2013-06-14T11:37:23-05:00 2012-09-30 420714325 MCGLADREY LLP 201 N HARRISON STREET SUITE 300 DAVENPORT IA 528011999 990 2011-10-01 421081055 FORT MADISON COMMUNITY HOSPITAL FORT 3193726530 5445 AVENUE O FORT MADISON IA 52627 BRADLEY J KOKJOHN 3193762125 2013-06-11 1 JOHN J ROMANO P00227323 5638884000 2011 2016-03-07 17:11:31Z X C JAMES PLATT 5445 AVENUE O FORT MADISON IA 52627 55580924 0 X WWW.FMCHOSP.COM X 1977 IA TO ADVANCE THE HEALTH AND WELL BEING OF ALL PEOPLE THROUGH COMPASSIONATE QUALITY CARE, EDUCATION AND COMMUNITY SERVICE. 7 7 499 50 17893 -17772 200000 270000 48811847 54266323 242098 239802 308996 801073 49562941 55577198 59927 66980 0 0 29604451 31208880 0 0 0 19335916 20939445 49000294 52215305 562647 3361893 49410754 59520859 10016611 16825522 39394143 42695337 X TO ADVANCE THE HEALTH AND WELL BEING OF ALL PEOPLE THROUGH COMPASSIONATE QUALITY CARE, EDUCATION AND COMMUNITY SERVICE. 0 0 45617805 66980 54852359 FORT MADISON COMMUNITY HOSPITAL (FMCH) IS A GENERAL MEDICAL AND SURGICAL HOSPITAL, LOCATED IN FORT MADISON, IOWA, TO MEET THE HEALTHCARE NEEDS OF ITS COMMUNITIES AS WELL AS PROVIDE PROGRAMS AND SERVICES AIMED AT HEALTH, SAFETY, EDUCATION, PREVENTION, AND OVERALL HEALTH AND WELLNESS. IN SO DOING, THEY STRENGTHEN THEIR ROLE AS A PARTNER IN THE COMMUNITY BY IMPROVING THE HEALTH OF AREA CITIZENS AND THE QUALITY OF LIFE IN THE COMMUNITIES THEY SERVE. FORT MADISON COMMUNITY HOSPITAL IS COMMITTED TO PROVIDING HEALTH CARE SERVICES TO AREA RESIDENTS. FMCH SERVES THE RESIDENTS OF SOUTHEAST IOWA AND WEST CENTRAL ILLINOIS. THE 50 BED HOSPITAL HAD 2,285 PATIENT ADMISSIONS AND 7,600 PATIENT DAYS OF MEDICAL CARE. THIS INCLUDED 907 PATIENT ACCOUNTS WHO RECEIVED UNCOMPENSATED CARE. HEALTH SERVICES AND CARE PROVIDED BY FMCH INCLUDE: PHYSICIANS AND SURGEONS PRACTICING IN THE FOLLOWING AREAS: FAMILY PRACTICE, INTERNAL MEDICINE, OBSTETRICS & GYNECOLOGY, ORTHOPEDICS & SPORTS MEDICINE, PEDIATRICS, PSYCHIATRY, SURGERY AND UROLOGY; BIRTHPLACE SERVICES; SPECIALTY CLINICS IN THE FOLLOWING AREAS: CARDIOLOGY, DERMATOLOGY, OTOLARYNGOLOGY, GASTROENTEROLOGY AND NEUROLOGY; EMERGENCY DEPARTMENT SERVICES; HOME HEALTH CARE; REHABILITATION/THERAPY SERVICES; LABORATORY AND PATHOLOGY SERVICES; AND WOUND HEALING CARE. 45617805 1 1 0 0 0 0 0 0 0 0 1 0 1 0 0 1 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 57 0 1 499 1 1 1 0 0 0 0 0 0 0 0 0 X 7 7 1 1 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 X BRADLEY J KOKJOHN 3193726530 5445 AVENUE O FORT MADISON IA 526270174 JOHN MCKILLIP 2.00 X 2427 0 0 DEANNA BARR 2.00 X X 1135 0 0 JAMES GERDES 2.00 X 711 0 0 BOB BONTA 2.00 X X 0 0 0 JEANNINE HANEY 2.00 X 98 0 0 VICKI STEPHENSON 2.00 X 15 0 0 ANN MENKE 2.00 X 598 0 0 C JAMES PLATT 40.00 X 299056 0 65891 BRADLEY KOKJOHN 40.00 X 226383 0 46191 MITCHELL PAUL MD 40.00 X 542872 0 26864 ROY J TINGUELY MD 40.00 X 392667 0 31736 MARK S CALKINS MD 40.00 X 694763 0 25426 TIMOTHY S STAUDTE MD 40.00 X 473649 0 34061 TODD W GRAY MD 40.00 X 384327 0 31736 3018701 0 261905 25 0 1 1 UNITED HEALTHCARE PLAN PO BOX 88832 CHICAGO IL 60695 HEALTH EE INSURANCE 3366830 CARDINAL HEALTH 110 INC 2840 ELM POINT DRIVE ST CHARLES MO 63301 PHARMACY DRUGS AND SUPPLIES 2071183 EMCARE PHYSICIAN SERVICES INC 7032 COLLECTION CENTER DRIVE CHICAGO IL 60693 EMERGENCY ROOM PHYSICIAN STAFFING 1688673 ABOLT INCORPORATED 2887 CHALK RIDGE ROAD FORT MADISON IA 52627 GENERAL CONTRACTOR 1242216 MEDICAL INFORMATION TECHNOLOGY PO BOX 74569 CHICAGO IL 60696 SOFTWARE VENDOR 1020187 51 270000 270000 NET PATIENT SERVICE RE 621110 53943863 53943863 SE RENAL DIALYSIS 621300 322460 322460 54266323 243528 243528 70339 0 70339 70339 70339 3726 -3726 -3726 -3726 MISCELLANEOUS 900099 536551 536551 CAFETERIA REVENUE 722210 126805 126805 HOUSEKEEPING, MAINTENA 811000 42656 24763 17893 24722 24722 730734 55577198 54852359 17893 436946 66980 66980 603726 603726 24017101 21628094 2389007 779352 701829 77523 4321161 3891330 429831 1487540 1339573 147967 295925 295925 40220 40220 69815 69815 3008251 2440405 567846 256910 380 256530 6273162 6158649 114513 938395 928072 10323 166274 124762 41512 124930 90824 34106 3141977 2284219 857758 488455 120154 368301 PROVISION FOR BAD DEBTS 2398285 2398285 PHYSICIAN FEES 2291917 2291917 MEDICAID ASSESSMENT 394422 394422 RECRUITMENT 325045 325045 725462 432865 292597 52215305 45617805 6597500 0 1322056 4637326 3476857 1589605 5956166 9748372 0 4165 1320 0 692912 709861 970294 996178 59928526 34412199 23043657 25516327 9891467 11992084 4018656 4180490 37369 146451 49410754 59520859 5897649 9832628 4030533 6992894 88429 0 10016611 16825522 X 39192891 42470132 3934 25387 197318 199818 39394143 42695337 49410754 59520859 X 3361893 -60699 X X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 1139463 1139463 27663006 13185583 14477423 27359636 20902417 6457219 3766421 324199 3442222 25516327 SE RENAL DIALYSIS, LC 1007138 C INVESTMENT IN SUBSIDIARIES 3173352 C 4180490 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: THE HOSPITAL AND AFFILIATES, EXCEPT FOR RENAISSANCE HEALTH SERVICES, INC., ARE NOT-FOR-PROFIT CORPORATIONS AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE AND ARE EXEMPT FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE CODE. RENAISSANCE HEALTH SERVICES, INC. IS A FOR PROFIT CORPORATION SUBJECT TO FEDERAL AND STATE INCOME TAXES, HOWEVER THERE WERE NO MATERIAL INCOME TAX PROVISIONS FOR THE YEARS ENDED SEPTEMBER 30, 2012 AND 2011. THE HOSPITAL, FOUNDATION AND FORT MADISON PROFESSIONAL BUILDING ASSOCIATION FILE A FORM 990 (RETURN OF ORGANIZATION EXEMPT FROM INCOME TAX) ANNUALLY. WHEN THESE RETURNS ARE FILED, IT IS HIGHLY CERTAIN THAT SOME POSITIONS TAKEN WOULD BE SUSTAINED UPON EXAMINATION BY THE TAXING AUTHORITIES, WHILE OTHERS ARE SUBJECT TO UNCERTAINTY ABOUT THE MERITS OF THE TAX POSITION TAKEN OR THE AMOUNT OF THE POSITION THAT WOULD ULTIMATELY BE SUSTAINED. EXAMPLES OF TAX POSITIONS COMMON TO ORGANIZATIONS SUCH AS THIS INCLUDE SUCH MATTERS AS THE FOLLOWING: THE TAX EXEMPT STATUS OF THE ENTITY, THE CONTINUED TAX EXEMPT STATUS OF BONDS ISSUED BY THE HOSPITAL, THE NATURE, THE CHARACTERIZATION AND TAXABILITY OF JOINT VENTURE INCOME AND VARIOUS POSITIONS RELATIVE TO POTENTIAL SOURCES OF UNRELATED BUSINESS INCOME (UBI). UBI IS REPORTED ON FORM 990T, AS APPROPRIATE. THE BENEFIT OF A TAX POSITION IS RECOGNIZED IN THE FINANCIAL STATEMENTS IN THE PERIOD DURING WHICH, BASED ON ALL AVAILABLE EVIDENCE, MANAGEMENT BELIEVES THAT IT IS MORE LIKELY THAN NOT THAT THE POSITION WILL BE SUSTAINED UPON EXAMINATION, INCLUDING THE RESOLUTION OF APPEALS OR LITIGATION PROCESSES, IF ANY. TAX POSITIONS ARE NOT OFFSET OR AGGREGATED WITH OTHER POSITIONS. TAX POSITIONS THAT MEET THE "MORE LIKELY THAN NOT" RECOGNITION THRESHOLD ARE MEASURED AS THE LARGEST AMOUNT OF TAX BENEFIT THAT IS MORE THAN 50% LIKELY TO BE REALIZED ON SETTLEMENT WITH THE APPLICABLE TAXING AUTHORITY. THE PORTION OF THE BENEFITS ASSOCIATED WITH TAX POSITIONS TAKEN THAT EXCEEDS THE AMOUNT MEASURED AS DESCRIBED ABOVE WOULD BE REFLECTED AS A LIABILITY FOR UNRECOGNIZED TAX BENEFITS IN THE ACCOMPANYING BALANCE SHEET ALONG WITH ANY ASSOCIATED INTEREST AND PENALTIES THAT WOULD BE PAYABLE TO THE TAXING AUTHORITIES UPON EXAMINATION. HOWEVER, AS OF SEPTEMBER 30, 2012 AND 2011, THERE WERE NO UNRECOGNIZED TAX BENEFITS IDENTIFIED AND RECORDED AS A LIABILITY AS MANAGEMENT DOES NOT BELIEVE THE ORGANIZATION HAS TAKEN ANY TAX POSITIONS THAT WOULD NOT BE SUSTAINED UPON EXAMINATION BY THE TAXING AUTHORITIES. FORMS 990 AND 990T FILED BY THE HOSPITAL, FOUNDATION AND FORT MADISON PROFESSIONAL BUILDING ASSOCIATION ARE GENERALLY SUBJECT TO EXAMINATION BY THE INTERNAL REVENUE SERVICE (IRS) UP TO THREE YEARS FROM THE EXTENDED DUE DATE OF EACH RETURN. THE HOSPITAL'S IRS FORMS 990 AND 990T ARE NO LONGER SUBJECT TO EXAMINATION FOR THE YEARS ENDED SEPTEMBER 30, 2008 AND PRIOR. RENAISSANCE HEALTH SERVICES, INC. IS A TAXABLE ORGANIZATION AND CURRENTLY FILES INCOME TAX RETURNS IN THE U.S. FEDERAL JURISDICTION AND THE APPLICABLE STATE JURISDICTIONS. THIS ENTITY IS NO LONGER SUBJECT TO INCOME TAX EXAMINATIONS FOR YEARS ENDED SEPTEMBER 30, 2008 AND PRIOR. 1 1 1 X 1 X 1 1 0 1 0 1120896 0 1120896 0.02250 4358199 3955685 402514 0.00810 0 0 5479095 3955685 1523410 0.03060 494278 0 494278 0.00990 95362 0 95362 0.00190 11274405 9433797 1840608 0.03690 0 0 66980 0 66980 0.00130 11931025 9433797 2497228 0.05000 17410120 13389482 4020638 0.08060 1 2398285 0 10974734 11384226 -409492 X 1 1 1 SE RENAL DIALYSIS DIALYSIS SERVICES 0.20000 0.00000 0.00000 1 1 FORT MADISON COMMUNITY HOSPITAL

5445 AVENUE O FORT MADISON IA 52627

X X X X TRAUMA CENTER FORT MADISON COMMUNITY HOSPITAL 1 1 1 150.000000000000 1 350.000000000000 1 X X X X 1 1 X X X X 1 0 1 X 0 0 PART I, LINE 3C: NOT APPLICABLE PART I, LINE 6A: NOT APPLICABLE PART I, LINE 7: THE ORGANIZATION CALCULATED THE COST AMOUNTS NOTED IN PART 1, LINE 7 BY UTILIZING ITS CURRENT COST ACCOUNTING SYSTEM. THE COST ACCOUNTING SYSTEM ADDRESSES ALL PATIENT SEGMENTS REPORTED ON, INCLUDING, BUT NOT LIMITED TO INPATIENT, OUTPATIENT, MEDICAID, UNINSURED, AND MEDICARE. WORKSHEET 2, RATIO OF PATIENT CARE COST TO CHARGES, AS PROVIDED IN THE IRS INSTRUCTIONS, WAS USED TO DETERMINE THE APPROPRIATE RATIO. PART I, LINE 7G: THE AMOUNTS REPORTED ON LINE 7G ARE ASSOCIATED WITH PHYSICIAN CLINICS. PART I, L7 COL(F): $2,398,285 OF BAD DEBT EXPENSE IS SUBTRACTED FOR PURPOSES OF COMPUTING THE PERCENTAGE IN PART I, LINE 7K, COLUMN F. THE ORGANIZATION'S TOTAL COMMUNITY BENEFIT EXPENSE AS A PERCENTAGE OF TOTAL EXPENSES, LESS BAD DEBT, IS 34.95%, AND THE PERCENTAGE INCREASES TO 57.80% IF MEDICARE ALLOWABLE COSTS ARE INCLUDED IN TOTAL COMMUNITY BENEFIT EXPENSE. PART III, LINE 4: THE ORGANIZATION USED ITS AUDITED FINANCIAL STATEMENTS TO DETERMINE THE AMOUNT OF BAD DEBT EXPENSE TO REPORT ON LINE 2. THE ORGANIZATION DOES NOT ISSUE A STANDALONE FINANCIAL STATEMENT; HOWEVER, IT IS INCLUDED AS A PART OF THE FORT MADISON COMMUNITY HOSPITAL AND AFFILIATES CONSOLIDATED FINANCIAL STATEMENTS. THE FOOTNOTE FROM THE CONSOLIDATED FINANCIAL STATEMENT IS AS FOLLOWS: PATIENT RECEIVABLES DUE DIRECTLY FROM THE PATIENTS ARE CARRIED AT THE ORIGINAL CHARGE FOR THE SERVICE PROVIDED, LESS AMOUNTS COVERED BY THIRD-PARTY PAYORS AND LESS AN ESTIMATED ALLOWANCE FOR DOUBTFUL RECEIVABLES BASED ON A REVIEW OF ALL OUTSTANDING AMOUNTS ON A MONTHLY BASIS. MANAGEMENT DETERMINES THE ALLOWANCE FOR DOUBTFUL ACCOUNTS BY IDENTIFYING TROUBLED ACCOUNTS, BY HISTORICAL EXPERIENCE APPLIED TO AN AGING OF ACCOUNTS AND BY CONSIDERING THE PATIENT'S FINANCIAL HISTORY AND CURRENT ECONOMIC CONDITIONS. THE HOSPITAL DOES NOT CHARGE INTEREST ON PATIENT RECEIVABLES. PATIENT RECEIVABLES ARE WRITTEN OFF AS BAD DEBT WHEN DEEMED UNCOLLECTIBLE. RECOVERIES OF RECEIVABLES PREVIOUSLY WRITTEN OFF ARE RECORDED AS A REDUCTION OF BAD DEBT WHEN RECEIVED. THE CHARITY CARE FOOTNOTE DISCLOSURE AS REPORTED IN THE CONSOLIDATED FINANCIAL STATEMENT IS AS FOLLOWS: THE ORGANIZATION PROVIDES CARE TO PATIENTS WHO MEET CERTAIN CRITERIA UNDER ITS CHARITY CARE POLICY WITHOUT CHARGE OR AT AMOUNTS LESS THAN ITS ESTABLISHED RATES. BECAUSE THE ORGANIZATION DOES NOT PURSUE COLLECTION OF AMOUNTS DETERMINED TO QUALIFY AS CHARITY CARE, THEY ARE NOT REPORTED AS REVENUE. THE AMOUNT OF CHARGES FOREGONE FOR SERVICES AND SUPPLIES FURNISHED UNDER THE ORGANIZATION'S CHARITY CARE POLICY AGGREGATED TO APPROXIMATELY $1,483,000 FOR THE YEAR ENDED SEPTEMBER 30, 2012. COMMENCING IN THE YEAR ENDED SEPTEMBER 30, 2012, THE ORGANIZATION PROVIDED A SELF-PAY DISCOUNT TO PATIENTS THAT DID NOT HAVE INSURANCE COVERAGE. THE AMOUNT OF ADJUSTMENTS APPROXIMATED $583,000 FOR THE YEAR ENDED SEPTEMBER 30, 2012. PART III, LINE 8: THE ORGANIZATION DERIVED ITS COSTING METHODOLOGY USED TO DETERMINE THE MEDICARE ALLOWABLE COSTS REPORTED IN THE ORGANIZATION'S MEDICARE COST REPORT BY USING COST REPORT WORKSHEETS. MEDICARE COSTS ARE DETERMINED THROUGH THE MEDICARE COST FINDING PROCESS WHICH ALLOCATES GENERAL SERVICE CENTER COSTS TO REVENUE DEPARTMENTS. ROUTINE AND ICU COSTS ARE DETERMINED BASED ON AN AVERAGE COST PER DAY MULTIPLIED BY THE NUMBER OF MEDICARE ALLOWABLE DAYS. MEDICARE ANCILLARY COSTS ARE DETERMINED BY THE RATIO OF DEPARTMENT COSTS TO DEPARTMENT CHARGES, THEN THE RESULTING PERCENT IS APPLIED TO MEDICARE ALLOWABLE CHARGES. THE METHODOLOGY DESCRIBED IN THE INSTRUCTIONS TO SCHEDULE H, PART III, SECTION B, LINE 6 DOES NOT TAKE INTO ACCOUNT ALL COSTS INCURRED BY THE HOSPITAL AND DOES NOT REPRESENT THE TOTAL COMMUNITY BENEFIT CONFERRED IN THIS AREA. THE MEDICARE SHORTFALL ON FEE SCHEDULE REIMBURSED SERVICES TOTALED $532,614 FOR THE REPORTABLE YEAR. THIS SHORTFALL IS NOT INCLUDED ON SCH H, PART III, LINE 7.THE REASONS MEDICARE SHORTFALL SHOULD BE TREATED AS A COMMUNITY BENEFIT ARE: ABSENT THE MEDICARE PROGRAM, IT IS LIKELY MANY OF THE INDIVIDUALS WHOULD QUALIFY FOR FINANCIAL ASSISTANCE OR OTHER NEEDS-BASED GOVERNMENT PROGRAMS; BY ACCEPTING PAYMENT BELOW COST TO TREAT THESE INDIVIDUALS, THE BURDENS OF GOVERNMENT ARE RELIEVED WITH RESPECT TO THESE INDIVIDUALS; THERE IS A SIGNIFICANT POSSIBILITY THAT CONTINUED REDUCTION IN REIMBURSEMENT MAY ACTUALLY CREATE DIFFICULTIES IN ACCESS FOR THESE INDIVIDUALS; AND THE AMOUNT SPENT TO COVER MEDICARE SHORTFALL IS MONEY NOT AVAILABLE TO COVER FINANCIAL ASSISTANCE AND OTHER COMMUNITY BENEFIT NEEDS. PART III, LINE 9B: THE FORT MADISON COMMUNITY HOSPITAL (FMCH) CHARITY PROGRAM IS DESIGNED TO IDENTIFY THOSE ACCOUNTS WHERE THE GUARANTOR IS NOT ABLE TO MAKE PAYMENT, OR ONLY LIMITED PAYMENTS THAT WOULD WORK A DEFINITE HARDSHIP ON THE HOUSEHOLD, AND "ADJUST" THOSE ACCOUNTS AS EARLY AS POSSIBLE.FINANCIAL EVALUATION OF PATIENT - IF THE PRIMARY PAYOR IS OTHER THAN AN INSURANCE COMPANY, FMCH EVALUATES THE ABILITY OF THE GUARANTOR TO: 1) HANDLE THE PROJECTED FINANCIAL OBLIGATION PERSONALLY; 2) QUALIFY FOR COUNTY, STATE OR FEDERAL ASSISTANCE. ASSISTANCE MAY BE AVAILABLE IF: A) THERE ARE DEPENDENT CHILDREN IN THE HOME (MEDICAID); B) POSSIBLE DETERMINATION OF DISABILITY BY THE SOCIAL SECURITY ADMINISTRATION; AND C) PATIENT IS PREGNANT (MEDICAID); 3) IF PATIENT APPEARS TO QUALIFY FOR ASSISTANCE IN ONE OF THE ABOVE CATEGORIES, FMCH EVALUATES HOW LIKELY IT IS THAT THE PATIENT WILL FOLLOW THROUGH WITH THE APPLICATION PROCESS. IF THE PATIENT IS NOT LIKELY TO FOLLOW THROUGH, ASSISTANCE IS OBTAINED FROM AN OUTSIDE AGENCY TO HELP THE PATIENT THROUGH THE APPLICATION PROCESS; 4) IF THE INITIAL REVIEW INDICATES THERE IS NO OTHER PAYOR THAN THE INDIVIDUAL GUARANTOR, AND AN ASSESSMENT OF THE GUARANTOR'S MEANS (INCOME, ASSETS AND LIABILITIES) LEAVES CONSIDERABLE QUESTIONS AS TO HOW HE/SHE WILL RESOLVE THE IMPENDING DEBT, FMCH THEN DETERMINES IF FULL OR PARTIAL CHARITY IS APPROPRIATE; 5) RESIDENCY TEST - TO BE ELIGIBLE FOR CHARITY CARE, THE PATIENT'S HOME MUST BE WITHIN THE PRIMARY OR SECONDARY SERVICE AREA OF FMCH. THESE AREAS ARE DEFINED BY ZIP CODES; 6) USING THE COMPLETED PERSONAL FINANCIAL STATEMENT, A COPY OF THE MOST RECENT TAX RETURN, A COPY OF THE MOST RECENT PAYROLL STUBS AND ANY OTHER INFORMATION THAT MAY BE APPROPRIATE, THE GUARANTOR'S INCOME MUST BE EVALUATED ON A SLIDING SCALE BASED ON POVERTY GUIDELINES; 7) ADDITIONAL CIRCUMSTANCES SUCH AS, BUT NOT LIMITED TO, IF THE GUARANTOR HAS LIMITED CASH INCOME BUT HAS SIGNIFICIANT PROPERTY HOLDINGS (PERSONAL OR BUSINESS), THOSE ASSETS MUST BE TAKEN INTO ACCOUNT AND MAY SUPERSEDE THE APPLICATION OF THE ABOVE DISCOUNT GUIDELINES;NEGOTIATIONS - DEPENDENT UPON THE GUARANTOR'S MEANS, FMCH MAY NEGOTIATE A SETTLEMENT. IF A RESONABLE MONTHLY PAYMENT FOR THE BALANCE OWED CAN NOT BE AGREED UPON, IT IS IN EVERYONE'S BEST INTEREST TO RESOLVE THE DEBT EARLIER BY AGREEING TO A NEGOTIATED AMOUNT. RECOMMENDATIONS FROM STAFF SUCH AS THE CEO, CFO, DON, RU, DOCTORS AND DEPARTMENT HEADS TO ASSIST WITH PATIENTS THAT ARE HAVING FINANCIAL DIFFICULTY IS ALWAYS CONSIDERED. FOLLOWING DISCHARGE OR BILLING, A DETERMINATION OF CHARITY MAY BE MADE BY USING THE ABOVE PROCESS AS SOON AS THE QUESTION OF POSSIBLE CHARITY IS RAISED. THIS DETERMINATION SHOULD ALWAYS BE MADE AT THE EARLIEST POSSIBLE TIME IN THE LIFE OF THE ACCOUNT. PART VI, LINE 2: FORT MADISON COMMUNITY HOSPITAL UTILIZES A COMMUNITY HEALTH NEEDS ASSESSMENT PERFORMED BY THE LOCAL UNITED WAY. IN ADDITION TO THIS NEEDS ASSESSMENT, THE HOSPITAL BOARD OF DIRECTORS HOLD AN ANNUAL PLANNING MEETING WITH REPRESENTATIVES FROM THE MEDICAL STAFF IN ATTENDANCE. THIS PHYSICIAN REPRESENTATION ALLOWS FOR GOOD INPUT OF THE COMMUNITY MEDICAL NEEDS BY THOSE THAT ARE CLOSEST TO THE ISSUES. PART VI, LINE 3: THE HOSPITAL HAS A WRITTEN CHARITY CARE POLICY IN PLACE TO ENSURE THAT NECESSARY HEALTH CARE SERVICES ARE NOT DENIED BASED ON ABILITY TO PAY AND THAT ALL PATIENTS ARE TREATED FAIRLY AND EQUITABLY, AND WITH RESPECT AND COMPASSION. THE HOSPITAL ASSISTS PERSONS WITHOUT INSURANCE COVERAGE BY WAIVING ALL OR PART OF THE CHARGES FOR SERVICES IT PROVIDES. CHARGES FOR SERVICES ARE DISCOUNTED ON A SLIDING FEE SCALE BASED ON FEDERAL POVERTY GUIDELINES. INDIVIDUALS WHOSE INCOME IS WITHIN 0% TO 350% OF THE FEDERAL POVERTY GUIDELINES ARE ELIGIBLE FOR FREE OR DISCOUNTED SERVICES. THE FINANCIAL ASSISTANCE CONTACT INFORMATION IS AVAILABLE AT ALL OF THE REGISTRATION POINTS IN WHICH ELIGIBLE PATIENTS ARE LIKELY TO BE PRESENT. IN ADDITION, FINANCIAL ASSISTANCE CONTACT INFORMATION IS INCLUDED IN THE PATIENT BILLS, INCLUDED IN A PATIENT'S HANDBOOK GIVEN UPON ADMISSION, ADDRESSED IN LETTER FORM TO PATIENTS THAT APPEAR TO BE HAVING DIFFICULTY PAYING THEIR BILL AND/OR A DISCUSSION IS HAD WITH THE PATIENT ON THE AVAILABILITY OF VARIOUS GOVERNMENT BENEFITS, SUCH AS MEDICAID OR STATE PROGRAMS. WHERE APPLICABLE, THE PATIENT IS ASSISTED WITH QUALIFICATION FOR SUCH PROGRAMS.ADDITIONALLY, A CONCERTED EFFORT IS MADE TO INFORM NON-ENGLISH SPEAKING PATIENTS ABOUT FINANCIAL ASSISTANCE POLICIES. MULTILINGUAL SIGNS ARE POSTED IN THE REGISTRATION AND WAITING AREAS SO THAT THE POLICIES ARE CLEARLY COMMUNICATED TO PATIENTS AND PROSPECTIVE PATIENTS. THE ROLE AND RESPONSIBILITIES OF THE FINANCIAL ASSISTANCE COUNSELOR INCLUDE HOW TO QUALIFY PATIENTS FOR MEDICAID, SCHIP AND OTHER GOVERNMENT PROGRAMS. PART VI, LINE 4: FORT MADISON COMMUNITY HOSPITAL SERVES A COMMUNITY OF APPROXIMATELY 12,916 AND A COMBINED SERVICE AREA OF APPROXIMATELY 39,879. THE HOSPITAL'S PRIMARY SERVICE AREA INCLUDES MOST OF LEE COUNTY, IA AS WELL AS PORTIONS OF HANCOCK COUNTY, IL. THE PRIMARY SERVICE AREA HAS A POPULATION OF APPROXIMATELY 22,505 AND A MEDIAN AGE OF 43.6. FORT MADISON COMMUNITY HOSPITAL RECEIVES 50.8% OF THE PRIMARY SERVICE AREA INPATIENT MARKET SHARE. THE HOSPITAL'S SECONDARY SERVICE AREA INCLUDES PORTIONS OF LEE COUNTY, IA, VAN BUREN COUNTY, IA AND HANCOCK COUNTY, IL. THE SECONDARY SERVICE AREA HAS A POPULATION OF APPROXIMATELY 17,374 AND A MEDIAN AGE OF 42. FORT MADISON COMMUNITY HOSPITAL RECEIVES 10.2% OF THE SECONDARY SERVICE AREA INPATIENT MARKET SHARE. PART VI, LINE 5: FORT MADISON COMMUNITY HOSPITAL FURTHERS ITS EFFORTS TO PROMOTE THE HEALTH OF THE COMMUNITY BY ENSURING THE MAJORITY OF THE ORGANIZATION'S GOVERNING BODY IS COMPRISED OF PERSONS WHO RESIDE IN THE ORGANIZATION'S PRIMARY SERVICE AREA WHO ARE NEITHER EMPLOYEES NOR CONTRACTORS OF THE ORGANIZATION, NOR FAMILY MEMBERS OF SUCH. THE ORGANIZATION ALSO EXTENDS MEDICAL PRIVILEGES TO ALL QUALIFIED PHYSICIANS IN ITS COMMUNITY FOR SOME OR ALL OF ITS DEPARTMENTS. FORT MADISON COMMUNITY HOSPITAL IS COMMITTED TO SERVING THE RESIDENTS OF AREA COMMUNITIES. THE HOSPITAL CONTINUES THESE EFFORTS BY USING EXCESS FUNDS TO EXPAND ITS FACILITIES AND SERVICES TO BETTER SERVE THE COMMUNITY. FURTHERMORE, THE ORGANIZATION HAS PARTNERED WITH JEFFERSON ELEMENTARY SCHOOL TO IMPROVE THE HEALTH AND WELL-BEING OF THE YOUNGEST MEMBERS OF OUR COMMUNITY. FORT MADISON COMMUNITY HOSPITAL IS A DISPROPORTIONATE SHARE (FOR MEDICAID) HOSPITAL WHICH PARTICIPATES IN MEDICARE, MEDICAID, CHAMPUS, TRICARE AND OTHER GOVERNMENT SPONSORED HEALTH CARE PROGRAMS. PAYMENTS FOR SERVICES PROVIDED TO BENEFICIARIES OF THESE PROGRAMS ARE BASED ON PRE-ESTABLISHED AND UNILATERALLY SET FEE SCHEDULES IN ACCORDANCE WITH THE PATIENT'S DIAGNOSIS OR TEST OR PROCEDURE PERFORMED. THE DIFFERENCE BETWEEN THE SERVICE PRICE AND THE CONTRACTED PRICE IS WRITTEN-OFF BY THE HOSPITAL. THE CONTRACTED AMOUNT RECEIVED FROM THESE PROGRAMS IS OFTEN LESS THAN THE ACTUAL COST OF THE SERVICE, THE DIFFERENCE OF WHICH REPRESENTS A BENEFIT TO THE PATIENT AND THE COMMUNITY.FORT MADISON COMMUNITY HOSPITAL OPERATES AN EMERGENCY ROOM THAT IS OPEN 24 HOURS PER DAY, 365 DAYS PER YEAR. THE EMERGENCY ROOM HAS A TRAUMA CENTER WITH A CERTIFICATION LEVEL OF III. THE HOSPITAL'S EMERGENCY ROOM PROVIDES SERVICES TO ALL INDIVIDUALS, REGARDLESS OF THEIR ABILITY TO PAY AND DENIES SERVICES TO NO ONE.FORT MADISON COMMUNITY HOSPITAL PARTICIPATES IN COMMUNITY BUILDING ACTIVITIES IN A VARIETY OF WAYS. FMCH EMPLOYEES ROUTINELY PARTICIPATE IN COMMUNITY ACTIVITIES SUCH AS PARADES, FIRST AID TENTS AT COMMUNITY EVENTS AND BIG BROTHER-BIG SISTER ACTIVITIES. THEY ALSO PARTICIPATE IN COMMUNITY HEALTH IMPROVEMENT ADVOCACY EFFORTS. THE HOSPITAL MARKETING DIRECTOR IS ON THE LOCAL CHAMBER OF COMMERCE BOARD OF DIRECTORS AND THE CEO IS A MEMBER OF THE SOUTHEAST IOWA REGIONAL RIVERBOAT COMMISSION THAT AWARDS GRANTS TO LOCAL COMMUNITY BENEFIT PROJECTS.IN ADDITION TO THE ABOVE, THE HOSPITAL BUILD A NEW OUTPATIENT REHABILITATION CENTER. THE BUILDING INCLUDES SPACE FOR PHYSICAL, OCCUPATIONAL AND SPEECH THERAPY SERVICES, INCLUDING A SMALL POOL. THE DESIGN INCLUDES A WALKING TRACK FOR USE BY THE PUBLIC. THE WALKING TRACK IS USED TO PROMOTE WELLNESS WITH ALL OF OUR CLIENT GROUPS: BUSINESS, PATIENTS, EMPLOYEES. THE HOSPITAL PROVIDES VARIOUS PROGRAMS AND SERVICES TO INFORM AND TRAIN MEMBERS OF THE COMMUNITY ON SAFETY, HEALTH AND LIFESTYLE TOPICS, AS WELL AS PROVIDE OPPORTUNITIES FOR LEARNING IN A SAFE ENVIRONMENT. THE PROGRAMS ARE FREE OR A NOMINAL FEE IS CHARGED TO DEFRAY A PORTION OF THE COST. EXAMPLES OF THE PROGRAMS ARE EDUCATION PROGRAMS FOR ADVANCED DIRECTIVES, DIABETES, CPR/FIRST AID, PRENATAL, FAMILY/PARENTING AND SIBLING RELATIONSHIPS, AS WELL AS TRAINING TO STUDENTS OF A VARIETY OF AGES. THE HOSPITAL ORGANIZED SUPPORT GROUPS FOR VARIOUS GROUPS INCLUDING CANCER, DIABETES, OSTOMY AND OTHER HEALTH TOPICS.FITNESS, EXERCISE AND SELF-HELP PROGRAMS WERE OFFERED TO PROMOTE AND SUPPORT THE BENEFITS OF PHYSICAL FITNESS, EXERCISE, HEALTHY LIFESTYLES AND STRESS MANAGEMENT. THE HOSPITAL SPONSORED OR PARTICIPATED IN COMMUNITY HEALTH FAIRS AND THE COMMUNITY HEALTH AND FITNESS FAIR IS HELD ANNUALLY BY THE HOSPITAL FOR THE COMMUNITY CONSISTING OF VARIOUS EXHIBITS ON HEALTH RELATED TOPICS. IT IS OPEN TO ALL AGES. ANOTHER ANNUAL EVENT IS THE WOMEN'S HEALTH CONFERENCE FOR AREA WOMEN OF ALL AGES. THE CONFERENCE INCLUDES SPEAKERS ON WOMEN RELATED HEALTH ISSUES. THE HOSPITAL ALSO SPONSORS A KID'S DAY AT THE LEE COUNTY FAIR, THE LEE COUNTY FAIR SENIOR DAY, LEE COUNTY SAFETY DAY AND THE LOCAL RELAY FOR LIFE. THE HOSPITAL PROVIDES A COURTESY TRANSPORTATION SERVICE TO RESIDENTS OF SEVERAL AREA COMMUNITIES. VARIOUS PICK-UP TIMES AND LOCATIONS ARE PROVIDED.FORT MADISON COMMUNITY HOSPITAL MAINTAINS A WEBSITE TO PROVIDE THE COMMUNITY WITH FREE INFORMATION ON HEALTH AND WELLNESS TOPICS, PHYSICIANS, COMMUNITY PROGRAMS, HEALTH SERVICES AND EMPLOYMENT OPPORTUNITIES.THE HOSPITAL PROVIDES VARIOUS SERVICES TO AREA BUSINESSES ON A CONTRACT BASIS INCLUDING EDUCATION PROGRAMS ON WELLNESS AND WORKPLACE INJURY PREVENTION, ON-SITE ERGONOMIC EVALUATIONS, DRUG/ALCOHOL TESTING/SCREENING, EVALUATION OF WORK RELATED INJURIES AND BACK ASSESSMENTS. THE HOSPITAL UNDERWRITES A PORTION OF THE COST OF THESE SERVICES. PART VI, LINE 6: NOT APPLICABLE REPORTS FILED WITH STATES PART VI, LINE 7 IA 1 FORT MADISON RODEO CORP PO BOX 80 FORT MADISON IA 52627 420658297 501(C)(4) 11000 PROMOTE COMMUNITY ACTIVE LIFESTYLE LEE COUNTY ECONOMIC DEVELOPMENT GROUP 110 MAIN STREET SUITE 200 MONTROSE IA 52639 043605260 501(C)(3) 5000 PROMOTE ENTITIES MISSION AND ACTIVITIES FORT MADISON ECONOMIC DEVELOPMENT CORP PO BOX 427 FORT MADISON IA 52627 421300666 501(C)(3) 10000 GENERAL SUPPORT 2 1 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: AS DONATION REQUESTS ARE RECEIVED BY THE HOSPITAL, AN INDEPENDENT SENIOR LEADERSHIP TEAM EVALUATES AND APPROVES THE RECIPIENTS FOR THE CHARITABLE/COMMUNITY BENEFIT DONATIONS. X X X 0 0 0 0 0 0 0 0 0 C JAMES PLATT 250375 0 41421 0 7260 0 11962 0 53929 0 364947 0 0 0 BRADLEY KOKJOHN 180610 0 45773 0 0 0 9055 0 37136 0 272574 0 0 0 MITCHELL PAUL MD 542872 0 0 0 0 0 12250 0 14614 0 569736 0 0 0 ROY J TINGUELY MD 235019 0 157648 0 0 0 12250 0 19486 0 424403 0 0 0 MARK S CALKINS MD 600018 0 94745 0 0 0 8373 0 17053 0 720189 0 0 0 TIMOTHY S STAUDTE MD 230006 0 243643 0 0 0 12250 0 21811 0 507710 0 0 0 TODD W GRAY MD 230006 0 154321 0 0 0 12250 0 19486 0 416063 0 0 0 SUPPLEMENTAL INFORMATION PART III AMOUNTS REPORTED IN PART II FOR C JAMES PLATT AND BRADLEY KOKJOHN WERE PAID BY QUORUM HEALTH RESOURCES, A HEALTHCARE MANAGEMENT SERVICES COMPANY. CITY OF FORT MADISON IOWA 426004688 NONEAVAIL 2002-03-01 6010000 REFUND THE ISSUER'S PREVIOUS ISSUE OF HOSPITAL REFUNDING REVENUE BONDS (FORT 0 1 0 CITY OF FORT MADISON IOWA 426004688 NONEAVAIL 2003-08-01 5810000 (1) PAYING A PORTION OF THE COSTS OF CONSTRUCTING AND EQUIPPING A 30,225 SQU 0 1 0 CITY OF FORT MADISON IOWA 426004688 NONEAVAIL 2011-10-01 8500000 FINANCE A PORTION OF COSTS OF REMODELING, CONSTRUCTING, EQUIPPING AND FURNIS 0 1 0 6010000 5906320 103680 1 0 1 1 5810000 1710500 99500 4000000 2004 1 0 1 1 8500000 8500000 2013 0 0 0 1 0 0 0 0 0.00000 0.00000 0.00000 0 0 0 0 0 0.00000 0.00000 0.00000 0 0 0 0 0 0.00000 0.00000 0.00000 0 1 0 0 0 0 0 1 0 0 0 0 0 1 1 0 0 0 0 TODD W GRAY MD EDUCATIONAL X 4167 4165 0 1 1 4165 FORM 990, PART VI, SECTION A, LINE 2 C. JAMES PLATT AND BRADLEY J. KOKJOHN HAVE A BUSINESS RELATIONSHIP AS BOTH ARE BOARD MEMBERS OF RENAISSANCE HEALTH SERVICES, INC., A RELATED ORGANIZATION. FORM 990, PART VI, SECTION A, LINE 3 C. JAMES PLATT, CEO AND BRAD KOKJOHN, CFO ARE EMPLOYED BY QUORUM HEALTH RESOURCES, A HEALTHCARE MANAGEMENT SERVICES COMPANY, WHICH PROVIDES MANAGEMENT SERVICES TO THE ORGANIZATION. FORM 990, PART VI, SECTION B, LINE 11 A COPY OF THE FORM 990 IS REVIEWED BY THE CFO WITH THE EXTERNAL ACCOUNTANTS FOR COMPLETENESS AND ACCURACY PRIOR TO FILING THE FORM 990. A COPY OF THE FINAL VERSION IS PROVIDED TO EACH BOARD MEMBER PRIOR TO FILING WITH THE INTERNAL REVENUE SERVICE. FORM 990, PART VI, SECTION B, LINE 12C EACH DIRECTOR, PRINCIPAL OFFICER AND MEMBER OF A COMMITTEE WITH BOARD DELEGATED POWERS ANNUALLY SIGNS A STATEMENT WHICH AFFIRMS THAT SUCH PERSON: 1) HAS RECEIVED A COPY OF THE CONFLICT OF INTEREST POLICY, 2) HAS READ AND UNDERSTANDS THE POLICY, 3) HAS AGREED TO COMPLY WITH THE POLICY, AND 4) UNDERSTANDS THAT THE HOSPITAL IS A CHARITABLE ORGANIZATION AND THAT IN ORDER TO MAINTAIN ITS FEDERAL TAX EXEMPTION IT MUST ENGAGE PRIMARILY IN ACTIVITIES WHICH ACCOMPLISH ONE OR MORE OF ITS TAX-EXEMPT PURPOSES. IN CONNECTION WITH ANY ACTUAL OR POSSIBLE CONFLICTS OF INTEREST, ANY INTERESTED PERSON MUST DISCLOSE THE EXISTENCE AND NATURE OF HIS OR HER FINANCIAL INTEREST TO THE DIRECTORS AND MEMBERS OF COMMITTEES WITH BOARD DELEGATED POWERS CONSIDERING THE PROPOSED TRANSACTION OR ARRANGEMENT. UPON ANY DISCLOSURE OF THE FINANCIAL INTEREST, THE INTERESTED PERSON LEAVES THE BOARD OR COMMITTEE WHILE THE FINANCIAL INTEREST IS DISCUSSED AND VOTED UPON. THE REMAINING BOARD OR COMMITTEE MEMBERS DECIDE IF A CONFLICT OF INTEREST EXISTS. ALL SUCH ACTIONS ARE RECORDED IN THE MINUTES OF THE BOARD OR COMMITTEE MEETING. FORM 990, PART VI, SECTION B, LINE 15 THE COMPENSATION COMMITTEE, ACTING ON BEHALF OF THE BOARD OF DIRECTORS, MEETS AT LEAST ANNUALLY TO ASSIST THE BOARD OF DIRECTORS IN FULFILLING ITS OVERSIGHT RESPONSIBILITIES FOR EXECUTIVE COMPENSATION. QUORUM HEALTH RESOURCES, AN INDEPENDENT MANAGEMENT CONSULTANT, PRESENTS TO THE FULL BOARD OF DIRECTORS COMPENSATION INFORMATION WHICH INCLUDES COMPARABLES AND INDUSTRY GUIDELINES ALONG WITH RECOMMENDATIONS FOR THE BOARD'S APPROVAL FOR COMPENSATION OF THE CEO AND CFO. THE COMPENSATION COMMITTEE REVIEWS COMPENSATION DATA AND RELATED POLICIES AND DETERMINES WHETHER SUCH COMPENSATION IS REASONABLE AND CONSISTENT WITH FAIR MARKET VALUE IN ORDER TO RECOMMEND TO THE FULL BOARD OF DIRECTORS COMPENSATION AMOUNTS FOR APPROVAL. COMPENSATION OF PHYSICIANS EMPLOYED OR CONTRACTED BY FMCH OR AN AFFILIATE ARE REVIEWED ANNUALLY USING THE MGMA DATA FOR COMPARISON. THE COMPENSATION COMMITTEE MAINTAINS DOCUMENTATION, CONSISTENT WITH THE RECORD RETENTION POLICY, OF ITS ACTIVITIES AND THE BASIS FOR ITS DECISIONS. THIS PROCESS OCCURS ANNUALLY. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE NOT MADE AVAILABLE TO THE PUBLIC. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED LOSSES ON INVESTMENTS: -30,073. EQUITY IN SUBSIDIARY EARNINGS 239,374. CONTRIBUTION FROM SUBSIDIARY REPORTED AS NET ASSET TRANSFER ON REPORT -200,000. CONTRIBUTION FROM SUBSIDIARY -70,000. TOTAL TO FORM 990, PART XI, LINE 5: -60,699. FORM 990, PART XII, LINE 2C THE FORT MADISON COMMUNITY HOSPITAL GOVERNING BOARD MEETS WITH THE AUDITORS TO REVIEW THE AUDIT REPORT AND MANAGEMENT LETTER. THIS PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. FORM 990, PART VII, LINE 1A FORT MADISON COMMUNITY HOSPITAL (FMCH), FORT MADISON COMMUNITY HOSPITAL FOUNDATION (FMCHF), AND FORT MADISON PROFESSIONAL BUILDING ASSOCIATION (FMPBA) ARE RELATED ENTITIES. AS A RESULT, BOARD OVERLAP EXISTS AMONG THESE ENTITIES, AND THEIR RESPECTIVE POSITION AND TIME DEVOTED TO EACH ENTITY IS AS FOLLOWS: C. JAMES PLATT: OFFICER OF FMCHF AND FMPBA; 1 HOUR DEVOTED TO EACH ORGANIZATION BRADLEY KOKJOHN: OFFICER OF FMCHF AND FMPBA; 1 HOUR DEVOTED TO EACH ORGANIZATION JAMES GERDES: DIRECTOR OF FMCHF AND OFFICER OF FMPBA; 1 HOUR DEVOTED TO EACH ORGANIZATION FORT MADISON PROFESSIONAL BUILDING ASSOCIATION 5445 AVENUE O FORT MADISON IA 52627 421298064 SUPPORT FORT MADISON COMMUNITY HOSPITAL IA 501(C)(3) 11(A) FORT MADISON COMMUNITY HOSPITAL 1 FORT MADISON COMMUNITY HOSPITAL FOUNDATION 5445 AVENUE O FORT MADISON IA 52627 421446727 SUPPORT FORT MADISON COMMUNITY HOSPITAL IA 501(C)(3) 11(A) FORT MADISON COMMUNITY HOSPITAL 1 RENAISSANCE HEALTH SERVICES INC 5445 AVENUE O FORT MADISON IA 52627 421298222 MEDICAL SERVICE IA N/A C 0 1 1 0 0 0 0 0 0 1 1 0 0 0 0 1 0 0 FORT MADISON PROFESSIONAL BUILDING ASSOCIATION J 469548 FAIR MARKET VALUE FORT MADISON PROFESSIONAL BUILDING ASSOCIATION C 200000 FAIR MARKET VALUE FORT MADISON COMMUNITY HOSPITAL FOUNDATION C 70000 FAIR MARKET VALUE