2024-11-13T10:35:21-06:00 2023-12-31 381357951 PLANTE & MORAN PLLC 2601 CAMBRIDGE CT STE 300 AUBURN HILLS MI 48326 990 2023-01-01 390452970 MARSHFIELD CLINIC INC MARS 7153875511 1000 N OAK AVENUE MARSHFIELD WI 54449 BRIAN HOERNEMAN MD INTERIM CEO 7153875511 2024-11-11 1 1 DAVID LOWENTHAL P00378651 2483757100 2024-11-11 2023 2024-10-15 13:58:12Z ALPA SHAH MD 1000 N OAK AVENUE MARSHFIELD WI 54449 678886823 0 X WWW.MARSHFIELDCLINIC.ORG X 1916 WI WE ENRICH LIVES TO CREATE HEALTHY COMMUNITIES THROUGH ACCESSIBLE, AFFORDABLE, COMPASSIONATE HEALTH CARE. 11 0 1408 400 7333800 56542 57333847 38600784 597264485 582938276 15485433 12035563 -39897 13503 670043868 633588126 1973495 691520 0 0 405742600 358306664 0 0 0 266851085 259276145 674567180 618274329 -4523312 15313797 840083001 800024445 713294782 615460091 126788219 184564354 WE ENRICH LIVES TO CREATE HEALTHY COMMUNITIES THROUGH ACCESSIBLE, AFFORDABLE, COMPASSIONATE HEALTH CARE. 0 0 608216420 691520 575836657 MARSHFIELD CLINIC, INC., FOUNDED IN 1916, IS A NOT-FOR-PROFIT GROUP MEDICAL PRACTICE ENGAGED IN PROVIDING HEALTHCARE, HEALTHCARE EDUCATION, MEDICAL RESEARCH, AND COMMUNITY SERVICE. MARSHFIELD CLINIC RESEARCH INSTITUTE, A DIVISION OF MARSHFIELD CLINIC, ENGAGES IN MEDICAL AND SCIENTIFIC RESEARCH AND THE PROMOTION OF PUBLIC HEALTH, MEDICAL EDUCATION, AND COMMUNITY SERVICE. 608216420 1 1 0 0 0 0 0 1 0 0 1 1 1 0 1 1 0 1 0 0 1 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 1 0 1 0 1 X 0 0 1408 1 1 1 0 0 0 0 0 0 0 0 0 0 0 X 11 0 0 0 0 0 1 1 1 1 1 0 0 0 1 1 1 1 1 1 1 1 1 WI X JANETTE TOWNSEND VP OF FINANCE 7153875511 1000 N OAK AVENUE MARSHFIELD WI 54449 ALPA SHAH MD CHAIR 38.00 5.00 X X 294888 0 10485 EDWARD FERNANDEZ MD VICE CHAIR - PART YEAR 53.00 4.00 X X 536206 0 43230 ELVIS PETER MD VICE CHAIR 53.00 4.00 X X 855841 0 46401 KENT RAY DO SECRETARY 53.00 3.00 X X 395418 0 48610 JOHN NEAL MD TREASURER - PART YEAR 52.00 3.00 X X 518663 0 49488 MATTHEW THOMAS MD TREASURER 52.00 3.00 X X 863924 0 42049 TYLER DAHL MD BOARD MEMBER 52.00 2.00 X 908550 0 40730 MATTHEW OELSTROM MD BOARD MEMBER 52.00 2.00 X 441175 0 38014 JAYANTH VEDRE MD BOARD MEMBER 52.00 2.00 X 678686 0 28536 BART ISAACSON MD BOARD MEMBER 52.00 2.00 X 287416 0 33958 BARBARA BOYER MD BOARD MEMBER 52.00 2.00 X 415567 0 44927 DAVID JUNKER MD BOARD MEMBER 52.00 2.00 X 833402 0 51188 PATRICK WOLF DO BOARD MEMBER 52.00 3.00 X 343977 0 39691 SUMITHRA TIRUNAGARAM MD BOARD MEMBER - PART YEAR 52.00 2.00 X 526562 0 43258 SUSAN TURNEY MD MCHS CEO - PART YEAR 1.00 54.00 X 0 3125033 382007 BRIAN HOERNEMAN MD INTERIM MCHS CEO 1.00 54.00 X 0 848741 40127 CATHY BUKOWSKI MCHS CFO - PART YEAR 1.00 54.00 X 0 725840 23393 JEANETTE WOJTALEWICZ INTERIM MCHS CFO 1.00 54.00 X 0 116564 0 WILLIAM MELMS MD CHIEF MEDICAL OFFICER - PART YEAR 1.00 54.00 X 0 1053823 21091 SAMANTHA KLEBE DO CHIEF MEDICAL OFFICER 1.00 54.00 X 0 515015 29993 KATHY BRESSLER MCHS COO 1.00 54.00 X 0 839857 28816 JERARD JENSEN MCHS GENERAL COUNSEL 1.00 54.00 X 0 983883 44933 VIVEKANANDA GONUGUNTA MD PHYSICIAN 50.00 0.00 X 2039667 0 12105 WILLIAM MCCORMICK MD PHYSICIAN 50.00 0.00 X 1204382 0 46171 ADEDAYO ONITILO MD PHYSICIAN 50.00 0.00 X 1777779 0 40127 ALICE LE HUU MD PHYSICIAN 50.00 0.00 X 1337228 0 29518 MOHAMMAD ALAOUA MD PHYSICIAN 50.00 0.00 X 1368629 0 46677 15627960 8208756 1305523 710 0 1 0 MAYO MEDICAL LABORATORIES PO BOX 9146 MINNEAPOLIS MN 55480 LAB SERVICES 2018688 BOLDT CO 2121 E CAPITOL DRIVE APPLETON WI 54911 CONSTRUCTION 1906692 CIOX HEALTH LLC PO BOX 409669 ATLANTA GA 30384 PROFESSIONAL SERVICES 1245807 BECKMAN COULTER INC DEPT CH 10164 PALATINE IL 60055 LAB SERVICES 932285 BECTON DICKINSON & CO 21588 NETWORK PLACE CHICAGO IL 60673 LAB SERVICES 857126 99 4134981 34465803 38600784 INTERCOMPANY REVENUE 621110 303995016 303995016 NET PATIENT SERVICE REVENUE 621110 278957352 271623552 7333800 MISC OTHER OPERATING REVENUE 621110 -14092 -14092 582938276 7288519 7288519 296312 282809 13503 13503 13503 49291916 471016 44777053 238835 4514863 232181 4747044 232181 4514863 633588126 575836657 7333800 11816885 691520 691520 8460840 8460840 331328438 327921055 3407383 2186435 2114719 71716 11526655 10778584 748071 4804296 4623739 180557 608943 608943 22207141 20903290 1303851 873869 868053 5816 6182148 6058777 123371 307007 306320 687 1936451 1934094 2357 724394 690968 33426 29864 13915 15949 22293135 22293135 20017102 20017102 3257311 3257311 MEDICAL SUPPLIES 172477672 172453163 24509 I/C PURCHASED SERVICES 3862005 384696 3477309 EQUIPMENT REPAIRS 2185275 2184663 612 BAD DEBT EXPENSE 2126406 2126406 187422 134070 53352 618274329 608216420 10057909 0 1630771 4897039 9344153 22700411 788595 43524834 41643220 19894645 17874334 14988705 13284778 1094467 3603271 582616566 319324544 283093829 263292022 208325603 228052409 160084297 112259319 96117989 90204732 370691 370691 1613017 1053624 840083001 800024445 294478175 272522256 160949 207102 323165819 229328890 25451 1947 95464388 113399896 713294782 615460091 X 125698183 183474318 1090036 1090036 126788219 184564354 840083001 800024445 X 15313797 10731196 31731142 X 0 1 X 1 1 1 X SCH A, PART I: PER IRS INSTRUCTIONS FOR THE FORM 990, THE DEFINITION OF HOSPITALS FOR SCHEDULE A (FORM 990 OR 990-EZ), PART I, IS DIFFERENT FROM THE DEFINITION FOR SCHEDULE H (FORM 990), HOSPITALS. ACCORDINGLY, AN ORGANIZATION THAT CHECKS THIS BOX MAY OR MAY NOT BE REQUIRED TO COMPLETE SCHEDULE H (FORM 990). MARSHFIELD CLINIC IS NOT RECOGNIZED BY ANY STATE AS A HOSPITAL. THEREFORE, MARSHFIELD CLINIC IS NOT REQUIRED TO COMPLETE SCHEDULE H. RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 3527576 X 0 22835049 22835049 509204920 283939070 225265850 2926395 2328812 597583 29454043 22089161 7364882 18196159 10967501 7228658 263292022 LTD PTNSHP COMM INV 112259319 F 112259319 INVESTMENT IN FHC 90204732 C 90204732 DEFERRED COMPENSATION 99893015 MALPRACTICE CLAIMS RESERVE 12532720 SEVERANCE & SABBATICAL LIABILITY 974161 113399896 X PART III, LINE 4: THE MISSION OF MARSHFIELD CLINIC IS TO SERVE PATIENTS THROUGH ACCESSIBLE, HIGH QUALITY HEALTH CARE, RESEARCH AND EDUCATION. AS PART OF SERVING PATIENTS, THE CLINIC STRIVES TO PROVIDE AN INVITING ATMOSPHERE TO TREAT PATIENTS AND ASSIST IN THE HEALING PROCESS. PLEASANT FACILITIES AND GROUNDS, PLUS APPROPRIATE WORKS OF ART ALL ASSIST IN THIS HEALING PROCESS, AS WELL AS SERVE TO ENHANCE THE CLINIC'S EDUCATIONAL MISSION BY DISPLAYING ART WORK FOR SCHOOL CHILDREN AS WELL AS PATIENTS AND VISITORS. PART X, LINE 2: THE ORGANIZATION APPLIES FINANCIAL ACCOUNTING STANDARDS BOARD (FASB) ACCOUNTING STANDARDS CODIFICATION (ASC) TOPIC 740, INCOME TAXES (ASC 740), WHICH CLARIFIES THE ACCOUNTING FOR UNCERTAINTY IN INCOME TAXES RECOGNIZED IN A COMPANY'S FINANCIAL STATEMENTS. ASC 740 PRESCRIBES A MORE-LIKELY-THAN-NOT RECOGNITION THRESHOLD AND MEASUREMENT ATTRIBUTE FOR THE FINANCIAL STATEMENT RECOGNITION AND MEASUREMENT OF A TAX POSITION TAKEN OR EXPECTED TO BE TAKEN. UNDER ASC 740, TAX POSITIONS WILL BE EVALUATED FOR RECOGNITION, DERECOGNITION, AND MEASUREMENT USING CONSISTENT CRITERIA AND WILL PROVIDE MORE INFORMATION ABOUT THE UNCERTAINTY IN INCOME TAX ASSETS AND LIABILITIES. THE SYSTEM HAS DETERMINED THAT IT DOESN'T HAVE ANY MATERIAL UNCERTAIN TAX POSITIONS AS OF DECEMBER 31, 2023 OR DECEMBER 31, 2022. 1 CENTRAL AMERICA AND THE CARIBBEAN 0 0 INVESTMENTS N/A 691253 0 0 0 0 0 0 691253 0 691253 1 0 0 0 1 0 1 FAMILY HEALTH CENTER OF MARSHFIELD INC 1000 N OAK AVE MARSHFIELD WI 54449 391681547 501(C)(3) 691520 0 N/A N/A GENERAL SUPPORT 1 0 PART I, LINE 2: MARSHFIELD CLINIC, INC. PROVIDES ASSISTANCE (PRIMARILY CONTRIBUTIONS) TO A VARIETY OF ORGANIZATIONS, ALL OF WHICH ARE 501(C)(3). MARSHFIELD CLINIC MAKES DETERMINATIONS ON GRANTS AND OTHER ASSISTANCE BASED ON THE RECIPIENT ORGANIZATION'S MISSION, REPUTATION, AND THE ORGANIZATION'S INTENDED USE OF FUNDS. X X 1 1 X X X X X 1 1 0 0 0 0 0 1 0 SUSAN TURNEY MD MCHS CEO - PART YEAR 0 1225308 0 450000 0 1449725 0 361730 0 20277 0 3507040 0 264534 VIVEKANANDA GONUGUNTA MD PHYSICIAN 2002922 0 273 0 36472 0 9900 0 2205 0 2051772 0 0 0 ADEDAYO ONITILO MD PHYSICIAN 1742147 0 0 0 35632 0 9900 0 30227 0 1817906 0 0 0 MOHAMMAD ALAOUA MD PHYSICIAN 1351463 0 5000 0 12166 0 9900 0 36777 0 1415306 0 0 0 ALICE LE HUU MD PHYSICIAN 1185376 0 149446 0 2406 0 9900 0 19618 0 1366746 0 0 0 WILLIAM MCCORMICK MD PHYSICIAN 1109113 0 60183 0 35086 0 9900 0 36271 0 1250553 0 0 0 WILLIAM MELMS MD CHIEF MEDICAL OFFICER - PART YEAR 0 206266 0 152673 0 694884 0 9900 0 11191 0 1074914 0 0 JERARD JENSEN MCHS GENERAL COUNSEL 0 811898 0 148695 0 23290 0 9900 0 35033 0 1028816 0 0 TYLER DAHL MD BOARD MEMBER 761771 0 111693 0 35086 0 9900 0 30830 0 949280 0 0 0 MATTHEW THOMAS MD TREASURER 812848 0 8320 0 42756 0 9900 0 32149 0 905973 0 0 0 ELVIS PETER MD VICE CHAIR 820410 0 0 0 35431 0 9900 0 36501 0 902242 0 0 0 BRIAN HOERNEMAN MD INTERIM MCHS CEO 0 741668 0 73943 0 33130 0 9900 0 30227 0 888868 0 0 DAVID JUNKER MD BOARD MEMBER 792770 0 5000 0 35632 0 9900 0 41288 0 884590 0 0 0 KATHY BRESSLER MCHS COO 0 729760 0 58468 0 51629 0 9900 0 18916 0 868673 0 0 CATHY BUKOWSKI MCHS CFO - PART YEAR 0 571918 0 9200 0 144722 0 9900 0 13493 0 749233 0 0 JAYANTH VEDRE MD BOARD MEMBER 454636 0 188964 0 35086 0 9900 0 18636 0 707222 0 0 0 EDWARD FERNANDEZ MD VICE CHAIR - PART YEAR 349775 0 148993 0 37438 0 9900 0 33330 0 579436 0 0 0 SUMITHRA TIRUNAGARAM MD BOARD MEMBER - PART YEAR 396376 0 117465 0 12721 0 9900 0 33358 0 569820 0 0 0 JOHN NEAL MD TREASURER - PART YEAR 483495 0 2615 0 32553 0 9900 0 39588 0 568151 0 0 0 SAMANTHA KLEBE DO CHIEF MEDICAL OFFICER 0 466567 0 21085 0 27363 0 9900 0 20093 0 545008 0 0 MATTHEW OELSTROM MD BOARD MEMBER 333083 0 97579 0 10513 0 9900 0 28114 0 479189 0 0 0 BARBARA BOYER MD BOARD MEMBER 397095 0 4500 0 13972 0 9900 0 35027 0 460494 0 0 0 KENT RAY DO SECRETARY 382286 0 0 0 13132 0 9900 0 38710 0 444028 0 0 0 PATRICK WOLF DO BOARD MEMBER 312010 0 19085 0 12882 0 9900 0 29791 0 383668 0 0 0 BART ISAACSON MD BOARD MEMBER 271450 0 5000 0 10966 0 8597 0 25361 0 321374 0 0 0 ALPA SHAH MD CHAIR 284161 0 0 0 10727 0 8525 0 1960 0 305373 0 0 0 PART I, LINE 1A THE ORGANIZATION MAY OCCASIONALLY REIMBURSE OR PROVIDE A HOUSING ALLOWANCE FOR KEY EXECUTIVES IN ORDER TO ASSIST WITH RELOCATING TO THE AREA. THE ORGANIZATION MAY ALSO CONTRIBUTE TO OR REIMBURSE FOR HEALTH AND SOCIAL CLUB DUES AS DEEMED NECESSARY IN ORDER TO SUPPORT A BUSINESS NEED. PART I, LINE 3 THE MARSHFIELD CLINIC HEALTH SYSTEM'S (MCHS) INDEPENDENT COMPENSATION COMMITTEE (THE COMMITTEE) HAS FINAL AUTHORITY FOR APPROVING COMPENSATION AND BENEFITS OF ALL DISQUALIFIED PERSONS EMPLOYED BY ANY OF THE ORGANIZATIONS IN THE SYSTEM. THE COMMITTEE USES COMBINATIONS OF THE FOLLOWING TO EVALUATE COMPENSATION: COMPENSATION COMMITTEE, INDEPENDENT COMPENSATION CONSULTANT, COMPENSATION SURVEY OR STUDY, APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE, AND WRITTEN EMPLOYMENT CONTRACTS. PART I, LINES 4A-B LINE 4A: IN 2023, SUSAN TURNEY, MD RECEIVED A SEVERANCE PAYMENT IN THE AMOUNT OF $614,466, WILLIAM MELMS, MD RECEIVED A SEVERANCE PAYMENT IN THE AMOUNT OF $610,615, AND CATHY BUKOWSKI RECEIVED A SEVERANCE PAYMENT IN THE AMOUNT OF $82,431. LINE 4B: THE FOLLOWING INDIVIDUALS PARTICIPATED IN A 457(F) SUPPLEMENTAL NON-QUALIFIED RETIREMENT PLAN AND RECEIVED A DISTRIBUTION FROM OR HAD AMOUNTS VEST IN THE PLAN: SUSAN TURNEY, MD - $275,424 THE FOLLOWING INDIVIDUALS PARTICATED IN A 457(F) SUPPLEMENTAL NON-QUALIFIED RETIREMENT PLAN BUT DID NOT RECEIVE A DISTRIBUTION OR HAVE AN AMOUNT VEST IN THE PLAN. UNDER THE PLAN, AMOUNTS DO NOT VEST UNTIL TWO YEARS AFTER SEPARATION FROM THE ORGANIZATION: WILLIAM MELMS, MD ALPA SHAH, MD EDWARD FERNANDEZ, MD MATTHEW THOMAS, MD JERARD JENSEN TYLER DAHL, MD ELVIS PETER, MD PATRICK WOLF, DO MATTHEW OELSTROM, MD JOHN NEAL, MD BART ISAACSON, MD JAYANTH VEDRE, MD KENT RAY, DO BRIAN HOERNEMAN, MD CATHY BUKOWSKI BARBARA BOYER, MD SUMITHRA TIRUNAGARAM, MD VIVEKANANDA GONUGUNTA, MD SAMANTHA KLEBE, DO ADEDAYO ONITILO, MD WILLIAM MCCORMICK, MD MOHAMMAD ALAOUA, MD DAVID JUNKER, MD PART I, LINE 7 SEVERAL INDIVIDUALS MAY RECEIVE INCENTIVE COMPENSATION BASED ON A VARIETY OF FACTORS, INCLUDING NOT ONLY FINANCIAL MEASURES SUCH AS REVENUE GROWTH OR EARNINGS, BUT ALSO QUALITY, SERVICE, MARKET EXPANSION, COMMUNITY & EMPLOYEE ENGAGEMENT, AND OTHER OUTCOMES OR EXPECTATIONS SET BY THE BOARD AND/OR CEO. ANY PERFORMANCE BONUS IS SUBJECT TO REVIEW BY THE SYSTEM'S INDEPENDENT COMPENSATION COMMITTEE FOR REASONABLENESS. SHANA VIFIAN RAY MD FAMILY RELATIONSHIP WITH BOARD MEMBER KENT RAY, DO 541044 COMPENSATION 0 MILIND SHAH MD FAMILY RELATIONSHIP WITH BOARD MEMBER ALPA SHAH, MD 968265 COMPENSATION 0 TANYA HOERNEMAN MD FAMILY RELATIONSHIP WITH INTERIM MCHS CEO BRIAN HOERNEMAN, MD 110144 COMPENSATION 0 PART IV, LINE 4: MARSHFIELD CLINIC HEALTH SYSTEM (INCLUDING MARSHFIELD CLINIC) IS A MEMBER OF VARIOUS HEALTHCARE ASSOCIATIONS (I.E. WISCONSIN HOSPITAL ASSOCIATION) THAT MAY PERFORM SOME LOBBYING ACTIVITY. ALL ASSOCIATED DUES ARE DISCLOSED ON THE FORM 990 OF MARSHFIELD CLINIC HEALTH SYSTEM, INC. FORM 990, PART V, LINE 1C: COMPENSATION REPORTED FOR THE INDEPENDENT CONTRACTORS HAS BEEN PAID BY A RELATED ORGANIZATION AND CENTRAL PURCHASING ORGANIZATION, MARSHFIELD CLINIC HEALTH SYSTEM, EIN 46-1495343. COMPENSATION REPORTED REPRESENTS SERVICES SOLELY PROVIDED TO MARSHFIELD CLINIC, INC SO IS INCLUDED AS IF PAID BY THE ORGANIZATION. MARSHFIELD CLINIC HEALTH SYSTEM HAS COMPLIED WITH A/P FILING REQUIREMENTS. PART V, LINE 2A: ALL PERSONNEL SERVICES FOR MARSHFIELD CLINIC, INC. ARE PERFORMED BY EMPLOYEES OF MARSHFIELD CLINIC HEALTH SYSTEM, INC. ALL PHYSICIAN SERVICES FOR MARSHFIELD CLINIC, INC. ARE PERFORMED BY EMPLOYEES OF MARSHFIELD CLINIC, INC. FORM 990, PART VI, SECTION A, LINE 6 THE CORPORATION HAS TWO CLASSES OF MEMBERS: (I) CLASS A MEMBERS, WHO SHALL BE INDIVIDUALS MEETING THE REQUIREMENTS SET FORTH IN THE CORPORATION'S BYLAWS, AND (II) A SINGLE CLASS B MEMBER, MARSHFIELD CLINIC HEALTH SYSTEM, INC., WHICH SHALL BE THE SOLE CORPORATE MEMBER. CLASS A MEMBERS HAVE THE RIGHT TO ELECT THE MEMBERS OF THE GOVERNING BODY AND APPROVE CERTAIN SIGNIFICANT DECISIONS OF THE GOVERNING BODY. THE CLASS B MEMBER HAS THE RIGHT TO APPROVE CERTAIN SIGNIFICANT DECISIONS OF THE GOVERNING BODY AND TO RECEIVE THE REMAINING ASSETS OF THE CORPORATION (OR DIRECT DISTRIBUTION OF THE ASSETS TO OTHER 501(C)(3) ORGANIZATIONS) UPON DISSOLUTION. FORM 990, PART VI, SECTION A, LINE 7A CLASS A MEMBERS HAVE THE RIGHT TO ELECT THE ORGANIZATION'S OFFICERS AND DIRECTORS. FORM 990, PART VI, SECTION A, LINE 7B ALL MEMBERS HAVE THE RIGHT TO APPROVE ANY CHANGES TO THE ORGANIZATION'S ARTICLES OF INCORPORATION AND BYLAWS AND TO APPROVE ANY DISSOLUTION OR LIQUIDATION OF THE ORGANIZATION. FORM 990, PART VI, SECTION B, LINE 11B MARSHFIELD CLINIC HEALTH SYSTEM, INC. ENGAGES A PUBLIC ACCOUNTING FIRM TO PREPARE AND REVIEW THE FORM 990 IN ADDITION TO REVIEW BY THE SYSTEM CFO, VP OF FINANCE AND TAX DEPARTMENT. PRIOR TO FILING THE FORM WITH THE IRS, THE CFO AND HIS/HER DESIGNEE WILL PROVIDE TO EACH MEMBER OF THE SYSTEM'S AUDIT AND COMPLIANCE COMMITTEE (A SUBCOMMITTEE OF THE BOARD OF DIRECTORS) A COPY IN ELECTRONIC OR PAPER FORM OF THE COMPLETED FORM 990 (AND ALL REQUIRED SCHEDULES) FOR REVIEW. FORM 990, PART VI, SECTION B, LINE 12C ALL OFFICERS, BOARD DIRECTORS, AND KEY EMPLOYEES OF EVERY MARSHFIELD CLINIC HEALTH SYSTEM (MCHS) ENTITY, AS WELL AS ANY OTHER PERSON DESIGNATED BY THE AUDIT AND COMPLIANCE COMMITTEE (ACC) TO BE A REQUIRED REPORTER BY VIRTUE OF HIS OR HER POSITION AT A SYSTEM ENTITY, SHALL ANNUALLY COMPLETE A CONFLICT OF INTEREST DISCLOSURE FORM. SUCH FORMS SHALL BE DISTRIBUTED AND RECORDED BY THE SYSTEM'S DESIGNATED COMPLIANCE OFFICER. ALL FINANCIAL INTERESTS DISCLOSED AS PART OF THE ANNUAL DISCLOSURE PROCESS SHALL BE REVIEWED BY THE ACC. THE ACC SHALL INFORM THE BOARD OF DISCLOSED FINANCIAL INTERESTS WHICH MAY BEAR UPON OR RELATE TO A TRANSACTION UPON WHICH THE BOARD OR ANOTHER BOARD, COMMITTEE OR OTHER BODY OF A SYSTEM ENTITY, MAY DELIBERATE OR ACT. IN ADDITION TO THE ANNUAL DISCLOSURES, IF AT ANY TIME BETWEEN ANNUAL DISCLOSURES, A REQUIRED REPORTER BECOMES AWARE THAT THE BOARD, OR A BOARD, COMMITTEE OR OTHER BODY, OF ANY SYSTEM ENTITY MAY DELIBERATE OR ACT UPON ANY TRANSACTION THAT MAY HAVE ANY BEARING OF ANY KIND UPON, OR MAY RELATE IN ANY MANNER TO, AN EXISTING, INTENDED OR EXPECTED FINANCIAL INTEREST OF THE REQUIRED REPORTER, HE OR SHE SHALL DISCLOSE THE FINANCIAL INTEREST TO THE RELEVANT SYSTEM ENTITY BOARD, COMMITTEE OR BODY CHAIR, AS WELL AS TO THE SYSTEM'S COMPLIANCE OFFICER, IN ADVANCE OF ANY DELIBERATIONS OR ACTION, WRITTEN DISCLOSURE OF THE EXISTENCE, NATURE AND EXTENT OF HIS OR HER FINANCIAL INTEREST. ALL WRITTEN OR ORAL DISCLOSURES OF FINANCIAL INTERESTS SHALL BE RECORDED IN THE MINUTES OF THE BOARD AND BY THE OFFICE OF THE COMPLIANCE OFFICER. THE COMPLIANCE OFFICER SHALL DISCLOSE THE COMPLETED FORMS AS NECESSARY TO THOSE MCHS EMPLOYEES RESPONSIBLE FOR COMPLETION OF THE IRS FORM 990. FORM 990, PART VI, SECTION B, LINE 15 THE SYSTEM'S INDEPENDENT COMPENSATION COMMITTEE (COMPENSATION COMMITTEE) SHALL HAVE FINAL AUTHORITY FOR APPROVING COMPENSATION AND BENEFITS OF ALL DISQUALIFIED PERSONS (AS THAT TERM IS DEFINED IN 4958 OF THE INTERNAL REVENUE CODE (THE CODE)) EMPLOYED BY THE CORPORATION, INCLUDING BUT NOT LIMITED TO THE CORPORATION'S CEO. THE TERM DISQUALIFIED PERSONS INCLUDES (BUT IS NOT LIMITED TO) ANY PERSON (OR THE PERSON'S FAMILY MEMBER) WHO WAS, AT ANY TIME DURING THE 5-YEAR PERIOD ENDING ON THE DATE OF THE TRANSACTION, IN A POSITION TO EXERCISE SUBSTANTIAL INFLUENCE OVER THE AFFAIRS OF THE ORGANIZATION. IT SHALL BE THE RESPONSIBILITY OF THE COMPENSATION COMMITTEE TO INSURE THAT THE SYSTEM DOES NOT PAY AN AMOUNT THAT EXCEEDS REASONABLE COMPENSATION FOR ANY DISQUALIFIED PERSON. THE COMPENSATION COMMITTEE AND ITS OPERATING PROCEDURES SHALL BE DESIGNED TO ESTABLISH THE REBUTTABLE PRESUMPTION OF REASONABLENESS OF COMPENSATION OUTLINED IN TREASURY REG. SEC. 53.4958-6 WITH RESPECT TO EACH DISQUALIFIED PERSON. IN DETERMINING REASONABLENESS OF COMPENSATION, THE COMPENSATION COMMITTEE SHALL EVALUATE APPROPRIATE INFORMATION AS TO COMPARABILITY OF COMPENSATION, INCLUDING BUT NOT LIMITED TO: COMPENSATION LEVELS PAID BY SIMILARLY SITUATED ORGANIZATIONS FOR COMPARABLE POSITIONS; THE AVAILABILITY OF SIMILAR SERVICES IN THE SYSTEM'S GEOGRAPHIC AREA; CURRENT COMPENSATION SURVEYS COMPILED BY INDEPENDENT FIRMS; AND ACTUAL WRITTEN JOB OFFERS FROM SIMILAR INSTITUTIONS. THE COMPENSATION COMMITTEE SHALL HAVE INDEPENDENT AUTHORITY TO OBTAIN OUTSIDE EXPERT OPINIONS ON THE REASONABLENESS AND FAIR MARKET VALUE OF COMPENSATION AND GATHER OTHER INFORMATION IT CONSIDERS NECESSARY OR APPROPRIATE TO MAKE ITS DECISIONS ON COMPENSATION. THE COMPENSATION COMMITTEE SHALL TIMELY DOCUMENT ITS DETERMINATION OF REASONABLENESS OF COMPENSATION. FORM 990, PART VI, SECTION C, LINE 19 MARSHFIELD CLINIC, INC. DOES NOT MAKE ITS CURRENT GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY OR FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UNLESS INCLUDED AS PART OF A FORM THAT IS REQUIRED TO BE PUBLICLY AVAILABLE. FORM 990, PART XI, LINE 9: EQUITY INCOME FROM DTC 5,330. EQUITY INCOME ADJUSTMENT - FHC -5,468,170. NET ASSET TRANSFERS WITH RELATED ORGANIZATIONS 37,193,982. SECURITY HEALTH PLAN OF WISCONSIN INC 1515 N ST JOSEPH AVE MARSHFIELD WI 54449 391572880 HMO WI 501(C)(4) N/A MCHS 0 FLAMBEAU HOSPITAL INC 98 SHERRY AVE PARK FALLS WI 54552 390973724 HOSPITAL WI 501(C)(3) LINE 3 MCHS HOSP 0 LAKEVIEW MEDICAL CENTER INC 1700 W STOUT ST RICE LAKE WI 54868 390837206 HOSPITAL WI 501(C)(3) LINE 3 MCHS HOSP 0 MARSHFIELD CLINIC HEALTH SYSTEM INC 1000 N OAK AVE MARSHFIELD WI 54449 461495343 SUPPORT ORG WI 501(C)(3) LINE 12D, III-O N/A 0 VOLUNTEER PARTNERS OF LAKEVIEW MEDICAL 1700 W STOUT ST RICE LAKE WI 54868 391329084 SUPPORT ORG WI 501(C)(3) LINE 12D, III-O N/A 0 FAMILY HEALTH CENTER OF MARSHFIELD INC 1000 N OAK AVE MARSHFIELD WI 54449 391681547 COM HLTH CTR WI 501(C)(3) LINE 7 N/A 0 MCHS HOSPITALS INC 1000 N OAK AVE MARSHFIELD WI 54449 810977948 HOSPITAL WI 501(C)(3) LINE 3 MCHS 0 MCHS FOUNDATION INC 1000 N OAK AVE MARSHFIELD WI 54449 812822823 PHILANTHROPY WI 501(C)(3) LINE 7 MCHS 0 BEAVER DAM COMMUNITY HOSPITALS INC 707 S UNIVERSITY AVE BEAVER DAM WI 53916 391157876 HOSPITAL WI 501(C)(3) LINE 3 MCHS HOSP 0 MEMORIAL HOSPITAL INC N3708 RIVER AVE NEILLSVILLE WI 54456 390806828 HOSPITAL WI 501(C)(3) LINE 3 MCHS HOSP 0 DICKINSON COUNTY HEALTHCARE SYSTEM 1721 S STEPHENSON AVE IRON MOUNTAIN MI 49801 382780429 HOSPITAL MI 501(C)(3) LINE 3 MCHS HOSP 0 THE DIAGNOSTIC & TREATMENT CENTER LLC 3401 CRANBERRY BLVD WESTON WI 54476 200691634 MEDICAL SVCS WI N/A RELATED 5330 0 1 0.50000 0 1 1 1 0 0 0 0 0 1 1 1 0 0 0 1 1 1 1 SECURITY HEALTH PLAN L 18061467 COST SCH R, PART I: MARSHFIELD CLINIC HEALTH SYSTEM, INC. (A 501(C)3 ORGANIZATION) IS THE PARENT ORGANIZATION OF MARSHFIELD CLINIC, INC. THE FOLLOWING COMPANIES ARE RELATED TO MARSHFIELD CLINIC, INC. THROUGH BROTHER/SISTER RELATIONSHIPS DUE TO A COMMON PARENT ORGANIZATION: SECURITY HEALTH PLAN OF WISCONSIN, INC. MCHS HOSPITALS, INC. MARSHFIELD CLINIC HEALTH SYSTEM FOUNDATION, INC.