2017-05-12T09:42:23-05:00 2016-06-30 476097913 SEIM JOHNSON LLP 18081 BURT STREET SUITE 200 OMAHA NE 680224722 990 2015-07-01 420859940 BURGESS HEALTH CENTER BURG 7124232311 1600 DIAMOND STREET ONAWA IA 51040 FRANCIS TRAMP PRESIDENT/CEO 7124232311 2017-05-12 1 WENDY R COOLEY P01523804 4023302660 2015 2021-01-29 14:40:06Z FRANCIS TRAMP 1600 DIAMOND STREET ONAWA IA 51040 34887514 0 X WWW.BURGESSHC.ORG X 1959 IA TO PROVIDE HEALTHCARE SERVICES TO THE COMMUNITY 10 8 334 78 2214269 -126877 428894 125341 28240524 30778702 845073 738016 251530 134455 29766021 31776514 0 0 0 0 14320902 15732998 0 0 0 13208291 14949472 27529193 30682470 2236828 1094044 36869464 35487489 8671655 7069092 28197809 28418397 BURGESS HEALTH CENTER IS COMMITTED TO IMPROVE THE QUALITY OF LIFE FOR THE PEOPLE AND COMMUNITIES IT SERVES BY PROVIDING EXCELLENT HEALTHCARE AND EXCEPTIONAL PATIENT EXPERIENCES. 0 0 26059637 28610169 THE BURGESS HEALTH CENTER IS A NOT-FOR-PROFIT ACUTE CARE HOSPITAL. THE HEALTH CENTER PROVIDES RELATED HEALTHCARE ANCILLARY, OUTPATIENT, PHYSICIAN CLINIC SERVICES, AND A RETAIL PHARMACY. 26059637 1 1 0 1 0 0 0 0 0 0 1 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0 1 1 1 0 0 1 89 0 1 334 1 1 1 0 0 0 0 0 0 0 0 0 X 10 8 0 0 0 0 1 0 1 1 1 0 0 1 1 1 1 1 1 1 0 0 X NANCY CARLSON VICE PRESIDENT OF FI 7124239213 1600 DIAMOND STREET ONAWA IA 51040 JIM WESTERGAARD CHAIRMAN 2.00 0.00 X X 0 0 0 TERRY FRAMKE VICE CHAIRMAN 2.00 2.00 X X 0 0 0 STEVE PRATT SECRETARY/TREASURER 2.00 0.00 X X 0 0 0 JUDY CONNEALY BOARD MEMBER 2.00 0.00 X 0 0 0 SHEILA DUARTE DDS BOARD MEMBER 2.00 0.00 X 0 0 0 PAUL DUDLEY MD BOARD MEMBER 2.00 0.00 X 0 0 0 JOHN GARRED JR MD BOARD MEMBER 2.00 0.00 X 58933 0 0 MARI MILLER BOARD MEMBER 2.00 0.00 X 0 0 0 KEITH SCHRUNK OD BOARD MEMBER 2.00 0.00 X 0 0 0 CHARLES SEDERSTROM BOARD MEMBER 2.00 0.00 X 0 0 0 FRANCIS TRAMP PRESIDENT / CEO 39.00 1.00 X 176210 0 29151 NANCY CARLSON VICE PRESIDENT OF FINANCE 39.00 1.00 X 123236 0 24131 MONTY MCKINVEN CRNA 40.00 0.00 X 397853 0 26659 WASEEM ALOUNK MD PHYSICIAN 40.00 0.00 X 304785 0 28338 PETER DAHER MD PHYSICIAN 40.00 0.00 X 289990 0 18919 SANDRA ROSE RETAIL PHARMACIST 40.00 0.00 X 127323 0 6479 JENNIFER SCHENNE DO PHYSICIAN 40.00 0.00 X 126000 0 5038 1604330 0 138715 13 0 1 0 EVIDENT PO BOX 850309 MOBILE AL 36685 BILLING, IT SUPPORT 487730 SHARED MEDICAL SERVICES INC 209 LIMESTONE PASS COTTAGE GROVE WI 53527 MRI 324970 FAMILY MEDICINE CLINIC PC 1614 DIAMOND ST ONAWA IA 51040 ER & CLINIC COVERAGE, WORK COMP SERVICES 308613 GRAPETREE MEDICAL STAFFING 1003 23RD STREET MILFORD IA 51351 STAFFING 209324 MCKESSON INFORMATION SOLUTIONS PO BOX 98347 CHICAGO IL 60693 EQUIPMENT, SOFTWARE 183829 6 94477 24676 6188 125341 MEDICARE/MEDICAID PAYMENTS 624100 16611657 16611657 PATIENT REVENUE 624100 11441931 11441931 RETAIL PHARMACY 446110 2214269 2214269 MEANINGFUL USE INCENTIVE PAYMENTS 624100 308609 308609 202236 202236 30778702 648209 648209 111201 104714 6487 6487 6487 3094093 2000 3006286 0 87807 2000 89807 89807 CAFETERIA / DIETARY 722210 82232 82232 REBATES / DISCOUNTS 900099 45736 45736 127968 31776514 28610169 2214269 826735 411661 58933 352728 63210 63210 12485923 10664516 1821407 275259 245569 29690 1648670 1419621 229049 848275 735451 112824 27703 27703 56800 56800 2259918 1947602 312316 107365 107365 1640993 945060 695933 11561 11561 807697 726199 81498 125751 101784 23967 122421 122421 1553278 868830 684448 121520 121520 MEDICAL SUPPLIES 4804899 4804899 RETAIL PHARMACY EXPENSE 2168827 2168827 BAD DEBT EXPENSE 872625 872625 FOOD 100324 100324 167790 95741 72049 30682470 26059637 4622833 0 306027 352146 7337079 4590330 3775380 4756828 202921 57396 1051101 1169488 207107 191715 31018458 18872343 12143585 12146115 11635767 11899253 7811 5090 202686 319128 36869464 35487489 2579679 2431378 4913934 4637714 1178042 0 8671655 7069092 X 28197809 28418397 28197809 28418397 36869464 35487489 1094044 -873456 0 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 5575 5575 0 PART II-B, LINE 1: BURGESS HEALTH CENTER PAYS ASSOCIATION DUES TO THE IOWA HOSPITAL ASSOCIATION (IHA) AND AMERICAN HOSPITAL ASSOCIATION (AHA). PORTIONS OF THE ASSOCIATION DUES ARE EXPENDED BY THE ASSOCIATIONS FOR LOBBYING PURPOSES. IN FISCAL YEAR 2016, BURGESS HEALTH CENTER PAID DUES OF $16,965, AND $8,508 OF WHICH 21% AND 23.65%, REPECTIVELY, WERE ESTIMATED TO BE NON-DEDUCTIBLE EXPENSES (BY THE ASSOCIATIONS) FOR LOBBYING ACTIVITIES. 55042 55042 19211496 10219685 8991811 11018879 8193312 2825567 733041 459346 273695 12146115 X PART X, LINE 2: THE HEALTH CENTER AND FOUNDATION ARE NOT-FOR-PROFIT CORPORATIONS AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE AND ARE EXEMPT FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE CODE. THE INTERNAL REVENUE SERVICE HAS ESTABLISHED STANDARDS TO BE MET TO MAINTAIN THE HEALTH CENTER AND FOUNDATION'S TAX EXEMPT STATUS. IN GENERAL, SUCH STANDARDS REQUIRE THE HEALTH CENTER AND FOUNDATION TO MEET A COMMUNITY BENEFITS STANDARD AND COMPLY WITH VARIOUS LAWS AND REGULATIONS. THE HEALTH CENTER AND FOUNDATION ACCOUNT FOR UNCERTAINTIES IN ACCOUNTING FOR INCOME TAX ASSETS AND LIABILITIES USING GUIDANCE INCLUDED IN FASB ASC 740, INCOME TAXES. THE HEALTH CENTER AND FOUNDATION RECOGNIZE THE EFFECT OF INCOME TAX POSITIONS ONLY IF THOSE POSITIONS ARE MORE LIKELY THAN NOT OF BEING SUSTAINED. AT JUNE 30, 2016 AND 2015, THE HEALTH CENTER AND FOUNDATION HAD NO UNCERTAIN TAX POSITIONS ACCRUED. 1 1 1 X 1 X 245.000000000000 1 1 0 0 562 197000 197000 0.00660 5748 1018575 1018575 0.03420 6310 1215575 1215575 0.04080 15 2072 19414 1133 18281 0.00060 6 23194 4305648 3534255 771393 0.02590 1 40 659 659 0.00000 22 25306 4325721 3535388 790333 0.02650 22 31616 5541296 3535388 2005908 0.06730 1 872625 610838 10518651 10763057 -244406 X 1 1 1 1 BURGESS HEALTH CENTER 1600 DIAMOND STREET ONAWA IA 61040 WWW.BURGESSHC.ORG 670082H X X X X BURGESS HEALTH CENTER 1 0 0 1 X X X X X X X X X 15 1 0 1 1 X WWW.BURGESSHC.ORG X 1 15 1 WWW.BURGESSHC.ORG 0 0 1 X 100.000000000000 245.000000000000 X X X X 1 1 X X X X 1 X WWW.BURGESSHC.ORG X WWW.BURGESSHC.ORG X WWW.BURGESSHC.ORG X X X X X 1 X 0 X X X X 1 X 0 0 BURGESS HEALTH CENTER PART V, SECTION B, LINE 5: IN ORDER TO ENSURE EXTERNAL INPUT WAS RECEIVED IN ADDITION TO RESPONSES TO THE SURVEY, THE FOLLOWING ENTITIES WERE CONTACTED FOR INPUT:- MONONA COUNTY PUBLIC HEALTH- BURGESS MEDICAL STAFF- MONONA COUNTY DENTISTSIN ADDITION, MONONA COUNTY PUBLIC HEALTH'S COMMUNITY HEALTH NEEDS IMPROVEMENT PLAN FOR MONONA COUNTY WAS REVIEWED FOR IDENTIFIED COMMUNITY NEEDS AND PRIORITIES. BURGESS HEALTH CENTER PART V, SECTION B, LINE 6B: -MONONA COUNTY PUBLIC HEALTH BURGESS HEALTH CENTER PART V, SECTION B, LINE 11: TO ADDRESS, EDUCATE AND PREVENT THE PRIMARY CONCERNS OF THE CHNA, BURGESS HEALTH CENTER HAS DEVELOPED THE FOLLOWING PROGRAMS TO ADDRESS THE NEEDS IDENTIFIED IN OUR SERVICE AREA:HEART DISEASE THE WEAR RED HEART HEALTH COMMUNITY EVENT TOOK PLACE FEBRUARY 11, 2016. TWO HOSPITAL HEALTHCARE PROVIDERS SPOKE ABOUT HEART HEALTH, PREVENTION, AND STRESS REDUCTION. A HEALTH FAIR WAS HELD CONSISTING OF WELLNESS RESOURCES AVAILABLE IN THE COUNTY.CHILD ABUSE & NEGLECTBURGESS HEALTH CENTER CONTINUES TO PROMOTE EDUCATING CHILDREN ABOUT HEALTHY LIVING THROUGH THE HEALTH SMART KIDS OUTREACH PROGRAM PROVIDED TO 6 COMMUNITY SCHOOLS IN THE SERVICE AREA. OVER 400 CHILDREN ARE INVOLVED WITH THE PROGRAM EACH YEAR. TARGET AUDIENCE IS 2ND AND 4TH GRADERS. STUDENTS ARE INSTRUCTED OVER A FOUR WEEK PERIOD ON BEHAVIORS THAT PROMOTE HEALTHY LIVES AND ARE ENCOURAGED TO PRACTICE THESE BEHAVIORS TO PROMOTE HEALTH. 1. NUTRITION - EATING FRUITS, VEGETABLES, MILK AND BREAKFAST2. EXERCISE - 60 MINUTES OF ACTIVITY PER DAY3. SLEEP - 10 HOURS SLEEP EVERY NIGHT4. CREATIVE ACTIVITIES - ACTIVITIES TO DO OTHER THAN TV AND/OR VIDEO GAMESIN WEEK #5, WE HAVE A CELEBRATION THAT REWARDS THE STUDENTS FOR ALL THE HEALTHY BEHAVIORS THEY HAVE BEEN PRACTICING; PLAYING GAMES THAT REINFORCE THE HEALTHY BEHAVIORS AND PRIZES.PHYSICAL ACTIVITYBURGESS HEALTH CENTER'S MEDICALLY ORIENTED GYM (MOG) PROVIDES A PLACE FOR COMMUNITY MEMBERS TO RECEIVE A CUSTOMIZED FITNESS PROGRAM THAT ACCOMODATES INDIVIDUAL NEEDS. POVERTY BURGESS HEALTH CENTER IS USING REOCCURRING FACEBOOK ADS TO PROMOTE THEIR STUDENT LOAN FORGIVENESS PROGRAM TO POTENTIAL NEW EMPLOYEES.SIGNIFICANT NEEDS THAT WERE IDENTIFIED, BUT NOT ADDRESSED INCLUDE DIABETES, RADON TESTING AND PREVENTION, IMMUNIZATIONS, CANCER SCREENINGS, LOW BIRTH WEIGHT, DEPRESSION, ACCIDENTS AND EMERGENCY PREPAREDNESS. THESE NEEDS WERE NOT ADDRESSED BECAUSE OTHER EXISTING PROGRAMS ARE ALREADY ADDRESSING THE NEED OR THERE IS A LACK OF HUMAN AND FINANCIAL RESOURCES TO DEDICATE TO THE ISSUE. BURGESS HEALTH CENTER PART V, SECTION B, LINE 13B: BURGESS HEALTH CENTER USES HUD GUIDELINES FOR IOWA WHICH ARE LESS RESTRICTIVE FOR THE PATIENTS. THESE GUIDELINES CAN BE FOUND AT HUDUSER.GOV. BURGESS HEALTH CENTER PART V, SECTION B, LINE 22D: THE HOSPITAL USED DISCOUNTS OR WROTE OFF THE BALANCE DUE PER FINANCIAL ASSISTANCE GUIDELINES IN THE HOSPITAL'S FINANCIAL ASSISTANCE POLICY. 5 1 - BURGESS FAMILY CLINIC - MAPLE VALLEY 513 SOUTH MUCKEY STREET MAPLETON IA 51304 FAMILY MEDICAL CLINIC 2 - BURGESS CLINIC WHITING 153 BLAIR STREET WHITING IA 51063 FAMILY MEDICAL CLINIC 3 - BURGESS FAMILY CLINIC - SLOAN 409 EVANS SLOAN IA 51055 FAMILY MEDICAL CLINIC 4 - BURGESS FAMILY CLINIC - DUNLAP 612 IOWA AVENUE DUNLAP IA 51529 FAMILY MEDICAL CLINIC 5 - BURGESS FAMILY CLINIC - DECATUR 12TH BROADWAY DECATUR NE 68020 FAMILY MEDICAL CLINIC PART I, LINE 3C: BURGESS HEALTH CENTER USES HUD GUIDELINES WHICH ARE LESS RESTRICTIVE FOR OUR PATIENTS. THE HOSPITAL DOES NOT USE ASSET TESTING OR OTHER FACTORS REGARDLESS OF INCOME AS A FACTOR TO DETERMINE ELIGIBILITY FOR FREE OR DISCOUNTED CARE. PART I, LINE 7: BURGESS HEALTH CENTER USES LYONS SOFTWARE TO TRACK ALL PROGAMS THROUGHOUT THE YEAR. WHEN A PROGRAM IS USED, THE PERSON IN CHARGE WILL TRACK THE PROGRAM IN THE SOFTWARE BY RECORDING THE CATEGORY, THE RELATED COSTS AND REVENUE AND THE NUMBER OF PARTICIPANTS. PART I, LINE 7G: ALL COSTS REPORTED ON PART I, LINE 7G ARE ATTRIBUTABLE TO THE PHYSICIAN CLINICS. 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 $ 872,625. PART II, COMMUNITY BUILDING ACTIVITIES: BURGESS HEALTH CENTER DID NOT REPORT ANY COMMUNITY BUILDING ACTIVITIES IN PART II OF SCHEDULE H. PART III, LINE 2: IN EVALUATING THE COLLECTIBILITY OF ACCOUNTS RECEIVABLE, THE HEALTH CENTER ANALYZES ITS PAST HISTORY AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYER SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND PROVISION FOR BAD DEBTS. MANAGEMENT REGULARLY REVIEWS DATA ABOUT THESE MAJOR PAYER SOURCES OF REVENUE IN EVALUATING THE SUFFICIENCY OF THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. FOR RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRD-PARTY COVERAGE, THE HEALTH CENTER ANALYZES CONTRACTUALLY DUE AMOUNTS AND PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS AND A PROVISION FOR BAD DEBTS FOR THOSE ACCOUNTS OVER A CERTAIN AGE BASED ON DISCHARGE 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 HEALTH CENTER 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 3: THE BAD DEBT RECOGNIZED OF $872,625, IS 2.88% OF NET PATIENT SERVICE REVENUE FOR THE FISCAL YEAR. 9% OF PEOPLE LIVING IN MONONA COUNTY HAVE INCOME BELOW NATIONAL POVERTY GUIDELINES. USING THESE FACTS, BURGESS HEALTH CENTER ESTIMATES THAT THE MAJORITY (70%) OF SERVICES THAT END IN BAD DEBT ARE FOR PATIENTS WHO WOULD QUALIFY FOR CHARITY CARE IF THEY WOULD APPLY. PART III, LINE 4: THE HOSPITAL'S FINANCIAL STATEMENTS DO NOT CONTAIN A SPECIFIC FOOTNOTE DESCRIBING BAD DEBT. HOWEVER, PAGES 8 AND 10 OF THE ATTACHED AUDITED FINANCIAL STATEMENTS INCLUDE FOOTNOTES TITLED "PATIENT RECEIVABLES, NET" "NET PATIENT SERVICE REVENUE, AND "CHARITY CARE". PART III, LINE 8: THE MEDICARE SHORTFALL IS BASED ON THE INFORMATION FROM THE COST REPORT. THE COSTS ARE MEDICARE REIMBURSABLE COSTS, NOT ALL COSTS. THE MEDICARE SHORTFALL SHOULD BE TREATED AS A COMMUNITY BENEFIT BECAUSE THE SERVICES ARE PROVIDED WITHOUT THE EXPECTATION THAT MEDICARE REVENUES WILL COVER OUR COSTS. THE ORGANIZATION USED THE COST REPORT AND MEDICARE PS&R FOR THE YEAR ENDED JUNE 30, 2016. PART III, LINE 9B: BURGESS HEALTH CENTER HAS TWO FINANCIAL COUNSELORS WHO WILL REVIEW OUTSTANDING ACCOUNTS WITH PATIENTS TO HELP THEM QUALIFY FOR ASSISTANCE IN PAYING THE OUTSTANDING BILL. THIS ASSISTANCE INCLUDES COMPLETING PAPERWORK AND GATHERING SOURCE DOCUMENTS TO DETERMINE IF THE PATIENT QUALIFIES FOR FINANCIAL ASSISTANCE. THE FINANCIAL COUNSELOR WILL ALSO ASSIST PATIENTS IN COMPLETING PAPERWORK IN ORDER FOR THEM TO QUALIFY FOR GOVERNMENT ASSISTANCE. PART VI, LINE 2: BURGESS HEALTH CENTER REVIEWS DATA FROM THE IOWA DEPARTMENT OF PUBLIC HEALTH. BURGESS HEALTH CENTER FOCUSES ON TOP ADMISSIONS TO THE HOSPITAL AND REVIEWS THE AGGREGATE DATA FROM WELLNESS SCREENS. PART VI, LINE 3: PATIENTS' BILLS CONTAIN INFORMATION REGARDING THE AVAILABILITY OF FINANCIAL ASSISTANCE AND GIVES CONTACT INFORMATION FOR OBTAINING THIS ASSISTANCE. IF A PATIENT HAS NOT RESPONDED TO THE BILL, THE FINANCIAL COUNSELOR WILL CONTACT THE PATIENT TO MAKE ARRANGEMENTS TO HELP THE PATIENT APPLY FOR FINANCIAL ASSISTANCE. PART VI, LINE 4: BURGESS HEALTH CENTER IS SITUATED IN MONONA COUNTY, IA. THE SERVICE AREA IS CONSIDERED A RURAL SETTING WITH A POPULATION OF APPROXIMATELY 10,000. OF THIS POPULATION, 24.3% OF MONONA COUNTY IS OVER AGE 65 COMPARED TO THE IOWA AVERAGE OF 15.6%. THE SERVICE AREA RANKS LOW REGARDING THE MEDIAN HOUSEHOLD INCOME. THE IOWA MEDIAN HOUSEHOLD INCOME FOR 2009-2013 IS $51,843 WITH MONONA COUNTY HAVING A MEDIAN HOUSEHOLD INCOME OF $42,025, NEARLY $10,000 LOWER. PART VI, LINE 5: PROMOTING THE HEALTH OF THE COMMUNITIES BURGESS HEALTH CENTER SERVES IS IMPORTANT TO BURGESS HEALTH CENTER. FURTHERMORE, IT IS PART OF THE MISSION STATEMENT OF BURGESS HEALTH CENTER. - "BURGESS HEALTH CENTER IS COMMITTED TO IMPROVE THE QUALITY OF LIFE FOR THE PEOPLE AND COMMUNITIES WE SERVE BY PROVIDING EXCELLENT HEALTHCARE AND EXCEPTIONAL PATIENT EXPERIENCES." TO HELP SUPPORT THAT MISSION BURGESS HEALTH CENTER HAS OPENED UP MEDICALLY ORIENTED GYMS (MOGS) IN 2 COMMUNITIES OF OUR SERVICE AREA, MAPLETON AND ONAWA. THROUGH FITNESS, WELLNESS AND GUIDANCE, THE MOGS ARE SPECIFICALLY DESIGNED TO IMPROVE THE LIFE AND HEALTH OF OUR COMMUNITY MEMBERS. THE PROFESSIONAL STAFF DEVELOP CUSTOMIZED FITNESS PROGRAMS TO HELP PEOPLE OF ALL AGES OBTAIN A HEALTHY LIFESTYLE.BURGESS HEALTH CENTER ALSO PARTNERS WITH OTHER ORGANIZATIONS IN THE COMMUNITY TO IMPROVE COMMUNITY HEALTH AND WELL BEING. BURGESS HEALTH CENTER PARTICIPATES IN MEDICARE, MEDICAID CHAMPUS AND TRICARE. PART VI, LINE 6: BURGESS HEALTH CENTER IS NOT PART OF AN AFFILIATED HEALTH CARE SYSTEM. X X X 0 0 0 0 0 0 0 0 0 FRANCIS TRAMP PRESIDENT / CEO 175825 0 0 0 385 0 5630 0 23521 0 205361 0 0 0 MONTY MCKINVEN CRNA 396902 0 0 0 951 0 7670 0 18989 0 424512 0 0 0 WASEEM ALOUNK MD PHYSICIAN 304612 0 0 0 173 0 7950 0 20388 0 333123 0 0 0 PETER DAHER MD PHYSICIAN 289474 0 0 0 516 0 0 0 18919 0 308909 0 0 0 A CITY OF ONAWA IOWA 426005064 2012-07-13 6259250 REFUND PRIOR ISSUE (06/08/05) 0 0 0 A 1830766 6259250 125185 6134065 2007 1 0 1 1 A 0 0 0 0 0.00000 0.00000 0.00000 0 0 1 A 0 0 1 1 1 0 0 0 1 A 1 SCHEDULE K, PART IV, ARBITRAGE, LINE 2C DATE THE REBATE COMPUTATION WAS PERFORMED: 01/13/2013 NOTE REGARDING THE REBATE COMPUTATION; SINCE THE BOND PROCEEDS HAVE BEEN SPENT, A SPENDING EXCEPTION WAS MET AND THE DEBT SERVICE FUND WAS OPERATED ON A BONA FIDE BASIS, NO FURTHER REBATE CALCULATIONS ARE NECESSARY. KATHRYN GARRED EMPLOYEE OF ORGANIZATION AND SPOUSE OF JOHN GARRED JR., MD, BOARD MEMBER 63210 EMPLOYEES W-2 WAGES 0 FAMILY MEDICINE CLINIC DR. PAUL DUDLEY OWNS 100% OF THE CLINIC AND IS A CURRENT BOARD MEMBER 308613 CONTRACTED SERVICES PROVIDED FOR ER COVERAGE 0 FORM 990, PART VI, SECTION A, LINE 6 BURGESS HEALTH CENTER HAS MEMBERS. A PERSON MAY BECOME A MEMBER IF HE OR SHE (1) IS AT THAT TIME A RESIDENT OF THE GEOGRAPHIC AREA SERVED BY THE CORPORATION; (2) COMPLETES A MEMBERSHIP REGISTRATION FORM, AND (3) PAYS A LIFE MEMBERSHIP FEE OF $10. FORM 990, PART VI, SECTION A, LINE 7B THERE IS AN ANNUAL MEETING OF THE MEMBERS. AT THE MEETING, THE MEMBERS RECEIVE AN ANNUAL REPORT ON THE AFFAIRS OF THE CORPORATION AND HAVE THE OPPORTUNITY TO OFFER THEIR INPUT ON ANY MATTER AFFECTING THE CORPORATION. THE MEMBERS SHALL ALSO CARRY OUT ANY DUTIES RESERVED TO MEMBERS UNDER THE IOWA NONPROFIT CORPORATION ACT. EACH MEMBER HAS ONE VOTE. THE ACT OF A MAJORITY OF MEMBERS PRESENT AND VOTING SHALL BE THE ACT OF THE MEMBERS. FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 AND RELATED SCHEDULES ARE PRESENTED TO THE FINANCE COMMITTEE BY NANCY CARLSON, VICE PRESIDENT OF FINANCE, AT THE FIRST SCHEDULED FINANCE COMMITTEE MEETING AFTER THE COMPLETION OF THE FORM 990. WITH THE EXTENSIONS, THE FORM 990 IS DUE MAY 15TH AND WILL BE EMAILED TO THE BOARD OF DIRECTORS FOR REVIEW PRIOR TO SUBMISSION TO IRS. FORM 990, PART VI, SECTION B, LINE 12C ON A ANNUAL BASIS, ALL BOARD MEMBERS ALONG WITH THE MANAGEMENT STAFF (MANAGERS, DIRECTORS, OFFICERS) COMPLETE A CONFLICT OF INTEREST QUESTIONNAIRE. THE RESULTS ARE REVIEWED AT ONE OF THE BOARD MEETINGS. IF THERE IS A CONFLICT, THE BOARD MEMBER REFRAINS FROM VOTING ON THAT ISSUE. FORM 990, PART VI, SECTION B, LINE 15A THE CEO SALARY IS DETERMINED BASED ON GRADE, NUMBER OF YEARS IN THE POSITION AND COMPARED TO IOWA HOSPITAL ASSOCIATION DATA SHOWING MARKET RATES FOR THE BURGESS CUSTOM GROUP. THIS INFORMATION IS PASSED ON TO THE EXECUTIVE COMMITTEE OF THE BOARD WHO MAKES A RECOMMENDATION TO THE COMPLETE BOARD OF DIRECTORS. THE BOARD OF DIRECTORS IS RESPONSIBLE FOR THE FINAL DECISION. FORM 990, PART VI, SECTION C, LINE 19 BURGESS HEALTH CENTER DOES NOT MAKE ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, OR FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC. FORM 990, PART XI, LINE 2C: THE BOARD OF DIRECTORS ASSUMES THE RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT OF ITS CONSOLIDATED FINANCIAL STATEMENTS AND SELECTION OF AN INDEPENDENT ACCOUNTANT. THIS PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. BURGESS FOUNDATION 1600 DIAMOND STREET ONAWA IA 51040 421188964 RAISING FUNDS FOR BURGESS HEALTH CENTER IA 501(C)(3) LINE 7 BURGESS HEALTH CENTER 1 0 0 1 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0 BURGESS FOUNDATION C 94477 CASH - FMV