2015-02-12T15:37:38-06:00 2014-06-30 476097913 SEIM JOHNSON LLP 18081 BURT STREET SUITE 200 OMAHA NE 680224722 990 2013-07-01 420859940 BURGESS HEALTH CENTER BURG 7124232311 1600 DIAMOND STREET ONAWA IA 51040 FRANCIS TRAMP PRESIDENT/CEO 7124232311 2015-02-12 1 BARBARA J FAJEN P00400874 4023302660 2013 2016-02-25 16:41:14Z FRANCIS TRAMP 1600 DIAMOND STREET ONAWA IA 51040 31181971 0 X WWW.BURGESSHC.ORG X 1959 IA TO PROVIDE HEALTHCARE SERVICES TO THE COMMUNITY 10 10 297 83 1920249 -132139 51684 43614 26139861 27076930 435356 1004005 68975 60496 26695876 28185045 0 0 0 0 11932153 13038237 0 0 0 13369759 13089537 25301912 26127774 1393964 2057271 32020703 35240179 8088937 8616462 23931766 26623717 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 21757690 25156681 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. 21757690 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 0 0 0 0 0 0 1 1 1 0 0 1 86 0 1 297 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 NEAL GORHAM BOARD MEMBER(THRU 1/2014) 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 156237 0 21600 SHAWN GOSCH CFO (THRU 6/2014) 39.00 1.00 X 110665 0 17131 MONTY MCKINVEN CRNA 40.00 0.00 X 357649 0 17813 WASEEM ALOUNK ER PHYSICIAN 40.00 0.00 X 297159 0 16866 PETER DAHER MD ER PHYSICIAN 40.00 0.00 X 177497 0 11399 SCOTT NORTH DIRECTOR OF PHARMACY 40.00 0.00 X 108159 0 23516 SANDRA ROSE DIRECTOR OF WHITING PHARMACY 40.00 0.00 X 115858 0 4542 1323224 0 112867 9 0 1 0 FAMILY MEDICINE CLINIC 1614 DIAMOND ST ONAWA IA 51040 ER COVERAGE 357689 CPSI PO BOX 850309 MOBILE AL 36685 COMPUTER SUPPORT 331741 SHARED SERVICE SYSTEMS INC PO BOX 330 COTTAGE GROVE WI 53527 MRI & DIAGNOSTIC SERVICES 309649 SIEMENS HEALTHCARE DIAGNOSTICS PO BOX 121102 DALLAS TX 75312 LAB SERVICES 304141 ALEGENT HEALTH COMMUNITY MEMORIAL 631 NORTH EIGTH STREET MISSOURI VALLEY IA 51555 340B DISPENSING 258347 14 854 42760 43614 PATIENT REVENUE 624100 14241880 14241880 MEDICARE/MEDICAID PAYMENTS 624100 10365311 10365311 RETAIL PHARMACY 446110 1920249 1920249 MEANINGFUL USE INCENTIVE PAYMENTS 624100 215441 215441 MENTAL HEALTH APPR 624100 82386 82386 251663 251663 27076930 537858 537858 125219 64723 60496 60496 60496 3398350 2932203 466147 466147 466147 28185045 25156681 1920249 1064501 305633 305633 57805 57805 10592925 9000088 1592837 206321 180579 25742 1142599 1030999 111600 732954 633772 99182 17791 17791 56900 56900 2163550 1794885 368665 111252 111252 1836890 1124556 712334 10206 10206 364486 236277 128209 152444 128172 24272 147194 147194 1237701 569394 668307 97482 97482 MEDICAL SUPPLIES 4188156 4188156 RETAIL PHARMACY EXPENSE 1894406 1894406 BAD DEBT EXPENSE 571371 571371 DUES AND SUBSCRIPTIONS 95868 42125 53743 143840 86165 57675 26127774 21757690 4370084 0 3499413 309524 3161877 6678694 3763369 4407892 154723 168807 906267 953998 212864 172962 28204379 16174405 12075970 12029974 7948975 10283863 3833 7183 293412 227282 32020703 35240179 1701685 2338441 5847470 5386822 539782 891199 8088937 8616462 X 23931766 26623717 23931766 26623717 32020703 35240179 2057271 634680 0 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 55042 55042 20225379 8718078 11507301 7353104 7047078 306026 570854 409249 161605 12029974 THIRD-PARTY PAYOR SETTLEMENTS 891199 891199 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, 2014, THE HEALTH CENTER AND FOUNDATION HAD NO UNCERTAIN TAX POSITIONS ACCRUED. WITH FEW EXCEPTIONS, THE HEALTH CENTER IS NO LONGER SUBJECT TO INCOME TAX EXAMINATIONS BY U.S. FEDERAL, STATE, OR LOCAL TAX AUTHORITIES FOR YEARS BEFORE 2011. 1 1 1 X 1 X 245.000000000000 1 1 0 0 479 272000 272000 0.01060 3817 2045651 1308388 737263 0.02880 4296 2317651 1308388 1009263 0.03940 12 1433 20238 2350 17888 0.00070 4 13819 2342273 1617810 724463 0.02830 1 275 2806 2806 0.00010 17 15527 2365317 1620160 745157 0.02910 17 19823 4682968 2928548 1754420 0.06850 1 571371 399959 10197293 10330117 -132824 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 1 X X X X X X X X X 12 1 0 1 X WWW.BURGESSHC.ORG X X X X X X X X X 1 0 1 1 100.000000000000 1 245.000000000000 1 X X X X X X X 1 1 X X X X 1 0 X 1 X 0 0 BURGESS HEALTH CENTER PART V, SECTION B, LINE 3: 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 18E: THE HEALTH CENTER MADE NO SUCH EFFORTS. BURGESS HEALTH CENTER PART V, SECTION B, LINE 20D: THE HOSPITAL USED DISCOUNTS OR WROTE OFF THE BALANCE DUE. 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 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 $ 571,371. 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 $571,371, IS 2.15% 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 ORGANIZATION'S FINANCIAL STATEMENTS DO NOT CONTAIN A SPECIFIC FOOTNOTE DESCRIBING BAD DEBT. HOWEVER, THE FOLLOWING IS THE TEXT OF THE FOOTNOTES TITLED "PATIENT RECEIVABLES, NET" "NET PATIENT SERVICE REVENUE," AND "CHARITY CARE":PATIENT RECEIVABLES, NET:THE HEALTH CENTER REPORTS PATIENT ACCOUNTS RECEIVABLE FOR SERVICES RENDERED AT NET REALIZABLE AMOUNTS FROM THIRD-PARTY PAYERS, PATIENTS AND OTHERS. ACCOUNTS RECEIVABLE ARE REDUCED BY AN ALLOWANCE FOR DOUBTFUL ACCOUNTS. 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.NET PATIENT SERVICE REVENUE:THE HEALTH CENTER HAS AGREEMENTS WITH THIRD PARTY PAYORS THAT PROVIDE FOR PAYMENTS TO THE HEALTH CENTER AT AMOUNTS DIFFERENT FROM ITS ESTABLISHED RATES. PAYMENT ARRANGEMENTS INCLUDE REIMBURSED COSTS DISCOUNTED CHARGES AND PER DIEM PAYMENTS. NET PATIENT SERVICE REVENUE IS REPORTED AT THE ESTIMATED NET REALIZABLE AMOUNTS FROM PATIENTS, THIRD-PARTY PAYORS AND OTHERS FOR SERVICES RENDERED INCLUDING ESTIMATED RETROACTIVE ADJUSTMENTS UNDER REIMBURSEMENT AGREEMENTS WITH THIRD-PARTY PAYORS. RETROACTIVE ADJUSTMENTS ARE ACCRUED ON AN ESTIMATED BASIS IN THE PERIOD THE RELATED SERVICES ARE RENDERED AND ADJUSTED IN THE FUTURE PERIODS AS FINAL SETTLEMENTS ARE DETERMINED.CHARITY CARE:THE HEALTH CENTER PROVIDES CARE TO PATIENTS WHO MEET CERTAIN CRITERIA UNDER ITS CHARITY CARE POLICY WITHOUT CHARGE OR AT AMOUNTS LESS THAN ITS ESTABLISHED RATES. BECAUSE THE HEALTH CENTER DOES NOT PURSUE COLLECTION OF AMOUNTS DETERMINED TO QUALIFY AS CHARITY CARE THEY ARE NOT REPORTED IN THE CONSOLIDATED STATEMENT OF OPERATIONS.THE HEALTH CENTER IS DEDICATED TO PROVIDING COMPREHENSIVE HEALTH CARE SERVICES TO ALL SEGMENTS OF SOCIETY INCLUDING THE AGED AND OTHERWISE ECONOMICALLY DISADVANTAGED. IN ADDITION, THE HEALTH CENTER PROVIDES A VARIETY OF COMMUNITY HEALTH SERVICES AT OR BELOW COST.ESTIMATED BAD DEBT FOR PATIENTS ELIGIBLE FOR CHARITY CARE WAS PROVIDED BY THE HEALTH CENTER'S FINANCIAL COUNSELOR WHO IS THE ONLY EMPLOYEE THAT ASSISTS THE PATIENTS WITH THEIR HOSPITAL BILL. THE FINANCIAL COUNSELOR IS THE EXPERT IN THIS AREA AND PROVIDES HER ESTIMATE BASED ON HER KNOWLEDGE OF THE PATIENTS SHE ASSISTS AND THE FINANCIAL ASSISTANCE POLICY. 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, 2014. PART III, LINE 9B: BURGESS HEALTH CENTER HAS A FINANCIAL COUNSELOR 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 15,000. 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 155920 0 0 0 317 0 3561 0 18039 0 177837 0 0 0 MONTY MCKINVEN CRNA 356783 0 0 0 866 0 3914 0 13899 0 375462 0 0 0 WASEEM ALOUNK ER PHYSICIAN 296992 0 0 0 167 0 5467 0 11399 0 314025 0 0 0 PETER DAHER MD ER PHYSICIAN 177194 0 0 0 303 0 0 0 11399 0 188896 0 0 0 A CITY OF ONAWA IOWA 426005064 2012-07-13 6259250 REFUND PRIOR ISSUE (06/08/05) 0 0 0 A 872428 6259250 125185 6134065 2007 1 0 1 1 A 0 0 0 0 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. KATE GARRED KATE GARRED IS THE SPOUSE OF JOHN GARRED JR., MD, A CURRENT BOARD MEMBER 57805 KATE GARRED IS EMPLOYED BY BURGESS HEALTH CENTER 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 EXTENSION, THE FORM 990 IS DUE FEBRUARY 17, 2015 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 BURGESS HEALTH CORP EMPLOYEE BENEFIT TRUST 1600 DIAMOND STREET ONAWA IA 51040 421320408 PROVIDE HEALTH BENFITS TO EMPLOYEES OF BURGESS HEALTH CENTER IA 501(C)(9) N/A BURGESS HEALTH CENTER 1 0 0 1 0 0 0 0 0 0 0 0 0 0 1 1 0 1 1 1 BURGESS HEALTH CORP EMPLOYEE BENEFIT TRUST Q 151578