2012-06-15T08:36:15-05:00 2011-10-31 DENMAN & COMPANY LLP 1601 22ND STREET SUITE 400 WEST DES MOINES IA 50266 990 2010-11-01 420948420 MARSHALLTOWN MEDICAL & SURGICAL CENTER MARS 6417545126 3 SOUTH 4TH AVE MARSHALLTOWN IA 50158 BRIAN D BURNSIDE 6417545126 2012-06-13 1 BRUCE CAHILL 5152258400 2010 2016-02-24 21:20:13Z BRIAN D BURNSIDE 3 SOUTH 4TH AVE MARSHALLTOWN IA 50158 62584994 0 X HTTP://WWW.EVERYDAYCHAMPIONS.ORG/ X 1969 IA TO CREATE AND CONTINUALLY IMPROVE SERVICES THAT RESPOND TO HEALTHCARE NEEDS IN OUR COMMUNITY. 12 11 791 325 90005 0 247242 102638 60538324 58594131 85952 220701 1913617 2303565 62785135 61221035 0 0 0 0 36858733 35330101 0 0 0 29090037 23787961 65948770 59118062 -3163635 2102973 65085738 67593035 6723117 7119779 58362621 60473256 TO PROVIDE QUALITY HEALTHCARE TO THE COMMUNITY. 0 0 50508783 58594131 TO PROVIDE INPATIENT AND OUTPATIENT HEALTHCARE SERVICES TO MEMBERS OF THE COMMUNITY AND SURROUNDING COMMUNITIES REGARDLESS OF ABILITY TO PAY. CARE INCLUDES PREVENTION, DIAGNOSIS, TREATMENT, REHABILITATION AND OTHER SERVICES. 50508783 1 1 0 1 0 0 0 0 0 1 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 1 100 0 791 1 1 1 0 0 0 0 0 0 0 0 0 X 12 11 0 0 0 0 1 1 0 1 1 0 0 1 1 1 1 1 1 1 1 0 IA X X MARY K PFANTZ 6417545126 3 SOUTH 4TH AVE MARSHALLTOWN IA 50158 BRIAN D BURNSIDE 40.00 X X X X 212951 0 26682 GREGG SHARP 2.00 X X 0 0 0 TERRENCE BRIGGS MD 2.00 X X 0 0 0 KILEEN REZAC 2.00 X X 0 0 0 KEITH BLOOMQUIST 2.00 X X 0 0 0 CAROL HIBBS 1.00 X 0 0 0 MIKE MASON 1.00 X 0 0 0 NANCY BURK 1.00 X 0 0 0 JC POLLPETER 1.00 X 0 0 0 LORAS NEUROTH 1.00 X 0 0 0 POLLY HINEMAN 1.00 X 52148 0 4507 JENNIFER MILLER 1.00 X 0 0 0 ROBERT L DOWNEY 40.00 X 196311 0 25777 JOHN L MCCUNE 40.00 X 396660 0 42818 DARWIN KARR-PETERSON 40.00 X 381218 0 31950 RONALD C TERRILL 40.00 X 284432 0 29736 NARASIMHA PALAGUMMI 40.00 X 254919 0 27328 KATHLEEN GRAUERHOLZ 40.00 X 232966 0 26230 ROBERT B COOPER X 338542 0 27039 LARAE SCHELLING X 233356 0 13906 2583503 0 255973 9 1 1 0 MCFARLAND CLINIC PC 1215 DUFF AVENUE AMES IA 50010 ER PHYSICIAN SERVICES & MISC 2052684 ARAMARK CORPORATION 12483 COLLECTIONS CENTER CHICAGO IL 60673 CLINICAL ENGINEERING 448351 SALAHUDDIN SYED MD PC 1209 IDAHO AVENUE AMES IA 50010 PATHOLOGY SERVICES 397500 IOWA HEART CENTER 5880 UNIVERSITY AVE WEST DES MOINES IA 50266 CARDIOLOGY SERVICES 331121 ARAMARK HEALTHCARE FOOD PO BOX CHARLOTTE NC 28208 NUTRITION SERVICES 287338 5 11100 91538 102638 NET PATIENT SERVICE RE 900099 58594131 58594131 58594131 151663 151663 1945785 1171921 773864 773864 773864 6749 254327 192038 6749 62289 69038 69038 CAFETERIA INCOME 722210 458041 458041 XIX MEANINGFUL USE PAY 900099 366734 366734 HOME HEALTH SUPPORT SE 621610 329357 329357 375569 90005 285564 1529701 61221035 58594131 90005 2434261 578695 578695 27309069 27309069 1286342 1057187 229155 4292703 3483185 809518 1863292 1516676 346616 50539 50539 34000 34000 460609 460609 290637 290637 231351 231351 120454 98563 21891 3671802 2761255 910547 506659 506659 SUPPLIES 9184689 8453523 731166 ER PHYSICIAN PROFESSION 1720566 1720566 OTHER PHYSICIAN PROFESS 1153077 1153077 REPAIRS & MAINTENANCE 1125707 779145 346562 OTHER ADMINISTRATIVE EX 1016322 1016322 4221549 2176537 2045012 59118062 50508783 8609279 0 39131 14812 10922475 17059639 58240 36023 10320843 10471325 776684 569072 1661703 1651456 804980 359758 97799794 61047495 39784311 36752299 184791 198894 149000 383580 479757 65085738 67593035 5265985 5662647 1457132 1457132 6723117 7119779 X 58110490 60235320 252131 237936 58362621 60473256 65085738 67593035 X 2102973 7662 X X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 0 0 0 0 1 14769 14769 0 EXPLANATION OF OTHER LOBBYING ACTIVITIES: PART II-B, LINE 1I: MARSHALLTOWN MEDICAL & SURGICAL HAS PAID MEMBERSHIP DUES TO THE AMERICAN HOSPITAL ASSOCIATION AND THE IOWA HOSPITAL ASSOCIATION. THESE ORGANIZATIONS HAVE PROVIDED AN ESTIMATED PERCENTAGE OF DUES USED FOR LOBBYING ACTIVITIES. 640301 3375810 4016111 18403994 41193899 32767719 26830174 38177 32638341 27300473 5376045 351451 1157821 979303 529969 36752299 ESTIMATED 3RD PARTY SETTLEMENT 1457132 1457132 61221035 59118062 2102973 7662 7662 2110635 61124476 0 61124476 96559 96559 61221035 59029927 0 59029927 88135 88135 59118062 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: THE HOSPITAL FOLLOWS THE ACCOUNTING FOR UNCERTAINTY IN INCOME TAX REQUIREMENTS AS REQUIRED BY THE INCOME TAXES TOPIC OF THE FASB ACCOUNTING STANDARDS OF CODIFICATION. THE HOSPITAL HAS EVALUATED THEIR MATERIAL TAX POSITIONS AND DETERMINED NO INCOME TAX EFFECTS WITH RESPECT TO THE FINANCIAL STATEMENTS. THE HOSPITAL'S FEDERAL INCOME TAX RETURNS SINCE 2007 OPEN BY STATUTE ARE SUBJECT TO EXAMINATION BY THE TAX AUTHORITIES. THE HOSPITAL HAS NOT BEEN NOTIFIED OF ANY IMPENDING EXAMINATIONS BY AUTHORITIES, AND NO EXAMINATIONS ARE IN PROCESS. PART XII, LINE 4B - OTHER ADJUSTMENTS: RESTRICTED INTEREST INCOME 453. MANAGEMENT SERVICES 90,005. RESTRICTED DUES 11,100. RC ADDITIONAL RENTAL EXPENSE -5,000. ROUNDING 1. PART XIII, LINE 4B - OTHER ADJUSTMENTS: MANAGEMENT SERVICES 90,005. RESTRICTED EXPENSES 3,130. RC RENTAL EXPENSE -5,000. 1 1 1 X 1 X 1 1 1 0 1 1 779823 779823 0.01320 5735632 4758784 976848 0.01650 6515455 4758784 1756671 0.02970 267819 41133 226686 0.00380 8881 8881 0.00020 2333589 1896972 436617 0.00740 35130 35130 0.00060 2645419 1938105 707314 0.01200 9160874 6696889 2463985 0.04170 52943 52943 0.00090 52943 52943 0.00090 1 2304259 76174 20590416 21083422 -493006 X 1 1 1 NONE 1 1 MARSHALLTOWN MEDICAL & SURGICAL CENTER

3 SOUTH 4TH AVENUE MARSHALLTOWN IA 501581928

X X X MARSHALLTOWN MEDICAL & SURGICAL CENTER 1 1 1 100.000000000000 1 200.000000000000 1 X X X X 1 1 X 1 X X X 1 X X X X X X X 1 X 0 1 PART I, LINE 6A: A COMMUNITY BENEFIT REPORT IS PREPARED ANNUALLY IN A COLLABORATIVE EFFORT WITH THE IOWA HOSPITAL ASSOCIATION. THIS INFORMATION IS SHARED IN TOTAL FOR THE ENTIRE STATE THROUGH PRESS RELEASES AND FOR OUR INDIVIDUAL HOSPITAL BY INCLUDING THIS INFORMATION IN OUR ANNUAL CORPORATE REPORT, ON OUR WEBSITE AND A LOCAL PRESS RELEASE. PART I, LINE 7: AMOUNTS REPORTED IN THIS TABLE WERE CALCULATED BASED ON IRS WORKSHEETS 1-8, USING ENTITY SPECIFIC COST TO CHARGE RATIOS. PART I, LINE 7G: THE AMOUNT REPORTED ON THIS LINE INCLUDES SUBSIDIZED HEALTH SERVICES AT 2 PHYSICIAN CLINICS LOCATED IN 2 SMALL RURAL COMMUNITIES IN OUR GEOGRAPHIC SERVICE AREA. PHYSICIAN CLINICS ARE PROVIDED IN THE SMALL RURAL COMMUNITIES OF TAMA/TOLDEO, AND CONRAD, IOWA TO IMPROVE ACCESS TO HEALTH CARE SERVICES BY REDUCING GEOGRAPHIC AND FINANCIAL BARRIERS. THESE COMMUNITIES WOULD BE MEDICALLY UNDERSERVED IF THESE SERVICES WERE NOT PROVIDED. PART II: THE COMMUNITY BUILDING ACTIVITIES EXPENSE INCURRED BY MARSHALLTOWN MEDICAL & SURGICAL CENTER ARE EXPENSES INCURRED TO RECRUIT PHYSICIANS WHO WOULD NOT OTHERWISE COME TO THIS MEDICALLY UNDERSERVED AREA AND TO RETAIN PHYSICIANS IN THIS MEDICALLY UNDERSERVED AREA.THE AMOUNT ON LINE 8 IS AN ESTIMATE BASED UPON THE NUMBER OF FINANCIAL ASSISTANCE APPLICATIONS NOT RETURNED AND THE NUMBER OF FINANCIAL ASSISTANCE APPLICATIONS RETURNED WITH INSUFFICIENT DOCUMENTATION. EVERY EFFORT IS MADE TO COLLECT FINANCIAL ASSISTANCE APPLICATIONS AND TO COLLECT ADEQUATE INFORMATION TO MAKE A DETERMINATION OF FINANCIAL ASSISTANCE. PART III, LINE 4: THE ORGANIZATIONS BAD DEBT EXPENSE (AT COST) IS DETERMINED USING THE SAME METHODOLOGY AS CHARITY CARE AND OTHER COMMUNITY BENEFITS USING AN ENTITY SPECIFIC COST TO CHARGE RATIO.THE ORGANIZATIONS AUDITED FINANCIAL STATEMENTS DO NOT INCLUDE FOOTNOTE DISCLOSURE REGARDING BAD DEBT, RECEIVABLES OR ALLOWANCES.THIS HOSPITAL PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS BASED UPON A REVIEW OF OUTSTANDING RECEIVABLES, HISTORICAL COLLECTION INFORMATION AND EXISTING ECONOMIC CONDITIONS. THE HOSPITAL BILLS THIRD PARTY PAYERS DIRECTLY AND BILLS THE PATIENT ONLY WHEN THE PATIENT'S LIABILITY IS DETERMINED. PATIENTS ACCOUNTS RECEIVABLE ARE DUE IN FULL WHEN BILLED. ACCOUNTS ARE CONSIDERED DELINQUENT AND SUBSEQUENTLY WRITTEN OFF AS BAD DEBTS BASED ON INDIVIDUAL CREDIT EVALUATION, LACK OF PAYMENTS, AND SPECIFIC CIRCUMSTANCES OF THE ACCOUNT. EVERY EFFORT IS MADE TO MAKE PATIENTS AWARE OF THE AVAILABILITY OF FINANCIAL ASSISTANCE. A STATEMENT IS INCLUDED IN THE FIRST BILLING TO PATIENTS REGARDING THE AVAILABILITY OF FINANCIAL ASSISTANCE AND SIGNS ARE POSTED IN THE REGISTRATION AREAS. THE AMOUNT ON LINE 3 IS AN ESTIMATE BASED UPON THE NUMBER OF FINANCAL ASSISTANCE APPLICATIONS NOT RETURNED AND THE NUMBER OF FINANCIAL ASSISTANCE APPLICATIONS RETURNED WITH INSUFFICIENT DOCUMENTATION. EVERY EFFORT IS MADE TO COLLECT FINANCIAL ASSISTANCE APPLICATIONS AND TO COLLECT ADEQUATE INFORMATION TO MAKE A DETERMINATION OF FINANCIAL ASSISTANCE. PART III, LINE 8: COSTS WERE DERIVED USING THE MEDICARE COST REPORT.THE AMOUNT OF THE MEDICARE SHORTFALL SHOULD BE INCLUDED AS COMMUNITY BENEFIT FOR THE FOLLOWING REASONS:1) MANY MEDICARE RECIPIENTS ARE LOW-INCOME INDIVIDUALS AND IF NOT FOR MEDICARE, WOULD QUALIFY FOR CHARITY CARE OR OTHER MEANS TESTED GOVERNMENT PROGRAM.2) BY ACCEPTING PAYMENT BELOW COST TO TREAT THESE INDIVIDUALS, THE BURDENS OF GOVERNMENT ARE RELIEVED WITH RESPECT TO THESE INDIVIDUALS.3) IRS REV RULING 69-545 ESTABLISHED THE COMMUNITY BENEFIT STANDARD FOR HOSPITALS, WHICH INDICATES, THAT IF A HOSPITAL SERVES PATIENTS COVERED BY GOVERNMENTAL HEALTH BENEFITS (INCLUDING MEDICARE), THEN THIS INDICATES THE HOSPITAL OPERATES TO PROMOTE THE HEALTH OF THE COMMUNITY. PART III, LINE 9B: AFTER A PATIENT MEETS THE QUALIFICATIONS FOR FINANCIAL ASSISTANCE, THE ACCOUNT BALANCE IS EITHER PARTIALLY OR ENTIRELY WRITTEN-OFF. ANY REMAINING BALANCE, IF ANY, WOULD BE COLLECTED UNDER THE NORMAL DEBT COLLECTION POLICY. MARSHALLTOWN MEDICAL & SURGICAL CENTER PART V, SECTION B, LINE 19D: THE HOSPITAL OFFERS A 20% DISCOUNT TO THOSE INDIVIDUALS NOT HAVING INSURANCE AND DON'T MEET THE FINANCIAL ASSISTANCE REQUIREMENTS IF PROMPT PAYMENT IS MADE. MARSHALLTOWN MEDICAL & SURGICAL CENTER PART V, SECTION B, LINE 21: ALL PATIENTS ARE CHARGED STANDARD PATIENT CHARGES. GROSS CHARGES ARE THE BASIS FOR ALL CHARGES THAT DO NOT INVOLVE A NEGOTIATED INSURANCE DISCOUNT. AFTER A BILL HAS BEEN PROCESSED BY INSURANCE, THE INDIVIDUAL IS BILLED FOR CO-PAYS AND DEDUCTIBLES, AND NON-COVERED SERVICES. ONLY THOSE PATIENTS WHO FAIL TO RESPOND TO THE PROMPT PAY 20% DISCOUNT ARE SUBJECT TO PAYING FULL CHARGES. PART VI, LINE 2: MARSHALLTOWN MEDICAL & SURGICAL CENTER AND THE MARSHALL COUNTY BOARD OF HEALTH AND THE PIONEERING HEALTHIER COMMUNITY COALITION PARTNERED TO COMPLETE A COMPREHENSIVE COMMUNITY HEALTH NEEDS ASSESSMENT IN 2009-2010. THROUGH THESE EFFORTS PRIORITIES AND STRATEGIES HAVE BEEN DEVELOPED. REPRESENTATIVES OF MARSHALLTOWN MEDICAL & SURGICAL CENTER ARE INVLOVED IN THE ABOVE MENTIONED GROUPS AND THE LARGER COALITION.THE HEALTH NEEDS OF THE COMMUNITY ARE ASSESSED THROUGH A COMMUNITY NEEDS ASSESSMENTS PROCESS EVERY THREE YEARS. A COMMUNITY NEEDS ASSESSMENT IS A POINT-IN-TIME EFFORT TO MEASURE THE HEALTH AND WELL BEING OF THE COMMUNITY, AND TO ASSIST OUR COMMUNITY PARTNERS IN FOCUSING ON OUR COMMUNITIES FURTURE HEALTH NEEDS. THIS ASSESSMENT SERVES AS THE BASIS FOR MARSHALL COUNTY PUBLIC HEALTH, PIONEERING HEALTHIER COMMUNITIES, AND OUR OVERALL HEALTHCARE COMMUNITY TO DEVELOP ACTION PLANNING TO DEVELOP HEALTH POLICY, ALLOCATE RESOURCES, IMPROVE OR EXPAND EXISTING SERVICES, IMPLEMENT NEW PROGRAMS AND COLLABORATE WITH OTHER COMMUNITY HEALTHCARE PROVIDERS. A COMMUNITY NEEDS ASSESSMENT ALSO SERVES AS A BENCHMARK FOR FUTURE ASSESSMENT OF RELATIVE PROGRESS TOWARD ESTABLISHED COMMUNITY HEALTH OBJECTIVES.THIS COMMUNITY NEEDS ASSESSMENT PROVIDES THE OPPORTUNITY TO:- GAIN INSIGHT INTO THE NEEDS AND ASSETS OF THE COMMUNITIES SERVED- IDENTIFY AND ADDRESS THE NEEDS OF VULNERABLE POPULATIONS WITHIN THE COMMUNITY- ENHANCE HOSPITAL/COMMUNITY RELATIONSHIPS AND THE OPPORTUNITY FOR COLLABORATIVE COMMUNITY ACTION, INCLUDING INVOLVEMENT WITH COALITIONS, PARTNERSHIPS, BOARDS, COMMITTEES, COMMISSIONS, ADVISORY GROUPS AND PANELS- PROVIDE THE INFORMATION REQUIRED FOR COMMUNITY OUTREACH PLANNINGMARSHALLTOWN MEDICAL & SURGICAL CENTER ACTIVELY CONTRIBUTES TO THE COMMUNITY NEEDS ASSESSMENT AND ENGAGES IN THE PRIORITIES THAT MATCH ITS VISION AND MISSION. MEASUREMENT AND EVALUATION TOOLS ARE COLLECTED AND MONITORED BY THE LARGER COMMUNITY COALITION ENGAGED IN THE VARIOUS EFFORTS.IN ADDITION TO THESE ORGANIZED COMMUNITY EFFORTS, MARSHALLTOWN MEDICAL & SURGICAL CENTER MONITORS COMMUNITY NEEDS SPECIFIC TO ITS SERVICE LINES AND RESOURCES AVAILABLE. INDIVIDUAL DEPARTMENTS ALSO WORK TO IDENTIFY COMMUNITY NEEDS AS RELATED TO THEIR SERVICES AND THE POPULATION SERVED. PART VI, LINE 3: SIGNS STATING THAT FINANCIAL ASSISTANCE AND FREE CARE ARE AVAILABLE ARE POSTED IN THE HOSPITAL REGISTRATION AND CASHIER AREAS. REGISTRATION STAFF HAVE EDUCATIONAL MATERIAL AND APPLICATION FORMS THAT ARE MADE AVAILABLE TO PATIENTS WANTING INFORMATION OR AN APPLICATION FOR OUR COMMUNITY ASSITANCE PROGRAM. PATIENT FINANCIAL SERVICE REPS CONSULT AND ADVISE SELF PAY PATIENTS ON THEIR OPTIONS FOR GOVERNMENT SPONSORED FINANCIAL ASSISTANCE AS WELL AS THE HOSPITAL'S FINANCIAL ASSISTANCE PROGRAM.ADDITIONALLY, AN OUTSIDE VENDOR CONTACTS ADMITTED SELF PAY PATIENTS AND DISCUSSES OPTIONS FOR GOVERNMENT SPONSORED FINANCIAL ASSISTANCE AND PROVIDES ASSISTANCE TO PATIENTS APPLYING FOR A SPECIFIC PROGRAM. OUR OUTSIDE VENDOR DIRECTS PATIENTS THAT DO NOT QUALIFY FOR A GOVERNMENT SPONSORED PROGRAM TO A HOSPITAL FINANCIAL SERVICE REP. TO FOLLOW UP WITH AN APPLICATION FOR COMMUNITY ASSISTANCE. WE FURTHER USE AN "EARLY OUT" SELF PAY VENDOR THAT PROVIDES INFORMATION ON GOVERNMENT PROGRAMS AND THE HOSPITAL'S COMMUNITY ASSISTANCE PROGRAM. OUR SELF PAY VENDOR PROVIDES COMMUNITY ASSISTANCE APPLICATIONS TO PATIENTS WHEN AN APPLICATION IS REQUESTED AND MAKES REFERRALS FOR POSSIBLE APPLICATION TO GOVERNMENT SPONSORED ASSISTANCE PROGRAMS. ALSO, A STATEMENT IS INCLUDED IN THE FIRST BILLING TO PATIENTS REGARDING THE AVAILABILITY OF FINANCIAL ASSISTANCE. PART VI, LINE 4: MARSHALL COUNTY, POPULATION 40,648, IS COMPRISED OF 13 INCORPORATED COMMUNITIES AND THEIR SURROUNDING AREAS. THE POPULATION IS SOMEWHAT CONCENTRATED IN THE CENTRAL CITY OF MARSHALLTOWN WHERE ABOUT 66% OF COUNTY RESIDENTS LIVE. THE COUNTY'S POPULATION HAS REMAINED STABLE OVER THE PAST 50 YEARS; HOWEVER, THE DEMOGRAPHICS OF THE POPULATION HAVE SHIFTED DRAMATICALLY IN THE PAST 15 YEARS. NEW IMMIGRANTS RECRUITED TO THE COMMUNITY BY THE MEAT PACKING INDUSTRY HAVE DRIVEN THESE CHANGES. LARGE NUMBERS OF HISPANIC IMMIGRANTS HAVE LEFT THE SUB-MINIMUM WAGE EXISTENCE IN CENTRAL MEXICO TO TRAVEL TO THE AMERICAN MIDWEST FOR JOBS IN MEAT PACKING. THIS INDUSTRY IS THE LARGEST PRIVATE EMPLOYER IN MARSHALL COUNTY WITH PAY RANGING FROM $9-13 PER HOUR.THESE CHANGES HAVE RESULTED IN AN INCREASE IN THE NUMBER OF PEOPLE LIVING IN POVERTY AND AN UPSURGE IN THE NUMBER OF UNINSURED OR UNDERINSURED RESIDENTS. MARSHALL COUNTY IS DESIGNATED AS A HEALTH PROVIDER SHORTAGE AREA (HPSA). FURTHER, THE COUNTY HAS BEEN DESIGNATED AS A MEDICALLY UNDERSERVED COMMUNITY (MUC) AND THE IMMIGRANT POPULATION HAS BEEN DESIGNATED AS A MEDICALLY UNDERSERVED POPULATION (MUP) DUE TO LANGUAGE AND CULTURAL BARRIERS IN ACCESSING HEALTH CARE SERVICES.ACCORDING TO THE 2010 U.S. CENSUS DATA: 17.3% OF THE MARSHALL COUNTY'S POPULATION IS OF HISPANIC OR LATINO ORIGIN COMPARED TO 5.0% IN THE STATE OF IOWA; 16.3% OF MARSHALL COUNTY'S POPULATION (AGE 5+) SPOKE A LANGUAGE OTHER THAN ENGLISH AT HOME COMPARED TO 6.8% IN THE STATE OF IOWA (2000 CENSUS); 85.7% OF MARSHALL COUNTY RESIDENTS ARE HIGH SCHOOL GRADUATES COMPARED TO 89.9% IN IOWA (2000); 18.7% OF MARSHALL COUNTY POPULATION HAD A BACHELOR'S DEGREE OR HIGHER COMPARED TO 24.5% IN IOWA (2000); THE MEDIAN HOUSEHOLD INCOME IN 2004 IN MARSHALL COUNTY WAS $45,232 COMPARED TO $48,872 IN IOWA; PERSONS LIVING BELOW POVERTY IN MARSHALL COUNTY WAS 12.7% COMPARED TO 11.6% IN IOWA. PART VI, LINE 6: MARSHALLTOWN MEDICAL & SURGICAL CENTER IS A SOLE COMMUNITY HOSPITAL AND A RURAL REFERRAL CENTER BY CMS'S DEFINITIONS. THE HOSPITAL IS LOCATED IN A RURAL, MEDICALLY UNDERSERVED AREA AND IS THE ONLY HOSPITAL WITHIN A 30 MILE RADIUS. THE HOSPITAL IS ORGANIZED AND OPERATED EXCLUSIVELY FOR CHARITABLE PURPOSES WITH THE GOAL OF PROMOTING THE HEALTH OF THE COMMUNITIES IT SERVES AND CONTINUALLY IMPROVING SERVICES TO RESPOND TO HEALTH CARE NEEDS. THE HOSPITAL PROVIDES A 24 HOUR EMERGENCY DEPARTMENT, INCLUDING AMBULANCE COVERAGE, AVAILABLE TO ALL INDIVIDUALS REGARDLESS OF ABILITY TO PAY.A MAJORITY OF THE ORGANIZATION'S GOVERNING BODY IS COMPRISED OF PERSONS WHO RESIDE IN THE ORGANIZATION'S PRIMARY SERVICE AREA WHO ARE NEITHER EMPLOYEES, NOR CONTRACTORS, NOR FAMILY MEMBERS THEREOF AND ARE A BROAD CROSS SECTION OF COMMUNITY LEADERS. THE ORGANIZATION PROVIDES AN OPEN MEDICAL STAFF TO ALL QUALIFIED PHYSICIANS, SUBJECT TO THE NORMAL, EXCLUSIVE CONTRACTS FOR HOSPITAL-BASED SERVICES SUCH AS ANESTHESIOLOGY, RADIOLOGY, PATHOLOGY, EMERGENCY DEPARTMENT, AND HEART CATHETERIZATION LAB. THE EXCLUSIVE CONTRACTS ARE NECESSARY TO ASSURE THAT THESE MUCH NEEDED SERVICES ARE PROVIDED IN THIS RURAL MEDICALLY UNDERSERVED COMMUNITY.ALL SURPLUS FUNDS ARE USED TO MEET AND TO RESPOND TO THE HEALTHCARE NEEDS OF THE COMMUNITIES THIS ORGANIZATION SERVES. X X X X 1 0 0 0 0 0 0 0 0 BRIAN D BURNSIDE 209995 0 0 0 2956 0 10821 0 15861 0 239633 0 0 0 ROBERT L DOWNEY 188038 0 0 0 8273 0 10048 0 15729 0 222088 0 0 0 JOHN L MCCUNE 395112 0 0 0 1548 0 20078 0 22740 0 439478 0 0 0 DARWIN KARR-PETERSON 196497 0 0 0 184721 0 19184 0 12766 0 413168 0 0 0 RONALD C TERRILL 235468 0 0 0 48964 0 14413 0 15323 0 314168 0 0 0 NARASIMHA PALAGUMMI 196932 0 0 0 57987 0 12900 0 14428 0 282247 0 0 0 KATHLEEN GRAUERHOLZ 196932 0 0 0 36034 0 11802 0 14428 0 259196 0 0 0 ROBERT B COOPER 43614 0 0 0 294928 0 5395 0 21644 0 365581 0 0 0 LARAE SCHELLING 88421 0 0 0 144935 0 5566 0 8340 0 247262 0 0 0 NARASIMHA PALAGUMMI X 110000 22000 0 1 1 KATHLEEN GRAUERHOLZ X 150000 60000 0 1 1 82000 JOHN MCCARVILLE MD - 50 OWNER OF FORMER BOARD MEMBER 100000 PAYMENT TO PROVIDE OBSTETRICS/GYNECOLOGY CARE TO THE UNINSURED OR UNDERINSURED WOMEN IN THE HOSPITAL'S SERVICE AREA. 0 SCH L, PART II, LOANS TO AND/OR FROM INTERESTED PERSONS: IN AN EFFORT TO RECRUIT AND RETAIN PHYSICIANS TO PRACTICE MEDICINE IN THIS RURAL, MEDICALLY UNDERSERVED AREA, IT HAS BECOME NECESSARY TO OFFER INCENTIVES TO PHYSICIANS. ONE SUCH INCENTIVE IS A FORGIVABLE LOAN. THIS LOAN IS GIVEN TO A PHYSICIAN AS AN INCENTIVE TO ESTABLISH A PRACTICE AND IS FORGIVEN OVER A PERIOD OF YEARS AS AN INCENTIVE TO MAINTAIN PRACTICE. FORM 990, PART VI, SECTION A, LINE 6 MEMBERS IN THIS ENTITY SHALL BE BONA FIDE CITIZENS OF THE AREA SERVED BY THIS HOSPITAL WHO ARE AT LEAST 18 YEARS OF AGE AND WHO HAVE PAID THEIR ANNUAL DUES. FORM 990, PART VI, SECTION A, LINE 7A AN ANNUAL MEETING IS HELD IN WHICH THE AGENDA INCLUDES ELECTION OF TRUSTEES. PROXY VOTES MAY BE CAST BY ELIGIBLE MEMBERS WHO ARE UNABLE TO ATTEND THE MEETING. THE BOARD MEMBERSHIP SHALL INCLUDE MEMBERS FROM THE COMMUNITIES THAT ARE SERVED BY MARSHALLTOWN MEDICAL & SURGICAL CENTER. FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 AND ALL RELATED SCHEDULES AND SUPPLEMENTAL INFORMATION WERE MAILED TO ALL BOARD MEMBERS PRIOR TO FILING. ALL BOARD MEMBER INQUIRIES WERE RESOLVED PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C THE CONFLICT OF INTEREST POLICY REQUIRES ANNUAL CERTIFICATION THAT EACH TRUSTEE HAS THE CONFLICT OF INTEREST POLICY, THAT THEY HAVE A COPY OF THE SECTION OF THE ORGANIZATIONAL BY-LAWS THAT DISCUSS CONFLICTS OF INTEREST, AND THAT THEY AGREE TO COMPLY WITH THE POLICY. THE EXECUTIVE ASSISTANT TO THE PRESIDENT IS ASSIGNED TO ASSURE THAT ALL RECIPIENTS ANNUALLY SIGN THE CONFLICT OF INTEREST POLICY. FORM 990, PART VI, SECTION B, LINE 15 THE COMPENSATION COMMITTEE IS COMPRISED OF INDEPENDENT BOARD MEMBERS WHO MEET MULTIPLE TIMES PER YEAR TO REVIEW THE IOWA HOSPITAL ASSOCIATION'S WAGE SURVEY DATA. THE COMMITTEE RECOMMENDS CHANGES BASED ON SURVEY COMPARISONS AND ANNUAL PERFORMANCE EVALUATIONS. THE RECOMMENDATIONS ARE PRESENTED TO THE FULL BOARD. FORM 990, PART VI, SECTION C, LINE 18 THE ORGANIZATION'S 990 AND 990-T ARE AVAILABLE ON GUIDESTAR.COM AS WELL AS UPON REQUEST. THE ORGANIZATION'S FORM 1023 IS AVAILABLE UPON REQUEST. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS ARE AVAILABLE TO THE PUBLIC UPON REQUEST. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED GAINS ON INVESTMENTS: 7,662. FORM 990, PART XI, LINE 2(C): THE ORGANIZATION HAS A COMMITTEE THAT ASSUMES RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT OF ITS FINANCIAL STATEMENTS AND SELECTION OF AN INDEPENDENT ACCOUNTANT. THIS PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. THE AUDITORS MEET WITH THE COMMITTEE PRIOR TO THE AUDIT AND THE AUDITORS MAKE A PRESENTATION OF THEIR FINDINGS TO THE FULL BOARD. GENERAL INFORMATION: MARSHALLTOWN MEDICAL & SURGICAL CENTER IS A SOLE COMMUNITY HOSPITAL AND A RURAL REFERRAL CENTER BY CMS'S DEFINITION. THE HOSPITAL IS LOCATED IN A RURAL, MEDICALLY UNDER SERVED AREA AND IS THE ONLY HOSPITAL WITHIN A 30 MILE RADIUS. THE HOSPITAL IS ORGANIZED AND OPERATED EXCLUSIVELY FOR CHARITABLE PURPOSES WITH THE GOAL OF PROMOTING THE HEALTH OF THE COMMUNITIES IT SERVES AND CONTINUALLY IMPROVING SERVICES TO RESPOND TO THE HEALTHCARE NEEDS OF THE COMMUNITIES. MARSHALLTOWN MEDICAL & SURGICAL CENTER SUPPORTS THIS MISSION WITH A COMMUNITY BOARD AND 24 HOUR EMERGENCY DEPARTMENT AVAILABLE TO ALL PATIENTS REGARDLESS OF ABILITY TO PAY. CHARITY CARE IS PROVIDED TO PATIENTS WITH A DEOMONSTRATED INABILITY TO PAY. MARSHALLTOWN MEDICAL & SURGICAL CENTER HAS A CHARITY CARE POLICY, USES THE FEDERAL POVERTY GUIDELINES TO DETERMINE ELIGIBILITY FOR CHARITY, ANNUALLY BUDGETS FOR CHARITY CARE AND THE ANNUAL AMOUNT OF CHARITY CARE PROVIDED EXCEEDS THE BUDGETED AMOUNT. FORM 990, SCHEDULE L, PART II: IN AN EFFORT TO RECRUIT AND RETAIN PHYSICIANS TO PRACTICE MEDICINE IN THIS RURAL, MEDICALLY UNDERSERVED AREA IT HAS BECOME NECESSARY TO OFFER INCENTIVES TO PHYSICIANS. ONE SUCH INCENTIVE IS A FORGIVABLE LOAN. THIS LOAN IS GIVEN TO PHYSICIANS AS AN INCENTIVE TO ESTABLISH A PRACTICE AND IT IS FORGIVEN OVER A PERIOD OF YEARS AS AN INCENTIVE TO MAINTAIN A PRACTICE.