2017-05-15T12:43:22-05:00 2016-06-30 390758449 WIPFLI LLP PO BOX 12237 GREEN BAY WI 543072237 990 2015-07-01 390944012 MOUNDVIEW MEMORIAL HOSPITAL & CLINICS MOUN 6083393331 402 WEST LAKE STREET FRIENDSHIP WI 53934 DONALD HEINZ CEO 6083393331 2017-05-15 1 TERRI REXRODE CPA MST P00096513 9206620016 2017-05-15 2015 2021-01-29 14:40:06Z DONALD HEINZ 402 WEST LAKE STREET FRIENDSHIP WI 53934 21358450 0 X WWW.MOUNDVIEW.ORG X 1959 WI MOUNDVIEW MEMORIAL HOSPITAL & CLINICS PROVIDES INPATIENT HOSPITAL AND GENERAL HEALTH CARE SERVICES WITH THE PRIMARY MARKET OF ADAMS COUNTY WISCONSIN BY OPERATING A 25 BED CRITICAL ACCESS HOSPITAL. 7 7 167 60 0 0 33654 147649 19218661 20714051 34396 61855 262588 379869 19549299 21303424 0 0 0 0 8092356 8988779 0 0 0 10245028 10261237 18337384 19250016 1211915 2053408 16086782 17080865 8163444 7110411 7923338 9970454 X MOUNDVIEW MEMORIAL HOSPITAL AND CLINICS, INCORPORATED, AS A COMMUNITY HEALTH RESOURCE WILL PROVIDE MODERN FACILITIES AND EQUIPMENT TO ENSURE THE DELIVERY OF SERVICES WITH AN EMPHASIS ON PRIMARY HEALTH CARE TO THE PEOPLE OF THE HOSPITAL SERVICE AREA. THE HOSPITAL'S LEADERSHIP, WITH ITS RESOURCES WILL RESPOND IN A TIMELY MANNER TO PHYSICAL, PSYCHOLOGICAL AND SPIRITUAL NEEDS, EMPHASIZING THE 'WHOLE PERSON.' MOUNDVIEW MEMORIAL HOSPITAL AND CLINCS, INCORPORATED WILL PROVIDE MANAGEMENT, AND WELL TRAINED STAFF TO PROVIDE COMPASSIONATE HEALTH CARE. MOUNDVIEW MEMORIAL HOSPITAL AND CLINICS, INCORPORATED SHALL EXPLORE THOSE PROPOSALS FOR NETWORKS, AFFILIATIONS, MERGERS, AND PARTICIPATE IN HMO'S AS DEEMED IN THE BEST INTEREST OF THOSE WE SERVE. 0 0 17126633 20925511 THE HOSPITAL IS A GENERAL MEDICAL CRITICAL ACCESS HOSPITAL LICENSED FOR 25 BEDS. DURING FISCAL YEAR 2016, THE HOSPITAL HAD 364 ACUTE INPATIENT DAYS AND 287 MEDICARE SKILL NURSING DAYS (SWING BED). THE HOSPITAL ALSO HAD 5,527 EMERGENCY ROOM VISITS, 1,191 URGENT CARE VISITS AND32,883 OUTPATIENT CLINIC AND OTHER OUTPATIENT ANCILLARY VISITS. 17126633 1 1 0 1 0 0 0 0 0 0 1 0 0 0 1 0 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 1 0 0 0 1 0 0 0 0 0 0 0 0 0 1 0 0 0 1 183 0 167 1 0 0 0 0 0 0 0 0 0 0 X 7 7 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 WI X DONALD HEINZ 6083393331 402 WEST LAKE STREET FRIENDSHIP WI 53934 MARY POLIVKA PRESIDENT 2.50 X X 0 0 0 DEBRA SEGINA VICE PRESIDENT 2.50 X X 0 0 0 RICHARD STERNHAGEN TREASURER 2.50 X X 0 0 0 DIANA BRONIEC SECRETARY 2.50 X X 0 0 0 PETER MURPHY BOARD MEMBER 2.50 X 0 0 0 RENEE SCHINDLBECK BOARD MEMBER 2.50 X 0 0 0 BARBARA ALBRECHT BOARD MEMBER 2.50 X 0 0 0 DONALD HEINZ CEO 40.00 X 215034 0 29934 MARK HATTON PHYSICIAN 40.00 X 230536 0 26504 JOHN DAVID PHYSICIAN 40.00 X 193892 0 27125 JASON BELLAK PHYSICIAN 40.00 X 267106 0 25383 DAVID SHAPIRO DIRECTOR OF ANCILLIARY SERVICES 40.00 X 144054 0 15210 CYNTHIA GANNON PHYSICIAN 40.00 X 229671 0 31175 1280293 0 155331 11 0 1 0 EMCARE PHYSICIAN SERVICES INC 7032 COLLECTION CENTER DRIVE CHICAGO IL 60693 ER PHYSICIAN COVERAGE 1212831 CHG HEALTHCARE PO BOX 972633 DALLAS TX 753972633 LOCUM SPECIALTY PHYSICIAN SERVICES 624156 CERNER CORPORATION PO BOX 959156 ST LOUIS MO 63195 SOFTWARE MAINTENANCE / SUPPORT 260498 SHARED IMAGING SERVICES PO BOX 88450 MILWAUKEE WI 88450 MEDICAL IMAGING SERVICES 234985 FIRST REFLECTIONS INC 228 N PINE STREET ADAMS WI 53910 CRNA PROFESSIONAL SERVICES 227281 10 58436 78271 10942 147649 NET PATIENT SERVICE REVENUE 900099 20529035 20529035 MISCELLANEOUS REVENUE 900099 127307 127307 MEDICAL BUILDING RENT 900099 34877 34877 DIETARY INCOME 900099 22832 22832 20714051 61855 61855 38419 55026 -16607 -16607 -16607 EHR INCENTIVE 900099 396476 396476 396476 21303424 20983220 0 172555 X 244969 244969 7052355 6388880 663475 97261 97261 1123997 988580 135417 470197 415230 54967 55302 55302 51600 51600 3702203 3477415 224788 40408 40408 2058010 1908649 149361 7562 5293 2269 233492 212590 20902 65809 58205 7604 232873 211962 20911 1060186 931317 128869 251276 226481 24795 BAD DEBT EXPENSE 1319973 1319973 REPAIRS & MAINTENANCE 603342 515231 88111 EQUIPMENT RENTS & LEASE 357306 324690 32616 COLLECTION EXPENSE 72884 72884 149011 44876 104135 19250016 17126633 2123383 0 700 700 3162292 4246540 2655251 2802226 20000 10000 22000 391351 426002 324712 258526 20056363 11447930 8880550 8608433 629926 728438 16086782 17080865 2810125 2241659 622197 548097 4011000 3596000 720122 318312 0 406343 8163444 7110411 X 7469777 9572908 453561 397546 7923338 9970454 16086782 17080865 X 2053408 -6292 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 1596 1596 0 PART II-B, LINE 1: WHA MEMBERSHIP DUES 63641 63641 12244179 5116217 7127962 123411 64323 59088 7625132 6267390 1357742 8608433 OBLIGATIONS UNDER CAPITAL LEASES 406343 406343 20087614 -1270836 -1270836 21358450 -55026 -55026 21303424 17985069 55026 55026 17930043 1319973 1319973 19250016 PART XI, LINE 2D - OTHER ADJUSTMENTS: FOUNDATION MARKET ADJUSTMENT 49,137. BAD DEBT EXPENSE -1,319,973. PART XI, LINE 4B - OTHER ADJUSTMENTS: RENTAL EXPENSES -55,026. PART XII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES 55,026. PART XII, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT EXPENSE 1,319,973. 1 1 X 1 X 175.000000000000 1 X 175.000000000000 1 1 1 0 1 1 52918 52918 0.00300 3370985 2689869 681116 0.03800 3423903 2689869 734034 0.04100 210465 12497 197968 0.01100 18689 18689 0.00100 229154 12497 216657 0.01200 3653057 2702366 950691 0.05300 0 521158 57200 6310092 6358882 -48790 X 1 1 1 1 MOUNDVIEW MEMORIAL HOSPITAL 402 WEST LAKE STREET FRIENDSHIP WI 53934 WWW.MOUNDVIEW.ORG 1014 X X X X MOUNDVIEW MEMORIAL HOSPITAL 1 0 0 1 X X X X X X X X X 15 1 0 1 1 X HTTP://WWW.MOUNDVIEW.ORG/IMAGES/PDFS/COUNTYNEEDSASSESSMENT.PDF X HTTP://CO.ADAMS.WI.GOV/DEPARTMENTS/HEALTHHUMANSERVICES/PUBLICHEALTH/TABID/2 X X 1 15 1 HTTP://WWW.MOUNDVIEW.ORG/IMAGES/PDFS/COUNTYNEEDSASSESSMENT.PDF 0 0 1 X 175.000000000000 175.000000000000 X X 1 1 X X X X 1 X HTTP://WWW.MOUNDVIEW.ORG/PATIENTS-VISITORS/FINANCIAL-ASSISTANCE X HTTP://WWW.MOUNDVIEW.ORG/PATIENTS-VISITORS/FINANCIAL-ASSISTANCE X HTTP://WWW.MOUNDVIEW.ORG/PATIENTS-VISITORS/FINANCIAL-ASSISTANCE X X X X X 1 X 0 X X X X 1 X 0 0 MOUNDVIEW MEMORIAL HOSPITAL PART V, SECTION B, LINE 3J: A TEAM OF KEY STAKEHOLDERS AND COMMUNITY REPRESENTATIVES REPRESENTING A BROAD CROSS SECTION OF ADAMS COUNTY REVIEWED LOCAL AND STATE DATA DURING A SERIES OF MEETINGS. SINCE ADAMS COUNTY'S COUNTY HEALTH RANKING WAS SIGNIFICANTLY LOW ACROSS ALL AREAS EXCEPT PHYSICAL ENVIRONMENT, THE TEAM HELD AN INITIAL RANKING OF HEALTH ISSUES. SIX THEMES WERE RATED AND SCORED INCLUDING SOCIAL SUPPORT, PHYSICAL ACTIVITY, EMPLOYMENT, HEALTH LITERACY, AND ACCESS TO HIGH QUALITY CARE AND HEALTHY NUTRITION. LOCAL DATA WAS FURTHER RESEARCHED AND PRESENTED ON THESE SIX AREAS THROUGH A SERIES OF PRESENTATIONS TO BETTER UNDERSTAND THE ISSUES IDENTIFIED IN THE LOCAL STATISTICS. ADDITIONAL DATA WAS COLLECTED THROUGH A SURVEY AND FOCUS GROUPS CONDUCTED BY MOUNDVIEW REGARDING THE COMMUNITY'S PERCEPTION OF THE TOP COUNTY HEALTH PRIORITIES. SURVEY RESPONDENTS AND FOCUS GROUPS WERE ASKED A QUESTION ABOUT THE COMMUNITY'S GREATEST HEALTH NEEDS AND WERE ASKED TO RATE THE SERIOUSNESS OF THESE ISSUES. DATA AND VISION THEMES WERE THEN WITH THE COMMUNITY TEAM TO IDENTIFY THE TOP THREE KEY COMMUNITY HEALTH PRIORITIES FOR ADAMS COUNTY. THE THREE PRIORITIES CHOSEN WERE SOCIAL SUPPORT AND SOCIAL COHESION, EMPLOYMENT, AND ADEQUATE, APPROPRIATE AND SAFE FOOD AND NUTRITION. MOUNDVIEW MEMORIAL HOSPITAL PART V, SECTION B, LINE 5: FIRST, KEY STAKEHOLDERS AND COMMUNITY REPRESENTATIVES WERE IDENTIFIED AND INVITED TO JOIN A "COMMUNITY TEAM" TO CONDUCT THE NEEDS ASSESSMENT. THE TEAM REPRESENTED A CROSS SECTION OF THE RESIDENTS AND ORGANIZATIONS IN ADAMS COUNTY. INPUT WAS ALSO SOUGHT FROM THE GENERAL COMMUNITY THROUGH A COMMUNITY OPINION SURVEY (CONDUCTED BY TELEPHONE) AND FOCUS GROUPS CONDUCTED BY A MARKET RESEARCH GROUP ON BEHALF OF MOUNDVIEW MEMORIAL. SURVEY RESPONDENTS AND FOCUS GROUPS WERE ASKED A QUESTION ABOUT THE COMMUNITY'S GREATEST HEALTH NEEDS AND WERE ASKED TO RATE THE SERIOUSNESS OF THESE ISSUES. MOUNDVIEW MEMORIAL HOSPITAL PART V, SECTION B, LINE 6B: THE NEEDS ASSESSMENT WAS PARTNERSHIP BETWEEN ADAMS COUNTY HEALTH PUBLIC HEALTH AND MOUNDVIEW MEMORIAL HOSPITAL & CLINICS. SEVERAL OTHER ORGANIZATIONS PARTICIPATED AND/OR CONTRIBUTED INCLUDING ADAMS COUNTY HEALTH AND HUMAN SERVICES STAFF AND BOARD, ADAMS COUNTY UW EXTENSION, ADAMS-FRIENDSHIP SCHOOL DISTRICT, CENTRAL WISCONSIN COMMUNITY ACTION COUNCIL, ADAMS COUNTY RURAL AND INDUSTRIAL DEVELOPMENT COMMISSION, ADAMS COUNTY GOVERNMENT, ADAMS COUNTY DISTRICT ATTORNEY, ADAMS COUNTY SHERIFF'S DEPARTMENT, ADAMS COUNTY CHAMBER OF COMMERCE, ADAMS COUNTY PARKS AND RECREATION, RIVERVIEW HOSPITAL, WISCONSIN DELLS PARK AND RECREATION. MOUNDVIEW MEMORIAL HOSPITAL PART V, SECTION B, LINE 7D: A DISPLAY BOARD ON THE NEEDS ASSESSMENT FINDINGS WAS ALSO CREATED AND DISPLAYED AT LARGE SCALE COMMUNITY EVENTS AND AT THE ADAMS COUNTY COMMUNITY CENTER. INFORMATION IS REPORTED TO THE WISCONSIN HOSPITAL ASSOCIATION. MOUNDVIEW MEMORIAL HOSPITAL PART V, SECTION B, LINE 11: MOUNDVIEW HAS ADDRESSED THE NEEDS OF NUTRITION/PHYSICAL ACTIVITY AND SOCIAL SUPPORT/COHESION AS INDICATED IN OUR IMPLEMENTATION PLAN, ADAPTING THE PLAN AS NEEDED. ADDITIONALLY, MOUNDVIEW HAS WORKED ON ISSUES REGARDING "SUBSTANCE ABUSE" WHICH WAS NOT CHOSEN AS A NEEDS ASSESSMENT PRIORITY, BUT WAS IDENTIFIED BY MOUNDVIEW AS AN IMPORTANT HEALTH ISSUE. MOUNDVIEW IS LIMITED IN WHAT WE CAN DO TO SUPPORT THE "EMPLOYMENT" PRIORITY THAT WAS IDENTIFIED THROUGH THE NEEDS ASSESSMENT. MOUNDIVEW STAFF HAD PLANNED TO SERVE ON THE PROMISE NEIGHBORHOOD COMMUNITY WORK GROUP TASKED WITH ADDRESSING THIS ISSUE BUT THE GROUP IS NOT ACTIVE DUE TO THE PROMISE NEIGHBORHOOD GRANT ENDING. MOUNDVIEW WILL CONTINUE TO LOOK FOR OPPORTUNITIES TO WORK WITH OUR COMMUNITY PARTNERS ON THIS ISSUE. MOUNDVIEW DOES CONTINUE TO PROVIDE CAREER SHADOWING/JOB EXPLORATION OPPORTUNITIES AND CLINICAL EXPERIENCES TO HIGH SCHOOL AND COLLEGE STUDENTS, ATTEND JOB FAIRS, SPEAK TO AREA YOUTH AT HIGH SCHOOL CAREER DAYS AND ENCOURAGE THOSE PURSUING HEALTH CARE CAREERS TO CONSIDER RETURNING TO ADAMS COUNTY TO WORK. MOUNDVIEW MEMORIAL HOSPITAL PART V, SECTION B, LINE 22D: THE HOSPITAL USED THE LOOKBACK METHOD BASED ON THE LOWEST COMMERCIAL RATES 1 1 - MOUNDVIEW CLINIC 402 WEST LAKE STREET FRIENDSHIP WI 53934 CLINIC PART I, LINE 6A: WI HOSPITAL ASSOCIATION PART I, LINE 7: UTILIZE THE MEDICARE COST TO CHARGE METHODOLOGY. PART I, LINE 7, COLUMN (F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $ 1,319,973. PART II, COMMUNITY BUILDING ACTIVITIES: THE HOSPITAL'S COMMUNITY BUILDING ACTIVITIES PROMOTES HEALTH OF THE COMMUNITIES IT SERVES THROUGH LOCAL ADVERTISEMENTS, INVOLVEMENT WITH CHAMBER OF COMMERCE, DEPARTMENT OF AGING AND OTHER COMMUNITY ORGANIZATIONS. THE AMOUNT OF SUPPORT IS DIFFICULT TO QUANTIFY. PART III, LINE 2: THE RATIO OF PATIENT COST TO CHARGES WAS CALCULATED BY DIVIDING HOSPITAL EXPENSES NET OF NON-PATIENT REVENUE AND IDENTIFIED COMMUNITY BENEFIT EXPENSE BY GROSS PATIENT REVENUE. THE PERCENTAGE WAS THEN MULTIPLED BY THE GROSS REVENUES ON BAD DEBT ACCOUNTS. PART III, LINE 3: IT IS CONSIDERED COMMUNITY BENEFIT AS THE HOSPITAL IS REIMBURSED ON MEDICARE ALLOWABLE COSTS. MEDICARE ALLOWABLE COSTS ARE DEFINED BY MEDICARE. THEY DO NOT NECESSARILY CAPTURE ALL COSTS OF THE HOSPITAL PROVIDING SERVICES TO THE COMMUNITY. CONSEQUENTLY, THERE ARE COSTS NOT REIMBURED BY EITHER PATIENT OR THE PROGRAM. THE COST METHODOLOGY USED TO DETERMINE MEDICARE ALLOWABLE COSTS IS A STEP-DOWN ALLOCATION OF COSTS FROM NON-REVENUE AREAS TO REVENUE AREAS. THIS ALLOCATION IS DONE FOLLOWING MEDICARE RULES AND REGULATIONS. PART III, LINE 4: PATIENT ACCOUNTS RECEIVABLE ARE RECORDED IN THE ACCOMPANYING CONSOLIDATED BALANCE SHEETS NET OF CONTRACTUAL ADJUSTMENTS AND AN ALLOWANCE FOR DOUBTFUL ACCOUNTS, WHICH REFLECT MANAGEMENT'S BEST ESTIMATE OF AMOUNTS THAT WILL NOT BE COLLECTED. MANAGEMENT PROVIDES FOR CONTRACTUAL ADJUSTMENTS UNDER TERMS OF THIRD-PARTY REIMBURSEMENT AGREEMENTS THROUGH A REDUCTION OF GROSS REVENUE AND A CREDIT TO PATIENT ACCOUNTS RECEIVABLE. IN ADDITION, MANAGEMENT PROVIDES FOR PROBABLE UNCOLLECTIBLE AMOUNTS, PRIMARILY UNINSURED PATIENTS AND AMOUNTS PATIENTS ARE PERSONALLY RESPONSIBLE FOR, THROUGH A REDUCTION OF GROSS REVENUE AND A CREDIT TO THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. BALANCES STILL OUTSTANDING AFTER MANAGEMENT HAS USED REASONABLE COLLECTION EFFORTS ARE WRITTEN OFF THROUGH A CHARGE TO THE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND A CREDIT TO ACCOUNTS RECEIVABLE.IN EVALUATING THE COLLECTIBILITY OF PATIENT ACCOUNTS RECEIVABLE, THE HOSPITAL ANALYZES PAST RESULTS AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYOR SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL 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 DOUBTFUL ACCOUNTS. SPECIFICALLY, FOR RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRD-PARTY COVERAGE, THE HOSPITAL ANALYZES CONTRACTUALLY DUE AMOUNTS AND PROVIDES AN ALLOWANCE FOR DOUBTFUL 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 HOSPITAL RECORDS A SIGNIFICANT 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 DOUBTFUL ACCOUNTS. PART III, LINE 8: IT IS CONSIDERED COMMUNITY BENEFIT AS THE HOSPITAL IS REIMBURSED ON MEDICARE ALLOWABLE COSTS. MEDICARE ALLOWABLE COSTS ARE DEFINED BY MEDICARE. THEY DO NOT NECESSARILY CAPTURE ALL COSTS OF THE HOSPITAL PROVIDING SERVICES TO THE COMMUNITY. CONSEQUENTLY, THERE ARE COSTS NOT REIMBURSED BY EITHER PATIENT OR THE PROGRAM. THE COST METHODOLOGY USED TO DETERMINE MEDICARE ALLOWABLE COSTS IS A STEP-DOWN ALLOCATION OF COSTS FROM NON-REVENUE AREAS TO REVENUE AREAS. THIS ALLOCATION IS DONE FOLLOWING MEDICARE RULES AND REGULATIONS. PART III, LINE 9B: PATIENTS UPON REGISTRATION ARE GIVEN THE POLICY AND REQUIREMENTS TO BE ELIGIBLE FOR CARITY CARE. THEY ARE ENCOURAGED BY A FINANCIAL ADVISOR TO REVIEW THEIR SITUATION FOR ELIGIBILITY. PART VI, LINE 2: THE HOSPITAL DEVELOPS COMMUNITY SURVEY WITH CONJUNCTION OF THE LOCAL PUBLIC HEALTH DEPARTMENT TO ASSESS SPECIFIC UNMET COMMUNITY NEEDS. PART VI, LINE 3: THE HOSPITAL ANNUALLY PUBLISHES IN THE LOCAL PAPER THE EXISTENCE OF ITS CHARITY PLAN AND QUALIFYING INCOME NEEDS TO QUALIFY. THE EXISTENCE OF A CHARITY PLAN IS POSTED IN THE ADMITTING AREA. UPON REGISTRATION, THE PATIENT IS INFORMED OF THE HOSPITAL'S CHARITY PLAN, ELIGIBILITY AND METHODS FOR APPLYING. ANYONE INTERESTED IN FURTHER INFORMATION IS REFERRED TO THE PATIENT ACCOUNT COORDINATOR FOR QUESTIONS AND ELIGIBILITY. THIS PERSON WORKS WITH THE PATIENT IN APPLICATION AS WELL AS EXPLORING THE POSSIBLE ELIGIBILITY OF ANY OTHER GOVERNMENT PROGRAM THAT MAY BE APPLICABLE. IE MEDICAID, BADGER CARE. PART VI, LINE 4: THE ORGANIZATION SERVES ADAMS COUNTY WISCONSIN BORDERED BY HWY 82 SOUTH, COUNTY C NORTH. PART VI, LINE 5: THE HOSPITAL WORKS WITH THE LOCAL PUBLIC HEALTH AGENCIES TO COORDINATE COMMUNITY HEALTH SERVICES TO MEET THE NEEDS OF THE LOCAL COMMUNITY. LONG-RANGE STRATEGIC AND CAPITAL BUDGET PLANNING WITH ADMINISTRATION, MEDICAL STAFF AND BOARD OF DIRECTORS. SURVEY OF OPINIONS FROM HOSPITAL ASSOCIATION. PART VI, LINE 6: N/A PART VI, LINE 7, REPORTS FILED WITH STATES WI X X X 0 0 0 0 0 0 0 0 0 DONALD HEINZ CEO 173003 0 38656 0 3375 0 6635 0 23299 0 244968 0 0 0 MARK HATTON PHYSICIAN 216676 0 13860 0 0 0 3433 0 23071 0 257040 0 0 0 JOHN DAVID PHYSICIAN 187476 0 6416 0 0 0 1041 0 26084 0 221017 0 0 0 JASON BELLAK PHYSICIAN 247106 0 0 0 20000 0 7414 0 17969 0 292489 0 0 0 DAVID SHAPIRO DIRECTOR OF ANCILLIARY SERVICES 127646 0 16408 0 0 0 4325 0 10885 0 159264 0 0 0 CYNTHIA GANNON PHYSICIAN 228638 0 1033 0 0 0 0 0 31175 0 260846 0 0 0 A VILLAGE OF FRIENDSHIP REVENUE BONDS 396006271 2003-11-01 5000000 WI HOSPITAL DEVELOPMENT REVENUE BONDS 0 0 0 A 415000 5000000 110000 4890000 2005 0 0 1 1 A 0 0 0 0 0 0 1 A 0 1 0 0 0 0 0 0 0 A 0 FORM 990, SCHEDULE K, PART III, LINE 7 MANAGEMENT CALCULATES AND REVIEWS BOND COVENANTS ON A MONTHLY BASIS. THE BOND COVENANTS ARE REPORTED TO THE BOARD OF DIRECTORS. DR JOHN DAVID EMPLOYEE OF HOSPITAL SIGNING BONUS X 30000 10000 0 1 1 10000 FORM 990, PART VI, SECTION A, LINE 6 ANY PERSON OVER THE AGE OF EIGHTEEN YEARS WHO IS A RESIDENT OF ADAMS COUNTY MAY BE A MEMBER OF THE CORPORATION. MEMBERSHIP MAY BE ATTAINED BY ANY SUCH PERSON WHO SHALL AGREE IN WRITING TO BECOME A MEMBER OF THIS CORPORATION BY SUBSCRIBING TO A MEMBERSHIP LIST OF SAID CORPORATION. ANNUAL MEMBERSHIPS WILL BE IN EFFECT FROM JULY 1ST TO JUNE 30TH OF EACH FISCAL YEAR. FORM 990, PART VI, SECTION A, LINE 7A EACH PERSON WHO WAS A MEMBER IN GOOD STANDING AS OF THE PREVIOUS JUNE 30TH IS ENTITLED TO ONE VOTE FOR EACH SEAT OF THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION A, LINE 7B MEMBERS OF THE ORGANIZATION MUST APPROVE BYLAW CHANGES. FORM 990, PART VI, SECTION B, LINE 11 THE 990 IS REVIEWED BY THE CEO PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C THE CONFLICT OF INTEREST POLICY IS REVIEWED EVERY YEAR BY THE POLICY AND PROCEDURE COMMITTEE AND BY THE CEO. OFFICERS AND DIRECTORS ARE REQUIRED TO REVIEW THE POLICY AND DISCLOSE CONFLICTS. THE CEO REVIEWS THE SIGNED STATEMENTS. IF THERE IS A CONFLICT, THE CONFLICT WOULD BE DECLARED AND THE MEMBER WOULD ABSTAIN FROM VOTING. FORM 990, PART VI, SECTION B, LINE 15 CEO COMPENSATION IS BASED ON DIRECT NEGOTIATIONS BETWEEN THE BOARD MEMBERS WITHOUT CONFLICT AND THE INDIVIDUAL UTILIZING CURRENT RELEVANT MARKET SURVEYS AS A GUIDE WITH THE LANGUAGE OF CONTRACT GIVEN TO MMC ATTORNEYS FOR REVIEW AND COMMENTS. SUBSEQUENT MODIFICATIONS ARE PERFORMANCE BASED AND MARKET DRIVEN. FOR OTHER OFFICERS AND KEY EMPLOYEES THE CEO DETERMINES SALARY BASED ON THE MARKET, EXPERIENCE AND INDUSTRY SURVEY GUIDES. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION BELIEVES THE GOVERNING DOCUMENTS, AND POLICIES ARE THE PROPERTY OF THE ORGANIZATION AND ARE NOT AVAILABLE FOR PUBLIC INSPECTION. THE AUDITED FINANCIAL STATEMENTS ARE NOW REQUIRED TO BE ATTACHED TO FORM 990. AUDITED FINANCIAL INFORMATION IS POSTED ANNUALLY ON THE HOSPITAL'S WEBSITE. FORM 990, PART IX, LINE 11G MEDICAL PROFESSIONAL FEES: PROGRAM SERVICE EXPENSES 2,761,015. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,761,015. HUMAN RESOURCES: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 19,418. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 19,418. FISCAL SERVICES: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 59,769. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 59,769. COMMUNITY RELATIONS: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 18,418. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 18,418. OTHER PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 716,400. MANAGEMENT AND GENERAL EXPENSES 127,183. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 843,583. FORM 990, PART XI, LINE 9: CHANGE IN ASSETS HELD IN POLIVKA TRUST -6,292. FORM 990, PART XII, LINE 2C: THIS PROCESS HAS NOT CHANGED FROM THE PRIOR YEARS. MEMORIAL HEALTHCARE FOUNDATION OF ADAMS CO PO BOX 40 FRIENDSHIP WI 53934 391775074 RAISE FUNDS FOR MOUNDVIEW MEMORIAL HOSPITAL & CLINICS WI 501(C)(3) 11B, TYPE I N/A 1 0 0 1 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 MEMORIAL HEALTHCARE FOUNDATION OF ADAMS COUNTY B 58436 ACTUAL