2015-08-20T08:16:50-05:00 2014-09-30 390758449 WIPFLI LLP PO BOX 12237 GREEN BAY WI 543072237 990 2013-10-01 390806359 COMMUNITY HEALTH NETWORK INC COMM 9203611313 225 MEMORIAL DR BERLIN WI 54923 TOM KRYSTOWIAK CFO 9203611313 2015-08-20 1 TERRI REXRODE CPA MST P00096513 9206620016 2015-08-12 2013 2016-03-07 17:11:31Z TOM KRYSTOWIAK 225 MEMORIAL DR BERLIN WI 54923 87840534 0 X WWW.CHNWI.ORG X 1910 WI COMMUNITY HEALTH NETWORK, INC PROVIDES INPATIENT AND OUTPATIENT HOSPITAL AND CLINIC SERVICES, HOME CARE SERVICES AND SKILLED NURSING SERVICES TO GREEN LAKE COUNTY AND SURROUNDING COUNTIES WITH TOTAL NET PATIENT SERVICE REVENUES OF $79,049,000 (TOTAL GROSS REVENUE OF $185,821,000). 12 9 837 110 1817749 -170160 51692 9480 84988117 84662655 591288 67227 738685 2656247 86369782 87395609 21039 85199 0 0 48085669 48806755 0 0 0 37740787 39141447 85847495 88033401 522287 -637792 59518792 64384767 32090661 38575741 27428131 25809026 X TO PROVIDE SUPERIOR SERVICES TO IMPROVE THE HEALTH OF THOSE WE SERVE. 0 0 77086743 85199 79378332 COMMUNITY HEALTH NETWORK OPERATES A 25-BED ACUTE CARE FACILITY, 50 BED EXTENDED CARE FACILITY, PHYSICIAN CLINICS LOCATED IN 8 COMMUNITIES, A HOME HEALTH AGENCY, REHABILITATION SERVICES AND RETAIL PHARMACY SERVICES. IN PURSUIT OF OUR PRIMARY EXEMPT PURPOSE OF PROVIDING HEALTH CARE SERVICES, COMMUNITY HEALTH NETWORK PROVIDES MEDICAL CARE AND HEALTH INFORMATION AIMED AT IMPROVING THE HEALTH STATUS OF THE COMMUNITIES WE SERVE. WE BELIEVE THAT WE HAVE A SPECIAL DUTY TO MEET THE NEEDS OF THE POOR, INDIGENT, AND MEDICALLY UNDERSERVED IN OUR COMMUNITIES AND SURROUNDING AREAS. WE HAVE PROVIDED CARE TO ALL PATIENTS WITHOUT REGARD FOR THE ABILITY TO PAY. COMMUNITY HEALTH NETWORK OPERATES AN EMERGENCY ROOM THAT IS OPEN TO ALL PERSONS REGARDLESS OF ABILITY TO PAY. IT HAS AN OPEN MEDICAL STAFF WITH PRIVILEGES AVAILABLE TO ALL QUALIFIED PHYSICIANS IN THE AREA. THE MAJORITY OF THE BOARD OF DIRECTORS IS COMPRISED OF INDEPENDENT INDIVIDUALS WHO ARE REPRESENTATIVE OF THE COMMUNITY. COMMUNITY HEALTH NETWORK ENGAGES IN TRAINING AND EDUCATION OF HEALTH CARE PROFESSIONALS THROUGH INTERNSHIP PROGRAMS. COMMUNITY HEALTH NETWORK'S VISION INCLUDES A HEALTHIER COMMUNITY. TO ACHIEVE THIS VISION, IT CONTINUALLY ASSESSES THE COMMUNITIES FOR OPPORTUNITIES FOR HEALTH CARE IMPROVEMENT. DIABETES MANAGEMENT HAS BEEN IDENTIFIED AS A COMMUNITY NEED. DIABETES EDUCATION CONTINUES TO BE A COMMUNITY PROGRAM OFFERED TO THE COMMUNITY AT NO COST. COMMUNITY HEALTH NETWORK PARTICIPATES IN GOVERNMENT-SPONSORED HEALTH CARE PROGRAMS SUCH AS MEDICAID, MEDICARE, CHAMPUS, AND TRICARE. IN FISCAL YEAR 2013 OVER 1700 ACCOUNTS RECEIVED CHARITY CARE WITH A TOTAL COST OF OVER $1.5 MILLION. THE COST OF SERVICES PROVIDED TO MEDICAID PATIENTS THAT WERE NOT REIMBURSED TOTALED MORE THAN $3.4 MILLION. COMMUNITY HEALTH NETWORK'S LOSS FOR PROVIDING LONG TERM CARE SERVICES TO THE COMMUNITIES WAS $476,000 IN 2014. FINANCIAL AND IN-KIND CONTRIBUTIONS TO THE COMMUNITY TOTALED APPROXIMATELY $80,000. IN ADDITION, COMMUNITY HEALTH NETWORK ACTIVELY PROVIDED OR PARTICIPATED IN THE FOLLOWING COMMUNITY-BASED ACTIVITIES AND PROGRAMS OF WHICH APPROXIMATELY 7,000 PERSONS IN THE COMMUNITIES THAT WE SERVE PARTICIPATED AT A TOTAL COST TO COMMUNITY HEALTH NETWORK OF APPROXIMATELY $120,000. - GENERAL HEALTH EDUCATION SERVICES SUCH AS HEALTH FAIRS; CANCER EDUCATION; HEART DISEASE EDUCATION; DIABETES EDUCATION; FAMILY, PARENT, AND SIBLING EDUCATION; FAMILY PLANNING; AND WOMEN'S HEALTH EDUCATION- PROVIDED HEALTH INFORMATION ON THE CORPORATION'S WEB SITE AND THROUGH HEALTH RELATED PUBLICATIONS DISTRIBUTED AT NO CHARGE- SUPPORT GROUPS SUCH AS DIABETES, CANCER, AND BEREAVEMENT- HOSTED SELF-HELP AND WELLNESS PROGRAMS SUCH AS NUTRITION, WEIGHT MANAGEMENT AND FITNESS,- BLOOD PRESSURE SCREENINGS, CHOLESTEROL TESTING AND SCHOOL-BASED TESTING- GUIDANCE, REFERRAL AND ENROLLMENT ASSISTANCE FOR PUBLIC MEDICAL PROGRAMS AND OTHER FAMILY SUPPORT ASSISTANCE- DISCOUNTED OR FREE MEDICAL SUPPLIES AND EQUIPMENT TO THOSE UNABLE TO PAY BASED ON OUR FAP- DELIVERED HOT IN-HOME MEALS- PROMOTED PARTICIPATION IN BLOOD DRIVES BY EMPLOYEES- CONTRIBUTED TO THE EDUCATION OF STUDENT NURSES AND OTHER HEALTH CARE PROFESSIONALS- PROVIDED FIRST AID FOR COMMUNITY SPORTING EVENTS- PARTICIPATED IN WORK SITE HEALTH EDUCATION PROGRAMS - MADE CASH CONTRIBUTIONS TO SUPPORT COMMUNITY SERVICES AND EVENTS- PROVIDED MEETING ROOMS TO COMMUNITY GROUPS AT NO CHARGE 77086743 1 1 0 1 0 0 0 0 0 1 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 1 1 1 0 0 0 1 0 1 1 1 0 0 0 0 1 1 1 1 0 0 1 45 0 837 1 1 1 0 0 0 0 0 0 0 0 0 X 12 9 1 0 1 0 1 1 1 1 1 0 0 0 1 1 1 1 1 0 0 0 WI X THOMAS KRYSTOWIAK 9203611313 225 MEMORIAL DRIVE BERLIN WI 54923 PAT MCCONNELL BOARD MEMBER 1.00 X 2100 0 0 PAUL KUJAWA BOARD MEMBER 1.00 X 2800 0 0 FRANK CUMBERBATCH BOARD MEMBER 1.00 X 2700 0 0 THOMAS RIEK BOARD MEMBER 1.00 X 2900 0 0 DAVID BUDDE MD BOARD MEMBER/PHYSICIAN 40.00 X 454223 0 36527 JOLENE HOSTAK BOARD MEMBER 1.00 X 2700 0 0 P MICHAEL SHATTUCK MD BOARD MEMBER/PHYSICIAN 40.00 X 222561 0 25636 KELLY WHITE DDS BOARD MEMBER 1.00 X 2100 0 0 KRISTIN GALATOWITSCH CHAIRMAN 1.00 X X 7404 0 0 RUSSELL KUEHN VICE CHAIRMAN 1.00 X X 4600 0 0 THOMAS WILLETT DO SECRETARY 1.00 X X 88882 0 0 LARRY WISE TREASURER 1.00 X X 5600 0 0 JOHN FEENEY PRESIDENT/CEO 40.00 X 295243 0 22620 NATHAN LUEDKE BOARD MEMBER 40.00 X 70391 0 17461 THOMAS KRYSTOWIAK CFO 40.00 2.00 X 190631 0 30070 DAVID JONES MD PHYSICIAN 40.00 X 1300546 0 28870 URI VAISMAN MD PHYSICIAN 40.00 X 740645 0 30079 JOHN HORAN MD PHYSICIAN 40.00 X 733159 0 23355 HORACE LO MD PHYSICIAN 40.00 X 642577 0 34370 ROBERT GELLER MD PHYSICIAN 40.00 X 660617 0 12067 5432379 0 261055 51 0 1 0 ZR ENTERPRISES SC 6809 MAGNOLIA COURT GREENDALE WI 53129 ER PHYSICIAN SERVICE 1446240 CENTRAL WI ANESTHESIA PO BOX 249 BERLIN WI 54923 ANESTHESIA SERVICES 712615 SHARED MEDICAL SERVICES PO BOX 330 COTTAGE GROVE WI 53527 MRI SERVICES 483500 DAVID RESEN MD PO BOC 42 GREEN LAKE WI 54941 PATHOLOGY SERVICES 131250 4 6085 3395 9480 PATIENT SERVICE REVENUE 624100 64745214 59589303 5155911 PHARMACY REVENUE 446110 19561769 17200041 1817749 543979 MOB RENTAL 900099 221772 221772 CAFETERIA REVENUE 900099 133900 133900 84662655 376672 376672 110269 43010 67259 67259 67259 92470 401915 0 -401915 92470 -309445 -309445 EHR INCENTIVE INCOME 900099 2588988 2588988 2588988 87395609 79378332 1817749 6190048 77699 77699 7500 7500 5521500 4960532 560968 34638543 29716712 4921831 591124 496490 94634 6069002 5180946 888056 1986586 1652421 334165 99172 99172 6714385 5617981 1096404 215509 9049 206460 14319393 13947429 371964 1584757 51799 1532958 1484167 1430122 54045 338873 258346 80527 60411 1805 58606 854926 842723 12203 4591038 4580248 10790 579773 365527 214246 PROVISION FOR BAD DEBTS 4312726 4312726 EQUIPMENT RENTAL AND MA 3094013 2824542 269471 MEDICAID ASSESSMENT 543900 543900 LICENSES, DUES, AND CER 172882 120685 52197 175522 87561 87961 88033401 77086743 10946658 0 3846 59034 4172746 5528529 16558337 16797233 118917 75000 1111303 1433837 736969 426276 60478585 37481728 19565996 22996857 12356990 12221542 45607 15703 4848081 4830756 59518792 64384767 7018223 5338090 62091 12490000 11554244 3335305 3219516 9247133 18401800 32090661 38575741 X 26268159 25809026 1159972 0 27428131 25809026 59518792 64384767 X -637792 178659 -1159972 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 4804 4804 0 PART II-B, LINE 1: WHA DUES OF $4,804. 13316961 293584 1207187 1454548 125345 13237839 11731635 1188523 1208164 811361 13316961 9942971 1110976 1431598 753910 11731635 9548648 1099960 46867 752504 9942971 8326892 1558801 644527 981572 9548648 0.91000 0.00000 0.09000 0 1 1 897715 897715 19394931 11403254 7991677 1208648 1130158 78490 36955669 24311185 12644484 2021622 637131 1384491 22996857 UNAMORTIZED BOND ISSUE COSTS 90601 INTEREST RECEIVABLE 1647 ACCOUNTS RECEIVABLE - WILD ROSE 4000000 ACCOUNTS RECEIVABLE - WORKER'S COMP 353208 EHR INCENTIVE 385300 4830756 DEFERRED COMPENSATION 7183250 ACCRUED INTEREST 1371 SELF FUNDED HEALTH INSURANCE 851518 NET AMOUNTS PAYABLE FROM THIRD-PARTY REIMBURSEMENT PROGRAMS 875186 WORKERS COMPENSATION PAYABLE 352033 ACCRUED PHARMACY TAX -15750 DUE TO THEDACARE, INC. 9154192 18401800 X PART V, LINE 4: ENDOWMENT FUNDS ARE TO BE UTILIZED TO SUPPORT THE ORGANIZATION'S MISSION AND PURPOSE. PART X, LINE 2: THE CONSOLIDATED ENTITIES ARE NONPROFIT CORPORATIONS AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE (THE "CODE") AND ARE EXEMPT FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE CODE. THE CONSOLIDATED ENTITIES ARE ALSO EXEMPT FROM STATE INCOME TAXES ON RELATED INCOME. IN ORDER TO ACCOUNT FOR ANY UNCERTAIN TAX POSITIONS, THEDACARE DETERMINES WHETHER IT IS MORE LIKELY THAN NOT THAT A TAX POSITION WILL BE SUSTAINED UPON EXAMINATION OF THE TECHNICAL MERITS OF THE POSITION, ASSUMING THE TAXING AUTHORITY HAS FULL KNOWLEDGE OF ALL INFORMATION. IF THE TAX POSITION DOES NOT MEET THE MORE-LIKELY-THAN-NOT RECOGNITION THRESHOLD, THE BENEFIT OF THAT POSITION IS NOT RECOGNIZED IN THE CONSOLIDATED FINANCIAL STATEMENTS. THEDACARE RECORDED NO ASSETS OR LIABILITIES RELATED TO UNCERTAIN TAX POSITIONS OR UNRECOGNIZED TAX BENEFITS IN 2014 AND 2013. TAX RETURNS FOR THE YEARS ENDED 2011 AND BEYOND REMAIN SUBJECT TO EXAMINATION BY APPLICABLE TAXING AUTHORITIES. 1 1 1 X 1 X 1 1 1 0 1 1 1783312 1783312 0.02130 10230550 7836427 2394123 0.02860 12013862 7836427 4177435 0.04990 112393 112393 0.00130 6907 6907 0.00010 449184 449184 0.00540 568484 568484 0.00680 12582346 7836427 4745919 0.05670 1 1772983 12702116 12746360 -44244 X 1 1 1 1 BERLIN MEMORIAL HOSPITAL 225 MEMORIAL DRIVE BERLIN WI 54923 WWW.COMMUNITYHEALTHNETWORK.ORG 1060 X X X X BERLIN MEMORIAL HOSPITAL 1 1 X X X X X X X X X 13 1 1 1 X SEE WEBSITE ON 5D X X X X X X X X X X 0 0 1 1 150.000000000000 1 300.000000000000 1 X X 1 1 X X X X 1 0 1 X 0 0 BERLIN MEMORIAL HOSPITAL PART V, SECTION B, LINE 3: IN ORDER TO ENSURE CONSIDERATION OF BROAD COMMUNITY INTERESTS, THE CREATION OF THE 2013 CHNA WAS A PARTNERSHIP BETWEEN COMMUNITY HEALTH NETWORK, INC. D/B/A BERLIN MEMORIAL HOSPITAL ("CHN") AND EACH COUNTY HEALTH DEPARTMENT THAT COMPRISES CHN'S PRIMARY SERVICE AREA: GREEN LAKE COUNTY, WAUSHARA COUNTY AND MARQUETTE COUNTY. BERLIN MEMORIAL HOSPITAL PART V, SECTION B, LINE 4: WILD ROSE COMMUNITY MEMORIAL HOSPITAL BERLIN MEMORIAL HOSPITAL PART V, SECTION B, LINE 5D: HTTPS://WWW.THEDACARE.ORG/~/ MEDIA/THEDACARE%20INTERNET%20FILES/06%20GET%20INVOLVED/2013CHNA_CHN.PDF BERLIN MEMORIAL HOSPITAL PART V, SECTION B, LINE 7: FOR EXAMPLE, ALTHOUGH WE ARE ACTIVE IN THE PREVENTION OF ALCOHOL AND DRUG ABUSE BY PARTICIPATION ON OUR COUNTY COALITIONS, WE ARE UNABLE TO ADDRESS BEYOND THAT BASED ON FINANCIAL CONSTRAINTS AND DIFFICULTY IN RECRUITING IN THIS AREA. CHN MANAGES THESE BEHAVIORS THROUGH PRIMARY CARE SERVICES. ADDITIONALLY, WE ARE ACTIVELY LOOKING FOR PARTNERSHIPS WITH LARGER HEALTH SYSTEMS TO INCREASE SPECIALTY SERVICES THAT CAN ADDRESS THESE NEEDS. WE DO NOT INTEND TO ADDRESS ENVIRONMENTAL AND OCCUPATIONAL HEALTH IN WAUSHARA COUNTY THE WAY THAT COMMUNITY HEALTH NEEDS ASSESSMENT IDENTIFIES IT AS IT IS BEYOND OUR SCOPE. BERLIN MEMORIAL HOSPITAL PART V, SECTION B, LINE 20D: COMMUNITY HEALTH NETWORK, INC. MAINTAINS WRITTEN POLICIES TO DETERMINE PATIENTS' ABILITY TO PAY AND ELIGIBILITY FOR FINANCIAL ASSISTANCE. APPLICANTS TO THE COMMUNITY CARE ASSISTANCE PROGRAM ARE REQUIRED TO COMPLETE AN APPLICATION TO DETERMINE ELIGIBILITY AND MAY QUALIFY FOR 25%, 50% OR 100% REDUCTION IN GROSS CHARGES. ELIGIBILITY IS DETERMINED ON THE BASIS ON A PATIENTS INCOME AND ASSETS. COMMUNITY CARE WILL BE APPROVED IN A THREE (3) TIER PROGRAM.1. 100% FOR APPLICANTS AT OR BELOW 150% OF FEDERAL POVERTY GUIDELINES.2. 50% FOR APPLICANTS BETWEEN 150% AND 200% OF FEDERAL POVERTY GUIDELINES.3. 25% FOR APPLICANTS BETWEEN 200% AND 300% OF FEDERAL POVERTY GUIDELINES. 13 CHN MEDICAL OFFICE BUILDING 225 MEMORIAL DRIVE BERLIN WI 54923 OUTPATIENT PHYSICIAN CLINIC CHN MEDICAL CENTER - WAUTOMA N HIGHWAY 22 WAUTOMA WI 54982 OUTPATIENT PHYSICIAN CLINIC CHN MEDICAL CENTER - MARKESAN 340 ENTERPRISE DRIVE MARKESAN WI 53946 OUTPATIENT PHYSICIAN CLINIC CHN MEDICAL CENTER - PRINCETON 502 W WATER STREET PRINCETON WI 54968 OUTPATIENT PHYSICIAN CLINIC CHN MEDICAL CENTER - MONTELLO 315 CHURCH STREET MONTELLO WI 53949 OUTPATIENT PHYSICIAN CLINIC CHN MEDICAL CENTER - RIPON 1080 FOND DU LAC STREET RIPON WI 54971 OUTPATIENT PHYSICIAN CLINIC CHN MEDICAL CENTER - REDGRANITE 402 PRESTON LANE REDGRANITE WI 54970 OUTPATIENT PHYSICIAN CLINIC CHN MEDICAL CENTER - EASTRIDGE W832 HIGHWAY 91 BERLIN WI 54923 OUTPATIENT PHYSICIAN CLINIC CHN ORTHOPEDICS & SPORTS MEDICINE 191 MEMORIAL DRIVE BERLIN WI 54923 OUTPATIENT PHYSICIAN CLINIC JULIETTE MANOR 169 EAST HURON STREET BERLIN WI 54923 SKILLED NURSING FACILITY CHN HOME CARE 270 MARQUETTE STREET BERLIN WI 54923 HOME HEALTH CARE COMMUNITY MEDICAL CENTER - GREEN LAKE 670 CTY HIGHWAY A GREEN LAKE WI 54941 OUTPATIENT PHYSICIAN CLINIC CHN MEDICAL CENTER - GREEN LAKE N6205 BUSSE DR GREEN LAKE WI 54941 OUTPATIENT PHYSICIAN CLINIC PART I, LINE 7: THE NUMBERS IN THE TABLE FOR CHARITY CARE AND UNREIMBURSED MEDICAID WERE DERIVED FROM USE OF IRS WORKSHEET 2 COST-TO-CHARGE RATIO. THE COST OF THE COMMUNITY HEALTH IMPROVEMENTS WERE CALCULATED BASED ON LABOR COSTS, SUPPLY COSTS AND ROOM COSTS. HEALTH PROFESSIONAL EDUCATION COSTS WERE BASED ON THE AMOUNT OF SCHOLARSHIPS AWARDED AND THE ROOM & LABOR COSTS FOR PROVIDING COMMUNITY EDUCATION FOR HEALTH PROFESSIONALS IN OUR COMMUNITIES. CASH IS THE AMOUNT OF CONTRIBUTIONS TO THE COMMUNITY AND IN-KIND DONATIONS ARE BASED ON THE COST OF THE IN-KIND DONATION. PART I, LN 7 COL(F): THE HOSPITAL BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25(A) OF $4,312,726 WAS SUBTRACTED TO CALCULATE THE PERCENTAGE IN COLUMN (F). PART II, COMMUNITY BUILDING ACTIVITIES: COMMUNITY HEALTH NETWORK ENGAGES IN SEVERAL COMMUNITY BUILDING ACTIVITIES. OUR DISASTER READINESS PROGRAMS ARE DEVELOPED TO EXCEED THE MINIMUM REQUIREMENTS IN ORDER TO PROVIDE A RESPONSIBLE LEVEL OF SERVICE TO THE COMMUNITY. WE ALSO PROVIDE MEETING ROOMS AND SUPPORT TO OTHER NOT-FOR-PROFIT ORGANIZATIONS THAT IMPROVE THE HEALTH OF THE COMMUNITY. ALL OF THESE EFFORTS ARE FOCUSED ON MINIMIZING THE HEALTH IMPACT OF CATASTROPHES, LARGE AND SMALL, AS WELL AS SUPPORTING HEALTH ACTIVITIES AND GROUPS WITH A QUALITY OF LIFE FOCUS. PART III, LINE 4: USED COST TO CHARGE RATIO BASED ON COST BEING THE TOTAL OPERATING EXPENSE NET OF COMMUNITY BENEFIT EXPENSE AND NON-PATIENT CARE OPERATIONS AND CHARGES BEING PATIENT CHARGES NET OF COMMUNITY BENEFIT CHARGES. MANY PATIENTS WHOSE ACCOUNTS/OUT-OF-POCKET LIABILITY ARE WRITTEN OFF TO BAD DEBT ARE UNABLE TO PAY BUT DID NOT COMPLETE THE PROCESS FOR CHARITY CARE/FINANCIAL ASSISTANCE. BECAUSE THESE PATIENTS WOULD HAVE QUALIFIED FOR CHARITY CARE, BUT DIDN'T COMPLETE THE PROCESS, THESE BAD DEBT WRITE-OFFS SHOULD BE CONSIDERED COMMUNITY BENEFIT AS CHARITY CARE. IN ADDITION, COMMUNITY HEALTH NETWORK CONTINUES TO SERVE PATIENTS WHOSE ACCOUNTS ARE WRITTEN OFF TO BAD DEBT EVEN THOUGH THERE IS A GOOD CHANCE FUTURE SERVICES MAY CONTINUE TO BE WRITTEN OFF TO BAD DEBT, WHICH DEMONSTRATES A COMMUNITY BENEFIT - SERVING PATIENTS EVEN THOUGH WE MAY NOT BE PAID. PART III, LINE 8: ANY SHORTFALL SHOULD BE TREATED AS COMMUNITY BENEFIT BECAUSE CHN CONTINUES TO SERVE THE MEDICARE POPULATION REGARDLESS OF WHETHER THEY COVER THEIR COSTS. COMMUNITY HEALTH NETWORK HAS A SURPLUS BECAUSE IT IS A CRITICAL ACCESS HOSPITAL AND AS A CRITICAL ACCESS HOSPITAL, IT RECEIVES 101% OF ITS COST PER THE MEDICARE COST REPORT. PART III, LINE 9B: PATIENTS WHO HAVE AN APPLICATION OUTSTANDING ARE NOT KNOWINGLY SENT TO COLLECTIONS. PATIENTS WHO QUALIFY FOR 100% CHARITY HAVE THE ENTIRE AMOUNT OF THE BILL WRITTEN OFF AND NO FURTHER COLLECTION PROCEDURES ARE DONE. BALANCES REMAINING AFTER CHARITY CARE PERCENTAGE HAS BEEN DETERMINED (THOSE WHO QUALIFY FOR FINANCIAL ASSISTANCE/PARTIAL CHARITY CARE) ARE CONSIDERED SELF PAY AND PAYMENT ARRANGEMENTS MUST BE MADE. SHOULD THE PATIENT FAIL TO MAKE PAYMENT ARRANGEMENTS OR MAINTAIN THE PAYMENTS AGREED UPON THEY WILL BE NOTIFIED IN WRITING THAT THE ACCOUNT BALANCE IS PAST DUE AND THE ACCOUNT WILL BE SUBJECT TO NORMAL COLLECTION PROCEDURES. PART VI, LINE 2: COMMUNITY HEALTH NETWORK WORKS IN COLLABORATION WITH GREEN LAKE AND WAUSHARA COUNTY PUBLIC HEALTH TO ASSESS COMMUNITY NEEDS IN ORDER TO CREATE A PLAN OF CARE BASED ON THOSE ISSUES AND CONCERNS IDENTIFIED. COMMUNITY HEALTH NETWORK ALSO PARTICIPATES WITH THE GREEN LAKE COUNTY AND WAUSHARA COUNTY WELLNESS COALITION. IN THE EFFORT TO PROVIDE COMPREHENSIVE CARE, THE WELLNESS COALITION ALSO STRIVES TO DECREASE INEFFICIENCIES DUE TO OVERLAP OF CARE PROVIDERS AND ORGANIZATIONS IN THE AREA. COMMUNITY HEALTH NETWORK ALSO ASSESSES COMMUNITY NEED BY USING UNIVERSITY OF WISCONSIN HEALTH RANKINGS WHICH PROVIDES COUNTY BY COUNTY BREAKDOWNS OF HEALTH OUTCOMES, HEALTH FACTORS, AND HEALTH ISSUES TO ASSIST IN DETERMINING COMMUNITY NEED. PART VI, LINE 3: SELF PAY PATIENTS ARE CONTACTED BY A MEMBER OF THE PATIENT ACCOUNTING STAFF TO INFORM THEM OF AVAILABLE GOVERNMENT PROGRAMS AND CHARITY CARE. IF APPROPRIATE, THE PATIENT ACCOUNTING STAFF WILL OFFER ASSISTANCE WITH THE COMPLETION OF THE COMMUNITY CARE (CHARITY CARE) APPLICATION. PART VI, LINE 4: COMMUNITY HEALTH NETWORK PRIMARILY SERVES RESIDENTS FROM GREEN LAKE, MARQUETTE, AND WAUSHARA COUNTIES. THE SERVICE AREA HAD AN ESTIMATED POPULATION OF 59,000 AND IS MOSTLY RURAL. THE POPULATION CONSISTS OF 19.8% UNDER THE AGE OF 18, 26.8% FROM 18 TO 44, 32.1% FROM 45 TO 64 AND 21.3% WHO WERE 65 AND OLDER. PORTIONS OF THE COMMUNITY HEALTH NETWORK SERVICE AREA ARE FEDERALLY QUALIFIED HPSA AREAS. COMMUNITY HEALTH NETWORK OPERATES THE ONLY HOSPITAL IN GREEN LAKE COUNTY. PART VI, LINE 5: THE MAJORITY OF OUR ORGANIZATION'S GOVERNING BODY IS COMPRISED OF PERSONS WHO RESIDE IN THE ORGANIZATION'S PRIMARY SERVICE AREA WHO ARE NEITHER EMPLOYEES NOR CONTRACTORS OF THE ORGANIZATION, NOR FAMILY MEMBERS THEREOF. COMMUNITY HEALTH NETWORK CONDUCTS HEALTH FAIRS FOR THE COMMUNITY TO ENCOURAGE HEALTHY LIFESTYLES AND TO RAISE AWARENESS OF HEALTH ISSUES AND TRENDS. COMMUNITY HEALTH NETWORK ALSO CONDUCTS CPR AND FIRST AID CLASSES, EDUCATION AND OUTREACH FOR SENIOR CITIZENS, AND EDUCATION OPPORTUNITIES FOR PHYSICIANS AND MEDICAL STUDENTS. IN ADDITION, WE ADMINISTER A DIABETES SUPPORT GROUP. PART VI, LINE 6: COMMUNITY HEALTH NETWORK ENGAGES IN SEVERAL COMMUNITY BUILDING ACTIVITIES. OUR DISASTER READINESS PROGRAMS ARE DEVELOPED TO EXCEED THE MINIMUM REQUIREMENTS IN ORDER TO PROVIDE A RESPONSIBLE LEVEL OF SERVICE TO THE COMMUNITY. WE ALSO PROVIDE MEETING ROOMS AND SUPPORT TO OTHER NOT-FOR-PROFIT ORGANIZATIONS THAT IMPROVE THE HEALTH OF THE COMMUNITY. ALL OF THESE EFFORTS ARE FOCUSED ON MINIMIZING THE HEALTH IMPACT OF CATASTROPHES, LARGE AND SMALL, AS WELL AS SUPPORTING HEALTH ACTIVITIES AND GROUPS WITH A QUALITY OF LIFE FOCUS. 0 PARTNERS HEALTH SYSTEM FOUNDATION INC 225 MEMORIAL DRIVE BERLIN WI 54923 731639346 14107 FOUNDATION FUNDRAISING EVENT BOYS AND GIRLS CLUB 501 E PARKWAY AVE PO BOX 411 OSHKOSH WI 54903 396120658 51500 TC CAPITAL CAMPAIGN 2 0 SCHOLARSHIPS 10 7500 X X X 0 1 0 1 1 0 0 0 0 DAVID BUDDE MD BOARD MEMBER/PHYSICIAN 216510 0 219925 0 17788 0 9108 0 27419 0 490750 0 0 0 P MICHAEL SHATTUCK MD BOARD MEMBER/PHYSICIAN 193100 0 29461 0 0 0 6120 0 19516 0 248197 0 0 0 JOHN FEENEY PRESIDENT/CEO 245243 0 50000 0 0 0 0 0 22620 0 317863 0 0 0 THOMAS KRYSTOWIAK CFO 176715 0 3459 0 10457 0 7491 0 22579 0 220701 0 0 0 DAVID JONES MD PHYSICIAN 897839 0 338459 0 64248 0 0 0 28870 0 1329416 0 0 0 URI VAISMAN MD PHYSICIAN 605007 0 135638 0 0 0 7500 0 22579 0 770724 0 0 0 JOHN HORAN MD PHYSICIAN 449599 0 10000 0 273560 0 0 0 23355 0 756514 0 0 0 HORACE LO MD PHYSICIAN 488368 0 154209 0 0 0 5000 0 29370 0 676947 0 0 0 ROBERT GELLER MD PHYSICIAN 531153 0 129464 0 0 0 5000 0 7067 0 672684 0 0 0 PART I, LINE 4B ALL HIGHLY COMPENSATED PARTICIPATE, BUT DID NOT RECEIVE PAYMENT FROM A NON-QUALIFIED PLAN. PART I, LINE 5 RADIOLOGISTS RECEIVE 60% OF REVENUE FROM PROFESSIONAL FEES OVER $2.2 MILLION. IN CALENDAR YEAR 2013, DR. KURTZ RECEIVED $104,227 AND DR. VAISMAN RECEIVED $135,638. SERVICES PROVIDED BY RADIOLOGISTS AT WILD ROSE HOSPITAL ARE INCLUDED. DR HORAN COMPENSATION ADVANCE X 225000 75000 0 1 1 75000 P MICHAEL SHATTUCK MD CHN BOARD MEMBER 24034 CHN RENTS SPACE FROM DR. SHATTUCK FOR MEDICAL GROUP OFFICES 0 THOMAS WILLETT DO BOARD MEMBER 84082 SPACE RENTAL 0 FORM 990, PART VI, SECTION A, LINE 2 RUSSELL KUEHN AND THOMAS WILLETT ARE MEMBERS OF THE BOARD OF DIRECTORS OF 1ST NATIONAL BANK. PATRICK MCCONNELL IS A MEMBER OF THE BOARD OF DIRECTORS OF HORICON BANK. THOMAS WILLET HAS A BUSINESS RELATIONSHIP. FORM 990, PART VI, SECTION A, LINE 4 THE ORGANIZATION'S ARTICLES OF INCORPORATION AND BYLAWS WERE AMENDED, EFFECTIVE JUNE 30, 2014, TO REFLECT THE AFFILIATION WITH THEDACARE, INC. IN ADDITION, THE FISCAL YEAR OF THE ORGANIZATION IS NOW A CALENDAR YEAR. FORM 990, PART VI, SECTION A, LINE 6 EFFECTIVE JUNE 30, 2014, COMMUNITY HEALTH NETWORK, INC.'S SOLE MEMBER OF THE SINGLE CLASS OF VOTING MEMBERS IS THEDACARE, INC. PRIOR TO JUNE 30, 2014, MEMBERSHIP COULD BE OBTAINED BY ANYONE EIGHTEEN OR MORE YEARS OF AGE AND EITHER: (A) RESIDE OR WORK IN THE CORPORATION'S SERVICE AREA, WHICH IS DEFINED AS THE FOLLOWING ZIP CODES: 53919, 53923, 53926, 53930, 53931, 53935, 53939, 53946, 53947, 53949, 53952, 53953, 53956, 53964, 54909, 54921, 54923, 54930, 54934, 54940, 54941, 54943, 54960, 54963, 54964, 54965, 54966, 54967, 54968, 54970, 54971, 54976, 54980, 54982, 54984, AND 54986. AN INDIVIDUAL IS DEEMED TO WORK WITHIN THE CORPORATION'S SERVICE AREA IF HIS OR HER PRIMARY SOURCE OF INCOME STEMS FROM WORK PERFORMED IN THE SERVICE AREA; OR (B) AN EMPLOYEE OF THE CORPORATION OR MEMBER OF HIS OR HER FAMILY. MAY BECOME A MEMBER OF THE CORPORATION UPON SUBMISSION OF A SIGNED APPLICATION DELIVERED TO THE PRINCIPAL OFFICE OF THE CORPORATION. THE CORPORATION'S BOARD OF DIRECTORS OR ITS DESIGNEE(S) HAS THE AUTHORITY TO, FROM TIME TO TIME, MAKE GOOD FAITH DETERMINATIONS REGARDING WHETHER AN APPLICANT OR AN EXISTING MEMBER MEETS THE QUALIFICATIONS FOR MEMBERSHIP OF THE CORPORATION. ANY PERSON WHO DOES NOT MEET THE CRITERIA AS DETERMINED BY THE BOARD OF DIRECTORS OR ITS DESIGNEE(S) WILL NOT BE A MEMBER. AN INDIVIDUAL'S MEMBERSHIP SHALL BE TERMINATED UPON DEATH, RESIGNATION OR THE FAILURE TO MEET THE QUALIFICATION. INDIVIDUALS GRANTED HONORARY MEMBERSHIP IN THE CORPORATION SHALL BE ENTITLED TO LIFELONG VOTING MEMBERSHIP IN THE CORPORATION. FORM 990, PART VI, SECTION A, LINE 7A PRIOR TO JUNE 30, 2014, THERE WERE TWELVE DIRECTORS ON THE BOARD OF DIRECTORS THAT ARE ELECTED ANNUALLY BY THE MEMBERS AT THE ANNUAL MEETING OR AT A SPECIAL MEETING HELD FOR SUCH PURPOSE. THE CHIEF EXECUTIVE OFFICER WAS AN EX-OFFICIO MEMBER OF THE BOARD OF DIRECTORS. EFFECTIVE JUNE 30, 2014, THEDACARE, INC. HAS THE AUTHORITY IN THE COPORATION TO VOTE AND TAKE ANY ACTION WITH RESPECT TO THE ELECTION OF DIRECTORS AND OFFICERS. A CONSULTATION WOULD OCCUR WITH CHN BEFORE SUCH ACTIONS WERE TAKEN. FORM 990, PART VI, SECTION A, LINE 7B PRIOR TO JUNE 30, 2014, MEMBERS HAD THE FOLLOWING RESERVED POWERS 2.2.1 TO APPROVE ALL AMENDMENTS AND RESTATEMENTS OF ARTICLES OF INCORPORATION AND BYLAWS 2.2.2 TO VOTE ON NOMINATIONS TO FILL OPEN BOD POSITIONS AT THE ANNUAL MEETING 2.2.3. TO RECEIVE AN ANNUAL REPORT ON THE CORPORATIONS BUSINESS AND OPERATIONS 2.2.4 TO VOTE ON NOMINATIONS TO FILL OPEN NON-DIRECTOR GOVERNANCE AND NOMINATIONS COMMITTEE POSITIONS PURSUANT TO THE PROCEDURES ET FORTH IN SECTION 6.6.4 OF THESE BYLAWS. EFFECTIVE JUNE 30, 2014, THEDACARE, INE. HAS THE AUTHORITY WITH RESPECT TO THE FOLLOWING MATTERS: 1. MERGE, CONSOLIDATE, OR CHANGE CONTROL OF THE ORGANIZATION 2. SELL, LEASE, TRANSFER, OR DISPOSE OF MATERIAL ASSETS 3. ENTER JOINT VENTURES OR AFFILIATIONS 4. AMEND BYLAWS AND ARTICLES OF INCORPORATION 5. DEVELOP AND APPROVE CAPITAL AND OPERATING BUDGETS 6. AUTHORIZE AND MAKE CAPITAL EXPENDITURES 7. APPROVE STRATEGIC PLANS, WITH MANAGEMENT AND BOARD OVERSIGHT 8. APPROVE THE SAFETY AND QUALITY PLAN 9. APPROVE THE DISSOLUTION OR LIQUIDATION 10. APPOINT AUDITORS AND LEGAL COUNSEL 11. RETAIN INVESTMENT ADVISORS AND ESTABLISH INVESTMENT POLICIES 12. HIRE OR TERMINATE THE CEO 13. BORROW AND INCUR DEBT FORM 990, PART VI, SECTION B, LINE 11 THE BOARD OF DIRECTORS HAS DELEGATED THE DETAIL REVIEW OF THE FORM 990 TO THE MANAGEMENT OF THE CORPORATION. THEY COMPLETED THEIR REVIEW PRIOR TO SUBMISSION. FORM 990, PART VI, SECTION B, LINE 12C IT IS THE DIRECTOR, OFFICER AND/OR COMMITTEE MEMBER'S RESPONSIBILITY TO DISCLOSE TO THE BOARD OF DIRECTORS OR COMMITTEE CONSIDERING A TRANSACTION, ANY POTENTIAL FINANCIAL INTEREST. THE CHAIRPERSON OF THE BOARD OR COMMITTEE MAY THEN QUESTION THE INTERESTED PERSON FURTHER. THE BOARD OR COMMITTEE MAKES THE DECISION WHETHER A CONFLICT OF INTEREST EXISTS. IN ADDITION TO THE ABOVE, DIRECTORS, OFFICERS AND COMMITTEE MEMBERS EXECUTE AND DELIVER TO CHN A "CERTIFICATE REGARDING CONFLICTS OF INTEREST" ON AN ANNUAL BASIS. PER THE POLICY, THE BOARD IS TO CONDUCT PERIODIC REVIEWS OF ITS TRANSACTIONS AND ARRANGEMENTS. REVIEW SHALL INCLUDE: - WHETHER COMPENSATION ARRANGEMENTS AND BENEFITS ARE REASONABLE AND ARE THE RESULT OF ARM'S-LENGTH BARGAINING - WHETHER ACQUISITIONS OF PHYSICIAN PRACTICES AND OTHER PROVIDER SERVICES RESULT IN PRIVATE INUREMENT OR IMPERMISSIBLE PRIVATE BENEFIT - WHETHER PARTNERSHIPS, JOINT VENTURES, AND OTHER TYPES OF ARRANGEMENTS FURTHER CHN'S CHARITABLE PURPOSE AND DO NOT RESULT IN PRIVATE INUREMENT OR IMPERMISSIBLE PRIVATE BENEFIT IF IT IS DETERMINED A CONFLICT OF INTEREST EXISTS, THE INTERESTED PERSON IS PROHIBITED FROM PARTICIPATING IN THE TRANSACTION. FORM 990, PART VI, SECTION B, LINE 15 THE COMPENSATION DETERMINATION FOR THE CEO OF COMMUNITY HEALTH NETWORK IS AS FOLLOWS: THE CEO IS UNDER AN EMPLOYMENT CONTRACT. HIS SALARY IS REVIEWED PER HIS CONTRACT BY THE EXECUTIVE COMMITTEE OF THE BOARD OF DIRECTORS (THOSE WITHOUT CONFLICT). THE EXECUTIVE COMMITTEE REVIEWS COMPENSATION BENCHMARK DATA, COMPARES THE DATA WITH THE CEO'S CURRENT SALARY AND MAKES A SALARY DETERMINATION WHICH IS THEN VOTED ON BY THE EXECUTIVE COMMITTEE. THE COMPENSATION DETERMINATION FOR THE CFO IS AS FOLLOWS. ONCE A YEAR, CHN'S CEO REVIEWS COMPENSATION BENCHMARK DATA AND COMPARES THE DATA WITH THE CFO'S CURRENT SALARY AND THE PROPOSED INCREASE. BASED ON THE DATA, THE CEO, A PERSON WITHOUT CONFLICT, DETERMINES THE CFO'S SALARY FOR THE COMING YEAR. THE SALARY IS DISCUSSED AND AGREED UPON BY CHN'S CEO AND THE INDIVIDUAL. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION BELIEVES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE THE PROPERTY OF THE ORGANIZATION AND DOES NOT MAKE THEM AVAILABLE TO THE PUBLIC. FORM 990, PART XI, LINE 9: ELIMINATION OF INTEREST IN PARTNERS HEALTH SYSTEM FOUNDATION, INC. -1,159,972. FORM 990, PART XII, LINE 2C MANAGEMENT PROVIDES OVERSIGHT OF THE AUDIT. THE AUDIT IS PRESENTED TO THE FINANCE COMMITTEE OF THE BOARD OF DIRECTORS. FORM 990, PART XI, LINE 2C THE PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. 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