2011-08-15T12:40:43-05:00 2010-09-30 WIPFLI LLP PO BOX 12237 GREEN BAY WI 543072237 990 2009-10-01 391568866 Affinity Health System Inc AFFI 9207201300 1570 Midway Pl Menasha WI 54952 JEFF BADGER 9207201300 2011-08-11 1 Terri Rexrode CPA MST 9206620016 2011-08-11 2009 2016-02-24 21:20:13Z JEFF BADGER 1570 Midway Pl Menasha WI 54952 54889853 0 X WWW.AFFINITYHEALTH.ORG X 1986 IL 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. 19 11 513 0 0 0 59934 70890 58170708 53151258 1040181 1661191 0 59270823 54883339 0 0 31132897 31121287 0 0 39455609 34622951 70588506 65744238 -11317683 -10860899 104352414 130707919 308841103 355293928 -204488689 -224586009 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 communites we serve, especially the poor. 0 0 11101282 53151258 The entity believes in meeting the healthcare needs of the poor, indigent, and underserved. Care is provided to the patients without regard for the ability to pay. The entity provides administrative support to three hospitals, and twenty-FIVE clinic locations. The entity also provides: Free newsletters Focusing on Women's Health issues; Children's Health and Safety Issues; Health Information Spots on Television and Radio; and Classes on a variety of health related topics including pregnancy and child rearing. 11101282 1 1 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 1 59 0 1 513 1 0 0 0 0 0 0 0 0 0 19 11 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 X JEFF BADGER 9207201300 1570 MIDWAY PLACE MENASHA WI 54952 X CARLA ALTEPETER 0.30 X 0 0 0 FRED KLEIN MD 0.30 X 0 0 0 JOHN RUSSO 0.30 X 0 0 0 MARY HARP-JIRSCHELE 0.30 X 0 0 0 RICHARD WELLS 0.30 X 0 0 0 STEPHEN MORTON 0.30 X 0 0 0 SUSAN VETTE 0.30 X 0 0 0 THOMAS SCHMIDT 0.30 X 0 0 0 WAYNE TREMBLY 0.30 X 0 0 0 BARBARA STRAND MD 0.30 X 0 246725 44862 DAVID ROMOND MD 0.30 X 0 356995 73445 FRANK CHYBOWSKI MD 0.30 X 0 426681 46174 JOSEPH MCcORMICK MD 0.30 X 0 1103090 40904 Stacy Sensor DO 0.30 X 0 474712 37600 CATHERINE TIERNEY 0.30 X X 0 0 0 DAVID GITTER 0.30 X X 0 0 0 MARK FAUSTICH MD 0.30 X 0 341378 35789 JAY MULLER MD 0.30 X 0 350620 38744 DAN NEUFELDER 0.30 X X 0 739579 56150 NICHOLAS DESIEN 0.30 X X 0 0 0 JOHN OLIVERIO 0.30 X X 0 0 0 JEFF BADGER 0.00 X 0 404050 58682 0 4443830 432350 0 0 1 0 Ministry Healthcare 11925 Lake Park Dr Suite 100 Milwaukee WI 53224 I.S. Services 2272241 VON BRISEN & ROPER 411 E WISCONSIN AVE MILWAUKEE WI 53202 LEGAL 1044341 STATE COLLECTION SERVICE 2509 s stoughton MADISON WI 53716 COLLECTION AGENCY 909759 MCMURRY INC 1010 E MISSOURI AVE PHOENIX AZ 85014 PUBLISHING 394935 KPMG 777 E Wisconsin Ave Suite 3100 MilWAUKEE WI 53202 AUDIT 363305 17 70890 70890 SERVICES TO AFFILIATES 561000 52810894 52810894 MISCELLANEOUS OPERATIN 561000 285060 285060 WOMEN'S CENTER 561000 34231 34231 LAMAZE CLASSES 561000 21073 21073 53151258 1663705 1663705 4000 6514 -2514 -2514 -2514 54883339 53151258 0 1661191 24162518 5127401 19035117 1153478 244774 908704 4291276 910629 3380647 1514015 321281 1192734 756229 756229 443715 443715 4918456 258665 4659791 1082686 1082686 2734963 234094 2500869 4318554 248945 4069609 1188782 1188782 722277 14844 707433 10954989 2134079 8820910 6056919 1179914 4877005 46180 46180 MISCELLAENOUS EXPENSES 633351 61264 572087 RELATED ORGANIZATION AL 353161 353161 RECRUITING EXPENSE 278297 278297 DUES AND LICENSES 134392 12231 122161 65744238 11101282 54642956 0 399 400 393649 2761622 61269177 74046367 16021537 36677000 838614 850982 1202803 1127899 44685125 34758901 9642427 9926224 14983808 5317425 104352414 130707919 14215971 11152627 289836249 338644409 4788883 5496892 308841103 355293928 X -204488689 -224586009 -204488689 -224586009 104352414 130707919 X 0 1 1 X 0 X X 0 0 0 MERCY MEDICAL CENTER OF OSHKOSH INC 390806268 3 1 1 1 0 MERCY HEALTH FOUNDATION 237140261 9 1 1 1 0 ST ELIZABETH HOSPITAL INC 390816818 3 1 1 1 0 ST ELIZABETH HOSPITAL COMMUNITY FOUNDATION INC 391256677 11a 1 1 1 0 NETWORK HEALTH SYSTEM INC 391127163 3 1 1 1 0 CALUMET MEDICAL CENTER 390905385 3 1 1 1 0 6 0 RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 459782 142323 317459 3409694 3409694 0 39389805 30653503 8736302 1425844 553381 872463 9926224 PENSION LIABILITY 4785871 457B Plan Liability 711021 5496892 54883339 65744238 -10860899 -9236421 -9236421 -20097320 -2532369 -4548356 -4548356 2015987 52867352 52867352 54883339 12580183 0 12580183 53164055 53164055 65744238 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: GAIN ON INVESTMENT IN NETWORK HEALTH PLAN: 2185928. CHANGE IN INTEREST IN NETWORK HEALTH PLAN: -4195195. PENSION ADJUSTMENT: -6994695. TWIN MED DISTRIBUTION: -232459. Part XII, Line 2d - Other Adjustments: ALLOCATED REVENUE REIMBURSED TO RELATED PARTIES: -353161. SUBSIDIARY INCOME/LOSS - NHP: -4195195. Part XII, Line 4b - Other Adjustments: ALLOCATED EXPENSES REIMBURSED BY RELATED PARTIES: 52810894. DONATIONS REPORTED TO NET ASSETS: 56458. Part XIII, Line 4b - Other Adjustments: ALLOCATED EXPENSES REIMBURSED BY RELATED PARTIES: 52810894. ALLOCATED REVENUE REIMBURSED TO RELATED PARTIES: 353161. X X 0 1 X X X X X 0 0 0 0 0 0 0 0 0 BARBARA STRAND MD 0 245788 0 0 0 937 0 22625 0 22237 0 291587 0 0 DAVID ROMOND MD 0 356995 0 0 0 0 0 56169 0 17276 0 430440 0 0 FRANK CHYBOWSKI MD 0 425275 0 0 0 1406 0 25758 0 20416 0 472855 0 0 JOSEPH MCcORMICK MD 0 1102035 0 0 0 1055 0 18759 0 22145 0 1143994 0 0 Stacy Sensor DO 0 474503 0 0 0 209 0 19676 0 17924 0 512312 0 0 MARK FAUSTICH MD 0 339519 0 0 0 1859 0 28691 0 7098 0 377167 0 0 JAY MULLER MD 0 350236 0 0 0 384 0 18826 0 19918 0 389364 0 0 DAN NEUFELDER 0 530018 0 200017 0 9544 0 44114 0 12036 0 795729 0 0 JEFF BADGER 0 289422 0 94610 0 20018 0 39221 0 19461 0 462732 0 0 Part I, Line 1b BUSINESS TRAVEL EXPENSES FOR SPOUSES OF EXECUTIVES AND GOLF CLUB MEMBERSHIP FOR EXECUTIVES ARE REIMBURSED AS PART OF THEIR TAXABLE 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. Form 990, Part VI, Section A, line 6 Corporate members are Ministry Health Care and Wheaton Franciscan Services, Inc. Form 990, Part VI, Section A, line 7a Ministry Health Care and Wheaton Franciscan Services, Inc. have joint power to elect and remove the Board of Directors of AHS. Form 990, Part VI, Section A, line 7b Amendments of the articles of incorporation and bylaws must be approved by corporate members. Form 990, Part VI, Section B, line 11 THE 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 12c The Board of Directors receives a conflict of interest questionaire every year. Form 990, Part VI, Section B, line 15 EACH 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. WAGES FOR AFFINITY HEALTH SYSTEM, INC. ARE ALLOCATED TO AFFILIATED RELATED ORGANIZATIONS. Form 990, Part VI, Section C, line 19 The organization believes the financial statements, governing documents, and policies are the property of the organization and are not available for public inspection. FORM 990, PART VII HOURS WORKED FOR RELATED ORGANIZATIONS Frank 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 40 hours per week for related organizations. Jeff Badger worked an average of 40 hours per week for related organizations. Mark Kehrberg worked an average of 40 hours per week for related organizations. Vincent Gallucci worked an average of 40 hours per week for related organizations. FORM 990, PART XI, LINE 2B-2C PROCESS FOR OVERSIGNT OF AUDIT AND SELECTION OF INDEPENDENT ACCOUNTANT Affinity Health System (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, Ministry Health CFO, and the audit committee. This process has not changed from the prior year. Mercy Medical Center of Oshkosh Inc 500 s oakwood oshkosh WI 54904 390806268 Hospital WI 501(c)(3) 3 N/A Calumet Medical Center Inc 614 MEMORIAL DRIVE CHILTON WI 53014 390905385 Hospital WI 501(c)(3) 3 N/A Network Health System Inc 1570 APPLETON ROAD MENASHA WI 54952 391127163 CLINICAL HEALTHCARE SERVICES WI 501(c)(3) 3 N/A Mercy Health Foundation Inc PO BOX 3370 OSHkOSH WI 54903 237140261 PUBLIC WELFARE THROUGH COMMUNITY HEALTH DEVELOPMENT WI 501(c)(3) 9 N/A St Elizabeth Community Foundation Inc 1506 S ONEIDA STREET APPLETON WI 54915 391256677 RAISE FUNDS IN SUPPORT OF ST. ELIZABETH HOSPITAL AND RELATED ENTITIES WI 501(c)(3) 11A-I N/A St Elizabeth Hospital Inc 1506 S ONEIDA STREET APPLETON WI 54915 390816818 Hospital WI 501(c)(3) 3 N/A Twin Med LLP PO BOX 8005 MENASHA WI 54952 391180341 RENTAL PROPERTY WI NETWORK HEALTH SYSTEM RELATED 369938 1081728 0 1 NETWORK HEALTH PLAN 1570 Midway Place Menasha WI 54952 391442058 INSURANCE WI Network Health System C 12392977 80298598 1.00000 Network Health Insurance Corporation 1570 Midway Place menasha WI 54952 392020474 InsURANCE WI network Health Plan C 9997616 35259179 1.00000 0 0 1 1 1 0 0 0 0 1 1 0 0 1 1 1 0 0 NETWORK HEALTH SYSTEM INC D 1000000 Mercy Medical Center Inc E 11000000 St Elizabeth Hospital E 11000000 Network Health Plan J 160276 St Elizabeth Hospital K 11373851 Mercy Medical Center Inc K 9289702 NETWORK HEALTH SYSTEM INC K 10654442 Network Health Plan K 2646527 Calumet Medical Center K 1136797 St Elizabeth Hospital N 122476 Mercy Medical Center Inc N 73727 st Elizabeth Hospital O 710709 Mercy Medical Center Inc O 1130460 NETWORK HEALTH SYSTEM INC O 475116 Network Health Plan O 229850 St Elizabeth Hospital P 5859190 Mercy Medical Center Inc P 4621495 NETWORK HEALTH SYSTEM INC P 5064884 Network Health Plan P 1230935 Calumet Medical Center P 579910