2014-11-14T16:52:27-06:00 2013-12-31 391173131 SCHENCK SC 100 MARITIME DRIVE SUITE 2B MANITOWOC WI 54220 990 2013-01-01 390806395 HOLY FAMILY MEMORIAL INC HOLY 9203202011 2300 WESTERN AVE PO BOX 1450 MANITOWOC WI 542211450 MARK HERZOG PRESIDENT / CEO 9203203470 2014-11-10 1 KELLY BLOCK CPA P00199509 9206845500 2013 2015-11-30 17:44:51Z MARK HERZOG 2300 WESTERN AVE PO BOX 1450 MANITOWOC WI 542211450 138622352 0 X WWW.HFMHEALTH.ORG X 1899 WI HEALTH CARE SERVICESSEE SCHEDULE O HOLY FAMILY MEMORIAL IS A NETWORK OF HEALTH PROFESSIONALS WHO, ROOTED IN THE HEALING MINISTRY OF JESUS CHRIST, PROVIDE SERVICES TO HELP INDIVIDUALS AND OUR COMMUNITIES ACHIEVE HEALTHIER LIVES. HFM PROVIDES ACUTE, OUTPATIENT, CLINIC, HOME CARE AND HOSPICE SERVICES FOR MANITOWOC COUNTY, STRIVING FOR MEDICIAL EXCELLENCE AND VALUED OUTCOMES WITHIN A COMPASSIONATE, VALUES BASED, CHRISTIAN ENVIRONMENT. 18 13 1269 330 -248066 -20625 760996 596002 126777153 132958817 1731265 3202328 224576 179589 129493990 136936736 44350 65719 0 0 78476976 78978708 0 0 210770 48878691 53410505 127400017 132454932 2093973 4481804 170044589 176647204 65733371 64072941 104311218 112574263 X HOLY FAMILY MEMORIAL IS A NETWORK OF HEALTH PROFESSIONALS WHO, ROOTED IN THE HEALING MINISTRY OF JESUS CHRIST, PROVIDE SERVICES TO HELP INDIVIDUALS AND OUR COMMUNITIES ACHIEVE HEALTHIER LIVES. 0 0 120029634 65719 136841923 HOLY FAMILY MEMORIAL IS AN INTEGRATED NETWORK PROVIDING HEALTH CARE SERVICES INTENDED TO BENEFIT THE HEALTH AND WELLBEING OF THE COMMUNITIES IT SERVES. THESE SERVICES INCLUDE PRIMARY AND SPECIALTY CLINIC CARE, PREVENTIVE CARE SUCH AS HEALTH SCREENINGS, VACCINATION CLINICS AND HEALTH EDUCATION CLASSES, 24/7 EMERGENCY CARE, WALK-IN, INPATIENT ACUTE CARE, OUTPATIENT CARE, HOME CARE AND HOSPICE, HOME MEDICAL EQUIPMENT, PRESCRIPTIONS, OCCUPATIONAL HEALTH SERVICES, AND MEDICALLY BASED FITNESS AND WELLNESS. HOLY FAMILY MEMORIAL HAS BEEN ABLE TO ACHIEVE A GREATER IMPACT IN THE COMMUNITY BY PARTNERING FINANCIAL, HUMAN AND PROGRAMMATIC RESOURCES WITH OTHER ORGANIZATIONS. (CONTINUED ON SCHEDULE O)THESE PARTNERSHIPS INCLUDE A COMMITMENT TO COLLABORATE WITH OTHER HEALTH AND SOCIAL SERVICE AGENCIES TO IMPROVE ACCESS TO CARE, FOCUS ON PREVENTIVE SERVICES, REDUCE COMMUNITY HEALTH RISKS AND CONTRIBUTE TO A HEALTHIER, VIBRANT COMMUNITY.HOLY FAMILY MEMORIAL PROVIDES MEDICALLY NECESSARY SERVICES WITHOUT CHARGE OR AT AMOUNTS LESS THAN ITS ESTABLISHED RATES TO PATIENTS WHO MEET CERTAIN CRITERIA UNDER ITS CHARITY CARE POLICIES. IN ASSESSING A PATIENT'S ABILITY TO PAY, HOLY FAMILY MEMORIAL UTILIZES GENERALLY RECOGNIZED POVERTY INCOME LEVELS OF THE COMMUNITIES IT SERVES AND CONSIDERS SITUATIONS WHERE INCURRED CHARGES ARE SIGNIFICANT WHEN COMPARED TO THE PATIENT'S FINANCIAL RESOURCES. BECAUSE HOLY FAMILY MEMORIAL DOES NOT EXPECT TO RECEIVE PAYMENT OF AMOUNTS DETERMINED TO QUALIFY AS CHARITY CARE, THESE AMOUNTS ARE NOT INCLUDED IN NET PATIENT SERVICE REVENUES. HOLY FAMILY MEMORIAL'S TOTAL COMMUNITY BENEFIT INCLUDES THE COST OF CHARITY CARE AND UNPAID COST OF PUBLIC PROGRAMS (MEDICARE AND MEDICAID) AS WELL AS THOSE DISCUSSED ABOVE. HOLY FAMILY MEMORIAL'S COMMUNITY BENEFIT WAS APPROXIMATELY $24,527,000 FOR THE YEAR ENDED DECEMBER 2013. THIS AMOUNT INCLUDES THE NET COST OF CHARITY CARE OF APPROXIMATELY $1,774,920. MORE INFORMATION AVAILABLE FROM OUR COMMUNITY BENEFIT REPORT WHICH CAN BE LOCATED ON OUR WEBSITE AT WWW.HFMHEALTH.ORG. 120029634 1 1 0 1 0 0 0 0 0 1 1 1 0 0 0 0 1 1 0 0 0 0 0 0 1 0 1 1 0 1 1 1 0 0 0 0 0 0 0 0 1 1 0 0 0 0 1 1 1 1 0 0 1 32 0 1 1269 1 1 1 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 X 18 13 0 0 0 0 1 1 1 1 1 0 0 0 1 1 1 1 1 1 1 0 WI X X MARK HERZOG PRESIDENT CEO 9203203470 2300 WESTERN AVENUE MANITOWOC WI 542211450 X RYAN M DOPIRAK MD PHYSICIAN COUNCIL CHAIR 40.00 X 1492021 0 32898 MATTHEW L CAMPBELL MD DIRECTOR 40.00 X 331984 0 30294 WILLIAM D HAMPTON MD DIRECTOR 40.00 X 307649 0 30499 PRADEEP GIRIYAPPA MD DIRECTOR 40.00 X 257837 0 24302 MARY A GOVIER MD DIRECTOR 40.00 X 178534 0 32565 DEREK R BOWN DC DIRECTOR 40.00 X 120749 0 28097 DONALD R BRISCH DIRECTOR/TREASURER 2.00 X X 0 0 0 WILLIAM R CASEY TREASURER/CHAIR 2.00 X X 0 0 0 WILLIAM C CENSKY CHAIR 2.00 X X 0 0 0 LAURIE CRAWFORD SECRETARY 2.00 X X 0 0 0 JEFFREY S DUNN DIRECTOR 2.00 X 0 0 0 SISTER LORITA M GAFFNEY DIRECTOR 2.00 X 0 0 0 MARILYN KAUFMANN DIRECTOR 2.00 X 0 0 0 LEE H KUMMER DIRECTOR 2.00 X 0 0 0 SISTER MARY ANN NUGENT DIRECTOR 2.00 X 0 0 0 JANE L PFEFFER VICE CHAIR 2.00 X X 0 0 0 MARK SWANSON DIRECTOR 2.00 X 0 0 0 SISTER ELAINE TURBA DIRECTOR 2.00 X 0 0 0 SISTER PAULA VANDEN HOGEN DIRECTOR 2.00 X 0 0 0 SISTER JAN VILLEMURE DIRECTOR 2.00 X 0 0 0 KATHLEEN A ZUCCHI DIRECTOR 2.00 X 0 0 0 SISTER LAURA WOLF DIRECTOR 2.00 X 0 0 0 MARK P HERZOG DIRECTOR, PRESIDENT, CEO 40.00 X X 513429 0 94944 PATRICIA HUETTL CHIEF FINANCIAL OFFICER 40.00 X 280959 0 69239 STEVEN D DRIGGERS MD CHIEF MEDICAL OFFICER 40.00 X 633237 0 94781 MARY MAURER CHIEF INNOVATION OFFICER 40.00 X 221434 0 32924 KIRK DIMITRIS MD PHYSICIAN 40.00 X 1428538 0 27691 DAVID MIKOLYZK MD PHYSICIAN 40.00 X 869849 0 32572 CHARLES L LAHAM MD PHYSICIAN 40.00 X 534324 0 33106 NANCY N BUTLER MD PHYSICIAN 40.00 X 673591 0 14191 JEFFREY A JACOBY MD PHYSICIAN 40.00 X 1192377 0 26448 9036512 0 604551 88 0 1 0 CARETECH SOLUTIONS 901 WILSHIRE DRIVE STE 250 TROY MI 48084 IT SERVICES 5453746 COMPLETERX LTD 3100 S GESSNER STE 640 HOUSTON TX 77063 PHARMACY SERVICES 2871805 PATRIOT MEDICAL TECH PO BOX 415000 NASHVILLE TN 372415000 BIO-MED SERVICES 1177752 RADIATION ONCOLOGY SPECIALISTS PO BOX 678 STURGEON BAY WI 54235 CANCER CARE SERVICES 594931 ST VINCENT HOSPITAL PO BOX 13508 GREEN BAY WI 543073508 LINEN SERVICES 547783 17 36241 123264 436497 8500 596002 INTEGRATED HEALTH CARE 900099 115941557 115941557 LAB 621500 10955627 10932927 22700 PHARMACY 446110 6061633 6061633 132958817 3563091 3563091 342683 320856 21827 21827 21827 838202 1198965 -360763 -360763 -360763 111660 36241 26875 84785 84785 4090 3062 1028 1028 171071 135858 35213 35213 INVESTMENT HFHS & DME 446110 165304 165304 MISCELLANEOUS 900003 -128568 177411 -305979 36736 136936736 136841923 -248066 -253123 65719 65719 4828158 2879519 1948639 60786331 56349475 4321235 115621 769664 712192 55882 1590 9057322 8613351 405519 38452 3537233 3222445 307015 7773 758373 93717 664656 147000 147000 118416 118416 1470188 1470188 637368 70190 567178 522744 415848 100205 6691 5134907 5134907 2496853 1549530 915679 31644 411190 254694 156073 423 347988 214782 133206 2159704 2159704 7561019 7404291 154647 2081 851312 849785 1527 MEDICAL/SURGICAL SUPPLI 16035078 16035078 PURCHASED SERVICES 6634890 4610963 2017716 6211 MAINTENANCE 3312274 3271621 40653 STATE PROVIDER ASSESSME 2990864 2990864 1820337 1660771 159282 284 132454932 120029634 12214528 210770 X 11487108 8531070 3911962 4555671 20269 20269 18598147 21930752 0 300000 1945539 2251697 6130142 7393728 178144283 111675054 69275651 66469229 34883872 41497975 19549808 19892686 3814204 3381711 427887 422416 170044589 176647204 13673022 14813355 29660 30639 51602802 48806531 427887 422416 65733371 64072941 X 102395650 110297499 273086 350024 1642482 1926740 104311218 112574263 170044589 176647204 X 4481804 3599242 181999 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 1 0 0 0 0 1 1700 0 1 12640 14340 0 PART II-B, LINE 1: PART II-B, LINES 1B & 1G: HOLY FAMILY MEMORIAL SENT A REPRESENTATIVE TO WASHINGTON DC ONCE TO DISCUSS SPECIFIC LEGISLATIVE MATTERS WITH THEIR FEDERAL REPRESENTATIVES. HFM ALSO ATTENDED ONE DAY WHERE A SMALL NUMBER OF STAFF VISITED THE CAPITAL TO EDUCATE THEIR LEGISLATORS ON VARIOUS HEALTHCARE TOPICS. PART II-B, LINE 1I, OTHER ACTIVITIES: HOLY FAMILY MEMORIAL BELONGS TO HOSPITAL ASSOCIATIONS WHICH USE A PERCENTAGE OF THE DUES FOR LOBBYING PURPOSES. 0 0 1915567 374287 179201 192292 2276763 1637918 514026 236377 1915567 1602667 202680 -9775 500 157154 1637918 1429395 240013 162063 500 228304 1602667 1223863 485645 -107593 500 172020 1429395 0.93000 0.07000 0.00000 0 1 1 4863318 4863318 107643909 62277697 45366212 5207634 4634208 573426 58500692 43968868 14531824 1928730 794281 1134449 66469229 19892686 F 19892686 140356765 3420041 -12 3420029 136936736 0 136936736 132454918 -14 -14 132454932 0 132454932 PART V, LINE 4: HOLY FAMILY MEMORIAL'S ENDOWMENT FUNDS WERE ESTABLISHED TO PROVIDE FINANCIAL SUPPORT ON AN ONGOING BASIS TO MEET THE CURRENT AND FUTURE NEEDS OF HOLY FAMILY MEMORIAL AND THE PEOPLE IT SERVES. FUNDS ARE USED FOR CAPITAL EQUIPMENT, MAJOR BUILDING IMPROVEMENTS, PROGRAM DEVELOPMENT, AND OPERATIONS. PART XI, LINE 2D - OTHER ADJUSTMENTS: ROUNDING -12. PART XII, LINE 2D - OTHER ADJUSTMENTS: ROUNDING -14. 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X X X X X X X X X 1 0 1 1 100.000000000000 1 200.000000000000 1 X X X X X 1 1 X X 1 0 X X X 1 X 0 0 HOLY FAMILY MEMORIAL INC PART V, SECTION B, LINE 4: ASSESSMENT WAS COMPLETED WITH A FORMAL COMMUNITY GROUP WITH MEMBERSHIP TO INCLUDE AURORA MEDICAL CENTER, TWO RIVERS. HOLY FAMILY MEMORIAL INC PART V, SECTION B, LINE 14G: HOLY FAMILY MEMORIAL'S COMMUNITY CARE PROGRAM IS COMMUNICATED ON THE WEBSITE SUMMARIZING THE ELIGIBILITY REQUIREMENTS TO INCLUDE SERVICES COVERED, INCOME GUIDELINES, APPLICATION FORM, AND OTHER DOCUMENTS NEEDED FOR COMPLETION OF THE APPLICATION. THE COMMUNITY CARE PROGRAM IS ALSO COMMUNICATED VIA PAYMENT GUIDELINE BROCHURES AVAILABLE IN THE REGISTRATION AREAS AT ALL HFM LOCATIONS THROUGHOUT THE COMMUNITY, AND TO PATIENTS IN COMMUNICATION WITH PRICE ESTIMATIONS AND COLLECTIONS, BOTH VERBAL AND WRITTEN. THE POLICY IS ALSO AVAILABLE UPON REQUEST. HOLY FAMILY MEMORIAL INC PART V, SECTION B, LINE 18E: PAYMENT GUIDELINES AND FINANCIAL ASSISTANCE POLICY IS POSTED IN PATIENT ROOMS AND LOBBIES, ADMISSION/REGISTRATION AREAS, GIVEN TO ALL SURGERY PATIENTS, AND PUBLISHED ON THE BACK OF ALL PATIENT STATEMENTS. HOLY FAMILY MEMORIAL INC PART V, SECTION B, LINE 20D: THE HOSPITAL FACILITY USED THE AVERAGE OF ITS FIVE LOWEST NEGOTIATED COMMERCIAL INSURANCE RATES WHEN CALCULATING THE MAXIMUM AMOUNTS THAT CAN BE CHARGED. 2 HOLY FAMILY HEALTH SERVICES INC 3310 CALUMET AVENUE MANITOWOC WI 54220 RETAIL PHARMACY NORTH END HOME MEDICAL SERVICES LLC 3310 CALUMET AVENUE MANITOWOC WI 54220 DURABLE MEDICAL EQUIPMENT PART I, LINE 7: COMMUNITY BENEFITS ARE PROGRAMS OR ACTIVITIES THAT PROVIDE CARE AND/OR PROMOTE HEALTH AND HEALING AS A RESPONSE TO IDENTIFIED COMMUNITY NEEDS. HOLY FAMILY MEMORIAL'S COMMUNITY BENEFIT PROGRAMS INCLUDE SERVICES FOR THOSE WHO CAN NOT AFFORD HEALTH CARE AND INITIATIVES FOR IMPROVING HEALTH IN THE BROADER COMMUNITY. PROVIDING COMMUNITY BENEFITS DEMONSTRATES THAT HOLY FAMILY MEMORIAL IS FULFILLING ITS CHARITABLE MISSION AND DEMONSTRATING ITS PREFERENTIAL TAX STATUS IS DESERVED. SCHEDULE H, PART I, LINE 7, COLUMN F PERCENTAGE OF COMMUNITY BENEFIT EXPENSE TO OVERALL ENTITY'S EXPENSES. PART II, COMMUNITY BUILDING ACTIVITIES: COMMUNITY BUILDING ACTIVITIES INDICATED IN PART II PROMOTE THE HEALTH OF THE MANITOWOC COMMUNITY BY ACTIVELY ADDRESSING EXPRESSED AND REPORTED ISSUES. SPECIFICALLY, THROUGH THE PROGRAMS INDICATED, HOLY FAMILY MEMORIAL AND IN PARTNERSHIP WITH OTHERS, WORKS DILIGENTLY TO ACHIEVE AN OVERALL HEALTHIER COMMUNITY. MAJOR INITIATIVES WITH POSITIVE RESULTS INCLUDE: IMPROVED ACCESS TO HEALTH CARE, IMPROVED MENTAL HEALTH ACCESS AND CARE, INCREASED EXERCISE FOR ADULTS AND CHILDREN, HEALTHY FOOD OPTIONS IN SCHOOLS, AND ACCESS TO FRESH FRUITS AND VEGETABLES FOR THE POOR. PART III, LINE 4: AN ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS IS ESTABLISHED ON AN AGGREGATE BASIS BY USING HISTORICAL WRITE-OFF FACTORS APPLIED TO UNPAID ACCOUNTS BASED ON AGING. LOSS RATE FACTORS ARE BASED ON HISTORICAL LOSS EXPERIENCE AND ADJUSTED FOR ECONOMIC CONDITIONS AND OTHER TRENDS AFFECTING THE ORGANIZATION'S ABILITY TO COLLECT OUTSTANDING AMOUNTS. UNCOLLECTIBLE AMOUNTS ARE WRITTEN OFF AGAINST THE ALLOWANCE FOR DOUBTFUL ACCOUNTS IN THE PERIOD THEY ARE DETERMINED TO BE UNCOLLECTIBLE. PART III, LINE 8: HOLY FAMILY MEMORIAL IS A LICENSED MEDICARE PROVIDER WITH APPROXIMATLEY 47 PERCENT OF ITS PATIENT BASE QUALIFYING FOR THIS PROGRAM. AT PRESENT, THE REIMBURSEMENT RATE FOR THE MEDICARE PROGRAM DOES NOT FULLY COVER THE COST OF CARE TO THESE PATIENTS. THIS REPRESENTS THE ESTIMATED SHORTFALL CREATED WHEN HOLY FAMILY MEMORIAL RECEIVES PAYMENTS BELOW THE COSTS OF TREATING MEDICARE AND OTHER PUBLIC PROGRAM BENEFICIARIES.COST METHODOLOGY = COST TO CHARGE RATIO PART III, LINE 9B: PAYMENT OPTIONS AS WELL AS COMMUNITY CARE ASSISTANCE IS NOTED ON ALL COLLECTION LETTERS, AS WELL AS INSURANCE BENEFIT PAPERWORK THAT IS SENT TO PATIENTS FOR INPATIENT, SAME DAY SURGERY, MRI, CT SCAN, ER SERVICES. A PATIENT FINANCIAL ADVISOR AND/OR ELIGIBILITY SPECIALIST SEES SELF-PAY INPATIENTS TO INTERVIEW & ADVISE PATIENTS OF ANY PROGRAMS THEY MAY QUALIFY FOR INCLUDING, BUT NOT LIMITED TO MEDICAID, VETERANS ADMINISTRATION, OR OUR OWN CHARITY CARE PROGRAM. IF THEY MAY QUALIFY FOR MEDICAID OR VETERANS ADMINISTRATION, THE ELIGIBILITY SPECIALIST WILL HELP THEM COMPLETE THE APPLICATION PROCESS AND FOLLOW UP ON THEIR APPLICATION THROUGH TO APPROVAL/DISAPPROVAL. FOR THE NETWORK CHARITY PROGRAM, AN APPLICATION IS PROVIDED AND THE PATIENT IS INSTRUCTED ON WHOM TO CALL FOR ASSISTANCE IN APPLYING. WHEN CONTACTING PATIENTS BY PHONE, THE PATIENT FINANCIAL ADVISOR IS TRAINED TO IDENTIFY PATIENTS WHO MAY QUALIFY FOR OUTSIDE STATE OR FEDERAL ASSISTANCE AND WILL DIRECT THOSE PATIENTS ON WHERE TO GO TO APPLY FOR THOSE PROGRAMS. THE ELIGIBILITY SPECIALIST WILL ASSIST AS WELL. SCHEDULE H, PART III, LINE 3: THROUGH ANALYTICAL TOOLS, A COLLECTION PREDICTION SCORE IS APPLIED TO ALL ACCOUNTS WRITTEN OFF TO BAD DEBT THROUGH A COLLECTION AGENCY. THOSE SCORING LOW/UNCOLLECTIBLE ARE ASSUMED CHARITY/COMMUNITY BENEFIT. PART VI, LINE 2: HOLY FAMILY MEMORIAL UTILIZES FOUR DISTINCT PROCESSES TO ASSESS THE HEALTH CARE NEEDS OF THE COMMUNITIES WE SERVE. FIRST, AS A PART OF THE ANNUAL STRATEGIC PLANNING PROCESS, AN ENVIRONMENTAL ASSESSMENT IS DONE. INCLUDED IN THAT REPORT AND ANALYSIS IS CURRENT POPULATION DATA, COMMUNITY INPUT AND INPUT FROM VARIOUS CONSTITUENCIES RELATIVE TO PERCEIVED MET AND UNMET COMMUNITY HEALTH NEEDS. SECOND, HOLY FAMILY MEMORIAL PARTICIPATES IN A TRI-ANNUAL FULL COMMUNITY HEALTH NEEDS ASSESSMENT PROCESS IN PARTNERSHIP WITH HEALTHIEST MANITOWOC COUNTY, AURORA MEDICAL CENTER, MANITOWOC COUNTY PUBLIC HEALTH DEPT AND THE UNITED WAY. THIS ASSESSMENT CONSISTS OF INPUT OBTAINED FROM HUNDREDS OF COMMUNITY RESIDENTS, LEADERS, BUSINESSES; INCLUDING ALL AGE GROUPS, BEGINNING FROM HIGH SCHOOL AGE. THE INFORMATION IS TABULATED, ANALYZED AND UTILIZED TO DETERMINE PRIORITIZED HEALTH NEEDS. HOLY FAMILY MEMORIAL USES THIS INFORMATION IN ITS COMMUNITY IMPLEMENTATION PLAN. THIRD, HOLY FAMILY MEMORIAL CONDUCTS REGULAR INPUT SESSSIONS WITH LOCAL EMPLOYERS TO ASCERTAIN HEALTH NEEDS FROM AN OCCUPATIONAL HEALTH PERSPECTIVE. THIS INFORMATION IS THEN UTILIZED TO DEVELOP AND PROVIDE NEEDED EMPLOYER/EMPLOYEE HEALTH SERVICES THROUGHOUT THE BUSINESS COMMUNITY. LASTLY, HOLY FAMILY MEMORIAL UTILIZES A COMBINATION OF PATIENT FEEDBACK FROM ONGOING PATIENT SATISFACTION SURVEYS (CONDUCTED POST PROVISION OF SERVICES) AND COMMUNITY RESEARCH STUDIES COMMISSIONED BY HOLY FAMILY MEMORIAL, TO ASSESS PROGRAM AND SERVICE HEALTH CARE NEEDS OF THE COMMUNITY. PART VI, LINE 3: PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCE AREAS / WEBSITE / BROCHURES / ADMISSIONS STAFF / COLLECTION CORRESPONDENTS AS WELL AS INSURANCE BENEFIT PAPERWORK THAT IS SENT TO PATIENTS FOR INPATIENT, SAME DAY SURGERY, MRI, AND CT SCANS. A PATIENT FINANCIAL ADVISOR AND/OR ELIGIBILITY SPECIALIST SEES/COMMUNICATES TO SELF-PAY INPATIENTS TO INTERVIEW AND ADVISE PATIENT OF ANY PROGRAMS THEY MAY QUALIFY FOR INCLUDING, BUT NOT LIMITED TO MEDICAID, VETERANS ADMINISTRATION OR OUR OWN CHARITY PROGRAM. IF THEY QUALIFY FOR MEDICAID OR VETERANS ADMINISTRATION, WE ASSIST THEM IN COMPLETING THE APPLICATION AND FOLLOW UP ON THE APPLICATION THROUGH APPROVAL. FOR THE NETWORK CHARITY PROGRAM, AN APPLICATION IS PROVIDED AND THE PATIENT IS INSTRUCTED ON WHOM TO CALL FOR ASSISTANCE IN APPLYING. WHEN CONTACTING PATIENTS BY PHONE, THE PATIENT FINANCIAL ADVISOR OR ELIGIBILITY SPECIALIST IS TRAINED TO IDENTIFY PATIENTS WHO MAY QUALIFY FOR OUTSIDE STATE OR FEDERAL ASSISTANCE AND WILL ASSIST THOSE PATIENTS ON APPLYING FOR THOSE PROGRAMS. PART VI, LINE 4: THE COMMUNITY THAT HOLY FAMILY MEMORIAL SERVICES IS CONSIDERED TO BE LOCATED IN THE RURAL LAKESHORE REGION OF NORTHEAST WISCONSIN. THE PRIMARY SERVICE AREA IS MANITOWOC COUNTY WITH SECONDARY NEIGHBORING COUNTIES; BROWN, KEWAUNEE, CALUMET AND SHEBOYGAN. SPECIFICALLY, THE COMMUNITY SERVED IS AN OLDER POPULATION WITH 18.1% OF THE PEOPLE AGE 65 OR OLDER WITH MEDIAN HOUSEHOLD INCOME OF APPROXIMATELY $50,000. 14.3% OF OUR SERVICES ARE DEDICATED TO PROVIDING CARE TO MEDICAID AND SELF-PAY PATIENTS. THE 2014 SERVICE AREA IS EXPECTED TO REMAIN AT 2013 LEVELS WITH A SLIGHT GROWTH TOWARD THE 65+ AGE AND RETRACTION OF THOSE 18-44. REFLECTIVE OF THIS NUMBER IS THAT OVER 47% OF OUR SERVICES ARE DEDICATED TO PROVIDING CARE TO MEDICARE PATIENTS. THE COMMUNITY IS MAINLY CAUCASIAN WITH SEVERAL OTHER NATIONALITIES INCLUDING AFRICAN AMERICAN, ASIAN AND HISPANIC. OTHER PROVIDERS IN THE AREA CONSIST OF THE AURORA MEDICAL GROUP, MANITOWOC SURGERY CENTER, AND SEVERAL OTHER INDEPENDENT PROVIDERS. PART VI, LINE 5: ALL OF HOLY FAMILY MEMORIAL'S BOARD MEMBERS RESIDE IN THE PRIMARY SERVICE AREA. THE BOARD CONSISTS OF COMMUNITY REPRESENTATIVES, PHYSICIANS AND REPRESENTATIVES OF THE SPONSOR ORGANIZATION. THE MEDICAL/DENTAL STAFF IS OPEN TO ALL QUALIFIED PROVIDERS WHO MEET THE REQUIREMENTS OF MEDICAL/DENTAL STAFF MEMBERSHIP. THE NETWORK OF PHYSICIANS AND OTHER PROVIDERS ARE COMMITTED TO PROVIDING EACH PATIENT WITH THE HIGHEST LEVEL OF PERSONAL CARE, RESPECT AND COMPASSION TO ENHANCE THE PATIENT'S QUALITY OF LIFE AND HEALTH STATUS. ALL SURPLUS FUNDS ARE REINVESTED IN THE ORGANIZATION TO PURCHASE NECESSARY MEDICAL EQUIPMENT, COMPENSATE EMPLOYEES, AND PLAN FOR FUTURE NEEDS. NONE OF THE SURPLUS EARNINGS BENEFIT ANY INDIVIDUALS OR OTHER CORPORATE ENTITIES. PART VI, LINE 6: THE HEALTH CARE NETWORK IS SPONSORED BY THE FRANCISCAN SISTERS OF CHRISTIAN CHARITY, LOCATED AT HOLY FAMILY CONVENT, MANITOWOC, WISCONSIN. THE CONVENT, SITUATED ON SILVER LAKE, THREE MILES WEST OF LAKE MICHIGAN, IS HOME FOR OVER 350 CONGREGATION MEMBERS WHO SERVE THROUGHOUT THE UNITED STATES AND ARE PRIMARILY ENGAGED IN EDUCATION, PARISH AND HEALTH MINISTRIES. THE HEALTHCARE MINISTRY SPANS THREE STATES - WISCONSIN, NEBRASKA AND OHIO - AND HAS EXISTED FOR OVER 100 YEARS. THE MISSION OF THE FRANCISCAN SISTERS OF CHRISTIAN CHARITY HEALTHCARE MINISTRY IS TO CARRY OUT THE COMMITMENT OF THE SPONSOR IN THE HEALING MISSION OF THE CATHOLIC CHURCH THROUGH THE PROVISION OF QUALITY HEALTHCARE SERVICES TO THE PEOPLE OF GOD IN OUR COMMUNITIES. PART VI, LINE 7, REPORTS FILED WITH STATES WI,NE 1 SCHOLARSHIPS 11 13400 ACTUAL TUITION COST SCHOLARSHIPS - EDUCATION 15 38300 ACTUAL TUITION COST SCHEDULE I, PART III: HOLY FAMILY MEMORIAL'S SCHOLARSHIP PROGRAM IS DESIGNED AS A RECRUITMENT TOOL FOR EMPLOYMENT OF CANDIDATES IN SPECIFIED POSITIONS, CONSIDERED DIFFICULT TO FILL AND TO ASSIST STUDENTS IN THEIR PURSUIT OF A HEALTH CARE RELATED DEGREE. AREAS OF STUDY INCLUDE NURSING, PHARMACY, PHYSICAL THERAPY AND OTHERS. IN RETURN FOR THE SCHOLARSHIP, AN EMPLOYMENT SERVICE COMMITMENT IS MADE. IN ORDER TO BE ELIGIBLE: 1) STUDENTS MUST BE ACCEPTED INTO AN ACCREDITED PROGRAM 2) CANDIDATES MUST BE ATTENDING SCHOOL AS A FULL OR PART TIME STUDENT AND REMAIN IN THAT STATUS 3) STUDENTS MUST HAVE AND MAINTAIN A 3.0 CUMULATIVE GRADE POINT AVERAGE. SCHOLARSHIPS ARE AWARDED ON THE BASIS OF GRADE POINT AVERAGE, VERIFIED WITH OFFICIAL TRANSCRIPT OF GRADES, COMPLETION OF EMPLOYMENT APPLICATION AND PERSONAL INTERVIEW. THE SCHOLARSHIP IS USED FOR TUITION COST. THE SCHOLARSHIPS ARE GIVEN OUT EACH SEMESTER AND ARE PAID DIRECTLY TO THE SCHOOL THE STUDENT ATTENDS. APPLICANTS WHO ARE AWARDED THE SCHOLARSHIP MUST MAKE A SIX-MONTH COMMITMENT TO WORK AT HOLY FAMILY MEMORIAL FOR EACH SEMESTER THE SCHOLARSHIP IS AWARDED. THE SCHOLARSHIP RECIPIENT MUST REPAY THE FULL AMOUNT OF THE SCHOLARSHIP IF HE/SHE: 1) DROPS OUT OF SCHOOL 2) FALLS BELOW A 3.0 CUMULATIVE GRADE POINT AVERAGE 3) DOES NOT ACCEPT EMPLOYMENT 4) DOES NOT COMPLETE FULL LENGTH OF EMPLOYMENT COMMITMENT 5) DOES NOT OBTAIN WISCONSIN LICENSURE, AS REQUIRED. THE SCHOLARSHIP AWARD THROUGH EDUCATION ARE USED TO PROMOTE HEALTH CARE CAREERS. THE REQUIREMENTS FOR THE MEDICAL/DENTAL ENDOWMENT INCLUDE ACCEPTANCE AT AN ACCREDITED COLLEGE, UNIVERSITY, OR TECHNICAL SCHOOL, A MANITOWOC COUNTY RESIDENT, A GRADE POINT AVERAGE OF 3.0 OR ABOVE IS DESIRED, DEMONSTRATE HEALTH CAREER INTEREST AND FINANCIAL NEED. THESE SCHOLARSHIPS ARE OFFERED FOR ONE YEAR WITH POSSIBLE CONTINUATION BASED ON MEETING CRITERIA. THE CRITERIA FOR THE RONCALLI SCHOLARSHIP INCLUDES ACCEPTANCE AT AN ACCREDITED COLLEGE, UNIVERSITY, OR TECHNICAL SCHOOL, A MANITOWOC COUNTY RESIDENT, A GRADE POINT AVERAGE OF 3.0 OR ABOVE IS DESIRED, AND DEMONSTRATED HEALTH CAREER INTEREST. THESE SCHOLARSHIPS ARE PROVIDED FOR ONE YEAR. X X 1 1 X X X X 0 0 0 0 0 1 0 1 0 RYAN M DOPIRAK MD PHYSICIAN COUNCIL CHAIR 688278 0 743203 0 60540 0 5646 0 29502 0 1527169 0 0 0 MATTHEW L CAMPBELL MD DIRECTOR 305498 0 0 0 26486 0 5646 0 26898 0 364528 0 0 0 WILLIAM D HAMPTON MD DIRECTOR 279909 0 26000 0 1740 0 5646 0 27102 0 340397 0 0 0 PRADEEP GIRIYAPPA MD DIRECTOR 207928 0 36755 0 13154 0 5646 0 20698 0 284181 0 0 0 MARY A GOVIER MD DIRECTOR 173892 0 0 0 4642 0 3832 0 30673 0 213039 0 0 0 MARK P HERZOG DIRECTOR, PRESIDENT, CEO 439846 0 56485 0 17098 0 66509 0 30684 0 610622 0 0 0 PATRICIA HUETTL CHIEF FINANCIAL OFFICER 218976 0 20372 0 41611 0 39456 0 31953 0 352368 0 37228 0 STEVEN D DRIGGERS MD CHIEF MEDICAL OFFICER 404058 0 36875 0 192304 0 67881 0 28117 0 729235 0 187353 0 MARY MAURER CHIEF INNOVATION OFFICER 194266 0 17464 0 9704 0 29776 0 5204 0 256414 0 0 0 KIRK DIMITRIS MD PHYSICIAN 715082 0 696970 0 16486 0 5646 0 24294 0 1458478 0 0 0 DAVID MIKOLYZK MD PHYSICIAN 705836 0 144631 0 19382 0 5646 0 29175 0 904670 0 10242 0 CHARLES L LAHAM MD PHYSICIAN 524592 0 8000 0 1732 0 5646 0 29709 0 569679 0 0 0 NANCY N BUTLER MD PHYSICIAN 330609 0 241437 0 101545 0 5646 0 10794 0 690031 0 0 0 JEFFREY A JACOBY MD PHYSICIAN 544232 0 647605 0 540 0 5646 0 23052 0 1221075 0 0 0 PART I, LINE 1A CIVIC PAY, CEO, CFO, KEY EMPLOYEES (5 EMPLOYEES - $1,650-$5,776), BENEFIT TREATED AS TAXABLE INCOME CIVIC DUES, 1 KEY EMPLOYEE ($660), BENEFIT NOT TREATED AS TAXABLE INCOME PART I, LINE 6 THE SENIOR SUCCESSSHARE PROGRAM IS AN AT RISK COMPENSATION PROGRAM WHICH IS BASED ON BALANCED STRATEGIC ACCOMPLISHMENTS AS APPROVED ANNUALLY BY THE COMPENSATION AND EVALUATION SUBCOMMITTEE OF THE BOARD OF DIRECTORS. ELIGIBLE PERSONS INCLUDE THE PRESIDENT/CEO, CHIEF MEDICAL OFFICER, CHIEF FINANCIAL OFFICER, AND CHIEF INNOVATION OFFICER. PART I, LINE 7 A PORTION OF PHYSICIAN SALARY IS BASED ON INDIVIDUAL PRODUCTION FOR PERSONALLY RENDERED SERVICES. A WISCONSIN HEALTH AND EDUCATION FACILITIES 391337855 97710VPE2 2003-09-09 9922000 SEE SCHEDULE K, PART V 0 0 0 B WISCONSIN HEALTH AND EDUCATION FACILITIES 391337855 97710V2S6 2007-04-26 45170000 SEE SCHEDULE K, PART V 0 0 0 A 1839000 9922000 244000 9677000 2006 0 0 1 1 B 5117000 45170000 2553000 485000 4990000 2009 1 1 1 1 A 0 0 0 0 0 0 1 B 0 0 0 0 0 0 1 A 0 0 0 1 1 0 0 0 1 B 0 0 0 1 0 0 0 0 1 A 1 B 1 DATE REBATE COMPUTATION PERFORMED ISSUER NAME: WISCONSIN HEALTH AND EDUCATION FACILITIES DATE THE REBATE COMPUTATION WAS PERFORMED: 10/06/2008 ISSUER NAME: WISCONSIN HEALTH AND EDUCATION FACILITIES DATE THE REBATE COMPUTATION WAS PERFORMED: 06/01/2012 PART I, LINE A, COLUMN F: THE PURPOSE OF THE BOND ISSUE WAS A PROJECT CONSISTING OF THE CONSTRUCTION, RENOVATION AND EQUIPPING OF AMBULATORY CARE, DIAGNOSTIC IMAGING, REHABILITATION, OCCUPATIONAL MEDICINE, PRIMARY CARE AND ORTHOPEDIC FACILITIES AT CERTAIN HOLY FAMILY MEMORIAL HEALTH FACILITIES. PART I, LINE B, COLUMN F: THE PURPOSE OF THE BOND ISSUE WERE 1) THE ACQUISITION, CONSTRUCTION, RENOVATION, REMODELING AND EQUIPPING OF CERTAIN HOSPITAL AND OTHER HEALTHCARE FACILITIES AS IDENTIFIED IN A NOTICE OF PUBLIC HEARING PUBLISHED IN CONNECTION WITH THE ISSUANCE OF THE BONDS INCLUDING THE ACQUISITION OF TELEMETRY MONITORS AND AN MRI SYSTEM 2) THE CURRENT REFUNDING OF ALL THE WISCONSIN HEALTH AND EDUCATIONAL FACILITIES AUTHORITY REVENUE (WHEFA) BONDS, SERIES 1995, 3) THE ADVANCE REFUNDING OF ALL OF THE WHEFA BONDS, SERIES 1998A, AND 4) THE ADVANCE REFUNDING OF A PORTION OF THE WHEFA BONDS, SERIES 2003A. NORTH END HOME MED SVC LLC SERVE AS DIRECTORS ON BOTH ORGANIZATIONS -64970 INCOME FROM CONTINUOUS OPS - 100% OWNED 0 HOLY FAMILY HEALTH SERVICES SERVE AS DIRECTORS ON BOTH ORGANIZATIONS 379528 INCOME FROM CONTINUOUS OPERATIONS - 100% OWNED 0 LINDSAY BRISCH DAUGHTER OF DIRECTOR/OFFICER 25578 REPORTABLE COMPENSATION (W2) AND ESTIMATE OF OTHER COMPENSATION 0 FORM 990, PART VI, SECTION A, LINE 6 HOLY FAMILY MEMORIAL IS SPONSORED BY FRANCISCAN SISTERS OF CHRISTIAN CHARITY SPONSORED MINISTRIES, INC. WHICH IS THE SOLE CORPORATE MEMBER OF THE ORGANIZATION. FORM 990, PART VI, SECTION A, LINE 7A HOLY FAMILY MEMORIAL OPERATES AN INTEGRATED HEALTHCARE DELIVERY SYSTEM, PRIMARILY TO THE RESIDENTS OF MANITOWOC COUNTY, WISCONSIN. HOLY FAMILY MEMORIAL IS OPERATED BY FRANCISCAN SISTERS OF CHRISTIAN CHARITY SPONSORED MINISTRIES, INC., WHICH IS THE SOLE CORPORATE MEMBER OF THE ORGANIZATION. FRANCISCAN SISTERS OF CHRISTIAN CHARITY SPONSORED MINISTRIES, INC. IS A NOT-FOR-PROFIT HEALTHCARE HOLDING COMPANY INCORPORATED TO MONITOR AND MANAGE HEALTHCARE OPERATIONS. THE BOARD OF DIRECTORS SHALL CONSIST OF NO MORE THAN EIGHTEEN INDIVIDUALS. THE PRESIDENT OF THE CORPORATION AND CHAIR OF THE PHYSICIAN COUNCIL SHALL BE EX-OFFICIO MEMBERS WITH FULL VOTING PRIVILEGES. IN ADDITION TO THE EX-OFFICIO BOARD POSITIONS, THE BOARD OF DIRECTORS SHALL INCLUDE FOUR MEMBERS OF FRANCISCAN SISTERS OF CHRISTIAN CHARITY AND AT LEAST FOUR PHYSICIANS. FORM 990, PART VI, SECTION A, LINE 7B SOME DECISIONS OF THE GOVERNING BODY ARE SUBJECT TO APPROVAL BY THE MEMBER AS OUTLINED IN THE CORPORATE BYLAWS. FOR EXAMPLE, THE GOVERNING BOARD SUBMITS NAMES OF NEW BOARD MEMBERS TO THE MEMBER AND THE MEMBER APPOINTS THEM. APPROVAL OF THE BUDGET, MORTGAGE, PHILOSOPHY, MISSION & VISION, LEASE OR SALE OF REAL ESTATE MUST BE APPROVED BY THE MEMBER. A CERTIFIED AUDIT OF CORPORATE FUNDS OR THE ANNUAL FISCAL AUDIT MUST BE APPROVED BY THE MEMBER. FORM 990, PART VI, SECTION B, LINE 11 THE CHAIR OF THE GOVERNING BOARD REVIEWS THE 990 PRIOR TO FILING. AN OVERVIEW OF THE 990 ALONG WITH SPECIFIC SECTIONS ON GOVERNANCE, COMMUNITY BENEFITS, AND CONFLICT OF INTEREST IS PRESENTED TO THE BOARD OR BOARD COMMITTEE. THE COMPENSATION AND EVALUATION SUBCOMMITTEE REVIEWS THE 990 SECTIONS RELATED TO COMPENSATION PRIOR TO FILING. COPIES ARE AVAILABLE TO ALL BOARD MEMBERS. FORM 990, PART VI, SECTION B, LINE 12C ANNUALLY, GOVERNING BOARD MEMBERS ARE PROVIDED A COPY OF THE CONFLICT OF INTEREST POLICY TO REVIEW AND SIGN THE CERTIFICATION ON WHICH THEY DISCLOSE ANY CONFLICTS. AT EACH BOARD OR COMMITTEE MEETING WHERE THERE WILL BE A VOTE, THE CHAIRPERSON ASKS IF THERE ARE ANY CONFLICTS TO THE PARTICULAR ISSUE. IF THERE IS A CONFLICT, THAT PERSON ABSTAINS FROM DISCUSSION & VOTING. ALL PHYSICIANS, LEADERS, AND KEY EMPLOYEES SIGN A CONFLICT OF INTEREST ANNUALLY. CONFLICT OF INTEREST IS MONITORED THROUGH HOLY FAMILY MEMORIAL'S COMPLIANCE DEPARTMENT. FORM 990, PART VI, SECTION B, LINE 15 LINES 15 A & B - HOLY FAMILY MEMORIAL HAS A SENIOR LEADER COMPENSATION POLICY. THE PROCESS OF DETERMINING THESE SALARIES IS GOVERNED BY THE COMPENSATION AND EVALUATION SUBCOMMITTEE OF THE BOARD. THE POLICY COVERS THE FOLLOWING POSITIONS: PRESIDENT AND CEO, CHIEF FINANCIAL OFFICER, CHIEF MEDICAL OFFICER AND CHIEF INNOVATION OFFICER. SENIOR LEADER SALARY DATA IS EVALUATED ANNUALLY BY AN EXTERNAL EXECUTIVE COMPENSATION FIRM. TOTAL COMPENSATION FOR SENIOR LEADERS (SALARY, BENEFITS AND INCENTIVE) IS EVALUATED EVERY THREE YEARS BY AN EXTERNAL EXECUTIVE COMPENSATION FIRM (LAST DONE DEC 2011). ALSO CONSIDERED ARE CURRENT MARKET CONDITIONS AND MARKET COMPETITIVENESS. THE POLICY REFLECTS HOLY FAMILY MEMORIAL'S MISSION AND VALUES AND THE LOCAL COMMUNITY EXPERIENCE BY EMPHASIZING REWARDS BASED ON WELL ROUNDED ACCOMPLISHMENTS IN THE AREAS OF MISSION AND RELATIONSHIPS, KEY STRATEGIES AND OPERATIONS, INCLUDING FINANCE. FORM 990, PART VI, SECTION C, LINE 19 HOLY FAMILY MEMORIAL'S ARTICLES OF INCORPORATION ARE PUBLICLY AVAILABLE FROM THE WI DEPARTMENT OF FINANCIAL INSTITUTIONS. THE CONFLICT OF INTEREST POLICY IS AVAILABLE UPON REQUEST. HOLY FAMILY MEMORIAL'S FINANCIAL STATEMENTS ARE AVAILABLE ON THE DACBOND.COM WEBSITE AND HOLY FAMILY MEMORIAL SUBMITS FINANCIAL INFORMATION TO THE STATE OF WI ANNUALLY. OUR FORM 990 IS AVAILABLE UPON REQUEST AND CAN BE SEEN ON THE GUIDESTAR WEBSITE. FORM 990, PART VII, SECTION A, PART 1A LINES 1 THROUGH 5: HOLY FAMILY MEMORIAL'S BOARD OF DIRECTORS INCLUDES SIX EMPLOYED PROVIDERS. THE COMPENSATION REPORTED FOR THESE DIRECTORS IS FOR THEIR SERVICES AS A PROVIDER. FORM 990, PART XI, LINE 9: RESTRICTED CONTRIBUTIONS NET OF ASSETS RELEASED 181,999. FORM 990, PART XII, LINE 2C: THE ORGANIZATION HAS NOT CHANGED ITS OVERSIGHT PROCESS OR SELECTION PROCESS DURING THE TAX PROCESS. NORTH END HOME MED SCS LLC 3310 CALUMET AVENUE MANITOWOC WI 54220 391868808 MEDICAL EQUIPMENT WI -63611 1984169 HFM INC FRANCISCAN SISTERS OF CHRISTIAN CHARITY 1415 SOUTH RAPIDS ROAD MANITOWOC WI 54220 391530622 HEALTHCARE WI 501(C)(3) LINE 1 N/A 0 ST PAUL ELDER SERVICES INC 316 EAST 14TH STREET KAUKAUNA WI 54130 391029149 ELDER CARE WI 501(C)(3) LINE 1 N/A 0 GOOD SAMARITAN MEDICAL CENTER 800 FOREST AVENUE ZANESVILLE OH 43701 314379479 HOLDING CO. OH 501(C)(3) LINE 3 N/A 0 FRANCISCAN CARE SERVICES INC 430 N MONITOR ST WEST POINT NE 68788 470486026 HEALTHCARE NE 501(C)(3) LINE 3 N/A 0 SILVER LAKE COLLEGE OF THE HOLY FAMILY INC 2406 SOUTH ALVERNO ROAD MANITOWOC WI 54220 390980974 HIGHER EDUCATION WI 501(C)(3) LINE 2 N/A 0 HOLY FAMILY CONVENT OF THE FRANCISCAN SISTERS OF CHRISTIAN CHARITY 2409 SOUTH ALVERNO ROAD MANITOWOC WI 54220 390808523 RELIGIOUS WI 501(C)(3) LINE 1 N/A 0 HOLY FAMILY HEALTH SERVICES 3310 CALUMET AVENUE MANITOWOC WI 54220 391572253 PHARMACY WI HFM INC C 228915 1746900 1.00000 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 1 0 0 HOLY FAMILY HEALTH SERVICES - REIMBURSEMENT OF SALARYBENEFITSUPPLIESRENT Q 942554 ACTUAL REVENUE FRANCISCAN SISTERS OF CHRISTIAN CHARITY - BUILDING RENT J 51425 ACTUAL REVENUE FRANCISCAN SISTERS OF CHRISTIAN CHARITY - AUDIT FEES P 83930 ACTUAL EXPENSE FRANCISCAN SISTERS OF CHRISTIAN CHARITY - ADMINISTRATIVE SERVICES P 701000 ACTUAL EXPENSE FRANCISCAN SISTERS OF CHRISTIAN CHARITY-LIABBUILDINGWORKERS COMP INSURANC P 1392264 ACTUAL EXPENSE FRANCISCAN SISTERS OF CHRISTIAN CHARITY - HEALTH INSURANCE PREMIUMS P 9499000 ACTUAL EXPENSE