2019-11-18T15:09:20-06:00 2019-05-31 390758449 WIPFLI LLP PO BOX 8700 MADISON WI 537088700 990 2018-06-01 264321839 LAKESHORE COMMUNITY HEALTH CARE INC LAKE 9207836633 1721 SAEMANN AVENUE SHEBOYGAN WI 53081 KRISTIN BLANCHARD STEARNS CEO 9207836633 2019-11-06 1 BRITTANY MERGEN P01656288 6082741980 2019-11-06 108.67.179.172 2019-11-06 14:07:14 CS P DA39A3EE5E6B4B0D3255BFEF95601890AFD80709 B5AD917698A966612AE7A77B4536F2DC0D4C4089 2018 2020-03-31 21:24:44Z KRISTIN BLANCHARD STEARNS 1721 SAEMANN AVENUE SHEBOYGAN WI 53081 10994001 0 X WWW.LAKESHORECHC.ORG X 2009 WI LCHC STRIVES TO CREATE COMMUNITIES WHERE ALL PEOPLE LIVE HEALTHY, ACTIVE, AND PROSPEROUS LIVES. LCHC ASPIRES TO BE A PREFERRED PROVIDER AND AN EMPLOYER OF CHOICE. 14 14 139 16 0 0 5940904 2132094 7994589 8771921 54527 65106 4877 6048 13994897 10975169 462129 440609 0 0 7178082 7192998 79436 81309 90057 3662083 3839590 11381730 11554506 2613167 -579337 12204148 8999501 4067803 980363 8136345 8019138 LAKESHORE COMMUNITY HEALTH CARE PROVIDES ACCESS TO COMPREHENSIVE, INTEGRATED HEALTH CARE, REGARDLESS OF ABILITY TO PAY, ELIMINATING HEALTH DISPARITIES AMONG THE UNDERSERVED. 0 0 8640756 440609 8771921 LAKESHORE COMMUNITY HEALTH CARE, INC. PROVIDES HEALTH CARE SERVICES TO PEOPLE WHO STRUGGLE TO FIND A DOCTOR, DENTIST OR A COUNSELOR FOR CARE. THE ORGANIZATION ALSO PROVIDES PHARMACY AND CHIROPRACTIC SERVICES. THE ORGANIZATION WORKS WITH OUR COMMUNITY PARTNERS TO REFER PATIENTS FOR ANY SERVICES THE ORGANIZATION IS UNABLE TO PROVIDE. THE ORGANIZATION WORKS VERY HARD TO MAKE SURE PATIENTS GET WHAT THEY NEED, AND PROVIDE UP TO 90% DISCOUNTS FOR ANYONE WHO CANNOT AFFORD TO PAY FOR THESE SERVICES. 8640756 1 1 0 0 0 0 0 0 0 0 1 0 0 0 1 1 0 1 0 0 0 0 0 1 1 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 16 0 139 1 0 0 0 0 0 0 0 0 0 0 0 0 X 14 14 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 WI X MARTIN SCHALLER 9207836808 1721 SAEMANN AVENUE SHEBOYGAN WI 53081 DANA CLARK BOARD MEMBER (THRU 8/1/18) 2.00 X 0 0 0 MICHELE EDLER BOARD MEMBER 2.00 X 0 0 0 DEANNA FLOWERS BOARD MEMBER 2.00 X 0 0 0 BECK GROUMAN BOARD MEMBER 2.00 X 0 0 0 CARLY HAKALA BOARD MEMBER 2.00 X 0 0 0 SCOTT HAYES BOARD MEMBER 2.00 X 0 0 0 KATHY KURER BOARD MEMBER (THRU 6/7/18) 2.00 X 0 0 0 GERALYN LEANNAH BOARD MEMBER 2.00 X 0 0 0 DIANE LIEBENTHAL BOARD MEMBER 2.00 X 0 0 0 JOSEPH RUPNIK BOARD MEMBER 2.00 X 0 0 0 PENNY SENKBEIL BOARD MEMBER 2.00 X 0 0 0 BRENDA SMITH BOARD MEMBER 2.00 X 0 0 0 URIAH WARNER BOARD MEMBER 2.00 X 0 0 0 TAMMY HARRIS PRESIDENT 2.00 X X 0 0 0 BARBARA DODGE VICE PRESIDENT 2.00 X X 0 0 0 RACHEL LABORDE SECRETARY/TREASURER 2.00 X X 0 0 0 KRISTIN BLANCHARD STEARNS CEO 40.00 1.00 X 98313 0 25711 MARTIN SCHALLER CFO/COO 40.00 1.00 X 95624 0 29311 ROBERT WENBERG MD MEDICAL DIRECTOR 40.00 X 249972 0 37048 CASEY WILSON DDS DENTAL DIRECTOR 40.00 X 157669 0 17340 ASHLEY WALSH DDS DENTIST 40.00 X 143074 0 13467 MAURA DARNIEDER DDS DENTIST 40.00 X 122276 0 17646 KAREN LIM APNP FNP PSYCH 40.00 X 115838 0 18506 982766 0 159029 7 0 1 0 BARTON ASSOCIATES PO BOX 417844 BOSTON MA 02241 PHYSICIAN STAFFING SERVICES 463537 PLEXUS HEALTH SOLUTIONS INC PO BOX 0655 KENOSHA WI 53141 CONTRACT BILLING SERVICES 373662 SABERCOR LLC 2935 S FISH HATCHERY ROAD UNIT 283 FITCHBURG WI 53711 HOUSEKEEPING/JANITORIAL SERVICES 130451 T&K DENTAL LABS INC 2331 SUNFLOWER AVENUE SHEBOYGAN WI 53081 DENTAL PROSTHETICS LAB SERVICES 102101 4 25150 2066425 40519 2132094 PATIENT SERVICE REVENUE 621400 8427603 8427603 PHARMACY REVENUE 621400 311244 311244 33074 33074 8771921 68183 68183 3077 -3077 -3077 -3077 3276 25150 15755 -12479 -12479 18527 18527 18527 10975169 8771921 0 71154 X 440609 440609 269820 269820 5526896 4225295 1301601 191295 144042 47253 796110 564096 232014 408877 299198 109679 2321 117 2204 22600 86 22514 81309 81309 1186800 804647 382153 12063 6814 5249 63459 38467 24992 148979 90296 58683 732770 563888 168882 35965 18504 17461 67806 54863 12943 109143 74970 34173 223309 175118 48191 27492 16021 11471 MEDICAL SUPPLIES 653139 653106 33 OTHER STAFF SUPPORT 181548 137615 43933 EQUIPMENT 176558 150949 25609 ELECTRONIC HEALTH RECOR 170028 170028 25610 12027 4835 8748 11554506 8640756 2823693 90057 392641 712529 796502 1197826 4010723 383894 859743 858444 4955250 4955250 9787 7875 173034 131398 1702189 960938 868218 741251 138250 11034 12204148 8999501 898910 858580 3130901 93018 37992 28765 4067803 980363 X 3832165 7162846 4304180 856292 8136345 8019138 12204148 8999501 X -579337 462130 X 0 1 X 1 1 1 X SCHEDULE A: THE ORGANIZATION IS NOT LICENSED AS A HOSPITAL IN THE STATE OF WISCONSIN. THE ORGANIZATION HAS RECEIVED ITS IRS DETERMINATION LETTER SHOWING THAT THE ORGANIZATION'S PUBLIC CHARITY STATUS IS SECTION 170(B)(1)(A)(III). RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 204768 37458 167310 1497421 923480 573941 741251 CAPITAL LEASE OBLIGATIONS 28765 28765 X PART X, LINE 2: THE ORGANIZATION RECOGNIZES THE BENEFITS OF A TAX POSITION ONLY AFTER DETERMINING WHETHER IT IS MORE LIKELY THAN NOT THAT THE TAXING AUTHORITY WOULD SUSTAIN THE TAX POSITION UPON EXAMINATION OF THE TECHNICAL MERITS OF THE TAX POSITION, ASSUMING THE TAXING AUTHORITY HAS FULL KNOWLEDGE OF ALL INFORMATION. THE ORGNAIZATION RECORDED NO ASSETS OR LIABILITIES RELATED TO UNCERTAIN TAX POSITIONS. X X X X X 1 NON-PROFIT FUNDRAISING PARTNERS 1711 VAN HISE AVENUE MADISON WI 53726 CAPITAL CAMPAIGN FUNDRAISING, GRANT WRITING AND FUNDRAISING 0 3710328 81309 3629019 3710328 81309 3629019 WI CAVEMAN RUN 28426 25150 3276 4268 241 294 10952 28426 25150 3276 4268 241 294 10952 15755 -12479 1 LCHC QALICB INC 1721 SAEMANN AVENUE SHEBOYGAN WI 53081 815453995 501(C)(3) 440609 GENERAL SUPPORT 1 0 PART I, LINE 2: RECORDS ARE MAINTAINED FOR ALL BOARD APPROVALS FOR FUNDS DESIGNATED TO LCHC QALICB INC. X X 0 0 0 0 0 0 0 0 0 ROBERT WENBERG MD MEDICAL DIRECTOR 247992 0 0 0 1980 0 11550 0 25498 0 287020 0 0 0 CASEY WILSON DDS DENTAL DIRECTOR 157429 0 0 0 240 0 7360 0 9980 0 175009 0 0 0 ASHLEY WALSH DDS DENTIST 140158 0 0 0 2916 0 6369 0 7098 0 156541 0 0 0 FORM 990, PART VI, SECTION B, LINE 11B BOARD MEMBERS ARE GIVEN COPIES OF THE FORM 990 TO REVIEW BEFORE FILING WITH THE INTERNAL REVENUE SERVICE. FORM 990, PART VI, SECTION B, LINE 12C EVERY MEMBER OF THE ORGANIZATION SIGNS A CONFLICT OF INTEREST STATEMENT ANNUALLY. ADMINISTRATION MONITORS THIS WITH THE USE OF A CHECKLIST. EACH INDIVIDUAL SHALL DISCLOSE TO THE ORGANIZATION, ANY PERSONAL INTEREST THAT HE OR SHE MAY HAVE IN ANY MATTER PENDING BEFORE THE ORGANIZATION AND SHALL REFRAIN FROM PARTICIPATION IN ANY DECISION ON SUCH MATTER. FORM 990, PART VI, SECTION B, LINE 15 THE ORGANIZATION LOOKS AT NATIONAL AND LOCAL COMPARISON DATA FROM NACHC AND MGMA TO SET SALARY RANGES FOR EACH POSITION. ACTUAL SALARIES ARE DETERMINED BASED ON QUALIFICATIONS. FORM 990, PART VI, SECTION C, LINE 19 GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS ARE MADE AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART IX, LINE 11G TRANSLATION SERVICES: PROGRAM SERVICE EXPENSES 77,732. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 77,732. ADMINISTRATIVE SERVICES: PROGRAM SERVICE EXPENSES 11,738. MANAGEMENT AND GENERAL EXPENSES 33,211. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 44,949. BILLING SERVICES: PROGRAM SERVICE EXPENSES 539. MANAGEMENT AND GENERAL EXPENSES 348,942. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 349,481. DENTAL LAB SERVICES: PROGRAM SERVICE EXPENSES 171,212. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 171,212. CLINICAL SERVICES: PROGRAM SERVICE EXPENSES 543,426. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 543,426. FORM 990, PART XI, LINE 9: CHANGE IN NET ASSETS OF LCHC QALICB INC. 462,130. LCHC QALICB INC 1721 SAEMANN AVENUE SHEBOYGAN WI 53081 815453995 TO SUPPORT LAKESHORE COMMUNITY HEALTH CARE, INC. WI 501(C)(3) LINE 12A, I LAKESHORE COMMUNITY HEALTH CARE INC 1 0 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 LCHC QALICB INC B 440609 FAIR MARKET VALUE