2023-11-14T14:11:00-06:00 2022-12-31 990 2022-01-01 237296923 GOOD SAMARITAN FOUNDATION - DAYTON GOOD 9374999942 110 N MAIN ST SUITE 500 DAYTON OH 45402 J MICHAEL SIMS TREASURER 9374999942 2023-11-14 J MICHAEL SIMS 999009999 0 2 AAL1 IAL1 2022 2023-04-26 12:10:37Z JENNY M LEWIS ONE WYOMING ST DAYTON OH 45402 32943990 0 X WWW.PREMIERHEALTH.COM X 1973 OH SEE PART III, LINE 1 11 8 3 13 0 0 608096 433870 0 0 1292640 319648 0 650 1900736 754168 629222 292670 0 0 276421 241478 0 0 147831 121980 77973 1027623 612121 873113 142047 14545050 11970218 83291 51601 14461759 11918617 X INSPIRE PHILANTHROPY TO ENHANCE THE HEALTH AND WELL-BEING OF THE GREATER DAYTON COMMUNITIES AND THE HEALTHCARE PROFESSIONALS WHO CARE FOR THEM. 0 0 75000 75000 SAMARITAN HEALTH CENTER IS A FEDERALLY QUALIFIED HEALTH CENTER OPERATED BY FIVE RIVERS HEALTH CENTERS IN DAYTON, OHIO. SAMARITAN HEALTH CENTER PROVIDES MEDICAL, DENTAL, AND MENTAL HEALTH CARE TO MORE THAN 1,300 PATIENTS EACH YEAR. MOST PATIENTS ARE HOMELESS OR LOW-INCOME AND AT RISK OF BECOMING HOMELESS. SAMARITAN HEALTH CENTER OFFERS COMPREHENSIVE HEALTH CARE SERVICES, INCLUDING PRIMARY CARE, PODIATRY, AND BEHAVIORAL HEALTH SERVICES, AS WELL AS ACCESS TO PATIENT EDUCATION, A DIETICIAN, AND A SOCIAL WORKER. THE MICHAEL SAWDEY SAMARITAN CLINIC FOR WOMEN AND CHILDREN IS LOCATED INSIDE ST. VINCENT DE PAUL'S GATEWAY HOMELESS SHELTER AND PROVIDES WOMEN, CHILDREN, AND FAMILIES LIVING AT THE SHELTER WITH ACCESS TO PEDIATRIC CARE, WOMEN'S HEALTH CARE, AND PRIMARY CARE. IN 2022, TOTAL PATIENT VISITS WERE 4,988. 73247 73247 MOTHERS EMPOWERED PROVIDES HIGH-QUALITY, COMPREHENSIVE PRENATAL CARE AND PARENTING EDUCATION TO PREGNANT WOMEN IN GREATER DAYTON WHO ARE AT RISK OF LOSING A BABY TO INFANT MORTALITY. MOTHERS EMPOWERED IS A COLLABORATION BETWEEN LIFESTAGES CENTERS FOR WOMEN, A LOCAL OBGYN PRACTICE, AND GOOD SAMARITAN FOUNDATION-DAYTON, COMPOSED OF AN RN PROGRAM COORDINATOR, A PART TIME MEDICAL ASSISTANT, AND A CERTIFIED NURSE MIDWIFE. THESE HEALTH CARE PROFESSIONALS PROVIDE THE EVIDENCE-BASED, BEST-PRACTICE CENTERING PREGNANCY GROUP MODEL OF PRENATAL CARE. PREGNANT MOTHERS ARE GROUPED BY DUE DATE, SO THEY GO THROUGH THE SAME STAGE OF PREGNANCY TOGETHER, LEARNING ABOUT THEIR NEW BABIES WHILE FORMING FRIENDSHIPS WITH OTHER MOMS AND BUILDING TRUSTING RELATIONSHIPS WITH THEIR MEDICAL PROVIDERS. IN 2022, 72 WOMEN WERE SERVED. 42221 42221 THE CORONAVIRUS EMERGING NEEDS FUND WAS ESTABLISHED TO PROVIDE EQUIPMENT, RESOURCES, AND SUPPORT FOR MEDICAL STAFF DURING THE COVID-19 PANDEMIC. DONATIONS ENABLED THE PURCHASE OF ESSENTIAL TESTING AND TREATMENT EQUIPMENT, MEALS TO SUPPORT FRONTLINE WORKERS, AND RESPITE SPACES FOR STAFF TO HELP EASE THE STRAIN OF LONG HOURS CARING FOR PATIENTS. 175520 102202 163481 THIS NUMBER REPRESENTS THE BALANCE OF TOTAL EXPENDITURES OF TEMPORARILY RESTRICTED FUNDS FOR RELATED HOSPITALS NET OF PROGRAMS DESCRIBED IN SERVICE ACCOMPLISHMENTS. 175520 102202 163481 365988 1 1 0 0 0 0 0 0 0 1 1 1 0 0 1 1 0 1 0 0 0 0 0 0 1 0 0 1 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 1 0 0 0 1 0 0 3 1 0 0 0 0 0 0 0 0 0 0 0 0 X 11 8 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 0 0 0 X J MICHAEL SIMS 9374999942 110 N MAIN ST SUITE 500 DAYTON OH 45402 JENNY M LEWIS PRESIDENT/SYS VP OF PHILANTHROPY 13.33 26.67 X X 0 345322 45562 MILINDA S NIMMO ZABRAMBA TRUSTEE 0.50 39.50 X 0 347845 35754 GEORGE T BRODERICK JR MD TRUSTEE 0.50 0.00 X 0 137040 0 KENNETH M WATSON SR BOARD CHAIR 0.50 0.00 X X 0 0 0 JO ANNE REILING BOARD VICE-CHAIR 0.50 0.00 X X 0 0 0 FATHER BENJAMIN SPEARE-HARDY II BOARD SECRETARY 0.50 0.00 X X 0 0 0 DIANE ANDERSON DO TRUSTEE 0.50 0.00 X 0 0 0 SUZANNE DONOVAN SC TRUSTEE 0.50 0.00 X 0 0 0 RICHARD T FERGUSON TRUSTEE 0.50 0.00 X 0 0 0 PAMELA A PHELPS TRUSTEE 0.50 0.00 X 0 0 0 ANN SCHUERMAN TRUSTEE (TO AUG) 0.50 0.00 X 0 0 0 CHARLENE J SIMS TRUSTEE 0.50 0.00 X 0 0 0 J MICHAEL SIMS BOARD TREASURER 0.50 39.50 X 0 677602 50344 0 1507809 131660 0 0 1 0 0 1520 65623 5500 361227 82147 433870 145044 145044 32359774 32185170 174604 174604 174604 5302 65623 4652 650 650 754168 0 0 320298 283670 283670 9000 9000 207440 51860 51860 103720 23700 5925 5925 11850 10338 2585 2585 5168 23544 23544 43922 10981 10981 21960 4282 1071 1071 2140 1318 330 330 658 1920 1440 480 722 722 DUES & SUBSCRIPTIONS 2265 566 566 1133 612121 365988 98302 147831 145051 100819 220857 192583 7315 0 0 7315 9858386 7381796 4245756 4212705 75000 75000 14545050 11970218 35855 32342 47436 19259 83291 51601 X 2754959 2345422 11706800 9573195 14461759 11918617 14545050 11970218 X 142047 -1953139 -732050 X 0 1 X 1 0 X 557500 615433 802762 608096 433870 3017661 557500 615433 802762 608096 433870 3017661 373873 2643788 236819 216433 156350 153863 145044 908509 3926170 5302 0.67340 0.65950 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 11706800 416984 -1437430 -1113160 9573195 10656520 522412 1132315 604446 11706800 9446814 680596 1059761 530651 10656520 8570381 503148 1335433 962148 9446814 9461345 454878 -537350 808492 8570381 0.00000 0.43490 0.56510 0 0 7315 7315 7315 SECURITIES 4212705 F 4212705 AFFILIATES PAYABLE 15592 DEFERRED ANNUITIES 3667 19259 X PART V, LINE 4: THE GOOD SAMARITAN FOUNDATION-DAYTON (GSF-DAYTON) MAKES EVERY EFFORT TO FOLLOW THE INTENT AND WISHES OF ALL ITS DONORS. THE INTENDED USES OF THE ORGANIZATION'S ENDOWMENT FUNDS AND/OR EARNINGS FROM ENDOWMENT FUNDS ARE DRIVEN BY THE WISHES/RESTRICTIONS PLACED ON THE FUNDS BY THE DONOR. A PERMANENT ENDOWMENT RESULTS WHEN A DONATION IS RECEIVED WITH A RESTRICTION THAT THE PRINCIPAL OR GIFT AMOUNT IS TO BE RETAINED IN PERPETUITY AND CANNOT BE SPENT. THE EARNINGS FROM THE PERMANENT ENDOWMENT ARE USED FOR THE PURPOSE SPECIFIED BY THE DONOR. TEMPORARY ENDOWMENTS ARE FUNDS IN WHICH ALL OR PART OF THE PRINCIPAL MAY BE EXPENDED ONLY AFTER THE EXPIRATION OF A STATED PERIOD OF TIME OR OCCURRENCE OF A SPECIFIED EVENT, DEPENDING ON THE DONOR'S WISHES. EARNINGS FROM TEMPORARILY RESTRICTED ENDOWMENTS CAN BE EITHER UNRESTRICTED OR RESTRICTED. THE GSF-DAYTON USES THE TEMPORARILY RESTRICTED ENDOWMENTS FOR THE INTENDED PURPOSE SETUP BY THE DONOR, ONLY AFTER THE PERIOD OF TIME OR SPECIFIED EVENT SET BY THE DONOR HAS BEEN MET. THE CATEGORIES OF PERMANENTLY AND TEMPORARILY RESTRICTED ENDOWMENTS ARE AS FOLLOWS: TO SUPPORT THE LOCAL COMMUNITY HOMELESS CLINIC OPERATIONS (17%); TO FUND EDUCATIONAL PROGRAMS/SCHOLARSHIPS (19%); TO FUND THE FOUNDATION OPERATIONS (16%); TO SUPPORT HEART DISEASE (10%); TO SUPPORT MOTHERS EMPOWERED (ME) TO PROVIDE FREE MEDICAL CARE AND PRENATAL AND PARENTING EDUCATION TO PREGNANT WOMEN IN NEED (8%), TO SUPPORT ELDER CARE (2%); TO BENEFIT SPECIFIC PROGRAMS FOR A SAMARITAN HEALTH PARTNER'S AFFILIATE (8%); AND MISCELLANEOUS (20%). PART X, LINE 2: THE FOLLOWING FOOTNOTE IS FROM THE 2022 CONSOLIDATED AUDITED FINANCIAL STATEMENTS FOR PREMIER HEALTH (PHP) AND AFFILIATES. PHP IS THE SOLE MEMBER OF GOOD SAMARITAN FOUNDATION-DAYTON. PHP HAS BEEN DETERMINED BY THE INTERNAL REVENUE SERVICE TO BE A TAX-EXEMPT NON-PROFIT CORPORATION UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. AS A TAX-EXEMPT ORGANIZATION, ITS INCOME IS EXEMPT FROM FEDERAL TAX EXCEPT TO THE EXTENT OF ANY UNRELATED BUSINESS ACTIVITIES. PHP CONSOLIDATES CERTAIN SUBSIDIARIES WHICH ARE FOR-PROFIT CORPORATIONS SUBJECT TO FEDERAL INCOME TAXES. THESE ARE: * PREMIER HEALTH INSURING CO. (PHIC), AND PREMIER HEALTH HOLDING COMPANY (PHHC) (WHOLLY OWNED SUBSIDIARIES OF PHP), * PREMIER HEALTH PLAN (PHPLAN) (A WHOLLY OWNED SUBSIDIARY OF PHIC), * MVHE, INC., SAMARITAN FAMILY CARE, INC., PREMIER HEALTH SPECIALISTS, INC. AND PREMIER HEALTH URGENT CARE, INC. (SUBSIDIARIES OF PHHC), * PREMIER HEALTH ACO OF OHIO AND UVMC MANAGEMENT CORPORATION - CLOSED JUNE 2022 (SUBSIDIARIES OF PHP) MANAGEMENT ANNUALLY REVIEWS THE TAX POSITIONS AND HAS DETERMINED THAT THERE ARE NO MATERIAL UNCERTAIN TAX POSITIONS. RAYS OF HOPE 70925 65623 5302 2272 1755 625 70925 65623 5302 2272 1755 625 4652 650 1 MIAMI VALLEY HOSPITAL 110 N MAIN ST SUITE 500 DAYTON OH 45402 310537504 501(C)(3) 70743 35847 FAIR MARKET VALUE PERSONAL PROTECTION EQUIPMENT AND FOOD OPERATIONS FIVE RIVERS HEALTH CENTERS 2261 PHILADELPHIA DRIVE SUITE 200 DAYTON OH 45406 450914398 501(C)(3) 79910 0 N/A N/A OPERATIONS PREMIER HEALTH PARTNERS 110 N MAIN ST SUITE 500 DAYTON OH 45402 311446699 501(C)(3) 42350 2508 FAIR MARKET VALUE PAPER OPERATIONS SAMARITAN BEHAVIORAL HEALTH 110 N MAIN ST SUITE 500 DAYTON OH 45402 020633634 501(C)(3) 2889 10800 FAIR MARKET VALUE FOOD OPERATIONS WRIGHT STATE UNIVERSITY FOUNDATION 3070 PRESIDENTIAL DR FAIRBORN OH 45324 237019799 501(C)(3) 11321 0 N/A N/A OPERATIONS COMPUNET CLINICAL LABS 110 N MAIN ST SUITE 500 DAYTON OH 45402 311258010 501(C)(3) 0 8171 FAIR MARKET VALUE FOOD OPERATIONS 6 0 EDUCATIONAL SCHOLARSHIPS 6 9000 PART I, LINE 2: ALL DISTRIBUTIONS (GRANTS PAID) FOLLOW THE ENTITY'S DISBURSEMENT POLICY, INCLUDING: (A) ASSUMING FUNDS AVAILABILITY, HOSPITAL DEPARTMENT PERSONNEL COMPLETE A FOUNDATION REQUEST FORM. FOR AMOUNTS IN EXCESS OF $1,000, DIRECTOR'S & VICE-PRESIDENT'S SIGNATURES ARE REQUIRED TO REQUEST FOUNDATION FUNDING. (B) FOR A REQUEST GREATER THAN $5,000, THE FOUNDATION'S DISTRIBUTION COMMITTEE REVIEWS AND APPROVES THE REQUEST. THE CHECK ALSO REQUIRES A SECOND SIGNATURE. (C) REPORTING FOR GRANTS IS THE RESPONSIBILITY OF THE OPERATIONAL UNIT. (D) BEFORE DISBURSING FUNDS, EACH REQUEST IS VERIFIED/MATCHED FOR ITS INTENDED PURPOSE. FOR EXAMPLE, SCHOLARSHIP REQUIREMENTS INCLUDE: A) GPA REQUIREMENTS; B) LENGTH OF SERVICE; C) SPECIFIC FIELDS OF STUDY. 0 1 0 0 0 0 0 0 0 J MICHAEL SIMS BOARD TREASURER 0 355741 0 138119 0 183742 0 19235 0 31109 0 727946 0 0 JENNY M LEWIS PRESIDENT/SYS VP OF PHILANTHROPY 0 261652 0 80626 0 3044 0 17633 0 27929 0 390884 0 0 MILINDA S NIMMO ZABRAMBA TRUSTEE 0 310006 0 16500 0 21339 0 9356 0 26398 0 383599 0 0 PART I, LINE 3 COMPENSATION FOR THE GSF-DAYTON CEO IS REVIEWED AND APPROVED BY PREMIER, WITH WHICH GSF-DAYTON IS AN AFFILIATE. PART I, LINE 4B DUE TO RESTRICTIONS IMPOSED BY THE INTERNAL REVENUE CODE, CERTAIN PERSONS ARE LIMITED IN THE AMOUNT OF BENEFIT THAT CAN BE EARNED UNDER A QUALIFIED RETIREMENT PLAN. LIKE MANY EMPLOYERS, GOOD SAMARITAN FOUNDATION-DAYTON (GSF-DAYTON) AND ITS AFFILIATED ORGANIZATIONS COMPENSATE FOR THIS LIMITATION AND SUPPLEMENT THE AFFECTED EXECUTIVES' QUALIFIED PENSION THROUGH CERTAIN NONQUALIFIED PLANS. GSF-DAYTON SUPPLEMENTS THE AFFECTED EXECUTIVES THROUGH A PENSION RESTORATION PLAN AND A SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN (SERP). THE BENEFITS UNDER THESE SUPPLEMENTAL NONQUALIFIED PLANS ARE SUBJECT TO MULTI-YEAR VESTING AND A PARTICIPANT CAN FORFEIT BENEFITS EARNED IF VESTING REQUIREMENTS ARE NOT SATISFIED. UNDER THE TERMS OF THE SUPPLEMENTAL PLANS, AND BECAUSE OF TAX RULES PERTAINING TO TAXATION OF THE EARNED BENEFITS UPON VESTING, CERTAIN INDIVIDUALS RECEIVED A PAYOUT OF THE CUMULATIVE VESTED BENEFITS UNDER THEIR SUPPLEMENTAL PLAN DURING 2022. THE INDIVIDUAL LISTED BELOW HAS MET THE MULTI-YEAR VESTING REQUIREMENT UNDER THE PENSION RESTORATION PLAN AND RECEIVED THE ASSOCIATED PAYMENT IN 2022: J. MICHAEL SIMS $156,921. BASED ON THE GUIDANCE PROVIDED IN THE INSTRUCTIONS TO THE FORM 990, ANY PAYMENTS TO THE PARTICIPANTS RELATED TO THESE PLANS THAT WERE MADE WITHIN 2-1/2 MONTHS AFTER THE END OF THE ORGANIZATION'S TAX YEAR ARE NOT TREATED AS DEFERRED COMPENSATION FOR PURPOSES OF SCHEDULE J. SUCH AMOUNTS ARE PROPERLY REPORTED AS COMPENSATION FOR FORM 990 PURPOSES WHEN INCLUDED IN THE PARTICIPANTS' FORM W-2 WAGES. X EMPLOYEE FOOD 10 54818 FMV X FURNITURE 1 23121 FMV X SUPPLIES/PRIZES 2 4208 FMV 0 0 1 0 FORM 990, PART VI, SECTION A, LINE 6 THE GOOD SAMARITAN FOUNDATION (GSF-DAYTON) HAS ONE CORPORATE MEMBER: PREMIER HEALTH (PREMIER), AN OHIO NON-PROFIT CORPORATION. FORM 990, PART VI, SECTION A, LINE 7A PREMIER HAS THE SOLE AUTHORITY TO ELECT THE BOARD OF TRUSTEES FOR GSF-DAYTON. PREMIER HAS THE AUTHORITY TO REMOVE SUCH TRUSTEES AT ANY REGULAR OR SPECIAL MEETING OR BY WRITTEN CONSENT. FORM 990, PART VI, SECTION A, LINE 7B SEE 7A FORM 990, PART VI, SECTION B, LINE 11B THIS 990 FILING AND ATTACHED SCHEDULES (THE RETURN) ARE PREPARED BY A STAFF MEMBER IN THE TAX DEPARTMENT OF PREMIER, WITH WHICH GSF-DAYTON IS AN AFFILIATE. THE RETURN IS REVIEWED BY THE MANAGER AND DIRECTOR OF TAX COMPLIANCE OF PREMIER. AFTER ALL CHANGES FROM THE ABOVE PERSONS ARE MADE, THE RETURN IS REVIEWED BY THE VICE PRESIDENT/CONTROLLER OF PREMIER. A FINAL VERSION OF THE RETURN IS PROVIDED TO THE BOARD OF TRUSTEES FOR REVIEW. AT THE BOARD OF TRUSTEES' MEETING, THE VICE PRESIDENT/CONTROLLER OF PREMIER (OR DESIGNEE) SHARES DETAILED INFORMATION ON COMPENSATION AND OTHER KEY AREAS, AS WELL AS ADDRESS ANY OTHER QUESTIONS FROM THE BOARD OF TRUSTEES, PENDING THEIR REVIEW. THE 990 FILING IS ALSO SHARED WITH THE AUDIT COMMITTEE OF PREMIER. FORM 990, PART VI, SECTION B, LINE 12C PREMIER, WITH WHICH GSF-DAYTON IS AN AFFILIATE, REQUIRES ALL BOARD MEMBERS, BOARD COMMITTEE MEMBERS, MEDICAL DIRECTORS, SUPPLY CHAIN DIVISION MEMBERS, AUTHORIZED SIGNERS, DIRECTORS, EXECUTIVES, MEDICAL EXECUTIVE COMMITTEE MEMBERS, MEDICAL DEPARTMENT AND SECTION CHAIRS, PHYSICIAN PARTNERSHIP COMMITTEE MEMBERS, PHYSICIAN GUIDANCE GROUP MEMBERS, AND ALL EMPLOYED PHYSICIANS TO ANNUALLY REVIEW THE PREMIER COMPREHENSIVE CONFLICT OF INTEREST STATEMENT, AN EXPLANATORY MEMORANDUM, THE ANTITRUST COMPLIANCE POLICY, AND COMPLETE AN INDIVIDUAL QUESTIONNAIRE DISCLOSING ANY POTENTIAL CONFLICTS AS DEFINED IN THE CONFLICT OF INTEREST POLICY. THIS IS ACCOMPLISHED EITHER BY WAY OF AN ELECTRONIC COMMUNICATION SENT OUT DIRECTLY BY THE CORPORATE COMPLIANCE DEPARTMENT OR BY WAY OF A MEMO SENT OUT FROM THE CHAIRMAN OF THE BOARD AND CHIEF EXECUTIVE OFFICER OF PREMIER. IT ALSO INCLUDES AN EXPLANATORY MEMORANDUM OF SPECIFIC ACTIVITIES THAT MIGHT GIVE CAUSE TO A CONFLICT AND AN INDIVIDUAL QUESTIONNAIRE TO DISCLOSE ALL SUCH ACTIVITIES. THIS QUESTIONNAIRE MUST BE COMPLETED AND SIGNED BY THE INDIVIDUAL. THIS CORRESPONDENCE INCLUDES A COPY OF THE ANTITRUST COMPLIANCE POLICY THAT MUST BE SIGNED BY THE INDIVIDUAL. ALL OF THESE DOCUMENTS ARE SENT TO THE CORPORATE COMPLIANCE DEPARTMENT. THE CORPORATE COMPLIANCE DEPARTMENT ENSURES ALL FORMS ARE RETURNED AND RETAINS THE DOCUMENTS FOR FIVE YEARS. IN ADDITION, AT EACH MEETING OF THE BOARD OR ANY BOARD COMMITTEE, FOLLOWING APPROVAL OF THE PREVIOUS MEETING'S MINUTES, THE BOARD OR COMMITTEE CHAIR SHALL REQUEST ANY BOARD MEMBER WHO PERCEIVES A POTENTIAL CONFLICT OF INTEREST ON ANY OF THE MEETING'S AGENDA ITEMS TO DISCLOSE THE POTENTIAL CONFLICT. ADDITIONALLY, AT ANY BOARD OR BOARD COMMITTEE MEETING WHERE THE SUBJECT OF CONFLICT OF INTEREST IS DISCUSSED, THE MINUTES SHALL CONTAIN THE NAME OF THE PARTY DISCUSSING A POTENTIAL CONFLICT OF INTEREST, THE NATURE OF THE POTENTIAL CONFLICT OF INTEREST AND WHETHER A CONFLICT OF INTEREST WAS FOUND TO EXIST. IF A CONFLICT OF INTEREST IS DETERMINED BY THE BOARD TO EXIST, THE MEMBER WILL BE EXCUSED FROM PARTICIPATING IN ANY DISCUSSION OR VOTING ON THE PARTICULAR AGENDA ITEM. THE CHIEF COMPLIANCE AND ENTERPRISE RISK OFFICER REPORTS THE RESULTS OF THE PREMIER CONFLICT OF INTEREST QUESTIONNAIRES NO LESS THAN ANNUALLY TO THE BOARD OF TRUSTEES BY WAY OF THE COMPLIANCE AND AUDIT COMMITTEE. THIS REVIEW IS DOCUMENTED IN THE MINUTES OF THE MEETING. PERIODICALLY, THE INTERNAL AUDIT DEPARTMENT WILL REVIEW A SAMPLE OF COMPLETED CONFLICT OF INTEREST QUESTIONNAIRES AND REPORT THE RESULTS TO THE COMPLIANCE AND AUDIT COMMITTEE. THE ANNUAL CONFLICT OF INTEREST QUESTIONNAIRES ARE INDIVIDUALLY SUMMARIZED IN A DOCUMENT AND SENT ELECTRONICALLY TO THE FINANCE DEPARTMENT FOR ANY NECESSARY DISCLOSURES REQUIRED ON THE 990 FILING. FORM 990, PART VI, SECTION C, LINE 19 THE GOVERNING DOCUMENTS AND FINANCIAL STATEMENTS ARE MADE AVAILABLE TO THE PUBLIC WHEN REQUIRED BY LAW OR FOR ACCREDITATION PURPOSES. THE CONFLICT OF INTEREST POLICY IS AVAILABLE UPON REQUEST. FORM 990, PART XI, LINE 9: CAPITAL DONATIONS -735,000. PLEDGE RESERVE 2,950. PREMIER HEALTH 110 MAIN STREET SUITE 500 DAYTON OH 45402 311446699 PARENT OH 501 (C) (3) 12B N/A 0 MEDAMERICA HEALTH SYSTEMS CO 110 MAIN STREET SUITE 500 DAYTON OH 45402 311040228 SUPPORT ORG OH 501 (C) (3) 12B N/A 0 MIAMI VALLEY HOSPITAL 110 MAIN STREET SUITE 500 DAYTON OH 45402 310537504 HOSPITAL OH 501 (C) (3) 3 PREMIER HEALTH 0 MIAMI VALLEY HOSPITAL FOUNDATION 110 MAIN STREET SUITE 500 DAYTON OH 45402 311040231 FOUNDATION OH 501 (C) (3) 7 PREMIER HEALTH 0 FIDELITY HEALTH CARE INC 110 MAIN STREET SUITE 500 DAYTON OH 45402 311075381 HOME HEALTH OH 501 (C) (3) 10 PREMIER HEALTH 0 PREMIER COMMUNITY HEALTH 110 MAIN STREET SUITE 500 DAYTON OH 45402 311122883 HEALTH EDUCATION OH 501 (C) (3) 10 FIDELITY HEALTH CARE 0 ATRIUM HEALTH SYSTEM 110 MAIN STREET SUITE 500 DAYTON OH 45402 310537492 SUPPORT ORG OH 501 (C) (3) 12B N/A 0 ATRIUM MEDICAL CENTER 110 MAIN STREET SUITE 500 DAYTON OH 45402 311079309 HOSPITAL OH 501 (C) (3) 3 PREMIER HEALTH 0 UVMC 110 MAIN STREET SUITE 500 DAYTON OH 45402 341850683 SUPPORT ORG OH 501 (C) (3) 12B N/A 0 UPPER VALLEY MEDICAL CENTER 110 MAIN STREET SUITE 500 DAYTON OH 45402 310537095 HOSPITAL OH 501 (C) (3) 3 PREMIER HEALTH 0 UPPER VALLEY PROFESSIONAL CORP 110 MAIN STREET SUITE 500 DAYTON OH 45402 311400963 HEALTH CARE OH 501 (C) (3) 10 PREMIER HEALTH HOLDING CO 0 UVPC SPECIALISTS 110 MAIN STREET SUITE 500 DAYTON OH 45402 203687536 HEALTH CARE OH 501 (C) (3) 10 PREMIER HEALTH HOLDING CO 0 UVMC NURSING CARE INC 110 MAIN STREET SUITE 500 DAYTON OH 45402 311224064 NURSING HOME OH 501 (C) (3) 10 PREMIER HEALTH 0 COMPUNET CLINICAL LABORATORIES LLC 110 MAIN STREET SUITE 500 DAYTON OH 45402 311258010 LAB OH 501 (C) (3) 12B PREMIER HEALTH 0 SAMARITAN BEHAVIORAL HEALTH INC 110 MAIN STREET SUITE 500 DAYTON OH 45402 020633634 BEHAVIORAL HEALTH OH 501 (C) (3) 7 PREMIER HEALTH 0 SWEITZER STREET LLC 110 N MAIN STREET SUITE 500 DAYTON OH 45402 454700417 REAL ESTATE OH MVHE INC EXCLUDED 0 0 SWEITZER MOB LLC 110 N MAIN STREET SUITE 500 DAYTON OH 45402 474554657 REAL ESTATE OH MVHE INC EXCLUDED 0 0 MVHE INC 110 NORTH MAIN STREET SUITE 500 DAYTON OH 45402 311185270 PHYSICIAN SVCS OH PREMIER HEALTH HOLDING CO C 0 PREMIER HEALTH SPECIALISTS 110 NORTH MAIN STREET SUITE 500 DAYTON OH 45402 061744704 PHYSICIAN SVCS OH PREMIER HEALTH HOLDING CO C 0 SAMARITAN FAMILY CARE 110 NORTH MAIN STREET SUITE 500 DAYTON OH 45402 311299450 PHYSICIAN SVCS OH PREMIER HEALTH HOLDING CO C 0 AFTER HOURS FAMILY CARE 110 NORTH MAIN STREET SUITE 500 DAYTON OH 45402 311269483 HEALTH CARE OH UPPER VALLEY PROFESSIONAL CORP C 0 UVMC MANAGEMENT CORP 110 NORTH MAIN STREET SUITE 500 DAYTON OH 45402 311360489 MANAGEMENT COMPANY OH PREMIER HEALTH C 0 PREMIER HEALTH URGENT CARE INC 110 NORTH MAIN STREET SUITE 500 DAYTON OH 45402 822079409 URGENT CARE OH PREMIER HEALTH HOLDING CO C 0 PREMIER HEALTH INT'L INSURANCE BUTTERFIELD BANK BLDG 6TH FLOOR 6 HAMILTON BD HM12 980548485 INSURANCE BD PREMIER HEALTH C 0 PREMIER HEALTH PLAN INC 110 NORTH MAIN STREET SUITE 500 DAYTON OH 45402 463024049 HEALTH INSURANCE OH PREMIER HEALTH INSURING CO C 0 GOOD SAMARITAN HOSPITAL 110 NORTH MAIN STREET SUITE 500 DAYTON OH 45402 310536981 HOSPITAL OH PREMIER HEALTH C 0 PREMIER HEALTH ACO OF OHIO 110 NORTH MAIN STREET SUITE 500 DAYTON OH 45402 474049773 MEDICARE ACO OH PREMIER HEALTH C 0 PREMIER HEALTH HOLDING CO 110 NORTH MAIN STREET SUITE 500 DAYTON OH 45402 812419110 HOLDING CO OH PREMIER HEALTH C 0 PREMIER HEALTH INSURING CO 110 NORTH MAIN STREET SUITE 500 DAYTON OH 45402 464766841 HEALTH INSURANCE OH PREMIER HEALTH C 0 0 1 1 0 0 0 0 0 0 0 1 0 0 0 0 1 1 0 0