2012-05-14T14:51:40-05:00 2011-06-30 WIPFLI LLP PO BOX 12237 GREEN BAY WI 543072237 990 2010-07-01 390944012 MOUNDVIEW MEMORIAL HOSPITAL & CLINICS MOUN 6083393331 402 WEST LAKE STREET FRIENDSHIP WI 53934 JEREMY NORMINGTON 6083393331 2012-05-14 1 TERRI REXRODE CPA MST 9206620016 2012-05-14 2010 2016-02-24 21:20:13Z JEREMY NORMINGTON 402 WEST LAKE STREET FRIENDSHIP WI 53934 15831096 0 X WWW.MOUNDVIEW.ORG X 1959 WI 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. 7 7 155 32 0 0 126878 99989 15171789 15597900 86110 61380 54586 63513 15439363 15822782 0 0 0 0 7240740 7388932 0 0 0 7954865 7654838 15195605 15043770 243758 779012 14381585 14696929 9594717 9063353 4786868 5633576 X 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. 0 0 11796425 15489002 THE HOSPITAL IS A GENERAL MEDICAL CRITICAL ACCESS HOSPITAL LICENSED FOR 25 BEDS. DURING FISCAL YEAR 2011, THE HOSPITAL HAD 669 ACUTE INPATIENT DAYS AND 776 MEDICARE SKILL NURSING DAYS (SWING BED). THE HOSPITAL ALSO HAD 5,013 EMERGENCY ROOM VISITS, 1,337 URGENT CARE VISITS AND 17,489 OTHER OUTPATIENT ANCILLARY ENCOUNTERS. 11796425 1 1 0 1 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 0 0 0 0 0 0 0 0 0 0 1 1 1 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 0 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 DENNIS GORDER 2.50 X 0 0 0 HARVEY WAGNER 2.50 X 0 0 0 LINDA MCFARLIN 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 141857 0 24710 DONALD HEINZ 40.00 X 104699 0 16646 MARK HATTON MD 40.00 X 203154 0 21830 JASON BELLAK MD 40.00 X 191585 0 18206 SHERYL KUGEL FNP APNP 40.00 X 126005 0 18042 DAVE SHAPIRO 40.00 X 115770 0 6480 ERNESTINE WAGNER PA-C 40.00 X 100313 0 9734 983383 0 115648 8 0 1 0 EMCARE INC 7032 COLLECTION CENTER DRIVE CHICAGO IL 60693 ER PHYSICIANS/CHARGE CODING 1126896 SECURITY HEALTH PLAN 1515 SAINT JOSEPH AVE PO BOX 800 MARSHFIELD WI 54449 HEALTH INSURANCE CARRIER 1094414 SHARED IMAGING SVCS PO BOX 45686 MADISON WI 53744 ULTRASOUND, NUCLEAR MED, CARDIAC ECHO 386463 FIRST REFLECTIONS INC 228 N PINE ST ADAMS WI 53910 ANESTHESIOLOGIST 300000 MINISTRY HEALTH CARE 11925 W LAKE PARK DR SUITE 100 MILWAUKEE WI 53224 MANAGEMENT AND CONSULTING SERVICES 194149 10 79282 20707 99989 NET PATIENT REVENUE 900099 15474818 15474818 MISCELLANEOUS 900099 108898 108898 DIETARY INCOME 900099 14184 14184 15597900 60880 60880 71827 8314 63513 63513 63513 500 500 500 500 15822782 15489002 0 233791 287912 287912 5701698 5079486 622212 899538 749310 150228 499784 398018 101766 183804 183804 52450 52450 32000 32000 2774569 2690479 84090 47640 47640 1595658 1368168 227490 226899 206187 20712 79885 61562 18323 746 746 294351 267481 26870 457303 406694 50609 115320 29541 85779 BAD DEBT EXPENSE 947390 947390 EQUIPMENT RENTS & LEASE 416180 351434 64746 REPAIRS & MAINTENANCE 251233 152240 98993 COLLECTION EXPENSE 82403 82403 DUES & SUBSCRIPTIONS 58432 28722 29710 38575 7103 31472 15043770 11796425 3247345 0 588 600 2974719 3116239 1515619 1478344 5291 1404 442525 403755 138214 136504 16234161 7387924 8618969 8846237 685660 713846 14381585 14696929 2119240 2098615 5856735 5537032 457615 582232 1161127 845474 9594717 9063353 X 4231926 5050831 554942 582745 4786868 5633576 14381585 14696929 X 779012 67696 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 2836 2836 0 EXPLANATION OF OTHER LOBBYING ACTIVITIES: PART II-B, LINE 1I: WHA MEMBERSHIP DUES 43973 43973 11329464 3421758 7907706 7750 462 7288 4429898 3965704 464194 423076 423076 8846237 PAYABLE TO THIRD PARTY REIMBURSEMENT PROGRAMS 845474 845474 15822782 15043770 779012 67696 67696 846708 15868149 37053 37053 15831096 -8314 -8314 15822782 15052084 8314 8314 15043770 0 15043770 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 RECORDS NO ASSETS OR LIABILITIES FOR UNCERTAIN TAX POSITIONS OR UNRECOGNIZED TAX BENEFITS IN 2011 OR 201. FEDERAL INCOME TAX RETURNS FOR THE YEARS ENDED 2008 AND BEYOND REMAIN SUBJECT TO EXAMINATION BY THE INTERNAL REVENUE SERVICE. PART XI, LINE 8 - OTHER ADJUSTMENTS: CHANGE IN ASSETS HELD IN POLIVKA TRUST 67,696. PART XII, LINE 2D - OTHER ADJUSTMENTS: FOUNDATION MARKET ADJUSTMENT 37,053. PART XII, LINE 4B - OTHER ADJUSTMENTS: RENTAL EXPENSES -8,314. PART XIII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES 8,314. 1 1 1 X 0 1 1 1 0 1 1 539004 0 539004 0.03820 3120079 2231672 888407 0.06300 3659083 2231672 1427411 0.10120 122461 17757 104704 0.00740 2747785 2328311 419474 0.02980 2870246 2346068 524178 0.03720 6529329 4577740 1951589 0.13840 0 473773 0 5916318 5872740 43578 X 1 1 1 1 MOUNDVIEW MEMORIAL HOSPITAL

402 WEST LAKE STREET FRIENDSHIP WI 53934

X X X X MOUNDVIEW MEMORIAL HOSPITAL 1 1 MOUNDVIEW CLINIC

402 WEST LAKE STREET FRIENDSHIP WI 53934

CLINIC PART I, LINE 3C: THE ORGANIZAITON DOES NOT OFFER DISCOUNTED CARE. PATIENTS UPON REGISTRATION ARE GIVEN THE POLICY AND REQUIREMENTS TO BE ELIGIBLE FOR CARITY CARE. IF A PATIENT IS QUALIFIED FOR CHARITY CARE, THE ENTIRE AMOUNT IS WRITTEN OFF. PART I, LINE 6A: WI HOSPITAL ASSOCIATION 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 $ 947390. 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. PART I, LINE 7, COLUMN (F)BAD DEBT EXPENSE OF $947,930 INCLUDED ON FORM 990, PART IX, LINE 25 WAS EXCLUDED FROM THE DENOMINATOR PER INSTRUCTIONS WHEN CALCULATING THE PERCENT TATAL EXPENSES ON SCHEDULE H. PART I, LINE 7:AMOUNTS CALCULATED IN PART I, LINE 7 ARE DETERMINED BASED ON COST TO CHARGE RATIOS AND AMOUNTS PER THE FINANCIAL STATEMENTS. PART 1, LINE 7G - THE SUBSIDIZED HEALTH CARE SERVICES WERE ATTRIBUTABLE TO HOSPITAL SERVICES. NONE OF THE SUBSIDIZED HEALTH CARE SERVICES WERE ATTRIBUTABLE TO PHYSICIAN SERVICES. 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 6: 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 134609 0 7056 0 192 0 0 0 24710 0 166567 0 166567 0 MARK HATTON MD 180948 0 21174 0 1032 0 0 0 21830 0 224984 0 224984 0 JASON BELLAK MD 115403 0 75966 0 216 0 0 0 18206 0 209791 0 209791 0 VILLAGE OF FRIENDSHIP REVENUE BONDS 396006271 2003-11-01 5000000 WI HOSPITAL DEVELOPMENT REVENUE BONDS 0 0 0 5000000 133406 4794336 2005 0 0 1 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. 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 ATTRAINED 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 67,696. TOTAL TO FORM 990, PART XI, LINE 5: 67,696. FORM 990, PART XI, LINE 2C OVERSIGHT OF AUDIT AND SELECTION OF INDEPENDENT AUDITOR IS THE RESPONSIBILITY OF THE AUDIT COMMITTEE. THIS PROCESS HAS NOT CHANGE 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 MEMORIAL HOSPITAL FOUNDATION OF ADAMS CO C 20867 CASH CONTRIBUTIONS