2014-05-13T10:02:55-05:00 2013-06-30 410746749 CLIFTONLARSONALLEN LLP 220 SOUTH SIXTH STREET SUITE 300 MINNEAPOLIS MN 55402 990 2012-07-01 390890676 ST CROIX REGIONAL MEDICAL CENTER STCR 7154830556 235 STATE STREET ST CROIX FALLS WI 54024 JOHN TREMBLE 7154830556 2014-05-13 1 KOREY BOELTER P00775161 6123764500 2012 2015-11-30 17:44:51Z DAVE DOBOSENSKI 235 STATE STREET ST CROIX FALLS WI 54024 70079659 0 X WWW.SCRMC.ORG X 1954 WI TO PROVIDE QUALITY HEALTHCARE SERVICES TO ALL RESIDENTS OF THE SERVICE AREA. 9 5 591 135 85 0 55060 93297 65202932 68295010 172182 53500 851058 926239 66281232 69368046 20000 12000 0 0 24030427 29501299 0 0 0 39246411 35176147 63296838 64689446 2984394 4678600 48531694 51473772 27596751 26202418 20934943 25271354 X THE MISSION OF SCRMC IS TO PROVIDE THE HIGHEST QUALITY, ACCESSIBLE, INTEGRATED, COST EFFECTIVE CARE FOR INDIVIDUALS AND FAMILIES SERVED. 1 0 42666645 0 49371302 OUTPATIENT SERVICES - SURGICAL, LABORATORY, BASIC, AND ADVANCED RADIOLOGY PROCEDURES. PRIMARY AND SPECIALITY CARE FOR AMBULATORY PATIENTS AT FOUR SERVICE SITES. DURING FISCAL YEAR 2013, THERE WERE 6,813 EMERGENCY ROOM VISITS RECORDED, 1,510 OUTPATIENT SURGERIES, AND 212,790 LAB TESTS COMPLETED.UNITY PHARMACY IS A NEW FULL-SERVICE RETAIL PHARMACY, WHICH INCLUDES A DRIVE-UP WINDOW FOR QUICK PRESCRIPTION PICK-UP AND OVER THE COUNTER MEDICATION. A MEDICATION THERAPY MANAGEMENT (MTM) CONSULT WITH A PHARMACIST IS AVAILABLE BY APPOINTMENT. 14065785 12000 16276089 INPATIENT SERVICES - OBSTETRIC, MEDICAL-SURGICAL, INTENSIVE CARE, AND SHORT STAY INPATIENT CARE. DURING FISCAL YEAR 2013, THERE WERE 268 BIRTHS, 1,668 INPATIENT ADMISSIONS, AND A TOTAL OF 5,481 INPATIENT DAYS FOR AN AVERAGE LENGTH OF STAY OF 3.29 DAYS. 2288071 0 2647619 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. 59020501 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 1 0 0 0 0 1 1 1 0 0 0 1 83 0 591 1 0 0 0 0 0 0 0 0 0 0 X 9 5 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 0 0 WI X X X JOHN TREMBLE CFO VP 7154830317 235 STATE STREET ST CROIX FALLS WI 54024 HARLEN HEGDAL 4.00 X X 800 0 0 MARSHA BEYER MD 2.00 X X 0 0 0 LARRY COLLINS 3.00 X X 1045 0 0 CLYDE VAN OORT 2.00 X X 0 0 0 STEVE TESCH 2.00 X 0 0 0 JOSEPH RUEGEMER MD 2.00 X 0 0 0 JEANINE BRUNCLIK MD 2.00 X 0 0 0 WILLIAM SCHULTZ MD 2.00 X 0 0 0 MICHAEL BUCHITE 2.00 X 0 0 0 CARLA GOETZ 2.00 X 0 0 0 DAVE DOBOSENSKI 40.00 X 230117 0 22823 JOHN TREMBLE 40.00 X 183297 0 12520 GURDESH BEDI 40.00 X 578092 0 21297 CLAUDIO NUNES 40.00 X 381663 0 37394 GEOFFREY GORRES 40.00 X 262907 0 20980 THOMAS HINCK 40.00 X 255427 0 23571 PAUL MITTELSTADT 40.00 X 254660 0 9769 2148008 0 148354 21 0 1 0 RIVER VALLEY MEDICAL CENTER 208 SOUTH ADAMS STREET ST CROIX FALLS WI 54024 PHYSICIAN SERVICES 8243958 ST CROIX VALLEY ANESTHESIA 2196 84TH AVENUE OSCEOLA WI 54020 CRNA SERVICES 1023170 VOYAGEUR RADIOLOGY LLC 9975 DELLWOOD ROAD STILLWATER MN 55082 RADIOLOGY SERVICES 1000891 CMDI PO BOX 158 MILACA MN 56353 RADIOLOGY SERVICES 799406 HEALTHPARTNERS PO BOX 64059 ST PAUL MN 55164 CARDIOLOGY/ONCOLOGY SERVICES 495291 29 93297 93297 PATIENT SERVICES 624100 64991545 64991545 CONTRACT PHARMACY 624100 2647619 2647619 UNITY PHARMACY 624100 389730 389730 CAFETERIA MEAL SALES 722210 266116 266116 68295010 58621 58621 52447 27667 24780 24780 24780 678825 683946 -5121 -5121 -5121 MISCELLANEOUS 900099 542740 542740 EHR PAYMENT 900099 195844 195844 JOINT VENTURE REVENUE 900099 103604 103604 59271 85 59186 901459 69368046 68028894 85 1245770 X 12000 12000 449833 449833 22770477 19760556 3009921 1039109 901754 137355 3688104 3200591 487513 1553776 1348390 205386 66561 66561 161093 161093 15001559 14659719 341840 15300 3634 11666 650953 590405 60548 791797 724494 67303 1664748 1523244 141504 117929 95489 22440 224416 210032 14384 456227 417448 38779 2957511 2706123 251388 426989 423725 3264 SUPPLIES 9304247 9272673 31574 BAD DEBTS 1715588 1715588 OTHER EXPENSES 1158376 1047087 111289 COLLECTIONS 215199 215199 247654 192350 55304 64689446 59020501 5668945 0 5803309 7204870 1698119 1041927 9164690 9506071 174084 226565 1140192 1375251 221040 315197 53285341 25527231 25354659 27758110 3001739 2593857 1200815 868591 594881 443333 178166 140000 48531694 51473772 12193330 11697456 10447239 9295774 360000 650000 4596182 4559188 27596751 26202418 X 20934943 25271354 20934943 25271354 48531694 51473772 4678600 -42462 -299728 0 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 1 0 1 0 0 0 1 3750 1 0 0 3750 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: WE HAVE HIRED STRATEGIC HEALTHCARE TO ASSIST US IN DISCUSSING CAH DESIGNATION FOR 10 MILE HOSPITALS. 1 20250 49911 55021 13605 0 924202 924202 27884404 11908492 15975912 1097211 566178 531033 18815121 13052561 5762560 4564403 4564403 27758110 DEFERRED COMPENSATION PLAN 771541 ASSET RETIREMENT OBLIGATION 228487 THIRD PARTY PAYOR 3559160 4559188 X 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. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: 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 TAX RETURNS FOR THE YEARS 2010 TO 2012 ARE OPEN TO EXAMINATION BY FEDERAL, LOCAL AND STATE AUTHORITIES. THE MEDICAL CENTER IS THE SOLE CORPORATE MEMBER OF UNITY PHARMACY LLC. UNITY PHARMACY LLC IS TREATED AS A 501(C)(3) FOR FEDERAL TAX PURPOSES AS IT COMES UNDER THE MEDICAL CENTER'S TAX-EXEMPT STATUS. THE MEDICAL CENTER HAS ELECTED TO ADOPT GUIDANCE IN THE INCOME TAX STANDARD REGARDING THE RECOGNITION AND MEASUREMENT OF UNCERTAIN TAX POSITIONS. THE MEDICAL CENTER FOLLOWS THE ACCOUNTING STANDARD FOR CONTINGENCIES FOR EVALUATING UNCERTAIN TAX POSITIONS. THE ADOPTION OF THIS STANDARD HAS NO EFFECT ON THE FINANCIAL STATEMENTS. 1 1 X 1 X 130.000000000000 1 X 1 1 1 0 1 1 974413 974413 0.01550 8400893 6067080 2333813 0.03710 9375306 6067080 3308226 0.05260 114772 114772 0.00180 114772 114772 0.00180 9490078 6067080 3422998 0.05440 2 42 16059 16059 0.00030 750 750 0.00000 85646 85646 0.00140 47791 47791 0.00080 44 150246 150246 0.00250 1 1715587 914065 16846129 15141188 1704941 X 1 1 1 1 ST CROIX REGIONAL MEDICAL CENTER

235 STATE STREET ST CROIX FALLS WI 54024

X X X X ST CROIX REGIONAL MEDICAL CENTER 1 1 X X X X X X X X X 12 1 1 1 X X X X X X X X X X 0 0 1 1 130.000000000000 0 1 X X X X X X X 1 1 X X X X X 1 0 X X X X X 1 X 0 0 4 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

FREE STANDING CLINIC ST CROIX FALLS CLINIC

235 STATE STREET ST CROIX FALLS WI 54024

PROVIDER BASED 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 130% 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 SCHEUDLE H INSTRUCTIONS. PART I, L7 COL(F): BAD DEBT EXPENSES OF $1,715,587 WERE SUBTRACTED FROM THE TOTAL EXPENSES OF $64,689,446 IN CALCULATING THE PERCENTAGES IN PART I, LINE 7, COLUMN F. PART II: THE ORGANIZATION PROVIDES DIRECT SUPPORT TO OVER 57 COMMUNITY ACTIVITIES, PROVIDES OVER 18,000 HOURS OF VOLUNTEER TIME IN INDIRECT PATIENT CARE ACTIVITIES, AND OVER 400 HOURS OF EDUCATION FOR HEALTHCARE PROFESSIONALS. PART III, LINE 4: FROM THE PATIENT ACCOUNTS RECEIVABLE AND ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS PARAGRAPH IN NOTE 1 TO THE AUDITED FINANCIAL STATEMENTS:"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 COLLECTIBILITY 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."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 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 $1,491,500MEDICAID- MINNESOTA 122,300CHAMPUS AND VA 48,700MEDICARE - PHYSICIAN 1,842,700MEDICARE ADVANTAGE 196,400ALL GOVERNMENT PAYORS $ 3,701,600TOTAL CHARITY CARE, UNCOMPENSATED CARE AND UNDER COMPENSATED CARE BY GOVERNMENT PAYORS WAS $5,417,187 THIS REPRESENTS 8.4% OF NET OPERATING REVENUES OF THE MEDICAL CENTER.THE MEDICARE ALLOWABLE COSTS INCLUDED IN PART III, LINE 6 WERE DERIVED USING THE FILED 2013 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. ST. CROIX REGIONAL MEDICAL CENTER PART V, SECTION B, LINE 3: 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 4: 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 5C: THE MEDICAL CENTER'S COMMUNITY HEALTH NEEDS ASSESSMENT WAS ALSO MADE AVAILABLE TO THE PUBLIC ONLINE AT THE POLK COUNTY'S WEBITE AT (URL: WWW.HEALTHYPOLKCOUNTY.COM). ST. CROIX REGIONAL MEDICAL CENTER PART V, SECTION B, LINE 7: 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 10: 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. (4) INDIVIDUAL OR FAMILY ASSETS QUALIFICATION IS BASED ON ASSET LEVELS ESTABLISHED BY MEDICAL ASSISTANCE, FAMILY SIZE, AND INCOME LEVELS BASED ON FEDERAL POVERTY GUIDELINES AS PUBLISHED ANNUALLY BY THE FEDERAL GOVERNMENT. GRANTING OF UNINSURED/UNDERINSURED - AMOUNT: PATIENTS THAT QUALIFY FOR ST CROIX REGIONAL MEDICAL CENTER'S UNINSURED/UNDERINSURED PROGRAM WILL RECEIVE A 10% DISCOUNT OF THEIR BILLED CHARGES REGARDLESS OF INCOME. PATIENTS THAT ARE UNINSURED AND HAVE INCOMES UP TO 150% OF THE FEDERAL POVERTY LEVEL WILL RECEIVE AN 80% DISCOUNT; 151% - 175% WILL RECEIVE A 60% DISCOUNT; 176% - 200% WILL RECEIVE A 40% DISCOUNT; AND 201% - 250% WILL RECEIVE A 20% DISCOUNT. GRANTING OF UNINSURED/UNDERINSURED - TERM: PATIENTS THAT QUALIFY FOR ST CROIX REGIONAL MEDICAL CENTER'S UNINSURED/UNDERINSURED PROGRAM WILL RECEIVE DISCOUNTS FOR A SPECIFIC TIME PERIOD.ALL PATIENTS RECEIVING DISCOUNTS MUST RE-APPLY EVERY 12 MONTHS OR IF THEIR STATUS CHANGES. ST. CROIX REGIONAL MEDICAL CENTER PART V, SECTION B, LINE 14G: ST. CROIX REGIONAL MEDICAL CENTER ALSO HAS MADE THE APPLICATION AVAILABLE ONLINE THROUGH OUR WEBSITE. ST. CROIX REGIONAL MEDICAL CENTER PART V, SECTION B, LINE 18E: 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 20D: 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 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 GRANTSBERG 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. REPORTS FILED WITH STATES PART VI, LINE 7 WI 1 SCHOLARSHIPS 12 12000 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, 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 223117 0 7000 0 0 0 13458 0 9365 0 252940 0 0 0 JOHN TREMBLE 159224 0 5000 0 19073 0 9917 0 2603 0 195817 0 0 0 GURDESH BEDI 578092 0 0 0 0 0 15000 0 6297 0 599389 0 0 0 CLAUDIO NUNES 381663 0 0 0 0 0 15000 0 22394 0 419057 0 0 0 GEOFFREY GORRES 262907 0 0 0 0 0 11488 0 9492 0 283887 0 0 0 THOMAS HINCK 255427 0 0 0 0 0 13352 0 10219 0 278998 0 0 0 PAUL MITTELSTADT 254660 0 0 0 0 0 7860 0 1909 0 264429 0 0 0 PART I, LINE 4B CONTRIBUTIONS TO A 457(F) SUPPLEMENTAL NON-QUALIFIED RETIREMENT PLAN: JOHN TREMBLE - $19,073 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 5936395 13000000 13000000 2008 0 0 1 1 B 1451263 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 RIVER VALLEY MEDICAL CENTER FOUR OWNER SERVE ON THE BOARD OF DIRECTORS OF SCRMC 8448302 PHYSICIAN SERVICES 0 FORM 990, PART IV FOUR OWNERS OF RVMC THE FOUR OWNERS OF RVMC INCLUDE MARSHA BEYER, JOSEPH RUGEMER, JEANINE BRUNCLIK, WILLIAM SCHULTZ. NEW PROGRAM SERVICES FORM 990, PART III, LINE 2 DURING FISCAL YEAR ENDING 6/30/2012, SCRMC FORMED UNITY PHARMACY, LLC, A FULL-SERVICE RETAIL PHARMACY, OF WHICH SCRMC IS THE SOLE CORPORATE MEMBER. OPERATIONS BEGAN DURING FISCAL YEAR ENDING 6/30/2013 AND ARE INCLUDED IN BOTH THE FORM 990 AND CONSOLIDATED FINANCIAL STATEMENTS OF SCRMC. 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 APPROVAL 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) A DETAILED REVIEW WAS CONDUCTED BY THE ORGANIZATION'S CFO, (B) THE FORM 990 WAS PRESENTED FOR REVIEW AND APPROVAL TO THE ORGANIZATION'S FINANCE COMMITTEE IN APRIL 2014 AND (C) THE ORGANIZATION'S BOARD OF DIRECTORS REVIEWED AND APPROVED THE FORM 990 IN APRIL 2014. 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 2013. 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 2013. FORM 990, PART VI, SECTION C, LINE 19 THE MEDICAL CENTER'S GOVERING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS ARE NOT MADE AVAILABLE TO THE PUBLIC. OTHER FEES FORM 990, PART IX, LINE 11G PHYSICIAN FEES: PROGRAM SERVICE EXPENSES 10,736,103. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 10,736,103. THERAPIST & OTHER PHYS FEES: PROGRAM SERVICE EXPENSES 232,804. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 232,804. PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 1,951,251. MANAGEMENT AND GENERAL EXPENSES 200,178. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,151,429. CONSULTING SERVICES: PROGRAM SERVICE EXPENSES 38,959. MANAGEMENT AND GENERAL EXPENSES 132,646. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 171,605. INDEPENDENT CONTRACTORS: PROGRAM SERVICE EXPENSES 1,700,602. MANAGEMENT AND GENERAL EXPENSES 9,016. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,709,618. REIMBURSEMENTS FOR PHYSICIAN SERVICES 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 389795 379326 ST CROIX REGIONAL MEDICAL CENTER 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