2013-03-19T15:15:15-05:00 2012-06-30 390758449 WIPFLI LLP PO BOX 12237 GREEN BAY WI 543072237 990 2011-07-01 390944012 MOUNDVIEW MEMORIAL HOSPITAL & CLINICS MOUN 6083393331 402 WEST LAKE STREET FRIENDSHIP WI 53934 JEREMY NORMINGTON 6083393331 2013-03-07 1 TERRI REXRODE CPA MST P00096513 9206620016 2013-03-07 2011 2016-02-25 16:41:14Z JEREMY NORMINGTON 402 WEST LAKE STREET FRIENDSHIP WI 53934 16206094 0 X WWW.MOUNDVIEW.ORG X 1959 WI MOUNDVIEW MEMORIAL HOSPITAL AND CLINICS, INCORPORATED, AS A COMMUNITY HEALTH RESOURCE WILL PROVIDE MODERN FACILITIES AND EQUIPMENT TO ENSURE THE DELIVERY OF SERVICES WITH AN EMPHASIS ON PRIMARY HEALTH CARE TO THE PEOPLE OF THE HOSPITAL SERVICE AREA. THE HOSPITAL'S LEADERSHIP, WITH ITS RESOURCES WILL RESPOND IN A TIMELY MANNER TO PHYSICAL, PSYCHOLOGICAL AND SPIRITUAL NEEDS, EMPHASIZING THE 'WHOLE PERSON.' MOUNDVIEW MEMORIAL HOSPITAL AND CLINCS, INCORPORATED WILL PROVIDE MANAGEMENT, AND WELL TRAINED STAFF TO PROVIDE COMPASSIONATE HEALTH CARE. MOUNDVIEW MEMORIAL HOSPITAL AND CLINICS, INCORPORATED SHALL EXPLORE THOSE PROPOSALS FOR NETWORKS, AFFILIATIONS, MERGERS, AND PARTICIPATE IN HMO'S AS DEEMED IN THE BEST INTEREST OF THOSE WE SERVE. 7 7 155 64 0 0 99989 58305 15597900 16043468 61380 31307 63513 64630 15822782 16197710 0 0 0 0 7388932 7579588 0 0 0 7654838 8085271 15043770 15664859 779012 532851 14696929 14866435 9063353 8697751 5633576 6168684 MOUNDVIEW MEMORIAL HOSPITAL & CLINICS PROVIDES INPATIENT HOSPITAL AND GENERAL HEALTH CARE SERVICES WITH THE PRIMARY MARKET OF ADAMS COUNTY WISCONSIN BY OPERATING A 25 BED CRITICAL ACCESS HOSPITAL. 0 0 12083310 15787209 THE HOSPITAL IS A GENERAL MEDICAL CRITICAL ACCESS HOSPITAL LICENSED FOR 25 BEDS. DURING FISCAL YEAR 2012, THE HOSPITAL HAD 447 ACUTE INPATIENT DAYS AND 480 MEDICARE SKILL NURSING DAYS (SWING BED). THE HOSPITAL ALSO HAD 5,092 EMERGENCY ROOM VISITS, 1,233 URGENT CARE VISITS AND 16,633 OTHER OUTPATIENT ANCILLARY ENCOUNTERS. MOUNDVIEW MEMORIAL HOSPITAL CONVERTED TO ELECTRONIC MEDICAL RECORDS FOR THE RECORDING, DOCUMENTATION, AND ANALYSIS OF MEDICAL HEALTH INFORMATION. 12083310 1 1 0 1 0 0 0 0 0 0 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 1 1 0 0 0 1 7 0 1 155 1 0 0 0 0 0 0 0 0 0 0 X 7 7 0 0 0 0 1 1 1 1 1 0 0 0 1 1 1 1 1 1 1 0 WI X JEREMY NORMINGTON 6083393331 402 WEST LAKE STREET FRIENDSHIP WI 53934 JOE PARLANTE DDS 2.50 X X 0 0 0 MARY POLIVKA 2.50 X X 0 0 0 DEBRA SEGINA 2.50 X X 0 0 0 JEFF WEINKAUF 2.50 X X 0 0 0 BARBARA ALBRECHT 2.50 X 0 0 0 TOM CROKE 2.50 X 0 0 0 DIANA BRONIEC 2.50 X 0 0 0 JEREMY NORMINGTON 40.00 X 176539 0 26414 DONALD HEINZ 40.00 X 137960 0 17676 MARK HATTON MD 40.00 X 205481 0 22755 RICARDO ALMONTE 40.00 X 206328 0 2019 JASON BELLAK MD 40.00 X 133897 0 27451 SHERYL KUGEL FNP APNP 40.00 X 128547 0 31299 DAVE SHAPIRO 40.00 X 118842 0 24412 RICK PARONI 16.00 X 142595 0 0 1250189 0 152026 8 0 1 0 EMCARE 7032 COLLECTION CENTER DRIVE CHICAGO IL 60693 ER PHYSCIAN COVERAGE 1126816 SHARED IMAGING SVCS PO BOX 45686 MADISON WI 73744 MEDICAL IMAGING SERVICES 386463 FIRST REFLECTIONS 228 N PINE ST ADAMS WI 53910 CRNA PROFESSIONAL SERVICES 300000 MINISTRY HEALTH CARE 11925 W LAKE PARK DR SUITE 100 MILWAUKEE WI 53224 CONSULTING 242272 WIPFLI LLP 11 SCOTT STREET WAUSAU WI 54402 AUDITING, FINANCIAL ACCOUNTING 156792 10 46333 11972 58305 NET PATIENT REVENUE 900099 15768838 15768838 MISCELLANEOUS 900099 256259 256259 DIETARY INCOME 900099 18371 18371 16043468 30587 30587 73014 8384 64630 64630 64630 720 0 720 720 720 16197710 15787209 0 352196 360173 360173 5856246 5323708 532538 520567 499447 21120 842602 745293 97309 173604 173604 95748 95748 38600 38600 2844211 2715086 129125 55734 55734 1438183 1184532 253651 235300 213821 21479 61454 47021 14433 524 524 302233 274644 27589 602606 536239 66367 161218 28283 132935 BAD DEBT EXPENSE 1182085 1182085 EQUIPMENT RENTS & LEASE 369928 271925 98003 REPAIRS & MAINTENANCE 350213 180477 169736 COLLECTION EXPENSE 79835 79835 93795 62834 30961 15664859 12083310 3581549 0 600 600 3116239 1526827 1478344 1626288 90000 1404 14926 403755 419007 136504 298274 17977841 7792529 8846237 10185312 713846 705201 14696929 14866435 2098615 1742418 5537032 5468177 582232 1387356 845474 99800 9063353 8697751 X 5050831 5599767 582745 568917 5633576 6168684 14696929 14866435 X 532851 2257 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 1543 1543 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: WHA MEMBERSHIP DUES OF $13,440 INCLUDE A PORTION OF DUES THAT ARE SPENT ON LOBBYING ISSUES REGARDING HEALTHCARE. THERE WAS $1,543 ALLOCATED TO LOBBYING THIS FISCAL YEAR. 43973 43973 11376767 3699627 7677140 29426 2134 27292 6527675 4090768 2436907 10185312 PAYABLE TO THIRD PARTY REIMBURSEMENT PROGRAMS 99800 99800 16197710 15664859 532851 2257 2257 535108 16268953 62859 62859 16206094 -8384 -8384 16197710 15673243 8384 8384 15664859 0 15664859 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: IN ORDER TO ACCOUNT FOR ANY UNCERTAIN TAX POSITIONS, ASC TOPIC 740-10, INCOME TAXES, REQUIRES AN ORGANIZATION TO ASSESS WHETHER IT IS MORE LIKELY THAN NOT THAT A TAX POSITION WILL BE SUSTAINED UPON EXAMINATION OF THE TECHNICAL MERITS OF THE POSITION, ASSUMING THE TAXING AUTHORITY HAS FULL KNOWLEDGE OF ALL INFORMATION. IF THE TAX POSITION DOES NOT MEET THE MORE-LIKELY-THAN-NOT RECOGNITION THRESHOLD, THE BENEFIT OF THAT POSITION IS NOT RECOGNIZED IN THE FINANCIAL STATEMENTS. THE HOSPITAL AND FOUNDATAION RECORDED NO ASSETS OR LIABILITIES FOR UNCERTAIN TAX POSITIONS OR UNRECOGNIZED TAX BENEFITS IN 2012 OR 2011. FEDERAL INCOME TAX RETURNS FOR THE YEARS ENDED 2009 AND BEYOND REMAIN SUBJECT TO EXAMINATION BY THE INTERNAL REVENUE SERVICE. PART XI, LINE 8 - OTHER ADJUSTMENTS: CHANGE IN ASSETS HELD IN POLIVKA TRUST 2,257. PART XII, LINE 2D - OTHER ADJUSTMENTS: FOUNDATION MARKET ADJUSTMENT 62,859. PART XII, LINE 4B - OTHER ADJUSTMENTS: RENTAL EXPENSES -8,384. PART XIII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES 8,384. 1 1 1 X 1 X 0.0 1 1 1 1 1 1 583000 0 583000 0.04030 2222264 2050895 171369 0.01180 2805264 2050895 754369 0.05210 147389 15691 131698 0.00910 6927 0 6927 0.00050 154316 15691 138625 0.00960 2959580 2066586 892994 0.06170 0 587168 176150 5803031 5751019 52012 X 1 1 1 1 MOUNDVIEW MEMORIAL HOSPITAL

402 WEST LAKE STREET FRIENDSHIP WI 53934

X X X X MOUNDVIEW MEMORIAL HOSPITAL 1 1 1 200.000000000000 1 200.000000000000 1 X 1 1 X X X X 1 0 1 X 0 0 1 MOUNDVIEW CLINIC

402 WEST LAKE STREET FRIENDSHIP WI 53934

CLINIC PART I, LINE 3C: THE ORGANIZATION DOES NOT OFFER DISCOUNTED CARE. PATIENTS UPON REGISTRATION ARE GIVEN THE POLICY AND REQUIREMENTS TO BE ELIGIBLE FOR CHARITY CARE. IF A PATIENT IS QUALIFIED FOR CHARITY CARE, THE ENTIRE AMOUNT IS WRITTEN OFF. IN FISCAL YEAR 2013, WE HAVE ADOPTED A SLIDING SCALE PAYMENT SCHEDULE FOR PATIENTS WHICH WE DO NOT WRITE-OFF 100%. PART I, LINE 6A: WI HOSPITAL ASSOCIATION PART I, LINE 7: THE COST-TO-CHARGE RATIO FROM THE MEDICARE COST REPORT WAS USED AS PER IRS WORKSHEET 2. PART I, L7 COL(F): AT LEAST 30% OF THE AMOUNT OF BAD DEBT IS ESTIMATED TO BE CHARITY CARE. THERE ARE TIMES THAT THE PATIENT DOES NOT COMPLETE THE FINANCIAL AID FORMS TIMELY, DESPITE FREQUENT COMMUNICATIONS. THESE AMOUNTS EVENTUALLY END UP BEING WRITTEN OFF TO BAD DEBT. PART II: THE HOSPITAL'S COMMUNITY BUILDING ACTIVITIES PROMOTES HEALTH OF THE COMMUNITIES IT SERVES THROUGH LOCAL ADVERTISEMENTS, INVOLVEMENT WITH CHAMBER OF COMMERCE, DEPARTMENT OF AGING AND OTHER COMMUNITY ORGANIZATIONS. PART III, LINE 4: THE RATIO OF PATIENT COST TO CHARGES WAS CALCULATED BY DIVIDING HOSPITAL EXPENSES NET OF NON-PATIENT REVENUES AND IDENTIFIED COMMUNITY BENEFIT EXPENSES BY GROSS PATIENT REVENUES. THIS PERCENTAGE WAS THEN MULTIPLIED BY THE GROSS REVENUES ON BAD DEBT ACCOUNTS. PART III, LINE 8: IT IS CONSIDERED COMMUNITY BENEFIT AS THE HOSPITAL IS REIMBURSED ON MEDICARE ALLOWABLE COSTS. MEDICARE ALLOWABLE COSTS ARE DEFINED BY MEDICARE. THEY DO NOT NECESSARILY CAPTURE ALL COSTS OF THE HOSPITAL PROVIDING SERVICES TO THE COMMUNITY. CONSEQUENTLY, THERE ARE COSTS NOT REIMBURSED BY EITHER PATIENT OR THE PROGRAM. THE COST METHODOLOGY USED TO DETERMINE MEDICARE ALLOWABLE COSTS IS A STEP-DOWN ALLOCATION OF COSTS FROM NON-REVENUE AREAS TO REVENUE AREAS. THIS ALLOCATION IS DONE FOLLOWING MEDICARE RULES AND REGULATIONS. PART III, LINE 9B: PATIENTS UPON REGISTRATION ARE GIVEN THE POLICY AND REQUIREMENTS TO BE ELIGIBLE FOR CARITY CARE. THEY ARE ENCOURAGED BY A FINANCIAL ADVISOR TO REVIEW THEIR SITUATION FOR ELIGIBILITY. MOUNDVIEW MEMORIAL HOSPITAL PART V, SECTION B, LINE 19D: CARE FOR THE INDIGENT IS DETERMINED PROSPECTIVELY PER POLICY. HOSPITAL CHARGES AT TIME OF SERVICE ARE CONSISTENT WITH ALL INDIVIDUALS GETTING SERVICE AT MOUNDVIEW. ELIGIBILITY FOR ASSISTANCE IS 200% OF FEDERAL POVERTY GUIDELINES OF HOUSEHOLD FAMILY SIZE. FAMILY INCOME ONLY-ASSETS ARE NOT CONSIDERED. ALL ELIGIBLE INDIIDUALS HAVE 100% OF CHARGES FORGIVEN. PART VI, LINE 2: THE HOSPITAL DEVELOPS COMMUNITY SURVEY WITH CONJUNCTION OF THE LOCAL PUBLIC HEALTH DEPARTMENT TO ASSESS SPECIFIC UNMET COMMUNITY NEEDS. PART VI, LINE 3: THE HOSPITAL ANNUALLY PUBLISHES IN THE LOCAL PAPER THE EXISTENCE OF ITS CHARITY PLAN AND QUALIFYING INCOME NEEDS TO QUALIFY. THE EXISTENCE OF A CHARITY PLAN IS POSTED IN THE ADMITTING AREA. UPON REGISTRATION, THE PATIENT IS INFORMED OF THE HOSPITAL'S CHARITY PLAN, ELIGIBILITY AND METHODS FOR APPLYING. ANYONE INTERESTED IN FURTHER INFORMATION IS REFERRED TO THE PATIENT ACCOUNT COORDINATOR FOR QUESTIONS AND ELIGIBILITY. THIS PERSON WORKS WITH THE PATIENT IN APPLICATION AS WELL AS EXPLORING THE POSSIBLE ELIGIBILITY OF ANY OTHER GOVERNMENT PROGRAM THAT MAY BE APPLICABLE. IE MEDICAID, BADGER CARE. PART VI, LINE 4: THE ORGANIZATION SERVES ADAMS COUNTY WISCONSIN BORDERED BY HWY 82 SOUTH, COUNTY C NORTH. PART VI, LINE 5: THE HOSPITAL WORKS WITH THE LOCAL PUBLIC HEALTH AGENCIES TO COORDINATE COMMUNITY HEALTH SERVICES TO MEET THE NEEDS OF THE LOCAL COMMUNITY. LONG-RANGE STRATEGIC AND CAPITAL BUDGET PLANNING WITH ADMINISTRATION, MEDICAL STAFF AND BOARD OF DIRECTORS. SURVEY OF OPINIONS FROM HOSPITAL ASSOCIATION. X X X X 0 0 0 0 0 0 0 0 0 JEREMY NORMINGTON 163348 0 12921 0 270 0 0 0 26414 0 202953 0 0 0 DONALD HEINZ 119753 0 18207 0 0 0 0 0 17676 0 155636 0 0 0 MARK HATTON MD 183328 0 22153 0 0 0 0 0 22755 0 228236 0 0 0 RICARDO ALMONTE 176146 0 28946 0 1236 0 0 0 2019 0 208347 0 0 0 JASON BELLAK MD 119326 0 14355 0 216 0 0 0 27451 0 161348 0 0 0 SHERYL KUGEL FNP APNP 106269 0 22096 0 182 0 0 0 31299 0 159846 0 0 0 VILLAGE OF FRIENDSHIP REVENUE BONDS 396006271 2003-11-01 5000000 WI HOSPITAL DEVELOPMENT REVENUE BONDS 0 0 0 1370000 5000000 110000 4890000 2005 0 0 1 0 0 0 0 0 0.00000 0.00000 0.00000 1 0 0 0 0 0 0 FORM 990, SCHEDULE K, PART III, LINE 7 MANAGEMENT CALCULATES AND REVIEWS BOND COVENANTS ON A MONTHLY BASIS. THE BOND COVENANTS ARE REPORTED TO THE BOARD OF DIRECTORS. JASON BELLAK X 90000 90000 0 1 1 90000 FORM 990, PART VI, SECTION A, LINE 6 ANY PERSON OVER THE AGE OF EIGHTEEN YEARS WHO IS A RESIDENT OF ADAMS COUNTY MAY BE A MEMBER OF THE CORPORATION. MEMBERSHIP MAY BE ATTAINED BY ANY SUCH PERSON WHO SHALL AGREE IN WRITING TO BECOME A MEMBER OF THIS CORPORATION BY SUBSCRIBING TO A MEMBERSHIP LIST OF SAID CORPORATION. ANNUAL MEMBERSHIPS WILL BE IN EFFECT FROM JULY 1ST TO JUNE 30TH OF EACH FISCAL YEAR. FORM 990, PART VI, SECTION A, LINE 7A EACH PERSON WHO WAS A MEMBER IN GOOD STANDING AS OF THE PREVIOUS JUNE 30TH IS ENTITLED TO ONE VOTE FOR EACH SEAT OF THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION A, LINE 7B MEMBERS OF THE ORGANIZATION MUST APPROVE BYLAW CHANGES. FORM 990, PART VI, SECTION B, LINE 11 THE 990 IS REVIEWED BY THE CEO AND CFO PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C THE CONFLICT OF INTEREST POLICY IS REVIEWED EVERY YEAR BY THE POLICY AND PROCEDURE COMMITTEE AND BY THE CEO. OFFICERS AND DIRECTORS ARE REQUIRED TO REVIEW THE POLICY AND DISCLOSE CONFLICTS. FORM 990, PART VI, SECTION B, LINE 15 CEO COMPENSATION IS BASED ON DIRECT NEGOTIATIONS BETWEEN THE BOARD MEMBERS WITHOUT CONFLICT AND THE INDIVIDUAL UTILIZING CURRENT RELEVANT MARKET SURVEYS AS A GUIDE WITH THE LANGUAGE OF CONTRACT GIVEN TO MMC ATTORNEYS FOR REVIEW AND COMMENTS. SUBSEQUENT MODIFICATIONS ARE PERFORMANCE BASED AND MARKET DRIVEN. FOR OTHER OFFICERS AND KEY EMPLOYEES THE CEO DETERMINES SALARY BASED ON THE MARKET, EXPERIENCE AND INDUSTRY SURVEY GUIDES. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION BELIEVES THE GOVERNING DOCUMENTS, AND POLICIES ARE THE PROPERTY OF THE ORGANIZATION AND ARE NOT AVAILABLE FOR PUBLIC INSPECTION. THE FINANCIAL STATEMENTS ARE NOW REQUIRED TO BE ATTACHED TO FORM 990. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: CHANGE IN ASSETS HELD IN POLIVKA TRUST 2,257. TOTAL TO FORM 990, PART XI, LINE 5: 2,257. OVERSIGHT OF AUDIT AND SELECTION OF INDEPENDENT AUDITOR IS THE RESPONSIBILITY OF THE AUDIT COMMITTEE. THIS PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. MEMORIAL HEALTHCARE FOUNDATION OF ADAMS CO PO BOX 40 FRIENDSHIP WI 53934 391775074 RAISE FUNDS FOR MOUNDVIEW MEMORIAL HOSPITAL & CLINICS WI 501(C)(3) 11B, TYPE II MOUNDVIEW MEMORIAL HOSPITAL & CLINICS 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0