2013-11-12T15:16:57-07:00 2012-12-31 990 2012-01-01 910712166 HIGHLINE MEDICAL CENTER HIGH 2062484758 16251 SYLVESTER ROAD SW BURIEN WA 98166 Bud Musselman 2064315235 2013-11-12 2012 2016-02-24 21:20:13Z Mark Benedum 16251 Sylvester Road SW Burien WA 98166 208218924 0 X www.highlinemedicalcenter.org X 1959 WA Improve the health of our community by delivering integrated care that is safe, high-quality and patient-centered. 17 14 1488 308 117477 47871 6684 473258 163985543 161631607 1389389 3134137 13064288 9559547 178445904 174798549 0 0 0 0 92794160 90891940 0 0 0 99057200 90373745 191851360 181265685 -13405456 -6467136 245430626 228267120 169699548 162230060 75731078 66037060 Improve the health of our community by delivering integrated care that is safe, high-quality and patient-centered. 0 0 119964599 0 0 Highline Medical Center serviced 8,963 inpatients (including nursery) and 8,846 special procedures, observation, and short-stay patients, and handled 243,717 emergency room and other outpatient visits in 2012. Highline Medical Center provides care to persons covered by governmental programs at below cost. Recognizing its mission to the community, services are provided to both Medicare and Medicaid patients. To the extent reimbursement is below cost, Highline Medical Center recognizes these amounts as uncompensated care. The Medical Center provides care to patients who meet certain criteria under its charity care policy without charge or at amounts less than its established rates. Because the Medical Center does not pursue collection of amounts determined to qualify as charity care, they are not reported as revenue. Charity care is also provided through many reduced price services and free programs offered throughout the year based upon activities and services which Highline Medical Center believes will serve a bona fide community health need. During 2012, the value of charity care and community programs was $16,376,842. The value of uncompensated care and contractual discounts, not including bad debt, was $361,286,719. 0 0 0 Highline Medical Center is fully accredited by the Joint Commission. Highlines acute and sub-acute rehabilitation programs successfully completed a three-year accreditation survey by the Commission on Accreditation of Rehabiliation Facilities (CARF). This award certifies that the program operates according to the GOLD standards established by the rehabilitation profession. 0 0 0 In 2012, for the second year in a row, Highline Medical Center received a five-star rating for its joint replacement surgery and excellence in orthopedics from HealthGrades, the nation's largest independent healthcare ratings organization. HealthGrades analyzed 40 million patient records from the nation's 4,500 hospitals and evaluated complication rates and mortality data. Hospitals were given ratings of one, three or five stars. On average, five-star rated hospitals had lower complication rates and higher quality. The HealthGrades ratings help consumers make well-informed decisions about their health care choices. 0 0 0 The Family Childbirth Center at Highline Medical Center received recognition from the Institute of Healthcare Improvement (IHI) Perinatal Improvement Project for its work to ensure the safety of moms and babies during childbirth. Highline was applauded for receiving the best results of all participating hospitals. 0 0 0 Highline Medical Center is a member of the Washington State Hospital Association and is accredited by the American College of Surgeons Commission on Cancer. The American College of Surgeons Commission on Cancer surveyed the Cancer Care Program at Highline Medical Center. The Commission has 36 standards that encompass eight major elements for cancer programs, including: Institutional and Programmatic Resources, Cancer Committee Leadership, Cancer Data Management and Cancer Registry Operations, Clinical Management, Research, Community Outreach, Professional Education and Staff Support, and Quality Management. All standards are mandatory and form the basis for the approval award. Upon successful completion of the survey, Highlines Cancer Care Program was awarded full accreditation and received commendation in seven areas and has been fully accredited for 26 years. 0 0 0 Highline Medical Center Laboratory, along with Highline and Specialty Centers Respiratory Care departments, are in a select group of departments that have been evaluated and found to be in compliance with the College of American Pathologists (CAP) accreditation standards. This rigorous standard is designed to help ensure quality patient care. The CAPs program is the most respected and recognized laboratory accreditation program in the world and has long been considered the gold standard against which others are measured. 0 0 0 In October 2012, Highline received certification as a Primary Stroke Center by the Joint Commission. The Joint Commission is an independent organization that accredits and certifies healthcare programs throughout the U.S. The certification program was developed in collaboration with eht American Healt Association and American Stroke Association to ensure best practices in stroke treatment. Certification is a symbol of quality based upon stringent performance standards. 0 0 0 119964599 1 1 0 1 0 0 0 0 0 0 1 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 1 0 1 234 0 1488 1 1 1 0 0 0 0 0 X 17 14 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 1 1 X Gregg Terreson 2062484758 12844 Military Road S Tukwila WA 98168 Geraldine Fain 2.00 0 X 0 0 0 Larry Bjork 2 0 X X 0 0 0 Uli Chi PhD 2.00 0 X X 0 0 0 Christine M Henshaw EdD RN 1 0 X 0 0 0 Sue O'Brien MD 1 0 X 0 0 0 Butch Leonardson 1 0 X 0 0 0 Kent D Matheson EdD 1 0 X 0 0 0 Frederick Mendoza Esq 1 0 X 0 0 0 Harry Pierce DO 1.00 0 X 41469 0 0 Kindred Ritchie MD 1 0 X 0 0 0 Rodney Skoglund MD 1 0 X 18170 0 0 Peter Maurice MD 2.00 0 X 41667 0 0 Rebecha Cusack 1 0 X 0 0 0 David Hoheimer 1 0 X 0 0 0 Steve Davolt 1 0 X 0 0 0 Judy Beste 1 0 X 0 0 0 Rev Kathleen O'Connor PhD 1 0 X 0 0 0 Mark Benedum 40 0 X 362494 0 31597 Lloyd Musselman 40 0 X 280309 0 32189 Susan Pursell 0 40 X 166088 0 15248 Matthew A Crockett 40 0 X 187188 0 29548 Kathleen Fondren 40 0 X 178135 0 20704 Dyanne Lane 40 0 X 170376 0 25274 Grace Henley 40 0 X 158822 0 20582 Mara Burke 40 0 X 151802 0 29293 Sohaila Mulvihill 49.00 0 X 154833 0 31063 Thuy Vo 40 0 X 144250 0 24753 Jan Cannon 50.00 0 X 152839 0 18690 En K Kwak 40.00 0 X 127654 0 31857 Gregg Terreson 40.00 0 X 141274 0 30594 Paula Rice-Glen 43 0 X 134866 0 17432 Paul Tucker 0 0 X 0 0 37626 Myrna Anderson 41 0 X 119849 0 16370 Sandee Singer 46 0 X 116624 0 21204 Susan Oveisi 38 0 X 100767 0 27268 2949476 0 461292 95 1 1 0 CONNELLY LAW OFFICES 2301 NORTH 30TH ST TACOMA WA 98403 Legal services 1867259 HIGHLINE PHYSICAL THERAPY SERVICES 181 SOUTH 333RD STREET SUITE 250 FEDERAL WAY WA 98003 PHYSICAL THERAPY SERVICES 1604418 HALL ENTERPRISES 4123 STRIDER LOOP BELLINGHAM WA 98226 LAUNDRY SERVICES 761481 CAREFUSION SOLUTIONS LLC 3750 Torrey View Court San Diego CA 92130 EQUIPMENT LEASE 467463 WEST ASSET MANAGEMENT PO BOX 2140 OMAHA NE 681030140 COLLECTION SERVICES 448169 28 0 0 0 0 0 473258 0 473258 Medicare/Medicaid Revenue 622000 51363305 51325974 37331 0 HMO/PPO and Medicare HMO/PPO 622000 95189523 95120337 69186 0 Commercial 622000 7284998 7279703 5295 0 Government 622000 4012216 4009300 2916 0 Self Pay 622000 3781565 3778816 2749 0 0 0 0 0 161631607 1157479 0 0 1157479 517462 0 0 517462 0 0 0 0 1494766 0 0 0 1494766 0 1494766 0 0 1494766 34879071 500 33417487 2888 1461584 -2388 1459196 0 0 1459196 0 Sales to Other Hospital 622000 3951313 0 0 3951313 Partnership Revenue 622000 1935949 0 0 1935949 Life Insurance Benefit 622000 877158 0 0 877158 1300361 0 0 1300361 8064781 174798549 161514130 117477 12693684 0 0 0 0 0 0 0 0 2475038 680882 1794156 66145940 51418426 14727514 3725238 2895807 829431 11830214 9199136 2631078 6715510 5220289 1495221 975263 413 974850 277223 277223 124046 124046 13199060 5362862 7836198 945815 1040 944775 859988 694198 165790 3409244 3409244 3309646 948009 2361637 560005 144817 415188 7143193 7143193 12515253 9307867 3207386 2093737 1449025 644712 Medical supplies 22057906 21573313 484593 0 Licenses and taxes 6065166 39251 6025915 0 Purchased medical services 5982322 5982322 0 0 Equipment rental and maintenance 2943231 2427986 515245 0 7912647 2618956 5293691 181265685 119964599 61301086 0 17686945 10041923 3507693 4599662 0 0 43352186 40978320 0 0 0 0 0 0 2826676 3141174 2339868 2314094 235360398 130651823 116226687 104708575 26315614 25344317 0 0 30968607 35071594 0 0 2206350 2067461 245430626 228267120 28381517 29273757 123314012 120829809 335436 410477 17668583 11716017 169699548 162230060 X 74539174 65365531 1191904 671529 0 0 75731078 66037060 245430626 228267120 X -6467136 0 0 0 0 -3226882 X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 1 39315 0 0 0 39315 0 SchC_P2B_S00_L01 Schedule C, Part II-B, Line 1 For the calendar year 2012, the Washington State Hospital Association had determined that 23.5% of the membership dues were expended in activities that meet the Medicare definition of lobbying. 23.98% of the 2012 American Hospital Association membership dues were determined as used in activities that meet the Medicare definition of lobbying. 2360091 0 2360091 107912723 0 47175469 60737254 3061096 0 2702560 358536 117473182 0 77890787 39582395 4553306 0 2883007 1670299 104708575 Assets whose use is limited 19185128 F Insurance policy CSV 9541843 F Investment in subsidiaries 6344623 C 35071594 Professional liability claims 6398047 Excess professional liability claims 1307668 Capital leases 748066 Other long-term liabilities 3262236 11716017 174798549 0 0 0 0 0 174798549 0 0 0 174798549 181265685 0 0 0 0 0 181265685 0 0 0 181265685 1 1 1 X 1 X 1 1 1 0 0 4915107 4915107 0.0258 29690823 21732965 7957858 0.0418 0 0 34605930 21732965 12872965 0.0676 473574 573574 0.0025 733882 733882 0.0039 0 0 1207456 0 1307456 0.0064 0 0 35813386 21732965 14180421 0.0740 1 6979752 0 47564734 43756217 3808517 X 1 1 Des Moines Medical Plaza Real Estate Rental 1 0 0 Highline Medical Group Outpatient Clinic Services 1 0 0 Highline Imaging LLC Medical Diagnostic Imaging Services 0.8 0 0.2 Highline Physical Therapy Health Services - Physical Therapy 0.5 0.5 0 Military Road Properties Real Estate Rental 0.5 0.5 0 Performance Modalities Inc Durable Equipment Rental 0.5 0 0.5 1 1 Highline Medical Center Main Campus

16251 Sylvester Road SW Burien WA 98166

X X X Highline Medical Center Main Campus 1 1 1 200 1 400 1 X X X X X 1 1 X X X X X X 1 0 1 X 0 0 SchH_P01_S00_L07 Schedule H, Part I, Line 7 In order to calculate the amounts reported in the table for line 7, a cost-to-charge ratio was used. This cost-to-charge ratio was derived from Worksheet 2, Ratio of Patient Care Cost-to-Charges as provided within the IRS Instructions for completion of Schedule H. SchH_P03_S0A_L04 Schedule H, Part III, Section A, Line 4 Accounts receivable are reduced by an allowance for doubtful accounts. In evaluating the collectibility of accounts receivable, the Medical Center analyzes its past history and identifies trends for each of its major payor sources of revenue to estimate the appropriate allowance for doubtful accounts and provision for bad debts. Management regularly reviews data about these major payor sources of revenue in evaluating the sufficiency of the allowance for doubtful accounts. For receivables associated with services provided to patients who have third-party coverage, the Medical Center analyzes contractually due amounts and provides an allowance for doubtful accounts and a provision for bad debts, if necessary (for example, for expected uncollectible deductibles and copayment balances due for which third-party coverage exists for part of the bill). The Medical Center records a significant provision for bad debts in the period of services 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 Medical Center's allowance for doubtful accounts for self-pay patients decreased from 59% of self-pay accounts receivable at December 31, 2011, to 53% of self-pay accounts receivable at December 31, 2012. In addition, self-pay write-offs decreased by $5,808,922 from $30,724,372 for fiscal year 2011 to $24,915,450 for fiscal year 2012. Both decreases were the result of a decrease in total receivables from self-pay patients in fiscal year 2012 compared to fiscal year 2011 as well as improved collection efforts from self pay payors. The Medical Center has not changed its charity care or uninsured discount policies during fiscal years 2012 and 2011. SchH_P03_S0B_L08 Schedule H, Part III, Section B, Line 8 Reasons why Medicare shortfall should be treated as community benefit are (1) absent the Medicare program, it is likely many of the individuals would qualify for charity care or other needs-based government program, (2) by accepting payment below cost to treat these patients, the burdens of government are lessened with respect to those individuals, (3) there is a significant possibility that continued reduction in reimbursement may actually create difficulties in access for these individuals, and (4) the amount spent to cover the Medicare shortfall is money not available to cover other programs which would improve the health of the community served by Highline Medical Center. The Medicare allowable costs reported on Schedule H, Part III, Section B, Line 6 was calculated based on the filed cost report for year 2012. SchH_P03_S0C_L09b Schedule H, Part III, Section C, Line 9b Highline Medical Center is committed to providing appropriate urgent/emergent medical care to all persons regardless of their ability to pay. Highline is further committed to the provision of appropriate hospital-based medical services on a discounted basis to Indigent Persons, Medically Indigent Persons, and Uninsured Persons of Limited Means ("Charity Care"). In order to fulfill its commitment to provide Charity Care, Highline Medical Center, in accordance with Washington RCW 70.170 and WAC 246-453, provides no charge and sliding scale discounted services to Indigent Persons. The federal poverty guidlines assist Highline in making consistent and objective decisions regarding eligibility for Charity Care. In addition, Highline may provide Charity Care to all persons with insufficient income to enable them to pay for care or cost-sharing amounts. During the patient registration process, Highline makes an initial determination regarding Charity Care eligibility based on an oral or written application for Charity Care. Provided that the Responsible Party is cooperative under its Billing and Collection policy, Highline will suspend all collection efforts, agency placement, credit reporting, garnishments, liens, and other legal action, and will not require any deposit pending an initial determination of Charity Care eligibility. In the event that a Responsible party pays a portion of all of the charges related to appropriate hospital-based medical care services, and is subsequently found to have met the Charity Care criteria at the time services were provided, any payments in excess of the amount eligible for discount shall be refunded to the patient within thirty days of establishing Charity Care eligibility. SchH_P05_S0B_L14 Schedule H, Part V, Section B, Line 14 Line 14g: Written notice regarding the existence of the financial assistance policy is provided to patients upon admittance to the hospital. SchH_P06_S00_L02 Schedule H, Part VI, Line 2 Highline Medical Center utilizes a multi-step process that identifies community need, develops services and programs responsive to the prioritized needs and then evaluates the effectiveness and breadth of the programs developed. Highline actively participates in committees that are formed in its service area, surrounding communities and the broader region to identify unmet health needs and develop plans to address those needs, including the Childrens Hospital community transformation grant. Highline also keeps abreast of data reports released by various organizations including the Washington State Department of Health, the Seattle-King County Health Department and the federal government so that we are assured of using the latest data and the best practices available as we plan and implement strategies. At the local level, Highline works closely with community organizations, including the Health Department, the Community Mental Health Center and with various low-income health clinics (community health centers) and outreach providers to serve individuals that otherwise have very limited access to care. When data released by the County demonstrated that Highline's primary service area was hit disproportionately harder than other areas of the County in rates of unemployment and underemployment, Highline responded by increasing charity care (defined as medically necessary care provided to persons below 200% of the federal poverty level that are unable to pay for the care or to pay deductibles or co-insurance amounts required by a third-party payer) by more than 99% over 2010 levels ($16,125,574 and $16,376,842 in 2012 and 2011 charges, respectively). In 2012, as part of the CHNA process, Highline worked with the Health Department, the School District, the City of Burien, Seatac, and Tukwila, Navos, and other agencies to identify and address health disparities, in order to improve the health status of a large population of diverse, otherwise underserved groups. Highline is an active participant in the Burien Wellness Cluster, a multi-agency group that meets regularly with a goal of supporting the health and viability of the City of Burien and its citizens. Highline also works exceptionally close with the Highline School District in support of the health of its 18,000+ students and their families and staff. For example, the Medical Center sponsors a school calendar for families within the district featuring a monthly health tips for children. In addition, Highline participated in the District's health fair offering health screenings and information to its employees. To stay abreast of issues affecting the community, Highline Medical Center regularly collects and analyzes patient survey data as well as publicly available data, including demographics and inpatient and outpatient health services utilization. A summary of the community benefit programs offered is summarized below: * Community Health Education and Outreach: activities included health fairs, speaker's bureaus, newborn car seats, bicycle safety, and high school work experience programs. * Screenings: Blood pressure clinics, hearing examinations, cancer screenings, and participation in Breast & Cervical Health Program for low income women * Support Groups and Counseling: Support groups for chron¬ically/terminally ill patients and bereavement support for their families. * Clinics: Highline Medical Group in partnership with public health agencies support the Youth Health Center, Roxbury Family Healthcare and the Women, Infant & Children program meeting the needs of our underserved populations * Immunizations: Flu shot clinics for older adults and other at-risk populations; and * Patient Education/Wellness:, Diabetes management classes, weight loss classes, stress management classes, nutrition and fitness programs, education on other specific health conditions Highline Medical Center's leadership team monitors and supports the community benefit efforts. Key initiatives and outreach activities are planned to ensure a link between clinical providers and community need. In 2011 Highline Medical Center formed a strategic working group to conduct a community health needs assessment as required by Section 501(r)(1)(A) of the Internal Revenue Code for 2013 and actively participated in meetings with members of the community and public health experts. SchH_P06_S00_L03 Schedule H, Part VI, Line 3 Highline Medical Center is committed to providing safe, compassion and quality healthcare. Highline Medical provides urgent and emergent medical care to all persons regardless of their financial resource and their ability to pay. Furthermore, Highline is committed to the provision of appropriate hospital-based medical services on a discounted basis to those with limited financial resources. As defined by its Charity Care program, Highline Medical Center offers a sliding scale discount to those whose income is equal to or below 400% of the federal poverty standards. Highline's Charity Care program extends to insured patients who meet criteria and cannot pay their co-insurance or deductibles as required by their insurance company. Highline Medical Centers effectively communicates with patients their payment obligations as well as financial assistance offered by third party sources, government programs, or the hospital. Financial counseling is available to patients and families at pre-registration and registration process. Financial counseling is also available through the Discharge staff at as well as the Business Office. A third party, is on-site actively working with patients to qualify them for government based programs such as Medicaid, GAU and the Undocumented Alien Program. RCA works with King County and the State of Washington to gain health care coverage for patients, food stamps and emergency funds. The Medical Center reimburses RCA as a percentage of received reimbursement. These programs take time to complete necessary paperwork and await qualification notification. Therefore patient eligibility and financial assistance may occur during pre-admission, during the stay, or after discharge. Notification of financial assistance occurs at all points of registration and externally via the hospital's website and on financial statements. Financial assistance forms are available at all points of registration and the Business Office and are printed in both English and Spanish. Translation services are available to assist patients and staff in completing all necessary documentation. Information about financial assistance is posted in registration in the following areas: Emergency Department, 1 Alder inpatient registration, Day Surgery, Cancer Center, Wound Center, Business Office, Outpatient Registration 5 Birch, Imaging, Lab 160th, and Southwest Medical Imaging. Highline Medical Center's Board of Trustees approved its Charity Care policy and the staff at the medical center supports and carries out the policy. Staff is trained to work closely with patients to ensure those that qualify follow the requirements and apply for financial assistance. Highline has dedicated staff and resources to follow up on charity applications and to qualify all individuals who meet the policy's requirements. A patient may apply for financial assistance prior to, during their stay, or post discharge or service. SchH_P06_S00_L04 Schedule H, Part VI, Line 4 Highline Medical Center is a Washington nonprofit corporation. The Medical Center owns and operates a hospital, located in Burien, Washington, in Southwest King County, just south of Seattle, approximately 9.5 miles from the next nearest hospital, and a specialty campus, located in Tukwila, Washington. Based on the most current information available from the U.S. Census Bureau, Burien had an estimated population of 33,000. The Medical Center is licensed to operate 269 general-acute-care hospital beds and provides inpatient care, outpatient, and intensive care and cardiac care services. The Medical Center's service area is divided into a primary service area comprising zip codes 98146, 98148, 98158, 98166, 98168, 98188 and 98198 ; a secondary service area north, comprised of zip codes 98070, 98106, 98108, 98116, 98126, 98136, and 98178 ; and a secondary service area south comprised of zip codes 98001, 98003, 98023, 98031, and 98032. Our market area is one of the most diverse in the nation, with patients representing about 80 nationalities and speaking 70 different languages. SchH_P06_S00_L05 Schedule H, Part VI, Line 5 Highline Medical Center has a 18-member community board comprised of a majority of community members. Six members of the board conduct business with related organizations. The remaining 12 members are all a cross-section of community representatives. No members are family members. The medical staff of Highline Medical Center is organized in the public interest. Medical Staff priviledges in the hospital are open and available to all qualified physicians and we have a large, diverse medical staff. Highline Medical Center operates two very active emergency rooms, one located at the Main Campus and the other one located at the Specialty Campus. The Main Campus emergency room is one of the busiest in the State of Washington. Both emergency rooms are accessible to anyone needing care regardless of ability to pay. No part of the income of Highline Medical Center inures to the benefit of any private individual nor is any private interest being served. All surplus funds are reinvested into the facility, equipment or programs of the hospital to improve the quality and safety of patient care, expand and upgrade our facilities, and advance our medical training and education. Over the last few years, the Medical Center invested in a major information systems upgrade and Electronic Medical Records (EMR) to further benefit the patients and community it serves. EMR facilitates instant access to a patient's medical information,including medication allergies, past medical conditions, laboratory and radiology results, scanned images and medical diagnoses. Physicians and all care providers have access to the same information at their fingertips, without needing to wait for paper charts to be retrieved from the medical records department or archived storage. The EMR reduces the risk of losing important medical information documented on paper. Electronic documentation standardizes language and eliminates the need to interpret handwritten documentation that occasionally is not clear. The EMR allows for information sharing between providers (i.e. primary and specialty care, emergency, outpatient and long-term care). The EMR also shares information between non-affiliated health systems, improving patient safety, response time, and reducing costs, which benefits the patients and the community. Highline Medical Center has a vibrant Volunteer program, offering varied opportunities to members of the community to volunteer. During fiscal year 2012, 308 volunteers contributed their time. SchH_P06_S00_L06 Schedule H, Part VI, Line 6 The organization is an independent community hospital, not part of an affiliated health care system. SchH_P06_S00_L07 Schedule H, Part VI, Line 7 Not applicable SchH_P06_S00_L08 Schedule H, Part VI, Line 8 Not applicable. X 1 1 X X X X X 1 1 0 0 0 0 0 0 0 Mark Benedum 360430 0 0 0 2064 0 17500 0 22238 0 402232 0 0 0 Lloyd Musselman 279121 0 0 0 1188 0 17500 0 19579 0 317388 0 0 0 Matthew A Crockett 186646 0 272 0 270 0 9402 0 23840 0 220430 0 0 0 Kathleen Fondren 177381 0 340 0 414 0 12458 0 12138 0 202731 0 0 0 Dyanne Lane 60625 0 0 0 109751 0 12063 0 15145 0 197584 0 0 0 Susan Pursell 62185 0 0 0 103903 0 11649 0 5145 0 182882 0 0 0 Mara Burke 151243 0 288 0 270 0 10686 0 21886 0 184373 0 0 0 Sohaila Mulvihill 154112 0 721 0 0 0 10917 0 20201 0 185951 0 0 0 Grace Henley 157274 0 360 0 1188 0 11136 0 13283 0 183241 0 0 0 Jan Cannon 152839 0 0 0 0 0 10699 0 8046 0 171584 0 0 0 Gregg Terreson 140506 0 288 0 480 0 9968 0 23929 0 175171 0 0 0 Thuy Vo 143775 0 0 0 475 0 10064 0 14910 0 169224 0 0 0 En K Kwak 127654 0 0 0 0 0 9189 0 22723 0 159566 0 0 0 Paul Tucker 0 0 0 0 0 0 37626 0 0 0 37626 0 0 Myrna Anderson 119705 0 144 0 0 0 8379 0 8046 0 136274 0 0 Paula Rice-Glen 134866 0 0 0 0 0 9441 0 8046 0 152353 0 0 Sandee Singer 116624 0 0 0 0 0 8205 0 13053 0 137882 0 0 0 Susan Oveisi 100623 0 144 0 0 0 7122 0 20201 0 128090 0 0 SchJ_P01_S00_L01a Schedule J, Part I, Line 1a The Medical Center sponsors a Board approved unfunded nonqualified supplemental retirement plan. Pursuant to the Plan, annual retirement benefits are adjusted for IRC 457(f) taxes. SchJ_P01_S00_L04 Schedule J, Part I, Line 4 Line 4b: The Medical Center sponsors a Board approved unfunded nonqualified supplemental retirement plan that is consistent with practice in the health care industry regionally and nationally. The plan provides for supplemental retirement benefits which are a function of years of service and average compensation. Payment of future plan retirement benefits to participants is subject to the solvency of the Medical Center and subject to restrictions and substantial risk of forfeiture if employment is voluntarily terminated before age 65. During 2012 the Medical Center's Board amended the plan, which resulted in a non recurring increase in the unvested plan amount for Mark Benedum of $214,680 and Bud Musselman of $136,454. The estimated and unvested plan amount representing the increase in actuarial value attributable to the 2012 service period for Mark Benedum is $92,521 and for Lloyd Musselman is $95,744. ****** Line 4a: Payments of $88,816 and $81,142 were made to Susan Pursell and Dyanne Lane, respectively, during the year 2012. A Highline Medical Center 910712166 93978EU34 2008-08-27 126225141 Build a new ER tower and facilities expansion 0 0 0 A 2325000 0 126225141 10215000 3992855 0 1225608 1160100 1390743 65597384 42643451 0 2010 1 0 1 1 A 0 0 0 0 0 0 0 1 0 1 A 1 0 0 1 AEGON Institutional .02 1 0 1 A 1 F990_P06_S0B_L11b Form 990, Part VI, Section B, Line 11b The Medical Center has a policy outlining form 990 review and approval process. Prior to preparing form 990 an educational presentation of the new form 990 was provided to the Medical Center's Executive Committee by an independent CPA. The Executive Committee comprises members of the Board. Form 990 was prepared by the Medical Center and reviewed by an independent CPA. As stated under the Hospital's policy upon completion of 2011 form 990, the return was provided to the Executive Committee, for review and approval prior to its filing. The approved form 990 was provided to all Hospital Board members, voting and nonvoting, prior to filing with the IRS. F990_P06_S0B_L12c Form 990, Part VI, Section B, Line 12c The Medical Center's Conflict of Interest Policy is reviewed annually with the management and the Board. Disclosure and completion of the form is done annually and conflicts are followed up by the Compliance Officer and the CEO, who also follow-up on conflicts that may come to their attention during the year. F990_P06_S0B_L15 Form 990, Part VI, Section B, Line 15 Compensation for officers and key employees is within the charter of the Executive Committee. The Executive Committee comprises a subgroup of Board members who are independent with respect to those whose compensation is within their scope. As and when compensation adjustments and contract renewals occur, the Executive Committee considers performance evaluations as well as comparative market data for like-size hospitals for purposes of this work. From time to time the Executive Committee engages an independent compensation consultant to assist with this work. The Executive Committee documents its decisions in the Executive Committee minutes. F990_P06_S0C_L19 Form 990, Part VI, Section C, Line 19 Highline Medical Center makes its Form 990 and Form 1023 available to the public in accordance with the public disclosure requirements of the Internal Revenue Code. Financial statements are readily available to all bond holders.Pursuant to WA State licensing requirements, the Medical Center's financial statements are publicly available on the Department of Health' website at www.doh.gov. At present, the organization does not make its conflict of interest policy available to the public. F990_P11_S00_L09 Form 990, Part XI, Line 9 $2,080,000 capital contributions to Highline Medical Group; $520,375 net assets released from restriction for property acquisition; $282,658 change in pension liability; $371,199 change in net unrealized gains on investments. Highline Imaging LLC PO BOX 184 Brush Prairie WA 98606 200460005 Medical Diagnostic Imaging WA Highline Medical Center Related 284914 1786054 0 0 0 0.8 Des Moines Medical Plaza 11747 NE 1st Street Suite 220 Bellevue WA 98005 911586438 Real estate rental WA Highline Medical Center Related 213826 1586882 0 0 0 1 Highline Medical Group 15811 Ambaum Blvd SW Suite A Burien WA 98166 911407026 Outpatient Clinic Services WA Highline Medical Center C -6049147 5689139 1 1 1 1 0 0 0 0 0 0 0 1 1 1 0 0 1 0 1 0 1 Highline Medical Group a-iv 289440 Market rental rate for leased space Highline Medical Group b 2080000 Cash value of capital contributions. Highline Medical Group j 239105 Monthly amortization for leased equipment. Highline Medical Group q 5826789 Reimbursement based on actual invoices paid by Highline Medical Center on behalf of Highline Medical Group. Highline Imaging LLC o 873606 Time card hours allocation, multiplied by the hourly pay rate. Des Moines Medical Plaza k 129576 Leasing agreements based on market rates for the area. Highline Imaging LLC s 400000 Cash value of received distributions. Des Moines Medical Plaza s 186617 Cash value of received distributions. SchR_P03_S00_L00 Schedule R, Part III Throughout the year 2012, Highline Medical Center owned 82.8% of the assets of Des Moines Medical Plaza. As of December 31, 2012, Highline Medical Center acquired 100% ownership of Des Moines Medical Plaza.