2014-08-15T14:37:31-05:00 2013-09-30 390758449 WIPFLI LLP 3703 OAKWOOD HILLS PARKWAY EAU CLAIRE WI 54701 990 2012-10-01 204560540 MIDWEST MEDICAL CENTER MIDW 8157771340 ONE MEDICAL CENTER DRIVE GALENA IL 61036 TRACY BAUER 8157771340 2014-08-13 1 HOLLY POKRANDT CPA P00449155 7158323407 2014-08-13 2012 2015-11-30 17:44:51Z TRACY BAUER ONE MEDICAL CENTER DRIVE GALENA IL 61036 18896833 0 X WWW.MIDWESTMEDICALCENTER.ORG X 2006 IL TO PROVIDE HEALTHCARE SERVICES TO THE RESIDENTS OF THE CITY OF GALENA, ILLINOIS AND THE SURROUNDING AREA REGARDLESS OF A PATIENT'S ABILITY TO PAY. 10 10 226 0 30899 -6350 141373 79512 18561798 18754974 168942 35731 -54585 -61072 18817528 18809145 8523 7763 0 0 7830686 7972988 0 0 0 12530635 11757329 20369844 19738080 -1552316 -928935 47106686 45971126 50165610 49958985 -3058924 -3987859 X MIDWEST MEDICAL CENTER, INCLUDING THE GALENA-STAUSS SENIOR CARE COMMUNITY, WILL PROVIDE TO THE MEMBERS OF THE COMMUNITY CARING, COMPETENT, AND COST EFFECTIVE HEALTHCARE. 0 0 12446528 7763 13628682 MIDWEST MEDICAL CENTER OWNS AND OPERATES A 25-BED CRITICAL ACCESS HOSPITAL, AND LEADS IN THE DELIVERY OF HEALTHCARE SERVICES TO ITS REGION WITH OVER 200 ASSOCIATES, INCLUDING 17 PHYSICIANS AND ONE MID-LEVEL PRACTITIONER, WHICH COORDINATE PATIENT CARE AS AN INTEGRATED UNIT. THE HOSPITAL AND ITS ASSOCIATES WORK SEAMLESSLY TO MEET THE NEEDS OF THE COMMUNITIES THEY SERVE. THE ACCOMPLISHMENTS WHICH FOLLOW ARE ATTRIBUTABLE TO THE HOSPITAL AND ALL OF ITS DEPARTMENTS AS A WHOLE.REQUIREMENTS OF THE IRS COMMUNITY BENEFIT STANDARD FOR TAX-EXEMPT ORGANIZATIONS ARE A KEY COMPONENT TO THE ORGANIZATION'S LARGER CHARITABLE MISSION OF IMPROVING HEALTH AND QUALITY OF LIFE. SPECIFICALLLY, THE ORGANIZATION IS GOVERNED BY AN INDEPENDENT BOARD OF DIRECTORS, WHICH INCLUDES COMMUNITY LEADERS, CONSUMER REPRESENTATIVES, AND BUSINESS AND CLINICAL HEALTHCARE EXPERTS. THE BOARD OF DIRECTORS IS COMMITTED TO ACTING WITH THE HIGHEST INTEGRITY AND HAS BEEN PROACTIVELY EVALUATING OPPORTUNITIES TO VOLUNTARILY ADOPT GOVERNANCE BEST PRACTICES TO ENSURE THE ORGANIZATION CONTINUES TO OPERATE SOLELY FOR THE BENEFIT OF THE COMMUNITY. DURING THE YEAR, THE BOARD WORKED WITH MANAGEMENT TO OVERSEE CRITICAL FUNCTIONS OF THE ORGANIZATION. FOR EXAMPLE:-THE COMPLIANCE COMMITTEE OF THE BOARD WAS ASSIGNED RESPONSIBILITY FOR OVERSIGHT OF THE CORPORATE COMPLIANCE PLAN AND FOR OVERSIGHT OF DEFINED COMPONENTS OF THE ORGANIZATION'S INTERNAL CONTROL FUNCTIONS.-POLICIES CURRENTLY EXIST THAT REGULATE DOCUMENT RETENTION/DESTRUCTION AND WHISTLEBLOWER PROTECTION.-POLICIES ON CONFIDENTIALITY OF PATIENT AND CORPORATE INFORMATION ARE REVIEWED ANNUALLY AS A COMPONENT OF MANDATORY EDUCATION, AND A CONFIDENTIALITY STATEMENT IS SIGNED ANNUALLY BY ALL EMPLOYEES AND BOARD MEMBERS.-THE ORGINAZATION'S CODE OF ETHICS/CODE OF CONDUCT IS PUBLISHED IN THE EMPLOYEE AND PHYSICIAN HANDBOOKS AND INCLUDED IN THE GENERAL ORIENTATION OF ALL NEW EMPLOYEES AND VOLUNTEERS. ALSO, AN ETHICS HOTLINE POLICY WAS IMPLEMENTED IN JANUARY 2013.THE HOSPITAL ALSO MAKES MEDICAL CARE ACCESSIBLE TO THE ENTIRE REGION IT SERVES. THE HOSPITAL OPERATES A FULL-TIME EMERGENCY ROOM AND PROVIDES EMERGENCY CARE REGARDLESS OF ABILITY TO PAY. THE HOSPITAL HAD OVER 3,800 EMERGENCY CENTER VISITS DURING FISCAL YEAR 2013. THE HOSPITAL PROVIDES CLINICAL AND ANCILLARY SERVICES REQUIRED TO SUPPORT THE EMERGENCY CENTER INCLUDING DIAGNOSTIC TESTING SUCH AS LABORATORY, RADIOLOGY, CT SCANNING, AND MRI SCANNING SERVICES. FULL-TIME ON-SITE EMERGENCY MEDICAL PHYSICIANS ARE PROVIDED THROUGH AN ARRANGEMENT WITH THE UNIVERSITY OF ILLINOIS-CHICAGO PHYSICIANS.IN ADDITION, MIDWEST MEDICAL CENTER PROVIDES NON-EMERGENCY SERVICES TO THE REGION IT SERVES. IT MAKES THESE SERVICES ACCESSIBLE TO THE REGION THROUGH PARTICIPATION IN GOVENMENT PROGRAMS LIKE MEDICARE AND MEDICAID AND BY OFFERING ASSISTANCE THROUGH THE HOSPITAL'S CHARITY CARE PROGRAM.THE HOSPITAL'S CHARITY CARE POLICY PROVIDES DISCOUNTED AND FREE SERVICES TO PATIENTS WHO LACK THE RESOURCES TO BE FULLY RESPONSIBLE FOR THE HEALTH CARE THEY RECEIVE. THE HOSPITAL'S CHARITY CARE POLICY IS DESIGNED TO ENSURE THAT THE ENTIRE REGION IS SERVED BY THE HOSPITAL AND HAS ACCESS TO NEEDED HEALTHCARE SERVICES. THE HOSPITAL'S BOARD OF DIRECTORS OVERSEES THE SERVICES DELIVERED UNDER THE HOSPITAL'S CHARITY CARE POLICY, INCLUDING ASSESSING HEALTH NEEDS OF THE REGION, APPROVING ELIGIBILITY CRITERIA, AND MONITORING THE EFFECTIVENESS OF THE PROGRAM IN PROVIDING REGIONAL ACCESS TO MEDICAL CARE.ELIGIBILITY FOR DISCOUNTED OR FREE SERVICES UNDER THE CHARITY CARE POLICY IS BASED ON INCOME LEVELS AND FAMILY SIZE. GENERALLY, INDIVIDUALS EARNING INCOME OF UP TO 300% OF THE FEDERAL POVERTY INCOME GUIDELINES ARE ELIGIBLE FOR VARYING LEVELS OF DISCOUNTS, INCLUDING FULL DISCOUNTS FOR CERTAIN INCOME LEVELS. IN ADDITION, AN AUTOMATIC DISCOUNT OF CHARGES IS PROVIDED TO ANY PATIENT THAT IS DETERMINED TO NOT HAVE INSURANCE OF ANY TYPE. APPLICATIONS FOR COVERAGE UNDER THE PROGRAM MAY BE OBTAINED AT ANY DESIGNATED HOSPITAL PATIENT REGISTRATION AREA OR BY CALLING THE HOSPITAL'S BUSINESS OFFICE.THE HOSPITAL MAINTAINS RECORDS TO IDENTIFY AND MONITOR THE LEVEL OF CARE PROVIDED UNDER THE CHARITY CARE PROGRAM. THESE RECORDS INCLUDE THE AMOUNT OF CHARGES FOREGONE FOR SERVICES AND SUPPLIES FURNISHED UNDER ITS CHARITY CARE POLICY. THE HOSPITAL REDUCED CHARGES TO PATIENTS UNDER THE CHARITY CARE PROGRAM FOR THE YEAR ENDED 2013 BY APPROXIMATELY $232,000. (SEE ADDITIONAL INFORMATION REGARDING THE COST OF PROVIDING CHARITY CARE IN SCHEDULE H TO THE FORM 990.)THE HOSPITAL TAKES ITS MISSION TO IMPROVE THE HEALTH AND QUALITY OF LIFE OF THE PEOPLE IT SERVES A STEP FURTHER BY REACHING OUT TO MEET THE BROAD HEALTH NEEDS OF THE REGION IT SERVES. THE HOSPITAL STRIVES TO IDENTIFY THE NEEDS OF THE REGION BEYOND BASIC HEALTHCARE, AND THEN RESPONDS TO THEM BY AIMING TO MAKE A POSITIVE, LIFE-ENHANCING DIFFERENCE IN THE REGION. THE HOSPITAL TAKES A STRATEGIC, REGIONAL NEEDS BASED APPROACH TO DELIVERING BENEFITS TO THE REGION. THE HOSPITAL HAS RESPONSIBILITY FOR LEADING THE ORGANIZATION TO ACHIEVE THESE OBJECTIVES:1. COLLABORATE WITH COMMUNITIES TO IDENTIFY UNMET COMMUNITY HEALTH NEEDS AND UNDERSERVED POPULATIONS.2. ADDRESS UNDERSERVED POPULATIONS AND UNMET NEEDS.3. IMPROVE THE HEALTH OF THE COMMUNITIES.THIS POSITION LINKS ALL COMMUNITY BENEFITS ACTIVITIES UNDER ONE MANAGEMENT UMBRELLA WITH A CONSISTENT CONTACT POINT. ORGANIZATIONAL FOCUS ON COMMUNITY BENEFIT HAS BEEN ELEVATED BY STRENGTHENING INFRASTRUCTURE TO SUPPORT AND COMMUNICATE COMMUNITY BENEFIT WORK.THE HOSPITAL DEMONSTRATES ITS COMMITMENT TO PROVIDING COMMUNITY BENEFIT THROUGH THE FOLLOWING SPECIFIC ACCOMPLISHMENTS:THE HOSPITAL IS A NON-PROFIT CORPORATION PROVIDING HEALTHCARE AND RESIDENTIAL SERVICES IN GALENA, ILLINOIS AND NEIGHBORING COMMUNITIES. ALL OF THESE SERVICES ARE OFFERED UNDER THE MISSION OF THE ORGANIZATION, WHICH STATES THAT "MIDWEST MEDICAL CENTER, INCLUDING THE GALENA-STAUSS SENIOR CARE COMMUNITY, WILL PROVIDE TO THE MEMBERS OF THE COMMUNITY CARING, COMPETENT, AND COST EFFECTIVE HEALTHCARE." IN FISCAL YEAR 2013 THE HOSPITAL PROVIDED 415 ACUTE INPATIENT DAYS, 1,237 SWING BED DAYS, 3,812 EMERGENCY ROOM VISITS, 5,667 RADIOLOGY SERVICES, 91,373 LABORATORY TESTS, 8,552 PHYSICAL THERAPY TREATMENTS, AND 267 SURGICAL PROCEDURES AMONG MANY OF THE PATIENT SERVICES PROVIDED DURING THE YEAR. 3172796 3477822 MIDWEST MEDICAL CENTER RECOGNIZES THAT THE AGING AND DISABLED POPULATION OF PATIENTS ARE OFTEN AN UNDERSERVED DEMOGRAPHIC OF THE POPULATION AND TO MEET THE HEALTHCARE NEEDS OF THESE PATIENTS THE HOSPITAL OPERATES THE GALENA-STAUSS SENIOR CARE COMMUNITY. THIS SENIOR CARE CAMPUS PROVIDES SENIOR CARE SERVICES THROUGH ITS 57-BED LONG-TERM CARE FACILITY, AN ASSISTED LIVING FACILITY, AS WELL AS ADULT DAY CARE SERVICES. THE SENIOR CARE CAMPUS PROVIDED 18,609 DAYS OF SKILLED NURSING AND INTERMEDIATE NURSING HOME CARE DAYS IN ADDITION TO THE ASSISTED LIVING AND ADULT DAY CARE SERVICES. THE SENIOR CARE CAMPUS OFFERS SKILLED NURSING TO RESIDENTS AND PATIENTS IN BOTH SHORT TERM REHABILITATION PROGRAMS AND LONG-TERM CARE RESIDENT PROGRAMS. SOME OF THE SPECIALIZED CARE SERVICES OFFERED INCLUDE IV THERAPY, WOUND CARE, PHYSICAL THERAPY, OCCUPATIONAL THERAPY, AND SPEECH THERAPY AMONG MANY OF THE CARE PROGRAMS PROVIDED. THE SENIOR CARE CAMPUS OPERATES IN CONJUNCTION WITH THE MIDWEST MEDICAL CENTER HOSPITAL TO PROVIDE A SMOOTH TRANSITION FOR PATIENTS NEEDING EXTENDED REHABILITATION OR LONG-TERM CARE SERVICES. THE COORDINATION OF FACILITIES ALSO ALLOWS THE ORGANIZATION TO SHARE MANY DEPARTMENTS AND SERVICES IN MIDWEST MEDICAL CENTER'S CONTINUED EFFORT TO PROVIDE HIGH QUALITY AND LOW COST CARE TO THE COMMUNITY. 2684959 1617571 MIDWEST MEDICAL CENTER ALSO OPERATES A PHYSICIAN CLINIC KNOWN AS THE MIDWEST HEALTH CLINIC. A TOTAL OF 9,924 CLINIC VISITS WERE PROVIDED DURING FISCAL YEAR 2013. THE CARE IN THE MIDWEST HEALTH CLINIC IS COORDINATED WITH THE CARE OF MIDWEST MEDICAL CENTER'S HOSPITAL IN AN EFFORT TO CONTINUE TO PROVIDE LOW COST AND HIGH QUALITY PATIENT CARE FOR THE RESIDENTS OF GALENA, ILLINOIS AND THE SURROUNDING AREAS. THE HEALTH CLINIC OPERATES AS A PROVIDER-BASED RURAL HEALTH CLINIC TO MIDWEST MEDICAL CENTER'S HOSPITAL AND THE PRACTICE IS MADE UP OF THREE FAMILY PRACTICE PHYSICIANS, AN INTERNAL MEDICINE PHYSICIAN, AND ONE MID-LEVEL PRACTITIONER. ADDITIONAL SERVICES ARE ALSO PROVIDED IN THE CLINIC BY OUTREACH DOCTORS THAT PROVIDE SERVICES ON A LIMITED BASIS IN THE AREAS OF ORTHOPEDIC SURGERY, GENERAL SURGERY, PODIATRY, AND PLASTIC SURGERY.THE CLINIC PROVIDERS ALSO ENGAGE IN MANY ACTIVITIES WHICH PROMOTE THE WELL-BEING OF THE COMMUNITY AND PROVIDE HEALTH EDUCATION TO THE COMMUNITY. AN EXAMPLE OF THESE SERVICES IS DR. WELLS, WHO IS ON STAFF AT THE UNIVERSITY OF ILLINOIS ROCKFORD MEDICAL SCHOOL AND PROVIDES EDUCATIONAL EXPERIENCES AND TRAINING TO MEDICAL STUDENTS AT THE MIDWEST HEALTH CLINIC FOR THOSE STUDENTS INTERESTED IN LEARNING ABOUT RURAL MEDICINE. ANOTHER EXAMPLE IS DR. MATT GULLONE, WHO SPECIALIZES IN SPORTS MEDICINE AND PROVIDES FREE CARE TO LOCAL ATHLETES DURING SPORTING EVENTS. DR. BETH GULLONE AND PEG DITTMAR, ANP, ALSO PROVIDE BREAST CANCER EDUCATION TO SEVERAL GROUPS WITHIN JO DAVIESS COUNTY. 18304283 1 1 0 1 0 0 0 0 0 1 1 0 1 0 1 1 0 1 0 0 0 0 0 0 1 0 1 1 0 1 1 1 0 0 0 0 0 1 0 0 1 0 0 0 0 0 0 1 0 0 0 1 37 0 226 1 1 1 0 0 0 0 0 0 0 0 0 X 10 10 0 0 0 0 0 0 1 1 1 0 0 1 1 1 1 1 1 1 1 0 IL X TRACY BAUER 8157771340 ONE MEDICAL CENTER DRIVE GALENA IL 61036 X HELEN KILGORE 2.00 X 0 0 0 FRANK WAITES 2.00 0.50 X 0 0 0 VINCE TOEPFER 2.00 X 0 0 0 CAROL WRABL 2.00 X 0 0 0 ROY CLINGMAN 2.00 X 0 0 0 DAVID HEY 2.00 X 0 0 0 MARY ROONEY-SHEAHEN RN 2.00 0.50 X X 0 0 0 CHERYL FARRUGGIA 2.00 0.50 X X 0 0 0 WILLIAM MORDEN 2.00 0.50 X X 0 0 0 ROBERT MILLER 2.00 0.50 X X 0 0 0 TRACY BAUER 50.00 X 155411 0 34877 JENNIFER STEINES 50.00 X 89001 0 13660 DEBRA HOPPMAN 50.00 X 116058 0 4771 MICHAEL WELLS MD 36.00 X 161678 0 33469 ELIZABETH GULLONE MD 36.00 X 163999 0 26776 MATTHEW GULLONE MD 36.00 X 172121 0 18696 DEBBIE CIHAK MD 40.00 X 278511 0 26766 1136779 0 159015 6 0 1 0 MICHAEL GREEN MD 1340 W NEWPORT CHICAGO IL 60657 ER PHYSICIAN COVERAGE 204816 BIKRAM DHILLON MD 432 JASON COURT SCHAUMBURG IL 60173 ER PHYSICIAN COVERAGE 183805 RALPH LOSEY MD 207 SOUTH PROSPECT STREET GALENA IL 61036 ER PHYSICIAN COVERAGE 166983 JOSEPH COLLA MD 41 EAST 8TH STREET APT 3304 CHICAGO IL 60605 ER PHYSICIAN COVERAGE 123120 HINSHAW & CULBERTSON LLP 8142 SOLUTIONS CENTER DRIVE CHICAGO IL 60677 LEGAL 111456 5 316 24522 46867 7807 79512 HOSPITAL PATIENT REVENUE 621990 13278591 13278591 SENIOR CARE REVENUE 623000 3477822 3477822 CLINIC REVENUE 621110 1648470 1617571 30899 CAFETERIA REVENUE 621990 226173 226173 FITNESS CENTER REVENUE 621990 123918 123918 18754974 34034 34034 5824 78390 -72566 -72566 -72566 1697 0 1697 1697 1697 20792 316 9298 11494 11494 18809145 18724075 30899 -25341 7763 7763 275850 275850 6181883 5872723 309160 169505 161030 8475 912703 867068 45635 433047 395422 37625 111456 111456 1346211 1346211 968623 323027 645596 3540621 3540621 78565 78565 2281052 2281052 240542 240542 MEDICAL SUPPLIES 2344077 2344077 PROVISION FOR BAD DEBT 505327 505327 FOOD AND DIETARY SUPPLI 340855 340855 19738080 18304283 1433797 0 1592769 1070433 3269698 2461604 18684 24441 327426 314641 358154 319266 58880 79818 54829107 21698666 33118905 33130441 7536457 7611740 3256 0 822457 958742 47106686 45971126 2778237 2774259 45485000 45135208 1955433 1902373 94085 50165610 49958985 X -4512380 -5442756 1254807 1256248 198649 198649 -3058924 -3987859 47106686 45971126 -928935 0 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 9091 9091 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: MIDWEST MEDICAL CENTER PAYS ANNUAL ASSOCIATION MEMBERSHIP DUES TO THE ILLINOIS HOSPITAL ASSOCIATION (IHA) AND THE ILLINOIS CRITICAL ACCESS HOSPITAL NETWORK (ICAHN). THESE DUES ARE PRIMARILY TO ACCESS EDUCATIONAL MATERIALS AND FOR STAFF TRAINING AND MATERIALS. THE ORGANIZATIONS RECOGNIZE THAT A PORTION OF THE ACTIVITIES CONDUCTED BY BOTH IHA AND ICAHN ARE FUNDED IN CONJUNCTION WITH THE TOTAL ANNUAL DUES PAID. MIDWEST MEDICAL CENTER ESTIMATED THAT $9,091 OUT OF THE TOTAL DUES PAID TO IHA AND ICAHN WERE USED IN CONJUNCTION WITH LOBBYING ACTIVITIES WITH THE GOAL OF IMPROVING THE OVERALL HEALTHCARE ENVIRONMENT IN ILLINOIS. 341497 1696 500 342693 342707 650 1860 341497 345853 439 3585 342707 354096 1314 9557 345853 349405 6191 1500 354096 0.00000 0.57970 0.42030 0 0 559916 559916 42874568 14412856 28461712 9750113 7285810 2464303 1644510 1644510 33130441 BOARD DESIGNATED INVESTMENTS FOR CAP. IMPROVEMENTS 1153280 C UNDER BOND AGREEMENT-RESERVE FUNDS 3420146 F UNDER BOND AGREEMENT-PRINCIPAL/INTEREST FUNDS 1893850 F DONOR RESTRICTED-MEDICAL SCHOLARSHIPS 1144464 C 7611740 SECURITY DEPOSITS HELD 94085 94085 X DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: THE ENDOWMENTS CONSIST OF TWO DONOR-RESTRICTED FUNDS, WHICH WERE ESTABLISHED TO PROVIDE INVESTMENT INCOME FOR MEDICAL EDUCATION SCHOLARSHIPS. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X, LINE 2: THE SYSTEM AND ITS AFFILIATES ARE NONPROFIT CORPORATIONS AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE (THE "CODE") AND ARE EXEMPT FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE CODE. THE SYSTEM AND ITS AFFILIATES ARE ALSO EXEMPT FROM STATE INCOME TAXES ON RELATED INCOME. THE SYSTEM IS ALSO ENGAGED, TO A LIMITED EXTENT, IN CERTAIN ACTIVITIES SUBJECT TO TAXATION AS UNRELATED BUSINESS INCOME (UBI). THE UBI IS NOT SIGNIFICANT. IN ORDER TO ACCOUNT FOR ANY UNCERTAIN TAX POSITIONS, THE SYSTEM DETERMINES WHETHER IT IS MORE LIKELY THAN NOT THAT A TAX POSITION WILL BE SUSTAINED UPON EXAMINATION OF THE TECHNICAL MERITS OF THE POSITION, ASSUMING THE TAXING AUTHORITY HAS FULL KNOWLEDGE OF ALL INFORMATION. IF THE TAX POSITION DOES NOT MEET THE MORE LIKELY THAN NOT RECOGNITION THRESHOLD, THE BENEFIT OF THAT POSITION IS NOT RECOGNIZED IN THE CONSOLIDATED FINANCIAL STATEMENTS. THE SYSTEM HAS NOT RECORDED ANY ASSETS OR LIABILITIES RELATED TO UNCERTAIN TAX BENEFITS OR UNRECOGNIZED TAX BENEFITS AS OF SEPTEMBER 30, 2013 OR 2012. FEDERAL TAX RETURNS FOR THE FISCAL YEARS SEPTEMBER 30, 2010, AND BEYOND REMAIN SUBJECT TO EXAMINATION BY THE INTERNAL REVENUE SERVICE. GOLF OUTING 21108 316 20792 900 3988 2710 1700 21108 316 20792 900 3988 2710 1700 9298 11494 1 1 1 X 1 X 1 1 1 0 0 193153 193153 0.01000 3383093 1910632 1472461 0.07660 3576246 1910632 1665614 0.08660 4997765 3022921 1974844 0.10270 10328 10328 0.00050 5008093 3022921 1985172 0.10320 8584339 4933553 3650786 0.18980 0 420229 210114 7945588 7973380 -27792 X 1 1 1 1 MIDWEST MEDICAL CENTER

ONE MEDICAL CENTER DRIVE GALENA IL 61036

WWW.MIDWESTMEDICALCENTER.ORG X X X X PROVIDER BASED RURAL HEALTH CLINIC MIDWEST MEDICAL CENTER 1 1 X X X X X X X X X 12 1 0 1 X X X X X X X X X 0 0 1 1 150.000000000000 1 300.000000000000 1 X X X 1 1 X X X 1 X X X 1 X X X X X X 1 X 0 0 1 GALENA-STAUSS SENIOR CARE CAMPUS

215 SUMMIT STREET GALENA IL 61036

SKILLED NURSING FACILITY, ASSISTED LIVING, AND ADULT DAY CARE PART I, LINE 3C: MIDWEST MEDICAL CENTER PRIMARILY USES FEDERAL POVERTY GUIDELINES TO ESTABLISH CHARITY OR DISCOUNTED CARE TO THOSE IN NEED OF CARE IN THE COMMUNITY, HOWEVER THERE ARE OTHER CONSIDERATIONS GIVEN TO PATIENTS TO AVOID HAVING PATIENTS BE IN FINANCIAL DISTRESS DUE TO CONCERNS OVER THEIR MEDICAL BILLS. BELOW ARE THE GENERAL GUIDELINES AS DEFINED IN MIDWEST MEDICAL CENTER'S CHARITY CARE POLICY WHICH ARE FOLLOWED BY THE ORGANIZATION:PATIENT ACCOUNT GUARANTORS WITH AN ADJUSTED GROSS INCOME AT OR BELOW 150% OF THE FEDERAL POVERTY GUIDELINES FOR THE NUMBER OF DEPENDENTS IN THE DEBTOR'S HOUSEHOLD WILL BE ELIGIBLE FOR 100% CHARITY CARE.PATIENT ACCOUNT GUARANTORS WITH AN ADJUSTED GROSS INCOME GREATER THAN 150%, BUT EQUAL TO OR LESS THAN 300% OF THE FEDERAL POVERTY GUIDELINES FOR THE NUMBER OF DEPENDENTS IN THE DEBTOR'S HOUSEHOLD, WILL BE ELIGIBLE FOR PARTIAL FINANCIAL ASSISTANCE.PATIENT ACCOUNT GUARANTORS WITH INSUFFICIENT ASSETS TO PAY THE AMOUNT DUE, AND WHO DO NOT QUALIFY FOR CHARITY CARE ON THE BASIS OF THE FEDERAL POVERTY GUIDELINES, WILL BE ELIGIBLE FOR A CATASTROPHIC CHARITY ADJUSTMENT WHEN THE TOTAL AMOUNT DUE TO MIDWEST MEDICAL CENTER EQUALS AT LEAST 20% OF THE DEBTOR'S ADJUSTED GROSS INCOME. CATASTROPHIC CHARITY IS AN EIGHTY PERCENT (80%) ADJUSTMENT OFF BILLED CHARGES FOR MEDICALLY NECESSARY SERVICES. PART I, LINE 7: THE COSTING METHOD USED ON FORM 990 IS BASED ON A COST TO CHARGE RATIO WHICH IS DEVELOPED BASED ON THE HOSPITAL'S TOTAL OPERATING EXPENSES (EXCLUDING THE PROVISION FOR BAD DEBTS) DIVIDED BY GROSS PATIENT SERVICE REVENUE. THIS COST TO CHARGE RATIO IS APPLIED AGAINST VARIOUS REVENUE AND EXPENSE CATEGORIES TO COMPUTE THE ESTIMATED COMMUNITY BENEFIT EXPENSE UNDER IRS SUGGESTED COSTING METHODS FOR THE FORM 990. (THE COSTING METHODOLOGY FOR SUBSIDIZED HEALTH SERVICES FOR LINE 7G OF SCHEDULE H OF THE FORM 990 IS BASED ON COST ALLOCATIONS FROM THE MEDICARE COST REPORT. THIS ALLOCATION METHOD AND PRINCIPLES OF ALLOCATION WERE USED TO DERIVE A SPECIFIC AMOUNT OF COST ALLOCATION TO THE VARIOUS PROGRAMS AND COST CENTERS OPERATED BY THE HOSPITAL.) PART I, LINE 7G: SUBSIDIZED HEALTH SERVICES AT MIDWEST MEDICAL CENTER INCLUDES THE OPERATION OF SEVERAL DEPARTMENTS. THESE DEPARTMENTS AND SERVICES INCLUDE: THE ADULTS AND PEDIATRICS HOSPITAL INPATIENT UNIT AND THE EMERGENCY ROOM UNIT. A MAJORITY OF THESE DEPARTMENTS ARE OPERATED, OR ARE KEPT AT MINIMAL STAFFING LEVELS, IN ORDER TO PROVIDE ACCESS TO THE EMERGENCY ROOM OR EMERGENCY INPATIENT CARE OR CRITICAL CARE SERVICES WHICH SUPPLEMENT OTHER SERVICES AT THE HOSPITAL OR ARE BASED ON NEEDS IN THE COMMUNITY. THE EMERGENCY ROOM AND INPATIENT UNIT ARE STAFFED 24 HOURS PER DAY TO PROVIDE NEEDED ACCESS TO EMERGENCY CARE IN THE GALENA, ILLINOIS COMMUNITY OR AS REQUIRED BY REGULATIONS TO BE ON-CALL AND AVAILABLE TO PROVIDE ACCESS TO EMERGENCY INPATIENT CARE AS A PART OF OPERATING A HOSPITAL IN THE STATE OF ILLINOIS. THE INPATIENT UNIT ALSO PROVIDES CARE TO OVERNIGHT OBSERVATION PATIENTS WHICH ARE KEPT FOR OBSERVATION IN FOLLOW UP CARE FROM THE EMERGENCY ROOM AS WELL AS PROVIDING A SIGNIFICANT NUMBER OF SWING BED SERVICES. IN THE PAST, THERE WAS NO MEDICARE CERTIFIED NURSING HOME IN THE CITY OF GALENA, ILLINOIS OR IN THE IMMEDIATE SURROUNDING AREA AND AS OF FISCAL YEAR 2013 THERE ARE ONLY 5 MEDICARE CERTIFIED SKILLED NURSING BEDS IN JO DAVIESS COUNTY, ILLINOIS. IN RESPONSE TO THE NEED IN THE SURROUNDING AREA, THE HOSPITAL PARTICIPATES IN THE MEDICAL RURAL HOSPITAL SWING BED PROGRAM WHICH PROVIDES SKILLED NURSING CARE IN AVAILABLE BEDS IN THE HOSPITAL INPATIENT UNIT. IT IS THE GOAL OF MIDWEST MEDICAL CENTER TO PROVIDE THESE SERVICES TO THE COMMUNITY REGARDLESS OF A PATIENT'S ABILITY TO PAY. PART I, L7 COL(F): THE COSTING METHOD AND CALCULATIONS USED ON FORM 990 ARE BASED ON TOTAL OPERATING EXPENSES EXCLUDING BAD DEBT EXPENSE. THE COMMUNITY BENEFIT EXPENSE PERCENTAGES ARE CALCULATED BY DIVIDING THE COMMUNITY BENEFIT EXPENSE FOR EACH CATEGORY OF COMMUNITY SERVICES PROVIDED BY MIDWEST MEDICAL CENTER REPORTED IN THE TABLE ON LINE 7 PART I OF THE SCHEDULE H BY THE TOTAL OPERATING EXPENSES OF THE HOSPITAL LESS THE PROVISION FOR BAD DEBTS OF $505,327. PART II: WHILE THERE IS GROWING AGREEMENT IN THE UNITED STATES ABOUT WHAT CONSTITUTES A NON-PROFIT HOSPITAL'S "COMMUNITY BENEFIT," THESE EFFORTS CONTINUE TO BE A WORK IN PROGRESS. MIDWEST MEDICAL CENTER PROVIDES SIGNIFICANT CHARITY CARE AND OTHER COMMUNITY BENEFITS AS DEFINED BY THE IRS AND IN ADDITION, THE ORGANIZATION BELIEVES THAT IT PROVIDES A CRITICALLY IMPORTANT BENEFIT WHICH IS NOT QUANTIFIED. MIDWEST MEDICAL CENTER, LIKE MOST COMMUNITY HOSPITALS, WAS CREATED AND IS MAINTAINED IN ORDER TO PROVIDE CARE LOCALLY WHICH WITHOUT THE HOSPITAL, WOULD NOT BE AVAILABLE LOCALLY. PART III, LINE 4: MANAGEMENT PROVIDES FOR PROBABLE UNCOLLECTIBLE AMOUNTS, PRIMARILY UNINSURED PATIENTS AND AMOUNTS PATIENTS ARE PERSONALLY RESPONSIBLE FOR, THROUGH A CHARGE TO OPERATIONS AND A CREDIT TO A VALUATION ALLOWANCE BASED ON ITS ASSESSMENT OF HISTORICAL COLLECTION LIKELIHOOD AND THE CURRENT STATUS OF INDIVIDUAL ACCOUNTS. BALANCES THAT ARE STILL OUTSTANDING AFTER THE ORGANIZATION HAS USED REASONABLE COLLECTION EFFORTS ARE WRITTEN OFF THROUGH A CHARGE TO THE VALUATION ALLOWANCE AND A CREDIT TO ACCOUNTS RECEIVABLE. MANY TIMES PATIENTS DO NOT COMPLETE THE REQUIRED CHARITY CARE APPLICATION AND ARE TRANSFERRED TO COLLECTION SERVICES EVEN THOUGH THE HOSPITAL PROVIDES THIS INFORMATION TO ALL PATIENTS AND ASSISTANCE WITH THE APPLICATIONS. DUE TO NO RESPONSES FROM SOME PATIENTS, A SIGNIFICANT AMOUNT OF BAD DEBTS COULD BE CONSIDERED AS CHARITY CARE AND THE HOSPITAL HAS REFLECTED AN ESTIMATED AMOUNT OF THESE ADDITIONAL BAD DEBTS IN PART III OF SCHEDULE H OF THE 990.THE COSTING METHODOLOGY USED ON FORM 990 IS BASED ON A COST TO CHARGE RATIO WHICH IS DEVELOPED BASED ON THE HOSPITAL'S TOTAL OPERATING EXPENSES LESS PROVISION FOR BAD DEBTS DIVIDED BY GROSS PATIENT SERVICE REVENUE. THIS COST TO CHARGE RATIO IS APPLIED AGAINST THE TOTAL CHARGES THAT ARE WRITTEN OFF DURING THE FISCAL YEAR TO ESTIMATE THE COST OF THE CARE OF PATIENTS THAT HAVE ACCOUNTS THAT ARE DEEMED TO BE BAD DEBTS TO THE HOSPITAL. THE HOSPITAL ALSO RECOGNIZES THAT IT PROVIDES A DISCOUNT TO SELF-PAY OR UNINSURED PATIENTS. THESE AMOUNTS ARE INCLUDED IN THE CONTRACTUAL ADJUSTMENTS ON THE FINANCIAL STATEMENTS AND ARE NOT INCLUDED IN THE RATIO AS DESCRIBED ABOVE AND APPROVED BY THE IRS FOR USE ON FORM 990. IF CONSIDERED, THESE ADDITIONAL WRITE-OFF AMOUNTS TO UNINSURED ACCOUNTS WOULD ALSO INCREASE THE ESTIMATED BAD DEBT EXPENSE AMOUNT ASSOCIATED WITH THESE UNCOLLECTIBLE ACCOUNTS TO THE HOSPITAL. THE AUDITED FINANCIAL STATEMENTS DO NOT CONTAIN A SEPARATE FOOTNOTE REGARDING BAD DEBT EXPENSE. PART III, LINE 8: THE TOTAL MEDICARE REVENUE SHOWN IN SCHEDULE H TO THE FORM 990 IS BASED ON THE IRS 990 INSTRUCTIONS AND INCLUDES ONLY A PORTION OF THE GROSS MEDICARE REVENUE OF THE HOSPITAL, AND ALSO DOES NOT CONSIDER ALL CONTRACTUAL ADJUSTMENTS FOR SERVICES REIMBURSED BY THE MEDICARE PROGRAM. AMOUNTS LISTED FOR MEDICARE REVENUES DO NOT INCLUDE PHYSICIAN SERVICES FOR THE COVERAGE OF THE EMERGENCY DEPARTMENT AT THE HOSPITAL AS WELL AS HOSPITAL INPATIENT PHYSICIAN PROFESSIONAL SERVICES, SURGICAL PHYSICIAN PROFESSIONAL SERVICES, RADIOLOGY PHYSICIAN PROFESSIONAL SERVICES, AND REVENUES FOR ANY PATIENTS COVERED UNDER MEDICARE ADVANTAGE PLAN PROGRAMS. PHYSICIAN PROFESSIONAL SERVICES ARE REIMBURSED PRIMARILY ON FEE SCHEDULE REIMBURSEMENTS AT RATES THAT ARE OFTEN BELOW THE COSTS OF CARING FOR PATIENTS. EMERGENCY AND PHYSICIAN SERVICES PROVIDED TO MEDICARE PATIENTS ARE VITAL TO THE WELL-BEING OF THE COMMUNITY AND AS SUCH THESE COSTS AND SHORTFALLS SHOULD ALSO BE CONSIDERED AS AN ADDITIONAL BENEFIT THAT MIDWEST MEDICAL CENTER PROVIDES TO THE COMMUNITY AND SURROUNDING AREAS. THE COSTING METHOD USED ABOVE FOR IRS 990 COMPLIANCE REPORTING IS ALSO BASED ON THE FILED MEDICARE COST REPORT FOR THE YEAR ENDED SEPTEMBER 30, 2013, AND DOES NOT CONSIDER MEDICARE NON-ALLOWABLE EXPENSES, AS IT IS BASED ON TOTAL HOSPITAL PATIENT SERVICE REVENUES (IGNORING CONTRACTUAL ADJUSTMENTS ON FEE SCHEDULE REIMBURSED ITEMS AND NON-ALLOWABLE MEDICARE EXPENSES AS NOTED ABOVE). MIDWEST MEDICAL CENTER ALSO SUFFERS A LARGER MEDICARE LOSS NOTED ON THE FORM 990 THAN MANY OTHER CRITICAL ACCESS HOSPITALS DUE TO A REGULATION WHICH AFFECTS LAB REIMBURSEMENT FOR CRITICAL ACCESS HOSPITALS. DUE TO THIS REGULATION, THE HOSPITAL DOES NOT RECEIVE THE FULL COST OF PROVIDING LAB SERVICES TO MEDICARE BENEFICIARIES.WHETHER THERE IS A SHORTFALL OR SURPLUS ON SERVICES PROVIDED TO MEDICARE BENEFICIARIES, THESE PEOPLE, WHO ARE TYPICALLY ELDERLY OR DISABLED MEMBERS OF THE COMMUNITY, ARE AN UNDERSERVED POPULATION WHO EXPERIENCE ISSUES WITH ACCESS TO HEALTHCARE SERVICES. WITHOUT TAX-EXEMPT HOSPITALS PROVIDING MEDICARE PATIENT SERVICES, THE CENTERS FOR MEDICARE AND MEDICAID (CMS) WOULD BEAR THE BURDEN OF DIRECTLY PROVIDING SERVICES TO THE ELDERLY AND DISABLED MEMBERS OF THE COMMUNITY. PART III, LINE 9B: UNDER THE HOSPITAL'S COLLECTION AND CHARITY CARE POLICIES, MIDWEST MEDICAL CENTER MAKES EVERY ATTEMPT TO IDENTIFY AND PROMOTE CHARITY CARE TO PATIENTS. INCLUDED IN THE HOSPITAL'S CHARITY CARE POLICY IT IS NOTED THAT PATIENTS MAY QUALIFY FOR CHARITY CARE EITHER PRIOR TO ADMISSION OR FOLLOWING DISCHARGE. ALL INPATIENT SELF-PAY ADMISSIONS ARE SCREENED BY THE HOSPITAL'S BUSINESS OFFICE OR SOCIAL WORKERS TO ALLOW THESE PATIENTS THE ABILITY TO COMPLETE THEIR APPLICATION DURING THEIR STAY AT THE HOSPITAL, DEPENDING UPON THE PATIENT'S CONDITION, OR THE PATIENT'S RESPONSIBLE PARTY MAY BE CONTACTED TO COMPLETE AND RETURN THE FORMS AT A LATER TIME WHEN THEIR CARE ALLOWS THIS COMPLETION. DURING THE PATIENT ACCOUNT COLLECTION PROCESS, SELF-PAY PATIENTS ARE ALSO INFORMED OF THE HOSPITAL'S COLLECTION POLICIES AS WELL AS THE CHARITY CARE PROGRAM TO ALLOW PATIENTS THE OPPORTUNITY TO COMPLETE THE APPROPRIATE FORMS AND QUALIFY UNDER THE PROGRAM. MIDWEST MEDICAL CENTER PART V, SECTION B, LINE 3: MIDWEST MEDICAL CENTER FORMED THREE FOCUS GROUPS COMPRISED OF AREA HEALTHCARE PROFESSIONALS/PARTNERS, LOCAL OFFICIALS, COMMUNITY LEADERS, AND COMMUNITY OFFICIALS. EACH FOCUS GROUP SESSION RESULTED IN A LIST OF PRIORITIZED HEALTH NEEDS AND ISSUES. MIDWEST MEDICAL CENTER PART V, SECTION B, LINE 7: THERE WERE ITEMS IDENTIFIED IN THE CHNA WHICH WERE NOT ADDRESSED BY MIDWEST MEDICAL CENTER; HOWEVER, ALL ITEMS WERE CONSIDERED IF A NEED WAS BROUGHT TO THE ATTENTION OF THE GROUP DURING THE INFORMATION GATHERING PHASE OF THE CHNA PROCESS. THE ITEMS THAT WERE NOT ADDRESSED PRIMARILY WERE NOT ADDRESSED DUE TO THE FINANCIAL CONSTRAINT OF PROVIDING A NEW SERVICE FOR A LIMITED POPULATION OF PEOPLE WITHIN THE PRIMARY SERVICE AREA. ONE NEED THAT WAS IDENTIFIED BUT IS NOT BEING ADDRESSED INCLUDES IMPROVING ACCESS TO OUT OF AREA NON-EMERGENCY TRANSPORTATION. THIS NEED IS NOT CURRENTLY BEING ADDRESSED AS IT LIES BEYOND THE TRADITIONAL SCOPE OF CARE PROVIDED BY MIDWEST MEDICAL CENTER AND ITS MEDICAL STAFF. MIDWEST MEDICAL CENTER PART V, SECTION B, LINE 14G: THE POLICY IS OFFERED IF A PATIENT STATES ANY PROBLEM IN REGARDS TO PAYING THEIR BILL. THERE IS ALSO A REFERENCE ON ALL PATIENT STATEMENTS THAT STATES FINANCIAL ASSISTANCE IS AVAILABLE. MIDWEST MEDICAL CENTER PART V, SECTION B, LINE 18E: PATIENTS ARE GIVEN THE OPPORTUNITY TO APPLY FOR CHARITY CARE PRIOR TO ANY COLLECTION PRACTICES NOTED EARLIER UNDER POLICIES OF MIDWEST MEDICAL CENTER. THE POLICY AND APPLICATION ARE OFFERED IF A PATIENT STATES ANY PROBLEM IN REGARDS TO PAYING THEIR BILL. THERE IS ALSO A REFERENCE ON ALL PATIENT STATEMENTS THAT STATES FINANCIAL ASSISTANCE IS AVAILABLE. MIDWEST MEDICAL CENTER PART V, SECTION B, LINE 20D: THE HOSPITAL FOLLOWS ITS NORMAL PROCEDURES FOR COLLECTIONS OF THESE ACCOUNTS, INCLUDING DISCOUNTS BASED ON INCOME/ASSET LEVELS AND CATASTROPHIC CHARITY DISCOUNTS. PATIENT ACCOUNT GUARANTORS WITH INSUFFICIENT ASSETS TO PAY THE AMOUNT DUE, AND WHO DO NOT QUALIFY FOR CHARITY CARE ON THE BASIS OF THE FEDERAL POVERTY GUIDELINES, WILL BE ELIGIBLE FOR A CATASTROPHIC CHARITY ADJUSTMENT WHEN THE TOTAL AMOUNT DUE TO MIDWEST MEDICAL CENTER EQUALS AT LEAST 20% OF THE DEBTOR'S ADJUSTED GROSS INCOME. CATASTROPHIC CHARITY IS AN EIGHTY PERCENT (80%) ADJUSTMENT OFF BILLED CHARGES FOR MEDICALLY NECESSARY SERVICES. IN ADDITION, THE MEDICAL CENTER PROVIDES ADDITIONAL DISCOUNTS TO UNINSURED HOSPITAL PATIENTS UNDER THE HOSPITAL UNINSURED PATIENT DISCOUNT ACT AS REQUIRED BY ILLINOIS STATE LAW. PART VI, LINE 2: MIDWEST MEDICAL CENTER ASSESSES THE HEALTH CARE NEEDS OF THE COMMUNITIES AND AREAS IT SERVES BY REVIEWING LOCAL DEMOGRAPHICS AND TRENDS IN PATIENT SERVICE UTILIZATION TO DETERMINE WHICH SERVICES COULD AND SHOULD BE MADE AVAILABLE TO THE COMMUNITY IN A COST-EFFECTIVE MANNER TO BE CONSISTENT WITH MIDWEST MEDICAL CENTER'S MISSION IN THE COMMUNITY. MIDWEST MEDICAL CENTER ALSO REVIEWS STATISTICS IN THE HOSPITAL, CLINIC, AND OTHER ORGANIZATIONAL DEPARTMENTS TO REVIEW THE CURRENT SERVICES BEING OFFERED AND ENSURE THAT RESOURCES ARE BEING APPROPRIATELY ALLOCATED TO AREAS IN NEED BY COMMUNITY MEMBERS AND PATIENTS. THE ORGANIZATION ALSO MEETS WITH LOCAL COMMUNITY MEMBERS AND IT'S PHYSICIAN GROUP TO DETERMINE WHICH SERVICES MAY BENEFIT THE COMMUNITY. DURING FISCAL YEAR 2013, MIDWEST MEDICAL CENTER COMPLETED A FORMALIZED COMMUNITY HEALTH NEEDS ASSESSMENT (CHNA) TO BETTER UNDERSTAND THE HEALTH NEEDS OF THE COMMUNITY. PART VI, LINE 3: UNINSURED AND UNDER INSURED PATIENTS ARE ASKED TO MEET WITH THE ORGANIZATION'S BUSINESS OFFICE EITHER AT THE TIME SERVICE IS PROVIDED OR WHEN THE PATIENT'S BILL IS GENERATED. A HOSPITAL REPRESENTATIVE WILL EXPLAIN THE VARIOUS PAYMENT OPTIONS AVAILABLE TO THE PATIENT AS WELL AS THE HOSPITAL'S CHARITY CARE PROGRAM AND OFFERS THE CHARITY CARE APPLICATION WHEN APPROPRIATE. IF OTHER PROGRAMS ARE AVAILABLE TO THE PATIENT, SUCH AS THE ILLINOIS PUBLIC AID PROGRAMS, THESE PATIENTS ARE REFERRED TO THE APPROPRIATE GOVERNMENT AGENCY FOR FURTHER ASSISTANCE. PART VI, LINE 4: THE PRIMARY SERVICE AREA FOR MIDWEST MEDICAL CENTER ENCOMPASSES ALL PERSONS LIVING WITHIN A 20 TO 30 MILE RADIUS OF THE HOSPITAL. PART VI, LINE 5: MIDWEST MEDICAL CENTER IS AN INDEPENDENT COMMUNITY HOSPITAL GOVERNED BY A 10-MEMBER BOARD OF DIRECTORS WHO RESIDE WITHIN THE PRIMARY SERVICE AREA. SEE ADDITIONAL INFORMATION REGARDING PROMOTION OF COMMUNITY HEALTH IN PART III, LINE 4A OF THE FORM 990. 1 NOTES RECEIVABLE FOR SCHOLARSHIPS FORGIVEN 7763 CURRENT NOTE RECEIVABLE BALANCE FORGIVENESS OF NOTES RECEIVABLE IS GOVERNED BY THE HOSPITAL'S MEDICAL EDUCATION SCHOLARSHIP PROGRAM AND FORGIVENESS IS GRANTED IF INDIVIDUALS FULFILL FUTURE SERVICE REQUIREMENTS WITH MIDWEST MEDICAL CENTER IN HEALTH PROFESSIONAL RELATED FIELDS. THE HOSPITAL TRACKS THIS INFORMATION ANNUALLY AND AWARDS THE FORGIVENESS BASED ON THE COMPLETION OF THE REQUIRED CRITERIA OF THE PROGRAM. PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: MIDWEST MEDICAL CENTER TRACKS THE GRANTS PROVIDED THROUGH THE USE OF NOTES RECEIVABLE AS THE SCHOLARSHIP PROGRAMS ARE INTENDED TO SUPPLEMENT AND BE A FORM OF STUDENT LOANS FOR MEMBERS OF THE COMMUNITY PURSUING ADDITIONAL EDUCATION IN HEALTH RELATED FIELDS. PRIOR TO APPROVING A NOTE TO A PERSPECTIVE STUDENT, AN APPLICATION IS REVIEWED FOR APPROVAL BY THE HOSPITAL'S CONTROLLER TO ENSURE THAT ALL BACKGROUND INFORMATION ON THE CANDIDATE WAS PROVIDED. AFTER REVIEW BY THE CONTROLLER, THIS INFORMATION IS PRESENTED TO THE BOARD OF DIRECTORS FOR REVIEW AND APPROVAL. EACH STUDENT MUST SIGN A PROMISSORY NOTE WITH MIDWEST MEDICAL CENTER THAT THEY COMMIT TO COMPLETE THE EDUCATIONAL PROGRAM AND THAT UPON GRADUATION THEY WILL PERFORM SERVICES FOR MIDWEST MEDICAL CENTER (PENDING AN AVAILABLE POSITION IN THE HOSPITAL AT THE TIME) OR THEY WILL REPAY THE NOTE WITH INTEREST. (THE REPAYMENT TERMS ENSURE THAT THE ENDOWED AND DONATED FUNDS ARE AVAILABLE IN FUTURE YEARS TO OTHER MEMBERS OF THE COMMUNITY OR THAT SERVICES ARE RETURNED TO THE COMMUNITY THROUGH SERVICE TO THE MEDICAL CENTER.) SERVICES PERFORMED AT MIDWEST MEDICAL CENTER RESULT IN FORGIVENESS OF NOTES RECEIVABLE AMOUNTS BASED ON HOURS WORKED. 1 X X 0 0 0 0 0 0 0 0 0 TRACY BAUER 155411 0 0 0 0 0 6518 0 28359 0 190288 0 0 0 MICHAEL WELLS MD 161678 0 0 0 0 0 5110 0 28359 0 195147 0 0 0 ELIZABETH GULLONE MD 163999 0 0 0 0 0 6757 0 20019 0 190775 0 0 0 MATTHEW GULLONE MD 172121 0 0 0 0 0 6698 0 11998 0 190817 0 0 0 DEBBIE CIHAK MD 278511 0 0 0 0 0 4954 0 21812 0 305277 0 0 0 A ILLINOIS FINANCE AUTHORITY 861091967 45200BJ66 2006-10-01 45485000 CONSTRUCTION OF NEW HOSPITAL FACILITY 0 0 0 A 350000 45485000 3420238 909700 41155062 2007 0 0 1 1 A 0 0 0 0 0 0 0 A 0 1 0 0 0 0 0 0 0 A 0 TRACY BAUER CEO EDUCATION LOAN X 25937 24441 0 1 1 24441 PAMELA SMITH FAMILY MEMBER OF TRACY BAUER, CEO 33614 EMPLOYMENT COMPENSATION 0 PATRICIA BAUER FAMILY MEMBER OF TRACY BAUER, CEO 20604 EMPLOYMENT COMPENSATION 0 CONNIE TRAVIS FAMILY MEMBER OF TRACY BAUER, CEO 16592 EMPLOYMENT COMPENSATION 0 FORM 990, PART VI, SECTION A, LINE 7B THE BOARD OF DIRECTORS OF MIDWEST MEDICAL CENTER PREVIOUSLY ISSUED TAX-EXEMPT BONDS THROUGH THE ILLINOIS FINANCE AUTHORITY TO FINANCE THE CONSTRUCTION OF A REPLACEMENT HOSPITAL. UNDER THE TERMS OF THE BOND AGREEMENTS, THE ORGANIZATION IS LIMITED AS TO ISSUING NEW DEBT, PURCHASING SIGNIFICANT CAPITAL ASSETS, DISPOSING OF SIGNIFICANT ASSETS, AND/OR SETTING UP NEW CORPORATIONS OR SUBSTANTIALLY RESTRUCTURING THE CURRENT ORGANIZATION WITHOUT FIRST OBTAINING APPROVAL OF THE BOND TRUSTEES. FORM 990, PART VI, SECTION B, LINE 11 THE BOARD OF DIRECTORS RECEIVED A COPY OF THE FINAL 990 FOR REVIEW AND APPROVAL THROUGH POSTING TO AN ELECTRONIC SECURE WEBSITE BY MANAGEMENT OF MIDWEST MEDICAL CENTER PRIOR TO ITS SUBMISSION TO THE IRS. FORM 990, PART VI, SECTION B, LINE 12C SINCE MIDWEST MEDICAL CENTER IS PART OF A SMALL COMMUNITY, CONFLICTS OF INTEREST ARE GENERALLY KNOWN. THE BOARD OF DIRECTORS AND KEY EMPLOYEES ARE REQUIRED TO COMPLETE ANNUAL DISCLOSURE STATEMENTS. THESE ARE KEPT ON FILE AT THE HOSPITAL AND ALL MEMBERS OF THE BOARD OF DIRECTORS, INCLUDING MANAGEMENT WHICH ATTEND MEETINGS, ARE TOLD OF THE CONFLICTS. ANY MEMBERS WITH KNOWN CONFLICTS ABSTAIN FROM VOTING ON THESE CONFLICTS DURING MEETINGS AND ENGAGE IN ONLY LIMITED DISCUSSIONS ON THESE TOPICS. THE BOARD AND MANAGEMENT HOLD EACH OTHER ACCOUNTABLE THROUGH OBSERVATION AND ENFORCEMENT OF THE POLICY DURING MEETINGS AND AT ORGANIZATION FUNCTIONS. FORM 990, PART VI, SECTION B, LINE 15 THE BOARD OF DIRECTORS REVIEWS EVALUATIONS FOR THESE INDIVIDUALS, COMPARES DATA TO COMPETITIVE MARKET DATA OBTAINED FROM SALARY SURVEYS, AND CONSULTS WITH OUTSIDE ORGANIZATIONS AS NEEDED IN REVIEWING CONTRACTS. LEGAL AND OUTSIDE VALUATION SERVICES ARE OBTAINED IN ENSURING THE KEY EMPLOYEES, EXECUTIVES, AND PHYSICIANS SALARIES ARE IN LINE WITH REASONABLE AND PRUDENT BUYER CONCEPTS AS WELL. FORM 990, PART VI, SECTION C, LINE 19 THE GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE MADE AVAILABLE TO THE PUBLIC UPON REQUEST. EXPLANATION OF HOURS WORKED FORM 990, PART VII, SECTION A THE BOARD OF DIRECTORS OF MIDWEST MEDICAL CENTER ALSO SERVES AS THE BOARD OF DIRECTORS FOR THE MIDWEST REGIONAL HEALTH SYSTEM. NO ADDITIONAL HOURS OF SERVICE ARE DEDICATED TO THE BOARD POSITIONS ON THE MIDWEST REGIONAL HEALTH SYSTEM. THE MIDWEST REGIONAL HEALTH SYSTEM WAS ORGANIZED TO SERVE AS A SUPPORTING ORGANIZATION FOR MIDWEST MEDICAL CENTER AND MIDWEST REGIONAL HEALTH FOUNDATION. ADDITIONALLY, SOME OFFICERS AND BOARD MEMBERS ALSO SERVE AS BOARD MEMBERS OF MIDWEST REGIONAL HEALTH FOUNDATION. THE HOURS OF SERVICE PROVIDED TO THIS ORGANIZATION IS REFLECTED ON LINE 2 OF COLUMN B. FORM 990, PART XI, LINE 2C: THE BOARD OF DIRECTORS ASSUMES RESPONSIBILITY FOR SELECTION OF AN INDEPENDENT ACCOUNTANT, AND THE CEO OVERSEES THE AUDIT PROCESS. THE BOARD CHAIR TAKES TIME ANNUALLY TO MEET PRIVATELY WITH THE INDEPENDENT ACCOUNTANT WITHOUT MANAGEMENT PRESENT AND THE ENTIRE BOARD IS ALSO GIVEN THIS OPPORTUNITY DURING THE IN PERSON PRESENTATION OF THE AUDIT RESULTS BY THE INDEPENDENT ACCOUNTANT. NO CHANGES IN THE OVERSIGHT OR SELECTION OF AN INDEPENDENT ACCOUNTANT HAVE OCCURRED IN THE PAST YEAR. MIDWEST REGIONAL HEALTH FOUNDATION ONE MEDICAL CENTER DRIVE GALENA IL 61036 204560639 FUNDRAISING IL 501(C)3 11 TYPE I MIDWEST REGIONAL HEALTH SYSTEM 0 MIDWEST REGIONAL HEALTH SYSTEM ONE MEDICAL CENTER DRIVE GALENA IL 61036 204560381 SUPPORTING ORGANIZATION IL 501(C)3 11 TYPE III-FI N/A 0 0 0 1 0 0 0 0 0 0 0 0 0 1 1 1 0 0 0 0