2013-05-15T14:50:42-05:00 2012-06-30 390758449 WIPFLI LLP PO BOX 12237 GREEN BAY WI 543072237 990 2011-07-01 381443361 ASPIRUS KEWEENAW HOSPITAL ASPI 9063376500 205 OSCEOLA LAURIUM MI 49913 CHUCK NELSON 9063376500 2013-05-14 1 TERRI REXRODE CPA MST P00096513 9206620016 2013-05-14 2011 2016-02-24 21:20:13Z CHUCK NELSON 205 OSCEOLA STREET LAURIUM MI 49913 41306009 0 X WWW.ASPIRUSKEWEENAW.ORG X 1939 MI ASPIRUS KEWEENAW HOSPITAL PROVIDES COMPREHENSIVE INPATIENT, OUTPATIENT, EMERGENCY, MEDICAL AND PHYSICIAN CLINIC SERVICES. 14 10 415 34 0 0 47254 39367 34650606 38368528 696312 235459 121767 171134 35515939 38814488 0 0 0 0 20126634 21850300 0 0 0 14488131 14790977 34614765 36641277 901174 2173211 26325831 26435429 11209590 8497469 15116241 17937960 TO PROVIDE COMPREHENSIVE INPATIENT, OUTPATIENT, EMERGENCY, MEDICAL, AND PHYSICIAN CLINIC SERVICES. 0 0 31282533 38249626 ASPIRUS KEWEENAW HOSPITAL PROVIDES COMPREHENSIVE INPATIENT, OUTPATIENT, EMERGENCY, MEDICAL, AND PHYSICIAN CLINIC SERVICES. 31282533 1 1 0 1 0 0 0 0 0 0 1 1 0 1 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 94 0 1 415 1 0 0 0 0 0 0 0 0 0 0 X 14 10 0 0 0 0 1 1 1 1 1 0 0 0 1 1 1 1 1 1 1 0 X CHUCK NELSON 9063376500 205 OSCEOLA STREET LAURIUM MI 49913 CHUCK NELSON 40.00 X X 237395 0 27258 DANIEL L DALQUIST 0.50 X X 0 0 0 EDWARD JENICH 0.50 X X 0 0 0 DAVID H GILBERT MD 0.50 X X 0 0 0 ELIZABETH BENYI DO 40.00 X 234367 0 16047 JERRY W LUOMA MD 20.00 X 228814 0 34269 GLENN KAUPPILA DO 40.00 X 194788 0 19976 RICK NEVERS 0.50 X 0 0 0 DARRYL PIERCE 0.50 X 0 0 0 JOEL TUORINIEMI 0.50 X 0 0 0 BETTY J ANDERSON 0.50 X 0 0 0 DALE TAHTINEN 0.50 X 0 0 0 DARRELL LENTZ 0.50 X 0 0 0 DUANE L ERWIN 0.50 X 0 0 0 MIKE HAUSWIRTH 40.00 X 151433 0 23066 SHANE JACQUES 40.00 X 127021 0 25449 MICHAEL HAGWELL 40.00 X 0 0 0 GRACE TOUSIGNANT 40.00 X 120684 0 19728 JOHN NOVOSAD MD 40.00 X 271238 0 17518 MARY LIMBACK MD 40.00 X 370688 0 29579 BRAD LAITINEN MD 40.00 X 296222 0 27499 JAMES BLACK MD 40.00 X 273263 0 30525 BRUCE HARVEY MD 40.00 X 305770 0 24484 2811683 0 295398 26 0 1 0 MARK R SHEBUSKI MD PC 301 W LAKE AVENUE HOUGHTON MI 49931 PROVIDER SERVICES & BUILDING 867336 UP HEALTH CARE NETWORK INC 228 W WASHINGTON ST STE 2 MARQUETTE MI 49855 HEALTHCARE NETWORK SERVICES 252707 CHG COMPANIES INC PO BOX 972651 DALLAS TX 75397 SUPPLIED ORTHOPEDIC SURGEON 225625 DLP MARQUETTE GENERAL HOSPITAL 103 POWELL CT BRENTWOOD TN 37027 VARIOUS MEDICAL SERVICES 156564 UPPER PENINSULA MARKETING DEPARTMENT 616 SHELDON 207 HOUGHTON MI 49931 MARKETING SERVICES 113278 5 8825 30542 39367 NET PATIENT SERVICE RE 621990 38249626 38249626 CAFETERIA REVENUE 624200 110542 110542 VENDING REVENUE 624200 8360 8360 38368528 156492 156492 174029 2895 171134 171134 171134 2542764 24829 2486677 1949 56087 22880 78967 78967 38814488 38249626 0 525495 3267081 2535047 732034 14607069 13274481 1332588 632762 561231 71531 2159141 1959079 200062 1184247 1050373 133874 75364 75364 67492 67492 3475726 2924092 551634 210033 3839 206194 5515468 4890567 624901 465366 419043 46323 220631 153700 66931 3348 98 3250 200876 180880 19996 995250 896181 99069 716876 533865 183011 PROVISION FOR BAD DEBTS 1753859 1753859 OTHER EXPENSES 993510 146198 847312 RECRUITMENT EXPENSE 97178 97178 36641277 31282533 5358744 0 26424 650806 4214093 6911803 3892233 4563534 425266 499225 287647 862639 21503754 15083856 6745769 6419898 4580689 2946344 1987357 1464183 91833 91833 4074520 2025164 26325831 26435429 5080698 3479985 5441150 4121242 687742 896242 11209590 8497469 X 14855922 17685063 260319 252897 15116241 17937960 26325831 26435429 X 2173211 648508 X 0 1 0 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 6457 6457 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: ORGANIZATION HAS INDIRECT LOBBYING ACTIVITIES THROUGH THE PAYMENT OF HOSPITAL ASSOCIATION DUES. 746455 746455 13714060 10032136 3681924 7005302 5051720 1953582 37937 37937 6419898 INVESTMENT IN UPPER PENINSULA HEALTH NETWORK, LLC 757683 F INVESTMENT IN MERCY AMBULANCE, INC. 256500 C INVESTMENT IN ASPIRUS VNA HOME HEALTH, INC. 450000 C 1464183 DUE FROM ASPIRUS KEWEENAW ENTERPRISES 1186630 DUE FROM (TO) THIRD-PARTY REIMBURSEMENT -92534 DUE FROM ASPIRUS, INC. 4570 DUE FROM ASPIRUS KEWEENAW FOUNDATION 18326 NOTE RECEIVABLE 901000 DUE FROM OTHER ENTITIES 7172 2025164 LONG TERM INSURANCE PAYABLE 896242 896242 38814488 36641277 2173211 -506492 1155000 648508 2821719 36875368 0 36875368 1939120 1939120 38814488 34719923 0 34719923 1921354 1921354 36641277 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: IN ORDER TO ACCOUNT FOR ANY UNCERTAIN TAX POSITIONS, THE ORGANIZATION DETERMINES 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 CONSOLIDATED FINANCIAL STATEMENTS. THE ORGANIZATION RECORDED NO ASSETS OR LIABILITIES FOR UNCERTAIN TAX POSITIONS OR UNRECOGNIZED TAX BENEFITS IN 2012 OR 2011. FEDERAL TAX RETURNS FOR THE YEARS ENDED JUNE 30, 2009, AND BEYOND REMAIN SUBJECT TO EXAMINATION BY THE APPLICABLE TAXING AUTHORITIES. PART XI, LINE 8 - OTHER ADJUSTMENTS: EQUITY TRANSFER WITH FOUNDATION 1,155,000. SCHEDULE D PART XII, LINE 4B; IS COMPRISED OF RENTAL EXPENSE AND EXPENSES PER THE 990 THAT ARE INCLUDED IN OTHER INCOME ON THE FINANCIAL STATEMENTS OF $75,946. SCHEDULE D, PART XIII, LINE 4B; IS COMPRISED OF RENTAL EXPENSE AND EXPENSES PER THE 990 THAT ARE INCLUDED IN OTHER INCOME ON THE FINANCIAL STATEMENTS $75,946. 1 1 1 X 1 X 180.000000000000 1 0 0 38290 38290 0.00110 3006604 1445882 1560722 0.04480 3044894 1445882 1599012 0.04590 200252 6370 193882 0.00560 200252 6370 193882 0.00560 3245146 1452252 1792894 0.05150 0 924681 323638 11227178 11391958 -164780 X 1 1 1 1 ASPIRUS KEWEENAW HOSPITAL

205 OSCEOLA STREET LAURIUM MI 49913

X X X X ASPIRUS KEWEENAW HOSPITAL 1 1 1 100.000000000000 1 180.000000000000 1 X X X X X 1 1 X 1 0 1 X 0 0 5 ASPIRUS KEWEENAW MEDICAL ARTS

301 LAKESHORE DR HOUGHTON MI 49931

CLINIC ASPIRUS KEWEENAW OUTPATIENT THERAPIES

342 HECLA STREET LAURIUM MI 49913

OUTPATIENT THERAPY ASPIRUS KEWEENAW OUTPATIENT THERAPIES

960 RAZORBACK DRIVE SUITE 3 HOUGHTON MI 49931

OUTPATIENT THERAPY ASPIRUS KEWEENAW LAKE LINDEN CLINIC

110 CALUMET ST LAKE LINDEN MI 49945

CLINIC ASPIRUS KEWEENAW FASTCARE

900 MEMORIAL RD HOUGHTON MI 49931

CLINIC PART I, LINE 7: THE COST METHOD THAT IS USED ON THE 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. THIS IS THEN DIVIDED BY GROSS PATIENT SERVICES REVENUE. 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 $ 1793558. PART II: WHILE THERE IS GROWING AGREEMENT IN THE UNITED STATES ABOUT WHAT CONSTITUTES A NON-PROFITS HOSPITAL'S COMMUNITY BENEFIT AND CHARITY CARE, THESE EFFORTS CONTINUE TO BE A WORK IN PROGRESS. ASPIRUS KEWEENAW HOSPITAL, INC., IN ADDITION TO PROVIDING SIGNIFICANT CHARITY CARE AND OTHER COMMUNITY BENEFITS AS DEFINED BY THE IRS, THE ORGANIZATION BELIEVES THAT IT PROVIDES A CRITICALLY IMPORTANT BENEFIT WHICH IS NOT QUANTIFIED. ASPIRUS KEWEENAW HOSPITAL, LIKE MOST COMMUNITY HOSPITALS, WAS CREATED AND IS MAINTAINED IN ORDER TO PROVIDE CARE LOCALLY WHICH WITHOUT THE HOSPITAL WOULD NOT BE AVAILABLE LOCALLY. IN ADDITION TO INPATIENT HOSPITALIZATIONS, THE ORGANIZATION PROVIDES LOCAL ACCESS TO MANY SERVICES INCLUDING: EMERGENCY SERVICES, RESPIRATORY THERAPY, OCCUPATIONAL THERAPY, PHYSICAL THERAPY, FAMILY PRACTICE CLINICS, AND LABORATORY AND PATHOLOGY SERVICES. PART III, LINE 4: IN EVALUATING THE COLLECTABILITY OF ACCOUNTS RECEIVABLE, THE ORGANIZATION ANALYZES PAST RESULTS AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYOR SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND THE PROVISION FOR BAD DEBTS. MANAGEMENT REGULARLY REVIEWS DATA ABOUT THESE MAJOR PAYOR SOURCES OF REVENUE IN EVALUATING THE SUFFICIENCY OF THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. SPECIFICALLY, FOR RECEIVABLES RELATING TO SERVICES PROVIDED TO PATIENTS HAVING THIRD-PARTY COVERAGE, THE ORGANIZATION 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 PAYOR HAS NOT YET PAID, OR FOR PAYORS WHO ARE KNOWN TO BE HAVING FINANCIAL DIFFICULTIES THAT MAKE THE REALIZATION OF AMOUNTS DUE UNLIKELY. FOR RECEIVABLES ASSOCIATED WITH SELF-PAY PATIENTS (WHICH INCLUDES BOTH PATIENTS WITHOUT INSURANCE AND PATIENTS WITH DEDUCTIBLE AND COPAYMENT BALANCES DUE FOR WHICH THIRD-PARTY COVERAGE EXISTS FOR PART OF THE BILL), THE ORGANIZATION 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.THE HOSPITAL ESTIMATES THE APPROXIMATELY 35% OF BAD DEBT EXPENSE DURING FY2012 WAS ATTRIBUTED TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S CHARITY FINANCIAL ASSISTANCE POLICY THAT DID NOT COMPLETE THE APPLICATION PROCESS.THE ORGANIZATION BELIEVES THIS SHOULD BE CHARITY CARE BECAUSE IF THE PROPER APPLICATION WOULD HAVE BEEN COMPLETED, THIS AMOUNT WOULD HAVE BEEN APPROPRIATELY RECORDED. PART III, LINE 8: ALLOWABLE MEDICARE COSTS WERE OBTAINED FROM THE ORGANIZATION'S FILED MEDICARE COST REPORT. AS SUCH THEY ONLY INCLUDE THE AMOUNTS ALLOWED IN THE FORM 990 INSTRUCTIONS. THEREFORE, THEY ONLY INCLUDE A PORTION OF THE GROSS MEDICARE REVENUE OF THE ORGANIZATION AND DO NOT CONSIDER ALL OF THE CONTRACTUAL ADJUSTMENTS FOR SERVICES REIMBURSED BY THE MEDICARE PROGRAM. THE MEDICARE REVENUES AMOUNTS LISTED DO NOT INCLUDE PHYSICIAN SERVICES FOR THE COVERAGE OF THE EMERGENCY DEPARTMENT AT THE HOSPITAL AS WELL AS ANESTHESIA PROFESSIONAL SERVICES, REVENUES FOR ANY PATIENTS COVERED UNDER MEDICARE ADVANTAGE PLAN PROGRAMS, PHYSICAL THERAPY SERVICES PROVIDED TO NURSING HOME RESIDENTS, AND A SIGNIFICANT PORTION OF LAB SERVICES PROVIDED TO AREA CLINIC PATIENTS. PART III, LINE 9B: UNDER THE ORGANIZATION'S COLLECTION AND CHARITY CARE POLICIES, ASPIRUS KEWEENAW HOSPITAL MAKES EVERY ATTEMPT TO IDENTIFY AND PROMOTE CHARITY CARE TO PATIENTS. INCLUDED IN THE ORGANIZATION'S CHARITY CARE POLICY IT IS NOTED THAT PATIENTS MAY QUALIFY FOR CHARITY CARE EITHER PRIOR TO ADMISSION OR FOLLOWING DISCHARGE.ASPIRUS KEWEENAW HOSPITAL WILL PROVIDE MEDICALLY ACUTE SERVICES TO PATIENTS WHO MEET THE CRITERIA OF THE PATIENT FINANCIAL ASSISTANCE PROGRAM WITHOUT CHARGE OR AT AMOUNTS LESS THAN ESTABLISHED RATES FOR QUALIFYING PATIENTS. THIS PROGRAM IS PROVIDED FOR PATIENTS WHO ARE UNINSURED, UNDERINSURED, AND/OR MEDICALLY INDIGENT. PATIENTS AND THEIR FAMILIES HAVE A RESPONSIBILITY TO HELP THE HOSPITAL QUALIFY THEM FOR THE APPROPRIATE LEVEL OR TYPE OF FINANCIAL ASSISTANCE GIVEN THEIR CIRCUMSTANCES.DURING THE PATIENT ACCOUNT COLLECTION PROCESS, SELF-PAY PATIENTS ARE ALSO INFORMED OF THE HOSPITAL'S COLLECTION POLICIES AS WELL AS THE CARITY CARE PROGRAM TO ALLOW PATIENTS THE OPPORTUNITY TO COMPLETE THE APPROPRIATE FORMS AND QUALIFY UNDER THE PROGRAM.AN ACCOUNT WILL BE CONSIDERED DELINQUENT IF ADEQUATE AND TIMELY PAYMENTS ARE NOT MADE AND/OR THERE IS A LACK OF COMMUNICATION FROM THE PATIENT/FAMILY:1.) 60 DAYS AFTER BALANCE BECOMES THE RESPONSIBILITY OF THE PATIENT/GUARANTOR. 2.) IF A PATIENT/GUARANTOR REFUSES TO PAY AN ACCOUNT WITHOUT VALID REASON. 3.) STATEMENTS ARE MAIL-RETURNED AND THE PATIENT/GUARANTOR CANNOT BE LOCATED. 4.) A PATIENT/GUARANTOR ACCOUNT HISTORY SHOWS THE DEBT IS UNLIKELY TO BE PAID. 5.) ACCOUNT PAYMENTS ARE INADEQUATE FOR THE BALANCE AND AGE OF ACCOUNT. 6.) THE PATIENT/GUARANTOR STOPS MAKING SCHEDULED PAYMENTS. ASPIRUS KEWEENAW HOSPITAL PART V, SECTION B, LINE 19D: THE ORGANIZATION DETERMINES THE AMOUNT BILLED FOR ELIGIBLE FAP PATIENTS BY STARTING WITH A DISCOUNT OF 20% AND THEN INCREASES THIS PERCENTAGE BASED ON FPG. PART VI, LINE 2: THE ORGANIZATION MEETS WITH A LOCAL FEDERALLY QUALIFIED HEALTH CENTER TO CONSULT AND DETERMINE HOW TO MEET THE HEALTH CARE NEEDS IN THE ORGANIZATION'S GEOGRAPHICAL AREA. IN ADDITION, THE ORGANIZATION ITSELF EVALUATES ITS' OWN SERVICES OFFERED IN THEIR SERVICE AREA AND EVALUATES OTHER SERVICES THAT COULD BE PROVIDED TO BENEFIT THE COMMUNITY SERVED. PART VI, LINE 3: ASPIRUS KEWEENAW HOSPITAL WILL PROVIDE MEDICALLY ACUTE SERVICES TO PATIENTS WHO MEET THE CRITERIA OF THE PATIENT FINANCIAL ASSISTANCE PROGRAM (PFAP) WITHOUT CHARGE OR AT AMOUNTS LESS THAN ESTABLISHED RATES FOR QUALIFYING PATIENTS. THIS PROGRAM IS PROVIDED FOR PATIENTS WHO ARE UNINSURED, UNDERINSURED, AND/OR MEDICALLY INDIGENT. PATIENTS AND THEIR FAMILIES HAVE A RESPONSIBILITY TO HELP THE HOSPITAL QUALIFY THEM FOR THE APPROPRIATE LEVEL OR TYPE OF FINANCIAL ASSISTANCE GIVEN THEIR CIRCUMSTANCE.A PFAP BROCHURE IS GIVEN TO EACH INPATIENT. THE BROCHURE INFORMS PATIENTS OF OUR PATIENT FINANCIAL ASSISTANCE PROGRAM AND HOW TO APPLY. WE HAVE SIGNS POSTED IN ALL ASPIRUS KEWEENAW HOSPITAL AND CLINIC LOCATIONS THAT LET THE PATIENT KNOW ABOUT OUR PFAP PROGRAM. PFAP BROCHURES ARE DISPLAYED IN PATIENT AREAS OF OUR CLINICS AND HOSPITAL. SIGNS ARE POSTED THROUGHOUT AKH TO INFORM THE PATIENT THAT WE PARTICIPATE IN THE MEDICAID PROGRAM. A NOTICE REGARDING OUR SLIDING FEE SCALE AND HOW TO APPLY FOR IT, IS POSTED AT ALL PHYSICIAN RECEPTION AREAS. ALL BILLERS AND FRONT LINE STAFF DIRECT PATIENT INQUIRIES REGARDING PAYMENT, MEDICAID, AND FINANCIAL ASSISTANCE TO A FINANCIAL COUNSELOR. SELF PAY PATIENTS ARE INFORMED OF THE COST OF HIGH DOLLAR PROCEDURES AND OFFERED OPTIONS FOR PAYMENT AND ASSISTANCE PROGRAMS PRIOR TO SCHEDULING THE PROCEDURE. AN ASPIRUS KEWEENAW SOCIAL WORKER COUNSELS PATIENTS AND MAKES THEM AWARE OF ALL AVAILABLE COMMUNITY RESOURCES, INCLUDING MEDICAID AND OUR AKH PATIENT FINANCIAL ASSISTANCE PROGRAM. SHE ASSISTS THEM IN COMPLETING THE MEDICAID APPLICATION. A FINANCIAL COUNSELOR WILL VISIT THE PATIENT IF REQUESTED DURING THE SOCIAL WORKER INTERVIEW WITH THE PATIENT. FINANCIAL COUNSELORS SUGGEST OUR PFAP TO ELIGIBLE PATIENTS WHILE MAKING PAYMENT ARRANGEMENTS. PART VI, LINE 4: THE ORGANIZATION PROVIDES SERVICES PRIMARILY TO THE ELDERLY AND FRAIL OF NORTHERN HOUGHTON AND KEWEENAW COUNTIES. THE LARGEST CITIES IN THESE REGIONS INCLUDE HOUGHTON, HANCOCK, LAURIUM AND CALUMET. AS A PERCENTAGE OF TOTAL REVENUE, MEDICARE AND MEDICAID COMPRISE OF 60% AND 11%, RESPECTIVELY FOR THE ORGANIZATION. PART VI, LINE 5: THE BOARD OF DIRECTOR'S IS COMPRISED OF INDEPENDENT COMMUNITY MEMBERS. THE ORGANIZATION PROVIDES, FREE OF CHARGE TO THE LOCAL SCHOOL, AN ATHLETIC TRAINER. X X X 0 1 0 0 0 0 0 0 0 CHUCK NELSON 231411 0 0 0 5984 0 8572 0 18686 0 264653 0 0 0 ELIZABETH BENYI DO 233412 0 0 0 955 0 9400 0 6647 0 250414 0 0 0 JERRY W LUOMA MD 228714 0 0 0 100 0 6847 0 27422 0 263083 0 160000 0 GLENN KAUPPILA DO 136443 0 52624 0 5721 0 5600 0 14376 0 214764 0 0 0 MIKE HAUSWIRTH 151025 0 0 0 408 0 5680 0 17386 0 174499 0 0 0 SHANE JACQUES 126980 0 0 0 41 0 4921 0 20528 0 152470 0 0 0 JOHN NOVOSAD MD 270686 0 0 0 552 0 9800 0 7718 0 288756 0 0 0 MARY LIMBACK MD 229044 0 140689 0 955 0 9400 0 20179 0 400267 0 0 0 BRAD LAITINEN MD 281051 0 0 0 15171 0 9800 0 17699 0 323721 0 0 0 JAMES BLACK MD 272659 0 0 0 604 0 9800 0 20725 0 303788 0 0 0 BRUCE HARVEY MD 304867 0 0 0 903 0 4900 0 19584 0 330254 0 0 0 PART I, LINE 4B JERRY LUOMA RECEIVED A PAYMENT OF $160,000 FROM A SUPPLEMENTAL NON-QUALIFIED RETIREMENT PLAN DURING THE YEAR. VILLAGE OF LAURIUM FINANCE AUTHORITY 386007184 2004-03-05 3546723 REFUNDING BOND SERIES 1997 0 0 0 977946 3546723 3546723 1998 1 0 1 1 0 0 0 0 0 0 0 0 0 0 0 FORM 990, PART VI, SECTION A, LINE 6 ASPIRUS, INC. AND KEWEENAW HEALTH FOUNDATION ARE VOTING MEMBERS. FORM 990, PART VI, SECTION A, LINE 7A THE BOARD OF DIRECTORS IS COMPRISED OF 3 MEMBERS FROM ASPIRUS, INC. AND 11 MEMBERS FROM KEWEENAW HEALTH FOUNDATION. FORM 990, PART VI, SECTION A, LINE 7B MAJOR OPERATING DECISION ITEMS UPON APPROVAL BY THE BOARD OF ASPIRUS KEWEENAW HOSPITAL REQUIRE APPROVAL BY THE ASPIRUS, INC. BOARD OF DIRECTORS. FORM 990, PART VI, SECTION B, LINE 11 THE BOARD OF DIRECTORS HAS DELEGATED THE REVIEW PROCESS OF THE FORM 990 TO THE CFO. FORM 990, PART VI, SECTION B, LINE 12C ANNUALLY, BOARD MEMBERS ARE REQUIRED TO DISCLOSE CONFLICTS TO THE BOARD. THIS PROCESS IS MONITORED THROUGH SELF DISCLOSURE. FORM 990, PART VI, SECTION B, LINE 15 COMPENSATION IS DETERMINED BY USE OF STATE HOSPITAL ASSOCIATION SURVEY AND SYSTEM SURVEY. THE COMPENSATION OF THE CEO IS DETERMINED BY AN EXECUTIVE COMPENSATION COMMITTEE OF THE BOARD OF DIRECTORS. TO DETERMINE WAGE COMPENSATION FOR OTHER EXECUTIVE POSITIONS, AN ANNUAL WAGE ANALYSIS IS COMPLETED. THE ORGANIZATION USES SALARY SURVEYS AND SALARY AGENCIES TO DETERMINE THE WAGE SCALE. CONSULTATION ON THE SETTING OF PAY IS PROVIDED TO THE ORGANIZATION BY ASPIRUS, INC. HUMAN RESOURCES. ANY INCREASES IN EXECUTIVE COMPENSATION IS APPROVED BY THE BOARD WITH THE ACTUAL AMOUNT OF SALARY INCREASE BASED OFF OF AN ANNUAL EMPLOYEE EVALUATION. FOR ALL EXECUTIVES, A BONUS POOL IS ESTABLISHED AND CRITERIA IS DEVELOPED AND DETERMINED AT THE BOARD OF DIRECTOR LEVEL. THE BOARD THEN REVIEWS ANNUALLY THE PLAN AND DETERMINES IF A PAYOUT WILL BE PROVIDED. ALL COMPENSATION DECISIONS ARE DOCUMENTED THROUGH A COMPENSATION SUB-COMITTEE OF THE BOARD OF DIRECTORS BY INDIVIDUALS WITHOUT CONFLICT. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION HAS DEEMED THAT ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE THE PROPERTY OF THE ORGANIZATION AND ARE NOT AVAILABLE FOR PUBLIC INSPECTION. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED LOSSES ON INVESTMENTS: -506,492. EQUITY TRANSFER WITH FOUNDATION 1,155,000. TOTAL TO FORM 990, PART XI, LINE 5: 648,508. KEWEENAW HEALTH FOUNDATION 205 OSCEOLA STREET LAURIUM MI 49913 352340440 DEVELOP RESOURCES TO IMPROVE THE HEALTH AND WELL BEING OF THE PEOPLE MI 501(C)(3) LINE 7 N/A 0 ASPIRUS KEWEENAW ENTERPRISES 205 OSCOLA ST LAURIUM MI 49913 383390273 PHARMACY MI ASPIRUS KEWEENAW HOSPITAL C 139441 1710955 1.00000 1 0 0 0 0 0 0 0 1 1 1 1 1 1 1 1 0 1 ASPIRUS KEWEENAW ENTERPRISES A 104584 FMV ASPIRUS KEWEENAW ENTERPRISES R 1082046 FMV