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

MediumBullet The organization may have to use a copy of this return to satisfy state reporting requirements.
OMB No. 1545-0047
2011
Open to Public Inspection
A For the calendar year, or tax year beginning 07-01-2011 and ending 06-30-2012
BCheck if applicable:
CName of organization
MERCY HEALTH SERVICES - IOWA CORP
 
Doing Business As
SEE SCHEDULE O FOR LIST
 
Number and street (or P.O. box if mail is not delivered to street address)
1000 4TH STREET SW
 
Room/suite
City or town, state or country, and ZIP + 4
MASON CITY, IA50401
D Employer identification number

31-1373080
E Telephone number

G Gross receipts $ 654,614,901
F Name and address of principal officer:
LARRY WARREN
20555 VICTOR PARKWAY
LIVONIA,MI48152
I
Tax-exempt status: (   ) LeftBullet (insert no.) or
J
Website:MediumBullet
WWW.TRINITY-HEALTH.ORG
H(a)
Is this a group return for
affiliates?
H(b)
Are all affiliates included?
If "No," attach a list. (see instructions)
H(c)
Group exemption number MediumBullet  
K Form of organization:
 
L Year of formation: 1993
M State of legal domicile: DE
Part I
Summary
Activities & Governance 1 Briefly describe the organization’s mission or most significant activities: HEALTH CARE SERVICES
2 Check this box MediumBullet
3 Number of voting members of the governing body (Part VI, line 1a)..... 3 5
4 Number of independent voting members of the governing body (Part VI, line 1b) .... 4 3
5 Total number of individuals employed in calendar year 2011 (Part V, line 2a) ... 5 5,771
6 Total number of volunteers (estimate if necessary) .... 6 721
7a Total unrelated business revenue from Part VIII, column (C), line 12 .. 7a 27,917,292
b Net unrelated business taxable income from Form 990-T, line 34 .. 7b -96,844
Revenues; Prior Year Current Year
8 Contributions and grants (Part VIII, line 1h) ......... 2,752,838 5,119,441
9 Program service revenue (Part VIII, line 2g) ......... 594,512,963 596,818,878
10 Investment income (Part VIII, column (A), lines 3, 4, and 7d ) .... 13,925,192 7,604,918
11 Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e) 38,506,676 43,539,149
12 Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)................... 649,697,669 653,082,386
Expenses; 13 Grants and similar amounts paid (Part IX, column (A), lines 1–3 )... 785,503 760,366
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) 288,394,581 292,395,511
16a Professional fundraising fees (Part IX, column (A), line 11e)..... 0 0
b Total fundraising expenses (Part IX, column (D), line 25) MediumBullet798,082    
17 Other expenses (Part IX, column (A), lines 11a–11d, 11f–24f).... 342,909,212 355,998,098
18 Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25) 632,089,296 649,153,975
19 Revenue less expenses. Subtract line 18 from line 12....... 17,608,373 3,928,411
Net Assets or Fund Balances; Beginning of Current Year End of Year
20 Total assets (Part X, line 16)............. 785,655,787 796,474,081
21 Total liabilities (Part X, line 26)............. 286,395,955 299,729,385
22 Net assets or fund balances. Subtract line 21 from line 20..... 499,259,832 496,744,696
Part II
Signature Block
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete. Declaration of preparer (other than officer) is based on all information of which preparer has any knowledge.
Sign Here
JumboBullet
Signature of officer Date
JumboBullet
Type or print name and title.
Paid preparer use only
Print/type preparer's name
 
Preparer's signature
Date
PTIN
Firm's name Right pointing arrowhead image

Firm's EIN Right pointing arrowhead image
Firm's address Right pointing arrowhead image



Phone no.
May the IRS discuss this return with the preparer shown above? See instructions .........bullet
For Paperwork Reduction Act Notice, see the separate instructions.
Cat. No. 11282Y
Form 990 (2011)
Form 990 (2011)
Page 2
Part III
Statement of Program Service Accomplishments
Check if Schedule O contains a response to any question in this Part III .........
1
Briefly describe the organization’s mission: HEALTH CARE SERVICES - SEE SCHEDULE H FOR MORE INFORMATION
2
Did the organization undertake any significant program services during the year which were not listed on
the prior Form 990 or 990-EZ? ....................
If “Yes,” describe these new services on Schedule O.
3
Did the organization cease conducting, or make significant changes in how it conducts, any program services? ..........................
If “Yes,” describe these changes on Schedule O.
4
Describe the organization’s program service accomplishments for each of its three largest program services, as measured by expenses. Section 501(c)(3) and 501(c)(4) organizations and section 4947(a)(1) trusts are required to report the amount of grants and allocations to others, the total expenses, and revenue, if any, for each program service reported.
4a (Code:   ) (Expenses $ 583,962,090 including grants of $ 760,366 ) (Revenue $ 593,872,280 )
MERCY HEALTH SERVICES-IOWA, CORP. OPERATED FOUR HOSPITAL DIVISIONS IN THE STATE OF IOWA THAT PROVIDED 154,137 PATIENT DAYS OF HEALTHCARE SERVICES TO THEIR COMMUNITIES. THE MISSION STATEMENT OF MERCY HEALTH SERVICES-IOWA CORP. IS AS FOLLOWS:WE SERVE TOGETHER IN TRINITY HEALTHIN THE SPIRIT OF THE GOSPELTO HEAL BODY, MIND, AND SPIRITTO IMPROVE THE HEALTH OF OUR COMMUNITIESAND TO STEWARD THE RESOURCES ENTRUSTED TO US.
4b (Code:   ) (Expenses $   including grants of $   ) (Revenue $   )
4c (Code:   ) (Expenses $   including grants of $   ) (Revenue $   )
4d Other program services (Describe in Schedule O.)
(Expenses $   including grants of $   ) (Revenue $   )
4e Total program service expensesMediumBullet$ 583,962,090
Form 990 (2011)
Form 990 (2011)
Page 3
Part IV
Checklist of Required Schedules
Yes
No
1
Is the organization described in section 501(c)(3) or 4947(a)(1) (other than a private foundation)? If “Yes,” complete Schedule AClick to see attachment.....................
1
Yes
 
2
Is the organization required to complete Schedule B, Schedule of Contributors? Click to see attachment........
2
Yes
 
3
Did the organization engage in direct or indirect political campaign activities on behalf of or in opposition to candidates for public office? If “Yes,” complete Schedule C, Part IClick to see attachment..........
3
 
No
4
Section 501(c)(3) organizations. Did the organization engage in lobbying activities? If “Yes,” complete Schedule C,
Part IIClick to see attachment.........................
4
Yes
 
5
Is the organization a section 501(c)(4), 501(c)(5), or 501(c)(6) organization that receives membership dues, assessments, or similar amounts as defined in Revenue Procedure 98-19? If “Yes,” complete Schedule C, Part IIIClick to see attachment........................
5
 
No
6
Did the organization maintain any donor advised funds or any similar funds or accounts for which donors have the right to provide advice on the distribution or investment of amounts in such funds or accounts? If “Yes,” complete Schedule D, Part IClick to see attachment....................
6
 
No
7
Did the organization receive or hold a conservation easement, including easements to preserve open space,
the environment, historic land areas or historic structures? If “Yes,” complete Schedule D, Part IIClick to see attachment...
7
 
No
8
Did the organization maintain collections of works of art, historical treasures, or other similar assets? If “Yes,” complete Schedule D, Part III Click to see attachment....................
8
 
No
9
Did the organization report an amount in Part X, line 21; serve as a custodian for amounts not listed in Part X; or provide credit counseling, debt management, credit repair, or debt negotiation services? If “Yes,”
complete Schedule D, Part IVClick to see attachment...................
9
 
No
10
Did the organization, directly or through a related organization, hold assets in temporarily restricted endowments, permanent endowments, or quasi-endowments? If “Yes,” complete Schedule D, Part VClick to see attachment
10
Yes
 
11
If the organization’s answer to any of the following questions is ‘Yes,’ then complete Schedule D, Parts VI, VII, VIII, IX, or X as applicable:
a
Did the organization report an amount for land, buildings, and equipment in Part X, line10? If “Yes,” complete Schedule D, Part VI.Click to see attachment
11a
Yes
 
b
Did the organization report an amount for investments—other securities in Part X, line 12 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part VII.Click to see attachment
11b
Yes
 
c
Did the organization report an amount for investments—program related in Part X, line 13 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part VIII.Click to see attachment
11c
 
No
d
Did the organization report an amount for other assets in Part X, line 15 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part IX.Click to see attachment
11d
Yes
 
e
Did the organization report an amount for other liabilities in Part X, line 25? If “Yes,” complete Schedule D, Part X.Click to see attachment
11e
Yes
 
f
Did the organization’s separate or consolidated financial statements for the tax year include a footnote that addresses the organization’s liability for uncertain tax positions under FIN 48 (ASC 740)? If “Yes,” complete Schedule D, Part X.Click to see attachment
11f
 
No
12a
Did the organization obtain separate, independent audited financial statements for the tax year?
If “Yes,” complete Schedule D, Parts XI, XII, and XIII Click to see attachment
12a
 
No
b
Was the organization included in consolidated, independent audited financial statements for the tax year? If “Yes,” and if the organization answered ‘No’ to line 12a, then completing Schedule D, Parts XI, XII, and XIII is optional Click to see attachment
12b
Yes
 
13
Is the organization a school described in section 170(b)(1)(A)(ii)? If “Yes,” complete Schedule E
13
 
No
14a
Did the organization maintain an office, employees, or agents outside of the United States?....
14a
 
No
b
Did the organization have aggregate revenues or expenses of more than $10,000 from grantmaking, fundraising, business, investment, and program service activities outside the United States or aggregate foreign investments valued at $100,000 or more? If “Yes,” complete Schedule F, Part I.........
14b
 
No
15
Did the organization report on Part IX, column (A), line 3, more than $5,000 of grants or assistance to any organization or entity located outside the U.S.? If “Yes,” complete Schedule F, Part II..
15
 
No
16
Did the organization report on Part IX, column (A), line 3, more than $5,000 of aggregate grants or assistance to individuals located outside the U.S.? If “Yes,” complete Schedule F, Part III..
16
 
No
17
Did the organization report a total of more than $15,000, of expenses for professional fundraising services on Part IX, column (A), lines 6 and 11e? If “Yes,” complete Schedule G, Part I
17
 
No
18
Did the organization report more than $15,000 total of fundraising event gross income and contributions on Part VIII, lines 1c and 8a? If “Yes,” complete Schedule G, Part II..........
18
Yes
 
19
Did the organization report more than $15,000 of gross income from gaming activities on Part VIII, line 9a? If “Yes,” complete Schedule G, Part III...................
19
 
No
20a
Did the organization operate one or more hospitals? If “Yes,” complete Schedule H..... Click to see attachment
20a
Yes
 
b
If “Yes” to line 20a, did the organization attach a copy of its audited financial statement to this return? Note. All Form 990 filers that operated one or more hospitals must attach audited financial statements. Click to see attachment
20b
Yes
 
Form 990 (2011)
Form 990 (2011)
Page 4
Part IV
Checklist of Required Schedules (continued)
21
Did the organization report more than $5,000 of grants and other assistance to any government or organization in the United States on Part IX, column (A), line 1? If “Yes,” complete Schedule I, Parts I and II.. Click to see attachment
21
Yes
 
22
Did the organization report more than $5,000 of grants and other assistance to individuals in the United States on Part IX, column (A), line 2? If “Yes,” complete Schedule I, Parts I and III..... Click to see attachment
22
 
No
23
Did the organization answer “Yes” to Part VII, Section A, questions 3, 4, or 5, about compensation of the organization’s current and former officers, directors, trustees, key employees, and highest compensated employees? If “Yes,” complete Schedule J................ Click to see attachment
23
Yes
 
24a
Did the organization have a tax-exempt bond issue with an outstanding principal amount of more than $100,000 as of the last day of the year, that was issued after December 31, 2002? If “Yes,” answer questions 24b–24d and complete Schedule K. If “No,” go to line 25................
24a
 
No
b
Did the organization invest any proceeds of tax-exempt bonds beyond a temporary period exception?...
24b
 
 
c
Did the organization maintain an escrow account other than a refunding escrow at any time during the year
to defease any tax-exempt bonds?......................
24c
 
 
d
Did the organization act as an “on behalf of” issuer for bonds outstanding at any time during the year?...
24d
 
 
25a
Section 501(c)(3) and 501(c)(4) organizations. Did the organization engage in an excess benefit transaction with a disqualified person during the year? If “Yes,” complete Schedule L, Part I...... Click to see attachment
25a
 
No
b
Is the organization aware that it engaged in an excess benefit transaction with a disqualified person in a prior year, and that the transaction has not been reported on any of the organization’s prior Forms 990 or 990-EZ? If “Yes,” complete Schedule L, Part I................ Click to see attachment
25b
 
No
26
Was a loan to or by a current or former officer, director, trustee, key employee, highly compensated employee, or disqualified person outstanding as of the end of the organization’s tax year? If “Yes,” complete Schedule L,
Part II......................... Click to see attachment
26
 
No
27
Did the organization provide a grant or other assistance to an officer, director, trustee, key employee, substantial contributor or employee thereof, a grant selection committee member, or to a 35% controlled entity or family member of any of these persons? If “Yes,” complete Schedule L, Part III......... Click to see attachment
27
 
No
28
Was the organization a party to a business transaction with one of the following parties? (see Schedule L, Part IV instructions for applicable filing thresholds, conditions, and exceptions):
a
A current or former officer, director, trustee, or key employee? If “Yes,” complete Schedule L, Part IV ......................... Click to see attachment
28a
 
No
b
A family member of a current or former officer, director, trustee, or key employee? If “Yes,”
complete Schedule L, Part IV................... Click to see attachment
28b
Yes
 
c
An entity of which a current or former officer, director, trustee, or key employee (or a family member thereof) was an officer, director, trustee, or owner? If “Yes,” complete Schedule L, Part IV.. Click to see attachment
28c
Yes
 
29
Did the organization receive more than $25,000 in non-cash contributions? If “Yes,” complete Schedule M
29
 
No
30
Did the organization receive contributions of art, historical treasures, or other similar assets, or qualified conservation contributions? If “Yes,” complete Schedule M............
30
 
No
31
Did the organization liquidate, terminate, or dissolve and cease operations? If “Yes,” complete Schedule N,
Part I...........................
31
 
No
32
Did the organization sell, exchange, dispose of, or transfer more than 25% of its net assets? If “Yes,” complete Schedule N, Part II.......................
32
 
No
33
Did the organization own 100% of an entity disregarded as separate from the organization under Regulations sections 301.7701-2 and 301.7701-3? If “Yes,” complete Schedule R, Part I........ Click to see attachment
33
 
No
34
Was the organization related to any tax-exempt or taxable entity? If “Yes,” complete Schedule R, Parts II, III, IV, and V, line 1..................... Click to see attachment
34
Yes
 
35a
Did the organization have a controlled entity within the meaning of section 512(b)(13)?
35a
Yes
 
b
If ‘Yes’ to line 35a, did the organization receive any payment from or engage in any transaction with a controlled entity within the meaning of section 512(b)(13)? If “Yes,” complete Schedule R, Part V, line 2... Click to see attachment
35b
Yes
 
36
Section 501(c)(3) organizations. Did the organization make any transfers to an exempt non-charitable related organization? If “Yes,” complete Schedule R, Part V, line 2........... Click to see attachment
36
 
No
37
Did the organization conduct more than 5% of its activities through an entity that is not a related organization and that is treated as a partnership for federal income tax purposes? If “Yes,” complete Schedule R, Part VIClick to see attachment
37
 
No
38
Did the organization complete Schedule O and provide explanations in Schedule O for Part VI, lines 11 and 19? Note. All Form 990 filers are required to complete Schedule O. ............
38
Yes
 
Form 990 (2011)
Form 990 (2011)
Page 5
Part V
Statements Regarding Other IRS Filings and Tax Compliance
Check if Schedule O contains a response to any question in this Part V .........
Yes
No
1a
Enter the number reported in Box 3 of Form 1096. Enter -0- if not applicable. .......
1a
946
b
Enter the number of Forms W-2G included in line 1a. Enter -0- if not applicable.
1b
32
c
Did the organization comply with backup withholding rules for reportable payments to vendors and reportable gaming (gambling) winnings to prize winners? ..................
1c
Yes
 
2a
Enter the number of employees reported on Form W-3, Transmittal of Wage and Tax Statements filed for the calendar year ending with or within the year covered by this return .....................
2a
5,771
b
If at least one is reported on line 2a, did the organization file all required federal employment tax returns?

Note. If the sum of lines 1a and 2a is greater than 250, you may be required to e-file. (see instructions)
2b
Yes
 
3a
Did the organization have unrelated business gross income of $1,000 or more during the year?.............................
3a
Yes
 
b
If “Yes,” has it filed a Form 990-T for this year? If “No,” provide an explanation in Schedule O.....
3b
Yes
 
4a
At any time during the calendar year, did the organization have an interest in, or a signature or other authority over, a financial account in a foreign country (such as a bank account or securities account)?.......................
4a
 
No
b
If "Yes," enter the name of the foreign country: MediumBullet
See instructions for filing requirements for Form TD F 90-22.1, Report of Foreign Bank and Financial Accounts.
5a
Was the organization a party to a prohibited tax shelter transaction at any time during the tax year?..
5a
 
No
b
Did any taxable party notify the organization that it was or is a party to a prohibited tax shelter transaction?
5b
 
No
c
If “Yes” to line 5a or 5b, did the organization file Form 8886-T? ........
5c
 
 
6a
Does the organization have annual gross receipts that are normally greater than $100,000, and did the organization solicit any contributions that were not tax deductible?..........
6a
 
No
b
If “Yes,” did the organization include with every solicitation an express statement that such contributions or gifts were not tax deductible?........................
6b
 
 
7
Organizations that may receive deductible contributions under section 170(c).
a
Did the organization receive a payment in excess of $75 made partly as a contribution and partly for goods and services provided to the payor?....................
7a
Yes
 
b
If “Yes,” did the organization notify the donor of the value of the goods or services provided?.....
7b
Yes
 
c
Did the organization sell, exchange, or otherwise dispose of tangible personal property for which it was required to file Form 8282?...........................
7c
 
No
d
If “Yes,” indicate the number of Forms 8282 filed during the year ....
7d
 
e
Did the organization receive any funds, directly or indirectly, to pay premiums on a personal benefit contract?..........................
7e
 
No
f
Did the organization, during the year, pay premiums, directly or indirectly, on a personal benefit contract?..
7f
 
No
g
If the organization received a contribution of qualified intellectual property, did the organization file Form 8899 as required?...................
7g
 
 
h
If the organization received a contribution of cars, boats, airplanes, or other vehicles, did the organization file a Form 1098-C?...............
7h
 
 
8
Sponsoring organizations maintaining donor advised funds and section 509(a)(3) supporting organizations. Did the supporting organization, or a donor advised fund maintained by a sponsoring organization, have excess business holdings at any time during the year?................
8
 
 
9
Sponsoring organizations maintaining donor advised funds.
a
Did the organization make any taxable distributions under section 4966?.........
9a
 
 
b
Did the organization make a distribution to a donor, donor advisor, or related person?......
9b
 
 
10
Section 501(c)(7) organizations. Enter:
a
Initiation fees and capital contributions included on Part VIII, line 12 ...
10a
 
b
Gross receipts, included on Form 990, Part VIII, line 12, for public use of club facilities
10b
 
11
Section 501(c)(12) organizations. Enter:
a
Gross income from members or shareholders .........
11a
 
b
Gross income from other sources (Do not net amounts due or paid to other sources against amounts due or received from them) ........
11b
 
12a
Section 4947(a)(1) non-exempt charitable trusts. Is the organization filing Form 990 in lieu of Form 1041?
12a
 
 
b
If “Yes,” enter the amount of tax-exempt interest received or accrued during the year.
12b
 
13
Section 501(c)(29) qualified nonprofit health insurance issuers.
a
Is the organization licensed to issue qualified health plans in more than one state?
Note. All 501(c)(29) organizations must list in Schedule O each state in which they are licensed to issue qualified health plans, the amount of reserves required by each state, and the amount of reserves the organization allocated to each state.
13a
 
 
b
Enter the aggregate amount of reserves the organization is required to maintain by the states in which the organization is licensed to issue qualified health plans.
13b
 
c
Enter the aggregate amount of reserves on hand.
13c
 
14a
Did the organization receive any payments for indoor tanning services during the tax year?.....
14a
 
 
b
If "Yes," has it filed a Form 720 to report these payments? If “No,” provide an explanation in Schedule O..
14b
 
 
Form 990 (2011)
Form 990 (2011)
Page 6
Part VI
Governance, Management, and Disclosure For each “Yes” response to lines 2 through 7b below, and for a “No” response to lines 8a, 8b, or 10b below, describe the circumstances, processes, or changes in Schedule O. See instructions.
Check if Schedule O contains a response to any question in this Part VI .........
Section A. Governing Body and Management
Yes
No
1a
Enter the number of voting members of the governing body at the end of the tax year
If the governing body delegated broad authority to an executive committee or similar committee, explain in Schedule O.
1a
5
b
Enter the number of voting members included in line 1a, above, who are independent .................
1b
3
2
Did any officer, director, trustee, or key employee have a family relationship or a business relationship with any other officer, director, trustee, or key employee? .................
2
 
No
3
Did the organization delegate control over management duties customarily performed by or under the direct supervision of officers, directors or trustees, or key employees to a management company or other person? .
3
Yes
 
4
Did the organization make any significant changes to its governing documents since the prior Form 990 was filed?
4
 
No
5
Did the organization become aware during the year of a significant diversion of the organization’s assets? .
5
 
No
6
Did the organization have members or stockholders? ................
6
Yes
 
7a
Did the organization have members, stockholders, or other persons who had the power to elect or appoint one or more members of the governing body? .................
7a
Yes
 
b
Are any governance decisions of the organization reserved to (or subject to approval by) members, stockholders, or persons other than the governing body? ............
7b
Yes
 
8
Did the organization contemporaneously document the meetings held or written actions undertaken during the year by the following:
a
The governing body? .........................
8a
Yes
 
b
Each committee with authority to act on behalf of the governing body? ..........
8b
Yes
 
9
Is there any officer, director, trustee, or key employee listed in Part VII, Section A, who cannot be reached at the organization’s mailing address? If “Yes,” provide the names and addresses in Schedule O .....
9
 
No
Section B. Policies (This Section B requests information about policies not required by the Internal
Revenue Code.)
Yes
No
10a
Did the organization have local chapters, branches, or affiliates? ............
10a
 
No
b
If “Yes,” did the organization have written policies and procedures governing the activities of such chapters, affiliates, and branches to ensure their operations are consistent with the organization's exempt purposes? ....
10b
 
 
11a
Has the organization provided a complete copy of this Form 990 to all members of its governing body before filing the form?
11a
Yes
 
b
Describe in Schedule O the process, if any, used by the organization to review the Form 990. .....
12a
Did the organization have a written conflict of interest policy? If “No,” go to line 13.......
12a
Yes
 
b
Were officers, directors or trustees, and key employees required to disclose annually interests that could give rise to conflicts? ........................
12b
Yes
 
c
Did the organization regularly and consistently monitor and enforce compliance with the policy? If “Yes,” describe in Schedule O how this was done ....................
12c
Yes
 
13
Did the organization have a written whistleblower policy? ...............
13
Yes
 
14
Did the organization have a written document retention and destruction policy? .........
14
Yes
 
15
Did the process for determining compensation of the following persons include a review and approval by independent persons, comparability data, and contemporaneous substantiation of the deliberation and decision?
a
The organization’s CEO, Executive Director, or top management official ...........
15a
Yes
 
b
Other officers or key employees of the organization ................
15b
Yes
 
If "Yes," to line 15a or 15b, describe the process in Schedule O (see instructions).
16a
Did the organization invest in, contribute assets to, or participate in a joint venture or similar arrangement with a taxable entity during the year? ......................
16a
Yes
 
b
If “Yes,” did the organization follow a written policy or procedure requiring the organization to evaluate its participation in joint venture arrangements under applicable federal tax law, and take steps to safeguard the organization’s exempt status with respect to such arrangements? ............
16b
 
No
Section C. Disclosure
17
List the States with which a copy of this Form 990 is required to be filedMediumBullet
IA
18
Section 6104 requires an organization to make its Form 1023 (or 1024 if applicable), 990, and 990-T (501(c)(3)s only) available for public inspection. Indicate how you made these available. Check all that apply.
19
Describe in Schedule O whether (and if so, how), the organization made its governing documents, conflict of interest policy, and financial statements available to the public during the tax year.
20
State the name, physical address, and telephone number of the person who possesses the books and records of the organization: MediumBullet
BETH GDOWIK
20555 VICTOR PARKWAY
LIVONIA,MI481527018
(734) 343-1000
Form 990 (2011)
Form 990 (2011)
Page 7
Part VII
Compensation of Officers, Directors,Trustees, Key Employees, Highest Compensated Employees, and Independent Contractors
Check if Schedule O contains a response to any question in this Part VII .........
Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees
1a Complete this table for all persons required to be listed. Report compensation for the calendar year ending with or within the organization’s tax year.
RoundBullet List all of the organization’s current officers, directors, trustees (whether individuals or organizations), regardless of amount
of compensation, and current key employees. Enter -0- in columns (D), (E), and (F) if no compensation was paid.

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

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

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

List persons in the following order: individual trustees or directors; institutional trustees; officers; key employees; highest
compensated employees; and former such persons.
Check this box if neither the organization nor any related organizations compensated any current or former officer, director, or trustee.
(A)
Name and Title 		(B)
Average hours per week (describe hours for related organizations in Schedule O) 		(C)
Position (do not check more than one box, unless person is both an officer and a director/trustee) 		(D)
Reportable compensation from the organization (W- 2/1099-MISC) 		(E)
Reportable compensation from related organizations (W- 2/1099-MISC) 		(F)
Estimated amount of other compensation from the organization and related organizations
Individual Trustee or Director; Institutional Trustee; Officer; Key Employee; Highest compensated employee; Former;
(1) JOSEPH SWEDISH
TRINITY PRES & CEO
 5.00 X   X       0 5,186,660 576,202
(2) MARY MOLLISON CSA
CHAIR
 2.00 X   X       0 0 0
(3) MELANIE DREHER
VICE CHAIR
 2.00 X   X       0 25,000 0
(4) SUZANNE BRENNAN CSC
TRUSTEE
 2.00 X           0 0 0
(5) ROBERT LADENBURGER
TRUSTEE UNTIL 12/11
 2.00 X           0 20,500 0
(6) JOSE SANTILLAN
TRUSTEE AS OF 1/12
 2.00 X           0 21,250 0
(7) PAUL NEUMANN
SECRETARY, TRIN SVP & GEN COUNSEL
 5.00     X       0 732,791 97,794
(8) AGNES HAGERTY
ASST SEC/VP GEN CSL TRINITY
 2.00     X       0 379,449 51,225
(9) BENJAMIN CARTER
TREASURER, TRINITY SVP & CFO
 5.00     X       0 755,014 102,689
(10) JAMES BOSSCHER
ASST TREASURER, TRINITY SVP TREASURY
 2.00     X       0 523,454 88,842
(11) KEDRICK ADKINS
TRINITY PRES INTEGRATED SVCS
 5.00       X     0 1,405,226 117,120
(12) MICHAEL MURPHY
TRINITY EVP HEALTH NTWKS UNTIL 4/12
 5.00       X     0 474,370 75,538
(13) RICHARD O'CONNELL
TRINITY COO-HOSPITAL NETWORKS
 5.00       X     0 943,237 118,221
(14) JAMES FITZPATRICK
CEO-MASON CITY (MC) UNTIL 3/12
 50.00       X     0 604,846 109,263
(15) RODNEY SCHLADER
INTER.CEO(MC)AS OF 3/12,FORMER CFO
 50.00       X     0 279,323 54,439
(16) ROBERT PEEBLES
CEO-SIOUX CITY (SC)
 50.00       X     0 566,715 77,662
(17) RUSSELL KNIGHT
CEO-DUBUQUE (DUB)
 50.00       X     0 474,577 75,949
Form 990 (2011)
Form 990 (2011)
Page 8
Part VII
Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees (continued)
(A)
Name and Title 		(B)
Average hours per week (describe hours for related organizations in Schedule O) 		(C)
Position (do not check more than one box, unless person is both an officer and a director/trustee) 		(D)
Reportable compensation from the organization (W- 2/1099-MISC) 		(E)
Reportable compensation from related organizations (W- 2/1099-MISC) 		(F)
Estimated amount of other compensation from the organization and related organizations
Individual Trustee or Director; Institutional Trustee; Officer; Key Employee; Highest compensated employee; Former;
(18) LARRY SELLERS
CMO-SIOUX CITY (SC)
 50.00       X     0 430,901 60,842
(19) STEVEN EAVENSON TATUM LLC
CFO-SIOUX CITY (SC)
 50.00       X     132,300 241,678 18,014
(20) PAUL MANTERNACH
SVP, PHYS. INTEG. (MC)
 50.00       X     0 370,326 38,279
(21) MARILYN KAPTAIN-DAHLEN
COO-SIOUX CITY (SC)
 50.00       X     0 287,392 55,538
(22) TERESA MOCK
SVP MERCY CLINICS (MC)
 50.00       X     0 285,117 52,932
(23) DIANE FISCHELS
VP OPERATIONS (MC)
 50.00       X     0 258,783 56,402
(24) GARY GUETZKO
VP BUSINESS DEVELOPMENT (DUB)
 50.00       X     0 228,800 58,135
(25) LINDA KREI
VP, HR & ORG. INTG. (SC)
 50.00       X     0 226,825 32,947
(26) MICHAEL JOHNSTON
VP, NETWORK DEVELOPMENT (MC)
 50.00       X     0 220,340 32,071
(27) KAY TAKES
VP, PATIENT CARE (DUB)
 50.00       X     0 203,460 40,789
(28) ROBERT SHAFER
CFO-DUBUQUE (DUB)
 50.00       X     0 189,547 85,598
(29) BERNARD FOX
VP, PROF & SUPP SVCS (DUB)
 50.00       X     0 187,277 28,040
(30) BRIAN MONSMA
VP, REGIONALIZATION (SC)
 50.00       X     0 183,123 35,710
(31) ALIREZA YARAHMADI
PHYSICIAN, NEUROLOGY
 50.00         X   694,180 0 97,309
(32) JAMES SIMON
PHYSICIAN, ONCOLOGY
 50.00         X   626,959 0 135,656
(33) PHILLIP ALSCHER
PHYSICIAN, NEPHROLOGY
 50.00         X   625,404 0 104,265
(34) JAMES KARKOS
PHYSICIAN, DERMATOLOGY
 50.00         X   619,431 0 129,471
(35) CARL PLANK
PHYSICIAN, DERMATOLOGY
 50.00         X   583,152 0 129,274
(36) DANIEL HALE
FORMER OFFICER
 5.00           X 0 925,954 106,225
(37) MARIANNE CUNNINGHAM
FORMER OFFICER
 2.00           X 0 162,829 31,606
(38) EDWARD CHADWICK
FORMER OFFICER
 0.00           X 0 159,057 0
(39) PAUL BROWNE
FORMER KEY EMPLOYEE
 5.00           X 0 781,601 94,628
(40) DEBRA CANALES
FORMER KEY EMPLOYEE
 5.00           X 0 890,622 86,371
(41) PAUL CONLON
FORMER KEY EMPLOYEE
 5.00           X 0 416,037 97,783
(42) LOUIS FIERENS
FORMER KEY EMPLOYEE
 5.00           X 0 489,708 65,100
(43) PRESTON GEE
FORMER KEY EMPLOYEE
 5.00           X 0 487,615 76,609
(44) MICHAEL HOLPER
FORMER KEY EMPLOYEE
 5.00           X 0 402,101 69,885
(45) TERRENCE O'ROURKE
FORMER KEY EMPLOYEE
 5.00           X 0 863,581 50,709
(46) MARIA SZYMANSKI
FORMER KEY EMPLOYEE
 5.00           X 0 666,060 106,893
(47) KIM PRICE
FORMER KEY EMPLOYEE
 0.00           X 132,372 0 42,258
(48) MICHAEL SLUBOWSKI
FORMER KEY EMPLOYEE
 0.00           X 0 150,838 1,101
(49) MARY EBELING
FORMER KEY EMPLOYEE
 0.00           X 0 134,677 46,640
1b Sub-Total................MediumBullet
c Total from continuation sheets to Part VII, Section A....MediumBullet
d Total (add lines 1b and 1c)............MediumBullet 3,413,798 22,236,661 3,612,024
2
Total number of individuals (including but not limited to those listed above) who received more than $100,000 of reportable compensation from the organizationMediumBullet245
Yes
No
3
Did the organization list any former officer, director or trustee, key employee, or highest compensated employee on line 1a? If “Yes,” complete Schedule J for such individual .............
3
Yes
 
4
For any individual listed on line 1a, is the sum of reportable compensation and other compensation from the organization and related organizations greater than $150,000? If “Yes,” complete Schedule J for such individual...........................
4
Yes
 
5
Did any person listed on line 1a receive or accrue compensation from any unrelated organization or individual for services rendered to the organization? If “Yes,” complete Schedule J for such person .....
5
Yes
 
Section B. Independent Contractors
1
Complete this table for your five highest compensated independent contractors that received more than $100,000 of compensation from the organization. Report compensation for the calendar year ending with or within the organization’s tax year.
(A)
Name and business address 		(B)
Description of services 		(C)
Compensation
HENKEL CONSTRUCTION COMPANY
208 E STATE STREET
MASON CITY,IA50402 		CONSTRUCTION SERVICES 7,736,538
UNITED CLINICAL LABORATORIES
205 BLUFF STREET
DUBUQUE,IA52001 		LABORATORY SERVICES 5,657,656
MASON CITY CLINIC PC
250 S CRESCENT DRIVE
MASON CITY,IA50401 		MEDICAL SERVICES 4,789,252
CONLON CONSTRUCTION
PO BOX 3400
DUBUQUE,IA52004 		CONSTRUCTION SERVICES 2,721,913
MEDICAL ASSOCIATES CLINIC PC
1500 ASSOCIATES DRIVE
DUBUQUE,IA52002 		MEDICAL SERVICES 2,070,150
2
Total number of independent contractors (including but not limited to those listed above) who received more than $100,000 of compensation from the organization MediumBullet79
Form 990 (2011)
Form 990 (2011)
Page 9
Part VIII
Statement of Revenue
(A)
Total revenue 		(B)
Related or
exempt
function
revenue 		(C)
Unrelated
business
revenue 		(D)
Revenue
excluded from
tax under sections
512, 513, or 514
Contributions, Gifts, Grants and Other Similar Amounts 1a Federated campaigns..1a  
b Membership dues....1b  
c Fundraising events....1c 12,625
d Related organizations...1d 4,113,131
e Government grants (contributions)1e 220,339
f All other contributions, gifts, grants, and
similar amounts not included above1f 		773,346
g Noncash contributions included in lines 1a-1f:$ 14,843
h Total. Add lines 1a-1f.......MediumBullet 5,119,441
Program Service Revenue Business Code
2a NET PATIENT SVC REV 900,099 555,075,320 555,075,320    
b PHARMACY REVENUE 446,110 39,124,485   23,966,087 15,158,398
c LABORATORY REVENUE 621,500 2,619,073   2,619,073  
d
e
f All other program service revenue .        
g Total. Add lines 2a–2f........MediumBullet 596,818,878
Other Revenue 3 Investment income (including dividends, interest
and other similar amounts).....MediumBullet 4,521,051     4,521,051
4 Income from investment of tax-exempt bond proceeds..MediumBullet        
5 Royalties............MediumBullet        
(i) Real (ii) Personal
6a Gross rents 1,636,018 1,500
b Less: rental expenses 1,404,415 0
c Rental income or (loss) 231,603 1,500
d Net rental income or (loss).......MediumBullet 233,103     233,103
(i) Securities (ii) Other
7a Gross amount from sales of assets other than inventory 3,066,179 110,656
b Less: cost or other basis and sales expenses 0 92,968
c Gain or (loss) 3,066,179 17,688
d Net gain or (loss)..........MediumBullet 3,083,867     3,083,867
8a Gross income from fundraising events (not including
$ 12,625
of contributions reported on line 1c). See Part IV, line 18 ...
a 138,924
b Less: direct expenses ...b 35,132
c Net income or (loss) from fundraising events..MediumBullet 103,792   103,792
9a Gross income from gaming activities.
See Part IV, line 19 ...
a  
b Less: direct expenses ...b  
c Net income or (loss) from gaming activities...MediumBullet        
10a Gross sales of inventory, less
returns and allowances .
a  
b Less: cost of goods sold ..b  
c Net income or (loss) from sales of inventory..MediumBullet        
Miscellaneous Revenue Business Code
11a MEDICARE/MEDICAID HIT 900,099 5,399,702 5,399,702    
b CAFETERIA REVENUE 900,099 3,073,162     3,073,162
c            
d All other revenue .... 34,729,390 33,397,258 1,332,132  
e Total. Add lines 11a–11d ......MediumBullet 43,202,254
12 Total revenue. See Instructions....MediumBullet 653,082,386 593,872,280 27,917,292 26,173,373
Form 990 (2011)
Form 990 (2011)
Page 10
Part IX
Statement of Functional Expenses
Section 501(c)(3) and 501(c)(4) organizations must complete all columns. All other organizations must complete column (A) but are not required to complete columns (B), (C), and (D).
Check if Schedule O contains a response to any question in this Part IX. .........
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 21 760,366 760,366
2 Grants and other assistance to individuals in the United States. See Part IV, line 22    
3 Grants and other assistance to governments, organizations, and individuals outside the United States. See Part IV, lines 15 and 16    
4 Benefits paid to or for members    
5 Compensation of current officers, directors, trustees, and key employees .... 6,202,922   6,202,922  
6 Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) .... 401,968 227,015 174,953  
7 Other salaries and wages 231,067,276 206,610,053 23,936,565 520,658
8 Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) .... 16,630,561 15,030,218 1,600,343  
9 Other employee benefits ....... 21,826,369 19,276,101 2,471,294 78,974
10 Payroll taxes ........... 16,266,415 14,205,393 2,025,632 35,390
11 Fees for services (non-employees):        
a Management ...... 1,256,508   1,256,508  
b Legal ......... 424,001   424,001  
c Accounting ........... 16,100   16,100  
d Lobbying ........... 28,200   28,200  
e Professional fundraising. See Part IV, line 17..    
f Investment management fees ......        
g Other .......... 35,218,382 30,769,381 4,387,590 61,411
12 Advertising and promotion .... 1,868,124 1,631,654 232,667 3,803
13 Office expenses ....... 10,287,168 8,949,804 1,276,206 61,158
14 Information technology ...... 29,846,703 26,121,834 3,724,869  
15 Royalties ..        
16 Occupancy ........... 11,540,636 10,962,815 576,990 831
17 Travel ............ 1,629,796 1,425,051 203,206 1,539
18 Payments of travel or entertainment expenses for any federal, state, or local public officials ......        
19 Conferences, conventions, and meetings .... 178,197 155,958 22,239  
20 Interest ........... 7,436,735 7,436,735    
21 Payments to affiliates .......        
22 Depreciation, depletion, and amortization ..... 32,945,977 31,298,621 1,647,296 60
23 Insurance .............. 5,951,579 5,654,000 297,579  
24 Other expenses. Itemize expenses not covered above (List miscellaneous expenses in line 24f. If line 24f amount exceeds 10% of line 25, column (A) amount, list line 24f expenses on Schedule O.)
a MEDICAL SUPPLIES 124,911,803 118,652,859 6,244,887 14,057
b BAD DEBT 32,066,537 32,066,537    
c INTERCO. PURCHASED SVCS 22,631,547 19,807,130 2,824,417  
d CONTRACT LABOR 18,603,816 16,282,060 2,321,756  
e
f All other expenses 19,156,289 16,638,505 2,497,583 20,201
25 Total functional expenses. Add lines 1 through 24f 649,153,975 583,962,090 64,393,803 798,082
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 MediumBullet if following SOP 98-2 (ASC 958-720).        
Form 990 (2011)
Form 990 (2011)
Page 11
Part X Balance Sheet
(A)
Beginning of year 		(B)
End of year
Assets 1 Cash—non-interest-bearing .......... 10,534,564 1 8,054,907
2 Savings and temporary cash investments ....... 140,450 2 184,914
3 Pledges and grants receivable, net ......... 103 3 0
4 Accounts receivable, net ......... 76,226,060 4 76,134,208
5 Receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of
Schedule L .......... 1,108 5  
6 Receivables from other disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B). Complete Part II of
Schedule L ..........   6  
7 Notes and loans receivable, net ............. 2,550,376 7 2,728,047
8 Inventories for sale or use .............. 14,719,435 8 16,040,653
9 Prepaid expenses and deferred charges ............ 1,324,122 9 2,388,595
10a Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D 10a 559,001,304
b Less: accumulated depreciation. ..... 10b 373,725,252 163,228,880 10c 185,276,052
11 Investments—publicly traded securities .......... 148,017,953 11 118,256,549
12 Investments—other securities. See Part IV, line 11 ...... 159,896,944 12 173,929,347
13 Investments—program-related. See Part IV, line 11 ..   13  
14 Intangible assets .........   14  
15 Other assets. See Part IV, line 11 ........... 209,015,792 15 213,480,809
16 Total assets. Add lines 1 through 15 (must equal line 34)... 785,655,787 16 796,474,081
Liabilities 17 Accounts payable and accrued expenses . 61,333,329 17 64,741,719
18 Grants payable ..........   18  
19 Deferred revenue .......... 260,654 19 883,079
20 Tax-exempt bond liabilities ..........   20  
21 Escrow or custodial account liability. Complete Part IV of Schedule D..   21  
22 Payables to current and former officers, directors, trustees, key
employees, highest compensated employees, and disqualified
persons. Complete Part II of Schedule L..........   22  
23 Secured mortgages and notes payable to unrelated third parties ..   23  
24 Unsecured notes and loans payable to unrelated third parties ....   24  
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..... 224,801,972 25 234,104,587
26 Total liabilities. Add lines 17 through 25..... 286,395,955 26 299,729,385
Net Assets or Fund Balance Organizations that follow SFAS 117, check here MediumBullet and complete lines 27 through 29, and lines 33 and 34.
27 Unrestricted net assets ..... 499,098,319 27 496,540,675
28 Temporarily restricted net assets ..... 136,513 28 179,021
29 Permanently restricted net assets ..... 25,000 29 25,000
Organizations that do not follow SFAS 117, check here MediumBullet and complete lines 30 through 34.
30 Capital stock or trust principal, or current funds .....   30  
31 Paid-in or capital surplus, or land, building or equipment fund .....   31  
32 Retained earnings, endowment, accumulated income, or other funds   32  
33 Total net assets or fund balances ..... 499,259,832 33 496,744,696
34 Total liabilities and net assets/fund balances ..... 785,655,787 34 796,474,081
Form 990 (2011)
Form 990 (2011)
Page 12
Part XI
Reconcilliation of Net Assets
Check if Schedule O contains a response to any question in this Part XI .........
1
Total revenue (must equal Part VIII, column (A), line 12) ...
1
653,082,386
2
Total expenses (must equal Part IX, column (A), line 25) ....
2
649,153,975
3
Revenue less expenses. Subtract line 2 from line 1 ...
3
3,928,411
4
Net assets or fund balances at beginning of year (must equal Part X, line 33, column (A)) ..
4
499,259,832
5
Other changes in net assets or fund balances (explain in Schedule O) ...
5
-6,443,547
6
Net assets or fund balances at end of year. Combine lines 3, 4, and 5 (must equal Part X, line 33, column (B)) ....
6
496,744,696
Part XII
Financial Statements and Reporting
Check if Schedule O contains a response to any question in this Part XII .........
Yes
No
1
Accounting method used to prepare the Form 990:  
If the organization changed its method of accounting from a prior year or checked "Other," explain in
Schedule O.
2a
Were the organization’s financial statements compiled or reviewed by an independent accountant?....
2a
 
No
b
Were the organization’s financial statements audited by an independent accountant?........
2b
Yes
 
c
If “Yes,” to 2a or 2b, does the organization have a committee that assumes responsibility for oversight of the audit, review, or compilation of its financial statements and selection of an independent accountant? If the organization changed either its oversight process or selection process during the tax year, explain in Schedule O. ...........................
2c
Yes
 
d
If “Yes” to line 2a or 2b, check a box below to indicate whether the financial statements for the year were issued on a separate basis, consolidated basis, or both:
3a
As a result of a federal award, was the organization required to undergo an audit or audits as set forth in the Single Audit Act and OMB Circular A-133? ................
3a
Yes
 
b
If “Yes,” did the organization undergo the required audit or audits? If the organization did not undergo the required audit or audits, explain why in Schedule O and describe any steps taken to undergo such audits. ..
3b
Yes
 
Form 990 (2011)
Additional Data


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

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

Complete if the organization is a section 501(c)(3) organization or a section
4947(a)(1) nonexempt charitable trust.
right arrow Attach to Form 990 or Form 990-EZ. right arrow See separate instructions.
OMB No. 1545-0047
2011
Open to Public
Inspection
Name of the organization
MERCY HEALTH SERVICES - IOWA CORP
 
Employer identification number

31-1373080
Part I
Reason for Public Charity Status (All organizations must complete this part.) See instructions
The organization is not a private foundation because it is: (For lines 1 through 11, check only one box.)
1
2
3
4
5
section 170(b)(1)(A)(iv). (Complete Part II.)
6
7
8
9
receipts from activities related to its exempt functions—subject to certain exceptions, and (2) no more than 331/3% of
its support from gross investment income and unrelated business taxable income (less section 511 tax) from businesses
acquired by the organization after June 30, 1975. See section 509(a)(2). (Complete Part III.)
10
11
e
f
g
(i) a person who directly or indirectly controls, either alone or together with persons described in (ii)
Yes
No
and (iii) below, the governing body of the the supported organization? ................
11g(i)
 
 
(ii) a family member of a person described in (i) above? ......................
11g(ii)
 
 
(iii) a 35% controlled entity of a person described in (i) or (ii) above? ................
11g(iii)
 
 
h
(i)
Name of supported organization 		(ii)
EIN 		(iii)
Type of organization (described on lines 1- 9 above or IRC section (see instructions)) 		(iv)
Is the organization in col. (i) listed in your governing document? 		(v)
Did you notify the organization in col. (i) of your support? 		(vi)
Is the organization in col. (i) organized in the U.S.? 		(vii)
Amount of support?
Yes No Yes No Yes No
Total                  

For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 11285F
Schedule A (Form 990 or 990-EZ) 2011
Schedule A (Form 990 or 990-EZ) 2011
Page 2
Part II
Support Schedule for Organizations Described in IRC 170(b)(1)(A)(iv) and 170(b)(1)(A)(vi)
(Complete only if you checked the box on line 5, 7, or 8 of Part I or if the organization failed to qualify under Part III. If the organization fails to qualify under the tests listed below, please complete Part III.)
Section A. Public Support
Calendar year(or fiscal year beginning in) (a) 2007 (b) 2008 (c) 2009 (d) 2010 (e) 2011 (f) Total
1 Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") ....            
2 Tax revenues levied for the organization's benefit and either paid to or expended on its behalf.......            
3 The value of services or facilities furnished by a governmental unit to the organization without charge..            
4 Total. Add lines 1 through 3..            
5 The portion of total contributions by each person (other than a governmental unit or publicly supported organization) included on line 1 that exceeds 2% of the amount shown on line 11, column (f)..            
6 Public Support. Subtract line 5 from line 4.            
Section B. Total Support
Calendar year(or fiscal year beginning in) (a) 2007 (b) 2008 (c) 2009 (d) 2010 (e) 2011 (f) Total
7 Amounts from line 4..            
8 Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..            
9 Net income from unrelated business activities, whether or not the business is regularly carried on..            
10 Other income. (Explain in Part IV.) Do not include gain or loss from the sale of capital assets..            
11 Total support (Add lines 7 through 10).            
12
12
 
13
Section C. Computation of Public Support Percentage
14
14
 
15
15
 
16a
b
17a
b
18
Schedule A (Form 990 or 990-EZ) 2011
Schedule A (Form 990 or 990-EZ) 2011
Page 3
Part III
Support Schedule for Organizations Described in IRC 509(a)(2)
(Complete only if you checked the box on line 9 of Part I or if the organization failed to qualify under Part II. If the organization fails to qualify under the tests listed below, please complete Part II.)
Section A. Public Support
Calendar year(or fiscal year beginning in) (a) 2007 (b) 2008 (c) 2009 (d) 2010 (e) 2011 (f) Total
1 Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") .            
2 Gross receipts from admissions, merchandise sold or services performed, or facilities furnished in any activity that is related to the organization's tax-exempt purpose......            
3 Gross receipts from activities that are not an unrelated trade or business under section 513..            
4 Tax revenues levied for the organization's benefit and either paid to or expended on its behalf...            
5 The value of services or facilities furnished by a governmental unit to the organization without charge..            
6 Total. Add lines 1 through 5.            
7a Amounts included on lines 1, 2, and 3 received from disqualified persons...            
b Amounts included on lines 2 and 3 received from other than disqualified persons that exceed the greater of $5,000 or 1% of the amount on line 13 for the year.            
c Add lines 7a and 7b..            
8 Public Support (Subtract line 7c from line 6.)            
Section B. Total Support
Calendar year (or fiscal year beginning in) (a) 2007 (b) 2008 (c) 2009 (d) 2010 (e) 2011 (f) Total
9 Amounts from line 6...            
10a Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..            
b Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.            
c Add lines 10a and 10b.            
11 Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on.            
12 Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)            
13 Total support (Add lines 9, 10c, 11 and 12.).            
14
Section C. Computation of Public Support Percentage
15
15
 
16
16
 
Section D. Computation of Investment Income Percentage
17
17
 
18
18
 
19a
b
20
Schedule A (Form 990 or 990-EZ) 2011
Schedule A (Form 990 or 990-EZ) 2011
Page 4
Part IV
Supplemental Information. Supplemental Information. Complete this part to provide the explanation required by Part II, line 10; Part II, line 17a or 17b; or Part III, line 12. Also complete this part for any additional information. (See instructions).
Facts And Circumstances Test
 
Explanation
 
 
 
 
Schedule A (Form 990 or 990-EZ) 2011

Additional Data


Software ID:  
Software Version:  
Schedule B
(Form 990, 990-EZ,
or 990-PF)
Department of the Treasury
Internal Revenue Service
Schedule of Contributors
Arrow Bullet Attach to Form 990, 990-EZ, or 990-PF.
OMB No. 1545-0047
2011
Name of organization
MERCY HEALTH SERVICES - IOWA CORP
 
Employer identification number

31-1373080
Organization type (check one):
Filers of:
Section:
Form 990 or 990-EZ





Form 990-PF




Check if your organization is covered by the General Rule or a Special Rule.  
Note. Only a section 501(c)(7), (8), or (10) organization can check boxes for both the General Rule and a Special Rule. See instructions.
General Rule
Special Rules
......................... Arrow Bullet   $    
Caution. An Organization that is not covered by the General Rule and/or the Special Rules does not file Schedule B (Form 990,
990-EZ, or 990-PF), but it must answer “No” on Part IV, line 2, of its Form 990; or check the box on line H of its
Form 990-EZ or on Part I, line 2, of its Form 990-PF, to certify that it does not meet the filing requirements of Schedule B (Form 990,
990-EZ, or 990-PF).
For Paperwork Reduction Act Notice, see the Instructions
for Form 990, 990-EZ, or 990-PF.
Cat. No. 30613XSchedule B (Form 990, 990-EZ, or 990-PF) (2011)

Page 2
Schedule B (Form 990, 990-EZ, or 990-PF) (2011)
Name of organization
MERCY HEALTH SERVICES - IOWA CORP
  		Employer identification number

31-1373080
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




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

     
 
   

$  




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

     
 
   

$  




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

     
 
   

$  




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

     
 
   

$  




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

     
 
   

$  




(Complete Part II if there is a noncash contribution.)
Schedule B (Form 990, 990-EZ, or 990-PF) (2011)

Page 3
Schedule B (Form 990, 990-EZ, or 990-PF) (2011)
Name of organization
MERCY HEALTH SERVICES - IOWA CORP
  		Employer identification number

31-1373080
Part II
Noncash Property (see Instructions). Use duplicate copies of Part II if additional space is needed.
     
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions). 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions). 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions). 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions). 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions). 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions). 		(d)
Date received
 
$    
Schedule B (Form 990, 990-EZ, or 990-PF) (2011)

Page 4
Schedule B (Form 990, 990-EZ, or 990-PF) (2011)
Name of organization
MERCY HEALTH SERVICES - IOWA CORP
  		Employer identification number

31-1373080
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		 (c)
Use of gift		 (d)
Description of how gift is held
 
(e)
Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
       
 
(a) No.
from
Part I		 (b)
Purpose of gift		 (c)
Use of gift		 (d)
Description of how gift is held
 
(e)
Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
       
 
(a) No.
from
Part I		 (b)
Purpose of gift		 (c)
Use of gift		 (d)
Description of how gift is held
 
(e)
Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
       
 
(a) No.
from
Part I		 (b)
Purpose of gift		 (c)
Use of gift		 (d)
Description of how gift is held
 
(e)
Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
       
 
Schedule B (Form 990, 990-EZ, or 990-PF) (2011)

Additional Data


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

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

For Organizations Exempt From Income Tax Under section 501(c) and section 527
SchCMd Bullet Complete if the organization is described below.
SchCMd Bullet Attach to Form 990 or Form 990-EZ. SchCMd Bullet See separate instructions.
OMB No. 1545-0047
2011
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, line 35c (Proxy Tax), then
Round Bullet Section 501(c)(4), (5), or (6) organizations: Complete Part III.
Name of the organization
MERCY HEALTH SERVICES - IOWA CORP
 
Employer identification number

31-1373080
Part I-A
Complete if the organization is exempt under section 501(c) or is a section 527 organization.

1
Provide a description of the organization’s direct and indirect political campaign activities in Part IV.
2
Political expenditures ....................................SchCMd Bullet
$  
3
Volunteer hours ........................................
 

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

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

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










For Privacy Act and Paperwork Reduction Act Notice, see the instructions for Form 990.
Cat. No. 50084S
Schedule C (Form 990 or 990-EZ) 2011

Schedule C (Form 990 or 990-EZ) 2011
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 expenses, and share of excess lobbying expenditures).
B Check
Limits on Lobbying Expenditures
(The term "expenditures" means amounts paid or incurred.) 		(a) Filing
organization's
totals 		(b) Affiliated group
totals
1a Total lobbying expenditures to influence public opinion (grass roots lobbying) ......    
b Total lobbying expenditures to influence a legislative body (direct lobbying) .......    
c Total lobbying expenditures (add lines 1a and 1b) ...................    
d Other exempt purpose expenditures ........................    
e Total exempt purpose expenditures (add lines 1c and 1d) ...............    
f Lobbying nontaxable amount. Enter the amount from the following table in both
columns.		    
  If the amount on line 1e, column (a) or (b) is:The lobbying nontaxable amount is:    
  Not over $500,00020% of the amount on line 1e.    
  Over $500,000 but not over $1,000,000$100,000 plus 15% of the excess over $500,000.    
  Over $1,000,000 but not over $1,500,000$175,000 plus 10% of the excess over $1,000,000.    
  Over $1,500,000 but not over $17,000,000$225,000 plus 5% of the excess over $1,500,000.    
  Over $17,000,000$1,000,000.    
       
g Grassroots nontaxable amount (enter 25% of line 1f) .................    
h Subtract line 1g from line 1a. If zero or less, enter -0-. ................    
i Subtract line 1f from line 1c. If zero or less, enter -0-. ................    
j If there is an amount other than zero on either line 1h or line 1i, did the organization file Form 4720 reporting
section 4911 tax for this year? ......................................

4-Year Averaging Period Under Section 501(h)
(Some organizations that made a section 501(h) election do not have to complete all of the five
columns below. See the instructions for lines 2a through 2f on page 4.)
Lobbying Expenditures During 4-Year Averaging Period
  Calendar year (or fiscal year
beginning in) 		(a) 2008 (b) 2009 (c) 2010 (d) 2011 (e) Total
             
2a Lobbying non-taxable 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) 2011


Schedule C (Form 990 or 990-EZ) 2011
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
No
(b)
Amount
1
During the year, did the filing organization attempt to influence foreign, national, state or local legislation, including any attempt to influence public opinion on a legislative matter or referendum, through the use of:
a
Volunteers? .........................................
Yes
 
b
Paid staff or management (include compensation in expenses reported on lines 1c through 1i)? ....
Yes
 
c
Media advertisements? ....................................
 
No
 
d
Mailings to members, legislators, or the public? .........................
Yes
 
 
e
Publications, or published or broadcast statements? .......................
 
No
 
f
Grants to other organizations for lobbying purposes? .......................
Yes
 
130,755
g
Direct contact with legislators, their staffs, government officials, or a legislative body? ........
Yes
 
45,245
h
Rallies, demonstrations, seminars, conventions, speeches, lectures, or any similar means? ......
 
No
 
i
Other activities? ..........................
 
No
 
j
Total. Add lines 1c through 1i ...............................
176,000
2a
Did the activities in line 1 cause the organization to be not described in section 501(c)(3)? .....
 
No
b
If "Yes," enter the amount of any tax incurred under section 4912 .................
 
c
If "Yes," enter the amount of any tax incurred by organization managers under section 4912 .....
 
d
If the filing organization incurred a section 4912 tax, did it file Form 4720 for this year? .......
 
 
Part III-A
Complete if the organization is exempt under section 501(c)(4), section 501(c)(5), or section 501(c)(6).
Yes
No
1
Were substantially all (90% or more) dues received nondeductible by members? ................
1
 
 
2
Did the organization make only in-house lobbying expenditures of $2,000 or less? ................
2
 
 
3
Did the organization agree to carry over lobbying and political expenditures from the prior year? ..........
3
 
 
Part III-B
Complete if the organization is exempt under section 501(c)(4), section 501(c)(5), or section 501(c)(6) 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”.
1
Dues, assessments and similar amounts from members .....................
1
 
2
Section 162(e) nondeductible lobbying and political expenditures (do not include amounts of political
expenses for which the section 527(f) tax was paid).
a
Current year .........................................
2a
 
b
Carryover from last year ....................................
2b
 
c
Total ...........................................
2c
 
3
Aggregate amount reported in section 6033(e)(1)(A) notices of nondeductible section 162(e) dues .
3
 
4
If notices were sent and the amount on line 2c exceeds the amount on line 3, what portion of the excess does the organization agree to carryover to the reasonable estimate of nondeductible lobbying and political expenditure next year? ................................
4
 
5
Taxable amount of lobbying and political expenditures (see instructions) ..............
5
 
Part IV
Supplemental Information
Complete this part to provide the descriptions required for Part l-A, line 1; Part l-B, line 4; Part l-C, Part II-A; line 5; and Part ll-B, line 1.
Also, complete this part for any additional information.
Identifier Return Reference Explanation
EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: LOBBYING ACTIVITY INCLUDED ENCOURAGING ASSOCIATES TO WRITE LETTERS TO PUBLIC OFFICIALS AND THE USE OF PAID STAFF MEMBERS AND MANAGEMENT PERSONNEL. MANAGEMENT PERSONNEL REGULARLY ISSUE MAILINGS TO LEGISLATORS ATTEMPTING TO INFLUENCE LEGISLATIVE MATTERS AND REFERENDUM, AND ORGANIZE AND HOST MEETINGS AMONG HOSPITAL EXECUTIVES AND THEIR LEGISLATORS. PAID STAFF MEMBERS HAVE ON LIMITED OCCASIONS WRITTEN LETTERS TO LEGISLATORS. MERCY HEALTH SERVICES - IOWA, CORP (MHS-IA) HAS MADE GRANTS TO OTHER ORGANIZATIONS FOR LOBBYING PURPOSES IN THE FORM OF MEMBERSHIP DUES PAID TO REGIONAL AND NATIONAL HEALTH CARE ORGANIZATIONS. THESE ORGANIZATIONS HAVE PROVIDED MHS-IA WITH AN ESTIMATED PERCENTAGE OF DUES PAYMENTS THAT ARE USED FOR LOBBYING ACTIVITIES. SIMILARLY, THESE HEALTH CARE ORGANIZATIONS WILL ARRANGE CONFERENCES AND SEMINARS FOR MEMBER ORGANIZATIONS AND THEIR EXECUTIVES THAT WILL INVOLVE LEGISLATORS OR OTHER POLITICAL FIGURES AS GUEST SPEAKERS. FEDERAL AND STATE ADVOCACY PRIORITIES FOR FY12 INCLUDED: (1) SECURE COVERAGE AND ACCESS FOR ALL (2) ACHIEVE COORDINATED CARE: PROMOTE SAFE, HIGH-QUALITY COORDINATED CARE ACROSS THE HEALTH CARE CONTINUUM (3) ACHIEVE HIGH-VALUE CARE, INCLUDING: - ADVOCATE FOR MEDICARE AND MEDICAID SAVINGS THROUGH PAYMENT AND DELIVERY REDESIGN - REFORM MEDICARE TO INCLUDE SUSTAINABLE SOLUTIONS TO ADDRESS GEOGRAPHIC PAYMENT DISPARITIES - SECURE ADEQUATE FUNDING FOR IMPLEMENTATION OF HEALTH CARE REFORM RULES - ENCOURAGE USE OF SAFETY/QUALITY MEASUREMENTS - PROMOTE IDEAS TO REDUCE HEALTH CARE COSTS LOBBYING ACTIVITY PERFORMED BY MERCY HEALTH SERVICES-IOWA, CORP. INCLUDED: - AN "ADVOCACY ACTION" WEBSITE TO ENGAGE ASSOCIATES IN FEDERAL ADVOCACY - DESIGNATE AN ADVOCACY LIAISON - ENGAGEMENT OF A LOBBYIST IN WASHINGTON, D.C. BY TRINITY HEALTH CORPORATION - LEGISLATOR VISITS - COLLABORATION WITH THE CATHOLIC HOSPITAL ASSOCIATION, AND THE AMERICAN HOSPITAL ASSOCIATION - ADVOCACY ACTION DAY IN IOWA DIRECTED TO STATE OFFICIALS AND ATTENDED BY EXECUTIVES REPRESENTING MEMBER HOSPITALS
Schedule C (Form 990 or 990EZ) 2011

Additional Data


Software ID:  
Software Version:  

SCHEDULE D
(Form 990)
Department of the Treasury
Internal Revenue Service
Supplemental Financial Statements
SchDMd Bullet Complete if the organization answered "Yes," to Form 990,
Part IV, line 6, 7, 8, 9, 10, 11a, 11b, 11c, 11d, 11e, 11f, 12a, or 12b
SchDMd Bullet Attach to Form 990. SchDMd Bullet See separate instructions.
OMB No. 1545-0047
2011
Open to Public Inspection
Name of the organization
MERCY HEALTH SERVICES - IOWA CORP
 
Employer identification number

31-1373080
Part I
Organizations Maintaining Donor Advised Funds or Other Similar Funds or Accounts. Complete if the organization answered "Yes" to Form 990, Part IV, line 6.
(a) Donor advised funds (b) Funds and other accounts
1 Total number at end of year .......    
2 Aggregate contributions to (during year) ...    
3 Aggregate grants from (during year) ...    
4 Aggregate value at end of year .......    
5
Did the organization inform all donors and donor advisors in writing that the assets held in donor advised
funds are the organization's property, subject to the organization's exclusive legal control? ............
6
Did the organization inform all grantees, donors, and donor advisors in writing that grant funds 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? ...................................
Part II
Conservation Easements. Complete if the organization answered "Yes" to Form 990, Part IV, line 7.
1
Purpose(s) of conservation easements held by the organization (check all that apply).
2
Complete lines 2a 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.
Held at the End of the Year
a Total number of conservation easements ....................... 2a  
b Total acreage restricted by conservation easements .................. 2b  
c Number of conservation easements on a certified historic structure included in (a) ..... 2c  
d Number of conservation easements included in (c) acquired after 8/17/06, and not on a historic structure listed in the National Register .................... 2d  
3
Number of conservation easements modified, transferred, released, extinguished, or terminated by the organization during
the tax year SchDMd Bullet  
4
Number of states where property subject to conservation easement is located SchDMd Bullet  
5
Does the organization have a written policy regarding the periodic monitoring, inspection, handling of violations, and
enforcement of the conservation easements it holds? .............................
6
Staff and volunteer hours devoted to monitoring, inspecting and enforcing conservation easements during the year SchDMd Bullet  
7
Amount of expenses incurred in monitoring, inspecting, and enforcing conservation easements during the year
SchDMd Bullet $  
8
Does each conservation easement reported on line 2(d) above satisfy the requirements of section
170(h)(4)(B)(i) and 170(h)(4)(B)(ii)? ....................................
9
In Part XIV, describe how the organization reports conservation easements in its revenue and expense statement, and
balance sheet, and include, if applicable, the text of the footnote to the organization’s financial statements that describes
the organization’s accounting for conservation easements.
Part III
Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets.
Complete if the organization answered "Yes" to Form 990, Part IV, line 8.
1a
If the organization elected, as permitted under SFAS 116 (ASC 958), not to report in its revenue statement and balance sheet works of
art, historical treasures, or other similar assets held for public exhibition, education or research in furtherance of public service,
provide, in Part XIV, the text of the footnote to its financial statements that describes these items.
b
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 $  
2
If the organization received or held works of art, historical treasures, or other similar assets for financial gain, provide the
following amounts required to be reported under SFAS 116 (ASC 958), relating to these items:
a
Revenues included in Form 990, Part VIII, line 1 ..........................SchDMd Bullet $  
b
Assets included in Form 990, Part X ...............................SchDMd Bullet $  
For Privacy Act and Paperwork Reduction Act Notice, see the Intructions for Form 990
Cat. No. 52283D
Schedule D (Form 990) 2011

Schedule D (Form 990) 2011
Page 2
Part III
Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets (continued)
3
Using the organization’s accession and other records, check any of the following that are a significant use of its collection
items (check all that apply):
a
d
b
e
 
c
4
Provide a description of the organization’s collections and explain how they further the organization’s exempt purpose in
Part XIV.
5
During the year, did the organization solicit or receive donations of art, historical treasures or other similar
assets to be sold to raise funds rather than to be maintained as part of the organization’s collection?........
Part IV
Escrow and Custodial Arrangements. Complete if the organization answered "Yes" to Form 990,
Part IV, line 9, or reported an amount on Form 990, Part X, line 21.
1a
Is the organization an agent, trustee, custodian or other intermediary for contributions or other assets not
included on Form 990, Part X? ....................................
b
If "Yes," explain the arrangement in Part XIV and complete the following table:
Amount
c Beginning balance ................................. 1c  
d Additions during the year .............................. 1d  
e Distributions during the year ............................. 1e  
f Ending balance ................................... 1f  
2a
Did the organization include an amount on Form 990, Part X, line 21? .....................
b
If “Yes,” explain the arrangement in Part XIV.
Part V
Endowment Funds. Complete if the organization answered "Yes" to Form 990, Part IV, line 10.
(a)Current Year (b)Prior Year (c)Two Years Back (d)Three Years Back (e)Four Years Back
1a Beginning of year balance .... 25,000 25,000 25,000 25,000
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 ...... 25,000 25,000 25,000 25,000
2
Provide the estimated percentage of the year end balance (line 1g) held as:
a
Board designated or quasi-endowment SchDMd Bullet  
b
Permanent endowment SchDMd Bullet100.000 %
c
Temporarily restricted endowment SchDMd Bullet  
The percentages in lines 2a, 2b, and 2c should equal 100%.
3a
Are there endowment funds not in the possession of the organization that are held and administered for the
organization by:

Yes
No
(i) unrelated organizations ........................
3a(i)
Yes
 
(ii) related organizations ........................
3a(ii)
Yes
 
b
If "Yes" to 3a(ii), are the related organizations listed as required on Schedule R? .........
3b
Yes
 
4
Describe in Part XIV the intended uses of the organization's endowment funds.
Part VI
Land, Buildings, and Equipment. See Form 990, Part X, line 10.
Description of property (a) Cost or other basis (investment) (b)Cost or other basis (other) (c) Accumulated depreciation (d) Book value
1a Land .................   10,445,234 10,445,234
b Buildings ................   315,827,738 208,199,545 107,628,193
c Leasehold improvements ............        
d Equipment ................   210,937,655 165,215,156 45,722,499
e Other .................   21,790,677 310,551 21,480,126
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).).......SchDMdBullet 185,276,052
Schedule D (Form 990) 2011

Schedule D (Form 990) 2011
Page 3
Part VII
Investments—Other Securities. See Form 990, Part X, line 12.
(a) Description of security or category
(including name of security)		 (b)Book value (c) Method of valuation:
Cost or end-of-year market value
(1)Financial derivatives    
(2)Closely-held equity interests    
(3)Other
(A) COMMINGLED FUNDS DIRECTLY HOLDING SECURITIES 		98,185,922 F

(B) EQUITY METHOD INVESTMENTS 		75,743,425 C







Total. (Column (b) must equal Form 990, Part X, col. (B) line 12.)Small Bullet 173,929,347
Part VIII
Investments—Program Related. See Form 990, Part X, line 13.
(a) Description of investment type (b) Book value (c) Method of valuation:
Cost or end-of-year market value








Total. (Column (b) must equal Form 990, Part X, col.(B) line 13.)Small Bullet  
Part IX
Other Assets. See Form 990, Part X, line 15.
(a) Description (b) Book value
(1) OTHER RECEIVABLES 10,684,016
(2) INTERCOMPANY ACCOUNTS RECEIVABLE 2,212,994
(3) INVESTMENT IN AFFILIATES 162,447,391
(4) OTHER ASSETS 2,074,721
(5) INTERCOMPANY OTHER LT ASSETS 36,061,687




Total. (Column (b) must equal Form 990, Part X, col.(B) line 15.)...........Small Bullet 213,480,809
Part X
Other Liabilities. See Form 990, Part X, line 25.
1.(a) Description of Liability (b) Book value
Federal Income Taxes  
INTERCOMPANY ACCOUNTS PAYABLE 12,374,610
DEFERRED COMPENSATION 10,896,874
LONG TERM ASSET RETIREMENT OBLIGATION (FIN 47) 3,324,482
INTERCOMPANY NOTES PAYABLE 204,474,824
OTHER LIABILITIES 2,588,967
LEASE OBLIGATION 380,850
ANNUITY PAYABLE 63,980


Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)Small Bullet 234,104,587
2. Fin 48 (ASC 740) Footnote. In Part XIV, provide the text of the footnote to the organization's financial statements that reports the organization's liability for uncertain tax positions under FIN 48 (ASC740).
Schedule D (Form 990) 2011

Schedule D (Form 990) 2011
Page 4
Part XI Reconciliation of Change in Net Assets from Form 990 to Financial Statements
1 Total revenue (Form 990, Part VIII, column (A), line 12) .................... 1  
2 Total expenses (Form 990, Part IX, column (A), line 25) ..................... 2  
3 Excess or (deficit) for the year. Subtract line 2 from line 1 ............. 3  
4 Net unrealized gains (losses) on investments .......................... 4  
5 Donated services and use of facilities ............................. 5  
6 Investment expenses ................................... 6  
7 Prior period adjustments .................................. 7  
8 Other (Describe in Part XIV.) ................................. 8  
9 Total adjustments (net). Add lines 4 through 8 ......................... 9  
10 Excess or (deficit) for the year per financial statements. Combine lines 3 and 9 ......... 10  
Part XII Reconciliation of Revenue per Audited Financial Statements With Revenue per Return
1 Total revenue, gains, and other support per audited financial statements ....... 1  
2 Amounts included on line 1 but not on Form 990, Part VIII, line 12:
a Net unrealized gains on investments .......... 2a  
b Donated services and use of facilities ......... 2b  
c Recoveries of prior year grants ........... 2c  
d Other (Describe in Part XIV.) ............ 2d  
e Add lines 2a through 2d ..................... 2e  
3 Subtract line 2e from line 1..................... 3  
4 Amounts included on Form 990, Part VIII, line 12, but not on line 1:
a Investment expenses not included on Form 990, Part VIII, line 7b . 4a  
b Other (Describe in Part XIV.) ........... 4b  
c Add lines 4a and 4b....................... 4c  
5 Total Revenue. Add lines 3 and 4c. (This must equal Form 990, Part I, line 12.) ...... 5  
Part XIII Reconciliation of Expenses per Audited Financial Statements With Expenses per Return
1 Total expenses and losses per audited financial statements ............. 1  
2 Amounts included on line 1 but not on Form 990, Part IX, line 25:
a Donated services and use of facilities .......... 2a  
b Prior year adjustments .............. 2b  
c Other losses ................ 2c  
d Other (Describe in Part XIV.) ............ 2d  
e Add lines 2a through 2d...................... 2e  
3 Subtract line 2e from line 1..................... 3  
4 Amounts included on Form 990, Part IX, line 25, but not on line 1:
a Investment expenses not included on Form 990, Part VIII, line 7b .. 4a  
b Other (Describe in Part XIV.) ............ 4b  
c Add lines 4a and 4b....................... 4c  
5 Total expenses. Add lines 3 and 4c. (This must equal Form 990, Part I, line 18.) ...... 5  
Part XIV
Supplemental Information
Complete this part to provide the descriptions required for Part II, lines 3, 5, and 9; Part III, lines 1a and 4; Part lV, lines 1b and 2b;
Part V, line 4; Part X; Part XI, line 8; Part XII, lines 2d and 4b; and Part XIII, lines 2d and 4b. Also complete this part to provide any additional information.
Identifier Return Reference Explanation
DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: THE ENDOWMENT FUNDS OF MERCY HEALTH SERVICES - IOWA, CORP. INCLUDE $25,000 KNOWN AS THE VIANNA HOLSCHLAG SCHOLARSHIP FUND. INTEREST INCOME FROM THE FUND IS MADE AVAILABLE FOR NURSING SCHOLARSHIPS.
Schedule D (Form 990) 2011

Additional Data


Software ID:  
Software Version:  




SCHEDULE G (Form 990 or 990-EZ)
Department of the Treasury
Internal Revenue Service
Supplemental Information Regarding
Fundraising or Gaming Activities
Complete if the organization answered "Yes" to Form 990, Part IV, lines 17, 18, or 19,or if the organization entered more than $15,000 on Form 990-EZ, line 6a.right arrowAttach to Form 990 or Form 990-EZ. right arrowSee separate instructions.
OMB No. 1545-0047
2011
Open to Public Inspection
Name of the organization
MERCY HEALTH SERVICES - IOWA CORP
 
Employer identification number

31-1373080
Part I
Fundraising Activities. Complete if the organization answered "Yes" to Form 990, Part IV, line 17.
1
Indicate whether the organization raised funds through any of the following activities. Check all that apply.
a e
b f
c g
d
2a
Did the organization have a written or oral agreement with any individual (including officers, directors, trustees
or key employees listed in Form 990, Part VII) or entity in connection with professional fundraising services?
b
If “Yes,” list the ten highest paid individuals or entities (fundraisers) pursuant to agreements under which the fundraiser is
to be compensated at least $5,000 by the organization. Form 990-EZ filers are not required to complete this table.
(i) Name and address of individual
or entity (fundraiser) 		(ii) Activity (iii) Did fundraiser have custody or control of contributions? (iv) Gross receipts
from activity 		(v) Amount paid to
(or retained by)
fundraiser listed in
col. (i) 		(vi) Amount paid to
(or retained by)
organization
Yes No
Total .................right arrow      
3
List all states in which the organization is registered or licensed to solicit funds or has been notified it is exempt from registration or licensing.
For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50083H
Schedule G (Form 990 or 990-EZ) 2011
Schedule G (Form 990 or 990-EZ) 2011
Page 2
Part II
Fundraising Events. Complete if the organization answered "Yes" to Form 990, Part IV, line 18, or reported more than $15,000 on Form 990-EZ, line 6a. List events with gross receipts greater than $5,000.
(a) Event #1

GALA
(event type) 		(b) Event #2

FUND DRIVE
(event type) 		(c) Other Events

  
(total number) 		(d) Total Events
(Add col. (a) through col. (c))
VerticalRevenue 1 Gross receipts . . . 123,658 27,891   151,549
2 Less: Charitable
contributions . . . 		12,625     12,625
3 Gross income (line 1
minus line 2) . . . 		111,033 27,891   138,924
VerticalDirectExpenses 4 Cash prizes . . .        
5 Non-cash prizes . .        
6 Rent/facility costs . .   325   325
7 Food and beverages . .   3,943   3,943
8 Entertainment . . .   1,400   1,400
9 Other direct expenses . 26,766 2,698   29,464
10 Direct expense summary. Add lines 4 through 9 in column (d) ........... right arrow 35,132
11 Net income summary. Combine lines 3 and 10 in column (d)............ right arrow 103,792
Part III
Gaming. Complete if the organization answered "Yes" to Form 990, Part IV, line 19, or reported more than $15,000 on Form 990-EZ, line 6a.
VerticalRevenue (a) Bingo (b) Pull tabs/Instant
bingo/progressive bingo 		(c) Other gaming (d) Total gaming (Add col. (a) through col. (c))
1 Gross revenue . . . .        
VerticalDirectExpenses 2 Cash prizes . . . .        
3 Non-cash prizes . . .        
4 Rent/facility costs . . .        
5 Other direct expenses . .        
6 Volunteer labor . . .
 
 
 
7 Direct expense summary. Add lines 2 through 5 in column (d) ........... right arrow  
8 Net gaming income summary. Combine lines 1 and 7 in column (d) .......... right arrow  
9
Enter the state(s) in which the organization operates gaming activities:
a
Is the organization licensed to operate gaming activities in each of these states? ............
b
If "No," Explain:
 
10a
Were any of the organization's gaming licenses revoked, suspended or terminated during the tax year? .....
b
If "Yes," Explain:
 
11
Does the organization operate gaming activities with nonmembers? .................
12
Is the organization a grantor, beneficiary or trustee of a trust or a member of a partnership or other entity
formed to administer charitable gaming? ..........................
Schedule G (Form 990 or 990-EZ) 2011
Schedule G (Form 990 or 990-EZ) 2011
Page 3
13
Indicate the percentage of gaming activity operated in:
a
The organization's facility ......................
13a
 
b
An outside facility ........................
13b
 
14
Provide the name and address of the person who prepares the organization's gaming/special events books and records:
Name right arrow
Address right arrow
15a
Does the organization have a contract with a third party from whom the organization receives gaming
revenue? ......................................
b
If "Yes," enter the amount of gaming revenue received by the organization right arrow $   and the
amount of gaming revenue retained by the third party right arrow $   .
c
If "Yes," enter name and address:
Name right arrow
Address right arrow
 
 
16
Gaming manager information:
Name right arrow
Gaming manager compensation right arrow $  
Description of services provided right arrow
 
17
Mandatory distributions:
a
Is the organization required under state law to make charitable distributions from the gaming proceeds to
retain the state gaming license? ............................
b
Enter the amount of distributions required under state law distributed to other exempt organizations or spent
in the organization's own exempt activities during the tax year right arrow$  
Part IV
Complete this part to provide additional information for responses to quuestion on Schedule G (see instructions.)
Identifier ReturnReference Explanation
Schedule G (Form 990 or 990-EZ) 2011
Additional Data


Software ID:  
Software Version:  
SCHEDULE H (Form 990)
Department of the Treasury
Internal Revenue Service
Hospitals
MediumBullet Complete if the organization answered "Yes" to Form 990, Part IV, question 20.
MediumBullet Attach to Form 990. MediumBullet See separate instructions.
OMB No. 1545-0047
2011
Open to Public Inspection
Name of the organization
MERCY HEALTH SERVICES - IOWA CORP
 
Employer identification number

31-1373080
Part I
Charity Care and Certain Other Community Benefits at Cost
Yes
No
1a
Did the organization have a financial assistance policy during the tax year? If "No," skip to question 6a....
1a
Yes
 
b
If "Yes," was it a written policy? .......................
1b
Yes
 
2
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.
3
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.
a
Did the organization use Federal Poverty Guidelines (FPG) to determine eligibility for providing free care?
If "Yes," indicate which of the following was the FPG family income limit for eligibility for free care:
3a
Yes
 
b
Did the organization use FPG to determine eligibility for providing discounted care? If "Yes," indicate which of the
following was the family income limit for eligibility for discounted care: ............
3b
Yes
 
c
If the organization did not use FPG to determine eligibility, describe in Part VI the income based criteria for determining eligibility for free or discounted care. Include in the description whether the organization used an asset test or other threshold, regardless of income, to determine eligibility for free or discounted care.
4
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"? ..............

4

Yes

 
5a
Did the organization budget amounts for free or discounted care provided under its financial assistance policy during the tax year? ............................

5a

Yes

 
b
If "Yes," did the organization's financial assistance expenses exceed the budgeted amount?......
5b
 
No
c
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?...............
5c
 
 
6a
Did the organization prepare a community benefit report during the tax year?...........
6a
Yes
 
b
If "Yes," did the organization make it available to the public? ...............
6b
Yes
 
Complete the following table using the worksheets provided in the Schedule H instructions. Do not submit these worksheets with the Schedule H.
7
Financial Assistance and Certain Other Community Benefits at Cost
Financial Assistance
and Means-Tested Government Programs		 (a) Number of activities or programs (optional) (b) Persons served (optional) (c) Total community benefit expense (d) Direct offsetting revenue (e) Net community benefit expense (f) Percent of total expense
a Financial Assistance at cost
(from Worksheet 1) .. 		5 14,098 12,350,418 0 12,350,418 2.000 %
b Medicaid (from Worksheet 3, column a) ..... 39 52,996 44,776,676 33,357,928 11,418,748 1.850 %
c Costs of other means-tested government programs (from Worksheet 3, column b) . 0 30,930        
dTotal Financial Assistance and
Means-Tested Government Programs ..... 		44 98,024 57,127,094 33,357,928 23,769,166 3.850 %
Other Benefits
e Community health improvement
services and community
benefit operations (from
(Worksheet 4) .... 		68 237,456 3,632,808 404,014 3,228,794 0.520 %
f Health professions education
(from Worksheet 5) .. 		17 21,169 8,553,222 2,722,259 5,830,963 0.940 %
g Subsidized health services
(from Worksheet 6) .. 		27 78,036 21,776,506 12,853,671 8,922,835 1.450 %
h Research (from Worksheet 7) 3 864 227,920 0 227,920 0.040 %
i Cash and in-kind contributions for community benefit (from Worksheet 8) .... 28 107,601 1,638,951 132,663 1,506,288 0.240 %
jTotal Other Benefits ... 143 445,126 35,829,407 16,112,607 19,716,800 3.190 %
kTotal. Add lines 7d and 7j. .. 187 543,150 92,956,501 49,470,535 43,485,966 7.040 %
For Paperwork Reduction Act Notice, see the Instructions for Form 990. Cat. No. 50192T Schedule H (Form 990) 2011
Schedule H (Form 990) 2011
Page
Part II
Community Building Activities Complete this table if the organization conducted any community building activities during the tax year, and describe in Part VI how its community building activities promoted the health of the communities it serves.
(a) Number of activities or programs (optional) (b) Persons served (optional) (c) Total community building expense (d) Direct offsetting
revenue 		(e) Net community building expense (f) Percent of total expense
1 Physical improvements and housing 1 703 74,610   74,610 0.010 %
2 Economic development 2 105 13,961   13,961 0 %
3 Community support 5 98 19,615   19,615 0 %
4 Environmental improvements 3 217 9,810   9,810 0 %
5 Leadership development and training for community members 0 0 0      
6 Coalition building 0 0 0      
7 Community health improvement advocacy 1 0 79,738   79,738 0.010 %
8 Workforce development 1 0 203,389   203,389 0.030 %
9 Other   0 0      
10 Total 13 1,123 401,123   401,123 0.050 %
Part III
Bad Debt, Medicare, & Collection Practices
Section A. Bad Debt Expense
Yes
No
1
Did the organization report bad debt expense in accordance with Heathcare Financial Management Association Statement No. 15? ..........................
1
 
No
2
Enter the amount of the organization's bad debt expense........
2
10,723,795
3
Enter the estimated amount of the organization's bad debt expense attributable to patients eligible under the organization's financial assistance policy .....
3
2,012,613
4
Provide in Part VI the text of the footnote to the organization's financial statements that describes bad debt expense. In addition, describe the costing methodology used in determining the amounts reported on lines 2 and 3, and rationale for including a portion of bad debt amounts as community benefit.
Section B. Medicare
5
Enter total revenue received from Medicare (including DSH and IME).....
5
209,015,096
6
Enter Medicare allowable costs of care relating to payments on line 5.....
6
206,209,583
7
Subtract line 6 from line 5. This is the surplus or (shortfall)........
7
2,805,513
8
Describe in Part VI the extent to which any shortfall reported in line 7 should be treated as community benefit.Also describe in Part VI the costing methodology or source used to determine the amount reported on line 6.Check the box that describes the method used:
Section C. Collection Practices
9a
Did the organization have a written debt collection policy during the tax year? ..........
9a
Yes
 
b
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.......................

9b

Yes

 
Part IV
Management Companies and Joint Ventures
(see instructions)
(a) Name of entity (b) Description of primary
activity of entity 		(c) Organization's
profit % or stock
ownership % 		(d) Officers, directors,
trustees, or key
employees' profit %
or stock ownership% 		(e) Physicians'
profit % or stock
ownership %
11 DUBUQUE REGIONAL AMBULATORY SURGICAL CENTER LLC
  		AMBULATORY SURGICAL SERVICES 50.000 %   50.000 %
22 MEDICAL ASSOCIATESMERCY FAMILY CARE NETWORK LLC
  		PRIMARY CARE PHYSICIAN SERVICES 50.000 %   50.000 %
33 TRI-STATE OCCUPATIONAL HEALTH LLC
  		OCCUPATIONAL HEALTH SERVICES 50.000 %   50.000 %
44 FOREST PARK IMAGING LLC
  		IMAGING SERVICES 52.890 %   47.110 %
55 MAGNETIC RESONANCE SERVICES PARTNERSHIP
  		MRI SERVICES 49.000 %   51.000 %
66 MASON CITY AMBULATORY SURGERY CENTER LLC
  		AMBULATORY SURGICAL SERVICES 51.000 %   49.000 %
77 MERCY HEART CENTER OUTPATIENT SERVICES LLC
  		OUTPATIENT ECHOCARDIOGRAPHY AND NUCLEAR MEDICINE SERVICES 51.000 %   49.000 %
88 SURGICAL CENTER BUILDING ASSOCIATES LLC
  		OWNS AND LEASES SURGICAL CENTER BUILDING 35.000 %   65.000 %
99 SIOUXLAND SURGERY CENTER
  		AMBULATORY SURGICAL SERVICES 31.240 %   68.760 %
1010 MERCY WEIGHT LOSS CENTER LLC
  		PRE-OP AND POST-OP COUNSELING SERVICES TO BARIATRIC PATIENTS 25.000 %   75.000 %
11
12
13
Schedule H (Form 990) 2011
Schedule H (Form 990) 2011
Page
Part VFacility Information
Section A. Hospital Facilities
(list in order of size from largest to smallest)
How many hospital facilities did the organization operate during the tax year?6
Name and address 		Licensed Hospital General-Medical-Surgical Children's Hospital Teaching Hospital Critical Hospital Research Facility ER-24Hours ER-Other Other (Describe)
1 MERCY MEDICAL CENTER-NORTH IOWA
1000 FOURTH STREET SW
MASON CITY,IA50401 		X X   X   X X    
2 MERCY MEDICAL CENTER-SIOUX CITY
801 FIFTH STREET
SIOUX CITY,IA51102 		X X         X   EMPLOYED PHYSICIANS, SKILLED CARE UNIT
3 MERCY MEDICAL CENTER - DUBUQUE
250 MERCY DRIVE
DUBUQUE,IA52001 		X X         X   REHAB,LAB,PHARM, X-RAY,HOME CARE
4 SIOUXLAND SURGERY CENTER
600 SIOUX POINT ROAD
DAKOTA DUNES,SD57049 		X X              
5 MERCY MEDICAL CENTER-NEW HAMPTON
308 NORTH MAPLE AVE
NEW HAMPTON,IA50659 		X       X   X   EMPLOYED PHYSICIANS
6 MERCY MEDICAL CENTER - DYERSVILLE
1111 THIRD STREET SW
DYERSVILLE,IA52040 		X X     X   X   REHAB,LAB,PHARM, X-RAY,HOME CARE
Schedule H (Form 990) 2011
Schedule H (Form 990) 2011
Page
Part VFacility Information (continued)

Section B. Facility Policies and Practices.

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

Yes No
Community Health Needs Assessment (Lines 1 through 7 are optional for 2011)
1 During the tax year or any prior tax year, did the hospital facility conduct a community health needs assessment (“Needs Assessment”)? If “No,” skip to question 8. ..................... 1    
If “Yes,” indicate what the Needs Assessment describes (check all that apply):
a A definition of the community served by the hospital facility
b Demographics of the community
c Existing health care facilities and resources within the community that are available to respond to the health needs of the community
d How data was obtained
e The health needs of the community
f Primary and chronic disease needs and other health issues of uninsured persons, low-income persons, and minority groups
g The process for identifying and prioritizing community health needs and services to meet the community health needs
h The process for consulting with persons representing the community’s interests
i Information gaps that limit the hospital facility’s ability to assess the community’s health needs
j Other (describe in Part VI)
2 Indicate the tax year the hospital facility last conducted a Needs Assessment: 20  
3 In conducting its most recent Needs Assessment, did the hospital facility take into account input from persons who represent the community served by the hospital facility? If “Yes,” describe in Part VI how the hospital facility took into account input from persons who represent the community, and identify the persons the hospital facility consulted. 3    
4 Was the hospital facility’s Needs Assessment conducted with one or more other hospital facilities? If “Yes,” list the other hospital facilities in Part VI............................ 4    
5 Did the hospital facility make its Needs Assessment widely available to the public? ........... 5    
If “Yes,” indicate how the Needs Assessment was made widely available (check all that apply):
a Hospital facility’s website
b Available upon request from the hospital facility
c Other (describe in Part VI)
6 If the hospital facility addressed needs identified in its most recently conducted Needs Assessment, indicate how (check all that apply):
a Adoption of an implementation strategy to address the health needs of the hospital facility’s community
b Execution of the implementation strategy
c Participation in the development of a community-wide community benefit plan
d Participation in the execution of a community-wide community benefit plan
e Inclusion of a community benefit section in operational plans
f Adoption of a budget for provision of services that address the needs identified in the Needs Assessment
g Prioritization of health needs in the community
h Prioritization of services that the hospital facility will undertake to meet health needs in its community
i Other (describe in Part VI)
7 Did the hospital facility address all of the needs identified in its most recently conducted Needs Assessment? If “No,” explain in Part VI which needs it has not addressed and the reasons why it has not addressed such needs. .... 7    
Financial Assistance Policy
Did the hospital facility have in place during the tax year a written financial assistance policy that:
8 Explained eligibility criteria for financial assistance, and whether such assistance includes free or discounted care? 8 Yes  
9 Used federal poverty guidelines (FPG) to determine eligibility for providing free care?........... 9 Yes  
If "Yes," indicate the FPG family income limit for eligibility for free care: 150.000000000000%
If "No," explain in Part VI the criteria the hospital facility used.
Schedule H (Form 990) 2011
Schedule H (Form 990) 2011
Page
Part VFacility Information (continued)

Yes No
10 Used FPG to determine eligibility for providing discounted care?................. 10 Yes  
If “Yes,” indicate the FPG family income limit for eligibility for discounted care: 400.000000000000%
If "No," explain in Part VI the criteria the hospital facility used.
11 Explained the basis for calculating amounts charged to patients?................. 11 Yes  
If “Yes,” indicate the factors used in determining such amounts (check all that apply):
a Income level
b Asset level
c Medical indigency
d Insurance status
e Uninsured discount
f Medicaid/Medicare
g State regulation
h Other (describe in Part VI)
12 Explained the method for applying for financial assistance?................... 12 Yes  
13 Included measures to publicize the policy within the community served by the hospital facility?....... 13 Yes  
If “Yes,” indicate how the hospital facility publicized the policy (check all that apply):
a The policy was posted on the hospital facility’s web site
b The policy was attached to all billing invoices
c The policy was posted in the hospital facility’s emergency rooms or waiting rooms
d The policy was posted in the hospital facility’s admissions offices
e The policy was provided, in writing, to patients upon admission to the hospital facility
f The policy was available upon request
g Other (describe in Part VI)
Billing and Collections
14 Did the hospital facility have in place during the tax year a separate billing and collections policy, or a written financial assistance policy (FAP) that explained actions the hospital facility may take upon non-payment?....... 14 Yes  
15 Check all of the following collection actions against an individual that were permitted under the hospital facility's policies during the tax year before making reasonable efforts to determine the patient’s eligibility under the facility’s FAP:
a Reporting to credit agency
b Lawsuits
c Liens on residences
d Body attachments
e Other similar actions (describe in Part VI)
16 Did the hospital facility or an authorized third party perform any of the following actions during the tax year before making reasonable efforts to determine the patient’s eligibility under the facility’s FAP?.......... 16   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)
17 Indicate which efforts the hospital facility made before initiating any of the actions checked in line 16 (check all that apply):
a Notified patients of the financial assistance policy upon admission
b Notified patients of the financial assistance policy prior to discharge
c Notified patients of the financial assistance policy in communications with the patients regarding the patients’ bills
d Documented its determination of whether patients were eligible for financial assistance under the hospital facility’s financial assistance policy
e Other (describe in Part VI)
Schedule H (Form 990) 2011
Schedule H (Form 990) 2011
Page
Part VFacility Information (continued)

Policy Relating to Emergency Medical Care
Yes No
18 Did the hospital facility have in place during the tax year a written policy relating to emergency medical care that requires the hospital facility to provide, without discrimination, care for emergency medical conditions to individuals regardless of their eligibility under the hospital facility’s financial assistance policy?.......... 18 Yes  
If “No,” indicate why:
a The hospital facility did not provide care for any emergency medical conditions
b The hospital facility’s policy was not in writing
c The hospital facility limited who was eligible to receive care for emergency medical conditions (describe in Part VI)
d Other (describe in Part VI)
Individuals Eligible for Financial Assistance
19 Indicate how the hospital facility determined, during the tax year, the maximum amounts that can be charged to FAP-eligible individuals for emergency or other medically necessary care.
a The hospital facility used its lowest negotiated commercial insurance rate when calculating the maximum amounts that can be charged
b The hospital facility used the average of it's three lowest negotiated commercial insurance rates when calculating the maximum amounts that can be charged
c The hospital facility used the Medicare rates when calculating the maximum amounts that can be charged
d Other (describe in Part VI)
20 Did the hospital facility charge any of its patients who were eligible for assistance under the hospital facility’s financial assistance policy, and to whom the hospital facility provided emergency or other medically necessary services, more than the amounts generally billed to individuals who had insurance covering such care?......... 20   No
If “Yes,” explain in Part VI.
21 Did the hospital facility charge any of its FAP-eligible patients an amount equal to the gross charge for any services provided to that patient?............................... 21   No
If “Yes,” explain in Part VI.
Schedule H (Form 990) 2011
Schedule H (Form 990) 2011
Page
Part VFacility Information (continued)

Section B. Facility Policies and Practices.

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

Yes No
Community Health Needs Assessment (Lines 1 through 7 are optional for 2011)
1 During the tax year or any prior tax year, did the hospital facility conduct a community health needs assessment (“Needs Assessment”)? If “No,” skip to question 8. ..................... 1    
If “Yes,” indicate what the Needs Assessment describes (check all that apply):
a A definition of the community served by the hospital facility
b Demographics of the community
c Existing health care facilities and resources within the community that are available to respond to the health needs of the community
d How data was obtained
e The health needs of the community
f Primary and chronic disease needs and other health issues of uninsured persons, low-income persons, and minority groups
g The process for identifying and prioritizing community health needs and services to meet the community health needs
h The process for consulting with persons representing the community’s interests
i Information gaps that limit the hospital facility’s ability to assess the community’s health needs
j Other (describe in Part VI)
2 Indicate the tax year the hospital facility last conducted a Needs Assessment: 20  
3 In conducting its most recent Needs Assessment, did the hospital facility take into account input from persons who represent the community served by the hospital facility? If “Yes,” describe in Part VI how the hospital facility took into account input from persons who represent the community, and identify the persons the hospital facility consulted. 3    
4 Was the hospital facility’s Needs Assessment conducted with one or more other hospital facilities? If “Yes,” list the other hospital facilities in Part VI............................ 4    
5 Did the hospital facility make its Needs Assessment widely available to the public? ........... 5    
If “Yes,” indicate how the Needs Assessment was made widely available (check all that apply):
a Hospital facility’s website
b Available upon request from the hospital facility
c Other (describe in Part VI)
6 If the hospital facility addressed needs identified in its most recently conducted Needs Assessment, indicate how (check all that apply):
a Adoption of an implementation strategy to address the health needs of the hospital facility’s community
b Execution of the implementation strategy
c Participation in the development of a community-wide community benefit plan
d Participation in the execution of a community-wide community benefit plan
e Inclusion of a community benefit section in operational plans
f Adoption of a budget for provision of services that address the needs identified in the Needs Assessment
g Prioritization of health needs in the community
h Prioritization of services that the hospital facility will undertake to meet health needs in its community
i Other (describe in Part VI)
7 Did the hospital facility address all of the needs identified in its most recently conducted Needs Assessment? If “No,” explain in Part VI which needs it has not addressed and the reasons why it has not addressed such needs. .... 7    
Financial Assistance Policy
Did the hospital facility have in place during the tax year a written financial assistance policy that:
8 Explained eligibility criteria for financial assistance, and whether such assistance includes free or discounted care? 8 Yes  
9 Used federal poverty guidelines (FPG) to determine eligibility for providing free care?........... 9 Yes  
If "Yes," indicate the FPG family income limit for eligibility for free care: 150.000000000000%
If "No," explain in Part VI the criteria the hospital facility used.
Schedule H (Form 990) 2011
Schedule H (Form 990) 2011
Page
Part VFacility Information (continued)

Yes No
10 Used FPG to determine eligibility for providing discounted care?................. 10 Yes  
If “Yes,” indicate the FPG family income limit for eligibility for discounted care: 300.000000000000%
If "No," explain in Part VI the criteria the hospital facility used.
11 Explained the basis for calculating amounts charged to patients?................. 11 Yes  
If “Yes,” indicate the factors used in determining such amounts (check all that apply):
a Income level
b Asset level
c Medical indigency
d Insurance status
e Uninsured discount
f Medicaid/Medicare
g State regulation
h Other (describe in Part VI)
12 Explained the method for applying for financial assistance?................... 12 Yes  
13 Included measures to publicize the policy within the community served by the hospital facility?....... 13 Yes  
If “Yes,” indicate how the hospital facility publicized the policy (check all that apply):
a The policy was posted on the hospital facility’s web site
b The policy was attached to all billing invoices
c The policy was posted in the hospital facility’s emergency rooms or waiting rooms
d The policy was posted in the hospital facility’s admissions offices
e The policy was provided, in writing, to patients upon admission to the hospital facility
f The policy was available upon request
g Other (describe in Part VI)
Billing and Collections
14 Did the hospital facility have in place during the tax year a separate billing and collections policy, or a written financial assistance policy (FAP) that explained actions the hospital facility may take upon non-payment?....... 14 Yes  
15 Check all of the following collection actions against an individual that were permitted under the hospital facility's policies during the tax year before making reasonable efforts to determine the patient’s eligibility under the facility’s FAP:
a Reporting to credit agency
b Lawsuits
c Liens on residences
d Body attachments
e Other similar actions (describe in Part VI)
16 Did the hospital facility or an authorized third party perform any of the following actions during the tax year before making reasonable efforts to determine the patient’s eligibility under the facility’s FAP?.......... 16   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)
17 Indicate which efforts the hospital facility made before initiating any of the actions checked in line 16 (check all that apply):
a Notified patients of the financial assistance policy upon admission
b Notified patients of the financial assistance policy prior to discharge
c Notified patients of the financial assistance policy in communications with the patients regarding the patients’ bills
d Documented its determination of whether patients were eligible for financial assistance under the hospital facility’s financial assistance policy
e Other (describe in Part VI)
Schedule H (Form 990) 2011
Schedule H (Form 990) 2011
Page
Part VFacility Information (continued)

Policy Relating to Emergency Medical Care
Yes No
18 Did the hospital facility have in place during the tax year a written policy relating to emergency medical care that requires the hospital facility to provide, without discrimination, care for emergency medical conditions to individuals regardless of their eligibility under the hospital facility’s financial assistance policy?.......... 18 Yes  
If “No,” indicate why:
a The hospital facility did not provide care for any emergency medical conditions
b The hospital facility’s policy was not in writing
c The hospital facility limited who was eligible to receive care for emergency medical conditions (describe in Part VI)
d Other (describe in Part VI)
Individuals Eligible for Financial Assistance
19 Indicate how the hospital facility determined, during the tax year, the maximum amounts that can be charged to FAP-eligible individuals for emergency or other medically necessary care.
a The hospital facility used its lowest negotiated commercial insurance rate when calculating the maximum amounts that can be charged
b The hospital facility used the average of it's three lowest negotiated commercial insurance rates when calculating the maximum amounts that can be charged
c The hospital facility used the Medicare rates when calculating the maximum amounts that can be charged
d Other (describe in Part VI)
20 Did the hospital facility charge any of its patients who were eligible for assistance under the hospital facility’s financial assistance policy, and to whom the hospital facility provided emergency or other medically necessary services, more than the amounts generally billed to individuals who had insurance covering such care?......... 20   No
If “Yes,” explain in Part VI.
21 Did the hospital facility charge any of its FAP-eligible patients an amount equal to the gross charge for any services provided to that patient?............................... 21   No
If “Yes,” explain in Part VI.
Schedule H (Form 990) 2011
Schedule H (Form 990) 2011
Page
Part VFacility Information (continued)

Section B. Facility Policies and Practices.

(Complete a separate Section B for each of the hospital facilities listed in Part V, Section A)
MERCY MEDICAL CENTER-DUBUQUE
Name of Hospital Facility:  
Line Number of Hospital Facility (from Schedule H, Part V, Section A):3

Yes No
Community Health Needs Assessment (Lines 1 through 7 are optional for 2011)
1 During the tax year or any prior tax year, did the hospital facility conduct a community health needs assessment (“Needs Assessment”)? If “No,” skip to question 8. ..................... 1    
If “Yes,” indicate what the Needs Assessment describes (check all that apply):
a A definition of the community served by the hospital facility
b Demographics of the community
c Existing health care facilities and resources within the community that are available to respond to the health needs of the community
d How data was obtained
e The health needs of the community
f Primary and chronic disease needs and other health issues of uninsured persons, low-income persons, and minority groups
g The process for identifying and prioritizing community health needs and services to meet the community health needs
h The process for consulting with persons representing the community’s interests
i Information gaps that limit the hospital facility’s ability to assess the community’s health needs
j Other (describe in Part VI)
2 Indicate the tax year the hospital facility last conducted a Needs Assessment: 20  
3 In conducting its most recent Needs Assessment, did the hospital facility take into account input from persons who represent the community served by the hospital facility? If “Yes,” describe in Part VI how the hospital facility took into account input from persons who represent the community, and identify the persons the hospital facility consulted. 3    
4 Was the hospital facility’s Needs Assessment conducted with one or more other hospital facilities? If “Yes,” list the other hospital facilities in Part VI............................ 4    
5 Did the hospital facility make its Needs Assessment widely available to the public? ........... 5    
If “Yes,” indicate how the Needs Assessment was made widely available (check all that apply):
a Hospital facility’s website
b Available upon request from the hospital facility
c Other (describe in Part VI)
6 If the hospital facility addressed needs identified in its most recently conducted Needs Assessment, indicate how (check all that apply):
a Adoption of an implementation strategy to address the health needs of the hospital facility’s community
b Execution of the implementation strategy
c Participation in the development of a community-wide community benefit plan
d Participation in the execution of a community-wide community benefit plan
e Inclusion of a community benefit section in operational plans
f Adoption of a budget for provision of services that address the needs identified in the Needs Assessment
g Prioritization of health needs in the community
h Prioritization of services that the hospital facility will undertake to meet health needs in its community
i Other (describe in Part VI)
7 Did the hospital facility address all of the needs identified in its most recently conducted Needs Assessment? If “No,” explain in Part VI which needs it has not addressed and the reasons why it has not addressed such needs. .... 7    
Financial Assistance Policy
Did the hospital facility have in place during the tax year a written financial assistance policy that:
8 Explained eligibility criteria for financial assistance, and whether such assistance includes free or discounted care? 8 Yes  
9 Used federal poverty guidelines (FPG) to determine eligibility for providing free care?........... 9 Yes  
If "Yes," indicate the FPG family income limit for eligibility for free care: 150.000000000000%
If "No," explain in Part VI the criteria the hospital facility used.
Schedule H (Form 990) 2011
Schedule H (Form 990) 2011
Page
Part VFacility Information (continued)

Yes No
10 Used FPG to determine eligibility for providing discounted care?................. 10 Yes  
If “Yes,” indicate the FPG family income limit for eligibility for discounted care: 400.000000000000%
If "No," explain in Part VI the criteria the hospital facility used.
11 Explained the basis for calculating amounts charged to patients?................. 11 Yes  
If “Yes,” indicate the factors used in determining such amounts (check all that apply):
a Income level
b Asset level
c Medical indigency
d Insurance status
e Uninsured discount
f Medicaid/Medicare
g State regulation
h Other (describe in Part VI)
12 Explained the method for applying for financial assistance?................... 12 Yes  
13 Included measures to publicize the policy within the community served by the hospital facility?....... 13 Yes  
If “Yes,” indicate how the hospital facility publicized the policy (check all that apply):
a The policy was posted on the hospital facility’s web site
b The policy was attached to all billing invoices
c The policy was posted in the hospital facility’s emergency rooms or waiting rooms
d The policy was posted in the hospital facility’s admissions offices
e The policy was provided, in writing, to patients upon admission to the hospital facility
f The policy was available upon request
g Other (describe in Part VI)
Billing and Collections
14 Did the hospital facility have in place during the tax year a separate billing and collections policy, or a written financial assistance policy (FAP) that explained actions the hospital facility may take upon non-payment?....... 14 Yes  
15 Check all of the following collection actions against an individual that were permitted under the hospital facility's policies during the tax year before making reasonable efforts to determine the patient’s eligibility under the facility’s FAP:
a Reporting to credit agency
b Lawsuits
c Liens on residences
d Body attachments
e Other similar actions (describe in Part VI)
16 Did the hospital facility or an authorized third party perform any of the following actions during the tax year before making reasonable efforts to determine the patient’s eligibility under the facility’s FAP?.......... 16   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)
17 Indicate which efforts the hospital facility made before initiating any of the actions checked in line 16 (check all that apply):
a Notified patients of the financial assistance policy upon admission
b Notified patients of the financial assistance policy prior to discharge
c Notified patients of the financial assistance policy in communications with the patients regarding the patients’ bills
d Documented its determination of whether patients were eligible for financial assistance under the hospital facility’s financial assistance policy
e Other (describe in Part VI)
Schedule H (Form 990) 2011
Schedule H (Form 990) 2011
Page
Part VFacility Information (continued)

Policy Relating to Emergency Medical Care
Yes No
18 Did the hospital facility have in place during the tax year a written policy relating to emergency medical care that requires the hospital facility to provide, without discrimination, care for emergency medical conditions to individuals regardless of their eligibility under the hospital facility’s financial assistance policy?.......... 18 Yes  
If “No,” indicate why:
a The hospital facility did not provide care for any emergency medical conditions
b The hospital facility’s policy was not in writing
c The hospital facility limited who was eligible to receive care for emergency medical conditions (describe in Part VI)
d Other (describe in Part VI)
Individuals Eligible for Financial Assistance
19 Indicate how the hospital facility determined, during the tax year, the maximum amounts that can be charged to FAP-eligible individuals for emergency or other medically necessary care.
a The hospital facility used its lowest negotiated commercial insurance rate when calculating the maximum amounts that can be charged
b The hospital facility used the average of it's three lowest negotiated commercial insurance rates when calculating the maximum amounts that can be charged
c The hospital facility used the Medicare rates when calculating the maximum amounts that can be charged
d Other (describe in Part VI)
20 Did the hospital facility charge any of its patients who were eligible for assistance under the hospital facility’s financial assistance policy, and to whom the hospital facility provided emergency or other medically necessary services, more than the amounts generally billed to individuals who had insurance covering such care?......... 20   No
If “Yes,” explain in Part VI.
21 Did the hospital facility charge any of its FAP-eligible patients an amount equal to the gross charge for any services provided to that patient?............................... 21   No
If “Yes,” explain in Part VI.
Schedule H (Form 990) 2011
Schedule H (Form 990) 2011
Page
Part VFacility Information (continued)

Section B. Facility Policies and Practices.

(Complete a separate Section B for each of the hospital facilities listed in Part V, Section A)
SIOUXLAND SURGERY CENTER
Name of Hospital Facility:  
Line Number of Hospital Facility (from Schedule H, Part V, Section A):4

Yes No
Community Health Needs Assessment (Lines 1 through 7 are optional for 2011)
1 During the tax year or any prior tax year, did the hospital facility conduct a community health needs assessment (“Needs Assessment”)? If “No,” skip to question 8. ..................... 1    
If “Yes,” indicate what the Needs Assessment describes (check all that apply):
a A definition of the community served by the hospital facility
b Demographics of the community
c Existing health care facilities and resources within the community that are available to respond to the health needs of the community
d How data was obtained
e The health needs of the community
f Primary and chronic disease needs and other health issues of uninsured persons, low-income persons, and minority groups
g The process for identifying and prioritizing community health needs and services to meet the community health needs
h The process for consulting with persons representing the community’s interests
i Information gaps that limit the hospital facility’s ability to assess the community’s health needs
j Other (describe in Part VI)
2 Indicate the tax year the hospital facility last conducted a Needs Assessment: 20  
3 In conducting its most recent Needs Assessment, did the hospital facility take into account input from persons who represent the community served by the hospital facility? If “Yes,” describe in Part VI how the hospital facility took into account input from persons who represent the community, and identify the persons the hospital facility consulted. 3    
4 Was the hospital facility’s Needs Assessment conducted with one or more other hospital facilities? If “Yes,” list the other hospital facilities in Part VI............................ 4    
5 Did the hospital facility make its Needs Assessment widely available to the public? ........... 5    
If “Yes,” indicate how the Needs Assessment was made widely available (check all that apply):
a Hospital facility’s website
b Available upon request from the hospital facility
c Other (describe in Part VI)
6 If the hospital facility addressed needs identified in its most recently conducted Needs Assessment, indicate how (check all that apply):
a Adoption of an implementation strategy to address the health needs of the hospital facility’s community
b Execution of the implementation strategy
c Participation in the development of a community-wide community benefit plan
d Participation in the execution of a community-wide community benefit plan
e Inclusion of a community benefit section in operational plans
f Adoption of a budget for provision of services that address the needs identified in the Needs Assessment
g Prioritization of health needs in the community
h Prioritization of services that the hospital facility will undertake to meet health needs in its community
i Other (describe in Part VI)
7 Did the hospital facility address all of the needs identified in its most recently conducted Needs Assessment? If “No,” explain in Part VI which needs it has not addressed and the reasons why it has not addressed such needs. .... 7    
Financial Assistance Policy
Did the hospital facility have in place during the tax year a written financial assistance policy that:
8 Explained eligibility criteria for financial assistance, and whether such assistance includes free or discounted care? 8 Yes  
9 Used federal poverty guidelines (FPG) to determine eligibility for providing free care?........... 9 Yes  
If "Yes," indicate the FPG family income limit for eligibility for free care: 150.000000000000%
If "No," explain in Part VI the criteria the hospital facility used.
Schedule H (Form 990) 2011
Schedule H (Form 990) 2011
Page
Part VFacility Information (continued)

Yes No
10 Used FPG to determine eligibility for providing discounted care?................. 10 Yes  
If “Yes,” indicate the FPG family income limit for eligibility for discounted care: 300.000000000000%
If "No," explain in Part VI the criteria the hospital facility used.
11 Explained the basis for calculating amounts charged to patients?................. 11 Yes  
If “Yes,” indicate the factors used in determining such amounts (check all that apply):
a Income level
b Asset level
c Medical indigency
d Insurance status
e Uninsured discount
f Medicaid/Medicare
g State regulation
h Other (describe in Part VI)
12 Explained the method for applying for financial assistance?................... 12 Yes  
13 Included measures to publicize the policy within the community served by the hospital facility?....... 13 Yes  
If “Yes,” indicate how the hospital facility publicized the policy (check all that apply):
a The policy was posted on the hospital facility’s web site
b The policy was attached to all billing invoices
c The policy was posted in the hospital facility’s emergency rooms or waiting rooms
d The policy was posted in the hospital facility’s admissions offices
e The policy was provided, in writing, to patients upon admission to the hospital facility
f The policy was available upon request
g Other (describe in Part VI)
Billing and Collections
14 Did the hospital facility have in place during the tax year a separate billing and collections policy, or a written financial assistance policy (FAP) that explained actions the hospital facility may take upon non-payment?....... 14 Yes  
15 Check all of the following collection actions against an individual that were permitted under the hospital facility's policies during the tax year before making reasonable efforts to determine the patient’s eligibility under the facility’s FAP:
a Reporting to credit agency
b Lawsuits
c Liens on residences
d Body attachments
e Other similar actions (describe in Part VI)
16 Did the hospital facility or an authorized third party perform any of the following actions during the tax year before making reasonable efforts to determine the patient’s eligibility under the facility’s FAP?.......... 16   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)
17 Indicate which efforts the hospital facility made before initiating any of the actions checked in line 16 (check all that apply):
a Notified patients of the financial assistance policy upon admission
b Notified patients of the financial assistance policy prior to discharge
c Notified patients of the financial assistance policy in communications with the patients regarding the patients’ bills
d Documented its determination of whether patients were eligible for financial assistance under the hospital facility’s financial assistance policy
e Other (describe in Part VI)
Schedule H (Form 990) 2011
Schedule H (Form 990) 2011
Page
Part VFacility Information (continued)

Policy Relating to Emergency Medical Care
Yes No
18 Did the hospital facility have in place during the tax year a written policy relating to emergency medical care that requires the hospital facility to provide, without discrimination, care for emergency medical conditions to individuals regardless of their eligibility under the hospital facility’s financial assistance policy?.......... 18   No
If “No,” indicate why:
a The hospital facility did not provide care for any emergency medical conditions
b The hospital facility’s policy was not in writing
c The hospital facility limited who was eligible to receive care for emergency medical conditions (describe in Part VI)
d Other (describe in Part VI)
Individuals Eligible for Financial Assistance
19 Indicate how the hospital facility determined, during the tax year, the maximum amounts that can be charged to FAP-eligible individuals for emergency or other medically necessary care.
a The hospital facility used its lowest negotiated commercial insurance rate when calculating the maximum amounts that can be charged
b The hospital facility used the average of it's three lowest negotiated commercial insurance rates when calculating the maximum amounts that can be charged
c The hospital facility used the Medicare rates when calculating the maximum amounts that can be charged
d Other (describe in Part VI)
20 Did the hospital facility charge any of its patients who were eligible for assistance under the hospital facility’s financial assistance policy, and to whom the hospital facility provided emergency or other medically necessary services, more than the amounts generally billed to individuals who had insurance covering such care?......... 20   No
If “Yes,” explain in Part VI.
21 Did the hospital facility charge any of its FAP-eligible patients an amount equal to the gross charge for any services provided to that patient?............................... 21   No
If “Yes,” explain in Part VI.
Schedule H (Form 990) 2011
Schedule H (Form 990) 2011
Page
Part VFacility Information (continued)

Section B. Facility Policies and Practices.

(Complete a separate Section B for each of the hospital facilities listed in Part V, Section A)
MERCY MEDICAL CENTER-NEW HAMPTON
Name of Hospital Facility:  
Line Number of Hospital Facility (from Schedule H, Part V, Section A):5

Yes No
Community Health Needs Assessment (Lines 1 through 7 are optional for 2011)
1 During the tax year or any prior tax year, did the hospital facility conduct a community health needs assessment (“Needs Assessment”)? If “No,” skip to question 8. ..................... 1    
If “Yes,” indicate what the Needs Assessment describes (check all that apply):
a A definition of the community served by the hospital facility
b Demographics of the community
c Existing health care facilities and resources within the community that are available to respond to the health needs of the community
d How data was obtained
e The health needs of the community
f Primary and chronic disease needs and other health issues of uninsured persons, low-income persons, and minority groups
g The process for identifying and prioritizing community health needs and services to meet the community health needs
h The process for consulting with persons representing the community’s interests
i Information gaps that limit the hospital facility’s ability to assess the community’s health needs
j Other (describe in Part VI)
2 Indicate the tax year the hospital facility last conducted a Needs Assessment: 20  
3 In conducting its most recent Needs Assessment, did the hospital facility take into account input from persons who represent the community served by the hospital facility? If “Yes,” describe in Part VI how the hospital facility took into account input from persons who represent the community, and identify the persons the hospital facility consulted. 3    
4 Was the hospital facility’s Needs Assessment conducted with one or more other hospital facilities? If “Yes,” list the other hospital facilities in Part VI............................ 4    
5 Did the hospital facility make its Needs Assessment widely available to the public? ........... 5    
If “Yes,” indicate how the Needs Assessment was made widely available (check all that apply):
a Hospital facility’s website
b Available upon request from the hospital facility
c Other (describe in Part VI)
6 If the hospital facility addressed needs identified in its most recently conducted Needs Assessment, indicate how (check all that apply):
a Adoption of an implementation strategy to address the health needs of the hospital facility’s community
b Execution of the implementation strategy
c Participation in the development of a community-wide community benefit plan
d Participation in the execution of a community-wide community benefit plan
e Inclusion of a community benefit section in operational plans
f Adoption of a budget for provision of services that address the needs identified in the Needs Assessment
g Prioritization of health needs in the community
h Prioritization of services that the hospital facility will undertake to meet health needs in its community
i Other (describe in Part VI)
7 Did the hospital facility address all of the needs identified in its most recently conducted Needs Assessment? If “No,” explain in Part VI which needs it has not addressed and the reasons why it has not addressed such needs. .... 7    
Financial Assistance Policy
Did the hospital facility have in place during the tax year a written financial assistance policy that:
8 Explained eligibility criteria for financial assistance, and whether such assistance includes free or discounted care? 8 Yes  
9 Used federal poverty guidelines (FPG) to determine eligibility for providing free care?........... 9 Yes  
If "Yes," indicate the FPG family income limit for eligibility for free care: 150.000000000000%
If "No," explain in Part VI the criteria the hospital facility used.
Schedule H (Form 990) 2011
Schedule H (Form 990) 2011
Page
Part VFacility Information (continued)

Yes No
10 Used FPG to determine eligibility for providing discounted care?................. 10 Yes  
If “Yes,” indicate the FPG family income limit for eligibility for discounted care: 400.000000000000%
If "No," explain in Part VI the criteria the hospital facility used.
11 Explained the basis for calculating amounts charged to patients?................. 11 Yes  
If “Yes,” indicate the factors used in determining such amounts (check all that apply):
a Income level
b Asset level
c Medical indigency
d Insurance status
e Uninsured discount
f Medicaid/Medicare
g State regulation
h Other (describe in Part VI)
12 Explained the method for applying for financial assistance?................... 12 Yes  
13 Included measures to publicize the policy within the community served by the hospital facility?....... 13 Yes  
If “Yes,” indicate how the hospital facility publicized the policy (check all that apply):
a The policy was posted on the hospital facility’s web site
b The policy was attached to all billing invoices
c The policy was posted in the hospital facility’s emergency rooms or waiting rooms
d The policy was posted in the hospital facility’s admissions offices
e The policy was provided, in writing, to patients upon admission to the hospital facility
f The policy was available upon request
g Other (describe in Part VI)
Billing and Collections
14 Did the hospital facility have in place during the tax year a separate billing and collections policy, or a written financial assistance policy (FAP) that explained actions the hospital facility may take upon non-payment?....... 14 Yes  
15 Check all of the following collection actions against an individual that were permitted under the hospital facility's policies during the tax year before making reasonable efforts to determine the patient’s eligibility under the facility’s FAP:
a Reporting to credit agency
b Lawsuits
c Liens on residences
d Body attachments
e Other similar actions (describe in Part VI)
16 Did the hospital facility or an authorized third party perform any of the following actions during the tax year before making reasonable efforts to determine the patient’s eligibility under the facility’s FAP?.......... 16   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)
17 Indicate which efforts the hospital facility made before initiating any of the actions checked in line 16 (check all that apply):
a Notified patients of the financial assistance policy upon admission
b Notified patients of the financial assistance policy prior to discharge
c Notified patients of the financial assistance policy in communications with the patients regarding the patients’ bills
d Documented its determination of whether patients were eligible for financial assistance under the hospital facility’s financial assistance policy
e Other (describe in Part VI)
Schedule H (Form 990) 2011
Schedule H (Form 990) 2011
Page
Part VFacility Information (continued)

Policy Relating to Emergency Medical Care
Yes No
18 Did the hospital facility have in place during the tax year a written policy relating to emergency medical care that requires the hospital facility to provide, without discrimination, care for emergency medical conditions to individuals regardless of their eligibility under the hospital facility’s financial assistance policy?.......... 18 Yes  
If “No,” indicate why:
a The hospital facility did not provide care for any emergency medical conditions
b The hospital facility’s policy was not in writing
c The hospital facility limited who was eligible to receive care for emergency medical conditions (describe in Part VI)
d Other (describe in Part VI)
Individuals Eligible for Financial Assistance
19 Indicate how the hospital facility determined, during the tax year, the maximum amounts that can be charged to FAP-eligible individuals for emergency or other medically necessary care.
a The hospital facility used its lowest negotiated commercial insurance rate when calculating the maximum amounts that can be charged
b The hospital facility used the average of it's three lowest negotiated commercial insurance rates when calculating the maximum amounts that can be charged
c The hospital facility used the Medicare rates when calculating the maximum amounts that can be charged
d Other (describe in Part VI)
20 Did the hospital facility charge any of its patients who were eligible for assistance under the hospital facility’s financial assistance policy, and to whom the hospital facility provided emergency or other medically necessary services, more than the amounts generally billed to individuals who had insurance covering such care?......... 20   No
If “Yes,” explain in Part VI.
21 Did the hospital facility charge any of its FAP-eligible patients an amount equal to the gross charge for any services provided to that patient?............................... 21   No
If “Yes,” explain in Part VI.
Schedule H (Form 990) 2011
Schedule H (Form 990) 2011
Page
Part VFacility Information (continued)

Section B. Facility Policies and Practices.

(Complete a separate Section B for each of the hospital facilities listed in Part V, Section A)
MERCY MEDICAL CENTER-DYERSVILLE
Name of Hospital Facility:  
Line Number of Hospital Facility (from Schedule H, Part V, Section A):6

Yes No
Community Health Needs Assessment (Lines 1 through 7 are optional for 2011)
1 During the tax year or any prior tax year, did the hospital facility conduct a community health needs assessment (“Needs Assessment”)? If “No,” skip to question 8. ..................... 1    
If “Yes,” indicate what the Needs Assessment describes (check all that apply):
a A definition of the community served by the hospital facility
b Demographics of the community
c Existing health care facilities and resources within the community that are available to respond to the health needs of the community
d How data was obtained
e The health needs of the community
f Primary and chronic disease needs and other health issues of uninsured persons, low-income persons, and minority groups
g The process for identifying and prioritizing community health needs and services to meet the community health needs
h The process for consulting with persons representing the community’s interests
i Information gaps that limit the hospital facility’s ability to assess the community’s health needs
j Other (describe in Part VI)
2 Indicate the tax year the hospital facility last conducted a Needs Assessment: 20  
3 In conducting its most recent Needs Assessment, did the hospital facility take into account input from persons who represent the community served by the hospital facility? If “Yes,” describe in Part VI how the hospital facility took into account input from persons who represent the community, and identify the persons the hospital facility consulted. 3    
4 Was the hospital facility’s Needs Assessment conducted with one or more other hospital facilities? If “Yes,” list the other hospital facilities in Part VI............................ 4    
5 Did the hospital facility make its Needs Assessment widely available to the public? ........... 5    
If “Yes,” indicate how the Needs Assessment was made widely available (check all that apply):
a Hospital facility’s website
b Available upon request from the hospital facility
c Other (describe in Part VI)
6 If the hospital facility addressed needs identified in its most recently conducted Needs Assessment, indicate how (check all that apply):
a Adoption of an implementation strategy to address the health needs of the hospital facility’s community
b Execution of the implementation strategy
c Participation in the development of a community-wide community benefit plan
d Participation in the execution of a community-wide community benefit plan
e Inclusion of a community benefit section in operational plans
f Adoption of a budget for provision of services that address the needs identified in the Needs Assessment
g Prioritization of health needs in the community
h Prioritization of services that the hospital facility will undertake to meet health needs in its community
i Other (describe in Part VI)
7 Did the hospital facility address all of the needs identified in its most recently conducted Needs Assessment? If “No,” explain in Part VI which needs it has not addressed and the reasons why it has not addressed such needs. .... 7    
Financial Assistance Policy
Did the hospital facility have in place during the tax year a written financial assistance policy that:
8 Explained eligibility criteria for financial assistance, and whether such assistance includes free or discounted care? 8 Yes  
9 Used federal poverty guidelines (FPG) to determine eligibility for providing free care?........... 9 Yes  
If "Yes," indicate the FPG family income limit for eligibility for free care: 150.000000000000%
If "No," explain in Part VI the criteria the hospital facility used.
Schedule H (Form 990) 2011
Schedule H (Form 990) 2011
Page
Part VFacility Information (continued)

Yes No
10 Used FPG to determine eligibility for providing discounted care?................. 10 Yes  
If “Yes,” indicate the FPG family income limit for eligibility for discounted care: 400.000000000000%
If "No," explain in Part VI the criteria the hospital facility used.
11 Explained the basis for calculating amounts charged to patients?................. 11 Yes  
If “Yes,” indicate the factors used in determining such amounts (check all that apply):
a Income level
b Asset level
c Medical indigency
d Insurance status
e Uninsured discount
f Medicaid/Medicare
g State regulation
h Other (describe in Part VI)
12 Explained the method for applying for financial assistance?................... 12 Yes  
13 Included measures to publicize the policy within the community served by the hospital facility?....... 13 Yes  
If “Yes,” indicate how the hospital facility publicized the policy (check all that apply):
a The policy was posted on the hospital facility’s web site
b The policy was attached to all billing invoices
c The policy was posted in the hospital facility’s emergency rooms or waiting rooms
d The policy was posted in the hospital facility’s admissions offices
e The policy was provided, in writing, to patients upon admission to the hospital facility
f The policy was available upon request
g Other (describe in Part VI)
Billing and Collections
14 Did the hospital facility have in place during the tax year a separate billing and collections policy, or a written financial assistance policy (FAP) that explained actions the hospital facility may take upon non-payment?....... 14 Yes  
15 Check all of the following collection actions against an individual that were permitted under the hospital facility's policies during the tax year before making reasonable efforts to determine the patient’s eligibility under the facility’s FAP:
a Reporting to credit agency
b Lawsuits
c Liens on residences
d Body attachments
e Other similar actions (describe in Part VI)
16 Did the hospital facility or an authorized third party perform any of the following actions during the tax year before making reasonable efforts to determine the patient’s eligibility under the facility’s FAP?.......... 16   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)
17 Indicate which efforts the hospital facility made before initiating any of the actions checked in line 16 (check all that apply):
a Notified patients of the financial assistance policy upon admission
b Notified patients of the financial assistance policy prior to discharge
c Notified patients of the financial assistance policy in communications with the patients regarding the patients’ bills
d Documented its determination of whether patients were eligible for financial assistance under the hospital facility’s financial assistance policy
e Other (describe in Part VI)
Schedule H (Form 990) 2011
Schedule H (Form 990) 2011
Page
Part VFacility Information (continued)

Policy Relating to Emergency Medical Care
Yes No
18 Did the hospital facility have in place during the tax year a written policy relating to emergency medical care that requires the hospital facility to provide, without discrimination, care for emergency medical conditions to individuals regardless of their eligibility under the hospital facility’s financial assistance policy?.......... 18 Yes  
If “No,” indicate why:
a The hospital facility did not provide care for any emergency medical conditions
b The hospital facility’s policy was not in writing
c The hospital facility limited who was eligible to receive care for emergency medical conditions (describe in Part VI)
d Other (describe in Part VI)
Individuals Eligible for Financial Assistance
19 Indicate how the hospital facility determined, during the tax year, the maximum amounts that can be charged to FAP-eligible individuals for emergency or other medically necessary care.
a The hospital facility used its lowest negotiated commercial insurance rate when calculating the maximum amounts that can be charged
b The hospital facility used the average of it's three lowest negotiated commercial insurance rates when calculating the maximum amounts that can be charged
c The hospital facility used the Medicare rates when calculating the maximum amounts that can be charged
d Other (describe in Part VI)
20 Did the hospital facility charge any of its patients who were eligible for assistance under the hospital facility’s financial assistance policy, and to whom the hospital facility provided emergency or other medically necessary services, more than the amounts generally billed to individuals who had insurance covering such care?......... 20   No
If “Yes,” explain in Part VI.
21 Did the hospital facility charge any of its FAP-eligible patients an amount equal to the gross charge for any services provided to that patient?............................... 21   No
If “Yes,” explain in Part VI.
Schedule H (Form 990) 2011
Schedule H (Form 990) 2011
Page
Part VFacility Information (continued)

Section C. Other Health Care Facilities That Are Not Licensed, Registered, or Similarly Recognized as a Hospital Facility
(list in order of size, from largest to smallest)
How many non-hospital health care facilities did the organization operate during the tax year?15
Name and address Type of Facility (describe)
1 MEDICAL ASSOCIATES WEST CAMPUS
1500 ASSOCIATES DRIVE
DUBUQUE,IA52001 		OCC. HEALTH, PHYS THER, AMBULATORY SURGERY
2 MEDICAL ASSOCIATES CLINIC
1240 BIG JACK ROAD
PLATTEVILLE,WI53818 		X-RAY, LAB, EMPLOYED PHYSICIANS
3 TRI-STATE OCCUPATIONAL HEALTH
1920 ELM STREET
DUBUQUE,IA52001 		PHYS THERAPY,EMPLOYED PHYSICIANS
4 MEDICAL ASSOCIATES CLINIC
10988 BARTELL BLVD
GALENA,IL61036 		HOME CARE,LAB, EMPLOYED PHYSICIANS
5 MERCY MEDICAL CENTER - DYERSVILLE
1121 THIRD STREET SW
DYERSVILLE,IA52040 		EMPLOYED PHYSICIANS
6 MEDICAL ASSOCIATES CLINIC
208 N 12TH STREET
BELLEVUE,IA52031 		EMPLOYED PHYSICIANS
7 MEDICAL ASSOCIATES CLINIC
911 NW CARTER
ELKADER,IA52043 		EMPLOYED PHYSICIANS
8 CASCADE FAMILY HEALTH CENTER
805 JOHNSON STREET SW
CASCADE,IA52033 		EMPLOYED PHYSICIANS, LAB, X-RAY, PT
9 MEDICAL ASSOCIATES CLINIC
117 SOUTH MADISON
CUBA CITY,WI53807 		X-RAY, LAB, EMPLOYED PHYSICIANS
10 MEDICAL ASSOCIATES CLINIC
560 PLEASANT ST
ELIZABETH,IL61028 		EMPLOYED PHYSICIANS
11 MEDICAL ASSOCIATES CLINIC
107 S PAGE
MONONA,IA52159 		EMPLOYED PHYSICIANS
12 MEDICAL ASSOCIATES EAST CAMPUS
1000 LANGWORTHY
DUBUQUE,IA52001 		OCC. HEALTH, PHYSICAL THERAPY
13 MERCY DAKOTA DUNES
705 SIOUX POINT ROAD
DAKOTA DUNES,SD57049 		WEIGHT LOSS CENTER
14 MASON CITY SURGERY CENTER
990 4TH STREET
MASON CITY,IA50401 		AMBULATORY SURGERY
15 MERCY FAMILY PRACTICE - BUFFALO CENTER
115 NORTH MAIN
BUFFALO CENTER,IA50424 		X-RAY, LAB, EMPLOYED PHYSICIANS
Schedule H (Form 990) 2011
Schedule H (Form 990) 2011
Page
Part VI
Supplemental Information
Complete this part to provide the following information.
1 Required descriptions. Provide the descriptions required for Part I, lines 3c, 6a, and 7; Part II; Part III, lines 4, 8, and 9b; and Part V, Section B, lines 1j, 3, 4, 5c, 6i, 7, 9, 10, 11h, 13g, 15e, 16e, 17e, 18d, 19d, 20, and 21.
2 Needs assessment. Describe how the organization assesses the health care needs of the communities it serves, in addition to any needs assessments reported in Part V, Section B.
3 Patient education of eligibility for assistance. Describe how the organization informs and educates patients and persons who may be billed for patient care about their eligibility for assistance under federal, state, or local government programs or under the organization’s financial assistance policy.
4 Community information. Describe the community the organization serves, taking into account the geographic area and demographic constituents it serves.
5 Promotion of community health. Provide any other information important to describing how the organization’s hospital facilities or other health care facilities further its exempt purpose by promoting the health of the community (e.g., open medical staff, community board, use of surplus funds, etc.).
6 Affiliated health care system. If the organization is part of an affiliated health care system, describe the respective roles of the organization and its affiliates in promoting the health of the communities served.
7 State filing of community benefit report. If applicable, identify all states with which the organization, or a related organization, files a community benefit report.
Identifier ReturnReference Explanation
    PART I, LINE 6A: MERCY HEALTH SERVICES-IOWA REPORTS ITS COMMUNITY BENEFIT INFORMATION AS PART OF THE CONSOLIDATED COMMUNITY BENEFIT INFORMATION REPORTED BY TRINITY HEALTH IN ITS ANNUAL REPORT, AVAILABLE AT WWW.TRINITY-HEALTH.ORG.IN ADDITION, THE HOSPITAL DIVISIONS OF MERCY HEALTH SERVICES-IOWA (MHS-IA) INCLUDE A COPY OF THEIR MOST RECENT SCHEDULE H ON THEIR RESPECTIVE WEBSITES. TRINITY HEALTH ALSO INCLUDES MHS-IA'S MOST RECENTLY FILED SCHEDULE H ON ITS WEBSITE.
    PART I, LINE 7: THE BEST AVAILABLE DATA WAS USED TO CALCULATE THE COST AMOUNTS REPORTED IN ITEM 7. FOR CERTAIN CATEGORIES, PRIMARILY TOTAL CHARITY CARE AND MEANS-TESTED GOVERNMENT PROGRAMS, SPECIFIC COST-TO-CHARGE RATIOS WERE CALCULATED AND APPLIED TO THOSE CATEGORIES. THE COST-TO-CHARGE RATIO WAS DERIVED FROM WORKSHEET 2, RATIO OF PATIENT CARE COST-TO-CHARGES. IN OTHER CATEGORIES, THE BEST AVAILABLE DATA WAS DERIVED FROM THE HOSPITALS' COST ACCOUNTING SYSTEMS.
    PART I, L7 COL(F): THE FOLLOWING NUMBER, $32,066,537, REPRESENTS THE AMOUNT OF BAD DEBT EXPENSE INCLUDED IN TOTAL FUNCTIONAL EXPENSES IN FORM 990, PART IX, LINE 25. PER IRS INSTRUCTIONS, THIS AMOUNT WAS EXCLUDED FROM THE DENOMINATOR WHEN CALCULATING THE PERCENT OF TOTAL EXPENSE FOR SCHEDULE H, PART I, LINE 7, COLUMN (F).
    PART II: COMMUNITY BUILDING ACTIVITIES - MERCY MEDICAL CENTER - SIOUX CITY:THE CHANGING DEMOGRAPHICS OF THE SIOUXLAND AREA REQUIRE AN UNDERSTANDING OF AND COMMITMENT TO DIVERSITY AND INCLUSION. MERCY MEDICAL CENTER-SIOUX CITY IS ENGAGED IN A COMPREHENSIVE PHYSICIAN RECRUITING EFFORT TO BRING NEEDED PHYSICIANS TO HEALTH PROFESSIONAL SHORTAGE AREAS. PHYSICIANS ARE RECRUITED BASED ON COMMUNITY NEED/SHORTAGE. WE ADVOCATE FOR AND SPEND RESOURCES TO BRING PHYSICIANS TO OUR COMMUNITY. THE PHYSICIANS USUALLY HAVE PRIVILEGES AT BOTH LOCAL HOSPITALS. AREAS OF CONCERN/NEED ARE RADIATION ONCOLOGY, PSYCHIATRY, INTERNAL MEDICINE, OBSTETRICS/GYNECOLOGY, ANESTHESIOLOGY, CARDIOLOGY, AND NEUROLOGY. MERCY MEDICAL CENTER GIFTED/SOLD PROPERTY IN THE DOWNTOWN AREA TO A LOCAL FOUNDATION FOR USE AS A PUBLIC SPIRITUAL GARDEN/GREEN SPACE. THE LOCATION IS NEXT TO THE DOWNTOWN PRESBYTERIAN CHURCH, THE DOWNTOWN PARTNERS, AND THE LOCAL CHURCH BELIEVES THE PROPERTY WILL BENEFIT THE COMMUNITY. DONATION OF THE PROPERTY IS VALUED $200,000 BELOW INVESTMENT. MERCY MEDICAL CENTER-SIOUX CITY STAFF ARE ALSO INVOLVED IN THE NW IOWA AMERICAN HEART TASK FORCE, SIOUXLAND INFECTIOUS DISEASE COMMITTEE, TRI-STATE DISASTER COMMITTEE, IOWA DISASTER MEDICAL ASSISTANCE TEAM, EMERGENCY CONFERENCE COMMITTEE (MERCY COMMITTEE), MERCY EMERGENCY PLANNING COMMITTEE AND HEALTH RESOURCE SERVICE ADMINISTRATION (HRSA).MERCY IS WORKING WITH LOCAL CHURCHES AND AGENCIES TO ADDRESS SOCIAL FACTORS CONTRIBUTING TO LESS THAN OPTIMAL HEALTH. THE FOCUS IS ON THE NEIGHBORHOODS WITH THE HIGHEST COMMUNITY NEEDS INDEX, AN INDEX THAT UTILIZES U.S. CENSUS DATA TO IDENTIFY NEEDS BASED ON A NUMBER OF DEMOGRAPHIC AND SOCIAL FACTORS. INTERVENTIONS ARE TARGETED IN 55103, 51105, AND 68776 ZIP CODES WITH THE HIGHEST NEEDS INDEX. IN ADDITION, A SELF-HELP KIOSK THAT DIRECTS PATIENTS TO LOCAL RESOURCES WAS PLACED IN MERCY'S SOUTH SIOUX CITY CLINIC. MERCY IS WORKING WITH THE MIDTOWN COMMUNITY CENTER AND AMERICORPS WORKERS ON BENEFITS ENROLLMENT OF LOCAL RESIDENTS OFF SITE (AT A NON HEALTH CARE SITE). THE AMERICORPS WORKERS ARE FAMILIAR WITH PEOPLE IN THE AREA AND THE ENVIRONMENT IS LESS INTIMIDATING OR OVERWHELMING THAN THE HOSPITAL ENVIRONMENT. IT IS BELIEVED THAT MANY PATIENTS IN THE LOCAL NEIGHBORHOOD QUALIFY FOR BENEFITS, BUT ARE NOT ENROLLING IN PROGRAMS. THIS LEADS TO INABILITY TO PAY, AND LACK OF ACCESS TO PRIMARY AND PREVENTATIVE HEALTH CARE. MERCY PROVIDED A TOTAL OF 300 COMPUTERS TO THE MARY TREGLIA COMMUNITY HOUSE AND THE MIDTOWN COMMUNITY CENTER. LOCAL COLLEGES WILL PROVIDE SOFTWARE UPDATES AND EDUCATION TO RESIDENTS IN THE 51103 AND 51105 ZIP CODES. ACCESS TO INTERNET SERVICES (FOR HELP WITH HEALTH INFORMATION, OTHER EDUCATION AND EMPLOYMENT) IS BEING EXPLORED WITH THE CITY OF SIOUX CITY.THE MEDICAL CENTER WORKS MOST CLOSELY WITH THE SIOUXLAND COMMUNITY HEALTH CENTER AND WINNEBAGO INDIAN HEALTH SERVICES. MERCY IS A PARTNER IN THE SIOUXLAND HEALTH INITIATIVES (A COLLABORATIVE GROUP OF HEALTH PROVIDERS AND SOCIAL SERVICE ORGANIZATIONS). MERCY PARTNERED WITH COMMUNITY ACTION OF SIOUXLAND AND MARY TREGLIA TO EDUCATE HEAD START AND OTHER FAMILIES ON HEALTH PROMOTION, ILLNESS PREVENTION, MEDICAL HOMES, AND EMERGENCY DEPARTMENT UTILIZATION.MERCY IS WORKING WITH THE YMCA AND ST. MICHAEL'S CATHOLIC CHURCH IN SOUTH SIOUX CITY TO ENCOURAGE EXERCISE AND OTHER HEALTHY BEHAVIORS. MERCY IS ALSO WORKING WITH GIRLS, INC., SIOUX CITY BOYS CLUB, AND LOCAL SIOUX CITY SCHOOLS TO ENCOURAGE EXERCISE, NUTRITION, AND HEALTHY BEHAVIOR CHOICES FOR YOUTH. IN THE PLANNING STAGES ARE HEALTH SCREENINGS AT THE CHURCH AND THE LOCAL MERCY CLINIC.MERCY MEDICAL CENTER - DUBUQUE: DURING ITS FISCAL YEAR ENDING JUNE 30, 2012, MERCY MEDICAL CENTER - DUBUQUE WAS ENGAGED IN THREE ACTIVITIES THAT WERE DOCUMENTED IN OUR COMMUNITY BENEFIT EXPENSES AS COMMUNITY BUILDING ACTIVITIES:MERCY SUBSIDIZES THE WAGES OF SEVERAL DEVELOPMENTALLY DISABLED YOUNG ADULTS WHO WORK AT MERCY IN THE ENVIRONMENTAL SERVICES DEPARTMENT. THIS PROGRAM IS IN PARTNERSHIP WITH GOODWILL INDUSTRIES. THE PARTNERS IN EMPLOYMENT ALLIANCE PROGRAM CONTRIBUTES TO THE ECONOMIC DEVELOPMENT OF THE COMMUNITY, IN A SMALL BUT VERY MEANINGFUL WAY, BY PROVIDING AN OPPORTUNITY FOR SKILL BUILDING AND JOB READINESS TO PEOPLE WHO HAVE THE POTENTIAL TO BECOME PRODUCTIVE MEMBERS OF THE COMMUNITY.MERCY OCCASIONALLY LENDS ITS EXPERTISE IN STRATEGIC PLANNING THROUGH FREE CONSULTING SERVICES TO OTHER COMMUNITY NOT-FOR-PROFIT ORGANIZATIONS THAT SHARE MERCY'S MISSION PRINCIPLES. FINALLY, MERCY SUBSIDIZES, FULLY OR PARTIALLY, THE FEES ASSOCIATED WITH ITS LIFELINE EMERGENCY RESPONSE SYSTEM FOR SENIORS AND HANDICAPPED INDIVIDUALS. THE PROGRAM EXTENDS THE PERIOD OF TIME THAT AN INDIVIDUAL CAN CONTINUE LIVING AT HOME OR WITH MINIMUM DIRECT SUPERVISION, BY PROVIDING A RELIABLE MEANS OF EMERGENCY COMMUNICATION. THIS IMPROVES THE COMMUNITY BY INCREASING THE NUMBER OF PEOPLE WHO ARE ABLE TO AGE IN THE LEAST RESTRICTIVE ENVIRONMENT.MERCY MEDICAL CENTER - NEW HAMPTON: AS ONE OF THE LARGEST EMPLOYERS IN THE AREA, MERCY MEDICAL CENTER - NEW HAMPTON (MMC-NH) TAKES ITS CIVIC RESPONSIBILITY VERY SERIOUSLY. SUPPORT OF, AND CONTRIBUTIONS TO, COMMUNITY ORGANIZATIONS, EVENTS, AND PROGRAMS, SUCH AS THE CHAMBER, NEW HORIZONS, AND THE INDUSTRIAL DEVELOPMENT CORPORATION HELP IMPROVE THE ECONOMY OF MMC-NH'S CATCHMENT COUNTIES. BY PROMOTING ECONOMIC DEVELOPMENT, MMC-NH HELPS CREATE A COMMUNITY THAT CONTINUES TO BUILD ITSELF THROUGH THE LEADERS WHO WORK AND VOLUNTEER AT THE HOSPITAL. ECONOMIC STABILITY IS INTRINSICALLY LINKED TO THE PREVENTION OF HEALTH PROBLEMS ASSOCIATED WITH POVERTY, HOMELESSNESS, AND ENVIRONMENTAL CHALLENGES, AND IS CRUCIAL IF THE COMMUNITY HOPES TO MAINTAIN A VIABLE HOSPITAL COMPLEX WITH A BROAD SPECTRUM OF ESSENTIAL SERVICES. IN ADDITION TO SUPPORTING ECONOMIC DEVELOPMENT IN OUR REGION, MMC-NH ENCOURAGES ITS LEADERSHIP STAFF TO SUPPORT AND PROVIDE LEADERSHIP TO NON-PROFIT ORGANIZATIONS THROUGHOUT THE AREA. IN ORDER TO CREATE AWARENESS OF THE OPPORTUNITIES IN HEALTHCARE IN RURAL IOWA, MMC-NH COLLABORATES WITH THE LOCAL HIGH SCHOOL TO PROVIDE THE SERVICE TO BRING IN STUDENTS TO SHADOW A VARIETY OF HEALTH-RELATED OCCUPATIONS IN ORDER TO SPARK INTEREST IN CONSIDERING A HEALTHCARE CAREER. MMC-NH ALSO IDENTIFIED A NEED FOR MEMBERS OF THE COMMUNITY TO MORE SAFELY DISPOSE OF THEIR SHARPS AND CONTAINERS. THE HOSPITAL NOW COLLABORATES WITH PHARMACIES IN NEW HAMPTON TO COLLECT THE CONTAINERS.
    PART III, LINE 4: MERCY HEALTH SERVICES - IOWA, CORP. IS INCLUDED IN THE CONSOLIDATED FINANCIAL STATEMENTS OF TRINITY HEALTH. THE FOLLOWING IS THE TEXT OF THE ALLOWANCE FOR DOUBTFUL ACCOUNTS FOOTNOTE FROM THOSE STATEMENTS: "SUBSTANTIALLY ALL OF THE CORPORATION'S RECEIVABLES ARE RELATED TO PROVIDING HEALTHCARE SERVICES TO PATIENTS. ACCOUNTS RECEIVABLE ARE REDUCED BY AN ALLOWANCE FOR AMOUNTS THAT COULD BECOME UNCOLLECTIBLE IN THE FUTURE. THE CORPORATION'S ESTIMATE FOR ITS ALLOWANCE FOR DOUBTFUL ACCOUNTS IS BASED UPON MANAGEMENT'S ASSESSMENT OF HISTORICAL AND EXPECTED NET COLLECTIONS BY PAYOR."COSTING METHODOLOGY FOR LINES 2 AND 3: AMOUNTS ARE CALCULATED ON LINE 2 USING A COST TO CHARGE RATIO METHODOLOGY.ANY DISCOUNTS PROVIDED OR PAYMENTS MADE TO A PARTICULAR PATIENT ACCOUNT ARE APPLIED TO THAT PATIENT ACCOUNT PRIOR TO ANY BAD DEBT WRITE-OFF AND ARE THUS NOT INCLUDED IN BAD DEBT EXPENSE. AS A RESULT OF THE PAYMENT AND ADJUSTMENT ACTIVITY BEING POSTED TO BAD DEBT ACCOUNTS, WE ARE ABLE TO REPORT BAD DEBT EXPENSE NET OF THESE TRANSACTIONS.THE AMOUNT ON LINE 3 WAS CALCULATED BASED ON THE INFORMATION SUPPLIED BY A THIRD PARTY VENDOR, H&R COLLECTION AGENCY, WHO USES THE FASTAG PROGRAM WHICH IDENTIFIES FINANCIAL ASSISTANCE BASED ON A PROPRIETARY PROCESS. FASTAG COMBINES ACCOUNT DATA, EXTERNAL INFORMATION AND THE HOSPITAL'S FINANCIAL ASSISTANCE POLICY TO ARRIVE AT A DISCOUNT RECOMMENDATION FOR EACH ACCOUNT.
    PART III, LINE 8: MERCY HEALTH SERVICES - IOWA, CORP. DOES NOT BELIEVE ANY MEDICARE SHORTFALL SHOULD BE TREATED AS COMMUNITY BENEFIT. THIS IS SIMILAR TO CHA RECOMMENDATIONS, WHICH STATE THAT SERVING MEDICARE PATIENTS IS NOT A DIFFERENTIATING FEATURE OF TAX-EXEMPT HEALTHCARE ORGANIZATIONS AND THAT THE EXISTING COMMUNITY BENEFIT FRAMEWORK ALLOWS COMMUNITY BENEFIT PROGRAMS THAT SERVE THE MEDICARE POPULATION TO BE COUNTED IN OTHER COMMUNITY BENEFIT CATEGORIES.PART III, LINE 8: COSTING METHODOLOGY FOR LINE 6 - MEDICARE COSTS WERE OBTAINED FROM THE FILED MEDICARE COST REPORT. THE COSTS ARE BASED ON MEDICARE ALLOWABLE COSTS AS REPORTED ON WORKSHEET B, COLUMN 27, WHICH EXCLUDE DIRECT MEDICAL EDUCATION COSTS. INPATIENT MEDICARE COSTS ARE CALCULATED BASED ON A COMBINATION OF ALLOWABLE COST PER DAY TIMES MEDICARE DAYS FOR ROUTINE SERVICES AND COST TO CHARGE RATIO TIMES MEDICARE CHARGES FOR ANCILLARY SERVICES. OUTPATIENT MEDICARE COSTS ARE CALCULATED BASED ON COST TO CHARGE RATIO TIMES MEDICARE CHARGES BY ANCILLARY DEPARTMENT.
    PART III, LINE 9B: MERCY HEALTH SERVICES - IOWA, CORP'S COLLECTION POLICY CONTAINS THE CRITERIA FOR FINANCIAL ASSISTANCE, AND CONTAINS THE FOLLOWING VERBIAGE FOR ARRANGEMENTS WITH OUTSIDE COLLECTION AGENCIES: THE AGREEMENT MUST DEFINE THE STANDARDS AND SCOPE OF PRACTICES TO BE USED BY OUTSIDE COLLECTION AGENTS ACTING ON BEHALF OF THE MINISTRY ORGANIZATION, ALL OF WHICH MUST BE IN COMPLIANCE WITH THIS POLICY.
MERCY MEDICAL CENTER-NORTH IOWA   PART V, SECTION B, LINE 19D: PATIENTS WITH INCOME AT OR BELOW 150% OF THE FEDERAL POVERTY GUIDELINES (FPG), ADJUSTED FOR FAMILY SIZE, ARE ELIGIBLE FOR 100% CHARITY CARE WRITE OFF OF THE CHARGES FOR MEDICALLY NECESSARY SERVICES. PATIENTS WITH INCOMES ABOVE 150% BUT NOT EXCEEDING 400% OF THE FPG, ADJUSTED FOR FAMILY SIZE, RECEIVE A PERCENTAGE DISCOUNT ON MEDICALLY NECESSARY SERVICES, BASED UPON A SLIDING SCALE.
MERCY MEDICAL CENTER-SIOUX CITY   PART V, SECTION B, LINE 19D: PATIENTS WITH INCOME AT OR BELOW 150% OF THE FEDERAL POVERTY GUIDELINES (FPG), ADJUSTED FOR FAMILY SIZE, ARE ELIGIBLE FOR 100% CHARITY CARE WRITE OFF OF THE CHARGES FOR MEDICALLY NECESSARY SERVICES. PATIENTS WITH INCOMES ABOVE 150% BUT NOT EXCEEDING 300% OF THE FPG, ADJUSTED FOR FAMILY SIZE, RECEIVE A PERCENTAGE DISCOUNT ON MEDICALLY NECESSARY SERVICES, BASED UPON A SLIDING SCALE.
MERCY MEDICAL CENTER-DUBUQUE   PART V, SECTION B, LINE 19D: PATIENTS WITH INCOME AT OR BELOW 150% OF THE FEDERAL POVERTY GUIDELINES (FPG), ADJUSTED FOR FAMILY SIZE, ARE ELIGIBLE FOR 100% CHARITY CARE WRITE OFF OF THE CHARGES FOR MEDICALLY NECESSARY SERVICES. PATIENTS WITH INCOMES ABOVE 150% BUT NOT EXCEEDING 400% OF THE FPG, ADJUSTED FOR FAMILY SIZE, RECEIVE A PERCENTAGE DISCOUNT ON MEDICALLY NECESSARY SERVICES, BASED UPON A SLIDING SCALE.
SIOUXLAND SURGERY CENTER   PART V, SECTION B, LINE 19D: PATIENTS WITH INCOME AT OR BELOW 150% OF THE FEDERAL POVERTY GUIDELINES (FPG), ADJUSTED FOR FAMILY SIZE, ARE ELIGIBLE FOR 100% CHARITY CARE WRITE OFF OF THE CHARGES FOR MEDICALLY NECESSARY SERVICES. PATIENTS WITH INCOMES ABOVE 150% BUT NOT EXCEEDING 300% OF THE FPG, ADJUSTED FOR FAMILY SIZE, RECEIVE A PERCENTAGE DISCOUNT ON MEDICALLY NECESSARY SERVICES, BASED UPON A SLIDING SCALE.
MERCY MEDICAL CENTER-NEW HAMPTON   PART V, SECTION B, LINE 19D: PATIENTS WITH INCOME AT OR BELOW 150% OF THE FEDERAL POVERTY GUIDELINES (FPG), ADJUSTED FOR FAMILY SIZE, ARE ELIGIBLE FOR 100% CHARITY CARE WRITE OFF OF THE CHARGES FOR MEDICALLY NECESSARY SERVICES. PATIENTS WITH INCOMES ABOVE 150% BUT NOT EXCEEDING 400% OF THE FPG, ADJUSTED FOR FAMILY SIZE, RECEIVE A PERCENTAGE DISCOUNT ON MEDICALLY NECESSARY SERVICES, BASED UPON A SLIDING SCALE.
MERCY MEDICAL CENTER-DYERSVILLE   PART V, SECTION B, LINE 19D: PATIENTS WITH INCOME AT OR BELOW 150% OF THE FEDERAL POVERTY GUIDELINES (FPG), ADJUSTED FOR FAMILY SIZE, ARE ELIGIBLE FOR 100% CHARITY CARE WRITE OFF OF THE CHARGES FOR MEDICALLY NECESSARY SERVICES. PATIENTS WITH INCOMES ABOVE 150% BUT NOT EXCEEDING 400% OF THE FPG, ADJUSTED FOR FAMILY SIZE, RECEIVE A PERCENTAGE DISCOUNT ON MEDICALLY NECESSARY SERVICES, BASED UPON A SLIDING SCALE.
    PART VI, LINE 2: NEEDS ASSESSMENT - MERCY HEALTH SERVICES - IOWA, CORP. (MHS-IA) ASSESSES THE HEALTH NEEDS OF THE COMMUNITY THROUGH COMMUNITY NEEDS ASSESSMENTS EVERY THREE YEARS. MERCY HEALTH SERVICES - IOWA, CORP. IS COMPRISED OF FIVE ENTITIES: MERCY MEDICAL CENTER-DUBUQUE, MERCY MEDICAL CENTER - DYERSVILLE, MERCY MEDICAL CENTER-NEW HAMPTON, MERCY MEDICAL CENTER-NORTH IOWA AND MERCY MEDICAL CENTER-SIOUX CITY. EACH MEDICAL CENTER COMPLETES ITS OWN NEEDS ASSESSMENT.A COMMUNITY NEEDS ASSESSMENT IS A POINT-IN-TIME EFFORT TO MEASURE THE HEALTH AND WELL BEING OF THE COMMUNITY. IT SERVES AS THE BASIS FOR MHS-IA'S STRATEGIC AND SUBSEQUENT ACTION PLANNING TO DEVELOP HEALTH POLICY, ALLOCATE RESOURCES, IMPROVE OR EXPAND EXISTING SERVICES, IMPLEMENT NEW PROGRAMS AND COLLABORATE WITH OTHER COMMUNITY HEALTHCARE PROVIDERS. A COMMUNITY NEEDS ASSESSMENT ALSO SERVES AS A BENCHMARK FOR FUTURE ASSESSMENT OF RELATIVE PROGRESS TOWARD ESTABLISHED COMMUNITY HEALTH OBJECTIVES.MHS-IA'S COMMUNITY NEEDS ASSESSMENT PROVIDES THE OPPORTUNITY TO:- GAIN INSIGHTS INTO THE NEEDS AND ASSETS OF THE COMMUNITIES SERVED - IDENTIFY AND ADDRESS THE NEEDS OF VULNERABLE POPULATIONS WITHIN THE COMMUNITY- ENHANCE HOSPITAL/COMMUNITY RELATIONSHIPS AND THE OPPORTUNITY FOR COLLABORATIVE COMMUNITY ACTION, INCLUDING INVOLVEMENT WITH COALITIONS, PARTNERSHIPS, BOARDS, COMMITTEES, COMMISSIONS, ADVISORY GROUPS AND PANELS- PROVIDE THE INFORMATION REQUIRED FOR COMMUNITY OUTREACH PLANNINGTHE MHS-IA COMMUNITY NEEDS ASSESSMENT PROCESS INVOLVES THE GATHERING OF TWO TYPES OF DATA: QUANTITATIVE (DEMOGRAPHICS, HEALTH INDICATORS, ETC.) AND QUALITATIVE (PUBLIC SURVEYS, FORUMS, FOCUS GROUPS). THE DATA HELPS SUPPORT SHORT-TERM AND LONG-TERM DECISIONS ABOUT ALLOCATION OF COMMUNITY HUMAN AND CAPITAL RESOURCES. THE MHS-IA COMMUNITY NEEDS ASSESSMENTS ARE CURRENT AS OF 2010 FOR NORTH IOWA AND NEW HAMPTON, AND 2011 FOR SIOUX CITY, DUBUQUE, AND DYERSVILLE.THE MERCY MEDICAL CENTER-SIOUX CITY COMMUNITY NEEDS ASSESSMENT ACTION PLANS TO ADDRESS IDENTIFIED COMMUNITY NEEDS HAVE BEEN DEVELOPED THROUGH JUNE 2014. THE COMMUNITY NEEDS ASSESSMENT WAS DEVELOPED WITH DATA FROM THE NATIONAL RESEARCH CORPORATION AND THOMSON REUTERS - COMMUNITY NEEDS INDEX, WHICH WAS COMBINED WITH COMMUNITY-SPECIFIC DATA INTO A COMPREHENSIVE REPORT THAT WAS SHARED WITHIN THE COMMUNITY. MERCY MEDICAL CENTER-SIOUX CITY ALSO WORKED CLOSELY WITH SIOUXLAND COMMUNITY HEALTH CENTER AND WINNEBAGO INDIAN HEALTH SERVICES. THE STATE OF IOWA HAS TEMPLATES FOR COMMUNITY HEALTH NEEDS ASSESSMENTS (CHNA) AND HEALTH IMPROVEMENT PLANS (HIP) AT HTTP://WWW.IDPH.STATE.IA.US/CHNAHIP/DEFAULT.ASP. MERCY MEDICAL CENTER WILL USE THE WOODBURY COUNTY CHNA AND HIP TO DEVELOP A WIDER CHNA AND COMMUNITY BENEFIT PLAN WITH OTHER PARTNERS. MERCY MEDICAL CENTER SERVES A 2/12/19 COUNTY AREA (PRIMARY 2 COUNTIES, SECONDARY 12 COUNTIES, TERTIARY 19 MORE COUNTIES).THE MERCY MEDICAL CENTER-DUBUQUE COMMUNITY NEEDS ASSESSMENT WAS CONDUCTED AS PART OF A COUNTY-WIDE HEALTH CARE ASSESSMENT PROCESS MANDATED FOR ALL COUNTIES BY THE STATE OF IOWA. PARTNERS INCLUDE LOCAL HOSPITALS, COMMUNITY AGENCIES, SOCIAL SERVICES, AND LOCAL BUSINESSES. MORE THAN 50 INDIVIDUALS MET IN SIX SEPARATE SUBCOMMITTEES TO EVALUATE NEEDS AND IDENTIFY STRATEGIES IN SIX CATEGORIES: PROMOTING HEALTHY BEHAVIORS, INJURY PREVENTION, PROTECT AGAINST ENVIRONMENTAL HAZARDS, PREPARE FOR, RESPOND TO AND RECOVER FROM PUBLIC HEALTH EMERGENCIES, PREVENT EPIDEMICS AND THE SPREAD OF DISEASE, AND STRENGTHEN PUBLIC HEALTH INFRASTRUCTURE. RESPONSIBILITY FOR COMPLETING VARIOUS ASPECTS OF THE HEALTH IMPROVEMENT PLAN ASSOCIATED WITH THIS HEALTH NEEDS ASSESSMENT ARE SHARED BY THE DUBUQUE COUNTY BOARD OF HEALTH AND LOCAL HOSPITALS, COMMUNITY AGENCIES, SOCIAL SERVICES, AND LOCAL BUSINESSES. THE ASSESSMENT IS POSTED FOR THE PUBLIC ON MERCY MEDICAL CENTER-DUBUQUE'S INTERNET WEBSITE.THE MERCY MEDICAL CENTER - NORTH IOWA COMMUNITY HEALTH CARE NEEDS ASSESSMENT ACTION PLANS, WHICH ARE ANNUALLY REVIEWED, TO ADDRESS IDENTIFIED COMMUNITY NEEDS HAVE BEEN DEVELOPED THROUGH JUNE 2013. THE ASSESSMENT COVERED THE 14-COUNTY SERVICE AREA OF MERCY - NORTH IOWA. THERE CONTINUES TO BE COORDINATION WITH CERRO GORDO PUBLIC HEALTH, NORTH IOWA COMMUNITY ACTION ORGANIZATION AND THE NORTH CENTRAL IOWA REGIONAL PLANNING COALITION, COMPRISED OF OTHER NOT-FOR-PROFIT AND GOVERNMENTAL AGENCIES AND ORGANIZATIONS REPRESENTING 14 NORTH IOWA COUNTIES: BUTLER, CERRO GORDO, CHICKASAW, FLOYD, FRANKLIN, HANCOCK, HARDIN, HOWARD, KOSSUTH, MITCHELL, PALO ALTO, WINNEBAGO, WORTH, AND WRIGHT. OUTSIDE REFERENCES SUCH AS THE DHS REPORT "HEALTHY PEOPLE 2020" AND IOWA DEPARTMENT.
    PART VI, LINE 3: PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCE - MERCY HEALTH SERVICES-IOWA IS COMMITTED TO: - PROVIDING ACCESS TO QUALITY HEALTHCARE SERVICES WITH COMPASSION, DIGNITY AND RESPECT FOR THOSE WE SERVE, PARTICULARLY THE POOR AND THE UNDERSERVED IN OUR COMMUNITIES- CARING FOR ALL PERSONS, REGARDLESS OF THEIR ABILITY TO PAY FOR SERVICES- ASSISTING PATIENTS WHO CANNOT PAY FOR PART OR ALL OF THE CARE THEY RECEIVE - BALANCING NEEDED FINANCIAL ASSISTANCE FOR SOME PATIENTS WITH BROADER FISCAL RESPONSIBILITIES IN ORDER TO SUSTAIN VIABILITY AND PROVIDE THE QUALITY AND QUANTITY OF SERVICES FOR ALL WHO MAY NEED CARE IN A COMMUNITYIN ACCORDANCE WITH AHA RECOMMENDATIONS, MHS-IA HAS ADOPTED THE FOLLOWING GUIDING PRINCIPLES WHEN HANDLING THE BILLING, COLLECTION AND FINANCIAL SUPPORT FUNCTIONS FOR OUR PATIENTS: - PROVIDE EFFECTIVE COMMUNICATIONS WITH PATIENTS REGARDING HOSPITAL BILLS- MAKE AFFIRMATIVE EFFORTS TO HELP PATIENTS APPLY FOR PUBLIC AND PRIVATE FINANCIAL SUPPORT PROGRAMS- OFFER FINANCIAL SUPPORT TO PATIENTS WITH LIMITED MEANS- IMPLEMENT POLICIES FOR ASSISTING LOW-INCOME PATIENTS IN A CONSISTENT MANNER- IMPLEMENT FAIR AND CONSISTENT BILLING AND COLLECTION PRACTICES FOR ALL PATIENTS WITH PATIENT PAYMENT OBLIGATIONSMHS-IA COMMUNICATES EFFECTIVELY WITH PATIENTS REGARDING PATIENT PAYMENT OBLIGATIONS. FINANCIAL COUNSELING IS PROVIDED TO PATIENTS ABOUT THEIR PAYMENT OBLIGATIONS AND HOSPITAL BILLS. INFORMATION ON HOSPITAL-BASED FINANCIAL SUPPORT POLICIES AND EXTERNAL PROGRAMS THAT PROVIDE COVERAGE FOR SERVICES ARE MADE AVAILABLE TO PATIENTS DURING THE PRE-REGISTRATION AND REGISTRATION PROCESSES AND/OR THROUGH COMMUNICATIONS WITH PATIENTS SEEKING FINANCIAL ASSISTANCE. EVERY EFFORT IS MADE TO DETERMINE A PATIENT'S ELIGIBILITY PRIOR TO OR AT THE TIME OF ADMISSION OR SERVICE. HOWEVER, DETERMINATION FOR FINANCIAL SUPPORT CAN BE MADE DURING ANY STAGE OF THE PATIENT'S STAY AFTER STABILIZATION OR COLLECTION CYCLE.MERCY MEDICAL CENTER-SIOUX CITY:MERCY MEDICAL CENTER-SIOUX CITY NOT ONLY COMMUNICATES FINANCIAL ASSISTANCE POLICIES VIA TRADITIONAL CHANNELS (REGISTRATION, AND BILLING); THE ORGANIZATION SHARES ITS FINANCIAL ASSISTANCE POLICY WITH OTHER SERVICE AGENCIES AND NOT-FOR PROFIT ORGANIZATIONS. FOR EXAMPLE, THROUGH THE MISSION HEALTH PROGRAM, COLLABORATION BETWEEN THE SIOUXLAND COMMUNITY HEALTH CENTER AND MERCY AND ST. LUKE'S HOSPITALS, MERCY MEDICAL CENTER-SIOUX CITY REACHES OUT TO CHURCHES AND SCHOOLS TO FIND THOSE WHO MAY BE IN NEED OF FINANCIAL ASSISTANCE. PARTICIPANTS ARE PRE-QUALIFIED FOR FINANCIAL ASSISTANCE AT BOTH LOCAL HOSPITALS, AND ARE INVITED TO CHOOSE A MEDICAL HOME. THE MISSION HEALTH PROGRAM HAS OVER 1400 ENROLLED PATIENTS, ALL OF WHOM HAVE A BETTER UNDERSTANDING AND REDUCED ANXIETY CONCERNING FINANCIAL OBLIGATIONS AND ASSISTANCE IF HOSPITALIZATION IS NEEDED. EVERY EFFORT IS MADE TO DETERMINE A PATIENT'S ELIGIBILITY PRIOR TO OR AT THE TIME OF ADMISSION OR SERVICE. HOWEVER, DETERMINATION FOR FINANCIAL SUPPORT CAN BE MADE DURING ANY STAGE OF THE PATIENT'S STAY AFTER STABILIZATION OR COLLECTION CYCLE.FINANCIAL COUNSELORS MAKE AFFIRMATIVE EFFORTS TO HELP PATIENTS APPLY FOR PUBLIC AND PRIVATE PROGRAMS FOR WHICH THEY MAY QUALIFY AND THAT MAY HELP THEM OBTAIN AND PAY FOR HEALTHCARE SERVICES. IN SIOUX CITY, SOCIAL WORKERS PROVIDE ASSISTANCE AND COUNSELING REGARDING FINANCIAL ASSISTANCE OPPORTUNITIES WITHIN THE ORGANIZATION, AND REFER PATIENTS AND FAMILIES TO APPROPRIATE AGENCIES FOR COVERAGE. MERCY ALSO WORKS WITH THE MIDLANDS GROUP TO ENLIST PATIENTS IN QUALIFYING PROGRAMS. MERCY UTILIZES A COMMUNITY NEEDS INDEX (CNI) TO TARGET SPECIFIC ZIP CODES WHERE PATIENTS IN NEED OF FINANCIAL ASSISTANCE OFTEN RESIDE. MERCY MEDICAL CENTER-DUBUQUE:MERCY MEDICAL CENTER-DUBUQUE CONTRACTS WITH A FIRM WITH A LONG TRACK RECORD OF COMPASSIONATE SERVICE TO PROVIDE COUNSELING, REFERRALS, AND ASSISTANCE TO PATIENTS IN DETERMINING ELIGIBILITY AND ENROLLING IN A WIDE VARIETY OF PUBLIC AND PRIVATE ASSISTANCE PROGRAMS, SUCH AS MEDICARE, MEDICAID, HAWK-I (AND THE CORRESPONDING SCHIPS PROGRAMS FOR ILLINOIS AND WISCONSIN) AND IOWA CARE, IOWA'S STATE ASSISTANCE PROGRAM FOR INDIGENT PERSONS. EVERY EFFORT IS MADE TO DETERMINE A PATIENT'S ELIGIBILITY PRIOR TO OR AT THE TIME OF ADMISSION OR SERVICE. HOWEVER, DETERMINATION FOR FINANCIAL SUPPORT CAN BE MADE DURING ANY STAGE OF THE PATIENT'S STAY AFTER STABILIZATION OR COLLECTION CYCLE.MERCY MEDICAL CENTER-NORTH IOWA (INCLUDING NEW HAMPTON):MERCY MEDICAL CENTER - NORTH IOWA EFFECTIVELY COMMUNICATES WITH PATIENTS REGARDING PATIENT PAYMENT OBLIGATIONS. INFORMATION ON HOSPITAL-BASED FINANCIAL SUPPORT POLICIES AND EXTERNAL PROGRAMS THAT PROVIDE COVERAGE FOR SERVICES IS MADE AVAILABLE TO PATIENTS DURING THE PRE-REGISTRATION AND REGISTRATION PROCESSES AND/OR THROUGH COMMUNICATIONS WITH PATIENTS SEEKING FINANCIAL ASSISTANCE. THE AVAILABILITY OF MERCY MEDICAL CENTER - NORTH IOWA'S FINANCIAL ASSISTANCE PROGRAM IS DISPLAYED IN VARIOUS ADMISSION AREAS THROUGHOUT THE HOSPITAL AND CLINICS. A "PATIENT FINANCIAL GUIDELINES" BROCHURE IS ALSO AVAILABLE AT EACH ADMISSION AREA. THIS BROCHURE PROVIDES INFORMATION REGARDING PAYMENT OPTIONS, FINANCIAL ASSISTANCE AND BILLING QUESTIONS. FINANCIAL COUNSELING IS ALSO PROVIDED TO PATIENTS ABOUT THEIR PAYMENT OBLIGATIONS AND HOSPITAL BILLS. AT TIME OF ADMISSION, THE NAMES OF UNINSURED AND UNDERINSURED PATIENTS ARE GIVEN TO FINANCIAL COUNSELORS WHO MAKES AFFIRMATIVE EFFORTS TO HELP PATIENTS APPLY FOR PUBLIC AND PRIVATE PROGRAMS FOR WHICH THEY MAY QUALIFY AND THAT MAY ASSIST THEM IN OBTAINING AND PAYING FOR HEALTHCARE SERVICES. THE FINANCIAL COUNSELORS HAVE A GOOD WORKING RELATIONSHIP WITH THE DEPARTMENT OF HUMAN SERVICES AND VARIOUS COUNTY AND COMMUNITY PROGRAMS. EVERY EFFORT IS MADE TO DETERMINE A PATIENT'S ELIGIBILITY PRIOR TO OR AT THE TIME OF ADMISSION FOR SERVICE. HOWEVER, DETERMINATION FOR FINANCIAL SUPPORT CAN BE MADE DURING ANY STAGE OF THE PATIENT'S STAY AFTER STABILIZATION OR COLLECTION CYCLE.MERCY MEDICAL CENTER - NORTH IOWA OFFERS FINANCIAL SUPPORT TO PATIENTS WITH LIMITED MEANS. THIS SUPPORT IS AVAILABLE TO UNINSURED AND UNDERINSURED PATIENTS WHO DO NOT QUALIFY FOR PUBLIC PROGRAMS OR OTHER ASSISTANCE. OUTPATIENTS, REFERRALS, OR SELF-REFERRALS RECEIVE THE SAME ATTENTION AND ASSISTANCE FROM FINANCIAL COUNSELORS. CONTACT MAY BE BY PHONE AND/OR LETTER PROCESS IF FACE-TO-FACE CONTACT IS NOT POSSIBLE.NOTIFICATION ABOUT FINANCIAL ASSISTANCE, INCLUDING CONTACT INFORMATION, IS AVAILABLE THROUGH VARIOUS MEANS: PATIENT BROCHURES, NOTICE MESSAGES INCLUDED ON PATIENT BILLS AND NOTICES IN PUBLIC REGISTRATION AREAS, INCLUDING EMERGENCY ROOM, ADMITTING AND REGISTRATION DEPARTMENTS, PATIENT ACCOUNTING DEPARTMENTS, AND OTHER PATIENT FINANCIAL SERVICES OFFICES THAT ARE LOCATED ON FACILITY CAMPUSES. INFORMATION REGARDING FINANCIAL ASSISTANCE PROGRAMS IS ALSO AVAILABLE ON THE HOSPITAL WEBSITE, IN THE ADMISSION PACKAGE DURING INTAKE, AND "PATIENT ASSISTANCE" BROCHURES AS WELL AS ON MERCY'S WEBSITE. IN ADDITION TO ENGLISH, THIS INFORMATION IS ALSO AVAILABLE IN SPANISH, REFLECTING THE OTHER PRIMARY LANGUAGE SPOKEN BY THE POPULATION SERVICED BY OUR HOSPITAL. PATIENT FINANCIAL SERVICES IS ABLE TO ASSIST SPANISH-SPEAKING PATIENTS WITH THE FINANCIAL APPLICATION PROCESS. A LANGUAGE LINE CONNECTION IS ALSO AVAILABLE FOR MORE THAN 170 OTHER LANGUAGES.THE PATIENT FINANCIAL SERVICES DEPARTMENT HAS ITS OWN TRAINING DEPARTMENT AND TRAINERS. MERCY MEDICAL CENTER - NORTH IOWA PATIENT REGISTRATION, FINANCIAL ASSISTANCE, PATIENT FINANCIAL SERVICES, CUSTOMER SERVICE, AND BILLING DEPARTMENTS RECEIVE TRAINING REGARDING THE POLICIES THAT ARE RELEVANT TO THEIR POSITIONS AND OUR MISSION VALUES. SCRIPTING IS USED AND FINANCIAL ASSISTANCE APPLICATIONS ARE AVAILABLE IN ENGLISH AND SPANISH. MERCY MEDICAL CENTER - NORTH IOWA ALSO PROVIDES FINANCIAL ASSISTANCE FOR PRESCRIBED MEDICATIONS. THERE ARE SEVERAL SHORT-TERM ASSISTANCE PROGRAMS, AS WELL AS A SOCIAL WORKER FACILITATING THE APPLICATION PROCESS FOR LONG-TERM ASSISTANCE FROM PHARMACEUTICAL PROGRAMS.
    PART VI, LINE 4: COMMUNITY INFORMATION - MERCY MEDICAL CENTER - SIOUX CITY:THIS HOSPITAL SERVES A 33-COUNTY AREA OF WESTERN IOWA, EASTERN NEBRASKA AND SOUTHEASTERN SOUTH DAKOTA, AN AREA THAT INCLUDES MANY ZIP CODES WITH A HIGH COMMUNITY NEED. IN ADDITION TO THE MAIN HOSPITAL IN SIOUX CITY, MERCY MEDICAL CENTER-SIOUX CITY OWNS RURAL HOSPITALS IN PRIMGHAR, IOWA, AND OAKLAND, NEBRASKA; MANAGES HOSPITALS IN PENDER, NEBRASKA AND HAWARDEN, IOWA; AND OPERATES A PRIMARY CARE CLINIC NETWORK, SPECIALTY CARE CLINICS AND HOME HEALTH SERVICES. MERCY ALSO PARTNERS WITH OTHER COMMUNITY HEALTHCARE PROVIDERS TO SPONSOR A REGIONAL CANCER CENTER, PARAMEDIC SERVICES, HOSPICE SERVICES, A FREESTANDING SURGERY CENTER AND A VARIETY OF OTHER HEALTH SERVICES.THE PRIMARY SERVICE AREA IS CONSIDERED URBAN (WITHIN SIOUX CITY). HOWEVER, MERCY SERVES MANY RURAL COMMUNITIES THROUGHOUT THE 33 COUNTY AREA, AND MANY DISTINCT ETHNIC AND CULTURAL GROUPS, INCLUDING HISPANIC, VIETNAMESE, SOMALI, AND NATIVE AMERICAN (WINNEBAGO, OMAHA, LAKOTA, AND PONCA TRIBES). THE AVERAGE HOUSEHOLD INCOME FOR THE 14-COUNTY SIOUX CITY AREA IS $55,562. ACCORDING TO THE STATE HEALTH ACCESS DATA ASSISTANCE CENTER, IN 2007, 27.9% PERCENT OF RESIDENTS WERE BELOW THE FEDERAL POVERTY GUIDELINES. MORE THAN 8.7% OF THE COMMUNITY IS UNINSURED, AND APPROXIMATELY 35.1% OF FAMILIES ARE ON MEDICAID OR OTHER ASSISTANCE PROGRAMS.ACCORDING TO 2012 NIELSEN COMPANY DATA, THE 14-COUNTY COMMUNITY HAS A POPULATION OF 301,832. EIGHTY-TWO PERCENT OF THE POPULATION IS WHITE, 12% HISPANIC, 2% ASIAN & PACIFIC ISLANDER AND 1% BLACK. MEDICAID ENROLLMENT IS 34% IN NEBRASKA AND 37.5% IN SOUTH DAKOTA. THE PERCENT OF POPULATIONS IN EACH STATE BELOW 200% OF THE FEDERAL POVERTY LEVEL IS 28.8% IN NEBRASKA AND 30.9% IN SOUTH DAKOTA. MERCY MEDICAL CENTER-NORTH IOWA:THIS HOSPITAL SERVES A 14-COUNTY SERVICE AREA WITHIN A 70-MILE RADIUS STRETCHING IN EVERY DIRECTION FROM MASON CITY. THE PRIMARY SERVICE AREA CONSISTS OF CERRO GORDO AND WORTH COUNTIES IN IOWA, WHILE THE SECONDARY SERVICE AREA IS COMPRISED OF AN ADDITIONAL 12 CONTIGUOUS COUNTIES IN IOWA (BUTLER, CHICKASAW, FLOYD, FRANKLIN, HANCOCK, HARDIN, HOWARD, KOSSUTH, MITCHELL, PALO ALTO, WINNEBAGO, AND WRIGHT). IN 2010 THE 14-COUNTY SERVICE AREA HAD AN ESTIMATED POPULATION OF 194,162. 94.9 PERCENT OF RESIDENTS ARE WHITE. THERE ARE 11 CRITICAL ACCESS HOSPITALS WITHIN MERCY - NORTH IOWA'S SERVICE AREA PROVIDING PRIMARY HEALTH CARE SERVICES, EIGHT OF WHICH ARE MERCY - NORTH IOWA AFFILIATES. PATIENTS FROM THE REMAINING IOWA COUNTIES UTILIZE MERCY - NORTH IOWA FOR TERTIARY LEVEL CARE. THE UNIVERSITY OF IOWA HOSPITALS IN IOWA CITY AND MAYO CLINIC IN ROCHESTER, MINNESOTA ALSO PROVIDE TERTIARY CARE FOR THIS AREA.MERCY - NORTH IOWA'S MARKET SHARE FOR THE 14-COUNTY SERVICE AREA IN CY 2011 IS 49.52 PERCENT, WHILE THE PRIMARY SERVICE AREA HAS 93.37 PERCENT OF THE MARKET, AS REPORTED BY IOWA HOSPITAL ASSOCIATION DATA.THE AVERAGE INCOME IN MERCY - NORTH IOWA'S SERVICE AREA IN 2010 WAS ESTIMATED TO BE $31,765, ACCORDING TO BUREAU OF ECONOMIC ANALYSIS (IOWA WORKFORCE DEVELOPMENT NEWS AND TRENDS). UNEMPLOYMENT WENT DOWN IN MERCY - NORTH IOWA'S SERVICE AREA. MERCY MEDICAL CENTER-NEW HAMPTON:MMC-NH SERVES THE CHICKASAW AREA AND SURROUNDING COUNTIES WITHIN A 20-MILE RADIUS STRETCHING IN EVERY DIRECTION FROM NEW HAMPTON. THE PRIMARY SERVICE AREA CONSISTS OF THE TOWNS OF NEW HAMPTON, FREDERICKSBURG, ALTA VISTA, IONIA, ELMA, WAUCOMA, LAWLER AND NASHUA. THE ESTIMATED POPULATION OF THIS AREA IS 13,500. ACCORDING TO THE U.S. CENSUS BUREAU, CHICKASAW COUNTY HAD AN ESTIMATED POPULATION OF 12,017 IN 2009. CHICKASAW COUNTY EXPERIENCED AN ESTIMATED 8.2% PERCENT DECLINE IN POPULATION FROM 2000-2009. THE STRESS THAT THIS TREND PLACES ON THE PROVISION OF SERVICES IS COMPOUNDED BY THE HIGHER THAN AVERAGE PROPORTION OF ELDERLY IN THE AREA. EIGHTEEN PERCENT OF THE POPULATION IN CHICKASAW AREA WAS OVER AGE 65 IN 2009, COMPARED TO 15 PERCENT FOR THE STATE AND 13 PERCENT FOR THE NATION. IOWA RANKS THIRD IN THE NATION IN PERCENTAGE OF POPULATION OVER 85, FIFTH IN PERCENTAGE OF POPULATION OVER THE AGE OF 65, AND HIGHEST IN THE NATION FOR PERCENTAGE OF POPULATION AGE 100 AND OVER. THIS LARGE PERCENTAGE OF ELDERLY PRESENTS SPECIAL CHALLENGES TO HEALTH CARE PROVIDERS BECAUSE THE ELDERLY HAVE THE HIGHEST INCIDENCE OF DISEASE AND MORTALITY IN MOST CATEGORIES AND, CORRESPONDINGLY, ARE THE BIGGEST USERS OF HEALTH CARE SERVICES. IN ADDITION, MEDICARE PAYMENT SHORTFALLS PRESENT AN ADDITIONAL BURDEN FOR RURAL HEALTH PROVIDERS. FOR FISCAL YEAR 2010, 59 PERCENT OF MMC-NH'S REVENUES (HOSPITAL INPATIENT AND OUTPATIENT) WERE GENERATED FROM MEDICARE PATIENTS. THE MEDIAN HOUSEHOLD INCOME IN CHICKASAW COUNTY WAS ESTIMATED AT $43,990 IN 2009. INDIVIDUALS BELOW THE POVERTY LEVEL COMPRISE 9.3% OF THE POPULATION. THE FISCAL YEAR 2010 PAYER MIX AT POINT OF REGISTRATION INCLUDES 34% COVERED BY MEDICARE, 9% COVERED BY MEDICAID AND 5% SELF-PAY.ACCORDING TO 2009 DATA FROM THE U.S. CENSUS BUREAU, THE RESIDENTS OF CHICKASAW COUNTY ARE 98.4% WHITE.MERCY MEDICAL CENTER-DUBUQUE:FOR PURPOSES OF ITS COMMUNITY HEALTH NEEDS ASSESSMENT, MERCY MEDICAL CENTER'S PRIMARY SERVICE AREA IS DUBUQUE COUNTY, IOWA. ABOUT 60% OF MERCY'S INPATIENT CASES AND MORE THAN 75% OF MERCY'S EMERGENCY DEPARTMENT CASES WERE FOR DUBUQUE COUNTY RESIDENTS.DUBUQUE COUNTY'S POPULATION IS 89,143. IT INCLUDES ONE URBAN COMMUNITY, THE CITY OF DUBUQUE. ITS 65+ POPULATION IS ALMOST AS HIGH AS IOWA'S, AND SIGNIFICANTLY HIGHER THAN THE U.S. AVERAGE FOR THIS AGE RANGE. CONVERSELY, THE 16-24 POPULATION IS NOTICEABLY LOWER THAN THE U.S. AVERAGE. ALTHOUGH MINORITY POPULATIONS IN DUBUQUE COUNTY HAVE INCREASED DURING THE LAST DECADE, THE POPULATION IS STILL 97.1% WHITE, WITH NO OTHER SINGLE RACIAL GROUP ACCOUNTING FOR MORE THAN 1%. THE COUNTY'S HISPANIC OR LATINO POPULATION IS 1.2%MEDIAN INCOME IN DUBUQUE COUNTY IS $39,582, SLIGHTLY HIGHER THAN IOWA, BUT LOWER THAN THE U.S. MEDIAN. IN THE COUNTY, HOUSEHOLDERS UNDER 25 AND OLDER THAN 65 ARE BELOW THAT MEDIAN, WHICH IS ALSO TRUE FOR IOWA AND THE U.S. PER CAPITA INCOME IN DUBUQUE COUNTY IS $19,600, EQUAL TO IOWA AND SOMEWHAT LOWER THAN THE U.S. DUBUQUE COUNTY BLACK PER CAPITA INCOME IS 51% OF WHITE PER CAPITA INCOME, COMPARED TO 61% IN IOWA AND 60% NATIONALLY. DUBUQUE COUNTY HISPANIC PER CAPITA INCOME IS 58% OF WHITE PER CAPITA INCOME, COMPARED TO 54% IN IOWA AND 51% NATIONALLY.
    PART VI, LINE 5: OTHER INFORMATION - MERCY MEDICAL CENTER-SIOUX CITY:MERCY MEDICAL CENTER-SIOUX CITY HAS EARNED MORE NATIONAL RECOGNITION FOR QUALITY PATIENT OUTCOMES THAN ANY OTHER HOSPITAL IN THE REGION. THE MEDICAL CENTER HAS EARNED MULTIPLE HONORS FOR ITS LEADERSHIP AND EXCELLENCE IN SEVERAL CLINICAL AREAS, INCLUDING CARDIAC CARE, ORTHOPEDIC SERVICES, VASCULAR SURGERY, STROKE CARE AND CANCER CARE.MERCY MEDICAL CENTER-SIOUX CITY IS HOME TO THE ONLY LEVEL II TRAUMA CENTER IN WESTERN IOWA, AND PROVIDES A VITAL, LIFESAVING LINK TO RURAL AREAS VIA MERCY AIR CARE, THE HOSPITAL'S HELICOPTER AMBULANCE SERVICE.MERCY MEDICAL CENTER-SIOUX CITY IS INVOLVED IN A NUMBER OF COMMUNITY VENTURES, AND SUPPORTS THE SIOUXLAND MEDICAL EDUCATION FOUNDATION (FAMILY MEDICINE RESIDENCY). WE ALSO WORK CLOSELY WITH WINNEBAGO INDIAN HEALTH SERVICES TO CLOSE HEALTH OUTCOMES DISPARITIES. IN ADDITION, THE MEDICAL CENTER COLLABORATES WITH ST. LUKE'S COLLEGE OF NURSING, WITCC SCHOOL OF NURSING, AND BRIAR CLIFF UNIVERSITY SCHOOL OF NURSING.MERCY MEDICAL CENTER - NORTH IOWA:MERCY MEDICAL CENTER - NORTH IOWA HAS BEEN PROVIDING MANAGEMENT SERVICES FOR RURAL HOSPITALS SINCE 1978. THESE COMMUNITY HOSPITALS OFFER QUALITY HEALTH CARE AND YET ARE STILL ABLE TO TAKE ADVANTAGE OF ALL THE RESOURCES MERCY MEDICAL CENTER - NORTH IOWA HAS TO OFFER AS A MAJOR REFERRAL CENTER. AS A TEACHING HOSPITAL, MERCY MEDICAL CENTER - NORTH IOWA HOSTS A FAMILY PRACTICE RESIDENCY PROGRAM, PHARMACY RESIDENCY, PALLIATIVE CARE FELLOWSHIP, CARDIOLOGY FELLOWSHIP, AND A SCHOOL OF RADIOLOGIC TECHNOLOGY. MERCY MEDICAL CENTER - NORTH IOWA IS A CLINICAL SITE FOR STUDENTS STUDYING TO BECOME PHYSICIANS, NURSES, PARAMEDICS, PHARMACISTS, MEDICAL ASSISTANTS AND OTHER ALLIED HEALTH PROFESSIONALS. IN ADDITION, THE MEDICAL CENTER MANAGES AN ADULT DAY CARE CENTER AND HOMELESS SHELTERS FOR MEN AND WOMEN IN COLLABORATION WITH OTHER NON-PROFITS. AS A SOLE COMMUNITY PROVIDER, SPECIALIZED SERVICES INCLUDE A HEART CENTER, CANCER CENTER, DIABETES CENTER, STROKE CENTER, BARIATRIC CENTER, LEVEL II BIRTH CENTER AND A LEVEL II EMERGENCY CENTER. EMERGENCY SERVICES ARE AVAILABLE TO ALL REGARDLESS OF THEIR ABILITY TO PAY. BECAUSE OF THE NEED BY INDIGENT ADULTS FOR DENTAL CARE, MERCY - NORTH IOWA HAS FULLY FURNISHED TWO ROOMS TO ACCOMMODATE EMERGENT DENTAL NEEDS. HALF-DAY CLINICS ARE MANNED BY AREA DENTISTS AND DENTAL ASSISTANTS WHO VOLUNTEER THEIR TIME AND GUIDANCE. BEING A RURAL AREA OFTEN CREATES A TRANSPORTATION BARRIER FOR ACCESS TO MEDICAL APPOINTMENTS. MERCY MEDICAL CENTER - NORTH IOWA HAS THREE SUBSIDIZED PROGRAMS THAT FACILITATE TRANSPORTATION FOR INDIVIDUALS WHO, BECAUSE OF AGE, DISABILITY, ECONOMICS AND/OR TREATMENT, NEED ASSISTANCE. THIS SERVES THOSE WHO LIVE IN MASON CITY AS WELL AS THROUGHOUT SURROUNDING NORTH IOWA COMMUNITIES. MERCY FAMILY HEALTH LINE, A 24-HOUR/7-DAY A WEEK TELEPHONE INFORMATION SERVICE, FIELDS NEARLY 30,000 CALLS A YEAR. REGISTERED NURSES PROVIDE MEDICAL TRIAGE AS WELL AS REFERRALS TO INTERNAL AND COMMUNITY HUMAN SERVICES RESOURCES. IN COLLABORATION WITH THE COMMUNITY KITCHEN, OUR HOSPITAL KITCHEN HANDLES THE PREPARATION OF MEALS ON WHEELS MONDAY THROUGH FRIDAY AND DONATES DELIVERY COORDINATION. IN CALENDAR YEAR 2011, OVER 21,000 MEALS WERE PREPARED AND DELIVERED.THE HOSPITAL EXTENDS MEDICAL STAFF PRIVILEGES TO ALL QUALIFIED COMMUNITY HEALTHCARE PROVIDERS IN ORDER TO BEST MEET THE NEEDS OF THOSE WHO LIVE IN NORTH IOWA COMMUNITIES.MERCY MEDICAL CENTER - NORTH IOWA ACTIVELY RECRUITS PHYSICIANS IN AN EFFORT TO PROMOTE ACCESSIBLE HEALTH CARE TO THE RESIDENTS OF THE COMMUNITIES WE SERVE THAT HAVE BEEN DESIGNATED AS A HEALTH PROFESSIONAL SHORTAGE AREA (HPSA) AND/OR MEDICALLY UNDERSERVED AREA (MUA). THESE EFFORTS SUPPORT THE COMMUNITIES BY PROVIDING EXPERTISE AND HEALTHCARE SERVICES, AND AS A CLAUSE IN THEIR CONTRACT STATES, SPECIAL CARE FOR INDIGENT AND UNDERSERVED POPULATIONS.MERCY MEDICAL CENTER - NEW HAMPTON:AS A SOLE COMMUNITY PROVIDER, MMC-NH PROVIDES A RANGE OF SPECIALIZED SERVICES, DIABETES EDUCATION AND NUTRITION AND AN EMERGENCY CENTER. EMERGENCY SERVICES ARE AVAILABLE TO ALL REGARDLESS OF THEIR ABILITY TO PAY. THE HOSPITAL EXTENDS MEDICAL STAFF PRIVILEGES TO ALL QUALIFIED COMMUNITY HEALTHCARE PROVIDERS, IN ORDER TO BEST MEET THE NEEDS OF OUR NORTHEAST IOWA COMMUNITIES.MERCY MEDICAL CENTER-DUBUQUE:MERCY MEDICAL CENTER-DUBUQUE PROVIDES SEVERAL SERVICES THAT ARE UNIQUE TO THE COMMUNITY, INCLUDING OPEN HEART SURGERY, NEONATAL INTENSIVE CARE AND INPATIENT COMMUNITY PSYCHIATRIC SERVICES. IN ADDITION, THE HOSPITAL OPERATES AN EMERGENCY ROOM AVAILABLE TO ALL REGARDLESS OF ABILITY TO PAY.
    PART VI, LINE 6: MERCY HEALTH SERVICES-IOWA IS A MEMBER ORGANIZATION OF TRINITY HEALTH, ONE OF THE LARGEST CATHOLIC HEALTH CARE SYSTEMS IN THE COUNTRY. BASED IN LIVONIA, MICHIGAN, TRINITY HEALTH ANNUALLY REQUIRES THAT ALL MEMBER ORGANIZATIONS DEVELOP, AND ARE HELD ACCOUNTABLE FOR ACHIEVING, COMMUNITY BENEFIT GOALS THAT INCLUDE DEVELOPING NEEDED SERVICES OR EXPANDING ACCESS TO SERVICES FOR LOW-INCOME INDIVIDUALS. AS A NOT-FOR-PROFIT HEALTH SYSTEM, TRINITY HEALTH REINVESTS ITS PROFITS BACK INTO THE COMMUNITY THROUGH PROGRAMS TO SERVE THE POOR AND UNINSURED, MANAGE CHRONIC CONDITIONS LIKE DIABETES, HEALTH EDUCATION AND PROMOTION INITIATIVES, AND OUTREACH FOR THE ELDERLY. IN FISCAL YEAR 2012, THIS INCLUDED OVER $615 MILLION IN SUCH COMMUNITY BENEFITS. THEREFORE, TRINITY HEALTH TAKES A SYSTEM APPROACH IN ITS COMMUNITY BENEFIT PLANNING AND IMPLEMENTATION, AND IS CONSEQUENTLY ABLE TO ENSURE THAT ITS MEMBER HOSPITALS AND OTHER ENTITIES/AFFILIATES ARE HELPING PROMOTE AND ADDRESS THE HEALTH NEEDS OF THEIR RESPECTIVE COMMUNITIES.FOR MORE INFORMATION ABOUT TRINITY HEALTH, VISIT WWW.TRINITY-HEALTH.ORG.
Schedule H (Form 990) 2011
Additional Data


Software ID:  
Software Version:  
Schedule I
(Form 990)
Department of the Treasury
Internal Revenue Service
Grants and Other Assistance to Organizations,
Governments and Individuals in the United States
Complete if the organization answered "Yes," to Form 990, Part IV, line 21 or 22.
lBullet Attach to Form 990
OMB No. 1545-0047
2011
Open to Public
Inspection
Name of the organization
MERCY HEALTH SERVICES - IOWA CORP
 
Employer identification number
31-1373080
Part I
General Information on Grants and Assistance
1
Does the organization maintain records to substantiate the amount of the grants or assistance, the grantees' eligibility for the grants or assistance, and
the selection criteria used to award the grants or assistance? ....................................
2
Describe in Part IV the organization's procedures for monitoring the use of grant funds in the United States.
Part II
Grants and Other Assistance to Governments and Organizations in the United States. Complete if the organization answered "Yes" to
Form 990, Part IV, line 21 for any recipient that received more than $5,000. Check this box if no one recipient received more than $5,000. Use
Part IV and Schedule I-1 (Form 990) if additional space is needed ......................... lBullet
(a) Name and address of organization
or government		 (b) EIN (c) IRC Code section
if applicable		 (d) Amount of cash grant (e) Amount of non-cash
assistance		 (f) Method of valuation
(book, FMV, appraisal,
other)		 (g) Description of
non-cash assistance		 (h) Purpose of grant
or assistance
(1) COUNCIL ON SEXUAL ASSUALT AND DOMESTIC VIOLENCEPO BOX 1565
SIOUX CITY,IA51102 		42-1104234 501(C)3 5,700       COMMUNITY SUPPORT
(2) NORTHEAST IOWA COMMUNITY ACTION CORP305 MONTGOMERY ST
DECORAH,IA52101 		42-6092713 501(C)3 6,000       COMMUNITY SUPPORT
(3) NORTHWESTERN YOUTH SERVICES INC2069 500TH STREET
CHEROKEE,IA51012 		20-4538859   7,200       COMMUNITY SUPPORT
(4) NORTH IOWA CORRIDOR ECONOMIC DEVELOPMENT CORPORATION25 WEST STATE STREET
MASON CITY,IA50401 		75-3190471 501(C)6 25,000       PLEDGE
(5) SIOUX CITY SYMPHONY ORCHESTRA520 PIERCE STREET
SIOUX CITY,IA51101 		42-6006580 501(C)3 5,000       PROGRAM SUPPORT - SPONSORSHIP OF IOWA PIANO COMPETITION
(6) SIOUXLAND HERITAGE FOUNDATION2901 JACKSON ST
SIOUX CITY,IA51104 		42-1516734 501(C)3 5,000       CAPITAL CAMPAIGN SUPPORT - FIFTH OF A FIVE PLEDGE FOR SIOUX CITY'S NEW MUSEUM
(7) SIOUXLAND COMMUNITY HEALTH CENTER1021 NEBRASKA STREET
SIOUX CITY,IA51102 		42-1374894 501(C)3 85,978       COMMUNITY SUPPORT
(8) CRESCENT COMMUNITY HEALTH CENTER1789 ELM STREET
DUBUQUE,IA52001 		48-1302204 501(C)3 10,000       DIABETES MANAGEMENT PROGRAM SUPPORT
(9) UNITED WAY OF SIOUXLAND INCPO BOX 204
SIOUX CITY,IA51102 		42-0680395 501(C)3 6,200       PLEDGE
(10) THE CRITTENTON CENTER303 WEST 24TH STREET
SIOUX CITY,IA51104 		42-0698246 501(C)3 71,826       COMMUNITY SUPPORT
(11) WINNEBAGO TRIBE OF NEBRASKAPO BOX 687
WINNEBAGO,NE68071 		47-0489118 TRIBAL GOVERNMENT 7,500       SUPPORT WELLNESS AND DIABETES PROGRAM
(12) LEGENDS OF GOLD INC47256 29TH STREET
BERESFORD,SD57004 		27-3794971 501(C)3 8,000       CAMP SCHOLARSHIP
(13) DAKOTA VALLEY SCHOOL DISTRICT #61-81150 NORTHSHORE DRIVE
NORTH SIOUX CITY,SD57049 		46-6003189 PUBLIC SCHOOL 6,000       SCHOLARSHIPS
(14) IOWA DENTAL FOUNDATIONPO BOX 31088
JOHNSTON,IA50131 		42-1405188 501(C)3 10,000       IOWA MISSION OF MERCY SPONSORSHIP
(15) IOWA LEGAL AID1111 9TH STREET
DES MOINES,IA50314 		42-1079227 501(C)3 7,500       HEALTH AND LAW PROJECT SUPPORT
(16) IOWA STATE UNIVERSITY FOUNDATION2505 UNIVERSITY BLVD
AMES,IA50001 		42-1143702 501(C)3 6,000       AMERICORPS MATCH FOR ONE PROGRAM
(17) NORTH IOWA COMMUNITY ACTION ORGANIZATION218 5TH ST SW
MASON CITY,IA50402 		42-0921505 501(C)3 78,000       COMMUNITY SUPPORT
(18) SIOUXLAND MENTAL HEALTH SERVICESPO BOX 1917
SIOUX CITY,IA51102 		42-6122297 501(C)3 10,000       COMMUNITY SUPPORT
(19) SISTERS OF ST FRANCIS3390 WINDSOR AVE
DUBUQUE,IA52001 		42-0757421 RELIGIOUS 12,000       GENERAL SUPPORT
(20) SUNRISE MANOR DBA SUNRISE RETIREMENT COMMUNITY5501 GORDON DRIVE
SIOUX CITY,IA51106 		42-0805391 501(C)3 5,100       DONATION TO CAPITAL CAMPAIGN AND FOUNTAINVIEW SPONSOR BENEFIT CONCERT
(21) UNITED WAY OF NORTH CENTRAL IOWA600 1ST STREET NW 102
MASON CITY,IA50401 		42-0680431 501(C)3 10,000       PLEDGE
2
Enter total number of section 501(c)(3) and government organizations listed in the line 1 table ................. Bullet Image
19
3
Enter total number of other organizations listed in the line 1 table ......................... . Bullet Image
2
For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50055P
Schedule I (Form 990) 2011

Schedule I (Form 990) 2011
Page 2
Part III
Grants and Other Assistance to Individuals in the United States. Complete if the organization answered "Yes" to Form 990, Part IV, line 22.
Use Schedule I-1 (Form 990) if additional space is needed.
(a)Type of grant or assistance (b)Number of
recipients		 (c)Amount of
cash grant		 (d)Amount of
non-cash assistance		 (e)Method of valuation (book,
FMV, appraisal, other)		 (f)Description of non-cash assistance













Part IV
Supplemental Information. Complete this part to provide the information required in Part I, line 2, and any other additional information.
Identifier Return Reference Explanation
PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: DONATIONS MADE BY MERCY HEALTH SERVICES - IOWA, CORP. TO CHARITABLE ORGANIZATIONS ARE MADE IN FURTHERANCE OF THE RECIPIENT ORGANIZATION'S EXEMPT PURPOSE AND ARE CONSIDERED UNRESTRICTED WITH REGARD TO THE USE OF THE FUNDS.
Schedule I (Form 990) 2011


Additional Data


Software ID:  
Software Version:  


Schedule J
(Form 990)
Department of the Treasury
Internal Revenue Service
Compensation Information
For certain Officers, Directors, Trustees, Key Employees, and Highest
Compensated Employees
SchJMediumBullet Complete if the organization answered "Yes" to Form 990,
Part IV, question 23.
SchJMediumBullet Attach to Form 990. SchJMediumBullet See separate instructions.
OMB No. 1545-0047
2011
Open to Public Inspection
Name of the organization
MERCY HEALTH SERVICES - IOWA CORP
 
Employer identification number

31-1373080
Part I
Questions Regarding Compensation
Yes
No
1a
Check the appropiate box(es) if the organization provided any of the following to or for a person listed in Form
990, Part VII, Section A, line 1a. Complete Part III to provide any relevant information regarding these items.
b
If any of the boxes in line 1a are checked, did the organization follow a written policy regarding payment or reimbursement or provision of all the expenses described above? If "No," complete Part III to explain....
1b
 
 
2
Did the organization require substantiation prior to reimbursing or allowing expenses incurred by all
officers, directors, trustees, and the CEO/Executive Director, regarding the items checked in line 1a? ....
2
 
 
3
Indicate which, if any, of the following the organization uses to establish the compensation of the
organization's CEO/Executive Director. Check all that apply. 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.
4
During the year, did any person listed in Form 990, Part VII, Section A, line 1a with respect to the filing organization or a related organization:
a
Receive a severance payment or change-of-control payment? ...............
4a
 
No
b
Participate in, or receive payment from, a supplemental nonqualified retirement plan? ........
4b
Yes
 
c
Participate in, or receive payment from, an equity-based compensation arrangement? ........
4c
 
No
If "Yes" to any of lines 4a-c, list the persons and provide the applicable amounts for each item in Part III.
Only 501(c)(3) and 501(c)(4) organizations only must complete lines 5-9.
5
For persons listed in form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the revenues of:
a
The organization? ...........................
5a
 
No
b
Any related organization? .........................
5b
 
No
If "Yes," to line 5a or 5b, describe in Part III.
6
For persons listed in form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the net earnings of:
a
The organization? ...........................
6a
 
No
b
Any related organization? .........................
6b
 
No
If "Yes," to line 6a or 6b, describe in Part III.
7
For persons listed in Form 990, Part VII, Section A, line 1a, did the organization provide any non-fixed
payments not described in lines 5 and 6? If "Yes," describe in Part III ............
7
 
No
8
Were any amounts reported in Form 990, Part VII, paid or accured pursuant to a contract that was
subject to the initial contract exception described in Regulations section 53.4958-4(a)(3)? If "Yes," describe
in Part III .............................
8
 
No
9
If "Yes" to line 8, did the organization also follow the rebuttable presumption procedure described in Regulations section 53.4958-6(c)? .........................
9
 
 
For Privacy Act and Paperwork Reduction Act Notice, see the Intructions for Form 990
Cat. No. 50053T
Schedule J (Form 990) 2011

Schedule J (Form 990) 2011
Page 2
Part II
Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees. Use duplicate copies if additional space is needed.
For each individual whose compensation must be reported in Schedule J, report compensation from the organization on row (i) and from related organizations, described in the
instructions on row (ii). Do not list any individuals that are not listed on Form 990, Part VII.

Note. The sum of columns (B)(i)-(iii) for each listed individual must equal the total amount of Form 990, Part VII, Section A, line 1a, applicable column (D) and column (E) for that individual.
(A) Name (B) Breakdown of W-2 and/or 1099-MISC compensation (C) Retirement and other deferred compensation (D) Nontaxable
benefits		 (E) Total of columns
(B)(i)-(D) 		(F) Compensation
reported as deferred
in prior Form 990
(i) Base compensation (ii) Bonus & incentive compensation (iii) Other reportable compensation
(1) JOSEPH SWEDISH (i)
(ii)		 0
1,279,458 		0
677,642 		0
3,229,560 		0
548,602 		0
27,600 		0
5,762,862 		0
2,698,342
(2) PAUL NEUMANN (i)
(ii)		 0
464,258 		0
161,126 		0
107,407 		0
69,874 		0
27,920 		0
830,585 		0
0
(3) AGNES HAGERTY (i)
(ii)		 0
345,590 		0
0 		0
33,859 		0
37,512 		0
13,713 		0
430,674 		0
0
(4) BENJAMIN CARTER (i)
(ii)		 0
509,505 		0
174,420 		0
71,089 		0
73,824 		0
28,865 		0
857,703 		0
0
(5) JAMES BOSSCHER (i)
(ii)		 0
318,984 		0
118,226 		0
86,244 		0
73,915 		0
14,927 		0
612,296 		0
36,335
(6) KEDRICK ADKINS (i)
(ii)		 0
743,978 		0
316,652 		0
344,596 		0
103,857 		0
13,263 		0
1,522,346 		0
143,708
(7) MICHAEL MURPHY (i)
(ii)		 0
402,598 		0
0 		0
71,772 		0
48,365 		0
27,173 		0
549,908 		0
0
(8) RICHARD O'CONNELL (i)
(ii)		 0
571,942 		0
230,946 		0
140,349 		0
85,919 		0
32,302 		0
1,061,458 		0
0
(9) JAMES FITZPATRICK (i)
(ii)		 0
387,599 		0
131,804 		0
85,443 		0
86,075 		0
23,188 		0
714,109 		0
33,108
(10) RODNEY SCHLADER (i)
(ii)		 0
235,441 		0
42,679 		0
1,203 		0
33,103 		0
21,336 		0
333,762 		0
0
(11) ROBERT PEEBLES (i)
(ii)		 0
371,901 		0
127,425 		0
67,389 		0
55,365 		0
22,297 		0
644,377 		0
0
(12) RUSSELL KNIGHT (i)
(ii)		 0
300,296 		0
98,812 		0
75,469 		0
66,829 		0
9,120 		0
550,526 		0
28,979
(13) LARRY SELLERS (i)
(ii)		 0
357,116 		0
69,318 		0
4,467 		0
37,711 		0
23,131 		0
491,743 		0
0
(14) STEVEN EAVENSON TATUM LLC (i)
(ii)		 132,300
182,625 		0
25,000 		0
34,053 		0
12,536 		0
5,478 		132,300
259,692 		0
0
(15) PAUL MANTERNACH (i)
(ii)		 0
316,073 		0
53,191 		0
1,062 		0
20,921 		0
17,358 		0
408,605 		0
0
(16) MARILYN KAPTAIN-DAHLEN (i)
(ii)		 0
234,192 		0
49,858 		0
3,342 		0
39,272 		0
16,266 		0
342,930 		0
0
(17) TERESA MOCK (i)
(ii)		 0
260,438 		0
22,140 		0
2,539 		0
34,393 		0
18,539 		0
338,049 		0
0
(18) DIANE FISCHELS (i)
(ii)		 0
222,004 		0
35,686 		0
1,093 		0
48,713 		0
7,689 		0
315,185 		0
0
(19) GARY GUETZKO (i)
(ii)		 0
183,222 		0
43,896 		0
1,682 		0
39,445 		0
18,690 		0
286,935 		0
0
(20) LINDA KREI (i)
(ii)		 0
186,417 		0
39,514 		0
894 		0
28,994 		0
3,953 		0
259,772 		0
0
(21) MICHAEL JOHNSTON (i)
(ii)		 0
190,009 		0
20,993 		0
9,338 		0
16,607 		0
15,464 		0
252,411 		0
0
(22) KAY TAKES (i)
(ii)		 0
166,182 		0
36,763 		0
515 		0
25,735 		0
15,054 		0
244,249 		0
0
(23) ROBERT SHAFER (i)
(ii)		 0
153,488 		0
34,676 		0
1,383 		0
69,326 		0
16,272 		0
275,145 		0
0
(24) BERNARD FOX (i)
(ii)		 0
149,987 		0
33,509 		0
3,781 		0
18,726 		0
9,314 		0
215,317 		0
0
(25) BRIAN MONSMA (i)
(ii)		 0
149,683 		0
33,123 		0
317 		0
15,238 		0
20,472 		0
218,833 		0
0
(26) ALIREZA YARAHMADI (i)
(ii)		 455,481
0 		189,752
0 		48,947
0 		57,794
0 		39,515
0 		791,489
0 		0
0
(27) JAMES SIMON (i)
(ii)		 588,332
0 		0
0 		38,627
0 		53,421
0 		82,235
0 		762,615
0 		0
0
(28) PHILLIP ALSCHER (i)
(ii)		 453,059
0 		141,170
0 		31,175
0 		38,040
0 		66,225
0 		729,669
0 		0
0
(29) JAMES KARKOS (i)
(ii)		 367,312
0 		201,381
0 		50,738
0 		78,790
0 		50,681
0 		748,902
0 		0
0
(30) CARL PLANK (i)
(ii)		 465,527
0 		86,903
0 		30,722
0 		64,588
0 		64,686
0 		712,426
0 		0
0
(31) DANIEL HALE (i)
(ii)		 0
479,340 		0
186,340 		0
260,274 		0
87,640 		0
18,585 		0
1,032,179 		0
155,414
(32) MARIANNE CUNNINGHAM (i)
(ii)		 0
162,045 		0
0 		0
784 		0
13,313 		0
18,293 		0
194,435 		0
0
(33) EDWARD CHADWICK (i)
(ii)		 0
0 		0
0 		0
159,057 		0
0 		0
0 		0
159,057 		0
0
(34) PAUL BROWNE (i)
(ii)		 0
460,713 		0
212,876 		0
108,012 		0
73,237 		0
21,391 		0
876,229 		0
48,148
(35) DEBRA CANALES (i)
(ii)		 0
498,701 		0
190,895 		0
201,026 		0
73,012 		0
13,359 		0
976,993 		0
86,184
(36) PAUL CONLON (i)
(ii)		 0
259,447 		0
93,548 		0
63,042 		0
73,512 		0
24,271 		0
513,820 		0
19,811
(37) LOUIS FIERENS (i)
(ii)		 0
321,453 		0
110,855 		0
57,400 		0
49,874 		0
15,226 		0
554,808 		0
12,188
(38) PRESTON GEE (i)
(ii)		 0
300,426 		0
110,215 		0
76,974 		0
49,086 		0
27,523 		0
564,224 		0
0
(39) MICHAEL HOLPER (i)
(ii)		 0
262,967 		0
92,035 		0
47,099 		0
47,570 		0
22,315 		0
471,986 		0
7,371
(40) TERRENCE O'ROURKE (i)
(ii)		 0
500,415 		0
209,835 		0
153,331 		0
22,851 		0
27,858 		0
914,290 		0
0
(41) MARIA SZYMANSKI (i)
(ii)		 0
371,031 		0
163,299 		0
131,730 		0
91,752 		0
15,141 		0
772,953 		0
83,518
(42) KIM PRICE (i)
(ii)		 124,713
0 		0
0 		7,659
0 		24,143
0 		18,115
0 		174,630
0 		0
0
(43) MICHAEL SLUBOWSKI (i)
(ii)		 0
13,394 		0
0 		0
137,444 		0
500 		0
601 		0
151,939 		0
136,445
(44) MARY EBELING (i)
(ii)		 0
99,541 		0
33,601 		0
1,535 		0
36,379 		0
10,261 		0
181,317 		0
0
Schedule J (Form 990) 2011

Schedule J (Form 990) 2011
Page 3
Part III
Supplemental Information
Complete this part to provide the information, explanation, or descriptions required for Part I, lines 1a, 1b, 3, 4c, 5a, 5b, 6a, 6b, 7, and 8. Also complete this part for any additional information.
Identifier Return Reference Explanation
  PART I, LINE 3 MERCY HEALTH SERVICES - IOWA, CORP. IS A SUBSIDIARY IN THE TRINITY HEALTH SYSTEM. MERCY HEALTH SERVICES - IOWA, CORP. HOSPITAL CEOS ARE PAID DIRECTLY BY THE SYSTEM'S PARENT ENTITY, TRINITY HEALTH CORPORATION. TRINITY HEALTH CORPORATION USED THE FOLLOWING METHODS TO ESTABLISH THE COMPENSATION OF MERCY HEALTH SERVICES - IOWA, CORP. CEOS: - COMPENSATION COMMITTEE - INDEPENDENT COMPENSATION CONSULTANT - FORM 990 OF OTHER ORGANIZATIONS - WRITTEN EMPLOYMENT CONTRACT - COMPENSATION SURVEY OR STUDY, AND - APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE
  PART I, LINE 4B THE FOLLOWING IS A PARTICIPANT IN A SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN (SERP). THE FOLLOWING SERP ACCRUAL FOR 2011 IS INCLUDED IN COLUMN C OF SCHEDULE J, PART II: JOSEPH SWEDISH - $265,000 PART I, LINE 4B: THE FOLLOWING ARE PARTICIPANTS IN THE TRINITY HEALTH PENSION RESTORATION PLAN, A NONQUALIFIED PLAN, WHICH PROVIDES RETIREMENT BENEFITS FOR CERTAIN ASSOCIATES WITH EARNINGS ABOVE THE IRS PAY CAP FOR QUALIFIED PLANS ($245,000 FOR 2011). THE FOLLOWING ACCRUALS FOR 2011 FOR THIS PLAN ARE INCLUDED IN COLUMN C OF SCHEDULE J, PART II: KEDRICK ADKINS - $91,607 JAMES BOSSCHER - $42,578 PAUL BROWNE - $53,119 DEBRA CANALES - $54,412 BENJAMIN CARTER - $54,011 PAUL CONLON - $31,100 LOUIS FIERENS - $29,740 JAMES FITZPATRICK - $53,685 PRESTON GEE - $28,495 DANIEL HALE - $42,034 MICHAEL HOLPER - $22,591 RUSSELL KNIGHT - $36,836 MICHAEL MURPHY - $27,513 PAUL NEUMANN - $49,293 RICHARD O'CONNELL - $66,279 ROBERT PEEBLES - $35,765 JOSEPH SWEDISH - $255,902 MARIA SZYMANSKI - $55,256 PART I, LINE 4B: THE FOLLOWING ARE PARTICIPANTS IN A MERCY HEALTH SERVICES-IOWA CORP. NON-QUALIFIED ELECTIVE DEFERRED COMPENSATION PLAN. THE FOLLOWING DEFERRALS FOR 2011 FOR THIS PLAN ARE INCLUDED IN COLUMN C OF SCHEDULE J, PART II: PHILLIP ALSCHER - $18,440 JAMES KARKOS - $47,225 CARL PLANK - $30,722 JAMES SIMON - $34,888 ALIREZA YARAHMADI - $44,162 PART II: STEVEN EAVENSON - THE AMOUNT LISTED IN COLUMN B(I), ROW (I), OF SCHEDULE J, PART II, ($132,300) REPRESENTS THE AMOUNT PAID BY MERCY HEALTH SERVICES - IOWA, CORP. (MHS-IA) IN CALENDAR 2011 TO TATUM, LLC FOR MR. EAVENSON'S SERVICES AS INTERIM CFO FOR MHS-IA'S SIOUX CITY FACILITY. MHS-IA DOES NOT KNOW HOW MUCH MR. EAVENSON RECEIVED AS WAGES FROM TATUM, LLC IN CALENDAR 2011. PART II: THE FOLLOWING INDIVIDUALS BECAME VESTED IN A SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN (SERP) DURING CALENDAR 2011. AS A RESULT, THE VESTED AMOUNTS WERE INCLUDED IN THEIR 2011 TAXABLE INCOMES. THE FOLLOWING VESTED SERP AMOUNTS ARE INCLUDED IN COLUMN B(III) OF SCHEDULE J, PART II: KEDRICK ADKINS - $220,648 JOSEPH SWEDISH - $2,740,000 COLUMN F OF SCHEDULE J INCLUDES THE PORTION OF THESE AMOUNTS THAT WERE REPORTED AS DEFERRED COMPENSATION IN PRIOR YEARS.
Schedule J (Form 990) 2011

Additional Data


Software ID:  
Software Version:  
Schedule L
(Form 990 or 990-EZ)
Department of the Treasury
Internal Revenue Service
Transactions with Interested Persons
MediumBullet Complete if the organization answered
"Yes" on Form 990, Part IV, lines 25a, 25b, 26, 27, 28a, 28b, or 28c,
or Form 990-EZ, Part V lines 38a or 40b.
MediumBullet Attach to Form 990 or Form 990-EZ. MediumBulletSee separate instructions.
OMB No. 1545-0047
2011
Open to Public Inspection
Name of the organization
MERCY HEALTH SERVICES - IOWA CORP
 
Employer identification number

31-1373080
Part I
Excess Benefit Transactions (section 501(c)(3) and section 501 (c)(4) organizations only).
Complete if the organization answered "Yes" on Form 990, Part IV, line 25a or 25b, or Form 990-EZ, Part V, line 40b.
1(a) Name of disqualified person (b) Description of transaction (c) Corrected?
Yes No





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

Part II
Loans to and/or From Interested Persons.
Complete if the organization answered "Yes" on Form 990, Part IV, line 26, or Form 990-EZ, Part V, line 38a.
(a) Name of interested person and purpose (b) Loan to or from the organization? (c)Original principal amount (d)Balance due (e) In default? (f) Approved by board or committee? (g)Written agreement?
To From Yes No Yes No Yes No
Total ...............Small Bullet $  
Part III
Grants or Assistance Benefitting Interested Persons.
Complete if the organization answered "Yes" on Form 990, Part IV, line 27.
(a) Name of interested person (b)Relationship between interested person and the organization (c)Amount of grant or type of assistance
For Privacy Act and Paperwork Reduction Act Notice, see the
Instructions for Form 990 or 990-EZ.
Cat. No. 50056A
Schedule L (Form 990 or 990-EZ) 2011
Schedule L (Form 990 or 990-EZ) 2011
Page 2
Part IV
Business Transactions Involving Interested Persons.
Complete if the organization answered "Yes" on Form 990, Part IV, line 28a, 28b, or 28c.
(a) Name of interested person (b) Relationship between interested person and the organization (c) Amount of transaction (d) Description of transaction (e) Sharing of organization's revenues?
Yes No
(1) UNITED CLINICAL LABORATORIES (UCL)
  		BERNARD FOX & ROBERT SHAFER, KEY EMPLOYEES, ALSO SERVE ON THE BD OF UCL 5,875,366 PAYMENTS MADE BY MERCY HEALTH SERVICES - IOWA, CORP. TO UNITED CLINICAL LABORATORIES FOR LABORATORY SERVICES.   No
(2) BARBARA SHAFER FAMILY MEMBER OF ROBERT SHAFER, KEY EMPLOYEE 65,697 EMPLOYMENT ARRANGEMENT   No
(3) NANCY ROLING FAMILY MEMBER OF ROBERT SHAFER, KEY EMPLOYEE 126,425 EMPLOYMENT ARRANGEMENT   No
(4) PREFERRED HEALTH CHOICES LLC (PHC)
  		RUSSELL KNIGHT, KEY EMPLOYEE, ALSO SERVES ON THE BOARD OF PHC 18,742,430 PAYMENTS MADE BY PREFERRED HEALTH CHOICES TO MERCY HEALTH SERVICES - IOWA, CORP. FOR MEDICAL SERVICES PROVIDED.   No
(5) PREFERRED HEALTH CHOICES LLC (PHC)
  		RUSSELL KNIGHT, KEY EMPLOYEE, ALSO SERVES ON THE BOARD OF PHC 12,275,096 PAYMENTS MADE BY MERCY HEALTH SERVICES - IOWA, CORP. TO PREFERRED HEALTH CHOICES FOR REIMBURSEMENT OF THIRD PARTY ADMINISTRATOR PAYMENTS.   No
(6) PREFERRED HEALTH CHOICES LLC (PHC)
  		RUSSELL KNIGHT, KEY EMPLOYEE, ALSO SERVES ON THE BOARD OF PHC 100,000 PARTNERSHIP DISTRIBUTION MADE BY PHC TO MERCY HEALTH SERVICES - IOWA, CORP. (MHS-IA IS A 50% PARTNER IN PHC)   No
(7) TRI-STATE OCCUPATIONAL HEALTH (TSOH)
  		RUSSELL KNIGHT, KEY EMPLOYEE, ALSO SERVES ON THE BD OF TSOH 149,000 PARTNERSHIP CAPITAL CONTRIBUTION MADE BY MERCY HEALTH SERVICES - IOWA, CORP. TO TSOH   No
(8) WELLMARK BLUE CROSS BLUE SHIELD OF IOWA AND SOUTH DAKOTA
  		MELANIE DREHER, BOARD MEMBER, ALSO SERVES ON THE BOARD OF WELLMARK BCBS 113,160,361 PAYMENTS MADE BY WELLMARK BCBS TO MERCY HEALTH SERVICES - IOWA, CORP FOR MEDICAL SERVICES PROVIDED.   No
(9) DUBUQUE REGIONAL AMBULATORY SURGERY CENTER LLC (DRASC)
  		RUSSELL KNIGHT, KEY EMPLOYEE, ALSO SERVES ON THE BOARD OF DRASC 3,000,000 PARTNERSHIP DISTRIBUTION MADE BY DRASC TO MHS-IA (MHS-IA IS A 50% PARTNER IN DRASC)   No
(10) MEDICAL ASSOCIATESMERCY FAMILY CARE NETWORK LLC (MAMFCN)
  		RUSSELL KNIGHT, KEY EMPLOYEE, ALSO SERVES ON THE BOARD OF MA/MFCN 580,000 PARTNERSHIP CAPITAL CONTRIBUTION MADE TO MA/MFCN BY MHS-IA (MHS-IA IS A 50% PARTNER IN MA/MFCN)   No
(11) RODGER MOCK FAMILY MEMBER OF TERESA MOCK, KEY EMPLOYEE 32,249 EMPLOYMENT ARRANGEMENT   No
(12) SIOUXLAND SURGERY CENTER
  		ROBERT PEEBLES, KEY EMPLOYEE, ALSO SERVES ON THE BOARD OF SIOUXLAND SURGERY 9,366,969 PARTNERSHIP DISTRIBUTION MADE BY SIOUXLAND SURGERY CENTER TO MERCY HEALTH SERVICES - IOWA, CORP. (MHS-IA IS A 31% PARTNER IN SIOUXLAND SURGERY CENTER)   No
Part V
Supplemental Information
Complete this part to provide additional information for responses to questions on Schedule L (see instructions).
Identifier Return Reference Explanation
Schedule L (Form 990 or 990-EZ) 2011

Additional Data


Software ID:  
Software Version:  




SCHEDULE O
(Form 990 or 990-EZ)

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

Complete to provide information for responses to specific questions on
Form 990 or to provide any additional information.
MediumBullet Attach to Form 990 or 990-EZ.
OMB No. 1545-0047
2011
Open to Public
Inspection
Name of the organization
MERCY HEALTH SERVICES - IOWA CORP
 
Employer identification number

31-1373080
Identifier Return Reference Explanation
  FORM 990, PART VI, SECTION A, LINE 3 MERCY HEALTH SERVICES - IOWA, CORP. (MHS-IA) HAS CONTRACTED WITH TATUM, LLC FOR THE PROVISION OF INTERIM CFO SERVICES AT ITS SIOUX CITY FACILITY. SEE SCHEDULE J, PART III FOR ADDITIONAL INFORMATION.
  FORM 990, PART VI, SECTION A, LINE 6 THE SOLE MEMBER OF MERCY HEALTH SERVICES - IOWA, CORP. IS TRINITY HEALTH - MICHIGAN. SEE LINE 7 FOR ADDITIONAL INFORMATION.
  FORM 990, PART VI, SECTION A, LINE 7A TRINITY HEALTH - MICHIGAN IS THE SOLE MEMBER OF MERCY HEALTH SERVICES - IOWA, CORP. TRINITY HEALTH - MICHIGAN HAS THE RIGHT TO APPOINT ALL PERSONS TO THE BOARD OF TRUSTEES OF MERCY HEALTH SERVICES - IOWA, CORP.
  FORM 990, PART VI, SECTION A, LINE 7B AS SOLE MEMBER, TRINITY HEALTH - MICHIGAN MUST APPROVE CERTAIN DECISIONS OF THE GOVERNING BODY, INCLUDING THE STRATEGIC PLAN, ANNUAL CAPITAL PLAN, AND ANNUAL OPERATING BUDGET. TRINITY HEALTH - MICHIGAN MUST ALSO APPROVE SIGNIFICANT CHANGES SUCH AS A MERGER, DISSOLUTION, SALE OF ASSETS IN EXCESS OF CERTAIN LIMITS, A MATERIAL CHANGE IN MISSION, AND MODIFICATIONS TO GOVERNING DOCUMENTS.
  FORM 990, PART VI, SECTION B, LINE 11 PRIOR TO FILING, THE FORM 990 FOR MERCY HEALTH SERVICES - IOWA, CORP. IS REVIEWED BY SENIOR MANAGEMENT. IN ADDITION, CERTAIN KEY SECTIONS ARE REVIEWED BY THE BOARD OF TRUSTEES. THE BOARD RECEIVES A COPY OF THE RETURN IN ITS FINAL FORM BEFORE IT IS FILED WITH THE INTERNAL REVENUE SERVICE.
  FORM 990, PART VI, SECTION B, LINE 12C MERCY HEALTH SERVICES - IOWA, CORP. HAS ADOPTED A CONFLICT OF INTEREST POLICY WHICH CONTAINS THE ELEMENTS IN THE MODEL CONFLICT OF INTEREST POLICY ISSUED BY THE IRS. IT APPLIES TO ALL "INTERESTED PERSONS" OF MERCY HEALTH SERVICES - IOWA, CORP., WHICH INCLUDES TRUSTEES, PRINCIPAL OFFICERS AND EXECUTIVES, AND MEMBERS OF COMMITTEES WITH BOARD DESIGNATED POWERS. INTERESTED PERSONS ARE REQUIRED TO ACT AT ALL TIMES IN A MANNER CONSISTENT WITH MERCY HEALTH SERVICES - IOWA, CORP.'S CHARITABLE PURPOSE AND SERVICE TO THE COMMUNITY AND TO AVOID CONFLICTS OF INTEREST. INTERESTED PERSONS ARE REQUIRED TO MAKE FULL DISCLOSURE TO MERCY HEALTH SERVICES - IOWA, CORP. OF ANY FINANCIAL OR BUSINESS INTERESTS THAT MIGHT RESULT IN OR HAVE THE APPEARANCE OF A CONFLICT OF INTEREST. INTERESTED PERSONS ARE REQUIRED TO RECUSE THEMSELVES FROM DISCUSSION AND VOTING ON MATTERS INVOLVING A CONFLICT OF INTEREST. THE BOARD OF TRUSTEES OF MERCY HEALTH SERVICES - IOWA, CORP. IS RESPONSIBLE FOR THE REVIEW AND APPROVAL OF TRANSACTIONS WITH INTERESTED PERSONS, INCLUDING DETERMINING THAT SUCH TRANSACTIONS ARE FAIR AND REASONABLE TO MERCY HEALTH SERVICES - IOWA, CORP. ON AN ANNUAL BASIS, INTERESTED PERSONS ARE REQUIRED TO COMPLETE A CONFLICT OF INTEREST DISCLOSURE STATEMENT AND TO AFFIRM THEIR RECEIPT OF THE CONFLICT OF INTEREST POLICY, COMPLIANCE WITH ITS REQUIREMENTS, AND AGREE TO NOTIFY THE ORGANIZATION OF CHANGES IMPACTING THEIR ANNUAL DISCLOSURE IN ACCORDANCE WITH THE POLICY. THE ANNUAL DISCLOSURES ARE REVIEWED WITH THE BOARD OF TRUSTEES OF MERCY HEALTH SERVICES - IOWA, CORP. ON AN ANNUAL BASIS.
  FORM 990, PART VI, SECTION B, LINE 15 TRINITY HEALTH FOLLOWS A PROCESS AND POLICY THAT IS INTENDED TO MIRROR THE IRC SECTION 4958 GUIDELINES FOR OBTAINING A "REBUTTABLE PRESUMPTION OF REASONABLENESS" WITH REGARD TO COMPENSATION AND BENEFITS. AS PART OF THAT PROCESS, THE COMPENSATION AND BENEFITS OF CERTAIN OFFICERS AND KEY MANAGEMENT OFFICIALS OF MERCY HEALTH SERVICES - IOWA, CORP. ARE REVIEWED AT LEAST ANNUALLY BY THE TRINITY HEALTH BOARD OR THE TRINITY HEALTH HUMAN RESOURCES AND COMPENSATION COMMITTEE (HRCC) OF THE BOARD, AUTHORIZED TO ACT ON BEHALF OF THE BOARD WITH RESPECT TO CERTAIN COMPENSATION MATTERS. AS PART OF ITS REVIEW PROCESS, THE HRCC RETAINS AN INDEPENDENT FIRM EXPERIENCED IN COMPENSATION AND BENEFIT MATTERS FOR NOT-FOR-PROFIT HEALTHCARE ORGANIZATIONS TO ADVISE IT IN THE DETERMINATIONS IT MAKES ON THE REASONABLENESS OF PROPOSED COMPENSATION AND BENEFITS ARRANGEMENTS.
  FORM 990, PART VI, SECTION C, LINE 19 MERCY HEALTH SERVICES - IOWA, CORP. IS A SUBSIDIARY ORGANIZATION IN THE TRINITY HEALTH SYSTEM. TRINITY HEALTH MAKES CERTAIN OF ITS KEY DOCUMENTS AVAILABLE TO THE PUBLIC ON ITS WEBSITE, WWW.TRINITY-HEALTH.ORG, IN THE "ABOUT US" SECTION. IN THIS SECTION, THE ANNUAL REPORT (WHICH INCLUDES COMMUNITY BENEFIT MINISTRY INFORMATION) AND CONSOLIDATED AUDITED FINANCIAL STATEMENTS ARE PUBLICLY AVAILABLE. IN ADDITION, THE HOSPITAL DIVISIONS OF MHS-IA INCLUDE A COPY OF THEIR MOST RECENT SCHEDULE H ON THEIR RESPECTIVE WEBSITES. TRINITY HEALTH ALSO INCLUDES MHS-IA'S MOST RECENTLY FILED SCHEDULE H ON ITS WEBSITE.
ESTIMATE OF THE AVERAGE HOURS PER WEEK DEVOTED TO RELATED ORGANIZATIONS: FORM 990, PART VII, SECTION A, LINE 1, COLUMN B: THE HOURS LISTED IN COLUMN B OF PART VII, SECTION A, LINE 1 REFLECT ONLY THE INDIVIDUALS' AVERAGE WEEKLY HOURS SPENT DIRECTLY ON THE ACTIVITIES OF THE REPORTING ORGANIZATION. IN ADDITION, THESE ARE THE AVERAGE HOURS PER WEEK DEVOTED TO RELATED ORGANIZATIONS: KEDRICK ADKINS - 50 HOURS JAMES BOSSCHER - 48 HOURS PAUL BROWNE - 45 HOURS DEBRA CANALES - 45 HOURS BENJAMIN CARTER - 45 HOURS PAUL CONLON - 45 HOURS MARIANNE CUNNINGHAM - 43 HOURS LOUIS FIERENS - 45 HOURS PRESTON GEE - 45 HOURS AGNES HAGERTY - 48 HOURS DANIEL HALE - 45 HOURS MICHAEL HOLPER - 45 HOURS MICHAEL MURPHY - 50 HOURS PAUL NEUMANN - 45 HOURS RICHARD O'CONNELL - 50 HOURS TERRENCE O'ROURKE - 45 HOURS JOSEPH SWEDISH - 50 HOURS MARIA SZYMANSKI - 45 HOURS
TRUSTEES: FORM 990, PART VII, SECTION A, LINE 1: SR. SUZANNE BRENNAN, CSC, IS A MEMBER OF THE CONGREGATION OF THE SISTERS OF THE HOLY CROSS. HAVING TAKEN A VOW OF POVERTY, SR. SUZANNE BRENNAN DID NOT RECEIVE COMPENSATION FOR THE SERVICES SHE PROVIDED TO MERCY HEALTH SERVICES - IOWA, CORP. INSTEAD, A TOTAL OF $25,000 WAS PAID BY TRINITY HEALTH CORPORATION DIRECTLY TO THE CONGREGATION OF THE SISTERS OF THE HOLY CROSS FOR SR. SUZANNE BRENNAN'S SERVICES AS A TRUSTEE FOR TRINITY HEALTH CORPORATION, MERCY HEALTH SERVICES - IOWA, CORP. AND TRINITY HEALTH - MICHIGAN. SR. MARY MOLLISON, CSA, IS A MEMBER OF THE CONGREGATION OF SAINT AGNES. HAVING TAKEN A VOW OF POVERTY, SR. MARY MOLLISON DID NOT RECEIVE COMPENSATION FOR THE SERVICES SHE PROVIDED TO MERCY HEALTH SERVICES - IOWA, CORP. INSTEAD, A TOTAL OF $50,000 WAS PAID BY TRINITY HEALTH CORPORATION DIRECTLY TO THE CONGREGATION OF SAINT AGNES FOR SR. MARY MOLLISON'S SERVICES AS BOARD CHAIR FOR TRINITY HEALTH CORPORATION, MERCY HEALTH SERVICES - IOWA, CORP. AND TRINITY HEALTH - MICHIGAN.
CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED LOSSES ON INVESTMENTS: -10,944,582. NET EQUITY TRANSFERS TO AFFILIATES: -9,868,448. EQUITY EARNINGS IN UNCONSOLIDATED AFFILIATES: 13,419,349. OTHER TRANSACTIONS: 950,134. TOTAL TO FORM 990, PART XI, LINE 5: -6,443,547.
  FORM 990, PART XII, LINE 2: MERCY HEALTH SERVICES -IOWA, CORP.'S FINANCIAL STATEMENTS WERE INCLUDED IN THE FY12 CONSOLIDATED FINANCIAL STATEMENTS OF TRINITY HEALTH, WHICH WERE AUDITED BY AN INDEPENDENT PUBLIC ACCOUNTING FIRM.
  FORM 990, PAGE 1, DOING BUSINESS AS NAMES: FOREST PARK PHARMACY, MARIAN HEALTH CENTER, MERCY HEALTH CENTER-DUBUQUE (ST. JOSEPH'S), MERCY HEALTH CENTER-DYERSVILLE (ST. MARY'S), MERCY HOME CARE-NORTH IOWA, MERCY MEDICAL CENTER-DUBUQUE, MERCY MEDICAL CENTER-DYERSVILLE, MERCY MEDICAL CENTER-NEW HAMPTON, MERCY MEDICAL CENTER-NORTH IOWA, MERCY MEDICAL CENTER-SIOUX CITY, NORTH IOWA MERCY HEALTH CENTER, NORTH IOWA MERCY HOME HEALTHCARE, SHEFFIELD PHARMACY, ST. JOSEPH COMMUNITY HOSPITAL
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.
Cat. No. 51056K
Schedule O (Form 990 or 990-EZ) 2011

Additional Data


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

OMB No. 1545-0047
2011
Open to Public Inspection
Name of the organization
MERCY HEALTH SERVICES - IOWA CORP
 
Employer identification number

31-1373080
Part I
Identification of Disregarded Entities (Complete if the organization answered "Yes" on Form 990, Part IV, line 33.)
(a)
Name, address, and EIN of disregarded entity


(b)
Primary activity


 		(c)
Legal domicile (state
or foreign country)

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


 		(f)
Direct controlling
entity

















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


(b)
Primary activity


 		(c)
Legal domicile (state
or foreign country)

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

 		(f)
Direct controlling
entity

 		(g)
Section 512(b)(13) controlled organization
Yes No
(1) ADVANTAGE HEALTHSAINT MARY'S MEDICAL GROUP

245 STATE ST SE

GRAND RAPIDS,MI49503
27-2491974 		HEALTHCARE SERVICES MI 501(C)(3) 9 TRINITY HEALTH-MICHIGAN
 
 
No
(2) AMICARE HOSPICE SERVICES INC

20555 VICTOR PARKWAY

LIVONIA,MI48152
38-2949053 		PROVIDE HOSPICE SERVICES MI 501(C)(3) 11, TYPE I TRINITY HOME HEALTH SERVICES INC
 
 
No
(3) AUXILIARY OF HOLY ROSARY HOSPITAL

351 SW 9TH STREET

ONTARIO,OR97914
94-3059469 		SUPPORTS SERVICES OF RELATED HOSPITAL OR 501(C)(3) 9 SAINT ALPHONSUS MEDICAL CENTER-ONTARIO
 
 
No
(4) BAUM HARMON MERCY HOSPITAL

255 NORTH WELCH AVENUE

PRIMGHAR,IA51245
42-1500277 		ACUTE/AMBULATORY HEALTHCARE SERVICES IA 501(C)(3) 3 MERCY HEALTH SERVICES-IOWA CORP
 
Yes
 
(5) BAUM HARMON MERCY HOSPITAL & CLINICS FOUNDATION

255 NORTH WELCH AVENUE

PRIMGHAR,IA51245
26-2973307 		SUPPORT THE SERVICES OF RELATED HOSPITAL IA 501(C)(3) 11, TYPE I BAUM HARMON MERCY HOSPITAL
 
Yes
 
(6) CATHERINE MCAULEY HEALTH SERVICES CORP

PO BOX 995

ANN ARBOR,MI48106
38-2507173 		FURTHER TRINITY HEALTH ACTIVITIES, ORGANIZE AND DEVELOP MEDICAL SERVICES MI 501(C)(3) 11, TYPE II TRINITY HEALTH-MICHIGAN
 
 
No
(7) COMMUNITY HEALTH PARTNERS OF SOUTH BEND

PO BOX 3998

SOUTH BEND,IN46619
26-3051440 		HEALTHCARE SERVICES IN 501(C)(3) 3 SAINT JOSEPH REGIONAL MEDICAL CENTER INC
 
 
No
(8) CRANBROOK HOSPICE CARE

281 ENTERPRISE COURT

BLOOMFIELD HILLS,MI48302
38-3320699 		PROVIDE HOSPICE HEALTH SERVICES MI 501(C)(3) 11, TYPE I TRINITY HOME HEALTH SERVICES INC
 
 
No
(9) DILEY RIDGE MEDICAL CENTER

6150 EAST BROAD STREET

COLUMBUS,OH43213
34-2032340 		HOSPITAL CAMPUS IN FAIRFIELD COUNTY OHIO OH 501(C)(3) 3 MOUNT CARMEL HEALTH SYSTEM
 
 
No
(10) DUBUQUE MERCY HEALTH FOUNDATION INC

250 MERCY DRIVE

DUBUQUE,IA52001
26-2227941 		SUPPORT THE SERVICES OF RELATED HOSPITAL IA 501(C)(3) 11, TYPE I MERCY HEALTH SERVICES-IOWA CORP
 
Yes
 
(11) DYERSVILLE HEALTH FOUNDATION INC

1111 3RD STREET SW

DYERSVILLE,IA52040
20-5383271 		SUPPORT THE SERVICES OF RELATED HOSPITAL IA 501(C)(3) 11, TYPE I MERCY HEALTH SERVICES-IOWA CORP
 
Yes
 
(12) GOTTLIEB COMMUNITY HEALTH SERVICES CORPORATION

701 W NORTH AVE

MELROSE PARK,IL60160
36-3332852 		SUPPORT THE SERVICES OF RELATED HOSPITAL IL 501(C)(3) 9 GOTTLIEB MEMORIAL HOSPITAL
 
 
No
(13) GOTTLIEB MEMORIAL FOUNDATION

701 W NORTH AVE

MELROSE PARK,IL60160
74-3260011 		SUPPORT THE SERVICES OF RELATED HOSPITAL IL 501(C)(3) 11, TYPE III-FI N/A
 
No
(14) GOTTLIEB MEMORIAL HOSPITAL

701 W NORTH AVE

MELROSE PARK,IL60160
36-2379649 		HEALTHCARE SERVICES IL 501(C)(3) 3 LOYOLA UNIVERSITY HEALTH SYSTEM
 
 
No
(15) HACKLEY HOSPITAL

1700 CLINTON ST PO BOX 3302

MUSKEGON,MI494433302
38-1358196 		HEALTHCARE SERVICES MI 501(C)(3) 3 MERCY HEALTH PARTNERS
 
 
No
(16) HACKLEY HOSPITAL SELF INSURANCE PROFESSIONAL LIABILITY TRUST

PO BOX 3302

MUSKEGON,MI494433302
38-2299878 		SELF INSURANCE FOR GENERAL AND MALPRACTICE LIABILITY MI 501(C)(3) 11, TYPE III-FI MERCY HEALTH PARTNERS
 
 
No
(17) HACKLEY LIFE COUNSELING

1352 TERRACE ST

MUSKEGON,MI494423545
38-1386362 		COUNSELING, EDUCATION, AND SUPPORT MI 501(C)(3) 9 MERCY HEALTH PARTNERS
 
 
No
(18) HACKLEY VISITING NURSE SERVICES AND HOSPICE INC

888 TERRACE ST

MUSKEGON,MI49440
38-1359598 		PROVIDE HOME HEALTH CARE SERVICES MI 501(C)(3) 7 MERCY HEALTH PARTNERS
 
 
No
(19) HOLY CROSS CARENET INC

PO BOX 9184

FARMINGTON HILLS,MI48333
52-1945054 		LONG-TERM CARE AND REHABILITATION FOR THE ELDERLY MD 501(C)(3) 9 TRINITY CONTINUING CARE SERVICES
 
 
No
(20) HOLY CROSS HOSPITAL FOUNDATION INC

11801 TECH ROAD

SILVER SPRING,MD20904
20-8428450 		CHARITABLE FUNDRAISING MD 501(C)(3) 11, TYPE I HOLY CROSS HOSPITAL OF SILVER SPRING
 
 
No
(21) HOLY CROSS HOSPITAL OF SILVER SPRING INC

1500 FOREST GLEN RD

SILVER SPRING,MD209101484
52-0738041 		HEALTHCARE SERVICES MD 501(C)(3) 3 TRINITY HEALTH CORPORATION
 
 
No
(22) HOLY CROSS MEDICAL CENTER

20555 VICTOR PARKWAY

LIVONIA,MI48152
95-1985442 		HEALTHCARE SERVICES (FORMERLY) CA 501(C)(3) 3 TRINITY HEALTH CORPORATION
 
 
No
(23) HOSPICE OF NORTH IOWA

232 SECOND STREET SE

MASON CITY,IA504016208
42-1173708 		HOSPICE HEALTH CARE SERVICES IA 501(C)(3) 7 MERCY HEALTH SERVICES-IOWA CORP
 
Yes
 
(24) HOSPICE OF WASHTENAW II

806 AIRPORT BLVD

ANN ARBOR,MI48108
38-3320707 		HOSPICE HEALTH CARE SERVICES MI 501(C)(3) 11, TYPE I TRINITY HEALTH-MICHIGAN
 
 
No
(25) HPCN

1675 LEAHY STREET

MUSKEGON,MI49442
30-0207909 		HEALTHCARE SERVICES MI 501(C)(3) 11, TYPE II MERCY HEALTH PARTNERS
 
 
No
(26) IHA HEALTH SERVICES CORPORATION

24 FRANK LLOYD WRIGHT DR LOBBY J

ANN ARBOR,MI48106
38-3316559 		PROVIDES OFFICE-BASED MEDICAL CARE MI 501(C)(3) 9 TRINITY HEALTH-MICHIGAN
 
 
No
(27) LAKESHORE COMMUNITY HOSPITAL INC

72 S STATE STREET

SHELBY,MI494551228
38-2549295 		ACUTE HEALTHCARE SERVICES MI 501(C)(3) 3 MERCY HEALTH PARTNERS
 
 
No
(28) LOYOLA UNIVERSITY HEALTH SYSTEM

2160 SOUTH FIRST AVENUE

MAYWOOD,IL60153
36-3342448 		HEALTHCARE SYSTEM MANAGEMENT AND SUPPORT IL 501(C)(3) 11, TYPE II TRINITY HEALTH CORPORATION
 
 
No
(29) LOYOLA UNIVERSITY MEDICAL CENTER

2160 SOUTH FIRST AVENUE

MAYWOOD,IL60153
36-4015560 		HEALTHCARE SERVICES IL 501(C)(3) 3 LOYOLA UNIVERSITY HEALTH SYSTEM
 
 
No
(30) MARIAN HOME HEALTHCARE

801 5TH STREET

SIOUX CITY,IA51101
38-3320705 		PROVIDE HOME HEALTH CARE SERVICES IA 501(C)(3) 11, TYPE I MERCY HEALTH SERVICES-IOWA CORP
 
Yes
 
(31) MCAULEY CLINIC CORPORATION

PO BOX 992

ANN ARBOR,MI48106
38-2561013 		HEALTHCARE SERVICES (FORMERLY) MI 501(C)(3) 3 CATHERINE MCAULEY HEALTH SERVICES CORP
 
 
No
(32) MERCY AMICARE HOME HEALTHCARE OAKLAND

281 ENTERPRISE COURT

BLOOMFIELD HILLS,MI483020312
38-3320698 		PROVIDE HOME HEALTH CARE SERVICES MI 501(C)(3) 11, TYPE I TRINITY HOME HEALTH SERVICES INC
 
 
No
(33) MERCY AMICARE HOME HEALTHCARE PORT HURON

505 HURON AVENUE

PORT HURON,MI48060
38-3320701 		PROVIDE HOME HEALTH CARE SERVICES MI 501(C)(3) 11, TYPE I TRINITY HOME HEALTH SERVICES INC
 
 
No
(34) MERCY FOUNDATION INC

2525 SOUTH MICHIGAN AVENUE

CHICAGO,IL60616
36-3227350 		SUPPORTS THE SERVICES OF RELATED HEALTH CARE SYSTEM IL 501(C)(3) 11, TYPE I MERCY HEALTH SYSTEM OF CHICAGO
 
 
No
(35) MERCY GENERAL HEALTH PARTNERS AMICARE HOMECARE

684 HARVEY STREET

MUSKEGON,MI49442
38-3321856 		PROVIDE HOME HEALTH CARE SERVICES MI 501(C)(3) 11, TYPE I TRINITY HOME HEALTH SERVICES INC
 
 
No
(36) MERCY HEALTH PARTNERS

1415 LEAHY STREET

MUSKEGON,MI49442
38-2589966 		HEALTHCARE SYSTEM SUPPORT MI 501(C)(3) 11, TYPE I TRINITY HEALTH-MICHIGAN
 
 
No
(37) MERCY HEALTH SERVICES - IOWA CORP

1000 4TH STREET SW

MASON CITY,IA50401
31-1373080 		HEALTHCARE SERVICES DE 501(C)(3) 3 TRINITY HEALTH-MICHIGAN
 
Yes
 
(38) MERCY HEALTH SYSTEM OF CHICAGO

2525 SOUTH MICHIGAN AVENUE

CHICAGO,IL60616
36-3163327 		HEALTHCARE SYSTEM MANAGEMENT AND SUPPORT IL 501(C)(3) 11, TYPE I TRINITY HEALTH CORPORATION
 
 
No
(39) MERCY HEALTH SYSTEM OF CHICAGO LIABILITY SELF INSURANCE TRUST

BK OF AMERICA 231 S LASALLE

CHICAGO,IL60697
91-2092113 		SELF INSURANCE FOR PROFESSIONAL AND COMPREHENSIVE LIABILITY IL 501(C)(3) 11, TYPE III-FI MERCY HEALTH SYSTEM OF CHICAGO
 
 
No
(40) MERCY HEALTHCARE FOUNDATION

1410 N 4TH ST

CLINTON,IA52732
42-1316126 		FUNDRAISING AND FINANCIAL ASSISTANCE FOR HOSPITAL CHARITABLE SERVICES IA 501(C)(3) 11, TYPE I MERCY MEDICAL CENTER-CLINTON
 
Yes
 
(41) MERCY HOSPITAL AND MEDICAL CENTER

2525 SOUTH MICHIGAN AVENUE

CHICAGO,IL60616
36-2170152 		HEALTHCARE SERVICES IL 501(C)(3) 3 MERCY HEALTH SYSTEM OF CHICAGO
 
 
No
(42) MERCY HOSPITAL CADILLAC FOUNDATION

400 HOBART

CADILLAC,MI496012331
20-3357131 		SUPPORT THE SERVICES OF RELATED HOSPITAL MI 501(C)(3) 11, TYPE I TRINITY HEALTH-MICHIGAN
 
 
No
(43) MERCY HOSPITAL GIFT SHOP

2601 ELECTRIC AVE

PORT HURON,MI48060
38-1630480 		VOLUNTEER SERVICE AUXILIARY MI 501(C)(3) 11, TYPE I TRINITY HEALTH-MICHIGAN
 
 
No
(44) MERCY MEDICAL CENTER - CLINTON INC

1410 NORTH 4TH ST

CLINTON,IA527322940
42-1336618 		TO PROVIDE QUALITY HEALTH CARE DE 501(C)(3) 3 MERCY HEALTH SERVICES-IOWA CORP
 
Yes
 
(45) MERCY MEDICAL CENTER - SIOUX CITY FOUNDATION

801 5TH STREET

SIOUX CITY,IA51102
14-1880022 		SUPPORT THE SERVICES OF RELATED HOSPITAL IA 501(C)(3) 7 MERCY HEALTH SERVICES-IOWA CORP
 
Yes
 
(46) MERCY MEDICAL CENTER FOUNDATION - NORTH IOWA

1000 4TH STREET SW

MASON CITY,IA504012800
42-1229151 		SUPPORT THE SERVICES OF RELATED HOSPITAL IA 501(C)(3) 11, TYPE III-FI N/A
 
No
(47) MERCY NORTH HOMECARE AND HOSPICE

7985 MACKINAW TRAIL

CADILLAC,MI49601
38-3313897 		HOME HEALTH AND HOSPICE SERVICES MI 501(C)(3) 11, TYPE I TRINITY HOME HEALTH SERVICES INC
 
 
No
(48) MERCY PHYSICIAN GROUP INC

1512 12TH AVENUE ROAD

NAMPA,ID83686
20-8192593 		TO PROVIDE QUALITY HEALTH CARE ID 501(C)(3) 9 SAINT ALPHONSUS MEDICAL CENTER-NAMPA
 
 
No
(49) MERCY SERVICES FOR AGING NON-PROFIT HOUSING CORPORATION

PO BOX 9184

FARMINGTON HILLS,MI483339184
38-2719605 		PROVIDES LONG-TERM CARE FOR THE ELDERLY MI 501(C)(3) 11, TYPE II TRINITY CONTINUING CARE SERVICES INC
 
 
No
(50) MIDWEST MEDFLIGHT

1300 VICTORS WAY

ANN ARBOR,MI48108
38-2684671 		AEROMEDICAL TRANSPORT MI 501(C)(3) 9 TRINITY HEALTH-MICHIGAN
 
 
No
(51) MOUNT CARMEL CARE CONTINUUM SERVICES CORP

793 WEST STATE STREET

COLUMBUS,OH43222
31-1126211 		COOPERATIVE HOSPITAL SERVICE ORGANIZATION OH 501(C)(3) 3 MOUNT CARMEL HEALTH SYSTEM
 
 
No
(52) MOUNT CARMEL COLLEGE OF NURSING

6150 EAST BROAD STREET

COLUMBUS,OH43213
31-1308555 		COLLEGE OF NURSING OH 501(C)(3) 2 MOUNT CARMEL HEALTH
 
 
No
(53) MOUNT CARMEL HEALTH

6150 EAST BROAD STREET

COLUMBUS,OH43213
31-4379602 		HEALTHCARE SERVICES OH 501(C)(3) 3 MOUNT CARMEL HEALTH SYSTEM
 
 
No
(54) MOUNT CARMEL HEALTH INSURANCE COMPANY

6150 EAST BROAD STREET

COLUMBUS,OH43213
25-1912781 		HEALTH INSURANCE OH 501(C)(4) N/A MOUNT CARMEL HEALTH SYSTEM
 
 
No
(55) MOUNT CARMEL HEALTH PLAN INC

6150 EAST BROAD STREET

COLUMBUS,OH43213
31-1471229 		MEDICARE HMO FOR SENIORS OH 501(C)(4) N/A MOUNT CARMEL HEALTH SYSTEM
 
 
No
(56) MOUNT CARMEL HEALTH SYSTEM

6150 EAST BROAD STREET

COLUMBUS,OH43213
31-1439334 		HEALTHCARE SYSTEM MANAGEMENT AND SUPPORT OH 501(C)(3) 11, TYPE I TRINITY HEALTH CORPORATION
 
 
No
(57) MOUNT CARMEL HEALTH SYSTEM FOUNDATION

6150 EAST BROAD STREET

COLUMBUS,OH43213
31-1113966 		SUPPORT THE SERVICES OF RELATED HOSPITAL OH 501(C)(3) 11, TYPE I MOUNT CARMEL HEALTH SYSTEM
 
 
No
(58) MOUNT CARMEL HOME CARE LLC

1144 DUBLIN ROAD SUITE B

COLUMBUS,OH43215
26-2729300 		PROVIDE HOME HEALTH CARE SERVICES OH 501(C)(3) 9 TRINITY HOME HEALTH SERVICES INC
 
 
No
(59) MOUNT CARMEL NEW ALBANY SURGICAL HOSPITAL

7333 SMITHS MILL RD

NEW ALBANY,OH43054
87-0790288 		HEALTHCARE SERVICES OH 501(C)(3) 3 MOUNT CARMEL HEALTH SYSTEM
 
 
No
(60) MRI MOBILE SERVICES OF WEST MICHIGAN

1820 - 44TH STREET

KENTWOOD,MI49508
38-3073745 		OPERATE MAGNETIC IMAGING RESONANCE (FORMERLY) MI 501(C)(3) 9 TRINITY HEALTH-MICHIGAN
 
 
No
(61) MUSKEGON COMMUNITY HEALTH PROJECT

565 W WESTERN AVENUE

MUSKEGON,MI49440
91-1932918 		FACILITATE AND COORDINATE HEALTHCARE AND RELATED SERVICES MI 501(C)(3) 7 MERCY HEALTH PARTNERS
 
 
No
(62) OAKLAND MERCY HOSPITAL

601 EAST 2ND STREET

OAKLAND,NE68045
20-8072234 		HEALTHCARE SERVICES NE 501(C)(3) 3 MERCY HEALTH SERVICES-IOWA CORP
 
Yes
 
(63) OAKLAND MERCY HOSPITAL FOUNDATION

601 E 2ND STREET

OAKLAND,NE68045
31-1678345 		SUPPORTS SERVICES OF RELATED HOSPITAL NE 501(C)(3) 11, TYPE III-FI OAKLAND MERCY HOSPITAL
 
Yes
 
(64) PORT HURON MERCY FAMILY CARE INC

2601 ELECTRIC AVE

PORT HURON,MI48060
20-1855647 		HEALTHCARE SERVICES MI 501(C)(3) 11, TYPE I TRINITY HEALTH-MICHIGAN
 
 
No
(65) PROFESSIONAL MED TEAM

965 FORK STREET

MUSKEGON,MI494423257
38-2638284 		MEDICAL CARE, TRANSPORTATION AND EDUCATION MI 501(C)(3) 9 TRINITY HEALTH-MICHIGAN
 
 
No
(66) PROFESSIONAL OFFICE CORPORATION

1303 EAST HERNDON AVE

FRESNO,CA93720
94-2839324 		HEALTHCARE SERVICES CA 501(C)(3) 11, TYPE I SAINT AGNES MEDICAL CENTER
 
 
No
(67) SAINT AGNES MEDICAL CENTER

1303 EAST HERNDON AVE

FRESNO,CA93720
94-1437713 		HEALTHCARE SERVICES CA 501(C)(3) 3 TRINITY HEALTH CORPORATION
 
 
No
(68) SAINT ALPHONSUS BUILDING COMPANY INC

1055 NORTH CURTIS RD

BOISE,ID83706
82-0401011 		SUPPORTS SERVICES OF RELATED HOSPITAL ID 501(C)(3) 11, TYPE I SAINT ALPHONSUS REGIONAL MEDICAL CENTER INC
 
 
No
(69) SAINT ALPHONSUS DIVERSIFIED CARE INC

1055 NORTH CURTIS RD

BOISE,ID83706
94-3028978 		SUPPORTS SERVICES OF RELATED HOSPITAL ID 501(C)(3) 11, TYPE I SAINT ALPHONSUS REGIONAL MEDICAL CENTER INC
 
 
No
(70) SAINT ALPHONSUS FOUNDATION-BAKER CITY INC

3325 POCAHONTAS ROAD

BAKER CITY,OR97814
94-3164869 		SUPPORT THE SERVICES OF RELATED HOSPITAL OR 501(C)(3) 7 SAINT ALPHONSUS MEDICAL CENTER - BAKER CITY
 
 
No
(71) SAINT ALPHONSUS FOUNDATION-ONTARIO INC

351 SW 9TH STREET

ONTARIO,OR97914
20-2683560 		SUPPORT THE SERVICES OF RELATED HOSPITAL OR 501(C)(3) 11, TYPE I SAINT ALPHONSUS MEDICAL CENTER-ONTARIO
 
 
No
(72) SAINT ALPHONSUS HEALTH SYSTEM INC

1055 N CURTIS ROAD

BOISE,ID83706
27-1929502 		HEALTHCARE SYSTEM MANAGEMENT AND SUPPORT ID 501(C)(3) 11, TYPE I TRINITY HEALTH CORPORATION
 
 
No
(73) SAINT ALPHONSUS MEDICAL CENTER-BAKER CITY

3325 POCAHONTAS ROAD

BAKER CITY,OR97814
27-1790052 		TO PROVIDE QUALITY HEALTH CARE OR 501(C)(3) 3 SAINT ALPHONSUS HEALTH SYSTEM INC
 
 
No
(74) SAINT ALPHONSUS MEDICAL CENTER-NAMPA

1512 12TH AVENUE ROAD

NAMPA,ID83686
82-0200896 		TO PROVIDE QUALITY HEALTH CARE ID 501(C)(3) 3 SAINT ALPHONSUS HEALTH SYSTEM INC
 
 
No
(75) SAINT ALPHONSUS MEDICAL CENTER-NAMPA HEALTH FOUNDATION INC

1512 12TH AVENUE ROAD

NAMPA,ID83686
26-1737256 		SUPPORT THE SERVICES OF RELATED HOSPITAL ID 501(C)(3) 7 SAINT ALPHONSUS MEDICAL CENTER-NAMPA
 
 
No
(76) SAINT ALPHONSUS MEDICAL CENTER-ONTARIO

351 SW 9TH STREET

ONTARIO,OR97914
27-1789847 		TO PROVIDE QUALITY HEALTH CARE OR 501(C)(3) 3 SAINT ALPHONSUS HEALTH SYSTEM INC
 
 
No
(77) SAINT ALPHONSUS REGIONAL MEDICAL CENTER

1055 NORTH CURTIS RD

BOISE,ID83706
82-0200895 		HEALTHCARE SERVICES ID 501(C)(3) 3 SAINT ALPHONSUS HEALTH SYSTEM INC
 
 
No
(78) SAINT JOSEPH REGIONAL MEDICAL CENTER - PLYMOUTH CAMPUS INC

1915 LAKE AVENUE PO BOX 670

PLYMOUTH,IN46563
35-1142669 		HEALTHCARE SERVICES IN 501(C)(3) 3 SAINT JOSEPH REGIONAL MEDICAL CENTER INC
 
 
No
(79) SAINT JOSEPH REGIONAL MEDICAL CENTER - SOUTH BEND CAMPUS INC

PO BOX 1935

SOUTH BEND,IN466341935
35-0868157 		HEALTHCARE SERVICES IN 501(C)(3) 3 SAINT JOSEPH REGIONAL MEDICAL CENTER INC
 
 
No
(80) SAINT JOSEPH REGIONAL MEDICAL CENTER MISHAWAKA AUXILIARY INC

5215 HOLY CROSS PARKWAY

MISHAWAKA,IN46545
35-6033285 		HOSPITAL SERVICE AUXILIARY IN 501(C)(4) N/A SAINT JOSEPH REGIONAL MEDICAL CENTER-S BEND
 
 
No
(81) SAINT JOSEPH REGIONAL MEDICAL CENTER PLYMOUTH AUXILIARY INC

1915 LAKE AVENUE

PLYMOUTH,IN46563
35-6043563 		HOSPITAL SERVICE AUXILIARY IN 501(C)(3) 11, TYPE II SAINT JOSEPH REGIONAL MEDICAL CENTER-PLYMOUTH
 
 
No
(82) SAINT JOSEPH REGIONAL MEDICAL CENTER INC

801 EAST LASALLE AVE

SOUTH BEND,IN46617
35-1568821 		HEALTHCARE SYSTEM MANAGEMENT AND SUPPORT IN 501(C)(3) 11, TYPE I TRINITY HEALTH CORPORATION
 
 
No
(83) SAINT JOSEPH'S TOWER INC

PO BOX 9184

FARMINGTON HILLS,MI483339184
31-1040468 		PROVIDES HOUSING FOR LOW INCOME ELDERLY INDIVIDUALS IN 501(C)(3) 9 TRINITY CONTINUING CARE SERVICES-INDIANA
 
 
No
(84) SAINT MARY'S AMICARE HOME HEALTHCARE

1430 MONROE NW

GRAND RAPIDS,MI49505
38-3320700 		PROVIDE HOME HEALTH CARE SERVICES MI 501(C)(3) 11, TYPE I TRINITY HOME HEALTH SERVICES INC
 
 
No
(85) SAINT MARY'S FOUNDATION (FKA SAINT MARY'S DORAN FOUNDATION)

200 JEFFERSON ST SE

GRAND RAPIDS,MI49503
38-1779602 		SUPPORTS SERVICES OF RELATED HOSPITAL MI 501(C)(3) 7 TRINITY HEALTH-MICHIGAN
 
 
No
(86) ST JOSEPH MERCY OAKLAND FOUNDATION

44405 WOODWARD AVE

PONTIAC,MI48341
35-2356789 		SUPPORTS SERVICES OF RELATED HOSPITAL MI 501(C)(3) 11, TYPE I TRINITY HEALTH-MICHIGAN
 
 
No
(87) ST ANN'S HOSPITAL

500 SOUTH CLEVELAND AVE

WESTERVILLE,OH43081
31-4412701 		HEALTHCARE SERVICES OH 501(C)(3) 3 MOUNT CARMEL HEALTH SYSTEM
 
 
No
(88) THE FOUNDATION OF SAINT JOSEPH REGIONAL MEDICAL CENTER

4215 EDISON LAKES PARKWAY

MISHAWAKA,IN46545
35-1654543 		SUPPORTS SERVICES OF RELATED HOSPITAL IN 501(C)(3) 11, TYPE I SAINT JOSEPH REGIONAL MEDICAL CENTER INC
 
 
No
(89) TRI-HOSPITAL MRI CENTER

4190 24TH AVENUE

FORT GRATIOT,MI48054
38-2884297 		MRI SERVICES MI 501(C)(3) 3 TRINITY HEALTH-MICHIGAN
 
 
No
(90) TRINITY CONTINUING CARE SERVICES

PO BOX 9184

FARMINGTON HILLS,MI483339184
38-2559656 		MANAGEMENT SERVICES FOR LONG TERM CARE AND SENIOR LIVING FACILITIES MI 501(C)(3) 11, TYPE I TRINITY HEALTH CORPORATION
 
 
No
(91) TRINITY CONTINUING CARE SERVICES - INDIANA INC

PO BOX 9184

FARMINGTON HILLS,MI483339184
93-0907047 		PROVIDES LONG-TERM CARE AND RESIDENTIAL HOUSING IN 501(C)(3) 9 TRINITY CONTINUING CARE SERVICES
 
 
No
(92) TRINITY HEALTH - MICHIGAN

20555 VICTOR PARKWAY

LIVONIA,MI48152
38-2113393 		HEALTHCARE SERVICES MI 501(C)(3) 3 TRINITY HEALTH CORPORATION
 
 
No
(93) TRINITY HEALTH CORPORATION

20555 VICTOR PARKWAY

LIVONIA,MI48152
35-1443425 		HEALTHCARE SYSTEM MANAGEMENT AND SUPPORT IN 501(C)(3) 11, TYPE I N/A
 
No
(94) TRINITY HEALTH INTERNATIONAL

20555 VICTOR PARKWAY

LIVONIA,MI48152
42-1253527 		HEALTHCARE TRAINING AND SUPPORT SERVICES MI 501(C)(3) 11, TYPE I TRINITY HEALTH CORPORATION
 
 
No
(95) TRINITY HEALTH WELFARE BENEFIT TRUST

20555 VICTOR PARKWAY

LIVONIA,MI48152
20-8151733 		RETIREE MEDICAL AND RETIREE LIFE INSURANCE COVERAGE MI 501(C)(9) N/A TRINITY HEALTH CORPORATION
 
 
No
(96) TRINITY HOME HEALTH SERVICES INC

17410 COLLEGE PARKWAY

LIVONIA,MI48152
38-2621935 		HOME HEALTH CARE SYSTEM MANAGEMENT SERVICES MI 501(C)(3) 11, TYPE I TRINITY HEALTH CORPORATION
 
 
No
For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50135Y
Schedule R (Form 990) 2011
Schedule R (Form 990) 2011
Page 2
Part III
Identification of Related Organizations Taxable as a Partnership (Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related organizations treated as a partnership during the tax year.)
(a)
Name, address, and EIN of
related organization



 		(b)
Primary activity




 		(c)
Legal
domicile
(state or foreign
country)


 		(d)
Direct controlling
entity



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

(f)
Share of total income




 		(g)
Share of end-of-year
assets



 		(h)
Disproprtionate allocations?




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



 		(k)
Percentage
ownership
Yes No Yes No
(1) ADVENT REHABILITATION LLC

607 DEWEY AVENUE SUITE 300
GRAND RAPIDS,MI49504
38-3306673 		REHABILITATION THERAPY SERVICES MI N/A
 N/A       No     No  
(2) BIG RUN MEDICAL OFFICE BUILDING LIMITED PARTNERSHIP

793 W STATE STREET
COLUMBUS,OH43222
31-1608125 		MEDICAL OFFICE BUILDING RENTAL OH N/A
 N/A       No     No  
(3) CENTER FOR DIGESTIVE CARE LLC

5300 ELLIOTT DRIVE
YPSILANTI,MI48197
03-0447062 		PROVIDE GASTROINTESTINAL SERVICES MI N/A
 N/A       No     No  
(4) CENTRAL OHIO SLEEP MEDICINE LTD

6150 EAST BROAD STREET
COLUMBUS,OH43213
31-1701029 		SLEEP MEDICINE SERVICES OH N/A
 N/A       No     No  
(5) CLINTON IMAGING SERVICES LLC

615 VALLEY VIEW DR STE 202
MOLINE,IL61265
41-2044739 		MRI DIAGNOSTIC SERVICES IA N/A
 N/A       No     No  
(6) FOREST PARK IMAGING LLC

1000 4TH STREET SW
MASON CITY,IA50401
13-4365966 		X-RAY AND MAMMOGRAPHY SERVICES IA MERCY HEALTH SERVICES-IOWA CORP
  		RELATED 1,123,059 269,599   No   Yes   52.889 %
(7) FRANCES WARDE MEDICAL LABORATORY

300 WEST TEXTILE ROAD
ANN ARBOR,MI48104
38-2648446 		LABORATORY MI N/A
 N/A       No     No  
(8) FRESNO IMAGING CENTER

1303 E HERNDON AVE
FRESNO,CA93720
77-0363563 		DIAGNOSTIC IMAGING CA N/A
 N/A       No     No  
(9) HAWARDEN REGIONAL HEALTH CLINICS LLC

1122 AVENUE L
HAWARDEN,IA51023
20-1444339 		MEDICAL CLINIC IA N/A
 N/A       No     No  
(10) IDAHO GYNONCOLOGY SERVICES LLC

1055 N CURTIS RD
BOISE,ID83706
20-2975807 		PROVIDE GYN ONCOLOGY SERVICES ID N/A
 N/A       No     No  
(11) INTERMOUNTAIN MEDICAL IMAGING LLC

877 WEST MAIN ST STE 603
BOISE,ID83702
82-0514422 		PROVIDE IMAGING SERVICES ID N/A
 N/A       No     No  
(12) LOYOLA AMBULATORY SURGERY CENTER

1S224 SUMMIT AVE STE 201
OAKBROOK TERRACE,IL60181
36-4119522 		SURGICAL SERVICES IL N/A
 N/A       No     No  
(13) MAGNETIC RESONANCE SERVICES PARTNERSHIP

1416 SIXTH STREET SW
MASON CITY,IA50401
42-1328388 		MRI SERVICES IA MERCY HEALTH SERVICES-IOWA CORP
  		RELATED 1,245,469 5,028   No   Yes   49.000 %
(14) MASON CITY AMBULATORY SURGERY CENTER LLC

990 4TH STREET SW
MASON CITY,IA50401
20-1960348 		SURGERY-SAME DAY IA MERCY HEALTH SERVICES-IOWA CORP
  		RELATED 2,380,446 2,662,567   No   Yes   51.000 %
(15) MCE MOB IV LIMITED PARTNERSHIP

793 W STATE STREET
COLUMBUS,OH43222
42-1544707 		MEDICAL OFFICE BUILDING RENTAL OH N/A
 N/A       No     No  
(16) MCMC POB III LIMITED PARTNERSHIP

793 W STATE STREET
COLUMBUS,OH43222
31-1392994 		MEDICAL OFFICE BUILDING RENTAL OH N/A
 N/A       No     No  
(17) MEDILUCENT MOB I

793 W STATE STREET
COLUMBUS,OH43222
20-4911370 		MEDICAL OFFICE BUILDING RENTAL OH N/A
 N/A       No     No  
(18) MERCY ADVANCED MRI LLC

2525 SOUTH MICHIGAN AVE
CHICAGO,IL60616
26-2116721 		SUBLEASE MRI EQUIPMENT IL N/A
 N/A       No     No  
(19) MERCY HEART & VASCULAR LLC

2525 SOUTH MICHIGAN AVE
CHICAGO,IL60616
20-5272726 		SUBLEASE CT EQUIPMENT IL N/A
 N/A       No     No  
(20) MERCY HEART CTR OP SERVICES LLC

1000 4TH STREET SW
MASON CITY,IA50401
13-4237594 		CARDIOVASCULAR SERVICES IA MERCY HEALTH SERVICES-IOWA CORP
  		RELATED 1,090,332 1,063,252   No     No 51.000 %
(21) MERCY OUTPATIENT SURGERY CENTER LLC

1512 12TH AVENUE ROAD
NAMPA,ID83686
84-1380439 		OUTPATIENT SURGERY ID N/A
 N/A       No     No  
(22) MICHIANA HEALTH INFORMATION NETWORK LLC

215 WEST MADISON STREET
SOUTH BEND,IN46601
35-2050128 		COMMUNITY BASED CLINICAL INFO SYS & DATA DEPOSITORY IN N/A
 N/A       No     No  
(23) MOUNT CARMEL EAST POB III LIMITED PARTNERSHIP

793 W STATE STREET
COLUMBUS,OH43222
31-1369473 		MEDICAL OFFICE BUILDING RENTAL OH N/A
 N/A       No     No  
(24) NEWCO AMBULATORY SURGERY CTR LLP

4190 24TH AVENUE
FORT GRATIOT,MI48059
30-0136708 		OUTPATIENT SURGERY CENTER MI N/A
 N/A       No     No  
(25) RIVERVIEW MEDICAL OFFICE BUILDING LIMITED PARTNERSHIP

793 W STATE STREET
COLUMBUS,OH43222
31-1531135 		MEDICAL OFFICE BUILDING RENTAL OH N/A
 N/A       No     No  
(26) SARMED OUTPATIENT PHARMACY LLC

999 N CURTIS RD STE 102
BOISE,ID83706
51-0483218 		PHARMACY ID N/A
 N/A       No     No  
(27) SIXTY FOURTH STREET LLC

2373 64TH ST STE 2200
BYRON CENTER,MI49315
20-2443646 		PROVIDE OUTPATIENT SURGICAL CARE MI N/A
 N/A       No     No  
(28) ST ALPHONSUS CALDWELL CANCER CTR LLC

3123 MEDICAL DR
CALDWELL,ID83605
82-0526861 		RADIATION ONCOLOGY ID N/A
 N/A       No     No  
(29) ST ANN'S MEDICAL OFFICE BLDG II LIMITED PARTNERSHIP

793 W STATE STREET
COLUMBUS,OH43222
31-1603660 		MEDICAL OFFICE BUILDING RENTAL OH N/A
 N/A       No     No  
(30) TAMARACK MEDICAL CLINIC LLC

610 VILLAGE DRIVE
DONNELLY,ID83615
20-1637921 		OUTPATIENT MEDICAL SERVICES ID N/A
 N/A       No     No  
(31) WESTAR MEDICAL OFFICE BUILDING LIMITED PARTNERSHIP

793 W STATE STREET
COLUMBUS,OH43222
31-1784409 		MEDICAL OFFICE BUILDING RENTAL OH N/A
 N/A       No     No  
(32) WOODLAND IMAGING CENTER LLC

5301 E HURON RIVER DR
ANN ARBOR,MI48106
76-0820959 		RADIOLOGY/IMAGING MI N/A
 N/A       No     No  
Part IV
Identification of Related Organizations Taxable as a Corporation or Trust (Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related organizations treated as a corporation or trust during the tax year.)
(a)
Name, address, and EIN of related organization



 		(b)
Primary activity



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


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

 		(f)
Share of total income



 		(g)
Share of
end-of-year
assets

 		(h)
Percentage
ownership
(1) COMMUNITY HEALTH VENTURES INC
565 W WESTERN AVE
MUSKEGON,MI49440
38-3522260 		SOFTWARE MARKETING MI N/A
 C      
(2) GOTTLIEB MANAGEMENT SERVICES INC
701 W NORTH AVE
MELROSE PARK,IL60160
36-3330529 		MANAGEMENT SERVICES IL N/A
 C      
(3) HACKLEY HEALTH MANAGEMENT CENTER
1415 LEAHY ST
MUSKEGON,MI49442
38-2961814 		WEIGHT MANAGEMENT MI N/A
 C      
(4) HACKLEY HEALTH VENTURES INC
1415 LEAHY ST
MUSKEGON,MI49442
38-2589959 		OTHER MEDICAL SERVICES MI N/A
 C      
(5) HACKLEY HEALTHCARE EQUIPMENT
1415 LEAHY ST
MUSKEGON,MI49442
38-2578569 		HOME MEDICAL EQUIPMENT MI N/A
 C      
(6) HACKLEY PROFESSIONAL CENTER
1415 LEAHY ST
MUSKEGON,MI49442
38-3024797 		REAL ESTATE RENTAL MI N/A
 C      
(7) HACKLEY PROFESSIONAL PHARMACY
1415 LEAHY ST
MUSKEGON,MI49442
38-2447870 		PHARMACY MI N/A
 C      
(8) HEF INC
1415 LEAHY ST
MUSKEGON,MI49442
38-3086401 		OFFICE STAFFING MI N/A
 C      
(9) HOLY CROSS PRIVATE HOME SERVICES CORP
11801 TECH ROAD
SILVER SPRING,MD20904
52-1986562 		HOME CARE SERVICES MD N/A
 C      
(10) HPC CO-OWNERS ASSOCIATION
1700 CLINTON
MUSKEGON,MI49442
27-0734448 		CONDOMINIUM ASSOCIATION MI N/A
 C      
(11) HURON ARBOR CORPORATION
5301 EAST HURON RIVER DR PO BOX 992
ANN ARBOR,MI48106
38-2475644 		PROVIDES OFFICE RENTAL SPACE MI N/A
 C      
(12) IHA AFFILIATION CORPORATION
24 FRANK LLOYD WRIGHT DR LOBBY J
ANN ARBOR,MI48106
38-3188895 		MEDICAL MANAGEMENT MI N/A
 C      
(13) LOYOLA UNIVERSITY OF CHICAGO INSURANCE CO LTD
23 LIME TREE BAY AVENUE
GRAND CAYMAN    
CJ
PROVISION OF INSURANCE COVERAGE CJ N/A
 C      
(14) MARYLAND CARE GROUP INC
11801 TECH ROAD
SILVER SPRING,MD20904
52-1815313 		HEALTHCARE HOLDING MD N/A
 C      
(15) MEDNOW INC
1512 12TH AVENUE ROAD
NAMPA,ID83686
82-0389927 		OUTPATIENT PHARMACY ID N/A
 C      
(16) MERCY MEDICAL SERVICES
801 5TH STREET
SIOUX CITY,IA51101
42-1283849 		PRIMARY CARE PHYSICIANS IA MERCY HEALTH SERVICES - IOWA CORP
  		C -7,419,788 11,809,222 100.000 %
(17) MERCY SERVICES CORPORATION
2525 SOUTH MICHIGAN AVENUE
CHICAGO,IL60616
36-3227348 		DORMANT IL N/A
 C      
(18) MICHIGAN ATHLETIC CLUB
2500 BURTON
GRAND RAPIDS,MI49546
38-2647304 		ATHLETIC CLUB MI N/A
 C      
(19) MOUNT CARMEL BEHAVIORAL HEALTHCARE SERVICES INC
6150 EAST BROAD STREET
COLUMBUS,OH43213
31-0971510 		BEHAVIORAL HEALTHCARE SERVICES OH N/A
 C      
(20) MOUNT CARMEL HEALTH PROVIDERS INC
6150 EAST BROAD STREET
COLUMBUS,OH43213
31-1382442 		MEDICAL SERVICES OH N/A
 C      
(21) NORTH IOWA MERCY MEDICAL SERVICES INC
1000 4TH ST SW
MASON CITY,IA50401
42-1382308 		MEDICAL SERVICES IA MERCY HEALTH SERVICES - IOWA CORP
  		C     100.000 %
(22) PRIORITY PLUS OF CALIFORNIA
PO BOX 27230
FRESNO,CA93729
77-0395267 		FORMERLY HLTH MGMT NOW DISCONTINUED OPERATIONS CA N/A
 C      
(23) SAINT ALPHONSUS PHYSICIANS PA
1055 NORTH CURTIS ROAD
BOISE,ID837061370
33-1078261 		PHYSICIANS ID N/A
 C      
(24) SAINT MARY'S HEALTH MANAGEMENT COMPANY
1640 EAST PARIS SE
GRAND RAPIDS,MI49546
38-3450733 		ATHLETIC CLUB MI N/A
 C      
(25) SURGERY CENTER FINANCING CORPORATION
6150 EAST BROAD STREET
COLUMBUS,OH43213
31-1531102 		FINANCE, INSURANCE AND REAL ESTATE OH N/A
 C      
(26) THRE SERVICES LLC
20555 VICTOR PARKWAY
LIVONIA,MI48152
45-2603654 		REAL ESTATE BROKERAGE SERVICES MI N/A
 C      
(27) TRINITY HEALTH EMPLOYEE BENEFIT TRUST
20555 VICTOR PARKWAY
LIVONIA,MI48152
38-3410377 		GRANTOR TRUST MI N/A
 T      
(28) VENZKE INSURANCE COMPANY LTD
PO BOX 1051 GRAND CAYMAN
GRAND CAYMAN    
CJ
98-0453602 		PROVISION OF INSURANCE COVERAGE CJ N/A
 C      
(29) WESTSHORE HEALTH NETWORK
1820 44TH STREET
KENTWOOD,MI49508
38-3280200 		PHYSICIAN HOSPITAL ORGANIZATION MI N/A
 C      
(30) WORKPLACE HEALTH OF GRAND HAVEN
1415 LEAHY ST
MUSKEGON,MI49442
38-3112035 		OCCUPATIONAL HEALTH MI N/A
 C      
Schedule R (Form 990) 2011
Schedule R (Form 990) 2011
Page 3
Part V
Transactions With Related Organizations (Complete if the organization answered "Yes" on Form 990, Part IV, line 34, 35, 35A, or 36.)
Note. Complete line 1 if any entity is listed in Parts II, III or IV.
Yes
No
1 During the tax year, did the orgranization engage in any of the following transactions with one or more related organizations listed in Parts II-IV?
a Receipt of (i) interest (ii) annuities (iii) royalties (iv) rent from a controlled entity . . . . . . . . . . . . . . . . . . . . . . .
1a
Yes
 
b Gift, grant, or capital contribution to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1b
Yes
 
c Gift, grant, or capital contribution from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1c
Yes
 
d Loans or loan guarantees to or for related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1d
 
No
e Loans or loan guarantees by related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1e
Yes
 
f Sale of assets to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1f
 
No
g Purchase of assets from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1g
 
No
h Exchange of assets with related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1h
 
No
i Lease of facilities, equipment, or other assets to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1i
 
No
j Lease of facilities, equipment, or other assets from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . .
1j
Yes
 
k Performance of services or membership or fundraising solicitations for related organization(s) . . . . . . . . . . . . . . . . . . . .
1k
Yes
 
l Performance of services or membership or fundraising solicitations by related organization(s) . . . . . . . . . . . . . . . . . . . .
1l
Yes
 
m Sharing of facilities, equipment, mailing lists, or other assets with related organization(s) . . . . . . . . . . . . . . . . . . . . .
1m
 
No
n Sharing of paid employees with related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1n
 
No
o Reimbursement paid to related organization(s) for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1o
Yes
 
p Reimbursement paid by related organization(s) for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1p
Yes
 
q Other transfer of cash or property to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1q
Yes
 
r Other transfer of cash or property from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1r
 
No
2
If the answer to any of the above is "Yes," see the instructions for information on who must complete this line, including covered relationships and transaction thresholds.
(a)
Name of other organization 		(b)
Transaction
type(a-r) 		(c)
Amount involved 		(d)
Method of determining amount involved
(1) TRINITY HEALTH CORPORATION

 J 903,670 PER BOOKS
(2) TRINITY HEALTH CORPORATION

 B 6,030,669 PER BOOKS
(3) TRINITY HEALTH CORPORATION

 E 8,000,000 PER BOOKS
(4) TRINITY HEALTH CORPORATION

 L 51,536,076 PER BOOKS
(5) TRINITY HEALTH CORPORATION

 O 41,906,496 PER BOOKS
(6) TRINITY HEALTH CORPORATION

 P 221,745 PER BOOKS
(7) TRINITY HEALTH CORPORATION

 Q 9,339,532 PER BOOKS
(8) TRINITY HEALTH CORPORATION

 C 59,225 PER BOOKS
(9) DUBUQUE MERCY HEALTH FOUNDATION

 C 2,125,562 PER BOOKS
(10) DYERSVILLE HEALTH FOUNDATION INC

 C 126,843 PER BOOKS
(11) MERCY HEART CTR OP SERVICES LLC

 A 94,225 PER BOOKS
(12) MERCY HEART CTR OP SERVICES LLC

 C 974,684 PER BOOKS
(13) MERCY HEART CTR OP SERVICES LLC

 K 1,745,245 PER BOOKS
(14) MERCY HEART CTR OP SERVICES LLC

 P 313,401 PER BOOKS
(15) MASON CITY AMBULATORY SURGERY CENTER LLC

 C 2,315,315 PER BOOKS
(16) MASON CITY AMBULATORY SURGERY CENTER LLC

 K 301,679 PER BOOKS
(17) FOREST PARK IMAGING LLC

 A 156,190 PER BOOKS
(18) FOREST PARK IMAGING LLC

 C 1,204,961 PER BOOKS
(19) FOREST PARK IMAGING LLC

 K 2,402,450 PER BOOKS
(20) FOREST PARK IMAGING LLC

 P 350,983 PER BOOKS
(21) HOSPICE OF NORTH IOWA

 P 626,851 PER BOOKS
(22) HOSPICE OF NORTH IOWA

 L 184,712 PER BOOKS
(23) HOSPICE OF NORTH IOWA

 A 21,187 PER BOOKS
(24) OAKLAND MERCY HOSPITAL

 A 25,955 PER BOOKS
(25) OAKLAND MERCY HOSPITAL

 C 69,846 PER BOOKS
(26) OAKLAND MERCY HOSPITAL

 P 105,121 PER BOOKS
(27) MERCY MEDICAL SERVICES

 A 50,662 PER BOOKS
(28) MERCY MEDICAL SERVICES

 B 8,129,863 PER BOOKS
(29) MERCY MEDICAL SERVICES

 K 148,235 PER BOOKS
(30) MERCY MEDICAL SERVICES

 L 113,679 PER BOOKS
(31) MERCY MEDICAL SERVICES

 O 1,657,733 PER BOOKS
(32) MERCY MEDICAL SERVICES

 P 2,238,418 PER BOOKS
(33) BAUM HARMON MERCY HOSPITAL

 A 30,209 PER BOOKS
(34) BAUM HARMON MERCY HOSPITAL

 C 511,781 PER BOOKS
(35) BAUM HARMON MERCY HOSPITAL

 O 138,453 PER BOOKS
(36) BAUM HARMON MERCY HOSPITAL

 P 199,727 PER BOOKS
(37) MERCY MEDICAL CENTER-SIOUX CITY FOUNDATION

 B 243,840 PER BOOKS
(38) MERCY MEDICAL CENTER-SIOUX CITY FOUNDATION

 C 1,570,959 PER BOOKS
(39) MERCY MEDICAL CENTER-CLINTON INC

 K 83,030 PER BOOKS
(40) MERCY MEDICAL CENTER FOUNDATION-NORTH IOWA

 B 460,396 PER BOOKS
(41) MERCY MEDICAL CENTER FOUNDATION-NORTH IOWA

 C 90,371 PER BOOKS
(42) MAGNETIC RESONANCE SERVICES PARTNERSHIP

 C 1,269,993 PER TAX RETURN
Schedule R (Form 990) 2011
Schedule R (Form 990) 2011
Page 4
Part VI
Unrelated Organizations Taxable as a Partnership (Complete if the organization answered "Yes" on Form 990, Part IV, line 37.)
Provide the following information for each entity taxed as a partnership through which the organization conducted more than five percent of its activities (measured by total assets or gross revenue) that was not a related organization. See instructions regarding exclusion for certain investment partnerships.
(a)
Name, address, and EIN of entity 		(b)
Primary activity 		(c)
Legal domicile
(state or foreign
country) 		(d)
Predominant income(related, unrelated, excluded from tax under sections 512-514)

(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 V—UBI
amount in box
20 of Schedule K-1
(Form 1065) 		(j)
General or
managing
partner? 		(k)
Percentage
ownership
Yes No Yes No Yes No






























Schedule R (Form 990) 2011
Schedule R (Form 990) 2011
Page 5
Part VII
Supplemental Information
Complete this part to provide additional information for responses to questions on Schedule R (see instructions).
Identifier Return Reference Explanation
Additional Data


Software ID:  
Software Version: