2021-11-19T14:38:10-06:00 2020-12-31 ERNST & YOUNG US LLP 155 N Wacker Drive Chicago IL 60606 990 2020-01-01 390845590 MEMORIAL HOSPITAL OF BOSCOBEL % RONDA FOSTERLING MEMO 6083754112 205 PARKER STREET BOSCOBEL WI 53805 JEN BOIGENZAHN FINC ADMINISTRATOR 6083754112 2021-11-19 true JEN BOIGENZAHN 999009999 JESS WAGENER P01622613 3128792000 2021-11-19 3 2020 2022-09-23 18:48:47Z SEE SCHEDULE O JEN BOIGENZAHN 205 PARKER STREET BOSCOBEL WI 53805 25517982 false X www.gundersenhealth.org/boscobel X 1952 WI WE WILL IMPROVE THE HEALTH OF OUR COMMUNITY THROUGH EXCELLENCE IN HIGH QUALITY, PATIENT CENTERED CARE. 11 5 185 25 0 270690 567097 22781410 24617302 18253 26168 141097 306886 23211450 25517453 0 0 0 0 8478296 9930221 0 0 0 11559776 12390070 20038072 22320291 3173378 3197162 21966731 32413174 5206250 12273921 16760481 20139253 X WE WILL ENHANCE THE HEALTH AND WELL-BEING OF OUR COMMUNITIES WHILE ENRICHING EVERY LIFE WE TOUCH, INCLUDING PATIENTS, FAMILIES AND STAFF. false false 18331169 21540520 GUNDERSEN BOSCOBEL AREA HOSPITAL AND CLINICS (THE "ORGANIZATION") PROVIDES INPATIENT, OUTPATIENT, EMERGENCY HEALTH CARE SERVICES AND OTHER FINANCIAL SUPPORT THROUGH VARIOUS PROGRAMS THAT ARE DESIGNED, AMONG OTHER MATTERS, TO ENHANCE THE HEALTH OF THE COMMUNITY INCLUDING THE HEALTH OF LOW-INCOME PATIENTS. SERVICES PROVIDED TO PATIENTS INCLUDE COLONOSCOPIES, LAPAROSCOPIC SURGERIES, AND KNEE REPLACEMENTS, AMONG OTHERS. THE ORGANIZATION IS AFFILIATED WITH GUNDERSEN HEALTH SYSTEM. THIS AFFILIATION PROVIDES LOCAL SERVICES IN CARDIOLOGY, NEUROLOGY, PODIATRY, DERMATOLOGY, UROLOGY, AND VASCULAR MEDICINE AS WELL AS MANY OTHER SERVICES. CONSISTENT WITH THE MISSION OF THE ORGANIZATION, CARE IS PROVIDED TO PATIENTS REGARDLESS OF THEIR ABILITY TO PAY, INCLUDING PROVIDING SERVICES TO THOSE PERSONS WHO ARE EITHER UNDERINSURED OR WHO CANNOT AFFORD HEALTH INSURANCE BECAUSE OF INADEQUATE RESOURCES. HEALTH CARE SERVICES TO PATIENTS UNDER GOVERNMENT PROGRAMS, SUCH AS THE MEDICAID PROGRAM, ARE ALSO CONSIDERED PART OF THE ORGANIZATION'S BENEFIT PROVIDED TO THE COMMUNITY, SINCE A SUBSTANTIAL PORTION OF SUCH SERVICES ARE REIMBURSED AT AMOUNTS LESS THAN THE COSTS OF PROVIDING CARE. (SEE ADDITIONAL INFORMATION REGARDING THE COST OF PROVIDING SERVICES TO MEDICAID PATIENTS IN SCHEDULE H OF THE FORM 990.) PATIENTS WHO MEET CERTAIN CRITERIA FOR CHARITY CARE, GENERALLY BASED ON FEDERAL POVERTY GUIDELINES, ARE PROVIDED CARE AT A SIGNIFICANTLY REDUCED RATE, DETERMINED BASED ON QUALIFYING CRITERIA AS DEFINED IN THE ORGANIZATION'S CHARITY CARE POLICY AND FROM APPLICATIONS COMPLETED BY PATIENTS AND THEIR FAMILIES. (SEE ADDITIONAL INFORMATION REGARDING THE COST OF PROVIDING SERVICES TO CHARITY CARE RECIPIENTS IN SCHEDULE H OF THE FORM 990.) BENEFITS FOR SERVING THE COMMUNITY ALSO INCLUDE UNPAID COSTS OF TREATING THE ELDERLY, HEALTH SCREENINGS, COMMUNITY EDUCATION THROUGH SEMINARS AND CLASSES, AND OTHER HEALTH-RELATED SERVICES. DURING 2020, HOSPITAL PATIENT DAYS TOTALED 912 AND TOTAL OUTPATIENT ENCOUNTERS WERE 23,776. KEY STATISTICS INCLUDED IN THESE TOTALS WERE 434 MEDICAL/SURGICAL INPATIENT DAYS, 482 SWING BED DAYS, 4,052 EMERGENCY ROOM VISITS, AND 321 SURGICAL OUTPATIENT VISITS. 3381905 THE ORGANIZATION OPERATES FAMILY PRACTICE CLINICS IN THREE LOCATIONS TO ENSURE COMMUNITY MEMBERS HAVE ACCESS TO CONVENIENT, QUALITY PRIMARY CARE. DURING 2020, TOTAL OUTPATIENT ENCOUNTERS AT THESE CLINICS TOTALED 11,321. THE THREE CLINICS ARE DESIGNATED AS RURAL HEALTH CLINICS BY THE MEDICARE AND MEDICAID PROGRAMS AND BY DEFINITION PROVIDE HEALTH CARE TO AREAS DESIGNATED AS MEDICAL PROFESSIONAL SHORTAGE AREAS WHERE WITHOUT THESE CLINICS THERE WOULD BE LIMITED ACCESS TO PRIMARY CARE CLINICAL SERVICES. IN ADDITION, THE ORGANIZATION'S CHARITY CARE PROGRAM IS ALSO AVAILABLE TO PATIENTS OF THE CLINICS AND IS INCLUDED IN THE CHARITY CARE AMOUNT REPORTED FOR THE HOSPITAL AS CHARITY CARE. 18331169 true false false true false false false false false false true false false false true false false true false false false false false false false false true true false false true true false false false false false false false false false false false false false false false true true false false false true 15 185 true 185 true false false false false false false false false false false false X 11 5 false true false false true true true true true false false true true true true true true false false false WI X RONDA FOSTERLING 6083754112 205 PARKER STREET BOSCOBEL WI 53805 X MARILU BINTZ MD BOARD MEMBER/MED VP GHS 39.5 0.5 X 0 574361 47619 ANDY NAHAS MD BOARD MEMBER/OPTOMETRY 0.5 0.0 X 0 202004 45717 SCOTT KNIPRATH VICE PRESIDENT/EXEC DIR GH 39.5 0.5 X X 0 165480 55764 THERESA BRAUDT ADMINISTRATOR 39.5 0.5 X 0 161137 34049 JAMES KLOCK BOARD MEMBER/DIR OF REG IS 39.5 0.5 X 0 131743 35626 TARA WOOD PHARMACIST 40.0 0.0 X 136117 0 27937 KEITH FRYE SECRETARY/ADMIN DIR - LAB 39.5 0.5 X X 0 120942 33669 MICHELLE PETERSON APNP FAMILY MEDICINE 40.0 0.0 X 128111 0 20510 DOUGLAS KNOBLE PHARMACIST 40.0 0.0 X 112955 0 30949 JENNIFER BOIGENZAHN FINANCE ADMINISTRATOR 39.5 0.5 X 0 122730 16402 DAWN THORSTEN BOARD MEMBER/DIR OF QUALITY 39.5 0.5 X 0 106269 32017 BRAD ECKLOR PA FAMILY MEDICINE 40.0 0.0 X 111704 0 24048 PETER ESSER BOARD MEMBER 0.5 0.0 X 0 0 0 MICHELLE MUELLER BOARD MEMBER 0.5 0.0 X 0 0 0 LORI BARRY TREASURER 0.5 0.0 X X 0 0 0 JERRY BERGE PRESIDENT 0.5 0.3 X X 0 0 0 CYNDE LARSON BOARD MEMBER 0.5 0.0 X 0 0 0 488887 1584666 404307 4 true true false WAPITI MEDICAL STAFFING 107 FLYNN DRIVE STE 600 MILBANK SD 57252 MEDICAL STAFFING 1985000 BEINBORN ANESTHESIA S C 62598 BLUFFS OF WILDERNEST PRAIRIE DU CHIEN WI 53821 CRNA PROF. SERVICES 302849 STAFFENCY 221 W COLLEGE AVE FLR 2 APPLETON WI 54911 LAB TECH/PT/ER STAFF 261477 ALPHA CONTROLS SERVICES LLC 4104 CHARLES STREET ROCKFORD IL 61108 EQUIPMENT/SVC CONTR 136796 SHARED MEDICAL SERVICES 209 LIMESTONE PASS COTTAGE GROVE WI 53527 MRI READS 102280 5 567097 567097 HOSPITAL PATIENT REVENUE 621110 19976436 19976436 CLINIC REVENUE 621110 3381905 3381905 PHARMACY REVENUE 446110 1258372 1258372 ALL OTHER PROGRAM SERVICE REVENUE 621110 589 589 24617302 26168 26168 0 0 2292 529 1763 0 1763 1763 0 0 0 0 0 0 0 0 0 0 RURAL CRITICAL CARE PAYMENT 900099 189428 189428 EHR INCENTIVE PAYMENTS 621990 88434 88434 REIMBURSEMENT FOR MAINTENANCE SVCS 900099 21000 21000 6261 6261 305123 25517453 24922425 27931 X 0 0 0 0 334317 334317 0 7608880 6193007 1415873 214796 159317 55479 1253958 784856 469102 518270 393573 124697 0 750 750 38140 38140 4198 4198 0 0 6157418 5327438 829980 86009 86009 242381 159154 83227 0 0 332322 276650 55672 33779 27992 5787 0 28761 20842 7919 145954 145954 0 873425 541815 331610 69705 69705 BILLABLE MEDICAL SUPPLIES 2653772 2645828 7944 0 PROVISION FOR BAD DEBTS 1141808 1141808 0 EQUIPMENT RENTAL 281760 265359 16401 0 REPAIRS & MAINTENANCE 225668 225653 15 0 74220 21923 52297 22320291 18331169 3989122 0 24218 25438 11828114 22094919 0 0 2252296 2661659 0 0 0 0 0 0 396773 390633 148677 236492 20709947 14627309 6508319 6082638 0 0 0 0 0 0 22486 16864 785848 904531 21966731 32413174 1430410 4904126 0 0 184238 4109922 3093640 2776693 0 0 0 0 195852 133987 0 0 302110 349193 5206250 12273921 X 16170485 19368178 589996 771075 16760481 20139253 21966731 32413174 X 3197162 181610 X X false true X true X false false false false false false false false true 4198 4198 false PART II-B, LINE 1, LOBBYING ACTIVITES GUNDERSEN BOSCOBEL AREA HOSPITAL AND CLINICS (THE "ORGANIZATION") PAYS ANNUAL ASSOCIATION MEMBERSHIP DUES TO THE WISCONSIN HOSPITAL ASSOCIATION (WHA). THESE DUES ARE PAID PRIMARILY TO ACCESS EDUCATIONAL MATERIALS AND FOR STAFF TRAINING. THE WHA HAS NOTIFIED THE ORGANIZATION THAT $1,440 OF THE ANNUAL DUES WERE USED IN CONJUNCTION WITH LOBBYING ACTIVITIES WITH THE GOAL OF IMPROVING THE OVERALL HEALTH CARE ENVIRONMENT. THE ORGANIZATION IS ALSO A MEMBER OF THE RURAL WISCONSIN HEALTH COOPERATIVE (RWHC). EACH YEAR THE ORGANIZATION PAYS MEMBERSHIP FEES TO RWHC. THE RWHC PROVIDES SUPPORT SERVICES FOR A NUMBER OF ITS MEMBER HOSPITALS THROUGHOUT THE STATE OF WISCONSIN. SOME OF THE MANY SERVICES PROVIDED TO MEMBER HOSPITALS INCLUDE PROVIDING ASSISTANCE TO ORGANIZATIONS IN FINDING GRANT FUNDING FOR NEW PROGRAMS, LEGAL SERVICES, REIMBURSEMENT REVIEW SERVICES, ACCOUNTING ASSISTANCE, CONTRACTING FOR THERAPIST COVERAGE, AND ADMINISTRATIVE CONSULTING SERVICES. AS A PART OF THESE SERVICES, RWHC ALSO PROVIDES AN ANALYSIS OF CURRENT HEALTH CARE ISSUES IN AN EFFORT TO PROMOTE AND BETTER HEALTHCARE FOR HOSPITALS IN RURAL COMMUNITIES THROUGHOUT WISCONSIN. ONE OF THESE EFFORTS ALSO INCLUDES A SMALL AMOUNT OF LOBBYING ON THE PART OF THE MEMBER HOSPITALS. THE RWHC DETERMINED THAT $1,940 OF THE FEES PAID BY THE ORGANIZATION IN 2020 RELATED TO LOBBYING ACTIVITIES WITH THE GOAL OF IMPROVING THE HEALTH CARE ENVIRONMENT IN THE STATE OF WISCONSIN. $818 OF MEMBERSHIP FEES PAID TO THE AMERICAN HOSPITAL ASSOCIATION WERE USED IN CONJUCTION WITH LOBBYING. 348441 348441 12985611 8785111 4200500 7375895 5842198 1533697 6082638 0 THIRD PARTY REIMBURSEMENT PAYABLE 322693 ASSET RETIREMENT OBLIGATION 26500 349193 X FORM 990, SCHEDULE D, PART X LINE 2 INCOME TAX MATTERS (IN THOUSANDS) THE SYSTEM QUALIFIES AS A TAX-EXEMPT ORGANIZATION UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE (THE CODE), WITH THE EXCEPTION OF GUNDERSEN LUTHERAN ENVISION, LLC, WHICH IS A FOR-PROFIT ENTITY. AT DECEMBER 31, 2020 AND 2019, NET DEFERRED TAX ASSETS OF $7,948 AND $6,900, RESPECTIVELY, WHICH PRIMARILY ARE RELATED TO NET OPERATING LOSS CARRYFORWARDS, HAVE VALUATION ALLOWANCES OF $7,948 AND $6,900, RESPECTIVELY, RECORDED AGAINST THEM DUE TO THE UNCERTAINTY OF REALIZING THOSE BENEFITS IN THE FUTURE. AT DECEMBER 31, 2020, THE SYSTEM'S FEDERAL NET OPERATING LOSS CARRYFORWARDS WERE APPROXIMATELY $29,800, AND THE STATE NET OPERATING LOSS CARRYFORWARDS WERE APPROXIMATELY $27,900, WHICH WILL EXPIRE BETWEEN 2029 AND 2038. THE SYSTEM HAS REVIEWED ITS TAX POSITIONS FOR ALL OPEN YEARS AND HAS CONCLUDED THAT NO LIABILITIES EXIST FOR UNCERTAIN TAX POSITIONS. THE SYSTEM'S INCOME TAX RETURNS ARE NO LONGER SUBJECT TO EXAMINATION FOR 2015 AND PRIOR YEARS. true true X true X true X true true false true true 180153 0 180153 0.00850 3087855 3196205 0 0.00000 0 0 0 0.00000 3268008 3196205 180153 0.00850 9003 0 9003 0.00040 0 0 0 0.00000 8492309 8282458 209851 0.00990 0 0 0 0.00000 7535 0 7535 0.00040 8508847 8282458 226389 0.01070 11776855 11478663 406542 0.01920 false 413375 201597 7613921 7577722 36199 X true true 1 1 memorial hospital of boscobel 205 Parker Street boscobel WI 53805 www.GUNDERSENHEALTH.ORG/BOSCOBEL 1048 X X X X memorial hospital of boscobel 1 false false true X X X X X X X X X 18 true true true true X SEE SUPPLEMENTAL INFORMATION X X true 19 true SEE SUPPLEMENTAL INFORMATION false true X 200. 400. X X X X X X true true X X X X true X SEE PART V, PAGE 8 X SEE PART V, PAGE 8 X SEE PART V, PAGE 8 X X X X X X true X false X X X X true X false false SCHEDULE H, PART V, SECTION B, LINE 5: The Community Health Needs Assessment (CHNA) engaged a number of sectors of the community at various levels of participation. Community participants were defined as key partners, stakeholders, or general community. Below are the definitions and roles of each group. Key Partners- Hospitals, Public Health, UW-Extension, ADRC The consortium of key partners met regularly to conduct the Community Health Needs Assessment. Tasks required of this group included identifying process, creating surveys, identifying target audiences for participation in the surveys, assembling and reviewing results of data, identifying communities for focus groups, and conducting focus groups. Stakeholders Individuals with a vested interest in the community, and individuals who represent a larger demographic (ie: social workers, free clinic workers, school principals, government officials). Stakeholders were asked to identify the sector or sectors of the population they represented, including: business, health care, faith-based, education, youth-serving, agriculture, government, aging, disabilities, low income, minority, education or other. The Stakeholder Survey was open from September 15 - October 31, 2018. 192 total responses were collected. All of the above sectors had adequate representation, with the lowest represented sector at 7.4% (minority), the highest at 50.6% (healthcare), and the average category ranging from 20-30% (education, youth, low income, government). General Community Individuals and community members representing their own interests were reached in two ways: A general survey completed via online sources, at public events and focus groups. The General Public Survey was open from October 31 - November 26, 2018. 142 total responses were collected. Respondents identified themselves by age and number of children in household. Focus group participants were identified by age and gender. Thirteen (13) focus groups were conducted in twelve (12) communities to provide qualitative data on topics such as perceived access to health care, barriers to health care, and ways health organizations can reach the public with information and education. Participants were asked brief questions about their general impressions of health and healthcare services in the community in which they live and/or work. SCHEDULE H, PART V, SECTION B, LINE 6A: THE CHNA WAS CONDUCTED IN JOINT EFFORT WITH THE FOLLOWING OTHER HOSPITALS: 1. CROSSING RIVERS HEALTH 2. GRANT REGIONAL HEALTH CENTER, INC. SCHEDULE H, PART V, SECTION B, LINE 6B: THE CHNA WAS CONDUCTED IN JOINT EFFORT WITH THE FOLLOWING OTHER ORGANIZATIONS: 1. CRAWFORD COUNTY PUBLIC HEALTH DEPARTMENT 2. GRANT COUNTY PUBLIC HEALTH DEPARTMENT 3. CRAWFORD COUNTY UNIVERSITY OF WISCONSIN - EXTENSION 4. GRANT COUNTY UNIVERSITY OF WISCONSIN - EXTENSION 5. AGING AND DISABILITY RESOURCE CENTER - CRAWFORD AND GRANT COUNTIES SCHEDULE H, PART V, SECTION B, LINE 7D: HTTP://WWW.GUNDERSENHEALTH.ORG/COMMUNITY-ASSESSMENT/ SCHEDULE H, PART V, SECTION B, LINE 10A HTTP://WWW.GUNDERSENHEALTH.ORG/COMMUNITY-ASSESSMENT/ SCHEDULE H, PART V, SECTION B, LINE 11: The Community Health Needs Assessment process provided crucial information about the health and wellness needs of the communities we serve, as well as identified gaps and barriers to health and healthcare services. Based on the data, research and validation efforts, the CHNA highlighted three (3) overarching health needs: 1. Empower people to improve their health through awareness and education 2. The need to connect people to services and resources 3. The need to create a healthy environment and a culture of wellness across the lifespan The Implementation Plan that Gundersen Boscobel Area Hospital and Clinics has developed and implemented will aim to address the identified needs. Below is a summary of 2020 initiatives and efforts thus far: Empower people to improve their health through awareness and education: To assist in empowering people to improve their overall health, we've worked diligently to pivot former class offerings and modify programs and outreach services to the area to meet enhanced safety precautions amid the global pandemic, while still making a local health impact and increasing overall awareness. Specifically, we continued to partner with the Boscobel Police Department for the safe disposal of unused medication and promote local Drug Take-Back events. Our in-house pharmacy team also works closely with clinic and registration staff to provide education to patients and families related to our Sharps and Needle Disposal Program and we continue to offer sharps and needle disposal at no cost to GBAHC patients. Much work was placed on developing and executing pain contracts within our Primary Care Clinics - providing education to patients and building plans for improved outcomes. We continued to enhance our diabetic education content and increased program engagement by adding a behavioral health component to the curriculum. This was made possible through a collaborative effort between primary care, phycologist Joni Downs and Chris Swan, RDN, CD. In addition, we partnered with GHS Office of Population Health, to bring the 6-week Health Living with Diabetes (HLWD) course to Boscobel (11/4/20-12/9/20). Connecting people to services and resources: In our pursuit to connect people to needed services and resources, we have focused on the following: Growing the number of specialty providers and conditions treated in the rural setting through partnerships with GHS clinicians and specialists. In 2020, two new specialties were added. We continue to expand telemedicine capabilities that allows greater access for follow-up care with specialty providers and services not offered at our location. 125 telemedicine visits were performed from GBAHC Specialty Clinic. Both have allowed GBAHC to keep care close to home (when appropriate); reducing the patient financial burden associated with traveling for healthcare. This has also afforded area residents, many of whom are low-income, elderly and/or have transportation barriers, improved health as they may have otherwise declined care due to these barriers. Clinical Services most noted in the CHNA as being needed in our rural setting, included: Mental Health, Alzheimer's and Dementia care and increased cancer screening and prevention. To address these needs, the Collaborative Care Model of Care continues to be refined and encouraged within our primary care setting. Through our Phycologist and LCSW, the behavioral health needs of our patients have been better supported and interventions are more quickly identified and encouraged. To reduce the stigma around mental health, our behavioral health team continues to play an active role in the Grant County Mental Health Matters initiative and provides insight through various mental health platforms, as well as providing outreach education for area EMTs/Fire Departments, school district staff, hospital and clinic staff (including new employees). To address available cancer screenings and service access within our primary service area, we worked with GHS to bring in-house 3D mammography to Boscobel. We also participated in various virtual community efforts aimed at raising awareness around the importance of timely screenings (social media, virtual run/walks, dress in pink days). We continue to grow and expand cancer care locally in partnership with GHS. While needing to limit the number of patients coming into the clinic setting during the pandemic to reduce risk of exposure, phone and video visit were launched in March/April 2020. Through innovation and technology, we were able to reimage care delivery where appropriate and still meet the needs of our community despite the challenges presented by the rapidly changing healthcare landscape. In total, 347 virtual visits and 524 telephone visits were completed in 2020. Creating a healthy environment and a culture of wellness across the lifespan: While our efforts to encourage a healthy environment and a culture of wellness had to look differently in 2020, we offered a virtual Safe At Home child safety course on June 30, 2020 in collaboration with GHS Office of Population Health which had 9 attendees. We also moved forward with offering our FLAG Program - a 12-week wellness program for children ages 8-12 and their families - through a hybrid delivery model to ensure families could still access the program's whole-person wellness content regardless of public health guidance (i.e. could engage from the safety of their homes or in-person). Staff were committed to connecting with area youth and shared their reading talents virtually by reading health and emotional well-being topics to elementary school aged children through our social media page. We also filmed a virtual hospital tour for area elementary schools which followed Copper the Bear throughout his hospital journey following a fall from a tree. Our internal Sensory Friendly efforts continued. To address at risk patients, Diabetic Screening letters were sent to the homes of at-risk patients who were due for their screening. 192 patients were also referred to Gundersen's Tobacco Cessation Intervention Program. Health Initiatives not implemented/Needs not met and reasons for each: As the global pandemic wages on, several classes, support groups and efforts to build upon past coalition work, had to be paused. Specially, the below initiatives were paused in 2020: . Onsite Grief Support Group - No meetings held due to COVID-19 pandemic . Attendance of area mental health coalition meetings to improve community access and awareness - No meetings held due to COVID-19 pandemic . Dementia Friendly Boscobel - Put on hold due to agency staffing availability and COVID-19 pandemic . Alzheimer's and Dementia Education - 5 events scheduled, cancelled due to COVID-19 . Development of Movin' & More Voucher Program to support and encourage cardiac rehab patients to continue their wellness journey by enrolling in the maintenance program - Implementation put on hold due to COVID-19 Pandemic and limited occupancy allowed in gym area. . Did not reach our 2020 goal for executed pain contracts with patients on the Chronic Pain Registry with a Chronic Pain Agreement documented - Number of Pain Contracts decreased due to COVID-19 and the inability to make appointments to update contracts. . Education events and tabling for community members, school districts, employers, and local entities was significantly down from years past due to the pandemic. Some of the training that was unable to be held, included: Vaping Education, Safe Sitter, Stop the Bleed, ACEs/TIC/RTIC and CPR trainings, speaking engagements, etc. SCHEDULE H, PART V, SECTION B, LINE 13H GUNDERSEN BOSCOBEL AREA HOSPITAL AND CLINCS (GBAHC) UNDERSTANDS THAT NOT ALL PATIENTS ARE ABLE TO COMPLETE A FINANCIAL ASSISTANCE APPLICATION OR COMPLY WITH REQUESTS FOR DOCUMENTATION. THERE MAY BE INSTANCES UNDER WHICH A PATIENT'S QUALIFICATION FOR FINANCIAL ASSISTANCE IS ESTABLISHED WITHOUT COMPLETING THE FORMAL FINANCIAL ASSISTANCE APPLICATION. OTHER INFORMATION MAY BE UTILIZED BY GBAHC TO DETERMINE WHETHER A PATIENT'S ACCOUNT IS UNCOLLECTIBLE, AND THIS INFORMATION WILL BE USED TO DETERMINE PRESUMPTIVE ELIGIBILITY. PRESUMPTIVE ELIGIBILITY MAY BE GRANTED TO PATIENTS BASED ON THEIR ELIGIBILITY FOR OTHER PROGRAMS OR LIFE CIRCUMSTANCES SUCH AS: 1. PATIENTS OR GUARANTORS WHO HAVE DECLARED BANKRUPTCY. IN CASES INVOLVING BANKRUPTCY, ONLY THE ACCOUNT BALANCE AS OF THE DATE THE BANKRUPTCY IS DISCHARGED WILL BE WRITTEN OFF. 2. PATIENTS OR GUARANTORS WHO ARE DECEASED WITH NO ESTATE IN PROBATE. 3. PATIENTS OR GUARANTORS DETERMINED TO BE HOMELESS. 4. ACCOUNTS RETURNED BY THE COLLECTION AGENCY AS UNCOLLECTIBLE DUE TO ANY OF THE ABOVE REASONS. 5. PATIENTS OR GUARANTORS WHO QUALIFY FOR STATE MEDICAID PROGRAMS, WILL BE ELIGIBLE FOR ASSISTANCE FOR ANY COST-SHARING OBLIGATIONS ASSOCIATED WITH THE PROGRAM OR UNCOVERED SERVICES. GBAHC UNDERSTANDS THAT CERTAIN PATIENTS MAY BE NON-RESPONSIVE TO GBAHC'S APPLICATION PROCESS. UNDER THESE CIRCUMSTANCES, GBAHC MAY UTILIZE OTHER SOURCES OF INFORMATION TO MAKE AN INDIVIDUAL ASSESSMENT OF FINANCIAL NEED. THIS INFORMATION WILL ENABLE GBAHC TO MAKE AN INFORMED DECISION ON THE FINANCIAL NEED OF NON- RESPONSIVE PATIENTS UTILIZING THE BEST ESTIMATES AVAILABLE IN THE ABSENCE OF INFORMATION PROVIDED DIRECTLY BY THE PATIENT. GBAHC MAY UTILIZE A THIRD-PARTY TO CONDUCT AN ELECTRONIC REVIEW OF PATIENT INFORMATION TO ASSESS FINANCIAL NEED. THIS REVIEW UTILIZES A HEALTHCARE INDUSTRY-RECOGNIZED MODEL THAT IS BASED ON PUBLIC RECORD DATABASES. THIS PREDICTIVE MODEL INCORPORATES PUBLIC RECORD DATA TO CALCULATE A SOCIO-ECONOMIC AND FINANCIAL CAPACITY SCORE THAT INCLUDES ESTIMATES FOR INCOME, ASSETS AND LIQUIDITY. THE ELECTRONIC TECHNOLOGY IS DESIGNED TO ASSESS EACH PATIENT TO THE SAME STANDARDS AND IS CALIBRATED AGAINST HISTORICAL APPROVALS FOR GBAHC FINANCIAL ASSISTANCE UNDER THE TRADITIONAL APPLICATION PROCESS. THE ELECTRONIC TECHNOLOGY, WHEN UTILIZED, WILL BE DEPLOYED PRIOR TO BAD DEBT ASSIGNMENT AFTER ALL OTHER ELIGIBILITY AND PAYMENT SOURCES HAVE BEEN EXHAUSTED. THIS ALLOWS GBAHC TO SCREEN ALL PATIENTS FOR FINANCIAL ASSISTANCE PRIOR TO PURSUING ANY EXTRAORDINARY COLLECTION ACTIONS. THE DATA RETURNED FROM THIS ELECTRONIC ELIGIBILITY REVIEW WILL CONSTITUTE ADEQUATE DOCUMENTATION OF FINANCIAL NEED UNDER THIS POLICY. WHEN ELECTRONIC ENROLLMENT IS USED AS THE BASIS FOR PRESUMPTIVE ELIGIBILITY, THE HIGHEST DISCOUNT LEVELS WILL BE GRANTED FOR ELIGIBLE SERVICES FOR RETROSPECTIVE DATES OF SERVICE ONLY. IF A PATIENT DOES NOT QUALIFY UNDER THE ELECTRONIC ENROLLMENT PROCESS, THE PATIENT MAY STILL BE CONSIDERED UNDER THE TRADITIONAL FINANCIAL ASSISTANCE APPLICATION PROCESS. PATIENT ACCOUNTS GRANTED PRESUMPTIVE ELIGIBILITY WILL BE RECLASSIFIED UNDER THE FINANCIAL ASSISTANCE POLICY. THEY WILL NOT BE SENT TO COLLECTION AND WILL NOT BE INCLUDED IN THE HOSPITAL'S BAD DEBT EXPENSE. SCHEDULE H, PART V, SECTION B, LINE 16A https://www.gundersenhealth.org/app/files/public/54813688-1ba8-49fd-b13c-9 d816f097e04/boscobel-financial-assistance-policy. SCHEDULE H, PART V, SECTION B, LINE 16B: https://www.gundersenhealth.org/app/files/public/c139890f-890b-408d-8e5d-7 f6e6f502645/Financial-Assistance-all-locations-financial-assistance-applic ation-English.pdf SCHEDULE H, PART V, SECTION B, LINE 16C: https://www.gundersenhealth.org/app/files/public/17ad7410-f492-4707-8c5b-3 8cf512cab48/financial-assistance-boscobel-plain-language-summary-16.pdf 3 GUNDERSEN BOSCOBEL CLINIC 208 PARKER STREET BOSCOBEL WI 53805 PROVIDER BASED RURAL HEALTH CLINIC GUNDERSEN FENNIMORE CLINIC 220 LINCOLN AVENUE FENNIMORE WI 53809 PROVIDER BASED RURAL HEALTH CLINIC GUNDERSEN MUSCODA CLINIC 525 NORTH WISCONSIN AVENUE MUSCODA WI 53573 PROVIDER BASED RURAL HEALTH CLINIC SCHEDULE H, PART I, LINE 3C: THE HOSPITAL USES THE FEDERAL POVERTY GUIDELINES AS ONE MEANS OF DETERMINING ELIGIBILITY FOR CHARITY CARE. THE FEDERAL POVERTY GUIDELINES ARE UPDATED AND PUBLISHED ANNUALLY BY THE U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES. AS A GENERAL RULE, A PATIENT'S INCOME, BASED ON FAMILY SIZE, MUST BE AT OR BELOW 200% OF THE FEDERAL POVERTY GUIDELINES TO BE ELIGIBLE FOR THE CHARITY CARE PROGRAM. A SLIDING SCALE BASED ON THE PATIENT'S INCOME LEVEL UNDER THE FEDERAL POVERTY GUIDELINES WILL BE USED TO DETERMINE THE PRECISE AMOUNT OF CHARITY CARE FOR WHICH A PATIENT WILL BE ELIGIBLE. SOME PATIENTS MAY EXCEED 200% OF THE FEDERAL POVERTY GUIDELINES BUT MAY STILL BE ELIGIBLE FOR CHARITY CARE WHEN ADDITIONAL CRITERIA SUCH AS CATASTROPHIC MEDICAL COSTS ARE CONSIDERED. CATASTROPHIC MEDICAL CARE COSTS ARE DETERMINED ON A CASE-BY-CASE BASIS TO PATIENTS WHO DUE TO A SIGNIFICANT OR RECURRENCE OF MEDICAL BILLS MAY NEED ADDITIONAL COMMUNITY SUPPORT TO HELP A PATIENT OR THEIR FAMILY THROUGH A DIFFICULT TIME. SCHEDULE H, PART I, LINE 7: THE COSTING METHOD USED ON FORM 990 IS BASED ON A COST-TO-CHARGE RATIO WHICH IS DEVELOPED BASED ON THE HOSPITAL'S TOTAL OPERATING EXPENSES LESS THE PROVISION FOR BAD DEBT DIVIDED BY GROSS PATIENT SERVICE REVENUE. THIS COST TO CHARGE RATIO IS APPLIED AGAINST VARIOUS REVENUE AND EXPENSE CATEGORIES TO COMPUTE THE ESTIMATED COMMUNITY BENEFIT EXPENSE UNDER IRS SUGGESTED COSTING METHODS FOR THE FORM 990. THE COSTING METHODOLOGY FOR SUBSIDIZED HEALTH SERVICES IS BASED ON COST ALLOCATIONS FROM THE MEDICARE COST REPORT. THIS ALLOCATION METHOD AND PRINCIPLES OF ALLOCATION WERE USED TO DERIVE A SPECIFIC AMOUNT OF COST ALLOCATION TO THE VARIOUS PROGRAMS AND COST CENTERS OPERATED BY THE HOSPITAL. SCHEDULE H, PART I, LINE 7, COLUMN (F): THE TOTAL BAD DEBT EXCLUDED FROM TOTAL EXPENSES IS $1,141,808 SCHEDULE H, PART I, LINE 7G: SUBSIDIZED HEALTH SERVICES AT GUNDERSEN BOSCOBEL AREA HOSPITAL AND CLINICS INCLUDE THE OPERATION OF THE EMERGENCY DEPARTMENT AND THE OPERATION OF THREE RURAL HEALTH CLINICS. THE EMERGENCY DEPARTMENT IS STAFFED 24-HOURS PER DAY TO PROVIDE NEEDED ACCESS TO EMERGENCY CARE IN THE BOSCOBEL, WISCONSIN COMMUNITY OR AS REQUIRED BY REGULATIONS TO BE ON-CALL AND AVAILABLE TO PROVIDE ACCESS TO EMERGENCY CARE AS A PART OF OPERATING A HOSPITAL IN THE STATE OF WISCONSIN. THE OPERATION OF THREE RURAL HEALTH CLINICS IS ALSO PROVIDED AS A SUBSIDIZED HEALTH SERVICE IN ORDER TO MEET HEALTH CARE NEEDS IN THE SURROUNDING COMMUNITIES. GUNDERSEN BOSCOBEL AREA HOSPITAL AND CLINICS CURRENTLY OPERATES RURAL HEALTH CLINICS IN BOSCOBEL, FENNIMORE, AND MUSCODA, WISCONSIN. IT IS THE GOAL OF THE HOSPITAL TO PROVIDE THESE SERVICES TO THE COMMUNITY REGARDLESS OF A PATIENT'S ABILITY TO PAY. SCHEDULE H, PART III, LINE 2: THE COSTING METHODOLOGY USED ON FORM 990 IS BASED ON A COST-TO-CHARGE RATIO, WHICH IS DEVELOPED BASED ON THE HOSPITAL'S TOTAL OPERATING EXPENSES EXCLUDING THE PROVISION FOR BAD DEBT, DIVIDED BY GROSS PATIENT SERVICE REVENUE. THIS COST-TO-CHARGE RATIO IS APPLIED AGAINST THE TOTAL CHARGES THAT ARE WRITTEN OFF DURING THE YEAR TO ESTIMATE THE COST OF CARE OF PATIENTS WHO HAVE ACCOUNTS THAT ARE DEEMED TO BE BAD DEBTS TO THE HOSPITAL. THE HOSPITAL ALSO RECOGNIZES THAT IT ALSO PROVIDES A DISCOUNT TO SELF-PAY OR UNINSURED PATIENTS. THESE AMOUNTS ARE EXCLUDED FROM GROSS PATIENT SERVICE REVENUE ON THE FINANCIAL STATEMENTS AND ARE NOT INCLUDED IN THE RATIO AS DESCRIBED ABOVE AND APPROVED BY THE IRS FOR USE ON FORM 990. IF CONSIDERED, THESE ADDITIONAL WRITE-OFF AMOUNTS TO UNINSURED ACCOUNTS WOULD ALSO INCREASE THE ESTIMATED BAD DEBT EXPENSE AMOUNT ASSOCIATED WITH THESE UNCOLLECTIBLE ACCOUNTS TO THE HOSPITAL. SCHEDULE H, PART III, LINE 3: MANAGEMENT PROVIDES FOR PROBABLE UNCOLLECTIBLE AMOUNTS, PRIMARILY UNINSURED PATIENTS AND AMOUNTS PATIENTS ARE PERSONALLY RESPONSIBLE FOR, THROUGH A CHARGE TO OPERATIONS AND A CREDIT TO A VALUATION ALLOWANCE BASED ON ITS ASSESSMENT OF HISTORICAL COLLECTION LIKELIHOOD AND THE CURRENT STATUS OF INDIVIDUAL ACCOUNTS. BALANCES THAT ARE STILL OUTSTANDING AFTER THE HOSPITAL HAS USED REASONABLE COLLECTION EFFORTS ARE WRITTEN OFF THROUGH A CHARGE TO THE VALUATION ALLOWANCE AND CREDIT TO ACCOUNTS RECEIVABLE. MANY TIMES, PATIENTS DO NOT COMPLETE THE REQUIRED CHARITY CARE APPLICATION AND ARE TRANSFERRED TO COLLECTION SERVICES EVEN THOUGH THE HOSPITAL PROVIDES THIS INFORMATION TO ALL PATIENTS AND ASSISTANCE WITH THE APPLICATIONS. DUE TO NO RESPONSES FROM SOME PATIENTS, A SIGNIFICANT AMOUNT OF BAD DEBTS COULD BE CONSIDERED AS CHARITY CARE. SCHEDULE H, PART III, LINE 4: ACCOUNTS RECEIVABLE AND CREDIT POLICY: IN EVALUATING THE COLLECTABILITY OF PATIENT ACCOUNTS RECEIVABLE, THE ORGANIZATION ANALYZES PAST RESULTS AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYOR SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS AND PROVISION FOR BAD DEBTS. MANAGEMENT REGULARLY REVIEWS DATA ABOUT THESE MAJOR PAYOR SOURCES OF REVENUE IN EVALUATING THE SUFFICIENCY OF THE ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS. SPECIFICALLY, FOR RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRD-PARTY PAYOR COVERAGE, THE ORGANIZATION ANALYZES CONTRACTUALLY DUE AMOUNTS AND PROVIDES AN ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS AND A PROVISION FOR BAD DEBTS FOR EXPECTED UNCOLLECTIBLE DEDUCTIBLES AND COPAYMENTS ON ACCOUNTS FOR WHICH THE THIRD-PARTY PAYOR HAS NOT YET PAID, OR FOR PAYORS WHO ARE KNOWN TO BE HAVING FINANCIAL DIFFICULTIES THAT MAKE THE REALIZATION OF AMOUNTS DUE UNLIKELY. FOR RECEIVABLES ASSOCIATED WITH SELF-PAY PATIENTS (WHICH INCLUDES BOTH PATIENTS WITHOUT INSURANCE AND PATIENTS WITH DEDUCTIBLE AND COPAYMENT BALANCES DUE FOR WHICH THIRD-PARTY COVERAGE EXISTS FOR PART OF THE BILL), THE ORGANIZATION RECORDS A PROVISION FOR BAD DEBTS IN THE PERIOD OF SERVICE ON THE BASIS OF ITS PAST EXPERIENCE, WHICH INDICATES THAT MANY PATIENTS ARE UNABLE OR UNWILLING TO PAY THE PORTION OF THEIR BILL FOR WHICH THEY ARE FINANCIALLY RESPONSIBLE. THE DIFFERENCE BETWEEN THE STANDARD RATES (OR THE DISCOUNTED RATES IF NEGOTIATED) AND THE AMOUNTS ACTUALLY COLLECTED AFTER ALL REASONABLE COLLECTION EFFORTS HAVE BEEN EXHAUSTED IS CHARGED OFF AGAINST THE ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS. THE AUDITED FINANCIAL STATEMENTS DO NOT CONTAIN A SEPARATE FOOTNOTE REGARDING BAD DEBT EXPENSE. SCHEDULE H, PART III, LINE 8: THE TOTAL MEDICARE REVENUE SHOWN IN SCHEDULE H OF THE FORM 990 IS BASED ON THE IRS 990 INSTRUCTIONS AND INCLUDES ONLY A PORTION OF THE GROSS MEDICARE REVENUE OF THE HOSPITAL, AND ALSO DOES NOT CONSIDER ALL CONTRACTUAL ADJUSTMENTS FOR SERVICES REIMBURSED BY THE MEDICARE PROGRAM. AMOUNTS LISTED FOR MEDICARE REVENUES DO NOT INCLUDE PHYSICIAN SERVICES FOR THE COVERAGE OF THE EMERGENCY DEPARTMENT AT THE HOSPITAL AS WELL AS HOSPITAL INPATIENT PHYSICIAN PROFESSIONAL SERVICES, RESPIRATORY THERAPY PROFESSIONAL SERVICES, RADIOLOGIST PROFESSIONAL SERVICES, SURGEON PROFESSIONAL SERVICES, AND REVENUES FOR ANY PATIENTS COVERED UNDER MEDICARE ADVANTAGE PLAN PROGRAMS. PHYSICIAN PROFESSIONAL SERVICES ARE REIMBURSED PRIMARILY ON FEE SCHEDULE REIMBURSEMENTS AT RATES THAT ARE OFTEN BELOW THE COSTS OF CARING FOR PATIENTS. EMERGENCY AND PHYSICIAN SERVICES PROVIDED TO MEDICARE PATIENTS ARE VITAL TO THE WELL-BEING OF THE COMMUNITY AND AS SUCH THESE COSTS AND SHORTFALLS SHOULD ALSO BE CONSIDERED AS AN ADDITIONAL BENEFIT THAT GUNDERSEN BOSCOBEL HOSPITAL AND CLINICS PROVIDES TO THE COMMUNITY AND SURROUNDING AREAS. THE COSTING METHOD USED ABOVE FOR IRS 990 COMPLIANCE REPORTING IS ALSO BASED ON THE FILED MEDICARE COST REPORT FOR THE PERIOD ENDED DECEMBER 31, 2019, AND DOES NOT CONSIDER MEDICARE NON-ALLOWABLE EXPENSES, AS IT IS BASED ON TOTAL HOSPITAL PATIENT SERVICE REVENUE (IGNORING CONTRACTUAL ADJUSTMENTS ON FEE SCHEDULE REIMBURSED ITEMS AND NON-ALLOWABLE MEDICARE EXPENSES AS NOTED ABOVE). WHETHER THERE IS A SHORTFALL OR SURPLUS ON SERVICES PROVIDED TO MEDICARE BENEFICIARIES, THESE PEOPLE, WHO ARE TYPICALLY ELDERLY OR DISABLED MEMBERS OF THE COMMUNITY, ARE AN UNDERSERVED POPULATION WHO EXPERIENCE ISSUES WITH ACCESS TO HEALTHCARE SERVICES. WITHOUT TAX-EXEMPT HOSPITALS PROVIDING MEDICARE PATIENT SERVICES, THE CENTERS FOR MEDICARE AND MEDICAID (CMS) WOULD BEAR THE BURDEN OF DIRECTLY PROVIDING SERVICES TO THE ELDERLY AND DISABLED MEMBERS OF THE COMMUNITY. SCHEDULE H, PART III, LINE 9B: UNDER THE HOSPITAL'S COLLECTION AND CHARITY CARE POLICIES, GUNDERSEN BOSCOBEL AREA HOSPITAL AND CLINICS MAKES EVERY ATTEMPT TO IDENTIFY AND PROMOTE CHARITY CARE TO PATIENTS. INCLUDED IN THE HOSPITAL'S CHARITY CARE POLICY IT IS NOTED THAT PATIENTS MAY QUALIFY FOR CHARITY CARE EITHER PRIOR TO ADMISSION OR FOLLOWING DISCHARGE. ALL INPATIENT SELF-PAY ADMISSIONS ARE SCREENED BY THE HOSPITAL'S PATIENT FINANCIAL COUNSELOR OR SOCIAL WORKERS TO ALLOW THESE PATIENTS THE ABILITY TO COMPLETE THEIR APPLICATION DURING THEIR STAY AT THE HOSPITAL, DEPENDING UPON THE PATIENT'S CONDITION, OR THE PATIENT'S RESPONSIBLE PARTY MAY BE CONTACTED TO COMPLETE AND RETURN THE FORMS AT A LATER TIME WHEN THEIR CARE ALLOWS THIS COMPLETION. DURING THE PATIENT ACCOUNT COLLECTION PROCESS, SELF-PAY PATIENTS ARE ALSO INFORMED OF THE HOSPITAL'S COLLECTION POLICIES AS WELL AS THE CHARITY CARE PROGRAM TO ALLOW PATIENTS THE OPPORTUNITY TO COMPLETE THE APPROPRIATE FORMS AND QUALIFY UNDER THE PROGRAM. SCHEDULE H, PART VI, LINE 2: GUNDERSEN BOSCOBEL AREA HOSPITAL AND CLINICS ASSESSES THE HEALTH CARE NEEDS OF THE COMMUNITIES AND AREAS IT SERVES BY REVIEWING LOCAL DEMOGRAPHICS AND TRENDS IN PATIENT SERVICE UTILIZATION TO DETERMINE WHICH SERVICES COULD AND SHOULD BE MADE AVAILABLE TO THE COMMUNITY IN A COST-EFFECTIVE MANNER TO BE CONSISTENT WITH THE HOSPITAL'S MISSION IN THE COMMUNITY. GUNDERSEN BOSCOBEL AREA HOSPITAL AND CLINICS ALSO REVIEWS STATISTICS IN THE HOSPITAL, CLINIC, AND OTHER ORGANIZATIONAL DEPARTMENTS TO REVIEW THE CURRENT SERVICES BEING OFFERED AND ENSURE THAT RESOURCES ARE BEING APPROPRIATELY ALLOCATED TO AREAS IN NEED BY COMMUNITY MEMBERS AND PATIENTS. THE HOSPITAL ALSO MEETS WITH LOCAL COMMUNITY MEMBERS AND ITS PHYSICIAN GROUP TO DETERMINE WHICH SERVICES MAY BENEFIT THE COMMUNITY. DURING FISCAL YEAR 2015, THE HOSPITAL COLLABORATED WITH OTHER AREA HOSPITALS TO COMPLETE A COMMUNITY HEALTH NEEDS ASSESSMENT (CHNA). THROUGH THE CHNA PROCESS THE HOSPITAL CONSIDERED, COUNTY HEALTH STATISTICS, MEDICAL RESOURCES, SAFETY FACTORS, SOCIO-ECONOMIC INDICATORS, TRANSPORTATION ISSUES, ACCESS TO RESOURCES, AND ENVIRONMENTAL QUALITY. SCHEDULE H, PART VI, LINE 3: THE PRIMARY SERVICE AREA FOR GUNDERSEN BOSCOBEL AREA HOSPITAL AND CLINICS ENCOMPASSES ALL PERSONS LIVING WITHIN A 20 TO 30 MILE RADIUS OF THE HOSPITAL. THE HOSPITAL ALSO DETERMINED THAT PRIMARY CLINICAL HEALTH CARE WAS A NEEDED SERVICE IN TWO SURROUNDING COMMUNITIES, SO THE HOSPITAL ALSO OPERATES PROVIDER-BASED RURAL HEALTH CLINICS IN FENNIMORE AND MUSCODA, WISCONSIN. OTHER PROGRAMS ARE AVAILABLE TO THE PATIENT, SUCH AS THE WISCONSIN MEDICAID OR BADGERCARE PROGRAMS, THESE PATIENTS ARE REFERRED TO THE APPROPRIATE GOVERNMENT AGENCY FOR FURTHER ASSISTANCE. THE HOSPITAL ALSO PROVIDES CERTIFIED APPLICATION COUNSELORS FOR ASSISTING PATIENTS WITH OBTAINING COVERAGE THROUGH THE HEALTH INSURANCE MARKETPLACE. SCHEDULE H, PART VI, LINE 4: THE PRIMARY SERVICE AREA FOR GUNDERSEN BOSCOBEL AREA HOSPITAL AND CLINICS ENCOMPASSES ALL PERSONS LIVING WITHIN A 20 TO 30 MILE RADIUS OF THE HOSPITAL. THE HOSPITAL ALSO DETERMINED THAT PRIMARY CLINICAL HEALTH CARE WAS A NEEDED SERVICE IN TWO SURROUNDING COMMUNITIES, SO THE HOSPITAL ALSO OPERATES PROVIDER-BASED RURAL HEALTH CLINICS IN FENNIMORE AND MUSCODA, WISCONSIN. SCHEDULE H, PART VI, LINE 5: GUNDERSEN BOSCOBEL AREA HOSPITAL AND CLINICS OFFERS HEALTH SCREENINGS, EDUCATIONAL DISPLAYS, AND PRESENTATIONS ON A VARIETY OF TOPICS SUCH AS HEALTHY EATING, EXERCISE, HEART HEALTH, CHOLESTEROL, ETC. TO MEMBERS OF THE COMMUNITY. PROGRAMS AND SERVICES ARE ALSO CONSIDERED BY THE HOSPITAL'S BOARD OF DIRECTORS, WHICH INCLUDES FIVE LOCAL COMMUNITY MEMBERS WHO RESIDE WITHIN A THIRTY MILE RADIUS OF THE HOSPITAL. THE HOSPITAL ALSO CONSIDERS A RELATIVELY OPEN MEDICAL STAFF POLICY ALLOWING PROPERLY CREDENTIALED PROVIDERS THE ABILITY TO PRACTICE MEDICINE AND FOLLOW-UP WITH PATIENTS UTILIZING THE HOSPITAL'S FACILITIES. SCHEDULE H, PART VI, LINE 6: GUNDERSEN BOSCOBEL AREA HOSPITAL AND CLINICS IS AFFILIATED WITH GUNDERSEN HEALTH SYSTEM. THIS AFFILIATION PROVIDES LOCAL SERVICES IN CARDIOLOGY, NEUROLOGY, PODIATRY, DERMATOLOGY, UROLOGY, GYNECOLOGY, ENDOCRINOLOGY, HEMATOLOGY/ONCOLOGY, AND VASCULAR MEDICINE AS WELL AS LAPAROSCOPIC AND ORTHOPEDIC SURGERY. SCHEDULE H, PART VI, LINE 7 LIST OF STATES RECEIVING COMMUNITY BENEFIT REPORT: WI false false false false false false false false false MARILU BINTZ MD BOARD MEMBER/MED VP GHS 0 569125 0 0 0 5236 0 41325 0 6294 0 621980 0 0 JAMES KLOCK BOARD MEMBER/DIR OF REG IS 0 130925 0 0 0 818 0 19780 0 15846 0 167369 0 0 SCOTT KNIPRATH VICE PRESIDENT/EXEC DIR GH 0 160206 0 0 0 5274 0 24180 0 31584 0 221244 0 0 KEITH FRYE SECRETARY/ADMIN DIR - LAB 0 119444 0 0 0 1498 0 17823 0 15846 0 154611 0 0 ANDY NAHAS MD BOARD MEMBER/OPTOMETRY 0 201504 0 0 0 500 0 29871 0 15846 0 247721 0 0 THERESA BRAUDT ADMINISTRATOR 0 151913 0 0 0 9224 0 18360 0 15689 0 195186 0 0 DOUGLAS KNOBLE PHARMACIST 112907 0 0 0 48 0 22783 0 8166 0 143904 0 0 0 TARA WOOD PHARMACIST 136084 0 0 0 33 0 12949 0 14988 0 164054 0 0 0 SCHEDULE J, PART 1, LINE 3: FOR THE PURPOSE OF DETERMINING EXECUTIVE COMPENSATION, GUNDERSEN BOSCOBEL HOSPITAL AND CLINICS RELIED ON ITS AFFILIATED ORGANIZATION, GUNDERSEN LUTHERAN ADMINISTRATIVE SERVICES, INC., TO ESTABLISH COMPENSATION OF THE CEO, CFO, AND OTHER OFFICERS. GUNDERSEN LUTHERAN ADMINISTRATIVE SERVICES, INC. USED THE FOLLOWING PRACTICES FOR ESTABLISHING COMPENSATION FOR SUCH INDIVIDUALS: COMPENSATION SURVEY OR STUDY, COMPENSATION COMMITTEE, AND APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE. A CITY OF BOSCOBEL WI 396005403 2007-07-26 4200000 SEE PART VI false false false B CITY OF BOSCOBEL WI 396005403 2003-03-01 2719054 SEE PART VI false false false A 1857876 0 4200000 0 0 0 84000 0 0 4116000 0 0 2007 false false true true B 2251644 0 2719054 0 0 0 54381 0 0 297952 2366721 0 2003 true false true true A false false false false 0 false false false false B false false false false 0 false false false false A false false true false false false 0 false 0 false false B false false true false false false 0 false 0 false false A false B false SCHEDULE K, PART I (A) ISSUER NAME: CITY OF BOSCOBEL, WI (F) DESCRIPTION OF PURPOSE: EMERGENCY ROOM CONSTRUCTION AND REMODEL (B) ISSUER NAME: CITY OF BOSCOBEL, WI (F) DESCRIPTION OF PURPOSE: PROVIDE FUNDS TO REFUND A PRIOR BOND ISSUE AND PURCHASE EQUIPMENT FORM 990, PART I, DOING BUSINESS AS: GUNDERSEN BOSCOBEL AREA HOSPITAL AND CLINICS FORM 990, PART VI, SECTION A, LINE 3: AS AN AFFILIATE OF GUNDERSEN LUTHERAN HEALTH SYSTEM, INC., GUNDERSEN BOSCOBEL AREA HOSPITAL AND CLINICS WILL ROUTINELY DELEGATE VARIOUS MANAGEMENT OR SUPPORT FUNCTIONS TO RELATED ENTITIES. FOR EXAMPLE, THE CEO AND CFO OF GUNDERSEN BOSCOBEL AREA HOSPITAL AND CLINICS, AS WELL AS SEVERAL MEMBERS OF THE BOARD OF DIRECTORS, ARE EMPLOYEES OF GUNDERSEN LUTHERAN HEALTH SYSTEM, INC. AND ITS AFFILIATED ORGANIZATIONS WHICH ARE ALSO TAX-EXEMPT ORGANIZATIONS. FORM 990, PART VI, SECTION A, LINE 6: THE ARTICLES OF INCORPORATION OF GUNDERSEN BOSCOBEL AREA HOSPITAL AND CLINICS PROVIDES FOR ONE MEMBER OF THE CORPORATION. THE SOLE CORPORATE MEMBER OF GUNDERSEN BOSCOBEL AREA HOSPITAL AND CLINICS IS GUNDERSEN LUTHERAN HEALTH SYSTEM, INC. FORM 990, PART VI, SECTION A, LINE 7A: AS THE SOLE CORPORATE MEMBER AND UNDER THE TERMS OF THE AFFILIATION AGREEMENT, GUNDERSEN LUTHERAN HEALTH SYSTEM, INC. MAY APPOINT, REMOVE, OR ELECT CERTAIN OFFICERS AND/OR MEMBERS OF THE BOARD OF DIRECTORS OF GUNDERSEN BOSCOBEL AREA HOSPITAL AND CLINICS. GUNDERSEN LUTHERAN HEALTH SYSTEM, INC. MAY APPOINT SIX MEMBERS OF THE BOARD OF DIRECTORS OF GUNDERSEN BOSCOBEL AREA HOSPITAL AND CLINICS. FORM 990, PART VI, SECTION A, LINE 7B: THE SOLE MEMBER, GUNDERSEN LUTHERAN HEALTH SYSTEM, INC., HAS THE FOLLOWING RESERVE RIGHTS OF APPROVAL: THE INCURRENCE OF DEBT (OTHER THAN DEBT INCURRED FOR THE ACQUISITION OF GOODS THAT ARE ACQUIRED IN THE ORDINARY COURSE OF BUSINESS OR DEBT INCLUDED IN APPROVED BUDGETS) AND THE GRANT OF ANY SECURITY INTERESTS, PLACE ANY ENCUMBRANCES, ENTER INTO ANY COVENANTS, AND DIRECT EXECUTION OF ANY DOCUMENTS AND THE TAKING OF ANY ACTIONS NECESSARY OR APPROPRIATE IN CONNECTION WITH THE INCURRENCE OF SUCH DEBT AND THE ANNUAL OPERATING BUDGET AND CAPITAL EXPENDITURES. FORM 990, PART VI, SECTION B, LINE 11B: THE FORM 990 IS PREPARED BY AN INDEPENDENT ACCOUNTING FIRM AND THEN REVIEWED BY THE ORGANIZATION'S MANAGEMENT. A FINAL COPY OF THE FORM 990 IS PROVIDED TO THE BOARD OF DIRECTORS PRIOR TO SUBMISSION. FORM 990, PART VI, SECTION B, LINE 12C: THE BOARD OF DIRECTORS DISCLOSES ANY CONFLICTS OF INTEREST BY COMPLETING A QUESTIONNAIRE AND DISCLOSURE FORM ANNUALLY. EMPLOYEES ARE REQUIRED TO REVIEW THE CONFLICT OF INTEREST POLICY UPON HIRE AND AT ANNUAL INTERVALS. IF ANY SIGNIFICANT CONFLICTS ARISE WITH MEMBERS OF THE BOARD OF DIRECTORS, MANAGEMENT, OR KEY EMPLOYEES, IT IS PROPERLY DOCUMENTED AND FOLLOWED UP ON BY THE APPROPRIATE GOVERNING GROUP OR DEPARTMENT WITHIN THE ORGANIZATION ACCORDING TO THE CONFLICT OF INTEREST POLICY. FORM 990, PART VI, SECTION B, LINE 15: FOR THE PURPOSES OF DETERMINING COMPENSATION, GUNDERSEN AREA BOSCOBEL HOSPITAL AND CLINICS RELIED ON ITS AFFILIATED ORGANIZATION, GUNDERSEN LUTHERAN ADMINISTRATIVE SERVICES, INC., TO ESTABLISH COMPENSATION OF THE CEO, CFO, AND OTHER OFFICERS. GUNDERSEN LUTHERAN ADMINISTRATIVE SERVICES, INC. USED THE FOLLOWING PRACTICES FOR ESTABLISHING COMPENSATION FOR SUCH INDIVIDUALS: COMPENSATION SURVEY OR STUDY, COMPENSATION COMMITTEE, AND APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE. FORM 990, PART VI, SECTION C, LINE 19: THE ABBREVIATED FINANCIAL STATEMENTS ARE MADE PUBLICLY AVAILABLE THROUGH THE WISCONSIN HOSPITAL ASSOCIATION AND THE COMPLETE AUDITED FINANCIAL STATEMENTS ARE AVAILABLE UPON REQUEST. GOVERNING DOCUMENTS AND THE CONFLICT OF INTEREST POLICY ARE ALSO AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART VII, LINE 1A, EXPLANATION OF HOURS WORKED: SOME OFFICERS AND BOARD MEMBERS ARE EMPLOYED BY GUNDERSEN LUTHERAN HEALTH SYSTEM, INC. AND ITS AFFILIATES. GUNDERSEN LUTHERAN HEALTH SYSTEM, INC.'S PURPOSE IS TO SERVE AS A SUPPORTING ORGANIZATION TO MULTIPLE SUBSIDIARY ORGANIZATIONS AS LISTED IN SCHEDULE R AND THESE OFFICERS AND BOARD MEMBERS OFTEN WORK IN EXCESS OF 40 HOURS PER WEEK PROVIDING SERVICES TO AFFILIATED ORGANIZATIONS. THESE HOURS ARE REFLECTED IN LINE 2 OF COLUMN B. FORM 990, PART IX, LINE 11G, OTHER FEES: ER PHYSICIAN COVERAGE: PROGRAM SERVICE EXPENSES 2,252,510. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,252,510. CLINIC PHYSICIAN COVERAGE: PROGRAM SERVICE EXPENSES 1,005,611. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,005,611. RADIOLOGY PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 500,511. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 500,511. OTHER PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 1,086,952. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,086,952. ADMINISTRATIVE/MANAGEMENT FEES: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 593,947. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 593,947. INFORMATION SYSTEMS PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 574,548. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 574,548. LAB SERVICES: PROGRAM SERVICE EXPENSES 842,214. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 842,214. FORM 990, PART XI, LINE 9, OTHER CHANGES IN NET ASSETS OR FUND BALANCES NET CHANGE IN INTEREST IN NET ASSETS OF FOUNDATION: $181,610 FORM 990 PART IX LINE 11G DESCRIPTION:HEALTHCARE PROFESSIONAL FEES TOTAL FEES:6157418 TRI-COUNTY MEMORIAL FOUNDATION INC 18601 LINCOLN STREET WHITEHALL WI 54773 300093022 foundation WI 501(C)(3) LINE 12A, I TRI-COUNTY M true GUNDERSEN LUTHERAN HEALTH SYSTEM INC 1836 SOUTH AVENUE LA CROSSE WI 54601 391866425 supporting or WI 501(C)(3) LINE 12B,II NA false GUNDERSEN LUTHERAN MEDICAL CENTER INC 1910 SOUTH AVENUE LA CROSSE WI 54601 390813416 HEALTHCARE WI 501(C)(3) LINE 3 GLHS true GUNDERSEN CLINIC LTD 1836 SOUTH AVENUE LA CROSSE WI 54601 391028657 HEALTHCARE WI 501(C)(3) LINE 3 GLHS true GUNDERSEN LUTHERAN MEDICAL FOUNDATIONIN 1836 SOUTH AVENUE LA CROSSE WI 54601 391249705 FOUNDATION WI 501(C)(3) LINE 7 GLHS true GUNDERSEN LUTHERAN CREDENTIALING SERVICE 1910 SOUTH AVENUE LA CROSSE WI 54601 391856898 CREDENTIALING WI 501(C)(3) LINE 12C GLHS true GUNDERSEN LUTHERAN ADMIN SERVICES INC 1910 SOUTH AVENUE LA CROSSE WI 54601 391606449 SUPPORTING OR WI 501(C)(3) LINE 12B,II GLHS true HARMONY COMMUNITY HEALTHCARE INC 815 MAIN AVENUE S HARMONY MN 55929 410711606 HEALTHCARE MN 501(C)(3) LINE 10 GLHS true TWEETEN LUTHERAN HEALTHCARE CENTER INC 125 FIFTH AVENUE SE SPRING GROVE MN 55974 411565003 HEALTHCARE MN 501(C)(3) LINE 10 GLHS true TRI-STATE AMBULANCE INC 235 CAUSEWAY BLVD LA CROSSE WI 56401 391965415 MED TRANSPORT WI 501(C)(3) LINE 3 GLHS true LUTHERAN REAL ESTATE HOLDING CORPORATION 1910 SOUTH AVENUE LA CROSSE WA 54601 391480826 HOUSING WI 501(C)(3) LN 12C, III GLHS true LUTHERAN HOUSING OF LA CROSSE INC 1900 SOUTH AVENUE LA CROSSE WI 54601 391751934 INDP. LIVING WI 501(C)(3) LINE 10 LREHC true COMMUNITY HOUSING OF LA CROSSE INC 1900 SOUTH AVENUE LA CROSSE WI 54601 391586700 INDP. LIVING WI 501(C)(3) LINE 10 LREHC true TRI-STATE REGIONAL AMBULANCE INC 235 CAUSEWAY BLVD LA CROSSE WV 54603 391962965 MED TRANSPORT WI 501(C)(3) LINE 10 GLHS true ST JOSEPH'S HEALTH SERVICES INC 400 WATER AVENUE HILLSBORO WI 54634 390929538 HEALTHCARE WI 501(C)(3) LINE 3 GLHS true TRI-COUNTY MEMORIAL HOSPITAL INC 18601 LINCOLN STREET WHITEHALL WI 54773 390704510 HEALTHCARE WI 501(C)(3) LINE 3 GLHS true MEMORIAL HOSPITAL OF BOSCOBEL FOUNDATION 205 PARKER STREET BOSCOBEL WI 53805 391688793 FOUNDATION WI 501(C)(3) LINE 7 MHB true ST JOSEPH'S MEMORIAL FOUNDATION INC 400 WATER AVENUE HILLSBORO WI 54634 391455787 FOUNDATION WI 501(c)(3) LINE 12A, I SJHS true PALMER LUTHERAN HEALTH CENTER 112 JEFFERSON STREET WEST UNION IA 52175 421320763 HEALTHCARE IA 501(C)(3) LINE 3 GLHS true PALMER MEMORIAL FOUNDATION 112 JEFFERSON STREET WEST UNION IA 52175 421032878 FOUNDATION IA 501(C)(3) LINE 7 PLHC true MOUNDVIEW MEMORIAL HOSPITAL & CLINICS I 402 W LAKE STREET FRIENDSHIP WI 53934 390944012 HEALTHCARE WI 501(C)(3) LINE 3 GLHS true MEMORIAL HEALTHCARE FOUNDATION INC PO BOX 40 FRIENDSHIP WI 53934 391775074 FOUNDATION WI 501(C)(3) LINE 12A, I MMHC true SAINT ELIZABETH'S HOSPITAL OF WABASHA 1200 5TH GRANT BOULEVARD WEST WABASHA WI 55981 410693877 HEALTHCARE MN 501(C)(3) LINE 3 GLHS false BOSCOBEL AREA HEALTH PARTNERS 205 PARKER STREET BOSCOBEL WI 53805 450498844 FUNDRAISING WI 501(C)(3) LINE 7 NA false GUNDERSEN ENVISION LLC - 1836 SOUTH AVENUE LA CROSSE WI 54601 264706546 RENEWABLE ENERGY WI GLHS C CORP 0 0 0.00000 true false false false false false false false false false false false false true true true true true false false