2014-03-17T11:51:29-05:00 2013-04-30 390758449 WIPFLI LLP 7601 FRANCE AVENUE SOUTH SUITE 400 MINNEAPOLIS MN 55435 990 2012-05-01 390908320 AMERY REGIONAL MEDICAL CENTER INC AMER 7152688000 265 GRIFFIN STREET EAST AMERY WI 54001 MICHAEL KARUSCHAK JR 7152688000 2014-03-14 1 TIM A RITTER CPA P00732856 9525483400 2014-03-14 2012 2016-03-07 17:11:31Z MICHAEL KARUSCHAK JR 265 GRIFFIN STREET EAST AMERY WI 54001 52536143 0 X WWW.AMERYMEDICALCENTER.ORG X 1998 WI TO PROVIDE CONVENIENT, QUALITY HEALTHCARE SERVICES TO ALL PEOPLE IN A CARING, EFFICIENT AND FINANCIALLY RESPONSIBLE MANNER THAT WILL ENHANCE THE QUALITY OF LIFE IN OUR COMMUNITY; TO PROMOTE COMMUNITY WELLNESS; AND, TO DO SO WITH COMPASSION, DIGNITY AND RESPECT FOR THOSE WE SERVE. 12 10 540 40 0 0 49655 146624 51948450 51291839 234131 59099 -126035 938573 52106201 52436135 90435 49754 0 0 22649882 21080450 0 0 0 29688558 30865977 52428875 51996181 -322674 439954 60799357 60240421 42155485 40761461 18643872 19478960 X AMERY REGIONAL MEDICAL CENTER (ARMC) IS COMMITTED TO PROVIDE ACCESSIBLE, COMPREHENSIVE, QUALITY HEALTHCARE AND TO PROMOTE THE HEALTH AND WELLNESS OF OUR COMMUNITY. 0 0 39432910 49754 51790510 AMERY REGIONAL MEDICAL CENTER (ARMC), A 25-BED CRITICAL ACCESS HOSPITAL WITH A 10 BED GERIATRIC PSYCH DISTINCT PART UNIT, WHICH PROMOTES HEALTH OF THE COMMUNITY BY PROVIDING A VARIETY OF HEALTH CARE SERVICES. IN ADDITION, THERE ARE 6 INFANT BEDS. AMERY REGIONAL MEDICAL CENTER HAD 1,128 ADMISSIONS IN 2013; 127 LIVE BIRTHS; 5,431 VISITS TO THE EMERGENCY CENTER; AND 1,786 SURGICAL CASES (INCLUDING AMBULATORY).ADDITIONAL PROGRAMS WHICH BENEFIT THE COMMUNITY INCLUDE:HEALTH PROFESSIONS TRAINING: STUDENTS IN NURSING, PHYSICIAN ASSISTANT PROGRAMS, PHYSICAL THERAPY, MEDICAL RECORDS, MEDICAL ASSISTANT, LAB TECHNICIAN, NURSE PRACTITIONERS, AND MEDICAL ADMINISTRATIVE ASSISTANTS STUDY AT THE MEDICAL CENTER. WE ALSO HAVE AN AGREEMENT WITH UW MADISON FOR 4TH YEAR MEDICAL STUDENTS AND UM-DULUTH FOR FIRST YEAR MED STUDENTS.PREVENTIVE CARE A PRIORITY: AMERY REGIONAL MEDICAL CENTER HAS TAKEN STEPS TO ENHANCE PREVENTIVE CARE FOR PEOPLE OF ALL AGES THROUGH THE DEVELOPMENT OF GUIDELINES TO ENSURE THAT THOSE WHO COME HERE FOR PREVENTIVE CARE RECEIVE THE SCREENINGS AND RECOMMENDATIONS APPROPRIATE TO THEIR PERSONAL AND FAMILY HISTORY.COMMUNITY RELATIONS: ARMC REACHES OUT TO PEOPLE AND COMMUNITIES THROUGHOUT POLK COUNTY, PARTS OF BARRON, BURNETT, AND ST. CROIX COUNTIES THROUGH COMMUNITY RELATIONS. ARMC'S CONCERN FOR THE GROWTH AND DEVELOPMENT OF THE SURROUNDING COMMUNITIES AS WELL A AS INDIVIDUAL WELFARE IS DEMONSTRATED BY PROVIDING EDUCATION AND RESOURCES TO ENCOURAGE POSITIVE COMMUNITY RELATIONS. IMPLEMENTATION OF VARIOUS PROGRAMS IS SPECIFICALLY INTENDED TO IMPROVE THE QUALITY OF LIFE IN THE COMMUNITIES WE SERVE. EXAMPLES INCLUDE DRUG AWARENESS PROGRAMS, RADIO HEALTH PROGRAMS, HEALTH FAIRS, LOCAL FOOD SHELF DONATIONS, CHILDREN'S SAFETY EVENTS, SCHOLARSHIPS TO SEVEN AREA HIGH SCHOOLS, VARIOUS SPONSORSHIPS, AND INVOLVEMENT IN THE AMERICAN CANCER SOCIETY ANNUAL 'WALK FOR LIFE' AS WELL AS ANNUAL INVOLVEMENT AND SPONSORSHIP IN THE ALZHEIMER'S ASSOCIATION "MEMORY WALK", AND ADOPT-A-FAMILY PROGRAM FOR FAMILIES IN NEED. PARTNERSHIPS WITH SCHOOLS, CHURCHES AND OTHER ORGANIZATIONS MAKE MANY OF THESE PROGRAMS POSSIBLE. FOR EXAMPLE, ARMC IS A STRONG ADVOCATE AND MEMBER OF THE ST. CROIX VALLEY SART (SEXUAL ASSAULT RESPONSE TEAM), WHICH FORMED IN ORDER TO HELP THOSE WHO HAVE EXPERIENCED ACUTE RAPE TRAUMA OR DOMESTIC ABUSE. TWO MEMBERS OF ARMC MEDICAL STAFF DONATED THEIR TIME AND SERVICES IN HAITI AND JAMAICA WHILE ARMC PROVIDED NEEDED PHARMACEUTICAL SUPPLIES TO AID THEIR EFFORTS. ARMC STAFF AND EMPLOYEES ALSO DONATE BLOOD TO THE AMERICAN RED CROSS BI-ANNUALLY. (SEE COMMUNITY EDUCATION FOR ADDITIONAL PROGRAMS/EDUCATION).IN ADDITION, STAFF AND EMPLOYEES DONATE MONTLY PROCEEDS COLLECTED FROM THE DENIM DAY INITIATIVE WHICH GIVES BACK TO LOCAL AREA AND NON-PROFIT ORGANIZATIONS LIKE LOCAL FOOD SHELVES, AMERICAN HEART ASSOCIATION, ARNELL HUMANE SOCIETY, AND ACS. HEALTH AND WELLNESS INFORMATION IS READILY AVAILABLE TO THE COMMUNITIES THROUGH BROCHURES, POSTERS, AND HEALTH INFORMATION VIA COMPUTER SOFTWARE AND THE ARMC WEBSITE. THE MEDICAL CENTER HAS A COMPUTER AVAILABLE IN THE WAITING AREAS FOR PATIENTS THAT PROVIDE EDUCATIONAL INFORMATION VIA SOFTWARE AND THROUGH INTERNET ACCESS. THERE ARE VARIOUS AREAS THROUGHOUT THE FACILITIES WHERE THIS INFORMATION IS AVAILABLE. DISEASE SPECIFIC INFORMATION ON BREAST CANCER, DEPRESSION, DIABETES, COLON CANCER, AUTISM, HEALTHY LIVING, ETC. ARE PROMOTED AND COINCIDE WITH THE HEALTH OBSERVANCES CALENDAR. IN ADDITION, KNOWLEDGE AND AWARENESS ON HEALTH-RELATED ISSUES ARE ADDRESSED IN A COMMUNITY NEWSLETTER DELIVERED QUARTERLY TO OVER 34,000 HOMES.COMMUNITY EDUCATION: ARMC HELPS EDUCATE THE LOCAL COMMUNITIES IN REGARDS TO HEALTH ISSUES BY PROVIDING THE FOLLOWING TYPES OF COMMUNITY EDUCATION: ASTHMA, BREASTFEEDING, CPR, CARDIAC SUPPORT, DIABETES, EXPECTANT PARENTS, HEALTH FAIRS, NUTRITION COUNSELING, PRENATAL, SMOKING CESSATION, AND SPORTS MEDICINE. THE MEDICAL CENTER ALSO WORKS CLOSELY WITH LOCAL AND COUNTY REPRESENTATIVES TO INFORM THE COMMUNITY ABOUT GOVERNMENTAL BENEFITS AND PROGRAMS AVAILABLE. THE MEDICAL CENTER PROVIDES EDUCATION AT OUR SCHOOLS BY HOLDING A 3RD GRADE HEALTH FAIR, 6TH GRADE & 8TH GRADE EDUCATIONAL SESSIONS, AND MEDICAL PROFESSIONAL SPEAKERS AT HEALTH CAREERS DAY FOR HIGH SCHOOL STUDENTS AND FOR HEALTH EDUCATION IN MIDDLE SCHOOL.CHARITY CARE: ARMC PROVIDES MEDICAL CARE TO MEMBERS OF THE COMMUNITY REGARDLESS OF ABILITY TO PAY. CHARITY CARE IN THE AMOUNT OF $1,536,071 WAS PROVIDED IN THE CURRENT YEAR. COMMUNITY BENEFITS: ARMC ESTIMATES THE COST OF THE PROVISION OF ADDITIONAL COMMUNITY BENEFITS TO BE $70,461.61 INCLUDING DONATIONS TO VARIOUS LOCAL CHARITABLE ORGANIZATIONS AND CIVIC GROUPS AND SCHOLARSHIPS TO NON-EMPLOYEES. ARMC HAS A HEALTH BENEFITS COUNSELOR WHICH HAS HELPED 84 UNINSURED PATIENTS WITH 402 APPLICATIONS RECEIVED FREE DRUGS AT AN AWP OF $227,597. ARMC IS ALSO COMMITTED TO PROVIDE FOR THE MENTAL HEALTH OF THE COMMUNITY BY ENSURING THAT SERVICES ARE PROVIDED IN AMERY. THE MEDICAL CENTER HAS A COURTESY VAN AVAILABLE TO PATIENTS IN NEED OF TRANSPORT FOR THEIR MEDICAL NEEDS. 39432910 1 1 0 1 0 0 0 0 0 0 1 1 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 1 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 41 0 540 1 0 0 0 0 0 0 0 0 0 0 X 12 10 0 1 0 0 1 1 1 1 0 0 0 0 1 1 1 1 1 0 0 0 X SCOTT EDIN CHIEF FINANCIAL OFFICER 7152688000 265 GRIFFIN STREET EAST AMERY WI 54001 DYLAN COE MD 1.00 1.00 X 1200 0 0 DAN DRAXLER 1.00 1.00 X 0 0 0 HEIDI ERSPAMER 1.00 1.00 X 1200 0 0 BETH HEINZ 1.00 1.00 X 0 0 0 KATHRYN ISAKSON 1.00 1.00 X 26832 0 597 NANCY MAGNINE PAC 1.00 1.00 X 0 0 0 RANAE NYGAARD 1.00 1.00 X 105904 0 9461 MARYANN SCOGLIO 1.00 1.00 X 1200 0 0 ANN SEAGREN MD 1.00 1.00 X 0 0 0 JOHN C WHITE 1.00 1.00 X 1200 0 0 DANIEL LIEN 1.00 1.00 X 1200 0 0 JAMES LEADHOLM 1.00 1.00 X X 1200 0 0 MICHAEL JENSON 1.00 1.00 X X 1200 0 0 ROSS BULLARD 1.00 1.00 X X 0 0 0 JOAN BYRNES 1.00 1.00 X X 1200 0 0 MIKE KARUSCHAK 40.00 1.00 X 255492 0 74460 SCOTT EDIN 50.00 1.00 X 170235 0 43540 JOYCE SCHAEFER 40.00 0.00 X 128347 0 21290 MARK TRYGGESTAD 40.00 0.00 X 143454 0 4703 SANDRA REED 40.00 0.00 X 114159 0 21183 MARK MOIOFFER 40.00 0.00 X 108752 0 12011 1062775 0 187245 7 0 1 0 GROUP HEALTH INC PO BOX 64059 ST PAUL MN 55164 PHYSICIAN SERVICES 8601122 QUORUM HEALTH RESOURCES 105 CONTINENTAL PLACE BRENTWOOD TN 37027 MANAGEMENT SERVICES 799141 ANESTHETISTS INC 130 S KNOWLES AVENUE NEW RICHMOND WI 54017 CRNAS 781595 DERRICK CONSTRUCTION 1505 HWY 65 NEW RICHMOND WI 54017 GENERAL CONTRACTOR 459835 HEALOGICS WOUND CARE 3087 MOMENTUM PLACE CHICAGO IL 60689 WOUND HEALING MANAGEMENT 370794 13 500 10902 120000 15222 146624 NET PATIENT SERVICE REVENUE 621110 50218819 50218819 OTHER OPERATING REVENUE 900099 896431 896431 FITNESS CENTER REVENUE 624110 156846 156846 CONTRACT SERVICE REVENUE 900099 19743 19743 51291839 143985 143985 140409 0 140409 140409 140409 15122 100008 -84886 -84886 -84886 EHR INCENTIVE 900099 498671 498671 CAFETERIA & OTHER SERVICES 900099 299493 299493 798164 52436135 51790510 0 499001 X 42754 42754 7000 7000 133592 50681 82911 16663702 12637433 4026269 245325 186050 59275 2579220 1956031 623189 1458611 1106183 352428 799141 799141 82504 8316 74188 48630 48630 11774069 9777020 1997049 285293 238304 46989 4374933 3317866 1057067 1545794 52470 1493324 1480160 1122525 357635 141743 107495 34248 65237 49474 15763 1415930 1073814 342116 4101631 3110599 991032 147043 111515 35528 DRUG EXPENSE 1987785 1987785 MEDICAL EQUIPMENT 1239750 1239750 BAD DEBT EXPENSE 905203 905203 FOOD EXPENSE 242742 242742 228389 101900 126489 51996181 39432910 12563271 0 180645 1438294 4230265 5459052 8168872 7784010 669222 671069 91509 46868 59106096 25498591 35773527 33607505 7142325 4438100 3956262 6253246 46297 35404 540433 506873 60799357 60240421 4976876 4688918 36990952 36041698 187657 30845 42155485 40761461 X 18559832 19394920 84040 84040 18643872 19478960 60799357 60240421 X 439954 -1753 396887 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 2203 2203 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: A PERCENTAGE OF MEMBERSHIP DUES PAID TO WISCONSIN HOSPITAL ASSOCIATION AND AMERICAN HOSPITAL ASSOCIATION IS FOR LOBBYING EXPENSES. WISCONSIN HOSPITAL ASSOCIATION LOBBIES TO PROMOTE POLICIES THAT HELP IMPROVE THE DELIVERY OF HOSPITAL CARE IN WISCONSIN AND OPPOSE POLICIES THAT NEGATIVELY IMPACT THAT CARE DELIVERY. AMERICAN HOSPITAL ASSOCIATION WORKS ON KEY ISSUES INCLUDING MEDICARE, ACCESS AND COVERAGE, AFFORDABILITY, AND OTHER ISSUES AFFECTION HOSPITALS. 1028135 1028135 27677488 9788603 17888885 29072253 14954079 14118174 1328220 755909 572311 33607505 CERTIFICATES OF DEPOSIT 2099165 C INVESTMENT MONEY MARKET NATIONAL MORTGAGES 2049106 C INVESTMENT IN CMDI 1118558 C INVESTMENT IN JOHNSON DRUGS 64398 C INVESTMENT IN ASSISTED LIVING 283102 C INVESTMENT IN AMERY DIALYSIS 333035 C INVESTMENT IN CANCER CENTER OF WI 305882 C 6253246 CAPITAL LEASE OBLIGATIONS 30845 30845 X 51959142 -1753 -475240 -476993 52436135 0 52436135 51090978 0 51090978 905203 905203 51996181 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 TAX 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 FINANCIAL STATEMENTS. MANAGEMENT DOES NOT BELIEVE THE HOSPITAL HAS ANY MATERIAL UNCERTAIN TAX POSITIONS OR UNRECOGNIZED TAX BENEFITS. THE HOSPITAL RECORDED NO ASSETS OR LIABILITIES FOR UNCERTAIN TAX POSITIONS OR UNRECOGNIZED TAX BENEFITS IN 2012 AND 2011. FEDERAL RETURNS FOR TAX YEARS 2008 AND BEYOND REMAIN SUBJECT TO EXAMINATION BY THE INTERNAL REVENUE SERVICE. PART XI, LINE 2D - OTHER ADJUSTMENTS: UNREALIZED GAIN ON INVESTMENTS IN UNCONSOLIDATED AFFILIATES 396,887. PROVISION FOR BAD DEBT -905,203. REVENUE OF CONSOLIDATED ENTITY 33,076. PART XII, LINE 4B - OTHER ADJUSTMENTS: PROVISION FOR BAD DEBT 905,203. 1 1 X 1 X 1 X 1 1 1 0 1 1 1177407 1177407 0.02300 5713971 3354239 2359732 0.04620 6891378 3354239 3537139 0.06920 16396 795 15601 0.00030 13111 13111 0.00030 33446 8304 25142 0.00050 62953 9099 53854 0.00110 6954331 3363338 3590993 0.07030 0 547055 410292 15384987 20651933 -5266946 X 1 1 2 1 AMERY REGIONAL MEDICAL CENTER

265 GRIFFIN STREET EAST AMERY WI 54001

X X X X 2 ARMC WEST CAMPUS

230 DERONDA STREET AMERY WI 54001

X X X AMERY REGIONAL MEDICAL CENTER 1 1 X X X X X X X X 12 1 1 1 X X X X X X X X 1 0 1 1 100.000000000000 1 200.000000000000 1 X X X X X X 1 1 X X 1 0 X X X X 1 X 0 0 ARMC WEST CAMPUS 2 1 X X X X X X X X 12 1 1 1 X X X X X X X X 1 0 1 1 100.000000000000 1 200.000000000000 1 X X X X X X 1 1 X X 1 0 X X X X 1 X 0 0 5 ARMC REHAB SERVICES

220 N KELLER AVENUE AMERY WI 54001

REHABILITATION LUCK MEDICAL CLINIC

137 FIRST AVENUE LUCK WI 54853

RURAL HEALTH CLINIC TURTLE LAKE MEDICAL CLINIC

550 MARTIN AVENUE TURTLE LAKE WI 54889

CLINIC CLEAR LAKE CLINIC

357 THIRD AVENUE CLEAR LAKE WI 54005

CLINIC LUCK PT & FITNESS

2547 STATE ROAD 35 SUITE 5 LUCK WI 54853

PHYSICAL THERAPY PART I, LINE 7: THE ORGANIZATION USES A COST TO CHARGES METHODOLOGY AS DETERMINED BY WORKSHEET 2 OF THE INSTRUCTIONS. 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 $ 905203. PART II: ARMC PROMOTES THE HEALTH OF THE COMMUNITY IT SERVICES IN A VARIETY OF WAYS. SOME WAYS, AS DESCRIBED BELOW, ARE TOO BURDENSOME TO RECORD EXACT AMOUNTS ADMINISTRATIVELY. HOWEVER, THAT DOES NOT DIMINISH THE VALUE THESE ACTIVITIES SERVE. ARMC PROVIDES A VARIETY OF PATIENT EDUCATION PROGRAMS THAT PROMOTE HEALTHY LIFESTYLES & WE PROVIDE A COMMUNITY FITNESS CENTER FOR OUR AREAS. THE COMMUNITY FITNESS CENTER'S ELIGIBILITY REQUIREMENTS ARE:1.MUST PROVIDE A REFERRAL FROM A PROVIDER OR SCHOOL.2.INDIVIDUAL MUST WORK OUT 10 TIMES A MONTH.3.A MINIMUM FEE WILL BE REQUIRED BY THE INDIVIDUAL THE FIRST VISIT OF EACH MONTH TO CONTINUE WORKING OUT FOR AN ENTIRE MONTH. THE FEE WILL BE BASED ON ABILITY TO PAY AND AT THE DISCRETION OF THE DIRECTOR OF REHAB. 4.THE MONTHLY CHARGE FOR A MEMBERSHIP IS $40. THE HOSPITAL WILL SUPPLEMENT THE REMAINDER OF THE AMOUNT DUE FOR THE MEMBERSHIP AFTER THE MEMBER PAYS THEIR FEE.5.QUALIFICATIONS ARE BASED UPON THE 90% COLUMN ON A CURRENT YEAR ARMC ASSISTANCE PROGRAM ALLOWANCE CHART.6.A COPY OF LAST YEAR'S TAX RETURN OR A LETTER FROM THE SCHOOL INDICATING REDUCED OR FREE LUNCH QUALIFICATION WITH THE AMOUNTS.7.COMPLETE ALL THE FITNESS CENTER REQUIRED PAPERWORK FOR MEMBERSHIP, AND IF UNDER AGE MUST HAVE PARENT OR GUARDIAN SIGNATURES.8.COMPLETE AN APPLICATION FOR FINANCIAL ASSISTANCE FOR THE FITNESS CENTER. PART III, LINE 4: ARMC USES THE COST TO CHARGE COST METHODOLOGY TO DETERMINE AMOUNT REPORTED AS BAD DEBT. ARMC BELIEVES THAT MANY OF THE ACCOUNTS IN BAD DEBT WOULD HAVE QUALIFIED FOR CHARITY CARE IF THE GUARANTORS WOULD HAVE COMPLETED THE FINANCIAL ASSISTANCE PAPERWORK. ARMC IS PROVIDING SERVICES TO INDIVIDUALS/FAMILIES IN OUR SERVICE AREA WHO ARE UNABLE/UNWILLING TO PAY FOR THESE SERVICES. THIS IS COMPARABLE TO PROVIDING CHARITY CARE WHICH WE ALSO INCLUDE AS A COMMUNITY BENEFIT.THE FINANCIAL STATEMENTS DO NOT HAVE A SEPARATE BAD DEBT FOOTNOTE. THE FOLLOWING IS PART OF THE PATIENT ACCOUNTS RECEIVABLE AND CREDIT POLICY FOOTNOTE: IN EVALUATING THE COLLECTABILITY OF PATIENT ACCOUNTS RECEIVABLE, THE HOSPITAL ANALYZES PAST RESULTS AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYER SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND PROVISION FOR BAD DEBTS. MANAGEMENT REGULARLY REVIEWS DATA ABOUT THESE MAJOR PAYER SOURCES OF REVENUE IN EVALUATING THE SUFFICIENCY OF THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. SPECIFICALLY, FOR RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRD-PARTY COVERAGE, THE HOSPITAL ANALYZES CONTRACTUALLY DUE AMOUNTS AND PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS AND A PROVISION FOR BAD DEBTS FOR EXPECTED UNCOLLECTIBLE DEDUCTIBLES AND COPAYMENTS ON ACCOUNTS FOR WHICH THE THIRD-PARTY PAYER HAS NOT YET PAID OR FOR PAYERS WHO ARE KNOWN TO BE HAVING FINANCIAL DIFFICULTIES THAT MAKE THE REALIZATION OF AMOUNTS DUE UNLIKELY. FOR RECEIVABLES ASSOCIATED WITH SELF-PAY PATIENTS (INCLUDING BOTH PATIENTS WITHOUT INSURANCE AND PATIENTS WITH DEDUCTIBLE AND COPAYMENT BALANCES DUE FOR WHICH THIRD-PARTY COVERAGE EXISTS FOR PART OF THE BILL), THE HOSPITAL RECORDS A SIGNIFICANT PROVISION FOR BAD DEBTS IN THE PERIOD OF SERVICE ON THE BASIS OF ITS PAST EXPERIENCE, WHICH INDICATES THAT MANY PATIENTS ARE UNABLE OR UNWILLING TO PAY THE PORTION OF THEIR BILL FOR WHICH THEY ARE FINANCIALLY RESPONSIBLE.THE DIFFERENCE BETWEEN THE STANDARD RATES (OR THE DISCOUNTED RATES IF NEGOTIATED) AND THE AMOUNTS ACTUALLY COLLECTED AFTER ALL REASONABLE COLLECTION EFFORTS HAVE BEEN EXHAUSTED IS CHARGED OFF AGAINST THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. PART III, LINE 8: THE COSTING METHODOLOGY USED IS COST TO CHARGE RATIO AS REQUIRED BY MEDICARE. THE SHORTFALL SHOULD BE TREATED AS COMMUNITY BENEFIT BECAUSE ARMC IS INCURRING THE COST OF PROVIDING SERVICES TO MEDICARE PATIENTS AND NOT GETTING PAID COMPLETELY BY MEDICARE FOR THE COST OF PROVIDING THESE SERVICES. PART III, LINE 9B: ARMC IS COMMITTED TO MEETING THE HEALTHCARE NEEDS OF THE COMMUNITY. AS PART OF THIS MISSION, WE ADMINISTER A FINANCIAL ASSISTANCE PROGRAM TO HELP PATIENTS WHO NEED MEDICAL CARE BUT HAVE DIFFICULTY WITH RELATED MEDICAL EXPENSES. IN OUR FACILITIES, NON-ELECTIVE PROFESSIONAL MEDICAL SERVICES WILL BE PROVIDED WITHOUT REGARD TO THE PATIENT'S ABILITY TO PAY AND FINANCIAL ASSISTANCE WILL BE MADE AVAILABLE. PROGRAM ELIGIBILITY IS BASED ON INCOME, ASSETS, LIABILITIES AND FAMILY SIZE UTILIZING A SLIDING DISCOUNT BASED ON THE LATEST HEALTH AND HUMAN/SERVICES (HHS) FEDERAL POVERTY GUIDELINES. PATIENTS IN NEED OF FINANCIAL ASSISTANCE ARE SENT AN APPLICATION AND FOLLOWED UP IN COORDINATION WITH THE HEALTH BENEFITS COUNSELOR. WE BELIEVE THAT MANY OF THE ACCOUNTS IN BAD DEBT WOULD HAVE QUALIFIED FOR CHARITY CARE IF THE GUARANTORS WOULD HAVE COMPLETED THE FINANCIAL ASSISTANCE PAPERWORK. AMERY REGIONAL MEDICAL CENTER PART V, SECTION B, LINE 3: THE CHNA USED A COMBINATION OF SURVEY'S TO DETERMINE THE LIFESTYLE AND PERCEIVED HEALTH OF THE COMMUNITY. THE ASSESSMENT INCLUDED PHONE SURVEYS, PAPER SURVEYS KEPT AT MEDICAL CENTERS, THROUGH THE MEDICAL CENTERS WEBSITES, AND SURVEYS MAILED DIRECTLY TO COMMUNITY MEMBERS. IN TOTAL, THE ASSESSMENT RECEIVED INPUT FROM 1,770 COMMUNITY MEMBERS TO DEVELOP 10 AREAS OF FOCUS. THERE WERE FOUR COMMUNITY FORUMS IN WHICH COMMUNITY MEMBERS IN ATTENDANCE OFFERED INPUT AND SUGGESTIONS ON THE 10 AREAS OF FOCUS. AT THE COMMENCEMENT OF EACH DISCUSSION, THOSE IN ATTENDENCE PLACED VOTES ON THE TOP 5 AREAS. FOLLOWING THESE OUTREACH ACTIVITIES, 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 COMMUNITY MEMBERS, AS WELL AS VOTING RESULTS FROM THE FORUMS. DURING THE MEETING, THIS GROUP COMPLETED A PAPER SURVEY TO CAST THEIR VOTES TO DETERMINE THE TOP THREE HEALTH FOCUS AREAS FOR THE COMMUNITY. THESE THREE AREAS DETERMINED WERE: 1. MENTAL HEALTH2. OBESITY3. ALCOHOL USE ARMC WEST CAMPUS PART V, SECTION B, LINE 3: THE CHNA USED A COMBINATION OF SURVEY'S TO DETERMINE THE LIFESTYLE AND PERCEIVED HEALTH OF THE COMMUNITY. THE ASSESSMENT INCLUDED PHONE SURVEYS, PAPER SURVEYS KEPT AT MEDICAL CENTERS, THROUGH THE MEDICAL CENTERS WEBSITES, AND SURVEYS MAILED DIRECTLY TO COMMUNITY MEMBERS. IN TOTAL, THE ASSESSMENT RECEIVED INPUT FROM 1,770 COMMUNITY MEMBERS TO DEVELOP 10 AREAS OF FOCUS. THERE WERE FOUR COMMUNITY FORUMS IN WHICH COMMUNITY MEMBERS IN ATTENDANCE OFFERED INPUT AND SUGGESTIONS ON THE 10 AREAS OF FOCUS. AT THE COMMENCEMENT OF EACH DISCUSSION, THOSE IN ATTENDENCE PLACED VOTES ON THE TOP 5 AREAS. FOLLOWING THESE OUTREACH ACTIVITIES, 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 COMMUNITY MEMBERS, AS WELL AS VOTING RESULTS FROM THE FORUMS. DURING THE MEETING, THIS GROUP COMPLETED A PAPER SURVEY TO CAST THEIR VOTES TO DETERMINE THE TOP THREE HEALTH FOCUS AREAS FOR THE COMMUNITY. THESE THREE AREAS DETERMINED WERE: 1. MENTAL HEALTH2. OBESITY3. ALCOHOL USE AMERY REGIONAL MEDICAL CENTER PART V, SECTION B, LINE 4: THE FOLLOWING HOSPITALS PARTICIPATED IN COMMUNITY HEALTH NEEDS ASSESSMENT: POLK COUNTY HEALTH DEPARTMENTAMERY REGIONAL MEDICAL CENTEROSCEOLA MEDICAL CENTERST. CROIX REGIONAL MEDICAL CENTER ARMC WEST CAMPUS PART V, SECTION B, LINE 4: THE FOLLOWING HOSPITALS PARTICIPATED IN COMMUNITY HEALTH NEEDS ASSESSMENT: POLK COUNTY HEALTH DEPARTMENTAMERY REGIONAL MEDICAL CENTEROSCEOLA MEDICAL CENTERST. CROIX REGIONAL MEDICAL CENTER AMERY REGIONAL MEDICAL CENTER PART V, SECTION B, LINE 5C: THE CHNA IS AVAILABLE ON THE ORGANIZATION'S WEBSITE: HTTP://WWW.AMERYMEDICALCENTER.ORG/AMERY2.NSF/VIEW/CHNA_2013THE CHNA IS ALSO AVAILABLE ON THE POLK COUNTY HEALTH DEPARTMENT WEBSITE: HTTP://HEALTHYPOLKCOUNTY.COM/COMMUNITY-HEALTH-NEEDS-ASSESSMENT/ ARMC WEST CAMPUS PART V, SECTION B, LINE 5C: THE CHNA IS AVAILABLE ON THE ORGANIZATION'S WEBSITE: HTTP://WWW.AMERYMEDICALCENTER.ORG/AMERY2.NSF/VIEW/CHNA_2013THE CHNA IS ALSO AVAILABLE ON THE POLK COUNTY HEALTH DEPARTMENT WEBSITE: HTTP://HEALTHYPOLKCOUNTY.COM/COMMUNITY-HEALTH-NEEDS-ASSESSMENT/ PART VI, LINE 2: THE ORGANIZATION COMPLETED A COMMUNITY HEALTH NEEDS ASSESSMENT IN COORDINATION WTIH THE POLK COUNTY HEALTH DEPARTMENT, OSCEOLA MEDICAL CENTER, AND ST. CROIX REGIONAL MEDICAL CENTER IN FISCAL YEAR 2013. THIS CHNA IDENTIFIED THE TOP TEN COMMUNITY NEEDS AND PROVIDES DETAILED STATISTICS BREAKING DOWN THOSE NEEDS AND THEIR EFFECT ON THE COMMUNITY IN RELATION WITH THE MEDICAL CENTER'S ROLE IN ADDRESSING THOSE NEEDS. PART VI, LINE 3: ARMC'S PATIENT FINANCIAL SERVICES DEPARTMENT WORKS WITH EACH PATIENT REGARDING ACCOUNT BALANCES LEFT TO PATIENT RESPONSIBILITY. PATIENTS WHO ARE NOT ALREADY ON GOVERNMENT ASSISTANCE OR HAVE LIMITED ASSISTANCE, ARE REFERRED TO OUR HEALTH BENEFITS COUNSELOR, WHO WORKS WITH THEM TO EVALUATE ASSISTANCE OPTIONS AND ASSISTS IN GETTING APPLICATIONS OR CONTACTS WITH THE APPROPRIATE PROGRAMS. IF ADDITIONAL ASSISTANCE IS NEEDED, THE COUNSELOR WILL WORK WITH THE PATIENT TO APPLY FOR FINANCIAL ASSISTANCE WITH THE MEDICAL CENTER AND HELPS THEM THROUGH THE PROCESS. THE FINANCIAL ASSISTANCE PROGRAM AND APPLICATION ARE LOCATED ON THE ARMC INTERNET SITE TO ALLOW PATIENTS DIRECT ACCESS TO THIS INFORMATION. PART VI, LINE 4: THE MEDICAL CENTER'S SERVICE AREA INCLUDES FIFTEEN DIFFERENT ZIP CODES IN NORTHWEST WISCONSIN THAT PRIMARILY REPRESENT POLK COUNTY. IT INCLUDES A RURAL HEALTH CLINIC IN LUCK, MEDICALLY UNDERSERVED AREA AND MENTAL HEALTH MEDICALLY UNDERSERVED AREA IN AMERY. THE WOUND CENTER & INPATIENT PSYCH SERVICE DRAWS PATIENTS FROM OUTSIDE OUR NORMAL SERVICE AREA. PART VI, LINE 5: TEN OF OUR TWELVE BOARD MEMBERS LIVE IN OUR SERVICE AREA. WE HAVE AN OPEN MEDICAL STAFF WHICH INCLUDES PROVIDERS FROM THE COMMUNITY, OTHER COMMUNITIES AS WELL AS THE TWIN CITIES. ANY SURPLUS FUNDS GENERATED ARE USED TO PURCHASE EQUIPMENT, BUILD NEW FACILITIES, AND EXPAND SERVICES AVAILABLE IN OUR COMMUNITY. PART VI, LINE 6: ARMC BECAME AFFILIATED WITH HEALTH PARTNERS MEDICAL GROUP IN 1998 WHEN HOSPITAL AND CLINIC SERVICES WERE MERGED. THE MERGER ELIMINATED DUPLICATIVE SERVICES THAT HAD BEEN PROVIDED BY BOTH ORGANIZATIONS. HEALTH PARTNERS MEDICAL GROUP IS A 12% OWNER IN ARMC. REPORTS FILED WITH STATES PART VI, LINE 7 WI 1 MENTAL HEALTH TASK FORCE OF POLK COUNTY PO BOX 432 ST CROIX FALLS WI 54024 271566890 501(C)(3) 7500 SUPPORT MENTAL HEALTH AWARENESS AND EDUCATION IN POLK COUNTY 1 0 STUDENT SCHOLARSHIPS 7 7000 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: EACH EMPLOYEE APPROVED FOR SCHOLARSHIP ASSISTANCE MUST SUBMIT ACTIVITY TO ARMC. EMPLOYEES SUBMIT GRADES AND RECEIPTS LINKED TO THEIR SCHOLARSHIP. ARMC ALSO GRANTS DONATIONS TO CERTAIN ORGANIZATIONS IN THE SERVICE AREA WHOSE MISSION AND PURPOSE IS ALIGNED WITH THAT OF ARMC. X X 1 0 0 0 0 0 0 0 0 MIKE KARUSCHAK 255492 0 0 0 0 0 0 0 74460 0 329952 0 0 0 SCOTT EDIN 170235 0 0 0 0 0 0 0 43540 0 213775 0 0 0 PART I, LINE 4A RANAE NYGAARD RECEIVED RETIREMENT PAY OF $40,698 IN FISCAL YEAR 2013. SUPPLEMENTAL INFORMATION PART III MICHAEL KARUSCHAK AND SCOTT EDIN ARE EMPLOYEES OF THE MANAGEMENT COMPANY QUORUM HEALTH RESOURCE. THEIR COMPENSATION INCLUDES SALARY AND BENEFITS PAID BY QUORUM HEALTH RESOURCE AND REIMBURSED BY AMERY REGIONAL MEDICAL CENTER. A VILLAGE OF LUCK WISCONSIN 396006307 2011-04-28 8500000 REFINANCING EXISTING INDEBTEDNESS 0 0 0 B CITY OF AMERY WISCONSIN 396005378 2011-04-13 8500000 REFINANCE EXISTING INDEBTEDNESS 0 0 0 C VILLAGE OF CLEAR LAKE WISCONSIN 396006238 2011-03-29 8500000 REFINANCE EXISTING INDEBTEDNESS 0 0 0 D TOWN OF BLACK BROOK POLK COUNTY WISCONSIN 391169876 2011-05-13 6150000 REFINANCE EXISTING INDEBTEDNESS 0 0 0 A 397628 8500000 170000 8330000 2007 1 0 1 1 B 397628 8500000 170000 8330000 2007 1 0 1 1 C 397628 8500000 170000 8330000 2007 1 0 1 1 D 282709 6150000 123000 6027000 2007 1 0 1 1 A 0 0 0 0 1 0 0 B 0 0 0 0 1 0 0 C 0 0 0 0 1 0 0 D 0 0 0 0 1 0 0 A 0 1 0 0 1 0 0 0 0 B 0 1 0 0 1 0 0 0 0 C 0 1 0 0 1 0 0 0 0 D 0 1 0 0 1 0 0 0 0 A 0 B 0 C 0 D 0 FORM 990, SCHEDULE K, PART IV, LINE 2A THRU 2C REBATE CALCULATION REBATE CALCULATION IS NOT DUE BUT EVERY 5 YEARS. THERE IS NO REBATE CACLULATION DUE FOR ANY BONDS LISTED IN SCHEDULE K, PART I. A TOWN OF LINCOLN POLK COUNTY WISCONSIN 391406159 2011-05-31 6150000 REFINANCE EXISTING INDEBTEDNESS 0 0 0 A 282709 6150000 123000 1709792 4317208 2007 1 0 1 1 A 0 0 0 0 1 0 0 A 0 1 0 0 1 0 0 0 0 A 0 FORM 990, PART VI, SECTION A, LINE 3 THE CEO AND CFO OF THE ORGANIZATION ARE EMPLOYED BY QUORUM HEALTH RESOURCES. THE BOARD OF DIRECTORS MAINTAINS ULTIMATE AUTHORITY, SUPERVISION, DIRECTION, AND CONTROL OVER THE BUSINESS, POLICIES, OPERATIONS AND ASSETS OF ARMC. THEIR DUTIES ARE TO EXECUTE AND PERFORM THE ADMINISTRATIVE FUNCTIONS OF ARMC AND ROUTINELY COMMUNICATE WITH THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION A, LINE 6 THE ORGANIZATION HAS TWO CORPORATE MEMBERS: GROUP HEALTH PLAN, INC. AND AMERY MEDICAL CENTER FOUNDATION INC. FORM 990, PART VI, SECTION A, LINE 7A TWO DIRECTORS ARE APPOINTED BY GROUP HEALTH PLAN, INC. SEVEN DIRECTORS SHALL BE COMMUNITY REPRESENTATIVES AND ARE APPOINTED BY AMERY REGIONAL MEDICAL CENTER FOUNDATION INC. THREE DIRECTORS ARE PHYSICIANS OR OTHER HEALTH CARE PROVIDERS. THESE DIRECTORS ARE NOMINATED BY THE PHYSICIAN GROUP STAFFING THE ORGANIZATION'S PRIMARY OUTPATIENT CLINIC AND ELECTED BY BOTH OF THE ORGANIZATION'S MEMBERS. FORM 990, PART VI, SECTION A, LINE 7B IN GENERAL, THE AFFAIRS OF THE ORGANIZATION ARE MANAGED BY THE BOARD OF DIRECTORS. HOWEVER, APPROVAL IS REQUIRED FROM THE MEMBERS FOR THE FOLLOWING ACTIONS: - THE MORTGAGE, LEASE, SALE, OR DISPOSITION OF ALL OR SUBSTANTIALLY ALL OF THE ORGANIZATION'S ASSETS - THE MERGER, CONSOLIDATION, OR DISSOLUTION OF THE ORGANIZATION - THE AMENDMENT OR RESTATEMENT OF THE ARTICLES OF INCORPORATION - THE AMENDMENT OF CERTAIN ARTICLES OF THE BYLAWS - THE APPROVAL OF AGREEMENTS BETWEEN THE ORGANIZATION AND GROUP HEALTH PLAN, INC. OR ANY OF ITS AFFILIATES FORM 990, PART VI, SECTION A, LINE 8B THE ORGANIZATION DOES NOT HAVE ANY COMMITTEES WITH AUTHORITY TO ACT ON BEHALF OF THE GOVERNING BODY. FORM 990, PART VI, SECTION B, LINE 11 FORM 990 IS REVIEWED BY THE ORGANIZATION'S SENIOR ACCOUNTANT, THEN THE CEO AND CFO PRIOR TO SUBMISSION TO THE INTERNAL REVENUE SERVICE. FORM 990, PART VI, SECTION B, LINE 12C AS PART OF THE PERFORMANCE REVIEW PROCESS, PERSONS ARE ASKED TO REVIEW THE CONFLICT OF INTEREST POLICY AND THEN COMPLETE A FORM AND SIGN. THE HUMAN RESOURCE DEPARTMENT ENSURES THE FORM IS RETURNED BY ALL STAFF AND REVIEWS THE FORMS. IF A POTENTIAL CONFLICT IS IDENTIFIED, THE COMPLIANCE OFFICER FOLLOWS UP. THE GOVERNING BOARD, CEO, AND CFO COMPLETE AND SIGN THE CONFLICT OF INTEREST FORM YEARLY. THE FORMS ARE REVIEWED BY THE BOARD SECRETARY AND IF A POTENTIAL CONFLICT IS IDENTIFIED, THE COMPLIANCE OFFICER FOLLOWS UP. BOARD MEMBERS WITH CONFLICTS ARE RESTRICTED FROM VOTING ON SUCH MATTERS. THE BOARD OF DIRECTORS APPROVES THE CONTRACT BETWEEN THE ORGANIZATION AND QUORUM HEALTH SERVICES FOR CEO AND CFO SERVICES. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. OTHER FEES FORM 990, PART IX, LINE 11G PROVIDER SERVICES : PROGRAM SERVICE EXPENSES 5,338,965. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 5,338,965. ER SERVICES : PROGRAM SERVICE EXPENSES 1,692,044. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,692,044. OTHER PROFESSIONAL SERVICES : PROGRAM SERVICE EXPENSES 2,746,011. MANAGEMENT AND GENERAL EXPENSES 1,997,049. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 4,743,060. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 9: UNREALIZED GAIN ON INVESTMENTS IN UNCONSOLIDATED AFFILIATES 396,887. FORM 990, PART XII, LINE 2C THE BOARD OF DIRECTORS OF THE ORGANIZATION ASSUMES RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT OF ITS FINANCIAL STATEMENTS AND SELECTION OF AN INDEPENDENT ACCOUNTANT. THIS PROCESS HAS NOT CHANGED FROM PRIOR YEAR. AMERY REGIONAL MEDICAL CENTER FOUNDATION 265 GRIFFIN STREET AMERY WI 54001 391726539 FUNDRAISING WI 501(C)(3) LINE 7 N/A 0 AMERY REGIONAL MEDICAL CENTER PHARMACY LLC 265 GRIFFIN STREET E AMERY WI 54001 390908320 PHARMACEUTICAL MN AMERY REGIONAL MEDICAL CENTER 25795 94983 0 1 0.50000 0 0 1 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0