2023-10-27T14:00:08+00:00 2022-12-31 346565596 ERNST & YOUNG US LLP 155 N WACKER DRIVE CHICAGO IL 60606 990 2022-01-01 391965415 Tri-State Ambulance Inc TRI- 6087848827 235 CAUSEWAY BOULEVARD LA CROSSE WI 546033119 MICHAEL MCKEE PRESIDENT 6087848827 2023-10-27 true Michael McKee 999009999 Emily Upstrom P01765498 4142748740 2022 2023-04-26 12:10:37Z MICHAEL MCKEE 235 CAUSEWAY BOULEVARD LA CROSSE WI 546033119 8543010 false X WWW.TRISTATEAMBULANCE.ORG X 2002 WI SEE SCHEDULE O. 6 3 60 3 0 0 149309 171305 7491424 8363377 2784 8328 0 0 7643517 8543010 27978 21515 0 0 4336562 4668817 0 0 0 2787335 3180089 7151875 7870421 491642 672589 6779441 7298962 859551 706483 5919890 6592479 SEE SCHEDULE O. false false 6850822 21515 8363377 SEE SCHEDULE O. 6850822 true true false false false false false false false true false false false true true false true false false false false false false false false false false true true false false false false false false false false false false false false false true true false false false true 24 0 true 60 true false false false false false false false false false false false false X 6 3 false false true false true true true true true false false true true true true true true true true false WI X STEVE LITTLE 6087827300 1900 SOUTH AVENUE NCA1-01 LA CROSSE WI 54601 BRYAN ERDMANN SECRETARY/TREASURER 1.0 47.5 X X 0 316306 72463 MICHAEL MCKEE PRESIDENT 1.0 47.0 X X 0 270756 67960 MICHAEL POELLINGER VICE PRESIDENT 1.0 0.5 X X 0 0 0 KYLE BAKKUM BOARD MEMBER 1.0 0.5 X 0 0 0 MICHAEL KITTELSON BOARD MEMBER 1.0 0.5 X 0 0 0 THERESE BINFET BOARD MEMBER 1.0 40.5 X 0 163779 45783 TOM TORNSTROM ADMINISTRATIVE DIRECTOR 1.0 40.5 X 0 146760 39263 CALLIE REVELS OPERATIONS SUPERVISOR 40.0 0 X 104790 0 12741 GREGG BULMAN PARAMEDIC 40.0 0 X 93815 0 30105 198605 897601 268315 2 false true false GUNDERSEN LUTHERAN ADMINISTRATIVE SERVICES 1900 South Ave LA CROSSE WI 54601 Purchased Services 468379 ECP SERVICES LLC 117 N MAIN ST 6 LAKE MILLS WI 535511609 Purchased Services 123322 2 171305 171305 PRE-HOSPITAL EMERGENCY 621910 8234010 8234010 MEDICAL SUPPLIES SERVICES 621990 64076 64076 MISCELLANEOUS RENTAL INCOME 621990 65291 65291 0 0 0 0 8363377 8328 8328 0 0 0 0 0 0 0 0 0 8543010 8363377 0 8328 3459 3459 18056 18056 0 0 3735864 3181206 554658 70655 60165 10490 600911 511695 89216 261387 222579 38808 173908 173908 1500 1500 403153 380627 22526 0 9354 9354 100406 41970 58436 31656 6327 25329 211870 180414 31456 37742 37742 59900 59900 564388 564388 28284 24085 4199 BAD DEBT EXPENSE 888615 888615 RENT, REPAIRS AND MAINTENANCE 358455 358455 SUPPLIES 286339 286339 MISCELLANEOUS OTHER EXPENSES 24519 23300 1219 0 0 0 0 7870421 6850822 1019599 0 300 300 2226425 3161502 0 0 1510572 1621761 0 0 0 0 0 0 0 0 114941 58411 6516508 4059520 2901269 2456988 0 0 25934 0 6779441 7298962 581678 495106 247122 196066 0 0 25934 0 4817 15311 859551 706483 X 5919890 6592479 5919890 6592479 6779441 7298962 672589 0 X X false true X true false X Schedule A, Part I, Line 3 CRITERIA FOR PUBLIC SUPPORT PURPOSES TRI-STATE AMBULANCE, INC. MEETS THIS CRITERIA FOR PUBLIC SUPPORT PURPOSES, BUT NOT FOR SCHEDULE H PURPOSES. FILING ORGANIZATION IS NOT LICENSED AND IS NOT REQUIRED TO BE LICENSED AS A HOSPITAL. ACCORDINGLY, SCHEDULE H DOES NOT APPLY AND IS NOT REQUIRED TO BE COMPLETED. RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 218543 218543 2003007 795624 1207383 2065061 1470512 594549 2229897 1793384 436513 2456988 UNCLAIMED PROPERTY 1679 DUE TO GLAS 13632 15311 X Schedule D, Part X, Line 2 FIN 48 (ASC 740) footnote THE SYSTEM QUALIFIES AS A TAX-EXEMPT ORGANIZATION UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE, WITH THE EXCEPTION OF GUNDERSEN LUTHERAN ENVISION, LLC, WHICH IS A FOR-PROFIT ENTITY. AT NOVEMBER 30, 2022 AND DECEMBER 31, 2021, NET DEFERRED TAX ASSETS OF $7,351 AND $7,545, RESPECTIVELY, WHICH PRIMARILY ARE RELATED TO NET OPERATING LOSS CARRYFORWARDS, HAVE VALUATION ALLOWANCES OF $7,351 AND $7,545, RESPECTIVELY, RECORDED AGAINST THEM DUE TO THE UNCERTAINTY OF REALIZING THOSE BENEFITS IN THE FUTURE. AT NOVEMBER 30, 2022, THE SYSTEM'S FEDERAL NET OPERATING LOSS CARRYFORWARDS WERE APPROXIMATELY $27,800, AND THE STATE NET OPERATING LOSS CARRYFORWARDS WERE APPROXIMATELY $25,700, WHICH WILL EXPIRE BETWEEN 2031 AND 2040. THE SYSTEM HAS REVIEWED ITS TAX POSITIONS FOR ALL OPEN YEARS AND HAS CONCLUDED THAT NO LIABILITIES EXIST FOR UNCERTAIN TAX POSITIONS. THE SYSTEM'S INCOME TAX RETURNS ARE NO LONGER SUBJECT TO EXAMINATION FOR 2016 AND PRIOR YEARS. true CHARITY CARE 13 18056 COST CHARITY CARE Schedule I, Part I, Line 2 Procedures for monitoring use of grant funds. WHEN A PATIENT HAS INDICATED OR DEMONSTRATED AN "INABILITY TO PAY", A TRI-STATE AMBULANCE REVENUE CYCLE REPRESENTATIVE WILL PROVIDE THE PATIENT WITH A FINANCIAL HARDSHIP APPLICATION (FHA) AND EXPLICIT INSTRUCTIONS FOR ITS COMPLETION ALONG WITH A REQUEST FOR ANY DOCUMENTS NECESSARY TO VERIFY POTENTIAL PATIENT ASSETS AND LIABILITIES. AFTER RECEIPT OF THE PACKET IT IS THEN REVIEWED AS COMPILED AND PUT ONTO A SLIDING POVERTY DETERMINATION SCALE. AN ANNUAL COMPLIANCE AUDIT IS COMPLETED TO ENSURE ALL POLICY STANDARDS ARE BEING FOLLOWED. false false false false false false false false false BRYAN ERDMANN SECRETARY/TREASURER 0 312047 0 0 0 4259 0 44225 0 28238 0 388769 0 0 MICHAEL MCKEE PRESIDENT 0 270131 0 0 0 625 0 40054 0 27906 0 338716 0 0 THERESE BINFET BOARD MEMBER 0 162354 0 0 0 1425 0 24049 0 21734 0 209562 0 0 TOM TORNSTROM ADMINISTRATIVE DIRECTOR 0 145795 0 0 0 965 0 21537 0 17726 0 186023 0 0 Schedule J, Part I, Line 3 EXECUTIVE COMPENSATION COMPENSATION FOR EXECUTIVES IS ESTABLISHED BY GUNDERSEN LUTHERAN HEALTH SYSTEM, INC., A RELATED PARTY. GUNDERSEN LUTHERAN HEALTH SYSTEM, INC. USED A COMPENSATION COMMITTEE, COMPENSATION SURVEY AND APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE TO ESTABLISH COMPENSATION FOR EXECUTIVES. Form 990, Part I, Line 1 ORGANIZATION'S MSSION THE MISSION OF TRI-STATE AMBULANCE, INC. IS TO BE A PRIMARY PROVIDER OF PRE-HOSPITAL EMERGENCY CARE AND TRANSPORATION IN THE TRI-STATE REGION. THE COMPANY UTILIZES A TEAM ENVIRONMENT WHERE ALL MEMBERS WORK TOWARD THE SHARED GOAL OF PROVIDING THE HIGHEST LEVEL OF PATIENT CARE TO THE LARGEST NUMBER OF PEOPLE IN AN EFFICIENT MANNER. WITH 38 EXPERIENCED PARAMEDICS, 22 EMTS, AND 13 AMBULANCES WE CONTINUOUSLY SET THE STANDARD FOR EMERGENCY MEDICAL SERVICES. SINCE 1970, TRI-STATE AMBULANCE HAS SERVED AS THE SOLE 911 ADVANCE LIFE SUPPORT PROVIDER FOR THE REGION COVERING NEARLY 2,200 SQUARE MILES AND SERVING A POPULATION OF APPROXIMATELY 150,000. TRI-STATE AMBULANCE OFFERS ITS RESIDENTS AND VISITORS UNSURPASSED PRE-HOSPITAL CARE. Form 990, Part III, Line 1 ORGANIZATION'S MISSION THE MISSION OF TRI-STATE AMBULANCE, INC. IS TO BE A PRIMARY PROVIDER OF PRE-HOSPITAL EMERGENCY CARE AND TRANSPORATION IN THE TRI-STATE REGION. THE COMPANY UTILIZES A TEAM ENVIRONMENT WHERE ALL MEMBERS WORK TOWARD THE SHARED GOAL OF PROVIDING THE HIGHEST LEVEL OF PATIENT CARE TO THE LARGEST NUMBER OF PEOPLE IN AN EFFICIENT MANNER. WITH 38 EXPERIENCED PARAMEDICS, 22 EMTS, AND 13 AMBULANCES WE CONTINUOUSLY SET THE STANDARD FOR EMERGENCY MEDICAL SERVICES. SINCE 1970, TRI-STATE AMBULANCE HAS SERVED AS THE SOLE 911 ADVANCE LIFE SUPPORT PROVIDER FOR THE REGION COVERING NEARLY 2,200 SQUARE MILES AND SERVING A POPULATION OF APPROXIMATELY 150,000. TRI-STATE AMBULANCE OFFERS ITS RESIDENTS AND VISITORS UNSURPASSED PRE-HOSPITAL CARE. Form 990, Part III, Line 4a PROGRAM SERVICE ACCOMPLISHMENT DESCRIPTION TRI-STATE AMBULANCE HAS PROUDLY SERVED SOUTHWEST WISCONSIN, SOUTHEAST MINNESOTA, AND NORTHEAST IOWA SINCE 1970, WITH THE MOST ADVANCED PRE-HOSPITAL PATIENT CARE AVAILABLE TO THOUSANDS OF PATIENTS EVERY YEAR. PRIMARY EMERGENCY 911 RESPONSE AS WELL AS EMERGENCY AND NON-EMERGENCY INTERFACILITY TRANSPORT AND INTERCEPT SERVICES ARE PROVIDED 24 HOURS A DAY. ANOTHER MEASURE OF TRI-STATE AMBULANCES' SUCCESS IS DESCRIBED IN A RECENT COMPREHENSIVE STUDY ANALYZING THE PERCENTAGE OF PATIENTS WHO WERE DISCHARGED FROM A HOSPITAL AFTER SUFFERING A CARDIAC ARREST IN WHICH THE EVENT WAS WITNESSED AND THE VICTIM WAS IN A SHOCKABLE HEART RHYTHM (WHERE A DEFIBRILLATOR COULD BE USED). IN SEPTEMBER 2011, TRI-STATE AMBULANCE PURCHASED A NEWLY RENOVATED 23,400 SQUARE FOOT FACILITY IN LA CROSSE, WI. THE SIZE OF THE NEW BUILDING HAS ALLOWED TRI-STATE AMBULANCE TO INCREASE TRAINING OPPORTUNITIES FOR BOTH EMERGENCY MEDICAL SERVICE PROVIDERS AND COMMUNITY MEMBERS, PROVIDE PROPER SERVICE AND MAINTENANCE TO THEIR FLEET VEHICLES, AND CONSOLIDATE CENTRAL SUPPLY OF MEDICAL SUPPLIES AND EQUIPMENT FOR DISBURSEMENT TO OUTLYING TRI-STATE AMBULANCE LOCATIONS. OPERATIONS BEGAN IN THE NEW FACILITY IN THE EARLY PART OF 2012. IN THE SPRING OF 2012, TRI-STATE AMBULANCE TOOK DELIVERY OF TWO NEW AMBULANCES AS PART OF A FOUR YEAR COMPREHENSIVE AMBULANCE FLEET REPLACEMENT PLAN. NOT ONLY ARE THE NEW AMBULANCES MARKED WITH HIGHLY VISIBLE LIGHTING AND REFLECTIVE STRIPING, BUT THEY ARE DESIGNED TO OFFER BOTH PATIENTS AND STAFF A SAFER, SMOOTHER, AND MORE SECURE AMBULANCE RIDE. THE SLIGHTLY SMALLER SIZE AND SWITCH FROM DIESEL MOTORS TO GASOLINE HAS MADE OUR FLEET 20 TO 30 PERCENT LESS EXPENSIVE TO PURCHASE AND 30 TO 40 PERCENT LESS COSTLY TO MAINTAIN AND SERVICE. IN ADDITION TO THE HIGHER VISIBILITY AMBULANCES, ALL PARAMEDICS AND EMT'S NOW HAVE HIGH-VISIBILITY OUTERWEAR THAT WILL HELP PROTECT THEM WHILE AT DANGEROUS SCENES. IN 2014, TRI-STATE AMBULANCE DEDICATED ONE OF THEIR AMBULANCES AS A CRITICAL CARE AMBULANCE. THIS ALLOWED FOR THE EXPANSION OF THEIR CRITICAL CARE AMBULANCE SERVICES TO BE ABLE TO RESPOND TO SMALL REGIONAL HOSPITALS. THIS PROGRAM ALLOWS TRI-STATE AMBULANCE TO PROVIDE LIFE SAVING ADVANCED CARE FOR THE SMALL REGIONAL HOSPITALS WHICH ARE UNDERSERVED BY ADVANCED PARAMEDICS. IN 2014, TRISTATE AMBULANCE ALSO INVESTED IN THE PURCHASE OF PULSEPOINT CITIZEN RESPONDER TECHNOLOGY. THE INVESTMENT IN THE PULSEPOINT CITIZEN RESPONDER TECHNOLOGY ASSISTS IN ALERTING USERS OF A SUDDEN CARDIAC ARREST IN A PUBLIC PLACE AND THE LOCATION OF THE NEARBY AUTOMATED EXTERNAL DEFIBRIALTORS (AEDS). IN 2016, TRI-STATE AMBULANCE BEGAN TO INSTALL POWER STRETCHER LIFTS IN THE AMBULANCES ALLOWING FOR INCREASED LEVEL OF SAFETY FOR PARAMEDICS, EMTS, AND PATIENTS. TRI-STATE AMBULANCE CONTINUES TO MEET AND EXCEED CONTRACTUAL RESPONSE TIME. IN 2016, TRI-STATE AMBULANCE SAW A RECORD YEAR IN THE SERVICE AREA OF CARDIAC ARREST SURVIVAL AND CONTINUES TO WORK WITH HOSPITALS THROUGHOUT THE SERVICE AREA TO INCREASE PATIENT SURVIVAL FROM MEDICAL EMERGENCIES. IN 2017, TRI-STATE AMBULANCE BEGAN A PARTNERSHIP WITH THE LA CROSSE FIRE DEPARTMENT IN WHICH FIREFIGHTER PARAMEDICS WILL BE ABLE TO WORK AS EMPLOYEES OF TRI-STATE AMBULANCE THIS ARRANGEMENT WILL ASSIST TRI-STATE AMBULANCE WITH MUCH NEEDED STAFF AND ALSO HELP THE FIRE DEPARTMENT LOWER THEIR TURNOVER. IN 2018, THE RELATIONSHIP WITH LA CROSSE FIRE DEPARTMENT CONTINUED TO GROW AND THE USE OF SHARED STAFFING HAS BEEN WORKING WELL. IN ADDITION, DURING THE LATTER PART OF 2018 TRI-STATE AMBULANCE DONATED BLEEDING CONTROL KITS TO NEARLY 50 BUSINESSES IN THE LA CROSSE AREA TO PLACE IN THE AED ENCLOSURES. TRI-STATE AMBULANCE ALSO PARTNERED WITH WESTERN TECHNICAL COLLEGE AS A GRANT RECIPIENT TO TRAIN ADDITIONAL PARAMEDICS. TRI-STATE AMBULANCE PROVIDES PRIMARY EMERGENCY 911 RESPONSE AS WELL AS EMERGENCY AND NON-EMERGENCY INTERFACILITY TRANSPORT AND INTERCEPT SERVICES. IN 2019, TRI-STATE AMBULANCE CONTINUED TO EXCEED RESPONSE TIMES AND IMPROVED CLINICAL QUALITY BY JOINING PROGRAMS OF COVERDALE STROKE, CARES REGISTRY. IN ADDITION, TRI-STATE AMBULANCE APPLIED FOR AND WERE CHOSEN TO PARTICIPATE IN A CMS INITIAIVE CALLED THE ET3 PROGRAM WHICH WILL DRASTICALLY CHANGE HOW PATIENT CARE IS PROVIDED. TRI-STATE AMBULANCE SPENT MUCH OF 2019 PREPARING FOR CAAS ACCREDITATION AND COMPLETED A RE-WRITE OF POLICIES AND PROCEDURES. TRI-STATE AMBULANCE ALSO BEGAN TESTING TELEMEDICINE IN THE AMBULANCES AND EXPANDED CLINICAL TREATMENT PROTOCOLS TO INCLUDE ADDITIONAL MEDICATIONS. TRI-STATE AMBULANCE ALSO WORKED CLOSELY WITH AREA HOSPITALS TO STREAMLINE PROCESSES FOR HEART ATTACK AND STROKE PATIENTS. IN 2019 TRI-STATE AMBULANCE HAD A GREATER THAN 90% FIRST PASS INTUBATION SUCCESS AND ALSO PAID OFF ALL LONG TERM DEBT WHICH HAS BEEN ON THE BOOKS FOR MANY YEARS. IN 2019, USING ADVANCED MEDICAL PROTOCOLS WE SEND ECGS OR ELECTROCARDIOGRAMS TO THE HOSPITALS VIA THE INTERNET TO SPEED UP THE TREATMENT OF HEART ATTACK VICTIMS. IN 2020, TRI-STATE AMBULANCE RESPONDED TO COVID PANDEMIC WHILE ENCOUNTERING LARGE PPE EXPENSES AND STAFFING EVEN THOUGH REVENUE DROPPED. TRI-STATE AMBULANCE, INC UTILIZED TELEHEALTH INTEGRATION TO ALLOW SPECIALISTS TO PARTICIPATE IN VIRTUAL CARE IN MOVING AMBULANCE. THEY WERE ONE OF LESS THAN 200 AMBULANCE SERVICES IN THE NATION CHOSEN TO PARTICIPATE IN ET3 - EMERGENCY TRIAGE, TREATMENT, AND TRANSPORT. THEY ARE PARTNERING WITH OTHER GUNDERSEN DEPARTMENTS TO INCREASE STAFF FLEXIBILITY AND ARE EXPANDING PULSEPOINT COMMUNITY APP. IN 2021, TRI-STATE AMBULANCE, INC WAS ACCREDITED BY THE COMMISSION ON ACCREDITATION OF AMBULANCE SERVICES (CAAS). IN 2022, TRI-STATE AMBULANCE HAD 11,590 TRANSPORTS, 221 STANDBYS, 6,203 NON-TRANSPORTS, AND 18,014 TOTAL CALLS. TSA HAS LAUNCHED A PROGRAM WHICH ALLOWS ALTERNATE DESTINATION TRANSPORTS AS WELL AS TELEHEALTH USE FOR 911 PATIENTS. IN 2022, TSA BECAME ACCREDITED WITH THE COMMISSION ON ACCREDITATION FOR AMBULANCE SERVIES (CAAS). THIS IS A THREE YEAR ACCREDITATION AND WILL BE UP FOR RENEWAL IN 2024. IN ADDITION, IN PARTNERSHIP WITH GUNDERSEN HEALTH SYSTEM, TSA LAUNCHED A "PARAMEDIC TRAINEE" PROGRAM WHICH IS AN "EARN WHILE YOU LEARN" OPPORTUNITY. TSA HIRED 7 EMTS IN FULL-TIME CAPACITY WHO WILL RECEIVE PAY AND BENEFITS WHILE THEY ATTEND PARAMEDIC SCHOOL. Form 990, Part VI, Line 4 Significant changes to organizational documents GUNDERSEN AND BELLIN HEALTH SYSTEMS, INC. (BELLIN), EACH A WISCONSIN NONPROFIT, NON-STOCK CORPORATION, ENTERED INTO A COMBINATION AGREEMENT DATED JULY 29, 2022 (THE AGREEMENT), TO ALIGN THEIR RESPECTIVE OPERATIONS AND TO FORM A SINGLE NONPROFIT HEALTH SYSTEM THROUGH THE CREATION OF BELLIN GUNDERSEN HEALTH SYSTEM, INC., A WISCONSIN NONPROFIT, NON-STOCK CORPORATION (BELLIN GUNDERSEN). ON DECEMBER 1, 2022, UPON CONSUMMATION OF THE ALIGNMENT OF THE TWO SYSTEMS (THE AFFILIATION), BELLIN GUNDERSEN BECAME THE SOLE CORPORATE MEMBER OF BOTH BELLIN AND GUNDERSEN. BELLIN AND GUNDERSEN AND THEIR RESPECTIVE AFFILIATES ARE EXPECTED TO MAINTAIN THEIR RESPECTIVE CORPORATE EXISTENCE. IN DECEMBER 2022, THE BYLAWS OF GUNDERSEN LUTHERAN HEALTH SYSTEM, INC. WERE AMENDED AND RESTATED TO UPDATE THE SOLE CORPORATE MEMBER TO BELLIN GUNDERSEN HEALTH SYSTEM, INC. THE BYLAWS WERE ALSO UPDATED TO SPECIFY THE POWERS RETAINED BY GUNDERSEN LUTHERAN HEALTH SYSTEM, INC. THE CHIEF EXECUTIVE OFFICER OF BELLIN GUNDERSEN LUTHERAN HEALTH SYSTEM, INC. RETAINS AUTHORITY TO APPROVE ANY SIGNIFICANT CHANGES TO THE CORPORATION. SUBJECT TO THE RESERVED POWERS SPECIFIED IN THE BYLAWS, THE AFFAIRS OF THE CORPORATION SHALL BE MANAGED BY ITS BOARD OF TRUSTEES. Form 990, Part VI, Line 6 Classes of members or stockholders GUNDERSEN LUTHERAN HEALTH SYSTEM, INC. IS THE SOLE CORPORATE MEMBER OF THIS ORGANIZATION. Form 990, Part VI, Line 7a Members or stockholders electing members of governing body THE SOLE CORPORATE MEMBER, GUNDERSEN LUTHERN HEALTH SYSTEM, INC. MAY ELECT THE GOVERNING BODY. Form 990, Part VI, Line 7b Decisions requiring approval by members or stockholders GUNDERSEN LUTHERAN HEALTH SYSTEM, INC. HAS THE ABILITY TO PROVIDE, BY RESOLUTION, FOR MORE THAN THE DESIGNATED SIX DIRECTORS. UPON DISSOLUTION, THE DISTRIBUTION OF ASSETS SHALL BE DETERMINED BY THE BOARD OF GOVERNORS AND THE BOARD OF TRUSTEES OF GUNDERSEN LUTHERAN HEALTH SYSTEM, INC. Form 990, Part VI, Line 11b Review of form 990 by governing body PRIOR TO FILING THE FORM 990, IT IS REVIEWED FOR COMPLETENESS AND ACCURACY BY MANAGEMENT. FOR THIS PURPOSE, MANAGEMENT IS THE ACCOUNTING MANAGER, THE EXECUTIVE DIRECTOR FINANCE FOR THE GUNDERSEN LUTHERAN HEALTH SYSTEM, INC., AND THE PRINCIPAL OFFICER OF THE ORGANIZATION. A COPY OF THE FORM 990 IS MADE AVAILABLE TO ALL BOARD MEMBERS. Form 990, Part VI, Line 12c Conflict of interest policy EACH MEMBER OF THE TRI-STATE AMBULANCE, INC. GOVERNING BOARD SIGNS A CONFLICT OF INTEREST STATEMENT EACH YEAR. MEMBERS ARE ASKED TO DISCLOSE CONFLICTS AS APPROPRIATE AND ABSTAIN FROM VOTING WHEN APPLICABLE. Form 990, Part VI, Line 15a Process to establish compensation of top management official THE COMPENSATION OF THE OPERATIONS MANAGER IS DETERMINED ANNUALLY BY THE TRI-STATE AMBULANCE, INC. 39-1965415 PRESIDENT OF THE BOARD. THE DETERMINATION IS MADE AFTER A REVIEW OF THE MARKET DATA IS OBTAINED FROM SEVERAL ORGANIZATIONS. THE COMPENSATION AMOUNTS ARE NOT EFFECTIVE UNTIL THE BOARD APPROVES THEM. MEETING MINUTES ARE TAKEN AND KEPT AT THE MEETINGS WHERE THE BOARD REVIEWS AND APPROVES THE COMPENSATION OF THE KEY EMPLOYEES. Form 990, Part VI, Line 19 Required documents available to the public REQUESTS FOR FORM 990 AND CERTAIN OTHER INFORMATION IS AVAILABLE FOR PUBLIC INSPECTION AND COPYING THROUGH THE GUNDERSEN LUTHERAN HEALTH SYSTEM, INC.'S LEGAL DEPARTMENT. A COPY OF THE TRI-STATE AMBULANCE, INC. FORM 990 CAN ALSO BE FOUND ELECTRONICALLY ON WWW.GUIDESTAR.ORG Form 990, Part XII, Line 2c Change of oversight process or selection process THE AUDITOR IS SELECTED BY GUNDERSEN LUTHERAN HEALTH SYSTEM, INC. GUNDERSEN LUTHERAN HEALTH SYSTEM INC 1836 SOUTH AVENUE LA CROSSE WI 54601 391866425 SUPPORTING ORG WI 501(c)(3) Type II BGHS false GUNDERSEN LUTHERAN MEDICAL CENTER INC 1910 SOUTH AVENUE LA CROSSE WI 54601 390813416 HEALTHCARE WI 501(c)(3) 3 GLHS false GUNDERSEN CLINIC LTD 1836 SOUTH AVENUE LA CROSSE WI 54601 391028657 HEALTHCARE WI 501(c)(3) 3 GLHS false GUNDERSEN LUTHERAN ADM SERVICES INC 1910 SOUTH AVENUE LA CROSSE WI 54601 391606449 SUPPORTING ORG WI 501(c)(3) Type II GLHS false GUNDERSEN LUTHERAN MEDICAL FOUNDATION INC 1836 SOUTH AVENUE LA CROSSE WI 54601 391249705 FOUNDATION WI 501(c)(3) 7 GLHS false GUNDERSEN LUTHERAN CREDENTIALING SVS INC 1910 SOUTH AVENUE LA CROSSE WI 54601 391856898 CREDENTIALING WI 501(c)(3) Type III-FI GLHS false TRI-COUNTY MEMORIAL HOSPITAL INC 18601 LINCOLN STREET WHITEHALL WI 54773 390704510 HEALTHCARE WI 501(c)(3) 3 GLHS false HARMONY COMMUNITY HEALTHCARE INC 815 MAIN AVENUE HARMONY MN 55939 410711606 HEALTHCARE MN 501(c)(3) 10 GLHS false TWEETEN LUTHERAN HEALTHCARE CENTER INC 125 FIFTH AVENUE SE SPRING GROVE MN 55974 411565003 HEALTHCARE MN 501(c)(3) 10 GLHS false TRI-STATE REGIONAL AMBULANCE INC 235 CAUSEWAY BLVD LA CROSSE WI 54603 391962965 MEDICAL TRANSPORT WI 501(c)(3) 10 GLHS false LUTHERAN REAL ESTATE HOLDING CORPORATION 1910 SOUTH AVENUE LA CROSSE WI 54601 391480826 HOUSING WI 501(c)(3) Type III-FI GLHS false COMMUNITY HOUSING OF LA CROSSE INC 1900 SOUTH AVENUE LA CROSSE WI 54601 391586700 INDEPENDENT LIVING WI 501(c)(3) 10 LREH CORP false LUTHERAN HOUSING OF LA CROSSE INC 1900 SOUTH AVENUE LA CROSSE WI 54601 391751934 INDEPENDENT LIVING WI 501(c)(3) 10 LREH CORP false ST JOSEPH'S HEALTH SERVICES INC 400 WATER AVENUE HILLSBORO WI 54634 390929538 HEALTHCARE WI 501(c)(3) 3 GLHS false ST JOSEPH'S MEMORIAL FOUNDATION INC 400 WATER AVENUE HILLSBORO WI 54634 391455787 FOUNDATION WI 501(c)(3) Type I ST JO HTH SV false TRI-COUNTY MEMORIAL FOUNDATION INC 18601 LINCOLN STREET WHITEHALL WI 54773 300093022 FOUNDATION WI 501(c)(3) Type I TRI CTY HSPT false MEMORIAL HOSPITAL OF BOSCOBEL 205 PARKER STREET BOSCOBEL WI 53805 390845590 HEALTHCARE WI 501(c)(3) 3 GLHS false PALMER LUTHERAN HEALTH CENTER INC 112 JEFFERSON STREET WEST UNION IA 52175 421320763 HEALTHCARE IA 501(c)(3) 3 GLHS false MOUNDVIEW MEMORIAL HOSPITALS & CLINICS 402 WEST LAKE STREET FRIENDSHIP WI 53934 390944012 HEALTHCARE WI 501(c)(3) 3 GLHS false MEMORIAL HC FDN OF ADAMS COUNTY INC 402 WEST LAKE STREET FRIENDSHIP WI 53934 391775074 FOUNDATION WI 501(c)(3) Type I MDVW MEM HOS false SAINT ELIZABETH'S HOSP OF WABASHA INC 1200 5TH GRANT BOULEVARD WEST WABASHA MN 55981 410693877 HEALTHCARE MN 501(c)(3) 3 GLHS false BELLIN GUNDERSEN HEALTH SYSTEM INC 1836 SOUTH AVENUE LA CROSSE WI 54601 920504278 SUPPORTING ORG WI 501(c)(3) Type II NA false BELLIN HEALTH SYSTEMS INC 744 SOUTH WEBSTER AVE GREEN BAY WI 54301 391512904 SUPPORTING ORG WI 501(c)(3) Type II BGHS false LAKE MICHIGAN HEALTH SERVICES INC 744 SOUTH WEBSTER AVE GREEN BAY WI 54301 391512903 SUPPORTING ORG WI 501(c)(3) Type II BHS false BELLIN COLLEGE INC 3201 EATON ROAD GREEN BAY WI 54311 391620530 EDUCATION WI 501(c)(3) 2 BHS false BELLIN PSYCHIATRIC CENTER INC PO BOX 23725 GREEN BAY WI 54301 391657627 HEALTHCARE WI 501(c)(3) 3 BHS false BELLIN MEMORIAL HOSPITAL INC 744 SOUTH WEBSTER AVE GREEN BAY WI 54301 390884478 HEALTHCARE WI 501(c)(3) 3 BHS false THE BELLIN HEALTH FOUNDATION INC PO BOX 23400 GREEN BAY WI 54301 391809171 FOUNDATION WI 501(c)(3) 7 BHS false OCONTO HOSPITAL & MEDICAL CENTER INC 820 ARBUTUS AVENUE OCONTO WI 54153 061745397 HEALTHCARE WI 501(c)(3) 3 BMH false GUNDERSEN LUTHERAN ENVISION LLC 1836 SOUTH AVENUE LA CROSSE WI 54601 264706546 RENEWABLE ENERGY WI GLHS C Corporation false BEL-REGIONAL HOME MEDICAL INC 617 S ROOSEVELT GREEN BAY WI 54301 391504766 DURABLE MEDICAL EQUIPMENT, RETAIL WI NA C Corporation false BELLIN INVESTMENTS INC 744 SOUTH WEBSTER AVE GREEN BAY WI 54301 391564939 OTHER WI NA C Corporation false false false false false false false false false false false false false false false false true true false false