Ambulatory Surgical Facility and Ambulatory Surgery Center

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)-1^ Certificate of Need ^ 20?0?.0'J Determination of

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Ambulatory Surgical Facility and Ambulatory Surgery Center; '^ ^(Do not use this form for any other type of ASC/F project)

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Certificate of Need submissions must include a fee in accordance with WashingtonAdministrative Code (WAC) 246-310-990.

The Department of Health (department) will use this form to determine whether my ambulatory surgicalcenter or facility requires a Certificate of Need under state law and rules. Criteria and considerationused to make the required determinations are Revised Code of Washington (RCW) 70,38 andWashington Administrative Code (WAC) 246-310. I certify that the statements in the submissions arecorrect to the best of my knowledge and belief. I understand that any misrepresentation, misleadingstatements, evasion, or suppression of material fact in this application may be used to take actionsidentified in WAC 246-310-500.

My signature authorizes the department to verify any responses provided. The department will usesuch information as appropriate to further program purposes. The department may disclose thisinformation when requested by a third party to the extent allowed by law.

Owner/Operator Name of the surgical facility as it appears on the UBI/Master Business License

Sight Partners Holdings, LLCClinical Practice UBI #: 604491467

Surgery Center UBI #: 604491467

Mailing Address3405188th SW #303Lynnwood.WA 98037

Federal Tax ID (FEIN)#

83-3467355

Surgery Center Address332NENorthgateWaySeattle, WA 98125

Website Address:www.sightpartners.com & www.nweyes.com

Phone number (10-digit):

800.826.4631Name and Title of Responsible Officer(Print):Lance Baldwin

VP of Operations

Email Address:

lbaldv\[email protected]^Re^ponsible Officer:

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Date<6^STgriattfreT17l\4arch2020

Identify the purpose of your request:D New Facility D Facility Expansion - Operating Room Increase

D Change of Ownership D Facility Expansion - Service Increase

Facility Relocation D Other (please provide a letter describing)

DOH 260-014 June 2019

Existing Facility Status, complete for all applications conperging existing facilities

1. The CN Program previously determined the facility was not subject to CN Revle^/(if yes, attach DOR letter)

^ Yes D No

Surgical Facility Owner/Operator Information

2. Provide a copy of any applicable governance documents, including operatingagreements, shareholder agreements or corporate governing documents.

Facility Information

3. Although you are not required to apply for an ASF license before a CNdetermination is issued, have you or do you intend to, apply for a license?*

^ Yes D No

*Your answer to this question will allow the CN program to effectively coordinatethe licensure process with other DOH offices.

4.

Number of existing operating and procedure rooms:Number of new operating and procedure rooms:

Total:33

Clinical and Surgical Services

aDDvaD

5. Check all surgical procedures currently performed in the facility.Ear, Nose, & Throat DPlastic Surgery DOrthopedics nOphthalmology DOther (describe)This is a new facility, no surgical procedures are currently performed

GynecologyGastroenterologyPodiatryPain Management

aaDn

Oral SurgeryMaxillo facialGeneral SurgeryUrology

Check all new surgical procedures proposed to performed in the facilityD Ear, Nose, & Throat DD Plastic Surgery Da Orthopedics Da Ophthalmoiogy nn Other (describe)

Gynecology DGastroenteroiogy DPodiatry DPain Management a

Oral SurgeryMaxillo facialGeneral SurgeryUrology

DOH 260-014 June 2019

6. A facility that receives more than 50% of their income or 50% of their visits fromsurgeries is subject to CN requirements. In order to determine If your project issubject to CN review, please provide the current (existing facility) or proposed (newfacility) percentages of income and visits for clinical and surgical services. Includeail assumptions used to determine the percentages provided.

Total revenue for clinical servicesprovided at this site.Total revenue for this site.Total clinical patient visits for thissite.

Total surgical visits at this site.Total patient visits at this site.

Most recent full year ofoperation at current

surgica! site

$12,199,800

$17,407,700

22,115

4.60426,719

Projected first full year ofoperation after thechange in location

$12,809,790

$18.278,805

23,220

4,83428,054

DOH 260-014 June 2019

Certificate of Need Program Revised Code of Washington (RCW)and Washington Administrative Code (WAC)

Certificate of Need Program laws RCW 70.38

Certificate of Need Program rules WAC 246-310

WAC Reference

246-310-010

246-310-270

Title/Topic

Certificate of Need Program —Definitions

Certificate of Need Program —Ambulatory Surgery

Licensing Resources:Ambulatory Surgical Facilities Laws, RCW 70.230Ambulatory Surcjical Facilities Rules, WAC 246-330Ambulatory Surqical Facilities Prociram Web Paae

Construction Review Services Resources:Construction Review Services Program Web PaaePhone:(360)236-2944Email: [email protected]

DOH 260-014 June 2019

Exhibit 1NWES Seattle Assumptions

Goal of Application:

Sight Partner Holdings, LLC dba Northwest Eye Surgeons (NWES) is a physician ownedorganization with 4 ASCs and 7 clinics conducting business and performing ophthalmic eyesurgery in Washington, Due to the rising facility costs NWES is relocating its CON approvedlocation at 10330 Meridian Ave N, Seattle, WA within the planning area to 332 NE NorthgateWay, Seattle, WA. The application fora new CON has been submitted. The application iscurrently under a concurrent review process because of another organization's CONapplication.

NWES will continue with CON application but wishes to request an exemption for its newlocation until the CON decision is complete. This would allow NWES to begin construction andbegin services. NWES was previously a CON exempt ASC. NWES remains a physician ownedentity and only employed physicians provide surgery at the location.

Growth Assumption:

NWES determined that 5% growth in patients and revenue wi!l be accomplished throughimproved processes in the new location and better access for patients. Historicaily, NWES hasobtained a minimum of 5% growth year over year.

Exhibit2NWES OrganizationalChart and Ownership

Breakdown

1-6 Organizational Structure Chart

Governing Body/Executive Committee:

Kristi Bailey, MDBrett Bence, OD

Board of Directors:WernerCadera, MDBruce Cameron, MD

Aaron Kuzin, MDAudrey Tailey Rostov, MD

IManaging Partner: Kristi Bailey, MD

It

CEO: Spencer Michael

Procedure Review Board:

Director of NursingASC ManagersBilling and Coding Manager

1IVtedical Director: Aaron Kuzln. MD

Directors:

Director of OptometryDirector of NursingDirector of Clinical OperationsDirector of Finance

Risk Management Committee:

Director of Nursing

Director of Clinical OperationsDirector of Finance

CEOBilling and Coding Manager

Medical Advisors:

WernerCadera, MD

Audrey Talley Rostov, MD

Quality Assessment and PerformanceImprovement Committees:

QAPI performed at each Surgica)Center

Site Medical Director

ASC Manager

OD Designee

NWES QA Nurse

CRNA Designee

ASC infection Control SDeciaiist

Infection Control Plan Designees:

Director of NursingASC Managers

Site Medical Director

Seattle: Bruce Cameron, MD

Renton: Susan Hoki, MD

Mount Vernon: KrEsti Bailey, MD

Sequim: Matthew Niemeyer, MD

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Exhibit 3NWES

1.7 Governance Policy

9NORTHWEST EYE SURGEONS

Title: Governance

Approval Date: 01/06/2018

Effective Date: 01/06/2018

P&P#:XXX

Review: Annual

Policy and Procedure

1,7 GovernanceCMS CFR 416.41. WAG 246-330-115

Policy:Northwest Eye Surgeons (NWES) Governing Body assumes full lega! responsibility andensures policies are implemented in order to provide quality health care in a safeenvironment (CFR 416.41}. The Governing Body is regulated by a governing document thathas the consent of each member of the body, and each member will have equal votingauthority, and wi!l meet at least quarterly in one of the following manners: in person, phoneconference or email Minutes of each "official" Governance meeting are recorded and filedwith the original rules and regulations. The medical staff will be accountable to theGoverning Body (CFff 416.45).

Responsibilities of the Governing Body include, but are not limited to:> Determine the mission, goals, and objectives; ensuring the facilities and personnel

are adequate and appropriate to carry out the mission; formulating long-range plansin accordance with the mission, goals, and objectives.

> Ensure financial responsibiiity; establishing an appropriate system of financialmanagement and accountability.

> Review and take appropriate action on al! legai and ethical matters concerning theorganization and its staff

o Establish a policy for identifying and reporting healthcare providers whenunprofessional conduct occurs.

> Ensure that all marketing and advertising clearly focus only on care and servicesthat are provided by the organization.

> Provide full disclosure of ownership to employees and patients.> Establish the organizational structure.> Establish policy for how individual surgeons deal with each other and external

parties, and on surgeons ro!e in properly dealing with patients.> Establish a policy on "patient's rights";> Adopt and implement a policy for reporting suspected patient abuse.> Comply with the 'Equal Employment Act' and the 'American's With Disabilities Act'> Establish, implement, and monitor policies governing the ASC's total operation,

including ail necessary policies regarding drugs and biologicals. These will bereviewed and revised annually.

14

> Develop a "Quality Assessment and Performance Improvement Program", includingrisk management, infection control and WISHA programs; ensure quafity of care isevaluated and that identified problems are appropriately addressed; adopt a policyon continuing education for personnel.

> Develop a policy for notifying a patient of an unanticipated outcome.> Approve and ensure compliance of ail major contracts or arrangements affecting the

medicai care provided under its auspices, including but not limited to, thoseconcerning:

> The employment, contracting, and periodic review of health care professionals> The use of external pathology and medical laboratory services> The provision of after-hours patient care.> Centers for Medicare & MedicaEd Services (CMS)> Participation with a managed care organization for services> Adopt and implement a policy and procedure to address how ciinical trials wili be

authorized and reviewed.> Maintain effective communication throughout the organization; adopt policies and

procedures to resolve grievances and external appeals, as required by state andfederal law and regulations.

15

Exhibit 4NWES

1.8 Managing Partner,Medical Director and

Medical Advisors Policy

aPolicy and Procedure

NORTHWEST EYE SURGEONS

Title: Managing Partner, Medical Director and Advisors



P&P#:XXX

Review: Annual

1.8 Managing Partner, Medical Director and AdvisorsCMS CFR 416.41, WAC 246-330-115

The Board of Northwest Eye Surgeons will nominate the Managing Partner. The MANAGINGPARTNER will be the managing physician of Northwest Eye Surgeons, PC who will act as therepresentative of the Governing Body and, subject to its policies, is responsible for theefficient administration of all affairs of the organization and ambulatory surgical facility.

The Board of Northwest Eye Surgeons will appoint the Medical Director for a term of 2-3years, which can be extended by mutual agreement of the Board and Medical Director.

The Board of Northwest Eye Surgeons will designate two Medical Advisors for a term oftwelve months who, En the Medical Directors absence will exercise all of his/herresponsibilities. There will be no limitation on number of terms that may be served. TheMedicai Advisors will meet with the Medical Director and Board of Northwest Eye Surgeonsat least annually.

Managing Partner> Is a member of the Board.> Is a partner with the Board and Directors in achieving the organization's vision,

mission and values.

> In partnership with the Board and Directors, will establish lines of authority,accountability and supervision of personnel

> Provides leadership to the Board, who sets policy and to whom the CEO andDirectors is accountable.

> Chairs meetings of the Board after developing the agenda with the CEO.> Encourages Board's role in strategic planning.

o Participates in long and short range planning needs of NW Eye Surgeons asdetermined by the Governing Body

> Appoints the chairpersons of committees, in consultation with other Boardmembers.

> Serves ex officio as a member of Board or other committees and attends meetingswhen invited.

> Discusses issues confronting the organization with the CEO.> Helps guide and mediate Board actions with respect to organizational priorities and

governance concerns.

16

> Reviews with the CEO any issues of concern to the Board.> Monitors financial planning and financial reports.> Formally evaluates the performance of the CEO and evaluates the effectiveness of

the Board members.

> Along with the Board and Directors, evaluates annually the performance of theorganization in achieving its mission

> Guide management and employee actions by participating in development ofprocedures and methods that reinforce organization culture and values

> Establishes professional working relationships with our referring OD providers andprovider organizations, to support the development of successful partnerships

> Along with other Board Members, participate in the orientation and coaching of newphysicians

> Ensure legal compliance by monitoring and implementing as applicable " medical,federal, and state requirements; conducting investigations; maintaining records;representing the organization at hearings

> Take all reasonable steps to insure that NW Eye Surgeons facilities comply with ailapplicable provisions of the law and other regulations relating to the operation of thefacilities, including those required for participation in the federal United Statesgovernment Centers for Medfcare/Medicaid Service Programs

> Performs other responsibiiities assigned by the Board

Medical Director> Functions in the ro!e of medical leadership for the effective integration of

operations, utilization/case management activities, quality improvement activities,and provider relations

> Provide leadership and guidance in the quality and appropriateness of care,evaluate provider performance standards, advise management on how to bestresolve physicians issues and concerns; counsels with physicians and managementas needed

o Provides current medical expertise and direction for clinical policies,procedures and programs

o Oversees provider education regarding pharmacy, utilization, qualityimprovement and health care expenditures to improve clinical outcomes.

o initiates dialogue with providers as necessary to resolve differences inopinions concerning utilization management

> Along with other Board Members, participate in the orientation and coaching of newphysicians

> Participate in the development and maintenance of a QAPI programo Manages day-to-day quality improvement and medical management activitieso Monitoring and evaluating outcomes, including cllnica! and physician

services - lead the Peer Review Process

Medical Advisors> Act as liaison among the medical staff, the Medical Director and the Governing

Body.

17

> Reviewing policies and making appropriate recommendations to the GoverningBody.

> Reviewing the credentials of all applicants and making recommendations to theGoverning Body for staff membership and delineation of clinical privileges.

> Periodically reviewing Information regarding the performance and clinicalcompetence of medical staff members and, as a resuit of such review, makingrecommendations for reappointments and renewal of, or changes in, clinicalprivileges.

> Reviewing the credentials of any Assistant to Physician for whom an application hasbeen made by a member of the Medical staff and making recommendations forappropriate action.

> Comprehensively reviewing on an on-going basis the quality of care provided atNorthwest Eye Surgeons, PC and making recommendations to the Governing Body.Such review will include, but not be Hmited to, the medical necessity of proceduresand appropriateness of care.

18

ExhibitsNWES Seattle License

Verifications, CONVerification, AAAASF

Accreditation and SurveyReports

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DEPARTMENT OF HEALTHPO Hox 47^2'Olympm, Wa^hmôn 9^04-78^2

November 6, 2018

CERTIFIED MAIL // 7017 3380 0000 0863 8406

Lance Baldwin, Director of Nursing

Northwest Eye Surgeons, PC1330 Meridian Avenue North, #370Seattle, Washington 98133

RE; Certificate of Need Application #18-25"North King County

Dear Mr. Baldwin:

Enclosed is Certificate of Need #1749 issued to Northwest Eye Surgeons, PC approving theestablishment of an ambulatory surgery center in Seattle, within North King County.

The certificate is not an approval for any other local, federal, or state statutes, rules, or regulations.

Such a project may also need Department of Health approval for a construction plan and facilitylicensing or certification, as well as other federal or local jurisdiction permits.

The Certificate of Need is valid for two years. The project must begin during this time. If there issubstantial and continuing progress, we may extend the certificate for one six month period. For

an extension, you must submit an extension request at least 120 days before the expiration. You

cannot begin a project after the expiration date.

This decision may be appealed. The appeal options are listed below.

Appeal Option 1:Any person with standing may request a public hearing to reconsider this decision. The requestmust state the specific reasons for reconsideration in accordance with Washington AdministrativeCode 246-310-560. A reconsideration request must be received within 28 calendar days from the

date of the decision at one of the following addresses:

Mailing Address:Department of HealthCertificnte of Need Program

Mail Stop 47852Olympia, WA 98504-7852

Physical Address:Department of HealthCertificate of Need Program

111 Israel Road SETumwater,WA9850l

Lance Baldwin, Northwest Bye Surgeons, PC

Certificate of Need App #18-25-North King CountyNovember 6, 2018Page 2 of 2

Appeal Option 2:Any person with standing may request an acljudicative proceeding to contest this decision within28 calendar clays from the date of this letter. The notice of appeal must be filed according to theprovisions of Revised Code ofWashington 34.05 and Washington Administrative Code 246-310-610. A request for an adjudicativc proceeding must be received within the 28 days at one of thefollowing addresses:

Mailing Address: Physical AddressDepartment of Health Department of HealthAdjuciicative Service Unit Acljudicative Service UnitMail Stop 47879 11 1 Israel Road SEOlympia, WA 98504-7879 Tumwatcr, WA 98501

We monitor projects until completed or the expiration date, whichever occurs last. We do this withquarterly progress reports. At least 30 days before the report's due date, you will receive a form to

complete and return.

If you have any questions, please contact Janis Sigman, Manager of the Certificate of Need

Program at (360) 236-2955.

Sincerely,

^//^-^// LmcyTôn, I^xecuti'Nancy Tôh, executive Director

Health Facilities and Certificate of NeedCommunity Health Systems

Enclosure

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^HealthThis Certificate is granted under the authority of RCW 70.38. Issuance of tliis Certificate does notconstitute approval under any other local, federal or state statute, implementing rules and regulations.Examples where additional approval may be necessary include, but are not limited to, construction plan

approval through the Construction Review Unit oftlic Department of Health, facility liccnsing/ccrtificationthrough the Department of Social and Health Services or Department of Health, and other federal or localjurisdiction permits.

Certificate of Need #1749 is issued to:

Applicant's Legal Name: Northwest Eye Surgeons, PC10330 Meridian Avenue North, ^370Seattle Washington 98133Ambulatory Surgical FacilityAmbulatory Surgical FacilityNorthwest Eye Surgeons10330 Meridian Avenue North, #370Seattle Washington 98133

Applicant's Address:

Facility TypeProject TypeFacility Name:

Facility Address:

ISSUANCE OF THIS CERTIFICATE OF NEED IS BASED ON THE DEPARTMENT'SRECORD AND EVALUATION DATED OCTOBER 24, 2018 (CN APP # 18-25)

Project DescriptionThis certificate approves the establishment of a two-operating room ambulatory surgical facility in Seattle, withinNorth King County. The surgery center will serve patients aged 5 years and older that require surgical servicesthat can be served appropriately in an outpatient setting. Surgical services within the two ORs are limited thoseassociated with ophthalmic surgical procedures, such as cataract extraction and laser eye surgery.

Service Area

North King County

ConditionsThe conditions are identified on page 2 of this certificate

Approved Capital ExpenditureThere is no capital expenditure associated with this project.

Tins Certificate authorizes commencement of the project from November 6, 2018 to November 6, 2020unless extended, withdrawn, suspended, or revoked in accordance with applicable sections of the

Certificate of Need law and regulations.

Date Certificate Issued: November 6, 2018i>

.^f. /^ x y—Nancy t^bfi, Executive DirectorHealth Facilities and Certificate of NeedWashington State Department of Health

This Certificate is not transferable

Certificate of Need #1749Page Two

Conditions

1. Northwest Eye Surgeons, PC agrees with the project description as statedabove. Northwest Eye Surgeons, PC further agrees that any change to theproject as described in the project description is a new project that requires anew Certificate of Need.

2. Northwest Eye Surgeons, PC will provide charity care in compliance with itscharity care. Northwest Eye Surgeons, PC will use reasonable efforts toprovide charity care consistent with the regional average or the amountidentified in the application - whichever is higher. The regional charity careaverage from 2014-2016 was 0.94% of gross revenue and 2.00% of adjustedrevenue. Northwest Eye Surgeons, PC will maintain records of charity careapplications received and the dollar amount of charity care discounts grantedat the location of the surgery center. The records must be available uponrequest.

3. Northwest Eye Surgeons, PC agrees that the ASF will maintain Medicare andMedicaid certification, regardless of facility ownership.

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Re-Accreditation Decision Letter

Date of Notice: Thursday, June 13,2019

Director: Bruce D Cameron, M.D.

Thank you for participating in this important quality assurance and patient safety process administered by theAmerican Association for Accreditation of Ambulatory Surgery Facilities. The following report containsinformation relevant to the conclusion of your recent accreditation survey process including your facilityaccreditation demographic information/ accreditation decision, and recent survey history. AAAASF requires thatall standards be met in order to achieve accreditation and that 100% compliance must be maintained at all times.AAAASF reserves the right to conduct additional surveys to validate the findings of previous surveys and to ensurecontinued compliance with standards.

Attached you will find a report containing all of the deficiencies cited during the accreditation survey along withthe corrective action plans submitted to AAAASF. The Final Accreditation Decision based on the findings andcorrective action taken in response to your recent survey process is Full.

Survey Details Below

Accrediting Organization: AAAASF

Survey Identification Number: 24922

AAAASF Facility Identification Number: 5705

Program Type: ASC

CCN Number: 50C0001018

Provider/Supplier Name and Address:Northwest Eye Surgeons, P.C.

10330 Meridian Avenue North, Suite 370Seattle/ WA 98133United States

Survey Request Type: Self-Evaluation

Survey Type: Full Accreditation Survey

Page 1 of 2

Survey Began: Tuesday, May 28, 2019 Survey Ended: Tuesday, May 28, 2019

Date Acceptable Plan of Correction Received: N/A

Method of Follow Up: N/A

Accreditation Decision: Fu!

Effective Date of Accreditation: Wednesday/ June 19,2019

Expiration Date of Accreditation: Saturday, June 19, 2021

Recommended for Continued Deemed Status: Yes

CMS Condition for Coverage Cited: N/A

Recent Survey History:

Survey

24922

Survey Description

Full Accreditation Survey

Survey Type

Re-Survey

Begin

5/28/2019End

5/28/2019Deficiencies

0Corrected

0

Decision

Full

Sincerely,

VLUd/^M^y

Jeanne HenryDirector of Accreditation

Page 2 of 2

ExhibitGNorth King CountySecondary Health

Services Planning Area

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Exhibit 7Summary of Terms

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Exhibit 8NWES

1.11 Credentialing andPrivileging Policy

Policy and ProcedureNORTHWEST EYE SURGEONS

Title: Credentiallng and Privileging



P&P#:XXX

Applies to: RASC, MVASQ SASC, SQASC

1,11 Credentialing and PrivilegingCMS CFR 426.41, CMS CFR 416.45

Policy:Northwest Eye Surgeons will complete a process to assess and validate the qualifications ofan individual who provides services to ensure that the individual has, and maintains, thespecialized professional background which he or she claims and that the position requires.

Process:The process for "CREDENTIALING & PRIVILEGING" is completed by ensuring:

1. Applicant has completed the required application

2. Relevant education, training and experience are verified and appiicabie documentsobtained:

> Professional diplomas> Board certifications or eligibility> Source verifications as appropriate for schooling including residencies,

fellowships and so forth> Curriculum vitae> Former employment and references

3. Current competence is verified in writing by three (3) individuals personally familiarwith the applicant's clinical, professional and ethica! performance and whenavailable, by data based on analysis of treatment outcomes.

4. Current llcensures and certifications are obtained> Professional license> DEA license> BLS or ACLS

5. Proof of current medical liability coverage

6. Health file with TB screen and Hepatitis B immunization status

7. Other pertinent information is reviewed> Professional IJabiHty claims history> Licensure revocation, suspension, voluntary relinquishment, licensure

probationary status, or other licensure conditions or iimitations> Complaints or adverse action reports filed against the applicant with a local,

state, or national professional society or licensure board> Refusal or cancellation of professional liability coverage

24

> Denial, suspension, limitation, termination, or non-renewai of professional

privileges at any clinic, hospital, health plan, or other institution> DEA or state license action> Disclosure of any Medicare/Medicaid sanctions> Conviction of a criminal offense> Current physical, mental heafth, or chemical dependency problems that

would interfere with an applicant's ability to provide high quality patient careand professional services

> Signed statement releasing Northwest Eye Surgeons from liability andattesting to the correctness and compfeteness of submitted Information

8. Applicant's requested privileges falls within the dinica! procedures and treatmentsoffered at Northwest Eye Surgeons and that he or she has the qualifications relatedto training and experience to perform them.

9. Completed applications will be submitted to the Governing Body. The GoverningBody will evaluate the character, qualifications, professional standing and suitabilityof the applicant and will make and record their recommendation concerningacceptance, deferment or denial of the applicant. The Governing Body will haveultimate authority En all decisions concerning appointments or re-appointments ofapplicants.

10. Applicants are reappointed at least every 2 years and must include peer reviews inaddition to the standard credentialing and privileging requirements.

11. CORRECTIVE ACTION:Whenever the activities or professional conduct of any physician with clinicalprivileges are not consistent with the standards of the medica! staff, are disruptiveto the operations of the facility or are detrimental to patient care, corrective actionmay be requested by any member of the Medical Staff, Governing Body orAdministrator. A!l requests will be made in writing to the Governing Body and will besupported by references to the specific activity or conduct which constitutes suchgrounds for the request.

GROUNDS:Grounds for requesting corrective action include but are not limited to:

> Professional conduct inconsistent with standards of Medical Staff> Substandard practices which may or may not have caused patient injury> Unethical practices> Failure to keep adequate records> Signs of physical or mental impairment which impact the quality of care

rendered> Loss of DEA license> Loss of malpractice insurance> Revocation or suspension of medical license

INVESTIGATION:Upon receipt of such request the Governing Body will investigate the matter. TheGoverning Body may appoint an Ad Hoc committee from the shareholders tomanage the investigation. The fact finding committee will conduct an investigation

25

within 14 days after receipt of the request to determine the facts and circumstancesof the incident that is the basis of the request for corrective action. If the committeecannot complete the investigation within the 14 days, they may ask for additionaltime, however, the additional time cannot exceed a total of 30 days from the receiptof the request. The Governing Body will review the results and recommendations ofthe investigation committee and make a written report of its findings and any actionto be taken within 14 days of the receipt of the investigation committee report. TheGoverning Body will have ultimate authority in any decisions concerning correctiveaction.

REPORTING:The Governing Body is responsible for reporting affirmed acts of unprofessionalconduct as well as voluntary restrictions or terminations by a healthcare provider tothe Department of Health (RCW 70.230.120) within 15 days of its findings. TheGoverning Body will provide a copy of the investigation committee report in additionto all available contact information for the individual.

NOTE: My changes in ownership or physician staff must be reported in writing tothe AAAASF office within 30 days of such change, with copies of the appropriatecredentials of any new staff. Including current medical license, ABMS BoardCertification or letter of eligibility and current documentation of appropriate hospitafprivileges or satisfactory explanation for the fack thereof. Any action affecting thecurrent medical license of a member of the medical staff, such as revocation orsuspension, must also be reported in writing within 10 business days of such action.

26

Exhibit 9NWES Seattle

Historic Services;Identified by Top 30

CPT Codes

NWES Seattle Historic Services; Identified by Top 30 CPT Codes

! Code Code Description

! 66984 CE IOL - Standard

166821 YAG Caps Laser

\ 66982 CE IOL - ComplexBlepharoplasty - Upper Eyelid - Excessive Skin

15823 Weighing Lid Down

166761 VAG Peripheral iridotomy Laser

165855 SLT Laser

IV2632 IOL - Posterior Chamber

165756 Corneal Transplant - Endofhelial

BIepharoptosis Repair - Conjunctivo-Tarso-Muiler's

167908 Resection

I66821VC YAG Caps Laser - VC

165400 Corneal Lesion Excision

166999LS Lasik - Facility

10290T IEK - intraiase Laser Add-On

Brow Ptosis - SupercHiary - Mid-Forehead or Corona!

167900 Approach

165730 Corneaf Transplant (Non-Aphakia)

165760VC Lasik - VC - Facility

165426 Pterygium

i65760 LasikStrabismus - Recession/Resection - One Horizontai

[67311 MuscSe

166999CRIVC Corneal Relaxing incision - VC

166250 Bleb RevisionStrabismus - Recession/Resection - One Vertical

167314 Muscle (Excluding Superior Oblique)

166986 iOL Exchange

165820 Goniotomy

!66170T Trabeculectomy

166999PRK PRK - Facility

IS0812 PTK

166999RLE Refractive Lens Exchange

i66175 Canalopiasty with Stent

I0191T iStent Implantation

SVCPRK PRK-VC

2015

1,844

396

235

103

62

44

80

34

43

79

48

43

34

43

35

58

21

3

22

28

18

15

21

6

26

17

11

16

12

22

2016

2,068

379

126

92

2

72

45

52

30

13

24

33

19

19

26

44

25

34

14

13

9

2

1

7

19

6

11

15

26

2017

1,945

414

42

157

2

63

54

40

36

28

32

27

30

63

17

27

21

7

20

11

20

13

32

Total 3,419 3,226 3,101


2.14 Patient Admission,Assessment and Discharge

Policy


Title: Patient Admission, Assessment and Discharge



Review: Annual

Applies to: RASC, MVASC, SASC, SQASC

2-14 Patient Admission, Assessment and DischargeQ-0260, 416.52 CMS Condition for Coverage, WAC 246-330-205

NWES will ensure each patient has the appropriate pre-surgical and post-surgicalassessments and that all elements of the discharge requirements are completed.

1. Not more than 30 days before the date of the scheduled surgery, each patient musthave a comprehensive medical history and physical assessment completed by aqualified practitioner legally authorized to practice in Washington and providingservices within their authorized scope of practice. Such practitioner may be thepatient's primary care provider rather than a member of NWES' medical staff. CO-0261, 416.52(a)(l) Standard: Admission and Pre-Surgical Assessment)

a. The patient's medical history must assess the patient's readiness forsurgery and is required regardless of the type of surgical procedure. (Q-0261,416.52(a)(l) Standard: Admission and Pre-Surgical Assessment)

b. NWES will not require a genitourinary or rectal examination2. Patients must meet NWES Pre-Operative Guidelines. Final determination of

clearance for surgery will be at the sole discretion and responsibility of the operatingsurgeon.

a. NWES patients must fall within the ASA Anesthesia Classifications I, II, andIll

Class!Class HClass III

Class !V

Class V

Healthy patientMild systemic diseaseNon-incapacitating severe systemicdiseaseSevere systemic disease—constantthreat to lifeNot expected to live without surgicalintervention

No physical limitationsWell-controlled disease of one body systemControlled disease of more than one bodysystemPoorly controlled or end-stage with at least onesevere diseaseDanger of death imminent

NWES patients must be abie to effectively transfer on own with and withoutsedation or bring personnel familiar with and able to transfer patientNWES will attempt to obtain the primary care physician chart note dated fromwithin the last 12 months of surgery patients for review by surgical team.NWES patients assessed with any of the following will be referred to theirPOP or condition managing physician for further evaluation and risk control:

i. Pulse iess than 50, more than 100, or irregular without prior historyduring surgery consultation visit

ii. Blood pressure more than 180 systolic, more than 100 diastolicduring surgery consultation visit

35

iii. Serious cardiac event within the last 6 months, to include but notlimited to: Unstable angina as indicated by increased frequency ofepisodes, increased use of nitroglycerin for relief, or angina at rest

1. Myocardial infarct2. Stent placement3. Angioplasty4. Cardiothoracic Surgerywithin the previouG 6 monthG

iv. Unstable congestive heart failure as indicated by increased dyspneaon exertion, or dyspnea at rest

v. Stroke within the previous 6 monthsvi. Chemotherapy within the previous 3 months

vli. Current ronal diQlyoiGNew diaiysls patient of less than 1 yearvlii. Referrals to PCP or managing physician will be documented in the

patient's medical record.

e. NWES patients must be able to understand and follow instructions.f. NWES requires the following labs pre-operatively

i. INR within 24hrs of scheduled surgery for patients onWarfarin/Coumadin

1. INR expected to be less than 3.0 for regional blockanesthesia

2. INR expected to be !ess than 3.5 for topical and localanesthetic

Ei. Diabetic patients will have blood sugar tested preoperatively; FSBSis expected to be less than 350.

3. The patient's medical history and physical must be placed in the patient's medicalrecord prior to the surgical procedure. (Q-02G3,4l6.52(a)(3) Standard: Admission and Pre-Surgical Assessment)

a. NWES requires that En most cases the comprehensive H&P be submittedprior to the patient's scheduled surgery date, in order to allow sufficient timefor review and adjustments if necessary, including postponement orcancellations of the surgery. (Q-0263, 416.52(a)(3) interpretive Guidelsnes)

b. In some situations, it may not be possible to have an H&P performed prior tothe date of surgery. The comprehensive medical history and physical maybe performed on the same day if:

i. It is performed by qualified personnel, is comprehensive and isplaced in the patient's medical record prior to surgery. At aminimum, it must be placed in the medical record prior to the pre-surgical assessment, since that assessment must first consider thefindings of the H&P before examining the patient for changes. (Q-0263, 416.52^3) Interpretive Guidelines)

ii. The referring physician indicates on the medical record that it ismedically necessary for the patient to have the surgery on thesame day as the referral to the ASC, and that surgery in an ASCsetting is suitable for the patient. (Q-0261,4i6.52(a)(l) Standard: Noticeof Rights, Interpretive Guidelines)

c. Rarely, the pre-surgicai H&P may not be available when the patient reportsfor surgery. In this case, at the so!e discretion and responsibiiity of the

36

operating surgeon, the H&P may be done on the date of surgery subject toS.b.i, above.

4. Upon admission, each NWES patient must have a pre-surgical assessmentcompleted by a physician to evaluate the risk of the anesthesia and of theprocedure for that patient that includes, at a minimum, an updated medical recordentry documenting an examination for any changes in the patient's condition sincecompletion of the H&P, including documentation of any allergies to drugs orbiologicals. (Q-OOGl, 416.42(a) Standard: Anesthetic Risk and Evaluation) (Q-0262, 416.52(a)Standard: Admission and Pre-Surgical Assessment) The pre-surgical assessment will includeat a minimum:

a. Review of H&Pb. Review of current medications

c. Review of allergiesd. Examination

5. Each patient will be assessed prior to discharge (Q-0264, 416.52, Standard: post-surg'icai

Assessment according to the foiiowing criteria:a. Return to preoperative baseline level of consciousnessb. Stability of vital signs (no dyspnea, oximetry 92% or above, systolic blood

pressure +/- 20% of admission BP with a minimum of 90 systolic and amaximum of 100 diastolic)

c. Absence of protracted nausea

d. Adequate pain controle. Return of motor sensory control to preoperative baselinef. Saline lock discontinued as applicable

6. NWES will ensure that each patient has a discharge order, signed during the post-operative period by the physician who performed the surgery or procedure. (Q-0266,416.52(0} Standard: Discharge)

7. NWES will ensure that each patient is provided with written discharge instructions,prescriptions as needed and overnight supplies as needed.

8. NWES will ensure all patients are discharged in the company of a responsible adult,except those patients exempted by the attending physician (0-0267,4i6.52© Standard:Discharge) according to the following criteria:

a. Vital signs stableb. Alert and orientedc. Driving vision in either eye or ability to see to safely get home If taking public

transportation

37


1.2 Patient Rightsand Responsibilitiesand 1.3 Grievances


Title: Patient Rights



P&P#:XXX

AppUes to: RASC, MVASC, SASQ SQASC

1.2 Patient RightsCFR 416.50 (a)(i), WAC 246-330-125

Policy:NWES will ensure all patients, or their representative, are informed of their rights as patientsin advance of the day of surgery, and will actively protect and promote the exercise of suchrights regardless of the type of procedure performed. NWES will provide required verbal andwritten notifications in a language or manner which the patient, or the patient'srepresentative understands. A written copy of NWES Patient Rights & Responsibilities will bedisplayed In an area where it can be seen by ati patients, or their representative, enteringthe ASC.

> At the time a surgical procedure is scheduled, the patient will be verbally informedthat they have certain rights as a patient in our ASC.

> Patients will be given the information needed to make decisions regarding their carebefore a surgical or minor procedure is performed.

> When a patient schedules in person, a written copy of their rights andresponsibilities will be provided to them in addition to verbal notification. If thepatient schedules by phone, written notification of rights and responsibilities will besent in a time frame which assures the patient, or their representative, receives itprior to the day of surgery.

> The only circumstance in which a patient is informed of their rights as a patient onthe day of surgery, is when the referral to the ASC is made on the same day, thereferring physician indicates in writing that it is medically necessary for the patientto have surgery on the same day, and that the ASC is a suitable setting for thatpatient. With such situations, notice must be provided prior to obtaining thepatient's informed consent and prior to the start of the surgical procedure.

> When necessary, NWES will make use of translation services to communicate in aclear and thorough manner. If it is not possible to translate the written notificationinto a language the patient understands, comprehensive verbal communication andunderstanding of the patient's rights via translator will be documented in thepatients record.

> When the patient arrives on the day of surgery, the signed and dated Patient'sRights & Responsibilities form will be included in the patient's record.

> Reported incidents of abuse, neglect or harassment will be investigated (seeGoverning Policies, Patient Abuse or Neglect).

> NWES will not take punitive action or discriminate against patients who exercisetheir rights.

> Patient consent will be obtained prior to permitting the presence, during treatment,of anyone not Involved in the care of the patient.

> if a patient has been adjudged incompetent under applicable State iaws by a courtof proper jurisdiction, the person appointed under State law to act on the patient'sbehaif may exercise any and all rights afforded to NWES patients.

aPolicy and Procedure


Title: Grievances



P&P#:XXX

Applies to: RASC. MVASC> SASC, SQASC

1.3 GrievancesCMS CFR 416.50(a)(3)

Policy:Northwest Eye Surgeons (NWES) will provide a process for documenting the existence,submission, investigation and disposition of a patient's written or verbal grievance to theAmbulatory Surgical Facility or the clinic. Alleged violations may include, but not be limitedto, mistreatment, neglect, verbal, mental, sexuai or physical abuse, or ASF compliance

issues. Grievances may be filed by a patient or by the patient's representative.

It is the obligation of staff members to report grievances to the Medical Director or amember of the Governing Body who has the authority to address grievances.

> Information regarding the submission of patient concerns to a NWES representative,the Washington State Department of Health or the Office of Medicare BeneficiaryOmbudsman will be included in the written notification of Patient Rights &Responsibilities.

> Patients will be verbally advised and furnished with a printed copy of the PatientRights & Responsibilities notice in the instructional information packet which ismailed to them In advance of their initial appointment.

> Patients shall provide written acknowledgement of receipt and understanding ofNWES Patient Rights & Responsibilities notice.

> A copy of the Patient Rights & Responsibilities will be prominentiy displayed in allNWES facilities.

> Complaints resolved at the time they are registered are exempt from the grievanceprocess, as is information obtained from patient satisfaction surveys, unless thepatient attaches a written compiaint to the survey requesting resolution.

> Investigation will include a thorough review of systemic problems which may havecontributed to the grievance via the Quality Assessment and PerformanceImprovement Committee.

> The start of an investigation will commence upon receipt of a grievance.> NWES will make every effort to conclude investigations and provide a response to

the patient or the patient's representative within 14 days of having received agrievance.

> NWES will document all Investigation findings, how the complaint was addressed,and pertinent details of the decision process.


Non-Discrimination Policy


NORTHWEST EYE SURGEONS, P.C. - PATIENT RIGHTS & RESPONSIBLITIES

As a patient of Northwest Eye Surgeons P.C., you have the right to:• Receive care in a safe setting regardless of race, color, gender, national origin, religion, or sexual

preference.

• Be treated with respect and dignity, free from abuse, neglect or harassment, and be given access toprotective services.

• File grievances without fear of discrimination, reprisal, or denial of care.

• Be provided appropriate personal privacy, spiritual care and communication, and be informed ifcommunication restrictions are necessary for the care and safety of yourself or others in the facility.

• Expect disclosures, information and records to be treated confidentiaily and, except when required bylaw, be given the opportunity to approve or refuse their release.

• Review your records and receive a copy of them. You may also ask to amend your healthcare record.• Know the names, professional status and responsibilities of your healthcare providers.• Seek another medical opinion and change primary or specialty healthcare providers.

• Receive, to the degree known, complete information concerning your diagnosis, evaluation, treatmentand expected, or unanticipated, outcomes. When medically inadvisable to give such information to apatient, the information is provided to a person designated by the patient or to a legally authorizedperson.

• Make informed decisions about your treatment and care. When patient participation or exercise of anyright is contraindicated due to medical incapacity or adjudged incompetence, a legally authorizedperson may participate in decision making and act on the patient's behalf to exercise any and all rights.

• Refuse a recommended treatment or plan of care, to the extent permitted by law, and to be informed ofany medical consequences related to that decision.

• Be informed if you will be part of research, investigational or clinical trials. Access to care will not bedenied or hindered if you refuse to participate in research or trials.

• Know that Northwest Eye Surgeons P.C. has an Advance Directives Policy (described on the reverse ofthis form). Questions about our policy may be directed to the physician performing your procedure or toour surgical coordinating staff.

• Resolve problems with care decisions and voice grievances regarding care or service which is (or fails tobe) provided without fear of reprisal or discrimination. Grievances will be investigated and a responseprovided within 14 days. Complaints and grievances may be verbal or written and directed to:

o Spencer Michael, CEO 206-528-6000 ext. 3880

• Know the following physician shareholders who practice at NWES have an ownership interest in all ofNWES's faciiities.

o Kristi Baiiey o WernerCadera o Aaron Kuzino Brett Bence o Bruce Cameron o Audrey TaHey Rostov

As a Northwest Eye Surgeons P.C. patient, you have the responsibility to:

• Provide complete and accurate medica! information.• Participate with providers in making decisions about your treatment or plan of care.

• Follow the treatment plan to which you agreed or let us know if you do not understand or cannot followyour healthcare instructions.

• Arrive for scheduled appointments on time or give notice at least 24 hours in advance if you mustcancel or reschedule an appointment (NWES reserves the right to terminate services if you miss two ormore appointments without calling in advance to cancel).

• Know your health plan benefits, provide complete insurance information and timely notification of anychanges.

• Pay your bili in a timely fashion or seek assistance for discussing payment options.• Treat our staff and physicians with respect and dignity and respect the rights of others.• Let us know if you have concerns or complaints about any aspect of your care.• Respect that we prohibit smoking, the use of alcohol or illegal drugs, and carrying firearms or other

weapons in our facilities.5

NOTICE OFADVANCE DIRECTIVES POLICY

An Advance Directive is a document which allows patients to give direction about future medical care in theevent they are unable to express their wishes or make medical decisions on their own behalf. AdvanceDirectives are generally in the form of a living will, durable power of attorney for healthcare, or a !Efe-sustainingprocedures declaration (POLST). As allowed by Washington State Law, Northwest Eye Surgeons, P.C. and ourASC staff decline to honor non-resuscitative elements which may be contained in an Advance Directive orPOLST.

• Compliance with the 1990 Patient Self-Determination Act Is intended when individuals with anadvanced life-limiting illness are admitted to an in-patient facility.

• In Washington State, the directive is used only if you have a terminal condition where life-sustainingtreatment would artificiatiy prolong the process of dying, or Ef you are in an irreversible coma and thereis no reasonable hope of recovery.

• Healthcare providers at Northwest Eye Surgeons, P.C.'s Ambulatory Surgery Centers, are conscEentiousiycommitted to do all in their power to assure the safe recovery of every surgical patient, includingresuscitation if it becomes necessary.

Because Northwest Eye Surgeons. P.C. may not honor all elements contained within an Advance Directive, youmay request to have your procedure or surgery performed at a facility or hospital which does honor them.Please notify your surgeon, a surgical coordinator, oroneof our healthcare staff, and we will make every effortto accommodate your request.

For more information on Washington State law regarding Advance Directives, or to obtain a printable AdvanceDirective form, please visit the following websites or ask us to print the desired information for you:

• www.wsma.org/patient resources/advance-directives.cfm

• www.uslivjnfiwillregistry.com

• www.agingkingcounty.org

Contact information for the Washington State Department of Health and Office of the Medicare BeneficiaryOmbudsman:

Washington State Department of HealthHSQA Complaint Hotline

P.O. Box 47857Olympia, WA 98504-7857

Phone: 360-236-4700 Toll Free: 800-633-6828 Fax: 360-236-2626httD://[email protected],goy

Office of the Medicare Beneficiary OmbudsmanhttD://www.medicare.gov/claims-and-ap_peals/medicare-rights/fiet^help/ombudsman.htm

Medicare Help and Support: 1-800-MEDICARE

I was verbally informed of my rights as a patient and have read and understand Northwest Eye Surgeons'Patient Rights & Responsibilities and Advance Directives Policy.

Patient Name: _ Date Received_ Time_Patient/Guardian Signature: _ Date_ Time.Relationship to Patient

Federal regulations require that you sign this document prior to the day of your procedure and bring it withyou to the Surgery Center.


1.23 Charity Care andCommunity Service Plan

Policy

3 -...„.•Policy and Procedure


Title: ASC Staffing Strategy



Applies to: RASC, SASC/ MVASC, & SQASC

P&P#:XXX

Review: Annual

1.23 Charity Care & Community Service

PurposeNWES allows for a charity care discount of up to 100% off the total visit cost to provide carefor local indigent population.

PolicyThe NWES charity care policy of up to 100% will be extended to eiigibfe patients uponnotification from the physician or billing department that the patient meets the NWES-identified criteria noted below. Application for charity Is available upon request at NWES ASClocations. Patients will also be provided information of charity care prior to extraordinarycollection actions.

ProcedureIn order to qualify for the charity care discount, patients must satisfy the followingconditions:

l. if physician or clinic is a DSHS provider, the patient's monthly income must be at, orbelow, 150% of the Federa! Poverty Level (see table below); or

2. If physician or clinic is not a DSHS provider, and the patient presents with a valid,current DSHS coupon:

a. The physician elects to see the patient;b. The patient acknowledged financial responsibility.

3. Notification of charity care is provided in patient's billing documentation.4. NWES administration reserves the right to select patients for charity care discount

without satisfying above conditions.

2016 POVERTY GUIDELINES FOR THE 48CONTIGUOUS STATES AND THE DISTRICTOF COLUMBIAPERSONS IN FAMILY/HOUSEHOLD POVERTY GUIDELINEFor families/households with more than 8persons, add $4,160 for each additionalperson.

1 $11,8802 16,0203 20,1604 24,3005 28,4406 32,5807 36,7308 40,890

Source: US Department of Health & Human Services

https://aspe.hhs.gov/povertv"guidelines

Exhibit 14Average 2013, 2014

and 2015 King Countyhospital's charity care

and NWES Seattleprojected charity care

Average of 2013,2014, and 2015 Hospital Charity Care;NWES Seattle projected charity care

Uc. No Reglon/HospitalTotal Patient

Service Revenue(Less) Medicare

Revenue(Less) Medicaid

RevsnueAdjusted PaUentService Revenue Charity Care

Charity Careas a % cS

ToiaS PallenttSen/ice Revenue

Chanty Careas a % of

Adjusted PatientServk^ Revenue

148 Kindred Hospital Seaitie 126,139,047 61,117,01614 SeatMe Chlktren's Hospiia) 2,018.295,479 22,598.469

128 UW Mec!!c!ne/UreversKy of Washington 2,194,854,816 708,116,252

130 UW Msdiclne/NOftimest Hospital 975.532,206 443,105,476

6,029,865 58,992,168 0

944.053,131 1,051,643,879 26,061,772

391.&86.<<47 1,094,852,117 18,046,234

130,044,322 402,382,408 7,341,000

0,00%

1.29%

0.82%

0.75%

0.00%

2.48%

1.65%

1.62%

I North King County Planning 0.72% 1.49%\

92112620235

20116418391913131

2102041959042915510

Cascade Behavioral Health

CHIfHighllne Community HospflalCHI/Regtonal KospifalCHI/Saint Elizabeth HospitalCHI/Sainl Francis Community Hospilaf

EvergreenHeallh/Kirfdand

Center*

Nav&s

Overtake Hospifa! Medicat CenterProvide nce/Swedteh • Cherry Hil!

Provldence/Swedlsh. First Htl!

Providence/Swedish • Issaquah

Seallle Cancef Care Alliance

Sncxtualmle Vaitey Hospila!UHS/BHC Fairfax HospitalCenter

UW MecHcineA/atley Medical CenlerVirginia Mason Medical Center

35,922,820

759,417,495

40,966,581

151,841,881

369,970,981

1,512,772,435

717,761,091

19,147,898

1,269,191,611

1,667,865,050

3,543,189,488

513,667,550

765,473,963

40.717,733

135,717,138

2.089,326,&43

1,550,749,311

2,107,459,157

21,067,125

317,599,619

31,047,635

41,913,626

363,113,057

588,414,315

305,153,866

6,474,729

553,303,296

834,654,108

1,248,537,286

173,381,194

243,082,765

20.804,889

13,270,127

630,722,132

523,225,604

899,466,889

7,591,875

208,350,3263,010,278

29,664,589217,056,838147,077,316192,604,257

9,155,282

83,673,084

217,996,881

614,499,785

46,580,644

84,312,810

5,520,928

37,100,831

691,789.660

363,442,241

128,566,297

7,263,820233,467,550

6,908,66880,263,666

389,601,086777,280,804220,022,968

3,517,887

632,209,231618,214,061

1,680.152,417

293,705,712

438,068.388l'f.391,916

79.346,180776.815,051664.081,466

1,079,465,981

20.353(2,245,9&8)

874,412822,646

6,989,727

1,940,933

8,175,121

604,0208,890,648

14,309,38524,465,167

3,834,1466,057,574

1,461.873

797,07662,804,689

8,671,895

12,496,081

0.06%

-0.30%

2.13%

0.61%

0.93%

0.33%

1.14%

3.15%

0.70%

0.86%

0.69%

0.75%

0.79%

3.59%

0.59%

2.&9%

0.56%

0.59%

0.28%

-0.56%

12.66%

1.15%

2.31%

0.64%

3.72%

17.17%

1.41%

2.33%

1.45%

1.31%

1.38%

10.16%

1.00%

8.08%

1.31%

1.16%

Remaining King CountyCombined Klna Count

1.12',.0.92%

Lie. No Region/Hospital

Revenue Categories - Patient Ser^tee Revenue • (BffledCharges)

Total PatientService Revenue

(Less) Med tea reRevenue

(Less) Me d tea IdRevenue

Adjusted PatientSefvice Revenue Charity Care

Charity Careas a % of

Tofal PsflenttSen/ice Revenue

Charity Careas a % of

Adjusted Pa lie ntSen/fce Reveriua

148 Kindred Hospital Sealtle14 Seattle Children's Hospital

128 UW Medlclne/UnlvsrSfly of Washington130 LJWMedicine/NorthwestHospfta!

107,521,0461,870,722,051

1,942,510,188

890,084,921

50,32-<,08333,688,770

608,208,488

416,412,523

2,395,889

861,072,513334,802,728

84,242,830

54,801,074

975,950,768

999,499,272389,429,568

029,843,579

36,959,237

16,730.788

0,00%1.60%

1.90%

1.88%

0,00%3.06°,

3.70°,

4.30'/t

I North King County Planning 1.34% 2.76%|

921126202

3520116418391913131

2102(M

19590429

15510

Cascade Behavioral Health

CHI/HigNine Community Hospital

CHi/Reglonai HospitalCHi/SatntElbabethHospHaf

CHi/Saint Francts Community Hospital

EvergreenHealt h/Kirkl a nd

Cenler

Navos

Overtake Hospital Med tea I Center

Provide nce/Swedteh - Chsrry Hill

Prot/ldence/Swedteh - First HltlProvldence/Swedish - !ssaquah

Seattle Cancer Care Alliance

Snoqualmfe Va I toy Hospital

UHS/BHC Fairfax HospilalCenfer

LJW Medidne/Valley Medical Center

Virginia Mason Medical Center

18,142,3876&3,643,443

20,027,674

132.962,270

859,564,704

1,304,415,187

672,158,77-1

18,897,706

1,201,438,338

1,525,577,7053,302,035,918

449,')99,759

698,069,767

35,008,751

124,861,266

1,916,945,143

1,402,386,8602,012,240,032

11,033,395

302,385,348

9,451,747

39,554,011

327,977,493

498,876,246280,961,678

5,857,155

512,080,656

796.129,601

1,158,805,878

144,260,601

215.222,447

16,031,46018,121,200

534,163,521

-(81.995,659

833.532,181

419,820

145,398,780

1.456,688

19,839,696

158,742,834107,672,587

173,632,197

9,380,260

62,549,592

194,393,971

565,768,163

41,245,196

71,904,391

4,794,825

45,634,400575,719,447278,018,676

99,804,376

6,689,172

235,859,315

9,119,23973,568,563

372,844,377

697,866,354

217,564,899

3,560,291

626,808,090

535,054,133

1,577,521,877263,993,962410,942,929

14,182,466

61,105,666

807,062,175

642,372,545

1,078,903,175

32,17012.810,949

01,745,731

13.S46.725

5,366,169

10,416,508

471,004

19,294,19617,921,371

28,727,734

4,708,561

7,414,749

823,569

1,226,969

167,681,000

22,740,801

13,701,194

0.18%

1.87%

0.00%

1.31%

1.59%

0.41%

1.55%

2.49%

1.61%

1.17%

0.87%

1.05%

1.06%

2.35%

0.88%

8.75%

1,62%

0,68%

0.48%

5,')3%

0.00%

2.37%

3,66%0.77%

4.79%13.23%

3.08%

3.35%

1.82%

1.78%

1.80%

5.81%

2.01%

20.78%

3.54%

1.27%

Remaining King County

ComAfned[Ktniff County^1.64%i.4y/,

4.?Z%3.4S'/,

Lie. No RegionlHosâal

F

Tolal Patent Scrrico

Revenue

•yenua Categories- F

(Less) MeiScse

nianl Senica Rove nud -1 B Bed Chaiges)

(Leis)Medi:aIdRevenue

Adjusted PatientSendcs Rexnua Charity Caro

ChafftyCareas a % of

To(a) Pafcntt SWVKB

Revenue

ChantyCaiaas a V, of

Acfjusted PaUentSence Revenue

Kindred Mosplal Seatlto

Soatlta Ctiadren's HospHal

Unheraity ofWastihgwn Medcat Center

Noritiwest Hospitai

98.448.636

1.664.910.732

1.765,665.477

844.423.781

44,69^285

23.379. SB 1

421,231,997

3B9,B23.906

a,553,3BZ

761.603,159

216.B62.087

59.51 B.918

45,196,969

879,927.992

1.12S.365.391

395,080.957

32,837,240

46,9K,45S

16,575,074

0.00%

1.97%

2.77%

1.66%

0.00%

3,73%

4.35%

4.20%

Honh IVngPlMnlna Area

Auburn Regicnai 1,'eA.W Center

BHC FaiffM HospiUBW

Eve-rgrecfl HospBsl Medical Center

HaiborriswMedcalCentef

Higtiana Cwnmunay HospilaB

Navos

Overtake HuspiUJ htecfcal Centef

Regtonat He spites

Saint Efcabeth HoipBal

Saint Ffancls Conun unity Hospaal

SeafUe Cancer Care Wiance

Snoqnainie Vafey KaspilaSW

Swedish lssaquah#

Swecfsh Medcal Center- Hrel Hii

Swe<foh WeiScst Cenler- Cheriy Hin

Valley Meifeal Centef- Renton

Virgiria Mascn Medcal Center

SS3.9t4.034

9B.OT6.959

1,17Z,29»,459

1,785,909,000

316,932,909

16.565.6&S

1.1?S.8t3.499

38,396,827

124,775.295

808,172,473

6ZS.400.663

32,022,806

4S7.(MB,192

3,m<M9.66S

1.446.599.051

1,255.937.307

1,873.202,028

2M.-179.552

14,120.918

456.272,769

482.72 7.995

139.362,213

5,098,445

458.794.629

Z1.1CtS.33Z

as.9ai.osi

228.628,397

1B0.343.fi24

15,75?. 740

1S9.29I.612

1.074.968.7U1

758.i06.B10

187,528,614

780.185,7? 7

132,357.021

31.331,440

81,753,369

370,915.029

S3.344.220

7.956.605

46.634.557

Z,344.B7Z

13.967.242

120,182.491

59,694.539

3. tU,505

23.680.21Z

409,7BS,774

11B, 392.603

63.049.3ZI

62.095.273

167.077.461

53.514.601

6M.260.321

932,265,976

124,226.476

3.510.3SS

62t.324.313

14.M6.623

74.626.972

459.361.5a5

386.362,300

13.131.561

Z94.076.368

1,696,292,090

570.099,&}3

1.005,359.472

1.03[>,9Zft978

18.256.113

1.942.250

10.4 83.7 W

219,080.000

7,7W,B10

2U,76t

21.743.0S7

566.023

2,572 ,SZS

22.733.136

7.940.316

S97.A BS

7.590.167

60.164.60S

32,870,660

24.639.644

26.791.783

324%

).%%

0.89%

»Z.Z7%

2.46%

1.41%

1.93%

1.4?%

2.06%

2.61%

1.27%

1.24%

1.66%

1.89'A

2.27%

1.96%

1.43%

\0.93%

3.63';4

1.65%

23.50%

8.27%

6.66%

3.50%

3.79%

3,-M%

4.95%

Z,06%

3,03 it

2-58%

3.55%

5.77%

2.45'A

2,60%

Lie. Ho R&gion/Hospital

NWES SeautoCharity Cars Pm^ctun 20161

Charity Cars Projedion2019|ChaiBy Care PfojectKn2020|

Tctd Patiert Serves

7.543.037

7.937.S3S

8.S52.672

Rama/nhtfffOngCcunfif

CmnblncdKlng County

3 Yew Awaga Horth King County Csmbtned

J fear Avenge Kfnfl County ComWntd

Rmenua C;

(Less} ^(ScaeRsvwve

3.207. B5S

3,375.625

3,652,171

AvttagtvfUwtvwgreui

iegories - Patient Senrtce Revanue- (Bated Chafgss)

(Less) Me<ficaMRavenua

Adjusted PatientSewico Rsvenua

%ofTmalPalwntSerfce Re-.-eme

3Z0.147 4.015.035 101.340

3 36.890 4.225.023 IOB.T44

354,510 4.44 5. Ml 114.432

1.4 Stt

s.om

».M%

f.sdtt

J^7X

Charity Care as a %

ofAiflusled PatientService Revenue

117,641

1Zi793130.26S

s.ny,

4.1W

3.4W

3.43',,

2.MK

Charity Car^

as a % ofToldPatienttSemIoe

Rek'enue

1.37<

1.3716

l.3Th

CtitHiyCaroasaôf

Adjusted PaUentSen-ice Rave nus

2.93%

2.93X

2-93%


Single Line Drawing

;v

1-11/Xn N3L^&M

riS 9b39^0N

n n-UW aLiiyayj

JS b^.

rfT^F-n

um<svdO 3^c!/-LIUC]V

r!S bi.

/?T^T^Liy^y

j9 bL/?T^hnuium

/ffH-j^Liysivra'

fc)NW-L9 Aiddrs-j^yai^

jsb^R^Niwtetl

^S 913

c^^d y3i^

J9 bit

Nv-iNcoaa

yoaiâ? '^n9s^wsia

rfr^F-n

3fcWh3SICI


Lease Agreement

ruRPAI

EXHIBIT A-3

LCD OF PREMISES

NOfthffK* North 3WM >^t<! !LOI.^«r«-^rD<T^îtrrij,-»-

Northwest K\e Surgeons Lease i L^2li )') A-t3

Documents

Ambulatory Surgical Facility and Ambulatory Surgery Center