Memorial Hospital of Boscobel

“As an affiliate of Gundersen Lutheran Health System, Inc., Gundersen Boscobel Area Hospital and Clinics will routinely delegate various management or support functions to related entities. For example, the CEO and CFO of Gundersen Boscobel Area Hospital and Clinics, as well as Several members of the board of directors, are employees of Gundersen Lutheran Health System, Inc. and its affiliated organizations which are also tax-exempt organizations.”

“The articles of incorporation of Gundersen Boscobel Area Hospital and Clinics provides for one member of the corporation. The sole corporate member of Gundersen Boscobel Area Hospital and Clinics is Gunersen Lutheran Health System, Inc.”

“As the sole corporate member and under the terms of the affiliation agreement, Gundersen Lutheran Health System, Inc. may appoint, remove, or elect certain officers and/or members of the Board of Directors of Gundersen Boscobel Area Hospital and Clinics. Gundersen Lutheran Health System, Inc. may appoint six members of the board of directors of Gundersen Boscobel Area Hospital and Clinics.”

“The sole member, Gundersen Lutheran Health System, inc., has the following reserve rights of approval: The incurrence of debt (other than debt incurred for the acquisition of goods that are acquired in the ordinary course of business oR debt included in approved budgets) and the grant OF any security interests, place any encumbrances, enter into any covenants, and direct execution of any documents and the taking of any actions necessary or appropriate in connection with the incurrance of such debt; and the Annual operating budget and capital expenditures.”

“The Form 990 is prepared by an independent accounting firm and then reviewed by the Organization's management. A final copy of the Form 990 is provided to the board of directors prior to submission.”

“The Board of Directors discloses any conflicts of interest by completing a questionnaire and disclosure form annually. Employees are required to review the conflict of interest policy upon hire and at annual intervals. If any significant conflicts arise with members of the Board of Directors, management, or key employees, it is properly documented and followed up on by the appropriate governing group or department within the Organization according to the conflict of interest policy.”

“For the purposes of determining compensation, Gundersen Area Boscobel Hospital and Clinics relied on its affiliated organization, Gundersen Lutheran Administrative Services, Inc., to establish compensation of the CEO, CFO, and other officers. Gundersen Lutheran Administrative Services, Inc. used the following practices for establishing compensation for such individuals: compensation survey or study, compensation committee, and approval by the board or compensation committee.”

“The abbreviated financial statements are made publicly available through the Wisconsin Hospital Association and the complete audited financial statements are available upon request. Governing documents and the conflict of interest policy are ALSO available to the public upon request.”

“Some officers and board members are employed by Gundersen Lutheran Health System, Inc. and its affiliates. Gundersen Lutheran Health System, Inc.'s purpose is to serve as a supporting organization to multiple subsidiary organizations as listed in Schedule R and these officers and board members often work in excess of 40 hours per week providing services to affiliated organizations. These hours are reflected in Line 2 of column B.”

“ER Physician Coverage: Program service expenses 1,465,531. Management and general expenses 0. Fundraising expenses 0. Total expenses 1,465,531. Clinic Physician Coverage: Program service expenses 755,336. Management and general expenses 0. Fundraising expenses 0. Total expenses 755,336. Radiology Purchased Services: Program service expenses 670,192. Management and general expenses 0. Fundraising expenses 0. Total expenses 670,192. Other purchased services: Program service expenses 1,234,093. Management and general expenses 0. Fundraising expenses 0. Total expenses 1,234,093. Administrative/Management Fees: Program service expenses 0. Management and general expenses 445,279. Fundraising expenses 0. Total expenses 445,279. Information Systems Purchased Services: Program service expenses 0. Management and general expenses 589,571. Fundraising expenses 0. Total expenses 589,571.”

“Net Change in Interest in Net Assets of Foundation 40,092.”

“The board of directors of Gundersen Boscobel Area Hospital and Clinics is responsible for the selection of the independent accountant and oversight of the annual audit. The board of directors meets with the independent auditors on an annual basis and approves the audit report. THIS PROCESS HAS NOT CHANGED IN THE PAST YEAR.”