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 07-01-2012 , 2012, and ending 06-30-2013
BCheck if applicable:
CName of organization
OUR LADY OF THE LAKE ASCENSION
COMMUNITY HOSPITAL
Doing Business As
ST ELIZABETH HOSPITAL
 
Number and street (or P.O. box if mail is not delivered to street address)
1125 HIGHWAY 30
Suite
Room/suite
City or town, state or country, and ZIP + 4
GONZALES, LA70737
D Employer identification number

72-1470744
E Telephone number

G Gross receipts $ 88,370,581
F Name and address of principal officer:
ROBERT BURGESS
1125 HIGHWAY 30
GONZALES,LA70737
I
Tax-exempt status: (   ) LeftBullet (insert no.) or
J
Website:MediumBullet
www.steh.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 MediumBullet0928
K Form of organization:
 
L Year of formation: 2000
M State of legal domicile: LA
Part I
Summary
Activities & Governance 1 Briefly describe the organization’s mission or most significant activities: The purpose of the hospital is to provide for the care of the ill, injured, or disabled persons and to enhance the health of those in the community through research and education.
2 Check this box MediumBullet
3 Number of voting members of the governing body (Part VI, line 1a) ........ 3 18
4 Number of independent voting members of the governing body (Part VI, line 1b) ..... 4 11
5 Total number of individuals employed in calendar year 2011 (Part V, line 2a) ...... 5 949
6 Total number of volunteers (estimate if necessary) ............. 6 39
7a Total unrelated business revenue from Part VIII, column (C), line 12 ........ 7a 1,253
b Net unrelated business taxable income from Form 990-T, line 34 ......... 7b 0
Revenues Prior Year Current Year
8 Contributions and grants (Part VIII, line 1h) ......... 469,500 261,396
9 Program service revenue (Part VIII, line 2g) ......... 90,425,776 87,392,371
10 Investment income (Part VIII, column (A), lines 3, 4, and 7d ) .... 83,981 -189,800
11 Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e) 357,750 465,148
12 Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)................... 91,337,007 87,929,115
Expenses; 13 Grants and similar amounts paid (Part IX, column (A), lines 1–3 )... 56,187 87,089
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) 48,617,568 48,232,311
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).... 35,423,451 36,402,452
18 Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25) 84,097,206 84,721,852
19 Revenue less expenses. Subtract line 18 from line 12....... 7,239,801 3,207,263
Net Assets or Fund Balances; Beginning of Current Year End of Year
20 Total assets (Part X, line 16)............. 95,702,620 100,132,176
21 Total liabilities (Part X, line 26)............. 32,744,634 35,611,550
22 Net assets or fund balances. Subtract line 21 from line 20..... 62,957,986 64,520,626
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: INSPIRED BY THE VISION OF ST. FRANCIS OF ASSISI AND IN THE TRADITION OF THE ROMAN CATHOLIC CHURCH, WE EXTEND THE HEALING MINISTRY OF JESUS CHRIST TO GOD'S PEOPLE, ESPECIALLY THOSE MOST IN NEED. WE CALL FORTH THOSE WHO SERVE IN THIS HEALTHCARE MINISTRY, TO SHARE THEIR GIFTS AND TALENTS TO CREATE A SPIRIT OF HEALING-WITH REVERENCE AND LOVE FOR ALL OF LIFE, WITH JOYFULNESS OF SPIRIT, AND WITH HUMILITY AND JUSTICE FOR ALL THOSE ENTRUSTED TO OUR CARE. WE ARE, WITH GOD'S HELP, A HEALING AND SPIRITUAL PRESENCE FOR EACH OTHER AND FOR THE COMMUNITIES WE ARE PRIVILEGED TO SERVE.
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 $ 33,516,876 including grants of $ 87,089 ) (Revenue $ 50,842,028 )
ST. ELIZABETH HOSPITAL PROVIDES QUALITY HOSPITAL AND MEDICAL SERVICES TO ITS PATIENTS. THE MEDICAL CENTER IS AN ACTIVE, CARING MEMBER OF THE COMMUNITIES IT SERVES. IN CARRYING OUT ITS MISSION OF MEETING THE HEALTHCARE NEEDS OF THE PEOPLE OF GOD, THE MEDICAL CENTER HAS ESTABLISHED A POLICY UNDER WHICH IT PROVIDES CARE TO THE NEEDY MEMBERS OF ITS COMMUNITIES. FOLLOWING THAT POLICY, HEALTH CARE SERVICES WERE PROVIDED WITHOUT CHARGE OR AT RATES WHICH ARE LESS THAN THE COST OF PROVIDING SUCH SERVICES. THE HOSPITAL PROVIDED INPATIENT AND OUTPATIENT MEDICAL SERVICES FOR 10,288 PATIENT DAYS AND 176,769 PHYSICIAN OFFICE VISITS.
4b (Code:   ) (Expenses $ 8,443,263 including grants of $   ) (Revenue $ 12,399,616 )
THE HOSPITAL PROVIDES PATIENTS WITH SURGICAL CARE. 244,626 SURGICAL MINUTES WERE USED DURING THE YEAR.
4c (Code:   ) (Expenses $ 6,075,408 including grants of $   ) (Revenue $ 24,150,727 )
THE HOSPITAL PROVIDES RADIOLOGY SERVICES TO ITS INPATIENTS AND OUTPATIENTS. DURING THE CURRENT YEAR, THE HOSPITAL PERFORMED 38,269 RADIOLOGY PROCEDURES.
4d Other program services (Describe in Schedule O.)
(Expenses $   including grants of $   ) (Revenue $   )
4e Total program service expensesMediumBullet48,035,547
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 I..........
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 II........
4
 
No
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 III............................
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
 
No
d
Did the organization report an amount for other assets in Part X, line 15 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part IXClick to see attachment............
11d
 
No
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
Yes
 
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......... Click to see attachment
14b
Yes
 
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 IVClick to see attachment
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... Click to see attachment
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).... Click to see attachment
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............ Click to see attachment
18
Yes
 
19
Did the organization report more than $15,000 of gross income from gaming activities on Part VIII, line 9a? If “Yes,” complete Schedule G, Part III................... Click to see attachment
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... Click to see attachment
21
Yes
 
22
Did the organization report more than $5,000 of grants and other assistance to individuals in the United States on Part IX, column (A), line 2? If “Yes,” complete Schedule I, Parts I and III........ Click to see attachment
22
Yes
 
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................
24a
 
No
b
Did the organization invest any proceeds of tax-exempt bonds beyond a temporary period exception?...
24b
 
 
c
Did the organization maintain an escrow account other than a refunding escrow at any time during the year
to defease any tax-exempt bonds?......................
24c
 
 
d
Did the organization act as an “on behalf of” issuer for bonds outstanding at any time during the year?...
24d
 
 
25a
Section 501(c)(3) and 501(c)(4) organizations. Did the organization engage in an excess benefit transaction with a disqualified person during the year? If “Yes,” complete Schedule L, Part I........ Click to see attachment
25a
 
No
b
Is the organization aware that it engaged in an excess benefit transaction with a disqualified person in a prior year, and that the transaction has not been reported on any of the organization’s prior Forms 990 or 990-EZ? If “Yes,” complete Schedule L, Part I................... Click to see attachment
25b
 
No
26
Was a loan to or by a current or former officer, director, trustee, key employee, 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
Yes
 
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
Yes
 
b
If ‘Yes’ to line 35a, did the organization receive any payment from or engage in any transaction with a controlled entity within the meaning of section 512(b)(13)? If “Yes,” complete Schedule R, Part V, line 2... Click to see attachment
35b
Yes
 
36
Section 501(c)(3) organizations. Did the organization make any transfers to an exempt non-charitable related organization? If “Yes,” complete Schedule R, Part V, line 2............. Click to see attachment
36
 
No
37
Did the organization conduct more than 5% of its activities through an entity that is not a related organization and that is treated as a partnership for federal income tax purposes? If “Yes,” complete Schedule R, Part VIClick to see attachment
37
 
No
38
Did the organization complete Schedule O and provide explanations in Schedule O for Part VI, lines 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
55
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
949
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
Yes
 
b
If “Yes,” did the organization notify the donor of the value of the goods or services provided?.....
7b
Yes
 
c
Did the organization sell, exchange, or otherwise dispose of tangible personal property for which it was required to file Form 8282?...........................
7c
 
No
d
If “Yes,” indicate the number of Forms 8282 filed during the year ....
7d
 
e
Did the organization receive any funds, directly or indirectly, to pay premiums on a personal benefit contract?............................
7e
 
No
f
Did the organization, during the year, pay premiums, directly or indirectly, on a personal benefit contract?..
7f
 
No
g
If the organization received a contribution of qualified intellectual property, did the organization file Form 8899 as required?............................
7g
 
 
h
If the organization received a contribution of cars, boats, airplanes, or other vehicles, did the organization file a Form 1098-C?..........................
7h
 
 
8
Sponsoring organizations maintaining donor advised funds and section 509(a)(3) supporting organizations. Did the supporting organization, or a donor advised fund maintained by a sponsoring organization, have excess business holdings at any time during the year?............
8
 
 
9
Sponsoring organizations maintaining donor advised funds.
a
Did the organization make any taxable distributions under section 4966?..........
9a
 
 
b
Did the organization make a distribution to a donor, donor advisor, or related person?.......
9b
 
 
10
Section 501(c)(7) organizations. Enter:
a
Initiation fees and capital contributions included on Part VIII, line 12 ...
10a
 
b
Gross receipts, included on Form 990, Part VIII, line 12, for public use of club facilities
10b
 
11
Section 501(c)(12) organizations. Enter:
a
Gross income from members or shareholders .........
11a
 
b
Gross income from other sources (Do not net amounts due or paid to other sources against amounts due or received from them.) ..........
11b
 
12a
Section 4947(a)(1) non-exempt charitable trusts. Is the organization filing Form 990 in lieu of Form 1041?
12a
 
 
b
If “Yes,” enter the amount of tax-exempt interest received or accrued during the year. ....................
12b
 
13
Section 501(c)(29) qualified nonprofit health insurance issuers.
a
Is the organization licensed to issue qualified health plans in more than one state?
Note. 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
18
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
11
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
 
No
b
Other officers or key employees of the organization ................
15b
Yes
 
If "Yes" to line 15a or 15b, describe the process in Schedule O (see instructions).
16a
Did the organization invest in, contribute assets to, or participate in a joint venture or similar arrangement with a taxable entity during the year? ......................
16a
Yes
 
b
If “Yes,” did the organization follow a written policy or procedure requiring the organization to evaluate its participation in joint venture arrangements under applicable federal tax law, and take steps to safeguard the organization’s exempt status with respect to such arrangements? ............
16b
Yes
 
Section C. Disclosure
17
List the States with which a copy of this Form 990 is required to be filedMediumBullet
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:
MediumBulletJEFF LIMBOCKER1125 W HIGHWAY 30GONZALESLA70737 (225) 647-5071
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) BILL MARTIN........................................................................
BOARD MEMBER - CHAIR
 2.0
.......................0.0 		X   X       0 0 0
(2) ROBERT BURGESS........................................................................
PRESIDENT AND CEO
 50.0
.......................0.0 		X   X       0 137,089 13,967
(3) CHRIS TREVINO MD........................................................................
BOARD MEMBER
 2.0
.......................0.0 		X           0 0 0
(4) CARY PAUL AGUILLARD JR MD........................................................................
BOARD MEMBER
 40.0
.......................0.0 		X           290,857 0 38,398
(5) THE HONORABLE JOHN A BERTHELOT........................................................................
BOARD MEMBER
 2.0
.......................0.0 		X           0 0 0
(6) GREGORY BRANDAO EDD........................................................................
BOARD MEMBER
 2.0
.......................0.0 		X           0 0 0
(7) SR HELEN CAHILL OSF........................................................................
BOARD MEMBER
 1.0
.......................0.0 		X           0 0 0
(8) THE HONORABLE TERI CASSO........................................................................
VICE CHAIR
 2.0
.......................0.0 		X   X       0 0 0
(9) DEBORAH CAVALIER MD........................................................................
BOARD MEMBER
 2.0
.......................0.0 		X           0 0 0
(10) JAMES D'ANTONI MD........................................................................
CHIEF OF STAFF/BOARD MEMBER
 40.0
.......................0.0 		X           215,719 0 31,059
(11) JOHN F FRAICHE MD........................................................................
BOARD MEMBER
 40.0
.......................0.0 		X           641,046 0 11,830
(12) ROGER KEESE........................................................................
BOARD MEMBER - SECRETARY
 2.0
.......................0.0 		X   X       0 0 0
(13) ANTHONY NOBILE........................................................................
BOARD MEMBER
 2.0
.......................0.0 		X           0 0 0
(14) TESS STROMBERG........................................................................
BOARD MEMBER
 2.0
.......................0.0 		X           0 0 0
(15) SCOTT PETRIE MD........................................................................
BOARD MEMBER
 2.0
.......................0.0 		X           0 0 0
(16) DONALD SONGY........................................................................
BOARD MEMBER
 2.0
.......................0.0 		X           0 0 0
(17) HONORABLE ALVIN TURNER JR........................................................................
BOARD MEMBER
 2.0
.......................0.0 		X           0 0 0
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) DAWN ZITMAN MD........................................................................
BOARD MEMBER
 40.0
.......................0.0 		X           164,619 0 18,501
(19) SUE KNIGHT........................................................................
CHIEF OPERATING OFFICER
 40.0
.......................6.5 		    X       230,810 0 56,121
(20) SCOTT RICHARD CPA........................................................................
VP FINANCE
 40.0
.......................0.0 		    X       191,219 0 16,859
(21) CRAIG A VITRANO MD........................................................................
CHIEF MEDICAL OFFICER
 40.0
.......................0.0 		      X     462,846 0 69,548
(22) LESLIE NORMAN RN C N A........................................................................
CHIEF NURSING OFFICER
 40.0
.......................0.0 		      X     211,557 0 40,649
(23) THOMAS EWING MD........................................................................
STAFF PHYSICIAN
 40.0
.......................0.0 		        X   476,786 0 33,451
(24) DAWN SHARP MD........................................................................
STAFF PHYSICIAN
 40.0
.......................0.0 		        X   366,247 0 37,739
(25) JOHN KNAPP MD........................................................................
STAFF PHYSICIAN
 40.0
.......................0.0 		        X   426,481 0 33,697
(26) RAHIL D SHAH MD........................................................................
STAFF PHYSICIAN
 40.0
.......................0.0 		        X   408,647 0 11,332
(27) LARRY W WARNER JR MD........................................................................
STAFF PHYSICIAN
 40.0
.......................0.0 		        X   390,350 0 24,841
(28) DOLORES N LEJEUNE RN C N A........................................................................
FORMER CEO/RETIRED JUNE 2012
 0.0
.......................0.0 		          X 0 370,673 59,572




1b Sub-Total................MediumBullet
c Total from continuation sheets to Part VII, Section A....MediumBullet
d Total (add lines 1b and 1c)............MediumBullet 4,477,184 507,762 497,564
2
Total number of individuals (including but not limited to those listed above) who received more than $100,000 of reportable compensation from the organizationMediumBullet59
Yes
No
3
Did the organization list any former officer, director or trustee, key employee, or highest compensated employee on line 1a? If “Yes,” complete Schedule J for such individual ..............
3
Yes
 
4
For any individual listed on line 1a, is the sum of reportable compensation and other compensation from the organization and related organizations greater than $150,000? If “Yes,” complete Schedule J for such individual...........................
4
Yes
 
5
Did any person listed on line 1a receive or accrue compensation from any unrelated organization or individual for services rendered to the organization? If “Yes,” complete Schedule J for such person ........
5
 
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
FMOL HEALTH SYSTEM, 4200 ESSEN LANEBATON ROUGELA70809 MANAGEMENT SERVICES 9,084,041
OUR LADY OF THE LAKE RMC, 5000 HENNESSY BLVDBATON ROUGELA70809 MANAGEMENT FEES 546,978
PATRIOT MEDICAL TECHNOLOGIES OF OHI, 7100 COMMERCE WAY SUITE 280BRENTWOODTN37027 EQUIP. MAINTENANCE 392,132
THEREX, PO BOX 2121MEMPHISTN38159 PT SERVICES 370,475
LOTT SHEFFIELD ANESTHESIA, 5253 DIJON AVENUEBATON ROUGELA70809 ANESTHEISA SERVICE 333,057
2
Total number of independent contractors (including but not limited to those listed above) who received more than $100,000 of compensation from the organization MediumBullet25
Form 990 (2012)
Form 990 (2012)
Page 9
Part VIII
Statement of Revenue
Check if Schedule O contains a response to any question in this Part VIII ..............
(A)
Total revenue 		(B)
Related or
exempt
function
revenue 		(C)
Unrelated
business
revenue 		(D)
Revenue
excluded from
tax under sections
512, 513, or 514
Contributions, Gifts, Grants and Other Similar Amounts 1a Federated campaigns..1a  
b Membership dues....1b  
c Fundraising events....1c 28,017
d Related organizations...1d 182,000
e Government grants (contributions)1e 24,092
f All other contributions, gifts, grants, and
similar amounts not included above1f 		27,287
g Noncash contributions included in lines
1a-1f:$ 		275
h Total. Add lines 1a-1f.......MediumBullet 261,396
Program Service Revenue Business Code
2a PATIENT SERVICE REVENUE 900099 86,083,038 86,083,038    
b CAFETERIA 900099 243,448 243,448    
c PURCHASE DISCOUNTS 900099 154,862 154,862    
d OUTREACH LAB 900099 129,882 129,882    
e HEARING AND BALANCE 900099 110,959 110,959    
f All other program service revenue . 670,182 670,182    
g Total. Add lines 2a–2f........MediumBullet 87,392,371
Other Revenue 3 Investment income (including dividends, interest, and other similar amounts).......MediumBullet -91,869   654 -92,523
4 Income from investment of tax-exempt bond proceeds..MediumBullet 0      
5 Royalties...........MediumBullet 0      
(i) Real (ii) Personal
6a Gross rents 684,668  
b Less: rental expenses 207,170  
c Rental income or (loss) 477,498 0
d Net rental income or (loss).......MediumBullet 477,498 477,498    
(i) Securities (ii) Other
7a Gross amount from sales of assets other than inventory 118,428  
b Less: cost or other basis and sales expenses 215,137 1,222
c Gain or (loss) -96,709 -1,222
d Net gain or (loss)..........MediumBullet -97,931   599 -98,530
8a Gross income from fundraising events (not including
$ 28,017
of contributions reported on line 1c). See Part IV, line 18 ..
a 5,587
b Less: direct expenses ...b 17,937
c Net income or (loss) from fundraising events..MediumBullet -12,350   -12,350
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            
b            
c            
d All other revenue ....        
e Total. Add lines 11a–11d ...... MediumBullet 0
12 Total revenue. See Instructions......MediumBullet 87,929,115 87,869,869 1,253 -203,403
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 67,942 67,942
2 Grants and other assistance to individuals in the United States. See Part IV, line 22 16,147 16,147
3 Grants and other assistance to governments, organizations, and individuals outside the United States. See Part IV, lines 15 and 16 3,000 3,000
4 Benefits paid to or for members 0  
5 Compensation of current officers, directors, trustees, and key employees .... 3,902,433 3,199,995 702,438  
6 Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) .... 0      
7 Other salaries and wages 35,912,312 18,734,718 17,177,594  
8 Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) .... 3,713,391 2,434,619 1,278,772  
9 Other employee benefits ....... 2,229,003 1,475,482 753,521  
10 Payroll taxes ........... 2,475,172 1,486,667 988,505  
11 Fees for services (non-employees):        
a Management ...... 623,573 623,573    
b Legal ......... 130,844   130,844  
c Accounting ........... 680,402   680,402  
d Lobbying ........... 0      
e Professional fundraising services. See Part IV, line 17 0  
f Investment management fees ...... 11,134   11,134  
g Other (If line 11g amount exceeds 10% of line 25, column (A) amount, list line 11g expenses on Schedule O) ........ 11,118,651 2,662,271 8,456,380  
12 Advertising and promotion .... 630,716 4,236 626,480  
13 Office expenses ....... 3,362,326 1,717,965 1,644,361  
14 Information technology ...... 1,181,596 603,731 577,865  
15 Royalties .. 0      
16 Occupancy ........... 961,859 607,556 354,303  
17 Travel ............ 28,332 10,104 18,228  
18 Payments of travel or entertainment expenses for any federal, state, or local public officials ...... 0      
19 Conferences, conventions, and meetings .... 154,043 34,944 119,099  
20 Interest ........... 896,994 499,735 397,259  
21 Payments to affiliates ....... 0      
22 Depreciation, depletion, and amortization ..... 4,281,965 2,754,575 1,527,390  
23 Insurance .............. 1,245,109 945,530 299,579  
24 Other expenses. Itemize expenses not covered above (List miscellaneous expenses in line 24e. If line 24e amount exceeds 10% of line 25, column (A) amount, list line 24e expenses on Schedule O.)
a MEDICAL SUPPLIES EXPENSE 9,129,776 8,932,598 197,178 0
b MAINTENANCE & SERVICE CONTRACT 1,877,389 1,220,159 657,230  
c SPECIAL EVENTS 79,144   79,144  
d OTHER EXPENSE 8,599   8,599  
e All other expenses        
25 Total functional expenses. Add lines 1 through 24e 84,721,852 48,035,547 36,686,305 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 ............. 0 1 0
2 Savings and temporary cash investments ......... 16,417,706 2 18,806,620
3 Pledges and grants receivable, net ........... 0 3 0
4 Accounts receivable, net ............. 11,304,258 4 13,039,515
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 .............. 1,229,332 8 1,213,415
9 Prepaid expenses and deferred charges .......... 738,750 9 1,187,092
10a Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D 10a 87,823,044
b Less: accumulated depreciation ..... 10b 34,273,151 53,929,799 10c 53,549,893
11 Investments—publicly traded securities .......... 1,597,626 11 2,179,749
12 Investments—other securities. See Part IV, line 11 ..... 2,951,757 12 2,874,077
13 Investments—program-related. See Part IV, line 11 ..... 2,985,723 13 2,755,257
14 Intangible assets ............... 0 14 0
15 Other assets. See Part IV, line 11 ........... 4,547,669 15 4,526,558
16 Total assets. Add lines 1 through 15 (must equal line 34)...... 95,702,620 16 100,132,176
Liabilities 17 Accounts payable and accrued expenses ......... 12,302,036 17 13,805,074
18 Grants payable ................. 0 18 0
19 Deferred revenue ................ 0 19 0
20 Tax-exempt bond liabilities ............. 11,566,000 20 11,720,761
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 .. 5,155,766 23 4,358,841
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.................... 3,720,832 25 5,726,874
26 Total liabilities. Add lines 17 through 25......... 32,744,634 26 35,611,550
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 .............. 62,591,533 27 64,197,282
28 Temporarily restricted net assets ........... 366,453 28 323,344
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 ........... 62,957,986 33 64,520,626
34 Total liabilities and net assets/fund balances ........ 95,702,620 34 100,132,176
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
87,929,115
2
Total expenses (must equal Part IX, column (A), line 25) ............
2
84,721,852
3
Revenue less expenses. Subtract line 2 from line 1 ..............
3
3,207,263
4
Net assets or fund balances at beginning of year (must equal Part X, line 33, column (A)) ..
4
62,957,986
5
Net unrealized gains (losses) on investments ...............
5
302,978
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
-1,947,601
10
Net assets or fund balances at end of year. Combine lines 3 through 9 (must equal Part X, line 33, column (B))
10
64,520,626
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
OUR LADY OF THE LAKE ASCENSION
COMMUNITY HOSPITAL
Employer identification number

72-1470744
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
OUR LADY OF THE LAKE ASCENSION
COMMUNITY HOSPITAL
Employer identification number

72-1470744
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
OUR LADY OF THE LAKE ASCENSION
COMMUNITY HOSPITAL 		Employer identification number

72-1470744
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
OUR LADY OF THE LAKE ASCENSION
COMMUNITY HOSPITAL 		Employer identification number

72-1470744
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
OUR LADY OF THE LAKE ASCENSION
COMMUNITY HOSPITAL 		Employer identification number

72-1470744
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 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
OUR LADY OF THE LAKE ASCENSION
COMMUNITY HOSPITAL
Employer identification number

72-1470744
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 .................   3,747,277 3,747,277
b Buildings ................   57,240,111 15,245,472 41,994,641
c Leasehold improvements ............   759,601 523,133 236,468
d Equipment ................   25,743,034 18,504,548 7,238,486
e Other .................   333,021   333,021
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).).......SchDMdBullet 53,549,893
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








Total. (Column (b) must equal Form 990, Part X, col.(B) line 13.)Small Bullet  
Part IX
Other Assets. See Form 990, Part X, line 15.
(a) Description (b) Book value








Total. (Column (b) must equal Form 990, Part X, col.(B) line 15.)...........Small Bullet  
Part X
Other Liabilities. See Form 990, Part X, line 25.
1.(a) Description of liability (b) Book value
Federal income taxes 0
SELF-INSURANCE LIABILITY 2,539,318
DUE TO AFFILIATES 366,447
PATIENTS PAYABLES 2,897,799
MINORITY INTEREST OBLIGATION -76,690





Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)Small Bullet 5,726,874
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  
2 Amounts included on line 1 but not on Form 990, Part VIII, line 12:
a Net unrealized gains on investments .......... 2a  
b Donated services and use of facilities ......... 2b  
c Recoveries of prior year grants ........... 2c  
d Other (Describe in Part XIII.) ............ 2d  
e Add lines 2a through 2d ..................... 2e  
3 Subtract line 2e from line 1..................... 3  
4 Amounts included on Form 990, Part VIII, line 12, but not on line 1:
a Investment expenses not included on Form 990, Part VIII, line 7b . 4a  
b Other (Describe in Part XIII.) ........... 4b  
c Add lines 4a and 4b....................... 4c  
5 Total revenue. Add lines 3 and 4c. (This must equal Form 990, Part I, line 12.) ...... 5  
Part XII Reconciliation of Expenses per Audited Financial Statements With Expenses per Return
1 Total expenses and losses per audited financial statements ........... 1  
2 Amounts included on line 1 but not on Form 990, Part IX, line 25:
a Donated services and use of facilities .......... 2a  
b Prior year adjustments .............. 2b  
c Other losses ................ 2c  
d Other (Describe in Part XIII.) ............ 2d  
e Add lines 2a through 2d...................... 2e  
3 Subtract line 2e from line 1..................... 3  
4 Amounts included on Form 990, Part IX, line 25, but not on line 1:
a Investment expenses not included on Form 990, Part VIII, line 7b .. 4a  
b Other (Describe in Part XIII.) ............ 4b  
c Add lines 4a and 4b....................... 4c  
5 Total expenses. Add lines 3 and 4c. (This must equal Form 990, Part I, line 18.) ...... 5  
Part XIII
Supplemental Information
Complete this part to provide the descriptions required for Part II, lines 3, 5, and 9; Part III, lines 1a and 4; Part lV, lines 1b and 2b;
Part V, line 4; Part X, line 2; Part XI, lines 2d and 4b; and Part XII, lines 2d and 4b. Also complete this part to provide any additional information.
Identifier Return Reference Explanation
FIN 48 (ASC 740) FOOTNOTE   The Medical Center recognizes the effect of income tax positions only if those positions are more likely than not of being sustained. Recognized income tax positions are measured at the largest amount that is greater than 50% likely of being realized. Changes in recognition or measurement are reflected in the period in which the change in judgment occurs. No reserves for uncertain tax position have been recorded.
Schedule D (Form 990) 2012

Additional Data


Software ID:  
Software Version:  




SCHEDULE F(Form 990)
Department of the Treasury
Internal Revenue Service
Statement of Activities Outside the United States
Right pointing arrow large image Complete if the organization answered "Yes" to Form 990,Part IV, line 14b, 15, or 16.Right pointing arrow large image Attach to Form 990. Right pointing arrow large image See separate instructions.
OMB No. 1545-0047
2012
Open to Public Inspection
Name of the organization
OUR LADY OF THE LAKE ASCENSION
COMMUNITY HOSPITAL
Employer identification number

72-1470744
Part I
General Information on Activities Outside the United States. Complete if the organization answered “Yes” to Form 990, Part IV, line 14b.
1
For grantmakers. Does the organization maintain records to substantiate the amount of the grants or
assistance, the grantees’ eligibility for the grants or assistance, and the selection criteria used to award
the grants or assistance? ...................................
2
For grantmakers. Describe in Part V the organization’s procedures for monitoring the use of grant funds outside
the United States.
3
Activites per Region. (The following Part I, line 3 table can be duplicated if additional space is needed.)
(a) Region (b) Number of offices in the region (c) Number of employees, agents, and independent contractors in region (d) Activities conducted in region (by type) (e.g., fundraising, program services, investments, grants to recipients located in the region) (e) If activity listed in (d) is a program service, describe specific type of
service(s) in region		 (f) Total expenditures
for and investments
in region
Central America and the Caribbean     Investments   1,018,916
           
           
           
           
           
           
           
           
           
           
           
           
           
           
           
           
3a Sub-total .....     1,018,916
b Total from continuation sheets to Part I ...      
c Totals (add lines 3a and 3b)     1,018,916
For Paperwork Reduction Act Notice, see the Instructions for Form 990.Cat. No. 50082W Schedule F (Form 990) 2012
Schedule F (Form 990) 2012
Page 2
Part II
Grants and Other Assistance to Organizations or Entities Outside the United States. Complete if the organization answered “Yes” to Form 990, Part IV, line 15, for any recipient who received more than $5,000. Part II can be duplicated if additional space is needed.
1 (a) Name of organization (b) IRS code section
and EIN (if applicable)		 (c) Region (d) Purpose of
grant 		(e) Amount of
cash grant 		(f) Manner of
cash
disbursement 		(g) Amount of
of non-cash
assistance 		(h) Description
of non-cash
assistance 		(i) Method of
valuation
(book, FMV,
appraisal, other)
             
             
             
             
             
             
             
             
             
             
             
             
             
             
             
             
2 Enter total number of recipient organizations listed above that are recognized as charities by the foreign country, recognized as tax-exempt by the IRS, or for which the grantee or counsel has provided a section 501(c)(3) equivalency letter ....MediumBullet
 
3
Enter total number of other organizations or entities .......................MediumBullet
 
Schedule F (Form 990) 2012
Schedule F (Form 990) 2012Page 3
Part III
Grants and Other Assistance to Individuals Outside the United States. Complete if the organization answered "Yes" to Form 990, Part IV, line 16.
Part III can be duplicated if additional space is needed.
(a) Type of grant or assistance (b) Region (c) Number of recipients (d) Amount of
cash grant 		(e) Manner of cash
disbursement 		(f) Amount of
non-cash
assistance 		(g) Description
of non-cash
assistance 		(h) Method of
valuation
(book, FMV,
appraisal, other)
               
               
               
               
               
               
               
               
               
               
               
               
               
               
               
               
               
               
Schedule F (Form 990) 2012
Schedule F (Form 990) 2012
Page 4
Part IV
Foreign Forms
1 Was the organization a U.S. transferor of property to a foreign corporation during the tax year? If “Yes,”the organization may be required to file Form 926, Return by a U.S. Transferor of Property to a Foreign Corporation (see Instructions for Form 926)......................................
2 Did the organization have an interest in a foreign trust during the tax year? If “Yes,” the organizationmay be required to file Form 3520, Annual Return to Report Transactions with Foreign Trusts and Receipt of Certain Foreign Gifts, and/or Form 3520-A, Annual Information Return of Foreign Trust With a U.S. Owner (see Instructions for Forms 3520 and 3520-A).......................................
3 Did the organization have an ownership interest in a foreign corporation during the tax year? If "Yes," the organization may be required to file Form 5471, Information Return of U.S. Persons with Respect to Certain Foreign Corporations. (see Instructions for Form 5471)..............................
4 Was the organization a direct or indirect shareholder of a passive foreign investment company or a qualified electing fund during the tax year? If "Yes," the organization may be required to file Form 8621, Return by a Shareholder of a Passive Foreign Investment Company or Qualified Electing Fund. (see Instructions for Form 8621)
5 Did the organization have an ownership interest in a foreign partnership during the tax year? If "Yes," the organization may be required to file Form 8865, Return of U.S. Persons with Respect to Certain Foreign Partnerships. (see Instructions for Form 8865)....................................
6 Did the organization have any operations in or related to any boycotting countries during the tax year? If "Yes," the organization may be required to file Form 5713, International Boycott Report (see Instructions for Form 5713)................................................
Schedule F (Form 990) 2012
Schedule F (Form 990) 2012
Page 5
Part V
Supplemental Information
Complete this part to provide the information required by Part I, line 2 (monitoring of funds); Part I, line 3, column (f) (accounting method; amounts of investments vs. expenditures per region); Part II, line 1 (accounting method); Part III (accounting method); and Part III, column (c) (estimated number of recipients), as applicable. Also complete this part to provide any additional information (see instructions).
Identifier ReturnReference Explanation
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
Schedule F (Form 990) 2012
Additional Data


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Software Version:  



SCHEDULE G (Form 990 or 990-EZ)
Department of the Treasury
Internal Revenue Service
Supplemental Information Regarding
Fundraising or Gaming Activities
Complete if the organization answered "Yes" to Form 990, Part IV, lines 17, 18, or 19, or if the organization entered more than $15,000 on Form 990-EZ, line 6a. Form 990-EZ filers are not required to complete this part. right arrowAttach to Form 990 or Form 990-EZ. right arrowSee separate instructions.
OMB No. 1545-0047
2012
Open to Public Inspection
Name of the organization
OUR LADY OF THE LAKE ASCENSION
COMMUNITY HOSPITAL
Employer identification number

72-1470744
Part I
Fundraising Activities. Complete if the organization answered "Yes" to Form 990, Part IV, line 17.
1
Indicate whether the organization raised funds through any of the following activities. Check all that apply.
a e
b f
c g
d
2a
Did the organization have a written or oral agreement with any individual (including officers, directors, trustees
or key employees listed in Form 990, Part VII) or entity in connection with professional fundraising services?
b
If “Yes,” list the ten highest paid individuals or entities (fundraisers) pursuant to agreements under which the fundraiser is
to be compensated at least $5,000 by the organization.
(i) Name and address of individual
or entity (fundraiser) 		(ii) Activity (iii) Did fundraiser have custody or control of contributions? (iv) Gross receipts
from activity 		(v) Amount paid to
(or retained by)
fundraiser listed in
col. (i) 		(vi) Amount paid to
(or retained by)
organization
Yes No
             
             
             
             
             
             
             
             
             
             
Total .................right arrow      
3
List all states in which the organization is registered or licensed to solicit funds or has been notified it is exempt from registration or licensing.
For Paperwork Reduction Act Notice, see the Instructions for Form 990or 990-EZ.
Cat. No. 50083H
Schedule G (Form 990 or 990-EZ) 2012
Schedule G (Form 990 or 990-EZ) 2012
Page 2
Part II
Fundraising Events. Complete if the organization answered "Yes" to Form 990, Part IV, line 18, or reported more than $15,000 of fundraising event contributions and gross income on Form 990-EZ, lines 1 and 6b. List events with gross receipts greater than $5,000.
(a) Event #1

GOLF TOURNAMENT
(event type) 		(b) Event #2

 
(event type) 		(c) Other events

0
(total number) 		(d) Total events
(add col. (a) through col. (c))
VerticalRevenue 1 Gross receipts . . . 33,604     33,604
2 Less: Contributions . . 28,017     28,017
3 Gross income (line 1
minus line 2) . . . 		5,587     5,587
VerticalDirectExpenses 4 Cash prizes . . .        
5 Noncash prizes . . 837     837
6 Rent/facility costs . . 6,901     6,901
7 Food and beverages .        
8 Entertainment . . .        
9 Other direct expenses . 10,199     10,199
10 Direct expense summary. Add lines 4 through 9 in column (d) ........... right arrow 17,937
11 Net income summary. Combine line 3, column (d), and line 10. .......... right arrow -12,350
Part III
Gaming. Complete if the organization answered "Yes" to Form 990, Part IV, line 19, or reported more than $15,000 on Form 990-EZ, line 6a.
VerticalRevenue (a) Bingo (b) Pull tabs/Instant
bingo/progressive bingo 		(c) Other gaming (d) Total gaming (add col.(a) through col.(c))
1 Gross revenue . . . .        
VerticalDirectExpenses 2 Cash prizes . . . .        
3 Non-cash prizes . . .        
4 Rent/facility costs . . .        
5 Other direct expenses . .        
6 Volunteer labor . . .
 
 
 
7 Direct expense summary. Add lines 2 through 5 in column (d) ........... right arrow  
8 Net gaming income summary. Combine lines 1 and 7 in column (d) .......... right arrow  
9
Enter the state(s) in which the organization operates gaming activities:
a
Is the organization licensed to operate gaming activities in each of these states? ............
b
If "No," explain:
 
10a
Were any of the organization's gaming licenses revoked, suspended or terminated during the tax year? .....
b
If "Yes," explain:
 
Schedule G (Form 990 or 990-EZ) 2012
Schedule G (Form 990 or 990-EZ) 2012
Page 3
11
Does the organization operate gaming activities with nonmembers? .................
12
Is the organization a grantor, beneficiary or trustee of a trust or a member of a partnership or other entity
formed to administer charitable gaming? ..........................
13
Indicate the percentage of gaming activity operated in:
a
The organization's facility ......................
13a
 
b
An outside facility ........................
13b
 
14
Enter the name and address of the person who prepares the organization's gaming/special events books and records:
Name right arrow
Address right arrow
15a
Does the organization have a contract with a third party from whom the organization receives gaming
revenue? ......................................
b
If "Yes," enter the amount of gaming revenue received by the organization right arrow $   and the
amount of gaming revenue retained by the third party right arrow $   .
c
If "Yes," enter name and address of the third party:
Name right arrow
Address right arrow
 
 
16
Gaming manager information:
Name right arrow
Gaming manager compensation right arrow $  
Description of services provided right arrow
 
17
Mandatory distributions:
a
Is the organization required under state law to make charitable distributions from the gaming proceeds to
retain the state gaming license? ............................
b
Enter the amount of distributions required under state law distributed to other exempt organizations or spent
in the organization's own exempt activities during the tax year right arrow$  
Part IV
Supplemental Information. Complete this part to provide the explanations required by Part I, line 2b, columns (iii) and (v), and Part III, lines 9, 9b, 10b, 15b, 15c, 16, and 17b, as applicable. Also complete this part to provide any additional information (see instructions).
Identifier Return Reference Explanation
Schedule G (Form 990 or 990-EZ) 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
OUR LADY OF THE LAKE ASCENSION
COMMUNITY HOSPITAL
Employer identification number

72-1470744
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
 
No
c
If "Yes" to line 5b, as a result of budget considerations, was the organization unable to provide free or discountedcare to a patient who was eligibile for free or discounted care? ..............
5c
 
 
6a
Did the organization prepare a community benefit report during the tax year? ..........
6a
Yes
 
b
If "Yes," did the organization make it available to the public? ..............
6b
Yes
 
Complete the following table using the worksheets provided in the Schedule H instructions. Do not submit these worksheets with the Schedule H.
7
Financial Assistance and Certain Other Community Benefits at Cost
Financial Assistance and
Means-Tested
Government Programs
 (a) Number of activities or programs (optional) (b) Persons served (optional) (c) Total community benefit expense (d) Direct offsetting revenue (e) Net community benefit expense (f) Percent of total expense
a Financial Assistance at cost
(from Worksheet 1) .. 		    951,108   951,108 1.120 %
b Medicaid (from Worksheet 3,
column a) .... 		    11,357,636 4,704,999 6,652,637 7.850 %
c Costs of other means-tested
government programs (from
Worksheet 3, column b) . 		           
d Total Financial Assistance
and Means-Tested
Government Programs . 		    12,308,744 4,704,999 7,603,745 8.970 %
Other Benefits
     102,010   102,010 0.120 %
e Community health
improvement services and
community benefit operations
(from Worksheet 4) ..
f Health professions education
(from Worksheet 5) .. 		    318,377   318,377 0.380 %
g Subsidized health services
(from Worksheet 6) .. 		    428,333   428,333 0.510 %
h Research (from Worksheet 7)            
i Cash and in-kind
contributions for community
benefit (from Worksheet 8) 		    108,706   108,706 0.130 %
j Total. Other Benefits ..     957,426   957,426 1.140 %
k Total. Add lines 7d and 7j .     13,266,170 4,704,999 8,561,171 10.110 %
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     90   90  
2 Economic development     18,154   18,154 0.020 %
3 Community support     7,820   7,820 0.010 %
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     26,064   26,064 0.030 %
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
Yes
 
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
18,218,642
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
 
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
9,169,521
6
Enter Medicare allowable costs of care relating to payments on line 5.....
6
12,924,233
7
Subtract line 6 from line 5. This is the surplus (or shortfall)........
7
-3,754,712
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 %
1ST ELIZABETH IMAGIN
  		IMAGING SERVICES 51.000 % 12.250 % 36.750 %
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 ST ELIZABETH HOSPITAL
1125 HIGHWAY 30
GONZALES,LA70737
WWW.FMOLHS.ORG/STEH 		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)
ST ELIZABETH 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)  
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 Yes  
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 12
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 Yes  
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   No
5 Did the hospital facility make its CHNA report widely available to the public? ............. 5 Yes  
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   No
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   No
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: 200.%
If "No," explain in Part VI the criteria the hospital facility used.
11 Used FPG to determine eligibility for providing discounted care?................. 11 Yes  
If “Yes,” indicate the FPG family income limit for eligibility for discounted care: 400.%
If "No," explain in Part VI the criteria the hospital facility used.
12 Explained the basis for calculating amounts charged to patients?................. 12 Yes  
If “Yes,” indicate the factors used in determining such amounts (check all that apply):
a
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 Yes  
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?4
Name and address Type of Facility (describe)
1 ST ELIZABETH AFTER HOURS
1702 N BURNSIDE AVENUE
GONZALES,LA70737 		URGENT CARE CENTER
2 ST ELIZ-MARY BIRD PERKINS CANCER CENTER
4950 ESSEN LANE
BATON ROUGE,LA70809 		CANCER TREATMENT CENTER
3 ST ELIZABETH IMAGING CENTER
1125 HIGHWAY 30
GONZALES,LA70737 		IMAGING SERVICES
4 COMMUNITY HEALTH CLINIC
1125 HIGHWAY 30
GONZALES,LA70737 		LOW INCOME CLINIC
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 7   THE COST TO CHARGE RATIO, AS CALCULATED USING IRS WORKSHEET 2, IS UTILIZED AS THE COSTING METHODOLOGY TO CALCULATE THE AMOUNTS REPORTED IN PART 1, LINES 7A-F. THE COST ACCOUNTING SYSTEM OF THE ORGANIZATION WAS USED TO CALCULATE THE COST TO CHARGE RATIO OF THE SUBSIDIZED HEALTH SERVICES INCLUDED ON PART I, LINE 7G.
PART III, LINE 4   THE BAD DEBT FOOTNOTE IS ON PAGE 16 OF THE ATTACHED AUDITED FINANCIAL STATEMENTS.
PART III, LINE 8   CMS REGULATIONS/GUIDELINES ARE USED IN COMPLETING THE MEDICARE COST REPORT. THE MEDICARE COST REPORT IS THE TOOL USED IN DETERMINING MEDICARE ALLOWABLE COSTS.
PART III, LINE 9B   INDIVIDUALS WITH NO MEANS OF PAYMENTS ARE PROVIDED THE FINANCIAL ASSISTANCE INFORMATION AND APPLICATION. THE DETERMINATION OF FINANCIAL ASSISTANCE IS BASED ON THE PATIENT'S INCOME LEVEL AND OTHER CRITERIA AS SET FORTH IN THE FINANCIAL ASSISTANCE POLICY. IF IT IS DETERMINED THAT A PATIENT QUALIFIES FOR CHARITY CARE AFTER THE INDIVIDUAL'S ACCOUNT HAS BEEN SENT TO COLLECTIONS, ACCOUNT IS IMMEDIATELY REMOVED FROM THE COLLECTION PROCESS.
PART VI, LINE 2 NEEDS ASSESSMENT RESPONDING TO THE HEALTH NEEDS OF OUR COMMUNITY, ESPECIALLY TO THOSE MOST IN NEED IS PRIMARY TO THE MISSION OF ST. ELIZABETH HOSPITAL. ST. ELIZABETH HOSPITAL IDENTIFIES THE COMMUNITY'S HEALTH NEEDS BY UTILIZING THE FOLLOWING INFORMATION GATHERING TECHNIQUES: COMMUNITY SURVEY: ON AN ANNUAL BASIS, ST. ELIZABETH HOSPITAL, ALONG WITH THE HELP OF STRATEGIC MARKETING AND RESEARCH, LLC, PERFORM A COMMUNITY SURVEY AIMED AT IDENTIFYING THE HEALTH CARE NEEDS AND PREFERENCES OF LOCAL RESIDENTS. THE SURVEY IS CONDUCTED VIA PHONE WHILE USING A RANDOM SAMPLE OF 500 RESPONDENTS. THE FINDINGS FROM THIS RESEARCH SERVE AS A FOUNDATION FOR THE DEVELOPMENT OF FUTURE PROGRAMS FOR OFFERING HEALTHCARE IN ASCENSION PARISH. THE SURVEY ALSO IDENTIFIES THOSE SERVICES THAT ARE SOUGHT OUTSIDE OF ASCENSION PARISH, DUE TO SERVICES NOT BEING OFFERED OR NOT KNOWN TO BE OFFERED (PUBLIC AWARENESS). SUCH DATA HELPS ST. ELIZABETH HOSPITAL ASSESS WHETHER SPECIFIC MEDICAL NEEDS ARE UNDERSERVED. COMMUNITY EDUCATION SURVEY: EVERY TWO YEARS, THE COMMUNITY EDUCATION DEPARTMENT PREPARES A COMMUNITY EDUCATION SURVEY THAT IS GIVEN TO ASCENSION PARISH RESIDENTS WHO ATTEND LOCAL HEALTH SCREENINGS OR OTHER EDUCATIONAL EVENTS. THIS SURVEY IS DESIGNED TO IDENTIFY THE HEALTH EDUCATION NEEDS OF THE AREA RESIDENTS. COMMUNITY NEEDS ASSESSMENT: ST. ELIZABETH HOSPITAL PREPARES A COMMUNITY NEEDS ASSESSMENT ON AN AS-NEEDED BASIS. ST. ELIZABETH HOSPITAL IS ADOPTING A SYSTEMATIC PROCESS FOR IDENTIFYING AND EVALUATING THE NEEDS OF THE COMMUNITY BASED ON THE NEWLY PUBLISHED IRS REGULATIONS AND CATHOLIC HEALTH ASSOCIATION GUIDELINES. ST. ELIZABETH HOSPITAL CONDUCTED THE NEWLY DESIGNED COMMUNITY NEEDS ASSESSMENT IN FY2013 AND WILL CONTINUE EVERY THREE YEARS THEREAFTER.
PART VI, LINE 3 PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCE INDIVIDUALS ARE EDUCATED ABOUT ELIGIBILITY FOR ASSISTANCE UNDER FEDERAL, STATE OR LOCAL GOVERNMENT PROGRAMS AND UNDER THE ORGANIZATION'S CHARITY CARE POLICY AT VARIOUS STAGES OF THE ENCOUNTER WITH ST. ELIZABETH HOSPITAL: 1. SCHEDULING (OUTPATIENT/SURGERY): DURING THE SCHEDULING OF PROCEDURES, A SCHEDULER INFORMS INDIVIDUALS OF THE VARIOUS TYPES OF FINANCIAL ASSISTANCE VIA PHONE. IF THE INDIVIDUAL IS INTERESTED, A FORM IS PROVIDED EITHER BY MAIL OR PICKUP TO COMPLETE AND RETURN TO THE HOSPITAL VIA PRE-PAID POSTAGE ENVELOPE. 2. THE POLICY IS PROVIDED, IN WRITING, TO PATIENTS ON ADMISSION TO THE HOSPITAL FACILITY. 3. FINANCIAL COUNSELING: DURING FINANCIAL COUNSELING, THE INDIVIDUAL IS INFORMED OF THE VARIOUS TYPES OF FINANCIAL ASSISTANCE VIA PERSON TO PERSON CONVERSATION. IF THE INDIVIDUAL IS INTERESTED, A FORM IS PROVIDED AT THAT TIME FOR THE INDIVIDUAL TO COMPLETE AND RETURN TO THE HOSPITAL. ADDITIONALLY, CASHIERS HAVE POSTED NOTIFICATIONS OF THE FINANCIAL ASSISTANCE OPPORTUNITIES IN THE CASHIER'S OFFICE AND THE EMERGENCY ROOM COLLECTION DESK. 4. WEBSITE NOTIFICATION: ST. ELIZABETH HOSPITAL'S WEBSITE, LOCATED AT WWW.STEH.COM INCLUDES A PAGE CALLED "HELP FOR THE UNINSURED" WHICH PROVIDES INFORMATION CONCERNING ST. ELIZABETH HOSPITAL'S FINANCIAL ASSISTANCE POLICY. A TELEPHONE NUMBER IS ALSO PROVIDED TO THOSE WHO ARE INTERESTED IN CONTACTING OUR FINANCIAL COUNSELORS FOR ADDITIONAL INFORMATION. 5. THE POLICY IS AVAILABLE UPON REQUEST
PART VI, LINE 4 COMMUNITY INFORMATION ST. ELIZABETH HOSPITAL SERVES ASCENSION PARISH AND PORTIONS OF THE SURROUNDING PARISHES OF ASSUMPTION, IBERVILLE, EAST BATON ROUGE, AND ST. JAMES. THIS AREA HAS SEEN SIGNIFICANT GROWTH IN THE LAST DECADE. SOME OF THIS GROWTH CAN BE ATTRIBUTED TO THE HURRICANES THAT HAVE DEVASTATED THE LOUISIANA COASTLINE IN RECENT YEARS. SPECIFICALLY, THE HISPANIC/LATINO POPULATION HAS MORE THAN DOUBLED IN SOME PORTIONS OF THE SERVICE AREA. THE NORTHERN PARTS OF THE SERVICE AREA TEND TO HAVE A MORE AFFLUENT POPULATION; WHEREAS, THE SOUTHERN TRACTS HAVE CONTINUED BARRIERS TO HEALTHCARE. THE AVERAGE PER CAPITA INCOME FOR THE SERVICE AREA IS $22,535 WITH 17.6% OF FAMILIES LIVING BELOW THE POVERTY LEVEL. HEALTH STATISTICS THAT ARE ROUTINELY COLLECTED INDICATE THAT RESIDENTS OF THE SERVICE AREA EXPERIENCE MANY HEALTH PROBLEMS. SPECIFICALLY, THE POPULATION SUFFERS HIGHER RATES OF STROKE, OBESITY, CANCER, DIABETES AND HYPERTENSION THAN THE NATION AS A WHOLE.
PART II   ST. ELIZABETH PARTICIPATES IN COMMUNITY BUILDING ACTIVITIES BECAUSE IT UNDERSTANDS THAT IMPROVEMENTS TO A COMMUNITY HAVE A DIRECT LINK TO THE IMPROVED HEALTH OF COMMUNITY RESIDENTS. COMMUNITY BUILDING ACTIVITIES INCLUDE DEVOTING TIME TO NEIGHBORHOOD IMPROVEMENT AND REVITALIZATION PROJECTS, PARTICIPATING IN ECONOMIC DEVELOPMENT COUNCILS/CHAMBERS OF COMMERCE AND PARTICIPATING IN SCHOOL MENTORING PROGRAMS. ALL OF THESE PROGRAMS HELP DEVELOP THE GENERAL WELL-BEING OF THE COMMUNITY WHICH, IN TURN, PROMOTES THE HEALTH OF THE COMMUNITY ST. ELIZABETH SERVES. COMMUNITY BUILDING ACTIVITIES ALSO INCLUDE TIME DEVOTED TO FORMING COLLABORATIVE PARTNERSHIPS WITH VARIOUS ORGANIZATIONS SUCH AS THE DEPARTMENT OF HEALTH & HUMAN SERVICES, LOCAL SCHOOL BOARDS, AND OTHER LOCAL HOSPITALS TO IMPROVE THE GENERAL COMMUNITY HEALTH. ADDITIONALLY, ST. ELIZABETH PARTNERS WITH COMMUNITY COLLEGES AND UNIVERSITIES TO ADDRESS HEALTH CARE WORKFORCE SHORTAGES. IT ALSO PARTICIPATES IN SCHOOL-BASED PROGRAMS RELATED TO HEALTH CARE CAREERS.
OTHER INFORMATION   SEE THE QUALITATIVE DESCRIPTION OF COMMUNITY BENEFIT REPORT ON SCHEDULE O.
AFFILIATED HEALTH CARE SYSTEM   ST. ELIZABETH IS PART OF THE FMOLHS HEALTH CARE SYSTEM WHICH INCLUDES SEVERAL HOSPITALS AND TAX-EXEMPT AFFILIATES THROUGHOUT THE STATE. ST. ELIZABETH HOSPITAL SERVES THE COMMUNITY IN GONZALES, LA AND SURROUNDING PARISHES. ST. ELIZABETH HOSPITAL WORKS CLOSELY WITH OUR LADY OF THE LAKE REGIONAL MEDICAL CENTER (A TAX-EXEMPT HOSPITAL AFFILIATE) TO PROVIDE COMPREHENSIVE MEDICAL SERVICES AS PART OF THE OVERALL HEALTHCARE PROVIDED TO THE COMMUNITY.
PART V LINE 13   REGISTRATION PERSONNEL REFER PATIENTS THAT MAY HAVE DIFFICULTY PAYING FOR THEIR MEDICAL CARE TO FINANCIAL COUNSELORS TO DISCUSS QUALIFICATION FOR FREE OR DISCOUNTED CARE.
PART V, LINE 20   THE HOSPITAL FACILITY HAS CALCULATED THE AMOUNTS GENERALLY BILLED TO PATIENTS WITH INSURANCE FOR EMERGENCY AND OTHER MEDICALLY NECESSARY CARE AT APPROXIMATELY A 30% DISCOUNT FROM CHARGE MASTER RATES. UNDER THE HOSPITAL'S FINANCIAL ASSISTANCE POLICY (FAP), MULTIPLE LEVELS OF DISCOUNTS ARE PROVIDED FOR. THE MAJORITY OF FAP ELIGIBLE PATIENTS FALL IN THE 50%, 75%, AND 100% DISCOUNT LEVELS. THERE IS HOWEVER A 25% DISCOUNT LEVEL. THE HOSPITAL ALSO OFFERS A 25% SELF-PAY DISCOUNT. SO FOR UNINSURED FAP PATIENTS, MULTIPLE DISCOUNTS MAY APPLY. IT IS POSSIBLE, HOWEVER, THAT AN UNDERINSURED PATIENT WITHIN CERTAIN INCOME LEVELS WOULD BE OFFERED ONLY THE 25% CHARITY DISCOUNT. THE NUMBER OF PATIENTS IN THIS SCENARIO WOULD BE EXTREMELY SMALL, IF ANY, BUT IT IS POSSIBLE THAT THIS CATEGORY OF PATIENT MAY HAVE BEEN CHARGED MORE THAN AMOUNTS GENERALLY BILLED TO PATIENTS WITH INSURANCE COVERING SUCH CARE. IN ADDITION, THERE IS LOW PROBABILITY THAT ANY PATIENT IN THIS 25% CHARITY DISCOUNT CATEGORY ACTUALLY PAID MORE THAN AMOUNTS GENERALLY BILLED TO PATIENTS WITH INSURANCE COVERING SUCH CARE. THE HOSPITAL ADOPTED A NEW FAP POLICY AS OF JUNE 2013 THAT WILL ENSURE THAT FAP-ELIGIBLE PATIENTS ARE NOT BILLED MORE THAN AMOUNTS GENERALLY BILLED TO PATIENTS WITH INSURANCE COVERING SUCH CARE.
PART V, LINE 19D   THE HOSPITAL OFFERS VARIOUS LEVELS OF DISCOUNTS WHICH ARE BASED ON A SLIDING SCALE USING THE FEDERAL POVERTY GUIDELINE FAMILY INCOME LEVELS AND OTHER FACTORS. SUCH OTHER FACTORS INCLUDE ASSET LEVELS, MEDICAL INDIGENCY, AND A PATIENT'S QUALIFICATION FOR MEDICARE OR MEDICAID. TOGETHER THESE CRITERIA ARE USED TO SET THE MAXIMUM AMOUNT CHARGED. ALSO, A 25% SELF-PAY DISCOUNT IS GIVEN IN ADDITION TO THE CHARITY DISCOUNTS DESCRIBED ABOVE.
PART III, LINE 2   THE ORGANIZATION ACCOUNTS FOR BAD DEBTS BASED ON THE AGING OF ACCOUNTS AND HISTORICAL COLLECTION HISTORY ASSOCIATED WITH THE VARIOUS AGING CATEGORIES. ON A PERIODIC BASIS, THE ORGANIZATION CONDUCTS A RETROSPECTIVE REVIEW OF THE COLLECTIONS TO DETERMINE THE APPROPRIATE COLLECTION PERCENTAGE TO USE IN ESTIMATING BAD DEBT EXPENSE. DISCOUNTS PROVIDED ARE NOT INCLUDED IN BAD DEBT EXPENSE. NO ESTIMATE HAS BEEN MADE FOR ANY AMOUNTS INCLUDED IN BAD DEBT EXPENSE THAT MAY QUALIFY FOR FINANCIAL ASSISTANCE.
PART V, LINE 3   THE ORGANIZATION ENGAGED KEY COMMUNITY PARTNERS THROUGH PERSONAL INTERVIEWS AND RESEARCH OF CURRENT HEALTH STATISTICS AND TRENDS. ST. ELIZABETH TOOK INTO ACCOUNT INPUT FROM THOSE WITH SPECIALIZED KNOWLEDGE OF OR EXPERTISE IN PUBLIC HEALTH BY WORKING WITH KENNY MATASSA, DIRECTOR OF THE ASCENSION PARISH HEALTH UNIT. ST. ELIZABETH INTERVIEWED BOTH COMMUNITY MEMBERS AND HEALTHCARE PROVIDERS.
PART V, LINE 7   ST. ELIZABETH DID NOT ADDRESS ALL OF THE NEEDS IDENTIFIED IN ITS MOST RECENTLY CONDUCTED CHNA. ST. ELIZABETH CHOSE NOT TO FOCUS ON THE FOLLOWING: LOW INFANT BIRTH WEIGHT; RESPIRATORY DISEASES INCLUDING ASTHMA; MENTAL HEALTH INCLUDING DRUG AND ALCOHOL ABUSE; PHYSICAL ENVIRONMENT; TRANSPORTATION SERVICES. ST. ELIZABETH CHOSE NOT TO FOCUS ON THESE NEEDS BECAUSE OTHER ORGANIZATIONS IN THE COMMUNITY WERE ALREADY PROVIDING SERVICES TO ADDRESS THESE NEEDS OR ST. ELIZABETH DOES NOT HAVE THE EXPERTISE TO PROVIDE THE SERVICE.
Schedule H (Form 990) 2012
Additional Data


Software ID:  
Software Version:  
Schedule I
(Form 990)
Department of the Treasury
Internal Revenue Service
Grants and Other Assistance to Organizations,
Governments and Individuals in the United States
Complete if the organization answered "Yes," to Form 990, Part IV, line 21 or 22.
lBullet Attach to Form 990
OMB No. 1545-0047
2012
Open to Public
Inspection
Name of the organization
OUR LADY OF THE LAKE ASCENSION
COMMUNITY HOSPITAL
Employer identification number
72-1470744
Part I
General Information on Grants and Assistance
1
Does the organization maintain records to substantiate the amount of the grants or assistance, the grantees' eligibility for the grants or assistance, and
the selection criteria used to award the grants or assistance? ....................................
2
Describe in Part IV the organization's procedures for monitoring the use of grant funds in the United States.
Part II
Grants and Other Assistance to Governments and Organizations in the United States. Complete if the organization answered "Yes" to
Form 990, Part IV, line 21, for any recipient that received more than $5,000. Part II can be duplicated if additional space is needed.
(a) Name and address of organization
or government		 (b) EIN (c) IRC Code section
if applicable		 (d) Amount of cash grant (e) Amount of non-cash
assistance		 (f) Method of valuation
(book, FMV, appraisal,
other)		 (g) Description of
non-cash assistance		 (h) Purpose of grant
or assistance
(1) OUR LADY OF THE LAKE FOUNDATION
5000 HENNESSY BLVD
BATON ROUGE,LA70808 		72-1014324 501(C)(3) 6,000       general support
(2) MARCH OF DIMES
11960 BRICKSOME AVE
BATON ROUGE,LA70816 		13-1846366 501(C)(3) 10,800       GENERAL SUPPORT
(3) AMERICAN CANCER SOCIETY
4633 NORTH BLVD
BATON ROUGE,IA70809 		64-0329009 501(C)(3) 10,000       general support


















2
Enter total number of section 501(c)(3) and government organizations listed in the line 1 table ................ Bullet Image
3
3
Enter total number of other organizations listed in the line 1 table ........................ . Bullet Image
 
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50055P
Schedule I (Form 990) 2012

Schedule I (Form 990) 2012
Page 2
Part III
Grants and Other Assistance to Individuals in the United States. Complete if the organization answered "Yes" to Form 990, Part IV, line 22.
Part III can be duplicated if additional space is needed.
(a)Type of grant or assistance (b)Number of
recipients		 (c)Amount of
cash grant		 (d)Amount of
non-cash assistance		 (e)Method of valuation (book,
FMV, appraisal, other)		 (f)Description of non-cash assistance
(1) HARDSHIP ASSISTANCE 8 16,147      












Part IV
Supplemental Information.
Complete this part to provide the information required in Part I, line 2, Part III, column (b), and any other additional information.
Identifier Return Reference Explanation
PART I, QUESTION 2   All charitable donations are made to well-known charitable organizations or through referral from either a board or team member associated with the local/national charity. St. Elizabeth Hospital utilizes several resources to verify the integrity and authenticity of the charitable organization including, but not limited to, 1) Office of Inspector General Sanction List 2) General Services Administration Sanctions List 3) U.S Treasury Sanctions List 4) Internal Revenue Service's list of tax deductible charitable organizations or 5) Better Business Bureau Resource Library. Charitable recipients are asked to provide a donation letter explaining the intent for which the donation will be used.
Schedule I (Form 990) 2012


Additional Data


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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
OUR LADY OF THE LAKE ASCENSION
COMMUNITY HOSPITAL
Employer identification number

72-1470744
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
Yes
 
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
Yes
 
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
Yes
 
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)ROBERT BURGESSPRESIDENT AND CEO (i)
(ii)		 0
130,652 		0
0 		0
6,437 		0
5,305 		0
8,662 		0
151,056 		0
0
(2)CARY PAUL AGUILLARD JR MDBOARD MEMBER (i)
(ii)		 238,687
0 		51,532
0 		638
0 		10,000
0 		28,398
0 		329,255
0 		0
0
(3)JAMES D'ANTONI MDCHIEF OF STAFF/BOARD MEMBER (i)
(ii)		 161,790
0 		53,929
0 		0
0 		8,914
0 		22,145
0 		246,778
0 		0
0
(4)JOHN F FRAICHE MDBOARD MEMBER (i)
(ii)		 419,766
0 		101,280
0 		120,000
0 		10,000
0 		1,830
0 		652,876
0 		0
0
(5)DOLORES N LEJEUNE RN C N AFORMER CEO/RETIRED JUNE 2012 (i)
(ii)		 0
257,665 		0
109,900 		0
3,108 		0
53,435 		0
6,137 		0
430,245 		0
0
(6)DAWN ZITMAN MDBOARD MEMBER (i)
(ii)		 141,485
0 		23,034
0 		100
0 		6,438
0 		12,063
0 		183,120
0 		0
0
(7)CRAIG A VITRANO MDCHIEF MEDICAL OFFICER (i)
(ii)		 346,012
0 		93,381
0 		23,453
0 		48,366
0 		21,182
0 		532,394
0 		0
0
(8)SUE KNIGHTCHIEF OPERATING OFFICER (i)
(ii)		 184,672
0 		45,272
0 		866
0 		45,272
0 		10,849
0 		286,931
0 		0
0
(9)SCOTT RICHARD CPAVP FINANCE (i)
(ii)		 145,981
0 		39,572
0 		5,666
0 		14,086
0 		2,773
0 		208,078
0 		0
0
(10)LESLIE NORMAN RN C N ACHIEF NURSING OFFICER (i)
(ii)		 151,266
0 		37,360
0 		22,931
0 		28,089
0 		12,560
0 		252,206
0 		0
0
(11)THOMAS EWING MDSTAFF PHYSICIAN (i)
(ii)		 422,592
0 		54,194
0 		0
0 		10,000
0 		23,451
0 		510,237
0 		0
0
(12)DAWN SHARP MDSTAFF PHYSICIAN (i)
(ii)		 360,021
0 		6,226
0 		0
0 		10,000
0 		27,739
0 		403,986
0 		0
0
(13)JOHN KNAPP MDSTAFF PHYSICIAN (i)
(ii)		 341,207
0 		85,274
0 		0
0 		10,000
0 		23,697
0 		460,178
0 		0
0
(14)RAHIL D SHAH MDSTAFF PHYSICIAN (i)
(ii)		 390,000
0 		18,647
0 		0
0 		10,000
0 		1,332
0 		419,979
0 		0
0
(15)LARRY W WARNER JR MDSTAFF PHYSICIAN (i)
(ii)		 206,200
0 		184,050
0 		100
0 		10,000
0 		14,841
0 		415,191
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 I, Question 7   THE ORGANIZATION HAS PROVIDED LISTED PERSONS WITH INCENTIVE COMPENSATION WHICH IS BASED ON A FORMULA DERIVED FROM QUALITY, EFFICIENCY, AND OTHER PERFORMANCE MEASURES. SUCH BONUSES WERE APPROVED BY THE CEO OR THE COMPENSATION COMMITTEE OF THE BOARD OF DIRECTORS.
Part I question 4a   The former CEO was entitled to a severance benefit. The payout of such benefit was remote as it was effective only for a termination of employment without cause. If triggered, the executive would be paid her base salary and an annual incentive at target and provided retirement and welfare benefits for an entitlement period. The entitlement period ranges from 18 to 36 months months depending on the executive and the length of service. No payments were made under the plan in the current year. Other persons listed on part VII, Section A are entitled to a severance benefit. The payout of such benefit is remote as it is effective only for a termination of employment due to reorganization of hospital departments, hospital functions or downsizing activity. If triggered, the employee would be paid his or her base salary for an entitlement period. The entitlement period ranges from 4 weeks to 4 months depending on the length of service and the level of such employee. No payments were made to persons listed on Part VII, Section A under the plan in the current year.
PART I, QUESTION 3   THE CEO AND FORMER CEO WERE PAID BY FMOL HEALTH SYSTEM, A RELATED TAX EXEMPT ORGANIZATION. THE FMOLHS BOARD OF DIRECTORS DESIGNATES A COMPENSATION COMMITTEE, MADE UP OF INDEPENDENT BOARD MEMBERS, TO REVIEW AND SET THE CEO'S COMPENSATION ANNUALLY. THE COMPENSATION COMMITTEE OBTAINED AND RELIED UPON COMPARABLE DATA INCLUDING A COMPENSATION STUDY/SURVEY FROM AN INDEPENDENT COMPENSATION CONSULTANT. THE COMPENSATION COMMITTEE REVIEWED COMPENSATION PACKAGES AND APPROPRIATE COMPENSATION WAS DETERMINED AND APPROVED. THE BASIS FOR MAKING SUCH DETERMINATION WAS DOCUMENTED BY THE COMPENSATION COMMITTEE.
PART I, QUESTION 1a   THREE DIRECTORS LISTED IN PART VII RECEIVED REIMBURSEMENT FOR COMPANION TRAVEL. THESE AMOUNTS WERE NOT TREATED AS TAXABLE COMPENSATION TO THE DIRECTORS.
Schedule J (Form 990) 2012

Additional Data


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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
OUR LADY OF THE LAKE ASCENSION
COMMUNITY HOSPITAL
Employer identification number

72-1470744
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) JOHN F FRAICHE MD SON RECEIVES COMPENSATION 264,954 COMPENSATION AS PHYSICIAN   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
OUR LADY OF THE LAKE ASCENSION
COMMUNITY HOSPITAL
Employer identification number

72-1470744
Identifier Return Reference Explanation
PART VI, SECTION A, QUESTION 6 Question 8 FMOL HEALTH SYSTEM (AN IRC SECTION 501(C)(3) ORGANIZATION) IS THE SOLE MEMBER OF ST. ELIZABETH HOSPITAL
PART VI, SECTION A, QUESTION 7A   FMOL HEALTH SYSTEM, AS THE SOLE MEMBER OF ST. ELIZABETH HOSPITAL, RETAINS THE POWER TO APPOINT AND REMOVE THE MEMBERS OF THE BOARD OF TRUSTEES AND OFFICERS OF ST. ELIZABETH HOSPITAL
Page 6, Part VI, Section B Question 12c St. Elizabeth Hospital has a comprehensive conflict of interest policy that requires each officer, trustee, board committee member and employee to complete a conflict of interest disclosure statement annually. Completed disclosure forms are reviewed and maintained by the Chief Compliance Officer. If any trustee, Board committee member or senior manager has a potential conflict, the Executive Committee of the Board determines whether action needs to be taken and communicates any such action to the individual. A potential conflict of any other employee is reviewed by the CEO or a designee. The Executive Committee, CEO or designee, as applicable, determines if a conflict of interest EXISTS OR CREATES the appearance of impropriety. If such a determination is made, the individual will be excused from participating in the business decision. During the year, any change to the information in the disclosure statement must be disclosed promptly to the Chief Compliance Officer, who takes appropriate action. The process also requires affirmation from each individual that he OR SHE (a) has received a copy of the conflict of interest policy; (b) has read and understands the policy; (c) has agreed to comply with the policy; and (d) understands that St. Elizabeth Hospital is a charitable organization and that, in order to maintain its Federal tax exemption, it must engage primarily in activities which accomplish one or more of its tax-exempt purposes. In addition to the above, St. Elizabeth Hospital provides mechanisms for confidential reporting of compliance issues. These mechanisms include an anonymous hotline and Web site where individuals may raise issues, seek clarification, and report possible conflicts of interest or other concerns. These reports of possible conflicts of interest are reviewed and investigated by the Corporate Compliance Department and appropriate action is taken.
Page 6, Part VI, Section B Question 15 THE BOARD OF DIRECTORS DESIGNATES THE EXECUTIVE COMMITTEE, MADE UP OF INDEPENDENT BOARD MEMBERS TO REVIEW AND SET THE COMPENSATION ANNUALLY OF OUR EXECUTIVES AND KEY EMPLOYEES. THE EXECUTIVE COMMITTEE OBTAINS AND RELIES UPON COMPARABLE DATA INCLUDING INDUSTRY-WIDE COMPENSATION INFORMATION FROM AN OUTSIDE CONSULTING FIRM. THE EXECUTIVE COMMITTEE REVIEWS COMPENSATION PACKAGES AND APPROPRIATE COMPENSATION IS DETERMINED AND APPROVED. THE BASIS FOR DETERMINATION IS THEN DOCUMENTED BY THE EXECUTIVE COMMITTEE. THE PRESIDENT AND CEO OF ST. ELIZABETH HOSPITAL IS AN EMPLOYEE OF FMOL HEALTH SYSTEM, AND HIS SALARY IS DETERMINED BY THE PAY PRACTICES OF THAT ORGANIZATION WHICH RESEMBLE THE ABOVE.
Page 6, Part VI, Section C Question 19 THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE UPON REQUEST.
PART VI, SECTION A, QUESTION 7B   THE RESERVED POWERS TO FMOL HEALTH SYSTEM, INC. ARE AS FOLLOWS: 1. TO CHANGE PHILOSOPHY, OBJECTIVES AND PURPOSES OF CORPORATION 2. TO APPOINT OR REMOVE THE MEMBERS OF THE BOARD OF TRUSTEES AND OFFICERS OF THE CORPORATION 3. TO AMEND, ALTER, MODIFY OR REPEAL THE ARTICLES OF INCORPORATION AND BYLAWS OF THE CORPORATION 4. TO AUTHORIZE MERGER, CONSOLIDATION, OR AFFILIATION, OR PARTICIPATE IN JOINT VENTURES 5. TO DISSOLVE AND TO DISTRIBUTE ASSETS OF THE CORPORATION 6. TO APPOINT AND/OR TERMINATE WITH OR WITHOUT CAUSE THE CHIEF EXECUTIVE OFFICER OF THE CORPORATION 7. TO ACQUIRE, PURCHASE, SELL, LEASE, TRANSFER, OR ENCUMBER ANY IMMOVABLE PROPERTY ON BEHALF OF THE CORPORATION 8. TO ADD TO OR INCUR LONG-TERM DEBT IN EXCESS OF $5 MILLION BY THE CORPORATION 9. TO APPOINT THE FISCAL AUDITOR FOR THE CORPORATION 10. TO APPROVE ANY INCREMENT OR ADDITION TO THE CAPITAL DEBT OR EFFORTS TO RENEGOTIATE, MODIFY OR CHARGE THE EXISTING CAPITAL DEBT OBLIGATIONS OF THE CORPORATION 11. TO APPROVE THE ANNUAL OPERATING AND CAPITAL BUDGETS OF THE CORPORATION 12. TO APPROVE A STRATEGIC BUSINESS PLAN OF THE CORPORATION
PART VI, SECTION A, QUESTION 11   AFTER PREPARATION AND REVIEW OF FORM 990 BY KPMG, LLP, THE RETURN IS REVIEWED BY ONE OR MORE MEMBERS OF SENIOR MANAGEMENT. A COPY OF THE FORM 990 IS PROVIDED TO THE ORGANIZATION'S GOVERNING BODY BEFORE IT IS FILED WITH THE IRS.
Part VI, Section A Question 2   DR. CRAIG A. VITRANO AND DR. JOHN FRAICHE - BUSINESS RELATIONSHIP
PROGRAM SERVICE ACCOMPLISHMENTS   SECTION 1 - QUALITATIVE DESCRIPTION OF COMMUNITY BENEFIT 1. ORGANIZATIONAL COMMITMENT TO PROVIDE COMMUNITY BENEFIT ST. ELIZABETH HOSPITAL OPERATES AS A MISSION OF THE FRANCISCAN MISSIONARIES OF OUR LADY, A CATHOLIC HEALTHCARE ORGANIZATION. ST. ELIZABETH HOSPITAL IS PART OF CHA (CATHOLIC HEALTH ASSOCIATION OF THE UNITED STATES). ST. ELIZABETH HOSPITAL IS LOCATED IN GONZALES, LOUISIANA IN THE PARISH OF ASCENSION. THE HOSPITAL SERVES THE ENTIRE ASCENSION PARISH COMMUNITY ALONG WITH PARTS OF IBERVILLE AND LIVINGSTON PARISHES. THE HOSPITAL IS LOCATED OFF OF INTERSTATE 10 AT 1125 WEST HIGHWAY 30, GONZALES, LOUISIANA. ST. ELIZABETH ACQUIRED ST. ELIZABETH PHYSICIANS, A WHOLLY OWNED SUBSIDIARY, ON JULY 1, 2007 AS PART OF ITS STRATEGIC PLAN. IN FISCAL YEAR 2010, THE PRACTICE CONTINUED TO RECRUIT SPECIALISTS TO THE UNDERSERVED AREA OF ASCENSION PARISH. ST. ELIZABETH PHYSICIANS MAINTAIN OFFICES IN PRAIRIEVILLE, GONZALES, DUTCHTOWN, AND DONALDSONVILLE, LOUISIANA. ST. ELIZABETH PHYSICIANS ALSO OPERATES TWO AFTER HOURS CLINICS IN GONZALES AND PRAIRIEVILLE. THE HOSPITAL SERVES AS THE ONLY ACUTE CARE ACCESS HOSPITAL IN ASCENSION PARISH WITH EMERGENCY ROOM SERVICES. THE HOSPITAL IS ABLE TO SUPPORT THE NEEDS OF ASCENSION PARISH AS WELL AS OUTLYING PARISHES. THE HOSPITAL'S PHILOSOPHY IS TO SERVE ITS COMMUNITY AND IN PARTICULAR THOSE MOST IN NEED. THE HOSPITAL SERVES THE NEEDS OF THE UNDERSERVED IN ITS COMMUNITY THROUGH ACCESS TO PRIMARY HEALTHCARE VIA ITS EMERGENCY DEPARTMENT AND COMMUNITY CLINIC AS WELL AS THROUGH ITS RELATIONSHIP WITH COMMUNITY PHYSICIANS. THE HOSPITAL'S EFFORTS TO EXPAND SERVICES TO THE COMMUNITY THROUGH OUTREACH INCLUDE THE FOLLOWING: - THE HOSPITAL AND PHYSICIAN PRACTICE PROVIDED FLU VACCINES TO THE EMPLOYEES OF THE FOLLOWING COMMUNITY ORGANIZATIONS IN ORDER TO PROMOTE WELLNESS AND HAVE AN ACTIVE ROLE IN INCREASING THE HEALTH OF THE COMMUNITY: 1. ASCENSION PARISH SCHOOL BOARD 2. ASCENSION PARISH SHERIFF'S OFFICE 3. EAST ASCENSION HIGH SCHOOL 4. ST. AMANT HIGH SCHOOL 5. DONALDSONVILLE HIGH SCHOOL 6. DUTCHTOWN HIGH SCHOOL 7. St. John's Church - THE HOSPITAL AND PHYSICIAN PRACTICE PARTICIPATES IN HEALTHCARE EDUCATION FOR THE PARISH THROUGH THE ST. ELIZABETH HOSPITAL ANNUAL HEALTH FAIR AND IN A COLLABORATIVE EFFORT WITH OTHER NOT FOR PROFIT ORGANIZATIONS: EDUCATIONAL OFFERINGS INCLUDE, BUT ARE NOT LIMITED TO THE FOLLOWING: 1. LOSS AND GRIEF EDUCATION AND SUPPORT 2. THRIVING WITH DIABETES 3. GROWING UP-PRETEEN CLASSES 4. ALZHEIMER'S LNL 5. BODYWORKS 6. HEART FAILURE 7. MEN'S HEALTH 8. BREAST CANCER AWARENESS GROUP 9. WOMEN'S HEALTH LUNCHEON - THE HOSPITAL PROVIDES THE FOLLOWING SCREENINGS FOR THE COMMUNITY: 1. SKIN CANCER 2. PROSTATE CANCER 3. DIABETES 4. COLORECTAL CANCER 5. BLOOD PRESSURE 6. PHYSICALS FOR LOCAL SCHOOL ATHLETIC TEAMS AND SPECIAL OLYMPICS PARTICIPANTS - THE HOSPITAL HAS PARTNERED WITH MARY BIRD PERKINS CANCER CENTER TO PROVIDE CANCER TREATMENT SERVICES TO THE CITIZENS OF ASCENSION PARISH AND SURROUNDING AREAS. MARY BIRD PERKINS CANCER CENTER IS LOCATED ACROSS FROM ST. ELIZABETH HOSPITAL AND BEGAN SERVING PATIENTS IN FEBRUARY 2009. - THE HOSPITAL PARTICIPATES IN LEADERSHIP ASCENSION WHERE LEADERS FROM ST. ELIZABETH HOSPITAL AND ST. ELIZABETH PHYSICIANS LEARN ABOUT ASCENSION PARISH AND HOW TO MAKE A DIFFERENCE IN THE COMMUNITY THROUGH VOLUNTEERISM. - ST. ELIZABETH HOSPITAL SECURED OTHER FUNDING THROUGH FMOL FOR A COMMUNITY CLINIC. THE MISSION OF THIS CLINIC IS TO PROVIDE ACCESS TO CARE FOR THE UNINSURED AND UNDERINSURED RESIDENTS OF ASCENSION PARISH. SERVING THIS POPULATION OF ASCENSION PARISH RESIDENTS WILL ALLOW ST. ELIZABETH HOSPITAL TO POSITIVELY AFFECT THE FACE OF HEALTH CARE BY EDUCATING, TREATING AND MAINTAINING THE HEALTH STATUS OF ITS RESIDENTS. THE COMMUNITY CLINIC BEGAIN TREATING PATIENTS IN APRIL 2009 - St. Elizabeth Physicians secured grant funding through FMOL to begin providing diabetic education to individuals with diabetes in Ascension Parish. The Diabetic Clinic began seeing patients in September, 2011. - ST. ELIZABETH PHYSICIANS SECURED GRANT FUNDING THROUGH FMOL TO BEGIN PROVIDING A GERIATRIC SPECIALIST PHYSICIAN IN ASCENSION PARISH. DR. MOHAMMED SAEED BEGAN SEEING PATIENTS IN NOVEMBER 2012. - THE HOSPITAL AND PHYSICIAN PRACTICE PROVIDES FINANCIAL ASSISTANCE TO LOW INCOME PERSONS THROUGH ITS CHARITY CARE PROGRAM. IN ADDITION, THE HOSPITAL PROVIDES PROMPT PAY DISCOUNTS TO UNINSURED PATIENTS. THESE POLICIES ARE COMMUNICATED THROUGH FINANCIAL COUNSELORS EMPLOYED BY THE HOSPITAL. 2. ORGANIZATIONAL DESCRIPTION FOR TAX EXEMPTION THE HOSPITAL IS EXEMPT FROM FEDERAL INCOME TAX THROUGH ITS 501(C)(3) DESIGNATION. TO FULFILL ITS MISSION, THE HOSPITAL: A. OPERATES AN EMERGENCY DEPARTMENT THAT IS OPEN TO ALL PERSONS REGARDLESS OF ABILITY TO PAY; B. GRANTS MEDICAL STAFF PRIVILEGES TO THOSE PHYSICIANS QUALIFIED TO PARTICIPATE IN THEIR PARTICULAR SPECIALTY. C. HAS A GOVERNING BODY THAT IS COMPRISED OF MEMBERS OF THE MEDICAL STAFF, COMMUNITY MEMBERS, MEMBERS OF THE HOSPITAL'S SPONSORING ORDER (FMOL), AND HOSPITAL EMPLOYEES. THE MAJORITY OF THE BOARD IS COMPOSED OF INDEPENDENT PEOPLE REPRESENTATIVE OF THE COMMUNITY. D. THE HOSPITAL IS AN EDUCATIONAL SITE FOR SEVERAL DIFFERENT PROFESSIONAL HEALTH CARE STUDENTS. ST. ELIZABETH HOSPITAL CLINICAL AND PROFESSIONAL STAFF PROVIDES OVER 9,078 HOURS OF HEALTH PROFESSIONS EDUCATION TO STUDENT IN SPECIALTIES SUCH AS: " NURSING " PHARMACY " LABORATORY " RADIOLOGY " CARDIOPULMONARY " FOOD AND NUTRITIONAL THERAPY E. ST. ELIZABETH HOSPITAL PARTICIPATES IN MEDICAID, MEDICARE, CHAMPUS, TRICARE, AND OTHER GOVERNMENT SPONSORED HEALTH CARE PROGRAMS AS APPROPRIATE. 3. DESCRIPTION OF COMMUNITY BENEFIT PROGRAMS A. ST. ELIZABETH HOSPITAL SPONSORS AN ANNUAL HEALTH FAIR FOR THE CITIZENS OF ASCENSION PARISH AS WELL AS OTHER PARISHES. THE ANNUAL HEALTH FAIR IS COMPRISED OF NUMEROUS BOOTHS PROVIDING HEALTH EDUCATION, SCREENING AND DIAGNOSTIC TESTING. THE FAIR IS STAFFED BY THE TEAM MEMBERS OF ST. ELIZABETH HOSPITAL ALONG WITH OTHER HEALTH CARE PROFESSIONALS AND BUSINESSES FROM ASCENSION PARISH. IN 2012, ST. ELIZABETH PARTNERED WITH ASCENSION PARISH TO PROVIDE THE HEALTH FAIR IN A LARGER ENCLOSED LOCATION. THE OVERALL GOAL OF THE ANNUAL HEALTH FAIR IS TO RAISE AWARENESS AND OFFER HEALTH EDUCATION AND SCREENINGS TO THE CITIZENS OF ASCENSION PARISH. PUBLIC AWARENESS REGARDING THE EVENT IS DELIVERED VIA RADIO, TELEVISION AND NEWSPAPER. THE ST. ELIZABETH HOSPITAL ANNUAL HEALTH FAIR HAS BEEN WELL RECEIVED BY THE COMMUNITY. B. ST. ELIZABETH HOSPITAL TEAM MEMBERS DONATED OVER 2,447 HOURS OF TIME FOR VARIOUS COMMUNITY BENEFIT ACTIVITIES. THESE ACTIVITIES INCLUDE CHARITY INVOLVEMENT IN SUCH NOT FOR PROFIT ORGANIZATIONS AS BETTER BUSINESS BUREAU, ASCENSION CHAMBER OF COMMERCE, ARC OF EAST ASCENSION, ETC. AS AN EXPRESSION OF OUR MISSION AND CORE VALUES, THE TEAM MEMBERS OF ST. ELIZABETH HOSPITAL DONATE TIME TO COMMUNITY ACTIVITIES AS A WAY OF GIVING BACK TO THE COMMUNITY THAT WE SERVE. OUR GOAL IS TO REACH OUT TO THOSE WHO MAY NOT HAVE ACCESS TO THE SERVICES WE PROVIDE. DONATED HOURS ARE A WAY OF PROVIDING THAT ACCESS. SECTION 2 - QUANTIFIABLE COMMUNITY BENEFIT 1)CHARITY CARE - AT COST $ 739,039 2)MEDICAID SPONSORED HEALTHCARE - NET EXPENSE $ 4,543,745 3) COMMUNITY HEALTH SERVICES: COMMUNITY HEALTH EDUCATION $ 64,709 COMMUNITY BASED CLINICAL SERVICES $ 10,747 4) HEALTH PROFESSIONS EDUCATION TRAINING STAFF $ 318,377 5) FINANCIAL AND IN-KIND CONTRIBUTIONS: CASH DONATIONS $ 93,106 IN KIND DONATIONS $ 15,600 6) SUBSIDIZED HEALTH SERVICES COMMUNITY CLINIC LOSS $513,156 COMMUNITY NEEDS ASSESSMENT $23,307 7) COMMUNITY BENEFIT OPERATIONS: DEDICATED STAFF $ 3,247 8) COMMUNITY BUILDING ACTIVITIES: IN KIND DONATIONS $ 26,064 TOTAL QUANTIFIABLE COMMUNITY BENEFIT $ 6,351,097
Part XI, Question 9   Capital Transfer - $ (1,947,601)
PART IX, LINE 11G   FEES FOR SERVICES - OTHER PROFESSIONAL FEES 5,923,392 PURCHASED SERVICES 4,152,816 CONSULTING SERVICES 635,118 OTHER 282,634 AGENCY CONTRACT LABOR 124,691 ---------- TOTAL 11,118,651
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
OUR LADY OF THE LAKE ASCENSION
COMMUNITY HOSPITAL
Employer identification number

72-1470744
Part I
Identification of Disregarded Entities (Complete if the organization answered "Yes" to Form 990, Part IV, line 33.)
(a)
Name, address, and EIN (if applicable) of disregarded entity


(b)
Primary activity


 		(c)
Legal domicile (state
or foreign country)

 		(d)
Total income


 		(e)
End-of-year assets


 		(f)
Direct controlling
entity
(1) ST ELIZABETH PHYSICIANS
2647 S ST ELIZABETH BLVD
GONZALES,LA70737
72-1439296 		HEALTHCARE LA 22,529,359 5,727,683 STEH
 










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) ST BERNARD HEALTH FUND

4200 ESSEN LANE

BATON ROUGE,LA70809
20-4685614 		HEALTHCARE LA 501(C)(3) 11 TYPE 1 FMOLHS
 
 
No
(2) HEALTH PARTNERS NETWORK OF SOUTH LA

4801 AMBASSADOR CAFFERY PARKWAY

LAFAYETTE,LA70508
 HEALTHCARE LA 501(C)(3) 3 LOURDES RMC
 
Yes
 
(3) HEALTH CARE CENTERS IN SCHOOLS

5000 HENNESSY BLVD

BATON ROUGE,LA70808
72-1443935 		HEALTHCARE LA 501(C)(3) 7 OLOL
 
Yes
 








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
(1) HEART HOSPITAL OF ACADIANA

1105 KALISTE SALOOM ROAD
LAFAYETTE,LA70508
30-0442368 		HEALTHCARE LA LOURDES
  		N/A       No   Yes    
(2) PERKINS PLAZA MEDICAL ARTS DEVELOPMENT

5000 HENNESSY BOULEVARD
BATON ROUGE,LA70808
45-0516574 		REAL ESTATE LA OLOL
  		N/A       No   Yes    
(3) PERKINS PLAZA IMAGING DEVELOPMENT

5000 HENNESSY BOULEVARD
BATON ROUGE,LA70808
20-3894521 		REAL ESTATE LA OLOL
  		N/A       No   Yes    
(4) NUCLEAR IMAGING LLC

5000 HENNESSY BOULEVARD
BATON ROUGE,LA70808
72-1470061 		HEALTHCARE LA OLOL
  		N/A       No   Yes    
(5) P&S SURGERY CENTER LLC

312 GRAMMONT STREET
MONROE,LA71201
72-1387312 		HEALTHCARE LA SFMC
  		N/A       No   Yes    
(6) LOURDES IMAGING DEVELOPMENT LLC

4801 AMBASSADOR CAFFERY PARKWAY
LAFAYETTE,LA70508
20-8326287 		REAL ESTATE LA LOURDES
  		N/A       No   Yes    
(7) PARK PLACE SURGICAL HOSPITAL

7901 WILSON STREET
LAFAYETTE,LA70503
72-1404092 		HEALTHCARE LA LOURDES
  		N/A       No   Yes    
(8) BRPT LAKE REHABILITATION CENTERS LLC

530 SHADOWS LANE
BATON ROUGE,LA70806
72-1506100 		HEALTHCARE LA OLOL
  		N/A       No   Yes    
(9) CONVENIENT CARE LLC

7777 HENNESSY BOULEVARD SUITE 1004
BATON ROUGE,LA70808
72-1439481 		HEALTHCARE LA OLOL
  		N/A       No   Yes    
(10) PERKINS PLAZA AMBULATORY SURGERY CENTER

54 THE LEGENDS PARKWAY SUITE 159
EUREKA,MO63025
48-1264699 		HEALTHCARE LA OLOL
  		N/A       No   Yes    
(11) SURGICAL SPECIALTY CENTER OF BATON ROUGE

8080 BLUEBONNET BOULEVARD
BATON ROUGE,LA70810
26-3160962 		HEALTHCARE LA OLOL
  		N/A       No   Yes    
(12) ST ELIZABETH-MARY BIRD PERKINS

4950 ESSEN LANE
BATON ROUGE,LA70809
26-0628752 		HEALTHCARE LA STEH
  		RELATED 18,780 2,921,121   No 0 Yes   35.000 %
(13) REGIONAL EYE SURGERY CENTER LLC

7777 HENNESSY BLVD SUITE 400
BATON ROUGE,LA70808
72-1484653 		HEALTHCARE LA OLOL
  		N/A       No   Yes    
(14) ST MARY'S IMAGING CENTER II LLC

4801 AMBASSADOR CAFFERY PARKWAY
LAFAYETTE,LA70508
 HEALTHCARE LA LOURDES IMAGING
  		N/A       No   Yes    
(15) NORTHEAST LA CANCER INSTITUTE

141 DESIARD STREET SUITE 704
MONROE,LA71201
72-1329499 		HEALTHCARE LA SFMC
  		N/A       No   Yes    
(16) LHCG-XIII LLC

420 WEST PINHOOK ROAD SUITE A
LAFAYETTE,LA70503
20-8068308 		HEALTHCARE LA LOURDES
  		N/A       No   Yes    
(17) LOURDES AFTER HOURS LLC

7777 HENNESSY BLVD SUITE 1004-202
BATON ROUGE,LA70808
20-1367299 		HEALTHCARE LA LOUDRES
  		N/A       No   Yes    
(18) ST ELIZABETH IMAGING CENTER

1125 HIGHWAY 30
GONZALES,LA70737
72-1470744 		HEALTHCARE LA STEH
  		RELATED -137,311 -132,829   No 0 Yes   51.000 %
(19) CAPITAL AREA SHARED SERVICES ORG LLC

5000 HENNESSY BLVD
BATON ROUGE,LA70808
27-5173212 		HEALTHCARE LA OLOL PG
  		N/A       No   Yes    
(20) CAPITAL AREA SHARED SERVICES ORG LLC

5000 HENNESSY BLVD
BATON ROUGE,LA70808
27-5173212 		HEALTHCARE LA STEP
  		N/A -118,621 252,998   No 0 Yes   17.000 %
(21) LAKE URGENT CARE ASCENSION LLC

10319 JEFFERSON HWY
BATON ROUGE,LA70809
35-2463092 		HEALTHCARE LA STEH
  		N/A -3 99,997   No   Yes   20.000 %
(22) OLOL PONTCHARTRAIN SURGERY CENTER

15305 DALLAS PKWY STE 1600 LB 28
ADDISON,TX75001
46-1379031 		HEALTHCARE TX OLOLUSP
  		N/A       No   Yes    
(23) OLOLUSP SURGERY CENTER LLC

15305 DALLAS PKWY STE 1600 LB 28
ADDISON,TX75001
35-2463092 		HEALTHCARE LA OLOL
  		N/A       No   Yes    
(24) LAKE URGENT CARE ASCENSION LLC

10319 JEFFERSON HWY
BATON ROUGE,LA70809
35-2463092 		HEALTHCARE LA OLOL
  		N/A       No   Yes    
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) ST FRANCIS INSURANCE AGENCY

309 JACKSON STREET
MONROE,LA71201
72-1435136 		INSURANCE LA ST FRANCIS
  		C CORP          
(2) HOSPITAL ASSISTANCE SERVICES

POBOX 4027-C
LAFAYETTE,LA70502
72-1073486 		HEALTHCARE LA LOURDES
  		C CORP          
(3) LOUISE INSURANCE COMPANY

PO BOX 1051
    KY1-1102
CJ
INSURANCE CJ FMOL
  		C CORP          
(4) MONROE HEALTH SERVICES

POBOX 3187
MONROE,LA71210
72-1057820 		HEALTHCARE LA AMBULATORY
  		C CORP          
(5) Charitable Remainder Trust

 
 
INVESTMENT LA OLOL FOUNDATION
  		TRUST          
(6) FRANCISCAN HEALTH & WELLNESS SERVICES I

4200 ESSEN LANE
BATON ROUGE,LA70809
45-5492379 		HEALTHCARE LA FMOL
  		C CORP          
(7) FMOL HEALTH SYSTEM HOLDINGS INC

4200 ESSEN LANE
BATON ROUGE,LA70809
45-4405024 		INVESTMENT LA FMOL
  		C CORP          
(8) NORTHEAST LA HEALTH NETWORK

309 JACKSON STREET
MONROE,LA71201
72-1294587 		HEALTHCARE LA AMBULATORY
  		C CORP          
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
Yes
 
k Lease of facilities, equipment, or other assets from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . .
1k
 
No
l Performance of services or membership or fundraising solicitations for related organization(s) . . . . . . . . . . . . . . . . . . . .
1l
 
No
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
 
No
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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