2022-11-10T09:13:04-06:00 2021-12-31 390758449 WIPFLI LLP 1502 LONDON ROAD SUITE 200 DULUTH MN 55812 990 2021-01-01 390944012 MOUNDVIEW MEMORIAL HOSPITAL & CLINICS MOUN 6083393331 402 WEST LAKE STREET FRIENDSHIP WI 53934 FRANK PEREZ-GUERRA CEO 6083393331 2022-11-07 1 FRANK PEREZ-GUERRA 999009999 MICHAEL J PETERSON CPA P01833529 2187224705 2022-10-30 0 AAL1 IAL1 2021 2022-09-23 18:48:47Z GUNDERSEN MOUNDVIEW HOSPITAL & CLINICS FRANK PEREZ-GUERRA 402 WEST LAKE STREET FRIENDSHIP WI 53934 26119703 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 3 172 65 0 0 714119 3946443 19640027 21792390 99864 109562 210302 258112 20664312 26106507 1100 1350 0 0 9348389 9124660 0 0 0 9188772 11700235 18538261 20826245 2126051 5280262 20739931 21727345 9378738 5036680 11361193 16690665 WE WILL DISTINGUISH OURSELVES THROUGH EXCELLENCE IN PATIENT CARE, EDUCATION, AND IMPROVED HEALTH IN THE COMMUNITIES WE SERVE. 0 0 17643785 1350 21869135 THE HOSPITAL IS A GENERAL MEDICAL CRITICAL ACCESS HOSPITAL LICENSE FOR 25 BEDS. DURING FISCAL YEAR 2021, THE HOSPITAL HAD 565 ACUTE INPATIENT DAYS AND 569 SWING-BED DAYS. THE HOSPITAL ALSO HAD 6,196 EMERGENCY ROOM/URGENT CARE AND 10,245 CLINIC VISITS RESPECTIVELY. 17643785 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 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 1 201 0 172 1 0 0 0 0 0 0 0 0 0 0 0 0 X 8 3 0 0 0 0 1 1 1 1 1 0 0 0 1 1 1 1 1 1 0 0 WI X FRANK PEREZ-GUERRA 6083393331 402 WEST LAKE STREET FRIENDSHIP WI 53934 BRYAN ERDMANN BOARD TRUSTEE 2.50 40.00 X 0 296814 70078 STEPHANIE CARROLL BOARD TRUSTEE 2.50 40.00 X 0 298096 62139 FRANK PEREZ-GUERRA CEO 2.50 40.00 X 0 186080 51476 ROXANNE POTTS BOARD TRUSTEE 2.50 40.00 X 0 142577 39705 PAUL FISCH VICE CHAIR 2.50 40.00 X X 0 124910 40663 DIANA BRONIEC NURSE PRACTITIONER 40.00 0.00 X 153878 0 8391 SARAH ROSSMAN SECRETARY 2.50 40.00 X X 0 131378 21262 BRAD SHAW DIRECTOR 40.00 0.00 X 133157 0 3083 MOLLY MOLL PHYSICAL THERAPIST 40.00 0.00 X 107078 0 28141 LINDA CHARLES NURSE PRACTITIONER 40.00 0.00 X 114028 0 18738 LORI WITTIG DIRECTOR 40.00 0.00 X 122710 0 7473 RICHARD STERNHAGEN CHAIR 2.50 1.00 X X 0 0 0 RENEE SCHINDLBECK TREASURER (THRU DEC) 2.50 0.00 X X 0 0 0 KAREN MILLER BOARD TRUSTEE 2.50 0.00 X 0 0 0 JOE THEISEN BOARD TRUSTEE 2.50 0.00 X 0 0 0 630851 1179855 351149 5 0 1 0 GUNDERSEN HEALTH SYSTEM 1900 SOUTH AVENUE LA CROSSE WI 54601 ADMINISTRATIVE SERVICES 8534497 WEATHERBY HEALTHCARE PO BOX 972633 DALLAS TX 753972633 CONTRACT MD SERVICES 622821 STAFFENCY 221 W COLLEGE AVE FLOOR 2 APPLETON WI 54911 CONTRACT RN/LAB SERVICES 265847 SHC SERVICES INC PO BOX 677896 DALLAS TX 752677896 CONTRACT IMAGING PERSONNEL SERVICES 245587 RITA LUEDKE PO BOX 32 LOWELL WI 53557 CONTRACT CRNA SERVICES 168095 7 3926899 19544 3946443 NET PATIENT SERVICE REVENUE 621300 18492509 18492509 PHARMACY 446110 3229140 3229140 MEDICAL BUILDING RENT 531120 60420 60420 10321 10321 21792390 108378 108378 20877 13196 7681 7681 7681 1184 0 1184 1184 1184 E.H.R INCENTIVE 900099 76745 76745 CAFETERIA 722514 17699 17699 155987 155987 250431 26106507 21869135 0 290929 X 1350 1350 237556 237556 7150652 5996936 1153716 119435 110648 8787 1094110 885268 208842 522907 422489 100418 67342 67342 31550 31550 6619743 5629293 990450 64128 1040 63088 438156 323449 114707 314789 312682 2107 38381 34121 4260 18750 4171 14579 6460 5814 646 631316 568184 63132 49205 49205 MEDICAL SUPPLIES 2252691 2252691 BAD DEBT EXPENSE 717434 717434 EQUIPMENT REPAIRS AND M 309313 306368 2945 COLLECTION EXPENSE 8716 8716 132261 71847 60414 20826245 17643785 3182460 0 700 1176 12065743 11776826 2167154 2254866 208427 587479 79884 106584 8267721 2711278 5575746 5556443 0 760833 642277 683138 20739931 21727345 4661822 1063000 1741453 3183 169632 111687 2805831 3858810 9378738 5036680 X 10785611 16064689 575582 625976 11361193 16690665 20739931 21727345 X 5280262 72828 -23618 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 1767 1767 0 PART II-B, LINE 1: MOUNDVIEW MEMORIAL HOSPITAL & CLINICS PAYS ANNUAL ASSOCIATION MEMBERSHIP DUES TO THE WISCONSIN HOSPITAL ASSOCIATION (WHA). THESE DUES ARE PRIMARILY FOR ACCESS TO EDUCATIONAL MATERIALS AND STAFF TRAINING AND DEVELOPMENT. THE WHA HAS NOTIFIED MOUNDVIEW MEMORIAL HOSPITAL & CLINICS THAT $1,767 OF THE ANNUAL DUES WERE USED IN CONJUNCTION WITH LOBBYING ACTIVITIES WITH THE GOAL OF IMPROVING THE OVERALL HEALTHCARE ENVIRONMENT. 76500 76500 5475389 1016109 4459280 2213894 1346033 867861 501938 349136 152802 5556443 3RD PARTY SETTLEMENTS 1338768 OPERATING LEASE OBLIGATIONS 17760 DUE TO RELATED PARTY 359668 ADVANCE COVID PAYMENTS 2142614 3858810 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 2016 AND PRIOR YEARS. 1 1 X 1 X 1 X 1 1 1 0 1 1 236904 236904 0.01140 2711451 2158817 552634 0.02650 2948355 2158817 789538 0.03790 135041 3025 132016 0.00630 9707 9707 0.00050 7947013 4028812 3918201 0.18810 8091761 4031837 4059924 0.19490 11040116 6190654 4849462 0.23280 1 302344 12593 6381222 6318041 63181 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 SEE SUPPLEMENTAL INFORMATION X SEE SUPPLEMENTAL INFORMATION X SEE SUPPLEMENTAL INFORMATION 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 BUSINESS, 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, WE WILL PARTICIPATE IN THE COUNTY PUBLIC HEALTH'S COMMUNITY ACTION TEAMS TO CONDUCT A GAP ANALYSIS, GOALS, SMART OBJECTIVES, AND A WORKPLAN FOR IDENTIFIED HEALTH NEEDS. IN ADDITION, WE HAVE ALSO SET OBJECTIVES THROUGH OUR HOSPITAL SPECIFIC IMPLEMENTATION PLAN. AN EXAMPLE IS THE HOSPITAL LED MENTORING AND GRIEF SUPPORT PROGRAMS TO HELP ADDRESS MENTAL HEALTH NEEDS. WE WILL 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, LINE 16A, 16B, 16C PART V, LINE 16A, FAP WEBSITE:HTTPS://WWW.GUNDERSENHEALTH.ORG/APP/FILES/PUBLIC/FD66C1FB-C19E-4C8B-8B2F-17FADA3EE277/MOUNDVIEW%20FINANCIAL-ASSISTANCE-POLICY_7_2022.PDFPART V, LINE 16B, FAP APPLICATION WEBSITE:HTTPS://WWW.GUNDERSENHEALTH.ORG/APP/FILES/PUBLIC/9C388CFA-7D1D-4E08-8889-2458C7057388/GUNDERSEN%20FINANCIAL%20ASSISTANCE%20APPLICATION%20SYSTEMWIDE.PDFPART V, LINE 16C, FAP PLAIN LANGUAGE SUMMARY WEBSITE:HTTPS://WWW.GUNDERSENHEALTH.ORG/APP/FILES/PUBLIC/74503E41-12C0-4624-9F92-27AD0709FF69/FINANCIAL-ASSISTANCE-MOUNDVIEW-PLAIN-LANGUAGE-SUMMARY.PDF PART V, LINE 7A PART V, LINE 7A, HOSPITAL FACILITY'S WEBSITE:HTTPS://WWW.GUNDERSENHEALTH.ORG/APP/FILES/PUBLIC/25EB2FE9-2F2C-445C-B87C-0B48307B963D/COMMUNITY-NEEDS-ASSESSMENT-2021-MOUNDVIEW.PDF PART V, LINE 10 PART V, LINE 10, HOSPITAL'S RECENTLY ADOPTED IMPLEMENTATION STRATEGY:HTTPS://WWW.GUNDERSENHEALTH.ORG/APP/FILES/PUBLIC/A641705C-B399-45BF-9074-8A9BCF29B443/COMMUNITY-NEEDS-IMPLEMENTATION-PLAN-2022-MOUNDVIEW.PDF 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 CONSOLIDATED FINANCIAL STATEMENTS WHICH INCLUDE MOUNDVIEW MEMORIAL DO NOT HAVE A DETAILED FOOTNOTE DESCRIBING BAD DEBT. THE BELOW EXPLANATION HELPS EXPLAIN THE HOSPITALS APPROACH. PATIENT ACCOUNTS RECEIVABLE ARE RECORDED IN THE ACCOMPANYING CONSOLIDATED BALANCE SHEETS NET OF CONTRACTUAL ADJUSTMENTS AND AN ALLOWANCE FOR DOUBTFUL ACCOUNTS, THAT REFLECTS MANAGEMENT'S BEST ESTIMATE OF AMOUNTS THAT WILL NOT BE COLLECTED. MANAGEMENT PROVIDES FOR CONTRACTUAL ADJUSTMENTS UNDER TERMS OF THIRD-PARTY REIMBURSEMENT AGREEMENTS THROUGH A REDUCTION OF GROSS PATIENT SERVICE REVENUE AND A CREDIT TO PATIENT ACCOUNTS RECEIVABLE. IN ADDITION, MANAGEMENT PROVIDES FOR PROBABLE UNCOLLECTIBLE AMOUNTS, PRIMARILY FROM UNINSURED PATIENTS AND AMOUNTS PATIENTS ARE PERSONALLY RESPONSIBLE FOR, THROUGH A CHARGE TO OPERATIONS AND A CREDIT TO THE ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS BASED ON ITS ASSESSMENT OF HISTORICAL COLLECTION LIKELIHOOD AND CURRENT STATUS OF INDIVIDUAL ACCOUNTS.IN EVALUATING THE COLLECTABILITY OF PATIENT ACCOUNTS RECEIVABLE, THE ORGANIZATION ANALYZES PAST RESULTS AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYOR SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS AND PROVISION FOR BAD DEBTS. MANAGEMENT REGULARLY REVIEWS DATA ABOUT THESE MAJOR PAYOR SOURCES OF REVENUE IN EVALUATING THE SUFFICIENCY OF THE ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS. SPECIFICALLY, FOR RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRD-PARTY COVERAGE, THE ORGANIZATION ANALYZES CONTRACTUALLY DUE AMOUNTS AND PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS AND A PROVISION FOR BAD DEBTS FOR EXPECTED UNCOLLECTIBLE DEDUCTIBLES AND COPAYMENTS ON ACCOUNTS FOR WHICH THE THIRD-PARTY PAYOR HAS NOT YET PAID, OR FOR PAYORS WHO ARE KNOWN TO BE HAVING FINANCIAL DIFFICULTIES THAT MAKE THE REALIZATION OF AMOUNTS DUE UNLIKELY. FOR RECEIVABLES ASSOCIATED WITH SELF-PAY PATIENTS (WHICH INCLUDES BOTH PATIENTS WITHOUT INSURANCE AND PATIENTS WITH DEDUCTIBLE AND COPAYMENT BALANCES DUE FOR WHICH THIRD-PARTY COVERAGE .EXISTS FOR PART OF THE BILL). THE ORGANIZATION RECORDS A SIGNIFICANT PROVISION FOR BAD DEBTS IN THE PERIOD OF SERVICE BASED ON ITS EXPERIENCE, WHICH INDICATES THAT MANY PATIENTS ARE UNABLE OR UNWILLING TO PAY THE PORTION OF THEIR BILL FOR WHICH THEY ARE FINANCIALLY RESPONSIBLE. THE DIFFERENCE BETWEEN THE STANDARD RATES (OR THE DISCOUNTED RATES IF NEGOTIATED) AND THE AMOUNTS COLLECTED AFTER ALL REASONABLE COLLECTION EFFORTS HAVE BEEN EXHAUSTED IS CHARGED OFF AGAINST THE ALLOWANCE FOR UNCOLLECTIBLE 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. PART III, LINE 9B: PATIENTS UPON REGISTRATION ARE GIVEN THE POLICY AND REQUIREMENTS TO BE ELIGIBLE FOR CHARITY CARE. THEY ARE ENCOURAGED BY A FINANCIAL ADVISOR TO REVIEW THEIR SITUATION FOR ELIGIBILITY. PART VI, LINE 2: THE HOSPITAL ANNUALLY REVIEWS THE COUNTY HEALTH RANKINGS AS WELL AS INFECTION CONTROL/COMMUNICABLE DISEASE REPORTS WITH THE PUBLIC HEALTH OFFICE. THE HOSPITAL COMPLETES SURVEILLANCE ON INFECTIOUS AND COMMUNICABLE DISEASE AND MONITORS FOR OUTBREAKS. WE COMPLETE ANNUAL RISK ASSESSMENTS ON TB AND INFECTION CONTROL ISSUES. THE HOSPITAL ALSO COMMUNICATES REGULARLY WITH PUBLIC HEALTH TO ADDRESS COMMUNITY HEALTH NEEDS AS THEY ARISE. 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 20,875 PER CENSUS 2021 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 76% OF OUR REVENUE. THE MAJORITY OF ADAMS COUNTY RESIDENTS ARE WHITE (93.8%) AND RETIRED (30.2% ARE AGE 65 AND OVER). THE MEDIAN HOUSEHOLD INCOME IS $46,369 WHICH IS CONSIDERABLY LOWER THAN THE STATE MEDIAN. TOURISM IS THE COUNTY'S LARGEST INDUSTRY. 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 PROVIDES MONETARY AND IN-KIND SUPPORT TO NUMEROUS COMMUNITY HEALTH INITIATIVES SUCH AS RECREATIONAL/WELLNESS PROGRAMS, USE OF OUR MEETING ROOMS BY AREA NONPROFITS, STAFF TIME SERVING ON THE LOCAL HEALTH BOARD AND ON NUMEROUS COMMUNITY COALITIONS, AND IMPLEMENTED NUMEROUS INITIATIVES TO ADDRESS THE COVID-19 PANDEMIC. THE HOSPITAL BOARD INCLUDES COMMUNITY MEMBERS WHO ARE UNPAID. PART VI, LINE 6: THE ORGANIZATION IS PART OF GUNDERSEN 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 X X 0 0 0 0 0 0 0 0 0 BRYAN ERDMANN BOARD TRUSTEE 0 289952 0 2212 0 4650 0 42050 0 28028 0 366892 0 0 STEPHANIE CARROLL BOARD TRUSTEE 0 293496 0 4600 0 0 0 36302 0 25837 0 360235 0 0 FRANK PEREZ-GUERRA CEO 0 181446 0 2047 0 2587 0 27188 0 24288 0 237556 0 0 ROXANNE POTTS BOARD TRUSTEE 0 130912 0 5781 0 5884 0 17967 0 21738 0 182282 0 0 PAUL FISCH VICE CHAIR 0 113960 0 2098 0 8852 0 18157 0 22506 0 165573 0 0 DIANA BRONIEC NURSE PRACTITIONER 148200 0 4094 0 1584 0 4453 0 3938 0 162269 0 0 0 SARAH ROSSMAN SECRETARY 0 128019 0 2558 0 801 0 18816 0 2446 0 152640 0 0 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 990 IS REVIEWED BY THE CFO AND CEO PRIOR TO FILING. THE FILED 990 IS THEN SHARED WITH THE FINANCE COMMITTEE AND REVIEWED IN DETAIL . A COPY OF THE 990 IS ISSUED TO EACH MEMBER OF THE BOARD AS WELL. 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 RELAYS 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 2,768,765. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,768,765. ANESTHESIA SERVICE FEES: PROGRAM SERVICE EXPENSES 186,609. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 186,609. LABORATORY SERVICE FEES: PROGRAM SERVICE EXPENSES 153,931. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 153,931. PHARMACY SERVICE FEES: PROGRAM SERVICE EXPENSES 11,396. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 11,396. FAMILY MEDICINE SERVICE FEES: PROGRAM SERVICE EXPENSES 830,649. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 830,649. OTHER PROFESSIONAL FEES: PROGRAM SERVICE EXPENSES 1,677,943. MANAGEMENT AND GENERAL EXPENSES 990,450. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,668,393. FORM 990, PART XI, LINE 9: CHANGE IN ASSETS HELD IN POLIVKA TRUST -23,618. COMMUNITY HOUSING OF LA CROSSE INC 1900 SOUTH AVENUE LA CROSSE WI 54601 391586700 INDEPENDENT LIVING WI 501(C)(3) LINE 10 LUTHERAN REAL ESTATE HOLDING CORP 1 GUNDERSEN CLINIC LTD 1910 SOUTH AVENUE LA CROSSE WI 54601 391028657 HEALTHCARE WI 501(C)(3) LINE 3 GUNDERSEN LUTHERAN HEALTH SYSTEM 1 GUNDERSEN LUTHERAN ADMINISTRATIVE SVC 1910 SOUTH AVENUE LA CROSSE WI 54601 391606449 SUPPORTING ORG WI 501(C)(3) LINE 12B, II GUNDERSEN LUTHERAN HEALTH SYSTEM 1 GUNDERSEN LUTHERAN CREDENTIALING SVC INC 1910 SOUTH AVENUE LA CROSSE WI 54601 391856898 CREDENTIALING WI 501(C)(3) LINE 12C, III-FI GUNDERSEN LUTHERAN HEALTH SYSTEM 1 GUNDERSEN LUTHERAN HEALTH SYSTEM INC 1836 SOUTH AVENUE LA CROSSE WI 54601 391866425 SUPPORTING ORG WI 501(C)(3) LINE 12B, II N/A 0 GUNDERSEN LUTHERAN MEDICAL CENTER INC 1910 SOUTH AVENUE LA CROSSE WI 54601 390813416 HEALTHCARE WI 501(C)(3) LINE 3 GUNDERSEN LUTHERAN HEALTH SYSTEM 1 GUNDERSEN LUTHERAN MEDICAL FOUNDATION INC 1836 SOUTH AVENUE LA CROSSE WI 54601 391249705 FOUNDATION WI 501(C)(3) LINE 7 GUNDERSEN LUTHERAN HEALTH SYSTEM 1 HARMONY COMMUNITY HEALTHCARE INC 815 MAIN AVENUE SOUTH HARMONY MN 55939 410711606 HEALTHCARE MN 501(C)(3) LINE 10 GUNDERSEN LUTHERAN HEALTH SYSTEM 1 LUTHERAN HOUSING OF LA CROSSE 1900 SOUTH AVENUE LA CROSSE WI 54601 391751934 INDEPENDENT LIVING WI 501(C)(3) LINE 10 LUTHERAN REAL ESTATE HOLDING CORP 1 LUTHERAN REAL ESTATE HOLDING CORP 1910 SOUTH AVENUE LA CROSSE WI 54601 391480826 HOUSING WI 501(C)(3) LINE 12C, III-FI GUNDERSEN LUTHERAN HEALTH SYSTEM 1 MEMORIAL HEALTHCARE FOUNDATION OF ADAMS COUNTY INC PO BOX 40 FRIENDSHIP WI 53934 391775074 FOUNDATION WI 501(C)(3) LINE 12A, I MOUNDVIEW MEMORIAL HOSPITALS AND CLINICS 1 MEMORIAL HOSPITAL OF BOSCOBEL 205 PARKER STREET BOSCOBEL WI 53805 390845590 HEALTHCARE WI 501(C)(3) LINE 3 GUNDERSENT LUTHERAN HEALTH SYSTEM 1 MEMORIAL HOSPITAL OF BOSCOBEL FOUNDATION 205 PARKER STREET BOSCOBEL WI 53805 391688793 FUNDRAISING WI 501(C)(3) LINE 7 MEMORIAL HOSPITAL OF BOSCOBEL 1 PALMER LUTHERAN HEALTH CENTER INC 112 JEFFERSON STREET WEST UNION IA 52175 421320763 HEALTHCARE IA 501(C)(3) LINE 3 GUNDERSEN LUTHERAN HEALTH SYSTEM 1 PALMER MEMORIAL FOUNDATION 112 JEFFERSON STREET WEST UNION IA 52175 421032878 FOUNDATION IA 501(C)(3) LINE 7 PALMER LUTHERAN HEALTH CENTER 1 SAINT ELIZABETH'S HOSPITAL OF WABASHA 1200 GRANT BLVD WEST WABASHA MN 55981 410693877 HEALTHCARE MN 501(C)(3) LINE 3 GUNDERSEN LUTHERAN HEALTH SYSTEM 1 ST JOSEPH'S HEALTH SERVICES INC 400 WATER AVENUE HILLSBORO WI 54634 390929538 HEALTHCARE WI 501(C)(3) LINE 3 GUNDERSEN LUTHERAN HEALTH SYSTEM 1 ST JOSEPH'S MEMORIAL FOUNDATION INC 400 WATER AVENUE HILLSBORO WI 54634 391455787 FOUNDATION WI 501(C)(3) LINE 12A, I ST JOSEPH'S HEALTH SERVICES 1 TRI-COUNTY MEMORIAL FOUNDATION INC 18601 LINCOLN STREET WHITEHALL WI 54773 300093022 FOUNDATION WI 501(C)(3) LINE 12A, I TRI-COUNTY MEMORIAL HOSPITAL 1 TRI-COUNTY MEMORIAL HOSPITAL 18601 LINCOLN STREET WHITEHALL WI 54773 390704510 HEALTHCARE WI 501(C)(3) LINE 3 GUNDERSEN LUTHERAN HEALTH SYSTEM 1 TRI-STATE AMBULANCE INC 235 CAUSEWAY BOULEVARD LA CROSSE WI 54603 391965415 MEDICAL TRANSPORT WI 501(C)(3) LINE 10 GUNDERSEN LUTHERAN HEALTH SYSTEM 1 TRI-STATE REGIONAL AMBULANCE INC 235 CAUSEWAY BOULEVARD LA CROSSE WI 54603 391962965 MEDICAL TRANSPORT WI 501(C)(3) LINE 10 GUNDERSEN LUTHERAN HEALTH SYSTEM 1 TWEETEN LUTHERAN HEALTHCARE CENTER INC 125 FIFTH AVENUE SE SPRING GROVE MN 55974 411565003 HEALTHCARE WI 501(C)(3) LINE 10 GUNDERSEN LUTHERAN HEALTH SYSTEM 1 GUNDERSEN LUTHERAN ENVISION LLC 1836 SOUTH AVENUE LA CROSSE WI 54601 264706546 RENEWABLE ENERGY WI N/A C 1 3REALESTATE LLC 1900 SOUTH AVENUE LA CROSSE WI 54601 RENTAL WI N/A C 1 0 1 1 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0