCY ROOM (ER) VISITS AND 362,700 EXEMPLA PHYSICIAN NETWORK (OUTPATIENT CLINICS) ENCOUNTERS. COMPREHENSIVE MEDICAL SERVICES INCLUDE, BUT ARE NOT LIMITED TO, CARDIOLOGY, ONCOLOGY, ORTHOPEDIC, WOMEN AND FAMILY, PEDIATRICS, EMERGENCY AND TRAUMA, NEONATAL INTENSIVE CARE, NEUROLOGY, NEUROSURGERY, OB/GYN, GENERAL SURGICAL AND MEDICAL, PRIMARY CARE, INTERNAL MEDICINE, BEHAVIORAL HEALTH, HOSPICE CARE AND INTEGRATIVE HEALTH SERVICES. A STRONG COMMITMENT TO THE HEALTH OF THE COMMUNITY IS FURTHER EXEMPLIFIED, BUT NOT LIMITED TO, THE FOLLOWING PROGRAMS: EXEMPLA LUTHERAN MEDICAL CENTER WITH ITS 338 LICENSED BEDS, ELMC SERVED THE COMMUNITY WITH 13,983, INPATIENT ADMISSIONS AND 73,030 EMERGENCY ROOM VISITS. SERVICES AND PROGRAMS -THE CANCER CENTER AT ELMC INCLUDES ALL STAGES OF CARE INCLUDING INITIAL DIAGNOSIS; GIVING, MONITORING, AND MANAGING MEDICATIONS; PATIENTS AND FAMILY. THE CENTER INCLUDES STATE-OF-THE -ART-RADIATION ONCOLOGY CENTER, INFUSION CENTER, ONCOLOGY UNIT, CLINICAL TRIALS, NUTRITION COUNSELING, SOCIAL WORK SERVICES, SITE SPECIFIC CARE TEAM, EDUCATION AND SUPPORT SERVICES. -AT THE HEART AND NEUROVASCULAR CENTER, PATIENTS ARE TREATED BY AN INTERDISCIPLINARY TEAM FOR CARDIAC AND NEUROLOGICAL CARE. PATIENTS DO NOT NEED TO BE TRANSFERRED TO ANOTHER FACILITY. THE CENTER FEATURES ADVANCED IMAGING EQUIPMENT AND NEUROLOGICAL SUITES TO SPEED PATIENTS' CARE. -THE BREAST CARE CENTER ACCREDITED BY THE AMERICAN COLLEGE OF RADIOLOGY AND THE NATIONAL ACCREDITATION BREAST CARE CENTER, PROVIDES A FULL RANGE OF HIGH-TECH SERVICES IN ITS SCREENING AND DIAGNOSTIC SUITES INCLUDING DIGITAL MAMMOGRAPHY SCREENINGS AND DIAGNOSTIC SUITES INCLUDING DIGITAL MAMMOGRAPHY SCREENINGS AND DIAGNOSTIC SERVICES ULTRASOUND, STEREOTACTIC BIOPSIES, MEDICAL CONSULTATION, EDUCATION, AS WELL AS AN ALTERNATIVE HEALTH CENTER AND EMOTIONAL SUPPORT. -THE WOMEN AND FAMILY CENTER INCLUDES A LEVEL III NEONATAL INTENSIVE CARE UNIT AND COMPREHENSIVE PRENATAL AND PARENTING EDUCATION. THE ANTEPARTUM FAMILY UNIT HELPS PREGNANT WOMEN WHO NEED SPECIALIZED CARE FOR THEMSELVES AND/OR THEIR UNBORN BABIES. SUPPORT FOR THE NEW UNIT HELPS US REACH OUR GOAL TO HELP WOMEN HAVE HEALTHY PREGNANCIES, BIRTHS AND BABIES. o THE DIAGNOSTIC IMAGING CENTER IS ONE OF DENVER'S MOST ADVANCED IMAGING CENTER FEATURING COMPREHENSIVE STATE-OF-THE-ART DIAGNOSTIC IMAGING SERVICES FIVE BASIC MODALITIES: 40 SLICE CT SCANNER; 3.0 TELSA MRI SYSTEM; 3d MAMMO EQUIPMENT ULTRASOUND ROOMS WITH ADJOINED CHANGING ROOMS AND RESTROOMS; AND DIAGNOSTIC TECHNOLOGY IN ALL-DIGITAL ENVIRONMENT. -THE HUMAN MOTION INSTITUTE (HMI) OFFERS STATE-OF-THE-ART MUSCULOSKELETAL CARE. HMI COMBINES THE MOST ADVANCED MEDICAL TECHNOLOGY WITH A DEDICATED TEAM OF PHYSICIANS AND MEDICAL PROFESSIONALS. THE FOCUS IS ON PREVENTION, ASSESSMENT, TREATMENT AND REHABILITATION OF MUSCULOSKELETAL INJURIES. -BUSY 52 BED LEVEL 3 EMARGENCY DEPARTMENT PROVIDING CARE FOR ALL DIFFERENT TYPES OF PATIENTS RANGING FROM NEWBORN THOUGHT GERIARTICS. THE EMERGENCY DEPARTMENT PROVIDES MORE THAN 72,000 VISITS PER YEAR BETWEEN OUR MAIN ED AND OUR SENIOR EMAGRENCY DEPARTMENT. QUALIFIED PHYSICIANS, RN'S, AND TECHS ARE AVAILABLE 24 HRS/DAY, 7 DAYS A WEEK TO ATTEND TO ALL DIFFERENT TYPES OF EMERGENCIES. WE DELIVER CARE FOR ALL LEVELS THAT RANGE FROM SPRAINS AND STRAINS TO THE LIFE THREATENING EMERGENCIES SUCH AS TRAUMA, CARDIAC, AND STROKES. -COLLIER HOSPICE CENTER PROVIDES COMPASSIONATE, COMPREHENSIVE, INTERDISCIPLINARY END-OF-LIFE CARE FOR TERMINALLY ILL PATIENTS AND SUPPORT FOR THEIR FAMILIES. PATIENTS ARE SERVED IN THEIR HOMES, IN NURSING HOMES AND IN THE HOSPICE INPATIENT UNIT LOCATED ON ELMC'S CAMPUS. FREE COMMUNITY SERVICES: VOLUNTEER-BASED PRE-HOSPICE SUPPORT, GRIEF SUPPORT GROUPS, GRIEF EDUCATION WORKSHOPS, CAREGIVER SUPPORT GROUPS AND GRIEF SUPPORT FOR YOUNG PEOPLE. -EXEMPLA COLORADO LUTHERAN HOME (CLH) PROVIDES INDEPENDENT AND ASSISTED-LIVING ACCOMMODATIONS FOR OLDER ADULTS AND IS RECOGNIZED AS AN EDEN ALTERNATIVE FACILITY. IT IS AN ELDER-CENTERED COMMUNITY THAT IMBUES DAILY LIFE WITH VARIETY AND SPONTANEITY. CLH IS A SKILLED NURSING FACILITY THAT INCLUDES A SECURED ALZHEIMER'S UNITS FOR PATIENTS NEEDING 24/7 CARE. -EXEMPLA WEST PINES IS A BEHAVIORAL HEALTH FACILITY THAT PROVIDES INPATIENT AND OUTPATIENT PSYCHIATRIC AND ADDICTION SERVICES TO ADULTS. THE WEST PINES RECOVERY CENTER OFFERS AN INNOVATIVE TWO-WEEK ADDICTION RECOVERY PROGRAM TO CLIENTS AND THEIR FAMILIES WHO STRUGGLE WITH ADDICTION, OR ADDICTION PLUS MENTAL ILLNESS. AFTER THE TWO-WEEK STAY, CLIENTS RECEIVE INTENSIVE OUTPATIENT ASSISTANCE AND OPTIONAL MEDICATION MANAGEMENT. THE PROGRAM PROVIDES SHORTER STAYS AND LOWER COSTS. THE SENIOR BEHAVIORAL HEALTH IS A 20 BED UNIT LOCATED AT ELMC TO TREAT SENIORS WITH PSYCHIATRIC ILLNESSES. -BRIDGES INTEGRATIVE HEALTH AND WELLNESS OFFERS INTEGRATIVE CARE (ACUPUNCTURE, MASSAGE, HEALING TOUCH, PULMONARY REHABILITATION, PHYSICAL THERAPY AND CARDIAC REHABILITATION). -THE EXEMPLA LUTHERAN MEDICAL CENTER FOUNDATION WAS ESTABLISHED IN 2007, IN RESPONSE TO DONOR DEMAND FOR A FOUNDATION EXCLUSIVELY DEDICATED TO THE CURRENT AND FUTURE NEEDS OF ELMC. AT ITS CORE, THE FOUNDATION HAS A COMMITMENT AND DEDICATION TO PROVIDING FOR THE EVOLVING HEALTH CARE NEEDS OF OUR COMMUNITY, WHETHER THAT IS UPDATING FACILITIES, ADDING NEW TECHNOLOGIES, OR DEVELOPING INNOVATIVE NEW PARTNERSHIPS AND SERVICES. -ESTES STREET COMMUNITY CLINIC IS A PARTNERSHIP BETWEEN ELMC, THE JEFFCO ACTION CENTER AND METRO COMMUNITY PROVIDER NETWORK. THE CLINIC SERVES HOMELESS AND LOW-INCOME CHILDREN AND ADULTS WITHOUT INSURANCE. IT PROVIDES ACUTE AND PREVENTIVE CARE, IMMUNIZATIONS AND WELL-CHILD AND WELL-WOMEN CHECKUPS.
-ELMC PROVIDES COMPREHENSIVE EDUCATION PROGRAMS WITH OPPORTUNITIES FOR ALL		AGES. THROUGH EDUCATION, RELIABLE HEALTH INFORMATION AND SUPPORT, THE PROGRAM PARTNERS WITH DOCTORS AND OTHER HEALTH CARE EXPERTS TO IMPROVE COMMUNITY HEALTH. EXEMPLA GOOD SAMARITAN MEDICAL CENTER WITH ITS 234 LICENSED BEDS, EGSMC SERVED THE COMMUNITY WITH 13,232 INPATIENT ADMISSIONS AND 41,079 EMERGENCY ROOM VISITS. SERVICES AND PROGRAMS o CARDIAC AND VASCULAR SERVICES INCLUDES THE CARDIAC CALCIUM SCORE FOR DETECTING HEART DISEASE RISK. -EMERGENCY AND TRAUMA SERVICES INCLUDES A LEVEL III TRAUMA CENTER, INCLUDING STROKE AND TELEMEDICINE. -BONE AND JOINT INSTITUTE INCLUDES A COMPREHENSIVE TREATMENT OF ALL JOINT INJURIES AND REPLACEMENT. FULL SERVICE PHYSICAL THERAPY IS ALSO AVAILABLE. -NEUROSCIENCES: IN 2009, GOOD SAMARITAN MEDICAL CENTER ADDED TWO BREAKTHROUGH NEUROSCIENCE TECHNOLOGIES - THE INFRARED 800TM AND THE OPMI PENTERO - FOR TREATMENT OF STROKES, ANEURYSMS, BRAIN TUMORS AND OTHER CONDITIONS. IN 2010, THE HOSPITAL EMPLOYED A STROKE FELLOWSHIP-TRAINED PHYSICIAN AND HAS CREATED A STROKE CENTER. -OTOLARYNGOLOGY INCLUDES BALLOON SINUPLASTY. -WOMEN AND FAMILY CENTER INCLUDES A LEVEL II NEONATAL INTENSIVE CARE AND COMPREHENSIVE PRENATAL AND PARENTING EDUCATION. SUPPORT FOR THE UNIT HELPS US REACH OUR GOAL TO HELP WOMEN HAVE HEALTHY PREGNANCIES, BIRTHS AND BABIES. EGSMC ALSO IS THE FIRST HOSPITAL TO RECEIVE THE BABY-FRIENDLY DESIGNATION IN COLORADO. o INPATIENT AND OUTPATIENT SURGICAL SERVICES INCLUDES A BONE & JOINT INSTITUTE. -NEUROSURGERY, INCLUDING O-ARM TECHNOLOGY FOR COMPLEX NEUROSURGICAL CASES AND THE OPMI PENTERO MICROSCOPE, A STATE OF THE ART IMPROVEMENT IN INTRA-OPERATIVE VISUALIZATION FOR BRAIN TUMORS AND ANEURYSMS, THE ONLY ONE OF ITS KIND IN THE REGION. EGSMC ALSO BEGAN A DEEP BRAIN STIMULATION SERVICE FOR TREATMENT OF SEVERE MOVEMENT DISORDER LIKE ADVANCED PARKINSON'S DISEASE -INTERVENTIONAL AND DIAGNOSTIC RADIOLOGY INCLUDING A 64-SLICE CT SCANNER. OTHER SERVICES INCLUDE MRI, ULTRASOUND AND DIAGNOSTIC IMAGING. -EGSMC'S HEALTH & HEALING CENTER OFFERS INPATIENT AND OUTPATIENT INTEGRATIVE CARE (ACUPUNCTURE, MASSAGE, HEALING TOUCH, PULMONARY REHABILITATION, PHYSICAL THERAPY AND CARDIAC REHABILITATION). -THE EXEMPLA GOOD SAMARITAN MEDICAL CENTER FOUNDATION WAS ESTABLISHED IN 2005 TO FUND THE CURRENT AND FUTURE NEEDS OF EGSMC. AT ITS CORE, THE FOUNDATION HAS A COMMITMENT AND DEDICATION TO PROVIDING FOR THE EVOLVING HEALTH CARE NEEDS OF OUR COMMUNITY, WHETHER IT IS UPDATING FACILITIES, ADDING NEW TECHNOLOGIES, OR DEVELOPING INNOVATIVE NEW PARTNERSHIPS AND SERVICES. -EGSMC PROVIDES WELLNESS QUEST, A COMPREHENSIVE EDUCATION PROGRAM WITH OPPORTUNITIES FOR ALL AGES. THROUGH EDUCATION, RELIABLE HEALTH INFORMATION AND SUPPORT, THE PROGRAM PARTNERS WITH DOCTORS, OTHER HEALTH CARE EXPERTS AND SCHOOLS TO IMPROVE COMMUNITY HEALTH. -EGSMC WORKS CLOSELY WITH CLINICA CAMPESINA, A LAFAYETTE-BASED, FEDERALLY-QUALIFIED CLINIC FOR INDIGENT AND LOW INCOME INDIVIDUALS IN BOULDER COUNTY, PROVIDING ASSISTANCE TO FAMILIES IN NEED. -EGSMC PARTICIPATES IN THE CRAYONS TO CALCULATORS PROGRAM ANNUALLY TO ASSIST FAMILIES IN NEED WITH NECESSARY SCHOOL SUPPLIES, INCLUDING BACKPACKS. -EGSMC'S BABY'S FIRST RIDE PROGRAM IS A SERVICE OFFERED TO ALL FAMILIES DELIVERING AT OUR HOSPITAL. PARENTS ARE TAUGHT THE PROPER WAY TO INSTALL AND USE A CAR SEAT TO ENSURE THEIR BABY'S FIRST RIDE IS A SAFE ONE. -THE EGSMC FOUNDATION STRIVES TO BE THE OPEN DOOR FOR THOSE IN OUR COMMUNITY WHO ARE AS PASSIONATELY COMMITTED TO THE EXEMPLA GOOD SAMARITAN MEDICAL CENTER'S VISION AS WE ARE. THROUGH THE FOUNDATION, DONORS WILL BE ABLE TO HELP EXEMPLA GOOD SAMARITAN MEDICAL CENTER REMAIN A UNIQUE HEALING ENVIRONMENT IN THIS COMMUNITY, USE THE MOST ADVANCED MEDICAL TECHNOLOGY, USE THE BEST PRACTICES IN CLINICAL CARE ANYWHERE, AND BE A GOOD SAMARITAN TO THOSE WHO NEED US MOST. EXEMPLA PHYSICIAN NETWORK 2012 VOLUME - 362,700 CLINIC VISITS -19 PRIMARY CARE/OCCUPATIONAL MEDICINE/PHYSICAL AND OCCUPATIONAL THERAPY CLINICS -26 SPECIALTY CLINICS INCLUDE CARDIOLOGY, CARDIO-THORACIC SURGERY, ORTHOPEDIC SURGERY, NEUROSURGERY, NEUROLOGY, ENDOCRINOLOGY, OB-GYN, UROGYNECOLOGY, SPORTS MEDICINE, AND GENERAL SURGERY. -1 URGENT CARE CLINICS
BOND ISSUANCES	PART IV, QUESTION 24	DURING 2010, ALL TAX-EXEMPT BONDS, WITH THE EXCEPTION OF BONDS ISSUED PRIOR TO DECEMBER 31, 2002, WERE TRANSFERRED TO SISTERS OF CHARITY OF LEAVENWORTH HEALTH SYSTEM'S (SCLHS) MASTER TRUST INDENTURE. FURTHER, ALL EXISTING FIXED RATE DEBT OF EXEMPLA, INC. WAS REFINANCED UNDER THE SCLHS MASTER TRUST INDENTURE DURING 2010. AS EXEMPLA, INC. HAS NO OUTSTANDING TAX-EXEMPT BONDS ISSUED AFTER DECEMBER 31, 2002, EXEMPLA IS NOT REQUIRED TO COMPLETE SCHEDULE K. ALL DISCLOSURES FOR THE BONDS THAT ARE WITHIN SCLHS'S MASTER TRUST INDENTURE ARE INCLUDED IN THE SCLHS FORM 990. DELEGATION OF BOARD AUTHORITY TO AN EXECUTIVE COMMITTEE FORM 990, PART VI, QUESTION 1A PURSUANT TO THE BYLAWS, THE EXECUTIVE COMMITTEE OF THE ORGANIZATION HAS THE POWER TO TRANSACT ALL REGULAR BUSINESS OF THE ORGANIZATION DURING THE INTERIM BETWEEN MEETINGS OF THE BOARD, PROVIDED THAT ANY ACTION TAKEN BY THE EXECUTIVE COMMITTEE DOES NOT CONFLICT WITH THE ARTICLES OF INCORPORATION, THE BYLAWS OR THE POLICIES OR EXPRESSED WISHES OF THE BOARD. THE EXECUTIVE COMMITTEE SHALL REPORT ALL MATTERS ACTED UPON TO THE BOARD AT THE BOARD'S NEXT MEETING. THE EXECUTIVE COMMITTEE CONSISTS OF AT LEAST THREE MEMBERS, ALL OF WHOM SHALL BE MEMBERS OF THE BOARD OF DIRECTORS, AND INCLUDE THE CHAIRPERSON OF THE BOARD, THE PRESIDENT/CEO AND OTHERS AS DESIGNATED BY THE CHAIRPERSON. DELEGATION OF CONTROL OVER MANAGEMENT DUTIES FORM 990, PART VI, QUESTION 3 IN JUNE 2008, EXEMPLA, INC., AS MANAGER OF EXEMPLA SAINT JOSEPH HOSPITAL, ENTERED INTO A MANAGEMENT AGREEMENT WITH INSIGHT ONCOLOGY FOR THE MANAGEMENT OF THE HOSPITAL'S COMPREHENSIVE CANCER CENTER SERVICES. IN DECEMBER 2008, LUTHERAN CAMPUS ASC, LLC, LOCATED ON THE ELMC CAMPUS, OF WHICH EXEMPLA PARTNERS, LLC IS A MEMBER, ENTERED INTO AN AGREEMENT WITH PINNACLE III, LLC FOR THE MANAGEMENT OF THE COMPANY. CHANGES TO ORGANIZATIONAL DOCUMENTS FORM 990, Part VI, QUESTION 4 EFFECTIVE OCTOBER 1, 2012, SISTERS OF CHARITY OF LEAVENWORTH HEALTH SYSTEM (SCLHS) AND COMMUNITY FIRST FOUNDATION AGREED TO AMEND AND RESTATE THE BYLAWS OF EXEMPLA. UNDER THE AMENDMENTS, COMMUNITY FIRST FOUNDATION'S INTEREST IN THE JOINT OPERATING AGREEMENT AND OTHER RIGHTS OF COMMUNITY FIRST FOUNDATION RELATED TO EXEMPLA WERE TERMINATED. IN RETURN, SCLHS COMMITTED TO PROVIDE $275 MILLION TO COMMUNITY FIRST FOUNDATION OVER A PERIOD OF 20 YEARS. THE BOARD OF DIRECTORS OF EXEMPLA WILL CONTINUE TO CONSIST OF 10 MEMBERS, 9 OF WHICH ARE APPOINTED BY SCLHS AND 1 OF WHICH IS APPOINTED BY COMMUNITY FIRST FOUNDATION.
MEMBERS OR STOCKHOLDERS	FORM 990, PART VI, QUESTION 6	THE ORGANIZATION HAS TWO MEMBERS: COMMUNITY FIRST FOUNDATION (CFF) AND SISTERS OF CHARITY OF LEAVENWORTH HEALTH SYSTEM (SCLHS)
ELECTION OF MEMBERS OF GOVERNING BODY	FORM 990, PART VI, QUESTION 7A	CFF APPOINTS 5 OF THE DIRECTORS AND SCLHS APPOINTS 5.
DECISIONS OF GOVERNING BODY SUBJECT TO APPROVAL	FORM 990, PART VI, QUESTION 7B	BOTH MEMBERS (COMMUNITY FIRST FOUNDATION AND SISTERS OF CHARITY OF LEAVENWORTH HEALTH SYSTEM, SCLHS) HAVE CERTAIN RESERVE POWERS TO APPROVE CHANGES TO THE BYLAWS REGARDING APPOINTMENT OF BOARD MEMBERS. SCLHS ALSO HAS EXTENSIVE RESERVE POWERS OVER ANY CHANGE IN MISSION, CHANGES TO THE ARTICLES OF INCORPORATION OR BYLAWS, ACQUISITION OF ASSETS, INCURRENCE OF DEBT, MERGER OR DISSOLUTION, APPROVAL OF STRATEGIC PLANS AND BUDGETS, AND APPOINTMENT OF AUDITORS.
990 REVIEW PROCESS	FORM 990, PART VI, QUESTION 11B	ALL 990 REPORTING WAS REVIEWED INTERNALLY WITH SENIOR MANAGEMENT. ALL QUESTIONS AND CHANGES PROPOSED WERE ADDRESSED PRIOR TO FILING FORM 990. A DRAFT 990 WAS PROVIDED TO THE MEMBERS OF THE FINANCE COMMITTEE AND OF THE BOARD FOR REVIEW. A COMPLETE COPY OF THE FINAL FORM 990 WAS THEN PROVIDED ELECTRONICALLY TO EACH VOTING MEMBER OF THE EXEMPLA BOARD OF DIRECTORS PRIOR TO ITS SUBMISSION TO THE INTERNAL REVENUE SERVICE.
MONITORING COMPLIANCE WITH CONFLICT OF INTEREST POLICY	FORM 990, PART VI, QUESTION 12C	THE ORGANIZATION REGULARLY AND CONSISTENTLY MONITORS AND ENFORCES ITS CONFLICT OF INTEREST POLICY BY PROVIDING EDUCATION AND TRAINING FOR EACH OF ITS EMPLOYEES, STAFF, OFFICERS AND DIRECTORS, AS WELL AS HAVING EACH OF THESE INDIVIDUALS COMPLETE A CONFLICT OF INTEREST STATEMENT ON AN ANNUAL BASIS TO DISCLOSE ANY POTENTIAL CONFLICT ISSUES. THESE STATEMENTS ARE CAREFULLY REVIEWED BY THE LEGAL DEPARTMENT. WHEN A CONFLICT IS IDENTIFIED, THE LEGAL DEPARTMENT COMPILES ALL REPORTED CONFLICTS, AND EVALUATES THE DISCLOSURES FOR ACTUAL CONFLICTS. A REPORT IS PROVIDED TO ORGANIZATION'S PRESIDENT/CEO REGARDING EMPLOYEES AND OFFICERS, AND TO THE CHAIR OF THE BOARD AND CHAIR OF THE GOVERNANCE COMMITTEE REGARDING BOARD MEMBERS. THOSE WITH IDENTIFIED CONFLICTS OF INTEREST MUST RECUSE THEMSELVES FROM ANY MEETING DURING THE DISCUSSION AND VOTE THEREOF.
PROCESS FOR DETERMINING COMPENSATION OF CEO, OFFICERS, OR KEY EMPLOYEES	FORM 990, PART VI, QUESTION 15A & 15B	COMPENSATION FOR THE CEO IS PAID BY SISTERS OF CHARITY OF LEAVENWORTH HEALTH SYSTEM, A RELATED NON-PROFIT ORGANIZATION. COMPENSATION OF OTHER OFFICERS AND KEY EMPLOYEES IS PAID BY EITHER EXEMPLA, INC. OR SISTERS OF CHARITY OF LEAVENWORTH HEALTH SYSTEM. WHEN REVIEWING AND SETTING COMPENSATION FOR 'DISQUALIFIED PERSONS', EXEMPLA'S PROCESS INCLUDES: THE COMPENSATION COMMITTEE OF THE BOARD IS CHARGED WITH THE RESPONSIBILITY FOR SETTING THE OVERALL COMPENSATION PHILOSOPHY AND FOR EVALUATING THE TOTAL COMPENSATION PROGRAMS FOR DISQUALIFIED PERSONS. THE BOARD MEMBERS ARE INDEPENDENT MEMBERS AND IN THESE DISCUSSIONS THE CEO RECUSES HIMSELF FROM THE DISCUSSIONS AROUND HIS OWN COMPENSATION. THE COMMITTEE OBTAINS VALID, COMPARABLE MARKET DATA (FROM INDEPENDENTLY PUBLISHED SOURCES) FOR COMPARABLE POSITIONS AND FROM FORM 990 FILINGS. THIS COMMITTEE ENGAGES THE SERVICES OF AN INDEPENDENT EXPERT IN EXECUTIVE COMPENSATION TO REVIEW THE MARKET DATA AND PROVIDE AN OPINION AS TO THE REASONABLENESS OF THE TOTAL COMPENSATION PROGRAM. FOR THE PAST SEVERAL YEARS, THE INDEPENDENT FIRM HAS BEEN WATSON WYATT. WATSON WYATT VALIDATES THE PROCESS USED BY MANAGEMENT FOR IDENTIFYING 'DISQUALIFIED PERSONS' AND THEN CONDUCTS A COMPARABILITY STUDY/ANALYSIS OF PAY AT SIMILAR TYPES AND SIZES OF ORGANIZATIONS AND REVIEWS BASE SALARY, INCENTIVE (OR OVER-BASE PROGRAMS), BENEFITS, RETIREMENT PLANS AND PERQUISITES. WATSON WYATT REVIEWS THE FINDINGS WITH THE BOARD COMMITTEE AND MINUTES ARE PREPARED AND SHARED WITH ALL THE VOTING BOARD MEMBERS EACH YEAR THAT DOCUMENTS THE DISCUSSION AND ANY ACTIONS THAT MAY HAVE BEEN TAKEN. A COPY OF A FORMAL OPINION LETTER PREPARED BY WATSON WYATT FOLLOWING THE DISCUSSION WITH THE COMPENSATION COMMITTEE IS PROVIDED TO THE BOARD CHAIR AND SHARED WITH THE FULL BOARD. THIS PROCESS IS UNDERTAKEN EACH YEAR. SCLHS EMPLOYS THE EXECUTIVE TEAM AT EACH OF ITS HOSPITAL AFFILIATES, INCLUDING EXEMPLA. AS PART OF ITS ANNUAL REVIEW PROCESS, SCLHS USES THE FOLLOWING IN ESTABLISHING THE COMPENSATION OF THOSE IN THESE POSITIONS: 1) COMPENSATION COMMITTEE, 2) INDEPENDENT COMPENSATION CONSULTANT, 3) FORM 990 OF OTHER ORGANIZATIONS, 4) WRITTEN EMPLOYMENT CONTRACTS, 5) COMPENSATION SURVEYS AND STUDIES, 6) APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE. THE ABOVE SUPPORT THE COMPENSATION COMMITTEE'S EFFORTS TO ENSURE THAT THE LEVEL OF COMPENSATION PROVIDED TO ITS EXECUTIVES (OFFICERS, KEY EMPLOYEES, ETC.) IS CONSISTENT WITH MARKET VALUE AND THE PAY PHILOSOPHY SET BY THE BOARD. THE PAY PHILOSOPHY SET BY THE BOARD IS TO PAY AT THE MIDDLE OF THE MARKET FOR EXECUTIVES OF SIMILAR SIZED ORGANIZATIONS OVERALL. SCLHS' EXECUTIVE COMPENSATION IS COMPARABLE TO THAT PROVIDED IN SIMILAR, NOT-FOR-PROFIT HEALTHCARE SYSTEMS AND HOSPITALS.
AVAILABILITY OF GOVERNING DOCS, CONFLICT OF INTEREST POLICY, FINANCIALS	FORM 990, PART VI, QUESTION 19	GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, FINANCIAL STATEMENTS, AND RELATED DOCUMENTS ARE PROVIDED UPON REQUEST AS DEEMED APPROPRIATE.
INDEPENDENT CONTRACTORS	PART VII, SECTION B, QUESTION 2 AND PART V, LINES 1A-1B	EXEMPLA, INC., AS THE PARENT COMPANY/MANAGER OF OTHER ENTITIES, INCLUDING ST JOSEPH HOSPITAL, MAKES ALL VENDOR PAYMENTS FOR THOSE ENTITIES. THE DOLLAR AMOUNTS AND TOTAL NUMBER OF PAYMENTS TO INDEPENDENT CONTRACTORS REFLECTED IN THIS RETURN ARE THE COMBINED PAYMENTS FOR EXPENDITURES OF ALL SUCH ENTITIES.
OTHER CHANGES IN NET ASSETS	PART XI, LINE 9	OTHER CHANGES IN NET ASSETS: CHANGE IN FUNDED STATUS OF PENSION (2,171,446) CHANGE IN INVESTMENT IN SCLHS (5,623,047) MISCELLANEOUS ADJUSTMENT (16,946) TOTAL (7,811,439)

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

Cat. No. 51056K

Schedule O (Form 990 or 990-EZ) 2012

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

2012

Open to Public Inspection

Name of the organization

EXEMPLA INC FKA LUTHERAN HOSPITAL

Employer identification number

84-1103606

Part I

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

(a) Name, address, and EIN (if applicable) of disregarded entity	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Total income	(e) End-of-year assets	(f) Direct controlling entity
(1) EXEMPLA PARTNERS LLC 8300 W 38TH AVE WHEAT RIDGE,CO80033 02-0749530	JT VENTURE IN	CO	48,114	2,030,235	EXEMPLA INC
(2) Lutheran Health Partners LLC 8300 W 38TH AVE WHEAT RIDGE,CO80033 84-1103606	HC IMPROVEMEN	CO	0	550,370	EXEMPLA PART
(3) EXEMPLA GOOD SAMARITAN MEDICAL CTR LLC 200 EXEMPLA CIRCLE LAFAYETTE,CO80026 43-1982139	HEALTHCARE	CO	256,422,929	388,642,559	EXEMPLA INC

Part II

Identification of Related Tax-Exempt Organizations (Complete if the organization answered "Yes" to 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 entity?
(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) SISTERS OF CHARITY LEAVENWORTH HLTH SYST 2420 W 26TH AVE SUITE 100D DENVER,CO80211 23-7379161	SUPPORT MMBRS	KS	501(C)(3)	11B-TYPE II	NA		No
(2) CARITAS CLINICS INC 818 NORTH 7TH STREET LEAVENWORTH,KS66048 48-1009910	CLINIC SVCS	KS	501(C)(3)	3	SCLHS	Yes
(3) MARIAN CLINIC INC 1001 SW GARFIELD TOPEKA,KS66604 48-1046905	CLINIC SVCS	KS	501(C)(3)	3	SCLHS	Yes
(4) MARILLAC CLINIC INC 2333 N 6TH STREET GRAND JUNCTION,CO81501 84-1085822	CLINIC SVCS	CO	501(C)(3)	3	SCLHS	Yes
(5) PROVIDENCE MEDICAL CENTER 8929 PARALLEL PARKWAY KANSAS CITY,KS66112 48-0784446	HEALTHCARE	KS	501(C)(3)	3	SCLHS	Yes
(6) ST JOHN HOSPITAL INC 3500 SOUTH FOURTH STREET LEAVENWORTH,KS66048 48-0543768	HEALTHCARE	KS	501(C)(3)	3	PMC	Yes
(7) BETHANY COMMUNITY PLAZA INC 15 NORTH 12TH STREET KANSAS CITY,KS66102 48-1207407	HEALTHCARE	KS	501(C)(3)	3	PMC	Yes
(8) PROVIDENCEST JOHN FOUNDATION INC 8929 PARALLEL PARKWAY KANSAS CITY,KS66112 48-0925688	SUPPORT 501C3	KS	501(C)(3)	7	PMC	Yes
(9) ST FRANCIS HEALTH CENTER INC 1700 SW 7TH STREET TOPEKA,KS66606 48-0547719	HEALTHCARE	KS	501(C)(3)	3	SCLHS	Yes
(10) ST FRANCIS HEALTH CENTER FOUNDATION 1700 SW 7TH STREET TOPEKA,KS66606 48-1092520	SUPPORT 501C3	KS	501(C)(3)	11A-TYPE I	SFHC	Yes
(11) ST MARYS HOSPITAL & MEDICAL CENTER INC 2635 N 7TH STREET GRAND JUNCTION,CO81502 84-0425720	HEALTHCARE	CO	501(C)(3)	3	SCLHS	Yes
(12) ST MARYS HOSPITAL FOUNDATION 2635 N 7TH STREET GRAND JUNCTION,CO81502 23-7001007	SUPPORT 501C3	CO	501(C)(3)	11A-TYPE I	SMHMC	Yes
(13) SAINT JOSEPH HOSPITAL FOUNDATION 1835 FRANKLIN STREET DENVER,CO80218 84-0735096	SUPPORT 501C3	CO	501(C)(3)	11A-TYPE I	SJH	Yes
(14) HOLY ROSARY HEALTHCARE 2600 WILSON MILES CITY,MT59301 81-0231792	HEALTHCARE	MT	501(C)(3)	3	SCLHS	Yes
(15) HOLY ROSARY HEALTHCARE FOUNDATION INC 2600 WILSON MILES CITY,MT59301 20-2270238	SUPPORT 501C3	MT	501(C)(3)	11A-TYPE I	HRHC	Yes
(16) ST VINCENT HEALTHCARE 1233 NORTH 30TH BILLINGS,MT59101 81-0232124	HEALTHCARE	MT	501(C)(3)	3	SCLHS	Yes
(17) ST VINCENT HEALTHCARE FOUNDATION PO BOX 35200 BILLINGS,MT59107 81-0468034	SUPPORT 501C3	MT	501(C)(3)	7	SVHC	Yes
(18) NORTHWEST RESEARCH & EDUCATION INSTITUTE 315 NORTH 25TH STREET BILLINGS,MT59101 20-1343024	COMM HLTH RES	MT	501(C)(3)	9	SVHC	Yes
(19) ST JAMES HEALTHCARE 400 SOUTH CLARK STREET BUTTE,MT59701 81-0231785	HEALTHCARE	MT	501(C)(3)	3	SCLHS	Yes
(20) ST JAMES HEALTHCARE FOUNDATION 400 SOUTH CLARK STREET BUTTE,MT59701 65-1202190	SUPPORT 501C3	MT	501(C)(3)	11A-TYPE I	SJHC	Yes
(21) SAINT JOHNS HEALTH CENTER 2121 SANTA MONICA BLVD SANTA MONICA,CA90404 95-1684082	HEALTHCARE	CA	501(C)(3)	3	SCLHS	Yes
(22) JOHN WAYNE CANCER INSTITUTE 2000 SANTA MONICA BLVD SANTA MONICA,CA90404 95-4291515	CANCER R&D	CA	501(C)(3)	4	SJHHC	Yes
(23) SAINT JOHNS HOSPITAL & HLTH CENTER FNDTN 2121 SANTA MONICA BLVD SANTA MONICA,CA90404 95-6100079	SUPPORT 501C3	CA	501(C)(3)	11A-TYPE I	SJHHC	Yes
(24) EXEMPLA LUTHERAN MEDICAL CENTER FNDTN 2480 W 26TH AVESUITE 360B DENVER,CO80211 20-8846152	SUPPORT 501C3	CO	501(C)(3)	7	EXEMPLA INC	Yes
(25) EXEMPLA GOOD SAMARITAN MEDICAL CTR FNDTN 200 EXEMPLA CIRCLE LAFAYETTE,CO80026 84-1649162	SUPPORT 501C3	CO	501(C)(3)	7	EXEMPLA INC	Yes
(26) LUTH MED CNTR PRO&GEN LIAB SELF-INS TRST 2480 W 26TH AVE SUITE 360B DENVER,CO80211 74-2571584	INSURANCE	CO	501(C)(3)	11A-TYPE I	EXEMPLA INC	Yes
(27) SAINT JOSEPH HOSPITAL 1835 FRANKLIN STREET DENVER,CO80218 84-0417134	HEALTHCARE	CO	501(C)(3)	3	SCLHS	Yes
(28) MOUNT ST VINCENT HOME INC 4159 LOWELL BOULEVARD DENVER,CO80211 84-0405260	RESIDENT CARE	CO	501(C)(3)	11A-TYPE I	SCLHS	Yes

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

Cat. No. 50135Y

Schedule R (Form 990) 2012

Page 2

Part III

Identification of Related Organizations Taxable as a Partnership (Complete if the organization answered "Yes" to Form 990, Part IV, line 34 because it had one or more related organizations treated as a partnership during the tax year.)

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(e) Predominant income(related, unrelated, excluded from tax under sections 512-514)	(f) Share of total income	(g) Share of end-of-year assets	(h) Disproprtionate allocations?		(i) Code VUBI amount in box 20 of Schedule K-1 (Form 1065)	(j) General or managing partner?		(k) Percentage ownership
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity		(f) Share of total income	(g) Share of end-of-year assets	Yes	No	(i) Code VUBI amount in box 20 of Schedule K-1 (Form 1065)	Yes	No
(1) PAVILION IMAGING LLC 750 WELLINGTON GRAND JUNCTION,CO81501 03-0516198	RADIOLOGY	CO	NA	N/A				No			No
(2) GRAND VALLEY SURGICAL CENTER LLC 710 WELLINGTON GRAND JUNCTION,CO81501 84-1505075	OP SURGERY	CO	NA	N/A				No			No
(3) SAN JUAN CANCER CENTER LLC 600 SOUTH 5TH STREET MONTROSE,CO81401 20-2856331	OP CANCER	CO	NA	N/A				No			No
(4) BILLINGS MRI CENTER LLC 1041 NORTH 29TH STREET BILLINGS,MT59101 81-0450943	MRI-PET SCAN	MT	NA	N/A				No			No
(5) LUTHERAN CAMPUS ASC LLC 3455 LUTHRN PKW SUITE 150 WHEATRIDGE,CO800336028 02-0749532	OP SURGERY	CO	EXEMPLA PTNRS	RELATED	969,875	1,274,214		No			No	52.320 %
(6) COLORADO SURGICAL VENTURES LLC 30 S WACKER DR SUITE 2302 CHICAGO,IL60605 20-8038915	OP SURGERY	CO	St Joseph Hosp	Related				No	0		No	85.000 %
(7) COLORADO SURGICAL HOSPITAL LLC 30 S WACKER DR SUITE 2302 CHICAGO,IL60605 20-8038977	OP SURGERY	CO	CO SURG VENTURE	N/A				No	0		No	51.000 %

Part IV

Identification of Related Organizations Taxable as a Corporation or Trust (Complete if the organization answered "Yes" to 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	(i) Section 512(b)(13) controlled entity?
(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	Yes	No
(1) CARITAS INC AND SUBSIDIARIES 9801 RENNER BOULEVARD SUITE 100 LENEXA,KS66219 48-0941069	OTHER MEDICAL	KS		C CORP
(2) LEAVEN INSURANCE COMPANY LTD 23 LIME TREE BAY AVE PO BOX 1051 GEORGETOWN,GRAND CAYMANKY1-1102 CJ 98-0370522	INSURANCE	CJ

Schedule R (Form 990) 2012

Page 3

Part V

Transactions With Related Organizations (Complete if the organization answered "Yes" to Form 990, Part IV, line 34, 35b, or 36.)

Note. Complete line 1 if any entity is listed in Parts II, III, or IV of this schedule.

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 or (iv) rent from a controlled entity . . . . . . . . . . . . . . . . . . . . . . .

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

Yes

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

Yes

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

Yes

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

Yes

f Dividends from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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

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

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

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

Yes

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

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

Yes

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

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

Yes

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

Yes

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

Yes

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

Yes

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

s 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-s)	(c) Amount involved	(d) Method of determining amount involved
(1) SAINT JOSEPH HOSPITAL	O	174,552,345	ACCRUAL
(2) SAINT JOSEPH HOSPITAL	N	5,623,048	CHANGE IN INVES
(3) SAINT JOSEPH HOSPITAL	L	44,167,683	ACCRUAL
(4) SAINT JOSEPH HOSPITAL	S	1,801,555	ACCRUAL
(5) SAINT JOSEPH HOSPITAL	E	60,000,000	AMOUNT LOANED
(6) EXEMPLA LUTHERAN MEDICAL CENTER FOUNDATION	O	242,245	ACCRUAL
(7) EXEMPLA GOOD SAMARITAN MEDICAL CTR FOUNDATION	O	260,715	ACCRUAL
(8) EXEMPLA GOOD SAMARITAN MEDICAL CTR FOUNDATION	P	212,467	ACCRUAL
(9) EXEMPLA GOOD SAMARITAN MEDICAL CTR FOUNDATION	C	142,107	ACCRUAL
(10) LUTHERAN CAMPUS ASC LLC	D	2,456,128	AMT GUARANTEED
(11) SAINT JOSEPH HOSPITAL	Q	151,700,629	ACCRUAL
(12) SAINT JOSEPH HOSPITAL	D	12,250,785	ACCRUAL
(13) SAINT JOSEPH HOSPITAL	P	19,706	ACCRUAL
(14) EXEMPLA LUTHERAN MEDICAL CENTER FOUNDATION	C	530,955	ACCRUAL

Schedule R (Form 990) 2012

Page 4

Part VI

Unrelated Organizations Taxable as a Partnership (Complete if the organization answered "Yes" to 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) 2012

Page 5

Part VII

Supplemental Information

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

Identifier	Return Reference	Explanation
METHOD TO DETERMINE VALUE OF SCHEDULE R TRANSACTIONS	SCHEDULE R, PART V, LINE 2 COLUMN D	THE ORGANIZATION USED THE AMOUNT RECOGNIZED ON THE BOOKS AND RECORDS OF THE ORGANIZATION OF CASH RECEIVED OR PROVIDED, ADJUSTED TO THE ACCRUAL BASIS, TO DETERMINE THE VALUE OF SCHEDULE R TRANSACTIONS, WHICH APPROXIMATES FAIR VALUE.

Additional Data

Software ID:
Software Version:

1	Briefly describe the organization’s mission or most significant activities: WE REVEAL AND FOSTER GOD'S HEALING LOVE BY IMPROVING THE HEALTH OF THE PEOPLE AND COMMUNITIES WE SERVE, ESPECIALLY THOSE WHO ARE POOR AND VULNERABLE.
2	Check this box
3	Number of voting members of the governing body (Part VI, line 1a) ........	3	9
4	Number of independent voting members of the governing body (Part VI, line 1b) .....	4	6
5	Total number of individuals employed in calendar year 2011 (Part V, line 2a) ......	5	5,419
6	Total number of volunteers (estimate if necessary) .............	6	1,303
7a	Total unrelated business revenue from Part VIII, column (C), line 12 ........	7a	248,236
b	Net unrelated business taxable income from Form 990-T, line 34 .........	7b	198,130

		Prior Year	Current Year
8	Contributions and grants (Part VIII, line 1h) .........	851,145	950,284
9	Program service revenue (Part VIII, line 2g) .........	632,213,008	672,336,029
10	Investment income (Part VIII, column (A), lines 3, 4, and 7d ) ....	8,590,908	13,737,537
11	Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e)	20,177,599	1,651,613
12	Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)...................	661,832,660	688,675,463
13	Grants and similar amounts paid (Part IX, column (A), lines 1–3 )...	757,960	750,100
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)	320,796,735	301,121,289
16a	Professional fundraising fees (Part IX, column (A), line 11e).....	0	0
b	Total fundraising expenses (Part IX, column (D), line 25) 0
17	Other expenses (Part IX, column (A), lines 11a–11d, 11f–24e)....	303,553,068	352,538,252
18	Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25)	625,107,763	654,409,641
19	Revenue less expenses. Subtract line 18 from line 12.......	36,724,897	34,265,822
		Beginning of Current Year	End of Year
20	Total assets (Part X, line 16).............	925,782,307	956,351,142
21	Total liabilities (Part X, line 26).............	521,531,546	514,335,976
22	Net assets or fund balances. Subtract line 21 from line 20.....	404,250,761	442,015,166

Sign Here

	Signature of officer	Date

	Type or print name and title


4a	(Code: ) (Expenses $ 439,029,971 including grants of $ 465,195 ) (Revenue $ 573,802,226 )
	Provision of hospital based healthcare services, including charity care and unreimbursed Medicaid - see description in Schedule O

4b	(Code: ) (Expenses $ 69,019,450 including grants of $ 0 ) (Revenue $ 55,435,533 )
	Physician clinics - See detailed descriptions in Schedule O

4c	(Code: ) (Expenses $ 15,902,633 including grants of $ 0 ) (Revenue $ 19,653,199 )
	West Pines Behavioral Health - See detailed description in Schedule O

4d	Other program services (Describe in Schedule O.)
	(Expenses $ 19,634,016 including grants of $ 284,905 ) (Revenue $ 25,163,935 )
4e	Total program service expenses543,586,070

(A) Name and Title	(B) Average hours per week (list any hours for related organizations below dotted line)			(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) MARGARET CAIN PRICE........................................................................ VP-OPERATIONS (ELMC)	50.0 .......................0.0	X		0	268,103	51,458
(19) KAREN M SCREMIN........................................................................ VP-FINANCE (ELMC)	50.0 .......................0.0	X		0	231,319	42,331
(20) SUSAN E KERSCHEN........................................................................ VP-CHIEF NURSING OFFCR (EGSMC)	50.0 .......................0.0	X		0	230,786	47,136
(21) JOHN D HIGGINS........................................................................ VP FINANCE (EGSMC)	50.0 .......................0.0	X		0	197,838	48,775
(22) GRANT WICKLUND........................................................................ PRESIDENT & CEO-ELMC	50.0 .......................0.0	X		0	523,203	71,423
(23) TOWNDROWGERALDINE M........................................................................ VP-CHIEF NURSING OFFICER(ELMC)	50.0 .......................0.0	X		231,600	0	7,380
(24) MARK C WATTS........................................................................ PHYSICIAN	50.0 .......................0.0		X	725,795	0	25,844
(25) KEVIN B MILLER........................................................................ PHYSICIAN	50.0 .......................0.0		X	691,783	0	34,733
(26) LAMONDRODERICK G........................................................................ PHYSICIAN	50.0 .......................0.0		X	834,953	0	32,159
(27) LANKENAUJOHN E........................................................................ PHYSICIAN	50.0 .......................0.0		X	804,331	0	34,599
(28) THOMPSONDONALD C........................................................................ PHYSICIAN	50.0 .......................0.0		X	663,380	0	25,056

1b	Sub-Total................
c	Total from continuation sheets to Part VII, Section A....
d	Total (add lines 1b and 1c)............	4,147,703	8,251,984	1,113,725

				(A) Total revenue	(B) Related or exempt function revenue	(C) Unrelated business revenue	(D) Revenue excluded from tax under sections 512, 513, or 514
1a	Federated campaigns..1a
b	Membership dues....1b
c	Fundraising events....1c
d	Related organizations...1d		673,062
e	Government grants (contributions)1e		20,227

f	All other contributions, gifts, grants, and similar amounts not included above1f		256,995

g	Noncash contributions included in lines 1a-1f:$
h	Total. Add lines 1a-1f.......			950,284
			Business Code
2a	NET PATIENT REVENUE		621110	659,471,500	659,228,027	243,473
b	OTHER AFFILIATED RENT INCOME		531120	1,302,411	1,302,411
c	PHARMACY SALES		446110	221,446	221,446
d	MEANINGFUL USE INCENTIVE		621110	3,978,185	3,978,185
e	ADMIN MISC INCOME		900099	4,763		4,763
f	All other program service revenue .			7,357,724	7,357,724
g	Total. Add lines 2a–2f........			672,336,029
3	Investment income (including dividends, interest, and other similar amounts).......			6,329,600			6,329,600
4	Income from investment of tax-exempt bond proceeds..			0
5	Royalties...........			0
		(i) Real	(ii) Personal
6a	Gross rents	376,230
b	Less: rental expenses	443,481
c	Rental income or (loss)	-67,251	0
d	Net rental income or (loss).......			-67,251			-67,251
		(i) Securities	(ii) Other
7a	Gross amount from sales of assets other than inventory	7,442,816	22,596
b	Less: cost or other basis and sales expenses		57,475
c	Gain or (loss)	7,442,816	-34,879
d	Net gain or (loss)..........			7,407,937			7,407,937
8a	Gross income from fundraising events (not including $ of contributions reported on line 1c). See Part IV, line 18 ..
	a
b	Less: direct expenses ...b
c	Net income or (loss) from fundraising events..			0
9a	Gross income from gaming activities. See Part IV, line 19 ...
	a
b	Less: direct expenses ...b
c	Net income or (loss) from gaming activities...			0
10a	Gross sales of inventory, less returns and allowances .
	a		2,801,059
b	Less: cost of goods sold ..b		2,951,832
c	Net income or (loss) from sales of inventory..			-150,773	-150,773
Miscellaneous Revenue			Business Code
11a	OTHER RENTAL REVENUE		900099	68,082	68,082
b	EQUALIZATION		900099	1,801,555	1,801,555
c
d	All other revenue ....
e	Total. Add lines 11a–11d ......			1,869,637
12	Total revenue. See Instructions......			688,675,463	673,806,657	248,236	13,670,286


				(A) Beginning of year		(B) End of year
1	Cashnon-interest-bearing .............			36,838,938	1	37,123,179
2	Savings and temporary cash investments .........			20,000,007	2	7
3	Pledges and grants receivable, net ...........			0	3	0
4	Accounts receivable, net .............			78,956,055	4	77,582,388
5	Loans and other receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of Schedule L ..................
				0	5	0
6	Loans and other receivables from other disqualified persons (as defined under section 4958(f)(1)), persons described in section 4958(c)(3)(B), and contributing employers and sponsoring organizations of section 501(c)(9) voluntary employees' beneficiary organizations (see instructions) Complete Part II of Schedule L
				0	6	0
7	Notes and loans receivable, net .............			15,755,574	7	18,619,696
8	Inventories for sale or use ..............			9,877,289	8	11,170,590
9	Prepaid expenses and deferred charges ..........			6,209,225	9	4,885,023
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	1,033,339,025
b	Less: accumulated depreciation .....	10b	550,394,462	518,658,820	10c	482,944,563
11	Investments—publicly traded securities ..........			235,899,311	11	319,620,389
12	Investments—other securities. See Part IV, line 11 .....			639,339	12	1,457,558
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 ...........			2,947,749	15	2,947,749
16	Total assets. Add lines 1 through 15 (must equal line 34)......			925,782,307	16	956,351,142
17	Accounts payable and accrued expenses .........			85,436,196	17	76,973,827
18	Grants payable .................			0	18	0
19	Deferred revenue ................			1,203,012	19	943,340
20	Tax-exempt bond liabilities .............			1,601,494	20	1,601,494
21	Escrow or custodial account liability. Complete Part IV of Schedule D..			0	21	0
22	Loans and other 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 ....			21,077,752	24	19,594,147
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....................			412,213,092	25	415,223,168
26	Total liabilities. Add lines 17 through 25.........			521,531,546	26	514,335,976
	Organizations that follow SFAS 117 (ASC 958), check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets ..............			404,184,776	27	441,936,645
28	Temporarily restricted net assets ...........			65,985	28	78,521
29	Permanently restricted net assets ...........			0	29	0
	Organizations that do not follow SFAS 117 (ASC 958), 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 ...........			404,250,761	33	442,015,166
34	Total liabilities and net assets/fund balances ........			925,782,307	34	956,351,142

1	Was the organization a U.S. transferor of property to a foreign corporation during the tax year? If “Yes,”the organization may be required to file Form 926, Return by a U.S. Transferor of Property to a Foreign Corporation (see Instructions for Form 926)......................................	Yes	No
2	Did the organization have an interest in a foreign trust during the tax year? If “Yes,” the organizationmay be required to file Form 3520, Annual Return to Report Transactions with Foreign Trusts and Receipt of Certain Foreign Gifts, and/or Form 3520-A, Annual Information Return of Foreign Trust With a U.S. Owner (see Instructions for Forms 3520 and 3520-A).......................................	Yes	No
3	Did the organization have an ownership interest in a foreign corporation during the tax year? If "Yes," the organization may be required to file Form 5471, Information Return of U.S. Persons with Respect to Certain Foreign Corporations. (see Instructions for Form 5471)..............................	Yes	No
4	Was the organization a direct or indirect shareholder of a passive foreign investment company or a qualified electing fund during the tax year? If "Yes," the organization may be required to file Form 8621, Return by a Shareholder of a Passive Foreign Investment Company or Qualified Electing Fund. (see Instructions for Form 8621)	Yes	No
5	Did the organization have an ownership interest in a foreign partnership during the tax year? If "Yes," the organization may be required to file Form 8865, Return of U.S. Persons with Respect to Certain Foreign Partnerships. (see Instructions for Form 8865)....................................	Yes	No
6	Did the organization have any operations in or related to any boycotting countries during the tax year? If "Yes," the organization may be required to file Form 5713, International Boycott Report (see Instructions for Form 5713)................................................	Yes	No