2012-11-14T07:35:24-06:00 2011-12-31 990 2011-01-01 420698265 ALLEN MEMORIAL HOSPITAL CORPORATION ALLE 3192353995 1825 LOGAN AVE WATERLOO IA 507031916 RENEE A RASMUSSEN 3192353544 2012-10-17 2011 2016-03-07 17:11:31Z TOM TIBBITTS 1825 LOGAN AVE WATERLOO IA 507031916 259091664 0 X WWW.ALLENHOSPITAL.ORG X 1938 IA IMPROVE THE HEALTH OF THE PEOPLE AND COMMUNITIES WE SERVE THROUGH HEALING, CARING AND TEACHING. 18 11 2263 745 1518216 -92353 4842489 4076680 211657935 204453091 6237244 3713202 2047124 1601374 224784792 213844347 4663803 5824903 0 0 92967024 89039701 0 0 0 111701607 107263108 209332434 202127712 15452358 11716635 236917508 240687848 106978269 109217221 129939239 131470627 X THE MISSION OF ALLEN MEMORIAL HOSPITAL CORPORATION IS TO IMPROVE THE HEALTH OF THE PEOPLE AND COMMUNITIES WE SERVE THROUGH HEALING, CARING AND TEACHING. 0 0 157813583 4984622 205981645 HEALTH-CARE SERVICESALLEN MEMORIAL HOSPITAL CORPORATION IS AN IMPORTANT ELEMENT OF THE HEALTH-CARE DELIVERY SYSTEM THAT THE GREATER CEDAR VALLEY COMMUNITIES RELY ON EVERY DAY. IT IS COMMITTED TO PROVIDING QUALITY HEALTH-CARE AND TO USING ITS RESOURCES TO THE GREATEST COMMUNITY BENEFIT. ALLEN MEMORIAL HOSPTIAL CORPORATION PROVIDES INPATIENT AND OUTPATIENT MEDICAL SERVICES TO TREAT INDIVIDUALS WITH DISEASES, ILLNESS AND INJURIES WITH VARYING COMPLEXITIES. IT PROVIDES SERVICES TO IMPROVE THE HEALTH OF PATIENTS AND TO BETTER THEIR QUALITY OF LIFE. ALL SERVICES ARE PROVIDED REGARDLESS OF AN INDIVIDUAL'S RACE, CREED, SEX, NATIONALITY, HANDICAP, AGE OR ABILITY TO COMPENSATE FOR SERVICES RENDERED. THESE INCLUDE, BUT ARE NOT LIMITED TO, GENERAL ACUTE CARE, SURGERIES, HOME HEALTH, INTENSIVE CARE AND CRITICAL CARE, MENTAL HEALTH CARE, CARDIOLOGY, ONCOLOGY, REHABILITATION, BEHAVIORAL DISORDER PROGRAMS, MATERNAL/CHILD CARE, LABORATORY, PHARMACEUTICAL DRUGS, WOUND CARE, EMERGENCY SERVICES, OUTPATIENT CLINICS, CHECK-UPS AND RADIOLOGY. SOME OF THE SERVICES PROVIDED DO NOT GENERATE ENOUGH INCOME TO OFFSET THEIR COST. IN THE FISCAL PERIOD ENDED DECEMBER 31, 2011, ALLEN MEMORIAL HOSPITAL CORPORATION ADMITTED 10,777 PATIENTS WITHOUT NEWBORNS AND 11,730 PATIENTS WITH NEWBORNS, RESULTING IN A TOTAL OF 39,869 PATIENT DAYS WITHOUT NURSERY AND NICU, AND 42,488 PATIENT DAYS WITH NURSERY AND NICU. OUTPATIENT VISITS TOTALED 290,251 AND TOTAL OUTPATIENT SURGERY REGISTRATIONS FOR THE SAME PERIOD WERE 9504. THERE WERE ALSO 32,712 EMERGENCY ROOM VISITS AND 914 BABIES DELIVERED. 13100724 840281 0 COMMUNITY BENEFIT, INCLUDING CHARITY CARECHARITY CARE AND MEANS-TESTED PROGRAMS: ALLEN MEMORIAL HOSPITAL CORPORATION PROVIDES CHARITY CARE AND OTHER MEANS-TESTED PROGRAMS WITH THE GOAL TO IMPROVE THE COMMUNITY'S OVERALL HEALTH AND ACCESS TO CARE. THIS INCLUDES HEALTH-CARE SERVICES REGARDLESS OF THE PATIENT'S INSURANCE COVERAGE OR FINANCIAL STATUS. CHARITY CARE AND PARTIAL TO FULL FINANCIAL ASSISTANCE IS PROVIDED TO PATIENTS ON A CASE-BY-CASE BASIS. CHARITY CARE WAS MADE AVAILABLE TO OVER 2,000 PEOPLE AT A VALUE OF $4,343,937 IN 2011. OFTEN TIMES, ALLEN MEMORIAL HOSPITAL CORPORATION RECEIVES PAYMENTS FROM PAYORS OR PATIENTS THAT ARE LESS THAN IT CHARGES FOR SERVICES. ALLEN MEMORIAL HOSPITAL CORPORATION PARTICIPATES IN MEDICAID AND OTHER GOVERNMENT-SPONSORED HEALTH-CARE PROGRAMS. ALLEN MEMORIAL HOSPITAL CORPORATION'S NET COST OF PROVIDING CARE FOR WHICH IT RECEIVES PAYMENT BELOW ITS COST IS $4,262,152 FOR 2011. TOTAL CHARITY CARE AND MEANS-TESTED PROGRAMS REPORTED VALUE: $8,606,089.OTHER BENEFITS: ALLEN MEMORIAL HOSPITAL CORPORATION PROVIDES SEVERAL OTHER BENEFITS THAT ASSIST THE COMMUNITY. PROGRAMS MAY INCLUDE, BUT ARE NOT LIMITED TO, COMMUNITY HEALTH IMPROVEMENT SERVICES AND COMMUNITY BENEFIT OPERATIONS SUCH AS PREVENTION AND HEALTH SCREENINGS; HEALTH PROFESSIONAL'S EDUCATION; SUBSIDIZED HEALTH SERVICES; RESEARCH, AND CASH AND IN-KIND CONTRIBUTIONS TO COMMUNITY GROUPS. ALLEN MEMORIAL HOSPITAL CORPORATION COLLABORATES WITH OTHER HOSPITALS, CHURCHES, SCHOOLS, CHAMBERS OF COMMERCE AND DAYCARE CENTERS TO IMPROVE COMMUNITY HEALTH AND EXPAND ACCESS TO HEALTH CARE. ALLEN MEMORIAL HOSPITAL CORPORATION HAS DEDICATED STAFF TO ASSIST COMMUNITY BENEFIT EFFORTS. APPROXIMATELY 7,940 PERSONS WERE SERVED THROUGH THESE PROGRAMS. TOTAL OTHER BENEFITS REPORTED VALUE: $4,494,635. 170914307 1 1 0 0 0 0 0 0 0 1 1 0 0 0 1 1 0 1 0 0 0 0 0 0 1 0 1 1 1 1 1 0 0 0 0 0 0 1 1 0 0 0 0 0 1 0 0 0 0 1 161 0 1 2263 1 1 1 0 0 0 0 1 1 0 0 0 0 X 18 11 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 1 1 IA X X RENEE RASMUSSEN SR VP FINANCECFO 3192353995 1825 LOGAN AVE WATERLOO IA 50703 RUSSELL ADAMS MD 1.00 X 1041 316748 46960 ASHAR AFZAL MD 1.00 X 50 0 0 MARK BALDWIN 1.00 X X 352 1572 0 BOB BUCKLEY 1.00 X 1161 0 0 MICHAEL CHRISTIASON 1.00 X 1276 0 0 DAVE HAPPEL 1.00 X 860 0 0 BETH HANSEN 1.00 X 1250 0 0 JOHN KNOX TO 1111 40.00 X X 525417 0 35333 LAWRENCE LIEBSCHER MD 1.00 X 50 13250 0 KATHY MCCOY 1.00 X 1045 0 0 BEV SMITH 1.00 X 860 0 0 ROBERT SMITH 1.00 X 860 0 0 BETTY STEEGE 1.00 X 917 0 0 KALYANA SUNDARAM MD 1.00 X 988 0 0 KEVIN SWALLEY 1.00 X X 1224 0 0 TOM TIBBITS FR 1111 40.00 X X 0 758496 24275 JEAN TRAINOR 1.00 X X 107 0 0 BISHOP STEVE ULLESTAD 1.00 X 1128 0 0 MIKE WILLIAMS 1.00 X 988 15385 0 RENEE RASMUSSEN 40.00 X 301785 0 61876 JEFFREY CRANDALL MD TO 511 40.00 X 0 327040 44943 JENNIFER FRIEDLY 40.00 X 182804 0 24338 TIM HORRIGAN MD FR 311 40.00 X 0 232829 50104 SARA POLING TO 111 40.00 X 466063 0 13075 JUDITH RENAAS 40.00 X 277940 0 73214 JAMES WATERBURY 40.00 X 230273 0 80552 BILAL KAAKI 40.00 X 498937 0 16107 CHRISTOPHER HILL 40.00 X 444019 0 18395 PAUL MCCAUGHEY 40.00 X 496298 0 35313 HIND MOUSSA 40.00 X 370874 0 15191 PUBLIO ORTIZ 40.00 X 442115 0 31218 RICHARD SEIDLER TO 610 0.00 X 0 727601 95987 JAY WILLSHER TO 910 0.00 X 0 279425 89547 4250682 2672346 756428 81 1 1 0 CEDAR VALLEY MEDICAL SPECIALISTS PO BOX 2758 WATERLOO IA 50704 MEDICAL SERVICES 3394451 ARAMARK SERVICEMASTER FACILITY 22506 NETWORK PLACE CHICAGO IL 60673 PERSONNEL 2208670 LARSON CONSTRUCTION CO INC PO BOX 112 INDEPENDENCE IA 50644 CONSTRUCTION SERVICES 1472910 MAYO COLLABORATIVE SERVICES PO BOX 9146 MINNEAPOLIS MN 55480 LABORATORY SERVICES 1290022 EXECUTIVE HEALTH RESOURCES INC PO BOX 822688 PHILADELPHIA PA 19182 MEDICAL REVIEW SERVICES 948445 120 3414 2798342 1255420 19504 4076680 NET PATIENT REVENUE 900099 150334265 150334265 PHARMACY REVENUE 446110 49405449 45306501 1498247 2600701 MGMT & SUPPORT SVCS 561000 2078590 1348934 729656 RENTAL INCOME 531100 1805683 1804603 1080 MISCELLANEOUS REVENUE 900099 913191 913191 -84087 -100150 16063 204453091 1715479 1715479 9104 1328 7776 7776 7776 46960180 40746 44903512 99691 2056668 -58945 1997723 1997723 70475 48819 21656 21656 237355 193967 43388 43388 CAFETERIA/FOOD SVCS 722210 1013025 1010979 2046 MISCELLANEOUS REVENUE 900099 480980 480980 PHARMACY REVENUE 446110 34549 33769 780 1528554 213844347 201133072 1518216 7116379 5824903 5824903 2943958 2943958 69406173 61803167 7603006 2625872 2338225 287647 9173710 8168788 1004922 4889988 4354321 535667 3276959 16986 3259973 1576404 1309 1575095 327894 327894 21532374 13733081 7799293 483634 147800 335834 50041803 49394237 647566 10329164 9330689 998475 2984011 2981011 3000 312132 196968 115164 276708 215925 60783 3230404 3230404 12392316 12058956 333360 29048 29048 MISCELLANEOUS EXPENSE 461210 318846 142364 INCOME TAXES 9000 9000 BAD DEBT EXPENSE 47 47 202127712 170914307 31213405 0 3748 3431635 19296085 11946275 420605 1823270 22046453 23135969 4810917 5017238 6071709 6011290 691855 765761 210329011 109831318 102334056 100497693 71269803 80081908 172362 102355 6000763 4199562 3799152 3664892 0 10000 236917508 240687848 16345685 19060424 22729 28894 45448 91554 5416895 5894584 85147512 84141765 106978269 109217221 X 123972242 125520236 4150372 4164387 1816625 1786004 129939239 131470627 236917508 240687848 X 11716635 -10185247 X 0 1 1 X 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 75776848 12020271 -907542 2013448 238357 84637772 62282606 6212189 8740976 1180548 278375 75776848 42620642 10459126 10425170 1016429 205903 62282606 59647961 2042078 -12929473 6014219 125705 42620642 0.92970 0.02110 0.04920 0 1 1 645250 645250 2081053 116913067 56275078 62719042 6562485 4168615 2393870 81450505 49387625 32062880 2676651 2676651 100497693 ASBESTOS REMOVAL LIABILITY 4433167 DUE TO AFFILIATES 6180748 LONG-TERM RETENTION INCENTIVES 1334930 MISCELLANEOUS LIABILITY 75000 IOWA HEALTH SYSTEM NOTE PAYABLE 59818780 SELF-INSURANCE RESERVE 5682463 DEFINED BENEFIT RETIREMENT PLAN LIABILITY 5551215 HEALTH AND WELFARE BENEFITS RESERVE 1065462 84141765 213844347 202127712 11716635 -4305034 -5880213 -10185247 1531388 207023000 -4274413 195296 -4079117 211102117 238357 2503873 2742230 213844347 194267000 195296 195296 194071704 238357 7817651 8056008 202127712 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: THE ORGANIZATION RETAINS FUNDS FOR INTENDED FUTURE USES, INCLUDING PURCHASE OF EQUIPMENT, INDIGENT CARE, FUNDING OF MISSION RELATED OPERATIONS, AND HEALTH EDUCATION. IN ADDITION, SOME FUNDS ARE HELD FOR INVESTMENT IN PERPETUITY. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: IOWA HEALTH SYSTEM AND MOST OF ITS SUBSIDIARIES ARE CLASSIFIED AS TAX-EXEMPT ORGANIZATIONS AS DESCRIBED IN SECTIONS 501(C)(3) AND 501(C)(2) OF THE INTERNAL REVENUE CODE (THE CODE). TAX-EXEMPT ORGANIZATIONS ARE NOT SUBJECT TO FEDERAL AND STATE INCOME TAXES ON RELATED INCOME, PURSUANT TO SECTION 501(A) OF THE CODE. THESE ORGANIZATIONS ARE SUBJECT TO FEDERAL AND STATE INCOME TAXES TO THE EXTENT THEY HAVE UNRELATED BUSINESS INCOME AS DESCRIBED UNDER PROVISIONS OF SECTION 511 OF THE CODE. THE HEALTH SYSTEM FILES FORM 990 FOR SUBSTANTIALLY ALL OF ITS OPERATING ENTITIES IN THE U.S. FEDERAL JURISDICTION AND IS NO LONGER SUBJECT TO EXAMINATION BY TAX AUTHORITIES FOR THE YEARS BEFORE 2008. THE HEALTH SYSTEM HAS NO MATERIAL UNCERTAIN TAX POSITIONS. CERTAIN SUBSIDIARIES ARE SUBJECT TO FEDERAL AND STATE INCOME TAXES. SOME OF THESE CORPORATIONS HAVE ACCUMULATED NET OPERATING LOSS CARRYFORWARDS THAT ARE AVAILABLE TO OFFSET FUTURE TAXABLE INCOME DURING THE CARRYFORWARD PERIOD. NO INCOME TAX BENEFIT HAS BEEN RECOGNIZED FOR THE NET OPERATING LOSS CARRYFORWARDS OR OTHER POTENTIAL DEFERRED TAX ASSETS IN THE CONSOLIDATED FINANCIAL STATEMENTS BECAUSE THE HEALTH SYSTEM BELIEVES REALIZATION OF THESE BENEFITS IS UNLIKELY. PART XI, LINE 8 - OTHER ADJUSTMENTS: CHANGES IN PENSION LIABILITY -5,880,213. PART XII, LINE 2D - OTHER ADJUSTMENTS: COST OF GOODS SOLD 193,968. RENTAL EXPENSES REPORTED AS OFFSET TO RENTAL INCOME 1,328. PART XII, LINE 4B - OTHER ADJUSTMENTS: REVENUES IN UNRESTRICTED FUND BALANCE 1,651,432. REVENUES IN TEMPORARILY RESTRICTED FUND BALANCE 14,015. IOWA HEALTH SYSTEM CONTRACTING SERVICES, LC PURCHASE REBATES 837,848. ROUNDING 578. PART XIII, LINE 2D - OTHER ADJUSTMENTS: COST OF GOODS SOLD 193,968. RENTAL EXPENSES REPORTED AS OFFSET TO RENTAL INCOME 1,328. PART XIII, LINE 4B - OTHER ADJUSTMENTS: EXPENSES IN UNRESTRICTED FUND BALANCE 6,979,610. IOWA HEALTH SYSTEM CONTRACTING SERVICES, LC PURCHASE REBATES 837,848. ROUNDING 193. SCRUB SALES 41580 41580 33855 BOOK SALES 9676 9676 3300 6 19219 19219 11664 70475 70475 48819 48819 21656 1 1 X 1 X 1 X 1 1 0 1 1 4343937 4343937 0.02150 22065 20732378 16470226 4262152 0.02110 22065 25076315 16470226 8606089 0.04260 7940 1536325 49493 1486832 0.00740 90665 90665 0.00040 232220 232220 0.00110 24 4061752 1376834 2684918 0.01330 24 7940 5920962 1426327 4494635 0.02220 24 30005 30997277 17896553 13100724 0.06480 10 1807 42371 42371 0.00020 1 47 47 0.00000 1 25 631476 631476 0.00310 1 15 524 524 0.00000 13 1847 674418 674418 0.00330 0 2510764 70928780 65868124 5060656 X 1 1 1 ALLEN MEMORIAL HOSPITAL ORTHOPEDIC CO-MANAGEMENT COMPANY LLC MANAGE ORTHOPEDIC SERVICE LINE 0.20000 0.80000 1 1 ALLEN MEMORIAL HOSPITAL CORPORATION

1825 LOGAN AVENUE WATERLOO IA 50703

X X X ALLEN MEMORIAL HOSPITAL CORPORATION 1 0 1 1 200.000000000000 1 400.000000000000 1 X X X X X 1 1 X X X X X X 1 X X X X 1 X X X X X X X 1 X 0 1 14 ALLEN DIGESTIVE DISEASE CENTER-TWR PARK

125 EAST TOWER PARK DRIVE WATERLOO IA 50701

OUTPATIENT ONLY - DIGESTIVE DISEASE CENTER ALLEN WOMEN'S HEALTH CENTER

233 VOLD STREET WATERLOO IA 50703

OUTPATIENT ONLY - WOMEN'S HEALTH CENTER ALLEN WOMEN'S HEALTH CENTER

1824 W 8TH STREET CEDAR FALLS IA 50613

OUTPATIENT ONLY - WOMEN'S HEALTH CENTER PMP OCCUPATIONAL HEALTH

4612 PRAIRIE PARKWAY SUITE 102 CEDAR FALLS IA 50613

OUTPATIENT ONLY - OCCUPATIONAL HEALTH ALLEN WOMEN'S HEALTH CENTER

91 E BREMER AVENUE WAVERLY IA 50677

OUTPATIENT ONLY - WOMEN'S HEALTH CENTER ALLEN WOMEN'S HEALTH CENTER

3316 CEDAR HEIGHTS DRIVE CEDAR FALLS IA 50613

OUTPATIENT ONLY - WOMEN'S HEALTH CENTER ALLEN WOMEN'S HEALTH CENTER

1600 1ST STREET E INDEPENDENCE IA 50644

OUTPATIENT ONLY - WOMEN'S HEALTH CENTER BREAST BIOPSY SERVICES LC

4250 GLASS ROAD NE CEDAR RAPIDS IA 52402

PROVIDE BREAST BIOPSY SERVICES CEDAR VALLEY COMMUNITY HEALTHCARE LLC

999 HOME PLAZA SUITE 210B WATERLOO IA 50701

REGIONAL HEALTH INSURANCE POOL DIGITAL MAMOGRAPHY IMAGING SERVICES LLC

4250 GLASS ROAD NE SUITE 200 CEDAR RAPIDS IA 52402

DIGITAL MAMOGRAPHY IMAGING HEALTH ENTERPRISES VENTURES LC

4250 GLASS ROAD NE CEDAR RAPIDS IA 52402

INVESTMENT VEHICLE OWNING PARTS OF EACH OF THE CLINICAL JOINT VENTURES MRIOWA LC

4250 GLASS ROAD NE CEDAR RAPIDS IA 52402

PROVIDE MOBILE MRI SERVICE NE IA PHYSICAL THERAPY AND SPORTS MED

1825 LOGAN AVENUE WATERLOO IA 50703

ATHLETIC TRAINING AND SPORTS MEDICINE HEALTH ENTERPRISES OF IOWA

4250 GLASS ROAD NE SUITE 200 CEDAR RAPIDS IA 52402

MANAGEMENT COMPANY PART I, LINE 6A: ALLEN MEMORIAL HOSPITAL'S COMMUNITY BENEFIT REPORT IS CONTAINED WITHIN THE IOWA HEALTH SYSTEM COMMUNITY BENEFIT REPORT WHICH CAN BE LOCATED AT WWW.IHS.ORG. THIS SYSTEM-WIDE REPORT IS COMPLETED IN ADDITION TO THE COMMUNITY BENEFIT REPORT FOR THE HOSPITAL AND ITS REGIONAL AFFILIATES. PART I, LINE 7: A COST-TO-CHARGE RATIO (FROM WORKSHEET 2) IS USED TO CALCULATE THE AMOUNTS ON LINE 7A. THE AMOUNTS ON LINES 7B-7C (UNREIMBURSED MEDICAID AND OTHER MEANS-TESTED GOVERNMENT PROGRAMS) ARE OBTAINED FROM A COST ACCOUNTING SYSTEM OF APPLICABLE PATIENT SEGMENTS. SEGMENTS NOT PASSED TO COST ACCOUNTING SYSTEM USE COST-TO-CHARGE RATIO. THE AMOUNTS FOR LINES 7E, F, H, AND I WOULD COME FROM THE BOOKS AND RECORDS OF SPECIFIC SEGMENTS OF THE ORGANIZATION AND ARE BASED ON COST. THE AMOUNTS ON 7G ARE DERIVED FROM A COST ACCOUNTING SYSTEM OF APPLICABLE PATIENT SEGMENTS. SEGMENTS NOT PASSED TO A COST ACCOUNTING SYSTEM USE THE COST-TO-CHARGE RATIO. PART II: COMMUNITY BUILDING ACTIVITIES ARE ESSENTIAL ROLES FOR HEALTH-CARE ORGANIZATIONS IN THAT THEY ADDRESS MANY OF THE UNDERLYING DETERMINANTS OF HEALTH. RESEARCH HAS CONTINUALLY SHOWN THAT WHEN THE FACTORS INFLUENCING HEALTH ARE EXPLORED, HEALTH CARE ACTUALLY PLAYS THE SMALLEST ROLE PROPORTIONATELY. A REPORT IN THE JOURNAL OF AMERICAN MEDICAL ASSOCIATION AND THE CENTER FOR DISEASE CONTROL (MCGINNIS, 1996) SUGGESTS THAT THE FACTORS IMPACTING HEALTH ARE AS FOLLOWS: LIFESTYLE AND BEHAVIORS, 50%, ENVIRONMENT (HUMAN AND NATURAL), 20%, GENETICS AND HUMAN BIOLOGY, 20%, AND HEALTH CARE, 10%. COMMUNITY BUILDING ACTIVITIES HELP TO ADDRESS THE OTHER INDICATORS OUTSIDE OF THE ROLE TRADITIONALLY PLAYED BY HEALTH-CARE ORGANIZATIONS. THESE ACTIVITIES ARE ALMOST EXCLUSIVELY DONE IN SOME FORM OF PARTNERSHIP IN WHICH THE COMMUNITY OR OTHER ORGANIZATIONS ARE BETTER SUITED TO ADDRESS. HEALTH-CARE ORGANIZATIONS GENERALLY PROVIDE TIMELY AND SPECIFIC RESOURCES TO HELP THESE ISSUES. HEALTH-CARE ORGANIZATIONS CAN BE A RICH AND VALUABLE COMMUNITY RESOURCE IN WAYS NOT TYPICALLY CONSIDERED. OFTEN THE MOST EFFECTIVE WAY TO HELP IMPACT AND IMPROVE THE COMMUNITY HEALTH STATUS IS TO SUPPORT OTHER AGENCIES AND ORGANIZATIONS IN A VARIETY OF WAYS OUTSIDE OF HEALTH SERVICES. THIS IS OFTEN DONE THROUGH CASH OR IN-KIND SERVICES TO SUPPORT OTHER NON-PROFITS, DONATIONS OF DURABLE MEDICAL EQUIPMENT AND SUPPLIES TO CERTAIN AGENCIES, OR THROUGH LEADERSHIP AND EDUCATIONAL EXPERTISE. THE HOSPITAL CONTRIBUTES FINANCIALLY TO A WIDE VARIETY OF COMMUNITY ORGANIZATIONS THAT ADDRESS THE BROADER NEEDS OF THE COMMUNITY. THESE DONATIONS ALLOW OTHER NON-PROFIT ORGANIZATIONS TO FULFILL THEIR MISSIONS TO IMPROVE THE WELL BEING OF THE COMMUNITY AND CONTRIBUTE TO ITS OVERALL HEALTH STATUS IN WAYS THAT MAY DIFFER FROM THE DIRECT SERVICES OF THE HOSPITAL ORGANIZATION AND MAXIMIZE THE RESOURCES THEY HAVE TO WORK WITH. THE HOSPITAL EMPLOYEES ARE ACTIVE IN EDUCATING PARTNERS ON A WIDE VARIETY OF HEALTH SUBJECTS THAT ADVANCE THEIR WORK. FURTHER, THE HOSPITAL EMPLOYEES ARE MEMBERS OF MANY NON-PROFIT BOARDS TO PROVIDE LEADERSHIP OR COLLABORATE TO ADDRESS COMPLEX HEALTH ISSUES. THESE TYPES OF ACTIVITIES SPEAK TO THE BREADTH AND CAPACITY THAT THE HOSPITAL HAS IN IMPACTING THE HEALTH STATUS OF THE COMMUNITY IN A COMPREHENSIVE AND INTENTIONAL APPROACH. PART III, LINE 4: THE HEALTH SYSTEM PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS BASED UPON A REVIEW OF OUTSTANDING RECEIVABLES, HISTORICAL COLLECTION INFORMATION AND EXISTING ECONOMIC CONDITIONS. AS A SERVICE TO THE PATIENT, THE HEALTH SYSTEM BILLS THIRD-PARTY PAYERS DIRECTLY AND BILLS THE PATIENT WHEN THE PATIENT'S LIABILITY IS DETERMINED. PATIENT ACCOUNTS RECEIVABLE ARE DUE IN FULL WHEN BILLED. ACCOUNTS ARE CONSIDERED DELINQUENT AND SUBSEQUENTLY WRITTEN OFF AS BAD DEBTS BASED ON INDIVIDUAL CREDIT EVALUATION AND SPECIFIC CIRCUMSTANCES OF THE ACCOUNT.THE AMOUNT REPORTED ON LINE 2 WAS CALCULATED USING IRS WORKSHEET 2 'RATIO OF PATIENT CARE COST TO CHARGES' TO CALCULATE THE COST TO CHARGE RATIO FOR ALLEN MEMORIAL HOSPITAL CORPORATION. THIS RATIO WAS THEN APPLIED AGAINST THE BAD DEBT ATTRIBUTABLE TO PATIENT ACCOUNTS USING IRS WORKSHEET A TO ARRIVE AT THE BAD DEBT EXPENSE AT COST REPORTED ON LINE 2. PART III, LINE 8: AMOUNTS ON LINE 6 WERE CALCULATED USING IRS WORKSHEET B 'TOTAL MEDICARE ALLOWABLE COSTS.' THE MEDICARE ALLOWABLE COSTS WERE OBTAINED FROM THE MEDICARE COST REPORTS AND THEN REDUCED BY ANY AMOUNTS ALREADY CAPTURED IN COMMUNITY BENEFIT EXPENSE IN PART I ABOVE. PART III, LINE 9B: AFTER THE PATIENT MEETS THE QUALIFICATIONS FOR FINANCIAL ASSISTANCE, THE ACCOUNT BALANCE IS PARTIALLY OR ENTIRELY WRITTEN OFF, AS APPROPRIATE. ANY REMAINING BALANCE, IF ANY, WOULD BE COLLECTED UNDER THE NORMAL DEBT COLLECTION POLICY. ALLEN MEMORIAL HOSPITAL CORPORATION PART V, SECTION B, LINE 15E: GUARANTORS RECEIVE A CYCLE BILL EVERY 30 DAYS FOR THE LIFE OF THE ACCOUNT ON A/R. ON DAY 41, 11 DAYS AFTER THE SECOND BILLING CYCLE, A FIRST COLLECTION ATTEMPT IS MADE FROM THE TELEVOX DIALER. THE SECOND COLLECTION ATTEMPT IS MADE BY THE DIALER ON DAY 71, 11 DAYS AFTER THE THIRD AND FINAL BILLING CYCLE. THE THIRD COLLECTION ATTEMPT IS MADE BY THE DIALER ON DAY 87, 3 DAYS BEFORE THE ACCOUNT IS REVIEWED FOR COLLECTIONS. ACCOUNTS WITH SATISFACTORY PAYMENTS OR PREARRANGED PAYMENT ARRANGEMENTS THAT ARE CURRENT ARE NOT SENT TO THE DIALER. ACCOUNTS WITH A MENTAL HEALTH DIAGNOSIS, WORKERS COMPENSATION ACCOUNTS, ACCOUNTS WITH SKILLED NURSING FACILITIES, AND ACCOUNTS WITH NO PHONE NUMBER ARE ALSO NOT SENT TO THE DIALER. THESE ACCOUNTS ARE ON A MANUAL LIST WHICH THE COLLECTION TEAM REVIEWS AND MAKES CALLS MANUALLY AS DEEMED APPROPRIATE. WHEN THE ACCOUNTS ARE GREATER THAN OR EQUAL TO $5,000, THE COLLECTION TEAM WILL SEND A FINANCIAL ASSISTANCE APPLICATION IF THEY CANNOT MAKE CONTACT WITH THE GUARANTOR AND 10 BUSINESS DAYS LATER, A PAST LETTER. THEY WILL ALSO CHECK FOR MEDICAID ELIGIBILITY FOR THEIR STATE OF RESIDENCE. ALLEN MEMORIAL HOSPITAL CORPORATION PART V, SECTION B, LINE 19D: IF THE INDIVIDUAL APPLIES AND QUALIFIES FOR FINANCIAL ASSISTANCE UNDER THE FACILITY'S FINANCIAL ASSISTANCE POLICY, THE HOSPITAL FACILITY USES THE AVERAGE OF THE THREE LOWEST NEGOTIATED COMMERCIAL INSURANCE RATES FOR THOSE SERVICES AT THE HOSPITAL FACILITY TO DETERMINE THE AMOUNTS BILLED FOR ALL SERVICES, INCLUDING EMERGENCY OR MEDICALLY NECESSARY CARE. THIS OCCURS REGARDLESS WHETHER THE INDIVIDUAL HAS INSURANCE COVERAGE. ALSO, IF THE INDIVIDUAL HAS INSURANCE COVERAGE AND DOES NOT APPLY OR QUALIFY FOR FINANCIAL ASSISTANCE UNDER THE FACILITY'S FINANCIAL ASSISTANCE POLICY, THE HOSPITAL FACILITY USES THE INSURER'S NEGOTIATED RATE FOR THOSE SERVICES AT THE HOSPITAL FACILITY. HOWEVER, IF THE INDIVIDUAL DOES NOT HAVE INSURANCE COVERAGE AND EITHER DOES NOT APPLY OR DOES NOT QUALIFY FOR FINANCIAL ASSISTANCE UNDER THE FACILITY'S FINANCIAL ASSISTANCE POLICY, THE HOSPITAL FACILITY USES THE GROSS RATES FOR THOSE SERVICES TO DETERMINE THE AMOUNTS BILLED. IF THE UNINSURED INDIVIDUAL AGREES TO PAY THE BILL IN FULL, THE HOSPITAL FACILITY WILL PROVIDE A 20% DISCOUNT FROM THE GROSS RATES FOR THOSE INDIVIDUALS. ALLEN MEMORIAL HOSPITAL CORPORATION PART V, SECTION B, LINE 21: AS DESCRIBED IN SCHEDULE H, PART V, LINE 19, IF THE PATIENT DOES NOT APPLY OR QUALIFY FOR FINANCIAL ASSISTANCE AND ALSO IS UNINSURED OR RECEIVES NO BENEFIT FROM THEIR INSURANCE ON A SERVICE PROVIDED BY THE HOSPITAL FACILITY, THEY WOULD BE CHARGED AMOUNTS EQUAL TO GROSS CHARGES FOR THE SERVICES PROVIDED TO THE PATIENT. HOWEVER, IF THE PATIENT AGREES TO PAY IN FULL, THEY WILL RECEIVE A 20% DISCOUNT FROM THE GROSS CHARGES. PART VI, LINE 2: ALLEN MEMORIAL HOSPITAL CONTINUALLY WORKS WITH COMMUNITY PARTNERS IN WATERLOO, IOWA TO ASSESS THE HEALTH NEEDS OF THE COMMUNITY. SPECIFICALLY, ALLEN MEMORIAL HOSPITAL IS A SPONSORING PARTNER OF THE COMMUNITY HEALTH ADVISORY BOARD, WHICH IS A COMMUNITY COLLABORATIVE CONVENED BY ALLEN HOSPITAL TO ASSESS, ADDRESS AND MONITOR THE HEALTH NEEDS OF BLACK HAWK COUNTY. THROUGH A PLANNED AND ORGANIZED EFFORT, THE COMMUNITY HEALTH ADVISORY BOARD DEVELOPS A HEALTH AGENDA BY IDENTIFYING SPECIFIC HEALTH PRIORITIES THAT ARE RELEVANT TO THE COMMUNITY. THE COMMUNITY HEALTH ADVISORY BOARD WORKS COLLECTIVELY TO ADDRESS THE PRIORITIES THROUGH LEVERAGING THE RESOURCES OF THE COMMUNITY. ALLEN MEMORIAL HOSPITAL, AS A SPONSORING AGENCY, ACTIVELY CONTRIBUTES TO THIS PROCESS AND ENGAGES IN THE IDENTIFIED PRIORITIES THAT MATCH ITS MISSION AND CAPACITY. THE COMMUNITY HEALTH ADVISORY BOARD CONVENES EIGHT MEETINGS ANNUALLY TO SEEK PUBLIC INPUT ON HEALTH INITIATIVES. ALLEN HOSPITAL IS ALSO A SPONSORING PARTNER IN TOGETHER FOR YOUTH. THIS COLLABORATIVE ALSO COMPLETES A COMMUNITY HEALTH ASSESSMENT. FROM THIS, PRIORITIES AND STRATEGIES HAVE BEEN IDENTIFIED. ALLEN HOSPITAL HAS ACTIVELY ENGAGED IN ADDRESSING AND MONITORING HEALTH ISSUES AND NEEDS AS A RESULT OF THIS PROCESS. ALLEN HOSPITAL ALSO PARTICIPATES AS PART OF THE UNITED WAY OF THE CEDAR VALLEY. THIS GROUP ACTIVELY ADDRESSES NEED AND STRATEGIES ASSOCIATED WITH HEALTH. MORE SPECIFICALLY, THIS GROUP OFTEN FOCUSES ON THE SOCIAL DETERMINANTS OF HEALTH AND HOW TO IMPACT THEM IN THE EFFORT TO RAISE THE COMMUNITY HEALTH STATUS. THIS WIDE BASED COLLABORATIVE PROVIDES OPPORTUNITIES FOR ALLEN HOSPITAL TO ENGAGE IN VARIOUS AREAS OF SERVICE TO THE COMMUNITY THAT MAY BE OUTSIDE OF ITS TYPICAL EXPERTISE BUT WITHIN ITS EXISTING RESOURCES. IN ADDITION TO THESE ORGANIZED COMMUNITY EFFORTS, ALLEN HOSPITAL CONTINUALLY MONITORS COMMUNITY NEEDS SPECIFIC TO ITS SERVICE LINES AND THE RESOURCES IT CAN LEVERAGE TO ADDRESS THEM. INDIVIDUAL DEPARTMENTS OFTEN WORK TO IDENTIFY SPECIFIC NEEDS RELATED TO THEIR SERVICES AND THE POPULATION THEY IMPACT. ADDITIONALLY, ALLEN MEMORIAL HOSPITAL IS CURRENTLY CONDUCTING ITS FIRST TRI-ANNUAL COMMUNITY HEALTH NEEDS ASSESSMENT OF ITS MARKET AREA OF 10 COUNTIES. RESULTS WILL BE PUBLISHED BY DECEMBER 31, 2012. PART VI, LINE 3: ALLEN MEMORIAL HOSPITAL PERFORMS THE FOLLOWING ACTIVITIES TO COMMUNICATE THE AVAILABILITY OF CHARITY CARE AND FINANCIAL ASSISTANCE TO ALL PATIENTS: 1) PLACES SIGNAGE, INFORMATION, AND/OR BROCHURES IN APPROPRIATE AREAS OF THE PROVIDER (E.G., THE EMERGENCY DEPARTMENT, AND REGISTRATION AND CHECK-OUT/CASHIER AREAS) STATING THE PROVIDER/PHYSICIAN PRACTICE OFFERS CHARITY CARE AND DESCRIBES HOW TO OBTAIN MORE INFORMATION ABOUT FINANCIAL ASSISTANCE, 2) PLACES A NOTE ON THE HEALTH-CARE BILL AND STATEMENTS REGARDING HOW TO REQUEST INFORMATION ABOUT FINANCIAL ASSISTANCE, 3) DESIGNATES INDIVIDUALS WHO CAN EXPLAIN THE PROVIDER'S CHARITY CARE POLICY, AND 4) INSTRUCTS STAFF WHO INTERACT WITH PATIENTS TO DIRECT QUESTIONS REGARDING THE CHARITY CARE POLICY TO THE PROPER PROVIDER REPRESENTATIVE AND, 5) POSTS CHARITY CARE AND PATIENT-DISCOUNT INFORMATION ON THE HOSPITAL WEB SITES HOME PAGE AT WWW.ALLENHOSPITAL.ORG UNDER FINANCE. PART VI, LINE 4: ALLEN MEMORIAL HOSPITAL IS A 216-BED COMMUNITY HOSPITAL SERVING THE CEDAR VALLEY OF IOWA. ALLEN MEMORIAL HOSPITAL IS NONDENOMINATIONAL AND SERVES ALL WHO COME HERE, REGARDLESS OF REASON OR CIRCUMSTANCE.80% OF ALLEN MEMORIAL HOSPITAL'S MARKET RESIDENTS LIVE WITHIN THE IOWA COUNTIES OF BLACK HAWK, BREMER, BUCHANAN, FAYETTE, TAMA, AND BUTLER.ALLEN MEMORIAL ADMITS APPROXIMATELY 11,000 INPATIENTS AND CARES FOR 32,000 EMERGENCY PATIENTS PER YEAR. ALLEN MEMORIAL HOSPITAL CARES FOR MORE INPATIENTS, OUTPATIENTS, EMERGENCY PATIENTS AND CARDIAC PATIENTS THAN ANY OTHER HOSPITAL IN THE CEDAR VALLEY OF IOWA. THERE ARE 5 OTHER HOSPITALS WITHIN THE 6-COUNTY SERVICE AREACOMPRISING 80% OF THE MARKET.MEDIAN HOUSEHOLD INCOMES RANGE FROM 41,800 TO 54,500] AND THE AVERAGE POVERTY RATE IS 12%. MORE THAN 50% OF ALLEN HOSPITAL INPATIENTS ARE ELIGIBLE FOR MEDICARE OR MEDICAID. BLACK HAWK COUNTY, THE ONLY COUNTY IN THE SERVICE AREA WITH SIGNIFICANT MINORITY POPULATION, IS 86% CAUCASIAN AMERICAN AND BOSNIAN, 9% AFRICAN-AMERICAN, 4% HISPANIC AND 1% ALL OTHER MINORITY POPULATIONS. PART VI, LINE 5: THE HOSPITAL IS ORGANIZED AND OPERATED EXCLUSIVELY FOR CHARITABLE PURPOSES WITH THE GOAL OF PROMOTING THE HEALTH OF THE COMMUNITIES IT SERVES. THE HOSPITAL SUPPORTS THIS MISSION WITH A COMMUNITY BOARD, OPEN MEDICAL STAFF, AND AN EMERGENCY ROOM AVAILABLE TO PATIENTS REGARDLESS OF ABILITY TO PAY. THE BOARD OF DIRECTORS OF THE HOSPITAL IS COMPOSED OF CIVIC LEADERS WHO RESIDE IN THE SERVICE AREA OF THE HOSPITAL. THE BOARD ACTIVELY DEBATES AND SETS POLICY AND STRATEGIC DIRECTION FOR THE HOSPITAL BUT DOES NOT GET INVOLVED IN ISSUES RELATED TO THE DIRECT OPERATIONS OF THE HOSPITAL. THE BOARD TAKES A BALANCED APPROACH WHEN ADDRESSING COMMUNITY AND BUSINESS/FINANCIAL CONCERNS. THE BOARD IS ALSO THE PRIMARY GROUP FOR DETERMINING THE USE OF HOSPITAL SURPLUS FUNDS, WHICH ARE ALL USED TO FURTHER OUR CHARITABLE PURPOSE. PART VI, LINE 6: THE HOSPITAL IS PART OF IOWA HEALTH SYSTEM. INITIALLY FORMED IN 1995, IOWA HEALTH SYSTEM IS THE STATE'S FIRST AND LARGEST INTEGRATED HEALTH SYSTEM, SERVING NEARLY ONE OF EVERY THREE PATIENTS IN IOWA. THROUGH RELATIONSHIPS WITH 27 HOSPITALS IN METROPOLITAN AND RURAL COMMUNITIES AND MORE THAN 200 PHYSICIAN CLINICS, IOWA HEALTH SYSTEM PROVIDES CARE THROUGHOUT IOWA AND ILLINOIS.IOWA HEALTH SYSTEM ENTITIES EMPLOY THE STATE'S LARGEST NONPROFIT WORKFORCE, WITH MORE THAN 24,000 EMPLOYEES WORKING TOWARD INNOVATIVE ADVANCEMENTS TO DELIVER THE BEST OUTCOME FOR EVERY PATIENT EVERY TIME. EACH YEAR, THROUGH MORE THAN 3.1 MILLION PATIENT VISITS, IOWA HEALTH SYSTEM HOSPITALS AND CLINICS PROVIDE A FULL RANGE OF CARE TO PATIENTS AND FAMILIES. WITH ANNUAL REVENUES OF $2.8 BILLION, IOWA HEALTH SYSTEM IS THE FIFTH LARGEST NONDENOMINATIONAL HEALTH SYSTEM IN AMERICA AND PROVIDES COMMUNITY BENEFIT PROGRAMS AND SERVICES TO IMPROVE THE HEALTH OF PEOPLE IN ITS COMMUNITIES. IOWA HEALTH SYSTEM AND ITS AFFILIATES ENGAGE IN COMMUNITY HEALTH PROGRAMS AND SERVICES THROUGHOUT IOWA, AND WORK WITH VOLUNTEER AND CIVIC ORGANIZATIONS, SCHOOLS, BUSINESSES, INSURERS AND INDIVIDUALS TO SUPPORT ACTIVITIES THAT BENEFIT PEOPLE THROUGHOUT THE STATE. IN 2011, IOWA HEALTH SYSTEM AND ITS AFFILIATES PROVIDED MORE THAN $387 MILLION OF COMMUNITY BENEFIT. THE CONTRIBUTIONS TO THEIR COMMUNITIES BY IOWA HEALTH SYSTEM AND ITS AFFILIATES ARE REPORTED IN DETAIL IN STATEMENT OF PROGRAM SERVICE ACCOMPLISHMENTS (PART III) OF THE IRS FORM 990 OF THOSE AFFILIATES. REPORTS FILED WITH STATES PART VI, LINE 7 IA 1 AMERICAN HEART ASSOCIATION 460 N LINDBERGH BLVD ST LOUIS MO 63141 135613797 501(C)(3) 35000 PROGRAM SUPPORT GALLEGHER BLUEDORN UNI UNIVERSITY OF NORTHERN IA CEDAR FALLS IA 50613 426004333 501(C)(3) 25536 PROGRAM SUPPORT ALLEN HEALTH SYSTEMS INC 1825 LOGAN AVENUE WATERLOO IA 50703 421201924 501(C)(3) 35813 PROGRAM SUPPORT IOWA HOME HEALTH CARE - INTRUST 11333 AURORA AVENUE DES MOINES IA 50315 421477471 501(C)(3) 810680 PROGRAM SUPPORT IOWA HEALTH PHYSICIANS 8101 BIRCHWOOD COURT SUITE N JOHNSTON IA 50131 421411630 501(C)(3) 4864143 PROGRAM SUPPORT 5 0 SCHOLARSHIPS 40 12000 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: ALLEN MEMORIAL HOSPITAL CORPORATION MONITORS THE USE OF GRANT FUNDS ACCORDING TO THE STANDARD FINANCIAL POLICIES OF THE ORGANIZATION AND AS REQUIRED BY THE GRANT OR GRANTOR. THE POLICIES AND PROTOCOLS OF THE FUNDING SOURCE ARE ENFORCED AND MONITORED BY THE ORGANIZATION AND REPORTED AS REQUIRED. X 1 1 X X X X X 1 1 0 0 0 0 0 0 0 RUSSELL ADAMS MD 1041 310860 0 4768 0 1120 0 29494 0 17466 1041 363708 0 0 JOHN KNOX TO 1111 281004 0 78465 0 165948 0 7893 0 27440 0 560750 0 0 0 TOM TIBBITS FR 1111 0 197906 0 50000 0 510590 0 12250 0 12025 0 782771 0 456583 RENEE RASMUSSEN 207055 0 71099 0 23631 0 36343 0 25533 0 363661 0 0 0 JEFFREY CRANDALL MD TO 511 0 234934 0 90806 0 1300 0 31944 0 12999 0 371983 0 0 JENNIFER FRIEDLY 129670 0 20831 0 32303 0 4670 0 19668 0 207142 0 0 0 TIM HORRIGAN MD FR 311 0 227296 0 4018 0 1515 0 28600 0 21504 0 282933 0 0 SARA POLING TO 111 4416 0 73416 0 388231 0 598 0 12477 0 479138 0 162806 0 JUDITH RENAAS 192507 0 61529 0 23904 0 66617 0 6597 0 351154 0 0 0 JAMES WATERBURY 157755 0 49834 0 22684 0 61064 0 19488 0 310825 0 0 0 BILAL KAAKI 492312 0 125 0 6500 0 5746 0 10361 0 515044 0 0 0 CHRISTOPHER HILL 417679 0 0 0 26340 0 11873 0 6522 0 462414 0 0 0 PAUL MCCAUGHEY 467105 0 0 0 29193 0 9968 0 25345 0 531611 0 0 0 HIND MOUSSA 368222 0 0 0 2652 0 8595 0 6596 0 386065 0 0 0 PUBLIO ORTIZ 440375 0 1000 0 740 0 11873 0 19345 0 473333 0 0 0 RICHARD SEIDLER TO 610 0 433126 0 166284 0 128191 0 83659 0 12328 0 823588 0 0 JAY WILLSHER TO 910 0 199974 0 50635 0 28816 0 63222 0 26325 0 368972 0 0 PART I, LINE 1A TRAVEL FOR COMPANIONS SPOUSES SOMETIMES ACCOMPANY BOARD MEMBERS AND/OR OFFICERS ON ORGANIZATIONAL ACTIVITIES, INCLUDING BOARD RELATED TRAVEL. THE ADDITIONAL COST ATTRIBUTABLE TO THE SPOUSE IS TREATED AS TAXABLE COMPENSATION TO THE BOARD MEMBER OR OFFICER AND REPORTED AS APPROPRIATE TO THE IRS. PART I, LINES 4A-B SEVERANCE PAYMENT: THE FOLLOWING INDIVIDUALS RECEIVED A SEVERANCE PAYMENT DURING THE YEAR THAT WAS INCLUDED IN THEIR TAXABLE INCOME: JOHN KNOX $43,149 AND SARA POLING $216,148. SUPPLEMENTAL NONQUALIFIED RETIREMENT PLAN: THE FOLLOWING INDIVIDUALS PARTICIPATED IN A NON-QUALIFIED RETIREMENT PLAN WITH THE FOLLOWING CHANGES TO THEIR ACCOUNTS: RENEE RASMUSSEN $31,670, JUDITH RENAAS $42,494, RICHARD SEIDLER $66,665, AND JAMES WATERBURY $50,543. ALLEN MEMORIAL HOSPITAL ORTHOPEDIC CO-MANAGEMENT COMPANY LLC COMMON BOARD MEMBER/OFFICER 29000 INVESTMENT 0 CEDAR VALLEY COMMUNITY HEALTHCARE LLC COMMON BOARD MEMBER/OFFICER 44000 INVESTMENT 0 CEDAR VALLEY MEDICAL SPECIALISTS PC COMMON BOARD MEMBER/OFFICER 4461000 RENT, MEDICAL SERVICES, LAUNDRY, PHONE, ETC. 0 KAREN KNOX FAMILY MEMBER OF OFFICER JOHN KNOX 14490 EMPLOYMENT 0 KIRK GROSS COMPANY COMMON BOARD MEMBER/OFFICER 152000 FURNITURE AND DESIGN SERVICES 0 NINA THOMAS FAMILY MEMBER OF BOARD MEMBER BEV SMITH 40404 EMPLOYMENT 0 NORTHEAST IOWA PHYSICAL THERAPY AND SPORTS MEDICINE LLC COMMON BOARD MEMBER/OFFICER 28000 INVESTMENT 0 FORM 990, PART VI, SECTION A, LINE 6 ALLEN HEALTH SYSTEMS, INC., A TAX-EXEMPT IOWA NONPROFIT CORPORATION, IS THE SOLE MEMBER. FORM 990, PART VI, SECTION A, LINE 7A THE SOLE MEMBER, ALLEN HEALTH SYSTEMS, INC., HAS THE POWER TO NOMINATE AND APPOINT BOARD OF DIRECTORS. FORM 990, PART VI, SECTION A, LINE 7B THE SOLE MEMBER, ALLEN HEALTH SYSTEMS, INC., HAS THE POWER TO APPROVE CHANGES IN ARTICLES AND BYLAWS, DISSOLUTIONS OR MERGER, AND APPOINT BOARD OF DIRECTORS. IN ADDITION, THE EXECUTIVE COMMITTEE WILL BE THE SAME AS ALLEN HEALTH SYSTEMS, INC. FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 IS PREPARED INTERNALLY BY THE IOWA HEALTH SYSTEM TAX DEPARTMENT USING INFORMATION GATHERED FROM VARIOUS FUNCTIONAL AREAS OF THE ORGANIZATION. EACH SECTION OF THE RETURN IS REVIEWED BY THE RESPONSIBLE FUNCTIONAL AREA ALONG WITH THE TAX DEPARTMENT. A DRAFT COPY OF THE RETURN IS PROVIDED TO THE CFO FOR REVIEW. A FULL COPY OF THE FORM 990 IS PROVIDED TO THE BOARD OF DIRECTORS PRIOR TO FILING WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C THE ORGANIZATION HAS A CONFLICT OF INTEREST POLICY. ANNUALLY ALL OFFICERS, DIRECTORS, KEY EMPLOYEES AND REPORTING PHYSICIANS ARE REQUESTED TO COMPLETE A QUESTIONNAIRE TO REPORT POTENTIAL CONFLICTS OF INTEREST. PERSONS WHO HAVE NOT RETURNED QUESTIONNAIRES ARE CONTACTED ADDITIONAL TIMES IN AN EFFORT TO RECEIVE COMPLETE AND ACCURATE RESPONSES FROM ALL PERSONS. THE ANNUAL QUESTIONNAIRES INCLUDE AN ACKNOWLEDGEMENT THAT THE OFFICER, DIRECTOR, KEY EMPLOYEE OR REPORTING PHYSICIAN: 1) HAS ACCESS TO A COPY OF THE CONFLICT OF INTEREST POLICY; 2) HAS READ AND UNDERSTANDS THE POLICY; 3) AGREES TO COMPLY WITH THE POLICY; 4) UNDERSTANDS THAT THE POLICY APPLIES TO ALL COMMITTEES AND SUBCOMMITTEES HAVING BOARD-DELEGATED POWERS; AND 5) UNDERSTANDS THAT THE ORGANIZATION IS A CHARITABLE ORGANIZATION AND THAT IN ORDER TO MAINTAIN ITS TAX-EXEMPT STATUS, IT MUST CONTINUOUSLY ENGAGE PRIMARILY IN ACTIVITIES WHICH ACCOMPLISH ONE OR MORE OF ITS TAX-EXEMPT PURPOSES. SENIOR ADMINISTRATIVE STAFF AT ALL RELATED ORGANIZATIONS PROVIDE INFORMATION TO A CENTRAL COORDINATOR RELATED TO THE IDENTIFICATION OF WHICH INDIVIDUALS SHOULD RECEIVE THE QUESTIONNAIRE FOR COMPLETION. THE RESULTS ARE COMPILED CENTRALLY AND REVIEWED BY THE IOWA HEALTH SYSTEM COMPLIANCE OFFICER AND DIRECTOR OF INTERNAL AUDIT. THE DETAIL RESULTS ARE REPORTED TO A COMMITTEE OF THE SYSTEM BOARD. THE RESULTS RELATED TO SPECIFIC REGIONAL PARENT COMPANIES, THEIR HOSPITALS AND RELATED ORGANIZATIONS, ARE DISTRIBUTED IN DETAIL TO THE CHAIRPERSON OF THE REGIONAL PARENT ORGANIZATION, THE CHIEF EXECUTIVE OFFICER, CHIEF FINANCIAL OFFICER AND COMPLIANCE MANAGER. THESE INDIVIDUALS ARE ALSO REMINDED OF THE APPROPRIATE PROCESS TO BE FOLLOWED DURING THE YEAR TO ADDRESS POTENTIAL CONFLICTS OF INTEREST THAT RELATE TO MATTERS THAT ARE BROUGHT TO THE BOARD OF DIRECTORS FOR ACTION. THE INFORMATION DISCLOSED IS USED TO IDENTIFY POTENTIAL CONFLICTS OF INTEREST AND TO ASSIST IN COMPLETING IRS AND MEDICAID QUESTIONNAIRES. ANY DUALITY OF INTEREST OR POSSIBLE CONFLICT OF INTEREST ON THE PART OF ANY ORGANIZATIONAL OFFICER, DIRECTOR, KEY EMPLOYEE OR REPORTING PHYSICIAN TOGETHER WITH ALL MATERIAL FACTS, SHOULD BE DISCLOSED TO THE BOARD OF DIRECTORS AND MADE A MATTER OF RECORD, EITHER THROUGH AN ANNUAL PROCEDURE OR WHEN THE INTEREST OCCURS OR BECOMES A MATTER OF BOARD ACTION. ANY ORGANIZATIONAL OFFICER, DIRECTOR, KEY EMPLOYEE OR REPORTING PHYSICIAN HAVING A CONFLICT OF INTEREST IN ANY MATTER SHOULD NOT BE PRESENT DURING GENERAL DISCUSSION NOR VOTE OR USE HIS OR HER PERSONAL INFLUENCE ON THE MATTER, AND HE OR SHE SHOULD NOT BE COUNTED IN DETERMINING THE EXISTENCE OF A QUORUM FOR PURPOSES OF THE MATTER OR ITEM AS TO WHICH A CONFLICT EXISTS. THE BOARD SHOULD EXCLUDE THE INDIVIDUAL FROM ANY DISCUSSION OR VOTE IN WHICH THE BOARD DECIDES WHETHER OR NOT A CONFLICT OF INTEREST EXISTS. IN CASES IN WHICH AN OFFICER, DIRECTOR, KEY EMPLOYEE, REPORTING PHYSICIAN OR THE INDIVIDUAL'S HOUSEHOLD MEMBER HAS A CONFLICT OF INTEREST IN AN ARRANGEMENT OR TRANSACTION, THE FOLLOWING ADDITIONAL STEPS MAY BE TAKEN AT THE DIRECTION OF THE BOARD OF DIRECTORS: 1) AFTER DISCLOSURE OF THE FINANCIAL INTEREST AND ALL MATERIAL FACTS, AND AFTER ANY DISCUSSION WITH THE INTERESTED PERSON, HE OR SHE SHALL LEAVE THE BOARD OR COMMITTEE MEETING WHILE THE DETERMINATION OF A CONFLICT OF INTEREST IS DISCUSSED AND VOTED UPON. THE REMAINING BOARD OR COMMITTEE MEMBERS SHALL 1) DECIDE IF A CONFLICT OF INTEREST EXISTS, 2) A DISINTERESTED PERSON OR COMMITTEE MAY BE APPOINTED TO INVESTIGATE ALTERNATIVES TO THE PROPOSED ARRANGEMENT OR TRANSACTION; 3) IN ORDER TO APPROVE THE ARRANGEMENT OR TRANSACTION, THE BOARD MUST FIRST FIND, BY MAJORITY VOTE OF DISINTERESTED MEMBERS, THAT THE ARRANGEMENT OR TRANSACTION IS IN THE ORGANIZATION'S BEST INTEREST, IS FAIR AND REASONABLE TO THE ORGANIZATION, AND, AFTER REASONABLE INVESTIGATION, THE DISINTERESTED MEMBERS HAVE DETERMINED THAT A MORE ADVANTAGEOUS TRANSACTION OR ARRANGEMENT CANNOT BE OBTAINED WITH REASONABLE EFFORTS UNDER THE CIRCUMSTANCES; THE MINUTES OF THE BOARD AND ALL COMMITTEES WITH BOARD-DELEGATED POWERS SHALL CONTAIN: 1) THE NAMES OF THE PERSONS WHO DISCLOSED OR OTHERWISE WERE FOUND TO HAVE A FINANCIAL INTEREST IN CONNECTION WITH AN ACTUAL OR POSSIBLE CONFLICT OF INTEREST, THE NATURE OF THE FINANCIAL INTEREST, ANY ACTION TAKEN TO DETERMINE WHETHER A CONFLICT OF INTEREST WAS PRESENT, AND THE BOARD'S OR COMMITTEE'S DECISION AS TO WHETHER A CONFLICT OF INTEREST IN FACT EXISTED; 2) THE NAMES OF THE PERSONS WHO WERE PRESENT FOR DISCUSSIONS AND VOTES RELATING TO THE TRANSACTION OR ARRANGEMENT, THE CONTENT OF THE DISCUSSION, INCLUDING ANY ALTERNATIVES TO THE PROPOSED TRANSACTION OR ARRANGEMENT, AND A RECORD OF ANY VOTES TAKEN IN CONNECTION THEREWITH; IN ORDER TO PROTECT THE ORGANIZATION'S BEST INTERESTS, APPROPRIATE DISCIPLINARY ACTION MAY BE TAKEN WITH RESPECT TO AN OFFICER, DIRECTOR, KEY EMPLOYEE OR REPORTING PHYSICIAN WHO VIOLATES THE CONFLICT OF INTEREST POLICY. FORM 990, PART VI, SECTION B, LINE 15 THE EXECUTIVE COMMITTEE OF THE IOWA HEALTH SYSTEM BOARD OF DIRECTORS ("COMMITTEE") CONDUCTS A COMPREHENSIVE ANNUAL REVIEW OF ALL COMPENSATION AND BENEFITS PROVIDED TO THE ORGANIZATION'S OFFICERS AND KEY EMPLOYEES, INCLUDING THE IHS CHIEF EXECUTIVE OFFICER (THE "CEO"). THIS ANNUAL REVIEW COMPARES THE TOTAL COMPENSATION AND VALUE OF BENEFITS PROVIDED TO EACH EXECUTIVE, ON A POSITION BY POSITION BASIS, TO THAT PROVIDED TO FUNCTIONALLY SIMILAR POSITIONS IN SIMILARLY SITUATED ORGANIZATIONS. THIS REVIEW IS CONDUCTED BY THE COMMITTEE WITH THE ASSISTANCE OF A NATIONAL, INDEPENDENT COMPENSATION CONSULTANT REPORTING DIRECTLY TO THE COMMITTEE. THE COMMITTEE HAS BEEN DELEGATED THE RESPONSIBILITY FOR OVERSIGHT OF EXECUTIVE COMPENSATION AND IS MADE UP ENTIRELY OF INDEPENDENT DIRECTORS WITHIN THE MEANING OF THE "REBUTTABLE PRESUMPTION OF REASONABLENESS" UNDER THE FEDERAL INCOME TAX INTERMEDIATE SANCTIONS RULES. THE COMPENSATION CONSULTANT HOLDS ITSELF OUT TO THE PUBLIC AS A COMPENSATION CONSULTANT, PERFORMS THESE VALUATIONS ON A REGULAR BASIS, IS QUALIFIED TO MAKE THE VALUATIONS OF THE SERVICES INVOLVED, AND HAS SO INDICATED IN A WRITTEN CERTIFICATION TO THE COMMITTEE. BASED UPON THE ADVICE OF THE COMPENSATION CONSULTANT, AND APPLYING THE BOARD'S COMPENSATION PHILOSOPHY, THE COMMITTEE ESTABLISHES THE OVERALL ADJUSTMENT IN COMPENSATION AND BENEFITS FOR APPROXIMATELY THE TOP FIFTY EXECUTIVES IN THE ENTIRE HEALTH SYSTEM (SEVERAL OF WHICH ARE EMPLOYEES OF THE FILING ORGANIZATION) AND DELEGATES TO THE CEO THE AUTHORITY TO MAKE ADJUSTMENTS, CONSISTENT WITH THE COMMITTEE'S DIRECTION, FOR THE OTHER EXECUTIVES. THE COMMITTEE DETERMINES ALL ASPECTS OF THE COMPENSATION AND BENEFITS OF THE CEO. THE COMMITTEE INTENTIONALLY TAKES ALL THE STEPS NECESSARY TO QUALIFY FOR THE REBUTTABLE PRESUMPTION OF REASONABLENESS UNDER THE FEDERAL INCOME TAX LAW INTERMEDIATE SANCTIONS RULES, INCLUDING CONTEMPORANEOUS SUBSTANTIATION OF ALL COMMITTEE MEETINGS AND ACTIONS. THE ORGANIZATION BELIEVES IT IS IN FULL COMPLIANCE WITH SECTION 4958 OF THE IRC, PROVIDES NO MORE THAN REASONABLE AND FAIR MARKET VALUE COMPENSATION AND BENEFITS FOR ITS EMPLOYEES AND DOES NOT PROVIDE ANY EXCESS COMPENSATION OR BENEFITS AS PROHIBITED BY SECTION 4958. THE ANNUAL REVIEW OF COMPENSATION AND BENEFITS WAS LAST PERFORMED IN NOVEMBER 2011 FOR THE FOLLOWING INDIVIDUALS: JOHN KNOX, RENEE RASMUSSEN, JUDITH RENAAS, RICHARD SEIDLER, JAMES WATERBURY, AND JAY WILLSHER. THE COMPENSATION AND BENEFITS OF THE OTHER PERSONS LISTED ON FORM 990, PART VII WAS ESTABLISHED BY AN INDEPENDENT PERSON/COMMITTEE USING AN INDEPENDENT COMPENSATION CONSULTANT AND/OR COMPENSATION SURVEY OR STUDY FOR SIMILARLY QUALIFED PERSONS IN FUNCTIONALLY COMPARABLE POSITIONS AT SIMILARLY SITUATED ORGANIZATIONS. COMPENSATION AND BENEFITS ARE BASED ON THE FAIR MARKET VALUE OF THE SERVICES PROVIDED TO THE ORGANIZATION. FORM 990, PART VI, SECTION C, LINE 19 IOWA HEALTH SYSTEM, OUR PARENT ORGANIZATION, HAS VOLUNTARILY ADOPTED MANY OF OUR INDUSTRY'S GOVERNANCE "BEST PRACTICES." IOWA HEALTH SYSTEM HAS DONE SO TO FURTHER ASSURE OUR STAKEHOLDERS THAT OUR GOVERNANCE AND MANAGEMENT IS CONDUCTED RESPONSIBLY AND WARRANTS THE TRUST YOU PLACE IN US. IN SEPTEMBER 2003, THE IOWA HEALTH SYSTEM BOARD OF DIRECTORS VOLUNTARILY ADOPTED OVER 40 CHANGES TO ITS GOVERNANCE STRUCTURE TO BETTER COMPLY WITH GOVERNANCE BEST PRACTICES AND THE INTENT AND APPLICABLE REQUIREMENTS OF THE SARBANES-OXLEY ACT OF 2003. IN ADDITION, GOVERNANCE POLICIES AND RELATED INFORMATION HAS BEEN ADDED TO THE IOWA HEALTH SYSTEM WEBSITE, WWW.IHS.ORG, INCLUDING BUT NOT LIMITED TO: OVER 130 CORPORATE COMPLIANCE POLICIES, INCLUDING CHARITY CARE AND CONFLICTS OF INTEREST POLICIES; GOVERNANCE BEST PRACTICE POLICIES; THE IDENTIFICATION OF BOARD MEMBERS AND BOARD COMMITTEES; COMPENSATION FOR HOSPITAL CEO'S; AND FINANCIAL INFORMATION FOR THE PAST SEVEN YEARS. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED LOSSES ON INVESTMENTS: -4,305,034. CHANGES IN PENSION LIABILITY -5,880,213. TOTAL TO FORM 990, PART XI, LINE 5: -10,185,247. ALLEN COLLEGE 1825 LOGAN AVENUE WATERLOO IA 50703 421351526 EDUCATE AND DEVELOP HEALTHCARE PROFESSIONALS IA 501(C)(3) 170(B)(1) (A)(II) ALLEN HEALTH SYSTEMS INC 1 ALLEN HEALTH SYSTEMS INC 1825 LOGAN AVENUE WATERLOO IA 50703 421201924 SUPPORT AFFILIATES' MISSION TO IMPROVE HEALTH CARE IA 501(C)(3) 509(A)(3), TYPE II IOWA HEALTH SYSTEM 1 ALLEN MEMORIAL HOSPITAL CORPORATION 1825 LOGAN AVENUE WATERLOO IA 50703 420698265 HOSPITAL IA 501(C)(3) 170(B)(1) (A)(III) ALLEN HEALTH SYSTEMS INC 1 ANAMOSA AREA AMBULANCE SERVICE 101 GRANT WOOD DRIVE ANAMOSA IA 52205 421466284 PROVIDE AMBULANCE SERVICES IA 501(C)(3) 509(A)(2) ST LUKE'SJONES REGIONAL MEDICAL CENTER 1 CENTRAL IOWA HEALTH PROPERTIES CORPORATION 1200 PLEASANT STREET DES MOINES IA 50309 421233759 PROPERTY HOLDING COMPANY IA 501(C)(2) CENTRAL IOWA HEALTH SYSTEM 1 CENTRAL IOWA HEALTH SYSTEM 1200 PLEASANT STREET DES MOINES IA 50309 421189791 SUPPORT AFFILIATES' MISSION TO IMPROVE HEALTH CARE IA 501(C)(3) 509(A)(3), TYPE II IOWA HEALTH SYSTEM 1 CENTRAL IOWA HOSPITAL CORPORATION 1200 PLEASANT STREET DES MOINES IA 50309 420680452 HOSPITAL IA 501(C)(3) 170(B)(1) (A)(III) CENTRAL IOWA HEALTH SYSTEM 1 FINLEY TRI-STATES HEALTH GROUP INC 350 NORTH GRANDVIEW AVENUE DUBUQUE IA 52001 421307495 SUPPORT AFFILIATES' MISSION TO IMPROVE HEALTH CARE IA 501(C)(3) 509(A)(3), TYPE II IOWA HEALTH SYSTEM 1 HNC SERVICES 1200 PLEASANT STREET DES MOINES IA 50309 270987243 SUPPORT AFFILIATES' MISSION TO IMPROVE HEALTH CARE IA 501(C)(3) 509(A)(2) IOWA HEALTH SYSTEM 1 INTEGRATED CARE ORGANIZATION 1200 PLEASANT STREET DES MOINES IA 50309 274665007 PROMOTE, SUPPPORT THE INTERESTS AND PURPOSES OF AFFILIATES' HOSPITALS IA 501(C)(3) 509(A)(2) IOWA HEALTH SYSTEM 1 INTRUST 11333 AURORA AVENUE URBANDALE IA 50322 421477471 HOME HEALTH CARE IA 501(C)(3) 509(A)(2) IOWA HEALTH SYSTEM 1 IOWA HEALTH FOUNDATION 2700 GRAND AVE SUITE 109 DES MOINES IA 50312 421467682 CHARITABLE FUNDRAISING IA 501(C)(3) 509(A)(3), TYPE III CENTRAL IOWA HEALTH SYSTEM 1 IOWA HEALTH SYSTEM 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IA IHS C 338870 13238641 1.00000 CHARITABLE REMAINDER UNITRUST #1 INVESTMENT IA SLHCF T CHARITABLE REMAINDER UNITRUST #2 INVESTMENT IA SLHCF T CHARITABLE REMAINDER UNITRUST #3 INVESTMENT IA SLHCF T CHARITABLE REMAINDER UNITRUST #6 INVESTMENT IA SLHCF T IOWA HEALTH SYSTEM 457 DEF COMP PLAN 1415 WOODLAND AVE 2ND FL DES MOINES IA 50309 421435199 INVESTMENT IA IHS T 266087 4546270 1.00000 METHODIST HEALTH VENTURES INC PO BOX 87 PEORIA IL 61650 371140939 PHARMACY/OFFICE STAFFING IL MHSC C 868566 2437393 1.00000 MEDIMORE INC 1200 PLEASANT ST DES MOINES IA 50309 421414390 MANAGED CARE IA IHS C 210170 1.00000 METHODIST PHYSICIAN SERVICES INC PO BOX 87 PEORIA IL 61650 363858550 MEDICAL SERVICES IL MHVI C 11908671 1305915 1.00000 PRECEDENCE INC 4622 PROGRESS DRIVE STE A DAVENPORT IA 52807 371288604 MANAGED MENTAL CARE IA RYC C 506534 435657 1.00000 PROVIDER RESOURCE MANAGEMENT INC PO BOX 87 PEORIA IL 61650 371223550 RESOURCE MANAGEMENT IL MHSC C 57427 1.00000 RURAL IOWA SPECIALTY PHYSICIAN CONSORTIUM INC 700 E UNIVERSITY AVE DES MOINES IA 50316 261271143 SPECIALTY PHYSICIANS MEDICAL CARE IA CIHC C 481860 198055 0.57000 STL HEALTH RESOURCES CO 1026 A AVE NE CEDAR RAPIDS IA 52402 421193499 PHYSICIAN OFFICE RENTAL IA SLMH C 322129 5577505 1.00000 TRIMARK PHYSICIANS GROUP INC 802 KENYON ROAD FORT DODGE IA 50501 421335554 MEDICAL CLINICS IA THS C 44216247 1.00000 TRINITY HEALTH ENTERPRISES INC 2701 17TH ST ROCK ISLAND IL 61201 363320141 RETAIL DURABLE MEDICAL EQUIPMENT & PHARMACY IL TRHS C 3295832 2957465 1.00000 0 1 1 0 0 0 0 0 1 0 1 1 1 1 1 1 0 1 SECTION 512(B)(13) CONTROLLED ENTITY SCHEDULE R, PART II, COLUMN (G) THE ORGANIZATION IS A MEMBER OF A CONSOLIDATED HEALTH SYSTEM AND HAS A COMMON PARENT ORGANIZATION, "IOWA HEALTH SYSTEM." FOR ENTITIES THAT ARE PART OF THE CONSOLIDATED HEALTH SYSTEM (WITH COMMON CONTROL) THE ATTRIBUTION RULES OF IRC SECTION 318 APPLY; MEANING THAT ALL ORGANIZATIONS ARE DEEMED TO HAVE CONTROL OF THE ORGANIZATIONS OWNED BY THE CONTROLLING ORGANIZATION. AS SUCH, WE ARE REPORTING ALL RELATED ORGANIZATIONS OF THE HEALTH SYSTEM IN PARTS II, III & IV. FOR PART V REPORTING, THE TRANSACTIONS DISCLOSED ARE THOSE BETWEEN THE DIRECTLY CONTROLLED PARENT-SUBSIDIARY ONLY.