Iefile GRAPHIC print - DO NOT PROCESS lAs Filed Data - Form990 Department of the Treasury Internal Revenue Servrce foundations) Return of Organization Exempt From Income Tax Under section 501(c), 527, or 4947(a)(1) of the Internal Revenue Code (except private II- Do not enter socral security numbers on this form as it may be made public II-Information about Form 990 and Its Instructions is at DLN: 93493131020756I OMB No 1545-0047 2014 Open to Public Inspection A For the Check if applicable Address change Name change Initial retu rn Final return/terminated Amended l_ Application pending 2014 calendar year, or tax year beginning 07-01-2014 and ending 06-30-2015 Name of organization MERCY HEALTH SYSTEM CORPORATION Employer identification number 39-0816848 Dorng busrness as Telephone number Number and street (or 0 box if mail is not delivered to street address) Room/surte PO BOX 5003 - 1000 MINERAL POINT (608) 756-6000 return City or town, state or provrnce, country, and ZIP or foreign postal code JAN ESVILLE, WI 535475003 Gross receipts 540,200,479 Name and address of princrpal officer JAVON BEA PO BOX 5003 - 1000 MINERAL POINT 535475003 I Tax?exem pt status I7 501(c)(3) l? 501(c)( )1 (insert no) 4947(a)(1) or 527 Website:ll- ORG H(a) Is this a group return for subordinates? I?Yesl7No Are all subordinates Yes No included? If"No," attach a list (see instructions) Group exemption number II- Form of organization '7 Corporation Trust Assocration Other F- 1 Summary Year of formation 1972 I State of legal domicrle WI Briefly describe the organization?s missron or most Significant actiVities THE MISSION OF MERCY HEALTH SYSTEM IS TO PROVIDE EXCEPTIONAL HEALTH CARE SERVICES RESULTING IN HEALING IN THE BROADEST SENSE 2 Check this box if the organization discontinued its operations or disposed of more than 25% ofits net assets L5 3 Number ofvoting members ofthe governing body (PartVI, line 1a) 3 10 2 4 Number of independent voting members of the governing body (Part VI, line 1b) 4 7 5 TotalnumberofindiViduals employedincalendaryear2014 (PartV,line 2a) 5 3,876 In: Total number ofvolunteers (estimate if necessary) 6 7aTota unrelated busrness revenue from Part column (C), line 12 7a 10,543,700 bNet unrelated busrness taxableincome from Form 34 7b 0 Prior Year Current Year 8 Contributions and grants 1h) 263,821 211,005 Program servrce revenue 29) 515,758,827 540,911,259 10 Investmentincome (A), lines 3,4,and 7d) 293,559 1,387,588 a: 11 5,6d,8c,9c,10c,and11e) 2,856,252 -4,058,585 12 Total revenue?add lines 8 through 11 (must equal Part column (A), line 12) 519,172,459 538,451,267 13 Grants and srmilar amounts paid (Part IX, column (A), lines 1?3) 0 0 14 Benefits paid to orfor members (Part IX, column (A), line 4) 0 15 benefits (PartIX,column 297,341,530 310,745,853 16a Professronalfundraisrng fees 11e) Total fundraisrng expenses (Part column (D), line 25) F0 17 Otherexpenses (PartIX, column 11a?11d,11f?24e) 206,767,003 211,011,871 18 Totalexpenses Addlines 13?17 (must 504,108,533 521,757,724 19 Revenue less expenses Subtract line 18 from line 12 15,063,926 3 Beginning of Current End of Year ?g Year 33 20 Totalassets (PartX, ine 16) 497,525,602 515,850,817 5E 21 Totalliabilities(PartX,line 26) 303,051,697 309,395,101 Elf 22 Net assets orfund balances Subtractline 21 fromline 20 194,473,905 206,455,716 Signature Block Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete Declaration of preparer (other than officer) is based on all information of which preparer has any knowledge Sign Signature of officer Date Here JAVON BEA Type or print name and title Print/Type preparer's name Preparers Signature Date Check '7 If PTIN _d BRADLEY MCGUIRE CPA BRADLEY MCGUIRE CPA 2016?05?09 se f_employed P00643763 al Finn's name .- BAKER TILLY VIRCHOW KRAUSE LLP Finn's EIN .- 39?0859910 Pre pare Finn's address 500 MIDLAND COURT PO BOX 8130 Phone no (608) 752?5835 Use Only JANESVILLE, WI 535478130 May the IRS discuss this return With the preparer shown above? (see instructions) . . . . I7Yes For Paperwork Reduction Act Notice, see the separate instructions. at No 1 1 2 82Y Form 990 (2 1 4) Form 990 (2014) Page 2 Statement of Program Service Accomplishments . . . . . . . . . . . . . .I7 1 Briefly describe the organization?s THE MISSION OF MERCY HEALTH SYSTEM IS TO PROVIDE EXCEPTIONAL HEALTH CARE SERVICES RESULTING IN HEALING IN THE BROADEST SENSE the organization undertake any Signi?cant program serVIces during the year which were not listed on the prior Form 990 or If"Yes," describe these new serVIces on Schedule 0 Yes I7 No the organization cease conducting, or make significant changes In how it conducts, any program serVIces? . . . . . _Yes I7 No If"Yes," describe these changes on Schedule 0 Describe the organization's program serVIce accomplishments for each oflts three largest program serVIces, as measured by expenses Section 501(c)(3) and 501(c)(4) organizations are reqUIred to report the amount ofgrants and allocations to others, the total expenses, and revenue, ifany, for each program serVIce reported (Code (Expenses 417,872,148 (Revenue 529,080,363 HOSPITAL DISCHARGES 8,600, NURSING HOME ADMISSIONS 294, BIRTHS 1,055, OUTPATIENT VISITS HEALTH SYSTEM CONTINUES ITS TRADITION OF GIVING BACK TO EACH OF THE COMMUNITIES WE SERVE IN A WIDE VARIETY OF FASHIONS ONE OF THE LARGER AREAS OF CONTRIBUTION IS IN THE AREA OF PUBLIC HEALTH SERVICES THIS INCLUDES EXTENSIVE DONATIONS OF TIME AND SUPPLIES TO HEALTHNET OF ROCK COUNTY, A LARGE FREE PRIMARY CARE CLINIC SERVING THE REGION MORE THAN EIGHTY PERCENT OF THE PHYSICIAN SERVICES PROVIDED AT THE CLINIC ARE SUPPLIED THROUGH MERCY HEALTH SYSTEM WE HAVE A SIMILAR COMMITMENT TO OPEN ARMS FREE CLINIC THAT SERVICES LOW INCOME RESIDENTS IN WALWORTH COUNTY ADDITIONALLY, WE PROVIDE HEALTH SCREENING AND RELATED SERVICES AT NUMEROUS EVENTS IN ROCK AND WALWORTH COUNTIES IN WISCONSIN AND MCHENRY COUNTY IN ILLINOIS MERCY ALSO PROVIDES FINANCIAL AND IN KIND CONTRIBUTIONS TO OTHER PRIVATE NOT FOR PROFIT HEALTH RELATED AGENCIES AND ORGANIZATION IN OUR SERVICE AREA BENEFICIARIES INCLUDED BUT ARE NOT LIMITED TO THE AMERICAN HEART ASSOCIATION, AMERICAN CANCER SOCIETY, UNITED WAY ORGANIZATIONS IN ROCK, WALWORTH, AND MCHENRY COUNTIES, YWCA CARE HOUSE, YMCA, AMERICAN LUNG ASSOCIATION, WALWORTH COUNTY ALLIANCE FOR CHILDREN, TURNING POINT CENTER IN MCHENRY, OPEN ARMS FREE CLINIC, AND THE RED CROSS, TO NAME JUST A FEW RECIPIENTS MERCY ALSO ENCOURAGES ITS PARTNERS (EMPLOYEES) TO DONATE THEIR TIME AND ENERGY TO SUPPORT A WHOLE HOST OF COMMUNITY BASED CAUSES THOUSANDS OF HOURS EACH YEAR ARE DONATED TO NOT FOR PROFIT AND PUBLIC AGENCIES THROUGHOUT OUR SERVICE AREA EXAMPLES OF VOLUNTEER ACTIVITIES BEING SUPPORTED INCLUDE NURSING SERVICES AT COMMUNITY AND FREE CLINICS THROUGHOUT THE REGION, MEALS ON WHEELS DELIVERY ACTIVITIES, ACTIVE INVOLVEMENT AS GOVERNING BOARD MEMBERS FOR SUCH ORGANIZATIONS AS UNITED WAY, CRIME STOPPERS, ROTARY BOTANICAL GARDENS, HEALTHNET, AND MANY OTHER ORGANIZATIONS ANOTHER EXAMPLE OF COMMITMENT TO COMMUNITY IS ITS SUPPORT OF THE OPERATIONS THROUGH OFFERING SAFE RESIDENCE TO HOMELESS WOMEN AND THEIR CHILDREN AT THE HOUSE OF MERCY HOMELESS CENTER SINCE ITS OPENING IN 1996, THE CENTER HAS SERVED MORE THAN 5500 PERSONS, MOST OF WHOM ARE UNDER THE AGE OF 18 AT THE CENTER THE CENTER OFFERS A SAFE HARBOR FOR THESE INDIVIDUALS AS WELL AS CASE MANAGEMENT, ASSISTANCE WITH JOB SEARCHES, FINDING PERMANENT HOUSING AND EDUCATION Including grants of 4b (Code (Expenses including giants of (Revenue 4c (Code (Expenses including giants of (Revenue 4d 4e Other program serVIces (Describe in Schedule 0 Including grants of$ (Revenue (Expenses Total program service expenses IIForm 990(2014) Form 990 (201420a Page 3 Part IV Checklist of Required Schedules Yes No Is the organization described In section 501(c)(3) or 4947(a)(1) (other than a private foundation)? If ?Yes,? Yes complete Schedule Ag 1 Is the organization reqUIred to complete Schedule B, Schedule of Contributors (see instructions)? 2 Yes Did the organization engage in direct or indirect political campaign actIVIties on behalf ofor in opp05ition to No candidates for public office? If "Yes,"complete Schedule C, Part I 3 Section 501(c)(3) organizations. Did the organization engage in lobbying actIVIties, or have a section 501(h) No election in effect during the tax year? If "Yes, "complete Schedule C, Part II 4 Is the organization a section 501(c)(4), 501(c)(5), or 501(c)(6) organization that receives membership dues, assessments, or amounts as defined in Revenue Procedure 98-19? If "Yes,"complete Schedule C, Part 5 0 Did the organization maintain any donor adVIsed funds or any Similarfunds or accounts for which donors have the right to prowde adVIce on the distribution or investment ofamounts in such funds or accounts? If "Yes," complete Schedule D, Part IE 5 0 Did the organization receive or hold a conservation easement, including easements to preserve open space, the enVIronment, historic land areas, or historic structures? If "Yes," complete Schedule D, Part II 7 0 Did the organization maintain collections of works ofart, historical treasures, or other Similar assets? If ?Yes,? complete Schedule D, Part 3 0 Did the organization report an amount in Part X, line 21 for escrow or custodial account liability, serve as a custodian for amounts not listed in Part X, or prowde credit counseling, debt management, credit repair, or debt N0 negotiation serVIces? If ?Yes,? complete Schedule D, PartI 9 Did the organization, directly or through a related organization, hold assets in temporarily restricted endowments, 10 No permanent endowments, or quaSI-endowments? If ?Yes,? complete Schedule D, Part Ifthe organization?s answerto any ofthe followmg questions is "Yes," then complete Schedule D, Parts VI, VII, IX, or as applicable Did the organization report an amount for land, bUIldings, and eqUIpment in Part X, line 10? If ?Yes,? complete Schedule D, Part VI 11-3 es Did the organization report an amount for investments?other securities in Part X, line 12 that is 5% or more of its total assets reported in Part X, line 16? If "Yes," complete Schedule D, Part 11'? es Did the organization report an amount for investments?program related in Part X, line 13 that is 5% or more of its total assets reported in Part X, line 16? If "Yes," complete Schedule D, Part 11C 0 Did the organization report an amount for other assets in Part X, line 15 that is 5% or more ofits total assets N0 reported in Part X, line 16? If "Yes," complete Schedule D, Part IXE . . . . . . . . 11" Did the organization report an amount for other liabilities in Part X, line 25? If "Yes," complete Schedule D, PartXE me Yes Did the organization?s separate or consolidated finanCIal statements for the tax year include a footnote that 11f No addresses the organization's liability for uncertain tax p05itions under FIN 48 (ASC 740)? If ?Yes,? complete Schedule D, Part XE Did the organization obtain separate, independent audited finanCIal statements for the tax year? If ?Yes,? complete Schedule D, Parts XI and XII 123 N0 Was the organization included in consolidated, independent audited finanCIal statements for the tax year? If 12b Yes ?Yes,? and if the organization answered "No" to line 12a, then completing Schedule D, Parts XI and XII IS optional Is the organization a school described in section If "Yes,"complete ScheduleE 13 No Did the organization maintain an office, employees, or agents outSIde ofthe United States? 14a No Did the organization have aggregate revenues or expenses of more than $10,000 from grantmaking, fundraismg, busmess, investment, and program serVIce actIVIties outSIde the United States, or aggregate foreign investments valued at $100,000 or more? If "Yes,"complete ScheduleF, Parts I and IV . 14" N0 Did the organization report on Part IX, column (A), line 3, more than $5,000 ofgrants or other a55istance to or for any foreign organization? If "Yes,"complete Schedule F, Parts II and IV 15 0 Did the organization report on Part IX, column (A), line 3, more than $5,000 ofaggregate grants or other a55istance to orforforeign indiViduals? If ?Yes,?complete ScheduleF, Parts and IV . 16 0 Did the organization report a total of more than $15,000 ofexpenses for professmnal fundraismg serVIces on Part 17 No IX, column (A), lines 6 and 11e? If ?Yes,? complete Schedule G, Part I (see instructions) Did the organization report more than $15,000 total offundraismg event gross income and contributions on Part lines 1c and 8a? If "Yes,"complete Schedule G, Part II 18 0 Did the organization report more than $15,000 ofgross income from gaming actIVIties on Part line 9a? If 19 No ?Yes,? complete Schedule G, Part Did the organization operate one or more hospital faCIlities? If "Yes," complete ScheduleH 20a Yes If"Yes" to line 20a, did the organization attach a copy ofits audited finanCIal statements to this return? 20b Yes Form 990(2014) Form 990 (2014Page 4 Part IV Checklist of Required Schedules (continued) the organization report more than $5,000 ofgrants or other as5Istance to any domestIc organization or 21 No domestic government on Part IX, column (A), We 1? If "Yes,"complete Schedule I, Parts I and II Did the organization report more than $5,000 ofgrants or other aSSIstance to or for domestic on Part 22 IX, column (A), line 2? If ?Yes,? complete Schedule I, Parts I and 0 Did the organization answer "Yes" to Part VII, Section A, Ine 3, 4, or 5 about compensation of the organIzatIon's current and former of?cers, directors, trustees, key employees, and highest compensated employees? If "Yes," 23 es complete Schedule] . Did the organization have a tax-exempt bond issue With an outstanding prInCIpaI amount of more than $100,000 as of the last day of the year, that was issued after December 31, 2002? If ?Yes,?answerlines 24b through 24d and complete Schedule K. If ?No, "go to lIne 25a 24a 0 Did the organization invest any proceeds of tax-exempt bonds beyond a temporary period exception? 24 Did the organization maintain an escrow account other than a refunding escrow at any time during the year to defease any tax-exempt bonds? 24C Did the organization act as an "on behalfof" Issuerfor bonds outstandIng at any time during the year? 24d Section 501(c)(3), 501(c)(4), and 501(c)(29) organizations. Did the organization engage In an excess benefIt transaction With a disqualified person durIng the year? If "Yes, "complete Schedule L, PartI 253 N0 Is the organization aware that It engaged In an excess benefit transaction With a disqualified person In a prior year, and that the transaction has not been reported on any ofthe organizatIon?s prior Forms 990 or If 25b No ?Yes,? complete Schedule L, Part I Did the organization report any amount on Part X, line 5, 6, or 22 for recerabIes from or payables to any current or former officers, directors, trustees, key employees, highest compensated employees, or disqualified persons? 26 No If ?Yes,? complete Schedule L, Part II Did the organization prOVIde a grant or other aSSIstance to an of?cer, director, trustee, key employee, substantial contributor or employee thereof,a grant selection committee member,or to a 35% controlled entity orfamily 27 N0 member of any ofthese persons? If ?Yes,? complete Schedule L, Part Was the organization a party to a busmess transaction With one of the followmg partIes (see Schedule L, Part IV instructions for applicable thresholds, conditions, and exceptions) A current or former officer, director, trustee, or key employee? If "Yes," complete Schedule L, Part 28a No A family member of a current or former officer, director, trustee, or key employee? If "Yes," completeScheduleL,PartIV . . . . . . . . . . . . . . . . . . . . . 28'? es An entity of which a current or former of?cer, director, trustee, or key employee (or a family member thereof) was No an officer, director, trustee, or direct or indirect owner? If ?Yes,? complete Schedule L, Part IV . 23C Did the organization receive more than $25,000 In non?cash contributions? If "Yes,"complete ScheduleM 29 No the organizatIon receive contrIbutIons ofart, historical treasures, or other Similar assets, or qualified conservation contributions? If "Yes,"complete ScheduleM 30 the organizatIon IIqUIdate, terminate, or dissolve and cease operations? If "Yes," complete Schedule N, PartI 31 the organizatIon sell, exchange, dispose of, or transfer more than 25% of Its net assets? If "Yes," complete Schedule N, Part II 32 the organizatIon own 100% ofan entIty disregarded as separate from the organizatIon under RegulatIons N0 sections 301 7701?2 and 301 7701-3? If "Yes,"complete Schedule R, PartI 33 Was the organization related to any tax-exempt or taxable entIty? If "Yes,"complete Schedule R, Part II, orIV, Yes and Part V, line 1 34 the organizatIon have a controlled entIty WithIn the meaning ofsectIon 512(b)(13)? 35a Yes If?Yes'to line 35a, did the organization recere any payment from or engage In any transactIon With a controlled entIty WithIn the meaning of sectIon 5 12(b)(13)? If Yes, complete Schedule R, Part V, line 2 Section 501(c)(3) organizations. Did the organization make any transfers to an exempt non?charitable related organization? If ?Yes,? complete Schedule R, Part V, line 2 35 the organizatIon conduct more than 5% of Its actIVItIes through an entity that Is not a related organization and that Is treated as a partnershIp for federal Income tax purposes? If "Yes, "complete Schedule R, Part VI 37 the organizatIon complete Schedule 0 and prOVIde explanations In Schedule 0 for Part VI, IInes 11b and 19? Note. All Form 990 fIIers are reqUIred to complete Schedule 0 38 es Form 990 (2014) Form 990 (2014) Page5 Statements Regarding Other IRS Filings and Tax Compliance Check IfSchedule contaIns a response or note to any lIne In thIs Part . . . . . . . . . . . . . Yes No 1a Enter the number reported In Box 3 of Form 1096 Enter -0- Ifnot applicable . . 1a 402 Enter the number of Forms W-ZG Included In Me 1a Enter-O- If not appIIcable 1b 0 the organIzatIon comply WIth backup WIthholdIng rules for reportable payments to vendors and reportable . . . . . . . . . . . . . . . . . . 1C Yes 2a Enter the number ofemployees reported on Form W-3, TransmIttal ofWage and Tax Statements, fIled forthe calendar year endIng WIth or WIthIn the year covered by thIs return . . . . . . . . . . . . . . . . . . 23 3,876 Ifat least one Is reported on Me 2a, dId the organIzatIon ?le all reqUIred federal employment tax returns? Note. Ifthe sum ofIInes 1a and 2a Is greater than 250, you may be reqUIred to e?fIIe (see InstructIons) 2b Yes 3a the organIzatIon have unrelated busmess gross Income of$1,000 or more durIng the year? . . . 3a Yes If"Yes," has It ?led a Form 990-T forthIs year? If ?No?to/Ine 3b, provrde an explanation In Schedu/any tIme durIng the calendar year, dId the organIzatIon have an Interest In, or a SIgnature or other authorIty over, a Manual account In a foreIgn country (such as a bank account, securItIes account, or other fInanCIal 4" No If"Yes," enter the name of the foreIgn country II- See InstructIons reqUIrements for Form 114, Report of ForeIgn Bank and FInanCIal Accounts (FBAR) 5a Was the organIzatIon a party to a prothIted tax shelter transactIon at any tIme durIng the tax year? . . 5a No any taxable party notIfy the organIzatIon that It was or Is a party to a prothIted tax shelter transactlon? 5b No If"Yes," to Me 5a or 5b, dId the organIzatIon ?le Form 5c 6a Does the organIzatIon have annual gross receIpts that are normally greater than $100,000, and dId the Ga No organIzatIon so ICIt any contrIbutIons that were not tax deducthle as charItable contrIbutIons? If "Yes," dId the organIzatIon Include WIth every so ICItatIon an express statement that such contrIbutIons or 6b 7 Organizations that may receive deductible contributions under section 170(c). a the organIzatIon recewe a payment In excess of$75 made partly as a contrIbutIon and partly for goods and 7a No serVIces prowded to the payor? If"Yes," dId the organIzatIon notIfy the donor of the value of the goods or serVIces prOVIdedthe organIzatIon sell, exchange, or otherWIse dIspose of tangIble personal property for It was reqUIred to No If"Yes," IndIcate the number of Forms 8282 ?led durIng the year . . . . I 7d I the organIzatIon recere any funds, dIrectly or IndIrectly, to pay prequms on a personal bene?t No the organIzatIon, durIng the year, pay prequms, dIrectly or IndIrectly, on a personal bene?t contract? . . 7f No 9 Ifthe organIzatIon recered a contrIbutIon Intellectual property, dId the organIzatIon ?le Form 8899 as Ifthe organIzatIon recered a contrIbutIon ofcars, boats, aIrplanes, or other vehIcles, dId the organIzatIon ?le a 7h 8 Sponsoring organizations maintaining donor advised funds. a donor adVIsed fund maIntaIned by the sponsorIng organIzatIon have excess busmess holdIngs at any tIme 8 9a the sponsorIng organIzatIon make any taxable dIstrIbutIons under sectIon 4966? . . . 9a the sponsorIng organIzatIon make a dIstrIbutIon to a donor, donor adVIsor, or related person? . . . 9b 10 Section 501(c)(7) organizations. Enter InItIatIon fees and capItal contrIbutIons Included on Part lIne 12 . . . 10a Gross receIpts, Included on Form 990, Part Me 12, for publIc use ofclub 10b 11 Section 501(c)(12) organizations. Enter Gross Income from members or shareholders . . . . . . . . . 11a Gross Income from other sources (Do not net amounts due or paId to other sources agaInstamounts due or recered from them11b 12a Section 4947(a)(1) non-exempt charitable trusts. Is the organIzatIon fIlIng Form 990 In lIeu of Form 1041? 12a If "Yes," enter the amount of tax-exempt Interest recered or accrued durIng the year 12b 13 Section 501(c)(29) qualified nonprofit health insurance issuers. a Is the organIzatIon lIcensed to Issue health plans In more than one state? Note. See the InstructIons for addItIonal Informatlon the organIzatIon must report on Schedule 0 13a Enter the amount of reserves the organIzatIon Is reqUIred to maIntaIn by the states In the organIzatIon Is lIcensed to Issue health plans . . . . 13" Enter the amount of reserves on hand . . . . . . . . . . . . 13c 14a the organIzatIon recere any payments for Indoor tannIng serVIces durIng the tax year"Yes," has It ?led a Form 720 to report these payments? If "No,?prov1de an explanation In Schedule 0 . . 14b Form 990(2014) Form 990 (2014) Page 6 Governance, Management, and Disclosure For each ?Yes? response to lines 2 through 7b below, and for a "No" response to lines 8a, 8b, or 10b below, describe the circumstances, processes, or changes in Schedule 0. See instructions. Check IfSchedule contaIns a response or note to any ?ne In thIs Part VI .I7 Section A. Governing Body and Management Yes No 1a Enter the number ofvotIng members ofthe governIng body at the end ofthe tax 1a 10 year Ifthere are material differences In votIng among members of the governIng body, or Ifthe governIng body delegated broad authorIty to an executIve commIttee or commIttee, explaIn In Schedule 0 Enter the number ofvotIng members Included In Me 1a, above, who are Independent 1b 7 2 any of?cer, dIrector, trustee, or key employee have a famIIy relatIonshIp or a busmess relatIonshIp WIth any other of?cer, dIrector, trustee, or key employee? 2 N0 3 the organIzatIon delegate control over management dutIes customarIIy performed by or under the dIrect 3 No superVISIon of of?cers, dIrectors or trustees, or key employees to a management company or other person? 4 the organIzatIon make any SIgnIfIcant changes to Its governIng documents smce the prIor Form 990 was ?led? No 5 the organIzatIon become aware durIng the year ofa SIgnIfIcant dIverSIon of the organIzatIon?s assets? No 6 the organIzatIon have members or stockholders? No 7a the organIzatIon have members, stockholders, or other persons who had the power to elect or appomt one or more members of the governIng body? 7a N0 Are any governance deCISIons of the organIzatIon reserved to (or subject to approval by) members, stockholders, 7b No or persons other than the governIng body? 8 the organIzatIon contemporaneously document the meetIngs held or ertten actIons undertaken durIng the year by the followmg a The governIng body? 8a Yes Each commIttee WIth authorIty to act on behalfof the governIng body? 8b Yes 9 Is there any of?cer, dIrector, trustee, or key employee Isted In Part VII, SectIon A, who cannot be reached at the organIzatIon?s address? If "Yes,"provrde the names and addresses In Schedule Section B. Policies (This Section requests information about policies not required by the Internal Revenue Code.) Yes No 10a the organIzatIon have local chapters, branches, or 10a No If"Yes," dId the organIzatIon have ertten poIICIes and procedures governIng the actIVItIes ofsuch chapters, and branches to ensure theIr operatIons are conSIstent WIth the organIzatIon's exempt purposes? 10" 11a Has the organIzatIon prOVIded a complete copy ofthIs Form 990 to all members ofIts governIng body before ?lIng the form? 11a N0 In Schedule 0 the process, Ifany, used by the organIzatIon to reVIew thIs Form 990 12a the organIzatIon have a ertten coanIct of Interest poIIcy? If "No,"go to line 13 12a Yes Were of?cers, dIrectors, or trustees, and key employees reqUIred to dIsclose annually Interests that could gIve rIse to coanIcts? 12b Yes the organIzatIon regularly and conSIstently monItor and enforce compllance WIth the poIIcy? If In Schedule 0 how this was done 12C Yes 13 the organIzatIon have a ertten poIIcy? 13 Yes 14 the organIzatIon have a ertten document retentIon and destructIon poIIcy? 14 Yes 15 the process for determInIng compensatlon of the followmg persons Include a reVIew and approval by Independent persons, data, and contemporaneous substantIatIon of the dellberatlon and deCISIon? a The organIzatIon?s CEO, ExecutIve DIrector, or top management of?CIal 15a Yes Other of?cers or key employees of the organIzatIon 15b Yes If"Yes" to ?ne 15a or 15b, descrIbe the process In Schedule 0 (see InstructIons) 16a the organIzatIon Invest In, contrIbute assets to, or partICIpate In a Jomt venture or arrangement WIth a taxable entIty durIng the year? 16a N0 If "Yes," dId the organIzatIon follow a ertten poIIcy or procedure reqUIrIng the organIzatIon to evaluate Its partICIpatIon In Jomt venture arrangements under appIIcabIe federal tax law, and take steps to safeguard the organIzatIon's exempt status WIth respect to such arrangements? 16b Section C. Disclosure 17 LIst the States WIth a copy ofthIs Form 990 Is reqUIred to be ?ledlrIL WI 18 Sectlon 6104 reqUIres an organIzatIon to make Its Form 1023 (or 1024 IfappIIcable), 990, and 990-T (501(c) (3)s only) avaIIabIe for pubIIc InspectIon IndIcate how you made these avaIIabIe Check all that apply Own webSIte Another's webSIte I7 Upon request Other (explaIn In Schedule 0) 19 In Schedule 0 whether (and Ifso, how) the organIzatIon made Its governIng documents, coanIct of Interest poIIcy, and fInanCIaI statements avaIIable to the pubIIc durIng the tax year 20 State the name, address, and telephone number of the person who possesses the organIzatIon's books and records II-JOHN COOK 1000 MINERAL POINT 535475003 (608) 756-6642 Form 990(2014) Form 990 (2014) Compensation of Officers, Directors,Trustees, Key Employees, Highest Compensated Employees, and Independent Contractors Check ifSchedule 0 contains a response or note to any line In this Part VII . . . . . . . . . . . . . Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees 1a Complete this table for all persons reqUIred to be listed Report compensation for the calendar year ending With or Within the organization's tax year I- List all ofthe organization?s current of?cers, directors, trustees (whether indIVIduals or organizations), regardless ofamount ofcompensation Enter -0- In columns (D), (E), and (F) if no compensation was paid I- List all ofthe organization?s current key employees, ifany See instructions for de?nition of"key employee l- List the organization?s ?ve current highest compensated employees (other than an of?cer, director, trustee or key employee) who received reportable compensation (Box 5 of Form W-2 and/or Box 7 of Form 1099-MISC) of more than $100,000 from the organization and any related organizations I- List all ofthe organization?s former of?cers, key employees, or highest compensated employees who received more than $100,000 of reportable compensation from the organization and any related organizations I- List all ofthe organization?s former directors or trustees that received, in the capaCIty as a former director or trustee ofthe organization, more than $10,000 of reportable compensation from the organization and any related organizations List persons in the followmg order indIVIdual trustees or directors, institutional trustees, of?cers, key employees, highest compensated employees, and former such persons Check this box if neither the organization nor any related organization compensated any current of?cer, director, or trustee (A) (B) (C) (D) (E) (F) Name and Title Average P05ition (do not check Reportable Reportable Estimated hours per more than one box, unless compensation compensation amount of other week (list person is both an of?cer from the from related compensation any hours and a director/trustee) organization (W- organizations (W- from the for related 3 I I _n organization and organizations a E. 3.1: 9 related below 5 .1: 101$ 3 organizations ii 3 Wu:- dotted line) i: :r a-Form 990(2014) Form 990 (2014) Page8 Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees (continued) (A) (B) (C) (D) (E) (F) Name and Title Average P05ition (do not check Reportable Reportable Estimated hours per more than one box, unless compensation compensation amount of other week (list person is both an officer from the from related compensation any hours and a director/trustee) organization organizations (W- from the for related ,3 3 3 I _n organization and organizations a .2 3.1: 9 related below II: 3 organizations 9% '1 a II-I dotted lineSub-Total Total from continuation sheets to Part VII, Section A Total (add lines 1b and 1c) 17,619,136 0 627,291 2 Total number of (including but not limited to those listed above) who received more than $100,000 of reportable compensation from the organizationII-325 Yes No 3 Did the organization list any former officer, director ortrustee, key employee, or highest compensated employee on line 1a? If ?Yes,? complete Schedu/leor such indiwduaFor any indiVidual listed on line 1a, is the sum of reportable compensation and other compensation from the organization and related organizations greater than $150,000? If "Yes," complete Schedu/leorsuch 5 Did any person listed on line 1a receive or accrue compensation from any unrelated organization or indiViduaI for serVIces rendered to the organization? If ?Yes,? complete Schedu/leor such person . . . 5 No Section B. Independent Contractors 1 Complete this table for yourfive highest compensated independent contractors that received more than $100,000 of compensation from the organization Report compensation for the calendar year ending With or Within the organization?s tax year (A) (B) (C) Name and business address Description of serwces Compensation EPIC SYSTEMS CORPORATION MAINTENANCE 3,489,643 1979 MILKY WAY VERONA, WI 53593 MAGILL CONSTRUCTION COMPANY CONSTRUCTION 2,868,447 977 KOOPMAN LANE 53121 HAYES LOCUMS LLC PHYSICIAN LOCUM 1,907,992 6700 ANDREWS AVE STE 600 FORT LAUDERDALE, FL 33309 WALSH CONSTRUCTION COMPANY II LLC CONSTRUCTION 1,656,452 929 WEST ADAMS CHICAGO, IL 60607 CAM ELOT RADIOLOGY ASSOCIATES PHYSICIAN SERVICES 1,013,916 3849 PERRYVILLE RD ROCKFORD, IL 61114 2 Total number of independent contractors (including but not limited to those listed above) who received more than $100,000 ofcompensation from the organization F49 Form 990(2014) Form 990 (2014) Page9 Statement of Revenue CheckifScheduleO contains a response ornote to any linein this . . . . . (A) (B) (C) (D) Total revenue Related or Unrelated Revenue exempt busmess excluded from function revenue tax under revenue sections 512-514 3 1a Federated campaigns . . 1a Membership dues . . . . 1b :5 E: Fundraismg events . . . . 1c Related organizations . . . 1d 119,870 :5 Government grants (contributions) 1e 37,794 as All other contributions, gifts, grants, and 1f 53,341 .11 Similar amounts not included above 5 Noncash contributions included in lines a 1a?1f$ '5 Total.Add lines la-211,005 in 2 Busmess Code 2a PATIENT SERVICE REVENUE 621110 529,080,363 529,080,363 :u UNRELATED BUSINESS INCOME 561000 10,543,700 10,543,700 3 CAFETERIA 722210 1,287,196 1,287,196 a All other program serVIce revenue Total. Add lines 2a?2f II- 540,911,259 3 Investment income (including leldendS, interest, 1 365 279 1 365 279 and other Similar amounts) . Income from investment of tax?exempt bond proceeds II- Real (ii) Personal 6a Gross rents Less rental expenses Rental income or (loss) Net rentalincome or(lossSecurities (ii) Other 7a Gross amount from sales of 1,761,394 10,127 assets other than inventory Less cost or other ba5is and 1,748,415 797 sales expenses Gain or (loss) 12,979 9,330 Net gain or (loss) . 22,309 22,309 8a Gross income from fundraismg events (not including ofcontributions reported on line 1c) See PartIV,line 18 . l_ a :5 Less direct expenses . . . Net income or (loss) from fundraismg events . . p. 9a Gross income from gaming actIVIties See Part IV, line 19 . . . a Less direct expenses . . . Net income or (loss) from gaming actIVIties . . 10a Gross sales ofinventory, less returns and allowances a Less cost ofgoods sold . . Net income or (loss) from sales of inventory . . p. Miscellaneous Revenue Busmess Code OTHER INVESTMENTS 900099 -4,083,186 -4,083,186 All other revenue Total.Addlines 11a?11d . . . . II- -4,058,585 12 Total revenue. See Instructions p. 538,451,267 529,080,363 10,543,700 ?1,383,801 Form 990 (2014) Form 990 (2014) Page 10 Statement of Functional Expenses Section 501(c)(3) and 501(c)(4) organizations must complete all columns All other organizatlons must complete column (A) Check ifSchedule contalns a response or note to any llne in this Part IX . . . . Do not include amounts reported on lines 6b, (A) Prograglemce Manag?rizent and Fun?gasmg 7b! 8b! 9b! and 10b Of Part Tetal eXpenses expenses general expenses expenses 1 Grants and other aSSIstance to domestic organizations and domestic governments See Part IV, line 21 2 Grants and other a55lstance to domestic lnlelduaIS See Part IV, line 22 3 Grants and other a55lstance to foreign organizations, foreign governments, and foreign lnlelduals See Part IV, lines 15 and 16 Bene?ts paid to or for members 5 Compensation ofcurrent officers, directors, trustees, and key employees 11,465,076 11,465,076 6 Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons In sectlon 4958(c)(3)(B) Other salaries and wages 245,123,814 198,971,029 46,152,785 Pen5ion plan accruals and contributions (include sectlon 401(k) and 403(b) employer contributions) 7,804,014 6,259,599 1,544,415 9 Other employee bene?ts 31,897,171 24,086,976 7,810,195 10 Payroll taxes 14,455,778 10,776,172 3,679,606 11 Fees for serVIces (non-employees) a Management Legal 861,718 861,718 Accounting 45,100 45,100 Lobbying Professmnal fundralsmg serVIces See Part IV, llne 17 Investment management fees 33,035 33,035 9 Other (If llne 11g amount exceeds 10% of line 25, column (A) amount, list line 1 lg expenses on Schedule 0) 28,536,009 16,003,141 12,532,868 12 Advertismg and promotion 2,922,634 29,538 2,893,096 13 Office expenses 89,521,539 84,516,705 5,004,834 14 Information technology 1,072,397 364,988 707,409 15 Royalties 16 Occupancy 8,627,984 7,739,906 888,078 17 Travel 1,087,435 493,135 594,300 18 Payments of travel or entertalnment expenses for any federal, state, or local publlc offICIals 19 Conferences, conventions, and 1,504,964 1,082,196 422,768 20 Interest 9,229,088 8,279,138 949,950 21 Payments to affillates 22 DepreCIation, depletion, and amortlzation 25,883,670 23,197,204 2,686,466 23 Insurance 5,248,405 3,682,329 1,566,076 24 Other expenses Itemlze expenses not covered above (Llst mlscellaneous expenses in llne 24e Ifllne 24e amount exceeds 10% of line 25, column (A) amount, list line 24e expenses on Schedule 0) a BAD DEBTS 23,755,339 23,755,339 EQ UIPMENT REPAIRS MAI 8,069,744 5,360,792 2,708,952 WI MEDICAID OTHER TAX 7,825,864 7,825,864 TRANSACTIO ?7,150,979 ?5,527,125 ?1,623,854 All other expenses 3,937,925 975,222 2,962,703 25 Total functional expenses. Add lines 1 through 24e 521,757,724 417,872,148 103,885,576 0 26 Joint costs. Complete this llne only ifthe organizatlon reported In column (B) costs from a combined educational campaign and fundraismg sollmtatlon Check here Ir iffollowmg SOP 98-2 (ASC 958-720) Form 990 (2014) Form 990 (2014) Balance Sheet Page 11 Check ifSchedule 0 contains a response or note to any line In this Part . . (A) (B) Beginning ofyear End ofyear 1 Cash?non-interest-bearing 24,990 1 26,759 2 Sayings and temporary cash Investments 19,975,876 2 42,527,506 3 Pledges and grants receivable, net 3 4 Accounts receivable, net 87,097,875 4 92,564,232 5 Loans and other receivables from current and former officers, directors, trustees, key employees, and highest compensated employees Complete Part II of Schedule 5 6 Loans and other receivables from other disqualified persons (as defined under section 49 58(f)(1 persons described in section 4958(c)(3)(B), and contributing employers and sponsoring organizations ofsection 501(c)(9) voluntary employees' benefICIary organizations (see instructions) Complete Part II ofSchedule 6 3: 7 Notes and loans receivable, net 7 8 Inventories for sale or use 10,737,552 8 11,486,031 9 Prepaid expenses and deferred charges 5,824,521 9 3,631,138 10a Land, and eqUIpment cost or other basis Complete Part VI ofSchedule 10a 550394358 Less accumulated depreCIation 10b 269.989734 288,590,194 10c 280.904,624 11 Investments?publicly traded securities 11 12 Investments?other securities See Part IV, line 11 73,661,949 12 72,290,520 13 Investments?program-related See Part IV, line 11 13 14 Intangible assets 14 15 Other assets See Part IV, line 11 11,612,645 15 12,420,007 16 Total assets. Add lines 1 through 15 (must equal line 34) 497,525,602 16 515,850,817 17 Accounts payable and accrued expenses 60,162,338 17 67,931,328 18 Grants payable 18 19 Deferred revenue 19 20 Tax?exempt bond liabilities 20 21 Escrow or custodial account liability Complete Part IV ofSchedule 21 22 Loans and other payables to current and former officers, directors, trustees, key employees, highest compensated employees, and disqualified persons Complete Part II ofSchedule 22 23 Secured mortgages and notes payable to unrelated third parties 7104.728 23 5.942428 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 ofSchedule 235,784,631 25 235,521,345 26 Total liabilities. Add lines 17 through 25 303,051,697 26 309,395,101 Organizations that follow SFAS 117 (ASC 958), check here hr '7 and complete 3 lines 27 through 29, and lines 33 and 34. 27 Unrestricted net assets 194,473,905 27 206,455,716 28 Temporarily restricted net assets 28 29 Permanently restricted net assets 29 IE Organizations that do not follow SFAS 117 (ASC 958), check here h- and :5 complete lines 30 through 34. 30 Capital stock or trust prinCIpal, or current funds 30 31 Paid?in or capital surplus,orland, oreqUIpment fund 31 a? 32 Retained earnings, endowment, accumulated income, or other funds 32 33 Total net assets or fund balances 194,473,905 33 206,455,716 2 34 Total liabilities and net assets/fund balances 497,525,602 34 515,850,817 Form 990(2014) Form 990 (2014) Reconcilliation of Net Assets Check IfSchedule contaIns a response or note to any Me In thIs PartXI . . . . . . . . . . . . . . I7 1 Total revenue (must equal Part column (A538,451,267 2 Total expenses (must equal PartIX, column (A), lIne 25521,757,724 3 Revenue less expenses Subtract Me 2 from 16,693,543 4 Net assets orfund balances at begInnIng ofyear (must equal Part X, lIne 33, column . . 4 194,473,905 5 Net unrealized gaIns (losses) on Investments . . . . . . . . . . . . . . . 5 -1,186,128 6 Donated serVIces and use . . . . . . . . . . . . . . . . . 6 7 8 9 Other changes In net assets orfund balances (explaIn In Schedule -3,525,604 10 Net assets orfund balances at end ofyear CombIne lInes 3 through 9 (must equal Part X, lIne 33, column 10 206,455,716 Financial Statements and Reporting Check IfSchedule contaIns a response or note to any Me In thIs Part XII . . . . . . . . . . . . Yes No 1 AccountIng method used to prepare the Form 990 Cash I7 Accrual _Other Ifthe organIzatIon changed Its method ofaccountIng from a prIor year or checked "Other," explaIn In Schedule 0 2a Were the organIzatIon?s fInanCIal statements compIIed or reVIewed by an Independent accountant? 2a No a box below to IndIcate whether the fInanCIal statements forthe year were compIIed or reVIewed on a separate basIs, consolldated or both Separate Consolldated Both consolldated and separate basIs Were the organIzatIon?s fInanCIal statements audIted by an Independent accountant? 2b Yes a box below to IndIcate whether the fInanCIal statements forthe year were audIted on a separate baSIs, consolldated or both Separate I7 Consolldated Both consolldated and separate basIs If "Yes," to Me 2a or 2b, does the organIzatIon have a commIttee that assumes for overSIght ofthe audIt, reVIew, or compIIatIon ofIts fInanCIal statements and selectIon ofan Independent accountant? 2C Yes Ifthe organIzatIon changed eIther Its overSIght process or selectIon process durIng the tax year, explaIn In Schedule 0 3a As a result ofa federal award, was the organIzatIon reqUIred to undergo an audIt or audIts as set forth "Yes," dId the organIzatIon undergo the reqUIred audIt or audIts? Ifthe organIzatIon dId not undergo the 3b reqUIred audIt or audIts, explaIn why In Schedule 0 and descrIbe any steps taken to undergo such audIts Form 990(2014) Additional Data Software ID: Software Version: EIN: 39?0816848 Name: MERCY HEALTH SYSTEM CORPORATION Form 990, Part VII - Compensation of Officers, Directors,Trustees, Key Employees, Highest Compensated Employees, and Inde :iendent Contractors (A) (B) (C) (D) (E) (F) Name and Title Average P05ition (do not check Reportable Reportable Estimated amount hours per more than one box, unless compensation compensation of other week (list person is both an officer from the from related compensation any hours and a director/trustee) organization (W- organizations (W- from the for related 5, 3 I I _n organization and organizations a; 3 9 related below a E3 organizations dotted line(1) ROWLAND MCCLELLAN 1 00 .. 0 0 0 CHAIRPERSON DIRECTOR (1) THOMAS POOL 1 00 .. 19,500 0 0 DIRECTO (2) LARRY SQUIRE 1 00 .. 2,333 0 0 TREASURER DIRECTOR (3) ELIZABETH HANSCH 1 00 .. 0 0 0 DIRECTOR (4) DAVE SYVERSON 1 00 .. 15,000 0 0 DIRECTOR (5) MARK GOELZER MD 55 00 .. 457,757 0 31,022 (6) KATHERINE SCHACK 1 00 .. 664 0 0 DIRECTOR (7) MARK KOPP 1 00 .. 1,735 0 0 DIRECTOR (8) DENNIS UEHARA 1 00 .. 0 0 0 DIRECTOR 55 00 (9) CURTIS WORDEN 1 00 .. 0 0 0 DIRECTOR (10) BARB BORTNER 55 00 .. 216,651 0 36,963 VICE-PRESIDENT (11) DAN COLBY 55 00 .. 273,892 0 30,198 (12) DAVID KURTZ 55 00 .. 254,723 0 27,222 (13) JOHN COOK 55 00 .. 414,941 0 39,695 (14) KATHLEEN HARRIS 55 00 .. 146,755 0 30,816 (15) RUTH YARBROUGH 55 00 .. 272,996 0 24,986 (16) RICHARD GRUBER 55 00 .. 225,377 0 30,391 (17) PATRICK CRANLEY 55 00 .. 13,288 0 0 (18) JOANNA BENNING 55 00 .. 0 0 0 (19) JOSEPH NEMETH 55 00 .. 229,563 0 28,952 (20) SUE RIPSCH 55 00 .. 408,512 0 34,595 (21) JENNIFER 1 00 .. 240,824 0 41,637 (22) PAUL VAN DEN HEUVEL 1 00 .. 321,557 0 39,065 (23) JAVON BEA 55 00 .. 8,005,192 0 38,785 PRESIDENT DIRECTOR (24) BRADLEY FIDELER 40 00 .. 1,389,324 0 44,924 PHYSICIAN Form 990, Part VII - Compensation of Officers, Directors,Trustees, Key Employees, Highest Compensated Employees, and Independent Contractors (A) (B) (C) (D) (E) (F) Name and Title Average P05Ition (do not check Reportable Reportable Estimated amount hours per more than one box, unless compensation compensation of other week (list person is both an of?cer from the from related compensation any hours and a director/trustee) organization (W- organizations (W- from the for related I I _n organization and organizations a :l 3.3: 9 related below E. .1. 3 organizations i1 3 u, II-I dotted line) I: :r H- E- 2 15(26) MERLE RUST 40 00 .. 1,265,325 44,441 PHYSICIAN (1) ROBB WHINNEY 40 00 .. 1,188,907 34,767 PHYSICIAN (2) CRAIG LYON 40 00 .. 1,156,541 40,504 PHYSICIAN (3) JONATHAN EHRHARDT 40 00 1,097,779 28,328 PHYSICIAN Iefile GRAPHIC print - DO NOT PROCESS As Filed Data - SCHEDULE A (Form 990 or 990EZ) Department of the Treasury Internal Revenue SeNice OMB No 1545-0047 Open to Public Inspection Public Charity Status and Public Support Complete if the organization is a section 501(c)(3) organization or a section 4947(a)(1) nonexempt charitable trust. Attach to Form 990 or Form 990-EZ. Information about Schedule A (Form 990 or 990-EZ) and its instructions is at [form990. Name of the organization MERCY HEALTH SYSTEM CORPORATION Employer identification number 39-0816848 Reason for Public Charity Status (All organizations must complete this part.) See instructions. The organization IS not a private foundation because it IS (For lines 1 through 11, check only one box) 1 A church, convention ofchurches, or assomation ofchurches described In section 2 A school described In section (Attach Schedule 3 I7 A hospital or a cooperative hospital serVIce organization described in section 4 A medical research organization operated in conjunction With a hospital described in section Enter the hospital's name, City, and state 5 An organization operated for the benefit ofa college or univerSIty owned or operated by a governmental unit described in section (Complete Part II 6 A federal, state, or local government or governmental unit described in section 7 An organization that normally receives a substantial part ofits support from a governmental unit orfrom the general public described in section (Complete Part II 8 A community trust described in section 170(b)(1)(A)(vi) (Complete Part II 9 An organization that normally receives (1) more than 331/3% of its support from contributions, membership fees, and gross receipts from actIVIties related to its exempt functions?subject to certain exceptions, and (2) no more than 331/3% of its support from gross investment income and unrelated busmess taxable income (less section 511 tax) from busmesses achIred by the organization afterJune 30, 1975 See section 509(a)(2). (Complete Part 10 An organization organized and operated excluswely to test for public safety See section 509(a)(4). 11 An organization organized and operated excluswely for the benefit of, to perform the functions of, or to carry out the purposes of one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2) See section 509(a)(3). Check the box in lines 11a through 11d that describes the type ofsupporting organization and complete lines lle, 11f, and 119 a Type I. A supporting organization operated, superVIsed, or controlled by its supported organization(s), typically by giVing the supported organization(s) the powerto regularly appomt 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 havmg 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 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 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 ifthe organization received a written determination from the IRS that it is a Type I, Type II, Type functionally integrated, orType non-functionally integrated supporting organization Enter the number ofsupported organizations . . . . . . . . Prowde the followmg information about the supported organization(s) (i)Name ofsupported (ii) EIN Type of (iv) Is the organization Amount of (vi) Amount of organization organization listed in your governing monetary support other support (see (described on lines document? (see instructions) instructions) 1? 9 above section (see instructions)) Yes No Total For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990EZ. Cat NO 11285F ScheduleA(Form Schedule A (Form 990 or 2014 Page 2 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 PartI or if the organization failed to qualify under Part If the organization fails to qualify under the tests listed below, please complete Part Section A. Public Support Calendar year (or fiscal year beginning 1 6 (a)2010 (b)2011 (c)2012 (d)2013 (e)2014 (f)Total in) Gifts, grants, contributions, and membership fees received (Do not include any "unusual grants Tax revenues leVIed forthe organization's benefit and either paid to or expended on its behalf The value ofserVIceS or faCIlitieS furnished by a governmental unit to the organization Without charge Total.Add lines 1 through 3 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 (0 Public support. Subtract line 5 from line 4 Section B. Total Support Calendar year (or fiscal year beginning 7 8 10 11 12 13 Section C. Computation of Public Support Percentage (a)2010 (b)2011 (c)2012 (d)2013 (e)2014 (f)Total in) It Amounts from line 4 Gross income from interest, leIdendS, payments received on securities loans, rents, royalties and income from Similar sources Net income from unrelated busmess actIVIties, whether or not the busmess is regularly carried on Other income Do not include gain or loss from the sale ofcapital assets (Explain in Part VI) Total support Add lines 7 through 10 Gross receipts from related actIVIties, etc (see instructions) 12 First five years. Ifthe 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 . . . . . 14 15 16a 17a 18 Public support percentage for 2014 (line 6, column lelded by line 11, column 14 15 33 1/3?/o support test?2014.1fthe organization did not check the box on line 13, and line 14 iS 33 1/3?/o or more, check this box and stop here. The organization qualifies aS a publicly supported organization 33 1/3?/o support test?2013.Ifthe 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 I'l? 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 organization did not check a box on line 13, 16a, 16b, or 17a, and line 15 is 10% or more, and ifthe 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 Private foundation. Ifthe organization did not check a box on line 13, 16a, 16b, 17a, or 17b, check this box and see instructions Public support percentage for 2013 Schedule A, Part II, line 14 Schedule A (Form 990 or 990-EZ) 2014 Schedule A (Form 990 or 2014 Page 3 Support Schedule for Organizations Described in Section 509(a)(2) (Complete only If you checked the box on Ine 9 of PartI or If the organizatIon failed to qualify under Part II. If the organization fails to qualify under the tests Isted below, please complete Part II.) Section A. Public Support Calendar year (or fiscal year beginning 1 7a 8 (a)2010 (b)2011 (c)2012 (d)2013 (e)2014 (f)Tota in)! Gifts, grants, contributions, and membership fees received (Do not Include any "unusual grants Gross receipts from admISSIons, merchandise sold or services performed, furnished In any actIVIty that Is related to the organizatIon's tax-exempt purpose Gross receipts from actIVItIes that are not an unrelated trade or busmess under section 513 Tax revenues leVIed forthe organizatIon's benefit and eIther paId to or expended on Its behalf The value ofserVIces furnished by a governmental unIt to the organizatIon Without charge Total.Add Ines 1 through 5 Amounts Included on Ines 1, 2, and 3 recered from dIsqualierd persons Amounts Included on Ines 2 and 3 recered from other than persons that exceed the greater of$5,000 or 1% ofthe amount on Ine 13 for the year Add lines 7a and 7b Public support (Subtract Ine 7c from line 6 Section B. Total Support Calendar year (or fiscal year beginning 9 10a 11 12 13 14 (a)2010 (b)2011 (c)2012 (d)2013 (e)2014 (f)Tota in)? Amounts from Me 6 Gross Income from Interest, dIVIdends, payments received on securItIes loans, rents, royalties and Income from sources Unrelated busmess taxable Income (less section 511 taxes) from busmesses achIred after June 30, 1975 Add Ines 10a and 10b Net Income from unrelated busmess actIVItIes not Included In line 10b, whether or not the busmess Is regularly carrIed on Other Income Do not Include gain or loss from the sale of capItaI assets (Explain In Part VI Total support. (Add Ines 9, 10c, 11, and 12 First five years. Ifthe Form 990 Is for the organIzatIon's ?rst, second, third, fourth, or fifth tax year as a sectIon 501(c)(3) organIzatIon, check this box and stop here Section C. Computation of Public Support Percentage 15 Public support percentage for 2014 ( Ine 8, column dIVIded by line 13, column 15 16 Public support percentage from 2013 Schedule 15 15 Section D. Computation of Investment Income Percentage 17 Investment Income percentage for 2014(line 10c, column dIVIded by line 13, column 17 18 Investment Income percentage from 2013 Schedule A, Part 111, line 17 13 19a 33 1/3?/o support tests?2014.Ifthe organizatIon dId not check the box on line 14, and line 15 Is more than 33 and Me 17 Is not more than 33 check this box and stop here. The organIzatIon quali?es as a publicly supported organIzatIon 33 1/3?/o support tests?2013.Ifthe organizatIon dId not check a box on line 14 or Me 19a, and Me 16 Is more than 33 1/3?/o and line 18 Is not more than 33 check this box and stop here. The organIzatIon quali?es as a publicly supported organIzatIon Fl? 20 Private foundation. Ifthe organizatIon dId not check a box on Me 14, 19a, or 19b, check this box and see InstructIons Schedule A (Form 990 or 990-EZ) 2014 Schedule A (Form 990 or 990-EZ) 2014 Part IV Supporting Organizations (Complete only Ifyou checked a box on line 11 ofPart I Ifyou checked 11a ofPart I, complete Sections A and Ifyou checked 11b ofPart I, complete Sections A and Ifyou checked 11c ofPart I, complete Sections A, D, and Ifyou checked 11d ofPart I, complete Sections A and D, and complete Part Section A. All Supporting Organizations Page4 3a 5a Are all of the organIzation's supported organIzations IIsted 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 de5ignation. If historic and continumg relationship, explain. the organization have any supported organization that does not have an IRS determination ofstatus under section 509 or (2 )9 If ?Yes,? explain in Part VI how the organization determined that the supported organization was described in section 509(a)(1) or (2). the organization have a supported organization In section 501(c)(4), (5), or If "Yes," answer and below. the organization con?rm that each supported organization qualified under section 501(c)(4), (5), or (6) and satIs?ed the public support tests under section 509(a)(2)7 If ?Yes,? describe in Part VI when and how the organization made the determination. the organization ensure that all support to such organizations was used excluswely 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 11a or 11b in Part I, answer and below. 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 orsuperwsed by or in connection With its supported organizations. the organization support any foreign supported organization that does not have an IRS determination under sections 501(c)(3) and 509(a)(1) or If in Part VI what controls the organization used to ensure that all support to the foreign supported organization was used excluswely for section 170(c)(2)(B) purposes. the organization add, substitute, or remove any supported organizations durIng the tax year? If ?Yes,?answer and below (if applicable). Also, prowde detail in Part VI, including the names and EIN numbers of the supported organizations added, substituted, or removed, (ii) the reasons for each such action, the authority under the organization?s organizmg document authorizmg such action, and (iv) how the action was accomplished (such as by amendment to the organizmg document). Type I or Type II only. Was any added or supported organlzation part ofa class already deSIgnated In 9a 10a 11 the organlzation's organizmg document? Substitutions only. Was the substitution the result ofan event beyond the organizatlon's control? the organizatlon prOVIde support (whether In the form ofgrants or the ofserVIces or faCIlitIes) to anyone otherthan Its supported organizatlons, IndIVIduals that are part of the charItable class benefited by one or more of Its supported organizatlons, or other supporting organizatlons that also support or bene?t one or more of the filIng organizatIon?s supported organizatlons? If ?Yes,?prowde detail in Part VI. the organizatlon prOVIde a grant, loan, compensation, or other payment to a substantial contributor (de?ned In IRC a famlly member ofa substantlal contrIbutor, or a 35-percent controlled entity With regard to a substantlal contrIbutor? If ?Yes,?complete PartI of ScheduleL (Form 990). the organizatlon make a loan to a disquall?ed person (as de?ned In section 4958) not In line If ?Yes, complete Part II of Schedule (Form 990). Was the organIzation controlled directly or IndIrectly at any time during the tax year by one or more dIsquali?ed persons as de?ned In sectIon 4946 (other than foundatIon managers and organizatlons descrIbed In sectIon 509 or If ?Yes,?prowde detail in Part VI. one or more dIsquali?ed persons (as defined In Me hold a controlling Interest In any entIty In the supporting organizatlon had an Interest? If ?Yes,?prowde detail in Part VI. a dIsquali?ed person (as de?ned In line have an ownershIp Interest In, or derIve any personal benefit from, assets In the organizatlon also had an Interest? If ?Yes,?prowde detail in Part VI. Was the organIzation subject to the excess busmess holdIngs rules 4943 because 4943(f) (regarding certaIn Type II supporting organIzations, and all Type non?functlonally Integrated supportIng organIzations)? If ?Yes,?answerb below. the organizatlon have any excess busmess holdings In the tax year? (Use Schedule C, Form 4720, to determine whether the organization had excess busmess holdings). Has the organizatlon accepted a gift or contrIbutIon from any of the followmg persons? A person who dIrectly or Indirectly controls, eIther alone ortogether With persons described In and below, the governing body ofa supported organlzation? A family member ofa person described In above? A 35% controlled entity ofa person In or above? If ?Yes?to a, b, or c, prowde detail in Part VI10a 10b 11a 11b 11c Schedule A (Form 990 or 990-EZ) 2014 ScheduleA (Form 990 or990?EZ)2014 Page5 Supporting Organizations (continued) Section B. Type I Supporting Organizations Yes No 1 the directors, trustees, or membership ofone or more supported organizations have the power to regularly appomt 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, supervrsed, or controlled the organization?s actIVIties. If the organization had more than one supported organization, describe how the powers to appomt 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. 1 2 the organization operate for the benefit ofany supported organization other than the supported organization(s) that operated, superVIsed, or controlled the supporting organization? If ?Yes,?explain In Part VI how prowding 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 No 1 Were a majority ofthe organization's directors or trustees during the tax year also a majority of the directors or trustees ofeach 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). 1 Section D. All Type Supporting Organizations Yes No 1 the organization prowde to each of its supported organizations, by the last day ofthe fIfth month ofthe organization?s tax year, (1) a written notice describing the type and amount ofsupport prowded during the prIor tax year, (2) a copy of the Form 990 that was most recently ?led as ofthe date of notification, and (3) copies of the organization?s governing documents In effect on the date of notification, to the extent not preVIously prowded? 1 2 Were any of the organization?s officers, directors, or trustees either (I) appomted or elected by the supported organization(s) or (Ii) servmg on the governing body ofa supported organization? If "No,"explain In Part VI how the organization maintained a close and continuous working relationship With the supported organization(s). 2 3 By reason of the relationship described In (2), the organization's supported organizations have a Significant v0ice In the organization?s Investment p0l C es and in dIrectIng the use ofthe 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. 3 Section E. Type Functionally-Integrated Supporting Organizations 1 Check the box next to the method that the organization used to satisfy the Integral Part Test during the year (see instructions) a The organization satisfied the ActIVItIes Test Complete line 2 below The organization IS the parent ofeach ofits supported organizations Complete line 3 below The organization supported a governmental entity Describe in Part VI how you supported a government entity (see instructions) 2 ACtIVItles Test Answer and below. Yes No a substantially all of the organization's actIVIties during the tax year directly further the exempt purposes of the supported organization(s) to the organization was responswe? If "Yes," then In Part VI identify those supported orga niza tions and explain how these actIVItIes directly furthered their exempt purposes, how the organization was responswe to those supported organizations, and how the organization determined that these actIVItIes constituted substantially all of Its actIVIties. 2a the actIVItIes described In 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. 2b 3 Parent of Supported rganlzations Answer and below. a the organization have the power to regularly appomt or elect a maJorIty of the officers, directors, or trustees of each of the supported organizations? Prowde details in Part VI. 3a the organization exerCIse a substantial degree ofdlrection over the programs and actIVItIes ofeach of its supported organizations? If "Yes," describe In Part VI the role played by the organization In this regard. 3b Schedule A (Form 990 or 990-EZ) 2014 ScheduleA (Form 990 or990?EZ)2014 Page6 Part Type Non-Functionally Integrated 509(a)(3) Supporting Organizations 1 Check here ifthe organization satisfied the Integral Part Test as a qualifying trust on Nov 20, 1970 See instructions. All other Type non-functionally Integrated supporting organizations must complete Sections A through (B) Current Year Section A - Adjusted Net Income (A) P??rYear (optmar) Net short?term capital gain Recoveries of prior-year distributions Other gross Income (see Instructions) Add lInes 1 through 3 DepreCIation and depletion UI-hwui-I Portion ofoperating expenses paid or Incurred for production or collection of gross Income orfor management, conservatIon, or maIntenance of property held for production ofincome (see Instructions) Oi Oi 7 Other expenses (see instructions) 7 8 Adjusted Net Income (subtract lines 5, 6 and 7 from lIne 4) 8 (B) Current Year Section - Minimum Asset Amount (A) Prlor Year (optlonal) Aggregate fair market value ofall non-exempt-use assets (see instructions for short tax year or assets held for part ofyear) 1 Average value ofsecurities 1a Average cash balances 1b Fair market value of other non-exempt-use assets 1c Total(add lInes 1a,1b,and 1c) 1d Discount claimed for blockage or otherfactors (explain in detail In Part VI) AchIsItion Indebtedness applicable to non?exempt use assets 2 EDEN (D Subtract line 2 from line 1d Cash deemed held for exempt use Enter 1-1/2% ofline 3 (for greater amount, see instructIons) Net value of non-exempt-use assets (subtract lIne 4 from lIne 3) Multiply line 5 by 035 Recoveries of prior-year distributions MNmm-h Minimum Asset Amount (add lIne 7 to lIne 6) Section - Distributable Amount Current Year Adjusted net Income for prIor year (from Section A, line 8, Column A) Enter 85% ofline 1 MinImum asset amount for prIor year (from Section B, line 8, Column A) Enter greater ofllne 2 orllne 3 Income tax Imposed In prIor year mthNi-I Distributable Amount. Subtract line 5 from line 4, unless subject to emergency temporary reduction (see instructions) 01 Check here If the current year is the organization's ?rst as a non-functionally-Integrated Type supporting organization (see Instructions) Schedule A (Form 990 or 990-EZ) 2014 Sc hedule A (Form 990 or 990-EZ) 2014 Page 7 ection - Distributions Current Year 1 Amounts paid to supported organizations to accomplish exempt purposes 2 Amounts paid to perform actIVIty that directly furthers exempt purposes ofsupported organizations, In excess of Income from actIVIty 3 Administrative expenses paid to accomplish exempt purposes ofsupported organizations 4 Amounts paid to achIre exempt?use assets 5 Quali?ed set?aSIde amounts (prior IRS approval reqUIred) 6 Other distributions (describe in Part VI) See instructions 7 Total annual distributions. Add lines 1 through 6 8 Distributions to attentive supported organizations to which the organization is responswe (prowde details in Part VI) See instructions 9 Distributable amount for 2014 from Section C, line 6 10 Line 8 amount diVided by Line 9 amount Section - Distribution Allocations (see (ii) Underdist ribut ions Excess Dist ribut ions re_2014 instructions) Distributable Amount for 2014 1 Distributable amount for 2014 from Section C, line 6 Underdistributions, ifany, for years prior to 2014 (reasonable cause reqUIred--see instructions) Excess distributions carryover, ifany, to 2014 From 2009. From 2010. From 2011. From 2012. From 2013. Total oflines 3a through Applied to underdistributions of prior years Applied to 2014 distributable amount Carryoverfrom 2009 not applied (see instructions) Remainder Subtract lines 39, 3h, and 3i from 3f 4 Distributions for 2014 from Section D, line 7 Applied to underdistributions of prior years Applied to 2014 distributable amount Remainder Subtract lines 4a and 4b from 4 5 Remaining underdistributions for years prior to 2014, ifany Subtract lines 39 and 4a from line 2 (if amount greater than zero, see instructions) 6 Remaining underdistributions for 2014 Subtract lines 3h and 4b from line 1 (ifamount greater than zero, see instructions) 7 Excess distributions carryover to 2015. Add lines 3] and 4c 8 Breakdown ofline 7 a From 2010. From 2011. From 2012. From 2013. From 2014. Schedule A (Form 990 or 990-EZ) (20 14) Schedule A (Form 990 or 990-EZ) 2014 Page 8 Supplemental Information. Prowde the explanations reqUIred by Part II, line 10; Part II, line 17a or 17b; Part line 12; Part IV, Section A, lines 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 Section D, lines 5, 6, and 8; and Part V, Section E, lines 2, 5, and 6. Also complete this part for any additional information. (See instructions). Facts And Circumstances Test Return Reference Explanation Schedule A (Form 990 or 990-EZ) 2014 Iefile GRAPHIC print - DO NOT PROCESS lAs Filed Data - SCHEDULE (Form 990) Depailment of the Treasury Internal Revenue Sewioe Name of the organization MERCY HEALTH SYSTEM CORPORATION OMB No 1545-0047 Open to Public Inspection Employer identification number Supplemental Financial Statements II- Complete if the organization answered "Yes," to Form 990, Part IV, line 6, 7, 8, 9, 10, 11a, 11b, 11c, 11d, 11e, 11f, 12a, or 12b. II- Attach to Form 990. Information about Schedule (Form 990) and its instructions is at 39-0816848 Organizations Maintaining Donor Advised Funds or Other Similar Funds or Accounts. Complete if the organization answered "Yes" to Form 990 Part IV, line 6. Donor adVIsed funds Funds and other accounts Total number at end of year Aggregate value ofcontributions to (during year) Aggregate value ofgrants from (during year) Aggregate value at end ofyear 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 excluswe 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 N0 Conservation Easements. Complete if the organization answered "Yes" to Form 990, Part IV, line 7. 1 9.07? Purpose(s) ofconservation easements held by the organization (check all that apply) Preservation ofland for public use (e recreation or education) Preservation ofan historically important land area Protection of natural habitat Preservation ofa certified historic structure Preservation ofopen space Complete lines 2a through 2d ifthe organization held a qualified conservation contribution in the form ofa conservation easement on the last day ofthe tax year Held at the End of the Year Total number ofconservation easements 2a Total acreage restricted by conservation easements 2b Number ofconservation easements on a certified historic structure included in 2c Number ofconservation easements included in achIred after 8/17/06, and not on a historic structure listed in the National Register 2d Number ofconservation easements modified, transferred, released, or terminated by the organization during the tax year I Number ofstates where property subject to conservation easement is located hr Does the organization have a written policy regarding the periodic monitoring, inspection, handling ofVIolations, and enforcement of the conservation easements it holds? N0 Staff and volunteer hours devoted to monitoring, inspecting, and enforcmg conservation easements during the year h- Amount ofexpenses incurred in monitoring, inspecting, and enforcmg conservation easements during the year Does each conservation easement reported on line 2(d) above satisfy the reqUIrements ofsection and section 170(h)(4)(B)(ii)7 Yes No In Part describe how the organization reports conservation easements in its revenue and expense statement, and balance sheet, and include, ifapplicable, the text of the footnote to the organization?s finanCIal statements that describes the organization's accounting for conservation easements Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets. 1a For Paperwork Reduction Act Notice, see the Instructions for Form 990. Complete if the organization answered "Yes" to Form 990, Part IV, line 8. Ifthe organization elected, as permitted under SFAS 116 (ASC 958), not to report in its revenue statement and balance sheet works ofart, historical treasures, or other Similar assets held for public exhibition, education, or research in furtherance of public serVIce, prowde, in Part the text of the footnote to its finanCIal Statements that describes these items Ifthe organization elected, as permitted under SFAS 116 (ASC 958), to report in its revenue statement and balance sheet works ofart, historical treasures, or other Similar assets held for public exhibition, education, or research in furtherance of public serVIce, prowde the followmg amounts relating to these items Revenue included in Form 990, Part line 1 Ir (ii)Assets includedin Form 990,PartX Ifthe organization received or held works ofart, historical treasures, or other Similar assets for finanCIal gain, prowde the followmg amounts reqUIred to be reported under SFAS 116 (ASC 958) relating to these items Revenueincluded in Form Assets includedin Form 990,PartX Cat No 5 2283 Schedule (Form 990) 2014 Schedule (Form 990) 2014 Page 2 Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets (continued) 3 Usmg the organIzatIon?s achISItion, accessmn, and other records, check any of the followmg that are a Signi?cant use of Its collection Items (check all that apply) a PublIc ethbItIon Scholarly research Loan or exchange programs Other PreservatIon forfuture generations 4 Prowde a descrIptIon of the organIzatIon?s collections and explaIn how they further the organIzatIon?s exempt purpose In Part 5 DurIng the year, did the organIzation so ICIt or recere donations ofart, hIstorical treasures or other Similar assets to be sold to raIse funds ratherthan to be maIntaIned as part ofthe organIzatIon?s collection? Yes l? N0 Escrow and Custodial Arrangements. Complete If the organization answered "Yes" to Form 990, Part IV, line 9, or reported an amount on Form 990, Part X, IIne 21. 1a Is the organization an agent, trustee, custodian or other Intermediary for contrIbutIons or other assets not Included on Form 990,Part I_Yes _No If "Yes," explaIn the arrangement In Part and complete the followmg table Amount BegInnIng balance 1c Additions durIng the year 1d 3 DIstrIbutIons during the year 1e EndIng balance 1f 2a the organIzatIon Include an amount on Form 990,Part X, Ine 21,forescroworcustodial accountliabIlity? I_Yes If"Yes," explaIn the arrangement In Part Check here Ifthe explanation has been prOVIded In Part Endowment Funds. Complete If the organIzation answered "Yes" to 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 Contributions Net Investment earnings, gains, and losses Grants or scholarshIps Other expendItures for faCIlItIes and programs AdmInIstrative expenses 9 End ofyear balance 2 Prowde the estImated percentage ofthe current year end balance (lIne lg, column held as a Board deSIgnated or quaSI?endowment II- Permanent endowment I Temporarily restricted endowment hr The percentages In lInes 2a, 2b, and 2c should equal 100% 3a Are there endowment funds not In the posses5Ion ofthe organIzation that are held and admInistered for the organIzation by Yes No unrelated organIzatIons 3a(i) (ii) related organIzatIons . . . . . . . . . . . . . . . If"Yes" to are the related organIzatIons listed as reqUIred on Schedule 3b 4 DescrIbe In Part the Intended uses ofthe organIzatIon's endowment funds Land, Buildings, and Equipment. Complete if the organization answered 'Yes' to Form 990, Part IV, line 11a. See Form 990, Part X, line 10. Descriptlon of property Cost or other (b)Cost or other Accumulated Book value (Investment) (other) depreCIation 1a Land 27,052,591 27,052,591 303,684,416 117,743,138 185,941,278 Leasehold Improvements 5,414,556 4,207,254 1,207,302 EqU pment 201,330,721 142,793,763 58,536,958 Other . . . . . . . . . . . . . . . 13,412,074 5,245,579 8,166,495 Total. Add lines 1a through 1e (Column must equal Form 990, Part X, column (B), line . . . . . . . II- 280,904,624 Schedule (Form 990) 2014 ScheduleD(Form990)2014 Page3 Investments?Other Securities. Complete If the organization answered 'Yes' to Form 990, Part IV, line 11b. See Form 990, Part X, line 12. Description ofsecurlty or category (b)Book value Method of valuation (including name ofsecurity) Cost or end-of?year market value (1)FinanCIal derivatives (2)Closely-held eqUIty Interests (3)Other - FUTURE REPLACE OF PROP, PLANT EQUIPMENT 32,902,139 UNDER BONDINDENTURE AGREEMENT 4,355,413 COMPENSATION 12,545,681 IN MERCYCARE 17,732,416 4,754,871 Total. (Column must equal Form 990, Part/Y, col (B) lIne 12) 72,290,520 Investments?Program Related. Complete If the organization answered 'Yes' to Form 990, Part IV, line 11c. See Form 990 Part We 13. Description of investment Book value Method of valuation Cost or end-of? ear market value Total. Column must Form Part col line 13 Other Assets. Com ete ifthe anizatlon answered 'Yes' to Form 990 Part IV line 11d See Form 990 Part line 15 a Descri on Book value Total. Column must Form 990 Part col line 15Other Liabilities. Complete if the organization answered 'Yes? to Form 990, Part IV, line He or 11f. See Form 990, Part X, line 25. 1 Description of liability Book value Federal income taxes DEFERRED COMPENSATION 12,545,681 PENSION LIABILITY 23,408,000 CAPITAL LEASES PAYABLE 119,500 DUE TO RELATED PARTY 198,001,399 DUE TO THIRD PARTIES 1,446,765 Total. (Column must equal Fomi 990, col (B) line 25) p. 235,52 1345 2. LIabilIty for uncertain tax pOSItlonS In Part prOVIde the text ofthe footnote to the organization's finanCIal statements that reports the organization's liability for uncertain tax p05itions under FIN 48 (ASC 740) Check here If the text ofthe footnote has been prowded in Part Schedule (Form 990) 2014 ScheduleD(Form990)2014 Page4 Reconciliation of Revenue per Audited Financial Statements With Revenue per Return Complete if the organization answered 'Yes' to 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 line 12 a Net unrealized gains (losses) on investments . . . . 2a Donated serVIces and use of faCIlities . . . . . . . . . 2b Recoveries of prior year grants . . . . . . . . . . . 2c Other (Describe in Part . . . . . . . . . . . . 2d Add lines 2a through Subtract line 2e from line Amounts included on Form 990, Part line 12, but not on line 1 a Investment expenses notincluded on Form 990,Part 7b . 4a Other (Describe in Part . . . . . . . . . . . 4b Addlines4aand4bTotal revenue Add lines 3and 4c. (This must equal Form 990, Part I, line 12Reconciliation of Expenses per Audited Financial Statements With Expenses per Return. Complete if the organization answered 'Yes' to Form 990, Part IV, line 12a. 1 Total expenses and losses per audited finanCIaI 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 Prior year adjustments . . . . . . . . . . . . . . 2b Otherlosses . . . . . . . . . . . . . . . . 2c Other (Describe in Part . . . . . . . . . . . . 2d Add lines 2a through Subtract line 2e from line Amounts included on Form 990, Part IX, line 25, but not on line 1: a Investment expenses notincluded on Form 7b . . 4a Other (Describe in Part . . . . . . . . . . . . 4b Addlines4aand4bTotal expenses Add lines 3 and 4c. (This must equal Form 990, Part Supplemental Information Prowde the descriptions reqUIred for Part II, lines 3, 5, and 9, Part lines 1a and 4, Part IV, 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 prowde any additional information Return Reference Explanation Schedule (Form 990) 2014 Schedule (Form 990) 2013 Supplemental Information (continued) Page 5 Return Reference Explanation Schedule (Form 990) 2014 Iefile GRAPHIC print - DO NOT PROCESS lAs Filed Data - SCHEDULE (Form 990) Department of the Treasury Internal Revenue Sewice Hospitals F- Complete if the organization answered "Yes" to Form 990, Part IV, question 20. II- Attach to Form 990. Name of the organization MERCY HEALTH SYSTEM CORPORATION 39-0816848 OMB No 1545-0047 F- Information about Schedule (Form 990) and its instructions is at open to pubiic Inspection Employer identification number Financial Assistance and Certain Other Community Benefits at Cost Yes No 1a Did the organization have a finanCIal a55istance policy during the tax year? If"No," skip to question 6a 1a Yes If"Yes," was it a written policy? 1b Yes 2 Ifthe organization had multiple hospital faCIlities, indicate which of the followmg best describes application of the finanCIal a55istance policy to Its various hospital faCIlities during the tax year i7 Applied uniformly to all hospital faCIlities Applied uniformly to most hospital faCIlities Generally tailored to indiVidual hospital faCIlities 3 Answer the followmg based on the finanCIal a55istance eligibility criteria that applied to the largest number of the organization's patients during the tax year a Did the organization use Federal Poverty GUIdelines (FPG) as a factor in determining eligibility for prOVIding free care? If"Yes," indicate which of the followmg was the FPG family income limit for eligibility for free care 3a Yes i? 100% l7 150% l? 200% l? Other Did the organization use FPG as a factor in determining eligibility for prowding discounted care? If "Yes," indicate which of the followmg was the family income limit for eligibility for discounted care 3b Yes i? 200% l? 250% l7 300% l? 350% l? 400% l? Other 0/0 Ifthe organization used factors otherthan 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 4 Did the organization's finanCIal a55istance policy that applied to the largest number of its patients during the tax year prowde forfree or discounted care to the "medically indigentDid the organization budget amounts forfree or discounted care prowded under its finanCIal a55istance policy during the tax year? 5a Yes If "Yes," did the organization's finanCIal a55istance expenses exceed the budgeted amount? 5b No If"Yes" to line 5b, as a result of budget conSIderations, was the organization unable to prowde free or discounted care to a patient who was eligibile for free or discounted care? 5c 6a Did the organization prepare a community benefit report during the tax year? 5a No If"Yes," did the organization make it available to the public? 5b Complete the followmg table usmg the worksheets prowded in the Schedule instructions Do not submit these worksheets With the Schedule 7 FinanCIal ASSIStance and Certain Other Community Benefits at Cost Financial Assistance and NumberOf Persons Total community Direct offsetting Net community benefit Percent of Means_1?ested aCt'V't'es or served benefit expense revenue expense total expense programs Government Programs (opmnai) (opt'ona') a FinanCIal A55istance at cost (from Worksheet 1) . 2,594,823 0 2,594,823 0 520 Medicaid (from Worksheet 3, column a) . . . . 145,920,882 98,833,216 47,087,666 9 460 Costs of other means-teste government programs (from Worksheet 3, column b) 4,736,755 2,818,984 1,917,771 0 390 0/6 Total FinanCIal A55lstance and Means?Tested Government Programs 153,252,460 101,652,200 51,600,260 10 370 Other Benefits Community health improvement seNlces and community benefit operations (from Worksheet 4) 1,588,117 186,781 1,401,336 0 280 0/0 Health profe55lons education (from Worksheet 5) 6,205,630 814,443 5,391,187 1 080 health sewices (from Worksheet 6) 15,993,759 12,329,893 3,663,866 0 740 Research (from Worksheet 7) 0 0 0 i Cash and ln?klnd contributions for community benefit (from Worksheet 8) 856,316 0 856,316 0 170 0/0 Total. Other Benefits 24,643,822 13,331,117 11,312,705 2 270 0/0 Total. Add lines 7d and 7] 177,896,282 114,983,317 62,912,965 12 640 0/0 For Paperwork Reduction Act Notice, see the Instructions for Form 990. Cat No 50192T Schedule (Form 990) 2014 Schedule (Form 990) 2014 Page 2 Community Building Activities Complete thIs table If the organIzatIon conducted any communlty bUIIdlng actIVItIes durIng the tax year, and descrIbe In Part VI how Its communlty bUIIdlng actIVItIes promoted the health of the communities It serves. Number of Persons Total communlty DIrect offsettIng Net communlty Percent of actIVItIes or served (optlonal) bUIldIng expense revenue bUIldIng expense total expense programs (optlonal) 1 PhySIcal Improvements and housmg 2 EconomIc development 3 Communlty support 54,100 54,100 0 010 4 EnVIronmental Improvements 5 LeadershIp development and traInIng for communlty members 5 Coalltlon bUIldIng 33,290 33,290 0 010 0/0 7 Communlty health Improvement advocacy 20,810 20,810 0 0/0 3 Workforce development 35,370 35,370 0 010 9 Other 1? Total 143,570 143,570 0 030 0/0 Bad Debt, Medicare, Collection Practices Section A. Bad Debt Expense Yes No 1 the organIzatIon report bad debt expense In accordance WIth Heathcare FInanCIal Management StatementNolSEnter the amount of the organIzatIon's bad debt expense ExplaIn In Part VI the methodology used by the organIzatIon to estImate thIs amount 2 9,065,269 3 Enter the estImated amount of the organIzatIon's bad debt expense attrIbutable to patIents eIIgIbIe under the organIzatIon's fInanCIal aSSIstance poIIcy ExplaIn In Part VI the methodology used by the organIzatIon to estImate thIs amount and the ratIonale, If any,forInc udIng thIs portIon ofbad debt as communlty bene?t 3 1,571,011 4 In Part VI the text of the footnote to the organIzatIon?s fInanCIal statements that descrIbes bad debt expense or the page number on thIs footnote Is contaIned In the attached fInanCIal statements Section B. Medicare 5 Enter total revenue recered from MedIcare (IncludIng DSH and IME) 5 59,026,628 6 Enter MedIcare allowable costs ofcare relatIng to payments on Me 5 6 91,163,939 7 Subtract Me 6 from Me 5 ThIs IS the surplus (or shortfall) . . . 7 -32,137,311 8 DescrIbe In Part VI the extent to any shortfall reported In Me 7 should be treated as communlty bene?t Also descrIbe In Part VI the costIng methodology or source used to determIne the amount reported on Me 6 Check the box that descrIbes the method used Cost accountIng system I7 Cost to charge ratIo Other Section C. Collection Practices 9a the organIzatIon have a ertten debt collectIon poIIcy durIng the tax year? 9a Yes If "Yes," dId the organIzatIon?s collectIon pollcy that appIIed 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 quaIIfy forfInanCIal aSSIstance? DescrIbe In Part VI 9'3 Yes Pa rt IV Management companies and Joint VentureS(owned 10% or more by of?cers, dIrectors, trustees, key employees, and phySICIans?see InstructIons) Name of entIty DescrIptIon of prImary actIVIty of entIty Organlzatlon's pro?t 0/0 or stock ownershIp OffIcers, dIrectors, tmstees, or key employees' pro?t 0/0 or stock ow nershIp 0/0 PhySICIans' pro?t 0/0 or stock ownershIp 10 11 12 13 Schedule (Form 990) 2014 Schedule (Form 990) 2014 Facility Information Page 2 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? 2 Name, 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) leiidsou pasLiaol?I [uni?irra 13- [end-am eluaipllug inn-dew [end-30L] [mung Jimmie; smog 15-3?53 mun?Ha Other (describe) FaCIlity reporting group See Additional Data Table Schedule (Form 990) 2014 Schedule (Form 990) 2014 Facility Information (continued) Section B. Facility Policies and Practices (Complete a separate Section for each of the hospital faCIlities orfaCIlity reporting groups listed In Part V, Section A) Page 2 MERCY HOSPITAL AND TRAUMA CENTER 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 No Community Health Needs Assessment 1 2 6a 9.079 12a 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 yearWas the hospital faCIlity achIred or placed into serVIce as a tax-exempt hospital in the current tax year or the immediately preceding tax year? If?Yes,? prowde details ofthe achISItion in Section . . . . . . During the tax year or either of the two immediately preceding tax years, did the hospital faCIlity conduct a community health needs assessment If"No," Skip to line 12 If indicate what the CHNA report describes (check all that apply) I7 A definition ofthe community served by the hospital faCIlity '7 Demographics of the community '7 EXIsting health care faCIlities and resources Within the community that are available to respond to the health needs of the community I7 How data was obtained '7 The Significant health needs ofthe community '7 Primary and chronic disease needs and other health issues ofuninsured persons, low?income persons, and minority groups I7 The process for identifying and prioritizmg community health needs and serVIceS to meet the community health needs I7 The process for consulting With persons representing the community's interests Information gaps that limit the hospital faCIlity's ability to assess the community?s health needs Other (describe in Section C) Indicate the tax year the hospital faCIlity last conducted a CHNA 20 13 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 ofor expertise in public health? If "Yes," describe in Section how the hospital faCIlity took into account input from persons who represent the community, and identify the persons the hospital faCIlity consulted . . . . . . . . . . . . . . Was the hospital faCIlity's CHNA conducted With one or more other hospital faCIlities? If "Yes," list the other hospital faCIlitieSInSectionC Was the hospital faCIlity's CHNA conducted With one or more organizations other than hospital faCIlities?? If?Yes,? list the other organizations in Section . . . . . Did the hospital faCIlity make its CHNA report . indicate how the CHNA report was made Widely available (check all that apply) '7 Hospital faCIlity?s webSite (list url) ORG Other webSite (list url) '7 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 If"No," skip to line 11 Indicate the tax year the hospital faCIlity last adopted an implementation strategy 20 13 Widely available to the public? . Is the hospital faCIlity's most recently adopted implementation strategy posted on a webSIte? . If?Yes" (list ur ) ORG If"No," iS the hospital faCIlity's most recently adopted implementation Strategy attached to this returnDescribe in Section 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 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)(3line 12a, did the organization file Form 4720 to report the section 4959 eXCIse taxline 12b, what iS the total amount ofsection 4959 eXCIse tax the organization reported on Form 47 20 for all of its hospital faCIlities12b Schedule (Form 990) 2014 ScheduleH (Form 990)2014 Page2 Facility Information (continued) MERCY HOSPITAL AND TRAUMA CENTER Name of hospital facility or letter of facility reporting group Yes No Financial Assistance Policy (FAP) Did the hospital faCIlity have In place during the tax year a written finanCIal aSSIstance policy that 13 Explained eligibility criteria forfinanCIal aSSIstance, and whether such aSSIstance Included free or discounted care? 13 Yes If?Yes,? indicate the eligibility criteria explained In the FAP a '7 Federal poverty gmdelines (FPG), With FPG family Income limit for eligibility forfree care of 150 0000000000000/0 and FPG family Income limit for eligibility for discounted care of300 0000000000000/0 Income level other than FPG (describe In Section C) '7 Asset level '7 Medical Indigency '7 Insurance status '7 Underinsurance discount 9 '7 ReSIdency Other (describe In Section C) 14 Explained the baSIs for calculating amounts charged to patientsExplained the method for applying forfinanCIal a55istanceYes If?Yes,? indicate how the hospital faCIlity?s FAP or FAP application form (Including accompanying Instructions) explained the method for applying for finanCIal as5Istance (check all that apply) a '7 Described the Information the hospital faCIlity may reqUIre an IndIVIdual to prOVIde as part ofhis or her application '7 Described the supporting documentation the hospital faCIlity may reqUIre an IndIVIdual to submit as part ofhis or her application '7 PrOVIded the contact Information of hospital faCIlity staff who can prowde 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 a55istance With FAP applications 6 Other (describe In Section C) 15 Included measures to pubIICIze the policy Within the community served by the hospital faCIlity"Yes," Indicate how the hospital faCIlity publICIzed the policy (check all that apply) I7 The FAP was Widely available on a webSIte (list url) ORG I7 The FAP application form was Widely available on a webSIte (list url) ORG '7 A plain language summary of the FAP was Widely available on a webSIte (list url) ORG '7 The FAP was available upon request and Without charge (in public locations in the hospital faCIlity and by mail) I7 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) 9 '7 Notice ofavailability of the FAP was conspicuously displayed throughout the hospital faCIlity Notified members ofthe community who are most likely to reqUIre finanCIal a55istance about availability of the FAP i '7 Other (describe In Section C) Billing and Collections 17 Did the hospital faCIlity have In place during the tax year a separate billing and collections policy, ora written finanCIal a55istance policy (FAP) that explained all of the actions the hospital faCIlity or other authorized party may take upon 17Yes 18 Check all of the followmg actions against an indiVidual that were permitted underthe hospital faCIlity's p0 C es during the tax year before making reasonable efforts to determine the IndIVIdual?s eligibility under the faCIlity?s FAP '7 Reporting to credit agency(ies) Selling an indiVidual's debt to another party Actions that reqUIre a legal orJudICIal process Other actions (describe In Section C) (DO-DUN None ofthese actions or other Similar actions were permitted Schedule (Form 990) 2014 ScheduleH (Form 990)2014 Page2 Facility Information (continued) MERCY HOSPITAL AND TRAUMA CENTER Name of hospital facility or letter of facility reporting group Yes No 19 Did the hospital or other authorized third party perform any of the followmg actions during the tax year before making reasonable efforts to determine theindIVIdual?s eligibility under the . . . . . . . . . 19 N0 If"Yes," check all actions In which the hospital or a third party engaged Reporting to credit agency(Ies) Selling an IndIVIdual?s debt to another party Actions that reqUIre a legal orJudICIal process Other Similar actions (describe In Section C) 20 Indicate which efforts the hospital or other authorized party made before Initiating any ofthe actions listed (whether or not checked) In line 18 (check all that apply) '7 Notified IndIVIduals ofthe finanCIal aSSIstance policy on admissmn '7 Notified IndIVIduals ofthe finanCIal aSSIstance policy prior to discharge Notified IndIVIduals ofthe finanCIal aSSIstance policy In communications With the IndIVIduals regarding the IndIVIduals? bills Documented Its determination ofwhether IndIVIduals were eligible forfinanCIal aSSIstance underthe hospital finanCIal aSSIstance policy Other (describe In Section C) None ofthese efforts were made 0. Policy Relating to Emergency Medical Care 21 Did the hospital have In place during the tax year a written policy relating to emergency medical care that reqUIred the hospital to prowde, Without discrimination, care for emergency medical conditions to IndIVIduals regardless of their eligibility underthe hospital finanCIal aSSIstance policyIndicate why The hospital did not prOVIde care for any emergency medical conditions The hospital policy was not In writing our!? The hospital limited who was eligible to receive care for emergency medical conditions (describe In Section C) Other (describe In Section C) Charges to Individuals Eligible for Assistance Under the FAP (FA P-Eligible Individuals) 22 Indicate how the hospital determined, during the tax year, the maXImum amounts that can be charged to FAP- eligible IndIVIduals for emergency or other medically necessary care a The hospital used Its lowest negotiated commerCIal insurance rate when calculating the maXImum amounts that can be charged The hospital used the average ofIts three lowest negotiated commerCIal Insurance rates when calculating the maXImum amounts that can be charged The hospital used the Medicare rates when calculating the maXImum amounts that can be charged '7 Other (describe In Section C) 23 During the tax year, did the hospital charge any FAP-eligible indIVIdual to whom the hospital prowded emergency or other medically necessary serVIces more than the amounts generally billed to IndIVIduals who had insurance 23 N0 If"Yes," explain In Section 24 During the tax year, did the hospital charge any FAP-eligible IndIVIdual an amount equal to the gross charge for any . . . . . . . . . . . . . . . . . . . . . . . . . . 24 N0 If"Yes," explain In Section Schedule (Form 990) 2014 ScheduleH (Form 990)2014 Page2 Facility Information (continued) Section B. Facility Policies and Practices (Complete a separate Section for each of the hospital faCIlities orfaCIlity reporting groups listed In Part V, Section A) MERCY WALWORTH HOSPITAL AND MEDICAL CENT Name of hospital facility or letter of facility reporting group Line number of hospital facility, or line numbers of hospital facilities in a facility 2 reporting group (from Part V, Section A): Yes No Community Health Needs Assessment 1 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 yearWas the hospital faCIlity achIred or placed into serVIce as a tax-exempt hospital in the current tax year or the immediately preceding tax year? If?Yes,? prowde details ofthe achISItion in Section . . . . . . 2 No 3 During the tax year or either of the two immediately preceding tax years, did the hospital faCIlity conduct a community health needs assessment If"No," Skip to line 12 . . 3 Yes If indicate what the CHNA report describes (check all that apply) I7 A definition ofthe community served by the hospital faCIlity '7 Demographics of the community '7 EXIsting health care faCIlities and resources Within the community that are available to respond to the health needs of the community I7 How data was obtained I7 The Significant health needs ofthe community '7 Primary and chronic disease needs and other health issues ofuninsured persons, low?income persons, and minority groups 9 I7 The process for identifying and prioritizmg community health needs and serVIceS to meet the community health needs I7 The process for consulting With persons representing the community's interests i Information gaps that limit the hospital faCIlity's ability to assess the community?s health needs Other (describe in Section C) 4 Indicate the tax year the hospital faCIlity last conducted a CHNA 20 13 5 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 ofor expertise in public health? If "Yes," describe in Section how the hospital faCIlity took into account input from persons who represent the community, and identify the persons the hospital faCIlity consulted . . . . . . . . . . . . . . 5 YES 6a Was the hospital faCIlity's CHNA conducted With one or more other hospital faCIlities? If "Yes," list the other hospital faCIlitieSInSectionC 6aYes Was the hospital faCIlity's CHNA conducted With one or more organizations other than hospital faCIlities?? If?Yes,? list the other organizations in Section . . . . . . . . . . . . . . . 5b YES 7 Did the hospital faCIlity make its CHNA report Widely available to the public? . . 7 YES indicate how the CHNA report was made Widely available (check all that apply) a '7 Hospital faCIlity?s webSite (list url) ORG Other webSite (list url) I7 Made a paper copy available for public inspection Without charge at the hospital faCIlity Other (describe in Section C) 8 Did the hospital faCIlity adopt an implementation strategy to meet the Significant community health needs Yes identified through its most recently conducted If"No," skip to line 11 8 9 Indicate the tax year the hospital faCIlity last adopted an implementation strategy 20 13 10 Is the hospital faCIlity's most recently adopted implementation strategy posted on a webSIte? . 10 Yes a If?Yes? (list url) ORG If"No," iS the hospital faCIlity's most recently adopted implementation Strategy attached to this returnDescribe in Section 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 line 12a, did the organization file Form 4720 to report the section 4959 eXCIse taxline 12b, what iS the total amount ofsection 4959 eXCIse tax the organization reported on Form 47 20 for all of its hospital faCIlities? Schedule (Form 990) 2014 ScheduleH (Form 990)2014 Page2 Facility Information (continued) MERCY WALWORTH HOSPITAL AND MEDICAL CENT Name of hospital facility or letter of facility reporting group Yes No Financial Assistance Policy (FAP) Did the hospital faCIlity have In place during the tax year a written finanCIal aSSIstance policy that 13 Explained eligibility criteria forfinanCIal aSSIstance, and whether such aSSIstance Included free or discounted care? 13 Yes If?Yes,? indicate the eligibility criteria explained In the FAP a '7 Federal poverty gmdelines (FPG), With FPG family Income limit for eligibility forfree care of 150 0000000000000/0 and FPG family Income limit for eligibility for discounted care of300 0000000000000/0 Income level other than FPG (describe In Section C) '7 Asset level '7 Medical Indigency '7 Insurance status '7 Underinsurance discount 9 '7 ReSIdency Other (describe In Section C) 14 Explained the baSIs for calculating amounts charged to patientsExplained the method for applying forfinanCIal a55istanceYes If?Yes,? indicate how the hospital faCIlity?s FAP or FAP application form (Including accompanying Instructions) explained the method for applying for finanCIal as5Istance (check all that apply) a '7 Described the Information the hospital faCIlity may reqUIre an IndIVIdual to prOVIde as part ofhis or her application '7 Described the supporting documentation the hospital faCIlity may reqUIre an IndIVIdual to submit as part ofhis or her application '7 PrOVIded the contact Information of hospital faCIlity staff who can prowde 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 a55istance With FAP applications 6 Other (describe In Section C) 15 Included measures to pubIICIze the policy Within the community served by the hospital faCIlity"Yes," Indicate how the hospital faCIlity publICIzed the policy (check all that apply) I7 The FAP was Widely available on a webSIte (list url) ORG I7 The FAP application form was Widely available on a webSIte (list url) ORG '7 A plain language summary of the FAP was Widely available on a webSIte (list url) ORG '7 The FAP was available upon request and Without charge (in public locations in the hospital faCIlity and by mail) I7 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) 9 '7 Notice ofavailability of the FAP was conspicuously displayed throughout the hospital faCIlity Notified members ofthe community Who are most likely to reqUIre finanCIal a55istance about availability of the FAP i '7 Other (describe In Section C) Billing and Collections 17 Did the hospital faCIlity have In place during the tax year a separate billing and collections policy, ora written finanCIal a55istance policy (FAP) that explained all of the actions the hospital faCIlity or other authorized party may take upon 17Yes 18 Check all of the followmg actions against an indiVidual that were permitted underthe hospital faCIlity's during the tax year before making reasonable efforts to determine the IndIVIdual?s eligibility under the faCIlity?s FAP '7 Reporting to credit agency(ies) Selling an indiVidual's debt to another party Actions that reqUIre a legal orJudICIal process Other actions (describe In Section C) (DO-DUN None ofthese actions or other Similar actions were permitted Schedule (Form 990) 2014 ScheduleH (Form 990)2014 Page2 Facility Information (continued) MERCY WALWORTH HOSPITAL AND MEDICAL CENT Name of hospital facility or letter of facility reporting group Yes No 19 Did the hospital or other authorized third party perform any of the followmg actions during the tax year before making reasonable efforts to determine theindIVIdual?s eligibility under the . . . . . . . . . 19 N0 If"Yes," check all actions In which the hospital or a third party engaged Reporting to credit agency(Ies) Selling an IndIVIdual?s debt to another party Actions that reqUIre a legal orJudICIal process Other Similar actions (describe In Section C) 20 Indicate which efforts the hospital or other authorized party made before Initiating any ofthe actions listed (whether or not checked) In line 18 (check all that apply) '7 Notified IndIVIduals ofthe finanCIal aSSIstance policy on admissmn '7 Notified IndIVIduals ofthe finanCIal aSSIstance policy prior to discharge Notified IndIVIduals ofthe finanCIal aSSIstance policy In communications With the IndIVIduals regarding the IndIVIduals? bills Documented Its determination ofwhether IndIVIduals were eligible forfinanCIal aSSIstance underthe hospital finanCIal aSSIstance policy Other (describe In Section C) None ofthese efforts were made 0. Policy Relating to Emergency Medical Care 21 Did the hospital have In place during the tax year a written policy relating to emergency medical care that reqUIred the hospital to prowde, Without discrimination, care for emergency medical conditions to IndIVIduals regardless of their eligibility underthe hospital finanCIal aSSIstance policyIndicate why The hospital did not prOVIde care for any emergency medical conditions The hospital policy was not In writing our!? The hospital limited who was eligible to receive care for emergency medical conditions (describe In Section C) Other (describe In Section C) Charges to Individuals Eligible for Assistance Under the FAP (FA P-Eligible Individuals) 22 Indicate how the hospital determined, during the tax year, the maXImum amounts that can be charged to FAP- eligible IndIVIduals for emergency or other medically necessary care a The hospital used Its lowest negotiated commerCIal insurance rate when calculating the maXImum amounts that can be charged The hospital used the average ofIts three lowest negotiated commerCIal Insurance rates when calculating the maXImum amounts that can be charged The hospital used the Medicare rates when calculating the maXImum amounts that can be charged '7 Other (describe In Section C) 23 During the tax year, did the hospital charge any FAP-eligible indIVIdual to whom the hospital prowded emergency or other medically necessary serVIces more than the amounts generally billed to IndIVIduals who had insurance 23 N0 If"Yes," explain In Section 24 During the tax year, did the hospital charge any FAP-eligible IndIVIdual an amount equal to the gross charge for any . . . . . . . . . . . . . . . . . . . . . . . . . . 24 N0 If"Yes," explain In Section Schedule (Form 990) 2014 Schedule (Form 990) 2014 Page 6 2 Facility Information (continued) Section C. Supplemental Information for Part V, Section B. Prowde descriptions reqwred for Part V, Section B, lines 2, 5, 6a, 6b, 7d, 11, 13b, 13h, 15e, 16i, 18d, 19d, 20e, 21c, 21d, 22d, 23, and 24. If applicable, prowde separate descriptions for each hospital faCIlity in a faCIlity reporting group, de5ignated by faCIlity reporting group letter and hospital faCIlity line number from Part V, Section A etc.) and name of hospital faCIlity. Form and Line Reference Explanation See Additional Data Table Schedule (Form 990) 2014 ScheduleH (Form 990)2014 Page8 2 Facility 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 the organization operate during the tax year? 51 Name and address Type of (describe) 1 See Data Table Schedule (Form 990) 2014 Schedule (Form 990) 2014 Page 9 2 Supplemental Information Prowde the followmg Information 1 2 Required descriptions. Prowde the descriptions reqUIred for Part I, lines 3c, 6a, and 7, Part II and Part lines 2, 3, 4, 8 and 9b 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 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 a55istance underfederal, state, or local government programs or underthe organization?s finanCIal a55istance policy Community information. Describe the community the organization serves, taking into account the geographic area and demographic constituents it serves Promotion of community health. Prowde 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 ofthe community (e open medical staff, community board, use ofsurplus funds, etc) Affiliated health care system. Ifthe organization IS part ofan affiliated health care system, describe the respective roles ofthe organization and its affiliates In promoting the health ofthe communities served 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 IPART I, LINE 6A MERCY HEALTH SYSTEM, CORP (MHS) SUBMITS AN ANNUAL COMMUNITY BENEFIT STATEMENT TO THE WISCONSIN HOSPITAL ASSOCIATION (WHA) PERIODICALLY, IT PUBLISHES A PAMPHLET EXPLAINING THE COMMUNITY BENEFITS THAT THE RELATED ORGANIZATIONS OF MHS PROVIDE TO THE COMMUNITIES THEY SERVE MHS HAS SUPPLIED SUPPLEMENTAL COMMUNITY BENEFIT STATEMENT INFORMATION WITH ITS 990 TAX RETURN SINCE FISCAL YEAR 2006 (TAX FORM 2005) MHS ISSUED A PRESS RELEASE RELATING TO THE HEALTH COMMUNITY BENEFITS AND HAS THE SAME ON ITS WEBSITE, IT FURTHER REFERENCES THE AVAILABILITY REPORT VLVG GEIAIHEIG VLVG DNISH ?Nouvanaa SN GNV sanmaas iNawaAoade 4 319w NI GEIDNEIHEHEIEI HEIHLO EIHVI) ouva SEII woaj GEIAIHEIG SVM ouva swvasoad (JELLSELL HEIHLO GasanawlaaNn 'aava ALIHVHD GEILVIDOSSV SVM ouva ?5 uoneumdxg aoueJaJea aun pue Form and LIne Reference Explanation I, LINE 7G THE SUBSIDIZED HEALTH CARE LINE INCLUDES $3,446,340 OF EXPENSES (COLUMN $1,667,081 OF NET EXPENSES (COLUMN TO THE COSTS OF TRAUMA SURGEONS THESE SURGEONS STAFF THE LEVEL II TRAUMA PROGRAM OF MERCY HEALTH SYSTEM CORP 24/7 MERCY SOUTH - FAMILY PRACTICE CLINIC WAS ALSO INCLUDED IN THIS LINE EXPENSES IN COLUMN TOTALED $3,426,774 AND COLUMN HAD $267,858 OF NET EXPENSES Form and LIne Reference Explanation PARTI LN 7 COHF) BAD DEBT EXPENSE OF $23,755,339 INCLUDED ON FORM 990, PART IX, LINE I EXCLUDED FROM EXPENSES WHEN CALCULATING THE PERCENTAGE IN THIS COLUMN (anoavut S.VEIHV OJ. iHDnoaa 3mm 0353 GNV SiHOdzlEl swam GEIEIN i?lnSElH EIHEIM magmas GNV 1kva smaaw Ema??ma II iHVd' uoneumdxg aoueJaJea aun pue sv GNV (JEILVIAIILSEI 350m ouva 150:) AEI (JEINIIAIHELLEIG iHVd 'z NO GVEI 1? ?Nd uoneumdxg aoueJaJea aun pue s350dand ALIHVHD 303 (131315913333 33v (JVEI 3o NO GEISVEI 3an913 SIHJ. 0/025 LI iv GELLVIAIILSEI SI AEI mom HEldVd a3doad GVH) 3am s.dao:) WEILSAS Aaa3w HDHOHHJ. EIAVH Avw ova 3o EILVWILSEI 1? iHVd' uoneumdxg aoueJaJea aun pue smnoaav 1n3ian00 2303 SI EIAVH SM 0333 11v HElile 033331103 s3wa EIHLHO) SEILVH NEIEIMLEIEI 3:)N3a33310 532330 ova 303 GNV 3n3ian00 >303 3wIadoaddv 3:)N3Ia3dx3 5503 33v303 NO 3:)N3Ia3dx3 5503 30 3H30Nuvmvn3 NI 033331103 353 smnowv EILVWILSEI 35323 530313323 30 03030333 323v 31avn1333a smnoaav ?331in (330:) WEILSAS A333w 30 SI 3N1 A033w - s3iv11133v GNV DNI A333w 30 033mm! I NI 5v) NI >303 SI 32330 0x153 ?7 1? iHVd' uoneumdxg aoueJaJea aun pue vwnvai GNV Aauaw) swedaa aavamaw s.dao:) WEILSAS NO GEISVEI SI aavamaw GNV iHVd 9?8 9 305 VLVG 8 1? iHVd' uoneumdxg aoueJaJea aun pue EIZIS GNV NO GEISVEI EIEI EIHVI) HO GEIGNELLXEI NI EIHVC) ALINHWWOD 80d Adl?lV?b OHM AHVSSEIDEIN ADHEHAI GNV EIHVD 80d EIHVD S.SHW SN GNV ElElzl S.SHW WOEH EIHVI) (SHIAI) Ale?lvnb AEIHLHEIHLEIHM ssa?laavsaa aav OHM 96 1? iHVd' uoneumdxg aoueJaJea aun pue Nouav GNV NO SEIAHEIS Aaa3w iw3/3103wvaw isoa-G33na3a HQ 3333 GNV 303 won/111331330 sm3wmw3a 3313 GNV aomammoa SGEIEIN GNV Ganl AVMGEILINHUIA SiHOdzlEl 3A1iva3dooa GNV 3mm Goo?Ia 5503:) GEIHUA iDElfOHd ss3NIGv3a moam 331Aa3s (13033v EISIMHEIHLO OHM N3wom 303 Aaa3w iv swvasowwvw OJ. 3o AHNEIHDIAI ?va3 (AI S331Aa3s 313m Aaa3w AHNEIHDIAI NI 3333 GHVAHVH NI GNV ?va3 OJ. S331Aa3s GNV ?aw 051v Aau3w SEIDIAHEIS 313m Aaa3w NI 3333 (II A3N3sa3w3 AHVSSEIDEINNH NI Nonnw G3Avs SVH G3Aoadw1 SVH HDVEI ooz a3Ao SEIEIS G3Aa3sa3GNn am 30 33Gow MEIN ina3c1 GNV NDISEIG iN3wNa3A09 1va3033 GNV >m OM 3o nns3a SI SIHJ. GNV OJ. EIHVI) GNV 3333 NI SIHJ. N3do OJ. 3N1 Hill? @33wa Aaa3w 9002 NI 30 am ?a3iN33 ALINHWWOD Aau3w HEILNEII) ALINHWWOD GNV Aaa3w 3o s31dwvx3 3Aa3s SHIAI GNV HHW NI SGEIEIN ss3ssv SHOIHVA sxaom 33v?s GEILVDIGEIG SVH daoa WELLSAS Aaa3w OJ. ADNEIHDIAI x303 3o amend NI GHVAHVH ADHEHN HELSIS daoa WELLSAS Aaa3w 1" iHVd' uoneumdxg aoueJaJea aun pue EIAVH GIV OJ. inOElV NO GEINIVEIJ. EIAVH NI SI NOdn S.ADHEIW EIHV uoneumdxg DUE 5393VH3 A8 sv) 9102 ?08 5 an 17IOZ Ammo 3332\133513 013310301 0/028 ST 0/0617 0v aamam SM 303 SDIHdv3sow30 5330:) IAIELLSAS A333w (EIOZ-ZIOZ HVEIA WOOHDS) 333M If VAEINEIE) 33w NI smaanis 0/009 0/09 EIDVHEIAV GNV 3iv3 (1M) GEIHILLVIAI SIHJ. NI mawmwwamn 303 saumni30330 NI 9N1>i3om SI 30 330mm 3 0301A033 wo33 0333mm Nouvw3 03m 333005 AHVGNODEIS snsmaa sums (13?an GNV 311803 30 ALISHEIAINH '5333005 ALEIIHVA wo33 VLVG WELLSAS A3330: ?530039 50303 GNV wo33 @33st VLVG OJ. NOILIGGV NI SGNEIEIJ. 31Hdv390w30 GNV 303 GNV 333M srmsa3 haw?mam 333M 5350103533 EIDNO 882) 03A13333 %17 wo33 03A13333 350103533 3 musajn 31N03H3 '3311 AiI?Ivnb '3333 553333 s338waw 0002 03i0813i510 Ska/x305 313wvs woan3 3 Ci 533IVNNousanb 33 WEILSAS A333w SEIDIAHEIS 4/172 5301A033 SGEIEI 92 303 3 SI NI SI HDIHM IM VAEINEIE) 3331 NI 03wao1 SI 333M NI smaanis 30 0/009 3mm 0/06 17I 39v33/w 5531 ms 'O/os ZI EIDVHEIAV NVHJ. 339331 >003 0/09 SI ?ZIoz NI 30 Nvmaw GNV SI HDIHM 3303 NI 918?09$ awoam Nvmaw '0/09 A GNV %0 333M 0/09 8 3303 NI wv39033 ADNEIGISEIH DNIHDVEIJ. 3 SI II vwnv3i ,1le SVH SGEIEI Elian 0172 303 03501311 SI NI 333:) EILHDV omuo EINO SI SIEIELLNEII) A3330: 17 uoneumdxg DUE ALIHOEVW Vle AGOEI SVH SHIAI SVEIEIV NI sasa?nmad jaws ?Ivamaw NV SVH daoa WELLSAS 9 1" iHVd' uoneumdxg aoueJaJea aun pue GNV GEIGNELLXEI SEINO HIEIHJ. EIEIV HDIHM NI EISFIOH NI DNIGEIEIN GNV EIEIV GNV NI SHIN NI SV SADHEIIN SiHOddnS SIHJ. EIVEIA EIVGNEFIVI) NI IEVI SI DNI ADHEIIN SEIVEIA EIEIHHJ. EIHIHVEIA 062 EIDVHEIAV NV SHEIJJEIHS MON NI SSEINSSEFIEIINOH INEIINOM ADHEIIN NI OJ. ADHEIIN SMEIONI SHIN SV GNV SHIN OJ. EIEIVI) EIING EIINOH EIHVC) GELLSISSV ADHEIIN AHNEIHDIN NI SEIDIAHEIS EIEIVI) ELLIIDV GHVAEIVH ADHEIIN DNI EIHVI) GELLSISSV ADHEIIN (JNVI DNI GEIVAEIVH ADHEIIN ISHIN SI DNI ADHEIIN SNOIIVZINVDHO SI GNV GEIIVHDELLNI iHVd SI SHIN GNV NI SEIDIAHEIS EIHVI) ELLIIDV OMJ. SVH (SHIN) ADHEIIN 9 uoneu9 dx3 DUE Fornmanlene Reference Expmnanon PART VI, LINE 7, REPORTS FILED WITH STATES I Que?.3 wee no?: Additional Data Software ID: Software Version: EIN: Name: 39-0816848 MERCY HEALTH SYSTEM CORPORATION Form 990 Part Section Supplemental Information for Part V, Section B. Section C. Supplemental Information for Part V, Section B.Prowde descriptions reqwred for Part V, Section B, lines 3, 4, 5d, 7, 10, 11, 12i, 14g, 16e, 17e, 18e, 19c, 19d, 20d, 21, and 22. If applicable, prOVIde separate descriptions for each faCIlity in a faCIlity reporting group, de5ignated by "FaCIlity "FaCIlity etc. Form and Line Reference Explanation IMERCY HOSPITAL AND TRAUMA CENTER PART V, SECTION B, LINE 5 MERCY HEALTH SYSTEM CORP OUT TO GATHER INFORMATION ON THE COMMUNITY OF ROCK MHS COLLABO RATED WITH BELOIT HEALTH SYSTEM, ROCK COUNTY HEALTH DEPARTMENT, UNIVERSITY OF WISCONSIN - EXTENSION ROCK COUNTY, ROCK COUNTY, HEALTHNET OF ROCK COUNTY, EDGERTON HOSPITAL AND HEALTH SERVICES, SSM HEALTHCARE OFWISCONSIN THE GROUP GATHERED INFORMATION THROUGH HOUSEHOLD SURVEYS AND SECONDARY DATA SOURCES MHS DISTRIBUTED HEALTH QUESTIONNAIRES TO A RANDOM SAMPLE OF ROCK COUNTY RESIDENTS THE FIFTY QUESTION SURVEY WAS DISTRIBUTED TO 2,000 MEMBERS OFTHE COMMUNITY AND COVERED VARIOUS TOPICS, INCLUDING ACCESS TO CARE, QUALITY OF LIFE, CHRONIC LIFESTYLE FACTORS A RESPONSE WAS RECEIVED FROM 32 8% OF HOUSEHOLDS THAT RECEIVED THE SURVEY IN ADDITION TO THE DATA GATHERED FROM HOUSEHOLD SURVEYS AND FOCUS GROUPS, MHS ANALYZED HEALTH-RELATED DATA FROM A VARIETY OF EXISTING SOURCES, INCLUDING WISCONSIN COUNTY HEALTH DEPARTMENT OFTRANSPORTATION, DEPARTMENT OF DEPARTMENT OF HEALTH SERVICES, CENSUS OTHERS SECONDARY SOURCE COMBINED WITH THE INFORMATION GATHERED FROM THE HOUSEHOLD SURVEYS, PROVIDED A PICTURE OFWHAT IS WORKING WELL IN ADDITION TO IDENTIFYING OPPORTUNITIES FOR IMPROVEMENT FORTHE HEALTHCARE INFRASTRUCTURE OF ROCK COUNTY AND THE COMMUNITY AS A WHOLE Form 990 Part Section Supplemental Information for Part V, Section B. Section C. Supplemental Information for Part V, Section B.Prowde descriptions reqwred for Part V, Section B, lines 3, 4, 5d, 7, 10, 11, 12i, 14g, 16e, 17e, 18e, 19c, 19d, 20d, 21, and 22. If applicable, prOVIde separate descriptions for each faCIlity in a faCIlity reporting group, de5ignated by "FaCIlity "FaCIlity etc. Form and Line Reference Explanation IMERCY WALWORTH HOSPITAL AND MEDICAL CENT PART V, SECTION B, LINE 5 MERCY HEALTH SYSTEM CORP (MHS) DISTRIBUTED HEALTH QUESTIONNAIRES TO A RANDOM SAMPLE OFWALWORTH COUNTY RESIDENTS THE SURVEY, DISTRIBUTED TO 2000 MEMBERS OF THE COMMUNITY, COVERED VARIOUS TOPICS, INCLUDING ACCESS TO CARE, QUALITY OF LIFE, CHRONIC LIFESTYLE FACTORS A RESPONSE WAS RECEIVED FROM 14 4% OF HOUSEHOLDS THAT RECEIVED THE SURVEY (288 SURVEYS) ONCE THE SURVEY RESPONSES WERE SURVEY RESULTS WERE EVALUATED AND ANALYZED FOR HEALTH AND DEMOGRAPHIC TRENDS IN ADDITION TO THE DATA GATHERED FROM HOUSEHOLD SURVEYS AND FOCUS GROUPS, MHS ANALYZED HEALTH-RELATED DATA FROM A VARIETY OF EXISTING SOURCES, INCLUDING THE UNIVERSITY OF WISCONSIN POPULATION HEALTH INSTITUTES COUNTY HEALTH DEPARTMENT OF PUBLIC THE UNITED STATES CENSUS BUREAU SECONDARY SOURCE COMBINED WITH THE INFORMATION GATHERED FROM THE HOUSEHOLD SURVEYS, PROVIDED A PICTURE OFWHAT IS WORKING WELL IN ADDITION TO IDENTIFYING OPPORTUNITIES FOR IMPROVEMENT FORTHE HEALTHCARE INFRASTRUCTURE OF WALWORTH COUNTY Form 990 Part Section Supplemental Information for Part V, Section B. Section C. Supplemental Information for Part V, Section B.Prowde descriptions reqwred for Part V, Section B, lines 3, 4, 5d, 7, 10, 11, 12i, 14g, 16e, 17e, 18e, 19c, 19d, 20d, 21, and 22. If applicable, prOVIde separate descriptions for each faCIlity in a faCIlity reporting group, de5ignated by "FaCIlity "FaCIlity etc. Form and Line Reference Explanation MERCY HOSPITAL AND TRAUMA CENTER SERVICES, SSM HEALTHCARE OF WI PART V, SECTION B, LINE 6A BELOIT HEALTH SYSTEM, EDGERTON HOSPITAL AND HEALTH Form 990 Part Section Supplemental Information for Part V, Section B. Section C. Supplemental Information for Part V, Section B.Prowde descriptions reqwred for Part V, Section B, lines 3, 4, 5d, 7, 10, 11, 12i, 14g, 16e, 17e, 18e, 19c, 19d, 20d, 21, and 22. If applicable, prOVIde separate descriptions for each faCIlity in a faCIlity reporting group, de5ignated by "FaCIlity "FaCIlity etc. Form and Line Reference Explanation MERCY WALWORTH HOSPITAL ND MEDICAL CENT PART V, SECTION B, LINE 6A AURORA LAKELAND MEDICAL CENTER Form 990 Part Section Supplemental Information for Part V, Section B. Section C. Supplemental Information for Part V, Section B.Prowde descriptions reqwred for Part V, Section B, lines 3, 4, 5d, 7, 10, 11, 12i, 14g, 16e, 17e, 18e, 19c, 19d, 20d, 21, and 22. If applicable, prOVIde separate descriptions for each faCIlity in a faCIlity reporting group, de5ignated by "FaCIlity "FaCIlity etc. Form and Line Reference Explanation IMERCY HOSPITAL AND TRAUMA CENTER ROCK COUNTY HEALTH DEPARTMENT PART V, SECTION B, LINE 68 ROCK COUNTY HEALTH DEPARTMENT, UNIVERSITY OF WISCONSIN - EXTENSION ROCK COUNTY, ROCK COUNTY, HEALTH NET OF ROCK COUNTY, Form 990 Part Section Supplemental Information for Part V, Section B. Section C. Supplemental Information for Part V, Section B.Prowde descriptions reqwred for Part V, Section B, lines 3, 4, 5d, 7, 10, 11, 12i, 14g, 16e, 17e, 18e, 19c, 19d, 20d, 21, and 22. If applicable, prOVIde separate descriptions for each faCIlity in a faCIlity reporting group, de5ignated by "FaCIlity "FaCIlity etc. Form and Line Reference Explanation PART V, SECTION B, LINE 6B DEPARTMENT OF HEALTH AND HUMAN SERVICES (DHHS), PUBLIC HEALTH, MEDICAL COLLEGE OF WISCONSIN (WALWORTH COUNTY PUBLIC HEALTH STUDENT), DENTAL PERFECTIONS, DUNCAN MEDICATION SERVICES LLC, ROCK-WALWORTH COMMUNITY ACTION, ST BENEDICT CHURCH, UW-EXTENSION, GODFREY, LEIBSLE, BLACKBURN, HOWARTH ELKHORN SCHOOLS, GATEWAY TECHNICAL COLLEGE, AURORA HEALTH CARE EAST TROY, COMMUNITY HEALTH SYSTEMS INC WALWORTH COUNTY JOB CENTER, FORT HEALTH CARE, ROCK-WALWORTH COMPREHENSIVE FAMILY SERVICES, UW-WHITEWATER, VIP SERVICES INC UNIV HEALTH CENTER, FAMILY LIVING EDUCATOR, UW-EXTENSION, PARENT CONNECTIONS-ELKHO RN SCHOOL DISTRICT, LAKELAND ANIMAL SHELTER, FRANKLIN HEALTH DEPARTMENT, BENEFIT CONCEPTSINC SMILE IMERCY WALWORTH HOSPITAL AND MEDICAL CENT 5311Nn00 13130111111111 0Nv>1003 NI 113311133 311105 333 GNV 3333 H0003H1 0330511035 103311'53133 131111313 111 50N1N33305 33330 01331115 1103311 GNV 5310113011 1111an1100 1311/11 533N1333 1103311 30 VEIHV 3H1 NI 01111-10 1v1N30 3333 1111101033 3131 01531H5305N035 GNV 51Nv30 1v33N30 H0003H1 0301A033 0N135 33v 531N011 '33v0 1311130 30 VEIHV 3131 NI 100 031103 33H13n3 0N135 33v 0113(9102 '02 3Nnr - 5102 '1 mnr3v31 1110513) 5102 311311 x31 0111300 303 031n031?105 33v 53A1103150 3531-11 5311Nn00 1113011113111 0Nv>1003 NI 11330-11130 011511nv 30 0151Nv30 5301A335 GNV 1N31131n03 0Nv'N011v0nc135111111331303 5111130033 13033115 11511nv 353330111 01 035115 33011 MEIN 11033 DNINIVE) NI 1035530005 GNV NI N011v0Nn03 11 1311/11 0333N13v3 SVH 1103311 N011v0n<13 GNV 1131133131 1N311v31n0 303 11110113110 131101110011 011115 01 131131111 1103311?35053 30Nv15505 0N15v33030 01111 13033n5 11511nv'33v0 13113313 13111311 01 03111-133 53A1103150 30 VEIHV 3H1 NI 5111130033 3531-11 0N11011033 5311Nn00 H105 NI 530N310nv 01 03103310 511330033 DNISILHEIAGV GNV 011113331111 03535 011035 3311 5130333 3531-1130113 511330033 1101135530 011130115 NI 3111310113113 0153311013113 3131-11303 5301A033 051v 1103311 5311Nno0 NI 510131510 3330 113311133 333 01110115 GNV 3333 01 50N1N33305 0333330 035115 1311111 NI GNV 3n0 1v 50N1N33305 3333 0301/1033 '531113 13113313 1111an1100 5n03311nN NI 03111310113113 11033111510202 3Nnr-1102 '1 11101311311 11-10513) 1102 31/311 xv130 353n00 3H1 0N13n<1 5310313315 353H130 ?In355300n5 1351131100011 01 01111 3003 NI 035115 31311?m11 5331113113 1103311 5311Nn00 1113011113111 GNV 3003 NI 5311130133 33v 511330033 01111 1101130003 11115350 0N11303dns '553N33vmv N015N3133311H 0N11011033 51111-13 511100 "1103 01 1103311 N0110v SGEIEIN 1111an1100 GNV 3003 3H1 1N31515N00 11 ?5 N011035 13113 uoneu2 dx3 au11 pue u110: '01s Amman A11 10e: ? Aq pa1eu?lsap ?anJ? @1102; q0ea 10,1 5u011du0sap aqemdes 'a qe0l dd211 'zz pue ?12 ?p02 ?p61 ?061 ?081 ?eg ?091 ?6171 ?01 ?1 ?19 ?pg ?17 ?9 sauu ?g u0110es 119d .10; pameaJ 5u011du0sep apIAOJd'g uonaas ?ed .10; uonewJowI e:uawa ddns '3 uonaas '9 uonaas ?ed .10; uonewJowI 3 uonaas A ?ed 055 5311Nn00 13130111111111 0Nv>1003 NI 113311133 311105 333 GNV 3333 H0003H1 0330511035 103311'53133 131111313 111 50N1N33305 33330 01331115 1103311 GNV 5310113011 1111an1100 1311/11 533N1333 1103311 30 VEIHV 3H1 NI 01111-10 1v1N30 3333 1111101033 3131 01531H5305N035 GNV 51Nv30 1v33N30 H0003H1 0301A033 0N135 33v 531N011 '33v0 1311130 30 VEIHV 3131 NI 100 031103 33H13n3 0N135 33v 0113(9102 '02 3Nnr - 5102 '1 mnr3v31 1110513) 5102 311311 x31 0111300 303 031n031?105 33v 53A1103150 3531-11 5311Nn00 1113011113111 0Nv>1003 NI 11330-11130 011511nv 30 0151Nv30 5301A335 GNV 1N31131n03 0Nv'N011v0nc135111111331303 5111130033 13033115 11511nv 353330111 01 035115 33011 MEIN 11033 DNINIVE) NI 1035530005 GNV NI N011v0Nn03 11 1311/11 0333N13v3 SVH 1103311 N011v0n<13 GNV 1131133131 1N311v31n0 303 11110113110 131101110011 011115 01 131131111 1103311?35053 30Nv15505 0N15v33030 01111 13033n5 11511nv'33v0 13113313 13111311 01 03111-133 53A1103150 30 VEIHV 3H1 NI 5111130033 3531-11 0N11011033 5311Nn00 H105 NI 530N310nv 01 03103310 511330033 DNISILHEIAGV GNV 011113331111 03535 011035 3311 5130333 3531-1130113 511330033 1101135530 011130115 NI 3111310113113 0153311013113 3131-11303 5301A033 051v 1103311 5311Nno0 NI 510131510 3330 113311133 333 01110115 GNV 3333 01 50N1N33305 0333330 035115 1311111 NI GNV 3n0 1v 50N1N33305 3333 0301/1033 '531113 13113313 1111an1100 5n03311nN NI 03111310113113 11033111510202 3Nnr-1102 '1 11101311311 11-10513) 1102 31/311 xv130 353n00 3H1 0N13n<1 5310313315 353H130 ?In355300n5 1351131100011 01 01111 3003 NI 035115 31311?m11 5331113113 1103311 5311Nn00 1113011113111 GNV 3003 NI 5311130133 33v 511330033 01111 1101130003 11115350 0N11303dns '553N33vmv N015N3133311H 0N11011033 51111-13 511100 "1103 01 1103311 N0110v SGEIEIN 1111an1100 WED GNV GNV 3003 3H1 1N31515N00 11 ?5 N011035 13113 uoneu2 dx3 au11 pue u110: '01s Amman A11 10e: ? Aq pa1eu?lsap ?anJ? @1102; q0ea 10,1 5u011du0sap aqemdes 'a qe0l dd211 'zz pue ?12 ?p02 ?p61 ?061 ?081 ?eg ?091 ?6171 ?01 ?1 ?19 ?pg ?17 ?9 sauu ?g u0110es 119d .10; pameaJ 5u011du0sep apIAOJd'g uonaas ?ed .10; uonewJowI e:uawa ddns '3 uonaas '9 uonaas ?ed .10; uonewJowI 3 uonaas A ?ed 055 Form 990 Part Section Supplemental Information for Part V, Section B. Section C. Supplemental Information for Part V, Section B.Prowde descriptions reqwred for Part V, Section B, lines 3, 4, 5d, 7, 10, 11, 12i, 14g, 16e, 17e, 18e, 19c, 19d, 20d, 21, and 22. If applicable, prOVIde separate descriptions for each faCIlity in a faCIlity reporting group, de5ignated by "FaCIlity "FaCIlity etc. Explanation PART V, SECTION B, LINE 16I AVAILABLE THROUGH PATIENT FINANCIAL COUNSELO RS MERCY HOSPITAL AND TRAUMA CENTER WHO DO PRE- OR POST-FO LLOW UP WITH SELF-PAY PATIENTS Form and Line Reference Form 990 Part Section Supplemental Information for Part V, Section B. Section C. Supplemental Information for Part V, Section B.Prowde descriptions reqwred for Part V, Section B, lines 3, 4, 5d, 7, 10, 11, 12i, 14g, 16e, 17e, 18e, 19c, 19d, 20d, 21, and 22. If applicable, prOVIde separate descriptions for each faCIlity in a faCIlity reporting group, de5ignated by "FaCIlity "FaCIlity etc. Form and Line Reference Explanation MERCY WALWORTH HOSPITAL ND MEDICAL CENT PART V, SECTION B, LINE 16I AVAILABLE THROUGH PATIENT FINANCIAL COUNSELO RS WHO DO PRE- OR POST-FO LLOW UP WITH SELF-PAY PATIENTS Form 990 Part Section Supplemental Information for Part V, Section B. Section C. Supplemental Information for Part V, Section B.Prowde descriptions reqwred for Part V, Section B, lines 3, 4, 5d, 7, 10, 11, 12i, 14g, 16e, 17e, 18e, 19c, 19d, 20d, 21, and 22. If applicable, prOVIde separate descriptions for each faCIlity in a faCIlity reporting group, de5ignated by "FaCIlity "FaCIlity etc. Explanation PART V, SECTION B, LINE 22D THE HOSPITAL FACILITY USED THE AVERAGE COMMERCIAL MERCY HOSPITAL AND TRAUMA CENTER CHARGE Form and Line Reference Form 990 Part Section Supplemental Information for Part V, Section B. Section C. Supplemental Information for Part V, Section B.Prowde descriptions reqwred for Part V, Section B, lines 3, 4, 5d, 7, 10, 11, 12i, 14g, 16e, 17e, 18e, 19c, 19d, 20d, 21, and 22. If applicable, prOVIde separate descriptions for each faCIlity in a faCIlity reporting group, de5ignated by "FaCIlity "FaCIlity etc. Form and Line Reference Explanation MERCY WALWORTH HOSPITAL ND MEDICAL CENT CHARGE PART V, SECTION B, LINE 22D THE HOSPITAL FACILITY USED THE AVERAGE COMMERCIAL Form 990 Part Section Supplemental Information for Part V, Section B. Section C. Supplemental Information for Part V, Section B.Prowde descriptions reqwred for Part V, Section B, lines 3, 4, 5d, 7, 10, 11, 12i, 14g, 16e, 17e, 18e, 19c, 19d, 20d, 21, and 22. If applicable, prOVIde separate descriptions for each faCIlity in a faCIlity reporting group, de5ignated by "FaCIlity "FaCIlity etc. Form and Line Reference Explanation FINANCIAL ASSISTANCE POLICY WEBSITE AVAILABILITY IPART V, SECTION B, LINE l6 Form 990 Part Section Supplemental Information for Part V, Section B. Section C. Supplemental Information for Part V, Section B.Prowde descriptions reqwred for Part V, Section B, lines 3, 4, 5d, 7, 10, 11, 12i, 14g, 16e, 17e, 18e, 19c, 19d, 20d, 21, and 22. If applicable, prOVIde separate descriptions for each faCIlity in a faCIlity reporting group, de5ignated by "FaCIlity "FaCIlity etc. Form and Line Reference Explanation IMERCY HOSPITAL AND TRAUMA ORG CENTER PART v, SECTION B, LINE 16A WEBSITE Form 990 Part Section Supplemental Information for Part V, Section B. Section C. Supplemental Information for Part V, Section B.Prowde descriptions reqwred for Part V, Section B, lines 3, 4, 5d, 7, 10, 11, 12i, 14g, 16e, 17e, 18e, 19c, 19d, 20d, 21, and 22. If applicable, prOVIde separate descriptions for each faCIlity in a faCIlity reporting group, de5ignated by "FaCIlity "FaCIlity etc. Form and Line Reference Explanation IMERCY HOSPITAL AND TRAUMA ORG CENTER PART v, SECTION B, LINE 168 WEBSITE Form 990 Part Section Supplemental Information for Part V, Section B. Section C. Supplemental Information for Part V, Section B.Prowde descriptions reqwred for Part V, Section B, lines 3, 4, 5d, 7, 10, 11, 12i, 14g, 16e, 17e, 18e, 19c, 19d, 20d, 21, and 22. If applicable, prOVIde separate descriptions for each faCIlity in a faCIlity reporting group, de5ignated by "FaCIlity "FaCIlity etc. Form and Line Reference Explanation IMERCY HOSPITAL AND TRAUMA ORG CENTER PART v, SECTION B, LINE 16C WEBSITE Form 990 Part Section Supplemental Information for Part V, Section B. Section C. Supplemental Information for Part V, Section B.Prowde descriptions reqwred for Part V, Section B, lines 3, 4, 5d, 7, 10, 11, 12i, 14g, 16e, 17e, 18e, 19c, 19d, 20d, 21, and 22. If applicable, prOVIde separate descriptions for each faCIlity in a faCIlity reporting group, de5ignated by "FaCIlity "FaCIlity etc. Form and Line Reference Explanation IMERCY WALWORTH HOSPITAL AND MEDICAL CENT PART V, SECTION B, LINE 16A WEBSITE ORG Form 990 Part Section Supplemental Information for Part V, Section B. Section C. Supplemental Information for Part V, Section B.Prowde descriptions reqwred for Part V, Section B, lines 3, 4, 5d, 7, 10, 11, 12i, 14g, 16e, 17e, 18e, 19c, 19d, 20d, 21, and 22. If applicable, prOVIde separate descriptions for each faCIlity in a faCIlity reporting group, de5ignated by "FaCIlity "FaCIlity etc. Form and Line Reference Explanation IMERCY WALWORTH HOSPITAL AND MEDICAL CENT PART V, SECTION B, LINE 165 WEBSITE ORG Form 990 Part Section Supplemental Information for Part V, Section B. Section C. Supplemental Information for Part V, Section B.Prowde descriptions reqwred for Part V, Section B, lines 3, 4, 5d, 7, 10, 11, 12i, 14g, 16e, 17e, 18e, 19c, 19d, 20d, 21, and 22. If applicable, prOVIde separate descriptions for each faCIlity in a faCIlity reporting group, de5ignated by "FaCIlity "FaCIlity etc. Form and Line Reference Explanation IMERCY WALWORTH HOSPITAL AND MEDICAL CENT PART V, SECTION B, LINE 16C WEBSITE ORG Form 990 Schedule H, Part Section D. Other Facilities That Are Not Licensed, Registered, or Similarly Recognized as a Hospital Facility Section D. Other Health Care Facilities That Are Not Licensed, Registered, or Similarly Recognized as a Hospital Facility (list In order of snze, from largest to smallest) How many non-hospital health care dId the organization operate during the tax year? Name and address Type of (describe) MERCY MANOR TRANSITION CENTER SKILLED CARE FACILITY 1000 MINERAL POINT AVENUE 53548 MERCY REGIONAL CANCER CENTER SKILLED CARE FACILITY 1000 MINERAL POINT AVENUE 53548 HOUSE OF MERCY HOMELESS SHELTER SKILLED CARE FACILITY 320 LINCOLN STREET 53548 MERCY ALGONQUIN MEDICAL CENTER SKILLED CARE FACILITY 2401 HARNISH DRIVE SUITE 101 60102 MERCY BARIATRIC WELLNESS CENTER SKILLED CARE FACILITY 250 CENTER DRIVE SUITE 201 VERNON 60061 MERCY BARRINGTON MEDICAL CENTER SKILLED CARE FACILITY 500 WEST HIGHWAY 22 60010 MERCY BELOIT MEDICAL CENTER SKILLED CARE FACILITY 2825 PRAIRIE AVENUE 53511 MERCY BRODHEAD MEDICAL CENTER SKILLED CARE FACILITY 2310 FIRST CENTER AVENUE 53520 MERCY CENTER FOR CORRECTIVE EYE SURGERY SKILLED CARE FACILITY 5400 ELM STREET SUITE 120 60050 MERCY CENTER FOR CORRECTIVE EYE SURGERY SKILLED CARE FACILITY 8780 WGOLF ROAD STE 304 60714 MERCY CLINIC EAST SKILLED CARE FACILITY 3524 EAST MILWAUKEE STREET 53546 MERCY CLINIC EAST PHARMACY SKILLED CARE FACILITY 3524 EAST MILWAUKEE STREET 53546 MERCY CLINIC SOUTH SKILLED CARE FACILITY 849 KELLOGG AVENUE 53546 MERCY CLINIC WEST SKILLED CARE FACILITY 1000 MINERAL POINT AVENUE 53548 MERCY CLINIC WEST PHARMACY SKILLED CARE FACILITY 1000 MINERAL POINT AVENUE 53548 Form 990 Schedule H, Part Section D. Other Facilities That Are Not Licensed, Registered, or Similarly Recognized as a Hospital Facility Section D. Other Health Care Facilities That Are Not Licensed, Registered, or Similarly Recognized as a Hospital Facility (list In order of snze, from largest to smallest) How many non-hospital health care dId the organization operate during the tax year? Name and address Type of (describe) MERCY LAKE CHIROPRACTIC AND REHA SKILLED CARE FACILITY 330 WTERRA COTTA ROAD RTE 176 60014 MERCY LAKE MEDICAL CENTER EAST SKILLED CARE FACILITY 390 CONGRESS PARKWAY 60014 MERCY LAKE MEDICAL CENTER WEST SKILLED CARE FACILITY 350 CONGRESS PARKWAY 60014 MERCY LAKE OBGYN SKILLED CARE FACILITY 750 TERRA COTTA STE 60014 MERCY LAKE MEDICAL CENTER SOUTH SKILLED CARE FACILITY 415-A CONGRESS PARKWAY 60014 MERCY DELAVAN MEDICAL CENTER SKILLED CARE FACILITY 1038 GENEVA ST 53115 MERCY EDGERTON MEDICAL CENTER SKILLED CARE FACILITY 217 MAIN STREET 53534 MERCY EVANSVILLE MEDICAL CENTER SKILLED CARE FACILITY 300 UNION STREET 53536 MERCY HARVARD CLINIC SOUTH SKILLED CARE FACILITY 348 DIVISION 60033 MERCY HEALTH MALL SKILLED CARE FACILITY 1010 NORTH WASHINGTON 53548 MERCY HEALTH MALL PHARMACY SKILLED CARE FACILITY 1010 NORTH WASHINGTON 53548 MERCY LAKE GENEVA MEDICAL CENTER SKILLED CARE FACILITY 350 PELLER ROAD LAKE 53147 MERCY LAKESIDE ORTHOPAEDICS SKILLED CARE FACILITY 352 PELLER ROAD LAKE 53147 MERCY MCHENRY INTERNAL MEDICINE CENTER SKILLED CARE FACILITY 633 RIDGEVIEW DRIVE 60050 MERCY MCHENRY MEDICAL CENTER SKILLED CARE FACILITY 3922 MERCY DRIVE 60050 Form 990 Schedule H, Part Section D. Other Facilities That Are Not Licensed, Registered, or Similarly Recognized as a Hospital Facility Section D. Other Health Care Facilities That Are Not Licensed, Registered, or Similarly Recognized as a Hospital Facility (list In order of snze, from largest to smallest) How many non-hospital health care dId the organization operate during the tax year? Name and address Type of (describe) MERCY MILTON MEDICAL CENTER SKILLED CARE FACILITY 725 SOUTH JANESVILLE STREET 53563 MERCY MILTON PHARMACY SKILLED CARE FACILITY 725 SOUTH JANESVILLE STREET 53563 MERCY NORTHWEST GROUP SKILLED CARE FACILITY 47 WEST ACORN LANE LAKE IN THE 601564804 MERCY OPTIONS-COOPERATIVE CHILDCARE INST SKILLED CARE FACILITY 20 EAST COURT STREET 53548 MERCY OPTIONS-JANESVILLE SKILLED CARE FACILITY 903 MINERAL POINT AVENUE 53548 MERCY REGIONAL DIALYSIS CENTER SKILLED CARE FACILITY 903 MINERAL POINT AVENUE 53548 MERCY REGIONAL LUNG CENTER SKILLED CARE FACILITY 903 MINERAL POINT AVENUE 53548 MERCY RICHMOND MEDICAL CENTER SKILLED CARE FACILITY 9715 PRAIRIE RIDGE 60071 MERCY SHARON MEDICAL CENTER SKILLED CARE FACILITY 118 PLAIN STREET 53585 MERCY SPORTS MEDICINE AND REHABILITATION SKILLED CARE FACILITY 557 NORTH WASHINGTON 53548 MERCY TERRACE SKILLED CARE FACILITY 510 TERRACE STREET 53548 MERCY WALWORTH PHARMACY SKILLED CARE FACILITY N2950 STATE ROAD 67 LAKE 53147 MERCY WHITEWATER MEDICAL CENTER SKILLED CARE FACILITY 507 WEST MAIN STREET 53190 MERCY WHITEWATER SPORTS MEDICINE REHAB SKILLED CARE FACILITY 519 WEST MAIN STREET 53190 MERCY WOODSTOCK MEDICAL CENTER SKILLED CARE FACILITY 2000 LAKE AVENUE 60098 Form 990 Schedule H, Part Section D. Other Facilities That Are Not Licensed, Registered, or Similarly Recognized as a Hospital Facility 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? Name and address Type of FaCIlity (describe) MERCY WOODSTOCK PHARMACY SKILLED CARE FACILITY 2000 LAKE AVENUE 60098 MERCY HEALTHCARE CENTER - ALCONQ SKILLED CARE FACILITY 2230 HUNTINGTON DR 60102 MERCY HEALTHCARE CENTER - ELGIN SKILLED CARE FACILITY 750 FLETCHER DR STE 206 60123 HEALTH CENTER - HOFFMAN ESTATES SKILLED CARE FACILITY 1555 BARRINGTON RD STE 2300A HOFFMAN 60169 MERCY ELKHORN MEDICAL CENTER SKILLED CARE FACILITY 839 WISCONSIN ST 53121 MERCYCARE BUILDING SKILLED CARE FACILITY 580 WASHINGTON ST 53548 Iefile GRAPHIC print - DO NOT PROCESS IAs Filed Data - Schedule (Form 990) Depariment of the Treasury Internal Revenue Sen/Ice Name of the organrzatron MERCY HEALTH SYSTEM CORPORATION Compensation Information For certain Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees 39-0816848 Questions Regarding Compensation 1a OMB No 1545-0047 It Complete if the organization answered "Yes" to Form 990, Part IV, line 23. hr Attach to Form 990. Open to P_ublIc it Information about Schedule (Form 990) and its instructions is at (form990. InSPeCtlon Employer identification number Check the approprate box(es) rfthe organrzatron provrded any of the followrng to or for a person Irsted In Form 990, Part VII, Sectron A, Ine 1a Complete Part to provrde any relevant InformatIon these Items FIrst?class or charter travel I7 Housrng allowance or resrdence for personal use Travel for companrons I7 Payments for busrness use of personal resrdence Tax and gross-up payments I7 Health or socral club dues or InItIatIon fees DIscretIonary spendIng account I7 Personal servrces (e mard, chauffeur, chef) Ifany of the boxes In Me 1a are checked, dId the organrzatron followa polrcy payment or rermbursement or provrsron ofall ofthe expenses above? If"No," complete Part to explarn the organrzatron requrre substantratron prIor to or allowrng expenses Incurred by all dIrectors, trustees, of?cers, rncludrng the CEO/Executrve Drrector, the Items checked In Irne 1a? IndIcate thch, Ifany, ofthe followrng the organrzatron used to estabIIsh the compensatron of the organrzatron's CEO/ExecutIve Drrector Check all that apply Do not check any boxes for methods used by a related organrzatron to estabIIsh compensatron of the CEO/Executrve Drrector, but explarn In Part I7 WrItten employment contract I7 Compensatron survey or study I7 Compensatron I7 Independent compensatron consultant I7 Form 990 of other organrzatrons I7 Approval by the board or compensatron DurIng the year, any person Irsted In Form 990, Part VII, Sectron A, Ine 1a respect to the organrzatron or a related organrzatron Recerve a severance payment or change?of?control payment? In, or recere payment from, a supplemental retIrement plan? In, or recere payment from, an equrty-based compensatron arrangement? If"Yes" to any ofIInes 4a-c, Ist the persons and provrde the appIIcabIe amounts for each Item In Part Only 501(c)(3), 501(c)(4), and 501(c)(29) organizations must complete lines 5-9. For persons Irsted In Form 990, Part VII, Sectron A, Irne 1a, dId the organrzatron pay or accrue any compensatron on the revenues of The organrzatron? Any related organrzatron? If"YesPart For persons Irsted In Form 990, Part VII, Sectron A, We 1a, dId the organrzatron pay or accrue any compensatron on the net earnIngs of The organrzatron? Any related organrzatron? If"Yes," to Irne 6a or 6b, In Part For persons Irsted In Form 990, Part VII, Sectron A, Irne 1a, dId the organrzatron provrde any non-fIxed payments not In Ines 5 and 67 If"Yes," In Part Were any amounts reported In Form 990, Part VII, mm or accured pursuant to a contract that was subject to the contract exceptIon In Regulatrons sectIon 53 If"Yes," In If"Yes" to Ine 8, the organrzatron also follow the rebuttable presumptIon procedure In Regulatrons sectIon For Paperwork Reduction Act Notice, see the Instructions for Form 990. Cat No 50053T Schedule (Form 990) 2014 Schedule (Form 990) 2014 Page 2 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 In Schedule J, report compensation from the organization on row and from related organizations, described In the instructions, on row (II) Do not list any that are not lIsted on Form 990, Part VII Note. The sum ofcolumns 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 ofW?Z and/or compensation Base compensation (ii) Bonus incentive compensation Other reportable corn pensatIon (C) Retirement and other deferred compensation (D) Nontaxable benefits (E) Total of columns (F) Compensation In column(B) reported as deferred In prior Form 990 See Additional Data Table Schedule (Form 990) 2014 Schedule (Form 990) 2014 Page 3 Supplemental Information Prowde the Information, explanation, or descriptions reqUIred for Part I, lines 1aand for Part II Also complete this part for any additional Information Ret urn Reference Explanation PART I, LINE 1A RESIDENCE FOR PERSONAL USE - THE CEO IS PROVIDED WITH A RESIDENCE THE COST OF RENTING THE RESIDENCE IS TREATED AS TAXABLE COMPENSATION PAYMENTS FOR BUSINESS USE OF PERSONAL RESIDENCE - THE CEO IS REIMBURSED FOR INTERNET ACCESS AND COMMUNICATION COSTS USED FOR BUSINESS PURPOSES AT HIS PERSONAL RESIDENCE THE REIMBURSEMENT IS TREATED AS TAXABLE COMPENSATION HEALTH CLUB DUES - THE CEO IS REIMBURSED FOR HEALTH CLUB DUES THIS IS TREATED AS TAXABLE COMPENSATION PERSONAL SERVICES - THE CEO IS REIMBURSED FOR INCOME TAX PREPARATION SERVICES THIS IS TREATED AS TAXABLE COMPENSATION Schedule (Form 990) 2014 Additional Data Software ID: Software Version: EIN: 39-0816848 Name: MERCY HEALTH SYSTEM CORPORATION Form 990, Schedule J, Part II - Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees (A) Name and (B) Breakdown of W-2 and/or 1099-MISC compensatlon (C) Retirement and (D) Nontaxable (E) Total ofcolumns (F) compensatlon Base (ii) Bonus Other other deferred bene?ts Compensatlon Incentive reportable compensat'on prlor Form 990 compensatlon compensatlon MARK GOELZER (I) 4531043 0 4714 17160 13 862 488 779 0 DIRECTOR PHYSICIAN (II(I) 138,043 75,288 3,320 14,119 22,844 253,614 0 (II) 0 0 0 0 0 (I) 182,449 82,473 8,970 17,160 13,038 304,090 0 (II(I) 135,957 103,889 14,877 11,346 15,876 281,945 0 (II$233533?! (I) 268,004 140,656 6,281 17,160 22,535 454,636 0 (II(I) 881158 51,942 6,655 8,780 22,036 177,571 0 (II(I) 168,823 91,244 12,929 17,160 7,826 297,982 0 (II) 0 0 0 0 0 (I) 130,941 82,314 12,122 14,517 15,874 255,768 0 (II(I) 1391639 80,675 9,249 14,731 14,221 258,515 0 (II(I) 252,313 132,817 23,382 17,160 17,435 443,107 0 (II) 0 0 0 0 0 (I) 152,798 83,905 4,121 16,082 25,555 282,461 0 (II(I) 2241-270 84,375 12,912 16,037 23,028 360,622 0 (II(I) 1,076,489 3,313,796 3,614,907 17,160 21,625 8,043,977 0 (II) 0 0 0 0 0 (I) 1.3881496 0 828 17,160 27,764 1,434,248 0 (IIMERLE PHYSICIAN (I) 1.2641497 0 828 17,160 27,281 1,309,766 0 (II(I) 1.188367 0 540 17,160 17,607 1,223,674 0 (IICRAIG PHYSICIAN (I) 1.1561217 0 324 17,085 23,419 1,197,045 0 (IIEHRHARDTI (I) 1,097,419 0 360 17,160 11,168 1,126,107 0 (II) 0 0 0 0 0 Iefile GRAPHIC print - DO NOT PROCESS lAs Filed Data - DLN: 93493131020756I Schedule Transactions With Interested Persons OMB 1545'0047 (Form 990 or 99042) II- Complete if the organization answered "Yes" on Form 990, Part IV, lines 25a, 25b, 26, 27, 28a, 28b, or 28c, or Form 990-EZ, Part V, line 38a or 40b. Depailment ofthe Treasury Ir Attach to Form 990 or Form 990-EZ. Open to Public internal Revenue Service II-Information about Schedule (Form 990 or 990-EZ) and its instructions is at Inspection [form990. Name of the organization Employer identification number MERCY HEALTH SYSTEM CORPORATION 39?0816848 Excess Benefit Transactions (section 501(c)(3), section 501(c)(4), and 501(c)(29) organizations only) Complete ifthe organization answered "Yes" on Form 990, Part IV, line 25a or 25b, or Form 990-EZ, Part V, line 40b 1 Name ofdisqualified person Relationship between disqualified Description oftransaction Corrected? person and organization Yes No 2 Enter the amount of tax incurred by organization managers or disqualified persons during the year under section 3 Enter the amount of tax, ifany, on line 2, above, reimbursed by the organization . . . . . . . It Loans to and/or From Interested Persons. Complete ifthe organization answered "Yes" on Form 990-EZ, Part V, line 38a, or Form 990, Part IV, line 26, or ifthe organization reported an amount on Form 990, Part X, line 5, 6, or 22 Name of Relationship Loan to (e)0rigina (f)Ba ance In (i)Written interested With organization Purpose of or from the prinCIpal due default? Approved agreement? person loan organization? amount by board or committeeTotal I I I Grants or Assistance Benefiting Interested Persons. Complete if the organization answered "Yes" on Form 990, Part IV, line 27. Name of interested Relationship between Amount ofa55istance Type ofa55istance Purpose ofa55istance person interested person and the organization For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ. Cat No 50056A Schedule (Form 990 990-52) 2014 Schedule (Form 990 or 990-EZ) 2014 Part IV Business Transactions Involving Interested Persons. Complete if the organization answered "Yes" on Form 990, Part IV, line 28a, 28b, or 28c. Page 2 Name ofinterested person Relationship Amount of Description oftransaction Sharing between interested transaction of person and the organization's organization revenues? Yes No FAMILY MEMBER OF 355,171 EMPLOYMENT-PHYSICIAN No MARK GOELZER, DIRECTOR KURTZ FAMILY MEMBER OF 37,858 EMPLOYMENT-PATIENT No DAVID KURTZ, ACCOUNT REPRESENTATIVE OFFICER BENNING FAMILY MEMBEROF 106,032 EMPLOYMENT-DIRECTOR No JAVON BEA, PRESIDENT DIRECTOR KRAUSE FAMILY MEMBEROF 100,243 EMPLOYMENT-MANAGER No SUE RIPSCH, OFFICER FAMILY MEMBEROF 24,956 No RICHARD GRUBER, OFFICER Part Supplemental Information Prowde additional information for responses to questions on Schedule (see Instructions) Ret urn Reference Expla nation Schedule (Form 990 or 990-EZ) 2014 Iefile GRAPHIC print - DO NOT PROCESS IAs Filed Data - DLN: 93493131020756 OMB No 1545-0047 Supplemental Information to Form 990 or 990-EZ 4 Complete to provide information for responses to specific questions on Form 990 or 990-EZ or to provide any additional information. Open to It Attach to Form 990 or 990-Ez. Inspection h- Information about Schedule 0 (Form 990 or 990-EZ) and its instructions is at Depaiimeni of the Treasury Iniemal Revenue Sen/Ice Name of the organization Employer identification number MERCY HEALTH SYSTEM CORPORATION 39-0816848 990 Schedule 0, Supplemental Information Return Reference Explanation FORM 990, PART VI, SECTION B, MANAGEMENT REVIEWS THE FORM 990 BEFORE FILING AND IT IS AVAILABLE TO THE BOARD OF LINE 11 DIRECTORS FORM 990, PART VI, SECTION B, OFFICERS, DIRECTORS, AND KEY EMPLOYEES ARE REQUIRED TO REPORT ALL CONFLICTS OF LINE 12C INTEREST HE COMPLIANCE OFFICER IS RESPONSIBLE FOR INVESTIGATING ALL CONFLICTS AND REPORTING TO THE BOARD FORM 990, PART VI, SECTION B, THE MERCY ALLIANCE COMPENSATION COMMITTEE IS COMPRISED OF THE BOARD CHAIRPERSON, LINE 15 SECRETARY AND THE TREASURER THE COMPENSATION COMMITTEE IS ASSISTED BY INDEPENDENT LEGAL COUNCIL A ND AN INDEPENDENT COMPENSATION CONSULTANT THE COMPENSATION COMMITTEE LEGAL COUNCIL, AND THE COMPENSATION CONSULTANT THROUGHOUT THE YEAR AND REPORT DIRECTLY TO THE BOARD OF IRECTORS ANNUALLY THIS PROCESS WAS COMPLETED FOR 2014 FORM 990, PART VI, SECTION C, GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY FINANCIAL STATEMENTS ARE LINE 19 AVAILABLE UPON REQUEST FORM 990, PART XI, LINE 9 CHANGES IN PENSION OBLIGATIONS -3,552,000 OTHER 26,396 Iefile GRAPHIC print - DO NOT PROCESS IAs Filed Data - DLN: 93493131020756 SCHEDULE (Form 990) Department of the Treasury Internal Revenue Servrce Related Organizations and Unrelated Partnerships Ir Complete if the organization answered "Yes" on Form 990, Part IV, line 33, 34, 35b, 36, or 37. hr Attach to Form 990. hr Information about Schedule (Form 990) and its instructions is at OMB No 1545-0047 2014 Open to Public Inspection Name of the organrzatron MERCY HEALTH SYSTEM CORPORATION 39-0816848 Identification of Disregarded Entities Complete If the organrzatron answered "Yes" on Form 990, Part IV, lrne 33. Employer identification number Name, address, and EIN (rf of drsregarded Prrmary (C) Legal (state or forergn country) Total Income (6) End?of-year assets (0 Drrect Identification of Related Tax-Exempt Organizations Complete If the organrzatron answered "Yes" on Form 990, Part IV, lrne 34 because It had one or more related tax-exempt organrzatrons durrng the tax year. Name, address, and EIN of related organrzatron Prrmary (C) Legal (state or forergn country) Exem pt Code sectron Publrc charrty status (If sectron 501(c)(3)) Drrect Sectron 512(b) (13) controlled Yes No See Data Table For Paperwork Reduction Act Notice, see the Instructions for Form 990. Cat No 50135Y Schedule (Form 990) 2014 Schedule (Form 990) 2014 Page 2 Identification of Related Organizations Taxable as a Partnership Complete If the organIzatIon answered "Yes" on Form 990, Part IV, Me 34 because It had one or more related organizations treated as a partnershIp durIng the tax year. Name, address, and EIN of PrImary actIVIty Legal DIrect PredomInant Share of Share of DIsproprtIonate Code General or Percentage related organIzatIon domICIle Income(related, total Income end-of-year allocatIons? amount In box managIng ownershIp (state or unrelated, assets 20 of partner? foreIgn excluded from Schedule K-1 country) tax under (Form 1065) sectIons 512? 514) Yes No Y6 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 organlzatIons treated as a corporatIon or trust durIng the tax year. Name, address, and EIN of PrImary actIVIty Legal DIrect Type of Share of total Share of end?of? Percentage Sectlon 512 related organIzatIon d0m C e (C corp, Income year ownershIp (state or foreIgn corp, assets controlled country) or trust) Yes No (1) JANESVILLE MEDICAL MANAGEMENT OF UNION WI MERCY HEALTH 200 100 000 Yes CENTER INC EMPLOYEES SYSTEM CORPORATION 1000 MINERAL POINT AVE JANESVILLE, WI 53548 39-1520130 (2) MERCYCARE INSURANCE INSURANCE WI MERCY HEALTH 101,883,691 46,162,778 100 000 Yes COMPANY SYSTEM CORPORATION 580 WASHINGTON ST JANESVILLE, WI 53546 39?1768192 (3) MERCYCARE HMO INC INSURANCE WI MERCY HEALTH 100 000 0/0 Yes CONSOLIDATED WITH SYSTEM MERCYCARE INSURANCE CO CORPORATION 580 WASHINGTON ST JANESVILLE, WI 53546 20?1482553 (4) ROCKFORD HEALTH INSURANCE BD No INSURANCE LTD WELLESLEY HOUSE SO 2ND FL PEMBROOKE, HM BD Schedule (Form 990) 2014 ScheduleR(Form 990)2014 Page3 Transactions With Related Organizations Complete if the organization answered "Yes" on Form 990, Part IV, line 34, 35b, or 36. Note. Complete line 1 ifany entity is listed In Parts II, or IV ofthis schedule Yes N0 1 During the tax year, did the orgranization engage In any ofthe followmg transactions With one or more related organizations listed In Parts II-IV7 a Receipt of interest, (ii) annUIties, royalties, or (iv) rent from a controlled entity 1a Yes Gift, grant, or capital contribution to related organization(s) 1b Yes Gift, grant, or capital contribution from related organization(s) 1C N0 Loans or loan guarantees to or for related organization(s) 1d N0 Loans or loan guarantees by related organization(s) 19 Yes DiVidends from related organization(s) 1f N0 9 Sale ofassets to related organization(s) lg No Purchase ofassets from related organization(s) 1h N0 i Exchange ofassets With related organization(s) 1i N0 Lease offaCIlities, eqUIpment, or other assets to related organization(s) 1i Yes Lease of faCIlities, eqUIpment, or other assets from related organization(s) 1k Yes I Performance ofserVIces or membership or fundraismg SOIICItations for related organization(s) 1' N0 Performance ofserVIces or membership orfundraismg solimtations by related organization(s) N0 Sharing of faCIlities, eqUIpment, mailing lists, or other assets With related organization(s) 1? Yes 0 Sharing of paid employees With related organization(s) 10 Yes Reimbursement paid to related organization(s) for expenses 1p Yes Reimbursement paid by related organization(s) for expenses 1?1 Yes Other transfer ofcash or property to related organization(s) 1r No 5 Other transfer ofcash or property from related organization(s) 15 N0 2 Ifthe answer to any ofthe above is "Yes," see the instructions for information on who must complete this line, including covered relationships and transaction thresholds (C) Name of related organization Transaction Amount involved Method of determining amount involved type (1) MERCYCARE INSURANCE COMPANY 7,663,492 COST OF SERVICES PROVIDED Schedule (Form 990) 2014 Schedule (Form 990) 2014 Unrelated Organizations Taxable as a Partnership Complete if the organization answered "Yes" on Form 990, Part IV, line 37. Prowde the followmg 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 exclusmn for certain investment partnerships Page 4 Name, address, and EIN of entity Primary actIVIty (C) Legal domICIle (state or foreign country) Predominant Income (related, unrelated, excluded from tax under sections 512? 514) (6) Are all partners section 501(c)(3) organizations? Yes No (D Share of total income (9) Share of end?of-year assets Disproprtionate allocations? Yes No 0) Code amount in box 20 of Schedule (Form 1065) (R) General or Percentage managing ownership partner? Yes No Schedule (Form 990) 2014 Schedule (Form 990) 2014 Page 5 Supplemental Information Prowde additional Information for responses to questions on Schedule (see instructions) Ret urn Reference Explanation Schedule (Form 990) 2014 Additional Data Software ID: Software Version: EIN: 39-0816848 Name: MERCY HEALTH SYSTEM CORPORATION Form 990, Schedule R, Part II Identification of Related Tax-Exempt Organizations (C) Name, address, and EIN of related organization Primary actiVity Legal domICIIe Exempt Code Public charity Direct controlling (state section status entity orforeign (ifsection 501(c) country) (9) Section 5 1 2 controlled entity? ALLIANCE INC 1000 MINERAL POINT AVE JANESVILLE, W153548 39-1679859 SUPPORT OF HEALTHCARE WI LINE MERCYROCKFO RD HEALTH SYSTEM CORPORATION Yes No No FOUNDATION INC 1000 MINERAL POINT AVE JANESVILLE, WI 53548 23-7275336 SUPPORT OF HEALTHCARE WI LINE MERCY HEALTH SYSTEM CORPORATION (2) MERCY HEALTH SYSTEM ASSOCIATION OF VOLUNTEERS 1000 MINERAL POINT AVE JANESVILLE, WI 53548 39-0912682 SUPPORT OF HEALTHCARE WI LINE 11C, MERCY HEALTH SYSTEM CORPORATION (3) MERCY ASSISTED CARE INC 901 MINERAL POINT AVE JANESVILLE, WI 53548 39-1035110 HEALTHCARE WI LINE 9 MERCY ALLIANCE INC HARVARD HOSPITAL INC 901 GRANT STREET HARVARD, IL 60033 31-1551871 HEALTHCARE IL LINE 3 MERCY ALLIANCE INC No MEMORIAL HOSPITAL FOUNDATION 901 GRANT STREET HARVARD, IL 60033 36-4308662 SUPPORT OF HEALTHCARE IL LINE MERCY HARVARD HOSPITAL INC No LAKE HOSPITAL AND MEDICAL CENTER 1000 MINERAL POINT AVE JANESVILLE, WI 535475003 20-1673011 NONE IL LINE 3 MERCY ALLIANCE INC No HEALTH SYSTEM CORPORATION 2400 ROCKTON AVE ROCKFORD, IL 61103 47-2158680 SUPPORT OF HEALTHCARE IL LINE No MEMORIAL HOSPITAL 2400 ROCKTON AVE ROCKFORD, IL 61103 36-2167847 HEALTHCARE IL LINE 3 ROCKFORD HEALTH SYSTEM (9) ROCKFORD HEALTH SYSTEM 2400 ROCKTON AVE ROCKFORD, IL 61103 36-3197915 SUPPORT OF HEALTHCARE IL LINE 11C, MERCYROCKFO RD HEALTH SYSTEM CORPORATION (10) ROCKFORD MEMORIAL DEVELOPMENT FOUNDATION 2400 ROCKTON AVE ROCKFORD, IL 61103 36-3197918 SUPPORT OF HEALTHCARE IL LINE ROCKFORD HEALTH SYSTEM NURSES ASSN OF THE ROCKFORD AREA 4223 STATE STREET ROCKFORD, IL 61108 36-2167945 HEALTHCARE IL LINE 9 ROCKFORD HEALTH SYSTEM (12) ROCKFORD HEALTH PHYSICIANS 2400 ROCKTON AVE ROCKFORD, IL 61103 36-3097436 HEALTHCARE IL LINE 3 ROCKFORD HEALTH SYSTEM No