2024-05-11T09:13:43-05:00 2023-06-30 410746749 CLIFTONLARSONALLEN LLP 10700 NORTHUP WAY SUITE 200 BELLEVUE WA 98004 990 2022-07-01 420680407 SOUTHEAST IOWA REGIONAL MEDICAL CENTER INC SOUT 3197681000 1221 SOUTH GEAR AVENUE WEST BURLINGTON IA 52655 JEREMY ALEXANDER CFO 3197681000 2024-05-08 1 JEREMY ALEXANDER XXX-XX-XXXX 1 KURT BENNION CPA P01469618 4252506100 2024-05-08 2 AAL1 IAL1 2022 2023-04-26 12:10:37Z DR MICHAEL MCCOY 1221 SOUTH GEAR AVENUE WEST BURLINGTON IA 52655 362323486 0 X WWW.GREATRIVERHEALTH.ORG X 1895 IA IMPROVING THE REGION'S HEALTH BY PROVIDING HIGH-QUALITY HEALTH CARE. 7 6 2316 176 152494 0 52801561 34495455 307954230 325802142 874483 411876 9087002 945464 370717276 361654937 168393959 11733292 0 0 165178126 166082098 0 0 14297 183122071 202604921 516694156 380420311 -145976880 -18765374 268865294 252815297 87497042 91046703 181368252 161768594 X SOUTHEAST IOWA REGIONAL MEDICAL CENTER EMPOWERS OUR PEOPLE TO PROVIDE COMPASSIONATE, HIGH QUALITY CARE, WHILE BEING GOOD STEWARDS OF OUR RESOURCES. 0 0 367299824 11733292 325738436 SOUTHEAST IOWA REGIONAL MEDICAL CENTER (SIRMC) IS A TWO CAMPUS HOSPITAL. ONE IS A 50 BED HOSPITAL LOCATED IN FORT MADISON, IOWA. THE OTHER IS A 378-BED REGIONAL MEDICAL CENTER LOCATED IN WEST BURLINGTON, IOWA OFFERING ACUTE AND INTERMEDIATE CARE TO RESIDENTS OF SOUTHEAST IOWA, WEST CENTRAL ILLINOIS AND NORTHEAST MISSOURI. THE HOSPITAL OFFERS COMPREHENSIVE MEDICAL, EXTENSIVE SURGICAL, AND EMERGENCY CARE SERVICES. DURING FISCAL YEAR ENDING 6/30/23, SIRMC HAD 10,537 PATIENT ADMISSIONS AND 60,559 PATIENT DAYS OF MEDICAL CARE. SIRMC ALSO HAD 354,366 OUTPATIENT VISITS, 44,073 EMERGENCY ROOM VISITS AND 36,750 HOME HEALTH-CARE VISITS. SIRMC PROVIDES MEDICAL SERVICES REGARDLESS OF ABILITY TO PAY AND ACCEPTS MEDICARE AND MEDICAID.THE HOSPITAL'S 160-BED KLEIN CENTER OFFERS LONG-TERM AND SKILLED CARE ON THE HOSPITAL'S CAMPUS. THE CANCER CENTER, WHICH PROVIDES MEDICAL AND RADIATION THERAPY SERVICES FOR THE TREATMENT OF VARIOUS FORMS OF CANCER AND BLOOD DISEASES, OFFERS THE LATEST THREE-DIMENSIONAL TREATMENT-PLANNING COMPUTER TECHNOLOGY AVAILABLE IN ONLY A FEW HEALTH-CARE CENTERS IN THE STATE. THE WELLNESS PLAZA IS HOME TO ONE OF THE STATE'S PREMIER REHABILITATION AND FITNESS PROGRAMS. 367299824 1 1 0 1 0 0 0 0 0 0 1 1 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 115 0 1 2316 1 1 1 0 0 0 0 0 0 0 0 0 0 0 X 7 6 1 1 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 X CHERYL ALBIN 3197681000 1221 SOUTH GEAR AVENUE WEST BURLINGTON IA 52655 LOUIS KANZAVELOS PHYSICIAN 40.00 0.00 X 1235319 0 42510 MATT WENZEL PRESIDENT/CEO (THROUGH 10/12/22) 24.00 19.00 X X 0 1122540 53171 BRENT WOODBURY PHYSICIAN 40.00 0.00 X 872640 0 36895 TIMOTHY STAUDTE PHYSICIAN 40.00 0.00 X 764140 0 50270 JEREMY ALEXANDER CFO 40.00 3.00 X 0 671653 51571 MEGHAN WOOSTER PHYSICIAN 40.00 0.00 X 693849 0 15636 DR MICHAEL MCCOY PRESIDENT/CEO 24.00 19.00 X X 0 624684 51091 CHARLES FRANK PHYSICIAN 40.00 0.00 X 360261 0 14147 DAVE POLAND CHAIRPERSON 1.00 0.00 X X 0 0 0 VICKI STEPHENSON VICE CHAIRMAN 1.00 0.00 X X 0 0 0 JOY ANDERSON SECRETARY 1.00 0.00 X X 0 0 0 DR STEVE DAVIS DIRECTOR 1.00 0.00 X 0 0 0 NEAL DODD DIRECTOR 1.00 0.00 X 0 0 0 BOB HUFFMAN DIRECTOR 1.00 1.00 X 0 0 0 3926209 2418877 315291 234 0 1 0 MEDEFIS INC 2121 NORTH 117TH AVENUE SUITE 200 OMAHA NE 68164 STAFFING AGENCY 6000237 MUTUAL CONSULTING & MGMT SVC INC 1221 S GEAR AVENUE WEST BURLINGTON IA 52655 EXECUTIVE MANAGEMENT 4637581 WAPITI MEDICAL GROUP 107 FLYNN DRIVE SUITE 600 MILBANK SD 57252 STAFFING AGENCY 3244067 MYERS CONSTRUCTION 651 MAIN STREET PO BOX 118 MEDIAPOLIS IA 52637 CONSTRUCTION 1908431 MIKE NELSON CONCRETE PAVING COMPANY 6430 115TH AVENUE BURLINGTON IA 52601 CONSTRUCTION 1717449 94 31006603 3488852 34495455 PATIENT SERVICE INCOME 621110 301990641 301990641 OTHER OPERATING INCOME 621300 22805630 22741924 63706 PARTNERSHIP INCOME 621400 1005871 1005871 325802142 385726 385726 1265841 630299 635542 635542 88788 546754 64400 38250 26150 26150 26150 MISCELLANEOUS INCOME 900099 309922 309922 309922 361654937 325738436 152494 1268552 X 11733292 11733292 2710626 2710626 137305561 136955382 350179 5061575 4645820 415755 14245510 13829221 416289 6758826 6732410 26416 766737 766737 470530 470530 87308 87308 3266 3266 100269642 95889173 4366523 13946 1289189 1494074 -205236 351 4192500 4191332 1168 312267 309679 2588 891185 891185 14476818 13754875 721943 6001805 3735582 2266223 MEDICAL SUPPLIES 27113622 27113622 DRUGS 24523657 24523618 39 BAD DEBT 11645250 11645250 REPAIRS/MAINTENANCE 4241810 4239738 2072 6319335 4378304 1941031 380420311 367299824 13106190 14297 889137 1968822 7767411 15879957 41286511 36199908 2965515 4016575 3892615 2350197 2347973 2278579 441313097 279121808 166953617 162191289 15396363 0 22577831 22944537 3349029 3284900 524292 224712 915000 1475821 268865294 252815297 27730445 28895504 119076 135211 33259156 26665551 26388365 35350437 87497042 91046703 X 170307714 151262966 11060538 10505628 181368252 161768594 268865294 252815297 X -18765374 -626790 -207494 X X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 1 45000 0 1 42308 87308 0 PART II-B, LINE 1: SOUTHEAST IOWA REGIONAL MEDICAL CENTER PAID DUES TO THE AMERICAN HOSPITAL ASSOCIATION AND THE IOWA HOSPITAL ASSOCIATION. THESE ASSOCIATIONS PARTICIPATE IN LOBBYING ACTIVITIES RELATED TO HEALTHCARE. CAPITOL CONSULTANTS OF IOWA PROVIDES LOBBYING SERVICES RELATED TO STATE-LEVEL HEALTHCARE ISSUES. 14160986 14160986 182802285 83271085 99531200 15919721 10150158 5769563 226122773 185700565 40422208 2307332 2307332 162191289 1665071 F INSURANCE COMPANY ANNUITY DEPOSITS 21279466 F 22944537 DEFERRED COMPENSATION LIABILITY 24745724 THIRD PARTY PAYABLE 3031022 DUE TO RELATED ORGANIZATIONS 7006119 RIGHT-OF-USE LEASE LIABILITIES 567572 35350437 X PART X, LINE 2: THE ORGANIZATION IS EXEMPT FROM INCOME TAXES UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. HOWEVER, THE ORGANIZATION IS SUBJECT TO FEDERAL INCOME TAX ON ANY UNRELATED BUSINESS TAXABLE INCOME. MANAGEMENT HAS EVALUATED THEIR INCOME TAX POSITIONS UNDER THE GUIDANCE INCLUDED IN ASC 740. BASED ON THEIR REVIEW, MANAGEMENT HAS NOT IDENTIFIED ANY MATERIAL UNCERTAIN TAX POSITIONS TO BE RECORDED OR DISCLOSED IN THE COMBINED FINANCIAL STATEMENTS. 1 1 X 1 X 1 X 1 1 0 1 1 4581205 4581205 0.01240 61174959 40080955 21094004 0.05720 65756164 40080955 25675209 0.06960 195919 195919 0.00050 6160139 1565245 4594894 0.01250 71030 71030 0.00020 6427088 1565245 4861843 0.01320 72183252 41646200 30537052 0.08280 1 11645250 0 79851716 101981200 -22129484 X 1 1 1 1 SOUTHEAST IOWA REGIONAL MEDICAL CENTER 1221 SOUTH GEAR AVENUE WEST BURLINGTON IA 52655 WWW.GREATRIVERHEALTH.ORG 290147H X X X X TRAUMA CENTER SOUTHEAST IOWA REGIONAL MEDICAL CENTER 1 0 0 1 X X X X X X X X X 21 1 1 1 1 X SEE LINE 7D X X 1 21 1 SEE LINE 7D 0 1 X 200.000000000000 300.000000000000 X X X X X X 1 1 X X X 1 X SEE LINE 16J X SEE LINE 16J X SEE LINE 16J X X X X X X X 1 X 0 X X X X X 1 X 0 0 SOUTHEAST IOWA REGIONAL MEDICAL CENTER PART V, SECTION B, LINE 5: SOUTHEAST IOWA REGIONAL MEDICAL CENTER, PART OF GREAT RIVER HEALTH SYSTEM, CONDUCTED A COMMUNITY HEALTH NEEDS ASSESSMENT TO DISTINGUISH THE UNMET MEDICAL AND PUBLIC HEALTH NEEDS IN DES MOINES AND LEE COUNTIES. THE STUDY HAS THREE OBJECTIVES:1. TO CONDUCT AN ASSESSMENT THAT PROVIDES A FOUNDATION FOR SOUTHEAST IOWA REGIONAL MEDICAL CENTER AND ITS PARTNERS TO BUILD A CONSENSUS ABOUT THE AREA'S MOST CRITICAL HEALTH CARE NEEDS.2. TO MEET STATE AND FEDERAL REQUIREMENTS FOR HOSPITALS THAT MUST CONDUCT A COMMUNITY HEALTH NEEDS ASSESSMENT EVERY 3 YEARS.3. TO DEVELOP ACTION PLANS FOR INTERVENTIONS TO ADDRESS CONCERNS HIGHLIGHTED BY THE COMMUNITY AND HEALTH DATA.INFORMATION WAS COLLECTED THROUGH VIRTUAL MEETINGS, PAPER AND ONLINE SURVEYS, KEY INFORMANT QUESTIONNAIRES, AND A REVIEW AND ANALYSIS OF PUBLICLY COLLECTED HEALTH AND DEMOGRAPHIC STATISTICS. THE SURVEY WAS MADE AVAILABLE AT SEVERAL LOCATIONS IN THE STUDY AREA. LOCATIONS WERE CHOSEN BASED ON EASE OF ACCESS AND TRAFFIC BUT WERE RESTRICTED BY COVID-19. THE SURVEY WAS DESIGNED TO ELICIT PUBLIC RESPONSES ABOUT HEALTH NEEDS IN DES MOINES AND LEE COUNTIES. THE SURVEY INCLUDED MULTIPLE CHOICE, OPEN-ENDED AND SCALED QUESTIONS THAT ASKED PEOPLE WHAT THEY PERCEIVED TO BE THE GREATEST AREAS OF COMMUNITY NEED. A TOTAL OF 1,204 SURVEYS WERE RETURNED AND ANALYZED, A DECREASE OF 46 PERCENT FROM THE 2019 COMMUNITY HEALTH NEEDS ASSESSMENT SURVEY. DECREASES IN RESPONSES WERE TO BE EXPECTED DUE TO A SHORTENED SURVEY WINDOW AND REDUCED OPPORTUNITIES FOR DISBURSEMENT.INTERVIEWS WERE CONDUCTED WITH LOCAL PROFESSIONALS AND KEY INFORMANTS, INCLUDING PROFESSIONALS IN EDUCATION, LAW ENFORCEMENT, PUBLIC HEALTH AND SOCIAL SERVICES, AND OTHER PROFESSIONALS REPRESENTING UNDERSERVED POPULATIONS IN THE SERVICE AREA. PARTICIPANTS WERE ASKED TO IDENTIFY THE LARGEST HEALTH CONCERNS IN THE COMMUNITY AND TO SUGGEST WAYS TO IMPROVE UNMET HEALTH NEEDS. THE HEALTH AND DEMOGRAPHIC DATA AVAILABLE FOR DES MOINES AND LEE COUNTIES WERE INVESTIGATED BY FOCUSING ON THE PROBLEMS INDICATED FROM THE INTERVIEWS AND COMMUNITY SURVEY. UTILIZING A STATISTICAL RANKING METHOD TO INCORPORATE INFORMATION FROM COLLABORATIVE MEETINGS, SURVEYS, AND THE INTERVIEWS, THE FOLLOWING FOUR UNMET HEALTH NEEDS WERE CHOSEN: MENTAL HEALTH SUBSTANCE MISUSE POVERTY AND EQUITY OBESITY AND OVERWEIGHTTHESE FOUR NEEDS WILL BE THE FOCUS OF SOUTHEAST IOWA REGIONAL MEDICAL CENTER AND GREAT RIVER HEALTH SYSTEM'S EFFORTS TO IMPROVE THE HEALTH OF DES MOINES AND LEE COUNTIES. SOUTHEAST IOWA REGIONAL MEDICAL CENTER PART V, SECTION B, LINE 6B: SOUTHEAST IOWA REGIONAL MEDICAL CENTER CONTINUALLY WORKS WITH PARTNERS AND STAKEHOLDERS OUTSIDE THE HOSPITAL TO MEET THE HEALTH NEEDS OF THE COMMUNITY. SOUTHEAST IOWA REGIONAL MEDICAL CENTER COLLABORATED WITH DES MOINES COUNTY DEPARTMENT OF PUBLIC HEALTH, COMMUNITY HEALTH CENTERS OF SOUTHEASTERN IOWA, BLESSING HEALTH KEOKUK, AND LEE COUNTY HEALTH DEPARTMENT ON A JOINT COMMUNITY HEALTH NEEDS ASSESSMENT. SOUTHEAST IOWA REGIONAL MEDICAL CENTER PART V, SECTION B, LINE 7D: SIRMC'S COMMUNITY HEALTH NEEDS ASSESSMENT AND IMPLEMENTATION STRATEGY ARE AVAILABLE ONLINE AT: HTTPS://WWW.GREATRIVERHEALTH.ORG/ABOUT-US/COMMUNITY-HEALTH-NEEDS-ASSESSMENT/ SOUTHEAST IOWA REGIONAL MEDICAL CENTER PART V, SECTION B, LINE 11: SOUTHEAST IOWA REGIONAL MEDICAL CENTER WORKED WITH DES MOINES AND LEE COUNTIES RESPECTIVE PARTNERS TO REVIEW THE DATA AND INFORMATION GATHERED BY THE COMMUNITY HEALTH NEEDS ASSESSMENT PROCESS. AFTER REVIEWING THE DATA FROM THE SURVEY, VIRTUAL TOWN HALL MEETINGS, AND COMMENTS FROM THE KEY INFORMANT QUESTIONNAIRE, THE FOLLOWING HIGH PRIORITY HEALTH CONCERNS WERE SELECTED: MENTAL HEALTH SUBSTANCE MISUSE POVERTY AND EQUITY OBESITY AND OVERWEIGHTLEADERS AT SOUTHEAST IOWA REGIONAL MEDICAL CENTER HIGHLIGHTED THE FOLLOWING IMPLEMENTATION STRATEGIES, POTENTIAL IMPACTS, AND RESOURCES NEEDED FOR EACH FOCUS AREA.MENTAL HEALTH- EXPAND EXISTING PROGRAMS- GERIATRIC INPATIENT UNIT- RECRUITMENTSUBSTANCE MISUSE-OPIOID MANAGEMENT IMPROVEMENTS-PEER RECOVERY GROUP-SUPPORT AND PARTICIPATION IN COMMUNITY BASED INITIATIVES-FITNESS VOUCHER PILOT PROGRAMOBESITY/OVERWEIGHT -POPULATION HEALTH PLATFORM-LIVE HEALTHY LEE COUNTY-HEALTHY LIVING COMMUNITY EDUCATIONPOVERTY AND EQUITY-RURAL PUBLIC HEALTH WORKFORCE TRAINING NETWORK PROGRAM-SOCIAL DETERMINANTS OF HEALTH ASSESSMENT WORKFLOW-GOOD FAITH ESTIMATES-GREAT RIVER HEALTH FOUNDATION PARTNERSHIP WITH SOUTHEASTERN COMMUNITY COLLEGE SOUTHEAST IOWA REGIONAL MEDICAL CENTER PART V, SECTION B, LINE 13H: SIRMC MAY USE PRESUMPTIVE FINANCIAL ASSISTANCE ELIGIBILITY:THERE ARE INSTANCES WHEN A PATIENT/INDIVIDUAL MAY APPEAR TO BE ELIGIBLE FOR CHARITY-CARE DISCOUNTS, BUT THERE IS NO COMPLETED FINANCIAL ASSISTANCE FORM ON FILE BECAUSE OF A LACK OF SUPPORTING DOCUMENTATION. OFTEN THERE IS ADEQUATE INFORMATION PROVIDED BY THE PATIENT OR THROUGH OTHER RESOURCES THAT COULD PROVIDE SUFFICIENT EVIDENCE TO DETERMINE ELIGIBILITY.1. INFORMATION IS PROVIDED WEEKLY TO AN OUTSIDE SOURCE. OUTSIDE SOURCE RETURNS RESULTS TO SOUTHEAST IOWA REGIONAL MEDICAL CENTER ABOUT PATIENT QUALIFICATIONS BASED ON OUR FINANCIAL ASSISTANCE POLICY.2. OUTSIDE SOURCE USES DEMOGRAPHIC AND HOUSEHOLD INFORMATION, AND CREDIT-SCORING TECHNOLOGY TO DETERMINE THE PERCENTAGE OF ASSISTANCE FOR WHICH A PATIENT MAY BE ELIGIBLE.3. SOUTHEAST IOWA REGIONAL MEDICAL CENTER WILL ATTEMPT TO CONTACT PATIENTS BASED ON THEIR PRESUMPTIVE ASSISTANCE QUALIFICATION TO ALLOW THE PATIENT TO APPLY FOR FINANCIAL ASSISTANCE.4. PATIENTS WILL NOT BE DISQUALIFIED FROM FINANCIAL ASSISTANCE BASED ON PRESUMPTIVE ASSISTANCE RESULTS.5. IF THE ACCOUNT IS PAST DUE AND THERE IS NO COMPLETED FINANCIAL ASSISTANCE APPLICATION OR SUPPORTING DOCUMENTATION, THE PATIENT'S ACCOUNT COULD BE CONSIDERED FOR FINANCIAL ASSISTANCE BASED ON OUTSIDE SOURCE'S RESULTS.6. PRESUMPTIVE ELIGIBILITY ALSO CAN BE DETERMINED BASED ON LIFE CIRCUMSTANCES INCLUDING: -ELIGIBILITY FOR OTHER STATE OR LOCAL ASSISTANCE PROGRAMS THAT ARE UNFUNDED -FOOD STAMP ELIGIBILITY -HOMELESS OR RECEIVED CARE FROM A HOMELESS CLINIC -LOW INCOME/SUBSIDIZED HOUSING PROVIDED AS A VALID ADDRESS -PARTICIPATION IN THE WOMEN INFANTS AND CHILDREN (WIC) PROGRAM -PATIENT IS DECEASED WITH NO KNOWN ESTATE -STATE-FUNDED PRESCRIPTION PROGRAMS -SUBSIDIZED SCHOOL LUNCH PROGRAM ELIGIBILITY7. IT ALSO IS ACCEPTABLE TO USE PROXY INFORMATION TO DETERMINE ELIGIBILITY WHEN INCOME LEVELS CANNOT BE DIRECTLY DETERMINED. SUCH INFORMATION COULD INCLUDE STATEMENTS LIKE "STAYS WITH FRIENDS OR "OCCASIONALLY WORKS."8. PATIENTS WHO MEET PRESUMPTIVE-CARE GUIDELINES MAY QUALIFY FOR FINANCIAL ASSISTANCE DISCOUNTS. THIS DETERMINATION IS AT THE DISCRETION OF SOUTHEAST IOWA REGIONAL MEDICAL CENTER.9. IN A SITUATION, WHERE PRESUMPTIVE ELIGIBILITY IS GIVEN TO A PATIENT AND A FINANCIAL ASSISTANCE APPLICATION IS OBTAINED LATER, THE UPDATED ELIGIBILITY WILL BE BASED ON THE FINANCIAL ASSISTANCE APPLICATION WITH SUPPORTING DOCUMENTATION. IN THIS CASE, SOUTHEAST IOWA REGIONAL MEDICAL CENTER COULD ADJUST FINANCIAL ASSISTANCE UP TO THREE MONTHS BEFORE THE APPLICATION DATE. SOUTHEAST IOWA REGIONAL MEDICAL CENTER PART V, SECTION B, LINE 16J: THE FINANCIAL ASSISTANCE POLICY, PLAIN LANGUAGE SUMMARY AND FINANCIAL ASSISTANCE APPLICATION ARE AVAILABLE ONLINE AT WWW.GREATRIVERHEALTH.ORG/PATIENTS-VISITORS/BILLING-FINANCIAL-SERVICES/. SOUTHEAST IOWA REGIONAL MEDICAL CENTER PART V, SECTION B, LINE 20E: SIRMC USES AN OUTSIDE SOURCE TO SCREEN PATIENTS TO SEE IF THEY COULD BE ELIGIBLE FOR FINANCIAL ASSISTANCE. THE HOSPITAL GETS NOTIFICATION BACK AS TO HOW MUCH OF A FINANCIAL ASSISTANCE DISCOUNT THEY WOULD BE ELIGIBLE FOR. IF THE PATIENT DOESN'T RESPOND TO PHONE CALLS REGARDING THE FINANCIAL ASSISTANCE APPLICATION OR THEY DON'T COMPLETE THE APPLICATION, THE HOSPITAL MAY STILL DISCOUNT THE PATIENT'S CHARGES UNDER THEIR PRESUMPTIVE CHARITY POLICY. THE HOSPITAL'S PRESUMPTIVE CHARITY PROGRAM GIVES THE HOSPITAL THE OPPORTUNITY TO DISCOUNT PATIENT ACCOUNTS BASED ON INFORMATION IT MAY HAVE REGARDING A PATIENT BEING HOMELESS OR UNEMPLOYED. 4 1 - KEOKUK CLINIC 3285 MAIN STREET KEOKUK IA 52632 PROVIDER HEALTH CLINIC 2 - MEDIAPOLIS CLINIC 401 N ORCHARD STREET MEDIAPOLIS IA 52637 PROVIDER HEALTH CLINIC 3 - WAPELLO CLINIC 220 MULBERRY STREET SUITE A WAPELLO IA 52653 PROVIDER HEALTH CLINIC 4 - URGENT CARE CLINIC 1321 S GEAR AVENUE WEST BURLINGTON IA 52655 URGENT CARE CLINIC PART I, LINE 3C: SOUTHEAST IOWA REGIONAL MEDICAL CENTER (SIRMC) 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. THE HOSPITAL ALSO USES A PRESUMPTIVE CHARITY CARE PROGRAM THAT ANALYZES 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 INTO 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 POVERTY LIMITS ARE GRANTED CHARITY ON A SLIDING SCALE. PART I, LINE 7: THE AMOUNTS INCLUDED IN PART I, LINES 7A-7D WERE CALCULATED USING COST TO CHARGE RATIO DERIVED FROM WORKSHEET 2 OF THE IRS SCHEDULE H INSTRUCTIONS. PART I, LINES 7E-7J ARE ACTUAL COSTS. PART I, LINE 7G: THE SUBSIDIZED HEALTH SERVICES INCLUDED IN PART I, LINE 7G IS MENTAL HEALTH SERVICES PROVIDED BY SIRMC. PART I, LINE 7, COLUMN (F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $ 11,645,250. PART III, LINE 2: 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 HISOTRY, CREDIT HISTORY, AND CURRENT ECONOMIC CONDITIONS. PART III, LINE 3: SOUTHEAST IOWA REGIONAL MEDICAL CENTER CONTRACTS WITH AN EXTERNAL ORGANIZATION. THE ORGANIZATION RECEIVES WEEKLY LISTINGS OF PATIENT RECEIVABLES FROM SIRMC'S PATIENT FINANCIAL SERVICES STAFF. THEY RETURN RESULTS TO SIRMC IDENTIFYING INDIVIDUALS WHO COULD QUALIFY FOR THE FINANCIAL ASSISTANCE PROGRAM. THE DATA IS BASED ON PATIENT INCOME AS WELL AS THEIR CREDIT REPORTING. THE RESULTS ARE APPLIED TO SIRMC'S FINANCIAL ASSISTANCE MATRIX TO IDENTIFY IF AN INDIVIDUAL WOULD QUALIFY AND FOR WHAT PERCENTAGE. SIRMC'S PATIENT FINANCIAL SERVICES STAFF THEN CONTACT THE PATIENT TO ACQUIRE A FINANCIAL ASSISTANCE APPLICATION. PART III, LINE 4: SEE THE "PATIENTS RECEIVABLES" PARAGRAPH IN NOTE 1 ON PAGE 10 OF THE ATTACHED AUDITED FINANCIAL STATEMENTS FOR A DESCRIPTION OF BAD DEBT EXPENSE. 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. 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 REASONS MEDICARE SHORTFALL SHOULD BE TREATED AS A COMMUNITY BENEFIT ARE (A) ABSENT THE MEDICARE PROGRAM, IT IS LIKELY MANY OF THE INDIVIDUALS WOULD QUALIFY FOR FINANCIAL ASSISTANCE OR OTHER NEEDS-BASED GOVERNMENT PROGRAMS; (B) BY ACCEPTING PAYMENT BELOW COST TO TREAT THESE INDIVIDUALS, THE BURDENS OF GOVERNMENT ARE RELIEVED WITH RESPECT TO THESE INDIVIDUALS; AND (C) 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: AN EXCERPT FROM SIRMC'S FINANCIAL ASSISTANCE PROGRAM WRITTEN POLICY, RELATIONSHIP OF FINANCIAL ASSISTANCE PROGRAM TO COLLECTION POLICIES: SOUTHEAST IOWA REGIONAL MEDICAL CENTER MANAGEMENT HAS DEVELOPED POLICIES AND PROCEDURES FOR INTERNAL AND EXTERNAL COLLECTION PRACTICES (INCLUDING ACTIONS THE HOSPITAL MAY TAKE IN THE EVENT OF NON-PAYMENT, WHICH INCLUDES COLLECTION ACTION AND REPORTING TO CREDIT AGENCIES) THAT TAKE INTO ACCOUNT THE FOLLOWING: A) THE EXTENT TO WHICH THE PATIENT QUALIFIES FOR CHARITY; B) PATIENT'S GOOD FAITH EFFORT TO APPLY FOR GOVERNMENTAL PROGRAMS; C) PATIENT'S GOOD FAITH EFFORT TO APPLY FOR SOUTHEAST IOWA REGIONAL MEDICAL CENTER'S FINANCIAL ASSISTANCE PROGRAM; D) PATIENT'S GOOD FAITH EFFORT TO COMPLY WITH PAYMENT AGREEMENTS MADE WITH SOUTHEAST IOWA REGIONAL MEDICAL CENTER. PATIENTS WHO QUALIFY FOR FINANCIAL ASSISTANCE AND WHO ARE COOPERATING IN GOOD FAITH TO RESOLVE THEIR DISCOUNTED HOSPITAL BILLS, SOUTHEAST IOWA REGIONAL MEDICAL CENTER WILL DO THE FOLLOWING: A) MAY OFFER EXTENDED PAYMENT PLANS; B) WILL NOT SEND UNPAID BALANCES TO OUTSIDE COLLECTION AGENCIES; C) WILL CEASE ALL COLLECTION EFFORTS WITH OUTSIDE COLLECTION AGENCIES. SOUTHEAST IOWA REGIONAL MEDICAL CENTER AND AGENCIES ACTING ON ITS BEHALF WILL NOT IMPOSE EXTRAORDINARY COLLECTION ACTIONS WITHOUT FIRST MAKING REASONABLE EFFORTS TO DETERMINE IF THE PATIENT IS ELIGIBLE FOR FINANCIAL ASSISTANCE UNDER THIS POLICY. REASONABLE EFFORTS SHALL INCLUDE: A) VALIDATING THAT THE PATIENT OWES THE UNPAID BILLS AND THAT ALL SOURCES OF THIRD PARTY PAYMENTS HAVE BEEN IDENTIFIED AND BILLED BY THE HOSPITAL; B) DOCUMENTATION THAT SOUTHEAST IOWA REGIONAL MEDICAL CENTER HAS ATTEMPTED TO OFFER THE PATIENT THE OPPORTUNITY TO APPLY FOR FINANCIAL ASSISTANCE PURSUANT TO THIS POLICY AND THAT THE PATIENT HAS NOT COMPLIED WIHT THE HOSPITAL'S APPLICATION REQUIREMENTS; C) DOCUMENTATION THAT THE PATIENT HAS BEEN OFFERED A PAYMENT PLAN BUT HAS NOT HONORED THE TERMS OF THAT PLAN. SOUTHEAST IOWA REGIONAL MEDICAL CENTER WILL NOT SEND OUTSTANDING BALANCES TO AN OUTSIDE COLLECTION AGENCY UNTIL 120 DAYS FROM THE DATE THE BALANCE BECAME THE PATIENT'S RESPONSIBILITY. AN OUTSIDE AGENCY ACTING ON THE BEHALF OF SOUTHEAST IOWA REGIONAL MEDICAL CENTER WILL NOT TAKE EXTRAORDINARY COLLECTION AGENCY UNTIL AN ADDITIONAL 120 DAYS HAVE BEEN EXHAUSTED. EXTRAORDINARY COLLECTION ACTION INCLUDES BUT IS NOT LIMITED TO THE FOLLOWING: A) SELLING DEBT TO A THIRD PARTY OTHER THAN A COLLECTION AGENCY; B) REPORTING ADVERSE INFORMATION TO A CONSUMER CREDIT REPORTING AGENCY OR CREDIT BUREAU; C) FILING A CLAIM FOR UNPAID DEBT THROUGH THE COURT SYSTEM. REFER TO SOUTHEAST IOWA REGIONAL MEDICAL CENTER BILLING AND COLLECTION POLICY INCLUDED IN EXHIBIT C FOR ADDITIONAL INFORMATION. PART III, SECTION A, LINE 1: THE ORGANIZATION REPORTS BAD DEBT IN ACCORDANCE WITH GENERALLY ACCEPTED ACCOUNTING PRINCIPLES (GAAP). HFMA STATEMENT 15 IS FOLLOWED TO THE EXTENT THAT IT ALIGNS WITH THE GUIDELINES SET FORTH BY GAAP. PART VI, LINE 2: SIRMC'S BOARD OF DIRECTORS IS COMMUNITY BASED. REPRESENTATIVES FROM VARIOUS SEGMENTS OF THE COMMUNITY MAKE UP THE BOARD. IN ADDITION, BOARD MEMBERS ARE SELECTED IN OUTLYING COMMUNITIES THAT SIRMC SERVES. THESE BOARD MEMBERS CONSTANTLY PROVIDE INPUT TO THE HEALTHCARE NEEDS OF OUR COMMUNITY THROUGH THE ANNUAL STRATEGIC PLANNING PROCESS. PART VI, LINE 3: NOTIFICATION ABOUT GOVERNMENT PROGRAM AND/OR FINANCIAL ASSISTANCE FROM SIRMC IS DISSEMINATED BY VARIOUS MEANS AT SIRMC, WHICH INCLUDES - PUBLICATION OF NOTICES IN PATIENT BILLS AND POSTED NOTICES IN THE EMERGENCY ROOMS, ADMISSION FORMS, ADMITTING AND REGISTRATION DEPARTMENT, HOSPITAL BUSINESS OFFICES, AND THE FINANCIAL SERVICES OFFICE ON THE FACILITY CAMPUS. SIRMC ALSO POSTS AT THE LOCAL DEPARTMENT OF HEALTH SERVICES OFFICE. SIRMC ALSO PUBLISHES AND WIDELY PUBLICIZES A SUMMARY OF THE ASSISTANCE OPTIONS ON THE FACILITY WEBSITE AND IN BROCHURES AVAILABLE IN PATIENT ACCESS SITES. REFERRAL OF PATIENTS FOR CHARITY MAY BE MADE BY ANY MEMBER OF THE SIRMC STAFF. ALSO REQUESTS FOR CHARITY MAY BE MADE BY THE PATIENT OR A FAMILY MEMBER, CLOSE FRIEND, OR ASSOCIATE OF THE PATIENT, SUBJECT TO APPLICABLE PRIVACY LAWS. FINANCIAL COUNSELORS MEET WITH PATIENTS TO ASSIST IN COMPLETING A QUESTIONNAIRE THAT HELPS THEM DETERMINE IF THE PATIENT QUALIFIES FOR A GOVERNMENT PROGRAM. PART VI, LINE 4: A REVIEW WAS CONDUCTED BY SIRMC TO ANALYZE THE ORIGIN OF PATIENTS UTILIZING THE SERVICES PROVIDED BY THE MEDICAL CENTER. THE REVIEW INDICATED THAT DES MOINES COUNTY COMPRISES THE MEDICAL CENTER'S 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. BASED ON THE US CENSUS BUREAU STATISTICAL ESTIMATES FOR 2021, THE PRIMARY SERVICE AREA POPULATION IS ESTIMATED AT 38,242 RESIDENTS. THE SECONDARY SERVICE AREA POPULATIONS ARE ESTIMATED TO TOTAL 87,121 RESIDENTS. OVER AGE 65 GROUP IS CURRENTLY 21.6% OF THE PRIMARY SERVICE AREA POPULATION, AS COMPARED TO 18.3% OF THE STATE OF IOWA POPULATION AND 17.3% OF THE UNITED STATES POPULATION. THE MEDIAN HOUSEHOLD INCOME IN THE PRIMARY SERVICE AREA IS $58,084 COMPARED TO THE STATE AND NATIONAL AVERAGES OF $70,571 AND $75,149, RESPECTIVELY. THE PRIMARY SERVICE AREA POPULATION BELOW POVERTY LEVEL IS 14.8% AS COMPARED TO THE STATE AND NATIONAL AVERAGES OF 11.0% AND 11.5%, RESPECTIVELY.SOUTHEAST IOWA REGIONAL MEDICAL CENTER IS THE ONLY HOSPITAL IN THE PRIMARY SERVICE AREA AND THE LARGEST SERVICE PROVIDER, INCLUDING THE BROADEST SCOPE OF SERVICES, IN THE PRIMARY AND SECONDARY SERVICE AREAS. PART VI, LINE 5: SOUTHEAST IOWA REGIONAL MEDICAL CENTER FURTHERS ITS EFFORTS TO PROMOTE THE HEALTH OF THE COMMUNITY BY ENSURING THE MAJORITY OF THE ORGANIZATION'S GOVERNING BODY COMPRISES MEMBERS WHO RESIDE IN THE ORGANIZATION'S PRIMARY SERVICE AREA WHO ARE NEITHER EMPLOYEES NOR CONTRACTORS OF THE ORGANIZATION, NOR FAMILY MEMBERS OF SUCH.SOUTHEAST IOWA REGIONAL MEDICAL CENTER PROVIDES MEMBERSHIP TO ALL PHYSICIANS WHO MEET MEMBERSHIP AND CLINICAL REQUIREMENTS.SOUTHEAST IOWA REGIONAL MEDICAL CENTER RECRUITS PHYSICIANS, PHYSICIAN ASSISTANTS, NURSE PRACTITIONERS, AND OTHER HEALTH PROFESSIONALS TO IMPROVE ACCESS TO HEALTH CARE IN THE HOSPITAL'S SERVICE AREA. IT ALSO PROMOTES HEALTH CAREER EDUCATION BY WORKING CLOSELY WITH SOUTHEASTERN COMMUNITY COLLEGE'S NURSING AND OTHER PROGRAMS.SOUTHEAST IOWA REGIONAL MEDICAL CENTER PARTICIPATES IN COMMUNITY BENEFIT ACTIVITIES SUCH AS PARTNERING WITH LOCAL SCHOOLS, COMMUNITY EDUCATION, COMMUNITY INITIATIVE EVENTS, PRENATAL EDUCATION CLASSES, A PARTICIPATING IN HEALTH FAIRS.SOUTHEAST IOWA REGIONAL MEDICAL CENTER MAINTAINS AN EMERGENCY ROOM 24 HOURS A DAY. IT IS OPEN TO ALL, REGARDLESS OF ABILITY TO PAY.SURPLUS FUNDS OF THE HOSPITAL ARE INVESTED IN IMPROVING AND UPDATING CAPITAL EQUIPMENT, AND INCREASING THE SERVICES OFFERED TO ALLOW FOR BETTER CARE OF THE PATIENTS THAT ARE SERVED. PART VI, LINE 6: SOUTHEAST IOWA REGIONAL MEDICAL CENTER IS PART OF GREAT RIVER HEALTH SYSTEM.GREAT RIVER HEALTH SYSTEM CONSISTS OF TWO HOSPITALS, A HOSPICE HOUSE, HOME HEALTH SERVICES, AMBULANCE SERVICES, THREE PHARMACIES, A DURABLE MEDICAL EQUIPMENT COMPANY, A LONG-TERM CARE NURSING HOME, ABOUT 25 PRIMARY-CARE AND SPECIALTY PHYSICIAN CLINICS, AND IS AFFILIATED WITH AN OUTPATIENT RENAL DIALYSIS CENTER.THE NON-HOSPITAL HEALTH CARE FACILITIES THAT ARE OPERATED BY ORGANIZATIONS RELATED TO THE HOSPITAL ARE: GREAT RIVER HEALTH SYSTEM-ANESTHESIA; GREAT RIVER HEALTH SYSTEM-AUDIOLOGY; GREAT RIVER HEALTH SYSTEM-BUSINESS HEALTH; GREAT RIVER HEALTH SYSTEM-CANCER CENTER; GREAT RIVER HEALTH SYSTEM-CARDIOLOGY; GREAT RIVER HEALTH SYSTEM-DIABETIC FOOT CLINIC; GREAT RIVER HEALTH SYSTEM-EYE SPECIALISTS; GREAT RIVER HEALTH SYSTEM-FAMILY MEDICINE; GREAT RIVER HEALTH SYSTEM-FAMILY MEDICINE, MERCY PLAZA; GREAT RIVER HEALTH SYSTEM-GASTROENTEROLOGY; GREAT RIVER HEALTH SYSTEM-HEALTHY LIVING; GREAT RIVER HEALTH SYSTEM-HERITAGE FAMILY PHARMACY; GREAT RIVER HEALTH SYSTEM-HERITAGE MEDICAL EQUIPMENT AND SUPPLIES; GREAT RIVER HEALTH SYSTEM-HERITAGE PARK PHARMACY; GREAT RIVER HEALTH SYSTEM-HERITAGE PARTNERS PHARMACY; GREAT RIVER HEALTH SYSTEM-KEOKUK; GREAT RIVER HEALTH SYSTEM-MEDIAPOLIS; GREAT RIVER HEALTH SYSTEM-MEDICINE SPECIALISTS; GREAT RIVER HEALTH SYSTEM-MENTAL HEALTH; GREAT RIVER HEALTH SYSTEM-NEPHROLOGY; GREAT RIVER HEALTH SYSTEM-ORTHOPAEDIC SPECIALISTS; GREAT RIVER HEALTH SYSTEM-PULMONOLOGY; GREAT RIVER HEALTH SYSTEM-QUICK CARE; GREAT RIVER HEALTH SYSTEM-SURGEONS; GREAT RIVER HEALTH SYSTEM-UROLOGY; GREAT RIVER HEALTH SYSTEM-WAPELLO; GREAT RIVER HEALTH SYSTEM-WEST POINT; GREAT RIVER HEALTH SYSTEM-WOMEN'S HEALTH; GREAT RIVER HEALTH SYSTEM-WOUND AND HYPERBARIC; SOUTHEASTERN RENAL DIALYSIS. PART VI, LINE 7: SIRMC DOES NOT FILE A COMMUNITY BENEFIT REPORT WITH THE STATE OF IOWA. HOWEVER, COMMUNITY BENEFIT INFORMATION IS PROVIDED TO THE IOWA HOSPITAL ASSOCIATION. 1 GREAT RIVER HEALTH SYSTEM INC 1221 SOUTH GEAR AVENUE WEST BURLINGTON IA 52655 421193185 501(C)(3) 6000000 0 N/A N/A TRANSFER DUE TO MERGER IOWA POISON CONTROL CENTER 401 DOUGLAS STREET SUITE 501 SIOUX CITY IA 51101 421509042 501(C)(3) 12000 0 N/A N/A GENERAL SUPPORT SOUTHEASTERN COMMUNITY COLLEGE 1500 WEST AGENCY ROAD WEST BURLINGTON IA 52655 420926823 501(C)(3) 5654982 0 N/A N/A NURSING PROGRAM 3 0 PART I, LINE 2: GRANTEES ARE REQUIRED TO PROVIDE FOLLOW-UP INFORMATION WHEN THE PROJECT IS CARRIED OUT OR COMPLETED. IF GRANTEES DON'T COMPLY, SIRMC DOES NOT PROVIDE FURTHER GRANTS TO THEM. X 1 1 1 0 0 0 0 0 0 0 0 LOUIS KANZAVELOS PHYSICIAN 1228565 0 0 0 6754 0 15250 0 27260 0 1277829 0 0 0 MATT WENZEL PRESIDENT/CEO (THROUGH 10/12/22) 0 740784 0 213774 0 167982 0 15250 0 37921 0 1175711 0 0 BRENT WOODBURY PHYSICIAN 866148 0 0 0 6492 0 10355 0 26540 0 909535 0 0 0 TIMOTHY STAUDTE PHYSICIAN 755974 0 0 0 8166 0 15250 0 35020 0 814410 0 0 0 JEREMY ALEXANDER CFO 0 552461 0 117896 0 1296 0 15250 0 36321 0 723224 0 0 MEGHAN WOOSTER PHYSICIAN 692727 0 0 0 1122 0 0 0 15636 0 709485 0 0 0 DR MICHAEL MCCOY PRESIDENT/CEO 0 532528 0 80672 0 11484 0 15250 0 35841 0 675775 0 0 CHARLES FRANK PHYSICIAN 358133 0 0 0 2128 0 0 0 14147 0 374408 0 0 0 PART I, LINE 1A MATT WENZEL, HEALTH/SOCIAL CLUB DUES, $4,463. THIS AMOUNT WAS INCLUDED IN TAXABLE COMPENSATION. PART I, LINE 3 THE COMPENSATION OF THE OFFICERS IS PAID BY RIVERVIEW SYSTEMS LTD., A RELATED ORGANIZATION, BUT DETERMINED BY GREAT RIVER HEALTH SYSTEM. THE FOLLOWING WERE USED BY GREAT RIVER HEALTH SYSTEM IN DETERMINING THE OFFICERS' 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 PART I, LINE 4A MATT WENZEL RECEIVED A SEVERANCE PAYMENT OF $164,442. THIS AMOUNT WAS INCLUDED IN W-2 WAGES. A IOWA FINANCE AUTHORITY 521699886 2017-05-31 25545000 REFUND OF PRIOR ISSUE (7/24/08) 0 0 0 B DES MOINES COUNTY IOWA 426004310 250087AA1 2012-04-04 60000000 SEE PART VI 0 0 0 A 14695000 25545000 284957 25260043 2000 1 0 1 1 B 44736842 60000000 616000 30076758 29307242 2013 1 0 1 1 A 0 0 1 1 0 0 0 0 1 B 0 0 1 1 0 0 0 0 1 A 1 B 1 DATE REBATE COMPUTATION PERFORMED ISSUER NAME: IOWA FINANCE AUTHORITY DATE THE REBATE COMPUTATION WAS PERFORMED: 11/30/2017 ISSUER NAME: DES MOINES COUNTY, IOWA DATE THE REBATE COMPUTATION WAS PERFORMED: 11/20/2013 PART I, COLUMN F, ROW B: REFUND PRIOR ISSUE (07/25/2001) AND CONSTRUCT, RENOVATE, EXPAND AND EQUIP FACILITIES SCHEDULE K, PART IV, LINE 2C: NOTE REGARDING THE 11/30/2017 REBATE COMPUTATION: SINCE THE BOND PROCEEDS HAVE BEEN SPENT, A SPENDING EXCEPTION WAS MET, AND THE DEBT SERVICE FUND WAS OPERATED ON A BONA FIDE BASIS, NO FURTHER REBATE CALCULATIONS ARE NECESSARY. SCHEDULE K, PART IV, LINE 2C: NOTE REGARDING THE 11/20/2013 REBATE COMPUTATION: SINCE THE BOND PROCEEDS HAVE BEEN SPENT AND THE DEBT SERVICE FUND WAS OPERATED ON A BONA FIDE BASIS, NO FURTHER REBATE CONCULATIONS ARE NECESSARY. FORM 990, PART VI, SECTION A, LINE 1A THE EXECUTIVE COMMITTEE SHALL BE COMPOSED OF THE CHAIRMAN OF THE BOARD, THE PRESIDENT AND CHIEF EXECUTIVE OFFICER, AND TWO OR MORE ADDITIONAL TRUSTEES. 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. FORM 990, PART VI, SECTION A, LINE 2 DR. MICHAEL MCCOY, MATT WENZEL AND JEREMY ALEXANDER HAVE BUSINESS RELATIONSHIPS BY SERVING AS OFFICERS AND/OR BOARD MEMBERS OF FOR-PROFIT SUBSIDIARIES OF GREAT RIVER HEALTH SYSTEM. FORM 990, PART VI, SECTION A, LINE 3 ALL EXECUTIVE LEADERSHIP FUNCTIONS FOR SOUTHEAST IOWA REGIONAL MEDICAL CENTER ARE PROVIDED BY MUTUAL CONSULTING AND MANAGEMENT SERVICES, INC. MUTUAL CONSULTING AND MANAGEMENT SERVICES IS A SUBSIDIARY OF RIVERVIEW SYSTEMS LTD, WHICH IS A SUBSIDIARY OF GREAT RIVER HEALTH SYSTEM. FORM 990, PART VI, SECTION A, LINE 6 GREAT RIVER HEALTH SYSTEM INC., IS THE SOLE MEMBER OF SOUTHEAST IOWA REGIONAL MEDICAL CENTER. FORM 990, PART VI, SECTION A, LINE 7A THE SOLE MEMBER, GREAT RIVER HEALTH SYSTEM, INC (GRHS), HAS THE SOLE POWER TO ELECT OR REMOVE ALL BOARD MEMBERS OF SOUTHEAST IOWA REGIONAL MEDICAL CENTER. THE NOMINATING COMMITTEE SHALL PRESENT A RECOMMENDATION FOR THE ELECTION OF DIRECTORS TO THE BOARD, WHICH UPON APPROVAL OF THE BOARD AND THE SUBSEQUENT APPROVAL OF GRHS, SHALL BE ELECTED TO THE BOARD. FORM 990, PART VI, SECTION A, LINE 7B THE GRHS BOARD OF DIRECTORS HAS THE FOLLOWING SPECIFIC POWERS RELATED TO ALL SUBSIDIARY CORPORATIONS AND AFFILIATED ORGANIZATIONS: 1. ELECT OR REMOVE THE BOARD OF DIRECTORS, OR ANY OTHER MEMBER OF THE BOARD OF DIRECTORS; 2. AMEND THE ARTICLES OF INCORPORATION OR THE BYLAWS; 3. DISSOLVE OR APPROVE MERGER WITH ANY OTHER CORPORATE ENTITY; 4. APPROVE STRATEGIC OR OTHER BUSINESS PLANS; 5. APPROVE CAPITAL AND OPERATING BUDGETS; 6. APPROVAL OF ANY INDEBTEDNESS INCURRED; 7. TRANSFER, SELL OR CLOSE ANY FACILITY, DEPARTMENT OR FUNCTION; 8. APPROVE ANY CHARITABLE DISBURSEMENTS, WHETHER INTERNAL OR EXTERNAL, IN EXCESS OF ONE HUNDRED THOUSAND DOLLARS ($100,000.00) IN THE AGGREGATE DURING ANY FISCAL YEAR; 9. THE SALE, DISPOSITION OR ANY ENCUMBRANCE (OTHER THAN ROUTINE LEASE TRANSACTIONS) OF ANY REAL ESTATE; 10. ADOPT, AMEND, OR TERMINATE EMPLOYEE BENEFIT PROGRAMS OR PLANS; 11. APPOINT OR TERMINATE THE CHIEF EXECUTIVE OFFICER; 12. APPROVE THE ELECTION OF ANY OFFICER OR CHAIRPERSON OF THE BOARD OF DIRECTORS; AND 13. TO TAKE ANY OTHER ACTION NECESSARY DEEMED IN THE BEST INTERESTS OF GRHS. FORM 990, PART VI, SECTION B, LINE 11B THE FORM 990 WAS PREPARED BY AN EXTERNAL ACCOUNTANT. A DRAFT OF THE FORM 990 WAS REVIEWED IN DETAIL BY A MEMBER OF THE ACCOUNTING DEPARTMENT, DIRECTOR OF FINANCE AND CFO. ANY NECESSARY ADJUSTMENTS WERE MADE PRIOR TO FINALIZING THE FORM. A COPY OF THE FINAL FORM 990 WAS MADE AVAILABLE TO THE BOARD MEMBERS FOR THEIR REVIEW PRIOR TO FILING WITH THE IRS. ANY QUESTIONS OF THE BOARD MEMBERS WERE ADDRESSED THROUGH THE ACCOUNTING DEPARTMENT. FORM 990, PART VI, SECTION B, LINE 12C BOTH CORPORATE AND SUBSIDIARY BOARD MEMBERS ARE PROVIDED EDUCATION REGARDING CONFLICTS OF INTEREST. THIS EDUCATION IS PROVIDED BY THE CHIEF COMPLIANCE OFFICER. ALL BOARD MEMBERS ARE REQUIRED TO COMPLETE A CONFLICT OF INTEREST DISCLOSURE FORM. RELATIONSHIPS NOTED ON THIS FORM MAY BE DISCUSSED WITH THE RESPECTIVE BOARD MEMBER IF THERE ARE QUESTIONS. IF AN INDIVIDUAL HAS A CONFLICT OF INTEREST, THEY MAY NOT PARTICIPATE IN DISCUSSIONS RELATING TO THE TRANSACTION IN QUESTION AND MAY NOT VOTE ON MATTERS RELATED TO THE TRANSACTION. CONFLICT OF INTEREST PROCEEDINGS ARISING FROM CONFLICTS OF INTEREST ARE DOCUMENTED IN THE BOARD MINUTES. FORM 990, PART VI, SECTION B, LINE 15 COMPENSATION OF OFFICERS IS PAID BY A RELATED FOR-PROFIT SUBSIDIARY. THE COMPENSATION FOR THE CEO AND OTHER OFFICERS IS DETERMINED BY THE EXECUTIVE COMPENSATION COMMITTEE OF GREAT RIVER HEALTH SYSTEM, INC. THE ROLE OF THE COMPENSATION COMMITTEE IS TO ACT ON BEHALF OF THE CORPORATE BOARD OF DIRECTORS IN ADOPTING, REVIEWING AND MAINTAINING AN EXECUTIVE COMPENSATION PHILOSOPHY. THE COMPENSATION COMMITTEE IS COMPRISED OF THREE BOARD MEMBERS, ALL OF WHOM ARE INDEPENDENT FROM THE CEO AND OTHER OFFICERS. THE COMPENSATION COMMITTEE REVIEWS THE COMPENSATION OF THE CEO AND OTHER OFFICERS ON AN ANNUAL BASIS. THE DELIBERATIONS AND DECISIONS ARE DOCUMENTED IN MINUTES TAKEN AT THE MEETINGS. GREAT RIVER HEALTH SYSTEM, INC. PARTICIPATES IN AND UTILIZES EXECUTIVE SALARY SURVEYS TO DETERMINE COMPENSATION RANGES. THE COMMITTEE REVIEWS PREVAILING MARKET DATA TO ENSURE CONTINUED MARKET COMPETITIVENESS. THE COMPENSATION COMMITTEE ALSO ENGAGES AN INDEPENDENT THIRD PARTY COMPENSATION CONSULTING GROUP BIANNUALLY TO ASSESS AND VALIDATE THE ENTIRETY OF EXECUTIVE COMPENSATION AND BENEFITS PACKAGES TO ENSURE REGULATORY COMPLIANCE, EXTERNAL COMPETITIVENESS, AND INTERNAL EQUITY. THE MOST RECENT YEAR OF AN INDEPENDENT THIRD PARTY REVIEW WAS 2023. FORM 990, PART VI, SECTION C, LINE 19 SOUTHEAST IOWA REGIONAL MEDICAL CENTER MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE UPON REQUEST. FORM 990, PART IX, LINE 11G CONTRACTED SERVICES: PROGRAM SERVICE EXPENSES 95,889,173. MANAGEMENT AND GENERAL EXPENSES 4,366,523. FUNDRAISING EXPENSES 13,946. TOTAL EXPENSES 100,269,642. FORM 990, PART XI, LINE 9: CHANGE IN BENEFICIAL INTEREST IN TRUSTS -207,494. FORM 990, PART XII, LINE 2C: THE PROCESS FOR OVERSIGHT AND SELECTION OF AN INDEPENDENT ACCOUNTANT HAS NOT CHANGED FROM THE PRIOR YEAR. GREAT RIVER HEALTH SYSTEM INC 1221 SOUTH GEAR AVENUE WEST BURLINGTON IA 52655 421193185 HEALTH CARE IA 501(C)(3) LINE 12C, III-FI N/A 0 GRHS HOLDINGS INC 1221 SOUTH GEAR AVENUE WEST BURLINGTON IA 52655 421193186 SUPPORT RELATED ORGANIZATIONS IA 501(C)(3) LINE 12B, II GREAT RIVER HEALTH SYSTEMS INC 0 HENRY COUNTY HEALTH CENTER INC 1221 SOUTH GEAR AVENUE WEST BURLINGTON IA 52655 862701018 HOSPITAL IA 501(C)(3) LINE 3 GREAT RIVER HEALTH SYSTEMS INC 0 GREAT RIVER HEALTH FOUNDATION INC 1221 SOUTH GEAR AVENUE WEST BURLINGTON IA 52655 421446727 SUPPORT RELATED ORGANIZATIONS IA 501(C)(3) LINE 12B, II GREAT RIVER HEALTH SYSTEMS INC 0 SOUTHEAST RENAL DIALYSIS LC 507 SOUTH WHITE STREET MOUNT PLEASANT IA 52641 391878280 MEDICAL SERVICES IA N/A RELATED 696213 3271898 1 0 0.50000 RIVERVIEW SYSTEM LTD 1221 SOUTH GEAR AVE WEST BURLINGTON IA 52655 421191960 MEDICAL SERVICES IA N/A C 0 GREAT RIVER MEDICAL SERVICES INC 1221 SOUTH GEAR AVE WEST BURLINGTON IA 52655 421493449 MEDICAL SERVICES IA N/A C 0 MUTUAL CONSULTING & MANAGEMENT SERVICES 1221 SOUTH GEAR AVE WEST BURLINGTON IA 52655 421349668 MANAGEMENT SERVICES IA N/A C 0 HERITAGE PARK PHARMACY 1221 SOUTH GEAR AVE WEST BURLINGTON IA 52655 421191957 PHARMACY IA N/A C 0 HERITAGE MEDICAL EQUIPMENT & SUPPLY 1221 SOUTH GEAR AVE WEST BURLINGTON IA 52655 421191958 MEDICAL SUPPLY IA N/A C 0 RIGHTCHOICE INC 1221 SOUTH GEAR AVE WEST BURLINGTON IA 52655 923383523 STAFFING AGENCY IA N/A C 0 0 1 1 0 0 0 0 0 0 0 0 0 1 1 1 1 1 1 1