2014-05-12T14:22:09-05:00 2013-06-30 390758449 WIPFLI LLP PO BOX 12237 GREEN BAY WI 543072237 990 2012-07-01 390944012 MOUNDVIEW MEMORIAL HOSPITAL & CLINICS MOUN 6083393331 402 WEST LAKE STREET FRIENDSHIP WI 53934 JEREMY NORMINGTON 6083393331 2014-05-09 1 TERRI REXRODE CPA MST P00096513 9206620016 2014-05-09 2012 2015-11-30 17:44:51Z JEREMY NORMINGTON 402 WEST LAKE STREET FRIENDSHIP WI 53934 17289935 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 7 165 60 0 0 58305 182577 16043468 16534881 31307 20195 64630 521585 16197710 17259238 0 0 0 0 7579588 7930676 0 0 0 8085271 8978258 15664859 16908934 532851 350304 14866435 15762089 8697751 9224495 6168684 6537594 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 13743925 16883692 THE HOSPITAL IS A GENERAL MEDICAL CRITICAL ACCESS HOSPITAL LICENSED FOR 25 BEDS. DURING FISCAL YEAR 2012, THE HOSPITAL HAD 418 ACUTE INPATIENT DAYS AND 340 MEDICARE SKILL NURSING DAYS (SWING BED). THE HOSPITAL ALSO HAD 4,880 EMERGENCY ROOM VISITS, 1,114 URGENT CARE VISITS AND 15,430 OTHER OUTPATIENT ANCILLARY VISITS. 13743925 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 1 0 0 0 1 0 0 0 0 0 0 0 0 0 1 0 0 0 1 189 0 1 165 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 JEREMY NORMINGTON 6083393331 402 WEST LAKE STREET FRIENDSHIP WI 53934 JOE PARLANTE DDS 2.50 X 0 0 0 MARY POLIVKA 2.50 X X 0 0 0 DEBRA SEGINA 2.50 X X 0 0 0 RICHARD STERNHAGEN 2.50 X X 0 0 0 JEFF WEINKAUF 2.50 X 0 0 0 BARBARA ALBRECHT 2.50 X 0 0 0 DIANA BRONIEC 2.50 X X 0 0 0 JEREMY NORMINGTON 40.00 X 242860 0 37863 DONALD HEINZ 40.00 X 145606 0 31823 RICARDO ALMONTE 40.00 X 211720 0 11231 JASON BELLAK MD 40.00 X 144994 0 27747 SHERYL KUGEL FNP APNP 40.00 X 114055 0 17411 DAVE SHAPIRO 40.00 X 121043 0 7843 ERNESTINE WAGNER PA-C 40.00 X 116478 0 21278 MARY FENDT 40.00 X 102411 0 16735 1199167 0 171931 8 0 1 0 EMCARE 7032 COLLECTION CENTER DRIVE CHICAGO IL 60693 ER PHYSICIAN COVERAGE 1109761 CERNER CORPORATION 2800 ROCKCREEK PARKWAY NORTH KANSAS CITY MO 64117 SOFTWARE MAINTENANCE/SUPPORT 327093 SHARED IMAGING SVCS PO BOX 45686 MADISON WI 53744 MEDICAL IMAGING SERVICES 250134 FIRST REFLECTIONS 228 N PINE ST ADAMS WI 53910 CRNA PROFESSIONAL SERVICES 244262 UWMF-DEPT OF MEDICINE 1685 HIGHLAND AVENUE MADISON WI 53705 CARDIOLOGIST 219752 11 171923 10654 182577 NET PATIENT REVENUE 900099 16404300 16404300 MISCELLANEOUS 900099 109842 109842 DIETARY INCOME 900099 20739 20739 16534881 20195 20195 93629 30697 62932 62932 62932 EHR INCENTIVE 900099 458653 458653 458653 17259238 16883692 0 192969 X 681102 681102 5732893 5125470 607423 175175 137011 38164 906037 780020 126017 435469 359634 75835 155016 155016 56759 56759 45800 45800 2828216 2597207 231009 54538 54538 1550795 1284523 266272 228998 208094 20904 63176 42464 20712 2542 2542 341296 310141 31155 905892 814227 91665 204310 19534 184776 BAD DEBT EXPENSE 1485904 1485904 REPAIRS & MAINTENANCE 532996 257969 275027 EQUIPMENT RENTS & LEASE 374930 275185 99745 COLLECTION EXPENSE 73311 73311 73779 46542 27237 16908934 13743925 3165009 0 600 600 1449667 1963529 1703448 2121379 104926 88856 419007 419444 298274 274880 18861051 8662218 10185312 10198833 705201 694568 14866435 15762089 1742418 1935667 1134509 5468177 5149883 1387356 1004436 99800 0 8697751 9224495 X 5631585 5903278 537099 634316 6168684 6537594 14866435 15762089 X 350304 18606 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 1466 1466 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: WHA MEMBERSHIP DUES 43973 43973 12112903 4044031 8068872 29426 6324 23102 6667403 4611863 2055540 7346 7346 10198833 X 15969637 -1320298 -1320298 17289935 -30697 -30697 17259238 15453727 30697 30697 15423030 1485904 1485904 16908934 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X, LINE 2: IN ORDER TO ACCOUNT FOR ANY UNCERTAIN TAX POSITIONS, ASC TOPIC 740-10, INCOME TAXES, REQUIRES AN ORGANIZATION TO ASSESS 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 THAT POSITION IS NOT RECOGNIZED IN THE FINANCIAL STATEMENTS. THE HOSPITAL RECORDS NO ASSETS OR LIABILITIES FOR UNCERTAIN TAX POSITIONS OR UNRECOGNIZED TAX BENEFITS IN 2013 OR 2012. FEDERAL INCOME TAX RETURNS FOR THE YEARS ENDED JUNE 30, 2010 AND BEYOND REMAIN SUBJECT TO EXAMINATION BY THE INTERNAL REVENUE SERVICE. PART XI, LINE 2D - OTHER ADJUSTMENTS: FOUNDATION MARKET ADJUSTMENT 165,606. BAD DEBT EXPENSE -1,485,904. PART XI, LINE 4B - OTHER ADJUSTMENTS: RENTAL EXPENSES -30,697. PART XII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES 30,697. PART XII, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT EXPENSE 1,485,904. 1 1 1 X 175.000000000000 1 X 175.000000000000 1 1 1 0 1 1 707934 0 707934 0.04590 2851643 1741817 1109826 0.07200 3559577 1741817 1817760 0.11790 157062 23081 133981 0.00870 13530 13530 0.00090 170592 23081 147511 0.00960 3730169 1764898 1965271 0.12750 0 1485904 707934 6071193 6055531 15662 X 1 1 1 1 MOUNDVIEW MEMORIAL HOSPITAL

402 WEST LAKE STREET FRIENDSHIP WI 53934

X X X X MOUNDVIEW MEMORIAL HOSPITAL 1 1 X X X X X X X 12 1 0 1 X X X X X X X X X 0 0 1 1 175.000000000000 1 175.000000000000 1 X X 1 1 X X X X X X 1 0 X X X X 1 X 0 0 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 $ 1485904. PART II: 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. PART III, LINE 4: THE RATIO OF PATIENT COST TO CHARGES WAS CALCULATED BY DIVIDING HOSPITAL EXPENSES NET OF NON-PATIENT REVENUES AND IDENTIFIED COMMUNITY BENEFIT EXPENSES BY GROSS PATIENT REVENUES. THIS PERCENTAGE WAS THEN MULTIPLIED BY THE GROSS REVENUES ON BAD DEBT 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. MOUNDVIEW MEMORIAL HOSPITAL PART V, SECTION B, LINE 3: FIRST KEY STAKEHOLDERS AND COMMUNITY REPRESENTATIVES WERE IDENTIFIED AND INVITED TO JOIN A "COMMUNITY TEAM" TO CONDUCT THE NEEDS ASSESSEMENT. THE TEAM REPRESENTED A CROSS SECTION OF THE RESIDENTS AND ORGANIZATIONS IN ADAMS COUNTY. INPUT WAS ALSO SOUGHT FROM THE GENERAL COMMMUNITY THROUGH A COMMUNITY OPINION SURVEY (CONDUCTED BY TELEPHONE) 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 5C: THE CHNA IS AVAILABE ON THE HOSPITAL'S WEBSITE WWW.MOUNDVIEW.ORG MOUNDVIEW MEMORIAL HOSPITAL PART V, SECTION B, LINE 7: THE COMMUNITY HEALTH NEEDS ASSESSMENT WAS FINALIZED NEAR THE END OF FY 2013. THE EVALUATION OF NEEDS NOT ASSESSED IS ONGOING FOR FY 2014. 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. X X X X 0 0 0 0 0 0 0 0 0 JEREMY NORMINGTON 177145 0 65715 0 0 0 7267 0 30596 0 280723 0 0 0 DONALD HEINZ 128752 0 16854 0 0 0 5877 0 25946 0 177429 0 0 0 RICARDO ALMONTE 192300 0 19420 0 0 0 8161 0 3070 0 222951 0 0 0 JASON BELLAK MD 111689 0 33305 0 0 0 5695 0 22052 0 172741 0 0 0 A VILLAGE OF FRIENDSHIP REVENUE BONDS 396006271 2003-11-01 5000000 WI HOSPITAL DEVELOPMENT REVENUE BONDS 0 0 0 A 1510000 5000000 110000 4890000 2005 0 0 1 1 A 0 0 0 0 1 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. JASON BELLAK TO ENABLE PHYSICIAN TO COMPLETE FELLOWSHIP AT THE UNIVERSITY OF WISCONSIN X 90000 60000 0 1 1 60000 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 ATTRAINED 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 SENIOR MANAGEMENT, THEN PRESENTED AND REVIEWED BY THE BOARD OF DIRECTORS PRIOR TO SUBMISSION. 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. OTHER FEES FORM 990, PART IX, LINE 11G MEDICAL PROFESSIONAL FEES: PROGRAM SERVICE EXPENSES 2,597,207. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,597,207. ADMINISTRATION PROFESSIONAL FEES: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 231,009. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 231,009. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 9: CHANGE IN ASSETS HELD IN POLIVKA TRUST 18,606. FORM 990, PART XII, LINE 2C OVERSIGHT OF AUDIT AND SELECTION OF INDEPENDENT AUDITOR IS THE RESPONSIBILITY OF THE AUDIT COMMITTEE. THIS PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. 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 II 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0