2011-05-11T16:33:06-05:00 2010-09-30 WIPFLI LLP 10000 INNOVATION DR SUITE 250 MILWAUKEE WI 532264837 990 2009-10-01 390286215 Fort HealthCare Inc FORT 8004214677 611 E Sherman Avenue Fort Atkinson WI 53538 James Nelson 8004214677 2011-05-11 1 JAY ADKISSON 4144319300 2011-05-09 2009 2016-02-24 21:20:13Z James Nelson 611 E Sherman Avenue Fort Atkinson WI 53538 127281501 0 X www.forthealthcare.com X 1942 WI OUR MISSION AT FORT HEALTHCARE IS TO PROVIDE EXCELLENT, COMPASSIONATE CARE FOR THE PEOPLE OF OUR COMMUNITIES. 12 7 1123 310 0 0 324936 201172 119968537 122401567 -1703553 3449727 1090272 118589920 127142738 0 0 52344882 50834906 0 0 66376704 69335448 118721586 120170354 -131666 6972384 167138311 172806943 86932076 83116500 80206235 89690443 Our Mission at Fort HealthCare is to provide excellent, compassionate care for the people of our communities. 0 0 72372470 88652811 Operation of a 72-bed acute care facility with an emergency room and full complement of ancillary services. 28160208 29612184 Operation of physician clinics with outreach into the surrounding communities 3047592 2923252 Operation of a 28-bed subacute unit to care for the frail and elderly 1525306 1213320 Operation of a home health agency to care for homebound seniors and others in the community 1525306 1213320 105105576 1 1 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 1 0 0 1 1 0 0 0 0 0 0 0 1 1 1 0 0 0 0 0 1 1 0 0 1 165 0 1123 1 0 0 0 0 0 0 0 0 0 12 7 0 0 1 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 1 1 WI X James Nelson 9205685000 611 E Sherman Avenue Fort Atkinson WI 53538 Michael S Wallace 40.00 X 295716 0 32438 Jonathan McLaughlin MD 3.00 X X 0 502427 29403 Sharon Schmeling 3.00 X X 0 0 0 F Bradford Meyers MD 3.00 X X 0 264168 25847 Dean Johnson 3.00 X X 0 0 0 Carol Knox 3.00 X 0 0 0 Richard Martin 3.00 X 0 0 0 Thomas Norland MD 3.00 X 0 677288 30003 Jeffrey McGuire MD 3.00 X 0 0 0 Michael Rumpf 3.00 X 0 0 0 Robert Schramm 3.00 X 0 0 0 DONALD WILLIAMS MD 3.00 X 0 219774 19446 Mary Kay Diderrich 40.00 X 116422 0 3362 Gary Fiedler 40.00 X 143955 0 17032 Edwin Fischer MD 40.00 X 0 298970 30003 James J Nelson 40.00 X 189723 0 30305 Kay E Wipperfurth 40.00 X 156422 0 27434 Sarah S Sisbach 40.00 X 155016 0 7637 Michael Anderson 40.00 X 0 640763 29403 Randall Jennings 40.00 X 0 1009363 30003 Edgardo Jiongco 40.00 X 0 1300043 11521 Craig Kozler 40.00 X 0 544541 30003 Isidoro Zambrano 40.00 X 0 580105 24160 1057254 6037442 378000 33 1 1 0 Fort medical Group 611 E Sherman Avenue Fort Atkinson WI 53538 Physician Services 17493179 Dynacare Laboratories 9200 W Wisconsin Avenue Milwaukee WI 53226 Laboratory Services 572838 Aramark Corporation 22506 Network Place Chicago IL 606731225 Support Service Management 495300 St Mary's Hospital Medical Ctr 700 S Park Street Madison WI 53715 Laboratory Testing 450772 Diversified Clinical Services PO Box 850001 Orlando FL 328850248 Services 234733 11 201172 201172 Hospital services 623000 84451671 84451671 physician clinic reven 621110 29555800 29555800 other OPERATING REVENU 623990 4257524 4257524 subacute unit revenue 623000 2923252 2923252 Home Health Agency 621610 1213320 1213320 122401567 1536120 1536120 805614 805614 805614 805614 1746328 306042 138763 1746328 167279 1913607 1913607 Equity Income in nonco 623000 277246 277246 Fort Care Income 623000 7412 7412 284658 127142738 122401567 0 4539999 39494108 34711862 4782246 1360192 1195490 164702 7186397 6316214 870183 2794209 2455865 338344 1133077 609881 523196 11792056 11771724 20332 3553834 3056297 497537 96743 93676 3067 3726442 3204740 521702 7810754 6717248 1093506 390305 335662 54643 professional fees 16375972 16175004 200968 PURCHASED SERVICES 9960351 7229339 2731012 Provision for Bad Debts 6095501 6095501 Other expenses 5511964 4887562 624402 dues 2772020 162437 2609583 116429 87074 29355 120170354 105105576 15064778 0 8669 9809 12977456 5756189 18218543 19922257 1811600 1799462 790827 1352801 150037256 74279888 73275818 75757368 41014073 51050969 15260559 13126343 3780766 4031745 167138311 172806943 11026799 9506369 62375000 60416629 59030 13471247 13193502 86932076 83116500 X 80206235 89690443 80206235 89690443 167138311 172806943 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 636155 636155 61649558 24592757 37056801 1639157 1360690 278467 86112386 48326441 37785945 75757368 Money Market Funds 4946751 F CERTIFICATES OF DEPOSIT 8179592 F 13126343 DEFERRED COMPENSATION 268558 Capitol Lease obligations 9425926 Deferred gain of sale-leaseback 3499018 13193502 127142738 120170354 6972384 2511824 2511824 9484208 127142738 0 127142738 0 127142738 120170354 0 120170354 0 120170354 Part X: Description of Uncertain Tax Positions Under FIN 48: Part X: In order to account for any uncertain tax positions, the System determines whether it is more likely than not that a tax position will be sustained upon examination on the technical merits of the position, assuming the taxing authority has full knowledge of all information. If the tax position does not meet the more likely than not recognition threshold, the benefit of that position is not recognized in the financial statements. The System recorded no assets or liabilities related to uncertain tax positions in 2010 and 2009. Tax returns for the years ended September 30, 2009, 2008, and 2007 remain subject to examination by the applicable taxing authorities. 1 1 1 X 1 X 1 1 0 1 1 848028 848028 0.00740 13905589 3612761 10292828 0.09020 14753617 3612761 11140856 0.09760 736492 312168 424324 0.00370 2406786 2194030 212756 0.00190 186083 1 186082 0.00160 3329361 2506199 823162 0.00720 18082978 6118960 11964018 0.10480 0 2787556 418000 20941492 23937003 -2995511 X 1 1 Medical Health Building Group Rental of medical buildings 0.20000 0.25000 Fort Healthcare Inc

611 Sherman Avenue East Fort Atkinson WI 53538

X X X Part I, Line 7: Overall cost to charge ratio Part I, Line 7f: Part III, Line 4: The carrying amounts of accounts receivable are reduced by allowances that reflect management's best estimate of the amounts that will not be collected. Management provides for contractual adjustments under terms of third-party reimbursement agreements through a reduction of gross revenue and a credit to patient receivables. In addition, management provides for probable uncollectible amounts, primarily uninsured patients and amounts patients are personally responsible for, through a charge to operations and a credit to a valuation allowance based on its assessment of historical collection likelihood and the current status of individual accounts. Balances that are still outstanding after management has used reasonable collection efforts are written off through a charge to the valuation allowance and a credit to patient accounts receivable.Costing methodology - overall cost to charge ratio. Rationale for including bad debt amounts in community benefit- We are the only hospital in our service area and patients would have to travel to another community to receive care. Part III, Line 9b: Persons whose income is less than 150% of the Federal Poverty Guidelines, but not more than 300% of the guidelines, shall be eligible for Community Care on a reduced charge basis. Persons whose income is less than 150% of the guidelines will be considered for complete forgiveness of their outstanding charges. Part VI, Line 2: Fort HealthCare performs regular market research to assess the healthcare needs and concerns of the community. Focus groups with current patients and non-patients have helped us improve the quality of clinic based services. An annual mailed questionnaire (5,000 samples size, randomly selected) is also implemented. Many questions relate specifically to health needs, concerns, behaviors and concerns. The survey also assesses satisfaction with Fort HealthCare services and hospital of preference for a variety of medical and hospital based services. Part VI, Line 3: Information is available on the patient statement, in monthly newsletters and on the organizations website. An annual Community Benefit report is filed with the Wisconsin Hospital Association. A printed report is prepared and delivered to 48,000 households within the primary service area as an insert into the HealthSource Community Magazine. Part VI, Line 4: Fort HealthCare's primary service area constitutes an eight zip code region comprised of the communities of Fort Atkinson, Jefferson, Johnson Creek, Helenville, Whitewater, Cambridge, Lake Mills and Palmyra. There are approximately 75,000 persons living in the region. Fort Memorial Hospital is the only hospital within the primary service area. The region is not considered a medically underserved region. Part VI, Line 5: Part VI, Line 6: The Fort HealthCare Board of Directors is a community oriented board, with representatives solicited directly from the majority of communities in the primary service area. The majority of representatives are not employees, contractors or relatives of Fort HealthCare staff. The members are not compensated for their service. The Fort Memorial Hospital operates with an 'open' medical staff. Physicians unaffiliated with the organization may request privileges at any time. The Planning Committee determines need for specialty care according to a well established medical manpower plan that includes community need for services. Physicians are granted medical staff status based on need. The medical staff is represented by members of Fort Medical Group (owned by Fort HealthCare), Dean/St. Mary's Regional Clinics, UW Health and others. Fort HealthCare is a non-profit organization and net revenues are used for improvements in the status of Fort HealthCare. Funds are used to purchase capital equipment, enhance physical facilities and improve patient services. Fort HealthCare gives generously to area community organizations. In FY 2010, more than $65,000 was provided in direct support of community events. In addition, Fort HealthCare resources were expended to support those activities- including significant staff time, volunteer time, medical supplies, giveaway items and more. Approximately $1.8 million was provided in charity care. Fort HealthCare staff serve on the board of directors for a number of local non-profit agencies. Fort HealthCare is very supportive of United Way, Tomorrow's Hope, Relay for Life and many other fundraising causes in the community. Part VI, Line 7: Fort HealthCare is an independent, non-profit organization. There are no affiliated organizations. WI 1 X X X X X X 1 0 0 1 1 0 0 0 0 Michael S Wallace 295716 0 0 0 0 0 9800 0 22638 0 328154 0 0 0 Jonathan McLaughlin MD 0 485314 0 17113 0 0 0 9800 0 19603 0 531830 0 0 F Bradford Meyers MD 0 264168 0 0 0 0 0 9800 0 16047 0 290015 0 0 Thomas Norland MD 0 658054 0 19234 0 0 0 9800 0 20203 0 707291 0 0 DONALD WILLIAMS MD 0 219774 0 0 0 0 0 334 0 19112 0 239220 0 0 Gary Fiedler 143955 0 0 0 0 0 5260 0 11772 0 160987 0 0 0 Edwin Fischer MD 0 298970 0 0 0 0 0 9800 0 20203 0 328973 0 0 James J Nelson 189723 0 0 0 0 0 7667 0 22638 0 220028 0 0 0 Kay E Wipperfurth 156422 0 0 0 0 0 6291 0 21143 0 183856 0 0 0 Sarah S Sisbach 155016 0 0 0 0 0 6148 0 1489 0 162653 0 0 0 Michael Anderson 0 443573 0 197190 0 0 0 9800 0 19603 0 670166 0 0 Randall Jennings 0 773838 0 235525 0 0 0 9800 0 20203 0 1039366 0 0 Edgardo Jiongco 0 1300043 0 0 0 0 0 9800 0 1721 0 1311564 0 0 Craig Kozler 0 544541 0 0 0 0 0 9800 0 20203 0 574544 0 0 Isidoro Zambrano 0 580105 0 0 0 0 0 9800 0 14360 0 604265 0 0 Part I, Line 4a Gary Fiedler Severance Pay $40,272 Part I, Line 5 Executive pay increases and bonuses have an element relating to the financial performance of the organization and related organizations. Physicians compensation is tied to net revenues of their practices. Wisconsin Health & Educational Facilities Authority 391337855 97710VTU2 2004-05-18 40072037 Construction & Equipment 0 0 Wisconsin Health & Educational Facilities Authority 391337855 97710V4Q8 2007-09-20 26000000 Construction & Equipment & refunding prior issue 0 0 40072037 3000700 320000 36751337 2006 0 0 1 1 26000000 481154 9548835 391832 15577679 2010 0 1 1 1 0 0 0 0 0 1 0 0 0 0 0 1 0 0 0 1 XL Asset Funding Company LLC 2.670000000000 1 0 0 0 1 0 0 0 0 500 McMillen Group LLP Partnership in which current director Donald Williams is a partner 316468 Rent for the lease of office space 0 Cambridge State Bank Employer of Former Board Member David Keleher 1000000 Filing organization has certificates of deposits with the bank 0 Julie Mokhtar MD Wife of Edwin Fischer 484817 Employee 1 Johnson Bank Board member Dean Johnson is a director of the Johnson Bank Advisory Board 1000000 Certificates of deposit 0 Melanie Rumpf Wife of Board Member Michael Rumpf 46018 Employee 0 Cambridge State Bank Board member Michael Rumpf is a Board member of Cambridge State Bank 1000000 Filing organization has certificates of deposits with the bank 0 Form 990, Part VI, Section A, line 4 The organization created a compensation committee whose voting members do not receive any compensation from the organization. Compensation matters were previously handled by the Executive Committee. Form 990, Part VI, Section B, line 11 A copy of Form 990 is given to the Board members for review. It is approved by the Board of Directors before filing. Form 990, Part VI, Section B, line 12c Each board member of the entity and related entities annually complete a conflict of interest questionnaire disclosing their conflicts of interest. A summary of conflicts are distributed to the chairman of the board and to administrative support personnel. Board members are coached on how to manage their conflicts. Form 990, Part VI, Section B, line 15 Other organizations are used as benchmarks to determine compensation. Independent reviews of compensation are also done periodically. Form 990, Part VI, Section C, line 19 All documents are available to the public upon request. Summaries of financial statements are available to the public via an annual report that Fort Healthcare publishes. The annual report is direct mailed to households and is also available to the public on Fort Healthcare's website. Fort Memorial Hospital Foundation 611 Sherman Ave East Fort Atkinson WI 53538 391397028 Foundation WI 501(c)(3) Line 11a, I N/A Fort Healthcare Partners 611 Sherman Ave East Fort Atkinson WI 53538 391040145 Volunteers WI 501(c)(3) Line 3 N/A Fort Medical Group Inc 611 Sherman Ave East Fort Atkinson WI 53538 391736513 Provide physician services WI N/A C 2511606 1.00000 Fort Care Inc 611 Sherman Ave East Fort Atkinson WI 53538 391725831 Preferred Provider Organization WI N/A C 7412 65888 1.00000 0 0 1 0 0 0 0 0 0 0 0 0 1 1 1 1 0 0 Fort Memorial Hospital Foundation C 63749 Fort HealthCare Partners C 88031 Fort Medical Group O 17493179 Fort Care Inc P 78343