2011-05-16T15:22:38-05:00 2010-06-30 LARSONALLEN LLP 220 SOUTH SIXTH STREET SUITE 300 MINNEAPOLIS MN 55402 990 2009-07-01 420680407 GREAT RIVER MEDICAL CENTER GREA 3197681000 1221 SOUTH GEAR AVENUE WEST BURLINGTON IA 52655 TODD SLADKY 3197681000 2011-05-16 6123764500 2009 2016-02-24 21:20:13Z TODD SLADKY 1221 SOUTH GEAR AVENUE WEST BURLINGTON IA 52655 199553194 0 X www.greatrivermedical.org X 1895 IA IMPROVING THE REGION'S HEALTH BY PROVIDING HIGH-QUALITY HEALTH CARE. 13 12 1586 457 405852 0 1914479 39280172 155024127 159219042 386510 585890 -510156 280174 156814960 199365278 323627 1119732 0 74692557 78390336 0 73969 69438119 73686940 144454303 153197008 12360657 46168270 254675411 300910073 86129167 87750416 168546244 213159657 GREAT RIVER HEALTH SYSTEM IS DEDICATED TO IMPROVING THE REGION'S HEALTH BY PROVIDING HIGH-QUALITY CARE, WORLD-CLASS CUSTOMER SERVICE, AND UNCOMPROMISING VALUE FOR OUR PATIENTS AND THEIR FAMILIES. 0 0 147872889 159219042 THE 213-BED ACUTE AND 143-BED LONG-TERM CARE HOSPITAL HAD 7,760 PATIENT ADMISSIONS AND 76,299 PATIENT DAYS OF MEDICAL CARE. IN ADDITION, NUMEROUS OUTPATIENT AND EMERGENCY ROOM PROCEDURES WERE PERFORMED. GREAT RIVER MEDICAL CENTER HAS ACCEPTED PAYMENT FROM MEDICARE AND MEDICAID REDUCING THE MEDICAL BILLS FOR AREA RESIDENTS BY $7,411,916. COMMUNITY BENEFIT INFORMATION: SCHOOL PARTNERING: $6,192COMMUNITY EDUCATION: $8,511COMMUNITY INITIATIVE PARTICIPATION/MEETINGS: $12,303SCREENINGS/FIRST AID STATIONS: $2,825PRENATAL EDUCATION: $13,370HEALTH FAIRS: $8,344CASH CONTRIBUTIONS: $163,199TOTAL: $214,744 147872889 1 1 0 1 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 1 1 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 113 0 1 1586 1 1 1 0 0 0 0 0 0 0 0 13 12 0 1 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 0 0 0 X CHRISTINE DES JARDINS 3197683603 1221 SOUTH GEAR AVENUE WEST BURLINGTON IA 52655 X kent Gaudian 1.00 X X 0 0 0 Dan Wiedemeier 1.00 X X 0 0 0 ROBERT MCCULLEY 1.00 X X 0 0 0 MARK RICHARDSON 1.00 X X 0 406007 250421 Ken Aspelmeier 1.00 X 0 0 0 DR michael mccoy MD 1.00 X 0 0 0 Lorrin DeBlieck 1.00 X 0 0 0 DENNIS HINKLE 1.00 X 0 0 0 Jack Hobbs 1.00 X 0 0 0 DR JO ELLEN HOTH MD 1.00 X 0 0 0 ROBERT Mfleming 1.00 X 0 0 0 JAN TOWNE 1.00 X 0 0 0 Doug Peters MD 1.00 X 0 0 0 TONY HAYES 1.00 X 0 279231 108450 TODD SLADKY 1.00 X 0 251314 98137 Leo Banwart 40.00 X 110395 0 11046 Gail Boyd 40.00 X 105810 0 16752 Darwin Cooley 40.00 X 127731 0 23250 James Kammerer 40.00 X 95930 0 23003 Jon Williams 40.00 X 125157 0 9262 469093 936552 517318 22 0 1 0 Southeastern Iowa Medical Services Inc 1221 S GEAR AVE West Burlington IA 52655 PHYSICIANS 4028675 Mutual Consulting & Management Services 1221 S GEAR AVE West Burlington IA 52655 Executive Management 3173251 NUPATH PC 1221 SOUTH GEAR AVENUE WEst Burlington IA 52655 PATHOLOGY 271942 HRSERASE 200 NE MULBERRY SUITE 200 LEES SUMMIT MO 64086 COLLECTION 211906 Merritt Hawkins & Associates 5001 STATESMAN DRIVE IRVING TX 75063 PHYSICIAN SEARCH FIRM 201262 11 38848350 431822 39280172 PATIENT SERVICE INCOME 621110 157155271 157155271 OTHER OPERATING INCOME 621300 2063771 1657919 405852 159219042 393743 393743 105606 55433 50173 50173 50173 324630 132483 192147 192147 192147 MISCELLANEOUS INCOME 900099 230001 230001 230001 199365278 158813190 405852 866064 1119732 1119732 1419536 1419536 60012838 59847273 124414 41151 2661999 2653601 6270 2128 9777070 9751207 22378 3485 4518893 4507177 8640 3076 1730776 1730776 104055 15651 88404 92300 92300 292698 74523 218175 19679412 19633103 44712 1597 609388 467535 141853 351295 313646 35609 2040 3283603 3283603 12852284 12718269 134015 1913632 940147 973485 CONTRACTUAL SERVICES 9341499 9341499 Bad Debt 7601525 7601525 DRUGS 6959074 6959074 SPECIALIST FEES 4230855 4230855 FOOD 1519656 1519656 3124888 2802513 301883 20492 153197008 147872889 5250150 73969 -1 8316567 11155271 20006409 18622192 1258800 984954 2589531 3099074 1852162 1887318 251839667 121525590 134531069 130314077 84624067 133440511 1496807 1406676 254675411 300910073 7310556 8080066 66206962 64281373 12611649 15388977 86129167 87750416 X 164403808 209155550 3125128 2904229 1017308 1099878 168546244 213159657 254675411 300910073 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 30071 30071 0 Part II-B, Line 1i: Explanation of Other Lobbying Activities: Great River Medical Center paid dues to the American Hospital Association and the Iowa Hospital Association. These associations participate in lobbying activities related to healthcare. 5234256 5234256 96618276 25906719 70711557 9308655 3628167 5680488 140228881 91990704 48238177 449599 449599 130314077 127392185 F Cash and Short-term Investments 5873 F Insurance Company Annuity Deposits 1106782 F Investments in Deferred Comp Plan 4052421 F Investments in Voluntary Hospital Investment Plan 154600 F Investments in Renal Dialysis 728650 F 133440511 Deferred Compensation Liability 1116362 THIRD PARTY PAYABLE 3130000 PTO RESERVE 6723476 FAIR VALUE OF CASH FLOW HEDGING SWAP 4419139 15388977 1 1 1 X 1 X 1 1 1 0 1 1 2627990 2627990 0.01720 16272418 14859075 1413343 0.00930 18900408 14859075 4041333 0.02650 163199 163199 0.00110 163199 163199 0.00110 19063607 14859075 4204532 0.02760 0 3315610 795746 54270521 59627341 -5356820 X 1 1 GREAT RIVER MEDICAL CENTER

1221 SOUTH GEAR AVENUE WEST BURLINGTON IA 52655

X X X Part I, Line 3c: The Organization uses the FPG to determine free or discounted care. Individuals who are below 200% of the FPG qualify for free care. In most instances, they have to provide financial documentation and fill out a charity care application. We also use a presumptive charity care program that analzyes public and private databases to help determine eligibility for charity care. These individuals do not have any other documentation to provide. This program is used after collection attempts have been discontinued. Extraordinary assets are taken in to consideration when determining charity care eligibility. Medically indigent individuals are covered under the same charity care policy. Individuals between 200% and 300% of the federal proverty limits are granted charity on a sliding scale Part I, Line 7f: If an individual does not have a residence that can be used to run through the preseumptive charity care application and they do not fill out the appropriate paperwork to apply for charity, their account balance will be written off to bad debt. Based upon a review of charity applications that were rejected due to incomplete/missing information, it has been determined that approximately 24% of the applications we receive are rejected but the patient appears to qualify for charity but they haven't not completed the appropriate forms. Part III, Line 4: THE FOLLOWING IS FROM THE "ACCOUNTS RECEIVABLE AND ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS" PARAGRAPH IN NOTE 1 TO the Great River Medical Center, GRMC Foundation and Great River Foundation, Inc. Combined Financial Statements:"Patient receivables where a third-party payor is responsible for paying the amount are carried at a net amount determined by the original charge for the service provided, less an estimate made for contractual adjustments or discounts provided to third-party payors. Patient receivables due directly from patients are carried at the original charge for the service provided less amounts covered by third-party payors and less an estimated allowance for doubtful receivables based on a review of all outstanding amounts on a monthly basis. Management determines the allowance for doubtful accounts by identifying troubled accounts, by historical experience applied to an aging of accounts and by considering the patients' financial history, credit history and current economic conditions. The Medical Center does not charge interest on patient receivables. Patient receivables are written off as bad debt expenses when deemed uncollectible. Recoveries of receivables peviously written off are recorded as a reduction of bad debt expense when received."THE AMOUNT OF BAD DEBT EXPENSE (AT COST) REPORTED IN PART III, LINE 2 IS CALCULATED AS FOLLOWS: PAYMENT ARRANGEMENT INCLUDE PROSPECTIVELY DETERMINED RATES PER DISCHARGE, 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. Part III, Line 8: A cost-to-charge ratio as determined by the 2010 Medicare Cost Report was used to determine the amounts in Part III, lines 5 and 6. The shortfall reported on part III, line 7 represents the co-insurance and patient deductible amounts. Part III, Line 9b: Collection efforts are discontinued once the patient has been approved for charity care. Part VI, Line 2: GRMC is an active participant in community and county government task forces on health needs assessment and health services planning and coordination. GRMC assesses our communities' needs through programs we offer, requests that are received, and our own staff involvement in their communities. We also collaborate with other community organizations as well, when our services are needed. An annual health fair is hosted to provide information and education to our community about health issues and to promote our healthcare services. We encourage our community members to take an active role in their own health care by taking steps towards a healthier lifestyle through membership to our gym, a multitude of exercise programs offered through our facility, and offering many wellness programs to the community. Part VI, Line 3: Financial counselors meet with patients. The patient fills out a questionairre that helps them determine if they qualify for Medicaid, Crime Victims, COBRA, and other misc programs. On the statements, there is printed information about financial assistance and the financial assistance application is on the hospital website. There are plans to also have the charity care policy available via the web. Part VI, Line 4: A review conducted by the Medical Center analyzing the origin of patients utilizing the services provided by Medical Center during the fiscal year ended June 30, 2010 indicates that Des Moines County comprises the Medical Centers primary service area and that the secondary service area of the Medical Center consists of Henry, Lee and Louisa Counties in Iowa and Hancock and Henderson Counties in Illinois. The Des Moines County population is estimated at 40,295 residents for 2010, with Burlington and West Burlington totaling 28,464 as of 2007. The over 65 age group is currently 17.4% of the population which is higher than the state average of 14.8%. The median household income was $43,489 with 14.7% of the population being below the poverty level. Great River Medical Center is part of a larger Health System that consists of one hospital, multiple specialty physician clinics, home health services, a hospice house, ambulance services, a day care center, three pharmacies, a durable medical equipment company, and a long-term care nursing home. Part VI, Line 5: GRMC is involved in getting physicians and healthcare workers to the area to improve the access to healthcare needs in the medical center's service area. GRMC also promotes health care related jobs education by working closely with Southeastern Community College and their nursing program. Part VI, Line 6: The hospital provides membership to all physicians who meet membership and clinical requirements. Surplus funds are invested in improved and/or updated capital equipment to allow for better care of the patients that are served. Part VI, Line 7: Great River Health System serves as a holding company of various subsidiaries providing health care in West Burlington, Iowa. Riverview Systems, LTD, povides management services, rents faciliaties to physicians and the health care organizations, operate pharmacies, rent and sell medical equipment, and operate health care clinics. 1 GREAT RIVER HEALTH SYSTEM 1221 SOUTH GEAR AVENUE WEST BURLINGTON IA 52655 421193185 501(C)(3) 1000000 Support general operations. SE IA COMMUNITY ACTION 2850 Mt Pleasant Street burLINGTON IA 52601 420923961 501(C)(3) 20000 COMMUNITY BENEFIT FLINT RIVER RECREATIONAL TRAIL PO BOX 714 BURLINGTON IA 52601 501(C)(3) 10000 TO EXPAND THE WALKING/HIKING TRAIL. WAPELLO COMMUNITY AMBULANCE SERVICE 400 US Highway 61 South WAPELLO IA 52653 421334472 501(C)(3) 10000 COMMUNITY BENEFIT GLADSTONE VOLUNTEER AMBULANCE SERVICE PO BOX 219 GLADSTONE IL 61437 501(C)(3) 9440 EXTENSION HOSE AND MINI-CUTTERS. QUAD TOWNSHIP FIRE DEPARTMENT 301 BROADWAY STREET WEST BURLINGTON IA 52655 421148764 501(C)(3) 9000 COMMUNITY BENEFIT DENMARK FIRE & RESCUE 708 Main Street P O Box 50 DENMARK IA 52639 421456311 501(C)(3) 8750 COMMUNITY BENEFIT YMCAYWCA DOMESTIC VIOLENCE SHELTER 616 NORTH 8TH STREET BURLINGTON IA 52601 420680483 501(C)(3) 8022 ASSIST WOMEN AND CHILDREN. MEDIA STRONGHURST TERRE HAUTE FIRE RR 1 BOX 41 STRONGHURST IL 61480 501(C)(3) 8000 RESCUE EQUIPMENT. SPECIAL NEEDS FOUNDATION 829 HARRISON BURLINGTON IA 52601 421090677 501(C)(3) 7500 MEDICAL EQUIPMENT. NIOTA FIRE DEPARTMENT Highway 96 NIOTA IL 62358 501(C)(3) 7500 COMMUNITY BENEFIT MORNING SUN COMMUNITY AMBULANCE PO Box 174 MORNING SUN IA 52640 421322329 501(C)(3) 6120 COMMUNITY BENEFIT DALLAS CITY FIRE DEPARTMENT 381 EAST THIRD STREET DALLAS CITY IL 62330 501(C)(3) 5400 RESCUE EQUIPMENT. LAHARPE VOLUNTEER AMBULANCE 708 East Main PO Box 12 LAHARPE IL 61450 501(C)(3) 5000 COMMUNITY BENEFIT SE IA AREA BREASTFEEDING COALITION 1221 S Gear Avenue West BURLINGTON IL 52655 501(C)(3) 5000 Assist women and children. 15 0 Procedure for Monitoring Grants in the U.S.: Part I, Line 2: Schedule I, Part I, Line 2: GRANTEES ARE REQUIRED TO PROVIDE FOLLOW-UP INFORMATION WHEN THE PROJECT WAS CARRIED OUT OR COMPLETED. IF GRANTEES DON'T COMPLY, GRMC DOES NOT PROVIDE FURTHER GRANTS TO THEM. 0 0 0 0 0 0 0 0 0 MARK RICHARDSON 0 376007 0 30000 0 0 0 200308 0 50113 0 656428 0 0 TONY HAYES 0 279231 0 0 0 0 0 68500 0 39950 0 387681 0 0 TODD SLADKY 0 251314 0 0 0 0 0 59500 0 38637 0 349451 0 0 Darwin Cooley 125595 0 2136 0 0 0 0 0 23250 0 150981 0 0 0 Supplemental Information Part III PART I, LINE 2: THE COMPENSATION OF THE PRESIDENT & CEO IS DETERMINED BY GREAT RIVER HEALTH SYSTEM, A RELATED ORGANIZATION. THE FOLLOWING WERE USED BY GREAT RIVER HEALTH SYSTEM IN DETERMINING THE PRESIDENT & CEO'S COMPENSATION: 1. COMPENSATION COMMITTEE 2. INDEPENDENT COMPENSATION CONSULTANT 3. FORM 990 OF OTHER ORGANIZATIONS 4. WRITTEN EMPLOYMENT CONTRACT 5. COMPENSATION SURVEY OR STUDY 6. APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE IOWA FINANCE AUTHORITY 521699886 462466BV4 2008-07-01 37475000 PROCEEDS USED TO REFUND SERIES 1997 ADJUSTABLE DEMAND REVENUE BONDS 0 0 37475000 0 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 Form 990, Part VI, Section A, line 3 Per the bylaws of the organization: "The board of directors has an executive committee. When the board is not in session, the executive committee shall have and exercise the power and authority of the board to transact all regular business of the Corporation, subject to any prior limitations imposed by the Board or by statute. The executive committee has general responsibility for the investment of all endowment and other capital funds of the hospital." Form 990, Part VI, Section A, line 6 GREAT RIVER HEALTH SYSTEMS, INC., IS THE SOLE MEMBER OF GREAT RIVER MEDICAL CENTER. Form 990, Part VI, Section A, line 7a ONE TRUSTEE IS THE PRESIDENT AND CHIEF EXECUTIVE OFFICER OF GREAT RIVER MEDICAL CENTER AND THE REMAINING TRUSTEES ARE ELECTED BY THE SOLE MEMBER. Form 990, Part VI, Section A, line 7b THE FOLLOWING MATTERS ARE AUTHORIZED ONLY AFTER APPROVAL OF THE MEMBER: A. MERGER OR CONSOLIDATION WITH ANY OTHER CORPORATION OR LEGAL ENTITY. B. ANY CHANGE IN GREAT RIVER MEDICAL CENTER'S ARTICLES OF INCORPORATION. Form 990, Part VI, Section B, line 11 BEFORE THE FORM 990 WAS FILED WITH THE IRS, IT WAS REVIEWED BY MANAGEMENT AND BY ALL BOARD MEMBERS. Form 990, Part VI, Section B, line 12c EVERY YEAR, THE ACCOUNTING SUPERVISOR IN THE ACCOUNTING DEPARTMENT PROVIDES TO THE BOARD THE MEANING OF THE CONFLICT OF INTEREST STATEMENT, HOW IT APPLIES, HOW IT IMPACTS THE BOARD, AND WHAT THEIR RESPONSIBILITIES ARE. ALL BOARD MEMBERS ARE REQUIRED TO FILL OUT A CONFLICT OF INTEREST FORM AND THE FORM IS THEN REVIEWED BY THE ACCOUNTING SUPERVISOR. RELATIONSHIPS NOTED ON THE FORM MAY BE DISCUSSED WITH THE BOARD MEMBER IF THERE ARE QUESTIONS. IF AN INDIVIDUAL HAS A CONFLICT OF INTEREST, THEY MAY NOT PARTICIPATE IN DISCUSSIONS OF THE TRANSACTION AND MAY NOT VOTE ON MATTERS RELATED TO THE TRANSACTION. Form 990, Part VI, Section C, line 19 GREAT RIVER MEDICAL CENTER MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE UPON REQUEST. GREAT RIVER HEALTH SYSTEMS 1221 SOUTH GEAR AVENUE WEST BURLINGTON IA 52655 421193185 HEALTH CARE IA 501(C)(3) 11 - TYPE 2 N/A GREAT RIVER MEDICAL CENTER FOUNDATION 1221 SOUTH GEAR AVENUE WEST BURLINGTON IA 52655 421193186 FUNDRAISING IA 501(C)(3) 11 - TYPE 2 N/A GREAT RIVER FOUNDATION 1221 SOUTH GEAR AVENUE WEST BURLINGTON IA 52655 421469162 FUNDRAISING IA 501(C)(3) 11 - TYPE 2 N/A RIVERVIEW SYSTEMS LTD PO BOX 640 WEST BURLINGTON IA 52655 421191960 MEDICAL SERVICES IA N/A C GREAT RIVER MEDICAL SERVICES INC 1201 WEST AGENCY ROAD WEST BURLINGTON IA 52655 421493449 MEDICAL SERVICES IA N/A C 0 1 1 0 0 0 0 0 1 0 0 1 1 1 0 0 1 1 Great River Meidcal Center Foundation R 8558996 Great River Foundation R 30289354 Great River Health Systems Q 1754418