2019-10-07T18:57:32-05:00 2018-12-31 410746749 CLIFTONLARSONALLEN LLP 220 SOUTH SIXTH STREET SUITE 300 MINNEAPOLIS MN 55402 990 2018-01-01 390872080 SAUK PRAIRIE HEALTHCARE INC SAUK 6086433311 260 26TH STREET PRAIRIE DU SAC WI 53578 JAMES DREGNEY CFO 6086433311 2019-09-30 1 KOREY BOELTER P00775161 6123764500 67.137.57.251 2019-09-30 08:46:57 CD P FD302F4D5CE3C660ABAF9933EAAEEC9F457F14F9 A6AD3476A9076C5B724E5E12CCE393A62F1B66BA 2018 2020-01-14 16:20:31Z SHAWN LERCH 260 26TH STREET PRAIRIE DU SAC WI 53578 94880780 0 X WWW.SAUKPRAIRIEHEALTHCARE.ORG X 1956 WI EXTRAORDINARY HEALTHCARE FROM THE HEART - ONE PERSON AT A TIME. 11 8 719 110 0 0 588425 238288 86896490 90943792 404514 3134736 -48795 -50574 87840634 94266242 191919 54942 0 0 49411520 51929798 0 0 84709 39845392 39658309 89448831 91643049 -1608197 2623193 146084505 147187959 74974081 73943490 71110424 73244469 X EXTRAORDINARY HEALTHCARE FROM THE HEART - ONE PERSON AT A TIME.VISION: WE WILL SET THE STANDARD FOR COMMUNITY-BASED HEALTHCARE THAT IMPROVES THE HEALTH AND QUALITY OF LIFE OF THE PEOPLE WE SERVE. 0 0 60214240 54942 75801816 SAUK PRAIRIE HEALTHCARE ("THE HOSPITAL"), A 36-BED ACUTE CARE GENERAL HOSPITAL, IS A NONPROFIT, NONSTOCK WISCONSIN CORPORATION PROVIDING SERVICES TO SAUK CITY, PRAIRIE DU SAC, AND THE SURROUNDING COMMUNITIES.TOTAL ADMISSIONS FOR 2018 WERE 1,909 WITH PATIENT DAYS OF 3,835. KEY PATIENT SERVICES INCLUDING 353 BIRTHS IN THE NURSERY, 5,171 SURGICAL PROCEDURES, 70,682 REHABILITATION THERAPY SERVICES, 27,853 MEDICAL IMAGING SERVICES, AND 14,452 EMERGENCY ROOM VISITS ARE AMONG MANY OF THE SERVICES PROVIDED TO PATIENTS DURING 2018.THE HOSPITAL FULFILLS ITS MISSION AND VISION BY OFFERING HIGH-QUALITY SERVICES IN RURAL COMMUNITIES, THEREBY ALLOWING OUR PATIENTS TO BE TREATED LOCALLY WITHOUT LENGTHY COMMUTES OR WAITING. THE HOSPITAL HAS GAINED A REGIONAL REPUTATION OF EXCELLENCE IN ORTHOPEDICS, GENERAL SURGERY, SPINE SURGERY, AND GYNECOLOGY SURGERY. THE HOSPITAL OPERATES FOUR CLINICS IN RURAL AREAS: LODI, SPRING GREEN, PLAIN, AND MAZOMAINE, BRINGING PRIMARY CARE TO THOSE COMMUNITIES. THE CLINICS HAD CLOSE TO 36,468 VISITS IN 2018. AS A CHARITABLE ORGANIZATION, THE HOSPITAL PROVIDED OVER $ 1.85 MILLION IN FREE CARE TO PATIENTS IN OUR SERVICE AREA IN 2018, IN ADDITION TO SUBSIDIZING SERVICES THAT DO NOT COVER COSTS, FREE HEALTH SCREENINGS, EDUCATION PROGRAMS, AND YOUTH OUTREACH. 15975766 0 15141976 THE HOSPITAL ALSO OWNS AND OPERATES CLINICS IN SPRING GREEN (DBA RIVER VALLEY CLINIC), MAZOMANIE (DBA WISCONSIN HEIGHTS CLINIC), PLAIN, AND LODI, WISCONSIN, AS WELL AS OPERATES ORTHOPEDIC AND SURGICAL PHYSICIAN PRACTICES AND THE BETTER HEALTH CENTER IN PRAIRIE DE SAC, WISCONSIN. TOTAL CLINIC VISITS TO THESE SITES IN 2018 WERE 62,007. 76190006 1 1 0 1 0 0 0 0 0 1 1 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 1 1 0 1 1 1 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 0 0 0 1 42 0 719 1 0 0 0 0 0 0 0 0 0 0 0 0 X 11 8 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 0 0 WI X JAMES DREGNEY 6086433311 260 26TH STREET PRAIRIE DU SAC WI 53578 RICHARD MARINO PRESIDENT 2.80 X X 7500 0 0 ROXI MAIER VICE PRESIDENT 1.60 X X 4400 0 0 VICKIE WENZEL SECRETARY 3.20 X X 8300 0 0 TOM SCHWARZ TREASURER 2.80 X X 7700 0 0 TAMMY ADLER TRUSTEE 5.00 X 13500 0 0 NEIL BISHOP TRUSTEE 2.50 X 7000 0 0 NANCY BREUNIG TRUSTEE 4.50 X 11900 0 0 JASON BRICKL TRUSTEE 2.20 X 5950 0 0 DALE CARLSON TRUSTEE (THROUGH MARCH 2018) 0.40 X 1000 0 0 RYAN KRAEMER TRUSTEE 2.00 X 5400 0 0 ALLAN PECKHAM TRUSTEE 1.50 X 3600 0 0 TODD SCHAD MD TRUSTEE 0.00 X 0 0 0 SHAWN LERCH CEO 40.00 X 270763 0 43996 JAMES DREGNEY CFO 40.00 X 251007 0 40324 DENISE COLE-OUZOUNIAN VP PATIENT SERVICES 40.00 X 151691 0 39634 ANDREW ERTL MD SURGEON 40.00 X 1046828 0 50644 MATTHEW HERBERT MD SURGEON 40.00 X 959025 0 43737 MICHAEL LAMSON MD SURGEON 40.00 X 1042727 0 43737 DAVID MARCU MD SURGEON 40.00 X 954091 0 41804 THEODORE PARINS MD SURGEON 40.00 X 526315 0 44530 5278697 0 348406 74 0 1 0 CENTRAL MINNESOTA DIAGNOSTICS 150 10TH STREET NW MILACA MN 563531221 CT & MRI SERVICES 1230259 SHARED IMAGING PO BOX 88450 MILWAUKEE WI 532880450 ULTRASOUNDS, CARDIAC ECHO & NUCLEAR MED 1132845 FASTAFF LLC PO BOX 911452 DENVER CO 802911452 CONTRACTED NURSING CARE 382021 NTT DATA SERVICE 2300 W PLANO PARKWAY PLANO TX 75075 SERVER STORAGE 328713 MERITER LABORATORIES PO BOX 681166 CHICAGO IL 606952166 LABORATORY TESTING SERVICE 269085 11 238288 238288 HOSPITAL PATIENT REVENUE 621990 74505877 74505877 CLINIC REVENUE 621110 15141976 15141976 OTHER HOSPITAL SERVICES 621990 1010679 1010679 CAFETERIA AND VENDING 621990 285260 285260 90943792 853379 853379 123440 174014 -50574 -50574 -50574 2690954 30927 434586 5938 2256368 24989 2281357 2281357 94266242 89647853 0 4380101 54942 54942 797413 797413 41740576 37277108 4399846 63622 1663927 1492266 169114 2547 5207363 4649101 550233 8029 2520519 2178706 337302 4511 149915 149915 47439 47439 7021086 5700917 1320169 278335 66599 211736 2027738 1395277 627099 5362 1209057 1209057 1113013 156468 955907 638 44026 33756 10270 2876018 2876018 5849037 4797206 1051831 311871 81244 230627 MEDICAL SUPPLIES 12337695 12337695 REPAIRS & MAINTENANCE 1669145 1264320 404825 MEDICAID ASSESSMENT TAX 1258168 1258168 MISCELLANEOUS EXPENSES 1247082 126756 1120326 2218684 1701627 517057 91643049 76190006 15368334 84709 82259 -379165 14957137 20666164 10179136 10939125 1076333 1019233 887588 982313 131872202 53521645 82810365 78350557 31030694 30690916 250000 1051379 1131726 3759614 3787090 146084505 147187959 9518299 10137032 62551361 61205033 2904421 2601425 74974081 73943490 X 67350810 69457379 1984892 2097249 1774722 1689841 71110424 73244469 146084505 147187959 X 2623193 -934000 444852 X 0 1 X 1 0 X 0 0 0 1 0 0 1 0 1 12461 12461 0 PART II-B, LINE 1: PART II-B, LINE 1: SAUK PRAIRIE HEALTHCARE ("THE HOSPITAL) PAYS ANNUAL ASSOCIATION MEMBERSHIP DUES TO THE WISCONSIN HOSPITAL ASSOCIATION (WHA). THESE DUES ARE PRIMARILY FOR ACCESS TO EDUCATIONAL MATERIALS AND STAFF TRAINING DEVELOPMENT. THE HOSPITAL IS ALSO A MEMBER OF THE RURAL WISCONSIN HEALTH COOPERATIVE (RWHC). EACH YEAR, THE HOSPITAL PAYS MEMBERSHIP FEES TO THE 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 AND EMERGENCY ROOM PATIENT CARE COVERAGE, AND ADMINISTRATIVE CONSULTING SERVICES. AS A PART OF THESE SERVICES, THE RWHC ALSO DOES PROVIDE ANALYSIS ON CURRENT HEALTHCARE ISSUES IN AN EFFORT TO PROMOTE AND BETTER HEALTHCARE FOR HOSPITALS IN RURAL COMMUNITIES THROUGHOUT WISCONSIN. ONE OF THESE EFFORTS ALSO INCLUDES SOME LOBBYING ON THE PART OF THE MEMBER ORGANIZATIONS. PART II-B, LINE 1 (D AND G): REPRESENTATIVES FROM THE HOSPITAL ANNUALLY PARTICIPATE IN THE WISCONSIN HOSPITAL ASSOCIATION'S ADVOCACY DAY WHERE THE REPRESENTATIVES ARE GIVEN THE OPPORTUNITY TO GATHER WITH OTHER HEALTHCARE ORGANIZATIONS IN THE STATE OF WISCONSIN AND ALSO MEET WITH STATE GOVERNMENT REPRESENTATIVES WITH THE PURPOSE OF IMPROVING THE DELIVERY OF HEALTHCARE NOT ONLY AT SAUK PRAIRIE HEALTHCARE BUT ALSO COLLECTIVELY IN THE STATE OF WISCONSIN. AS ISSUES OR PROPOSED LEGISLATION ARISE THROUGHOUT THE YEAR, OFFICIALS OF THE HOSPITAL WILL SEND LETTERS OF COMMENT TO LOCAL, STATE, AND FEDERAL GOVERNMENT REPRESENTITIVES TO EITHER SHOW SUPPORT OF PROPOSED CHANGES OR VOICE AN OPINION TO IMPROVE THE OUTCOME OF PROPOSED LEGISLATION OR OTHER CHANGES. THESE ACTIVITIES RESULT IN MINIMAL COST TO THE OPERATION OF THE HOSPITAL. 2075699 -28275 2047424 1843376 232323 2075699 1688056 155320 1843376 1654555 33501 1688056 1495840 158715 1654555 0.00000 0.82500 0.17500 0 1 1 7338643 7338643 64954277 19308694 45645583 1615010 452197 1162813 57621335 33760754 23860581 342937 342937 78350557 DEFERRED COMPENSATION LIABILITY 1854146 THIRD PARTY SETTLEMENTS 747279 2601425 X 89853165 591390 591390 89261775 5004467 5004467 94266242 90502482 174014 174014 90328468 1314581 1314581 91643049 PART V, LINE 4: THE SCHNELLER SISTERS FUND SHALL BE HELD AS A SEPARATE PERMANENT ENDOWMENT FUND ON THE BOOKS AND RECORDS OF THE FOUNDATION, THE INCOME FROM WHICH SHALL BE DISTRIBUTED TO SAUK PRAIRIE HEALTHCARE FOR UNRESTRICTED NEEDS. ALL DISTRIBUTIONS FROM THE SCHNELLER SISTERS FUND SHALL BE DESIGNATED AS HAVING BEEN MADE "IN MEMORY OF THE SCHNELLER SISTERS: CECELIA SCHNELLER MUELLER, ADLYNN F. BALFANZ, AND MARY ANN ROSAR." PART X, LINE 2: IN ORDER TO ACCOUNT FOR ANY UNCERTAIN TAX POSITIONS, THE HOSPITAL ASSESSES WHETHER IT IS MORE LIKELY THAN NOT THAT A TAX POSITION WILL BE SUSTAINED UPON EXAMINATION OF THE TECHNICAL MERITS OF THE POSITION, ASSUMING THE TAXING AUTHORITY HAS FULL KNOWLEDGE OF ALL INFORMATION. IF THE TAX POSITION DOES NOT MEET THE MORE LIKELY THAN NOT RECOGNITION THRESHOLD, THE BENEFIT OF THE TAX POSITION IS NOT RECOGNIZED IN THE ACCOMPANYING FINANCIAL STATEMENTS. THE HOSPITAL HAS NOT RECORDED ANY ASSETS OR LIABILITIES RELATED TO UNCERTAIN TAX POSITIONS OR UNRECOGNIZED TAX BENEFITS AS OF DECEMBER 31, 2018 OR 2017. PART XI, LINE 2D - OTHER ADJUSTMENTS: NET ASSETS RELEASED FROM RESTRICTION 417,376. RENTAL EXPENSES 174,014. PART XI, LINE 4B - OTHER ADJUSTMENTS: GOOD NEIGHBOR CLINIC SERVICES PROVIDED 171,750. CONTRIBUTION FROM RELATED ORGANIZATION 214,579. BAD DEBT EXPENSE 1,142,831. INVESTMENT INCOME 786,484. OTHER INCOME 400,378. SALE OF INTEREST IN BUSINESS 1,800,000. SALE OF MOB 488,445. PART XII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES 174,014. PART XII, LINE 4B - OTHER ADJUSTMENTS: GOOD NEIGHBOR CLINIC SERVICES PROVIDED 171,750. BAD DEBT EXPENSE 1,142,831. 1 1 X 1 X 1 X 1 1 1 0 1 1 784118 784118 0.00860 6730464 3345012 3385452 0.03690 7514582 3345012 4169570 0.04550 293301 293301 0.00320 283555 283555 0.00310 4788936 2518877 2270059 0.02480 133495 133495 0.00150 5499287 2518877 2980410 0.03260 13013869 5863889 7149980 0.07810 9807 9807 0.00010 622 622 0.00000 16917 16917 0.00020 3722 3722 0.00000 34077 34077 0.00040 65145 65145 0.00070 0 1142831 0 17109654 21797080 -4687426 X 1 1 1 1 SAUK PRAIRIE HEALTHCARE INC 260 26TH STREET PRAIRIE DU SAC WI 53578 WWW.SAUKPRAIRIEHEALTHCARE.ORG 122 X X X SAUK PRAIRIE HEALTHCARE INC 1 0 0 1 X X X X X X X X X X 18 1 1 1 1 X WWW.SAUKPRAIRIEHEALTHCARE.ORG/ABOUT/COMMUNITY-HEALTH X X 1 18 1 WWW.SAUKPRAIRIEHEALTHCARE.ORG/ABOUT/COMMUNITY-HEALTH 0 1 X 100.000000000000 400.000000000000 X X X X X 1 1 X X X X 1 X HTTP://WWW.SAUKPRAIRIEHEALTHCARE.ORG/PATIENTS/BILLING/COMMUNITY-CARE X HTTP://WWW.SAUKPRAIRIEHEALTHCARE.ORG/PATIENTS/BILLING/COMMUNITY-CARE X HTTP://WWW.SAUKPRAIRIEHEALTHCARE.ORG/PATIENTS/BILLING/COMMUNITY-CARE X X X X X X 1 X 0 X X X X 1 X 0 0 SAUK PRAIRIE HEALTHCARE, INC. PART V, SECTION B, LINE 3J: THE COMMUNITY HEALTH NEEDS ASSESSMENT REPORT INCLUDES STRATEGY PLANNING INPUT AND FINDINGS FROM THE COMMUNITY INPUT SESSIONS CONDUCTED BY NEIGHBORING HOSPITALS AND COUNTY HEALTH DEPARTMENTS. SAUK PRAIRIE HEALTHCARE, INC. PART V, SECTION B, LINE 5: ALONG WITH COLLECTING AND ANALYZING DATA FROM THE SAUK COUNTY HEALTH AND WELLNESS COALITION SURVEY (INCLUDING 648 RESPONDENTS FROM THE SPH SERVICE AREA) AND ONLINE DATA SOURCES, SIX KEY INFORMANT FOCUS GROUP MEETINGS WERE CONDUCTED WITH STAKEHOLDERS REPRESENTING BROAD INTERESTS OF THE AREA. THE GROUPS INCLUDED, BUT WERE NOT LIMITED TO, SCHOOL REPRESENTATIVES, LAW ENFORCEMENT OFFICERS, HEALTHCARE PROVIDERS, EMERGENCY RESPONSE PROFESSIONALS, CLERGY MEMBERS, MUNICIPAL OFFICIALS, AND COMMUNITY GROUP LEADERS. THE QUESTIONS ASKED WERE RELATED TO GENERAL COMMUNITY ISSUES AND CONCERNS, AT-RISK POPULATIONS, ISSUES IN THE COMMUNITY THAT PROMOTE POOR HEALTH, AND ISSUES RELATED TO HEALTHCARE ACCESS. AT THE MEETINGS, HEALTH CONCERNS WERE IDENTIFIED AND PRIORITIZED. IN ADDITION TO THE KEY INFORMANT MEETINGS FACILITATED BY SPH, MANY OTHER COMMUNITY FORUMS WERE HELD BY MEMBERS OF THE SAUK COUNTY HEALTH AND WELLNESS COALITION. ON JANUARY 16, 2019, A "CREATING OUR HEALTH COMMUNITY PLAN" FORUM AND PRIORITY SESSION WAS HELD IN SAUK PRAIRIE. SAUK PRAIRIE HEALTHCARE, INC. PART V, SECTION B, LINE 6A: THE COMMUNITY HEALTH NEEDS ASSESSMENT WAS CONDUCTED IN JOINT EFFORT WITH THE FOLLOWING OTHER HOSPITALS: SSM-ST. CLARE HOSPITAL (BARABOO, WI) AND REEDSBURG AREA MEDICAL CENTER (REEDSBURG, WI). SAUK PRAIRIE HEALTHCARE, INC. ALSO WORKED WITH THE RICHLAND HOSPITAL (RICHLAND CENTER) AND UPLAND HILLS HEALTH (DODGEVILLE), BUT TO A LESSER DEGREE THAN SSM-ST. CLARE AND REEDSBURG. SAUK PRAIRIE HEALTHCARE, INC. PART V, SECTION B, LINE 6B: SAUK PRAIRIE HEALTHCARE, INC. WORKED WITH REEDSBURG AREA MEDICAL CENTER (REEDSBURG, WI) AND SSM-ST. CLARE HOSPITAL (BARABOO, WI) AND THE SAUK COUNTY DEPARTMENT OF HEALTH TO IDENTIFY AND PRIORITIZE HEALTH NEEDS. THIS GROUP MEETS ON AT LEAST A QUARTERLY BASIS TO CONTINUALLY ASSESS NEEDS AND COORDINATE AND REPORT ON HEALTH INITIATIVE PROGRESS IN EACH MEMBER'S RESPECTIVE SERVICE AREA. SAUK PRAIRIE HEALTHCARE, INC. PART V, SECTION B, LINE 7D: THE COMMUNITY HEALTH NEEDS ASSESSMENT (CHNA) WAS MADE PUBLICLY AVAILABLE IN JANUARY 2019 AND ITS AVAILABILITY WAS ANNOUNCED VIA A COMMUNITY NEWSLETTER TO MORE THAN 20,000 HOUSEHOLDS IN APRIL 2019. THE CHNA WAS INTERNALLY ANNOUNCED TO EMPLOYEES AND MEDICAL STAFF OF THE HOSPITAL IN JANUARY 2019. SAUK PRAIRIE HEALTHCARE, INC. PART V, SECTION B, LINE 11: THE FOLLOWING STEPS AND ACTIONS WERE TAKEN IN 2018 TO ADDRESS SIGNIFICANT HEALTH NEEDS IDENTIFIED IN PRIOR COMMUNITY HEALTH NEEDS ASSESSMENTS. (1) SAUK PRAIRIE HEALTHCARE FOUNDATION ("SPHF") FUNDED MENTAL HEALTH FIRST AID CLASSES TO TEACH STAFF AND COMMUNITY MEMBERS HOW TO IDENTIFY THE SIGNS OF MENTAL ILLNESS AND THE RESOURCES AVAILABLE FOR HELP. (2) TO PREVENT SUICIDE AND SHARE RESOURCES AND EDUCATION TO LOWER THE LIKELIHOOD THAT OUR COMMUNITY WILL LOSE A MEMBER TO SUICIDE, SPH HAD THREE REPRESENTATIVES PARTICIPATE IN HOPE SAUK PRAIRIE. (3) IN OUR EFFORTS TO REDUCE THE PREVALENCE OF TYPE 2 DIABETES, SPH SPONSORED A 16 SESSION/12-MONTH PRE-DIABETIC CLASSROOM PROGRAM AIMED AT EDUCATING PARTICIPANTS ON LIFESTYLE CHANGES TO REDUCE THEIR RISK OF DEVELOPING DIABETES. (4) TO CREATE AN ENVIRONMENT OF HEART HEALTH AWARENESS, SPH AND SPH FOUNDATION CONTINUED OUR SUPPORT OF THE HEART ZONES PROGRAM IN ALL 4 SCHOOL DISTRICTS IN THE SPH COMMUNITY. (5) THROUGH EFFORTS TO EDUCATE STUDENTS ON THE HEALTH BENEFITS OF FRUITS AND VEGETABLES, 8 CLASSES WERE TAUGHT IN A RURAL GRADE SCHOOL IN THE 2017/2018 SCHOOL YEAR. (6) SPH AND SPH FOUNDATION DONATED A COMBINED $1,000 TO THE LONE ROCK SPLASH PAD COALITION TO HELP PHYSICAL ACTIVITY IN THAT COMMUNITY. (7) SPH PROVIDED A CLASSROOM PROGRAM FOR THOSE IN THE COMMUNITY WHO WANT ASSISTANCE QUITTING SMOKING. (8) SPH COORDINATED EIGHT PHYSICIAN-LED WALKS TO PROMOTE FITNESS AND ACTIVITY IN THREE OF THE SPH COMMUNITIES. SAUK PRAIRIE HEALTHCARE, INC. PART V, SECTION B, LINE 13B: PATIENTS WHO ARE UNABLE TO COMPLETE AN APPLICATION FORM MAY BE ELIGIBLE FOR COMMUNITY CARE IF OTHER EVIDENCE IS AVAILABLE WHICH MAY INDICATE FINANCIAL HARDSHIP. THIS INFORMATION MAY BE OBTAINED FROM A PATIENT INTERVIEW, CREDIT REPORT, OR OTHER AVAILABLE RECORDS. CONSIDERATION WILL BE GIVEN ON AN INDIVIDUAL BASIS.OTHER PROVISIONS UNDER PRESUMPTIVE ELIGIBILITY:I. DECEASED WITH NO ESTATE - BASED ON THE CONCLUSION THAT THE DESCENDANT HAS NO ASSETS, AND THEREFORE NO ABILITY TO PAY. *II. ACCOUNTS UNCOLLECTIBLE DUE TO DISCHARGE OF DEBTOR BY BANKRUPTCY. *III. IF IT HAS BEEN DETERMINED THAT A PATIENT HAS BEEN APPROVED FOR MEDICAL ASSISTANCE, ALL ACCOUNTS CURRENTLY IN THE A/R WITH SPH WILL BE WRITTEN OFF TO COMMUNITY CARE AFTER PAYMENT IS RECEIVED FROM THE INSURANCE. *IV. ANY ACCOUNT RETURNED BY THE COLLECTION AGENCY THAT HAS BEEN DETERMINED TO BE UNCOLLECTIBLE WILL BE CONSIDERED COMMUNITY CARE. *V. QUALIFIED INDIVIDUALS UNDER ANOTHER ORGANIZATION'S SIMILAR COMMUNITY CARE APPLICATION PROCESS.* NO COMMUNITY CARE APPLICATION NEEDS TO BE COMPLETED IN THESE INSTANCES. SAUK PRAIRIE HEALTHCARE, INC. PART V, SECTION B, LINE 16J: INFORMATION ABOUT THE POLICY IS INCLUDED ON BILLING INVOICES, ON ADMISSION INFORMATION, ON THE WEBSITE, AND IS REFERENCED IN COLLECTION EFFORTS. IT IS ALSO MENTIONED IN COMMUNITY TALKS ON HEALTH INSURANCE. 6 1 - ORTHOPEDIC ASSOCIATES OF SAUK PRAIRIE 250 26TH STREET SUITE 150 PRAIRIE DU SAC WI 53578 ORTHOPEDIC CLINIC 2 - LODI MEDICAL CENTER 160 VALLEY DRIVE LODI WI 53555 PHYSICIAN CLINIC 3 - RIVER VALLEY MEDICAL CENTER 436 SUNRISE DRIVE SPRING GREEN WI 53588 RURAL HEALTH CLINIC 4 - WISCONSIN HEIGHTS CLINIC 506 CROCKER STREET SUITE 3 MAZOMANIE WI 53560 PHYSICIAN CLINIC 5 - PLAIN MEDICAL CLINIC 825 MAIN STREET PLAIN WI 53577 RURAL HEALTH CLINIC 6 - SURGICAL ASSOCIATES 250 26TH STREET SUITE 210 PRAIRIE DU SAC WI 53577 SURGICAL CLINIC PART I, LINE 3C: ELIGIBILITY FOR SAUK PRAIRIE HEALTHCARE'S COMMUNITY CARE (FINANCIAL ASSISTANCE) PROGRAM IS CONSIDERED FOR INDIVIDUALS WHO ARE UNINSURED, UNDERINSURED, INELIGIBLE FOR GOVERNMENTAL HEALTH PLANS, AND WHO ARE UNABLE TO PAY FOR THEIR CARE. ABILITY TO PAY IS DETERMINED BY COMPARING FAMILY INCOME TO FEDERAL POVERTY LEVELS, BUT IT ALSO CONSIDERS THE FAMILY'S ASSETS. DETERMINATIONS ARE BASED UPON AN INDIVIDUAL'S FINANCIAL NEED AND DO NOT TAKE INTO ACCOUNT GENDER, RACE, SOCIAL STATUS, SEXUAL ORIENTATION, OR RELIGIOUS AFFILIATION. INDIVIDUALS MUST RESIDE OR HAVE A PRIMARY CARE PHYSICIAN IN SAUK PRAIRIE HEALTHCARE'S SERVICE AREA TO BE ELIGIBLE. PATIENTS WHO ARE UNABLE TO COMPLETE A COMMUNITY CARE APPLICATION MAY BE ELIGIBLE FOR ASSISTANCE IF OTHER EVIDENCE IS AVAILABLE THAT MAY INDICATE FINANCIAL HARDSHIP. THIS INFORMATION MAY BE OBTAINED FROM A PATIENT INTERVIEW, CREDIT REPORT, OR OTHER AVAILABLE RECORDS. THIS INCLUDES THE FOLLOWING SITUATIONS:1. DECEASED WITH NO ESTATE2. DISCHARGE OF DEBTOR BY BANKRUPTCY3. PATIENT HAS BEEN APPROVED FOR MEDICAL ASSISTANCE4. ACCOUNT IS RETURNED BY THE COLLECTION AGENCY AS UNCOLLECTIBLE5. QUALIFICATION UNDER ANOTHER ORGANIZATION'S SIMILAR FINANCIAL ASSISTANCE APPLICATION PROCESS PART I, LINE 7: THE COSTING METHODOLOGY USED ON FORM 990 IS PRIMARILY BASED ON A COST TO CHARGE RATIO WHICH IS DEVELOPED BASED ON THE HOSPITAL'S TOTAL OPERATING EXPENSES LESS THE PROVISION FOR BAD DEBTS 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 SUGGESTED COSTING METHODS FOR THE FORM 990. THE COSTING METHOD FOR SUBSIDIZED HEALTH SERVICES IS BASED ON INTERNAL RECORDS ALLOCATIONS WHICH ARE SIMILAR TO A DIRECT COSTING ACCOUNTING SYSTEM FOR THESE SERVICES NOTED AS SUBSIDIZED HEALTH SERVICES. PART I, LINE 7G: SUBSIDIZED HEALTH SERVICES AT SAUK PRAIRIE HEALTHCARE, INC. INCLUDE THE OPERATION OF SEVERAL HOSPITAL DEPARTMENTS THAT OPERATE AT A LOSS FROM OPERATIONS, BUT ARE CONSIDERED VITAL HOSPITAL AND CLINIC SERVICES SUCH AS THE INTENSIVE CARE UNIT, OUTPATIENT PHYSICIAN CLINICS, INCLUDING INTERNAL MEDICINE (HOSPITAL MEDICINE), AND SEVERAL OTHER DEPARTMENTS. A LARGE PORTION OF THESE SERVICES ARE ACCESSED BY COMMUNITY MEMBERS THROUGH THE HOSPITAL'S EMERGENCY SERVICES DEPARTMENT. IT IS THE GOAL OF SAUK PRAIRIE HEALTHCARE, INC. TO PROVIDE THESE SERVICES TO THE COMMUNITY REGARDLESS OF A PATIENT'S ABILITY TO PAY. PART II, COMMUNITY BUILDING ACTIVITIES: THE HOSPITAL'S COMMUNITY BUILDING EFFORTS PROMOTE BOTH THE PHYSICAL AND ECONOMIC HEALTH OF THE COMMUNITIES IT SERVES. FROM AN ECONOMIC PERSPECTIVE, SAUK PRAIRIE HEALTHCARE, INC. STAFF CONTRIBUTES HUNDREDS OF HOURS TO CHAMBERS OF COMMERCE ACTIVITIES AND SUPPORT WORKFORCE DEVELOPMENT THROUGH COMMUNITY AND EDUCATIONAL PROGRAMS. THE PHYSICAL HEALTH OF THE COMMUNITY IS SUPPORTED THROUGH THE DEVELOPMENT OF HEALTH-RELATED COALITIONS, PARTICULARLY THE SAUK PRAIRIE WELLNESS MOVEMENT AND THE SAUK COUNTY HEALTH AND WELLNESS COALITION. 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 FOR INDIVIDUALS 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. 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 ORGANIZATION HAS USED REASONABLE COLLECTION EFFORTS ARE WRITTEN OFF THROUGH A CHARGE TO THE VALUATION ALLOWANCE AND A CREDIT TO ACCOUNTS RECEIVEABLE. PART III, LINE 4: FOR AN EXPLANATION OF THE ORGANIZATION'S BAD DEBT EXPENSE, SEE THE "PATIENT ACCOUNTS RECEIVABLES AND CREDIT POLICY" PARAGRAPHS IN NOTE 1 OF THE AUDITED FINANCIAL STATEMENTS, LOCATED ON PAGES 7-8 OF THE ATTACHED FINANCIAL STATEMENTS. PART III, LINE 8: WHETHER THERE IS SHORTFALL OR A SURPLUS ON SERVICES PROVIDED TO MEDICARE BENEFICIARIES, THESE PATIENTS, WHO ARE TYPICALLY ELDERLY 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. THE TOTAL MEDICARE REVENUE SHOWN ON SCHEDULE H IS BASED ON THE IRS FORM 990 INSTRUCTIONS AND ONLY INCLUDE THE CHARGES FROM MEDICARE PROGRAM BENEFICIARIES THAT ARE REPORTED ON THE HOSPITAL'S MEDICARE COST REPORT. THE AMOUNTS LISTED FOR MEDICARE REVENUES DO NOT INCLUDE PHYSICIAN SERVICES FOR THE COVERAGE OF THE EMERGENCY DEPARTMENT AT SAUK PRAIRIE HEALTHCARE, INC., PHYSICIAN SERVICES FOR THE INTERNAL MEDICINE (HOSPITALIST) PROGRAM, PHYSICIAN SERVICES PROVIDED TO TWO OF THE FOUR OUTLYING PHYSICIAN CLINICS, CRNA SERVICES PROVIDED TO PATIENTS UNDERGOING ANESTHESIA AT THE HOSPITAL, AND A SIGNIFICANT PORTION OF LAB AND PHYSICAL THERAPY SERVICES WHICH ARE REIMBURSED BY THE MEDICARE PROGRAM UNDER ANOTHER METHODOLOGY. PHYSICIAN COVERAGE OUTPATIENT LAB SERVICES AND OUTPATIENT PHYSICAL THERAPY SERVICES ARE REIMBURSED PRIMARILY ON A FEE SCHEDULE REIMBURSEMENT AT RATES THAT ARE OFTEN BELOW THE COST OF CARING FOR PATIENTS. EMERGENCY 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 SAUK PRAIRIE HEALTHCARE, INC. PROVIDES TO THE COMMUNITY AND SURROUNDING AREAS. THE COSTING METHODOLOGY USED ABOVE FOR IRS FORM 990 COMPLIANCE REPORTING IS ALSO BASED ON AN OVERALL AVERAGE COST TO CHARGE RATIO AND DOES NOT CONSIDER MEDICARE NON-ALLOWABLE EXPENSES AS IT IS BASED ON TOTAL OPERATING EXPENSES LESS THE PROVISION FOR BAD DEBT EXPENSE DIVIDED BY HOSPITAL PATIENT SERVICE REVENUES (IGNORING CONTRACTUAL ADJUSTMENT ON FEE SCHEDULE REIMBURSED ITEMS AND NON-ALLOWABLE MEDICARE EXPENSES AS NOTED ABOVE). THIS RATIO IS THEN MULTIPLIED BY THE TOTAL MEDICARE SERVICES, WHICH ARE REIMBURSED ON A COST REPORTING METHODOLOGY. INCLUDING THE FEE SCHEDULE ITEMS, SUCH AS PHYSICIAN SERVICES, WOULD PRODUCE A LARGER LOSS OR SHORTFALL ON THESE SERVICES TO BE REPORTED ON THE FORM 990 IN ANY GIVEN YEAR. PART III, LINE 9B: IT IS THE POLICY OF SAUK PRAIRIE HEALTHCARE, INC. THAT EACH PATIENT RECEIVES CARE REGARDLESS OF THE ABILITY TO PAY. IF DURING THE COLLECTION PROCESS A PATIENT DOES NOT COMPLETE THE NECESSARY PAPERWORK OR RESPOND TO ATTEMPTS BY THE HOSPITAL TO PROVIDE CHARITY SERVICES, THE PATIENT MAY STILL REQUEST CHARITY INFORMAITON AND COMPLETE THE INFORMATION AT ANY TIME DURING THE COLLECTION PROCESS. THE PATIENT WILL BE REFERRED TO THE HOSPITAL'S CHARITY CARE POLICY AND CAN QUALIFY FOR CHARITY CARE, AND HAVE ANY COLLECTION ISSUES REVERSED BY THE ORGANIZATION, IF THEY SHOW A NEED FOR CARE BASED ON THE HOSPITAL'S POLICY. PART VI, LINE 2: THE HOSPITAL ENGAGES IN THE FOLLOWING ACTIVITIES TO ASSESS THE HEALTHCARE NEEDS OF THE 42,000 RESIDENTS THROUGHOUT ITS 700 SQUARE MILE PRIMARY SERVICE AREA: ANALYZE HEALTH STATUS INFORMATION, EPIDEMIOLOGICAL DATA, AND HOSPITAL DISCHARGE DATA FURNISHED BY THE STATE OF WISCONSIN AND SAUK COUNTY TO IDENTIFY ISSUES AND TRENDS; MEET MONTHLY WITH THE COUNTY HEALTH DEPARTMENT AND TWO OTHER NEARBY HOSPITALS TO ASSESS HIGH PRIORITY HEALTH NEEDS AND COORDINATE ACTION; PARTICIPATE IN AND HELP COORDINATE COUNTY-WIDE INPUT SESSIONS WITH THE COUNTY HEALTH DEPARTMENT; LEAD AND PARTICIPATE IN COMMUNITY WELLNESS GROUPS AND INITIATIVES THROUGHOUT THE SERVICE AREA; CONDUCT "COMMUNITY HEALTH NEED" FOCUS GROUPS CONSISTING OF COMMUNITY LEADERS AND RANDOMLY SELECTED RESIDENTS; ANALYZE THE POPULATION-BASED NEED FOR MEDICAL PROVIDERS BY SPECIALTY. THIS INFORMATION IS ASSESSED AND MODIFIED BY MEMBERS OF THE HOSPITAL MEDICAL STAFF; LEADER PARTICIPATION AND LEADERSHIP IN CIVIC AND COMMUNITY SERVICE ORGANIZATIONS; ACTIVELY ENGAGE HOSPITAL BOARD MEMBERS IN COMMUNITY HEALTH IMPROVEMENT INITIATIVES AND PROVIDE THE BOARD WITH MONTHLY UPDATES REGARDING COMMUNITY HEALTH ACTIVITIES. PART VI, LINE 3: AT THE TIME OF REGISTRATION, A REGISTRATION SPECIALIST WILL INQUIRE IF THERE IS HEALTH INSURANCE. IF NOT, THEY WILL BE ADVISED OF THE HOSPITAL'S COMMUNITY CARE PROGRAM IF THEY RESIDE WITHIN OUR SERVICE AREA. THOSE WHO HAVE A SAUK PRAIRIE BASED PHYSICIAN WILL ALSO BE CONSIDERED FOR ELIGIBILITY. COMMUNITY CARE INFORMATION IS ALSO POSTED ON THE HOSPITAL WEBSITE AND BILLS STATE THAT IF THE PATIENT IS HAVING DIFFICULTY PAYING THEY SHOULD CONTACT A HOSPITAL REPRESENTATIVE, AS THEY MAY BE ELIGIBLE FOR FREE OR REDUCED FEES.ANY PATIENT REQUESTING ADDITIONAL INFORMATION ABOUT THE COMMUNITY CARE PROGRAM WILL BE REFERRED TO THE PATIENT ACCOUNTS SPECIALIST, WHO WILL EXPLAIN THE PROGRAM AND ITS ELIGIBLITY CRITERIA. WHEN APPLICABLE, ALL GOVERNMENT ASSISTANCE PROGRAMS SUCH AS MEDICAID, BADGER CARE, AND CRIME VICTIMS MUST BE EXHAUSTED BEFORE APPLYING FOR COMMUNITY CARE (EXCEPTION: THE GOVERNMENT ASSISTANCE PROGRAM APPLICATION MAY BE WAIVED BASED ON RELIGIOUS BELIEFS). COMMUNITY CARE IS NOT AVAILABLE FOR ELECTIVE PROCEDURES. PERSONS RESIDING IN SAUK PRAIRIE MEMORIAL HOSPITAL, INC.'S PRIMARY SERVICE AREA WILL BE CONSIDERED FOR ELIGIBLITY DETERMINATION. IN THE CASE OF EMERGENCY SERVICES, COMMUNITY CARE MAY BE EXTENDED TO THOSE RESIDING OUTSIDE OF THE PRIMARY SERVICE AREA.THE INFORMATION IS ALSO POSTED ON OUR WEBSITE UNDER "PREPARING FOR YOUR STAY." IF AT ANY TIME PRIOR TO, DURING, OR AFTER THE SERVICES ARE PROVIDED THE PATIENT EXPRESSED CONCERNS ABOUT PAYMENT, THE COMMUNITY CARE PROGRAM IS EXPLAINED. INFORMATION IS ALSO PRINTED ON PATIENT STATEMENTS AND DISCUSSED WITH THE PATIENT DURING THE BILLING PROCESS. PART VI, LINE 4: THE HOSPITAL'S PRIMARY SERVICE AREA ENCOMPASSES A 700 SQUARE MILE REGION IN RURAL SOUTH CENTRAL WISCONSIN, INCLUDING SAUK, SOUTHERN COLUMBIA, NORTHWEST DANE, NORTHERN IOWA AND EASTERN RICHLAND COUNTIES. THE HOSPITAL IS LOCATED IN SAUK PRAIRIE (COMMON NAME FOR THE NEIGHBORING MUNICIPALITIES OF SAUK CITY AND PRAIRIE DU SAC) AND THE CLINICS ARE LOCATED IN FOUR TOWNS SURROUNDING SAUK PRAIRIE (MAZOMANIE, SPRING GREEN, PLAIN, AND LODI). NO OTHER HOSPITALS ARE LOCATED WITHIN THE PRIMARY SERVICE AREA, BUT EIGHT INPATIENT HOSPITALS (INCLUDING 5 RURAL AND 3 TERTIARY FACILITIES) ARE LOCATED WITHIN A 30 MILES RADIUS OF SAUK PRAIRIE HEALTHCARE, INC. DEMOGRAPHIC ANALYSIS INDICATES A 5-YEAR GROWTH RATE OF 2.5% COMPARED TO THE STATE OF WISCONSIN'S RATE OF 1.9%. AGE GROUPS THAT WILL GROW AT A CONSIDERABLY FASTER RATE THAN THE STATE INCLUDE 0-17 YEAR OLDS (1.9%), 25-34 (15.2%), AND 65+ (16.65%). HEALTH ISSUES AFFECTING THESE AGE SEGMENTS INCLUDE PRENATAL SCREENING, TEEN PREGNANCY, LACK OF ACCESS TO HEALTHCARE, AND MEDICAL ISSUES ASSOCIATED WITH AGING. THE AREA HAS LITTLE RACIAL AND ETHNIC DIVERSITY, ALTHOUGH THE NUMBER OF HISPANIC RESIDENTS HAS INCREASED CONSIDERABLY SINCE 2000. SPECIFIC HEALTH-RELATED ISSUES CONFRONTING THIS POPULATION INCLUDE DIABETES, ACCESS TO CARE, AND LANGUAGE BARRIERS. AVERAGE HOUSEHOLD INCOME OF SERVICE AREA RESIDENTS IS 10% HIGHER THAN THE STATE AVERAGE. THIS DIFFERENCE IS DUE IN LARGE PART BECAUSE OF THE RELATIVELY STRONG JOB MARKET IN MADISON, WHICH ATTRACTS COMMUTERS FROM THE SERVICE AREA. THROUGHOUT THE SERVICE AREA, HOWEVER, AGRICULTURE AND TOURISM REPRESENT A CONSIDERABLE NUMBER OF LOW-PAYING JOBS, TYPCIALLY WITHOUT HEALTH BENEFITS. A PORTION OF THE HOSPITAL PRIMARY SERVICE AREA IS DESIGNATED AS A MEDICALLY UNDERSERVED AREA/POPULAITON. THIS AREA IS LOCATED IN THE TOWN OF ARENA (MCD 02575). SAUK COUNTY IS ALSO DESIGNATED AS A HEALTH MANPOWER SHORTAGE AREA FOR PSYCHIATRY. PART VI, LINE 5: SAUK PRAIRIE HEALTHCARE, INC. (SPH) IS AN INDEPENDENT COMMUNITY HOSPITAL GOVERNED BY AN 11-MEMBER BOARD OF DIRECTORS WHO RESIDE WITHIN THE PRIMARY SERVICE AREA. THE BOARD IS ELECTED BY THE 120-MEMBER COMMUNITY HOSPITAL ASSOCIATION. AN INDEPENDENT HOSPITAL IS A CRUCIAL PART OF THE HOSPITAL'S VISION, BECAUSE IT KEEPS CONTROL AT THE LOCAL LEVEL, NOT IN A CORPORATE HEADQUARTERS LOCATED ELSEWHERE. LOCAL CONTROL ALLOWS THE HOSPITAL TO MAKE DECISIONS THAT ARE BEST FOR THE LOCAL COMMUNITIES. SPH'S STRATEGIC PLAN SPECIFICALLY ADDRESSES OUR DESIRE TO "IMPROVE THE HEALTH OF THE COMMUNITIES WE SERVE AND THE ORGANIZATION'S EFFORTS TO ASSESS THE NEEDS OF THE COMMUNITY AND ADDRESS THOSE NEEDS. SPH PROMOTES COMMUNITY HEALTH THROUGH A BROAD ARRAY OF APPROACHES. THE FOLLOWING LIST DESCRIBES SPECIFIC PROGRAMS AND ACTIVITIES THAT CONTRIBUTE TO IMPROVING THE HEALTH OF THE COMMUNITY AND ENHANCING THE PROVISION OF MEDICAL CARE: TRAINING MEDICAL STUDENTS, NURSING STUDENTS, AND OTHER HEALTH PROFESSIONALS; CONTRIBUTE TIME AND FINANCIAL RESOURCES TO COMMUNITY HEALTH INITIATIVES, COLLABORATIVE WITH OTHER INDIVIDUALS AND ORGANIZATIONS IN THE COMMUNITY; ORGANIZE AND/OR PARTICIPATE IN HEALTH FAIRS; OFFER CPR/FIRST AID CLASSES; ISSUE EDUCATIONAL NEWS RELEASES; PROVIDE SERVICES FOR THE GOOD NEIGHBOR CLINIC OF SAUK PRAIRIE, INC. (LOCAL FREE CLINIC); MEDICATION TAKE BACK DAY; ADVANCED DIRECTIVES COUNSELING; BLOOD DRIVES; BREASTFEEDING EDUCATION; CANCER EDUCATION; CLINICS FOR UNDERINSURED/LAB & MEDICATION COSTS; COMMUNITY GARDEN; COMMUNITY HEALTH IMPROVEMENT ADVOCACY; DIABETES EDUCATION; FAMILY/PARENTING/SIBLING EDUCATION; MOBILE MEALS; SCHOOL-BASED HEALTH EDUCATION PROGRAMS; SELF-HELP/FITNESS AND EXERCISE; SELF-HELP/NUTRITION AND WEIGHT MANAGEMENT; SPORTS INJURY PREVENTION; SHARPS COLLECTION; SUPPORT GROUPS-BEREAVEMENT/GRIEF; SUPPORT GROUPS-BREASTFEEDING; SUPPORT GROUP-DIABETES; SUPPORT GROUPS-NEW MOM; SUPPORT GROUPS-SLEEP APNEA; AND TRANSPORTATION TOKENS (BUS, CAB FARE). PART VI, LINE 7, REPORTS FILED WITH STATES WI 1 TUITION REIMBURSEMENT 20 54942 PART I, LINE 2: TO SUPPORT THE NEEDS OF LOW-INCOME COMMUNITY MEMBERS, SAUK PRAIRIE HEALTHCARE (SPH) PROVIDES SPACE IN OUR OLD HOSPITAL TO GOOD NEIGHBOR CLINIC TO SERVE THOSE INDIVIDUALS. ANY PRODUCTS GIVEN TO GOOD NEIGHBOR CLINIC ARE HAND-DELIVERED. THE SHARED SPACE ENABLES SPH TO SEE HOW THE SUPPLIES ARE BEING USED. SPH ALSO PROVIDES FINANCIAL ASSISTANCE TO EMPLOYEES OF SPH TO ADVANCE THEIR KNOWLEDGE, SKILLS AND ABILITIES THROUGH POST-SECONDARY EDUCATION. APPLICATION FOR TUITION REIMBURSEMENT MUST BE MADE AT LEAST TWO WEEKS PRIOR TO THE COURSE STARTING DATE. THE APPLICATION MATERIALS MUST INCLUDE A COPY OF THE CLASS OR CURRICULUM DESCRIPTION BEING SUBMITTED FOR APPROVAL AND THE COST PER COURSE OR PER CREDIT. THE TUITION REIMBURSEMENT REQUEST FORM MUST BE COMPLETED AND SIGNED BY THE EMPLOYEE, DEPARTMENT DIRECTOR, AND VICE PRESIDENT PRIOR TO THE FIRST DATE OF CLASS. WITHIN 60 DAYS OF COMPLETION OF THE COURSE(S), THE EMPLOYEE MUST SUBMIT RECEIPTS FOR TUITION PAID BY THE EMPLOYEE AND PROOF OF SATISFACTORY COMPLETION TO THE HUMAN RESOURCES DEPARTMENT. UPON VERIFICATION OF ALL INFORMATION, HUMAN RESOURCES WILL ARRANGE FOR A REIMBURSEMENT CHECK TO BE ISSUED TO THE EMPLOYEE. 1 X X X X X 0 0 0 0 0 0 0 0 0 SHAWN LERCH CEO 269380 0 0 0 1383 0 13750 0 30246 0 314759 0 0 0 JAMES DREGNEY CFO 238765 0 7500 0 4742 0 12259 0 28065 0 291331 0 0 0 DENISE COLE-OUZOUNIAN VP PATIENT SERVICES 143662 0 7500 0 529 0 7970 0 31664 0 191325 0 0 0 ANDREW ERTL MD SURGEON 798985 0 232209 0 15634 0 13750 0 36894 0 1097472 0 0 0 MATTHEW HERBERT MD SURGEON 767311 0 190994 0 720 0 13750 0 29987 0 1002762 0 0 0 MICHAEL LAMSON MD SURGEON 794950 0 247057 0 720 0 13750 0 29987 0 1086464 0 0 0 DAVID MARCU MD SURGEON 773945 0 179714 0 432 0 13750 0 28054 0 995895 0 0 0 THEODORE PARINS MD SURGEON 374292 0 151428 0 595 0 13750 0 30780 0 570845 0 0 0 A WISCONSIN HEALTH AND EDUCATIONAL FACILITIES AUTHORITY 391337855 97710B6V9 2013-01-19 38000000 CONSTRUCTION OF NEW HOSPITAL 0 0 0 B WISCONSIN HEALTH AND EDUCATIONAL FACILITIES AUTHORITY 391337855 2013-01-19 30000000 CONSTRUCTION OF NEW HOSPITAL 0 0 0 A 38000000 3384222 562253 34053525 2014 0 0 1 1 B 5983635 30000000 1993018 542647 27469720 2014 0 0 1 1 A 0 0 0 0 0 0 1 B 0 0 0 0 0 0 1 A 0 0 0 1 0 0 0 0 1 B 0 0 0 1 1 0 0 0 1 A 1 B 1 DATE REBATE COMPUTATION PERFORMED ISSUER NAME: WISCONSIN HEALTH AND EDUCATIONAL FACILITIES AUTHORITY DATE THE REBATE COMPUTATION WAS PERFORMED: 02/26/2018 ISSUER NAME: WISCONSIN HEALTH AND EDUCATIONAL FACILITIES AUTHORITY DATE THE REBATE COMPUTATION WAS PERFORMED: 04/03/2018 BALLWEG CHEVORLET-BUICK INC JASON BRICKL IS A BOARD MEMBER OF SPH AND 100% OWNER OF THE DEALERSHIP. 39601 VEHICLE PURCHASE. 0 FORM 990, PART VI, SECTION A, LINE 1 THE ORGANIZATION HAS AN EXECUTIVE COMMITTEE COMPRISED OF THE CURRENT AND PAST BOARD PRESIDENTS, CURRENT BOARD VICE PRESIDENT, AND CURRENT BOARD TREASURER & SECRETARY. THE EXECUTIVE COMMITTEE, AT ITS SOLE DISCRETION, IS EMPOWERED TO EXERCISE THE POWERS OF THE FULL BOARD WITH RESPECT TO ANY MATTER THAT SHOULD NOT BE POSTPONED UNTIL THE NEXT MEETING OF THE BOARD OF DIRECTORS. THE COMMITTEE SHALL: -ACT ON BEHALF OF THE BOARD OF DIRECTORS WHEN NECESSARY -ACT AS A RESOURCE FOR THE CEO ON EMERGING, CONFIDENTIAL, AND SENSITIVE MATTERS -CONDUCT THE CEO'S ANNUAL PERFORMANCE EVALUATION -NEGOTIATE AND RECOMMEND THE CEO'S COMPENSATION PACKAGE -NEGOTIATE THE CEO'S EMPLOYMENT CONTRACT -REGULARLY REPORT ITS ACTIONS TO THE BOARD OF DIRECTORS FORM 990, PART VI, SECTION A, LINE 6 ANNUAL MEMBERSHIP WILL BE CONFERRED FOR ONE YEAR UPON PERSONS CONTRIBUTING THE SUM OF TEN DOLLARS TO THE CORPORATION AND/OR THE SAUK PRAIRIE HEALTHCARE FOUNDATION. LIFE MEMBERSHIP WILL BE CONFERRED UPON PERSONS CONTRIBUTING THE SUM OF ONE HUNDRED DOLLARS TO THE CORPORATION AND/OR SAUK PRAIRIE HEALTHCARE FOUNDATION. TWO LIFE MEMBERSHIPS WILL BE CONFERRED UPON TWO PERSONS CONTRIBUTING THE SUM OF TWO HUNDRED DOLLARS OR MORE TO THE CORPORATION AND/OR SAUK PRAIRIE HEALTHCARE FOUNDATION. FORM 990, PART VI, SECTION A, LINE 7A THE BOARD OF DIRECTORS SHALL BE ELECTED BY THE MEMBERS AT THE ANNUAL MEETING OF THE MEMBERS. FORM 990, PART VI, SECTION A, LINE 7B AN ANNUAL AND LIFE MEMBERSHIP SHALL BE ENTITLED TO ONE VOTE AT THE ANNUAL MEETING OR AT ANY SPECIAL MEETINGS OF THE MEMBERSHIP. THOSE WITH LIFE MEMBERSHIPS MAY ALSO HOLD OFFICE AS A DIRECTOR OF THE CORPORATION OR SERVE ON A COMMITTEE. MEMBERS MAY VOTE ON ELECTIONS OF BOARD MEMBERS, CHANGES TO THE BYLAWS, AND OTHER BUSINESS ALLOWED BY LAW. FORM 990, PART VI, SECTION B, LINE 11B THE FORM 990 WAS REVIEWED IN DETAIL BY THE DIRECTOR OF FINANCE, THE CFO, AND A DISCUSSION WAS HELD WITH THE CEO FOR ANY NEW OR UNUSUAL ITEMS. UPON APPROVAL, THE BOARD OF DIRECTORS RECEIVES AN ELECTRONIC COPY OF THE FORM 990 PRIOR TO SUBMISSION WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C SINCE SAUK PRAIRIE HEALTHCARE, INC. IS A PART OF A SMALL COMMUNITY, CONFLICTS ARE GENERALLY KNOWN, IF NOT DISCLOSED THROUGH THE ANNUAL PROCESS CONDUCTED BY HUMAN RESOURCES. THE ANNUAL PROCESS INCLUDES ALL DIRECTOR LEVEL EMPLOYEES AND ABOVE OF THE HOSPITAL. THE BOARD OF DIRECTORS HAS A CONFLICT OF INTEREST POLICY AND MUST ANNUALLY SIGN A DISCLOSURE FORM STATING ANY POTENTIAL CONFLICTS OF INTEREST. THE BOARD PRESIDENT THEN DISCLOSES ANY CONFLICTS OF INTEREST TO THE FULL BOARD OF DIRECTORS. CONFLICT OF INTEREST STATEMENTS COMPLETED BY BOARD MEMBERS ARE REVIEWED BY THE BOARD PRESIDENT AND EMPLOYEE'S CONFLICT OF INTEREST STATEMENTS ARE REVIEWED BY STAFF LEADERSHIP AND/OR ADMINISTRATION. THESE INDIVIDUALS ARE CHARGED WITH THE RESPONSIBILITY OF ENSURING THAT BUSINESS IS CONDUCTED IN A MANNER THAT ADHERES TO THE HOSPITAL'S FORMALLY APPROVED CONFLICT OF INTEREST POLICY. FORM 990, PART VI, SECTION B, LINE 15A THE BOARD OF DIRECTORS HAS ESTABLISHED POLICY BG-8 FOR ITS COMPENSATION PHILOSOPHY WITH RESPECT TO EXECUTIVE COMPENSATION AND TO DEFINE PRACTICES ASSOCIATED IN ACCORDANCE WITH IRC 4958. HOSPITAL EXECUTIVE SALARY IS SET ANNUALLY USING COMPARABILITY DATA FROM OUTSIDE CONSULTANTS AND THIRD-PARTY SURVEY DATA. THE EXECUTIVE COMMITTEE IS RESPONSIBLE FOR SETTING SALARY FOR THE CEO BASED ON THE CEO'S JOB PERFORMANCE. THE COMMITTEE RELIES UPON COMPARABILITY DATA DEVELOPED BY OUTSIDE CONSULTANTS TO SUPPORT ITS DECISION MAKING PROCESS AND TO ENSURE COMPETITIVE SALARY LEVELS. THE BOARD REVIEWS BG-8 ANNUALLY AT THE GOVERNANCE COMMITTEE. COMPENSATION FOR OTHER KEY EMPLOYEES IS ESTABLISHED BY APPLICATION OF THE HOSPITAL'S COMPENSATION PHILOSOPHY, WHEREIN RATES OF PAY ARE COMPARED TO MARKET RATES OBTAINED THROUGH PARTICIPATION IN WAGE AND BENEFIT SURVEYS. PAY RANGES ARE OBTAINED FROM SURVEYS OF SIMILARLY SITUATED HOSPITALS LOCATED WITHIN THE STATE OF WISCONSIN IN TERMS OF SIZE AND REVENUE CATEGORY. THE HOSPITAL ADOPTED A "MEET THE MARKET" APPROACH TO COMPENSATION FOR POSITIONS AT THESE LEVELS. THIS MEANS THAT SAUK PRAIRIE HEALTHCARE, INC. TARGETS THE MIDPOINT OF THE PAY RANGE ASSOCIATED WITH EACH POSITION. THE CEO APPROVES COMPENSATION FOR ALL OTHER OFFICERS AND KEY EMPLOYEES BASED ON THE CRITERIA ABOVE. FORM 990, PART VI, SECTION C, LINE 19 THE ABBREVIATED FINANCIAL STATEMENTS ARE A PART OF THE HOSPITAL'S ANNUAL REPORT PRESENTED TO THE PUBLIC AT THE ANNUAL MEETING AND POSTED ON THE HOSPITAL'S WEBSITE. THE ABBREVIATED FINANCIAL STATEMENTS ARE ALSO MADE PUBLICLY AVAILABLE THROUGH THE WISCONSIN HOSPITAL ASSOCIATION. THE HOSPITAL'S GOVERNING DOCUMENTS AND CONFLICT OF INTEREST POLICY ARE MADE AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART XI, LINE 9: CHANGE IN INTEREST IN NET ASSETS OF FOUNDATION 444,852. SAUK PRAIRIE HEALTHCARE FOUNDATION LTD 80 FIRST STREET PRAIRIE DU SAC WI 53578 930841113 FUNDRAISING WI 501(C)(3) LINE 10 N/A 0 FRIENDS OF SAUK PRAIRIE HEALTHCARE 260 26TH STREET PRAIRIE DU SAC WI 53578 391453754 VOLUNTEERING WI 501(C)(3) LINE 12C, III-FI N/A 0 0 0 1 0 0 0 0 0 0 0 0 1 1 1 1 0 0 0 0