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
2012
Open to Public Inspection
A For the 2012 calendar year, or tax year beginning 01-01-2012 , 2012, and ending 12-31-2012
BCheck if applicable:
CName of organization
Protestant Memorial Medical Center Inc
 
Doing Business As
 
 
Number and street (or P.O. box if mail is not delivered to street address)
4500 Memorial Drive
Suite
Room/suite
City or town, state or country, and ZIP + 4
Belleville, IL622265399
D Employer identification number

37-0635502
E Telephone number

G Gross receipts $ 271,290,397
F Name and address of principal officer:
Mark J Turner President
4500 Memorial Drive
Belleville,IL622265399
I
Tax-exempt status: (   ) LeftBullet (insert no.) or
J
Website:MediumBullet
www.memhosp.com
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: 1947
M State of legal domicile: IL
Part I
Summary
Activities & Governance 1 Briefly describe the organization’s mission or most significant activities: PROTESTANT MEMORIAL MEDICAL CENTER OPERATES AN ACUTE CARE HOSPITAL AND SKILLED NURSING FACILITY WHOSE MISSION IS TO PROVIDE EXCEPTIONAL HEALTHCARE & COMPASSIONATE SERVICE TO THE RESIDENTS OF SOUTHWEST IL.
2 Check this box MediumBullet
3 Number of voting members of the governing body (Part VI, line 1a) ........ 3 14
4 Number of independent voting members of the governing body (Part VI, line 1b) ..... 4 13
5 Total number of individuals employed in calendar year 2011 (Part V, line 2a) ...... 5 2,683
6 Total number of volunteers (estimate if necessary) ............. 6 351
7a Total unrelated business revenue from Part VIII, column (C), line 12 ........ 7a 388,435
b Net unrelated business taxable income from Form 990-T, line 34 ......... 7b  
Revenues Prior Year Current Year
8 Contributions and grants (Part VIII, line 1h) ......... 691,855 554,503
9 Program service revenue (Part VIII, line 2g) ......... 256,830,196 256,791,318
10 Investment income (Part VIII, column (A), lines 3, 4, and 7d ) .... 7,702,888 1,010,236
11 Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e) 2,548,714 6,495,204
12 Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)................... 267,773,653 264,851,261
Expenses; 13 Grants and similar amounts paid (Part IX, column (A), lines 1–3 )... 0 0
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) 141,633,648 143,601,872
16a Professional fundraising fees (Part IX, column (A), line 11e)..... 0 0
b Total fundraising expenses (Part IX, column (D), line 25) MediumBullet0    
17 Other expenses (Part IX, column (A), lines 11a–11d, 11f–24e).... 100,338,209 98,105,573
18 Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25) 241,971,857 241,707,445
19 Revenue less expenses. Subtract line 18 from line 12....... 25,801,796 23,143,816
Net Assets or Fund Balances; Beginning of Current Year End of Year
20 Total assets (Part X, line 16)............. 204,939,895 214,224,624
21 Total liabilities (Part X, line 26)............. 68,829,448 62,347,341
22 Net assets or fund balances. Subtract line 21 from line 20..... 136,110,447 151,877,283
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 MediumBullet

Firm's EIN MediumBullet
Firm's address MediumBullet



Phone no.
May the IRS discuss this return with the preparer shown above? (see instructions) ............
For Paperwork Reduction Act Notice, see the separate instructions.
Cat. No. 11282Y
Form 990 (2012)
Form 990 (2012)
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: MEMORIAL IS COMMITTED TO BEING THE HEALTHCARE PROVIDER OF CHOICE BY DELIVERING EXTRAORDINARY CARE AND COMPASSIONATE SERVICE TO PATIENTS OF SOUTHWEST ILLINOIS THROUGH EXPANDED SERVICES, PHYSICAL FACILITIES, AND ADVANCED TECHNOLOGY.
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 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 $ 204,629,439 including grants of $   ) (Revenue $ 248,672,494 )
GENERAL SHORT TERM ACUTE CARE HOSPITAL: 316 BEDS, 16,416 PATIENTS ADMITTED, 69,453 PATIENT DAYS, 65,768 EMERGENCY ROOM VISITS, 33,714 MEDICARE PATIENT DAYS, 338,088 OUTPATIENT DEPARTMENT VISITS, AND 11,707 MEDICAID PATIENT DAYS. SEE SCHEDULE O FOR ADDITIONAL STATISTICS AND VALUE OF COMMUNITY BENEFITS PROVIDED DURING 2012.
4b (Code:   ) (Expenses $ 8,311,924 including grants of $   ) (Revenue $ 8,751,115 )
SKILLED NURSING FACILITY-MEMORIAL CARE CENTER: 108 BEDS, 948 PATIENTS ADMITTED, 20,723 PATIENT DAYS, 14,386 MEDICARE PATIENT DAYS, 323 MEDICAID PATIENT DAYS.
4c (Code:   ) (Expenses $   including grants of $   ) (Revenue $   )
4d Other program services (Describe in Schedule O.)
(Expenses $   including grants of $   ) (Revenue $   )
4e Total program service expensesMediumBullet212,941,363
Form 990 (2012)
Form 990 (2012)
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 (see instructions)? 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, or have a section 501(h) election in effect during the tax year? 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 for escrow or custodial account liability; 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
 
No
11
If the organization’s answer to any of the following questions is "Yes," then complete Schedule D, Parts VI, VII, VIII, IX, or X as applicable.
a
Did the organization report an amount for land, buildings, and equipment in Part X, line 10?
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 VIIClick to see attachment.......
11b
 
No
c
Did the organization report an amount for investments—program related in Part X, line 13 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part VIIIClick to see attachment.......
11c
Yes
 
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 IXClick 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 XClick 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 XClick 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 and XII 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 and XII 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, Parts I and IV.........
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 United States? If “Yes,” complete Schedule F, Parts II and IV
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 United States? If “Yes,” complete Schedule F, Parts III and IV...
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 (see instructions)....
17
 
No
18
Did the organization report more than $15,000 total of fundraising event gross income and contributions on Part VIII, lines 1c and 8a? If “Yes,” complete Schedule G, Part II............
18
 
No
19
Did the organization report more than $15,000 of gross income from gaming activities on Part VIII, line 9a? If “Yes,” complete Schedule G, Part III...................
19
 
No
20a
Did the organization operate one or more hospital facilities? 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 statements to this return? Click to see attachment
20b
Yes
 
Form 990 (2012)
Form 990 (2012)
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...
21
 
No
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........
22
 
No
23
Did the organization answer “Yes” to Part VII, Section A, line 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 lines 24b through 24d and complete Schedule K. If “No,” go to line 25................ Click to see attachment
24a
Yes
 
b
Did the organization invest any proceeds of tax-exempt bonds beyond a temporary period exception?...
24b
 
No
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
 
No
d
Did the organization act as an “on behalf of” issuer for bonds outstanding at any time during the year?...
24d
 
No
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, highest 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 direct or indirect owner? If “Yes,” complete Schedule L, Part IV... Click to see attachment
28c
 
No
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, Part II, III, or IV, and Part 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
 
No
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...
35b
 
 
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 11b and 19? Note. All Form 990 filers are required to complete Schedule O. ............
38
Yes
 
Form 990 (2012)
Form 990 (2012)
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
159
b
Enter the number of Forms W-2G included in line 1a. Enter -0- if not applicable .
1b
0
c
Did the organization comply with backup withholding rules for reportable payments to vendors and reportable gaming (gambling) winnings to prize winners? ..................
1c
Yes
 
2a
Enter the number of employees reported on Form W-3, Transmittal of Wage and
Tax Statements, filed for the calendar year ending with or within the year covered by this return ..................
2a
2,683
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, securities account, or other financial 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 as charitable contributions?...
6a
 
No
b
If “Yes,” did the organization include with every solicitation an express statement that such contributions or gifts were not tax deductible?........................
6b
 
 
7
Organizations that may receive deductible contributions under section 170(c).
a
Did the organization receive a payment in excess of $75 made partly as a contribution and partly for goods and services provided to the payor?....................
7a
 
No
b
If “Yes,” did the organization notify the donor of the value of the goods or services provided?.....
7b
 
 
c
Did the organization sell, exchange, or otherwise dispose of tangible personal property for which it was required to file Form 8282?...........................
7c
 
No
d
If “Yes,” indicate the number of Forms 8282 filed during the year ....
7d
 
e
Did the organization receive any funds, directly or indirectly, to pay premiums on a personal benefit contract?............................
7e
 
No
f
Did the organization, during the year, pay premiums, directly or indirectly, on a personal benefit contract?..
7f
 
No
g
If the organization received a contribution of qualified intellectual property, did the organization file Form 8899 as required?............................
7g
 
 
h
If the organization received a contribution of cars, boats, airplanes, or other vehicles, did the organization file a Form 1098-C?..........................
7h
 
 
8
Sponsoring organizations maintaining donor advised funds and section 509(a)(3) supporting organizations. Did the supporting organization, or a donor advised fund maintained by a sponsoring organization, have excess business holdings at any time during the year?............
8
 
 
9
Sponsoring organizations maintaining donor advised funds.
a
Did the organization make any taxable distributions under section 4966?..........
9a
 
 
b
Did the organization make a distribution to a donor, donor advisor, or related person?.......
9b
 
 
10
Section 501(c)(7) organizations. Enter:
a
Initiation fees and capital contributions included on Part VIII, line 12 ...
10a
 
b
Gross receipts, included on Form 990, Part VIII, line 12, for public use of club facilities
10b
 
11
Section 501(c)(12) organizations. Enter:
a
Gross income from members or shareholders .........
11a
 
b
Gross income from other sources (Do not net amounts due or paid to other sources against amounts due or received from them.) ..........
11b
 
12a
Section 4947(a)(1) non-exempt charitable trusts. Is the organization filing Form 990 in lieu of Form 1041?
12a
 
 
b
If “Yes,” enter the amount of tax-exempt interest received or accrued during the year. ....................
12b
 
13
Section 501(c)(29) qualified nonprofit health insurance issuers.
a
Is the organization licensed to issue qualified health plans in more than one state?
Note. See the instructions for additional information the organization must report on Schedule O.
13a
 
 
b
Enter the 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 amount of reserves on hand ............
13c
 
14a
Did the organization receive any payments for indoor tanning services during the tax year?.....
14a
 
No
b
If "Yes," has it filed a Form 720 to report these payments? If “No,” provide an explanation in Schedule O..
14b
 
 
Form 990 (2012)
Form 990 (2012)
Page 6
Part VI
Governance, Management, and Disclosure For each “Yes” response to lines 2 through 7b below, and for a “No” response to lines 8a, 8b, or 10b below, describe the circumstances, processes, or changes in Schedule O. See instructions.
Check if Schedule O contains a response to any question in this Part VI ...............
Section A. Governing Body and Management
Yes
No
1a
Enter the number of voting members of the governing body at the end of the tax year .....................
1a
14
If there are material differences in voting rights among members of the governing body, or if the governing body delegated broad authority to an executive committee or similar committee, explain in Schedule O.
b
Enter the number of voting members included in line 1a, above, who are independent ...................
1b
13
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
Yes
 
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
 
No
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 this 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
 
No
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
 
 
Section C. Disclosure
17
List the States with which a copy of this Form 990 is required to be filedMediumBullet
IL
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:
MediumBulletMEMORIAL HOSPITAL - CONTROLL4500 MEMORIAL DRIVEBELLEVILLEIL62226 (618) 257-5602
Form 990 (2012)
Form 990 (2012)
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. 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 organization compensated any current officer, director, or trustee.
(A)
Name and Title 		(B)
Average hours per week (list any hours for related organizations below dotted line) 		(C)
Position (do not check more than one box, unless person is both an officer and a director/trustee) 		(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) R BRAD RINGHOFER MD........................................................................
DIRECTOR
 .5
........................5 		X           0 0 0
(2) LESLIE MEHRTENS........................................................................
DIRECTOR
 .5
........................85 		X           0 0 0
(3) KEITH COOK........................................................................
DIRECTOR
 .5
.......................1.2 		X           0 0 0
(4) EDWARD HOERING........................................................................
DIRECTOR
 .5
.......................1.2 		X           0 0 0
(5) GARRETT REUTER........................................................................
DIRECTOR
 .5
........................85 		X           0 0 0
(6) LARY ECKERT........................................................................
CHAIRMAN, DIRECTOR
 .5
.......................1.2 		X           0 0 0
(7) THOMAS LIPPERT........................................................................
DIRECTOR
 .5
........................85 		X           0 0 0
(8) ARTHUR PARRISH........................................................................
DIRECTOR
 .5
.......................1.2 		X           0 0 0
(9) EDWARD ROSE MD........................................................................
DIRECTOR
 .5
........................5 		X           0 0 0
(10) ROLAND THOUVENOT........................................................................
DIRECTOR
 .5
........................85 		X           0 0 0
(11) ROBERT WANLESS MD........................................................................
DIRECTOR
 .5
........................5 		X           0 437,325 48,955
(12) SCOTT GIVENS........................................................................
DIRECTOR
 .5
........................5 		X           0 0 0
(13) MARQUITA WILEY........................................................................
DIRECTOR
 .5
........................5 		X           0 0 0
(14) JEFFRY LUTZ........................................................................
DIRECTOR
 .5
.......................1.2 		X           0 0 0
(15) MARK TURNER........................................................................
PRESIDENT
 55.0
.......................5.62 		    X       607,129 0 178,217
(16) JOE LANIUS........................................................................
VP FINANCE
 23.0
.......................27.62 		    X       136,469 191,057 74,849
(17) MARIO GIOIA........................................................................
VP ENVIRON. SERVICES
 50.0
.......................0.0 		    X       62,802 0 15,322
Form 990 (2012)
Form 990 (2012)
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 (list any hours for related organizations below dotted line) 		(C)
Position (do not check more than one box, unless person is both an officer and a director/trustee) 		(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) NANCY WESTON........................................................................
VP NURSING SERVICES
 60.0
.......................0.0 		    X       270,566 0 45,960
(19) RUTH HOLMES........................................................................
ADMINISTRATOR MEMORIAL EAST
 23.0
.......................37.0 		    X       95,459 133,641 34,635
(20) JOHN KESSLER........................................................................
VP GEN SERVICES
 55.0
.......................0.0 		    X       185,626 0 33,677
(21) CHERYL CREASY........................................................................
VP RISK MANAGEMENT
 50.0
.......................1.0 		    X       162,252 0 29,172
(22) JAMES DAVIS........................................................................
VP PHYSICIAN SERVICES
 1.0
.......................63.0 		    X       0 200,319 33,684
(23) WILLIAM CASPERSON MD........................................................................
VP MEDICAL AFFAIRS
 60.0
.......................0.0 		    X       361,861 0 72,075
(24) AMY THOMAS........................................................................
VICE PRESIDENT FINANCE
 60.0
.......................0.0 		    X       164,630 0 24,075
(25) JOHN ZIEGLER........................................................................
VP HUMAN RESOURCES
 59.0
.......................1.54 		    X       169,064 0 31,291
(26) MICHAEL MCMANUS........................................................................
CHIEF OPERATING OFFICER
 55.0
.......................0.0 		    X       142,086 0 10,116
(27) LINDA FRITSCHE........................................................................
TELEMETRY NURSE
 60.0
.......................0.0 		        X   171,483 0 19,201
(28) MARGARET LOWERY........................................................................
GENERAL COUNSEL
 50.0
.......................0.0 		        X   167,947 0 18,563
(29) MARIA GHORMLEY........................................................................
EMERGENCY NURSE
 60.0
.......................0.0 		        X   165,307 0 15,663
(30) STARLA ELLER........................................................................
DIRECTOR SURGICAL SERVICES
 50.0
.......................0.0 		        X   173,159 0 6,222
(31) JENNIFER MEINKOTH........................................................................
DIRECTOR INFORMATION TECHNOLOG
 55.0
.......................0.0 		        X   157,365 0 24,750
1b Sub-Total................MediumBullet
c Total from continuation sheets to Part VII, Section A....MediumBullet
d Total (add lines 1b and 1c)............MediumBullet 3,193,205 962,342 716,427
2
Total number of individuals (including but not limited to those listed above) who received more than $100,000 of reportable compensation from the organizationMediumBullet62
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
 
No
4
For any individual listed on line 1a, is the sum of reportable compensation and other compensation from the organization and related organizations greater than $150,000? If “Yes,” complete Schedule J for such individual...........................
4
Yes
 
5
Did any person listed on line 1a receive or accrue compensation from any unrelated organization or individual for services rendered to the organization? If “Yes,” complete Schedule J for such person ........
5
 
No
Section B. Independent Contractors
1
Complete this table for your five highest compensated independent contractors that received more than $100,000 of compensation from the organization. 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
BELLEVILLE EMERGENCY PHYSICIANS PC, ONE BRONZE POINTBELLEVILLEIL62226 PHYSICIAN SERVICES 1,143,005
SLU CARE, 1402 S GRAND BLVDST LOUISMO63104 PHYSICIAN SERVICES 1,110,083
FOCUS ONE SOLUTIONS, 13609 CALIFORNIA STREETOMAHANE68154 STAFFING SERVICES 1,375,323
JACOBUS CONSULTING, 29883 SANTA MARGARITA PKY SUITE 40RANCHO SANTA MARGARITACA92688 CONSULTING SERVICES 1,404,903
PHILLIPS INTEXT SYSTEMS, 1414 SOUTH STATE STREETFREEBURGIL62243 CONSTRUCTION SRVCS 1,085,848
2
Total number of independent contractors (including but not limited to those listed above) who received more than $100,000 of compensation from the organization MediumBullet61
Form 990 (2012)
Form 990 (2012)
Page 9
Part VIII
Statement of Revenue
Check if Schedule O contains a response to any question in this Part VIII ..............
(A)
Total revenue 		(B)
Related or
exempt
function
revenue 		(C)
Unrelated
business
revenue 		(D)
Revenue
excluded from
tax under sections
512, 513, or 514
Contributions, Gifts, Grants and Other Similar Amounts 1a Federated campaigns..1a  
b Membership dues....1b  
c Fundraising events....1c  
d Related organizations...1d 554,503
e Government grants (contributions)1e  
f All other contributions, gifts, grants, and
similar amounts not included above1f 		 
g Noncash contributions included in lines
1a-1f:$ 		 
h Total. Add lines 1a-1f.......MediumBullet 554,503
Program Service Revenue Business Code
2a PATIENT SERVICES -          
b ACUTE CARE HOSP. 621110 248,040,203 247,651,768 388,435  
c PATIENT SERVICES -          
d SKILLED NURS. FAC 621110 8,751,115 8,751,115    
e
f All other program service revenue .        
g Total. Add lines 2a–2f........MediumBullet 256,791,318
Other Revenue 3 Investment income (including dividends, interest, and other similar amounts).......MediumBullet 1,034,372     1,034,372
4 Income from investment of tax-exempt bond proceeds..MediumBullet 0      
5 Royalties...........MediumBullet 0      
(i) Real (ii) Personal
6a Gross rents 46,728  
b Less: rental expenses    
c Rental income or (loss) 46,728 0
d Net rental income or (loss).......MediumBullet 46,728     46,728
(i) Securities (ii) Other
7a Gross amount from sales of assets other than inventory 6,415,000  
b Less: cost or other basis and sales expenses 6,439,136  
c Gain or (loss) -24,136  
d Net gain or (loss)..........MediumBullet -24,136     -24,136
8a Gross income from fundraising events (not including
$  
of contributions reported on line 1c). See Part IV, line 18 ..
a  
b Less: direct expenses ...b  
c Net income or (loss) from fundraising events..MediumBullet 0    
9a Gross income from gaming activities.
See Part IV, line 19 ...
a  
b Less: direct expenses ...b  
c Net income or (loss) from gaming activities...MediumBullet 0      
10a Gross sales of inventory, less
returns and allowances .
a  
b Less: cost of goods sold ..b  
c Net income or (loss) from sales of inventory..MediumBullet 0      
Miscellaneous Revenue Business Code
11a CAFETERIA/COFFEE SHOP SALES 722210 1,799,175     1,799,175
b VHA PATRONAGE PROG 621110 599,428 599,428    
c EMR INCENTIVE PAYMENT 900099 3,947,670     3,947,670
d All other revenue .... 102,203 32,863   69,340
e Total. Add lines 11a–11d ...... MediumBullet 6,448,476
12 Total revenue. See Instructions......MediumBullet 264,851,261 257,035,174 388,435 6,873,149
Form 990 (2012)
Form 990 (2012)
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).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 0  
2 Grants and other assistance to individuals in the United States. See Part IV, line 22 0  
3 Grants and other assistance to governments, organizations, and individuals outside the United States. See Part IV, lines 15 and 16 0  
4 Benefits paid to or for members 0  
5 Compensation of current officers, directors, trustees, and key employees .... 2,843,468   2,843,468  
6 Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) .... 47,252 47,252    
7 Other salaries and wages 102,206,459 93,716,308 8,490,151  
8 Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) .... 4,108,290 3,665,417 442,873  
9 Other employee benefits ....... 26,777,799 23,891,154 2,886,645  
10 Payroll taxes ........... 7,618,604 6,797,319 821,285  
11 Fees for services (non-employees):        
a Management ...... 0      
b Legal ......... 370,758   370,758  
c Accounting ........... 95,198   95,198  
d Lobbying ........... 0      
e Professional fundraising services. See Part IV, line 17 0  
f Investment management fees ...... 0      
g Other (If line 11g amount exceeds 10% of line 25, column (A) amount, list line 11g expenses on Schedule O) ........ 12,458,725 9,298,804 3,159,921  
12 Advertising and promotion .... 1,531,096   1,531,096  
13 Office expenses ....... 43,305,650 42,558,133 747,517  
14 Information technology ...... 0      
15 Royalties .. 0      
16 Occupancy ........... 3,796,914 3,387,607 409,307  
17 Travel ............ 278,718 196,171 82,547  
18 Payments of travel or entertainment expenses for any federal, state, or local public officials ...... 0      
19 Conferences, conventions, and meetings .... 0      
20 Interest ........... 402,403   402,403  
21 Payments to affiliates ....... 0      
22 Depreciation, depletion, and amortization ..... 15,821,971 14,124,939 1,697,032  
23 Insurance .............. 3,233,778 2,935,769 298,009  
24 Other expenses. Itemize expenses not covered above (List miscellaneous expenses in line 24e. If line 24e amount exceeds 10% of line 25, column (A) amount, list line 24e expenses on Schedule O.)
a REPAIRS & MAINTENANCE 6,243,068 3,973,313 2,269,755  
b ASSOCIATION DUES 602,275   602,275  
c MICROFILMING 175,042   175,042  
d MEDICAL WASTE DISPOSAL 166,046 166,046    
e All other expenses 9,623,931 8,183,131 1,440,800  
25 Total functional expenses. Add lines 1 through 24e 241,707,445 212,941,363 28,766,082 0
26 Joint costs. Complete this line only if the organization reported in column (B) joint costs from a combined educational campaign and fundraising solicitation. Check here MediumBullet if following SOP 98-2 (ASC 958-720).        
Form 990 (2012)
Form 990 (2012)
Page 11
Part X Balance Sheet Check if Schedule O contains a response to any question in this Part X ...............
(A)
Beginning of year 		(B)
End of year
Assets 1 Cash—non-interest-bearing ............. 4,200 1 4,200
2 Savings and temporary cash investments ......... 13,151,352 2 20,068,627
3 Pledges and grants receivable, net ........... 0 3 0
4 Accounts receivable, net ............. 46,471,537 4 53,445,518
5 Loans and other receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of
Schedule L ..................
0 5 0
6 Loans and other receivables from other disqualified persons (as defined under section 4958(f)(1)), persons described in section 4958(c)(3)(B), and contributing employers and sponsoring organizations of section 501(c)(9) voluntary employees' beneficiary organizations (see instructions) Complete Part II of Schedule L
0 6 0
7 Notes and loans receivable, net ............. 0 7 0
8 Inventories for sale or use .............. 3,169,187 8 3,036,697
9 Prepaid expenses and deferred charges .......... 3,355,358 9 3,476,931
10a Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D 10a 225,052,075
b Less: accumulated depreciation ..... 10b 151,054,770 74,494,521 10c 73,997,305
11 Investments—publicly traded securities .......... 34,402,995 11 33,281,697
12 Investments—other securities. See Part IV, line 11 ..... 0 12 0
13 Investments—program-related. See Part IV, line 11 ..... 9,745,020 13 10,730,498
14 Intangible assets ............... 0 14 0
15 Other assets. See Part IV, line 11 ........... 20,145,725 15 16,183,151
16 Total assets. Add lines 1 through 15 (must equal line 34)...... 204,939,895 16 214,224,624
Liabilities 17 Accounts payable and accrued expenses ......... 38,384,122 17 32,778,835
18 Grants payable ................. 0 18 0
19 Deferred revenue ................ 0 19 0
20 Tax-exempt bond liabilities ............. 14,455,432 20 14,132,595
21 Escrow or custodial account liability. Complete Part IV of Schedule D.. 0 21 0
22 Loans and other payables to current and former officers, directors, trustees, key employees, highest compensated employees, and disqualified
persons. Complete Part II of Schedule L.......... 0 22 0
23 Secured mortgages and notes payable to unrelated third parties .. 0 23 0
24 Unsecured notes and loans payable to unrelated third parties .... 0 24 0
25 Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17-24). Complete Part X of Schedule D.................... 15,989,894 25 15,435,911
26 Total liabilities. Add lines 17 through 25......... 68,829,448 26 62,347,341
Net Assets or Fund Balance Organizations that follow SFAS 117 (ASC 958), check here MediumBullet and complete lines 27 through 29, and lines 33 and 34.
27 Unrestricted net assets .............. 126,365,427 27 141,146,785
28 Temporarily restricted net assets ........... 9,745,020 28 10,730,498
29 Permanently restricted net assets ........... 0 29 0
Organizations that do not follow SFAS 117 (ASC 958), 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 ........... 136,110,447 33 151,877,283
34 Total liabilities and net assets/fund balances ........ 204,939,895 34 214,224,624
Form 990 (2012)
Form 990 (2012)
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
264,851,261
2
Total expenses (must equal Part IX, column (A), line 25) ............
2
241,707,445
3
Revenue less expenses. Subtract line 2 from line 1 ..............
3
23,143,816
4
Net assets or fund balances at beginning of year (must equal Part X, line 33, column (A)) ..
4
136,110,447
5
Net unrealized gains (losses) on investments ...............
5
2,528,624
6
Donated services and use of facilities .................
6
 
7
Investment expenses .....................
7
 
8
Prior period adjustments .....................
8
 
9
Other changes in net assets or fund balances (explain in Schedule O) ........
9
-9,905,604
10
Net assets or fund balances at end of year. Combine lines 3 through 9 (must equal Part X, line 33, column (B))
10
151,877,283
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
If ‘Yes,’ check a box below to indicate whether the financial statements for the year were compiled or reviewed on a separate basis, consolidated basis, or both:
b
Were the organization’s financial statements audited by an independent accountant?
2b
Yes
 
If ‘Yes,’ check a box below to indicate whether the financial statements for the year were audited on a separate basis, consolidated basis, or both:
c
If “Yes,” to line 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?
2c
Yes
 
If the organization changed either its oversight process or selection process during the tax year, explain in Schedule O.
3a
As a result of a federal award, was the organization required to undergo an audit or audits as set forth in the Single Audit Act and OMB Circular A-133?
3a
 
No
b
If “Yes,” did the organization undergo the required audit or audits? If the organization did not undergo the required audit or audits, explain why in Schedule O and describe any steps taken to undergo such audits
3b
 
 
Form 990 (2012)
Form 990, Special Condition Description:
Special Condition Description
Additional Data


Software ID:  
Software Version:  
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
2012
Open to Public
Inspection
Name of the organization
Protestant Memorial Medical Center Inc
 
Employer identification number

37-0635502
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 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
Provide the following information about the supported organization(s).
(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 monetary support
Yes No Yes No Yes No
Total                  

For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990EZ.
Cat. No. 11285F
Schedule A (Form 990 or 990-EZ) 2012
Schedule A (Form 990 or 990-EZ) 2012
Page 2
Part II
Support Schedule for Organizations Described in Sections 170(b)(1)(A)(iv) and 170(b)(1)(A)(vi)
(Complete only if you checked the box on line 5, 7, or 8 of Part I or if the organization failed to qualify under Part III. If the organization fails to qualify under the tests listed below, please complete Part III.)
Section A. Public Support
Calendar year (or fiscal year beginning in) right arrow (a) 2008 (b) 2009 (c) 2010 (d) 2011 (e) 2012 (f) Total
1 Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") ....            
2 Tax revenues levied for the organization's benefit and either paid to or expended on its behalf.......            
3 The value of services or facilities furnished by a governmental unit to the organization without charge..            
4 Total. Add lines 1 through 3            
5 The portion of total contributions by each person (other than a governmental unit or publicly supported organization) included on line 1 that exceeds 2% of the amount shown on line 11, column (f)..            
6 Public support. Subtract line 5 from line 4.            
Section B. Total Support
Calendar year (or fiscal year beginning in) right arrow (a) 2008 (b) 2009 (c) 2010 (d) 2011 (e) 2012 (f) Total
7 Amounts from line 4..            
8 Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources...            
9 Net income from unrelated business activities, whether or not the business is regularly carried on..            
10 Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)..            
11 Total support (Add lines 7 through 10).            
12
12
 
13
First five years. If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization, check this box and stop here........................................right arrow
Section C. Computation of Public Support Percentage
14
14
 
15
15
 
16a
b
17a
b
18
Private foundation. If the organization did not check a box on line 13, 16a, 16b, 17a, or 17b, check this box and see
instructions ..................................................... right arrow
Schedule A (Form 990 or 990-EZ) 2012
Schedule A (Form 990 or 990-EZ) 2012
Page 3
Part III
Support Schedule for Organizations Described in Section 509(a)(2)
(Complete only if you checked the box on line 9 of Part I or if the organization failed to qualify under Part II. If the organization fails to qualify under the tests listed below, please complete Part II.)
Section A. Public Support
Calendar year (or fiscal year beginning in) right arrow (a) 2008 (b) 2009 (c) 2010 (d) 2011 (e) 2012 (f) Total
1 Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") .            
2 Gross receipts from admissions, merchandise sold or services performed, or facilities furnished in any activity that is related to the organization's tax-exempt purpose......            
3 Gross receipts from activities that are not an unrelated trade or business under section 513..            
4 Tax revenues levied for the organization's benefit and either paid to or expended on its behalf...            
5 The value of services or facilities furnished by a governmental unit to the organization without charge..            
6 Total. Add lines 1 through 5.            
7a Amounts included on lines 1, 2, and 3 received from disqualified persons...            
b Amounts included on lines 2 and 3 received from other than disqualified persons that exceed the greater of $5,000 or 1% of the amount on line 13 for the year.            
c Add lines 7a and 7b..            
8 Public support (Subtract line 7c from line 6.)            
Section B. Total Support
Calendar year (or fiscal year beginning in) right arrow (a) 2008 (b) 2009 (c) 2010 (d) 2011 (e) 2012 (f) Total
9 Amounts from line 6...            
10a Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..            
b Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.            
c Add lines 10a and 10b.            
11 Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on.            
12 Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.) ..            
13 Total support. (Add lines 9, 10c, 11, and 12.)..            
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) 2012
Schedule A (Form 990 or 990-EZ) 2012
Page 4
Part IV
Supplemental Information. Complete this part to provide the explanations required by Part II, line 10; Part II, line 17a or 17b; and Part III, line 12. Also complete this part for any additional information. (See instructions).
Facts And Circumstances Test
 
Explanation
 
 
 
 
Schedule A (Form 990 or 990-EZ) 2012

Additional Data


Software ID:  
Software Version:  
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
2012
Name of the organization
Protestant Memorial Medical Center Inc
 
Employer identification number

37-0635502
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) (2012)

Schedule B (Form 990, 990-EZ, or 990-PF) (2012)
Page 2
Name of organization
Protestant Memorial Medical Center Inc
  		Employer identification number

37-0635502
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) (2012)

Schedule B (Form 990, 990-EZ, or 990-PF) (2012)
Page 3
Name of organization
Protestant Memorial Medical Center Inc
  		Employer identification number

37-0635502
Part II
Noncash Property (see instructions). Use duplicate copies of Part II if additional space is needed.
     
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
Schedule B (Form 990, 990-EZ, or 990-PF) (2012)

Schedule B (Form 990, 990-EZ, or 990-PF) (2012)
Page 4
Name of organization
Protestant Memorial Medical Center Inc
  		Employer identification number

37-0635502
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) (2012)

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
2012
Open to Public
Inspection
If the organization answered “Yes” to Form 990, Part IV, Line 3, or Form 990-EZ, Part V, line 46 (Political Campaign Activities), then
Round Bullet Section 501(c)(3) organizations: Complete Parts I-A and B. Do not complete Part I-C.
Round Bullet Section 501(c) (other than section 501(c)(3)) organizations: Complete Parts I-A and C below. Do not complete Part I-B.
Round Bullet Section 527 organizations: Complete Part I-A only.
If the organization answered “Yes” to Form 990, Part IV, Line 4, or Form 990-EZ, Part VI, line 47 (Lobbying Activities), then
Round Bullet Section 501(c)(3) organizations that have filed Form 5768 (election under section 501(h)): Complete Part II-A. Do not complete Part II-B.
Round Bullet Section 501(c)(3) organizations that have NOT filed Form 5768 (election under section 501(h)): Complete Part II-B. Do not complete Part II-A.
If the organization answered “Yes” to Form 990, Part IV, Line 5 (Proxy Tax) or Form 990-EZ, Part V, line 35c (Proxy Tax), then
Round Bullet Section 501(c)(4), (5), or (6) organizations: Complete Part III.
Name of the organization
Protestant Memorial Medical Center Inc
 
Employer identification number

37-0635502
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 Paperwork Reduction Act Notice, see the instructions for Form 990 or 990-EZ.
Cat. No. 50084S
Schedule C (Form 990 or 990-EZ) 2012

Schedule C (Form 990 or 990-EZ) 2012
Page 2
Part II-A
Complete if the organization is exempt under section 501(c)(3) and filed Form 5768 (election under section 501(h)).
A Check SchCMd Bulletexpenses, and share of excess lobbying expenditures).
B Check SchCMd Bullet
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) 2009 (b) 2010 (c) 2011 (d) 2012 (e) Total
             
2a Lobbying nontaxable amount          
             
b Lobbying ceiling amount
(150% of line 2a, column(e)) 		         
             
c Total lobbying expenditures          
             
d Grassroots nontaxable amount          
             
e Grassroots ceiling amount
(150% of line 2d, column (e))		          
             
f Grassroots lobbying expenditures          
Schedule C (Form 990 or 990-EZ) 2012


Schedule C (Form 990 or 990-EZ) 2012
Page 3
Part II-B
Complete if the organization is exempt under section 501(c)(3) and has NOT filed Form 5768 (election under section 501(h)).
For each “Yes” response to lines 1a through 1i below, provide in Part IV a detailed description of the lobbying activity.
(a)
No
Yes
(b)
Amount
1
During the year, did the filing organization attempt to influence foreign, national, state or local legislation, including any attempt to influence public opinion on a legislative matter or referendum, through the use of:
a
Volunteers? .........................................
 
No
b
Paid staff or management (include compensation in expenses reported on lines 1c through 1i)? ....
 
No
c
Media advertisements? ....................................
 
No
 
d
Mailings to members, legislators, or the public? .........................
 
No
 
e
Publications, or published or broadcast statements? .......................
 
No
 
f
Grants to other organizations for lobbying purposes? .......................
 
No
 
g
Direct contact with legislators, their staffs, government officials, or a legislative body? ........
 
No
 
h
Rallies, demonstrations, seminars, conventions, speeches, lectures, or any similar means? ......
 
No
 
i
Other activities? ..........................
Yes
 
75,313
j
Total. Add lines 1c through 1i ...............................
75,313
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, line 5; Part II-A (affiliated group list); Part II-A, line 2; and Part ll-B, line 1. Also, complete this part for any additional information.
Identifier Return Reference Explanation
SCHEDULE C SUPPLEMENTAL INFORMATION 1. PART II-B, LINE 1i PROTESTANT MEMORIAL MEDICAL CENTER, INC PAID MEMBERSHIP DUES TO ILLINOIS HOSPITAL ASSOCIATION AND THE AMERICAN HOSPITAL ASSOCIATION. THESE ORGANIZATIONS ESTIMATED EXPENSES ALLOCABLE TO LOBBYING ACTIVITIES TO BE 28% OF MEMBERSHIP DUES. PROTESTANT MEMORIAL MEDICAL CENTER, INC ENGAGED AND PAID KANE CONSULTING $48,000 TO ASSIST MEMORIAL HOSPITAL WORKING WITH THE ILLINOIS DEPARTMENT OF HEALTHCARE AND FAMILY SERVICES (DHFS) ON THE MEDICAL CENTER'S MEDICAID REIMBURSEMENTS.
Schedule C (Form 990 or 990EZ) 2012

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
2012
Open to Public Inspection
Name of the organization
Protestant Memorial Medical Center Inc
 
Employer identification number

37-0635502
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 section 170(h)(4)(B)(ii)? .......................................
9
In Part XIII, describe how the organization reports conservation easements in its revenue and expense statement, and
balance sheet, and include, if applicable, the text of the footnote to the organization’s financial statements that describes
the organization’s accounting for conservation easements.
Part III
Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets.
Complete if the organization answered "Yes" to Form 990, Part IV, line 8.
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 XIII, 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 Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 52283D
Schedule D (Form 990) 2012

Schedule D (Form 990) 2012
Page 2
Part III
Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets (continued)
3
Using the organization’s acquisition, accession, and other records, check any of the following that are a significant use of its collection items (check all that apply):
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 XIII.
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 XIII 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 XIII. Check here if the explanation has been provided in Part XIII ........
Part V
Endowment Funds. Complete if the organization answered "Yes" to Form 990, Part IV, line 10.
(a)Current year (b)Prior year b (c)Two years back (d)Three years back (e)Four years back
1a Beginning of year balance ....          
b Contributions ........          
c Net investment earnings, gains, and losses          
d Grants or scholarships .....          
e Other expenditures for facilities
and programs ........ 		         
f Administrative expenses ....          
g End of year balance ......          
2
Provide the estimated percentage of the current year end balance (line 1g, column (a)) held as:
a
Board designated or quasi-endowment SchDMd Bullet  
b
Permanent endowment SchDMd Bullet  
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)
 
 
(ii) related organizations ........................
3a(ii)
 
 
b
If "Yes" to 3a(ii), are the related organizations listed as required on Schedule R? .........
3b
 
 
4
Describe in Part XIII the intended uses of the organization's endowment funds.
Part VI
Land, Buildings, and Equipment. See Form 990, Part X, line 10.
Description of property (a) Cost or other basis (investment) (b)Cost or other basis (other) (c) Accumulated depreciation (d) Book value
1a Land .................   1,486,451 1,486,451
b Buildings ................   34,984,324 29,054,057 5,930,267
c Leasehold improvements ............   5,210,871 3,725,275 1,485,596
d Equipment ................   182,050,842 118,275,438 63,775,404
e Other .................   1,319,587   1,319,587
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).).......SchDMdBullet 73,997,305
Schedule D (Form 990) 2012

Schedule D (Form 990) 2012
Page 3
Part VII
Investments—Other Securities. See Form 990, Part X, line 12.
(a) Description of security or category
(including name of security)		 (b)Book value (c) Method of valuation:
Cost or end-of-year market value
(1)Financial derivatives    
(2)Closely-held equity interests    
Other








Total. (Column (b) must equal Form 990, Part X, col. (B) line 12.)Small Bullet  
Part VIII
Investments—Program Related. See Form 990, Part X, line 13.
(a) Description of investment type (b) Book value (c) Method of valuation:
Cost or end-of-year market value
(1) NET ASSETS OF MEMORIAL FOUNDAT 10,730,498 F








Total. (Column (b) must equal Form 990, Part X, col.(B) line 13.)Small Bullet 10,730,498
Part IX
Other Assets. See Form 990, Part X, line 15.
(a) Description (b) Book value
(1) AUXILIARY OTHER ASSETS 191,563
(2) DUE FROM AFFILIATED CORPS 555,677
(3) DUE FROM INSURANCE AFFILIATE 15,435,911






Total. (Column (b) must equal Form 990, Part X, col.(B) line 15.)...........Small Bullet 16,183,151
Part X
Other Liabilities. See Form 990, Part X, line 25.
1.(a) Description of liability (b) Book value
Federal income taxes 0
ESTIMATED PROFESSIONAL LIABILI 15,435,911








Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)Small Bullet 15,435,911
2. Fin 48 (ASC 740) Footnote. In Part XIII, provide the text of the footnote to the organization's financial statements that reports the organization's liability for uncertain tax positions under FIN 48 (ASC 740). Check here if the text of the footnote has been provided in Part XIII .....................................................
Schedule D (Form 990) 2012

Schedule D (Form 990) 2012
Page 4
Part XI Reconciliation of Revenue per Audited Financial Statements With Revenue per Return
1 Total revenue, gains, and other support per audited financial statements ....... 1 267,533,373
2 Amounts included on line 1 but not on Form 990, Part VIII, line 12:
a Net unrealized gains on investments .......... 2a 2,622,086
b Donated services and use of facilities ......... 2b  
c Recoveries of prior year grants ........... 2c  
d Other (Describe in Part XIII.) ............ 2d 60,026
e Add lines 2a through 2d ..................... 2e 2,682,112
3 Subtract line 2e from line 1..................... 3 264,851,261
4 Amounts included on Form 990, Part VIII, line 12, but not on line 1:
a Investment expenses not included on Form 990, Part VIII, line 7b . 4a  
b Other (Describe in Part XIII.) ........... 4b  
c Add lines 4a and 4b....................... 4c  
5 Total revenue. Add lines 3 and 4c. (This must equal Form 990, Part I, line 12.) ...... 5 264,851,261
Part XII Reconciliation of Expenses per Audited Financial Statements With Expenses per Return
1 Total expenses and losses per audited financial statements ........... 1 241,715,075
2 Amounts included on line 1 but not on Form 990, Part IX, line 25:
a Donated services and use of facilities .......... 2a  
b Prior year adjustments .............. 2b  
c Other losses ................ 2c  
d Other (Describe in Part XIII.) ............ 2d 7,630
e Add lines 2a through 2d...................... 2e 7,630
3 Subtract line 2e from line 1..................... 3 241,707,445
4 Amounts included on Form 990, Part IX, line 25, but not on line 1:
a Investment expenses not included on Form 990, Part VIII, line 7b .. 4a  
b Other (Describe in Part XIII.) ............ 4b  
c Add lines 4a and 4b....................... 4c  
5 Total expenses. Add lines 3 and 4c. (This must equal Form 990, Part I, line 18.) ...... 5 241,707,445
Part XIII
Supplemental Information
Complete this part to provide the descriptions required for Part II, lines 3, 5, and 9; Part III, lines 1a and 4; Part lV, lines 1b and 2b;
Part V, line 4; Part X, line 2; Part XI, lines 2d and 4b; and Part XII, lines 2d and 4b. Also complete this part to provide any additional information.
Identifier Return Reference Explanation
PART XI, LINE 2D   $60,026 INVESTMENT INCOME OF MEMORIAL HOSPITAL SELF INSURANCE TRUST FUND (EIN#37-1064809), A RELATED 501(C)(3) ORGANIZATION IS INCLUDED ON THE AUDITED FINANCIAL STATEMENTS OF PROTESTANT MEMORIAL MEDICAL CENTER, INC.
PART XII, LINE 2D   $7,630 EXPENSES OF MEMORIAL HOSPITAL SELF INSURANCE TRUST (EIN# 37-1064809), A RELATED 501(C)(3) ORGANIZATION IS INCLUDED ON THE AUDITED FINANCIAL STATEMENTS OF THE PROTESTANT MEMORIAL MEDICAL CENTER, INC.
PART V   SCHEDULE D, PART V HAS NOT BEEN COMPLETED. THE ORGANIZATION ONLY REPORTS SUCH FUNDS ON THE BALANCE SHEET DUE TO AN AUDIT REQUIREMENT THAT THE INTEREST IN A RELATED FOUNDATION BE RECOGNIZED ON THE BOOKS. THE FUNDS HAVE BEEN ANALYZED ON FORM 990 OF MEMORIAL FOUNDATION, INC. (EIN#37-1186034).
PART X, LINE 2-FIN 48   MANAGEMENT HAS EVALUATED THEIR INCOME TAX POSITIONS UNDER THE GUIDANCE INCLUDED IN ASC 740. BASED ON THEIR REVIEW, MANAGEMENT HAS NOT IDENTIFIED ANY MATERIAL UNCERTAIN TAX POSITIONS TO BE RECORDED OR DISCLOSED IN THE FINANCIAL STATEMENTS.
Schedule D (Form 990) 2012

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
2012
Open to Public Inspection
Name of the organization
Protestant Memorial Medical Center Inc
 
Employer identification number

37-0635502
Part I
Financial Assistance 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) as a factor in determining eligibility for providing free care?
If "Yes," indicate which of the following was the FPG family income limit for eligibility for free care:
3a
Yes
 
b
Did the organization use FPG as a factor in determining eligibility for providing discounted care? If "Yes," indicate
which of the following was the family income limit for eligibility for discounted care: .........
3b
Yes
 
%
c
If the organization used factors other than FPG in determining eligibility, describe in Part VI the income based criteria for determining eligibility for free or discounted care. Include in the description whether the organization used an asset test or other threshold, regardless of income, as a factor in determining eligibility for free or discounted care.
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
Yes
 
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
 
No
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) .. 		    5,056,125   5,056,125 2.090 %
b Medicaid (from Worksheet 3,
column a) .... 		    32,712,996 18,194,905 14,518,091 6.000 %
c Costs of other means-tested
government programs (from
Worksheet 3, column b) . 		           
d Total Financial Assistance
and Means-Tested
Government Programs . 		    37,769,121 18,194,905 19,574,216 8.090 %
Other Benefits
     1,440,083   1,440,083 0.600 %
e Community health
improvement services and
community benefit operations
(from Worksheet 4) ..
f Health professions education
(from Worksheet 5) .. 		           
g Subsidized health services
(from Worksheet 6) .. 		           
h Research (from Worksheet 7)            
i Cash and in-kind
contributions for community
benefit (from Worksheet 8) 		    171,182   171,182 0.070 %
j Total. Other Benefits ..     1,611,265   1,611,265 0.670 %
k Total. Add lines 7d and 7j .     39,380,386 18,194,905 21,185,481 8.760 %
For Paperwork Reduction Act Notice, see the Instructions for Form 990. Cat. No. 50192T Schedule H (Form 990) 2012
Schedule H (Form 990) 2012
Page
Part II
Community Building Activities Complete this table if the organization conducted any community building activities during the tax year, and describe in Part VI how its community building activities promoted the health of the communities it serves.
(a) Number of activities or programs (optional) (b) Persons served (optional) (c) Total community building expense (d) Direct offsetting
revenue 		(e) Net community building expense (f) Percent of total expense
1 Physical improvements and housing            
2 Economic development            
3 Community support            
4 Environmental improvements            
5 Leadership development and training for community members            
6 Coalition building            
7 Community health improvement advocacy            
8 Workforce development            
9 Other            
10 Total            
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. Explain in Part VI the methodology used by the organization to estimate this amount. ......
2
16,262,864
3
Enter the estimated amount of the organization's bad debt expense attributable to patients eligible under the organization's financial assistance policy. Explain in Part VI the methodology used by the organization to estimate this amount and the rationale, if any, for including this portion of bad debt as community benefit. ......
3
2,439,430
4
Provide in Part VI the text of the footnote to the organization’s financial statements that describes bad debt expense or the page number on which this footnote is contained in the attached financial statements.
Section B. Medicare
5
Enter total revenue received from Medicare (including DSH and IME).....
5
88,801,606
6
Enter Medicare allowable costs of care relating to payments on line 5.....
6
112,716,340
7
Subtract line 6 from line 5. This is the surplus (or shortfall)........
7
-23,914,734
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(owned 10% or more by officers, directors, trustees, key employees, and physicians—see instructions)
(a) Name of entity (b) Description of primary
activity of entity 		(c) Organization's
profit % or stock
ownership % 		(d) Officers, directors,
trustees, or key
employees' profit %
or stock ownership % 		(e) Physicians'
profit % or stock
ownership %
1
2
3
4
5
6
7
8
9
10
11
12
13
Schedule H (Form 990) 2012
Schedule H (Form 990) 2012
Page
Part VFacility Information
Section A. Hospital Facilities
(list in order of size from largest to smallest—see instructions)
How many hospital facilities did the organization operate during the tax year?1
Name, address, and primary website address 		Licensed Hospital General-Medical-Surgical Children's Hospital Teaching Hospital Critical Hospital Research Facility ER-24Hours ER-Other Other (Describe) Facility reporting group
1 MEMORIAL HOSPITAL
4500 MEMORIAL DRIVE
BELLEVILLE,IL62226 		X X         X      
Schedule H (Form 990) 2012
Schedule H (Form 990) 2012
Page
Part VFacility Information (continued)

Section B. Facility Policies and Practices

(Complete a separate Section B for each of the hospital facilities or facility reporting groups listed in Part V, Section A)
MEMORIAL HOSPITAL
Name of hospital facility or facility reporting group  
For single facility filers only: line Number of Hospital Facility (from Schedule H, Part V, Section A) 1
Yes No
Community Health Needs Assessment (Lines 1 through 8c are optional for tax years begining on or before March 23, 2012)
1 During the tax year or either of the two immediately preceding tax years, did the hospital facility conduct a community health needs assessment (CHNA)? If "No," skip to line 9.................... 1    
If “Yes,” indicate what the CHNA report describes (check all that apply):
a
b
c
d
e
f
g
h
i
j
2 Indicate the tax year the hospital facility last conducted a CHNA: 20  
3 In conducting its most recent CHNA, did the hospital facility take into account input from representatives of the community served by the hospital facility, including those with special knowledge of or expertise in public health? If “Yes,” describe in Part VI how the hospital facility took into account input from persons who represent the community, and identify the persons the hospital facility consulted .................... 3    
4 Was the hospital facility’s CHNA 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 CHNA report widely available to the public? ............. 5    
If “Yes,” indicate how the CHNA report was made widely available (check all that apply):
a
b
c
6 If the hospital facility addressed needs identified in its most recently conducted CHNA, indicate how (check all that apply to date):
a
b
c
d
e
f
g
h
i
7 Did the hospital facility address all of the needs identified in its most recently conducted CHNA? If “No,” explain in Part VI which needs it has not addressed and the reasons why it has not addressed such needs ........ 7    
8a Did the organization incur an excise tax under section 4959 for the hospital facility's failure to conduct a CHNA as required by section 501(r)(3)? ........................... 8a    
b If "Yes" to line 8a, did the organization file Form 4720 to report the section 4959 excise tax? ...... 8b    
c If "Yes" to line 8b, what is the total amount of section 4959 excise tax the organization reported on Form 4720 for all of its hospital facilities? $  

Schedule H (Form 990) 2012
Schedule H (Form 990) 2012
Page
Part VFacility Information (continued)

Financial Assistance Policy Yes No
9 Did the hospital facility have in place during the tax year a written financial assistance policy that:
Explained eligibility criteria for financial assistance, and whether such assistance includes free or discounted care? 9 Yes  
10 Used federal poverty guidelines (FPG) to determine eligibility for providing free care?........... 10 Yes  
If "Yes," indicate the FPG family income limit for eligibility for free care: 249.%
If "No," explain in Part VI the criteria the hospital facility used.
11 Used FPG to determine eligibility for providing discounted care?................. 11 Yes  
If “Yes,” indicate the FPG family income limit for eligibility for discounted care: 350.%
If "No," explain in Part VI the criteria the hospital facility used.
12 Explained the basis for calculating amounts charged to patients?................. 12 Yes  
If “Yes,” indicate the factors used in determining such amounts (check all that apply):
a
b
c
d
e
f
g
h
13 Explained the method for applying for financial assistance?................... 13 Yes  
14 Included measures to publicize the policy within the community served by the hospital facility?....... 14 Yes  
If “Yes,” indicate how the hospital facility publicized the policy (check all that apply):
a
b
c
d
e
f
g
Billing and Collections
15 Did the hospital facility have in place during the tax year a separate billing and collections policy, or a written financial assistance policy (FAP) that explained actions the hospital facility may take upon non-payment?....... 15 Yes  
16 Check all of the following actions against an individual that were permitted under the hospital facility's policies during the tax year before making reasonable efforts to determine the patient’s eligibility under the facility’s FAP:
a
b
c
d
e
17 Did the hospital facility or an authorized third party perform any of the following actions during the tax year before making reasonable efforts to determine the patient’s eligibility under the facility’s FAP?.......... 17   No
If “Yes,” check all actions in which the hospital facility or a third party engaged:
a
b
c
d
e
Schedule H (Form 990) 2012
Schedule H (Form 990) 2012
Page
Part VFacility Information (continued)

18 Indicate which efforts the hospital facility made before initiating any of the actions listed in line 17 (check all that apply):
a
b
c
d
e
Policy Relating to Emergency Medical Care
Yes No
19 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?.......... 19 Yes  
If “No,” indicate why:
a
b
c
d
Charges to Individuals Eligible for Assistance under the FAP (FAP-Eligible Individuals)
20 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
b
c
d
21 During the tax year, did the hospital facility charge any FAP-eligible individuals to whom the hospital facility provided emergency or other medically necessary services, more than the amounts generally billed to individuals who had insurance covering such care? ............................ 21   No
If “Yes,” explain in Part VI.
22 During the tax year, did the hospital facility charge any FAP-eligible individuals an amount equal to the gross charge for any service provided to that individual? ......................... 22   No
If “Yes,” explain in Part VI.
Schedule H (Form 990) 2012
Schedule H (Form 990) 2012
Page
Part VFacility Information (continued)

Section C. Other Health Care Facilities That Are Not Licensed, Registered, or Similarly Recognized as a Hospital Facility
(list in order of size, from largest to smallest)
How many non-hospital health care facilities did the organization operate during the tax year?2
Name and address Type of Facility (describe)
1 MEMORIAL CARE CENTER
4315 MEMORIAL DRIVE
BELLEVILLE,IL62226 		SKILLED NURSING FACILITY
2 BELLEVILLE HEALTH & SPORTS CENTER
1001 SOUTH 74TH STREET
BELLEVILLE,IL62223 		SPORTS FACILITY
3
4
5
6
7
8
9
10
Schedule H (Form 990) 2012
Schedule H (Form 990) 2012
Page
Part VI
Supplemental Information
Complete this part to provide the following information.
1 Required descriptions. Provide the descriptions required for Part I, lines 3c, 6a, and 7; Part II; Part III, lines 4, 8, and 9b; Part V, Section A; and Part V, Section B, lines 1j, 3, 4, 5c, 6i, 7, 10, 11, 12h, 14g, 16e, 17e, 18e, 19c, 19d, 20d, 21, and 22.
2 Needs assessment. Describe how the organization assesses the health care needs of the communities it serves, in addition to any needs assessments reported in Part V, Section B.
3 Patient education of eligibility for assistance. Describe how the organization informs and educates patients and persons who may be billed for patient care about their eligibility for assistance under federal, state, or local government programs or under the organization’s financial assistance policy.
4 Community information. Describe the community the organization serves, taking into account the geographic area and demographic constituents it serves.
5 Promotion of community health. Provide any other information important to describing how the organization’s hospital facilities or other health care facilities further its exempt purpose by promoting the health of the community (e.g., open medical staff, community board, use of surplus funds, etc.).
6 Affiliated health care system. If the organization is part of an affiliated health care system, describe the respective roles of the organization and its affiliates in promoting the health of the communities served.
7 State filing of community benefit report. If applicable, identify all states with which the organization, or a related organization, files a community benefit report.
8 Facility reporting group(s). If applicable, for each hospital facility in a facility reporting group provide the descriptions required for Part V, Section B, lines 1j, 3, 4, 5c, 6i, 7, 10, 11, 12h, 14g, 16e, 17e, 18e, 19c, 19d, 20d, 21, and 22.
Identifier ReturnReference Explanation
PART I, LINE 3C   FINANCIAL ASSISTANCE (CHARITY CARE) I. PURPOSE TO DESCRIBE THE GUIDELINES AND PROCESS BY WHICH MEMORIAL WILL GRANT CHARITY CARE TO PATIENTS. II. POLICY MEMORIAL HOSPITAL AND MEMORIAL CARE CENTER (COLLECTIVELY "MEMORIAL") ARE NOT-FOR-PROFIT HEALTHCARE FACILITIES ESTABLISHED TO MEET THE HEALTH CARE NEEDS OF THE COMMUNITY. ACCORDINGLY, MEMORIAL MAINTAINS AN OPEN-DOOR POLICY, RENDERING SERVICE TO ALL INDIVIDUALS WHO PRESENT THEMSELVES FOR MEDICAL CARE. INDIVIDUALS WHO NEED FINANCIAL ASSISTANCE AND DO NOT POSSESS SUFFICIENT RESOURCES TO PAY ALL OR A PORTION OF MEMORIAL'S BILL MAY BE ELIGIBLE FOR CHARITY CARE ACCORDING TO THE GUIDELINES SET FORTH IN THIS POLICY. CHARITY CARE IS AVAILABLE FOR ALL SERVICES PROVIDED BY MEMORIAL WITH THE EXCEPTION OF THE FOLLOWING: 1. ELECTIVE COSMETIC SURGERY, ELECTIVE STERILIZATION AND REVERSE STERILIZATION PROCEDURES AND SCREENING TESTS 2. ANY SERVICES NOT COVERED BY MEDICARE. 3. MEMORIAL CARE CENTER SERVICES FOR LONG-TERM RESIDENTIAL CARE. 4. SERVICES NOT BILLED BY MEMORIAL (E.G., AMBULANCE SERVICES, PHYSICIAN SERVICES, ETC.) PATIENTS WHO DO NOT QUALIFY FOR ASSISTANCE PURSUANT TO THIS POLICY MAY BE ELIGIBLE FOR DISCOUNTS PURSUANT TO AP 740 (UNINSURED PATIENT DISCOUNT POLICY). III. GUIDELINES 1. ELIGIBILITY FOR FINANCIAL ASSISTANCE WILL BE BASED UPON INCOME GUIDELINES APPROVED BY THE BOARD OF DIRECTORS, AS WELL AS THE SIZE OF THE PATIENT'S BILL RELATIVE TO THE PATIENT'S HOUSEHOLD INCOME. A. ELIGIBILITY BASED ON INCOME. ELIGIBILITY FOR FINANCIAL ASSISTANCE WILL BE BASED UPON INCOME GUIDELINES APPROVED BY THE MEMORIAL BOARD OF DIRECTORS, BASED ON FEDERAL POVERTY GUIDELINES PUBLISHED BY THE UNITED STATES DEPARTMENT OF HEALTH & HUMAN SERVICES ("INCOME ELIGIBILITY"). THE INCOME ELIGIBILITY GUIDELINES, AS AMENDED FROM TIME TO TIME BY THE BOARD OF DIRECTORS, ARE SET FORTH IN ATTACHMENT A TO THIS POLICY. B. ELIGIBILITY BASED ON CATASTROPHIC MEDICAL EXPENSES. ELIGIBILITY FOR FINANCIAL ASSISTANCE ALSO WILL BE BASED ON THE SIZE OF THE PATIENT'S BILL RELATIVE TO THE PATIENT'S HOUSEHOLD INCOME. PAYMENT RESPONSIBILITY FOR PATIENTS QUALIFYING FOR INCOME ELIGIBILITY WILL BE CAPPED AT TEN PERCENT (10%) OF ANNUAL FAMILY INCOME,AS DETERMINED IN THE APPLICATION PROCESS. UNINSURED PATIENTS WHO FACE EXTRAORDINARY MEDICAL EXPENSES AND WHO DO NOT QUALIFY FOR CHARITY CARE BASED ON INCOME ELIGIBILITY WILL QUALIFY FOR FINANCIAL ASSISTANCE IF THEIR SELF-PAY BALANCES EXCEED TEN PERCENT (10%) OF ANNUAL FAMILY INCOME ("MEDICAL EXPENSE ELIGIBILITY"). PATIENTS ELIGIBLE ON THE BASIS OF MEDICAL EXPENSE ELIGIBILITY WILL BE RESPONSIBLE FOR THE PORTION OF THE SELF-PAY BALANCE UP TO 10% OF ANNUAL FAMILY INCOME. CHARITY CARE WILL BE GRANTED TO COVER THE EXCESS AMOUNT. 2. MEMORIAL WILL IDENTIFY PATIENTS REQUIRING FINANCIAL ASSISTANCE AS SOON AS POSSIBLE AND AT ANY TIME DURING THE BILLING AND COLLECTION PROCESS. BECAUSE OF THE WAY IN WHICH MEDICAL SERVICES ARE DELIVERED, MOST PATIENTS WILL NOT BE IDENTIFIED AS ELIGIBLE FOR CHARITY CARE PRIOR TO RECEIVING SERVICES. IN ADDITION, CIRCUMSTANCES RELATING TO A PATIENT'S (OR A RESPONSIBLE PARTY'S) ABILITY TO PAY MAY CHANGE SUBSEQUENT TO THE RENDERING OF MEDICAL SERVICES. ACCORDINGLY, A CHARITY CARE DETERMINATION CAN BE MADE FOR A PATIENT AT THE TIME OF SERVICE OR AT ANY TIME DURING THE BILLING AND COLLECTION PROCESS. 3. THE AVAILABILITY OF CHARITY CARE WILL BE COMMUNICATED TO PATIENTS THROUGH A VARIETY OF MEANS TO ENSURE THAT MEMORIAL'S POLICY REACHES PERSONS IN NEED OF ASSISTANCE. COMMUNICATIONS TO PATIENTS REGARDING THE AVAILABILITY OF CHARITY CARE WILL BE CLEAR AND CONCISE AND WILL INCLUDE, BUT NOT BE LIMITED TO, INFORMATION PROVIDED BY REGISTRATION PERSONNEL, STATEMENTS INCLUDED ON CONSENT FORMS AND PATIENT STATEMENTS, PATIENT HANDBOOKS, SIGNAGE WITHIN THE HOSPITAL AND PUBLICATION ON MEMORIAL'S WEBSITE. COPIES OF MEMORIAL'S APPLICATION FOR FINANCIAL ASSISTANCE FORM ("APPLICATION FORM") WILL BE AVAILABLE FOR DISTRIBUTION IN THE PATIENT ACCOUNTS DEPARTMENTS. RECOGNIZING THE SENSITIVITY OF PATIENTS AND THEIR FAMILIES REGARDING THE NEED FOR CHARITY, ALL PUBLICATIONS, FORMS, ETC. WILL USE THE TERM "FINANCIAL ASSISTANCE" IN LIEU OF "CHARITY CARE" OR "CHARITY ASSISTANCE." 4. PATIENTS' SPECIFIC QUESTIONS ABOUT FINANCIAL ASSISTANCE SHOULD BE DIRECTED TO ONE OF THE FOLLOWING PATIENT ACCOUNTS EMPLOYEES: FINANCIAL COUNSELOR, PATIENT FINANCIAL SERVICES MANAGER, ASSISTANT DIRECTOR, OR DIRECTOR. 5. ALL PATIENTS SEEKING FINANCIAL ASSISTANCE WILL BE REQUESTED TO COMPLETE AN APPLICATION FORM. EACH PATIENT OR A PATIENT REPRESENTATIVE WILL BE REQUESTED TO COMPLETE THE APPLICATION FORM IN ORDER FOR MEMORIAL TO DETERMINE ELIGIBILITY FOR FINANCIAL ASSISTANCE ON THE BASIS OF EITHER INCOME ELIGIBILITY OR MEDICAL EXPENSE ELIGIBILITY, PROVIDED THAT PATIENTS WHO DEMONSTRATE ELIGIBILITY FOR GENERAL ASSISTANCE WILL BE DEEMED ELIGIBLE FOR CHARITY ASSISTANCE WITHOUT AN APPLICATION FORM. IT IS THE RESPONSIBILITY OF THE PERSON SEEKING ASSISTANCE TO PROVIDE MEMORIAL WITH SUFFICIENT AND COMPLETE FINANCIAL INFORMATION TO EVALUATE ANY REQUEST FOR CHARITY CARE. MEMORIAL PERSONNEL ARE AVAILABLE TO ASSIST WITH COMPLETION OF THE APPLICATION FORM BY TELEPHONE OR IN PERSON. IF TRANSLATION IS NEEDED TO FACILITATE COMPLETION OF APPLICATIONS, IT WILL BE PROVIDED. CONFIDENTIALITY OF INFORMATION AND PRESERVATION OF PRIVACY SHALL BE MAINTAINED FOR ALL PATIENTS WHO SEEK CHARITY CARE. NO INFORMATION OBTAINED IN THE APPLICATION PROCESS WILL BE RELEASED TO THIRD PARTIES WITHOUT THE PATIENT'S WRITTEN CONSENT. 6. THE PATIENT OR RESPONSIBLE PARTY MUST APPLY TO ANY LOCAL, STATE OR FEDERAL GOVERNMENT PROGRAM FOR WHICH THE PATIENT MAY BE ELIGIBLE FOR MEDICAL PAYMENT ASSISTANCE WHEN APPLICABLE. MEMORIAL PERSONNEL WILL ASSIST THE PATIENT OR RESPONSIBLE PARTY IN THE COMPLETION OF ANY REQUIRED APPLICATION(S). A GOVERNMENT APPLICATION FORM MAY BE SUBSTITUTED FOR THE APPLICATION FORM. 7. ANY INSURANCE BENEFIT OR THIRD PARTY OBLIGATION THAT IS AVAILABLE FOR COVERING THE COST OF MEMORIAL'S SERVICES MUST BE CONSIDERED PRIOR TO THE DETERMINATION OF CHARITY CARE. THIS INCLUDES ANY MEDICAL LIABILITY, NO-FAULT OR INSURANCE BENEFITS. MEMORIAL RESERVES THE RIGHT TO RECOVER ANY AMOUNT PREVIOUSLY APPROVED FOR CHARITY CARE THAT IS SUBSEQUENTLY PAID BY SUCH INSURANCE BENEFIT OR THIRD PARTY. 8. MEMORIAL MAY CONSIDER THE AVAILABILITY OF LIQUID ASSETS IN DETERMINING CHARITY CARE. IN DETERMINING WHETHER A PATIENT QUALIFIES FOR CHARITY CARE, MEMORIAL MAY ALSO CONSIDER THE EXTENT TO WHICH THE PERSON HAS LIQUID ASSETS (CASH AND INVESTMENTS) THAT COULD BE USED TO MEET THE FINANCIAL OBLIGATION. THE PATIENT'S PRINCIPLE RESIDENCE, AUTOMOBILE AND OTHER PERSONAL PROPERTY ARE SPECIFICALLY EXEMPTED FROM CONSIDERATION IN THE DETERMINATION OF FINANCIAL NEED. 9. A DETERMINATION OF THE PATIENT'S ELIGIBILITY FOR CHARITY CARE WILL BE MADE WITHIN FIFTEEN (15) BUSINESS DAYS FROM THE RECEIPT OF A COMPLETED APPLICATION FORM, AND COLLECTION EFFORTS WILL BE SUSPENDED PENDING SUCH DETERMINATION AND OTHERWISE IN COMPLIANCE WITH AP 730 (BILLING AND COLLECTIONS POLICY). PATIENTS WILL BE NOTIFIED IN WRITING OF MEMORIAL'S DECISION TO GRANT OR TO DENY FINANCIAL ASSISTANCE. CHARITY CARE WILL BE EXTENDED FOR ANY OPEN ACCOUNT AT THE TIME OF APPLICATION AND MAY CONTINUE FOR A PERIOD OF SIX (6) MONTHS OR UNTIL A CHANGE IN PATIENT FINANCIAL STATUS IS DETERMINED. EACH APPLICATION FOR FINANCIAL ASSISTANCE (OTHER THAN FINANCIAL ASSISTANCE BASED ON ELIGIBILITY FOR GENERAL ASSISTANCE) MUST BE APPROVED BY THE FOLLOWING PERSONS, IN ORDER FOR CHARITY CARE TO BE EXTENDED: DIRECTOR OF PATIENT ACCOUNTS AND VICE PRESIDENT FINANCE 10. MEMORIAL OFFERS PAYMENT PLAN OPTIONS TO PATIENTS ELIGIBLE FOR CHARITY CARE TO SUCCESSFULLY RETIRE SELF-PAY BALANCES. CHARITY CARE PATIENTS ARE OFFERED INTEREST FREE PAYMENT PLANS TO ASSIST THEM IN RETIRING THEIR OUTSTANDING HOSPITAL BILLS. 11. MEMORIAL WILL OFFER PATIENTS THE OPPORTUNITY TO APPLY FOR CHARITY CARE PRIOR TO REFERRING AN OUTSTANDING HOSPITAL BILL TO COLLECTION. MEMORIAL WILL OFFER TO CONDUCT A FINANCIAL ASSESSMENT OR WILL ARRANGE FOR AN ALTERNATIVE PAYMENT PLAN PRIOR TO SENDING A BILL TO COLLECTION. (SEE AP 730 (BILLING AND COLLECTIONS POLICY)) 12. MEMORIAL WILL TRAIN ITS STAFF IN THE ADMITTING/REGISTRATION AND PATIENT ACCOUNTING DEPARTMENTS WITH REGARD TO THE AVAILABILITY OF FINANCIAL ASSISTANCE UNDER THIS POLICY. 13. MEMORIAL WILL PERIODICALLY EVALUATE ITS CHARITY CARE PROGRAM AND WILL FILE ANNUAL REPORTS AS APPROPRIATE. MANAGEMENT WILL MAKE PERIODIC REPORTS TO THE BOARD OF DIRECTORS REGARDING CHARITY CARE. THIS POLICY WILL BE REVIEWED PERIODICALLY BY SENIOR MANAGERS FOR POSSIBLE REVISION. ANY REVISIONS RECOMMENDED BY MANAGEMENT WILL BE SUBMITTED TO THE BOARD OF DIRECTORS FOR APPROVAL. THE COSTS OF CHARITY CARE WILL BE REPORTED ANNUALLY IN MEMORIAL'S COMMUNITY BENEFIT PLAN REPORT FILED WITH THE STATE OF ILLINOIS AND IN AUDITED FINANCIAL STATEMENTS. ATTACHMENT A - - - - - - - INCOME ELIGIBILITY GUIDELINES APPROVED BY THE BOARD OF DIRECTORS EFFECTIVE JANUARY 1, 2010 BASED UPON THE
PART I, LINE 6A   SEE SCHEDULE O - COMMUNITY BENEFITS REPORT FILED WITH ILLINOIS OFFICE OF ATTORNEY GENERAL PREPARED BY PMMCI
PART I, LINE 7, COLUMN (F)   THE COST OF CHARITY AND OTHER COMMUNITY BENEFITS WERE DIVIDED BY ORGANIZATIONS TOTAL OPERATING EXPENSES.
PART I, LINE 7   CHARITY CARE AND OTHER COMMUNITY BENEFITS WERE CALCULATED IN ACCORDANCE WITH STATE OF ILLINOIS REQUIREMENTS FOR COMMUNITY BENEFITS REPORT. THE MEDICARE COST TO CHARGE RATIO WAS USED FROM THE MEDICARE COST REPORT.
PART III, LINE 4   THE AMOUNT ON LINE 2 REPRESENTS THE AMOUNT WRITTEN OFF TO BAD DEBT EXPENSE DURING 2012. THE ORGANIZATION DID NOT EMPLOY A METHODOLOGY TO ITS ESTIMATE OF BAD DEBT EXPENSE ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE CHARITY CARE AS THERE ARE NO SUPPORTING STATISTICS AVAILABLE. RATHER, THE AMOUNT INCLUDED ON LINE 3 REPRESENTS AN ESTIMATED 15% OF THE TOTAL BAD DEBT EXPENSE REPORTED ON LINE 2. FOOTNOTE FROM AUDITED FINANCIAL STATEMENTS: "ACCOUNTS RECEIVABLE ARE REDUCED BY AN ALLOWANCE FOR DOUBTFUL ACCOUNTS. IN EVALUATING THE COLLECTIBILITY OF ACCOUNTS RECEIVABLE, THE MEDICAL CENTER ANALYZES ITS PAST HISTORY AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYER SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND PROVISION FOR BAD DEBTS. MANAGEMENT REGULARLY REVIEWS DATA ABOUT THESE MAJOR PAYER SOURCES OF REVENUE IN EVALUATING THE SUFFICIENCY OF THE ALLOWANCE FOR DOUBTFUL ACCOUNTS."
PART III, LINE 8   MEDICARE COST REPORT IS FILED FOLLOWING COST REPORT GUIDELINES. MEDICARE PAYMENT SHORTFALLS SHOULD BE REFLECTED AS COMMUNITY BENEFIT AS THE FEDERAL GOVERNMENT PROSPECTIVELY SETS THE HOSPITAL PAYMENT RATES; THE RATES ARE NOT NEGOTIABLE AND CONSEQUENTLY NO LONGER COVER THE HOSPITAL'S COST TO PROVIDE SERVICES TO MEDICARE BENEFICIARIES.
PART III, LINE 9B   BILLING AND COLLECTIONS I. PURPOSE TO INSURE BILLING AND COLLECTION EFFORTS ARE FAIR, CONSISTENT AND IN ACCORDANCE WITH APPLICABLE LAW. II. POLICY MEMORIAL HOSPITAL AND MEMORIAL CARE CENTER (COLLECTIVELY, "MEMORIAL") ARE NOT-FOR-PROFIT HEALTHCARE FACILITIES ESTABLISHED TO MEET THE HEALTH CARE NEEDS OF THE COMMUNITY. ACCORDINGLY, MEMORIAL SHALL PURSUE PATIENT ACCOUNTS FAIRLY AND CONSISTENTLY PURSUANT TO THE LAW AND ONLY AFTER OFFERING PATIENTS THE OPPORTUNITY TO APPLY FOR CHARITY CARE PURSUANT TO AP 700 ("FINANCIAL ASSISTANCE POLICY") AND/OR APPLYING A DISCOUNT PURSUANT TO AP 740 ("UNINSURED PATIENT DISCOUNT POLICY"). III. GUIDELINES 1. BILL INFORMATION. WHEN MEMORIAL BILLS A PATIENT FOR HEALTH CARE SERVICES, IT SHALL PROVIDE THE FOLLOWING INFORMATION: (A) THE DATE OR DATES THAT HEALTH CARE SERVICES WERE PROVIDED TO THE PATIENT; (B) A BRIEF DESCRIPTION OF THE SERVICES; (C) THE AMOUNT OWED FOR SERVICES; (D) CONTACT INFORMATION FOR ADDRESSING BILLING INQUIRIES TO MEMORIAL; (E) NOTICE THAT THE PATIENT MAY OBTAIN AN ITEMIZED BILL UPON REQUEST; AND (F) A STATEMENT REGARDING HOW AN UNINSURED PATIENT MAY APPLY FOR CONSIDERATION UNDER THE FINANCIAL ASSISTANCE POLICY ON OR WITH EACH MEMORIAL BILL SENT TO AN UNINSURED PATIENT. 2. BILL INQUIRIES. MEMORIAL WILL PROVIDE PATIENTS WITH A TELEPHONE NUMBER TO INQUIRE ABOUT OR DISPUTE A BILL. MEMORIAL WILL RETURN CALLS MADE BY PATIENTS PROMPTLY, AND IN ANY CASE NO LATER THAN TWO BUSINESS DAYS AFTER RECEIPT. IF MEMORIAL RECEIVES CORRESPONDENCE FROM THE PATIENT REGARDING A BILL, MEMORIAL WILL RESPOND WITHIN TEN BUSINESS DAYS OF RECEIPT. 3. COLLECTIONS; LIMITATION ON COLLECTIONS. (A) IN GENERAL. MEMORIAL AND ITS AGENTS WILL NOT PURSUE A COLLECTION ACTION AGAINST A PATIENT UNTIL THE PATIENT HAS HAD THE OPPORTUNITY TO ASSESS THE ACCURACY OF THE BILL AND APPLY FOR FINANCIAL ASSISTANCE UNDER THE FINANCIAL ASSISTANCE POLICY OR ESTABLISH A REASONABLE PAYMENT PLAN UNDER THE FINANCIAL ASSISTANCE POLICY OR THIS POLICY. (B) APPROVAL OF COLLECTION ACTIONS. MEMORIAL WILL NOT REFER AN ACCOUNT TO COLLECTIONS, AND WILL NOT PERMIT ANY COLLECTION AGENCY, LAW FIRM OR INDIVIDUAL TO INITIATE LEGAL ACTION FOR NON-PAYMENT OF A HOSPITAL BILL AGAINST A PATIENT, WITHOUT THE WRITTEN APPROVAL OF THE DIRECTOR OF PATIENT ACCOUNTS OR THE PATIENT FINANCIAL SERVICES MANAGER. THE DIRECTOR OF PATIENT ACCOUNTS OR PATIENT FINANCIAL SERVICES MANAGER WILL APPROVE SUCH ACTION ONLY IF HE OR SHE REASONABLY BELIEVES THAT THE CONDITIONS FOR PURSUING THE ACTION UNDER THIS POLICY ARE MET. (C) SPECIAL CONSIDERATIONS FOR UNINSURED PATIENTS. AN UNINSURED PATIENT WILL HAVE SIXTY DAYS FOLLOWING THE DATE OF DISCHARGE OR RECEIPT OF CARE OR THIRTY DAYS FOLLOWING THE INITIAL BILL (WHICHEVER IS LONGER) TO SUBMIT AN APPLICATION FOR FINANCIAL ASSISTANCE OR TO REQUEST A REASONABLE PAYMENT PLAN. THEREAFTER, MEMORIAL MAY PURSUE COLLECTION ACTION AGAINST AN UNINSURED PATIENT ONLY WHEN: (I) THE PATIENT HAS NOT PAID HIS OR HER BILL (AS ADJUSTED PURSUANT TO THE UNINSURED PATIENT DISCOUNT POLICY) DURING SUCH TIME AND HAS NOT CONTACTED MEMORIAL ABOUT PAYMENT; (II) THE PATIENT HAS INFORMED MEMORIAL THAT HE OR SHE HAS APPLIED FOR A GOVERNMENT SPONSORED HEALTHCARE PROGRAM BUT THE PATIENT'S APPLICATION HAS BEEN DENIED; (III) THE PATIENT HAS AGREED TO A REASONABLE PAYMENT PLAN WITH MEMORIAL AND THE PATIENT HAS FAILED TO MAKE PAYMENTS IN ACCORDANCE WITH THAT REASONABLE PAYMENT PLAN; OR (IV) THE PATIENT REQUESTS A REASONABLE PAYMENT PLAN BUT FAILS TO AGREE TO A PLAN WITHIN THIRTY DAYS OF THAT REQUEST. (D) OTHER CONSIDERATIONS. (I) MEMORIAL WILL NOT PURSUE LEGAL ACTION FOR NON-PAYMENT OF BILLS AGAINST PATIENTS WHO QUALIFY FOR FINANCIAL ASSISTANCE AND WHO HAVE CLEARLY DEMONSTRATED THAT THEY HAVE NEITHER SUFFICIENT INCOME NOR ASSETS TO MEET THEIR FINANCIAL OBLIGATION. (II) LEGAL ACTION MAY BE TAKEN BY MEMORIAL TO ENFORCE THE TERMS OF THE PAYMENT PLAN WHEN THERE IS EVIDENCE THAT THE RESPONSIBLE PARTY HAS SUFFICIENT INCOME AND/OR ASSETS TO MEET HIS OR HER FINANCIAL OBLIGATION. (III) MEMORIAL WILL NOT PLACE A LIEN ON THE PRIMARY RESIDENCE OF A PATIENT RECEIVING FINANCIAL ASSISTANCE UNLESS THE VALUE OF THE PROPERTY CLEARLY INDICATES AN ABILITY TO ASSUME SIGNIFICANT FINANCIAL OBLIGATIONS. FURTHER, MEMORIAL WILL NOT EXECUTE A LIEN BY FORCING THE SALE OR FORECLOSURE OF THE PRIMARY RESIDENCE OF A PATIENT RECEIVING FINANCIAL ASSISTANCE TO PAY FOR AN OUTSTANDING MEDICAL BILL. (IV) MEMORIAL WILL NOT USE BODY ATTACHMENT TO REQUIRE ANY PERSON, WHETHER RECEIVING FINANCIAL ASSISTANCE OR NOT, TO APPEAR IN COURT. (E) ADOPTION OF STANDARDS BY COLLECTION AGENCIES. MEMORIAL WILL ENSURE THAT THE GUIDELINES OUTLINED ABOVE ARE ADHERED TO BY ANY EXTERNAL COLLECTION AGENCY, LAW FIRM OR INDIVIDUAL ENGAGED TO ASSIST IN OBTAINING PAYMENT ON OUTSTANDING BILLS FROM PATIENTS. 4. PERIODIC REVIEW. MEMORIAL WILL REVIEW THIS POLICY PERIODICALLY FOR COMPLIANCE WITH THE FEDERAL FAIR DEBT COLLECTION PRACTICES ACT, THE ILLINOIS FAIR PATIENT BILLING ACT AND THE ILLINOIS HOSPITAL UNINSURED PATIENT DISCOUNT ACT.
PART V   1 HOSPITAL & 1 SKILLED NURSING FACILITY ILLINOIS
NEEDS ASSESSMENT   SEE SCHEDULE O - COMMUNITY BENEFITS REPORT REGARDING COMMUNITY NEEDS.
PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCE   FINANCIAL ASSISTANCE IS COMMUNICATED VIA SIGNS POSTED THROUGHOUT THE HOSPITAL, NEWSPAPER, BROCHURES, WEBSITE, AND PATIENT BILLING STATEMENTS.
COMMUNITY INFORMATION   SEE SCHEDULE O - COMMUNITY BENEFIT REPORT FOR DESCRIPTION OF THE GEOGRAPHIC AND DEMOGRAPHIC PROFILES OF PATIENTS SERVED.
PROMOTION OF COMMUNITY HEALTH   SEE SCHEDULE O - COMMUNITY BENEFIT REPORT REGARDING SUBSIDIZED COMMUNITY OUTREACH, COMMUNITY EDUCATION, SUPPORT GROUPS AND SCREENINGS
OTHER INFORMATION REQUIRED   SEE SCHEDULE O - COMMUNITY BENEFITS REPORT FOR A DESCRIPTION OF ACTIVITIES THAT FURTHER THE ORGANIZATION'S EXEMPT PURPOSE. ADDITIONALLY, THE FOLLOWING IS THE UNINSURED PATIENT DISCOUNT POLICY: UNINSURED PATIENT DISCOUNT I. PURPOSE TO DESCRIBE THE GUIDELINES AND PROCESS BY WHICH MEMORIAL WILL GRANT UNINSURED PATIENTS A DISCOUNT FROM BILLED CHARGES. II. POLICY MEMORIAL HOSPITAL AND MEMORIAL CARE CENTER (COLLECTIVELY "MEMORIAL") ARE NOT-FOR-PROFIT HEALTHCARE FACILITIES ESTABLISHED TO MEET THE HEALTH CARE NEEDS OF THE COMMUNITY. ACCORDINGLY, MEMORIAL MAINTAINS AN OPEN-DOOR POLICY, RENDERING SERVICE TO ALL INDIVIDUALS WHO PRESENT THEMSELVES FOR MEDICAL CARE. IN AN EFFORT TO PROVIDE AFFORDABLE HEALTH CARE SERVICES, PATIENTS WHO LACK PRIVATE OR PUBLIC HEALTH INSURANCE WILL RECEIVE AN AUTOMATIC DISCOUNT FROM MEMORIAL'S BILLED CHARGES. THE UNINSURED PATIENT DISCOUNT IS AVAILABLE FOR ALL SERVICES PROVIDED BY MEMORIAL WITH THE EXCEPTION OF THE FOLLOWING: 1. ELECTIVE COSMETIC SURGERY, ELECTIVE STERILIZATION AND REVERSE STERILIZATION PROCEDURES AND PROCEDURES OR OTHER SERVICES NOT COVERED BY MEDICARE. 2. MEMORIAL CARE CENTER SERVICES FOR LONG-TERM RESIDENTIAL CARE. 3. NON-MEDICAL SERVICES (E.G., SOCIAL AND VOCATIONAL SERVICES). 4. SERVICES NOT BILLED BY MEMORIAL (E.G., AMBULANCE SERVICES, PHYSICIAN SERVICES ETC.) THIS POLICY WILL BE INTERPRETED AND APPLIED IN A MANNER CONSISTENT WITH THE ILLINOIS HOSPITAL UNINSURED PATIENT DISCOUNT ACT. III. GUIDELINES 1. ELIGIBILITY FOR THE DISCOUNT. AN "UNINSURED PATIENT" IS DEFINED AS: ANY PATIENT WHO IS NOT COVERED UNDER A POLICY OF HEALTH INSURANCE AND IS NOT A BENEFICIARY UNDER A PUBLIC OR PRIVATE HEALTH INSURANCE, HEALTH BENEFIT, OR OTHER HEALTH COVERAGE PROGRAM, INCLUDING HIGH DEDUCTIBLE HEALTH INSURANCE PLANS, WORKERS' COMPENSATION, ACCIDENT LIABILITY INSURANCE OR OTHER THIRD PARTY LIABILITY OR NO FAULT INSURANCE. PATIENTS THAT ARE INSURED BUT NOT COVERED FOR A PARTICULAR SERVICE DO NOT QUALIFY FOR THE UNINSURED PATIENT DISCOUNT. THE AVAILABILITY OF THE UNINSURED DISCOUNT IS CONTINGENT UPON THE UNINSURED PATIENT APPLYING, AT MEMORIAL'S REQUEST, FOR COVERAGE UNDER PUBLIC PROGRAMS (I.E., MEDICARE, MEDICAID, ETC.) IF MEMORIAL DETERMINES THERE IS A BASIS TO BELIEVE THE PATIENT MAY BE ELIGIBLE FOR SUCH PROGRAMS. 2. CALCULATION OF THE DISCOUNT. THE DISCOUNT IS CALCULATED AS THE DIFFERENCE BETWEEN BILLED CHARGES AND ONE HUNDRED THIRTY-FIVE PERCENT (135%) OF COST, USING THE TOTAL COST-TO-CHARGE RATIO FROM MEMORIAL'S MOST RECENTLY FILED MEDICARE COST REPORT (WORKSHEET C, PART I). 3. MAXIMUM ANNUAL COLLECTION. THE MAXIMUM AMOUNT COLLECTED FROM AN ELIGIBLE PATIENT IN A TWELVE-MONTH PERIOD IS TWENTY-FIVE PERCENT (25%) OF THE FAMILY'S ANNUAL HOUSEHOLD INCOME. THE TWELVE-MONTH PERIOD BEGINS AS OF THE FIRST DATE OF SERVICE ELIGIBLE FOR DISCOUNT. FOR SUBSEQUENT SERVICES TO BE COUNTED TOWARD THE MAXIMUM, THE PATIENT MUST INFORM MEMORIAL THAT HE/SHE HAD RECEIVED PRIOR DISCOUNTED SERVICES FROM MEMORIAL. THE ANNUAL CAP IS APPLICABLE ONLY TO SERVICES PROVIDED AT MEMORIAL AND DOES NOT INCLUDE SERVICES PROVIDED AT OTHER HOSPITAL FACILITIES. 4. COMMUNICATION TO PATIENTS. MEMORIAL WILL INCLUDE A STATEMENT ON ALL PATIENT BILLS THAT FINANCIAL ASSISTANCE MAY BE AVAILABLE ON THE REMAINING ACCOUNT BALANCE, PURSUANT TO AP 700 (FINANCIAL ASSISTANCE POLICY).
PART V, LINE 20D   ATTACHMENT A TO THE FINANCIAL ASSISTANCE POLICY DESCRIBED IN THE NOTE FOR PART I, LINE 3C PROVIDES THE FACTORS FOR DETERMINING THE MAXIMUM AMOUNTS THAT CAN BE CHARGED TO FAP-ELIGIBLE PATIENTS.
PART V, LINE 18E   AVAILABILITY OF FINANCIAL AID IS DISCUSSED WITH PATIENTS DURING TELEPHONE COLLECTION CALLS IN WHICH THE PATIENTS INDICATE THEY WILL HAVE DIFFICULTY PAYING THEIR BILL.
STATE FILING OF COMMUNITY BENEFIT REPORT   IL,
Schedule H (Form 990) 2012
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
2012
Open to Public Inspection
Name of the organization
Protestant Memorial Medical Center Inc
 
Employer identification number

37-0635502
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 of 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 filing organization used to establish the compensation of the
organization's CEO/Executive Director. Check all that apply. Do not check any boxes for methods
used by a related organization to establish compensation of the CEO/Executive Director, but explain in Part III.
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 Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50053T
Schedule J (Form 990) 2012

Schedule J (Form 990) 2012
Page 2
Part II
Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees. Use duplicate copies if additional space is needed.
For each individual whose compensation must be reported in Schedule J, report compensation from the organization on row (i) and from related organizations, described in the
instructions, on row (ii). Do not list any individuals that are not listed on Form 990, Part VII.
Note. The sum of columns (B)(i)-(iii) for each listed individual must equal the total amount of Form 990, Part VII, Section A, line 1a, applicable column (D) and (E) amounts for that individual.
(A) Name and Title (B) Breakdown of W-2 and/or 1099-MISC compensation (C) Retirement and other deferred compensation (D) Nontaxable
benefits		 (E) Total of columns
(B)(i)-(D) 		(F) Compensation
reported as deferred
in prior Form 990
(i) Base compensation (ii) Bonus & incentive compensation (iii) Other reportable compensation
(1)MARK TURNERPRESIDENT (i)
(ii)		 590,129
0 		0
0 		17,000
0 		158,576
0 		19,641
0 		785,346
0 		0
0
(2)JOE LANIUSVP FINANCE (i)
(ii)		 129,386
181,140 		0
0 		7,083
9,917 		25,170
35,237 		6,017
8,424 		167,656
234,718 		0
0
(3)NANCY WESTONVP NURSING SERVICES (i)
(ii)		 253,566
0 		0
0 		17,000
0 		35,893
0 		10,067
0 		316,526
0 		0
0
(4)RUTH HOLMESADMINISTRATOR MEMORIAL EAST (i)
(ii)		 92,477
129,467 		0
0 		2,982
4,174 		7,265
10,171 		7,166
10,032 		109,890
153,844 		0
0
(5)ROBERT WANLESS MDDIRECTOR (i)
(ii)		 0
431,627 		0
0 		0
5,698 		0
35,995 		0
12,960 		0
486,280 		0
0
(6)JOHN KESSLERVP GEN SERVICES (i)
(ii)		 171,379
0 		0
0 		14,247
0 		17,022
0 		16,655
0 		219,303
0 		0
0
(7)CHERYL CREASYVP RISK MANAGEMENT (i)
(ii)		 155,924
0 		0
0 		6,328
0 		11,775
0 		17,397
0 		191,424
0 		0
0
(8)JAMES DAVISVP PHYSICIAN SERVICES (i)
(ii)		 0
187,543 		0
0 		0
12,776 		0
18,361 		0
15,323 		0
234,003 		0
0
(9)WILLIAM CASPERSON MDVP MEDICAL AFFAIRS (i)
(ii)		 344,861
0 		0
0 		17,000
0 		56,691
0 		15,384
0 		433,936
0 		0
0
(10)LINDA FRITSCHETELEMETRY NURSE (i)
(ii)		 171,483
0 		0
0 		0
0 		5,131
0 		14,070
0 		190,684
0 		0
0
(11)MARGARET LOWERYGENERAL COUNSEL (i)
(ii)		 167,947
0 		0
0 		0
0 		11,290
0 		7,273
0 		186,510
0 		0
0
(12)MARIA GHORMLEYEMERGENCY NURSE (i)
(ii)		 165,307
0 		0
0 		0
0 		4,605
0 		11,058
0 		180,970
0 		0
0
(13)AMY THOMASVICE PRESIDENT FINANCE (i)
(ii)		 164,630
0 		0
0 		0
0 		11,322
0 		12,753
0 		188,705
0 		0
0
(14)JOHN ZIEGLERVP HUMAN RESOURCES (i)
(ii)		 161,149
0 		0
0 		7,915
0 		13,861
0 		17,430
0 		200,355
0 		0
0
(15)STARLA ELLERDIRECTOR SURGICAL SERVICES (i)
(ii)		 173,159
0 		0
0 		0
0 		0
0 		6,222
0 		179,381
0 		0
0
(16)JENNIFER MEINKOTHDIRECTOR INFORMATION TECHNOLOG (i)
(ii)		 157,365
0 		0
0 		0
0 		10,680
0 		14,070
0 		182,115
0 		0
0
(17)MICHAEL MCMANUSCHIEF OPERATING OFFICER (i)
(ii)		 142,086
0 		0
0 		0
0 		0
0 		10,116
0 		152,202
0 		0
0
Schedule J (Form 990) 2012

Schedule J (Form 990) 2012
Page 3
Part III
Supplemental Information
Complete this part to provide the information, explanation, or descriptions required for Part I, lines 1a, 1b, 3, 4a, 4b, 4c, 5a, 5b, 6a, 6b, 7, and 8, and for Part II.
Also complete this part for any additional information.
Identifier Return Reference Explanation
PART II, 4B   DEFERRED COMPENSATION AND RETIREMENT CONTRIBUTIONS PER PART 11(C): ROBERT WANLESS, MEMORIAL MEDICAL GROUP PHYSICIAN: RETIREMENT CONTRIBUTION - $19,495 DEFERRED COMPENSATION - $16,500 JAMES DAVIS, VICE PRESIDENT PHYSICIAN SERVICES: RETIREMENT CONTRIBUTION - $11,971 DEFERRED COMPENSATION - $6,390 MARK TURNER, PRESIDENT: RETIREMENT CONTRIBUTION - $19,495 DEFERRED COMPENSATION - $139,081 JOE LANIUS, VICE PRESIDENT FINANCE: RETIREMENT CONTRIBUTION - $19,495 DEFERRED COMPENSATION - $40,912 JOHN KESSLER, VICE PRESIDENT GENERAL SERVICES: RETIREMENT CONTRIBUTION - $9,897 DEFERRED COMPENSATION - $7,125 RUTH HOLMES, ADMINISTRATOR MEMORIAL EAST: RETIREMENT CONTRIBUTION - $13,858 DEFERRED COMPENSATION - $3,579 MARIA GHORMLEY, EMERGENCY DEPARTMENT NURSE: RETIREMENT CONTRIBUTION - $4,605 DEFERRED COMPENSATION - NONE JOHN ZIEGLER, VICE PRESIDENT HUMAN RESOURCES: RETIREMENT CONTRIBUTION - $9,902 DEFERRED COMPENSATION - $3,959 CHERYL CREASY, VICE PRESIDENT RISK MANAGEMENT: RETIREMENT CONTRIBUTION - $8,610 DEFERRED COMPENSATION - $3,165 NANCY WESTON, VICE PRESIDENT NURSING SERVICES: RETIREMENT CONTRIBUTION - $16,583 DEFERRED COMPENSATION - $19,310 WILLIAM CASPERSON, VICE PRESIDENT MEDICAL AFFAIRS: RETIREMENT CONTRIBUTION - $19,495 DEFERRED COMPENSATION - $37,196 AMY THOMAS, VICE PRESIDENT FINANCE: RETIREMENT CONTRIBUTION - $11,322 DEFERRED COMPENSATION - NONE MARGARET LOWERY, GENERAL COUNSEL: RETIREMENT CONTRIBUTION - $11,290 DEFERRED COMPENSATION - NONE STARLA ELLER, DIRECTOR SURGICAL SERVICES: RETIREMENT CONTRIBUTION - NONE DEFERRED COMPENSATION - NONE LINDA FRITSCHE, TELEMETRY NURSE: RETIREMENT CONTRIBUTION - $5,131 DEFERRED COMPENSATION - NONE JENNIFER MEINKOTH, DIRECTOR INFORMATION TECHNOLOGY: RETIREMENT CONTRIBUTION - $10,680 DEFERRED COMPENSATION - NONE MICHAEL MCMANUS, CHIEF OPERATING OFFICER RETIREMENT CONTRIBUTION - NONE DEFERRED COMPENSATION - NONE
Schedule J (Form 990) 2012

Additional Data


Software ID:  
Software Version:  
Schedule K
(Form 990)
Department of the Treasury
Internal Revenue Service
Supplemental Information on Tax Exempt Bonds
SchKMediumBullet Complete if the organization answered "Yes" to Form 990, Part IV, line 24a. Provide descriptions,
explanations, and any additional information in Part VI.
SchKMediumBullet Attach to Form 990. SchKMediumBullet See separate instructions.
OMB No. 1545-0047
2012
Open to Public
Inspection
Name of the organization
Protestant Memorial Medical Center Inc
 
Employer identification number
37-0635502
Part I
Bond Issues
(a) Issuer name (b) Issuer EIN (c) CUSIP # (d) Date issued (e) Issue price (f) Description of purpose (g) Defeased (h) On
behalf of
issuer 		(i) Pool
financing
Yes No Yes No Yes No
A SOUTHWEST ILLINOIS DEVELOPMENT
  		37-1234684   08-11-2011 30,000,000 CAPITAL BUILDING PROJECTS   X   X   X
Part II
Proceeds
A B C D
1 Amount of bonds retired . . . . . . . . . . . . . . 0      
2 Amount of bonds legally defeased . . . . . . . . . . . 0      
3 Total proceeds of issue . . . . . . . . . . . . . . 14,455,433      
4 Gross proceeds in reserve funds . . . . . . . . . . . . 0      
5 Capitalized interest from proceeds . . . . . . . . . . . 0      
6 Proceeds in refunding escrows . . . . . . . . . . . . 0      
7 Issuance costs from proceeds . . . . . . . . . . . . 0      
8 Credit enhancement from proceeds . . . . . . . . . . . 0      
9 Working capital expenditures from proceeds . . . . . . . . . 0      
10 Capital expenditures from proceeds . . . . . . . . . . . 13,783,417      
11 Other spent proceeds . . . . . . . . . . . . . . 0      
12 Other unspent proceeds . . . . . . . . . . . . . . 672,016      
13 Year of substantial completion . . . . . . . . . . . . 2013
Yes No Yes No Yes No Yes No
14 Were the bonds issued as part of a current refunding issue? . . . . .   X            
15 Were the bonds issued as part of an advance refunding issue? . . . . .   X            
16 Has the final allocation of proceeds been made? . . . . . . . .   X            
17 Does the organization maintain adequate books and records to support the final allocation of proceeds? . . . . . . . . . . . . . . X              
Part III
Private Business Use
A B C D
Yes No Yes No Yes No Yes No
1 Was the organization a partner in a partnership, or a member of an LLC, which owned property financed by tax-exempt bonds? . . . . . . .   X            
2 Are there any lease arrangements that may result in private business use of bond-financed property? . . . . . . . . .   X            
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50193E
Schedule K (Form 990) 2012
Schedule K (Form 990) 2012
Page 2
Part III
Private Business Use (Continued)
A B C D
Yes No Yes No Yes No Yes No
3a Are there any management or service contracts that may result in private business use of bond-financed property? . . . . . . . . . . . .   X            
b If "Yes" to line 3a, does the organization routinely engage bond counsel or other outside counsel to review any management or service contracts relating to the financed property? . . . . . . . . . . . . . . . .                
c Are there any research agreements that may result in private business use of bond-financed property? . . . . . . . . . . . . . . .   X            
d If "Yes" to line 3c, does the organization routinely engage bond counsel or other outside counsel to review any research agreements relating to the financed property? .                
4 Enter the percentage of financed property used in a private business use by entities other than a section 501(c)(3) organization or a state or local government . . SchKMediumBullet 0%   %   %   %
5 Enter the percentage of financed property used in a private business use as a result of unrelated trade or business activity carried on by your organization, another section 501(c)(3) organization, or a state or local government . . . . . . . SchKMediumBullet   %   %   %   %
6 Total of lines 4 and 5 . . . . . . . . . . . . . . .   %   %   %   %
7 Does the bond issue meet the private security or payment test? . . . . . X              
8a Has there been a sale or disposition of any of the bond financed property to a nongovernmental person other than a 501(c)(3) organization since the bonds were issued?. . . . . . . . . . . . . . . . .   X            
b If “Yes” to line 8a, enter the percentage of bond-financed property sold or disposed of.   %   %   %   %
c If “Yes” to line 8a, was any remedial action taken pursuant to Regulations sections 1.141-12 and 1.145-2? . . . . . . . . . . . . .   X            
9 Has the organization established written procedures to ensure that all nonqualified bonds of the issue are remediated in accordance with the requirements under
Regulations sections 1.141-12 and 1.145-2?
X              
Part IV
Arbitrage
A B C D
Yes No Yes No Yes No Yes No
1 Has the issuer filed Form 8038-T? . . . . .   X            
2 If "No" to line 1, did the following apply? . . . .
a Rebate not due yet? . . . . . . . . X              
b Exception to rebate? . . . . . . . .                
c No rebate due? . . . . . . . . . .
               
If you checked "No rebate due" in line 2c, provide in Part VI the date the rebate computation was performed
3 Is the bond issue a variable rate issue? . . . . X              
4a Has the organization or the governmental issuer entered into a qualified hedge with respect to the bond issue?   X            
b Name of provider . . . . . . . . . 0
  		 
  		 
  		 
 
c Term of hedge . . . . . . . . . .        
d Was the hedge superintegrated? . . . . . .                
e Was a hedge terminated? . . . . . . .                
Schedule K (Form 990) 2012
Schedule K (Form 990) 2012
Page 3
Part IV
Arbitrage (Continued)
A B C D
Yes No Yes No Yes No Yes No
5a Were gross proceeds invested in a guaranteed investment contract (GIC)? . . . . . . . . .   X            
b Name of provider . . . . . . . . . 0
  		 
  		 
  		 
 
c Term of GIC . . . . . . . . . .        
d Was the regulatory safe harbor for establishing the fair market value of the GIC satisfied? . . . . .                
6 Were any gross proceeds invested beyond an available temporary period? . . . . . . . .   X            
7 Has the organization established written procedures to monitor the requirements of section 148? . . . X              
Part V
Procedures To Undertake Corrective Action
A B C D
Yes No Yes No Yes No Yes No
1 Has the organization established written procedures to ensure that violations of federal tax requirements are timely identified and corrected through the voluntary closing agreement program if self-remediation is not available under applicable regulations? X              
Part VI
Supplemental Information. Complete this part to provide additional information for responses to questions on Schedule K (see instructions).
Identifier Return Reference Explanation
PROTESTANT MEMORIAL MEDICAL CENTER, INC. RECEIVED PROCEEDS OF $14,455,433 AND SOUTHWEST ILLINOIS HEALTH VENTURES, INC.,A RELATED 501(C)(3) ORGANIZATION, RECEIVED PROCEEDS OF $15,544,567.
Schedule K (Form 990) 2012

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, line 38a or 40b.
MediumBullet Attach to Form 990 or Form 990-EZ. MediumBullet See separate instructions.
OMB No. 1545-0047
2012
Open to Public Inspection
Name of the organization
Protestant Memorial Medical Center Inc
 
Employer identification number

37-0635502
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) Relationship between disqualified person and organization (c) Description of transaction (d) Corrected?
Yes No





2
Enter the amount of tax incurred by 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-EZ, Part V, line 38a, or Form 990, Part IV, line 26; or if the organization reported an amount on Form 990, Part X, line 5, 6, or 22
(a) Name of interested person (b) Relationship with organization (c) Purpose of loan (d) Loan to or from the organization? (e)Original principal amount (f)Balance due (g) In default? (h) Approved by board or committee? (i)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 assistance (d) Type of assistance (e) Purpose of assistance
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.
Cat. No. 50056A
Schedule L (Form 990 or 990-EZ) 2012
Schedule L (Form 990 or 990-EZ) 2012
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) SUSAN MCMANUS COO FAMILY MEMBER 47,252 EMPLOYMENT   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) 2012

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
2012
Open to Public
Inspection
Name of the organization
Protestant Memorial Medical Center Inc
 
Employer identification number

37-0635502
Identifier Return Reference Explanation
COMMUNITY BENEFIT INFORMATION   I. SUMMARY THE VALUE OF COMMUNITY BENEFITS PROVIDED BY MEMORIAL HOSPITAL DURING 2012 EXCEEDED $55.2 MILLION. COMMUNITY BENEFIT VALUE - - - - - - - - - - - - UNPAID COSTS OF MEDICAID AND MEDICARE $32,346,723 BAD DEBTS 16,259,816 CHARITY CARE 5,056,125 VOLUNTEER SERVICES 460,756 SUBSIDIZED HEALTH SERVICES 322,024 EDUCATION 585,369 DONATIONS 171,182 LANGUAGE ASSISTANT SERVICES 55,068 OTHER COMMUNITY ACTIVITIES 16,866 TOTAL COMMUNITY BENEFITS FOR 2012 $55,273,929 IN 2013 MEMORIAL HOSPITAL WILL CONTINUE TO PROVIDE A COMPREHENSIVE RANGE OF QUALITY HEALTHCARE SERVICES TO RESIDENTS OF THE COMMUNITIES IT SERVES THROUGHOUT SOUTHWESTERN ILLINOIS, CONTINUE ITS CHARITY CARE ASSISTANCE PROGRAM, AND IMPROVE COMMUNICATION WITH COMMUNITY PARTNERS AND PATIENTS REGARDING THE HEALTH RESOURCES AND PATIENT CARE. II. MISSION STATEMENT PROVIDE EXCEPTIONAL HEALTHCARE AND COMPASSIONATE SERVICE. III. VISION STATEMENT MEMORIAL, IN PARTNERSHIP WITH ITS MEDICAL STAFF, EMPLOYEES, VOLUNTEERS, AND THE COMMUNITY, IS COMMITTED TO BEING THE HEALTHCARE PROVIDER OF CHOICE BY: -DELIVERING EXTRAORDINARY CARE AND COMPASSIONATE SERVICE TO PATIENTS EVERY DAY -CONTINUALLY IDENTIFYING PERFORMANCE IMPROVEMENT OPPORTUNITIES" EXPANDING SERVICES BASED ON COMMUNITY NEED AND ENHANCING ACCESSIBILITY TO CARE -PROVIDING PHYSICAL FACILITIES AND ACQUIRING THE ADVANCED TECHNOLOGY TO EXCEED PATIENT AND PHYSICIAN EXPECTATIONS -BEING THE EMPLOYER OF CHOICE, CONTINUING TO RECRUIT AND RETAIN SKILLED STAFF COMMITTED TO PROVIDING SERVICE EXCELLENCE TO PATIENTS, VISITORS, AND CO-WORKERS IV. COMMUNITY BENEFITS PROVIDED IN 2012 DURING 2012 MEMORIAL PROVIDED THE FOLLOWING COMMUNITY OUTREACH SERVICES TO AREA RESIDENTS AT NO OR MINIMAL COST:
COMMUNITY BENEFIT INFORMATION (CONT)   SERVICE PERSONS SERVED - - - - - - - - - - - - - - - - - - - - - - - - - - - - 1. COMMUNITY HEALTH EDUCATION -BIONESS PROGRAMS 30 -SAFESITTER 36 -AARP 55 ALIVE DRIVING PROGRAM 40 -HEALTHY CONVERSATION-XIAFLEX INJECTION DUPUYTERIS 75 -HEALTHY CONVERSATION-MEDITATION 23 -HEALTHY CONVERSATION-ALZHEIMER'S 35 -HEALTHY CONVERSATION-A NEW YOU 35 -HEALTHY CONVERSATION-LASER VEIN TREATMENT 26 -HEALTHY CONVERSATION-PHYSICAL MEDICINE&REHAB 28 2. WELLNESS PROGRAMS -HEALTHY LIFESTYLE 47 -FREEDOM FROM SMOKING 18 -LIVELY LUNGS 72 VISITS-BELLEVILLE HEALTH & SPORTS AND YMCA 4,217 -CARDIAC WELLNESS/REHAB PROGRAM 733 -BELLEVILLE EAST HEALTH EDUCATION CLUB 300 -MOVE-IT PROGRAM IN AREA GRADE AND MIDDLE SCHOOL 7,000 -TASTE BUDS-NUTRITION PROGRAM FOR GRADE SCHOOLS 2,300 -PARISH NURSES 12 3. SPEAKERS BUREAU -HEALTH, WELLNESS AND FAITH 730 TOTAL -STROKE PARTICIPANTS -CARDIAC REHAB IN -COPD/HEART FAILURE SPEAKERS -BREATHING/MEDITATION BUREAU -STRESS MANAGEMENT -INFECTION CONTROL -PHLEBOTOMY -HEART HEALTH -DIABETES -HEALTH REFORM AND IMPACT ON MH -PERSONAL TRAINING -RESPIRATORY ISSUES -NUTRITION -OCCUPATIONAL THERAPY AS A CAREER -FLU SHOTS -HEART-RELATED ILLNESSES/PREVENTION/TREATMENT -ORTHOPEDIC AND NEUROSCIENCES SERVICES -BREAST HEALTH/SELF BREAST EXAM -ALZHEIMER'S DISEASE -EMERGENCY MEDICAL SERVICES 4. CLINICS, SCREENINGS AND SERVICES -PACESETTERS 75 -SKIN CANCER SCREENING 152 -KIDNEY MOBILE 150 -COLORECTAL SCREENING 170 BLOOD DRIVE DONATIONS: -MEMORIAL BLOOD DRIVES 357 5. SUPPORT GROUPS -DIABETES 157 -PULMONARY REHAB 385 -FIBROMYALGIA 65 -MENDED HEARTS 144 -HOPE BLOOMS 97 -AWAKE 190 -GRAVES DISEASE 60 6. SPECIAL EVENTS AND PARTNERSHIPS -MATERNITY FAIR 275 -MARCH OF DIMES WALK FOR BABIES 100 -HEART WALK (AMERICAN HEART ASSOCIATION) 200 -IT'S NOT SO SCARY PEDIATRIC VIDEO 750 -AMERICAN CANCER SOCIETY MAKING STRIDES 40 AGAINST BREAST CANCER -AMERICAN DIABETES ASSOCIATION WALK/RUN 35 -TREASURE YOUR HEART-HEART FAIR 80 -SUSAN G. KOMEN RACE FOR THE CURE 105 -SUGAR AND SPICE. . .AND EVERYTHING DIABETES 115 -LIPSTIK WOMEN'S EVENT 50 -CAR CRUISE BENEFIT 100 -SPRING FLING 930 -CAREER DAY 30 -READ WRITE RUN 100 -LIVING WELL EXPO 1,000 -O'FALLON GRAN PRIX 1,500 -BACK PACK TO SCHOOL 300 -FAMILY FITNESS NIGHT 75 COMMUNITY HEALTH FAIRS AND SCREENINGS: -BELLEVILLE EAST HIGH SCHOOL (3) -MACY'S GO RED DAY -CASINO QUEEN (2) -MONROE COUNTY EMPLOYEES -COLLINSVILLE MIDDLE SCHOOL -MADISON COUNTY GOVERNMENT (2) -EMGE SCHOOL(2) -GOVERNOR FRENCH ACADEMY -ALLSUP -SCOTT AIR FORCE BASE -CITY OF COLLINSVILLE -CABLOFILL -METRO LINK EMPLOYEES -NEW ANTIOCH BAPTIST CHURCH -LMI -FAIRMOUNT PARK EMPLOYEES -ROHO GROUP -BELLEVILLE WEST HIGH SCHOOL -ST. PAUL UCC-WATERLOO -MISSIONARY ASSOCIATION -MCKENDREE UNIVERSITY -THE NATIONAL SHRINE OF OUR LADY OF THE SNOWS -VATTEROT COLLEGE -SHOP-N-SAVE STORES -ST.NICHOLAS CHURCH-O'FALLON -AMERICAN SOCIETY OF MILITARY COMPTROLLERS -PROGRAMS AND SERVICES FOR OLDER PERSONS -FITNESS NIGHT-O'FALLON SCHOOLS HEALTHY DIRECTION (WELLNESS VEHICLE) -PROGRAMS AND PERSONS FOR OLDER PERSONS -RELIANCE BANK - MULTIPLE LOCATIONS -MADISON COUNTY GOVERNMENT OFFICES -METROLINK (2) -DILLARD'S - FAIRVIEW HEIGHTS -MCKENDREE UNIVERSITY - LEBANON -ST. TERESA'S CATHOLIC CHURCH - BELLEVILLE -CASINO QUEEN - EAST ST. LOUIS -PLUMMER JOHNSON - FAIRVIEW HEIGHTS -ST. PAUL UNITED CHURCH OF CHRIST - WATERLOO -BELLEVILLE EAST HIGH SCHOOL -LINDENWOOD UNIVERSITY-PINK OUT EVENT -MACY'S-FAIRVIEW HEIGHTS -SCOUT EVENT-DUPO, ILLINOIS -BANK OF EDWARDSVILLE-MULTIPLE LOCATIONS -SAM'S CLUB-O'FALLON -MAKING STRIDES WALK -SHOP-N-SAVE STORES-MULTIPLE LOCATIONS -SCOTT CREDIT UNION -CENTRAL JUNIOR HIGH SCHOOL HEALTHY DIRECTION SCREENINGS INCLUDE: -SCREENING MAMMOGRAPHY -BLOOD PRESSURE -BMI WITH BODY FAT PERCENTAGE -CHOLESTEROL/GLUCOSE -LIPID PANELS -PSAS -FORCED VITAL CAPACITY -PULSE OXIMETRY -COLORECTAL SCREENINGS -SKIN CANCER SCREENING -CARDIAC RISK PROFILES -COOLING STATION OTHER -HEART WALK - MEMORIAL AND ITS EMPLOYEES PARTICIPATED IN THE AMERICAN HEART ASSOCIATION HEART WALK AND HAVE BEEN REPRESENTED ON VARIOUS COMMITTEES. -MARCH OF DIMES WALK AMERICa - MEMORIAL HAS BEEN A CHECK POINT SPONSOR FOR THIS EVENT THE PAST SEVERAL YEARS AND HAS HAD REPRESENTATION ON ITS BOARD VIA A NURSERY NURSE. MEMORIAL HAS BEEN THE HOST SITE FOR THIS EVENT SINCE 2009. -MAKING STRIDES AGAINST BREAST CANCER - MEMORIAL HAS SUPPORTED THIS EVENT THROUGH SPONSORSHIP, PARTICIPATION, AND OTHER IN-KIND SUPPORT. -SUSAN G. KOMEN RACE FOR THE CURE - MEMORIAL SUPPORTS EMPLOYEES WHO WISH TO PARTICIPATE IN THIS EVENT BY PAYING ONE HALF OF THE WALKER/RUNNER REGISTRATION FEE. -AMERICAN DIABETES ASSOCIATION RUN/WALK - AS A CERTIFIED CENTER FOR DIABETIC EDUCATION, MEMORIAL SERVED A MAJOR SPONSOR FOR THIS RUN/WALK THROUGH PARTICIPATION AND IN-KIND SUPPORT. HEALTH EDUCATION AND OUTREACH PROGRAMS BENEFITED OVER 25,000 PERSONS IN THE COMMUNITIES SERVED BY MEMORIAL. TOTAL COMMUNITY BENEFITS TOTAL COMMUNITY BENEFITS, INCLUDING OUTREACH PROGRAMS, TOTALED $52,273,929 DURING 2012. BELOW IS A SUMMARY OF THESE ACTIVITIES: 1. UNPAID COSTS OF PROVIDING CARE TO MEDICAID AND MEDICARE PATIENTS A. TARGET POPULATIONS - MEDICAID AND MEDICARE ENROLLEES B. OBJECTIVES - PROVIDE NEEDED INPATIENT AND OUTPATIENT SERVICES TO THE COMMUNITY C. COSTS AND OUTCOMES - $32,346,723 2. BAD DEBTS A. TARGET POPULATIONS - BROAD COMMUNITY B. OBJECTIVES - PROVIDE NEEDED INPATIENT AND OUTPATIENT SERVICES TO THE COMMUNITY C. COSTS AND OUTCOMES - $16,259,816 3. CHARITY CARE A. TARGET POPULATIONS - LOW INCOME UNINSURED, UNDERINSURED RESIDENTS B. OBJECTIVES - PROVIDE MEDICAL SERVICES TO PATIENTS UNABLE TO PAY FOR CARE C. COSTS AND OUTCOMES - $5,056,125 4. VOLUNTEER SERVICES A. TARGET POPULATIONS - MEMORIAL PATIENTS, FAMILY, VISITORS AND BROAD COMMUNITY B. OBJECTIVES - PROMOTE EMPLOYEE AND VOLUNTEER PARTICIPATION IN COMMUNITY BENEFIT ACTIVITIES C. COMMUNITY PARTNERS - VARIOUS NON-PROFIT AGENCIES D. COSTS AND OUTCOMES - $400,756 OVER 37,000 VOLUNTEER HOURS 5. COMMUNITY OUTREACH: EDUCATION, SCREENINGS, SUPPORT GROUPS, SELF HELP PROGRAMS A. TARGET POPULATIONS - BROAD COMMUNITY, THE UNINSURED, LOW INCOME RESIDENTS, RESIDENTS WITHOUT A PRIMARY CARE PHYSICIAN B. OBJECTIVES - PROVIDE HEALTH AND WELLNESS, SAFETY, EARLY DISEASE DETECTION, DISEASE MAINTENANCE/SUPPORT C. COMMUNITY PARTNERS - VARIOUS LOCAL GROUPS D. COSTS AND OUTCOMES - $322,024 6. HEALTH CARE EDUCATION A. TARGET POPULATIONS - POTENTIAL HEALTH CARE WORKERS B. OBJECTIVES - ADDRESS WORKFORCE SHORTAGE WITH SCHOLARSHIPS, STUDENT TRAINING OPPORTUNITIES C. COMMUNITY PARTNERS - AREA COLLEGES AND UNIVERSITIES D. COSTS AND OUTCOMES - $585,396
COMMUNITY BENEFIT INFORMATION (CONT)   7. CASH AND IN KIND DONATIONS A. TARGET POPULATIONS - BROAD COMMUNITY, LOW INCOME RESIDENTS B. OBJECTIVES - PROVIDE FUNDS, SERVICES, STAFF, SPACE TO SUPPORT LOCAL AGENCIES AND COMMUNITY PROGRAMS. C. COMMUNITY PARTNERS - SOCIAL SERVICE AGENCIES, CHURCHES, SCHOOLS, HEALTH CARE PROVIDERS D. COSTS AND OUTCOME - $171,182 8. LANGUAGE ASSISTANT SERVICES A. TARGET POPULATIONS - NON-ENGLISH SPEAKING RESIDENTS B. OBJECTIVES - PROVIDE COMMUNICATION ASSISTANTS C. COMMUNITY PARTNERS - SOCIAL SERVICE AGENCIES D. COSTS AND OUTCOME - $55,068 9. OTHER COMMUNITY BENEFITS A. COSTS AND OUTCOMES - $16,866 IV. 2013 COMMUNITY BENEFIT PLAN THIS SECTION DESCRIBES THE COMMUNITIES SERVED BY MEMORIAL, THE HEALTH NEEDS IDENTIFIED, PROGRAM GOALS AND OBJECTIVES FOR 2013, AND PROGRAM PRIORITIES. A. POPULATIONS AND COMMUNITIES SERVED BY MEMORIAL HOSPITAL 1. MEMORIAL HOSPITAL'S PRIMARY SERVICE AREA IS ST. CLAIR COUNTY WHICH ACCOUNTS FOR 83% OF ITS INPATIENTS. 2012 ADULT & PEDIATRIC INPATIENT DISCHARGES BY COUNTY OF RESIDENCE COUNTY NUMBER PERCENT OF TOTAL ST. CLAIR 13,642 83.1% MADISON 1,035 6.3 MONROE 340 2.1 RANDOLPH 350 2.1 CLINTON 292 1.8 OTHER 757 4.6 - - - - - - - - - - - TOTAL 16,416 100.0% 2. MORE THAN HALF OF MEMORIAL'S INPATIENTS RESIDE IN FOUR CITIES: BELLEVILLE, O'FALLON, FAIRVIEW HEIGHTS, AND CAHOKIA. 2012 ADULT & PEDIATRIC INPATIENT DISCHARGES BY ZIP CODE OF RESIDENTS ZIP CODE CITY # OF DISCHARGES PERCENT OF TOTAL 62226 BELLEVILLE 2,150 13.1% 62223 BELLEVILLE 1,397 8.5 62221 BELLEVILLE 1,258 7.7 62269 O'FALLON 1,228 7.5 62208 FAIRVIEW HEIGHTS 970 5.9 62220 BELLEVILLE 893 5.5 62206 CAHOKIA 864 5.3 - - - - - - - - - - TOTAL 8,760 53.5 62223 CASEYVILLE 624 3.8 62234 COLLINSVILLE 572 3.5 62203 EAST ST. LOUIS 558 3.4 - - - - - - - - - - TOTAL 1,754 10.7 ALL OTHER 5,861 35.8 TOTAL 16,375 100% 3. MEDICAL AND SURGICAL PATIENTS ACCOUNT FOR 89.1 PERCENT OF MEMORIAL'S INPATIENTS. 2012 ADULT & PEDIATRIC INPATIENT DISCHARGES BY CLINICAL SERVICE SERVICE TYPE NUMBER PERCENT OF TOTAL MEDICAL 10,053 61.4% SURGERY 4,544 27.7 OBSTETRICS 1,702 10.4 PEDIATRICS 63 0.4 ORAL/DENTAL 13 0.1 - - - - - - - - - - TOTAL 16,375 100.0% 4. PATIENTS ENROLLED IN GOVERNMENT-SPONSORED HEALTHCARE PROGRAMS ACCOUNT FOR 60% OF MEMORIAL'S INPATIENTS. SELF-PAY PATIENTS, FROM WHOM MEMORIAL RECEIVES LIMITED PAYMENT, ACCOUNT FOR 4% OF ADMISSIONS. 2012 ADULT & PEDIATRIC DISCHARGES BY FINANCIAL CLASS FINANCIAL CLASS NUMBER PERCENT OF TOTAL MEDICARE 7,100 43.4% MEDICAID 2,440 14.9 TRICARE 365 2.2 - - - - - - - - - - - 9,905 60.5 MANAGED CARE & COMMERCIAL 5,197 31.7 SELF-PAY 789 4.8 OTHER 484 3.0 - - - - - - - - - - TOTAL 16,375 100.0% 5. NEARLY 47% PERCENT OF MEMORIAL'S INPATIENTS ARE ADULTS AGE 65 AND OVER. 2012 ADULT & PEDIATRIC INPATIENT DISCHARGES BY AGE GROUP AGE GROUP NUMBER PERCENT OF TOTAL 0 - 14 66 0.4% 15 - 44 3,875 23.7 45 - 64 4,699 28.7 65 - 74 2,803 17.1 75+ 4,932 30.1 - - - - - - - - - - TOTAL 16,375 100.0% 6. WHILE ADULTS COMPRISE THE MAJORITY OF EMERGENCY DEPARTMENT OUTPATIENT VISITS, CHILDREN UNDER 15 ACCOUNT FOR NEARLY 19% OF THE VISITS. 2012 EMERGENCY DEPARTMENT VISITS BY AGE GROUP (EXCLUDES ADMITTED PATIENTS) SERVICE NUMBER PERCENT OF TOTAL 0 - 14 10,283 18.9% 15 - 44 25,964 47.8 45 - 64 11,200 20.6 65 - 74 2,948 5.4 75+ 3,930 7.3 - - - - - - - - - - - - TOTAL 54,325 100.0% 7. NEARLY 52% OF EMERGENCY DEPARTMENT OUTPATIENTS ARE ENROLLED IN GOVERNMENT-SPONSORED PROGRAMS WHILE ROUGHLY 15% ARE SELF-PAY. 2012 EMERGENCY DEPARTMENT VISITS BY FINANCIAL CLASS (EXCLUDES ADMITTED PATIENTS) FINANCIAL CLASS NUMBER PERCENT OF TOTAL MEDICARE 7,605 14.0% MEDICAID 17,757 32.7 TRICARE 3,086 5.7 - - - - - - - - - - 28,448 52.4 MANAGED CARE/ COMMERCIAL 16,943 31.2 SELF-PAY 8,109 14.9 OTHER 825 1.5 - - - - - - - - - - TOTAL 54,325 100.0% IN SUMMARY, THE ABOVE DATA SHOWS THAT MEMORIAL PRIMARILY SERVES THE RESIDENTS OF ST. CLAIR COUNTY, PARTICULARLY THOSE LIVING IN BELLEVILLE AND ADJACENT COMMUNITIES. TARGET POPULATIONS WITHIN THE COUNTY INCLUDE THE ELDERLY, CHILDREN, MEDICARE AND MEDICAID ENROLLEES AND THE UNINSURED.
COMMUNITY BENEFIT INFORMATION (CONT)   B. HEALTHCARE NEEDS ASSESSMENT 1. THE FOLLOWING TABLE BELOW SHOWS THAT ST. CLAIR COUNTY RANKS 88TH IN HEALTH OUTCOMES AND 92ND IN HEALTH FACTORS AMONG 102 COUNTIES OVERALL IN ILLINOIS. COMPARED TO OTHER COUNTIES, ST. CLAIR COUNTY RESIDENTS FACE HIGH RATES OF VIOLENT CRIME, CANCER DEATHS, SEXUALLY TRANSMITTED DISEASES, AND SMOKING. HEALTH OUTCOMES ST CLAIR 2013 ILLINOIS 2013 US 2013 1. MORTALITY 8,345 6,604 5,317 -PREMATURE DEATH-YEARS OF POTENTIAL LIFE LOST BEFORE AGE 75 PER 100,000 POPULATION 2. MORBIDITY -POOR OR FAIR HEALTH- 16% 15% 10% PERCENT OF ADULTS REPORTING FAIR OR POOR HEALTH (AGE-ADJUSTED) -POOR PHYSICAL HEALTH 3.8 3.4 2.6 DAYS-AVERAGE NUMBER OF PHYSICALLY UNHEALTHY DAYS REPORTED IN THE PAST 30 DAYS (AGE-ADJUSTED) -LOW BIRTHWEIGHT-PECENT 9.5% 8.4% 6.0% OF LIVE BIRTHS WITH LOW BIRTHWEIGHT (<2500 GRAMS) HEALTH FACTORS: HEALTH BEHAVIORS -ADULT SMOKING-PERCENT OF 22% 19% 13% ADULTS THAT REPORT SMOKING >=100 CIGARETTES AND CURRENTLY SMOKING -ADULT OBESITY-PERCENT OF 30% 27% 25% ADULTS THAT REPORT A BMI>=30 -MOTOR VEHICLE CRASH DEATH 12 10 10 RATE-MOTOR VEHICLE CRASH DEATHS PER 100,000 POPULATION -SEXUALLY TRANSMITTED 857 473 92 INFECTIONS-CHLAMYDIA RATE PER 100,000 POPULATION CLINICAL CARE -UNINSURED ADULTS-PERCENT OF 12% 16% 11% POPULATION UNDER AGE 65 WITHOUT HEALTH INSURANCE -DIABETIC SCREENING-PERCENT 83% 84% 90% OF DIABETIC MEDICARE ENROLLEES THAT RECEIVE HBA1C SCREENING -MAMMOGRAPHY SCREENING-PERCENT 65% 65% 73% OF FEMALE MEDICARE ENROLLEES THAT RECEIVE MAMMOGRAPHY SCREENING SOCIAL AND ECONOMIC FACTORS -VIOLENT CRIME RATE-VIOLENT 978 486 66 CRIME RATE PER 100,000 POPULATION PHYSICAL ENVIRONMENT -ACCESS TO HEALTHY FOODS- 15% 4% 1% HEALTH FOOD OUTLETS INCLUDE STANDS/ FARMERS' MARKETS SOURCE: WWW.COUNTYHEALTHRANKINGS.ORG/ILLINOIS/ST-CLAIR 2. A STATEWIDE COMPARISON REVEALS THAT ST. CLAIR COUNTY MORE AFRICAN-AMERICAN RESIDENTS BUT FEWER HISPANIC RESIDENTS, AND FEWER NOT PROFICIENT IN ENGLISH. DEMOGRAPHIC CHARACTERISTICS OF ST. CLAIR COUNTY CHARACTERISTIC ST. CLAIR COUNTY ILLINOIS POPULATION 268,858 12,875,255 % UNDER 18 YEARS OF AGE 25% 24% % 65 AND OLDER 13% 13% % AFRICAN-AMERICAN 30% 15% % ASIAN 1% 5% % HISPANIC OR LATINO 3% 16% % LANGUAGE OTHER THAN ENGLISH SPOKEN AT HOME 5% 22% % FOREIGN BORN 2% 14% SOURCE: U.S. CENSUS BUREAU (2011) THE HEALTHCARE NEEDS ASSESSMENT AND ANALYSIS OF MEMORIAL'S PATIENTS INDICATE HEALTHCARE NEEDS WHICH ARE ADDRESSED IN MEMORIAL'S 2013 GOALS AND OBJECTIVES AND PROGRAM PRIORITIES. C. 2013 GOALS AND OBJECTIVES PRIORITY HEALTH ISSUES FOR ST. CLAIR COUNTY, AS IDENTIFIED THROUGH MEMORIAL'S COMMUNITY HEALTH NEEDS ASSESSMENT INCLUDE: 1. LUNG CANCER 2. CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) 3. DIABETES 4. CARDIOVASCULAR DISEASE MEMORIAL HOSPITAL PLANS TO PROVIDE THE FOLLOWING COMMUNITY BENEFITS IN 2013: 1. PROVIDE FREE OR DISCOUNTED HEALTHCARE SERVICES THROUGH MEMORIAL'S UNINSURED PATIENT DISCOUNT AND CHARITY CARE POLICIES TO PERSONS WHO ARE UNABLE TO PAY. 2. PROVIDE MINIMAL OR NO COST NEEDED HEALTH SERVICES, SUCH AS COMMUNITY HEALTH SCREENINGS, HEALTH EDUCATION AND SUPPORT GROUPS TO RESIDENTS IN THE COMMUNITIES SERVED. 3. SERVE THE RESIDENTS OF ST. CLAIR COUNTY AND SURROUNDING COUNTIES AS THE AREA'S IDPH RESOURCE HOSPITAL AND REGIONAL HOSPITAL COORDINATION CENTER. 4. WORK CLOSELY WITH LOCAL, STATE, AND FEDERAL DISASTER PREPAREDNESS AGENCIES AS THE IDPH HOSPITAL IN ST. CLAIR COUNTY AND NINE SURROUNDING COUNTIES AND COORDINATE NECESSARY DISASTER RESPONSE AND RELIEF ACTIVITIES IN CASE OF SEVERE EMERGENCY EVENTS. 5. ASSURE ACCESS TO PRIMARY CARE AND SPECIALTY PHYSICIANS FOR AREA RESIDENTS THROUGH CONTINUED RECRUITMENT EFFORTS.
COMMUNITY BENEFIT INFORMATION (CONT)   D. COMMUNITY BENEFIT PROGRAM PRIORITIES BASED ON THE POPULATIONS SERVED BY MEMORIAL HOSPITAL AND THE ASSESSMENT OF HEALTHCARE NEEDS, THE FOLLOWING PRIORITIES ARE IDENTIFIED FOR THE 2013 COMMUNITY BENEFIT PROGRAM: 1. ACCESS: ACCESS TO HEALTHCARE SERVICES IS THE NUMBER ONE PRIORITY DUE TO THE HIGH PERCENTAGE OF THE SERVICE AREA POPULATION THAT IS UNINSURED OR INSURED THROUGH PUBLIC PROGRAMS SUCH AS MEDICAID AND MEDICARE. MEMORIAL IS COMMITTED TO PROVIDING HEALTHCARE SERVICES TO PATIENTS IN THE SERVICE AREA REGARDLESS OF ABILITY TO PAY. MEMORIAL DOES NOT DISCRIMINATE BASED ON RACE, SEX, RELIGION, COLOR, OR NATIONAL ORIGIN. ADDITIONALLY, MEMORIAL WILL CONTINUE ITS EFFORTS TO PROVIDE CHARITY CARE TO THOSE IN NEED BY: -COMMUNICATING THE AVAILABILITY OF CHARITY CARE TO PATIENTS. -QUICKLY IDENTIFYING PATIENTS REQUIRING FINANCIAL ASSISTANCE. -ASSISTING PATIENTS IN COMPLETING APPROPRIATE APPLICATIONS FOR FINANCIAL ASSISTANCE. 2. PHYSICIAN RECRUITMENT: MEMORIAL WILL CONTINUE TO INVEST IN PHYSICIAN RECRUITMENT TO IMPROVE ACCESS TO PRIMARY AND SPECIALTY HEALTHCARE SERVICES FOR AREA RESIDENTS. 3. AGE-SPECIFIC PROGRAMS: ADULTS, SENIORS, AND CHILDREN DIFFER IN TERMS OF HEALTH CONDITIONS, HEALTH BEHAVIORS, SOURCES OF FINANCING, AND OTHER ISSUES OF ACCESS. PROGRAMS WILL BE TARGETED FOR SPECIFIC AGE GROUPS, PARTICULARLY SENIORS AND CHILDREN, AND WILL INCLUDE THE FOLLOWING: -CHILDREN -VISITS TO SCHOOLS AND AN ONSITE HEALTH FAIR TO ACQUAINT CHILDREN WITH THE HOSPITAL BABYSITTER CLASSES, CAR SEAT SAFETY CHECKS, HEALTH FAIRS, ASTHMA EDUCATION, SCREENING FOR SCHOOL SPORTS PARTICIPANTS, FAMILY SAFETY CLASSES. -SENIORS - OLDER ADULT DRIVING COURSE, HEALTH FAIRS FOR SENIORS, ALZHEIMER'S SUPPORT GROUP, SENIOR CARE OUTPATIENT MENTAL HEALTH PROGRAM, SKILLED NURSING CARE IN MEMORIAL CARE CENTER, COOPERATION AND SUPPORT OF VARIOUS COMMUNITY AGENCIES SERVING SENIORS. 4. DISEASE MANAGEMENT: CHRONIC ILLNESSES SUCH AS DIABETES, HEART DISEASE AND HYPERTENSION AFFECT MANY ST. CLAIR COUNTY RESIDENTS. ACCORDING TO THE CENTERS FOR DISEASE CONTROL, PREMATURE MORTALITY RATES FOR LEADING CHRONIC DISEASE CONDITIONS IN ST. CLAIR COUNTY ARE: CARDIOVASCULAR DISEASE 74.5 COPD 11.0 DIABETES 16.7 LUNG CANCER 22.1 EFFORTS WILL BE MADE TO ENHANCE SELF-MANAGEMENT OF CHRONIC CONDITIONS TO BENEFIT INDIVIDUALS AND THEIR FAMILIES, SUCH AS: -HEART DISEASE - PRESENTATIONS BY PHYSICIANS AND DIETITIANS, SMOKING CESSATION CLASSES, CHOLESTEROL AND BLOOD PRESSURE CHECKS, HEALTH FAIRS, CPR CLASSES, CARDIAC SUPPORT GROUPS, MEDITATION CLASSES, REHABILITATION EXERCISE PROGRAMS, AND A HEART FAILURE PROGRAM. -COPD AND LUNG CANCER-SMOKING CESSATION CLASSES AND CONSULTATIONS, EDUCATION TO SCHOOL-AGED CHILDREN, COPD/PULMONARY REHAB PROGRAM AND SUPPORT GROUP, ASTHMA EDUCATION, AND EXERCISE PROGRAMS. -DIABETES - DIABETES INSTRUCTION, NUTRITIONAL CLASSES, SUPPORT GROUPS, HEALTH FAIRS, WEIGHT MANAGEMENT CLASSES. -HYPERTENSION - BLOOD PRESSURE CHECKS, NUTRITIONAL COUNSELING, MEDITATION AND WEIGHT MANAGEMENT CLASSES. 5. HEALTHY LIFESTYLES: SOME OF THE MOST DANGEROUS HEALTHCARE PROBLEMS RESULT FROM INDIVIDUAL LIFESTYLE CHOICES WHICH ULTIMATELY CAUSE CHRONIC CONDITIONS, HOSPITALIZATION, AND DEATH. MEMORIAL WILL WORK COLLABORATIVELY WITH SCHOOLS, COMMUNITY AGENCIES, AND OTHERS TO PROMOTE HEALTHY LIFESTYLES AND A SAFE COMMUNITY THROUGH: -EMPLOYEE WELLNESS CHALLENGE - CONTINUE TO EDUCATE AND PROMOTE HEALTHY LIVING BY PROVIDING FREE RESOURCES AND INCENTIVES TO ACHIEVE A HEALTHY BALANCED LIFE AMONG EMPLOYEES. -SELF-HELP PROGRAMS - SMOKING CESSATION, WEIGHT MANAGEMENT. -EDUCATION - OLDER ADULT DRIVING COURSE THROUGH AARP, FAMILY SAFETY, SAFE SITTER CLASSES, CAR SEAT SAFETY CHECKS, NUTRITION, PARTNERSHIPS WITH RADIO DISNEY AND LOCAL FARMERS' MARKETS TO PROMOTE HEALTHY LIFESTYLES TO STUDENTS AS WELL AS WITH LOCAL HIGH SCHOOL HEALTH EDUCATION CLUBS. 6. SCREENINGS: REGULAR, EASILY ACCESSIBLE SCREENINGS ARE ESSENTIAL IN ORDER TO DETECT DISEASE IN ITS EARLY STAGES AND TO FACILITATE RESPONSIBILITY FOR DISEASE MANAGEMENT BY THE INDIVIDUAL. MANY IN ST. CLAIR COUNTY DO NOT USE THE FORMAL HEALTHCARE SYSTEM ON A REGULAR BASIS DUE TO ACCESS ISSUES. MEMORIAL WILL CONTINUE TO CONDUCT SCREENING PROGRAMS, TARGETED BY CONDITION AND AGE TO REACH THE COMMUNITY. THESE PROGRAMS INCLUDE: -HEALTHY DIRECTION, MEMORIAL'S WELLNESS VEHICLE WILL INCREASE THE NUMBER OF DIGITAL SCREENING MAMMOGRAPHY, DIABETES AND CHOLESTEROL SCREENINGS, PULSE OXIMETERS AS WELL AS A VARIETY OF OTHER HEALTH SCREENINGS AND EXAMS. -SCREENINGS FOR HEART DISEASE, HYPERTENSION, SKIN CANCER, AND COLORECTAL SCREENING. 7. OTHER ACTIVITIES: IN ADDITION TO THE ABOVE PRIORITIES, MEMORIAL IS UNDERTAKING THE FOLLOWING ACTIVITIES IN 2013 TO IMPROVE CARE FOR THE RESIDENTS IN THE COMMUNITIES IT SERVES THROUGHOUT SOUTHWEST ILLINOIS: -CONTINUE TO DEVELOP THE CARDIOVASCULAR CENTER OF EXCELLENCE TO ENHANCE THE QUALITY OF CARDIOVASCULAR CARE PROVIDED TO OUR COMMUNITIES. -PROMOTE CONGESTIVE HEART FAILURE CLINIC TO REDUCE PATIENT MORTALITY AND READMISSION. -PROMOTE AND FURTHER DEVELOP A COMPREHENSIVE DISEASE MANAGEMENT CENTER OF CONGESTIVE HEART FAILURE AND DIABETIC EDUCATION. -REDUCE THE NUMBER OF EMERGENCY DEPARTMENT PATIENTS LEAVING WITHOUT BEING SEEN BY A PROVIDER. -CONTINUE TO IMPLEMENT AND ELECTRONIC MEDICAL RECORD SYSTEM TO IMPROVE PATIENT CARE AND SAFETY. NEW FUNCTIONALITY TO INCLUDE PHYSICIAN ORDER ENTRY AND PHYSICIAN DOCUMENTATION. -COMPLETE RENOVATION OF MEMORIAL CARE CENTER (MCC) TO ENHANCE OUR PATIENT EXPERIENCE. -SEEK RE-ACCREDITATION FOR THE FOLLOWING SERVICES: NURSING (MAGNET); DIAGNOSTIC ULTRASOUND (ACR), AND VASCULAR LAB (ICANL). -CONTINUE TO PROMOTE THE SERVICES AVAILABLE IN THE CENTER FOR ORTHOPEDIC AND NEUROSCIENCES LOCATED ON MEMORIAL'S MAIN CAMPUS. THE 85,000-SQUARE-FOOT FACILITY HOUSES OUTPATIENT SERVICES INCLUDING PHYSICAL, OCCUPATION, SPEECH AND HAND THERAPY; PAIN MANAGEMENT; SPORTS MEDICINE; AN OPEN MRI AND CT SCANNER. -BREAK GROUND FOR MEMORIAL HOSPITAL-EAST, A 94-BED SATELLITE HOSPITAL TO BE BUILT IN NEARBY SHILOH. THIS FACILITY, ANTICIPATED TO OPEN IN JUNE 2015, WILL PROVIDE FOR ALL PRIVATE BEDS AT BOTH THE BELLEVILLE AND SHILOH HOSPITAL LOCATIONS.
GOVERNANCE AND DISCLOSURE FORM 990, PART VI, LINES 6, 7A & 7B PROTESTANT MEMORIAL MEDICAL CENTER, INC. HAS TWO CLASSES OF MEMBERS - COMMUNITY AND CORPORATE. COMMUNITY MEMBERS, WHICH INCLUDE BOTH INDIVIDUALS AND LOCAL AREA CHURCHES, HAVE THE EXCLUSIVE POWER TO APPROVE NOMINEES FOR ELECTION AS ELECTED DIRECTORS. THE CORPORATE MEMBER, MEMORIAL GROUP, INC HAS THE POWER TO ELECT, REMOVE, AND REPLACE ANY ELECTED DIRECTOR, APPROVE AMMENDMENTS TO GOVERNING DOCUMENTS AND TO MAKE INVESTMENT POLICY.
REVIEW PROCESS FORM 990, PART VI, LINE 11A DIRECTORS OF PROTESTANT MEMORIAL MEDICAL CENTER , INC. ARE PROVIDED A COPY OF THE TAX RETURN PRIOR TO FILING FOR REVIEW. ANY DISCREPANCIES OR QUESTIONS ARE THEN SUBMITTED TO THE VICE PRESIDENT OF FINANCE.
CONFLICT OF INTEREST POLICY FORM 990, PART VI, LINE 12C OFFICERS AND DIRECTORS OF PROTESTANT MEMORIAL MEDICAL CENTER, INC. COMPLETE A CONFLICT OF INTEREST STATEMENT ANNUALLY. TRANSACTIONS DISCLOSED ON THE STATEMENTS ARE REVIEWED BY THE BOARD. THE BOARD OR A DULY CONSTITUTED COMMITTEE THEREOF SHALL DETERMINE WHETHER A CONFLICT EXISTS AND IN THE CASE OF AN EXISTING CONFLICT, WHETHER THE CONTEMPLATED TRANSACTION MAY BE AUTHORIZED AS JUST, FAIR, AND REASONABLE.
COMPENSATION POLICIES FORM 990, PART VI, LINE 15A & 15B THE COMPENSATION COMMITTEE UTILIZES THE SERVICES OF AN INDEPENDENT CONSULTANT TO DEVELOP HOSPITAL SURVEY DATA TO COMPARE SALARIES AND BENEFITS FOR MEMORIAL'S CORPORATE OFFICERS (CEO AND VICE PRESIDENTS). BASED ON THE SURVEY RESULTS, THE COMPENSATION COMMITTEE ESTABLISHES COMPENSATION FOR THE ENSUING YEAR.
PUBLIC DISCLOSURE FORM 990, PART VI, LINE 18 & 19 UPON FILING FORM 990 AND SUPPORTING SCHEDULES, PUBLIC DISCLOSURE COPIES ARE AVAILABLE FOR PUBLIC INSPECTION IN THE OFFICE OF THE PRESIDENT OF PROTESTANT MEMORIAL MEDICAL CENTER, INC. DURING REGULAR BUSINESS HOURS OF 8:30AM-5:00PM. COPIES ARE PROVIDED UPON REQUEST FOR A NOMINAL FEE. WRITTEN REQUESTS ARE HONORED WITHIN 30 DAYS. REQUESTS IN PERSON ARE PROVIDED ON THE DAY OF REQUEST. PROTESTANT MEMORIAL MEDICAL CENTER, INC. PROVIDES FOR PUBLIC INSPECTION THE MOST RECENT THREE YEARS OF FILINGS. PROTESTANT MEMORIAL MEDICAL CENTER, INC. DOES NOT MAKE ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, OR FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC, OTHER THAN THE COPY OF THE FINANCIAL STATEMENTS REQUIRED TO BE ATTACHED TO THE PUBLIC DISCLOSURE COPY OF FORM 990.
RECONCILIATION OF NET ASSETS FORM 990, PART XI, LINE 9 $1,750,000 FUND BALANCE TRANSFER FROM SOUTHWEST ILLINOIS HEALTH VENTURES, INC., A RELATED 501(C)(3) ORGANIZATION $8,064,000 FUND BALANCE TRANSFER FROM MEMORIAL GROUP, INC., A RELATED 501(C)(3) ORGANIZATION. ($20,705,083) FUND BALANCE TRANSFER TO MEMORIAL MEDICAL GROUP, LLC., A RELATED DISREGARDED ENTITY WHOLLY OWNED BY MEMORIAL GROUP, INC., A RELATED 501(C)(3) ORGANIZATION. $985,479 NET CHANGE IN INTEREST IN MEMORIAL FOUNDATION, INC., A RELATED 501(C)(3) ORGANIZATION. ($9,905,604) TOTAL OTHER CHANGES IN NET ASSETS OR FUND BALANCES.
BUSINESS RELATIONSHIPS FORM 990, PART VI, LINE 2 MARK TURNER, WILLIAM CASPERSON, ATHUR PARRISH, AND LARY ECKERT ALL HAVE A BUSINESS RELATIONSHIP AS A RESULT OF ALSO SERVING AS OFFICERS OR DIRECTORS OF MEMORIAL CAPTIVE INSURANCE COMPANY, A RELATED TAXABLE ENTITY.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.
Cat. No. 51056K
Schedule O (Form 990 or 990-EZ) 2012

Additional Data


Software ID:  
Software Version:  
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
2012
Open to Public Inspection
Name of the organization
Protestant Memorial Medical Center Inc
 
Employer identification number

37-0635502
Part I
Identification of Disregarded Entities (Complete if the organization answered "Yes" to Form 990, Part IV, line 33.)
(a)
Name, address, and EIN (if applicable) of disregarded entity


(b)
Primary activity


 		(c)
Legal domicile (state
or foreign country)

 		(d)
Total income


 		(e)
End-of-year assets


 		(f)
Direct controlling
entity










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


(b)
Primary activity


 		(c)
Legal domicile (state
or foreign country)

 		(d)
Exempt Code section


 		(e)
Public charity status
(if section 501(c)(3))

 		(f)
Direct controlling
entity

 		(g)
Section 512(b)(13) controlled entity?
Yes No
(1) MEMORIAL HOSP SELF INSURANCE TRUST FUND

4500 MEMORIAL DRIVE

BELLEVILLE,IL62226
37-1064809 		INSURANCE IL 501(C)(3) 11-TYPE I MGI
 
 
No
(2) MEMORIAL FOUNDATION INC

4500 MEMORIAL DRIVE

BELLEVILLE,IL62226
37-1186034 		FUNDRAISING IL 501(C)(3) 11-TYPE I MGI
 
 
No
(3) SOUTHWEST ILLINOIS HEALTH VENTURES INC

4500 MEMORIAL DRIVE

BELLEVILLE,IL62226
37-1413286 		MANAGEMENT IL 501(C)(3) 11-TYPE I MGI
 
 
No
(4) MEMORIAL GROUP INC

4500 MEMORIAL DRIVE

BELLEVILLE,IL62226
37-1186035 		MANAGEMENT IL 501(C)(3) 11-TYPE I NA
 
 
No






For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50135Y
Schedule R (Form 990) 2012
Schedule R (Form 990) 2012
Page 2
Part III
Identification of Related Organizations Taxable as a Partnership (Complete if the organization answered "Yes" to Form 990, Part IV, line 34 because it had one or more related organizations treated as a partnership during the tax year.)
(a)
Name, address, and EIN of
related organization



 		(b)
Primary activity




 		(c)
Legal
domicile
(state or foreign
country)


 		(d)
Direct controlling
entity



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

(f)
Share of total income




 		(g)
Share of end-of-year
assets



 		(h)
Disproprtionate allocations?




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



 		(k)
Percentage
ownership
Yes No Yes No












Part IV
Identification of Related Organizations Taxable as a Corporation or Trust (Complete if the organization answered "Yes" to Form 990, Part IV, line 34 because it had one or more related organizations treated as a corporation or trust during the tax year.)
(a)
Name, address, and EIN of
related organization
 		(b)
Primary activity
 		(c)
Legal
domicile
(state or foreign
country)
 		(d)
Direct controlling
entity
 		(e)
Type of entity
(C corp, S corp,
or trust) 		(f)
Share of total income
 		(g)
Share of end-of-year
assets
 		(h)
Percentage
ownership
 		(i)
Section 512(b)(13) controlled entity?
Yes No
(1) MEMORIAL CAPTIVE INSURANCE CO

1850 N CENTRAL AVENUE STE 1700
PHOENIX,AZ85004
20-1267507 		INSURANCE AZ MGI
  		C CORP 0 0 0 %   No
(2) MEMORIAL CAPTIVE INSURANCE COMPANY

94 SOLARIS 2ND FLOOR
GEORGETOWN,CAYMAN ISLANDS  
CJ
98-1082415 		INSURANCE CJ MGI
  		C-CORP 0 0 0 %   No










Schedule R (Form 990) 2012
Schedule R (Form 990) 2012
Page 3
Part V
Transactions With Related Organizations (Complete if the organization answered "Yes" to Form 990, Part IV, line 34, 35b, or 36.)
Note. Complete line 1 if any entity is listed in Parts II, III, or IV of this schedule.
Yes
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 or (iv) rent from a controlled entity . . . . . . . . . . . . . . . . . . . . . . .
1a
 
No
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
 
No
f Dividends from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1f
 
No
g Sale of assets to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1g
 
No
h Purchase of assets from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1h
 
No
i Exchange of assets with related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1i
 
No
j Lease of facilities, equipment, or other assets to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1j
 
No
k Lease of facilities, equipment, or other assets from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . .
1k
Yes
 
l Performance of services or membership or fundraising solicitations for related organization(s) . . . . . . . . . . . . . . . . . . . .
1l
Yes
 
m Performance of services or membership or fundraising solicitations by related organization(s) . . . . . . . . . . . . . . . . . . . .
1m
Yes
 
n Sharing of facilities, equipment, mailing lists, or other assets with related organization(s) . . . . . . . . . . . . . . . . . . . . .
1n
Yes
 
o Sharing of paid employees with related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1o
Yes
 
p Reimbursement paid to related organization(s) for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1p
Yes
 
q Reimbursement paid by related organization(s) for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1q
Yes
 
r Other transfer of cash or property to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1r
Yes
 
s Other transfer of cash or property from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1s
Yes
 
2
If the answer to any of the above is "Yes," see the instructions for information on who must complete this line, including covered relationships and transaction thresholds.
(a)
Name of other organization 		(b)
Transaction
type (a-s) 		(c)
Amount involved 		(d)
Method of determining amount involved





Schedule R (Form 990) 2012
Schedule R (Form 990) 2012
Page 4
Part VI
Unrelated Organizations Taxable as a Partnership (Complete if the organization answered "Yes" to Form 990, Part IV, line 37.)
Provide the following information for each entity taxed as a partnership through which the organization conducted more than five percent of its activities (measured by total assets or gross revenue) that was not a related organization. See instructions regarding exclusion for certain investment partnerships.
(a)
Name, address, and EIN of entity 		(b)
Primary activity 		(c)
Legal domicile
(state or foreign
country) 		(d)
Predominant income (related, unrelated, excluded from tax under section 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) 2012
Schedule R (Form 990) 2012
Page 5
Part VII
Supplemental Information
Complete this part to provide additional information for responses to questions on Schedule R (see instructions).
Identifier Return Reference Explanation

Additional Data


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