TY 2019 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) RICK DADO...................................................................... DIRECTOR	1.75 ................. 0.25	X		700	0	0
(2) HEIDI ERSPAMER...................................................................... DIRECTOR & VICE CHAIR	1.75 ................. 0.25	X	X	1,200	0	0
(3) JAMES A LEADHOLM JR...................................................................... DIRECTOR & CHAIR	1.75 ................. 0.25	X	X	1,200	0	0
(4) MARGO ROSEN...................................................................... DIRECTOR	1.75 ................. 0.25	X		800	0	0
(5) STEVEN SCHAFFFER...................................................................... DIRECTOR	1.75 ................. 0.25	X		1,500	0	0
(6) CHRIS PETERSEN...................................................................... DIRECTOR	1.75 ................. 0.25	X		1,200	0	0
(7) ORALEE SCHOCK...................................................................... DIRECTOR & SECRETARY	1.75 ................. 0.25	X	X	1,200	0	0
(8) ROSS R BULLARD...................................................................... DIRECTOR & TREASURER	1.00 ................. 46.00	X	X	0	236,514	70,370
(9) DYLAN COE MD...................................................................... DIRECTOR	0.25 ................. 39.75	X		0	328,646	91,647
(10) MARTIN E RICHARDS MD...................................................................... DIRECTOR	0.25 ................. 39.75	X		0	490,399	57,228
(11) ANN SEAGREN MD...................................................................... DIRECTOR	0.25 ................. 49.75	X		0	233,514	72,952
(12) THEODORE WEGLEITNER...................................................................... DIRECTOR	0.25 ................. 52.75	X		0	548,976	116,564
(13) MARYANN SCOGLIO CANP...................................................................... DIRECTOR	0.25 ................. 64.75	X		0	169,933	43,446
(14) JASON J LUHRS...................................................................... CFO (JAN-AUG)	0.50 ................. 49.50		X	0	231,590	53,365
(15) SANDRA M REED...................................................................... VP - AMBULATORY CARE	50.00 ................. 0.00		X	184,600	0	42,107
(16) DEBRA RUDQUIST...................................................................... PRESIDENT	53.00 ................. 0.00		X	0	329,096	61,861
(17) PATRICK SURA MD...................................................................... CHIEF MEDICAL OFFICER	0.25 ................. 64.75		X	0	457,353	56,749

(A) Name and business address	(B) Description of services	(C) Compensation
RIVER VALLEY ANESTHESIA INC PO BOX 118 NEW RICHMOND,WI54017	NURSE ANESTHETISTS	993,561
TWIN CITIES ORTHOPEDICS PA 5803 NEAL AVE N OAK PARK HEIGHTS,MN55082	PROFESSIONAL SERVICES	849,037
SHARED MEDICAL TECHNOLOGY INC 202 W NEWTON ST RICE LAKE,WI54868	PROFESSIONAL SERVICES	383,128
HEALOGICS WOUND CARE 28525 NETWORK PLACE CHICAGO,IL60673	WOUND HEALING MANAGEMENT	339,205
ABBOT VASCULAR DIVISION PO BOX 91138 CHICAGO,IL60675	PROFESSIONAL SERVICES	221,191
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 12

- 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.
right arrow

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

Go to www.irs.gov/Form990 for instructions and the latest information.

OMB No. 1545-0047

2019

Open to Public
Inspection

Name of the organization

AMERY REGIONAL MEDICAL CENTER INC

Employer identification number

39-0908320

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 12, 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 (Form 990 or 990-EZ).)

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 agricultural research organization described in 170(b)(1)(A)(ix) operated in conjunction with a land-grant college or university or a non-land grant college of agriculture. See instructions. Enter the name, city, and state of the college or university:

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 in lines 12a through 12d that describes the type of supporting organization and complete lines 12e, 12f, and 12g.

Type I. A supporting organization operated, supervised, or controlled by its supported organization(s), typically by giving the supported organization(s) the power to regularly appoint or elect a majority of the directors or trustees of the supporting organization. You must complete Part IV, Sections A and B.

Type II. A supporting organization supervised or controlled in connection with its supported organization(s), by having control or management of the supporting organization vested in the same persons that control or manage the supported organization(s). You must complete Part IV, Sections A and C.

Type III functionally integrated. A supporting organization operated in connection with, and functionally integrated with, its supported organization(s) (see instructions). You must complete Part IV, Sections A, D, and E.

Type III non-functionally integrated. A supporting organization operated in connection with its supported organization(s) that is not functionally integrated. The organization generally must satisfy a distribution requirement and an attentiveness requirement (see instructions). You must complete Part IV, Sections A and D, and Part V.

Check this box if the organization received a written determination from the IRS that it is a Type I, Type II, Type III functionally integrated, or Type III non-functionally integrated supporting organization.

Enter the number of supported organizations ...............................

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

(i) Name of supported organization	(ii) EIN	(iv) Is the organization listed in your governing document?		(v) Amount of monetary support (see instructions)	(vi) Amount of other support (see instructions)
(i) Name of supported organization	(ii) EIN	Yes	No	(v) Amount of monetary support (see instructions)	(vi) Amount of other support (see instructions)


Total

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

Cat. No. 11285F

Schedule A (Form 990 or 990-EZ) 2019

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 failed to qualify under the tests listed below, please complete Part III.)

Section A. Public Support

Calendar year (or fiscal year beginning in)		(a) 2015	(b) 2016	(c) 2017	(d) 2018	(e) 2019	(f) Total
1	Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grant.") ..
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) 2015	(b) 2016	(c) 2017	(d) 2018	(e) 2019	(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 VI.)..
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 section 501(c)(3) organization, check this box and stop here........................................ right arrow

Section C. Computation of Public Support Percentage

Public support percentage for 2019 (line 6, column (f) divided by line 11, column (f)) .........

Public support percentage for 2018 Schedule A, Part II, line 14 ...............

16a

33 1/3% support test—2019. 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—2018. 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—2019. 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 VI how the organization meets the "facts-and-circumstances" test. The organization qualifies as a publicly supported
organization ..................................................... right arrow

10%-facts-and-circumstances test—2018. 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 VI 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) 2019

Page 3

Part III

Support Schedule for Organizations Described in Section 509(a)(2)
(Complete only if you checked the box on line 10 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) 2015	(b) 2016	(c) 2017	(d) 2018	(e) 2019	(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) 2015	(b) 2016	(c) 2017	(d) 2018	(e) 2019	(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 VI.) ..
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 section 501(c)(3) organization,
check this box and stop here............................................. right arrow

Section C. Computation of Public Support Percentage

Public support percentage for 2019 (line 8, column (f) divided by line 13, column (f)) .........

Public support percentage from 2018 Schedule A, Part III, line 15 ...............

Section D. Computation of Investment Income Percentage

Investment income percentage for 2019 (line 10c, column (f) divided by line 13, column (f)) ......

Investment income percentage from 2018 Schedule A, Part III, line 17 .............

19a

331/3% support tests—2019. 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—2018. 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) 2019

Page 4

Part IV

Supporting Organizations

(Complete only if you checked a box on line 12 of Part I. If you checked 12a of Part I, complete Sections A and B. If you checked 12b of Part I, complete Sections A and C. If you checked 12c of Part I, complete Sections A, D, and E. If you checked 12d of Part I, complete Sections A and D, and complete Part V.)

Section A. All Supporting Organizations

Yes

Are all of the organization’s supported organizations listed by name in the organization’s governing documents?
If "No," describe in Part VI how the supported organizations are designated. If designated by class or purpose,
describe the designation. If historic and continuing relationship, explain.

Did the organization have any supported organization that does not have an IRS determination of status under section 509(a)(1) or (2)? If "Yes," explain in Part VI how the organization determined that the supported organization was described in section 509(a)(1) or (2).

Did the organization have a supported organization described in section 501(c)(4), (5), or (6)? If "Yes," answer (b) and (c) below.

Did the organization confirm that each supported organization qualified under section 501(c)(4), (5), or (6) and satisfied the public support tests under section 509(a)(2)? If "Yes," describe in Part VI when and how the organization made the determination.

Did the organization ensure that all support to such organizations was used exclusively for section 170(c)(2)(B) purposes? If "Yes," explain in Part VI what controls the organization put in place to ensure such use.

Was any supported organization not organized in the United States ("foreign supported organization")? If “Yes” and if you checked 12a or 12b in Part I, answer (b) and (c) below.

Did the organization have ultimate control and discretion in deciding whether to make grants to the foreign supported organization? If “Yes,” describe in Part VI how the organization had such control and discretion despite being controlled or supervised by or in connection with its supported organizations.

Did the organization support any foreign supported organization that does not have an IRS determination under sections 501(c)(3) and 509(a)(1) or (2)? If “Yes,” explain in Part VI what controls the organization used to ensure that all support to the foreign supported organization was used exclusively for section 170(c)(2)(B) purposes.

Did the organization add, substitute, or remove any supported organizations during the tax year? If “Yes,” answer (b) and (c) below (if applicable). Also, provide detail in Part VI, including (i) the names and EIN numbers of the supported organizations added, substituted, or removed; (ii) the reasons for each such action; (iii) the authority under the organization's organizing document authorizing such action; and (iv) how the action was accomplished (such as by amendment to the organizing document).

Type I or Type II only. Was any added or substituted supported organization part of a class already designated in the organization's organizing document?

Substitutions only. Was the substitution the result of an event beyond the organization's control?

Did the organization provide support (whether in the form of grants or the provision of services or facilities) to anyone other than (i) its supported organizations, (ii) individuals that are part of the charitable class benefited by one or more of its supported organizations, or (iii) other supporting organizations that also support or benefit one or more of the filing organization’s supported organizations? If “Yes,” provide detail in Part VI.

Did the organization provide a grant, loan, compensation, or other similar payment to a substantial contributor (defined in section 4958(c)(3)(C)), a family member of a substantial contributor, or a 35% controlled entity with regard to a substantial contributor? If “Yes,” complete Part I of Schedule L (Form 990 or 990-EZ) .

Did the organization make a loan to a disqualified person (as defined in section 4958) not described in line 7? If “Yes,” complete Part I of Schedule L (Form 990 or 990-EZ).

Was the organization controlled directly or indirectly at any time during the tax year by one or more disqualified persons as defined in section 4946 (other than foundation managers and organizations described in section 509(a)(1) or (2))? If “Yes,” provide detail in Part VI.

Did one or more disqualified persons (as defined in line 9a) hold a controlling interest in any entity in which the supporting organization had an interest? If “Yes,” provide detail in Part VI.

Did a disqualified person (as defined in line 9a) have an ownership interest in, or derive any personal benefit from, assets in which the supporting organization also had an interest? If “Yes,” provide detail in Part VI.

10a

Was the organization subject to the excess business holdings rules of section 4943 because of section 4943(f) (regarding certain Type II supporting organizations, and all Type III non-functionally integrated supporting organizations)? If “Yes,” answer line 10b below.

10a

Did the organization have any excess business holdings in the tax year? (Use Schedule C, Form 4720, to determine whether the organization had excess business holdings).

10b

Schedule A (Form 990 or 990-EZ) 2019

Page 5

Part IV

Supporting Organizations (continued)

Yes

Has the organization accepted a gift or contribution from any of the following persons?

A person who directly or indirectly controls, either alone or together with persons described in (b) and (c) below, the governing body of a supported organization?

11a

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

11b

A 35% controlled entity of a person described in (a) or (b) above? If “Yes” to a, b, or c, provide detail in Part VI.

11c

Section B. Type I Supporting Organizations

Yes

Did the directors, trustees, or membership of one or more supported organizations have the power to regularly appoint or elect at least a majority of the organization’s directors or trustees at all times during the tax year? If “No,” describe in Part VI how the supported organization(s) effectively operated, supervised, or controlled the organization’s activities. If the organization had more than one supported organization, describe how the powers to appoint and/or remove directors or trustees were allocated among the supported organizations and what conditions or restrictions, if any, applied to such powers during the tax year.

Did the organization operate for the benefit of any supported organization other than the supported organization(s) that operated, supervised, or controlled the supporting organization? If “Yes,” explain in Part VI how providing such benefit carried out the purposes of the supported organization(s) that operated, supervised or controlled the supporting organization.

Section C. Type II Supporting Organizations

Yes

Were a majority of the organization’s directors or trustees during the tax year also a majority of the directors or trustees of each of the organization’s supported organization(s)? If “No,” describe in Part VI how control or management of the supporting organization was vested in the same persons that controlled or managed the supported organization(s).

Section D. All Type III Supporting Organizations

Yes

Did the organization provide to each of its supported organizations, by the last day of the fifth month of the organization’s tax year, (i) a written notice describing the type and amount of support provided during the prior tax year, (ii) a copy of the Form 990 that was most recently filed as of the date of notification, and (iii) copies of the organization’s governing documents in effect on the date of notification, to the extent not previously provided?

Were any of the organization’s officers, directors, or trustees either (i) appointed or elected by the supported organization(s) or (ii) serving on the governing body of a supported organization? If "No," explain in Part VI how the organization maintained a close and continuous working relationship with the supported organization(s).

By reason of the relationship described in (2), did the organization’s supported organizations have a significant voice in the organization’s investment policies and in directing the use of the organization’s income or assets at all times during the tax year? If "Yes," describe in Part VI the role the organization’s supported organizations played in this regard.

Section E. Type III Functionally-Integrated Supporting Organizations

Check the box next to the method that the organization used to satisfy the Integral Part Test during the year (see instructions):

The organization satisfied the Activities Test. Complete line 2 below.

The organization is the parent of each of its supported organizations. Complete line 3 below.

The organization supported a governmental entity. Describe in Part VI how you supported a government entity (see instructions)

Activities Test. Answer (a) and (b) below.

Yes

Did substantially all of the organization’s activities during the tax year directly further the exempt purposes of the supported organization(s) to which the organization was responsive? If "Yes," then in Part VI identify those supported organizations and explain how these activities directly furthered their exempt purposes, how the organization was responsive to those supported organizations, and how the organization determined that these activities constituted substantially all of its activities.

Did the activities described in (a) constitute activities that, but for the organization’s involvement, one or more of the organization’s supported organization(s) would have been engaged in? If "Yes," explain in Part VI the reasons for the organization’s position that its supported organization(s) would have engaged in these activities but for the organization’s involvement.

Parent of Supported Organizations. Answer (a) and (b) below.

Did the organization have the power to regularly appoint or elect a majority of the officers, directors, or trustees of each of the supported organizations? Provide details in Part VI.

Did the organization exercise a substantial degree of direction over the policies, programs and activities of each of its supported organizations? If "Yes," describe in Part VI. the role played by the organization in this regard.

Schedule A (Form 990 or 990-EZ) 2019

Page 6

Part V

Type III Non-Functionally Integrated 509(a)(3) Supporting Organizations

Check here if the organization satisfied the Integral Part Test as a qualifying trust on Nov. 20, 1970 (explain in Part VI). See instructions. All other Type III non-functionally integrated supporting organizations must complete Sections A through E.

	Section A - Adjusted Net Income		(A) Prior Year	(B) Current Year (optional)
1	Net short-term capital gain	1
2	Recoveries of prior-year distributions	2
3	Other gross income (see instructions)	3
4	Add lines 1 through 3	4
5	Depreciation and depletion	5
6	Portion of operating expenses paid or incurred for production or collection of gross income or for management, conservation, or maintenance of property held for production of income (see instructions)	6
7	Other expenses (see instructions)	7
8	Adjusted Net Income (subtract lines 5, 6 and 7 from line 4)	8

	Section B - Minimum Asset Amount		(A) Prior Year	(B) Current Year (optional)
1	Aggregate fair market value of all non-exempt-use assets (see instructions for short tax year or assets held for part of year):	1
a	Average monthly value of securities	1a
b	Average monthly cash balances	1b
c	Fair market value of other non-exempt-use assets	1c
d	Total (add lines 1a, 1b, and 1c)	1d
e	Discount claimed for blockage or other factors (explain in detail in Part VI):
2	Acquisition indebtedness applicable to non-exempt use assets	2
3	Subtract line 2 from line 1d	3
4	Cash deemed held for exempt use. Enter 1-1/2% of line 3 (for greater amount, see instructions).	4
5	Net value of non-exempt-use assets (subtract line 4 from line 3)	5
6	Multiply line 5 by .035	6
7	Recoveries of prior-year distributions	7
8	Minimum Asset Amount (add line 7 to line 6)	8

	Section C - Distributable Amount		Current Year
1	Adjusted net income for prior year (from Section A, line 8, Column A)	1
2	Enter 85% of line 1	2
3	Minimum asset amount for prior year (from Section B, line 8, Column A)	3
4	Enter greater of line 2 or line 3	4
5	Income tax imposed in prior year	5
6	Distributable Amount. Subtract line 5 from line 4, unless subject to emergency temporary reduction (see instructions)	6

Check here if the current year is the organization's first as a non-functionally-integrated Type III supporting organization (see instructions)

Schedule A (Form 990 or 990-EZ) 2019

Page 7

Part V

Type III Non-Functionally Integrated 509(a)(3) Supporting Organizations(continued)

Section D - Distributions		Current Year
1 Amounts paid to supported organizations to accomplish exempt purposes
2 Amounts paid to perform activity that directly furthers exempt purposes of supported organizations, in excess of income from activity
3 Administrative expenses paid to accomplish exempt purposes of supported organizations
4 Amounts paid to acquire exempt-use assets
5 Qualified set-aside amounts (prior IRS approval required)
6 Other distributions (describe in Part VI). See instructions
7Total annual distributions. Add lines 1 through 6.
8 Distributions to attentive supported organizations to which the organization is responsive (provide details in Part VI). See instructions
9 Distributable amount for 2019 from Section C, line 6
10 Line 8 amount divided by Line 9 amount

Section E - Distribution Allocations (see instructions)		(i) Excess Distributions	(ii) Underdistributions Pre-2019	(iii) Distributable Amount for 2019
1 Distributable amount for 2019 from Section C, line 6
2 Underdistributions, if any, for years prior to 2019 (reasonable cause required-- explain in Part VI). See instructions.
3 Excess distributions carryover, if any, to 2019:
a From 2014.......
b From 2015.......
c From 2016.......
d From 2017.......
e From 2018.......
fTotal of lines 3a through e
g Applied to underdistributions of prior years
h Applied to 2019 distributable amount
i Carryover from 2014 not applied (see instructions)
j Remainder. Subtract lines 3g, 3h, and 3i from 3f.
4Distributions for 2019 from Section D, line 7:
$
a Applied to underdistributions of prior years
b Applied to 2019 distributable amount
c Remainder. Subtract lines 4a and 4b from 4.
5 Remaining underdistributions for years prior to 2019, if any. Subtract lines 3g and 4a from line 2. If the amount is greater than zero, explain in Part VI. See instructions.
6 Remaining underdistributions for 2019. Subtract lines 3h and 4b from line 1. If the amount is greater than zero, explain in Part VI. See instructions.
7 Excess distributions carryover to 2020. Add lines 3j and 4c.
8 Breakdown of line 7:
a Excess from 2015.....
b Excess from 2016.....
c Excess from 2017.....
d Excess from 2018.....
e Excess from 2019.....

Schedule A (Form 990 or 990-EZ) (2019)

Schedule A (Form 990 or 990-EZ) 2019

Page 8

Part VI

Supplemental Information. Provide the explanations required by Part II, line 10; Part II, line 17a or 17b; Part III, line 12; Part IV, Section A, lines 1, 2, 3b, 3c, 4b, 4c, 5a, 6, 9a, 9b, 9c, 11a, 11b, and 11c; Part IV, Section B, lines 1 and 2; Part IV, Section C, line 1; Part IV, Section D, lines 2 and 3; Part IV, Section E, lines 1c, 2a, 2b, 3a and 3b; Part V, line 1; Part V, Section B, line 1e; Part V Section D, lines 5, 6, and 8; and Part V, Section E, lines 2, 5, and 6. Also complete this part for any additional information. (See instructions).

Facts And Circumstances Test

Return Reference	Explanation

Schedule A (Form 990 or 990-EZ) 2019

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.

Go to www.irs.gov/Form990 for the latest information.

OMB No. 1545-0047

2019

Name of the organization

AMERY REGIONAL MEDICAL CENTER INC

Employer identification number

39-0908320

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, contributions totaling $5,000 or more (in money or other property) from any one contributor. Complete Parts I and II. See instructions for determining a contributor's total contributions.

Special Rules

For an organization described in section 501(c)(3) 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), that checked Schedule A (Form 990 or 990-EZ), Part II, line 13, 16a, or 16b, and that received from any one contributor, during the year, total contributions 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 an organization described in section 501(c)(7), (8), or (10) filing Form 990 or 990-EZ that received from any one contributor,
during the year, total contributions of more than $1,000 exclusively for religious, charitable, scientific, literary, or educational purposes, or for the prevention of cruelty to children or animals. Complete Parts I, II, and III.

For an organization described in section 501(c)(7), (8), or (10) filing Form 990 or 990-EZ that received from any one contributor,
during the year, contributions exclusively for religious, charitable, etc., purposes, but no such contributions totaled 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. Don't complete any of the parts unless the General Rule applies to this organization because it received nonexclusively religious, charitable, etc., contributions totaling $5,000 or more during the year ......... Arrow Bullet

Caution: An organization that isn't covered by the General Rule and/or the Special Rules doesn't 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 its Form 990PF, Part I, line 2, to certify that it doesn't 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) (2019)

Schedule B (Form 990, 990-EZ, or 990-PF) (2019) Page 2

Name of organization AMERY REGIONAL MEDICAL CENTER INC

Part I Contributors	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	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
Schedule B (Form 990, 990-EZ, or 990-PF) (2019)

Schedule B (Form 990, 990-EZ, or 990-PF) (2019)

Page 3

Name of organization AMERY REGIONAL MEDICAL CENTER INC		Employer identification number 39-0908320

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) (2019)

Schedule B (Form 990, 990-EZ, or 990-PF) (2019)

Page 4


Name of organization AMERY REGIONAL MEDICAL CENTER INC			Employer identification number 39-0908320
Part III Exclusively religious, charitable, etc., contributions to organizations described in section 501(c)(7), (8), or (10) that total more than $1,000 for the year from any one contributor. 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.) $ 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) (2019)

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

Go to www.irs.gov/Form990 for instructions and the latest information.

OMB No. 1545-0047

2019

Open to Public
Inspection

If the organization answered "Yes" on 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" on 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" on Form 990, Part IV, Line 5 (Proxy Tax) (see separate instructions) or Form 990-EZ, Part V, line 35c (Proxy Tax) (see separate instructions), then
Round Bullet

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

Name of the organization

AMERY REGIONAL MEDICAL CENTER INC

Employer identification number

39-0908320

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 (see instructions for definition of “political campaign activities")

Political campaign activity expenditures (see instructions) .................................................................... SchCMd Bullet

Volunteer hours for political campaign activities (see instructions) ..................................................................

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-.
1
2
3
4
5
6

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

Cat. No. 50084S

Schedule C (Form 990 or 990-EZ) 2019

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.)		(b) Affiliated group totals
1a	Total lobbying expenditures to influence public opinion (grass roots lobbying) ......................
b	Total lobbying expenditures to influence a legislative body (direct lobbying) ........................
c	Total lobbying expenditures (add lines 1a and 1b) ............................................................
d	Other exempt purpose expenditures ...............................................................................
e	Total exempt purpose expenditures (add lines 1c and 1d) ..................................................
f	Lobbying nontaxable amount. Enter the amount from the following table in both columns.
	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) .................................................
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 separate instructions for lines 2a through 2f.)
Lobbying Expenditures During 4-Year Averaging Period
	Calendar year (or fiscal year beginning in)	(a) 2016	(b) 2017	(c) 2018	(d) 2019	(e) Total

2a	Lobbying nontaxable amount

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

c	Total lobbying expenditures

d	Grassroots nontaxable amount

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

f	Grassroots lobbying expenditures

Schedule C (Form 990 or 990-EZ) 2019

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 on lines 1a through 1i below, provide in Part IV a detailed description of the lobbying activity.

(a)

Yes|No

(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? ...................................................................................................................

Yes

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

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, lines 1 and 2 (see instructions), and Part ll-B, line 1. Also, complete this part for any additional information.

Return Reference	Explanation
PART II-B, LINE 1:	AMERY REGIONAL MEDICAL CENTER, INC. PAYS FOR CERTAIN CORPORATE AND EMPLOYEE PROFESSIONAL ASSOCIATION MEMBERSHIPS. A PORTION OF SUCH MEMBERSHIP DUES POTENTIALLY COULD BE USED BY THE PROFESSIONAL ASSOCIATIONS FOR LOBBYING ACTIVITIES.

Schedule C (Form 990 or 990EZ) 2019

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," on 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

Go to www.irs.gov/Form990 for instructions and the latest information.

OMB No. 1545-0047

2019

Open to Public Inspection

Name of the organization

AMERY REGIONAL MEDICAL CENTER INC

Employer identification number

39-0908320

Part I

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

		(a) Donor advised funds	(b) Funds and other accounts
1	Total number at end of year .........
2	Aggregate value of contributions to (during year)
3	Aggregate value of 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" on 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 7/25/06, 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, handling of violations, and enforcing conservation easements during the year
SchDMd Bullet

Amount of expenses incurred in monitoring, inspecting, handling of violations, 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" on Form 990, Part IV, line 8.

If the organization elected, as permitted under FASB 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 FASB 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)

Revenue included on 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 FASB ASC 958 relating to these items:

Revenue included on 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) 2019

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" on 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


b	If "Yes," explain the arrangement in Part XIII and complete the following table:		Amount
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, for escrow or custodial account liability? ...

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" on Form 990, Part IV, line 10.

		(a) Current year	(b) Prior year	(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

Term endowment SchDMd Bullet

The percentages on 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" on 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.
Complete if the organization answered "Yes" on Form 990, Part IV, line 11a. See Form 990, Part X, line 10.

Description of property		(a) Cost or other basis (investment)	(b) Cost or other basis (other)	(c) Accumulated depreciation	(d) Book value

1a	Land .....	983,722		983,722
b	Buildings ....	24,300,372	15,578,685	8,721,687
c	Leasehold improvements	3,834,151	178,092	3,656,059
d	Equipment ....	30,296,051	23,667,845	6,628,206
e	Other .....	2,179,257	680,889	1,498,368
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).)..				21,488,042

Schedule D (Form 990) 2019

Page 3

Part VII

InvestmentsOther Securities.
Complete if the organization answered "Yes" on Form 990, Part IV, line 11b. 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........
(3)Other
(B)
(C)
(D)
(E)
(F)
(G)
(H)
(I)
Total. (Column (b) must equal Form 990, Part X, col. (B) line 12.)

Part VIII

InvestmentsProgram Related. Complete if the organization answered 'Yes' on Form 990, Part IV, line 11c. See Form 990, Part X, line 13.

(a) Description of investment	(b) Book value	(c) Method of valuation: Cost or end-of-year market value
(1)LONG TERM INVESTMENTS	2,680,017	C
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
Total. (Column (b) must equal Form 990, Part X, col.(B) line 13.)	2,680,017

Part IX

Other Assets.
Complete if the organization answered 'Yes' on Form 990, Part IV, line 11d. See Form 990, Part X, line 15.

(a) Description				(b) Book value

(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
Total. (Column (b) must equal Form 990, Part X, col.(B) line 15.)...........

Part X

Other Liabilities.
Complete if the organization answered 'Yes' on Form 990, Part IV, line 11e or 11f. See Form 990, Part X, line 25.

1.(a) Description of liability	(b) Book value
(1) Federal income taxes
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)	449,833
2. Liability for uncertain tax positions. 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) 2019

Page 4

Part XI Reconciliation of Revenue per Audited Financial Statements With Revenue per Return. Complete if the organization answered 'Yes' on Form 990, Part IV, line 12a.
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 (losses) 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. Complete if the organization answered 'Yes' on Form 990, Part IV, line 12a.
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

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.

Return Reference

Explanation

PART X, LINE 2:

AMERY REGIONAL MEDICAL CENTER, INC. IS INCLUDED IN THE HEALTHPARTNERS, INC. (HP) CONSOLIDATED AUDITED FINANCIAL STATEMENT. HP'S ACCOUNTING POLICY PROVIDES THAT A TAX BENEFIT FROM AN UNCERTAIN TAX POSITION MAY BE RECOGNIZED WHEN IT IS MORE LIKELY THAN NOT THAT THE POSITION WILL BE SUSTAINED UPON EXAMINATION, INCLUDING RESOLUTIONS OF ANY RELATED APPEALS OR LITIGATION PROCESSES, BASED ON THE TECHNICAL MERITS. HP RECORDED NO LIABILITIES AT DECEMBER 31, 2019 OR 2018 FOR UNRECOGNIZED TAX BENEFITS.

Schedule D (Form 990) 2019

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" on Form 990, Part IV, question 20.
MediumBullet

Attach to Form 990.
MediumBullet

Go to www.irs.gov/Form990EZ for instructions and the latest information.

OMB No. 1545-0047

2019

Open to Public Inspection

Name of the organization

AMERY REGIONAL MEDICAL CENTER INC

Employer identification number

39-0908320

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 %

If the organization used factors other than FPG in determining eligibility, describe in Part VI the criteria used 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? . . . . . .

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		(a) Number of activities or programs (optional)	(b) Persons served (optional)	(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) . . .			697,878	0	697,878	1.140 %
b	Medicaid (from Worksheet 3, column a) . . . . .			9,506,988	7,118,154	2,388,834	3.890 %
c	Costs of other means-tested government programs (from Worksheet 3, column b) . .
d	Total Financial Assistance and Means-Tested Government Programs . . . . .			10,204,866	7,118,154	3,086,712	5.030 %
Other Benefits
e	Community health improvement services and community benefit operations (from Worksheet 4).	24	1,807	290,635	2,082	288,553	0.470 %
f	Health professions education (from Worksheet 5) . . .	9	137	32,172		32,172	0.050 %
g	Subsidized health services (from Worksheet 6) . . . .
h	Research (from Worksheet 7) .
i	Cash and in-kind contributions for community benefit (from Worksheet 8) . . . .	10	72	149,377	6,230	143,147	0.230 %
j	Total. Other Benefits . .	43	2,016	472,184	8,312	463,872	0.750 %
k	Total. Add lines 7d and 7j .	43	2,016	10,677,050	7,126,466	3,550,584	5.780 %

For Paperwork Reduction Act Notice, see the Instructions for Form 990. Cat. No. 50192T Schedule H (Form 990) 2019

Schedule H (Form 990) 2019

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)	(c) Total community building expense	(e) Net community building expense	(f) Percent of total expense
1	Physical improvements and housing
2	Economic development
3	Community support	1	1,321	1,321	0 %
4	Environmental improvements	1	5,677	5,677	0.010 %
5	Leadership development and training for community members
6	Coalition building
7	Community health improvement advocacy
8	Workforce development	1	49	49	0 %
9	Other
10	Total	3	7,047	7,047	0.010 %

Part III

Bad Debt, Medicare, & Collection Practices

Section A. Bad Debt Expense

Yes

Did the organization report bad debt expense in accordance with Healthcare 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. ......

2,301,601

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. ......

1,314,561

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).....

22,116,989

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

22,116,989

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

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) 2019

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?1Name, address, primary website address, and state license number (and if a group return, the name and EIN of the subordinate hospital organization that operates the hospital facility)
1	AMERY REGIONAL MEDICAL CENTER 265 GRIFFIN STREET EAST AMERY,WI54001 WWW.AMERYMEDICALCENTER.ORG CAH CERT LICENSE 1010	X	X	X	X

Schedule H (Form 990) 2019

Page 4

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)

	AMERY REGIONAL MEDICAL CENTER INC
Name of hospital facility or letter of facility reporting group

Line number of hospital facility, or line numbers of hospital facilities in a facility
reporting group (from Part V, Section A):

Yes

Community Health Needs Assessment

Was the hospital facility first licensed, registered, or similarly recognized by a state as a hospital facility in the current tax year or the immediately preceding tax year?........................

Was the hospital facility acquired or placed into service as a tax-exempt hospital in the current tax year or the immediately preceding tax year? If “Yes,” provide details of the acquisition in Section C...............

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 12......................

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 significant 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

The impact of any actions taken to address the significant health needs identified in the hospital facility's prior CHNA(s)

Other (describe in Section C)

Indicate the tax year the hospital facility last conducted a CHNA: 20 18

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

Yes

6 a

Was the hospital facility’s CHNA conducted with one or more other hospital facilities? If "Yes," list the other hospital facilities in Section C..................................

Yes

Was the hospital facility’s CHNA conducted with one or more organizations other than hospital facilities?” If “Yes,” list the other organizations in Section C. ............................

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 (list url): WWW.AMERYMEDICALCENTER.ORG/COMMUNITY_HEALTH_NEEDS_ASSESSMENT.ASPX

Other website (list url):

Made a paper copy available for public inspection without charge at the hospital facility

Other (describe in Section C)

Did the hospital facility adopt an implementation strategy to meet the significant community health needs
identified through its most recently conducted CHNA? If "No," skip to line 11. ..............

Yes

Indicate the tax year the hospital facility last adopted an implementation strategy: 20 19

Is the hospital facility's most recently adopted implementation strategy posted on a website?.........

Yes

If "Yes" (list url): WWW.AMERYMEDICALCENTER.ORG/COMMUNITY_HEALTH_NEEDS_ASSESSMENT.ASPX

If "No," is the hospital facility’s most recently adopted implementation strategy attached to this return? ......

10b

Describe in Section C how the hospital facility is addressing the significant needs identified in its most recently conducted CHNA and any such needs that are not being addressed together with the reasons why such needs are not being addressed.

12a

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)?...............................

12a

If "Yes" on line 12a, did the organization file Form 4720 to report the section 4959 excise tax?........

12b

If "Yes" on line 12b, 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) 2019

Page 5

Part VFacility Information (continued)

Financial Assistance Policy (FAP)

	AMERY REGIONAL MEDICAL CENTER INC
Name of hospital facility or letter of facility reporting group

Yes

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 included free or discounted care?

Yes

If “Yes,” indicate the eligibility criteria explained in the FAP:

Federal poverty guidelines (FPG), with FPG family income limit for eligibility for free care of 200.000000000000%
and FPG family income limit for eligibility for discounted care of 300.000000000000%

Income level other than FPG (describe in Section C)

Asset level

Medical indigency

Insurance status

Underinsurance discount

Residency

Other (describe in Section C)

Explained the basis for calculating amounts charged to patients?.................

Yes

Explained the method for applying for financial assistance?...................

Yes

If “Yes,” indicate how the hospital facility’s FAP or FAP application form (including accompanying instructions) explained the method for applying for financial assistance (check all that apply):

Described the information the hospital facility may require an individual to provide as part of his or her application

Described the supporting documentation the hospital facility may require an individual to submit as part of his or
her application

Provided the contact information of hospital facility staff who can provide an individual with information about the
FAP and FAP application process

Provided the contact information of nonprofit organizations or government agencies that may be sources of
assistance with FAP applications

Other (describe in Section C)

Was widely publicized within the community served by the hospital facility?........

Yes

If "Yes," indicate how the hospital facility publicized the policy (check all that apply):

The FAP was widely available on a website (list url):

HTTPS://WWW.AMERYMEDICALCENTER.ORG/MEDICAL_SERVICES/PATIENT_FINANCIAL_SERVI

The FAP application form was widely available on a website (list url):

HTTPS://WWW.AMERYMEDICALCENTER.ORG/MEDICAL_SERVICES/PATIENT_FINANCIAL_SERVI

A plain language summary of the FAP was widely available on a website (list url):
HTTPS://WWW.AMERYMEDICALCENTER.ORG/MEDICAL_SERVICES/PATIENT_FINANCIAL_SERVI

The FAP was available upon request and without charge (in public locations in the hospital facility and by mail)

The FAP application form was available upon request and without charge (in public locations in the hospital facility
and by mail)

A plain language summary of the FAP was available upon request and without charge (in public locations in the
hospital facility and by mail)

Individuals were notified about the FAP by being offered a paper copy of the plain language summary of the FAP, by
receiving a conspicuous written notice about the FAP on their billing statements, and via conspicuous public displays or
other measures reasonably calculated to attract patients' attention

Notified members of the community who are most likely to require financial assistance about availability of the FAP

The FAP, FAP application form, and plain language summary of the FAP were translated into the primary language(s)
spoken by LEP populations

Other (describe in Section C)

Schedule H (Form 990) 2019

Page 6

Part VFacility Information (continued)

Billing and Collections

	AMERY REGIONAL MEDICAL CENTER INC
Name of hospital facility or letter of facility reporting group

Yes

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 all of the actions the hospital facility or other authorized party may take upon nonpayment?..................................

Yes

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 individual’s eligibility under the facility’s FAP:

Reporting to credit agency(ies)

Selling an individual’s debt to another party

Deferring, denying, or requiring a payment before providing medically necessary care due to nonpayment of a previous
bill for care covered under the hospital facility's FAP

Actions that require a legal or judicial process

Other similar actions (describe in Section C)

None of these actions or other similar actions were permitted

Did the hospital facility or other authorized party perform any of the following actions during the tax year before making reasonable efforts to determine the individual’s eligibility under the facility’s FAP?............

If "Yes," check all actions in which the hospital facility or a third party engaged:

Reporting to credit agency(ies)

Selling an individual’s debt to another party

Deferring , denying, or requiring a payment before providing medically necessary care due to nonpayment of a previous
bill for care covered under the hospital facility's FAP

Actions that require a legal or judicial process

Other similar actions (describe in Section C)

Indicate which efforts the hospital facility or other authorized party made before initiating any of the actions listed (whether or not checked) in line 19. (check all that apply):

Provided a written notice about upcoming ECAs (Extraordinary Collection Action) and a plain language summary of the
FAP at least 30 days before initiating those ECAs (if not, describe in Section C)

Made a reasonable effort to orally notify individuals about the FAP and FAP application process (if not, describe in
Section C)

Processed incomplete and complete FAP applications (if not, describe in Section C)

Made presumptive eligibility determinations (if not, describe in Section C)

Other (describe in Section C)

None of these efforts were made

Policy Relating to Emergency Medical Care

Did the hospital facility have in place during the tax year a written policy relating to emergency medical care that required 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 Section C)

Other (describe in Section C)

Schedule H (Form 990) 2019

Page 7

Part VFacility Information (continued)

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

	AMERY REGIONAL MEDICAL CENTER INC
Name of hospital facility or letter of facility reporting group

Yes

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 a look-back method based on claims allowed by Medicare fee-for-service during a prior 12-month period

The hospital facility used a look-back method based on claims allowed by Medicare fee-for-service and all private health insurers that pay claims to the hospital facility during a prior 12-month period

The hospital facility used a look-back method based on claims allowed by Medicaid, either alone or in combination with
Medicare fee-for-service and all private health insurers that pay claims to the hospital facility during a prior 12-month
period

The hospital facility used a prospective Medicare or Medicaid method

During the tax year, did the hospital facility charge any FAP-eligible individual 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 Section C.

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

If "Yes," explain in Section C.

Schedule H (Form 990) 2019

Page 8

Part V

Facility Information (continued)

Section C. Supplemental Information for Part V, Section B. Provide descriptions required for Part V, Section B, lines 2, 3j, 5, 6a, 6b, 7d, 11, 13b, 13h, 15e, 16j, 18e, 19e, 20a, 20b, 20c, 20d, 20e, 21c, 21d, 23, and 24. If applicable, provide separate descriptions for each hospital facility in a facility reporting group, designated by facility reporting group letter and hospital facility line number from Part V, Section A (“A, 1,” “A, 4,” “B, 2,” “B, 3,” etc.) and name of hospital facility.
Form and Line Reference	Explanation
AMERY REGIONAL MEDICAL CENTER, INC.	PART V, SECTION B, LINE 5: THE WAYS WE BRING THE MISSION TO LIFE IS TO WORK WITH COMMUNITY PARTNERS TO BETTER UNDERSTAND WHAT CONTRIBUTES TO AND STANDS IN THE WAY OF GOOD HEALTH AND HOW WE CAN WORK TOGETHER TO IMPROVE HEALTH OUTCOMES. THE COMMUNITY HEALTH NEEDS ASSESSMENT (CHNA) PROCESS IS AN OPPORTUNITY FOR US TO IDENTIFY THE SIGNIFICANT HEALTH NEEDS OF OUR COMMUNITY AND THE MEASURES AND RESOURCES REQUIRED TO ADDRESS THOSE NEEDS. HEALTHPARTNERS WORKED WITH LOCAL HEALTH DEPARTMENTS, LOCAL COALITIONS, THE CENTER FOR COMMUNITY HEALTH (CCH) AND COMMUNITY PARTNERS TO CONDUCT A COMPREHENSIVE CHNA. IN ADDITION, EACH HOSPITAL ENGAGED WITH LOCAL PUBLIC HEALTH PARTNERS AND OTHER LOCAL HEALTH CARE ORGANIZATIONS ON THE CHNA PROCESS THROUGH PARTICIPATION IN TWO LOCAL COLLABORATIVES: THE CENTER FOR COMMUNITY HEALTH EAST METRO CHA (COMMUNITY HEALTH ASSESSMENT)/CHNA COLLABORATIVE AND THE WEST METRO CHNA COLLABORATION. COMMUNITY INPUT: AS PART OF ITS CHNA PROCESS, AMERY AND ITS PARTNERS WORKED COLLABORATIVELY WITH POLK AND BARRON COUNTIES TO ENGAGE COMMUNITY MEMBERS AND HEALTH CARE PROVIDERS IN THE PROCESS TO GATHER INPUT ON WHAT THEIR TOP HEALTH CONCERNS ARE.THE COMMUNITY INPUT IN THIS REPORT INCLUDES:COUNTY PRIORITY DATA: EACH COUNTY IN THE AMERY SERVICE AREA HAS DETERMINED THE TOP HEALTH PRIORITIES FOR ITS COMMUNITY THROUGH A COUNTY-LEVEL COMMUNITY HEALTH ASSESSMENT PROCESS (CHA). BARRON COUNTY COMMUNITY SURVEY DATA: IN 2018, BARRON COUNTY CONDUCTED A COMMUNITY SURVEY ABOUT HEALTH NEEDS AND BARRIERS TO HEALTH FOR ITS COMMUNITY HEALTH ASSESSMENT. A TOTAL OF 815 COMMUNITY MEMBERS PARTICIPATED IN THE SURVEY.POLK COUNTY COMMUNITY SURVEY DATA: IN 2015, POLK COUNTY CONDUCTED A COMMUNITY HEALTH SURVEY ABOUT HEALTH NEEDS AND BARRIERS TO HEALTH FOR ITS 2016 COMMUNITY HEALTH ASSESSMENT. A TOTAL OF 650 SURVEYS WERE COMPLETED BY COUNTY RESIDENTS.PROVIDER SURVEY: IN 2018, HEALTHPARTNERS SURVEYED HEALTH CARE PROVIDERS TO UNDERSTAND THEIR PERCEPTIONS OF LEADING HEALTH NEEDS AND COMMUNITY RESOURCES AVAILABLE TO HELP THEIR PATIENTS. THE SURVEY ALSO ASKED PROVIDERS TO IDENTIFY BARRIERS THEY FACE IN ADDRESSING HEALTH NEEDS AND RESOURCES TO BETTER SERVE THEIR PATIENTS. TWENTY-THREE HEALTH CARE PROVIDERS COMPLETED THE SURVEY, INCLUDING 11 WHO PRACTICE AT AMERY.
AMERY REGIONAL MEDICAL CENTER, INC.	PART V, SECTION B, LINE 6A: HEALTHPARTNERS COLLABORATED ACROSS SIX HOSPITALS WITHIN ITS FAMILY OF CARE FOR THE 2018 CHNA: - AMERY HOSPITAL & CLINIC (AMERY, WI) - HUDSON HOSPITAL & CLINIC (HUDSON, WI) - LAKEVIEW MEMORIAL HOSPITAL ASSOCIATION (STILLWATER, MN) - PARK NICOLLET HEALTH SERVICES INCLUDING PARK NICOLLET METHODIST HOSPITAL (ST. LOUIS PARK, MN)- REGIONS HOSPITAL (ST. PAUL, MN)- WESTFIELDS HOSPITAL & CLINIC (NEW RICHMOND, WI)
AMERY REGIONAL MEDICAL CENTER, INC.	PART V, SECTION B, LINE 11: THE 2018 HEALTHPARTNERS CHNA CONDUCTED RESULTED IN THE FOLLOWING PRIORITIES: PRIORITY 1: ACCESS TO CARE PRIORITY 2: ACCESS TO HEALTH PRIORITY 3: MENTAL HEALTH AND WELL-BEING PRIORITY 4: NUTRITION AND PHYSICAL ACTIVITY PRIORITY 5: SUBSTANCE ABUSEPRIORITIES NOT SELECTED: HEALTHPARTNERS DISCUSSED AND CONSIDERED ADDITIONAL OR ALTERNATIVE PRIORITIES DURING THE PRIORITIZATION PROCESS, INCLUDING: OLDER ADULT HEALTH/AGING, MATERNAL AND CHILD HEALTH, ENVIRONMENTAL HEALTH AND INJURY AND VIOLENCE. THESE NEEDS WERE NOT SELECTED AS TOP FIVE PRIORITIES IN THE CONSENSUS BUILDING PROCESS; HOWEVER, THE THEMES WILL BE CONSIDERED IN THE IMPLEMENTATION FOR THE SELECTED PRIORITY AREAS. A FULL REPORT OF AMERY'S 2018 CHNA AND ANNUAL IMPLEMENTATION PLAN UPDATE IS POSTED ON AMERY'S WEBPAGE AT WWW.AMERYMEDICALCENTER.ORG/COMMUNITY_HEALTH_NEEDS_ASSESSMENT.ASPX
PART V, SECTION B, LINE 3E	AMERY ADDRESSES THE SIGNIFICANT HEALTH NEEDS OF THE COMMUNITY THROUGH OUR CHNA.
SCHEDULE H, PART V, LINE 20A	AMERY DOES NOT PERFORM ANY ECAS (EXTRAORDINARY COLLECTION ACTIONS), THEREFORE WE WOULD NOT GIVE A PATIENT A WRITTEN NOTICE OF DOING SO.

Schedule H (Form 990) 2019

Page 9

Part VFacility Information (continued)

Section D. 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?6
Name and address		Type of Facility (describe)
1	1 - ARMC REHAB SERVICES 220 N KELLER AVENUE AMERY,WI54001	REHABILITATION
2	2 - LUCK MEDICAL CLINIC 137 FIRST AVENUE LUCK,WI54853	RURAL HEALTH CLINIC
3	3 - TURTLE LAKE MEDICAL CLINIC 550 MARTIN AVENUE TURTLE LAKE,WI54889	RURAL HEALTH CLINIC
4	4 - CLEAR LAKE CLINIC 357 THIRD AVENUE CLEAR LAKE,WI54005	RURAL HEALTH CLINIC
5	5 - LUCK PT & FITNESS 2547 STATE ROAD 35 SUITE 5 LUCK,WI54853	PHYSICAL THERAPY
6	6 - AMERY REGIONAL MEDICAL CENTER WEST 230 DERONDA STREET AMERY,WI54001	10 BED INPATIENT DPU OF AMERY
7
8
9
10

Schedule H (Form 990) 2019

Page 10

Part VI

Supplemental Information

Provide the following information.

1	Required descriptions. Provide the descriptions required for Part I, lines 3c, 6a, and 7; Part II and Part III, lines 2, 3, 4, 8 and 9b.
2	Needs assessment. Describe how the organization assesses the health care needs of the communities it serves, in addition to any CHNAs 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.

Form and Line Reference	Explanation
PART I, LINE 7:	AMERY REGIONAL MEDICAL CENTER (AMERY) USES THE COST-TO-CHARGE RATIO METHOD WHEN CALCULATING THE AMOUNTS REPORTED ON PART I. LINE 7. THE COST-TO-CHARGE RATIO WAS DERIVED USING WORKSHEET 2, RATIO OF PATIENT CARE-COST-TO-CHARGE, FROM THE SCHEDULE H INSTRUCTIONS
PART II, COMMUNITY BUILDING ACTIVITIES:	COMMUNITY BUILDING ACTIVITIES AT AMERY PRIMARILY INCLUDE ENVIRONMENTAL IMPROVEMENTS AND WORKFORCE DEVELOPMENT. AMERY CONTINUES TO BE A SUSTAINABILITY CHAMPION AND HOSTS AN ANNUAL ELECTRONICS RECYCLING EVENT AND ATTENDS THE ANNUAL CLEANMED CONFERENCE WHICH IS A NATIONAL ENVIRONMENTAL CONFERENCE FOR LEADERS IN HEALTH CARE SUSTAINABILITY. AMERY ALSO HAS REPRESENTATIVES SERVE ON THE WITC MEDICAL ASSISTANT ADVISORY COMMITTEE, WITC ADVISORY COUNCIL, AND WITC HEALTH INFORMATION TECHNOLOGY ADVISORY COMMITTEE.
PART III, LINE 3:	AMERY USES THE COST TO CHARGE METHODOLOGY TO DETERMINE AMOUNT REPORTED AS BAD DEBT. AMERY BELIEVES THAT MANY OF THE ACCOUNTS IN BAD DEBT WOULD HAVE QUALIFIED FOR CHARITY IF THE GUARANTORS WOULD HAVE COMPLETED THE FINANCIAL ASSISTANCE PAPERWORK. AMERY IS PROVIDING SERVICES TO INDIVIDUALS/FAMILIES IN ITS SERVICE AREA THAT ARE UNABLE/UNWILLING TO PAY FOR THESE SERVICES. THIS IS COMPARABLE TO PROVIDING CHARITY CARE WHICH AMERY ALSO INCLUDES AS A COMMUNITY BENEFIT.
PART III, LINE 4:	SEE THE ORGANIZATION'S FOOTNOTES 1.O AND 1.Q, ON PAGES 13 & 14 OF THE ATTACHED CONSOLIDATED FINANCIAL STATEMENT.
PART III, LINE 8:	AMERYS MEDICARE COST IS DERIVED BASED ON THE RATIO OF MEDICARE FFS CHARGES TO TOTAL CHARGES MULTIPLIED BY TOTAL EXPENSES (LESS CHARITY CARE & BAD DEBT). NONE OF THE MEDICARE FFS LOSS REPORTED ON SCHEDULE H, PART III, LINE 7 IS TREATED AS COMMUNITY BENEFIT ON SCHEDULE H, PART I, LINE 7A.
PART III, LINE 9B:	COLLECTIONS PRACTICESAMERY'S DEBT COLLECTION POLICY CONTAINS PROVISIONS ON COLLECTION PRACTICES TO BE FOLLOWED FOR PATIENTS WHO ARE KNOWN TO BE ELIGIBLE FOR CHARITY CARE OR FINANCIAL ASSISTANCE. AMERY WILL NOT REFER ANY ACCOUNT TO A THIRD PARTY DEBT COLLECTION AGENCY UNLESS IT HAS CONFIRMED THAT:- THERE IS REASONABLE BASIS TO BELIEVE THAT THE PATIENT OWES THE DEBT.- ALL KNOWN THIRD-PARTY PAYERS HAVE BEEN PROPERLY BILLED, AND THE PATIENT IS RESPONSIBLE FOR THE REMAINING DEBT.- IF THE PATIENT HAS INDICATED AN INABILITY TO PAY THE FULL AMOUNT, THE PATIENT HAS BEEN OFFERED A REASONABLE PAYMENT PLAN. AMERY WILL NOT REFER PATIENTS TO DEBT COLLECTION AGENCIES WHO ARE PERFORMING AS SPECIFIED IN THEIR PAYMENT PLANS.- THE PATIENT HAS BEEN GIVEN AN OPPORTUNITY TO SUBMIT A CHARITY CARE (FINANCIAL ASSISTANCE) APPLICATION. IF THE PATIENT HAS SUBMITTED AN APPLICATION FOR CHARITY CARE, ALL COLLECTION ACTIVITY WILL BE SUSPENDED UNTIL THE APPLICATION HAS BEEN PROCESSED.
PART VI, LINE 2:	IN 2018, A COMPREHENSIVE COMMUNITY HEALTH NEEDS ASSESSMENT (CHNA) COLLABORATION WAS CONDUCTED FOR HEALTHPARTNERS AND SIX OF ITS HOSPITALS, INCLUDING REGIONS HOSPITAL, LAKEVIEW HOSPITAL, HUDSON HOSPITAL & CLINIC, WESTFIELDS HOSPITAL & CLINIC, AMERY HOSPITAL & CLINIC, AND PARK NICOLLET METHODIST HOSPITAL) BY THE IMPROVEGROUP TO DETERMINE THE GREATEST HEALTH NEEDS IN THE COMMUNITIES THEY SERVE. THESE HOSPITALS SERVE SIMILAR COMMUNITIES AND HAVE OVERLAPPING STUDY AREAS. THE SYSTEM'S STUDY AREA IS DEFINED AS DAKOTA, HENNEPIN, RAMSEY, SCOTT, AND WASHINGTON COUNTIES IN MINNESOTA AND POLK AND ST. CROIX COUNTIES IN WISCONSIN. AMERY'S SPECIFIC STUDY AREA IS DEFINED AS: BARRON COUNTY POLK COUNTYMETHODOLOGYIN 2018, HEALTHPARTNERS AND AMERY CONTRACTED WITH THE IMPROVE GROUP TO ANALYZE AND REPORT ON THE DATA DESCRIBING THE COMMUNITIES WE SERVE. HEALTHPARTNERS PROVIDED THE IMPROVE GROUP WITH THE DEFINITION OF THE HOSPITAL'S SERVICE AREA, THE INDICATORS TO STUDY FOR THE HEALTH AND DEMOGRAPHIC DATA SUMMARIES AND DATA COLLECTED DURING COMMUNITY CONVERSATIONS. COMMUNITY INPUT WAS COLLECTED IN PARTNERSHIP WITH HEALTHPARTNERS AND PARTNER ORGANIZATIONS THROUGH COMMUNITY CONVERSATIONS AND MULTIPLE SURVEYS. THE IMPROVE GROUP THEN GATHERED SECONDARY DATA FROM PUBLIC SOURCES, ANALYZED COMMUNITY INPUT DATA AND DEVELOPED SUMMARY REPORTS TO GUIDE A PRIORITIZATION PROCESS. PRIORITIZED NEEDSTHE HEALTHPARTNERS CHNA TEAM INCLUDED REPRESENTATIVES FROM EACH HEALTHPARTNERS HOSPITAL AND HEALTHPARTNERS LEADERSHIP. ON SEPTEMBER 14, 2018, THE CHNA TEAM MET TO REVIEW THE DATA AND PRIORITIZE THE COMMUNITY HEALTH NEEDS ACROSS THE SYSTEM. HEALTHPARTNERS COLLECTIVELY PRIORITIZED COMMUNITY HEALTH NEEDS USING A PROCESS INFORMED BY THE HANLON METHOD AND OTHER COMMONLY USED PRIORITIZATION METHODS. EACH HOSPITAL SHARED ITS 4 OR 5 PRIORITY TOPIC AREAS AND RATIONALE FOR EACH TOPIC AREA BASED ON: SIZE: NUMBER OF PERSONS AFFECTED, TAKING INTO ACCOUNT VARIANCE FROM BENCHMARK DATA AND TARGETS; SERIOUSNESS: THE DEGREE TO WHICH THE PROBLEM LEADS TO DEATH, DISABILITY AND IMPAIRMENT OF ONE'S QUALITY OF LIFE (MORTALITY AND MORBIDITY); EQUITY: DEGREE TO WHICH SPECIFIC GROUPS ARE AFFECTED BY THE PROBLEM; VALUE: THE IMPORTANCE OF THE PROBLEM TO THE COMMUNITY; AND CHANGE: WHAT IS THE SAME AND WHAT IS DIFFERENT FROM YOUR PREVIOUS CHNA? HEALTHPARTNERS HOSPITALS WORKED IN A THOROUGH, FACILITATED LARGE AND SMALL GROUP PROCESS TO REACH CONSENSUS ON TOP PRIORITIES. THE CHNA TEAM CONSIDERED THE CRITERIA DESCRIBED ABOVE AS WELL AS COMMUNITY INPUT DATA IN THESE DISCUSSIONS. THE FIVE PRIORITIES ARE OF EQUAL IMPORTANCE AND ARE PRESENTED IN ALPHABETICAL ORDER. THE FIVE PRIORITY AREAS ARE:ACCESS TO CAREACCESS TO CARE REFERS TO HAVING EQUITABLE ACCESS TO APPROPRIATE, CONVENIENT AND AFFORDABLE HEALTH CARE. THIS INCLUDES FACTORS SUCH AS PROXIMITY TO CARE, ACCESS TO PROVIDERS, COST, INSURANCE COVERAGE, MEDICAL TRANSPORTATION, CARE COORDINATION WITHIN THE HEALTH CARE SYSTEM AND CULTURAL SENSITIVITY AND RESPONSIVENESS. ACCESS TO HEALTHACCESS TO HEALTH REFERS TO THE SOCIAL AND ENVIRONMENTAL CONDITIONS THAT DIRECTLY AND INDIRECTLY AFFECT PEOPLE'S HEALTH, SUCH AS HOUSING, INCOME, EMPLOYMENT, EDUCATION AND MORE. THESE FACTORS, ALSO REFERRED TO AS SOCIAL DETERMINANTS OF HEALTH, DISPROPORTIONATELY IMPACT LOW INCOME COMMUNITIES AND COMMUNITIES OF COLOR. MENTAL HEALTH AND WELL-BEINGMENTAL HEALTH AND WELL-BEING REFERS TO THE INTERCONNECTION BETWEEN MENTAL ILLNESS, MENTAL HEALTH, MENTAL WELL-BEING AND THE ASSOCIATED STIGMA. POOR MENTAL HEALTH IS ASSOCIATED WITH POOR QUALITY OF LIFE, HIGHER RATES OF CHRONIC DISEASE AND A SHORTER LIFESPAN.NUTRITION AND PHYSICAL ACTIVITYNUTRITION AND PHYSICAL ACTIVITY REFERS TO EQUITABLE ACCESS TO NUTRITION, PHYSICAL ACTIVITY AND FOOD AND FEEDING CHOICES. POOR NUTRITION AND PHYSICAL INACTIVITY ARE MAJOR CONTRIBUTORS TO OBESITY AND CHRONIC DISEASES SUCH AS DIABETES, HEART DISEASE AND STROKE, WHICH DISPROPORTIONALLY IMPACT LOW INCOME COMMUNITIES AND COMMUNITIES OF COLOR. SUBSTANCE ABUSESUBSTANCE ABUSE AND ADDICTION ARE THE EXCESSIVE USE OF SUBSTANCES INCLUDING ALCOHOL, TOBACCO, PRESCRIPTION DRUGS, OPIOIDS AND OTHER DRUGS IN A MANNER THAT IS HARMFUL TO HEALTH AND WELL-BEING. PRIORITIES NOT SELECTED: HEALTHPARTNERS DISCUSSED AND CONSIDERED ADDITIONAL OR ALTERNATIVE PRIORITIES DURING THE PRIORITIZATION PROCESS, INCLUDING: OLDER ADULT HEALTH/AGING, MATERNAL AND CHILD HEALTH, ENVIRONMENTAL HEALTH AND INJURY AND VIOLENCE. THESE NEEDS WERE NOT SELECTED AS TOP FIVE PRIORITIES IN THE CONSENSUS BUILDING PROCESS; HOWEVER, THE THEMES WILL BE CONSIDERED IN THE IMPLEMENTATION FOR THE SELECTED PRIORITY AREAS.
PART VI, LINE 3:	AMERY'S PATIENT FINANCIAL SERVICES DEPARTMENT WORKS WITH EACH PATIENT REGARDING ACCOUNT BALANCES LEFT TO PATIENT RESPONSIBILITY. PATIENTS WHO ARE NOT ALREADY ON GOVERNMENT ASSISTANCE OR HAVE LIMITED ASSISTANCE ARE REFERRED TO AMERY'S HEALTH BENEFITS COUNSELOR, WHO WORKS WITH THEM TO EVALUATE ASSISTANCE OPTIONS AND ASSISTS IN GETTING APPLICATIONS OR CONTACTS WITH THE APPROPRIATE PROGRAMS. IF ADDITIONAL ASSISTANCE IS NEEDED, THE COUNSELOR WILL WORK WITH THE PATIENT TO APPLY FOR FINANCIAL ASSISTANCE WITH AMERY AND HELPS THEM THROUGH THE PROCESS. THE FINANCIAL ASSISTANCE PROGRAM AND APPLICATION ARE LOCATED ON AMERY'S INTERNET SITE TO ALLOW PATIENTS DIRECT ACCESS TO THIS INFORMATION.
PART VI, LINE 4:	THE AMERY REGIONAL MEDICAL CENTER (AMERY) SERVICE AREA INCLUDED 15 DIFFERENT ZIP CODES IN NORTHWEST WISCONSIN THAT PRIMARILY REPRESENT POLK COUNTY. IT INCLUDES THREE RURAL HEALTH CLINICS IN LUCK, TURTLE LAKE, AND CLEAR LAKE, WHICH ARE ALL MEDICALLY UNDERSERVED AREAS. THE AMERY COMMUNITY IS ALSO CONSIDERED A MENTAL HEALTH MEDICALLY UNDERSERVED AREA. THE WOUND CENTER & INPATIENT PSYCH SERVICE DRAWS FROM OUTSIDE AMERY'S NORMAL SERVICE AREA.
PART VI, LINE 5:	TEN OF AMERY'S THIRTEEN BOARD MEMBERS LIVE IN AMERY'S SERVICE AREA. AMERY HAS AN OPEN MEDICAL STAFF WHICH INCLUDES PROVIDERS FROM THE COMMUNITY, AND OTHER COMMUNITIES AS WELL AS THE TWIN CITIES. ANY SURPLUS FUNDS GENERATED ARE USED TO PURCHASE EQUIPMENT, BUILD NEW FACILITIES, AND EXPAND SERVICES AVAILABLE IN AMERY'S COMMUNITY.
PART VI, LINE 6:	HEALTHPARTNERS AND AMERY HAVE HAD A LONG-STANDING RELATIONSHIP, WITH HEALTHPARTNERS EMPLOYING AND SOURCING PHYSICIANS AND MID-LEVEL PRACTITIONERS TO AMERY FOR AMERY'S PRIMARY CARE CLINICS. IN 2014, AMERY BECAME PART OF THE HEALTHPARTNERS FAMILY OF MISSION-DRIVEN NON-PROFIT ORGANIZATIONS. AS PART OF HEALTHPARTNERS, AMERY USES HEALTHPARTNERS' INTEGRATED ELECTRONIC HEALTH RECORD SYSTEM, PARTICIPATES IN COORDINATED CHNA PROCESSES AND IMPLEMENTATION STRATEGIES, AND ACCESSES CENTRALIZED SUPPORT SERVICES IN FINANCE, LEGAL, IS&T, AND QUALITY. THE FOUR HEALTHPARTNERS HOSPITALS IN THE ST. CROIX VALLEY - STILLWATER MN AND HUDSON, NEW RICHMOND, AND AMERY WI - WORK TOGETHER TO ESTABLISH ACCESSIBLE AND COORDINATED SPECIALTY SERVICES FOR VALLEY RESIDENTS. EXAMPLES OF THESE SERVICES INCLUDE RADIATION THERAPY ON THE NEW RICHMOND CAMPUS, BREAST DIAGNOSTICS ON THE STILLWATER CAMPUS, AND GERIATRIC BEHAVIORAL HEALTH SERVICES ON THE ARMC CAMPUS. HEALTHPARTNERS INCLUDES INSURANCE AND HMO (HEALTH MAINTENANCE ORGANIZATION) ENTITIES THAT PROVIDE CARE COORDINATION, DISEASE MANAGEMENT, ON-LINE CARE OF BASIC CONDITIONS, A 24-HOUR/7-DAY PER WEEK NURSE LINE, AND OTHER SERVICES THAT ENHANCE CARE OF MEMBERS, PATIENTS AND THE COMMUNITY.
PART VI, LINE 7, REPORTS FILED WITH STATES	WI

Schedule H (Form 990) 2019

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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," on Form 990, Part IV, line 21 or 22.
lBullet

Attach to Form 990.
lBullet

Go to www.irs.gov/Form990 for the latest information.

OMB No. 1545-0047

2019

Open to Public
Inspection

Name of the organization
AMERY REGIONAL MEDICAL CENTER INC

Employer identification number
39-0908320

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 Domestic Organizations and Domestic Governments. Complete if the organization answered "Yes" on 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 section (if applicable)	(d) Amount of cash grant	(e) Amount of non-cash assistance	(f) Method of valuation (book, FMV, appraisal, other)	(g) Description of noncash assistance	(h) Purpose of grant or assistance
(1) AMERY REGIONAL MEDICAL CENTER FOUNDATION 8170 33RD AVE S BLOOMINGTON,MN554401309	39-1726539	501(C)(3)	18,100				PROGRAM SUPPORT
(2) AMERICAN CANCER SOCIETY 250 WILLIAMS STREET NW ATLANTA,GA30303	13-1788491	501(C)(3)	5,000				PROGRAM SUPPORT

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) 2019

Page 2

Part III

Grants and Other Assistance to Domestic Individuals. Complete if the organization answered "Yes" on 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	(c) Amount of cash grant	(d) Amount of noncash assistance	(e) Method of valuation (book, FMV, appraisal, other)	(f) Description of noncash assistance

(1)
(2)
(3)
(4)
(5)
(6)
(7)

Part IV

Supplemental Information. Provide the information required in Part I, line 2; Part III, column (b); and any other additional information.

Return Reference	Explanation
PART I, LINE 2:	AMERY REGIONAL MEDICAL CENTER, INC. (ARMC) MANAGEMENT STAFF REVIEWS THE MISSION AND PURPOSE OF POTENTIAL GRANTEE ORGANIZATIONS TO ASSURE CONSISTENCY WITH ARMC'S MISSION AND PURPOSE. AMOUNTS SUBSEQUENTLY GRANTED ARE SUBJECT TO ARMC'S FORMAL SPENDING APPROVAL AND DOCUMENTATION PROCESS BASED ON AMOUNT OF THE EXPENDITURE.

Schedule I (Form 990) 2019

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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" on Form 990, Part IV, line 23.
SchJMediumBullet

Attach to Form 990.
SchJMediumBullet

Go to www.irs.gov/Form990 for instructions and the latest information.

OMB No. 1545-0047

2019

Open to Public Inspection

Name of the organization

AMERY REGIONAL MEDICAL CENTER INC

Employer identification number

39-0908320

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 on 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 on 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
directors, trustees, officers, including the CEO/Executive Director, regarding the items checked on 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 on 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? .............

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

Yes

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), 501(c)(4), and 501(c)(29) organizations must complete lines 5-9.

For persons listed on 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," on line 5a or 5b, describe in Part III.

For persons listed on 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," on line 6a or 6b, describe in Part III.

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

Were any amounts reported on 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" on 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) 2019

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 on 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 in column (B) reported as deferred on 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)
1ROSS R BULLARD DIRECTOR & TREASURER	(i) (ii)	0 ------------- 194,405	0 ------------- 37,530	0 ------------- 4,579	0 ------------- 37,435	0 ------------- 32,935	0 ------------- 306,884	0 ------------- 0
2DYLAN COE MD DIRECTOR	(i) (ii)	0 ------------- 169,210	0 ------------- 0	0 ------------- 159,436	0 ------------- 70,917	0 ------------- 20,730	0 ------------- 420,293	0 ------------- 50,770
3MARTIN E RICHARDS MD DIRECTOR	(i) (ii)	0 ------------- 378,478	0 ------------- 13,300	0 ------------- 98,621	0 ------------- 21,000	0 ------------- 36,228	0 ------------- 547,627	0 ------------- 0
4ANN SEAGREN MD DIRECTOR	(i) (ii)	0 ------------- 212,661	0 ------------- 0	0 ------------- 20,853	0 ------------- 41,335	0 ------------- 31,617	0 ------------- 306,466	0 ------------- 0
5THEODORE WEGLEITNER DIRECTOR	(i) (ii)	0 ------------- 434,318	0 ------------- 108,899	0 ------------- 5,759	0 ------------- 79,487	0 ------------- 37,077	0 ------------- 665,540	0 ------------- 0
6MARYANN SCOGLIO CANP DIRECTOR	(i) (ii)	0 ------------- 133,559	0 ------------- 0	0 ------------- 36,374	0 ------------- 13,194	0 ------------- 30,252	0 ------------- 213,379	0 ------------- 0
7JASON J LUHRS CFO (JAN-AUG)	(i) (ii)	0 ------------- 191,700	0 ------------- 33,727	0 ------------- 6,163	0 ------------- 23,722	0 ------------- 29,643	0 ------------- 284,955	0 ------------- 0
8SANDRA M REED VP - AMBULATORY CARE	(i) (ii)	158,243 ------------- 0	18,133 ------------- 0	8,224 ------------- 0	7,458 ------------- 0	34,649 ------------- 0	226,707 ------------- 0	0 ------------- 0
9DEBRA RUDQUIST PRESIDENT	(i) (ii)	0 ------------- 270,025	0 ------------- 49,041	0 ------------- 10,030	0 ------------- 30,600	0 ------------- 31,261	0 ------------- 390,957	0 ------------- 0
10PATRICK SURA MD CHIEF MEDICAL OFFICER	(i) (ii)	0 ------------- 351,644	0 ------------- 8,473	0 ------------- 97,236	0 ------------- 21,000	0 ------------- 35,749	0 ------------- 514,102	0 ------------- 0
11DOUGLAS JOHNSON CFO (AUG-DEC)	(i) (ii)	0 ------------- 299,890	0 ------------- 55,505	0 ------------- 25,400	0 ------------- 121,094	0 ------------- 32,168	0 ------------- 534,057	0 ------------- 0
12MARK A TRYGGESTAD DIRECTOR OF PHARMACY	(i) (ii)	169,158 ------------- 0	1,973 ------------- 0	8,537 ------------- 0	6,898 ------------- 0	13,121 ------------- 0	199,687 ------------- 0	0 ------------- 0
13JAMES ERICKSON RN SUPERVISOR	(i) (ii)	129,625 ------------- 0	714 ------------- 0	5,169 ------------- 0	5,739 ------------- 0	33,730 ------------- 0	174,977 ------------- 0	0 ------------- 0
14ANTHONY GOULD ANCILLARY SERVICES	(i) (ii)	119,567 ------------- 0	2,301 ------------- 0	6,142 ------------- 0	5,094 ------------- 0	33,422 ------------- 0	166,526 ------------- 0	0 ------------- 0
15ANN SCHILLING HR SR DIRECTOR	(i) (ii)	118,213 ------------- 0	7,878 ------------- 0	878 ------------- 0	5,429 ------------- 0	32,846 ------------- 0	165,244 ------------- 0	0 ------------- 0
16BENJAMIN BOGLE PROVIDER-APNP	(i) (ii)	121,258 ------------- 0	6,000 ------------- 0	3,595 ------------- 0	4,044 ------------- 0	33,619 ------------- 0	168,516 ------------- 0	0 ------------- 0
17JOANNE L JACKSON FORMER HR, PR AND MKTG DIR	(i) (ii)	135,348 ------------- 0	8,617 ------------- 0	16,929 ------------- 0	6,532 ------------- 0	21,012 ------------- 0	188,438 ------------- 0	0 ------------- 0

Schedule J (Form 990) 2019

Page 3

Part III

Supplemental Information

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.

Return Reference	Explanation
PART I, LINE 3	AMERY'S PRESIDENT AND ITS OFFICERS ARE EMPLOYED BY REGIONS HOSPITAL (REGIONS) OR BY GROUP HEALTH PLAN, INC. (GHI), BOTH OF WHICH ARE RELATED ORGANIZATIONS, OR BY AMERY. GHI, REGIONS, AND AMERY HAVE AN ANNUAL PROCESS TO REVIEW THE MARKET COMPARABILITY OF THE TOTAL COMPENSATION OF AMERY'S PRESIDENT AND OTHER OFFICERS.
PART I, LINE 4B	DEFERRED COMPENSATION IN COLUMN C OF SCHEDULE J, PART II INCLUDES AMOUNTS FROM A NONQUALIFIED 457(F) PLAN FOR THE FOLLOWING DIRECTOR: TED WEGLEITNER $38,373
990, SCHEDULE J, PART II COLUMN F: PRIOR REPORTED COMPENSATION	COLUMN (F) INCLUDES AMOUNTS PAID TO PARTICIPANTS IN THE CURRENT YEAR, WHICH WERE PREVIOUSLY REPORTED IN COLUMN (C) OF PRIOR YEARS' 990'S AS RETIREMENT AND DEFERRED COMPENSATION, GOT FOR THE FOLLOWING DIRECTOR: DYLAN COE, MD $50,770

Schedule J (Form 990) 2019

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Schedule K
(Form 990)

Department of the Treasury
Internal Revenue Service

Supplemental Information on Tax-Exempt Bonds

Complete if the organization answered "Yes" to Form 990, Part Ⅵ, line 24a. Provide descriptions,
explanations, and any additional information in Part Ⅵ.
SchKMediumBullet

Attach to Form 990.
SchKMediumBullet

Go to www.irs.gov/Form990 for instructions and the latest information.

OMB No. 1545-0047

2019

Open to Public
Inspection

Name of the organization
AMERY REGIONAL MEDICAL CENTER INC

Employer identification number
39-0908320

Part Ⅰ

Bond Issues

(a) Issuer name		(b) Issuer EIN	(c) CUSIP #	(d) Date issued	(e) Issue price	(f) Description of purpose	(g) Defeased		(h) On behalf of issuer		(i) Pool financing
(a) Issuer name		(b) Issuer EIN	(c) CUSIP #	(d) Date issued	(e) Issue price	(f) Description of purpose	Yes	No	Yes	No	Yes	No
A	VILLAGE OF LUCK WISCONSIN	39-6006307		04-28-2011	8,500,000	REFINANCE EXISTING DEBT		X		X		X
B	CITY OF AMERY WISCONSIN	39-6005378		04-13-2011	8,500,000	REFINANCE EXISTING DEBT		X		X		X
C	VILLAGE OF CLEAR LAKE WISCONSIN	39-6006238		03-29-2011	8,500,000	REFINANCE EXISTING DEBT		X		X		X
D	TOWN OF BLACK BROOK POLK COUNTY WISCONSIN	39-1169876		05-13-2011	6,150,000	REFINANCE EXISTING DEBT		X		X		X
	TOWN OF LINCOLN POLK COUNTY WISCONSIN	39-1406159		05-31-2011	6,150,000	REFINANCE EXISTING DEBT		X		X		X

Part Ⅱ

Proceeds

	A		B		C		D
	1 Amount of bonds retired ..................	5,811,558		5,811,558		5,811,558		4,169,069
2 Amount of bonds legally defeased ..............
3 Total proceeds of issue ..................	8,500,000		8,500,000		8,500,000		6,150,000
4 Gross proceeds in reserve funds .............
5 Capitalized interest from proceeds .............
6 Proceeds in refunding escrows ...............
7 Issuance costs from proceeds ...............	170,000		170,000		170,000		123,000
8 Credit enhancement from proceeds .............
9 Working capital expenditures from proceeds .............
10 Capital expenditures from proceeds .............	1,709,792
11 Other spent proceeds .............	8,330,000		8,330,000		8,330,000		6,027,000
12 Other unspent proceeds .............
13 Year of substantial completion .............	2007		2007		2007		2007
	Yes	No	Yes	No	Yes	No	Yes	No
14 Were the bonds issued as part of a current refunding issue of tax-exempt bonds (or, if issued prior to 2018, a current refunding issue)? ........	X		X		X		X
15 Were the bonds issued as part of an advance refunding issue of taxable bonds (or, if issued prior to 2018, an advance refunding issue)? ........		X		X		X		X
16 Has the final allocation of proceeds been made? ..........	X		X		X		X
17 Does the organization maintain adequate books and records to support the final allocation of proceeds? ..................	X		X		X		X

Part Ⅲ

Private Business Use

	A		B		C		D
	Yes	No	Yes	No	Yes	No	Yes	No
1 Was the organization a partner in a partnership, or a member of an LLC, which owned property financed by tax-exempt bonds? .............		X		X		X		X
2 Are there any lease arrangements that may result in private business use of bond-financed property? ...............	X		X		X		X

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

Cat. No. 50193E

Schedule K (Form 990) 2019

Page 2

Part Ⅲ

Private Business Use (Continued)

	A		B		C		D
	Yes	No	Yes	No	Yes	No	Yes	No
3a Are there any management or service contracts that may result in private business use of bond-financed property? .............		X		X		X		X
b If "Yes" to line 3a, does the organization routinely engage bond counsel or other outside counsel to review any management or service contracts relating to the financed property?
c Are there any research agreements that may result in private business use of bond-financed property? .............		X		X		X		X
d If "Yes" to line 3c, does the organization routinely engage bond counsel or other outside counsel to review any research agreements relating to the financed property?
4 Enter the percentage of financed property used in a private business use by entities other than a section 501(c)(3) organization or a state or local government ....	0.090 %		0.090 %		0.090 %		0.090 %
5 Enter the percentage of financed property used in a private business use as a result of unrelated trade or business activity carried on by your organization, another section 501(c)(3) organization, or a state or local government .........
6 Total of lines 4 and 5 .............	0.090 %		0.090 %		0.090 %		0.090 %
7 Does the bond issue meet the private security or payment test? ...	X		X		X		X
8a Has there been a sale or disposition of any of the bond-financed property to a nongovernmental person other than a 501(c)(3) organization since the bonds were issued?.............		X		X		X		X
b If "Yes" to line 8a, enter the percentage of bond-financed property sold or disposed of. ..
c If "Yes" to line 8a, was any remedial action taken pursuant to Regulations sections 1.141-12 and 1.145-2? .............
9 Has the organization established written procedures to ensure that all nonqualified bonds of the issue are remediated in accordance with the requirements under Regulations sections 1.141-12 and 1.145-2? ........		X		X		X		X

Part Ⅳ

Arbitrage

	A		B		C		D
	Yes	No	Yes	No	Yes	No	Yes	No
1 Has the issuer filed Form 8038-T, Arbitrage Rebate, Yield Reduction and Penalty in Lieu of Arbitrage Rebate? ...		X		X		X		X
2 If "No" to line 1, did the following apply? ....
a Rebate not due yet? .......	X		X		X		X
b Exception to rebate? ........		X		X		X		X
c No rebate due? .........		X		X		X		X
If "Yes" to line 2c, provide in Part Ⅵ the date the rebate computation was performed ......
3 Is the bond issue a variable rate issue? .....	X		X		X		X
4a Has the organization or the governmental issuer entered into a qualified hedge with respect to the bond issue?		X		X		X		X
b Name of provider ..........
c Term of hedge .........
d Was the hedge superintegrated? ......
e Was the hedge terminated? ........

Schedule K (Form 990) 2019

Page 3

Part Ⅳ

Arbitrage (Continued)

	A		B		C		D
	Yes	No	Yes	No	Yes	No	Yes	No
5a Were gross proceeds invested in a guaranteed investment contract (GIC)?		X		X		X		X
b Name of provider ..........
c Term of GIC .........
d Was the regulatory safe harbor for establishing the fair market value of the GIC satisfied? ........
6 Were any gross proceeds invested beyond an available temporary period?		X		X		X		X
7 Has the organization established written procedures to monitor the requirements of section 148? ...		X		X		X		X

Part Ⅴ

Procedures To Undertake Corrective Action

---------------------------------------------------------------------------------------------------------------	A		B		C		D
	Yes	No	Yes	No	Yes	No	Yes	No
Has the organization established written procedures to ensure that violations of federal tax requirements are timely identified and corrected through the voluntary closing agreement program if self-remediation is not available under applicable regulations?		X		X		X		X

Part Ⅵ

Supplemental Information. Provide additional information for responses to questions on Schedule K. (See instructions).

Return Reference	Explanation
FORM 990, SCHEDULE K, PART IV, LINE 2A THRU 2C	REBATE CALCULATION IS NOT DUE BUT EVERY 5 YEARS. THERE IS NO REBATE CALCULATION DUE FOR ANY BONDS LISTED IN SCHEDULE K, PART I.

Schedule K (Form 990) 2019

Additional Data

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Software Version:

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Note: To capture the full content of this document, please select landscape mode (11" x 8.5") when printing.

Schedule K
(Form 990)

Department of the Treasury
Internal Revenue Service

Supplemental Information on Tax-Exempt Bonds

Complete if the organization answered "Yes" to Form 990, Part Ⅵ, line 24a. Provide descriptions,
explanations, and any additional information in Part Ⅵ.
SchKMediumBullet

Attach to Form 990.
SchKMediumBullet

Go to www.irs.gov/Form990 for instructions and the latest information.

OMB No. 1545-0047

2019

Open to Public
Inspection

Name of the organization
AMERY REGIONAL MEDICAL CENTER INC

Employer identification number
39-0908320

Part Ⅰ

Bond Issues

(a) Issuer name		(b) Issuer EIN	(c) CUSIP #	(d) Date issued	(e) Issue price	(f) Description of purpose	(g) Defeased		(h) On behalf of issuer		(i) Pool financing
(a) Issuer name		(b) Issuer EIN	(c) CUSIP #	(d) Date issued	(e) Issue price	(f) Description of purpose	Yes	No	Yes	No	Yes	No
A	VILLAGE OF LUCK WISCONSIN	39-6006307		04-28-2011	8,500,000	REFINANCE EXISTING DEBT		X		X		X
B	CITY OF AMERY WISCONSIN	39-6005378		04-13-2011	8,500,000	REFINANCE EXISTING DEBT		X		X		X
C	VILLAGE OF CLEAR LAKE WISCONSIN	39-6006238		03-29-2011	8,500,000	REFINANCE EXISTING DEBT		X		X		X
D	TOWN OF BLACK BROOK POLK COUNTY WISCONSIN	39-1169876		05-13-2011	6,150,000	REFINANCE EXISTING DEBT		X		X		X
	TOWN OF LINCOLN POLK COUNTY WISCONSIN	39-1406159		05-31-2011	6,150,000	REFINANCE EXISTING DEBT		X		X		X

Part Ⅱ

Proceeds

	A		B		C		D
	1 Amount of bonds retired ..................	5,811,558		5,811,558		5,811,558		4,169,069
2 Amount of bonds legally defeased ..............
3 Total proceeds of issue ..................	8,500,000		8,500,000		8,500,000		6,150,000
4 Gross proceeds in reserve funds .............
5 Capitalized interest from proceeds .............
6 Proceeds in refunding escrows ...............
7 Issuance costs from proceeds ...............	170,000		170,000		170,000		123,000
8 Credit enhancement from proceeds .............
9 Working capital expenditures from proceeds .............
10 Capital expenditures from proceeds .............	1,709,792
11 Other spent proceeds .............	8,330,000		8,330,000		8,330,000		6,027,000
12 Other unspent proceeds .............
13 Year of substantial completion .............	2007		2007		2007		2007
	Yes	No	Yes	No	Yes	No	Yes	No
14 Were the bonds issued as part of a current refunding issue of tax-exempt bonds (or, if issued prior to 2018, a current refunding issue)? ........	X		X		X		X
15 Were the bonds issued as part of an advance refunding issue of taxable bonds (or, if issued prior to 2018, an advance refunding issue)? ........		X		X		X		X
16 Has the final allocation of proceeds been made? ..........	X		X		X		X
17 Does the organization maintain adequate books and records to support the final allocation of proceeds? ..................	X		X		X		X

Part Ⅲ

Private Business Use

	A		B		C		D
	Yes	No	Yes	No	Yes	No	Yes	No
1 Was the organization a partner in a partnership, or a member of an LLC, which owned property financed by tax-exempt bonds? .............		X		X		X		X
2 Are there any lease arrangements that may result in private business use of bond-financed property? ...............	X		X		X		X

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

Cat. No. 50193E

Schedule K (Form 990) 2019

Page 2

Part Ⅲ

Private Business Use (Continued)

	A		B		C		D
	Yes	No	Yes	No	Yes	No	Yes	No
3a Are there any management or service contracts that may result in private business use of bond-financed property? .............		X		X		X		X
b If "Yes" to line 3a, does the organization routinely engage bond counsel or other outside counsel to review any management or service contracts relating to the financed property?
c Are there any research agreements that may result in private business use of bond-financed property? .............		X		X		X		X
d If "Yes" to line 3c, does the organization routinely engage bond counsel or other outside counsel to review any research agreements relating to the financed property?
4 Enter the percentage of financed property used in a private business use by entities other than a section 501(c)(3) organization or a state or local government ....	0.090 %		0.090 %		0.090 %		0.090 %
5 Enter the percentage of financed property used in a private business use as a result of unrelated trade or business activity carried on by your organization, another section 501(c)(3) organization, or a state or local government .........
6 Total of lines 4 and 5 .............	0.090 %		0.090 %		0.090 %		0.090 %
7 Does the bond issue meet the private security or payment test? ...	X		X		X		X
8a Has there been a sale or disposition of any of the bond-financed property to a nongovernmental person other than a 501(c)(3) organization since the bonds were issued?.............		X		X		X		X
b If "Yes" to line 8a, enter the percentage of bond-financed property sold or disposed of. ..
c If "Yes" to line 8a, was any remedial action taken pursuant to Regulations sections 1.141-12 and 1.145-2? .............
9 Has the organization established written procedures to ensure that all nonqualified bonds of the issue are remediated in accordance with the requirements under Regulations sections 1.141-12 and 1.145-2? ........		X		X		X		X

Part Ⅳ

Arbitrage

	A		B		C		D
	Yes	No	Yes	No	Yes	No	Yes	No
1 Has the issuer filed Form 8038-T, Arbitrage Rebate, Yield Reduction and Penalty in Lieu of Arbitrage Rebate? ...		X		X		X		X
2 If "No" to line 1, did the following apply? ....
a Rebate not due yet? .......	X		X		X		X
b Exception to rebate? ........		X		X		X		X
c No rebate due? .........		X		X		X		X
If "Yes" to line 2c, provide in Part Ⅵ the date the rebate computation was performed ......
3 Is the bond issue a variable rate issue? .....	X		X		X		X
4a Has the organization or the governmental issuer entered into a qualified hedge with respect to the bond issue?		X		X		X		X
b Name of provider ..........
c Term of hedge .........
d Was the hedge superintegrated? ......
e Was the hedge terminated? ........

Schedule K (Form 990) 2019

Page 3

Part Ⅳ

Arbitrage (Continued)

	A		B		C		D
	Yes	No	Yes	No	Yes	No	Yes	No
5a Were gross proceeds invested in a guaranteed investment contract (GIC)?		X		X		X		X
b Name of provider ..........
c Term of GIC .........
d Was the regulatory safe harbor for establishing the fair market value of the GIC satisfied? ........
6 Were any gross proceeds invested beyond an available temporary period?		X		X		X		X
7 Has the organization established written procedures to monitor the requirements of section 148? ...		X		X		X		X

Part Ⅴ

Procedures To Undertake Corrective Action

---------------------------------------------------------------------------------------------------------------	A		B		C		D
	Yes	No	Yes	No	Yes	No	Yes	No
Has the organization established written procedures to ensure that violations of federal tax requirements are timely identified and corrected through the voluntary closing agreement program if self-remediation is not available under applicable regulations?		X		X		X		X

Part Ⅵ

Supplemental Information. Provide additional information for responses to questions on Schedule K. (See instructions).

Return Reference	Explanation
FORM 990, SCHEDULE K, PART IV, LINE 2A THRU 2C	REBATE CALCULATION IS NOT DUE BUT EVERY 5 YEARS. THERE IS NO REBATE CALCULATION DUE FOR ANY BONDS LISTED IN SCHEDULE K, PART I.

Schedule K (Form 990) 2019

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 990-EZ or to provide any additional information.
MediumBullet

Attach to Form 990 or 990-EZ.
MediumBullet

Go to www.irs.gov/Form990 for the latest information.

OMB No. 1545-0047

2019

Open to Public
Inspection

Name of the organization

AMERY REGIONAL MEDICAL CENTER INC

Employer identification number

39-0908320

Return Reference	Explanation
FORM 990, PART III, LINE 4A - EXEMPT PURPOSE AND ACHIEVEMENTS	AMERY REGIONAL MEDICAL CENTER (ARMC), A STATE LICENSED 25-BED, LEVEL IV CRITICAL ACCESS HOSPITAL (CAH), IS A WISCONSIN NON-PROFIT CORPORATION RECOGNIZED AS EXEMPT FROM FEDERAL INCOME TAX UNDER INTERNAL REVENUE CODE ("IRC") SECTION 501(C)(3) AND IS PART OF THE FAMILY OF HEALTHPARTNERS ORGANIZATIONS "HEALTHPARTNERS". FOUNDED IN 1957, HEALTHPARTNERS IS AN INTEGRATED HEALTH CARE ORGANIZATION, PROVIDING HEALTH CARE SERVICES AND HEALTH PLAN FINANCING AND ADMINISTRATION, AND IS THE LARGEST CONSUMER-GOVERNED NONPROFIT HEALTH CARE ORGANIZATION IN THE COUNTRY. HEALTHPARTNERS' MISSION IS TO IMPROVE HEALTH AND WELL-BEING IN PARTNERSHIP WITH OUR MEMBERS, PATIENTS AND COMMUNITY. HEALTHPARTNERS SEEKS TO TRANSFORM HEALTH CARE THROUGH A RELENTLESS FOCUS ON THE TRIPLE AIM - PROVIDING EXCEPTIONAL EXPERIENCE FOR THE INDIVIDUAL, IMPROVING THE HEALTH OF THE POPULATION, AND MAINTAINING AFFORDABILITY. HEALTHPARTNERS, INC. (HPI) IS A MINNESOTA NON-PROFIT CORPORATION AND LICENSED HEALTH MAINTENANCE ORGANIZATION (HMO) RECOGNIZED AS EXEMPT FROM FEDERAL INCOME TAX UNDER INTERNAL REVENUE CODE (IRC) SECTION 501(C)(4) AND IS THE PARENT ENTITY OF HEALTHPARTNERS ORGANIZATIONS REFERRED TO COLLECTIVELY AS "HEALTHPARTNERS". HEALTHPARTNERS INCLUDES AN ARRAY OF TAX-EXEMPT AND TAXABLE ORGANIZATIONS. HEALTHPARTNERS PROVIDES A FULL RANGE OF HEALTH CARE DELIVERY AND HEALTH PLAN SERVICES INCLUDING INSURANCE, PATIENT CARE, ADMINISTRATION AND HEALTH AND WELL-BEING PROGRAMS. HEALTHPARTNERS HEALTH PLANS SERVE MORE THAN 1.8 MILLION MEDICAL AND DENTAL MEMBERS NATIONWIDE. HEALTHPARTNERS MEDICAL CARE SYSTEM INCLUDES MORE THAN 1,800 PHYSICIANS AND DENTISTS, SEVEN OWNED HOSPITALS WITH OVER 1,000 ACUTE CARE BEDS, OVER 125 PRIMARY AND SPECIALTY CARE MEDICAL FACILITIES AND DENTAL FACILITIES WITH PRACTICES IN MINNESOTA AND WESTERN WISCONSIN SERVING MORE THAN 1.2 MILLION PATIENTS. HEALTHPARTNERS HEALTH PLANS CONTRACT WITH OTHER PRIMARY AND SPECIALTY MEDICAL FACILITIES AND DENTAL FACILITIES, PHYSICIAN GROUPS, HOSPITALS AND RELATED HEALTHCARE PROVIDERS TO SERVE PLAN MEMBERS. HEALTHPARTNERS ALSO PROVIDES MEDICAL EDUCATION AND TRAINING TO MEDICAL PROFESSIONALS AND CONDUCTS RESEARCH AND FUNDRAISING ACTIVITIES THAT SUPPORT THE HEALTH CARE DELIVERY SYSTEM. HEALTHPARTNERS COLLABORATES WITH OTHER PLANS, CARE PROVIDERS AND OTHER COMMUNITY AND BUSINESS ORGANIZATIONS IN THE REGION AND THROUGHOUT THE NATION TO INCREASE ACCESS, CREATE AND SHARE QUALITY MEASURES AND INITIATIVES, PARTICIPATE IN DEVELOPMENT OF PUBLIC POLICY, AND COLLABORATE IN IMPROVEMENTS THAT SUPPORT THE TRIPLE AIM. AMONG HEALTHPARTNERS' SIGNATURE INITIATIVES CONTINUING IN 2019 ARE TOTAL COST OF CARE MEASUREMENTS (A NATIONALLY RECOGNIZED METRIC, ENDORSED BY THE NATIONAL QUALITY FORUM, ENABLING MEASUREMENT AND INCENTIVES BASED ON COORDINATION AND EVIDENCE-BASED PRACTICES), MENTAL HEALTH (REDUCING STIGMA, AND ASSURING ACCESS TO HIGH QUALITY CARE IN THE MOST APPROPRIATE SETTINGS), CHILDREN'S HEALTH (IMPROVING CHILD HEALTH BY PROMOTING EARLY BRAIN DEVELOPMENT, PROVIDING FAMILY CENTERED CARE, AND STRENGTHENING COMMUNITIES), AND SUSTAINABILITY (ENERGY EFFICIENCY, WASTE REDUCTION, AND RESOURCE MANAGEMENT). A COMPLETE LISTING OF ALL ORGANIZATIONS WITHIN HEALTHPARTNERS, AND THE RELATIONSHIP BETWEEN THEM, CAN BE FOUND ON SCHEDULE R WITHIN THIS 990 RETURN. DETAILED INFORMATION ABOUT THE COMMUNITY BENEFIT ACTIVITIES AND ACCOMPLISHMENTS OF EACH TAX-EXEMPT ORGANIZATION CAN BE FOUND IN THE INDIVIDUAL FORM 990 RETURN FOR THAT ORGANIZATION. HEALTHPARTNERS IS DRIVING CHANGE THAT HELPS OUR MEMBERS AND PATIENTS LIVE HEALTHIER LIVES. HEALTHPARTNERS COLLABORATE WITH OTHER PLANS, CARE PROVIDERS AND OTHER COMMUNITY AND BUSINESS ORGANIZATIONS IN THE REGION AND THROUGHOUT THE NATION TO INCREASE ACCESS, CREATE AND SHARE QUALITY MEASURES AND INITIATIVES, PARTICIPATE IN DEVELOPMENT OF PUBLIC POLICY, AND COLLABORATE IN IMPROVEMENTS THAT SUPPORT THE TRIPLE AIM. AMONG HEALTHPARTNERS' SIGNATURE INITIATIVES CONTINUING IN 2019 ARE TOTAL COST OF CARE MEASUREMENTS (DEVELOPMENT OF A NATIONALLY RECOGNIZED METRIC, ENDORSED BY THE NATIONAL QUALITY FORUM, ENABLING MEASUREMENT AND INCENTIVES BASED ON COORDINATION AND EVIDENCE-BASED PRACTICES), MENTAL HEALTH (REDUCING STIGMA, AND ASSURING ACCESS TO HIGH QUALITY CARE IN THE MOST APPROPRIATE SETTINGS), CHILDREN'S HEALTH (IMPROVING CHILD HEALTH BY PROMOTING EARLY BRAIN DEVELOPMENT, PROVIDING FAMILY CENTERED CARE, AND STRENGTHENING COMMUNITIES), AND SUSTAINABILITY (ENERGY EFFICIENCY, WASTE REDUCTION, AND RESOURCE MANAGEMENT). HEALTHPARTNERS, INC. (HPI) IS THE PARENT ENTITY OF HEALTHPARTNERS AND IS A MINNESOTA NON-PROFIT CORPORATION AND LICENSED HEALTH MAINTENANCE ORGANIZATION (HMO) RECOGNIZED AS EXEMPT FROM FEDERAL INCOME TAX UNDER IRC SECTION 501(C)(4). HPI IS THE SOLE CORPORATE MEMBER OF HPI-RAMSEY, A MINNESOTA NON-PROFIT CORPORATION RECOGNIZED AS EXEMPT FROM FEDERAL INCOME TAX UNDER IRC SECTION 501(C)(3). IN TURN, HPI-RAMSEY IS THE SOLE CORPORATE MEMBER OF REGIONS HOSPITAL, REGIONS HOSPITAL FOUNDATION, CAPITOL VIEW TRANSITIONAL CARE CENTER, LAKEVIEW HEALTH, RAMSEY INTEGRATED HEALTH SERVICES AND RH-WISCONSIN, INC., ALL OF WHICH ARE NON-PROFIT CORPORATIONS EXEMPT FROM FEDERAL INCOME TAX UNDER IRC SECTION 501(C)(3). RH-WISCONSIN AND GROUP HEALTH PLAN, INC. (GHI) ARE CORPORATE MEMBERS OF ARMC. GHI IS A MINNESOTA NON-PROFIT CORPORATION AND LICENSED HEALTH MAINTENANCE ORGANIZATION (HMO) RECOGNIZED AS EXEMPT FROM FEDERAL INCOME TAX UNDER IRC SECTION 501(C)(3). IN TURN, ARMC IS THE SOLE CORPORATE MEMBER OF THE AMERY REGIONAL MEDICAL CENTER FOUNDATION (FOUNDATION) A WISCONSIN NON-STOCK CORPORATION EXEMPT FROM FEDERAL INCOME TAX UNDER INTERNAL REVENUE CODE (IRC) SECTION 501(C)(3). BENEFIT TO THE COMMUNITY: 1. COMMUNITY HEALTH IMPROVEMENT SERVICES: $ 79,175 - COMMUNITY HEALTH EDUCATION - ARMC HELPS EDUCATE THE LOCAL COMMUNITIES IN REGARDS TO HEALTH ISSUES BY PROVIDING THE FOLLOWING TYPES OF COMMUNITY EDUCATION: CPR/BLS CLASSES, MONTHLY DIABETES SUPPORT GROUP REACHING OVER 100 INDIVIDUALS, MONTHLY BREASTFEEDING SUPPORT GROUP, EXPECTANT PARENTS/PRE-NATAL AND BREASTFEEDING CLASSES REACHING 48 PARENTS, 3 HEALTH FAIRS WITH FOCUS ON HEART HEALTH, STROKE PREVENTION, WOUND HEALING, DIABETES EDUCATION, AND NUTRITION, 13 MENTAL HEALTH FOCUSED COMMUNITY EDUCATION CLASSES WITH A REACH OF OVER 230 INDIVIDUALS. CONTINUING IN 2019, ARMC OFFERED AT LEAST ONE FREE COMMUNITY EDUCATION CLASS EVERY MONTH IN ADDITION TO A MEDICAL NUTRITION THERAPY CLASS TAUGHT BY A REGISTERED DIETITIAN WITH A FOCUS ON DIABETES PREVENTION, OFFERED AT NO COST. BEYOND THE MONTHLY CLASS OFFERINGS, OVER FOUR COMMUNITY-FOCUSED MENTAL HEALTH-RELATED CLASSES WERE TAUGHT BY BEHAVIORAL HEALTH STAFF ON TOPICS SUCH AS: DEMENTIA, SUICIDE PREVENTION, REDUCING MENTAL HEALTH STIGMA, AND MENTAL ILLNESS. ARMC PROVIDES EDUCATION AT OUR SCHOOLS BY HOLDING A 3RD GRADE HEALTH FAIR REACHING 189 STUDENTS FROM AMERY, CLEAR LAKE, CLAYTON, AND TURTLE LAKE. POWERUP, A COMMUNITY-WIDE INITIATIVE TO MAKE IT EASY, FUN AND POPULAR TO EAT BETTER AND MOVE MORE SO YOUTH CAN REACH THEIR FULL POTENTIAL, COMPLETED ITS FOURTH FULL YEAR IN AMERY. OUTREACH AND PROGRAM SUCCESSES INCLUDE: ANNUAL CANDLELIGHT NIGHT ON THE STOWER EVENT DONE IN PARTNERSHIP WITH THE FRIENDS OF THE STOWER SEVEN LAKES STATE TRAIL. THIS FREE EVENT FEATURES TWO MILES OF ILLUMINATED TRAILS WHERE KIDS AND ADULTS OF ALL AGES CAN ENJOY A WALK, SNOWSHOE, CROSS-COUNTRY SKI, OR FAT TIRE BIKING. FREE SNOWSHOES WERE AVAILABLE FOR KIDS AND ADULTS TO TRY ALONG WITH VEGGIE CHILI AND HOT CIDER. OVER 120 WERE IN ATTENDANCE. "VEGGIE FARMER MEET & SEED" EVENT AT LIEN ELEMENTARY DONE IN PARTNERSHIP WITH LIEN ELEMENTARY SCHOOL GARDEN COMMITTEE AND A TEAM OF SIX LOCAL VEGETABLE FARMERS INCLUDED MORNING SESSIONS FOR ALL STUDENTS ON HOW TO PLANT A SEED AND NURTURE A PLANT SO IT GROWS INTO A WHOLESOME AND DELICIOUS VEGETABLE OR BEAUTIFUL FLOWER. STUDENTS ALSO LEARNED ABOUT OUR REGION'S VEGETABLE-GROWING FAMILY FARMS. THESE SEEDLINGS WERE THEN RAISED IN THE SCHOOL HALLWAYS UNTIL READY FOR THE SCHOOL GARDEN. APPROXIMATELY 420 STUDENTS RECEIVED A PACK OF BABY CARROTS TO HELP CELEBRATE. POWERUP AT LIEN ELEMENTARY 4K ORIENTATION FEATURING A SINK OR FLOAT GAME AND OUTREACH MATERIALS. OVER 80 KIDS GUESSED WHETHER DIFFERENT FRUITS AND VEGGIES WOULD SINK OR FLOAT IN A BOWL OF WATER. POWERUP AT THE THIRD GRADE HEALTH FAIR FEATURING A VEGGIE VOTE WHERE APPROXIMATELY 250 STUDENTS TASTE TASTED TWO DIFFERENT VEGETABLES. THIS FUN AND PRESSURE-FREE WAY TO EXPLORE VEGGIES GETS KIDS EXCITED TO TRY! POWERUP SPORTS NUTRITION TALK (FUELING FOR PERFORMANCE, RECOVERY AND INJURY PREVENTION) WITH THE AMERY HIGH SCHOOL GIRLS SOCCER TEAM; APPROXIMATELY 35 STUDENTS.
PART III, CONT.	POWERUP WEEK IS A TIME TO HAVE FUN, GET INSPIRED, AND POWERUP WITH ACTIVITIES TO HELP KIDS, FAMILIES AND THE ENTIRE COMMUNITY EAT BETTER AND MOVE MORE. THIS SPECIAL WEEK IS A GREAT WAY FOR COMMUNITIES IN THE ST. CROIX VALLEY TO COME TOGETHER AND DO WHAT'S BEST FOR OUR KIDS, SO THEY CAN GROW UP HEALTHY AND STRONG. THIS YEAR, POWERUP WEEK IN AMERY FEATURED: A 2K RUN/WALK WITH 132 PARTICIPANTS, CHOMP'S BIRTHDAY PARTY AT AMERY PUBLIC LIBRARY WITH OVER 40 KIDS AND ADULTS, FAMILY YOGA WITH 22 KIDS AND ADULTS, AND A DANCE PARTY WITH OVER 50 KIDS AND ADULTS. MOBILE TEACHING KITCHEN KNOWN AS THE CHARLIE CART CONTINUED IN A PARTNERSHIP WITH AMERY PUBLIC LIBRARY AND REACHED 80 KIDS. PART OF THE MISSION OF BOTH THE CHARLIE CART PROGRAM AND POWERUP IS TO GIVE KIDS THE POWER TO MAKE HEALTHY CHOICES FOR LIFE THROUGH HANDS-ON EXPERIENCES WITH "BETTER-FOR-YOU" FOODS. POWERUP COOKING CLASSES AT FARM TABLE CONTINUED IN 2019 AND REACHED OVER 150 STUDENTS. COOKING CLASSES GIVE STUDENTS HANDS-ON EXPERIENCES WITH A VARIETY OF ESSENTIAL COOKING SKILLS, HELP THEM LEARN TO READ RECIPES, ADJUST MEASUREMENTS, AND PRACTICE TEAMWORK AND PRACTICE TEAMWORK AND ORGANIZATION. POWERUP, FARM TABLE, AND THE FITNESS CENTER PARTNERED TO HOST 30 POLK COUNTY SPECIAL OLYMPICS ATHLETES IN A TWO-PART CLASS TO HELP THEM PREPARE FOR THEIR UPCOMING BASKETBALL AND SHOW SHOE SEASON. THE GROUP HAD A POWERUP COOKING CLASS AT FARM TABLE AND THEN THEY TOOK A SHORT WALK DOWN THE STREET TO THE FITNESS CENTER WHERE THEY HAD A FITNESS CLASS. LIEN ELEMENTARY SCHOOL CARNIVAL WITH "POWERED UP" FOOD OPTIONS INCLUDING A TACO BAR, FRUIT CUPS, POPCORN, VEGGIE AND DIP CUPS, AND FRESH MADE SMOOTHIES; APPROXIMATELY 200 IN ATTENDANCE. AMERY INTERMEDIATE SCHOOL WALK-A-THON "POWERED UP" THEIR ANNUAL FUNDRAISER FOR THE SECOND YEAR BY COLLECTING DONATIONS (INSTEAD OF SELLING PROCESSED FOODS) AND EARNING THEM BY WALKING/RUNNING AROUND THE TRACK DURING AN ALLOTTED TIME. CLASSROOMS WITHIN EACH GRADE LEVEL THAT HAVE THE MOST LAPS EARN A POWERUP SMOOTHIE PARTY! OPEN GYMS IN THE WINTER MONTHS GIVE KIDS AND FAMILIES A SAFE PLACE TO MOVE THEIR BODIES. IN 2019, OPEN GYMS TOOK PLACE IN AMERY, CLEAR LAKE, AND TURTLE LAKE. TOTAL REACH BETWEEN ALL COMMUNITIES WAS 731 KIDS AND ADULTS. POWERUP FRUIT AND VEGGIE RX CONTINUED THIS YEAR WITH PROVIDERS ASKING CHILDREN AGES 2-17 YEARS OLD ABOUT FRUITS AND VEGGIES, AND THEN "PRESCRIBING" TRYING MORE FRUIT & VEGGIES WHILE ALSO GIVING OUT A $10 VOUCHER FOR PRODUCE AT THE LOCAL GROCERY STORE. AVERAGE REDEMPTION RATE FOR ALL FOUR AMERY HOSPITAL & CLINIC LOCATIONS WAS 51%. THE POWER OF PRODUCE (POP) CLUB WAS NEW THIS SUMMER AND RAN FOR 11 WEEKS AT THE AMERY FARMERS MARKET. EACH WEEK, CHILDREN RECEIVED A $2 TOKEN TO SPEND ON FRESH FRUITS, VEGETABLES, OR FOOD PLANTS. CHILDREN AND FAMILIES WERE ALSO PROVIDED WITH SEASONAL RECIPES, RESOURCES ON HOW TO BUY, USE, AND STORE VEGETABLES, AND A FRUIT OR VEGGIE-INSPIRED ACTIVITY. IN 11 WEEKS, THERE WERE 85 YOUTH THAT PARTICIPATED. OF THE 168 TOKENS FOR $2 THAT WERE DISTRIBUTED, 137 WERE REDEEMED (81.5% REDEMPTION RATE). FAMILY AND YOUTH FEEDBACK FOR THE PROGRAM WAS OVERWHELMINGLY POSITIVE AND HAD KIDS EXCITED TO PICK OUT THEIR OWN PRODUCE. SOME FAMILIES REPORTED AN INCREASED INTEREST IN THEIR CHILD CONSUMING FRUITS AND VEGETABLES BECAUSE OF THIS. - COMMUNITY-BASED CLINICAL SERVICES - $ 342 BEHAVIORAL HEALTH SCREENED 9TH GRADE TEENS FOR DEPRESSION, SUICIDAL THOUGHTS AND STRESSORS AT THE AMERY HIGH SCHOOL. - HEALTH CARE SUPPORT SERVICES - $ 189,700 SOCIAL WORKER, HEALTH BENEFIT COUNSELORS, AND PATIENT FINANCIAL SERVICES REPRESENTATIVES PROVIDE HEALTH CARE SUPPORT SERVICES TO INDIVIDUALS ON A ONE-ON-ONE BASIS. THESE STAFF MEMBERS HELP EDUCATE AND ASSIST INDIVIDUALS WITH ADVANCE DIRECTIVE SUPPORT, INFORMATION AND REFERRAL SERVICES, ENROLLMENT ASSISTANCE IN GOVERNMENT PROGRAMS, FINDING OTHER SOURCES OF PAYMENT, AND ACCESSING SERVICES BEYOND MEDICAL CARE. ARMC SPENT $66,136 IN STAFF TIME TO ASSIST PATIENTS IN ENROLLING IN PUBLIC MEDICAL PROGRAMS, FREE DRUG PROGRAMS, AND REFER INDIVIDUALS TO COMMUNITY SERVICES/PUBLIC HEALTH ASSISTANCE. ARMC'S PATIENT EMERGENCY FUND, SUPPORTED BY EMPLOYEES AND STAFF, DONATED OVER $665 TO HELP 27 INDIVIDUALS IN NEED RECEIVE CARE AT ARMC. FUNDS PROVIDED TO INDIVIDUALS WERE FOR EMERGENT NEEDS RELATED TO THEIR HEALTH INCLUDING EMERGENCY MEDICATIONS AND GAS CARDS. ARMC OPERATES A VAN TRANSPORTATION SERVICE FOR ITS RURAL PATIENT POPULATION. PATIENTS WHO ARE UNABLE TO ARRANGE THEIR OWN TRANSPORTATION TO ARMC FOR CARE AND TREATMENT MAY SCHEDULE A TRANSPORT. PERSONS WHO USE THE SERVICE ARE ASKED TO PAY $2.00 PER RIDE. OVER 1,100 PATIENTS USED THIS SERVICE IN 2019, WITH REVENUE OF $2,082 AND OPERATING COST OF $68,633. - SOCIAL & ENVIRONMENTAL IMPROVEMENT ACTIVITIES - $38,918 DUE THE HEALTH PROFESSIONAL SHORTAGE AREA IN THE ARMC SERVICE AREA, NUMEROUS RESOURCES WERE INVESTED IN PHYSICIAN AND ADVANCED PRACTICE PROVIDER RECRUITMENT, TOTALING AT LEAST $33,200. ARMC WELCOMED ONE DOCTOR OF OSTEOPATHIC MEDICINE, ONE ADULT NURSE PRACTITIONER, AND ONE FAMILY NURSE PRACTITIONER. IN 2019, OVER 825 MEDICAL STUDENTS APPLIED AND OVER 24 WERE INTERVIEWED FOR THE NEWLY INITIATED WESTERN WISCONSIN RURAL RESIDENCY PROGRAM AT ARMC. TWO STUDENTS WERE CHOSEN AND WERE EXPECTED TO START JUNE 10, 2020. ARMC CONTINUES TO PARTNER WITH THE CITY OF AMERY TO OFFER 18 GARDENING PLOTS AT THE COMMUNITY GARDEN LOCATED ON ARMC GROUNDS. 2. HEALTH PROFESSIONAL EDUCATION: $32,712 STUDENTS IN NURSING, PHYSICAL THERAPY, PHARMACY, OCCUPATIONAL THERAPY, RADIOLOGIC TECHNOLOGY, MEDICAL RECORDS, MEDICAL ASSISTANT, LAB TECHNICIAN, NURSE PRACTITIONERS, AND MEDICAL ADMINISTRATIVE ASSISTANTS STUDY AT ARMC. ARMC ALSO HAS AN AGREEMENT WITH THE UNIVERSITY OF MINNESOTA-DULUTH FOR FIRST YEAR AND SECOND YEAR MEDICAL STUDENT ROTATIONS. IN ADDITION, ARMC ACTIVELY COLLABORATES WITH THE WISCONSIN INDIANHEAD TECHNICAL COLLEGE (WITC) TO HELP EDUCATE AND TRAIN NURSES. IN 2019, ARMC PROVIDED CLINICAL TRAINING FOR: 111 NURSES, 3 CERTIFIED REGISTERED NURSE ANESTHETIST STUDENTS, 5 MEDICAL STUDENTS, 1 LAB TECHNICIAN STUDENT, 1 OCCUPATIONAL THERAPIST STUDENT, 3 OCCUPATIONAL THERAPIST ASSISTANT STUDENTS, 5 PHYSICAL THERAPY STUDENTS, 2 PHYSICAL THERAPY ASSISTANTS, 1 PARAMEDIC STUDENT, 4 PHARMACY STUDENTS, 1 RADIOLOGY STUDENT, 2 SOCIAL WORK STUDENTS, 1 PSYCHIATRIST, AND 1 FITNESS CENTER ASSISTANT. EACH YEAR, ARMC AND THE FOUNDATION PROVIDE SEVEN $1,000 SCHOLARSHIPS TO LOCAL HIGH SCHOOL SENIORS PURSUING A CAREER IN A HEALTH-RELATED FIELD. ARMC'S SHARE OF THE COST WAS $3,500. 3. SUBSIDIZED HEALTH SERVICES: NONE 4. FINANCIAL CONTRIBUTIONS: $ 143,147 - CASH DONATIONS - ARMC HELPED VARIOUS NON-PROFIT ORGANIZATIONS, COMMUNITY GROUPS, AND SCHOOL PROGRAMS THROUGH CASH DONATIONS TOTALING $13, 980. - IN-KIND DONATIONS - IN-KIND SERVICES DONATED INCLUDED STAFF HOURS SPENT IN SUPPORT OF LOCAL COMMUNITY BOARDS OR COMMITTEE WORK SUCH AS: VALLEY BEHAVIORAL HEALTH STEERING COMMITTEE, NORTHWESTERN WISCONSIN HEALTHCARE COALITION, MENTAL HEALTH TASK FORCE OF POLK COUNTY, AND THE POLK COUNTY NUTRITION & PHYSICAL ACTIVITY WORKGROUP. ARMC ATHLETIC TRAINERS ARE IN BOTH AMERY AND LUCK SCHOOL DISTRICTS, PROVIDING OVER 2,000 HOURS OF ATHLETIC TRAINING AND SUPPORT FOR A MINIMAL FEE TOTALING $6,230, WITH THE BENEFIT OF DONATED SERVICES TOTALING $43,932. ARMC HOSTED THREE BLOOD DRIVES IN 2019 COLLECTING OVER 65 UNITS OF BLOOD FROM OVER 60 INDIVIDUALS IN SUPPORT OF THE AMERICAN RED CROSS. ARMC PROVIDES MEETING SPACE FOR NON-PROFIT AND COMMUNITY GROUPS WITH A HEALTH FOCUS SUCH AS THE AMERICAN RED CROSS, BABY & ME, PRENATAL & BREASTFEEDING SUPPORT, DAVITA KIDNEY SMART, AND WITC NURSING PROGRAM TOTALING $5,000. IN ORDER TO HELP COMBAT POVERTY, ARMC PROVIDES AMERY AREA FOOD SHELF WITH FREE RENT, HEAT AND SHELVING FOR FOOD ITEMS. IN 2019, OVER $74,829 WAS PROVIDED TO SUPPORT THIS LOCAL PROGRAM.
PART III, CONT.	5. COMMUNITY BUILDING ACTIVITIES: $7,047 - ENVIRONMENTAL IMPROVEMENTS - ARMC HAD REPRESENTATIVES ATTEND THE ANNUAL CLEANMED CONFERENCE WHICH IS A NATIONAL ENVIRONMENTAL CONFERENCE FOR LEADERS IN HEALTH CARE SUSTAINABILITY. ARMC CONTINUES TO BE A SUSTAINABILITY CHAMPION AND HOSTS AN ANNUAL ELECTRONICS RECYCLING EVENT. - WORKFORCE DEVELOPMENT - ARMC HAS REPRESENTATIVES SERVE ON THE WITC MEDICAL ASSISTANT ADVISORY COMMITTEE, WITC ADVISORY COUNCIL, AND WITC HEALTH INFORMATION TECHNOLOGY ADVISORY COMMITTEE. 6. COMMUNITY BENEFIT OPERATIONS: $16,023 A COMMUNITY HEALTH SPECIALIST HAS TIME ALLOTTED TO THE TRAINING, MANAGEMENT, AND REPORTING OF COMMUNITY BENEFITS TO BEST CAPTURE ARMC'S COMMITMENT TO COMMUNITY HEALTH IMPROVEMENT. 7. ORGANIZATION AWARDS AND ACHIEVEMENTS 2019 PRACTICE GREENHEALTH AWARDS: EMERALD AWARD GREENING THE OR RECOGNITION CIRCLES OF EXCELLENCE (TOP 10): WATER
FORM 990, PART VI, SECTION A, LINE 6	RH WISCONSIN, INC. IS THE CLASS A MEMBER AND GHI IS THE CLASS B MEMBER OF ARMC.
FORM 990, PART VI, SECTION A, LINE 7A	ARMC'S BOARD OF DIRECTORS IS COMPRISED OF NOT MORE THAN 13 PERSONS APPOINTED AS FOLLOWS: - 7 COMMUNITY REPRESENTATIVES APPOINTED BY THE CLASS A MEMBER (RH-WISCONSIN), FROM RECOMMENDATIONS BY THE EXECUTIVE COMMITTEE OF THE BOARD OF DIRECTORS. - 3 REPRESENTATIVES APPOINTED BY THE CLASS B MEMBER (GHI). - 3 HEALTH CARE PROVIDERS NOMINATED BY THE PHYSICIAN GROUP STAFFING ARMC'S PRIMARY CARE CLINIC, AND APPOINTED BY THE CLASS B MEMBER (GHI). - THE PRESIDENT AND CHIEF MEDICAL OFFICER OF ARMC SIT IN EX-OFFICIO CAPACITIES, WITHOUT THE RIGHT TO VOTE.
FORM 990, PART VI, SECTION A, LINE 7B	THE CLASS A AND CLASS B MEMBERS (RH WISCONSIN, INC. AND GHI RESPECTIVELY) BOTH MUST APPROVE THE DECISIONS OF THE BOARD OF DIRECTORS AS FOLLOWS: - AMENDMENT OF ARTICLES OR BYLAWS IMPACTING MEMBERSHIP - RESIGNATION OF A MEMBER - DISSOLUTION - ANY CHANGE IN THE FUNDAMENTAL NATURE OR PURPOSE - MERGER OR CONSOLIDATION WITH ANOTHER CORPORATION - DISPOSITION OF SUBSTANTIALLY ALL ASSETS. ONLY THE CLASS A MEMBER MUST APPROVE THE DECISIONS OF THE BOARD OF DIRECTORS AS FOLLOWS: - AMENDMENT OF ARTICLES OR BYLAWS NOT IMPACTING MEMBERSHIP - ANNUAL OPERATING AND CAPITAL BUDGETS AND STRATEGIC PLANS - ESTABLISHMENT OF NEW ENTITIES OR SIGNIFICANT RELATIONSHIPS WITH OTHER ENTITIES - UNBUDGETED EXPENDITURES IN EXCESS OF AMOUNTS ESTABLISHED BY THE MEMBER - GUARANTEEING THE DEBT OF ANY OTHER PERSON OR ENTITY - A LOAN OR OTHER INDEBTEDNESS IN EXCESS OF AMOUNTS ESTABLISHED BY THE MEMBER - TRANSFER OF ASSETS TO ANOTHER ENTITY - APPOINTMENT OF THE PRESIDENT AND THE BOARD CHAIR.
FORM 990, PART VI, SECTION B, LINE 11B	ARMC'S 990 RETURN HAS A COMPREHENSIVE REVIEW PROCESS THAT IS FOLLOWED BEFORE IT IS PRESENTED TO THE GOVERNING BODY OF ARMC. THE REVIEW PROCESS INCLUDES A LAYERED REVIEW BY THE TAX DEPARTMENT OF GROUP HEALTH PLAN, INC. (GHI), THE MANAGEMENT TEAM OF ARMC, GHI'S INTERNAL LEGAL DEPARTMENT AND ARMC'S OUTSIDE INDEPENDENT ACCOUNTANTS. EACH ONE OF THOSE AREAS HAS AN OPPORTUNITY TO REVIEW, ASK QUESTIONS AND MAKE COMMENTS BACK TO THE TAX DEPARTMENT OF GHI BEFORE THE FORM 990 IS COMPLETED AND PRESENTED TO THE GOVERNING BODY OF ARMC. ARMC MAKES AVAILABLE TO THE GOVERNING BODY (BOARD OF DIRECTORS) A COPY OF THE 990 FOR REVIEW AND COMMENT PRIOR TO THE FILING OF THE 990 RETURN. THIS COPY IS PROVIDED IN A PRE-MEETING PACKET, AND IS AN AGENDA ITEM AT A MEETING OF THE FULL BOARD OF DIRECTORS. THIS PROCESS IS NOTED AND DOCUMENTED IN THE WRITTEN MINUTES OF THE MEETING.
FORM 990, PART VI, SECTION B, LINE 12C	THE AMERY BOARD MONITORS POTENTIAL CONFLICTS OF INTEREST ON THE PART OF ITS BOARD MEMBERS, PRINCIPAL OFFICERS, MEMBERS OF COMMITTEES WITH BOARD DELEGATED POWERS, AND KEY EMPLOYEES ("COVERED PERSONS") BY MAINTAINING A CONFLICT OF INTEREST POLICY. UNDER THE POLICY, COVERED PERSONS ANNUALLY ARE PROVIDED WITH A COPY OF THE POLICY AND ASKED TO COMPLETE A QUESTIONNAIRE IDENTIFYING ANY POTENTIAL CONFLICTS OF INTERESTS. THE LEGAL DEPARTMENT OF HEALTHPARTNERS REVIEWS THE QUESTIONNAIRE RESPONSES AND DEVELOPS A REPORT DETAILING ANY POTENTIALLY MATERIAL CONFLICTS FOR THE PRESIDENT AND CHAIR OF THE BOARD. A VERBAL SUMMARY IS ALSO GIVEN TO THE FULL BOARD OR APPROPRIATE COMMITTEE ENDING WITH A REMINDER TO COVERED PERSONS OF THE POLICY'S MANDATE THAT EACH PERSON IS OBLIGATED TO DISCLOSE ANY NEW POTENTIAL CONFLICTS AS THEY MAY ARISE THROUGHOUT THE YEAR. BOARD AGENDAS AND EXECUTIVE DECISIONS ARE MONITORED IN RELATION TO THIS POLICY.
FORM 990, PART VI, SECTION B, LINE 15	AMERY'S PRESIDENT AND ITS OFFICERS ARE EMPLOYED BY REGIONS HOSPITAL (REGIONS), LAKEVIEW HEALTH OR BY GROUP HEALTH PLAN, INC. (GHI), ALL OF WHICH ARE RELATED ORGANIZATIONS, OR BY AMERY. GHI, REGIONS, LAKEVIEW HEALTH AND AMERY HAVE AN ANNUAL PROCESS TO REVIEW THE MARKET COMPARABILITY OF THE TOTAL COMPENSATION OF AMERY'S PRESIDENT AND OTHER OFFICERS. EVERY THREE YEARS, THE INDEPENDENT COMPENSATION COMMITTEE OF THE GHI BOARD OF DIRECTORS (THE "COMMITTEE"), RETAINS AN EXTERNAL COMPENSATION EXPERT TO CONDUCT AN EXTENSIVE MARKET COMPARABILITY REVIEW FOR ALL OFFICERS OF THE ORGANIZATION. THE REVIEW INCLUDES ALL COMPONENTS OF TOTAL COMPENSATION: BASE SALARY, ANNUAL INCENTIVES, BENEFITS AND PERQUISITES. THE MARKET SURVEY RESULTS ARE PRESENTED TO, REVIEWED BY AND APPROVED BY THE APPROPRIATE COMMITTEE. BASED ON THIS DATA, EITHER THE EXECUTIVE COMMITTEE OF REGIONS, THE COMPENSATION COMMITTEE OF GHI OR THE AMERY EXECUTIVE COMMITTEE (THE "COMMITTEES") DETERMINE MINIMUM AND MAXIMUM TOTAL COMPENSATION RANGES FOR EACH EMPLOYED OFFICER. IN INTERIM YEARS, GHI'S HUMAN RESOURCES STAFF, UNDER THE COMMITTEES' DIRECTION, UPDATES CHANGES IN THE SALARY STRUCTURE BASED ON THE SAME INDEPENDENT STUDIES PERFORMED BY THE COMPENSATION CONSULTANT FOR THE COMMITTEE. FOR CERTAIN POSITIONS FULL INDEPENDENT REVIEWS ARE PERFORMED TO SET SALARY RANGES BASED ON THE COMPETITIVE MARKET DATA SPECIFIC TO THOSE POSITIONS. THE COMMITTEES REVIEW AND APPROVE EACH YEAR'S COMPENSATION RESULTS. IN ALL CASES, THE COMMITTEES' MEMBERS COMPLETE AN ANNUAL CONFLICT OF INTEREST SURVEY TO ASSURE THE COMMITTEES MEMBERS' INDEPENDENCE AND THIS IS UPDATED AT ANY MEETING AT WHICH DECISIONS ARE BEING MADE. STAFF (OTHER THAN THE SECRETARY TO THE BOARD) IS NOT IN THE ROOM DURING DELIBERATIONS OR VOTE INCLUDING EXECUTIVE SESSIONS, AND CONTEMPORANEOUS MINUTES ARE KEPT. WITH AMERY'S BOARD OF DIRECTORS INPUT, THE ST CROIX VALLEY EXECUTIVE LEADER CONDUCTS THE ANNUAL PERFORMANCE REVIEW AND, WITH AMERY'S BOARD APPROVAL, DETERMINES THE COMPENSATION OF THE ARMC CEO. THE AMERY'S BOARD HAS DELEGATED TO THE PRESIDENT THE ACCOUNTABILITY TO CONDUCT ANNUAL PERFORMANCE REVIEWS AND DETERMINE THE COMPENSATION OF ALL ARMC-EMPLOYED OFFICERS WITHIN THE COMPENSATION RANGES DETERMINED BY THE COMMITTEE. ANY EXCEPTIONS TO COMPENSATION IN EXCESS OF THE APPROVED RANGES ARE APPROVED BY THE AMERY EXECUTIVE COMMITTEE. TOTAL COMPENSATION IS APPROPRIATELY DOCUMENTED ON THE FORM 990 AND ON THE EMPLOYEE'S W-2.
FORM 990, PART VI, SECTION C, LINE 18	AMERY'S 990 RETURNS ARE MADE AVAILABLE TO ANY PERSON WHO REQUESTS THE INFORMATION FROM ANERY OR HEALTHPARTNERS, INC.
FORM 990, PART VI, SECTION C, LINE 19	AMERY MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST.
990, PART VII, SEC A, LN 1A, COL (B) - RELATED ORGANIZATION AVERAGE HOURS	DIRECTORS AND OFFICERS OF ARMC ARE EMPLOYED AND COMPENSATED BY GHI, INC., REGIONS HOSPITAL OR ARMC. REPORTED AVERAGE HOURS WORKED ARE BASED ON THEIR TOTAL COMPENSATION FROM ALL RELATED ORGANIZATIONS.
FORM 990, PART XI, LINE 9:	CONTRIBUTION FROM AMERY HOSPITAL FOUNDATION -224,341.

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

Cat. No. 51056K

Schedule O (Form 990 or 990-EZ) 2019

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" on Form 990, Part IV, line 33, 34, 35b, 36, or 37.
MediumBullet

Attach to Form 990.
MediumBullet

Go to www.irs.gov/Form990 for instructions and the latest information.

OMB No. 1545-0047

2019

Open to Public Inspection

Name of the organization

AMERY REGIONAL MEDICAL CENTER INC

Employer identification number

39-0908320

Part I

Identification of Disregarded Entities. Complete if the organization answered "Yes" on 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" on 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)HEALTHPARTNERS INC 8170 33RD AVE S PO BOX 1309 MPLS,MN554401309 41-1693838	HYBRID STAFF MODEL/NETWORK MODEL HEALTH MAINTENANCE ORGANIZATION	MN	501(C)(4)		N/A		No
(2)HPI-RAMSEY 8170 33RD AVE S PO BOX 1309 MPLS,MN554401309 41-1793333	CORPORATE PLANNING AND OVERSIGHT	MN	501(C)(3)	509(A)(3) TYPE I	HEALTHPARTNERS INC		No
(3)GROUP HEALTH PLAN INC 8170 33RD AVE S PO BOX 1309 MPLS,MN554401309 41-0797853	STAFF MODEL HEALTH MAINTENANCE ORGANIZATION	MN	501(C)(3)	170(B)(1) (A)(III)	HEALTHPARTNERS INC		No
(4)RH WISCONSIN INC 8171 33RD AVE S PO BOX 1309 MPLS,MN554401309 20-2287016	CORPORATE PLANNING AND OVERSIGHT	MN	501(C)(3)	509(A)(3) TYPE I	HEALTHPARTNERS INC		No
(5)HEALTHPARTNERS INSTITUTE 8170 33RD AVE S PO BOX 1309 MPLS,MN554401309 41-1670163	HEALTHCARE EDUCATION AND RESEARCH	MN	501(C)(3)	509(A)(3) TYPE I	HEALTHPARTNERS INC		No
(6)CAPITOL VIEW TRANSITIONAL CARE CENTER 8170 33RD AVE S PO BOX 1309 MPLS,MN554401309 41-2011453	TRANSITIONAL CARE SERVICES, STEP DOWN FROM INPATIENT HOSPITAL	MN	501(C)(3)	170(B)(1) (A)(III)	HPI - RAMSEY		No
(7)REGIONS HOSPITAL 8170 33RD AVE S PO BOX 1309 MPLS,MN554401309 41-0956618	HOSPITAL	MN	501(C)(3)	170(B)(1) (A)(III)	HPI - RAMSEY		No
(8)REGIONS HOSPITAL FOUNDATION 8170 33RD AVE S PO BOX 1309 MPLS,MN554401309 41-1888902	PROVIDE SUPPORT TO HOSPITAL AND COMMUNITY HEALTH	MN	501(C)(3)	170(B)(1) (A)(VI)	HPI - RAMSEY		No
(9)RHSC INC 8170 33RD AVE S PO BOX 1309 MPLS,MN554401309 41-1891928	HEALTHCARE STAFFING AND INTENSE REHAB SERVICES	MN	501(C)(3)	509(A)(3) TYPE II	HPI - RAMSEY		No
(10)PHYSICIANS NECK & BACK CLINICS 8170 33RD AVE S PO BOX 1309 MPLS,MN554401309 27-0684883	SPECIALTY PATIENT CARE	MN	501(C)(3)	509(A)(3) TYPE II	GROUP HEALTH PLAN INC		No
(11)HUDSON HOSPITAL INC 8170 33RD AVE S PO BOX 1309 MPLS,MN554401309 39-0804125	HOSPITAL	WI	501(C)(3)	170(B)(1) (A)(III)	RH-WISCONSIN INC		No
(12)HUDSON HOSPITAL FOUNDATION INC 8170 33RD AVE S PO BOX 1309 MPLS,MN554401309 39-1279567	PROVIDE SUPPORT TO HOSPITAL AND COMMUNITY HEALTH	WI	501(C)(3)	170(B)(1) (A)(VI)	HUDSON HOSPITAL INC		No
(13)LAKEVIEW HEALTH FOUNDATION 8170 33RD AVE S PO BOX 1309 MPLS,MN554401309 41-1386635	PROVIDE SUPPORT TO HOSPITAL AND COMMUNITY HEALTH	MN	501(C)(3)	170(B)(1) (A)(VI)	LAKEVIEW HEALTH		No
(14)LAKEVIEW MEMORIAL HOSPITAL ASSOCIATION INC 8170 33RD AVE S PO BOX 1309 MPLS,MN554401309 41-0811697	HOSPITAL	MN	501(C)(3)	170(B)(1) (A)(III)	LAKEVIEW HEALTH		No
(15)STILLWATER MEDICAL GROUP 8170 33RD AVE S PO BOX 1309 MPLS,MN554401309 83-0379473	CLINIC STAFF AND FACILITIES	MN	501(C)(3)	509(A)(3) TYPE I	LAKEVIEW HEALTH		No
(16)LAKEVIEW HEALTH 8170 33RD AVE S PO BOX 1309 MPLS,MN554401309 30-0221189	CORPORATE PLANNING AND OVERSIGHT	MN	501(C)(3)	509(A)(3) TYPE II	HPI - RAMSEY		No
(17)WESTFIELDS HOSPITAL INC 8170 33RD AVE S PO BOX 1309 MPLS,MN554401309 39-0808442	HOSPITAL	WI	501(C)(3)	170(B)(1) (A)(III)	RH-WISCONSIN INC		No
(18)WESTFIELDS HOSPITAL FOUNDATION INC 8170 33RD AVE S PO BOX 1309 MPLS,MN554401309 39-1770913	PROVIDE SUPPORT TO HOSPITAL AND COMMUNITY HEALTH	WI	501(C)(3)	170(B)(1) (A)(VI)	WESTFIELDS HOSPITAL INC		No
(19)RAMSEY INTEGRATED HEALTH SERVICES 8170 33RD AVE S PO BOX 1309 MPLS,MN554401309 41-1503090	HOME CARE AND HOSPICE	MN	501(C)(3)	509(A)(2)	HPI - RAMSEY		No
(20)PARK NICOLLET HEALTH SERVICES 6500 EXCELSIOR BLVD ST LOUIS PARK,MN55426 36-3465840	CORPORATE PLANNING AND OVERSIGHT	MN	501(C)(3)	509(A)(2)	HEALTHPARTNERS INC		No
(21)PARK NICOLLET FOUNDATION 6500 EXCELSIOR BLVD ST LOUIS PARK,MN55426 23-7346465	SUPPORT TO RELATED ENTITIES AND COMMUNITY HEALTH	MN	501(C)(3)	170(B)(1) (A)(VI)	PARK NICOLLET HEALTH SERVICES		No
(22)PARK NICOLLET METHODIST HOSPITAL 6500 EXCELSIOR BLVD ST LOUIS PARK,MN55426 41-0132080	HOSPITAL	MN	501(C)(3)	170(B)(1) (A)(III)	PARK NICOLLET HEALTH SERVICES		No
(23)PARK NICOLLET HEALTH CARE PRODUCTS 6500 EXCELSIOR BLVD ST LOUIS PARK,MN55426 01-0638901	DURABLE MEDICAL EQUIPMENT , PHARMACY AND OTHER HEALTH CARE RETAIL SALES	MN	501(C)(3)	509(A)(3) TYPE I	PARK NICOLLET HEALTH SERVICES		No
(24)PARK NICOLLET CLINIC 6500 EXCELSIOR BLVD ST LOUIS PARK,MN55426 41-0834920	CLINIC SERVICES	MN	501(C)(3)	170(B)(1) (A)(III)	PARK NICOLLET HEALTH SERVICES		No
(25)PNMC HOLDINGS 6500 EXCELSIOR BLVD ST LOUIS PARK,MN55426 41-1741792	HEALTHCARE REAL ESTATE	MN	501(C)(3)	509(A)(3) TYPE I	PARK NICOLLET HEALTH SERVICES		No
(26)AMERY REGIONAL MEDICAL CENTER FOUNDATION INC 8170 33RD AVE S PO BOX 1309 MPLS,MN554401309 39-1726539	PROVIDE SUPPORT TO HOSPITAL AND COMMUNITY HEALTH	WI	501(C)(3)	170(B)(1) (A)(VI)	AMERY REGIONAL MEDICAL CENTER INC	Yes
(27)HUTCHINSON HEALTH 8170 33RD AVE S PO BOX 1309 MPLS,MN554401309 84-1715908	HOSPITAL	MN	501(C)(3)	170(B)(1) (A)(III)	PARK NICOLLET HEALTH SERVICES		No
(28)HUTCHINSON HEALTH FOUNDATION 8170 33RD AVE S PO BOX 1309 MPLS,MN554401309 36-3317820	PROVIDE SUPPORT TO HOSPITAL	MN	501(C)(3)	509(A)(3) TYPE III	HUTCHINSON HEALTH		No

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

Cat. No. 50135Y

Schedule R (Form 990) 2019

Page 2

Part III

Identification of Related Organizations Taxable as a Partnership. Complete if the organization answered "Yes" on 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	(e) Predominant income(related, unrelated, excluded from tax under sections 512-514)	(f) Share of total income	(g) Share of end-of-year assets	(h) Disproprtionate allocations?		(i) Code V-UBI amount in box 20 of Schedule K-1 (Form 1065)	(j) General or managing partner?		(k) Percentage ownership
(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 V-UBI amount in box 20 of Schedule K-1 (Form 1065)	Yes	No
(1) AMERY REGIONAL MEDICAL CENTER PHARMACY LLC 265 GRIFFIN STREET E AMERY,WI54001 39-1979705	PHARMACEUTICAL	WI	AMERY REGIONAL MEDICAL CENTER	RELATED	-36,941	-30,168		No		Yes		50.000 %

Part IV

Identification of Related Organizations Taxable as a Corporation or Trust. Complete if the organization answered "Yes" on 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) HEALTHPARTNERS ADMINISTRATORS INC 8170 33RD AVE S PO BOX 1309 MPLS,MN554401309 41-1629390	THIRD PARTY ADMINISTRATOR	MN	HEALTHPARTNERS INC	C				No
(2) HEALTHPARTNERS ASSOCIATES INC 8170 33RD AVE S PO BOX 1309 MPLS,MN554401309 52-2365151	MEDICAL CLINIC STAFFING AND ASSET MANAGEMENT	MN	HEALTHPARTNERS ADMINISTRATORS INC	C				No
(3) HEALTHPARTNERS SERVICES INC 8170 33RD AVE S PO BOX 1309 MPLS,MN554401309 41-1683568	MEDICAL CLINIC STAFFING AND ASSET MANAGEMENT	MN	HEALTHPARTNERS ADMINISTRATORS INC	C				No
(4) HEALTHPARTNERS INSURANCE COMPANY 8170 33RD AVE S PO BOX 1309 MPLS,MN554401309 41-1683523	MEDICAL AND DENTAL INSURANCE	MN	HEALTHPARTNERS ADMINISTRATORS INC	C				No
(5) DENTAL SPECIALTIES INC 8170 33RD AVE S PO BOX 1309 MPLS,MN554401309 45-1297583	PROFESSIONAL DENTAL SERVICES	MN	HEALTHPARTNERS ADMINISTRATORS INC	C				No
(6) HEALTHPARTNERS CENTRAL MINNESOTA CLINICS INC 8170 33RD AVE S PO BOX 1309 MPLS,MN554401309 41-1236798	MEDICAL CLINIC STAFFING	MN	HEALTHPARTNERS ADMINISTRATORS INC	C				No
(7) PARK NICOLLET ENTERPRISES 6500 EXCELSIOR BLVD ST LOUIS PARK,MN55426 41-1656735	REAL ESTATE FOR RELATED ORGANIZATIONS	MN	PARK NICOLLET HEALTH SERVICES	C				No

Schedule R (Form 990) 2019

Page 3

Part V

Transactions With Related Organizations. Complete if the organization answered "Yes" on 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) ...................

Yes

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

Yes

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

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

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

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

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 related organization	(b) Transaction type (a-s)	(c) Amount involved	(d) Method of determining amount involved
(1) HEALTHPARTNERS INC - CLAIMSHEALTHCARE SERVICES	L	197,530	FAIR VALUE
(2) AMERY REGIONAL MEDICAL CENTER FOUNDATION	C	265,113	FAIR VALUE

Schedule R (Form 990) 2019

Page 4

Part VI

Unrelated Organizations Taxable as a Partnership. Complete if the organization answered "Yes" on 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 V-UBI 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 V-UBI amount in box 20 of Schedule K-1 (Form 1065)	Yes	No

Schedule R (Form 990) 2019

Page 5

Part VII

Supplemental Information

Provide additional information for responses to questions on Schedule R. (see instructions).

Return Reference	Explanation

Schedule R (Form 990) 2019

Additional Data

Software ID:
Software Version:

		Prior Year	Current Year
8	Contributions and grants (Part VIII, line 1h) .........	107,300	282,579
9	Program service revenue (Part VIII, line 2g) .........	60,760,964	62,357,101
10	Investment income (Part VIII, column (A), lines 3, 4, and 7d ) ....	184,444	390,681
11	Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e)	207,576	148,025
12	Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)	61,260,284	63,178,386
13	Grants and similar amounts paid (Part IX, column (A), lines 1–3 )...	35,749	42,401
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)	39,932,985	40,651,486
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)....	20,487,659	20,789,982
18	Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25)	60,456,393	61,483,869
19	Revenue less expenses. Subtract line 18 from line 12.......	803,891	1,694,517
		Beginning of Current Year	End of Year
20	Total assets (Part X, line 16).............	51,714,878	53,164,869
21	Total liabilities (Part X, line 26).............	30,089,212	29,387,833
22	Net assets or fund balances. Subtract line 21 from line 20.....	21,625,666	23,777,036

Sign Here

	Signature of officer	Date

	Type or print name and title


4a	(Code: ) (Expenses $ 55,479,136 including grants of $ 42,401 ) (Revenue $ 62,357,101 )
	SEE SCHEDULE O - EXEMPT PURPOSE AND ACHIEVEMENTS FOR A DESCRIPTION OF PROGRAM SERVICE ACCOMPLISHMENTS

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 expenses55,479,136

(A) Name and title	(B) Average hours per week (list any hours for related organizations below dotted line)				(D) Reportable compensation from the organization (W-2/1099-MISC)	(E) Reportable compensation from related organizations (W-2/1099-MISC)	(F) Estimated amount of other compensation from the organization and related organizations
(A) Name and title
(18) DOUGLAS JOHNSON........................................................................ CFO (AUG-DEC)	13.75 .......................41.25	X			0	380,795	153,262
(19) MARK A TRYGGESTAD........................................................................ DIRECTOR OF PHARMACY	48.00 .......................0.00		X		179,668	0	20,019
(20) JAMES ERICKSON........................................................................ RN SUPERVISOR	40.00 .......................0.00		X		135,508	0	39,469
(21) ANTHONY GOULD........................................................................ ANCILLARY SERVICES	40.00 .......................0.00		X		128,010	0	38,516
(22) ANN SCHILLING........................................................................ HR SR DIRECTOR	40.00 .......................0.00		X		126,969	0	38,275
(23) BENJAMIN BOGLE........................................................................ PROVIDER-APNP	40.00 .......................0.00		X		130,853	0	37,663
(24) JOANNE L JACKSON........................................................................ FORMER HR, PR AND MKTG DIR	0.00 .......................45.00			X	160,894	0	27,544

1b	Sub-Total................
c	Total from continuation sheets to Part VII, Section A....
d	Total (add lines 1b and 1c)...........	1,054,302	3,406,816	1,021,037

1	Briefly describe the organization’s mission or most significant activities: TO PROVIDE ACCESSIBLE, COMPREHENSIVE, QUALITY HEALTHCARE
2	Check this box
3	Number of voting members of the governing body (Part VI, line 1a) ........	3	13
4	Number of independent voting members of the governing body (Part VI, line 1b) .....	4	7
5	Total number of individuals employed in calendar year 2019 (Part V, line 2a) ......	5	500
6	Total number of volunteers (estimate if necessary) .............	6	26
7a	Total unrelated business revenue from Part VIII, column (C), line 12 ........	7a	0
b	Net unrelated business taxable income from Form 990-T, line 39 .........	7b	0

1a	Federated campaigns..		1a
b	Membership dues..		1b
c	Fundraising events..		1c
d	Related organizations		1d	274,285
e	Government grants (contributions)		1e	6,186

f	All other contributions, gifts, grants, and similar amounts not included above		1f	2,108

g	Noncash contributions included in lines 1a - 1f:$		1g

h Total. Add lines 1a-1f.......		282,579

		Business Code
2a	NET PATIENT SERVICE	621110	61,379,378	61,379,378
b	OTHER OPERATING	900099	686,060	686,060
c	FITNESS CENTER	624110	150,421	150,421
d	SUBSIDIARY REVENUE	900099	141,242	141,242
e
f	All other program service revenue.
g	Total. Add lines 2a–2f .....		62,357,101

3 Investment income (including dividends, interest, and othersimilar amounts) ......			390,681			390,681
4 Income from investment of tax-exempt bond proceeds
5 Royalties...........
		(ii) Personal	(i) Real
6a	Gross rents		54,711	6a
b	Less: rental expenses		49,351	6b
c	Rental income or (loss)		5,360	6c
d	Net rental income or (loss).......			5,360			5,360
		(ii) Other	(i) Securities
7a	Gross amount from sales of assets other than inventory			7a
b	Less: cost or other basis and sales expenses			7b
c	Gain or (loss)			7c
d	Net gain or (loss).........
8a	Gross income from fundraising events (not including $ of contributions reported on line 1c). See Part IV, line 18 ....
			8a
b	Less: direct expenses ...		8b
c	Net income or (loss) from fundraising events..
9a	Gross income from gaming activities. See Part IV, line 19 ...
			9a
b	Less: direct expenses ...		9b
c	Net income or (loss) from gaming activities..
10a	Gross sales of inventory, less returns and allowances ..
			10a
b	Less: cost of goods sold ..		10b
c	Net income or (loss) from sales of inventory..
Business Code			Miscellaneous Revenue
11a	CAFETERIA AND OTHER		900099	135,587			135,587
b	GIFT SHOP		453220	7,078			7,078
c
d	All other revenue ....
e	Total. Add lines 11a–11d ......			142,665
12	Total revenue. See instructions.....			63,178,386	62,357,101	0	538,706

1	Grants and other assistance to domestic organizations and domestic governments. See Part IV, line 21 ....	42,401	42,401
2	Grants and other assistance to domestic individuals. See Part IV, line 22 ...........
3	Grants and other assistance to foreign organizations, foreign governments, and foreign individuals. See Part IV, lines 15 and 16. .............
4	Benefits paid to or for members .......
5	Compensation of current officers, directors, trustees, and key employees ...........	234,507		234,507
6	Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) .........
7	Other salaries and wages........	35,801,286	32,944,874	2,856,412
8	Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) ....	661,021	608,281	52,740
9	Other employee benefits .......	2,358,186	2,170,038	188,148
10	Payroll taxes ...........	1,596,486	1,469,110	127,376
11	Fees for services (non-employees):
a	Management ......
b	Legal .........	16,127		16,127
c	Accounting ...........
d	Lobbying ...........
e	Professional fundraising services. See Part IV, line 17
f	Investment management fees ......
g	Other (If line 11g amount exceeds 10% of line 25, column (A) amount, list line 11g expenses on Schedule O)	3,254,056	2,820,353	433,703
12	Advertising and promotion ....	216,118	38,654	177,464
13	Office expenses .......	707,015	523,629	183,386
14	Information technology ......	178,734	143,779	34,955
15	Royalties ..
16	Occupancy ...........	1,006,829	756,149	250,680
17	Travel ............	100,886	47,533	53,353
18	Payments of travel or entertainment expenses for any federal, state, or local public officials .
19	Conferences, conventions, and meetings ....	22,309	11,218	11,091
20	Interest ...........	788,485	788,485
21	Payments to affiliates .......
22	Depreciation, depletion, and amortization ..	3,304,096	3,142,650	161,446
23	Insurance ...	201,221	99,532	101,689
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	MEDICAL & DRUG SUPPLIES	7,970,099	7,951,342	18,757
b	EQUIP. RENT & REPAIR	1,995,726	1,264,592	731,134
c	OTHER EXPENSE	663,444	496,131	167,313
d	TAXES & ASSESSMENTS	159,527		159,527
e	All other expenses	205,310	160,385	44,925
25	Total functional expenses. Add lines 1 through 24e	61,483,869	55,479,136	6,004,733	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).

1	Cash–non-interest-bearing ........			23,668	1	15,748
2	Savings and temporary cash investments .........			8,912,534	2	8,593,132
3	Pledges and grants receivable, net ......				3
4	Accounts receivable, net .............			7,412,905	4	7,933,690
5	Loans and other payables to any current or former officer, director, trustee, key employee, creator or founder, substantial contributor, or 35% controlled entity or family member of any of these persons .......
					5
6	Loans and other receivables from other disqualified persons (as defined under section 4958(f)(1)), and persons described in section 4958(c)(3)(B) ...
					6
7	Notes and loans receivable, net ...........				7
8	Inventories for sale or use ............			734,425	8	771,028
9	Prepaid expenses and deferred charges ......			126,448	9	150,822
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	61,593,553
b	Less: accumulated depreciation	10b	40,105,511	23,503,059	10c	21,488,042
11	Investments—publicly traded securities .			8,125,113	11	10,871,204
12	Investments—other securities. See Part IV, line 11 .....				12
13	Investments—program-related. See Part IV, line 11 ..			2,719,280	13	2,680,017
14	Intangible assets ...............				14
15	Other assets. See Part IV, line 11 ...........			157,446	15	661,186
16	Total assets. Add lines 1 through 15 (must equal line 33)...			51,714,878	16	53,164,869

17	Accounts payable and accrued expenses .....	5,581,652	17	5,499,230
18	Grants payable ...		18
19	Deferred revenue .........		19
20	Tax-exempt bond liabilities .........	24,507,560	20	23,438,770
21	Escrow or custodial account liability. Complete Part IV of Schedule D		21
22	Loans and other payables to any current or former officer, director, trustee, key employee, creator or founder, substantial contributor, or 35% controlled entity or family member of any of these persons .........
			22
23	Secured mortgages and notes payable to unrelated third parties ..		23
24	Unsecured notes and loans payable to unrelated third parties ..		24
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	0	25	449,833
26	Total liabilities. Add lines 17 through 25..	30,089,212	26	29,387,833

	Organizations that follow FASB ASC 958, check here and complete lines 27, 28, 32, and 33.
27	Net assets without donor restrictions ..........	21,625,666	27	23,777,036
28	Net assets with donor restrictions ...........		28
	Organizations that do not follow FASB ASC 958, check here and complete lines 29 through 33.
29	Capital stock or trust principal, or current funds .....		29
30	Paid-in or capital surplus, or land, building or equipment fund ...		30
31	Retained earnings, endowment, accumulated income, or other funds		31
32	Total net assets or fund balances ...........	21,625,666	32	23,777,036
33	Total liabilities and net assets/fund balances ........	51,714,878	33	53,164,869