ASCENSION NE WISCONSIN INC: Form 990, tax year 2009

View the entire original 990 at ProPublica ↗

Organization
ASCENSION NE WISCONSIN INC (EIN 39-0816818)
Tax period
2009-10-01 to 2010-09-30
Filed
2011-08-15
IRS object ID
201102279349302970
Schema version
2009v1.7
Source
Download XML · Original 990 at ProPublica

Every field in the e-filed return. Faint text is the IRS element name, for citing.

Return header ReturnHeader

FieldValueIRS element (for citing)
Timestamp2011-08-15T12:40:43-05:00Timestamp
Tax Period End Date2010-09-30TaxPeriodEndDate

Preparer Firm PreparerFirm

Preparer Firm Business Name PreparerFirmBusinessName

FieldValueIRS element (for citing)
Business Name Line1WIPFLI LLPBusinessNameLine1

Preparer Firm US Address PreparerFirmUSAddress

FieldValueIRS element (for citing)
Address Line1PO BOX 12237AddressLine1
CityGREEN BAYCity
StateWIState
ZIP Code543072237ZIPCode
FieldValueIRS element (for citing)
Return Type990ReturnType
Tax Period Begin Date2009-10-01TaxPeriodBeginDate

Filer Filer

FieldValueIRS element (for citing)
EIN390816818EIN

Name Name

FieldValueIRS element (for citing)
Business Name Line1St Elizabeth Hospital IncBusinessNameLine1
FieldValueIRS element (for citing)
Name ControlSTELNameControl
Phone9207382000Phone

US Address USAddress

FieldValueIRS element (for citing)
Address Line11506 S Oneida StreetAddressLine1
CityAppletonCity
StateWIState
ZIP Code549151397ZIPCode

Officer Officer

FieldValueIRS element (for citing)
NameJEFF BADGERName
TitleCFOTitle
Phone9207382000Phone
Date Signed2011-08-11DateSigned
Authorize Third Party1AuthorizeThirdParty

Preparer Preparer

FieldValueIRS element (for citing)
NameTERRI REXRODE CPAName
Phone9206620016Phone
Date Prepared2011-08-11DatePrepared
FieldValueIRS element (for citing)
Tax Year2009TaxYear
Build TS2016-02-24 21:20:13ZBuildTS

Form 990 IRS990

FieldValueIRS element (for citing)
Name Of Principal Officer PersonJEFF BADGERNameOfPrincipalOfficerPerson

Address Principal Officer US AddressPrincipalOfficerUS

FieldValueIRS element (for citing)
Address Line11506 S Oneida StreetAddressLine1
CityAppletonCity
StateWIState
ZIP Code549151397ZIPCode
FieldValueIRS element (for citing)
Gross Receipts157680784GrossReceipts
Group Return For Affiliates0GroupReturnForAffiliates
Group Exemption Number0928GroupExemptionNumber
Organization501cXOrganization501c
Web Sitewww.affinityhealth.orgWebSite
Type Of Organization CorporationXTypeOfOrganizationCorporation
Year Formation1899YearFormation
State Legal DomicileWIStateLegalDomicile
Activity Or Mission DescriptionFOR MORE THAN 100 YEARS, WE HAVE BEEN A LEADER IN PROVIDING QUALITY HEALTH CARE TO FOX VALLEY RESIDENTS, ESPECIALLY THE MEDICALLY UNDERSERVED. THE HOSPITAL MEETS A BROAD VARIETY OF PATIENT NEEDS THROUGH GENERAL CARE, SURGICAL SERVICES AND NUMEROUS MEDICAL SPECIALTIES INCLUDING CARDIOLOGY, ONCOLOGY, PEDIATRICS, EMERGENCY, INTENSIVE CARE AND OBSTETRICS. WITH 352 LICENSED PATIENT BEDS AND MORE THAN 420 SKILLED MEDICAL STAFF, WE OFFER COMPLETE, COMPASSIONATE, QUALITY HEALTH CARE FOR THE ENTIRE FAMILY.AVAILABLE SERVICES: ALLERGY; CANCER; CARDIAC REHABILITATION; CARDIOLOGY; CARDIOVASCULAR SURGERY; DIABETES, NUTRITION AND ENDOCRINOLOGY; EMERGENCY/TRAUMA; GENERAL SURGERY; GENETIC COUNSELING; GYNECOLOGY; HOSPITALIST; HYPERBARIC OXYGEN THERAPY; LABORATORY; LIFELINE HOME MONITORING; LIFESPAN; OBSTETRICS; ORTHOPAEDICS; PAIN MANAGEMENT; PALLIATIVE CARE (END OF LIFE CARE); PEDIATRICS; PSYCHIATRY/PSYCHOLOGY; PULMONOLOGY; SPIRITUAL SERVICES; UROLOGY; VASCULAR MEDICINE; AND WOUND CARE.ActivityOrMissionDescription
Nbr Voting Members Governing Body19NbrVotingMembersGoverningBody
Nbr Independent Voting Members11NbrIndependentVotingMembers
Total Nbr Employees1262TotalNbrEmployees
Total Nbr Volunteers517TotalNbrVolunteers
Total Gross UBI122259TotalGrossUBI
Net Unrelated Business Txbl Income-78595NetUnrelatedBusinessTxblIncome
Contributions Grants Prior Year535420ContributionsGrantsPriorYear
Contributions Grants Current Year335395ContributionsGrantsCurrentYear
Program Service Revenue Prior Year152155495ProgramServiceRevenuePriorYear
Program Service Revenue CY150372410ProgramServiceRevenueCY
Investment Income Prior Year4750880InvestmentIncomePriorYear
Investment Income Current Year4739260InvestmentIncomeCurrentYear
Other Revenue Prior Year648590OtherRevenuePriorYear
Other Revenue Current Year851529OtherRevenueCurrentYear
Total Revenue Prior Year158090385TotalRevenuePriorYear
Total Revenue Current Year156298594TotalRevenueCurrentYear
Grants And Similar Amnts Prior Year329054GrantsAndSimilarAmntsPriorYear
Grants And Similar Amnts CY643255GrantsAndSimilarAmntsCY
Benefits Paid To Members CY0BenefitsPaidToMembersCY
Salaries Etc Prior Year66213290SalariesEtcPriorYear
Salaries Etc Current Year69353862SalariesEtcCurrentYear
Total Prof Fundrsng Exp CY0TotalProfFundrsngExpCY
Total Fundrsng Exp Current Year0TotalFundrsngExpCurrentYear
Other Expense Prior Year74209242OtherExpensePriorYear
Other Expenses Current Year67540912OtherExpensesCurrentYear
Total Expenses Prior Year140751586TotalExpensesPriorYear
Total Expenses Current Year137538029TotalExpensesCurrentYear
Revenues Less Expenses Prior Year17338799RevenuesLessExpensesPriorYear
Revenues Less Expenses CY18760565RevenuesLessExpensesCY
Total Assets BOY235874261TotalAssetsBOY
Total Assets EOY268264475TotalAssetsEOY
Total Liabilities BOY67181684TotalLiabilitiesBOY
Total Liabilities EOY83211158TotalLiabilitiesEOY
Net Assets Or Fund Balances BOY168692577NetAssetsOrFundBalancesBOY
Net Assets Or Fund Balances EOY185053317NetAssetsOrFundBalancesEOY
Mission DescriptionST. ELIZABETH HOSPITAL HAS ADOPTED THE MISSION STATEMENT OF AFFINITY HEALTH SYSTEM. THE MISSION OF AFFINITY HEALTH SYSTEM IS TO LIVE OUT THE HEALING MINISTRY OF CHRIST BY PROVIDING SERVICES THAT PROMOTE THE HEALTH AND WELL-BEING OF THE COMMUNITIES WE SERVE, ESPECIALLY THE POOR.MissionDescription
Significant New Program Services0SignificantNewProgramServices
Significant Change0SignificantChange
Expense105844397Expense
Grants643255Grants
Revenue149386712Revenue
DescriptionTHE ENTITY BELIEVES THERE IS A STRONG DUTY TO MEET THE NEEDS OF THE POOR, INDIGENT, AND MEDICALLY UNDERSERVED IN THE COMMUNITIES. IN KEEPING WITH THE PHILOSOPHY OF EMPOWERMENT AND TRANSFORMATION OF ALL INDIVIDUALS, CARE HAS BEEN PROVIDED TO ALL PATIENTS WITHOUT REGARDS FOR ABILITY TO PAY.OTHER SERVICES INCLUDE:-FREE MAMMOGRAPHY SCREENING AND BREAST EXAMS FOR LOW INCOME WOMEN-FREE NEWSLETTERS FOCUSING ON WOMENS HEALTH ISSUES-FREE HEART DISEASE SCREENING FOR INDIVIDUALS-CHILDREN'S HEALTH AND SAFETY ISSUES-FREE SPEAKERS BUREAU-WOMENS RUN FOR HEALTH-TEEN PREGNANCY, PARENTING, AND NURTURING PROGRAMS-THROUGH PATHWAY TO PEACE, A COMPREHENSIVE SERVICE FOR PARENTS AND FAMILIES WHO HAVE EXPERIENCED A PREGNANCY LOSS OF AN INFANT-TELEVISED MASS FOR THE HOMEBOUND IN THE COMMUNITY-CHAPLAINCY AND SUPPORT SERVICES FOR THOSE WHO HAVE HAD A FAMILY MEMBER OR FRIEND DIE-FREE BLOOD PRESSURE SCREENING-FREE PROSTATE SCREENING-COMMUNITY BLOOD DRIVES-HEALTH INFORMATION SPOTS ON TELEVISION AND RADIODescription
Total Program Service Expense105844397TotalProgramServiceExpense
Described In501 C31DescribedIn501C3
Schedule B Required1ScheduleBRequired
Political Activities0PoliticalActivities
Lobbying Activities1LobbyingActivities
Donor Advised Funds0DonorAdvisedFunds
Conservation Easements0ConservationEasements
Collections Of Art0CollectionsOfArt
Credit Counseling0CreditCounseling
Term Or Permanent Endowments0TermOrPermanentEndowments
Balance Sheet Amounts Reported1BalanceSheetAmountsReported
Independent Audit Financial Stmt0IndependentAuditFinancialStmt
Consolidated Audit Financial Stmt1ConsolidatedAuditFinancialStmt
School0School
Foreign Office0ForeignOffice
Foreign Activities0ForeignActivities
More Than5000 K To Organizations0MoreThan5000KToOrganizations
More Than5000 K To Individuals0MoreThan5000KToIndividuals
Professional Fundraising0ProfessionalFundraising
Fundraising Activities0FundraisingActivities
Gaming0Gaming
Hospital1Hospital
Grants To Organizations1GrantsToOrganizations
Grants To Individuals0GrantsToIndividuals
Schedule J Required1ScheduleJRequired
Tax Exempt Bonds0TaxExemptBonds
Excess Benefit Transaction0ExcessBenefitTransaction
Prior Excess Benefit Transaction0PriorExcessBenefitTransaction
Loan To Officer Or DQP0LoanToOfficerOrDQP
Grant To Related Person0GrantToRelatedPerson
Bsnss Rltnshp With Organization0BsnssRltnshpWithOrganization
Bsnss Rltnshp Thru Family Member0BsnssRltnshpThruFamilyMember
Officer Entity With Bsnss Rltnshp0OfficerEntityWithBsnssRltnshp
Deductible Non Cash Contributions0DeductibleNonCashContributions
Deductible Contributions Of Art0DeductibleContributionsOfArt
Terminated0Terminated
Partial Liquidation0PartialLiquidation
Disregarded Entity0DisregardedEntity
Related Entity1RelatedEntity
Related Org Controlled Entity0RelatedOrgControlledEntity
Transfers To Exempt Non Chrtbl Org0TransfersToExemptNonChrtblOrg
Activities Conducted Partnership0ActivitiesConductedPartnership
Schedule O Required1ScheduleORequired
Number Forms Transmitted With109656NumberFormsTransmittedWith1096
Number W2 G Included0NumberW2GIncluded
Compliance With Backup Witholding1ComplianceWithBackupWitholding
Number Of Employees1262NumberOfEmployees
Employment Tax Returns Filed1EmploymentTaxReturnsFiled
Unrelated Business Income1UnrelatedBusinessIncome
Form990-T Filed1Form990-TFiled
Foreign Financial Account0ForeignFinancialAccount
Prohibited Tax Shelter Trans0ProhibitedTaxShelterTrans
Taxable Party Notification0TaxablePartyNotification
Non Deductible Contributions0NonDeductibleContributions
Quid Pro Quo Contributions0QuidProQuoContributions
Form8282 Property Disposed Of0Form8282PropertyDisposedOf
Funds To Pay Premiums0FundsToPayPremiums
Premiums Paid0PremiumsPaid
Nbr Voting Governing Body Members19NbrVotingGoverningBodyMembers
Number Independent Voting Members11NumberIndependentVotingMembers
Family Or Business Relationship0FamilyOrBusinessRelationship
Delegation Of Management Duties0DelegationOfManagementDuties
Changes To Organizing Docs0ChangesToOrganizingDocs
Material Diversion Or Misuse0MaterialDiversionOrMisuse
Members Or Stockholders1MembersOrStockholders
Election Of Board Members1ElectionOfBoardMembers
Decisions Subject To Approval1DecisionsSubjectToApproval
Minutes Of Governing Body1MinutesOfGoverningBody
Minutes Of Committees1MinutesOfCommittees
Officer Mailing Address0OfficerMailingAddress
Local Chapters0LocalChapters
Form990 Provided To Governing Body1Form990ProvidedToGoverningBody
Conflict Of Interest Policy1ConflictOfInterestPolicy
Annual Disclosure Covered Persons1AnnualDisclosureCoveredPersons
Regular Monitoring Enforcement1RegularMonitoringEnforcement
Whistleblower Policy1WhistleblowerPolicy
Document Retention Policy1DocumentRetentionPolicy
Compensation Process CEO1CompensationProcessCEO
Compensation Process Other1CompensationProcessOther
Investment In Joint Venture0InvestmentInJointVenture
States Where Copy Of Return Is FiledWIStatesWhereCopyOfReturnIsFiled
Upon RequestXUponRequest

The Books Are In Care Of TheBooksAreInCareOf

Name Business NameBusiness

FieldValueIRS element (for citing)
Business Name Line1JEFF BADGERBusinessNameLine1
FieldValueIRS element (for citing)
Telephone Number9207201300TelephoneNumber

Address US AddressUS

FieldValueIRS element (for citing)
Address Line11570 Midway PlaceAddressLine1
CityMenashaCity
StateWIState
ZIP Code54952ZIPCode

Form990 Part VII Section A Form990PartVIISectionA (28 entries)

TitleTitleAverage Hours Per WeekAverageHoursPerWeekIndividual Trustee Or DirectorIndividualTrusteeOrDirectorOfficerOfficerReportable Comp From OrganizationReportableCompFromOrganizationReportable Comp From Related OrgsReportableCompFromRelatedOrgsOther CompensationOtherCompensationKey EmployeeKeyEmployeeHighest Compensated EmployeeHighestCompensatedEmployee
Daniel E Neufelder
President CEO12.00XX23000950956956151
David Gitter
Board Treasurer0.30XX000
Catherine J Tierney
Board Secretary0.30XX000
Frank Chybowski MD
Board Member0.30X042668146174
Joseph McCormick MD
Board Member0.30X0110309040904
David Romond MD
Board Member0.30X035699573445
Barbara Strand MD
Board Member0.30X024672544862
Carla Altepeter
Board Member0.30X000
Mary Harp-Jirschele
Board Member0.30X000
Frederick Klein MD
Board Member0.30X000
Stephen C Morton
Board Member0.30X000
John Russo
board Member0.30X000
Thomas Schmidt
board Member0.30X000
Wayne Trembly
board Member0.30X000
Susan Vette
Board Member0.30X000
Richard Wells
Board Member0.30X000
STACEY SENSOR DO
BOARD MEMBER0.30X047471237600
MARK FAUSTICH MD
BOARD MEMBER0.30X034137835789
JAY MULLER MD
BOARD MEMBER0.30X035062038744
nicholas desien
board member0.30XX000
John Oliverio
board member0.30XX01737485222799
jeFF BADGER
CFO12.00X12566027839058683
Travis Andersen
President- STE12.00334109048174X
BRIAN HUMPHREY
SR ULTRASOUND TECH40.00168228029327X
RICHARD GOODMAN
MEDICAL PHYSICIST40.00164207019938X
Jennie Gaurkee
PHARMACY DIRECTOR40.00162410023086X
Debra Lastofka
PHARMACIST40.00143025044705X
ANNETTE SIEDSCHLAG
CLINICAL LEAD PHARMACIST40.00140674040997X
FieldValueIRS element (for citing)
Total Reportable Comp From Org1468322TotalReportableCompFromOrg
Total Reportable Comp Frm Rltd Orgs5825645TotalReportableCompFrmRltdOrgs
Total Other Compensation861378TotalOtherCompensation
Number Individuals GT100 K20NumberIndividualsGT100K
Formers Listed0FormersListed
Total Comp GT150 K1TotalCompGT150K
Compensation From Other Sources0CompensationFromOtherSources

Contractor Compensation ContractorCompensation (5 entries)

Address Line1AddressOfContractor/AddressUS/AddressLine1CityAddressOfContractor/AddressUS/CityStateAddressOfContractor/AddressUS/StateZIP CodeAddressOfContractor/AddressUS/ZIPCodeDescription Of ServicesDescriptionOfServicesCompensationCompensation
AFFINITY HEALTH SYSTEM INC
1570 MIDWAY PLACEMENASHAWI54952consulting/legal/misc/salaries/misc serv14001071
WHEATON FRANCISCAN SERVICES INC
26W171 ROOSEVELT RDWHEATONIL60187MANAGEMENT1360335
Network Health System Inc
1570 MIDWAY PLACEMENASHAWI54952PHYSICIAN SERVICES1130560
Keystone Imaging LLC
PO Box 330Cottage GroveWI53527Medical Services722100
Mercy Medical Center
2700 W Ninth AveOshkoshWI54904Salaries/sleep lab681485
FieldValueIRS element (for citing)
Number Of Contractors GT100 K27NumberOfContractorsGT100K
All Other Contributions335395AllOtherContributions
Total Contributions335395TotalContributions

Program Service Revenue ProgramServiceRevenue (3 entries)

DescriptionDescriptionBusiness CodeBusinessCodeTotal Revenue ColumnTotalRevenueColumnRelated Or Exempt Function IncomeRelatedOrExemptFunctionIncomeExclusionExclusionAmountUnrelated Business RevenueUnrelatedBusinessRevenue
NET PATIENT REVENUE an621990149386712149386712
CAFETERIA INCOME722210863439$863,439
OUPATIENT LAB REVENUE621500122259122259
FieldValueIRS element (for citing)
Total Program Service Revenue150372410TotalProgramServiceRevenue

Investment Income InvestmentIncome

FieldValueIRS element (for citing)
Total Revenue Column4715499TotalRevenueColumn
Exclusion$4,715,499ExclusionAmount

Gross Rents GrossRents

FieldValueIRS element (for citing)
Real2233719Real

Less Rental Expenses LessRentalExpenses

FieldValueIRS element (for citing)
Real1382190Real

Rental Income Or Loss RentalIncomeOrLoss

FieldValueIRS element (for citing)
Real851529Real

Net Rental Income Or Loss NetRentalIncomeOrLoss

FieldValueIRS element (for citing)
Total Revenue Column851529TotalRevenueColumn
Exclusion$851,529ExclusionAmount

Gross Amount Sales Assets GrossAmountSalesAssets

FieldValueIRS element (for citing)
Other23761Other

Gain Or Loss GainOrLoss

FieldValueIRS element (for citing)
Other23761Other

Net Gain Or Loss Investments NetGainOrLossInvestments

FieldValueIRS element (for citing)
Total Revenue Column23761TotalRevenueColumn
Exclusion$23,761ExclusionAmount

Total Revenue TotalRevenue

FieldValueIRS element (for citing)
Total Revenue Column156298594TotalRevenueColumn
Related Or Exempt Function Income149386712RelatedOrExemptFunctionIncome
Unrelated Business Revenue122259UnrelatedBusinessRevenue
Exclusion$6,454,228ExclusionAmount

Grants To Domestic Orgs GrantsToDomesticOrgs

FieldValueIRS element (for citing)
Total643255Total
Program Services643255ProgramServices

Comp Current Officers Directors CompCurrentOfficersDirectors

FieldValueIRS element (for citing)
Total773666Total
Management And General773666ManagementAndGeneral

Other Salaries And Wages OtherSalariesAndWages

FieldValueIRS element (for citing)
Total53455974Total
Program Services41802967ProgramServices
Management And General11653007ManagementAndGeneral

Pension Plan Contributions PensionPlanContributions

FieldValueIRS element (for citing)
Total2145774Total
Program Services1681940ProgramServices
Management And General463834ManagementAndGeneral

Other Employee Benefits OtherEmployeeBenefits

FieldValueIRS element (for citing)
Total9560285Total
Program Services7389246ProgramServices
Management And General2171039ManagementAndGeneral

Payroll Taxes PayrollTaxes

FieldValueIRS element (for citing)
Total3418163Total
Program Services2637360ProgramServices
Management And General780803ManagementAndGeneral

Fees For Services Other FeesForServicesOther

FieldValueIRS element (for citing)
Total12969118Total
Program Services7496885ProgramServices
Management And General5472233ManagementAndGeneral

Office Expenses OfficeExpenses

FieldValueIRS element (for citing)
Total29748028Total
Program Services28736170ProgramServices
Management And General1011858ManagementAndGeneral

Information Technology InformationTechnology

FieldValueIRS element (for citing)
Total11831Total
Program Services11831ProgramServices

Occupancy Occupancy

FieldValueIRS element (for citing)
Total3411862Total
Program Services2603700ProgramServices
Management And General808162ManagementAndGeneral

Travel Travel

FieldValueIRS element (for citing)
Total270085Total
Program Services44128ProgramServices
Management And General225957ManagementAndGeneral

Interest Interest

FieldValueIRS element (for citing)
Total1667234Total
Program Services1272319ProgramServices
Management And General394915ManagementAndGeneral

Depreciation Depletion DepreciationDepletion

FieldValueIRS element (for citing)
Total7792643Total
Program Services6124372ProgramServices
Management And General1668271ManagementAndGeneral

Insurance Insurance

FieldValueIRS element (for citing)
Total505133Total
Management And General505133ManagementAndGeneral

Other Expenses OtherExpenses (3 entries)

DescriptionDescriptionTotalTotalProgram ServicesProgramServicesManagement And GeneralManagementAndGeneral
OTHER EXPENSES57659941091885656806
BAD DEBT52503465250346
DUES AND LICENSES14863840690107948

Total Functional Expenses TotalFunctionalExpenses

FieldValueIRS element (for citing)
Total137538029Total
Program Services105844397ProgramServices
Management And General31693632ManagementAndGeneral
Fundraising0Fundraising

Cash Non Interest Bearing CashNonInterestBearing

FieldValueIRS element (for citing)
BOY5333BOY
EOY5282EOY

Savings And Temp Cash Investments SavingsAndTempCashInvestments

FieldValueIRS element (for citing)
BOY14961389BOY
EOY16584094EOY

Accounts Receivable AccountsReceivable

FieldValueIRS element (for citing)
BOY18457101BOY
EOY18088856EOY

Other Notes Loans Receivable Net OtherNotesLoansReceivableNet

FieldValueIRS element (for citing)
BOY136272342BOY
EOY151829447EOY

Inventories For Sale Or Use InventoriesForSaleOrUse

FieldValueIRS element (for citing)
BOY2908476BOY
EOY2693852EOY

Prepaid Expenses Deferred Charges PrepaidExpensesDeferredCharges

FieldValueIRS element (for citing)
BOY265179BOY
EOY489624EOY
FieldValueIRS element (for citing)
Land Buildings Equipment Basis206306434LandBuildingsEquipmentBasis
Land Bldg Equipment Accum Deprec131742203LandBldgEquipmentAccumDeprec

Land Buildings Equipment Basis Net LandBuildingsEquipmentBasisNet

FieldValueIRS element (for citing)
BOY58222568BOY
EOY74564231EOY

Investments Other Securities InvestmentsOtherSecurities

FieldValueIRS element (for citing)
BOY1205047BOY
EOY1233710EOY

Other Assets Total OtherAssetsTotal

FieldValueIRS element (for citing)
BOY3576826BOY
EOY2775379EOY

Total Assets TotalAssets

FieldValueIRS element (for citing)
BOY235874261BOY
EOY268264475EOY

Accounts Payable Accrued Expenses AccountsPayableAccruedExpenses

FieldValueIRS element (for citing)
BOY28470611BOY
EOY27073134EOY

Mort Notes Pybl Secured Invest Prop MortNotesPyblSecuredInvestProp

FieldValueIRS element (for citing)
BOY26736441BOY
EOY44201773EOY

Other Liabilities OtherLiabilities

FieldValueIRS element (for citing)
BOY11974632BOY
EOY11936251EOY

Total Liabilities TotalLiabilities

FieldValueIRS element (for citing)
BOY67181684BOY
EOY83211158EOY
FieldValueIRS element (for citing)
Follow SFAS117XFollowSFAS117

Unrestricted Net Assets UnrestrictedNetAssets

FieldValueIRS element (for citing)
BOY168644201BOY
EOY185004941EOY

Temporarily Restricted Net Assets TemporarilyRestrictedNetAssets

FieldValueIRS element (for citing)
BOY48376BOY
EOY48376EOY

Total Net Assets Fund Balances TotalNetAssetsFundBalances

FieldValueIRS element (for citing)
BOY168692577BOY
EOY185053317EOY

Total Liab Net Assets Fund Balances TotalLiabNetAssetsFundBalances

FieldValueIRS element (for citing)
BOY235874261BOY
EOY268264475EOY
FieldValueIRS element (for citing)
Method Of Accounting AccrualXMethodOfAccountingAccrual
Accountant Compile Or Review0AccountantCompileOrReview
FS Audited1FSAudited
Audit Committee1AuditCommittee
Financial Statement ConsolidatedXFinancialStatementConsolidated
Federal Grant Audit Required0FederalGrantAuditRequired

Schedule A IRS990ScheduleA

FieldValueIRS element (for citing)
Hospital170b1 AiiiXHospital170b1Aiii

Schedule B IRS990ScheduleB

Contributor Info ContributorInfo

FieldValueIRS element (for citing)
Contributor NumberRESTRICTEDContributorNumber

Contributor Name Business ContributorNameBusiness

FieldValueIRS element (for citing)
Business Name Line1RESTRICTEDBusinessNameLine1

Contributor Address US ContributorAddressUS

FieldValueIRS element (for citing)
Address Line1RESTRICTEDAddressLine1
Address Line2RESTRICTEDAddressLine2
CityRESTRICTEDCity
StateRESTRICTEDState
ZIP CodeRESTRICTEDZIPCode
FieldValueIRS element (for citing)
Aggregate ContributionsRESTRICTEDAggregateContributions

Schedule C IRS990ScheduleC

FieldValueIRS element (for citing)
Volunteers0Volunteers
Paid Staff Or Management0PaidStaffOrManagement
Media Advertisements0MediaAdvertisements
Mailings Members0MailingsMembers
Publications Or Broadcast0PublicationsOrBroadcast
Grants Other Organizations0GrantsOtherOrganizations
Direct Contact Legislators0DirectContactLegislators
Rallies Demonstrations0RalliesDemonstrations
Other Activities1OtherActivities
Other Activities$10,787OtherActivitiesAmount
Total Lobbying Expenditures IIB10787TotalLobbyingExpendituresIIB
Not Described In501c30NotDescribedIn501c3

Form990 Schedule C Part IV Form990ScheduleCPartIV

FieldValueIRS element (for citing)
IdentifierPart II-B, Line 1i:Identifier
Return ReferenceExplanation of Other Lobbying Activities:ReturnReference
ExplanationAHA, WHA & CHA MEMBERSHIP DUESExplanation

Schedule D IRS990ScheduleD

Land Land

FieldValueIRS element (for citing)
Other Cost Or Other Basis1379730OtherCostOrOtherBasis
Book Value1379730BookValue

Buildings Buildings

FieldValueIRS element (for citing)
Other Cost Or Other Basis89978654OtherCostOrOtherBasis
Depreciation47697643Depreciation
Book Value42281011BookValue

Leasehold Improvements LeaseholdImprovements

FieldValueIRS element (for citing)
Other Cost Or Other Basis2872885OtherCostOrOtherBasis
Depreciation2117973Depreciation
Book Value754912BookValue

Equipment Equipment

FieldValueIRS element (for citing)
Other Cost Or Other Basis97983344OtherCostOrOtherBasis
Depreciation81883495Depreciation
Book Value16099849BookValue

Other Land Buildings OtherLandBuildings

FieldValueIRS element (for citing)
Other Cost Or Other Basis14091821OtherCostOrOtherBasis
Depreciation43092Depreciation
Book Value14048729BookValue
FieldValueIRS element (for citing)
Total Of Book Value Land Buildings74564231TotalOfBookValueLandBuildings

Other Liabilities OtherLiabilities (4 entries)

DescriptionDescriptionAmountAmount
DUE TO 3RD PARTY - RESERVE$849,713
OTHER LIABILITIES$5,626
PENSION LIABILITY$10,867,722
457b PLAN$213,190
FieldValueIRS element (for citing)
Total Of Amounts11936251TotalOfAmounts
Total Revenue156298594TotalRevenue
Total Expenses137538029TotalExpenses
Excess Or Deficit For Year18760565ExcessOrDeficitForYear
Net Unrealized GL On Investments10865NetUnrealizedGLOnInvestments
Other-$2,410,690OtherAmount
Total Adjustments-2399825TotalAdjustments
Excess Or Deficit Per FS16360740ExcessOrDeficitPerFS
Tot Revenue Etc Audited Fincl Stmt157377731TotRevenueEtcAuditedFinclStmt
Revenue Not Rptd F9900RevenueNotRptdF990
Revenue Subtotal157377731RevenueSubtotal
Other Revenues Not Included-1079137OtherRevenuesNotIncluded
Revenue Not Rptd On Fin Stmt-1079137RevenueNotRptdOnFinStmt
Total Revenue Per Form990156298594TotalRevenuePerForm990
Tot Expenses Etc Audited Fincl Stmt138316483TotExpensesEtcAuditedFinclStmt
Other Expenses Included1369209OtherExpensesIncluded
Expenses Not Rptd F9901369209ExpensesNotRptdF990
Expenses Subtotal136947274ExpensesSubtotal
Other Expenses Not Included590755OtherExpensesNotIncluded
Expenses Not Rptd On Fin Stmt590755ExpensesNotRptdOnFinStmt
Total Expenses Per Form990137538029TotalExpensesPerForm990

Form990 Schedule D Part XIV Form990ScheduleDPartXIV (5 entries)

IdentifierIdentifierReturn ReferenceReturnReferenceExplanationExplanation
Part X:Description of Uncertain Tax Positions Under FIN 48:FASB ASC Subtopic 740-10, Income Taxes Overall, prescribes a recognition threshold and measurement attribute for the financial statement recognition and measurement of a tax position taken or expected to be taken in a tax return. The amount of unrecognized tax expense related to these criteria for the Corporation was zero as of September 30, 2010 and 2009.
Part XI, Line 8 - Other Adjustments:PENSION ADJUSTMENT: -2410690.
Part XII, Line 4b - Other Adjustments:RENTAL EXPENSE in revenue: -1369209. CONTRIBUTIONS IN NET ASSETS: 290072.
Part XIII, Line 2d - Other Adjustments:RENTAL EXPENSE IN REVENUE: 1369209.
Part XIII, Line 4b - Other Adjustments:GRANT TO SPONSOR ORGANIZATION: 590755.

Schedule H IRS990ScheduleH

FieldValueIRS element (for citing)
Charity Care Policy1CharityCarePolicy
Written Policy1WrittenPolicy
FPG Reference Free Care1FPGReferenceFreeCare
Pcent200XPcent200
FPG Reference Discounted Care1FPGReferenceDiscountedCare

Discounted Other DiscountedOther

FieldValueIRS element (for citing)
OtherXOther
Discounted Other Percentage662.000000000000DiscountedOtherPercentage
FieldValueIRS element (for citing)
Free Disc Care Medically Indigent1FreeDiscCareMedicallyIndigent
Amounts Budgeted For Charity Care1AmountsBudgetedForCharityCare
Expenses Exceeded Budget1ExpensesExceededBudget
Unable To Provide Care0UnableToProvideCare
Annual Community Benefit Report1AnnualCommunityBenefitReport
Report Publically Available1ReportPublicallyAvailable

Charity Care At Cost CharityCareAtCost

FieldValueIRS element (for citing)
Persons Served532PersonsServed
Total Community Benefit Expense999881TotalCommunityBenefitExpense
Net Community Benefit Expense999881NetCommunityBenefitExpense
Percent Of Total Expense0.00760PercentOfTotalExpense

Unreimbursed Medicaid UnreimbursedMedicaid

FieldValueIRS element (for citing)
Persons Served19299PersonsServed
Total Community Benefit Expense1913546TotalCommunityBenefitExpense
Net Community Benefit Expense1913546NetCommunityBenefitExpense
Percent Of Total Expense0.01450PercentOfTotalExpense

Unreimbursed Costs UnreimbursedCosts

FieldValueIRS element (for citing)
Total Community Benefit Expense87946TotalCommunityBenefitExpense
Net Community Benefit Expense87946NetCommunityBenefitExpense
Percent Of Total Expense0.00070PercentOfTotalExpense

Total Charity Care TotalCharityCare

FieldValueIRS element (for citing)
Persons Served19831PersonsServed
Total Community Benefit Expense3001373TotalCommunityBenefitExpense
Net Community Benefit Expense3001373NetCommunityBenefitExpense
Percent Of Total Expense0.02280PercentOfTotalExpense

Community Health Services CommunityHealthServices

FieldValueIRS element (for citing)
Number Of Activities Or Programs3NumberOfActivitiesOrPrograms
Persons Served2002PersonsServed
Total Community Benefit Expense11848TotalCommunityBenefitExpense
Net Community Benefit Expense11848NetCommunityBenefitExpense
Percent Of Total Expense0.00010PercentOfTotalExpense

Health Professions Education HealthProfessionsEducation

FieldValueIRS element (for citing)
Number Of Activities Or Programs4NumberOfActivitiesOrPrograms
Persons Served75PersonsServed
Total Community Benefit Expense1112481TotalCommunityBenefitExpense
Direct Offsetting Revenue209731DirectOffsettingRevenue
Net Community Benefit Expense902750NetCommunityBenefitExpense
Percent Of Total Expense0.00680PercentOfTotalExpense

Subsidized Health Services SubsidizedHealthServices

FieldValueIRS element (for citing)
Number Of Activities Or Programs3NumberOfActivitiesOrPrograms
Persons Served3584PersonsServed
Total Community Benefit Expense7980722TotalCommunityBenefitExpense
Direct Offsetting Revenue7695247DirectOffsettingRevenue
Net Community Benefit Expense285475NetCommunityBenefitExpense
Percent Of Total Expense0.00220PercentOfTotalExpense

Cash And In Kind Contributions CashAndInKindContributions

FieldValueIRS element (for citing)
Number Of Activities Or Programs3NumberOfActivitiesOrPrograms
Persons Served19038PersonsServed
Total Community Benefit Expense262406TotalCommunityBenefitExpense
Net Community Benefit Expense262406NetCommunityBenefitExpense
Percent Of Total Expense0.00200PercentOfTotalExpense

Total Other Benefits TotalOtherBenefits

FieldValueIRS element (for citing)
Number Of Activities Or Programs13NumberOfActivitiesOrPrograms
Persons Served24699PersonsServed
Total Community Benefit Expense9367457TotalCommunityBenefitExpense
Direct Offsetting Revenue7904978DirectOffsettingRevenue
Net Community Benefit Expense1462479NetCommunityBenefitExpense
Percent Of Total Expense0.01110PercentOfTotalExpense

Total Community Benefits TotalCommunityBenefits

FieldValueIRS element (for citing)
Number Of Activities Or Programs13NumberOfActivitiesOrPrograms
Persons Served44530PersonsServed
Total Community Benefit Expense12368830TotalCommunityBenefitExpense
Direct Offsetting Revenue7904978DirectOffsettingRevenue
Net Community Benefit Expense4463852NetCommunityBenefitExpense
Percent Of Total Expense0.03390PercentOfTotalExpense

Physical Improvements And Housing PhysicalImprovementsAndHousing

FieldValueIRS element (for citing)
Number Of Activities Or Programs1NumberOfActivitiesOrPrograms
Persons Served5PersonsServed
Total Community Building Expense1462TotalCommunityBuildingExpense
Net Community Building Expense1462NetCommunityBuildingExpense
Percent Of Total Expense0.00000PercentOfTotalExpense

Workforce Development WorkforceDevelopment

FieldValueIRS element (for citing)
Number Of Activities Or Programs1NumberOfActivitiesOrPrograms
Persons Served96PersonsServed
Total Community Building Expense494TotalCommunityBuildingExpense
Net Community Building Expense494NetCommunityBuildingExpense
Percent Of Total Expense0.00000PercentOfTotalExpense

Total Total

FieldValueIRS element (for citing)
Number Of Activities Or Programs2NumberOfActivitiesOrPrograms
Persons Served101PersonsServed
Total Community Building Expense1956TotalCommunityBuildingExpense
Net Community Building Expense1956NetCommunityBuildingExpense
FieldValueIRS element (for citing)
Bad Debt Expense Reported0BadDebtExpenseReported
Bad Debt Expense$1,924,612BadDebtExpenseAmount
Amount Reimbursed By Medicare57025656AmountReimbursedByMedicare
Cost Of Care Reimbursed By Medicare54768489CostOfCareReimbursedByMedicare
Medicare Surplus Or Shortfall2257167MedicareSurplusOrShortfall

Costing Methodology Used CostingMethodologyUsed

FieldValueIRS element (for citing)
Cost Accounting SystemXCostAccountingSystem
FieldValueIRS element (for citing)
Written Debt Collection Policy1WrittenDebtCollectionPolicy
Provision For Charity Care1ProvisionForCharityCare

Form990 Schedule H Part V Form990ScheduleHPartV

Name Name

FieldValueIRS element (for citing)
Business Name Line1ST ELIZABETH HOSPITAL INCBusinessNameLine1

Address Address

FieldValueIRS element (for citing)
Address Line11506 S ONEIDA STREETAddressLine1
CityAPPLETONCity
StateWIState
ZIP Code54915ZIPCode
FieldValueIRS element (for citing)
Licensed HospitalXLicensedHospital
General Medical And SurgicalXGeneralMedicalAndSurgical
Teaching HospitalXTeachingHospital
Er24 HoursXEr24Hours

Form990 Schedule H Part VI Form990ScheduleHPartVI

FieldValueIRS element (for citing)
Income Based CriteriaPart I, Line 3c: It is the policy of St. Elizabeth Hospital to provide medically necessary health care services to people in the communities it serves, regardless of their ability to pay. Affinity Care financial assistance is granted based upon the patient's inability to pay and to individuals who are uninsured, underinsured or medically indigent. Affinity Care works in collaboration with other financial (both public and private) assistance programs. This is to ensure holistic wellness of patients by facilitating knowledge of available services and programs for health while practicing good stewardship of funds. Key criteria utilized to determine eligibility for Affinity Care financial assistance includes family size, federal poverty income guidelines and available assets. The available asset test includes consideration of the amount of equity in a home, automobiles, and savings accounts which are considered part of total allowable income when assessing against the federal poverty income guidelines.IncomeBasedCriteria
Costing Method UsedPart 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 Charges. Prior year cost report settlements are excluded from the shortfall calculation in order to get a true fiscal year shortfall amount.CostingMethodUsed
Percent Of Total Expense ExplnPart I, Line 7f: Bad debt expense of $5,250,346 included on Form 990, Part IX, Line 25 was excluded from the denominator per instructions when calculating the percent of total expenses on Schedule H.PercentOfTotalExpenseExpln
Bad Debt FootnotePart III, Line 4: No footnote exists in St. Elizabeth Hospital's financials statements that describe bad debt expense. Bad debt expense is recorded in a consistent manner with the organization's collection policies. Bad debt expense includes accounts which are written off and estimates made on live accounts based on historical payment trends and account modeling.A number of patients are truly unable to pay their out-of-pocket liability, but do not complete the process required to apply for financial assistance under the hospital's Affinity Care policy. These patients would qualify for Affinity Care if they completed the charity application, so the bad debt expense associated with treating them should be treated as community benefit. The organization does have a presumptive eligibility program in place to help identify indigent patients and minimize the instances of when they become a bad debt. The administrative requirements to determine whether patients who do not cooperate with the financial assistance process would have qualified for charity can be burdensome, particularly for small balances.BadDebtFootnote
Shortfall As Community BenefitPart III, Line 8: The shortfall associated with Medicare should be considered a community benefit for several reasons. First, IRS Rev. Rul. 69-545, which established the community benefit standard for non-profit hospitals, states that if a hospital serves patients with government health benefits, including Medicare, then this is an indication that the hospital operates to promote the health of the community. This implies that treating Medicare patients is a community benefit. Second, for-profit specialty hospitals have been carving out certain high-margin services (i.e. cardiac, orthopedics, and oncology), leaving general acute care hospitals with lower-margin Medicare services. This indicates that Medicare losses can be a result of rendering these lower-margin services (which benefit the community) rather than inefficient operations. Lastly, the community which the organization serves has Medicare as the largest payer. The organization must accept these patients regardless of whether they make a surplus or deficit from providing such services. If the Medicare participation is premised on this fact, then providing Medicare services promotes access to healthcare services which is a community benefit. The demographic of the community is also an aging and underserved population who experience issues with access to healthcare services. Without tax-exempt hospitals providing Medicare services, CMS would bear the burden of directly providing services to the elderly.ShortfallAsCommunityBenefit
Debt Collection PolicyPart III, Line 9b: St. Elizabeth Hospital 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.DebtCollectionPolicy
General ExplanationPart VI, Line 8, list of states receiving community benefit report: WISt. Elizabeth Hospital files their community benefit results in the State of Wisconsin. Their data is incorporated into a report for all of Affinity Health System that ultimately is published in the area newspapers.GeneralExplanation
Needs AssessmentPart VI, Line 2: St. Elizabeth Hospital performs community health needs assessments as needed. Planning workgroups consisting of community partners are formed to define the community and its health needs through review of United Way Life Study results, Healthy 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 health needs assessments. The leadership at Affinity takes their commitment to the health and well-bring of the community it serves very seriously. In fact, it is listed as one of the key strategic goals of the health system. Senior leaders and management are also highly encouraged to provide direct service to the poor in their communities. St. Elizabeth and the leadership also subscribe to publications like the Advisory Board to compare national trends to local trends to ensure the hospital is resourcing areas to meet patient needs.NeedsAssessment
Patient Education AssistancePart VI, Line 3: St. Elizabeth Hospital 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 Affinity Care policy. The Affinity Care policy and application is posted on the organization's website. Admissions and other key areas contain summary information of the Affinity 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, care encounter, treatment, or upon discharge it becomes evident that a patient may need financial assistance, the patient shall be referred to the organization's Affinity Care program. Patients may be identified as needing financial assistance at any time during the course of an encounter. A referral for consideration of Affinity 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 Affinity Care financial assistance. The Affinity Care policy was also translated into dialects prevalent in the community in order to reach out to those that may speak another language (Spanish and Hmong). Patient Registration staff and Financial Counselors are provided with scripts to follow when interacting with patients. As part of the Affinity Care process, patients must register with the county public assistance to see if they may qualify under any other federal or state programs.PatientEducationAssistance
Community InformationPart 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. St. Elizabeth Hospital 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 community hospitals, was created and is maintained in order to provide care locally-care that without our hospital, may not be available locally.Certain specialized services available include: I/P Adult Behavioral Health services, I/P Adolescent Behavioral Health services and Neonatal Intensive Care services.CommunityInformation
Community Building ActivitiesPart VI, Line 5: Community-building activities include programs that, while not directly related to health care, provide opportunities to address the root causes of health problems, such as poverty, homelessness, and environmental problems. These activities support community assets by offering the expertise and resources of the organization. Costs for these activities include cash, in-kind donations, and expenditures for the development of a variety of community health programs and partnerships. Some examples include: "Rebuilding Together" in which managers from St. Elizabeth Hospital went out to help low-income elderly members of the community with remodeling projects to improve safety or condition of their homes. Another example is the Health Career Experience Day in which professionals from St. Elizabeth Hospital highlight a variety of healthcare careers and talk about their professions (i.e. Nursing, Surgery, Laboratory and Radiology).CommunityBuildingActivities
Other InformationPart VI, Line 6: St. Elizabeth Hospital's governing board consists primarily of persons who reside within the primary service area. They are not employees of the organization.The organization strives to further its exempt purposes by the following:St. Elizabeth Hospital participates in government-sponsored health programs (Medicare, Medicaid, CHAMPUS, General Relief, Specialized County Programs and Area Prisons )St. Elizabeth Hospital donates food to an area half-way house and their dietary department also subsidizes mobile meals programs for the elderly and low income individuals. St. Elizabeth Hospital Foundation donated funds to support area organizations that provide services to the following sectors of our population: low-income, homeless, physically and mentally challenged and chronically ill. St. Elizabeth Hospital works with the local Public Health Department to do Needs Assessment for Behavioral Health Services.St. Elizabeth Hospital provides community health improvement services through health education lectures, health fairs and support groups.St. Elizabeth Hospital subsidizes YMCA instructors to work with individuals who have rehabilitation needs. Also hold free follow-up clinics of infants born in the hospital NICU.Discounted care is provided to low income families up to 662% of Federal Poverty Guidelines.St. Elizabeth Hospital is a Disproportionate Share Hospital with a combined Medicaid and SSI utilization of over 23.58%.St. Elizabeth Hospital provides a subsidy to UW-Family Practice Physician Residency Program. Also subsidize a School of Medical Technology Program.St. Elizabeth Hospital serves as a sponsor site for clinical training of college students in various health care programs.St. Elizabeth Hospital helps to subsidize an area community clinic that serves the uninsured and low income members of the community. Support consists of cash donations for operations, nursing staff and lab and x-ray services.OtherInformation
Affiliated Health Care SystemPart VI, Line 7: St. Elizabeth Hospital, of Appleton, Wisconsin is part of an affiliated health care system called Affinity Health System. Affinity Health System also has two other hospitals, Mercy Medical Center, in Oshkosh, WI and Calumet Medical Center, in Chilton, WI. The latter hospital qualifies as a Critical Access Hospital. In addition to the hospitals, Affinity Health System also has 25 area clinics under the control of Affinity Medical Group. The mission of Affinity, as a Catholic health care system, is to live out the healing ministry of Christ by providing services that promote the health and well being of the communities we serve, especially the poor. Affinity Health System is sponsored equally by two Catholic health systems, Ministry Health Care, headquartered in Milwaukee, WI and Wheaton Franciscan Health Care, also headquartered in Milwaukee, WI. St. Elizabeth Hospital and Mercy Medical Center both subsidize area community medical clinics as well as community dental clinics. The 3 hospitals and the 25 clinics provide free or minimal cost health education, support and screening services for the populations they serve. St. Elizabeth Hospital and Mercy Medical Center both provide support for educational programs to educate future health care professionals. There is also an expectation that all people in management services at Affinity Health System will provide direct services to the poor. St. Elizabeth Hospital has a foundation which is not included within the operations of the organization. The foundation provides cash donations which help support the mission of the organization and the affiliated health care system. Examples of the donations are included in item #6 above.AffiliatedHealthCareSystem

Schedule I IRS990ScheduleI

FieldValueIRS element (for citing)
Records Maintained1RecordsMaintained

Recipient Table RecipientTable (2 entries)

Address Line1AddressUS/AddressLine1CityAddressUS/CityStateAddressUS/StateZIP CodeAddressUS/ZIPCodeEIN Of RecipientEINOfRecipientIRC SectionIRCSectionAmount Of Cash GrantAmountOfCashGrantPurpose Of GrantPurposeOfGrant
Wheaton Fransican Services Inc
26 W 171 Roosevelt RdWheatonIL601890667363262111501(c)(3)590755INITIATIVE FOR THE POOR
FOX CITIES COMMUNITY HEALTH CENTER INC
1800 APPLETON RDMENASHAWI54952202090446501(c)(3)52500Provide healthcare to the indigent and underserved
FieldValueIRS element (for citing)
Total Nbr Of501 C3 And Govt Grants2TotalNbrOf501C3AndGovtGrants
Total Nbr Of Other Organizations0TotalNbrOfOtherOrganizations

Form990 Schedule I Part IV Form990ScheduleIPartIV

FieldValueIRS element (for citing)
IdentifierProcedure for Monitoring Grants in the U.S.:Identifier
Return ReferencePart I, Line 2:ReturnReference
ExplanationSchedule I, Part I, Line 2: EACH YEAR ST. ELIZABETH HOSPITAL PROVIDES A GRANT BASED ON AN INTEGRATION AGREEMENT. THE INTEGRATION AGREEMENT SUBSTANTIATES THE AMOUNT AND THE RECIPIENT OF THE GRANT.Explanation

Schedule J IRS990ScheduleJ

FieldValueIRS element (for citing)
Travel For CompanionsXTravelForCompanions
Club Dues Or FeesXClubDuesOrFees
Written Policy Re T And E Expenses0WrittenPolicyReTAndEExpenses
Substantiation Required1SubstantiationRequired
Compensation CommitteeXCompensationCommittee
Independent ConsultantXIndependentConsultant
Written Employment ContractXWrittenEmploymentContract
Compensation SurveyXCompensationSurvey
Board Or Committee ApprovalXBoardOrCommitteeApproval
Severance Payment0SeverancePayment
Supplemental Nonqual Retire Plan1SupplementalNonqualRetirePlan
Equity Based Comp Arrangement0EquityBasedCompArrangement
Comp Based On Revenue Of Filing Org0CompBasedOnRevenueOfFilingOrg
Comp Based On Revenue Related Orgs0CompBasedOnRevenueRelatedOrgs
Comp Based Net Earnings Filing Org0CompBasedNetEarningsFilingOrg
Comp Based Net Earnings Relate Orgs0CompBasedNetEarningsRelateOrgs
Any Non Fixed Payments0AnyNonFixedPayments
Initial Contract Exception0InitialContractException

Form990 Schedule J Part II Form990ScheduleJPartII (16 entries)

Base Compensation Filing OrgBaseCompensationFilingOrgComp Based On Related OrgsCompBasedOnRelatedOrgsBonus Filing OrgBonusFilingOrgBonus Related OrgsBonusRelatedOrgsOther Compensation Filing OrgOtherCompensationFilingOrgOther Compensation Related OrgsOtherCompensationRelatedOrgsDeferred Comp Filing OrgDeferredCompFilingOrgDeferred Comp Related OrgsDeferredCompRelatedOrgsNontaxable Benefits Filing OrgNontaxableBenefitsFilingOrgNontaxable Benefits Related OrgsNontaxableBenefitsRelatedOrgsTotal Compensation Filing OrgTotalCompensationFilingOrgTotal Compensation Related OrgsTotalCompensationRelatedOrgsComp Report Prior990 Filing OrgCompReportPrior990FilingOrgComp Report Prior990 Related OrgsCompReportPrior990RelatedOrgs
Daniel E Neufelder
164836365182622051378122968657513720303953743829324747254825700
Frank Chybowski MD
04252750001406025758020416047285500
Joseph McCormick MD
0110203500010550187590221450114399400
David Romond MD
03569950000056169017276043044000
Barbara Strand MD
0245788000937022625022237029158700
STACEY SENSOR DO
0474503000209019676017924051231200
MARK FAUSTICH MD
0339519000185902869107098037716700
JAY MULLER MD
0350236000384018826019918038936400
John Oliverio
08977900477700036199501584820643170196028400
jeFF BADGER
900101994122942465186622613792121982702360531340914391131882200
Travis Andersen
2485740660640194710263490218250382283000
BRIAN HUMPHREY
167700000528022947063800197555000
RICHARD GOODMAN
1630740001133083270116110184145000
Jennie Gaurkee
16238800022085050145810185496000
Debra Lastofka
142538000487037993067120187730000
ANNETTE SIEDSCHLAG
13859900020750287910122060181671000

Form990 Schedule J Part III Form990ScheduleJPartIII (2 entries)

Return ReferenceReturnReferenceExplanationExplanation
Part I, Line 1bBUSINESS TRAVEL EXPENSES FOR SPOUSES OF EXECUTIVES AND GOLF CLUB MEMBERSHIP FOR EXECUTIVES ARE REIMBURSED AS PART OF THEIR EXECUTIVE FLEX CREDIT ACCOUNT. RECEIPTS ARE PROVIDED TO SR. ADMINISTRATIVE ASSISTANT IN HR WHO REVIEWS FOR ACCURACY, COMPLETES A REIMBURSEMENT FORM WITH SUBSTANTIATION TO PAYROLL FOR REIMBURSEMENT.
Part I, Line 4b:John Oliverio received a 2009 taxable payout of $346,993 related to a supplemental nonqualified retirement plan know as the Wheaton Franciscan Services Benefit Restoration Plan.

Schedule O IRS990ScheduleO

General Explanation GeneralExplanation (9 entries)

IdentifierIdentifierExplanationExplanationReturn ReferenceReturnReference
Form 990, Part VI, Section A, line 6WHEATON FRANSICAN SERVICES, INC IS A CORPORATE MEMBER AND AFFINITY HEALTH SYSTEM IS A MANAGING MEMBER.
Form 990, Part VI, Section A, line 7aWHEATON FRANCISCAN SERVICES, INC. HAS THE POWER TO APPROVE AND REMOVE DIRECTORS FROM ST. ELIZABETH HOSPITAL
Form 990, Part VI, Section A, line 7bAMENDMENTS OF THE ARTICLES OF INCORPORATION AND BYLAWS MUST BE APPROVED BY WHEATON FRANCISCAN SERVICES, INC.
Form 990, Part VI, Section B, line 11THE CONTROLLER AND CFO OF AFFINITY HEALTH SYSTEM PERFORM A DETAIL REVIEW OF THE 990. AFTER MANAGEMENT REVIEW, A COPY OF THE 990 IS PROVIDED TO THE BOARD OF DIRECTORS PRIOR TO FILING.
Form 990, Part VI, Section B, line 12cTHE BOARD OF DIRECTORS RECEIVES A CONFLICT OF INTEREST QUESTIONNAIRE EVERY YEAR.
Form 990, Part VI, Section B, line 15EACH YEAR THE ORGANIZATION ENGAGES AN INDEPENDENT COMPENSATION FIRM TO PROVIDE MARKET DATA FOR CEO, EXECUTIVES AND KEY EMPLOYEE POSTIONS. THIS STUDY IS SHARED WITH THE COMPENSATION COMMITTEE OF THE BOARD OF DIRECTORS FOR THEIR REVIEW AND RECOMMENDATIONS REGARDING ANY COMPENSATION CHANGES. THE COMPENSATION COMMITTEE IS COMPRISED OF INDEPENDENT MEMBERS. THE CEO REVIEWS EACH EXECUTIVE AND KEY EMPLOYEE'S ANNUAL PERFORMANCE APPRAISAL RATINGS IN MAKING HIS COMPENSATION RECOMMENDATIONS TO THE COMPENSATION COMMITTEE. THE COMPENSATION COMMITTEE HAS THE FINAL AUTHORITY TO APPROVE ANY AND ALL AMOUNTS OF COMPENSATION FOR MEMBERS OF THE EXECUTIVE TEAM. THE FINAL APPROVAL OF COMPENSATION AMOUNTS ARE DOCUMENTED.
Form 990, Part VI, Section C, line 19THE ORGANIZATION BELIEVES THE FINANCIAL STATEMENTS, GOVERNING DOCUMENTS, AND POLICES ARE THE PROPERTY OF THE ORGANIZATION AND ARE NOT AVAILABLE FOR PUBLIC INSPECTION.
FORM 990, PART VIIFrank Chybowski, MD worked an average of 40 hours per week for a related organization. Mark Faustich, MD worked an average of 40 hours per week for a related organization. Joseph McCormick, MD worked an average of 40 hours per week for a related organization. Jay Muller, MD worked an average of 40 hours per week for a related organization. David Romond, MD worked an average of 40 hours per week for a related organization. Stacey Sensor, DO worked an average of 40 hours per week for a related organization. Barbara Strand, MD worked an average of 40 hours per week for a related organization. Daniel Neufelder worked an average of 28 hours per week for related organizations. Jeff Badger worked an average of 28 hours per week for related organizations. Travis Anderson worked an average of 28 hours per week for related organizations. Nicholas Desien worked an average of 40 hours per week for a related organization. John Oliverio worked an average of 40 hours per week for a related organization.HOURS WORKED FOR RELATED ORGANIZATIONS
Form 990, Part XI, Line 2B-2CSt. Elizabeth Hospital, Inc. (Organization) does not receive separately audited financial statements. The Organization is audited and reported through consolidated financial statements. The audit committee is responsible for the auditor selection. The audit statements are reviewed by the Controller, CFO, and the audit committee. This process has not changed from the prior year.Process for oversight of audit and selection of an independent accountant

Schedule R IRS990ScheduleR

Form990 Schedule R Part II Form990ScheduleRPartII (6 entries)

Address Line1AddressUS/AddressLine1CityAddressUS/CityStateAddressUS/StateZIP CodeAddressUS/ZIPCodeEINEINPrimary ActivitiesPrimaryActivitiesLegal Domicile StateLegalDomicileStateExempt Code SectionExemptCodeSectionPublic Charity StatusPublicCharityStatusDirect Controlling Entity NADirectControllingEntityNA
AFFINITY HEALTH SYSTEM INC
1570 MIDWAY PLMENASHAWI54952391568866SUPPORT RELATED HEALTHCARE ORGRANIZATIONSIL501(C)(3)11A-IN/A
MERCY MEDICAL CENTER OF OSHKOSH INC
500 S OAKWOODOSHKOSHWI54904390806268HEALTH CARE SERVICESWI501(C)(3)3N/A
NETWORK HEALTH SYSTEM INC
1570 miDWAY PLMENASHAWI54952391127163CLINICAL HEALTHCARE SERVICESWI501(C)(3)3N/A
ST ELIZABETH HOSPITAL COMMUNITY FOUNDATION
1506 SOUTH ONEIDA STREETAPPLETONWI54915391256677RAISE FUNDSWI501(C)(3)11A-IN/A
MINISTRY HEALTH CARE INC
11925 W LAKE PARK DRIVEMILWAUKEEWI53224391490371sUPPORT RELATED HEALTHCARE ORGRANIZATIONSWI501(C)(3)11A-IN/A
WHEATON FRANCISCAN SERVICES INC
26 W171 ROOSEVELT ROADWHEATONIL60187363262111SUPPORT RELATED HEALTHCARE ORGRANIZATIONSIL501(C)(3)11A-IN/A
FieldValueIRS element (for citing)
Receipt Of Int Ann Rents Royalties0ReceiptOfIntAnnRentsRoyalties
Gift Grant Or Cap Contr To Other Org0GiftGrantOrCapContrToOtherOrg
Gift Grant Or Cap Contr Fr Other Org1GiftGrantOrCapContrFrOtherOrg
Loans Or Guarantees To Other Org1LoansOrGuaranteesToOtherOrg
Loans Or Guarantees From Other Org0LoansOrGuaranteesFromOtherOrg
Sale Of Assets To Other Org0SaleOfAssetsToOtherOrg
Purchase Of Assets From Other Org0PurchaseOfAssetsFromOtherOrg
Exchange Of Assets0ExchangeOfAssets
Rental Of Facilities To Other Orgs1RentalOfFacilitiesToOtherOrgs
Rental Of Facilities Fr Other Orgs1RentalOfFacilitiesFrOtherOrgs
Perform Of Services For Other Orgs0PerformOfServicesForOtherOrgs
Perform Of Services By Other Orgs1PerformOfServicesByOtherOrgs
Sharing Of Facilities1SharingOfFacilities
Sharing Of Paid Employees1SharingOfPaidEmployees
Reimbursement Paid To Other Org1ReimbursementPaidToOtherOrg
Reimbursement Paid By Other Org1ReimbursementPaidByOtherOrg
Other Transfer To Other Org0OtherTransferToOtherOrg
Other Transfer From Other Org0OtherTransferFromOtherOrg

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