2016-05-13T15:43:43-05:00 2015-06-30 476097913 SEIM JOHNSON LLP 18081 BURT STREET SUITE 200 OMAHA NE 680224722 990 2014-07-01 420859940 BURGESS HEALTH CENTER BURG 7124232311 1600 DIAMOND STREET ONAWA IA 51040 FRANCIS TRAMP PRESIDENT/CEO 7124232311 2016-05-12 1 BARBARA J FAJEN P00400874 4023302660 2014 2016-08-17 19:52:53Z FRANCIS TRAMP 1600 DIAMOND STREET ONAWA IA 51040 32404090 0 X WWW.BURGESSHC.ORG X 1959 IA TO PROVIDE HEALTHCARE SERVICES TO THE COMMUNITY 10 10 312 76 2172351 -143275 43614 428894 27076930 28240524 1004005 845073 60496 251530 28185045 29766021 0 0 0 0 13038237 14320902 0 0 0 13089537 13208291 26127774 27529193 2057271 2236828 35240179 36869464 8616462 8671655 26623717 28197809 BURGESS HEALTH CENTER IS COMMITTED TO IMPROVE THE QUALITY OF LIFE FOR THE PEOPLE AND COMMUNITIES IT SERVES BY PROVIDING EXCELLENT HEALTHCARE AND EXCEPTIONAL PATIENT EXPERIENCES. 0 0 23038745 26183274 THE BURGESS HEALTH CENTER IS A NOT-FOR-PROFIT ACUTE CARE HOSPITAL. THE HEALTH CENTER PROVIDES RELATED HEALTHCARE ANCILLARY, OUTPATIENT, PHYSICIAN CLINIC SERVICES, AND A RETAIL PHARMACY. 23038745 1 1 0 0 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 1 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0 1 1 1 0 0 1 76 0 1 312 1 1 1 0 0 0 0 0 0 0 0 0 X 10 10 0 0 0 0 1 0 1 1 1 0 0 1 1 1 1 1 1 1 0 0 X NANCY CARLSON VICE PRESIDENT OF FI 7124239213 1600 DIAMOND STREET ONAWA IA 51040 JIM WESTERGAARD CHAIRMAN 2.00 0.00 X X 0 0 0 TERRY FRAMKE VICE CHAIRMAN 2.00 2.00 X X 0 0 0 STEVE PRATT SECRETARY/TREASURER 2.00 0.00 X X 0 0 0 JUDY CONNEALY BOARD MEMBER 2.00 0.00 X 0 0 0 PAUL DUDLEY MD BOARD MEMBER 2.00 0.00 X 0 0 0 JOHN GARRED JR MD BOARD MEMBER 2.00 0.00 X 0 0 0 MARI MILLER BOARD MEMBER 2.00 0.00 X 0 0 0 CHARLES SEDERSTROM BOARD MEMBER 2.00 0.00 X 0 0 0 KEITH SCHRUNK OD BOARD MEMBER 2.00 0.00 X 0 0 0 SHEILA DUARTE DDS BOARD MEMBER 2.00 0.00 X 0 0 0 FRANCIS TRAMP PRESIDENT / CEO 39.00 1.00 X 160696 0 23273 NANCY CARLSON VICE PRESIDENT OF FINANCE 39.00 1.00 X 34687 0 3954 MONTY MCKINVEN CRNA 40.00 0.00 X 374084 0 21322 WASEEM ALOUNK MD PHYSICIAN 40.00 0.00 X 286002 0 19199 PETER DAHER MD PHYSICIAN 40.00 0.00 X 229353 0 11399 JENNIFER SCHENNE DO PHYSICIAN 40.00 0.00 X 118241 0 3817 SANDRA ROSE RETAIL PHARMACIST 40.00 0.00 X 118509 0 5808 1321572 0 88772 8 0 1 0 FAMILY MEDICINE CLINIC PC 1614 DIAMOND ST ONAWA IA 51040 ER COVERAGE 365732 SHARED MEDICAL SERVICES INC 209 LIMESTONE PASS COTTAGE GROVE WI 53527 MRI 189380 NATIONWIDE ANESTHESIA SERVICES INC PO BOX 992 SANDERSVILLE GA 30049 CRNA COVERAGE 127807 ALLSCRIPTS LLC 8529 SIX FORKS RD RALEIGH NC 27615 SOFTWARE MAINTENANCE 108754 MCKESSON INFORMATION SOLUTIONS 5995 WINDWARD PARKWAY ALPHARETTA GA 30005 EQUIPMENT, SOFTWARE 105690 5 125287 42779 260828 428894 PATIENT REVENUE 624100 14097252 14097252 MEDICARE/MEDICAID PAYMENTS 624100 11703641 11703641 RETAIL PHARMACY 446110 2172351 2172351 MEANINGFUL USE INCENTIVE PAYMENTS 624100 131914 131914 135366 135366 28240524 699677 699677 116076 64102 51974 51974 51974 2710863 8500 2573967 0 136896 8500 145396 145396 REBATES / DISCOUNTS 900099 115101 115101 CAFETERIA / DIETARY 722210 84455 84455 199556 29766021 26183274 2172351 981502 222610 222610 62898 62898 11513676 9742705 1770971 246712 217015 29697 1475840 1229791 246049 799166 671768 127398 18157 18157 97479 97479 2048789 1754054 294735 43038 43038 1937938 1260096 677842 10215 10215 345834 256892 88942 168883 132284 36599 135581 135581 1342331 667171 675160 104809 104809 MEDICAL SUPPLIES 4130463 4130463 RETAIL PHARMACY EXPENSE 2157536 2157536 BAD DEBT EXPENSE 379598 379598 FOOD 103260 103260 184380 115152 69228 27529193 23038745 4490448 0 309524 306027 6678694 7337079 4407892 3775380 168807 202921 953998 1051101 172962 207107 29625584 17481999 12029974 12143585 10283863 11635767 7183 7811 227282 202686 35240179 36869464 2338441 2579679 5386822 4913934 891199 1178042 8616462 8671655 X 26623717 28197809 26623717 28197809 35240179 36869464 2236828 -662736 0 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 55042 55042 20896763 9448465 11448298 7995145 7604383 390762 678634 429151 249483 12143585 THIRD-PARTY PAYOR SETTLEMENTS 1178042 1178042 X PART X, LINE 2: THE HEALTH CENTER AND FOUNDATION ARE NOT-FOR-PROFIT CORPORATIONS AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE AND ARE EXEMPT FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE CODE. THE INTERNAL REVENUE SERVICE HAS ESTABLISHED STANDARDS TO BE MET TO MAINTAIN THE HEALTH CENTER AND FOUNDATION'S TAX EXEMPT STATUS. IN GENERAL, SUCH STANDARDS REQUIRE THE HEALTH CENTER AND FOUNDATION TO MEET A COMMUNITY BENEFITS STANDARD AND COMPLY WITH VARIOUS LAWS AND REGULATIONS. THE HEALTH CENTER AND FOUNDATION ACCOUNT FOR UNCERTAINTIES IN ACCOUNTING FOR INCOME TAX ASSETS AND LIABILITIES USING GUIDANCE INCLUDED IN FASB ASC 740, INCOME TAXES. THE HEALTH CENTER AND FOUNDATION RECOGNIZE THE EFFECT OF INCOME TAX POSITIONS ONLY IF THOSE POSITIONS ARE MORE LIKELY THAN NOT OF BEING SUSTAINED. AT JUNE 30, 2015 AND 2014, THE HEALTH CENTER AND FOUNDATION HAD NO UNCERTAIN TAX POSITIONS ACCRUED. 1 1 1 X 1 X 245.000000000000 1 1 0 0 541 247000 247000 0.00910 5161 2868215 2205818 662397 0.02440 5702 3115215 2205818 909397 0.03350 1868 22010 1220 20790 0.00080 15090 2718926 1994341 724585 0.02670 122 1004 1004 0.00000 17080 2741940 1995561 746379 0.02750 22782 5857155 4201379 1655776 0.06100 1 379598 265719 10408824 10559870 -151046 X 1 1 1 1 BURGESS HEALTH CENTER 1600 DIAMOND STREET ONAWA IA 61040 WWW.BURGESSHC.ORG 670082H X X X X BURGESS HEALTH CENTER 1 0 0 1 X X X X X X X X X 12 1 0 1 1 X WWW.BURGESSHC.ORG X 1 12 1 WWW.BURGESSHC.ORG 0 0 1 X 100.000000000000 245.000000000000 X X X X 1 1 X X X X 1 X WWW.BURGESSHC.ORG X WWW.BURGESSHC.ORG X X X X X 1 X 0 X X X X 1 X 0 0 BURGESS HEALTH CENTER PART V, SECTION B, LINE 5: IN ORDER TO ENSURE EXTERNAL INPUT WAS RECEIVED IN ADDITION TO RESPONSES TO THE SURVEY, THE FOLLOWING ENTITIES WERE CONTACTED FOR INPUT:- MONONA COUNTY PUBLIC HEALTH- BURGESS MEDICAL STAFF- MONONA COUNTY DENTISTSIN ADDITION, MONONA COUNTY PUBLIC HEALTH'S COMMUNITY HEALTH NEEDS IMPROVEMENT PLAN FOR MONONA COUNTY 2010-2011 WAS REVIEWED FOR IDENTIFIED COMMUNITY NEEDS AND PRIORITIES. BURGESS HEALTH CENTER PART V, SECTION B, LINE 6B: -MONONA COUNTY PUBLIC HEALTH-BURGESS MEDICAL STAFF-MONONA COUNTY DENTISTS BURGESS HEALTH CENTER PART V, SECTION B, LINE 11: TO ADDRESS, EDUCATE AND PREVENT THE PRIMARY CONCERN OF THE CHNA, CHRONIC DISEASE MANAGEMENT, BURGESS HEALTH CENTER HAS DEVELOPED THE FOLLOWING PROGRAMS WITHIN OUR SERVICE AREAS.DIABETES EDUCATION AND PREVENTIONDIABETES SERVICES INCLUDE: - AADE RECOGNIZED OUTPATIENT DIABETES SELF MANAGEMENT EDUCATION PROGRAM - MEDICAL NUTRITION THERAPY - PROFESSIONAL CGMS - ACTIVE DIABETES SUPPORT GROUP - NO COST COMMUNITY DIABETES PREVENTION CLASS - NO COST DIABETES REFRESHER CLASSES BURGESS HEALTH CENTER IS IN THE IMPLEMENTATION STAGES OF DEVELOPING A DIABETES PREVENTION PROGRAM (DPP) WHICH WILL HELP PREVENT THE ONSET OF DIABETES IN HIGH RISK POPULATIONS. MONONA COUNTY IS CURRENTLY ABOVE THE STATE AVERAGE WHEN IT COMES TO PEOPLE WITH DIABETES. AN EFFECTIVE DPP WILL SIGNIFICANTLY AFFECT THE HEALTH OF OUR LOCAL POPULATION.HEALTH SMART KIDSHEALTH SMART KIDS IS AN OUTREACH PROGRAM TO 6 COMMUNITY SCHOOLS IN OUR SERVICE AREA. OVER 400 CHILDREN ARE INVOLVED WITH THE PROGRAM EACH YEAR. TARGET AUDIENCE IS 2ND AND 4TH GRADERS. STUDENTS ARE INSTRUCTED OVER A FOUR WEEK PERIOD ON BEHAVIORS THAT PROMOTE HEALTHY LIVES AND ARE ENCOURAGED TO PRACTICE THESE BEHAVIORS TO PROMOTE HEALTH. 1. NUTRITION - EATING FRUITS, VEGETABLES, MILK AND BREAKFAST2. EXERCISE - 60 MINUTES OF ACTIVITY PER DAY3. SLEEP - 10 HOURS SLEEP EVERY NIGHT4. CREATIVE ACTIVITIES - ACTIVITIES TO DO OTHER THAN TV AND/OR VIDEO GAMESIN WEEK #5, WE HAVE A CELEBRATION THAT REWARDS THE STUDENTS FOR ALL THE HEALTHY BEHAVIORS THEY HAVE BEEN PRACTICING; PLAYING GAMES THAT REINFORCE THE HEALTHY BEHAVIORS AND PRIZES.REAL WEIGH BURGESS HEALTH CENTER OFFERS A WEIGHT MANAGEMENT PROGRAM THAT IS LED BY HOSPITAL DIETICIANS THAT IS AVAILABLE FOR COMMUNITY MEMBERS. THE PROGRAM FOCUSES ON LIFE STYLE CHANGE AND WITH THE HELP OF PROFESSIONALS, HELPS THE CLIENT TO NAVIGATE THEIR WAY TO A HEALTHIER LIFE. THE REAL WEIGH CONSISTS OF 3 INDIVIDUAL VISITS WITH THE DIETICIAN AND 11 GROUPS SESSIONS OVER 4 MONTHS.MEDICALLY ORIENTED GYM (MOG)MOGS HAVE BEEN ESTABLISHED IN THE COMMUNITIES OF MAPLETON AND ONAWA. THEY ARE MEMBERSHIP BASED FITNESS CENTERS THAT INCLUDE COMPREHENSIVE HEALTH EVALUATIONS BY A PROFESSIONAL TRAINER, PERSONAL TRAINING SESSIONS TO PERSONALIZE STRENGTH AND CONDITIONING PROGRAMS, QUARTERLY REPORTS TO THE MEMBERS PHYSICIAN, NUTRITION GUIDANCE AND BIOMETRIC DATA COLLECTION FOR MEMBERS TO ASSIST IN IDENTIFYING AND MEETING HEALTH GOALS. BURGESS HEALTH CENTER PART V, SECTION B, LINE 13B: BURGESS HEALTH CENTER USES HUD GUIDELINES FOR IOWA WHICH ARE LESS RESTRICTIVE FOR THE PATIENTS. THESE GUIDELINES CAN BE FOUND AT HUDUSER.GOV. BURGESS HEALTH CENTER PART V, SECTION B, LINE 22D: THE HOSPITAL USED DISCOUNTS OR WROTE OFF THE BALANCE DUE PER FINANCIAL ASSISTANCE GUIDELINES IN THE HOSPITAL'S FINANCIAL ASSISTANCE POLICY. PART V, SECTION B, LINE 16 FINANCIAL ASSISTANCE POLICY WEBSITE AVAILABILITY BURGESS HEALTH CENTER PART V, SECTION B, LINE 16A WEBSITE: WWW.BURGESSHC.ORG BURGESS HEALTH CENTER PART V, SECTION B, LINE 16C WEBSITE: WWW.BURGESSHC.ORG 4 BURGESS FAMILY CLINIC - MAPLE VALLEY 513 SOUTH MUCKEY STREET MAPLETON IA 51304 FAMILY MEDICAL CLINIC BURGESS FAMILY CLINIC - SLOAN 409 EVANS SLOAN IA 51055 FAMILY MEDICAL CLINIC BURGESS FAMILY CLINIC - DUNLAP 612 IOWA AVENUE DUNLAP IA 51529 FAMILY MEDICAL CLINIC BURGESS FAMILY CLINIC - DECATUR 12TH BROADWAY DECATUR NE 68020 FAMILY MEDICAL CLINIC PART I, LINE 3C: BURGESS HEALTH CENTER USES HUD GUIDELINES WHICH ARE LESS RESTRICTIVE FOR OUR PATIENTS. THE HOSPITAL DOES NOT USE ASSET TESTING OR OTHER FACTORS REGARDLESS OF INCOME AS A FACTOR TO DETERMINE ELIGIBILITY FOR FREE OR DISCOUNTED CARE. PART I, LINE 7: BURGESS HEALTH CENTER USES LYONS SOFTWARE TO TRACK ALL PROGAMS THROUGHOUT THE YEAR. WHEN A PROGRAM IS USED, THE PERSON IN CHARGE WILL TRACK THE PROGRAM IN THE SOFTWARE BY RECORDING THE CATEGORY, THE RELATED COSTS AND REVENUE AND THE NUMBER OF PARTICIPANTS. PART I, LINE 7G: ALL COSTS REPORTED ON PART I, LINE 7G ARE ATTRIBUTABLE TO THE PHYSICIAN CLINICS. PART I, LINE 7, COLUMN (F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $ 379,598. PART II, COMMUNITY BUILDING ACTIVITIES: BURGESS HEALTH CENTER DID NOT REPORT ANY COMMUNITY BUILDING ACTIVITIES IN PART II OF SCHEDULE H. PART III, LINE 2: IN EVALUATING THE COLLECTIBILITY OF ACCOUNTS RECEIVABLE, THE HEALTH CENTER ANALYZES ITS PAST HISTORY AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYER SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND PROVISION FOR BAD DEBTS. MANAGEMENT REGULARLY REVIEWS DATA ABOUT THESE MAJOR PAYER SOURCES OF REVENUE IN EVALUATING THE SUFFICIENCY OF THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. FOR RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRD-PARTY COVERAGE, THE HEALTH CENTER ANALYZES CONTRACTUALLY DUE AMOUNTS AND PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS AND A PROVISION FOR BAD DEBTS FOR THOSE ACCOUNTS OVER A CERTAIN AGE BASED ON DISCHARGE 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 HEALTH CENTER RECORDS A SIGNIFICANT PROVISION FOR BAD DEBTS IN THE PERIOD OF SERVICE ON THE BASIS OF ITS PAST 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 ACTUALLY COLLECTED AFTER ALL REASONABLE COLLECTION EFFORTS HAVE BEEN EXHAUSTED IS CHARGED OFF AGAINST THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. PART III, LINE 3: THE BAD DEBT RECOGNIZED OF $379,598, IS 1.36% OF NET PATIENT SERVICE REVENUE FOR THE FISCAL YEAR. 9% OF PEOPLE LIVING IN MONONA COUNTY HAVE INCOME BELOW NATIONAL POVERTY GUIDELINES. USING THESE FACTS, BURGESS HEALTH CENTER ESTIMATES THAT THE MAJORITY (70%) OF SERVICES THAT END IN BAD DEBT ARE FOR PATIENTS WHO WOULD QUALIFY FOR CHARITY CARE IF THEY WOULD APPLY. PART III, LINE 4: THE HOSPITAL'S FINANCIAL STATEMENTS DO NOT CONTAIN A SPECIFIC FOOTNOTE DESCRIBING BAD DEBT. HOWEVER, PAGES 8 AND 10 OF THE ATTACHED AUDITED FINANCIAL STATEMENTS INCLUDE FOOTNOTES TITLED "PATIENT RECEIVABLES, NET" "NET PATIENT SERVICE REVENUE, AND "CHARITY CARE". PART III, LINE 8: THE MEDICARE SHORTFALL IS BASED ON THE INFORMATION FROM THE COST REPORT. THE COSTS ARE MEDICARE REIMBURSABLE COSTS, NOT ALL COSTS. THE MEDICARE SHORTFALL SHOULD BE TREATED AS A COMMUNITY BENEFIT BECAUSE THE SERVICES ARE PROVIDED WITHOUT THE EXPECTATION THAT MEDICARE REVENUES WILL COVER OUR COSTS. THE ORGANIZATION USED WORKSHEETS D-1, D-4, E AND E-3 OF THE COST REPORT FOR THE YEAR ENDED JUNE 30, 2015. PART III, LINE 9B: BURGESS HEALTH CENTER HAS TWO FINANCIAL COUNSELORS WHO WILL REVIEW OUTSTANDING ACCOUNTS WITH PATIENTS TO HELP THEM QUALIFY FOR ASSISTANCE IN PAYING THE OUTSTANDING BILL. THIS ASSISTANCE INCLUDES COMPLETING PAPERWORK AND GATHERING SOURCE DOCUMENTS TO DETERMINE IF THE PATIENT QUALIFIES FOR FINANCIAL ASSISTANCE. THE FINANCIAL COUNSELOR WILL ALSO ASSIST PATIENTS IN COMPLETING PAPERWORK IN ORDER FOR THEM TO QUALIFY FOR GOVERNMENT ASSISTANCE. PART VI, LINE 2: BURGESS HEALTH CENTER REVIEWS DATA FROM THE IOWA DEPARTMENT OF PUBLIC HEALTH. BURGESS HEALTH CENTER FOCUSES ON TOP ADMISSIONS TO THE HOSPITAL AND REVIEWS THE AGGREGATE DATA FROM WELLNESS SCREENS. PART VI, LINE 3: PATIENTS' BILLS CONTAIN INFORMATION REGARDING THE AVAILABILITY OF FINANCIAL ASSISTANCE AND GIVES CONTACT INFORMATION FOR OBTAINING THIS ASSISTANCE. IF A PATIENT HAS NOT RESPONDED TO THE BILL, THE FINANCIAL COUNSELOR WILL CONTACT THE PATIENT TO MAKE ARRANGEMENTS TO HELP THE PATIENT APPLY FOR FINANCIAL ASSISTANCE. PART VI, LINE 4: BURGESS HEALTH CENTER IS SITUATED IN MONONA COUNTY, IA. THE SERVICE AREA IS CONSIDERED A RURAL SETTING WITH A POPULATION OF APPROXIMATELY 10,000. OF THIS POPULATION, 24.3% OF MONONA COUNTY IS OVER AGE 65 COMPARED TO THE IOWA AVERAGE OF 15.6%. THE SERVICE AREA RANKS LOW REGARDING THE MEDIAN HOUSEHOLD INCOME. THE IOWA MEDIAN HOUSEHOLD INCOME FOR 2009-2013 IS $51,843 WITH MONONA COUNTY HAVING A MEDIAN HOUSEHOLD INCOME OF $42,025, NEARLY $10,000 LOWER. PART VI, LINE 5: PROMOTING THE HEALTH OF THE COMMUNITIES BURGESS HEALTH CENTER SERVES IS IMPORTANT TO BURGESS HEALTH CENTER. FURTHERMORE, IT IS PART OF THE MISSION STATEMENT OF BURGESS HEALTH CENTER. - "BURGESS HEALTH CENTER IS COMMITTED TO IMPROVE THE QUALITY OF LIFE FOR THE PEOPLE AND COMMUNITIES WE SERVE BY PROVIDING EXCELLENT HEALTHCARE AND EXCEPTIONAL PATIENT EXPERIENCES."BURGESS HEALTH CENTER PARTNERS WITH OTHER ORGANIZATIONS IN THE COMMUNITY TO IMPROVE COMMUNITY HEALTH AND WELL BEING. BURGESS HEALTH CENTER PARTICIPATES IN MEDICARE, MEDICAID CHAMPUS AND TRICARE. PART VI, LINE 6: BURGESS HEALTH CENTER IS NOT PART OF AN AFFILIATED HEALTH CARE SYSTEM. X X X 0 0 0 0 0 0 0 0 0 FRANCIS TRAMP PRESIDENT / CEO 160367 0 0 0 329 0 4934 0 18339 0 183969 0 0 0 MONTY MCKINVEN CRNA 373184 0 0 0 900 0 7423 0 13899 0 395406 0 0 0 WASEEM ALOUNK MD PHYSICIAN 285822 0 0 0 180 0 7800 0 11399 0 305201 0 0 0 PETER DAHER MD PHYSICIAN 229010 0 0 0 343 0 0 0 11399 0 240752 0 0 0 A CITY OF ONAWA IOWA 426005064 2012-07-13 6259250 REFUND PRIOR ISSUE (06/08/05) 0 0 0 A 1345316 6259250 125185 6134065 2007 1 0 1 1 A 0 0 0 0 0.00000 0.00000 0.00000 0 0 1 A 0 0 1 1 1 0 0 0 1 A 1 SCHEDULE K, PART IV, ARBITRAGE, LINE 2C DATE THE REBATE COMPUTATION WAS PERFORMED: 01/13/2013 NOTE REGARDING THE REBATE COMPUTATION; SINCE THE BOND PROCEEDS HAVE BEEN SPENT, A SPENDING EXCEPTION WAS MET AND THE DEBT SERVICE FUND WAS OPERATED ON A BONA FIDE BASIS, NO FURTHER REBATE CALCULATIONS ARE NECESSARY. KATHRYN GARRED EMPLOYEE OF ORGANIZATION AND SPOUSE OF JOHN GARRED JR., MD, BOARD MEMBER 62898 EMPLOYEES W-2 WAGES 0 FAMILY MEDICINE CLINIC DR. PAUL DUDLEY OWNS 100% OF THE CLINIC AND IS A CURRENT BOARD MEMBER 365732 CONTRACTED SERVICES PROVIDED FOR ER COVERAGE 0 FORM 990, PART VI, SECTION A, LINE 6 BURGESS HEALTH CENTER HAS MEMBERS. A PERSON MAY BECOME A MEMBER IF HE OR SHE (1) IS AT THAT TIME A RESIDENT OF THE GEOGRAPHIC AREA SERVED BY THE CORPORATION; (2) COMPLETES A MEMBERSHIP REGISTRATION FORM, AND (3) PAYS A LIFE MEMBERSHIP FEE OF $10. FORM 990, PART VI, SECTION A, LINE 7B THERE IS AN ANNUAL MEETING OF THE MEMBERS. AT THE MEETING, THE MEMBERS RECEIVE AN ANNUAL REPORT ON THE AFFAIRS OF THE CORPORATION AND HAVE THE OPPORTUNITY TO OFFER THEIR INPUT ON ANY MATTER AFFECTING THE CORPORATION. THE MEMBERS SHALL ALSO CARRY OUT ANY DUTIES RESERVED TO MEMBERS UNDER THE IOWA NONPROFIT CORPORATION ACT. EACH MEMBER HAS ONE VOTE. THE ACT OF A MAJORITY OF MEMBERS PRESENT AND VOTING SHALL BE THE ACT OF THE MEMBERS. FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 AND RELATED SCHEDULES ARE PRESENTED TO THE FINANCE COMMITTEE BY NANCY CARLSON, VICE PRESIDENT OF FINANCE, AT THE FIRST SCHEDULED FINANCE COMMITTEE MEETING AFTER THE COMPLETION OF THE FORM 990. WITH THE EXTENSIONS, THE FORM 990 IS DUE MAY 15TH AND WILL BE EMAILED TO THE BOARD OF DIRECTORS FOR REVIEW PRIOR TO SUBMISSION TO IRS. FORM 990, PART VI, SECTION B, LINE 12C ON A ANNUAL BASIS, ALL BOARD MEMBERS ALONG WITH THE MANAGEMENT STAFF (MANAGERS, DIRECTORS, OFFICERS) COMPLETE A CONFLICT OF INTEREST QUESTIONNAIRE. THE RESULTS ARE REVIEWED AT ONE OF THE BOARD MEETINGS. FORM 990, PART VI, SECTION B, LINE 15A THE CEO SALARY IS DETERMINED BASED ON GRADE, NUMBER OF YEARS IN THE POSITION AND COMPARED TO IOWA HOSPITAL ASSOCIATION DATA SHOWING MARKET RATES FOR THE BURGESS CUSTOM GROUP. THIS INFORMATION IS PASSED ON TO THE EXECUTIVE COMMITTEE OF THE BOARD WHO MAKES A RECOMMENDATION TO THE COMPLETE BOARD OF DIRECTORS. THE BOARD OF DIRECTORS IS RESPONSIBLE FOR THE FINAL DECISION. FORM 990, PART VI, SECTION C, LINE 19 BURGESS HEALTH CENTER DOES NOT MAKE ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, OR FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC. FORM 990, PART XI, LINE 2C: THE BOARD OF DIRECTORS ASSUMES THE RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT OF ITS CONSOLIDATED FINANCIAL STATEMENTS AND SELECTION OF AN INDEPENDENT ACCOUNTANT. THIS PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. BURGESS FOUNDATION 1600 DIAMOND STREET ONAWA IA 51040 421188964 RAISING FUNDS FOR BURGESS HEALTH CENTER IA 501(C)(3) LINE 7 BURGESS HEALTH CENTER 1 0 0 1 0 0 0 0 0 0 0 0 0 0 1 1 0 0 1 1 BURGESS FOUNDATION C 125287 CASH - FMV