Form990
Click to see list of attachments
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
Memorial Medical Center
 
Doing Business As
 
 
Number and street (or P.O. box if mail is not delivered to street address)
3701 Doty Road
 
Room/suite
City or town, state or country, and ZIP + 4
Woodstock, IL60098
D Employer identification number

36-2179764
E Telephone number

G Gross receipts $ 146,713,032
F Name and address of principal officer:
Michael S Eesley
385 Millennium Drive
Crystal Lake,IL60012
I
Tax-exempt status: (   ) LeftBullet (insert no.) or
J
Website:MediumBullet
www.centegra.org
H(a)
Is this a group return for
affiliates?
H(b)
Are all affiliates included?
If "No," attach a list. (see instructions)
H(c)
Group exemption number MediumBullet  
K Form of organization:
 
L Year of formation: 1914
M State of legal domicile: IL
Part I
Summary
Activities & Governance 1 Briefly describe the organization’s mission or most significant activities: The mission of Memorial Medical Center is to provide quality healthcare services with innovative and responsible use of resources and promote wellness for the greater McHenry County area.
2 Check this box MediumBullet
3 Number of voting members of the governing body (Part VI, line 1a) ........ 3 13
4 Number of independent voting members of the governing body (Part VI, line 1b) ..... 4 6
5 Total number of individuals employed in calendar year 2011 (Part V, line 2a) ...... 5 910
6 Total number of volunteers (estimate if necessary) ............. 6 112
7a Total unrelated business revenue from Part VIII, column (C), line 12 ........ 7a 13,042
b Net unrelated business taxable income from Form 990-T, line 34 ......... 7b -19,526
Revenues Prior Year Current Year
8 Contributions and grants (Part VIII, line 1h) ......... 301,669 1,049,541
9 Program service revenue (Part VIII, line 2g) ......... 142,560,130 135,525,699
10 Investment income (Part VIII, column (A), lines 3, 4, and 7d ) .... 242,958 2,622,367
11 Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e) 1,782,543 2,017,005
12 Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)................... 144,887,300 141,214,612
Expenses; 13 Grants and similar amounts paid (Part IX, column (A), lines 1–3 )...   0
14 Benefits paid to or for members (Part IX, column (A), line 4).....   0
15 Salaries, other compensation, employee benefits (Part IX, column (A), lines 5–10) 61,928,279 55,892,100
16a Professional fundraising fees (Part IX, column (A), line 11e).....   0
b Total fundraising expenses (Part IX, column (D), line 25) MediumBullet0    
17 Other expenses (Part IX, column (A), lines 11a–11d, 11f–24e).... 87,578,161 76,099,310
18 Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25) 149,506,440 131,991,410
19 Revenue less expenses. Subtract line 18 from line 12....... -4,619,140 9,223,202
Net Assets or Fund Balances; Beginning of Current Year End of Year
20 Total assets (Part X, line 16)............. 99,636,157 122,545,695
21 Total liabilities (Part X, line 26)............. 65,282,827 79,344,065
22 Net assets or fund balances. Subtract line 21 from line 20..... 34,353,330 43,201,630
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: The mission of Memorial Medical Center is to provide quality healthcare services with innovative and responsible use of resources and promote wellness for the greater McHenry County area.
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 $ 114,593,412 including grants of $   ) (Revenue $ 135,586,760 )
See Schedule O
4b (Code:   ) (Expenses $   including grants of $   ) (Revenue $   )
4c (Code:   ) (Expenses $   including grants of $   ) (Revenue $   )
4d Other program services (Describe in Schedule O.)
(Expenses $   including grants of $   ) (Revenue $   )
4e Total program service expensesMediumBullet114,593,412
Form 990 (2012)
Form 990 (2012)
Page 3
Part IV
Checklist of Required Schedules
Yes
No
1
Is the organization described in section 501(c)(3) or 4947(a)(1) (other than a private foundation)? If “Yes,” complete Schedule AClick to see attachment........................
1
Yes
 
2
Is the organization required to complete Schedule B, Schedule of Contributors (see instructions)? Click to see attachment...
2
Yes
 
3
Did the organization engage in direct or indirect political campaign activities on behalf of or in opposition to candidates for public office? If “Yes,” complete Schedule C, Part IClick to see attachment..........
3
 
No
4
Section 501(c)(3) organizations. Did the organization engage in lobbying activities, or have a section 501(h) election in effect during the tax year? If “Yes,” complete Schedule C, Part IIClick to see attachment........
4
Yes
 
5
Is the organization a section 501(c)(4), 501(c)(5), or 501(c)(6) organization that receives membership dues, assessments, or similar amounts as defined in Revenue Procedure 98-19? If “Yes,” complete Schedule C,
Part IIIClick to see attachment............................
5
 
No
6
Did the organization maintain any donor advised funds or any similar funds or accounts for which donors have the right to provide advice on the distribution or investment of amounts in such funds or accounts? If “Yes,” complete Schedule D, Part IClick to see attachment........................
6
 
No
7
Did the organization receive or hold a conservation easement, including easements to preserve open space,
the environment, historic land areas, or historic structures? If “Yes,” complete Schedule D, Part IIClick to see attachment...
7
 
No
8
Did the organization maintain collections of works of art, historical treasures, or other similar assets? If “Yes,” complete Schedule D, Part III Click to see attachment....................
8
 
No
9
Did the organization report an amount in Part X, line 21 for escrow or custodial account liability; serve as a custodian for amounts not listed in Part X; or provide credit counseling, debt management, credit repair, or debt negotiation services? If “Yes,” complete Schedule D, Part IVClick to see attachment..............
9
 
No
10
Did the organization, directly or through a related organization, hold assets in temporarily restricted endowments, permanent endowments, or quasi-endowments? If “Yes,” complete Schedule D, Part VClick to see attachment......
10
 
No
11
If the organization’s answer to any of the following questions is "Yes," then complete Schedule D, Parts VI, VII, VIII, IX, or X as applicable.
a
Did the organization report an amount for land, buildings, and equipment in Part X, line 10?
If “Yes,” complete Schedule D, Part VI.Click to see attachment...................
11a
Yes
 
b
Did the organization report an amount for investments—other securities in Part X, line 12 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part VIIClick to see attachment.......
11b
 
No
c
Did the organization report an amount for investments—program related in Part X, line 13 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part VIIIClick to see attachment.......
11c
 
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
Yes
 
e
Did the organization report an amount for other liabilities in Part X, line 25? If “Yes,” complete Schedule D, Part XClick to see attachment
11e
Yes
 
f
Did the organization’s separate or consolidated financial statements for the tax year include a footnote that addresses the organization’s liability for uncertain tax positions under FIN 48 (ASC 740)? If “Yes,” complete Schedule D, Part XClick to see attachment.........................
11f
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.........
14b
 
No
15
Did the organization report on Part IX, column (A), line 3, more than $5,000 of grants or assistance to any organization or entity located outside the United States? If “Yes,” complete Schedule F, Parts II and IV
15
 
No
16
Did the organization report on Part IX, column (A), line 3, more than $5,000 of aggregate grants or assistance to individuals located outside the United States? If “Yes,” complete Schedule F, Parts III and IV...
16
 
No
17
Did the organization report a total of more than $15,000 of expenses for professional fundraising services on Part IX, column (A), lines 6 and 11e? If “Yes,” complete Schedule G, Part I (see instructions)....
17
 
No
18
Did the organization report more than $15,000 total of fundraising event gross income and contributions on Part VIII, lines 1c and 8a? If “Yes,” complete Schedule G, Part II............
18
 
No
19
Did the organization report more than $15,000 of gross income from gaming activities on Part VIII, line 9a? If “Yes,” complete Schedule G, Part III...................
19
 
No
20a
Did the organization operate one or more hospital facilities? If “Yes,” complete Schedule H.... Click to see attachment
20a
Yes
 
b
If “Yes” to line 20a, did the organization attach a copy of its audited financial statements to this return? Click to see attachment
20b
Yes
 
Form 990 (2012)
Form 990 (2012)
Page 4
Part IV
Checklist of Required Schedules (continued)
21
Did the organization report more than $5,000 of grants and other assistance to any government or organization in the United States on Part IX, column (A), line 1? If “Yes,” complete Schedule I, Parts I and II...
21
 
No
22
Did the organization report more than $5,000 of grants and other assistance to individuals in the United States on Part IX, column (A), line 2? If “Yes,” complete Schedule I, Parts I and III........
22
 
No
23
Did the organization answer “Yes” to Part VII, Section A, line 3, 4, or 5 about compensation of the organization’s current and former officers, directors, trustees, key employees, and highest compensated employees? If “Yes,” complete Schedule J....................... Click to see attachment
23
Yes
 
24a
Did the organization have a tax-exempt bond issue with an outstanding principal amount of more than $100,000 as of the last day of the year, that was issued after December 31, 2002? If “Yes,” answer lines 24b through 24d and complete Schedule K. If “No,” go to line 25................
24a
 
No
b
Did the organization invest any proceeds of tax-exempt bonds beyond a temporary period exception?...
24b
 
No
c
Did the organization maintain an escrow account other than a refunding escrow at any time during the year
to defease any tax-exempt bonds?......................
24c
 
No
d
Did the organization act as an “on behalf of” issuer for bonds outstanding at any time during the year?...
24d
 
No
25a
Section 501(c)(3) and 501(c)(4) organizations. Did the organization engage in an excess benefit transaction with a disqualified person during the year? If “Yes,” complete Schedule L, Part I........ Click to see attachment
25a
 
No
b
Is the organization aware that it engaged in an excess benefit transaction with a disqualified person in a prior year, and that the transaction has not been reported on any of the organization’s prior Forms 990 or 990-EZ? If “Yes,” complete Schedule L, Part I................... Click to see attachment
25b
 
No
26
Was a loan to or by a current or former officer, director, trustee, key employee, highest compensated employee, or disqualified person outstanding as of the end of the organization’s tax year? If “Yes,” complete Schedule L,
Part II.......................... Click to see attachment
26
 
No
27
Did the organization provide a grant or other assistance to an officer, director, trustee, key employee, substantial contributor or employee thereof, a grant selection committee member, or to a 35% controlled entity or family member of any of these persons? If “Yes,” complete Schedule L, Part III......... Click to see attachment
27
 
No
28
Was the organization a party to a business transaction with one of the following parties (see Schedule L, Part IV instructions for applicable filing thresholds, conditions, and exceptions):
a
A current or former officer, director, trustee, or key employee? If “Yes,” complete Schedule L, Part IV .......................... Click to see attachment
28a
Yes
 
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
Yes
 
29
Did the organization receive more than $25,000 in non-cash contributions? If “Yes,” complete Schedule M..
29
 
No
30
Did the organization receive contributions of art, historical treasures, or other similar assets, or qualified conservation contributions? If “Yes,” complete Schedule M.............
30
 
No
31
Did the organization liquidate, terminate, or dissolve and cease operations? If “Yes,” complete Schedule N,
Part I...........................
31
 
No
32
Did the organization sell, exchange, dispose of, or transfer more than 25% of its net assets? If “Yes,” complete Schedule N, Part II......................
32
 
No
33
Did the organization own 100% of an entity disregarded as separate from the organization under Regulations sections 301.7701-2 and 301.7701-3? If “Yes,” complete Schedule R, Part I........ Click to see attachment
33
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
 
No
b
If ‘Yes’ to line 35a, did the organization receive any payment from or engage in any transaction with a controlled entity within the meaning of section 512(b)(13)? If “Yes,” complete Schedule R, Part V, line 2... Click to see attachment
35b
 
No
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
85
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
910
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
 
 
4a
At any time during the calendar year, did the organization have an interest in, or a signature or other authority over, a financial account in a foreign country (such as a bank account, securities account, or other financial account)?..........................
4a
 
No
b
If "Yes," enter the name of the foreign country: MediumBullet
See instructions for filing requirements for Form TD F 90-22.1, Report of Foreign Bank and Financial Accounts.
5a
Was the organization a party to a prohibited tax shelter transaction at any time during the tax year?..
5a
 
No
b
Did any taxable party notify the organization that it was or is a party to a prohibited tax shelter transaction?
5b
 
No
c
If “Yes,” to line 5a or 5b, did the organization file Form 8886-T? ............
5c
 
 
6a
Does the organization have annual gross receipts that are normally greater than $100,000, and did the organization solicit any contributions that were not tax deductible as charitable contributions?...
6a
 
No
b
If “Yes,” did the organization include with every solicitation an express statement that such contributions or gifts were not tax deductible?........................
6b
 
 
7
Organizations that may receive deductible contributions under section 170(c).
a
Did the organization receive a payment in excess of $75 made partly as a contribution and partly for goods and services provided to the payor?....................
7a
 
No
b
If “Yes,” did the organization notify the donor of the value of the goods or services provided?.....
7b
 
 
c
Did the organization sell, exchange, or otherwise dispose of tangible personal property for which it was required to file Form 8282?...........................
7c
 
No
d
If “Yes,” indicate the number of Forms 8282 filed during the year ....
7d
0
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
 
No
h
If the organization received a contribution of cars, boats, airplanes, or other vehicles, did the organization file a Form 1098-C?..........................
7h
 
No
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
 
No
9
Sponsoring organizations maintaining donor advised funds.
a
Did the organization make any taxable distributions under section 4966?..........
9a
 
No
b
Did the organization make a distribution to a donor, donor advisor, or related person?.......
9b
 
No
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
 
No
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
 
No
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
 
No
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
13
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
6
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
Yes
 
4
Did the organization make any significant changes to its governing documents since the prior Form 990 was filed? ...........................
4
 
No
5
Did the organization become aware during the year of a significant diversion of the organization’s assets? .
5
 
No
6
Did the organization have members or stockholders? ................
6
Yes
 
7a
Did the organization have members, stockholders, or other persons who had the power to elect or appoint one or more members of the governing body? ....................
7a
Yes
 
b
Are any governance decisions of the organization reserved to (or subject to approval by) members, stockholders, or persons other than the governing body? ...................
7b
 
No
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
 
No
b
Describe in Schedule O the process, if any, used by the organization to review this Form 990. .....
12a
Did the organization have a written conflict of interest policy? If “No,” go to line 13.......
12a
Yes
 
b
Were officers, directors, or trustees, and key employees required to disclose annually interests that could give rise to conflicts? ..........................
12b
Yes
 
c
Did the organization regularly and consistently monitor and enforce compliance with the policy? If “Yes,” describe in Schedule O how this was done.......................
12c
Yes
 
13
Did the organization have a written whistleblower policy? ...............
13
Yes
 
14
Did the organization have a written document retention and destruction policy? .........
14
Yes
 
15
Did the process for determining compensation of the following persons include a review and approval by independent persons, comparability data, and contemporaneous substantiation of the deliberation and decision?
a
The organization’s CEO, Executive Director, or top management official ...........
15a
Yes
 
b
Other officers or key employees of the organization ................
15b
Yes
 
If "Yes" to line 15a or 15b, describe the process in Schedule O (see instructions).
16a
Did the organization invest in, contribute assets to, or participate in a joint venture or similar arrangement with a taxable entity during the year? ......................
16a
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
IL
18
Section 6104 requires an organization to make its Form 1023 (or 1024 if applicable), 990, and 990-T (501(c)(3)s only) available for public inspection. Indicate how you made these available. Check all that apply.
19
Describe in Schedule O whether (and if so, how), the organization made its governing documents, conflict of interest policy, and financial statements available to the public during the tax year.
20
State the name, physical address, and telephone number of the person who possesses the books and records of the organization:
MediumBulletDavid Tomlinson385 Millennium DriveCrystal LakeIL60012 (815) 788-5800
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) Parmod Narang........................................................................
Director
 .33
.......................1.67 		X           0 0 0
(2) Michael S Eesley........................................................................
CEO
 13.00
.......................27.00 		X   X       0 1,277,730 446,911
(3) Kathy Powell........................................................................
Director
 .33
.......................3.67 		X           0 0 0
(4) Jack Porter........................................................................
Director
 .33
........................67 		X           0 0 0
(5) Angela McAuley........................................................................
Director & VP
 .33
.......................1.67 		X           0 0 0
(6) Luke Johnsos........................................................................
Director
 .33
.......................1.67 		X           0 0 0
(7) Micheal Luecht........................................................................
Director
 .33
.......................1.67 		X           0 0 0
(8) Charles Ruth........................................................................
Director
 .33
.......................2.67 		X           0 0 0
(9) Tom Carey........................................................................
Director
 .33
.......................4.67 		X           0 0 0
(10) Terrence J Bugno........................................................................
Director
 .33
........................67 		X           0 0 0
(11) Patrick Morehead........................................................................
Treasurer
 .33
.......................1.67 		X   X       0 0 0
(12) William Cox........................................................................
Secretary
 .33
.......................1.67 		X   X       0 0 0
(13) Mike Curran........................................................................
Vice Chairman
 .33
........................67 		X   X       0 0 0
(14) Charie Zanck........................................................................
Chairman
 .66
.......................1.34 		X   X       0 0 0
(15) Matthew Towler........................................................................
Vice President
 19.50
.......................20.50 		    X       0 229,090 22,461
(16) Mattias Carlen........................................................................
Vice President
 3.33
.......................36.67 		    X       0 130,801 25,775
(17) Christopher Westerkamp........................................................................
Vice President
 13.33
.......................26.67 		    X       0 177,279 6,284
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) Robin K Purdy........................................................................
Vice President
 13.33
.......................26.67 		    X       0 300,194 30,787
(19) Neil Murphy........................................................................
Senior VP, CNO
 13.33
.......................26.67 		    X       0 284,790 5,394
(20) Kumar Nathan........................................................................
Vice President
 13.33
.......................26.67 		    X       0 224,423 31,838
(21) Bernadette Szczepanski........................................................................
Vice President
 13.33
.......................26.67 		    X       0 219,911 18,963
(22) Gail Rudolph........................................................................
Vice President
 .50
.......................39.50 		    X       0 178,816 21,597
(23) Rachel Sebastian........................................................................
Vice President
 .50
.......................39.50 		    X       0 280,727 40,770
(24) Pasquale Bernardi........................................................................
Vice President
 13.33
.......................26.67 		    X       0 383,404 23,129
(25) Zbigniew Lorenc........................................................................
Vice President
 13.33
.......................26.67 		    X       0 301,170 24,289
(26) Sheila Senn........................................................................
Vice President
 40.00
.......................0.00 		    X       150,138 0 32,254
(27) Susan Milford........................................................................
Senior VP
 13.33
.......................26.67 		    X       0 286,937 89,719
(28) Barbara Johnson........................................................................
Senior VP
 13.33
.......................26.67 		    X       0 369,160 20,728
(29) Aaron Shepley........................................................................
Sr VP/CQO Couns
 13.33
.......................26.67 		    X       0 428,888 75,450
(30) Robert Rosenberger........................................................................
Sr. VP & CFO
 13.00
.......................27.00 		    X       0 627,306 39,398
(31) David Tomlinson........................................................................
Senior VP, CIO
 13.33
.......................26.67 		    X       0 331,725 38,118
(32) Jason Sciarro........................................................................
President & COO
 13.00
.......................27.00 		    X       0 724,714 96,798
(33) Suellen D Aus-Der-Au........................................................................
Pharmacist
 35.00
.......................0.00 		        X   140,493 0 19,665
(34) Deborah J Golden........................................................................
Ultrasonographer
 40.00
.......................0.00 		        X   135,507 0 13,621
(35) Lisa Evan........................................................................
Pharmacist
 35.00
.......................0.00 		        X   132,943 0 9,832
(36) Anthony K Leung........................................................................
Pharmacist
 40.00
.......................0.00 		        X   127,843 0 24,718
(37) Laurie M Parisi........................................................................
Emergency Manager
 40.00
.......................0.00 		        X   120,250 0 23,885
1b Sub-Total................MediumBullet
c Total from continuation sheets to Part VII, Section A....MediumBullet
d Total (add lines 1b and 1c)............MediumBullet 807,174 6,757,065 1,182,384
2
Total number of individuals (including but not limited to those listed above) who received more than $100,000 of reportable compensation from the organizationMediumBullet18
Yes
No
3
Did the organization list any former officer, director or trustee, key employee, or highest compensated employee on line 1a? If “Yes,” complete Schedule J for such individual ..............
3
 
No
4
For any individual listed on line 1a, is the sum of reportable compensation and other compensation from the organization and related organizations greater than $150,000? If “Yes,” complete Schedule J for such individual...........................
4
Yes
 
5
Did any person listed on line 1a receive or accrue compensation from any unrelated organization or individual for services rendered to the organization? If “Yes,” complete Schedule J for such person ........
5
 
No
Section B. Independent Contractors
1
Complete this table for your five highest compensated independent contractors that received more than $100,000 of compensation from the organization. Report compensation for the calendar year ending with or within the organization’s tax year.
(A)
Name and business address 		(B)
Description of services 		(C)
Compensation
Town Square Anesthia LLC3703 Doty Road Suite 7WoodstockIL60098 Anesthesia Services 235,000
Sodexo Inc & Affiliates4880 Paysphere CircleChicagoIL60674 Food, ES & POM Mgmt 2,513,669
Hearthstone Management Service920 North Seminary AveWoodstockIL600982996 Extended Care Servic 223,114
Executive Health ResourcesPO Box 822688PhiladelphiaPA191822688 Compliance Consultan 338,450
Diversified Clinical ServicesPO Box 636981CincinnatiOH452636981 Wound Care Services 365,762
2
Total number of independent contractors (including but not limited to those listed above) who received more than $100,000 of compensation from the organization MediumBullet9
Form 990 (2012)
Form 990 (2012)
Page 9
Part VIII
Statement of Revenue
Check if Schedule O contains a response to any question in this Part VIII ..............
(A)
Total revenue 		(B)
Related or
exempt
function
revenue 		(C)
Unrelated
business
revenue 		(D)
Revenue
excluded from
tax under sections
512, 513, or 514
Contributions, Gifts, Grants and Other Similar Amounts 1a Federated campaigns..1a  
b Membership dues....1b  
c Fundraising events....1c  
d Related organizations...1d 240,177
e Government grants (contributions)1e 809,364
f All other contributions, gifts, grants, and
similar amounts not included above1f 		 
g Noncash contributions included in lines
1a-1f:$ 		 
h Total. Add lines 1a-1f.......MediumBullet 1,049,541
Program Service Revenue Business Code
2a Routine Patient Services 621990 53,638,101 53,638,101    
b IDPA Provider Tax Revenue 622110 6,123,398 6,123,398    
c Charity Care/Admin Allow 621990 -14,988,850 -14,988,850    
d Ancillary O/P Services 621990 81,338,238 81,338,238    
e Ancillary I/P Services 621990 9,414,812 9,414,812    
f All other program service revenue .        
g Total. Add lines 2a–2f........MediumBullet 135,525,699
Other Revenue 3 Investment income (including dividends, interest, and other similar amounts).......MediumBullet 2,117,083     2,117,083
4 Income from investment of tax-exempt bond proceeds..MediumBullet 7,468     7,468
5 Royalties...........MediumBullet 0      
(i) Real (ii) Personal
6a Gross rents 808,983  
b Less: rental expenses    
c Rental income or (loss) 808,983  
d Net rental income or (loss).......MediumBullet 808,983     808,983
(i) Securities (ii) Other
7a Gross amount from sales of assets other than inventory 5,996,236  
b Less: cost or other basis and sales expenses 5,498,420  
c Gain or (loss) 497,816  
d Net gain or (loss)..........MediumBullet 497,816     497,816
8a Gross income from fundraising events (not including
$  
of contributions reported on line 1c). See Part IV, line 18 ..
a  
b Less: direct expenses ...b  
c Net income or (loss) from fundraising events..MediumBullet 0    
9a Gross income from gaming activities.
See Part IV, line 19 ...
a  
b Less: direct expenses ...b  
c Net income or (loss) from gaming activities...MediumBullet 0      
10a Gross sales of inventory, less
returns and allowances .
a  
b Less: cost of goods sold ..b  
c Net income or (loss) from sales of inventory..MediumBullet 0      
Miscellaneous Revenue Business Code
11a Other Misc Income 621990 163,694     163,694
b Other Income 621990 309,693     309,693
c Cafeteria Sales 722210 527,800     527,800
d All other revenue .... 206,835 61,061 13,042 132,732
e Total. Add lines 11a–11d ...... MediumBullet 1,208,022
12 Total revenue. See Instructions......MediumBullet 141,214,612 135,586,760 13,042 4,565,269
Form 990 (2012)
Form 990 (2012)
Page 10
Part IX
Statement of Functional Expenses
Section 501(c)(3) and 501(c)(4) organizations must complete all columns. All other organizations must complete column (A).Check if Schedule O contains a response to any question in this Part IX ...............
Do not include amounts reported on lines 6b,
7b, 8b, 9b, and 10b of Part VIII. 		(A)
Total expenses 		(B)
Program service expenses 		(C)
Management and general expenses 		(D)
Fundraising expenses
1 Grants and other assistance to governments and organizations in the United States. See Part IV, line 21 0  
2 Grants and other assistance to individuals in the United States. See Part IV, line 22 0  
3 Grants and other assistance to governments, organizations, and individuals outside the United States. See Part IV, lines 15 and 16 0  
4 Benefits paid to or for members 0  
5 Compensation of current officers, directors, trustees, and key employees .... 190,571   190,571  
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 45,325,403 38,048,739 7,276,664  
8 Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) .... 845,056 706,418 138,638  
9 Other employee benefits ....... 6,302,981 5,268,930 1,034,051  
10 Payroll taxes ........... 3,228,089 2,698,497 529,592  
11 Fees for services (non-employees):        
a Management ...... 727,206 254,535 472,671  
b Legal ......... 0      
c Accounting ........... 0      
d Lobbying ........... 26,196   26,196  
e Professional fundraising services. See Part IV, line 17 0  
f Investment management fees ...... 0      
g Other (If line 11g amount exceeds 10% of line 25, column (A) amount, list line 11g expenses on Schedule O) ........ 8,057,554 6,848,921 1,208,633  
12 Advertising and promotion .... 15,195 15,195    
13 Office expenses ....... 20,674,475 19,877,481 796,994  
14 Information technology ...... 11,243 8,243 3,000  
15 Royalties .. 0      
16 Occupancy ........... 2,650,900 2,216,000 434,900  
17 Travel ............ 95,923 90,884 5,039  
18 Payments of travel or entertainment expenses for any federal, state, or local public officials ...... 0      
19 Conferences, conventions, and meetings .... 65,925 54,342 11,583  
20 Interest ........... 2,316,830 1,936,737 380,093  
21 Payments to affiliates ....... 0      
22 Depreciation, depletion, and amortization ..... 5,790,934 4,840,888 950,046  
23 Insurance .............. 1,740,333 1,454,818 285,515  
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 Other Misc. Expenses 130,324 -33,944 164,268  
b IDPA Provider Tax Assessment 4,215,389 4,215,389    
c Provision for Bad Debts 8,310,629 8,310,629    
d Purch Srvs Rltd Prty (Sch O) 21,270,254 17,780,710 3,489,544  
e All other expenses 0      
25 Total functional expenses. Add lines 1 through 24e 131,991,410 114,593,412 17,397,998 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 ............. 71,217 1 146,602
2 Savings and temporary cash investments ......... 4,413,128 2 6,673,666
3 Pledges and grants receivable, net ...........   3 0
4 Accounts receivable, net ............. 18,855,273 4 18,642,999
5 Loans and other receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of
Schedule L ..................
  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
  6 0
7 Notes and loans receivable, net .............   7 0
8 Inventories for sale or use .............. 2,143,966 8 1,937,420
9 Prepaid expenses and deferred charges .......... 923,510 9 1,048,808
10a Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D 10a 132,849,037
b Less: accumulated depreciation ..... 10b 90,066,247 36,762,509 10c 42,782,790
11 Investments—publicly traded securities .......... 26,457,995 11 26,934,735
12 Investments—other securities. See Part IV, line 11 .....   12 0
13 Investments—program-related. See Part IV, line 11 ..... 4,421,540 13 4,782,763
14 Intangible assets ...............   14 0
15 Other assets. See Part IV, line 11 ........... 5,587,019 15 19,595,912
16 Total assets. Add lines 1 through 15 (must equal line 34)...... 99,636,157 16 122,545,695
Liabilities 17 Accounts payable and accrued expenses ......... 16,159,498 17 14,592,913
18 Grants payable .................   18  
19 Deferred revenue ................   19  
20 Tax-exempt bond liabilities ............. 46,148,409 20 62,481,669
21 Escrow or custodial account liability. Complete Part IV of Schedule D..   21  
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..........   22  
23 Secured mortgages and notes payable to unrelated third parties ..   23  
24 Unsecured notes and loans payable to unrelated third parties ....   24  
25 Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17-24). Complete Part X of Schedule D.................... 2,974,920 25 2,269,483
26 Total liabilities. Add lines 17 through 25......... 65,282,827 26 79,344,065
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 .............. 31,698,965 27 40,391,223
28 Temporarily restricted net assets ........... 2,654,365 28 2,810,407
29 Permanently restricted net assets ...........   29  
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 ........... 34,353,330 33 43,201,630
34 Total liabilities and net assets/fund balances ........ 99,636,157 34 122,545,695
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
141,214,612
2
Total expenses (must equal Part IX, column (A), line 25) ............
2
131,991,410
3
Revenue less expenses. Subtract line 2 from line 1 ..............
3
9,223,202
4
Net assets or fund balances at beginning of year (must equal Part X, line 33, column (A)) ..
4
34,353,330
5
Net unrealized gains (losses) on investments ...............
5
-108,640
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
-266,262
10
Net assets or fund balances at end of year. Combine lines 3 through 9 (must equal Part X, line 33, column (B))
10
43,201,630
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: 12000229
Software Version: 2012v2.0
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
Memorial Medical Center
 
Employer identification number

36-2179764
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: 12000229
Software Version: 2012v2.0
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
Memorial Medical Center
 
Employer identification number

36-2179764
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
Memorial Medical Center
  		Employer identification number

36-2179764
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
Memorial Medical Center
  		Employer identification number

36-2179764
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
Memorial Medical Center
  		Employer identification number

36-2179764
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: 12000229
Software Version: 2012v2.0
SCHEDULE C
(Form 990 or 990-EZ)

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

For Organizations Exempt From Income Tax Under section 501(c) and section 527
SchCMd Bullet Complete if the organization is described below.SchCMd Bullet Attach to Form 990 or Form 990-EZ.
SchCMd Bullet See separate instructions.
OMB No. 1545-0047
2012
Open to Public
Inspection
If the organization answered “Yes” to Form 990, Part IV, Line 3, or Form 990-EZ, Part V, line 46 (Political Campaign Activities), then
Round Bullet Section 501(c)(3) organizations: Complete Parts I-A and B. Do not complete Part I-C.
Round Bullet Section 501(c) (other than section 501(c)(3)) organizations: Complete Parts I-A and C below. Do not complete Part I-B.
Round Bullet Section 527 organizations: Complete Part I-A only.
If the organization answered “Yes” to Form 990, Part IV, Line 4, or Form 990-EZ, Part VI, line 47 (Lobbying Activities), then
Round Bullet Section 501(c)(3) organizations that have filed Form 5768 (election under section 501(h)): Complete Part II-A. Do not complete Part II-B.
Round Bullet Section 501(c)(3) organizations that have NOT filed Form 5768 (election under section 501(h)): Complete Part II-B. Do not complete Part II-A.
If the organization answered “Yes” to Form 990, Part IV, Line 5 (Proxy Tax) or Form 990-EZ, Part V, line 35c (Proxy Tax), then
Round Bullet Section 501(c)(4), (5), or (6) organizations: Complete Part III.
Name of the organization
Memorial Medical Center
 
Employer identification number

36-2179764
Part I-A
Complete if the organization is exempt under section 501(c) or is a section 527 organization.

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

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

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

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










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

Schedule C (Form 990 or 990-EZ) 2012
Page 2
Part II-A
Complete if the organization is exempt under section 501(c)(3) and filed Form 5768 (election under section 501(h)).
A Check SchCMd Bulletexpenses, and share of excess lobbying expenditures).
B Check SchCMd Bullet
Limits on Lobbying Expenditures
(The term "expenditures" means amounts paid or incurred.) 		(a) Filing
organization's
totals 		(b) Affiliated group
totals
1a Total lobbying expenditures to influence public opinion (grass roots lobbying) ......    
b Total lobbying expenditures to influence a legislative body (direct lobbying) .......    
c Total lobbying expenditures (add lines 1a and 1b) ...................    
d Other exempt purpose expenditures ........................    
e Total exempt purpose expenditures (add lines 1c and 1d) ...............    
f Lobbying nontaxable amount. Enter the amount from the following table in both
columns.		    
  If the amount on line 1e, column (a) or (b) is:The lobbying nontaxable amount is:    
  Not over $500,00020% of the amount on line 1e.    
  Over $500,000 but not over $1,000,000$100,000 plus 15% of the excess over $500,000.    
  Over $1,000,000 but not over $1,500,000$175,000 plus 10% of the excess over $1,000,000.    
  Over $1,500,000 but not over $17,000,000$225,000 plus 5% of the excess over $1,500,000.    
  Over $17,000,000$1,000,000.    
       
g Grassroots nontaxable amount (enter 25% of line 1f) .................    
h Subtract line 1g from line 1a. If zero or less, enter -0-. ................    
i Subtract line 1f from line 1c. If zero or less, enter -0-. ................    
j If there is an amount other than zero on either line 1h or line 1i, did the organization file Form 4720 reporting
section 4911 tax for this year? ......................................

4-Year Averaging Period Under Section 501(h)
(Some organizations that made a section 501(h) election do not have to complete all of the five
columns below. See the instructions for lines 2a through 2f on page 4.)
Lobbying Expenditures During 4-Year Averaging Period
  Calendar year (or fiscal year
beginning in) 		(a) 2009 (b) 2010 (c) 2011 (d) 2012 (e) Total
             
2a Lobbying nontaxable amount          
             
b Lobbying ceiling amount
(150% of line 2a, column(e)) 		         
             
c Total lobbying expenditures          
             
d Grassroots nontaxable amount          
             
e Grassroots ceiling amount
(150% of line 2d, column (e))		          
             
f Grassroots lobbying expenditures          
Schedule C (Form 990 or 990-EZ) 2012


Schedule C (Form 990 or 990-EZ) 2012
Page 3
Part II-B
Complete if the organization is exempt under section 501(c)(3) and has NOT filed Form 5768 (election under section 501(h)).
For each “Yes” response to lines 1a through 1i below, provide in Part IV a detailed description of the lobbying activity.
(a)
No
Yes
(b)
Amount
1
During the year, did the filing organization attempt to influence foreign, national, state or local legislation, including any attempt to influence public opinion on a legislative matter or referendum, through the use of:
a
Volunteers? .........................................
 
No
b
Paid staff or management (include compensation in expenses reported on lines 1c through 1i)? ....
 
No
c
Media advertisements? ....................................
 
No
 
d
Mailings to members, legislators, or the public? .........................
 
No
 
e
Publications, or published or broadcast statements? .......................
 
No
 
f
Grants to other organizations for lobbying purposes? .......................
 
No
 
g
Direct contact with legislators, their staffs, government officials, or a legislative body? ........
 
No
 
h
Rallies, demonstrations, seminars, conventions, speeches, lectures, or any similar means? ......
 
No
 
i
Other activities? ..........................
Yes
 
26,196
j
Total. Add lines 1c through 1i ...............................
26,196
2a
Did the activities in line 1 cause the organization to be not described in section 501(c)(3)? .....
 
No
b
If "Yes," enter the amount of any tax incurred under section 4912 .................
 
c
If "Yes," enter the amount of any tax incurred by organization managers under section 4912 .....
 
d
If the filing organization incurred a section 4912 tax, did it file Form 4720 for this year? .......
 
No
Part III-A
Complete if the organization is exempt under section 501(c)(4), section 501(c)(5), or section 501(c)(6).
Yes
No
1
Were substantially all (90% or more) dues received nondeductible by members? ................
1
 
 
2
Did the organization make only in-house lobbying expenditures of $2,000 or less? ................
2
 
 
3
Did the organization agree to carry over lobbying and political expenditures from the prior year? ..........
3
 
 
Part III-B
Complete if the organization is exempt under section 501(c)(4), section 501(c)(5), or section 501(c)(6) and if either (a) BOTH Part III-A, lines 1 and 2, are answered “No” OR (b) Part III-A, line 3, is answered “Yes."
1
Dues, assessments and similar amounts from members .....................
1
 
2
Section 162(e) nondeductible lobbying and political expenditures (do not include amounts of political
expenses for which the section 527(f) tax was paid).
a
Current year .........................................
2a
 
b
Carryover from last year ....................................
2b
 
c
Total ............................................
2c
 
3
Aggregate amount reported in section 6033(e)(1)(A) notices of nondeductible section 162(e) dues .
3
 
4
If notices were sent and the amount on line 2c exceeds the amount on line 3, what portion of the excess does the organization agree to carryover to the reasonable estimate of nondeductible lobbying and political expenditure next year? ................................
4
 
5
Taxable amount of lobbying and political expenditures (see instructions) ..............
5
 
Part IV
Supplemental Information
Complete this part to provide the descriptions required for Part l-A, line 1; Part l-B, line 4; Part l-C, line 5; Part II-A (affiliated group list); Part II-A, line 2; and Part ll-B, line 1. Also, complete this part for any additional information.
Identifier Return Reference Explanation
Part II-B, Line 1i Part II-B, Line 1i - Other Activities Description As part of our payment of Illinois Hospital Association dues, approximately 27% in calendar year 2012 and 34% in calendar year 2013 are allocable to lobbying activities. As part of our payment of Metropolitan Chicago Healthcare Council dues, approximately 25% are allocable to lobbying activities.
Schedule C (Form 990 or 990EZ) 2012

Additional Data


Software ID: 12000229
Software Version: 2012v2.0

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
Memorial Medical Center
 
Employer identification number

36-2179764
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 .................   223,785 223,785
b Buildings ................   72,321,558 47,098,949 25,222,609
c Leasehold improvements ............   3,212,830 1,848,155 1,364,675
d Equipment ................   57,510,391 41,119,143 16,391,248
e Other .................   -419,527   -419,527
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).).......SchDMdBullet 42,782,790
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
(1) Other Receivables 2,678,748
(2) Due from Affiliates 16,917,164







Total. (Column (b) must equal Form 990, Part X, col.(B) line 15.)...........Small Bullet 19,595,912
Part X
Other Liabilities. See Form 990, Part X, line 25.
1.(a) Description of liability (b) Book value
Federal income taxes  
Self-Insured Professional Liability 2,198,927
Other Long-Term Liabilities 70,556







Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)Small Bullet 2,269,483
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
Part X Part X : FIN48 Footnote ASC Topic 740, Income Taxes, addresses the determination of how tax benefits claimed or expected to be claimed on a tax return should be recorded in the consolidated financial statements. Under ASC Topic 740, the Health System must recognize the tax benefit from an uncertain tax position only if it is more likely than not that the tax position will be sustained on examination by the taxing authorities, based on the technical merits of the position. The tax benefits recognized in the consolidated financial statements from such a position are measured based on the largest benefit that has a greater than fifty percent likelihood of being realized upon ultimate settlement. ASC Topic 740 also provides guidance on derecognition, classification, interest and penalties on income taxes, accounting in interim periods and requires increased disclosures. As of June 30, 2013 and 2012, the Health System does not have a liability for unrecognized tax benefits.
Schedule D (Form 990) 2012

Additional Data


Software ID: 12000229
Software Version: 2012v2.0




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
Memorial Medical Center
 
Employer identification number

36-2179764
Part I
Financial Assistance and Certain Other Community Benefits at Cost
Yes
No
1a
Did the organization have a financial assistance policy during the tax year? If "No," skip to question 6a ...
1a
Yes
 
b
If "Yes," was it a written policy? .......................
1b
Yes
 
2
If the organization had multiple hospital facilities, indicate which of the following best describes application of the financial assistance policy to its various hospital facilities during the tax year.
3
Answer the following based on the financial assistance eligibility criteria that applied to the largest number of the organization's patients during the tax year.
a
Did the organization use Federal Poverty Guidelines (FPG) as a factor in determining eligibility for providing free care?
If "Yes," indicate which of the following was the FPG family income limit for eligibility for free care:
3a
Yes
 
%
b
Did the organization use FPG as a factor in determining eligibility for providing discounted care? If "Yes," indicate
which of the following was the family income limit for eligibility for discounted care: .........
3b
Yes
 
c
If the organization used factors other than FPG in determining eligibility, describe in Part VI the income based criteria for determining eligibility for free or discounted care. Include in the description whether the organization used an asset test or other threshold, regardless of income, as a factor in determining eligibility for free or discounted care.
4
Did the organization's financial assistance policy that applied to the largest number of its patients during the tax year provide for free or discounted care to the "medically indigent"? ..............

4

Yes

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

5a

Yes

 
b
If "Yes," did the organization's financial assistance expenses exceed the budgeted amount? ......
5b
Yes
 
c
If "Yes" to line 5b, as a result of budget considerations, was the organization unable to provide free or discountedcare to a patient who was eligibile for free or discounted care? ..............
5c
 
No
6a
Did the organization prepare a community benefit report during the tax year? ..........
6a
Yes
 
b
If "Yes," did the organization make it available to the public? ..............
6b
Yes
 
Complete the following table using the worksheets provided in the Schedule H instructions. Do not submit these worksheets with the Schedule H.
7
Financial Assistance and Certain Other Community Benefits at Cost
Financial Assistance and
Means-Tested
Government Programs
 (a) Number of activities or programs (optional) (b) Persons served (optional) (c) Total community benefit expense (d) Direct offsetting revenue (e) Net community benefit expense (f) Percent of total expense
a Financial Assistance at cost
(from Worksheet 1) .. 		    4,403,571   4,403,571 3.340 %
b Medicaid (from Worksheet 3,
column a) .... 		    14,070,747 7,223,934 6,846,813 5.190 %
c Costs of other means-tested
government programs (from
Worksheet 3, column b) . 		           
d Total Financial Assistance
and Means-Tested
Government Programs . 		    18,474,318 7,223,934 11,250,384 8.530 %
Other Benefits
 20 16,088 170,635 8,434 162,201 0.120 %
e Community health
improvement services and
community benefit operations
(from Worksheet 4) ..
f Health professions education
(from Worksheet 5) .. 		4 288 160,985   160,985 0.120 %
g Subsidized health services
(from Worksheet 6) .. 		1 31 4,179   4,179  
h Research (from Worksheet 7)            
i Cash and in-kind
contributions for community
benefit (from Worksheet 8) 		4 382 1,343   1,343  
j Total. Other Benefits .. 29 16,789 337,142 8,434 328,708 0.240 %
k Total. Add lines 7d and 7j . 29 16,789 18,811,460 7,232,368 11,579,092 8.770 %
For Paperwork Reduction Act Notice, see the Instructions for Form 990. Cat. No. 50192T Schedule H (Form 990) 2012
Schedule H (Form 990) 2012
Page
Part II
Community Building Activities Complete this table if the organization conducted any community building activities during the tax year, and describe in Part VI how its community building activities promoted the health of the communities it serves.
(a) Number of activities or programs (optional) (b) Persons served (optional) (c) Total community building expense (d) Direct offsetting
revenue 		(e) Net community building expense (f) Percent of total expense
1 Physical improvements and housing            
2 Economic development 1 1 1,069   1,069  
3 Community support 1   502,639   502,639 0.380 %
4 Environmental improvements            
5 Leadership development and training for community members 2 175 19,716   19,716 0.010 %
6 Coalition building 1 400 916   916  
7 Community health improvement advocacy 7 768 7,894   7,894 0.010 %
8 Workforce development 1 1 381   381  
9 Other            
10 Total 13 1,345 532,615   532,615 0.400 %
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
8,310,629
3
Enter the estimated amount of the organization's bad debt expense attributable to patients eligible under the organization's financial assistance policy. Explain in Part VI the methodology used by the organization to estimate this amount and the rationale, if any, for including this portion of bad debt as community benefit. ......
3
2,253,047
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
35,374,278
6
Enter Medicare allowable costs of care relating to payments on line 5.....
6
42,986,724
7
Subtract line 6 from line 5. This is the surplus (or shortfall)........
7
-7,612,446
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 %
1ARSC Real Estate Holdings
  		Real Estate Holding Company 25.000 %    
2Algonquin Road Surgery Cen
  		Outpatient Surgery Center 12.750 %    
3
4
5
6
7
8
9
10
11
12
13
Schedule H (Form 990) 2012
Schedule H (Form 990) 2012
Page
Part VFacility Information
Section A. Hospital Facilities
(list in order of size from largest to smallest—see instructions)
How many hospital facilities did the organization operate during the tax year?1
Name, address, and primary website address 		Licensed Hospital General-Medical-Surgical Children's Hospital Teaching Hospital Critical Hospital Research Facility ER-24Hours ER-Other Other (Describe) Facility reporting group
1 Memorial Medical Center
3701 Doty Road
Woodstock,IL60098 		X X         X      
Schedule H (Form 990) 2012
Schedule H (Form 990) 2012
Page
Part VFacility Information (continued)

Section B. Facility Policies and Practices

(Complete a separate Section B for each of the hospital facilities or facility reporting groups listed in Part V, Section A)
Memorial Medical Center
Name of hospital facility or facility reporting group  
For single facility filers only: line Number of Hospital Facility (from Schedule H, Part V, Section A) 1
Yes No
Community Health Needs Assessment (Lines 1 through 8c are optional for tax years begining on or before March 23, 2012)
1 During the tax year or either of the two immediately preceding tax years, did the hospital facility conduct a community health needs assessment (CHNA)? If "No," skip to line 9.................... 1 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 10
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 Yes  
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 Yes  
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   No
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: 200.0000%
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: 600.0000%
If "No," explain in Part VI the criteria the hospital facility used.
12 Explained the basis for calculating amounts charged to patients?................. 12 Yes  
If “Yes,” indicate the factors used in determining such amounts (check all that apply):
a
b
c
d
e
f
g
h
13 Explained the method for applying for financial assistance?................... 13 Yes  
14 Included measures to publicize the policy within the community served by the hospital facility?....... 14 Yes  
If “Yes,” indicate how the hospital facility publicized the policy (check all that apply):
a
b
c
d
e
f
g
Billing and Collections
15 Did the hospital facility have in place during the tax year a separate billing and collections policy, or a written financial assistance policy (FAP) that explained actions the hospital facility may take upon non-payment?....... 15 Yes  
16 Check all of the following actions against an individual that were permitted under the hospital facility's policies during the tax year before making reasonable efforts to determine the patient’s eligibility under the facility’s FAP:
a
b
c
d
e
17 Did the hospital facility or an authorized third party perform any of the following actions during the tax year before making reasonable efforts to determine the patient’s eligibility under the facility’s FAP?.......... 17   No
If “Yes,” check all actions in which the hospital facility or a third party engaged:
a
b
c
d
e
Schedule H (Form 990) 2012
Schedule H (Form 990) 2012
Page
Part VFacility Information (continued)

18 Indicate which efforts the hospital facility made before initiating any of the actions listed in line 17 (check all that apply):
a
b
c
d
e
Policy Relating to Emergency Medical Care
Yes No
19 Did the hospital facility have in place during the tax year a written policy relating to emergency medical care that requires the hospital facility to provide, without discrimination, care for emergency medical conditions to individuals regardless of their eligibility under the hospital facility’s financial assistance policy?.......... 19 Yes  
If “No,” indicate why:
a
b
c
d
Charges to Individuals Eligible for Assistance under the FAP (FAP-Eligible Individuals)
20 Indicate how the hospital facility determined, during the tax year, the maximum amounts that can be charged to FAP-eligible individuals for emergency or other medically necessary care.
a
b
c
d
21 During the tax year, did the hospital facility charge any FAP-eligible individuals to whom the hospital facility provided emergency or other medically necessary services, more than the amounts generally billed to individuals who had insurance covering such care? ............................ 21   No
If “Yes,” explain in Part VI.
22 During the tax year, did the hospital facility charge any FAP-eligible individuals an amount equal to the gross charge for any service provided to that individual? ......................... 22   No
If “Yes,” explain in Part VI.
Schedule H (Form 990) 2012
Schedule H (Form 990) 2012
Page
Part VFacility Information (continued)

Section C. Other Health Care Facilities That Are Not Licensed, Registered, or Similarly Recognized as a Hospital Facility
(list in order of size, from largest to smallest)
How many non-hospital health care facilities did the organization operate during the tax year?3
Name and address Type of Facility (describe)
1 Centegra Rehab & Sports Medicine
10450 Algonquin Rd
Huntley,IL60142 		Rehabiliation & Sports Medicine Clinic
2 Centegra Wound & Hyberbaric Center
11650 S Route 47
Huntley,IL60142 		Wound Care & Hyperbaric Center
3 Centegra Health Center-Huntley
10350 Haligus Rd
Huntley,IL60142 		Laboratory and Medical Imaging Services
4
5
6
7
8
9
10
Schedule H (Form 990) 2012
Schedule H (Form 990) 2012
Page
Part VI
Supplemental Information
Complete this part to provide the following information.
1 Required descriptions. Provide the descriptions required for Part I, lines 3c, 6a, and 7; Part II; Part III, lines 4, 8, and 9b; Part V, Section A; and Part V, Section B, lines 1j, 3, 4, 5c, 6i, 7, 10, 11, 12h, 14g, 16e, 17e, 18e, 19c, 19d, 20d, 21, and 22.
2 Needs assessment. Describe how the organization assesses the health care needs of the communities it serves, in addition to any needs assessments reported in Part V, Section B.
3 Patient education of eligibility for assistance. Describe how the organization informs and educates patients and persons who may be billed for patient care about their eligibility for assistance under federal, state, or local government programs or under the organization’s financial assistance policy.
4 Community information. Describe the community the organization serves, taking into account the geographic area and demographic constituents it serves.
5 Promotion of community health. Provide any other information important to describing how the organization’s hospital facilities or other health care facilities further its exempt purpose by promoting the health of the community (e.g., open medical staff, community board, use of surplus funds, etc.).
6 Affiliated health care system. If the organization is part of an affiliated health care system, describe the respective roles of the organization and its affiliates in promoting the health of the communities served.
7 State filing of community benefit report. If applicable, identify all states with which the organization, or a related organization, files a community benefit report.
8 Facility reporting group(s). If applicable, for each hospital facility in a facility reporting group provide the descriptions required for Part V, Section B, lines 1j, 3, 4, 5c, 6i, 7, 10, 11, 12h, 14g, 16e, 17e, 18e, 19c, 19d, 20d, 21, and 22.
Identifier ReturnReference Explanation
  Part VI - Additional Information Part I, Line 7The amounts in Lines 7a-7d were calculated by applying the Medicare cost-to-charge ratio to the net patient revenue for each category. The amounts in Lines 7e-7k were calculated based on actual expenses for each community benefit activity category.Part I, Line 7, Column (f)Form 990, Part IX, line 25 includes $8,310,629 for Bad Debt Expense. This amount cannot be subtracted from total expenses in order to calculate the column (f) percentages in lines 7a-7k due to software limitations.Part I, Line 7, Line (g)This is the amount reported in Community Benefits for Medication Assistance for those Living in Poverty.
  Part V - Explanation of Number of Facility Type Memorial Medical Center is comprised of one licensed hospital, one center housing laboratory and medical imaging services, one center housing a rehabilitation and sports medicine clinic, and one location housing a wound care and hyberbaric center.
  Part VI - States Where Community Benefit Report Filed IL
  Part VI - Affilated Health Care System Roles and Promotion See Schedule O for response to Form 990, Part III, Line 4a.
  Part VI - Explanation Of How Organization Furthers Its Exempt Purpose See Schedule O for response to Form 990, Part III, Line 4a.
  Part VI - Community Building Activities Representatives of Memorial Medical Center participated in many different community groups and committees, such as the Fire/EMS Chief Association, the Police Chief Association, the Health and Human Services Network, the Child Advocacy Board, and the Family Violence Coordinating Council. Through these meetings, representatives of Memorial Medical Center can promote the health system's role in improving the health of the individuals that these different groups serve. Also included Part II are expenses related to our Spanish language interpreters. Hispanics comprise 11.7% of the population of McHenry County and our Spanish language interpreters are imperative to the effort to improve the health of this traditionally underserved population.
  Part VI - Community Information Centegra Health System defines its primary service area as McHenry County, an area of approximately 603 square miles and 327,142 residents. This county is among the fastest growing counties in Illinois with an 18.7% population growth from 2000-2010. The age groups with projected population growth from 2012 to 2017 are the 0-19 with 0.6% and the 65+ age group with 15.3% growth. The county's overall population is projected to increase by 1.4% in the next five years (2012 to 2017). For 2010, the age distribution of the population was as follows: 30% 0-19, 32% 20-44, 28% 45-64, and 10% 65+. McHenry County has relatively high socioeconomic status compared to the rest of Illinois. Median household income for 2011 was $76,909 compared to the IL state median income of $56,576. The 2013 unemployment rate was 9.3% which is lower than the state average of 9.4%. The McHenry County uninsured in 2011 was 9.1%, compared to the state uninsured rate of 13.1%
  Part VI - Patient Education of Eligibility for Assistance 1. Uninsured patients arriving at our emergency department and/or direct admits are screened at time of service by either an Emergency Department Financial Counselor or the health system's In-Patient Financial Counseling Team, Public Aid Representatives and a Medication Assistance Coordinator to identify eligibility guidelines for federal, state and local government programs as well as charity care. Centegra Health System's Self Pay Process includes a screening which is completed by using hospital form C910050 03-09 prompting an interview offering payment options and eligibility guidelines. It is at this time that a patient becomes aware of the Hospital Uninsured Patient Discount Act, Medicaid, Medication Assistance Programs, Crime Victims, IBCCP, Cash Pay Fee Schedules, and other hospital discount incentives. Patients are advised of time lines for completing application processes at time of service in person. Appropriate scripting is followed by Centegra Health System (CHS) Associates. Discounts were established following the 200%, 350% and 600% federal poverty guidelines to assist in determining charity adjustments. Applications were designed by Centegra Health System Self Pay Committee in accordance to our Financial Policy (Policy Number 9850-2) identifying qualifications for the medically needy/catastrophic aid.2. Uninsured patients opting for elective services are contacted by phone prior to their date of service by the CHS Out-Patient Financial Counseling Team. CHS's Self Pay Process is followed and includes a screening for federal, state and local government programs as well charity care. An interview offering payment options and eligibility guidelines using hospital form C910050 03/09 prompts a quick eligibility determination. It is at this time that a patient becomes aware of the Uninsured Patient Discount Act, Medicaid, Medication Assistance Programs, Crime Victims, IBCCP, Cash Pay Fee Schedules, and other hospital discount incentives. Patients are advised of time lines for completing application processes prior to their elective services via phone. Appropriate scripting is followed by CHS Associates. Discounts were established following the 200%, 350% and 600% federal poverty guidelines to assist in determining charity adjustments. Applications were designed by CHS Self Pay Committee in accordance to our Financial Policy (Policy Number 9850-2) identifying qualifications for the medically needy/catastrophic aid.3. Our health system's web site offers FAQ's and answers as well as encourages patients to contact our Customer Service Team when they are unable to pay for services.4. Our health system's statements also identify detailed account and billing information encouraging the patient to contact our Customer Service Team and inquire about Financial Assistance options.5. Documentation is essential in effective communication. Follow up teams will then move forward in a timely manner with the appropriate actions to insure all necessary documents (if applicable) are received for eligibility determinations.6. CHS advertises a Price Line encouraging patients to inquire about estimated costs for future services. The Price Line is manned by our Out-Patient Financial Counselors from 8:00am - 7:00pm. When calls are returned with estimated costs, a conversation ensues to identify a possible financial hardship. Our Self Pay Process is put into effect at this time.7. Site Registrars will notify the CHS Financial Counseling Team when a financial hardship is identified.8. Emergency Department Financial Counseling positions were created to meet the needs of our ED patients. In addition, a full time Financial Counselor position was created to meet the special needs of our cancer patients.9. A Financial Assistance Coordinator reviews all financial applications, gathers needed documents, determines financial assistance and prepares each patient file for leadership approval.
  Part VI - Needs Assessment Centegra Health System worked with the McHenry County Department of Public Health and other participating organizations to conduct a community health assessment and identify leading indicators to help highlight the health needs of the county. Those indicators identified include percentage of physically inactive people, percentage of obese people, percentage of current smokers over the age of 18, percentage of binge drinkers, reported new aids cases, suicide rate, mortality rate from unintentional injuries, firearm-related mortality rate, homicide rate, percentage of children with elevated lead levels age 1-6, percentage of children 19 to 35 months of age in full immunization compliance, percentage of people with no health insurance, and percentage of pregnant women who begin prenatal care in the 1st trimester. Centegra Health System has been an active participant in the McHenry County Health Department's MAPP process (Mobilizing for Action through Planning & Partnerships), which is an ongoing effort: Phase 1: Organize for Success/ Partnership Development; Phase 2: Vision, Value Statements; Phase 3: Conducting MAPP Assessments; Phase 4: Identify Strategic Issues; Phase 5: Formulate Goals and Strategies; Phase 6: Action Cycle (current stage). MAPP priorities have been defined as: 1) Increase Access to Medical, Dental and Mental Health care: Goal 1: Provide increased access to follow up care (medical, dental, mental) for the under/uninsured residents of McHenry County; Goal 2: Increase access to (medical, dental, mental) prevention, education, and screening programs available for all residents of McHenry County; 2) Information & Referral: Goal 1: Centralize and update Information and Referral located on Crisis Services web site; Goal 2: Market Crisis Line #/Web site (future 2-1-1) to community to increase visibility; Goal 3: 2-1-1 Information and Referral System; 3) Cardiovascular Care: Goal: By 2017, reduce the death rate from cardiovascular disease by 20%. Centegra's initiatives will target the following defined community needs as priorities: Access to Care, Information & Referral Services, and Clinical Areas of Cardiovascular and Cancer-related programs and services. Centegra's Community Benefits programming will continue to target: community wellness and prevention programs, community health education, community health advocacy and assistance, clinical education, community collaborations, and community-based clinical initiatives.
Number of Hospital Faciltiy - 1 Part V, Line 20d - Other Billing Determination of Individuals Without Insurance Patients without insurance are given a 25% discount off of the standard charge for service.
Number of Hospital Faciltiy - 1 Part V, Line 6i - Describe Other Needs Identified Using information and analysis from the Household Survey, Focus Groups, Key Informant Interviews and Community Analysis, priorities were identified based on their prominence as community needs. As part of the priority selection process, issues were weighted based on their magnitude defined by size and severity, significance to the community,and whether current activities were adequate and effective in addressing the problem.The four primary priorities were:INFORMATION AND REFERRAL SYSTEMACCESS TO DENTAL CARE FOR LOW-INCOME POPULATIONACCESS TO MENTAL HEALTH AND SUBSTANCE ABUSE SERVICESOBESITY AND NUTRITIONSecondary priorities include:Cardiovascular DiseaseDiversity of Population/Lack of IntegrationEnvironment - Open Space and Groundwater ProtectionLack of Public TransportationCentegra Health System is an active participant in the McHenry County Health Departments on-going MAPP (Mobilizing for Action through Planning and Partnerships) process. Teams were formed to work on the priorities identified above. Representatives from Centegra Health System have participated as part of the core team leading the process, as well as all of the healthcare related workgroups: Information & Referral Workgroup, Obesity and Nutrition Workgroup, Cardiovascular Workgroup and Access to Mental Health and Substance Abuse Services Workgroup.
Number of Hospital Faciltiy - 1 Part V, Line 5c - Description of Making Needs Assessment Widely Available A community presentation highlighting the results of the study was held April 13, 2011 at McHenry County College. The meeting was open to the public.
Number of Hospital Faciltiy - 1 Part V, Line 4 - List Other Hospital Facilities that Jointly Conducted Needs Assessment The 2010 McHenry County Healthy Community Study was led and directed by representatives from 19 partner organizations who served as steering committee members. Those organizations were:Centegra Health System, Advocate Good Shepherd Hospital, League of United Latin Amer. Citizens, McHenry County Mental Health Board, Crystal Lake Chamber of Commerce, Pioneer Center, Environmental Defenders, Sherman Hospital, 1st Congregational Church of Crystal Lake, Senior Services Associates Inc., Leadership Greater McHenry County, United Way of Greater McHenry County, McHenry County College, Woodstock Christian Life (Hearthstone), McHenry County Community Foundation, Woodstock Community Unit School District 200, McHenry County Conservation District, Village of Prairie Grove, and the McHenry County Department of Health.The Core Team included Centegra Health System, Advocate Good Shepherd Hospital, McHenry County Community Foundation, McHenry County Department of Health and United Way of Greater McHenry County.
Number of Hospital Faciltiy - 1 Part V, Line 3 - Account Input from Person Who Represent the Community Input from representatives of the community served by the hospital facility was received through three main types of input:HOUSEHOLD SURVEY. Description of community issues and problems based on a random sample of McHenry County households. Surveys were sent to 8,000, one in thirteen households, proportional to zip codes within the county.FOCUS GROUPS. Discussions with small groups of persons who represent target populations likely to use or need health and human services. Discussion topics addressed positive and negative aspects of living in McHenry County, needed services, service gaps and barriers, and experiences with local agencies.The eleven focus groups as identified by the Steering Committee reflect similar groups included in 2006. The 2010 focus groups were: at risk youth, homeless persons, Latino adults, low income adults, parents of children/youth with mental illness, persons with a developmental disability, persons with mental illness, seniors, unemployed and dislocated workers, veterans, and young adults ages 18-24.KEY INFORMANTS. Interviews with 34 community leaders, agency directors, and other persons considered experts in their field based on professional expertise, knowledge of local human services system, or position of influence. These interviewees include:Pam Althoff (Illinois State Senator), Sandy Lewis (McHenry County Mental Health Board), David Barber (United Way of Greater McHenry County), Carol Louise (Family Alliance), Kay Bates (McHenry County Chamber of Commerce), Richard Mack (Metra), Cort Carlson (McHenry County Convention & Visitors Bureau), Carl Martens (McHenry County Workforce Investment Board), Julie Biel Claussen (Corporation for Affordable Homes of McHenry County (CAHMCO)), Patrick McNulty and Andy Andresky (McHenry County Department of Health), Michael Eesley (Centegra Health System), Mary Miller (McHenry County College Trustees), Pedro Enriquez (Illinois Migrant Council), Keith Nygren (McHenry County Sheriffs Department), Jane Farmer (Turning Point), Jason Osborn (McHenry County Department of Transportation), Dr. Bud Friend-Jones (Faith Bridge-First Congregational Church of Crystal Lake), Sandy Oslance (Algonquin/Lake in the Hills Chamber of Commerce), Suzanne Hoban (Family Health Partnership Clinic),Maggie Rivera (League of United Latin American Citizens (LULAC)), Mike Iwanicki (Veterans Assistance), John Rung (Northwest Herald), Catherine Jones (McHenry County College-SHAH Center), Dennis Sandquist (McHenry County Planning and Development 48), Patrick Kerin (McHenry County Pride), Mary Lu Seidel (Corporation for Affordable Homes of McHenry County (CAHMCO)), Elizabeth Kessler (McHenry County Conservation District), Astrid Larsen (McHenry County Crisis Line), Cindy Sullivan (Options and Advocacy), Brian Shahinian (Northern Illinois Special Recreation Association (NISRA)), Mike Tryon (Illinois State Representative), Joe Small and Jo Williams (McHenry County Community Foundation), Dan Volkers (McHenry County Farm Bureau), and Joe Williams (Regional Office of Education)
  Part III, Line 9b - Provisions On Collection Practices For Qualified Patients If a patient qualifies for a 100% charity/financial assistance discount, collection of the account is not pursued as a bad debt. The account is written off in full at the time of the decision. If a patient receives a partial discount for Financial Assistance, any remaining balances will be treated in accordance with the Financial Policy regarding self pay balances and may be offered a payment plan option. The payment plan is in installments ($25 minimum), with the first payment due at discharge. Payment plans are not to exceed 36 months without documentation or verbal communication of ability to pay. Documentation may include a completed financial statement. Patients who have not completed arrangements for one of the payment options within 120 days of the billing date will be automatically turned over to a collection agency. Patients with delinquent payments, 15 or more days late, will be turned over to a collection agency. After insurance processing, patients who have not made payments or enrolled in one of the payment options for co-insurance and deductible amounts within 120 days of insurance payment will be turned over to a collection agency. As an exception, the Director of Patient Financial Services may review and recommend further discounts. No interest charges will accrue on account balances in which payments are being made.
  Part III, Line 8 - Explanation Of Shortfall As Community Benefit The amount shown in line 6 represents the actual costs incurred to treat Medicare patients and is calculated by applying the Medicare cost-to-charge ratio. Therefore, the entire amount of line 7 constitutes a community benefit.
  Part III, Line 4 - Bad Debt Expense The footnote discussing the organizations bad debt expense is on page 16 and 17 of the attached audited statements.
  Part III, Line 3 - Methodology of Estimated Amount & Rationale for Including in Community Benefit The estimated amount of bad debt expense (at cost) which could be reasonably attributable to patients who would likely qualify for financial assistance under the organizations charity care policy if sufficient information had been available to make a determination of their eligibility was based on the self pay patient accounts which were written off as bad debts. These amounts were then multiplied by the cost to charge ratio. Any payments received during the fiscal year on these accounts were deducted from the cost.
  Part III, Line 2 - Methodology Used To Estimate Bad Debt Expense The organization uses an analysis based on history of the type of payer and the days outstanding of the receivable to determine an estimate of the amount that will be uncollectible.
Schedule H (Form 990) 2012
Additional Data


Software ID: 12000229
Software Version: 2012v2.0
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
Memorial Medical Center
 
Employer identification number

36-2179764
Part I
Questions Regarding Compensation
Yes
No
1a
Check the appropiate box(es) if the organization provided any of the following to or for a person listed in Form
990, Part VII, Section A, line 1a. Complete Part III to provide any relevant information regarding these items.
b
If any of the boxes in line 1a are checked, did the organization follow a written policy regarding payment or reimbursement or provision of all of the expenses described above? If "No," complete Part III to explain....
1b
 
 
2
Did the organization require substantiation prior to reimbursing or allowing expenses incurred by all officers,
directors, trustees, and the CEO/Executive Director, regarding the items checked in line 1a? .......
2
 
 
3
Indicate which, if any, of the following the filing organization used to establish the compensation of the
organization's CEO/Executive Director. Check all that apply. Do not check any boxes for methods
used by a related organization to establish compensation of the CEO/Executive Director, but explain in Part III.
4
During the year, did any person listed in Form 990, Part VII, Section A, line 1a with respect to the filing organization or a related organization:
a
Receive a severance payment or change-of-control payment? ................
4a
 
No
b
Participate in, or receive payment from, a supplemental nonqualified retirement plan? .........
4b
Yes
 
c
Participate in, or receive payment from, an equity-based compensation arrangement? .........
4c
 
No
If "Yes" to any of lines 4a-c, list the persons and provide the applicable amounts for each item in Part III.
Only 501(c)(3) and 501(c)(4) organizations only must complete lines 5-9.
5
For persons listed in Form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the revenues of:
a
The organization? ...........................
5a
 
No
b
Any related organization? .........................
5b
 
No
If "Yes," to line 5a or 5b, describe in Part III.
6
For persons listed in Form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the net earnings of:
a
The organization? ...........................
6a
 
No
b
Any related organization? .........................
6b
 
No
If "Yes," to line 6a or 6b, describe in Part III.
7
For persons listed in Form 990, Part VII, Section A, line 1a, did the organization provide any non-fixed
payments not described in lines 5 and 6? If "Yes," describe in Part III ............
7
 
No
8
Were any amounts reported in Form 990, Part VII, paid or accured pursuant to a contract that was
subject to the initial contract exception described in Regulations section 53.4958-4(a)(3)? If "Yes," describe
in Part III .............................
8
 
No
9
If "Yes" to line 8, did the organization also follow the rebuttable presumption procedure described in Regulations section 53.4958-6(c)? .........................
9
 
No
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)Zbigniew LorencVice President (i)
(ii)		  
249,763 		 
48,001 		 
3,406 		 
14,700 		 
9,589 		 
325,459 		 
 
(2)Susan MilfordSenior VP (i)
(ii)		  
223,295 		 
63,642 		 
  		 
66,549 		 
23,170 		 
376,656 		 
5,506
(3)Suellen D Aus-Der-AuPharmacist (i)
(ii)		 140,493
  		 
  		 
  		 
  		19,665
  		160,158
  		 
 
(4)Sheila SennVice President (i)
(ii)		 133,314
  		16,824
  		 
  		9,492
  		22,762
  		182,392
  		 
 
(5)Robin K PurdyVice President (i)
(ii)		  
271,332 		 
28,862 		 
  		 
14,700 		 
16,087 		 
330,981 		 
 
(6)Robert RosenbergerSr. VP & CFO (i)
(ii)		  
469,516 		 
122,154 		 
35,636 		 
15,893 		 
23,505 		 
666,704 		 
19,889
(7)Rachel SebastianVice President (i)
(ii)		  
243,577 		 
37,150 		 
  		 
17,520 		 
23,250 		 
321,497 		 
 
(8)Pasquale BernardiVice President (i)
(ii)		  
322,584 		 
60,820 		 
  		 
  		 
23,129 		 
406,533 		 
 
(9)Neil MurphySenior VP, CNO (i)
(ii)		  
225,156 		 
59,634 		 
  		 
  		 
5,394 		 
290,184 		 
 
(10)Michael S EesleyCEO (i)
(ii)		  
822,323 		 
451,843 		 
3,564 		 
435,234 		 
11,677 		 
1,724,641 		 
261,678
(11)Mattias CarlenVice President (i)
(ii)		  
124,601 		 
6,200 		 
  		 
  		 
25,775 		 
156,576 		 
 
(12)Matthew TowlerVice President (i)
(ii)		  
193,312 		 
35,778 		 
  		 
  		 
22,461 		 
251,551 		 
 
(13)Kumar NathanVice President (i)
(ii)		  
213,992 		 
10,431 		 
  		 
13,925 		 
17,913 		 
256,261 		 
 
(14)Jason SciarroPresident & COO (i)
(ii)		  
564,364 		 
156,422 		 
3,928 		 
73,224 		 
23,574 		 
821,512 		 
19,515
(15)Gail RudolphVice President (i)
(ii)		  
178,816 		 
  		 
  		 
5,056 		 
16,541 		 
200,413 		 
 
(16)David TomlinsonSenior VP, CIO (i)
(ii)		  
276,560 		 
55,165 		 
  		 
14,700 		 
23,418 		 
369,843 		 
 
(17)Christopher WesterkampVice President (i)
(ii)		  
162,609 		 
14,670 		 
  		 
4,786 		 
1,498 		 
183,563 		 
 
(18)Bernadette SzczepanskiVice President (i)
(ii)		  
194,954 		 
24,957 		 
  		 
13,327 		 
5,636 		 
238,874 		 
 
(19)Barbara JohnsonSenior VP (i)
(ii)		  
312,899 		 
56,261 		 
  		 
9,966 		 
10,762 		 
389,888 		 
56,261
(20)Anthony K LeungPharmacist (i)
(ii)		 127,843
  		 
  		 
  		 
  		24,718
  		152,561
  		 
 
(21)Aaron ShepleySr VP/CQO Couns (i)
(ii)		  
333,458 		 
95,430 		 
  		 
52,000 		 
23,450 		 
504,338 		 
14,724
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
Schedule J (Form 990) 2012

Additional Data


Software ID: 12000229
Software Version: 2012v2.0
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
Memorial Medical Center
 
Employer identification number

36-2179764
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) Rachel Sebastian Family Membe 321,497 Employee   No
(2) Carey Electric Director 488,932 Electrical Contractor   No
(3) American Community Bank Chairman 106,282 Certificate of Deposit   No
(4) American Community Bank Director 106,282 Certificate of Deposit   No
(5) Home State Bank Director 100,000 Certificate of Deposit   No
(6) Home State Bank Treasurer 100,000 Certificate of Deposit   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
    All business transactions with interested persons are arms length transactions, see Conflict of Interest disclosure for Form 990, Part VI, Line 2.
Schedule L (Form 990 or 990-EZ) 2012

Additional Data


Software ID: 12000229
Software Version: 2012v2.0




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
Memorial Medical Center
 
Employer identification number

36-2179764
Identifier Return Reference Explanation
  Form 990, Part VI, Line 12c 1. In connection with any actual or possible conflicts of interest, an interested person or other person subject to this policy must disclose the existence and nature of his or her financial interest in writing to the President of Centegra or the Chief Corporate Responsibility Officer or designee, who shall provide such written disclosure to the Governors Affairs Committee of Centegra, which shall consider all conflicts of interest issues and, if appropriate, to the directors and members of committees with board-delegated powers considering the proposed transaction or arrangement. The disclosure must occur, at minimum, annually, with a Conflict of Interest Disclosure Statement being submitted no later than January 31 st of each year. Copies of disclosure statements filed by Board members shall be distributed to the Board annually at the February Board meeting. 2. When a conflict of interest is disclosed at meeting of the board or committee thereof, after disclosure of the financial interest, the interested person shall leave the board or committee meeting while the financial interest is discussed and voted upon. The remaining board or committee members shall decide if a conflict of interest exists. The interested person's leaving such meeting shall not affect whether a quorum exists at such meeting. 3. Procedures for Addressing the Transaction or Arrangement From Which the Conflict Arose. The chairperson of the board or committee shall, if appropriate, appoint a disinterested person or committee to investigate alternatives to the proposed transaction or arrangement. After exercising due diligence, the board or committee shall determine whether Centegra can obtain a more advantageous transaction or arrangement with reasonable efforts from a person or entity that would not give rise to a conflict of interest. If a more advantageous transaction or arrangement is not reasonably attainable under circumstances that would not give rise to a conflict of interest, the board or committee shall determine by a majority vote of the disinterested directors whether the transaction or arrangement is in Centegra's best interest and for its own benefit and whether the transaction is fair and reasonable to Centegra and shall make its decision as to whether to enter into the transaction or arrangement in conformity with such determination. 4. Violations of the Conflicts of Interest Policy: If the administration, the board, or a committee has a reasonable cause to believe that a member has failed to disclose actual or possible conflicts of interest, it shall inform the member of the basis for such belief and afford the member an opportunity to explain the alleged failure to disclose. If, after hearing the response of the member and making such further investigation as may be warranted in the circumstances, the board or committee determines that the member has, in fact, failed to disclose an actual or possible conflict of interest, it shall refer the matter to the Governors Affairs Committee for consideration, which shall subsequently recommend appropriate disciplinary and corrective action to such board or committee. 5. The minutes of the board and all committees with board-delegated powers shall contain the names of the persons who disclosed or otherwise were found to have a financial interest in connection with an actual or possible conflict of interest, the nature of the financial interest, any action taken to determine whether a conflict of interest was present, and the board's or committee's decision as to whether a conflict of interest, in fact, existed. The names of the persons who were present for discussions and votes relating to the transaction or arrangement, the content of the discussion, including any alternatives to the proposed transaction or arrangement, and a record of any votes taken in connection therewith. Continued below.
  Form 990, Part IV, Line 24 Memorial Medical Center holds a liability on its books for tax-exempt bonds, which is an allocation from its sole corporate member, Centegra Health System. As a result, the question was answered no, and Shedule K will be completed ib Centegra Health System's Form 990.
  Form 990, Part III, Line 4a Con't What's Aphasia? is a group for stroke survivors and family members who have an impairment of their ability to speak or comprehend words; Wingspan is a group that provides the opportunity for open discussions, question and answer sessions, lectures, and social events for people recovering from strokes as well as their families; Y-Me Breast Cancer Support Program is a national program designed to let participants listen to physicians, survivors, social workers, and nurses who have been invited to speak on topics such as handling anger, considered prostheses, and recent concerns about breast implant risks. Memorial Medical Center participates in various community projects such as Meals on Wheels, Immunization Clinics, National Depression/Anxiety Screening Day, and county and business health fairs in order to promote health and awareness in the community. Memorial Medical Center also sponsors shadowing opportunities for area students. The Medical Center provides free blood pressure, skin cancer, colorectal cancer, glaucoma, hearing and other screenings and displays for health fairs, trade shows and county fairs; as well as lipid and mammogram screenings and free flu shots. The Medical Center also distributes thousands of informational brochures, service listings, and flyers at the request of area schools, churches, and organizations on an ongoing basis. Centegra S.H.I.P. (Senior Health Insurance Program) provides trained volunteers on a weekly basis to answer questions regarding insurance coverage. Silver Key Club is the senior citizens group for Centegra Health System. It is a free membership group for people 55 years of age and older, which provides: four issues of a senior newsletter each year, a health diary for members to list their medications and health history, and a discount in the hospital cafeterias at both MMC and NIMC. At certain times of the year, there are discounted screenings and/or special services available for members. Community education is also made available to Silver Key members through early bird reservations, or through general news releases. Memorial Medical Center, in conjunction with Centegra Health System and Northern Illinois Medical Center, works in cooperation with McHenry County College and Health Bridge Fitness Center to provide a complete series of specialized training for those interested in developing their knowledge of emergency basics, or in pursuing a career in the emergency health care field. Local fire and police departments use these programs extensively.
  Form 990, Part III, Line 4a Con't Together with the American Cancer Society, Gavers Community Cancer Foundation, Sage Cancer Center, and McHenry County College, Centegra Health System sponsors Cancer Awareness Programs including Skin Cancer Screening, Colorectal Cancer Screening, Cancer Survivors Day, Breast Cancer, and Prostate Cancer: Early Detection & Treatment Programs. "Once and For All" Quit Smoking Clinic approaches quitting smoking with wellness in mind. The Medical Center sponsors several programs specializing in issues of concern for women as well as reduced fee mammograms. Making Peace with Your Body is a program to teach women body acceptance with an emphasis on what you can realistically change with diet and exercise. Additional behavioral health programs include: depression and anxiety screenings, What To Do When Your Loved One Is Depressed, Relationship Addiction, Step Families: Steps to Harmonious Living, and Mind/Body Medicine: An Introduction. Other programs include a Critical Care Class, You're In Control Diabetic Education Program, Men and Depression and a variety of ophthalmology programs. Still more educational programs are offered to assist members of the community in taking charge of the special needs in their lives, in their changing lifestyles for healthier lives, as well as programs to inform the community about Advance Medical Directives including living wills, durable power of attorney issues and organ donations and Understanding Medicare. Eye programs may include: Refractive Surgery-correcting your vision with surgery, Understanding Childhood Eye Diseases, Diabetes And Your Eyes, and glaucoma education programs. Memorial Medical Center, in conjunction with Centegra Health System, Northern Illinois Medical Center, and Health Bridge Fitness Center, offers specialized exercise programs that help participants get moving and stay active for a healthier lifestyle. These include: Low Back Water Class, Basketball League, Racquetball League, Arthritis Water Exercise Class, Seniors in Motion, Senior Citizen's Exercise Group, The Get Off Your Rocker Program designed for individuals at least 55 years of age to improve flexibility, strength, and endurance; and the Stroke Exercise Program which is a general physical conditioning exercise program for stroke patients to improve coordination and increase range of motion. Yoga, Tai Chi, relaxation management, weight management, and a variety of other classes are offered through Health Bridge Fitness Center. Together We Can Immunization Partnership Clinics were instituted at Memorial Medical Center, Northern Illinois Medical Center and other medical office buildings to provide immunizations for the unvaccinated children (under age 18) of McHenry County. Clinics are held once per month at both medical centers providing Hepatitis B, DTP, Hib, OPV, MMR, and TB immunizations. Fees are based upon ability to pay with a maximum charge of $15.00 per immunization. The Rehabilitation and Sports Medicine Clinic at Health Bridge Fitness Center provides sports medicine, aquatics, outpatient physical and occupational therapy programs. The Back to Work Program, an industrial injury prevention and rehabilitation program provides physical therapy, ergonomic consultation and back safety programs. The program also uses the aquatic pool located at the Rehabilitation and Sports Medicine Clinic at the Health Bridge Fitness Center.
  Form 990, Part III, Line 4a Con't The Centegra Pain Management Center specializes in providing advanced, innovative treatments that succeed in relieving most types of pain. The physicians, pain psychologist, nurses, and staff are specially trained and experienced in the field of pain management. Educational materials on chronic pain were developed and made available to the community at trade/health fairs. Centegra Health System is a learning center (clinical site) for students from a multitude of colleges and universities. Students have completed internships in programs such as nurse practitioner, nursing, nurse aide, physician assistant, social work, speech therapy, phlebotomy, diagnostic medical sonography, medical imaging, medical records, pharmacy, medical physics, surgical technology, professional counselor, substance abuse counselor, and medical assistant. Centegra Health System is also a learning site for 3rd and 4th year medical students from the University of Illinois at Rockford.
  Form 990, Part III, Line 4a Con't Memorial Medical Center offers a variety of classes that can help people save lives. By sponsoring these classes, the Medical Center is helping the community in two ways; first, by building skills and confidence levels of the class participants; and second, by making trained help available for the community in case of emergencies. There are three levels of training available. The First Responder is designed to instruct laymen in the following skills: identifying the emergency situation, stabilizing the victim, and providing basic emergency care until emergency medical personnel arrive. The Emergency Medical Technician - Basic provides a more in-depth study of the recognition and management of victims of traumatic injuries or medical emergencies, and includes hospital clinical experience. This course enables the participant to become a State of Illinois licensed EMT-Basic. The Emergency Medical Technician - Paramedic program provides an intensive learning experience in the use of advanced life support procedures for the management of traumatic injuries and medical emergencies prior to the arrival at the hospital. This course enables the participant to become a State of Illinois licensed Paramedic. An Emergency Medical Dispatcher Course, designed to prepare individuals for employment as dispatchers for a public service agency providing dispatch to law enforcement, fire service, and or Emergency Medical Service, is also offered. Memorial Medical Center, in conjunction with Centegra Health System and Northern Illinois Medical Center, makes available a variety of educational programs designed to promote the wellness of all members of the community. Although many of these programs are offered for a nominal fee to help defray costs, this fee may be waived if the participant does not possess the ability to pay. Memorial Medical Center offers a variety of classes that can help people save lives. The Medical Center offers American Red Cross first aid classes that include First Aid/CPR and a CPR Instructor Course. Cardiopulmonary resuscitation (CPR) classes help community members learn CPR prior to certification or brush up on skills for re-certification. The Medical Center also provided International Trauma Life Support training, Advanced Cardiac Life Support training, and Pediatric Advanced Life Support training. The American Heart Association has recognized Centegra Health System as one of the top ten A.H.A. training sites in the Chicago Metro area. Family health and wellness programs presented by the Medical Center are designed to promote a healthier community. Emergency Room Treatment Forms are available for parent/guardian permission to administer emergency treatment to minors in their absence. Supersitters is a class which teaches the responsibilities of being a babysitter and includes basic first aid and accident prevention, as well as the importance of tender loving care. The Medical Center offers education classes for expectant families including prenatal, grandparents and cesarean birth as well as sibling classes and low rent pagers. At discharge, all new parents are presented with the video, "Baby's First Months: What Do We Do Now". The Medical Center provides various classes to assist with our busy life styles. Relaxation Training teaches techniques to bring the mind and body in balance. Nutrition related offerings include Food and Feelings, Healthy Heart Nutrition and a Weight Management program. Cholesterol Commitment and Improving Your Blood Pressure are programs that assist participants in recognizing the factors that affect your blood pressure, early warning signs of heart attack and offer tips for better control as well as the importance of early intervention. Lipid screening is offered twice each year.
  Form 990, Part III, Line 4a Con't Each of the following ongoing support groups is held at the Medical Center or in the community and is free of charge. By supporting these groups the Medical Center is able to provide one or all of the following three things: 1.) Staff who either act as facilitators of the group or function as "Guest Speakers". 2.) Space offered free of charge. 3.) Free marketing to educate the community about these services. Support groups include: Alcoholics Anonymous is a twelve-step program for individuals recovering from alcohol dependence; Al-Anon is a twelve-step program for codependent individuals; Arthritis Support Group meets the first Tuesday of every month for individuals with arthritis; Bariatric Support Group is for individuals who have had weight loss surgery; Better Breathers Club is for those individuals with pulmonary disease and their families; Caregivers Support Group is for those who are caring for someone with a chronic or life threatening illness; Diabetes Support Group is for individuals with diabetes and their families; Epilepsy Support Group is for parents of children with epilepsy; Families Anonymous is a support group for family members of chemically dependent people; Fibromyalgia Support Group is for those suffering from Fibromyalgia; Get Help Live Longer is a smoking cessation education and support group; Hat's Off is a group for women diagnosed with any type of cancer meeting every month; Headwinds is a support group offered to survivors of traumatic brain injury and their family members and caregivers. This group hosts speakers including medical professionals who specialize in traumatic brain injuries. The Medical Center participates in conjunction with the Pioneer Center. Participants receive information on topics such as dealing with behavioral problems and the financial issues of long-term care; Infertility Support Group is a group for couples or individuals experiencing infertility problems; Living with Grief, sponsored by Centegra pastoral care, offers support for adults grieving the loss of a loved one; Looking Beyond is for people diagnosed with cancer, their family members, and friends; Make Today Count is a group for anyone with a life-threatening illness as well as their family and friends. The purpose of the program is to help members cope and gain emotional strength. The Group also puts participants in touch with professional resources available to help them; McHenry County Crisis Line for 24-hour mental health information, referral service, and crisis assistance; Multiple Sclerosis (MS) Support Group is under the greater Illinois Chapter of the National Multiple Sclerosis Society. The group is open to persons with MS, their family members and others interested in treatment and management of the disease. Specialists are often invited to speak to the group regarding the symptoms of the disease; Narcotics Anonymous is a twelve-step support program for those recovering from narcotic dependence; Nuts and Bolts is a unique support group for stroke survivors who are 55 years of age or younger. The emphasis of this group is on assisting the families as they adapt to the special lifestyle changes of the young stroke survivor. The group has earned attention from the National Stroke Conference leaders, as it is one of the first support groups of its type; Perinatal Grief Support Group is for anyone who has experienced the loss of a newborn or infant through miscarriage, ectopic pregnancy or sudden infant death syndrome; St. Peregrine's Cancer Support Group is a non-denominational support group for patients and their family and friends;
  Form 990, Part III, Line 4a The primary mission of Memorial Medical Center is to provide quality health care services with innovative and responsible use of resources and promote wellness for the greater McHenry County area. Memorial Medical Center uses a holistic approach to providing health care services with honesty and integrity, an attitude of respect and caring, teamwork and education throughout its organization and the community. It is the Medical Center's objective to serve the community with respect to providing health care services and education. The Medical Center provides quality health care regardless of race, creed, sex, national origin, handicap, age or ability to pay. Although reimbursement for services rendered is critical to the operation and stability of Memorial Medical Center, it is recognized that not all individuals possess the ability to purchase essential medical services. Therefore, in keeping with the Medical Center's commitment to serve all members of its community, free care and/or subsidized care will be considered where the need and/or an individual's inability to pay exist. Medical services are provided in a dignified manner to Medicare, Medicaid and indigent patients. Memorial Medical Center is affiliated with Northern Illinois Medical Center through their common parent, Centegra Health System. Memorial Medical Center's services include, but are not limited to 170 licensed-bed acute care medical center (29,879 patient days in fiscal year 2013), Level II Trauma Center, Emergency Medicine and Physicians, 24-hours a day, On-site heliport, Surgery and Ambulatory Treatment Services, Intensive and Intermediate Care Unit, Respiratory Therapy, Physical Medicine and Rehab, Obstetrics, including Level II Nursery facility, Pediatrics, Full-body CT Scanner and Magnetic Resonance Imaging (MRI), Mammography screening at two sites, Extended Care Unit, Behavioral Health Unit: Adult, and Chemical Dependency/Detox Programs, Sleep Disorders Center, First Step Substance Abuse Center: 800-675-8448, TDD for the hearing impaired: 815-338-0008, Poison Control Hotline: 815-338-5975, McHenry County Crisis Line: 800-892-8900, Pharmacy Information Line: 815-338-9090, Associate Health Program: 815-334-3944, Pastoral Care, Social Services, Community Education Programs, Support Programs. Recognizing its mission to enhance the health of the community, services are provided to Medicare, Medicaid and indigent patients. The Medical Center may partially recognize these amounts as charity care. Charity Care includes care provided to persons covered by governmental programs at below cost, as well as health activities and programs to support the community. These activities include wellness programs, community education programs, and special programs for the elderly, handicapped, mentally under served, and a variety of broad community support activities. The unreimbursed value of providing charity care was approximately $35,032,712 in fiscal year 2013. During that year, the Medical Center provided in excess of 29,879 inpatient days of service, which included over 13,984 days of Medicare inpatient service. The Medical Center is cognizant of the significant need for high quality, yet cost effective health care services. The Medical Center recognizes the ongoing need to be good stewards of Medicare and Medicaid dollars. As such, the Medical Center has implemented Service Excellence programs designed to reduce health care costs while maintaining high quality standards. Memorial Medical Center believes in a holistic approach to health care that embraces the physical, psychological, spiritual, social and economic needs of the entire public served. In order to provide this care, Memorial Medical Center supports a variety of services, educational programs and support groups. Memorial Medical Center, in conjunction with Centegra Health System and Northern Illinois Medical Center, sponsors or hosts many support groups for its patients as well as the community.
Form 990, Part XI, Line 9 Other Changes In Net Assets Or Fund Balances - Other Increases Interest in Foundation (non-capital, temp restricted) = $156042
Form 990, Part XI, Line 9 Other Changes In Net Assets Or Fund Balances - Other Decreases Extraordinary Loss on GE = -$482450
Form 990, Part XI, Line 9 Other Changes In Net Assets Or Fund Balances - Other Increases Change in Fair Value of Derivative = $57871
Form 990, Part XI, Line 9 Other Changes In Net Assets Or Fund Balances - Other Increases Capital Grant from Foundation = $2275
Form 990, Part VI, Line 19 Form 990, Part VI, Line 19: Other Organization Documents Publicly Available All documents are available upon request.
Form 990, Part VI, Line 15b Form 990, Part VI, Line 15b: Compensation Review and Approval Process for Officers and Key Employees The Board of Directors of Centegra Health System, through the Compensation Committee comprised of independent members free of conflict, reviewed executive compensation levels and other features of the compensation plan in accordance with the organization's approved compensation philosophy and strategy: The Committee is comprised of members of the Board of Directors, who are independent of Centegra management, have no personal interest in the compensation arrangements, are not related to, or under the control of any individual whose compensation arrangement is being reviewed and have no material business relationship with Centegra.The Chief Executive Officer's compensation is determined by the Compensation Committee in relation to appropriate comparability data. Compensation for other members of the executive staff are developed by the CEO, reviewed by the Committee, evaluated against market data, and approved by the Committee. The Committee approves all compensation decisions in advance of their implementation and documents its determinations and discussions. Its decisions and deliberations are thoroughly documented and meeting minutes are kept and distributed to the Committee members (for historical reference). The Compensation Committee uses a number of external resources and comparisons, and their review includes total compensation (cash compensation, plus benefits provided by Centegra) in relation to organizational performance and prevailing industry practices of comparably-sized organizations. They have engaged the services of a compensation consulting firm (Sullivan Cotter) specializing in the not-for-profit sector that has worked with Centegra and reports directly to the Compensation Committee.
Form 990, Part VI, Line 12c Form 990, Part VI, Line 12c: Explanation of Monitoring and Enforcement of Conflicts Continued from above. 6. A voting member of any committee whose jurisdiction includes compensation matters and who receives compensation, directly or indirectly, from Centegra for services is precluded from voting on matters pertaining to that member's compensation, Physicians who receive compensation, directly or indirectly, from Centegra, whether as employees or independent contractors, are precluded from membership on any committee whose jurisdiction includes compensation matters and in which such physician may have a direct or indirect interest. 7. Each director, principal officer, and member of a committee with board-delegated powers shall annually sign a statement which affirms that such person has received a copy of the conflicts of interest policy; has read and understands the policy; has agreed to comply with the policy; and understands that Centegra 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. 8. To ensure that Centegra operates in a manner consistent with its charitable purposes and that it does not engage in activities that could jeopardize its status as an organization exempt from federal income tax, periodic reviews shall be conducted by the Governors Affairs Committee of Centegra. The periodic reviews shall, at a minimum, include the following subjects: Whether acquisition of physician practices and other provider services result in inurement or impermissible private benefit. Whether partnership and joint venture arrangements and arrangements with management service organizations and physician hospital organizations conform to written policies, are properly recorded, reflect reasonable payment for goods and services, further Centegra's charitable purposes and do not result in inurement or impermissible private benefit. Whether agreements to provide healthcare and agreements with other healthcare providers, employees, and third party payors further Centegra's charitable purposes and do not result in inurement or impermissible private benefit. Whether business transactions on behalf of Centegra or an entity controlled by it are the result of arms-length dealing and are no less advantageous than competitively available goods and services of like grade and quality. 9.In conducting the periodic reviews provided for in Article VII, Centegra may, but need not, use outside advisors. If outside experts are used, their use shall not relieve the board of its responsibility for ensuring that periodic reviews are conducted.
Form 990, Part VI, Line 11b Form 990, Part VI, Line 11b: Form 990 Review Process The review process for the 990 include compilation by internal staff, detailed review by an outside auditor, bond counsel, the Controller and Chief Financial Officer, prior to submission to the IRS. The tax return will be made available for the Board to review after submission to the IRS.
Form 990, Part VI, Line 6 Form 990, Part VI, Line 6: Explanation of Classes of Members or Shareholder Centegra Health System is the sole member of MMC. Centegra Health System has a single class of members.
Form 990, Part VI, Line 3 Form 990, Part VI, Line 3: Description of Delegated Duties to Management Company Management companies were used for the daily operations and management of the following services for the health system. Sodexho was used for Food & Nutrition, Plant Operations and Maintenance, and Environmental Services work. Dell Marketing LP was used for the management of the Information Systems area. Professional Business Consultants is used for the management of the Managed Care department. Hearthstone Management Services was used for daily operations of the Skilled Nursing Facility. These companies were responsible for staffing decisions, personnel supervision, and financial planning. None of the organization's current of former officers, directors, trustees, key employees or highest compensated employees were compensated by the management companies during the calendar year 2012.
Form 990, Part VI, Line 2 Form 990, Part VI, Line 2: Description of Business or Family Relationship of Officers, Directors, Et Memorial Medical Center, (MMC), adopted specific conflict of interest policies for its governing and management staff. The policy includes, but is not limited to, when an individual, governor, committee member, officer, agent or employee believes that he or she, or member of his or her immediate family might have or does have a real or apparent conflict, he or she should in addition to filing the disclosure notice required, abstain from making motions, voting, executing agreements, or taking any other similar direct action on behalf of MMC. Not with standing, it is realized that both real and apparent conflicts of interest sometimes naturally occur in the course of conducting daily affairs. Conflicts occur because the many persons associated with MMC should be expected to have, and do in fact generally have multiple interests and affiliations, and various positions of responsibility with the community. The long-range interests of MMC do not require the termination of an association with persons who have real or apparent conflicts, if an effective method can render such conflicts harmless to all concerned. During fiscal year 2013, MMC purchased certain goods and/or services from organizations with director's affiliation. All transactions were competitively bid and conducted at arms length. The fees paid were at fair market value. Rachel Sebastian, Vice President, is the daughter of Michael Eesley, CEO. Director Kathy Powell is an employee and vice president of Home State Bank. Treasurer Patrick Morehead is on the Board of Directors and a 2% owner of Home State Bank. Chairman Charie Zanck is CEO and Vice Chairman of American Community Bank & Trust. Director Charles Ruth is the Board Chairman of American Community Bank & Trust. Director Tom Carey is the Vice President and Majority Owner of Carey Electric.
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: 12000229
Software Version: 2012v2.0
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
Memorial Medical Center
 
Employer identification number

36-2179764
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) Centegra Insurance Services LTD
PO Box 1051
Grand Cayman   KY1-1102
CJ
Malpractice Insurance Provider CJ     Centegra Health System
 
(2) Centegra Health & Wellness Network LLC
385 Millennium Drive
Crystal Lake,IL60012
36-4740459 		Clinically Integrated Healthcare Network IL     Centegra Health System
 
(3) Centegra Clinical Laboratories LLC
385 Millennium Drive
Crystal Lake,IL60012
36-4706465 		Laboratory and pathology services DE     N/A
(4) Centegra Primary Care LLC
385 Millennium Drive
Crystal Lake,IL60012
36-4085398 		Physician Practice IL     Centegra Health System
 
(5) Centegra Health Bridge Fitness Center
385 Millennium Drive
Crystal Lake,IL60012
26-1277524 		Health & Fitness Center IL     Health Bridge Corporation
 


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) Centegra Hospital-Huntley

10400 Haligus Road

Huntley,IL60142
45-3449737 		Hospital Operations IL 501(c)(3) 3 Centegra Health System
 
 
No
(2) Oak Creek Lodge

385 Millennium Drive

Crystal Lake,IL60012
36-3591359 		Hospital Operations IL 501(c)(3) 3 Centegra Health System
 
 
No
(3) Health Bridge Corporation

385 Millennium Drive

Crystal Lake,IL60012
36-3196550 		Health & Fitness Center IL 501(c)(3) 11c Centegra Health System
 
 
No
(4) NIMED Corporation

385 Millennium Drive

Crystal Lake,IL60012
36-3119911 		Property Management IL 501(c)(3) 11c Centegra Health System
 
 
No
(5) Centegra Health System Foundation

385 Millennium Drive

Crystal Lake,IL60012
36-3723610 		Fundraising for Medical Centers IL 501(c)(3) 11a Centegra Health System
 
 
No
(6) Northern Illinois Medical Center

4201 Medical Center Drive

McHenry,IL60050
36-2338884 		Hospital Operations IL 501(c)(3) 3 Centegra Health System
 
 
No
(7) Centegra Health System

385 Millennium Drive

Crystal Lake,IL60012
36-3196559 		Hospital Operations Support IL 501(c)(3) 11c N/A
 
No
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50135Y
Schedule R (Form 990) 2012
Schedule R (Form 990) 2012
Page 2
Part III
Identification of Related Organizations Taxable as a Partnership (Complete if the organization answered "Yes" to Form 990, Part IV, line 34 because it had one or more related organizations treated as a partnership during the tax year.)
(a)
Name, address, and EIN of
related organization



 		(b)
Primary activity




 		(c)
Legal
domicile
(state or foreign
country)


 		(d)
Direct controlling
entity



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

(f)
Share of total income




 		(g)
Share of end-of-year
assets



 		(h)
Disproprtionate allocations?




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



 		(k)
Percentage
ownership
Yes No Yes No












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

385 Millennium Drive
Crystal Lake,IL60012
36-4028114 		Physician Practice Mgmt IL Centegra Health System
  		C corp         No












Schedule R (Form 990) 2012
Schedule R (Form 990) 2012
Page 3
Part V
Transactions With Related Organizations (Complete if the organization answered "Yes" to Form 990, Part IV, line 34, 35b, or 36.)
Note. Complete line 1 if any entity is listed in Parts II, III, or IV of this schedule.
Yes
No
1 During the tax year, did the orgranization engage in any of the following transactions with one or more related organizations listed in Parts II-IV?
a Receipt of (i) interest (ii) annuities (iii) royalties or (iv) rent from a controlled entity . . . . . . . . . . . . . . . . . . . . . . .
1a
 
No
b Gift, grant, or capital contribution to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1b
 
No
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
Yes
 
l Performance of services or membership or fundraising solicitations for related organization(s) . . . . . . . . . . . . . . . . . . . .
1l
Yes
 
m Performance of services or membership or fundraising solicitations by related organization(s) . . . . . . . . . . . . . . . . . . . .
1m
Yes
 
n Sharing of facilities, equipment, mailing lists, or other assets with related organization(s) . . . . . . . . . . . . . . . . . . . . .
1n
 
No
o Sharing of paid employees with related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1o
 
No
p Reimbursement paid to related organization(s) for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1p
 
No
q Reimbursement paid by related organization(s) for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1q
 
No
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


Software ID: 12000229
Software Version: 2012v2.0