2013-08-15T12:08:42-05:00 2012-09-30 390758449 WIPFLI LLP PO BOX 12237 GREEN BAY WI 543072237 990 2011-10-01 396089134 WILD ROSE COMMUNITY MEMORIAL HOSPITAL INC WILD 9206223257 PO BOX 243 WILD ROSE WI 549840243 DONALD R CAVES 9206223257 2013-08-15 1 TERRI REXRODE CPA P00096513 9206620016 2013-08-15 2011 2016-02-25 16:41:14Z DONALD R CAVES PO BOX 243 WILD ROSE WI 549840243 14995911 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 8 173 74 0 0 153539 24848 13602051 14964341 5355 6722 1922 0 13762867 14995911 0 0 0 0 6083063 6755574 0 0 0 7524737 7692271 13607800 14447845 155067 548066 6030710 6107089 7497268 7022973 -1466558 -915884 X PROVIDE SUPERIOR SERVICES TO IMPROVE THE HEALTH OF THOSE WE SERVE. 0 0 12646873 14836046 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 CHARGE- DIABETES EDUCATION AND SUPPORT GROUP AND BALANCE TRAINING (PHYSICAL THERAPY)- HOSTED SELF-HELP AND WELLNESS PROGRAMS SUCH AS AA, AL-ANON, DIET- BLOOD PRESSURE SCREENINGS, CHOLESTEROL TESTING AND SCHOOL-BASED TESTING- GUIDANCE, REFERRAL AND ENROLLMENT ASSISTANCE FOR PUBLIC MEDICAL PROGRAMS AND OTHER FAMILY SUPPORT ASSISTANCE- DISCOUNTED OR FREE MEDICAL SUPPLIES AND EQUIPMENT TO THOSE UNABLE TO PAY- HOSTED FIVE BLOOD DRIVES AND ENCOURAGED EMPLOYEE PARTICIPATION- CONTRIBUTED TO THE EDUCATION OF STUDENT NURSES AND OTHER HEALTH CARE PROFESSIONALS- PROVIDED FIRST AID FOR COMMUNITY SPORTING EVENTS- PARTICIPATED IN WORK HEALTH EDUCATION PROGRAMS THROUGH PRIMARY CARE INITIATIVE PROGRAM- MADE CASH CONTRIBUTIONS TO SUPPORT COMMUNITY SERVICES AND EVENTS- PROVIDED 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 2012 OVER 350 ACCOUNTS RECEIVED CHARITY CARE WITH A TOTAL COST OF OVER $306,000. 12646873 1 1 0 1 0 0 0 0 0 0 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 0 0 0 0 0 0 0 1 0 0 0 0 1 11 0 1 173 1 0 0 0 0 0 0 0 0 0 0 X 10 8 1 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 X 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 9.00 X X 42527 114475 15580 MICHAEL STAUDINGER MD 40.00 X X 0 338475 28546 THOMAS KRYSTOWIAK 1.00 X 4215 164409 28960 CHAD VOSKUIL MD 40.00 X 0 265568 34496 REGINALDO ABOLEDA MD 40.00 X 0 240837 19352 CHANDLER CAVES MD 40.00 X 0 322610 32517 CATHERINE TRUEHL 40.00 X 106446 0 6775 153188 1446374 166226 1 0 1 0 COMMUNITY HEALTH NETWORK 225 MEMORIAL DRIVE BERLIN WI 54923 MANAGEMENT AND PHYSICIAN SERVICES 3562989 SHARED MEDICAL EQUIPMENT PO BOX 330 COTTAGE GROVE WI 53527 EQUIPMENT LEASES 150000 SHARED MEDICAL SERVICES INC PO BOX 330 COTTAGE GROVE WI 53527 TECHNICAL SUPPORT 109853 3 17000 7848 24848 NET PATIENT SERVICE RE 621990 14836046 14836046 OTHER OPERATING REVENU 900099 128295 128295 14964341 6722 6722 14995911 14836046 0 135017 407968 407968 4952418 4141663 810755 117967 97283 20684 915394 905032 10362 361827 301279 60548 47795 47795 11500 11500 2840393 2807660 32733 15107 145 14962 1745436 1678859 66577 83985 83985 823226 747008 76218 62872 59391 3481 2901 2901 232261 188725 43536 182629 148396 34233 42183 42183 PROVISION FOR BAD DEBT 1349193 1349193 MISCELLANEOUS 195161 53186 141975 LICENSE AND CERTIFICATI 32895 26879 6016 ASSOCIATION DUES 17539 10175 7364 7195 2930 4265 14447845 12646873 1800972 0 1338349 1179177 71372 66568 2633387 2477353 224683 207879 35281 30722 5328362 3185580 1727638 2142782 0 2608 6030710 6107089 863472 897385 679549 619141 5954247 5506447 7497268 7022973 X -1466558 -918492 2608 -1466558 -915884 6030710 6107089 X 548066 2608 X X 0 1 1 X 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: WHA DUES OF $1,275 71372 3129 5325 69176 63947 6904 521 71372 162815 520 99388 63947 0 96338 66477 0 162815 1.00000 1 1 0 72982 72982 2321462 1367405 954057 66340 60294 6046 2316223 1757881 558342 551355 551355 2142782 LONG TERM NOTES PAYABLE TO RELATED PARTY 4000000 DUE TO THIRD-PARTY REIMBURSEMENT PROGRAM 1403919 ACCOUNTS PAYABLE DUE TO RELATED PARTY 102528 5506447 14995911 14447845 548066 2608 2608 550674 14995911 0 14995911 0 14995911 14447845 0 14447845 0 14447845 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: 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 8 - OTHER ADJUSTMENTS: CHANGE IN INTEREST IN PARTNERS HEALTH SYSTEM FOUNDATION, INC. 2,608. PART XII, LINE 2D - OTHER ADJUSTMENTS: EXPENSE ALLOCATION TO RENTAL INCOME PART XIII, LINE 2D - OTHER ADJUSTMENTS: EXPENSE ALLOCATION TO RENTAL INCOME 1 1 X 1 X 1 X 1 1 1 0 1 1 306919 0 306919 0.02340 1791895 642808 1149087 0.08770 2098814 642808 1456006 0.11110 6 595 7793 225 7568 0.00060 885 885 0.00010 155 12334 12334 0.00090 161 595 21012 225 20787 0.00160 161 595 2119826 643033 1476793 0.11270 660 660 0.00010 660 660 0.00010 1 649786 0 4124774 3813851 310923 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 11 1 1 1 X X X X X X X X 0 1 1 150.000000000000 1 300.000000000000 1 X X X X X X 1 1 X X 1 0 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 $1,349,193 FROM FORM 990, PART IX, LINE 25 WAS REMOVED FOR THE PURPOSE OF CALCULATING THE PERCENTAGES IN PART 1, LINE 7, COLUMN (F). PART II: WILD ROSE HOSPITAL ENGAGES IN SEVERAL COMMUNITY BUILDING ACTIVITIES. OUR DISASTER READINESS PROGRAMS ARE DEVELOPED TO EXCEED THE MINIMUM REQUIREMENTS IN ORDER TO PROVIDE A RESPONSIBLE LEVEL OF SERVICE TO THE COMMUNITY. WE PARTICIPATE ON THE COUNTY PUBLIC SAFETY COMMITTEE, THE LOCAL EMERGENCY COMMITTEE, AND THE REGIONAL HOSPITAL EMERGENCY PREPAREDNESS COMMITTEE. ALL OF THESE EFFORTS ARE FOCUSED ON MINIMIZING THE HEALTH IMPACT OF CATASTROPHES, LARGE AND SMALL, AS WELL AS SUPPORTING HEALTHY ACTIVITIES AND GROUPS WITH A QUALITY OF LIFE FOCUS. 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: WAUSHARA COUNTY PUBLIC HEALTH WEBSITE WILD ROSE COMMUNITY MEMORIAL HOSPITAL PART V, SECTION B, LINE 7: NEEDS WERE PRIORITIZED BASED ON THE LARGEST POSITIVE IMPACT TO THE COMMUNITY. ANY NEEDS NOT ADDRESSED ARE DUE TO LIMITATIONS ON RESOURCES AVAILABLE. WILD ROSE COMMUNITY MEMORIAL HOSPITAL PART V, SECTION B, LINE 13G: THE POLICY IS PROVIDED TO PATIENTS UPON ADMISSION IF THEY HAVE NO INSURANCE AND OR EXPRESS CONCERNS ABOUT THE ABILITY TO PAY. WILD ROSE COMMUNITY MEMORIAL HOSPITAL PART V, SECTION B, LINE 19D: COMMUNITY CARE WILL BE APPROVED IN A THREE (3) TIER PROGRAM PER POLICY. 100% FOR APPLICANTS AT OR BELOW 150% OF THE FEDERAL POVERTY GUIDELINES. 5% FOR APPLICANTS BETWEEN 150% AND 200% OF FEDERAL POVERTY GUIDELINES. 25% FOR APPLICANTS BETWEEN 200% AND 300% OF FEDERAL POVERTY GUIDELINES. THE PATIENT MUST MAKE ARRANGEMENTS TO PAY THE REMAINDER OF THE BALANCE AFTER THE COMMUNITY CARE ADJUSTMENT. 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 33689 70938 0 0 8838 43537 699 3443 1957 9481 45183 127399 0 0 MICHAEL STAUDINGER MD 0 316171 0 20092 0 2212 0 7350 0 21196 0 367021 0 0 THOMAS KRYSTOWIAK 3840 149778 0 0 375 14631 219 8540 505 19696 4939 192645 0 0 CHAD VOSKUIL MD 0 265568 0 0 0 0 0 7350 0 27146 0 300064 0 0 REGINALDO ABOLEDA MD 0 240837 0 0 0 0 0 9736 0 9616 0 260189 0 0 CHANDLER CAVES MD 0 287317 0 6264 0 29029 0 7350 0 25167 0 355127 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. 35001 COMPENSATION 0 CHANDLER CAVES MD SON OF CEO 355127 COMPENSATION - COMMON LAW EMPLOYEE. CHANDLER IS EMPLOYED BY CHN (RELATED PARTY) BUT WORKS EXCLUSIVELY AT WILD ROSE HOSPITAL. 0 FORM 990, PART VI, SECTION A, LINE 2 MARK KJENTVET HAS A FAMILY RELATIONSHIP WITH ANDREEN KJENTVET, EMPLOYEE OF WILD ROSE HOSPITAL. DONALD CAVES HAS A FAMILY RELATIONSHIP WITH CHANDLER CAVES M.D. WHOM IS EMPLOYED BY RELATED PARTY. 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 PERIODIC REVIEWS ARE PERFORMED. THE PRESIDENT OF WILD ROSE HOSPITAL WAS EMPLOYED BY COMMUNITY HEALTH NETWORK (CHN) UNTIL THE 4TH QUARTER. ONCE A YEAR, CHN'S CEO REVIEWS COMPENSATION BENCHMARK DATA AND COMPARES THE DATA WITH WILD ROSE HOSPITAL PRESIDENT'S CURRENT SALARY AND THE PROPOSED INCREASE. BASED ON THE DATA, THE CEO DETERMINES THE PRESIDENT'S SALARY FOR THE COMING YEAR. THE QUESTION IS MARKED "NO" BECAUSE THE PROCESS IS NOT DOCUMENTED. THE COMPENSATION FOR THE NEW CEO POSITION FOR WILD ROSE WAS DETERMINED USING A CONSULTANT AND COMPARATIVE DATA FOR SIMILAR POSITIONS. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S FINANCIAL STATEMENTS, CONFLICT OF INTEREST POLICY, AND GOVERNING DOCUMENTS ARE THE PROPERTY OF THE ORGANIZATION AND ARE NOT AVAILABLE FOR INSPECTION, EXCEPT DISCLOSURE OF THE FINANCIAL STATEMENTS WITH THE FORM 990, AS REQUIRED. AVERAGE HOURS WORKED AT RELATED ORGANIZATIONS: FORM 990, PART VII, SECTION A, COLUMN B DONALD CAVES WORKED AT RELATED ORGANIZATION AN AVERAGE OF 9 HOURS PER WEEK FOR 9 MONTHS OF THE CALENDAR YEAR AND 40.0 HOURS PER WEEK FOR 3 MONTHS OF THE CALENDAR YEAR. THOMAS KRYSTOWIAK WORKED AN AVERAGE OF 39.0 HOURS PER WEEK AT A RELATED ORGANIZATION. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: CHANGE IN INTEREST IN PARTNERS HEALTH SYSTEM FOUNDATION, INC. 2,608. TOTAL TO FORM 990, PART XI, LINE 5: 2,608. 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 0 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 0 0 0 0 0 1 0 0 0 0 1 0 0 0 1 1 1 0 0