2015-11-12T10:44:40-06:00 2014-12-31 390758449 WIPFLI LLP PO BOX 12237 GREEN BAY WI 543072237 990 2014-01-01 390824015 APPLETON MEDICAL CENTER INC APPL 9207355560 PO BOX 8025 APPLETON WI 54912 TIM A OLSON CHIEF FINANCIAL OFFICER 9207355560 2015-10-26 1 TERRI REXRODE CPA MST P00096513 9206620016 2015-10-26 2014 2016-04-25 22:37:26Z TIM A OLSON PO BOX 8025 APPLETON WI 54912 252114280 0 X WWW.THEDACARE.ORG X 1958 WI TO IMPROVE THE HEALTH OF OUR COMMUNITY. 15 11 0 469 786149 -67933 470238 168503 236362664 251778383 198132 -35105 382181 150405 237413215 252062186 0 0 0 0 113055200 116601921 0 0 0 110374179 109668147 223429379 226270068 13983836 25792118 340798306 366986127 1572915 1978618 339225391 365007509 TO PROVIDE THE HIGHEST QUALITY HEALTH CARE, DELIVERED IN THE MOST EFFICIENT AND COST-EFFECTIVE WAYS, AND ACCESSIBLE TO ALL MEMBERS OF THE COMMUNITY. 0 0 195238709 250118290 160-BED ACUTE CARE HOSPITAL, HEART, CANCER, AND OUTPATIENT SURGERY CENTERS, AND WELLNESS PROGRAMS. WITH CORPORATE PARENT THEDACARE, WE OFFER PUBLIC AWARENESS CAMPAIGNS, CHARITY CARE, SUPPORT GROUPS, AND EDUCATION PROGRAMS TARGETED TO LOCAL COMMUNITY NEEDS. 195238709 1 1 0 1 0 0 0 0 0 0 1 0 0 1 0 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 0 0 0 1 1 0 0 0 0 0 0 0 0 0 X 15 11 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 X KRISTEN COGSWELL 9207386471 122 EAST COLLEGE AVENUE APPLETON WI 54911 STELLMACHER JON BOARD CHAIR 1.00 2.00 X X 0 0 0 WELLER MIKE BOARD MEMBER 1.00 2.00 X 0 0 0 WHITESIDE JEFFREY MD SECRETARY 1.00 2.00 X X 0 0 0 GRUNER DEAN BOARD MEMBER/CEO - SYSTEM 5.00 38.00 X X 120869 1087821 176335 EDELMAN GARY MD BOARD MEMBER/PHYSICIAN 1.00 42.00 X 0 416823 28643 TURK NORMA MD BOARD MEMBER/PHYSICIAN 41.00 2.00 X 277642 0 16665 MOARD DOUGLAS MD BOARD MEMBER/PHYSICIAN 1.00 42.00 X 0 337196 32121 JONES GINGER BOARD MEMBER 1.00 2.00 X 0 0 0 LARSON JIM BOARD MEMBER 1.00 3.00 X 0 0 0 DAVIS JOHN BOARD MEMBER 1.00 2.00 X 0 0 0 BRENNAN PATRICK MD BOARD MEMBER 1.00 2.00 X 0 0 0 TIMBERLAKE KAREN BOARD MEMBER 1.00 2.00 X 0 0 0 WALSH CYRIL MD BOARD MEMBER 1.00 3.00 X 0 0 0 KLISTER PAUL BOARD MEMBER 1.00 2.00 X 0 0 0 DALEY-ULLEM BETH BOARD MEMBER 1.00 2.00 X 0 0 0 OLSON TIM VP CFO SYSTEM 4.00 38.00 X 48594 437352 108726 LIVINGSTON KEITH VP SR CIO 4.00 36.00 X 47685 429165 89435 PISTONE MAUREEN VP SR HR SERVICES 4.00 36.00 X 44020 396186 83053 BARNAS KIM VP SR AMC & TC 16.00 24.00 X 276890 415335 23158 BURMEISTER BRIAN VP SR AMC & TC 6.00 36.00 X 65942 373670 73139 CORREIA KATHRYN FORMER VP. SR. HOSPITAL SERVICES 0.00 0.00 X 325418 0 0 FERRANTE ROBERT MD PHYSICIAN 40.00 0.00 X 788294 0 30875 WILSON ROBERT MD PHYSICIAN 40.00 0.00 X 612795 0 31954 MARIANO DIONISIO MD PHYSICIAN 40.00 0.00 X 612696 0 32728 GUTTORMSEN BRIAN MD PHYSICIAN 40.00 0.00 X 615967 0 31303 ACKELL PETER MD PHYSICIAN 40.00 0.00 X 610712 0 34424 4447524 3893548 792559 78 1 1 0 RADIOLOGY ASSOCIATES OF APPLETON PO BOX 117 APPLETON WI 54912 MEDICAL SERVICES 662899 CLEAN POWER LLC PO BOX 88369 MILWAUKEE WI 53288 ENVIRONMENTAL SERVICES 340877 FRESENIUS MANAGEMENT SVCS INC 16343 COLLECTION CENTER DR CHICAGO IL 60693 MANAGEMENT SERVICES 318825 DAILY CARE HOSPITALIST LLC 2919 SHELTER CREEK GREEN BAY WI 54313 MEDICAL SERVICES 138848 AUREUS RADIOLOGY LLC PO BOX 3037 OMAHA NE 68103 MEDICAL SERVICES 113516 5 168503 168503 OUTPATIENT REVENUE 621400 140809342 140809342 INPATIENT REVENUE 621990 109308948 109308948 CAFETERIA REVENUE 900099 830784 830784 LAB REFERRAL REVENUE 621500 786149 786149 OTHER MISC REVENUE 900099 43160 43160 251778383 14181 14181 150405 0 150405 150405 150405 2808 52094 -49286 -49286 -49286 252062186 250118290 786149 989244 964295 294307 669988 89590225 72761888 16828337 3160087 3160087 17310081 14149684 3160397 5577233 5577233 21733246 12649597 9083649 163270 163270 1846592 866591 980001 6107183 5798196 308987 86370 86370 273282 273282 5207884 5207884 14132474 14132474 736973 736973 CLIENT & PATIENT SERVIC 50649276 50649276 BAD DEBT EXPENSE 4921042 4921042 EQUIPMENT MAINTENANCE 3810555 3810555 226270068 195238709 31031359 0 3500 29048936 31978239 1306927 1844978 227945744 130867532 103172109 97078212 207266834 236084698 340798306 366986127 1572915 1978618 1572915 1978618 X 339225391 365007509 339225391 365007509 340798306 366986127 X 25792118 -10000 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 11329 11329 0 PART II-B, LINE 1: PORTION OF WHA DUES = $11,329 2384215 2384215 146276678 66195385 80081293 1105025 653260 451765 78179826 64018887 14160939 97078212 DUE FROM AFFILIATES 236084698 236084698 X PART X, LINE 2: 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 IN 2014 AND 2013. TAX RETURNS FOR THE YEARS ENDED 2011 AND BEYOND REMAIN SUBJECT TO EXAMINATION BY THE INTERNAL REVENUE SERVICE. 1 1 X 1 X 1 X 1 0 1 1 1736648 1736648 0.00780 21570287 18447973 3122314 0.01410 23306935 18447973 4858962 0.02190 23 241714 1263927 1263927 0.00570 3 586 553002 553002 0.00250 4 4427630 4427630 0.02000 2 64 370506 22885 347621 0.00160 6 406450 810430 810430 0.00370 38 648814 7425495 22885 7402610 0.03350 38 648814 30732430 18470858 12261572 0.05540 1 50 17535 4944 12591 0.00010 1 100000 4670 4670 0.00000 1 1683 1683 0.00000 1 8301 7689 7689 0.00000 1 198427 670 670 0.00000 1 25 194 194 0.00000 1 150 4887 4887 0.00000 7 306953 37328 4944 32384 0.00010 0 2160492 1728896 41894768 43843126 -1948358 X 1 1 1 1 APPLETON MEDICAL CENTER PO BOX 8025 APPLETON WI 54912 HTTPS://WWW.THEDACARE.ORG 169 X X X APPLETON MEDICAL CENTER 1 0 0 1 X X X X X X X X X X 13 1 1 0 1 X SEE 7D X X 1 13 1 SEE 7D 1 0 1 X 200.000000000000 300.000000000000 X X X X X 1 1 X X X X X 1 X X X X X 0 0 X X X 1 X 0 0 APPLETON MEDICAL CENTER PART V, SECTION B, LINE 3J: APPLETON MEDICAL CENTER'S CHNA ALSO IDENTIFIED OWNER EXPECTATIONS, MISSION/VALUES, KEY COMPONENTS OF OUR COMMITMENT, ORGANIZATIONAL SUPPORT, ADVISORY TEAM GUIDANCE AND THE HEALTH IMPROVEMENT MODEL. APPLETON MEDICAL CENTER PART V, SECTION B, LINE 5: PUBLIC HEALTHTHEDACARE WORKED CLOSELY WITH LOCAL OUTAGAMIE AND CALUMET COUNTY PUBLIC HEALTH DEPARTMENTS THROUGHOUT THE ENTIRE NEEDS ASSESSMENT PROCESS. THEDACARE HAS REPRESENTATION ON THE FOX VALLEY COMMUNITY HEALTH IMPROVEMENT COALITION WHICH MEETS MONTHLY WITH LOCAL HEALTH SYSTEM REPRESENTATIVES AND PUBLIC HEALTH OFFICIALS FROM THE COUNTIES OF OUTAGAMIE, CALUMET AND WINNEBAGO AND CITIES OF APPLETON AND MENASHA. PUBLIC HEALTH IS REPRESENTED ON THEDACARE'S NEEDS ASSESSMENT ADVISORY COMMITTEE AND ALSO ON THE THEDACARE-LED COMMUNITY HEALTH ACTION TEAM. IN ADDITION TO THESE FORMAL MEETINGS, ONE-ON-ONE INTERVIEWS WITH PUBLIC HEALTH OFFICIALS WERE CONDUCTED EITHER OVER THE PHONE OR IN PERSON. SOURCES: MARY DORN, OUTAGAMIE COUNTY PUBLIC HEALTH MANAGER; KURT EGGEBRECHT, CITY OF APPLETON PUBLIC HEALTH OFFICER; BONNIE KOLBE, CALUMET COUNTY PUBLIC HEALTH OFFICER.COMMUNITY HEALTH ACTION TEAMS (CHAT) ARE THE PRIMARY RESOURCES THEDACARE USES TO ENGAGE THE COMMUNITY IN BETTER UNDERSTANDING THE LOCAL HEALTH NEEDS AND DEVELOPING PLANS FOR ACTION. THEDACARE'S COMMUNITY HEALTH SPECIALISTS HELP FACILITATE THE CHAT EFFORTS FOR FOUR CHAT TEAMS IN THE FOX CITIES, NEW LONDON, SHAWANO AND WAUPACA AREAS. EACH CHAT TEAM IS COMPRISED OF LOCAL COMMUNITY LEADERS FROM BUSINESS, EDUCATION, PUBLIC HEALTH, AREA HEALTH SYSTEMS, FAITH COMMUNITIES, NON-PROFIT ORGANIZATIONS AND GOVERNMENT. THESE LEADERS SELECT ISSUES TO STUDY, ORGANIZE "PLUNGE" EXPERIENCES (DAY-LONG FIELD TRIPS) TO GAIN IN-DEPTH UNDERSTANDING AND COLLABORATE IN PROBLEM-SOLVING INITIATIVES. THIS RESULTS IN SUSTAINABLE, EFFECTIVE COMMUNITY-BASED SOLUTIONS TO SYSTEMIC HEALTH ISSUES. APPLETON MEDICAL CENTER PROVIDERS AND STAFF ARE INTEGRATED INTO A WIDE VARIETY OF THESE INITIATIVES. THE FOX CITIES CHAT INCLUDES LEADERS FROM PUBLIC HEALTH, UNITED WAY, COMMUNITY FOUNDATION, NON-PROFITS, EDUCATION, AND HEALTH ORGANIZATIONS WHICH COLLECTIVELY REPRESENT THE BROAD INTERESTS OF THE COMMUNITY. 2014 FOX CITIES COMMUNITY HEALTH ACTION TEAM ROSTERROGER BERTSCHAUSEN, FOX VALLEY UNITARIAN UNIVERSALIST FELLOWSHIPWILL BLOEDOW, RETIRED RAY DURKEE, APPLETON MEDICAL CENTER FOUNDATIONKURT EGGEBRECHT, CITY OF APPLETON HEALTH DEPARTMENTMICHAEL FROHNA, THEDACARE FOUNDATIONSJAY FULKERSON, HEALTH PAYMENT SYSTEMSTIM GALLOWAY, GALLOWAY COMPANYERNESTO GONZALES, CASA HISPANADEAN GRUNER, THEDACAREPAM HENSON, GANNETTMARTI HEMWALL, COMMUNITY FOUNDATION FOR THE FOX VALLEY REGIONCHAD HERSHNER, CHILDREN'S HOSPITAL OF WISCONSINPETER KELLY, UNITED WAY OF THE FOX CITIESSHANNON KENEVAN, HARMONY CAF /GOODWILL INDUSTRIESGREG LEMKE ROCHON, CPO BOYS & GIRLS CLUB OF THE FOX VALLEYCHRIS MATHENY, VP FOX VALLEY TECHNICAL COLLEGEJOHN MIELKE, MD, THEDACAREPAULA MORGEN, THEDACARECATHY MUTSCHLER, COMMUNITY FIRSTAMY PUTZER, OSHKOSH AREA COMMUNITY FOUNDATIONROLLIE STEPHENSON, FAITH TECHNOLOGIESLISA TRUMAN, MINISTRY HEALTH SYSTEMBEN VOGEL, APPLETON AREA SCHOOL DISTRICTDEBORAH WETTER, VALLEY TRANSITKEY INFORMANT INTERVIEWS WERE CONDUCTED WITH EXPERTS REPRESENTING VULNERABLE OR MARGINALIZED POPULATIONS IN OUR COMMUNITY INCLUDING FARM FAMILIES, LATINO POPULATION, LESBIAN, GAY, BISEXUAL TRANSGENDER (LGBT), LOW INCOME, HMONG. SOURCES: RHONDA STREBEL, RURAL HEALTH INITIATIVE; ERNESTO GONZALES, CASA HISPANA; DR. IRIS TORRES AND PATRICIA SARVALA, FOX CITIES COMMUNITY HEALTH CENTER; TONY GONZALES, THOMPSON COMMUNITY CENTER; TRICIA NELSON, THEDACARE MEDICAL HOME; LO LEE AND JENNIFER GAINES BATES, HMONG AMERICAN PARTNERSHIP; CHAT INCLUDE BREAKFAST, JAN & MAY 2013. APPLETON MEDICAL CENTER PART V, SECTION B, LINE 6A: AFFINITY HEALTH SYSTEM APPLETON MEDICAL CENTER PART V, SECTION B, LINE 7D: THE CHNA WAS MADE AVAILABLE TO LOCAL CHAT, THEDACARE BOARDS AND LEADERSHIP TEAMS.FULL CHNA AND IMPLEMENTATION STRATEGY WEBSITE: WWW.THEDACARE.ORG/HOSPITALS-AND-CLINICS/APPLETON-MEDICAL-CENTER.ASPX APPLETON MEDICAL CENTER PART V, SECTION B, LINE 11: NEEDS IDENTIFIED AND WORKING ON:OBESITY-ESTABLISHED WEIGHT OF THE FOX VALLEY - A FOUR HEALTHCARE SYSTEM APPROACH TO TACKLING OBESITY, IS IN THE PROCESS OF FORMING WORK GROUPS. THEDACARE SUPPORTS THIS WITH FINANCIAL CONTRIBUTIONS AND PARTICIPATION ON THE LEADERSHIP AND CORE TEAMS.-ESTABLISHED EAT SMART - A LOCAL RESTAURANT INITIATIVE PROMOTING HEALTHY EATING-PROVIDES FUNDING TO LOCAL FARMER'S MARKETS TO PROVIDE HEALTHY FOOD TO THE COMMUNITY -CONTRIBUTED FINANCIALLY TO THE CONSTRUCTION OF HOOP HOUSES AT THE COMMUNITY GARDEN -THEDACARE PARTNERS WITH LOCAL YMCA'S TO EDUCATE CHILDREN ABOUT EATING HEALTHY AND THE BENEFITS OF BEING ACTIVE-THEDACARE SPONSORS MULTIPLE FAMILY EVENTS THAT CONTRIBUTE TO EXERCISE AND FAMILY ACTIVITY AND SUPPORTS THE YMCA HEALTHY KIDS CAMPAIGN.-IN 2014, THEDACARE ESTABLISHED GOOD TO GO WEEK AN EMPLOYEE LED INITIATIVE THAT TOOK PLACE IN 6 SCHOOL DISTRICTS THROUGHOUT THE THEDACARE SYSTEM. ACTIVITIES WILL INCLUDE HEALTHY SNACKS, BUILD A SCHOOL GARDEN, FATS IN FOODS, MEASURE YOUR DRINK, LEADING GYM CLASSES. MENTAL HEALTH: -THEDACARE PROVIDES FINANCIAL AND IN-KIND SUPPORT FOR THE PRIMARY CARE/MENTAL HEALTH INITIATIVE AIMED AT IMPROVING PCP'S ABILITY TO TREAT BASIC MENTAL HEALTH ISSUES,-PROVIDES LEADERSHIP AND FINANCIAL SUPPORT FOR CATALPA HEALTH - HELPING CHILDREN AND FAMILIES OBTAIN MENTAL HEALTH AND WELLNESS-PROVIDES LEADERSHIP AND FUNDING FOR THE FOX VALLEY COMMUNITY CLINIC-PROVIDED OVER $1,000,000 IN SUBSIDIZED MENTAL HEALTH SERVICES, PROVIDED LEADERSHIP AND FINANCIAL SUPPORT FOR THE NEW MENTAL HEALTH CONNECTION-SUPPORTS THE NEW MENTAL HEALTH CONNECTION, A COALITION OF MENTAL HEALTH PROVIDERS-ESTABLISHED NO WRONG DOOR, A SAFETY NET SYSTEM TO DETECT KIDS IN CRISIS-PROVIDES LEADERSHIP TO THE SUICIDE PREVENTION TASK FORCESUBSTANCE ABUSE:-IS WORKING WITH LOCAL LEGISLATORS AND LOCAL COMMUNITIES TO CHANGE SOCIAL NORMS AND LAWS-CONTINUES TO HOST ANNUALLY PARTY AT THE PAC - EDUCATING TEENS ABOUT THE DANGERS OF DRIVING WHILE DRINKING OR TEXTING-USES STANDARD WORK PROCEDURES TO SCREEN PATIENTS FOR DOCTOR AND PRESCRIPTION SHOPPINGEND OF LIFE:-WITH THE GOAL OF INCREASING PEOPLE WHO HAVE WRITTEN END OF LIFE DIRECTIVES, THEDACARE IS WORKING WITH OTHER HEALTHCARE SYSTEMS TO DEVELOP A COMMON SYSTEM-THEDACARE PROVIDES FINANCIAL AND LEADERSHIP SUPPORT TO THE END OF LIFE COALITIONTEEN PREGNANCY:-PROVIDES FINANCIAL AND LEADERSHIP SUPPORT FOR CUIDATE - A CULTURALLY SENSITIVE DELAYED PREGNANCY PREVENTION INITIATIVEVIOLENCE:-PROVIDES FUNDING AND LEADERSHIP TO INCLUDE - CHANGING ATTITUDES ABOUT THE LGBT COMMUNITY IN THE FOX VALLEY BY EDUCATING BOTH YOUTH & ADULTS ON THE EFFECTS OF BULLYING AND OTHER BEHAVIORS.-PROVIDES FUNDING AND LEADERSHIP TO VOICES OF MEN - MAKING A POWERFUL STATEMENT THAT COMMITTING, CONDONING OR REMAINING SILENT ABOUT MEN'S VIOLENCE AGAINST WOMEN AND CHILDREN IS NOT ACCEPTABLE.-PROVIDES FUNDING AND LEADERSHIP TO WOMEN'S FUND - ADDRESSING LEADERSHIP IN YOUNG WOMENACCESS TO CARE:-PROVIDE FINANCIAL SUPPORT TO THE PARTNERSHIP COMMUNITY HEALTH CENTER-PROVIDE 24/7 ACCESS TO MEDICAL CALL ADVISE VIA TELEPHONE-PROVIDE LEADERSHIP AND FINANCIAL SUPPORT TO THE RURAL HEALTH INITIATIVE - AN INITIATIVE THAT TAKES HEALTHCARE RIGHT TO THE FARMER'S DOORIDENTIFIED BUT NOT ADDRESSED:1.NUMBER OF PRIMARY CARE PROVIDERS - THIS ISSUE IS LIMITED TO EASTERN CALUMET COUNTY WHICH IS SERVICED BY OTHER HEALTH SYSTEMS.2.POVERTY - BEYOND WHAT OUR RESOURCES CAN SUPPORT AT THIS TIME3.SMOKING - PROGRESS HAS ALREADY BEEN MADE ON THIS ISSUE4.DIABETES - ADDRESSED THROUGH THE OBESITY PRIORITY APPLETON MEDICAL CENTER PART V, SECTION B, LINE 15E: OFFERED TO WORK DIRECTLY WITH PATIENTS TO COMPLETE THE APPLICATION IF NEEDED AND PROVIDED ASSISTANCE BEYOND THEDACARE ASSISTANCE FOR UNINSURED PATIENTS BY ASSISTING WITH THE FUNDING OF STAFF AT "PARTNERSHIP COMMUNITY EDUCATION CENTER". THEY ARE A NOT FOR PROFIT AGENCY THAT ASSISTS ANY MEMBER OF ANY COMMUNITY WITH MARKETPLACE INSURANCE ENROLLMENT AS WELL AS ASSESSING THE NEED FOR ADDITIONAL COMMUNITY BENEFITS THAT MAY BENEFIT THE PATIENT. APPLETON MEDICAL CENTER PART V, SECTION B, LINE 16I: THE FAP AND APPLICATION WERE AVAILABLE AT HOSPITAL CASHIER OFFICES, ON WEB SITE AND OFFERED TO ALL PATIENTS THAT EXPRESSED A FINANCIAL HARDSHIP WHEN CALLING THE BILLING OFFICE. THE PLS WAS PRINTED ON EVERY STATEMENT AND A FOOTER WAS ADDED TO THE FRONT OF THE STATEMENT ADVISING PATIENT TO SEE REVERSE SIDE OF STATEMENT FOR FINANCIAL ASSISTANCE AND PAYMENT OPTIONS. NOTIFICATION OF FINANCIAL ASSISTANCE AVAILABILITY WAS ADDED TO THE INITIAL LETTER SENT BY THE THIRD PARTY COLLECTION AGENCY. APPLETON MEDICAL CENTER PART V, SECTION B, LINE 20E: THEDACARE AND/OR THIRD PARTY COLLECTION AGENCY ARE PLACING A MINIMUM OF ONE OUTBOUND CALL TO ADVISE CUSTOMER OF PAYMENT OPTIONS INCLUDING FA PRIOR TO CREDIT BUREAU REPORTING OR LEGAL JUDGEMENT. PROCESS ADJUSTED TO ENSURE NO ECA UNTIL CUSTOMER RECEIVES AT LEAST 4 BILLING STATEMENTS AFTER DATE OF DISCHARGE. NO ECA UNTIL AT LEAST 120 DAYS AFTER DISCHARGE. APPLETON MEDICAL CENTER PART V, SECTION B, LINE 22D: LOOKBACK METHOD: FOR ER PATIENTS, TAKE THE 3 LARGEST COMMERCIAL INSURERS PLUS MEDICARE. ADD ALL PAYMENTS AND ALL CHARGES TO ARRIVE AT A DEDUCTION PERCENTAGE. REDUCE THE PATIENT'S BILL BY THIS PERCENTAGE. FOR NON-ER PATIENTS, TAKE THE 3 LARGEST COMMERCIAL INSURERS. ADD ALL PAYMENTS AND ALL CHARGES TO ARRIVE AT A DEDUCTION PERCENTAGE. PART V, LINE 13 PATIENTS ARE SENT AN OVERVIEW LETTER EXPLAINING THE PROCESS FOR APPLYING FOR OUR ASSISTANCE PROGRAM OR OUR STAFF WALKS THEM THROUGH THE PROCESS. THEY ARE ASKED TO COMPLETE AN APPLICATION THAT INCLUDES REQUESTS FOR INFORMATION. THIS INFORMATION IS NEEDED IN ORDER TO MAKE A DECISION AS TO WHETHER THE PATIENT MEETS THE CRITERIA FOR ACCEPTANCE, AND IF ACCEPTED, WHAT LEVEL OF ASSISTANCE WILL BE PROVIDED. ONCE THE DECISION IS MADE, WE WILL NOTIFY THE PATIENT AND IF ACCEPTABLE, WRITE OFF THE BALANCE AS DETERMINED. PART V, SECTION B, LINE 16 FINANCIAL ASSISTANCE POLICY WEBSITE AVAILABILITY APPLETON MEDICAL CENTER PART V, SECTION B, LINE 16A WEBSITE: WWW.THEDACARE.ORG/~/LINK.ASPX?_ID=206478F0E2874D2EAD353B71BC978623& APPLETON MEDICAL CENTER PART V, SECTION B, LINE 16B WEBSITE: WWW.THEDACARE.ORG/~/LINK.ASPX?_ID=206478F0E2874D2EAD353B71BC978623& 1 GROTH SURGERY CENTER PO BOX 8025 APPLETON WI 54912 OUTPATIENT SURGERY CENTER PART I, LINE 3C: IT IS THE ORGANIZATION'S POLICY THAT NO PATIENT SHOULD BE DENIED APPROPRIATE AND NECESSARY CARE ON THE BASIS OF INCOME. IN RESPONSE TO THIS POLICY, THE CARING HEARTS FINANCIAL ASSISTANCE PROGRAM WAS SET UP TO PROVIDE SHELTER TO THOSE PATIENTS WHO ARE UNABLE TO PAY FOR THEIR MEDICAL SERVICES. MEDICAL SERVICE FEES ARE WRITTEN OFF UNDER THE FINANCIAL ASSISTANCE PROGRAM THAT WOULD OTHERWISE HAVE BEEN SENT TO A COLLECTION AGENCY. PART I, LINE 7: THE COSTING METHODOLOGY USED TO CALCULATE THE AMOUNTS IN THE TABLE IS A COMBINATION OF AVERAGE COSTS AND ACTUAL COSTS PERTAINING TO SUPPLIES, WAGES, AND BENEFITS. FOR SUPPLIES, THE ACTUAL COST OF ITEMS USED FOR EACH EVENT IS APPLIED. IF NO ACTUAL COST IS AVAILABLE, WE THEN USE AN ESTIMATE. WAGES ARE CALCULATED BY MULTIPLYING THE AVERAGE WAGE RATE TIMES ACTUAL HOURS WORKED. THE BENEFIT RATE USED INCLUDES A FRINGE RATIO OF ALL BENEFITS RELATED TO THE ABOVE WAGE CALCULATION. THE COST ACCOUNTING SYSTEM DOES NOT DIFFERENTIATE BETWEEN DIFFERENT PAYER TYPES AND NO COST-TO-CHARGE RATIO IS USED. PART I, LINE 7G: NO PHYSICIAN CLINICS ARE INCLUDED IN SUBSIDIZED HEALTH SERVICES. PART I, LN 7 COL(F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990 (PART IX, LINE 25, COLUMN A) BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $4,921,042. PART II, COMMUNITY BUILDING ACTIVITIES: THE HEALTH OF THE COMMUNITY APPLETON MEDICAL CENTER SERVES IS PROMOTED THROUGH SEVERAL COMMUNITY BUILDING ACTIVITIES AS DESCRIBED BELOW:WELL CITY INITIATIVE - PROMOTES DEVELOPMENT OF A HEALTHY WORKPLACE THROUGHOUT THE FOX CITIES.NEW MENTAL HEALTH CONNECTION - COALITION OF MENTAL HEALTH PROVIDERS MEETING TO IMPROVE ACCESS TO MENTAL HEALTH SERVICES THROUGHOUT FOX CITIES.CHAMBER OF COMMERCE SUPPORT - ENCOURAGES ECONOMIC DEVELOPMENT WHICH IN TURN PROVIDES JOBS AND INCOME, BOTH CONTRIBUTORS TO HEALTH.VOICES OF MEN - WORKS TO ADDRESS THE ROOT CAUSE OF VIOLENCE AGAINST WOMEN AND GIRLS WHICH INCLUDES DEVALUING AND OBJECTIFYING WOMEN AND TREATING WOMEN AS PROPERTY. NO WRONG DOOR - EFFORT TO DEVELOP COMMUNITY WIDE MENTAL HEALTH SAFETY NET.DISASTER READINESS - HELPS ENSURE THE ENTIRE COMMUNITY IS READY FOR POTENTIAL EMERGENCIES. COMMUNITY ACTION FOR HEALTHY LIVING - COALITION THAT ADVOCATES FOR HEALTHY LIFESTYLE CHANGE. THEDACARE NEIGHBORHOOD GARDEN/FARMER'S MARKETS - PROVIDES FRESH PRODUCE TO AREA FOOD PANTRIES AND THE COMMUNITY.FOX VALLEY END OF LIFE COALITION - A GRASSROOTS CONSORTIUM WITH A MISSION TO IMPROVE END-OF-LIFE CARE AND CHOICES FOR ALL PEOPLE, THEIR FAMILIES, AND THEIR PHYSICIANS IN THE FOX CITIES.EMERGING LEADERS - MAKING AN IMPACT IN OUR COMMUNITY THROUGH DEDICATION TO SERVICE AND PHILANTHROPY.SUMMIT FOR HOPE - AIMS TO RAISE AWARENESS ABOUT SUBSTANCE ABUSE AND THE GROWING HEROIN ISSUE. PARTY AT THE PAC - PUTS TEEN SAFETY INTO FOCUS.ELECTRONIC RECYCLING EVENT - WORKING TO TREAT THE EARTH WITH THE RESPECT THAT IT DESERVES.COMMUNITY SHARPS COLLECTION - REDUCING THE RISKS OF INFECTIOUS WASTE.WISCONSIN SUSTAINABLE BUSINESS COUNCIL - TAKING AN ACTIVE POSITION ON THE ROLE OF CLIMATE CHANGE AND BUILDING HEALTHY COMMUNITIES BY REDUCING OR ELIMINATING OUR ENERGY WASTE AND WATER FOOTPRINT. ORGAN/TISSUE DONATION - ADVANCING ORGAN DONATION EDUCATION.RURAL HEALTH INITIATIVE - ADDRESSING GROWING CONCERNS REGARDING THE HEALTH AND SAFETY ISSUES FACING TODAY'S FARM FAMILIES. YMCA STRONG KIDS - PROVIDING KIDS THE OPPORTUNITIES THEY NEED TO REACH THEIR FULL POTENTIAL, LIVE HEALTHIER, HAPPIER LIVES TODAY, AND GROW INTO PRODUCTIVE ADULTS IN THE FUTURE. FOX VALLEY FAMILY MEDICINE RESIDENCY PROGRAM - TEACHING THE ART AND HEART OF CARE.BUILDING FOR KIDS - BUILDING KIDS IMAGINATION, CREATIVITY AND CONFIDENCE. CHAT - COMMUNITY LEADERS WORKING TOGETHER TO EXPLORE LOCAL AND REGIONAL HEALTH ISSUES. THEDACARE CENTER FOR HEALTHCARE VALUE - OFFERS LEARNING EXPERIENCES THAT DEVELOP HEALTHCARE LEADERS WHO ARE CAPABLE OF CONFIDENTLY DRIVING THE LEAN TRANSFORMATION OF THEIR ORGANIZATIONS TO DELIVER MEASURABLY BETTER VALUE TO THE PATIENTS, FAMILIES AND COMMUNITIES THEY SERVE. TRAUMA SYMPOSIUM - FOCUSING ON EMERGENCY PREPAREDNESS. SEXUAL ASSAULT NURSE EXAMINER - WORKING TO END SEXUAL AND DOMESTIC VIOLENCE. UNITED WAY - WORKING EVERY DAY TO IMPROVE THE COMMUNITY.END OF LIFE COALITION - WORKING TOWARDS GETTING END OF LIFE DECISIONS COORDINATED AND DOCUMENTS SO THAT PEOPLE HAVE THEIR LAST WISHES RECOGNIZED.INSTITUTE FOR HEALTH CARE IMPROVEMENT - SUPPORT FOR COMMUNITY TRANSFORMATION EFFORTS PART III, LINE 8: HOSPITALS MUST ACCEPT MEDICARE PATIENTS REGARDLESS OF WHETHER THEY MAKE A SURPLUS OR DEFICIT FROM PROVIDING SERVICES TO THOSE PATIENTS. WE DID NOT REPORT ANY SHORTFALL AS A COMMUNITY BENEFIT. THE COSTING METHODOLOGY USED TO DETERMINE THE MEDICARE ALLOWABLE COSTS REPORTED IN THE ORGANIZATIONS MEDICARE COST REPORT IS STEP DOWN. PART III, LINE 9B: OUR POLICY IS NOT TO PURSUE PATIENT ACCOUNTS TO THE EXTENT ANY CHARGES ARE ELIGIBLE AND WRITTEN OFF THROUGH OUR CHARITY CARE/FINANCIAL ASSISTANCE PROGRAM. IF ONLY A PORTION OF THE CHARGES ARE ELIGIBLE AND WRITTEN OFF THROUGH OUR CHARITY CARE/FINANCIAL ASSISTANCE PROGRAM, THE REMAINING BALANCE WILL BE BILLED TO THE PATIENT AND COLLECTED IN ACCORDANCE WITH OUR NORMAL COLLECTION POLICY. PART VI, LINE 2: THEDACARE SERVES A 9 COUNTY PRIMARY SERVICE AREA. FIVE THEDACARE HOSPITALS PROVIDE SERVICE IN THIS AREA. THEDACARE CONDUCTS A COMMUNITY NEEDS ASSESSMENT EVERY THREE YEARS FOR THE ENTIRE SYSTEM GATHERING DATA PERTINENT TO EACH COMMUNITY. INFORMATION COLLECTED INCLUDES DATA FROM THE WISCONSIN COUNTY HEALTH RANKINGS, FOX CITIES LIFE STUDY (LOCAL INDICATORS FOR EXCELLENCE), THE BEHAVIORAL RISK FACTOR SURVEILLANCE SURVEY, INSIGHTS FROM INTERVIEWS OF PUBLIC HEALTH OFFICIALS, INSIGHTS FROM INTERVIEWS WITH REPRESENTATIVES OF VULNERABLE POPULATIONS, EMERGENCY DEPARTMENT PATIENT DATA AND INSIGHTS GATHERED FROM MONTHLY MEETINGS OF THE THEDACARE-LED CHAT TEAM (COMMUNITY HEALTH ACTION TEAM) COMPRISED OF 25 COMMUNITY LEADERS IN BUSINESS, NON-PROFIT, CLERGY, HEALTHCARE, UNITED WAY, PUBLIC HEALTH AND THE LOCAL COMMUNITY FOUNDATION. PART VI, LINE 3: PATIENT EDUCATION BEGINS WHEN A PATIENT IS ADMITTED TO A THEDACARE HOSPITAL. ADMISSION SPECIALISTS MEET WITH EACH PERSON INDIVIDUALLY TO ASSESS INSURANCE STATUS AND FINANCIAL NEED. IF NECESSARY, SPECIALISTS REFER PATIENTS TO CARE MANAGEMENT SPECIALISTS WHO ASSIST WITH THE ENROLLMENT OF PATIENTS IN AN APPLICABLE PROGRAM. THE HOSPITAL PATIENT HANDBOOK IS PROVIDED TO ALL IN-PATIENTS. INTERNAL POLICIES SUCH AS DISCOUNTED SERVICES POLICY, CARING HEARTS POLICY AND PAYMENT FOR SERVICE POLICY FOR SELF-PAY BALANCES PROVIDE GUIDANCE.THE THEDACARE WEBSITE, WWW.THEDACARE.ORG, PROVIDES EDUCATION REGARDING THE AFFORDABLE CARE ACT IN EASY TO UNDERSTAND LANGUAGE. IT DISCUSSES OPTIONS AND WHERE TO GO FOR ASSISTANCE.THE THEDACARE WEBSITE, WWW.THEDACARE.ORG, PROVIDES EDUCATION REGARDING THE AFFORDABLE CARE ACT IN EASY TO UNDERSTAND LANGUAGE. IT DISCUSSES OPTIONS AND WHERE TO GO FOR ASSISTANCE. PART VI, LINE 4: APPLETON MEDICAL CENTER'S SERVICE AREA CONSISTS OF OUTAGAMIE AND CALUMET COUNTIES AND IS LOCATED EAST-CENTRAL WISCONSIN. THE TWO-COUNTY AREA HOSTS A POPULATION OF 225,666 COMBINED WITH CONCENTRATION IN THE FOX CITIES URBAN AREA.OUTAGAMIE COUNTY:-OVER THE LAST DECADE, OUTAGAMIE COUNTY POPULATION HAS GROWN BY 9.77%. THIS WILL MAKE OUTAGAMIE THE 5TH MOST POPULOUS COUNTY IN WISCONSIN BY 2035. -OUTAGAMIE COUNTY HIGH SCHOOL GRADUATION RATE IS 90%.-TRADE/TRANSPORTATION/UTILITIES, ALONG WITH MANUFACTURING EMPLOY THE MOST PEOPLE IN THE TWO-COUNTY REGION FOLLOWED BY EDUCATION/HEALTH. THESE THREE SECTORS EMPLOY 40% OF THE AREA'S WORKFORCE.-IN COMPARISON TO MORE RURAL COUNTIES IN THE THEDACARE SERVICE AREA, OUTAGAMIE AND CALUMET COUNTIES CONTINUE TO HAVE A HIGHER PERCENTAGE OF CHILDREN.-IN OUTAGAMIE COUNTY 8% OF THE POPULATION LIVE BELOW 100% OF THE FEDERAL POVERTY LEVEL AND 9% OF THE POPULATION IS UNINSURED.-THE PERCENTAGE OF NON-CAUCASIAN POPULATION HAS GROWN FROM 6.2% TO 8.8%. NINETY SIX PERCENT OF THE SERVICE AREA IS CAUCASIAN WITH HISPANIC POPULATION OF 2% SEEING THE FASTEST GROWTH. HMONG ARE ARRIVING AS REFUGEES FOR SIMULATION. THE LARGEST MINORITY POPULATIONS ARE LATINO AND ASIAN. NATIVE AMERICANS ACCOUNT FOR APPROXIMATELY 1% OF THE POPULATION AND AFRICAN-AMERICANS REPRESENT LESS THAN 1%. THE MOST SIGNIFICANT GROWTH AMONG MINORITY POPULATIONS FROM 2000 TO 2010 OCCURRED AMONG LATINOS.CALUMET COUNTY:-OVER THE PAST DECADE, CALUMET COUNTY HAS GROWN IN POPULATION BY 20.53%.-THE CALUMET COUNTY HIGH SCHOOL GRADUATION RATE IS 94%-TRADE/TRANSPORTATION/UTILITIES ALONG WITH MANUFACTURING EMPLOY THE MOST PEOPLE IN THE TWO-COUNTY REGION FOLLOWED BY EDUCATION/HEALTH. THESE THREE SECTORS EMPLOY 40% OF THE AREA'S WORKFORCE.-IN COMPARISON TO MORE RURAL COUNTIES IN THE THEDACARE SERVICE AREA, OUTAGAMIE AND CALUMET COUNTIES CONTINUE TO HAVE A HIGHER PERCENTAGE OF CHILDREN-SIX PERCENT OF THE CALUMET COUNTY POPULATION LIVE BELOW 100% OF THE FEDERAL POVERTY LEVEL, 7% OF CALUMET COUNTY POPULATION ARE UNINSURED.-THE PERCENTAGE OF NON-CAUCASIAN POPULATION HAS GROWN FROM 6.2% TO 8.8%. NINETY SIX PERCENT OF SERVICE AREA IS CAUCASIAN WITH HISPANIC POPULATION OF 2% SEEING THE FASTEST GROWTH. HMONG ARE ARRIVING AS REFUGEES FOR SIMULATION. THE LARGEST MINORITY POPULATIONS ARE LATINO AND ASIAN. NATIVE AMERICANS ACCOUNT FOR APPROXIMATELY 1% OF THE POPULATION AND AFRICAN-AMERICANS REPRESENT LESS THAN 1%. THE MOST SIGNIFICANT GROWTH AMONG MINORITY POPULATIONS FROM 2000 TO 2010 OCCURRED AMONG LATINOS PART VI, LINE 5: EACH YEAR, APPLETON MEDICAL CENTER'S PARENT ORGANIZATION THEDACARE SETS ASIDE A PERCENTAGE OF EXCESS NET BUDGETED INCOME TO FUND AN EFFORT CALLED CHAT (COMMUNITY HEALTH ACTION TEAM). CHAT IS A GROUP OF 25 COMMUNITY LEADERS WHO STUDY SYSTEMIC HEALTH ISSUES OUTSIDE THE WALLS OF OUR HOSPITALS AND CLINICS AND WORK TO IDENTIFY INNOVATIVE, COLLABORATIVE SOLUTIONS THAT DRAW UPON THE WIDE ARRAY OF RESOURCES AND STRENGTHS OF OUR COMMUNITY. THROUGH CHAT, SUCH EFFORTS AS THE SHAWANO COUNTY RURAL HEALTH INITIATIVE HAVE BEEN DEVELOPED. THIS INITIATIVE TAKES BASIC HEALTH CARE AND SCREENING SERVICES TO THE FARM. EACH YEAR HUNDREDS OF FARM FAMILIES LIVING WITHOUT INSURANCE OR ONLY CATASTROPHIC COVERAGE RECEIVE CRITICAL ASSISTANCE. THIS INITIATIVE HAS NOW SPREAD TO OUTAGAMIE, WINNEBAGO AND WAUPACA COUNTIES. ANOTHER INITIATIVE IS THE THE NEW MENTAL HEALTH CONNECTION WHICH IS WORKING TO IMPROVE ACCESS TO MENTAL HEALTH SERVICES IN THE AREA. HIGH LATINO TEEN PREGNANCY RATES INSPIRED CHAT TO LAUNCH CUIDATE!, A CULTURALLY BASED TEEN PREGNANCY PREVENTION PROGRAM IN PARTNERSHIP WITH THE FOX CITIES COMMUNITY HEALTH CENTER. MAKING THE RIDE HAPPEN IS ANOTHER CHAT EFFORT THAT PROVIDES TRANSPORTATION TO OLDER ADULTS WHO OTHERWISE WOULD STAY COOPED UP IN APARTMENTS AND FIGHT DEPRESSION AND ISOLATION. PROJECT PROMISE IS A POVERTY INITIATIVE DEVELOPED THROUGH CHAT THAT BROUGHT TOGETHER MANY LOCAL AGENCIES AND BUSINESSES TO WORK TO ADDRESS POVERTY IN A COLLABORATIVE FASHION. VOICES OF MEN WAS LAUNCHED WITH SUPPORT FROM CHAT TO RAISE AWARENESS OF EVERYDAY BEHAVIORS OF MEN THAT CAN LEAD TO AN ACCEPTANCE OF VIOLENCE TOWARD WOMEN. ANOTHER RECENT INITIATIVE IS INCLUDE WHICH FOCUSES ON BUILDING INCLUSIVENESS AND TOLERANCE TO PREVENT SUICIDE AMONG THE GAY, LESBIAN, BISEXUAL, TRANSGENDER POPULATION. THEDACARE PROVIDES FUNDING AND STAFF SUPPORT TO MAKE CHAT AND COMMUNITY HEALTH EFFORTS POSSIBLE. OTHER WAYS THAT THEDACARE HOSPITALS IMPROVE THE HEALTH OF THE COMMUNITY INCLUDE:-IN 2014, THEDACARE SHARED ITS CUTTING EDGE APPLICATION OF LEAN PRODUCTION IMPROVEMENTS WITH HUNDREDS OF HEALTHCARE AND NON-HEALTHCARE VISITORS FROM AROUND THE WORLD. MOST WERE VISITORS WERE FROM HOSPITALS AND HEALTH SYSTEMS IN THE UNITED STATES LOOKING TO IMPROVE QUALITY AND REDUCE COSTS.-THEDACARE HOSPITALS PROVIDED SUPPORT TO THE THEDACARE CENTER FOR HEALTHCARE VALUE WHICH IS COORDINATING EFFORTS ACROSS THE COUNTRY TO SHARE QUALITY IMPROVEMENT AND COST REDUCTION LEARNINGS. -ALL THEDACARE HOSPITALS PROVIDE HEALTH EDUCATION PROGRAMMING FOR THEIR RESPECTIVE COMMUNITIES FOCUSING ON SUCH CRITICAL TOPICS AS PROPER NUTRITION, DIABETES IDENTIFICATION, AND CANCER PREVENTION.-THEDACARE PARTNERS WITH THE FOX CITIES/UW RESIDENCY CENTER TO PROVIDE HANDS ON EXPERIENCE FOR MEDICAL STUDENTS.-THEDACARE ALSO PARTNERS WITH AREA NURSING SCHOOLS SUCH AS UW OSHKOSH AND FOX VALLEY TECHNICAL COLLEGE TO PROVIDE PROFESSIONAL MENTORS FOR THEIR NURSING PROGRAMS AND VENUES FOR NURSING STUDENTS TO PRACTICE THEIR SKILLS.-THEDACARE HOSPITALS PROVIDED FINANCIAL AS WELL AS DIAGNOSTIC AND LAB SUPPORT TO TWO AREA CLINICS PROVIDING MEDICAL AND DENTAL CARE TO THE UNDERSERVED IN OUR SERVICE AREA.-THEDACARE HOSPITAL EMPLOYEES TAKE PART IN HELPING HEARTS, AN EMPLOYEE VOLUNTEERISM PROGRAM ENCOURAGING STAFF TO GIVE OF THEIR TIME IN THE COMMUNITY. THEDACARE PROVIDES PAID STAFF TO COORDINATE THE PROGRAM AND IDENTIFY AND PROMOTE VOLUNTEERISM OPPORTUNITIES. THEDACARE EMPLOYEES DONATED MORE THAN $1,434,000 IN UNPAID VOLUNTEER HOURS TO LOCAL NON-PROFITS IN 2014. -THEDACARE SPONSORS PARTY AT THE PAC FOR THOUSANDS OF AREA YOUTH TO EDUCATE YOUTH ON THE PERILS OF RISKY BEHAVIOR AND DRIVING. HOSTED AT OUR PERFORMING ARTS CENTER, LIVE DRAMATIZATIONS ALONG WITH STORIES OF YOUTH DISABLED DUE TO DRIVING AND RISKY BEHAVIOR ENCOURAGE TEENS TO THINK TWICE BEFORE DRINKING OR TEXTING AND DRIVING. -APPLETON MEDICAL CENTER STAFF WORK WITH THE AREA CHAMBER OF COMMERCE AND LOCAL HIGH SCHOOLS AND COLLEGES TO INFORM YOUTH ABOUT MEDICAL CAREER OPPORTUNITIES AND TO HELP PREPARE OUR EDUCATIONAL FACILITIES TO MEET THE HEALTHCARE STAFFING NEEDS FOR THE COMMUNITIES WE SERVE.-APPLETON MEDICAL CENTER SUPPORTS THE AMERICAN CANCER SOCIETY'S SOLE BURNER RUN AND THE AMERICAN HEART ASSOCIATION HEART WALK EVENTS TO HELP RAISE FUNDS FOR THE NON-PROFIT ORGANIZATIONS.-APPLETON MEDICAL CENTER STAFF SUPPORT THE THEDACARE NEIGHBORHOOD GARDEN WHICH SUPPLIES PRODUCE TO THE LOCAL EMERGENCY SHELTER. -APPLETON MEDICAL CENTER SUPPLIES ATHLETIC TRAINING SERVICES TO AREA HIGH SCHOOLS AT REDUCED COST.-APPLETON MEDICAL CENTER ORGANIZES SUPPORT GROUPS FOR CANCER AND DIABETES AND PROVIDES A TELEPHONE HOTLINE FOR NUTRITION COUNSELING.-APPLETON MEDICAL CENTER MAKES FINANCIAL AND IN-KIND DONATIONS TO NON-PROFIT ORGANIZATIONS INCLUDING UNITED WAY, AREA SCHOOLS, AMERICAN HEART ASSOCIATION, AMERICAN CANCER SOCIETY. -THEDA CARE STAFF PARTICIPATES IN LEADERSHIP FOX CITIES TO GROOM MIDDLE MANAGERS IN THE WORKINGS OF THE ENTIRE COMMUNITY, FROM EDUCATION SYSTEMS AND RECYCLING PROGRAMS TO GOVERNMENT AND JUSTICE SYSTEMS. -APPLETON MEDICAL CENTER STAFF ARE INVOLVED IN STATEWIDE AND REGIONAL DISASTER READINESS PLANNING TO PREPARE OUR COMMUNITY FOR TIMES OF CRISIS.-THEDA CARE PRESIDENT AND CEO IS ENGAGED IN STATEWIDE WISCONSIN COLLABORATIVE FOR HEALTHCARE QUALITY MAKING QUALITY HEALTHCARE DATA TRANSPARENT. -WITH INFORMATION GATHERS FROM A PLUNGE INTO THE END OF LIFE, THEDACARE IS WORKING IN PARTNERSHIP WITH THE AFFINITY AND MINISTRY HEALTH SYSTEMS TO DEVELOP A COMMON SET OF DOCUMENTS WITH WILL CAPTURE END OF LIFE WISHES FOR PEOPLE LIVING IN THE FOX VALLEY AND BEYOND. PART VI, LINE 6: THEDACARE, THE PARENT ORGANIZATION, PROVIDES DIRECTION RELATED TO COMMUNITY NEEDS ASSESSMENT FOR ALL HOSPITALS AND MARKETS WITHIN ITS SERVICE AREA. EACH THEDACARE HOSPITAL, ALONG WITH COMMUNITY HEALTH IMPROVEMENT (CHI) STAFF AND COMMUNITY MEMBERS DETERMINE HOW BEST TO MEET LOCAL NEEDS. IMPLEMENTATION OF COMMUNITY PROGRAMMING OCCURS AT THE LOCAL LEVEL. PART VI, LINE 7, REPORTS FILED WITH STATES WI X X 1 1 X X X X 1 1 0 0 0 0 0 1 0 GRUNER DEAN BOARD MEMBER/CEO - SYSTEM 98643 887783 21136 190227 1090 9811 15606 140459 2027 18243 138502 1246523 0 0 EDELMAN GARY MD BOARD MEMBER/PHYSICIAN 0 389957 0 20798 0 6068 0 9800 0 18843 0 445466 0 0 TURK NORMA MD BOARD MEMBER/PHYSICIAN 238253 0 36604 0 2785 0 9800 0 6865 0 294307 0 0 0 MOARD DOUGLAS MD BOARD MEMBER/PHYSICIAN 0 334356 0 404 0 2436 0 9800 0 22321 0 369317 0 0 OLSON TIM VP CFO SYSTEM 40976 368787 5500 49501 2118 19064 9040 81360 1833 16493 59467 535205 0 0 LIVINGSTON KEITH VP SR CIO 42177 379589 4627 41643 881 7933 7083 63746 1861 16745 56629 509656 0 0 PISTONE MAUREEN VP SR HR SERVICES 38287 344585 3958 35623 1775 15978 6445 58009 1860 16739 52325 470934 0 0 BARNAS KIM VP SR AMC & TC 121854 182782 18832 28247 136204 204306 8532 12799 731 1096 286153 429230 0 0 BURMEISTER BRIAN VP SR AMC & TC 56862 322219 6171 34967 2909 16484 8166 46273 2805 15895 76913 435838 0 0 CORREIA KATHRYN FORMER VP. SR. HOSPITAL SERVICES 325418 0 0 0 0 0 0 0 0 0 325418 0 0 0 FERRANTE ROBERT MD PHYSICIAN 736096 0 50404 0 1794 0 9800 0 21075 0 819169 0 0 0 WILSON ROBERT MD PHYSICIAN 581668 0 24779 0 6348 0 9800 0 22154 0 644749 0 0 0 MARIANO DIONISIO MD PHYSICIAN 580894 0 24779 0 7023 0 9800 0 22928 0 645424 0 0 0 GUTTORMSEN BRIAN MD PHYSICIAN 581698 0 29779 0 4490 0 9800 0 21503 0 647270 0 0 0 ACKELL PETER MD PHYSICIAN 579198 0 24779 0 6735 0 9800 0 24624 0 645136 0 0 0 PART I, LINE 1A EXECUTIVES RECEIVE REIMBURSEMENT FOR PERSONAL MEDICAL EXPENSES AT AN AMOUNT GROSSED-UP FOR TAXES. ALL EXECUTIVES IN THE SENIOR MANAGEMENT BENEFIT CATEGORY ARE ELIGIBLE TO HAVE HEALTH OR FITNESS CLUB FEES PAID DIRECTLY TO THE CLUB, OR REIMBURSED TO THEM ON EVIDENCE OF PAYMENT. SENIOR EXECUTIVES WHOSE DUTIES INCLUDE MEETING WITH PEOPLE OUTSIDE THE COMPANY FOR PURPOSES OF DEVELOPING BUSINESS RELATIONSHIPS HAVE COMPANY PAID MEMBERSHIPS AT A LOCAL COUNTRY CLUB. 6 EMPLOYEES RECEIVED TAXABLE MEDICAL EXPENSE REIMBURSEMENTS AND 4 EMPLOYEES RECEIVED CLUB DUES REIMBURSEMENTS. PART I, LINE 3 SENIOR LEVEL EXECUTIVES OF THE COMPANY ARE ENTITLED TO AN ANNUAL FLEXIBLE BENEFIT EQUAL TO 20% OF THE MIDPOINT OF THEIR SALARY RANGE. THIS 457(F) SUPPLEMENTAL BENEFIT PLAN COMPLIES WITH THE FINAL REGULATIONS UNDER SECTION 409A AND 457(F) OF THE INTERNAL REVENUE CODE. PARTICIPANTS MAY ELECT THE BENEFIT TO BE USED TO PURCHASE PARTICULAR INSURANCE BENEFITS, INVESTED IN A CAPITAL ACCUMULATION ACCOUNT, OR A COMBINATION OF THE TWO. BENEFITS ARE ACCRUED ON A MONTHLY BASIS AND ARE SUBJECT TO THE SUBSTANTIAL RISK OF FORFEITURE AGREEMENT SIGNED BY THE PARTICIPANTS. PLAN CONTRIBUTIONS ARE MADE ON A QUARTERLY BASIS. PART I, LINES 4A-B EXECUTIVE AT RISK COMPENSATION PLAN THE PLAN OBJECTIVES ARE TO ENHANCE THEDACARE INC'S ABILITY TO ACHIEVE ITS GOALS BY PROVIDING A TOOL FOR STIMULATING AND REWARDING SUPERIOR LEVELS OF PERFORMANCE AMONG KEY EXECUTIVES, IMPROVE THEDACARE INC'S ABILITY TO COMPETE WITH OTHER EMPLOYERS FOR HIGH TALENT EXECUTIVES AND TO ENCOURAGE TOP-LEVEL EXECUTIVES TO WORK TOGETHER AS A COHESIVE GROUP TOWARD COMMON GOALS. THE PRESIDENT OF THEDACARE INC. DEVELOPS A LIST OF SENIOR LEVEL EXECUTIVES WHO ARE ELIGIBLE TO PARTICIPATE IN THIS PLAN, AS WELL AS THE PERFORMANCE LEVELS THE SENIOR EXECUTIVES MUST ACHIEVE AND THE BONUS AMOUNTS THAT THE EXECUTIVES WILL RECEIVE. THE PRESIDENT THEN SUBMITS THIS LIST TO THE EXECUTIVE COMMITTEE OF THE BOARD OF TRUSTEES FOR FINAL APPROVAL. THESE EXECUTIVES MUST BE IN ACTIVE REGULAR SERVICE OF THEDACARE INC. FOR THE ENTIRE PLAN YEAR (JANUARY 1, 2013 TO DECEMBER 31, 2013) TO RECEIVE THEIR 2014 BONUSES. IF THE EMPLOYEE RETIRES, BECOMES DISABLED, MOVES TO A POSITION THAT IS ELIGIBLE UNDER THE BONUS PLAN OR MOVES TO A POSITION THAT IS NO LONGER ELIGIBLE FOR THE BONUS PLAN OR DIES, THE PLAN WILL BE PRORATED FOR THE AMOUNT OF TIME THEY SERVED THE COMPANY. IF AN ELIGIBLE EMPLOYEE IS FIRED OR LEAVES THE COMPANY FOR ANY OTHER REASON THE PLAN BONUS EARNED WILL BE FORFEITED. CARING FOR SUCCESS THE PLAN OBJECTIVES ARE TO PROVIDE INCENTIVE TO FOCUS THE ORGANIZATION'S RESOURCES, ENERGY AND ATTENTION ON THE FULFILLMENT OF THEDACARE'S MISSION. EMPLOYEE ELIGIBILITY IS BASED ON THE NUMBER OF HOURS WORKED, AND ALL ELIGIBLE EMPLOYEES SHARE IN THE PAYOUT. THE PAYOUT AMOUNT IS DETERMINED BASED ON BOTH FINANCIAL AND EMPLOYEE HEALTH AND SAFETY THRESHOLDS. THE AMOUNT PER EMPLOYEE IS DETERMINED BY DIVIDING THE TOTAL GAIN REALIZED (THE EMPLOYEE SHARE) BY HOURS PAID TO ALL ELIGIBLE EMPLOYEES. THE RESULTING DOLLAR UNIT PAYOUT IS MULTIPLIED BY AN INDIVIDUAL EMPLOYEE'S NUMBER OF HOURS PAID. THIS PLAN IS OVERSEEN BY AN ADMINISTRATIVE COMMITTEE. THE THEDACARE BOARD OF TRUSTEES MUST APPROVE THE PLAN. DURING 2014, KIM BARNAS RECEIVED A SEVERANCE PAYMENT OF $219,735. FORM 990, PART I, LINE 5 THEDACARE INC. CENTRALIZES PAYROLL AND TAX WITHHOLDING FUNCTIONS FOR A NUMBER OF AFFILIATED ENTITIES, WHILE ALL FILING UNDER THEDACARE'S FEDERAL IDENTIFICATION NUMBER. APPLETON MEDICAL CENTER (AMC) REPORTS "0" EMPLOYEES BECAUSE EMPLOYEES ARE PAID BY THEDACARE, INC., THEREFORE, AMC DOES NOT FILE ANY W-2 FORMS. THEDACARE INC. IS REIMBURSED BY AMC FOR SALARY EXPENSES FOR THE EMPLOYEES WHO ARE PERMANENTLY ASSIGNED TO AMC. FORM 990, PART VI, SECTION A, LINE 6 APPLETON MEDICAL CENTER, INC.'S SOLE MEMBER OF THE SINGLE CLASS OF VOTING MEMBERS IS THEDACARE, INC. FORM 990, PART VI, SECTION A, LINE 7A THEDACARE, INC. HAS SOLE AUTHORITY IN THE CORPORATION TO VOTE AND TAKE ANY ACTION WITH RESPECT TO THE ELECTION OF DIRECTORS AND OFFICERS. FORM 990, PART VI, SECTION A, LINE 7B THEDACARE, INC. HAS THE SOLE AUTHORITY WITH RESPECT TO THE FOLLOWING MATTERS: 1. AMENDMENT OF THE ARTICLES OF INCORPORATION 2. ADOPTION AND AMENDMENT OF BYLAWS OF THE CORPORATION 3. CONSOLIDATION, MERGER AND DISSOLUTION OF THE CORPORATION 4. MONITORING COMPLIANCE WITH LAWS AND REGULATIONS 5. SELECTION, APPOINTMENT, AND REMOVAL OF A CHIEF OPERATING OFFICER 6. PROVISION FOR LONG-RANGE FINANCIAL STABILITY OF THE HOSPITAL AND PROVISION FOR THE CONTROL AND USE OF THE PHYSICAL AND FINANCIAL RESOURCES OF THE HOSPITAL 7. ESTABLISHMENT OF A LONG-RANGE PLANNING MECHANISM 8. APPROVAL OF A HOSPITAL ORGANIZATION AND MAJOR AUTHORITY DELEGATION PATTERNS 9. APPROVAL OF FINANCIAL, CAPITAL, AND OTHER ITEMS 10. APPROVAL OF DEBT OR LEASES 11. CONSIDERATION AND ACTION UPON POLICIES CONCERNING RELATIONS WITH EXTERNAL GROUPS AND ORGANIZATIONS FORM 990, PART VI, SECTION B, LINE 11 A DRAFT OF THE FORM 990 IS PROVIDED TO THE ORGANIZATION'S DESIGNATED COMMITTEE OF THE BOARD OF DIRECTORS FOR REVIEW AND DISCUSSION AT A BOARD MEETING. THE FINAL VERSION OF THE FORM 990 IS EMAILED TO THE ENTIRE BOARD BEFORE THE RETURN IS FILED. FORM 990, PART VI, SECTION B, LINE 12C QUESTIONNAIRES ARE SENT TO ALL MANAGERS, TRUSTEES AND OFFICERS ANNUALLY. COMPLETED FORMS ARE RETURNED TO THE COMPLIANCE OFFICER. THE COMPLIANCE OFFICER REVIEWS THE QUESTIONNAIRES AND FOLLOWS UP WITH ANY QUESTIONS ABOUT THE MANAGERS' ANSWERS ON THE CONFLICT OF INTEREST FORMS. ALL EMPLOYEES AND BOARD MEMBERS ARE COVERED UNDER THE CONFLICT OF INTEREST POLICY. THE CORPORATE COMPLIANCE COMMITTEE REVIEWS THE POTENTIAL CONFLICT AND THE CFO/BOARD OF TRUSTEES REVIEW ALL CONFLICTS. AFTER DISCLOSURE OF THE CONFLICT, THE EMPLOYEE SHALL NOT PARTICIPATE IN THE DECISION WHETHER TO ENGAGE IN THE TRANSACTION IN WHICH THE EMPLOYEE HAS AN INTEREST. FORM 990, PART VI, SECTION B, LINE 15 THEDACARE HIRES AN OUTSIDE CONSULTING FIRM TO CONDUCT A THOROUGH MARKET REVIEW OF EXECUTIVE COMPENSATION EVERY OTHER YEAR. INTERNALLY, A COMPENSATION COMMITTEE REAFFIRMS THE COMPENSATION POLICY, REVIEWS DATA FROM CONSULTANTS, AND WITH INPUT FROM THE SR VP OF HUMAN RESOURCES, ADVISES, VALIDATES, AND APPROVES A RANGE FOR CEO COMPENSATION. THE COMMITTEE ALSO RATIFIES THE BONUS PLAN. FORM 990, PART VI, SECTION C, LINE 19 APPLETON MEDICAL CENTER INC. DOES NOT MAKE ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND INTERNAL FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC. FORM 990, PART XI, LINE 9: EQUITY RECLASS -10,000. FORM 990, PART XII, LINE 2C THIS PROCESS DID NOT CHANGE DURING THE YEAR. 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