2014-08-14T14:14:00-05:00 2013-09-30 390758449 WIPFLI LLP PO BOX 12237 GREEN BAY WI 543072237 990 2012-10-01 396089134 WILD ROSE COMMUNITY MEMORIAL HOSPITAL INC WILD 9206223257 PO BOX 243 WILD ROSE WI 549840243 DONALD R CAVES 9206223257 2014-08-14 1 TERRI REXRODE CPA P00096513 9206620016 2014-08-14 2012 2015-11-30 17:44:51Z DONALD R CAVES PO BOX 243 WILD ROSE WI 549840243 14881555 0 X WWW.WILDROSEHOSPITAL.ORG X 1956 WI WILD ROSE HOSPITAL PROVIDES INPATIENT AND OUTPATIENT HOSPITAL AND CLINIC SERVICES TO THE WAUSHARA COUNTY AREA. 10 8 186 76 0 0 24848 67166 14964341 14807211 6722 7178 0 0 14995911 14881555 0 0 0 0 6755574 6673193 0 0 0 7692271 8115835 14447845 14789028 548066 92527 6107089 6526843 7022973 7338444 -915884 -811601 X PROVIDE SUPERIOR SERVICES TO IMPROVE THE HEALTH OF THOSE WE SERVE. 0 0 13225146 14572683 WILD ROSE HOSPITAL'S MISSION IS TO "PROVIDE SUPERIOR SERVICES TO IMPROVE THE HEALTH OF THOSE WE SERVE." IN PURSUIT OF ITS PRIMARY EXEMPT PURPOSE OF PROVIDING INPATIENT AND OUTPATIENT HOSPITAL AND CLINIC SERVICES TO THE WAUSHARA COUNTY AREA, WILD ROSE HOSPITAL PROVIDES MEDICAL CARE AND OTHER FINANCIAL SUPPORT THROUGH VARIOUS PROGRAMS THAT ARE DESIGNED, AMONG OTHER MATTERS, TO ENHANCE THE HEALTH OF THE COMMUNITY. WILD ROSE HOSPITAL BELIEVES IT HAS A SPECIAL DUTY TO MEET THE NEEDS OF THE POOR, INDIGENT, AND MEDICALLY UNDERSERVED IN THE COMMUNITIES AND SURROUNDING AREAS. THEY HAVE PROVIDED CARE TO ALL PATIENTS WITHOUT REGARD FOR THE ABILITY TO PAY.WILD ROSE HOSPITAL ACTIVELY PROVIDED OR PARTICIPATED IN THE FOLLOWING COMMUNITY-BASED ACTIVITIES AND PROGRAMS:GENERAL HEALTH EDUCATION SERVICES SUCH AS HEALTH FAIRS- PROVIDED HEALTH INFORMATION ON THE CORPORATION'S WEB SITE AND THROUGH HEALTH RELATED PUBLICATIONS DISTRIBUTED AT NO CHARGEDIABETES EDUCATION AND SUPPORT GROUP AND BALANCE TRAINING (PHYSICAL THERAPY)HOSTED SELF-HELP AND WELLNESS PROGRAMS SUCH AS AA, AL-ANON, DIETBLOOD PRESSURE SCREENINGS, CHOLESTEROL TESTING AND SCHOOL-BASED TESTINGGUIDANCE, REFERRAL AND ENROLLMENT ASSISTANCE FOR PUBLIC MEDICAL PROGRAMS AND OTHER FAMILY SUPPORT ASSISTANCEDISCOUNTED OR FREE MEDICAL SUPPLIES AND EQUIPMENT TO THOSE UNABLE TO PAYHOSTED FIVE BLOOD DRIVES AND ENCOURAGED EMPLOYEE PARTICIPATIONCONTRIBUTED TO THE EDUCATION OF STUDENT NURSES AND OTHER HEALTH CARE PROFESSIONALSPROVIDED FIRST AID FOR COMMUNITY SPORTING EVENTSPARTICIPATED IN WORK HEALTH EDUCATION PROGRAMS THROUGH PRIMARY CARE INITIATIVE PROGRAM MADE CASH CONTRIBUTIONS TO SUPPORT COMMUNITY SERVICES AND EVENTSPROVIDED MEETING ROOMS TO COMMUNITY GROUPS AT NO CHARGEWILD ROSE HOSPITAL 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 PHYSICIAN IN THE AREA. THE MAJORITY OF THE BOARD OF DIRECTORS IS COMPRISED OF INDEPENDENT INDIVIDUALS WHO ARE REPRESENTATIVE OF THE COMMUNITY. CONSISTENT WITH WILD ROSE HOSPITAL'S MISSION, CARE IS PROVIDED TO PATIENTS REGARDLESS OF THEIR ABILITY TO PAY, INCLUDING PROVIDING SERVICES TO THOSE PERSONS WHO CANNOT AFFORD HEALTH INSURANCE BECAUSE OF INADEQUATE RESOURCES OR THOSE WHO ARE UNDERINSURED. WILD ROSE HOSPITAL GIVES DISCOUNTS FROM ESTABLISHED CHARGES TO SELF-PAY PATIENTS WITHOUT REGARD TO ABILITY TO PAY AND CONSIDERS THESE DISCOUNTS A PART OF ITS COMMUNITY BENEFIT. HEALTH CARE SERVICES TO PATIENTS UNDER GOVERNMENT PROGRAMS, SUCH AS MEDICAID, ARE ALSO CONSIDERED PART OF WILD ROSE HOSPITAL'S BENEFIT PROVIDED TO THE COMMUNITY SINCE A SUBSTANTIAL PORTION OF SUCH SERVICES ARE REIMBURSED AT AMOUNTS LESS THAN THE COST OF PROVIDING CARE. PATIENTS WHO MEET CRITERIA FOR CHARITY CARE, GENERALLY BASED ON FEDERAL POVERTY GUIDELINES, ARE PROVIDED CARE WITHOUT CHARGE OR AT A REDUCED RATE. ELIGIBILITY FOR CHARITY CARE IS DETERMINED BASED ON QUALIFYING CRITERIA AS DEFINED IN WILD ROSE HOSPITAL'S CHARITY CARE POLICY AND FROM APPLICATIONS COMPLETED BY PATIENTS AND THEIR FAMILIES. IN 2013 OVER 132 ACCOUNTS RECEIVED CHARITY CARE WITH A TOTAL COST OF OVER $469,102. 13225146 1 1 0 1 0 0 0 0 0 1 1 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 1 1 0 0 0 0 0 0 1 1 1 0 0 1 12 0 186 0 0 0 0 0 0 0 0 0 0 0 X 10 8 0 1 0 0 0 0 1 1 1 0 0 0 1 1 1 1 1 0 0 0 WI X THOMAS P KRYSTOWIAK 9203611313 225 MEMORIAL DRIVE BERLIN WI 54984 LYNN CREAMER 0.50 X 0 0 0 RICHARD A HOTCHKISS 0.50 X 0 0 0 JAMES ERDMAN 0.50 X 0 0 0 PATRICK MORROW 0.50 X 0 0 0 MARK KJENTVET MD 0.50 X 0 0 0 ROGER WILLIAMS 0.50 X X 0 0 0 FREDERICK GELLERUP 0.50 X X 0 0 0 CAROL WILLIAMS 0.50 X X 0 0 0 ALLEN STEA 0.50 X X 0 0 0 DONALD R CAVES 31.00 9.00 X X 62883 71342 19744 MICHAEL STAUDINGER MD 40.00 X X 0 369083 31634 THOMAS KRYSTOWIAK 1.00 39.00 X 0 206172 31546 CHAD VOSKUIL MD 40.00 X 0 260901 35714 REGINALDO ABOLEDA MD 40.00 X 0 235082 18329 CHANDLER CAVES MD 40.00 X 0 472132 37833 GILBERT STEFFANIDES MD 40.00 X 0 204991 27894 62883 1819703 202694 0 0 1 0 COMMUNITY HEALTH NETWORK 225 MEMORIAL DRIVE BERLIN WI 54923 MANAGEMENT AND PHYSICIAN SERVICES 3480984 AMERISOURCE-BERGEN PO BOX 27550 CHICAGO IL 606731275 PHARMACEUTICAL PRODUCTS 711879 SHARED MEDICAL SERVICES PO BOX 330 COTTAGE GROVE WI 535270330 TECHNICAL SUPPORT 161050 SHARED MEDICAL EQUIPMENT GROUP LLC PO BOX 330 COTTAGE GROVE WI 535270330 HOSPITAL EQUIPMENT RENTAL 152390 UNIVERSAL HOSPITAL SERVICES SDS 120940 PO BOX 86 MINNEAPOLIS MN 554860940 HOSPITAL EQUIPMENT RENTAL 115567 6 25490 7483 34193 67166 NET PATIENT SERVICE REVENUE 621990 14572683 14572683 OTHER OPERATING REVENUE 900099 234528 234528 14807211 7178 7178 14881555 14572683 0 241706 X 66137 66137 5180872 4311833 869039 123450 101203 22247 927132 920279 6853 375602 310867 64735 35331 35331 -3500 -3500 2920750 2863046 57704 23081 559 22522 1503574 1444909 58665 64592 64592 884720 811879 72841 51924 46497 5427 2486 2486 234561 190594 43967 238438 193474 44964 28752 28752 PROVISION FOR BAD DEBT 1852557 1852557 RECRUITMENT 40518 40518 LICENSE AND CERTIFICATI 29978 22510 7468 ASSOCIATION DUES 15871 8041 7830 192202 51068 141134 14789028 13225146 1563882 0 1179177 430130 66568 64728 2477353 3294026 207879 249203 30722 101462 5556948 3424018 2142782 2132930 2608 254364 6107089 6526843 897385 1390438 619141 555848 5506447 5392158 7022973 7338444 X -918492 -825965 2608 14364 -915884 -811601 6107089 6526843 X 92527 11756 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 1275 1275 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: A PORTION OF THE WHA DUES REPRESENT LOBBYING PERFORMED IN REGARD TO HEALTHCARE ISSUES. THE AMOUNT FOR 2012 WAS $1,275. 69176 18060 17335 25479 79092 71372 3129 5325 69176 63947 6904 521 71372 162815 520 99388 63947 96338 66477 162815 1.00000 1 1 0 167668 167668 2413685 1423303 990382 66340 61008 5332 2905405 1939707 965698 3850 3850 2132930 LONG TERM NOTES PAYABLE TO RELATED PARTY 4000000 DUE TO THIRD-PARTY REIMBURSEMENT PROGRAM 815296 ACCOUNTS PAYABLE DUE TO RELATED PARTY 576862 5392158 X 12988665 -1852557 -1852557 14841222 40333 40333 14881555 12936471 0 12936471 1852557 1852557 14789028 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: ENDOWMENT EARNINGS ARE TO BE UTILIZED TO SUPPORT THE ORGANZIATIONS MISSION AND PURPOSE. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X, LINE 2: IN ORDER TO ACCOUNT FOR ANY UNCERTAIN TAX POSITIONS, THE HOSPITAL 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 FINANCIAL STATEMENTS. THE HOSPITAL RECORDED NO ASSETS OR LIABILITIES RELATED TO UNCERTAIN TAX POSITIONS OR UNRECOGNIZED TAX BENEFITS IN 2012 OR 2011. THE HOSPITAL IS ALSO ENGAGED, TO A LIMITED EXTENT, IN ACTIVITIES WHICH THE INTERNAL REVENUE SERVICE CONSIDERS UNRELATED TO THE HOSPITAL'S EXEMPT PURPOSE, AND THEREFORE TAXABLE. THESE ACTIVITIES, HOWEVER, ANNUALLY RESULT IN NET OPERATING LOSSES FOR INCOME TAX PURPOSES. THE HOSPITAL DOES NOT PRESENTLY ANTICIPATE THAT A TAX BENEFIT FROM THESE NET OPERATING LOSSES WILL BE REALIZED IN THE FUTURE. ACCORDINGLY, ANY POTENTIAL DEFERRED TAX ASSET RESULTING FROM THE AVAILABILITY OF NET OPERATING LOSS CARRYFORWARDS IS OFFSET BY A VALUATION ALLOWANCE OF EQUAL AMOUNT. NO DEFERRED TAX ASSETS AND LIABILITIES HAVE BEEN RECOGNIZED SINCE NO OTHER DIFFERENCES EXIST BETWEEN THE FINANCIAL AND TAX BASES OF REPORTING THE HOSPITAL'S ASSETS AND LIABILITIES. THE HOSPITAL'S POLICY IS TO RECOGNIZE INTEREST AND ANY PENALTIES RELATED TO INCOME TAX MATTERS IN INCOME TAX EXPENSE WHEN INCURRED. AS OF AND FOR THE YEARS ENDED SEPTEMBER 30, 2012 AND 2011, THERE WAS NO INCOME TAX EXPENSE, TAX PENALTIES, OR INTEREST RELATED TO TAX PENALTIES RECORDED BY THE HOSPITAL IN THE FINANCIAL STATEMENTS. PART XI, LINE 2D - OTHER ADJUSTMENTS: BAD DEBT EXPENSE -1,852,557. PART XI, LINE 4B - OTHER ADJUSTMENTS: CONTRIBUTION 40,333. PART XII, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT EXPENSE 1,852,557. 1 1 1 X 1 X 0 1 0 1 1 292855 292855 0.02260 1522069 803141 718928 0.05560 1814924 803141 1011783 0.07820 15238 200 15038 0.00120 600 600 0.00000 12334 12334 0.00100 28172 200 27972 0.00220 1843096 803341 1039755 0.08040 1 1852557 4001283 3961666 39617 X 1 1 1 1 WILD ROSE COMMUNITY MEMORIAL HOSPITAL

601 GROVE AVE WILD ROSE WI 54984

X X X X WILD ROSE COMMUNITY MEMORIAL HOSPITAL 1 1 X X X X X X X X X 12 1 1 1 X X X X X X X 0 0 1 1 150.000000000000 1 300.000000000000 1 X X X X X X 1 1 X X X 1 0 X X X X 1 X 0 0 4 WFP WILD ROSE

701 GROVE AVE WILD ROSE WI 54984

OUTPATIENT PHYSICIAN CLINIC WFP PLAINFIELD

N6493 VALLEY CIRCLE ROAD PLAINFIELD WI 54966

OUTPATIENT PHYSICIAN CLINIC WFP WAUTOMA

N2934 HWY 22 NORTH WAUTOMA WI 54982

OUTPATIENT PHYSICIAN CLINIC WFP COLOMA

141 FRONT STREET COLOMA WI 54930

OUTPATIENT PHYSICIAN CLINIC PART I, LINE 7: COST TO CHARGE RATIO. PART I, L7 COL(F): BAD DEBT EXPENSE OF $1,852,557 FROM FORM 990, PART IX, LINE 25 WAS REMOVED FOR THE PURPOSE OF CALCULATING THE PERCENTAGES IN PART 1, LINE 7, COLUMN (F). PART III, LINE 4: THE COSTING METHODOLOGY USED IN DETERMINING THE AMOUNTS ABOVE IS A COST TO CHARGE RATIO BASED ON THE TOTAL OPERATING EXPENSE NET OF COMMUNITY BENEFIT EXPENSES AND NON-PATIENT CARE OPERATIONS, AND 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, WILD ROSE HOSPITAL 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: THE ORGANIZATION USES A COST TO CHARGE RATIO TO CALCULATE ALLOWABLE COSTS ABOVE. ANY SHORTFALL SHOULD BE TREATED AS COMMUNITY BENEFIT BECAUSE WILD ROSE HOSPITAL CONTINUES TO SERVE THE MEDICARE POPULATION REGARDLESS OF WHETHER THEY COVER THEIR COSTS. WILD ROSE HOSPITAL HAS A SURPLUS BECAUSE IT IS A CRITICAL ACCESS HOSPITAL AND AS A CRITICAL ACCESS HOSPITAL, IT RECEIVES 101% OF ITS COST PER MEDICARE. 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 ASSITANCE/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 WRITTING THAT THE ACCOUNT BALANCE IS PAST DUE AND THE ACCOUNT WILL BE SUBJECT TO NORMAL COLLECTION PROCEDURES. WILD ROSE COMMUNITY MEMORIAL HOSPITAL PART V, SECTION B, LINE 3: MEMBERS OF THE COMMUNITY WERE SURVEYED AT THE WAUSHARA COUNTY FAIR, WILD ROSE HOSPITAL PERSONNEL ALSO CONSULTED WITH THE WAUSHARA COUNTY PUBLIC HEALTH OFFICE REGARDING THE NEEDS OF THE AMISH COMMUNITY AND WITH LA CLINICA FOR INPUT ON THE HISPANIC RESIDENTS OF WAUSHARA COUNTY. WILD ROSE COMMUNITY MEMORIAL HOSPITAL PART V, SECTION B, LINE 4: BERLIN MEMORIAL HOSPITAL WILD ROSE COMMUNITY MEMORIAL HOSPITAL PART V, SECTION B, LINE 5C: HTTP://WILDROSEHOSPITAL.ORG/SITE/INDEX.PHP/FOR-PATIENTS/COMMUNITY-HEALTH-NEEDS-ASSESSMENT-COMMUNITY-HEALTH-IMPROVEMENT-PLAN-2013-2018 WILD ROSE COMMUNITY MEMORIAL HOSPITAL PART V, SECTION B, LINE 7: THE NEEDS WERE PRIORITIZED WITH COMMUNITY PARTNERS AND THOSE THAT WOULD HAVE THE BROADEST IMPACT WERE SELECTED BY THE GROUP. COMMITTEES WERE DEVELOPED TO WORK ON THE PLAN. WHILE SOME NEEDS WERE NOT SELECTED TO ACTIVELY WORK ON, PREVENTION STRATEGIES ARE USED IN HOPE OF IMPACTING ALL AREAS OVER TIME. WILD ROSE COMMUNITY MEMORIAL HOSPITAL PART V, SECTION B, LINE 14G: THE POLICY IS COMMUNICATED DIRECTLY TO PATIENTS BY BILLING STAFF WHEN THEY INDICATE THEY DO NOT HAVE THE FINANCIAL MEANS TO PAY THEIR BILL, OR BY NURSING STAFF DURING THE ADMISSION ASSESSMENT WHEN A PATIENT INDICATES THEY HAVE FINANCIAL CONCERNS. PART VI, LINE 2: WILD ROSE HOSPITAL WORKS IN COLLABORATION WITH WAUSHARA COUNTY WELLNESS COALITION TO ASSESS COMMUNITY NEEDS IN ORDER TO CREATE A HEALTH IMPROVEMENT PLAN BASED ON THOSE ISSUES AND CONCERNS IDENTIFIED. THE WAUSHARA WELLNESS COALITION CONSISTS OF MULTIDISCIPLINARY TEAM THAT INCLUDES THE AGING AND DISABILITY RESOURCE CENTER AND PUBLIC HEALTH. IN THE EFFORT TO PROVIDE COMPREHENSIVE CARE, THE WAUSHARA WELLNESS COALITION ALSO STRIVES TO DECREASE INEFFICIENCIES DUE TO OVERLAP OF CARE PROVIDERS AND ORGNAIZATIONS IN THE AREA. 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: WILD ROSE HOSPITAL IS IN AN HPSA AREA AND IS THE ONLY HOSPITAL IN WAUSHARA COUNTY. AS OF THE CENSUS OF 2007 THERE WERE 25,215 RESIDENTS OCCUPYING 9,500 HOUSEHOLDS WITH A 75% INCREASE IN POPULATION DURING THE SUMMER. THE ELDERLY COMPRISE 18.3% OF THE POPULATION COMPARED WITH 15.2% STATEWIDE. THE AVERAGE ANNUAL WAGE IN 2009 WAS ABOUT 30% LESS THAN THE STATE AVERAGE. APPROXIMATELY 10.3% OF THE POPULATION LIVE BELOW THE POVERTY LEVEL . THERE ARE NO MAJOR POPULATION CENTERS IN WAUSHARA COUNTY WITH THE LARGEST COMMUNITY BEING WAUTOMA HAVING A POPULATION OF 2194. THE POPULATION CONSISTS OF 20% UNDER THE AGE OF 20, 12% FROM 20 TO 29, 33% FROM 30 TO 54, 16% FROM 55 TO 64 AND 19% WHO WERE 65 AND OLDER. THE MEDIAN AGE WAS 42 YEARS AND THE GENDER PERCENTAGE IS 50.39% MALE, 49.61% FEMALE. 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. WILD ROSE HOSPITAL CONDUCTS HEALTH FAIRS AND CAREER FAIRS FOR THE COMMUNITY TO ENCOURAGE HEALTHY LIFESTYLES AND TO RAISE AWARENESS OF HEALTH ISSUES AND TRENDS AS WELL AS CAREER OPPORTUNITIES WITHIN THE LOCAL HEALTH FACILITIES.WE ALSO CONDUCT CPR AND FIRST AID CLASSES, EDUCATION AND OUTREACH FOR SENIOR CITIZENS, EDUCATIONAL OPPORTUNITIES FOR RESIDENTS AND MEDICAL STUDENTS, AS WELL AS CHOLESTEROL SCREENING. IN ADDITION, WE ADMINISTER A DIABETES SUPPORT GROUP. PART VI, LINE 6: WILD ROSE HOSPITAL IS AFFILIATED WITH COMMUNITY HEALTH NETWORK THROUGH PARTNERS HEALTH SYSTEM (PHS). THE BENEFIT IS A COORDINATED EFFORT TO PROVIDE COMPREHENSIVE HEALTH CARE TO AN EXTENDED, MULTI-COUNTY RURAL AREA. AN ADDITIONAL BENEFIT IS INCREASED EFFICIENCIES THROUGH SHARED RESOURCES, THEREFORE PROVIDING A WIDER RANGE OF HEALTH SERVICES THROUGHOUT THE ENTIRE COMBINED SERVICE AREA. REPORTS FILED WITH STATES PART VI, LINE 7 WI X X X 0 1 0 0 0 0 0 0 0 DONALD R CAVES 62883 0 0 0 0 71342 1464 0 1790 16490 66137 87832 0 0 MICHAEL STAUDINGER MD 0 333073 0 0 0 36010 0 9588 0 22046 0 400717 0 0 THOMAS KRYSTOWIAK 0 175502 0 20000 0 10670 0 9166 0 22380 0 237718 0 0 CHAD VOSKUIL MD 0 250901 0 10000 0 0 0 7277 0 28437 0 296615 0 0 REGINALDO ABOLEDA MD 0 235082 0 0 0 0 0 6533 0 11796 0 253411 0 0 CHANDLER CAVES MD 0 376515 0 51508 0 44109 0 9420 0 28413 0 509965 0 0 GILBERT STEFFANIDES MD 0 204991 0 0 0 0 0 1007 0 26887 0 232885 0 0 PART I, LINE 4B MICHAEL STAUDINGER, MD, CHAD VOSKUIL, MD, REGINALDO ABOLEDA, MD, AND CHANDLER CAVES, MD PARTICIPATED BUT DID NOT RECEIVE PAYMENT FROM A NONQUALIFIED RETIREMENT PLAN. ANDREEN KJENTVET SPOUSE OF BOARD MEMBER. 34559 COMPENSATION 0 DANAE SHUMAN DAUGHTER OF COO 20997 COMPENSATION 0 FORM 990, PART VI, SECTION A, LINE 3 WILD ROSE COMMUNITY MEMORIAL HOSPITAL IS AFFILIATED WITH COMMUNITY HEALTH NETWORK (CHN), A 501(C)(3) ORGANIZATION, THROUGH AN AFFILIATION AGREEMENT BETWEEN THE TWO ORGANIZATIONS. THE AFFILIATION AGREEMENT IS DATED AUGUST 19, 2009, EFFECTIVE OCTOBER 1, 2009. BOTH ORGANIZATIONS HAVE FORMED PARTNERS HEALTH SYSTEM (PHS), A 501(C)(3) ORGANIZATION, WITH THE INTENT OF CREATING AN INTEGRATED HEALTH CARE DELIVERY SYSTEM. THROUGH PHS, SOME OF WILD ROSE HOSPITAL'S MANAGEMENT DUTIES ARE DELEGATED TO PHS OR CHN SUCH AS: - CONTRACTING FOR SERVICES AND PURCHASING OF EQUIPMENT AND SUPPLIES - SETTING OF CHARGES - BILLING AND COLLECTIONS - DEVELOPMENT OF POLICIES AND PROCEDURES - PREPARATION OF BUDGETS - PREPARATION OF FINANCIAL AND COST REPORTS - CONTRACTING FOR SERVICES BY HEALTH CARE PROVIDERS - HANDLING OF MATTERS INVOLVING MEDICAL STAFF RELATIONS - PROVIDE ANESTHESIA COVERAGE FORM 990, PART VI, SECTION A, LINE 7B WILD ROSE HOSPITAL(WRH) HAS DELEGATED TO THE PARTNERS HEALTH SYSTEM (PHS) BOARD THE FOLLOWING AUTHORITY: - PHS SHALL ESTABLISH OVERALL STRATEGIC & BUDGETARY OBJECTIVES FOR THE SYSTEM (INCLUDES WRH) - PHS SHALL REVIEW, CONSOLIDATE, MODIFY AND APPROVE OR DISAPPROVE STRATEGIC PLANS PREPARED BY THE PARTIES - PHS SHALL INITIATE AND APPROVE CAPITAL PROJECTS FOR OR ON BEHALF OF THE PARTIES - PHS SHALL INITIATE AND APPROVE THE INCURRENCE OF DEBT BY THE PARTIES - PHS MAY CONTRACT ON BEHALF OF THE PARTIES - PHS SHALL ESTABLISH CHARGE RATES FOR THE PARTIES - PHS CEO SHALL HIRE THE CEOS OF THE PARTIES SUBJECT TO APPROVAL OF THE BOARD OF DIRECTORS OF THE APPLICABLE PARTY - PHS CEO SHALL HAVE THE AUTHORITY TO TERMINATE THE CEO OF A PARTY, SUBJECT TO THE CONSENT OF THE CHAIR OF THE BOARD OF THE PARTY. - PHS SHALL MANAGE THE SYSTEMS EMPLOYED PHYSICIANS FORM 990, PART VI, SECTION B, LINE 11 THE BOD HAS DELEGATED THE DETAILED REVIEW OF THE FORM 990 TO MANAGEMENT OF THE CORPORATION. THEY COMPLETED THE 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. CHAIRPERSON OF THE BOARD OR COMMITTEE MAKES A DECISION WHETHER A CONFLICT OF INTEREST EXISTS. THE BOARD OF DIRECTORS OR A COMMITTEE THEREOF TO WHICH SUCH DISCLOSURE IS MADE SHALL DETERMINE, BY MAJORITY VOTE, IF SUCH PERSON SHALL NOT VOTE ON, NOR SUCH HIS PERSONAL INFLUENCE ON, NOR PARTICIPATE (OTHER THAN TO PRESENT FACTUAL INFORMATION OR TO RESPOND TO QUESTIONS) IN THE DISCUSSIONS OR DELIBERATIONS WITH RESPECT TO SUCH CONTRACT OR TRANSACTION. IN ADDITION TO THE ABOVE, DIRECTORS, OFFICERS AND COMMITTEE MEMBERS EXECUTE AND DELIVER TO THE CORPORATION 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 PHYSICIANS PRACTICES AND OTHER PROVIDER SERVICES RESULT IN PRIVATE INUREMENT OR IMPERMISSIBLE PRIVATE BENEFIT - WHETHER PARTNERSHIPS, JOINT VENTURES, AND OTHER TYPES OF ARRANGEMENT FURTHER THE CORPORATION'S CHARITABLE PURPOSE AND DO NOT RESULT IN INUREMENT OR IMPERMISSIBLE PRIVATE BENEFIT. 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. THE PROCESS WAS NOT FULLY DOCUMENTED IN THE MINUTES THUS A "NO" RESPONSE. 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. OTHER FEES FORM 990, PART IX, LINE 11G PURCHASED MEDICAL SERVICES: PROGRAM SERVICE EXPENSES 2,863,046. MANAGEMENT AND GENERAL EXPENSES 57,704. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,920,750. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 9: CHANGE IN INTEREST IN PARTNERS HEALTH SYSTEM FOUNDATION, INC. 11,756. OVERSIGHT OF AUDIT FORM 990, PART XI, LINE 2C MANAGEMENT PROVIDES OVERSIGHT OF THE AUDIT. AUDIT RESULTS ARE PRESENTED TO MANAGEMENT AND THE BOARD OF DIRECTORS. THE PROCESS HAS NOT CHANGED FROM PRIOR YEAR. COMMUNITY HEALTH NETWORK INC 225 MEMORIAL DRIVE BERLIN WI 54923 390806359 HOSPITAL WI 501(C)(3) LINE 3 PARTNERS HEALTH SYSTEM INC 1 PARTNERS HEALTH SYSTEM INC 225 MEMORIAL DRIVE BERLIN WI 54923 271119447 SUPPORTING ORGANIZATION WI 501(C)(3) LINE 11B, II N/A 0 PARTNERS HEALTH SYSTEM FOUNDATION 225 MEMORIAL DRIVE BERLIN WI 54923 731639346 SUPPORTING ORGANIZATION WI 501(C)(3) LINE 11B, II PARTNERS HEALTH SYSTEM INC 1 0 0 0 1 0 0 0 0 0 1 0 0 0 1 1 0 0 0 0 COMMUNITY HEALTH NETWORK INC N 2743694