2023-10-23T09:52:29-05:00 2022-12-31 390758449 WIPFLI LLP 1502 LONDON ROAD SUITE 200 DULUTH MN 55812 990 2022-01-01 390944012 MOUNDVIEW MEMORIAL HOSPITAL & CLINICS MOUN 6083393331 402 WEST LAKE STREET FRIENDSHIP WI 53934 FRANK PEREZ-GUERRA CEO 6083393331 2023-10-17 1 FRANK PEREZ-GUERRA 999009999 1 MICHAEL J PETERSON CPA P01833529 2187224705 2023-10-17 2 AAL1 IAL1 2022 2023-04-26 12:10:37Z GUNDERSEN MOUNDVIEW HOSPITAL & CLINICS FRANK PEREZ-GUERRA 402 WEST LAKE STREET FRIENDSHIP WI 53934 29495945 0 X WWW.GUNDERSENHEALTH.ORG/MOUNDVIEW X 1959 WI WE WILL ENHANCE THE HEALTH AND WELL-BEING OF OUR COMMUNITIES WHILE ENRICHING EVERY LIFE WE TOUCH, INCLUDING PATIENTS, FAMILIES, AND STAFF. 8 3 177 65 0 0 3946443 596964 21792390 28523764 109562 67633 258112 207882 26106507 29396243 1350 551107 0 0 9124660 9471727 0 0 0 11700235 19030738 20826245 29053572 5280262 342671 21727345 19154587 5036680 2121251 16690665 17033336 WE WILL DISTINGUISH OURSELVES THROUGH EXCELLENCE IN PATIENT CARE, EDUCATION, AND IMPROVED HEALTH IN THE COMMUNITIES WE SERVE. 0 0 17741790 551107 18898501 THE HOSPITAL IS A GENERAL MEDICAL CRITICAL ACCESS HOSPITAL LICENSED FOR 25 BEDS. DURING FISCAL YEAR 2022, THE HOSPITAL HAD 375 ACUTE INPATIENT DAYS AND 750 SWING-BED DAYS. THE HOSPITAL ALSO HAD 7,022 EMERGENCY ROOM/URGENT CARE AND 8,447 CLINIC VISITS. 7351529 0 9691066 THE HOSPITAL ALSO HAS AN OUTPATIENT PHARMACY THAT IS THE ONLY IN IT'S COUNTY (ADAMS, WI), AND IN 2022 FILLED 95,969 PRESCRIPTIONS. 25093319 1 1 0 1 0 0 0 0 0 0 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 1 212 0 177 1 0 0 0 0 0 0 0 0 0 0 0 0 X 8 3 0 0 1 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 0 0 WI X FRANK PEREZ-GUERRA 6083393331 402 WEST LAKE STREET FRIENDSHIP WI 53934 RICHARD STERNHAGEN CHAIR 2.50 1.00 X X 0 0 0 PAUL FISCH VICE CHAIR 2.50 40.00 X X 0 46800 5344 SARAH ROSSMAN SECRETARY 2.50 40.00 X X 0 150665 8950 STEPHANIE CARROLL BOARD TRUSTEE/MD HOSPITALIST 2.50 40.00 X 0 297599 31696 BRYAN ERDMANN BOARD TRUSTEE/COO 2.50 40.00 X 0 316306 40438 ROXANNE POTTS BOARD TRUSTEE/CLINICAL OPS. DIRECTOR 2.50 40.00 X 0 157034 26912 KAREN MILLER BOARD TRUSTEE 2.50 X 0 0 0 JOE THEISEN BOARD TRUSTEE 2.50 X 0 0 0 FRANK PEREZ-GUERRA CEO 40.00 1.00 X 0 190450 31881 LISA PETERS EMERGENCY DEPARTMENT MANAGER 40.00 X 111016 0 34528 BRAD SHAW IMPATIENT PHARMACY MANAGER 40.00 X 149983 0 3241 DEENA KEDROWSKI OUTPATIENT PHARMACY MANAGER 40.00 X 157736 0 32949 PRESTON PIETRZAK PHARMACIST 40.00 X 134759 0 16738 DAVID BROWN PHARMACIST 40.00 X 146362 0 1175 699856 1158854 233852 16 0 1 0 GUNDERSEN HEALTH SYSTEM 1900 SOUTH AVENUE LA CROSSE WI 54601 ADMINISTRATIVE SERVICES 5277004 STAFFENCY 221 W COLLEGE AVE FLOOR 2 APPLETON WI 54911 CONTRACT RN/LAB SERVICES 1007057 COMPHEALTH PO 972651 DALLAS TX 753972651 CONTRACT STAFFING SERVICES 336348 MEDICAL SOLUTIONS LLC 1010 N 102ND ST OMAHA NE 68114 CONTRACT STAFFING SERVICES 215250 RN NETWORK PO BOX 974088 DALLAS TX 753974088 CONTRACT STAFFING SERVICES 211109 12 40503 556432 29 596964 NET PATIENT SERVICE REVENUE 621300 18771761 18771761 PHARMACY 456110 9691066 9691066 MEDICAL BUILDING RENT 531120 52046 52046 8891 8891 28523764 155019 155019 17983 12316 5667 5667 5667 84001 3385 -84001 -3385 -87386 -87386 E.H.R INCENTIVE 900099 65803 65803 CAFETERIA 722514 22607 22607 113805 113805 202215 29396243 28589567 0 209712 X 551107 551107 222331 222331 7501201 6311557 1189644 116956 94860 22096 1121807 888772 233035 509432 409740 99692 117380 117380 42850 42850 2985 2985 8863144 7291330 1571814 54962 1593 53369 526452 389085 137367 21698 21698 361327 326718 34609 42859 39118 3741 23111 14464 8647 2134 1921 213 659129 593216 65913 58504 574 57930 MEDICAL SUPPLIES 7267808 7267808 BAD DEBT EXPENSE 333503 333503 EQUIPMENT REPAIRS AND M 300647 286405 14242 PHARMACY DRUGS AND VACC 218949 218949 133296 50901 82395 29053572 25093319 3960253 0 1176 875 11776826 9233752 2254866 2492118 587479 635752 106584 59090 8847300 3177170 5556443 5670130 760833 744167 683138 318703 21727345 19154587 1063000 1349717 3183 41076 111687 226262 3858810 504196 5036680 2121251 X 16064689 16500336 625976 533000 16690665 17033336 21727345 19154587 342671 0 X X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 2985 2985 0 PART II-B, LINE 1: MOUNDVIEW MEMORIAL HOSPITAL & CLINICS PAYS ANNUAL ASSOCIATION MEMBERSHIP DUES TO THE WISCONSIN HOSPITAL ASSOCIATION (WHA) & AMERICAN HOSPITAL ASSOCIATION VIA WHA. THESE DUES ARE PRIMARILY FOR ACCESS TO EDUCATIONAL MATERIALS AND STAFF TRAINING AND DEVELOPMENT. THE WHA HAS NOTIFIED MOUNDVIEW MEMORIAL HOSPITAL & CLINICS THAT $2,985 OF THE COMBINED ANNUAL DUES WERE USED IN CONJUNCTION WITH LOBBYING ACTIVITIES WITH THE GOAL OF IMPROVING THE OVERALL HEALTHCARE ENVIRONMENT. 76500 76500 5755569 1290081 4465488 2627831 1524777 1103054 387400 362312 25088 5670130 OPERATING LEASE OBLIGATIONS 8075 DUE TO RELATED PARTY 474388 403 (B) PLAN 21733 504196 X PART X, LINE 2: GUNDERSEN HEALTH SYSTEM HAS REVIEWED TAX POSITIONS FOR ALL OPEN YEARS AND HAS CONCLUDED THAT NO LIABILITIES EXIST FOR UNCERTAIN TAX POSITIONS. THE SYSTEM'S INCOME TAX RETURNS ARE NO LONGER SUBJECT TO EXAMINATION FOR 2017 AND PRIOR YEARS. 1 1 X 1 X 1 X 1 1 1 0 1 1 166142 166142 0.00570 3737516 2534523 1202993 0.04140 3903658 2534523 1369135 0.04710 169773 11480 158293 0.00540 18796 18796 0.00060 7991185 5357521 2633664 0.09060 8179754 5369001 2810753 0.09660 12083412 7903524 4179888 0.14370 1 183601 7711 6002993 6002900 93 X 1 1 1 1 MOUNDVIEW MEMORIAL HOSPITAL & CLINICS 402 WEST LAKE STREET PO BOX 40 FRIENDSHIP WI 53934 WWW.GUNDERSENHEALTH.ORG/MOUNDVIEW 1014 X X X X MOUNDVIEW MEMORIAL HOSPITAL 1 0 0 1 X X X X X X X X X 21 1 1 1 1 X SEE SUPPLEMENTAL INFORMATION X 1 21 1 SEE SUPPLEMENTAL INFORMATION 0 1 X 200.000000000000 400.000000000000 X X X X X X X 1 1 X X X X 1 X HTTP://WWW.GUNDERSENHEALTH.ORG/PAY-MY-BILL/FINANCIAL-ASSISTANCE X HTTP://WWW.GUNDERSENHEALTH.ORG/PAY-MY-BILL/FINANCIAL-ASSISTANCE X HTTP://WWW.GUNDERSENHEALTH.ORG/PAY-MY-BILL/FINANCIAL-ASSISTANCE X X X X X X 1 X 0 X X X X 1 X 0 0 MOUNDVIEW MEMORIAL HOSPITAL PART V, SECTION B, LINE 5: A 52 QUESTION SURVEY WAS AVAILABLE FOR COMMUNITY MEMBERS TO COMPLETE FROM JUNE 14-AUGUST 8, 2021. THE SURVEY WAS AVAILABLE ONLINE VIA SURVEY MONKEY AND SHARED THROUGH FACEBOOK AND EMAILS TO VARIOUS COMMUNITY BUSINESSES, AGENCIES, COALITION MEMBERS, AND CHURCHES. PAPER COPIES WERE AVAILABLE AT HEALTH & HUMAN SERVICES, GUNDERSEN MOUNDVIEW, LIBRARIES IN ADAMS, ROME AND WI DELLS, THE COUNTY FAIR, AREA FOOD PANTRIES, FRIENDSHIP CONNECTION, AND WAS DISTRIBUTED TO THE COUNTY'S MEALS ON WHEELS RECIPIENTS. A SURVEY WAS TRANSLATED INTO SPANISH WITH COPIES SENT TO AREA FARMS THAT EMPLOY SPANISH SPEAKING WORKERS. PRESS RELEASES WERE SENT AND ADS PLACED THROUGH LOCAL MEDIA. THERE WERE 607 RESPONDENTS. TWO COMMUNITY FOCUS GROUPS WERE ALSO SCHEDULED AND ADVERTISED WITH NO ONE ATTENDING. TWO FOCUS GROUPS FOR COMMUNITY STAKEHOLDERS WERE HELD WITH TEN PARTICIPANTS. THERE WERE ALSO 23 KEY INFORMANT INTERVIEWS WITH COMMUNITY MEMBERS AND KEY STAKEHOLDERS. COMMUNITY STAKEHOLDER PARTICIPANTS INCLUDED MEDICAL PROVIDERS, SERVICE AGENCIES, SCHOOL LEADERS, COUNTY GOVERNMENT, BUSINESS LEADERS AS WELL AS MANY OTHERS WHO REPRESENTED LOW INCOME AND DISABILITY POPULATIONS. MOUNDVIEW MEMORIAL HOSPITAL PART V, SECTION B, LINE 6A: ASPIRUS AND SSM HEALTH CARE ST. CLARE HOSPITAL ALSO PARTICIPATED IN THE COUNTY-WIDE NEEDS ASSESSMENT HOSTED IN 2021 BY PUBLIC HEALTH. OUR NEEDS ASSESSMENT INCLUDES BRIEF INFO SPECIFIC TO US THAT IS THEN ATTACHED TO THE COUNTY-WIDE ASSESSMENT. MOUNDVIEW MEMORIAL HOSPITAL PART V, SECTION B, LINE 6B: ADAMS COUNTY HEALTH AND HUMAN SERVICES - DIVISION OF PUBLIC HEALTH AND GREAT RIVERS UNITED WAY MOUNDVIEW MEMORIAL HOSPITAL PART V, SECTION B, LINE 11: GUNDERSEN MOUNDVIEW IS ADDRESSING IDENTIFIED HEALTH NEEDS THROUGH COUNTY AND HOSPITAL SPECIFIC IMPLEMENTATION PLANS. THE INITIAL IDENTIFICATION OF HEALTH PRIORITIES THROUGH THE ASSESSMENT ARE, OVERALL, ENCOMPASSED IN OUR FOUR HOSPITAL PRIORITY AREAS, IN 2022, TWO COUNTY PUBLIC HEALTH COMMUNITY ACTION TEAMS WERE ESTABLISHED - MENTAL HEALTH AND ACCESS TO CARE. THE HOSPITAL PARTICIPATED WITH OTHER AGENCIES IN BOTH OF THESE GROUPS TO CONDUCT A GAP ANALYSIS, GOALS, SMART OBJECTIVES, AND WORK PLANS FOR IDENTIFIED HEALTH NEEDS. ADDITIONAL WORK TEAMS HAVE BEEN FORMED FROM THESE INITIAL CAT GROUPS SUCH AS TRANSPORTATION AND RECRUITMENT AND RETENTION OF HEALTHCARE PROVIDERS. IN 2023, THE HOSPITAL WILL PARTICIPATE IN THE ESTABLISHMENT OF TWO ADDITIONAL CAT GROUPS BASED ON IDENTIFIED HEALTH NEEDS. IN ADDITION, THE HOSPITAL HAS CONTINUED ITS OWN WORK SUCH AS SERVING ON NUMEROUS COMMUNITY COALITIONS AND PROVIDING SCHOOL SUPPORT THROUGH SERVING ON REFERENDUM COMMITTEES AND CONTINUING THE LOCAL STUDENT MENTORING PROGRAM INCLUDING EXPANDING IT TO FOUNDATION AND HOSPITAL BOARD VOLUNTEERS. WE ANNUALLY REVIEW PROGRESS ON OUR IMPLEMENTATION GOALS. MOUNDVIEW MEMORIAL HOSPITAL PART V, SECTION B, LINE 13H: HOSPITAL PATIENTS NOT MEETING FINANCIAL ASSISTANCE ELIGIBILITY THRESHOLDS MAY BE ELIGIBLE FOR ASSISTANCE UNDER CIRCUMSTANCES WHEN HOSPITAL MEDICAL BILLS WOULD RESULT IN SEVERE FINANCIAL HARDSHIP. PATIENTS, OR THEIR GUARANTORS, MAY BE ELIGIBLE FOR CATASTROPHIC CARE ASSISTANCE IF THEY HAVE INCURRED OUT-OF-POCKET OBLIGATIONS RESULTING FROM MEDICAL SERVICES PROVIDED BY GMV THAT EXCEED 25% OF FAMILY INCOME AND HAVE ASSETS BELOW THE EQUIVALENT OF 600% OF THE FPL THRESHOLD. PART V, SECTION B LINE 7A HTTPS://WWW.GUNDERSENHEALTH.ORG/COMMUNITY-ASSESSMENT/ 2 1 - GUNDERSEN FRIENDSHIP CLINIC 402 WEST LAKE STREET PO BOX 40 FRIENDSHIP WI 53934 RURAL HEALTH CLINIC 2 - GUNDERSEN WESTFIELD CLINIC 207 NORTH PIONEER PARK ROAD WESTFIELS WI 53964 RURAL HEALTH CLINIC PART I, LINE 3C: HOSPITAL PATIENTS NOT MEETING FINANCIAL ASSISTANCE ELIGIBILITY THRESHOLDS MAY BE ELIGIBLE FOR ASSISTANCE UNDER CIRCUMSTANCES WHEN HOSPITAL MEDICAL BILLS WOULD RESULT IN SEVERE FINANCIAL HARDSHIP. PATIENTS, OR THEIR GUARANTORS, MAY BE ELIGIBLE FOR CATASTROPHIC CARE ASSISTANCE IF THEY HAVE INCURRED OUT-OF-POCKET OBLIGATIONS RESULTING FROM MEDICAL SERVICES PROVIDED BY GMV THAT EXCEED 25% OF FAMILY INCOME AND HAVE ASSETS BELOW THE EQUIVALENT OF 600% OF THE FPL THRESHOLD. PART I, LINE 7: THE RATIO OF PATIENT COST TO CHARGES WAS CALCULATED BY DIVIDING HOSPITAL EXPENSES NET OF NON-PATIENT REVENUE AND IDENTIFIED COMMUNITY BENEFIT EXPENSE BY GROSS PATIENT REVENUE. THE PERCENTAGE WAS THEN MULTIPLIED BY THE GROSS REVENUES ON BAD DEBT ACCOUNTS. PART I, LINE 7G: THE ORGANIZATION OPERATES 2 RURAL HEALTH CLINICS, AN OBSERVATION ROOM AND EMERGENCY ROOM WHERE THE COSTS EXCEED THE NET PATIENT SERVICE REVENUE. THESE SERVICES WOULD NOT BE PROVIDED TO THE COMMUNITY IF NOT FOR THE LEADERSHIP OF THE HOSPITAL. THE ORGANIZATION UTILIZED THEIR COST REPORT AND OTHER INTERNAL INFORMATION TO DETERMINE THE AMOUNTS TO BE RECORDED PER WORKSHEET 6 OF THE IRS FORM SCHEDULE H INSTRUCTIONS. AMOUNTS RECORDED HERE HAVE NOT BEEN DUPLICATED IN OTHER AREAS OF THE FORM, MEDICAID, BAD DEBT, FINANCIAL ASSISTANCE HAS BEEN REMOVED FROM THE AMOUNTS REPORTED AND THESE SERVICES WERE EXCLUDED FROM THE MEDICARE SURPLUS/SHORTFALL CALCULATION. PART II, COMMUNITY BUILDING ACTIVITIES: 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. THE AMOUNT OF SUPPORT IS DIFFICULT TO QUANTIFY. PART III, LINE 2: THE RATIO OF PATIENT COST TO CHARGES WAS CALCULATED BY DIVIDING HOSPITAL EXPENSES NET OF NON-PATIENT REVENUE AND IDENTIFIED COMMUNITY BENEFIT EXPENSE BY GROSS PATIENT REVENUE. THE PERCENTAGE WAS THEN MULTIPLIED BY THE GROSS REVENUES ON BAD DEBT ACCOUNTS. PART III, LINE 3: 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. PART III, LINE 4: THE ORGANIZATION IS PART OF THE GUNDERSEN HEALTH SYSTEM'S CONSOLIDATED AUDIT IN WHICH THE FOOTNOTE THAT DISCUSSES THE BAD DEBT (IMPLICIT PRICE CONCESSIONS) EXPENSE IS LOCATED IN FOOTNOTE #2, PAGES 10, 11, 18 AND 19. PART III, LINE 8: THE TOTAL MEDICARE REVENUE SHOWN IN SCHEDULE H TO THE FORM 990 IS BASED ON THE IRS 990 INSTRUCTIONS AND INCLUDES ONLY A PORTION OF THE GROSS MEDICARE REVENUE OF THE ORGANIZATION AND DOES NOT CONSIDER ALL CONTRACTUAL ADJUSTMENTS FOR SERVICES REIMBURSED BY THE MEDICARE PROGRAM. AMOUNTS LISTED FOR MEDICARE REVENUE DO NOT INCLUDE PHYSICIAN SERVICES FOR THE COVERAGE OF THE EMERGENCY DEPARTMENT AT THE ORGANIZATION AS WELL AS ANESTHESIA PROFESSIONAL SERVICES, SURGICAL PHYSICIAN PROFESSIONAL SERVICES, AND REVENUE FOR ANY PATIENTS COVERED UNDER MEDICARE ADVANTAGE PLAN PROGRAMS. PHYSICIAN PROFESSIONAL SERVICES ARE REIMBURSED PRIMARILY ON FEE SCHEDULE REIMBURSEMENTS AT RATES THAT ARE OFTEN BELOW THE COSTS OF CARING FOR PATIENTS. EMERGENCY, SURGICAL, AND CLINICAL PHYSICIAN SERVICES PROVIDED TO MEDICARE PATIENTS ARE VITAL TO THE WELL-BEING OF THE COMMUNITY AND AS SUCH THESE COSTS AND SHORTFALLS SHOULD ALSO BE CONSIDERED AS AN ADDITIONAL BENEFIT THAT MOUNDVIEW MEMORIAL HOSPITAL & CLINICS PROVIDES TO THE COMMUNITY AND SURROUNDING AREAS. THE COSTING METHOD USED ABOVE FOR IRS 990 COMPLIANCE REPORTING IS ALSO BASED ON THE FILED MEDICARE COST REPORT, AND DOES NOT CONSIDER MEDICARE NON-ALLOWABLE EXPENSES, AS IT IS BASED ON TOTAL HOSPITAL PATIENT SERVICE REVENUE (IGNORING CONTRACTUAL ADJUSTMENTS ON FEE SCHEDULE REIMBURSED ITEMS AND NON-ALLOWABLE MEDICARE EXPENSES AS NOTED ABOVE).WHETHER THERE IS A SHORTFALL OR SURPLUS ON SERVICES PROVIDED TO MEDICARE BENEFICIARIES, THESE PEOPLE, WHICH ARE TYPICALLY ELDERLY OR DISABLED MEMBERS OF THE COMMUNITY, ARE AN UNDERSERVED POPULATION WHO EXPERIENCE ISSUES WITH ACCESS TO HEALTHCARE SERVICES. WITHOUT TAX-EXEMPT HOSPITALS PROVIDING MEDICARE PATIENT SERVICES, THE CENTERS FOR MEDICARE AND MEDICAID (CMS) WOULD BEAR THE BURDEN OF DIRECTLY PROVIDING SERVICES TO THE ELDERLY AND DISABLED MEMBERS OF THE COMMUNITY. PART III, LINE 9B: THE ORGANIZATION FOLLOWS GUNDERSEN HEALTH SYSTEM'S GUIDELINES FOR COLLECTION PRACTICES RELATED TO PATIENTS QUALIFYING FOR CHARITY OR FINANCIAL ASSISTANCE. A PATIENT CAN APPLY FOR CHARITY OR FINANCIAL ASSISTANCE AT ANY TIME DURING THE COLLECTION CYCLE. ONCE QUALIFYING DOCUMENTATION IS RECEIVED THE PATIENT'S ACCOUNT IS ADJUSTED. PATIENT ACCOUNTS FOR THE QUALIFYING PATIENT IN THE PREVIOUS SIX MONTHS MAY ALSO BE CONSIDERED FOR CHARITY OR FINANCIAL ASSISTANCE. ONCE A PATIENT QUALIFIES FOR CHARITY OR FINANCIAL ASSISTANCE, ALL COLLECTION ACTIVITY IS SUSPENDED. PART VI, LINE 2: THE HOSPITAL COMMUNICATES REGULARLY WITH PUBLIC HEALTH TO ADDRESS COMMUNITY HEALTH NEEDS. WE ANNUALLY REVIEW LOCAL, REGIONAL AND STATE DATA SOURCES. THE HOSPITAL COMPLETES REPORTS ON INFECTIOUS AND COMMUNICABLE DISEASE AND MONITORS FOR OUTBREAKS. ANNUAL RISK ASSESSMENTS ARE COMPLETED ON TB AND INFECTION CONTROL ISSUES. THE HOSPITAL MEASURES CHRONIC DISEASE SCREENING RATES. THE HOSPITAL REVIEWS DATA RELEVANT TO WORK BEING COMPLETED THROUGH THE LOCAL COMMUNITY ACTION TEAMS WHO ARE ADDRESSING THE PRIORITIZED HEALTH NEEDS. PART VI, LINE 3: THE HOSPITAL ANNUALLY UPDATES THE AVAILABILITY OF ITS CHARITY PLAN AND QUALIFYING INCOME NEEDS TO QUALIFY ON THE HOSPITAL WEBSITE. 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, I.E. MEDICAID, BADGER CARE. PART VI, LINE 4: GUNDERSEN MOUNDVIEW SERVES ALL RESIDENTS OF ADAMS COUNTY (POPULATION 21,226 PER CENSUS 2022 QUICK FACTS). WE ALSO SERVE WESTFIELD AREA RESIDENTS, LOCATED IN MARQUETTE COUNTY. HOWEVER, OUR PRIMARY SERVICE AREA IS THE CENTRAL PORTION OF ADAMS COUNTY INCLUDING THE ZIP CODES OF ADAMS, FRIENDSHIP, ARKDALE AND GRAND MARSH WHICH MAKE UP OVER 74% OF OUR REVENUE. THE MAJORITY OF ADAMS COUNTY RESIDENTS ARE WHITE (93.1%) AND A HIGH PERCENTAGE (31%) ARE AGE 65 AND OVER. THE MEDIAN HOUSEHOLD INCOME ($51,878) IS CONSIDERABLY LOWER THAN THE STATE. TOURISM AND AGRICULTURE ARE AMONG THE COUNTY'S LARGEST INDUSTRIES. THE COUNTY IS MEDICALLY UNDERSERVED AND HAS RANKED IN THE BOTTOM OF THE WI COUNTY HEALTH RANKINGS IN TERMS OF HEALTH OUTCOMES AND FACTORS. PART VI, LINE 5: THE HOSPITAL IS A STRONG COMMUNITY PARTNER IN MANY LOCAL HEALTH EFFORTS. WE PROVIDE MONETARY AND IN-KIND SUPPORT TO SEVERAL INITIATIVES SUCH AS DONATIONS TO RECREATIONAL/WELLNESS PROGRAMS (EXAMPLE-PROVIDING FREE BIKE HELMETS TO YOUTH AND FUNDING TENNIS RACKETS TO BE USED BY SCHOOL STUDENTS AND AT YMCA TENNIS CLASSES). WE ALSO HAVE A PHYSICIAN SERVING ON THE LOCAL HEALTH BOARD, STAFF SERVING ON NUMEROUS COMMUNITY COALITIONS, COLLECT DONATIONS FOR AREA FOOD PANTRIES AND MUCH MORE. THESE ARE JUST A FEW AREAS WE HAVE ASSISTED. THE HOSPITAL BOARD ALSO INCLUDES COMMUNITY MEMBERS WHO ARE UNPAID. PART VI, LINE 6: THE ORGANIZATION IS PART OF GUNDERSEN LUTHERAN HEALTH SYSTEM. EACH AFFILIATE DEVELOPS ITS OWN NEEDS ASSESSMENT AND IMPLEMENTATION PLAN, WITH SUPPORT FROM THE SYSTEM AS NEEDED. THE SYSTEM HOLDS QUARTERLY COMMUNITY BENEFIT MEETINGS AMONG THE AFFILIATES TO REVIEW PROGRESS ON GOALS. PART VI, LINE 7, REPORTS FILED WITH STATES WI 1 MOUNDVIEW MEMORIAL FOUNDATION PO BOX 40 FRIENDSHIP WI 53934 391775074 501(C)(3) 551107 0 TRANSFER OF ASSETS HELD IN CHARITIES AND DONATIONS TO FOUNDATION FOR DISBURSEMENT TO LOCAL NON-PROFITS FOR VARIOUS AID/PROGRAMS IN THE COMMUNITY 1 0 X X 0 0 0 0 0 0 0 0 0 BRYAN ERDMANN BOARD TRUSTEE/COO 0 304833 0 601 0 10872 0 12200 0 28238 0 356744 0 0 STEPHANIE CARROLL BOARD TRUSTEE/MD HOSPITALIST 0 293496 0 4103 0 0 0 6103 0 25593 0 329295 0 0 FRANK PEREZ-GUERRA CEO 0 185365 0 519 0 4566 0 7737 0 24144 0 222331 0 0 DEENA KEDROWSKI OUTPATIENT PHARMACY MANAGER 156521 0 183 0 1032 0 4926 0 28023 0 190685 0 0 0 ROXANNE POTTS BOARD TRUSTEE/CLINICAL OPS. DIRECTOR 0 150022 0 591 0 6421 0 5418 0 21494 0 183946 0 0 SARAH ROSSMAN SECRETARY 0 148119 0 1617 0 929 0 6008 0 2942 0 159615 0 0 BRAD SHAW IMPATIENT PHARMACY MANAGER 149279 0 488 0 216 0 1800 0 1441 0 153224 0 0 0 PRESTON PIETRZAK PHARMACIST 134520 0 23 0 216 0 4083 0 12655 0 151497 0 0 0 PART I, LINE 3 A RELATED ORGANIZATION OF THE FILING ORGANIZATION USES ONE OR MORE OF THE FOLLOWING TO ESTABLISH THE COMPENSATION OF THE ORGANIZATION'S TOP MANAGEMENT OFFICIAL: -COMPENSATION COMMITTEE -INDEPENDENT COMPENSATION CONSULTANT -COMPENSATION SURVEY OR STUDY, AND -APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE PLEASE REFER TO THE FORM 990, PART VI, LINE 15A DISCLOSURE IN SCHEDULE O FOR ADDITIONAL DETAILS ON HOW COMPENSATION OF THE ORGANIZATION'S TOP MANAGEMENT OFFICIAL IS ESTABLISHED. FORM 990, PART VI, SECTION A, LINE 4 GUNDERSEN AND BELLIN HEALTH SYSTEMS, INC. (BELLIN), EACH A WISCONSIN NONPROFIT, NON-STOCK CORPORATION, ENTERED INTO A COMBINATION AGREEMENT DATED JULY 29, 2022 (THE AGREEMENT), TO ALIGN THEIR RESPECTIVE OPERATIONS AND TO FORM A SINGLE NONPROFIT HEALTH SYSTEM THROUGH THE CREATION OF BELLIN GUNDERSEN HEALTH SYSTEM, INC., A WISCONSIN NONPROFIT, NON-STOCK CORPORATION (BELLIN GUNDERSEN). ON DECEMBER 1, 2022, UPON CONSUMMATION OF THE ALIGNMENT OF THE TWO SYSTEMS (THE AFFILIATION), BELLIN GUNDERSEN BECAME THE SOLE CORPORATE MEMBER OF BOTH BELLIN AND GUNDERSEN. BELLIN AND GUNDERSEN AND THEIR RESPECTIVE AFFILIATES ARE EXPECTED TO MAINTAIN THEIR RESPECTIVE CORPORATE EXISTENCE. IN DECEMBER 2022, THE BYLAWS OF GUNDERSEN LUTHERAN HEALTH SYSTEM, INC. WERE AMENDED AND RESTATED TO UPDATE THE SOLE CORPORATE MEMBER TO BELLIN GUNDERSEN HEALTH SYSTEM, INC. THE BYLAWS WERE ALSO UPDATED TO SPECIFY THE POWERS RETAINED BY GUNDERSEN LUTHERAN HEALTH SYSTEM, INC. THE CHIEF EXECUTIVE OFFICER OF BELLIN GUNDERSEN LUTHERAN HEALTH SYSTEM, INC. RETAINS AUTHORITY TO APPROVE ANY SIGNIFICANT CHANGES TO THE CORPORATION. SUBJECT TO THE RESERVED POWERS SPECIFIED IN THE BYLAWS, THE AFFAIRS OF THE CORPORATION SHALL BE MANAGED BY ITS BOARD OF TRUSTEES. FORM 990, PART VI, SECTION A, LINE 6 THE HOSPITAL HAS A NINE MEMBER BOARD OF DIRECTORS COMPRISED OF FIVE MEMBERS FROM THE HEALTH SYSTEM AND FOUR COMMUNITY DIRECTORS CHOSEN FROM OUR LOCAL SERVICE AREA. FORM 990, PART VI, SECTION A, LINE 7A THE BOARD OF DIRECTORS SOLICITS NOMINATIONS FROM CANDIDATES TO FILL OPEN BOARD SEATS. THE FULL BOARD THEN VOTES TO APPROVE OR DISAPPROVE THE NEW POSITION. FORM 990, PART VI, SECTION A, LINE 7B MEMBERS OF THE BOARD OF DIRECTORS MUST APPROVE ANY BYLAW CHANGES. FORM 990, PART VI, SECTION B, LINE 11B THE IRS FORM 990 IS REVIEWED BY MANAGEMENT AND PROVIDED TO THE FINANCE COMMITTEE AND THEN ENTIRE BOARD 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. THE CEO REVIEWS THE SIGNED STATEMENTS. IF THERE IS A CONFLICT, THE CONFLICT WOULD BE DECLARED, AND THE MEMBER WOULD ABSTAIN FROM VOTING. FORM 990, PART VI, SECTION B, LINE 15A THE HEALTH SYSTEM RELIES ON MARKET COMPARABLE SALARY DATA TO SET THE RANGE OF COMPENSATION FOR THE CEO POSITION. THE RANGES ARE ADJUSTED AND REVIEWED ANNUALLY BY THE BOARD'S COMPENSATION COMMITTEE, WITH FINAL APPROVAL BY THE SYSTEM BOARD OF DIRECTORS. 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 AUDITED FINANCIAL STATEMENTS ARE NOW REQUIRED TO BE ATTACHED TO FORM 990. AUDITED FINANCIAL INFORMATION IS POSTED ANNUALLY ON THE HOSPITAL'S WEBSITE. FORM 990, PART IX, LINE 11G EMERGENCY ROOM SERVICE FEES: PROGRAM SERVICE EXPENSES 3,099,252. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 3,099,252. ANESTHESIA SERVICE FEES: PROGRAM SERVICE EXPENSES 329,560. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 329,560. LABORATORY SERVICE FEES: PROGRAM SERVICE EXPENSES 385,133. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 385,133. PHARMACY SERVICE FEES: PROGRAM SERVICE EXPENSES 82,648. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 82,648. FAMILY MEDICINE SERVICE FEES: PROGRAM SERVICE EXPENSES 790,861. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 790,861. OTHER PROFESSIONAL FEES: PROGRAM SERVICE EXPENSES 2,603,876. MANAGEMENT AND GENERAL EXPENSES 1,571,814. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 4,175,690. 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