2021-08-04T11:37:07-05:00 2020-09-30 390758449 WIPFLI LLP PO BOX 12237 GREEN BAY WI 543072237 990 2019-10-01 390286215 FORT HEALTHCARE INC FORT 8004214677 611 SHERMAN AVENUE EAST FORT ATKINSON WI 53538 JAMES NELSON SR. VICE PRESIDENT / CFO 8004214677 2021-08-03 1 TERRI REXRODE CPA MST P00096513 9206620016 2021-08-03 2019 2022-09-23 18:48:47Z JAMES NELSON 611 SHERMAN AVENUE EAST FORT ATKINSON WI 53538 175658184 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 8 964 130 0 0 96269 8640198 131176721 117283172 2952559 1073423 779594 1024046 135005143 128020839 114500 125280 0 0 51557068 51737236 0 0 148506 72446783 70548708 124118351 122411224 10886792 5609615 212863864 229066980 59273496 64416153 153590368 164650827 X OUR MISSION AT FORT HEALTHCARE IS TO IMPROVE THE HEALTH AND WELL-BEING OF OUR COMMUNITY. 0 0 68432472 83972 94462467 OPERATION OF A 49-BED ACUTE CARE FACILITY WITH AN EMERGENCY ROOM AND FULL COMPLEMENT OF ANCILLARY SERVICES.FORT HEALTHCARE COMMUNITY IMPACT:CHARITY CARE $564,814 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 $569,019 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 $137,566 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 $56,618 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 $66,111 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 $111,477 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 2020 $1,505,605 33663889 41308 22478300 OPERATION OF PHYSICIAN CLINICS WITH OUTREACH INTO THE SURROUNDING COMMUNITIES. 233113 EQUITY INCOME IN UNCONSOLIDATED AFFILIATES - HEALTH CLINIC. 102096361 1 1 0 1 0 0 0 0 0 0 1 1 0 0 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 1 1 1 0 0 0 0 0 1 1 1 0 0 1 148 0 964 1 0 0 0 0 0 0 0 0 0 0 0 0 X 13 8 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 MATTHEW BLISS MD PHYSICIAN 1.00 40.00 X 0 1225463 24400 MICHAEL ANDERSON MD SECRETARY 3.00 40.00 X X 0 1134358 38275 ISIDORO ZAMBRANO MD PHYSICIAN 1.00 40.00 X 0 907035 38275 PAUL SCHUPPNER DO PHYSICIAN 1.00 40.00 X 0 815389 25358 MICHAEL WALLACE PRESIDENT/CEO 40.00 1.00 X X 561112 0 39159 WILLIAM HOFMANN MD PHYSICIAN 1.00 40.00 X 0 520699 21264 BILLIE KONTNY MD BOARD MEMBER 3.00 40.00 X 0 450761 40052 JONATHAN MCLAUGHLIN MD PHYSICIAN 1.00 40.00 X 0 448931 40437 JAMES NELSON SR. VICE PRESIDENT / CFO 40.00 1.00 X 300661 0 39157 STEPHANIE NOTTESTAD MD BOARD MEMBER 3.00 40.00 X 0 266395 39860 MARY BECK METZGER BOARD MEMBER 40.00 1.00 X 61851 0 14893 RONALD MEYER MD CHIEF OF STAFF 3.00 40.00 X 0 0 0 MARY BEHLING CHAIR 3.00 X X 0 0 0 JAMES FITZPATRICK PHD VICE CHAIR 3.00 1.00 X X 0 0 0 ROY BUDLONG TREASURER 3.00 1.00 X X 0 0 0 KATHI CAULEY BOARD MEMBER 3.00 X 0 0 0 JAY SMITH BOARD MEMBER 3.00 1.00 X 0 0 0 RICHARD TELFER BOARD MEMBER 3.00 X 0 0 0 THOMAS VINZ BOARD MEMBER 3.00 1.00 X 0 0 0 923624 5769031 361130 29 0 1 0 FORT MEDICAL GROUP INC 611 SHERMAN AVENUE EAST FORT ATKINSON WI 53538 PHYSICIAN SERVICES 16127435 CERNER CORPORATION PO BOX 959156 ST LOUIS MO 63195 PROFESSIONAL SERVICES 5713792 UNIVERSITY OF WISCONSIN MEDICAL FOUNDATI 600 HIGHLAND AVENUE MADISON WI 53792 RADIOLOGY SERVICES 1872879 JP CULLEN AND SONS INC 330 E DELAVAN DR JANESVILLE WI 53546 CONSTRUCTION SERVICES 1007673 GE HEALTHCARE SYSTEMS PO BOX 96483 CHICAGO IL 60693 EQUIPMENT MAINTENANCE 670736 25 44103 8518647 77448 8640198 HOSPITAL SERVICES 623000 77630274 77630274 PHYSICIAN CLINIC REVENUE 621110 27801088 27801088 OTHER OPERATING REVENUE 623990 11565045 11222640 342405 RENTAL INCOME - SPECIALTY CLINIC 621610 286765 286765 117283172 2286441 2286441 109549 120908 -11359 -11359 -11359 45858044 445375 47326099 190338 -1468055 255037 -1213018 -1213018 EQUITY INCOME 623000 1035405 233113 802292 1035405 128020839 117173880 0 2206761 X 125280 125280 1016833 1016833 39316962 36944642 2261091 111229 1445569 1277942 164524 3103 7274719 6679622 583732 11365 2683153 2513631 161086 8436 2562060 2562060 25978 21770 4208 58100 58100 30109851 28427858 1681993 487135 25325 461810 11969042 11672588 296432 22 4464409 4464409 4167665 3314297 852110 1258 41150 39008 1386 756 2205480 2205480 6378881 2968816 3405037 5028 276122 6107 270015 PROVISION FOR BAD DEBTS 2492930 2492930 HOSPITAL ASSESSMENT 1965394 1965394 EAR PROJECT 1134756 1134756 EQUIPMENT 499065 421244 77821 1710690 1468485 234896 7309 122411224 102096361 20166357 148506 13571596 23167067 18956257 18528261 2319014 2633625 1835143 1895806 154376921 109452527 46929690 44924394 102664566 103905450 22771960 29807234 3815638 4205143 212863864 229066980 10185151 11623386 37658839 35481438 225086 210756 11204420 17100573 59273496 64416153 X 153590368 164650827 153590368 164650827 212863864 229066980 5609615 5450844 0 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 9401 9401 0 PART II-B, LINE 1: LOBBYING PORTION OF DUES PAID TO WHA AND AHA. 1752926 1752926 74827943 46275036 28552907 74893787 63177491 11716296 2902265 2902265 44924394 ALTERNATIVE INVESTMENTS 29807234 F 29807234 DEFERRED COMPENSATION 1638737 CAPITAL LEASE OBLIGATIONS 5837218 DEFERRED GAIN OF SALES-LEASEBACK 818504 RELATED PARTY PAYABLE 1306114 MEDICARE ADVANCEMENT PAYABLE 7500000 17100573 X 133082250 5450844 -510341 4940503 128141747 -120908 -120908 128020839 122021791 120908 120908 121900883 510341 510341 122411224 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 ARE 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. PART XI, LINE 2D - OTHER ADJUSTMENTS: BAD DEBT INCLUDED IN EXPENSES -2,492,930. RENTAL INCOME 1,982,589. PART XI, LINE 4B - OTHER ADJUSTMENTS: RENTAL EXPENSES -120,908. PART XII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES 120,908. PART XII, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT INCLUDED IN EXPENSES 2,492,930. RENTAL INCOME -1,982,589. 1 1 X 1 X 1 X 1 1 0 1 1 564756 564756 0.00470 14540620 3505019 11035601 0.09200 15105376 3505019 11600357 0.09670 1531185 656506 874679 0.00730 192041 4435 187606 0.00160 1723226 660941 1062285 0.00890 16828602 4165960 12662642 0.10560 0 2492930 174505 15383634 17341309 -1957675 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 18 1 1 1 1 X SEE STATEMENT FOR LINE 7D X X 1 18 1 SEE STATEMENT FOR LINE 7D 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: BEAVER DAM COMMUNITY HOSPITAL 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: BEAVER DAM COMMUNITY HOSPITAL, THE DODGE COUNTY HUMAN SERVICES AND HEALTH DEPARTMENT, FORT HEALTHCARE, GREATER WATERTOWN COMMUNITY HEALTH FOUNDATION, JEFFERSON COUNTY HEALTH DEPARTMENT, WATERTOWN DEPARTMENT OF PUBLIC HEALTH, AND WATERTOWN REGIONAL MEDICAL CENTER, REFERRED TO AS "THE PARTNERSHIP." FORT HEALTHCARE, INC. PART V, SECTION B, LINE 7D: WWW.FORTHEALTHCARE.COM/COMMUNITY-HEALTH-NEEDS-ASSESSMENT/ FORT HEALTHCARE, INC. PART V, SECTION B, LINE 11: FORT HEALTHCARE CONTINUES TO SUPPORT THE WORK OF THE ROCK RIVER COMMUNITY CLINIC AND THE COMMUNITY DENTAL CLINIC, WHICH OFFERS FREE SERVICES TO THOSE WHO LIVE IN OUR SERVICE AREA. ADDITIONALY, WE CONTINUE TO ADDRESS OBESITY AND LACK OF PHYSICAL ACTIVITY THROUGH TARGETED COMMUNITY PROGRAMS OFFERED IN ALL OF THE COMMUNITIES WE SERVE. FORT HEALTHCARE CONTINUES TO OFFER A FREE WELLNESS CHALLENGE, SLIMDOWN, TO EDUCATE AND MOTIVATE THE GENERAL PUBLIC TO LIVE WELL AND MAKE GOOD, HEALTHY FOOD CHOICES. WITH REGARD TO PHYSICAL ACTIVITY WE CONTINUE TO OFFER ROCK THE WALK STEP CHALLENGE, FREE TO ALL COMMUNITY MEMBERS, IN AN EFFORT TO INCREASE KNOWLEDGE REGARDING THE BENEFITS OF REGULAR PHYSICAL ACTIVITY. 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. 12 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 - CENTER FOR WOMEN'S HEALTH 650 MCMILLEN STREET FORT ATKINSON WI 53538 OBSTETRICS AND GYNECOLOGY 4 - INTERNAL MEDICINE & PEDIATRICS 500 MCMILLEN STREET FORT ATKINSON WI 53538 INTERNAL MEDICINE & PEDIATRICS, BEHAVIORAL HEALTH 5 - EAR NOSE & THROAT SPECIALISTS 512 WILCOX STREET FORT ATKINSON WI 53538 ENT 6 - LAKE MILLS CLINIC 200 EAST TYRANENA PARK ROAD LAKE MILLS WI 53551 FAMILY PRACTICE, BEHAVIORAL HEALTH, ORTHOPAEDIC 7 - INTEGRATED FAMILY CARE 1520 MADISON AVENUE FORT ATKINSON WI 53538 FAMILY PRACTICE, BEHAVIORAL HEALTH 8 - DERMATOLOGY 611 SHERMAN AVENUE EAST 3RD FLOOR FORT ATKINSON WI 53538 DERMATOLOGY 9 - JOHNSON CREEK 400 DOCTORS COURT JOHNSON CREEK WI 53038 FAMILY PRACTICE, WOUND & EDEMA 10 - JEFFERSON 840 WEST RACINE STREET JEFFERSON WI 53549 FAMILY PRACTICE, ORTHOPAEDIC 11 - CAMBRIDGE CLINIC 704 KATIE COURT CAMBRIDGE WI 53523 FAMILY PRACTICE, BEHAVIORAL HEALTH, ORTHOPAEDIC 12 - WHITEWATER 1461 WEST MAIN STREET WHITEWATER WI 53190 OBSTETRICS & GYNECOLOGY, INTERNAL MEDICINE & PEDIATRICS, EAR, NOSE & THROAT PART I, LINE 7: OVERALL COST TO CHARGE RATIO PART I, LINE 7, COLUMN (F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $ 2,492,930. 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 MEDICAL GROUP (OWNED BY 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 / 2020 CHARITY CARE $1,464,769. 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-OFFSRATIONALE 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. FORT HEALTHCARE HAS CREATED COMMUNITY HEALTH COALITIONS THROUGHOUT THE SERVICE AREA AND CONTINUES TO WORK CLOSELY WITH THOSE. 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/BEHAVIORIAL 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 48,000 HOUSEHOLDS WITHIN THE PRIMARY SERVICE AREA AS AN INSERT INTO THE HEALTH365 COMMUNITY MAGAZINE. 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 INCLUDING FULL FUNDING FOR A 0.6 FTE APNP OR PROVIDER AND SUBSIDIZED LAB AND RADIOLOGY SERVICES. 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 MEDICAL GROUP (OWNED BY 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 GLACIAL HERITAGE DEVELOPMENT PARTNERSHIP 864 COLLINS ROAD SUITE 111 JEFFERSON WI 53549 813362283 501(C)(3) 30000 ECOMONIC DEVELOPMENT INVESTMENT - THRIVE 2021 "GROWING PROSPERITY IN JEFFERSON & DODGE COUNTIES" SCHOOL DISTRICT OF JEFFERSON 206 SOUTH TAFT STREET JEFFERSON WI 53549 391207754 CITY OF JEFFERSON 5000 POOL VENUE SPONSOR ROCK RIVER COMMUNITY CLINIC 520 HANDEYSIDE LN FORT ATKINSON WI 53538 205297560 501(C)(3) 65180 SUPPORT OF CLINIC'S TAX EXEMPT HEALTHCARE OPERATIONS DISCOVER WHITEWATER SERIES 405 PANTHER CT WHITEWATER WI 53190 455010028 501(C)(3) 5000 RUNNING SERIES TITLE SPONSOR FORT ATKINSON CHAMBER OF COMMERCE 244 N MAIN ST FORT ATKINSON WI 53538 390286155 501(C)(3) 7100 GOLF SCRAMBLE FLAG SPONSOR; FARMER'S MARKET SPONSOR; FOOD ACCESS PROGRAM SPONSOR; PROJECT LEAD SPONSOR; NEW TEACHER WELCOME SPONSOR SCHOOL DISTRICT OF FORT ATKINSON 201 PARK ST FORT ATKINSON WI 53538 396008361 CITY OF FORT ATKINSO 5000 HIGH SCHOOL SCORER'S TABLE SPONSOR YOUNG AUDITORIUM 930 W MAIN ST WHITEWATER WI 53190 391805963 501(C)(3) 7500 PERFORMING ARTS VENUE SPONSOR 7 0 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 0 0 0 1 0 0 0 0 MATTHEW BLISS MD PHYSICIAN 0 1027038 0 194373 0 4052 0 11200 0 13200 0 1249863 0 0 MICHAEL ANDERSON MD SECRETARY 0 565957 0 564781 0 3620 0 11200 0 27075 0 1172633 0 0 ISIDORO ZAMBRANO MD PHYSICIAN 0 761312 0 142103 0 3620 0 11200 0 27075 0 945310 0 0 PAUL SCHUPPNER DO PHYSICIAN 0 709554 0 102485 0 3350 0 11200 0 14158 0 840747 0 0 MICHAEL WALLACE PRESIDENT/CEO 422058 0 123196 0 15858 0 11200 0 27959 0 600271 0 0 0 WILLIAM HOFMANN MD PHYSICIAN 0 450426 0 65141 0 5132 0 10000 0 11264 0 541963 0 0 BILLIE KONTNY MD BOARD MEMBER 0 404491 0 41138 0 5132 0 11200 0 28852 0 490813 0 0 JONATHAN MCLAUGHLIN MD PHYSICIAN 0 402660 0 41138 0 5133 0 11200 0 29237 0 489368 0 0 JAMES NELSON SR. VICE PRESIDENT / CFO 246798 0 48410 0 5453 0 11200 0 27957 0 339818 0 0 0 STEPHANIE NOTTESTAD MD BOARD MEMBER 0 219488 0 46250 0 657 0 8444 0 31416 0 306255 0 0 PART I, LINE 5 PHYSICIAN COMPENSATION IS TIED TO THE NET REVENUES OF THEIR PRACTICE. A WISCONSIN HEALTH & EDUCATIONAL FACILITIES AUTHORITY 391337855 97712DJH0 2014-12-01 28195000 CONSTRUCTION & EQUIPMENT 0 0 0 B WISCONSIN HEALTH & EDUCATIONAL FACILITIES AUTHORITY 391337855 97710V4Q8 2015-06-30 16480000 CONSTRUCTION & EQUIPMENT & REFUNDING PRIOR ISSUE 0 0 0 A 1220000 28195000 4497804 350383 23346813 2014 0 1 1 1 B 805000 16480000 180000 16300000 2014 0 1 1 1 A 0 0 0 0 0 0 0 B 0 0 0 0 0 0 0 A 0 1 0 0 0 0 0 0 0 B 0 1 0 0 0 0 0 0 0 A 1 B 1 MEDICAL HEALTH BUILDING GROUP PARTNERSHIP OWNED BY BOARD MEMBER BILLIE KONTNY 2247356 RENT FOR THE LEASE OF OFFICE SPACE 0 FORM 990, PART VI, SECTION B, LINE 11B THE 990 IS REVIEWED BY THE ORGANIZATION'S ACCOUNTING MANAGER AND CFO. A COPY OF THE 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 1,681,993. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,681,993. ANESTHESIA CRNA SERVICES: PROGRAM SERVICE EXPENSES 1,926,055. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,926,055. BEHAVIORAL HEALTH SERVICES: PROGRAM SERVICE EXPENSES 507,012. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 507,012. CENTER FOR DERMATALOGY SERVICES: PROGRAM SERVICE EXPENSES 618,170. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 618,170. CENTER FOR WOMEN'S HEALTH SERVICES: PROGRAM SERVICE EXPENSES 2,039,853. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,039,853. ENT SERVICES: PROGRAM SERVICE EXPENSES 1,279,003. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,279,003. HOSPITALISTS BILLING SERVICES: PROGRAM SERVICE EXPENSES 2,384,103. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,384,103. INTEGRATED FAMILY CARE SERVICES: PROGRAM SERVICE EXPENSES 720,537. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 720,537. INTERNAL MEDICINE SERVICES: PROGRAM SERVICE EXPENSES 1,164,186. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,164,186. LABORATORY SERVICES: PROGRAM SERVICE EXPENSES 1,638,880. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,638,880. LAKE MILLS SERVICES: PROGRAM SERVICE EXPENSES 884,106. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 884,106. ORTHOPAEDICS SERVICES: PROGRAM SERVICE EXPENSES 3,368,016. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 3,368,016. OTHER MEDICAL & PHYSICIAN SERVICES: PROGRAM SERVICE EXPENSES 5,257,766. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 5,257,766. PATIENT FINANCIAL SERVICES: PROGRAM SERVICE EXPENSES 1,236,032. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,236,032. PEDIATRICS SERVICES: PROGRAM SERVICE EXPENSES 1,124,766. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,124,766. RADIOLOGY SERVICES: PROGRAM SERVICE EXPENSES 2,434,066. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,434,066. SURGICAL ASSOCIATES SERVICES: PROGRAM SERVICE EXPENSES 1,845,307. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,845,307. PART XII, LINE 2C THIS PROCESS HAS NOT CHANGED FROM PRIOR YEAR. 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 284613 1150188 0 0 0.33330 FORT MEDICAL GROUP INC 611 SHERMAN AVENUE EAST FORT ATKINSON WI 53538 391736513 PROVIDE PHYSICIAN SERVICES WI FORT HEALTHCARE INC C 16127435 3115752 1.00000 1 FORTCARE INC 611 SHERMAN AVENUE EAST FORT ATKINSON WI 53538 391725831 PREFERRED PROVIDER ORGANIZATION WI FORT HEALTHCARE INC C 3273 74776 1.00000 1 0 0 1 0 0 0 0 0 0 0 0 0 0 1 1 1 1 0 0 FORT MEMORIAL HOSPITAL FOUNDATION INC Q 138898 FAIR MARKET VALUE FORT MEDICAL GROUP INC P 16127435 FAIR MARKET VALUE