| FORM 990, PART VI, SECTION A, LINE 2 |
BRADLEY J. KOKJOHN HAD A BUSINESS RELATIONSHIP WITH LYNN BEASLEY, PAT BIRA, AND C. JAMES PLATT AS THEY ALL WERE BOARD MEMBERS OF RENAISSANCE HEALTH SERVICES, INC., A RELATED ORGANIZATION, AT SOME POINT DURING THE TAX YEAR. |
| FORM 990, PART VI, SECTION A, LINE 3 |
PAT BIRA, LYNN BEASLEY, BRADLEY J. KOKJOHN, AND C. JAMES PLATT ARE EMPLOYED BY QUORUM HEALTH RESOURCES, A HEALTHCARE MANAGEMENT SERVICES COMPANY, WHICH PROVIDES MANAGEMENT SERVICES TO THE ORGANIZATION. |
| FORM 990, PART VI, SECTION B, LINE 11 |
A COPY OF THE FORM 990 IS REVIEWED BY THE ORGANIZATION'S CONTROLLER WITH THE EXTERNAL ACCOUNTANTS FOR COMPLETENESS AND ACCURACY PRIOR TO FILING THE FORM 990. A COPY OF THE FINAL VERSION IS PROVIDED TO EACH BOARD MEMBER AFTER THE RETURN IS FILED WITH THE INTERNAL REVENUE SERVICE. |
| FORM 990, PART VI, SECTION B, LINE 12C |
EACH DIRECTOR, PRINCIPAL OFFICER AND MEMBER OF A COMMITTEE WITH BOARD DELEGATED POWERS ANNUALLY SIGNS A STATEMENT WHICH AFFIRMS THAT SUCH PERSON: 1) HAS RECEIVED A COPY OF THE CONFLICT OF INTEREST POLICY, 2) HAS READ AND UNDERSTANDS THE POLICY, 3) HAS AGREED TO COMPLY WITH THE POLICY, AND 4) UNDERSTANDS THAT THE HOSPITAL IS A CHARITABLE ORGANIZATION AND THAT IN ORDER TO MAINTAIN ITS FEDERAL TAX EXEMPTION IT MUST ENGAGE PRIMARILY IN ACTIVITIES WHICH ACCOMPLISH ONE OR MORE OF ITS TAX-EXEMPT PURPOSES. IN CONNECTION WITH ANY ACTUAL OR POSSIBLE CONFLICTS OF INTEREST, ANY INTERESTED PERSON MUST DISCLOSE THE EXISTENCE AND NATURE OF HIS OR HER FINANCIAL INTEREST TO THE DIRECTORS AND MEMBERS OF COMMITTEES WITH BOARD DELEGATED POWERS CONSIDERING THE PROPOSED TRANSACTION OR ARRANGEMENT. UPON ANY DISCLOSURE OF THE FINANCIAL INTEREST, THE INTERESTED PERSON LEAVES THE BOARD OR COMMITTEE WHILE THE FINANCIAL INTEREST IS DISCUSSED AND VOTED UPON. THE REMAINING BOARD OR COMMITTEE MEMBERS DECIDE IF A CONFLICT OF INTEREST EXISTS. ALL SUCH ACTIONS ARE RECORDED IN THE MINUTES OF THE BOARD OR COMMITTEE MEETING. |
| FORM 990, PART VI, SECTION B, LINE 15 |
THE COMPENSATION COMMITTEE, ACTING ON BEHALF OF THE BOARD OF DIRECTORS, MEETS AT LEAST ANNUALLY TO ASSIST THE BOARD OF DIRECTORS IN FULFILLING ITS OVERSIGHT RESPONSIBILITIES FOR EXECUTIVE COMPENSATION. QUORUM HEALTH RESOURCES, AN INDEPENDENT MANAGEMENT CONSULTANT, PRESENTS TO THE FULL BOARD OF DIRECTORS COMPENSATION INFORMATION WHICH INCLUDES COMPARABLES AND INDUSTRY GUIDELINES ALONG WITH RECOMMENDATIONS FOR THE BOARD'S APPROVAL FOR COMPENSATION OF THE CEO AND CFO. THE COMPENSATION COMMITTEE REVIEWS COMPENSATION DATA AND RELATED POLICIES AND DETERMINES WHETHER SUCH COMPENSATION IS REASONABLE AND CONSISTENT WITH FAIR MARKET VALUE IN ORDER TO RECOMMEND TO THE FULL BOARD OF DIRECTORS COMPENSATION AMOUNTS FOR APPROVAL. COMPENSATION OF PHYSICIANS EMPLOYED OR CONTRACTED BY FMCH OR AN AFFILIATE ARE REVIEWED ANNUALLY USING THE MGMA DATA FOR COMPARISON. THE COMPENSATION COMMITTEE MAINTAINS DOCUMENTATION, CONSISTENT WITH THE RECORD RETENTION POLICY, OF ITS ACTIVITIES AND THE BASIS FOR ITS DECISIONS. THIS PROCESS OCCURS ANNUALLY. |
| FORM 990, PART VI, SECTION C, LINE 19 |
THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE NOT MADE AVAILABLE TO THE PUBLIC. |
| FORM 990, PART XI, LINE 9: |
EQUITY IN SUBSIDIARY EARNINGS 411,810. CONTRIBUTION FROM SUBSIDIARY REPORTED AS NET ASSET TRANSFER ON REPORT -300,000. |
| FORM 990, PART XII, LINE 2C: |
THE FORT MADISON COMMUNITY HOSPITAL GOVERNING BOARD MEETS WITH THE AUDITORS TO REVIEW THE AUDIT REPORT AND MANAGEMENT LETTER. THE OVERSIGHT AND SELECTION PROCESS HAS NOT CHANGED FROM THE PRIOR TAX YEAR. |
| FORM 990, PART VII, LINE 1A |
FORT MADISON COMMUNITY HOSPITAL, FORT MADISON COMMUNITY HOSPITAL FOUNDATION, AND FORT MADISON PROFESSIONAL BUILDING ASSOCIATION ARE RELATED ENTITIES. AS A RESULT, BOARD OVERLAP EXISTS AMONG THESE ENTITIES AND IT WOULD BE ADMINISTRATIVELY IMPRACTICAL FOR MEMBERS OF THE GOVERNING BOARD AND THE EXECUTIVE TEAM TO BREAKOUT THEIR HOURS DEVOTED AMONG EACH ORGANIZATION. |
Attach to Form 990 or 990-EZ.