Department of the Treasury Internal Revenue Service
Public Charity Status and Public Support
Complete if the organization is a section 501(c)(3) organization or a section
4947(a)(1) nonexempt charitable trust.
Attach to Form 990 or Form 990-EZ. See separate instructions. Information about Schedule A (Form 990 or 990-EZ) and its instructions is at www.irs.gov/form990.
OMB No. 1545-0047
2013
Open to Public Inspection
Name of the organization
HIGHLINE MEDICAL CENTER
Employer identification number
91-0712166
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
By checking this box, I certify that the organization is not controlled directly or indirectly by one or more disqualified persons other than foundation managers and other than one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2).
f
If the organization received a written determination from the IRS that it is a Type I, Type II, or Type III supporting organization, check this box
..................................................
g
Since August 17, 2006, has the organization accepted any gift or contribution from any of the following persons?
(i) A person who directly or indirectly controls, either alone or together with persons described in (ii)
Yes
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) 2013
Schedule A (Form 990 or 990-EZ) 2013
Page 2
Part II
Support Schedule for Organizations Described in Sections 170(b)(1)(A)(iv) and 170(b)(1)(A)(vi) (Complete only if you checked the box on line 5, 7, or 8 of Part I or if the
organization failed to qualify under Part III. If the organization fails to
qualify under the tests listed below, please complete Part III.)
Section A. Public Support
Calendar year (or fiscal year beginning in)
(a) 2009
(b) 2010
(c) 2011
(d) 2012
(e) 2013
(f) Total
1
Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") ....
2
Tax revenues levied for the organization's benefit and either paid to or expended on its behalf.......
3
The value of services or facilities furnished by a governmental unit to the organization without charge..
4
Total. Add lines 1 through 3
5
The portion of total contributions by each person (other than a governmental unit or publicly supported organization) included
on line 1 that exceeds 2% of the amount shown on line 11, column (f)..
6
Public support. Subtract line 5 from line 4.
Section B. Total Support
Calendar year
(or fiscal year beginning in)
(a) 2009
(b) 2010
(c) 2011
(d) 2012
(e) 2013
(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
Gross receipts from related activities, etc. (see instructions)
..................
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.................................................
Section C. Computation of Public Support Percentage
14
Public support percentage for 2013 (line 6, column (f) divided by line 11, column (f))
.........
14
15
Public support percentage for 2012 Schedule A, Part II, line 14
...............
15
16a
33 1/3% support test—2013.
If the organization did not check the box on line 13, and line 14 is 33 1/3% or more, check this box
and stop here. The organization qualifies as a publicly supported organization
.......................
b
33 1/3% support test—2012.
If the organization did not check a box on line 13 or 16a, and line 15 is 33 1/3% or more, check this
box and stop here. The organization qualifies as a publicly supported organization
.....................
17a
10%-facts-and-circumstances test—2013.
If the organization did not check a box on line 13, 16a, or 16b, and line 14
is 10% or more, and if the organization meets the "facts-and-circumstances" test, check this box and stop here. Explain
in Part IV how the organization meets the "facts-and-circumstances" test. The organization qualifies as a publicly supported
organization
.....................................................
b
10%-facts-and-circumstances test—2012.
If the organization did not check a box on line 13, 16a, 16b, or 17a, and line
15 is 10% or more, and if the organization meets the "facts-and-circumstances" test, check this box and stop here.
Explain in Part IV how the organization meets the "facts-and-circumstances" test. The organization qualifies as a publicly supported organization
................................................
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
.....................................................
Schedule A (Form 990 or 990-EZ) 2013
Schedule A (Form 990 or 990-EZ) 2013
Page 3
Part III
Support Schedule for Organizations Described in Section 509(a)(2) (Complete only if you checked the box on line 9 of Part I or if the organization
failed to qualify under Part II. If the organization fails to qualify under
the tests listed below, please complete Part II.)
Section A. Public Support
Calendar year (or fiscal year beginning in)
(a) 2009
(b) 2010
(c) 2011
(d) 2012
(e) 2013
(f) Total
1
Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") .
2
Gross receipts from admissions, merchandise sold or services performed, or facilities furnished in any activity that is related to the organization's tax-exempt purpose......
3
Gross receipts from activities that are not an unrelated trade or business under section 513..
4
Tax revenues levied for the organization's benefit and either paid to or expended on its behalf...
5
The value of services or facilities furnished by a governmental unit to the organization without charge..
6
Total. Add lines 1 through 5.
7a
Amounts included on lines 1, 2, and 3 received from disqualified persons...
b
Amounts included on lines 2 and 3 received from other than disqualified persons that exceed the greater of $5,000 or 1% of the amount on line 13 for the year.
c
Add lines 7a and 7b..
8
Public support (Subtract line 7c from line 6.)
Section B. Total Support
Calendar year (or fiscal year beginning in)
(a) 2009
(b) 2010
(c) 2011
(d) 2012
(e) 2013
(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
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.............................................
Section C. Computation of Public Support Percentage
15
Public support percentage for 2013 (line 8, column (f) divided by line 13, column (f))
.........
15
16
Public support percentage from 2012 Schedule A, Part III, line 15
...............
16
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2013 (line 10c, column (f) divided by line 13, column (f))
......
17
18
Investment income percentage from 2012 Schedule A, Part III, line 17
.............
18
19a
33 1/3% support tests—2013.
If the organization did not check the box on line 14, and line 15 is more than 33 1/3%, and line 17 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization
........
b
33 1/3% support tests—2012.
If the organization did not check a box on line 14 or line 19a, and line 16 is more than 33 1/3% and line 18 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization
.....
20
Private foundation.
If the organization did not check a box on line 14, 19a, or 19b, check this box and see instructions
.....
Schedule A (Form 990 or 990-EZ) 2013
Schedule A (Form 990 or 990-EZ) 2013
Page 4
Part IV
Supplemental Information.
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) 2013
Additional Data
Software ID:
13000248
Software Version:
2013v3.1
-
TIN:
SCHEDULE O (Form 990 or 990-EZ)
Department of the Treasury Internal Revenue Service
Supplemental Information to Form 990 or 990-EZ
Complete to provide information for responses to specific questions on
Form 990 or to provide any additional information.
Attach to Form 990 or 990-EZ.
Information about Schedule O (Form 990 or 990-EZ) and its instructions is at
www.irs.gov/form990.
OMB No. 1545-0047
2013
Open to Public Inspection
Name of the organization
HIGHLINE MEDICAL CENTER
Employer identification number
91-0712166
Return Reference
Explanation
Form 990, Part VI, Sec A, Line 6, Classes of members or stockholders
ACCORDING TO THE BYLAWS OF HIGHLINE MEDICAL CENTER, THE ENTITY'S SOLE MEMBER IS FRANCISCAN HEALTH SYSTEM, A WASHINGTON NONPROFIT CORPORATION.
Form 990, Part VI, Sec A, Line 7a, Members or stockholders electing members of governing body
PURSUANT TO SECTION 5.3 OF THE ORGANIZATION'S BYLAWS, TRUSTEES OF THE CORPORATION SHALL BE APPOINTED BY THE CORPORATE MEMBER NO LATER THAN JUNE 30 OF EACH YEAR.
Form 990, Part VI, Sec A, Line 7b, Decisions requiring approval by members or stockholders
THE ORGANIZATION'S CORPORATE MEMBER IS FRANCISCAN HEALTH SYSTEM. PURSUANT TO SECTION 4.4 OF THE ORGANIZATION'S BYLAWS, BOTH FRANCISCAN HEALTH SYSTEM AND CATHOLIC HEALTH INITIATIVES ("CHI") (FRANCISCAN HEALTH SYSTEM'S SOLE CORPORATE MEMBER) HAVE RESERVED POWERS AS OUTLINED IN THE CHI GOVERNANCE MATRIX. PURSUANT TO THE GOVERNANCE MATRIX THE FOLLOWING RIGHTS ARE HELD BY THE FRANCISCAN HEALTH SYSTEM BOARD: * APPROVE MEMBERS OF THE HIGHLINE MEDICAL CENTER BOARD * AMENDMENT OF THE CORPORATE DOCUMENTS OF HIGHLINE MEDICAL CENTER * APPROVE REMOVAL OF A MEMBER OF THE GOVERNING BODY OF HIGHLINE MEDICAL CENTER * ADOPTION OF LONG RANGE AND STRATEGIC PLANS FOR HIGHLINE MEDICAL CENTER THE FOLLOWING RIGHTS ARE RESERVED TO THE CHI BOARD DIRECTLY OR THROUGH POWERS DELEGATED TO THE CHI CHIEF EXECUTIVE OFFICER: * SUBSTANTIAL CHANGE IN THE MISSION OR PHILOSOPHY OF HIGHLINE MEDICAL CENTER * REMOVAL OF A MEMBER OF THE GOVERNING BODY OF HIGHLINE MEDICAL CENTER * APPROVAL OF ISSUANCE OF DEBT BY HIGHLINE MEDICAL CENTER * APPROVAL OF PARTICIPATION OF HIGHLINE MEDICAL CENTER IN A JOINT VENTURE * APPROVAL OF FORMATION OF A NEW CORPORATION BY HIGHLINE MEDICAL CENTER * APPROVAL OF A MERGER INVOLVING HIGHLINE MEDICAL CENTER * APPROVAL OF THE SALE OF ALL OR SUBSTANTIALLY ALL OF THE ASSETS OF HIGHLINE MEDICAL CENTER * TO REQUIRE THE TRANSFER OF ASSETS BY HIGHLINE MEDICAL CENTER TO CHI TO ACCOMPLISH CHI'S GOALS AND OBJECTIVES, AND TO SATISFY CHI DEBTS. PURSUANT TO SECTION 4.5.2 OF THE ORGANIZATION'S BYLAWS, FRANCISCAN HEALTH SYSTEM OR CHI MAY, IN EXERCISE OF THEIR APPROVAL POWERS, GRANT OR WITHHOLD APPROVAL IN WHOLE OR IN PART, OR MAY, IN ITS COMPLETE DISCRETION, AFTER CONSULTATION WITH THE BOARD AND ITS PRESIDENT AND THE CHIEF EXECUTIVE OFFICER OF THE ORGANIZATION, RECOMMEND SUCH OTHER OR DIFFERENT ACTIONS AS IT DEEMS APPROPRIATE.
Form 990, Part VI, Sec B, Line 11b, Review of form 990 by governing body
HIGHLINE MEDICAL CENTER'S FORM 990 IS PREPARED BY THE CHI TAX DEPARTMENT. THE FORM 990 WILL BE PRESENTED TO THE BOARD AT A BOARD MEETING SUBSEQUENT TO THE FILING OF THE TAX RETURN.
Form 990, Part VI, Sec B, Line 12c, Conflict of interest policy
HIGHLINE MEDICAL CENTER'S CONFLICT OF INTEREST POLICY IS REVIEWED ANNUALLY WITH THE MANAGEMENT AND THE BOARD. DISCLOSURE AND COMPLETION OF THE FORM IS DONE ANNUALLY AND CONFLICTS ARE FOLLOWED UP BY THE COMPLIANCE OFFICER AND THE CEO, WHO ALSO FOLLOW-UP ON CONFLICTS THAT MAY COME TO THEIR ATTENTION DURING THE YEAR. A PERSON HAS A POTENTIAL CONFLICT OF INTEREST IF THE PERSON HAS OR ENGAGES IN, DIRECTLY OR INDIRECTLY, THROUGH BUSINESS, INVESTMENT OR FAMILY: * AN OWNERSHIP INTEREST IN ANY ENTITY WITH WHICH THE HOSPITAL DOES BUSINESS OR COMPETES; * A COMPENSATION ARRANGEMENT WITH THE HOSPITAL OR WITH ANY ENTITY WITH WHICH THE HOSPITAL DOES BUSINESS OR COMPETES; * A POTENTIAL OWNERSHIP INTEREST IN, OR POTENTIAL COMPENSATION ARRANGEMENT WITH, THE HOSPITAL OR ANY ENTITY WITH WHICH THE HOSPITAL IS NEGOTIATING A TRANSACTION OR ARRANGEMENT OR WITH WHICH THE HOSPITAL COMPETES; OR * ANY UNCOMPENSATED ACTIVITIES WITH WHICH THE HOSPITAL CONDUCTS OR POTENTIALLY CONDUCTS BUSINESS, WITH WHICH IT COMPETES, OR WITH WHICH IT OTHERWISE HAS DISSIMILAR OR DIVERGENT INTERESTS. COMPENSATION ARRANGEMENT INCLUDES DIRECT AND INDIRECT REMUNERATION AS WELL AS GIFTS OR FAVORS THAT ARE SUBSTANTIAL IN NATURE. GIFTS IN EXCESS OF $300 DURING ANY CALENDAR YEAR ARE PRESUMPTIVELY SUBSTANTIAL IN NATURE. A CONFLICT OF INTEREST ARISES WHEN A COVERED PERSON MAY BENEFIT FROM A DECISION HE OR SHE COULD MAKE. A POTENTIAL CONFLICT OF INTEREST IS NOT NECESSARILY A CONFLICT OF INTEREST. FAMILY INCLUDES, BUT IS NOT LIMITED TO, SPOUSES AND SPOUSAL EQUIVALENTS, CHILDREN, PARENTS, GRANDPARENTS, GRANDCHILDREN, BROTHERS, SISTERS, MOTHERS-IN-LAW, FATHERS-IN-LAW, SISTERS-IN-LAW, BROTHERS-IN-LAW, SONS-IN-LAW, DAUGHTERS-IN-LAW, AUNTS, UNCLES, COUSINS, NIECES AND NEPHEWS. COVERED PERSONS SHALL ANNUALLY SUBMIT A SIGNED CONFLICT OF INTEREST DISCLOSURE AND CONFIDENTIALITY FORM. COVERED PERSONS MUST DISCLOSE ALL POTENTIAL CONFLICTS OF INTEREST ANNUALLY AND IN CONNECTION WITH ANY BOARD OR COMMITTEE DECISION. COVERED PERSONS SHALL MAKE ALL DISCLOSURES UNDER THIS POLICY TO THE BEST OF THE COVERED PERSON'S KNOWLEDGE AND BELIEF. A CONFLICT OF INTEREST EXISTS ONLY IF THE APPROPRIATE BOARD OR COMMITTEE EITHER FINDS THAT SUCH A CONFLICT OF INTEREST EXISTS OR ACCEPTS A COVERED PERSON'S CONCLUSION THAT THEY HAVE A CONFLICT OF INTEREST. IF ANY MEMBER OF THE BOARD OR A COMMITTEE FEELS THAT ANY COVERED PERSON HAS A CONFLICT OF INTEREST, THEN THE COVERED PERSON WILL, AFTER ANY DISCUSSION WITH THE BOARD OR COMMITTEE, BE EXCUSED FROM THE MEETING WHILE THE BOARD OR COMMITTEE DETERMINES IF THERE IS A CONFLICT OF INTEREST. WHEN THERE IS A CONFLICT OF INTEREST, THE COVERED PERSON MAY MAKE A STATEMENT TO THE BOARD OR COMMITTEE REGARDING THE TRANSACTION OR ARRANGEMENT FOR WHICH THEY HAVE A CONFLICT OF INTEREST, BUT WILL BE EXCUSED FROM THE MEETING SO THEY WILL NOT BE PRESENT DURING THE DISCUSSION OR VOTING ON THE ISSUE. THE BOARD OR COMMITTEE SHALL DETERMINE WHETHER THE HOSPITAL CAN OBTAIN WITH REASONABLE EFFORTS A MORE ADVANTAGEOUS TRANSACTION OR ARRANGEMENT FROM A PERSON OR ENTITY THAT WOULD NOT GIVE RISE TO A CONFLICT OF INTEREST. IF SUCH A TRANSACTION OR ARRANGEMENT IS NOT REASONABLY POSSIBLE, THEN THE DISINTERESTED MEMBERS OF THE BOARD OR COMMITTEE SHALL DETERMINE WHETHER THE TRANSACTION OR ARRANGEMENT IS IN THE HOSPITAL'S BEST INTEREST, FOR ITS OWN BENEFIT, AND WHETHER IT IS FAIR AND REASONABLE. THE EXECUTIVE COMMITTEE WILL MAKE A RECOMMENDATION TO THE BOARD FOR APPROPRIATE ACTION IF IT IS DISCOVERED THAT A COVERED PERSON VIOLATES THIS POLICY. THE MINUTES OF THE BOARD AND COMMITTEE MEETINGS WILL REFLECT WHEN A PERSON HAS A CONFLICT OF INTEREST AND ALSO WILL REFLECT THAT THE PERSON WAS NOT PRESENT FOR DISCUSSION OR VOTING ON THAT ISSUE.
Form 990, Part VI, Sec B, Line 15a, Process to establish compensation of top management official
COMPENSATION FOR OFFICERS AND KEY EMPLOYEES IS WITHIN THE CHARTER OF THE EXECUTIVE COMMITTEE. THE EXECUTIVE COMMITTEE COMPRISES A SUBGROUP OF BOARD MEMBERS WHO ARE INDEPENDENT WITH RESPECT TO THOSE WHOSE COMPENSATION IS WITHIN THEIR SCOPE. AS AND WHEN COMPENSATION ADJUSTMENTS AND CONTRACT RENEWALS OCCUR, THE EXECUTIVE COMMITTEE CONSIDERS PERFORMANCE EVALUATIONS AS WELL AS COMPARATIVE MARKET DATA FOR LIKE-SIZE HOSPITALS FOR PURPOSES OF THIS WORK. FROM TIME TO TIME THE EXECUTIVE COMMITTEE ENGAGES AN INDEPENDENT COMPENSATION CONSULTANT TO ASSIST WITH THIS WORK. THE EXECUTIVE COMMITTEE DOCUMENTS ITS DECISIONS IN THE EXECUTIVE COMMITTEE MINUTES.
Form 990, Part VI, Sec B, Line 15b, Process to establish compensation of other employees
SEE FORM 990, PART VI, LINE 15A DISCLOSURE.
FORM 990, PART VI, LINE 16B, EVALUATION OF PARTICIPATION IN JOINT VENTURE ARRANGEMENTS
HIGHLINE MEDICAL CENTER HAS NOT FORMALLY ADOPTED A WRITTEN POLICY OR WRITTEN PROCEDURE REGARDING JOINT VENTURES. HOWEVER CHI'S SYSTEM-WIDE JOINT VENTURE MODEL OPERATING AGREEMENT INCORPORATES CONTROLS OVER THE VENTURE SUFFICIENT TO ENSURE THAT (1) THE EXEMPT ORGANIZATION AT ALL TIMES RETAINS CONTROL OVER THE VENTURE SUFFICIENT TO ENSURE THAT THE PARTNERSHIP FURTHERS THE EXEMPT PURPOSE OF THE ORGANIZATION; (2) IN ANY PARTNERSHIP IN WHICH THE EXEMPT ORGANIZATION IS A PARTNER, ACHIEVEMENT OF EXEMPT PURPOSES IS PRIORITIZED OVER MAXIMIZATION OF PROFITS FOR THE PARTNERS; (3) THE PARTNERSHIP DOES NOT ENGAGE IN ANY ACTIVITIES THAT WOULD JEOPARDIZE THE EXEMPT ORGANIZATION'S EXEMPTION; (4) RETURNS OF CAPITAL, ALLOCATIONS, AND DISTRIBUTIONS MUST BE MADE IN PROPORTION TO THE PARTNERS' RESPECTIVE OWNERSHIP INTERESTS; AND (5) ALL CONTRACTS ENTERED INTO BY THE PARTNERSHIP WITH THE EXEMPT ORGANIZATION MUST BE AT ARM'S-LENGTH, WITH PRICES SET AT FAIR MARKET VALUE. ANY JOINT VENTURE AGREEMENTS THAT DO NOT CONFORM TO THE MODEL AGREEMENT ARE GENERALLY REVIEWED BY COUNSEL.
Form 990, Part VI, Sec C, Line 19, Required documents available to the public
HIGHLINE MEDICAL CENTER MAKES ITS FORM 990 AND FORM 1023 AVAILABLE TO THE PUBLIC IN ACCORDANCE WITH THE PUBLIC DISCLOSURE REQUIREMENTS OF THE INTERNAL REVENUE CODE. PURSUANT TO WA STATE LICENSING REQUIREMENTS, THE MEDICAL CENTER'S FINANCIAL STATEMENTS ARE PUBLICLY AVAILABLE ON THE DEPARTMENT OF HEALTH' WEBSITE AT WWW.DOH.GOV. AT PRESENT, THE ORGANIZATION DOES NOT MAKE ITS CONFLICT OF INTEREST POLICY AVAILABLE TO THE PUBLIC.
Form 990, Part IX, Line 11g, Other Expenses
CONTRACTED SERVICES - TOTAL EXPENSE: 15457976, PROGRAM SERVICE EXPENSE: 6337770, MANAGEMENT AND GENERAL EXPENSES: 9120206, FUNDRAISING EXPENSES: ; CONSULTING - TOTAL EXPENSE: 1531249, PROGRAM SERVICE EXPENSE: 627812, MANAGEMENT AND GENERAL EXPENSES: 903437, FUNDRAISING EXPENSES: ; CONTRACT LABOR - TOTAL EXPENSE: 6115090, PROGRAM SERVICE EXPENSE: 2507187, MANAGEMENT AND GENERAL EXPENSES: 3607903, FUNDRAISING EXPENSES: ;
Form 990 , Part XI, Line 9, Other changes in net assets or fund balances
INTERCO RECEIVABLE SETTLEMENT - -19856648;
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.