2011-06-14T14:00:50-05:00 2010-10-31 DENMAN & COMPANY LLP 1601 22ND STREET SUITE 400 WEST DES MOINES IA 50266 990 2009-11-01 420948420 MARSHALLTOWN MEDICAL & SURGICAL CENTER MARS 6417545126 3 SOUTH 4TH AVE MARSHALLTOWN IA 50158 BRIAN D BURNSIDE 6417545126 2011-06-14 1 Bruce Cahill 5152258400 2009 2016-02-24 21:20:13Z BRIAN D BURNSIDE 3 SOUTH 4TH AVE MARSHALLTOWN IA 50158 63974296 0 X http://www.everydaychampions.org/ X 1969 IA TO CREATE AND CONTINUALLY IMPROVE SERVICES THAT RESPOND TO HEALTHCARE NEEDS IN OUR COMMUNITY. 13 11 851 324 89909 0 299458 247242 65005224 60538324 92582 85952 1702223 1913617 67099487 62785135 0 0 37719603 36858733 0 0 30568787 29090037 68288390 65948770 -1188903 -3163635 68108090 65085738 6597134 6723117 61510956 58362621 TO PROVIDE QUALITY HEALTHCARE TO THE COMMUNITY. 0 0 51712361 60538324 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. 51712361 1 1 0 1 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 1 0 0 1 0 0 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 1 85 0 851 1 1 1 0 0 0 0 0 0 0 0 13 11 0 0 0 0 1 1 0 1 1 0 0 1 1 1 1 1 1 1 1 1 0 IA X X MARY K PFANTZ 6417545126 3 SOUTH 4TH AVE MARSHALLTOWN IA 50158 ROBERT B COOPER 40.00 X X X X 289662 0 36335 BRIAN D BURNSIDE 40.00 X X 0 0 0 GREGG SHARP 2.00 X X 0 0 0 TERRENCE BRIGGS MD 2.00 X X 11000 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 GREGG DAVISON 1.00 X 0 0 0 BRIAN HEITHOFF 1.00 X 0 0 0 JOHN MCCARVILLE MD 1.00 X 0 0 0 NANCY BURK 1.00 X 0 0 0 JENNIFER MILLER 1.00 X 0 0 0 JC POLLPETER 1.00 X 0 0 0 ROBERT L DOWNEY 40.00 X X 171309 0 24682 LARAE SCHELLING 40.00 X X X 179755 0 18375 JOHN L MCCUNE 40.00 X 397342 0 39843 DARWIN KARR-PETERSON 40.00 X 319442 0 35218 RONALD C TERRILL 40.00 X 276982 0 28866 NARASIMHA PALAGUMMI 40.00 X 263058 0 27497 ANDREW RIBNER 40.00 X 253712 0 24807 2162262 0 235623 8 0 1 0 MCFARLAND CLINIC PC 1215 DUFF AVENUE AMES IA 50010 ER PHYSICIAN SERVICES & MISC 1637975 SALAHUDDIN SYED MD PC 1209 IDAHO AVENUE AMES IA 50010 PATHOLOGY SERVICES 420000 BLOOD CENTER OF IOWA 431 E LOCUST STREET DES MOINES IA 50309 DIAGNOSTIC SERVICES 358533 ARAMARK NUTRITION SERVICES PO BOX 65109 CHARLOTTE NC 28208 NUTRITION MANAGEMENT SERVICES 357876 ARAMARK CORPORATION 24863 NETWORK PLACE CHICAGO IL 60673 FACILITY/EQUIPMENT MANAGEMENT 312707 5 11400 116211 119631 247242 NET PATIENT SERVICE RE 900099 60538324 60538324 60538324 84502 84502 1915132 1189161 725971 725971 725971 1450 1450 1450 1450 HOME HEALTH SUPPORT SE 621610 539131 539131 CAFETERIA INCOME 722210 459026 459026 PURCHASING GROUP INCOM 900099 96439 96439 93050 89909 3141 1187646 62785135 60538324 89909 1909660 1574018 1574018 27176075 22624476 4551599 1237335 1030099 207236 5037595 4193871 843724 1833710 1526590 307120 181055 181055 39780 39780 224475 224475 403251 403251 189756 189756 125906 90695 35211 4751386 3621801 1129585 672528 672528 SUPPLIES 8633565 7943722 689843 BAD DEBT 4473337 4473337 ER PHYSICIAN PROFESSION 1667667 1667667 OTHER PHYSICIAN PROFESS 1125421 1125421 UTILITIES 905397 905397 5696513 3414682 2281831 65948770 51712361 14236409 0 149505 39131 9357616 10922475 47992 58240 10318847 10320843 1105838 776684 1671797 1661703 339211 804980 96629526 56845215 44408498 39784311 47450 184791 9948 149000 651388 383580 68108090 65085738 5043852 5265985 1553282 1457132 6597134 6723117 X 61261989 58110490 248967 252131 61510956 58362621 68108090 65085738 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 15822 15822 0 Part II-B, Line 1i: Explanation of Other Lobbying Activities: 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. 663301 3352810 4016111 18385060 40727391 30772860 28339591 38178 32050995 25157128 6932045 351451 1060340 915227 496564 39784311 ESTIMATED 3RD PARTY SETTLEMENT 1457132 1457132 62785135 65948770 -3163635 15300 15300 -3148335 61731472 0 61731472 1053663 1053663 62785135 65929905 0 65929905 18865 18865 65948770 Part X: Description of Uncertain Tax Positions Under FIN 48: THE HOSPITAL IS A NONPROFIT CORPORATION AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE AND IS EXEMPT FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE CODE. EFFECTIVE NOVEMBER 1, 2009, THE HOSPITAL HAS ADOPTED THE ACCOUNTING FOR UNCERTAINTY IN INCOME TAX REQUIREMENTS AS REQUIRED BY THE INCOME TAXES TOPIC OF THE FASB ACCOUNTING STANDARDS 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 2006 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: RENTAL EXPENSE: -79828. DONATIONS: 119631. MISC GRANT INCOME: 116211. MANAGEMENT SERVICES: 89909. RENTAL: 720336. OTHER: -8498. INTEREST - SAVINGS: 84502. RESTRICTED DUES: 11400. Part XIII, Line 4b - Other Adjustments: MANAGEMENT SERVICES: 89909. RESTRICTED EXPENSES: 8784. RENTAL EXPENSE RECLASSED: -79828. 1 1 1 X 1 X 1 1 1 0 1 1 715049 0 715049 0.01160 6489885 4695887 1793998 0.02920 7204934 4695887 2509047 0.04080 257802 31964 225838 0.00370 9244 9244 0.00020 2714647 2274516 440131 0.00720 4600 4600 0.00010 2986293 2306480 679813 0.01120 10191227 7002367 3188860 0.05200 135113 135113 0.00220 135113 135113 0.00220 1 2224436 66733 17221459 18690212 -1468753 X 1 1 NONE MARSHALLTOWN MEDICAL & SURGICAL CENTER

3 SOUTH 4TH AVENUE MARSHALLTOWN IA 501581928

X X X MMSC CLINIC MARSHALLTOWN

405 E MAIN MARSHALLTOWN IA 501581928

CLINIC MMSC CLINIC STATE CENTER

503 3RD AVE SW STATE CENTER IA 502477719

CLINIC MMSC CLINIC TAMATOLDEO

1307 SOUTH BROADWAY - UPPER LEVEL TOLEDO IA 523422307

CLINIC MMSC CLINIC CONRAD

105 NORTH CHURCH CONRAD IA 506217714

CLINIC MMSC REHABILITATION CENTER

1902 SOUTH CENTER STREET MARSHALLTOWN IA 501585983

OUTPATIENT REHAB CLINIC MMSC TOLEDO REHABILITATION CENTER

1307 SOUTH BROADWAY - LOWER LEVEL TOLEDO IA 523422307

OUTPATIENT REHAB CLINIC Part I, Line 3c: 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 3 PHYSICIAN CLINICS LOCATED IN 3 SMALL RURAL COMMUNITIES IN OUR GEOGRAPHIC SERVICE AREA. PHYSICIAN CLINICS ARE PROVIDED IN THE SMALL RURAL COMMUNITIES OF STATE CENTER, 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 I, Line 7f: THE AMOUNT OF BAD DEBT EXPENSE REPORTED IN PART IX, LINE 25, BUT EXCLUDED FROM THE DENOMINATOR IN THIS CALCULATION WAS $4,473,337. 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 ALLOWANCE.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. Part V: 2 OUTPATIENT REHABILITATION CLINICS4 PHYSICIAN CLINICS, 3 OF WHICH ARE IN SMALL RURAL COMMUNITIES 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 39,555, 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 $9-11 PER HOUR.THESE CHANGES HAVE RESULTED IN AN INCREASE IN THE NUMBER OF PEOPLE LIVING IN POVERTY AND AN UPSURGE IN THE NUMBER OF UN- OR UNDER-INSURED 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 U.S. CENSUS DATA: 13.2% OF THE MARSHALL COUNTY'S POPULATION IS OF HISPANIC OR LATINO ORIGIN COMPARED TO 3.8% IN THE STATE OF IOWA (2006 ESTIMATE); 10.6% OF MARSHALL COUNTY'S POPULATION (AGE 5+) SPOKE A LANGUAGE OTHER THAN ENGLISH AT HOME COMPARED TO 5.8% IN THE STATE OF IOWA (2000 CENSUS); 82.3% OF MARSHALL COUNTY RESIDENTS ARE HIGH SCHOOL GRADUATES COMPARED TO 86.1% IN IOWA (2000); 17% OF MARSHALL COUNTY POPULATION HAD A BACHELOR'S DEGREE OR HIGHER COMPARED TO 21.2% IN IOWA (2000); THE MEDIAN HOUSEHOLD INCOME IN 2004 IN MARSHALL COUNTY WAS $41,344 COMPARED TO $42,865 IN IOWA; PERSONS LIVING BELOW POVERTY IN 2004 IN MARSHALL COUNTY WAS 12% COMPARED TO 10.5% 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 HOURS 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 0 0 0 0 0 0 0 0 0 ROBERT B COOPER 279590 0 0 0 10072 0 14824 0 21511 0 325997 0 0 0 ROBERT L DOWNEY 168008 0 0 0 3301 0 8775 0 15907 0 195991 0 0 0 LARAE SCHELLING 175194 0 0 0 4561 0 9120 0 9255 0 198130 0 0 0 JOHN L MCCUNE 395794 0 0 0 1548 0 20078 0 19765 0 437185 0 0 0 DARWIN KARR-PETERSON 317894 0 0 0 1548 0 16157 0 19061 0 354660 0 0 0 RONALD C TERRILL 274606 0 0 0 2376 0 13985 0 14881 0 305848 0 0 0 NARASIMHA PALAGUMMI 236871 0 0 0 26187 0 13259 0 14238 0 290555 0 0 0 ANDREW RIBNER 252425 0 0 0 1287 0 12801 0 12006 0 278519 0 0 0 N PALAGUMMI X 110000 44000 0 1 1 44000 JOHN MCCARVILLE MD - 50 OWNER OF BOARD MEMBER 100000 PAYMENT TO PROVIDE OBSTETRICS/GYNECOLOGY CARE TO THE UNINSURED OR UNDERINSURED WOMEN IN THE HOSPITAL'S SERVICE AREA. 0 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. A REVIEW PERIOD WAS HELD OPEN AND ALL QUESTIONS 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. 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 AND THIS PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. 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, PART VII: DURING THE FISCAL YEAR, MARSHALLTOWN MEDICAL & SURGICAL CENTER WAS IN A TRANSITION PERIOD FOR ITS CEO/PRESIDENT. WHEN ROBERT COOPER LEFT HIS POSITION AS THE CEO/PRESIDENT, A BOARD MEMBER, TERRENCE BRIGGS SERVED AS AN INTERIM CEO/PRESIDENT FOLLOWED BY LARAE SCHELLING WHO ALSO SERVED AS INTERIM. BRIAN BURNSIDE ASSUMED FULLTIME RESPONSIBILITY FOR THE CEO/PRESIDENT POSITION IN APRIL 2010. 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. FORM 990, PART VI, QUESTION 16(a): MARSHALLTOWN MEDICAL & SURGICAL CENTER HELD A ONE-THIRD INTEREST IN HEALTH CENTRAL, L.C. HEALTH CENTRAL, L.C. PROVIDED CALL SERVICES FOR PHYSICIAN CLINICS AND FIRST NURSE CALL SERVICES AT NO CHARGE TO THE GENERAL PUBLIC IN THE GEOGRAPHIC SERVICE AREA OF MARSHALLTOWN MEDICAL & SURGICAL CENTER. THIS ENTITY WAS DISSOLVED BY 12/31/2009.