2012-05-11T12:26:22-05:00 2011-09-30 WIPFLI LLP PO BOX 12237 GREEN BAY WI 543072237 990 2010-10-01 390806324 DOOR COUNTY MEMORIAL HOSPITAL DOOR 9207435566 323 SOUTH 18TH AVENUE STURGEON BAY WI 54235 ROBERT SCIESZINSKI 9207435566 2012-05-11 1 TERRI REXRODE CPA MST 9206620016 2012-05-11 2010 2016-02-24 21:20:13Z MINISTRY DOOR COUNTY MEDICAL CENTER ROBERT SCIESZINSKI 323 S 18TH AVE STURGEON BAY WI 54235 68554728 0 X WWW.MINISTRYHEALTH.ORG/DCMH/HOME.NWS X 1944 WI DOOR COUNTY MEMORIAL HOSPITAL, INC. IS A FULLY ACCREDITED, ACUTE-CARE HOSPITAL AND OUTPATIENT MEDICAL CENTER. THE HOSPITAL OFFERS A FULL RANGE OF SERVICES AND SPECIALTIES, INCLUDING HOME HEALTH, A SKILLED NURSING FACILITY FOR LONG-TERM CARE AND REHABILITATION SERVICES, A REHAB SERVICES DEPARTMENT AND NORTH SHORE MEDICAL CLINIC. 16 13 697 135 0 0 164367 241883 64035420 67866896 -151082 101841 138803 151460 64187508 68362080 22375 12748 0 0 38638502 40238125 0 0 0 21695788 23070832 60356665 63321705 3830843 5040375 74283847 79492952 22828722 23290341 51455125 56202611 OUR MISSION AS A CATHOLIC HEALTH CARE SYSTEM IS TO FURTHER THE HEALING MINISTRY OF JESUS BY CONTINUALLY IMPROVING THE HEALTH AND WELL BEING OF ALL PEOPLE, ESPECIALLY THE POOR, IN THE COMMUNITIES WE SERVE. 0 0 50326495 12748 67491402 DOOR COUNTY MEMORIAL HOSPITAL PROVIDES THE FOLLOWING HEALTH CARE PROGRAMS: HOSPITAL INPATIENT WITH DAYS TOTALING 4,728, OUTPATIENT SERVICES THAT SERVED 79,536 VISITS, 30 BED EXTENDED CARE FACILITY, CLINIC THAT SERVED 59,248 VISITS, AND A REHABILITATION AGENCY THAT HAD 39,613 VISITS. 50326495 1 1 0 1 0 0 0 0 0 0 1 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 1 1 1 1 1 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 83 0 1 697 0 0 0 0 0 0 0 0 0 0 0 X 16 13 0 0 0 0 1 1 1 1 1 0 0 0 1 1 1 1 1 1 1 0 WI X ROBERT SCIENSZINSKI 9207435566 323 SOUTH 18TH PLACE STURGEON BAY WI 542351495 CHARLES BRANN 1.00 X X 0 0 0 GREGORY CASPERSON 1.00 X 0 0 0 BARTH GUILETTE 1.00 X 0 0 0 TOM HERLACHE 1.00 X 0 0 0 DR JAMES LEWIS 1.00 X 0 24102 964 JOSEPH MCMAHON 1.00 X 0 0 0 PATRICK O'HERN 1.00 X 0 0 0 ERIC PAULSEN 1.00 X 0 0 0 SALLY PFEIFER 1.00 X 0 0 0 JEFF RABAS 1.00 X 0 0 0 DR GEORGE ROENNING 1.00 X 0 198620 35777 GRACE ROSSMAN 1.00 X 0 0 0 DR DORENE DEMPSTER 1.00 X 0 319154 38385 DAVID WARD 1.00 X 0 0 0 CATHY WIESE 1.00 X 0 0 0 GERALD WORRICK 40.00 X X 358343 0 51610 CORWIN DAHL 1.00 X 0 0 0 ROBERT SCIESZINSKI 40.00 X 245567 0 45291 JODY BOES 40.00 X 210204 0 40632 SANDRA MCKUEN 40.00 X 27944 0 0 STEVEN QUADE 40.00 X 128206 0 24661 MARY LOPAS 40.00 X 104823 0 33348 CHRISTA VANPAY 40.00 X 88770 0 35421 MARIBETH HETHERINTON 32.00 X 71009 0 2980 KELLI BOWLING 40.00 X 93896 0 26762 DANIEL TOMASZEWSKI 40.00 X 573501 0 36094 STEPHEN DAVIS 40.00 X 457103 0 43385 MICHAEL BRUNO 40.00 X 409185 0 40219 RICHARD HOGAN 40.00 X 359363 0 38385 MARTIN FINK 40.00 X 329174 0 41069 3457088 541876 534983 38 0 1 0 MARSHFIELD LABORATORIES 1000 N OAK AVE MARSHFIELD WI 54449 LABORATORY TEST 588576 NORTHERN X RAY CO INC 4TH S AVENUE MINNEAPOLIS MN 55404 RADIOLOGY EQUIP SERVICE CONTRACT 546179 INFINITY HEALTHCARE INC 111 E WISCONSIN AVE MILWAUKEE WI 54302 ER PHYSICIANS 495000 ARAMARK SERVICES 2300 WARRENVILLE ROAD DOWNERS GROVE IL 60515 MANAGEMENT OF DIETARY, HOUSEKEEPING AND 434997 HALL RENDER AND KILLIAN PO BOX 82064 INDIANAPOLIS IN 46282 LEGAL SERVICES 232565 13 241883 241883 NET PATIENT SERVICE R 624100 66691386 66691386 ONCOLOGY CLINIC REVENU 624100 585097 585097 CAFETERIA SALES 624100 228048 228048 WASHINGTON ISLAND SUB 624100 135000 135000 LIFELINE REVENUE 624100 111916 111916 115449 79919 35530 67866896 99234 99234 343932 192472 151460 151460 151460 2783 176 2607 2607 2607 68362080 67491402 0 628795 12748 12748 1591934 1591934 30229931 25800203 4429728 1458422 1227777 230645 4985482 3844967 1140515 1972356 1621057 351299 386336 386336 184167 184167 11850 11850 3884909 2423016 1461893 503609 6379 497230 8149655 7654067 495588 702529 168737 533792 1215367 1147100 68267 457014 272357 184657 653087 653087 3949405 3283885 665520 268566 288154 -19588 PROVISION FOR BAD DEBTS 1327741 1327741 RECRUITMENT 503264 434983 68281 HOSPITAL ASSESSMENT 384017 384017 DUES & SUBSCRIPTIONS 141052 43869 97183 COMMUNITY RELATIONS 131216 1937 129279 217048 114431 102617 63321705 50326495 12995210 0 22218 15197 7180719 7262371 8714090 9879313 1367938 1424809 913762 992006 1288649 1415034 73304707 34247305 38738717 39057402 2409008 2417245 13648746 17029575 74283847 79492952 7026271 5767538 15802451 17522803 22828722 23290341 X 51221755 55967056 233370 235555 51455125 56202611 74283847 79492952 X 5040375 -292889 X X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 5154 5154 0 EXPLANATION OF OTHER LOBBYING ACTIVITIES: PART II-B, LINE 1I: LOBBYING PORTION OF DUES PAID TO WHA - $2,117 LOBBYING PORTION OF DUES PAID TO RHWC - $3,037 831569 831569 44287597 15635434 28652163 668425 512377 156048 27304301 17946128 9358173 212815 153366 59449 39057402 THIRD PARTY SETTLEMENT 5445875 OTHER A/R 537821 FOUNDATION 230743 LSHS INVESTMENT 9220021 DUE FROM AFFILIATE 1595115 17029575 68362080 63321705 5040375 -48292 -244597 -292889 4747486 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: THE CORPORATION IS COMPRISED OF TAX-EXEMPT CORPORATIONS THAT HAVE BEEN RECOGNIZED AS SUCH PURSUANT TO SECTIONS 501C(3) AND 509 (A) (3) OF THE INTERNAL REVENUE CODE (THE CODE) WITH THE EXCEPTION OF TWO TAXABLE INSURANCE COMPANIES WHICH ARE A PART OF AFFINITY. THE CORPORATION IS, HOWEVER, SUBJECT TO FEDERAL AND STATE INCOME TAXES ON UNRELATED BUSINESS INCOME UNDER THE PROVISIONS OF SECTION 511 OF THE CODE. THE CORPORATION RECORDED ITS PROPORTIONAL SHARE OF INCOME TAXES RELATED TO THE AFFINITY INSURANCE COMPANIES OF $7,392 IN 2011 AND $5,982 IN 2010, INCLUDED IN NON-OPERATING GAINS (LOSSES)-NET IN THE ACCOMPANYING CONSOLIDATED STATEMENTS OF OPERATIONS. NO OTHER TAX PROVISION WAS RECORDED IN 2011 AND 2010. PART XI, LINE 8 - OTHER ADJUSTMENTS: NET TRANSFER FROM AFFILIATE -354. MINISTRY HOME CARE LOSS FUNDING -244,243. 1 1 1 X 1 X 1 1 0 1 1 2150384 2150384 0.03470 7126463 5848406 1278057 0.02060 9276847 5848406 3428441 0.05530 1594812 393013 1201799 0.01940 76573 76573 0.00120 308919 308919 0.00500 1980304 393013 1587291 0.02560 11257151 6241419 5015732 0.08090 3583 3583 0.00010 124 124 0.00000 11395 11395 0.00020 10883 10883 0.00020 176345 176345 0.00280 4518 4518 0.00010 147108 147108 0.00240 353956 353956 0.00580 1 753216 16703281 21595024 -4891743 X 1 1 1 1 DOOR COUNTY MEMORIAL HOSPITAL

323 S 18TH AVE STURGEON BAY WI 54235

X X X X DOOR COUNTY MEMORIAL HOSPITAL 1 4 NORTH SHORE MEDICAL CLINIC

323 S 18TH AVE STURGEON BAY WI 54235

OP PHYS CLINIC NORTH SHORE MEDICAL CLINIC

3711 HWY 42 FISH CREEK WI 54212

OP PHYS CLINIC NORTH SHORE MEDICAL CLINIC

815 JEFFERSON ST ALGOMA WI 54201

OP PHYS CLINIC NORTH SHORE MEDICAL CLINIC

910 MAIN RD WASHINGTON ISLAND WI 54201

OP PHYS CLINIC PART I, LINE 6A: AS PART OF MINISTRY HEALTH CARE, INC., THE ORGANIZATION FILES AN ANNUAL COMMUNITY BENEFIT REPORT ON ITS WEBPAGE. THE REPORT CAN BE VIEWED BY VISITING WWW.MINISTRYHEALTH.ORG/MINISTRYHEALTH/COMMUNITY.NWS. PART I, LINE 7: AMOUNTS CALCULATED IN PART I, LINE 7 ARE DETERMINED BOTH ON A COST ACCOUNTING SYSTEM AND A COST-TO-CHARGE RATIO. OTHER BENEFITS ARE DETERMINED BASED ON THE DIRECT AND INDIRECT COSTS (WHERE ALLOCATED) ASSOCIATED WITH A PROGRAM NET OF EARNED REVENUE. DETAIL FOR EACH PROGRAM/ACTIVITY IS MAINTAINED AND DETERMINED AT THE DEPARTMENT LEVEL. CHARITY CARE AND MEANS TESTED PROGRAMS ARE DETERMINED BASED ON A COST-TO-CHARGE RATIO CONSISTENT WITH WORKSHEET 2, RATIO OF PATIENT CARE COST TO CHARGE. PRIOR YEAR COST REPORT SETTLEMENTS ARE EXCLUDED FROM THE SHORTFALL CALCULATION IN ORDER TO GET A TRUE FISCAL YEAR SHORTFALL AMOUNT. PART I, L7 COL(F): IN THE CALCULATION OF PART I, LINE 7, COLUMN (F), THE TOTAL EXPENSES FROM PART IX, LINE 25 WERE REDUCED BY BAD DEBT EXPENSE OF $1,327,741. PART II: SOME OF THE THINGS INCLUDED IN THIS AREA ARE WORKING WITH COMMUNITY ORGANIZATIONS SUCH AS ROTARY, LEADERSHIP OF DOOR COUNTY, AND LOAVES AND FISHES. WORKFORCE DEVELOPMENT INCLUDES HEALTH CARE CAREER PRESENTATIONS AND SCHOOL/COMMUNITY PROGRAMS THAT ALLOW JOB SHADOWING AND MENTORING. SUPPORT A COMMUNITY GARDEN AND WORK WITH LOCAL EMERGENCY AGENCIES REGARDING DISASTER READINESS. PART III, LINE 4: THE CALCULATION ABOVE STARTED WITH THE ACTUAL PATIENT CHARGES WRITTEN OFF TO BAD DEBT AND CONTRACTUAL RESERVES MULTIPLIED BY RATIO OF PATIENT CARE COST TO CHARGE RATIO. THESE ACCOUNTS ARE CONSIDERED UNCOLLECTABLE. PART III, LINE 9B: DCMH HAS A DEBT COLLECTION POLICY WHICH SETS FORTH COLLECTION PRACTICES FOR PATIENTS WHO ARE KNOWN TO QUALIFY OR MAY QUALIFY FOR FINANCIAL ASSISTANCE UNDER THE CHARITY CARE PROGRAM. SUFFICIENT FINANCIAL COUNSELING SUPPORT IS MADE AVAILABLE TO PATIENTS SO THEY CAN EASILY ACCESS PATIENT FINANCIAL SERVICE REPRESENTATIVES AND HAVE THEIR QUESTIONS ANSWERED, AND GAIN AN UNDERSTANDING OF THE REASONS WHY THEY OWE A BALANCE. ACCOUNTS ARE DESIGNATED AS CHARITY CARE IN THE BUSINESS OFFICES SO NO ADDITIONAL TIME IS SPENT ON COLLECTION EFFORTS. PART VI, LINE 2: THE ORGANIZATION PERFORMS COMMUNITY NEEDS ASSESSMENTS AS NEEDED. PLANNING WORKGROUPS CONSISTING OF COMMUNITY PARTNERS ARE FORMED TO DEFINE THE COMMUNITY AND ITS NEEDS THROUGH REVIEW OF HEALTH PEOPLE INITIATIVES, CENSUS DOCUMENTS, AND LOCAL GOVERNMENT HEALTH AND WELFARE AGENCIES. CONSIDERING OTHER COMMUNITY RESOURCES/ASSETS, DATA COLLECTION METHODS ARE USED TO IDENTIFY PARTICULAR PROBLEMS OR SUBGROUPS AND AREAS KNOWN TO HAVE HIGH POVERTY RATES AND TO BE UNDERSERVED. THE DATA IS ANALYZED AND PRIORITIES ARE SET BASED ON TRENDING INFORMATION WHICH MAY TARGET A SPECIFIC NEED. WHEN A NEED IS IDENTIFIED, THE HOSPITAL DEVELOPS A PLAN TO IMPLEMENT A PROGRAM EITHER THROUGH COMMUNITY COLLABORATION OR INDIVIDUALLY. OUTCOMES FROM THE PROGRAMS ARE MEASURED AND CONSIDERED IN SUBSEQUENT COMMUNITY NEEDS ASSESSMENTS. COMMUNITY BENEFIT PLANS ARE PRESENTED TO SENIOR LEADERSHIP AND BOARD MEMBERS TO ENSURE THE FINDINGS ARE INCORPORATED INTO THE ORGANIZATION'S STRATEGY AND POLICY DEVELOPMENT. FOR EXAMPLE, SENIOR LEADERS ARE REQUIRED TO PROVIDE DIRECT SERVICE TO THE POOR HOURS AS PART OF THEIR PERFORMANCE GOALS. PART VI, LINE 3: THE ORGANIZATION GOES TO GREAT LENGTHS IN ORDER TO INFORM AND EDUCATE PATIENTS/PERSONS WHO MAY BE BILLED FOR PATIENT CARE ABOUT THEIR ELIGIBILITY FOR ASSISTANCE UNDER FEDERAL, STATE OR LOCAL GOVERNMENT PROGRAMS AND UNDER THE ORGANIZATION'S CHARITY CARE POLICY. THE CHARITY CARE POLICY AND APPLICATION IS POSTED ON THE ORGANIZATION'S WEBSITE. ADMISSIONS AND OTHER KEY AREAS CONTAIN SUMMARY INFORMATION OF THE CHARITY CARE POLICY. AS PART OF THE INTAKE/DISCHARGE PROCESS, PATIENTS ARE PROVIDED WITH A COPY OF THE POLICY AND OTHER INFORMATION FOR FINANCIAL ASSISTANCE. IF DURING THE COURSE OF THE PATIENT REGISTRATION PROCESS, TREATMENT, OR UPON DISCHARGE IT BECOMES EVIDENT THAT A PATIENT MAY NEED FINANCIAL ASSISTANCE, THE PATIENT SHALL BE REFERRED TO THE ORGANIZATION'S COMMUNITY CARE PROGRAM. PATIENTS MAY BE IDENTIFIED AS NEEDED FINANCIAL ASSISTANCE AT ANY TIME DURING THE COURSE OF AN ENCOUNTER. A REFERRAL FOR CONSIDERATION OF COMMUNITY CARE FINANCIAL ASSISTANCE CAN BE INITIATED BY ANY MEMBER OF THE HOSPITAL'S WORKFORCE, INCLUDING MEDICAL STAFF MEMBERS, WHO BECOME AWARE OF THE PATIENT'S POTENTIAL NEED FOR COMMUNITY CARE FINANCIAL ASSISTANCE. THE CHARITY CARE POLICY WAS ALSO TRANSLATED INTO DIALECTS PREVALENT IN THE COMMUNITY IN ORDER TO REACH OUT TO THOSE THAT MAY SPEAK ANOTHER LANGUAGE. PATIENT REGISTRATION STAFF AND FINANCIAL COUNSELORS ARE PROVIDED WITH SCRIPTS TO FOLLOW WHEN INTERACTING WITH PATIENTS. AS PART OF THE CHARITY CARE PROCESS, PATIENTS MUST REGISTER WITH THE COUNTY PUBLIC ASSISTANCE TO SEE IF THEY MAY QUALIFY UNDER ANY OTHER FEDERAL OR STATE PROGRAMS. PART VI, LINE 4: WHILE THERE IS GROWING AGREEMENT IN THE UNITED STATES ABOUT WHAT CONSTITUTES A NON-PROFIT HOSPITAL'S "COMMUNITY BENEFIT", THIS IS A WORK IN PROGRESS. DCMH PROVIDED SIGNIFICANT CHARITY CARE AND OTHER COMMUNITY BENEFITS AS DEFINED BY THE IRS. BUT IN ADDITION, WE BELIEVE THAT WE PROVIDE A CRITICALLY IMPORTANT COMMUNITY BENEFIT, WHICH IS NOT QUANTIFIED. OUR HOSPITAL, LIKE MOST RURAL HOSPITALS, WAS CREATED AND IS MAINTAINED IN ORDER TO PROVIDE CARE LOCALLY - CARE THAT WITHOUT OUR HOSPITAL, WOULD NOT BE AVAILABLE LOCALLY. PART VI, LINE 6: THE LOCAL BOARD FOR DOOR COUNTY MEMORIAL HOSPITAL IS MADE UP OF COMMUNITY MEMBERS THAT LIVE IN OUR PRIMARY SERVICE AREA. DOOR COUNTY MEMORIAL HOSPITAL PARTNERS WITH THE LOCAL YMCA ON VARIOS EVENTS PROMOTING HEALTH AND WELL BEING IN THE COMMUNITY. DOOR COUNTY MEMORIAL HOSPITAL EXTENDS MEDICAL PRIVILEGES TO ALL QUALIFIED PHYSICIANS IN THE COMMUNITY. DOOR COUNTY MEMORIAL HOSPITAL PARTICIPATES IN MEDICARE, MEDICAID, AND OTHER GOVERNMENT SPONSORED PROGRAMS. PART VI, LINE 7: THE ORGANIZATION IS PART OF AN AFFILIATED HEALTH CARE SYSTEM CALLED MINISTRY HEALTH CARE, INC. THE MISSION OF MINISTRY AS A CATHOLIC HEALTH CARE SYSTEM IS TO FURTHER THE HEALING MINISTRY OF JESUS BY CONTINUALLY IMPROVING THE HEALTH AND WELL BEING OF ALL PEOPLE, ESPECIALLY THE POOR, IN THE COMMUNITIES SERVED. MINISTRY SUPPORTS SUCH NON-HOSPITAL FACILITIES AS THE AGAPE COMMUNITY CENTER. AS A COMMUNITY CENTER, IT HAS THE UNIQUE ADVANTAGE OF WELCOMING YOUTH, ADULTS, FAMILIES AND SENIORS INTO THE FACILITY THROUGH A BROAD RANGE OF EDUCATIONAL, SOCIAL, RECREATIONAL, CULTURAL, HEALTH AND LIFE-LONG LEARNING OPPORTUNITIES IN AN IMPOVERISHED PORTION OF MILWAUKEE. OUR CATHOLIC IDENTITY EXPECTS LEADERS TO INITIATE AND SUPPORT EFFORTS TO REACH OUT TO THE POOR AND VULNERABLE PEOPLE, ESPECIALLY WHERE NO ONE ELSE WANTS TO GO. HEALTH CARE CAN BECOME VERY BUREAUCRATIC AND BURDENED WITH OVERSIGHT OF FINANCES, REGULATORY REQUIREMENTS AND STRATEGIC PLANNING. OUR FOCUS ON THESE ISSUES MAY CAUSE US TO LOSE TOUCH WITH THOSE FOR WHOM WE HAVE A PRIMARY RESPONSIBILITY, THOSE WHO ARE POOR AND VULNERABLE. TITHING OF TIME ALLOWS US TO LOOK INTO THE FACE OF THE POOR, HEAR THE VOICE OF THE POOR, AND HELP US BETTER UNDERSTAND THE DAILY CHALLENGES AND BARRIERS THEY FACE. AS AN AFFILIATED HEALTH SYSTEM, ALL LEADERS WITH DIRECT REPORTS ARE REQUIRED TO PROVIDE SERVICE TO THE POOR. THIS ALSO INCLUDES PHYSICIAN LEADERS AND HOURLY SUPERVISORY STAFF. THE ORGANIZATION ALSO PARTICIPATES IN THE MINISTRY HEALTH CARE FUND WHICH PROVIDES MONIES FOR SPECIAL PROJECTS WITHIN THE COMMUNITIES WE SERVE. ALL ORGANIZATIONS SPONSORED OR CO-SPONSORED BY MINISTRY HEALTH CARE, INC. SET ASIDE MONIES EACH YEAR TO ASSIST WITH THE NEEDS OF THE COMMUNITY AND THE POOR. AS THE MINISTRY HEALTH CARE FUND, THESE DOLLARS ARE FUNNELED BACK INTO OUR COMMUNITIES FOR A VARIETY OF PROGRAMS AND SERVICES THROUGH A COMMUNITY ASSETS AND NEEDS ASSESSMENT PROCESS. REPORTS FILED WITH STATES PART VI, LINE 7 WI 1 COMMUNITY CLINIC 12748 FREE COMMUNITY LAB SERVICES 1 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: WE PROVIDED ASSISTANCE TO THE COMMUNITY CLINIC BY PROVIDING FREE LAB SERVICES THAT AMOUNTED TO 12,748 FOR THE YEAR. THE OTHER TYPE OF ASSISTANCE WE PROVIDE IS COMMUNITY CARE OR CHARITY CARE FOR PATIENTS WHO ARE ELIGIBLE. DOCUMENTATION IS KEPT IN THE PATIENT RECORDS AND PATIENT FINANCIAL SERVICES OFFICE. X X X X 0 0 0 0 0 0 0 0 0 DR GEORGE ROENNING 0 196300 0 0 0 2320 0 11871 0 23906 0 234397 0 0 DR DORENE DEMPSTER 0 318880 0 0 0 274 0 16500 0 21885 0 357539 0 0 GERALD WORRICK 234259 0 52129 0 71955 0 30578 0 21032 0 409953 0 0 0 ROBERT SCIESZINSKI 147562 0 35000 0 63005 0 0 22347 0 22944 245567 45291 0 0 JODY BOES 156233 0 33062 0 20909 0 0 19159 0 21473 210204 40632 0 0 STEVEN QUADE 94154 0 21251 0 12801 0 0 24661 0 0 128206 24661 0 0 DANIEL TOMASZEWSKI 573501 0 0 0 0 0 12409 0 23685 0 609595 0 0 0 STEPHEN DAVIS 456683 0 0 0 420 0 14700 0 28685 0 500488 0 0 0 MICHAEL BRUNO 334108 0 74803 0 274 0 14700 0 25519 0 449404 0 0 0 RICHARD HOGAN 299307 0 59271 0 785 0 14700 0 23685 0 397748 0 0 0 MARTIN FINK 249975 0 78779 0 420 0 14700 0 26369 0 370243 0 0 0 WISCONSIN HEALTH AND EDUCATIONAL FACILITIES AUTHORITY 391337855 391337855 2009-10-21 11000000 CONSTRUCTION LOAN 0 0 0 10982841 17159 10982841 2011 0 0 1 1 0 0 0 0 1 0.00000 0.00000 0.00000 1 0 1 0 0 0 0 DR TOMASZEWSKI EMPLOYEE RETENTION LOAN X 125000 70833 0 1 1 DR TOMASZEWSKI EMPLOYEE EDUCATION LOAN X 163569 99752 0 1 1 170585 FORM 990, PART VI, SECTION A, LINE 6 MINISTRY HEALTH CARE, INC. IS THE CORPORATE MEMBER OF DOOR COUNTY MEMORIAL HOSPITAL, INC. FORM 990, PART VI, SECTION A, LINE 7A MINISTRY HEALTH CARE, INC. HAS THE POWER TO APPOINT AND REMOVE MEMBERS OF THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION A, LINE 7B MINISTRY HEALTH CARE, INC. HAS THE POWER TO INITIATE AND APPROVE ALL AMENDMENTS TO THE ARTICLES OF INCORPORATION AND BYLAWS. MINISTRY HEATH CARE, INC. CAN ALSO APPOINT AND REMOVE, WITH OR WITHOUT CAUSE, THE DIRECTORS, AUTHORIZE VACANCIES, AND DETERMINE THE NUMBER OF DIRECTORS. FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 WAS PROVIDED TO THE ORGANIZATION'S FINANCE COMMITTEE AFTER IT WAS FILED. THE EXECUTIVE COMMITTEE HAS DESIGNATED THE DETAIL REVIEW OF THE FORM 990 TO MANAGEMENT, BUT HAS FINAL APPROVAL OF THE RETURN. FORM 990, PART VI, SECTION B, LINE 12C JERRY WORRICK, CEO, ROBERT SCIESZINSKI, CFO, AND RON MOHOREK WATCH FOR PROPOSALS THAT ARE BEING VOTED ON AT THE BOARD MEETINGS IN THE EVENT THAT THE PARTICULAR PROPOSAL MIGHT BE CONSIDERED A CONFLICT OF INTEREST FOR ANY OF THE VOTING MEMBERS. FORM 990, PART VI, SECTION B, LINE 15 MINISTRY HEALTH CARE AND DOOR COUNTY MEMORIAL HOSPITAL USE COMPARABILITY DATA TO DETERMINE COMPENSATION. THE MINISTRY BOARD OF DIRECTORS HAS A COMPENSATION COMMITTEE THAT IS ASSISTED BY AN INDEPENDENT OUTSIDE CONSULTING FIRM; SILLIVAN COTTER. SULLIVAN COTTER, IN PARTNERSHIP WITH THE COMPENSATION COMMITTEE OF THE BOARD OF DIRECTORS, REVIEWS MARKET DATA FOR COMPENSATION AND BENEFITS AND COMPARABILITY DATA ON EVERY MINISTRY HEALTH CARE EXECUTIVE. GERALD WORRICK, CEO, AND GREG HOLUB, VP CLINIC, USES AMGA DATA BY REGION AND SPECIALTY TO DETERMINE COMPENSATION FOR THE PHYSICIANS. THIS PROCESS IS DOCUMENTED WITH THE MINISTRY HEALTH CARE COMPENSATION COMMITTEE. FORM 990, PART VI, SECTION C, LINE 19 UPON REQUEST CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED LOSSES ON INVESTMENTS: -48,292. NET TRANSFER FROM AFFILIATE -354. MINISTRY HOME CARE LOSS FUNDING -244,243. TOTAL TO FORM 990, PART XI, LINE 5: -292,889. AUDITED FINANCIAL STATEMENTS FORM 990 PART XI LINE 2B-C AND FORM 990 PART IV LINE 12 DOOR COUNTY MEMORIAL HOSPITAL'S FINANCIAL STATEMENTS ARE AUDITED AS PART OF MINISTRY HEALTH CARE'S CONSOLIDATED STATEMENTS. THERE HAS BEEN NO CHANGE IN THE OVERSIGHT OR SELECTION PROCESS BETWEEN THE CURRENT AND PRIOR YEAR. HOURS WORKED FOR A RELATED ORGANIZATION FORM 990, PART VII DR. JAMES LEWIS WORKED 40 HOURS FOR A RELATED ORGANIZATION. DR. GEORGE ROENNING WORKED 40 HOURS FOR A RELATED ORGANIZATION. DR. DORENE DEMPSTER WORKED 40 HOURS FOR A RELATED ORGANIZATION. MINISTRY HEALTH CARE 11925 W LAKE PARK DRIVE MILWAUKEE WI 53224 391490371 SUPPORT RELATED HEALTHCARE ORGANIZATIONS WI 501(C)(3) 11B-II N/A 0 DOOR COUNTY MEMORIAL HOSPITAL FOUNDATION INC 1843 MICHIGAN STREET STURGEON BAY WI 54235 391649104 RAISE FUNDS IN SUPPORT OF DOOR COUNTY MEMORIAL HOSPITAL, INC. WI 501(C)(3) 11A-I N/A 0 0 0 0 1 0 0 0 0 0 0 0 1 1 1 1 1 0 0