2014-08-15T15:17:06-05:00 2013-09-30 390758449 WIPFLI LLP 3703 OAKWOOD HILLS PARKWAY EAU CLAIRE WI 54701 990 2012-10-01 421017512 UPLAND HILLS HEALTH INC UPLA 6089308000 800 COMPASSION WAY DODGEVILLE WI 53533 ARTHUR K PUSTINA 6089308000 2014-08-14 1 HOLLY POKRANDT CPA P00449155 7158323407 2014-08-13 2012 2015-11-30 17:44:51Z LISA SCHNEDLER 800 COMPASSION WAY DODGEVILLE WI 53533 49613597 0 X WWW.UPLANDHILLSHEALTH.ORG X 1974 WI AS A HEALTH CARE ORGANIZATION, UPLAND HILLS HEALTH, INC.'S MISSION IS TO CONSISTENTLY MEET OR EXCEED THE EXPECTATIONS OF THOSE WE SERVE, AND OF THOSE WE HOPE TO SERVE, IN A COST-EFFECTIVE MANNER. TO LEAD A PARTNERSHIP WITH THE COMMUNITIES AND OUR MEDICAL STAFF, REFLECTING ADDITIONAL EMPHASIS ON HEALTH EDUCATION, CONTINUING MEDICAL EDUCATION, REHABILITATION, AND THE PREVENTION OF ILLNESS OR INJURY. TO APPROACH THE PATIENT AS A WHOLE PERSON RATHER THAN A SET OF SYMPTOMS OR A DISEASE STATE, FOCUSING ON THE CLINICAL AND EMOTIONAL WELL-BEING OF PATIENTS AND THEIR FAMILIES, AND PROVIDING CARE IN AN ENVIRONMENT COMMITTED TO IMPROVING PATIENT SAFETY. TO PARTICIPATE IN THE PROVISION OF HEALTH SERVICES TO THE POOR, MINORITIES, DISABLED, AND OTHER UNDER SERVED PERSONS IN OUR COMMUNITIES. 9 7 508 75 0 0 264745 144008 45328462 46205256 612822 660704 209805 218429 46415834 47228397 78363 107800 0 0 24773006 25673353 0 0 0 18869457 19179704 43720826 44960857 2695008 2267540 81440807 83233305 33055656 32585908 48385151 50647397 X UPLAND HILLS HEALTH, INC.'S MISSION IS TO PROVIDE THE IDEAL PATIENT EXPERIENCE. 0 0 33840575 107800 42294503 UPLAND HILLS HEALTH, INC. (UPLAND HILLS) PROVIDES HIGH QUALITY, COST EFFECTIVE, PRIMARY HOSPITAL CARE TO ALL PEOPLE IN NEED OF CARE. AMONG THE HOSPITAL INPATIENT AND OUTPATIENT SERVICES PROVIDED ARE DIAGNOSTIC IMAGING, REHABILITATION SERVICES, DIALYSIS, RESPIRATORY CARE, SURGICAL SERVICES, CARDIAC MONITORED CARE, LAB SERVICES, PHARMACY SERVICES, 24 HOUR EMERGENCY ROOM, OBSTETRICAL SERVICES, REGIONAL CLINIC SERVICES, AND MANY OTHERS. UPLAND HILLS ALSO PROVIDES ADDITIONAL SERVICES TO THE COMMUNITY BY PROVIDING OUTREACH PROGRAMS AND SERVICES THAT MEET IDENTIFIED NEEDS IN AN EFFORT TO ENHANCE THE HEALTH AND WELFARE OF THE PEOPLE IN ITS AREA.DURING FISCAL YEAR 2013, UPLAND HILLS HOSPITAL PROVIDED 3,192 DAYS OF INPATIENT CARE, 516 DAYS OF SWING BED CARE, OVER 9,700 EMERGENCY ROOM AND URGENT CARE PATIENT VISITS, OVER 2,000 CLINIC PATIENT VISITS, AND PERFORMED OVER 34,000 OTHER OUTPATIENT PROCEDURES AND SERVICES FOR PATIENTS IN NEED OF MEDICAL CARE.IN ITS EFFORT TO ATTAIN THIS MISSION AND GOAL, AND TO BE A PARTNER IN THE COMMUNITY, UPLAND HILLS PROVIDES:-FREE AND REDUCED COST CARE TO THOSE WITH A DEMONSTRATED NEED.-CARE TO THOSE COVERED UNDER GOVERNMENT ENTITLEMENT PROGRAMS WHICH MAY NOT COVER THE CHARGES OF COSTS OR SERVICES PROVIDED.-HEALTH EDUCATION AND OUTREACH PROGRAMS TO ALL MEMBERS OF THE COMMUNITY AT LITTLE OR NO COST TO THE PARTICIPANTS.-DIABETES SELF MANAGEMENT CLASSES - CLASSES ARE RECOGNIZED BY THE AMERICAN DIABETES ASSOCIATION AS QUALITY SELF-MANAGEMENT CLASSES AND ARE TAUGHT BY A REGISTERED DIETICIAN AND REGISTERED NURSE SPECIALLY TRAINED IN DIABETES EDUCATION.-PROGRAMS FOR NEW AND EXPECTANT PARENTS - CHILDBIRTH EDUCATION, PRE-DELIVERY CONFERENCE, SIBLING CLASS, BREASTFEEDING SUPPORT AND BREASTFEEDING SUPPLIES.-INDOOR FITNESS WALKING IS AVAILABLE AT THE HOSPITAL FACILITY FOR COMMUNITY MEMBERS DURING COLD OR INCLEMENT WEATHER.-SAFE SITTER BABYSITTING TRAINING - MEDICALLY ACCURATE BABYSITTING PREPARATION CLASS DESIGNED FOR BOYS AND GIRLS AGES 11 TO 13. THE PROGRAM TEACHES SITTERS HOW TO HAVE FUN WITH CHILDREN AS WELL AS HOW TO RECOGNIZE A MEDICAL EMERGENCY AND KNOW THE APPROPRIATE ACTION TO TAKE. STUDENTS ALSO LEARN INFANT AND CHILD CPR.THE COST OF PROVIDING CHARITY CARE TO PERSONS UTILIZING OUR HOSPITAL AMOUNTED TO APPROXIMATELY $508,000 IN 2013. IN ADDITION, UPLAND HILLS FURNISHES CARE TO PERSONS COVERED UNDER GOVERNMENT ENTITLEMENT PROGRAMS WHICH PAY AT RATES LESS THAN CHARGES. DISCOUNTS TO THESE PROGRAMS FOR HOSPITAL SERVICES AMOUNTED TO $29,022,095. UPLAND HILLS ALSO PROVIDES ASSISTANCE TO THE FREE CLINIC LOCATED IN DODGEVILLE, WISCONSIN ON AN ANNUAL BASIS.UPLAND HILLS ALSO OPERATES A THERAPY AND WELLNESS CENTER TO PROVIDE FITNESS AND WELLNESS OPPORTUNITIES TO EMPLOYEES AND THE PUBLIC. THE THERAPY AND WELLNESS CENTER HOUSES MODERN EQUIPMENT, INCLUDING CARDIO WORKOUT MACHINES, CIRCUIT TRAINING, AND FREE WEIGHTS. WELLNESS CLASSES AND MASSAGE THERAPY ARE OFFERED TO COMPLEMENT YOUR WELLNESS GOALS. CLASSES HAVE INCLUDED INTRO TO YOGA, ABS AND TONE, SENIOR STRENGTH BUILDING, TAI CHI, AND ZUMBA(R).UPLAND HILLS HOSPITAL HAS ALSO PROVIDED DIALYSIS SERVICES TO LOCAL RESIDENTS SINCE 2008. THE HOSPITAL REVIEWED THE POTENTIAL PROGRAM OPERATIONS OF THE DIALYSIS CENTER AND HEALTHCARE NEEDS IN THE COMMUNITY AND NOTED THAT THE DIALYSIS CENTER IS BUDGETED TO RUN IN A NET LOSS POSITION, HOWEVER IT WAS DETERMINED THAT THIS IS A NEEDED HEALTHCARE SERVICE FOR RESIDENTS OF THE DODGEVILLE, WISCONSIN COMMUNITY AND THE SURROUNDING AREAS AND SO THE BOARD OF DIRECTORS APPROVED THAT DIALYSIS SERVICES SHOULD BE SUPPLEMENTED AND PROVIDED BY UPLAND HILLS TO FURTHER ITS MISSION IN THE COMMUNITY. 2332694 2211341 UPLAND HILLS HEALTH, INC. (UPLAND HILLS) ALSO SERVES THE COMMUNITY BY OPERATING A 44-BED SKILLED NURSING FACILITY KNOWN AS THE "NURSING AND REHABILITATION CENTER". THE PRIMARY ACTIVITY OF THE NURSING AND REHABILITATION CENTER IS TO PROVIDE SKILLED AND INTERMEDIATE CARE FOR THE AGED AND DISABLED OF THE SURROUNDING AREA. THE CENTER PROVIDED 15,074 DAYS OF RESIDENT CARE IN FISCAL YEAR 2013. THE CENTER OFFERS SKILLED NURSING CARE IN BOTH SHORT TERM REHABILITATION PROGRAMS AND LONG-TERM CARE RESIDENT PROGRAMS. SOME OF THE SPECIALIZED CARE SERVICES OFFERED INCLUDE IV THERAPY CARE, WOUND CARE, PAIN MANAGEMENT, PHYSICAL THERAPY, OCCUPATIONAL THERAPY, AND SPEECH THERAPY AMONG MANY OF THE CARE PROGRAMS PROVIDED. THE CENTER OPERATES IN CONJUNCTION WITH UPLAND HILLS HOSPITAL TO PROVIDE A SMOOTH TRANSITION FOR PATIENTS NEEDING EXTENDED REHABILITATION OR LONG-TERM CARE SERVICES. THE COMBINATION AND COORDINATION OF FACILITIES ALSO ALLOWS THE ORGANIZATION TO SHARE MANY DEPARTMENTS AND SERVICES IN UPLAND HILLS CONTINUED EFFORT TO PROVIDE HIGH QUALITY AND LOW COST CARE TO THE COMMUNITY. 1464345 1556398 UPLAND HILLS HEALTH, INC.'S HOSPICE PROGRAM GIVES THOSE PATIENTS WITH LIFE-LIMITING OR TERMINAL ILLNESSES THE OPPORTUNITY TO LIVE PAIN-FREE AND WITH DIGNITY DURING THE LAST STAGE OF THEIR LIFE. TOTAL HOSPICE DAYS OF SERVICE PROVIDED TO PATIENTS IN FISCAL YEAR 2013 WERE 4,422.UPLAND HILLS HEALTH, INC.'S HOMECARE PROGRAM PROVIDES COMPREHENSIVE HEALTHCARE SERVICES IN THE MOST COMFORTABLE SETTING-THE PATIENT'S HOME. IN FISCAL YEAR 2013 THERE WERE 5,632 TOTAL HOMECARE VISITS PROVIDED TO PATIENTS. 37637614 1 1 0 1 0 0 0 0 0 1 1 0 1 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 1 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 1 1 1 0 0 1 75 0 508 1 1 1 0 0 0 0 0 0 0 0 0 X 9 7 1 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 WI X ARTHUR K PUSTINA 6089308000 800 COMPASSION WAY DODGEVILLE WI 53533 PEG KOEHLER 2.50 X 0 0 0 KATHRYN DALSING MD 2.50 X 0 0 0 JOHN THRONSON 2.50 X 0 0 0 TODD BURCHILL 2.50 X 0 0 0 LINDA TAPLIN STATZ 2.50 X 0 0 0 JODY VANDERLOO 2.50 X X 0 0 0 BRAD LAUFENBERG 2.50 1.00 X X 0 0 0 JIM MASSEY 2.50 X X 0 0 0 TED GREENHECK 2.50 X X 0 0 0 PHYLLIS FRITSCH 51.80 1.00 X 197212 0 27005 LISA SCHNEDLER 51.80 1.00 X 0 0 0 ARTHUR K PUSTINA 49.20 1.00 X 128615 0 26382 BARBARA HOSTETLER 36.80 X 421353 0 27170 ADAM DACHMAN 40.50 X 380519 0 10242 JEFF PIERCE 45.50 X 274350 0 31616 DONALD HART 40.60 X 257299 0 30943 ROBERT SCHMUS 31.40 X 268081 0 24108 1927429 0 177466 16 0 1 0 MADISON EMERGENCY PHYSICIANS SC INC 1221 JOHN Q HAMMONS DRIVE MADISON WI 537444966 24 HOUR EMERGENCY ROOM COVERAGE 2063926 SHARED IMAGING SERVICES INC PO BOX 45686 MADISON WI 537445686 X-RAY SCAN SERVICES 798316 RURAL WISCONSIN HEALTH COOPERATIVE INFOR 880 INDEPENDENCE LANE PO BOX 490 SAUK CITY WI 535830490 COMPUTER SUPPORT 762284 RURAL WISCONSIN HEALTH COOPERATIVE 880 INDEPENDENCE LANE PO BOX 490 SAUK CITY WI 535830490 AUDIOLOGY HOURS & SUPPLIES, EDUCATION, A 408941 SHARED MEDICAL SERVICES 209 LIMESTONE PASS COTTAGE GROVE WI 53527 MRI SERVICES 352185 13 77466 27548 38994 31191 144008 PATIENT SERVICE REVENUE 621990 45514460 45514460 CAFETERIA & NUTRITION 722210 187163 187163 MASSAGE/ACUPUNCTURE 621990 88765 88765 FITNESS CENTER 624100 75836 75836 LIFELINE 621990 65882 65882 273150 205972 67178 46205256 421042 421042 42 42 687416 523652 163764 163764 163764 2056159 45009 1824233 37315 231926 7694 239620 239620 10458 0 10458 10458 44207 0 44207 44207 47228397 46062242 0 1022147 X 107800 107800 488092 488092 19410443 16336115 3074328 551739 464352 87387 3884650 3269379 615271 1338429 1101506 236923 62413 62413 28715 28715 9185 9185 4909576 4385775 523801 194204 5074 189130 3070550 2650980 419570 644102 644102 1399074 1399074 214842 184259 30583 41022 41022 3302743 3302743 259280 94178 165102 MEDICAL SUPPLIES 2666476 2666476 PROVISION FOR BAD DEBTS 1146010 1146010 GENERAL EXPENSES 616946 314874 302072 DUES & SUBSCRIPTIONS 474408 92265 382143 140158 75732 64426 44960857 37637614 7323243 0 1607217 1794310 6456707 5420854 4029604 4829091 978704 946374 537813 587240 67333593 32334857 37263573 34998736 17290 17814 28896577 33231865 72600 72600 1580722 1334421 81440807 83233305 4478067 3794128 0 174821 27820000 27310000 411295 327598 59946 31172 286348 948189 33055656 32585908 X 48352151 50614397 33000 33000 48385151 50647397 81440807 83233305 X 2267540 -77606 72312 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 7210 7210 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: UPLAND HILLS HEALTH, INC. PAYS ANNUAL ASSOCIATION MEMBERSHIP DUES TO THE WISCONSIN HOSPITAL ASSOCIATION (WHA) AND THE AMERICAN HOSPITAL ASSOCIATION (AHA). THESE DUES ARE PRIMARILY TO ACCESS EDUCATIONAL MATERIALS AND FOR STAFF TRAINING AND MATERIALS, HOWEVER A PORTION OF THE ANNUAL DUES WERE USED IN CONJUCTION WITH LOBBYING ACTIVITIES WITH THE GOAL OF IMPROVING THE OVERALL HEALTHCARE ENVIRONMENT. UPLAND HILLS HEALTH, INC. IS ALSO A MEMBER OF THE RURAL WISCONSIN HEALTH COOPERATIVE (RWHC). EACH YEAR, UPLAND HILLS HEALTH, INC. PAYS MEMBERSHIP FEES TO THE RWHC. RWHC PROVIDES SUPPORT SERVICES FOR A NUMBER OF ITS MEMBER HOSPITALS THROUGHOUT THE STATE OF WISCONSIN. SOME OF THE MANY SERVICES PROVIDED TO MEMBER HOSPITALS INCLUDE PROVIDING ASSISTANCE TO ORGANIZATIONS IN FINDING GRANT FUNDING FOR NEW PROGRAMS, LEGAL SERVICES, REIMBURSEMENT REVIEW SERVICES, ACCOUNTING ASSISTANCE, CONTRACTING FOR THERAPIST AND EMERGENCY ROOM PATIENT CARE COVERAGE, AND ADMINISTRATIVE CONSULTING SERVICES. AS A PART OF THESE SERVICES, THE RWHC ALSO PROVIDES AN ANALYSIS OF CURRENT HEALTHCARE ISSUES IN AN EFFORT TO PROMOTE AND BETTER HEALTHCARE FOR HOSPITALS IN RURAL COMMUNITIES THROUGHOUT WISCONSIN. ONE OF THESE EFFORTS ALSO INCLUDES SOME LOBBYING ON THE PART OF THE MEMBER ORGANIZATIONS. THE WHA, AHA, AND RWHC DETERMINED THAT APPROXIMATELY $7,210 OF THE FEES PAID BY UPLAND HILLS HEALTH, INC. IN 2013 RELATED TO LOBBYING ACTIVITIES WITH THE GOAL OF IMPROVING THE HEALTHCARE ENVIRONMENT IN THE STATE OF WISCONSIN. 213277 1000 1504 1922 213859 210220 2000 1057 213277 208412 1016 792 210220 75366 131000 2046 208412 50366 25000 75366 0.00000 0.98370 0.01630 0 1 1 194076 194076 46696031 16853436 29842595 19094551 14814960 4279591 1348935 666461 682474 34998736 BOARD DESIGNATED FOR CAPITAL IMPROVEMENTS 31150108 F UNDER BOND INDENTURE AGREEMENTS 1863326 F STATE OF WI UNEMPLOYMENT FUNDING 218431 F 33231865 SECURITY DEPOSITS 50440 DEFERRED COMPENSATION PLAN LIABILITY 547599 AMOUNTS PAYABLE TO THIRD-PARTY REIMBURSEMENT PROGRAMS 350150 948189 X DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: UPLAND HILLS HEALTH, INC.'S ENDOWMENT CONSISTS OF TWO FUNDS HELD BY UPLAND HILLS HEALTH FOUNDATION, INC. THESE FUNDS WERE ESTABLISHED TO PROVIDE INCOME FOR THE FOUNDATION TO HELP SUPPORT SPECIFIC PROGRAMS OF UPLAND HILLS HEALTH, INC. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X, LINE 2: THE HOSPITAL IS A NONPROFIT CORPORATIONS AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE (THE "CODE") AND IS EXEMPT FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE CODE. THE HOSPITAL IS ALSO EXEMPT FROM STATE INCOME TAXES ON RELATED INCOME. THE HOSPITAL IS ALSO ENGAGED, TO A LIMITED EXTENT, IN CERTAIN ACTIVITIES SUBJECT TO TAXATION AS UNRELATED BUSINESS INCOME (UBI). UBI IS NOT SIGNIFICANT. THE HOLDING COMPANY IS A TAXABLE ENTITY, WHICH IS CONSIDERED A DISREGARDED ENTITY FOR TAX PURPOSES. THE PRIMARY ACTIVITY OF THE HOLDING COMPANY IS TO INVEST IN A PARTNERSHIP, WHICH IS A LIMITED LIABILITY COMPANY THAT IS ENGAGED IN THE BUSINESS OF SUPPLYING MEDICAL EQUIPMENT AND SUPPLIES TO PATIENTS IN THEIR HOMES OR FACILITIES. INCOME OR LOSS ATTRIBUTABLE TO THIS PARTNERSHIP INTEREST IS PASSED THROUGH TO THE HOSPITAL FOR TAX PURPOSES. EACH YEAR THE HOSPITAL EVALUATES WHETHER THIS INCOME OR A PORTION OF THE INCOME SHOULD BE CONSIDERED AS UNRELATED BUSINESS INCOME AND, AS SUCH, WOULD BE SUBJECT TO FEDERAL AND STATE INCOME TAXES. IF ANY TAX PROVISIONS OR CREDITS ARE DETERMINED TO BE NECESSARY, THE HOSPITAL RECORDS THESE AMOUNTS IN THE ACCOMPANYING CONSOLIDATED FINANCIAL STATEMENTS. IN ORDER TO ACCOUNT FOR ANY UNCERTAIN TAX POSITIONS, UPLAND HILLS ASSESSES 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 THE TAX POSITION IS NOT RECOGNIZED IN THE ACCOMPANYING CONSOLIDATED FINANCIAL STATEMENTS. UPLAND HILLS HAS NOT RECORDED ANY ASSETS OR LIABILITIES RELATED TO UNCERTAIN TAX POSITIONS OR UNRECOGNIZED TAX BENEFITS AS OF SEPTEMBER 30, 2013 OR 2012. FEDERAL TAX RETURNS FOR TAX YEARS ENDED SEPTEMBER 30, 2010, AND BEYOND REMAIN SUBJECT TO EXAMINATION BY THE INTERNAL REVENUE SERVICE. 1 1 1 X 1 X 1 1 1 0 1 1 503244 503244 0.01150 5307498 3375813 1931685 0.04410 5810742 3375813 2434929 0.05560 28493 7059 21434 0.00050 179718 179718 0.00410 3983661 3100992 882669 0.02010 143567 143567 0.00330 4335439 3108051 1227388 0.02800 10146181 6483864 3662317 0.08360 491 491 0.00000 3150 3150 0.00010 800 800 0.00000 4441 4441 0.00010 0 498249 249124 11845154 12803877 -958723 X 1 1 1 CRESTRIDGE ASSISTED LIVING LLC ASSISTED LIVING FACILITY 0.49000 1 1 UPLAND HILLS HEALTH INC

800 COMPASSION WAY DODGEVILLE WI 53533

WWW.UPLANDHILLSHEALTH.ORG X X X X UPLAND HILLS HEALTH INC 1 1 X X X X X X X X X 12 1 0 1 X X X X X X X X X X 0 0 1 1 200.000000000000 1 300.000000000000 1 X X X X X X X 1 1 X X X X X 1 X 1 X X X X X 1 X 0 0 7 UPLAND HILLS NURSING AND REHAB CENTER

800 COMPASSION WAY DODGEVILLE WI 53533

SKILLED NURSING FACILITY UPLAND HILLS HEALTH CENTER

800 COMPASSION WAY DODGEVILLE WI 53533

OUTPATIENT CLINIC UPLAND HILLS HEALTH CLINIC - HIGHLAND

551 N MAIN STREET HIGHLAND WI 53543

OUTPATIENT CLINIC UPLAND HILLS HEALTH CLINIC - MONTFORT

202 W US HIGHWAY 18 MONTFORT WI 53569

OUTPATIENT CLINIC UPLAND HILLS HEALTH CLINIC - SPRING GREE

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OUTPATIENT CLINIC UHH THERAPY CLINIC - BARNEVELD

103 QUAIL RIDGE DRIVE BARNEVELD WI 53507

OUTPATIENT PHYSICAL THERAPY CLINIC UHH THERAPY CLINIC - LANDS' END

1 LANDS END LANE DODGEVILLE WI 53533

LANDS END EMPLOYEE OUTPATIENT PHYSICAL THERAPY CLINIC PART I, LINE 7: THE COSTING METHOD USED ON FORM 990 IS BASED ON A COST TO CHARGE RATIO WHICH IS DEVELOPED BASED ON THE HOSPITAL'S TOTAL OPERATING EXPENSES LESS THE PROVISION FOR BAD DEBTS DIVIDED BY GROSS PATIENT SERVICE REVENUE. THIS COST TO CHARGE RATIO IS APPLIED AGAINST VARIOUS REVENUE AND EXPENSE CATEGORIES TO COMPUTE THE ESTIMATED COMMUNITY BENEFIT EXPENSE UNDER IRS SUGGESTED COSTING METHODS FOR THE FORM 990. PART I, LINE 7G: SUBSIDIZED HEALTH SERVICES AT UPLAND HILLS HEALTH, INC. INCLUDE THE OPERATION OF THE CLINICS AND THE DIALYSIS CENTER. THE CLINICS ARE OPERATED TO PROVIDE SUPPORT TO THE COMMUNITY BY PROVIDING FAMILY HEALTH, SURGICAL, AND OB/GYN SERVICES TO THE SURROUNDING AREAS, WHICH WOULD OTHERWISE BE UNDERSERVED. SEE PART III, LINE 4A FOR A DESCRIPTION OF THE DIALYSIS SERVICES OFFERED. IT IS THE GOAL OF UPLAND HILLS HEALTH TO PROVIDE THESE SERVICES TO THE COMMUNITY REGARDLESS OF A PATIENT'S ABILITY TO PAY. PART I, L7 COL(F): THE COSTING METHOD AND CALCULATIONS USED ON FORM 990 ARE BASED ON TOTAL OPERATING EXPENSES EXCLUDING BAD DEBT EXPENSE. THE COMMUNITY BENEFIT EXPENSE PERCENTAGES ARE CALCULATED BY DIVIDING THE COMMUNITY BENEFIT EXPENSE FOR EACH CATEGORY OF COMMUNITY SERVICES PROVIDED BY UPLAND HILLS HEALTH, INC. REPORTED IN THE TABLE ON LINE 7 PART I OF THE SCHEDULE H BY THE TOTAL OPERATING EXPENSES OF THE HOSPITAL LESS THE PROVISION FOR BAD DEBTS OF $1,146,010. PART II: WHILE THERE IS GROWING AGREEMENT IN THE UNITED STATES ABOUT WHAT CONSTITUTES A NON-PROFIT HOSPITAL'S "COMMUNITY BENEFIT," THESE EFFORTS CONTINUE TO BE A WORK IN PROGRESS. UPLAND HILLS HEALTH, INC. PROVIDES SIGNIFICANT AMOUNTS OF CHARITY CARE AND OTHER COMMUNITY BENEFITS AS DEFINED BY THE IRS AND IN ADDITION, THE HOSPITAL BELIEVES THAT IT PROVIDES A CRITICALLY IMPORTANT BENEFIT WHICH IS NOT QUANTIFIED. UPLAND HILLS HEALTH, INC., LIKE MOST COMMUNITY HOSPITALS, WAS CREATED AND IS MAINTAINED IN ORDER TO PROVIDE CARE LOCALLY WHICH WITHOUT THE HOSPITAL, WOULD NOT BE AVAILABLE LOCALLY. BEYOND INPATIENT HOSPITALIZATIONS, THE HOSPITAL PROVIDES LOCAL ACCESS TO MANY SERVICES INCLUDING: BIRTHING CENTER, DIAGNOSTICS, EMERGENCY SERVICES, HOSPICE, HOME CARE, RENAL DIALYSIS, INFUSION SERVICES, SWING BED SERVICES, NURSING HOME SERVICES, CLINICAL SERVICES, LABORATORY SERVICES, OCCUPATIONAL HEALTH, REHABILITATION SERVICES, SPECIALTY MEDICINE, SLEEP CENTER, SPEECH PATHOLOGY, SURGICAL SERVICES, AND WOMENS' SERVICES, TO NAME SOME OF THE MAJOR SERVICES PROVIDED. PART III, LINE 4: MANAGEMENT PROVIDES FOR PROBABLE UNCOLLECTIBLE AMOUNTS, PRIMARILY UNINSURED PATIENTS AND AMOUNTS PATIENTS ARE PERSONALLY RESPONSIBLE FOR, THROUGH A CHARGE TO OPERATIONS AND A CREDIT TO A VALUATION ALLOWANCE BASED ON ITS ASSESSMENT OF HISTORICAL COLLECTION LIKELIHOOD AND THE CURRENT STATUS OF INDIVIDUAL ACCOUNTS. BALANCES THAT ARE STILL OUTSTANDING AFTER THE HOSPITAL HAS USED REASONABLE COLLECTION EFFORTS ARE WRITTEN OFF THROUGH A CHARGE TO THE VALUATION ALLOWANCE AND A CREDIT TO ACCOUNTS RECEIVABLE. MANY TIMES PATIENTS DO NOT COMPLETE THE REQUIRED CHARITY CARE APPLICATION AND ARE TRANSFERRED TO COLLECTION SERVICES EVEN THOUGH THE HOSPITAL PROVIDES THIS INFORMATION TO ALL PATIENTS AND ASSISTANCE WITH THE APPLICATIONS. DUE TO NO RESPONSES FROM SOME PATIENTS A SIGNIFICANT AMOUNT OF BAD DEBTS COULD BE CONSIDERED AS CHARITY CARE.THE COST TO CHARGE RATIO IS APPLIED AGAINST THE TOTAL CHARGES THAT ARE WRITTEN OFF DURING THE FISCAL YEAR TO ESTIMATE THE COST OF THE CARE OF PATIENTS THAT HAVE ACCOUNTS THAT ARE DEEMED TO BE BAD DEBTS TO THE ORGANIZATION. THE HOSPITAL RECOGNIZES THAT IT ALSO PROVIDES A DISCOUNT TO SELF-PAY OR UNINSURED PATIENTS. THESE AMOUNTS ARE INCLUDED IN THE CONTRACTUAL ADJUSTMENTS ON THE FINANCIAL STATEMENTS AND ARE NOT INCLUDED IN THE RATIO AS DESCRIBED ABOVE AND APPROVED BY THE IRS FOR USE ON FORM 990. IF CONSIDERED, THESE ADDITIONAL WRITE-OFF AMOUNTS TO UNINSURED ACCOUNTS WOULD ALSO INCREASE THE ESTIMATED BAD DEBT EXPENSE AMOUNT ASSOCIATED WITH THESE UNCOLLECTIBLE ACCOUNTS TO THE HOSPITAL. THE AUDITED FINANCIAL STATEMENTS DO NOT CONTAIN A SEPARATE FOOTNOTE REGARDING BAD DEBT EXPENSE. PART III, LINE 8: THE TOTAL MEDICARE REVENUE SHOWN IN SCHEDULE H OF THE FORM 990 IS BASED ON THE IRS 990 INSTRUCTIONS AND INCLUDES ONLY A PORTION OF THE GROSS MEDICARE REVENUE OF THE HOSPITAL, AND ALSO DOES NOT CONSIDER ALL CONTRACTUAL ADJUSTMENTS FOR SERVICES REIMBURSED BY THE MEDICARE PROGRAM. AMOUNTS LISTED FOR MEDICARE REVENUES DO NOT INCLUDE PHYSICIAN SERVICES FOR THE COVERAGE OF THE EMERGENCY DEPARTMENT AT THE HOSPITAL AS WELL AS ANESTHESIA PROFESSIONAL SERVICES, CLINICAL PHYSICIAN PROFESSIONAL SERVICES, SURGEON PROFESSIONAL SERVICES, OUTPATIENT PHYSICAL THERAPY SERVICES PROVIDED TO NURSING HOME RESIDENTS, AND REVENUES FOR ANY PATIENTS COVERED UNDER MEDICARE ADVANTAGE PLAN PROGRAMS. PHYSICIAN PROFESSIONAL SERVICES ARE REIMBURSED PRIMARILY ON FEE SCHEDULE REIMBURSEMENTS AT RATES THAT ARE OFTEN BELOW THE COSTS OF CARING FOR PATIENTS. EMERGENCY, SURGERY, AND CLINICAL PHYSICIAN SERVICES PROVIDED TO MEDICARE PATIENTS ARE VITAL TO THE WELL-BEING OF THE COMMUNITY AND AS SUCH THESE COSTS AND SHORTFALLS SHOULD ALSO BE CONSIDERED AS AN ADDITIONAL BENEFIT THAT UPLAND HILLS HEALTH, INC. PROVIDES TO THE COMMUNITY AND SURROUNDING AREAS. THE COSTING METHOD USED ABOVE FOR IRS 990 COMPLIANCE REPORTING IS ALSO BASED ON THE FILED MEDICARE COST REPORT FOR THE YEAR ENDED SEPTEMBER 30, 2013, AND DOES NOT CONSIDER MEDICARE NON-ALLOWABLE EXPENSES, AS IT IS BASED ON TOTAL HOSPITAL PATIENT SERVICE REVENUES (IGNORING CONTRACTUAL ADJUSTMENTS ON FEE SCHEDULE REIMBURSED ITEMS AND NON-ALLOWABLE MEDICARE EXPENSES AS NOTED ABOVE).WHETHER THERE IS A SHORTFALL OR SURPLUS ON SERVICES PROVIDED TO MEDICARE BENEFICIARIES, THESE PEOPLE, WHICH ARE TYPICALLY ELDERLY OR DISABLED MEMBERS OF THE COMMUNITY, ARE AN UNDERSERVED POPULATION WHO EXPERIENCE ISSUES WITH ACCESS TO HEALTHCARE SERVICES. WITHOUT TAX-EXEMPT HOSPITALS PROVIDING MEDICARE PATIENT SERVICES, THE CENTERS FOR MEDICARE AND MEDICAID (CMS) WOULD BEAR THE BURDEN OF DIRECTLY PROVIDING SERVICES TO THE ELDERLY AND DISABLED MEMBERS OF THE COMMUNITY. PART III, LINE 9B: UNDER THE HOSPITAL'S COLLECTION AND CHARITY CARE POLICIES, UPLAND HILLS HEALTH, INC. MAKES EVERY ATTEMPT TO IDENTIFY AND PROMOTE CHARITY CARE TO PATIENTS. INCLUDED IN THE HOSPITAL'S CHARITY CARE POLICY IT IS NOTED THAT PATIENTS MAY QUALIFY FOR CHARITY CARE EITHER PRIOR TO ADMISSION OR FOLLOWING DISCHARGE. ALL INPATIENT SELF-PAY ADMISSIONS ARE SCREENED BY THE HOSPITAL'S PATIENT FINANCIAL COUNSELOR OR SOCIAL WORKERS TO ALLOW THESE PATIENTS THE ABILITY TO COMPLETE THEIR APPLICATION DURING THEIR STAY AT THE HOSPITAL, DEPENDING UPON THE PATIENT'S CONDITION, OR THE PATIENT'S RESPONSIBLE PARTY MAY BE CONTACTED TO COMPLETE AND RETURN THE FORMS AT A LATER TIME WHEN THEIR CARE ALLOWS THIS COMPLETION. DURING THE PATIENT ACCOUNT COLLECTION PROCESS, SELF-PAY PATIENTS ARE ALSO INFORMED OF THE HOSPITAL'S COLLECTION POLICIES AS WELL AS THE CHARITY CARE PROGRAM TO ALLOW PATIENTS THE OPPORTUNITY TO COMPLETE THE APPROPRIATE FORMS AND QUALIFY UNDER THE PROGRAM. UPLAND HILLS HEALTH, INC. PART V, SECTION B, LINE 3: THE COMMUNITY HEALTH NEEDS ASSESSMENT (CHNA) CONSIDERED INFORMATION OBTAINED FROM INTERVIEWS WITH STAKEHOLDERS WHO REPRESENT THE BROAD INTERESTS OF THE COMMUNITY. SEVENTEEN KEY STAKEHOLDERS PARTICIPATED IN THE INTERVIEW PROCESS. THE SEVENTEEN STAKEHOLDERS REPRESENT PUBLIC HEALTH EXPERTS; INDIVIDUALS FROM HEALTH OR OTHER DEPARTMENTS AND AGENICES; LEADERS OR REPRESENTATIVES OF MEDICALLY UNDERSERVED, LOW-INCOME, AND MINORITY POPULATIONS; AND OTHER COMMUNITY MEMBERS. THE CHNA ALSO CONSIDERED MULTIPLE OTHER DATA SOURCES, INCLUDING SECONDARY DATA SOURCES REGARDING DEMOGRAPHICS, HEALTH STATUS INDICATORS, AND MEASURES OF HEALTH CARE ACCESS. UPLAND HILLS HEALTH, INC. PART V, SECTION B, LINE 7: THERE WERE ITEMS IDENTIFIED IN THE COMMUNITY HEALTH NEEDS ASSESSMENT (CHNA) WHICH WERE NOT ADDRESSED BY UPLAND HILLS HEALTH, INC.; HOWEVER, ALL ITEMS WERE CONSIDERED IF A NEED WAS BROUGHT TO THE ATTENTION OF THE GROUP DURING THE INFORMATION GATHERING PHASE OF THE CHNA. SEVERAL OF THE ITEMS WHICH WERE NOT ADDRESSED PRIMARILY WERE NOT ADDRESSED DUE TO THE FINANCIAL CONSTRAINT OF PROVIDING A NEW SERVICE FOR A LIMITED POPULATION OF PEOPLE WITHIN THE PRIMARY SERVICE AREA OR AT THE PRESENT TIME IT WAS DETERMINED THAT ANOTHER ORGANIZATION MAY BE NEEDED TO MAKE A NEW HEALTH SERVICE A FINANCIALLY VIABLE OPTION IN THE LOCAL COMMUNITY. UPLAND HILLS HEALTH, INC. AGREED TO LIMIT THEIR FOCUS TO TWO PRIMARY GOALS. UPLAND HILLS HEALTH, INC. PART V, SECTION B, LINE 14G: THE POLICY WAS OFFERED TO ALL PRIVATE PAY PATIENTS IN THE EMERGENCY DEPARTMENT. PART VI, LINE 2: UPLAND HILLS HEALTH, INC. ASSESSES THE HEALTH CARE NEEDS OF THE COMMUNITIES AND AREAS IT SERVES BY REVIEWING LOCAL DEMOGRAPHICS AND TRENDS IN PATIENT SERVICE UTILIZATION TO DETERMINE WHICH SERVICES COULD AND SHOULD BE MADE AVAILABLE TO THE COMMUNITY IN A COST-EFFECTIVE MANNER TO BE CONSISTENT WITH THE HOSPITAL'S MISSION IN THE COMMUNITY. UPLAND HILLS HEALTH, INC. ALSO REVIEWS STATISTICS IN THE HOSPITAL, NURSING HOME, CLINIC, HOME HEALTH, AND OTHER ORGANIZATIONAL DEPARTMENTS TO REVIEW THE CURRENT SERVICES BEING OFFERED AND ENSURE THAT RESOURCES ARE BEING APPROPRIATELY ALLOCATED TO AREAS IN NEED BY COMMUNITY MEMBERS AND PATIENTS. THE HOSPITAL ALSO MEETS WITH LOCAL COMMUNITY MEMBERS AND IT'S PHYSICIAN GROUP TO DETERMINE WHICH SERVICES MAY BENEFIT THE COMMUNITY.DURING FISCAL YEAR 2013 UPLAND HILLS HEALTH, INC. COMPLETED A FORMAL COMMUNITY NEEDS ASSESSMENT TO BETTER UNDERSTAND THE HEALTH NEEDS OF THE COMMUNITY AND TO DEVELOP AN EFFECTIVE IMPLEMENTATION STRATEGY TO ADDRESS PRIORITY NEEDS. PART VI, LINE 3: UNINSURED AND UNDER INSURED PATIENTS ARE ASKED TO MEET WITH ONE OF THE HOSPITAL'S FINANCIAL COUNSELORS EITHER AT THE TIME SERVICE IS PROVIDED OR WHEN THE PATIENT'S BILL IS GENERATED. THE FINANCIAL COUNSELOR EXPLAINS THE VARIOUS PAYMENT OPTIONS AVAILABLE TO THE PATIENT AS WELL AS THE HOSPITAL'S CHARITY CARE PROGRAM AND OFFERS THE CHARITY CARE APPLICATION WHEN APPROPRIATE. IF OTHER PROGRAMS ARE AVAILABLE TO THE PATIENT, SUCH AS THE WISCONSIN MEDICAID OR BADGERCARE PROGRAMS, THESE PATIENTS ARE REFERRED TO THE APPROPRIATE GOVERNMENT AGENCY FOR FURTHER ASSISTANCE. PART VI, LINE 4: THE PRIMARY SERVICE AREA FOR UPLAND HILLS HEALTH, INC. ENCOMPASSES ALL PERSONS LIVING WITHIN A 20 TO 30 MILE RADIUS OF THE HOSPITAL. SOME OF THE COMMUNITIES INCLUDED IN THIS AREA ARE DODGEVILLE, MONTFORT, HIGHLAND, COBB, EDMUND, RIDGEWAY, LINDEN, AND MINERAL POINT, WISCONSIN, AMONG MANY OTHERS. UPLAND HILLS HEALTH, INC. IS THE ONLY HOSPITAL LOCATED IN IOWA COUNTY, WISCONSIN. THE HOSPITAL PROVIDES A SIGNFICANT PORTION OF ITS PATIENT SERVICES TO BENEFICIARIES OF THE MEDICARE AND MEDICAID PROGRAMS, ESPECIALLY THOSE BENEFICIARIES WHO RESIDE IN THE HOSPITAL'S LONG-TERM CARE FACILITY, OR PATIENTS WHO RECEIVE HOME HEALTH, HOSPICE, OR DIALYSIS SERVICES FROM UPLAND HILLS HEALTH, INC. IN 2013, THESE MEDICARE AND MEDICAID PATIENTS ACCOUNTED FOR APPROXIMATELY 49 PERCENT OF THE GROSS PATIENT SERVICE REVENUE PROVIDED BY THE HOSPITAL DURING THE YEAR. PART VI, LINE 6: UPLAND HILLS HEALTH, INC. MAINTAINS AN AFFILIATION AGREEMENT WITH SSM HEALTHCARE OF WISCONSIN, INC. SSM HEALTHCARE OF WISCONSIN, INC. OPERATES ST. MARY'S HOSPITAL IN MADISON, WISCONSIN AS WELL BEING AFFILIATED WITH OTHER AREA COMMUNITY HOSPITALS LOCATED NEAR MADISON, WISCONSIN. ST. MARY'S AND THE SSM HEALTHCARE SYSTEM IS A MULTI-SPECIALTY HEALTH SYSTEM. UPLAND HILLS HEALTH, INC. COLLABORATES WITH SSM HEALTHCARE TO PROMOTE HEALTH AND WELLNESS INITIATIVES IN THE COMMUNITIES SERVED AND THE REGION. AS NOTED PREVIOUSLY IN THE FORM 990, TWO REPRESENTATIVES FROM SSM HEALTHCARE HAVE ROLES ON THE BOARD OF DIRECTORS OF UPLAND HILLS HEALTH, INC. THE AFFILIATION HELPS ENHANCE ACCESSIBILITY OF HEALTH CARE SERVICES OFFERED AT UPLAND HILLS HEALTH, INC. AND MAKES AVAILABLE ADDITIONAL EXPERTISE AND SERVICES WHEN NEEDED TO PROVIDE ACCESS TO EXPANDED SERVICES FOR AREA RESIDENTS. REPORTS FILED WITH STATES PART VI, LINE 7 WI 1 COMMUNITY CONNECTIONS FREE CLINIC INC 201 S IOWA STREET DODGEVILLE WI 53533 721619112 501(C)(3) 0 98283 COST MEDICAL SERVICES & SUPPLIES TO PROVIDE ACCESS TO ADDITIONAL HEALTHCARE SERVICES TO THOSE IN NEED IN THE COMMUNITY. UPLAND HILLS HEALTH FOUNDATION INC 800 COMPASSION WAY DODGEVILLE WI 53533 260596045 501(C)(3) 9517 FMV MONETARY SUPPORT 2 0 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: UPLAND HILLS HEALTH, INC. HAS A BOARD APPROVED POLICY ON CHARITABLE GIVING FROM UPLAND HILLS HEALTH TO THE COMMUNITY FOR PURPOSES THAT FURTHER THE MISSION OF THE ORGANIZATION. GRANTS TO THE COMMUNITY CONNECTIONS FREE CLINIC ARE IN SUPPORT OF THIS MISSION TO PROVIDE ACCESS TO HEALTHCARE SERVICES TO THOSE IN NEED IN THE COMMUNITY AND SURROUNDING AREAS. EACH YEAR, UPLAND HILLS HEALTH PROVIDES AN AMOUNT THAT IS APPROVED IN THE ANNUAL OPERATING BUDGET BY THE BOARD OF DIRECTORS AND THIS ALLOTED AMOUNT IS GIVEN TO THE FREE CLINIC TO REFER PATIENTS IN NEED OF ADDITIONAL SERVICES TO UPLAND HILLS HEALTH TO BE PROVIDED FREE OF CHARGE. THE ORGANIZATION MONITORS THE AMOUNTS PROVIDED DURING THE YEAR AND ENSURES THAT THE CLINIC IS MADE AWARE OF REMAINING AVAILABLE ALLOCATED AMOUNTS. IF A TIME OF NEED IS DETERMINED FOR THE FREE CLINIC TO RECEIVE ADDITIONAL SERVICES BEYOND THE BUDGETED AMOUNT, THIS WOULD BE APPROVED BY THE BOARD OF DIRECTORS UNDER THE CHARITABLE GIVING POLICY OF UPLAND HILLS HEALTH. PATIENTS OF THE FREE CLINIC MAY ALSO QUALIFY FOR ADDITIONAL SERVICES UNDER THE HOSPITAL'S CHARITY CARE POLICY AT FREE OR REDUCED RATES DEPENDING ON INDIVIDUAL NEEDS. THESE TWO POLICIES ALLOW UPLAND HILLS HEALTH THE ABILITY TO PROVIDE A CONTINUUM OF CARE TO THOSE IN NEED. X X X 0 0 0 0 0 0 0 0 0 PHYLLIS FRITSCH 191143 0 0 0 6069 0 7855 0 19150 0 224217 0 0 0 ARTHUR K PUSTINA 127533 0 0 0 1082 0 5192 0 21190 0 154997 0 0 0 BARBARA HOSTETLER 419548 0 0 0 1805 0 9800 0 17370 0 448523 0 0 0 ADAM DACHMAN 379553 0 0 0 966 0 0 0 10242 0 390761 0 0 0 JEFF PIERCE 271578 0 0 0 2772 0 9800 0 21816 0 305966 0 0 0 DONALD HART 256670 0 0 0 629 0 8250 0 22693 0 288242 0 0 0 ROBERT SCHMUS 265309 0 0 0 2772 0 9233 0 14875 0 292189 0 0 0 A WISCONSIN HEALTH AND EDUCATIONAL FACILITIES AUTHORITY 391337855 977104K98 2006-10-03 20825012 CONSTRUCTION & RENOVATION OF HOSPITAL FACILITIES 0 0 0 B WISCONSIN HEALTH AND EDUCATIONAL FACILITIES AUTHORITY 391337855 97710VN93 2006-10-03 10300000 CONSTRUCTION & RENOVATION OF HOSPITAL FACILITIES 0 0 0 A 2875000 20825012 1351698 9340920 414461 9717934 2009 0 1 1 1 B 650000 10300000 225810 10074190 2009 0 0 1 1 A 0 0 0 0 0.00000 0.00000 0.00000 0 0 0 B 0 0 0 0 0.00000 0.00000 0.00000 0 0 0 A 0 0 0 1 0 0 0 0 0 B 1 0 0 0 0 0 A 0 B 0 SCHEDULE K PART IV, ARBITRAGE, LINE 2C DATE REBATE COMPUTATION PERFORMED ISSUER NAME: WISCONSIN HEALTH AND EDUCATIONAL FACILITIES AUTHORITY DATE THE REBATE COMPUTATION WAS PERFORMED: 05/15/2010 X LEADERSHIP AND PROFESSIONAL DEVELOPMENT TRAINING 1 31192 FAIR MARKET VALUE 0 1 1 THIRD PARTY USE: PART I, LINE 32B: UPLAND HILLS HEALTH, INC. USES A RELATED PARTY, UPLAND HILLS HEALTH FOUNDATION, INC., TO SOLICIT NON-CASH CONTRIBUTIONS. UPLAND HILLS HEALTH FOUNDATION, INC. SOLICITS GIFTS, BEQUESTS, AND GRANTS OF REAL OR PERSONAL PROPERTY FROM INDIVIDUALS, ESTATES, TRUSTS, ASSOCIATIONS, CORPORATIONS, AND OTHER ENTITIES TO FURTHER THE MISSION OF UPLAND HILLS HEALTH, INC. FORM 990, PART VI, SECTION A, LINE 2 LINDA TAPLIN STATZ AND TODD BURCHILL ARE MEMBERS OF THE BOARD OF DIRECTORS AND REPRESENT SSM HEALTHCARE OF WISCONSIN. THESE INDIVIDUALS ARE EMPLOYEES OF SSM HEALTHCARE OF WISCONSIN AND SERVE ON THE BOARD AT UPLAND HILLS HEALTH, INC. AS A PART OF THE AFFILIATION AGREEMENT BETWEEN UPLAND HILLS HEALTH, INC. AND SSM WISCONSIN, INC. (A NON-PROFIT CORPORATION WHICH OPERATES ST. MARY'S HOSPITAL IN MADISON, WISCONSIN.) FORM 990, PART VI, SECTION A, LINE 6 SSM HEALTHCARE OF WISCONSIN, INC., UNDER THE TERMS OF THE AFFILIATION AGREEMENT DATED SEPTEMBER 21, 2011, HOLDS A 17.39% EQUITY INTEREST IN UPLAND HILLS HEALTH, INC. FORM 990, PART VI, SECTION A, LINE 7A SSM HEALTHCARE OF WISCONSIN, INC. CAN APPOINT TWO MEMBERS TO THE UPLAND HILLS HEALTH, INC. BOARD OF DIRECTORS. FORM 990, PART VI, SECTION A, LINE 7B THE FOLLOWING DECISIONS BY THE BOARD SHALL REQUIRE BOTH THE APPROVING VOTE OF A MAJORITY OF THE ENTIRE BOARD AND THE APPROVAL OF SSM HEALTHCARE OF WISCONSIN, INC.: (I) APPROVAL OF ANY AMENDMENT OR RESTATEMENT AFFECTING ARTICLE TWELFTH OF THE ARTICLES OF INCORPORATION. (II) APPROVAL OF ANY AMENDMENT OR RESTATEMENT AFFECTING SECTION 1.4, SECTION 2.2, SECTION 2.6, SECTION 3.7, SECTION 5.2, OR ARTICLE X OF THE CORPORATE BYLAWS OF UPLAND HILLS HEALTH, INC. FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 IS REVIEWED BY THE VICE PRESIDENT OF FINANCE AND THE BOARD OF DIRECTORS PRIOR TO SUBMISSION. FORM 990, PART VI, SECTION B, LINE 12C UPLAND HILLS HEALTH, INC. REQUIRES ALL OFFICERS, DIRECTORS, TRUSTEES, KEY EMPLOYEES, AND HIGHEST-COMPENSATED EMPLOYEES TO COMPLETE AN ANNUAL DISCLOSURE STATEMENT. THESE STATEMENTS ARE THEN REVIEWED BY THE BOARD OF DIRECTORS, NOTING ANY RELATIONSHIPS THAT COULD POTENTIALLY CREATE A CONFLICT OF INTEREST. IF BOARD MEMBERS HAVE CONFLICTS THAT ARE NOTED, THESE MEMBERS ARE ASKED TO ABSTAIN FROM VOTING ON THOSE MATTERS. CONFLICTS NOTED BY EMPLOYEES ARE REVIEWED BY THE BOARD OF DIRECTORS TO ENSURE THAT ALL TRANSACTIONS ARE CONDUCTED AT ARMS LENGTH. FORM 990, PART VI, SECTION B, LINE 15 THE BOARD OF DIRECTORS HAS AN ESTABLISHED PROCESS TO REVIEW THE COMPENSATION OF OFFICERS, DIRECTORS, TRUSTEES, KEY EMPLOYEES, AND HIGHEST COMPENSATED EMPLOYEES AND TO DEFINE COMPENSATION PRACTICES. COMPARATIVE DATA FROM WAGE SURVEYS, AREA LABOR ADJUSTMENTS, AND MARKET RATES IN OTHER AREA FACILITIES ARE USED IN DETERMINING COMPENSATION. THE EXECUTIVE COMMITTEE OF THE BOARD OF DIRECTORS REVIEWS AND APPROVES ANY EXCEPTIONS TO ACROSS-THE-BOARD RAISES AND STANDARD NEW HIRE WAGES. DURING THE REVIEW PROCESS, DECISIONS AFFECTING COMPENSATION AND CONTRACTS ARE ONLY REVIEWED AND APPROVED BY INDIVIDUALS WHO DO NOT HAVE NOTED CONFLICTS. THE DECISIONS AND DELIBERATION ARE ALSO DOCUMENTED FOR KEY EMPLOYEES AND EXECUTIVES (WHICH MAINLY INCLUDE THE HIGHLY COMPENSATED EMPLOYEES OF THE ORGANIZATION) IN THE MINUTES OF THE BOARD OF DIRECTORS UPON APPROVAL BY THE BOARD. FORM 990, PART VI, SECTION C, LINE 19 UPLAND HILLS HEALTH, INC. MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST AT ITS BUSINESS LOCATION DURING NORMAL BUSINESS HOURS. OTHER FEES FORM 990, PART IX, LINE 11G OTHER FEES: PROGRAM SERVICE EXPENSES 4,385,775. MANAGEMENT AND GENERAL EXPENSES 523,801. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 4,909,576. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 9: INCREASE IN EQUITY OF INVESTMENTS IN UNCONSOLIDATED AFFILIATES 72,312. FORM 990, PART XI, LINE 2C, SELECTION OF INDEPENDENT ACCOUNTANT: THE BOARD OF DIRECTORS ASSUMES RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT OF THE FINANCIAL STATEMENTS BY AN INDEPENDENT ACCOUNTANT. THE BOARD OF DIRECTORS OF UPLAND HILLS HEALTH, INC. ALSO APPROVES THE SELECTION OF THE INDEPENDENT AUDITORS AND HISTORICALLY HAS USED A PROCESS OF SOLICITATION OF SEALED BIDS FROM INDEPENDENT AUDIT FIRMS WITH HEALTHCARE AUDIT EXPERIENCE EVERY FIVE YEARS SO THAT THE AUDIT FIRM REVIEW IS DONE ON A REGULAR BASIS. THIS PROCESS AND PROCEDURES HAVE NOT CHANGED IN THE CURRENT YEAR. FORM 990, PART VI, SECTION B, LINE 16B: UPLAND HILLS HEALTH, INC. DOES NOT HAVE A WRITTEN POLICY REGARDING THE EVALUATION OF PARTICIPATION IN JOINT VENTURE ARRANGEMENTS; HOWEVER, ALL POTENTIAL JOINT VENTURE ARRANGEMENTS ARE REVIEWED BY UPLAND HILLS HEALTH, INC.'S LEGAL COUNSEL PRIOR TO PARTICIPATION. THE LEGAL COUNSEL REVIEWS POTENTIAL JOINT VENTURE ARRANGEMENTS FOR COMPLIANCE WITH THE UPLAND HILLS HEALTH, INC. CORPORATE BY-LAWS AND ALSO REVIEWS FOR COMPLIANCE WITH APPLICABLE FEDERAL TAX LAW TO ENSURE THE SAFEGUARDING OF THE ORGANIZATION'S TAX EXEMPT STATUS. UPON LEGAL COUNSEL CONSENT, UPLAND HILLS HEALTH, INC. WILL PROCEED WITH A FORMAL WRITTEN AGREEMENT FOR ALL JOINT VENTURE ARRANGEMENTS. 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