2012-05-14T09:17:28-05:00 2011-06-30 SEIM JOHNSON LLP 18081 BURT STREET SUITE 200 OMAHA NE 680224722 990 2010-07-01 420859940 BURGESS HEALTH CENTER BURG 7124232311 1600 DIAMOND STREET ONAWA IA 51040 FRANCIS TRAMP 7124232311 2012-05-07 1 JULIE M GERKEN 4023302660 2010 2016-02-24 21:20:13Z FRANCIS TRAMP 1600 DIAMOND STREET ONAWA IA 51040 25186392 0 X WWW.BURGESSHC.ORG X 1959 IA TO PROVIDE HEALTHCARE SERVICES TO THE COMMUNITY 11 11 288 80 2507672 -184918 157780 88969 24053101 24154199 151917 217129 72316 77116 24435114 24537413 0 0 0 0 10532447 11527730 0 0 0 12504750 12881633 23037197 24409363 1397917 128050 30161690 29560109 10183746 8928755 19977944 20631354 BURGESS HEALTH CENTER IS COMMITTED TO IMPROVE THE QUALITY OF LIFE FOR THE PEOPLE AND COMMUNITIES IT SERVES BY PROVIDING EXCELLENT HELTHCARE AND EXCEPTIONAL PATIENT EXPERIENCES. 0 0 17293779 19138856 PROVIDES HEALTHCARE SERVICES TO COMMUNITY. 2471343 2507672 OPERATING A RETAIL PHARMACY IN TOWNS THAT WOULD NOT OTHERWISE HAVE THESE HEALTH SERVICES. 19765122 1 1 0 0 0 0 0 0 0 1 0 0 0 0 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 0 0 0 0 0 0 0 1 1 0 0 0 1 74 0 1 288 1 1 1 0 0 0 0 0 0 0 0 0 X 11 11 0 0 0 0 1 0 1 1 1 0 0 1 1 1 1 1 1 1 0 0 IA X SHAWN GOSCH CFO 7124239213 1600 DIAMOND STREET ONAWA IA 51040 JIM WESTERGAARD 1.00 X X 0 0 0 TERRY FRAMKE 1.00 X X 0 0 0 STEVE PRATT 1.00 X X 0 0 0 PAUL DUDLEY MD 1.00 X 0 0 0 MARY BLACK 1.00 X 0 0 0 JOHN GARRED JR MD 1.00 X 0 0 0 NEAL GORHAM 1.00 X 0 0 0 MARI MILLER 1.00 X 0 0 0 TODD SADLER 1.00 X 0 0 0 CHARLES SEDERSTROM 1.00 X 0 0 0 JIM STANGEL 1.00 X 0 0 0 FRANCIS TRAMP 40.00 X 151288 0 14799 SHAWN GOSCH 40.00 X 93620 0 13681 PETER DAHER MD 40.00 X 291940 0 17604 MONTY MCKINVEN 40.00 X 251150 0 16816 JENNIFER SCHENNE 40.00 X 119581 0 2644 RICHARD HUTCHSON 40.00 X 210644 0 4546 SCOTT NORTH 40.00 X 110021 0 2858 1228244 0 72948 7 0 1 0 CPSI PO BOX 850309 MOBILE AL 366850309 COMPUTER SERVICES 379204 SHARED SERVICES SYSTEMS 1725 SO 20TH STREET OMAHA NE 68108 MRI SERVICES 309016 ST LUKES DEPARTMENT OF LAB SERVICES 2720 STONE PARK BLVD SIOUX CITY IA 51104 LAB SERVICES 213562 WASEEM ALOUNK MD 3003 NORTH 170TH STREET OMAHA NE 68116 ER PHYSICIAN 208397 SIEMENS HEALTHCARE DIAGNOSTICS PO BOX 121102 DALLAS TX 75312 LAB SERVICES 180512 15 21958 50165 16846 88969 PATIENT REVENUE 624100 12125115 12125115 MEDICARE/MEDICAID PAYM 624100 9229475 9229475 RETAIL PHARMACY 446110 2507672 2507672 MENTAL HEALTH APPR 624100 69984 69984 PHYSICAL THERAPY SERVI 624100 50551 50551 171402 171402 24154199 194082 194082 122472 45356 77116 77116 77116 614054 12616 603623 10431 12616 23047 23047 24537413 21646527 2507672 294245 273388 273388 9237415 7750316 1487099 134130 118418 15712 1208320 1042803 165517 674477 576744 97733 30500 30500 52224 52224 1981159 1527098 454061 40182 32961 7221 4552896 4030378 522518 308961 192164 116797 121423 91269 30154 363006 363006 1695075 858502 836573 108712 108712 RETAIL PHARMACY EXPENSE 2471343 2471343 BAD DEBT EXPENSE 849882 849882 MISCELLANEOUS EXPENSES 173007 30343 142664 DUES AND SUBSCRIPTIONS 75253 28626 46627 LICENSES AND TAXES 58010 55563 2447 24409363 19765122 4644241 0 3138901 970520 2421838 3314009 3978089 4023643 9827 77325 42110 873502 859079 255788 410726 26215994 11801005 14966483 14414989 4030896 5049019 9178 10022 399863 465992 30161690 29560109 1828005 1748755 7545000 7180000 810741 0 10183746 8928755 X 19977944 20631354 19977944 20631354 30161690 29560109 X 128050 525359 X X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 74842 74842 18223428 6367075 11856353 7409769 5066286 2343483 507955 367644 140311 14414989 24537413 24409363 128050 525359 525359 653409 25062773 525359 525359 24537414 0 24537414 24409363 0 24409363 0 24409363 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: 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, 2011, THE HEALTH CENTER AND FOUNDATION HAD NO UNCERTAIN TAX POSITIONS ACCRUED. 1 1 1 X 1 X 245.000000000000 1 1 1 0 1 1 350 381075 381075 0.01620 3447 1465180 931638 533542 0.02260 3797 1846255 931638 914617 0.03880 1809 16774 3265 13509 0.00060 11099 2612684 2231186 381498 0.01620 12908 2629458 2234451 395007 0.01680 16705 4475713 3166089 1309624 0.05560 1 512349 334903 6755551 9538094 -2782543 X 1 1 1 1 BURGESS HEALTH CENTER

1600 DIAMOND STREET ONAWA IA 61040

X X X X NOT APPLICABLE 1 4 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 BURGESS FAMILY CLINIC - MAPLE VALLEY

111 S 5TH STREET MAPLETON IA 51304

FAMILY MEDICAL CLINIC PART I, LINE 6A: THE REPORT IS PREPARED BY THE STAFF OF BURGESS HEALTH CENTER. PART I, LINE 7: BURGESS HEALTH CENTER USES LIONS 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, L7 COL(F): BAD DEBT EXPENSES EXCLUDED FROM CALCULATING PART I, LINE 7, COLUMN (F) IS $852,494. PART II: BURGESS HEALTH CENTER DID NOT REPORT ANY COMMUNITY BUILDING ACTIVITIES IN PART II OF SCHEDULE H. PART III, LINE 4: THE BAD DEBT EXPENSE IS THE NET OF THE TOTAL CHARGES WRITTEN OFF TO EXPENSE LESS THE TOTAL OF BAD DEBT RECOVERIES USING THE RATIO OF PATIENT CARE COST TO CHARGES. THE MAJORITY OF THE AMOUNTS WRITTEN OFF TO BAD DEBT SHOULD BE CLASSIFIED AS CHARITY CARE BUT THE PATIENTS WHO WOULD QUALIFY FOR IT DO NOT FILE THE PROPER DOCUMENTATION AND JUST LET IT GO TO BAD DEBT.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:NET PATIENT RECEIVABLES CONSIST OF UNCOLLATERALIZED PATIENT AND THIRD PARTY OBLIGATIONS REDUCED BY A VALUATION ALLOWANCE FOR DOUBTFUL ACCOUNTS AND CONTRACTUAL ADJUSTMENTS FROM THIRD PARTY PAYORS. THE ALLOWANCES REFLECT MANAGEMENT'S ESTIMATE OF AMOUNTS THAT WILL NOT BE COLLECTED IN THE FUTURE AND ARE BASED ON REVIEWS OF PATIENT BALANCES BY PAYOR CLASSES. PERCENTAGES ARE APPLIED TO EACH PAYOR CLASS BASED ON CONTRACTUAL AGREEMENTS AND HISTORICAL COLLECTION AND RECOVERY INFORMATION TO DETERMINE THE NET REALIZABLE VALUE OF THE PATIENT RECEIVABLES.PAYMENT FOR SERVICES IS EXPECTED WITHIN THIRTY DAYS OF RECEIPT OF THE BILLING. ACCOUNTS CONSIDERED PAST DUE ARE SENT TO COLLECTION AGENCIES WHEN INTERNAL COLLECTION EFFORTS HAVE BEEN UNSUCCESSFUL. ANY AMOUNTS DEEMED UNCOLLECTIBLE ARE WRITTEN OFF ON A MONTHLY BASIS. THE HEALTH CENTER DOES NOT CHARGE INTEREST ON OUTSTANDING BALANCES OWED.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 AS REVENUE.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. PART III, LINE 8: BURGESS HEALTH CENTER DOES NOT FEEL THAT A MEDICARE SHORTFALL SHOULD BE LISTED AS A COMMUNITY BENEFIT AT THIS TIME. THE AMOUNT REPORTED ON PART III, LINE 6 WAS TAKEN FROM THE MEDICARE COST REPORT FOR THE YEAR ENDED JUNE 30, 2011. 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 V, SECTION B: NOT REQUIRED IN THE CURRENT YEAR. PART VI, LINE 2: BURGESS HEALTH CENTER REVIEWS DATA FROM THE IOWA DEPARTMENT OF PUBLIC HEALTH. BURGESS HEALTH CENTER FOCUSES ON TOP ADMITS TO THE HOSPITAL AND REVIEWS THE AGGREGATE DATA FROM WELLNESS SCREENS. PART VI, LINE 3: PATIENTS' BILLS CONTAIN INFORMATION REGARDING THE HEALTH CENTER PROVIDING ASSISTANCE IF NEEDED AND GIVES CONTACT INFORMATION FOR 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 IN RECEIVING ASSISTANCE. PART VI, LINE 4: BURGESS HEALTH CENTER IS SITUATED IN MONONA COUNTY, IA. THE SERVICE AREA IS CONSIDERED RURAL SETTING WITH A POPULATION OF APPROXIMATELY 15,000. OF THIS POPULATION, 30% IS CONSIDERED ELDERLY WHICH IS ONE OF THE HIGHEST IF NOT THE HIGHEST % OF ELDERLY FOR ANY AREA IN THE STATE OF IOWA. THE SERVICE AREA RANKS LOW REGARDING THE MEDIAN HOUSEHOLD INCOME. THE IOWA MEDIAN HOUSEHOLD INCOME FOR 2010 WAS $48,031 WITH MONONA COUNTY HAVING A MEDIAN HOUSEHOLD INCOME OF $43,052 - NEARLY $5,000 LOWER. PART VI, LINE 6: PROMOTING THE HEALTH OF THE COMMUNITIES BURGESS HEALTH CENTER SERVES IS IMPORTANT TO THE 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 7: BURGESS HEALTH CENTER IS NOT PART OF AN AFFILIATED HEALTH CARE SYSTEM. REPORTS FILED WITH STATES PART VI, LINE 7 IA X X X 0 0 0 0 0 0 0 0 0 FRANCIS TRAMP 151288 0 0 0 0 0 3135 0 11664 0 166087 0 0 0 PETER DAHER MD 291940 0 0 0 0 0 5940 0 11664 0 309544 0 0 0 MONTY MCKINVEN 251150 0 0 0 0 0 5152 0 11664 0 267966 0 0 0 RICHARD HUTCHSON 210644 0 0 0 0 0 4307 0 239 0 215190 0 0 0 CITY OF ONAWA IOWA HOSPITAL REVENUE BONDS SERIES 2005 426005064 682293AV7 2005-06-08 9200000 BUILDING PROJECT 0 0 0 2020000 9441583 734789 27621 184000 8495173 2007 0 0 1 1 0 0 0 0 1 0.00000 0.00000 0.00000 1 0 0 0 0 1 1 FORM 990, PART VI, SECTION A, LINE 6 BURGESS HEALTH CENTER HAS MEMBERS. A PERSON MAY BECOME A MEMBER IF HE OR SHE IS AT THAT TIME A RESIDENT OF THE GEOGRAPHIC AREA SERVED BY THE CORPORATION AND THEN ONLY UPON COMPLETION OF A MEMBERSHIP REGISTRATION FORM AND PAYMENT OF A LIFE MEMBERSHIP OF $10. FORM 990, PART VI, SECTION A, LINE 7B THERE IS AN ANNUAL MEETING OF THE MEMBERS. AT THE ANNUAL 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 THE RELATED SCHEDULES ARE PRESENTED TO THE FINANCE COMMITTEE BY SHAWN GOSCH, CFO, AT THE FIRST SCHEDULED FINANCE COMMITTEE MEETING AFTER THE COMPLETION OF THE FORM 990. WITH THE EXTENSION, THE FORM 990 IS DUE MAY 15, 2012 AND WILL BE REVIEWED PRIOR TO SUBMISSION. 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 CONFILCT OF INTREST 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 IHA (IOWA HOSPITAL ASSOC.) 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. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED GAINS ON INVESTMENTS: 525,359. 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) 11B N/A 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 N/A 1 0 0 1 0 0 0 0 0 0 0 0 0 1 1 0 1 1 1 BURGESS FOUNDATION C 21958 BURGESS HEALTH CORP EMPLOYEE BENEFIT TRUST Q 1078164