2011-01-18T10:29:06-06:00 2010-06-30 LARSONALLEN LLP 220 SOUTH SIXTH STREET SUITE 300 MINNEAPOLIS MN 55402 990 2009-07-01 390890676 ST CROIX REGIONAL MEDICAL CENTER STCR 7154830556 235 STATE STREET ST CROIX FALLS WI 54024 john tremble 7154830556 2011-01-10 1 6123764500 2009 2016-02-24 21:20:13Z dave Dobosenski 235 STATE STREET ST CROIX FALLS WI 54024 57869027 0 X WWW.SCRMC.ORG X 1954 WI To provide quality healthcare services to all residents of the service area. 9 5 488 138 197 0 500000 0 53162225 54164374 372197 916246 308909 271280 54343331 55351900 12000 15000 0 20567608 21397109 30000 0 0 32158377 32574953 52767985 53987062 1575346 1364838 38457454 40211504 23582773 23971985 14874681 16239519 The mission of SCRMC is to provide quality healthcare services to all residents of the service area. 0 0 23871996 15000 28555169 OUTPATIENT SERVICES - SURGICAL, LABORATORY, BASIC, AND ADVANCED RADIOLOGY PROCEDURES. DURING FY2010, THERE WERE 7,054 EMERGENCY ROOM VISITS RECORDED, 1,286 OUTPATIENT SURGERIES, AND 201,342 LAB TESTS COMPLETED. 13732551 0 11853089 CLINIC SERVICES - PRIMARY AND SPECIALTY CARE FOR AMBULATORY PATIENTS AT THREE SERVICE SITES. 85,942 PATIENT VISITS WERE RECORDED DURING FY2010. 11616064 0 13756116 INPATIENT SERVICES - OBSTETRIC, MEDICAL-SURGICAL, INTENSIVE CARE, AND SHORT STAY INPATIENT CARE. DURING FY2010, THERE WERE 338 BIRTHS, 1,979 INPATIENT ADMISSIONS, AND A TOTAL OF 5,218 INPATIENT DAYS FOR AN AVERAGE LENGTH OF STAY OF 2.7 DAYS. 49220611 1 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 1 0 1 1 1 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 0 0 0 1 132 0 1 488 1 0 0 0 0 0 0 0 0 0 9 5 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 0 1 0 WI X X X JOHN TREMBLE CFO VP 7154830317 235 STATE STREET ST CROIX FALLS WI 54024 LARRY COLLINS 4.00 X X 0 0 0 REBECCA LYMAN 2.00 X X 0 0 0 IVAN BOWEN 3.00 X X 0 0 0 MARSHA BEYER 2.00 X X 0 0 0 HARLEN HEGDAL 2.00 X 0 0 0 CLYDE VAN OORT 2.00 X 0 0 0 JEFF HALL 2.00 X 0 0 0 JEANNE BRUNCLIK 2.00 X 0 0 0 STEVE TESCH 2.00 X 0 0 0 Lenny Libis 40.00 X 243862 0 35546 JOHN TREMBLE 40.00 X 149410 0 19287 CINDY LUNDMARK 40.00 X 130540 0 25020 LAURA JENSEN 40.00 X 108742 0 23245 BARB KINNEY 40.00 X 80930 0 23412 CLAUDIO NUNES 40.00 X 341000 0 42039 JAMIE PEARSON 40.00 X 109265 0 20088 1163749 0 188637 6 0 1 0 RIVER VALLEY MEDICAL Center 208 S Adams Street St Croix Falls WI 54024 PHYSICIAN SERVICES 7257517 REGIONS HOSPITAL PO Box 1450 Minneapolis MN 55485 PHYSICIAN SERVICES 1500000 VOYAGEUR RADIOLOGY 208 S Adams Street St Croix Falls WI 54024 PHYSICIAN SERVICES 1169740 ST CROIX VALLEY ANESTHESIA 2196 84th Ave Osceola WI 54020 CRNA SERVICES 944532 VALLEY ORTHOPAEDICS 208 S Adams Street St Croix Falls WI 54024 PHYSICIAN SERVICES 537947 7 PATIENT SERVICES 624100 53877677 53877677 CAFETERIA MEAL SALES 722210 233414 233414 Other Hospitals 624100 53283 53283 54164374 909245 909245 47349 13649 33700 33700 33700 2510479 2503478 7001 7001 7001 MISCELLANEOUS 900099 143401 143401 JOINT VENTURE REVENUE 900099 93982 93982 REFERENCE LAB 621500 197 197 237580 55351900 53877677 197 1474026 15000 15000 851051 851051 15458745 13996779 1461966 789280 714636 74644 3141234 2844161 297073 1156799 1047398 109401 123768 123768 50716 50716 16376094 15612629 763465 18141 3628 14513 300353 206772 93581 806705 738135 68570 1700961 1568868 132093 87193 76261 10932 84664 64986 19678 648599 593468 55131 2613054 2390944 222110 170514 167850 2664 supplies 7372640 7247232 125408 bad debts 1401849 1401849 0 EQUIP RENTAL & MAINT 135736 73298 62438 Collections 108082 108082 Dues and Fees 101809 31990 69819 474075 424727 49348 53987062 49220611 4766451 0 1310070 2902570 4301445 1790966 7414901 8580474 136670 200010 1061155 1036075 435487 103494 45806911 23498745 20726216 22308166 2562085 2785319 235924 266453 273501 237977 38457454 40211504 9477222 10726497 13665229 12671910 80429 359893 573578 23582773 23971985 X 12918331 15989519 1956350 250000 14874681 16239519 38457454 40211504 X 0 1 1 X 0 X 243762 243762 24264950 8562799 15702151 779778 365111 414667 20461893 14570835 5891058 56528 56528 22308166 DEFERRED COMPENSATION PLAN 544178 ASSET RETIREMENT OBLIGATION 29400 573578 55351900 53987062 1364838 0 1364838 54327050 13649 13649 54313401 1038499 1038499 55351900 54000711 13649 13649 53987062 0 53987062 Part XII, Line 2d - Other Adjustments: rental expenses: 13649. Part XII, Line 4b - Other Adjustments: INTEREST INCOME: 909245. GAIN ON SALE OF ASSETS: 7001. OTHER NONOPERATING INCOME: 122253. Part XIII, Line 2d - Other Adjustments: rental expenses: 13649. 1 1 1 X 0 1 1 1 0 1 1 737217 737217 0.01400 8656858 7241735 1415123 0.02690 9394075 7241735 2152340 0.04090 18026 18026 0.00030 18026 18026 0.00030 9412101 7241735 2170366 0.04120 45 18026 18026 0.00030 45 18026 18026 0.00030 1 739647 36095881 38152796 -2056915 X 1 1 ST CROIX REGIONAL MEDICAL CENTER

235 STATE STREET st croix falls WI 54024

X X X X Part I, Line 3c: St Croix Regional Medical Center, through its Patient Advocates, evaluates each applicant's situation in accordance with criteria established annually by the Board of Directors. The criteria includes:1. Individual or family income2. Family size3. Other sources of payment for servicesQualification is based on asset levels established by Medical Assistance, family size, and income levels based on 150% of FederalPoverty Guidelines as published annually by the Federal Government.Granting of Community Care - Amount:Patients that qualify for St Croix Reginal Medical Center's Charity Care Program will receive 100% of their account balance applied to the fund.Granting of Community Care - Term:Patients that qualify for St Croix Reginal Medical Center's Charity Care program will receive Community Care for a specific hospitalization or for a specified course of treatment.All patients receiveing Charity Care must re-apply if their status changes or the treatment duration has ended. Part I, Line 7f: BAD DEBT EXPENSES OF $1,401,849 WERE SUBTRACTED FROM THE TOTAL EXPENSES OF $53,987,062 IN CALCULATING THE PERCENTAGES IN PART I, LINE 7, COLUMN F. Part III, Line 4: FROM THE PATIENT ACCOUNTS RECEIVABLE AND ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS PARAGRAPH IN NOTE 1 TO THE AUDITED FINANCIAL STATEMENTS:"PATIENTS ARE NOT REQUIRED TO PROVIDE COLLATERAL FOR SERVICES RENDERED. PAYMENT FOR SERVICES IS REQUIRED UPON RECEIPT OF AN INVOICE, AFTER PAYMENT OF INSURANCE, IF ANY. SELF-PAY ACCOUNTS ARE ANALYZED FOR COLLECTIBILITY BASED ON THE MONTHS PAST DUE AND PAYMENT HISTORY. AN ALLOWANCE IS ESTIMATED FOR THESE ACCOUNTS BASED ON THE HISTORICAL EXPERIENCE OF THE MEDICAL CENTER. ACCOUNTS THAT ARE DETERMINED TO BE UNCOLLECTIBLE ARE SENT TO A COLLECTION AGENCY AND WRITTEN OFF AT THAT TIME."OVERALL COST-TO-CHARGE RATIO PER AUDITED FINANCIAL STATEMENTS FOR FY2010 IS 56%. Part III, Line 8: OVERALL COST-TO-CHARGE RATIO PER AUDITED FINANCIAL STATEMENTS FOR FY2010 IS 56%.The Medical Center provides care to individuals where government departments determine the amount of reimbursement of service regardless of the cost to provide the service. Amounts reimbursed by government payors are estimated to be less than the costs to provide the services as follows:Medicaid- Wisconsin 1,981,090Medicaid- Minnesota 229,008Champus and VA 143,449Medicare - Physician 1,242,696Medicare - Hospital 417,532Medicare Advantage 396,587All Government Payors $ 4,410,362 Total charity care, uncompensated care and under compensated care by Government payors was $7,212,447. This represents 12.9% of net operating revenues of the Medical Center. Part III, Line 9b: The Medical Center has established guidelines for the provision of health services at reduced costs for individuals based upon their income and other circumstances. The Medical Center has a policy to provide an immediate discount to all uninsured patients of 20% of charges. Part VI, Line 2: OVERALL MARKETPLACE DEMOGRAPHICS AND COMPETITIVE ANALYSIS IS CONDUCTED ON A REGULAR BASIS. WHEN DEMAND FOR NEW SERVICE LINES IS INTENSIFIED, THEY ARE ADDED SLOWLY UNTIL DEMAND CAPACITY REACH CRITICAL LEVELS. Part VI, Line 3: ALL PATIENTS HAVE ACCESS TO WRITTEN MATERIALS AND PAMPHLETS AT OR NEAR THE POINT OF REGISTRATION. IN ADDITION, PATENTS HAVE ACCESS TO PATIENT ADVOCATES WITH FULL KNOWLEDGE OF RESOURSES AVAILABLE. Part VI, Line 4: THE ORGANIZATION SERVES A GEOGRAPHIC AREA OF APPROXIMATELY 300 SQUARE MILES IN WESTERN WISCONSIN THAT INCLUDES THE TOWNS OF ST CROIX FALLS, DRESSER, OSCEOLA, BALSAM LAKE, LUCK, MILLTOWN, FREDERIC, AND GRANTSBERG IN WISCONSIN AND TAYLORS FALLS AND LINDSTROM IN EASTERN MINNESOTA. Part VI, Line 5: THE ORGANIZATION PROVIDES DIRECT SUPPORT TO OVER 42 COMMUNITY ACTIVITIES, PROVIDES OVER 15,000 HOURS OF VOLUNTEER TIME IN INDIRECT PATIENT CARE ACTIVITIES, AND OVER 400 HOURS OF EDUCATION FOR HEALTHCARE PROFESSIONALS. Part VI, Line 7: THE CENTER IS NOT PART OF AN AFFILIATED HEALTH CARE SYSTEM. WI 1 Scholarships 30 15000 Procedure for Monitoring Grants in the U.S.: Part I, Line 2: Schedule I, Part I, Line 2: The organization's procedures include substantiation of expenses, grades, transcripts and receipts, as well as follow up with community organizations and leaders. X X X X X 0 1 0 0 0 1 1 0 0 Lenny Libis 243862 0 0 0 0 0 13680 0 21866 0 279408 0 0 0 JOHN TREMBLE 149410 0 0 0 0 0 9001 0 10286 0 168697 0 0 0 CINDY LUNDMARK 130540 0 0 0 0 0 7847 0 17173 0 155560 0 0 0 CLAUDIO NUNES 275000 0 66000 0 0 0 16500 0 25539 0 383039 0 0 0 Part I, Line 4a CONTRIBUTIONS TO A 457(F) SUPPLEMENTAL NON-QUALIFIED RETIREMENT PLAN: LENNY LIBIS $26,788 JOHN TREMBLE $18,626 CINDY LUNDMARK $15,058 LAURA JENSEN $12,871 Part I, Line 6 Annual employer contributions to the 457f plan are conditioned upon attaining certain pre-set goals and are contingent on approval by the Board of Directors. POLK COUNTY 396005730 2006-05-11 13000000 REFUND SERIES 2000 BONDS, FACILITY CONSTRUCTION AND EQUIPMENT PURCHASES 0 0 POLK COUNTY 396005730 2006-12-27 3683432 FACILITY CONSTRUCTION 0 0 13000000 237476 13000000 2008 0 1 1 1 3683432 429338 87878 3683432 2008 0 0 1 1 0 0 0 0 0 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 river valley medical center Four of RMVC owners serve on the BOD of SCRMC 7257517 physician services 0 Form 990, Part V, line 3b Form 990, Part V, Line 3a: UBI revenue is less than $1,000. For this reason Form 990T will not be filed. Form 990, Part VI, Section A, line 1 St. Croix Regional Medical Center has an executive committee with broad authority to act on behalf of its board of trustees. The executive committee includes the chair, vice chair, secretary, treasurer and one other trustee from the board of trustees. The executive committee has power to transact all regular business of the organization during the period between meetings of the board of trustees, subject to any period limitation imposed by the board of trustees and with the understanding that all matters of major importance will be referred to the board of trustees. Form 990, Part VI, Section A, line 6 ST. CROIX REGIONAL MEDICAL CENTER HAS TWO CLASSES OF MEMBERS - SPONSORING MEMBERS AND PHYSICIAN ELECTORS. INDIVIDUALS AND CORPORATIONS MAY BECOME SPONSORING MEMBERS THROUGH DONATIONS OF A SPECIFIED AMOUNT TO THE MEDICAL CENTER. INDIVIDUALS MAY BECOME PHYSICIAN ELECTORS BY PROVIDING SERVICES AT ST. CROIX REGIONAL MEDICAL CENTER THROUGH SPECIFIED EMPLOYMENT CONDITIONS. Form 990, Part VI, Section A, line 7a PHYSICIAN ELECTORS VOTE IN THE ELECTION OF FOUR PHYSICIAN TRUSTEES. SPONSORING MEMBERS VOTE IN THE ELECTION OF FIVE COMMUNITY TRUSTEES. Form 990, Part VI, Section A, line 7b THE MEMBERS VOTE ON THE AUDITORS EMPLOYED TO AUDIT THE BOOKS OF THE MEDICAL CENTER AND TO PREPARE AN ANNUAL REPORT. AN OPS COUNCIL, CONSISTING OF FIVE INDIVIDUALS APPOINTED BY RIVER VALLEY MEDICAL CENTER, A RELATED ORGANIZATION, HAS SIGNIFICANT OVERSIGHT AUTHORITY AT THE MEDICAL CENTER. THE OPS COUNCIL'S AUTHORITY INCLUDES, BUT IS NOT LIMITED TO, REVIEW AND APPROVE OF ALL POLICIES AND PROCEDURES AS THEY RELATE TO MEDICAL OPERATIONS AND APPROVAL OF THE ANNUAL CAPITAL AND OPERATING BUDGETS. Form 990, Part VI, Section B, line 11 THE FORM 990 WENT THROUGH THE FOLLOWING REVIEW PROCESS BEFORE FILING WITH THE IRS: (A) A DETAILED REVIEW WAS CONDUCTED BY THE ORGANIZATION'S CFO, (B) THE FORM 990 WAS PRESENTED FOR REVIEW AND APPROVAL TO THE ORGANIZATION'S FINANCE COMMITTEE ON DECEMBER 15, 2010, AND (C) THE ORGANIZATION'S BOARD OF DIRECTORS REVIEWED AND APPROVED THE FORM 990 ON DECEMBER 21, 2010. Form 990, Part VI, Section B, line 12c Board membership is contingent upon annual discosure of potential and actual conflicts of interest. The dertermination is made at the board level and all board members must certify annually. If a board member has a conflict, they refrain from voting or participating in discussions concerning that topic. Form 990, Part VI, Section B, line 15a CEO - annual performance and salary review is conducted by the Board of Directors using such outside information as deemed necessary. Reviews are conducted each June. The process last included review and approval by independent persons, comparability data and contemporaneous substantiation in 2010. Other officers - The Human Resource department conducts outside research to determine reasonable compensation. The CEO then determines the compensation of these individuals. Reviews are conducted each June. This process last occured in fiscal year 2010. Form 990, Part VI, Section C, line 19 The Medical Center's govering documents, conflict of interest policy and financial statements are not made available to the public. SCHEDULE L, PART IV AND SCHEDULE R, PART V, LINE 1O REIMBURSEMENTS FOR PHYSICIAN SERVICES ST. CROIX REGIONAL MEDICAL CENTER REIMBURSES RIVER VALLEY MEDICAL CENTER (RVMC), A RELATED ORGANIZATION, FOR PHYSICIAN SERVICES PROVIDED BY EMPLOYEES OF RVMC. ALL PAYMENTS ARE "GROSS", MEANING THAT THEY INCLUDE UNIDENTIFIED AMOUNTS FOR BENEFITS AND MALPRACTICE INSURANCE, AS WELL AS W-2 COMPENSATION. river valley medical center 208 South Adams St Croix Falls WI 54024 391152637 physician services WI N/A C 0 0 0 0 0 0 0 0 0 0 0 1 0 0 1 0 0 0