2016-05-12T08:49:12-05:00 2015-06-30 410746749 CLIFTONLARSONALLEN LLP 220 SOUTH SIXTH STREET SUITE 300 MINNEAPOLIS MN 55402 990 2014-07-01 390890676 ST CROIX REGIONAL MEDICAL CENTER STCR 7154830556 235 STATE STREET ST CROIX FALLS WI 54024 SALLY BAJAK INTERIM CFO 7154830556 2016-05-03 1 KOREY BOELTER P00775161 6123764500 2014 2016-08-17 19:52:53Z DAVE DOBOSENSKI 235 STATE STREET ST CROIX FALLS WI 54024 87909698 0 X WWW.SCRMC.ORG X 1954 WI TO PROVIDE QUALITY HEALTHCARE SERVICES TO ALL RESIDENTS OF THE SERVICE AREA. 9 9 640 152 0 0 279342 140309 72658448 86067301 288385 22905 1850399 1608057 75076574 87838572 19063 8947 0 0 27880971 29953548 0 0 0 40780547 48730724 68680581 78693219 6395993 9145353 58449400 62943736 26827705 22175837 31621695 40767899 X THE MISSION OF SCRMC IS TO PROVIDE THE HIGHEST QUALITY, ACCESSIBLE, INTEGRATED, COST EFFECTIVE CARE FOR INDIVIDUALS AND FAMILIES SERVED. 1 0 43950666 0 52027449 OUTPATIENT SERVICES - SURGICAL, LABORATORY, BASIC, AND ADVANCED RADIOLOGY PROCEDURES. DURING FISCAL YEAR 2015, THERE WERE 8,106 EMERGENCY ROOM VISITS RECORDED, 1,777 OUTPATIENT SURGERIES, AND 219,595 LAB TESTS COMPLETED. 20229941 8947 23947583 INPATIENT SERVICES - OBSTETRIC, MEDICAL-SURGICAL, INTENSIVE CARE, AND SHORT STAY INPATIENT CARE. DURING FISCAL YEAR 2015, THERE WERE 277 BIRTHS, 1,581 INPATIENT ADMISSIONS, AND A TOTAL OF 4,852 INPATIENT DAYS FOR AN AVERAGE LENGTH OF STAY OF 3.07 DAYS. 4056632 0 4802116 CONTRACT PHARMACY - ST. CROIX REGIONAL MEDICAL CENTER BECAME ELIGIBLE TO PARTICIPATE IN THE 340B DRUG PRICING PROGRAM, WHICH IS MANAGED BY THE HEALTH RESOURCES AND SERVICES ADMINISTRATION (HRSA) OFFICE OF PHARMACY AFFAIRS (OPA), RESULTING IN THE REALIZATION OF A CONTRACT PHARMACY SERVICE. PARTICIPATION IN THE 340B DRUG PRICING PROGRAM RESULTS IN SIGNIFICANT SAVINGS, ESTIMATED TO BE 20-50%, ON THE COST OF PHARMACEUTICALS FOR USE BY OUTPATIENTS OF THE FACILITY. THROUGH THIS PROGRAM, ST. CROIX REGIONAL MEDICAL CENTER IS ABLE TO REACH MORE ELIGIBLE PATIENTS AND PROVIDE MORE COMPREHENSIVE SERVICES. 4468905 0 5290153 ST. CROIX VALLEY PHARMACIES PROVIDE LOCAL PHARMACY CARE TO THE SERVICE AREA OF ST. CROIX REGIONAL MEDICAL CENTER. ST. CROIX VALLEY PHARMACIES IS THE SOLE MEMBER OF THE FOLLOWING COMMUNITY PHARMACIES: UNITY PHARMACY LOCATED IN THE UNITY CLINIC BUILDING NEAR BALSAM, WI, FREDERIC PHARMACY LOCATED IN THE FREDERIC CLINIC BUILDING IN FREDERIC, WI, AND ST. CROIX FALLS PHARMACY LOCATED IN THE ST. CROIX FALLS CLINIC BUILDING IN ST. CROIX FALLS, WI. 4468905 0 5290153 72706144 1 1 0 1 0 0 0 0 1 0 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 1 1 1 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 1 1 0 0 0 1 75 0 640 1 0 0 0 0 0 0 0 0 0 0 X 9 9 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 0 0 WI X X X SALLY BAJAK 7154830556 235 STATE STREET ST CROIX FALLS WI 54024 HARLEN HEGDAL CHAIR 2.00 X X 0 0 0 KRISTINE FUGE VICE CHAIR 0.50 X X 0 0 0 MICHAEL BUCHITE TREASURER 0.50 X X 0 0 0 JOSEPH RUEGEMER MD SECRETARY/CONTRACTED RVMC PHYSICIAN 0.50 X X 0 0 0 JEANINE BRUNCLIK MD TRUSTEE/CONTRACTED RVMC PROVIDER 0.50 X 0 0 0 SARAH CORNELL TRUSTEE 0.50 X 0 0 0 PATRICK MCDONOUGH MD TRUSTEE/CONTRACTED RVMC PROVIDER 0.50 X 0 0 0 WILLIAM SCHULTZ MD TRUSTEE/CONTRACTED RVMC PROVIDER 0.50 X X 0 0 0 STEVE TESCH TRUSTEE 0.50 X X 0 0 0 DAVE DOBOSENSKI CEO 40.00 X 281650 0 42676 JOHN TREMBLE CFO & VP 40.00 X 198507 0 14255 GURDESH BEDI PHYSICIAN OF SCRMC 40.00 X 601560 0 16329 STEPHEN DENNIS PHYSICIAN OF SCRMC 40.00 X 269739 0 40956 GEOFFREY GORRES PHYSICIAN OF SCRMC 40.00 X 267284 0 37166 ISLAM KHAN PHYSICIAN OF SCRMC 40.00 X 273295 0 32416 CLAUDIO NUNES PHYSICIAN OF SCRMC 40.00 X 393477 0 57033 2285512 0 240831 17 0 1 0 RIVER VALLEY MEDICAL CENTER 208 SOUTH ADAMS STREET ST CROIX FALLS WI 54024 PHYSICIAN SERVICES 8990434 VOYAGEUR RADIOLOGY LLC 9975 DELLWOOD ROAD STILLWATER MN 55082 RADIOLOGY SERVICES 1042539 ALLINA HEALTH SYSTEM PO BOX 9383 MINNEAPOLIS MN 55440 EMR SUPPORT SERVICES 1042499 ST CROIX VALLEY ANESTHESIA 2196 84TH AVENUE OSCEOLA WI 54020 CRNA SERVICES 1008933 CMDI PO BOX 158 MILACA MN 56353 RADIOLOGY SERVICES 899809 25 140309 41264 140309 PATIENT SERVICES 624100 75664301 75664301 CONTRACT PHARMACY 624100 4802116 4802116 FREDERIC PHARMACY 624100 2788363 2788363 SCF PHARMACY 624100 1269295 1269295 UNITY PHARMACY 624100 1232495 1232495 310731 310731 86067301 24343 24343 69059 26748 42311 42311 42311 1438 -1438 -1438 -1438 72113 42940 29173 29173 MISCELLANEOUS 900099 891995 891995 EHR PAYMENT 900099 579473 579473 JOINT VENTURE REVENUE 900099 65105 65105 1536573 87838572 85756570 0 1941693 X 8947 8947 498331 498331 25980883 22808578 3172305 1224219 1074740 149479 424173 372381 51792 1825942 1602992 222950 234502 234502 22576 22576 17148798 16695512 453286 113812 14550 99262 268816 203655 65161 265074 242013 23061 2334513 2121733 212780 104389 79244 25145 285500 248247 37253 342300 312520 29780 3446833 3146959 299874 426340 422589 3751 MEDICAL SUPPLIES 17269518 17249202 20316 OTHER EXPENSES 3821688 3505917 315771 BAD DEBTS 2219643 2219643 COLLECTIONS 168438 168438 257984 208284 49700 78693219 72706144 5987075 0 5641814 9649812 1155893 831879 13945868 16238342 210999 139704 1843205 2323996 399757 504897 57094251 28736274 30636802 28357977 2643647 1335156 1084630 2725886 866785 715237 20000 120850 58449400 62943736 14453665 10987967 7680960 6400536 503000 375000 4190080 4412334 26827705 22175837 X 31371695 40767899 250000 0 31621695 40767899 58449400 62943736 X 9145353 851 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 1 0 1 0 0 1 5625 1 0 5625 0 PART II-B, LINE 1: WE HAVE HIRED STRATEGIC HEALTHCARE TO ASSIST US IN DISCUSSING CAH DESIGNATION FOR 10 MILE HOSPITALS. 1 12638 57353 66294 3697 0 935442 935442 34652879 14494358 20158521 1714981 728393 986588 19790949 13513523 6277426 28357977 DEFERRED COMPENSATION PLAN 850843 ASSET RETIREMENT OBLIGATION 236491 THIRD PARTY PAYOR 3325000 4412334 X 85696832 -2184680 -2184680 87881512 -42940 -42940 87838572 76551478 77902 77902 76473576 2219642 2219642 78693218 PART IV, LINE 1B: ST. CROIX REGIONAL MEDICAL CENTER IS AN AGENT FOR A CHECKING ACCOUNT THAT HOUSES FUNDS FOR THE WEST CENTER REGIONAL TRAUMA ADVISORY COUNCIL. THE MONIES ARE USED TO FUND TRAUMA TRAINING FOR THOSE PARTICIPATING HOSPITALS WITHIN THE COUNCIL. PART X, LINE 2: THE MEDICAL CENTER IS A NONPROFIT CORPORATION AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE AND IS EXEMPT FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE CODE. THE MEDICAL CENTER IS ALSO EXEMPT FROM STATE INCOME TAXES. THE MEDICAL CENTER'S INCOME TAX RETURNS ARE SUBJECT TO REVIEW AND EXAMINATION BY FEDERAL, STATE, AND LOCAL AUTHORITIES. THE MEDICAL CENTER IS NOT AWARE OF ANY ADDITIONAL ACTIVITIES THAT ARE SUBJECT TO TAX ON UNRELATED BUSINESS INCOME OR EXCISE OR OTHER TAXES THAN ARE CURRENTLY FILED IN THE TAX RETURN. THE MEDICAL CENTER IS THE SOLE CORPORATE MEMBER OF SCV PHARMACIES. SCV PHARMACIES IS TREATED AS A 501(C)(3) FOR FEDERAL TAX PURPOSES AS IT COMES UNDER THE MEDICAL CENTER'S TAX-EXEMPT STATUS. SCV PHARMACIES IS THE SOLE MEMBER OF FREDERIC, UNITY, AND SCF PHARMACY, SO ALL OF THESE ENTITIES ARE ALSO TREATED AS A 501(C)(3) FOR FEDERAL TAX PURPOSES UNDER THE MEDICAL CENTER'S TAX-EXEMPT STATUS. SCV EMS IS A NONPROFIT CORPORATION AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE AND IS EXEMPT FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE CODE. SCV EMS IS ALSO EXEMPT FROM STATE INCOME TAXES. SCV EMS'S INCOME TAX RETURNS ARE SUBJECT TO REVIEW AND EXAMINATION BY FEDERAL, STATE, AND LOCAL AUTHORITIES. SCV EMS IS NOT AWARE OF ANY ADDITIONAL ACTIVITIES THAT ARE SUBJECT TO TAX ON UNRELATED BUSINESS INCOME OR EXCISE OR OTHER TAXES THAN ARE CURRENTLY FILED IN THE TAX RETURN. THE MEDICAL CENTER FOLLOWS GUIDANCE IN THE INCOME TAX STANDARD REGARDING THE RECOGNITION AND MEASUREMENT OF UNCERTAIN TAX POSITIONS. THE MEDICAL CENTER FOLLOWS THE ACCOUNTING STANDARD FOR INCOME TAXES FOR EVALUATING UNCERTAIN TAX POSITIONS. PART XI, LINE 2D - OTHER ADJUSTMENTS: PROVISION FOR UNCOLLECTIBLE ACCOUNTS -2,219,642. INCOME STATEMENT ELIMINATIONS 34,962. PART XI, LINE 4B - OTHER ADJUSTMENTS: COST OF GOODS SOLD -42,940. PART XII, LINE 2D - OTHER ADJUSTMENTS: COST OF GOODS SOLD 42,940. INCOME STATEMENT ELIMINATIONS 34,962. PART XII, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT 2,219,642. 1 1 X 1 X 1 X 1 1 0 1 1 1068383 1068383 0.01400 11012886 8579813 2433073 0.03180 12081269 8579813 3501456 0.04580 78778 78778 0.00100 78778 78778 0.00100 12160047 8579813 3580234 0.04680 1 42 16045 16045 0.00020 180373 180373 0.00240 52413 52413 0.00070 43 248831 248831 0.00330 1 2219642 1176410 13034599 19125677 -6091078 X 1 1 1 1 ST CROIX REGIONAL MEDICAL CENTER 235 STATE STREET ST CROIX FALLS WI 54024 WWW.SCRMC.ORG 1043240922 X X X X ST CROIX REGIONAL MEDICAL CENTER 1 0 0 1 X X X X X X X X X 12 1 1 1 1 X HTTPS://WWW.SCRMC.ORG/ABOUT/LEGAL-NOTICES/ X HTTP://HEALTHYPOLKCOUNTY.COM/COMMUNITY-HEALTH-NEEDS-ASSESSMENT/ X 1 12 0 0 0 1 X 100.000000000000 250.000000000000 X X X X X 1 1 X X X 1 X HTTPS://WWW.SCRMC.ORG/PATIENTS-AND-VISITORS/PAY-YOUR-BILL-BILL X HTTPS://WWW.SCRMC.ORG/PATIENTS-AND-VISITORS/PAY-YOUR-BILL X X X X 1 X 0 X X X X X 1 X 0 0 ST. CROIX REGIONAL MEDICAL CENTER PART V, SECTION B, LINE 5: IN THE COLLECTION OF DATA FOR THE COMMUNITY HEALTH NEEDS ASSESSMENT, THE MEDICAL CENTER UTILIZED HEALTH AND LIFESTYLE COMMUNITY SURVEYS. A COUNTY WIDE SURVEY OF THE HEALTH OF POLK COUNTY RESIDENTS WAS MADE AVAILABLE TO THE PUBLIC TO PARTICIPATE. THIS SURVEY WAS MADE AVAILABLE AT ALL OF THE LOCAL MEDICAL CENTERS AND THE HEALTH DEPARTMENT AS WELL AS ADVERTISED IN THE LOCAL NEWSPAPERS AND POSTED ON ALL FOUR OF THE PARTNER'S ORGANIZATION'S WEBSITES. ONCE THE DATA WAS COLLECTED FROM THE SURVEYS, FOUR COMMUNITY FORUMS WERE SPONSORED IN BALSAM LAKE, ST. CROIX FALLS, AMERY AND OSCEOLA. THE COMMUNITY MEMBERS IN ATTENDANCE OFFERED INPUT AND SUGGESTIONS ON THE HEALTH FOCUS AREAS. IN ADDITION, A PARTNER MEETING WAS HELD IN DRESSER, WI TARGETING KEY ORGANIZATIONS AS WELL AS LOCAL HEALTH-RELATED COALITIONS. AT EACH OF THESE VENUES, ATTENDEES HAD THE OPPORTUNITY TO PROVIDE INPUT ON THE 10 HEALTH FOCUS AREAS AS WELL AS VOTE FOR THEIR TOP FIVE. ON MARCH 8, 2013, A GROUP OF APPROXIMATELY 20 COMMUNITY PARTNERS PARTICIPATED IN A PROCESS FOCUSING ON REVIEW AND DISCUSSION OF COMPILED DATA ON THE CURRENT HEALTH STATUS OF POLK COUNTY CITIZENS, AS WELL AS VOTING RESULTS FROM THE COMMUNITY FORUMS AND PARTNER MEETING. DURING THIS MEETING, THIS GROUP COMPLETED A PAPER SURVEY TO CAST THEIR VOTES TO DETERMINE THE TOP THREE HEALTH FOCUS AREAS FOR POLK COUNTY, WI. THE MEDICAL CENTER CONSULTED WITH MIKE RUST, ABC FOR RURAL HEALTH, COURTNEY DRAXLER, PUBLIC HEALTH SPECIALIST AND KIM GEARIN, RESEARCH SCIENTIST, WHO COLLECTIVELY SPENT COUNTLESS HOURS EXAMINING THE HEALTH DATA AND TRENDS, COMPILING WRITTEN REPORTS AND POWERPOINT PRESENTATIONS TO BRING MEANING TO THIS DATA FOR THE COMMUNITY HEALTH NEEDS ASSESSEMENT. ST. CROIX REGIONAL MEDICAL CENTER PART V, SECTION B, LINE 6A: THE MEDICAL CENTER WORKED IN COLLOBORATION WITH THE POLK COUNTY HEALTH DEPARTMENT, AMERY REGIONAL MEDICAL CENTER AND OSCEOLA MEDICAL CENTER WITH THE ULTIMATE GOAL TO IDENTIFY PRIORITY HEALTH ISSUES AND TO DEVELOP STRATEGIES TO ADDRESS THE COMMUNITY'S HEALTH NEEDS. ST. CROIX REGIONAL MEDICAL CENTER PART V, SECTION B, LINE 6B: AS STATED ABOVE, SCRMC WORKED IN COLLABORATION WITH THE POLK COUNTY HEALTH DEPARTMENT FOR THEIR COMMUNITY HEALTH NEEDS ASSESSMENT. ST. CROIX REGIONAL MEDICAL CENTER PART V, SECTION B, LINE 11: THROUGH THE COUNTY-WIDE COMMUNITY HEALTH NEEDS ASSESSMENT SURVEY, TEN HEALTH FOCUS AREAS WERE IDENTIFIED FOR POLK COUNTY BY THE PARTICIPANTS. AS A RESULT OF THE COMMUNITY FORUMS SPONSORED WITHIN THE COMMUNITIES, ATTENDEES SELECTED THEIR TOP FIVE HEALTH NEEDS. THIS TOP FIVE WAS THEN REDUCED BY THE COMMUNITY PARTNERS TO THE TOP THREE PRIORITY AREAS. THE MEDICAL CENTER HAS FULLY SUPPORTED AND ADDRESSED THE TOP THREE PRIORITY AREAS IDENTIFIED IN THE COMMUNITY HEALTH NEEDS ASSESSEMENT. HOWEVER, THE REMAINING SEVEN NEEDS WERE NOT ADDRESSES AS A RESULT OF FINANCIAL COMMITMENT AND LACK OF RESOURCES. ST. CROIX REGIONAL MEDICAL CENTER PART V, SECTION B, LINE 20E: THE PATIENT WILL FIRST RECEIVE 2 BILLS FROM ST. CROIX REGIONAL MEDICAL CENTER. IF NO PAYMENT IS MADE AFTER 60 DAYS, THEN OUR PATIENT ADVOCATES CALL THE PATIENT LOOKING FOR PAYMENT. TWO PHONE CALLS ARE MADE BEFORE FURTHER COLLECTION EFFORTS ARE INITIATED. ST. CROIX REGIONAL MEDICAL CENTER PART V, SECTION B, LINE 22D: ST. CROIX REGIONAL MEDICAL CENTER USED THE AVERAGE PPO NEGOTIATED RATE AS THE MAXIMUM AMOUNT THAT CAN BE CHARGED TO INDIVIDUALS FOR EMERGENCY OR OTHER MEDICALLY NECESSARY CARE. PART V, SECTION B, LINE 16 FINANCIAL ASSISTANCE POLICY WEBSITE AVAILABILITY ST. CROIX REGIONAL MEDICAL CENTER PART V, SECTION B, LINE 16A WEBSITE: HTTPS://WWW.SCRMC.ORG/PATIENTS-AND-VISITORS/PAY-YOUR-BILL-BILL ST. CROIX REGIONAL MEDICAL CENTER PART V, SECTION B, LINE 16B WEBSITE: HTTPS://WWW.SCRMC.ORG/PATIENTS-AND-VISITORS/PAY-YOUR-BILL 5 FREDERIC CLINIC 107 OAK STREET E FREDERIC WI 54837 PROVIDER BASED CLINIC INGALLS CLINIC 7456 MAIN STREET WEBSTER WI 54893 PROVIDER BASED CLINIC UNITY CLINIC 1482 190TH AVE BALSAM LAKE WI 54024 PROVIDER BASED CLINIC ST CROIX FALLS CLINIC 235 STATE STREET ST CROIX FALLS WI 54024 PROVIDER BASED CLINIC LINDSTROM CLINIC 12375 LINDSTROM LANE LINDSTROM MN 55045 FREE STANDING CLINIC PART I, LINE 3C: ST. CROIX REGIONAL MEDICAL CENTER, THROUGH ITS PATIENT ADVOCATES, EVALUATES EACH APPLICANT'S SITUATION IN ACCORDANCE WITH CRITERIA ESTABLISHED ANNUALLY BY THE BOARD OF DIRECTORS. THE CRITERIA INCLUDES: (1) INDIVIDUAL OR FAMILY INCOME (2) FAMILY SIZE (3) OTHER SOURCES OF PAYMENT FOR SERVICES. QUALIFICATION IS BASED ON ASSET LEVELS ESTABLISHED BY MEDICAL ASSISTANCE, FAMILY SIZE, AND INCOME LEVELS BASED ON 100% OF FEDERAL POVERTY GUIDELINES AS PUBLISHED ANNUALLY BY THE FEDERAL GOVERNMENT. GRANTING OF COMMUNITY CARE - AMOUNT: PATIENTS THAT QUALIFY FOR ST CROIX REGIONAL MEDICAL CENTER'S CHARITY CARE PROGRAM WILL RECEIVE 100% OF THEIR ACCOUNT BALANCE APPLIED TO THE FUND. GRANTING OF COMMUNITY CARE - TERM: PATIENTS THAT QUALIFY FOR ST CROIX REGIONAL MEDICAL CENTER'S CHARITY CARE PROGRAM WILL RECEIVE COMMUNITY CARE FOR A SPECIFIC HOSPITALIZATION OR FOR A SPECIFIED COURSE OF TREATMENT. ALL PATIENTS RECEIVING CHARITY CARE MUST RE-APPLY IF THEIR STATUS CHANGES OR THE TREATMENT DURATION HAS ENDED. PART I, LINE 6A: ST. CROIX REGIONAL MEDICAL CENTER PARTICIPATES IN AN ANNUAL COMMUNITY BENEFIT REPORT PRODUCED BY THE WISCONSIN HOSPITAL ASSOCIATION. PART I, LINE 7: THE AMOUNTS INCLUDED IN PART I, LINE 7 WERE DERIVED USING THE COST-TO-CHARGE RATIO FROM WORKSHEET 2 OF THE IRS SCHEDULE H INSTRUCTIONS. PART I, LN 7 COL(F): BAD DEBT EXPENSES OF $2,219,642 WERE SUBTRACTED FROM TOTAL EXPENSES IN CALCULATING THE PERCENTAGES IN PART I, LINE 7, COLUMN F. PART II, COMMUNITY BUILDING ACTIVITIES: THE ORGANIZATION PROVIDES DIRECT SUPPORT TO OVER 49 COMMUNITY ACTIVITIES, PROVIDES OVER 18,000 HOURS OF VOLUNTEER TIME IN INDIRECT PATIENT CARE ACTIVITIES, AND OVER 440 HOURS OF EDUCATION FOR HEALTHCARE PROFESSIONALS. PART III, LINE 2: PATIENTS ARE NOT REQUIRED TO PROVIDE COLLATERAL FOR SERVICES RENDERED. PAYMENT FOR SERVICES IS REQUIRED UPON RECEIPT OF AN INVOICE, AFTER PAYMENT OF INSURANCE, IF ANY. SELF-PAY ACCOUNTS ARE ANALYZED FOR COLLECTABILITY BASED ON THE MONTHS PAST DUE AND PAYMENT HISTORY. AN ALLOWANCE IS ESTIMATED FOR THESE ACCOUNTS BASED ON THE HISTORICAL EXPERIENCE OF THE MEDICAL CENTER. ACCOUNTS THAT ARE DETERMINED TO BE UNCOLLECTIBLE ARE SENT TO A COLLECTION AGENCY AND WRITTEN OFF AT THAT TIME. PART III, LINE 3: THE AMOUNT OF BAD DEBT EXPENSE ESTIMATED BY THE ORGANIZATION TO BE ATTRIBUTABLE TO PATIENTS ELIGIBLE FOR CHARITY CARE ON PART III, LINE 3 WAS DERIVED BY TAKING THE COST TO CHARGE RATIO AGAINST TOTAL BAD DEBT EXPENSES INCLUDED IN LINE 2. PART III, LINE 4: SEE THE "PATIENT ACCOUNTS RECEIVABLE AND ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS" SECTION IN NOTE 1 (PAGE 10) TO THE FINANCIAL STATEMENTS FOR INFORMATION ABOUT THE CALCULATION OF BAD DEBTS. PART III, LINE 8: THE MEDICAL CENTER PROVIDES MEDICAL CARE TO INDIVIDUALS WHERE GOVERNMENT DEPARTMENTS DETERMINE THE AMOUNT OF REIMBURSEMENT OF SERVICE REGARDLESS OF THE COST TO PROVIDE THE SERVICE. AMOUNTS REIMBURSED BY GOVERNMENT PAYORS ARE ESTIMATED TO BE LESS THAN THE COSTS TO PROVIDE THE SERVICES AS FOLLOWS:MEDICAID- WISCONSIN $1,767,600 CHAMPUS AND VA $65,200MEDICARE - PHYSICIAN $2,999,700MEDICARE ADVANTAGE $417,200ALL GOVERNMENT PAYORS $5,249,500TOTAL CHARITY CARE, UNCOMPENSATED CARE AND UNDER COMPENSATED CARE BY GOVERNMENT PAYORS WAS $3,763,498 THIS REPRESENTS 5.1% OF NET OPERATING REVENUES OF THE MEDICAL CENTER.THE MEDICARE ALLOWABLE COSTS INCLUDED IN PART III, LINE 6 WERE DERIVED USING THE FILED 2015 MEDICARE COST REPORT. PART III, LINE 9B: THE MEDICAL CENTER HAS ESTABLISHED GUIDELINES FOR THE PROVISION OF HEALTH SERVICES AT REDUCED COSTS FOR INDIVIDUALS BASED UPON THEIR INCOME AND OTHER CIRCUMSTANCES. THE MEDICAL CENTER HAS A POLICY TO PROVIDE AN IMMEDIATE DISCOUNT TO ALL FAP ELIGIBLE AND UNINSURED PATIENTS OF 10% OF CHARGES. PART VI, LINE 2: OVERALL MARKETPLACE DEMOGRAPHICS AND COMPETITIVE ANALYSIS IS CONDUCTED ON A REGULAR BASIS. WHEN DEMAND FOR NEW SERVICE LINES IS INTENSIFIED, THEY ARE ADDED SLOWLY UNTIL DEMAND CAPACITY REACH CRITICAL LEVELS. PART VI, LINE 3: ALL PATIENTS HAVE ACCESS TO WRITTEN MATERIALS AND PAMPHLETS AT OR NEAR THE POINT OF REGISTRATION. IN ADDITION, PATENTS HAVE ACCESS TO PATIENT ADVOCATES WITH FULL KNOWLEDGE OF RESOURSES AVAILABLE. PART VI, LINE 4: THE ORGANIZATION SERVES A GEOGRAPHIC AREA OF APPROXIMATELY 300 SQUARE MILES IN WESTERN WISCONSIN THAT INCLUDES THE TOWNS OF ST CROIX FALLS, BALSAM LAKE, LUCK, MILLTOWN, FREDERIC, AND GRANTSBURG IN WISCONSIN AND TAYLORS FALLS AND LINDSTROM IN EASTERN MINNESOTA. PART VI, LINE 6: THE CENTER IS NOT PART OF AN AFFILIATED HEALTH CARE SYSTEM. PART VI, LINE 7, REPORTS FILED WITH STATES WI 1 TUITION REIMBURSEMENT 7 8947 PART I, LINE 2: THE ORGANIZATION'S PROCEDURES INCLUDE SUBSTANTIATION OF EXPENSES, GRADES, TRANSCRIPTS AND RECEIPTS, AS WELL AS FOLLOW UP WITH COMMUNITY ORGANIZATIONS AND LEADERS. X X X X X 0 1 0 0 0 1 0 0 0 DAVE DOBOSENSKI CEO 261175 0 20475 0 0 0 15300 0 27376 0 324326 0 0 0 JOHN TREMBLE CFO & VP 192127 0 5000 0 1380 0 10788 0 3467 0 212762 0 0 0 GURDESH BEDI PHYSICIAN OF SCRMC 600240 0 0 0 1320 0 15300 0 1029 0 617889 0 0 0 STEPHEN DENNIS PHYSICIAN OF SCRMC 269739 0 0 0 0 0 15300 0 25656 0 310695 0 0 0 GEOFFREY GORRES PHYSICIAN OF SCRMC 267284 0 0 0 0 0 15300 0 21866 0 304450 0 0 0 ISLAM KHAN PHYSICIAN OF SCRMC 273295 0 0 0 0 0 5100 0 27316 0 305711 0 0 0 CLAUDIO NUNES PHYSICIAN OF SCRMC 393477 0 0 0 0 0 15300 0 41733 0 450510 0 0 0 PART I, LINE 4B CONTRIBUTIONS TO A 457(F) SUPPLEMENTAL NON-QUALIFIED RETIREMENT PLAN: JOHN TREMBLE - $20,191 PART I, LINE 6 ANNUAL EMPLOYER CONTRIBUTIONS TO THE 457F PLAN ARE CONDITIONED UPON ATTAINING CERTAIN PRE-SET GOALS AND ARE CONTINGENT ON APPROVAL BY THE BOARD OF DIRECTORS. THE AWARD IS BASED ON TWO COMPONENTS - LONGEVITY AND PERFORMANCE. PERFORMANCE IS BASED ON MEETING 3 GOALS - NET REVENUE, NET MARGIN AND NET ASSETS. A POLK COUNTY 396005730 2006-05-11 13000000 REFUND SERIES 2000 BONDS, FACILITY CONSTRUCTION AND EQUIPMENT PURCHASES 0 0 0 B POLK COUNTY 396005730 2006-12-27 3683432 FACILITY CONSTRUCTION 0 0 0 A 8196293 13000000 13000000 2008 0 0 1 1 B 2086603 3683432 3683432 2008 0 0 1 1 A 0 0 0 0 0 0 1 B 0 0 0 0 0 0 1 A 0 0 1 0 0 0 0 0 1 B 0 0 1 0 0 0 0 0 1 A 0 B 0 X MEDICAL EQUIPMENT 1 41264 FMV 0 0 0 0 FORM 990, PART III, LINE 2 DURING THE YEAR ENDED JUNE 30, 2015, SCV PHARMACIES, THE SOLE MEMBER OF UNITY AND FREDERIC PHARMACIES, FORMED ST. CROIX FALLS PHARMACY, LLC (SCF PHARMACY). THE NEW ENTITY WAS CREATED AFTER A PURCHASE OF AN EXISTING PHARMACY PRACTICE IN ST. CROIX FALLS, WI. SCV PHARMACIES IS THE SOLE CORPORATE MEMBER OF SCF PHARMACY. FORM 990, PART VI, SECTION A, LINE 1 ST. CROIX REGIONAL MEDICAL CENTER HAS AN EXECUTIVE COMMITTEE WITH BROAD AUTHORITY TO ACT ON BEHALF OF ITS BOARD OF TRUSTEES. THE EXECUTIVE COMMITTEE INCLUDES THE CHAIR, VICE CHAIR, SECRETARY, TREASURER AND ONE OTHER TRUSTEE FROM THE BOARD OF TRUSTEES. THE EXECUTIVE COMMITTEE HAS POWER TO TRANSACT ALL REGULAR BUSINESS OF THE ORGANIZATION DURING THE PERIOD BETWEEN MEETINGS OF THE BOARD OF TRUSTEES, SUBJECT TO ANY PERIOD LIMITATION IMPOSED BY THE BOARD OF TRUSTEES AND WITH THE UNDERSTANDING THAT ALL MATTERS OF MAJOR IMPORTANCE WILL BE REFERRED TO THE BOARD OF TRUSTEES. FORM 990, PART VI, SECTION A, LINE 6 ST. CROIX REGIONAL MEDICAL CENTER HAS TWO CLASSES OF MEMBERS - SPONSORING MEMBERS AND PHYSICIAN ELECTORS. INDIVIDUALS AND CORPORATIONS MAY BECOME SPONSORING MEMBERS THROUGH DONATIONS OF A SPECIFIED AMOUNT TO THE MEDICAL CENTER. INDIVIDUALS MAY BECOME PHYSICIAN ELECTORS BY PROVIDING SERVICES AT ST. CROIX REGIONAL MEDICAL CENTER THROUGH SPECIFIED EMPLOYMENT CONDITIONS. FORM 990, PART VI, SECTION A, LINE 7A PHYSICIAN ELECTORS VOTE IN THE ELECTION OF FOUR PHYSICIAN TRUSTEES. SPONSORING MEMBERS VOTE IN THE ELECTION OF FIVE COMMUNITY TRUSTEES. FORM 990, PART VI, SECTION A, LINE 7B THE MEMBERS VOTE ON THE AUDITORS EMPLOYED TO AUDIT THE BOOKS OF THE MEDICAL CENTER AND TO PREPARE AN ANNUAL REPORT. AN OPS COUNCIL, CONSISTING OF FIVE INDIVIDUALS APPOINTED BY RIVER VALLEY MEDICAL CENTER, A RELATED ORGANIZATION, HAS SIGNIFICANT OVERSIGHT AUTHORITY AT THE MEDICAL CENTER. THE OPS COUNCIL'S AUTHORITY INCLUDES, BUT IS NOT LIMITED TO, REVIEW AND APPROVE OF ALL POLICIES AND PROCEDURES AS THEY RELATE TO MEDICAL OPERATIONS AND RECOMMENDATION OF THE ANNUAL CAPITAL AND OPERATING BUDGETS TO THE FINANCE COMMITTEE OF THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 WENT THROUGH THE FOLLOWING REVIEW PROCESS BEFORE FILING WITH THE IRS: A DETAILED REVIEW WAS CONDUCTED BY THE ORGANIZATION'S INTERIM CFO, UPON APPROVAL, THE FORM 990 WAS THEN PRESENTED FOR REVIEW AND APPROVAL TO THE ORGANIZATION'S BOARD OF DIRECTORS IN APRIL, 2016. FORM 990, PART VI, SECTION B, LINE 12C BOARD MEMBERSHIP IS CONTINGENT UPON ANNUAL DISCOSURE OF POTENTIAL AND ACTUAL CONFLICTS OF INTEREST. THE DERTERMINATION IS MADE AT THE BOARD LEVEL AND ALL BOARD MEMBERS MUST CERTIFY ANNUALLY. IF A BOARD MEMBER HAS A CONFLICT, THEY REFRAIN FROM VOTING OR PARTICIPATING IN DISCUSSIONS CONCERNING THAT TOPIC. FORM 990, PART VI, SECTION B, LINE 15A CEO - ANNUAL PERFORMANCE AND SALARY REVIEW IS CONDUCTED BY THE BOARD OF DIRECTORS USING SUCH OUTSIDE INFORMATION AS DEEMED NECESSARY. REVIEWS ARE CONDUCTED EACH JUNE. THE PROCESS LAST INCLUDED REVIEW AND APPROVAL BY INDEPENDENT PERSONS, COMPARABILITY DATA AND CONTEMPORANEOUS SUBSTANTIATION IN 2015. OTHER OFFICERS - THE HUMAN RESOURCE DEPARTMENT CONDUCTS OUTSIDE RESEARCH TO DETERMINE REASONABLE COMPENSATION. THE CEO THEN DETERMINES THE COMPENSATION OF THESE INDIVIDUALS. REVIEWS ARE CONDUCTED EACH JUNE. THIS PROCESS LAST OCCURED IN FISCAL YEAR 2015. FORM 990, PART VI, SECTION C, LINE 19 THE MEDICAL CENTER'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS ARE NOT MADE AVAILABLE TO THE PUBLIC. FORM 990, PART IX, LINE 11G PHYSICIAN FEES: PROGRAM SERVICE EXPENSES 11,767,698. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 11,767,698. THERAPIST & OTHER PHYS FEES: PROGRAM SERVICE EXPENSES 42,322. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 42,322. PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 3,405,589. MANAGEMENT AND GENERAL EXPENSES 227,476. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 3,633,065. CONSULTING SERVICES: PROGRAM SERVICE EXPENSES 374,652. MANAGEMENT AND GENERAL EXPENSES 217,056. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 591,708. INDEPENDENT CONTRACTORS: PROGRAM SERVICE EXPENSES 1,105,251. MANAGEMENT AND GENERAL EXPENSES 8,754. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,114,005. FORM 990, PART XI, LINE 9: ROUNDING ADJUSTMENT PER FS 851. SCHEDULE L, PART IV AND SCHEDULE R, PART V, LINE 1O ST. CROIX REGIONAL MEDICAL CENTER REIMBURSES RIVER VALLEY MEDICAL CENTER (RVMC), FOR PHYSICIAN SERVICES PROVIDED BY EMPLOYEES OF RVMC. ALL PAYMENTS ARE "GROSS", MEANING THAT THEY INCLUDE UNIDENTIFIED AMOUNTS FOR BENEFITS AND MALPRACTICE INSURANCE, AS WELL AS W-2 COMPENSATION. UNITY PHARMACY LLC 1504 190TH AVENUE SUITE 100 BALSAM LAKE WI 54810 454471131 PHARMACEUTICALS WI 1232625 588055 SCV PHARMACIES FREDERIC PHARMACY LLC 201 OAK STREET WEST FREDERIC WI 54837 464469897 PHARMACEUTICALS WI 2788363 1046273 SCV PHARMACIES ST CROIX VALLEY PHARMACY LLC 235 STATE STREET ST CROIX FALLS WI 54024 464463191 PHARMACEUTICALS WI 0 0 ST CROIX REGIONAL MEDICAL CENTER ST CROIX FALLS PHARMACY LLC 216 SOUTH ADAMS STREET ST CROIX FALLS WI 54024 464487348 PHARMACEUTICALS WI 1269335 489264 SCV PHARMACIES ST CROIX VALLEY EMERGENCY MEDICAL SERVICES INC 235 EAST STATE STREET ST CROIX FALLS WI 54024 452872803 TO LEASE, MAINTAIN, AND OPERATE AN EMERGENCY AMBULANCE SERVICE. WI 501(C)(3) LINE 9 ST CROIX REGIONAL MEDICAL CENTER 1 CANCER CENTER OF WESTERN WISCONSIN 501 HOSPITAL ROAD NEW RICHMOND WI 54017 273238660 TO PROVIDE CARE TO CANCER PATIENTS. WI 501(C)(3) LINE 11A, I N/A 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0