2012-08-15T13:04:15-05:00 2011-09-30 WIPFLI LLP 10000 INNOVATION DRIVE SUITE 250 MILWAUKEE WI 532264837 990 2010-10-01 390286215 FORT HEALTHCARE INC FORT 8004214677 611 E SHERMAN AVENUE FORT ATKINSON WI 53538 JAMES NELSON 8004214677 2012-08-15 1 JAY ADKISSON CPA 4144319300 2012-08-15 2010 2016-02-24 21:20:13Z JAMES NELSON 611 E SHERMAN AVENUE FORT ATKINSON WI 53538 133014281 0 X WWW.FORTHEALTHCARE.COM X 1942 WI OUR MISSION AT FORT HEALTHCARE IS TO IMPROVE THE HEALTH AND WELL-BEING OF OUR COMMUNITY. 12 7 1119 250 0 0 201172 189586 122401567 126821820 3449727 4640440 1090272 1224013 127142738 132875859 0 0 0 0 50834906 54037915 0 0 0 69335448 75434674 120170354 129472589 6972384 3403270 172806943 175966963 83116500 87134619 89690443 88832344 X OUR MISSION AT FORT HEALTHCARE IS TO IMPROVE THE HEALTH AND WELL-BEING OF OUR COMMUNITY. 0 1 80094108 95440772 OPERATION OF A 72-BED ACUTE CARE FACILITY WITH AN EMERGENCY ROOM AND FULL COMPLEMENT OF ANCILLARY SERVICES. 31879624 30404224 OPERATION OF PHYSICIAN CLINICS WITH OUTREACH INTO THE SURROUNDING COMMUNITIES 1618718 976824 OPERATION OF A HOME HEALTH AGENCY TO CARE FOR HOMEBOUND SENIORS AND OTHERS IN THE COMMUNITY 113592450 1 1 0 0 0 0 0 0 0 1 1 0 0 1 0 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 0 0 0 1 151 0 1 1119 1 0 0 0 0 0 0 0 0 0 0 X 12 7 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 MICHAEL S WALLACE 40.00 X X 386279 0 11844 JONATHAN MCLAUGHLIN MD 3.00 X X 0 470082 26615 SHARON SCHMELING 3.00 X X 0 0 0 DEAN JOHNSON 3.00 X X 0 0 0 F BRADFORD MEYERS MD 3.00 X X 0 223347 25695 CAROL WARD KNOX 3.00 X 0 0 0 ROBERT SCHRAMM 3.00 X 0 0 0 DONALD WILLIAMS MD 3.00 X 0 222751 0 THOMAS NORLAND MD 3.00 X 0 666019 7951 JEFFREY MCGUIRE MD 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 229608 0 8338 KAY E WIPPERFURTH 40.00 X 189736 0 7592 SARAH S SISBACH 40.00 X 146732 0 5353 MARY KAY DIDERRICH 40.00 X 129725 0 5163 EDWIN FISCHER 40.00 X 0 294916 24571 EDGARDO JIONGCO 40.00 X 0 1299004 17230 RANDALL JENNINGS 40.00 X 0 777383 24571 MICHAEL ANDERSON 40.00 X 0 506798 24571 ISIDORO ZAMBRANO 40.00 X 0 693153 22899 JULIE MOKHTAR 40.00 X 0 502695 9800 1082080 5656148 222193 36 0 1 0 FORT MEDICAL GROUP 611 E SHERMAN AVENUE EAST FORT ATKINSON WI 53538 PHYSICIAN SERVICES 17245010 MEDICUS HOSPITALISTS SERVICES LLC 7 INDUSTRIAL WAY UNIT 5 SALEM NH 03079 HOSPITALIST (PHYSICIAN) SERVICES 574288 ST MARY'S HOSPITAL MEDICAL CENTER 700 S PARK STREET MADISON WI 53715 LABORATORY SERVICES 511569 DYNACARE LABORATORIES 9200 W WISCONSIN AVENUE MILWAUKEE WI 53226 LABORATORY SERVICES 498694 UW MEDICAL FOUNDATION - RADIOLOGY 600 HIGHLAND AVE MADISON WI 53792 RADIOLOGY SERVICES 427050 14 189586 189586 HOSPITAL SERVICES 623000 91145886 91145886 PHYSICIAN CLINIC REVEN 621110 30038103 30038103 OTHER OPERATING REVENU 623990 4661007 4661007 HOME HEALTH AGENCY 621610 976824 976824 126821820 1422633 1422633 806827 806827 806827 806827 2994914 361315 138422 2994914 222893 3217807 3217807 EQUITY INCOME 623000 411363 411363 NON OPERATIN INCOME 623000 5823 5823 417186 132875859 126821820 0 5864453 1120369 996767 123602 39692565 35313574 4378991 1412829 1256962 155867 8910922 7927845 983077 2901230 2581158 320072 1380243 729314 650929 12714891 12698290 16601 3708203 2985338 722865 95022 90898 4124 3724385 3724385 7337295 7285215 52080 384162 309205 74957 PROFESSIONAL FEES 17049968 16796737 253231 PURCHASED SERVICES 12023232 7219376 4803856 OTHER EXPENSES 9477965 8873509 604456 PROVISION FOR BAD DEBTS 4513123 4513123 DUES 2840262 165789 2674473 185923 124965 60958 129472589 113592450 15880139 0 9809 0 5756189 2988178 19922257 24995969 1799462 1999488 1352801 878393 158446662 80116032 75757368 78330630 52997020 52342967 11180292 10374343 4031745 4056995 172806943 175966963 9506369 11959670 60416629 62309718 13193502 12865231 83116500 87134619 X 89690443 88832344 89690443 88832344 172806943 175966963 X 3403270 -4261369 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 636155 636155 62035135 26570850 35464285 1615167 1397807 217360 94160205 52147375 42012830 78330630 CERTIFICATES OF DEPOSIT 7372403 F MONEY MARKET FUNDS 3001940 F 10374343 DEFERRED COMPENSATION 299235 CAPITOL LEASE OBLIGATIONS 9340840 DEFERRED GAIN OF SALE-LEASEBACK 3225156 12865231 132875859 129472589 3403270 -4261369 -4261369 -858099 128614490 -4261369 -4261369 132875859 0 132875859 129472589 0 129472589 0 129472589 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 2011 AND 2010. TAX RETURNS FOR TAX YEARS 2007 AND BEYOND REMAIN SUBJECT TO EXAMINATION BY THE APPLICABLE TAXING AUTHORITIES. PART XIII, LINE 2D - OTHER ADJUSTMENTS: NONOPERATING EXPENSE - NET 1 1 1 X 1 X 1 1 0 1 1 925344 925344 0.00740 14902424 4527773 10374651 0.08300 15827768 4527773 11299995 0.09040 1065894 307282 758612 0.00610 1584352 2197396 -613044 0.00000 141039 1 141038 0.00110 2791285 2504679 286606 0.00720 18619053 7032452 11586601 0.09760 0 4513123 2215571 21577279 26243063 -4665784 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 PART I, LINE 7: OVERALL COST TO CHARGE RATIO 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 $ 4513123. PART II: FORT HEALTHCARE GIVES GENEROUSLY TO AREA COMMUNITY ORGANIZATIONS. IN FY 2011, MORE THAN $65,000 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 $1.7 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. ACTUAL AMOUNTS ARE NOT EASILY TRACKED HOWEVER THE HOSPITAL DOES PROVIDE A WIDE VARIETY OF COMMUNITY BUILDING ACTIVITIES. 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 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. 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. 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 6: 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 7: 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 324279 0 62000 0 0 0 9800 0 2044 0 398123 0 0 0 JONATHAN MCLAUGHLIN MD 0 406173 0 63909 0 0 0 9800 0 16815 0 496697 0 0 F BRADFORD MEYERS MD 0 223347 0 0 0 0 0 8880 0 16815 0 249042 0 0 DONALD WILLIAMS MD 0 222751 0 0 0 0 0 0 0 0 0 222751 0 0 THOMAS NORLAND MD 0 634961 0 31058 0 0 0 5907 0 2044 0 673970 0 0 JAMES J NELSON 198578 0 31030 0 0 0 8338 0 0 0 237946 0 0 0 KAY E WIPPERFURTH 164272 0 25464 0 0 0 7592 0 0 0 197328 0 0 0 SARAH S SISBACH 124802 0 21930 0 0 0 5353 0 0 0 152085 0 0 0 EDWIN FISCHER 0 294916 0 0 0 0 0 9800 0 14771 0 319487 0 0 EDGARDO JIONGCO 0 1299004 0 0 0 0 0 9800 0 7430 0 1316234 0 0 RANDALL JENNINGS 0 693585 0 83798 0 0 0 9800 0 14771 0 801954 0 0 MICHAEL ANDERSON 0 444585 0 62213 0 0 0 9800 0 14771 0 531369 0 0 ISIDORO ZAMBRANO 0 682800 0 10353 0 0 0 8128 0 14771 0 716052 0 0 JULIE MOKHTAR 0 502695 0 0 0 0 0 9800 0 0 0 512495 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 3687037 40072037 3000700 320000 36751337 2006 0 0 1 1 4185000 26000000 481154 9548835 391832 15577679 2010 0 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 XL ASSET FUNDING COMPANY 2.540000000000 1 0 0 0 1 0 0 0 0 500 MCMILLEN GROUP LLP PARTNERSHIP OWNED BY DONALD WILLIAMS BOARD CURRENT DIRECTOR 325963 RENT FOR THE LEASE OF OFFICE SPACE 0 CAMBRIDGE STATE BANK EMPLOYER OF BOARD MEMBER DAVID KELEHER 1000000 FILING ORGANIZATION HAS CERTIFICATES OF DEPOSITS WITH THE BANK 0 JULIE MOKHTAR MD WIFE OF EDWIN FISCHER 502695 EMPLOYEE 0 JOHNSON BANK BOARD MEMBER DEAN JOHNSON IS A DIRECTOR OF THE JOHNSON BANK ADVISORY BOARD 1000000 CERTIFICATES OF DEPOSIT 0 MELANIE RUMPF WIFE OF BOARD MEMBER MICHAEL RUMPF 49138 EMPLOYEE 0 BADGER BANK EMPLOYER OF FORMER BOARD MEMBER DAVID KELEHER 750000 CERTIFICATES OF DEPOSIT 0 CHANGES IN PROGRAM SERVICES FORM 990, PART III, LINE 3 EFFECTIVE 7/6/11 THE ORGANIZATION IS NO LONGER OPERATING THE SUBACUTE UNIT. 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. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED LOSSES ON INVESTMENTS: -4,261,369. 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 FORT MEDICAL GROUP INC 611 SHERMAN AVE EAST FORT ATKINSON WI 53538 391736513 PROVIDE PHYSICIAN SERVICES WI N/A C 2370138 1.00000 FORT CARE INC 611 SHERMAN AVE EAST FORT ATKINSON WI 53538 391725831 PREFERRED PROVIDER ORGANIZATION WI N/A C 11220 77107 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 69550 FAIR MARKET VALUE FORT HEALTHCARE PARTNERS C 84839 FAIR MARKET VALUE FORT MEMORIAL HOSPITAL FOUNDATION P 88921 FAIR MARKET VALUE FORT MEDICAL GROUP O 17385788 FAIR MARKET VALUE