2012-11-14T09:20:17-06:00 2011-12-31 990 2011-01-01 421487967 ST LUKE'SJONES REGIONAL MEDICAL CENTER STLU 3194626131 1795 HIGHWAY 64 EAST ANAMOSA IA 52205 ERIC BRIESEMEISTER 3194626131 2012-11-08 2011 2016-02-24 21:20:13Z JONES REGIONAL MEDICAL CENTER THEODORE E TOWNSEND JR 1795 HIGHWAY 64 EAST ANAMOSA IA 52205 25684419 0 X WWW.JONESREGIONAL.ORG X 1998 IA TO PROVIDE QUALITY SERVICES AND TO PROMOTE HEALTHY LIFESTYLES TO OUR CUSTOMERS. 9 4 184 39 0 0 44886 147630 16736391 19678786 296635 343494 48374 76857 17126286 20246767 6200 1525 0 0 7115660 7817828 0 0 0 7288460 7530067 14410320 15349420 2715966 4897347 27373014 31032719 10558076 9712000 16814938 21320719 X TO PROVIDE QUALITY SERVICES IN AN EFFICIENT, COST-EFFECTIVE MANNER AND TO PROMOTE HEALTHY LIFESTYLES TO OUR CUSTOMERS. 0 0 11406129 19885015 HEALTH-CARE SERVICESST. LUKE'S/JONES REGIONAL MEDICAL CENTER PROVIDES INPATIENT AND OUTPATIENT MEDICAL SERVICES TO TREAT INDIVIDUALS WITH DISEASES, ILLNESS AND INJURIES WITH VARYING COMPLEXITIES. IT PROVIDES SERVICES TO IMPROVE THE HEALTH OF PATIENTS AND TO BETTER THEIR QUALITY OF LIFE. ALL SERVICES ARE PROVIDED REGARDLESS OF AN INDIVIDUAL'S RACE, CREED, SEX, NATIONALITY, HANDICAP, AGE OR ABILITY TO COMPENSATE FOR SERVICES RENDERED. THESE INCLUDE, BUT ARE NOT LIMITED TO, GENERAL ACUTE CARE, SURGERIES, MENTAL HEALTH CARE, REHABILITATION, SKILLED NURSING, LABORATORY, PHARMACEUTICAL DRUGS, EMERGENCY SERVICES, OUTPATIENT CLINICS, AND RADIOLOGY. SOME OF THE SERVICES PROVIDED DO NOT GENERATE ENOUGH INCOME TO OFFSET THEIR COST. IN THE FISCAL PERIOD ENDED DECEMBER 31, 2011, ST. LUKE'S/JONES REGIONAL MEDICAL CENTER DISCHARGED 612 PATIENTS RESULTING IN A TOTAL OF 3,005 PATIENT DAYS. OUTPATIENT VISITS TOTALED 55,536 AND TOTAL OUTPATIENT SURGERY REGISTRATIONS FOR THE SAME PERIOD WERE 703. THERE WERE ALSO 8,016 EMERGENCY ROOM VISITS. 869920 1525 COMMUNITY BENEFIT, INCLUDING CHARITY CARECHARITY CARE AND MEANS-TESTED PROGRAMS: ST. LUKE'S/JONES REGIONAL MEDICAL CENTER PROVIDES CHARITY CARE AND OTHER MEANS-TESTED PROGRAMS WITH THE GOAL TO IMPROVE THE COMMUNITY'S OVERALL HEALTH AND ACCESS TO CARE. THIS INCLUDES HEALTH-CARE SERVICES REGARDLESS OF THE PATIENT'S INSURANCE COVERAGE OR FINANCIAL STATUS. CHARITY CARE AND PARTIAL TO FULL FINANCIAL ASSISTANCE IS PROVIDED TO PATIENTS ON A CASE-BY-CASE BASIS. CHARITY CARE WAS MADE AVAILABLE AT A VALUE OF $437,474 IN 2011. OFTENTIMES, ST. LUKE'S/JONES REGIONAL MEDICAL CENTER RECEIVES PAYMENTS FROM PAYORS OR PATIENTS THAT ARE LESS THAN IT CHARGES FOR SERVICES. ST. LUKE'S/JONES REGIONAL MEDICAL CENTER PARTICIPATES IN MEDICAID AND OTHER GOVERNMENT-SPONSORED HEALTH-CARE PROGRAMS. TOTAL CHARITY CARE AND MEANS-TESTED PROGRAMS REPORTED VALUE: $627,292. OTHER BENEFITS: ST. LUKE'S/JONES REGIONAL MEDICAL CENTER PROVIDES SEVERAL OTHER BENEFITS THAT ASSIST THE COMMUNITY. PROGRAMS INCLUDE, BUT ARE NOT LIMITED TO, COMMUNITY HEALTH IMPROVEMENT SERVICES AND COMMUNITY BENEFIT OPERATIONS SUCH AS PREVENTION AND HEALTH SCREENINGS; HEALTH PROFESSIONAL'S EDUCATION; SUBSIDIZED HEALTH SERVICES; RESEARCH, AND CASH AND IN-KIND CONTRIBUTIONS TO COMMUNITY GROUPS. ST. LUKE'S/JONES REGIONAL MEDICAL CENTER COLLABORATES WITH OTHER HOSPITALS, CHURCHES, SCHOOLS, CHAMBERS OF COMMERCE AND DAYCARE CENTERS TO IMPROVE COMMUNITY HEALTH AND EXPAND ACCESS TO HEALTH CARE. ST. LUKE'S/JONES REGIONAL MEDICAL CENTER HAS DEDICATED STAFF TO ASSIST COMMUNITY BENEFIT EFFORTS. TOTAL OTHER BENEFITS REPORTED VALUE: $242,628. 12276049 1 1 0 0 0 0 0 0 0 1 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 40 0 1 184 1 0 0 0 0 0 0 0 0 0 0 X 9 4 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 IA X X RACHEL VONBEHREN FISCAL SERVICES 3194816302 1795 HIGHWAY 64 EAST ANAMOSA IA 52205 MILTON AUNAN II 1.00 X X 0 366174 53717 ERIC BRIESEMEISTER 40.00 X X 0 102695 23547 VICTOR HAMRE 1.00 X X 0 0 0 JOHN HARMS 1.00 X 0 0 0 MICHELLE NIERMANN 40.00 X X 0 275318 47902 DOROTHY POSTEL TO 1211 1.00 X 0 0 0 JOHN SHEEHAN 1.00 X 0 459290 81146 THEODORE TOWNSEND JR 1.00 X X 0 607173 135676 JAY WILLEMS 1.00 X 0 0 0 VICTOR SALAS MD 40.00 X 302306 0 27906 CHARLES SCHAUBERGER MD 40.00 X 0 343571 16653 THOMAS SERBOUSEK MD 40.00 X 272313 0 25094 JENNY BUTLER MD 40.00 X 222274 0 14820 THOMAS DEVANEY 40.00 X 127893 0 16596 924786 2154221 443057 4 0 1 0 EAST CENTRAL IA ACUTE CARE LLP 1026 A AVE NE CEDAR RAPIDS IA 52402 ER DOCTOR SERVICES 629727 GRAPETREE MEDICAL STAFFING 703 16TH ST SPIRIT LAKE IA 51360 TRAVELING NURSES 192022 ALLIANCE HEALTHCARE SERVICES PO BOX 96485 CHICAGO IL 60693 MRI SERVICES 188300 PHILIPS MEDICAL CAPITAL PO BOX 92449 CLEVELAND OH 44193 IMAGING EQUIPMENT LEASE 114859 4 20182 127448 147630 NET PATIENT REVENUE 900099 17072895 17072895 PHARMACY REVENUE 446110 2388151 2388151 MISCELLANEOUS REVENUE 900099 127000 127000 MGMT & SUPPORT SVCS 561000 70815 70815 RENTAL REVENUE 531100 19925 19925 19678786 153676 153676 5623564 5433746 189818 189818 189818 9855 3906 5949 5949 CAFETERIA/FOOD SVCS 722210 54497 54497 SUBS & JOINT VENTURES 900099 13590 13590 MISCELLANEOUS REVENUE 900099 2821 2821 70908 20246767 19814200 0 284937 1525 1525 753861 753861 5586050 5549024 37026 113692 112938 754 945344 939078 6266 418881 416105 2776 10 10 18561 18561 3065576 2144509 921067 73822 14470 59352 1764815 1700700 64115 633694 633694 173476 173476 38920 24820 14100 39487 35643 3844 355142 355142 1119776 1119776 82277 82277 MISCELLANEOUS EXPENSE 164511 43985 120526 15349420 12276049 3073371 0 10280 4155882 4263578 3483715 1631943 2461849 24775 14807 198002 232280 40284 25814 16711719 2808865 14311430 13902854 6014438 5922296 878284 833222 27373014 31032719 1072073 1102995 135944 46765 2007827 1396524 7342232 7165716 10558076 9712000 X 15936654 20487497 878284 833222 16814938 21320719 27373014 31032719 X 4897347 -391566 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 6892721 -92142 45062 6755517 3068174 3533384 746263 455100 6892721 6061324 1425631 634751 5053532 3068174 3350789 3627901 -917366 6061324 0.87670 0.12330 0 1 1 297612 297612 12990802 1545798 11445004 3423305 1263067 2160238 13902854 DUE TO AFFILIATES 7165716 7165716 20246767 15349420 4897347 -346504 -45062 -391566 4505781 20170000 -346504 476699 130195 20039805 18531 188431 206962 20246767 15613000 369864 369864 15243136 18531 87753 106284 15349420 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: THE ORGANIZATION RETAINS FUNDS FOR INTENDED FUTURE USES, INCLUDING PURCHASE OF EQUIPMENT, INDIGENT CARE, FUNDING OF MISSION RELATED OPERATIONS, AND HEALTH EDUCATION. IN ADDITION, SOME FUNDS ARE HELD FOR INVESTMENT IN PERPETUITY. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: IOWA HEALTH SYSTEM AND MOST OF ITS SUBSIDIARIES ARE CLASSIFIED AS TAX-EXEMPT ORGANIZATIONS AS DESCRIBED IN SECTIONS 501(C)(3) AND 501(C)(2) OF THE INTERNAL REVENUE CODE (THE CODE). TAX-EXEMPT ORGANIZATIONS ARE NOT SUBJECT TO FEDERAL AND STATE INCOME TAXES ON RELATED INCOME, PURSUANT TO SECTION 501(A) OF THE CODE. THESE ORGANIZATIONS ARE SUBJECT TO FEDERAL AND STATE INCOME TAXES TO THE EXTENT THEY HAVE UNRELATED BUSINESS INCOME AS DESCRIBED UNDER PROVISIONS OF SECTION 511 OF THE CODE. THE HEALTH SYSTEM FILES FORM 990 FOR SUBSTANTIALLY ALL OF ITS OPERATING ENTITIES IN THE U.S. FEDERAL JURISDICTION AND IS NO LONGER SUBJECT TO EXAMINATION BY TAX AUTHORITIES FOR THE YEARS BEFORE 2008. THE HEALTH SYSTEM HAS NO MATERIAL UNCERTAIN TAX POSITIONS. CERTAIN SUBSIDIARIES ARE SUBJECT TO FEDERAL AND STATE INCOME TAXES. SOME OF THESE CORPORATIONS HAVE ACCUMULATED NET OPERATING LOSS CARRYFORWARDS THAT ARE AVAILABLE TO OFFSET FUTURE TAXABLE INCOME DURING THE CARRYFORWARD PERIOD. NO INCOME TAX BENEFIT HAS BEEN RECOGNIZED FOR THE NET OPERATING LOSS CARRYFORWARDS OR OTHER POTENTIAL DEFERRED TAX ASSETS IN THE CONSOLIDATED FINANCIAL STATEMENTS BECAUSE THE HEALTH SYSTEM BELIEVES REALIZATION OF THESE BENEFITS IS UNLIKELY. PART XI, LINE 8 - OTHER ADJUSTMENTS: CHANGE IN BENEFICIAL INTEREST OF JONES REGIONAL MEDICAL CENTER FOUNDATION -45,062. PART XII, LINE 2D - OTHER ADJUSTMENTS: EMLIMINATE SUBSIDIARY (AAAS) 472,793. SPECIAL EVENT EXPENSES 3,906. PART XII, LINE 4B - OTHER ADJUSTMENTS: REVENUE IN UNRESTRICTED FUND BALANCE 100,000. EXPENSE REIMBURSEMENTS/REVENUE OFFSETS 70,815. IOWA HEALTH SYSTEM CONTRACTING SERVICES PURCAHSE REBATE 13,590. ELMINATING ENTRIES 3,348. ROUNDING 678. PART XIII, LINE 2D - OTHER ADJUSTMENTS: ELIMINATE SUBSIDIARY (AAAS) 365,047. ROUNDING 911. SPECIAL EVENT EXPENSES 3,906. PART XIII, LINE 4B - OTHER ADJUSTMENTS: ELIMINATE ENTRIES 3,348. EXPENSE REIMBURSEMENTS/REVENUE OFFSETS 70,815. IOWA HEALTH SYSTEM CONTRACTING SERVICES PURCAHSE REBATE 13,590. 1 1 X 1 X 1 X 1 1 1 0 1 1 2256 437474 437474 0.02850 343093 153275 189818 0.01240 2256 780567 153275 627292 0.04090 55992 100448 23422 77026 0.00500 201 7421 7421 0.00050 558097 399916 158181 0.01030 56193 665966 423338 242628 0.01580 58449 1446533 576613 869920 0.05670 743 24917 1093 23824 0.00160 45 411 411 0.00000 56 263 263 0.00000 844 25591 1093 24498 0.00160 0 256248 X 1 1 1 1 JONES REGIONAL MEDICAL CENTER

1795 HIGHWAY 64 EAST SUITE 2 ANAMOSA IA 52205

X X X X ST LUKE'SJONES REGIONAL MEDICAL CENTER 1 0 1 1 200.000000000000 1 400.000000000000 1 X X X 1 1 X X X 1 X X X X 1 X X X X X X X 1 X 0 1 PART I, LINE 6A: ST. LUKE'S/JONES REGIONAL MEDICAL CENTER'S COMMUNITY BENEFIT REPORT IS CONTAINED WITHIN THE IOWA HEALTH SYSTEM COMMUNITY BENEFIT REPORT WHICH CAN BE LOCATED AT WWW.IHS.ORG. THIS SYSTEM-WIDE REPORT IS COMPLETED IN ADDITION TO THE COMMUNITY BENEFIT REPORT FOR THE HOSPITAL AND ITS REGIONAL AFFILIATES. PART I, LINE 7: A COST-TO-CHARGE RATIO (FROM WORKSHEET 2) IS USED TO CALCULATE THE AMOUNTS ON LINE 7A. THE AMOUNTS ON LINES 7B-7C (UNREIMBURSED MEDICAID AND OTHER MEANS-TESTED GOVERNMENT PROGRAMS) ARE OBTAINED FROM A COST ACCOUNTING SYSTEM OF APPLICABLE PATIENT SEGMENTS. SEGMENTS NOT PASSED TO COST ACCOUNTING SYSTEM USE COST-TO-CHARGE RATIO. THE AMOUNTS FOR LINES 7E, F, H, AND I WOULD COME FROM THE BOOKS AND RECORDS OF SPECIFIC SEGMENTS OF THE ORGANIZATION AND ARE BASED ON COST. THE AMOUNTS ON 7G ARE DERIVED FROM A COST ACCOUNTING SYSTEM OF APPLICABLE PATIENT SEGMENTS. SEGMENTS NOT PASSED TO A COST ACCOUNTING SYSTEM USE THE COST-TO-CHARGE RATIO. PART II: COMMUNITY BUILDING ACTIVITIES ARE ESSENTIAL ROLES FOR HEALTH-CARE ORGANIZATIONS IN THAT THEY ADDRESS MANY OF THE UNDERLYING DETERMINANTS OF HEALTH. RESEARCH HAS CONTINUALLY SHOWN THAT WHEN THE FACTORS INFLUENCING HEALTH ARE EXPLORED, HEALTH CARE ACTUALLY PLAYS THE SMALLEST ROLE PROPORTIONATELY. A REPORT IN THE JOURNAL OF AMERICAN MEDICAL ASSOCIATION AND THE CENTER FOR DISEASE CONTROL (MCGINNIS, 1996) SUGGESTS THAT THE FACTORS IMPACTING HEALTH ARE AS FOLLOWS: LIFESTYLE AND BEHAVIORS, 50%, ENVIRONMENT (HUMAN AND NATURAL), 20%, GENETICS AND HUMAN BIOLOGY, 20%, AND HEALTH CARE, 10%. COMMUNITY BUILDING ACTIVITIES HELP TO ADDRESS THE OTHER INDICATORS OUTSIDE OF THE ROLE TRADITIONALLY PLAYED BY HEALTH-CARE ORGANIZATIONS. THESE ACTIVITIES ARE ALMOST EXCLUSIVELY DONE IN SOME FORM OF PARTNERSHIP IN WHICH THE COMMUNITY OR OTHER ORGANIZATIONS ARE BETTER SUITED TO ADDRESS. HEALTH-CARE ORGANIZATIONS GENERALLY PROVIDE TIMELY AND SPECIFIC RESOURCES TO HELP THESE ISSUES. HEALTH-CARE ORGANIZATIONS CAN BE A RICH AND VALUABLE COMMUNITY RESOURCE IN WAYS NOT TYPICALLY CONSIDERED. OFTEN THE MOST EFFECTIVE WAY TO HELP IMPACT AND IMPROVE THE COMMUNITY HEALTH STATUS IS TO SUPPORT OTHER AGENCIES AND ORGANIZATIONS IN A VARIETY OF WAYS OUTSIDE OF HEALTH SERVICES. THIS IS OFTEN DONE THROUGH CASH OR IN-KIND SERVICES TO SUPPORT OTHER NON-PROFITS, DONATIONS OF DURABLE MEDICAL EQUIPMENT AND SUPPLIES TO CERTAIN AGENCIES, OR THROUGH LEADERSHIP AND EDUCATIONAL EXPERTISE. THESE TYPES OF ACTIVITIES SPEAK TO THE BREADTH AND CAPACITY THAT THE HOSPITAL HAS IN IMPACTING THE HEALTH STATUS OF THE COMMUNITY IN A COMPREHENSIVE AND INTENTIONAL APPROACH. PART III, LINE 4: THE HEALTH SYSTEM PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS BASED UPON A REVIEW OF OUTSTANDING RECEIVABLES, HISTORICAL COLLECTION INFORMATION AND EXISTING ECONOMIC CONDITIONS. AS A SERVICE TO THE PATIENT, THE HEALTH SYSTEM BILLS THIRD-PARTY PAYERS DIRECTLY AND BILLS THE PATIENT WHEN THE PATIENT'S LIABILITY IS DETERMINED. PATIENT ACCOUNTS RECEIVABLE ARE DUE IN FULL WHEN BILLED. ACCOUNTS ARE CONSIDERED DELINQUENT AND SUBSEQUENTLY WRITTEN OFF AS BAD DEBTS BASED ON INDIVIDUAL CREDIT EVALUATION AND SPECIFIC CIRCUMSTANCES OF THE ACCOUNT.THE AMOUNT REPORTED ON LINE 2 WAS CALCULATED USING IRS WORKSHEET 2 'RATIO OF PATIENT CARE COST TO CHARGES' TO CALCULATE THE COST TO CHARGE RATIO FOR ST. LUKE'S JONES REGIONAL MEDICAL CENETER. THIS RATIO WAS THEN APPLIED AGAINST THE BAD DEBT ATTRIBUTABLE TO PATIENT ACCOUNTS USING IRS WORKSHEET A TO ARRIVE AT THE BAD DEBT EXPENSE AT COST REPORTED ON LINE 2. PART III, LINE 9B: AFTER THE PATIENT MEETS THE QUALIFICATIONS FOR FINANCIAL ASSISTANCE, THE ACCOUNT BALANCE IS PARTIALLY OR ENTIRELY WRITTEN OFF, AS APPROPRIATE. ANY REMAINING BALANCE, IF ANY, WOULD BE COLLECTED UNDER THE NORMAL DEBT COLLECTION POLICY. ST. LUKE'S/JONES REGIONAL MEDICAL CENTER PART V, SECTION B, LINE 15E: GUARANTORS RECEIVE A CYCLE BILL EERY 30 DAYS FOR THE LIFE OF THE ACCOUNT ON A/R. ON DAY 41, 11 DAYS AFTER THE SECOND BILLING CYCLE, A FIRST COLLECTION ATTEMPT IS MADE FROM THE TELEVOX DIALER. THE SECOND COLLECTION ATTEMPT IS MADE BY THE DIALER ON DAY 71, 11 DAYS AFTER THE THIRD AND FINAL BILLING CYCLE. THE THIRD COLLECTION ATTEMPT IS MADE BY THE DIALER ON DAY 87, E DAYS BEFORE THE ACCOUNT IS REVIEWED FOR COLLECTIONS. ACCOUNTS WITH SATISFACTORY PAYMENTS OR PREARRANGED PAYMENT ARRANGEMENTS THAT ARE CURRENT ARE NOT SENT TO THE DIALER. ACCOUNTS WITH A MENTAL HEALTH DIAGNOSIS, WORKERS COMPENSATION ACCOUNTS, ACCOUNTS WITH SKILLED NURSING FACILITIES, AND ACCOUNTS WITH NO PHONE NUMBER ARE ALSO NOT SENT TO THE DIALER. THESE ACCOUNTS ARE ON A MANUAL LIST WHICH THE COLLECTION TEAM REVIEWS AND MAKES CALLS MANUALLY AS DEEMED APPROPRIATE. WHEN THE ACCOUNTS ARE GREATER THAN OR EQUAL TO $5,000, THE COLLECTION TEAM WILL SEND A FINANCIAL ASSISTANCE APPLICATION IF THEY CANNOT MAKE CONTACT WITH THE GUARANTOR AND 10 BUSINESS DAYS LATER, A PAST LETTER. THEY WILL ALSO CHECK FOR MEDICAID ELIGIBILITY FOR THEIR STATE OF RESIDENCE. ST. LUKE'S/JONES REGIONAL MEDICAL CENTER PART V, SECTION B, LINE 19D: IF THE INDIVIDUAL APPLIES AND QUALIFIES FOR FINANCIAL ASSISTANCE UNDER THE FACILITY'S FINANCIAL ASSISTANCE POLICY, THE HOSPITAL FACILITY USES THE AVERAGE OF THE THREE LOWEST NEGOTIATED COMMERCIAL INSURANCE RATES FOR THOSE SERVICES AT THE HOSPITAL FACILITY TO DETERMINE THE AMOUNTS BILLED FOR ALL SERVICES, INCLUDING EMERGENCY OR MEDICALLY NECESSARY CARE. THIS OCCURS REGARDLESS WHETHER THE INDIVIDUAL HAS INSURANCE COVERAGE. ALSO, IF THE INDIVIDUAL HAS INSURANCE COVERAGE AND DOES NOT APPLY OR QUALIFY FOR FINANCIAL ASSISTANCE UNDER THE FACILITY'S FINANCIAL ASSISTANCE POLICY, THE HOSPITAL FACILITY USES THE INSURER'S NEGOTIATED RATE FOR THOSE SERVICES AT THE HOSPITAL FACILITY. HOWEVER, IF THE INDIVIDUAL DOES NOT HAVE INSURANCE COVERAGE AND EITHER DOES NOT APPLY OR DOES NOT QUALIFY FOR FINANCIAL ASSISTANCE UNDER THE FACILITY'S FINANCIAL ASSISTANCE POLICY, THE HOSPITAL FACILITY USES THE GROSS RATES FOR THOSE SERVICES TO DETERMINE THE AMOUNTS BILLED. IF THE UNINSURED INDIVIDUAL AGREES TO PAY THE BILL IN FULL, THE HOSPITAL FACILITY WILL PROVIDE A 20%-30% DISCOUNT FROM THE GROSS RATES FOR THOSE INDIVIDUALS. THE PERCENTAGE OF GROSS CHARGES ON SELF-PAY ACCOUNTS WITH NO DISCOUNT FOR 2011 WAS 2.2%. ST. LUKE'S/JONES REGIONAL MEDICAL CENTER PART V, SECTION B, LINE 21: AS DESCRIBED IN SCHEDULE H, PART V, LINE 19, IF THE PATIENT DOES NOT APPLY OR QUALIFY FOR FINANCIAL ASSISTANCE AND ALSO IS UNINSURED OR RECEIVES NO BENEFIT FROM THEIR INSURANCE ON A SERVICE PROVIDED BY THE HOSPITAL FACILITY, THEY WOULD BE CHARGED AMOUNTS EQUAL TO GROSS CHARGES FOR THE SERVICES PROVIDED TO THE PATIENT. HOWEVER, IF THE PATIENT AGREES TO PAY IN FULL, THEY WILL RECEIVE A 20%-30% DISCOUNT FROM THE GROSS CHARGES. THE PERCENTAGE OF GROSS CHARGES ON SELF-PAY ACCOUNTS WITH NO DISCOUNT FOR 2011 WAS 2.2%. PART VI, LINE 2: ST. LUKE'S/JONES REGIONAL MEDICAL CENTER CONTINUALLYMONITORS COMMUNITY NEEDS SPECIFIC TO ITS SERVICE LINES AND THE RESOURCES IT CAN LEVERAGE TO ADDRESS THEM. INDIVIDUAL DEPARTMENTS WORK TO IDENTIFY SPECIFIC NEEDS RELATED TO THEIR SERVICES AND THE POPULATION THEY IMPACT. ALSO, MANY STAFF MEMBERS SERVE ON COMMITTEES OR BOARDS FOR ORGANIZATIONSIN THE COUNTY AND GATHER FEEDBACK FOR HEALTH NEEDS THROUGH THOSE RELATIONSHIPS. IN ADDITION, STAFF MEMBERS PRESENT TO MANY COMMUNITY GROUPS THROUGHOUT THE YEAR AND RECEIVE FEEDBACK ON HEALTH NEEDS THROUGH THESE VENUES. PART VI, LINE 3: ST. LUKE'S JONES REGIONAL MEDICAL CENTER PERFORMS THE FOLLOWING ACTIVITIES TO COMMUNICATE THE AVAILABILITY OF CHARITY CARE AND FINANCIAL ASSISTANCE TO ALL PATIENTS: 1) PLACES SIGNAGE, INFORMATION, AND/OR BROCHURES IN APPROPRIATE AREAS OF THE PROVIDER (E.G., THE EMERGENCY DEPARTMENT, AND REGISTRATION AND CHECK-OUT/CASHIER AREAS) STATING THE PROVIDER/PHYSICIAN PRACTICE OFFERS CHARITY CARE AND DESCRIBES HOW TO OBTAIN MORE INFORMATION ABOUT FINANCIAL ASSISTANCE, 2) PLACES A NOTE ON THE HEALTH-CARE BILL AND STATEMENTS REGARDING HOW TO REQUEST INFORMATION ABOUT FINANCIAL ASSISTANCE, 3) DESIGNATES INDIVIDUALS WHO CAN EXPLAIN THE PROVIDER'S CHARITY CARE POLICY, AND 4) INSTRUCTS STAFF WHO INTERACT WITH PATIENTS TO DIRECT QUESTIONS REGARDING THE CHARITY CARE POLICY TO THE PROPER PROVIDER REPRESENTATIVE. PART VI, LINE 4: ST. LUKE'S JONES REGIONAL MEDICAL CENTER IS A 22-BED COMMUNITY HOSPITAL SERVING EAST CENTRAL IOWA. ST. LUKE'S JONES REGIONAL MEDICAL CENTER IS NONDENOMINATIONAL AND SERVES ALL WHO COME HERE, REGARDLESS OF REASON OR CIRCUMSTANCE.80% OF ST. LUKE'S JONES REGIONAL MEDICAL CENTER MARKET RESIDENTS LIVE WITHIN THE IOWA COUNTIES OF JONES. ST. LUKE'S JONES REGIONAL MEDICAL CENTER ADMITS APPROXIMATELY 600 INPATIENTS AND CARES FOR 8,000 EMERGENCY PATIENTS PER YEAR. MEDIAN HOUSEHOLD INCOMES RANGE FROM $21,000 TO $47,955 AND THE AVERAGE POVERTY RATE IS 8%. 91% OF ST. LUKE'S JONES REGIONAL MEDICAL CENTER INPATIENTS ARE ELIGIBLE FOR MEDICARE OR MEDICAID. ST. LUKE'S JONES REGIONAL DEMOGRAPIC REGION IS COMPRISED OF 96% CAUCASION, 2% AFRICAN AMERICAN AND 2% HISPANIC. PART VI, LINE 5: THE HOSPITAL IS ORGANIZED AND OPERATED EXCLUSIVELY FOR CHARITABLE PURPOSES WITH THE GOAL OF PROMOTING THE HEALTH OF THE COMMUNITIES IT SERVES. THE HOSPITAL SUPPORTS THIS MISSION WITH A COMMUNITY BOARD, OPEN MEDICAL STAFF, AND AN EMERGENCY ROOM AVAILABLE TO PATIENTS REGARDLESS OF ABILITY TO PAY. THE BOARD OF DIRECTORS OF THE HOSPITAL IS COMPOSED OF CIVIC LEADERS WHO RESIDE IN THE SERVICE AREA OF THE HOSPITAL. THE BOARD ACTIVELY DEBATES AND SETS POLICY AND STRATEGIC DIRECTION FOR THE HOSPITAL BUT DOES NOT GET INVOLVED IN ISSUES RELATED TO THE DIRECT OPERATIONS OF THE HOSPITAL. THE BOARD TAKES A BALANCED APPROACH WHEN ADDRESSING COMMUNITY AND BUSINESS/FINANCIAL CONCERNS. THE BOARD IS ALSO THE PRIMARY GROUP FOR DETERMINING THE USE OF HOSPITAL SURPLUS FUNDS, WHICH ARE ALL USED TO FURTHER OUR CHARITABLE PURPOSE. PART VI, LINE 6: THE HOSPITAL IS PART OF IOWA HEALTH SYSTEM. INITIALLY FORMED IN 1995, IOWA HEALTH SYSTEM IS THE STATE'S FIRST AND LARGEST INTEGRATED HEALTH SYSTEM, SERVING NEARLY ONE OF EVERY THREE PATIENTS IN IOWA. THROUGH RELATIONSHIPS WITH 26 HOSPITALS IN METROPOLITAN AND RURAL COMMUNITIES AND MORE THAN 140 PHYSICIAN CLINICS, IOWA HEALTH SYSTEM PROVIDES CARE THROUGHOUT IOWA AND WESTERN ILLINOIS.IOWA HEALTH SYSTEM ENTITIES EMPLOY THE STATE'S LARGEST NONPROFIT WORKFORCE, WITH NEARLY 20,000 EMPLOYEES WORKING TOWARD INNOVATIVE ADVANCEMENTS TO DELIVER THE BEST OUTCOME FOR EVERY PATIENT EVERY TIME. EACH YEAR, THROUGH MORE THAN 2.5 MILLION PATIENT VISITS, IOWA HEALTH SYSTEM HOSPITALS AND CLINICS PROVIDE A FULL RANGE OF CARE TO PATIENTS AND FAMILIES. WITH ANNUAL REVENUES OF $2 BILLION, IOWA HEALTH SYSTEM IS THE SIXTH LARGEST NONDENOMINATIONAL HEALTH SYSTEM IN AMERICA AND PROVIDES COMMUNITY BENEFIT PROGRAMS AND SERVICES TO IMPROVE THE HEALTH OF PEOPLE IN ITS COMMUNITIES. IOWA HEALTH SYSTEM AND ITS AFFILIATES ENGAGE IN COMMUNITY HEALTH PROGRAMS AND SERVICES THROUGHOUT IOWA, AND WORK WITH VOLUNTEER AND CIVIC ORGANIZATIONS, SCHOOLS, BUSINESSES, INSURERS AND INDIVIDUALS TO SUPPORT ACTIVITIES THAT BENEFIT PEOPLE THROUGHOUT THE STATE. IN 2009, IOWA HEALTH SYSTEM AND ITS AFFILIATES PROVIDED MORE THAN $128 MILLION OF COMMUNITY BENEFIT. THE CONTRIBUTIONS TO THEIR COMMUNITIES BY IOWA HEALTH SYSTEM AND ITS AFFILIATES ARE REPORTED IN DETAIL IN STATEMENT OF PROGRAM SERVICE ACCOMPLISHMENTS (PART III) OF THE IRS FORM 990 OF THOSE AFFILIATES. REPORTS FILED WITH STATES PART VI, LINE 7 IA X X X X X 1 1 0 0 0 0 0 0 0 MILTON AUNAN II 0 258850 0 75067 0 32257 0 42716 0 11001 0 419891 0 0 MICHELLE NIERMANN 0 203181 0 55812 0 16325 0 26867 0 21035 0 323220 0 0 JOHN SHEEHAN 0 330891 0 87698 0 40701 0 57731 0 23415 0 540436 0 0 THEODORE TOWNSEND JR 0 413881 0 127527 0 65765 0 112089 0 23587 0 742849 0 0 VICTOR SALAS MD 302206 0 0 0 100 0 8868 0 19038 0 330212 0 0 0 CHARLES SCHAUBERGER MD 0 133769 0 83380 0 126422 0 9057 0 7596 0 360224 0 0 THOMAS SERBOUSEK MD 272203 0 0 0 110 0 8556 0 16538 0 297407 0 0 0 JENNY BUTLER MD 222174 0 0 0 100 0 6750 0 8070 0 237094 0 0 0 PART I, LINES 4A-B THE FOLLOWING INDIVIDUAL RECEIVED SEVERANCE PAYMENTS DURING THE YEAR THAT WERE INCLUDED IN TAXABLE INCOME: CHARLES SCHAUBERGER $100,117. THE FOLLOWING INDIVIDUALS PARTICIPATED IN A NON-QUALIFIED RETIREMENT PLAN WITH THE FOLLOWING CHANGES TO THEIR ACCOUNTS: MILTON AUNAN II $30,466, MICHELLE NIERMANN $15,746, JOHN SHEEHAN $45,463, AND THEODORE TOWNSEND, JR. $99,035. FORM 990, PART VI, SECTION A, LINE 6 ST. LUKE'S HEALTHCARE, A TAX-EXEMPT IOWA NONPROFIT CORPORATION, IS THE SOLE MEMBER. FORM 990, PART VI, SECTION A, LINE 7A ST. LUKE'S HEALTHCARE CAN APPOINT FIVE BOARD MEMBERS. FORM 990, PART VI, SECTION A, LINE 7B ST. LUKE'S HEALTHCARE, AS SOLE MEMBER SHALL APPROVE ARTICLE AND BYLAW AMENDMENTS, DISSOLUTIONS, APPOINT FIVE BOARD MEMBERS AND APPROVE APPOINTMENT OF PRESIDENT. FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 IS PREPARED INTERNALLY BY THE IOWA HEALTH SYSTEM TAX DEPARTMENT USING INFORMATION GATHERED FROM VARIOUS FUNCTIONAL AREAS OF THE ORGANIZATION. EACH SECTION OF THE RETURN IS REVIEWED BY THE RESPONSIBLE FUNCTIONAL AREA ALONG WITH THE TAX DEPARTMENT. A DRAFT COPY OF THE RETURN IS PROVIDED TO THE CFO FOR REVIEW. A FULL COPY OF THE FORM 990 IS PROVIDED TO THE BOARD OF DIRECTORS PRIOR TO FILING WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C THE ORGANIZATION HAS A CONFLICT OF INTEREST POLICY. ANNUALLY ALL OFFICERS, DIRECTORS, KEY EMPLOYEES AND REPORTING PHYSICIANS ARE REQUESTED TO COMPLETE A QUESTIONNAIRE TO REPORT POTENTIAL CONFLICTS OF INTEREST. PERSONS WHO HAVE NOT RETURNED QUESTIONNAIRES ARE CONTACTED ADDITIONAL TIMES IN AN EFFORT TO RECEIVE COMPLETE AND ACCURATE RESPONSES FROM ALL PERSONS. THE ANNUAL QUESTIONNAIRES INCLUDE AN ACKNOWLEDGEMENT THAT THE OFFICER, DIRECTOR, KEY EMPLOYEE OR REPORTING PHYSICIAN: 1) HAS ACCESS TO A COPY OF THE CONFLICT OF INTEREST POLICY; 2) HAS READ AND UNDERSTANDS THE POLICY; 3) AGREES TO COMPLY WITH THE POLICY; 4) UNDERSTANDS THAT THE POLICY APPLIES TO ALL COMMITTEES AND SUBCOMMITTEES HAVING BOARD-DELEGATED POWERS; AND 5) UNDERSTANDS THAT THE ORGANIZATION IS A CHARITABLE ORGANIZATION AND THAT IN ORDER TO MAINTAIN ITS TAX-EXEMPT STATUS, IT MUST CONTINUOUSLY ENGAGE PRIMARILY IN ACTIVITIES WHICH ACCOMPLISH ONE OR MORE OF ITS TAX-EXEMPT PURPOSES. SENIOR ADMINISTRATIVE STAFF AT ALL RELATED ORGANIZATIONS PROVIDE INFORMATION TO A CENTRAL COORDINATOR RELATED TO THE IDENTIFICATION OF WHICH INDIVIDUALS SHOULD RECEIVE THE QUESTIONNAIRE FOR COMPLETION. THE RESULTS ARE COMPILED CENTRALLY AND REVIEWED BY THE IOWA HEALTH SYSTEM COMPLIANCE OFFICER AND DIRECTOR OF INTERNAL AUDIT. THE DETAIL RESULTS ARE REPORTED TO A COMMITTEE OF THE SYSTEM BOARD. THE RESULTS RELATED TO SPECIFIC REGIONAL PARENT COMPANIES, THEIR HOSPITALS AND RELATED ORGANIZATIONS, ARE DISTRIBUTED IN DETAIL TO THE CHAIRPERSON OF THE REGIONAL PARENT ORGANIZATION, THE CHIEF EXECUTIVE OFFICER, CHIEF FINANCIAL OFFICER AND COMPLIANCE MANAGER. THESE INDIVIDUALS ARE ALSO REMINDED OF THE APPROPRIATE PROCESS TO BE FOLLOWED DURING THE YEAR TO ADDRESS POTENTIAL CONFLICTS OF INTEREST THAT RELATE TO MATTERS THAT ARE BROUGHT TO THE BOARD OF DIRECTORS FOR ACTION. THE INFORMATION DISCLOSED IS USED TO IDENTIFY POTENTIAL CONFLICTS OF INTEREST AND TO ASSIST IN COMPLETING IRS AND MEDICAID QUESTIONNAIRES. ANY DUALITY OF INTEREST OR POSSIBLE CONFLICT OF INTEREST ON THE PART OF ANY ORGANIZATIONAL OFFICER, DIRECTOR, KEY EMPLOYEE OR REPORTING PHYSICIAN TOGETHER WITH ALL MATERIAL FACTS, SHOULD BE DISCLOSED TO THE BOARD OF DIRECTORS AND MADE A MATTER OF RECORD, EITHER THROUGH AN ANNUAL PROCEDURE OR WHEN THE INTEREST OCCURS OR BECOMES A MATTER OF BOARD ACTION. ANY ORGANIZATIONAL OFFICER, DIRECTOR, KEY EMPLOYEE OR REPORTING PHYSICIAN HAVING A CONFLICT OF INTEREST IN ANY MATTER SHOULD NOT BE PRESENT DURING GENERAL DISCUSSION NOR VOTE OR USE HIS OR HER PERSONAL INFLUENCE ON THE MATTER, AND HE OR SHE SHOULD NOT BE COUNTED IN DETERMINING THE EXISTENCE OF A QUORUM FOR PURPOSES OF THE MATTER OR ITEM AS TO WHICH A CONFLICT EXISTS. THE BOARD SHOULD EXCLUDE THE INDIVIDUAL FROM ANY DISCUSSION OR VOTE IN WHICH THE BOARD DECIDES WHETHER OR NOT A CONFLICT OF INTEREST EXISTS. IN CASES IN WHICH AN OFFICER, DIRECTOR, KEY EMPLOYEE, REPORTING PHYSICIAN OR THE INDIVIDUAL'S HOUSEHOLD MEMBER HAS A CONFLICT OF INTEREST IN AN ARRANGEMENT OR TRANSACTION, THE FOLLOWING ADDITIONAL STEPS MAY BE TAKEN AT THE DIRECTION OF THE BOARD OF DIRECTORS: 1) AFTER DISCLOSURE OF THE FINANCIAL INTEREST AND ALL MATERIAL FACTS, AND AFTER ANY DISCUSSION WITH THE INTERESTED PERSON, HE OR SHE SHALL LEAVE THE BOARD OR COMMITTEE MEETING WHILE THE DETERMINATION OF A CONFLICT OF INTEREST IS DISCUSSED AND VOTED UPON. THE REMAINING BOARD OR COMMITTEE MEMBERS SHALL 1) DECIDE IF A CONFLICT OF INTEREST EXISTS, 2) A DISINTERESTED PERSON OR COMMITTEE MAY BE APPOINTED TO INVESTIGATE ALTERNATIVES TO THE PROPOSED ARRANGEMENT OR TRANSACTION; 3) IN ORDER TO APPROVE THE ARRANGEMENT OR TRANSACTION, THE BOARD MUST FIRST FIND, BY MAJORITY VOTE OF DISINTERESTED MEMBERS, THAT THE ARRANGEMENT OR TRANSACTION IS IN THE ORGANIZATION'S BEST INTEREST, IS FAIR AND REASONABLE TO THE ORGANIZATION, AND, AFTER REASONABLE INVESTIGATION, THE DISINTERESTED MEMBERS HAVE DETERMINED THAT A MORE ADVANTAGEOUS TRANSACTION OR ARRANGEMENT CANNOT BE OBTAINED WITH REASONABLE EFFORTS UNDER THE CIRCUMSTANCES; THE MINUTES OF THE BOARD AND ALL COMMITTEES WITH BOARD-DELEGATED POWERS SHALL CONTAIN: 1) THE NAMES OF THE PERSONS WHO DISCLOSED OR OTHERWISE WERE FOUND TO HAVE A FINANCIAL INTEREST IN CONNECTION WITH AN ACTUAL OR POSSIBLE CONFLICT OF INTEREST, THE NATURE OF THE FINANCIAL INTEREST, ANY ACTION TAKEN TO DETERMINE WHETHER A CONFLICT OF INTEREST WAS PRESENT, AND THE BOARD'S OR COMMITTEE'S DECISION AS TO WHETHER A CONFLICT OF INTEREST IN FACT EXISTED; 2) THE NAMES OF THE PERSONS WHO WERE PRESENT FOR DISCUSSIONS AND VOTES RELATING TO THE TRANSACTION OR ARRANGEMENT, THE CONTENT OF THE DISCUSSION, INCLUDING ANY ALTERNATIVES TO THE PROPOSED TRANSACTION OR ARRANGEMENT, AND A RECORD OF ANY VOTES TAKEN IN CONNECTION THEREWITH; IN ORDER TO PROTECT THE ORGANIZATION'S BEST INTERESTS, APPROPRIATE DISCIPLINARY ACTION MAY BE TAKEN WITH RESPECT TO AN OFFICER, DIRECTOR, KEY EMPLOYEE OR REPORTING PHYSICIAN WHO VIOLATES THE CONFLICT OF INTEREST POLICY. FORM 990, PART VI, SECTION B, LINE 15 THE EXECUTIVE COMMITTEE OF THE IOWA HEALTH SYSTEM BOARD OF DIRECTORS ("COMMITTEE") CONDUCTS A COMPREHENSIVE ANNUAL REVIEW OF ALL COMPENSATION AND BENEFITS PROVIDED TO THE ORGANIZATION'S OFFICERS AND KEY EMPLOYEES, INCLUDING THE IHS CHIEF EXECUTIVE OFFICER (THE "CEO"). THIS ANNUAL REVIEW COMPARES THE TOTAL COMPENSATION AND VALUE OF BENEFITS PROVIDED TO EACH EXECUTIVE, ON A POSITION BY POSITION BASIS, TO THAT PROVIDED TO FUNCTIONALLY SIMILAR POSITIONS IN SIMILARLY SITUATED ORGANIZATIONS. THIS REVIEW IS CONDUCTED BY THE COMMITTEE WITH THE ASSISTANCE OF A NATIONAL, INDEPENDENT COMPENSATION CONSULTANT REPORTING DIRECTLY TO THE COMMITTEE. THE COMMITTEE HAS BEEN DELEGATED THE RESPONSIBILITY FOR OVERSIGHT OF EXECUTIVE COMPENSATION AND IS MADE UP ENTIRELY OF INDEPENDENT DIRECTORS WITHIN THE MEANING OF THE "REBUTTABLE PRESUMPTION OF REASONABLENESS" UNDER THE FEDERAL INCOME TAX INTERMEDIATE SANCTIONS RULES. THE COMPENSATION CONSULTANT HOLDS ITSELF OUT TO THE PUBLIC AS A COMPENSATION CONSULTANT, PERFORMS THESE VALUATIONS ON A REGULAR BASIS, IS QUALIFIED TO MAKE THE VALUATIONS OF THE SERVICES INVOLVED, AND HAS SO INDICATED IN A WRITTEN CERTIFICATION TO THE COMMITTEE. BASED UPON THE ADVICE OF THE COMPENSATION CONSULTANT, AND APPLYING THE BOARD'S COMPENSATION PHILOSOPHY, THE COMMITTEE ESTABLISHES THE OVERALL ADJUSTMENT IN COMPENSATION AND BENEFITS FOR APPROXIMATELY THE TOP FIFTY EXECUTIVES IN THE ENTIRE HEALTH SYSTEM (SEVERAL OF WHICH ARE EMPLOYEES OF THE FILING ORGANIZATION) AND DELEGATES TO THE CEO THE AUTHORITY TO MAKE ADJUSTMENTS, CONSISTENT WITH THE COMMITTEE'S DIRECTION, FOR THE OTHER EXECUTIVES. THE COMMITTEE DETERMINES ALL ASPECTS OF THE COMPENSATION AND BENEFITS OF THE CEO. THE COMMITTEE INTENTIONALLY TAKES ALL THE STEPS NECESSARY TO QUALIFY FOR THE REBUTTABLE PRESUMPTION OF REASONABLENESS UNDER THE FEDERAL INCOME TAX LAW INTERMEDIATE SANCTIONS RULES, INCLUDING CONTEMPORANEOUS SUBSTANTIATION OF ALL COMMITTEE MEETINGS AND ACTIONS. THE ORGANIZATION BELIEVES IT IS IN FULL COMPLIANCE WITH SECTION 4958 OF THE IRC, PROVIDES NO MORE THAN REASONABLE AND FAIR MARKET VALUE COMPENSATION AND BENEFITS FOR ITS EMPLOYEES AND DOES NOT PROVIDE ANY EXCESS COMPENSATION OR BENEFITS AS PROHIBITED BY SECTION 4958. THE ANNUAL REVIEW OF COMPENSATION AND BENEFITS WAS LAST PERFORMED IN NOVEMBER 2011 FOR THE FOLLOWING INDIVIDUALS: MILTON AUNAN II, MICHELLE NIERMANN, JOHN SHEEHAN, THEODORE TOWNSEND, JR. THE COMPENSATION AND BENEFITS OF THE OTHER PERSONS LISTED ON FORM 990, PART VII WAS ESTABLISHED BY AN INDEPENDENT PERSON/COMMITTEE USING AN INDEPENDENT COMPENSATION CONSULTANT AND/OR COMPENSATION SURVEY OR STUDY FOR SIMILARLY QUALIFED PERSONS IN FUNCTIONALLY COMPARABLE POSITIONS AT SIMILARLY SITUATED ORGANIZATIONS. COMPENSATION AND BENEFITS ARE BASED ON THE FAIR MARKET VALUE OF THE SERVICES PROVIDED TO THE ORGANIZATION. FORM 990, PART VI, SECTION C, LINE 19 IOWA HEALTH SYSTEM, OUR PARENT ORGANIZATION, HAS VOLUNTARILY ADOPTED MANY OF OUR INDUSTRY'S GOVERNANCE "BEST PRACTICES." IOWA HEALTH SYSTEM HAS DONE SO TO FURTHER ASSURE OUR STAKEHOLDERS THAT OUR GOVERNANCE AND MANAGEMENT IS CONDUCTED RESPONSIBLY AND WARRANTS THE TRUST YOU PLACE IN US. IN SEPTEMBER 2003, THE IOWA HEALTH SYSTEM BOARD OF DIRECTORS VOLUNTARILY ADOPTED OVER 40 CHANGES TO ITS GOVERNANCE STRUCTURE TO BETTER COMPLY WITH GOVERNANCE BEST PRACTICES AND THE INTENT AND APPLICABLE REQUIREMENTS OF THE SARBANES-OXLEY ACT OF 2003. IN ADDITION, GOVERNANCE POLICIES AND RELATED INFORMATION HAS BEEN ADDED TO THE IOWA HEALTH SYSTEM WEBSITE, WWW.IHS.ORG, INCLUDING BUT NOT LIMITED TO: OVER 130 CORPORATE COMPLIANCE POLICIES, INCLUDING CHARITY CARE AND CONFLICTS OF INTEREST POLICIES; GOVERNANCE BEST PRACTICE POLICIES; THE IDENTIFICATION OF BOARD MEMBERS AND BOARD COMMITTEES; COMPENSATION FOR HOSPITAL CEO'S; AND FINANCIAL INFORMATION FOR THE PAST SEVEN YEARS. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED LOSSES ON INVESTMENTS: -346,504. CHANGE IN BENEFICIAL INTEREST OF JONES REGIONAL MEDICAL CENTER FOUNDATION -45,062. TOTAL TO FORM 990, PART XI, LINE 5: -391,566. 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IA IHS C 338870 13238641 1.00000 CHARITABLE REMAINDER UNITRUST #1 INVESTMENT IA SLHCF T CHARITABLE REMAINDER UNITRUST #2 INVESTMENT IA SLHCF T CHARITABLE REMAINDER UNITRUST #3 INVESTMENT IA SLHCF T CHARITABLE REMAINDER UNITRUST #6 INVESTMENT IA SLHCF T IOWA HEALTH SYSTEM 457 DEF COMP PLAN 1415 WOODLAND AVE 2ND FL DES MOINES IA 50309 421435199 INVESTMENT IA IHS T 266087 4546270 1.00000 METHODIST HEALTH VENTURES INC PO BOX 87 PEORIA IL 61650 371140939 PHARMACY/OFFICE STAFFING IL MHSC C 868566 2437393 1.00000 MEDIMORE INC 1200 PLEASANT ST DES MOINES IA 50309 421414390 MANAGED CARE IA IHS C 210170 1.00000 METHODIST PHYSICIAN SERVICES INC PO BOX 87 PEORIA IL 61650 363858550 MEDICAL SERVICES IL MHVI C 11908671 1305915 1.00000 PRECEDENCE INC 4622 PROGRESS DRIVE STE A DAVENPORT IA 52807 371288604 MANAGED MENTAL CARE IA RYC C 506534 435657 1.00000 PROVIDER RESOURCE MANAGEMENT INC PO BOX 87 PEORIA IL 61650 371223550 RESOURCE MANAGEMENT IL MHSC C 57427 1.00000 RURAL IOWA SPECIALTY PHYSICIAN CONSORTIUM INC 700 E UNIVERSITY AVE DES MOINES IA 50316 261271143 SPECIALTY PHYSICIANS MEDICAL CARE IA CIHC C 481860 198055 0.57000 STL HEALTH RESOURCES CO 1026 A AVE NE CEDAR RAPIDS IA 52402 421193499 PHYSICIAN OFFICE RENTAL IA SLMH C 322129 5577505 1.00000 TRIMARK PHYSICIANS GROUP INC 802 KENYON ROAD FORT DODGE IA 50501 421335554 MEDICAL CLINICS IA THS C 44216247 1.00000 TRINITY HEALTH ENTERPRISES INC 2701 17TH ST ROCK ISLAND IL 61201 363320141 RETAIL DURABLE MEDICAL EQUIPMENT & PHARMACY IL TRHS C 3295832 2957465 1.00000 1 0 1 0 1 0 1 1 0 0 0 1 1 1 1 0 0 0 ANAMOSA AREA AMBULANCE SERVICE A 3348 BASED ON GAAP, CASH, AND/OR FMV SECTION 512(B)(13) CONTROLLED ENTITY SCHEDULE R, PART II, COLUMN (G) THE ORGANIZATION IS A MEMBER OF A CONSOLIDATED HEALTH SYSTEM AND HAS A COMMON PARENT ORGANIZATION, "IOWA HEALTH SYSTEM." FOR ENTITIES THAT ARE PART OF THE CONSOLIDATED HEALTH SYSTEM (WITH COMMON CONTROL) THE ATTRIBUTION RULES OF IRC SECTION 318 APPLY; MEANING THAT ALL ORGANIZATIONS ARE DEEMED TO HAVE CONTROL OF THE ORGANIZATIONS OWNED BY THE CONTROLLING ORGANIZATION. AS SUCH, WE ARE REPORTING ALL RELATED ORGANIZATIONS OF THE HEALTH SYSTEM IN PARTS II, III & IV. FOR PART V REPORTING, THE TRANSACTIONS DISCLOSED ARE THOSE BETWEEN THE DIRECTLY CONTROLLED PARENT-SUBSIDIARY ONLY. THE ORGANIZATION E-FILED A REQUEST FOR AN ADDITIONAL EXTENSION OF TIME TO FILE TO NOVEMBER 15, 2012, ON PART II OF FORM 8868. THE E-FILED EXTENSION WAS ACCEPTED BY THE IRS ON JULY 31, 2012; HOWEVER, THE IRS ISSUED NOTICE CP211A, DATED AUGUST 27, 2012, WITH AN INCORRECT DATE FOR PART II OF AUGUST 15, 2012 INSTEAD OF NOVEMBER 15, 2012. AS SUCH, THE ORGANIZATION RESPECTUFLLY REQUESTS THE ORGANIZATION'S RECORDS BE UPDATED ACCORDINGLY TO SHOW THIS FORM 990 AS BEING EXTENDED TO NOVEMBER 15, 2012, AND TIMELY FILED.