2024-08-07T14:08:08-05:00 2023-09-30 390758449 WIPFLI LLP 170 N RADNOR-CHESTER RD SUITE 200 RADNOR PA 19087 990 2022-10-01 390286215 FORT HEALTHCARE INC FORT 8004214677 611 SHERMAN AVENUE EAST FORT ATKINSON WI 53538 JAMES NELSON SR. VICE PRESIDENT/CFO 8004214677 2024-07-29 1 0 SOLOMON MARDAKHAEV P01806552 6105653930 2024-07-22 2022 2024-08-08 14:25:15Z JAMES NELSON 611 SHERMAN AVENUE EAST FORT ATKINSON WI 53538 171676801 0 X WWW.FORTHEALTHCARE.COM X 1942 WI OUR MISSION AT FORT HEALTHCARE IS TO IMPROVE THE HEALTH AND WELL-BEING OF OUR COMMUNITY. 13 7 1065 100 0 0 3240027 510512 140029114 145791504 14297789 4140454 268716 186522 157835646 150628992 327075 323650 0 0 69813710 79353477 0 0 11672 68555889 65224177 138696674 144901304 19138972 5727688 241376447 247529031 67393284 57230641 173983163 190298390 X OUR MISSION AT FORT HEALTHCARE IS TO IMPROVE THE HEALTH AND WELL-BEING OF OUR COMMUNITY. 0 0 82181644 88650 110849911 OPERATION OF A 49-BED ACUTE CARE FACILITY WITH AN EMERGENCY ROOM AND FULL COMPLEMENT OF ANCILLARY SERVICES.FORT HEALTHCARE COMMUNITY IMPACT:CHARITY CARE - $634,042: CHARITY CARE IS DEFINED AS FREE OR DISCOUNTED HEALTH SERVICES PROVIDED TO THOSE WHO CANNOT AFFORD TO PAY AND WHO MEET ALL CRITERIA FOR FINANCIAL ASSISTANCE. CHARITY CARE IS BASED ON ACTUAL COSTS, NOT CHARGES, AND DOES NOT INCLUDE BAD DEBT.COMMUNITY HEALTH IMPROVEMENT SERVICES - $318,880: COMMUNITY HEALTH IMPROVEMENT SERVICES ARE DEFINED AS CLINICAL AND NON-CLINICAL SERVICES DESIGNED TO IMPROVE COMMUNITY HEALTH, WHICH ARE PROVIDED TO THE COMMUNITY FOR FREE OR FOR FEES THAT DID NOT COVER COSTS.FINANCIAL CONTRIBUTIONS - $130,926: FINANCIAL CONTRIBUTIONS ARE DEFINED AS CONTRIBUTIONS, INCLUDING CASH, NON-CASH ITEMS SUCH AS FOOD, FURNITURE, EQUIPMENT, SUPPLIES, AND LOANED STAFF FOR VOLUNTEER AND CHARITABLE PURPOSES, MADE TO INDIVIDUALS, COMMUNITY GROUPS, OR NONPROFIT ORGANIZATIONS FOR CHARITABLE PURPOSES.COMMUNITY BUILDING ACTIVITIES - $47,943: COMMUNITY BUILDING ACTIVITIES ARE DEFINED AS 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 ISSUES. COSTS FOR THESE ACTIVITIES INCLUDE CASH AND IN-KIND DONATIONS.COMMUNITY BENEFIT OPERATIONS - $0: COMMUNITY BENEFIT OPERATIONS ARE DEFINED AS COSTS ASSOCIATED WITH DEDICATED STAFF AND COMMUNITY HEALTH NEEDS AND/OR ASSESSMENT, AS WELL AS OTHER COSTS ASSOCIATED WITH COMMUNITY BENEFIT STRATEGY AND OPERATIONS.SUBSIDIZED HEALTH SERVICES - $145,040: SUBSIDIZED HEALTH SERVICES ARE DEFINED AS THE NEGATIVE MARGIN FOR CLINICAL SERVICES THAT ARE PROVIDED DESPITE A FINANCIAL LOSS BECAUSE OF AN IDENTIFIED COMMUNITY NEED THAT WOULD NEED TO BE MET BY THE GOVERNMENT OR ANOTHER NOT-FOR-PROFIT IF IT WAS NOT OFFERED. THE FINANCIAL LOSSES ARE SO SIGNIFICANT THAT NEGATIVE MARGINS REMAIN AFTER REMOVING THE EFFECTS OF CHARITY CARE, BAD DEBT, AND MEDICAID SHORTFALLS.TOTAL BENEFIT TO THE COMMUNITY FOR FISCAL YEAR 2023 WAS $1,276,831. 40884852 235000 34562608 OPERATION OF PHYSICIAN CLINICS WITH OUTREACH INTO THE SURROUNDING COMMUNITIES. 0 0 -205350 EQUITY INCOME IN UNCONSOLIDATED AFFILIATES - HEALTH CLINIC. 123066496 1 1 0 1 0 0 0 0 0 0 1 1 0 1 1 1 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 1 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 1 1 1 0 0 1 170 0 1065 1 0 0 0 0 0 0 0 0 0 0 0 0 X 13 7 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 1 1 WI X JAMES NELSON 9205685000 611 SHERMAN AVENUE EAST FORT ATKINSON WI 53538 MICHAEL ANDERSON MD PRESIDENT/CEO 40.00 1.00 X X 1595636 0 44201 PAUL SCHUPPNER DO BOARD MEMBER 40.00 X 761420 0 25285 MICHAEL WALLACE PRESIDENT/CEO (THRU DEC 2022) 40.00 1.00 X X 637198 0 45607 BILLIE KONTNY MD BOARD MEMBER 40.00 X 598425 0 42791 CHRISTINE CHUPPA MD CHIEF OF STAFF (THRU DEC 2022) 40.00 X 575079 0 42791 STEPHANIE NOTTESTAD MD BOARD MEMBER 40.00 X 369960 0 44712 NATHANIEL FULLERTON MD CHIEF OF STAFF 40.00 X 366545 0 48136 MARY BECK METZGER BOARD MEMBER 40.00 1.00 X 65927 0 15750 MARY BEHLING CHAIR (THRU DEC 2022) 3.00 X X 0 0 0 JAMES FITZPATRICK PHD CHAIR 3.00 1.00 X X 0 0 0 ROY BUDLONG VICE CHAIR & TREASURER 3.00 1.00 X X 0 0 0 THOMAS VINZ BOARD MEMBER/SECRETARY 3.00 1.00 X X 0 0 0 KATHI CAULEY BOARD MEMBER (THRU DEC 2022) 3.00 X 0 0 0 CARLA HAUBENSCHILD BOARD MEMBER 3.00 X 0 0 0 CHRISTOPHER MARTIN BOARD MEMBER 3.00 X 0 0 0 CHRISTI OTT BOARD MEMBER 3.00 1.00 X 0 0 0 RICHARD TELFER PHD BOARD MEMBER 3.00 X 0 0 0 JAMES NELSON SR. VICE PRESIDENT/CFO 40.00 1.00 X 363506 0 45461 MATTHEW BLISS MD PHYSICIAN 40.00 X 1035243 0 43811 ISIDORO ZAMBRANO MD PHYSICIAN 40.00 X 787534 0 42791 MARC ERICKSON MD PHYSICIAN 40.00 X 712404 0 42797 JONATHAN MCLAUGHLIN MD PHYSICIAN 40.00 X 469071 0 45139 WILLIAM HOFMANN MD PHYSICIAN 40.00 X 468047 0 42945 8805995 0 572217 80 0 1 0 CERNER CORPORATION PO BOX 959156 ST LOUIS MO 63195 PROFESSIONAL SERVICES 6249018 UW MEDICAL FOUNDATION-RADIOLOGY 600 HIGHLAND AVE MADISON WI 53792 RADIOLOGY SERVICES 1942383 JP CULLEN AND SONS INC 330 E DELAVAN DR JANESVILLE WI 53546 CONSTRUCTION SERVICES 1514941 GE MEDICAL SYSTEMS PO BOX 94683 CHICAGO IL 60693 SERVICE CONTRACT ON EQUIPMENT 1440436 MAXIM HEALTHCARE STAFFING SERVICES 933 N MAYFAIR RD STE 201 WAUWATOSA WI 53226 STAFFING SERVICES 1158927 36 54075 410935 45502 510512 HOSPITAL SERVICES 623000 97718984 97718984 PHYSICIAN CLINIC REVENUE 621110 35594196 35594196 OTHER OPERATING REVENUE 623990 12194037 11815052 378985 RENTAL INCOME - SPECIALTY CLINIC 621610 284287 284287 145791504 3147310 3147310 194301 236419 -42118 -42118 -42118 21505006 299528 20692126 119264 812880 180264 993144 993144 EQUITY INCOME 623000 228640 -205350 433990 228640 150628992 145207169 0 4911311 X 323650 323650 5166992 1291748 3875244 56601635 56409679 191768 188 1701808 1520064 181736 8 12597630 12124839 472725 66 3285412 3100860 184539 13 1866988 1866988 15155 15155 199599 199599 9795 9795 20183198 17781538 2401660 389969 37625 352344 14550081 14159650 390431 4842219 4842219 4802865 3726249 1075029 1587 41887 41045 842 1569370 1569370 6063044 2716659 3341451 4934 518453 7158 511295 PROVISION FOR BAD DEBTS 1992192 1992192 HOSPITAL ASSESSMENT 1872926 1872926 EAR PROJECT 1242727 1242727 EQUIPMENT 741191 629832 111359 4322518 4078838 238804 4876 144901304 123066496 21823136 11672 11828762 10194736 568557 560344 19107214 20266105 3058171 3233419 2753847 2723243 163701283 114236084 39711659 49465199 106774670 107188304 38680708 39645206 18892859 14252475 241376447 247529031 11548220 16615225 19986414 18474239 17952597 10232597 184063 134194 17721990 11774386 67393284 57230641 X 173983163 190298390 173983163 190298390 241376447 247529031 5727688 10587539 0 X X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 9795 9795 0 PART II-B, LINE 1: LOBBYING PORTION OF DUES PAID TO WHA AND AHA. 1620170 1620170 77441430 44261325 33180105 79597854 69974759 9623095 5041829 5041829 49465199 ALTERNATIVE INVESTMENTS 39645206 F 39645206 INVESTMENT IN SUBSIDIARIES 3808628 OPERATING LEASE 1562189 FINANCE LEASE 5807561 THIRD PARTY PAYOR RECEIVABLES 2697628 RELATED PARTY RECEIVABLES 376469 14252475 DEFERRED COMPENSATION 2255221 DEFERRED GAIN OF SALES-LEASEBACK 22120 FINANCE LEASE OBLIGATIONS 7876881 OPERATING LEASE OBLIGATIONS 1620164 11774386 X PART X, LINE 2: FORT MEDICAL GROUP PROVIDES FOR INCOME TAXES ON A LIABILITY METHOD WHEREBY DEFERRED TAX ASSETS ARE RECOGNIZED FOR DEDUCTIBLE TEMPORARY DIFFERENCES, OPERATING LOSSES, AND TAX CREDIT CARRYFORWARDS AND DEFERRED TAX LIABILITIES ARE RECOGNIZED FOR TAXABLE TEMPORARY DIFFERENCES. BOTH ARE CALCULATED USING ENACTED TAX RATES WHEN THE DIFFERENCES WILL BE REALIZED OR SETTLED. TEMPORARY DIFFERENCES ARE THE DIFFERENCES BETWEEN THE REPORTED AMOUNTS OF ASSETS AND LIABILITIES AND THEIR TAX BASES. DEFERRED TAX ASSETS ARE REDUCED BY A VALUATION ALLOWANCE WHEN, IN THE OPINION OF MANAGEMENT, IT IS MORE LIKELY THAN NOT THAT SOME PORTION OR ALL OF THE DEFERRED TAX ASSETS WILL NOT BE REALIZED. THE FINAL TAX RETURN FOR FMG WAS FILED AS OF JANUARY 1, 2022 SINCE FMG WAS MERGED INTO THE HOSPITAL AS OF THIS DATE. ALL NET OPERATING LOSS CARRYFORWARDS FROM FMG HAVE BEEN RELINQUISHED AS OF THE DATE OF THE MERGER. 1 1 X 1 X 1 X 1 1 0 1 1 627684 627684 0.00430 19241607 3570797 15670810 0.10810 19869291 3570797 16298494 0.11240 1590801 1076437 514364 0.00350 130926 130926 0.00090 1721727 1076437 645290 0.00440 21591018 4647234 16943784 0.11680 0 2082482 145774 17071833 19418148 -2346315 X 1 1 1 MEDICAL HEALTH BUILDING GROUP RENTAL OF MEDICAL BUILDINGS 0.20000 0.25000 1 1 FORT HEALTHCARE INC 611 SHERMAN AVENUE EAST FORT ATKINSON WI 53538 HTTPS://WWW.FORTHEALTHCARE.COM/ 1908-800 X X X FORT HEALTHCARE INC 1 0 0 1 X X X X X X X X X 22 1 1 1 1 X WWW.FORTHEALTHCARE.COM/COMMUNITY-HEALTH-NEEDS-ASSESSMENT/ X 1 22 1 WWW.FORTHEALTHCARE.COM/COMMUNITY-HEALTH-NEEDS-ASSESSMENT/ 0 1 X 200.000000000000 400.000000000000 X X 1 1 X X X 1 X WWW.FORTHEALTHCARE.COM/PATIENT-INFO/FINANCIAL-AID/ X WWW.FORTHEALTHCARE.COM/PATIENT-INFO/FINANCIAL-AID/ X WWW.FORTHEALTHCARE.COM/PATIENT-INFO/FINANCIAL-AID/ X X X X X X X 1 X 0 X X X X X 1 X 0 0 FORT HEALTHCARE, INC. PART V, SECTION B, LINE 5: FOCUS GROUPS WITH THE PUBLIC AND COMMUNITY PARTNERS WERE CONDUCTED, AS WELL AS SURVEYS (DETAILS OF PARTNERS IN THE REPORT ON OUR WEBSITE). BASED ON THE FEEDBACK THE TOP RATED ITEMS WERE DISCUSSED AND WILL BE THE FOCUS OF COMMUNITY HEALTH IMPROVEMENT PLAN AND PROCESS. FORT HEALTHCARE, INC. PART V, SECTION B, LINE 6A: MARSHFIELD MEDICAL CENTER-BEAVER DAM, AND WATERTOWN REGIONAL MEDICAL CENTER. FORT HEALTHCARE, INC. PART V, SECTION B, LINE 6B: THIS CHNA WAS CONDUCTED BY THE DODGE-JEFFERSON HEALTHIER COMMUNITY PARTNERSHIP WHICH IS COMPRISED OF: DODGE COUNTY HUMAN SERVICES AND HEALTH DEPARTMENT, FORT HEALTHCARE, GREATER WATERTOWN COMMUNITY HEALTH FOUNDATION, JEFFERSON COUNTY HEALTH DEPARTMENT, MARSHFIELD MEDICAL CENTER-BEAVER DAM, ROCK RIVER COMMUNITY CLINIC, WATERTOWN DEPARTMENT OF PUBLIC HEALTH, AND WATERTOWN REGIONAL MEDICAL CENTER, REFERRED TO AS "THE PARTNERSHIP." FORT HEALTHCARE, INC. PART V, SECTION B, LINE 11: FORT HEALTHCARE CONTINUES TO SUPPORT THE WORK OF THE ROCK RIVER COMMUNITY CLINIC WHICH OFFERS FREE SERVICES TO THOSE WHO LIVE IN OUR SERVICE AREA. ADDITIONALLY, WE CONTINUE TO ADDRESS OBESITY AND LACK OF PHYSICAL ACTIVITY THROUGH TARGETED COMMUNITY PROGRAMS OFFERED IN ALL OF THE COMMUNITIES WE SERVE. FORT HEALTHCARE, INC. PART V, SECTION B, LINE 13H: SERVICES ARE NOT ELECTIVE. FORT HEALTHCARE, INC. PART V, SECTION B, LINE 16J: THE FINANCIAL ASSISTANCE POLICY IS PUBLICIZED IN ALL FORT HEALTHCARE LOCATIONS AND DISCUSSED WITH PATIENTS AT TIME OF ADMIT AND ON FOLLOW UP CALLS. FORT HEALTHCARE, INC. PART V, SECTION B, LINE 20E: GENERATE AT LEAST 4 MONTHLY STATEMENTS TO GUARANTOR ON FILE. 13 1 - ORTHOPAEDIC ASSOCIATES 1504 MADISON AVENUE FORT ATKINSON WI 53538 ORTHOPAEDIC 2 - SURGICAL ASSOCIATES 212 MILWAUKEE AVENUE WEST FORT ATKINSON WI 53538 SURGICAL - GENERAL 3 - INTERNAL MEDICINE & PEDIATRICS 500 MCMILLEN STREET FORT ATKINSON WI 53538 INTERNAL MEDICINE & PEDIATRICS, BEHAVIORAL HEALTH 4 - EAR NOSE & THROAT SPECIALISTS 512 WILCOX STREET FORT ATKINSON WI 53538 ENT 5 - LAKE MILLS CLINIC 200 EAST TYRANENA PARK ROAD LAKE MILLS WI 53551 FAMILY PRACTICE, BEHAVIORAL HEALTH, ORTHOPAEDIC 6 - INTEGRATED FAMILY CARE 1520 MADISON AVENUE FORT ATKINSON WI 53538 FAMILY PRACTICE, BEHAVIORAL HEALTH 7 - CENTER FOR WOMEN'S HEALTH 650 MCMILLEN STREET FORT ATKINSON WI 53538 OBSTETRICS AND GYNECOLOGY 8 - PAIN MANAGEMENT CLINIC 1604 MADISON AVE FORT ATKINSON WI 53538 PAIN MANAGEMENT 9 - WHITEWATER 1461 WEST MAIN STREET WHITEWATER WI 53190 OBSTETRICS & GYNECOLOGY, INTERNAL MEDICINE & PEDIATRICS, EAR, NOSE & THROAT 10 - JOHNSON CREEK 400 DOCTORS COURT JOHNSON CREEK WI 53038 FAMILY PRACTICE, WOUND & EDEMA 11 - DERMATOLOGY 611 SHERMAN AVENUE EAST 3RD FLOOR FORT ATKINSON WI 53538 DERMATOLOGY 12 - JEFFERSON 840 WEST RACINE STREET JEFFERSON WI 53549 FAMILY PRACTICE, ORTHOPAEDIC 13 - CAMBRIDGE CLINIC 704 KATIE COURT CAMBRIDGE WI 53523 FAMILY PRACTICE, BEHAVIORAL HEALTH, ORTHOPAEDIC PART I, LINE 7: OVERALL COST TO CHARGE RATIO PART II, COMMUNITY BUILDING ACTIVITIES: 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 HEALTHCARE, SSM 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. PART III, LINE 2: 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. FORT HEALTHCARE IN SOUTHEAST WISCONSIN / 2023 CHARITY CARE $1,925,803. CHARITY CARE IS DEFINED AS FREE OR DISCOUNTED HEALTH SERVICES PROVIDED TO THOSE WHO CANNOT AFFORD TO PAY AND WHO MEET ALL CRITERIA FOR FINANCIAL ASSISTANCE. CHARITY CARE IS BASED ON ACTUAL COSTS, NOT CHARGES, AND DOES NOT INCLUDE BAD DEBT. PART III, LINE 3: 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 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 - BASED ON A PERCENTAGE OF COMMUNITY CARE WRITE-OFFS TO OVERALL SELF PAY WRITE-OFFS.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 8: WE ARE THE ONLY HOSPITAL IN OUR SERVICE AREA & PATIENTS WOULD HAVE TO TRAVEL TO ANOTHER COMMUNITY TO RECEIVE CARE.INPATIENT COSTS COME FROM WORKSHEET D-1 PART II & OUTPATIENT COSTS ARE BASED ON THE COST TO CHARGE RATIO OF THE MEDICARE CHARGES ON WORKSHEET D PART V. PART III, LINE 9B: PERSONS WHOSE INCOME IS MORE THAN 200% OF THE FEDERAL POVERTY GUIDELINES, BUT NOT MORE THAN 400% OF THE GUIDELINES, SHALL BE ELIGIBLE FOR COMMUNITY CARE ON A REDUCED CHARGE BASIS. PERSONS WHOSE INCOME IS LESS THAN 200% 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. THE PRIMARY RESEARCH TOOLS ARE SURVEYS, COMMUNITY FOCUS GROUPS AND MEETINGS. MANY QUESTIONS RELATE SPECIFICALLY TO HEALTH NEEDS, BEHAVIORS AND CONCERNS. THE SURVEY IS ADMINISTERED BY AN INDEPENDENT RESEARCH COMPANY. CONCERNED RESIDENTS AND COMMUNITY LEADERS, WITH THE ASSISTANCE OF FORT HEALTHCARE STAFF ARE DEVELOPING SPECIFIC COMMUNITY-RELEVANT STRATEGIES TO ADDRESS OBESITY, PHYSICAL ACTIVITY, NUTRITION, ADVANCE DIRECTIVES, CANCER AND DIABETIC SCREENINGS AND MENTAL/BEHAVIORAL HEALTH. PART VI, LINE 3: INFORMATION IS AVAILABLE ON THE PATIENT STATEMENT, IN MONTHLY NEWSLETTERS AND ON THE ORGANIZATION'S WEBSITE. AN ANNUAL COMMUNITY BENEFIT REPORT IS FILED WITH THE WISCONSIN HOSPITAL ASSOCIATION. A PRINTED REPORT IS PREPARED AND DELIVERED TO 40,500 HOUSEHOLDS WITHIN THE PRIMARY SERVICE AREA. THE FORT HEALTHCARE WEBSITE CONTAINS LINKS AND INFORMATION SPECIFIC TO THE POLICY ON CHARITY CARE, FINANCIAL AID AND REDUCED PAYMENT OPTION FOR SELF-PAY PATIENTS. INFORMATION IS ALSO AVAILABLE ON THE WEBSITE AND IN ALL FORT HEALTHCARE LOCATIONS REGARDING THE ROCK RIVER COMMUNITY CLINIC, A FREE AND REDUCED CARE CLINIC FUNDED IN A SIGNIFICANT MANNER BY FORT HEALTHCARE THROUGH A MULTI-YEAR GIFT AGREEMENT. FINANCIAL AID COUNSELOR IS AVAILABLE AT FORT MEMORIAL HOSPITAL TO ASSIST PATIENTS WITH COMPLETING PAPERWORK FOR GOVERNMENT ASSISTANCE PROGRAMS, WITH CONTACT INFORMATION ALSO AVAILABLE ON THE WEBSITE AND IN ADMISSION PACKETS. 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, HELENVILE, WHITEWATER, CAMBRIDGE, LAKE MILLS AND PALMYRA. THERE ARE APPROXIMATELY 85,000 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: 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 HEALTHCARE, SSM 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. PART VI, LINE 6: FORT HEALTHCARE IS AN INDEPENDENT, NON-PROFIT ORGANIZATION. THERE ARE NO AFFILIATED ORGANIZATIONS. PART VI, LINE 7, REPORTS FILED WITH STATES WI 1 ROCK RIVER COMMUNITY CLINIC 520 HANDEYSIDE LN FORT ATKINSON WI 53538 205297560 501(C)(3) 235000 0 GENERAL SUPPORT GLACIAL HERITAGE DEVELOPMENT PARTNERSHIP 864 COLLINS RD SUITE 111 JEFFERSON WI 53549 813362283 501(C)(3) 35000 0 GENERAL SUPPORT JEFFERSON COUNTY FAIR PARK 503 N JACKSON JEFFERSON WI 53549 GOV 30500 0 GENERAL SUPPORT FORT ATKINSON CHAMBER OF COMMERCE 244 N MAIN ST FORT ATKINSON WI 53538 390286155 501(C)(6) 7150 0 GENERAL SUPPORT BASE FORT ATKINSON 734 MADISON AVE FORT ATKINSON WI 53538 832103418 501(C)(3) 6000 0 GENERAL SUPPORT GREATER WHITEWATER COMMITTEE (DISCOVER WHITEWATER SERIES) 405 PANTHER CT WHITEWATER WI 53190 455010028 501(C)(6) 5000 0 GENERAL SUPPORT SCHOOL DISTRICT OF JEFFERSON 206 S TAFT AVE JEFFERSON WI 53549 391207754 501(C)(3) 5000 0 GENERAL SUPPORT 6 1 PART I, LINE 2: DEPARTMENTS RECEIVING GRANTS ARE RESPONSIBLE TO REPORT THE USE OF FUNDS, OUTCOMES AND ANECDOTAL STORIES THAT ILLUSTRATE THE IMPACT OF THEIR GRANT. REPORTING REQUIREMENTS WILL BE DETERMINED COLLABORATIVELY PRIOR TO A FINAL FUNDING DECISION. X X X X X X 0 1 0 0 1 0 0 1 0 MICHAEL ANDERSON MD PRESIDENT/CEO 627061 0 408271 0 560304 0 12839 0 31362 0 1639837 0 0 0 MATTHEW BLISS MD PHYSICIAN 913653 0 116458 0 5132 0 12200 0 31611 0 1079054 0 0 0 ISIDORO ZAMBRANO MD PHYSICIAN 703815 0 79667 0 4052 0 12200 0 30591 0 830325 0 0 0 PAUL SCHUPPNER DO BOARD MEMBER 681477 0 76593 0 3350 0 12200 0 13085 0 786705 0 0 0 MARC ERICKSON MD PHYSICIAN 469757 0 40000 0 202647 0 12200 0 30597 0 755201 0 0 0 MICHAEL WALLACE PRESIDENT/CEO (THRU DEC 2022) 463044 0 167455 0 6699 0 12200 0 33407 0 682805 0 0 0 BILLIE KONTNY MD BOARD MEMBER 533747 0 40000 0 24678 0 12200 0 30591 0 641216 0 0 0 CHRISTINE CHUPPA MD CHIEF OF STAFF (THRU DEC 2022) 296273 0 28832 0 249974 0 12200 0 30591 0 617870 0 0 0 JONATHAN MCLAUGHLIN MD PHYSICIAN 422697 0 40000 0 6374 0 12200 0 32939 0 514210 0 0 0 WILLIAM HOFMANN MD PHYSICIAN 257782 0 26469 0 183796 0 11718 0 31227 0 510992 0 0 0 NATHANIEL FULLERTON MD CHIEF OF STAFF 313516 0 50707 0 2322 0 12200 0 35936 0 414681 0 0 0 STEPHANIE NOTTESTAD MD BOARD MEMBER 344858 0 23968 0 1134 0 9111 0 35601 0 414672 0 0 0 JAMES NELSON SR. VICE PRESIDENT/CFO 273840 0 84208 0 5458 0 12200 0 33261 0 408967 0 0 0 PART I, LINE 4B MICHAEL WALLACE PARTICIPATED IN A NONQUALIFIED DEFERRED COMPENSATION PLAN. HOWEVER, HE IS 0% VESTED, EXCEPT IN THE CASE OF DEATH OR DISABILITY, AND HAS NO INTEREST IN THE DEFERRED COMPENSATION PLAN UNTIL JANUARY 1, 2024. THE PLAN IS A TOP-HAT PLAN THAT IS UNFUNDED. PART I, LINE 5 PHYSICIAN COMPENSATION IS TIED TO THE NET REVENUES OF THEIR PRACTICE. PART I, LINE 7 SCHEDULE J, PART II, COLUMN (B)(II) REPORTS DISCRETIONARY INCENTIVE AMOUNTS THAT WERE APPROVED BY THE BOARD BASED UPON PERFORMANCE. A WISCONSIN HEALTH & EDUCATIONAL FACILITIES AUTHORITY 391337855 97712DJH0 2014-12-01 28195000 CONSTRUCTION & EQUIPMENT 0 0 0 A 1410000 28195000 4497804 350383 23346813 2014 0 1 1 1 A 0 0 0 0 0 0 0 A 0 1 0 0 0 0 0 0 0 A 1 MEDICAL HEALTH BUILDING GROUP PARTNERSHIP OWNED BY BOARD MEMBER BILLIE KONTNY 1964096 RENT FOR THE LEASE OF OFFICE SPACE 0 FORM 990, PART VI, SECTION B, LINE 11B THE FORM 990 IS REVIEWED BY THE ORGANIZATION'S ACCOUNTING MANAGER AND CFO. A COPY OF THE FORM 990 IS PROVIDED TO THE FINANCE COMMITTEE AND THE BOARD OF DIRECTORS FOR REVIEW AND APPROVAL PRIOR TO 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. BOARD MEMBERS WITH A CONFLICT OF INTEREST ABSTAIN FROM VOTING ON THE MATTERS. 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. FORM 990, PART IX, LINE 11G ADMIN PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 2,401,660. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,401,660. ANESTHESIA CRNA SERVICES: PROGRAM SERVICE EXPENSES 186,183. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 186,183. CENTER FOR WOMEN'S HEALTH SERVICES: PROGRAM SERVICE EXPENSES 836,718. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 836,718. ENT SERVICES: PROGRAM SERVICE EXPENSES 4,262. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 4,262. HOSPITALISTS SERVICES: PROGRAM SERVICE EXPENSES 1,036,816. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,036,816. INTEGRATED FAMILY CARE SERVICES: PROGRAM SERVICE EXPENSES 454,866. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 454,866. INTERNAL MEDICINE SERVICES: PROGRAM SERVICE EXPENSES 363,399. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 363,399. LABORATORY SERVICES: PROGRAM SERVICE EXPENSES 1,599,357. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,599,357. LAKE MILLS SERVICES: PROGRAM SERVICE EXPENSES 234,363. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 234,363. ORTHOPAEDICS SERVICES: PROGRAM SERVICE EXPENSES 415,325. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 415,325. OTHER MEDICAL & PHYSICIAN SERVICES: PROGRAM SERVICE EXPENSES 8,974,243. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 8,974,243. PEDIATRICS SERVICES: PROGRAM SERVICE EXPENSES 236,240. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 236,240. RADIOLOGY SERVICES: PROGRAM SERVICE EXPENSES 3,252,407. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 3,252,407. SURGICAL ASSOCIATES SERVICES: PROGRAM SERVICE EXPENSES 187,359. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 187,359. PART XII, LINE 2C THIS PROCESS HAS NOT CHANGED FROM PRIOR YEAR. PAIN CENTER OF WISCONSIN-FORT ATKINSON LLC 1604 MADISON AVENUE FORT ATKINSON WI 53538 900777376 HEALTH CARE SERVICES WI 445366 938957 FORT HEALTHCARE INC FORT MEMORIAL HOSPITAL FOUNDATION INC 611 SHERMAN AVENUE EAST FORT ATKINSON WI 53538 391397028 FOUNDATION WI 501(C)(3) LINE 12A, I FORT HEALTHCARE INC 1 UW CANCER CENTER JOHNSON CREEK LLC 125 HOSPITAL DRIVE WATERTOWN WI 53098 200341996 CANCER CENTER WI N/A RELATED 155372 2577987 0 0 0.33330 FORTCARE INC 611 SHERMAN AVENUE EAST FORT ATKINSON WI 53538 391725831 PREFERRED PROVIDER ORGANIZATION WI FORT HEALTHCARE INC C -14492 1.00000 1 0 0 1 0 0 0 0 0 0 0 0 0 0 1 0 0 1 0 0 FORT MEMORIAL HOSPITAL FOUNDATION INC C 52132 CASH