2013-08-15T10:13:19-05:00 2012-09-30 390758449 WIPFLI LLP 10000 INNOVATION DRIVE SUITE 250 MILWAUKEE WI 532264837 990 2011-10-01 390286215 FORT HEALTHCARE INC FORT 8004214677 611 E SHERMAN AVENUE FORT ATKINSON WI 53538 JAMES NELSON 8004214677 2013-08-15 1 JAY ADKISSON CPA P01360892 4144319300 2013-08-14 2011 2016-02-25 16:41:14Z JAMES NELSON 611 E SHERMAN AVENUE FORT ATKINSON WI 53538 224454472 0 X WWW.FORTHEALTHCARE.COM X 1942 WI OUR MISSION AT FORT HEALTHCARE IS TO IMPROVE THE HEALTH AND WELL-BEING OF OUR COMMUNITY. 13 8 1131 253 0 0 189586 255640 126821820 126825803 4640440 2752384 1224013 1381141 132875859 131214968 0 0 0 0 54037915 53960425 0 0 0 75434674 75883556 129472589 129843981 3403270 1370987 175966963 179070478 87134619 85133939 88832344 93936539 OUR MISSION AT FORT HEALTHCARE IS TO IMPROVE THE HEALTH AND WELL-BEING OF OUR COMMUNITY. 0 0 79194465 96219065 OPERATION OF A 72-BED ACUTE CARE FACILITY WITH AN EMERGENCY ROOM AND FULL COMPLEMENT OF ANCILLARY SERVICES. 31868926 29377859 OPERATION OF PHYSICIAN CLINICS WITH OUTREACH INTO THE SURROUNDING COMMUNITIES 2043667 1228879 OPERATION OF A HOME HEALTH AGENCY TO CARE FOR HOMEBOUND SENIORS AND OTHERS IN THE COMMUNITY 113107058 1 1 0 0 0 0 0 0 0 0 1 0 0 0 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 1 1 1 0 0 0 0 0 1 1 1 0 0 1 155 0 1 1131 1 0 0 0 0 0 0 0 0 0 0 X 13 8 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 WI X JAMES NELSON 9205685000 611 E SHERMAN AVENUE FORT ATKINSON WI 53538 X MICHAEL S WALLACE 40.00 X X 342993 0 33297 JONATHAN MCLAUGHLIN MD 3.00 X X 0 452439 31238 SHARON SCHMELING 3.00 X X 0 0 0 DEAN JOHNSON 3.00 X X 0 0 0 THOMAS NORDLAND MD 3.00 X X 0 702441 33297 CAROL WARD KNOX 3.00 X 0 0 0 ROBERT SCHRAMM PHD 3.00 X 0 0 0 DONALD WILLIAMS MD 3.00 X 0 245619 31688 MICHAEL ANDERSON MD 3.00 X 0 594813 32367 BARRY CASH MD 3.00 X 0 0 0 ERIC RUNEZ 3.00 X 0 0 0 MICHAEL RUMPF 3.00 X 0 0 0 GREGORY WATERS 3.00 X 0 0 0 JAMES J NELSON 40.00 X 213291 0 31835 KAY E WIPPERFURTH 40.00 X 172083 0 27744 SARAH S SISBACH 40.00 X 84104 0 4475 RENEE CLARK 40.00 X 123361 0 6540 EDWIN FISCHER 40.00 X 0 302882 20599 ISIDORO ZAMBRANO MD 40.00 X 0 966552 27169 RANDALL JENNINGS MD 40.00 X 0 859212 33297 JULIE MOKHTAR MD 40.00 X 0 490823 20599 BILLIE KONTNY MD 40.00 X 0 453721 34018 SATWANT DHILLON MD 40.00 X 0 466392 33297 935832 5534894 401460 38 0 1 0 FORT MEDICAL GROUP 611 E SHERMAN AVENUE EAST FORT ATKINSON WI 53538 PHYSICIAN SERVICES 17060540 MEDICUS HOSPITALIST SERVICES LLC 7 INDUSTRIAL WAY UNIT 5 SALEM NH 03079 HOSPITALIST (PHYSICIAN) SERVICES 1500466 UW MEDICAL FOUNDATION - RADIOLOGY 600 HIGHLAND AVE MADISON WI 53792 RADIOLOGY SERVICES 1181725 REVENUE CYCLE PARTNERS LLC 1643 LEWIS AVENUE 203 BILLINGS MT 59102 BILLING SERVICES 637929 DYNACARE LABORATORIES 9200 W WISCONSIN AVENUE MILWAUKEE WI 53226 LABORATORY SERVICES 523717 25 132833 122807 255640 HOSPITAL SERVICES 623000 89395098 89395098 PHYSICIAN CLINIC REVEN 621110 29152090 29152090 OTHER OPERATING REVENU 623990 7049736 7049736 HOME HEALTH AGENCY 621610 1228879 1228879 126825803 1226797 1226797 1024226 0 1024226 1024226 1024226 94447288 317803 93219620 19884 1227668 297919 1525587 1525587 EQUITY INCOME 623000 352735 352735 NON OPERATING INCOME 623000 4180 4180 356915 131214968 126825803 0 4133525 1039723 937057 102666 40308671 36328435 3980236 1451292 1307986 143306 8191995 7383085 808910 2968744 2675599 293145 381685 381685 229013 229013 31932164 26468826 5463338 1212738 419623 793115 12114944 11898496 216448 733695 733695 6290049 5063888 1226161 95991 92569 3422 3626153 3626153 8195881 8144263 51618 348418 280435 67983 PROVISION FOR BAD DEBTS 5204602 5204602 DUES 2656070 102300 2553770 EQUIPMENT 723739 720279 3460 EDUCATION & RECRUITMENT 379085 300130 78955 1759329 1419637 339692 129843981 113107058 16736923 0 2988178 4508519 24995969 25328684 7475 1999488 1969648 878393 1379892 162581200 88177112 78330630 74404088 52342967 58156153 10374343 8874849 4056995 4441170 175966963 179070478 15925619 15620699 58288371 55276463 12920629 14236777 87134619 85133939 X 88832344 93936539 88832344 93936539 175966963 179070478 X 1370987 3733208 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 636155 636155 62416317 28622808 33793509 1642159 1457847 184312 97886569 58096457 39790112 74404088 DEFERRED COMPENSATION 395846 CAPITOL LEASE OBLIGATIONS 10368389 DEFERRED GAIN OF SALE-LEASEBACK 2951295 RELATED PARTY PAYABLE 521247 14236777 131214968 129843981 1370987 3733208 3733208 5104195 134948176 3733208 3733208 131214968 0 131214968 129843981 0 129843981 0 129843981 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: IN ORDER TO ACCOUNT FOR ANY UNCERTAIN TAX POSITIONS, THE SYSTEM DETERMINES WHETHER IT IS MORE LIKELY THAN NOT THAT A TAX POSITION WILL BE SUSTAINED UPON EXAMINATION ON 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 SYSTEM RECORDED NO ASSETS OR LIABILITIES RELATED TO UNCERTAIN TAX POSITIONS IN 2012 AND 2011. TAX RETURNS FOR TAX YEARS 2008 AND BEYOND REMAIN SUBJECT TO EXAMINATION BY THE APPLICABLE TAXING AUTHORITIES. 1 1 1 X 1 X 1 1 1 0 1 1 1017933 1017933 0.00820 15646554 2757243 12889311 0.10340 16664487 2757243 13907244 0.11160 1686654 347711 1338943 0.01070 129942 1 129941 0.00100 1816596 347712 1468884 0.01170 18481083 3104955 15376128 0.12330 0 2472816 0 10879057 16269586 -5390529 X 1 1 1 MEDICAL HEALTH BUILDING GROUP RENTAL OF MEDICAL BUILDINGS 0.20000 0.25000 1 1 FORT HEALTHCARE INC

611 SHERMAN AVENUE EAST FORT ATKINSON WI 53538

X X X FORT HEALTHCARE INC 1 0 1 1 150.000000000000 1 300.000000000000 1 X X 1 1 X X X X 1 X X 1 X X X X 1 X 0 0 1 FORT HEALTHCARE HOME HEALTH

715 SHERMAN AVENUE EAST FORT ATKINSON WI 53538

HOME HEALTH AGENCY PART I, LINE 7: OVERALL COST TO CHARGE RATIO PART I, LINE 7G: SUBSIDIZED HEALTH SERVICES DID NOT INCLUDE ANY PHYSICIAN CLINICS. PART I, LINE 7, COLUMN (F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $ 5204602. PART II: FORT HEALTHCARE GIVES GENEROUSLY TO AREA COMMUNITY ORGANIZATIONS. IN FY 2012, MORE THAN $60,000 WAS PROVIDED IN DIRECT SUPPORT OF COMMUNITY EVENTS. IN ADDITION, FORT HEALTHCARE RESOURCES WERE EXPENDED TO SUPPORT THOSE ACTIVITIES- INCLUDING SIGNIFICANT STAFF TIME, VOLUNTEER TIME, MEDICAL SUPPLIES, GIVEAWAY ITEMS AND MORE. APPROXIMATELY $2.15 MILLION WAS PROVIDED IN CHARITY CARE. FORT HEALTHCARE STAFF SERVE ON THE BOARD OF DIRECTORS FOR A NUMBER OF LOCAL NON-PROFIT AGENCIES. FORT HEALTHCARE IS VERY SUPPORTIVE OF UNITED WAY, TOMORROW'S HOPE, RELAY FOR LIFE AND MANY OTHER FUNDRAISING CAUSES IN THE COMMUNITY. THE COMMUNITY HEALTH & WELLNESS DEPARTMENT IS ACTIVELY ENGAGING NON-PROFIT ENTITIES IN AREA COMMUNITIES TO BUILD COLLABORATIVE RELATIONSHIPS WITH THE GOAL OF AFFECTING OBESITY, ACCESS TO CARE, DIET, FITNESS AND NUTRITION. FOR SEVERAL COMMUNITIES IN JEFFERSON COUNTY, KEY LEADERS HAVE BEEN IDENTIFIED TO REPRESENT THE HEALTHIEST COMMUNITIES COALITION IN THEIR RESPECTIVE CITIES. COALITION MEMBERSHIP INCLUDES REPRESENTATIVES FROM LOCAL SCHOOLS, CHURCHES, GOVERNMENT AGENCIES, BUSINESSES, COMMUNITY ORGANIZATIONS AND INTERESTED INDIVIDUALS. ALL ARE ENGAGED IN A CONCERTED EFFORT TO REDUCE THE OBESITY RATE IN JEFFERSON COUNTY. EACH COALITION IS ACTIVELY DEVELOPING STRATEGIES TO IMPLEMENT IN THEIR LOCAL COMMUNITIES, FOCUSING ON THE FOLLOWING PRIORITIES:-INCREASE ACCESS TO HEALTHY FOOD OPTIONS-APPLY INCENTIVES TO IMPROVE NUTRITION-INSTITUTE WORKPLACE INCENTIVES TO REWARD INCREASED PHYSICAL ACTIVITY-EDUCATE AND INFORM THE PUBLIC ABOUT SERVING SIZES AND NUTRITIONAL CONTENT OF FOOD OPTIONS AVAILABLE IN PUBLIC AREAS-IMPLEMENT COMPREHENSIVE PROGRAMS THAT PROMOTE PHYSICAL ACTIVITY AND NUTRITION-INCREASE ACCESS TO OPPORTUNITIES AND FACILITIES THAT PROMOTE PHYSICAL ACTIVITY 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 REDUCTION OF GROSS REVENUE AND A CREDIT TO PATIENT RECEIVABLES. IN ADDITION, MANAGEMENT PROVIDES FOR PROBABLE UNCOLLECTIBLE AMOUNTS, PRIMARILY 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 PATIENT ACCOUNTS RECEIVABLE.COSTING METHODOLOGY - OVERALL COST TO CHARGE RATIO. RATIONALE FOR INCLUDING BAD DEBT AMOUNTS IN COMMUNITY BENEFIT- WE ARE THE ONLY HOSPITAL IN OUR SERVICE AREA AND PATIENTS WOULD HAVE TO TRAVEL TO ANOTHER COMMUNITY TO RECEIVE CARE. PART III, LINE 8: WE ARE THE ONLY HOSPITAL IN OUR SERVICE AREA & PATIENTS WOULD HAVE TO TRAVEL TO ANOTHER COMMUNITY TO RECEIVE CARE INPATIENT COSTS COME FROM WORKSHEET D-1 PART II & OUTPATIENT COSTS ARE BASED ON THE COST TO CHARGE RATIO OF THE MEDICARE CHARGES ON WORKSHEET D PART V SUBACUTE COSTS ARE FROM WORKSHEET D-1 PART III. HOME HEALTH IS FROM WORKSHEET H-6 PART I PART III, LINE 9B: PERSONS WHOSE INCOME IS LESS THAN 150% OF THE FEDERAL POVERTY GUIDELINES, BUT NOT MORE THAN 300% OF THE GUIDELINES, SHALL BE ELIGIBLE FOR COMMUNITY CARE ON A REDUCED CHARGE BASIS. PERSONS WHOSE INCOME IS LESS THAN 150% OF THE GUIDELINES WILL BE CONSIDERED FOR COMPLETE FORGIVENESS OF THEIR OUTSTANDING CHARGES. PART III, LINE 3: THE ORGANIZATION DOES NOT HAVE THE INFORMATION AVAILABLE TO CALCULATE THE AMOUNT OF BAD DEBT EXPENSES ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S CHARITY FINANCIAL ASSISTANCE POLICY. FORT HEALTHCARE INC. PART V, SECTION B, LINE 19D: THE ORGANIZATION USES A SLIDING SCALE BASED ON FEDERAL POVERTY GUIDELINES. PART VI, LINE 2: FORT HEALTHCARE PERFORMS REGULAR MARKET RESEARCH TO ASSESS THE HEALTHCARE NEEDS AND CONCERNS OF THE COMMUNITY. FOCUS GROUPS WITH CURRENT PATIENTS AND NON-PATIENTS HAVE HELPED US IMPROVE THE QUALITY OF CLINIC BASED SERVICES. AN ANNUAL COMMUNITY HEALTH ASSESSMENT IS ALSO IMPLEMENTED. THE PRIMARY RESEARCH TOOL IS A DOOR-TO-DOOR SURVEY OF 400+ RESIDENTS IN THE SERVICE AREA. MANY QUESTIONS RELATE SPECIFICALLY TO HEALTH NEEDS, CONCERNS, BEHAVIORS AND CONCERNS. THE SURVEY IS ADMINISTERED BY AN INDEPENDENT RESEARCH COMPANY AFFILIATED WITH THE UNIVERSITY OF WISCONSIN-WHITEWATER. THE SURVEY WAS MOST RECENTLY ADMINISTERED IN SUMMER, 2012. FURTHERMORE, FORT HEALTHCARE HAS CREATED COMMUNITY HEALTH COALITIONS THROUGHOUT THE SERVICE AREA. CONCERNED RESIDENTS AND COMMUNITY LEADERS, WITH THE ASSISTANCE OF FORT HEALTHCARE STAFF ARE DEVELOPING SPECIFIC COMMUNITY-RELEVANT STRATEGIES TO ADDRESS OBESITY, PHYSICAL ACTIVITY, NUTRITION AND INCREASED CONSUMPTION OF WATER VS. SWEETENED BEVERAGES. PART VI, LINE 3: INFORMATION IS AVAILABLE ON THE PATIENT STATEMENT, IN MONTHLY NEWSLETTERS AND ON THE ORGANIZATION'S WEBSITE. AN ANNUAL COMMUNITY BENEFIT REPORT IS FILED WITH THE WISCONSIN HOSPITAL ASSOCIATION. A PRINTED REPORT IS PREPARED AND DELIVERED TO 48,000 HOUSEHOLDS WITHIN THE PRIMARY SERVICE AREA AS AN INSERT INTO THE HEALTH365 COMMUNITY MAGAZINE. THE FORT HEALTHCARE WEBSITE CONTAINS LINKS AND INFORMATION SPECIFIC TO THE POLICY ON CHARITY CARE, FINANCIAL AID AND REDUCED PAYMENT OPTION FOR SELF-PAY PATIENTS. INFORMATION IS ALSO AVAILABLE ON THE WEBSITE AND IN ALL FORT HEALTHCARE LOCATIONS REGARDING THE ROCK RIVER FREE CLINIC, A FREE AND REDUCED CARE CLINIC FUNDED IN A SIGNIFICANT MANNER BY FORT HEALTHCARE INCLUDING FULL FUNDING FOR A 1.0 FTE PHYSICIAN AND SUBSIDIZED LAB AND RADIOLOGY SERVICES. FINANCIAL AID COUNSELOR IS AVAILABLE AT FORT MEMORIAL HOSPITAL TO ASSIST PATIENTS WITH COMPLETING PAPERWORK FOR GOVERNMENT ASSISTANCE PROGRAMS, WITH CONTACT INFORMATION ALSO AVAILABLE ON THE WEBSITE AND IN ADMISSION PACKETS. PART VI, LINE 4: FORT HEALTHCARE'S PRIMARY SERVICE AREA CONSTITUTES AN EIGHT ZIP CODE REGION COMPRISED OF THE COMMUNITIES OF FORT ATKINSON, JEFFERSON, JOHNSON CREEK, HELENVILE, WHITEWATER, CAMBRIDGE, LAKE MILLS AND PALMYRA. THERE ARE APPROXIMATELY 75,000 PERSONS LIVING IN THE REGION. FORT MEMORIAL HOSPITAL IS THE ONLY HOSPITAL WITHIN THE PRIMARY SERVICE AREA. THE REGION IS NOT CONSIDERED A MEDICALLY UNDERSERVED REGION. PART VI, LINE 5: THE FORT HEALTHCARE BOARD OF DIRECTORS IS A COMMUNITY ORIENTED BOARD, WITH REPRESENTATIVES SOLICITED DIRECTLY FROM THE MAJORITY OF COMMUNITIES IN THE PRIMARY SERVICE AREA. THE MAJORITY OF REPRESENTATIVES ARE NOT EMPLOYEES, CONTRACTORS OR RELATIVES OF FORT HEALTHCARE STAFF. THE MEMBERS ARE NOT COMPENSATED FOR THEIR SERVICE. THE FORT MEMORIAL HOSPITAL OPERATES WITH AN 'OPEN' MEDICAL STAFF. PHYSICIANS UNAFFILIATED WITH THE ORGANIZATION MAY REQUEST PRIVILEGES AT ANY TIME. THE PLANNING COMMITTEE DETERMINES NEED FOR SPECIALTY CARE ACCORDING TO A WELL ESTABLISHED MEDICAL MANPOWER PLAN THAT INCLUDES COMMUNITY NEED FOR SERVICES. PHYSICIANS ARE GRANTED MEDICAL STAFF STATUS BASED ON NEED. THE MEDICAL STAFF IS REPRESENTED BY MEMBERS OF FORT MEDICAL GROUP (OWNED BY FORT HEALTHCARE), DEAN/ST. MARY'S REGIONAL CLINICS, UW HEALTH AND OTHERS. FORT HEALTHCARE IS A NON-PROFIT ORGANIZATION AND NET REVENUES ARE USED FOR IMPROVEMENTS IN THE STATUS OF FORT HEALTHCARE. FUNDS ARE USED TO PURCHASE CAPITAL EQUIPMENT, ENHANCE PHYSICAL FACILITIES AND IMPROVE PATIENT SERVICES. PART VI, LINE 6: FORT HEALTHCARE IS AN INDEPENDENT, NON-PROFIT ORGANIZATION. THERE ARE NO AFFILIATED ORGANIZATIONS. REPORTS FILED WITH STATES PART VI, LINE 7 WI X X X X X X 0 0 0 1 1 0 0 0 0 MICHAEL S WALLACE 342993 0 0 0 0 0 9800 0 23497 0 376290 0 0 0 JONATHAN MCLAUGHLIN MD 0 413478 0 38961 0 0 0 9800 0 21438 0 483677 0 0 THOMAS NORDLAND MD 0 607648 0 94793 0 0 0 9800 0 23497 0 735738 0 0 DONALD WILLIAMS MD 0 242357 0 3262 0 0 0 9737 0 21951 0 277307 0 0 MICHAEL ANDERSON MD 0 442283 0 152530 0 0 0 9800 0 22567 0 627180 0 0 JAMES J NELSON 213291 0 0 0 0 0 8533 0 23302 0 245126 0 0 0 KAY E WIPPERFURTH 172083 0 0 0 0 0 7101 0 20643 0 199827 0 0 0 EDWIN FISCHER 0 299937 0 2945 0 0 0 9800 0 10799 0 323481 0 0 ISIDORO ZAMBRANO MD 0 668846 0 297706 0 0 0 2952 0 24217 0 993721 0 0 RANDALL JENNINGS MD 0 648945 0 210267 0 0 0 9800 0 23497 0 892509 0 0 JULIE MOKHTAR MD 0 489060 0 1763 0 0 0 9800 0 10799 0 511422 0 0 BILLIE KONTNY MD 0 414733 0 38988 0 0 0 9800 0 24218 0 487739 0 0 SATWANT DHILLON MD 0 464629 0 1763 0 0 0 9800 0 23497 0 499689 0 0 PART I, LINE 5 EXECUTIVE PAY INCREASES AND BONUSES HAVE AN ELEMENT THAT RELATES TO THE FINANCIAL PERFORMANCE OF THE RELATED ORGANIZATION. PHYSICIAN COMPENSATION IS TIED TO THE NET REVENUES OF THEIR PRACTICE WISCONSIN HEALTH & EDUCATIONAL FACILITIES AUTHORITY 391337855 97710VTU2 2004-05-18 40072037 CONSTRUCTION & EQUIPMENT 0 0 0 WISCONSIN HEALTH & EDUCATIONAL FACILITIES AUTHORITY 391337855 97710V4Q8 2007-09-20 26000000 CONSTRUCTION & EQUIPMENT & REFUNDING PRIOR ISSUE 0 0 0 4507037 40072037 2926311 320000 36825725 2006 0 0 1 1 5565000 26000000 9548835 391832 500 16058833 2010 0 1 1 1 0 0 0 0 0.00000 0.00000 0.00000 0 0 0 0 0 0.00000 0.00000 0.00000 0 0 0 0 1 XL ASSET FUNDING COMPANY 2.500000000000 1 0 0 0 1 0 0 0 0 X 500 MCMILLEN GROUP LLP PARTNERSHIP OWNED BY DONALD WILLIAMS CURRENT BOARD DIRECTOR 334071 RENT FOR THE LEASE OF OFFICE SPACE 0 JULIE MOKHTAR MD WIFE OF OFFICER EDWIN FISCHER 490823 EMPLOYEE 0 MELANIE RUMPF WIFE OF BOARD MEMBER MICHAEL RUMPF 57714 EMPLOYEE 0 MEDICAL HEALTH BUILDING GROUP PARTNERSHIP OWNED BY BILLIE KONTNY, TOP 5 PAID EMPLOYEE 1974245 RENT FOR THE LEASE OF OFFICE SPACE 0 FORM 990, PART VI, SECTION B, LINE 11 A COPY OF THE 990 IS SENT TO EACH OF THE BOARD OF DIRECTORS PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C EACH BOARD MEMBER OF THE ENTITY AND RELATED ENTITIES ANNUALLY COMPLETE A CONFLICT OF INTEREST QUESTIONNAIRE DISCLOSING THEIR CONFLICTS OF INTEREST. A SUMMARY OF CONFLICTS ARE DISTRIBUTED TO THE CHAIRMAN OF THE BOARD AND TO ADMINISTRATIVE SUPPORT PERSONNEL. BOARD MEMBERS ARE COACHED ON HOW TO MANAGE THEIR CONFLICTS. FORM 990, PART VI, SECTION B, LINE 15 OTHER ORGANIZATIONS ARE USED AS BENCHMARKS TO DETERMINE COMPENSATION. INDEPENDENT REVIEWS OF COMPENSATION ARE ALSO DONE PERIODICALLY. FORM 990, PART VI, SECTION C, LINE 19 ALL DOCUMENTS ARE AVAILABLE TO THE PUBLIC UPON REQUEST. SUMMARIES OF FINANCIAL STATEMENTS ARE AVAILABLE TO THE PUBLIC VIA AN ANNUAL REPORT THAT FORT HEALTHCARE PUBLISHES. THE ANNUAL REPORT IS DIRECT MAILED TO HOUSEHOLDS AND IS ALSO AVAILABLE TO THE PUBLIC ON FORT HEALTHCARE'S WEBSITE. COMPENSATION FROM A RELATED ORGANIZATION: FORM 990, PART VII, SECTION A, LINE 1A THE FOLLOWING INDIVIDUALS EARNED WAGES FROM A RELATED ORGANIZATION: JONATHAN MCLAUGHLIN EARNED $452,439 IN W-2 WAGES AS A PHYSICIAN FOR FORT MEDICAL GROUP AND WORKED ON AVERAGE 40 HOURS PER WEEK RELATED TO THIS POSITION. THOMAS NORDLAND EARNED $702,441 IN W-2 WAGES AS A PHYSICIAN FOR FORT MEDICAL GROUP AND WORKED ON AVERAGE 40 HOURS PER WEEK RELATED TO THIS POSITION. DONALD WILLIAMS EARNED $245,619 IN W-2 WAGES AS A PHYSICIAN FOR FORT MEDICAL GROUP AND WORKED ON AVERAGE 40 HOURS PER WEEK RELATED TO THIS POSITION. MICHAEL ANDERSON EARNED $594,813 IN W-2 WAGES AS A PHYSICIAN FOR FORT MEDICAL GROUP AND WORKED ON AVERAGE 40 HOURS PER WEEK RELATED TO THIS POSITION. EDWIN FISCHER EARNED $302,882 IN W-2 WAGES AS A PHYSICIAN FOR FORT MEDICAL GROUP AND WORKED ON AVERAGE 40 HOURS PER WEEK RELATED TO THIS POSITION. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED GAINS ON INVESTMENTS: 3,733,208. FORT MEMORIAL HOSPITAL FOUNDATION 611 SHERMAN AVE EAST FORT ATKINSON WI 53538 391397028 FOUNDATION WI 501(C)(3) LINE 11A, I N/A 0 FORT HEALTHCARE PARTNERS 611 SHERMAN AVE EAST FORT ATKINSON WI 53538 391040145 VOLUNTEERS WI 501(C)(3) LINE 3 N/A 0 UW CANCER CENTER JOHNSON CREEK LLC 250 DOCTORS COURT JOHNSON CREEK WI 53038 200341996 CANCER CARE CENTER WI N/A RELATED 79868 568066 0 0 0.33300 MEDICAL HEALTH BUILDING GROUP LLC 43 SOUTH WATER STREET EAST FORT ATKINSON WI 53538 611571669 HOLD REAL ESTATE FOR MEDICAL PRACTICES WI N/A RELATED 254669 2636841 0 0 0.20000 PAIN CENTERS OF WISCONSIN - FORT ATKINSON LLC 4131 WEST LOOMIS ROAD GREENFIELD WI 53221 900777376 PROVIDE PAIN MANAGEMENT SERVICES WI N/A RELATED 274400 0 0 0.49000 FORT MEDICAL EQUIPMENT LLC 306 WASHINGTON ST FORT ATKINSON WI 53538 392042387 PROVIDE DURABLE MEDICAL EQUIPMENT WI N/A RELATED -19407 37476 0 0 0.30000 FORT MEDICAL GROUP INC 611 SHERMAN AVE EAST FORT ATKINSON WI 53538 391736513 PROVIDE PHYSICIAN SERVICES WI FORT HEALTHCARE INC C 2771566 1.00000 FORT CARE INC 611 SHERMAN AVE EAST FORT ATKINSON WI 53538 391725831 PREFERRED PROVIDER ORGANIZATION WI FORT HEALTHCARE INC C -4180 81287 1.00000 0 0 1 0 0 0 0 0 0 0 0 0 1 1 1 1 0 0 FORT MEMORIAL HOSPITAL FOUNDATION C 53620 FAIR MARKET VALUE FORT HEALTHCARE PARTNERS C 79213 FAIR MARKET VALUE FORT MEMORIAL HOSPITAL FOUNDATION P 88923 FAIR MARKET VALUE FORT MEDICAL GROUP O 16310706 FAIR MARKET VALUE