2012-05-14T13:54:40-05:00 2011-06-30 WIPFLI LLP PO BOX 12237 GREEN BAY WI 543072237 990 2010-07-01 390807236 AGNESIAN HEALTHCARE INC AGNE 9209264512 430 EAST DIVISION STREET FOND DU LAC WI 54935 BONNIE SCHMITZ 9209264512 2012-05-07 0 TERRI REXRODE CPA MST 9206620016 2012-05-07 2010 2016-02-24 21:20:13Z STEVEN LITTLE CEO 430 EAST DIVISION STREET FOND DU LAC WI 54935 361250412 0 1 0928 X WWW.AGNESIAN.COM X 1892 WI INTEGRATED HEALTHCARE DELIVERY SYSTEM - 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. 14 10 3000 640 80078 375847 0 0 266316587 292268282 2946481 6366707 12501754 13030448 281764822 311665437 0 0 0 0 110609444 118550970 0 0 0 159878453 169158135 270487897 287709105 11276925 23956332 321294193 397023480 159519424 185535734 161774769 211487746 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 196865218 280853914 HOSPITAL, CLINIC AND HOME HEALTH SERVICES PROVIDING DIAGNOSTIC AND THERAPEUTIC HEALTHCARE 11258080 15026091 LABORATORY SERVICES PROVIDING DIAGNOSTIC HEALTHCARE FOR CENTRAL WISCONSIN 6416751 5365964 RETAIL PHARMACY AND HOME MEDICAL EQUIPMENT SALES TO SERVICE POPULATION FOR HOSPITAL (INPATIENT AND OUTPATIENT), CLINIC AND HOME HEALTH 214540049 1 0 0 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 0 0 0 0 1 228 0 1 3000 1 1 1 1 CJ 0 0 0 0 0 0 0 1 1 0 0 X 14 10 0 0 0 0 0 0 1 1 1 0 0 1 1 1 1 1 1 1 1 0 WI X LESLIE STEPHANY 9209264512 430 EAST DIVISION STREET FOND DU LAC WI 54935 ROBERT A FALE 50.00 X X 722928 0 31431 SR ANN KOERNER 1.00 X 0 0 0 SR MARY NOEL BROWN 1.00 X 0 0 0 PATRICIA MILLER 1.00 X 0 0 0 DR STEPHEN MASSICK 1.00 X 0 0 0 WAYNE E MATZKE 1.00 X X 0 0 0 DR MICHAEL STRIGENZ 1.00 X 0 0 0 DR ROBERT MIKKELSEN 1.00 X 0 0 0 JAMES B SIMON 1.00 X X 5311 0 0 DR BRIAN CHRISTENSON 1.00 X 305904 0 31479 JAMES R CHATTERTON 1.00 X X 0 0 0 SR HERTHA LONGO 1.00 X 0 0 0 STEPHANIE M MARTIN 1.00 X 0 0 0 H JACK POLLEI 1.00 X 11294 0 0 JOSEPH REITEMEIER 1.00 X X 0 0 0 STEVEN N LITTLE 50.00 X 463767 0 29369 JANE HYDE 50.00 X 268861 0 19728 DENNIS YUNK 50.00 X 227566 0 26236 CAROL HYLAND 50.00 X 230767 0 28518 JAMES MUGAN 50.00 X 228075 0 35276 BARBARA KNUTZEN 50.00 X 181758 0 23187 DOUGLAS TROST 50.00 X 141992 0 26984 BONNIE R SCHMITZ 50.00 X 154695 0 16290 JOHN CHOI MD 50.00 X 941334 0 29237 JAMES GRAF MD 50.00 X 549272 0 34174 PONTUS OSTMAN MD 50.00 X 720992 0 15750 HONG WANG MD 50.00 X 525002 0 31666 YASIR HATAHET MD 50.00 X 904828 0 37153 6584346 0 416478 15 0 1 0 FOND DU LAC REGIONAL CLINIC 420 E DIVISION ST FOND DU LAC WI 54935 PHYSICIAN SERVICES 45114473 IBM CORPORATION 1 NEW ORCHARD RD ARMONK NY 105041722 COMPUTER SERVICES 7417852 CERNER CORP 2800 ROCKCREEK PKWY KANSAS CITY MO 64141 COMPUTER SERVICES 4906792 CD SMITH CONSTRUCTION PO BOX 1066 FOND DU LAC WI 54935 CONSTRUCTION 1698546 AMERICAN HEALTHCARE SERVICES PO BOX 945 TRAVERSE CITY MI 49685 TEMPORARY STAFFING 1099486 42 NET PATIENT SERVICE RE 621400 185640067 185640067 MEDICARE/MEDICAID SERV 621400 106628215 106628215 292268282 3025214 3025214 228633 228633 28996825 2152872 27662550 374287 1334275 1778585 3112860 3112860 29018212 21548138 7470074 7470074 CAFETERIA SALES 900099 974536 80078 894458 CLINIC REIMBURSEMENT 621110 950130 950130 WORK INJURY - SAH 592512 557483 557483 3078225 3078225 5560374 311665437 301245969 80078 10339390 3494345 313836 3180509 100412492 80272285 20140207 5170977 4022259 1148718 2614506 1381981 1232525 6858650 5187505 1671145 125032 6916 118116 108867 108867 58543091 54991131 3551960 1157163 87630 1069533 47021286 43588258 3433028 16124591 16124591 3376496 481466 2895030 464704 402465 62239 1050063 875984 174079 5518010 5518010 14918237 5069756 9848481 1498550 950507 548043 BAD DEBTS 11641015 11641015 HOSPITAL ASSESSMENT TAX 4749772 4749772 LOSS ON DEFEASANCE OF B 890214 890214 INVESTMENT FEES 565454 565454 DUES, SUBSCRIPTIONS AND 479709 222687 257022 925881 294596 631285 287709105 214540049 73169056 0 4270208 4836066 20242335 27011646 36757284 40185003 4669760 4707050 2502627 2254376 249858537 130283706 119413832 119574831 97433513 133092427 996299 992140 35008335 64369941 321294193 397023480 29413460 30889640 100125807 127115997 29980157 27530097 159519424 185535734 X 153297329 198310924 6338229 10715610 2139211 2461212 161774769 211487746 321294193 397023480 X 23956332 25756645 X X 0 1 1 X 0 X 996299 48126 50000 2285 992140 1020134 23156 45000 1991 996299 1014822 45000 -37548 2140 1020134 1.00000 0 1 1 6002505 6002505 113570764 46435540 67135224 2738272 875527 1862745 117314325 82972639 34341686 10232671 10232671 119574831 RECEIVABLE FROM AFFILIATED ENTITIES 1671744 LONG-TERM DEBT RECEIVABLE FROM AFFILIATED ENTITY 5000000 INVESTMENT - MERCURY CLINIC 3005130 INVESTMENT - SAH FOUNDATION 8732790 OTHER ASSETS 870422 BOND DEFERRED FINANCING COSTS 1457133 ASSETS WHOSE USE IS LIMITED - BOND FUNDS 25373321 ASSETS WHOSE USE IS LIMITED - PHYSICIAN SUPPLEMENTAL BENEFIT PLAN 17045302 MISCELLANEOUS RECEIVABLES 875877 RECEIVABLE FROM FOUNDATION 338222 64369941 CAPITAL LEASE PAYABLE 8873517 PHYSICIANS SUPPLEMENTAL LIFE 17045303 FUND BALANCE SWAP MKT ADJUSTMENT 1573905 DUE TO AFFILIATED ENTITIES 37372 27530097 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 2008, 2009, AND 2010 REMAIN SUBJECT TO EXAMINATION BY THE INTERNAL REVENUE SERVICE. 1 1 X 1 X 165.000000000000 1 X 1 1 1 0 1 1 3086000 3086000 0.01120 11601000 11601000 0.04200 0 14687000 14687000 0.05320 1175014 99644 1075370 0.00390 143629 143629 0.00050 518824 518824 0.00190 0 224368 224368 0.00080 2061835 99644 1962191 0.00710 16748835 99644 16649191 0.06030 111364 0.00040 111364 0.00040 1 5271520 85332934 123822193 -38489259 X 1 1 1 AGNESIAN HEALTHCARE DIALYSIS 1.00000 0.00000 0.00000 2 BEAVER DAM COMMUNITY 3 HOSPITAL VENTURE LLC 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 1 1 X X X X X 1 X 1 X X X X X X 1 X 0 1 4 FOND DU LAC REGIONAL CLINIC

420 E DIVISION STREET FOND DU LAC WI 54935

OUTPATIENT PHYSICIAN CLINIC CONSULTANTS LAB OF WISCONSIN

430 E DIVISION STREET FOND DU LAC WI 54935

LABORATORY AND TESTING AGNESIAN HEALTHCARE ENTERPRISES

430 E DIVISION STREET FOND DU LAC WI 54935

PHARMACEUTICALS, HOME HEALTH, MEDICAL EQUIPMENT AGNESIAN HOSBEAVER DAM COMM HOS

110 MONROE STREET BEAVER DAM WI 53916

DIALYSIS SERVICES 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 $289,101 FOR FY11. 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 $11,641,015 AND WAS EXCLUDED FROM THE DENOMINATOR PER INSTRUCTIONS. 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 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. ST. AGNES HOSPITAL PART V, SECTION B, LINE 15E: THE POLICY ALLOWS AGNESIAN HEALTHCARE TO IMPLEMENT A GARNISHMENT AGAINST WAGES FOR UNPAID BILLS. ST. AGNES HOSPITAL PART V, SECTION B, LINE 16E: DELINQUENT ACCOUNTS ARE REFERRED TO OUTSIDE COLLECTION AGENCIES. THESE AGENCIES ARE PERMITTED TO REPORT TO CREDIT AGENCIES, AS WELL AS IMPLEMENT A GARNISHMENT AGAINST WAGES FOR UNPAID BILLS. ST. AGNES HOSPITAL PART V, SECTION B, LINE 19D: UNINSURED PATIENTS AUTOMATICALLY RECEIVE A 15% DISCOUNT OFF GROSS CHARGES. ST. AGNES HOSPITAL PART V, SECTION B, LINE 21: UNINSURED PATIENTS WOULD AUTOMATICALLY RECEIVE A 15% DISCOUNT. INSURED PATIENTS MIGHT PAY FULL GROSS CHARGE IF THE ENTIRE CHARGE WAS APPLIED TO THEIR DEDUCTIBLE AND AGNESIAN HEALTHCARE DIDN'T HAVE A NEGOTIATED CONTRACT WITH THE PATIENT'S INSURANCE COMPANY. 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 EMERGANCY OR OTHER MEDICALLY NECESSARY CARE ARE BILLED AT A REDUCED RATE), OR GUARANTEED BANK LOANS. 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 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 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 INCLUDES 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 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. THIS 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 6: 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 7: 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 ROBERT A FALE 722928 0 0 0 0 0 0 0 31431 0 754359 0 0 0 DR BRIAN CHRISTENSON 280617 0 25287 0 0 0 0 0 31479 0 337383 0 0 0 STEVEN N LITTLE 463767 0 0 0 0 0 0 0 29369 0 493136 0 0 0 JANE HYDE 268861 0 0 0 0 0 0 0 19728 0 288589 0 0 0 DENNIS YUNK 227566 0 0 0 0 0 0 0 26236 0 253802 0 0 0 CAROL HYLAND 230767 0 0 0 0 0 0 0 28518 0 259285 0 0 0 JAMES MUGAN 228075 0 0 0 0 0 0 0 35276 0 263351 0 0 0 BARBARA KNUTZEN 181758 0 0 0 0 0 0 0 23187 0 204945 0 0 0 DOUGLAS TROST 141992 0 0 0 0 0 0 0 26984 0 168976 0 0 0 BONNIE R SCHMITZ 154695 0 0 0 0 0 0 0 16290 0 170985 0 0 0 JOHN CHOI MD 511163 0 430171 0 0 0 0 0 29237 0 970571 0 0 0 JAMES GRAF MD 549272 0 0 0 0 0 0 0 34174 0 583446 0 0 0 PONTUS OSTMAN MD 409822 0 311170 0 0 0 0 0 15750 0 736742 0 0 0 HONG WANG MD 525002 0 0 0 0 0 0 0 31666 0 556668 0 0 0 YASIR HATAHET MD 503721 0 401107 0 0 0 0 0 37153 0 941981 0 0 0 PART I, LINE 1A ALL GROSSUP PAYMENTS AND SOCIAL CLUB DUES ARE INCLUDED ON FORM 1099. PART I, LINE 1B THE SOCIAL CLUB DUES ARE PAID FOR DIRECTORS, AND GROSSUP PAYMENTS ARE INCLUDED IN FORM 1099 THEY RECEIVE. DOCUMENTATION IS REQUIRED BEFORE REIMBURSEMENT OCCURS. 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 49330000 48900000 430000 2005 1 0 1 1 29725000 57260000 4518399 25158698 767686 5557291 19601407 1 0 0 1 0 0 0 0 1 1 0 0 0 0 1 1 0 1 1 PIPER JAFFRAY 28.000000000000 0 0 0 0 0 0 0 0 0 0 0 ROBERT MIKKELSEN MD DIRECTOR 45114473 ROBERT MIKKELSEN, MD IS VICE PRESIDENT OF FOND DU LAC REGIONAL CLINIC, SC (FDLRC SC). AGNESIAN HEALTHCARE, INC. (AHC) CONTRACTS WITH FDLRC, SC FOR PHYSICIAN SERVICES. MEMBERS OF FDLRC, SC HAVE SERVED AND CONTINUE TO SERVE ON THE BOARD OF DIRECTORS OF AGNESIAN HEALTHCARE, INC., WHILE PROVIDING PROFESSIONAL SERVICES TO AHC AND ARE COMPENSATED BY FDLRC, SC FOR THOSE SERVICES. AHC COMPENSATED FDLRC, SC $45,114,473 FOR PROFESSIONAL SERVICES IN CALENDAR YEAR 2010. FDLRC, SC DISTRIBUTES THOSE FUNDS TO PHYSICIANS BASED ON THEIR OWN CALCULATIONS. AHC DOES NOT CONTROL THE DISBURSEMENT OF FUNDS TO THE FDLRC, SC PHYSICIANS. 0 WAYNE MATZKE DIRECTOR 34526 WAYNE MATZKE IS PRESIDENT/CEO OF GRANDE CHEESE. AGNESIAN HEALTHCARE, INC. PROVIDED OCCUPATIONAL HEALTH SERVICES TO GRANDE CHEESE, BILLING $34,526 FOR THESE SERVICES IN FISCAL 2011. 0 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 2010 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. COPIES OF THE RETURN ARE ALSO MADE AVAILABLE TO ALL AGNESIAN HEALTHCARE BOARD MEMBERS. 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 DISIGNATED 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: CAPITAL CONTRIBUTIONS FROM RELATED ENTITIES 14,000,000. CHANGE IN UNREALIZED GAINS/LOSSES ON INVESTMENTS 9,902,010. CHANGE IN NET ASSETS OF SAH FOUNDATION 1,364,234. CHANGE IN VALUE OF INTEREST RATE SWAP 399,020. CAPITAL CONTRIBUTIONS FROM FOUNDATION 90,182. OTHER 1,199. TOTAL TO FORM 990, PART XI, LINE 5: 25,756,645. 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. CONSULTANTS LABORATORY OF WISCONSIN LLC 430 E DIVISION STREET FOND DU LAC WI 54935 391528550 LAB SERVICES WI 15026091 12456513 N/A AGNESIAN HEALTHCARE ENTERPRISES LLC 430 E DIVISION STREET FOND DU LAC WI 54935 392038757 RETAIL PHARMACY WI 5365964 8760231 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 ANGESIAN HCBEAVER DAM COMMUNITY HOSPITALS VENTURE LLC 110 MONROE ST BEAVER DAM WI 53916 752992766 DIALYSIS WI N/A RELATED 100 100 0 0 1.00000 0 0 1 1 0 0 0 0 0 1 0 1 0 1 1 1 0 0 AGNESIAN HEALTHCARE FOUNDATION INC C 1002069 CASH RECEIPTS ST FRANCIS HOME D 5000000 BOND VALUE ST FRANCIS HOME L 76843 CASH PAYMENTS CONGREGATION OF SISTERS OF ST AGNES L 302013 CASH PAYMENTS CONGREGATION OF SISTERS OF ST AGNES N 345212 CASH PAYMENTS WAUPUN MEMORIAL HOSPITAL O 404079 CASH TRANSFER PART III, LINE A NAME: AGNESIAN HEALTHCARE/BEAVER DAM COMMUNITY HOSPITAL JOINT VENTURE, LLC PART V, LINE 2 NAME: RIPON MEDICAL CENTER, TRANSACTION TYPE O, AMOUNT $2,857, METHOD: CASH TRANSFER