2019-08-13T09:10:37-05:00 2018-09-30 390758449 WIPFLI LLP PO BOX 12237 GREEN BAY WI 543072237 990 2017-10-01 390286215 FORT HEALTHCARE INC FORT 8004214677 611 SHERMAN AVENUE EAST FORT ATKINSON WI 53538 JAMES NELSON SR. VICE PRESIDENT / CFO 8004214677 2019-08-12 1 TERRI REXRODE CPA MST P00096513 9206620016 2019-08-12 74.87.127.216 2019-08-12 12:55:30 CD P DA39A3EE5E6B4B0D3255BFEF95601890AFD80709 A43ECD1EE6AF4781A69F6BFA161A98BDE8FA2C07 2017 2019-02-21 02:37:17Z JAMES NELSON 611 SHERMAN AVENUE EAST FORT ATKINSON WI 53538 146474938 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 9 960 230 0 26140 202361 121932 122773725 124382394 7659204 2886005 1065138 967231 131700428 128357562 0 192200 0 0 47438266 49410026 0 0 0 72501304 71897740 119939570 121499966 11760858 6857596 200331339 204073380 67177917 61886880 133153422 142186500 X OUR MISSION AT FORT HEALTHCARE IS TO IMPROVE THE HEALTH AND WELL-BEING OF OUR COMMUNITY. 0 1 73204718 129888 92034952 OPERATION OF A 49-BED ACUTE CARE FACILITY WITH AN EMERGENCY ROOM AND FULL COMPLEMENT OF ANCILLARY SERVICES. 35118932 62312 32347442 OPERATION OF PHYSICIAN CLINICS WITH OUTREACH INTO THE SURROUNDING COMMUNITIES. 0 0 504857 EQUITY INCOME IN UNCONSOLIDATED AFFILIATES - HEALTH CLINIC 108323650 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 1 138 0 960 1 1 1 0 0 0 0 0 0 0 0 0 X 13 9 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 MEDICAL DIRECTOR-PERIOPERATIVE SVCS 3.00 40.00 X 0 858074 40204 MARY BECK METZGER BOARD MEMBER 40.00 1.00 X 62948 0 17174 KATHI CAULEY BOARD MEMBER 3.00 X 0 0 0 JAMES FITZPATRICK PHD BOARD MEMBER 3.00 1.00 X 0 0 0 BILLIE KONTNY MD BOARD MEMBER 3.00 40.00 X 0 500455 42754 CRAIG KOZLER MD BOARD MEMBER (THRU 5/1/18) 3.00 40.00 X 0 537265 41054 SHAUNA MEYER CHIEF OF STAFF 3.00 40.00 X 0 0 0 SHARON SCHMELING BOARD MEMBER (THRU 1/31/18) 3.00 1.00 X 0 0 0 RICHARD TELFER BOARD MEMBER 3.00 1.00 X 0 0 0 THOMAS VINZ BOARD MEMBER 3.00 1.00 X 0 0 0 MICHAEL WALLACE PRESIDENT/CEO 40.00 1.00 X X 504394 0 42787 MICHAEL RUMPF CHAIR 3.00 1.00 X X 0 0 0 MARY BEHLING VICE CHAIR 3.00 X X 0 0 0 BARRY CASH MD SECRETARY 3.00 X X 0 0 0 DEAN JOHNSON TREASURER (THRU 1/31/18) 3.00 1.00 X X 0 0 0 ROY BUDLONG TREASURER 3.00 1.00 X X 0 0 0 JAMES NELSON SR. VICE PRESIDENT / CFO 40.00 1.00 X 273490 0 42787 JAMES FOSKETT MD PHYSICIAN 0.00 40.00 X 0 528563 31279 CHRISTOPHER MANAKAS MD PHYSICIAN 0.00 40.00 X 0 547621 41054 JONATHAN MCLAUGHLIN MD MEDICAL DIRECTOR 0.00 40.00 X 0 527437 42787 PAUL SCHUPPNER DO PHYSICIAN 0.00 40.00 X 0 698822 33903 ISIDORO ZAMBRANO MD PHYSICIAN 0.00 40.00 X 0 844979 40204 840832 5043216 415987 27 0 1 0 FORT MEDICAL GROUP INC 611 SHERMAN AVENUE EAST FORT ATKINSON WI 53538 PHYSICIAN SERVICES 16674550 CERNER CORPORATION PO BOX 959156 ST LOUIS MO 63195 PROFESSIONAL SERVICES 5608757 GE HEALTHCARE SYSTEMS PO BOX 96483 CHICAGO IL 60693 EQUIPMENT MAINTENANCE 2437464 UNIVERSITY OF WISCONSIN MEDICAL FOUNDATI 7974 UW HEALTH COURT MIDDLETON WI 53562 RADIOLOGY SERVICES 1716011 J P CULLEN & SONS INC PO BOX 5957 JANESVILLE WI 53547 BUILDING MAINTENANCE 1059950 18 28416 93516 121932 HOSPITAL SERVICES 623000 83525350 83525350 PHYSICIAN CLINIC REVENUE 621110 29468220 29468220 OTHER OPERATING REVENUE 623990 11128871 11128871 RENTAL INCOME - SPECIALTY CLINIC 621610 259953 259953 124382394 1834969 1834969 86489 101601 -15112 -15112 -15112 17882134 1184677 17560753 455022 321381 729655 1051036 1051036 EQUITY INCOME 623000 982343 504857 477486 982343 128357562 124887251 0 3348379 X 192200 192200 976033 976033 37587569 33765644 3821925 1408024 1257094 150930 6757744 5989755 767989 2680656 2352704 327952 2222878 2222878 87328 87328 57123 57123 30743712 29166284 1577428 582873 149523 433350 12420977 12280375 140602 4148338 4148338 3973502 3934029 39473 59248 55854 3394 2575875 2575875 7241620 7203453 38167 262639 211393 51246 PROVISION FOR BAD DEBTS 2579157 2579157 HOSPITAL ASSESSMENT 2072979 2072979 EAR PROJECT 1102692 1102692 LAUNDRY 459083 416095 42988 1307716 943185 364531 121499966 108323650 13176316 0 16007972 14338557 13886488 16740821 2320500 2349971 1570910 1763702 172037302 121583007 54749730 50454295 103773069 80024728 3814476 34382518 4208194 4018788 200331339 204073380 12213213 9688805 42205170 39780367 0 241414 12759534 12176294 67177917 61886880 X 133153422 142186500 133153422 142186500 200331339 204073380 6857596 2175482 0 X X 0 1 X 1 0 X 0 0 0 0 0 0 0 0 1 8912 8912 0 PART II-B, LINE 1: LOBBYING PORTION OF DUES PAID TO WHA AND AHA. 1752926 1752926 85110065 52534738 32575327 84132799 69048269 15084530 1041512 1041512 50454295 CERTIFICATES OF DEPOSIT 1285126 F U.S. GOVERNMENT AND AGENCY OBLIGATIONS 6456947 F FIXED INCOME SECURITIES 4267513 F ALTERNATIVE INVESTMENTS 22372932 F 34382518 DEFERRED COMPENSATION 1355081 CAPITAL LEASE OBLIGATIONS 7866531 DEFERRED GAIN OF SALES-LEASEBACK 1349427 RELATED PARTY PAYABLE 1605255 12176294 X 129930178 2175482 -2477556 -302074 130232252 -1874690 -1874690 128357562 120897100 101601 101601 120795499 704467 704467 121499966 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 -2,579,157. RENTAL EXPENSES 101,601. PART XI, LINE 4B - OTHER ADJUSTMENTS: RENTAL INCOME -1,874,690. PART XII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES 101,601. PART XII, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT INCLUDED IN EXPENSES 2,579,157. RENTAL INCOME -1,874,690. 1 1 X 1 X 1 X 1 1 1 0 1 1 616095 616095 0.00520 14072078 1929874 12142204 0.10210 14688173 1929874 12758299 0.10730 1729566 578271 1151295 0.00970 234205 234205 0.00200 1963771 578271 1385500 0.01170 16651944 2508145 14143799 0.11900 0 2579157 180541 20208693 23620286 -3411593 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 17 1 0 1 1 X SEE STATEMENT FOR LINE 7D X X 1 17 1 HTTPS://WWW.FORTHEALTHCARE.COM/ABOUT-US/MISSION-VISION-STRATEGIC-PLAN/ 0 1 X 200.000000000000 400.000000000000 X X 1 1 X X X 1 X HTTPS://WWW.FORTHEALTHCARE.COM/PATIENT-INFO/FINANCIAL-AID/ X HTTPS://WWW.FORTHEALTHCARE.COM/PATIENT-INFO/FINANCIAL-AID/ X HTTPS://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: TWO FEEDBACK SESSIONS OPEN TO THE PUBLIC WERE HELD. 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 6B: JEFFERSON COUNTY HEALTHIER COMMUNITIES PARTNERSHIP FORT HEALTHCARE, INC. PART V, SECTION B, LINE 7D: HTTPS://WWW.FORTHEALTHCARE.COM/COMMUNITY-HEALTH-NEEDS-ASSESSMENT/ FORT HEALTHCARE, INC. PART V, SECTION B, LINE 11: FORT HEALTHCARE CONTINUES SUPPORT OF THE ROCK RIVER FREE CLINIC (RRFC) AND THE COMMUNITY DENTAL CLINIC SEAL A SMILE PROGRAM. IMPLEMENT THE PROTOCOL FOR RESPONDING TO AND ASSESSING PATIENTS' ASSETS, RISKS, AND EXPERIENCES (PRAPARE). CURRENTLY, IT IS ESTIMATED THAT OVER 6,000 RESIDENTS OF OUR SERVICE AREA ARE WITHOUT HEALTH INSURANCE. WE CONTINUE TO PROVIDE FINANCIAL SUPPORT FOR THESE INITIATIVES. FORT HEALTHCARE CONTINUES TO SUPPLY A FULL TIME PROVIDER TO STAFF RRFC. WE CONTINUE TO SUPPORT COMMUNITY BASED SOCIAL SUPPORT OF PHYSICAL ACTIVITY WALKING GROUPS, MULTI-LEVEL HEALTH BEHAVIOR PROGRAMS, AND INCREASE THE NUMBER OF COMMUNITY FITNESS PROGRAMS, COMMUNITY COMPLETE STREETS INITIATIVES, AND SCHOOLS AND COMMUNITIES WORKING TOWARD SAFE ROUTES TO SCHOOLS IN OUR AREA. WE CONTINUE TO PROVIDE INDOOR WALKING PATH, SUPPORT OF OUTDOOR WALKING PROGRAMS, WEEKLY EDUCATION AND FITNESS PROGRAMS. CONTINUED SUPPORT OF HEALTHY COMMUNITY COALITIONS, WEIGHT MANAGEMENT AND NUTRITION PROGRAMS IN OUR PRIMARY CARE CLINICS AND OUT IN OUR COMMUNITIES. THE GOAL OF THESE INITIATIVES IS TO REACH ALL RESIDENTS WITHIN JEFFERSON COUNTY AS WELL AS SOME SURROUNDING COMMUNITIES THAT PARTIALLY FALL WITHIN JEFFERSON COUNTY SUCH AS WHITEWATER, CAMBRIDGE, WATERLOO AND WATERTOWN. COMMUNITY MEMBERS ACROSS THE LIFESPAN WILL MAKE HEALTHIER CHOICES, SUPPORTING IMPROVED PERSONAL NUTRITION AND HEALTHY WEIGHT. MULTI-LEVEL DIET AND EXERCISE STRATEGIES. OUR PARTNERS FOR THESE INITIATIVES INCLUDE AMERICORPS FARM TO SCHOOL PROGRAM, SCHOOL GARDEN INITIATIVES, MEALS ON WHEELS, FAITH BASED COMMUNITY MEAL PROGRAMS, AND OUR NUTRITION PROGRAM PARTNERS. 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 - CENTER FOR WOMEN'S HEALTH 650 MCMILLEN STREET FORT ATKINSON WI 53538 OBSTETRICS AND GYNECOLOGY 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 - WHITEWATER 1461 WEST MAIN STREET WHITEWATER WI 53190 OBSTETRICS & GYNECOLOGY, INTERNAL MEDICINE & PEDIATRICS, EAR, NOSE & THROAT 8 - INTERNAL MEDICINE & PEDIATRICS 500 MCMILLEN STREET FORT ATKINSON WI 53538 INTERNAL MEDICINE & PEDIATRICS, BEHAVIORAL HEALTH 9 - DERMATOLOGY 611 SHERMAN AVENUE EAST 3RD FLOOR FORT ATKINSON WI 53538 DERMATOLOGY 10 - UROLOGY ASSOCIATES 520 HANDEYSIDE LANE SUITE 2 FORT ATKINSON WI 53538 UROLOGY 11 - CAMBRIDGE CLINIC 704 KATIE COURT CAMBRIDGE WI 53523 FAMILY PRACTICE, BEHAVIORAL HEALTH, ORTHOPAEDIC 12 - JEFFERSON 840 WEST RACINE STREET JEFFERSON WI 53549 FAMILY PRACTICE, ORTHOPAEDIC 13 - JOHNSON CREEK 400 DOCTORS COURT JOHNSON CREEK WI 53038 FAMILY PRACTICE, WOUND & EDEMA 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 $ 2,579,157. PART II, COMMUNITY BUILDING ACTIVITIES: FORT HEALTHCARE GIVES GENEROUSLY TO AREA COMMUNITY ORGANIZATIONS. FORT HEALTHCARE PROVIDES FUNDS IN DIRECT SUPPPORT OF COMMUNITY EVENTS. FORT HEALTHCARE IS ACTIVELY ENGAGING THE COMMUNITY TO BUILD COLLABORATIVE RELATIONSHIPS WITH THE GOAL OF AFFECTING OBESITY, ACCESS TO CARE, DIET, FITNESS, NUTRITION, MENTAL HEALTH AND OVERALL HEALTH NEEDS. FORT HEALTHCARE'S RESOURCES TO SUPPORT THESE ACTIVITIES INCLUDE SIGNIFICANT STAFF TIME, VOLUNTEER TIME, MEDICAL SUPPLIES, GIVEAWAY ITEMS AND MORE. FORT HEALTHCARE'S STAFF SERVE ON THE BOARD OF DIRECTORS FOR A NUMBER OF LOCAL NON-PROFIT AGENCIES. FORT HEALTHCARE IS SUPPORTIVE OF UNITED WAY, TOMORROW'S HOPE, RAINBOW HOSPICE AND MANY OTHER FUNDRAISING CAUSES IN THE COMMUNITY. THE COMMUNITY HEALTH AND WELLNESS DEPARTMENT IS ACTIVELY ENGAGING NON-PROFIT ENTITIES IN AREA COMMUNITIES TO BUILD COLLABORATIVE RELATIONSHIPS WITH THE GOAL OF AFFECTING OBESITY, ACCESS TO CARE, DIET, FITNESS AND NUTRITION. THE COALITIONS ARE ENGAGED IN A CONCERTED EFFORT TO REDUCE THE OBESITY RATE IN JEFFERSON COUNTY. EACH COALITION IS ACTIVELY DEVELOPING STRATEGIES TO IMPLEMENT IN THEIR LOCAL COMMUNITIES, FOCUSING THE PRIORITIES ON INCREASING ACCESS TO HEALTHY FOODS, PROMOTING PHYSICAL ACTIVITITY AND NUTRITION. 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. 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. AN ANNUAL COMMUNITY HEALTH ASSESSMENT IS IMPLEMENTED AND THE MOST RECENT ONE WAS POSTED IN MARCH OF 2018. THE PRIMARY RESEARCH TOOLS ARE SURVEYS, COMMUNITY FOCUS GROUPS AND MEETINGS. MANY QUESTIONS RELATE SPECIFICALLY TO HEALTH NEEDS, CONCERNS, 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 FREE CLINIC, A FREE AND REDUCED CARE CLINIC FUNDED IN A SIGNIFICANT MANNER BY FORT HEALTHCARE INCLUDING FULL FUNDING FOR A 1.0 FTE PHYSICIAN 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 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: 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 CITY OF FORT ATKINSON 101 NORTH MAIN STREET FORT ATKINSON WI 53534 396005451 CITY OF FORT ATKINSO 15000 EMS SUPPORT CITY OF JEFFERSON 317 SOUTH MAIN STREET JEFFERSON WI 53549 396005474 CITY OF JEFFERSON 128000 PARAMEDIC SUPPORT FORT ATKINSON COMMUNITY FOUNDATION 244 NORTH MAIN STREET FORT ATKINSON WI 53538 396220899 501(C)(3) 5000 FORT ATKINSON WHEELS PARK GLACIAL HERITAGE DEVELOPMENT PARTNERSHIP 864 COLLINS ROAD SUITE 111 JEFFERSON WI 53549 813362283 501(C)(3) 42500 GENERAL SUPPORT 4 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. THE HOSPITAL HAS CHOSEN THREE AREAS FOR FUNDING: EMS SUPPORT, PARAMEDIC SUPPORT, AND LOCAL WELLNESS INITIATIVES. X X X X X X 0 0 0 0 1 0 0 0 0 MICHAEL ANDERSON MD MEDICAL DIRECTOR-PERIOPERATIVE SVCS 0 471101 0 383915 0 3058 0 10800 0 29404 0 898278 0 0 BILLIE KONTNY MD BOARD MEMBER 0 428597 0 67287 0 4571 0 10800 0 31954 0 543209 0 0 CRAIG KOZLER MD BOARD MEMBER (THRU 5/1/18) 0 509726 0 24481 0 3058 0 10800 0 30254 0 578319 0 0 MICHAEL WALLACE PRESIDENT/CEO 387419 0 101555 0 15420 0 10800 0 31987 0 547181 0 0 0 JAMES NELSON SR. VICE PRESIDENT / CFO 218854 0 50926 0 3710 0 10800 0 31987 0 316277 0 0 0 JAMES FOSKETT MD PHYSICIAN 0 509102 0 15508 0 3953 0 10800 0 20479 0 559842 0 0 CHRISTOPHER MANAKAS MD PHYSICIAN 0 525301 0 19641 0 2679 0 10800 0 30254 0 588675 0 0 JONATHAN MCLAUGHLIN MD MEDICAL DIRECTOR 0 449346 0 73521 0 4570 0 10800 0 31987 0 570224 0 0 PAUL SCHUPPNER DO PHYSICIAN 0 629986 0 66102 0 2734 0 10800 0 23103 0 732725 0 0 ISIDORO ZAMBRANO MD PHYSICIAN 0 759897 0 82024 0 3058 0 10800 0 29404 0 885183 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 1125000 28195000 4497804 350383 23346813 2014 0 1 1 1 B 765000 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 MELANIE RUMPF WIFE OF BOARD MEMBER MICHAEL RUMPF 45406 EMPLOYEE 0 MEDICAL HEALTH BUILDING GROUP PARTNERSHIP OWNED BY BOARD MEMBER BILLIE KONTNY 2118349 RENT FOR THE LEASE OF OFFICE SPACE 0 FORM 990, PART III, LINE 3 AS OF MARCH 1, 2018, THE ACUTE CARE FACILITY REDUCED THE NUMBER OF BEDS FROM 72 TO 49. 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 ANESTHESIA CRNA SERVICES: PROGRAM SERVICE EXPENSES 1,790,312. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,790,312. CENTER FOR DERMATALOGY SERVICES: PROGRAM SERVICE EXPENSES 779,973. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 779,973. INFORMATION SYSTEMS SERVICES: PROGRAM SERVICE EXPENSES 882,068. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 882,068. ORTHOPAEDICS SERVICES: PROGRAM SERVICE EXPENSES 2,729,470. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,729,470. PEDIATRICS SERVICES: PROGRAM SERVICE EXPENSES 1,164,642. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,164,642. SURGICAL ASSOCIATES SERVICES: PROGRAM SERVICE EXPENSES 1,878,981. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,878,981. LABORATORY SERVICES: PROGRAM SERVICE EXPENSES 1,360,075. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,360,075. RADIOLOGY SERVICES: PROGRAM SERVICE EXPENSES 2,538,509. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,538,509. CENTER FOR WOMEN'S HEALTH SERVICES: PROGRAM SERVICE EXPENSES 1,890,918. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,890,918. LAKE MILLS SERVICES: PROGRAM SERVICE EXPENSES 1,239,353. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,239,353. HOSPITALISTS BILLING SERVICES: PROGRAM SERVICE EXPENSES 2,421,829. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,421,829. ENT SERVICES: PROGRAM SERVICE EXPENSES 1,378,762. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,378,762. OTHER MEDICAL & PHYSICIAN SERVICES: PROGRAM SERVICE EXPENSES 9,111,392. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 9,111,392. ADMIN PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 1,577,428. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,577,428. 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 130295 880367 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 3226591 1.00000 1 FORT CARE INC 611 SHERMAN AVENUE EAST FORT ATKINSON WI 53538 391725831 PREFERRED PROVIDER ORGANIZATION WI FORT HEALTHCARE INC C 2597 87435 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 152705 FAIR MARKET VALUE FORT MEDICAL GROUP INC P 16675840 FAIR MARKET VALUE