2013-11-14T14:23:54-06:00 2012-12-31 476097913 SEIM JOHNSON LLP 18081 BURT STREET SUITE 200 OMAHA NE 680224722 990 2012-01-01 420860039 STEWART MEMORIAL COMMUNITY HOSPITAL STEW 7124644200 1301 W MAIN LAKE CITY IA 51449 JIM HENKENIUS 7124644200 2013-11-14 1 JULIE M GERKEN P00400882 4023302660 2012 2016-02-25 16:41:14Z JIM HENKENIUS 1301 W MAIN LAKE CITY IA 51449 31845710 0 X WWW.STEWARTMEMORIAL.ORG X 1958 IA TO PROVIDE A COMPLETE CONTINUUM OF HEALTHCARE SERVICES TO THE PEOPLE OF LAKE CITY AND THE SURROUNDING COMMUNITIES WITHOUT REGARD FOR ABILITY TO PAY AND WITHOUT DISCRIMINATION. 9 8 315 70 4290546 -85722 153281 64405 27021806 30027896 188344 274881 1110747 521268 28474178 30888450 0 0 0 0 13685394 14815237 0 0 0 15389815 16179446 29075209 30994683 -601031 -106233 20004088 19479737 8766447 8177226 11237641 11302511 X STEWART MEMORIAL COMMUNITY HOSPITAL IS COMMITTED TO PROVIDING QUALITY HEALTHCARE WITH A PERSONAL TOUCH AND RESPONDING TO THE NEEDS OF THE COMMUNITIES AND PEOPLE WE SERVE. 0 0 2823528 1866710 MEDICAL/SURGICAL SERVICES. 1458757 2930631 RADIOLOGY SERVICES. 1456690 4927487 LABORATORY SERVICES. 23045207 16184348 OTHER MEDICAL SERVICES 23045207 16184348 28784182 1 1 0 0 0 0 0 0 0 0 1 0 0 1 0 1 1 0 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 0 0 0 0 1 33 0 1 315 1 1 1 0 0 0 0 0 0 0 0 0 X 9 8 0 0 0 0 0 0 0 1 1 0 0 0 1 1 1 1 1 1 0 0 X JIM HENKENIUS CFO 7124644200 1301 W MAIN STREET LAKE CITY IA 51449 CHARLES SCHMITT 2.00 0.00 X X 0 0 0 MARY WARNER 2.00 0.00 X X 0 0 0 HEATHER MCCLUE 2.00 0.00 X X 0 0 0 BRADLEY LANE 2.00 0.00 X X 0 0 0 DEBRA LIGHTNER 1.00 0.00 X 0 0 0 SCOTT NESBITT 1.00 0.00 X 0 0 0 LINDA BETTIN 1.00 0.00 X 0 0 0 CHADRIC DIETRICH 1.00 0.00 X 0 0 0 SUSAN HORNBACK 40.00 0.00 X 556281 0 35864 LEAH GLASGO 40.00 0.00 X 183015 0 9282 JIM HENKENIUS 40.00 0.00 X 130255 0 32163 DEREK DUNCAN 40.00 0.00 X 485249 0 37939 DAVID FRATE 40.00 0.00 X 362615 0 31323 PABLO AMADOR 40.00 0.00 X 348273 0 33456 PERRY HENELY 40.00 0.00 X 198608 0 22048 ADAM SWISHER 40.00 0.00 X 337481 0 28916 2601777 0 230991 17 0 1 1 RTG MEDICAL 1005 E 23RD STREET FREMONT NE 68025 NURSING/OR LOCUM TENENS 390041 LEE DEAKINE HIEB MD 524 W 4TH STREET LOGAN IA 51546 ORTHOPAEDIC SERVICES 340000 DIAGNOSTIC IMAGING ASSOC 1111 SIXTH AVENUE DES MOINES IA 50314 RADIOLOGY SERVICES 250977 AUREUS NURSING LLC PO BOX 3037 OMAHA NE 68103 NURSING LOCUM TENENS 189979 WESTERN IOWA SURGERY 311 S CLARK STREET CARROLL IA 51401 GENERAL SURGERY SERVICES 174000 6 64405 64405 PATIENT SERVICE REVENUE 621400 14164534 14164534 MEDICARE/MEDICAID REVENUE 621400 11572816 11572816 RETAIL PHARMACY REVENUE 446110 4290546 4290546 30027896 138378 138378 115587 58244 57343 57343 57343 983307 52212 869930 29086 113377 23126 136503 136503 OTHER REVENUE 621400 292099 292099 CAFETERIA SALES 900099 171826 171826 463925 30888450 25909176 4290546 624323 X 925805 592145 333660 11291869 10754205 537664 479299 461463 17836 1374707 1301969 72738 743557 697888 45669 21055 21055 23232 23232 119269 119269 26121 26121 3747892 3590499 157393 162301 161683 618 1476254 1248114 228140 303315 303315 198494 146814 51680 207810 207810 1457332 1023877 433455 180183 180183 RETAIL PHARMACY EXPENSE 3897188 3897188 MEDICAL SUPPLIES 2723934 2723934 BAD DEBT 1069120 1069120 MISCELLANEOUS 493073 394854 98219 72873 29121 43752 30994683 28784182 2210501 0 91268 41705 705414 705727 4252099 4405291 1102212 1386104 101350 33303 27044875 18068926 10217476 8975949 2967505 2901498 566764 1030160 20004088 19479737 2934018 3236237 3695000 3400000 2137429 1540989 8766447 8177226 X 11237641 11302511 11237641 11302511 20004088 19479737 -106233 171103 0 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 171513 171513 5840584 4202236 1638348 20277108 13325581 6951527 755670 541109 214561 8975949 INTEREST RECEIVABLE 10335 RENTAL PROPERTY NET 13705 OTHER RECEIVABLE 239759 DEFERRED FINANCING COSTS, NET 101450 ESTIMATED THIRD PARTY SETTLEMENTS 664911 1030160 X 30048677 171103 58244 229347 29819330 1069120 1069120 30888450 29983807 58244 58244 29925563 1069120 1069120 30994683 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X, LINE 2: THE HOSPITAL IS A NOT-FOR-PROFIT CORPORATION AS DESCRIBED IN SECTION 501(C)(3) OF THE CODE AND HAS RECEIVED A DETERMINATION LETTER THAT IT IS EXEMPT FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE CODE. THE INTERNAL REVENUE SERVICE HAS ESTABLISHED STANDARDS TO BE MET TO MAINTAIN THE HOSPITAL'S TAX EXEMPT STATUS. IN GENERAL, SUCH STANDARDS REQUIRE THE HOSPITAL TO MEET A COMMUNITY BENEFITS STANDARD AND COMPLY WITH VARIOUS LAWS AND REGULATIONS. THE HOSPITAL ACCOUNTS FOR UNCERTAINTIES IN ACCOUNTING FOR INCOME TAX ASSETS AND LIABILITIES USING GUIDANCE INCLUDED IN FASB ASC 740, INCOME TAXES. THE HOSPITAL RECOGNIZES THE EFFECT OF INCOME TAX POSITIONS ONLY IF THOSE POSITIONS ARE MORE LIKELY THAN NOT OF BEING SUSTAINED. AT DECEMBER 31, 2012 AND 2011, THE HOSPITAL HAD NO UNCERTAIN TAX POSITIONS ACCRUED. WITH FEW EXCEPTIONS, THE HOSPITAL IS NO LONGER SUBJECT TO INCOME TAX EXAMINATIONS FOR YEARS ENDED PRIOR TO DECEMBER 31, 2009. PART XI, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES 58,244. PART XI, LINE 4B - OTHER ADJUSTMENTS: PROVISION FOR UNCOLLECTIBLE ACCOUNTS 1,069,120. PART XII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES 58,244. PART XII, LINE 4B - OTHER ADJUSTMENTS: PROVISION FOR UNCOLLECTIBLE ACCOUNTS 1,069,120. 1 1 1 X 1 X 100.000000000000 0 1 0 1 1 180 155972 0 155972 0.00520 2888895 1708866 1180029 0.03940 180 3044867 1708866 1336001 0.04460 13 7519 97923 28502 69421 0.00230 3 22 31613 0 31613 0.00110 5 0 25510 0 25510 0.00090 21 7541 155046 28502 126544 0.00430 21 7721 3199913 1737368 1462545 0.04890 846 0 846 0.00000 846 846 1 1069120 0 8948989 9362566 -413577 X 1 0 1 1 STEWART MEMORIAL COMMUNITY HOSPITAL

1301 WEST MAIN STREET LAKE CITY IA 51449

X X X X STEWART MEMORIAL COMMUNITY HOSPITAL 1 1 X X X X X X 12 1 0 1 X X X X X X 0 0 1 1 200.000000000000 1 100.000000000000 0 0 1 X X 1 0 X 1 X 0 0 5 MCCRARY-ROST CLINIC

1351 WEST MAIN STREET LAKE CITY IA 51449

HEALTH CLINIC DAYTON CLINIC

24 SOUTH MAIN DAYTON IA 50530

HEALTH CLINIC GOWRIE CLINIC

1800 MAIN GOWRIE IA 50543

HEALTH CLINIC LAKE VIEW CLINIC

1160 3RD STREET LAKE VIEW IA 51540

HEALTH CLINIC ROCKWELL CITY CLINIC

505 EAST LAKE STREET ROCKWELL CITY IA 50579

HEALTH CLINIC PART I, LINE 3C: NOT APPLICABLE PART I, LINE 6A: STEWART MEMORIAL COMMUNTIY HOSPITAL'S COMMUNITY BENEFIT REPORT IS NOT PREPARED BY A RELATED ORGANIZATION. PART I, LINE 7: STEWART MEMORIAL COMMUNITY HOSPITAL USED THE WORKSHEETS PROVIDED IN THE IRS INSTRUCTIONS FOR SCHEDULE H IN ADDITION TO THE INTERNAL COST ACCOUNTING SYSTEM. PART I, LINE 7G: THERE ARE NO COSTS ATTRIBUTABLE TO A PHYSICIAN CLINIC INCLUDED ON LINE 7G. PART I, L7 COL(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 $1,069,120. PART II: OUR CEO IS A VOLUNTEER MEMBER OF THE COUNTY ECONOMIC DEVELOPMENT ORGANIZATION AND 2 MEMBERS OF OUR ORGANIZATION ALSO ARE ON OUR LOCAL BETTERMENT ORGANIZATION. AT THESE MONTHLY MEETINGS, THEY USE THEIR TIME TO PROMOTE THE SERVICES AND WELLNESS ACTIVITIES OUR HOSPITAL PROVIDES. CURRENT BUSINESSES AND PROSPECTIVE BUSINESSES UNDERSTAND THE VARIOUS HEALTH SERVICES THAT ARE MADE AVAILABLE TO THEM AND THEIR EMPLOYEES. OUR CEO AND AN EMPLOYED PHYSICIAN ARE MEMBERS OF THE CALHOUN COUNTY BOARD OF HEALTH. METHODOLOGY USED BY THE ORGANIZATION TO ESTIMATE BAD DEBT EXPENSE: PART III, LINE 2: IN EVALUATING THE COLLECTIBILITY OF ACCOUNTS RECEIVABLE, THE HOSPITAL ANALYZES ITS PAST HISTORY 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. FOR RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRD-PARTY COVERAGE, THE HOSPITAL ANALYZES CONTRACTUALLY DUE AMOUNTS AND ESTIMATES A PERCENTAGE OF THOSE ACCOUNTS THAT WILL TRANSITION TO SELF-PAY PATIENTS BASED ON HISTORICAL ANALYSIS. THE ESTIMATED PERCENTAGE OF THOSE TRANSITION ACCOUNTS ARE ADDED TO 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 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 4: THE ORGANIZATION'S FINANCIAL STATEMENTS DO NOT CONTAIN A SPECIFIC FOOTNOTE DESCRIBING BAD DEBT. HOWEVER, THE FOLLOWING IS THE TEXT OF THE FOOTNOTES TITLED "PATIENT RECEIVABLES, NET," "NET PATIENT SERVICE REVENUE," AND "CHARITY CARE." PATIENT RECEIVABLES, NET:THE HOSPITAL REPORTS PATIENT ACCOUNTS RECEIVABLE FOR SERVICES RENDERED AT NET REALIZABLE AMOUNTS FROM THIRD-PARTY PAYERS, PATIENTS AND OTHERS. ACCOUNTS RECEIVABLE ARE REDUCED BY AN ALLOWANCE FOR DOUBTFUL ACCOUNTS. IN EVALUATING THE COLLECTIBILITY OF ACCOUNTS RECEIVABLE, THE HOSPITAL ANALYZES ITS PAST HISTORY 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. FOR RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRD-PARTY COVERAGE, THE HOSPITAL ANALYZES CONTRACTUALLY DUE AMOUNTS AND ESTIMATES A PERCENTAGE OF THOSE ACCOUNTS THAT WILL TRANSITION TO SELF-PAY PATIENTS BASED ON HISTORICAL ANALYSIS. THE ESTIMATED PERCENTAGE OF THOSE TRANSITION ACCOUNTS ARE ADDED TO 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 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.PAYMENT FOR SERVICES IS EXPECTED WITHIN THIRTY DAYS OF RECEIPT OF THE BILLING. ACCOUNTS CONSIDERED PAST DUE ARE SENT TO COLLECTION AGENCIES WHEN EXTERNAL COLLECTION EFFORTS HAVE BEEN UNSUCCESSFUL. ANY AMOUNTS DEEMED UNCOLLECTIBLE ARE WRITTEN OFF ON A MONTHLY BASIS. THE HOSPITAL DOES NOT CHARGE INTEREST ON OUTSTANDING BALANCES OWED.NET PATIENT SERVICE REVENUE:THE HOSPITAL HAS AGREEMENTS WITH THIRD-PARTY PAYORS THAT PROVIDE FOR PAYMENTS TO THE HOSPITAL AT AMOUNTS DIFFERENT FROM ITS ESTABLISHED RATES. PAYMENT ARRANGEMENTS INCLUDE PROSPECTIVELY DETERMINED RATES PER DISCHARGE, REIMBURSED COSTS, DISCOUNTED CHARGES AND PER DIEM PAYMENTS. NET PATIENT SERVICE REVENUE IS REPORTED AT THE ESTIMATED NET REALIZABLE AMOUNTS FROM PATIENTS, RESIDENTS, THIRD-PARTY PAYORS, AND OTHERS FOR SERVICES RENDERED, INCLUDING ESTIMATED RETROACTIVE ADJUSTMENTS UNDER REIMBURSEMENT AGREEMENTS WITH THIRD-PARTY PAYORS. RETROACTIVE ADJUSTMENTS ARE ACCRUED ON AN ESTIMATED BASIS IN THE PERIOD THE RELATED SERVICES ARE RENDERED AND ADJUSTED IN FUTURE PERIODS AS FINAL SETTLEMENTS ARE DETERMINED.CHARITY CARE:TO FULFILL ITS MISSION OF COMMUNITY SERVICE, THE HOSPITAL 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 HOSPITAL DOES NOT PURSUE COLLECTION OF AMOUNTS DETERMINED TO QUALIFY AS CHARITY CARE, THEY ARE NOT REPORTED AS PATIENT SERVICE REVENUE.THE HOSPITAL IS DEDICATED TO PROVIDING COMPREHENSIVE HEALTHCARE SERVICES TO ALL SEGMENTS OF SOCIETY, INCLUDING THE AGED AND OTHERWISE ECONOMICALLY DISADVANTAGED. IN ADDITION, THE HOSPITAL PROVIDES A VARIETY OF COMMUNITY HEALTH SERVICES AT OR BELOW COST.THE BAD DEBT EXPENSE DOES NOT INCLUDE ANY PATIENTS ELIGIBLE UNDER OUR CHARITY CARE POLICY SINCE THEY ARE LISTED SEPARATELY IN THE GENERAL LEDGER. BAD DEBT EXPENSE IS NOT LISTED IN OUR COMMUNITY BENEFITS. PART III, LINE 8: NO MEDICARE SHORTFALL IS TREATED AS COMMUNITY BENEFIT. THE 2012 FILED MEDICARE COST REPORT WAS USED TO DETERMINE THE ALLOWABLE COSTS. PART III, LINE 9B: COLLECTION POLICY:PATIENTS ARE ADMITTED INTO THE HOSPITAL COMPUTER SYSTEM WITH APPROPRIATE FINANCIAL INFORMATION INCLUDING INSURANCE INFORMATION AND ARE ASSIGNED A FINANCIAL CLASS (F/C) USED TO SEGREGATE ACCOUNTS IN ACCOUNTS RECEIVABLE (A/R) BY PAYER TYPE. PATIENTS WHO ARE MINORS ARE ADMITTED WITH THE PARENT WHO CARRIES THE INSURANCE COVERAGE AS THE RESPONSIBLE PARTY OR IF NO INSURANCE, THE PARENT WHO BROUGHT THE CHILD IN FOR CARE IS LISTED AS GUARANTOR.THE BUSINESS OFFICE WILL SEND AN ITEMIZED STATEMENT OF CHARGES TO ALL PATIENTS WHO REQUEST A COPY. INSURANCE COMPANIES ARE BILLED ELECTRONICALLY THROUGH THE USE OF CAREMEDICS SOFTWARE WHENEVER POSSIBLE. ONCE THE INSURANCE COMPANY HAS PROCESSED THE CLAIM AND PAID ITS ENTIRE SHARE OR IF THE PATIENT DOESN'T HAVE INSURANCE, THEY WILL BE ASSIGNED A FINANCIAL CLASS OF P. SMCH ALLOWS PATIENTS TO SET UP PAYMENT ARRANGEMENTS FOLLOWING THIS SCHEDULE USING CHECK, MONEY ORDER, MASTERCARD OR VISA:BALANCE IS: MINIMUM PAYMENT:UNDER $250 $ 25.00 $251-$500 $ 50.00$501-$1000 $ 100.00$1001 - ABOVE $ 150.00THESE LIMITS ARE SET TO INSURE BALANCES ARE PAID IN FULL WITH 18 MONTHS IF AT ALL POSSIBLE. WHEN THE PATIENT IS ASSIGNED A FINANCIAL CLASS OF P, HE/SHE WILL RECEIVE A MONTHLY STATEMENT. IF NO PAYMENT OR ARRANGEMENT IS MADE AFTER 3 MONTHLY STATEMENTS, THE PATIENT IS SENT COLLECT LETTER 1 AT THE NEXT MONTHLY STATEMENT GENERATION. LETTER 1 STATES THE PATIENT HAS AN OUTSTANDING BALANCE DUE AND HE/SHE NEEDS TO MAKE A PAYMENT OR SETUP ARRANGEMENTS. IF THERE IS NO RESPONSE, THE PATIENT IS SENT COLLECT LETTER 2 AT THE NEXT MONTHLY STATEMENT GENERATION. LETTER 2 STATES THE PATIENT NEEDS TO CONTACT STEWART MEMORIAL COMMUNITY HOSPITAL WITHIN 10 DAYS OR THEIR ACCOUNT WILL BE TURNED OVER TO THE COLLECTION AGENCY. IF THERE IS NO RESPONSE TO LETTER 2, AT THE NEXT MONTHLY STATEMENT GENERATION, THE ACCOUNT CHANGES TO A FINANCIAL CLASS OF H OR N AND IS SENT TO THE COLLECTION AGENCY. STEWART MEMORIAL COMMUNITY HOSPITAL PART V, SECTION B, LINE 3: STEWART MEMORIAL COMMUNITY HOSPITAL (SMCH) CREATED A COMMUNITY NEEDS ASSESSMENT AND MADE IT AVAILABLE TO STAFF, COMMUNITY MEMBERS, MEMBERS OF OUR COUNTY PUBLIC HEALTH DEPARTMENT, LOCAL SCHOOLS AND OTHER ORGANIZATIONS. THE SURVEY WAS CREATED ONLINE AND ALLOWED FOR TABULATION OF RESPONSES AND IDENTIFIED NEEDS. THE SURVEY WAS PROMOTED VIA SMCH'S WEBSITE, EMAIL CAMPAIGN AND PAPER FLIERS. SMCH ALSO PARTNERED WITH AND USED INPUT FROM THE COUNTY PUBLIC HEALTH DEPARTMENT AS THEY HAD PREVIOUSLY CONDUCTED A COMMUNITY HEALTH NEEDS SURVEY IN 2011. STEWART MEMORIAL COMMUNITY HOSPITAL PART V, SECTION B, LINE 7: THE SURVEY WAS COMPLETED IN THE 4TH QUARTER OF 2012 WHICH DID NOT ALLOW ENOUGH TIME TO ADDRESS ALL OF THE NEEDS. SMCH IS DEVELOPING A PLAN WITHIN THE ORGANIZATION TO ADDRESS THE GREATEST CONCERNS AND THOSE THAT CAN HAVE A DIRECT IMPACT. STEWART MEMORIAL COMMUNITY HOSPITAL PART V, SECTION B, LINE 18E: THE HOSPITAL MADE NO SUCH EFFORTS. STEWART MEMORIAL COMMUNITY HOSPITAL PART V, SECTION B, LINE 20D: IT IS THE POLICY OF THE HOSPITAL TO DETERMINE ELIGIBILITY FOR THE FINANCIAL ASSISTANCE PROGRAM AFTER CARE IS ADMINSTERED. PART VI, LINE 2: WE COLLABORATE WITH THE COUNTY HEALTH DEPARTMENT IN ASSESSING THE HEALTH CARE NEEDS OF THE COMMUNIITES WE SERVE. WE ALSO EVALUATE USAGE DATA THROUGH THE IOWA HOSPITAL ASSOCIATION TO SEE THE PRIMARY MEDICAL DIAGNOSIS IN OUR COMMUNITIES. PART VI, LINE 3: WE HAVE A PATIENT ACCOUNTS MANAGER AS WELL AS A SOCIAL WORKER ON STAFF THAT IDENTIFY PATIENTS THAT MAY BE ELIGIBLE FOR ASSISTANCE OR QUALIFY FOR CHARITY CARE. THEY ASSIST THE PATIENT WITH AVAILABLE OPTIONS AND/OR THE NECESSARY PAPERWORK. PART VI, LINE 4: OUR SERVICE AREA IS A 35 MILE RADIUS SURROUNDING OUR COMMUNITY. THIS AREA CONSISTS OF MANY SMALL, RURAL COMMUNITIES THAT ARE AGRICULTURAL BASED. OUR PATIENT BASE CONSISTS OF A LARGE MEDICARE POPULATION. PART VI, LINE 5: WE PROVIDE THE COMMUNITIES WITH LABORATORY WELLNESS TESTING AND EDUCATIONAL PROGRAMS ON PROMOTING HEALTHY LIFESTYLES. WE PROVIDE CARE TO THE INDIGENT REGARDLESS OF THEIR ABILITY TO PAY. OUR BOARD OF DIRECTORS ARE REPRESENTED BY THE VARIOUS COMMUNITIES WE SERVE. PART VI, LINE 6: OUR HOSPITAL HAS JOINED WITH THE COUNTY DEPARTMENT OF HEALTH IN ESTABLISHING A PROGRAM CALLED "CARING HANDS CLOSET." CARING HANDS CLOSET IS A PROGRAM FOR EXPECTING MOTHERS AND NEW MOTHERS TO EARN POINTS TOWARDS BABY ITEMS BY ATTENDING THEIR DOCTOR APPOINTMENTS AND/OR EDUCATIONAL PROGRAMS. WE PROVIDE MONTHLY LABORATORY WELLNESS TESTING AND EDUCATIONAL PROGRAMS BI-MONTHLY. REPORTS FILED WITH STATES PART VI, LINE 7 IA X X X 0 0 0 0 0 0 0 0 0 SUSAN HORNBACK 274139 0 155000 0 127142 0 14670 0 21194 0 592145 0 0 0 LEAH GLASGO 169958 0 12973 0 84 0 8789 0 493 0 192297 0 0 0 JIM HENKENIUS 128837 0 1277 0 141 0 8310 0 23853 0 162418 0 0 0 DEREK DUNCAN 209993 0 178796 0 96460 0 12600 0 25339 0 523188 0 0 0 DAVID FRATE 218562 0 16836 0 127217 0 15000 0 16323 0 393938 0 0 0 PABLO AMADOR 220821 0 18339 0 109113 0 9493 0 23963 0 381729 0 0 0 PERRY HENELY 198216 0 0 0 392 0 9237 0 12811 0 220656 0 0 0 ADAM SWISHER 241417 0 0 0 96064 0 0 0 28916 0 366397 0 0 0 PART I, LINE 3 STARTING IN OCTOBER 2012, LEAH GLASGOW RECEIVED COMPENSATION FROM TRINITY HEALTH SYSTEMS, AN UNRELATED ENTITY, WHICH PROVIDES MANAGEMENT SERVICES TO ITS CLIENTS. HER COMPENSATION REPORTED IN PART VII REFLECTS THE TOTAL COMPENSATION SHE RECEIVED FOR THE YEAR, INCLUDING THE AMOUNT RECEIVED FROM TRINTIY HEALTH SYSTEMS. THE COMPENSATION COMMITTEE OF THE BOARD OF DIRECTORS MEETS ON AN ANNUAL BASIS TO DISCUSS THE TERMS OF THE CEO'S CONTRACT. THEY USE DATA FROM THE LATEST IOWA HOSPITAL ASSOCIATION SALARY SURVEY. A CITY OF LAKE CITY IOWA 426004850 508021AQ5 2006-02-08 5000000 CAPITAL IMPROVEMENTS 0 0 0 A 1600000 5146511 487673 4658839 2008 0 0 1 1 A 0 0 0 0 0 0 0 A 0 0 1 1 0 0 0 0 0 A 0 PART II, LINE 3: THE TOTAL PROCEEDS DO NOT AGREE TO THE ISSUE PRICE IN PART I, COLUMN (E) DUE TO INVESTMENT EARNINGS. PART IV, ARBITRAGE, LINE 2C: (A) ISSUER NAME: CITY OF LAKE CITY, IA DATE THE REBATE COMPUTATION WAS PERFORMED: 01/31/2011 PART V STEWART MEMORIAL COMMUNITY HOSPITAL IS IN THE PROCESS OF ADOPTING VCAP PROCEDURES. FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 WILL BE REVIEWED BY THE CEO AND CFO PRIOR TO SUBMISSION. THE FORM 990 WILL BE REVIEWED BY MEMBERS OF THE FINANCE COMMITTEE OF THE BOARD OF DIRECTORS AFTER SUBMISSION. FORM 990, PART VI, SECTION B, LINE 12C ANNUALLY EACH BOARD MEMBER SIGNS A CONFLICT OF INTEREST POLICY STATING THAT THEY WILL ABSTAIN FROM VOTING AND DISCUSSING ITEMS THAT WOULD BE IN CONFLICT. FORM 990, PART VI, SECTION B, LINE 15A THE COMPENSATION COMMITTEE OF THE BOARD OF DIRECTORS MEETS ON AN ANNUAL BASIS TO DISCUSS THE TERMS OF THE CEO'S CONTRACT. THEY USE DATA FROM THE LATEST IOWA HOSPITAL ASSOCIATION SALARY SURVEY. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION DOES NOT MAKE ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC. OTHER FEES FORM 990, PART IX, LINE 11G ONCOLOGY FEES: PROGRAM SERVICE EXPENSES 324,658. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 324,658. RADIOLOGIST FEES: PROGRAM SERVICE EXPENSES 250,977. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 250,977. NUCLEAR MEDICINE FEES: PROGRAM SERVICE EXPENSES 116,309. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 116,309. TRINITY MOBILE FEES: PROGRAM SERVICE EXPENSES 129,676. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 129,676. MRI FEES: PROGRAM SERVICE EXPENSES 110,565. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 110,565. OTHER FEES FOR SERVICES: PROGRAM SERVICE EXPENSES 2,658,314. MANAGEMENT AND GENERAL EXPENSES 157,393. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,815,707. FORM 990, PART XII, LINE 2C: THE BOARD OF DIRECTORS ASSUMES THE RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT OF ITS FINANCIAL STATEMENTS AND SELECTION OF THE INDEPENDENT ACCOUNTANT. THIS PROCESS HAS NOT CHANGED FROM THE PREVIOUS YEAR.