2014-02-15T11:59:49-06:00 2013-06-30 410746749 CLIFTONLARSONALLEN LLP 220 SOUTH SIXTH STREET SUITE 300 MINNEAPOLIS MN 55402 990 2012-07-01 420680407 GREAT RIVER MEDICAL CENTER GREA 3197681000 1221 SOUTH GEAR AVENUE WEST BURLINGTON IA 52655 TODD SLADKY 3197681000 2014-02-17 1 KACIE MCEWEN P01599614 6123764500 2012 2015-11-30 17:44:51Z MARK RICHARDSON 1221 SOUTH GEAR AVENUE WEST BURLINGTON IA 52655 165808077 0 X WWW.GREATRIVERMEDICAL.ORG X 1895 IA IMPROVING THE REGION'S HEALTH BY PROVIDING HIGH-QUALITY HEALTH CARE. 13 12 1709 424 547445 0 958666 1016251 171863980 163957745 600055 503139 -1252695 118667 172170006 165595802 4237225 1336000 0 0 80877822 81892550 0 0 88400 74896042 77248319 160011089 160476869 12158917 5118933 347121271 358931910 105853530 107387947 241267741 251543963 X GREAT RIVER MEDICAL CENTER IS DEDICATED TO IMPROVING THE REGION'S HEALTH BY PROVIDING HIGH-QUALITY CARE, WORLD-CLASS CUSTOMER SERVICE, AND UNCOMPROMISING VALUE FOR OUR PATIENTS AND THEIR FAMILIES. 0 0 154482154 1336000 163957745 THE 213-BED ACUTE AND 160-BED LONG-TERM CARE HOSPITAL HAD 7,809 PATIENT ADMISSIONS AND 74,895 PATIENT DAYS OF MEDICAL CARE. IN ADDITION, NUMEROUS OUTPATIENT AND EMERGENCY ROOM PROCEDURES WERE PERFORMED. GREAT RIVER MEDICAL CENTER HAS ACCEPTED PAYMENT FROM MEDICARE AND MEDICAID, REDUCING MEDICAL BILLS FOR AREA RESIDENTS BY $143,670,900. COMMUNITY BENEFIT INFORMATION: SCHOOL PARTNERING $3,185; COMMUNITY EDUCATION $1,622; COMMUNITY INITIATIVE PARTICIPATION $11,737.50; PRENTAL EDUCATION $12,232.50; HEALTH FAIRS $5,298.46; COMMUNITY LIBRARY $30,482; CASH DONATIONS $1,336,000; TOTAL: $1,400,557 154482154 1 1 0 1 0 0 0 0 0 0 1 1 0 0 1 0 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 87 0 1709 1 1 1 0 0 0 0 0 0 0 0 0 X 13 12 0 1 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 0 0 0 X CHRISTINE DES JARDINS 3197681000 1221 SOUTH GEAR AVENUE WEST BURLINGTON IA 52655 MARK RICHARDSON 40.00 1.00 X X 0 668126 46494 KENT GAUDIAN 1.00 0.00 X X 0 0 0 DAN WIEDEMEIER 1.00 0.00 X X 0 0 0 ROBERT MCCULLEY 1.00 0.00 X X 0 0 0 MICHAEL MCCOY MD 1.00 0.00 X 0 0 0 LORRIN DEBLICK 1.00 0.00 X 0 0 0 KENNETH ASPELMEIER 1.00 3.00 X 0 0 0 DENNIS HINKLE 1.00 0.00 X 0 0 0 JACK HOBBS 1.00 0.00 X 0 0 0 JAN TOWNE 1.00 0.00 X 0 0 0 JO ELLEN HOTH MD 1.00 0.00 X 0 0 0 WILLIAM DAWS MD 1.00 0.00 X 0 0 0 ROBERT FLEMING 1.00 3.00 X 0 0 0 DON SCHMIDGALL 1.00 0.00 X 0 0 0 TONY HAYES 40.00 1.00 X 0 405763 43896 TODD SLADKY 40.00 1.00 X 0 365701 45177 DARWIN COOLEY 40.00 0.00 X 160445 0 32710 JOHN MERCER III 40.00 0.00 X 133897 0 31461 JEFFREY TAEGER 40.00 0.00 X 127123 0 32127 JON WILLIAMS 40.00 0.00 X 129177 0 25872 TED SMITH 40.00 0.00 X 129350 0 24790 679992 1439590 282527 33 0 1 0 CARL A NELSON CO 1815 DES MOINES AVE BURLINGTON IA 52601 BUILDING CONSTRUCTION 14853511 SOUTHEASTERN IOWA MEDICAL SERVICES INC 1221 S GEAR AVE WEST BURLINGTON IA 52655 PHYSICIANS 5492412 MUTUAL CONSULTING & MANAGEMENT SERVICES 1221 S GEAR AVE WEST BURLINGTON IA 52655 EXECUTIVE MANAGEMENT 3479928 EXECUTIVE HEALTH RESOURCES INC 15 CAMPUS BLVD SUITE 200 NEWTOWN SQUARE PA 19073 PHYSICIAN ADVISORS 429694 UNIVERSITY OF IOWA HOSPITALS CLINICS 200 HAWKINS DRIVE IOWA CITY IA 52242 MEDICAL SERVICES 358663 14 1016251 1016251 PATIENT SERVICE INCOME 621110 160995662 160995662 OTHER OPERATING INCOME 621300 2962083 2414638 547445 163957745 648085 648085 106725 54641 52084 52084 52084 12688 157634 -144946 -144946 -144946 MISCELLANEOUS INCOME 900099 66583 66583 66583 165595802 163410300 547445 621806 X 1336000 1336000 1583941 1583941 63392720 63227720 113250 51750 2808646 2800546 5602 2498 9481185 9445211 23927 12047 4626058 4614517 8100 3441 1895987 1895987 65498 41143 24355 93655 93655 17211072 16954389 242191 14492 18341356 18325817 14170 1369 408601 240088 168513 420306 365124 54468 714 2981651 2981651 11788164 11758509 29655 1373032 724292 648740 DRUGS 8592858 8592858 BAD DEBT 8009636 8009636 REPAIRS/MAINTENANCE 1755248 1750723 4525 FOOD 1622892 1589894 31166 1832 2688363 1630381 1057725 257 160476869 154482154 5906315 88400 17874399 5375577 19406050 18797527 519733 428208 2509787 2866195 1666347 1868495 308005925 141206630 144388748 166799295 158680289 160811668 1214500 1258900 861418 726045 347121271 358931910 10775232 7257028 79123333 86320549 15954965 13810370 105853530 107387947 X 236853104 246813570 3250655 3521223 1163982 1209170 241267741 251543963 347121271 358931910 X 5118933 320897 4836392 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 31226 31226 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: GREAT RIVER MEDICAL CENTER PAID DUES TO THE AMERICAN HOSPITAL ASSOCIATION AND THE IOWA HOSPITAL ASSOCIATION. THESE ASSOCIATIONS PARTICIPATE IN LOBBYING ACTIVITIES RELATED TO HEALTHCARE. 5099725 5099725 122310811 29898543 92412268 11697481 5088094 6609387 150958707 106219993 44738714 17939201 17939201 166799295 155164159 F CASH AND SHORT-TERM INVESTMENTS 4326 F INSURANCE COMPANY ANNUITY DEPOSITS 5643183 F 160811668 DEFERRED COMPENSATION LIABILITY 1036732 THIRD PARTY PAYABLE 1372441 PTO RESERVE 7150391 FAIR VALUE OF CASH FLOW HEDGING SWAP 4204556 PLEDGES LIABILITY 46250 13810370 1 1 X 1 X 1 X 1 1 1 0 1 1 3991024 3991024 0.02620 18964960 19770976 -806016 0.00000 22955984 19770976 3185008 0.02620 64557 64557 0.00040 1336000 1336000 0.00880 1400557 1400557 0.00920 24356541 19770976 4585565 0.03540 1 8009636 1201445 53197629 58007636 -4810007 X 1 1 1 1 GREAT RIVER MEDICAL CENTER

1221 SOUTH GEAR AVENUE WEST BURLINGTON IA 52655

X X X GREAT RIVER MEDICAL CENTER 1 1 X X X X X X X X X 12 1 0 1 X X X X X X X X X X 0 0 1 1 200.000000000000 1 300.000000000000 1 X X X X X X X 1 1 X X X X X X 1 0 X X X X 1 X 0 0 PART I, LINE 3C: THE ORGANIZATION USES THE FPG TO DETERMINE FREE OR DISCOUNTED CARE. INDIVIDUALS WHO ARE BELOW 200% OF THE FPG QUALIFY FOR FREE CARE. IN MOST INSTANCES, THEY HAVE TO PROVIDE FINANCIAL DOCUMENTATION AND FILL OUT A CHARITY CARE APPLICATION. WE ALSO USE A PRESUMPTIVE CHARITY CARE PROGRAM THAT ANALYZES PUBLIC AND PRIVATE DATABASES TO HELP DETERMINE ELIGIBILITY FOR CHARITY CARE. THESE INDIVIDUALS DO NOT HAVE ANY OTHER DOCUMENTATION TO PROVIDE. THIS PROGRAM IS USED AFTER COLLECTION ATTEMPTS HAVE BEEN DISCONTINUED. EXTRAORDINARY ASSETS ARE TAKEN IN TO CONSIDERATION WHEN DETERMINING CHARITY CARE ELIGIBILITY. MEDICALLY INDIGENT INDIVIDUALS ARE COVERED UNDER THE SAME CHARITY CARE POLICY. INDIVIDUALS BETWEEN 200% AND 300% OF THE FEDERAL POVERTY LIMITS ARE GRANTED CHARITY ON A SLIDING SCALE. PART I, LINE 7: THE AMOUNTS INCLUDED IN PART I, LINE 7 WERE CALCULATED USING A RATIO OF COST TO CHARGES DERIVED FROM WORKSHEET 2 OF THE IRS SCHEDULE H INSTRUCTIONS. PART I, L7 COL(F): BAD DEBT EXPENSES OF $8,009,636 WERE SUBTRACTED FROM THE TOTAL EXPENSES OF $160,476,869 IN CALCULATING THE PERCENTAGES IN PART I, LINE 7, COLUMN F. PART III, LINE 4: THE FOLLOWING IS FROM THE "ACCOUNTS RECEIVABLE AND ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS" PARAGRAPH IN NOTE 1 TO THE GREAT RIVER MEDICAL CENTER, GRMC FOUNDATION AND GREAT RIVER FOUNDATION, INC. COMBINED FINANCIAL STATEMENTS:"PATIENT RECEIVABLES WHERE A THIRD-PARTY PAYOR IS RESPONSIBLE FOR PAYING THE AMOUNT ARE CARRIED AT A NET AMOUNT DETERMINED BY THE ORIGINAL CHARGE FOR THE SERVICE PROVIDED, LESS AN ESTIMATE MADE FOR CONTRACTUAL ADJUSTMENTS OR DISCOUNTS PROVIDED TO THIRD-PARTY PAYORS. PATIENT RECEIVABLES DUE DIRECTLY FROM PATIENTS ARE CARRIED AT THE ORIGINAL CHARGE FOR THE SERVICE PROVIDED LESS AMOUNTS COVERED BY THIRD-PARTY PAYORS AND LESS AN ESTIMATED ALLOWANCE FOR DOUBTFUL RECEIVABLES BASED ON A REVIEW OF ALL OUTSTANDING AMOUNTS ON A MONTHLY BASIS. MANAGEMENT DETERMINES THE ALLOWANCE FOR DOUBTFUL ACCOUNTS BY IDENTIFYING TROUBLED ACCOUNTS, BY HISTORICAL EXPERIENCE APPLIED TO AN AGING OF ACCOUNTS AND BY CONSIDERING THE PATIENTS' FINANCIAL HISTORY, CREDIT HISTORY AND CURRENT ECONOMIC CONDITIONS. THE MEDICAL CENTER DOES NOT CHARGE INTEREST ON PATIENT RECEIVABLES. PATIENT RECEIVABLES ARE WRITTEN OFF AS BAD DEBT EXPENSES WHEN DEEMED UNCOLLECTIBLE. RECOVERIES OF RECEIVABLES PEVIOUSLY WRITTEN OFF ARE RECORDED AS A REDUCTION OF BAD DEBT EXPENSE WHEN RECEIVED."THE AMOUNT OF BAD DEBT EXPENSE REPORTED IN PART III, LINE 2 IS CALCULATED AS FOLLOWS: PAYMENT ARRANGEMENT INCLUDE PROSPECTIVELY DETERMINED RATES PER DISCHARGE, 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.THE ESTIMATED AMOUNT OF THE ORGANIZATION'S BAD DEBT EXPENSE ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S FINANCIAL ASSISTANCE POLICY INCLUDED IN PART III, LINE 3 IS DETERMINED AS FOLLOWS: IF AN INDIVIDUAL DOES NOT HAVE A RESIDENCE THAT CAN BE USED TO RUN THROUGH THE PRESEUMPTIVE CHARITY CARE APPLICATION AND THEY DO NOT FILL OUT THE APPROPRIATE PAPERWORK TO APPLY FOR CHARITY, THEIR ACCOUNT BALANCE WILL BE WRITTEN OFF TO BAD DEBT. BASED UPON A REVIEW OF CHARITY APPLICATIONS THAT WERE REJECTED DUE TO INCOMPLETE/MISSING INFORMATION, IT HAS BEEN DETERMINED THAT APPROXIMATELY 15% OF THE APPLICATIONS WE RECEIVE ARE REJECTED BUT THE PATIENT APPEARS TO QUALIFY FOR CHARITY BUT THEY HAVEN'T NOT COMPLETED THE APPROPRIATE FORMS. PART III, LINE 8: A COST-TO-CHARGE RATIO AS DETERMINED BY THE 2013 MEDICARE COST REPORT WAS USED TO DETERMINE THE AMOUNTS IN PART III, LINES 5 AND 6. THE SHORTFALL REPORTED ON PART III, LINE 7 REPRESENTS THE CO-INSURANCE AND PATIENT DEDUCTIBLE AMOUNTS. PART III, LINE 9B: COLLECTION EFFORTS ARE DISCONTINUED ONCE THE PATIENT HAS BEEN APPROVED FOR CHARITY CARE. GREAT RIVER MEDICAL CENTER PART V, SECTION B, LINE 3: TO ENSURE THOROUGH RESPONSES FROM THE MEMBERS OF THE GREATER BURLINGTON COMMUNITY, GREAT RIVER MEDICAL CENTER USED FACE-TO-FACE INTERVIEWS WITH KEY STAKEHOLDERS FROM THE COMMUNITY AND DEVELOPED A PAPER SURVEY THAT ANY COMMUNITY MEMBER COULD COMPLETE. ALL PARTICIPANTS IN THIS COUNTYWIDE PROCESS IDENTIFIED AND ADDRESSED PRIORITY AREAS THAT WOULD IMPROVE THE HEALTH OF THE DES MOINES COUNTY COMMUNITY. EXTERNAL INTERVIEW PARTICIPANTS INCLUDED THE PUBLIC HEALTH OFFICER, THE DEPARTMENT DIRECTOR OF THE DES MOINES COUNTY DEPARTMENT OF PUBLIC HEALTH, A VARIETY OF PEOPLE FROM LOCAL AND STATE GOVERNMENT AGENCIES, AND LEADERS FROM COMMUNITY-BASED ORGANIZATIONS, FOUNDATIONS, AND ASSOCIATIONS. THESE PARTICIPANTS ARE EXPERTS IN A RANGE OF AREAS INCLUDING PUBLIC HEALTH, MINORITY POPULATIONS, UNDERSERVED POPULATIONS, SOCIAL DETERMINANTS OF HEALTH, AND HEALTH AND SOCIAL SERVICES. THE EXTERNAL PARTICIPANTS WERE INTERVIEWED USING A STANDARDIZED LIST OF QUESTIONS. THE QUESTIONS WERE DESIGNED TO IDENTIFY IMPORTANT HEALTH CONCERNS IN THE COMMUNITY, SUGGEST METHODS GREAT RIVER MEDICAL CENTER COULD USE TO BETTER ENGAGE AND COLLABORATE WITH THE COMMUNITY AND OFFER SUGGESTIONS FOR ADDRESSING HEALTH CARE PRIORITIES AND RECOMMENDATIONS. INTERVIEWERS WERE INSTRUCTED TO ASK ANY QUESTIONS THEY FELT WERE RELEVANT. THEY WERE NOT CONSTRAINED TO THE QUESTIONS LISTED ON THE INTERVIEW TEMPLATE. THE SECOND SOURCE OF COMMUNITY-MEMBER RESPONSE WAS THROUGH A PAPER SURVEY MADE AVAILABLE AT SEVERAL LOCATIONS THROUGHOUT DES MOINES COUNTY. THE SURVEY ASKED RESPONDENTS A VARIETY OF QUESTIONS CENTERING ON THREE HEALTH CONCERNS: OBESITY, TEENAGE PREGNANCY, AND MENTAL HEALTH. THESE CONCERNS HAD BEEN IDENTIFIED AS PRIORITIES THROUGH THE 2010 DES MOINES COUNTY HEALTH NEEDS ASSESSMENT. QUESTIONS ASKED ABOUT THE SIGNIFICANCE OF EACH OF THE CONCERNS AND THE SERVICES AVAILABLE TO ADDRESS THE HEALTH PROBLEM. THE SURVEY ALSO ASKED RESPONDENTS TO RATE THE THREE HEALTH CONCERNS THAT SHOULD BE THE FOCUS FOR IMPROVEMENT. LAST, RESPONDENTS WERE INVITED TO EXPRESS THOUGHTS AND IDEAS ABOUT GREAT RIVER MEDICAL CENTER AND THE HEALTH OF DES MOINES COUNTY RESIDENTS. GREAT RIVER MEDICAL CENTER PART V, SECTION B, LINE 5C: HTTP://GREATRIVERMEDICAL.ORG/ GREAT RIVER MEDICAL CENTER PART V, SECTION B, LINE 7: OUR STAKEHOLDERS FEEL THAT SUBSTANCE ABUSE AND TEENAGE PREGNANCIES ARE ISSUES BEST HANDLED BY ORGANIZATIONS THAT CAN HAVE A BROADER IMPACT ON THE ISSUE. HOWEVER, IF OR WHEN APPROACHED TO DEVELOP PARTNERSHIPS AND COLLABORATIONS TO COMBAT THESE TWO ISSUES, GRMC WILL WELCOME THESE OPPORTUNITIES. GREAT RIVER MEDICAL CENTER PART V, SECTION B, LINE 18E: THE HOSPITAL USES AN OUTSIDE SOURCE TO SCREEN PATIENTS TO SEE IF THEY COULD BE ELIGIBLE FOR FINANCIAL ASSISTANCE. WE GET NOTIFICATION BACK AS TO HOW MUCH OF A FINANCIAL ASSISTANCE DISCOUNT THEY WOULD BE ELIGIBLE FOR. IF THE PATIENT DOESN'T RESPOND TO OUR PHONE CALLS REGARDING FINANCIAL ASSISTANCE APPLICATION OR THEY DON'T COMPLETE THE APPLICATION, THE HOSPITAL WILL DISCOUNT THE PATIENT'S CHARGES AND THIS IS CONSIDERED PRESUMPTIVE CHARITY. PRESUMPTIVE CHARITY IS ALSO STATED IN OUR POLICY. IT ALSO GIVES THE HOSPITAL THE OPPORTUNITY TO DISCOUNT PATIENT ACCOUNTS BASED ON INFORMATION THAT WE MAY HAVE REGARDING A PATIENT BEING HOMELESS OR UNEMPLOYED. GREAT RIVER MEDICAL CENTER PART V, SECTION B, LINE 20D: THE MAXIMUM AMOUNT THAT CAN BE CHARGED IS BASED ON A CHARITY CARE MATRIX BASED ON THE FPG AND FAMILY SIZE. THE MAXIMUM AMOUNT CHARGED TO FAP-ELIGIBLE PATIENTS IS LESS THAN THE AMOUNTS GENERALLY BILLED TO PATIENTS COVERED BY COMMERCIAL INSURANCE. PART VI, LINE 2: GRMC IS AN ACTIVE PARTICIPANT IN COMMUNITY AND COUNTY GOVERNMENT TASK FORCES ON HEALTH NEEDS ASSESSMENT AND HEALTH SERVICES PLANNING AND COORDINATION. GRMC ASSESSES OUR COMMUNITIES' NEEDS THROUGH PROGRAMS WE OFFER, REQUESTS THAT ARE RECEIVED, AND OUR OWN STAFF INVOLVEMENT IN THEIR COMMUNITIES. WE ALSO COLLABORATE WITH OTHER COMMUNITY ORGANIZATIONS AS WELL, WHEN OUR SERVICES ARE NEEDED. AN ANNUAL HEALTH FAIR IS HOSTED TO PROVIDE INFORMATION AND EDUCATION TO OUR COMMUNITY ABOUT HEALTH ISSUES AND TO PROMOTE OUR HEALTHCARE SERVICES. WE ENCOURAGE OUR COMMUNITY MEMBERS TO TAKE AN ACTIVE ROLE IN THEIR OWN HEALTH CARE BY TAKING STEPS TOWARDS A HEALTHIER LIFESTYLE THROUGH MEMBERSHIP TO OUR GYM, A MULTITUDE OF EXERCISE PROGRAMS OFFERED THROUGH OUR FACILITY, AND OFFERING MANY WELLNESS PROGRAMS TO THE COMMUNITY. PART VI, LINE 3: FINANCIAL COUNSELORS MEET WITH PATIENTS. THE PATIENT FILLS OUT A QUESTIONNAIRE THAT HELPS THEM DETERMINE IF THEY QUALIFY FOR MEDICAID, CRIME VICTIMS, COBRA, AND OTHER MISC PROGRAMS. ON THE STATEMENTS, THERE IS PRINTED INFORMATION ABOUT FINANCIAL ASSISTANCE AND THE FINANCIAL ASSISTANCE APPLICATION IS ON THE HOSPITAL WEBSITE. THERE ARE PLANS TO ALSO HAVE THE CHARITY CARE POLICY AVAILABLE VIA THE WEB. PART VI, LINE 4: A REVIEW CONDUCTED BY THE MEDICAL CENTER ANALYZING THE ORIGIN OF PATIENTS UTILIZING THE SERVICES PROVIDED BY MEDICAL CENTER DURING THE FISCAL YEAR ENDED JUNE 30, 2013 INDICATES THAT DES MOINES COUNTY COMPRISES THE MEDICAL CENTER'S PRIMARY SERVICE AREA AND THAT THE SECONDARY SERVICE AREA OF THE MEDICAL CENTER CONSISTS OF HENRY, LEE AND LOUISA COUNTIES IN IOWA AND HANCOCK AND HENDERSON COUNTIES IN ILLINOIS. THE DES MOINES COUNTY POPULATION IS ESTIMATED AT 40,340 RESIDENTS FOR 2012, WITH BURLINGTON AND WEST BURLINGTON TOTALING 28,633 AS OF 2012. THE OVER 65 AGE GROUP IS CURRENTLY 18.1% OF THE POPULATION WHICH IS HIGHER THAN THE STATE AVERAGE OF 15.3%. THE MEDIAN HOUSEHOLD INCOME WAS $43,427 COMPARED TO THE STATE AVERAGE OF $51,129. DES MOINES COUNTY POPULATION BELOW POVERTY LEVEL IS 14.5% COMPARED TO THE STATE AVERAGE OF 12.2%. GREAT RIVER MEDICAL CENTER IS PART OF A LARGER HEALTH SYSTEM THAT CONSISTS OF ONE HOSPITAL, MULTIPLE SPECIALTY PHYSICIAN CLINICS, HOME HEALTH SERVICES, A HOSPICE HOUSE, AMBULANCE SERVICES, A DAY CARE CENTER, THREE PHARMACIES, A DURABLE MEDICAL EQUIPMENT COMPANY, AND A LONG-TERM CARE NURSING HOME. PART VI, LINE 5: GRMC IS INVOLVED IN GETTING PHYSICIANS AND HEALTHCARE WORKERS TO THE AREA TO IMPROVE THE ACCESS TO HEALTHCARE NEEDS IN THE MEDICAL CENTER'S SERVICE AREA. GRMC ALSO PROMOTES HEALTH CARE RELATED JOBS EDUCATION BY WORKING CLOSELY WITH SOUTHEASTERN COMMUNITY COLLEGE AND THEIR NURSING PROGRAM.THE HOSPITAL ALSO PROVIDES MEMBERSHIP TO ALL PHYSICIANS WHO MEET MEMBERSHIP AND CLINICAL REQUIREMENTS. SURPLUS FUNDS ARE INVESTED IN IMPROVED AND/OR UPDATED CAPITAL EQUIPMENT TO ALLOW FOR BETTER CARE OF THE PATIENTS THAT ARE SERVED. PART VI, LINE 6: GREAT RIVER HEALTH SYSTEM SERVES AS A HOLDING COMPANY OF VARIOUS SUBSIDIARIES PROVIDING HEALTH CARE IN WEST BURLINGTON, IOWA. 1 COMMUNITY ACTION OF SOUTHEAST IOWA 2850 MT PLEASANT ST SUITE 108 BURLINGTON IA 52601 420923961 501C3 20000 MEDICAL ASSISTANCE PROGRAM BURLINGTON NOON LIONS CLUB 2601 CLEARVIEW AVENUE BURLINGTON IA 52601 426056542 501C3 10000 COMMUNITY BENEFIT HOPE HAVEN 1307 BROADWAY WEST BURLINGTON IA 52655 421000580 501C3 20000 COMMUNITY BENEFIT MED-FORCE - QUAD CITY HELICOPTER EMS 6907 NOTTINGHAM LANE BETTENDORF IA 52722 421506559 501C3 6500 COMMUNITY BENEFIT GREAT RIVER FOUNDATION 1221 SOUTH GEAR AVENUE WEST BURLINGTON IA 52655 421469162 501C3 1200000 COMMUNITY BENEFIT RELATED TO THE GENERAL OPERATIONS OF GRPC. BIGGSVILLE FIRE PROTECTION DISTRICT PO BOX 43 BIGGSVILLE IL 61418 376146823 501C3 5520 COMMUNITY BENEFIT 10 0 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: GRANTEES ARE REQUIRED TO PROVIDE FOLLOW-UP INFORMATION WHEN THE PROJECT IS CARRIED OUT OR COMPLETED. IF GRANTEES DON'T COMPLY, GRMC DOES NOT PROVIDE FURTHER GRANTS TO THEM. 0 0 0 0 0 0 0 0 0 MARK RICHARDSON 0 405196 0 40000 0 222930 0 10000 0 36494 0 714620 0 0 TONY HAYES 0 311237 0 20000 0 74526 0 10000 0 33896 0 449659 0 0 TODD SLADKY 0 265663 0 20000 0 80038 0 10000 0 35177 0 410878 0 0 DARWIN COOLEY 160098 0 100 0 247 0 10086 0 22624 0 193155 0 0 0 JOHN MERCER III 133797 0 100 0 0 0 7581 0 23880 0 165358 0 0 0 JEFFREY TAEGER 127023 0 100 0 0 0 6565 0 25562 0 159250 0 0 0 JON WILLIAMS 129077 0 100 0 0 0 7606 0 18266 0 155049 0 0 0 TED SMITH 120250 0 9100 0 0 0 5600 0 19190 0 154140 0 0 0 SUPPLEMENTAL INFORMATION PART III PART I, LINE 2: THE COMPENSATION OF THE PRESIDENT & CEO IS DETERMINED BY GREAT RIVER HEALTH SYSTEMS, A RELATED ORGANIZATION. THE FOLLOWING WERE USED BY GREAT RIVER HEALTH SYSTEMS IN DETERMINING THE PRESIDENT & CEO'S COMPENSATION: 1. COMPENSATION COMMITTEE 2. INDEPENDENT COMPENSATION CONSULTANT 3. FORM 990 OF OTHER ORGANIZATIONS 4. WRITTEN EMPLOYMENT CONTRACT 5. COMPENSATION SURVEY OR STUDY 6. APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE A IOWA FINANCE AUTHORITY 521699886 462466BV4 2008-07-24 37475000 REFUND OF PRIOR ISSUE (12/19/97) 0 0 0 B DES MOINES COUNTY IOWA 426004310 250087AA1 2012-04-04 60000000 REFUND PRIOR ISSUE (7/25/01) & CONSTRUCT, RENOVATE, EXPAND & EQUIP FACILITY 0 0 0 A 7215000 37475070 306661 68339 70 37100000 2000 1 0 1 1 B 4035088 60000000 616000 30076758 29307242 2013 1 0 1 1 A 0 0 0 0 0 0 0 B 0 0 0 0 0 0 0 A 0 0 1 1 1 0 0 0 0 B 0 0 1 1 0 0 0 0 0 A 0 B 0 SCHEDULE K PART IV, ARBITRAGE, LINE 2C DATE REBATE COMPUTATION PERFORMED ISSUER NAME: IOWA FINANCE AUTHORITY DATE THE REBATE COMPUTATION WAS PERFORMED: 01/24/2009 ISSUER NAME: DES MOINES COUNTY, IOWA DATE THE REBATE COMPUTATION WAS PERFORMED: 01/31/2013 PART IV, LINE 2, REBATE CALCULATION NOTE REGARDING THE 01/24/2009 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. PART IV, LINE 2, REBATE CALCULATION NOTE REGARDING THE 01/31/2013 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. PART II, LINE 3, COLUMN A THE TOTAL PROCEEDS DO NOT AGREE TO THE ISSUE PRICE IN PART I, COLUMN E DUE TO INVESTMENT EARNINGS. PART III, PRIVATE BUSINESS USE SPECIAL RULES FOR REFUNDING OF PRE-2003 ISSUES GRMC IS NOT REQUIRED TO COMPLETE PART III OF SCHEDULE K FOR EITHER BONDS BECAUSE THE BOND ISSUANCES LISTED IN PART I WERE TO REFUND BONDS ISSUED PRIOR TO JANUARY 1, 2003. THE TAX SOFTWARE USED TO PREPARE THE FORM 990 DOESN'T ALLLOW FOR THE SUPPRESSING OF THIS SECTION, THEREFORE, THESE ANSWERS ARE ANSWERED NO INSTEAD OF BEING LEFT BLANK. FORM 990, PART VI, SECTION A, LINE 1 THE EXECUTIVE COMMITTEE SHALL BE COMPOSED OF THE CHAIRMAN OF THE BOARD, THE PRESIDENT AND CHIEF EXECUTIVE OFFICER, AND TWO OR MORE ADDITIONAL TRUSTEES. WHEN THE BOARD IS NOT IN SESSION, THE EXECUTIVE COMMITTEE SHALL HAVE AND EXERCISE THE POWER AND AUTHORITY OF THE BOARD TO TRANSACT ALL REGULAR BUSINESS OF THE CORPORATION, SUBJECT TO ANY PRIOR LIMITATIONS IMPOSED BY THE BOARD OR BY STATUTE. THE EXECUTIVE COMMITTEE HAS GENERAL RESPONSIBILITY FOR THE INVESTMENT OF AN ENDOWMENT AND OTHER CAPITAL FUNDS OF THE HOSPITAL. FORM 990, PART VI, SECTION A, LINE 3 ALL EXECUTIVE LEADERSHIP FUNCTIONS FOR GREAT RIVER MEDICAL CENTER ARE PROVIDED BY MUTUAL CONSULTING AND MANAGEMENT SERVICES, INC. MUTUAL CONSULTING AND MANAGEMENT SERVICES IS A SUBSIDIARY OF RIVERVIEW SYSTEMS LTD, WHICH IS A SUBSIDIARY OF GREAT RIVER HEALTH SYSTEMS. FORM 990, PART VI, SECTION A, LINE 6 GREAT RIVER HEALTH SYSTEMS INC., IS THE SOLE MEMBER OF GREAT RIVER MEDICAL CENTER. FORM 990, PART VI, SECTION A, LINE 7A ONE TRUSTEE IS THE PRESIDENT AND CHIEF EXECUTIVE OFFICER OF GREAT RIVER MEDICAL CENTER AND THE REMAINING TRUSTEES ARE ELECTED BY THE SOLE MEMBER. FORM 990, PART VI, SECTION A, LINE 7B THE FOLLOWING MATTERS ARE AUTHORIZED ONLY AFTER APPROVAL OF THE MEMBER: A. MERGER,CONSOLIDATION, OR DISSOLUTION OF GREAT RIVER MEDICAL CENTER WITH ANY OTHER CORPORATION OR LEGAL ENTITY. B. ANY CHANGE IN GREAT RIVER MEDICAL CENTER'S ARTICLES OF INCORPORATION. FORM 990, PART VI, SECTION B, LINE 11 GREAT RIVER MEDICAL CENTER FORM 990 WILL BE SENT OUT BY SECURE EMAIL MESSAGE TO ALL BOARD MEMBERS PRIOR TO FILING. IF THERE ARE ANY QUESTIONS, THEY CAN CONTACT THE ACCOUNTING OFFICE OR THEY CAN BE ADDRESSED AT THE NEXT BOARD MEETING. FORM 990, PART VI, SECTION B, LINE 12C EVERY YEAR, THE ACCOUNTING MANAGER IN THE ACCOUNTING DEPARTMENT PROVIDES TO THE BOARD THE MEANING OF THE CONFLICT OF INTEREST STATEMENT, HOW IT APPLIES, HOW IT IMPACTS THE BOARD, AND WHAT THEIR RESPONSIBILITIES ARE. ALL BOARD MEMBERS ARE REQUIRED TO FILL OUT A CONFLICT OF INTEREST FORM AND THE FORM IS THEN REVIEWED BY THE ACCOUNTING MANAGER. RELATIONSHIPS NOTED ON THE FORM MAY BE DISCUSSED WITH THE BOARD MEMBER IF THERE ARE QUESTIONS. IF AN INDIVIDUAL HAS A CONFLICT OF INTEREST, THEY MAY NOT PARTICIPATE IN DISCUSSIONS OF THE TRANSACTION AND MAY NOT VOTE ON MATTERS RELATED TO THE TRANSACTION. FORM 990, PART VI, SECTION C, LINE 19 GREAT RIVER MEDICAL CENTER MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE UPON REQUEST. OTHER FEES FORM 990, PART IX, LINE 11G CONTRACTED SERVICES: PROGRAM SERVICE EXPENSES 10,982,828. MANAGEMENT AND GENERAL EXPENSES 242,191. FUNDRAISING EXPENSES 14,492. TOTAL EXPENSES 11,239,511. SPECIALIST FEES: PROGRAM SERVICE EXPENSES 5,971,561. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 5,971,561. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 9: UNREALIZED GAIN ON INTEREST RATE SWAP 1,987,099. TRANSFER FROM RELATED PARTY 2,849,293. FORM 990, PART XII, LINE 2C THIS PROCESS IS CONSISTENT WITH PRIOR YEARS. GREAT RIVER HEALTH SYSTEMS INC 1221 SOUTH GEAR AVENUE WEST BURLINGTON IA 52655 421193185 HEALTH CARE IA 501(C)(3) 11 - TYPE 2 N/A 0 GRMC FOUNDATION CORP 1221 SOUTH GEAR AVENUE WEST BURLINGTON IA 52655 421193186 SUPPORT RELATED ORGANIZATIONS IA 501(C)(3) 11 - TYPE 2 GRHS 0 GREAT RIVER FOUNDATION INC 1221 SOUTH GEAR AVENUE WEST BURLINGTON IA 52655 421469162 SUPPORT RELATED ORGANIZATIONS IA 501(C)(3) 11 - TYPE 2 GRHS 0 RIVERVIEW SYSTEMS LTD PO BOX 640 WEST BURLINGTON IA 52655 421191960 MEDICAL SERVICES IA N/A C 0 GREAT RIVER MEDICAL SERVICES INC 1201 WEST AGENCY ROAD WEST BURLINGTON IA 52655 421493449 MEDICAL SERVICES IA N/A C 0 0 1 0 0 0 0 0 0 0 0 0 0 0 1 1 1 1 1 1