2013-02-01T14:20:15-06:00 2012-06-30 390758449 WIPLFLI LLP 3703 OAKWOOD HILLS PARKWAY EAU CLAIRE WI 54702 990 2011-07-01 390831153 CUMBERLAND MEMORIAL HOSPITAL & EXTENDED CARE UNIT INC CUMB 7158222741 1110 7TH AVENUE CUMBERLAND WI 54829 MICHAEL GUTSCH 7158222741 2013-01-31 1 HOLLY POKRANDT CPA P00449155 7158323407 2013-01-31 2011 2016-02-25 16:41:14Z MICHAEL GUTSCH 1110 7TH AVENUE CUMBERLAND WI 54829 22641426 0 X WWW.CUMBERLANDHEALTHCARE.COM X 1955 WI CUMBERLAND MEMORIAL HOSPITAL AND EXTENDED CARE UNIT, INC. IS COMMITTED TO CREATING A HEALTHIER COMMUNITY THROUGH PROVIDING AN ARRAY OF HIGH-QUALITY ACUTE CARE, AMBULATORY, AND SKILLED NURSING FACILITY SERVICES TO RESIDENTS OF THE SERVICE AREA. 7 3 307 127 0 0 91978 86518 19963622 22522381 36229 32527 0 0 20091829 22641426 1368 0 0 0 13147355 13244081 0 0 0 7247443 8423202 20396166 21667283 -304337 974143 16282101 17177122 6379554 6300432 9902547 10876690 X THE PRIMARY FUNCTION OF CUMBERLAND MEMORIAL HOSPITAL AND EXTENDED CARE UNIT, INC. (CMH-ECU) IS THE PROVISION OF HIGH QUALITY COMMUNITY-BASED HEALTH CARE TO ALL PEOPLE WITHOUT REGARD TO DISABILITY, RACE, CREED, COLOR, NATIONAL ORIGIN OR ABILITY TO PAY. QUALITY CARE ENCOMPASSES CURATIVE, RESTORATIVE, SUPPORTIVE AND PREVENTATIVE ASPECTS. IN PROVIDING THIS CARE, THE RIGHTS, DIGNITY AND PRIVACY OF THE PATIENT/RESIDENT WILL BE HELD IN HIGHEST REGARD. QUALITY HEALTH CARE CAN BEST BE PROVIDED BY FOSTERING A QUALITY WORK ENVIRONMENT TO ATTRACT AND RETAIN COMPETENT AND CARING EMPLOYEES. CMH-ECU ACCEPTS A LEADERSHIP ROLE IN THE COMMUNITY IN ASSESSING NEEDS, INSTITUTING CHANGES TO MEET THOSE NEEDS, AND PLANNING WITH OTHER AGENCIES FOR CONTINUITY AND COMPREHENSIVE HEALTH CARE IN A COST EFFECTIVE MANNER. 0 0 15802761 20031562 CUMBERLAND MEMORIAL HOSPITAL-EXTENDED CARE UNIT, INC. IS AN INDEPENDENT, NONPROFIT, COMMUNITY-BASED FACILITY THAT SERVES NORTHWEST WISCONSIN. CUMBERLAND MEMORIAL HOSPITAL BECAME A CRITICAL ACCESS HOSPITAL ON AUGUST 19, 2005, LICENSED FOR 25 ACUTE CARE BEDS, INCLUDING 3 IN THE BIRTHPLACE, PLUS 10 PSYCHIATRIC BEDS. SERVICES INCLUDE, BUT ARE NOT LIMITED TO, THERAPY, OBSTETRICS, AND GENERAL SURGERY. ACUTE CARE DAYS TOTALED 1,667 IN 2012, SWING BED DAYS TOTALED 918, NEWBORN DAYS TOTALED 68, AND BEHAVIORAL HEALTH DAYS TOTALED 1,895. DURING FISCAL YEAR 2012, CUMBERLAND MEMORIAL HOSPITAL PROVIDED 42 INPATIENT AND 440 OUTPATIENT SURGERIES ALONG WITH 271 SCOPE PROCEDURES. THERE WERE ALSO 2,725 EMERGENCY ROOM VISITS. 3512918 2351434 CUMBERLAND EXTENDED CARE UNIT, A 50 BED SKILLED NURSING HOME, IS DEDICATED TO MEETING THE PHYSICAL, MENTAL, EMOTIONAL, AND SPIRITUAL NEEDS OF THE RESIDENTS AND FAMILIES SERVED. TOTAL NURSING HOME DAYS IN FISCAL YEAR 2012 WERE 14,376. 77855 139385 THE LAKEWOOD REGENCY APARTMENTS ARE ATTACHED TO THE CUMBERLAND MEMORIAL HOSPITAL & EXTENDED CARE UNIT. THESE SPACIOUS APARTMENTS WERE DESIGNED AS A COMFORTABLE AND CONVENIENT LIVING CHOICE FOR SENIORS KEEPING SOCIAL INTEREST AND PERSONAL SAFETY IN MIND. THE OCCUPANCY PERCENTAGE FOR 2012 WAS APPROXIMATELY 70%. 19393534 1 1 0 1 0 0 0 0 0 0 1 0 0 1 0 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 45 0 1 307 1 0 0 0 0 0 0 0 0 0 0 X 7 3 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 WI X ANGIE MARTENS 7158222741 1110 7TH AVENUE CUMBERLAND WI 54829 CHARLES CHRISTENSEN 2.00 X X 5250 0 0 TOM LINGEN MD 1.00 X 7050 0 0 RAY HALL 1.00 X 750 0 0 CANDY COTONE 1.00 X X 2925 0 0 ANN HENDRICKS 1.00 X X 3700 0 0 JOSEPH LESCHISIN 1.00 X 1350 0 0 MATT GORES 1.00 X 3600 0 0 MARTIN PETERS 1.00 X X 2775 0 0 DEB KUNFERMAN 40.00 X 231145 0 8002 MARY ANN CLARK 37.00 X 107555 0 14722 ANGIE MARTENS 40.00 X 102635 0 4726 DR CHARLES MAYO II 40.00 X 230844 0 36454 JEFFREY KUEHN 20.00 X 195011 0 29397 DONALD FULLERTON 20.00 X 182896 0 31565 LAURIE POLUBINSKY 40.00 X 253910 0 18002 BENJAMIN BRENNA 40.00 X 115154 0 30515 1446550 0 173383 9 0 1 0 CUMBERLAND CLINIC 1475 WEBB STREET CUMBERLAND WI 54829 ER PHYSICIANS 645874 SHARED MEDICAL TECHNOLOGY 202 W NEWTON ST RICE LAKE WI 54868 RADIOLOGY 245177 ABM JANITORIAL SERVICES 75 REMITTANCE DRIVE SUITE 3011 CHICAGO IL 606753011 HOUSEKEEPING 216756 DMS HEALTH TECHNOLOGIES INC 11600 96TH AVENUE NORTH MAPLE GROVE MN 55369 MRI 171501 UNIVERSAL HOSPITAL SERVICES PO BOX 86 MINNEAPOLIS MN 55486 RADIOLOGY 171066 6 4787 81731 922 86518 HOSPITAL REVENUE 621990 20031562 20031562 NURSING HOME REVENUE 623000 2351434 2351434 APARTMENT REVENUE 623990 139385 139385 22522381 20062 20062 12465 12465 22641426 22522381 0 32527 784400 285390 499010 9116298 8760586 355712 228341 224707 3634 2445660 2250362 195298 669382 613293 56089 22996 22996 75251 75251 2565542 2488253 77289 144392 144392 757306 580084 177222 159855 159855 549257 428750 120507 1066873 832801 234072 97429 97429 PROVISION FOR BAD DEBTS 1133620 1133620 BILLABLE MEDICAL SUPPLI 1060703 1060703 REPAIRS & MAINTENACE 338676 320380 18296 MEDICAID ASSESSMENT 256086 256086 195216 158519 36697 21667283 19393534 2273749 0 443379 57828 4951837 5052682 2980767 2827477 338989 379297 67059 55912 20148474 12821753 7413612 7326721 86458 1477205 16282101 17177122 1719554 2060726 4490000 4239706 170000 0 6379554 6300432 X 9902547 10876690 9902547 10876690 16282101 17177122 974143 0 X X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 1229 1229 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: CUMBERLAND MEMORIAL HOSPITAL, INC. PAYS AN ANNUAL ASSOCIATION MEMBERSHIP TO THE WISCONSIN HOSPITAL ASSOCIATION (WHA). THESE DUES ARE PRIMARILY FOR ACCESS TO EDUCATIONAL MATERIALS AND STAFF TRAINING AND DEVELOPMENT. WHA HAS NOTIFIED CMH THAT APPROXIMATELY $1,229 OF THE ANNUAL DUES WERE USED IN CONJUNCTION WITH LOBBYING ACTIVITIES WITH THE GOAL OF IMPROVING THE OVERALL HEALTHCARE ENVIRONMENT. 295897 295897 11612127 6721029 4891098 8240450 6100724 2139726 7326721 UNAMORTIZED BOND ISSUE COSTS 38918 UNAMORTIZED BOND DISCOUNT 38287 AMOUNTS RECEIVABLE FROM THIRD-PARTY REIMBURSEMENT PROGRAMS 1400000 1477205 22641426 21667283 974143 974143 22660957 19531 19531 22641426 0 22641426 21686814 19531 19531 21667283 0 21667283 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: IN ORDER TO ACCOUNT FOR ANY UNCERTAIN TAX POSITIONS, THE FACILITY DETERMINES WHETHER IT IS MORE LIKELY THAN NOT THAT A TAX POSITION WILL BE SUSTAINED UPON EXAMINATION OF THE TECHNICAL MERITS OF THE POSITION, ASSUMING THE TAXING AUTHORITY HAS FULL KNOWLEDGE OF ALL INFORMATION. IF THE TAX POSITION DOES NOT MEET THE MORE LIKELY THAN NOT RECOGNITION THRESHOLD, THE BENEFIT OF THE TAX POSITION IS NOT RECOGNIZED IN THE FINANCIAL STATEMENTS. THE FACILITY'S POLICY IS TO RECOGNIZE INTEREST AND PENALTIES RELATED TO INCOME TAX MATTERS IN INCOME TAX EXPENSE WHEN INCURRED. AS OF AND FOR THE YEARS ENDED JUNE 30, 2012 AND 2011, THERE WAS NO INCOME TAX EXPENSE, TAX PENALTIES, OR INTEREST RELATED TO TAX PENALTIES RECORDED BY THE FACILITY IN THE FINANCIAL STATEMENTS. THE FACILITY RECORDED NO ASSETS OR LIABILITIES FOR UNCERTAIN TAX POSITIONS OR UNRECOGNIZED TAX BENEFITS IN 2012 OR 2011. FEDERAL RETURNS FOR THE YEARS ENDED JUNE 30, 2009, AND BEYOND REMAIN SUBJECT TO EXAMINATION BY THE INTERNAL REVENUE SERVICE. PART XII, LINE 2D - OTHER ADJUSTMENTS: DIETARY REVENUE NETTED AGAINST DIETARY EXPENSES 19,531. PART XIII, LINE 2D - OTHER ADJUSTMENTS: DIETARY EXPENSES NETTED AGAINST DIETARY REVENUE 19,531. 1 1 1 X 1 X 150.000000000000 1 1 1 0 1 1 85633 85633 0.00420 5464805 4154375 1310430 0.06380 5550438 4154375 1396063 0.06800 108200 108200 0.00530 1366886 632772 734114 0.03580 1475086 632772 842314 0.04110 7025524 4787147 2238377 0.10910 0 669472 53558 5953921 6147428 -193507 X 1 1 1 1 CUMBERLAND MEMORIAL HOSPITAL INC

1110 7TH AVENUE CUMBERLAND WI 54829

X X X X CUMBERLAND MEMORIAL HOSPITAL INC 1 1 1 100.000000000000 1 150.000000000000 1 X X X X X 1 1 X X 1 0 1 X 0 0 2 CUMBERLAND EXTENDED CARE UNIT

1110 7TH AVENUE CUMBERLAND WI 54829

SKILLED NURSING FACILITY LAKEWOOD REGENCY APARTMENTS

1110 7TH AVENUE CUMBERLAND WI 54829

SENIOR LIVING APARTMENTS PART I, LINE 7: THE COSTING METHODOLOGY USED ON FORM 990 IS BASED ON A COST TO CHARGE RATIO WHICH IS DEVELOPED BASED ON THE HOSPITAL'S TOTAL OPERATING EXPENSES, EXCLUDING THE PROVISION FOR BAD DEBTS DIVIDED BY GROSS PATIENT SERVICE REVENUES. THIS COST TO CHARGE RATIO IS APPLIED AGAINST HOSPITAL REVENUE AND EXPENSE CATEGORIES TO COMPUTE THE ESTIMATED COMMUNITY BENEFIT EXPENSE UNDER IRS SUGGESTED COSTING METHODS FOR THE FORM 990. THE COSTING METHODOLOGY USED FOR NURSING HOME SERVICES IS BASED ON MEDICARE COST REPORTING METHODS. PART I, LINE 7G: THE COST OF SUBSIDIZED SERVICES IS BASED ON C0ST ALLOCATIONS FROM THE MEDICARE COST REPORT. ALLOWABLE COSTS ARE ASSIGNED DIRECTLY TO DEPARTMENTS THROUGHOUT THE YEAR AND THEN THE COST REPORT USES THE ALLOCATION METHODOLOGY TO ASSIGN ALL OTHER COSTS TO CALCULATE SERVICE LINE COSTS. SUBSIDIZED HEALTH SERVICES INCLUDE THE OPERATION OF THE INPATIENT PSYCHIATRIC UNIT AND THE SKILLED NURSING HOME. IT HAS BEEN THE GOAL OF CUMBERLAND MEMORIAL HOSPITAL TO PROVIDE THESE SERVICES TO THE COMMUNITY REGARDLESS OF A PATIENT'S ABILITY TO PAY. 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 $ 1133620. PART II: WHILE THERE IS GROWING AGREEMENT IN THE UNITED STATES ABOUT WHAT CONSTITUTES A NON-PROFIT HOSPITAL'S 'COMMUNITY BENEFIT,' THIS IS A WORK IN PROGRESS. CUMBERLAND MEMORIAL HOSPITAL PROVIDES SIGNIFICANT CHARITY CARE AND OTHER COMMUNITY BENEFITS AS DEFINED BY THE IRS AND IN ADDITION, THE ORGANIZATION BELIEVES THAT IT PROVIDES A CRITICALLY IMPORTANT COMMUNITY BENEFIT WHICH IS NOT QUANTIFIED. SEE PART 1, LINE 7 FOR THE CALCULATED COST OF PROVIDING COMMUNITY SERVICES. CUMBERLAND MEMORIAL HOSPITAL, LIKE MOST RURAL HOSPITALS, WAS CREATED AND IS MAINTAINED IN ORDER TO PROVIDE CARE LOCALLY WHICH WITHOUT THE HOSPITAL, WOULD NOT BE AVAILABLE LOCALLY. BEYOND INPATIENT HOSPITALIZATIONS, THE ORGANIZATION PROVIDES LOCAL ACCESS TO MANY HEALTH SERVICES: PSYCHIATRIC SERVICES, AMBULANCE SERVICES, BIRTHING CENTER, DIAGNOSTICS, EMERGENCY SERVICES & URGENT CARE, EXTENDED CARE, INPATIENT CARE, LABORATORY SERVICES, OCCUPATIONAL HEALTH, REHABILITATION SERVICES, SPECIALTY MEDICINE, SLEEP CENTER, SPEECH, AND SURGICAL SERVICES. PART III, LINE 4: MANAGEMENT PROVIDES FOR PROBABLE UNCOLLECTIBLE AMOUNTS, PRIMARILY UNINSURED PATIENTS AND AMOUNTS PATIENTS ARE PERSONALLY RESPONSIBLE FOR, THROUGH A CHARGE TO OPERATIONS AND A CREDIT TO A VALUATION ALLOWANCE BASED ON ITS ASSESSMENT OF HISTORICAL COLLECTION LIKELIHOOD AND THE CURRENT STATUS OF INDIVIDUAL ACCOUNTS. BALANCES THAT ARE STILL OUTSTANDING AFTER THE ORGANIZATION HAS USED REASONABLE COLLECTION EFFORTS ARE WRITTEN OFF THROUGH A CHARGE TO THE VALUATION ALLOWANCE AND A CREDIT TO ACCOUNTS RECEIVABLE. MANY TIMES PATIENTS ARE UNABLE TO COMPLETE THE REQUIRED CHARITY CARE APPLICATION AND ARE TRANSFERRED TO COLLECTION SERVICES EVEN THOUGH THE ORGANIZATION PROVIDES THIS INFORMATION TO ALL PATIENTS ANS ASSISTANCE WITH THE APPLICATIONS. DUE TO NO RESPONSES FROM SOME PATIENTS A SIGNIFICANT AMOUNT OF BAD DEBTS COULD BE CONSIDERED AS CHARITY CARE.THE COSTING METHODOLOGY USED ON FORM 990 IS BASED ON A COST TO CHARGE RATIO WHICH IS DEVELOPED BASED ON THE ORGANIZATION'S TOTAL OPERATING EXPENSES LESS THE PROVISION FOR BED DEBTS DIVIDED BY GROSS PATIENT SERVICE REVENUES. THIS COST TO CHARGE RATIO IS APPLIED AGAINST THE TOTAL CHARGES THAT ARE WRITTEN OFF DURING THE FISCAL YEAR TO ESTIMATE THE COST OF THE CHARITY CARE OF PATIENTS THAT HAVE ACCOUNTS THAT ARE DEEMED TO BE BAD DEBTS TO THE ORGANIZATION. THE ORGANIZATION ALSO PROVIDES DISCOUNTS TO ELIGIBLE UNINSURED OR UNDERINSURED PATIENTS UNDER ITS CHARITABLE CARE POLICY. THESE AMOUNTS ARE INCLUDED IN THE CONTRACTUAL ADJUSTMENTS ON THE FINANCIAL STATEMENTS AND ARE NOT INCLUDED IN THE RATIO AS DESCRIBED ABOVE AND APPROVED BY THE IRS FOR USE ON FORM 990. IF CONSIDERED, THESE ADDITIONAL WRITE-OFF AMOUNTS TO UNINSURED OR UNDERINSURED ACCOUNTS WOULD ALSO INCREASE THE ESTIMATED BAD DEBT EXPENSE ASSOCIATED WITH THESE UNCOLLECTIBLE ACCOUNTS TO THE ORGANIZATION.THE AUDITED FINANCIAL STATEMENTS DO NOT INCLUDE A SEPARATE FOOTNOTE REGARDING BAD DEBT EXPENSE. PART III, LINE 8: CUMBERLAND MEMORIAL HOSPITAL IS DESIGNATED A CRITICAL ACCESS HOSPITAL AND AS SUCH A PORTION OF ITS REVENUES ARE PAID UNDER A COST REIMBURSEMENT SYSTEM. BASED ON THE INSTRUCTIONS, THE TOTAL MEDICARE REVENUE SHOWN ON THIS FORM 990 INCLUDES ONLY A PORTION OF THE GROSS MEDICARE REVENUE THAT IS ACTUALLY RECEIVED BY THE HOSPITAL FROM THE MEDICARE PROGRAM. THE AMOUNTS LISTED FOR MEDICARE DO NOT INCLUDE PHYSICIAN AND MID-LEVEL PRACTITIONER SERVICES FOR THE COVERAGE OF THE EMERGENCY DEPARTMENT AT CUMBERLAND MEMORIAL HOSPITAL OR AMBULANCE SERVICES. PHYSICIAN COVERAGE IS REIMBURSED PRIMARILY ON A FEE SCHEDULE REIMBURSEMENT METHODOLOGY AT RATES THAT ARE OFTEN BELOW THE COSTS OF CARING FOR PATIENTS. EMERGENCY AND AMBULANCE 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 CUMBERLAND MEMORIAL HOSPITAL PROVIDES TO THE COMMUNITY AND SURROUNDING AREA OF CUMBERLAND, WISCONSIN. THE COSTING METHOD USED ABOVE FOR IRS 990 COMPLIANCE REPORTING IS ALSO BASED ON AN OVERALL AVERAGE COST TO CHARGE RATIO AND DOES NOT CONSIDER MEDICARE NON-ALLOWABLE EXPENSES AS IT IS BASED ON TOTAL HOSPITAL PATIENT SERVICE REVENUES (IGNORING CONTRACTUAL ADJUSTMENTS ON FEE SCHEDULE REIMBURSED ITEMS AND NON-ALLOWABLE MEDICARE EXPENSES AS NOTED ABOVE) DIVIDED BY TOTAL OPERATING EXPENSES LESS THE PROVISION FOR BAD DEBT EXPENSE. THIS RATIO IS THEN MULTIPLIED BY THE TOTAL MEDICARE SERVICES WHICH ARE REIMBURSED ON A COST METHODOLOGY EXCLUDING THE FEE SCHEDULE ITEMS LIKE PHYSICIAN AND MID-LEVEL PRACTITIONER SERVICES WHICH THE HOSPITAL WOULD SHOW A LARGE LOSS ON THESE SERVICES. 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: UNDER THE ORGANIZATION'S COLLECTION AND CHARITABLE CARE POLICIES, CUMBERLAND MEMORIAL HOSPITAL MAKES EVERY ATTEMPT TO IDENTIFY AND PROMOTE CHARITY CARE TO PATIENTS. INCLUDED IN THE ORGANIZATION'S CHARITABLE CARE POLICY IT IS NOTED THAT PATIENTS MAY QUALIFY FOR CHARITY CARE EITHER PRIOR TO ADMISSION OR FOLLOWING DISCHARGE. ALL INPATIENT SELF-PAY ADMISSIONS ARE SCREENED BY THE HOSPITAL'S FINANCIAL COUNSELOR TO ALLOW THESE PATIENTS THE ABILITY TO COMPLETE THEIR APPLICATION DURING THEIR STAY AT THE HOSPITAL, DEPENDING UPON THE PATIENT'S CONDITION, THE PATIENT'S RESPONSIBLE PARTY MAY BE CONTACTED TO COMPELTE AND RETURN THE FORMS AT A LATER TIME WHEN THEIR CARE ALLOWS THIS COMPLETION. DURING THE PATIENT ACCOUNT COLLECTION PROCESS, SELF-PAY PATIENTS ARE ALSO INFORMED OF THE HOSPITAL'S COLLECTION POLICES AS WELL AS THE CHARITY AND COMMUNITY CARE PROGRAM TO ALLOW PATENTS THE OPPORTUNITY TO COMPLETE THE APPROPRIATE FORMS AND QUALIFY UNDER THE PROGRAM. INCLUDED IN THE POLICY, IT IS ALSO NOTED THAT THE ORGANIZATION RESERVES THE RIGHT TO MAKE OR GRANT ADDITIONAL CHARITY CARE ON A CASE BY CASE BASIS. CUMBERLAND MEMORIAL HOSPITAL, INC. PART V, SECTION B, LINE 13G: THE FINANCIAL ASSISTANCE POLICY IS AVAILABLE THROUGH THE BUSINESS OFFICE STAFF. PATIENTS ARE ENCOURAGED TO CONTACT A FINANCIAL COUNSELOR FOR FURTHER INFORMATION ON THE FINANCIAL ASSISTANCE POLICY. THE HOSPITAL'S WEBSITE ALSO ENCOURAGES PATIENTS TO INQUIRE ABOUT THE FINANCIAL ASSISTANCE POLICY. CUMBERLAND MEMORIAL HOSPITAL, INC. PART V, SECTION B, LINE 19D: THE HOSPITAL DETERMINES THE AMOUNT CHARGED TO FAP-ELIGIBLE INDIVIDUALS USING AN INCOME-BASED SLIDING FEE BASED ON FEDERAL POVERTY GUIDELINES. IF THE INDIVIDUAL IS AT 100% OR LESS OF THE FEDERAL POVERTY GUIDELINES THEN THEY GENERALLY RECEIVE FREE CARE. IF THE INDIVIDUAL EARNS BETWEEN 100% AND 150% OF THE FEDERAL POVERTY GUIDELINES THEN THEY RECEIVE A DISCOUNTED PRICE BASED ON A SLIDING FEE SCALE. PART VI, LINE 2: THE ORGANIZATION ASSESSES THE NEEDS OF THE COMMUNITY THROUGH SURVEYS AND BY RECOGNIZING WHY CERTAIN PATIENTS ARE REFERRED OUT OF THE AREA. THE ORGANIZATION THEN ATTEMPTS TO GET SPECIALISTS IN THE IDENTIFIED AREAS INTO THE FACILITY TO SEE PATIENTS AND MEET THEIR NEEDS. THE ORGANIZATION IS ALSO WORKING WITH OTHER HEALTH CARE PROVIDERS IN BARRON COUNTY TO ASSESS AND ADDRESS COMMUNITY NEEDS. PART VI, LINE 3: IF A PATIENT IS IDENTIFIED AS UNINSURED, HOSPITAL STAFF WORKS WITH THE PATIENT OR THEIR FAMILY TO DETERMINE IF THEY ARE ELIGIBLE FOR ANY TYPE OF GOVERNMENT PROGRAM OR QUALIFY FOR THE HOSPITAL'S CHARITY CARE PROGRAM. PART VI, LINE 4: THE ORGANIZATION SERVES THE COMMUNITIES OF CUMBERLAND, WI AND ALMENA, WI AND SURROUNDING COMMUNITIES WITHIN A 20 MILE RADIUS. THERE ARE THREE OTHER HOSPITALS LOCATED IN THE RURAL AREA THAT THE ORGANIZATION SERVES. PART VI, LINE 5: A MAJORITY OF OUR ORGANIZATION'S GOVERNING BODY IS COMPRISED OF PERSONS WHO RESIDE IN THE ORGANIZATION'S PRIMARY SERVICE AREA WHO ARE NEITHER EMPLOYEES NOR CONTRACTORS OF THE ORGANIZATION, NOR FAMILY MEMBERS THEREOF. OUR ORGANIZATION EXTENDS MEDICAL STAFF PRIVILEGES TO ALL QUALIFIED PHYSICIANS IN ITS COMMUNITY FOR SOME OR ALL OF ITS DEPARTMENTS. WE ALSO PARTICIPATE IN COMMUNITY HEALTH FAIRS AND PROVIDE SERVICE AT SPORTING EVENTS. SURPLUS FUNDS ARE INVESTED BACK INTO THE FACILITY AND ITS EQUIPMENT TO ENSURE THE NEEDED SERVICES ARE CONTINUED TO BE PROVIDED IN THIS COMMUNITY. REPORTS FILED WITH STATES PART VI, LINE 7 WI X X X X 1 0 0 0 0 0 0 0 0 DEB KUNFERMAN 181145 0 50000 0 0 0 5442 0 2560 0 239147 0 0 0 DR CHARLES MAYO II 230844 0 0 0 0 0 9583 0 26871 0 267298 0 0 0 JEFFREY KUEHN 195011 0 0 0 0 0 7995 0 21402 0 224408 0 0 0 DONALD FULLERTON 182896 0 0 0 0 0 5693 0 25872 0 214461 0 0 0 LAURIE POLUBINSKY 253910 0 0 0 0 0 7683 0 10319 0 271912 0 0 0 PART I, LINE 4A DEB KUNFERMAN, CEO RESIGNED FROM THE ORGANIZATION IN FISCAL YEAR 2012 AND RECEIVED 90 DAYS SEVERANCE PAY IN CALENDAR YEAR 2012 TOTALING $44,636. THE SEVERANCE PAY IS NOT REFLECTED IN THE ABOVE COMPENSATION BECAUSE IT OCCURRED WITHIN OUR FISCAL YEAR BUT AFTER DECEMBER 31, 2011. CITY OF CUMBERLAND 396005423 230849FE6 2008-10-23 5166566 REMODELING PROJECT 0 0 0 1036566 5166566 517000 103400 2524863 2021303 2009 1 0 1 1 0 0 0 0 0.00000 0.00000 0.00000 1 0 0 0 0 0 0 FORM 990, PART VI, SECTION B, LINE 11 THE CHIEF FINANCIAL OFFICER REVIEWED THE RETURN. THE BOARD MEMBERS OF CUMBERLAND MEMORIAL HOSPITAL AND EXTENDED CARE UNIT, INC. WERE THEN GIVEN A COPY OF FORM 990 AND GIVEN AN OPPORTUNITY TO COMMENT BEFORE SUBMISSION TO THE IRS. FORM 990, PART VI, SECTION B, LINE 12C CUMBERLAND MEMORIAL HOSPITAL & EXTENDED CARE UNIT, INC. REQUIRES ITS BOARD MEMBERS TO SIGN A CONFLICT OF INTEREST STATEMENT ANNUALLY. OFFICERS AND KEY EMPLOYEES OF CUMBERLAND MEMORIAL HOSPITAL & EXTENDED CARE UNIT, INC. SIGN A CODE OF CONDUCT STATEMENT. IN THE CODE OF CONDUCT STATEMENT IT MENTIONS THE CONFLICT OF INTEREST. FORM 990, PART VI, SECTION B, LINE 15 EFFECTIVE JULY 1, 2008, WAGE SCALES WERE SET FOR ALL NON-UNION EMPLOYEES. THESE SCALES WOULD INCLUDE ALL HIGHLY COMPENSATED EMPLOYEES. THE SCALES WERE SET BASED ON AN AREA SURVEY OF 6 OTHER HEALTHCARE FACILITIES. IT WAS THE GOAL OF THE CUMBERLAND MEMORIAL HOSPITAL-EXTENDED CARE UNIT, INC. TO SET SCALES THAT RAN AT ABOUT THE MIDLEVEL OF ALL FACILITIES SURVEYED FOR MOST POSITIONS. THESE SCALES ARE EVALUATED ON A YEARLY BASIS USING THE SALARY SURVEY TOOL AVAILABLE THROUGH THE ST. CROIX VALLEY EMPLOYER'S ASSOCIATION. THE ONLY TIME AN EMPLOYEE HOURLY WAGE MAY EXIST OUTSIDE OF THE SCALE IS IF THE EMPLOYEE IS AT THE TOP OF THE SCALE YET THEIR MERIT INCREASE OF UP TO 1% FOR THE YEAR BRINGS THEM TO A WAGE OUTSIDE OF THE SCALE. THE CEO, OFFICERS AND KEY EMPLOYEE'S SALARY ARE APPROVED BY THE BOARD OF DIRECTORS (THOSE WITHOUT CONFLICT) ANNUALLY AND THE CEO APPROVES ALL OTHER EMPLOYEES' SALARIES ANNUALLY ALSO. DOCUMENTATION IS MAINTAINED IN PERSONNEL FILES. FORM 990, PART VI, SECTION C, LINE 18 CUMBERLAND MEMORIAL HOSPITAL & EXTENDED CARE UNIT, INC. MAKES ITS FORM 990 AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART VI, SECTION C, LINE 19 CUMBERLAND MEMORIAL HOSPITAL & EXTENDED CARE UNIT, INC. MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. OVERSIGHT OF THE AUDIT AND INDEPENDENT ACCOUNTANT FORM 990, PART XI, LINE 2C CUMBERLAND MEMORIAL HOSPITAL & EXTENDED CARE UNIT INC.'S ENTIRE BOARD OF DIRECTORS IS RESPONSIBLE FOR THE FINANCIAL STATEMENT AUDIT AND SELECTION OF THE INDEPENDENT ACCOUNTANT. THE AUDITED FINANCIAL STATEMENTS ARE REVIEWED BY THE BOARD OF DIRECTORS ANNUALLY AND ANY QUESTIONS OR CONCERNS REGARDING THE STATEMENTS ARE ADDRESSED BY THE INDEPENDENT ACCOUNTANTS. THIS PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR.