2013-08-01T14:27:16-05:00 2012-09-30 390758449 WIPFLI LLP 3703 OAKWOOD HILLS PARKWAY EAU CLAIRE WI 54701 990 2011-10-01 390806404 VERNON MEMORIAL HEALTHCARE INC VERN 6086372101 507 SOUTH MAIN STREET VIROQUA WI 54665 MARY KOENIG 6086372101 2013-07-30 1 HOLLY POKRANDT CPA P00449155 7158323407 2013-07-30 2011 2016-02-24 21:20:13Z MARY KOENIG 507 SOUTH MAIN STREET VIROQUA WI 54665 70962945 0 X WWW.VMH.ORG X 1946 WI VERNON MEMORIAL HEALTHCARE HAS BEEN COMMITTED TO PROVIDING THE HIGHEST QUALITY CARE AND TREATMENT TO THE INJURED, AFFLICTED AND WELL PEOPLE WHO NEED THE RESOURCES WE HAVE AT OUR COMMAND, WITHOUT REGARD TO RACE, CREED, COLOR, SEX, HANDICAP, NATIONAL ORIGIN, OR ABILITY TO PAY. IT IS OUR INTENTION TO INSURE THAT IN EACH AND EVERY CASE OUR PATIENTS SHALL BE TREATED WITH COMPASSION, UNDERSTANDING AND DIGNITY. FURTHER, THE RIGHTS AND PRIVILEGES OF THE PEOPLE WE SERVE SHALL ALWAYS BE HELD IN THE HIGHEST REGARD, AND THEIR WELL-BEING MUST ALWAYS HAVE FIRST CONSIDERATION. VERNON MEMORIAL HEALTHCARE IS COMMITTED TO PROVIDING MODERN FACILITIES AND EQUIPMENT CONSISTENT WITH NEW AND CONTEMPORARY MEDICAL TECHNOLOGY. WE WILL FOSTER, STIMULATE, ENCOURAGE AND PROMOTE CONTINUING HEALTHCARE EDUCATION FOR EMPLOYEES AND THE COMMUNITY WE SERVE. ALL THIS, WE MOST SOLEMNLY AND SINCERELY PLEDGE TO THE PEOPLE WHO NEED US, RECOGNIZING FULLY, THAT SERVICE TO HUMANITY IS THE GREATEST SERVICE OF ALL. 11 11 559 200 4997367 -200270 620264 949517 66426192 66908887 619418 648129 239971 245357 67905845 68751890 257963 317912 0 0 31893997 31463148 0 0 0 28899693 30241849 61051653 62022909 6854192 6728981 78875894 86595072 32113444 31338140 46762450 55256932 X VERNON MEMORIAL HEALTHCARE, INC. WILL STRIVE TO HAVE THE VISION TO CONTINUALLY PROVIDE THE HIGHEST STANDARD OF CARE TO OUR PATIENTS AND THEIR FAMILIES WHILE BEING 'CLOSE TO HOME.' OUR MISSION IS TO PROVIDE COST-EFFECTIVE, ACCESSIBLE CARE AND SERVICE USING PROFESSIONALLY EDUCATED STAFF AND SUPERIOR TECHNOLOGY TO MEET THE HEALTH CARE NEEDS OF OUR COMMUNITY. OUR CARING AND COMMITMENT TO THE COMMUNITY WILL BE DEMONSTRATED BY OUR EMPHASIS ON HEALTH PROMOTION AND DISEASE PREVENTION THROUGH EDUCATION. 0 0 42747859 317912 49655325 WHILE THERE IS A GROWING AGREEMENT IN THE UNITED STATES ABOUT WHAT CONSTITUTES A NON-PROFIT HEALTHCARE ORGANIZATION'S COMMUNITY BENEFIT, THIS IS A WORK IN PROGRESS. OUR ORGANIZATION PROVIDES SIGNIFICANT CHARITY CARE AND OTHER COMMUNITY BENEFITS AS DEFINED BY THE IRS. BUT IN ADDITION, WE BELIEVE THAT WE PROVIDE A CRITICALLY IMPORTANT COMMUNITY BENEFIT WHICH CANNOT BE QUANTIFIED. OUR ORGANIZATION WAS CREATED AND IS MAINTAINED IN ORDER TO PROVIDE CARE LOCALLY-CARE THAT WITHOUT THE PRESENCE OF OUR ORGANIZATION, WOULD NOT BE AVAILABLE TO THE PEOPLE IN OUR SERVICE AREA.BEYOND MEDICAL, OBSTETRICAL, NEWBORN AND SURGICAL INPATIENT HOSPITALIZATIONS, WE PROVIDE LOCAL ACCESS TO MANY OTHER HEALTH SERVICES INCLUDING A BIRTHING CENTER, A DIALYSIS CENTER, DIAGNOSTIC SERVICES-LABORATORY, IMAGING AND CARDIAC TESTING, 24-HOUR EMERGENCY SERVICES, URGENT CARE SERVICES, INFUSION SERVICES, GASTROINTESTINAL SERVICES, HOME HEALTH CARE, HOSPICE, INPATIENT AND OUTPATIENT CARE, REHABILITATION SERVICES-PHYSICAL, OCCUPATIONAL, RESPIRATORY AND SPEECH THERAPY, SPECIALTY MEDICINE, AND PRIMARY CARE CLINICS.IN 2012, HOSPITAL INPATIENT SERVICES INCLUDED 3,594 ACUTE CARE PATIENT DAYS, 16 SWING BED PATIENT DAYS, AND 338 NEWBORN PATIENT DAYS. THERE WERE 1,499 SURGERY CASES, 6,002 EMERGENCY ROOM VISITS, AND 2,070 VISITS TO THE AFTER HOURS CLINIC. 11795728 11464232 A TOTAL OF 43,515 CLINIC VISITS OCCURRED IN FYE 2012 AT THE FOUR CLINICS LOCATED IN VIROQUA, LAFARGE, SOLDIERS GROVE, AND WESTBY. 1419652 791963 DURING FYE 2012, 2,054 HOME HEALTH VISITS WERE MADE TO 124 INDIVIDUALS. HOSPICE CARE WAS PROVIDED TO 79 INDIVIDUALS FOR A TOTAL OF 2,850 DAYS. 55963239 1 1 0 1 0 0 0 0 0 0 1 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 1 1 1 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 44 0 1 559 1 1 1 0 0 0 0 0 0 0 0 0 X 11 11 0 0 0 0 1 1 1 1 1 0 0 1 1 0 0 1 1 1 1 0 WI X MARY KOENIG 6086372101 507 SOUTH MAIN STREET VIROQUA WI 54665 PHYLLIS MALIN 1.00 X 0 0 0 TIM GASKELL 1.00 X 0 0 0 ENID NEUBAUER 1.00 X 0 0 0 JAMES LARSON 1.00 X X 0 0 0 CHET LEE 1.00 X X 0 0 0 RON MOILIEN 1.50 X X 0 0 0 JERRY MORAN 1.00 X 0 0 0 JUDY SCHMIRLER 1.00 X 0 0 0 BRAD STEINMETZ 2.00 X X 0 0 0 ROGER JOHNSON 1.00 X X 0 0 0 ROBERT KNADLE 1.00 X 0 0 0 LEE CUNNINGHAM 1.00 X 0 0 0 GARITH STEINER 40.00 X 993612 0 30542 MARY KOENIG 40.00 X 214839 0 24569 KYLE BAKKUM 40.00 X 240880 0 26412 DR JEFFREY MENN 40.00 X 491807 0 27644 DR ANTHONY MACASAET 40.00 X 285244 0 17988 DR DUANE KOONS 40.00 X 256651 0 30024 DR DEBORAH PRIOR 40.00 X 266115 0 29154 BRIAN MILLER 40.00 X 346300 0 25659 3095448 0 211992 35 0 1 0 GUNDERSEN LUTHERAN 1900 SOUTH AVE LA CROSSE WI 54601 LAB/RADIOLOGY 1327718 MARKET & JOHNSON 2350 GALLOWAY STREET EAU CLAIRE WI 54702 CONSTRUCTION 827200 GPS ANESTHESIA SERVICES N2685 POTATO RIDGE ROAD LA CROSSE WI 54601 ANESTHESIA SERVICES 388395 SHARED MEDICAL SERVICES PO BOX 330 COTTAGE GROVE WI 53527 MRI 313950 CLINICAL ULTRASOUND SERVICES PO BOX 7 POSTVILLE WI 52162 ULTRASOUND 230690 11 778657 170860 949517 HOSPITAL 621990 48675319 48675319 CLINIC 621110 11464232 11464232 RETAIL PHARMACY 446110 5797167 874027 4923140 HOME HEALTH & HOSPICE 621610 791963 791963 MEALS AND DIETARY 722210 180206 105979 74227 66908887 587383 587383 245357 0 245357 245357 245357 2194104 77697 2169162 41893 24942 35804 60746 60746 68751890 61911520 4997367 893486 317912 317912 1517362 1517362 22355878 21212030 1143848 918933 871915 47018 5095741 4835015 260726 1575234 1388024 187210 195740 195740 110525 110525 4721379 3909902 811477 67142 67142 322908 262414 60494 200126 200126 2417331 2417331 73018 56084 16934 2590640 1849883 740757 251433 251433 SUPPLIES 13108839 13082455 26384 BAD DEBT EXPENSE 3152108 3152108 EQUIPMENT RENTAL & MAIN 2482456 2302282 180174 DUES AND SUBSCRIPTIONS 428985 263729 165256 119219 42155 77064 62022909 55963239 6059670 0 1646574 1665824 13531553 16736254 496745 1268945 6166143 6984111 2289229 2108047 289245 208553 61574482 26134179 35024170 35440303 15811265 18397003 12180 12180 2115883 2126386 616452 583646 876455 1063820 78875894 86595072 7088121 6896857 23611292 22874705 90728 76662 1323303 1489916 32113444 31338140 X 46169672 53900077 592778 1356855 46762450 55256932 78875894 86595072 X 6728981 1765501 X X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 4165 4165 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: VERNON MEMORIAL HEALTHCARE, INC. PAYS ANNUAL ASSOCIATION MEMBERSHIPS TO THE WISCONSIN HOSPITAL ASSOCIATION AND RURAL WISCONSIN HEALTH COOPERATIVE. THESE DUES ARE PRIMARILY FOR ACCESS TO EDUCATIONAL MATERIALS AND STAFF TRAINING AND DEVELOPMENT. A SMALL PORTION OF THE ANNUAL DUES WERE USED IN CONJUCTION WITH LOBBYING ACTIVITIES WITH THE GOAL OF IMPROVING THE OVERALL HEALTHCARE ENVIRONMENT. 1188135 1188135 45275642 16195920 29079722 13762412 9938259 3824153 1348293 1348293 35440303 DEFERRED COMPENSATION PLAN LIABILITY - FUNDED 1282173 POSTRETIREMENT BENEFIT OBLIGATION 207743 1489916 68751890 62022909 6728981 1780081 -14580 1765501 8494482 70298116 1780081 1780081 68518035 233855 233855 68751890 61789054 0 61789054 233855 233855 62022909 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: IN ORDER TO ACCOUNT FOR ANY UNCERTAIN TAX POSITIONS, THE ORGANIZATION 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 THAT POSITION IS NOT RECOGNIZED IN THE FINANCIAL STATEMENTS. THE ORGANIZATION IS ALSO ENGAGED, TO A LIMITED EXTENT, IN ACTIVITIES WHICH THE INTERNAL REVENUE SERVICE CONSIDERS UNRELATED TO THE ORGANIZATION'S EXEMPT PURPOSE AND, THEREFORE, TAXABLE. THESE ACTIVITIES, HOWEVER, ANNUALLY RESULT IN NET OPERATING LOSSES FOR INCOME TAX PURPOSES. THE ORGANIZATION DOES NOT PRESENTLY ANTICIPATE THAT A TAX BENEFIT FROM THESE NET OPERATING LOSSES WILL BE REALIZED IN THE FUTURE. ACCORDINGLY, ANY POTENTIAL DEFERRED TAX ASSET RESULTING FROM THE AVAILABILITY OF NET OPERATING LOSS CARRYFORWARDS IS OFFSET BY A VALUATION ALLOWANCE OF EQUAL AMOUNT. NO DEFERRED TAX ASSETS AND LIABILITIES HAVE BEEN RECOGNIZED SINCE NO OTHER DIFFERENCES EXIST BETWEEN THE FINANCIAL AND TAX BASES OF REPORTING THE ORGANIZATION'S ASSETS AND LIABILITIES. THE ORGANIZATION RECORDED NO ASSETS OR LIABILITIES FOR UNCERTAIN TAX POSITIONS OR UNRECOGNIZED TAX BENEFITS IN 2012 OR 2011. FEDERAL RETURNS FOR THE YEARS ENDED SEPTEMBER 30, 2009, AND BEYOND REMAIN SUBJECT TO EXAMINATION BY THE INTERNAL REVENUE SERVICE. THE ORGANIZATION'S POLICY IS TO RECOGNIZE INTEREST AND PENALTIES RELATED TO INCOME TAX MATTERS IN INCOME TAX EXPENSE WHEN INCURRED. AS OF SEPTEMBER 31, 2012 AND 2011, THERE WERE NO MATERIAL TAX PENALTIES, OR INTEREST RELATED TO TAX PENALTIES, RECORDED BY THE ORGANIZATION IN THE FINANCIAL STATEMENTS. PART XI, LINE 8 - OTHER ADJUSTMENTS: NET ASSETS RELEASED FROM RESTRICTION FOR OPERATIONS -14,580. PART XII, LINE 4B - OTHER ADJUSTMENTS: EXPENSES NETTED AGAINST REVENUE ON THE AUDITED FINANCIALS 233,855. PART XIII, LINE 4B - OTHER ADJUSTMENTS: EXPENSES NETTED AGAINST REVENUE ON THE AUDITED FINANCIALS 233,855. 1 1 1 X 300.000000000000 1 X 1 1 0 1 1 692390 692390 0.01180 7201560 5874172 1327388 0.02250 7893950 5874172 2019778 0.03430 175902 13375 162527 0.00280 364209 364209 0.00620 396946 396946 0.00670 937057 13375 923682 0.01570 8831007 5887547 2943460 0.05000 2326 2326 0.00000 662 505 157 0.00000 720 720 0.00000 104661 735 103926 0.00180 108369 1240 107129 0.00180 0 1718862 1375090 10630518 11141919 -511401 X 1 0 1 1 VERNON MEMORIAL HOSPITAL INC

507 SOUTH MAIN ST VIROQUA WI 54665

X X X X VERNON MEMORIAL HOSPITAL INC 1 0 1 1 300.000000000000 1 300.000000000000 1 X X X X X X 1 1 X X X X X 1 0 1 X 0 0 9 HIRSCH CLINIC

407 S MAIN ST SUITE 400 VIROQUA WI 54665

PROVIDER BASED RURAL HEALTH CLINIC VERNON MEMORIAL HEALTHCARE PHARMACY

407 S MAIN ST SUITE 400 VIROQUA WI 54665

PHARMACY LAFARGE MEDICAL CLINIC

111 W SNOW ST LAFARGE WI 54639

PROVIDER BASED RURAL HEALTH CLINIC SOLAR TOWN PHARMACY

104 SUNSET AVE SOLDIERS GROVE WI 54655

PHARMACY BLAND CLINIC

100 MELBY ST WESTBY WI 54667

PROVIDER BASED RURAL HEALTH CLINIC KICKAPOO VALLEY MEDICAL CLINIC

102 SUNSET AVE SOLDIERS GROVE WI 54655

PROVIDER BASED RURAL HEALTH CLINIC VERNON MEMORIAL PHARMACY - WESTBY

115 W STATE STREET WESTBY WI 54667

PHARMACY VERNON MEMORIAL HEALTHCARE INC

507 S MAIN ST VIROQUA WI 54665

HOSPICE VERNON MEMORIAL HEALTHCARE INC

507 S MAIN ST VIROQUA WI 54665

HOME HEALTH AGENCY 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 HOSPITAL REVENUE AND EXPENSE CATEGORIES TO COMPUTE THE ESTIMATED COMMUNITY BENEFIT EXPENSE UNDER IRS COSTING METHODS FOR THE FORM 990. 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 $ 3152108. PART II, WHILE THERE IS A GROWING AGREEMENT IN THE UNITED STATES ABOUT WHAT CONSTITUTES A NON-PROFIT HOSPITAL'S COMMUNITY BENEFIT, THIS IS A WORK IN PROGRESS. OUR HOSPITAL PROVIDES CHARITY CARE AND OTHER COMMUNITY BENEFITS AS DEFINED BY THE IRS. BUT IN ADDITION, WE BELIEVE THAT WE PROVIDE A CRITICALLY IMPORTANT COMMUNITY BENEFIT WHICH IS NOT QUANTIFIED. OUR HOSPITAL, LIKE MOST RURAL HOSPITALS, WAS CREATED AND IS MAINTAINED IN ORDER TO PROVIDE LOCAL ACCESS TO MANY HEALTH SERVICES: BIRTHING CENTER, DIAGNOSTICS, EMERGENCY SERVICES AND URGENT CARE, HOME CARE, HOSPICE, INFUSION SERVICES, INPATIENT CARE, LABORATORY SERVICES, OCCUPATIONAL HEALTH, REHABILITATION SERVICES, SPECIALTY MEDICINE, SPEECH AND AUDIOLOGY, SURGICAL SERVICES, AND WOMENS HEALTH. PART III, LINE 4: ACCOUNTS RECEIVABLE AND CREDIT POLICY THE COSTING METHOD USED IS BASED ON A COST-TO-CHARGE RATIO WHICH WAS DEVELOPED BASED ON THE HOSPITAL'S TOTAL OPERATING EXPENSES LESS THE PROVISION FOR BAD DEBTS DIVIDED BY GROSS PATIENT SERVICE REVENUE. THE COST OF BAD DEBT AMOUNTS IS CONSIDERED A COMMUNITY BENEFIT BECAUSE IT REFLECTS THE COST OF SERVICES PROVIDED TO UNINSURED COMMUNITY MEMBERS AND DEDUCTIBLES OR COINSURANCE AMOUNTS FOR UNDERINSURED PATIENTS WHO ARE UNABLE TO PAY FOR A PORTION OF SERVICES.MANAGEMENT PROVIDES FOR CONTRACTUAL ADJUSTMENTS UNDER TERMS OF THIRD-PARTY REIMBURSEMENT AGREEMENTS THROUGH CHARGE TO GROSS PATIENT SERVICE REVENUE AND A CREDIT TO THE ACCOUNTS RECEIVABLE. IN ADDITION, 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 MANAGEMENT HAS USED REASONABLE COLLECTION EFFORTS ARE WRITTEN OFF THROUGH A CHARGE TO THE VALUATION ALLOWANCE AND A CREDIT TO ACCOUNTS RECEIVABLE. THE AUDITED FINANCIAL STATEMENTS DO NOT INCLUDE A SEPARATE FOOTNOTE REGARDING BAD DEBT EXPENSE. PART III, LINE 8: THE SHORTFALL SHOULD BE TREATED AS A COMMUNITY BENEFIT EXPENSE BECAUSE THE HOSPITAL PROFESSIONALS OFFER CLASSES TO THE COMMUNITY AIMED AT MAINTAINING AND IMPROVING THE GENERAL HEALTH OF THE POPULATION. ALSO A SIGNIFICANT PORTION OF THE PEOPLE RECEIVING SERVICES FROM THE HOSPITAL ARE COVERED BY EITHER MEDICARE OR MEDICAL ASSISTANCE PROGRAMS AND ARE RESIDENTS OF THE LOCAL COMMUNITY. THE COST TO CHARGE RATIO WAS CALCULATED USING THE MEDICARE COST REPORT. PART III, LINE 9B: PATIENTS RECEIVE OUR COMMUNITY CARE APPLICATION WHEN THEY PRESENT FOR SERVICES. THEY ARE ENCOURAGED TO REVIEW THE APPLICATION AND SUBMIT THE REQUIRED INFORMATION TO APPLY FOR POTENTIAL COVERAGE. IF THEY HAVE QUESTIONS OR NEED HELP WITH THE APPLICATION THEY MAY MEET WITH OUR PATIENT ACCOUNTS STAFF. ONCE A PATIENT APPLIES AND IS APPROVED FOR COMMUNITY CARE, THE APPLICATION IS CONSIDERED CURRENT AND VALID FOR THE FOLLOWING 12-MONTH PERIOD. VERNON MEMORIAL HOSPITAL, INC. PART V, SECTION B, LINE 13G: FORMS AND INSTRUCTIONS ARE AVAILABLE AT ALL REGISTRATION AREAS, INCLUDING THE MAIN HOSPITAL, EMERGENCY ROOM AND OUTLYING CLINICS. SIGNS REGARDING THE COMMUNITY CARE PROGRAM ARE POSTED AT ALL REGISTRATION LOCATIONS. PART VI, LINE 2: IN ADDITION TO THE COMMUNITY HEALTH NEEDS ASSESSMENT RECENTLY CONDUCTED IN CONJUNCTION WITH AREA HEALTH CARE FACILITIES, THE GREAT RIVERS UNITED WAY AND COUNTY HEALTH DEPARTMENTS, VERNON MEMORIAL HEALTHCARE CONTINUALLY GATHERS AND REVIEWS DATA RELATED TO COMMUNITY NEEDS BY UTILIZING MORE INFORMAL FOCUS AND ADVISORY GROUPS, DISCUSSIONS WITH AREA EMPLOYERS, AND WEB SURVEYS, AS WELL AS THROUGH SERVING ON LOCAL AND STATE BOARDS AND COMMITTEES. THE ORGANIZATION COLLABORATES WITH COMMUNITY ORGANIZATIONS, CHURCHES, BUSINESSES, AGENCIES, AND LOCAL COLLEGES AND UNIVERSITIES TO DETERMINE THE NEEDS OF THE COMMUNITIES SERVED. BOARD MEMBERS REPRESENT NOT ONLY THE CITY OF VIROQUA, BUT COME FROM THE DIFFERENT AREAS SERVED BY THE ORGANIZATION. THESE BOARD MEMBERS REGULARLY MEET WITH THE PEOPLE IN THEIR AREAS TO UTILIZE THE SERVICES OFFERED BY THE ORGANIZATION AND BRING BACK THEIR ISSUES AND CONCERNS. PART VI, LINE 3: VERNON MEMORIAL HEALTHCARE MAKES EVERY EFFORT TO EDUCATE PATIENTS ABOUT CHARITY CARE AND OTHER DISCOUNT PROGRAMS AVAILABLE AT THE TIME OF REGISTRATION AND FOLLOWING DISCHARGE. FORMS AND INSTRUCTIONS ARE AVAILABLE AT ALL REGISTRATION AREAS, INCLUDING THE MAIN HOSPITAL, EMERGENCY ROOM AND OUTLYING CLINICS. FINANCIAL COUNSELORS ARE AVAILABLE DURING DAYTIME HOURS TO ASSIST PATIENTS WITH COMPLETION OF FORMS, EITHER IN PERSON OVER THE PHONE. INFORMATION ABOUT CHARITY AND DISCOUNT PROGRAMS IS ALSO AVAILABLE ON THE ORGANIZATION'S WEBSITE AND E-NEWSLETTER. SIGNS REGARDING THE COMMUNITY CARE PROGRAM ARE POSTED AT ALL REGISTRATION LOCATIONS. PART VI, LINE 4: VERNON MEMORIAL HEALTHCARE SERVES THE CITY OF VIROQUA AND THE SURROUNDING AREA. OTHER TOWNS IN THE PRIMARY SERVICE AREA INCLUDE WESTBY, READSTOWN, SOLDIERS GROVE, CASHTON, AND LAFARGE. THE SECONDARY SERVICE AREA EXTENDS TO THE CITIES OF DESOTO, FERRYVILLE, HILLSBORO, COON VALLEY, RICHLAND CENTER, GAYS MILLS AND ONTARIO. THE COMMUNITIES AND SURROUNDING RURAL AREAS IN THE PRIMARY SERVICE AREA HAVE AN APPROXIMATE POPULATION OF 22,000. THE SECONDARY SERVICE AREA INCLUDES AN ADDITIONAL 25,000 PERSONS. THE ENTIRE ARE IS RURAL WITH AN AGING POPULATION AND RELATIVELY LOW INCOME LEVELS. PART VI, LINE 5: VERNON MEMORIAL HEALTHCARE PROVIDES A FULL RANGE OF INPATIENT AND OUTPATIENT SERVICES TO THE PEOPLE IN THE COMMUNITIES IT SERVES. SERVICES ARE PROVIDED WITHOUT REGARD TO RACE, COLOR, CREED, RELIGION, GENDER ORIENTATION, DISABILITY, AGE OR NATIONAL ORIGIN. VERNON MEMORIAL HOSPITAL OPERATES A 24/7 EMERGENCY ROOM THAT IS OPEN TO SERVE ALL IN NEED, REGARDLESS OF ABILITY TO PAY. THE ORGANIZATION OWNS AND OPERATES FOUR RURAL HEALTH CLINICS LOCATED IN THE CITIES OF VIROQUA, WESTBY, SOLDIERS GROVE AND LAFARGE, AS WELL AS THREE RETAIL PHARMACIES LOCATED IN VIROQUA, WESTBY AND SOLDIERS GROVE. HOME HEALTH AND HOSPICE SERVICES (INPATIENT AND OUTPATIENT) ARE ALSO PROVIDED. VERNON MEMORIAL HEALTHCARE COLLABORATES WITH COMMUNITIES, CHURCHES, BUSINESSES AND OTHER HEALTH CARE ORGANIZATIONS IN THE REGION TO FACILITATE AND STRENGTHEN ACCESSIBILITY OF QUALITY COMPREHENSIVE HEALTHCARE SERVICES. THE ORGANIZATION SUPPORTS THE LOCAL COMMUNITIES BY PROVIDING CONVENIENT LOCATIONS FOR PRIMARY CARE AND PHARMACY SERVICES. THE BOARD OF DIRECTORS IS COMPRISED OF INDEPENDENT COMMUNITY MEMBERS WHO REPRESENT THE MAKE-UP OF THE AREAS SERVED BY THE ORGANIZATION. VERNON MEMORIAL HEALTHCARE HAS AN OPEN MEDICAL STAFF MADE UP OF QUALIFIED PHYSICIANS WHO WORK WITH THE HOSPITAL TO PROVIDE CARE TO THE COMMUNITIES SERVED. ALL QUALIFIED PHYSICIANS AND AFFILIATED STAFF WHO ARE GRANTED PRIVILEGES UNDERGO A THOROUGH AND COMPREHENSIVE CREDENTIALING AND ORIENTATION PROCESS. ANY SURPLUS FUNDS GENERATED THROUGH OPERATIONS ARE USED TO CONTINUE TO MEET THE NEEDS OF THE PEOPLE THAT ARE SERVED THROUGH THE ADDITION OF NEW FACILITIES AND EQUIPMENT, OR THE ADDITION OR EXPANSION OF NEEDED SERVICES. REPORTS FILED WITH STATES PART VI, LINE 7 WI 1 VIROQUA AREA SCHOOLS 115 N EDUCATION AVE VIROQUA WI 54665 396004944 GOV'T ORGANIZATION 35797 GENERAL SUPPORT YOUTH INITIATIVE HIGH SCHOOL 500 EAST JEFFERSON ST VIROQUA WI 54665 391906073 501(C)(3) 15000 GENERAL SUPPORT VIROQUA AREA FOUNDATION PO BOX 262 VIROQUA WI 54665 391603279 501(C)(3) 30000 FAIRGROUNDS BUILDING WESTBY AREA SCHOOL DISTRICT 206 WEST AVE SOUTH WESTBY WI 54667 396005143 GOV'T ORGANIZATION 40000 SOFTBALL FIELD WESTERN TECHNICAL COLLEGE 400 7TH STREET NORTH LA CROSSE WI 54602 396002842 501(C)(3) 35000 PARTIAL COMPENSATION OF NURSING CLINICAL INSTRUCTOR UNIVERSITY OF WISCONSIN FOUNDATION 1848 UNIVERSITY AVENUE MADISON WI 53726 390743975 501(C)(3) 50000 ESTABLISHMENT OF SCHOLARSHIP FUND VIROQUA POLICE DEPARTMENT 702 E BROADWAY STREET VIROQUA WI 54665 396005636 GOV'T ORGANIZATION 8050 GENERAL SUPPORT VIROQUA CROSS COUNTRY 100 BLACKHAWK DRIVE VIROQUA WI 54665 273232536 501(C)(3) 5234 GENERAL SUPPORT DALE TORGERSON BENEFIT 911 SOUTH STREET CASHTON WI 54619 453000154 501(C)(3) 5000 GENERAL SUPPORT VIROQUA HILLS GOLF COURSE HIGHWAY 14 SOUTH VIROQUA WI 54665 396079135 501(C)(3) 22500 GENERAL SUPPORT AMERICAN CANCER SOCIETY 1285 RUDY ST SUITE 103 ONALASKA WI 54650 131788491 501(C)(3) 5631 GENERAL SUPPORT VERNON TRAILS 311 N WASHINGTON STREET VIROQUA WI 54665 710885732 501(C)(3) 15000 TRAIL MAINTENANCE VERNON COUNTY TREASURER 400 COURTHOUSE SQUARE VIROQUA WI 54665 396005749 GOV'T ORGANIZATION 34200 TRAIL CONSTRUCTION VERNON COUNTY SHERIFF'S OFFICE 1320 BAD AXE COURT VIROQUA WI 54665 396005749 GOV'T ORGANIZATION 10000 AUTOMATED EXTERNAL DEFIBRILLATORS WESTBY FOOTBALL CLUBNORSEMEN BOOSTER CLUB W2693 CTY RD N COON VALLEY WI 54623 392041425 501(C)(3) 6500 GENERAL SUPPORT 15 0 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: ALL DONEES ARE REQUIRED TO SUBMIT THEIR DONATION REQUESTS TO THE CEO OR MARKETING MANAGER OF VERNON MEMORIAL HEALTHCARE, INC. REQUESTS SUBMITTED TO THE MARKETING MANAGER ARE FORWARDED TO THE CEO FOR FINAL APPROVAL. THE REQUESTS MUST INCLUDE A DETAILED DESCRIPTION OF WHAT THE FUNDS WILL BE USED FOR AND HOW THEY WILL BENEFIT THE COMMUNITY. DONEES ARE ASKED TO PROVIDE CONFIRMATION OF RECEIPT AND AN EXPLANATION OF HOW THE FUNDS WERE USED, EITHER VERBALLY OR IN WRITING, TO THE CEO. IF THE REQUESTS ARE DEEMED BENEFICIAL TO THE NEEDS OF THE COMMUNITY, THE FUNDS ARE AWARDED TO THE APPLYING ORGANIZATION. X X X 0 0 0 0 0 0 0 0 0 GARITH STEINER 426457 0 23572 0 543583 0 16582 0 13960 0 1024154 0 0 0 MARY KOENIG 182939 0 15400 0 16500 0 10269 0 14300 0 239408 0 0 0 KYLE BAKKUM 225002 0 15878 0 0 0 12452 0 13960 0 267292 0 0 0 DR JEFFREY MENN 460787 0 14520 0 16500 0 12351 0 15293 0 519451 0 0 0 DR ANTHONY MACASAET 269354 0 15890 0 0 0 2695 0 15293 0 303232 0 0 0 DR DUANE KOONS 242060 0 14591 0 0 0 14731 0 15293 0 286675 0 0 0 DR DEBORAH PRIOR 231690 0 17925 0 16500 0 13861 0 15293 0 295269 0 0 0 BRIAN MILLER 333410 0 12890 0 0 0 10366 0 15293 0 371959 0 0 0 SUPPLEMENTAL INFORMATION PART III PART III: IN ADDITION TO THE COMPENSATION REPORTED IN PART II, THE ORGANIZATION ACCRUED ADDITIONAL PAID LEAVE TIME THAT IS RECOGNIZED AS UNFUNDED DEFERRED COMPENSATION FOR THREE INDIVIDUALS. THE UNFUNDED DEFERRED COMPENSATION EXPENSED IN FISCAL YEAR 2012 WAS AS FOLLOWS: GARITH STEINER $77,289 MARY KOENIG $6,752 KYLE BAKKUM $675 THE ORGANIZATION HAS ALSO INSTITUTED A POLICY WHEREBY THESE EXECUTIVES (GARITH STEINER AND MARY KOENIG) ARE ABLE TO ACCRUE VACATION TIME THAT IS NOT LIMITED BY THE ORGANIZATION'S STANDARD POLICY. IN 2011, GARITH STEINER USED A SIGNIFICANT PORTION OF THIS VACATION WHICH IS RECOGNIZED ON SCHEDULE J ($527,083). WISCONSIN HEALTH AND EDUCATIONAL FACILITIES AUTHORITY 391337855 97710VXQ6 2005-05-19 22894672 FINANCE CONSTRUCTION OF FACILITY EXPANSION 0 0 0 1350000 22894672 1846325 457893 20590454 2006 0 0 1 1 0 0 0 0 0.00000 0.02580 0.02580 1 0 0 0 0 0 0 FORM 990, PART VI, SECTION A, LINE 6 ANY PERSON WHO IS EIGHTEEN YEARS OF AGE OR OLDER AND A BONA FIDE RESIDENT OF VERNON COUNTY, WISCONSIN, OR THE AREA WITHIN A RADIUS OF TWENTY-FIVE MILES OF THE CITY OF VIROQUA, WISCONSIN, AND WHO HAS THE HERETOFORE OR MAY HEREAFTER CONTRIBUTE TEN DOLLARS OR MORE TO THE CORPORATION SHALL BE A MEMBER THEREOF. ALL MEMBERS OF THE CORPORATION SHALL BE VOTING MEMBERS. EACH MEMBER SHALL HAVE ONE VOTE ON ANY MATTER SUBMITTED TO A VOTE OF THE MEMBERS OF THE CORPORATION. FORM 990, PART VI, SECTION A, LINE 7A THE DUTIES OF THE MEMBERS OF THE VERNON MEMORIAL HEALTHCARE, INC ("THE CORPORATION") SHALL BE: THE ELECTION OF MEMBERS OF THE BOARD OF DIRECTORS OF THE CORPORATION, THE REMOVAL OF MEMBERS OF THE BOARD OF DIRECTORS OF THE CORPORATION, AND THE CHANGING OF THE NUMBER OF DIRECTORS CONSTITUTING THE BOARD OF DIRECTORS OF THE CORPORATION. FORM 990, PART VI, SECTION A, LINE 7B THE DUTIES OF THE MEMBERS OF THE VERNON MEMORIAL HEALTHCARE, INC ("THE CORPORATION") SHALL ALSO INCLUDE: THE AMENDMENT, RESTATEMENT, OR MODIFICATION OF THE ARTICLES OF INCORPORATION OR BYLAWS OF THE CORPORATION; AND THE APPROVAL OF THE SALE, LEASE, OR OTHER DISPOSITION OF ALL, OR SUBSTANTIALLY ALL OF THE ASSETS AND PROPERTY OF THE CORPORATION, THE DISSOLUTION OF THE CORPORATION, OR ITS MERGER WITH ANOTHER CORPORATION. FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 WAS REVIEWED BY THE BOARD OF DIRECTORS OF VERNON MEMORIAL HEALTHCARE, INC. AT THEIR JULY MEETING. FORM 990, PART VI, SECTION B, LINE 12 ALL BOARD MEMBERS OF VERNON MEMORIAL HEALTHCARE, INC. ARE REQUIRED TO DISCLOSE ALL POSSIBLE CONFLICTS OF INTEREST WHEN FIRST ELECTED TO THE BOARD OF DIRECTORS. DURING THEIR TERMS, IF ANY BUSINESS RELATIONSHIPS ARE ENTERED INTO WHICH MAY AFFECT THEIR INDEPENDENCE AS A MEMBER, THE MEMBER MUST IMMEDIATELY DISCLOSE THESE RELATIONSHIPS. FORM 990, PART VI, SECTION B, LINE 15 TO DETERMINE APPROPRIATE SALARY RANGES FOR UPPER MANAGEMENT POSITIONS, VERNON MEMORIAL HEALTHCARE, INC. UTILIZES BENCHMARK DATA FROM SURVEYS CONDUCTED BY RELEVANT TRADE ORGANIZATIONS. THE CEO HAS THE RIGHT TO AMEND THE DETERMINED AMOUNT FOR THE CFO AND COO. THE BOARD HAS THE RIGHT TO AMEND THE AMOUNT FOR THE CEO. THE EXECUTIVE COMMITTEE OF THE BOARD REVIEWS THE DATA FOR THE CEO ANNUALLY TO DETERMINE THE AMOUNT OF HIS COMPENSATION AND ANY CHANGES IN COMPENSATION ARE MAINTAINED IN THE PERSONNEL FILE. THE CEO REVIEWS THE DATA FOR THE CFO AND COO ANNUALLY TO DETERMINE THE AMOUNT OF COMPENSATION AND ANY CHANGES ARE MAINTAINED IN THE PERSONNEL FILE. FORM 990, PART VI, SECTION C, LINE 19 VERNON MEMORIAL HEALTHCARE, INC. MAKES ITS FINANCIAL STATEMENTS AND GOVERNING DOCUMENTS AVAILABLE TO THE PUBLIC ON A PER REQUEST BASIS. THE FORM 990 IS ALSO AVAILABLE TO THE PUBLIC ON A THIRD PARTY WEBSITE CALLED GUIDESTAR. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED GAINS ON INVESTMENTS: 1,780,081. NET ASSETS RELEASED FROM RESTRICTION FOR OPERATIONS -14,580. TOTAL TO FORM 990, PART XI, LINE 5: 1,765,501. OVERSIGHT OF AUDIT FORM 990, PART XI, LINE 2C VERNON MEMORIAL HEALTHCARE, INC. DOES NOT HAVE A SPECIFIC COMMITTEE WHICH ASSUMES THE RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT. THE ENTIRE BOARD OF DIRECTORS IS RESPONSIBLE FOR SELECTION OF THE INDEPENDENT ACCOUNTANT. NO CHANGES HAVE BEEN MADE IN THE PAST YEAR REGARDING THIS OVERSIGHT FUNCTION OF THE GOVERNING BODY. VERNON MEMORIAL HEALTHCARE FOUNDATION INC 507 SOUTH MAIN STREET VIROQUA WI 54665 391515716 FUNDRAISING WI 501(C)3 11 C - III - FI N/A 0 0 0 1 0 0 0 0 0 0 0 0 1 1 1 0 0 0 0