TY 2021 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)	(E) Reportable compensation from related organizations (W-2/1099-MISC/1099-NEC)
(1) Bruce W Dienst CHAIRMAN OF THE BOARD/DIRECTOR	1.0 ................. 3.0	X	X	0	0
(2) Christine Sobek VICE CHAIR OF THE BOARD/DIRECTOR	1.0 ................. 2.0	X	X	0	0
(3) John Diederich MA MBA FACHE President & CEO/Director	40.0 ................. 4.0	X	X	993,593	367,158
(4) Andrew VanEekeren DIRECTOR	1.0 ................. 2.0	X		0	0
(5) Catherine Cederoth DIRECTOR	1.0 ................. 3.0	X		0	0
(6) Dave Mead DIRECTOR	1.0 ................. 2.0	X		0	0
(7) Garrett Katula DO PHYSICIAN/DIRECTOR	40.0 ................. 2.0	X		369,006	30,737
(8) Herbert Knight DIRECTOR	1.0 ................. 2.0	X		0	0
(9) Jae B Joo MD VICE CHIEF OF STAFF/DIRECTOR	40.0 ................. 2.0	X		731,346	38,960
(10) James Baka DIRECTOR	1.0 ................. 2.0	X		0	0
(11) Luis Perez DIRECTOR	1.0 ................. 2.0	X		0	0
(12) Mark C Metzger DIRECTOR	1.0 ................. 3.0	X		0	0
(13) Maryanne Locklin DIRECTOR	1.0 ................. 2.0	X		0	0
(14) Maureen Strobl DIRECTOR	1.0 ................. 2.0	X		0	0
(15) Patrick Carmody DIRECTOR	1.0 ................. 2.0	X		0	0
(16) Richard Edelman DIRECTOR	1.0 ................. 2.0	X		0	0
(17) Ronald Hem DIRECTOR	1.0 ................. 2.0	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/1099-NEC)	(F) Estimated amount of other compensation from the organization and related organizations
(18) Syed Zaidi MD CHIEF OF STAFF/DIRECTOR	40.0 .......................2.0	X					551,356	31,286
(19) Trish Anen DIRECTOR	1.0 .......................2.0	X					0	0
(20) William Skoglund DIRECTOR	1.0 .......................2.0	X					0	0
(21) Brenda Van Wyhe SR. VP FINANCE & CFO/TREASURER	40.0 .......................3.0		X				655,663	78,019
(22) Ryan Asmus VP GENERAL COUNSEL/SECRETARY	40.0 .......................3.0		X				488,894	41,307
(23) Alex Pope VP. PHILANTHROPY & CDO	1.0 .......................40.0			X			416,451	57,084
(24) Brenda K Fann MD ASSISTANT VP. MEDICAL AFFAIRS	40.0 .......................0			X			412,833	22,725
(25) David Petasnick ASSISTANT VP, ANCILLARY SVCS	40.0 .......................0			X			329,839	54,968
(26) Hornbogen Abigail VP. PATIENT CARE & CNO	40.0 .......................0			X			369,931	35,328
(27) Mary F Shilkaitis SR VP Operations & COO	40.0 .......................1.0			X			552,428	69,491
(28) Steve B Lowenthal MD SR. VP MEDICAL AFFAIRS & CMO	40.0 .......................0			X			875,993	27,338
(29) Arif Saleem MD PHYSICIAN	40.0 .......................0				X		907,185	28,991
(30) Dmitry S Ruban MD PHYSICIAN	40.0 .......................0				X		920,019	35,630
(31) Jonathan L Tueting MD PHYSICIAN	40.0 .......................0				X		1,484,796	37,184
(32) Kevin V Kelly MD PHYSICIAN	40.0 .......................0				X		930,665	27,921
(33) Mark F Sharp-Schinsky MD PHYSICIAN	40.0 .......................0				X		1,217,363	14,305
(34) Barry C Finn Former President & CEO/Director	0.0 .......................0.0					X	368,652	0
(35) Dennis L Demasie FORMER VP, INFORMATION TECH, & CIO	0.0 .......................0					X	279,866	0
(36) Homan Diane MD FORMER VO, QUALITY & PSO	0.0 .......................0					X	377,000	0

(A) Name and business address	(B) Description of services	(C) Compensation
SODEXO PO BOX 536922 ATLANTA,GA303536922	FOOD AND CLEANING SERVICES	3,832,196
TRIMEDX LLC PO BOX 636129 CINCINNATI,OH452636129	EQUIPMENT MAINTENANCE	3,536,629
ATOS DEPT - 772066 PO BOX 78000 DETROIT,MI482781177	MEDICAL BILLING	2,676,198
OMNICELL INC PO BOX 787521 PHILADELPHIA,PA191787521	MEDICATION MANAGEMENT	984,921
DIVERSIFIED CLINICAL SERVICES PO BOX 636981 CINCINNATI,OH452636981	WOUND CENTER MANAGEMENT	813,609
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 29

- TIN:

SCHEDULE A
(Form 990)

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

OMB No. 1545-0047

2021

Open to Public
Inspection

Name of the organization

Copley Memorial Hospital Inc

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).)

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 33 1/3% 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 33 1/3% 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 on 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) 2021

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) 2017	(b) 2018	(c) 2019	(d) 2020	(e) 2021	(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) 2017	(b) 2018	(c) 2019	(d) 2020	(e) 2021	(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 5 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 2021 (line 6, column (f) divided by line 11, column (f)) .........

Public support percentage for 2020 Schedule A, Part II, line 14 ...............

16a

33 1/3% support test—2021. 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—2020. 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—2021. 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—2020. 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) 2021

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) 2017	(b) 2018	(c) 2019	(d) 2020	(e) 2021	(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) 2017	(b) 2018	(c) 2019	(d) 2020	(e) 2021	(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 on 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 5 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 2021 (line 8, column (f) divided by line 13, column (f)) .........

Public support percentage from 2020 Schedule A, Part III, line 15 ...............

Section D. Computation of Investment Income Percentage

Investment income percentage for 2021 (line 10c, column (f) divided by line 13, column (f)) ......

Investment income percentage from 2020 Schedule A, Part III, line 17 .............

19a

331/3% support tests—2021. 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—2020. 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) 2021

Page 4

Part IV

Supporting Organizations

(Complete only if you checked a box on line 12 of Part I. If you checked box 12a, of Part I, complete Sections A and B. If you checked box 12b, of Part I, complete Sections A and C. If you checked box 12c, of Part I, complete Sections A, D, and E. If you checked box12d, 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 lines 3b and 3c 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 box 12a or 12b in Part I, answer lines 4b and 4c 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 lines 5b and 5c 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) .

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

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 on 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 on 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) 2021

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 on lines 11b and 11c below, the governing body of a supported organization?

11a

A family member of a person described on 11a above?

11b

A 35% controlled entity of a person described on line 11a or 11b above? If “Yes” to 11a, 11b, or 11c, provide detail in Part VI.

11c

Section B. Type I Supporting Organizations

Yes

Did the officers, 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 line 2 above, 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 lines 2a and 2b 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 on line 2a, above 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 lines 3a and 3b 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?If "Yes" or "No", 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) 2021

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 0.015 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 0.035	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) 2021

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	1
2 Amounts paid to perform activity that directly furthers exempt purposes of supported organizations, in excess of income from activity	2
3 Administrative expenses paid to accomplish exempt purposes of supported organizations	3
4 Amounts paid to acquire exempt-use assets	4
5 Qualified set-aside amounts (prior IRS approval required - provide details in Part VI)	5
6 Other distributions (describe in Part VI). See instructions	6
7Total annual distributions. Add lines 1 through 6.	7
8 Distributions to attentive supported organizations to which the organization is responsive (provide details in Part VI). See instructions	8
9 Distributable amount for 2021 from Section C, line 6	9
10 Line 8 amount divided by Line 9 amount	10

Section E - Distribution Allocations (see instructions)		(i) Excess Distributions	(ii) Underdistributions Pre-2021	(iii) Distributable Amount for 2021
1 Distributable amount for 2021 from Section C, line 6
2 Underdistributions, if any, for years prior to 2021 (reasonable cause required-- explain in Part VI). See instructions.
3 Excess distributions carryover, if any, to 2021:
a From 2016.......
b From 2017.......
c From 2018.......
d From 2019.......
e From 2020.......
fTotal of lines 3a through e
g Applied to underdistributions of prior years
h Applied to 2021 distributable amount
i Carryover from 2016 not applied (see instructions)
j Remainder. Subtract lines 3g, 3h, and 3i from line 3f.
4Distributions for 2021 from Section D, line 7:
$
a Applied to underdistributions of prior years
b Applied to 2021 distributable amount
c Remainder. Subtract lines 4a and 4b from line 4.
5 Remaining underdistributions for years prior to 2021, 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 2021. 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 2022. Add lines 3j and 4c.
8 Breakdown of line 7:
a Excess from 2017.....
b Excess from 2018.....
c Excess from 2019.....
d Excess from 2020.....
e Excess from 2021.....

Schedule A (Form 990) (2021)

Schedule A (Form 990) 2021

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) 2021

Additional Data

Software ID:	21014044
Software Version:	2021v4.2

- TIN:

Schedule B
(Form 990)

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

2021

Name of the organization

Copley Memorial Hospital Inc

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) (2021)

Schedule B (Form 990) (2021) Page 2

Name of organization Copley Memorial Hospital Inc

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
RESTRICTED	,	$ RESTRICTED	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) (2021)

Schedule B (Form 990) (2021)

Page 3

Name of organization Copley Memorial Hospital Inc		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) (2021)

Schedule B (Form 990) (2021)

Page 4


Name of organization Copley Memorial Hospital Inc			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) (2021)

Additional Data

Software ID:	21014044
Software Version:	2021v4.2

- TIN:

SCHEDULE C
(Form 990)

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

2021

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

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.

Cat. No. 50084S

Schedule C (Form 990) 2021

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) 2018	(b) 2019	(c) 2020	(d) 2021	(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) 2021

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

42,864

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

42,864

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
Schedule C, Part II-B, Line 1 DETAILED DESCRIPTION OF THE LOBBYING ACTIVITY	COPLEY MEMORIAL HOSPITAL, INC. IS A MEMBER OF VARIOUS ORGANIZATIONS THAT ADVOCATE ON LEGAL AND POLICY ISSUES THAT AFFECT HEATLHCARE. 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) 2021

Additional Data

Software ID:	21014044
Software Version:	2021v4.2

- 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

2021

Open to Public Inspection

Name of the organization

Copley Memorial Hospital Inc

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) 2021

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 ....	16,582,486	13,390,581	13,022,428	11,969,298	11,691,205
b	Contributions ...	3,116,324	843,098	1,342,373	1,771,314	1,193,365
c	Net investment earnings, gains, and losses	-2,444,977	3,086,208	326,685	806,653	662,110
d	Grants or scholarships ...	0
e	Other expenditures for facilities and programs ...	1,407,482	737,401	1,300,905	1,524,837	1,577,382
f	Administrative expenses ....	0
g	End of year balance ......	15,846,351	16,582,486	13,390,581	13,022,428	11,969,298

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

Board designated or quasi-endowment SchDMd Bullet

34.1 %

Permanent endowment SchDMd Bullet

54.3 %

Term endowment SchDMd Bullet

11.6 %

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 .....	18,881,433		18,881,433
b	Buildings ....	264,072,845	149,174,138	114,898,707
c	Leasehold improvements	3,743,627	3,581,377	162,250
d	Equipment ....	188,263,720	132,372,245	55,891,475
e	Other .....	3,225,995		3,225,995
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).)..				193,059,860

Schedule D (Form 990) 2021

Page 3

Part VII

Investments - Other 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
(A)
(B)
(C)
(D)
(E)
(F)
(G)
(H)
Total. (Column (b) must equal Form 990, Part X, col. (B) line 12.)

Part VIII

Investments - Program 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

(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
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 RELATED PARTIES				298,988,115
(2)INVESTMENT IN AFFILIATES				21,840,934
(3)MALPRACTICE GROSS UP				2,598,378
(4)RIGHT OF USE ASSET				9,754,463
(5)OTHER RECEIVABLES				375,174
(5)
(6)
(7)
(8)
(9)
Total. (Column (b) must equal Form 990, Part X, col.(B) line 15.)...........				333,557,064

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
(8)
(9)
Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)	121,810,240
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) 2021

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

Schedule D, Part V, Line 4 Intended uses of endowment funds

RUSH COPLEY FOUNDATION HOLDS THE VORIS (INCOME FOR CMH CANCER CARE), KOBISK (BOARD RESTRICTED INCOME TO CMH), COPLEY (INCOME RESTRICTED TO HOSPITAL OPERATIONS), DOBBINS (INCOME FOR CMH WOMEN'S HEALTH), AND MOVEMENT DISORDER (INCOME FOR CMH MOVEMENT DISORDER PROGRAM) 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), PROMISE FUND (INCOME FOR EMPLOYEE HARDSHIPS), PART V, LINE 4: C/O RUSH COPLEY MEDICAL CENTER 36-2170840 COPLEY MEMORIAL HOSPITAL, INC. AND WATERFORD PLACE (INCOME FOR CMH CANCER RESOURCE CENTER) ENDOWMENTS. THESE FUNDS ARE HELD FOR THE BENEFIT OF COPLEY MEMORIAL HOSPITAL.

Schedule D (Form 990) 2021

Additional Data

Software ID:	21014044
Software Version:	2021v4.2

- 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

2021

Open to Public Inspection

Name of the organization

Copley Memorial Hospital Inc

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 %

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 %

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? . . . . . .

Yes

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		(a) Number of activities or programs (optional)	(b) Persons served (optional)	(c) Total community benefit expense	(d) Direct offsetting revenue	(e) Net community benefit expense	(f) Percent of total expense
a	Financial Assistance at cost (from Worksheet 1) . . .			4,495,352		4,495,352	1.25 %
b	Medicaid (from Worksheet 3, column a) . . . . .			86,275,773	71,360,600	14,915,173	4.14 %
c	Costs of other means-tested government programs (from Worksheet 3, column b) . .					0	0 %
d	Total Financial Assistance and Means-Tested Government Programs . . . . .	0	0	90,771,125	71,360,600	19,410,525	5.38 %
Other Benefits
e	Community health improvement services and community benefit operations (from Worksheet 4).			73,637		73,637	0.02 %
f	Health professions education (from Worksheet 5) . . .		3,081	6,022,937	1,301,939	4,720,998	1.31 %
g	Subsidized health services (from Worksheet 6) . . . .			16,637,426	335,168	16,302,258	4.52 %
h	Research (from Worksheet 7) .					0	0 %
i	Cash and in-kind contributions for community benefit (from Worksheet 8) . . . .			85,521		85,521	0.02 %
j	Total. Other Benefits . .	0	3,081	22,819,521	1,637,107	21,182,414	5.87 %
k	Total. Add lines 7d and 7j .	0	3,081	113,590,646	72,997,707	40,592,939	11.26 %

For Paperwork Reduction Act Notice, see the Instructions for Form 990. Cat. No. 50192T Schedule H (Form 990) 2021

Schedule H (Form 990) 2021

Page

Part II

Community Building Activities Complete this table if the organization conducted any community building activities during the tax year, and describe in Part VI how its community building activities promoted the health of the communities it serves.

		(a) Number of activities or programs (optional)	(b) Persons served (optional)	(c) Total community building expense	(d) Direct offsetting revenue	(e) Net community building expense
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		5	1,814		1,814
9	Other					0
10	Total	0	5	1,814	0	1,814

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. ......

32,431,370

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. ......

3,243,137

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).....

58,093,530

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

85,785,776

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

-27,692,246

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) 2021

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 Inc 2000 OGDEN AVENUE AURORA,IL605044206 WWW.RUSHCOPLEY.COM 2150791	X	X	X	X

Schedule H (Form 990) 2021

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 Inc
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 21

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): https://www.rush.edu/sites/default/files/media-documents/RCMC_2025-22_CHNA_CHIP_report.pdf

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 21

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

Yes

If "Yes" (list url): https://www.rush.edu/sites/default/files/media-documents/RCMC_2025-22_CHNA_CHIP_report.pdf

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) 2021

Page 5

Part VFacility Information (continued)

Financial Assistance Policy (FAP)

	COPLEY MEMORIAL HOSPITAL Inc
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 200.0%
and FPG family income limit for eligibility for discounted care of 600.0%

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):

https://www.rush.edu/patients-visitors/financial-assistance

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

https://www.rush.edu/patients-visitors/financial-assistance

A plain language summary of the FAP was widely available on a website (list url):
https://www.rush.edu/patients-visitors/financial-assistance

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) 2021

Page 6

Part VFacility Information (continued)

Billing and Collections

	COPLEY MEMORIAL HOSPITAL Inc
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) 2021

Page 7

Part VFacility Information (continued)

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

	COPLEY MEMORIAL HOSPITAL Inc
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) 2021

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
Schedule H, Part V, Section B, Line 5 Facility , 1	Facility , 1 - COPLEY MEMORIAL HOSPITAL Inc. 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: https://www.rush.edu/sites/default/files/media-documents/RCMC_2025-22_CHNA_CHIP_report.pdf
Schedule H, Part V, Section B, Line 6a Facility , 1	Facility , 1 - NORTHWESTERN DELNOR HOSPITAL, AMITA MERCY MEDICAL CENTER, AMITA ST. JOSEPH HOSPITAL, AND ADVOCATE SHERMAN HOSPITAL. 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.
Schedule H, Part V, Section B, Line 6b Facility , 1	Facility , 1 - THE KANE COUNTY HEALTH DEPARTMENT. 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.
Schedule H, Part V, Section B, Line 11 Facility , 1	Facility , 1 - COPLEY MEMORIAL HOSPITAL Inc. Rush Copley identified the following as the top health needs in the community to be addressed in the 2019 Community Health Needs Assessment, FY22 is the last year of the community health improvement plan for the identified needs: 1. Inequities in vulnerable populations: reduce inequities caused by the social, economic, and structural determinants of health 2. Mental and behavioral health, focusing on reducing the misuse of opioids and opioid-related deaths 3. Prevent and reduce chronic disease by focusing on risk factors, specifically reducing tobacco usage (including smoking and vaping) Rush Copley has implemented strategies to address all of these health needs, including the following: 1. Reduce inequities- through improved identification and connection of patients in need to available community resources Strategy 1: Identify, measure and mitigate the social determinants of health among those at greatest risk through improving the connection between vulnerable populations and needed socioeconomic resources * In collaboration with Rush University Medical Center, implemented a screening tool for RCMC inpatients and select ambulatory area patients that is now used to help identify the social, economic and structural determinants of health that could be affecting patient's health. * As patient needs are identified through the screening, increased and improved the referral process to resources that can help reduce inequities (NowPow). * Leveraged use of the EPIC medical record throughout the process * Rush Copley Promise Pantry established in March of 2021 to address food insecurity among Rush Copley patients, family members and caregivers and in May of 2022 partnered with Loaves and Fishes Community Services, a local food pantry to provide the pantry bags for the Promise Pantry. * All in-patient departments, Emergency Department, Cancer Care Center, Diabetes Center, Pediatric Offices, Outpatient Rehabilitation Therapy Center, and Waterford Place Cancer Resource Center * FY22 provided 717 (4,302 meals) Promise Pantry bags to patients and caregivers * In total the Promise Pantry has provided 1,562 (8,527 meals provided) Promise Pantry Bags since March of 2021 * Collaboration with Aurora Are Interfaith Food Pantry and Top Box Foods * Summer 2020, Two pop up pantries hosted that served 93 cancer care patients and caregivers * Summer 2021, One pop up pantry hosted that served 250 community members Strategy 2: Provide staff and physician education focused on the unique needs of vulnerable populations * Developed and implemented an education plan regarding social determinants of health to increase knowledge and awareness among care providers * Developed and implement care provider education focused on the unique needs of vulnerable populations. Gender affirming care modules made available to medical staff * Sexual orientation and gender identity screening incorporated in to patient profile to best meet the needs of each person. Strategy 3: Participate in local community health improvement collaborative(s) Participated in and partnered with city and county agencies, health systems, and community organizations, including but not limited to: * The Kane Health Counts Executive Committee and action team focused on access to health services. * Oswego Senior Center committee for Senior/dementia-friendly community * FUSE (Frequent Users System Engagement) initiative with the City of Aurora 2. Mental and Behavioral Health: Reduce the misuse of opioids and opioid-related deaths in the community Strategy 1: Reduce the number of opioid prescriptions and quantity prescribed * Incorporated intelligent design through the EPIC build and implementation processes that serves as a tool in the efforts to reduce opioid prescriptions/quantity prescribed. Included the following: * Updated order sets to optimize pain management while reducing the use of opioids * Implemented dose warnings for high morphine equivalent per day doses and prescribing advice of Narcan (naloxone) antidote * Developed opioid dashboards and reports to track and benchmark opioid use * Removed default durations in orders for opioid prescriptions * In partnership with Rush Copley Medical Group, implemented EPIC enhancements with Best Practice * Advisories with MME (Morphine Equivalents) * Developed and implemented provider education programs regarding the opioid crisis and ways to optimize pain management * System wide continuing education program rolled out around opioid ordering and using alternatives, which produced the following positive results. * Realized a 42% decrease in opioid prescriptions written for greater than 7 days * Realized a 60% decrease in opioid prescription written for greater than 90 Morphine * Milligram Equivalents (MME) per day. These dose levels have the highest risk of overdoses. * Realized a 49% decrease in opioid prescriptions written for greater than 50 MME per day Strategy 2: Reduce the number of opioids already existing in the community * Assessed the feasibility of implementing a prescription drop-off box on site and/or pharmaceutical disposal via mail * Additionally, disseminated information to providers, patients, and community on opioid take back locations * Assessed the feasibility of distributing Dispose Rx (or similar material) with opioid prescriptions Strategy 3: Develop and implement community, patient, and care provider education * Developed and implemented community and healthcare provider education programs regarding: * How to manage pain without medications * Education to consumers and providers regarding opioid use * How to properly dispose of unused medications * Improve discharge instructions and education through EPIC regarding opioid use Strategy 4: Participate in local community health improvement collaborative(s) Participated in and partnered with city and county agencies, health systems, and community organizations, including but not limited to: * Kane Health Counts Executive Committee * Kane County Opioid Task Force * Kane County Behavioral Health Council * Rush University System for Health Opioid Workforce * Kendall County to teach Narcan (naloxone) administration to the community 3. Prevent and Reduce Chronic Disease: Reducing tobacco usage in the community (including smoking and vaping) Strategy 1: Develop/enhance and implement education and resources to help patients and the community quit smoking/vaping * Developed/enhanced and implemented education, resources, and/or programs to help the community quit smoking * Continued to improve awareness through creating or utilizing materials in both English and * Spanish as well as having access to additional resources in other native languages for the patient population at Rush Copley * Implemented promotion and utilization of Pro-Change for Rush Copley and Rush Copley Medical Group patients and employees (web-based digital coaching for smoking cessation) * Hosted Spanish language Freedom from Smoking (FFS) programs in the community * Provided the FFS flyer to community partners to distribute among their population that are current smokers * Partnered with local school districts and health departments to discuss efforts around vaping/e-cigarette prevention and education for pre-teens, adolescents, and parents. * Community Education at schools with parents, students, school nurses and at after school program Strategy 2: Leverage the use of the EMR to improve documentation and reduce tobacco usage * Improved the assessment and documentation of patients' smoking history by implementing tools in the EPIC EMR to quantify the number of patients that smoke, as well as calculate and document their smoking history (pack year history) * Developed and implemented a tobacco smart set in the EPIC EMR for both the hospital and RCMG that will: * Track provider referrals for Freedom From Smoking program * Track provider referrals to the Illinois Tobacco Quitline * Participated in the pilot program for the Automation Referral for the Illinois Tobacco Quitline * Enhanced patient discharge instructions in the EPIC EMR system so that it incorporated and provided tobacco cessation resources for patients (state, local and Rush System resources)
Schedule H, Part V, Section B, Line 11 Facility , 2	Facility , 2 - COPLEY MEMORIAL HOSPITAL Inc. Strategy 3: Develop/enhance care provider education to increase engagement of tobacco cessation and assessment of willingness to quit * Strategically developed staff and physician education around engagement of tobacco cessation and addressing patients' willingness to quit smoking (among current smokers) * Began with education among RCMG practices and then transitioned into RCMC department education * Assessed and determined the best teaching methods for each department in order to engage their respective patient population(s) in tobacco cessation discussions and assessment of willingness to quit, which translated into a positive patient experience vs. a negative experience * Educated clinical staff regarding utilization of the Illinois Tobacco Quitline Referral Forms on Policy & Procedures Portal * Tobacco Cessation Resources SmartSet has been completed among clinical and non-clinical staff Vaping and Marijuana CME Strategy 4: Participate in local community and Rush System health improvement collaborative(s) Participated in and partnered with city and county agencies, health systems, and community organizations, including but not limited to: * Kane Health Counts Executive Committee * Kane County Tobacco Coalition * Rush University's Tobacco Oversight Committee 2022 Community Health Needs Assessment 1. Access to Health Services: Leverage patient and community-driven data to advance health equity. 2. Behavioral Health (includes mental health and substance abuse): Increase awareness on behavioral health conditions and navigation of behavioral health services in the community. Continue focus on reducing the misuse of opioids and opioid-related deaths. 3. Chronic Disease: Health Behaviors and Management: Reduce health behaviors related to chronic health conditions and increase management of chronic disease in the community. 4. Inequities in vulnerable populations: Reduce inequities caused by the social, economic, and structural determinants of health, focusing on reducing inequities in vulnerable populations through improved identification and connection of patients in need to available community resources. FY23-25 Community Health Implementation Plan 1. Access to Health Services: Leverage patient and community-driven data to advance health equity. * Increase referrals to a primary care provider or medical home for patients seen in the Emergency Room * Continue partnership with local federally qualified healthcare centers to connect uninsured patients with insurance benefits * Create culturally sensitivity training for staff on capturing Race, Ethnicity and Language (REAL) and Sexual Orientation and Gender Identity (SOGI) patient data * Continue to provide accessible community programing: Tobacco Cessation, Diabetes Management, Movement Disorders Program and Waterford Place Cancer Resource Center * Participate in local community health improvement collaborative(s) 2. Behavioral Health (includes mental health and substance abuse): Increase awareness on behavioral health conditions and navigation of behavioral health services in the community. Continue focus on reducing the misuse of opioids and opioid-related deaths. * Develop partnership with Kane County Health Department's Integrated Referral and Information System (IRIS) to provide close loop referrals * Develop partnership for "soft handoff" with community behavioral health organizations * Continue reduction on the number of opioid prescriptions and assess other opportunities to address the opioid crisis * Collaborate with local community based behavioral health organizations to establish educational opportunities * Participate in local community health improvement collaborative(s) 3. Chronic Disease: Health Behaviors and Management: Reduce health behaviors related to chronic health conditions and increase management of chronic disease in the community. * Adopt the Steps to Healthy Living, Chronic Disease Self-Management Workshop * Leverage community referral resource system (i.e. IRIS, Now Pow, Kane 211, etc.) to generate referrals for the Chronic Disease Self-Management Workshop * Continue to provide community programing: tobacco cessation, diabetes management, Movement Disorders and Waterford Place Cancer Resource Center * Partner with Kane County Health Department to create and develop a backbone entity in the community that builds and supports community-based programming related to nutrition, exercise and weight * Participate in local community health improvement collaborative(s) 4. Inequities in vulnerable populations: Reduce inequities caused by the social, economic, and structural determinants of health * Identify benchmarks for Social Determinants of Health (SDoH) screening * Continue to develop and establish SDoH screening to emergency room and ambulatory departments * Assess potential impact of a community health worker to conduct SDoH screening in Emergency Room * Partner with local food pantry to provide a healthy box of produce and protein to patients that screen positive for the SDoH, close loop referral * Participate in local community health improvement collaborative(s)

Schedule H (Form 990) 2021

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?6
Name and address		Type of Facility (describe)
1	RADIATION THERAPY CENTER AT RIVERWEST 1221 N HIGHLAND AVENUE AURORA,IL605044206	JV ONCOLOGY
2	CASTLE SURGICENTER 2111 OGDEN AVE AURORA,IL60504	AMBULATORY SURGERY CENTER
3	RUSH COPLEY HEALTHCARE CENTER 1100 WEST VETERANS PARKWAY YORKVILLE,IL60560	OUTPATIENT SERVICES
4	MIDWEST CENTER FOR ADVANCED IMAGING 4355 MONTGOMERY ROAD NAPERVILLE,IL60564	RADIOLOGY SERVICES
5	HEALTHPLEX OUTPATIENT REHABILITATION 1900 OGDEN AVENUE AURORA,IL60504	OUTPATIENT REHABILITATION SERVICES
6
7
8
9
10

Schedule H (Form 990) 2021

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
Schedule H, Part I, Line 3c	DETAILS ARE IDENTIFIED UNDER THE FINANCIAL ASSISTANCE POLICY, PATIENTS MUST COMPLETE AN APPLICATION, MEET THE QUALIFICATIONS AND RESPONSE WITH THE REQUESTED DOCUMENTATION UNDER THE POLICY TO DETERMINE THE DISCOUNT AMOUNT, IF ANY, THAT WOULD APPLY TO THEIR HOSPITAL BILL.
Schedule H, Part I, Line 7g Subsidized Health Services	Reported $16,302,258 costs from physician clinics
Schedule H, Part I, Line 7 Costing Methodology used to calculate financial assistance	A COST ACCOUNTING SYSTEM WAS USED TO CALCULATE THE AMOUNTS REPORTED IN THE TABLE. A COST TO CHARGE RATIO WAS UTILIZED. THE COST ACCOUNTING SYSTEM ADDRESSES ALL PATIENT SEGMENTS (INPATIENT, OUTPATIENT, EMERGENCY ROOM, PRIVATE INSURANCE, MEDICAID, MEDICARE, UNINSURED AND SELF PAY).
Schedule H, Part II Community Building Activities	Local high school students come to the hospital to observe various areas of the hospital to get an understand of the work performed in each area and how patients are cared for and treated. Hopefully this encourages some of the students to persue healthcare careers.
Schedule H, Part III, Line 2 Bad debt expense - methodology used to estimate amount	BAD DEBT EXPENSE IS CALCULATED BASED ON ACTUAL WRITE OFF'S DURING THE YEAR AND APPLYING HISTORICAL UNCOLLECTED PERCENTAGES TO CURRENT OUTSTANDING BALANCES.
Schedule H, Part III, Line 3 Bad Debt Expense Methodology	THE ESTIMATED AMOUNT OF BAD DEBT EXPENSE ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S FINANCIAL ASSISTANCE POLICY IS 10% OF THE ORGANIZATION'S BAD DEBT EXPENSE REPORTED ON PART III, LINE 2.
Schedule H, Part III, Line 4 Bad debt expense - financial statement footnote	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.
Schedule H, Part III, Line 8 Community benefit & methodology for determining medicare costs	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.
Schedule H, Part III, Line 9b Collection practices for patients eligible for financial assistance	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 DETERMINE 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.
Schedule H, Part V, Section B, Line 16a FAP website	- COPLEY MEMORIAL HOSPITAL Inc: Line 16a URL: https://www.rush.edu/patients-visitors/financial-assistance;
Schedule H, Part V, Section B, Line 16b FAP Application website	- COPLEY MEMORIAL HOSPITAL Inc: Line 16b URL: https://www.rush.edu/patients-visitors/financial-assistance;
Schedule H, Part V, Section B, Line 16c FAP plain language summary website	- COPLEY MEMORIAL HOSPITAL Inc: Line 16c URL: https://www.rush.edu/patients-visitors/financial-assistance;
Schedule H, Part VI, Line 2 Needs assessment	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.
Schedule H, Part VI, Line 3 Patient education of eligibility for assistance	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.
Schedule H, Part VI, Line 4 Community information	COPLEY MEMORIAL HOSPITAL INC.'S PRIMARY SERVICE AREA IS LOCATED 45 TO 55 MILES SOUTHWEST OF CHICAGO AND INCLUDES ALL OF AURORA AND MOST OF SOUTHERN KANE COUNTY AND KENDALL COUNTY, ILLINOIS. KANE COUNTY IS PREDOMINANTLY URBAN AND SUBURBAN, AND THE POVERTY RATE IS 10%. KENDALL COUNTY, TO THE SOUTH OF KANE, IS MOSTLY RURAL WHILE THE NORTHWEST SECTION OF THE COUNTY IS SUBURBAN, AND THE POVERTY RATE IN THE COUNTY IS 5.3%. THE PRIMARY SERVICE AREA HAS A POPULATION OF OVER 383,000 RESIDENTS. APPROXIMATELY 33.5% OF THE POPULATION IS OF HISPANIC OR LATINO ORIGIN. THE MEDIAN AGE OF THE COMMUNITY IS 34.3 YEARS. THE COMMUNITY CONTINUES TO RECOVER FROM THE ECONOMIC DOWNTOWN AND HAS SHOWN SIGNIFICANT IMPROVEMENT IN A NUMBER OF AREAS SINCE 2015, INCLUDING AN INCREASE IN MEDIAN HOUSING VALUES, MEDIAN HOUSEHOLD INCOME, AND IMPROVEMENT IN FORECLOSURE RATES, UNEMPLOYMENT RATES, AND ATTAINMENT OF HIGHER EDUCATION.
Schedule H, Part VI, Line 5 Promotion of community health	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, FREE AND REDUCED COST HEALTH SCREENINGS, LANGUAGE ASSISTANCE SERVICES, 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.
Schedule H, Part VI, Line 6 Affiliated health care system	RUSH SYSTEM FOR HEALTH ("RUSH"), IS A MULTIHOSPITAL HEALTH SYSTEM WITH OPERATIONS THAT CONSIST OF SEVERAL DIVERSE ACTIVITIES WITH A SHARED MISSION OF PATIENT CARE, EDUCATION, RESEARCH, AND COMMUNITY SERVICE. RUSH CONSISTS OF AN ACADEMIC MEDICAL CENTER, RUSH UNIVERSITY MEDICAL CENTER ("RUMC"), TWO COMMUNITY HOSPITALS, RUSH COPLEY MEDICAL CENTER ("RCMC") AND RUSH OAK PARK HOSPITAL ("RPPH"), THAT EACH SERVE DISTINCT MARKETS IN CHICAGO, ILLINOIS, METROPOLITAN AREA AND RUSH HEALTH, A PHYSICIAN HOSPITAL ORGANIZATION AND CLINICALLY INTEGRATED NETWORK.
Schedule H, Part VI, Line 7 State filing of community benefit report	IL

Schedule H (Form 990) 2021

Additional Data

Software ID:	21014044
Software Version:	2021v4.2

- 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

2021

Open to Public Inspection

Name of the organization

Copley Memorial Hospital Inc

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

Yes

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) 2021

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, 1099-MISC compensation, and/or 1099-NEC			(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)
1John Diederich MA MBA FACHE President & CEO/Director	(i) (ii)	605,503 ------------- 0	382,806 ------------- 0	5,284 ------------- 0	340,230 ------------- 0	26,928 ------------- 0	1,360,751 ------------- 0	0 ------------- 0
2Jae B Joo MD VICE CHIEF OF STAFF/DIRECTOR	(i) (ii)	499,580 ------------- 0	220,882 ------------- 0	10,884 ------------- 0	9,599 ------------- 0	29,361 ------------- 0	770,306 ------------- 0	0 ------------- 0
3Garrett Katula DO PHYSICIAN/DIRECTOR	(i) (ii)	268,474 ------------- 0	96,338 ------------- 0	4,194 ------------- 0	9,750 ------------- 0	20,987 ------------- 0	399,743 ------------- 0	0 ------------- 0
4Syed Zaidi MD CHIEF OF STAFF/DIRECTOR	(i) (ii)	489,521 ------------- 0	15,319 ------------- 0	46,516 ------------- 0	6,997 ------------- 0	24,289 ------------- 0	582,642 ------------- 0	0 ------------- 0
5Barry C Finn Former President & CEO/Director	(i) (ii)	0 ------------- 0	0 ------------- 0	368,652 ------------- 0	0 ------------- 0	0 ------------- 0	368,652 ------------- 0	0 ------------- 0
6Ryan Asmus VP GENERAL COUNSEL/SECRETARY	(i) (ii)	326,398 ------------- 0	158,794 ------------- 0	3,702 ------------- 0	41,307 ------------- 0	0 ------------- 0	530,201 ------------- 0	0 ------------- 0
7Brenda Van Wyhe SR. VP FINANCE & CFO/TREASURER	(i) (ii)	413,835 ------------- 0	235,355 ------------- 0	6,473 ------------- 0	56,313 ------------- 0	21,706 ------------- 0	733,682 ------------- 0	0 ------------- 0
8Dennis L Demasie FORMER VP, INFORMATION TECH, & CIO	(i) (ii)	0 ------------- 0	0 ------------- 0	279,866 ------------- 0	0 ------------- 0	0 ------------- 0	279,866 ------------- 0	0 ------------- 0
9Homan Diane MD FORMER VO, QUALITY & PSO	(i) (ii)	0 ------------- 0	0 ------------- 0	377,000 ------------- 0	0 ------------- 0	0 ------------- 0	377,000 ------------- 0	0 ------------- 0
10Hornbogen Abigail VP. PATIENT CARE & CNO	(i) (ii)	244,702 ------------- 0	122,817 ------------- 0	2,412 ------------- 0	8,350 ------------- 0	26,978 ------------- 0	405,259 ------------- 0	0 ------------- 0
11Brenda K Fann MD ASSISTANT VP. MEDICAL AFFAIRS	(i) (ii)	317,920 ------------- 0	90,207 ------------- 0	4,706 ------------- 0	6,500 ------------- 0	16,225 ------------- 0	435,558 ------------- 0	0 ------------- 0
12Steve B Lowenthal MD SR. VP MEDICAL AFFAIRS & CMO	(i) (ii)	505,854 ------------- 0	283,560 ------------- 0	86,579 ------------- 0	10,141 ------------- 0	17,197 ------------- 0	903,331 ------------- 0	0 ------------- 0
13David Petasnick ASSISTANT VP, ANCILLARY SVCS	(i) (ii)	218,853 ------------- 0	109,171 ------------- 0	1,815 ------------- 0	28,050 ------------- 0	26,918 ------------- 0	384,807 ------------- 0	0 ------------- 0
14Alex Pope VP. PHILANTHROPY & CDO	(i) (ii)	275,264 ------------- 0	137,952 ------------- 0	3,235 ------------- 0	28,356 ------------- 0	28,728 ------------- 0	473,535 ------------- 0	0 ------------- 0
15Mary F Shilkaitis SR VP Operations & COO	(i) (ii)	346,794 ------------- 0	198,492 ------------- 0	7,142 ------------- 0	46,319 ------------- 0	23,172 ------------- 0	621,919 ------------- 0	0 ------------- 0
16Kevin V Kelly MD PHYSICIAN	(i) (ii)	922,717 ------------- 0	3,763 ------------- 0	4,185 ------------- 0	1,560 ------------- 0	26,361 ------------- 0	958,586 ------------- 0	0 ------------- 0
17Dmitry S Ruban MD PHYSICIAN	(i) (ii)	915,546 ------------- 0	3,763 ------------- 0	710 ------------- 0	9,750 ------------- 0	25,880 ------------- 0	955,649 ------------- 0	0 ------------- 0
18Arif Saleem MD PHYSICIAN	(i) (ii)	604,707 ------------- 0	290,952 ------------- 0	11,526 ------------- 0	2,380 ------------- 0	26,611 ------------- 0	936,176 ------------- 0	0 ------------- 0
19Mark F Sharp-Schinsky MD PHYSICIAN	(i) (ii)	756,504 ------------- 0	378,752 ------------- 0	82,107 ------------- 0	3,120 ------------- 0	11,185 ------------- 0	1,231,668 ------------- 0	0 ------------- 0
20Jonathan L Tueting MD PHYSICIAN	(i) (ii)	749,755 ------------- 0	720,909 ------------- 0	14,132 ------------- 0	7,823 ------------- 0	29,361 ------------- 0	1,521,980 ------------- 0	0 ------------- 0

Schedule J (Form 990) 2021

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
Schedule J, Part I, Line 1a Health or social club dues or initiation fees	THE ORGANIZATION PROVIDES TO ALL EMPLOYEES THE USE OF AN ATHLETIC FACILITY THAT IS OWNED AND OPERATED BY A RELATED TAX EXEMPT ORGANIZATION. THESE AMOUNTS ARE NON-TAXABLE.
Schedule J, Part I, Line 4a Severance or change-of-control payment	BARRY FINN, FORMER PRESIDENT & CEO AND DIRECTOR, WAS PAID $368,652 IN 2021 PURSUANT TO HIS SEVERANCE AGREEMENT. DENNIS DEMASIE, FORMER VP, INFORMATION TECH & CIO, WAS PAID $279,866 IN 2021 PURSUANT TO HIS SEVERANCE AGREEMENT. DIANE HOMAN, FORMER VP, QUALITY & PSO, WAS PAID $377,000 IN 2021 PURSUANT TO HER SEVERANCE AGREEMENT.
Schedule J, Part I, Line 4b Supplemental nonqualified retirement plan	CMH OFFERS A SUPPLEMENTAL RETIREMENT PLAN TO CERTAIN EMPLOYEES WHO RECEIPT OF THESE AMOUNTS BY THE INDIVIDUALS UNTIL THEY ARE PAID OUT AS MEET THE REQUIRED VESTING PERIOD. ONCE VESTED, PAYOUTS WOULD BE THE AMOUNTS PAID OUT OF THIS PLAN IN 2020 WERE AS FOLLOWS: STEVE PARTICIPATE IN THE EXECUTIVE BENEFITS PROGRAM. THERE IS NO CONSTRUCTIVE THEY ARE SUBJECT TO A SUBSTANTIAL RISK OF FORFEITURE UNTIL INDIVIDUALS INCLUDED AS REPORTABLE COMPENSATION ON THE RECIPIENTS ANNUAL FORM W-2. STEVE LOWENTHAL - $66,300
Schedule J, Part I, Line 7 Non-fixed payments	INCENTIVE BONUS PLAN BASED ON A SERIES OF APPROVED STRATEGIC ACCOMPLISHMENTS.

Schedule J (Form 990) 2021

Additional Data

Software ID:	21014044
Software Version:	2021v4.2

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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

2021

Open to Public
Inspection

Name of the organization
Copley Memorial Hospital Inc

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
B	ILLINOIS FINANCE AUTHORITY	86-1091967	000000000	08-29-2019	36,752,000	BUILDINGS AND EQUIPMENT		X		X		X

Part Ⅱ

Proceeds

	A		B		C		D
	1 Amount of bonds retired ..................	9,700,000		1,885,000
2 Amount of bonds legally defeased ..............
3 Total proceeds of issue ..................	105,601,668		36,752,000
4 Gross proceeds in reserve funds .............
5 Capitalized interest from proceeds .............
6 Proceeds in refunding escrows ...............
7 Issuance costs from proceeds ...............	824,030		252,000
8 Credit enhancement from proceeds .............
9 Working capital expenditures from proceeds .............	145
10 Capital expenditures from proceeds .............			36,500,000
11 Other spent proceeds .............	104,777,493
12 Other unspent proceeds .............
13 Year of substantial completion .............			2019
	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 2020, a current refunding issue)? ........		X		X
15 Were the bonds issued as part of an advance refunding issue of taxable bonds (or, if issued prior to 2020, an advance refunding issue)? ........	X			X
16 Has the final allocation of proceeds been made? ..........	X		X
17 Does the organization maintain adequate books and records to support the final allocation of proceeds? ..................	X		X

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

Cat. No. 50193E

Schedule K (Form 990) 2021

Page 2

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		X
2 Are there any lease arrangements that may result in private business use of bond-financed property? ...............		X		X
3a Are there any management or service contracts that may result in private business use of bond-financed property? .............	X		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		X
c Are there any research agreements that may result in private business use of bond-financed property? .............		X		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 %		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 %		0 %
6 Total of lines 4 and 5 .............	0 %		0 %
7 Does the bond issue meet the private security or payment test? ...		X		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		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		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		X
2 If "No" to line 1, did the following apply? ....
a Rebate not due yet? .......		X	X
b Exception to rebate? ........		X		X
c No rebate due? .........	X			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	X

Schedule K (Form 990) 2021

Page 3

Part Ⅳ

Arbitrage (Continued)

	A		B		C		D
	Yes	No	Yes	No	Yes	No	Yes	No
4a Has the organization or the governmental issuer entered into a qualified hedge with respect to the bond issue?		X		X
b Name of provider ..........
c Term of hedge .........
d Was the hedge superintegrated? ......
e Was the hedge terminated? ........
5a Were gross proceeds invested in a guaranteed investment contract (GIC)?		X		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		X
7 Has the organization established written procedures to monitor the requirements of section 148? ...		X		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		X

Part Ⅵ

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

Return Reference	Explanation
Schedule K, Part I Bond Issues	(A) ISSUER NAME: ILLINOIS FINANCE AUTHORITY (F) DESCRIPTION OF PURPOSE: REFUND BONDS ISSUED 5/28/2008, 2/10/2009, AND 7/29/2009
Schedule K, 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, Part IV, Line 2c COLUMN A	Issuer name: ILLINOIS FINANCE AUTHORITY The calculation for computing no rebate due was performed on 03/06/2020

Schedule K (Form 990) 2021

Additional Data

Software ID:	21014044
Software Version:	2021v4.2

- TIN:

SCHEDULE O
(Form 990)

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

2021

Open to Public
Inspection

Name of the organization

Copley Memorial Hospital Inc

Employer identification number

36-2170840

Return Reference	Explanation
Form 990, Part VI, 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, Line 2 Family/business relationships amongst interested persons	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. - Business relationship
Form 990, Part VI, Line 3 Delegation of management duties	RESERVED POWERS OVER CERTAIN MANAGEMENT DUTIES HAVE BEEN DELEGATED TO RUSH SYSTEM FOR HEALTH ("RSH") AS THE PARENT ENTITY FOR THE RUSH SYSTEM. THESE DUTIES INCLUDE APPROVING VARIOUS RCMC ACTIONS, INCLUDING RCMC'S OPERATING BUDGET AND CERTAIN TRANSACTIONS, APPOINTMENT OF CERTAIN RCMC EXECUTIVES, APPOINTMENT OF RCMC'S BOARD MEMBERS, ETC.
Form 990, Part VI, Line 6 Classes of members or stockholders	RUSH COPLEY MEDICAL CENTER ("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, Line 7a Members or stockholders electing members of governing body	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, Line 7b Decisions requiring approval by members or stockholders	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, Line 11b Review of form 990 by governing body	THE FORM 990 TAX RETURN IS PREPARED BY OUR ORGANIZATION AND REVIEWED BY OUR EXTERNAL TAX ADVISOR. 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, Line 12c Conflict of interest policy	ANNUALLY, BOARD MEMBERS, DIRECTORS, MANAGEMENT TEAM (ADMINISTRATION, DIRECTORS AND MANAGERS) AND OTHER KEY EMPLOYEES OF RUSH COPLEY MEDICAL CENTER AND SUBSIDIARIES ("RCMC") ARE REQUIRED TO SUBMIT A CONFLICT OF INTEREST DISCLOSURE STATEMENT TO DISCLOSE ANY PERSONAL OR BUSINESS INTERESTS THAT MAY GIVE RISE TO A CONFLICT WITH THE WORK THEY DO FOR RCMC. THE DISCLOSURES ARE SUBMITTED AND REVIEWED BY THE CORPORATE INTEGRITY OFFICER, WHO IS AN EMPLOYEE OF COPLEY MEMORIAL HOSPITAL BUT REPRESENTS RUSH COPLEY MEDICAL CENTER AND SUBSIDIARIES, AND A REPORT IS SUBMITTED TO THE EXECUTIVE COMMITTEE OF THE BOARD OF DIRECTORS OF RCMC. THOSE KEY PERSONNEL WITH CONFLICTS ARE ADVISED TO RECUSE THEMSELVES FROM PARTICIPATING IN DECISION-MAKING RELATED TO THE CONFLICT.
Form 990, Part VI, Line 19 Required documents available to the public	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 Other changes in net assets or fund balances	CHANGE IN INTEREST IN NET ASSETS OF FOUNDATION - -65448; SWAP VALUE ADJUSTMENT - 4348914; OTHER CHANGE IN NET ASSETS - 80772655;

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

Cat. No. 51056K

Schedule O (Form 990) 2021

Additional Data

Software ID:	21014044
Software Version:	2021v4.2

- 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

2021

Open to Public Inspection

Name of the organization

Copley Memorial Hospital Inc

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 2000 OGDEN AVENUE AURORA,IL60504 36-3193787	PARENT COMPANY	IL	501(c)(3)	Type II	RUSH SYSTEM FOR HEALTH	Yes
(2)RUSH COPLEY FOUNDATION 2000 OGDEN AVENUE AURORA,IL60504 36-3093877	GRANTS TO CHARITABLE ORGANIZATIONS	IL	501(c)(3)	7	RUSH COPLEY MEDICAL CENTER	Yes
(3)COPLEY VENTURES INC 2000 OGDEN AVENUE AURORA,IL60504 36-3370216	RENTAL PROP., INFIRMARY CARE, AND HEALTHPLEX FITNESS CENTER	IL	501(c)(3)	3	RUSH COPLEY MEDICAL CENTER	Yes
(4)RUSH UNIVERSITY MEDICAL CENTER 1700 WEST VAN BUREN STREET CHICAGO,IL60612 36-2174823	HEALTHCARE	IL	501(c)(3)	3	RUSH SYSTEM FOR HEALTH	Yes
(5)RUSH SYSTEM FOR HEALTH 1725 W HARRISON STREET CHICAGO,IL60612 36-4046278	HOSPITAL	IL	501(c)(3)	Type III-FI	NA		No
(6)RUSH OAK PARK HOSPITAL INC 520 S MAPLE AVENUE OAK PARK,IL60304 36-2183812	HOSPITAL	IL	501(c)(3)	3	RUSH UNIVERSITY MEDICAL CENTER INC	Yes
(7)AMENDED & RESTATED GENERAL MALPRACTICE & WORKER'S COMP 1700 WEST VAN BUREN CHICAGO,IL60612 36-6673233	HEALTHCARE INSURANCE	IL	501(c)(3)	Type III-FI	RUSH UNIVERSITY MEDICAL CENTER INC	Yes
(8)AUXILIARY OF RUSH OAK PARK HOSPITAL - 520 S MAPLE AVE OAK PARK,IL60304 36-2255350	HOSPITAL SUPPORT	IL	501(c)(3)	Type I	RUSH OAK PARK HOSPITAL	Yes

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

Cat. No. 50135Y

Schedule R (Form 990) 2021

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	(k) Percentage ownership
(1) RUSH SURGICENTER AT THE PROFESSIONAL BUILDING LP 1725 W HARRISON STREET CHICAGO,IL60612 36-3853026	SURGERY CENTER	IL	NA	N/A				No			No
(2) RUSH COPLEY ORTHOPEDICS LLC 2000 OGDEN AVENUE AURORA,IL60504 61-1801175	MEDICAL SERVICES	IL	NA	N/A				No			No
(3) RUSH COPLEY SURGICENTER 2000 OGDEN AVENUE AURORA,IL60504 38-4012268	MEDICAL SERVICES	IL	COPLEY MEMORIAL HOSPITAL INC CO RUSH	Related	31,075	15,459,652		No		Yes		99 %

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	(h) Percentage ownership	(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	(h) Percentage ownership	Yes	No
(1) RUSH UNIVERSITY MEDICAL CENTER INSURANCE PO BOX 1051 GRAND CAYMAN CJ	INSURANCE	CJ	NA	C Corporation				Yes
(2) RUSH COPLEY MEDICAL GROUP NFP 2000 OGDEN AVENUE AURORA,IL60504 36-3235315	PHYSICIAN PRACTICES	IL	NA	C Corporation				Yes
(3) ROOM FIVE HUNDRED 1725 W HARRISON STREET CHICAGO,IL60612 23-7139832	DINING ROOM	IL	NA	C Corporation				Yes
(4) RUSH UNIVERSITY MEDICAL CENTER MASTER RETIREMENT TRUST 1700 W VAN BUREN STREET SUITE 501 CHICAGO,IL60612 91-2043520	PENSION TRUST	IL	NA	Trust				Yes
(5) RUSH HEALTH 1645 WEST JACKSON BLVD SUITE 501 CHICAGO,IL60612 36-3972171	CLINICALLY INTEGRATED NETWORK	IL	NA	C Corporation				Yes
(6) RUSH HEALTH ACO INC 1645 WEST JACKSON BLVD SUITE 501 CHICAGO,IL60612 82-1632136	ACO	IL	NA	C Corporation				Yes

Schedule R (Form 990) 2021

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) ............................

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) ............................

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

Yes

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

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	617,454	FAIR MARKET VALUE
(2) RUSH COPLEY FOUNDATION	C	423,488	FAIR MARKET VALUE
(3) COPLEY VENTURES INC	M	605,000	FAIR MARKET VALUE
(4) COPLEY VENTURES INC	R	1,139,202	FMV - RENTS
(5) RUSH UNIVERSITY MEDICAL CENTER	J	369,000	FAIR MARKET VALUE
(6) RUSH UNIVERSITY MEDICAL CENTER	P	8,028,092	FAIR MARKET VALUE
(7) RUSH COPLEY FOUNDATION	Q	994,985	FAIR MARKET VALUE
(8) RUSH HEALTH	M	1,647,970	FAIR MARKET VALUE
(9) RUSH HEALTH	P	516,430	FAIR MARKET VALUE
(10) RUSH HEALTH	P	55,448	FAIR MARKET VALUE
(11) RUSH HEALTH	S	2,295,058	FAIR MARKET VALUE
(12) RUSH SYSTEM FOR HEALTH	M	337,612	FAIR MARKET VALUE

Schedule R (Form 990) 2021

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?		(k) Percentage ownership
(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	(k) Percentage ownership

Schedule R (Form 990) 2021

Page 5

Part VII

Supplemental Information

Provide additional information for responses to questions on Schedule R. See instructions.

Return Reference	Explanation
Schedule R, Part III IDENTIFICATION OF RELATED ORGANIZATIONS TAXABLE AS PARTNERSHIP	NAME OF RELATED ORGANIZATION: RUSH COPLEY SURGICENTER DIRECT CONTROLLING ENTITY: COPLEY MEMORIAL HOSPITAL, INC. C/O RUSH COPLEY MEDICAL CENTER

Schedule R (Form 990) 2021

Additional Data

Software ID:	21014044
Software Version:	2021v4.2

1	Briefly describe the organization’s mission or most significant activities: THE MISSION OF RUSH COPLEY IS 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	20
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 2021 (Part V, line 2a) ......	5	2,743
6	Total number of volunteers (estimate if necessary) .............	6	170
7a	Total unrelated business revenue from Part VIII, column (C), line 12 ........	7a	0
b	Net unrelated business taxable income from Form 990-T, Part I, line 11 .........	7b	0

		Prior Year	Current Year
8	Contributions and grants (Part VIII, line 1h) .........	20,536,656	3,294,712
9	Program service revenue (Part VIII, line 2g) .........	376,386,724	377,387,341
10	Investment income (Part VIII, column (A), lines 3, 4, and 7d ) ....	6,754,688	19,028,974
11	Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e)	3,756,528	7,413,907
12	Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)	407,434,596	407,124,934
13	Grants and similar amounts paid (Part IX, column (A), lines 1–3 )...	0	500
14	Benefits paid to or for members (Part IX, column (A), line 4).....	0	0
15	Salaries, other compensation, employee benefits (Part IX, column (A), lines 5–10)	168,590,696	178,107,474
16a	Professional fundraising fees (Part IX, column (A), line 11e) .....	0	0
b	Total fundraising expenses (Part IX, column (D), line 25) 0
17	Other expenses (Part IX, column (A), lines 11a–11d, 11f–24e)....	177,283,966	182,457,578
18	Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25)	345,874,662	360,565,552
19	Revenue less expenses. Subtract line 18 from line 12.......	61,559,934	46,559,382
		Beginning of Current Year	End of Year
20	Total assets (Part X, line 16).............	974,963,685	954,609,869
21	Total liabilities (Part X, line 26).............	440,241,277	362,556,402
22	Net assets or fund balances. Subtract line 21 from line 20.....	534,722,408	592,053,467

Sign Here

	Signature of officer	Date

	Type or print name and title


4a	(Code: ) (Expenses $ 291,436,943 including grants of $ 500 ) (Revenue $ 383,365,737 )
	THE MISSION OF RUSH COPLEY IS TO PROVIDE ADVANCED MEDICINE WITH QUALITY OUTCOMES AND EXTRAORDINARY CARE. IN FY2022, 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 HEALTH EDUCATION AND WELLNESS PROGRAMS RANGING FROM DIABETES, HEART HEALTH, CANCER PREVENTION, WEIGHT CONTROL, SMOKING CESSATION, CHRONIC HEALTH, CHILDBIRTH EDUCATION AND MORE. SUMMARY OF FY22 HEALTH PROGRAMMING THE PANDEMIC HAD SIGNIFICANT IMPACT ON THE COMMUNITIES' PUBLIC PROGRAMMING AND, RELATEDLY, COPLEY MEMORIAL HOSPITAL SPONSORSHIP, PARTNERSHIP AND PARTICIPATION IN COMMUNITY PROGRAMS. IN FY22, THE HOSPITAL PARTICIPATED IN NEARLY 200 COMMUNITY-BASED PROGRAMS AND EVENTS WITH SPECIAL EMPHASIS ON IMPROVING THE HEALTH AND WELLNESS OF ADULTS, CHILDREN AND UNDERSERVED POPULATIONS. DIABETES EDUCATION PROGRAM FREE DIABETES EDUCATION IS PROVIDED TO LOW-INCOME PATIENTS, GIVING THEM THE KNOWLEDGE AND SKILLS THEY NEED TO AVOID OR DELAY LONG-TERM COMPLICATIONS OF DIABETES. IN FY22, FREE FASTING GLUCOSE SCREENINGS AND EDUCATION WERE PROVIDED TO APPROXIMATELY 228 UNIQUE COMMUNITY MEMBERS SERVED WITH 419 EDUCATION SESSIONS. FOOD INSECURITY THE RUSH COPLEY PROMISE PANTRY PROVIDES PATIENTS AND THEIR FAMILIES FACING FOOD INSECURITY WITH A BAG OF SHELF STABLE FOOD ITEMS ALONG WITH A LIST OF FOOD PANTRIES WITHIN RUSH COPLEY'S SERVICE AREA AND HANDOUT ON SNAP. IT WAS BORN FROM THE RUSH COPLEY PROMISE - A COMMITMENT WE MAKE TO ALL PATIENTS, THEIR FAMILIES AND GUESTS TO DO EVERYTHING POSSIBLE TO PROVIDE YOU WITH COMPASSIONATE AND EXCEPTIONAL CARE. IN MAY OF 2022 RUSH COPLEY MEDICAL CENTER PARTNERED WITH LOAVES AND FISHES COMMUNITY SERVICES, A LOCAL FOOD PANTRY THAT NOW PROVIDES THE BAGS OF SHELF STABLE FOOD ITEMS FOR THE RUSH COPLEY PROMISE PANTRY. IN FY22 THE RUSH COPLEY PROMISE PANTRY PROVIDED 717 PROMISE PANTRY BAGS, THIS IS EQUIVALENT TO 4,302 MEALS. ADDITIONALLY, THE COOK BOOK, "EAT WELL ON $4/DAY GOOD AND CHEAP" BY LEANNE BROWN AVAILABLE IN ENGLISH AND SPANISH ARE PROVIDED TO PATIENTS AND FAMILIES THROUGH THE RUSH COPLEY PROMISE PANTRY. OVER 400 COOK BOOKS WERE PROVIDED TO PATIENTS AND FAMILIES IN FY22. COMMUNITY FOOD DISTRIBUTION RUSH COPLEY MEDICAL CENTER PARTNERSHIP WITH TOP BOX, AMERICAN DIABETES ASSOCIATION, BLUE CROSS AND BLUE SHIELD OF ILLINOIS AND TOP BOX FOODS TO HOST A COMMUNITY FOOD DISTRIBUTION AT WATERFORD PLACE CANCER RESOURCES CENTER. COMMUNITY MEMBERS RECEIVED A BOX OF FRESH PRODUCE AND HEALTH PROTEINS, A TOTAL OF 250 BOXES WERE DISTRIBUTED IN FY22. 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, BIRTH CHOICES/WATER BIRTH, UNDERSTANDING BREASTFEEDING, BREASTFEEDING PART II, WORKING & BREASTFEEDING, BECOMING A GRANDPARENT, BOOT CAMP FOR NEW DADS, BRINGING HOME BABY, INFANT MASSAGE, FAMILY BIRTH CENTER TOURS, CHILD SEAT SAFETY, SIBLING CLASS, SIBLING TOURS, FIRST STEPS AND NOT WHAT I EXPECTED SUPPORT GROUPS, AND INFANT CPR AND HOME SAFETY. NEARLY 1,500 PEOPLE PARTICIPATED IN FY22. CHILD PASSENGER SAFETY COPLEY MEMORIAL HOSPITAL SERVES AS THE REGIONAL TRAFFIC SAFETY RESOURCE CENTER FOR SUBURBAN COOK AND SIX COLLAR COUNTIES (LAKE, DUPAGE, MCHENRY, KANE, KENDALL AND WILL). SIX OF THE SEVEN COUNTIES IN OUR REGION ARE PART OF THE ILLINOIS DEPARTMENT OF TRANSPORTATION'S 23-COUNTY MODEL. IN FY22, THE PROGRAM EDUCATED MORE THAN 5,000 CITIZENS ON TRAFFIC SAFETY, PEDESTRIAN SAFETY, MOTORCYCLE SAFETY, OLDER DRIVERS, AND BICYCLE SAFETY IN COOK AND COLLAR COUNTIES. TEEN PROGRAMMING FROM GIRL TO YOUNG WOMAN IS A PROGRAM FOR GIRLS 9 TO 12 YEARS OLD AND FOCUSES ON THE PHYSICAL AND MENTAL CHANGES THAT HAPPEN DURING THIS AGE. DURING FY22, 100 GIRLS AND THEIR FEMALE CAREGIVERS ATTENDED. MOVEMENT DISORDERS RUSH COPLEY'S MOVEMENT DISORDERS PROGRAM PROVIDES SUPPORT AND MANAGEMENT OF PARKINSON'S DISEASE, ESSENTIAL TREMOR, DYSTONIA AND ATAXIA, AS WELL AS OTHER MOVEMENT DISORDERS, TO HELP PARTICIPANTS MAXIMIZE THEIR MOBILITY, COORDINATION, AND QUALITY OF LIFE. PROGRAM OFFERINGS WERE OFFERED HYBRID IN FY22, AND INCLUDED MONTHLY SUPPORT GROUPS FOR PARTICIPANTS AND CARE PARTNERS/CAREGIVERS, EXERCISE CLASSES, AND MUSIC THERAPY TO MORE THAN 150 PARTICIPANTS. CANCER RESOURCE CENTER WATERFORD PLACE CANCER RESOURCE CENTER OFFERED 40 PROGRAMS PER MONTH IN FY22 IN-PERSON OR HYBRID. PROGRAMS INCLUDED WELLNESS, EXERCISE, SALON AND SPA, AND EDUCATION PROGRAMS REACHING 445 UNIQUE PARTICIPANTS WITH A TOTAL OF 3,110 VISITS. 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 8,000 PEOPLE USED THIS SERVICE IN FY22. HEALTH TALK HEALTH TALKS IS A SERIES OF FREE COMMUNITY HEALTH PROGRAMS HOSTED IN PERSON AND VIRTUALLY DURING FY22 ON A VARIETY OF TOPICS DESIGNED TO HELP IMPROVE WELL-BEING. RESPECTED RUSH EXPERTS SHARE INSIGHTS AND TIPS FOR HEALTHY LIVING. TOPICS INCLUDED: BREAST CANCER, CERVICAL CANCER, COLORECTAL CANCER, TOBACCO CESSATION. (ENGLISH AND SPANISH). MORE THAN 200 PARTICIPANTS ATTENDED IN PERSON OR VIRTUALLY. COMMUNITY HEALTH EVENTS RUSH COPLEY PARTICIPATED IN PLANNING AND IMPLEMENTATION FOR THE COMPANEROS EN SALUD HEALTH FESTIVAL TARGETED TOWARDS THE HISPANIC/LATINX COMMUNITY IN AURORA, AURORA AFRICAN AMERICAN HEALTH FAIR WHICH FOCUSED ON HEALTH AND WELLBEING OF THE AFRICAN AMERICAN/BLACK COMMUNITY, COMMUNITY COVID-19 VACCINATION EVENTS FOCUSED ON LOW VACCINATION RATE NEIGHBORHOODS. OVER 300 COMMUNITY MEMBERS PARTICIPATED IN THE EVENT. WEBSITE COPLEY MEMORIAL HOSPITAL'S WEBSITE, RUSHCOPLEY.COM, WITH TRANSLATION AVAILABLE INTO DOZENS OF LANGUAGES, OFFERS ACCESS TO FREE HEALTH INFORMATION. IN FY22, WWW.RUSH.EDU/RUSHCOPLEY HAD MORE THAN 1 MILLION SESSIONS.

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 expenses291,436,943

1b	Sub-Total................
c	Total from continuation sheets to Part VII, Section A....
d	Total (add lines 1b and 1c)...........	13,232,879	0	998,432

1a	Federated campaigns..		1a	0
b	Membership dues..		1b	0
c	Fundraising events..		1c	0
d	Related organizations		1d	431,190
e	Government grants (contributions)		1e	2,863,522

f	All other contributions, gifts, grants, and similar amounts not included above		1f	0

g	Noncash contributions included in lines 1a - 1f:$		1g	0

h Total. Add lines 1a-1f.......		3,294,712

		Business Code
2a	NET PATIENT SVC REV	621110	341,212,109	341,212,109
b	MEDICAID TAX REVENUE	621110	35,786,961	35,786,961
c	OTHER PROGRAM REVENUE	900009	388,271	388,271
d			0	0
e			0	0
f	All other program service revenue.		0	0	0	0
g	Total. Add lines 2a–2f .....		377,387,341

3 Investment income (including dividends, interest, and othersimilar amounts) ......			9,949,281			9,949,281
4 Income from investment of tax-exempt bond proceeds			0	0
5 Royalties...........			0	0
		(ii) Personal	(i) Real
6a	Gross rents		1,570,479	6a
b	Less: rental expenses		664,802	6b
c	Rental income or (loss)	0	905,677	6c
d	Net rental income or (loss).......			905,677			905,677
		(ii) Other	(i) Securities
7a	Gross amount from sales of assets other than inventory	53,933	241,845,966	7a
b	Less: cost or other basis and sales expenses	2,493	232,817,713	7b
c	Gain or (loss)	51,440	9,028,253	7c
d	Net gain or (loss).........			9,079,693			9,079,693
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	5,978,396	5,978,396
b	GIFT SHOP REVENUE		453220	518,309			518,309
c	CAFETERIA REVENUE		621990	11,525			11,525
d	All other revenue ....			0	0	0	0
e	Total. Add lines 11a–11d ......			6,508,230
12	Total revenue. See instructions.....			407,124,934	383,365,737	0	20,464,485

1	Grants and other assistance to domestic organizations and domestic governments. See Part IV, line 21 ....	500	500
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 ...........	8,357,320	0	8,357,320	0
6	Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) .........	507,641		507,641
7	Other salaries and wages........	135,282,901	101,400,402	33,882,499
8	Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) ....	3,514,344	2,635,758	878,586
9	Other employee benefits .......	18,440,156	13,830,117	4,610,039
10	Payroll taxes ...........	12,005,112	9,003,834	3,001,278
11	Fees for services (non-employees):
a	Management ......	6,860,368	5,145,276	1,715,092
b	Legal .........	78,207		78,207
c	Accounting ...........	80,874		80,874
d	Lobbying ...........	42,864		42,864
e	Professional fundraising services. See Part IV, line 17
f	Investment management fees ......	838,251		838,251
g	Other (If line 11g amount exceeds 10% of line 25, column (A) amount, list line 11g expenses on Schedule O)	10,251,589	7,688,692	2,562,897	0
12	Advertising and promotion ....	737,702	737,702
13	Office expenses .......	10,590,989	7,943,242	2,647,747
14	Information technology ......	12,416,007	9,312,005	3,104,002
15	Royalties ..	0	0	0
16	Occupancy ...........	5,415,087	4,061,315	1,353,772
17	Travel ............	84,588	63,441	21,147
18	Payments of travel or entertainment expenses for any federal, state, or local public officials .
19	Conferences, conventions, and meetings ....	106,721	80,041	26,680
20	Interest ...........	4,862,276	4,862,276
21	Payments to affiliates .......	0	0
22	Depreciation, depletion, and amortization ..	25,886,619	25,886,619
23	Insurance ...	6,131,107	4,598,330	1,532,777
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	59,209,416	59,209,416
b	MEDICAID PROVIDER TAX	19,915,670	19,915,670
c	PURCHASED SERVICES	15,547,747	11,660,811	3,886,936
d	COLLECTION FEES	1,191,184	1,191,184
e	All other expenses	2,210,312	2,210,312	0	0
25	Total functional expenses. Add lines 1 through 24e	360,565,552	291,436,943	69,128,609	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 ........			60,265,783	1	27,382,395
2	Savings and temporary cash investments .........				2
3	Pledges and grants receivable, net ......				3
4	Accounts receivable, net .............			50,744,544	4	54,826,702
5	Loans and other receivables from 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 .......
				0	5	0
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) ...
				0	6	0
7	Notes and loans receivable, net ...........				7
8	Inventories for sale or use ............			7,196,280	8	7,093,925
9	Prepaid expenses and deferred charges ......			1,681,880	9	1,632,377
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	478,187,620
b	Less: accumulated depreciation	10b	285,127,760	195,992,753	10c	193,059,860
11	Investments—publicly traded securities .			383,371,362	11	332,739,710
12	Investments—other securities. See Part IV, line 11 .....			0	12
13	Investments—program-related. See Part IV, line 11 ..			0	13
14	Intangible assets ...............			4,395,425	14	4,317,836
15	Other assets. See Part IV, line 11 ...........			271,315,658	15	333,557,064
16	Total assets. Add lines 1 through 15 (must equal line 33)...			974,963,685	16	954,609,869

17	Accounts payable and accrued expenses .....	124,212,952	17	117,052,674
18	Grants payable ...		18
19	Deferred revenue .........		19
20	Tax-exempt bond liabilities .........	127,291,589	20	123,693,488
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 .........
		0	22	0
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	188,736,736	25	121,810,240
26	Total liabilities. Add lines 17 through 25..	440,241,277	26	362,556,402

	Organizations that follow FASB ASC 958, check here and complete lines 27, 28, 32, and 33.
27	Net assets without donor restrictions ..........	528,122,501	27	585,519,008
28	Net assets with donor restrictions ...........	6,599,907	28	6,534,459
	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 ...........	534,722,408	32	592,053,467
33	Total liabilities and net assets/fund balances ........	974,963,685	33	954,609,869