2012-11-14T16:39:49-06:00 2011-12-31 391173131 SCHENCK SC 100 MARITIME DRIVE SUITE 2B MANITOWOC WI 54220 990 2011-01-01 390806395 HOLY FAMILY MEMORIAL INC HOLY 9203202011 2300 WESTERN AVE PO BOX 1450 MANITOWOC WI 542211450 MARK HERZOG 9203203470 2012-11-12 1 LACEY SILBERNAGEL CPA P01245590 9206845500 2011 2016-02-24 21:20:13Z MARK HERZOG 2300 WESTERN AVE PO BOX 1450 MANITOWOC WI 542211450 135015669 0 X WWW.HFMHEALTH.ORG X 1899 WI HEALTH CARE SERVICESSEE SCHEDULE 0HOLY FAMILY MEMORIAL IS A NETWORK OF HEALTH PROFESSIONALS, WHO ROOTED IN THE HEALING MINISTRY OF JESUS CHRIST, PROVIDE SERVICES TO HELP INDIVIDUALS AND OUR COMMUNITIES ACHIEVE HEALTHIER LIVES. HFM PROVIDES ACUTE, OUTPATIENT, CLINIC AND HOME CARE SERVICES FOR MANITOWOC COUNTY, STRIVING FOR MEDICIAL EXCELLENCE AND VALUED OUTCOMES WITHIN A COMPASSIONATE, VALUES BASED, CHRISTIAN ENVIRONMENT. 20 13 1367 349 160550 136165 1756485 933186 130165998 129021726 908139 3611146 741752 605790 133572374 134171848 46000 42000 0 0 77600710 77340656 0 0 225498 49777158 49572482 127423868 126955138 6148506 7216710 165522146 169230414 71786359 70216195 93735787 99014219 X HOLY FAMILY MEMORIAL IS A NETWORK OF HEALTH PROFESSIONALS WHO, ROOTED IN THE HEALING MINISTRY OF JESUS CHRIST, PROVIDE SERVICES TO HELP INDIVIDUALS AND OUR COMMUNITIES ACHIEVE HEALTHIER LIVES. 0 0 115384987 131019171 HOLY FAMILY MEMORIAL PROVIDES COMMUNITY SERVICES INTENDED TO BENEFIT THE UNDERSERVED AND ENHANCE THE HEALTH STATUS OF THE COMMUNITIES IT SERVES. THESE SERVICES INCLUDE 24 HOUR A DAY EMERGENCY CARE, COMMUNITY HEALTH SCREENINGS, VARIOUS SUPPORT GROUPS, HEALTH EDUCATION CLASSES, SPEAKERS AND PUBLICATIONS AND HOSPICE CARE. HOLY FAMILY MEMORIAL HAS BEEN ABLE TO ACHIEVE A GREATER IMPACT IN THE COMMUNITY BY PARTNERING FINANCIAL, HUMAN AND PROGRAMMATIC RESOURCES WITH OTHER ORGANIZATIONS. THESE PARTNERSHIPS INCLUDE A COMMITMENT TO COLLABORATE WITH OTHER HEALTH AND SOCIAL SERVICE AGENCIES TO IMPROVE ACCESS TO CARE, FOCUS ON PREVENTIVE SERVICES, REDUCE COMMUNITY HEALTH RISKS AND CONTRIBUTE TO A HEALTHIER, VIBRANT COMMUNITY.HOLY FAMILY MEMORIAL PROVIDES MEDICALLY NECESSARY SERVICES WITHOUT CHARGE OR AT AMOUNTS LESS THAN ITS ESTABLISHED RATES TO PATIENTS WHO MEET CERTAIN CRITERIA UNDER ITS CHARITY CARE POLICIES. IN ASSESSING A PATIENT'S ABILITY TO PAY, HOLY FAMILY MEMORIAL UTILIZES GENERALLY RECOGNIZED POVERTY INCOME LEVELS OF THE COMMUNITIES IT SERVES AND CONSIDERS SITUATIONS WHERE INCURRED CHARGES ARE SIGNIFICANT WHEN COMPARED TO THE PATIENT'S FINANCIAL RESOURCES. BECAUSE HOLY FAMILY MEMORIAL DOES NOT EXPECT TO RECEIVE PAYMENT OF AMOUNTS DETERMINED TO QUALIFY AS CHARITY CARE, THESE AMOUNTS ARE NOT INCLUDED IN NET PATIENT SERVICE REVENUES. HOLY FAMILY MEMORIAL'S TOTAL COMMUNITY BENEFIT INCLUDES THE COST OF CHARITY CARE AND UNPAID COST OF PUBLIC PROGRAMS (MEDICARE AND MEDICAID) AS WELL AS THOSE DISCUSSED ABOVE. HOLY FAMILY MEMORIAL'S COMMUNITY BENEFIT WAS APPROXIMATELY $23,495,000 FOR THE YEAR ENDED DECEMBER 2011. THIS AMOUNT INCLUDES THE NET COST OF CHARITY CARE OF APPROXIMATELY $1,723,000. MORE INFORMATION AVAILABLE FROM OUR COMMUNITY BENEFIT REPORT WHICH CAN BE LOCATED ON OUR WEBSITE AT WWW.HFMHEALTH.ORG. 115384987 1 1 0 1 0 0 0 0 0 1 1 1 0 0 1 0 1 1 0 0 0 0 0 0 1 1 1 1 0 1 1 1 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 1 1 1 0 0 1 24 0 1 1367 1 1 1 0 0 0 0 1 1 0 0 0 0 0 0 0 X 20 13 0 0 0 0 1 1 1 1 1 0 0 0 1 1 1 1 1 1 1 1 1 WI X X X MARK HERZOG PRESIDENT CEO 9203203470 2300 WESTERN AVENUE MANITOWOC WI 542211450 X SISTER LORITA GAFFNEY 2.00 X 0 0 0 PRADEEP GIRIYAPPA MD 40.00 X 274624 0 37514 MICHAEL B MCCORMICK MD 40.00 X 299661 0 40564 SISTER MARDELLE MEINHOLZ 2.00 X 0 0 0 AMY L STOCKHAUSEN MD 40.00 X 224182 0 34944 WILLIAM R CASEY 2.00 X 0 0 0 JAY A STREU 3.00 X 0 0 0 SISTER PAULA VANDEN HOGE 2.00 X 0 0 0 JOHN J ZIMMER 3.00 X 0 0 0 SISTER LAURA WOLF 2.00 X 0 0 0 GARY SCHMIDT MD 40.00 X 185112 0 13866 KATHLEEN A ZUCCHI 2.00 X 0 0 0 WILLIAM C CENSKY 3.00 X 0 0 0 MARY A GOVIER MD 40.00 X 200635 0 29467 SISTER MARY ANN NUGENT 2.00 X 0 0 0 EVELYN D SBAR MD 40.00 X 195777 0 15547 LAURIE CRAWFORD 2.00 X 0 0 0 LEE KUMMER 2.00 X 0 0 0 JANE PFEFFER 2.00 X 0 0 0 DONALD BRISCH 2.00 X 0 0 0 MARK SWANSON 2.00 X 0 0 0 JAMES HOFTIEZER MD 40.00 X 571357 0 38428 MARK P HERZOG 40.00 X 554293 0 107203 PATRICIA HUETTL 40.00 X 252878 0 54661 STEVEN DRIGGERS MD 40.00 X 505958 0 94166 MARY MAURER 40.00 X 246753 0 45742 RYAN DOPIRAK MD 40.00 X 1312074 0 39965 NANCY BUTLER MD 40.00 X 1069596 0 29345 JEFFREY JACOBY MD 40.00 X 1118805 0 38866 TRACY RUPKE MD 40.00 X 822707 0 39853 KIRK DIMITRIS MD 40.00 X 1142176 0 23459 PATRICK BRANDEL 0.00 X 105893 0 0 MARY DEBILZEN 40.00 X 98031 0 13134 9180512 0 696724 78 1 1 0 CARETECH SOLUTIONS 901 WILSHIRE DRIVE STE 250 TROY MI 48084 IT SERVICES 3032872 PATRIOT MEDICAL TECH PO BOX 415000 NASHVILLE TN 372415000 BIO-MED SERVICES 1062391 RADIATION ONCOLOGY SPECIALISTS PO BOX 678 STURGEON BAY WI 54235 CANCER CARE SERVICES 500694 QUEST DIAGNOSTICS 12989 COLLECTNS CTR DR CHICAGO IL 606930129 LABORATORY SERVICES 439233 ST VINCENT HOSPITAL PO BOX 13508 GREEN BAY WI 543073508 LAUNDRY SERVICES 375219 23 50074 179279 703833 24904 933186 INTEGRATED HEALTH CARE 900099 113552616 113552616 LAB 621500 9042559 9027261 15298 PHARMACY 446110 6426551 6414271 12280 129021726 1777326 1744830 32496 248852 7100 163086 0 85766 7100 92866 92866 2327950 494130 1833820 1833820 1833820 89124 50074 21046 68078 68078 23267 2227 21040 21040 194189 163332 30857 30857 INVESTMENT HFHS & DME 446110 198000 85244 112756 MISCELLANEOUS 900003 194949 194949 392949 134171848 131019171 160550 2058941 42000 42000 4479286 2286484 2192802 60214616 55771918 4287804 154894 1579595 1441618 133907 4070 7468133 6863185 560853 44095 3599026 3271663 316800 10563 97506 97506 109000 109000 626565 626565 484301 72504 411797 16505174 16253843 246163 5168 3041074 3041074 2985816 2985816 390023 268539 120295 1189 343869 173433 170436 2394566 2394566 9172539 9172539 710335 710335 PURCHASED SERVICES 6107690 4086949 2015222 5519 STATE PROVIDER ASSESSME 3274198 3274198 MAINTENANCE 2611268 2510646 100622 CONSULTING 689779 108333 581446 28779 28779 126955138 115384987 11344653 225498 X 6587436 9393054 3029507 3404090 26036 23190 18908121 21425602 603714 606872 1992813 2058558 5366828 5411183 172378009 100494176 72374491 71883833 34821666 30122020 17550008 20116445 3532874 3749813 728652 1035754 165522146 169230414 13414930 14880465 95678 66476 57546774 54233175 728652 1035754 325 325 71786359 70216195 X 92133119 97376300 270462 209193 1332206 1428726 93735787 99014219 165522146 169230414 X 7216710 -1938278 X X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 1 0 1 0 0 1 0 1 11890 11890 0 ORGANIZATIONS DIRECT AND INDIRECT POLITICAL CAMPAIGN ACTIVITIES: PART I-A, LINE 1: HOLY FAMILY MEMORIAL EXECUTIVES MET WITH LOCAL LEGISLATORS TO DISCUSS THE EFFECTS OF PENDING LEGISLATION ON HEALTHCARE. A SMALL NUMBER OF HOLY FAMILY MEMORIAL EMPLOYEES WROTE LETTERS TO THEIR LEGISLATORS TO EXPRESS THEIR VIEWS ON HEALTHCARE RELATED ISSUES. EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: HOLY FAMILY MEMORIAL BELONGS TO VARIOUS TRADE ASSOCIATIONS. A CERTAIN PERCENTAGE OF MEMBERSHIP DUES TO THE ASSOCIATIONS IS DETERMINED TO HAVE BEEN SPENT ON SPECIFIC LOBBYING PURPOSES. 0 0 1602667 202680 -9775 500 157154 1637918 1429395 240013 162063 500 228304 1602667 1223863 485645 -107593 500 172020 1429395 1372479 316645 -303997 500 160764 1223863 0.93000 0.07000 0 1 1 4629795 4629795 104256485 56736169 47520316 5395271 3554905 1840366 56139991 39556706 16583285 1956467 646396 1310071 71883833 20116445 C 20116445 SECURITY DEPOSIT 325 325 134171848 126955138 7216710 -1973529 35251 -1938278 5278432 136019610 -1973529 3821291 1847762 134171848 0 134171848 130776429 3821291 3821291 126955138 0 126955138 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: HOLY FAMILY MEMORIAL'S ENDOWMENT FUNDS WERE ESTABLISHED TO PROVIDE FINANCIAL SUPPORT ON AN ONGOING BASIS TO MEET THE CURRENT AND FUTURE NEEDS OF HOLY FAMILY MEMORIAL AND THE PEOPLE IT SERVES. FUNDS ARE USED FOR CAPITAL EQUIPMENT, BUILDING IMPROVEMENTS AND PROGRAM DEVELOPMENT, AS DIRECTED BY THE DONOR. PART XI, LINE 8 - OTHER ADJUSTMENTS: CHANGE IN RESTRICTED ASSETS 35,251. PART XII, LINE 2D - OTHER ADJUSTMENTS: BAD DEBTS: $3,845,165 PURCHASE DISCOUNTS: $4,905 TAXES: ($28,779) PART XIII, LINE 2D - OTHER ADJUSTMENTS: BAD DEBTS: $3,845,165 PURCHASE DISCOUNTS: $4,905 TAXES: ($28,779) FIESTA ITALIANO 20032 3122 16910 1409 SAMARITAN DAY 77145 39105 38040 14101 3 42021 7847 34174 5536 139198 50074 89124 21046 21046 68078 23267 1725 502 1 0.75000 23267 1725 502 2227 21040 WI 1 0 1 0 1.00000 ERIK BARBER PO BOX 1450 MANITOWOC WI 542211450 0 0 1 1 1 X 1 X 1 1 1 0 1 1 1612 1723067 1723067 0.01440 47843 11579059 4319164 7259895 0.06050 49455 13302126 4319164 8982962 0.07490 10989 154828 154828 0.00130 1166 262752 262752 0.00220 59 73348 73348 0.00060 854 186516 186516 0.00150 13068 677444 677444 0.00560 62523 13979570 4319164 9660406 0.08050 20947 20947 0.00020 45 4519 4519 0.00000 610 610 0.00000 49 2635 2635 0.00000 1075 4544 4544 0.00000 1169 33255 33255 0.00030 1 1562329 321385 40649551 54451395 -13801844 X 1 1 1 YORK STREET PROPERTIES LLC REAL ESTATE 0.36000 0.00000 0.00000 2 HOLY FAMILY MEMORIAL CANCER CENTER - ST VINCENT CANCER COLLABORATIVE PROFESSIONAL CANCER CARE SERVICES 0.50000 0.00000 0.00000 1 1 HOLY FAMILY MEMORIAL INC

2300 WESTERN AVE PO BOX 1450 MANITOWOC WI 542211450

X X X HOLY FAMILY MEMORIAL INC 1 1 1 100.000000000000 1 200.000000000000 1 X X X X 1 1 X X 1 0 1 X 0 0 2 HOLY FAMILY HEALTH SERVICES INC

3310 CALUMET AVENUE MANITOWOC WI 54220

RETAIL PHARMACY NORTH END HOME MEDICAL SERVICES LLC

3310 CALUMET AVENUE MANITOWOC WI 54220

DURABLE MEDICAL EQUIPMENT PART I, LINE 7: COMMUNITY BENEFITS ARE PROGRAMS OR ACTIVITIES THAT PROVIDE CARE AND/OR PROMOTE HEALTH AND HEALING AS A RESPONSE TO IDENTIFIED COMMUNITY NEEDS. HOLY FAMILY MEMORIAL'S COMMUNITY BENEFIT PROGRAMS INCLUDE SERVICES FOR THOSE WHO CAN NOT AFFORD HEALTH CARE AND INITIATIVES FOR IMPROVING HEALTH IN THE BROADER COMMUNITY. PROVIDING COMMUNITY BENEFITS DEMONSTRATES THAT HOLY FAMILY MEMORIAL IS FULFILLING ITS CHARITABLE MISSION AND DEMONSTRATING ITS PREFERENTIAL TAX STATUS IS DESERVED. SCHEDULE H, PART 1, LINE 7, COLUMN F PERCENTAGE OF COMMUNITY BENEFIT EXPENSE TO OVERALL ENTITY'S EXPENSES. PART II: COMMUNITY BUILDING ACTIVITIES INDICATED IN PART II PROMOTE THE HEALTH OF THE MANITOWOC COMMUNITY BY ACTIVELY ADDRESSING EXPRESSED AND REPORTED ISSUES. SPECIFICALLY, THROUGH THE PROGRAMS INDICATED, HOLY FAMILY MEMORIAL AND IN PARTNERSHIP WITH OTHERS, WORKS DILIGENTLY TO ACHIEVE AN OVERALL HEALTHIER COMMUNITY. MAJOR INITIATIVES WITH DISCERNABLE POSITIVE RESULTS INCLUDE: IMPROVED ACCESS TO HEALTH INFORMATION AND PROVIDER RESOURCES, REDUCTION IN COMMUNITY FALLS, REDUCTION IN ADULT SMOKING POPULATION RATES, REDUCTION IN TEENAGE PREGNANCY RATES AND REDUCTION IN TEENAGE AND ADULT DRINKING RATES. PART III, LINE 4: AN ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS IS ESTABLISHED ON AN AGGREGATE BASIS BY USING HISTORICAL WRITE-OFF FACTORS APPPLIED TO UNPAID ACCOUNTS BASED ON AGING. LOSS RATE FACTORS ARE BASED ON HISTORICAL LOSS EXPERIENCE AND ADJUSTED FOR ECONOMIC CONDITIONS AND OTHER TRENDS AFFECTING THE ORGANIZATION'S ABILITY TO COLLECT OUTSTANDING AMOUNTS. UNCOLLECTIBLE AMOUNTS ARE WRITTEN OFF AGAINST THE ALLOWANCE FOR DOUBTFUL ACCOUNTS IN THE PERIOD THEY ARE DETERMINED TO BE UNCOLLECTIBLE. PART III, LINE 8: HOLY FAMILY MEMORIAL IS A LICENSED MEDICARE PROVIDER WITH APPROXIMATLEY 45.4 PERCENT OF ITS PATIENT BASE QUALIFYING FOR THIS PROGRAM. AT PRESENT, THE REIMBURSEMENT RATE FOR THE MEDICARE PROGRAM DOES NOT FULLY COVER THE COST OF CARE TO THESE PATIENTS. THIS REPRESENTS THE ESTIMATED SHORTFALL CREATED WHEN HOLY FAMILY MEMORIAL RECEIVES PAYMENTS BELOW THE COSTS OF TREATING MEDICARE AND OTHER PUBLIC PROGRAM BENEFICIARIES.COST METHODOLOGY = COST TO CHARGE RATIO PART III, LINE 9B: PAYMENT OPTIONS AS WELL AS COMMUNITY CARE ASSISTANCE IS NOTED ON ALL COLLECTION LETTERS, AS WELL AS INSURANCE BENEFIT PAPERWORK THAT IS SENT TO PATIENTS FOR INPATIENT, SDS, MRI, CT AND ER SERVICES. A PATIENT FINANCIAL ADVISOR SEES SELF-PAY INPATIENTS AND ADVISES PATIENTS OF ANY PROGRAMS THEY MAY QUALIFY FOR INCLUDING, BUT NOT LIMITED TO MEDICAID, VETERANS ADMINISTRATION, OR OUR OWN CHARITY CARE PROGRAM. IF THEY MAY QUALIFY FOR MEDICAID OR VETERANS ADMINISTRATION, WE DIRECT THEM TO THE APPROPRIATE ORGANIZATION FOR APPLICATION AND ASSISTANCE. FOR THE NETWORK CHARITY PROGRAM, AN APPLICATION IS PROVIDED AND THE PATIENT IS INSTRUCTED ON WHOM TO CALL FOR ASSISTANCE IN APPLYING. WHEN CONTACTING PATIENTS BY PHONE, THE PATIENT FINANCIAL ADVISOR IS TRAINED TO IDENTIFY PATIENTS WHO MAY QUALIFY FOR OUTSIDE STATE OR FEDERAL ASSISTANCE AND WILL DIRECT THOSE PATIENTS ON WHERE TO GO TO APPLY FOR THOSE PROGRAMS. HOLY FAMILY MEMORIAL INC PART V, SECTION B, LINE 13G: HOLY FAMILY MEMORIAL'S COMMUNITY CARE PROGRAM IS COMMUNICATED ON THE HOSPITAL FACILITY'S WEBSITE SUMMARIZING THE ELIGIBILITY REQUIREMENTS TO INCLUDE SERVICES COVERED, INCOME GUIDELINES, APPLICATION FORM, AND OTHER DOCUMENTS NEEDED FOR COMPLETION OF THE APPLICATION. THE COMMUNITY CARE PROGRAM IS ALSO COMMUNICATED VIA PAYMENT GUIDELINE BROCHURES AVAILABLE IN THE REGISTRATION AREAS AT ALL HFM LOCATIONS THROUGHOUT THE COMMUNITY, AND TO PATIENTS IN COMMUNICATION WITH PRICE ESTIMATIONS AND COLLECTIONS, BOTH VERBAL AND WRITTEN. THE POLICY IS ALSO AVAILABLE UPON REQUEST. HOLY FAMILY MEMORIAL INC PART V, SECTION B, LINE 19D: THE HOSPITAL FACILITY USED THE AVERAGE OF ITS FIVE LOWEST NEGOTIATED COMMERCIAL INSURANCE RATES WHEN CALCULATING THE MAXIMUM AMOUNTS THAT CAN BE CHARGED. PART VI, LINE 2: HOLY FAMILY MEMORIAL UTILIZES FOUR DISTINCT PROCESSES TO ASSESS THE HEALTH CARE NEEDS OF THE COMMUNITIES WE SERVE. FIRST, AS A PART OF THE ANNUAL STRATEGIC PLANNING PROCESS, AN ENVIRONMENTAL ASSESSMENT IS DONE. INCLUDED IN THAT REPORT AND ANALYSIS IS CURRENT POPULATION DATA INCLUDING DEMOGRAPHICS, UTILIZATION, MORTALITY INFORMATION, DEMAND FORECASTING, PREVALENT DISEASE STATES AND FEEDBACK FROM VARIOUS CONSTITUENCIES RELATIVE TO PERCEIVED MET AND UNMET COMMUNITY HEALTH NEEDS. SECOND, HOLY FAMILY MEMORIAL PARTICIPANTS IN A TRI-ANNUAL FULL COMMUNITY HEALTH ASSESSMENT PROCESS IN CONJUNCTION WITH HEALTHIEST MANITOWOC COUNTY 2020. THIS ASSESSMENT CONSISTS OF INPUT OBTAINED FROM HUNDREDS OF COMMUNITY RESIDENTS, INCLUDING ALL AGE GROUPS, BEGINNING FROM HIGH SCHOOL AGE. THE INFORMATION IS TABULATED, ANALYZED AND UTILIZED TO DETERMINE PRIORITIZED HEALTH NEEDS. HOLY FAMILY MEMORIAL USES THIS INFORMATION IN ITS ANNUAL COMMUNITY BENEFIT PLANS. THIRD, HOLY FAMILY MEMORIAL CONDUCTS REGULAR INPUT SESSSIONS WITH LOCAL EMPLOYERS TO ASCERTAIN HEALTH NEEDS FROM AN OCCUPATIONAL HEALTH PERSPECTIVE. THIS INFORMATION IS THEN UTILIZED TO DEVELOP AND PROVIDE NEEDED EMPLOYER/EMPLOYEE HEALTH SERVICES THROUGHOUT THE BUSINESS COMMUNITY. LASTLY, HOLY FAMILY MEMORIAL UTILIZES A COMBINATION OF PATIENT FEEDBACK FROM ONGOING PATIENT SATISFACTION SURVEYS (CONDUCTED POST PROVISION OF SERVICES) AND COMMUNITY RESEARCH STUDIES COMMISSIONED BY HOLY FAMILY MEMORIAL, TO ASSESS PROGRAM AND SERVICE HEALTH CARE NEEDS OF THE COMMUNITY. PART VI, LINE 3: PATIENTS ARE INFORMED OF ELIGIBILITY FOR ASSISTANCE / PUBLIC NOTICES / WEBSITE / BROCHURES / ADMISSIONS STAFF / COLLECTION CORRESPONDENTS AS WELL AS INSURANCE BENEFIT PAPERWORK THAT IS SENT TO PATIENTS FOR INPATIENT, SDS, MRI, CT SERVICES. A PATIENT FINANCIAL ADVISOR SEES/COMMUNICATES TO SELF-PAY INPATIENTS TO INTERVIEW AND ADVISE PATIENT OF ANY PROGRAMS THEY MAY QUALIFY FOR INCLUDING, BUT NOT LIMITED TO MEDICAID, VETERANS ADMINISTRATION OR OUR OWN CHARITY PROGRAM. IF THEY QUALIFY FOR MEDICAID OR VETERANS ADMINISTRATION, WE ASSIST THEM TO THE APPROPRIATE ORGANIZATION FOR APPLICATION AND ASSISTANCE. FOR THE NETWORK CHARITIY PROGRAM, AN APPLICATION IS PROVIDED WHICH INCLUDES WHOM TO CALL FOR ASSISTANCE IN APPLYING. WHEN CONTACTING PATIENTS BY PHONE, THE PATIENT FINANCIAL ADVISOR IS TRAINED TO IDENTIFY PATIENTS WHO MAY QUALIFY FOR OUTSIDE STATE OR FEDERAL ASSISTANCE AND WILL DIRECT THOSE PATIENTS ON WHERE TO GO TO APPLY FOR THOSE PROGRAMS. PART VI, LINE 4: THE COMMUNITY THAT HOLY FAMILY MEMORIAL SERVICES IS CONSIDERED TO BE LOCATED IN THE RURAL LAKESHORE REGION OF NORTHEAST WISCONSIN. THE PRIMARY SERVICE AREA IS MANITOWOC COUNTY WITH SECONDARY NEIGHBORING COUNTIES; BROWN, KEWAUNEE, CALUMET AND SHEBOYGAN. THE COMMUNITY SERVED IS AN OLDER POPULATION WITH 16% OF THE PEOPLE AGE 65 OR OLDER WITH MEDIAN HOUSEHOLD INCOME OF APPROXIMATELY $45,000. 13.5% OF OUR SERVICES ARE DEDICATED TO PROVIDING CARE TO MEDICAID AND SELF-PAY PATIENTS. THIS NUMBER IS 3% HIGHER THAN THE STATE AVERAGE AND 2-3% HIGHER THAN SURROUNDING COUNTIES. THE 2012 SERVICE AREA IS EXPECTED TO REMAIN AT 2009 LEVELS WITH A SLIGHT GROWTH TOWARD THE 65+ AGE AND RETRACTION OF THOSE 18-44. REFLECTIVE OF THIS NUMBER IS THAT OVER 47% OF OUR SERVICES ARE DEDICATED TO PROVIDING CARE TO MEDICARE PATIENTS. THE COMMUNITY IS MAINLY CAUCASIAN WITH SEVERAL OTHER NATIONALITIES INCLUDING AFRICAN AMERICAN, ASIAN AND HISPANIC. OTHER PROVIDERS IN THE AREA CONSIST OF THE AUORORA MEDICAL GROUP, MANITOWOC SURGERY CENTER, AND SEVERAL OTHER INDEPENDENT PROVIDERS. PART VI, LINE 5: ALL OF HOLY FAMILY MEMORIAL'S BOARD MEMBERS RESIDE IN THE PRIMARY SERVICE AREA. THE BOARD CONSISTS OF COMMUNITY REPRESENTATIVES, PHYSICIANS AND REPRESENTATIVES OF THE SPONSOR ORGANIZATION. THE MEDICAL/DENTAL STAFF IS OPEN TO ALL QUALIFIED PHYSICIANS WHO MEET THE REQUIREMENTS OF MEDICAL/DENTAL STAFF MEMBERSHIP. THE NETWORK OF PHYSICIANS AND OTHER PROVIDERS IS COMMITTED TO PROVIDING EACH PATIENT WITH THE HIGHEST LEVEL OF PERSONAL CARE, RESPECT AND COMPASSION TO ENHANCE THE PATIENT'S QUALITY OF LIFE AND HEALTH STATUS. ALL SURPLUS FUNDS ARE REINVESTED IN THE ORGANIZATION TO PURCHASE NECESSARY MEDICAL EQUIPMENT, COMPENSATE EMPLOYEES, AND PLAN FOR FUTURE NEEDS. NONE OF THE SUPRLUS EARNINGS BENEFIT ANY INDIVIDUALS OR OTHER CORPORATE ENTITIES. PART VI, LINE 6: THE HEALTH CARE NETWORK IS SPONSORED BY THE FRANCISCAN SISTERS OF CHRISTIAN CHARITY, LOCATED AT HOLY FAMILY CONVENT, MANITOWOC, WISCONSIN. THE CONVENT, SITUATED ON SILVER LAKE, THREE MILES WEST OF LAKE MICHIGAN, IS HOME FOR OVER 350 CONGREGATION MEMBERS WHO SERVE THROUGHOUT THE UNITED STATES AND ARE PRIMARILY ENGAGED IN EDUCATION, PARISH AND HEALTH MINISTRIES. THE HEALTHCARE MINISTRY SPANS THREE STATES - WISCONSIN, NEBRASKA AND OHIO - AND HAS EXISTED FOR OVER 100 YEARS. THE MISSION OF THE FRANCISCAN SISTERS OF CHRISTIAN CHARITY HEALTHCARE MINISTRY IS TO CARRY OUT THE COMMITMENT OF THE SPONSOR IN THE HEALING MISSION OF THE CATHOLIC CHURCH THROUGHOUT THE PROVISION OF QUALITY HEALTHCARE SERVICES TO THE PEOPLE OF GOD IN OUR COMMUNITIES. REPORTS FILED WITH STATES PART VI, LINE 7 WI,NE 1 SCHOLARSHIPS 10 42000 ACTUAL TUITION COST HOLY FAMILY MEMORIAL'S SCHOLARSHIP PROGRAM IS DESIGNED AS A RECRUITMENT TOOL FOR EMPLOYMENT OF CANDIDATES IN SPECIFIED POSITIONS, CONSIDERED DIFFICULT TO FILL AND TO ASSIST STUDENTS IN THEIR PURSUIT OF A HEALTH CARE RELATED DEGREE. AREAS OF STUDY INCLUDE NURSING, PHARMACY, PHYSICAL THERAPY AND OTHERS. IN RETURN FOR THE SCHOLARSHIP, AN EMPLOYMENT SERVICE COMMITMENT IS MADE. IN ORDER TO BE ELIGIBLE: 1) STUDENTS MUST BE ACCEPTED INTO AN ACCREDITED PROGRAM 2) CANDIDATES MUST BE ATTENDING SCHOOL AS A FULL OR PART TIME STUDENT AND REMAIN IN THAT STATUS 3) STUDENTS MUST HAVE AND MAINTAIN A 3.0 CUMULATIVE GRADE POINT AVERAGE. SCHOLARSHIPS ARE AWARDED ON THE BASIS OF GRADE POINT AVERAGE, VERIFIED WITH OFFICIAL TRANSCRIPT OF GRADES, COMPLETION OF EMPLOYMENT APPLICATION AND PERSONAL INTERVIEW. THE SCHOLARSHIP IS USED FOR TUITION COST. THE SCHOLARSHIPS ARE GIVEN OUT EACH SEMESTER AND ARE PAID DIRECTLY TO THE SCHOOL THE STUDENT ATTENDS. APPLICANTS WHO ARE AWARDED THE SCHOLARSHIP MUST MAKE A SIX-MONTH COMMITMENT TO WORK AT HOLY FAMILY MEMORIAL FOR EACH SEMESTER THE SCHOLARSHIP IS AWARDED. THE SCHOLARSHIP RECIPIENT MUST REPAY THE FULL AMOUNT OF THE SCHOLARSHIP IF HE/SHE: 1) DROPS OUT OF SCHOOL 2) FALLS BELOW A 3.0 CUMULATIVE GRADE POINT AVERAGE 3) DOES NOT ACCEPT EMPLOYMENT 4) DOES NOT COMPLETE FULL LENGTH OF EMPLOYMENT COMMITMENT 5) DOES NOT OBTAIN WISCONSIN LICENSURE, AS REQUIRED. X X 1 1 X X X X 1 0 0 0 0 1 0 0 0 PRADEEP GIRIYAPPA MD 182802 0 77518 0 14304 0 19559 0 17955 0 312138 0 0 0 MICHAEL B MCCORMICK MD 268806 0 0 0 30855 0 18596 0 21968 0 340225 0 0 0 AMY L STOCKHAUSEN MD 149977 0 67552 0 6653 0 16198 0 18746 0 259126 0 0 0 GARY SCHMIDT MD 168142 0 6994 0 9976 0 9396 0 4470 0 198978 0 0 0 MARY A GOVIER MD 162601 0 27516 0 10518 0 9773 0 19694 0 230102 0 0 0 EVELYN D SBAR MD 178160 0 10449 0 7168 0 13387 0 2160 0 211324 0 0 0 JAMES HOFTIEZER MD 289419 0 267514 0 14424 0 14559 0 23869 0 609785 0 0 0 MARK P HERZOG 409175 0 47953 0 97165 0 85636 0 21567 0 661496 0 0 0 PATRICIA HUETTL 218214 0 0 0 34664 0 33331 0 21330 0 307539 0 0 0 STEVEN DRIGGERS MD 398118 0 42888 0 64952 0 76087 0 18079 0 600124 0 0 0 MARY MAURER 196254 0 21200 0 29299 0 42555 0 3187 0 292495 0 0 0 RYAN DOPIRAK MD 495010 0 813458 0 3606 0 19559 0 20406 0 1352039 0 0 0 NANCY BUTLER MD 274018 0 736403 0 59175 0 19559 0 9786 0 1098941 0 0 0 JEFFREY JACOBY MD 498841 0 600733 0 19231 0 19559 0 19307 0 1157671 0 0 0 TRACY RUPKE MD 441607 0 337792 0 43308 0 19559 0 20294 0 862560 0 0 0 KIRK DIMITRIS MD 445577 0 653291 0 43308 0 5000 0 18459 0 1165635 0 0 0 PATRICK BRANDEL 0 0 0 0 105893 0 0 0 0 0 105893 0 0 0 MARY DEBILZEN 94835 0 2500 0 696 0 4480 0 8654 0 111165 0 0 0 PART I, LINE 4A PATRICK BRANDEL, FORMER CFO, RECEIVED SEVERANCE PAYMENTS TOTALING $105,893. PART I, LINE 6 AN AT-RISK COMPENSATION TEAM AWARD PROGRAM WHICH REWARDS EFFORTS AND ACCOMPLISHMENT OF HFM'S GOALS. GOALS ARE APPROVED BY THE HFM BOARD EXECUTIVE COMMITTEE AND ARE DEVELOPED IN THE FOLLOWING AREAS: WORKFORCE AND ORGANIZATIONAL DEVELOPMENT, STRATEGIC INFRASTRUCTURE, IMPROVEMENT AND INNOVATION, AND CLINICAL AND SERVICE EXCELLENCE. BASED ON NET EARNINGS, A LEVEL OF ACHIEVEMENT IS CALCULATED. IN 2011, ALL REGULARLY SCHEDULED, NON-PHYSICIAN EMPLOYEES PARTICIPATED IN THE PROGRAM. WISCONSIN HEALTH AND EDUCATION FACILITIES 391337855 97710VPE2 2003-09-09 11293000 SEE SCHEDULE K, PART V 1 0 0 WISCONSIN HEALTH AND EDUCATION FACILITIES 391337855 97710VPE2 2003-09-09 9922000 SEE SCHEDULE K, PART V 0 0 0 WISCONSIN HEALTH AND EDUCATION FACILITIES 391337855 97710V2S6 2007-04-26 45170000 SEE SCHEDULE K, PART V 0 0 0 9571000 11293000 898000 1107000 146000 9142000 2006 1 0 1 1 9922000 244000 9677000 2006 0 0 1 1 45170000 2247000 37448000 485000 4990000 2009 1 1 1 1 0 0 0 0 1 0 0 0 0 1 0 0 0 0 1 1 0 0 0 0 1 1 1 0 0 0 1 0 0 0 0 0 1 X PART I, LINE A, COLUMN F: THE PURPOSE OF THE BOND ISSUE WAS A PROJECT CONSISTING OF CONSTRUCTION, RENOVATION AND EQUIPPING OF AMBULATORY CARE, DIAGNOSTIC IMAGING, REHABILITATION, OCCUPATIONAL MEDICINE, PRIMARY CARE AND ORTHOPEDIC FACILITIES AT CERTAIN HOLY FAMILY MEMORIAL HEALTH FACILITIES. PART I, LINE B, COLUMN F: THE PURPOSE OF THE BOND ISSUE WAS A PROJECT CONSISTING OF THE CONSTRUCTION, RENOVATION AND EQUIPPING OF AMBULATORY CARE, DIAGNOSTIC IMAGING, REHABILITATION, OCCUPATIONAL MEDICINE, PRIMARY CARE AND ORTHOPEDIC FACILITIES AT CERTAIN HOLY FAMILY MEMORIAL HEALTH FACILITIES. PART I, LINE C, COLUMN F: THE PURPOSE OF THE BOND ISSUE WERE 1) THE ACQUISITION, CONSTRUCTION, RENOVATION, REMODELING AND EQUIPPING OF CERTAIN HOSPITAL AND OTHER HEALTHCARE FACILITIES AS IDENTIFIED IN A NOTICE OF PUBLIC HEARING PUBLISHED IN CONNECTION WITH THE ISSUANCE OF THE BONDS INCLUDING THE ACQUISITION OF TELEMETRY MONITORS AND AN MRI SYSTEM 2) THE CURRENT REFUNDING OF ALL THE WISCONSIN HEALTH AND EDUCATIONAL FACILITIES AUTHORITY REVENUE (WHEFA) BONDS, SERIES 1995, 3) THE ADVANCE REFUNDING OF ALL OF THE WHEFA BONDS, SERIES 1998A, AND 4) THE ADVANCE REFUNDING OF A PORTION OF THE WHEFA BONDS, SERIES 2003A. LINDA BRANDEL SPOUSE OF FORMER CFO 25699 WAGES 0 ALAN SBAR MD SPOUSE OF M.D. COUNCIL CO-CHAIR 266926 WAGES 0 NORTH END HOME MED SCS LLC OFFICERS OF HFM 197170 100% OWNED LLC 0 HOLY FAMILY HEALTH SERVICES SERVE AS DIRECTORS ON BOTH ORGANIZATIONS 830 100% OWNED FOR PROFIT 0 JASON HOENISCH SON-IN-LAW OF CHIEF MEDICAL OFFICER 20197 WAGES 0 FORM 990, PART VI, SECTION A, LINE 6 HOLY FAMILY MEMORIAL IS SPONSORED BY FRANCISCAN SISTERS OF CHRISTIAN CHARITY HEALTH CARE MINISTRY INC., WHICH IS THE SOLE CORPORATE MEMBER OF THE ORGANIZATION. FORM 990, PART VI, SECTION A, LINE 7A HOLY FAMILY MEMORIAL OPERATES AN INTEGRATED HEALTHCARE DELIVERY SYSTEM, PRIMARILY TO THE RESIDENTS OF MANITOWOC COUNTY, WISCONSIN. HOLY FAMILY MEMORIAL IS OPERATED BY FRANCISCAN SISTERS OF CHRISTIAN CHARITY HEALTH CARE MINISTRY INC., WHICH IS THE SOLE CORPORATE MEMBER OF THE ORGANIZATION. FRANCISCAN SISTERS OF CHRISTIAN CHARITY HEALTH CARE MINISTRY INC. IS A NOT-FOR-PROFIT HEALTHCARE HOLDING COMPANY INCORPORATED TO MONITOR AND MANAGE HEALTHCARE OPERATIONS. THE BOARD OF DIRECTORS SHALL CONSIST OF NO MORE THAN EIGHTEEN INDIVIDUALS. THE PRESIDENT OF THE CORPORATION AND CHAIR OF THE PHYSICIAN COUNCIL SHALL BE EX-OFFICIO MEMBERS WITH FULL VOTING PRIVILEGES. IN ADDITION TO THE EX-OFFICIO BOARD POSITIONS, THE BOARD OF DIRECTORS SHALL INCLUDE FOUR MEMBERS OF FRANCISCAN SISTERS OF CHRISTIAN CHARITY AND AT LEAST FOUR PHYSICIANS. FORM 990, PART VI, SECTION A, LINE 7B SOME DECISIONS OF THE GOVERNING BODY ARE SUBJECT TO APPROVAL BY THE MEMBER AS OUTLINED IN THE CORPORATE BYLAWS. FOR EXAMPLE, THE GOVERNING BOARD SUBMITS NAMES OF NEW BOARD MEMBERS TO THE MEMBER AND THE MEMBER APPOINTS THEM. APPROVAL OF THE PHILOSOPHY, MISSION & VISION STATEMENTS MUST BE APPROVED BY THE MEMBER. A CERTIFIED AUDIT OF CORPORATE FUNDS OR THE ANNUAL FISCAL AUDITOR MUST BE APPROVED BY THE MEMBER, ETC. FORM 990, PART VI, SECTION B, LINE 11 THE CHAIR OF THE GOVERNING BOARD REVIEWS THE 990 PRIOR TO FILING. AN OVERVIEW OF THE 990 ALONG WITH SPECIFIC SECTIONS ON GOVERNANCE, COMMUNITY BENEFITS, CONFLICT OF INTEREST, AND COMPENSATION IS PRESENTED TO THE BOARD. THE COMPENSATION AND EVALUATION SUBCOMMITTEE REVIEWS THE 990 SECTIONS RELATED TO COMPENSATION PRIOR TO FILING. COPIES ARE AVAILABLE TO ALL BOARD MEMBERS. FORM 990, PART VI, SECTION B, LINE 12C ANNUALLY, GOVERNING BOARD MEMBERS ARE PROVIDED A COPY OF THE CONFLICT OF INTEREST POLICY TO REVIEW AND SIGN THE CERTIFICATION ON WHICH THEY DISCLOSE ANY CONFLICTS. AT EACH BOARD OR COMMITTEE MEETING WHERE THERE WILL BE A VOTE, THE CHAIRPERSON ASKS IF THERE ARE ANY CONFLICTS TO THE PARTICULAR ISSUE. IF THERE IS A CONFLICT, THAT PERSON ABSTAINS FROM DISCUSSION & VOTING. ALL PHYSICIANS, NETWORK LEADERS, AND KEY EMPLOYEES SIGN A CONFLICT OF INTEREST AT THE TIME OF THEIR CONTRACT RENEWAL OR PERFORMANCE APPRAISAL. CONFLICT OF INTEREST IS MONITORED THROUGH HOLY FAMILY MEMORIAL'S COMPLIANCE DEPARTMENT. PROVIDERS COMPLETE A CONFLICT OF INTEREST ACKNOWLEDGEMENT AS PART OF THE APPROVAL PROCESS FOR THE PURCHASE OF NEW PRODUCTS OR EQUIPMENT THAT THEY ARE DIRECTLY ASSOCIATED WITH. FORM 990, PART VI, SECTION B, LINE 15 LINES 15 A & B - HOLY FAMILY MEMORIAL HAS A SENIOR LEADER COMPENSATION POLICY. THE PROCESS OF DETERMINING THESE SALARIES ARE GOVERNED BY THE COMPENSATION AND EVALUATION SUBCOMMITTEE OF THE BOARD. THE POLICY COVERS THE FOLLOWING POSITIONS: PRESIDENT AND CEO, CHIEF FINANCIAL OFFICER, CHIEF MEDICAL OFFICER, CHIEF NURSING OFFICER AND CHIEF INNOVATION OFFICER. ANNUALLY (LAST DONE 6/21/10) EXECUTIVE SALARY DATA IS EVALUATED USING TWO MAIN SOURCES: HAY GROUP ANNUAL EXECUTIVE COMPENSATION SURVEY AND MSA/CLARK CONSULTING - HEALTHCARE LEADERSHIP COMPENSATION SURVEY. TOTAL COMPENSATION FOR EACH SENIOR LEADER (SALARY, BENEFITS AND INCENTIVE) IS TARGETED TO THE 65TH PERCENTILE OF COMPENSATION FOR COMPARABLE POSITIONS. ALSO CONSIDERED ARE CURRENT MARKET CONDITIONS, INDEPENDENT CONSULTANT INPUT AND MARKET COMPETITIVENESS. AN EXTERNAL REVIEW BY AN EXECUTIVE COMPENSATION FIRM IS ALSO DONE EVERY THREE YEARS (LAST DONE IN 2008). FORM 990, PART VI, SECTION C, LINE 19 HOLY FAMILY MEMORIAL'S ARTICLES OF INCORPORATION ARE PUBLICLY AVAILABLE FROM THE WI DEPARTMENT OF FINANCIAL INSTITUTIONS. THE CONFLICT OF INTEREST POLICY IS AVAILABLE UPON REQUEST. HOLY FAMILY MEMORIAL'S FINANCIAL STATEMENTS ARE AVAILABLE ON THE DACBOND.COM WEBSITE AND HOLY FAMILY MEMORIAL SUBMITS FINANCIAL INFORMATION TO THE STATE OF WI ANNUALLY. OUR FORM 990 IS AVAILABLE UPON REQUEST AND CAN BE SEEN ON THE GUIDESTAR WEBSITE. FORM 990, PART VII, SECTION A, PART 1A LINES 2, 3, 5, 11, 14, 16, 22: HOLY FAMILY MEMORIAL'S BOARD OF DIRECTORS INCLUDES SEVEN EMPLOYED PHYSICIANS. THE COMPENSATION REPORTED FOR THESE DIRECTORS IS FOR THEIR SERVICES AS A PHYSICIAN. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED LOSSES ON INVESTMENTS: -1,973,529. CHANGE IN RESTRICTED ASSETS 35,251. TOTAL TO FORM 990, PART XI, LINE 5: -1,938,278. FORM 990, PART XII, LINE 2C: THE ORGANIZATION HAS NOT CHANGED ITS OVERSIGHT PROCESS OR SELECTION PROCESS DURING THE TAX PROCESS. NORTH END HOME MED SCS LLC 3310 CALUMET AVENUE MANITOWOC WI 54220 391868808 MEDICAL EQUIPMENT WI 197170 2073543 HFM INC FRANCISCAN SISTERS OF CHRISTIAN CHARITY 1415 SOUTH RAPIDS ROAD MANITOWOC WI 54220 391530622 HEALTHCARE WI 501(C)(3) LINE 1 N/A 0 ST PAUL ELDER SERVICES INC 316 EAST 14TH STREET KAUKAUNA WI 54130 391029149 ELDER CARE WI 501(C)(3) LINE 5 N/A 0 GOOD SAMARITAN MEDICAL CENTER 800 FOREST AVENUE ZANESVILLE OH 43701 314379479 HOLDING CO. OH 501(C)(3) LINE 7 N/A 0 FRANCISCAN CARE SERVICES INC 430 N MONITOR ST WEST POINT NE 68788 470486026 HEALTHCARE NE 501(C)(3) LINE 7 N/A 0 HOLY FAMILY HEALTH SERVICES 3310 CALUMET AVENUE MANITOWOC WI 54220 391572253 PHARMACY WI HOLY FAMILY MEMORIAL INC C 830 1344357 1.00000 1 0 0 1 0 0 0 0 1 0 0 0 0 0 1 1 0 0 HOLY FAMILY HEALTH SERVICES - INTEREST ON LOAN A 32496 ACTUAL EXPENSE HOLY FAMILY HEALTH SERVICES - LOAN TO HOLY FAMILY HEALTH SERVICES D 500000 LOAN BALANCE HOLY FAMILY HEALTH SERVICES - REIMBURSEMENT OF SALARYBENEFITSUPPLIESRENT O 1579548 ACTUAL EXPENSE FRANCISCAN SISTERS OF CHRISTIAN CHARITY - BUILDING RENT A 51000 ACTUAL EXPENSE FRANCISCAN SISTERS OF CHRISTIAN CHARITY - AUDIT FEES O 85009 ACTUAL EXPENSE FRANCISCAN SISTERS OF CHRISTIAN CHARITY - ADMINISTRATIVE SERVICES O 692000 ACTUAL EXPENSE FRANCISCAN SISTERS OF CHRISTIAN CHARITY-LIABBUILDINGWORKERS COMP INSURANC O 1262652 ACTUAL EXPENSE FRANCISCAN SISTERS OF CHRISTIAN CHARITY - HEALTH INSURANCE PREMIUMS O 9065000 ACTUAL EXPENSE