TY 2017 Form 990

(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)
(1) THOMAS ALEXANDER...................................................................... DIRECTOR (END 9/17)	1.00 ................. 2.00	X	0	0
(2) TRISH ANEN...................................................................... DIRECTOR	1.00 ................. 2.00	X	0	0
(3) JAMES BAKA...................................................................... DIRECTOR	1.00 ................. 2.00	X	0	0
(4) PATRICK CARMODY...................................................................... DIRECTOR (START 9/17)	1.00 ................. 2.00	X	0	0
(5) CATI CEDEROTH...................................................................... DIRECTOR	1.00 ................. 2.00	X	0	0
(6) BRUCE DIENST...................................................................... CHAIRMAN OF BOARD/DIRECTOR	1.00 ................. 2.00	X	0	0
(7) RICHARD EDELMAN...................................................................... DIRECTOR	1.00 ................. 2.00	X	0	0
(8) RONALD HEM...................................................................... DIRECTOR	1.00 ................. 2.00	X	0	0
(9) GARRETT KATULA DO...................................................................... VICE CHIEF OF STAFF/DIRECTOR	41.00 ................. 2.00	X	282,985	31,661
(10) STEPHEN KELANIC MD...................................................................... VICE CHIEF OF STAFF/DIRECTOR	41.00 ................. 2.00	X	432,990	30,652
(11) HERBERT KNIGHT...................................................................... DIRECTOR	1.00 ................. 2.00	X	0	0
(12) MARYANNE LOCKLIN...................................................................... DIRECTOR	1.00 ................. 2.00	X	0	0
(13) DAVE MEAD...................................................................... DIRECTOR	1.00 ................. 2.00	X	0	0
(14) MARK METZGER...................................................................... DIRECTOR	1.00 ................. 2.00	X	0	0
(15) AVERY MILLER...................................................................... DIRECTOR	1.00 ................. 2.00	X	0	0
(16) LUIS PEREZ...................................................................... DIRECTOR (START 9/17)	1.00 ................. 2.00	X	0	0
(17) WILLIAM SKOGLUND...................................................................... VICE CHAIR BOARD/DIRECTOR	1.00 ................. 2.00	X	0	0

(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)	(E) Reportable compensation from related organizations (W-2/1099-MISC)	(F) Estimated amount of other compensation from the organization and related organizations
(18) CHRISTINE SOBEK........................................................................ DIRECTOR	1.00 .......................2.00	X				0	0
(19) ANDREW VANEEKEREN........................................................................ DIRECTOR	1.00 .......................2.00	X				0	0
(20) BARRY FINN........................................................................ PRESIDENT & CEO/DIRECTOR	40.00 .......................3.00	X	X			1,548,342	31,424
(21) RYAN ASMUS........................................................................ VP GENERAL COUNSEL/SECRETARY	40.00 .......................3.00		X			369,599	68,925
(22) BRENDA VAN WYHE........................................................................ SR. VP FINANCE & CFO/TREASURER	40.00 .......................3.00		X			451,921	73,852
(23) GAIL BUMGARNER........................................................................ SR. VP, STRATEGY	40.00 .......................0.00			X		425,727	13,696
(24) DENNIS DEMASIE........................................................................ VP, INFORMATION TECH & CIO	40.00 .......................0.00			X		706,868	16,312
(25) JOHN DIEDERICH........................................................................ SR. VP, OPERATIONS & COO	40.00 .......................1.00			X		546,495	166,993
(26) BRENDA FANN MD........................................................................ ASSISTANT VP, MEDAFFAIRS	40.00 .......................0.00			X		328,916	31,335
(27) DIANE HOMAN MD........................................................................ VP, QUALITY & PSO	40.00 .......................0.00			X		514,808	28,351
(28) STEVE LOWENTHAL MD........................................................................ SR. VP, MEDICAL AFFAIRS & CMO	40.00 .......................0.00			X		688,691	14,347
(29) DAVID PETASNICK........................................................................ ASSISTANT VP, ANCILLARY SVCS	40.00 .......................0.00			X		220,651	26,208
(30) ALEX POPE........................................................................ VP, PHILANTHROPY & CDO	40.00 .......................1.00			X		265,822	57,932
(31) MARY SHILKAITIS........................................................................ VP PATIENT CARE SRVCS & CNO	40.00 .......................0.00			X		329,112	69,372
(32) SUSAN STERCHI........................................................................ ASSISTANT VP, PATIENT CARE	40.00 .......................0.00			X		223,270	30,184
(33) MARK SHARP-SCHINSKY MD........................................................................ PHYSICIAN	40.00 .......................0.00				X	1,251,245	34,713
(34) DIMITRY RUBAN MD........................................................................ PHYSICIAN	40.00 .......................0.00				X	983,547	29,999
(35) KEVIN KELLY MD........................................................................ PHYSICIAN	40.00 .......................0.00				X	918,213	25,958
(36) ARIF SALEEM MD........................................................................ PHYSICIAN	40.00 .......................0.00				X	797,358	30,916
(37) TERESSA ALEXANDER MD........................................................................ PHYSICIAN	40.00 .......................0.00				X	786,376	30,836

(A) Name and business address	(B) Description of services	(C) Compensation
SODEXO 4880 PAYSPHERE CIRCLE CHICAGO,IL60674	FOOD AND CLEANING SERVICE MANAGEMENT	3,815,793
ANTHELIO HEALTHCARE SOLUTIONS 1 LINCOLN DR STE 200 5400 LBJ FRW DALLAS,TX75240	MEDICAL RECORDS MANAGEMENT	3,383,999
INTUITIVE SURGICAL INC 1020 KIFER ROAD SUNNYVALE,CA94086	MEDICAL EQUIPMENT REPAIR AND SERVICING	749,265
FOX VALLEY ACUTE DIALYSIS 1300 WATERFORD DRIVE AURORA,IL60504	DIALYSIS SERVICES	729,544
ANDERSON MIKOS ARCHITECHTS LTD 17W110 22ND ST STE 200 OAKBROOK TERRACE,IL60181	ARCHITECTS	705,498
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 23

- TIN:

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

Go to www.irs.gov/Form990 for instructions and the latest information.

OMB No. 1545-0047

2019

Open to Public
Inspection

Name of the organization

COPLEY MEMORIAL HOSPITAL INC
C/O RUSH COPLEY MEDICAL CTR

Employer identification number

36-2170840

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 12, check only one box.)

A church, convention of churches, or association of churches described in section 170(b)(1)(A)(i).

A school described in section 170(b)(1)(A)(ii). (Attach Schedule E (Form 990 or 990-EZ).)

A hospital or a cooperative hospital service organization described in section 170(b)(1)(A)(iii).

A medical research organization operated in conjunction with a hospital described in section 170(b)(1)(A)(iii). Enter the hospital's name, city, and state:

An organization operated for the benefit of a college or university owned or operated by a governmental unit described in section 170(b)(1)(A)(iv). (Complete Part II.)

A federal, state, or local government or governmental unit described in section 170(b)(1)(A)(v).

An organization that normally receives a substantial part of its support from a governmental unit or from the general public described in section 170(b)(1)(A)(vi). (Complete Part II.)

A community trust described in section 170(b)(1)(A)(vi). (Complete Part II.)

An agricultural research organization described in 170(b)(1)(A)(ix) operated in conjunction with a land-grant college or university or a non-land grant college of agriculture. See instructions. Enter the name, city, and state of the college or university:

An organization that normally receives: (1) more than 331/3% of its support from contributions, membership fees, and gross 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.)

An organization organized and operated exclusively to test for public safety. See section 509(a)(4).

An organization organized and operated exclusively for the benefit of, to perform the functions of, or to carry out the purposes of one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2). See section 509(a)(3). Check the box in lines 12a through 12d that describes the type of supporting organization and complete lines 12e, 12f, and 12g.

Type I. A supporting organization operated, supervised, or controlled by its supported organization(s), typically by giving the supported organization(s) the power to regularly appoint or elect a majority of the directors or trustees of the supporting organization. You must complete Part IV, Sections A and B.

Type II. A supporting organization supervised or controlled in connection with its supported organization(s), by having control or management of the supporting organization vested in the same persons that control or manage the supported organization(s). You must complete Part IV, Sections A and C.

Type III functionally integrated. A supporting organization operated in connection with, and functionally integrated with, its supported organization(s) (see instructions). You must complete Part IV, Sections A, D, and E.

Type III non-functionally integrated. A supporting organization operated in connection with its supported organization(s) that is not functionally integrated. The organization generally must satisfy a distribution requirement and an attentiveness requirement (see instructions). You must complete Part IV, Sections A and D, and Part V.

Check this box if the organization received a written determination from the IRS that it is a Type I, Type II, Type III functionally integrated, or Type III non-functionally integrated supporting organization.

Enter the number of supported organizations ...............................

Provide the following information about the supported organization(s).

(i) Name of supported organization	(ii) EIN	(iv) Is the organization listed in your governing document?		(v) Amount of monetary support (see instructions)	(vi) Amount of other support (see instructions)
(i) Name of supported organization	(ii) EIN	Yes	No	(v) Amount of monetary support (see instructions)	(vi) Amount of other support (see instructions)


Total

For Paperwork Reduction Act Notice, see the Instructions for
Form 990 or 990-EZ.

Cat. No. 11285F

Schedule A (Form 990 or 990-EZ) 2019

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 failed to qualify under the tests listed below, please complete Part III.)

Section A. Public Support

Calendar year (or fiscal year beginning in)		(a) 2015	(b) 2016	(c) 2017	(d) 2018	(e) 2019	(f) Total
1	Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grant.") ..
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) 2015	(b) 2016	(c) 2017	(d) 2018	(e) 2019	(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 VI.)..
11	Total support. Add lines 7 through 10

Gross receipts from related activities, etc. (see instructions) ..................

First five years. If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a section 501(c)(3) organization, check this box and stop here........................................ right arrow

Section C. Computation of Public Support Percentage

Public support percentage for 2019 (line 6, column (f) divided by line 11, column (f)) .........

Public support percentage for 2018 Schedule A, Part II, line 14 ...............

16a

33 1/3% support test—2019. 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 ....................... right arrow

33 1/3% support test—2018. 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 ..................... right arrow

17a

10%-facts-and-circumstances test—2019. 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 VI how the organization meets the "facts-and-circumstances" test. The organization qualifies as a publicly supported
organization ..................................................... right arrow

10%-facts-and-circumstances test—2018. 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 VI how the organization meets the "facts-and-circumstances" test. The organization qualifies as a publicly
supported organization ................................................ right arrow

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) 2019

Page 3

Part III

Support Schedule for Organizations Described in Section 509(a)(2)
(Complete only if you checked the box on line 10 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) 2015	(b) 2016	(c) 2017	(d) 2018	(e) 2019	(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) 2015	(b) 2016	(c) 2017	(d) 2018	(e) 2019	(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 VI.) ..
13	Total support. (Add lines 9, 10c, 11, and 12.)..

First five years. If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a section 501(c)(3) organization,
check this box and stop here............................................. right arrow

Section C. Computation of Public Support Percentage

Public support percentage for 2019 (line 8, column (f) divided by line 13, column (f)) .........

Public support percentage from 2018 Schedule A, Part III, line 15 ...............

Section D. Computation of Investment Income Percentage

Investment income percentage for 2019 (line 10c, column (f) divided by line 13, column (f)) ......

Investment income percentage from 2018 Schedule A, Part III, line 17 .............

19a

331/3% support tests—2019. 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 ....... right arrow

33 1/3% support tests—2018. 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 .... right arrow

Private foundation. If the organization did not check a box on line 14, 19a, or 19b, check this box and see instructions .... right arrow

Schedule A (Form 990 or 990-EZ) 2019

Page 4

Part IV

Supporting Organizations

(Complete only if you checked a box on line 12 of Part I. If you checked 12a of Part I, complete Sections A and B. If you checked 12b of Part I, complete Sections A and C. If you checked 12c of Part I, complete Sections A, D, and E. If you checked 12d of Part I, complete Sections A and D, and complete Part V.)

Section A. All Supporting Organizations

Yes

Are all of the organization’s supported organizations listed by name in the organization’s governing documents?
If "No," describe in Part VI how the supported organizations are designated. If designated by class or purpose,
describe the designation. If historic and continuing relationship, explain.

Did the organization have any supported organization that does not have an IRS determination of status under section 509(a)(1) or (2)? If "Yes," explain in Part VI how the organization determined that the supported organization was described in section 509(a)(1) or (2).

Did the organization have a supported organization described in section 501(c)(4), (5), or (6)? If "Yes," answer (b) and (c) below.

Did the organization confirm that each supported organization qualified under section 501(c)(4), (5), or (6) and satisfied the public support tests under section 509(a)(2)? If "Yes," describe in Part VI when and how the organization made the determination.

Did the organization ensure that all support to such organizations was used exclusively for section 170(c)(2)(B) purposes? If "Yes," explain in Part VI what controls the organization put in place to ensure such use.

Was any supported organization not organized in the United States ("foreign supported organization")? If “Yes” and if you checked 12a or 12b in Part I, answer (b) and (c) below.

Did the organization have ultimate control and discretion in deciding whether to make grants to the foreign supported organization? If “Yes,” describe in Part VI how the organization had such control and discretion despite being controlled or supervised by or in connection with its supported organizations.

Did the organization support any foreign supported organization that does not have an IRS determination under sections 501(c)(3) and 509(a)(1) or (2)? If “Yes,” explain in Part VI what controls the organization used to ensure that all support to the foreign supported organization was used exclusively for section 170(c)(2)(B) purposes.

Did the organization add, substitute, or remove any supported organizations during the tax year? If “Yes,” answer (b) and (c) below (if applicable). Also, provide detail in Part VI, including (i) the names and EIN numbers of the supported organizations added, substituted, or removed; (ii) the reasons for each such action; (iii) the authority under the organization's organizing document authorizing such action; and (iv) how the action was accomplished (such as by amendment to the organizing document).

Type I or Type II only. Was any added or substituted supported organization part of a class already designated in the organization's organizing document?

Substitutions only. Was the substitution the result of an event beyond the organization's control?

Did the organization provide support (whether in the form of grants or the provision of services or facilities) to anyone other than (i) its supported organizations, (ii) individuals that are part of the charitable class benefited by one or more of its supported organizations, or (iii) other supporting organizations that also support or benefit one or more of the filing organization’s supported organizations? If “Yes,” provide detail in Part VI.

Did the organization provide a grant, loan, compensation, or other similar payment to a substantial contributor (defined in section 4958(c)(3)(C)), a family member of a substantial contributor, or a 35% controlled entity with regard to a substantial contributor? If “Yes,” complete Part I of Schedule L (Form 990 or 990-EZ) .

Did the organization make a loan to a disqualified person (as defined in section 4958) not described in line 7? If “Yes,” complete Part I of Schedule L (Form 990 or 990-EZ).

Was the organization controlled directly or indirectly at any time during the tax year by one or more disqualified persons as defined in section 4946 (other than foundation managers and organizations described in section 509(a)(1) or (2))? If “Yes,” provide detail in Part VI.

Did one or more disqualified persons (as defined in line 9a) hold a controlling interest in any entity in which the supporting organization had an interest? If “Yes,” provide detail in Part VI.

Did a disqualified person (as defined in line 9a) have an ownership interest in, or derive any personal benefit from, assets in which the supporting organization also had an interest? If “Yes,” provide detail in Part VI.

10a

Was the organization subject to the excess business holdings rules of section 4943 because of section 4943(f) (regarding certain Type II supporting organizations, and all Type III non-functionally integrated supporting organizations)? If “Yes,” answer line 10b below.

10a

Did the organization have any excess business holdings in the tax year? (Use Schedule C, Form 4720, to determine whether the organization had excess business holdings).

10b

Schedule A (Form 990 or 990-EZ) 2019

Page 5

Part IV

Supporting Organizations (continued)

Yes

Has the organization accepted a gift or contribution from any of the following persons?

A person who directly or indirectly controls, either alone or together with persons described in (b) and (c) below, the governing body of a supported organization?

11a

A family member of a person described in (a) above?

11b

A 35% controlled entity of a person described in (a) or (b) above? If “Yes” to a, b, or c, provide detail in Part VI.

11c

Section B. Type I Supporting Organizations

Yes

Did the directors, trustees, or membership of one or more supported organizations have the power to regularly appoint or elect at least a majority of the organization’s directors or trustees at all times during the tax year? If “No,” describe in Part VI how the supported organization(s) effectively operated, supervised, or controlled the organization’s activities. If the organization had more than one supported organization, describe how the powers to appoint and/or remove directors or trustees were allocated among the supported organizations and what conditions or restrictions, if any, applied to such powers during the tax year.

Did the organization operate for the benefit of any supported organization other than the supported organization(s) that operated, supervised, or controlled the supporting organization? If “Yes,” explain in Part VI how providing such benefit carried out the purposes of the supported organization(s) that operated, supervised or controlled the supporting organization.

Section C. Type II Supporting Organizations

Yes

Were a majority of the organization’s directors or trustees during the tax year also a majority of the directors or trustees of each of the organization’s supported organization(s)? If “No,” describe in Part VI how control or management of the supporting organization was vested in the same persons that controlled or managed the supported organization(s).

Section D. All Type III Supporting Organizations

Yes

Did the organization provide to each of its supported organizations, by the last day of the fifth month of the organization’s tax year, (i) a written notice describing the type and amount of support provided during the prior tax year, (ii) a copy of the Form 990 that was most recently filed as of the date of notification, and (iii) copies of the organization’s governing documents in effect on the date of notification, to the extent not previously provided?

Were any of the organization’s officers, directors, or trustees either (i) appointed or elected by the supported organization(s) or (ii) serving on the governing body of a supported organization? If "No," explain in Part VI how the organization maintained a close and continuous working relationship with the supported organization(s).

By reason of the relationship described in (2), did the organization’s supported organizations have a significant voice in the organization’s investment policies and in directing the use of the organization’s income or assets at all times during the tax year? If "Yes," describe in Part VI the role the organization’s supported organizations played in this regard.

Section E. Type III Functionally-Integrated Supporting Organizations

Check the box next to the method that the organization used to satisfy the Integral Part Test during the year (see instructions):

The organization satisfied the Activities Test. Complete line 2 below.

The organization is the parent of each of its supported organizations. Complete line 3 below.

The organization supported a governmental entity. Describe in Part VI how you supported a government entity (see instructions)

Activities Test. Answer (a) and (b) below.

Yes

Did substantially all of the organization’s activities during the tax year directly further the exempt purposes of the supported organization(s) to which the organization was responsive? If "Yes," then in Part VI identify those supported organizations and explain how these activities directly furthered their exempt purposes, how the organization was responsive to those supported organizations, and how the organization determined that these activities constituted substantially all of its activities.

Did the activities described in (a) constitute activities that, but for the organization’s involvement, one or more of the organization’s supported organization(s) would have been engaged in? If "Yes," explain in Part VI the reasons for the organization’s position that its supported organization(s) would have engaged in these activities but for the organization’s involvement.

Parent of Supported Organizations. Answer (a) and (b) below.

Did the organization have the power to regularly appoint or elect a majority of the officers, directors, or trustees of each of the supported organizations? Provide details in Part VI.

Did the organization exercise a substantial degree of direction over the policies, programs and activities of each of its supported organizations? If "Yes," describe in Part VI. the role played by the organization in this regard.

Schedule A (Form 990 or 990-EZ) 2019

Page 6

Part V

Type III Non-Functionally Integrated 509(a)(3) Supporting Organizations

Check here if the organization satisfied the Integral Part Test as a qualifying trust on Nov. 20, 1970 (explain in Part VI). See instructions. All other Type III non-functionally integrated supporting organizations must complete Sections A through E.

	Section A - Adjusted Net Income		(A) Prior Year	(B) Current Year (optional)
1	Net short-term capital gain	1
2	Recoveries of prior-year distributions	2
3	Other gross income (see instructions)	3
4	Add lines 1 through 3	4
5	Depreciation and depletion	5
6	Portion of operating expenses paid or incurred for production or collection of gross income or for management, conservation, or maintenance of property held for production of income (see instructions)	6
7	Other expenses (see instructions)	7
8	Adjusted Net Income (subtract lines 5, 6 and 7 from line 4)	8

	Section B - Minimum Asset Amount		(A) Prior Year	(B) Current Year (optional)
1	Aggregate fair market value of all non-exempt-use assets (see instructions for short tax year or assets held for part of year):	1
a	Average monthly value of securities	1a
b	Average monthly cash balances	1b
c	Fair market value of other non-exempt-use assets	1c
d	Total (add lines 1a, 1b, and 1c)	1d
e	Discount claimed for blockage or other factors (explain in detail in Part VI):
2	Acquisition indebtedness applicable to non-exempt use assets	2
3	Subtract line 2 from line 1d	3
4	Cash deemed held for exempt use. Enter 1-1/2% of line 3 (for greater amount, see instructions).	4
5	Net value of non-exempt-use assets (subtract line 4 from line 3)	5
6	Multiply line 5 by .035	6
7	Recoveries of prior-year distributions	7
8	Minimum Asset Amount (add line 7 to line 6)	8

	Section C - Distributable Amount		Current Year
1	Adjusted net income for prior year (from Section A, line 8, Column A)	1
2	Enter 85% of line 1	2
3	Minimum asset amount for prior year (from Section B, line 8, Column A)	3
4	Enter greater of line 2 or line 3	4
5	Income tax imposed in prior year	5
6	Distributable Amount. Subtract line 5 from line 4, unless subject to emergency temporary reduction (see instructions)	6

Check here if the current year is the organization's first as a non-functionally-integrated Type III supporting organization (see instructions)

Schedule A (Form 990 or 990-EZ) 2019

Page 7

Part V

Type III Non-Functionally Integrated 509(a)(3) Supporting Organizations(continued)

Section D - Distributions		Current Year
1 Amounts paid to supported organizations to accomplish exempt purposes
2 Amounts paid to perform activity that directly furthers exempt purposes of supported organizations, in excess of income from activity
3 Administrative expenses paid to accomplish exempt purposes of supported organizations
4 Amounts paid to acquire exempt-use assets
5 Qualified set-aside amounts (prior IRS approval required)
6 Other distributions (describe in Part VI). See instructions
7Total annual distributions. Add lines 1 through 6.
8 Distributions to attentive supported organizations to which the organization is responsive (provide details in Part VI). See instructions
9 Distributable amount for 2019 from Section C, line 6
10 Line 8 amount divided by Line 9 amount

Section E - Distribution Allocations (see instructions)		(i) Excess Distributions	(ii) Underdistributions Pre-2019	(iii) Distributable Amount for 2019
1 Distributable amount for 2019 from Section C, line 6
2 Underdistributions, if any, for years prior to 2019 (reasonable cause required-- explain in Part VI). See instructions.
3 Excess distributions carryover, if any, to 2019:
a From 2014.......
b From 2015.......
c From 2016.......
d From 2017.......
e From 2018.......
fTotal of lines 3a through e
g Applied to underdistributions of prior years
h Applied to 2019 distributable amount
i Carryover from 2014 not applied (see instructions)
j Remainder. Subtract lines 3g, 3h, and 3i from 3f.
4Distributions for 2019 from Section D, line 7:
$
a Applied to underdistributions of prior years
b Applied to 2019 distributable amount
c Remainder. Subtract lines 4a and 4b from 4.
5 Remaining underdistributions for years prior to 2019, if any. Subtract lines 3g and 4a from line 2. If the amount is greater than zero, explain in Part VI. See instructions.
6 Remaining underdistributions for 2019. Subtract lines 3h and 4b from line 1. If the amount is greater than zero, explain in Part VI. See instructions.
7 Excess distributions carryover to 2020. Add lines 3j and 4c.
8 Breakdown of line 7:
a Excess from 2015.....
b Excess from 2016.....
c Excess from 2017.....
d Excess from 2018.....
e Excess from 2019.....

Schedule A (Form 990 or 990-EZ) (2019)

Schedule A (Form 990 or 990-EZ) 2019

Page 8

Part VI

Supplemental Information. Provide the explanations required by Part II, line 10; Part II, line 17a or 17b; Part III, line 12; Part IV, Section A, lines 1, 2, 3b, 3c, 4b, 4c, 5a, 6, 9a, 9b, 9c, 11a, 11b, and 11c; Part IV, Section B, lines 1 and 2; Part IV, Section C, line 1; Part IV, Section D, lines 2 and 3; Part IV, Section E, lines 1c, 2a, 2b, 3a and 3b; Part V, line 1; Part V, Section B, line 1e; Part V Section D, lines 5, 6, and 8; and Part V, Section E, lines 2, 5, and 6. Also complete this part for any additional information. (See instructions).

Facts And Circumstances Test

Return Reference	Explanation

Schedule A (Form 990 or 990-EZ) 2019

Additional Data

Software ID:
Software Version:

- TIN:

Schedule B
(Form 990, 990-EZ,
or 990-PF)

Department of the Treasury
Internal Revenue Service

Schedule of Contributors

Attach to Form 990, 990-EZ, or 990-PF.

Go to www.irs.gov/Form990 for the latest information.

OMB No. 1545-0047

2019

Name of the organization

COPLEY MEMORIAL HOSPITAL INC
C/O RUSH COPLEY MEDICAL CTR

Employer identification number

36-2170840

Organization type (check one):

Filers of:

Section:

Form 990 or 990-EZ

501(c)( ) (enter number) organization

4947(a)(1) nonexempt charitable trust not treated as a private foundation

527 political organization

Form 990-PF

501(c)(3) exempt private foundation

4947(a)(1) nonexempt charitable trust treated as a private foundation

501(c)(3) taxable private foundation

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

For an organization filing Form 990, 990-EZ, or 990-PF that received, during the year, contributions totaling $5,000 or more (in money or other property) from any one contributor. Complete Parts I and II. See instructions for determining a contributor's total contributions.

Special Rules

For an organization described in section 501(c)(3) filing Form 990 or 990-EZ that met the 33¹/3% support test of the regulations
under sections 509(a)(1) and 170(b)(1)(A)(vi), that checked Schedule A (Form 990 or 990-EZ), Part II, line 13, 16a, or 16b, and that received from any one contributor, during the year, total contributions of the greater of (1) $5,000 or (2) 2% of the amount on (i) Form 990, Part VIII, line 1h, or (ii) Form 990-EZ, line 1. Complete Parts I and II.

For an organization described in section 501(c)(7), (8), or (10) filing Form 990 or 990-EZ that received from any one contributor,
during the year, total contributions of more than $1,000 exclusively for religious, charitable, scientific, literary, or educational purposes, or for the prevention of cruelty to children or animals. Complete Parts I, II, and III.

For an organization described in section 501(c)(7), (8), or (10) filing Form 990 or 990-EZ that received from any one contributor,
during the year, contributions exclusively for religious, charitable, etc., purposes, but no such contributions totaled more than $1,000. If this box is checked, enter here the total contributions that were received during the year for an exclusively religious, charitable, etc., purpose. Don't complete any of the parts unless the General Rule applies to this organization because it received nonexclusively religious, charitable, etc., contributions totaling $5,000 or more during the year ......... Arrow Bullet

Caution: An organization that isn't covered by the General Rule and/or the Special Rules doesn't 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 its Form 990PF, Part I, line 2, to certify that it doesn't 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) (2019)

Schedule B (Form 990, 990-EZ, or 990-PF) (2019) Page 2

Name of organization COPLEY MEMORIAL HOSPITAL INC C/O RUSH COPLEY MEDICAL CTR

Part I Contributors	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
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
Schedule B (Form 990, 990-EZ, or 990-PF) (2019)

Schedule B (Form 990, 990-EZ, or 990-PF) (2019)

Page 3

Name of organization COPLEY MEMORIAL HOSPITAL INC C/O RUSH COPLEY MEDICAL CTR		Employer identification number 36-2170840

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) (2019)

Schedule B (Form 990, 990-EZ, or 990-PF) (2019)

Page 4


Name of organization COPLEY MEMORIAL HOSPITAL INC C/O RUSH COPLEY MEDICAL CTR			Employer identification number 36-2170840
Part III Exclusively religious, charitable, etc., contributions to organizations described in section 501(c)(7), (8), or (10) that total more than $1,000 for the year from any one contributor. 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.) $ Use duplicate copies of Part III if additional space is needed.

(a)
No. from Part I

(b) Purpose 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

(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

(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

(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) (2019)

Additional Data

Software ID:
Software Version:

- TIN:

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

Go to www.irs.gov/Form990 for instructions and the latest information.

OMB No. 1545-0047

2019

Open to Public
Inspection

If the organization answered "Yes" on 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" on 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" on Form 990, Part IV, Line 5 (Proxy Tax) (see separate instructions) or Form 990-EZ, Part V, line 35c (Proxy Tax) (see separate instructions), then
Round Bullet

Section 501(c)(4), (5), or (6) organizations: Complete Part III.

Name of the organization

COPLEY MEMORIAL HOSPITAL INC
C/O RUSH COPLEY MEDICAL CTR

Employer identification number

36-2170840

Part I-A

Complete if the organization is exempt under section 501(c) or is a section 527 organization.

Provide a description of the organization’s direct and indirect political campaign activities in Part IV (see instructions for definition of “political campaign activities")

Political campaign activity expenditures (see instructions) .................................................................... SchCMd Bullet

Volunteer hours for political campaign activities (see instructions) ..................................................................

Part I-B

Complete if the organization is exempt under section 501(c)(3).

Enter the amount of any excise tax incurred by the organization under section 4955 ................................ SchCMd Bullet

Enter the amount of any excise tax incurred by organization managers under section 4955 ....................... SchCMd Bullet

If the organization incurred a section 4955 tax, did it file Form 4720 for this year? .........................................

Yes No

Was a correction made? ......................................................................................................................

Yes No

If "Yes," describe in Part IV.

Part I-C

Complete if the organization is exempt under section 501(c), except section 501(c)(3).

Enter the amount directly expended by the filing organization for section 527 exempt function activities ..... SchCMd Bullet

Enter the amount of the filing organization's funds contributed to other organizations for section 527 exempt function activities ............................................................................................................................ SchCMd Bullet

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

Did the filing organization file Form 1120-POL for this year? ...................................................................

Yes No

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-.
1
2
3
4
5
6

For Paperwork Reduction Act Notice, see the instructions for Form 990 or 990-EZ.

Cat. No. 50084S

Schedule C (Form 990 or 990-EZ) 2019

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 Bullet

if the filing organization belongs to an affiliated group (and list in Part IV each affiliated group member's name, address, EIN, expenses, and share of excess lobbying expenditures).
B Check SchCMd Bullet

if the filing organization checked box A and "limited control" provisions apply.

Limits on Lobbying Expenditures (The term "expenditures" means amounts paid or incurred.)		(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? ...................................................................................................................	Yes No

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 separate instructions for lines 2a through 2f.)
Lobbying Expenditures During 4-Year Averaging Period
	Calendar year (or fiscal year beginning in)	(a) 2016	(b) 2017	(c) 2018	(d) 2019	(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) 2019

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 on lines 1a through 1i below, provide in Part IV a detailed description of the lobbying activity.

(a)

Yes|No

(b)

Amount

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:

Volunteers? ...........................................................................................................

Paid staff or management (include compensation in expenses reported on lines 1c through 1i)? ........

Media advertisements? ...................................................................................................

Mailings to members, legislators, or the public? .............................................................................

Publications, or published or broadcast statements? ...........................................................

Grants to other organizations for lobbying purposes? ..........................................................

Direct contact with legislators, their staffs, government officials, or a legislative body? .......................

Rallies, demonstrations, seminars, conventions, speeches, lectures, or any similar means? ..................

Other activities? ...................................................................................................................

Yes

52,616

Total. Add lines 1c through 1i ....................................................................................................

52,616

Did the activities in line 1 cause the organization to be not described in section 501(c)(3)? .....

If "Yes," enter the amount of any tax incurred under section 4912 ...........................................

If "Yes," enter the amount of any tax incurred by organization managers under section 4912 ...................

If the filing organization incurred a section 4912 tax, did it file Form 4720 for this year? ........................

Part III-A

Complete if the organization is exempt under section 501(c)(4), section 501(c)(5), or section 501(c)(6).

Yes

Were substantially all (90% or more) dues received nondeductible by members? ...............................................

Did the organization make only in-house lobbying expenditures of $2,000 or less? ............................................

Did the organization agree to carry over lobbying and political expenditures from the prior year? .................................

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."

Dues, assessments and similar amounts from members ......................................................................

Section 162(e) nondeductible lobbying and political expenditures (do not include amounts of political expenses for which the section 527(f) tax was paid).

Current year .............................................................................................................................

Carryover from last year ............................................................................................................

Total ...........................................................................................................................................

Aggregate amount reported in section 6033(e)(1)(A) notices of nondeductible section 162(e) dues .

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? ......................................................................................................................

Taxable amount of lobbying and political expenditures (see instructions) .........................................

Part IV

Supplemental Information

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, lines 1 and 2 (see instructions), and Part ll-B, line 1. Also, complete this part for any additional information.

Return Reference	Explanation
PART II-B, LINE 1:	COPLEY MEMORIAL HOSPITAL, INC. IS A MEMBER OF VARIOUS ORGANIZATIONS THAT ADVOCATE ON LEGAL AND POLICY ISSUES THAT AFFECT HEALTHCARE. A PORTION OF THE ANNUAL MEMBERSHIP DUES PAID BY COPLEY MEMORIAL HOSPITAL, INC. TO THESE ORGANIZATIONS IS ATTRIBUTABLE TO LOBBYING ACTIVITIES.

Schedule C (Form 990 or 990EZ) 2019

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE D
(Form 990)

Department of the Treasury
Internal Revenue Service

Supplemental Financial Statements

Complete if the organization answered "Yes," on 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

Go to www.irs.gov/Form990 for instructions and the latest information.

OMB No. 1545-0047

2019

Open to Public Inspection

Name of the organization

COPLEY MEMORIAL HOSPITAL INC
C/O RUSH COPLEY MEDICAL CTR

Employer identification number

36-2170840

Part I

Organizations Maintaining Donor Advised Funds or Other Similar Funds or Accounts. Complete if the organization answered "Yes" on Form 990, Part IV, line 6.

		(a) Donor advised funds	(b) Funds and other accounts
1	Total number at end of year .........
2	Aggregate value of contributions to (during year)
3	Aggregate value of grants from (during year)
4	Aggregate value at end of year ........

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? ............

Yes No

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? ...................................

Yes No

Part II

Conservation Easements.
Complete if the organization answered "Yes" on Form 990, Part IV, line 7.

Purpose(s) of conservation easements held by the organization (check all that apply).

Preservation of land for public use (e.g., recreation or education) Preservation of an historically important land area

Protection of natural habitat Preservation of a certified historic structure

Preservation of open space

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.


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 7/25/06, and not on a historic structure listed in the National Register ...	2d

Number of conservation easements modified, transferred, released, extinguished, or terminated by the organization during the
tax year SchDMd Bullet

Number of states where property subject to conservation easement is located SchDMd Bullet

Does the organization have a written policy regarding the periodic monitoring, inspection, handling of violations, and enforcement of the conservation easements it holds? ............

Yes No

Staff and volunteer hours devoted to monitoring, inspecting, handling of violations, and enforcing conservation easements during the year
SchDMd Bullet

Amount of expenses incurred in monitoring, inspecting, handling of violations, and enforcing conservation easements during the year
SchDMd Bullet

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)? .............................

Yes No

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" on Form 990, Part IV, line 8.

If the organization elected, as permitted under FASB 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.

If the organization elected, as permitted under FASB 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)

Revenue included on Form 990, Part VIII, line 1 ......................... SchDMd Bullet

(ii)

Assets included in Form 990, Part X ............................... SchDMd Bullet

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 FASB ASC 958 relating to these items:

Revenue included on Form 990, Part VIII, line 1 .......................... SchDMd Bullet

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) 2019

Page 2

Part III

Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets (continued)

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):

Public exhibition

Loan or exchange programs

Scholarly research

Other

Preservation for future generations

Provide a description of the organization’s collections and explain how they further the organization’s exempt purpose in
Part XIII.

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?...

Yes No

Part IV

Escrow and Custodial Arrangements. Complete if the organization answered "Yes" on Form 990, Part IV, line 9, or reported an amount on Form 990, Part X, line 21.

Is the organization an agent, trustee, custodian or other intermediary for contributions or other assets not
included on Form 990, Part X? ....................................

Yes No


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

Did the organization include an amount on Form 990, Part X, line 21, for escrow or custodial account liability? ...

Yes No

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" on Form 990, Part IV, line 10.

		(a) Current year	(b) Prior year	(c) Two years back	(d) Three years back	(e) Four years back

1a	Beginning of year balance ....	11,691,205	10,975,986	12,538,872	11,931,067	11,161,160
b	Contributions ...	1,193,365	2,004,750	1,093,070	2,373,022	1,178,338
c	Net investment earnings, gains, and losses	662,110	512,030	104,565	204,733	1,068,336
d	Grants or scholarships ...
e	Other expenditures for facilities and programs ...	1,577,382	1,801,561	2,760,521	1,969,950	1,476,767
f	Administrative expenses ....
g	End of year balance ......	11,969,298	11,691,205	10,975,986	12,538,872	11,931,067

Provide the estimated percentage of the current year end balance (line 1g, column (a)) held as:

Board designated or quasi-endowment SchDMd Bullet

22.000 %

Permanent endowment SchDMd Bullet

69.000 %

Term endowment SchDMd Bullet

9.000 %

The percentages on lines 2a, 2b, and 2c should equal 100%.

Are there endowment funds not in the possession of the organization that are held and administered for the
organization by:

Yes

(i) Unrelated organizations .................

3a(i)

(ii) Related organizations .................

3a(ii)

Yes

If "Yes" on 3a(ii), are the related organizations listed as required on Schedule R? .........

Yes

Describe in Part XIII the intended uses of the organization's endowment funds.

Part VI

Land, Buildings, and Equipment.
Complete if the organization answered "Yes" on Form 990, Part IV, line 11a. 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 .....	19,257,712		19,257,712
b	Buildings ....	234,484,556	122,430,595	112,053,961
c	Leasehold improvements	3,743,627	2,934,648	808,979
d	Equipment ....	144,913,914	109,660,255	35,253,659
e	Other .....	5,033,683		5,033,683
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).)..				172,407,994

Schedule D (Form 990) 2019

Page 3

Part VII

InvestmentsOther Securities.
Complete if the organization answered "Yes" on Form 990, Part IV, line 11b. See Form 990, Part X, line 12.

(a) Description of security or category (including name of security)	(b) Book value	(c) Method of valuation: Cost or end-of-year market value
(1) Financial derivatives.........
(2) Closely-held equity interests........
(3)Other
(B)
(C)
(D)
(E)
(F)
(G)
(H)
(I)
Total. (Column (b) must equal Form 990, Part X, col. (B) line 12.)

Part VIII

InvestmentsProgram Related. Complete if the organization answered 'Yes' on Form 990, Part IV, line 11c. See Form 990, Part X, line 13.

(a) Description of investment	(b) Book value	(c) Method of valuation: Cost or end-of-year market value

(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
Total. (Column (b) must equal Form 990, Part X, col.(B) line 13.)

Part IX

Other Assets.
Complete if the organization answered 'Yes' on Form 990, Part IV, line 11d. See Form 990, Part X, line 15.

(a) Description				(b) Book value
(1)DUE FROM AFFILIATES				86,316,107
(2)INVESTMENTS IN JOINT VENTURES				3,228,715
(3)MISCELLANEOUS				2,353,983
(4)
(5)
(6)
(7)
(8)
(9)
(10)
Total. (Column (b) must equal Form 990, Part X, col.(B) line 15.)...........				91,898,805

Part X

Other Liabilities.
Complete if the organization answered 'Yes' on Form 990, Part IV, line 11e or 11f. See Form 990, Part X, line 25.

1.(a) Description of liability	(b) Book value
(1) Federal income taxes
(7)
(8)
(9)
Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)	42,508,908
2. Liability for uncertain tax positions. 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) 2019

Page 4

Part XI Reconciliation of Revenue per Audited Financial Statements With Revenue per Return. Complete if the organization answered 'Yes' on Form 990, Part IV, line 12a.
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 (losses) 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. Complete if the organization answered 'Yes' on Form 990, Part IV, line 12a.
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

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.

Return Reference

Explanation

PART V, LINE 4:

RUSH COPLEY FOUNDATION HOLDS THE VORIS (INCOME FOR CMH CANCER CARE), KOBISK (BOARD RESTRICTED INCOME TO CMH), COPLEY (INCOME UNRESTRICTED), DOBBINS (INCOME FOR CMH WOMEN'S HEALTH), AND MOVEMENT DISORDER (INCOME FOR CMH MOVEMENT DISORDER PROGAM) ENDOWMENTS. RUSH COPLEY FOUNDATION ALSO HOLDS THE FOLLOWING QUASI ENDOWMENTS; NURSING (INCOME FOR CMH FUTURE OF NURSING SCHOLARSHIPS), FOX VALLEY HEART (INCOME FOR THE HEART INSTITUTE), WATERFORD PLACE (INCOME FOR CMH CANCER RESOURCE CENTER) AND COPLEY (INCOME FROM THE COPLEY ENDOWMENT). THESE FUNDS ARE HELD FOR THE BENEFIT OF COPLEY MEMORIAL HOSPITAL, INC.

PART X, LINE 2:

THE INTERNAL REVENUE SERVICE HAS DETERMINED THAT THE CORPORATION, THE HOSPITAL, VENTURES AND THE FOUNDATION ARE QUALIFIED AS TAX-EXEMPT ORGANIZATIONS UNDER CODE SECTION 501(C)(3); ACCORDINGLY, INCOME TAXES ARE NOT PROVIDED FOR IN THE ACCOMPANYING CONSOLIDATED FINANCIAL STATEMENTS. THE MEDICAL GROUP OPERATES AS A TAXABLE CORPORATION AND ACCOUNTS FOR INCOME TAXES UNDER FINANCIAL ACCOUNTING STANDARDS BOARD (FASB) ACCOUNTING STANDARDS CODIFICATION (ASC) 740. NO PROVISION FOR INCOME TAXES WAS RECORDED FOR 2018 AND 2017 DUE TO OPERATING LOSSES. AS OF JUNE 30, 2018, THE MEDICAL GROUP HAD NET OPERATING LOSS CARRYFORWARDS OF APPROXIMATELY $116,866,000 FOR INCOME TAX PURPOSES THAT ARE AVAILABLE TO OFFSET FUTURE TAXABLE INCOME. IF NOT UTILIZED, THESE CARRYFORWARDS WILL BEGIN TO EXPIRE IN 2019. BASED ON THE UNCERTAIN REALIZATION OF THESE CARRYFORWARDS, A VALUATION ALLOWANCE HAS BEEN RECORDED TO FULLY RESERVE THESE CARRYFORWARDS.

Schedule D (Form 990) 2019

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE H
(Form 990)

Department of the Treasury
Internal Revenue Service

Hospitals

Complete if the organization answered "Yes" on Form 990, Part IV, question 20.
MediumBullet

Attach to Form 990.
MediumBullet

Go to www.irs.gov/Form990EZ for instructions and the latest information.

OMB No. 1545-0047

2019

Open to Public Inspection

Name of the organization

COPLEY MEMORIAL HOSPITAL INC
C/O RUSH COPLEY MEDICAL CTR

Employer identification number

36-2170840

Part I

Financial Assistance and Certain Other Community Benefits at Cost

Yes

Did the organization have a financial assistance policy during the tax year? If "No," skip to question 6a . . . .

Yes

If "Yes," was it a written policy? ......................

Yes

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.

Applied uniformly to all hospital facilities Applied uniformly to most hospital facilities Generally tailored to individual hospital facilities

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.

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:

Yes

100% 150% 200% Other 20000.0000000000 %

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: . . . . . . . .

Yes

200% 250% 300% 350% 400% Other 60000.0000000000 %

If the organization used factors other than FPG in determining eligibility, describe in Part VI the criteria used 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.

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"? . . . . . . . . . . . . .

Yes

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

Yes

If "Yes," did the organization's financial assistance expenses exceed the budgeted amount? . . . . . .

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? . . . . . . . . . . . . .

Did the organization prepare a community benefit report during the tax year? . . . . . . . . .

Yes

If "Yes," did the organization make it available to the public? . . . . . . . . . . . . .

Yes

Complete the following table using the worksheets provided in the Schedule H instructions. Do not submit these worksheets with the Schedule H.

Financial Assistance and Certain Other Community Benefits at Cost

Financial Assistance and Means-Tested Government Programs		(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) . . .	3,961,766		3,961,766	1.400 %
b	Medicaid (from Worksheet 3, column a) . . . . .	68,800,321	54,093,488	14,706,833	5.200 %
c	Costs of other means-tested government programs (from Worksheet 3, column b) . .
d	Total Financial Assistance and Means-Tested Government Programs . . . . .	72,762,087	54,093,488	18,668,599	6.600 %
Other Benefits
e	Community health improvement services and community benefit operations (from Worksheet 4).	67,319		67,319	0.020 %
f	Health professions education (from Worksheet 5) . . .	4,031,361	1,091,639	2,939,722	1.040 %
g	Subsidized health services (from Worksheet 6) . . . .
h	Research (from Worksheet 7) .
i	Cash and in-kind contributions for community benefit (from Worksheet 8) . . . .	21,606		21,606	0.010 %
j	Total. Other Benefits . .	4,120,286	1,091,639	3,028,647	1.070 %
k	Total. Add lines 7d and 7j .	76,882,373	55,185,127	21,697,246	7.670 %

For Paperwork Reduction Act Notice, see the Instructions for Form 990. Cat. No. 50192T Schedule H (Form 990) 2019

Schedule H (Form 990) 2019

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.

		(f) Percent of total expense
1	Physical improvements and housing	0 %
2	Economic development	0 %
3	Community support	0 %
4	Environmental improvements	0 %
5	Leadership development and training for community members	0 %
6	Coalition building	0 %
7	Community health improvement advocacy	0 %
8	Workforce development	0 %
9	Other	0 %
10	Total

Part III

Bad Debt, Medicare, & Collection Practices

Section A. Bad Debt Expense

Yes

Did the organization report bad debt expense in accordance with Healthcare Financial Management Association Statement No. 15? ..........................

Yes

Enter the amount of the organization's bad debt expense. Explain in Part VI the methodology used by the organization to estimate this amount. ......

32,367,543

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. ......

3,236,754

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

Enter total revenue received from Medicare (including DSH and IME).....

88,098,623

Enter Medicare allowable costs of care relating to payments on line 5.....

109,421,433

Subtract line 6 from line 5. This is the surplus (or shortfall)........

-21,322,810

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:

Cost accounting system Cost to charge ratio Other

Section C. Collection Practices

Did the organization have a written debt collection policy during the tax year? ..........

Yes

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 .........................

Yes

Part IV

Management Companies and Joint Ventures(owned 10% or more by officers, directors, trustees, key employees, and physicians—see instructions)

(a) Name of entity	(b) Description of primary activity of entity	(c) Organization's profit % or stock ownership %	(d) Officers, directors, trustees, or key employees' profit % or stock ownership %	(e) Physicians' profit % or stock ownership %
1
2
3
4
5
6
7
8
9
10
11
12
13

Schedule H (Form 990) 2019

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?1Name, address, primary website address, and state license number (and if a group return, the name and EIN of the subordinate hospital organization that operates the hospital facility)
1	COPLEY MEMORIAL HOSPITAL 2000 OGDEN AVENUE AURORA,IL605044206 WWW.RUSHCOPLEY.COM 2150791	X	X	X	X

Schedule H (Form 990) 2019

Page 4

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)

	COPLEY MEMORIAL HOSPITAL
Name of hospital facility or letter of facility reporting group

Line number of hospital facility, or line numbers of hospital facilities in a facility
reporting group (from Part V, Section A):

Yes

Community Health Needs Assessment

Was the hospital facility first licensed, registered, or similarly recognized by a state as a hospital facility in the current tax year or the immediately preceding tax year?........................

Was the hospital facility acquired or placed into service as a tax-exempt hospital in the current tax year or the immediately preceding tax year? If “Yes,” provide details of the acquisition in Section C...............

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 12......................

Yes

If "Yes," indicate what the CHNA report describes (check all that apply):

A definition of the community served by the hospital facility

Demographics of the community

Existing health care facilities and resources within the community that are available to respond to the health needs of the community

How data was obtained

The significant health needs of the community

Primary and chronic disease needs and other health issues of uninsured persons, low-income persons, and minority groups

The process for identifying and prioritizing community health needs and services to meet the community health needs

The process for consulting with persons representing the community’s interests

The impact of any actions taken to address the significant health needs identified in the hospital facility's prior CHNA(s)

Other (describe in Section C)

Indicate the tax year the hospital facility last conducted a CHNA: 20 15

In conducting its most recent CHNA, did the hospital facility take into account input from persons who represent the broad interests of the community served by the hospital facility, including those with special knowledge of or expertise in public health? If "Yes," describe in Section C how the hospital facility took into account input from persons who represent the community, and identify the persons the hospital facility consulted .................

Yes

6 a

Was the hospital facility’s CHNA conducted with one or more other hospital facilities? If "Yes," list the other hospital facilities in Section C..................................

Was the hospital facility’s CHNA conducted with one or more organizations other than hospital facilities?” If “Yes,” list the other organizations in Section C. ............................

Did the hospital facility make its CHNA report widely available to the public?..............

Yes

If "Yes," indicate how the CHNA report was made widely available (check all that apply):

Hospital facility’s website (list url): SEE PART V, SECTION C.

Other website (list url):

Made a paper copy available for public inspection without charge at the hospital facility

Other (describe in Section C)

Did the hospital facility adopt an implementation strategy to meet the significant community health needs
identified through its most recently conducted CHNA? If "No," skip to line 11. ..............

Yes

Indicate the tax year the hospital facility last adopted an implementation strategy: 20 15

Is the hospital facility's most recently adopted implementation strategy posted on a website?.........

Yes

If "Yes" (list url): SEE PART V, SECTION C.

If "No," is the hospital facility’s most recently adopted implementation strategy attached to this return? ......

10b

Describe in Section C how the hospital facility is addressing the significant needs identified in its most recently conducted CHNA and any such needs that are not being addressed together with the reasons why such needs are not being addressed.

12a

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)?...............................

12a

If "Yes" on line 12a, did the organization file Form 4720 to report the section 4959 excise tax?........

12b

If "Yes" on line 12b, 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) 2019

Page 5

Part VFacility Information (continued)

Financial Assistance Policy (FAP)

	COPLEY MEMORIAL HOSPITAL
Name of hospital facility or letter of facility reporting group

Yes

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 included free or discounted care?

Yes

If “Yes,” indicate the eligibility criteria explained in the FAP:

Federal poverty guidelines (FPG), with FPG family income limit for eligibility for free care of 200.000000000000%
and FPG family income limit for eligibility for discounted care of 600.000000000000%

Income level other than FPG (describe in Section C)

Asset level

Medical indigency

Insurance status

Underinsurance discount

Residency

Other (describe in Section C)

Explained the basis for calculating amounts charged to patients?.................

Yes

Explained the method for applying for financial assistance?...................

Yes

If “Yes,” indicate how the hospital facility’s FAP or FAP application form (including accompanying instructions) explained the method for applying for financial assistance (check all that apply):

Described the information the hospital facility may require an individual to provide as part of his or her application

Described the supporting documentation the hospital facility may require an individual to submit as part of his or
her application

Provided the contact information of hospital facility staff who can provide an individual with information about the
FAP and FAP application process

Provided the contact information of nonprofit organizations or government agencies that may be sources of
assistance with FAP applications

Other (describe in Section C)

Was widely publicized within the community served by the hospital facility?........

Yes

If "Yes," indicate how the hospital facility publicized the policy (check all that apply):

The FAP was widely available on a website (list url):

SEE PART V, PAGE 8

The FAP application form was widely available on a website (list url):

SEE PART V, PAGE 8

A plain language summary of the FAP was widely available on a website (list url):
SEE PART V, PAGE 8

The FAP was available upon request and without charge (in public locations in the hospital facility and by mail)

The FAP application form was available upon request and without charge (in public locations in the hospital facility
and by mail)

A plain language summary of the FAP was available upon request and without charge (in public locations in the
hospital facility and by mail)

Individuals were notified about the FAP by being offered a paper copy of the plain language summary of the FAP, by
receiving a conspicuous written notice about the FAP on their billing statements, and via conspicuous public displays or
other measures reasonably calculated to attract patients' attention

Notified members of the community who are most likely to require financial assistance about availability of the FAP

The FAP, FAP application form, and plain language summary of the FAP were translated into the primary language(s)
spoken by LEP populations

Other (describe in Section C)

Schedule H (Form 990) 2019

Page 6

Part VFacility Information (continued)

Billing and Collections

	COPLEY MEMORIAL HOSPITAL
Name of hospital facility or letter of facility reporting group

Yes

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 all of the actions the hospital facility or other authorized party may take upon nonpayment?..................................

Yes

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 individual’s eligibility under the facility’s FAP:

Reporting to credit agency(ies)

Selling an individual’s debt to another party

Deferring, denying, or requiring a payment before providing medically necessary care due to nonpayment of a previous
bill for care covered under the hospital facility's FAP

Actions that require a legal or judicial process

Other similar actions (describe in Section C)

None of these actions or other similar actions were permitted

Did the hospital facility or other authorized party perform any of the following actions during the tax year before making reasonable efforts to determine the individual’s eligibility under the facility’s FAP?............

If "Yes," check all actions in which the hospital facility or a third party engaged:

Reporting to credit agency(ies)

Selling an individual’s debt to another party

Deferring , denying, or requiring a payment before providing medically necessary care due to nonpayment of a previous
bill for care covered under the hospital facility's FAP

Actions that require a legal or judicial process

Other similar actions (describe in Section C)

Indicate which efforts the hospital facility or other authorized party made before initiating any of the actions listed (whether or not checked) in line 19. (check all that apply):

Provided a written notice about upcoming ECAs (Extraordinary Collection Action) and a plain language summary of the
FAP at least 30 days before initiating those ECAs (if not, describe in Section C)

Made a reasonable effort to orally notify individuals about the FAP and FAP application process (if not, describe in
Section C)

Processed incomplete and complete FAP applications (if not, describe in Section C)

Made presumptive eligibility determinations (if not, describe in Section C)

Other (describe in Section C)

None of these efforts were made

Policy Relating to Emergency Medical Care

Did the hospital facility have in place during the tax year a written policy relating to emergency medical care that required 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?..................

Yes

If "No," indicate why:

The hospital facility did not provide care for any emergency medical conditions

The hospital facility’s policy was not in writing

The hospital facility limited who was eligible to receive care for emergency medical conditions (describe in Section C)

Other (describe in Section C)

Schedule H (Form 990) 2019

Page 7

Part VFacility Information (continued)

Charges to Individuals Eligible for Assistance Under the FAP (FAP-Eligible Individuals)

	COPLEY MEMORIAL HOSPITAL
Name of hospital facility or letter of facility reporting group

Yes

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.

The hospital facility used a look-back method based on claims allowed by Medicare fee-for-service during a prior 12-month period

The hospital facility used a look-back method based on claims allowed by Medicare fee-for-service and all private health insurers that pay claims to the hospital facility during a prior 12-month period

The hospital facility used a look-back method based on claims allowed by Medicaid, either alone or in combination with
Medicare fee-for-service and all private health insurers that pay claims to the hospital facility during a prior 12-month
period

The hospital facility used a prospective Medicare or Medicaid method

During the tax year, did the hospital facility charge any FAP-eligible individual 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? ...............................

If "Yes," explain in Section C.

During the tax year, did the hospital facility charge any FAP-eligible individual an amount equal to the gross charge for any service provided to that individual? ...........................

If "Yes," explain in Section C.

Schedule H (Form 990) 2019

Page 8

Part V

Facility Information (continued)

Section C. Supplemental Information for Part V, Section B. Provide descriptions required for Part V, Section B, lines 2, 3j, 5, 6a, 6b, 7d, 11, 13b, 13h, 15e, 16j, 18e, 19e, 20a, 20b, 20c, 20d, 20e, 21c, 21d, 23, and 24. If applicable, provide separate descriptions for each hospital facility in a facility reporting group, designated by facility reporting group letter and hospital facility line number from Part V, Section A (“A, 1,” “A, 4,” “B, 2,” “B, 3,” etc.) and name of hospital facility.
Form and Line Reference	Explanation
COPLEY MEMORIAL HOSPITAL	PART V, SECTION B, LINE 5: IN CONDUCTING THE COMMUNITY HEALTH NEEDS ASSESSMENT, THE HOSPITAL TOOK INTO ACCOUNT INPUT FROM PERSONS WHO REPRESENT THE BROAD INTERESTS OF THE COMMUNITY SERVED. THIS INCLUDED COMMUNITY RESIDENTS AND EXPERTS IN A RANGE OF AREAS INCLUDING PUBLIC HEALTH, MINORITY POPULATIONS, DISPARITIES IN HEALTH CARE, SOCIAL DETERMINANTS OF HEALTH, AND HEALTH & SOCIAL SERVICES. PERSONS WHO REPRESENT THE BROAD INTERESTS OF THE COMMUNITY SERVED INCLUDED: BOARD OF DIRECTORS, HOSPITAL ADMINISTRATION, COMMUNITY HEALTH NEEDS COMMITTEE, PARTNERSHIPS WITH KANE COUNTY, PARTNERSHIPS WITH KENDALL COUNTY, COMMUNITY HEALTH SURVEY, FOCUS GROUPS, AND SECONDARY DATA ANALYSIS. FOR COMPLETE DETAILS ABOUT HOW THE HOSPITAL TOOK INTO ACCOUNT INPUT FROM PERSONS WHO REPRESENT THE BROAD INTERESTS OF THE COMMUNITY SERVED, THE HOSPITAL'S COMMUNITY HEALTH NEEDS ASSESSMENT CAN BE ACCESSED AT: HTTP://WWW.RUSHCOPLEY.COM/ABOUT/COMMUNITY-HEALTH-NEEDS-ASSESSMENT-REPORT/
COPLEY MEMORIAL HOSPITAL	PART V, SECTION B, LINE 6A: THE KANE COUNTY HEALTH DEPARTMENT, RUSH COPLEY MEDICAL CENTER, NORTHWESTERN DELNOR HOSPITAL, AMITA MERCY MEDICAL CENTER, AMITA ST. JOSEPH HOSPITAL (ELGIN), AND ADVOCATE SHERMAN HOSPITAL WORKED TOGETHER ALONG WITH THE INC BOARD TO DEVELOP THE COUNTY'S IPLAN (ILLINOIS PROJECT FOR LOCAL ASSESSMENT OF NEEDS). THE IPLAN IS A COMMUNITY HEALTH ASSESSMENT AND PLANNING PROCESS THAT IS CONDUCTED EVERY THREE TO FIVE YEARS BY LOCAL HEALTH JURISDICTIONS IN ILLINOIS. THE COLLABORATIVE PARTICIPATION IN THE PLANNING PROCESS, PLAN DEVELOPMENT, AND IDENTIFICATION OF THE HEALTH NEEDS FOR THE COUNTY SERVED AS A FOUNDATION FOR THE DEVELOPMENT OF EACH OF THE HOSPITAL'S RESPECTIVE COMMUNITY HEALTH NEEDS ASSESSMENTS.
COPLEY MEMORIAL HOSPITAL	PART V, SECTION B, LINE 6B: THE KANE COUNTY HEALTH DEPARTMENT, RUSH COPLEY MEDICAL CENTER, NORTHWESTERN DELNOR HOSPITAL, AMITA MERCY MEDICAL CENTER, AMITA ST. JOSEPH HOSPITAL (ELGIN), AND ADVOCATE SHERMAN HOSPITAL WORKED TOGETHER ALONG WITH THE INC BOARD TO DEVELOP THE COUNTY'S IPLAN (ILLINOIS PROJECT FOR LOCAL ASSESSMENT OF NEEDS). THE IPLAN IS A COMMUNITY HEALTH ASSESSMENT AND PLANNING PROCESS THAT IS CONDUCTED EVERY THREE TO FIVE YEARS BY LOCAL HEALTH JURISDICTIONS IN ILLINOIS. THE COLLABORATIVE PARTICIPATION IN THE PLANNING PROCESS, PLAN DEVELOPMENT, AND IDENTIFICATION OF THE HEALTH NEEDS FOR THE COUNTY SERVED AS A FOUNDATION FOR THE DEVELOPMENT OF EACH OF THE HOSPITAL'S RESPECTIVE COMMUNITY HEALTH NEEDS ASSESSMENTS.
COPLEY MEMORIAL HOSPITAL	PART V, SECTION B, LINE 11: IMPLEMENTATION STRATEGY TO MEET SIGNIFICANT HEALTH NEEDS IDENTIFIED IN CHNA:RUSH COPLEY IS CURRENTLY WORKING ON THE IMPLEMENTATION OF STRATEGIES IDENTIFIED IN THE FY17-FY19 STRATEGY IMPLEMENTATION PLAN FOR THE THREE HEALTH NEED PRIORITIES IDENTIFIED IN THE FY2016 CHNA. KEY ACCOMPLISHMENT HIGHLIGHTS DURING THE YEAR ENDED JUNE 30, 2018 INCLUDE THE FOLLOWING: - DEVELOPED AND IMPLEMENTED A HEALTHY LIFESTYLE FAMILY PROGRAM FOR THE HISPANIC/LATINO COMMUNITY AT NO COST TO PARTICIPANTS (23 FAMILIES). A MAJORITY OF INDIVIDUALS IMPROVED THEIR KNOWLEDGE ABOUT A HEALTHY LIFESTYLE AND SAW AN IMPROVEMENT IN THEIR PHYSICAL ACTIVITY PERFORMANCE.- DESIGNED, DEVELOPED, AND IMPLEMENTED FOUR PROFESSIONALLY PRINTED BILINGUAL NUTRITION POSTERS THAT WERE INSTALLED AT FOUR LOCAL FOOD PANTIES FOR NATIONAL NUTRITION MONTH. ADDITIONALLY, RCMC PROVIDED EDUCATIONAL SESSIONS ON THE CONTENT OF THE NUTRITION POSTERS AT TWO OF THE FOOD PANTRIES WITH AN ESTIMATED 100 TOTAL PARTICIPANTS.- WORKED WITH CITY OF AURORA TO DEVELOP FOUR HEALTHY EATING COOKING DEMONSTRATION VIDEOS WITH BILINGUAL SUBTITLES THAT FEATURE HEALTHY HISPANIC/LATINO RECIPES.- PARTNERED WITH COMMUNITY ORGANIZATIONS TO DEVELOP A PILOT FOOD PRESCRIPTION PROGRAM FOR VULNERABLE POPULATIONS THROUGH THE NEW KANE COUNTY FOOD HUB PROGRAM.- CONTINUED TO OFFER THE 12-WEEK HEALTHY WEIGHT LOSS PROGRAM, YOUFIT, WHERE PARTICIPANTS SAW AN AVERAGE DECREASE OF 1.1 BMI POINTS AND LOST AN AVERAGE OF 7.3 POUNDS. - BASED ON PARTICIPANT FEEDBACK FROM THE YOUFIT PROGRAM, RCMC DEVELOPED A MAINTENANCE HEALTHY WEIGHT LOSS PROGRAM CALLED YOUFIT MORE, AN 8-WEEK PROGRAM FOR THOSE WHO ARE CONTINUING OR RENEWING THEIR WEIGHT LOSS GOALS.- CONTINUED THE PROCESS DEVELOPED BY RCMC CARE MANAGEMENT OF SCHEDULING POST-DISCHARGE FOLLOW-UP APPOINTMENTS WITH A PCP FOR PATIENTS TREATED IN THE ED WHO DO NOT HAVE A PCP OR ARE UNAWARE OF THEIR PCP, ESPECIALLY THOSE WHO ARE VULNERABLE, HAVE A CHRONIC DISEASE, AND/OR ARE HIGH UTILIZERS OF THE ED. CARE MANAGERS SCHEDULED APPROXIMATELY 1,800 POST-DISCHARGE FOLLOW-UP APPOINTMENTS IN FY18.- CONTINUED THE PROCESS DEVELOPED BY RCMC CARE MANAGEMENT OF SCHEDULING POST-DISCHARGE FOLLOW-UP APPOINTMENTS FOR THE HIGH-RISK CHRONIC DISEASE INPATIENTS. IN FY18, 83% OF CHF PATIENTS AND 100% OF STROKE PATIENTS HAD THEIR POST DISCHARGE FOLLOW-UP APPOINTMENT SCHEDULED FOR THEM BEFORE DISCHARGE. - DEVELOPED AND IMPLEMENTED A MEDICATION ADHERENCE PILOT PROGRAM FOR HEART FAILURE AND CORONARY INTERVENTION PATIENTS. DURING THE PILOT PROGRAM 92% OF PATIENTS HAD DISCREPANCIES IN THEIR MEDICATION LISTS WHICH WERE RECONCILED.- BEGAN THE DEVELOPMENT OF A CHRONIC DISEASE COMMUNITY EDUCATION SERIES TO PROVIDE TOOLS AND RESOURCES FOR HOW TO MANAGE CHRONIC HEALTH CONDITIONS. - CONTINUED TO ACTIVELY PARTICIPATE WITH COMMUNITY PARTNERS IN THE DISCUSSION AND DEVELOPMENT OF RESOURCES AND EDUCATION REGARDING APPROPRIATE CARE SETTINGS.- RCMC CARE MANAGEMENT PROVIDED ONE-ON-ONE EDUCATION IN THE ED ABOUT APPROPRIATE CARE SETTINGS TO APPROXIMATELY 1,000 PATIENTS IN FY18.- IN FY18, RAN 27 PROGRAMS IN THE COMMUNITY RELATED TO THE TOP IDENTIFIED NEEDS OF OBESITY, CHRONIC DISEASE AND ACCESS TO CARE WITH OVER 950 ATTENDEES.THE FOLLOWING NEEDS ARE NOT BEING ADDRESSED BY COPLEY MEMORIAL HOSPITAL: (1) BEHAVIORAL HEALTH, INCLUDING MENTAL HEALTH AND SUBSTANCE ABUSE. IT WOULD NOT BE FEASIBLE FOR THE HOSPITAL TO DEVELOP THIS TYPE OF PROGRAM, BUT THE HOSPITAL WORKS CLOSELY WITH BEHAVIORAL HEALTH PROGRAMS IN THE COMMUNITY IN ORDER TO ASSIST PATIENTS IN ACCESSING CARE. (2) ACCESS TO CARE: TRANSPORTATION FOR HEALTH CARE SERVICES. IT WOULD NOT BE FEASIBLE FOR THE HOSPITAL TO DEVELOP THIS TYPE OF PROGRAM, BUT THE HOSPITAL CONTINUES TO ADDRESS THE NEED FOR TRANSPORTATION THROUGH A NUMBER OF PROGRAMS, RESOURCES, GRANTS AND OUTREACH ACTIVITIES IN THE COMMUNITY, INCLUDING: PROVIDES CAB FARE AND BUS VOUCHERS, COORDINATES PUBLIC TRANSPORTATION, AND HELPS IDENTIFY PATIENTS APPROPRIATE FOR COUNTY-FUNDED TRANSPORTATION. (3) INCOME, JOB-READY WORKFORCE AND EDUCATION. THIS NEED IS BEING ADDRESSED THROUGH THE KANE COUNTY IPLAN WITH A DEDICATED KANE HEALTH COUNTS COMMITTEE DEVELOPING AND IMPLEMENTING STRATEGIES TO IMPROVE INCOME, JOB READINESS AND EDUCATION ATTAINMENT IN THE COMMUNITY. WHILE THE HOSPITAL IS NOT IN A POSITION TO IMPACT THIS NEED ON A LARGE SCALE THROUGHOUT THE COMMUNITY, THE HOSPITAL HAS A NUMBER OF PROGRAMS IN PLACE THAT HELP ADDRESS THIS NEED, INCLUDING: EMPLOYEE TUITION REIMBURSEMENT PROGRAM, OFFERING EMPLOYEES REIMBURSEMENT FOR SPECIALTY CERTIFICATION/CONTINUING EDUCATION, AND PARTNERING WITH LOCAL SCHOOLS TO PROVIDE JOB-READINESS PROGRAMS FOR THE HEALTH CARE WORKFORCE.
PART V, SECTION B, LINE 7A	HTTPS://WWW.RUSHCOPLEY.COM/APP/FILES/PUBLIC/3767/CHNA-FY2016-FINAL.PDF
PART V, SECTION B, LINE 10A	HTTPS://WWW.RUSHCOPLEY.COM/APP/FILES/PUBLIC/3768/RCMC-IMPLEMENTATION-STRATEGY---FY2016-FINAL.PDF
PART V, SECTION B, LINE 16A	HTTPS://WWW.RUSHCOPLEY.COM/APP/FILES/PUBLIC/4528/FINANCIAL-ASSISTANCE-CHARITY-CARE-POLICY.PDF
PART V, SECTION B, LINE 16B	HTTPS://WWW.RUSHCOPLEY.COM/APP/FILES/PUBLIC/4526/FINANCIAL-ASSISTANCE-APPLICATION.PDF
PART V, SECTION B, LINE 16C	HTTPS://WWW.RUSHCOPLEY.COM/APP/FILES/PUBLIC/4530/PLAIN-LANGUAGE-SUMMARY.PDF

Schedule H (Form 990) 2019

Page 9

Part VFacility Information (continued)

Section D. 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?5
Name and address		Type of Facility (describe)
1	1 - RIVER WEST RADIATION CENTER LLC 1221 N HIGHLAND AVENUE AURORA,IL605044206	JV ONCOLOGY
2	2 - CASTLE SURGICENTER 2111 OGDEN AVE AURORA,IL60504	AMBULATORY SURGERY CENTER
3	3 - RUSH COPLEY HEALTHCARE CENTER 1100 WEST VETERANS PARKWAY YORKVILLE,IL60560	FREE STANDING EMERGENCY CARE, RADIOLOGY, LAB, AND OCCUPATIONAL HEALTH SERVI
4	4 - RUSH COPLEY CARDIOVASCULAR 2000 OGDEN AVENUE AURORA,IL605044206	CARDIOVASCULAR SERVICES
5	5 - MIDWEST CENTER FOR ADVANCED IMAGING 4355 MONTGOMERY ROAD NAPERVILLE,IL60564	RADIOLOGY SERVICES
6
7
8
9
10

Schedule H (Form 990) 2019

Page 10

Part VI

Supplemental Information

Provide the following information.

1	Required descriptions. Provide the descriptions required for Part I, lines 3c, 6a, and 7; Part II and Part III, lines 2, 3, 4, 8 and 9b.
2	Needs assessment. Describe how the organization assesses the health care needs of the communities it serves, in addition to any CHNAs 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.

Form and Line Reference	Explanation
PART I, LINE 7:	THE COST TO CHARGE RATIO CALCULATED IN WORKSHEET 2 WAS USED TO CALCULATE THE AMOUNTS REPORTED IN TABLE A. THE COST ACCOUNTING SYSTEM ADDRESSES ALL PATIENT SEGMENTS (INPATIENT, OUTPATIENT, EMERGENCY ROOM, PRIVATE INSURANCE, MEDICAID, MEDICARE, UNINSURED AND SELF PAY).
PART III, LINE 4:	NET PATIENT SERVICE REVENUE IS REPORTED AT THE ESTIMATED NET REALIZABLE AMOUNTS FROM THIRD PARTY PAYORS, PATIENTS, AND OTHERS FOR SERVICES RENDERED. RCMC HAS AGREEMENTS WITH THIRD PARTY PAYORS THAT PROVIDE FOR PAYMENT AT AMOUNTS DIFFERENT FROM ESTABLISHED RATES. PAYMENT ARRANGEMENTS INCLUDE PROSPECTIVELY DETERMINED RATES PER DISCHARGE, REIMBURSED COSTS, PER DIEM PAYMENTS, AND DISCOUNTED CHARGES, INCLUDING ESTIMATED RETROACTIVE SETTLEMENTS UNDER PAYMENT AGREEMENTS WITH THIRD PARTY PAYORS. RCMC RECOGNIZES PATIENT SERVICE REVENUE ASSOCIATED WITH SERVICES PROVIDED TO PATIENT WHO HAVE THIRD PARTY PAYOR COVERAGE ON THE BASIS OF CONTRACTUAL RATES FOR SERVICES RENDERED. PROVISIONS FOR ADJUSTMENTS TO NET PATIENT SERVICE REVENUE ARE ACCRUED ON AN ESTIMATED BASIS IN THE PERIOD THE RELATED SERVICES ARE RENDERED AND ADJUSTED TO FUTURE PERIODS AS FINAL SETTLEMENTS ARE DETERMINED. FOR UNINSURED PATIENTS THAT DO NOT QUALIFY FOR CHARITY CARE, RCMC RECOGNIZES REVENUE BASED ON ITS DISCOUNTED RATES. ON THE BASIS OF HISTORICAL EXPERIENCE, A SIGNIFICANT PORTION OR RCMC'S UNINSURED PATIENTS WILL BE UNABLE OR UNWILLING TO PAY FOR SERVICES PROVIDED. THUS, RCMC RECORDS A SIGNIFICANT PROVISION FOR UNCOLLECTIBLE ACCOUNTS RELATED TO UNINSURED PATIENTS IN THE PERIOD THE SERVICES ARE PROVIDED.PATIENT ACCOUNTS RECEIVABLE ARE BASED ON GROSS CHARGES AND STATED AT NET REALIZABLE VALUE. ACCOUNTS RECEIVABLE ARE REDUCED BY AN ALLOWANCE FOR CONTRACTUAL ADJUSTMENTS, BASED ON EXPECTED PAYMENT RATES FROM PAYORS UNDER CURRENT REIMBURSEMENT METHODOLOGIES, AND ALSO BY AN ALLOWANCE FOR DOUBTFUL ACCOUNTS. IN EVALUATING THE COLLECTABILITY OF ACCOUNTS RECEIVABLE, THE HOSPITAL ANALYZES ITS PAST HISTORY AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYOR SOURCES OF REVENUE TO ESTIMATE APPROPRIATE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND PROVISION FOR UNCOLLECTIBLE ACCOUNTS BASED UPON MANAGEMENT'S ASSESSMENT OF HISTORICAL AND EXPECTED NET COLLECTIONS CONSIDERING BUSINESS AND ECONOMIC CONDITIONS, TRENDS IN HEALTH CARE COVERAGE, AND OTHER COLLECTION INDICATORS. MANAGEMENT REGULARLY REVIEWS DATA ABOUT THESE MAJOR PAYOR SOURCES OF REVENUE IN EVALUATING THE SUFFICIENCY OF THE ALLOWANCE FOR CONTRACTUAL ADJUSTMENTS AND ALLOWANCE FOR DOUBTFUL ACCOUNTS.FOR RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRD-PARTY COVERAGE, RCMC ANALYZES CONTRACTUALLY DUE AMOUNTS AND PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS AND A PROVISION FOR UNCOLLECTIBLE ACCOUNTS (FOR EXAMPLE, FOR EXPECTED UNCOLLECTIBLE DEDUCTIBLES AND COPAYMENTS ON ACCOUNTS FOR WHICH THE THIRD-PARTY PAYOR HAS NOT YET PAID, OR FOR PAYORS WHO ARE KNOWN TO BE HAVING FINANCIAL DIFFICULTIES THAT MAKE THE REALIZATION OF AMOUNTS DUE UNLIKELY). FOR RECEIVABLES ASSOCIATED WITH SELF-PAY PATIENTS (WHICH INCLUDES BOTH PATIENTS WITHOUT INSURANCE AND PATIENTS WITH DEDUCTIBLE AND COPAYMENT BALANCES DUE FOR WHICH THIRD-PARTY COVERAGE EXISTS FOR PART OF THE BILL), RCMC RECORDS A SIGNIFICANT PROVISION FOR UNCOLLECTIBLE ACCOUNTS IN THE PERIOD OF SERVICE ON THE BASIS OF ITS PAST EXPERIENCE, WHICH INDICATES THAT MANY PATIENTS ARE UNABLE OR UNWILLING TO PAY THE PORTION OF THEIR BILL FOR WHICH THEY ARE FINANCIALLY RESPONSIBLE.THE DIFFERENCE BETWEEN THE DISCOUNTED RATES AND THE AMOUNTS ACTUALLY COLLECTED AFTER ALL REASONABLE COLLECTION EFFORTS HAVE BEEN EXHAUSTED IS CHARGED OFF AGAINST THE ALLOWANCE FOR DOUBTFUL ACCOUNTS IN THE PERIOD THEY ARE DETERMINED UNCOLLECTIBLE.
PART III, LINE 8:	ALL OF THE SHORTFALL SHOULD BE TREATED AS COMMUNITY BENEFIT BECAUSE IF WE DID NOT PROVIDE THE SERVICE, THE BURDEN OF THE COSTS WOULD FALL ON THE GOVERNMENT.
PART III, LINE 9B:	IT IS OUR POLICY NOT TO PURSUE COLLECTION PRACTICES AGAINST PATIENTS KNOWN TO QUALIFY FOR CHARITY CARE OR OTHER FINANCIAL ASSISTANCE. IN CERTAIN CASES IT MAY NOT BE EASILY DETERMINED WHETHER OR NOT A PATIENT QUALIFIES FOR CHARITY CARE OR FINANCIAL ASSISTANCE. HOWEVER, IF AFTER COLLECTION PRACTICES HAVE BEGUN, IT BECOMES KNOWN THE PATIENT QUALIFIES, THE COLLECTION EFFORTS CEASE.
PART VI, LINE 2:	COMMUNITY NEED IS ASSESSED THROUGH REVIEW OF COMMUNITY AND HOSPITAL DATA, PERIODIC ASSESSMENTS WITH PHYSICIAN AND CLINICIANS, AND REPORTING OF INFORMATION FROM HOSPITAL COMMITTEES. FURTHER INPUT FROM THE COMMUNITY ARISES FROM THE COMMUNITY BASED BOARD OF DIRECTORS, VARIOUS FORMS OF PATIENT INPUT, AND HOSPITAL INVOLVEMENT WITH GOVERNMENT, HEALTH INDUSTRY, AND COMMUNITY AGENCIES. THE HOSPITAL ALSO ACTIVELY PARTICIPATES IN FORMAL NEEDS ASSESSMENTS CONDUCTED BY GOVERNMENT AND COMMUNITY AGENCIES.
PART VI, LINE 3:	AT THE TIME OF SERVICE, COPLEY MEMORIAL HOSPITAL, INC. PATIENTS ARE GIVEN A BILLING BROCHURE, WHICH DESCRIBES THE FINANCIAL ASSISTANCE/CHARITY CARE PROGRAMS AVAILABLE. THIS INFORMATION IS ALSO POSTED AT THE REGISTRATION CHECK-IN DESKS, IN AN INPATIENT GUIDE, AND ON THE RUSH COPLEY WEBSITE. FINANCIAL COUNSELORS ARE AVAILABLE TO EXPLAIN THE PROGRAM IN DETAIL TO PATIENTS WHO ARE SEEN WITHOUT INSURANCE COVERAGE. ALL PATIENT BILLING STATEMENTS ADVISE THE PATIENTS TO CALL AND INQUIRE ON THE DETAILS AS NEEDED.
PART VI, LINE 4:	COPLEY MEMORIAL HOSPITAL INC.'S PRIMARY SERVICE AREA IS APPROXIMATELY SOUTHERN KANE COUNTY AND KENDALL COUNTY, ILLINOIS LOCATED 45 TO 55 MILES SOUTHWEST OF CHICAGO. KANE COUNTY HAS A POPULATION OF 535,000 PEOPLE AND IS PREDOMINANTLY URBAN AND SUBURBAN. NEARLY 32% OF THE POPULATION IS OF HISPANIC OR LATINO ORIGIN. PERSONS OVER THE AGE OF 65 COMPRISE 13% OF THE POPULATION, AND THE POVERTY RATE IS 11%. AURORA IS THE SECOND LARGEST CITY IN ILLINOIS, AND IT DOMINATES THE COUNTY. HISTORICALLY AN INDUSTRIAL CITY, AURORA HAS EXPERIENCED A CONSIDERABLE LOSS OF MANUFACTURING JOBS AND IS TRANSITIONING ITS ECONOMY. KENDALL COUNTY, TO THE SOUTH OF KANE, HAS A POPULATION OF 127,000. PERSONS OVER THE AGE OF 65 COMPRISE 10.0% OF THE POPULATION, AND THE POVERTY RATE IS 5.4%. THE NORTHWEST SECTION OF THE COUNTY IS SUBURBAN WHILE THE REMAINDER IS RURAL.
PART VI, LINE 5:	COPLEY MEMORIAL HOSPITAL'S MISSION IS TO PROVIDE ADVANCED MEDICINE WITH QUALITY OUTCOMES AND EXTRAORDINARY CARE. TO THAT END, THE MEDICAL CENTER SEEKS TO SERVE THE COMMUNITY IN WAYS THAT ENGAGE, EDUCATE AND EMPOWER. COPLEY MEMORIAL HOSPITAL SERVES ALL PATIENTS WHO PRESENT FOR CARE AND SERVES THE SURROUNDING COMMUNITY ALONG WITH A BOARD OF DIRECTORS WITH A STRONG COMMUNITY BASE. THE BOARD MEMBERS ARE INDEPENDENT COMMUNITY LEADERS AND ARE SELECTED BASED UPON THEIR EXPERTISE AND EXPERIENCE IN A VARIETY OF AREAS OF BENEFIT TO THE ORGANIZATION AND THEIR ROLE AS BOARD MEMBERS WHO DIRECT AND GUIDE MANAGEMENT IN CARRYING OUT OUR MISSION. BOARD MEMBERS ARE NOT COMPENSATED FOR THEIR SERVICE. AS A CHARITABLE ORGANIZATION, ALL SURPLUS FUNDS ARE USED TO FURTHER OUR CHARITABLE PURPOSE, MISSION AND TO SERVE THE COMMUNITY. SOME OF OUR PRIMARY PROGRAMS ARE: COMMUNITY HEALTH FAIRS, BREASTFEEDING EDUCATION CLASSES, CHILD CARE CLASSES, ETC. COPLEY MEMORIAL HOSPITAL PROVIDES ACCESS TO PHYSICIAN, ACUTE CARE, DIAGNOSTIC, AND REHABILITATIVE SERVICES TO PEOPLE, REGARDLESS OF ABILITY TO PAY, THROUGH A NUMBER OF FACILITIES AND SERVICES LOCATED THROUGHOUT THE SERVICE AREA. IT PROVIDES PROGRAMMING RELATING TO HEALTH EDUCATION, PREVENTION, AND SUPPORT TARGETED TO SPECIFIC POPULATIONS. MEDICAL EDUCATION EXTENDS TO CLINICAL SETTINGS FOR NURSING EDUCATION AND A FAMILY PRACTICE RESIDENCY. EMPLOYEES FILL BOARD AND COMMITTEE LEADERSHIP POSITIONS FOR A NUMBER OF ECONOMIC DEVELOPMENT AND SOCIAL SERVICE AGENCIES IN COMMUNITIES THROUGHOUT THE SERVICE AREA.
PART VI, LINE 7, REPORTS FILED WITH STATES	IL
PART V, SECTION B, LINE 16I	THE FOLLOWING DISCLOSURE IS IN ACCORDANCE WITH REV. PROC 2015-21 SECTION 7 IN REGARDS TO SCHEDULE H, PART V, SECTION B, LINE 16I:FOR THE FISCAL YEAR ENDED 6/30/18, COPLEY MEMORIAL HOSPITAL, INC. (CMH) PROVIDED SPANISH TRANSLATIONS OF THE FINANCIAL ASSISTANCE POLICY, PLAIN LANGUAGE SUMMARY, AND FINANCIAL ASSISTANCE APPLICATION. ADDITIONALLY, CMH PROVIDES LANGUAGE ASSISTANCE FREE OF CHARGE FOR MANY OTHER LANGUAGES (SEE HTTPS://WWW.RUSHCOPLEY.COM/ABOUT/LANGUAGE-ASSISTANCE/). HOWEVER, FOR PART OF THE TAX YEAR, (CMH) DID NOT HAVE THE FINANCIAL ASSISTANCE POLICY, PLAIN LANGUAGE SUMMARY, AND FINANCIAL ASSISTANCE APPLICATION TRANSLATED INTO EACH OF THE PRIMARY LANGUAGES SPOKEN BY LIMITED ENGLISH PROFICIENCY (LEP) POPULATIONS. DUE TO THE AVAILABILITY OF TRANSLATION ASSISTANCE, CMH IS NOT AWARE OF ANY INDIVIDUALS WHO WERE ADVERSELY IMPACTED BY THIS OVERSIGHT. AS OF SEPTEMBER 30, 2018, CMH HAD ALL OF THE TRANSLATIONS COMPLETED AND AVAILABLE ON THEIR WEBSITE. CMH HAS ALSO IMPLEMENTED PROCEDURES TO ENSURE COMPLIANCE WITH THIS REQUIREMENT IN THE FUTURE BY ANNUALLY REVIEWING THE LEP POPULATIONS AND ADDING ADDITIONAL TRANSLATIONS AS NEEDED AND UPDATING THE TRANSLATIONS SHOULD THERE BE CHANGES TO THE DOCUMENTS.
PART V, SECTION B, LINE 20A	THE FOLLOWING DISCLOSURE IS IN ACCORDANCE WITH REV. PROC 2015-21 SECTION 7 IN REGARDS TO SCHEDULE H, PART V, LINE 20A: DURING THE TAX YEAR, COPLEY MEMORIAL HOSPITAL (CMH) DID NOT PROVIDE A PLAIN LANGUAGE SUMMARY OF THE FAP WITH THE WRITTEN NOTICE ABOUT UPCOMING ECAS PROVIDED TO PATIENTS AT LEAST 30 DAYS BEFORE INITIATING THOSE ECAS. IN FY18, CMH PROVIDED BILLING COMMUNICATIONS THAT INCLUDED COMMENTS ON THE FINANCIAL ASSISTANCE AVAILABLE TO PATIENTS, BUT DID NOT TECHNICALLY PROVIDE THE PLAIN LANGUAGE SUMMARY WITHIN THE WRITTEN NOTIFICATION. THIS WAS DISCOVERED IN APRIL 2019 AS CMH WORKED WITH TAX CONSULTANTS ON SCHEDULE H. CMH ESTIMATES THIS AFFECTED AN ESTIMATED 10,000 TO 12,000 CMH PATIENTS WHO RECEIVED THE WRITTEN NOTICE ABOUT UPCOMING ECAS WITHOUT THE PLAIN LANGUAGE SUMMARY. CMH HAS SINCE IMPLEMENTED PROCEDURES TO ENSURE COMPLIANCE WITH THIS REQUIREMENT GOING FORWARD. CMH WILL BEGIN INCLUDING THE PLAIN LANGUAGE SUMMARY WHEN MAILING A PREANNOUNCEMENT TO THE PATIENT THAT ECA WILL BE TAKEN. THE ANNOUNCEMENT IS MAILED A MINIMUM OF 30 DAYS PRIOR TO ANY ECA BEING TAKEN AND WILL NOW INCLUDE THE PLAIN LANGUAGE SUMMARY. THIS WILL ENSURE THAT ALL PATIENTS THAT COULD POTENTIALLY RECEIVE AN ECA IN THE EVENT OF NON-PAYMENT WILL HAVE RECEIVED THE PLAIN LANGUAGE SUMMARY AT LEAST 30 DAYS IN ADVANCE. ADDITIONALLY, CMH MAKES EFFORTS TO NOTIFY ALL PATIENTS OF THE AVAILABILITY OF FINANCIAL ASSISTANCE ORALLY THROUGHOUT THE BILLING PROCESS IN COMMUNICATIONS PRIOR TO INITIATING ANY ECAS.
PART V, SECTION B, LINE 22B	THE FOLLOWING DISCLOSURE IS IN ACCORDANCE WITH REV. PROC 2015-21 SECTION 7 IN REGARDS TO SCHEDULE H, PART V, SECTION B, LINE 22B:DURING THE TAX YEAR, COPLEY MEMORIAL HOSPITAL, INC. (CMH) COMPLETED THE AGB CALCULATION AND APPLIED IT TO PATIENT ACCOUNTS. HOWEVER, CMH DID NOT INCLUDE IN ITS FINANCIAL ASSISTANCE POLICY THE AMOUNTS GENERALLY BILLED (AGB) PERCENTAGE NOR DID IT EXPLAIN HOW MEMBERS OF THE PUBLIC MAY READILY OBTAIN SUCH PERCENTAGES. CMH'S AGB CALCULATION USES THE LOOK-BACK METHOD BASED ON CLAIMS ALLOWED BY MEDICARE FEE-FOR-SERVICE AND ALL PRIVATE HEALTH INSURERS THAT PAY CLAIMS TO THE HOSPITAL FACILITY DURING A PRIOR 12-MONTH PERIOD. CMH IS WORKING TO UPDATE THE FINANCIAL ASSISTANCE POLICY TO INCLUDE INFORMATION ON WHERE PATIENTS CAN FIND THE AGB PERCENTAGE AND WILL MAKE THIS AVAILABLE TO PATIENTS. CMH DETERMINED THAT THIS OVERSIGHT DID NOT CAUSE ANY PATIENTS WHO QUALIFY FOR FINANCIAL ASSISTANCE TO BE CHARGED GREATER THAN AGB AS THE PERCENTAGE WAS CORRECTLY CALCULATED AND APPLIED TO PATIENT ACCOUNTS. CMH HAS ALSO IMPLEMENTED PROCEDURES TO ENSURE ANNUAL COMPLIANCE WITH THIS REQUIREMENT IN THE FUTURE. CMH WILL REGULARLY REVIEW THE AGB PERCENTAGE AND WILL MONITOR THE PERCENTAGE USED TO MAKE SURE ANY PATIENT WHO QUALIFIES FOR FINANCIAL ASSISTANCE ISN'T OVER CHARGED.

Schedule H (Form 990) 2019

Additional Data

Software ID:
Software Version:

- TIN:

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" on Form 990, Part IV, line 23.
SchJMediumBullet

Attach to Form 990.
SchJMediumBullet

Go to www.irs.gov/Form990 for instructions and the latest information.

OMB No. 1545-0047

2019

Open to Public Inspection

Name of the organization

COPLEY MEMORIAL HOSPITAL INC
C/O RUSH COPLEY MEDICAL CTR

Employer identification number

36-2170840

Part I

Questions Regarding Compensation

Yes

Check the appropiate box(es) if the organization provided any of the following to or for a person listed on Form
990, Part VII, Section A, line 1a. Complete Part III to provide any relevant information regarding these items.

First-class or charter travel Housing allowance or residence for personal use

Travel for companions Payments for business use of personal residence

Tax idemnification and gross-up payments Health or social club dues or initiation fees

Discretionary spending account Personal services (e.g., maid, chauffeur, chef)

If any of the boxes on 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 .........

Yes

Did the organization require substantiation prior to reimbursing or allowing expenses incurred by all
directors, trustees, officers, including the CEO/Executive Director, regarding the items checked on Line 1a? ..

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.

Compensation committee Written employment contract

Independent compensation consultant Compensation survey or study

Form 990 of other organizations Approval by the board or compensation committee

During the year, did any person listed on Form 990, Part VII, Section A, line 1a, with respect to the filing organization or a related organization:

Receive a severance payment or change-of-control payment? .............

Participate in, or receive payment from, a supplemental nonqualified retirement plan? .........

Yes

Participate in, or receive payment from, an equity-based compensation arrangement? .........

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), 501(c)(4), and 501(c)(29) organizations must complete lines 5-9.

For persons listed on Form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the revenues of:

The organization? ....................

Any related organization? .......................

If "Yes," on line 5a or 5b, describe in Part III.

For persons listed on Form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the net earnings of:

The organization? ..................

Any related organization? ......................

If "Yes," on line 6a or 6b, describe in Part III.

For persons listed on Form 990, Part VII, Section A, line 1a, did the organization provide any nonfixed
payments not described in lines 5 and 6? If "Yes," describe in Part III ............

Yes

Were any amounts reported on 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 ..........................

If "Yes" on line 8, did the organization also follow the rebuttable presumption procedure described in Regulations section 53.4958-6(c)? .........................

For Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 50053T

Schedule J (Form 990) 2019

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 on 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 in column (B) reported as deferred on prior Form 990
(A) Name and Title		(i) Base compensation	(ii) Bonus & incentive compensation	(iii) Other reportable compensation	(C) Retirement and other deferred compensation	(D) Nontaxable benefits	(E) Total of columns (B)(i)-(D)
1GARRETT KATULA DO VICE CHIEF OF STAFF/DIRECTOR	(i) (ii)	242,706 ------------- 0	33,621 ------------- 0	6,658 ------------- 0	4,803 ------------- 0	26,858 ------------- 0	314,646 ------------- 0	0 ------------- 0
2STEPHEN KELANIC MD VICE CHIEF OF STAFF/DIRECTOR	(i) (ii)	292,307 ------------- 0	139,702 ------------- 0	981 ------------- 0	5,143 ------------- 0	25,509 ------------- 0	463,642 ------------- 0	0 ------------- 0
3BARRY FINN PRESIDENT & CEO/DIRECTOR	(i) (ii)	739,783 ------------- 0	304,470 ------------- 0	504,089 ------------- 0	5,400 ------------- 0	26,024 ------------- 0	1,579,766 ------------- 0	0 ------------- 0
4RYAN ASMUS VP GENERAL COUNSEL/SECRETARY	(i) (ii)	260,044 ------------- 0	89,490 ------------- 0	20,065 ------------- 0	43,447 ------------- 0	25,478 ------------- 0	438,524 ------------- 0	0 ------------- 0
5BRENDA VAN WYHE SR. VP FINANCE & CFO/TREASURER	(i) (ii)	343,863 ------------- 0	103,950 ------------- 0	4,108 ------------- 0	56,642 ------------- 0	17,210 ------------- 0	525,773 ------------- 0	0 ------------- 0
6GAIL BUMGARNER SR. VP, STRATEGY	(i) (ii)	264,528 ------------- 0	89,490 ------------- 0	71,709 ------------- 0	5,042 ------------- 0	8,654 ------------- 0	439,423 ------------- 0	0 ------------- 0
7DENNIS DEMASIE VP, INFORMATION TECH & CIO	(i) (ii)	255,408 ------------- 0	72,540 ------------- 0	378,920 ------------- 0	4,200 ------------- 0	12,112 ------------- 0	723,180 ------------- 0	274,721 ------------- 0
8JOHN DIEDERICH SR. VP, OPERATIONS & COO	(i) (ii)	442,975 ------------- 0	89,490 ------------- 0	14,030 ------------- 0	141,455 ------------- 0	25,538 ------------- 0	713,488 ------------- 0	0 ------------- 0
9BRENDA FANN MD ASSISTANT VP, MEDAFFAIRS	(i) (ii)	264,568 ------------- 0	40,519 ------------- 0	23,829 ------------- 0	5,163 ------------- 0	26,172 ------------- 0	360,251 ------------- 0	0 ------------- 0
10DIANE HOMAN MD VP, QUALITY & PSO	(i) (ii)	316,957 ------------- 0	108,330 ------------- 0	89,521 ------------- 0	4,012 ------------- 0	24,339 ------------- 0	543,159 ------------- 0	0 ------------- 0
11STEVE LOWENTHAL MD SR. VP, MEDICAL AFFAIRS & CMO	(i) (ii)	424,406 ------------- 0	139,730 ------------- 0	124,555 ------------- 0	5,400 ------------- 0	8,947 ------------- 0	703,038 ------------- 0	0 ------------- 0
12DAVID PETASNICK ASSISTANT VP, ANCILLARY SVCS	(i) (ii)	185,984 ------------- 0	32,298 ------------- 0	2,369 ------------- 0	3,600 ------------- 0	22,608 ------------- 0	246,859 ------------- 0	0 ------------- 0
13ALEX POPE VP, PHILANTHROPY & CDO	(i) (ii)	200,782 ------------- 0	61,776 ------------- 0	3,264 ------------- 0	32,679 ------------- 0	25,253 ------------- 0	323,754 ------------- 0	0 ------------- 0
14MARY SHILKAITIS VP PATIENT CARE SRVCS & CNO	(i) (ii)	225,317 ------------- 0	79,599 ------------- 0	24,196 ------------- 0	41,378 ------------- 0	27,994 ------------- 0	398,484 ------------- 0	0 ------------- 0
15SUSAN STERCHI ASSISTANT VP, PATIENT CARE	(i) (ii)	164,421 ------------- 0	35,074 ------------- 0	23,775 ------------- 0	2,400 ------------- 0	27,784 ------------- 0	253,454 ------------- 0	0 ------------- 0
16MARK SHARP-SCHINSKY MD PHYSICIAN	(i) (ii)	733,184 ------------- 0	496,389 ------------- 0	21,672 ------------- 0	1,440 ------------- 0	33,273 ------------- 0	1,285,958 ------------- 0	0 ------------- 0
17DIMITRY RUBAN MD PHYSICIAN	(i) (ii)	956,074 ------------- 0	8,879 ------------- 0	18,594 ------------- 0	5,400 ------------- 0	24,599 ------------- 0	1,013,546 ------------- 0	0 ------------- 0
18KEVIN KELLY MD PHYSICIAN	(i) (ii)	909,079 ------------- 0	5,544 ------------- 0	3,590 ------------- 0	692 ------------- 0	25,266 ------------- 0	944,171 ------------- 0	0 ------------- 0
19ARIF SALEEM MD PHYSICIAN	(i) (ii)	536,669 ------------- 0	239,099 ------------- 0	21,590 ------------- 0	5,400 ------------- 0	25,516 ------------- 0	828,274 ------------- 0	0 ------------- 0
20TERESSA ALEXANDER MD PHYSICIAN	(i) (ii)	471,139 ------------- 0	289,013 ------------- 0	26,224 ------------- 0	5,340 ------------- 0	25,496 ------------- 0	817,212 ------------- 0	0 ------------- 0

Schedule J (Form 990) 2019

Page 3

Part III

Supplemental Information

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.

Return Reference	Explanation
PART I, LINE 1A	THE ORGANIZATION PROVIDES TO ALL EMPLOYEES THE USE OF AN ATHLETIC FACILITY THAT IS OWNED AND OPERATED BY A RELATED TAX EXEMPT ORGANIZATION.
PART I, LINE 4B	CMH OFFERS A SUPPLEMENTAL RETIREMENT PLAN TO CERTAIN EMPLOYEES WHO PARTICIPATE IN THE EXECUTIVE BENEFITS PROGRAM. THERE IS NO CONSTRUCTIVE RECEIPT OF THESE AMOUNTS BY THE INDIVIDUALS UNTIL THEY ARE PAID OUT AS THEY ARE SUBJECT TO A SUBSTANTIAL RISK OF FORFEITURE UNTIL INDIVIDUALS MEET THE REQUIRED VESTING PERIOD. ONCE VESTED, PAYOUTS WOULD BE INCLUDED AS REPORTABLE COMPENSATION ON THE RECIPIENTS ANNUAL FORM W-2. THE AMOUNTS PAID OUT OF THIS PLAN IN 2017 WERE AS FOLLOWS: BARRY FINN - $474,302, STEVE LOWENTHAL - $85,214, DENNIS DEMAISE - $372,803, DIANE HOMAN - $60,566 AND GAIL BUMGARNER -$46,301.
PART I, LINE 7	INCENTIVE BONUS PLAN BASED ON A SERIES OF APPROVED STRATEGIC ACCOMPLISHMENTS.

Schedule J (Form 990) 2019

Additional Data

Software ID:
Software Version:

- TIN:

Note: To capture the full content of this document, please select landscape mode (11" x 8.5") when printing.

Schedule K
(Form 990)

Department of the Treasury
Internal Revenue Service

Supplemental Information on Tax-Exempt Bonds

Complete if the organization answered "Yes" to Form 990, Part Ⅵ, line 24a. Provide descriptions,
explanations, and any additional information in Part Ⅵ.
SchKMediumBullet

Attach to Form 990.
SchKMediumBullet

Go to www.irs.gov/Form990 for instructions and the latest information.

OMB No. 1545-0047

2019

Open to Public
Inspection

Name of the organization
COPLEY MEMORIAL HOSPITAL INC
C/O RUSH COPLEY MEDICAL CTR

Employer identification number
36-2170840

Part Ⅰ

Bond Issues

(a) Issuer name		(b) Issuer EIN	(c) CUSIP #	(d) Date issued	(e) Issue price	(f) Description of purpose	(g) Defeased		(h) On behalf of issuer		(i) Pool financing
(a) Issuer name		(b) Issuer EIN	(c) CUSIP #	(d) Date issued	(e) Issue price	(f) Description of purpose	Yes	No	Yes	No	Yes	No
A	ILLINOIS FINANCE AUTHORITY	86-1091967	45203HS45	02-11-2015	105,601,668	REFUND BONDS ISSUED 5/28/2008, 2/10/2009, AND 7/29/2009		X		X		X

Part Ⅱ

Proceeds

	A		B		C		D
	1 Amount of bonds retired ..................	3,085,000
2 Amount of bonds legally defeased ..............
3 Total proceeds of issue ..................	105,601,668
4 Gross proceeds in reserve funds .............
5 Capitalized interest from proceeds .............
6 Proceeds in refunding escrows ...............	86,043,195
7 Issuance costs from proceeds ...............	824,030
8 Credit enhancement from proceeds .............
9 Working capital expenditures from proceeds .............	145
10 Capital expenditures from proceeds .............
11 Other spent proceeds .............	22,355,870
12 Other unspent proceeds .............
13 Year of substantial completion .............
	Yes	No	Yes	No	Yes	No	Yes	No
14 Were the bonds issued as part of a current refunding issue of tax-exempt bonds (or, if issued prior to 2018, a current refunding issue)? ........
15 Were the bonds issued as part of an advance refunding issue of taxable bonds (or, if issued prior to 2018, an advance refunding issue)? ........
16 Has the final allocation of proceeds been made? ..........	X
17 Does the organization maintain adequate books and records to support the final allocation of proceeds? ..................	X

Part Ⅲ

Private Business Use

	A		B		C		D
	Yes	No	Yes	No	Yes	No	Yes	No
1 Was the organization a partner in a partnership, or a member of an LLC, which owned property financed by tax-exempt bonds? .............		X
2 Are there any lease arrangements that may result in private business use of bond-financed property? ...............		X

For Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 50193E

Schedule K (Form 990) 2019

Page 2

Part Ⅲ

Private Business Use (Continued)

	A		B		C		D
	Yes	No	Yes	No	Yes	No	Yes	No
3a Are there any management or service contracts that may result in private business use of bond-financed property? .............	X
b If "Yes" to line 3a, does the organization routinely engage bond counsel or other outside counsel to review any management or service contracts relating to the financed property?	X
c Are there any research agreements that may result in private business use of bond-financed property? .............		X
d If "Yes" to line 3c, does the organization routinely engage bond counsel or other outside counsel to review any research agreements relating to the financed property?
4 Enter the percentage of financed property used in a private business use by entities other than a section 501(c)(3) organization or a state or local government ....	0 %
5 Enter the percentage of financed property used in a private business use as a result of unrelated trade or business activity carried on by your organization, another section 501(c)(3) organization, or a state or local government .........	0 %
6 Total of lines 4 and 5 .............	0 %
7 Does the bond issue meet the private security or payment test? ...		X
8a Has there been a sale or disposition of any of the bond-financed property to a nongovernmental person other than a 501(c)(3) organization since the bonds were issued?.............		X
b If "Yes" to line 8a, enter the percentage of bond-financed property sold or disposed of. ..
c If "Yes" to line 8a, was any remedial action taken pursuant to Regulations sections 1.141-12 and 1.145-2? .............
9 Has the organization established written procedures to ensure that all nonqualified bonds of the issue are remediated in accordance with the requirements under Regulations sections 1.141-12 and 1.145-2? ........		X

Part Ⅳ

Arbitrage

	A		B		C		D
	Yes	No	Yes	No	Yes	No	Yes	No
1 Has the issuer filed Form 8038-T, Arbitrage Rebate, Yield Reduction and Penalty in Lieu of Arbitrage Rebate? ...		X
2 If "No" to line 1, did the following apply? ....
a Rebate not due yet? .......	X
b Exception to rebate? ........		X
c No rebate due? .........		X
If "Yes" to line 2c, provide in Part Ⅵ the date the rebate computation was performed ......
3 Is the bond issue a variable rate issue? .....		X
4a Has the organization or the governmental issuer entered into a qualified hedge with respect to the bond issue?		X
b Name of provider ..........
c Term of hedge .........
d Was the hedge superintegrated? ......
e Was the hedge terminated? ........

Schedule K (Form 990) 2019

Page 3

Part Ⅳ

Arbitrage (Continued)

	A		B		C		D
	Yes	No	Yes	No	Yes	No	Yes	No
5a Were gross proceeds invested in a guaranteed investment contract (GIC)?		X
b Name of provider ..........
c Term of GIC .........
d Was the regulatory safe harbor for establishing the fair market value of the GIC satisfied? ........
6 Were any gross proceeds invested beyond an available temporary period?		X
7 Has the organization established written procedures to monitor the requirements of section 148? ...		X

Part Ⅴ

Procedures To Undertake Corrective Action

---------------------------------------------------------------------------------------------------------------	A		B		C		D
	Yes	No	Yes	No	Yes	No	Yes	No
Has the organization established written procedures to ensure that violations of federal tax requirements are timely identified and corrected through the voluntary closing agreement program if self-remediation is not available under applicable regulations?		X

Part Ⅵ

Supplemental Information. Provide additional information for responses to questions on Schedule K. (See instructions).

Return Reference	Explanation
PART IV, LINE 6, COLUMN A:	THIS QUESTION IS BEING ANSWERED WITHOUT REGARD TO A YIELD-RESTRICTED ADVANCE REFUNDING ESCROW FINANCED WITH PROCEEDS OF THE BONDS.

Schedule K (Form 990) 2019

Additional Data

Software ID:
Software Version:

- 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 990-EZ or to provide any additional information.
MediumBullet

Attach to Form 990 or 990-EZ.
MediumBullet

Go to www.irs.gov/Form990 for the latest information.

OMB No. 1545-0047

2019

Open to Public
Inspection

Name of the organization

COPLEY MEMORIAL HOSPITAL INC
C/O RUSH COPLEY MEDICAL CTR

Employer identification number

36-2170840

Return Reference	Explanation
FORM 990, PART III, LINE 4A	SUMMARY OF FY18 HEALTH PROGRAMMING DURING FY18, COPLEY MEMORIAL HOSPITAL SPONSORED, PARTNERED OR PARTICIPATED IN OVER 600 COMMUNITY-BASED PROGRAMS AND EVENTS WITH SPECIAL EMPHASIS ON IMPROVING THE HEALTH AND WELLNESS OF ADULTS, CHILDREN AND UNDERSERVED POPULATIONS. NUTRITION AND WEIGHT LOSS YOUFIT HELD THREE 12-WEEK SESSIONS WITH A TOTAL OF 14 PARTICIPANTS ENROLLED IN THE PROGRAM. PARTICIPANTS LEARNED FROM A VARIETY OF EXPERTS INCLUDING RUSH COPLEY PHYSICIANS, HEALTHPLEX PERSONAL TRAINERS AND REGISTERED DIETICIANS. FAMILIA SALUDABLE - A SIX-SESSION, ONCE A MONTH FAMILY FOCUSED COMMUNITY NUTRITION AND FITNESS BASED HEALTHY LIFESTYLE PROGRAM EDUCATED 25 FAMILIES AND A TOTAL OF 58 PARTICIPANTS. THE NUTRITION PORTION OF THE PROGRAM WAS CONDUCTED IN ENGLISH WITH SPANISH INTERPRETATION. THE EXERCISE PORTION WAS CONDUCTED IN SPANISH. EACH FAMILY WAS PROVIDED WITH A BINDER THAT INCLUDED THE PRESENTATION AS WELL AS TOOLS SUCH AS ACTIVITY CALENDAR AND RECIPES. EACH FAMILY ALSO RECEIVED PORTION PLATES, STRETCH BANDS AND OTHER ITEMS TO CONTINUE THEIR HEALTHY LIFESTYLE JOURNEY. COMMUNITY WALKING CLUB RUSH COPLEY CONTINUES TO OFFER THE COMMUNITY THE TOOLS AND RESOURCES TO START THEIR OWN WALKING CLUB. PRESENTATIONS ARE PROVIDED TO ORGANIZATIONS SUCH AS SCHOOLS, PARK DISTRICTS AND ANYONE INTERESTED IN WALKING THEIR WAY TO HEALTH. A PRE AND POST TEST IS GIVEN TO THE PARTICIPANTS TO OBSERVE THEIR PROGRESS AND PEDOMETERS AND WALKING LOGS ARE PROVIDED TO KEEP THEM MOTIVATED. 30 NEW COMMUNITY MEMBERS WERE ADDED TO THE COMMUNITY WALKING CLUB. DIABETES FREE FASTING GLUCOSE SCREENINGS WERE PROVIDED TO OVER 69 COMMUNITY MEMBERS. SMOKING CESSATION FREEDOM FROM SMOKING SMOKING CESSATION FREEDOM FROM SMOKING IS A SEVEN-WEEK, EIGHT-SESSION PROGRAM SPONSORED BY THE AMERICAN LUNG ASSOCIATION AND HOSTED BY RUSH COPLEY MEDICAL CENTER. SESSIONS ARE LED BY A CERTIFIED FACILITATOR. FOUR PROGRAM SESSIONS WERE HOSTED WITH A TOTAL OF NINE PARTICIPANTS. CANCER AWARENESS AND INFORMATION RUSH COPLEY GASTROENTEROLOGISTS, DR. TOMMY PACANA, DR. DHIRAJ GULATI AND NURSING STAFF FROM THE DIGESTIVE HEALTH SERVICES PRESENTED GET THE SCOOP ON THE SCOPE TWO TIMES WITH A TOTAL OF 27 PARTICIPANTS. AT THE ANNUAL CELEBRATION OF NATIONAL CANCER SURVIVORS DAY HELD AT WATERFORD PLACE CANCER RESOURCE CENTER, THERE WERE MORE THAN 100 PARTICIPANTS IN ATTENDANCE. DR. HO MYONG, MEDICAL ONCOLOGIST AND HEMATOLOGIST AND STEPHANIE BEAM, CLINICAL ONCOLOGY PHARMACIST PRESENTED HORMONE THERAPY FOR BREAST CANCER: WHAT IS IT AND HOW DOES IT WORK? THERE WERE 25 PARTICIPANTS THAT ATTENDED. RUSH COPLEY'S COMMUNITY HEALTH OUTREACH COORDINATOR AND ADVANCE PRACTICE NURSE GYNE ONCOLOGY ALONG WITH THE AMERICAN CANCER SOCIETY HOSPITAL SYSTEMS MANAGER PRESENTED THE "YOU ARE THE KEY" PRESENTATION FROM THE CDC HPV VACCINATION TOOLKIT TO 26 EAST AURORA SCHOOL DISTRICT 131 SCHOOL NURSES AND HEALTHCARE COORDINATORS. RUSH COPLEY PARTNERED WITH ALAS-WINGS TO HOST ALAS ON WHEELS MOBILE SALON AT WATERFORD PLACE CANCER RESOURCE CENTER. AT THIS EVENT, 23 WOMEN BENEFITTED FROM RECEIVING A DONATION OF MASTECTOMY BRAS AND PROSTHESIS. COMMUNITY HEALTH TALKS COMMUNITY HEALTH TALKS IS AN EDUCATIONAL SERIES GEARED TOWARD THE HEALTHCARE NEEDS OF THE LATINO POPULATION. COMMUNITY HEALTH TALKS IS OFFERED SEVEN TIMES A YEAR FROM SEPTEMBER THROUGH APRIL AND TARGETS WOMEN, MEN AND CHILDREN OVER THE AGE OF 12 IN THE FOX VALLEY AREA. SOME OF THE TOPICS PRESENTED BY PROFESSIONAL HEALTHCARE PROVIDERS INCLUDE: ADVANCED DIRECTIVES FOR HEALTHCARE, STRENGTHENING PARENT CHILD RELATIONSHIPS, HOW TO MANAGE DIABETES DURING THE WINTER MONTHS, TAKING CARE OF YOUR HEALTH! THE IMPORTANCE OF CANCER SCREENINGS, HOW TO PREVENT/REVERSE CARDIAC DISEASE, THE AGING BRAIN AND HOW TO MANAGE CHRONIC DISEASE. TYPICALLY, BETWEEN 10 AND 25 WOMEN AND MEN ATTEND THE MONTHLY SESSIONS. CLOSE TO 120 PARTICIPANTS ATTENDED AND BENEFITTED FROM THE PRESENTATIONS IN FY18. HEALTH EXHIBITS AT SCI-TECH HANDS ON MUSEUM EXHIBITS CONTINUE TO BE DISPLAYED IN THE LUNCH ROOM AND ADJACENT CORRIDOR OF THE MUSEUM TARGETING VISITORS IN THE 5-16 AGE RANGE. THE EXHIBITS ENABLE VISITORS TO MEASURE THEIR HEART RATE AFTER EXERCISING AND MAKE THE LINK BETWEEN EXERCISE AND HEART HEALTH. ANOTHER TESTS VISITORS' KNOWLEDGE ABOUT THE AMOUNT OF SUGAR IN POPULAR BEVERAGES AND EDUCATES THEM ABOUT DIABETES. SMALLER EXHIBITS ON THE LUNCH ROOM PILLARS DISPLAY THE USDA'S "MY PLATE" GRAPHIC, THE "5-4-3-2-1-GO!" PROGRAM, "EAT-THIS-NOT-THAT" INFORMATION, AND OTHER KID-FRIENDLY INFORMATION ABOUT NUTRITION AND HEALTH. A HAND-WASHING EXHIBIT TO DEMONSTRATE THE IMPORTANCE OF EFFECTIVE HAND-WASHING TECHNIQUES WAS PLACED IN THE LUNCHROOM AT SCITECH TO ENSURE THAT THE MESSAGE REACHES CHILDREN AT A TIME WHEN THEY CAN APPLY THE LESSONS LEARNED DIRECTLY TO THEIR OWN EATING HABITS FOR IMMEDIATE REINFORCEMENT. CHILDREN PLACE THEIR HANDS IN THE SINK TO START AN INTERACTIVE VIDEO THAT SHOWS THE RIGHT TECHNIQUE AND LENGTH OF TIME NEEDED TO REMOVE DIRT AND GERMS. PINK LIGHTS SHINE ON THEIR HANDS, SIMULATING GERMS, UNTIL THE RIGHT AMOUNT OF TIME AND ACTIVITY HAS ELAPSED. IN ADDITION TO THE DAILY VISITORS THE MUSEUM HOSTS DAILY (75,000 VISITORS A YEAR), SCI-TECH HANDS ON MUSEUM CONTINUES TO PARTICIPATE IN FIRST FRIDAYS, A VENUE IN THE DOWNTOWN THAT PROVIDES ARTS AND CULTURE TO THE COMMUNITY AND DRAWS 100 300 COMMUNITY MEMBERS AND VISITORS TO THE MUSEUM FOR THE FIVE HOUR EVENT MOST MONTHS OF THE YEAR. HEALTHY HANDS TO HELP SCHOOL-AGED CHILDREN UNDERSTAND THE IMPORTANCE OF HAND WASHING, RUSH COPLEY MEDICAL CENTER OFFERS A FUN AND EDUCATIONAL PROGRAM FOR SCHOOLS AND COMMUNITY GROUPS CALLED HEALTHY HANDS. THE PROGRAM PROVIDES AN EXPLANATION OF GERMS AND HOW THEY SPREAD. AN INTERACTIVE PRESENTATION INCLUDES THE USE OF "GLOW" GERMS USING A GEL AND THE USE OF A BLACK LIGHT TO SHOW "GERMS." IF THE PARTICIPANTS WASH THEIR HANDS CORRECTLY AND FOR THE PROPER AMOUNT OF TIME USING ANTIBACTERIAL HAND GEL, THEIR HANDS SHOULD NOT SHOW THE "GLOW" GERMS WHEN THEY ARE PLACED UNDER THE BLACK LIGHT A SECOND TIME. THE CHILDREN ARE GIVEN A BOOK MARK THAT SHOWS HOW TO PROPERLY WASH THEIR HANDS. IN FY18 A TOTAL OF 84 CHILDREN PARTICIPATED IN THE HEALTHY HANDS DEMONSTRATION HELD AT A FITNESS FUN FAIR. PLAY IT SAFE PLAY IT SAFE IS A FUN AND INTERACTIVE FAMILY EVENT THAT EDUCATES PEOPLE OF ALL AGES ABOUT IMPORTANT HEALTH TOPICS AND INJURY PREVENTION. IT IS AN ANNUAL EVENT HOSTED BY RUSH COPLEY EMERGENCY SERVICES AND RUSH COPLEY HEALTHPLEX. MORE THAN 500 PEOPLE ATTEND THIS ANNUAL EVENT NOW IN ITS TENTH YEAR. OLDER ADULT EDUCATION RUSH COPLEY, IN COLLABORATION WITH THE OSWEGO SENIOR CENTER, THE UNIVERSITY OF ILLINOIS EXTENSION AND THE KENDALL COUNTY HEALTH DEPARTMENT, IS HOSTING AN ONGOING WORKSHOP AND CHALLENGE SERIES FOR SENIORS IN KENDALL COUNTY TO COMBAT OBESITY. KNOWN AS HEALTHY HABITS FOR SUCCESSFUL LIVING, THIS IS A 9-WEEK PROGRAM DESIGNED FOR SENIORS WHO WANT TO BE HEALTHIER - PARTICIPANTS ARE ENCOURAGED TO MAKE SUSTAINABLE LIFE CHANGES TO MEET THEIR HEALTH GOALS. RUSH COPLEY HEALTHPLEX FITNESS TRAINERS PROVIDE EXERCISE DEMONSTRATIONS FOR PARTICIPANTS TO ENCOURAGE AN ACTIVE LIFESTYLE. TEN SENIORS ENROLLED AND PARTICIPATED IN THE SESSION HELD FEBRUARY THROUGH APRIL 2018. IN FY18, RUSH COPLEY PROVIDED SPEAKERS FOR FIVE SCHEDULED PRESENTATIONS IN THE DOCTOR'S NOTES SERIES HELD AT THE OSWEGO SENIOR CENTER. THIS SERIES EDUCATES SENIORS ON VARIED HEALTH TOPICS RELATED TO AGING. OVER 60 SENIORS ATTENDED. ADDITIONAL PROGRAMS SCHEDULED FOR SENIORS WERE HELD AT VARIOUS LOCATIONS THROUGHOUT THE COMMUNITY AND INCLUDED TOPICS SUCH AS HEART HEALTH, DIABETES EDUCATION, STROKE AWARENESS, ADVANCED CARE PLANNING, HOW TO USE AN AED, AND JOINT REPLACEMENT. OVER 150 SENIORS ATTENDED THESE PROGRAMS. PREGNANCY AND CHILDBIRTH PRE-AND POSTNATAL CLASSES ARE OFFERED TO COUPLES AND FAMILIES WHO ARE EXPECTING OR HAVE A BABY. CLASS TOPICS INCLUDE: CHILDBIRTH EDUCATION. BABY CARE BASICS, BREASTFEEDING PART I, BREASTFEEDING PART II, WORKING & BREASTFEEDING, BECOMING A GRANDPARENT, BOOT CAMP FOR NEW DADS, BRINGING HOME BABY, INFANT MASSAGE CLASS, FAMILY BIRTH CENTER TOURS, CHILD SEAT SAFETY, SIBLING CLASS, AND INFANT CPR AND HOME SAFETY. OVER 1,860 PEOPLE PARTICIPATED IN FY18. HEART SURVIVOR WALK ATTENDEES RECEIVE A FREE VEIN SCREENING. THE 2018 HEART SURVIVOR WALK AND BREAKFAST AT BLACKBERRY FARM HAD 98 PARTICIPANTS. PARTICIPANTS PARTICIPATED IN A ONE MILE WALK AND ENJOYED COMPLIMENTARY BREAKFAST. AWARDS WERE GIVEN FOR THE OLDEST SURVIVOR, YOUNGEST SURVIVOR AND SUPER SURVIVOR. PARTICIPANTS AND THEIR GUESTS WERE EDUCATED BY DRS. ALWARSHETTY, NUYLES AND LOME ABOUT THE IMPORTANCE OF RECOGNIZING SIGNS AND SYMPTOMS OF A HEART ATTACK, THE IMPORTANCE OF CALLING 911 AND LEADING A HEART HEALTHY LIFESTYLE.
FORM 990, PART III, LINE 4A	SUMMARY OF FY18 HEALTH PROGRAMMING (CONTINUED FROM ABOVE) MOVEMENT DISORDERS RUSH COPLEY'S MOVEMENT DISORDERS PROGRAM PROVIDES SUPPORT AND MANAGEMENT OF PARKINSON'S DISEASE, ESSENTIAL TREMOR, DYSTONIA AND ATAXIA TO HELP PATIENTS MAXIMIZE THEIR MOBILITY, COORDINATION, AND QUALITY OF LIFE. PROGRAM OFFERINGS INCLUDE SUPPORT GROUPS, EXERCISE CLASSES BOTH ON LAND AND WATER, GROUP BOXING, ART AND MUSIC THERAPY AS WELL AS SPECIAL EVENTS WITH GUEST SPEAKERS TO MORE THAN 200 PARTICIPANTS. WOMEN OVER 50 WOMEN ATTENDED TWO PROGRAMS IN THE WOMEN TO WOMEN HEALTH SERIES. TOPICS INCLUDED TREATING GYNE CONDITIONS FROM ROBOTIC SURGERY TO RECOVERY AND FOOD SENSITIVITIES IN FAMILIES. STROKE PROGRAMS ON STROKE EDUCATION WERE HELD ON 5/1/18 WITH 30 PARTICIPANTS IN ATTENDANCE AND 5/16/18 WITH 25 PARTICIPANTS IN ATTENDANCE. PHYSICIAN REFERRAL AND SERVICE LINE COPLEY MEMORIAL HOSPITAL OFFERS A FREE PHYSICIAN AND INFORMATION REFERRAL TELEPHONE SERVICE TO THE COMMUNITY. THIS SERVICE ALLOWS COMMUNITY MEMBERS TO TALK WITH A CALL ADVISOR TO MATCH A PERSON'S HEALTH NEEDS AND PREFERENCES WITH THE PHYSICIAN OF THEIR CHOICE, LINKS CALLERS TO SERVICES PROVIDED BY THE MEDICAL CENTER AND MANAGES REGISTRATION FOR RUSH COPLEY CLASSES AND PROGRAMS. OVER 8,600 PEOPLE USED THIS SERVICE IN FY18. WEBSITE COPLEY MEMORIAL HOSPITAL'S WEBSITE, RUSHCOPLEY.COM, WITH TRANSLATION AVAILABLE INTO DOZENS OF LANGUAGES, OFFERS ACCESS TO FREE HEALTH INFORMATION. IN FY18, RUSHCOPLEY.COM HAD NEARLY 700,000 USER SESSIONS AND OVER 1,614,000 PAGE VIEWS.
FORM 990, PART VI, SECTION A, LINE 2	ALL OF THE PERSONS LISTED ON PART VII HAVE A "BUSINESS RELATIONSHIP" WITH EACH OTHER BY VIRTUE OF SITTING ON RELATED RUSH COPLEY MEDICAL CENTER ENTITY BOARDS.
FORM 990, PART VI, SECTION A, LINE 6	RUSH COPLEY MEDICAL CENTER, INC. ("RCMC") IS THE SOLE CORPORATE MEMBER OF COPLEY MEMORIAL HOSPITAL, INC. ("CMH"), RUSH COPLEY MEDICAL GROUP, NFP ("RCMG"), COPLEY VENTURES, INC. ("CV"), AND RUSH COPLEY FOUNDATION ("RCF").
FORM 990, PART VI, SECTION A, LINE 7A	CMH'S BOARD OF DIRECTORS INCLUDES AT LEAST NINE (9) INDIVIDUALS ELECTED BY THE SOLE CORPORATE MEMBER, RCMC. EACH OF THESE ELECTED DIRECTORS IS ALSO A MEMBER OF THE GOVERNING BOARD OF CMH'S SOLE CORPORATE MEMBER, RCMC. THE ELECTION AND RE-ELECTION OF ALL CMH DIRECTORS IS AT THE DIRECTION OF RCMC AT THE ANNUAL GOVERNING BOARD MEETING. VACANCIES ON THE CMH BOARD OF DIRECTORS ARE FILLED BY CMH'S SOLE CORPORATE MEMBER, RCMC. IN ACCORDANCE WITH CERTAIN PROCEDURAL REQUIREMENTS STATED IN THE BYLAWS, ELECTED DIRECTORS MAY BE REMOVED BY THE AFFIRMATIVE VOTE OF TWO-THIRDS OF THE BOARD OF DIRECTORS OF CMH'S SOLE CORPORATE MEMBER, RCMC.
FORM 990, PART VI, SECTION A, LINE 7B	THE BOARD OF DIRECTORS OF CMH'S SOLE CORPORATE MEMBER, RCMC, HAS THE FOLLOWING EXCLUSIVE POWERS OVER CMH: (1) THE ELECTION OF THE BOARD OF DIRECTORS; (2) ANY AMENDMENT TO THE ARTICLES OF INCORPORATION OR BYLAWS OF THIS CORPORATION (3) THE BORROWING OF ANY SUM, THE PRINCIPAL OF WHICH EXCEEDS $500,000.00, OR WHICH HAS A STATED TERM OF GREATER THAN ONE YEAR, OR WHICH IS SECURED BY A MORTGAGE OF ALL OR ANY PORTION OF THE CORPORATION'S REAL PROPERTY OR THE CREATION OF A SECURITY INTEREST IN THE CORPORATION'S ASSETS, INCLUDING PERSONAL PROPERTY AND REVENUES, FOR THE BENEFIT OF THE LENDER, LESSOR OR VENDOR, OR THE DEFEASANCE, ADVANCE PAYMENT OR CANCELLATION OF ANY OUTSTANDING DEBT OF THE CATEGORY DESCRIBED HEREIN; (4) ANY VOLUNTARY DISSOLUTION, MERGER, CONSOLIDATION, SALE OR TRANSFER OF ANY OF THE CORPORATION'S ASSETS (ABOVE A MATERIAL DOLLAR THRESHOLD AS A PERCENTAGE OF THE CORPORATION'S ASSETS AS DETERMINED IN CONJUNCTION WITH THE CORPORATE MEMBER) OR ANY CREATION OF A SUBSIDIARY OR AFFILIATE OF THIS CORPORATION; (5) APPLICATION TO THE ILLINOIS HEALTH FACILITIES PLANNING BOARD OR ANY SUCCESSOR FOR A PERMIT OR CERTIFICATE OF NEED FOR A PROPOSED ACTIVITY, WHETHER OR NOT INVOLVING A CAPITAL EXPENDITURE; (6) APPROVAL OF ALL NEW OR CHANGES TO EXISTING ANNUAL AND LONG-TERM CAPITAL AND OPERATIONAL BUDGETS OR LONG-TERM OR MASTER STRATEGIC PLANS; (7) ANY AGREEMENT OR TRANSACTION, EITHER OF WHICH IS OF A MATERIAL NATURE, WITH ANOTHER CORPORATION CONTROLLED BY OR AFFILIATED WITH THE CORPORATE MEMBER OR WHICH IS A SUBSIDIARY OF THE CORPORATE MEMBERS; (8) SALE OF ANY OF THE CORPORATION'S REAL PROPERTY OR INTEREST THEREIN OR PURCHASES OF ANY ADDITIONAL REAL ESTATE; (9) THE AUDITED FINANCIAL STATEMENTS AND BOND DISCLOSURES OF THE CORPORATION; (10) SELECTION AND ANNUAL EVALUATION OF THE PRESIDENT; AND (11) THE ANNUAL AUDITED FINANCIAL STATEMENTS AND BOND DISCLOSURES OF THE CORPORATION.
FORM 990, PART VI, SECTION B, LINE 11B	THE FORM 990 TAX RETURN IS PREPARED BY OUR EXTERNAL TAX ADVISOR WITH DATA PROVIDED BY OUR ORGANIZATION. A DRAFT OF THE FORM 990 IS PROVIDED TO MANAGEMENT FOR REVIEW AND COMMENT. THE BOARD OF DIRECTORS IS PROVIDED WITH AN APPROVED COPY OF THE FORM 990 BEFORE IT IS FILED.
FORM 990, PART VI, SECTION B, LINE 12C	ANNUALLY, OFFICERS, DIRECTORS, KEY EMPLOYEES, MANAGEMENT TEAM (DEPARTMENT DIRECTORS AND MANAGERS), AND BILLING OFFICE PERSONNEL OF COPLEY MEMORIAL HOSPITAL, INC. ARE REQUIRED TO DISCLOSE INTERESTS THAT COULD GIVE RISE TO CONFLICTS. THE CONFLICT OF INTEREST STATEMENTS ARE SUBMITTED AND REVIEWED BY THE CHIEF COMPLIANCE OFFICER AND THE AUDIT AND CORPORATE INTEGRITY COMMITTEE OF THE BOARD. THOSE KEY PERSONNEL WITH CONFLICTS ARE ADVISED TO RECUSE THEMSELVES FROM PARTICIPATING IN DECISION-MAKING RELATED TO THE CONFLICT.
FORM 990, PART VI, SECTION B, LINE 15	WITH RESPECT TO THE CEO/VPS OF THE ORGANIZATION AND KEY SENIOR MANAGEMENT, THE ORGANIZATION FOLLOWS A COMPENSATION APPROVAL PROCEDURE ANNUALLY THAT INVOLVES APPROVAL OF PROPOSED AND FINAL COMPENSATION ARRANGEMENTS BY THE ORGANIZATION'S COMPENSATION COMMITTEE AND FULL BOARD OF DIRECTORS USING COMPARABILITY DATA, AS WELL AS CONTEMPORANEOUS DOCUMENTATION OF COMPENSATION DECISIONS IN MINUTES.
FORM 990, PART VI, SECTION C, LINE 19	FORM 990 IS AVAILABLE UPON REQUEST. THE ORGANIZATION DOES NOT MAKE ITS GOVERNING DOCUMENTS OR CONFLICT OF INTEREST POLICY AVAILABLE TO THE PUBLIC. COPIES OF THE FINANCIAL STATEMENTS (WHETHER OR NOT AUDITED) ARE PROVIDED UPON REASONABLE REQUEST SUCH AS FOR A BANK LOAN OR TO A BOND RATING AGENCY. THE FINANCIAL STATEMENTS ARE AVAILABLE ON THE ATTORNEY GENERAL'S WEBSITE.
FORM 990, PART XI, LINE 9:	CHANGE IN INTEREST IN NET ASSETS OF FOUNDATION 100,019. SWAP VALUE ADJUSTMENT 1,893,927. OTHER -7,933.
FORM 990, PART XII, LINES 2A & 2B:	ALTHOUGH THE ORGANIZATION DOES NOT RECEIVE STAND ALONE GAAP FINANCIAL STATEMENTS IT DOES RECEIVE ON AN ANNUAL BASIS FROM INDEPENDENT AUDITORS CONSOLIDATED ENTITY GAAP FINANCIAL STATEMENTS (AUDITED) FOR ITSELF AND ITS AFFILIATES.

For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.

Cat. No. 51056K

Schedule O (Form 990 or 990-EZ) 2019

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE R
(Form 990)

Department of the Treasury
Internal Revenue Service

Related Organizations and Unrelated Partnerships

Complete if the organization answered "Yes" on Form 990, Part IV, line 33, 34, 35b, 36, or 37.
MediumBullet

Attach to Form 990.
MediumBullet

Go to www.irs.gov/Form990 for instructions and the latest information.

OMB No. 1545-0047

2019

Open to Public Inspection

Name of the organization

COPLEY MEMORIAL HOSPITAL INC
C/O RUSH COPLEY MEDICAL CTR

Employer identification number

36-2170840

Part I

Identification of Disregarded Entities. Complete if the organization answered "Yes" on Form 990, Part IV, line 33.

(a) Name, address, and EIN (if applicable) of disregarded entity	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Total income	(e) End-of-year assets	(f) Direct controlling entity

Part II

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

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Exempt Code section	(e) Public charity status (if section 501(c)(3))	(f) Direct controlling entity	(g) Section 512(b)(13) controlled entity?
(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	Yes	No
(1)RUSH COPLEY MEDICAL CENTER INC 2000 OGDEN AVENUE AURORA,IL60504 36-3193787	PARENT COMPANY	IL	501(C)(3)	LINE 12B, II	RUSH SYSTEM FOR HEALTH	Yes
(2)RUSH COPLEY HEALTH CARE SYSTEM INC 2000 OGDEN AVENUE AURORA,IL60504 36-3584043	BRIDGE BOARD RCMC & RUMC	IL	501(C)(3)	LINE 11A	RUSH UNIVERSITY MEDICAL CENTER INC	Yes
(3)RUSH COPLEY FOUNDATION 2000 OGDEN AVENUE AURORA,IL60504 36-3093877	GRANTS TO CHARITABLE ORGANIZATIONS	IL	501(C)(3)	LINE 7	RUSH COPLEY MEDICAL CENTER INC	Yes
(4)COPLEY VENTURES INC 2000 OGDEN AVENUE AURORA,IL60504 36-3370216	RENTAL PROP., INFIRMARY CARE, AND HEALTHPLEX FITNESS CENTER	IL	501(C)(3)	LINE 3	RUSH COPLEY MEDICAL CENTER INC	Yes
(5)RUSH UNIVERSITY MEDICAL CENTER 1700 WEST VAN BUREN STREET CHICAGO,IL60612 36-2174823	HEALTHCARE	IL	501(C)(3)	LINE 3	RUSH SYSTEM FOR HEALTH	Yes
(6)RUSH SYSTEM FOR HEALTH 1725 W HARRISON STREET CHICAGO,IL60612 36-4046278	HOSPITAL	IL	501(C)(3)	LINE 12C	N/A		No
(7)RUSH OAK PARK HOSPITAL INC 520 S MAPLE AVE OAK PARK,IL60304 36-2183812	HOSPITAL	IL	501(C)(3)	LINE 3	RUSH UNIVERSITY MEDICAL CENTER INC	Yes

For Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 50135Y

Schedule R (Form 990) 2019

Page 2

Part III

Identification of Related Organizations Taxable as a Partnership. Complete if the organization answered "Yes" on Form 990, Part IV, line 34, because it had one or more related organizations treated as a partnership during the tax year.

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(e) Predominant income(related, unrelated, excluded from tax under sections 512-514)	(f) Share of total income	(g) Share of end-of-year assets	(h) Disproprtionate allocations?		(i) Code V-UBI amount in box 20 of Schedule K-1 (Form 1065)	(j) General or managing partner?		(k) Percentage ownership
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity		(f) Share of total income	(g) Share of end-of-year assets	Yes	No	(i) Code V-UBI amount in box 20 of Schedule K-1 (Form 1065)	Yes	No
(1) CIRCLE IMAGING PARTNERS LP 1725 W HARRISON STREET CHICAGO,IL60612 36-3539382	OPERATION IMAGING	IL	N/A
(2) RUSH SURGICENTER AT THE PROFESSIONAL BUILDING LP 1725 W HARRISON STREET CHICAGO,IL60612 36-3853026	SURGERY CENTER	IL	N/A
(3) GUARDIAN HEALTH TECHNOLOGIES LLC 1653 W CONGRESS PARKWAY CHICAGO,IL60612 36-2174823	ANALYTICS SOFTWARE LICENSE HOLDER	IL	N/A
(4) YORKVILLE PHYSICAL THERAPY & SPORTS MEDICINE CENTER LLC 2000 OGDEN AVENUE AURORA,IL60504 36-4236345	PHYSICAL THERAPY & SPORTS MEDICINE	IL	N/A
(5) RUSH COPLEY CARDIOVASCULAR LLC 2000 OGDEN AVENUE AURORA,IL60504 27-3234201	CARDIOVASCULAR MEDICINE	IL	RUSH COPLEY MEDICAL CENTER INC	RELATED	4,652,713	11,753,471		No			No	99.000 %
(6) RUSH COPLEY HOSPITALISTS LLC 2000 OGDEN AVENUE AURORA,IL60504 61-1787188	MEDICAL SERVICES	IL	RUSH COPLEY MEDICAL CENTER INC	RELATED	783,564	1,856,794		No			No	99.000 %
(7) RUSH COPLEY ORTHOPEDICS LLC 2000 OGDEN AVENUE AURORA,IL60504 61-1801175	MEDICAL SERVICES	IL	N/A
(8) RUSH COPLEY SURGICENTER LLC 2000 OGDEN AVENUE AURORA,IL60504 38-4012268	MEDICAL SERVICES	IL	COPLEY MEMORIAL HOSPITAL INC	RELATED	3,270,621	13,170,240		No			No	99.000 %

Part IV

Identification of Related Organizations Taxable as a Corporation or Trust. Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related organizations treated as a corporation or trust during the tax year.

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(e) Type of entity (C corp, S corp, or trust)	(f) Share of total income	(g) Share of end-of-year assets	(i) Section 512(b)(13) controlled entity?
(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	Yes	No
(1) RUSH UNIVERSITY MEDICAL CENTER INSURANCE CO LTD PO BOX 1051 GRAND CAYMAN CJ	INSURANCE	CJ	N/A	C				No
(2) RUSH COPLEY MEDICAL GROUP NFP 2000 OGDEN AVENUE AURORA,IL60504 36-3235315	PHYSICIAN PRACTICES	IL	N/A	C				No

Schedule R (Form 990) 2019

Page 3

Part V

Transactions With Related Organizations. Complete if the organization answered "Yes" on 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

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 .....................

Yes

b Gift, grant, or capital contribution to related organization(s) ............................

c Gift, grant, or capital contribution from related organization(s) ............................

Yes

d Loans or loan guarantees to or for related organization(s) ............................

Yes

e Loans or loan guarantees by related organization(s) ............................

f Dividends from related organization(s) ............................

g Sale of assets to related organization(s) ............................

h Purchase of assets from related organization(s) ............................

i Exchange of assets with related organization(s) ............................

Yes

j Lease of facilities, equipment, or other assets to related organization(s) .......................

k Lease of facilities, equipment, or other assets from related organization(s) ......................

Yes

l Performance of services or membership or fundraising solicitations for related organization(s) .....................

m Performance of services or membership or fundraising solicitations by related organization(s) .................

Yes

n Sharing of facilities, equipment, mailing lists, or other assets with related organization(s) ...................

o Sharing of paid employees with related organization(s) ............................

Yes

p Reimbursement paid to related organization(s) for expenses ............................

Yes

q Reimbursement paid by related organization(s) for expenses ............................

Yes

r Other transfer of cash or property to related organization(s) ............................

Yes

s Other transfer of cash or property from related organization(s) ............................

Yes

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 related organization	(b) Transaction type (a-s)	(c) Amount involved	(d) Method of determining amount involved
(1) RUSH COPLEY MEDICAL GROUP NFP	A	636,349	FAIR MARKET VALUE
(2) RUSH COPLEY FOUNDATION	C	940,320	FAIR MARKET VALUE
(3) RUSH UNIVERSITY MEDICAL CENTER	D	621,247	FAIR MARKET VALUE
(4) COPLEY VENTURES INC	K	1,062,779	FAIR MARKET VALUE
(5) RUSH UNIVERSITY MEDICAL CENTER	Q	81,649	FAIR MARKET VALUE
(6) RUSH COPLEY FOUNDATION	Q	224,544	FAIR MARKET VALUE
(7) COPLEY VENTURES INC	R	570,000	FAIR MARKET VALUE

Schedule R (Form 990) 2019

Page 4

Part VI

Unrelated Organizations Taxable as a Partnership. Complete if the organization answered "Yes" on Form 990, Part IV, line 37.

Provide the following information for each entity taxed as a partnership through which the organization conducted more than five percent of its activities (measured by total assets or gross revenue) that was not a related organization. See instructions regarding exclusion for certain investment partnerships.

(a) Name, address, and EIN of entity	(b) Primary activity	(c) Legal domicile (state or foreign country)	(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?
(a) Name, address, and EIN of entity	(b) Primary activity	(c) Legal domicile (state or foreign country)	Yes	No	(f) Share of total income	(g) Share of end-of-year assets	Yes	No	(i) Code V-UBI amount in box 20 of Schedule K-1 (Form 1065)	Yes	No

Schedule R (Form 990) 2019

Page 5

Part VII

Supplemental Information

Provide additional information for responses to questions on Schedule R. (see instructions).

Return Reference	Explanation

Schedule R (Form 990) 2019

Additional Data

Software ID:
Software Version:

1	Briefly describe the organization’s mission or most significant activities: TO PROVIDE ADVANCED MEDICINE WITH QUALITY OUTCOMES AND EXTRAORDINARY CARE.
2	Check this box
3	Number of voting members of the governing body (Part VI, line 1a) ........	3	19
4	Number of independent voting members of the governing body (Part VI, line 1b) .....	4	16
5	Total number of individuals employed in calendar year 2019 (Part V, line 2a) ......	5	2,272
6	Total number of volunteers (estimate if necessary) .............	6	340
7a	Total unrelated business revenue from Part VIII, column (C), line 12 ........	7a	0
b	Net unrelated business taxable income from Form 990-T, line 39 .........	7b	42,376

		Prior Year	Current Year
8	Contributions and grants (Part VIII, line 1h) .........	1,184,698	940,320
9	Program service revenue (Part VIII, line 2g) .........	305,721,600	305,059,403
10	Investment income (Part VIII, column (A), lines 3, 4, and 7d ) ....	11,311,285	9,835,156
11	Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e)	3,263,860	1,457,569
12	Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)	321,481,443	317,292,448
13	Grants and similar amounts paid (Part IX, column (A), lines 1–3 )...	37,187	20,551
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)	141,773,145	142,023,489
16a	Professional fundraising fees (Part IX, column (A), line 11e) .....		0
b	Total fundraising expenses (Part IX, column (D), line 25) 0
17	Other expenses (Part IX, column (A), lines 11a–11d, 11f–24e)....	140,580,195	141,021,217
18	Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25)	282,390,527	283,065,257
19	Revenue less expenses. Subtract line 18 from line 12.......	39,090,916	34,227,191
		Beginning of Current Year	End of Year
20	Total assets (Part X, line 16).............	582,894,855	636,915,894
21	Total liabilities (Part X, line 26).............	266,830,962	275,843,333
22	Net assets or fund balances. Subtract line 21 from line 20.....	316,063,893	361,072,561

Sign Here

	Signature of officer	Date

	Type or print name and title


4a	(Code: ) (Expenses $ 224,155,520 including grants of $ 20,551 ) (Revenue $ 306,334,760 )
	COPLEY MEMORIAL HOSPITAL'S MISSION IS TO PROVIDE ADVANCED MEDICINE WITH QUALITY OUTCOMES AND EXTRAORDINARY CARE. TO THAT END, THE MEDICAL CENTER SEEKS TO SERVE THE COMMUNITY IN WAYS THAT ENGAGE, EDUCATE AND EMPOWER. IN FY2018, COPLEY MEMORIAL HOSPITAL PROUDLY COLLABORATED WITH DOZENS OF CIVIC AND COMMUNITY GROUPS TO IMPACT THE KNOWLEDGE, HEALTH AND WELL-BEING OF THE COMMUNITY. COPLEY MEMORIAL HOSPITAL OFFERS FREE EDUCATIONAL PROGRAMS RANGING FROM HAND HYGIENE EDUCATION AIMED AT PRESCHOOL AND PRIMARY GRADE SCHOOL AGED CHILDREN TO ANNUAL SEMINARS EDUCATING ADULTS ABOUT DIABETES, HEART HEALTH, CANCER PREVENTION, WEIGHT CONTROL, SMOKING CESSATION, CHRONIC HEALTH AND MORE.A COMMUNITY NEWSLETTER IS PUBLISHED AND HIGHLIGHTS HEALTH INFORMATION AND CALENDAR OF EVENTS INFO TO 80,000+ HOUSEHOLDS THROUGHOUT THE HOSPITAL SERVICE AREA. FREE AND REDUCED COST HEALTH SCREENINGS ARE REGULARLY OFFERED INCLUDING FREE BLOOD PRESSURE MONITORING ON A WALK-IN BASIS.ELECTRONIC NEWSLETTERS ALSO HIGHLIGHTING HEALTH INFORMATION, NEWS AND EVENTS ARE EMAILED MONTHLY: HEALTHY EUPDATE AND FITNOTES. THESE NEWSLETTERS AVERAGE 60,000 AND 6,000 EMAILS RESPECTFULLY. ADDITIONALLY, CANCER CARE NEWS, TARGETED AT CANCER CARE PATIENTS AND THEIR FAMILY AND CARE GIVERS, WAS SENT TO APPROXIMATELY 2,400 EMAIL ADDRESSES.DURING FY2018, COPLEY MEMORIAL HOSPITAL SPONSORED, PARTNERED OR PARTICIPATED IN OVER 600 COMMUNITY-BASED PROGRAMS AND EVENTS, SPECIFICALLY GROUPS AIMED AT IMPROVING THE LIVES OF CHILDREN AND ADULTS. PROGRAMMING HIGHLIGHTS INCLUDES CAR SEAT SAFETY CHECKS, NUTRITION AND WEIGHT LOSS INFORMATION, HEART HEALTH ADVICE, CANCER SURVIVORSHIP AND MORE.COPLEY MEMORIAL HOSPITAL OFFERS A FREE PHYSICIAN REFERRAL SERVICE, PROVIDES A FREE SPEAKER'S BUREAU TO COMMUNITY-BASED GROUPS AND ROUTINELY PARTICIPATES AND SPONSORS OR DONATES TO HEALTH FAIRS AIMED AT MINORITY POPULATIONS INCLUDING THE YEARLY AFRICAN AMERICAN HEALTH FAIR AND THE ANNUAL LATINO COMMUNITY HEALTH FESTIVAL.COPLEY MEMORIAL HOSPITAL'S WEBSITE, WITH TRANSLATION INTO DOZENS OF LANGUAGES, OFFERS FREE HEALTH INFORMATION AND ONLINE RESOURCES.TOGETHER, THESE INITIATIVES PROVIDED A POSITIVE INFLUENCE FOR THOUSANDS OF RESIDENTS IN THE COMMUNITIES SERVED BY COPLEY MEMORIAL HOSPITAL.

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 expenses224,155,520

1b	Sub-Total................
c	Total from continuation sheets to Part VII, Section A....
d	Total (add lines 1b and 1c)...........	12,072,936	0	843,666

1a	Federated campaigns..		1a
b	Membership dues..		1b
c	Fundraising events..		1c
d	Related organizations		1d	940,320
e	Government grants (contributions)		1e

f	All other contributions, gifts, grants, and similar amounts not included above		1f

g	Noncash contributions included in lines 1a - 1f:$		1g

h Total. Add lines 1a-1f.......		940,320

		Business Code
2a	NET PATIENT SVC REV	621110	280,453,805	280,453,805
b	MEDICAID TAX REVENUE	621110	26,268,734	26,268,734
c	OTHER PROGRAM REVENUE	900099	-1,663,136	-1,663,136
d
e
f	All other program service revenue.
g	Total. Add lines 2a–2f .....		305,059,403

3 Investment income (including dividends, interest, and othersimilar amounts) ......			6,715,380			6,715,380
4 Income from investment of tax-exempt bond proceeds
5 Royalties...........
		(ii) Personal	(i) Real
6a	Gross rents		1,028,489	6a
b	Less: rental expenses		1,527,099	6b
c	Rental income or (loss)		-498,610	6c
d	Net rental income or (loss).......			-498,610			-498,610
		(ii) Other	(i) Securities
7a	Gross amount from sales of assets other than inventory	1,421,788	15,091,651	7a
b	Less: cost or other basis and sales expenses	0	13,393,663	7b
c	Gain or (loss)	1,421,788	1,697,988	7c
d	Net gain or (loss).........			3,119,776			3,119,776
8a	Gross income from fundraising events (not including $ of contributions reported on line 1c). See Part IV, line 18 ....
			8a
b	Less: direct expenses ...		8b
c	Net income or (loss) from fundraising events..
9a	Gross income from gaming activities. See Part IV, line 19 ...
			9a
b	Less: direct expenses ...		9b
c	Net income or (loss) from gaming activities..
10a	Gross sales of inventory, less returns and allowances ..
			10a
b	Less: cost of goods sold ..		10b
c	Net income or (loss) from sales of inventory..
Business Code			Miscellaneous Revenue
11a	OUTSIDE SERVICE REV.		621990	1,275,357	1,275,357
b	CAFETERIA REVENUE		621990	370,143			370,143
c	GIFT SHOP REVENUE		453220	310,679			310,679
d	All other revenue ....
e	Total. Add lines 11a–11d ......			1,956,179
12	Total revenue. See instructions.....			317,292,448	306,334,760	0	10,017,368

1	Grants and other assistance to domestic organizations and domestic governments. See Part IV, line 21 ....	20,551	20,551
2	Grants and other assistance to domestic individuals. See Part IV, line 22 ...........
3	Grants and other assistance to foreign organizations, foreign governments, and foreign individuals. See Part IV, lines 15 and 16. .............
4	Benefits paid to or for members .......
5	Compensation of current officers, directors, trustees, and key employees ...........	12,517,291		12,517,291
6	Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) .........
7	Other salaries and wages........	97,794,335	73,345,751	24,448,584
8	Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) ....	2,731,101	2,048,326	682,775
9	Other employee benefits .......	19,269,235	14,451,926	4,817,309
10	Payroll taxes ...........	9,711,527	7,283,645	2,427,882
11	Fees for services (non-employees):
a	Management ......	7,231,028	5,423,271	1,807,757
b	Legal .........	301,084		301,084
c	Accounting ...........	205,028		205,028
d	Lobbying ...........	52,616		52,616
e	Professional fundraising services. See Part IV, line 17
f	Investment management fees ......	67,508		67,508
g	Other (If line 11g amount exceeds 10% of line 25, column (A) amount, list line 11g expenses on Schedule O)	8,038,431	6,028,823	2,009,608
12	Advertising and promotion ....	734,934	734,934
13	Office expenses .......	15,368,262	11,526,197	3,842,065
14	Information technology ......	10,354,941	7,766,206	2,588,735
15	Royalties ..
16	Occupancy ...........	7,613,985	5,710,489	1,903,496
17	Travel ............	179,743	134,807	44,936
18	Payments of travel or entertainment expenses for any federal, state, or local public officials .
19	Conferences, conventions, and meetings ....	79,399	59,549	19,850
20	Interest ...........	4,994,742	4,994,742
21	Payments to affiliates .......
22	Depreciation, depletion, and amortization ..	18,688,404	18,688,404
23	Insurance ...	159,749	119,812	39,937
24	Other expenses. Itemize expenses not covered above (List miscellaneous expenses in line 24e. If line 24e amount exceeds 10% of line 25, column (A) amount, list line 24e expenses on Schedule O.)
a	MEDICAL SUPPLIES	47,932,872	47,932,872
b	MEDICAID PROVIDER TAX	13,082,016	13,082,016
c	REPAIRS/MAINTAINENCE	845,744	845,744
d	COLLECTION FEES	557,626	557,626
e	All other expenses	4,533,105	3,399,829	1,133,276
25	Total functional expenses. Add lines 1 through 24e	283,065,257	224,155,520	58,909,737	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 if following SOP 98-2 (ASC 958-720).

1	Cash–non-interest-bearing ........				1
2	Savings and temporary cash investments .........			14,069,478	2	21,141,985
3	Pledges and grants receivable, net ......				3
4	Accounts receivable, net .............			47,096,725	4	48,943,347
5	Loans and other payables to any current or former officer, director, trustee, key employee, creator or founder, substantial contributor, or 35% controlled entity or family member of any of these persons .......
					5
6	Loans and other receivables from other disqualified persons (as defined under section 4958(f)(1)), and persons described in section 4958(c)(3)(B) ...
					6
7	Notes and loans receivable, net ...........				7
8	Inventories for sale or use ............			5,293,019	8	5,846,586
9	Prepaid expenses and deferred charges ......			12,924,563	9	5,868,524
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	407,433,492
b	Less: accumulated depreciation	10b	235,025,498	174,456,445	10c	172,407,994
11	Investments—publicly traded securities .			269,805,003	11	287,617,692
12	Investments—other securities. See Part IV, line 11 .....				12
13	Investments—program-related. See Part IV, line 11 ..				13
14	Intangible assets ...............			3,282,363	14	3,190,961
15	Other assets. See Part IV, line 11 ...........			55,967,259	15	91,898,805
16	Total assets. Add lines 1 through 15 (must equal line 33)...			582,894,855	16	636,915,894

17	Accounts payable and accrued expenses .....	132,461,230	17	134,171,486
18	Grants payable ...		18
19	Deferred revenue .........		19
20	Tax-exempt bond liabilities .........	101,622,859	20	99,162,939
21	Escrow or custodial account liability. Complete Part IV of Schedule D		21
22	Loans and other payables to any current or former officer, director, trustee, key employee, creator or founder, substantial contributor, or 35% controlled entity or family member of any of these persons .........
			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	32,746,873	25	42,508,908
26	Total liabilities. Add lines 17 through 25..	266,830,962	26	275,843,333

	Organizations that follow FASB ASC 958, check here and complete lines 27, 28, 32, and 33.
27	Net assets without donor restrictions ..........		27
28	Net assets with donor restrictions ...........		28
	Organizations that do not follow FASB ASC 958, check here and complete lines 29 through 33.
29	Capital stock or trust principal, or current funds .....		29
30	Paid-in or capital surplus, or land, building or equipment fund ...		30
31	Retained earnings, endowment, accumulated income, or other funds		31
32	Total net assets or fund balances ...........	316,063,893	32	361,072,561
33	Total liabilities and net assets/fund balances ........	582,894,855	33	636,915,894