2011-05-13T14:06:39-05:00 2010-06-30 WIPFLI LLP PO BOX 12237 GREEN BAY WI 543072237 990 2009-07-01 390807236 Agnesian Healthcare Inc AGNE 9209264480 430 East Division Street Fond du Lac WI 53935 BONNIE SCHMITZ 9209264480 2011-05-13 0 Terri Rexrode CPA MST 9206620016 2011-05-13 2009 2016-02-24 21:20:13Z ROBERT FALe 430 East Division Street Fond du Lac WI 53935 350340440 0 1 0928 X WWW.AGNESIAN.COM X 1892 WI INTEGRATED HEALTHCARE DELIVERY SYSTEM - THE MISSION OF AGNESIAN HEALTHCARE IS TO PROVIDE COMPASSIONATE CARE THAT BRINGS HOPE, HEALTH AND WHOLENESS TO THOSE WE SERVE BY HONORING THE SACREDNESS AND DIGNITY OF ALL PERSONS AT EVERY STAGE OF LIFE. 12 8 3014 650 63449 353111 0 265091471 266316587 -1762795 2946481 13310389 12501754 276639065 281764822 0 0 112066725 110609444 0 0 160966189 159878453 273032914 270487897 3606151 11276925 300829435 321294193 176251809 159519424 124577626 161774769 THE MISSION OF AGNESIAN HEALTHCARE IS TO PROVIDE COMPASSIONATE CARE THAT BRINGS HOPE, HEALTH AND WHOLENESS TO THOSE WE SERVE BY HONORING THE SACREDNESS AND DIGNITY OF ALL PERSONS AT EVERY STAGE OF LIFE. WE ARE ROOTED IN THE HEALING MINISTRY OF THE CATHOLIC CHURCH AS WE CONTINUE THE MISSION OF OUR SPONSOR, THE CONGREGATION OF SISTERS OF ST AGNES. 0 0 180873762 254523197 HOSPITAL, CLINIC AND HOME HEALTH SERVICES PROVIDING DIAGNOSTIC AND THERAPEUTIC HEALTHCARE 11141381 14339765 LABORATORY SERVICES PROVIDING DIAGNOSTIC HEALTHCARE FOR CENTRAL WISCONSIN 6203740 5476187 RETAIL PHARMACY AND HOME MEDICAL EQUIPMENT SALES TO SERVICE POPULATION FOR HOSPITAL (INPATIENT AND OUTPATIENT), CLINIC AND HOME HEALTH 1135353 1383176 FOND DU LAC SURGERY CENTER - PROVIDING OUTPATIENT SURGERY TO THE FOND DU LAC COMMUNITY AND SURROUNDING AREAS 1135353 1383176 199354236 1 0 0 0 0 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 0 0 1 1 0 0 0 0 0 0 0 1 0 1 0 0 0 0 1 1 0 0 0 1 192 0 1 3014 1 1 1 1 CJ 0 0 0 0 0 0 0 1 1 0 12 8 0 0 0 0 0 0 1 1 1 0 0 1 1 1 1 1 1 1 1 0 WI X BONNIE SCHMITZ 9209264480 430 EAST DIVISION STREET FOND DU LAC WI 54935 ROBERT A FALE 50.00 X X 617752 0 24315 SISTER ANN KOERNER 1.00 X 0 0 0 SISTER MARY NOEL BROWN 1.00 X 0 0 0 DEBRA HELLER 1.00 X 0 0 0 PATRICIA MILLER 1.00 X 0 0 0 Dr STEPHEN MASSICK MD 1.00 X 31956 0 0 WAYNE MATZKE 1.00 X 0 0 0 DrMICHAEL STRIGENZ MD 1.00 X 761 0 0 DRJEFFREY STRONG MD 1.00 X 171 0 0 JAMES B SIMON 1.00 X 6710 0 0 DRBRIAN CHRISTENSON MD 1.00 X 302265 0 24315 JAMES R CHATTERTON 1.00 X 0 0 0 STEVEN LITTLE 50.00 X 341010 0 25455 NORMA TIRADO 50.00 X 238457 0 7718 JANE HYDE 50.00 X 217477 0 13753 DENNIS YUNK 50.00 X 214402 0 20056 CAROL HYLAND 50.00 X 197308 0 21528 JAMES MUGAN 50.00 X 190708 0 27312 BARBARA KNUTZEN 50.00 X 163720 0 18972 DOUGLAS TROST 50.00 X 129362 0 21674 JOHN CHOI MD 50.00 X 1047516 0 22215 DENNIS FITZPATRICK MD 50.00 X 840291 0 22388 PONTUS OSTMAN MD 50.00 X 769520 0 9625 ISAM HABIB MD 50.00 X 761222 0 28424 YASIR HATAHET MD 50.00 X 709771 0 30306 6780379 0 318056 111 0 1 0 FOND DU LAC REGIONAL CLINIC SC 420 EAST DIVISION STREET FOND DU LAC WI 54935 PHYSICIAN SERVICES 43055064 IBM CORPORATION 1 NEW ORCHARD ROAD ARMONK NY 105041722 COMPUTER SERVICES 7237130 CERNER CORPORATION 2800 ROCKCREEK PARKWAY KANSAS CITY MO 64141 COMPUTER SERVICES 5466419 CD SMITH CONSTRUCTION PO BOX 1006 FOND DU LAC WI 54935 CONTRACTOR 1207514 AMERICAN HEALTHCARE SERVICES PO BOX 945 TRAVERSE CITY MI 49685 TEMPORARY STAFFING 789815 46 NET PATIENT SERVICE RE 621400 177419986 177419986 MEDICARE/MEDICAID SERV 621400 88896601 88896601 266316587 1550852 1550852 48962667 146000 47496543 216495 1466124 -70495 1395629 1395629 28803840 20862580 7941260 7941260 CLINIC REIMBURSEMENT 621110 851260 851260 CAFETERIA SALES 900099 773597 63449 710148 WORK INJURY - SAH 592512 613218 613218 2322419 2322419 4560494 281764822 275722325 63449 5979048 2802213 327051 2475162 95273096 75359864 19913232 3212914 2232362 980552 2890919 1697992 1192927 6430302 4919242 1511060 427072 7760 419312 112741 2291 110450 328959 328959 54573317 51143181 3430136 905998 87955 818043 48350445 40351551 7998894 10996507 53262 10943245 3491677 39977 3451700 482705 416733 65972 882573 720975 161598 4774711 4774711 15917115 5587533 10329582 2573626 1739294 834332 BAD DEBTS 10254858 9798362 456496 HOSPITAL ASSESSMENT TAX 4403515 4403515 MISCELLANEOUS 898805 254890 643915 DUES, SUBSCRIPTIONS, LI 462104 210401 251703 OTHER 41725 45 41680 270487897 199354236 71133661 0 26223771 4270208 6736516 20242335 37708950 36757284 4252709 4669760 2497143 2502627 235222188 115808356 124250831 119413832 52615403 97433513 1020134 996299 45523978 35008335 300829435 321294193 26085701 29413460 115592174 100125807 34573934 29980157 176251809 159519424 X 116865506 153297329 5608756 6338229 2103364 2139211 124577626 161774769 300829435 321294193 X 0 1 1 X 0 X 1020134 23156 45000 1991 996299 1014822 45000 -37548 2140 1020134 1.00000 0 1 1 6252636 6252636 112607633 41517746 71089887 1988981 602374 1386607 113118108 73688236 39429872 1254830 1254830 119413832 RECEIVABLE FROM FDLRC SC 357843 RECEIVABLE FROM AFFILIATED ENTITIES 490689 AMOUNTS DUE FROM THIRD PARTIES 626947 LONG-TERM DEBT RECEIVABLE FROM RELATED ENTITIES 5000000 DUE FROM FOUNDATION 552134 ASSETS WHOSE USE IS LIMITED - DEBT SVC AND PHYSICIAN SUPP. BENEFIT PLAN 14837462 INVESTMENT - MERCURY CLINIC 3005130 INVESTMENT - SAH FOUNDATION 7333092 OTHER ASSETS 2805038 35008335 CAPITAL LEASE PAYABLE 12443994 PHYSICIANS SUPPLEMENTAL LIFE 12236761 DUE TO WAUPUN MEMORIAL HOSPITAL 3326477 FUND BALANCE SWAP MKT ADJUSTMENT 1972925 29980157 Part V, Line 4: Description of Intended Use of Endowment Funds: AGNESIAN HEALTHCARE, INC. HOLDS AN ENDOWMENT FROM THE CONGREGATION OF THE SISTERS OF ST. AGNES. THE ORIGINAL ENDOWMENT OF $1,000,000 IS PERMANENTLY RESTRICTED. INCOME GENERATED FROM THE ENDOWMENT IS UNRESRICTED AND TO BE USED AT THE DISCRETION OF THE CHIEF EXECUTIVE OFFICER TO FUND PROGRAMS SUCH AS DOMESTIC VIOLENCE, CHARITY CARE, ETC. Part X: Description of Uncertain Tax Positions Under FIN 48: In order to account for any uncertain tax positions, ASC Topic 740-10, Accounting for Uncertainty in Income Taxes, requires an organization to assess whether it is more likely than not that a tax position will be sustained upon examination of 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 the tax position is not recognized in the financial statements. Agnesian recorded no assets or liabilities for uncertain tax positions or unrecognized tax benefits. Federal returns for the years ended 2007, 2008, and 2009 remain subject to examination by the Internal Revenue Service. 1 1 X 1 X 165.000000000000 1 X 1 1 0 1 1 2638000 2638000 0.01010 11888000 11888000 0.04570 14526000 14526000 0.05580 1119476 103737 1015739 0.00390 228673 228673 0.00090 312518 312518 0.00120 209651 209651 0.00080 1870318 103737 1766581 0.00680 16396318 103737 16292581 0.06260 85375 85375 0.00030 85375 85375 0.00030 1 4905802 73764593 113812280 -40047687 X 1 1 AGNESIAN HEALTHCARE DIALYSIS 0.50000 0.00000 0.00000 BEAVER DAM COMMUNITY HOSPITAL VENTURE LLC ST AGNES HOSPITAL

430 E DIVISION STREET FOND DU LAC WI 54935

X X X FOND DU LAC REGIONAL CLINIC

420 E DIVISION STREET FOND DU LAC WI 54935

OUTPATIENT PHYSICIAN CLINIC CONSULTANTS LAB OF WISCONSIN

430 E DIVISION STREET FOND DU LAC WI 54935

LABORATORY AND TESTING AGNESIAN HEALTHCARE ENTERPRISES

430 E DIVISION STREET FOND DU LAC WI 54935

PHARMACEUTICALS, HOME HEALTH, MEDICAL EQUIPMENT FOND DU LAC SURGERY CENTER

421 CAMELOT DRIVE FOND DU LAC WI 54935

X AGNESIAN HOSBEAVER DAM COMM HOS

110 MONROE STREET BEAVER DAM WI 53916

DIALYSIS SERVICES Part I, Line 6a: AN ANNUAL COMMUNITY BENEFIT REPORT IS COMPLETED BY THE FINANCE DEPARTMENT AND DISTRIBUTED TO THE PUBLIC THROUGH THE PUBLIC RELATIONS OFFICE OF AGNESIAN HEALTHCARE, INC. Part I, Line 7: A COST-TO-CHARGE RATIO WAS USED TO COMPUTE COST OF COMMUNITY BENEFIT SERVICES. OVERALL COSTS LESS TAXES WERE DIVISIBLE BY TOTAL CHARGES. Part I, Line 7g: SUBSIDIZED HEALTH SERVICES INCLUDES SAMARITAN CLINIC, A CLINIC OFFERING FREE MEDICAL SERVICES TO QUALIFIED INDIVIDUALS, AND COUNSELING SERVICES THROUGH BEHAVIORAL HEALTH SERVICES, SAMARITAN CLINIC COSTS WERE $301,842 FOR FY10. THE SAMARITAN HEALTH CLINIC PROVIDES PATIENTS WITH IMPORTANT BASIC HEALTH SERVICES, MEDICATIONS AND URGENT DENTAL NEEDS AT NO CHARGE TO THE PATIENT. Part I, Line 7f: BAD DEBT EXPENSES INCLUDED ON FORM 990, PART IX, LINE 25 WAS $10,254,858 AND WAS EXCLUDED FROM THE DENOMINATOR PER INSTRUCTIONS. 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 CHARGE TO CONTRACTUAL ADJUSTMENTS AND A CREDIT TO THE ALLOWANCE FOR CONTRACTUAL ADJUSTMENTS. IN ADDITION, MANAGEMENT PROVIDES FOR PROBABLE UNCOLLECTIBLE AMOUNTS, PRIMARILY FROM 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 ACCOUNTS RECEIVABLE. THE COSTING METHODOLOGY FOR DETERMINING BAD DEBTS IS A COST TO CHARGE RATIO. Part III, Line 8: MEDICARE SHORTFALL IS NOT TREATED AS A COMMUNITY BENEFIT. TO ARRIVE AT COST OF MEDICARE SERVICES, THE TOTAL EXPENSES LESS OTHER OPERATING REVENUE IS MULTIPLIED BY THE RATIO OF MEDICARE REVENUE TO TOTAL REVENUE. Part III, Line 9b: A ZERO DOLLAR AMOUNT WAS ESTIMATED FOR THE AMOUNT OF BAD DEBTS ATTRIBUTABLE TO PATIENTS WHO WOULD QUALIFY FOR FINANCIAL ASSISTANCE. IF PATIENTS QUALIFY, THEIR EXPENSES ARE RECLASSIFIED AS CHARITY CARE. PATIENTS WHO RECEIVED A COLLECTION NOTICE COULD APPLY FOR CHARITY CARE. IF THEIR APPLICATION IS APPROVED, THIS WOULD TRIGGER A TRANSFER OF EXPENSE FROM BAD DEBT TO CHARITY CARE. Part III, Line 9A: AGNESIAN HEALTHCARE, INC. HAS A WRITTEN DEBT COLLECTION POLICY. PAYMENT IS DUE WITHIN 30 DAYS OF RECEIPT OF A STATEMENT. IF PATIENTS DO NOT SET UP ACCEPTABLE PAYMENT ARRANGEMENTS, BILLS WILL BE REFERRED TO AN OUTSIDE COLLECTION AGENCY. FINANCIAL COUNSELORS WORK WITH ALL PATIENTS ON AN INDIVIDUAL BASIS AND MAY OFFER EXTENDED MONTHLY PAYMENTS WITHOUT INTEREST BASED ON DOLLAR AMOUNT, PRIVATE PAY DISCOUNTS (INDIVIDUALS WHO DO NOT HAVE INSURANCE COVERING EMERGANCY OR OTHER MEDICALLY NECESSARY CARE ARE TYPICALLY BILLED AT A REDUCED RATE), OR GUARANTEED BANK LOANS. Part VI, Line 2: AGNESIAN HEALTHCARE SENIOR LEADERS MEET REGULARLY WITH COMMUNITY LEADERS TO GATHER INPUT FROM AND RESPOND TO PATIENT AND CUSTOMER NEEDS. SENIOR LEADERS AND MEMBERS OF THE WORKFORCE PARTICIPATE IN A VARIETY OF ORGANIZATIONS IN SUPPORT OF AGNESIAN HEALTHCARE'S KEY COMMUNITIES. THROUGH AGNESIAN'S PARTICIPATION IN THESE ACTIVITIES, COMMUNITY MEMBERS LEARN OF AGNESIAN'S COMMITTMENT TO COMMUNITY-WIDE HEALTHCARE AND PROVIDE AGNESIAN WITH INSIGHT INTO COMMUNITY HEALTH NEEDS AND DESIRES. Part VI, Line 3: FINANCIAL COUNSELORS AT AGNESIAN HEALTHCARE ASSIST PATIENTS WITH APPLICATION TO COMMUNITY CARE. PATIENTS CAN BE REFERRED TO COMMUNITY CARE BY CLERGY, DEPARTMENTS OF AGNESIAN HEALTHCARE, SISTERS OF ST. AGNES, AREA SOCIAL AND HEALTH AGENCIES, FAMILY OR SELF. THE APPLICATION IS COMPLETED BY THE PATIENT WITH ASSISTANCE FROM THE FINANCIAL COUNSELOR IF NEEDED. THE FINANCIAL COUNSELOR WILL COMMUNICATE TO THE PATIENT WHAT PROGRAMS THEY WILL BE ELIGIBLE FOR, AS WELL AS PROVIDE NOTIFICATION OF APPROVAL OR DENIAL OF THEIR APPLICATION IN A TIMELY MANNER. Part VI, Line 4: COMMUNITY CARE APPLICATIONS ARE ACCEPTED ONLY FROM PATIENTS OF AGNESIAN HEALTHCARE WHO RESIDE IN THE COUNTIES OF CALUMET, DODGE, FOND DU LAC, GREEN LAKE, MARQUETTE, WAUSHARA OR WINNEBAGO. INDIVIDUALS MUST BE A RESIDENT OF ONE OF THOSE AREAS FOR A MINIMUM OF THREE MONTHS AND PROVIDE SUPPORTING DOCUMENTATION. ON OCCASION, INDIVIDUALS ARE NOT COMMUNITY MEMBERS BUT MAY NEED ASSISTANCE; THOSE APPLICATIONS ARE CONSIDERED ON A CASE-BY-CASE BASIS. THE SAMARITAN CLINIC SERVICES PATIENTS FROM DODGE AND FOND DU LAC COUNTIES. Part VI, Line 5: AGNESIAN HEALTHCARE OFFERS PROGRAMS TO THE COMMUNITY THAT ALLOW STUDENTS AND OTHERS TO LEARN ABOUT DIFFERENT OCCUPATIONS IN THE HEALTHCARE INDUSTRY BY BECOMING CERTIFIED AND GAINING ACTUAL WORK EXPERIENCE. THE DIFFERENT PROGRAMS PROVIDE HANDS-ON OPPORTUNITIES AND ALLOW JOB SHADOWING SO THE FUTURE OF THE PROFESSION CAN GAIN CONFIDENCE AND SKILLS. IN ADDITION, AGNESIAN HEALTHCARE SHARES ITS PROFESSIONAL STAFF AND EXPERTISE TO OFFER HEALTH EDUCATION CLASSES, HEALTH SCREENINGS, SUPPORT GROUPS, AND OTHER HEALTH PROMOTION ACTIVITIES THROUGHOUT THE YEAR. OTHER COMMUNITY INCLUDE SUPPORT AND TRAINING FOR THE DODGE CORRECTIONAL INSTITUTIONAL HOSPICE PROGRAM, SHARPS DISPOSAL SERVICES, ADOPT-A-FAMILY, DONATIONS TO FOOD PANTRIES, AND LEADERSHIP PARTICIPATION IN COMMUNITY NONPROFIT ORGANIZATIONS. Part VI, Line 6: AGNESIAN HEALTHCARE LEADERS DEVELOP GRANT APPLICATIONS IN SUPPORT OF PROGRAMS AND SERVICES SERVING THE GREATER NEEDS OF THE COMMUNITY, INCLUDING HOSPICE HOPE, DOMESTIC VIOLENCE PROGRAMS, CARDIAC CARE, AND PREVENTIVE HEALTH SCREENINGS AND SERVICES. PROVIDING THESE SERVICES LOCALLY IS A FOCUS OF OUR COMMUNITY BENEFIT PROGRAMS. Part VI, Line 7: AGNESIAN HEALTHCARE, INC. IS AN INTEGRATED, COMPREHENSIVE NOT-FOR-PROFIT HEALTHCARE DELIVERY SYSTEM COMPRISED OF SEVEN MINISTRIES: AGNESIAN HEALTHCARE ENTERPRISES, LLC, CONSULTANTS LAB OF WI, LLC, FOND DU LAC REGIONAL CLINIC, FOND DU LAC SURGERY CENTER, ST. AGNES HOSPITAL, ST. FRANCIS HOME AND WAUPUN MEMORIAL HOSPITAL. AGNESIAN PROVIDES A CONTINUUM OF HEALTHCARE SERVICES FROM BIRTH TO END OF LIFE. PREVENTIVE HEALTHCARE, DIAGNOSIS, TREATMENT AND FOLLOWUP, ASSISTED LIVING, AND INDEPENDENT AND SKILL CARE SERVICES. AGNESIAN HEALTHCARE IS COMMITTED TO ENSURING THAT INDIVIDUALS NEEDING VITAL HEALTHCARE SERVICES GET THE HELP THEY NEED AND DESERVE. WI X X 0 1 X X X X 0 1 0 1 0 0 0 0 0 ROBERT A FALE 494357 0 0 0 123395 0 0 0 24315 0 642067 0 0 0 DRBRIAN CHRISTENSON MD 276640 0 25625 0 0 0 0 0 24315 0 326580 0 0 0 STEVEN LITTLE 305042 0 0 0 35968 0 0 0 25455 0 366465 0 0 0 NORMA TIRADO 209973 0 0 0 28484 0 0 0 7718 0 246175 0 0 0 JANE HYDE 191414 0 0 0 26063 0 0 0 13753 0 231230 0 0 0 DENNIS YUNK 178298 0 0 0 36104 0 0 0 20056 0 234458 0 0 0 CAROL HYLAND 181675 0 0 0 15633 0 0 0 21528 0 218836 0 0 0 JAMES MUGAN 176035 0 0 0 14673 0 0 0 27312 0 218020 0 0 0 BARBARA KNUTZEN 150224 0 0 0 13496 0 0 0 18972 0 182692 0 0 0 DOUGLAS TROST 118953 0 0 0 10409 0 0 0 21674 0 151036 0 0 0 JOHN CHOI MD 532293 0 515223 0 0 0 0 0 22215 0 1069731 0 0 0 DENNIS FITZPATRICK MD 582366 0 257925 0 0 0 0 0 22388 0 862679 0 0 0 PONTUS OSTMAN MD 426563 0 342957 0 0 0 0 0 9625 0 779145 0 0 0 ISAM HABIB MD 416777 0 344445 0 0 0 0 0 28424 0 789646 0 0 0 YASIR HATAHET MD 491237 0 218534 0 0 0 0 0 30306 0 740077 0 0 0 Part I, Line 1a ALL GROSSUP PAYMENTS AND SOCIAL CLUB DUES ARE INCLUDED IN EMPLOYEE W-2, BOX 5. BENEFITS ARE PROVIDED PER THE EMPLOYMENT CONTRACT WITH EACH INDIVIDUAL EXECUTIVE. Part I, Line 1b THE SOCIAL CLUB DUES ARE DEFINED IN THE CONTRACTUAL AGREEMENT WITH THE INDIVIDUAL EXECUTIVE. GROSSUP PAYMENTS FOR ALL EXECUTIVES ARE INCLUDED IN THE EMPLOYEE W-2, LINE 5. DOCUMENTATION IS REQUIRED BEFORE REIMBURSEMENT OCCURS. Part I, Line 4a ALL EXECUTIVES EXCEPT CEO PARTICIPATE IN A 457(B) SUPPLEMENTAL NONQUALIFIED RETIREMENT PLAN. Part I, Line 5 COMPENSATION FOR SOME EMPLOYED PHYSICIANS IS BASED ON A PERCENTAGE OF GROSS BILLINGS. WI HEALTH AND EDUC FACILITIES AUTHORITY 391337855 97710Bgg1 2008-12-11 49330000 REFUNDING OF 2005 ISSUE 0 0 49330000 48900000 430000 2005 1 0 1 1 0 0 0 0 1 1 0 1 1 Piper jaffray 28.000000000000 0 0 0 STEPHEN MASSICK MD DIRECTOR OF FOND DU LAC REGIONAL CLINIC SC 43055064 HE IS A DIRECTOR OF FOND DU LAC REGIONAL CLINIC, SC. (FDLRC SC) AGNESIAN HEALTHCARE INC (ahc) CONTRACTS WITH FOND DU LAC REGIONAL CLINIC, SC FOR PHYSICIAN SERVICES. MEMBERS OF FDLRC SC HAVE SERVED AND CONTINUE TO SERVE ON THE BOARD OF DIRECTORS OF AGNESIAN HEALTHCARE, INC., WHILE PROVIDING PROFESSIONAL SERVICES TO AHC AND ARE COMPENSATED BY FDLRC SC FOR THOSE SERVICES. AHC COMPENSATED FDLRC SC $43,055,064 FOR PROFESSIONAL SERVICES IN FISCAL YEAR 2010. FDLRC SC DISTRIBUTES THOSE FUNDS TO PHYSICIANS BASED ON THEIR OWN CALCULATIONS. AHC DOES NOT CONTROL THE DISBURSEMENT OF FUNDS TO THE FDLRC PHYSICIANS. 0 WAYNE MATZKE DIRECTOR 49772 WAYNE MATZKE IS PRESIDENT/CEO OF GRANDE CHEESE. AGNESIAN HEALTHCARE, INC. PROVIDED OCCUPATIONAL HEALTH SERVICES TO GRANDE CHEESE, BILLING $49,772 FOR THESE SERVICES IN FISCAL 2010. 0 Form 990, Part VI, Section A, line 7b THE CONGREGATION OF THE SISTERS OF ST AGNES SPONSPORED MINISTRIES IS A CLASS B MEMBER WHO IS RESPONSIBLE FOR APPROVING CERTAIN ACTIVITIES OF THE CORPORATION. THE CONGREGATION OF THE SISTERS OF ST AGNES IS A CLASS A MEMBER WHO HAS THE SAME RESERVE POWERS AS THE CLASS B MEMBER. Form 990, Part VI, Section B, line 11 THE FINANCE DEPARTMENT PREPARES THE FORM 990 AND THE RETURN IS REVIEWED BY THE CFO AND CONTROLLER. A FINAL COPY OF THE 2009 FORM 990 IS PROVIDED TO THE BOARD EXECUTIVE COMMITTEE FOR REVIEW AND APPROVAL TO THE AGNESIAN HEALTHCARE BOARD BEFORE THE RETURN IS FILED WITH THE IRS. COPIES OF THE RETURN ARE ALSO MADE AVAILABLE TO ALL AGNESIAN HEALTHCARE BOARD MEMBERS. Form 990, Part VI, Section B, line 12c WE HAVE A WRITTEN CONFLICT OF INTEREST AND INSIDER TRANSACTION POLICY THAT REQUIRE EACH DIRECTOR, PRINCIPAL OFFICER, TRUSTEE OR COMMITTEE MEMBER TO DISCLOSE ON AN ANNUAL BASIS TO THE DISIGNATED AUTHORITY A CONFLICT OF INTEREST DISCLOSURE STATEMENT. THE DESIGNATED AUTHORITY ENSURES THAT ALL STATEMENTS ARE COMPLETED, REVIEWS THEM FOR CONFLICTS, AND SUBMITS TO THE BOARD FOR REVIEW ANY CONFLICT OF INTEREST DISCLOSURE STATEMENTS THAT DISCLOSE ACTUAL OR POTENTIAL CONFLICTS. Form 990, Part VI, Section B, line 15 DETERMINATION OF COMPENSATION OF THE CEO AND OFFICERS INCLUDES ANALYSIS OF COMPARABLE COMPENSATION SURVEYS BY AN INDEPENDENT COMPENSATION CONSULTANT, WHO RECOMMENDS RANGES OF APPROPRIATE COMPENSATION TO THE BOARD OF DIRECTORS. THE BOARD OF DIRECTORS APPROVES THE COMPENSATION PACKAGE FOR OFFICERS, AND COMTEMPORANEOUS SUBSTANTIATION OF THE DELIBERATION AND DECISION IS INCLUDED IN THE BOARD MINUTES. THE FINAL AGREEMENT IS DOCUMENTED WITH A WRITTEN CONTRACT, WHICH IS SIGNED BY BOTH PARTIES. Form 990, Part VI, Section C, line 19 AGNESIAN HEALTHCARE'S POLICY AND PROCEDURE FIN1069 DEFINES THE PROCEDURE FOR MAKING ANNUAL INFORMATION RETURNS AVAILABLE FOR PUBLIC INSPECTION. INDIVIDUALS REQUESTING INSPECTION ARE REFERRED TO THE ADMINISTRATION OFFICE, WHERE THEY ARE PROVIDED WITH THE DOCUMENTS AND A CONFERENCE ROOM FOR INSPECTING DOCUMENTS. PHOTOCOPIES WILL BE PROVIDED TO THE REQUESTOR. ANYONE MAY INSPECT THE RETURNS UPON DEMAND, WITHOUT AN APPOINTMENT OR ANY FOREWARNING, DURING AGNESIAN HEALTHCARE INC'S NORMAL BUSINESS HOURS. GOVERNING DOCUMENTS AND CONFLICT OF INTEREST STATEMENTS ARE NOT AVAILABLE FOR PUBLIC INSPECTION, BUT CAN BE MADE AVAILABLE IF THE REQUESTING PARTY HAS A BONAFIDE REASON. ALL FINANCIAL STATEMENTS ARE AVAILABLE TO THE PUBLIC THROUGH A POSTING ON A PUBLIC WEBSITE. FORM 990, PART XI, LINE 2B THE CONSOLIDATED FINANCIAL STATEMENTS OF AGNESIAN HEALTHCARE SYSTEM WERE AUDITED BY AN INDEPENDENT ACCOUNTING FIRM, WIPFLI LLP. TWO RELATED ENTITIES IN THE AGNESIAN HEALTHCARE SYSTEM, WAUPUN MEMORIAL HOSPITAL AND ST. FRANCIS HOME, FILE SEPARATE FORMS 990. REMAINING ENTITIES ARE REPRESENTED BY THE AGNESIAN HEALTHCARE TAX RETURN. FORM 990, PART XI, LINE 2C THE AUDIT COMMITTEE OF AGNESIAN HEALTHCARE, INC IS RESPONSIBLE FOR THE OVERSIGHT OF THE AUDIT BY THE INDEPENDENT ACCOUNTING FIRM. CONSULTANTS LABORATORY OF WISCONSIN LLC 430 EAST DIVISON STREET FOND DU LAC WI 54935 391528550 LAB SERVICES WI 23177879 10637317 N/A AGNESIAN HEALTHCARE ENTERPRISES 430 EAST DIVISON STREET FOND DU LAC WI 54935 392038757 RETAIL PHARMACY WI 28798360 9396155 N/A FOND DU LAC SURGERY CENTER 421 CAMELOT DRIVE FOND DU LAC WI 54935 203947006 OUTPATIENT SURGERY WI 1498343 0 N/A ST FRANCIS HOME OF FOND DU LAC 33 EVERETT STREET FOND DU LAC WI 54935 391029998 NURSING HOME WI 501(C)(3) 9 N/A CONGREGATION OF SISTERS OF ST AGNES 320 COUNTY ROAD K FOND DU LAC WI 54935 390806217 CONVENT WI 501(C)(3) 1 N/A AGNESIAN HEALTHCARE FOUNDATION 430 E DIVISION STREET FOND DU LAC WI 54935 391684956 FOUNDATION WI 501(C)(3) 11 N/A WAUPUN MEMORIAL HOSPITAL 620 WEST BROWN STREET WAUPUN WI 53963 390806265 HOSPITAL WI 501(C)(3) 3 N/A ANGESIAN HCBEAVER DAM COMMUNITY HOSPITALS VENTURE LLC 110 monroe st BEAVER DAM WI 53916 752992766 DIALYSIS WI N/A RELATED 50 50 0 0 0 0 1 1 0 0 0 0 0 1 0 1 0 1 0 1 0 0 AGNESIAN HEALTHCARE FOUNDATION INC C 393043 WAUPUN MEMORIAL HOSPITAL D 419812 ST FRANCIS HOME D 5000000 ST FRANCIS HOME L 72397 CONGREGATION OF SISTERS OF ST AGNES L 287831 CONGREGATION OF SISTERS OF ST AGNES N 124326 CONGREGATION OF SISTERS OF ST AGNES P 390