2025-08-15T09:28:55-05:00 2024-09-30 390758449 WIPFLI LLP 170 N RADNOR-CHESTER RD SUITE 200 RADNOR PA 19087 990 2023-10-01 390286215 FORT HEALTHCARE INC FORT 8004214677 611 SHERMAN AVENUE EAST FORT ATKINSON WI 53538 JAMES NELSON SR. VICE PRESIDENT/CFO 8004214677 2025-08-14 1 1 SOLOMON MARDAKHAEV P01806552 6105653930 2025-08-12 2023 2025-03-06 01:10:19Z JAMES NELSON 611 SHERMAN AVENUE EAST FORT ATKINSON WI 53538 225752421 0 X WWW.FORTHEALTHCARE.COM X 1942 WI OUR MISSION AT FORT HEALTHCARE IS TO IMPROVE THE HEALTH AND WELL-BEING OF OUR COMMUNITY. 12 6 1077 117 0 0 510512 104820 145791504 153986041 4140454 5295128 186522 1323040 150628992 160709029 323650 290400 0 0 79353477 78763986 0 0 26421 65224177 71231652 144901304 150286038 5727688 10422991 247529031 321991405 57230641 103776313 190298390 218215092 X OUR MISSION AT FORT HEALTHCARE IS TO IMPROVE THE HEALTH AND WELL-BEING OF OUR COMMUNITY. 0 0 86009498 70400 113927361 OPERATION OF A 49-BED ACUTE CARE FACILITY WITH AN EMERGENCY ROOM AND FULL COMPLEMENT OF ANCILLARY SERVICES.FORT HEALTHCARE COMMUNITY IMPACT:CHARITY CARE - $613,202: CHARITY CARE IS DEFINED AS FREE OR DISCOUNTED HEALTH SERVICES PROVIDED TO THOSE WHO CANNOT AFFORD TO PAY AND WHO MEET ALL CRITERIA FOR FINANCIAL ASSISTANCE. CHARITY CARE IS BASED ON ACTUAL COSTS, NOT CHARGES, AND DOES NOT INCLUDE BAD DEBT.COMMUNITY HEALTH IMPROVEMENT SERVICES - $320,224: COMMUNITY HEALTH IMPROVEMENT SERVICES ARE DEFINED AS CLINICAL AND NON-CLINICAL SERVICES DESIGNED TO IMPROVE COMMUNITY HEALTH, WHICH ARE PROVIDED TO THE COMMUNITY FOR FREE OR FOR FEES THAT DID NOT COVER COSTS.FINANCIAL CONTRIBUTIONS - $125,046: FINANCIAL CONTRIBUTIONS ARE DEFINED AS CONTRIBUTIONS, INCLUDING CASH, NON-CASH ITEMS SUCH AS FOOD, FURNITURE, EQUIPMENT, SUPPLIES, AND LOANED STAFF FOR VOLUNTEER AND CHARITABLE PURPOSES, MADE TO INDIVIDUALS, COMMUNITY GROUPS, OR NONPROFIT ORGANIZATIONS FOR CHARITABLE PURPOSES.COMMUNITY BUILDING ACTIVITIES - $42,637: COMMUNITY BUILDING ACTIVITIES ARE DEFINED AS PROGRAMS THAT, WHILE NOT DIRECTLY RELATED TO HEALTH CARE, PROVIDE OPPORTUNITIES TO ADDRESS THE ROOT CAUSES OF HEALTH PROBLEMS, SUCH AS POVERTY, HOMELESSNESS, AND ENVIRONMENTAL ISSUES. COSTS FOR THESE ACTIVITIES INCLUDE CASH AND IN-KIND DONATIONS.COMMUNITY BENEFIT OPERATIONS - $0: COMMUNITY BENEFIT OPERATIONS ARE DEFINED AS COSTS ASSOCIATED WITH DEDICATED STAFF AND COMMUNITY HEALTH NEEDS AND/OR ASSESSMENT, AS WELL AS OTHER COSTS ASSOCIATED WITH COMMUNITY BENEFIT STRATEGY AND OPERATIONS.SUBSIDIZED HEALTH SERVICES - $73,601: SUBSIDIZED HEALTH SERVICES ARE DEFINED AS THE NEGATIVE MARGIN FOR CLINICAL SERVICES THAT ARE PROVIDED DESPITE A FINANCIAL LOSS BECAUSE OF AN IDENTIFIED COMMUNITY NEED THAT WOULD NEED TO BE MET BY THE GOVERNMENT OR ANOTHER NOT-FOR-PROFIT IF IT WAS NOT OFFERED. THE FINANCIAL LOSSES ARE SO SIGNIFICANT THAT NEGATIVE MARGINS REMAIN AFTER REMOVING THE EFFECTS OF CHARITY CARE, BAD DEBT, AND MEDICAID SHORTFALLS.TOTAL BENEFIT TO THE COMMUNITY FOR FISCAL YEAR 2024 WAS $1,174,710. 42108909 220000 39632279 OPERATION OF PHYSICIAN CLINICS WITH OUTREACH INTO THE SURROUNDING COMMUNITIES. 0 0 132994 EQUITY INCOME IN UNCONSOLIDATED AFFILIATES - HEALTH CLINIC. 128118407 1 1 0 1 0 0 0 0 0 0 1 1 0 0 1 0 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 1 0 1 0 0 0 0 0 0 0 1 0 0 0 0 1 1 1 1 0 0 1 176 0 1077 1 0 0 0 0 0 0 0 0 0 0 0 0 X 12 6 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 1 1 WI X JAMES NELSON 9205685000 611 SHERMAN AVENUE EAST FORT ATKINSON WI 53538 PAUL SCHUPPNER DO BOARD MEMBER 40.00 X 850705 0 38395 MICHAEL ANDERSON MD PRESIDENT/CEO 40.00 1.00 X X 815683 0 46915 BILLIE KONTNY MD BOARD MEMBER 40.00 X 650274 0 46914 STEPHANIE NOTTESTAD MD BOARD MEMBER 40.00 X 420704 0 45656 NATHANIEL FULLERTON MD CHIEF OF STAFF (THRU OCT 2023) 40.00 X 409602 0 49635 MARY BECK METZGER BOARD MEMBER 24.00 1.00 X 67470 0 16023 ROBERTA WEDL MD CHIEF OF STAFF 3.00 X 24750 0 0 JAMES FITZPATRICK PHD CHAIR 3.00 1.00 X X 0 0 0 ROY BUDLONG VICE CHAIR & TREASURER 3.00 1.00 X X 0 0 0 THOMAS VINZ SECRETARY (THRU JAN 2024) 3.00 1.00 X X 0 0 0 LESLEY CHAPIN PSYD BOARD MEMBER 3.00 X 0 0 0 CARLA HAUBENSCHILD BOARD MEMBER 3.00 X 0 0 0 CHRISTOPHER MARTIN BOARD MEMBER 3.00 X 0 0 0 CHRISTI OTT BOARD MEMBER 3.00 1.00 X 0 0 0 RICHARD TELFER PHD BOARD MEMBER (THRU JAN 2024) 3.00 X 0 0 0 JAMES NELSON SR. VICE PRESIDENT/CFO 40.00 1.00 X 355156 0 49391 MATTHEW BLISS MD PHYSICIAN 40.00 X 1559256 0 44838 ISIDORO ZAMBRANO MD PHYSICIAN 40.00 X 925720 0 46959 MICHAEL WALLACE SENIOR ADVISOR (RETIRED PRES./CEO) 40.00 1.00 X 655083 0 47401 JONATHAN MCLAUGHLIN MD PHYSICIAN 40.00 X 611790 0 44806 MARC ERICKSON MD PHYSICIAN 40.00 X 532398 0 47606 7878591 0 524539 84 0 1 0 JP CULLEN AND SONS INC 330 E DELAVAN DR JANESVILLE WI 53546 CONSTRUCTION SERVICES 5657780 ORACLE CERNER CORPORATION 8779 HILLCREST RD KANSAS CITY MO 64138 PROFESSIONAL SERVICES 4388626 UW MEDICAL FOUNDATION-RADIOLOGY 600 HIGHLAND AVE MADISON WI 53792 RADIOLOGY SERVICES 2023256 UMR INC 11 SCOTT STREET SUITE 100 WAUSAU WI 54403 TPA SERVICES 1202910 FUSION MEDICAL STAFFING LLC PO BOX 30131 OMAHA NE 68103 STAFFING SERVICES 1175947 38 17645 72056 15119 104820 HOSPITAL SERVICES 623000 103192290 103192290 PHYSICIAN CLINIC REVENUE 621110 36343393 36343393 OTHER OPERATING REVENUE 623990 14138067 13711141 426926 RENTAL INCOME - SPECIALTY CLINIC 621610 312291 312291 153986041 3557300 3557300 684092 240682 443410 443410 443410 66079491 461047 61567844 3234866 4511647 -2773819 1737828 1737828 EQUITY INCOME 623000 879105 132994 746111 525 525 879630 160709029 153692634 0 6911575 X 290400 290400 3784425 946106 2838319 58332459 57169112 1163347 1921674 1583342 338332 11313145 11058042 255103 3412283 3214390 197893 2190525 2190525 127474 127474 19768086 17978549 1789537 501032 65798 435234 15245980 14827847 415054 3079 6601527 6601527 4841850 3851480 988913 1457 40273 38370 1903 801853 801853 5979123 2698056 3276230 4837 641760 22108 619652 PROVISION FOR BAD DEBTS 5064352 5064352 HOSPITAL ASSESSMENT 1960441 1960441 EAR PROJECT 1532604 1532604 EQUIPMENT 632061 560024 72037 5302711 5027302 258361 17048 150286038 128118407 22141210 26421 10194736 11619347 560344 866552 20266105 22536273 3233419 3264947 2723243 3069311 156978365 93411910 49465199 63566455 107188304 158712108 39645206 43570183 185236 14252475 14600993 247529031 321991405 16615225 21520847 18474239 58992579 10232597 9492597 134194 94637 11774386 13675653 57230641 103776313 X 190298390 218215092 190298390 218215092 247529031 321991405 X 10422991 17626707 -132996 X X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 14326 14326 0 PART II-B, LINE 1: LOBBYING PORTION OF DUES PAID TO WHA AND AHA. 836155 836155 74022174 38862535 35159639 64054920 54549375 9505545 18065116 18065116 63566455 ALTERNATIVE INVESTMENTS 43570183 F 43570183 DEFERRED COMPENSATION 1981327 FINANCE LEASE OBLIGATIONS 7644054 OPERATING LEASE OBLIGATIONS 4050272 13675653 1 1 X 1 X 1 X 1 1 0 1 1 613202 613202 0.00410 18767066 3908400 14858666 0.09890 19380268 3908400 15471868 0.10300 1582360 1145898 436462 0.00290 125046 125046 0.00080 1707406 1145898 561508 0.00370 21087674 5054298 16033376 0.10670 0 5115331 358073 17304292 18863276 -1558984 X 1 1 1 MEDICAL HEALTH BUILDING GROUP RENTAL OF MEDICAL BUILDINGS 0.20000 0.25000 1 1 FORT HEALTHCARE INC 611 SHERMAN AVENUE EAST FORT ATKINSON WI 53538 HTTPS://WWW.FORTHEALTHCARE.COM/ 1908-800 X X X FORT HEALTHCARE INC 1 0 0 1 X X X X X X X X X 22 1 1 1 1 X WWW.FORTHEALTHCARE.COM/COMMUNITY-HEALTH-NEEDS-ASSESSMENT/ X 1 22 1 WWW.FORTHEALTHCARE.COM/COMMUNITY-HEALTH-NEEDS-ASSESSMENT/ 0 1 X 200.000000000000 400.000000000000 X X 1 1 X X X 1 X WWW.FORTHEALTHCARE.COM/PATIENT-INFO/FINANCIAL-AID/ X WWW.FORTHEALTHCARE.COM/PATIENT-INFO/FINANCIAL-AID/ X WWW.FORTHEALTHCARE.COM/PATIENT-INFO/FINANCIAL-AID/ X X X X X X X 1 X 0 X X X X X 1 X 0 0 FORT HEALTHCARE, INC. PART V, SECTION B, LINE 5: FOCUS GROUPS WITH THE PUBLIC AND COMMUNITY PARTNERS WERE CONDUCTED, AS WELL AS SURVEYS (DETAILS OF PARTNERS IN THE REPORT ON OUR WEBSITE). BASED ON THE FEEDBACK THE TOP RATED ITEMS WERE DISCUSSED AND WILL BE THE FOCUS OF COMMUNITY HEALTH IMPROVEMENT PLAN AND PROCESS. FORT HEALTHCARE, INC. PART V, SECTION B, LINE 6A: MARSHFIELD MEDICAL CENTER-BEAVER DAM, AND WATERTOWN REGIONAL MEDICAL CENTER. FORT HEALTHCARE, INC. PART V, SECTION B, LINE 6B: THIS CHNA WAS CONDUCTED BY THE DODGE-JEFFERSON HEALTHIER COMMUNITY PARTNERSHIP WHICH IS COMPRISED OF: DODGE COUNTY HUMAN SERVICES AND HEALTH DEPARTMENT, FORT HEALTHCARE, GREATER WATERTOWN COMMUNITY HEALTH FOUNDATION, JEFFERSON COUNTY HEALTH DEPARTMENT, MARSHFIELD MEDICAL CENTER-BEAVER DAM, ROCK RIVER COMMUNITY CLINIC, WATERTOWN DEPARTMENT OF PUBLIC HEALTH, AND WATERTOWN REGIONAL MEDICAL CENTER, REFERRED TO AS "THE PARTNERSHIP." FORT HEALTHCARE, INC. PART V, SECTION B, LINE 11: FORT HEALTHCARE CONTINUES TO SUPPORT THE WORK OF THE ROCK RIVER COMMUNITY CLINIC WHICH OFFERS FREE SERVICES TO THOSE WHO LIVE IN OUR SERVICE AREA. ADDITIONALLY, WE CONTINUE TO ADDRESS OBESITY AND LACK OF PHYSICAL ACTIVITY THROUGH TARGETED COMMUNITY PROGRAMS OFFERED IN ALL OF THE COMMUNITIES WE SERVE. FORT HEALTHCARE, INC. PART V, SECTION B, LINE 13H: SERVICES ARE NOT ELECTIVE. FORT HEALTHCARE, INC. PART V, SECTION B, LINE 16J: THE FINANCIAL ASSISTANCE POLICY IS PUBLICIZED IN ALL FORT HEALTHCARE LOCATIONS AND DISCUSSED WITH PATIENTS AT TIME OF ADMIT AND ON FOLLOW UP CALLS. FORT HEALTHCARE, INC. PART V, SECTION B, LINE 20E: GENERATE AT LEAST 4 MONTHLY STATEMENTS TO GUARANTOR ON FILE. 13 1 - ORTHOPAEDIC ASSOCIATES 1504 MADISON AVENUE FORT ATKINSON WI 53538 ORTHOPAEDIC 2 - SURGICAL ASSOCIATES 212 MILWAUKEE AVENUE WEST FORT ATKINSON WI 53538 SURGICAL - GENERAL 3 - CENTER FOR WOMEN'S HEALTH 650 MCMILLEN STREET FORT ATKINSON WI 53538 OBSTETRICS AND GYNECOLOGY 4 - INTERNAL MEDICINE & PEDIATRICS 500 MCMILLEN STREET FORT ATKINSON WI 53538 INTERNAL MEDICINE & PEDIATRICS, BEHAVIORAL HEALTH 5 - INTEGRATED FAMILY CARE 1520 MADISON AVENUE FORT ATKINSON WI 53538 FAMILY PRACTICE, BEHAVIORAL HEALTH 6 - EAR NOSE & THROAT SPECIALISTS 512 WILCOX STREET FORT ATKINSON WI 53538 ENT 7 - PAIN MANAGEMENT CLINIC 1604 MADISON AVE FORT ATKINSON WI 53538 PAIN MANAGEMENT 8 - JOHNSON CREEK 400 DOCTORS COURT JOHNSON CREEK WI 53038 FAMILY PRACTICE, WOUND & EDEMA 9 - DERMATOLOGY 611 SHERMAN AVENUE EAST 3RD FLOOR FORT ATKINSON WI 53538 DERMATOLOGY 10 - LAKE MILLS CLINIC 200 EAST TYRANENA PARK ROAD LAKE MILLS WI 53551 FAMILY PRACTICE, BEHAVIORAL HEALTH, ORTHOPAEDIC 11 - WHITEWATER 1461 WEST MAIN STREET WHITEWATER WI 53190 OBSTETRICS & GYNECOLOGY, INTERNAL MEDICINE & PEDIATRICS 12 - CAMBRIDGE CLINIC 704 KATIE COURT CAMBRIDGE WI 53523 FAMILY PRACTICE, BEHAVIORAL HEALTH, ORTHOPAEDIC 13 - JEFFERSON 840 WEST RACINE STREET JEFFERSON WI 53549 FAMILY PRACTICE PART I, LINE 7: OVERALL COST TO CHARGE RATIO PART II, COMMUNITY BUILDING ACTIVITIES: THE FORT HEALTHCARE BOARD OF DIRECTORS IS A COMMUNITY ORIENTED BOARD, WITH REPRESENTATIVES SOLICITED DIRECTLY FROM THE MAJORITY OF COMMUNITIES IN THE PRIMARY SERVICE AREA. THE MAJORITY OF REPRESENTATIVES ARE NOT EMPLOYEES, CONTRACTORS OR RELATIVES OF FORT HEALTHCARE STAFF. THE MEMBERS ARE NOT COMPENSATED FOR THEIR SERVICE. THE FORT MEMORIAL HOSPITAL OPERATES WITH AN 'OPEN' MEDICAL STAFF. PHYSICIANS UNAFFILIATED WITH THE ORGANIZATION MAY REQUEST PRIVILEGES AT ANY TIME. THE PLANNING COMMITTEE DETERMINES NEED FOR SPECIALTY CARE ACCORDING TO A WELL ESTABLISHED MEDICAL MANPOWER PLAN THAT INCLUDES COMMUNITY NEED FOR SERVICES. PHYSICIANS ARE GRANTED MEDICAL STAFF STATUS BASED ON NEED. THE MEDICAL STAFF IS REPRESENTED BY MEMBERS OF FORT HEALTHCARE, SSM REGIONAL CLINICS, UW HEALTH AND OTHERS. FORT HEALTHCARE IS A NON-PROFIT ORGANIZATION AND NET REVENUES ARE USED FOR IMPROVEMENTS IN THE STATUS OF FORT HEALTHCARE. FUNDS ARE USED TO PURCHASE CAPITAL EQUIPMENT, ENHANCE PHYSICAL FACILITIES AND IMPROVE PATIENT SERVICES. PART III, LINE 2: THE CARRYING AMOUNTS OF ACCOUNTS RECEIVABLE ARE REDUCED BY ALLOWANCES THAT REFLECT MANAGEMENT'S BEST ESTIMATE OF THE AMOUNTS THAT WILL NOT BE COLLECTED. MANAGEMENT PROVIDES FOR CONTRACTUAL ADJUSTMENTS UNDER TERMS OF THIRD-PARTY REIMBURSEMENT AGREEMENTS THROUGH A REDUCTION OF GROSS REVENUE AND A CREDIT TO PATIENT RECEIVABLES. IN ADDITION, MANAGEMENT PROVIDES FOR PROBABLE UNCOLLECTIBLE AMOUNTS, PRIMARILY UNINSURED PATIENTS AND AMOUNTS PATIENTS ARE PERSONALLY RESPONSIBLE FOR, THROUGH A CHARGE TO OPERATIONS AND A CREDIT TO A VALUATION ALLOWANCE BASED ON ITS ASSESSMENT OF HISTORICAL COLLECTION LIKELIHOOD AND THE CURRENT STATUS OF INDIVIDUAL ACCOUNTS. BALANCES THAT ARE STILL OUTSTANDING AFTER MANAGEMENT HAS USED REASONABLE COLLECTION EFFORTS ARE WRITTEN OFF THROUGH A CHARGE TO THE VALUATION ALLOWANCE AND A CREDIT TO PATIENT ACCOUNTS RECEIVABLE. FORT HEALTHCARE IN SOUTHEAST WISCONSIN / 2023 CHARITY CARE $1,925,803. CHARITY CARE IS DEFINED AS FREE OR DISCOUNTED HEALTH SERVICES PROVIDED TO THOSE WHO CANNOT AFFORD TO PAY AND WHO MEET ALL CRITERIA FOR FINANCIAL ASSISTANCE. CHARITY CARE IS BASED ON ACTUAL COSTS, NOT CHARGES, AND DOES NOT INCLUDE BAD DEBT. PART III, LINE 3: RATIONALE FOR INCLUDING BAD DEBT AMOUNTS IN COMMUNITY BENEFIT - WE ARE THE ONLY HOSPITAL IN OUR SERVICE AREA AND PATIENTS WOULD HAVE TO TRAVEL TO ANOTHER COMMUNITY TO RECEIVE CARE. PART III, LINE 4: THE CARRYING AMOUNTS OF ACCOUNTS RECEIVABLE ARE REDUCED BY ALLOWANCES THAT REFLECT MANAGEMENT'S BEST ESTIMATE OF THE AMOUNTS THAT WILL NOT BE COLLECTED. MANAGEMENT PROVIDES FOR CONTRACTUAL ADJUSTMENTS UNDER TERMS OF THIRD-PARTY REIMBURSEMENT AGREEMENTS THROUGH A REDUCTION OF GROSS REVENUE AND A CREDIT TO PATIENT RECEIVABLES. IN ADDITION, MANAGEMENT PROVIDES FOR PROBABLE UNCOLLECTIBLE AMOUNTS, PRIMARILY UNINSURED PATIENTS AND AMOUNTS PATIENTS ARE PERSONALLY RESPONSIBLE FOR, THROUGH A CHARGE TO OPERATIONS AND A CREDIT TO A VALUATION ALLOWANCE BASED ON ITS ASSESSMENT OF HISTORICAL COLLECTION LIKELIHOOD AND THE CURRENT STATUS OF INDIVIDUAL ACCOUNTS. BALANCES THAT ARE STILL OUTSTANDING AFTER MANAGEMENT HAS USED REASONABLE COLLECTION EFFORTS ARE WRITTEN OFF THROUGH A CHARGE TO THE VALUATION ALLOWANCE AND A CREDIT TO PATIENT ACCOUNTS RECEIVABLE. FORT HEALTHCARE IN SOUTHEAST WISCONSIN / 2024 CHARITY CARE $2,075,094. CHARITY CARE IS DEFINED AS FREE OR DISCOUNTED HEALTH SERVICES PROVIDED TO THOSE WHO CANNOT AFFORD TO PAY AND WHO MEET ALL CRITERIA FOR FINANCIAL ASSISTANCE. CHARITY CARE IS BASED ON ACTUAL COSTS, NOT CHARGES, AND DOES NOT INCLUDE BAD DEBT. PART III, LINE 8: WE ARE THE ONLY HOSPITAL IN OUR SERVICE AREA & PATIENTS WOULD HAVE TO TRAVEL TO ANOTHER COMMUNITY TO RECEIVE CARE.INPATIENT COSTS COME FROM WORKSHEET D-1 PART II & OUTPATIENT COSTS ARE BASED ON THE COST TO CHARGE RATIO OF THE MEDICARE CHARGES ON WORKSHEET D PART V. PART III, LINE 9B: PERSONS WHOSE INCOME IS MORE THAN 200% OF THE FEDERAL POVERTY GUIDELINES, BUT NOT MORE THAN 400% OF THE GUIDELINES, SHALL BE ELIGIBLE FOR COMMUNITY CARE ON A REDUCED CHARGE BASIS. PERSONS WHOSE INCOME IS LESS THAN 200% OF THE GUIDELINES WILL BE CONSIDERED FOR COMPLETE FORGIVENESS OF THEIR OUTSTANDING CHARGES. PART VI, LINE 2: FORT HEALTHCARE PERFORMS REGULAR MARKET RESEARCH TO ASSESS THE HEALTHCARE NEEDS AND CONCERNS OF THE COMMUNITY. THE PRIMARY RESEARCH TOOLS ARE SURVEYS, COMMUNITY FOCUS GROUPS AND MEETINGS. MANY QUESTIONS RELATE SPECIFICALLY TO HEALTH NEEDS, BEHAVIORS AND CONCERNS. THE SURVEY IS ADMINISTERED BY AN INDEPENDENT RESEARCH COMPANY. CONCERNED RESIDENTS AND COMMUNITY LEADERS, WITH THE ASSISTANCE OF FORT HEALTHCARE STAFF ARE DEVELOPING SPECIFIC COMMUNITY-RELEVANT STRATEGIES TO ADDRESS OBESITY, PHYSICAL ACTIVITY, NUTRITION, ADVANCE DIRECTIVES, CANCER AND DIABETIC SCREENINGS AND MENTAL/BEHAVIORAL HEALTH. PART VI, LINE 3: INFORMATION IS AVAILABLE ON THE PATIENT STATEMENT, IN MONTHLY NEWSLETTERS AND ON THE ORGANIZATION'S WEBSITE. AN ANNUAL COMMUNITY BENEFIT REPORT IS FILED WITH THE WISCONSIN HOSPITAL ASSOCIATION. A PRINTED REPORT IS PREPARED AND DELIVERED TO 40,500 HOUSEHOLDS WITHIN THE PRIMARY SERVICE AREA. THE FORT HEALTHCARE WEBSITE CONTAINS LINKS AND INFORMATION SPECIFIC TO THE POLICY ON CHARITY CARE, FINANCIAL AID AND REDUCED PAYMENT OPTION FOR SELF-PAY PATIENTS. INFORMATION IS ALSO AVAILABLE ON THE WEBSITE AND IN ALL FORT HEALTHCARE LOCATIONS REGARDING THE ROCK RIVER COMMUNITY CLINIC, A FREE AND REDUCED CARE CLINIC FUNDED IN A SIGNIFICANT MANNER BY FORT HEALTHCARE THROUGH A MULTI-YEAR GIFT AGREEMENT. FINANCIAL AID COUNSELOR IS AVAILABLE AT FORT MEMORIAL HOSPITAL TO ASSIST PATIENTS WITH COMPLETING PAPERWORK FOR GOVERNMENT ASSISTANCE PROGRAMS, WITH CONTACT INFORMATION ALSO AVAILABLE ON THE WEBSITE AND IN ADMISSION PACKETS. PART VI, LINE 4: FORT HEALTHCARE'S PRIMARY SERVICE AREA CONSTITUTES AN EIGHT ZIP CODE REGION COMPRISED OF THE COMMUNITIES OF FORT ATKINSON, JEFFERSON, JOHNSON CREEK, HELENVILE, WHITEWATER, CAMBRIDGE, LAKE MILLS AND PALMYRA. THERE ARE APPROXIMATELY 85,000 PERSONS LIVING IN THE REGION. FORT MEMORIAL HOSPITAL IS THE ONLY HOSPITAL WITHIN THE PRIMARY SERVICE AREA. THE REGION IS NOT CONSIDERED A MEDICALLY UNDERSERVED REGION. PART VI, LINE 5: THE FORT HEALTHCARE BOARD OF DIRECTORS IS A COMMUNITY ORIENTED BOARD, WITH REPRESENTATIVES SOLICITED DIRECTLY FROM THE MAJORITY OF COMMUNITIES IN THE PRIMARY SERVICE AREA. THE MAJORITY OF REPRESENTATIVES ARE NOT EMPLOYEES, CONTRACTORS OR RELATIVES OF FORT HEALTHCARE STAFF. THE MEMBERS ARE NOT COMPENSATED FOR THEIR SERVICE. THE FORT MEMORIAL HOSPITAL OPERATES WITH AN 'OPEN' MEDICAL STAFF. PHYSICIANS UNAFFILIATED WITH THE ORGANIZATION MAY REQUEST PRIVILEGES AT ANY TIME. THE PLANNING COMMITTEE DETERMINES NEED FOR SPECIALTY CARE ACCORDING TO A WELL ESTABLISHED MEDICAL MANPOWER PLAN THAT INCLUDES COMMUNITY NEED FOR SERVICES. PHYSICIANS ARE GRANTED MEDICAL STAFF STATUS BASED ON NEED. THE MEDICAL STAFF IS REPRESENTED BY MEMBERS OF FORT HEALTHCARE, SSM REGIONAL CLINICS, UW HEALTH AND OTHERS. FORT HEALTHCARE IS A NON-PROFIT ORGANIZATION AND NET REVENUES ARE USED FOR IMPROVEMENTS IN THE STATUS OF FORT HEALTHCARE. FUNDS ARE USED TO PURCHASE CAPITAL EQUIPMENT, ENHANCE PHYSICAL FACILITIES AND IMPROVE PATIENT SERVICES. PART VI, LINE 6: FORT HEALTHCARE IS AN INDEPENDENT, NON-PROFIT ORGANIZATION. THERE ARE NO AFFILIATED ORGANIZATIONS. PART VI, LINE 7, REPORTS FILED WITH STATES WI 1 ROCK RIVER COMMUNITY CLINIC 520 HANDEYSIDE LN FORT ATKINSON WI 53538 205297560 501(C)(3) 220000 0 GENERAL SUPPORT GLACIAL HERITAGE DEVELOPMENT PARTNERSHIP 864 COLLINS RD SUITE 111 JEFFERSON WI 53549 813362283 501(C)(3) 35000 0 GENERAL SUPPORT FORT ATKINSON CHAMBER OF COMMERCE 244 N MAIN ST FORT ATKINSON WI 53538 390286155 501(C)(6) 8400 0 GENERAL SUPPORT ROCK LAKE ACTIVITY CENTER 229 FREMONT ST LAKE MILLS WI 53551 203293581 501(C)(3) 7000 0 GENERAL SUPPORT 3 1 PART I, LINE 2: DEPARTMENTS RECEIVING GRANTS ARE RESPONSIBLE TO REPORT THE USE OF FUNDS, OUTCOMES AND ANECDOTAL STORIES THAT ILLUSTRATE THE IMPACT OF THEIR GRANT. REPORTING REQUIREMENTS WILL BE DETERMINED COLLABORATIVELY PRIOR TO A FINAL FUNDING DECISION. X X X X X X 0 1 0 0 1 0 0 1 0 MATTHEW BLISS MD PHYSICIAN 1076627 0 477498 0 5131 0 10909 0 33929 0 1604094 0 0 0 ISIDORO ZAMBRANO MD PHYSICIAN 798831 0 122838 0 4051 0 13200 0 33759 0 972679 0 0 0 PAUL SCHUPPNER DO BOARD MEMBER 763367 0 83988 0 3350 0 13200 0 25195 0 889100 0 0 0 MICHAEL ANDERSON MD PRESIDENT/CEO 764441 0 40000 0 11242 0 13200 0 33715 0 862598 0 0 0 MICHAEL WALLACE SENIOR ADVISOR (RETIRED PRES./CEO) 246348 0 391961 0 16774 0 13200 0 34201 0 702484 0 0 0 BILLIE KONTNY MD BOARD MEMBER 603900 0 40000 0 6374 0 13200 0 33714 0 697188 0 0 0 JONATHAN MCLAUGHLIN MD PHYSICIAN 565416 0 40000 0 6374 0 13200 0 31606 0 656596 0 0 0 MARC ERICKSON MD PHYSICIAN 486024 0 40000 0 6374 0 13200 0 34406 0 580004 0 0 0 STEPHANIE NOTTESTAD MD BOARD MEMBER 340769 0 79126 0 809 0 10000 0 35656 0 466360 0 0 0 NATHANIEL FULLERTON MD CHIEF OF STAFF (THRU OCT 2023) 364945 0 42722 0 1935 0 13200 0 36435 0 459237 0 0 0 JAMES NELSON SR. VICE PRESIDENT/CFO 279993 0 70031 0 5132 0 13200 0 36191 0 404547 0 0 0 PART I, LINE 4B MICHAEL WALLACE PARTICIPATED IN A NONQUALIFIED DEFERRED COMPENSATION PLAN. HOWEVER, HE IS 0% VESTED, EXCEPT IN THE CASE OF DEATH OR DISABILITY, AND HAS NO INTEREST IN THE DEFERRED COMPENSATION PLAN UNTIL JANUARY 1, 2024. THE PLAN IS A TOP-HAT PLAN THAT IS UNFUNDED. JAMES NELSON PARTICIPATED IN A NONQUALIFIED DEFERRED COMPENSATION PLAN. HOWEVER, HE IS 0% VESTED, EXCEPT IN THE CASE OF DEATH OR DISABILITY, AND HAS NO INTEREST IN THE DEFERRED COMPENSATION PLAN UNTIL FISCAL YEAR 2025. THE PLAN IS A TOP-HAT PLAN THAT IS UNFUNDED. MICHAEL ANDERSON, M.D. PARTICIPATED IN A NONQUALIFIED DEFERRED COMPENSATION PLAN. HOWEVER, HE IS 0% VESTED, EXCEPT IN THE CASE OF DEATH OR DISABILITY, AND HAS NO INTEREST IN THE DEFERRED COMPENSATION PLAN UNTIL JANUARY 1, 2028. THE PLAN IS A TOP-HAT PLAN THAT IS UNFUNDED. PART I, LINE 5 PHYSICIAN COMPENSATION IS TIED TO THE NET REVENUES OF THEIR PRACTICE. PART I, LINE 7 SCHEDULE J, PART II, COLUMN (B)(II) REPORTS DISCRETIONARY INCENTIVE AMOUNTS THAT WERE APPROVED BY THE BOARD BASED UPON PERFORMANCE. A WISCONSIN HEALTH & EDUCATIONAL FACILITIES AUTHORITY 391337855 97712JJA2 2024-03-07 60001577 CONSTRUCTION & EQUIPMENT 0 0 0 A 60001577 24649215 36579832 0 1 0 0 A 0 0 1 0 0 0 0 0 A 0 1 0 0 1 0 0 0 1 A 1 MEDICAL HEALTH BUILDING GROUP PARTNERSHIP OWNED BY BOARD MEMBER BILLIE KONTNY 1945384 RENT FOR THE LEASE OF OFFICE SPACE 0 FORM 990, PART VI, SECTION B, LINE 11B THE FORM 990 IS REVIEWED BY THE ORGANIZATION'S ACCOUNTING MANAGER AND CFO. A COPY OF THE FORM 990 IS PROVIDED TO THE FINANCE COMMITTEE AND THE BOARD OF DIRECTORS FOR REVIEW AND APPROVAL PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C EACH BOARD MEMBER OF THE ENTITY AND RELATED ENTITIES ANNUALLY COMPLETE A CONFLICT OF INTEREST QUESTIONNAIRE DISCLOSING THEIR CONFLICTS OF INTEREST. A SUMMARY OF CONFLICTS ARE DISTRIBUTED TO THE CHAIRMAN OF THE BOARD AND TO ADMINISTRATIVE SUPPORT PERSONNEL. BOARD MEMBERS ARE COACHED ON HOW TO MANAGE THEIR CONFLICTS. BOARD MEMBERS WITH A CONFLICT OF INTEREST ABSTAIN FROM VOTING ON THE MATTERS. FORM 990, PART VI, SECTION B, LINE 15 OTHER ORGANIZATIONS ARE USED AS BENCHMARKS TO DETERMINE COMPENSATION. INDEPENDENT REVIEWS OF COMPENSATION ARE ALSO DONE PERIODICALLY. FORM 990, PART VI, SECTION C, LINE 19 ALL DOCUMENTS ARE AVAILABLE TO THE PUBLIC UPON REQUEST. SUMMARIES OF FINANCIAL STATEMENTS ARE AVAILABLE TO THE PUBLIC VIA AN ANNUAL REPORT THAT FORT HEALTHCARE PUBLISHES. THE ANNUAL REPORT IS DIRECT MAILED TO HOUSEHOLDS AND IS ALSO AVAILABLE TO THE PUBLIC ON FORT HEALTHCARE'S WEBSITE. FORM 990, PART IX, LINE 11G ADMIN PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 1,789,537. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,789,537. ANESTHESIA CRNA SERVICES: PROGRAM SERVICE EXPENSES 201,121. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 201,121. CENTER FOR WOMEN'S HEALTH SERVICES: PROGRAM SERVICE EXPENSES 959,198. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 959,198. ENT SERVICES: PROGRAM SERVICE EXPENSES 3,038. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 3,038. HOSPITALISTS SERVICES: PROGRAM SERVICE EXPENSES 1,803,369. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,803,369. INTEGRATED FAMILY CARE SERVICES: PROGRAM SERVICE EXPENSES 549,557. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 549,557. INTERNAL MEDICINE SERVICES: PROGRAM SERVICE EXPENSES 380,280. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 380,280. LABORATORY SERVICES: PROGRAM SERVICE EXPENSES 1,373,321. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,373,321. LAKE MILLS SERVICES: PROGRAM SERVICE EXPENSES 250,458. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 250,458. ORTHOPAEDICS SERVICES: PROGRAM SERVICE EXPENSES 391,257. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 391,257. OTHER MEDICAL & PHYSICIAN SERVICES: PROGRAM SERVICE EXPENSES 7,896,370. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 7,896,370. PEDIATRICS SERVICES: PROGRAM SERVICE EXPENSES 242,982. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 242,982. RADIOLOGY SERVICES: PROGRAM SERVICE EXPENSES 3,377,885. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 3,377,885. SURGICAL ASSOCIATES SERVICES: PROGRAM SERVICE EXPENSES 213,839. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 213,839. CONTRACT LABOR - STAFF: PROGRAM SERVICE EXPENSES 335,874. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 335,874. FORM 990, PART XI, LINE 9: NET ASSETS ADJUSTMENT - PAIN CENTERS OF WISCONSIN-FORT ATKINSON, LLC -132,996. PART XII, LINE 2C THIS PROCESS HAS NOT CHANGED FROM PRIOR YEAR. PAIN CENTER OF WISCONSIN-FORT ATKINSON LLC 1604 MADISON AVENUE FORT ATKINSON WI 53538 900777376 HEALTH CARE SERVICES WI 132996 1112734 FORT HEALTHCARE INC FORT MEMORIAL HOSPITAL FOUNDATION INC 611 SHERMAN AVENUE EAST FORT ATKINSON WI 53538 391397028 FOUNDATION WI 501(C)(3) LINE 12A, I FORT HEALTHCARE INC 1 UW CANCER CENTER JOHNSON CREEK LLC 125 HOSPITAL DRIVE WATERTOWN WI 53098 200341996 CANCER CENTER WI N/A RELATED 125989 2463175 0 0 0.33330 0 0 1 0 0 0 0 0 0 0 0 0 0 1 0 0 1 0 0 FORT MEMORIAL HOSPITAL FOUNDATION INC C 17645 CASH