Schedule J
(Form 990)
Department of the Treasury
Internal Revenue Service
Compensation Information
For certain Officers, Directors, Trustees, Key Employees, and Highest
Compensated Employees
SchJMediumBullet Complete if the organization answered "Yes" to Form 990, Part IV, line 23.
SchJMediumBullet Attach to Form 990. SchJMediumBullet See separate instructions.
SchJMediumBullet Information about Schedule J (Form 990) and its instructions is at www.irs.gov/form990.
OMB No. 1545-0047
2013
Open to Public Inspection
Name of the organization
Lutheran Hosp Assoc of the San Luis Valley
 
Employer identification number

84-0255530
Part I
Questions Regarding Compensation
Yes
No
1a
Check the appropiate box(es) if the organization provided any of the following to or for a person listed in Form
990, Part VII, Section A, line 1a. Complete Part III to provide any relevant information regarding these items.
b
If any of the boxes in line 1a are checked, did the organization follow a written policy regarding payment or reimbursement or provision of all of the expenses described above? If "No," complete Part III to explain
1b
 
 
2
Did the organization require substantiation prior to reimbursing or allowing expenses incurred by all
directors, trustees, officers, including the CEO/Executive Director, regarding the items checked in line 1a? ..
2
 
 
3
Indicate which, if any, of the following the filing organization used to establish the compensation of the
organization's CEO/Executive Director. Check all that apply. Do not check any boxes for methods
used by a related organization to establish compensation of the CEO/Executive Director, but explain in Part III.
4
During the year, did any person listed in Form 990, Part VII, Section A, line 1a with respect to the filing organization or a related organization:
a
Receive a severance payment or change-of-control payment? ................
4a
Yes
 
b
Participate in, or receive payment from, a supplemental nonqualified retirement plan? .........
4b
 
No
c
Participate in, or receive payment from, an equity-based compensation arrangement? .........
4c
 
No
If "Yes" to any of lines 4a-c, list the persons and provide the applicable amounts for each item in Part III.
Only 501(c)(3) and 501(c)(4) organizations only must complete lines 5-9.
5
For persons listed in Form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the revenues of:
a
The organization? ...........................
5a
 
No
b
Any related organization?
5b
 
No
If "Yes," to line 5a or 5b, describe in Part III.
6
For persons listed in Form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the net earnings of:
a
The organization?
6a
 
No
b
Any related organization?
6b
 
No
If "Yes," to line 6a or 6b, describe in Part III.
7
For persons listed in Form 990, Part VII, Section A, line 1a, did the organization provide any non-fixed
payments not described in lines 5 and 6? If "Yes," describe in Part III ............
7
Yes
 
8
Were any amounts reported in Form 990, Part VII, paid or accured pursuant to a contract that was
subject to the initial contract exception described in Regulations section 53.4958-4(a)(3)? If "Yes," describe
in Part III .............................
8
 
No
9
If "Yes" to line 8, did the organization also follow the rebuttable presumption procedure described in Regulations section 53.4958-6(c)? .........................
9
 
 
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50053T
Schedule J (Form 990) 2013
Page 2

Schedule J (Form 990) 2013
Page 2
Part II
Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees. Use duplicate copies if additional space is needed.
For each individual whose compensation must be reported in Schedule J, report compensation from the organization on row (i) and from related organizations, described in the
instructions, on row (ii). Do not list any individuals that are not listed on Form 990, Part VII.
Note. The sum of columns (B)(i)-(iii) for each listed individual must equal the total amount of Form 990, Part VII, Section A, line 1a, applicable column (D) and (E) amounts for that individual.
(A) Name and Title (B) Breakdown of W-2 and/or 1099-MISC compensation (C) Retirement and other deferred compensation (D) Nontaxable
benefits
(E) Total of columns
(B)(i)-(D)
(F) Compensation
reported as deferred
in prior Form 990
(i) Base compensation (ii) Bonus & incentive compensation (iii) Other reportable compensation
1steven w kitchenphysician (i)
(ii)
505,204
 
 
 
3,545
 
12,750
 
18,925
 
540,424
 
 
 
2nuwan pilapitiyaphysician (i)
(ii)
203,058
 
250
 
168
 
10,463
 
17,186
 
231,125
 
 
 
3henry garvincch administrator - former (i)
(ii)
155,845
 
 
 
34,666
 
63,465
 
16,012
 
269,988
 
 
 
4konnie martinceo (i)
(ii)
221,731
 
 
 
481
 
11,495
 
20,292
 
253,999
 
 
 
5robert marshallphysician (i)
(ii)
327,581
 
16,473
 
1,458
 
12,664
 
19,039
 
377,215
 
 
 
6patti thompsoncno (i)
(ii)
155,842
 
 
 
295
 
2,584
 
17,491
 
176,212
 
 
 
7greg mcauliffe mdcmo (i)
(ii)
252,110
 
 
 
1,660
 
12,750
 
20,500
 
287,020
 
 
 
8shane mortensencfo (i)
(ii)
146,199
 
 
 
268
 
7,650
 
16,962
 
171,079
 
 
 
9dennard ellisonphysician (i)
(ii)
390,004
 
 
 
18,499
 
12,311
 
19,039
 
439,853
 
 
 
10david geigerPHYSICIAN (i)
(ii)
337,976
 
17,904
 
19,097
 
12,750
 
18,925
 
406,652
 
 
 
11clifford robbinsPHYSICIAN (i)
(ii)
336,106
0
6,708
0
665
0
12,750
0
8,610
0
364,839
0
0
0
12carissa tripiphysician (i)
(ii)
495,717
 
25,000
 
432
 
3,462
 
12,251
 
536,862
 
 
 
13james grigsbyphysician (i)
(ii)
379,571
 
 
 
19,312
 
5,590
 
9,718
 
414,191
 
 
 
Schedule J (Form 990) 2013
Page 3

Schedule J (Form 990) 2013
Page 3
Part III
Supplemental Information
Provide the information, explanation, or descriptions required for Part I, lines 1a, 1b, 3, 4a, 4b, 4c, 5a, 5b, 6a, 6b, 7, and 8, and for Part II.
Also complete this part for any additional information.
Return Reference Explanation
schedule j, PART I, LINE 4A THE FOLLOWING AMOUNTS LISTED ARE SEVERANCE PAYMENTS: - HENRY GARVIN $90,131 $34,666 of this amount will be reported on henry garvin's 2013 w-2 and $55,465 will be reported on his 2014 w-2.
schedule j, part i, line 7 CLINICAL KEY EMPLOYEES MAY EARN A PRODUCTIVITY BONUS. SENIOR MANAGEMENT IS ELIGIBLE FOR ANNUAL VARIABLE PAY UP TO 35% FOR CEO AND 20% FOR ALL OTHER SENIOR MANAGEMENT BASED UPON CRITERIA INCLUDING HOSPITAL WIDE MEASURES AND POSITION SPECIFIC GOALS. VARIABLE PAY IS AWARED AT THE DISCRETION OF THE BOARD FOR THE CEO AND THE CEO FOR ALL OTHER SENIOR MANAGEMENT.
Schedule J (Form 990) 2013

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