2013-05-15T14:50:42-05:00 2012-06-30 390758449 WIPFLI LLP PO BOX 12237 GREEN BAY WI 543072237 990 2011-07-01 390807236 AGNESIAN HEALTHCARE INC AGNE 9209262300 430 EAST DIVISION STREET FOND DU LAC WI 54935 BONNIE SCHMITZ 9209262300 2013-05-14 0 TERRI REXRODE CPA MST P00096513 9206620016 2013-05-14 2011 2016-02-24 21:20:13Z STEVEN LITTLE CEO 430 EAST DIVISION STREET FOND DU LAC WI 54935 375986981 0 1 0928 X WWW.AGNESIAN.COM X 1892 WI AGNESIAN HEALTHCARE IS A LOCALLY-BASED, INTEGRATED HEALTHCARE SYSTEM WHICH BEGAN ITS MISSION IN 1892. THE SYSTEM IS COMPRISED OF SEVEN MINISTRIES - ST. AGNES HOSPITAL, WAUPUN MEMORIAL HOSPITAL, RIPON MEDICAL CENTER, ST. FRANCIS HOME, FOND DU LAC REGIONAL CLINIC, CONSULTANTS LABORATORY OF WISCONSIN, AND AGNESIAN HEALTHCARE ENTERPRISES. AGNESIAN PROVIDES A CONTINUUM OF HEALTHCARE SERVICES FROM BIRTH TO END OF LIFE, PREVENTIVE HEALTHCARE DIAGNOSIS, TREATMENT AND FOLLOWUP, ASSISTED LIVING, AND INDEPENDENT SKILL CARE SERVICES. 16 11 3139 350 5027249 484665 0 0 292268282 303846638 6366707 4671883 13030448 15415062 311665437 323933583 0 0 0 0 118550970 131086985 0 0 0 169158135 173115111 287709105 304202096 23956332 19731487 397023480 405106873 185535734 179598113 211487746 225508760 X THE MISSION OF AGNESIAN HEALTHCARE IS TO PROVIDE COMPASSIONATE CARE THAT BRINGS HOPE, HEALTH AND WHOLENESS TO THOSE WE SERVE BY HONORING THE SACREDNESS AND DIGNITY OF ALL PERSONS AT EVERY STAGE OF LIFE. WE ARE ROOTED IN THE HEALING MINISTRY OF THE CATHOLIC CHURCH AS WE CONTINUE THE MISSION OF OUR SPONSOR, THE CONGREGATION OF SISTERS OF ST AGNES. 0 0 208459936 290397234 AGNESIAN HEALTHCARE OPERATES ST. AGNES HOSPITAL, A 174-BED GENERAL/SURGICAL ACUTE CARE HOSPITAL WHICH PROVIDES INPATIENT AND OUTPATIENT SERVICES TO RESIDENTS OF FOND DU LAC AND THE SURROUNDING COUNTIES. DURING FISCAL YEAR 2012, ST. AGNES HOSPITAL HAD 6,066 INPATIENT ADMISSIONS, WITH TOTAL PATIENT DAYS OF 26,701. THERE WAS A TOTAL OF 27,841 EMERGENCY ROOM VISITS AND 12,926 SURGERIES PERFORMED IN FY12. IN ADDITION, ST. AGNES HOSPITAL PROVIDED 390,870 PHYSICIAN CLINIC VISITS, 103,838 MEDICAL IMAGING PROCEDURES, AND 1,275,705 PHYSICAL, OCCUPATIONAL AND SPEECH THERAPY UNITS. THERE WERE 1,570 CARDIAC CATH LAB VISITS AND 38,613 HOSPICE DAYS. THE HOSPITAL ALSO OPERATES SAMARITAN CLINIC, A FREE CLINIC OFFERING MEDICAL SERVICES TO QUALIFIED INDIVIDUALS. SAMARITAN CLINIC PROVIDED 4,880 VISITS TO PATIENTS, AT A COST OF $642,369 FOR FY12. THE HOSPITAL MAINTAINS RECORDS TO IDENTIFY AND MONITOR THE LEVEL OF CHARITY IT PROVIDES TO ITS PATIENTS. THE COST OF SERVICES AND SUPPLIES FURNISHED UNDER THE HOSPITAL'S CHARITY CARE POLICY WAS $3,134,320. IN ADDITION TO QUALITY HEALTH CARE SERVICES, ST. AGNES HOSPITAL PROVIDES ITS COMMUNITIES WITH EDUCATION, SUPPORT GROUPS AND OTHER COMMUNITY BENEFITS. THE NET COST OF THESE COMMUNITY BENEFITS WAS $2,497,034. 12585882 14766353 AGNESIAN HEALTHCARE OPERATES CONSULTANTS LABORATORY OF WISCONSIN, AN INDEPENDENT REFERENCE LAB SERVING FOND DU LAC, DODGE, OUTAGAMIE, WINNEBAGO AND COLUMBIA COUNTIES. CLW PROVIDED 1,139,485 TESTS DURING FISCAL YEAR 2012. THE LABORATORY ALSO PROVIDES THE COMMUNITY WITH CAREER EDUCATION, CONTRIBUTIONS AND SERVICES TO SAMARITAN CLINIC. THE NET COST OF THESE COMMUNITY BENEFITS WAS $310,035. 7166548 4929276 AGNESIAN HEALTHCARE OPERATES AGNESIAN ENTERPRISES, WHICH IS COMPRISED OF EIGHT PHARMACIES SERVING FOND DU LAC AND SURROUNDING TOWNS, AS WELL AS AGNESIAN HEALTH SHOPPE, WHICH SERVES THE POPULATION WITH HOSPITAL (INPATIENT AND OUTPATIENT), CLINIC AND HOME HEALTH EQUIPMENT. AGNESIAN ENTERPRISES FILLED 437,238 PRESCRIPTIONS DURING FY12. AGNESIAN HEALTH SHOPPE PROVIDES RETAIL SALES OF DURABLE MEDICAL EQUIPMENT, AS WELL AS TELECARE AND HOME OXYGEN SERVICES. 228212366 1 0 0 1 0 0 0 0 0 1 1 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 1 1 1 0 0 1 263 0 1 3139 1 1 1 1 CJ 0 0 0 0 0 0 0 0 X 16 11 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 1 1 X LESLIE STEPHANY 9209264512 430 EAST DIVISION STREET FOND DU LAC WI 54935 STEVEN N LITTLE 50.00 X X 728403 0 32425 SR MARY NOEL BROWN 1.00 X 0 0 0 JAMES R CHATTERTON 1.00 X X 0 0 0 JOAN KARSTEN 1.00 X 0 0 0 SR ANN KOERNER 1.00 X 0 0 0 SR HERTHA LONGO 1.00 X 0 0 0 M STEPHANIE MARTIN 1.00 X 0 0 0 STEPHEN MASSICK MD 1.00 X 0 0 0 WAYNE MATZKE 1.00 X X 0 0 0 PATRICIA MILLER 1.00 X 0 0 0 H JACK POLLEI 1.00 X 11066 0 0 JOSEPH REITEMEIER 1.00 X X 0 0 0 JAMES B SIMON 1.00 X X 5107 0 0 MICHAEL STRINGENZ MD 1.00 X 0 0 0 JEFFERY STRONG MD 1.00 X 0 0 0 ALLEN MILANI MD 1.00 X 482838 0 23868 ROBERT A FALE 50.00 X 1313324 0 31971 CAROL HYLAND 50.00 X 258936 0 29088 DENNIS YUNK 50.00 X 283226 0 26431 DOUGLAS TROST 50.00 X 166128 0 26964 JANE HYDE 50.00 X 220622 0 17919 JAMES MUGAN 50.00 X 261270 0 35572 BONNIE SCHMITZ 50.00 X 221990 0 17753 BARB KNUTZEN 50.00 X 192566 0 23774 SR MARY MOLLISON 50.00 X 163071 0 8498 JILL STENSON 50.00 X 162906 0 15756 JOHN CHOI MD 50.00 X 971218 0 29726 YASIR HATAHET MD 50.00 X 905433 0 38113 PONTUS OSTMAN MD 50.00 X 733680 0 15860 JAMES GRAF MD 50.00 X 553977 0 34769 HONG WANG MD 50.00 X 550445 0 31971 8186206 0 440458 108 0 1 0 FOND DU LAC REGIONAL CLINIC 420 E DIVISION ST FOND DU LAC WI 54935 PHYSICIAN SERVICES 45761663 CERNER CORP 2800 ROCKCREEK PKWY KANSAS CITY MO 64141 COMPUTER SERVICES 11894324 IBM CORPORATION 1 NEW ORCHARD RD ARMONK NY 105041722 COMPUTER SERVICES 10714511 CD SMITH CONSTRUCTION PO BOX 1066 FOND DU LAC WI 54935 CONSTRUCTION 8391302 AMERICAN HEALTHCARE SERVICES PO BOX 945 TRAVERSE CITY MI 49685 TEMPORARY STAFFING 1723095 49 NET PATIENT SERVICE RE 621400 195902570 194359094 1543476 MEDICARE/MEDICAID SERV 621400 107944068 107944068 303846638 4048938 4048938 90995 90995 30975434 18185 30459404 2265 516030 15920 531950 531950 30609061 21591729 9017332 5553547 3463785 WORK INJURY - SAH 592512 1282165 1282165 CAFETERIA SALES 900099 1131715 19988 1111727 CLINIC REIMBURSEMENT 621110 953989 953989 3029861 3029861 6397730 323933583 310092863 5027249 8813471 3161464 506706 2654758 109169864 87077579 22092285 5693187 4176093 1517094 5723066 3819774 1903292 7339404 5569141 1770263 239903 6885 233018 129500 129500 59405896 55394469 4011427 887854 96635 791219 40395338 38729475 1665863 17638092 61730 17576362 10841557 7429400 3412157 577709 472196 105513 642882 426754 216128 4007834 4007834 15748189 5424241 10323948 1967984 1102815 865169 BAD DEBTS 12692889 12692889 HOSPITAL ASSESSMENT TAX 4783756 4783756 INVESTMENT FEES 556809 556809 LOSS ON DEFEASANCE OF B 462260 462260 2136659 441828 1694831 304202096 228212366 75989730 0 4836066 5837093 27011646 8935657 40185003 44502314 4707050 4857997 2254376 2612600 281379258 144572655 119574831 136806603 134084567 146174087 64369941 55380522 397023480 405106873 30889640 27123150 127115997 125173728 27530097 27301235 185535734 179598113 X 198310924 212398409 10715610 10649139 2461212 2461212 211487746 225508760 397023480 405106873 X 19731487 -5710473 X X 0 1 1 X 0 X 0 0 0 0 0 0 0 0 1 16793 16793 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: OTHER LOBBYING ACTIVITIES: LOBBYING PORTION OF WHA DUES 992140 15366 2530 1004976 996299 48126 50000 2285 992140 1020134 23156 45000 1991 996299 1014822 45000 -37548 2140 1020134 1.00000 0 1 1 6002505 6002505 136087594 53637465 82450129 2600257 978567 1621690 125344104 89956623 35387481 11344798 11344798 136806603 RECEIVABLE FROM AFFILIATED ENTITIES 4048956 LONG-TERM DEBT FROM AFFILIATED ENTITY 5000000 INVESTMENT - MERCURY CLINIC 3005130 INVESTMENT - SAH FOUNDATION 8686221 OTHER ASSETS 625163 BOND DEFERRED FINANCING COSTS 1223251 ASSETS WHOSE USE IS LIMITED - BOND FUNDS 11898620 ASSETS WHOSE USE IS LIMITED - PHYSICIAN SUPPLEMENTAL BENEFIT PLAN 19400070 MISCELLANEOUS RECEIVABLES 670661 RECEIVABLE FROM FOUNDATION 822450 55380522 CAPITAL LEASE PAYABLE 4615072 PHYSICIANS SUPPLEMENTAL LIFE INSURANCE 19400070 FUND BALANCE SWAP MKT ADJUSTMENT 3191758 DUE TO MEDICARE/MEDICAID 94335 27301235 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: AGNESIAN HEALTHCARE, INC. HOLDS AN ENDOWMENT FROM THE CONGREGATION OF THE SISTERS OF ST. AGNES. THE ORIGINAL ENDOWMENT OF $1,000,000 IS PERMANENTLY RESTRICTED. INCOME GENERATED FROM THE ENDOWMENT IS UNRESRICTED AND TO BE USED AT THE DISCRETION OF THE CHIEF EXECUTIVE OFFICER TO FUND PROGRAMS SUCH AS DOMESTIC VIOLENCE, CHARITY CARE, ETC. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: IN ORDER TO ACCOUNT FOR ANY UNCERTAIN TAX POSITIONS, ASC TOPIC 740-10, ACCOUNTING FOR UNCERTAINTY IN INCOME TAXES, REQUIRES AN ORGANIZATION TO ASSESS 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 THE TAX POSITION IS NOT RECOGNIZED IN THE FINANCIAL STATEMENTS. AGNESIAN HEALTHCARE, INC. RECORDED NO ASSETS OR LIABILITIES FOR UNCERTAIN TAX POSITIONS OR UNRECOGNIZED TAX BENEFITS. FEDERAL RETURNS FOR THE YEARS ENDED 2009, 2010, AND 2011 REMAIN SUBJECT TO EXAMINATION BY THE INTERNAL REVENUE SERVICE. 1 1 1 X 165.000000000000 1 X 1 1 1 0 1 1 3134320 3134320 0.01080 12525002 12525002 0.04300 15659322 15659322 0.05380 1264530 129944 1134586 0.00390 405140 405140 0.00140 658422 658422 0.00230 608921 608921 0.00210 2937013 129944 2807069 0.00970 18596335 129944 18466391 0.06350 138270 138270 0.00050 138270 138270 0.00050 1 12692889 0 92082790 131944857 -39862067 X 1 1 1 1 ST AGNES HOSPITAL

430 E DIVISION STREET FOND DU LAC WI 54935

X X X ST AGNES HOSPITAL 1 1 1 165.000000000000 1 300.000000000000 1 X X X 1 1 X X X X X 1 0 1 X 0 0 3 FOND DU LAC REGIONAL CLINIC

420 E DIVISION STREET FOND DU LAC WI 54935

OUTPATIENT PHYSICIAN CLINIC CONSULTANTS LAB OF WISCONSIN LLC

430 E DIVISION STREET FOND DU LAC WI 54935

LABORATORY AND TESTING AGNESIAN HEALTHCARE ENTERPRISES LLC

430 E DIVISION STREET FOND DU LAC WI 54935

PHARMACEUTICALS, HOME HEALTH, MEDICAL SUPPLIES PART I, LINE 6A: AN ANNUAL COMMUNITY BENEFIT REPORT IS COMPLETED BY THE FINANCE DEPARTMENT AND DISTRIBUTED TO THE PUBLIC THROUGH THE PUBLIC RELATIONS OFFICE OF AGNESIAN HEALTHCARE, INC. PART I, LINE 7: A COST-TO-CHARGE RATIO WAS USED TO COMPUTE COST OF COMMUNITY BENEFIT SERVICES. OVERALL COSTS LESS TAXES WERE DIVISIBLE BY TOTAL CHARGES. PART I, LINE 7G: SUBSIDIZED HEALTH SERVICES INCLUDES SAMARITAN CLINIC, A CLINIC OFFERING FREE MEDICAL SERVICES TO QUALIFIED INDIVIDUALS, AND COUNSELING SERVICES THROUGH BEHAVIORAL HEALTH SERVICES. SAMARITAN CLINIC COSTS WERE $642,369 FOR FY12. THE SAMARITAN HEALTH CLINIC PROVIDES PATIENTS WITH IMPORTANT BASIC HEALTH SERVICES, MEDICATIONS AND URGENT DENTAL NEEDS AT NO CHARGE TO THE PATIENT. PART I, L7 COL(F): BAD DEBT EXPENSES INCLUDED ON FORM 990, PART IX, LINE 24 WAS $12,692,889 AND WAS EXCLUDED FROM THE DENOMINATOR PER INSTRUCTIONS. PART II, LINE 8: WORKFORCE DEVELOPMENT INCLUDES JOB SHADOWING, CAREERS CAMP, AND THE HEALTHCARE YOUTH APPRENTICE PROGRAM. THESE PROGRAMS ALLOW STUDENTS AND OTHERS TO LEARN ABOUT DIFFERENT OCCUPATIONS IN THE HEALTHCARE INDUSTRY BY BECOMING CERTIFIED AND GAINING ACTUAL WORK EXPERIENCE. THE PROGRAMS ALSO PROMOTE THESE STUDENTS TO BRING VALUABLE HEALTHCARE KNOWLEDGE BACK TO THEIR FAMILIES AND THE COMMUNITY. PART III, LINE 4: THE CARRYING AMOUNTS OF ACCOUNTS RECEIVABLE ARE REDUCED BY ALLOWANCES THAT REFLECT MANAGEMENT'S BEST ESTIMATE OF THE AMOUNTS THAT WILL NOT BE COLLECTED. MANAGEMENT PROVIDES FOR CONTRACTUAL ADJUSTMENTS UNDER TERMS OF THIRD-PARTY REIMBURSEMENT AGREEMENTS THROUGH A CHARGE TO CONTRACTUAL ADJUSTMENTS AND A CREDIT TO THE ALLOWANCE FOR CONTRACTUAL ADJUSTMENTS. IN ADDITION, MANAGEMENT PROVIDES FOR PROBABLE UNCOLLECTIBLE AMOUNTS, PRIMARILY FROM UNINSURED PATIENTS AND AMOUNTS PATIENTS ARE PERSONALLY RESPONSIBLE FOR, THROUGH A CHARGE TO OPERATIONS AND A CREDIT TO A VALUATION ALLOWANCE BASED ON ITS ASSESSMENT OF HISTORICAL COLLECTION LIKELIHOOD AND THE CURRENT STATUS OF INDIVIDUAL ACCOUNTS. BALANCES THAT ARE STILL OUTSTANDING AFTER MANAGEMENT HAS USED REASONABLE COLLECTION EFFORTS ARE WRITTEN OFF THROUGH A CHARGE TO THE VALUATION ALLOWANCE AND A CREDIT TO ACCOUNTS RECEIVABLE. THE COSTING METHODOLOGY FOR DETERMINING BAD DEBTS IS A COST TO CHARGE RATIO. PART III, LINE 8: MEDICARE SHORTFALL IS NOT TREATED AS A COMMUNITY BENEFIT. TO ARRIVE AT COST OF MEDICARE SERVICES, THE TOTAL EXPENSES LESS OTHER OPERATING REVENUE IS MULTIPLIED BY THE RATIO OF MEDICARE REVENUE TO TOTAL REVENUE. PART III, LINE 8: WE HAVEN'T REPORTED THE MEDICARE SHORTFALL AS A COMMUNITY BENEFIT. HOWEVER, IT SHOULD BE TREATED AS A COMMUNITY BENEFIT BECAUSE IT PROMOTES ACCESS TO HEALTHCARE TO THE UNDERSERVED ELDERLY POPULATION, WHO WOULD NOT HAVE ACCESS TO LOCAL CARE IF WE WERE NOT ABLE TO SERVE THEM. ALTHOUGH OUR HOSPITAL IS EFFICIENTLY OPERATED, THE CALCULATIONS USED FOR MEDICARE REIMBURSEMENT DO NOT ALLOW FOR PAYMENTS THAT COVER COSTS OF NECESSARY SERVICES. PART III, LINE 9A: AGNESIAN HEALTHCARE, INC. HAS A WRITTEN DEBT COLLECTION POLICY. PAYMENT IS DUE WITHIN 30 DAYS OF RECEIPT OF A STATEMENT. IF PATIENTS DO NOT SET UP ACCEPTABLE PAYMENT ARRANGEMENTS, BILLS WILL BE REFERRED TO AN OUTSIDE COLLECTION AGENCY. FINANCIAL COUNSELORS WORK WITH ALL PATIENTS ON AN INDIVIDUAL BASIS AND MAY OFFER EXTENDED MONTHLY PAYMENTS WITHOUT INTEREST BASED ON DOLLAR AMOUNT, PRIVATE PAY DISCOUNTS (INDIVIDUALS WHO DO NOT HAVE INSURANCE COVERING EMERGENCY OR OTHER MEDICALLY NECESSARY CARE ARE BILLED AT REDUCED RATE), OR GUARANTEED BANK LOANS. PART III LINE 9B: A ZERO DOLLAR AMOUNT WAS ESTIMATED FOR THE AMOUNT OF BAD DEBTS ATTRIBUTABLE TO PATIENTS WHO WOULD QUALIFY FOR FINANCIAL ASSISTANCE. IF PATIENTS QUALIFY, THEIR EXPENSES ARE RECLASSIFIED AS CHARITY CARE. PATIENTS WHO RECEIVED A COLLECTION NOTICE COULD APPLY FOR CHARITY CARE. IF THEIR APPLICATION IS APPROVED, THIS WOULD TRIGGER A TRANSFER OF EXPENSE FROM BAD DEBT TO CHARITY CARE. PART V, LINE 12: FINANCIAL COUNSELORS AT AGNESIAN HEALTHCARE ASSIST PATIENTS WITH APPLICATION TO COMMUNITY CARE. PATIENTS CAN BE REFERRED TO COMMUNITY CARE BY CLERGY, DEPARTMENTS OF AGNESIAN HEALTHCARE, SISTERS OF ST. AGNES, AREA SOCIAL AND HEALTH AGENCIES, FAMILY OR SELF. THE APPLICATION IS COMPLETED BY THE PATIENT WITH ASSISTNACE FROM THE FINANCIAL COUNSELOR IF NEEDED. THE FINANCIAL COUNSELOR WILL COMMUNICATE TO THE PATIENT WHAT PROGRAMS THEY WILL BE ELIGIBLE FOR, AS WELL AS PROVIDE NOTIFICATION OF APPROVAL OR DENIAL OF THEIR APPLICATION IN A TIMELY MANNER. ST. AGNES HOSPITAL PART V, SECTION B, LINE 19D: UNINSURED PATIENTS AUTOMATICALLY RECEIVE A 15% DISCOUNT OFF GROSS CHARGES. PATIENTS WHO HAVE INSURANCE BUT ARE ELIGIBLE FOR FINANCIAL ASSISTANCE ARE CHARGED THE FULL AMOUNT OF THEIR RESPONSIBILITY FOR COINSURANCE AND DEDUCTIBLE PER THE EOB FROM THEIR INSURANCE COMPANY. PART VI, LINE 2: AGNESIAN HEALTHCARE SENIOR LEADERS MEET REGULARLY WITH COMMUNITY LEADERS TO GATHER INPUT FROM AND RESPOND TO PATIENT AND CUSTOMER NEEDS. SENIOR LEADERS AND MEMBERS OF THE WORKFORCE PARTICIPATE IN A VARIETY OF ORGANIZATIONS IN SUPPORT OF AGNESIAN HEALTHCARE'S KEY COMMUNITIES. THROUGH AGNESIAN'S PARTICIPATION IN THESE ACTIVITIES, COMMUNITY MEMBERS LEARN OF AGNESIAN'S COMMITTMENT TO COMMUNITY-WIDE HEALTHCARE AND PROVIDE AGNESIAN WITH INSIGHT INTO COMMUNITY HEALTH NEEDS AND DESIRES. IN ADDITION, A COMMUNITY HEALTH NEEDS ASSESSMENT WAS INITIATED DURING FISCAL YEAR 2011, AND THE RESULTS WILL BE AVAILABLE DURING FISCAL YEAR 2012. THE ASSESSMENT WAS CONDUCTED IN CONJUNCTION WITH THE FOND DU LAC COUNTY HEALTH DEPARTMENT. THE ASSESSMENT DETERMINES PRIORITY HEALTH CONCERNS THROUGH AN EXAMINATION OF DATA FROM THE COUNTY AND STATE ON DISEASE INCIDENCE, DEATHS AND BIRTHS, DEMOGRAPHICS, ECONOMIC FACTORS, INJURY AND HEALTH BEHAVIOR, THE ENVIRONMENT AND COMMUNITY PERCEPTIONS. IT ALSO INCLUDES AN ASSESSMENT OF COMMUNITY RESOURCES CURRENTLY IN PLACE. RESULTS OF THE ASSESSMENT WILL BE WIDELY DISTRIBUTED THROUGHOUT THE COMMUNITY VIA MEDIA OUTLETS AND HOSPITAL AND COUNTY WEBSITES. PART VI, LINE 3: FINANCIAL COUNSELORS AT AGNESIAN HEALTHCARE ASSIST PATIENTS WITH APPLICATION TO COMMUNITY CARE. PATIENTS CAN BE REFERRED TO COMMUNITY CARE BY CLERGY, DEPARTMENTS OF AGNESIAN HEALTHCARE, SISTERS OF ST. AGNES, AREA SOCIAL AND HEALTH AGENCIES, FAMILY OR SELF. THE APPLICATION IS COMPLETED BY THE PATIENT WITH ASSISTANCE FROM THE FINANCIAL COUNSELOR IF NEEDED. THE FINANCIAL COUNSELOR WILL COMMUNICATE TO THE PATIENT WHAT PROGRAMS THEY WILL BE ELIGIBLE FOR, AS WELL AS PROVIDE NOTIFICATION OF APPROVAL OR DENIAL OF THEIR APPLICATION IN A TIMELY MANNER. PART VI, LINE 4: COMMUNITY CARE APPLICATIONS ARE ACCEPTED ONLY FROM PATIENTS OF AGNESIAN HEALTHCARE WHO RESIDE IN THE COUNTIES OF CALUMET, DODGE, FOND DU LAC, GREEN LAKE, MARQUETTE, WAUSHARA OR WINNEBAGO. INDIVIDUALS MUST BE A RESIDENT OF ONE OF THOSE AREAS FOR A MINIMUM OF THREE MONTHS AND PROVIDE SUPPORTING DOCUMENTATION. ON OCCASION, INDIVIDUALS ARE NOT COMMUNITY MEMBERS BUT MAY NEED ASSISTANCE; THOSE APPLICATIONS ARE CONSIDERED ON A CASE-BY-CASE BASIS. THE SAMARITAN CLINIC SERVICES PATIENTS FROM DODGE AND FOND DU LAC COUNTIES. PART VI, LINE 5: AGNESIAN HEALTHCARE LEADERS DEVELOP GRANT APPLICATIONS IN SUPPORT OF PROGRAMS AND SERVICES SERVING THE GREATER NEEDS OF THE COMMUNITY, INCLUDING HOSPICE HOPE, DOMESTIC VIOLENCE PROGRAMS, CARDIAC CARE, AND PREVENTIVE HEALTH SCREENINGS AND SERVICES. PROVIDING THESE SERVICES LOCALLY IS A FOCUS OF OUR COMMUNITY BENEFIT PROGRAMS. PART VI, LINE 5: AGNESIAN HEALTHCARE OFFERS PROGRAMS TO THE COMMUNITY THAT ALLOW STUDENTS AND OTHERS TO LEARN ABOUT DIFFERENT OCCUPATIONS IN THE HEALTHCARE INDUSTRY BY BECOMING CERTIFIED AND GAINING ACTUAL WORK EXPERIENCE. THE DIFFERENT PROGRAMS PROVIDE HANDS-ON OPPORTUNITIES AND ALLOW JOB SHADOWING SO THE FUTURE OF THE PROFESSION CAN GAIN CONFIDENCE AND SKILLS. IN ADDITION, AGNESIAN HEALTHCARE SHARES ITS PROFESSIONAL STAFF EXPERTISE TO OFFER HEALTH EDUCATION CLASSES, HEALTH SCREENINGS, SUPPORT GROUPS, AND OTHER HEALTH PROMOTION ACTIVITIES THROUGHOUT THE YEAR. OTHER COMMUNITY ACTIVITIES INCLUDE SUPPORT AND TRAINING FOR THE DODGE CORRECTIONAL INSTITUTIONAL HOSPICE PROGRAM, SHARPS DISPOSAL SERVICES, ADOPT-A-FAMILY, DONATIONS TO FOOD PANTRIES, AND LEADERSHIP PARTICIPATION IN COMMUNITY NONPROFIT ORGANIZATIONS. PART VI, LINE 6: AGNESIAN HEALTHCARE, INC. IS AN INTEGRATED, COMPREHENSIVE NOT-FOR-PROFIT HEALTHCARE DELIVERY SYSTEM COMPRISED OF SEVEN MINISTRIES: AGNESIAN HEALTHCARE ENTERPRISES, LLC, CONSULTANTS LAB OF WI, LLC, FOND DU LAC REGIONAL CLINIC, ST. AGNES HOSPITAL, ST. FRANCIS HOME, WAUPUN MEMORIAL HOSPITAL AND RIPON MEDICAL CENTER. AGNESIAN PROVIDES A CONTINUUM OF HEALTHCARE SERVICES FROM BIRTH TO END OF LIFE, PREVENTIVE HEALTHCARE, DIAGNOSIS, TREATMENT AND FOLLOWUP, ASSISTED LIVING, AND INDEPENDENT AND SKILL CARE SERVICES. AGNESIAN HEALTHCARE IS COMMITTED TO ENSURING THAT INDIVIDUALS NEEDING VITAL HEALTHCARE SERVICES GET THE HELP THEY NEED AND DESERVE. REPORTS FILED WITH STATES PART VI, LINE 7 WI X X 1 1 X X X X 0 1 0 1 0 0 0 0 0 STEVEN N LITTLE 372708 0 46395 0 309300 0 0 0 32425 0 760828 0 0 0 ALLEN MILANI MD 482838 0 0 0 0 0 0 0 23868 0 506706 0 0 0 ROBERT A FALE 612871 0 131225 0 569228 0 0 0 31971 0 1345295 0 0 0 CAROL HYLAND 229806 0 29130 0 0 0 0 0 29088 0 288024 0 0 0 DENNIS YUNK 227426 0 25800 0 30000 0 0 0 26431 0 309657 0 0 0 DOUGLAS TROST 147579 0 18549 0 0 0 0 0 26964 0 193092 0 0 0 JANE HYDE 192872 0 27750 0 0 0 0 0 17919 0 238541 0 0 0 JAMES MUGAN 232149 0 29121 0 0 0 0 0 35572 0 296842 0 0 0 BONNIE SCHMITZ 202100 0 19890 0 0 0 0 0 17753 0 239743 0 0 0 BARB KNUTZEN 169973 0 22593 0 0 0 0 0 23774 0 216340 0 0 0 SR MARY MOLLISON 143526 0 19545 0 0 0 0 0 8498 0 171569 0 0 0 JILL STENSON 142539 0 20367 0 0 0 0 0 15756 0 178662 0 0 0 JOHN CHOI MD 532665 0 438553 0 0 0 0 0 29726 0 1000944 0 0 0 YASIR HATAHET MD 511339 0 394094 0 0 0 0 0 38113 0 943546 0 0 0 PONTUS OSTMAN MD 733680 0 0 0 0 0 0 0 15860 0 749540 0 0 0 JAMES GRAF MD 553977 0 0 0 0 0 0 0 34769 0 588746 0 0 0 HONG WANG MD 550445 0 0 0 0 0 0 0 31971 0 582416 0 0 0 PART I, LINE 1A ALL GROSSUP PAYMENTS AND SOCIAL CLUB DUES ARE INCLUDED ON FORM 1099. THESE PAYMENTS ARE MADE FOR TWO MEMBERS OF THE BOARD OF DIRECTORS. PART I, LINE 4B ALL EXECUTIVES EXCEPT CEO PARTICIPATE IN A 457(B) SUPPLEMENTAL NONQUALIFIED RETIREMENT PLAN. PART I, LINE 5 COMPENSATION FOR SOME EMPLOYED PHYSICIANS IS BASED ON A PERCENTAGE OF GROSS BILLINGS. WI HEALTH AND EDUC FACILITIES AUTHORITY 391337855 97710BGG1 2008-12-11 49330000 REFUNDING OF 2005 ISSUE 0 0 0 WI HEALTH AND EDUC FACILITIES AUTHORITY 391337855 97710BYW6 2010-12-01 57260000 REFUNDING OF 2001 ISSUE, PRIVATE ROOM PROJECT 0 0 0 WI HEALTH AND EDUC FACILITIES AUTHORITY 391337855 NONEAVAIL 2011-12-15 10020000 PARTIAL REFUNDING OF 1998 ISSUE 0 0 0 1000000 49330000 430000 48900000 2005 1 0 1 1 1730000 57260000 4518399 767686 18012751 1574279 2661885 1 0 0 1 908000 10020000 90000 2011 1 0 1 1 0 0 0 0 0.01470 0.01470 1 0 0 0 0 1 0 0 0 0 1 0 1 1 PIPER JAFFRAY 28.000000000000 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 X JOSEPH REITEMEIER DIRECTOR 306593 JOSEPH REITEMEIER IS PRESIDENT OF FOND DU LAC ASSOCIATION OF COMMERCE. AGNESIAN HEALTHCARE, INC. PROVIDED OCCUPATIONAL HEALTH SERVICES TO THE ASSOCIATION OF COMMERCE, BILLING $453 FOR THESE SERVICES IN FISCAL YEAR 2012. IN ADDITION, AGNESIAN HEALTHCARE, INC. PURCHASED SERVICES TOTALING $306,140 FROM THE ASSOCIATION OF COMMERCE DURING FISCAL YEAR 2012. 0 JOSEPH REITEMEIER DIRECTOR 51461 JOSEPH REITEMEIER IS PRESIDENT OF FOND DU LAC ASSOCIATION OF COMMERCE. HIS DAUGHTER-IN-LAW, JENNIFER REITEMEIER, IS EMPLOYED AS AN RN AT AGNESIAN HEALTHCARE, EARNING AN ANNUAL SALARY OF $51,461. 0 FORM 990, PART VI, SECTION A, LINE 6 THE ORGANIZATION HAS TWO CLASSES OF MEMBERS - CLASS A MEMBERS WHO ARE MEMBERS OF THE CONGREGATION OF THE SISTERS OF ST. AGNES AND CLASS B MEMBERS WHO CONTITUTE THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION A, LINE 7A THE CLASS A MEMBERS, WHO ARE MEMBERS OF THE CONGREGATION OF THE SISTERS OF ST. AGNES, HAVE THE POWER TO ELECT OR APPOINT THE CLASS B MEMBERS. THE CLASS B MEMBERS CONSTITUTE THE BOARD OF DIRECTORS. THE CLASS B MEMBERS HAVE THE POWER TO SUBMIT RECOMMENDATIONS REGARDING THE SELECTION AND RETENTION OF THE CEO TO THE MEMBERS OF THE CORPORATION. FORM 990, PART VI, SECTION A, LINE 7B THE CONGREGATION OF THE SISTERS OF ST AGNES SPONSORED MINISTRIES IS A CLASS B MEMBER WHO IS RESPONSIBLE FOR APPROVING CERTAIN ACTIVITIES OF THE CORPORATION. THE CONGREGATION OF THE SISTERS OF ST AGNES IS A CLASS A MEMBER WHO HAS THE SAME RESERVE POWERS AS THE CLASS B MEMBER. FORM 990, PART VI, SECTION B, LINE 11 THE FINANCE DEPARTMENT PREPARES THE FORM 990 AND THE RETURN IS REVIEWED BY THE DIRECTOR OF FINANCE AND CFO. A FINAL COPY OF THE 2011 FORM 990 IS PROVIDED TO THE BOARD EXECUTIVE COMMITTEE FOR REVIEW AND APPROVAL TO THE AGNESIAN HEALTHCARE BOARD BEFORE THE RETURN IS FILED WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C WE HAVE A WRITTEN CONFLICT OF INTEREST AND INSIDER TRANSACTION POLICY THAT REQUIRES EACH DIRECTOR, PRINCIPAL OFFICER, TRUSTEE OR COMMITTEE MEMBER TO DISCLOSE ON AN ANNUAL BASIS TO THE DESIGNATED AUTHORITY A CONFLICT OF INTEREST DISCLOSURE STATEMENT. THE DESIGNATED AUTHORITY ENSURES THAT ALL STATEMENTS ARE COMPLETED, REVIEWS THEM FOR CONFLICTS, AND SUBMITS TO THE BOARD FOR REVIEW ANY CONFLICT OF INTEREST DISCLOSURE STATEMENTS THAT DISCLOSE ACTUAL OR POTENTIAL CONFLICTS. FORM 990, PART VI, SECTION B, LINE 15 DETERMINATION OF COMPENSATION OF THE CEO AND OFFICERS INCLUDES ANALYSIS OF COMPARABLE COMPENSATION SURVEYS BY AN INDEPENDENT COMPENSATION CONSULTANT, WHO RECOMMENDS RANGES OF APPROPRIATE COMPENSATION TO THE BOARD OF DIRECTORS. THE BOARD OF DIRECTORS APPROVES THE COMPENSATION PACKAGE FOR OFFICERS, AND CONTEMPORANEOUS SUBSTANTIATION OF THE DELIBERATION AND DECISION IS INCLUDED IN THE BOARD MINUTES. THE FINAL AGREEMENT IS DOCUMENTED WITH A WRITTEN CONTRACT, WHICH IS SIGNED BY BOTH PARTIES. FORM 990, PART VI, SECTION C, LINE 19 AGNESIAN HEALTHCARE'S POLICY AND PROCEDURE FIN1069 DEFINES THE PROCEDURE FOR MAKING ANNUAL INFORMATION RETURNS AVAILABLE FOR PUBLIC INSPECTION. INDIVIDUALS REQUESTING INSPECTION ARE REFERRED TO THE ADMINISTRATION OFFICE, WHERE THEY ARE PROVIDED WITH THE DOCUMENTS AND A CONFERENCE ROOM FOR INSPECTING DOCUMENTS. PHOTOCOPIES WILL BE PROVIDED TO THE REQUESTOR. ANYONE MAY INSPECT THE RETURNS UPON DEMAND, WITHOUT AN APPOINTMENT OR ANY FOREWARNING, DURING AGNESIAN HEALTHCARE INC'S NORMAL BUSINESS HOURS. GOVERNING DOCUMENTS AND CONFLICT OF INTEREST STATEMENTS ARE NOT AVAILABLE FOR PUBLIC INSPECTION, BUT CAN BE MADE AVAILABLE IF THE REQUESTING PARTY HAS A BONAFIDE REASON. ALL FINANCIAL STATEMENTS ARE AVAILABLE TO THE PUBLIC THROUGH A POSTING ON A PUBLIC WEBSITE. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: CHANGE IN UNREALIZED GAINS/LOSSES -4,550,665. CAPITAL CONTRIBUTION - FOUNDATION 542,172. CAPITAL CONTRIBUTION - OTHER 11,846. CHANGE IN SWAP FUND BALANCE -1,617,853. CHANGE IN FUND BALANCE - SAH FOUNDATION -98,083. CHANGE IN ERROR/SUSPENSE ACCOUNT 2,110. TOTAL TO FORM 990, PART XI, LINE 5: -5,710,473. FORM 990, PART XII, LINE 2B THE CONSOLIDATED FINANCIAL STATEMENTS OF AGNESIAN HEALTHCARE SYSTEM WERE AUDITED BY AN INDEPENDENT ACCOUNTING FIRM, WIPFLI, LLP. THREE RELATED ENTITIES IN THE AGNESIAN HEALTHCARE SYSTEM, WAUPUN MEMORIAL HOSPITAL, ST. FRANCIS HOME, AND RIPON MEDICAL CENTER, FILE SEPARATE FORMS 990. REMAINING ENTITIES ARE REPRESENTED BY THE AGNESIAN HEALTHCARE TAX RETURN. FORM 990, PART XII, LINE 2C THE AUDIT COMMITTEE OF AGNESIAN HEALTHCARE, INC IS RESPONSIBLE FOR THE OVERSIGHT OF THE AUDIT BY THE INDEPENDENT ACCOUNTING FIRM. THE PROCESS FOR THE OVERSIGHT AND SELECTION PROCESS DID NOT CHANGE DURING THE FISCAL YEAR. CONSULTANTS LABORATORY OF WISCONSIN LLC 430 E DIVISION STREET FOND DU LAC WI 54935 391528550 LAB SERVICES WI 16364249 13053315 N/A AGNESIAN HEALTHCARE ENTERPRISES LLC 430 E DIVISION STREET FOND DU LAC WI 54935 392038757 RETAIL PHARMACY WI 8392710 8750785 N/A ST FRANCIS HOME OF FOND DU LAC 33 EVERETT STREET FOND DU LAC WI 54935 391029998 NURSING HOME WI 501(C)(3) 9 N/A 0 CONGREGATION OF SISTERS OF ST AGNES 320 COUNTY ROAD K FOND DU LAC WI 54935 390806217 CONVENT WI 501(C)(3) 1 N/A 0 AGNESIAN HEALTHCARE FOUNDATION 430 E DIVISION STREET FOND DU LAC WI 54935 391684956 FOUNDATION WI 501(C)(3) 11 N/A 0 WAUPUN MEMORIAL HOSPITAL 620 WEST BROWN STREET WAUPUN WI 53963 390806265 HOSPITAL WI 501(C)(3) 3 N/A 0 RIPON MEDICAL CENTER 933 NEWBURY STREET RIPON WI 54971 391101287 HOSPITAL WI 501(C)(3) 3 N/A 0 0 0 1 1 0 0 0 0 0 1 0 1 0 1 1 1 0 0 AGNESIAN HEALTHCARE FOUNDATION INC C 712163 CASH RECEIPTS ST FRANCIS HOME D 5000000 BOND VALUE ST FRANCIS HOME L 66143 CASH PAYMENTS CONGREGATION OF SISTERS OF ST AGNES L 278047 CASH PAYMENTS CONGREGATION OF SISTERS OF ST AGNES N 489504 CASH PAYMENTS WAUPUN MEMORIAL HOSPITAL O 414097 CASH TRANSFER PART V, LINE 2: NAME: RIPON MEDICAL CENTER, TRANSACTION TYPE O, AMOUNT $3,487, METHOD: CASH TRANSFER