2011-08-12T09:50:01-05:00 2010-09-30 RSM McGladrey Inc 400 Locust St Ste 640 Des Moines IA 503092354 990 2009-10-01 421081055 FORT MADISON COMMUNITY HOSPITAL FORT 3193726530 PO BOX 174 FORT MADISON IA 52627 BRADLEY KOKJOHN 3193762125 2011-08-11 1 Crystal Jolin Tax Manager 5155586600 2009 2016-02-24 21:20:13Z C JAMES PLATT PO BOX 174 FORT MADISON IA 52627 48937329 0 X fmchosp.com X 1977 IA TO ADVANCE THE HEALTH AND WELL BEING OF ALL PEOPLE THROUGH COMPASSIONATE QUALITY CARE, EDUCATION AND COMMUNITY SERVICE. 7 7 489 50 34677 -1736 300000 250000 44736586 47985866 408623 356944 2224099 334063 47669308 48926873 42617 65716 0 28031477 28573638 0 0 17633410 19217790 45707504 47857144 1961804 1069729 49303502 49886926 11521657 10929024 37781845 38957902 TO ADVANCE THE HEALTH AND WELL BEING OF ALL PEOPLE THROUGH COMPASSIONATE QUALITY CARE, EDUCATION AND COMMUNITY SERVICE. 0 0 40760127 65716 48070416 FORT MADISON COMMUNITY HOSPITAL (FMCH) IS A GENERAL MEDICAL AND SURGICAL HOSPITAL, LOCATED IN FORT MADISON, IOWA, TO MEET THE HEALTHCARE NEEDS OF ITS COMMUNITIES AS WELL AS PROVIDE PROGRAMS AND SERVICES AIMED AT HEALTH, SAFETY, EDUCATION, PREVENTION, AND OVERALL HEALTH AND WELLNESS. IN SO DOING, THEY STRENGTHEN THEIR ROLE AS A PARTNER IN THE COMMUNITY BY IMPROVING THE HEALTH OF AREA CITIZENS AND THE QUALITY OF LIFE IN THE COMMUNITIES THEY SERVE. FORT MADISON COMMUNITY HOSPITAL IS COMMITTED TO PROVIDING HEALTH CARE SERVICES TO AREA RESIDENTS. FMCH SERVES THE RESIDENTS OF SOUTHEAST IOWA AND WEST CENTRAL ILLINOIS. THE 50 BED HOSPITAL HAD 2,518 PATIENT ADMISSIONS AND 8,766 PATIENT DAYS OF MEDICAL CARE. THIS INCLUDED 1,116 PATIENT ACCOUNTS WHO RECEIVED UNCOMPENSATED CARE. HEALTH SERVICES AND CARE PROVIDED BY FMCH INCLUDE: PHYSICIANS AND SURGEONS PRACTICING IN THE FOLLOWING AREAS: FAMILY PRACTICE, INTERNAL MEDICINE, OBSTETRICS & GYNECOLOGY, ORTHOPEDICS & SPORTS MEDICINE, PEDIATRICS, PSYCHIATRY, SURGERY AND UROLOGY; BIRTHPLACE SERVICES; SPECIALTY CLINICS IN THE FOLLOWING AREAS: CARDIOLOGY, DERMATOLOGY, OTOLARYNGOLOGY, GASTROENTEROLOGY AND NEUROLOGY; EMERGENCY DEPARTMENT SERVICES; HOME HEALTH CARE; REHABILITATION/THERAPY SERVICES; LABORATORY AND PATHOLOGY SERVICES; AND WOUND HEALING CARE. 40760127 1 1 0 0 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 1 0 0 0 0 0 0 0 1 1 0 0 1 64 0 1 489 1 1 1 0 0 0 0 0 0 0 0 7 7 1 1 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 IA X BRADLEY J KOKJOHN 3193726530 PO BOX 174 FORT MADISON IA 526270174 JOHN MCKILLIP 2.00 X X 3003 0 0 DEANNA BARR 2.00 X X 1963 0 0 JAMES GERDES 2.00 X X 1016 0 0 RICHARD CANELLA 2.00 X 39 0 0 JEANNINE HANEY 2.00 X 903 0 0 CHARLES BERTLSHOFER JR 2.00 X 114 0 0 ANN MENKE 2.00 X 787 0 0 C JAMES PLATT 40.00 X 313345 0 60433 BRADLEY KOKJOHN 40.00 X 198234 0 40604 MITCHELL PAUL 40.00 X 883426 0 31046 JAMES G KANNENBERG 40.00 X 501028 0 26582 ERIC R SARGENT 40.00 X 448920 0 26893 TIMOTHY S STAUDTE 40.00 X 409748 0 33320 KATHY J ANDERSON 40.00 X 381194 0 12527 3143720 0 231405 22 0 1 1 FIDELITY 900 SALEM STREET SMITHFIELD RI 02917 THIRD PARTY ADMINISTRATION 2017540 BI-STATE CONTRACTING 12917 115TH BURLINGTON IA 52601 CONTRACTOR BUILDING PHYSICAL THERAPY ADD 1413282 EMCARE PHYSICIAN SERVICES INC 7032 COLLECTION CENTER DRIVE CHICAGO IL 60693 EMERGENCY ROOM PHYSICIAN STAFFING 1360483 QUORUM HEALTH RESOURCES INC 105 CONTINENTAL PLACE BRENTWOOD TN 370275014 HOSPITAL MANAGEMENT SERVICES 921649 GE HEALTHCARE 3000 N GRANDVIEW BLVD WAUKESHA WI 53188 MEDICAL SUPPLIES/SERVICES 304687 18 250000 250000 NET PATIENT SERVICE RE 621110 47904780 47904780 SE RENAL DIALYSIS 621300 81086 81086 47985866 367400 367400 68555 68555 68555 68555 10456 -10456 -10456 -10456 CAFETERIA REVENUE 722210 141894 141894 HOUSEKEEPING, MAINTENA 811000 55925 21248 34677 PHARMACY 446110 23028 23028 44661 40274 4387 265508 48926873 48070416 34677 571780 65716 65716 624516 624516 21894713 19804884 2089829 806121 730292 75829 3869291 3496015 373276 1378997 1218583 160414 280951 156783 124168 35247 35247 59569 59569 3398493 3398493 241059 134522 106537 6118859 5114059 1004800 962414 537070 425344 160897 89788 71109 200475 111874 88601 3094241 1726725 1367516 695671 388216 307455 PROVISION FOR BAD DEBTS 1901505 1901505 PHYSICIAN FEES 1654619 1654619 REPAIRS AND MAINTENANCE 257713 143815 113898 SUBSCRIPTIONS 122827 68543 54284 33250 18625 14625 47857144 40760127 7097017 0 1337788 1444806 6495785 5076402 7185609 7152653 6393 664967 660181 822423 990650 50475934 29578082 19477674 20897852 9283396 9692639 3970585 3914028 65275 51322 49303502 49886926 4539949 5350925 6219528 5145176 762180 432923 11521657 10929024 X 37587027 38757181 4903 194818 195818 37781845 38957902 49303502 49886926 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 1139463 1139463 22227011 11912452 10314559 24717364 17665630 7051734 2392096 2392096 20897852 SE RENAL DIALYSIS, LC 697508 C INVESTMENT IN SUBSIDIARIES 3216520 C 3914028 48926873 47857144 1069729 133894 -27566 106328 1176057 49036157 133894 225390 359284 48676873 250000 250000 48926873 47860100 10456 10456 47849644 7500 7500 47857144 Part X: Description of Uncertain Tax Positions Under FIN 48: THE HOSPITAL, FOUNDATION AND FORT MADISON PROFESSIONAL BUILDING ASSOCIATION FILE A FORM 990 (RETURN OF ORGANIZATION EXEMPT FROM INCOME TAX) ANNUALLY. WHEN THESE RETURNS ARE FILED, IT IS HIGHLY CERTAIN THAT SOME POSITIONS TAKEN WOULD BE SUSTAINED UPON EXAMINATION BY THE TAXING AUTHORITIES, WHILE OTHERS ARE SUBJECT TO UNCERTAINTY ABOUT THE MERITS OF THE TAX POSITION TAKEN OR THE AMOUNT OF THE POSITION THAT WOULD ULTIMATELY BE SUSTAINED. EXAMPLES OF TAX POSITIONS COMMON TO ORGANIZATIONS SUCH AS THIS INCLUDE SUCH MATTERS AS THE FOLLOWING: THE TAX EXEMPT STATUS OF THE ENTITY, THE CONTINUTED TAX EXEMPT STATUS OF BONDS ISSUED BY THE HOSPITAL, THE NATURE, THE CHARACTERIZATION AND TAXABILITY OF JOINT VENTURE INCOME AND VARIOUS POSITIONS RELATIVE TO POTENTIAL SOURCES OF UNRELATED BUSINESS TAXABLE INCOME (UBIT). UBIT IS REPORTED ON FORM 990T, AS APPROPRIATE. THE BENEFIT OF A TAX POSITION IS RECOGNIZED IN THE FINANCIAL STATEMENTS IN THE PERIOD DURING WHICH, BASED ON ALL AVAILABLE EVIDENCE, MANAGEMENT BELIEVES THAT IT IS MORE LIKELY THAN NOT THAT THE POSITION WILL BE SUSTAINED UPON EXAMINATION, INCLUDING THE RESOLUTION OF APPEALS OR LITIGATION PROCESSES, IF ANY. TAX POSITIONS ARE NOT OFFSET OR AGGREGATED WITH OTHER POSITIONS. TAX POSITIONS THAT MEET THE "MORE LIKELY THAN NOT" RECOGNITION THRESHOLD ARE MEASURED AS THE LARGEST AMOUNT OF TAX BENEFIT THAT IS MORE THAN 50% LIKELY TO BE REALIZED ON SETTLEMENT WITH THE APPLICABLE TAXING AUTHORITY. THE PORTION OF THE BENEFITS ASSOCIATED WITH TAX POSITIONS TAKEN THAT EXCEEDS THE AMOUNT MEASURED AS DESCRIBED ABOVE WOULD BE REFLECTED AS A LIABILITY FOR UNRECOGNIZED TAX BENEFITS IN THE ACCOMPANYING BALANCE SHEET ALONG WITH ANY ASSOCIATED INTEREST AND PENALTIES THAT WOULD BE PAYABLE TO THE TAXING AUTHORITIES UPON EXAMINATION. HOWEVER, AS OF SEPTEMBER 30, 2010 AND 2009, THERE WERE NO UNRECOGNIZED TAX BENEFITS IDENTIFIED AND RECORDED AS A LIABILITY AS MANAGEMENT DOES NOT BELIEVE THE ORGANIZATION HAS TAKEN ANY TAX POSITIONS THAT WOULD NOT BE SUSTAINED UPON EXAMINATION BY THE TAXING AUTHORITIES. FORMS 990 AND 990T FILED BY THE HOSPITAL, FOUNDATION AND FORT MADISON PROFESSIONAL BUILDING ASSOCIATION ARE SUBJECT TO EXAMINATION BY THE INTERNAL REVENUE SERVICE (IRS) UP TO THREE YEARS FROM THE EXTENDED DUE DATE OF EACH RETURN. THE HOSPITAL'S IRS FORMS 990 AND 990T ARE NO LONGER SUBJECT TO EXAMINATION FOR THE YEARS 2006 AND PRIOR. RENAISSANCE HEALTH SERVICES, INC. IS A TAXABLE ORGANIZATION AND CURRENTLY FILES INCOME TAX RETURNS IN THE U.S. FEDERAL JURISDICTION AND THE APPLICABLE STATE JURISDICTIONS. THIS ENTITY IS NO LONGER SUBJECT TO INCOME TAX EXAMINATIONS FOR YEARS SEPTEMBER 30, 2006 AND PRIOR. Part XI, Line 8 - Other Adjustments: EQUITY IN NET INCOME OF SUBSIDIARIES: 214934. CONTRIBUTION INCOME REPORTED AS NET ASSET TRANSFER IN FINANCIAL STATEMENTS: -250000. UNMATCHED PORTION OF FUNDS COMMITTED IN 2008, UNCOMMITTED AND RECLASSIFIED: 7500. Part XII, Line 2d - Other Adjustments: INCOME ON EQUITY IN SUBSIDIARY: 214934. LOSS ON SALE OF FIXED ASSETS RECLASSIFIED AS REVENUE ON FORM 990: 10456. Part XII, Line 4b - Other Adjustments: CONTRIBUTION INCOME REPORTED AS NET ASSET TRANSER ON F/S: 250000. Part XIII, Line 2d - Other Adjustments: LOSS ON SALE OF FIXED ASSETS RECLASSIFIED AS REVENUE ON FORM 990: 10456. Part XIII, Line 4b - Other Adjustments: UNMATCHED PORTION OF FUNDS COMMITTED IN 2008, UNCOMMITTED AND RECLASSIFIED: 7500. 1 1 1 X 1 X 1 1 1 0 1 1 967439 967439 0.02110 4170831 3652084 518747 0.01130 0 0 5138270 3652084 1486186 0.03240 120581 255080 0 255080 0.00560 958 139095 0 139095 0.00300 0 0 0 0 1940 89404 89404 0.00190 123479 483579 483579 0.01050 123479 5621849 3652084 1969765 0.04290 0 0 12300 6216 0 6216 0.00010 7824 909 0 909 0.00000 0 0 0 0 0 0 25000 164 0 164 0.00000 0 0 0 0 45124 7289 7289 0.00010 1 960276 0 10981000 12171441 -1190441 X 1 1 SE RENAL DIALYSIS DIALYSIS SERVICES 0.20000 0.00000 0.00000 FORT MADISON COMMUNITY HOSPITAL

PO BOX 174 FORT MADISON IA 52627

X X X X TRAUMA CENTER Part I, Line 7: THE ORGANIZATION CALCULATED THE COST AMOUNTS NOTED IN PART 1, LINE 7 BY UTILIZING ITS CURRENT COST ACCOUNTING SYSTEM. THE COST ACCOUNTING SYSTEM ADDRESSES ALL PATIENT SEGMENTS REPORTED ON, INCLUDING, BUT NOT LIMITED TO INPATIENT, OUTPATIENT, MEDICAID, UNINSURED, AND MEDICARE. WORKSHEET 2, RATIO OF PATIENT CARE COST TO CHARGES, AS PROVIDED IN THE IRS INSTRUCTIONS WAS USED TO DETERMINE THE APPROPRIATE RATIO. Part I, Line 7f: THE AMOUNT OF BAD DEBT SUBTRACTED FROM OPERATING EXPENSES IN ORDER TO CALCULATE COLUMN F - % OF TOTAL EXPENSE - 1,901,505. Part III, Line 4: Patient accounts receivable due directly from the 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. Management determines the allowance for doubtful accounts by identifying troubled accounts and by historical experience applied to an aging of accounts. Patient accounts receivable are written off when deemed uncollectible. Recoveries of patient accounts receivable previously written off are recorded when received. The bad debt calculation for Line 2 is presented at cost based upon a cost to charge ratio. Worksheet 2, Ratio of Patient Care Cost to Charges, as provided in the IRS instructions was used to determine the appropriate ratio. Part III, Line 8: The Organization derived its costing methodology used to determine the Medicare allowable costs reported in the Organization's Medicare Cost Report by using Cost Report Worksheets. Medicare Costs are determined through the Medicare cost finding process which allocates general service center costs to revenue departments. Routine and ICU costs are determined based on an average cost per day multiplied by the number of Medicare allowable days. Medicare ancillary costs are determined by the ratio of department costs to department charges, then the resulting percent is applied to Medicare allowable charges. The methodology described in the instructions to Schedule H, Part III, Section B, Line 6 does not take into account all costs incurred by the hospital and does not represent the total community benefit conferred in this area. The Medicare shortfall on Fee Schedule Reimbursed Services totaled $465,189 for the reportable year. This shortfall is not included on Sch H, Part III, line 7.The reasons Medicare shortfall should be treated as a community benefit are: absent the Medicare program, it is likely many of the individuals whould qualify for financial assistance or other needs-based government programs; by accepting payment below cost to treat these individuals, the burdens of government are relieved with respect to these individuals; there is a significant possibility that continued reduction in reimbursement may actually create difficulties in access for these individuals; and the amount spent to cover Medicare shortfall is money not available to cover financial assistance and other community benefit needs. Part III, Line 9b: The Fort Madison Community Hospital (FMCH) charity program is designed to identify those accounts where the guarantor is not able to make payment, or only limited payments that would work a definite hardship on the household, and "adjust" those accounts as early as possible.Financial Evaluation of Patient - if the primary payor is other than an insurance company, FMCH evaluates the ability of the guarantor to: 1) Handle the projected financial obligation personally; 2) Qualify for county, state or federal assistance. Assistance may be available if: a) there are dependent children in the home (Medicaid); b) possible determination of disability by the Social Security Administration; and c) patient is pregnant (Medicaid); 3) If patient appears to qualify for assistance in one of the above categories, FMCH evaluates how likely is it that the patient will follow through with the application process. If the patient is not likely to follow through, assistance is obtained from an outside agency to help the patient through the application process; 4) If the initial review indicates there is no other payor than the individual guarantor, and an assessment of the guarantor's means (income, assets and liabilities) leaves considerable questions as to how he/she will resolve the impending debt, FMCH then determines if full or partial charity is appropriate; 5) Residenty Test - To be eligible for charity care, the patient's home must be within the primary or secondary service area of FMCH. These areas are defined by zip codes; 6) Using the completed Personal Financial Statement, a copy of the most recent tax return, a copy of the moste recent payroll stubs and any other information that may be appropriate, the guarantor's income must be evaluated on a sliding scale based on poverty guidelines; 7) Additional circumstances such as, but not limited to, if the guarantor has limited cash income but has significiant property holdings (personal or business), those assets must be taken into account and may supersede the application of the above discount guidelines;Negotiations - Dependent upon the guarantor's means, FMCH may negotiate a settlement. If a resonable monthly payment for the balance owed can not be agreed upon, it is in everyone's best interest to resolve the debt earlier by agreeing to a negotiated amount.Recommendations from staff such as the CEO, CFO, DON, RU, Doctors and Department Heads to assist with patients that are having financial difficulty is always considered.Following discharge or billing, a determination of charity may be made by using the above process as soon as the question of possible charity is raised. This determination should always be made at the earliest possible time in the life of the account. Part VI, Line 2: Fort Madison Community Hospital utilizes a community health needs assessment performed by the local United Way. In addition to this needs assessment, the hospital board of directors hold an annual planning meeting with representatives from the medical staff in attendance. This physician representation allows for good input of the community medical needs by those that are closest to the issues. Part VI, Line 3: The hospital has a written charity care policy in place to ensure that necessary health care services are not denied based on ability to pay and that all patients are treated fairly and equitably, and with respect and compassion. The hospital assists persons without insurance coverage by waiving all or part of the charges for services it provides. Charges for services are discounted on a sliding fee scale based on federal poverty guidelines. Individuals whose income is within 100 to 250% of the federal poverty guidelines are eligible for free or discounted services. The financial assistance contact information is available at all of the registration points in which eligible patients are likely to be present. In addition, financial assistance contact information is included in the patient bills, included in a patient's handbook given upon admission, addressed in letter form to patients that appear to be having difficulty paying their bill and/or a discussion is had with the patient on the availability of various government benefits, such as Medicaid or state programs. Where applicable, the patient is assisted with qualification for such programs.Additionally, a concerted effort is made to inform non-English speaking patients about financial assistance policies. Multilingual signs are posted in the registration and waiting areas so that hospital are clearly communicated to patients and prospective patients. The role and responsibilities of the financial assistance counselor include how to qualify patients for Medicaid, SCHIP and other government programs. Part VI, Line 4: Fort Madison Community Hospital serves a community of approximately 12,916 and a combined service area of approximately 39,879. The Hospital's primary service area includes most of Lee County, IA as well as portions of Hancock County, IL. The primary service area has a population of approximately 22,505 and a median age of 43.6. Fort Madison Community Hospital receives 50.8% of the primary service area inpatient market share. The Hospital's secondary service area includes portions of Lee County, IA, Van Buren County, IA and Hancock County, IL. The secondary service area has a population of approximately 17,374 and a median age of 42. Fort Madison Community Hospital receives 10.2% of the secondary service area inpatient market share. Part VI, Line 5: Fort Madison Community Hospital participates in Community Building activities in a variety of ways. FMCH employees routinely participate in community activities such as parades, first aid tents at community events and Big Brother-Big Sister activities. They also participate in community health improvement advocacy efforts. The hospital marketing director is on the local Chamber of Commerce board of directors and the CEO is a member of the Southeast Iowa Regional Riverboat Commission that awards grants to local community benefit projects.In addition to the above, the hospital is in the process of building a new Outpatient Rehabilitation Center. The building includes space for physical, occupational and speech therapy services, including a small pool. The design includes a walking track for use by the public. The walking track will be used to promote wellness with all of our client groups: business, patients, employees. Part VI, Line 6: Fort Madison Community Hospital furthers its efforts to promote the health of the community by ensuring the 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 of the organization, nor family members of such. The organization also extends medical privileges to all qualified physicians in its community for some or all of its departments. Fort Madison Community Hospital is committed to serving the residents of area communities. The hospital continues these efforts by using excess funds to expand its facilities and services to better serve the community. Furthermore, the organization has partnered with Jefferson Elementary School to improve the health and well-being of the youngest members of our community. Fort Madison Community Hospital is a disproportionate share (for Medicaid) hospital which participates in Medicare, Medicaid, CHAMPUS, Tricare and other government sponsored health care programs. Payments for services provided to beneficiaries of these programs are based on pre-established and unilaterally set fee schedules in accordance with the patient's diagnosis or test or procedure performed. The difference between the service price and the contracted price is written-off by the hospital. The contracted amount received from these programs is often less than the actual cost of the service, the difference of which represents a benefit to the patient and the community.Fort Madison Community Hospital operates an emergency room that is open 24 hours per day, 365 days per year. The emergency room has a trauma center with a certification level of III. The hospital's emergency room provides services to all individuals, regardless of their ability to pay and denies services to no one.The hospital provides various programs and services to inform and train members of the community on safety, health and lifestyle topics, as well as provide opportunities for learning in a safe environment. The programs are free or a nominal fee is charged to defray a portion of the cost. Examples of the programs are education programs for advanced directives, diabetes, CPR/first aid, prenatal, family/parenting and sibling relationships, as well as training to students of a variety of ages. The hospital served approximately 2,700 persons during educational programs.The hospital organized support groups for various groups including cancer, diabetes, ostomy and other health topics and served approximately 250 persons.Fitness, exercise and self-help programs were offered to promote and support the benefits of physical fitness, exercise, healthy lifestyles and stress management. The hospital sponsored or participated in community health fairs and the community health and fitness fair is held annually by the hospital for the community consisting of various exhibits on health related topics. It is open to all ages. Another annual event is the women's health conference for area women of all ages. The conference includes speakers on women related health issues. The hospital also sponsors a kid's day at the Lee County Fair, the Lee County Fair Senior Day, Lee County Safety Day and the local Relay for Life. Almost 13,000 persons benefited from these activities.The hospital provides a courtesy transportation service to almost 4,000 residents of several area communities. Various pick-up times and locations are provided.Fort Madison Community Hospital maintains a website to provide the community with free information on health and wellness topics, physicians, community programs, health services and employment opportunities.The hospital provides various services to area businesses on a contract basis including education programs on wellness and workplace injury prevention, on-site ergonomic evaluations, drug/alcohol testing/screening, evaluation of work related injuries and back assessments. The hospital underwrites a portion of the cost of these services. Part VI, Line 7: Not applicable IA 1 FORT MADISON RODEO CORP PO BOX 80 FORT MADISON IA 52627 420658297 501(C)(4) 10500 PROMOTE COMMUNITY ACTIVE LIFESTYLE FORT MADISON ECONOMIC DEVELOPMENT PO BOX 427 FORT MADISON IA 52627 421300666 501(C)(3) 10000 PROMOTE FORT MADISON TO INDUSTRIES AND BUSINESS DENMARK FIRE DEPARTMENT 408 5TH STREET DENMARK IA 52624 421722664 501(C)(3) 6000 PROMOTE SAFETY OF COMMUNITY AND SURROUNDING AREAS FORT MADISON COMMUNITY HOSPITAL FOUNDATION HIGHWAY 61 WEST FORT MADISON IA 52627 421446727 501(C)(3) 6883 PROMOTE FOUNDATION ACTIVITIES 3 1 Procedure for Monitoring Grants in the U.S.: Part I, Line 2: Schedule I, Part I, Line 2: AS DONATION REQUESTS ARE RECEIVED BY THE HOSPITAL, AN INDEPENDENT SENIOR LEADERSHIP TEAM EVALUATES AND APPROVES THE RECIPIENTS FOR THE CHARITABLE/COMMUNITY BENEFIT DONATIONS. X X X 0 0 0 1 0 0 0 1 0 C JAMES PLATT 245246 0 60839 0 7260 0 12250 0 48183 0 373778 0 0 0 BRADLEY KOKJOHN 169662 0 28572 0 0 0 7929 0 32675 0 238838 0 0 0 MITCHELL PAUL 883426 0 0 0 0 0 11500 0 19546 0 914472 0 0 0 JAMES G KANNENBERG 360277 0 140751 0 0 0 11500 0 15082 0 527610 0 0 0 ERIC R SARGENT 448920 0 0 0 0 0 11500 0 15393 0 475813 0 0 0 TIMOTHY S STAUDTE 227725 0 182023 0 0 0 11500 0 21820 0 443068 0 0 0 KATHY J ANDERSON 237515 0 143679 0 0 0 11500 0 1027 0 393721 0 0 0 Part I, Line 5 MITCHELL PAUL, JAMES KANNENBURG, ERIC SARGENT, TIMOTHY STAUDTE, AND KATHY ANDERSON COMPENSATION ARRANGEMENT INCLUDES A BASE COMPENSATION AMOUNT PLUS A PRODUCTIVITY BONUS BASED ON A CERTAIN PERCENT OF NET BILLINGS IN EXCESS OF CERTAIN NET BILLING THRESHOLDS. THE ANNUAL THRESHOLD IS SET BY THE BOARD OF DIRECTORS, REVIEWED BY THE COMPENSATION COMMITTEE AND INCLUDES A COMPENSATION CAP. Part I, Line 7 C. JAMES PLATT AND BRAD KOKJOHN COMPENSATION ARRANGEMENTS INCLUDE A BASE COMPENSATION PLUS A BONUS OF WHICH 80% IS BASED ON CERTAIN OPERATING FACTORS AND 20% BASED ON BOARD DISCRETION. Supplemental Information Part III AMOUNTS REPORTED IN PART II FOR C JAMES PLATT AND BRADLEY KOKJOHN WERE PAID BY QUORUM HEALTH RESOURCES. CITY OF FORT MADISON IOWA 426004688 NONEAVAIL 2003-09-08 5810000 CONSTRUCT BUILDING ADDITION AND ADVANCE REFUND OF 2001 SERIES 0 0 5810000 99500 4000000 2004 0 1 1 1 0 1 0 0 0 0.04670 0.00000 0.04670 1 0 0 0 0 0 0 RICHARD CANELLA BOARD MEMBER OF FMCH AND BOARD MEMBER OF BANK DOING BUSINESS WITH FMCH. 118722 BANK TRANSACTIONS AT ARMS LENGTH. 0 Form 990, Part VI, Section A, line 2 DUE TO OVERLAP OF BOARD MEMBERSHIP ON RELATED ENTITIES, THE FOLLOWING INDIVIDUALS HAVE/HAS A BUSINESS RELATIONSHIP: RICHARD CANELLA JAMES GERDES JEANNINE HANEY CHARLES BERTLSHOFER, JR. ANN MENKE Form 990, Part VI, Section A, line 3 C. JAMES PLATT, CEO AND BRAD KOKJOHN, CFO ARE EMPLOYED BY QUORUM HEALTH RESOURCES, A HEALTHCARE MANAGEMENT SERVICES COMPANY, WHICH PROVIDES MANAGEMENT SERVICES TO THE ORGANIZATION. Form 990, Part VI, Section B, line 11 A COPY OF THE FORM 990 WAS REVIEWED BY THE CFO WITH THE EXTERNAL ACCOUNTANTS FOR COMPLETENESS AND ACCURACY PRIOR TO FILING THE FORM 990. A COPY OF THE FINAL VERSION WAS PROVIDED TO EACH BOARD MEMBER PRIOR TO FILING WITH THE IRS. Form 990, Part VI, Section B, line 12c EACH DIRECTOR, PRINCIPAL OFFICER AND MEMBER OF A COMMITTEE WITH BOARD DELEGATED POWERS ANNUALLY SIGNS A STATEMENT WHICH AFFIRMS THAT SUCH PERSON: 1) HAS RECEIVED A COPY OF THE CONFLICT OF INTEREST POLICY, 2) HAS READ AND UNDERSTANDS THE POLICY, 3) HAS AGREED TO COMPLY WITH THE POLICY, AND 4) UNDERSTANDS THAT THE HOSPITAL IS A CHARITABLE ORGANIZATION AND THAT IN ORDER TO MAINTAIN ITS FEDERAL TAX EXEMPTION IT MUST ENGAGE PRIMARILY IN ACTIVITIES WHICH ACCOMPLISH ONE OR MORE OF ITS TAX-EXEMPT PURPOSES. IN CONNECTION WITH ANY ACTUAL OR POSSIBLE CONFLICTS OF INTEREST, ANY INTERESTED PERSON MUST DISCLOSE THE EXISTENCE AND NATURE OF HIS OR HER FINANCIAL INTEREST TO THE DIRECTORS AND MEMBERS OF COMMITTEES WITH BOARD DELEGATED POWERS CONSIDERING THE PROPOSED TRANSACTION OR ARRANGEMENT. UPON ANY DISCLOSURE OF THE FINANCIAL INTEREST, THE INTERESTED PERSON LEAVES THE BOARD OR COMMITTEE WHILE THE FINANCIAL INTEREST IS DISCUSSED AND VOTED UPON. THE REMAINING BOARD OR COMMITTEE MEMBERS DECIDE IF A CONFLICT OF INTEREST EXISTS. ALL SUCH ACTIONS ARE RECORDED IN THE MINUTES OF THE BOARD OR COMMITTEE MEETING. Form 990, Part VI, Section B, line 15 THE COMPENSATION COMMITTEE, ACTING ON BEHALF OF THE BOARD OF DIRECTORS, MEETS AT LEAST ANNUALLY TO ASSIST THE BOARD OF DIRECTORS IN FULFILLING ITS OVERSIGHT RESPONSIBILITIES FOR EXECUTIVE COMPENSATION. QUORUM HEALTH RESOURCES PRESENTS TO THE FULL BOARD OF DIRECTORS COMPENSATION INFORMATION WHICH INCLUDES COMPARABLES AND INDUSTRY GUIDELINES ALONG WITH RECOMMENDATIONS FOR THE BOARD'S APPROVAL FOR COMPENSATION OF THE CEO AND CFO. THE COMPENSATION COMMITTEE REVIEWS COMPENSATION DATA AND RELATED POLICIES AND DETERMINES WHETHER SUCH COMPENSATION IS REASONABLE AND CONSISTENT WITH FAIR MARKET VALUE IN ORDER TO RECOMMEND TO THE FULL BOARD OF DIRECTORS COMPENSATION AMOUNTS FOR APPROVAL. COMPENSATION OF PHYSICIANS EMPLOYED OR CONTRACTED BY FMCH OR AN AFFILIATE ARE REVIEWED ANNUALLY USING THE MGMA DATA FOR COMPARISON. THE COMPENSATION COMMITTEE MAINTAINS DOCUMENTATION, CONSISTENT WITH THE RECORD RETENTION POLICY, OF ITS ACTIVITIES AND THE BASIS FOR ITS DECISIONS. THIS PROCESS OCCURS ANNUALLY. Form 990, Part VI, Section C, line 19 THE ORGANIZATION PROVIDES A COPY OF ITS FORM 990 TO ANYONE WHO REQUESTS A COPY. OTHER DOCUMENTS ARE NOT MADE AVAILABLE. FORM 990, PART XI, LINE 2C: AUDITED FINANCIAL STATEMENT THERE WAS NO CHANGE IN THE PROCESS FROM PRIOR YEAR. FORM 990, SCHEDULE R, PART V: SCHEDULE R DISCLOSURES: ALL TRANSACTIONS REPORTED IN THIS SECTION ARE BASED UPON CORPORATE BOOKS AND RECORDS WHICH ARE KEPT ACCORDING TO GENERALLY ACCEPTED ACCOUNTING PRINCIPALS. FORT MADISON PROFESSIONAL BUILDING ASSOCIATION PO BOX 174 FORT MADISON IA 52627 421298064 SUPPORT FORT MADISON COMMUNITY HOSPITAL IA 501(C)(3) 11(A) FORT MADISON COMMUNITY HOSPITAL FORT MADISON COMMUNITY HOSPITAL FOUNDATION HIGHWAY 61 WEST FORT MADISON IA 52627 421446727 SUPPORT FORT MADISON COMMUNITY HOSPITAL IA 501(C)(3) 11(A) FORT MADISON COMMUNITY HOSPITAL RENAISSANCE HEALTH SERVICES INC HIGHWAY 61 WEST FORT MADISON IA 52627 421298222 MEDICAL SERVICE IA FORT MADISON PROFESSIONAL BUILDING ASSOCIATION C 13 13307 1.00000 0 1 1 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 FORT MADISON PROFESSIONAL BUILDING ASSOCIATION J 409940 FORT MADISON PROFESSIONAL BUILDING ASSOCIATION C 250000 FORT MADISON PROFESSIONAL BUILDING ASSOCIATION K 26460 FORT MADISON COMMUNITY HOSPITAL FOUNDATION B 6883