TY 2012 Form 990

(A) Name and Title	(B) Average hours per week (list any hours for related organizations below dotted line)	(C) Position (do not check more than one box, unless person is both an officer and a director/trustee)	(E) Reportable compensation from related organizations (W- 2/1099-MISC)
(1) JEFFREY THOMPSON MD........................................................................ CHIEF EXECUTIVE OFFICER	2.0 .......................44.0	X	X	711,992	61,084
(2) GREG PRAIRIE........................................................................ BOARD OF TRUSTEES - VP	2.0 .......................4.0	X	X	0	0
(3) DONALD FRANK........................................................................ BOARD OF TRUSTEES-SECRETARY	2.0 .......................6.0	X	X	0	0
(4) STEVEN BURGESS........................................................................ BOARD OF TRUSTEES - TREASURER	2.0 .......................4.0	X	X	0	0
(5) WILLIAM AGGER MD........................................................................ BOARD OF Governors - MEMBER	2.0 .......................44.0	X		243,914	58,444
(6) BRIAN RUDE........................................................................ BOARD OF TRUSTEES - MEMBER	2.0 .......................4.0	X		0	0
(7) MARK PLATT........................................................................ BOARD OF TRUSTEES - MEMBER	2.0 .......................4.0	X		0	0
(8) BRIAN MULRENNAN MD........................................................................ BD OF TRUSTEES/BD OF GOV-MBR	2.0 .......................44.0	X		277,381	62,584
(9) JONATHAN ZLABEK MD........................................................................ BD OF TRUSTEES/BD OF GOV-MBR	2.0 .......................44.0	X		258,654	60,084
(10) JULIO BIRD MD........................................................................ EXEC. VICE PRESIDENT/BD OF GOV	2.0 .......................44.0	X	X	664,632	58,584
(11) WENDY LOMMEN........................................................................ Bd OF TRUSTEES-MBR/TREASURER	2.0 .......................4.0	X		0	0
(12) FRANK ABERGER MD........................................................................ BD OF GOVERNORS - MEMBER	2.0 .......................44.0	X		486,314	62,584
(13) MARY KUFFEL MD........................................................................ BD OF GOVERNORS-MBR/CMO	2.0 .......................44.0	X	X	435,510	38,940
(14) STEPHEN SHAPIRO MD........................................................................ BD OF TRUSTEES/BD OF GOV-MBR	2.0 .......................46.0	X		432,458	61,084
(15) BRIAN SIECK MD........................................................................ BD OF TRUSTEES/GOV/SEC/TREAS	2.0 .......................44.0	X	X	359,638	60,496
(16) Greg Thompson MD........................................................................ BOARD OF GOVERNORS - MEMBER	2.0 .......................46.0	X		343,492	63,584
(17) BRAD STURM........................................................................ Board of Trustees - Member	2.0 .......................4.0	X		0	0

(A) Name and Title	(B) Average hours per week (list any hours for related organizations below dotted line)	(E) Reportable compensation from related organizations (W- 2/1099-MISC)	(F) Estimated amount of other compensation from the organization and related organizations
(18) GORDON EDWARDS........................................................................ CHIEF FINANCIAL OFFICER	0.0 .......................40.0	X				340,689	59,084
(19) SCOTT RATHGABER MD........................................................................ MEDICAL VICE PRESIDENT	0.0 .......................40.0		X			501,122	60,084
(20) MARILU BINTZ MD........................................................................ MEDICAL VICE PRESIDENT	0.0 .......................42.0		X			511,944	46,740
(21) SIGURD GUNDERSEN III MD........................................................................ MEDICAL VICE PRESIDENT	0.0 .......................42.8		X			442,760	58,584
(22) MICHAEL J DOLAN MD........................................................................ MEDICAL VICE PRESIDENT	0.0 .......................42.0		X			432,568	58,804
(23) MARY JO KLOS........................................................................ VICE PRESIDENT	0.0 .......................40.25		X			161,086	20,762
(24) DEBRA RISLOW........................................................................ VICE PRESIDENT	0.0 .......................41.0		X			287,545	51,648
(25) KATHLEEN KLOCK........................................................................ SENIOR VICE PRESIDENT	0.0 .......................40.0		X			395,360	37,500
(26) GERALD ARNDT........................................................................ SENIOR VICE PRESIDENT	0.0 .......................41.0		X			384,412	38,940
(27) JANICE DEHAAN........................................................................ VICE PRESIDENT	0.0 .......................41.5		X			266,624	57,004
(28) ROBERT TRINE........................................................................ SENIOR VICE PRESIDENT	0.0 .......................40.0		X			365,023	57,537
(29) MARY LU GERKE........................................................................ VICE PRESIDENT	0.0 .......................40.0		X			199,124	39,240
(30) Kelly Barton........................................................................ Vice President	0.0 .......................41.5		X			172,998	26,448
(31) Bryan Erdmann........................................................................ Vice President	0.0 .......................42.8		X			166,557	47,551
(32) BRIAN STEHULA........................................................................ MEDICATION SAFETY MANAGER	0.0 .......................40.0			X		132,432	45,351
(33) JOLENE GARRETT........................................................................ CLINICAL Manager, Pharmacy	0.0 .......................40.0			X		136,432	41,311
(34) MICHAEL MEYERS II........................................................................ ADMIN. DIRECTOR	0.0 .......................40.0			X		152,680	41,235
(35) RYAN HOLTE........................................................................ ADMINISTRATIVE DIRECTOR	0.0 .......................41.0			X		158,841	23,591
(36) Adam Gregg........................................................................ Pharmacist Edu. Coordinator	0.0 .......................40.0			X		129,196	41,124
(37) Daryl Applebury........................................................................ Chief of Corporate Ventures	0.0 .......................43.3				X	215,893	53,817

Do not include amounts reported on lines 6b, 7b, 8b, 9b, and 10b of Part VIII.	(A) Total expenses	(B) Program service expenses	(C) Management and general expenses	(D) Fundraising expenses
1	Grants and other assistance to governments and organizations in the United States. See Part IV, line 21	8,195,784	8,195,784
2	Grants and other assistance to individuals in the United States. See Part IV, line 22	7,550,072	7,550,072
3	Grants and other assistance to governments, organizations, and individuals outside the United States. See Part IV, lines 15 and 16	0
4	Benefits paid to or for members	0
5	Compensation of current officers, directors, trustees, and key employees ....	0
6	Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) ....	0
7	Other salaries and wages	96,960,248	94,576,160	2,384,088
8	Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) ....	12,387,695	12,076,563	311,132
9	Other employee benefits .......	19,269,185	17,478,108	1,791,077
10	Payroll taxes ...........	6,868,627	6,913,552	-44,925
11	Fees for services (non-employees):
a	Management ......	0
b	Legal .........	0
c	Accounting ...........	0
d	Lobbying ...........	0
e	Professional fundraising services. See Part IV, line 17	0
f	Investment management fees ......	0
g	Other (If line 11g amount exceeds 10% of line 25, column (A) amount, list line 11g expenses on Schedule O) ........	75,124,244	74,885,858	238,386
12	Advertising and promotion ....	0
13	Office expenses .......	50,217,995	50,195,081	22,914
14	Information technology ......	683,038	622,819	60,219
15	Royalties ..	0
16	Occupancy ...........	4,798,108	4,453,943	344,165
17	Travel ............	342,159	325,828	16,331
18	Payments of travel or entertainment expenses for any federal, state, or local public officials ......	0
19	Conferences, conventions, and meetings ....	172,907	168,974	3,933
20	Interest ...........	0
21	Payments to affiliates .......	85,206,782	25,806,606	59,400,176
22	Depreciation, depletion, and amortization .....	9,384,953	6,353,552	3,031,401
23	Insurance ..............	162,258	1,874	160,384
24	Other expenses. Itemize expenses not covered above (List miscellaneous expenses in line 24e. If line 24e amount exceeds 10% of line 25, column (A) amount, list line 24e expenses on Schedule O.)
a	BAD DEBTS/COLLECTIONS	16,984,749	16,984,749
b	DUES/MEMBERSHIOPS/LICENSE	43,435	42,800	635
c	RECRUITING	21,414	21,414
d	MISCELLANEOUS	12,790,767	54,089	12,736,678
e	All other expenses
25	Total functional expenses. Add lines 1 through 24e	407,164,420	326,707,826	80,456,594	0
26	Joint costs. Complete this line only if the organization reported in column (B) joint costs from a combined educational campaign and fundraising solicitation. Check here if following SOP 98-2 (ASC 958-720).

Part X Balance Sheet Check if Schedule O contains a response to any question in this Part X ...............
	1	Cashnon-interest-bearing .............	0	1	0
2	Savings and temporary cash investments .........	511,399	2	217,081
3	Pledges and grants receivable, net ...........	0	3	0
4	Accounts receivable, net .............	52,680,716	4	64,638,051
5	Loans and other receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of Schedule L ..................
		0	5	0
6	Loans and other receivables from other disqualified persons (as defined under section 4958(f)(1)), persons described in section 4958(c)(3)(B), and contributing employers and sponsoring organizations of section 501(c)(9) voluntary employees' beneficiary organizations (see instructions) Complete Part II of Schedule L
		0	6	0
7	Notes and loans receivable, net .............		7
8	Inventories for sale or use ..............	766,072	8	1,401,449
9	Prepaid expenses and deferred charges ..........	0	9	0
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	372,311,516
b	Less: accumulated depreciation .....	10b	153,445,643	126,212,820	10c	218,865,873
11	Investments—publicly traded securities ..........	0	11	15,000,000
12	Investments—other securities. See Part IV, line 11 .....	290,000	12	250,000
13	Investments—program-related. See Part IV, line 11 .....	0	13	0
14	Intangible assets ...............	0	14	0
15	Other assets. See Part IV, line 11 ...........	490,392,381	15	514,634,285
16	Total assets. Add lines 1 through 15 (must equal line 34)......	670,853,388	16	815,006,739
	17	Accounts payable and accrued expenses .........	11,061,619	17	12,247,496
18	Grants payable .................	0	18	0
19	Deferred revenue ................	0	19	0
20	Tax-exempt bond liabilities .............	0	20	0
21	Escrow or custodial account liability. Complete Part IV of Schedule D..	0	21	0
22	Loans and other payables to current and former officers, directors, trustees, key employees, highest compensated employees, and disqualified
	persons. Complete Part II of Schedule L..........	0	22	0
23	Secured mortgages and notes payable to unrelated third parties ..	0	23	0
24	Unsecured notes and loans payable to unrelated third parties ....	0	24	0
25	Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17-24). Complete Part X of Schedule D....................	133,662,415	25	160,492,977
26	Total liabilities. Add lines 17 through 25.........	144,724,034	26	172,740,473
		Organizations that follow SFAS 117 (ASC 958), check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets ..............	525,629,354	27	636,653,179
28	Temporarily restricted net assets ...........	500,000	28	5,613,087
29	Permanently restricted net assets ...........	0	29	0
	Organizations that do not follow SFAS 117 (ASC 958), check here and complete lines 30 through 34.
30	Capital stock or trust principal, or current funds ........		30
31	Paid-in or capital surplus, or land, building or equipment fund .....		31
32	Retained earnings, endowment, accumulated income, or other funds		32
33	Total net assets or fund balances ...........	526,129,354	33	642,266,266
34	Total liabilities and net assets/fund balances ........	670,853,388	34	815,006,739

- TIN:

SCHEDULE A
(Form 990 or 990EZ)

Department of the Treasury
Internal Revenue Service

Public Charity Status and Public Support

Complete if the organization is a section 501(c)(3) organization or a section
4947(a)(1) nonexempt charitable trust.

Attach to Form 990 or Form 990-EZ. right arrow

See separate instructions.

OMB No. 1545-0047

2012

Open to Public
Inspection

Name of the organization

GUNDERSEN LUTHERAN MEDICAL CENTER INC

Employer identification number

39-0813416

Part I

Reason for Public Charity Status (All organizations must complete this part.) See instructions.

The organization is not a private foundation because it is: (For lines 1 through 11, check only one box.)

A church, convention of churches, or association of churches described in section 170(b)(1)(A)(i).

A school described in section 170(b)(1)(A)(ii). (Attach Schedule E.)

A hospital or a cooperative hospital service organization described in section 170(b)(1)(A)(iii).

A medical research organization operated in conjunction with a hospital described in section 170(b)(1)(A)(iii). Enter the hospital's name, city, and state:

An organization operated for the benefit of a college or university owned or operated by a governmental unit described in

section 170(b)(1)(A)(iv). (Complete Part II.)

A federal, state, or local government or governmental unit described in section 170(b)(1)(A)(v).

An organization that normally receives a substantial part of its support from a governmental unit or from the general public described in section 170(b)(1)(A)(vi). (Complete Part II.)

A community trust described in section 170(b)(1)(A)(vi). (Complete Part II.)

An organization that normally receives: (1) more than 331/3% of its support from contributions, membership fees, and gross

receipts from activities related to its exempt functions—subject to certain exceptions, and (2) no more than 331/3% of

its support from gross investment income and unrelated business taxable income (less section 511 tax) from businesses

acquired by the organization after June 30, 1975. See section 509(a)(2). (Complete Part III.)

An organization organized and operated exclusively to test for public safety. See section 509(a)(4).

An organization organized and operated exclusively for the benefit of, to perform the functions of, or to carry out the purposes of one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2). See section 509(a)(3). Check the box that describes the type of supporting organization and complete lines 11e through 11h.

Type I

Type II

Type III - Functionally integrated

Type III - Non-functionally integrated

By checking this box, I certify that the organization is not controlled directly or indirectly by one or more disqualified persons other than foundation managers and other than one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2).

If the organization received a written determination from the IRS that it is a Type I, Type II, or Type III supporting organization, check this box ..................................................

Since August 17, 2006, has the organization accepted any gift or contribution from any of the
following persons?

(i) A person who directly or indirectly controls, either alone or together with persons described in (ii)

Yes

and (iii) below, the governing body of the supported organization? ................

11g(i)

(ii) A family member of a person described in (i) above? ......................

11g(ii)

(iii) A 35% controlled entity of a person described in (i) or (ii) above? ................

11g(iii)

Provide the following information about the supported organization(s).

(i) Name of supported organization	(ii) EIN	(iv) Is the organization in col. (i) listed in your governing document?		(v) Did you notify the organization in col. (i) of your support?		(vi) Is the organization in col. (i) organized in the U.S.?		(vii) Amount of monetary support
(i) Name of supported organization	(ii) EIN	Yes	No	Yes	No	Yes	No	(vii) Amount of monetary support


Total

For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990EZ.

Cat. No. 11285F

Schedule A (Form 990 or 990-EZ) 2012

Page 2

Part II

Support Schedule for Organizations Described in Sections 170(b)(1)(A)(iv) and 170(b)(1)(A)(vi)
(Complete only if you checked the box on line 5, 7, or 8 of Part I or if the organization failed to qualify under Part III. If the organization fails to qualify under the tests listed below, please complete Part III.)

Section A. Public Support

Calendar year (or fiscal year beginning in)		(a) 2008	(b) 2009	(c) 2010	(d) 2011	(e) 2012	(f) Total
1	Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") ....
2	Tax revenues levied for the organization's benefit and either paid to or expended on its behalf.......
3	The value of services or facilities furnished by a governmental unit to the organization without charge..
4	Total. Add lines 1 through 3
5	The portion of total contributions by each person (other than a governmental unit or publicly supported organization) included on line 1 that exceeds 2% of the amount shown on line 11, column (f)..
6	Public support. Subtract line 5 from line 4.

Section B. Total Support

Calendar year (or fiscal year beginning in)		(a) 2008	(b) 2009	(c) 2010	(d) 2011	(e) 2012	(f) Total
7	Amounts from line 4..
8	Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources...
9	Net income from unrelated business activities, whether or not the business is regularly carried on..
10	Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)..
11	Total support (Add lines 7 through 10).

Gross receipts from related activities, etc. (see instructions) ..................

First five years. If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization, check this box and stop here........................................ right arrow

Section C. Computation of Public Support Percentage

Public support percentage for 2012 (line 6, column (f) divided by line 11, column (f)) .........

Public support percentage for 2011 Schedule A, Part II, line 14 ...............

16a

33 1/3% support test—2012. If the organization did not check the box on line 13, and line 14 is 33 1/3% or more, check this box
and stop here. The organization qualifies as a publicly supported organization ....................... right arrow

33 1/3% support test—2011. If the organization did not check a box on line 13 or 16a, and line 15 is 33 1/3% or more, check this
box and stop here. The organization qualifies as a publicly supported organization ..................... right arrow

17a

10%-facts-and-circumstances test—2012. If the organization did not check a box on line 13, 16a, or 16b, and line 14
is 10% or more, and if the organization meets the "facts-and-circumstances" test, check this box and stop here. Explain
in Part IV how the organization meets the "facts-and-circumstances" test. The organization qualifies as a publicly supported
organization ..................................................... right arrow

10%-facts-and-circumstances test—2011. If the organization did not check a box on line 13, 16a, 16b, or 17a, and line
15 is 10% or more, and if the organization meets the "facts-and-circumstances" test, check this box and stop here.
Explain in Part IV how the organization meets the "facts-and-circumstances" test. The organization qualifies as a publicly
supported organization ................................................ right arrow

Private foundation. If the organization did not check a box on line 13, 16a, 16b, 17a, or 17b, check this box and see
instructions ..................................................... right arrow

Schedule A (Form 990 or 990-EZ) 2012

Page 3

Part III

Support Schedule for Organizations Described in Section 509(a)(2)
(Complete only if you checked the box on line 9 of Part I or if the organization failed to qualify under Part II. If the organization fails to qualify under the tests listed below, please complete Part II.)

Section A. Public Support

Calendar year (or fiscal year beginning in)		(a) 2008	(b) 2009	(c) 2010	(d) 2011	(e) 2012	(f) Total
1	Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") .
2	Gross receipts from admissions, merchandise sold or services performed, or facilities furnished in any activity that is related to the organization's tax-exempt purpose......
3	Gross receipts from activities that are not an unrelated trade or business under section 513..
4	Tax revenues levied for the organization's benefit and either paid to or expended on its behalf...
5	The value of services or facilities furnished by a governmental unit to the organization without charge..
6	Total. Add lines 1 through 5.
7a	Amounts included on lines 1, 2, and 3 received from disqualified persons...
b	Amounts included on lines 2 and 3 received from other than disqualified persons that exceed the greater of $5,000 or 1% of the amount on line 13 for the year.
c	Add lines 7a and 7b..
8	Public support (Subtract line 7c from line 6.)

Section B. Total Support

Calendar year (or fiscal year beginning in)		(a) 2008	(b) 2009	(c) 2010	(d) 2011	(e) 2012	(f) Total
9	Amounts from line 6...
10a	Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
b	Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
c	Add lines 10a and 10b.
11	Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on.
12	Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.) ..
13	Total support. (Add lines 9, 10c, 11, and 12.)..

First five years. If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization,
check this box and stop here............................................. right arrow

Section C. Computation of Public Support Percentage

Public support percentage for 2012 (line 8, column (f) divided by line 13, column (f)) .........

Public support percentage from 2011 Schedule A, Part III, line 15 ...............

Section D. Computation of Investment Income Percentage

Investment income percentage for 2012 (line 10c, column (f) divided by line 13, column (f)) ......

Investment income percentage from 2011 Schedule A, Part III, line 17 .............

19a

33 1/3% support tests—2012. If the organization did not check the box on line 14, and line 15 is more than 33 1/3%, and line 17 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization ........ right arrow

33 1/3% support tests—2011. If the organization did not check a box on line 14 or line 19a, and line 16 is more than 33 1/3% and line 18 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization ..... right arrow

Private foundation. If the organization did not check a box on line 14, 19a, or 19b, check this box and see instructions ..... right arrow

Schedule A (Form 990 or 990-EZ) 2012

Page 4

Part IV

Supplemental Information. Complete this part to provide the explanations required by Part II, line 10; Part II, line 17a or 17b; and Part III, line 12. Also complete this part for any additional information. (See instructions).

Facts And Circumstances Test

Explanation

Schedule A (Form 990 or 990-EZ) 2012

Additional Data

Software ID:
Software Version:

- TIN:

Schedule B
(Form 990, 990-EZ,
or 990-PF)

Department of the Treasury
Internal Revenue Service

Schedule of Contributors

Attach to Form 990, 990-EZ, or 990-PF.

OMB No. 1545-0047

2012

Name of the organization

GUNDERSEN LUTHERAN MEDICAL CENTER INC

Employer identification number

39-0813416

Organization type (check one):

Filers of:

Section:

Form 990 or 990-EZ

501(c)( ) (enter number) organization

4947(a)(1) nonexempt charitable trust not treated as a private foundation

527 political organization

Form 990-PF

501(c)(3) exempt private foundation

4947(a)(1) nonexempt charitable trust treated as a private foundation

501(c)(3) taxable private foundation

Check if your organization is covered by the General Rule or a Special Rule.
Note. Only a section 501(c)(7), (8), or (10) organization can check boxes for both the General Rule and a Special Rule. See instructions.

General Rule

For an organization filing Form 990, 990-EZ, or 990-PF that received, during the year, $5,000 or more (in money or
property) from any one contributor. Complete Parts I and II.

Special Rules

For a section 501(c)(3) organization filing Form 990 or 990-EZ that met the 33¹/3% support test of the regulations
under sections 509(a)(1) and 170(b)(1)(A)(vi) and received from any one contributor, during the year, a contribution of the
greater of (1) $5,000 or (2) 2% of the amount on (i) Form 990, Part VIII, line 1h, or (ii) Form 990-EZ, line 1. Complete Parts I and II.

For a section 501(c)(7), (8), or (10) organization filing Form 990 or 990-EZ that received from any one contributor,
during the year, total contributions of more than $1,000 for use exclusively for religious, charitable,
scientific, literary, or educational purposes, or the prevention of cruelty to children or animals. Complete Parts I, II, and
III.

For a section 501(c)(7), (8), or (10) organization filing Form 990 or 990-EZ that received from any one contributor,
during the year, contributions for use exclusively for religious, charitable, etc., purposes, but these contributions did
not total to more than $1,000. If this box is checked, enter here the total contributions that were received during
the year for an exclusively religious, charitable, etc., purpose. Do not complete any of the parts unless the General Rule
applies to this organization because it received nonexclusively religious, charitable, etc., contributions of $5,000 or more
during the year ......................... Arrow Bullet

Caution. An organization that is not covered by the General Rule and/or the Special Rules does not file Schedule B (Form 990,
990-EZ, or 990-PF), but it must answer “No” on Part IV, line 2 of its Form 990; or check the box on line H of its
Form 990-EZ or on Part I, line 2 of its Form 990-PF, to certify that it does not meet the filing requirements of Schedule B (Form 990,
990-EZ, or 990-PF).

For Paperwork Reduction Act Notice, see the Instructions
for Form 990, 990-EZ, or 990-PF.

Cat. No. 30613XSchedule B (Form 990, 990-EZ, or 990-PF) (2012)

Schedule B (Form 990, 990-EZ, or 990-PF) (2012)

Page 2

Name of organization GUNDERSEN LUTHERAN MEDICAL CENTER INC

Part I	Contributors (see instructions). Use duplicate copies of Part I if additional space is needed.
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
RESTRICTED	RESTRICTED RESTRICTED RESTRICTED RESTRICTED, RESTRICTED RESTRICTED	$RESTRICTED	Person Payroll Noncash (Complete Part II if there is a noncash contribution.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II if there is a noncash contribution.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II if there is a noncash contribution.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II if there is a noncash contribution.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II if there is a noncash contribution.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II if there is a noncash contribution.)
Schedule B (Form 990, 990-EZ, or 990-PF) (2012)

Schedule B (Form 990, 990-EZ, or 990-PF) (2012)

Page 3

Name of organization GUNDERSEN LUTHERAN MEDICAL CENTER INC

Part II	Noncash Property (see instructions). Use duplicate copies of Part II if additional space is needed.
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions)	(d) Date received
		$
Schedule B (Form 990, 990-EZ, or 990-PF) (2012)

Schedule B (Form 990, 990-EZ, or 990-PF) (2012)

Page 4

Name of organization
GUNDERSEN LUTHERAN MEDICAL CENTER INC

Employer identification number

39-0813416

Part III

Exclusively religious, charitable, etc., individual contributions to section 501(c)(7), (8), or (10) organizations
that total more than $1,000 for the year. Complete columns (a) through (e) and the following line entry.
For organizations completing Part III, enter the total of exclusively religious, charitable, etc.,
contributions of $1,000 or less for the year. (Enter this information once. See instructions.) Arrow Bullet

$
Use duplicate copies of Part III if additional space is needed.

(a) No.
from
Part I

(b) Purpose of gift

(d) Description of how gift is held

(e) Transfer of gift
Transferee's name, address, and ZIP 4	Relationship of transferor to transferee

(a) No.
from
Part I

(b) Purpose of gift

(d) Description of how gift is held

(e) Transfer of gift
Transferee's name, address, and ZIP 4	Relationship of transferor to transferee

(a) No.
from
Part I

(b) Purpose of gift

(d) Description of how gift is held

(e) Transfer of gift
Transferee's name, address, and ZIP 4	Relationship of transferor to transferee

(a) No.
from
Part I

(b) Purpose of gift

(d) Description of how gift is held

(e) Transfer of gift
Transferee's name, address, and ZIP 4	Relationship of transferor to transferee

Schedule B (Form 990, 990-EZ, or 990-PF) (2012)

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE C
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service

Political Campaign and Lobbying Activities

For Organizations Exempt From Income Tax Under section 501(c) and section 527
SchCMd Bullet

Complete if the organization is described below. SchCMd Bullet

Attach to Form 990 or Form 990-EZ.
SchCMd Bullet

See separate instructions.

OMB No. 1545-0047

2012

Open to Public
Inspection

If the organization answered “Yes” to Form 990, Part IV, Line 3, or Form 990-EZ, Part V, line 46 (Political Campaign Activities), then
Round Bullet

Section 501(c)(3) organizations: Complete Parts I-A and B. Do not complete Part I-C.
Round Bullet

Section 501(c) (other than section 501(c)(3)) organizations: Complete Parts I-A and C below. Do not complete Part I-B.
Round Bullet

Section 527 organizations: Complete Part I-A only.
If the organization answered “Yes” to Form 990, Part IV, Line 4, or Form 990-EZ, Part VI, line 47 (Lobbying Activities), then
Round Bullet

Section 501(c)(3) organizations that have filed Form 5768 (election under section 501(h)): Complete Part II-A. Do not complete Part II-B.
Round Bullet

Section 501(c)(3) organizations that have NOT filed Form 5768 (election under section 501(h)): Complete Part II-B. Do not complete Part II-A.
If the organization answered “Yes” to Form 990, Part IV, Line 5 (Proxy Tax) or Form 990-EZ, Part V, line 35c (Proxy Tax), then
Round Bullet

Section 501(c)(4), (5), or (6) organizations: Complete Part III.

Name of the organization

GUNDERSEN LUTHERAN MEDICAL CENTER INC

Employer identification number

39-0813416

Part I-A

Complete if the organization is exempt under section 501(c) or is a section 527 organization.

Provide a description of the organization’s direct and indirect political campaign activities in Part IV.

Political expenditures .................................... SchCMd Bullet

Volunteer hours ........................................

Part I-B

Complete if the organization is exempt under section 501(c)(3).

Enter the amount of any excise tax incurred by the organization under section 4955 ......... SchCMd Bullet

Enter the amount of any excise tax incurred by organization managers under section 4955 ...... SchCMd Bullet

If the organization incurred a section 4955 tax, did it file Form 4720 for this year? ..............

Yes No

Was a correction made? .........................................

Yes No

If "Yes," describe in Part IV.

Part I-C

Complete if the organization is exempt under section 501(c), except section 501(c)(3).

Enter the amount directly expended by the filing organization for section 527 exempt function activities SchCMd Bullet

Enter the amount of the filing organization's funds contributed to other organizations for section 527 exempt function activities ................................... SchCMd Bullet

Total exempt function expenditures. Add lines 1 and 2. Enter here and on Form 1120-POL, line 17b.. SchCMd Bullet

Did the filing organization file Form 1120-POL for this year? ..........................

Yes No

Enter the names, addresses and employer identification number (EIN) of all section 527 political organizations to which the filing
organization made payments. For each organization listed, enter the amount paid from the filing organization’s funds. Also enter the amount of political contributions received that were promptly and directly delivered to a separate political organization, such as a separate segregated fund or a political action committee (PAC). If additional space is needed, provide information in Part IV.

(a) Name	(b) Address	(c) EIN	(d) Amount paid from filing organization's funds. If none, enter -0-.	(e) Amount of political contributions received and promptly and directly delivered to a separate political organization. If none, enter -0-.

For Paperwork Reduction Act Notice, see the instructions for Form 990 or 990-EZ.

Cat. No. 50084S

Schedule C (Form 990 or 990-EZ) 2012

Page 2

Part II-A

Complete if the organization is exempt under section 501(c)(3) and filed Form 5768 (election under section 501(h)).

A Check SchCMd Bullet

if the filing organization belongs to an affiliated group (and list in Part IV each affiliated group member's name, address, EIN, expenses, and share of excess lobbying expenditures).
B Check SchCMd Bullet

if the filing organization checked box A and "limited control" provisions apply.

Limits on Lobbying Expenditures (The term "expenditures" means amounts paid or incurred.)		(a) Filing organization's totals	(b) Affiliated group totals
1a	Total lobbying expenditures to influence public opinion (grass roots lobbying) ......	0	0
b	Total lobbying expenditures to influence a legislative body (direct lobbying) .......	0	232,875
c	Total lobbying expenditures (add lines 1a and 1b) ...................	0	232,875
d	Other exempt purpose expenditures ........................	407,164,420	1,570,265,863
e	Total exempt purpose expenditures (add lines 1c and 1d) ...............	407,164,420	1,570,498,738
f	Lobbying nontaxable amount. Enter the amount from the following table in both columns.	1,000,000	1,000,000
	If the amount on line 1e, column (a) or (b) is:The lobbying nontaxable amount is:
	Not over $500,00020% of the amount on line 1e.
	Over $500,000 but not over $1,000,000$100,000 plus 15% of the excess over $500,000.
	Over $1,000,000 but not over $1,500,000$175,000 plus 10% of the excess over $1,000,000.
	Over $1,500,000 but not over $17,000,000$225,000 plus 5% of the excess over $1,500,000.
	Over $17,000,000$1,000,000.

g	Grassroots nontaxable amount (enter 25% of line 1f) .................	250,000	250,000
h	Subtract line 1g from line 1a. If zero or less, enter -0-. ................
i	Subtract line 1f from line 1c. If zero or less, enter -0-. ................
j	If there is an amount other than zero on either line 1h or line 1i, did the organization file Form 4720 reporting section 4911 tax for this year? ......................................		Yes No

4-Year Averaging Period Under Section 501(h) (Some organizations that made a section 501(h) election do not have to complete all of the five columns below. See the instructions for lines 2a through 2f on page 4.)
Lobbying Expenditures During 4-Year Averaging Period
	Calendar year (or fiscal year beginning in)	(a) 2009	(b) 2010	(c) 2011	(d) 2012	(e) Total

2a	Lobbying nontaxable amount	1,000,000	1,000,000	1,000,000	1,000,000	4,000,000

b	Lobbying ceiling amount (150% of line 2a, column(e))					6,000,000

c	Total lobbying expenditures	201,660	258,826	216,456	232,875	909,817

d	Grassroots nontaxable amount	250,000	250,000	250,000	250,000	1,000,000

e	Grassroots ceiling amount (150% of line 2d, column (e))					1,500,000

f	Grassroots lobbying expenditures				0	0

Schedule C (Form 990 or 990-EZ) 2012

Page 3

Part II-B

Complete if the organization is exempt under section 501(c)(3) and has NOT filed Form 5768 (election under section 501(h)).

For each “Yes” response to lines 1a through 1i below, provide in Part IV a detailed description of the lobbying activity.

(a)

Yes

(b)

Amount

During the year, did the filing organization attempt to influence foreign, national, state or local legislation, including any attempt to influence public opinion on a legislative matter or referendum, through the use of:

Volunteers? .........................................

Paid staff or management (include compensation in expenses reported on lines 1c through 1i)? ....

Media advertisements? ....................................

Mailings to members, legislators, or the public? .........................

Publications, or published or broadcast statements? .......................

Grants to other organizations for lobbying purposes? .......................

Direct contact with legislators, their staffs, government officials, or a legislative body? ........

Rallies, demonstrations, seminars, conventions, speeches, lectures, or any similar means? ......

Other activities? ..........................

Total. Add lines 1c through 1i ...............................

Did the activities in line 1 cause the organization to be not described in section 501(c)(3)? .....

If "Yes," enter the amount of any tax incurred under section 4912 .................

If "Yes," enter the amount of any tax incurred by organization managers under section 4912 .....

If the filing organization incurred a section 4912 tax, did it file Form 4720 for this year? .......

Part III-A

Complete if the organization is exempt under section 501(c)(4), section 501(c)(5), or section 501(c)(6).

Yes

Were substantially all (90% or more) dues received nondeductible by members? ................

Did the organization make only in-house lobbying expenditures of $2,000 or less? ................

Did the organization agree to carry over lobbying and political expenditures from the prior year? ..........

Part III-B

Complete if the organization is exempt under section 501(c)(4), section 501(c)(5), or section 501(c)(6) and if either (a) BOTH Part III-A, lines 1 and 2, are answered “No” OR (b) Part III-A, line 3, is answered “Yes."

Dues, assessments and similar amounts from members .....................

Section 162(e) nondeductible lobbying and political expenditures (do not include amounts of political
expenses for which the section 527(f) tax was paid).

Current year .........................................

Carryover from last year ....................................

Total ............................................

Aggregate amount reported in section 6033(e)(1)(A) notices of nondeductible section 162(e) dues .

If notices were sent and the amount on line 2c exceeds the amount on line 3, what portion of the excess does the organization agree to carryover to the reasonable estimate of nondeductible lobbying and political expenditure next year? ................................

Taxable amount of lobbying and political expenditures (see instructions) ..............

Part IV

Supplemental Information

Complete this part to provide the descriptions required for Part l-A, line 1; Part l-B, line 4; Part l-C, line 5; Part II-A (affiliated group list); Part II-A, line 2; and Part ll-B, line 1. Also, complete this part for any additional information.

Identifier	Return Reference	Explanation
PART II-A LINE 1A-D		GUNDERSEN LUTHERAN ADMINISTRATIVE SERVICES, INC., 1910 S. AVE., LA CROSSE, WI 54601, 39-1606449 LOBBYING EXPENSE - $222,647 OTHER EXEMPT PURPOSE EXPENSE - $619,465,375 GUNDERSEN CLINIC, LTD. 1836 S. AVE., LA CROSSE, WI 54601, 39-1028657 LOBBYING EXPENSE - $ 10,228 OTHER EXEMPT PURPOSE EXPENSE - $543,636,068 GUNDERSEN LUTHERAN MEDICAL CENTER, INC., 1910 S. AVE, LA CROSSE, WI 54601, 39-0813416 LOBBYING EXPENSE - $0 OTHER EXEMPT PURPOSE EXPENSE - $407,164,420 GUNDERSEN LUTHERAN HEALTH SYSTEM, INC., 1836 S. AVE., LA CROSSE, WI 54601, 39-1866425 LOBBYING EXPENSE - $0 OTHER EXEMPT PURPOSE EXPENSE - $0

Schedule C (Form 990 or 990EZ) 2012

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE D
(Form 990)

Department of the Treasury
Internal Revenue Service

Supplemental Financial Statements

Complete if the organization answered "Yes," to Form 990,
Part IV, line 6, 7, 8, 9, 10, 11a, 11b, 11c, 11d, 11e, 11f, 12a, or 12b
SchDMd Bullet

Attach to Form 990. SchDMd Bullet

See separate instructions.

OMB No. 1545-0047

2012

Open to Public Inspection

Name of the organization

GUNDERSEN LUTHERAN MEDICAL CENTER INC

Employer identification number

39-0813416

Part I

Organizations Maintaining Donor Advised Funds or Other Similar Funds or Accounts. Complete if the organization answered "Yes" to Form 990, Part IV, line 6.

		(a) Donor advised funds	(b) Funds and other accounts
1	Total number at end of year .........
2	Aggregate contributions to (during year) ...
3	Aggregate grants from (during year) .....
4	Aggregate value at end of year ........

Did the organization inform all donors and donor advisors in writing that the assets held in donor advised
funds are the organization's property, subject to the organization's exclusive legal control? ............

Yes No

Did the organization inform all grantees, donors, and donor advisors in writing that grant funds can be
used only for charitable purposes and not for the benefit of the donor or donor advisor, or for any other purpose conferring impermissible private benefit? ...................................

Yes No

Part II

Conservation Easements. Complete if the organization answered "Yes" to Form 990, Part IV, line 7.

Purpose(s) of conservation easements held by the organization (check all that apply).

Preservation of land for public use (e.g., recreation or education) Preservation of an historically important land area

Protection of natural habitat Preservation of a certified historic structure

Preservation of open space

Complete lines 2a through 2d if the organization held a qualified conservation contribution in the form of a conservation easement on the last day of the tax year.


a	Total number of conservation easements .......................	2a
b	Total acreage restricted by conservation easements ..................	2b
c	Number of conservation easements on a certified historic structure included in (a) .....	2c
d	Number of conservation easements included in (c) acquired after 8/17/06, and not on a historic structure listed in the National Register ....................	2d

Number of conservation easements modified, transferred, released, extinguished, or terminated by the organization during
the tax year SchDMd Bullet

Number of states where property subject to conservation easement is located SchDMd Bullet

Does the organization have a written policy regarding the periodic monitoring, inspection, handling of violations, and
enforcement of the conservation easements it holds? .............................

Yes No

Staff and volunteer hours devoted to monitoring, inspecting, and enforcing conservation easements during the year
SchDMd Bullet

Amount of expenses incurred in monitoring, inspecting, and enforcing conservation easements during the year
SchDMd Bullet

Does each conservation easement reported on line 2(d) above satisfy the requirements of section 170(h)(4)(B)(i) and section 170(h)(4)(B)(ii)? .......................................

Yes No

In Part XIII, describe how the organization reports conservation easements in its revenue and expense statement, and
balance sheet, and include, if applicable, the text of the footnote to the organization’s financial statements that describes
the organization’s accounting for conservation easements.

Part III

Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets.
Complete if the organization answered "Yes" to Form 990, Part IV, line 8.

If the organization elected, as permitted under SFAS 116 (ASC 958), not to report in its revenue statement and balance sheet works of art, historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service, provide, in Part XIII, the text of the footnote to its financial statements that describes these items.

If the organization elected, as permitted under SFAS 116 (ASC 958), to report in its revenue statement and balance sheet works of art, historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service, provide the following amounts relating to these items:

(i)

Revenues included in Form 990, Part VIII, line 1 ........................ SchDMd Bullet

(ii)

Assets included in Form 990, Part X .............................. SchDMd Bullet

If the organization received or held works of art, historical treasures, or other similar assets for financial gain, provide the
following amounts required to be reported under SFAS 116 (ASC 958) relating to these items:

Revenues included in Form 990, Part VIII, line 1 .......................... SchDMd Bullet

Assets included in Form 990, Part X ............................... SchDMd Bullet

For Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 52283D

Schedule D (Form 990) 2012

Page 2

Part III

Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets (continued)

Using the organization’s acquisition, accession, and other records, check any of the following that are a significant use of its collection items (check all that apply):

Public exhibition

Loan or exchange programs

Scholarly research

Other

Preservation for future generations

Provide a description of the organization’s collections and explain how they further the organization’s exempt purpose in
Part XIII.

During the year, did the organization solicit or receive donations of art, historical treasures or other similar
assets to be sold to raise funds rather than to be maintained as part of the organization’s collection?........

Yes No

Part IV

Escrow and Custodial Arrangements. Complete if the organization answered "Yes" to Form 990,
Part IV, line 9, or reported an amount on Form 990, Part X, line 21.

Is the organization an agent, trustee, custodian or other intermediary for contributions or other assets not
included on Form 990, Part X? ....................................

Yes No

If "Yes," explain the arrangement in Part XIII and complete the following table:


c	Beginning balance .................................	1c
d	Additions during the year ..............................	1d
e	Distributions during the year .............................	1e
f	Ending balance ...................................	1f

Did the organization include an amount on Form 990, Part X, line 21? .....................

Yes No

If “Yes,” explain the arrangement in Part XIII. Check here if the explanation has been provided in Part XIII ........

Part V

Endowment Funds. Complete if the organization answered "Yes" to Form 990, Part IV, line 10.

		(a)Current year	(b)Prior year	b (c)Two years back	(d)Three years back	(e)Four years back
1a	Beginning of year balance ....
b	Contributions ........
c	Net investment earnings, gains, and losses
d	Grants or scholarships .....
e	Other expenditures for facilities and programs ........
f	Administrative expenses ....
g	End of year balance ......

Provide the estimated percentage of the current year end balance (line 1g, column (a)) held as:

Board designated or quasi-endowment SchDMd Bullet

Permanent endowment SchDMd Bullet

Temporarily restricted endowment SchDMd Bullet

The percentages in lines 2a, 2b, and 2c should equal 100%.

Are there endowment funds not in the possession of the organization that are held and administered for the
organization by:

Yes

(i) unrelated organizations ........................

3a(i)

(ii) related organizations ........................

3a(ii)

If "Yes" to 3a(ii), are the related organizations listed as required on Schedule R? .........

Describe in Part XIII the intended uses of the organization's endowment funds.

Part VI

Land, Buildings, and Equipment. See Form 990, Part X, line 10.

Description of property		(b)Cost or other basis (other)	(c) Accumulated depreciation	(d) Book value
1a	Land .................	3,723,381		3,723,381
b	Buildings ................	274,624,743	86,358,703	188,266,040
c	Leasehold improvements ............	4,529,237	3,318,442	1,210,795
d	Equipment ................	89,434,155	63,768,498	25,665,657
e	Other .................
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).).......				218,865,873

Schedule D (Form 990) 2012

Page 3

Part VII

InvestmentsOther Securities. See Form 990, Part X, line 12.

(a) Description of security or category (including name of security)		(b)Book value	(c) Method of valuation: Cost or end-of-year market value
(1)Financial derivatives
(2)Closely-held equity interests
Other








Total. (Column (b) must equal Form 990, Part X, col. (B) line 12.)

Part VIII

InvestmentsProgram Related. See Form 990, Part X, line 13.

(a) Description of investment type		(b) Book value	(c) Method of valuation: Cost or end-of-year market value









Total. (Column (b) must equal Form 990, Part X, col.(B) line 13.)

Part IX

Other Assets. See Form 990, Part X, line 15.

(a) Description				(b) Book value
(1) INTERCOMPANY RECEIVABLES				514,232,675
(2) OTHER RECEIVABLES				401,610







Total. (Column (b) must equal Form 990, Part X, col.(B) line 15.)...........				514,634,285

Part X

Other Liabilities. See Form 990, Part X, line 25.

1.(a) Description of liability		(b) Book value
Federal income taxes		0
INTERCOMPANY PAYABLES		159,289,064
ASSET RETIREMENT OBLIGATION		261,702
SELF INSURANCE RESERVE		942,211






Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)		160,492,977
2. Fin 48 (ASC 740) Footnote. In Part XIII, provide the text of the footnote to the organization's financial statements that reports the organization's liability for uncertain tax positions under FIN 48 (ASC 740). Check here if the text of the footnote has been provided in Part XIII .....................................................

Schedule D (Form 990) 2012

Page 4

Part XI Reconciliation of Revenue per Audited Financial Statements With Revenue per Return
1	Total revenue, gains, and other support per audited financial statements .......		1
2	Amounts included on line 1 but not on Form 990, Part VIII, line 12:
a	Net unrealized gains on investments ..........	2a
b	Donated services and use of facilities .........	2b
c	Recoveries of prior year grants ...........	2c
d	Other (Describe in Part XIII.) ............	2d
e	Add lines 2a through 2d .....................		2e
3	Subtract line 2e from line 1.....................		3
4	Amounts included on Form 990, Part VIII, line 12, but not on line 1:
a	Investment expenses not included on Form 990, Part VIII, line 7b .	4a
b	Other (Describe in Part XIII.) ...........	4b
c	Add lines 4a and 4b.......................		4c
5	Total revenue. Add lines 3 and 4c. (This must equal Form 990, Part I, line 12.) ......		5

Part XII Reconciliation of Expenses per Audited Financial Statements With Expenses per Return
1	Total expenses and losses per audited financial statements ...........		1
2	Amounts included on line 1 but not on Form 990, Part IX, line 25:
a	Donated services and use of facilities ..........	2a
b	Prior year adjustments ..............	2b
c	Other losses ................	2c
d	Other (Describe in Part XIII.) ............	2d
e	Add lines 2a through 2d......................		2e
3	Subtract line 2e from line 1.....................		3
4	Amounts included on Form 990, Part IX, line 25, but not on line 1:
a	Investment expenses not included on Form 990, Part VIII, line 7b ..	4a
b	Other (Describe in Part XIII.) ............	4b
c	Add lines 4a and 4b.......................		4c
5	Total expenses. Add lines 3 and 4c. (This must equal Form 990, Part I, line 18.) ......		5

Part XIII

Supplemental Information

Complete this part to provide the descriptions required for Part II, lines 3, 5, and 9; Part III, lines 1a and 4; Part lV, lines 1b and 2b;
Part V, line 4; Part X, line 2; Part XI, lines 2d and 4b; and Part XII, lines 2d and 4b. Also complete this part to provide any additional information.

Identifier	Return Reference	Explanation
INCOME TAX MATTERS	PART X, LINE 2	THE OBLIGATED GROUP HAS REVIEWED ITS TAX POSITIONS FOR ALL OPEN YEARS AND HAS CONCLUDED THAT NO LIABILITIES EXIST FOR UNCERTAIN TAX POSITIONS AS OF DECEMBER 31, 2012 AND 2011. THE OBLIGATED GROUP'S INCOME TAX RETURNS ARE NO LONGER SUBJECT TO EXAMINATION FOR 2006 AND PRIOR.

Schedule D (Form 990) 2012

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE H (Form 990)

Department of the Treasury
Internal Revenue Service

Hospitals

Complete if the organization answered "Yes" to Form 990, Part IV, question 20.
MediumBullet

Attach to Form 990. MediumBullet

See separate instructions.

OMB No. 1545-0047

2012

Open to Public Inspection

Name of the organization

GUNDERSEN LUTHERAN MEDICAL CENTER INC

Employer identification number

39-0813416

Part I

Financial Assistance and Certain Other Community Benefits at Cost

Yes

Did the organization have a financial assistance policy during the tax year? If "No," skip to question 6a ...

Yes

If "Yes," was it a written policy? .......................

Yes

If the organization had multiple hospital facilities, indicate which of the following best describes application of the financial assistance policy to its various hospital facilities during the tax year.

Applied uniformly to all hospital facilities Applied uniformly to most hospital facilities Generally tailored to individual hospital facilities

Answer the following based on the financial assistance eligibility criteria that applied to the largest number of the organization's patients during the tax year.

Did the organization use Federal Poverty Guidelines (FPG) as a factor in determining eligibility for providing free care?

If "Yes," indicate which of the following was the FPG family income limit for eligibility for free care:

Yes

100% 150% 200% Other %

Did the organization use FPG as a factor in determining eligibility for providing discounted care? If "Yes," indicate

which of the following was the family income limit for eligibility for discounted care: .........

Yes

200% 250% 300% 350% 400% Other 325 %

If the organization used factors other than FPG in determining eligibility, describe in Part VI the income based criteria for determining eligibility for free or discounted care. Include in the description whether the organization used an asset test or other threshold, regardless of income, as a factor in determining eligibility for free or discounted care.

Did the organization's financial assistance policy that applied to the largest number of its patients during the tax year provide for free or discounted care to the "medically indigent"? ..............

Yes

Did the organization budget amounts for free or discounted care provided under its financial assistance policy during the tax year? ............................

Yes

If "Yes," did the organization's financial assistance expenses exceed the budgeted amount? ......

Yes

If "Yes" to line 5b, as a result of budget considerations, was the organization unable to provide free or discountedcare to a patient who was eligibile for free or discounted care? ..............

Did the organization prepare a community benefit report during the tax year? ..........

Yes

If "Yes," did the organization make it available to the public? ..............

Yes

Complete the following table using the worksheets provided in the Schedule H instructions. Do not submit these worksheets with the Schedule H.

Financial Assistance and Certain Other Community Benefits at Cost

Financial Assistance and Means-Tested Government Programs		(c) Total community benefit expense	(d) Direct offsetting revenue	(e) Net community benefit expense	(f) Percent of total expense
a	Financial Assistance at cost (from Worksheet 1) ..	3,074,064		3,074,064	0.940 %
b	Medicaid (from Worksheet 3, column a) ....	49,808,472	35,303,793	14,504,679	4.450 %
c	Costs of other means-tested government programs (from Worksheet 3, column b) .	4,792,960	3,120,720	1,672,240	0.510 %
d	Total Financial Assistance and Means-Tested Government Programs .	57,675,496	38,424,513	19,250,983	5.900 %
Other Benefits		154,179	19,410	134,769	0.040 %
e	Community health improvement services and community benefit operations (from Worksheet 4) ..	154,179	19,410	134,769	0.040 %
f	Health professions education (from Worksheet 5) ..	9,996,366	3,365,069	6,631,297	2.040 %
g	Subsidized health services (from Worksheet 6) ..
h	Research (from Worksheet 7)
i	Cash and in-kind contributions for community benefit (from Worksheet 8)
j	Total. Other Benefits ..	10,150,545	3,384,479	6,766,066	2.080 %
k	Total. Add lines 7d and 7j .	67,826,041	41,808,992	26,017,049	7.980 %

For Paperwork Reduction Act Notice, see the Instructions for Form 990. Cat. No. 50192T Schedule H (Form 990) 2012

Schedule H (Form 990) 2012

Page

Part II

Community Building Activities Complete this table if the organization conducted any community building activities during the tax year, and describe in Part VI how its community building activities promoted the health of the communities it serves.

		(a) Number of activities or programs (optional)	(b) Persons served (optional)	(c) Total community building expense	(d) Direct offsetting revenue	(e) Net community building expense	(f) Percent of total expense
1	Physical improvements and housing
2	Economic development
3	Community support
4	Environmental improvements
5	Leadership development and training for community members
6	Coalition building
7	Community health improvement advocacy
8	Workforce development
9	Other
10	Total

Part III

Bad Debt, Medicare, & Collection Practices

Section A. Bad Debt Expense

Yes

Did the organization report bad debt expense in accordance with Heathcare Financial Management Association Statement No. 15? ..........................

Enter the amount of the organization's bad debt expense. Explain in Part VI the methodology used by the organization to estimate this amount. ......

7,240,921

Enter the estimated amount of the organization's bad debt expense attributable to patients eligible under the organization's financial assistance policy. Explain in Part VI the methodology used by the organization to estimate this amount and the rationale, if any, for including this portion of bad debt as community benefit. ......

590,000

Provide in Part VI the text of the footnote to the organization’s financial statements that describes bad debt expense or the page number on which this footnote is contained in the attached financial statements.

Section B. Medicare

Enter total revenue received from Medicare (including DSH and IME).....

69,727,321

Enter Medicare allowable costs of care relating to payments on line 5.....

67,255,570

Subtract line 6 from line 5. This is the surplus (or shortfall)........

2,471,751

Describe in Part VI the extent to which any shortfall reported in line 7 should be treated as community benefit.Also describe in Part VI the costing methodology or source used to determine the amount reported on line 6.Check the box that describes the method used:

Cost accounting system Cost to charge ratio Other

Section C. Collection Practices

Did the organization have a written debt collection policy during the tax year? ..........

Yes

If "Yes," did the organization’s collection policy that applied to the largest number of its patients during the tax year contain provisions on the collection practices to be followed for patients who are known to qualify for financial assistance? Describe in Part VI.......................

Yes

Part IV

Management Companies and Joint Ventures(owned 10% or more by officers, directors, trustees, key employees, and physicians—see instructions)

(a) Name of entity	(b) Description of primary activity of entity	(c) Organization's profit % or stock ownership %	(d) Officers, directors, trustees, or key employees' profit % or stock ownership %	(e) Physicians' profit % or stock ownership %
1
2
3
4
5
6
7
8
9
10
11
12
13

Schedule H (Form 990) 2012

Page

Part VFacility Information

Section A. Hospital Facilities (list in order of size from largest to smallest—see instructions) How many hospital facilities did the organization operate during the tax year?1 Name, address, and primary website address
1	GUNDERSEN LUTHERAN MED CTRINC 1910 SOUTH AVE LA CROSSE,WI54601	X	X	X	X	X

Schedule H (Form 990) 2012

Page

Part VFacility Information (continued)

Section B. Facility Policies and Practices

(Complete a separate Section B for each of the hospital facilities or facility reporting groups listed in Part V, Section A)

	GUNDERSEN LUTHERAN MEDICAL CENTERINC
Name of hospital facility or facility reporting group

For single facility filers only: line Number of Hospital Facility (from Schedule H, Part V, Section A)

Yes

Community Health Needs Assessment (Lines 1 through 8c are optional for tax years begining on or before March 23, 2012)

During the tax year or either of the two immediately preceding tax years, did the hospital facility conduct a community health needs assessment (CHNA)? If "No," skip to line 9....................

Yes

If “Yes,” indicate what the CHNA report describes (check all that apply):

A definition of the community served by the hospital facility

Demographics of the community

Existing health care facilities and resources within the community that are available to respond to the health needs of the community

How data was obtained

The health needs of the community

Primary and chronic disease needs and other health issues of uninsured persons, low-income persons, and minority groups

The process for identifying and prioritizing community health needs and services to meet the community health needs

The process for consulting with persons representing the community’s interests

Information gaps that limit the hospital facility’s ability to assess the community’s health needs

Other (describe in Part VI)

Indicate the tax year the hospital facility last conducted a CHNA: 20 12

In conducting its most recent CHNA, did the hospital facility take into account input from representatives of the community served by the hospital facility, including those with special knowledge of or expertise in public health? If “Yes,” describe in Part VI how the hospital facility took into account input from persons who represent the community, and identify the persons the hospital facility consulted ....................

Yes

Was the hospital facility’s CHNA conducted with one or more other hospital facilities? If “Yes,” list the other hospital facilities in Part VI................................

Yes

Did the hospital facility make its CHNA report widely available to the public? .............

Yes

If “Yes,” indicate how the CHNA report was made widely available (check all that apply):

Hospital facility’s website

Available upon request from the hospital facility

Other (describe in Part VI)

If the hospital facility addressed needs identified in its most recently conducted CHNA, indicate how (check all that apply to date):

Adoption of an implementation strategy that addresses each of the community health needs identified through the CHNA

Execution of the implementation strategy

Participation in the development of a community-wide plan

Participation in the execution of a community-wide plan

Inclusion of a community benefit section in operational plans

Adoption of a budget for provision of services that address the needs identified in the CHNA

Prioritization of health needs in its community

Prioritization of services that the hospital facility will undertake to meet health needs in its community

Other (describe in Part VI)

Did the hospital facility address all of the needs identified in its most recently conducted CHNA? If “No,” explain in Part VI which needs it has not addressed and the reasons why it has not addressed such needs ........

Did the organization incur an excise tax under section 4959 for the hospital facility's failure to conduct a CHNA as required by section 501(r)(3)? ...........................

If "Yes" to line 8a, did the organization file Form 4720 to report the section 4959 excise tax? ......

If "Yes" to line 8b, what is the total amount of section 4959 excise tax the organization reported on Form 4720 for all of its hospital facilities? $

Schedule H (Form 990) 2012

Page

Part VFacility Information (continued)

Financial Assistance Policy			Yes	No
9	Did the hospital facility have in place during the tax year a written financial assistance policy that:
	Explained eligibility criteria for financial assistance, and whether such assistance includes free or discounted care?	9	Yes
10	Used federal poverty guidelines (FPG) to determine eligibility for providing free care?...........	10	Yes
	If "Yes," indicate the FPG family income limit for eligibility for free care: 200.% If "No," explain in Part VI the criteria the hospital facility used.
11	Used FPG to determine eligibility for providing discounted care?.................	11	Yes
	If “Yes,” indicate the FPG family income limit for eligibility for discounted care: 325.% If "No," explain in Part VI the criteria the hospital facility used.
12	Explained the basis for calculating amounts charged to patients?.................	12	Yes
	If “Yes,” indicate the factors used in determining such amounts (check all that apply):
a	Income level
b	Asset level
c	Medical indigency
d	Insurance status
e	Uninsured discount
f	Medicaid/Medicare
g	State regulation
h	Other (describe in Part VI)
13	Explained the method for applying for financial assistance?...................	13	Yes
14	Included measures to publicize the policy within the community served by the hospital facility?.......	14	Yes
	If “Yes,” indicate how the hospital facility publicized the policy (check all that apply):
a	The policy was posted on the hospital facility’s website
b	The policy was attached to billing invoices
c	The policy was posted in the hospital facility’s emergency rooms or waiting rooms
d	The policy was posted in the hospital facility’s admissions offices
e	The policy was provided, in writing, to patients on admission to the hospital facility
f	The policy was available upon request
g	Other (describe in Part VI)
Billing and Collections
15	Did the hospital facility have in place during the tax year a separate billing and collections policy, or a written financial assistance policy (FAP) that explained actions the hospital facility may take upon non-payment?.......	15	Yes
16	Check all of the following actions against an individual that were permitted under the hospital facility's policies during the tax year before making reasonable efforts to determine the patient’s eligibility under the facility’s FAP:
a	Reporting to credit agency
b	Lawsuits
c	Liens on residences
d	Body attachments
e	Other similar actions (describe in Part VI)
17	Did the hospital facility or an authorized third party perform any of the following actions during the tax year before making reasonable efforts to determine the patient’s eligibility under the facility’s FAP?..........	17		No
	If “Yes,” check all actions in which the hospital facility or a third party engaged:
a	Reporting to credit agency
b	Lawsuits
c	Liens on residences
d	Body attachments
e	Other similar actions (describe in Part VI)

Schedule H (Form 990) 2012

Page

Part VFacility Information (continued)

Indicate which efforts the hospital facility made before initiating any of the actions listed in line 17 (check all that apply):

Notified individuals of the financial assistance policy on admission

Notified individuals of the financial assistance policy prior to discharge

Notified individuals of the financial assistance policy in communications with the patients regarding the patients’ bills

Documented its determination of whether patients were eligible for financial assistance under the hospital facility’s financial assistance policy

Other (describe in Part VI)

Policy Relating to Emergency Medical Care

Yes

Did the hospital facility have in place during the tax year a written policy relating to emergency medical care that requires the hospital facility to provide, without discrimination, care for emergency medical conditions to individuals regardless of their eligibility under the hospital facility’s financial assistance policy?..........

Yes

If “No,” indicate why:

The hospital facility did not provide care for any emergency medical conditions

The hospital facility’s policy was not in writing

The hospital facility limited who was eligible to receive care for emergency medical conditions (describe in Part VI)

Other (describe in Part VI)

Charges to Individuals Eligible for Assistance under the FAP (FAP-Eligible Individuals)

Indicate how the hospital facility determined, during the tax year, the maximum amounts that can be charged to FAP-eligible individuals for emergency or other medically necessary care.

The hospital facility used its lowest negotiated commercial insurance rate when calculating the maximum amounts that can be charged

The hospital facility used the average of its three lowest negotiated commercial insurance rates when calculating the maximum amounts that can be charged

The hospital facility used the Medicare rates when calculating the maximum amounts that can be charged

Other (describe in Part VI)

During the tax year, did the hospital facility charge any FAP-eligible individuals to whom the hospital facility provided emergency or other medically necessary services, more than the amounts generally billed to individuals who had insurance covering such care? ............................

If “Yes,” explain in Part VI.

During the tax year, did the hospital facility charge any FAP-eligible individuals an amount equal to the gross charge for any service provided to that individual? .........................

If “Yes,” explain in Part VI.

Schedule H (Form 990) 2012

Page

Part VFacility Information (continued)

Section C. Other Health Care Facilities That Are Not Licensed, Registered, or Similarly Recognized as a Hospital Facility (list in order of size, from largest to smallest) How many non-hospital health care facilities did the organization operate during the tax year?12
Name and address		Type of Facility (describe)
1	GL HOSPICE INDUSTRIAL REHAB BUILDING 1843 SIMS PL LA CROSSE,WI54601	HOSPICE SERVICES
2	GL SATELLITE DIALYSIS-ONALASKA 3075 S KINNEY COULEE RD ONALASKA,WI54650	RENAL DIALYSIS CENTER
3	UNITY HOUSE FOR WOMEN 1312 S 5TH AVE LA CROSSE,WI54601	ALCOHOL AND OTHER DRUG ABUSE (AODA) SERVICES
4	UNITY HOUSE FOR MEN 1918-1924 MILLER ST LA CROSSE,WI54601	ALCOHOL AND OTHER DRUG ABUSE {AODA} SERVICES
5	GL SATELLITE DIALYSIS-VIROOUA 407 S MAIN ST VIROQUA,WI54665	RENAL DIALYSIS CENTER
6	GL SATELLITE DIALYSIS-BLACK RVR FALLS 711 W ADAMS ST BLACK RIVER FALLS,WI54615	RENAL DIALYSIS CENTER
7	GL SATELLITE DIALYSIS-PRAIRIE DU CHIEN 610 E TAYLOR ST PRAIRIE DU CHIEN,WI53821	RENAL DIALYSIS CENTER
8	GL SATELLITE DIALYSIS-TOMAH 321 BUTTS AVE TOMAH,WI54660	RENAL DIALYSIS CENTER
9	GL MENTAL HEALTH DAY TREAT BEHAV HLTH 123 16TH AVE S ONALASKA,WI54656	OUTPATIENT PSYCHOLOGICAL SERVICES
10	GL BEHAVIORAL HEALTH-SPARTA 218 W MAIN STREET SPARTA,WI54656	OUTPATIENT PSYCHOLOGICAL SERVICES
11	GL BEHAVIORAL HEALTH-TOMAH 601 N SUPERIOR AVE TOMAH,WI54660	OUTPATIENT PSYCHOLOGICAL SERVICES
12	GL SATELLITE DIALYSIS-RICHLAND CENTER 1313 W SEMINARY ST RICHLAND CENTER,WI53581	RENAL DIALYSIS CENTER

Schedule H (Form 990) 2012

Page

Part VI

Supplemental Information

Complete this part to provide the following information.

1	Required descriptions. Provide the descriptions required for Part I, lines 3c, 6a, and 7; Part II; Part III, lines 4, 8, and 9b; Part V, Section A; and Part V, Section B, lines 1j, 3, 4, 5c, 6i, 7, 10, 11, 12h, 14g, 16e, 17e, 18e, 19c, 19d, 20d, 21, and 22.
2	Needs assessment. Describe how the organization assesses the health care needs of the communities it serves, in addition to any needs assessments reported in Part V, Section B.
3	Patient education of eligibility for assistance. Describe how the organization informs and educates patients and persons who may be billed for patient care about their eligibility for assistance under federal, state, or local government programs or under the organization’s financial assistance policy.
4	Community information. Describe the community the organization serves, taking into account the geographic area and demographic constituents it serves.
5	Promotion of community health. Provide any other information important to describing how the organization’s hospital facilities or other health care facilities further its exempt purpose by promoting the health of the community (e.g., open medical staff, community board, use of surplus funds, etc.).
6	Affiliated health care system. If the organization is part of an affiliated health care system, describe the respective roles of the organization and its affiliates in promoting the health of the communities served.
7	State filing of community benefit report. If applicable, identify all states with which the organization, or a related organization, files a community benefit report.
8	Facility reporting group(s). If applicable, for each hospital facility in a facility reporting group provide the descriptions required for Part V, Section B, lines 1j, 3, 4, 5c, 6i, 7, 10, 11, 12h, 14g, 16e, 17e, 18e, 19c, 19d, 20d, 21, and 22.

Identifier	ReturnReference	Explanation
PART I, LINE 3C		GUNDERSEN LUTHERAN MEDICAL CENTER, INC. USES THE FEDERAL POVERTY GUIDELINES AS ONE MEANS OF DETERMINING ELIGIBILITY FOR CHARITY CARE. THE FEDERAL POVERTY GUIDELINES ARE UPDATED AND PUBLISHED ANNUALLY BY THE U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES. AS A GENERAL RULE, A PATIENT'S INCOME, BASED ON FAMILY SIZE, MUST BE AT OR BELOW 325% OF THE FEDERAL POVERTY GUIDELINES TO BE ELIGIBLE FOR THE CHARITY CARE PROGRAM. A SLIDING SCALE BASED ON THE PATIENT'S INCOME LEVEL UNDER THE FEDERAL POVERTY GUIDELINES WILL BE USED TO DETERMINE THE PRECISE AMOUNT OF CHARITY CARE FOR WHICH A PATIENT WILL BE ELIGIBLE. SOME PATIENTS MAY EXCEED 325% OF THE FEDERAL POVERTY GUIDELINES, BUT MAY STILL BE ELIGIBLE FOR CHARITY CARE WHEN ADDITIONAL CRITERIA SUCH AS CATASTROPHIC MEDICAL COSTS ARE CONSIDERED. "CATASTROPHIC" IS DEFINED AS MEDICAL EXPENSES GREATER THAN 25% OF ANNUAL GROSS INCOME. ADDITIONAL FACTORS ARE ALSO CONSIDERED WHEN DETERMINING ELIGIBILITY FOR CATASTROPHIC FINANCIAL ASSISTANCE: 1) THE AMOUNT OWED IN RELATION TO THE PATIENT'S TOTAL MEANS 2) MEDICAL STATUS 3) EMPLOYMENT POTENTIAL IN LIGHT OF THE PATIENT'S MEDICAL CONDITION ALONG WITH SKILLS 4) DOES THE PATIENT LIVE ON A FIXED INCOME 5) EXISTING LIABILITIES 6) LEVEL AND TYPE OF ASSETS 7) ADDITIONAL FINANCIAL OBLIGATIONS AND TYPE.
PART I,LINE 6A		GUNDERSEN LUTHERAN HEALTH SYSTEM, INC.
PART I, LINE 7		COST TO CHARGE RATIO WAS USED AS A STARTING POINT IN DETERMINING THE COST OF SERVICES PROVIDED TO PATIENTS. CERTAIN ADJUSTMENTS WERE MADE, CONSIDERING THE TYPES OF SERVICES PROVIDED, TO MORE ACCURATELY REFLECT THE ACTUAL COST OF SERVICES. WE ALSO ENSURED THAT THE FINAL RESULT WAS WITHIN THE EXPECTED RANGE BASED ON OUR AVERAGE COST TO CHARGE RATIO.
PART I, LINE 7 COLUMN(F)		THE PERCENT OF TOTAL EXPENSE WAS CALCULATED BY DIVIDING THE COMMUNITY BENEFIT COST BY TOTAL HOSPITAL EXPENSES LESS THE $16,984,749 PROVISION FOR UNCOLLECTIBLE ACCOUNTS.
PART I, LINE 6B		THE COMMUNITY BENEFIT REPORT IS FILED WITH THE WISCONSIN HOSPITAL ASSOCIATION (WHA). THE WHA MAKES AVAILABLE A COMBINED SUMMARY WITH ALL OF THE HOSPITALS IN WISCONSIN INCLUDED.
PART II		THE GUNDERSEN LUTHERAN HEALTH SYSTEM, WHICH INCLUDES THE GUNDERSEN LUTHERAN MEDICAL CENTER, INC. IS COMMITTED TO OUR COMMUNITIES AS VOICED IN OUR MISSION: WE DISTINGUISH OURSELVES THROUGH EXCELLENCE IN PATIENT CARE, EDUCATION, RESEARCH, AND THROUGH IMPROVED HEALTH IN THE COMMUNITIES WE SERVE. THE ACTIVITIES NOTED ABOVE ARE ONLY AN EXAMPLE OF THE INVOLVEMENT WITHIN OUR COMMUNITIES INCLUDING HEALTH IMPROVEMENT, ADVOCACY FOR PEOPLE WITH DISABILITIES, RECOGNITION OF DIVERSITY AND INCLUSION, MENTAL HEALTH, DOMESTIC VIOLENCE, WORKFORCE DEVELOPMENT, EDUCATION AND SAFETY. ACTIVITIES ARE GUIDED BY COMMUNITY NEEDS ASSESSMENT CONDUCTED IN PARTNERSHIP WITH UNITED WAY AND COUNTY HEALTH DEPARTMENTS. OTHER INFORMATION THAT GUIDES OUR WORK INCLUDES WORKSITE HEALTH RISK APPRAISALS, STATE AND NATIONAL DATA, AND OUR HEALTH SCORECARD MAINTAINED AT THE MEDICAL HEALTH SCIENCE CONSORTIUM. AS A LARGER SYSTEM, COMMUNITY BUILDING ACTIVITIES ENCOMPASS ALL CORPORATIONS. LEADERSHIP IN COMMUNITY HEALTH IMPROVEMENT IS EVIDENCED BY OUR ACTIVITY WITH SEVERAL COMMUNITY COALITIONS AND INITIATIVES WITH EMPHASIS ON REDUCING OBESITY AND ALCOHOL ABUSE AND ENHANCING MENTAL HEALTH SERVICES. AS OFTEN AS POSSIBLE, ACTIVITIES ARE MEASURED AND OUTCOMES REPORTED. DUE TO OUR CUTTING EDGE IMPROVEMENTS AND INNOVATIONS ON OUR LA CROSSE CAMPUS, OUR SUSTAINABILITY PLAN HAS GAINED NATIONAL ATTENTION AND HAS BECOME AN EXAMPLE FOR MANY BUSINESSES IN THE AREA SENSITIVE TO THE NEEDS OF OUR ENVIRONMENT.
PART III, LINE 2		COST TO CHARGE RATIO WAS OUR STARTING POINT FOR DETERMINING THE COST OF SERVICES PROVIDED TO PATIENT'S ACCOUNTS WITH A BAD DEBT ADJUSTMENT. THE COST OF SERVICES WAS ALLOCATED BETWEEN BAD DEBT ADJUSTMENT, PAYMENTS ON THE ACCOUNT, AND CHARITY ADJUSTMENTS WHERE APPLICABLE. A RATIO OF THE AMOUNT ALLOCATED TO BAD DEBT AND THE TOTAL BAD DEBT ADJUSTMENTS IN THE ACCOUNTS REVIEWED IS MULTIPLIED BY THE TOTAL BAD DEBT EXPENSE TO CALCULATE THE COST APPLICABLE TO BAD DEBT.
PART III, LINE 3		GUNDERSEN LUTHERAN'S FINANCIAL ASSISTANCE POLICY (FAP) PROVIDES FREE AND DISCOUNTED CARE UP TO 325% OF THE FEDERAL POVERTY GUIDELINES (FPG). SOME PATIENTS MAY EXCEED THE 325% FPG WHEN ADDITIONAL CRITERIA SUCH AS CATASTROPHIC MEDICAL COSTS ARE CONSIDERED. THE DATA USED IS FROM THE US CENSUS BUREAU, 2008-2010 AMERICAN COMMUNITY SURVEY (ACS) 3-YEAR DATA SET FOR THE WISCONSIN COUNTIES AND ACS 5-YEAR DATA SET FOR HOUSTON COUNTY. FOR HOUSTON COUNTY, WE USED THE MINNESOTA STATE AVERAGE BECAUSE 200% VALUE WAS SO HIGH FOR HOUSTON COUNTY. WE OBTAINED THE AVERAGE OF THE FIVE COUNTIES BY USING THE INFORMATION AT THE 2.00-2.99 (299%) OF FEDERAL POVERTY LEVEL (FPL) AND BELOW. THE NEXT RANGE WAS 3.00-3.99 RATIO OF INCOME TO POVERTY IN THE LAST 12 MONTHS. WE MULTIPLIED THE FIVE COUNTY AVERAGE AT 299% OF FPL TO THE BAD DEBT AT COST. WE DEDUCTED THE AMOUNT OF CHARITY CARE AT COST TO OBTAIN THE AMOUNT OF BAD DEBT AT COST TO PATIENTS ELIGIBLE UNDER FAP(BUT FOR WHOM INSUFFICIENT INFORMATION WAS OBTAINED TO DETERMINE THEIR ELIGIBILITY).
PART III, LINE 4		THE COLLECTION OF RECEIVABLES FROM THIRD-PARTY PAYORS AND PATIENTS IS THE OBLIGATED GROUP'S PRIMARY SOURCE OF CASH FOR OPERATIONS. THE PRIMARY COLLECTION RISKS RELATE TO UNINSURED PATIENT ACCOUNTS AND PATIENT DEDUCTIBLES AND COINSURANCE ON INSURERS' ACCOUNTS. PATIENT RECEIVABLES, INCLUDING THE PORTION THAT A THIRD-PARTY PAYOR IS RESPONSIBLE FOR, ARE CARRIED AT NET REALIZABLE VALUE, DETERMINED BY THE ORIGINAL CHARGE FOR THE SERVICE PROVIDED LESS AN ESTIMATE MADE FOR CONTRACTUAL ADJUSTMENTS OR DISCOUNTS PROVIDED TO THIRD-PARTY PAYORS. PATIENT RECEIVABLES DUE DIRECTLY FROM THE PATIENTS ARE CARRIED ON THE ACCOMPANYING COMBINED BALANCE SHEETS AT THE ORIGINAL CHARGE FOR THE SERVICE PROVIDED LESS AMOUNTS COVERED BY THIRD-PARTY PAYORS, ALLOWANCES FOR OTHER DISCOUNTS, AND AN ALLOWANCE FOR UNCOLLECTIBLE RECEIVABLES. MANAGEMENT DETERMINES AN ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS BY IDENTIFYING AMOUNTS AT RISK, BASED ON HISTORICAL COLLECTION EXPERIENCE, AGING OF ACCOUNTS, AND CONSIDERING CURRENT ECONOMIC CONDITIONS. THE OBLIGATED GROUP DOES NOT CHARGE INTEREST ON PAST DUE RECEIVABLES. RECEIVABLES ARE WRITTEN OFF AFTER COLLECTION EFFORTS HAVE BEEN FOLLOWED IN ACCORDANCE WITH THE OBLIGATED GROUP'S POLICIES. RECOVERIES OF RECEIVABLES PREVIOUSLY WRITTEN OFF ARE RECORDED AS A REDUCTION OF BAD DEBT EXPENSE. ACCOUNTS RECEIVABLE ARE REDUCED BY AN ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS. IN EVALUATING THE COLLECTABILITY OF ACCOUNTS RECEIVABLE, THE OBLIGATED GROUP ANALYZES ITS PAST HISTORY AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYOR SOURCES TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND PROVISION FOR BAD DEBTS. THE ANALYSIS IS PERFORMED USING A HINDSIGHT CALCULATION THAT UTILIZES WRITE-OFF DATA FOR ALL PAYOR CLASSES DURING A DETERMINED TIME PERIOD TO CALCULATE THE ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS AT A POINT IN TIME. ACCOUNTS RECEIVABLE BALANCES OVER 365 DAYS ARE FULLY ALLOWED FOR. AT DECEMBER 31, 2012 AND 2011, THE ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS WAS $35,459 AND $29,248 (DOLLARS IN THOUSANDS), RESPECTIVELY, WHICH AS A PERCENT OF ACCOUNTS RECEIVABLE, NET OF CONTRACTUAL ADJUSTMENTS, WAS 23 % AND 19%, RESPECTIVELY.
PART III, LINE 8		THE MEDICARE COST REPORT IS USED TO DETERMINE ALLOWABLE COSTS. THE UNREIMBURSED MEDICARE COSTS ON PART III, SECTION B OF SCHEDULE H ARE ALLOWABLE COSTS PER THE MEDICARE COST REPORT. THIS CALCULATION IS LIMITED TO PATIENTS WHO ARE COVERED UNDER THE MEDICARE FEE FOR SERVICE PLAN AND DOES NOT INCLUDE THOSE COVERED BY THE MEDICARE ADVANTAGE PLANS. IT ALSO DOES NOT INCLUDE ALL SERVICES PROVIDED BY THE HOSPITAL TO PATIENTS COVERED UNDER THE MEDICARE FEE FOR SERVICE PLAN. IT EXCLUDES HOME HEALTH SERVICES, HOSPICE SERVICES, AMBULANCE SERVICES, CLINICAL LABORATORY SERVICES, AND A FEW OTHER MISCELLANEOUS SERVICES. INCORPORATING ALL SERVICES TO ALL MEDICARE BENEFICIARIES, THE UNREIMBURSED COST FOR MEDICARE IS $14,501,728.
PART III, LINE 9B		WHEN A PATIENT HAS INDICATED OR DEMONSTRATED AN "INABILITY TO PAY", A GUNDERSEN LUTHERAN FINANCIAL REPRESENTATIVE (OR ANOTHER APPROPRIATE REPRESENTATIVE) WILL PROVIDE THE PATIENT WITH A FINANCIAL ASSISTANCE APPLICATION (FAA) AND FULL, EXPLICIT INSTRUCTIONS FOR ITS COMPLETION ALONG WITH A REQUEST FOR THE DOCUMENTS NECESSARY TO VERIFY POTENTIAL PATIENT ASSETS AND LIABILITIES. DEPENDING ON A PATIENT'S ELIGIBILITY, PARTIAL OR ENTIRE ACCOUNT BALANCES THAT CANNOT BE SETTLED DUE TO FINANCIAL HARDSHIP CAN BE WRITTEN-OFF AS CHARITY CARE IF A FINANCIAL ASSISTANCE APPLICATION IS COMPLETED AND APPROVED. IN DETERMINING THE AMOUNT OF CHARITY CARE FOR WHICH A PATIENT WILL BE ELIGIBLE, GUNDERSEN LUTHERAN WILL APPLY A SLIDING SCALE BASED ON THE PATIENT'S INCOME LEVEL UNDER THE FEDERAL POVERTY GUIDELINES.
PART V, SECTION B, LINE 1J	GUNDERSEN LUTHERAN MEDICAL CENTER, INC	HE COMPASS NOW 2012 PROCESS INCLUDED A VARIETY OF DATA COLLECTION METHODS USED TO CREATE AN OVERALL DESCRIPTION OF THE ISSUES FACING OUR COMMUNITIES. THESE METHODS INCLUDE A RANDOM HOUSEHOLD SURVEY, FOCUS GROUP DISCUSSIONS HELD WITH COMMUNITY MEMBERS, AN EXTENSIVE REVIEW OF SOCIO-ECONOMIC INDICATORS, AND AN INVENTORY OF COMMUNITY RESOURCES. THE DATA COLLECTED GUIDED THE DEVELOPMENT OF 4 PILLAR PROFILES. WE REFER TO THEM AS PILLARS SINCE THEY CREATE THE BUILDING BLOCKS TO A BETTER LIFE. THE PILLARS OF THE COMPASS NOW REPORT ARE: healh, income, education, and community. PART V, SECTION B, LINE 3 EIGHT KEY STAKEHOLDER MEETINGS WERE HELD. EACH COUNTY FOCUS GROUP TEAM IDENTIFIED KEY COMMUNITY LEADERS REPRESENTING A BROAD RANGE OF COMMUNITY INTERESTS TO PARTICIPATE IN THESE MEETINGS. TWO-HUNDRED FORTY COMMUNITY LEADERS REPRESENTING BUISNESS, CLERGY, HEALTHCARE PROVIDERS AND STAFF, ELECTED OFFICIALS, LAW ENFORCEMENT, EDUCATION, SCHOOL COUNSELORS, UNITED WAY PARTNER AGENCIES, FARMERS, AND COUNTY OFFICIALS FROM THE FIVE COUNTY AREA ATTENDED THE KEY STAKEHOLDER MEETINGS. PART V, SECTION B, LINE 4 THE COMPASS NOW 2012 PARTNERSHIP IS MADE UP OF THE GREAT RIVERS UNITED WAY, GUNDERSEN LUTHERAN, MAYO CLINIC HEALTH SYSTEM, ST. JOSEPH'S HEALTH SERVICES-GUNDERSEN LUTHERAN, TOMAH MEMORIAL HOSPITAL, TRI-COUNTY MEMORIAL, VERNON MEMORIAL HEALTHCARE, LA CROSSE COMMUNITY FOUNDATION, AND THE 5 COUNTY HEALTH DEPARTMENTS. PART V, SECTION B, LINE 5C THE DETAILED ASSESSMENT AND RELATED COMPONENTS ARE AVAILABLE VIA LINK ON WWW.GUNDERSENHEALTH.ORG; AVAILABLE ON REQUEST AND AVAILABLE FOR REVIEW AND LOAN AT THE MOONEY RESOURCE LIBRARY AT OUR LA CROSSE CAMPUS. The Implementation Strategy is available via link on www.gundersenhealth.org/upload/docs/Services/CommunityPreventive/Co mmunity-Health-Implementation-Plan.pdf. PART V, SECTION B, LINE 7 IDENTIFY THE PRIORITIES FOR AREAS THAT WE ARE NOT DIRECTLY ADDRESSING, BUT THAT WE WILL MAINTAIN ACTIVE PARTNERSHIPS WITH AND REMAIN SUPPORTIVE OF THE LEAD ORGANIZATIONS FOCUSED ON THESE PRIORITIES. PART V, SECTION B, LINE 12H MUST APPLY OR BE SCREENED FOR MEDICAID ELIGIBILITY BEFORE APPLYING FOR FINANCIAL ASSISTANCE.
PART V, SECTION B, LINE 14G	GUNDERSEN LUTHERAN MEDICAL CENTER, INC	GENERAL INFORMATION ABOUT THE POLICY IS POSTED IN THE EMERGENCY ROOM, ADMISSIONS OFFICE AND PROVIDED TO PATIENTS UPON ADMISSION. THE POLICY IS REFERENCED ON BILLING INVOICES AND THE PHONE NUMBER AND WEBSITE ARE LISTED AS CONTACT INFORMATION.
PART VI, LINE 2		IT IS THE POLICY OF GUNDERSEN LUTHERAN MEDICAL CENTER, INC. TO ENGAGE IN PRACTICES WHICH PROVIDE A BENEFIT TO THE COMMUNITY. THIS IS IN ACCORDANCE WITH ITS COMMUNITY SERVICE MISSION STATEMENT WHICH READS "WE SUPPORT AND STRENGTHEN THE COMMUNITIES WE SERVE WITH PARTNERSHIPS AND INVESTMENT THROUGH EFFECTIVE HEALTH IMPROVEMENT PROGRAMMING, CORPORATE CITIZENSHIP, VOLUNTEERISM, AND ECONOMIC CONTRIBUTIONS". DEFINITION OF COMMUNITY BENEFIT IN CONCERT WITH WISCONSIN HOSPITAL ASSOCIATION (WHA), CATHOLIC HOSPITAL ASSOCIATION (CHA), AND VETERANS HEALTH ADMINISTRATION (VHA), AND INTERPRETATION OF IRS GUIDELINES; GUNDERSEN LUTHERAN MEDICAL CENTER, INC. DEFINES "COMMUNITY BENEFIT" AS PROGRAMS OR ACTIVITIES THAT PROVIDE TREATMENT AND/OR PROMOTE HEALTH AND HEALING AS A RESPONSE TO IDENTIFIED COMMUNITY NEEDS, REGARDLESS OF SOURCE OR AVAILABILITY OF PAYMENT. THESE PROGRAMS OR ACTIVITIES PROVIDE MEASURABLE IMPROVEMENT IN HEALTH STATUS, ACCESS OR USE OF HEALTH CARE RESOURCES TO THE SERVICE COMMUNITY. SPECIFICALLY, GOALS INCLUDE ACCESS AND COVERAGE, HEALTH PROMOTIONS, SOCIAL AND BASIC NEEDS, CORPORATE CITIZENSHIP, ACTIVITIES INCLUDING FINANCIAL CONTRIBUTIONS, DONATIONS OF MATERIALS AND EMPLOYEE VOLUNTEERISM. BEGINNING IN LATE 2010 AND CONCLUDING IN JANUARY 2012, A COMMUNITY NEEDS ASSESSMENT WAS CONDUCTED FOR A 5-COUNTY GEOGRAPHIC AREA. PARTNERS IN THE COMMUNITY NEEDS ASSESSMENT INCLUDED GUNDERSEN LUTHERAN AND 7 OTHER HOSPITALS, 5 COUNTY HEALTH DEPARTMENTS AND THE UNITED WAY. A PAPER HOUSEHOLD SURVEY WAS CONDUCTED AND OVER 1,100 PEOPLE RESPONDED. OVER 38 FOCUS GROUPS AND KEY STAKEHOLDER GROUPS (HELD IN 3 LANGUAGES AND INCLUDING PEOPLE OF VARYING AGES AND ABILITIES) WERE HELD INVOLVING OVER 350 INDIVIDUALS. WELL OVER 100 SOCIOECONOMIC AND HEALTH INDICATORS WERE GATHERED TO SUPPORT THE MORE SUBJECTIVE DATA. THE LEADERSHIP TEAM REPRESENTING THE PARTNERS AND OTHER CONTENT EXPERTS LED THIS DATA GATHERING, WILL REVIEW THE REPORT, AND BASED ON THE REPORT, THEIR EXPERTISE, AND THE ESTABLISHED CRITERIA, PRIORITIZE ISSUES, THAT WILL BE CONSIDERED TO BE OUR COMMUNITY'S NEEDS. AN IMPLEMENTATION PLAN WAS DEVELOPED AND APPROVED BY THE BOARD OF GOVERNORS AND BOARD OF TRUSTEES IN AUGUST 2012 THAT INCLUDES GUNDERSEN LUTHERAN'S ACTION STEPS THAT WILL IMPACT THOSE IDENTIFIED NEEDS. THE NEEDS ASSESSMENT AND IMPLEMENTATION PLAN ARE AVAILABLE ON THE WEBSITE AND IN OUR CONSUMER LIBRARY.
PART VI, LINE 3		SUBJECT TO EMTALA REQUIREMENTS, WHEN A PATIENT IS ADMITTED TO GUNDERSEN LUTHERAN HOSPITAL, CHECKED-IN BY A RECEPTIONIST OR INITIALLY CONTACTED BY A HOME HEALTH REPRESENTATIVE, HE OR SHE IS NOTIFIED OF POTENTIAL OUT OF POCKET EXPENSE AND GUNERSEN LUTHERAN'S PATIENT PAYMENT GUIDLINES. IF THIS IS NOT POSSIBLE, THE PATIENT WILL BE ADVISED OF OUR POLICY REGARDING INSTALLMENT PAYMENTS. AT THIS TIME, INSURANCE COVERAGE IS ALSO VERIFIED. IF APPROPRIATE, FINANCIAL COUNSELING IS MADE AVAILABLE TO ASSIST PATIENTS TO BE SCREENED FOR ANY MEDICAL ASSISTANCE OR DISABILITY PROGRAMS, OR OTHER PAYMENT SOURCE WILL BE IDENTIFIED AND RECORDED. HOWEVER, NEITHER OF THESE PROCEDURES WILL BE FOLLOWED IN ANY SITUATION THAT MAY VIOLATE EMTALA PROVISIONS (SEE POLICY GL-3001). IN THAT INSTANCE THE PATIENT'S INSURANCE STATUS WILL BE RECORDED AS SOON AFTER STABILIZATION AS POSSIBLE. IF A PATIENT DOES NOT HAVE INSURANCE COVERAGE OR CANNOT PROVIDE EVIDENCE OF SUCH, HE OR SHE WILL BE CLASSIFIED AS "SELF-PAY" WITHIN THE PATIENT FINANCIAL SYSTEM. ON GUNDERSEN LUTHERAN MEDICAL CENTER, INC. PAYMENT POLICIES IS POSTED IN THE PATIENT REGISTRATION AREAS OF THE INSTITUTION AND FROM FINANCIAL COUNSELORS THROUGHOUT THE ORGANIZATION, AS WELL AS THE CORPORATE WEBSITE AT WWW.GUNDERSENHEALTH.ORG. IN ADDITION GUNDERSEN LUTHERAN'S PAYMENT OPTIONS ARE PRINTED ON THE REVERSE OF ALL GUNDERSEN LUTHERAN CLINIC AND HOSPITAL BILLING STATEMENTS AND ARE AVAILABLE AT ANY TIME UPON PATIENT REQUEST.
PART VI, LINE 4		GUNDERSEN LUTHERAN MEDICAL CENTER. INC. IS A MAJOR TERTIARY TEACHING HOSPITAL IN THE GUNDERSEN LUTHERAN HEALTH SYSTEM, INC. LOCATED IN LA CROSSE, WI, THE HOSPITAL SERVES PATIENTS FROM THE LA CROSSE AND SURROUNDING AREAS INCLUDING 19 COUNTIES IN WESTERN WISCONSIN, SOUTHEASTERN MINNESOTA AND NORTHEASTERN IOWA. LA CROSSE COUNTY, WITH A POPULATION OF SLIGHTLY OVER 114,500 PEOPLE, IS THE LARGEST COMMUNITY IN OUR SERVICE REGION. TOTAL 19 COUNTY SERVICE AREA POPULATION IS APPROXIMATELY 572,000 WITH AN AVERAGE HOUSEHOLD INCOME OF $54,453. 16.1% OF THE 19 COUNTY SERVICE AREA POPULATION IS COVERED BY MEDICAL ASSISTANCE OR MEDICAID (ACCORDING TO WI AND IA DATA). PROJECTED POPULATION GROWTH IS MUCH SLOWER AT 2.1% COMPARED TO THE NATIONAL POPULATION GROWTH PROJECTION OF 3.9%. 22.8% OF THE POPULATION ARE AGE 17 OR UNDER COMPARED TO 22.2% NATIONALLY. THE SERVICE AREA POPULATION OF 65 AND OLDER ADULTS IS 15.7% COMPARED TO 17.2% NATIONALLY. 6.4% OF THE POPULATION IS NON-WHITE. SEVERAL SMALLER RURAL COMMUNITY HOSPITALS ARE LOCATED THROUGHOUT THE REGION. TRI-COUNTY MEMORIAL HOSPITAL LOCATED IN WHITEHALL, WISCONSIN, ST. JOSEEPH'S MEMORIAL HOSPITAL LOCATED HILLSBORO, WISCONSIN AND PALMER LUTHERAN HOSPITAL LOCATED IN WEST UNION, IOWA ARE AFFILITATES OF THE GUNDERSEN LUTHERAN HEALTH SYSTEM, INC. SPECIALIZED SERVICES PERFORMED AT THE HOSPITAL INCLUDE: ALLERGY, AUDIOLOGY, BEHAVIORAL MEDICINE, CARDIOLOGY, CARDIOTESTING LAB, CATH LAB, DERMATOLOGY, ECHOCARDIOGRAPHY, ENDOCRINOLOGY, ENDODONTICS, EXERCISE PHYSIOLOGY, GASTROENTEROLOGY, HEMATOLOGY, HOSPITALIST, INFECTIOUS DISEASE, NEPHROLOGY, NEUROLOGY, NEUROPSYCHOLOGY, OB/GYN, OCCUPATIONAL SERVICES, ONCOLOGY, OPTHALMOLOGY, OTOLARYNGOLOGY, PATHOLOGY, PEDIATRICS, PERIODONTICS, PHYSICAL MEDICINE AND REHAB, PHYSICAL THERAPY, PLASTIC SURGERY, PODIATRY, PROSTHODONTICS, PSYCHIATRIC, PULMONARY RENAL DIALYSIS, RHEUMATOLOGY, SPEECH PATHOLOGY, SPORTS MEDICINE, SURGERY, AND UROLOGY. GUNDERSEN LUTHERAN PROVIDED SIGNIFICANT CHARITY CARE AND OTHER COMMUNITY BENEFITS AS DEFINED BY THE IRS. IN ADDITION, WE PROVIDE A CRITICALLY IMPORTANT COMMUNITY BENEFIT, MUCH OF WHICH IS NOT QUANTIFIED. OUR HOSPITAL, LIKE MOST COMMUNITY HOSPITALS, WAS CREATED AND IS MAINTAINED IN ORDER TO PROVIDE CARE LOCALLY, CARE THAT WITHOUT OUR HOSPITAL MAY NOT BE AVAILABLE LOCALLY.
PART VI, LINE 5		A MAJORITY OF THE HEALTH SYSTEM'S BOARD OF TRUSTEES ARE INDIVIDUALS FROM THE COMMUNITY WHO RESIDE IN THE LA CROSSE AREA. THESE INDIVIDUALS ARE NOT EMPLOYEES OF THE HEALTH SYSTEM. MANY OTHER EXAMPLES EXIST REFLECTING THE HEALTH SYSTEM'S SUPPORT AND PROMOTION OF THE HEALTH OF THE COMMUNITY. PROGRAMS FOR THE COMMUNITY ARE PROVIDED AT NO COST SUCH AS PHYSICAL ACTIVITY CHALLENGE, HEALTHY MENU PLANNING FOR LOCAL RESTAURANTS, AND HEALTH SCREENINGS AT NUMEROUS EVENTS THROUGHOUT THE YEAR. A FREE NURSE ADVISOR LINE IS AVAILABLE FOR ALL TO ASSIST CALLERS. PRIORITY ONE DESIGNATION ASSURES HEART ATTACK PATIENTS SEEN IN HOSPITALS THROGHOUT THE REGION ARE CARED FOR WITH PROVEN PROTOCOLS AND TIMELY PROCEDURES. GUNDERSEN LUTHERAN STAFF ARE ENCOURAGED TO PARTICIPATE IN THEIR LOCAL COMMUNITY ORGANIZATIONS. STAFF LEND THEIR EXPERTISE IN LEADERSHIP POSITIONS TO ORGANIZATIONS SUCH AS THE UNITED WAY, HEALTH MISSION, CHAMBER OF COMMERCE, HUMAN SERVICE ORGANIZATIONS AND HEALTH IMPROVEMENT INITIATIVES. STAFF FROM GUNDERSEN LUTHERAN HAVE BEEN INSTRUMENTAL IN ACHIEVING COMMUNITY NEEDS ASSESSMENTS AND IMPLEMENTATION OF COMMUNITY INITIATIVES IN AREAS OF OBESITY, ALCOHOL USE, CHILD SAFETY, DOMESTIC VIOLENCE AND ENVIRONMENTAL HEALTH. PATIENT ADVISORY GROUPS FROM VARIOUS SECTORS OF OUR COMMUNITY ARE COORDINATED IN ORDER FOR US TO BETTER MEET THE NEEDS OF OUR PATIENTS.
PART VI, LINE 6		ALL AFFILIATES OF THE HEALTH SYSTEM HAVE A RESPONSIBILITY TO PROMOTE THE HEALTH OF THE COMMUNITIES WE SERVE. THE MAJORITY OF EMPLOYEES, BASED IN THE ADMINISTRATIVE CORPORATION, ARE ACTIVELY INVOLVED IN PROGRAMS AND SERVICES FOR THE COMMUNITY AS WELL AS MAINTAINING PARTNERSHIPS WITH A VARIETY OF ORGANIZATIONS, COALITIONS, INITIATIVES AND AGENCIES IN OUR COMMUNITIES THAT PROMOTE HEALTH. THE ADMINISTRATIVE CORPORATION ALSO PROVIDES THE FINANCIAL CORPORATE CONTRIBUTIONS TO VARIOUS ORGANIZATIONS AND COMMUNITY ACTIVITIES. OUR FOUNDATION PROVIDES SUPPORT FOR NUMEROUS COMMUNITY HEALTH PROMOTION PROGRAMS AS WELL, PROVIDED BY THE HEALTH SYSTEM OR OTHER ORGANIZATIONS IN OUR COMMUNITY. CLINICAL STAFF SUPPORT SCREENINGS AND THE HEALTH MISSION. OUR LOCAL RURAL HOSPITAL AFFILIATES PROVIDE SUPPORT TO THEIR RESPECTIVE COMMUNITIES. OUR CLINICS, LOCATED IN OVER 20 COMMUNITIES PROVIDE SUPPORT UNIQUE TO THE NEEDS OF THAT COMMUNITY. THE MEDICAL CENTER, AS PART OF AN INTEGRATED HEALTH CARE DELIVERY SYSTEM, WORKS WITH AND IS RELATED TO GUNDERSEN CLINIC, LTD. WHICH PROVIDED UNCOMPENSATED CARE IN THE AMOUNT OF APPROXIMATELY $120,528,327. BASED ON POLICIES AND CONTRACTS ARRRANGED TO HELP SUPPORT THE COMMUNITY'S NEEDS RELATED TO HEALTH CARE SERVICES, THE $120,528,327 IS THE SUM OF UNREIMBURSED MEDICARE & MEDICAID COST PLUS CHARITY AT COST. ALL OF THESE ARE CALCULATED USING THE SAME METHOD UTILIZED FOR THE HOSPITAL CALCULATION OF CHARITY COST AND UNREIMBURSED MEDICARE AND MEDICAID COSTS. THE COST OF CHARITY IS CALCULATED BY ALLOCATING THE COST TO PROVIDE SERVICES TO A PATIENT BETWEEN ANY PAYMENTS, BAD DEBT, AND CHARITY WRITE-OFFS WHERE TOTAL PAYMENTS ARE LESS THAN THE COST OF SERVICES PROVIDED. THE UNREIMBURSED MEDICARE AND MEDICAID COSTS ARE CALCULATED BY COMPARING THE COST OF SERVICES TO MEDICARE AND MEDICAID PATIENTS TO THE NET REVENUE FOR THOSE SAME PATIENTS. UNREIMBURSED COST IS THE AMOUNT THE COST EXCEEDS THE NET REVENUE. AMOUNTS ARE REPORTED IN GUNDERSEN CLINIC, LTD SEPARATE 990.
PART VI, LINE 7	LIST OF STATES RECEIVING COMMUNITY BENEFIT REPORT	WI

Schedule H (Form 990) 2012

Additional Data

Software ID:
Software Version:

- TIN:

Schedule I
(Form 990)

Department of the Treasury
Internal Revenue Service

Grants and Other Assistance to Organizations,
Governments and Individuals in the United States

Complete if the organization answered "Yes," to Form 990, Part IV, line 21 or 22.
lBullet

Attach to Form 990

OMB No. 1545-0047

2012

Open to Public
Inspection

Name of the organization
GUNDERSEN LUTHERAN MEDICAL CENTER INC

Employer identification number
39-0813416

Part I

General Information on Grants and Assistance

Does the organization maintain records to substantiate the amount of the grants or assistance, the grantees' eligibility for the grants or assistance, and
the selection criteria used to award the grants or assistance? ....................................

Yes No

Describe in Part IV the organization's procedures for monitoring the use of grant funds in the United States.

Part II

Grants and Other Assistance to Governments and Organizations in the United States. Complete if the organization answered "Yes" to
Form 990, Part IV, line 21, for any recipient that received more than $5,000. Part II can be duplicated if additional space is needed.

(a) Name and address of organization or government	(b) EIN	(c) IRC Code section if applicable	(d) Amount of cash grant	(h) Purpose of grant or assistance
(1) Gundersen Lutheran Medical Foundation Inc 1836 South Avenue La Crosse,WI54601	39-1249705	501(c)(3)	8,195,784	Support of the GLMF

Enter total number of section 501(c)(3) and government organizations listed in the line 1 table ................ Bullet Image

Enter total number of other organizations listed in the line 1 table ........................ . Bullet Image

For Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 50055P

Schedule I (Form 990) 2012

Page 2

Part III

Grants and Other Assistance to Individuals in the United States. Complete if the organization answered "Yes" to Form 990, Part IV, line 22.
Part III can be duplicated if additional space is needed.

(a)Type of grant or assistance	(b)Number of recipients	(d)Amount of non-cash assistance	(e)Method of valuation (book, FMV, appraisal, other)	(f)Description of non-cash assistance
(1) CHARITY CARE	1208	7,550,072	FMV	CHARITY CARE

Part IV

Supplemental Information.

Complete this part to provide the information required in Part I, line 2, Part III, column (b), and any other additional information.

Identifier	Return Reference	Explanation
PART I, LINE 2		ASSISTANCE WAS MADE TO A RELATED ORGANIZATION. THE FUNDS ARE MONITORED BY MANAGEMENT AND THE BOARD OF TRUSTEES AND BOARD OF GOVERNORS.

Schedule I (Form 990) 2012

Additional Data

Software ID:
Software Version:

- TIN:

Schedule J
(Form 990)

Department of the Treasury
Internal Revenue Service

Compensation Information

For certain Officers, Directors, Trustees, Key Employees, and Highest
Compensated Employees
SchJMediumBullet

Complete if the organization answered "Yes" to Form 990,
Part IV, question 23.
SchJMediumBullet

Attach to Form 990. SchJMediumBullet

See separate instructions.

OMB No. 1545-0047

2012

Open to Public Inspection

Name of the organization

GUNDERSEN LUTHERAN MEDICAL CENTER INC

Employer identification number

39-0813416

Part I

Questions Regarding Compensation

Yes

Check the appropiate box(es) if the organization provided any of the following to or for a person listed in Form
990, Part VII, Section A, line 1a. Complete Part III to provide any relevant information regarding these items.

First-class or charter travel Housing allowance or residence for personal use

Travel for companions Payments for business use of personal residence

Tax idemnification and gross-up payments Health or social club dues or initiation fees

Discretionary spending account Personal services (e.g., maid, chauffeur, chef)

If any of the boxes in line 1a are checked, did the organization follow a written policy regarding payment or reimbursement or provision of all of the expenses described above? If "No," complete Part III to explain....

Did the organization require substantiation prior to reimbursing or allowing expenses incurred by all officers,
directors, trustees, and the CEO/Executive Director, regarding the items checked in line 1a? .......

Indicate which, if any, of the following the filing organization used to establish the compensation of the
organization's CEO/Executive Director. Check all that apply. Do not check any boxes for methods
used by a related organization to establish compensation of the CEO/Executive Director, but explain in Part III.

Compensation committee Written employment contract

Independent compensation consultant Compensation survey or study

Form 990 of other organizations Approval by the board or compensation committee

During the year, did any person listed in Form 990, Part VII, Section A, line 1a with respect to the filing organization or a related organization:

Receive a severance payment or change-of-control payment? ................

Yes

Participate in, or receive payment from, a supplemental nonqualified retirement plan? .........

Participate in, or receive payment from, an equity-based compensation arrangement? .........

If "Yes" to any of lines 4a-c, list the persons and provide the applicable amounts for each item in Part III.

Only 501(c)(3) and 501(c)(4) organizations only must complete lines 5-9.

For persons listed in Form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the revenues of:

The organization? ...........................

Any related organization? .........................

If "Yes," to line 5a or 5b, describe in Part III.

For persons listed in Form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the net earnings of:

The organization? ...........................

Any related organization? .........................

If "Yes," to line 6a or 6b, describe in Part III.

For persons listed in Form 990, Part VII, Section A, line 1a, did the organization provide any non-fixed
payments not described in lines 5 and 6? If "Yes," describe in Part III ............

Were any amounts reported in Form 990, Part VII, paid or accured pursuant to a contract that was
subject to the initial contract exception described in Regulations section 53.4958-4(a)(3)? If "Yes," describe
in Part III .............................

If "Yes" to line 8, did the organization also follow the rebuttable presumption procedure described in Regulations section 53.4958-6(c)? .........................

For Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 50053T

Schedule J (Form 990) 2012

Page 2

Part II

Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees. Use duplicate copies if additional space is needed.

For each individual whose compensation must be reported in Schedule J, report compensation from the organization on row (i) and from related organizations, described in the
instructions, on row (ii). Do not list any individuals that are not listed on Form 990, Part VII.
Note. The sum of columns (B)(i)-(iii) for each listed individual must equal the total amount of Form 990, Part VII, Section A, line 1a, applicable column (D) and (E) amounts for that individual.

(A) Name and Title		(B) Breakdown of W-2 and/or 1099-MISC compensation			(C) Retirement and other deferred compensation	(D) Nontaxable benefits	(E) Total of columns (B)(i)-(D)	(F) Compensation reported as deferred in prior Form 990
(A) Name and Title		(i) Base compensation	(ii) Bonus & incentive compensation	(iii) Other reportable compensation	(C) Retirement and other deferred compensation	(D) Nontaxable benefits	(E) Total of columns (B)(i)-(D)	(F) Compensation reported as deferred in prior Form 990
(1)JEFFREY THOMPSON MDCHIEF EXECUTIVE OFFICER	(i) (ii)	0 708,172	0 0	0 3,820	0 37,500	0 23,638	0 773,130	0 0
(2)WILLIAM AGGER MDBOARD OF Governors - MEMBER	(i) (ii)	0 239,510	0 4,000	0 404	0 37,050	0 23,884	0 304,848	0 0
(3)BRIAN MULRENNAN MDBD OF TRUSTEES/BD OF GOV-MBR	(i) (ii)	0 273,172	0 1,000	0 3,209	0 37,500	0 25,138	0 340,019	0 0
(4)JONATHAN ZLABEK MDBD OF TRUSTEES/BD OF GOV-MBR	(i) (ii)	0 253,172	0 2,500	0 2,982	0 37,500	0 22,638	0 318,792	0 0
(5)JULIO BIRD MDEXEC. VICE PRESIDENT/BD OF GOV	(i) (ii)	0 653,672	0 7,500	0 3,460	0 37,500	0 21,138	0 723,270	0 0
(6)SCOTT RATHGABER MDMEDICAL VICE PRESIDENT	(i) (ii)	0 497,172	0 0	0 3,950	0 37,500	0 22,638	0 561,260	0 0
(7)FRANK ABERGER MDBD OF GOVERNORS - MEMBER	(i) (ii)	0 438,672	0 0	0 47,642	0 37,500	0 25,138	0 548,952	0 0
(8)MARY KUFFEL MDBD OF GOVERNORS-MBR/CMO	(i) (ii)	0 431,912	0 0	0 3,598	0 37,500	0 1,494	0 474,504	0 0
(9)STEPHEN SHAPIRO MDBD OF TRUSTEES/BD OF GOV-MBR	(i) (ii)	0 428,072	0 4,000	0 386	0 37,500	0 27,072	0 497,030	0 0
(10)BRIAN SIECK MDBD OF TRUSTEES/GOV/SEC/TREAS	(i) (ii)	0 359,198	0 0	0 440	0 37,500	0 26,484	0 423,622	0 0
(11)MARILU BINTZ MDMEDICAL VICE PRESIDENT	(i) (ii)	0 508,124	0 0	0 3,820	0 37,500	0 9,294	0 558,738	0 0
(12)SIGURD GUNDERSEN III MDMEDICAL VICE PRESIDENT	(i) (ii)	0 438,922	0 0	0 3,838	0 37,500	0 21,138	0 501,398	0 0
(13)MICHAEL J DOLAN MDMEDICAL VICE PRESIDENT	(i) (ii)	0 432,182	0 0	0 386	0 36,220	0 26,072	0 494,860	0 0
(14)MARY JO KLOSVICE PRESIDENT	(i) (ii)	0 61,102	0 0	0 99,984	0 9,282	0 12,161	0 182,529	0 0
(15)DEBRA RISLOWVICE PRESIDENT	(i) (ii)	0 287,185	0 0	0 360	0 37,500	0 17,169	0 342,214	0 0
(16)KATHLEEN KLOCKSENIOR VICE PRESIDENT	(i) (ii)	0 385,000	0 10,000	0 360	0 37,500	0 3,488	0 436,348	0 0
(17)GERALD ARNDTSENIOR VICE PRESIDENT	(i) (ii)	0 374,412	0 10,000	0 0	0 37,500	0 4,928	0 426,840	0 0
(18)JANICE DEHAANVICE PRESIDENT	(i) (ii)	0 265,672	0 0	0 952	0 32,920	0 26,875	0 326,419	0 0
(19)GORDON EDWARDSCHIEF FINANCIAL OFFICER	(i) (ii)	0 317,589	0 10,000	0 13,100	0 37,500	0 21,638	0 399,827	0 0
(20)ROBERT TRINESENIOR VICE PRESIDENT	(i) (ii)	0 361,589	0 0	0 3,434	0 34,453	0 23,138	0 422,614	0 0
(21)MARY LU GERKEVICE PRESIDENT	(i) (ii)	0 199,124	0 0	0 0	0 30,000	0 11,314	0 240,438	0 0
(22)BRIAN STEHULAMEDICATION SAFETY MANAGER	(i) (ii)	0 128,722	0 0	0 3,710	0 20,667	0 24,738	0 177,837	0 0
(23)JOLENE GARRETTCLINICAL Manager, Pharmacy	(i) (ii)	0 131,780	0 600	0 4,052	0 20,227	0 21,138	0 177,797	0 0
(24)MICHAEL MEYERS IIADMIN. DIRECTOR	(i) (ii)	0 150,066	0 0	0 2,614	0 20,151	0 21,138	0 193,969	0 0
(25)RYAN HOLTEADMINISTRATIVE DIRECTOR	(i) (ii)	0 157,630	0 0	0 1,211	0 23,591	0 54	0 182,486	0 0
(26)Kelly BartonVice President	(i) (ii)	0 158,186	0 0	0 14,812	0 25,008	0 1,494	0 199,500	0 0
(27)Daryl AppleburyChief of Corporate Ventures	(i) (ii)	0 215,893	0	0	0 32,733	0 23,385	0 272,011	0
(28)Greg Thompson MDBOARD OF GOVERNORS - MEMBER	(i) (ii)	0 339,672	0 0	0 3,820	0 37,500	0 26,138	0 407,130	0 0
(29)Bryan ErdmannVice President	(i) (ii)	0 162,775	0 0	0 3,782	0 24,987	0 22,701	0 214,245	0 0
(30)Adam GreggPharmacist Edu. Coordinator	(i) (ii)	0 128,976	0 0	0 220	0 19,740	0 21,438	0 170,374	0 0

Schedule J (Form 990) 2012

Page 3

Part III

Supplemental Information

Complete this part to provide the information, explanation, or descriptions required for Part I, lines 1a, 1b, 3, 4a, 4b, 4c, 5a, 5b, 6a, 6b, 7, and 8, and for Part II.
Also complete this part for any additional information.

Identifier	Return Reference	Explanation
PART I LINE lA, 2, AND 3		ALL PERSONNEL SERVICES FOR GUNDERSEN LUTHERAN MEDICAL CENTER, INC. ARE PERFORMED BY EMPLOYEES OF GUNDERSEN LUTHERAN ADMINISTRATIVE SERVICES, INC. AND ALL PAYMENTS TO VENDORS ARE MADE BY GUNDERSEN LUTHERAN ADMINISTRATIVE SERVICES, INC.
PART I, LINE 4A	SEVERANCE PAYMENT	MARY JO KLOS - $98,500

Schedule J (Form 990) 2012

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE O
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service

Supplemental Information to Form 990 or 990-EZ

Complete to provide information for responses to specific questions on
Form 990 or to provide any additional information.
MediumBullet

Attach to Form 990 or 990-EZ.

OMB No. 1545-0047

2012

Open to Public
Inspection

Name of the organization

GUNDERSEN LUTHERAN MEDICAL CENTER INC

Employer identification number

39-0813416

Identifier	Return Reference	Explanation
FORM 990,PART I, LINE 1, DESCRIPTION OF ORGANIZATION MISSION:		GUNDERSEN LUTHERAN MEDICAL CENTER (GLMC) ESTABLISHED IN 1899, PROVIDES ACUTE AND TERTIARY CARE FOR 19 COUNTIES LOCATED THROUGHOUT WESTERN WISCONSIN, NORTHEASTERN IOWA AND SOUTHEASTERN MINNESOTA. GLMC IS A TEACHING HOSPITAL WITH 256 AVAILABLE BEDS AND A LEVEL II TRAUMA AND EMERGENCY CENTER. OUR MISSION IS TO DISTINGUISH OURSELVES THROUGH EXCELLENCE IN PATIENT CARE, EDUCATION, RESEARCH AND THROUGH IMPROVED HEALTH IN THE COMMUNITIES WE SERVE. WE WILL WORK AS A TEAM TO DEMONSTRATE OUR VALUES: INTEGRITY-PERFORM WITH HONESTY, RESPONSIBILITY AND TRANSPARENCY. EXCELLENCE-ACHIEVE EXCELLENCE IN ALL ASPECTS OF DELIVERING HEALTHCARE, RESPECT-TREAT PATIENTS, FAMILIES AND COWORKERS WITH DIGNITY, INNOVATION-EMBRACE CHANGE AND NEW IDEAS, COMPASSION-PROVIDE COMPASSIONATE CARE TO PATIENTS AND FAMILIES.
FORM 990, PART III, LINE 1, DESCRIPTION OF ORGANIZATION MISSION:		GUNDERSEN LUTHERAN MEDICAL CENTER (GLMC) ESTABLISHED IN 1899, PROVIDES ACUTE AND TERTIARY CARE FOR 19 COUNTIES LOCATED THROUGHOUT WESTERN WISCONSIN, NORTHEASTERN IOWA AND SOUTHEASTERN MINNESOTA. GLMC IS A TEACHING HOSPITAL WITH 256 AVAILABLE BEDS AND A LEVEL II TRAUMA AND EMERGENCY CENTER. OUR MISSION IS TO DISTINGUISH OURSELVES THROUGH EXCELLENCE IN PATIENT CARE, EDUCATION, RESEARCH AND THROUGH IMPROVED HEALTH IN THE COMMUNITIES WE SERVE. WE WILL WORK AS A TEAM TO DEMONSTRATE OUR VALUES: INTEGRITY-PERFORM WITH HONESTY, RESPONSIBILITY AND TRANSPARENCY. EXCELLENCE-ACHIEVE EXCELLENCE IN ALL ASPECTS OF DELIVERING HEALTHCARE, RESPECT-TREAT PATIENTS, FAMILIES AND COWORKERS WITH DIGNITY, INNOVATION-EMBRACE CHANGE AND NEW IDEAS, COMPASSION-PROVIDE COMPASSIONATE CARE TO PATIENTS AND FAMILIES.
FORM 990, PART VI, SECTION A, LINE 6:		GUNDERSEN LUTHERAN HEALTH SYSTEM, INC. IS THE SOLE MEMBER OF THIS ORGANIZATION.
FORM 990, PART VI SECTION A LINE 7A:		GUNDERSEN LUTHERAN HEALTH SYSTEM, INC.
FORM 990, PART VI, SECTION A, LINE 7B:		GUNDERSEN LUTHERAN HEALTH SYSTEM, INC. THE PARENT CORPORATION AND SOLE MEMBER OF THE CORPORATION, SHALL HAVE THE POWER TO RECOMMEND AND REVIEW, AS APPROPRIATE, AND APPROVE CERTAIN MATTERS. ARTICLES OF INCORPORATION MAY BE AMENDED BY VOTE OF THE SOLE MEMBER OF THE CORPORATION.
FORM 990 , PART VI, SECTION B, LINE 11:		THE GUNDERSEN LUTHERAN HEALTH SYSTEM FINANCE COMMITTEE RECEIVES A COPY OF THE 990 BEFORE FILING AND UPON FURTHER REVIEW FROM THE CONTROLLER, THE 990'S ARE APPROVED AND FILED.
FORM 990 PART VI, SECTION B LINE 12C:		GUNDERSEN LUTHERAN MEDICAL CENTER, INC. MONITORS CONFLICTS ON AN ANNUAL BASIS BY REVIEWING DISCLOSURES ON COMPLETED CONFLICT OF INTEREST STATEMENTS.
FORM 990, PART VI, SECTION B, LINE 15:		ALL PERSONNEL SERVICES FOR GUNDERSEN LUTHERAN MEDICAL CENTER, INC. ARE PERFORMED BY EMPLOYEES OF GUNDERSEN LUTHERAN ADMINISTRATIVE SERVICES, INC. THE COMPENSATION OF THE CEO IS DETERMINIED ANNUALLY BY A COMMITTEE MADE UP OF THE COMMUNITY MEMBERS OF THE BOARD OF TRUSTEES. THEIR DETERMINATION IS MADE AFTER A REVIEW OF MARKET DATA OBTAINED FROM SEVERAL ORGANIZATIONS AND CEO PERFORMANCE. MEETING MINUTES ARE TAKEN AND KEPT AT THE MEETINGS WHERE SUCH DISCUSSIONS TAKE PLACE. RECOMMENDATIONS FOR COMPENSATION FOR THE ORGANIZATIONS' KEY MANAGEMENT EMPLOYEES ARE DEVELOPED ANNUALLY BY THE CEO, AFTER A REVIEW OF PERFORMANCE AND COMPARABLE MARKET DATA. THE COMPENSATION RECOMMENDATIONS, ALONG WITH THE MARKET DATA, ARE PRESENTED TO A COMMITTEE MADE UP OF THE COMMUNITY MEMBERS OF THE BOARD OF TRUSTEES. THE COMPENSATION AMOUNTS ARE NOT EFFECTIVE UNTIL THE BOARD COMMITTEE 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, SECTION C, LINE 19:		REQUESTS FOR ALL DOCUMENTS ARE MADE THROUGH THE LEGAL DEPARTMENT AND THE APPROPRIATE DOCUMENTS ARE MADE AVAILABLE FOR INSPECTION IN THE LEGAL DEPARTMENT.
FORM 990, PART VII, SECTION A		ALL PERSONNEL SERVICES FOR GUNDERSEN LUTHERAN MEDICAL CENTER, INC. ARE PERFORMED BY EMPLOYEES OF GUNDERSEN LUTHERAN ADMINISTRATIVE SERVICES,INC.
FORM 990, PART VII, SECTION B		ALL PAYMENTS TO VENDORS ARE MADE BY GUNDERSEN LUTHERAN ADMINISTRATIVE SERVICES,INC.
FORM 990, PART XII, LINE 2C		THE PROCESS ALLOWS THE AUDIT COMMITTEE OF GUNDERSEN LUTHERAN HEALTH SYSTEM, INC. TO INDEPENDENTLY COMMUNICATE WITH THE EXTERNAL AUDIT FIRM THROUGHOUT THE YEAR, BUT FORMAL COMMUNICATION OCCURS BEFORE THE ENGAGEMENT AND UPON CONCLUSION. THE AUDIT COMMITTEE MEETS WITH THE AUDIT FIRM FOR PRESENTATION OF THE STATEMENTS. THE PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. AFFILIATED ENTITY CHARITY CARE AN AFFILIATE OF GUNDERSEN LUTHERAN MEDICAL CENTER, INC., GUNDERSEN CLINIC, LTD., IS NOT REQUIRED TO FILE SCHEDULE H OF FORM 990. GUNDERSEN CLINIC, LTD. PROVIDED COMMUNITY BENEFIT OF: CHARITY AT COST $2,063,495 MEDICARE UNREIMBURSED COST $94,820,318 MEDICAID UNREIMBURSED COST $23,644,514
FORM 990, PART IV, LINE 24A	TAX EXEMPT BOND ISSUE	GUNDERSEN LUTHERAN ADMINISTRATIVE SERVICES, INC IS A PART OF GUNDERSEN LUTHERAN'S OBLIGATED GROUP (GUNDERSEN LUTHERAN ADMINISTRATIVE SERVICES, INC., GUNDERSEN LUTHERAN MEDICAL CENTER, INC., GUNDERSEN CLINIC, LTD., AND GUNDERSEN LUTHERAN MEDICAL FOUNDATION,INC.) AND TAX-EXEMPT DEBT RESIDES ON THE BALANCE SHEET OF GUNDERSEN LUTHERAN ADMINISTRATIVE SERVICES, INC. FEIN 39-1606449
FORM 990, PART XI, LINE 9	OTHER CHANGES IN NET ASSETS	AUDIT ADJUSTMENT ($125,497) RECLASSIFICATION OF CONTRIBUTIONS ($200,001) CAPITATION AGREEMENT ADJ ($290,750) TOTAL PART XI, LINE 9 ($616,248)

For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.

Cat. No. 51056K

Schedule O (Form 990 or 990-EZ) 2012

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE R
(Form 990)

Department of the Treasury
Internal Revenue Service

Related Organizations and Unrelated Partnerships

Complete if the organization answered "Yes" to Form 990, Part IV, line 33, 34, 35, 36, or 37.
MediumBullet

Attach to Form 990. MediumBullet

See separate instructions.

OMB No. 1545-0047

2012

Open to Public Inspection

Name of the organization

GUNDERSEN LUTHERAN MEDICAL CENTER INC

Employer identification number

39-0813416

Part I

Identification of Disregarded Entities (Complete if the organization answered "Yes" to Form 990, Part IV, line 33.)

(a) Name, address, and EIN (if applicable) of disregarded entity	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Total income	(e) End-of-year assets	(f) Direct controlling entity

Part II

Identification of Related Tax-Exempt Organizations (Complete if the organization answered "Yes" to Form 990, Part IV, line 34 because it had one or more related tax-exempt organizations during the tax year.)

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Exempt Code section	(e) Public charity status (if section 501(c)(3))	(f) Direct controlling entity	(g) Section 512(b)(13) controlled entity?
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Exempt Code section	(e) Public charity status (if section 501(c)(3))	(f) Direct controlling entity	Yes	No
(1) GUNDERSEN LUTHERAN HEALTH SYSTEM INC 1836 SOUTH AVENUE LA CROSSE,WI54601 39-1866425	SUPTNG. ORG.	WI	501(C)(3)	LINE 11B II	NA		No
(2) GUNDERSEN CLINIC LTD 1910 SOUTH AVENUE LA CROSSE,WI54601 39-1028657	SUPTNG. ORG.	WI	501(c)(3)	LINE 3	GLHS		No
(3) GUNDERSEN LUTHERAN MEDICAL FDNINC 1836 SOUTH AVENUE LA CROSSE,WI54601 39-1249705	FOUNDATION	WI	501(C)(3)	LINE 7	GLHS		No
(4) GUNDERSEN LUTHERAN ADMIN SERVICES INC 1910 SOUTH AVENUE LA CROSSE,WI54601 39-1606449	SUPTNG. ORG.	WI	501(C)(3)	LINE 11B II	GLHS		No
(5) GUNDERSEN LUTHERAN HEALTH PLAN INC 1836 SOUTH AVENUE LA CROSSE,WI54601 39-1807071	HEALTH INS.	WI	501(C)(4)		GLHS		No
(6) GUNDERSEN LUTHERAN CREDENTIALING SVCINC 1910 SOUTH AVENUE LA CROSSE,WI54601 39-1856898	CREDENT.SERV	WI	501(C)(3)	LINE 11A,I	GLHS		No
(7) TRI -COUNTY MEMORIAL HOSPITAL INC 18601 LINCOLN STREET WHITEHALL,WI54773 39-0704510	HEALTH CARE	WI	501(C)(3)	LINE 3	GLHS		No
(8) HARMONY COMMUNITY HEALTHCARE INC 815 MAIN AVENUE S HARMONY,MN55939 41-0711606	HEALTH CARE	MN	501(C)(3)	line 9	GLHS		No
(9) TWEETEN LUTHERAN HEALTHCARE CENTER INC 125 FIFTH AVENUE SE SPRING GROVE,MN55974 41-1565003	HEALTH CARE	MN	501(C)(3)	LINE 9	GLHS		No
(10) TRI-STATE AMBULANCE INC 235 CAUSEWAY BLVD LA CROSSE,WI54603 39-1965415	MED. TRNSP.	WI	501(C)(3)	LINE 3	GLHS		No
(11) TRI-STATE REGIONAL AMBULANCE INC 235 CAUSEWAY BLVD LA CROSSE,WI54601 39-1962965	MED. TRNSP.	WI	501(C)(3)	LINE 9	GLHS		No
(12) LUTHERAN REAL ESTATE HOLDING CORP 1910 SOUTH AVENUE LA CROSSE,WI54601 39-1480826	HOUSING	WI	501(C)(3)	LINE 9	GLHS		No
(13) LUTHERAN HOUSING OF LA CROSSE INC 1900 SOUTH AVENUE LA CROSSE,WI54601 39-1751934	INDP. LIVING	WI	501(C)(3)	LINE 9	LREHC		No
(14) COMMUNITY HOUSING OF LA CROSSE INC 1900 SOUTH AVENUE LA CROSSE,WI54601 39-1586700	INDP. LIVIVG	WI	501(C)(3)	LINE 7	LREHC		No
(15) OPTIONS IN REPRODUCTIVE CARE INC 1201 CALEDONIA STREET LA CROSSE,WI54603 39-1166634	HEALTH CARE	WI	501(C)(3)	LINE 3	GLHS		No
(16) ST JOSEPH' S HEALTH SERVICES INC 400 WATER AVENUE HILLSBORO,WI54634 39-0929538	HEALTH CARE	WI	501(C)(3)	LINE 3	GLHS		No
(17) TRI-COUNTY MEMORIAL FOUNDATION INC 18601 LINCOLN STREET WHITEHALL,WI54773 30-0093022	FOUNDATION	WI	501(C)(3)	LINE 3	TRI-COUNTY		No
(18) GUNDERSEN LUTHERAN EXPRESS CARE INC 1836 SOUTH AVE LA CROSSE,WI54061 90-0102388	HEALTH CARE	WI	501(C)(3)	LINE 11	GLHS		No
(19) ST JOSEPH'S MEMORIAL FOUNDATION INC 400 WATER STREET HILLSBORO,WI54634 39-1455787	FOUNDATION	WI	501(C)(3)	LINE 11A, I	S JOSEPH HS		No
(20) GUNDERSEN LUTHERAN HEALTH PLAN MN INC 1900 SOUTH AVE LA CROSSE,WI54601 45-2633920	HEALTH INSUR	MN	501(C)(4)	SEE STMT	GLHP		No

For Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 50135Y

Schedule R (Form 990) 2012

Page 2

Part III

Identification of Related Organizations Taxable as a Partnership (Complete if the organization answered "Yes" to Form 990, Part IV, line 34 because it had one or more related organizations treated as a partnership during the tax year.)

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(f) Share of total income	(g) Share of end-of-year assets	(h) Disproprtionate allocations?		(i) Code VUBI amount in box 20 of Schedule K-1 (Form 1065)	(j) General or managing partner?
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(f) Share of total income	(g) Share of end-of-year assets	Yes	No	(i) Code VUBI amount in box 20 of Schedule K-1 (Form 1065)	Yes	No

Part IV

Identification of Related Organizations Taxable as a Corporation or Trust (Complete if the organization answered "Yes" to Form 990, Part IV, line 34 because it had one or more related organizations treated as a corporation or trust during the tax year.)

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(e) Type of entity (C corp, S corp, or trust)	(f) Share of total income	(g) Share of end-of-year assets	(i) Section 512(b)(13) controlled entity?
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(e) Type of entity (C corp, S corp, or trust)	(f) Share of total income	(g) Share of end-of-year assets	Yes	No
(1) DEGEN BERGLUND INC 1709 LOSEY BLVD S LA CROSSE,WI54601 39-0971110	RETAIL PHARMACY	WI	GLHS	C CORP	0	0		No
(2) GUNDERSEN LUTHERAN ENVISION LLC 1836 SOUTH AVENUE LA CROSSE,WI54601 26-4706546	RENEWLABLE ENERGY	WI	GLHS	C CORP	0	0		No

Schedule R (Form 990) 2012

Page 3

Part V

Transactions With Related Organizations (Complete if the organization answered "Yes" to Form 990, Part IV, line 34, 35b, or 36.)

Note. Complete line 1 if any entity is listed in Parts II, III, or IV of this schedule.

Yes

1 During the tax year, did the orgranization engage in any of the following transactions with one or more related organizations listed in Parts II-IV?

a Receipt of (i) interest (ii) annuities (iii) royalties or (iv) rent from a controlled entity . . . . . . . . . . . . . . . . . . . . . . .

b Gift, grant, or capital contribution to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

c Gift, grant, or capital contribution from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

d Loans or loan guarantees to or for related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

e Loans or loan guarantees by related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

f Dividends from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

g Sale of assets to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

h Purchase of assets from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

i Exchange of assets with related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

j Lease of facilities, equipment, or other assets to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . .

k Lease of facilities, equipment, or other assets from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . .

l Performance of services or membership or fundraising solicitations for related organization(s) . . . . . . . . . . . . . . . . . . . .

Yes

m Performance of services or membership or fundraising solicitations by related organization(s) . . . . . . . . . . . . . . . . . . . .

n Sharing of facilities, equipment, mailing lists, or other assets with related organization(s) . . . . . . . . . . . . . . . . . . . . .

o Sharing of paid employees with related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

p Reimbursement paid to related organization(s) for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

q Reimbursement paid by related organization(s) for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

r Other transfer of cash or property to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

s Other transfer of cash or property from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

If the answer to any of the above is "Yes," see the instructions for information on who must complete this line, including covered relationships and transaction thresholds.

(a) Name of other organization	(b) Transaction type (a-s)	(c) Amount involved	(d) Method of determining amount involved
(1) Gundersen Lutheran Health Plan Inc	P	72,698,468	Fair Value

Schedule R (Form 990) 2012

Page 4

Part VI

Unrelated Organizations Taxable as a Partnership (Complete if the organization answered "Yes" to Form 990, Part IV, line 37.)

Provide the following information for each entity taxed as a partnership through which the organization conducted more than five percent of its activities (measured by total assets or gross revenue) that was not a related organization. See instructions regarding exclusion for certain investment partnerships.

(a) Name, address, and EIN of entity	(b) Primary activity	(c) Legal domicile (state or foreign country)	(e) Are all partners section 501(c)(3) organizations?		(f) Share of total income	(g) Share of end-of-year assets	(h) Disproprtionate allocations?		(i) Code VUBI amount in box 20 of Schedule K-1 (Form 1065)	(j) General or managing partner?
(a) Name, address, and EIN of entity	(b) Primary activity	(c) Legal domicile (state or foreign country)	Yes	No	(f) Share of total income	(g) Share of end-of-year assets	Yes	No	(i) Code VUBI amount in box 20 of Schedule K-1 (Form 1065)	Yes	No

Schedule R (Form 990) 2012

Page 5

Part VII

Supplemental Information

Complete this part to provide additional information for responses to questions on Schedule R (see instructions).

Identifier	Return Reference	Explanation
PART II, PAGE 3, LINE 6		THE APPLICATION FOR 501(C)(4) IS PENDING.

Additional Data

Software ID:
Software Version:

1	Briefly describe the organization’s mission or most significant activities: SEE SCHEDULE O
2	Check this box
3	Number of voting members of the governing body (Part VI, line 1a) ........	3	16
4	Number of independent voting members of the governing body (Part VI, line 1b) .....	4	6
5	Total number of individuals employed in calendar year 2011 (Part V, line 2a) ......	5	0
6	Total number of volunteers (estimate if necessary) .............	6	0
7a	Total unrelated business revenue from Part VIII, column (C), line 12 ........	7a	221,187
b	Net unrelated business taxable income from Form 990-T, line 34 .........	7b	12,779

		Prior Year	Current Year
8	Contributions and grants (Part VIII, line 1h) .........	3,467,500	7,450,297
9	Program service revenue (Part VIII, line 2g) .........	422,284,451	479,506,052
10	Investment income (Part VIII, column (A), lines 3, 4, and 7d ) ....	6,195,933	36,779,091
11	Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e)	-39,567	182,140
12	Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)...................	431,908,317	523,917,580
13	Grants and similar amounts paid (Part IX, column (A), lines 1–3 )...	8,304,576	15,745,856
14	Benefits paid to or for members (Part IX, column (A), line 4).....	0	0
15	Salaries, other compensation, employee benefits (Part IX, column (A), lines 5–10)	134,997,126	135,485,755
16a	Professional fundraising fees (Part IX, column (A), line 11e).....	0	0
b	Total fundraising expenses (Part IX, column (D), line 25) 0
17	Other expenses (Part IX, column (A), lines 11a–11d, 11f–24e)....	239,020,150	255,932,809
18	Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25)	382,321,852	407,164,420
19	Revenue less expenses. Subtract line 18 from line 12.......	49,586,465	116,753,160
		Beginning of Current Year	End of Year
20	Total assets (Part X, line 16).............	670,853,388	815,006,739
21	Total liabilities (Part X, line 26).............	144,724,034	172,740,473
22	Net assets or fund balances. Subtract line 21 from line 20.....	526,129,354	642,266,266

Sign Here

	Signature of officer	Date

	Type or print name and title


4a	(Code: ) (Expenses $ 326,707,826 including grants of $ 15,745,856 ) (Revenue $ 479,506,052 )
	GLMC PROVIDES A COMPREHENSIVE RANGE OF INPATIENT, CLINICAL AND DIAGNOSTIC SERVICES IN NUMEROUS MEDICAL SPECIALTIES AND SUBSPECIALTIES. GLMC IS A TEACHING HOSPITAL WITH 256 AVAILABLE BEDS WITH SPECIALTY SERVICES INCLUDING RENAL DIALYSIS,CANCER CARE, REHABILITATION SERVICES, AND CARDIAC SERVICES. GLMC VOLUNTARILY PROVIDES MEDICALLY NECESSARY PATIENT CARE SERVICE THAT IS DISCOUNTED OR FREE OF CHARGE TO PERSONS WHO HAVE INSUFFICIENT RESOURCES AND/OR WHO ARE UNINSURED. DURING 2012, GLMC PROVIDED FINANCIAL ASSISTANCE ON APPROXIMATELY 1,208 PATIENT ACCOUNTS THAT RESULTED IN GLMC INCURRING ROUGHLY $3,074,064 IN UNCOMPENSATED COST ASSOCIATED WITH THIS PROGRAM.

4b	(Code: ) (Expenses $ including grants of $ ) (Revenue $ )












4c	(Code: ) (Expenses $ including grants of $ ) (Revenue $ )












4d	Other program services (Describe in Schedule O.)
	(Expenses $ including grants of $ ) (Revenue $ )
4e	Total program service expenses326,707,826

1b	Sub-Total................
c	Total from continuation sheets to Part VII, Section A....
d	Total (add lines 1b and 1c)............	0	9,767,271	1,493,823

(A) Name and business address	(B) Description of services	(C) Compensation
GUNDERSEN LUTHERAN ADMIN SERVICES, 1910 SOUTH AVENUELA CROSSEWI54601	PURCHASED SERVICES	643,930,338
GUNDERSEN CLINIC LTD, 1836 SOUTH AVENUELA CROSSEWI54601	PURCHASED SERVICES	96,532,211



2 Total number of independent contractors (including but not limited to those listed above) who received more than $100,000 of compensation from the organization 2

				(A) Total revenue	(B) Related or exempt function revenue	(C) Unrelated business revenue	(D) Revenue excluded from tax under sections 512, 513, or 514
1a	Federated campaigns..1a
b	Membership dues....1b
c	Fundraising events....1c
d	Related organizations...1d		6,936,752
e	Government grants (contributions)1e		296,133

f	All other contributions, gifts, grants, and similar amounts not included above1f		217,412

g	Noncash contributions included in lines 1a-1f:$
h	Total. Add lines 1a-1f.......			7,450,297
			Business Code
2a	MEDICAL SERVICE PROVIDED		621500	479,506,052	479,506,052
b
c
d
e
f	All other program service revenue .
g	Total. Add lines 2a–2f........			479,506,052
3	Investment income (including dividends, interest, and other similar amounts).......			36,755,091			36,755,091
4	Income from investment of tax-exempt bond proceeds..			0
5	Royalties...........			0
		(i) Real	(ii) Personal
6a	Gross rents	9,600
b	Less: rental expenses	48,647
c	Rental income or (loss)	-39,047	0
d	Net rental income or (loss).......			-39,047	0	0	-39,047
		(i) Securities	(ii) Other
7a	Gross amount from sales of assets other than inventory		24,000
b	Less: cost or other basis and sales expenses
c	Gain or (loss)		24,000
d	Net gain or (loss)..........			24,000			24,000
8a	Gross income from fundraising events (not including $ of contributions reported on line 1c). See Part IV, line 18 ..
	a
b	Less: direct expenses ...b
c	Net income or (loss) from fundraising events..			0
9a	Gross income from gaming activities. See Part IV, line 19 ...
	a
b	Less: direct expenses ...b
c	Net income or (loss) from gaming activities...			0
10a	Gross sales of inventory, less returns and allowances .
	a
b	Less: cost of goods sold ..b
c	Net income or (loss) from sales of inventory..			0
Miscellaneous Revenue			Business Code
11a	LABORATORY SERVICES		900099	221,187		221,187
b
c
d	All other revenue ....
e	Total. Add lines 11a–11d ......			221,187
12	Total revenue. See Instructions......			523,917,580	479,506,052	221,187	36,740,044


				(A) Beginning of year		(B) End of year
1	Cashnon-interest-bearing .............			0	1	0
2	Savings and temporary cash investments .........			511,399	2	217,081
3	Pledges and grants receivable, net ...........			0	3	0
4	Accounts receivable, net .............			52,680,716	4	64,638,051
5	Loans and other receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of Schedule L ..................
				0	5	0
6	Loans and other receivables from other disqualified persons (as defined under section 4958(f)(1)), persons described in section 4958(c)(3)(B), and contributing employers and sponsoring organizations of section 501(c)(9) voluntary employees' beneficiary organizations (see instructions) Complete Part II of Schedule L
				0	6	0
7	Notes and loans receivable, net .............				7
8	Inventories for sale or use ..............			766,072	8	1,401,449
9	Prepaid expenses and deferred charges ..........			0	9	0
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	372,311,516
b	Less: accumulated depreciation .....	10b	153,445,643	126,212,820	10c	218,865,873
11	Investments—publicly traded securities ..........			0	11	15,000,000
12	Investments—other securities. See Part IV, line 11 .....			290,000	12	250,000
13	Investments—program-related. See Part IV, line 11 .....			0	13	0
14	Intangible assets ...............			0	14	0
15	Other assets. See Part IV, line 11 ...........			490,392,381	15	514,634,285
16	Total assets. Add lines 1 through 15 (must equal line 34)......			670,853,388	16	815,006,739
17	Accounts payable and accrued expenses .........			11,061,619	17	12,247,496
18	Grants payable .................			0	18	0
19	Deferred revenue ................			0	19	0
20	Tax-exempt bond liabilities .............			0	20	0
21	Escrow or custodial account liability. Complete Part IV of Schedule D..			0	21	0
22	Loans and other payables to current and former officers, directors, trustees, key employees, highest compensated employees, and disqualified
	persons. Complete Part II of Schedule L..........			0	22	0
23	Secured mortgages and notes payable to unrelated third parties ..			0	23	0
24	Unsecured notes and loans payable to unrelated third parties ....			0	24	0
25	Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17-24). Complete Part X of Schedule D....................			133,662,415	25	160,492,977
26	Total liabilities. Add lines 17 through 25.........			144,724,034	26	172,740,473
	Organizations that follow SFAS 117 (ASC 958), check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets ..............			525,629,354	27	636,653,179
28	Temporarily restricted net assets ...........			500,000	28	5,613,087
29	Permanently restricted net assets ...........			0	29	0
	Organizations that do not follow SFAS 117 (ASC 958), check here and complete lines 30 through 34.
30	Capital stock or trust principal, or current funds ........				30
31	Paid-in or capital surplus, or land, building or equipment fund .....				31
32	Retained earnings, endowment, accumulated income, or other funds				32
33	Total net assets or fund balances ...........			526,129,354	33	642,266,266
34	Total liabilities and net assets/fund balances ........			670,853,388	34	815,006,739