MOUNDVIEW MEMORIAL HOSPITAL & CLINICS INC: Form 990, tax year 2015
View the entire original 990 at ProPublica ↗
- Organization
- MOUNDVIEW MEMORIAL HOSPITAL & CLINICS INC (EIN 39-0944012)
- Tax period
- 2015-07-01 to 2016-06-30
- Filed
- 2017-05-15
- IRS object ID
- 201721359349306302
- Schema version
- 2015v3.0
- Source
- Download XML · Original 990 at ProPublica
Every field in the e-filed return. Faint text is the IRS element name, for citing.
- Return header
- Form 990
- Schedule A
- Schedule B
- Schedule C
- Schedule D
- Schedule H
- Schedule J
- Schedule K
- Schedule L
- Schedule O
- Schedule R
Return header ReturnHeader
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return | 2017-05-15T12:43:22-05:00 | ReturnTs |
| Tax Period End | 2016-06-30 | TaxPeriodEndDt |
Preparer Firm PreparerFirmGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Firm EIN | 390758449 | PreparerFirmEIN |
Preparer Firm Name PreparerFirmName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | WIPFLI LLP | BusinessNameLine1Txt |
Preparer US Address PreparerUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | PO BOX 12237 | AddressLine1Txt |
| City | GREEN BAY | CityNm |
| State Abbreviation | WI | StateAbbreviationCd |
| ZIP | 543072237 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return Type | 990 | ReturnTypeCd |
| Tax Period Begin | 2015-07-01 | TaxPeriodBeginDt |
Filer Filer
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 390944012 | EIN |
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | MOUNDVIEW MEMORIAL HOSPITAL & CLINICS | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Control | MOUN | BusinessNameControlTxt |
| Phone | 6083393331 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 402 WEST LAKE STREET | AddressLine1Txt |
| City | FRIENDSHIP | CityNm |
| State Abbreviation | WI | StateAbbreviationCd |
| ZIP | 53934 | ZIPCd |
Business Officer BusinessOfficerGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person | DONALD HEINZ | PersonNm |
| Person Title | CEO | PersonTitleTxt |
| Phone | 6083393331 | PhoneNum |
| Signature | 2017-05-15 | SignatureDt |
| Discuss With Paid Preparer | Yes (1) | DiscussWithPaidPreparerInd |
Preparer Person PreparerPersonGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Person | TERRI REXRODE CPA MST | PreparerPersonNm |
| PTIN | P00096513 | PTIN |
| Phone | 9206620016 | PhoneNum |
| Preparation | 2017-05-15 | PreparationDt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tax | 2015 | TaxYr |
| Build TS | 2021-01-29 14:40:06Z | BuildTS |
Form 990 IRS990
| Field | Value | IRS element (for citing) |
|---|---|---|
| Principal Officer | DONALD HEINZ | PrincipalOfficerNm |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 402 WEST LAKE STREET | AddressLine1Txt |
| City | FRIENDSHIP | CityNm |
| State Abbreviation | WI | StateAbbreviationCd |
| ZIP | 53934 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Receipts | $21,358,450 | GrossReceiptsAmt |
| Group Return For Affiliates | 0 | GroupReturnForAffiliatesInd |
| Organization501c3 | Yes (X) | Organization501c3Ind |
| Website Address | WWW.MOUNDVIEW.ORG | WebsiteAddressTxt |
| Type Of Organization Corp | Yes (X) | TypeOfOrganizationCorpInd |
| Formation | 1959 | FormationYr |
| Legal Domicile State | WI | LegalDomicileStateCd |
| Activity Or Mission | MOUNDVIEW MEMORIAL HOSPITAL & CLINICS PROVIDES INPATIENT HOSPITAL AND GENERAL HEALTH CARE SERVICES WITH THE PRIMARY MARKET OF ADAMS COUNTY WISCONSIN BY OPERATING A 25 BED CRITICAL ACCESS HOSPITAL. | ActivityOrMissionDesc |
| Voting Members Governing Body | 7 | VotingMembersGoverningBodyCnt |
| Voting Members Independent | 7 | VotingMembersIndependentCnt |
| Total Employee | 167 | TotalEmployeeCnt |
| Total Volunteers | 60 | TotalVolunteersCnt |
| Total Gross UBI | $0 | TotalGrossUBIAmt |
| Net Unrelated Bus Txbl Incm | $0 | NetUnrelatedBusTxblIncmAmt |
| PY Contributions Grants | $33,654 | PYContributionsGrantsAmt |
| CY Contributions Grants | $147,649 | CYContributionsGrantsAmt |
| PY Program Service Revenue | $19,218,661 | PYProgramServiceRevenueAmt |
| CY Program Service Revenue | $20,714,051 | CYProgramServiceRevenueAmt |
| PY Investment Income | $34,396 | PYInvestmentIncomeAmt |
| CY Investment Income | $61,855 | CYInvestmentIncomeAmt |
| PY Other Revenue | $262,588 | PYOtherRevenueAmt |
| CY Other Revenue | $379,869 | CYOtherRevenueAmt |
| PY Total Revenue | $19,549,299 | PYTotalRevenueAmt |
| CY Total Revenue | $21,303,424 | CYTotalRevenueAmt |
| PY Grants And Similar Paid | $0 | PYGrantsAndSimilarPaidAmt |
| CY Grants And Similar Paid | $0 | CYGrantsAndSimilarPaidAmt |
| PY Benefits Paid To Members | $0 | PYBenefitsPaidToMembersAmt |
| CY Benefits Paid To Members | $0 | CYBenefitsPaidToMembersAmt |
| PY Salaries Comp Emp Bnft Paid | $8,092,356 | PYSalariesCompEmpBnftPaidAmt |
| CY Salaries Comp Emp Bnft Paid | $8,988,779 | CYSalariesCompEmpBnftPaidAmt |
| PY Total Prof Fndrsng Expns | $0 | PYTotalProfFndrsngExpnsAmt |
| CY Total Prof Fndrsng Expns | $0 | CYTotalProfFndrsngExpnsAmt |
| CY Total Fundraising Expense | $0 | CYTotalFundraisingExpenseAmt |
| PY Other Expenses | $10,245,028 | PYOtherExpensesAmt |
| CY Other Expenses | $10,261,237 | CYOtherExpensesAmt |
| PY Total Expenses | $18,337,384 | PYTotalExpensesAmt |
| CY Total Expenses | $19,250,016 | CYTotalExpensesAmt |
| PY Revenues Less Expenses | $1,211,915 | PYRevenuesLessExpensesAmt |
| CY Revenues Less Expenses | $2,053,408 | CYRevenuesLessExpensesAmt |
| Total Assets BOY | $16,086,782 | TotalAssetsBOYAmt |
| Total Assets EOY | $17,080,865 | TotalAssetsEOYAmt |
| Total Liabilities BOY | $8,163,444 | TotalLiabilitiesBOYAmt |
| Total Liabilities EOY | $7,110,411 | TotalLiabilitiesEOYAmt |
| Net Assets Or Fund Balances BOY | $7,923,338 | NetAssetsOrFundBalancesBOYAmt |
| Net Assets Or Fund Balances EOY | $9,970,454 | NetAssetsOrFundBalancesEOYAmt |
| Info In Schedule O Part III | Yes (X) | InfoInScheduleOPartIIIInd |
| Mission | MOUNDVIEW MEMORIAL HOSPITAL AND CLINICS, INCORPORATED, AS A COMMUNITY HEALTH RESOURCE WILL PROVIDE MODERN FACILITIES AND EQUIPMENT TO ENSURE THE DELIVERY OF SERVICES WITH AN EMPHASIS ON PRIMARY HEALTH CARE TO THE PEOPLE OF THE HOSPITAL SERVICE AREA. THE HOSPITAL'S LEADERSHIP, WITH ITS RESOURCES WILL RESPOND IN A TIMELY MANNER TO PHYSICAL, PSYCHOLOGICAL AND SPIRITUAL NEEDS, EMPHASIZING THE 'WHOLE PERSON.' MOUNDVIEW MEMORIAL HOSPITAL AND CLINCS, INCORPORATED WILL PROVIDE MANAGEMENT, AND WELL TRAINED STAFF TO PROVIDE COMPASSIONATE HEALTH CARE. MOUNDVIEW MEMORIAL HOSPITAL AND CLINICS, INCORPORATED SHALL EXPLORE THOSE PROPOSALS FOR NETWORKS, AFFILIATIONS, MERGERS, AND PARTICIPATE IN HMO'S AS DEEMED IN THE BEST INTEREST OF THOSE WE SERVE. | MissionDesc |
| Significant New Program Srvc | 0 | SignificantNewProgramSrvcInd |
| Significant Change | 0 | SignificantChangeInd |
| Expense | $17,126,633 | ExpenseAmt |
| Revenue | $20,925,511 | RevenueAmt |
| Desc | THE HOSPITAL IS A GENERAL MEDICAL CRITICAL ACCESS HOSPITAL LICENSED FOR 25 BEDS. DURING FISCAL YEAR 2016, THE HOSPITAL HAD 364 ACUTE INPATIENT DAYS AND 287 MEDICARE SKILL NURSING DAYS (SWING BED). THE HOSPITAL ALSO HAD 5,527 EMERGENCY ROOM VISITS, 1,191 URGENT CARE VISITS AND32,883 OUTPATIENT CLINIC AND OTHER OUTPATIENT ANCILLARY VISITS. | Desc |
| Total Program Service Expenses | $17,126,633 | TotalProgramServiceExpensesAmt |
| Described In Section501c3 | Yes (1) | DescribedInSection501c3Ind |
| Schedule B Required | Yes (1) | ScheduleBRequiredInd |
| Political Campaign Acty | 0 | PoliticalCampaignActyInd |
| Lobbying Activities | Yes (1) | LobbyingActivitiesInd |
| Subject To Proxy Tax | 0 | SubjectToProxyTaxInd |
| Donor Advised Fund | 0 | DonorAdvisedFundInd |
| Conservation Easements | 0 | ConservationEasementsInd |
| Collections Of Art | 0 | CollectionsOfArtInd |
| Credit Counseling | 0 | CreditCounselingInd |
| Temp Or Permanent Endowments | 0 | TempOrPermanentEndowmentsInd |
| Report Land Building Equipment | Yes (1) | ReportLandBuildingEquipmentInd |
| Report Investments Other Sec | 0 | ReportInvestmentsOtherSecInd |
| Report Program Related Invst | 0 | ReportProgramRelatedInvstInd |
| Report Other Assets | 0 | ReportOtherAssetsInd |
| Report Other Liabilities | Yes (1) | ReportOtherLiabilitiesInd |
| Include FIN48 Footnote | 0 | IncludeFIN48FootnoteInd |
| Independent Audit Fincl Stmt | 0 | IndependentAuditFinclStmtInd |
| Consolidated Audit Fincl Stmt | Yes (1) | ConsolidatedAuditFinclStmtInd |
| School Operating | 0 | SchoolOperatingInd |
| Foreign Office | 0 | ForeignOfficeInd |
| Foreign Activities | 0 | ForeignActivitiesInd |
| More Than5000 K To Org | 0 | MoreThan5000KToOrgInd |
| More Than5000 K To Individuals | 0 | MoreThan5000KToIndividualsInd |
| Professional Fundraising | 0 | ProfessionalFundraisingInd |
| Fundraising Activities | 0 | FundraisingActivitiesInd |
| Gaming Activities | 0 | GamingActivitiesInd |
| Operate Hospital | Yes (1) | OperateHospitalInd |
| Audited Financial Stmt Att | Yes (1) | AuditedFinancialStmtAttInd |
| Grants To Organizations | 0 | GrantsToOrganizationsInd |
| Grants To Individuals | 0 | GrantsToIndividualsInd |
| Schedule J Required | Yes (1) | ScheduleJRequiredInd |
| Tax Exempt Bonds | Yes (1) | TaxExemptBondsInd |
| Invest Tax Exempt Bonds | 0 | InvestTaxExemptBondsInd |
| Escrow Account | Yes (1) | EscrowAccountInd |
| On Behalf Of Issuer | 0 | OnBehalfOfIssuerInd |
| Engaged In Excess Benefit Trans | 0 | EngagedInExcessBenefitTransInd |
| PY Excess Benefit Trans | 0 | PYExcessBenefitTransInd |
| Loan Outstanding | Yes (1) | LoanOutstandingInd |
| Grant To Related Person | 0 | GrantToRelatedPersonInd |
| Business Rln With Org Mem | 0 | BusinessRlnWithOrgMemInd |
| Business Rln With Fam Mem | 0 | BusinessRlnWithFamMemInd |
| Business Rln With Officer Ent | 0 | BusinessRlnWithOfficerEntInd |
| Deductible Non Cash Contri | 0 | DeductibleNonCashContriInd |
| Deductible Art Contribution | 0 | DeductibleArtContributionInd |
| Terminate Operations | 0 | TerminateOperationsInd |
| Partial Liquidation | 0 | PartialLiquidationInd |
| Disregarded Entity | 0 | DisregardedEntityInd |
| Related Entity | Yes (1) | RelatedEntityInd |
| Related Organization Ctrl Ent | 0 | RelatedOrganizationCtrlEntInd |
| Trnsfr Exmpt Non Chrtbl Rltd Org | 0 | TrnsfrExmptNonChrtblRltdOrgInd |
| Activities Conducted Prtshp | 0 | ActivitiesConductedPrtshpInd |
| Schedule O Required | Yes (1) | ScheduleORequiredInd |
| IRP Document | 183 | IRPDocumentCnt |
| IRP Document W2 G | 0 | IRPDocumentW2GCnt |
| Employee | 167 | EmployeeCnt |
| Employment Tax Returns Filed | Yes (1) | EmploymentTaxReturnsFiledInd |
| Unrelated Bus Incm Over Limit | 0 | UnrelatedBusIncmOverLimitInd |
| Foreign Financial Account | 0 | ForeignFinancialAccountInd |
| Prohibited Tax Shelter Trans | 0 | ProhibitedTaxShelterTransInd |
| Taxable Party Notification | 0 | TaxablePartyNotificationInd |
| Nondeductible Contributions | 0 | NondeductibleContributionsInd |
| Quid Pro Quo Contributions | 0 | QuidProQuoContributionsInd |
| Form8282 Property Disposed Of | 0 | Form8282PropertyDisposedOfInd |
| Rcv Fnds To Pay Prsnl Bnft Cntrct | 0 | RcvFndsToPayPrsnlBnftCntrctInd |
| Pay Premiums Prsnl Bnft Cntrct | 0 | PayPremiumsPrsnlBnftCntrctInd |
| Indoor Tanning Services | 0 | IndoorTanningServicesInd |
| Info In Schedule O Part VI | Yes (X) | InfoInScheduleOPartVIInd |
| Governing Body Voting Members | 7 | GoverningBodyVotingMembersCnt |
| Independent Voting Member | 7 | IndependentVotingMemberCnt |
| Family Or Business Rln | 0 | FamilyOrBusinessRlnInd |
| Delegation Of Mgmt Duties | 0 | DelegationOfMgmtDutiesInd |
| Change To Org Documents | 0 | ChangeToOrgDocumentsInd |
| Material Diversion Or Misuse | 0 | MaterialDiversionOrMisuseInd |
| Members Or Stockholders | Yes (1) | MembersOrStockholdersInd |
| Election Of Board Members | Yes (1) | ElectionOfBoardMembersInd |
| Decisions Subject To Approva | Yes (1) | DecisionsSubjectToApprovaInd |
| Minutes Of Governing Body | Yes (1) | MinutesOfGoverningBodyInd |
| Minutes Of Committees | Yes (1) | MinutesOfCommitteesInd |
| Officer Mailing Address | 0 | OfficerMailingAddressInd |
| Local Chapters | 0 | LocalChaptersInd |
| Form990 Provided To Gvrn Body | Yes (1) | Form990ProvidedToGvrnBodyInd |
| Conflict Of Interest Policy | Yes (1) | ConflictOfInterestPolicyInd |
| Annual Disclosure Covered Prsn | Yes (1) | AnnualDisclosureCoveredPrsnInd |
| Regular Monitoring Enfrc | Yes (1) | RegularMonitoringEnfrcInd |
| Whistleblower Policy | Yes (1) | WhistleblowerPolicyInd |
| Document Retention Policy | Yes (1) | DocumentRetentionPolicyInd |
| Compensation Process CEO | Yes (1) | CompensationProcessCEOInd |
| Compensation Process Other | Yes (1) | CompensationProcessOtherInd |
| Investment In Joint Venture | 0 | InvestmentInJointVentureInd |
| States Where Copy Of Return Is Fld | WI | StatesWhereCopyOfReturnIsFldCd |
| Upon Request | Yes (X) | UponRequestInd |
Books In Care Of Detail BooksInCareOfDetail
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | DONALD HEINZ | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Phone | 6083393331 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 402 WEST LAKE STREET | AddressLine1Txt |
| City | FRIENDSHIP | CityNm |
| State Abbreviation | WI | StateAbbreviationCd |
| ZIP | 53934 | ZIPCd |
Form990 Part VII Section A Form990PartVIISectionAGrp (13 entries)
| TitleTitleTxt | Average Hours Per WeekAverageHoursPerWeekRt | Individual Trustee Or DirectorIndividualTrusteeOrDirectorInd | OfficerOfficerInd | Reportable Comp From OrgReportableCompFromOrgAmt | Reportable Comp From Rltd OrgReportableCompFromRltdOrgAmt | Other CompensationOtherCompensationAmt | Highest Compensated EmployeeHighestCompensatedEmployeeInd |
|---|---|---|---|---|---|---|---|
| MARY POLIVKA | |||||||
| PRESIDENT | 2.50 | Yes (X) | Yes (X) | $0 | $0 | $0 | |
| DEBRA SEGINA | |||||||
| VICE PRESIDENT | 2.50 | Yes (X) | Yes (X) | $0 | $0 | $0 | |
| RICHARD STERNHAGEN | |||||||
| TREASURER | 2.50 | Yes (X) | Yes (X) | $0 | $0 | $0 | |
| DIANA BRONIEC | |||||||
| SECRETARY | 2.50 | Yes (X) | Yes (X) | $0 | $0 | $0 | |
| PETER MURPHY | |||||||
| BOARD MEMBER | 2.50 | Yes (X) | $0 | $0 | $0 | ||
| RENEE SCHINDLBECK | |||||||
| BOARD MEMBER | 2.50 | Yes (X) | $0 | $0 | $0 | ||
| BARBARA ALBRECHT | |||||||
| BOARD MEMBER | 2.50 | Yes (X) | $0 | $0 | $0 | ||
| DONALD HEINZ | |||||||
| CEO | 40.00 | Yes (X) | $215,034 | $0 | $29,934 | ||
| MARK HATTON | |||||||
| PHYSICIAN | 40.00 | $230,536 | $0 | $26,504 | Yes (X) | ||
| JOHN DAVID | |||||||
| PHYSICIAN | 40.00 | $193,892 | $0 | $27,125 | Yes (X) | ||
| JASON BELLAK | |||||||
| PHYSICIAN | 40.00 | $267,106 | $0 | $25,383 | Yes (X) | ||
| DAVID SHAPIRO | |||||||
| DIRECTOR OF ANCILLIARY SERVICES | 40.00 | $144,054 | $0 | $15,210 | Yes (X) | ||
| CYNTHIA GANNON | |||||||
| PHYSICIAN | 40.00 | $229,671 | $0 | $31,175 | Yes (X) | ||
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Reportable Comp From Org | $1,280,293 | TotalReportableCompFromOrgAmt |
| Tot Reportable Comp Rltd Org | $0 | TotReportableCompRltdOrgAmt |
| Total Other Compensation | $155,331 | TotalOtherCompensationAmt |
| Indiv Rcvd Greater Than100 K | 11 | IndivRcvdGreaterThan100KCnt |
| Former Ofcr Employees Listed | 0 | FormerOfcrEmployeesListedInd |
| Total Comp Greater Than150 K | Yes (1) | TotalCompGreaterThan150KInd |
| Compensation From Other Srcs | 0 | CompensationFromOtherSrcsInd |
Contractor Compensation ContractorCompensationGrp (5 entries)
| Address Line1ContractorAddress/USAddress/AddressLine1Txt | CityContractorAddress/USAddress/CityNm | State AbbreviationContractorAddress/USAddress/StateAbbreviationCd | ZIPContractorAddress/USAddress/ZIPCd | ServicesServicesDesc | CompensationCompensationAmt |
|---|---|---|---|---|---|
| EMCARE PHYSICIAN SERVICES INC | |||||
| 7032 COLLECTION CENTER DRIVE | CHICAGO | IL | 60693 | ER PHYSICIAN COVERAGE | $1,212,831 |
| CHG HEALTHCARE | |||||
| PO BOX 972633 | DALLAS | TX | 753972633 | LOCUM SPECIALTY PHYSICIAN SERVICES | $624,156 |
| CERNER CORPORATION | |||||
| PO BOX 959156 | ST LOUIS | MO | 63195 | SOFTWARE MAINTENANCE / SUPPORT | $260,498 |
| SHARED IMAGING SERVICES | |||||
| PO BOX 88450 | MILWAUKEE | WI | 88450 | MEDICAL IMAGING SERVICES | $234,985 |
| FIRST REFLECTIONS INC | |||||
| 228 N PINE STREET | ADAMS | WI | 53910 | CRNA PROFESSIONAL SERVICES | $227,281 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Cntrct Rcvd Greater Than100 K | 10 | CntrctRcvdGreaterThan100KCnt |
| Related Organizations | $58,436 | RelatedOrganizationsAmt |
| Government Grants | $78,271 | GovernmentGrantsAmt |
| All Other Contributions | $10,942 | AllOtherContributionsAmt |
| Total Contributions | $147,649 | TotalContributionsAmt |
Program Service Revenue ProgramServiceRevenueGrp (4 entries)
| DescDesc | BusinessBusinessCd | Total Revenue ColumnTotalRevenueColumnAmt | Related Or Exempt Func IncomeRelatedOrExemptFuncIncomeAmt | ExclusionExclusionAmt |
|---|---|---|---|---|
| NET PATIENT SERVICE REVENUE | 900099 | $20,529,035 | $20,529,035 | |
| MISCELLANEOUS REVENUE | 900099 | $127,307 | $127,307 | |
| MEDICAL BUILDING RENT | 900099 | $34,877 | $34,877 | |
| DIETARY INCOME | 900099 | $22,832 | $22,832 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Revenue | $20,714,051 | TotalProgramServiceRevenueAmt |
Investment Income InvestmentIncomeGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $61,855 | TotalRevenueColumnAmt |
| Exclusion | $61,855 | ExclusionAmt |
Gross Rents GrossRentsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | $38,419 | RealAmt |
Less Rental Expenses LessRentalExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | $55,026 | RealAmt |
Rental Income Or Loss RentalIncomeOrLossGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | -$16,607 | RealAmt |
Net Rental Income Or Loss NetRentalIncomeOrLossGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | -$16,607 | TotalRevenueColumnAmt |
| Exclusion | -$16,607 | ExclusionAmt |
Other Revenue Misc OtherRevenueMiscGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Desc | EHR INCENTIVE | Desc |
| Business | 900099 | BusinessCd |
| Total Revenue Column | $396,476 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $396,476 | RelatedOrExemptFuncIncomeAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Revenue Total | $396,476 | OtherRevenueTotalAmt |
Total Revenue TotalRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $21,303,424 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $20,983,220 | RelatedOrExemptFuncIncomeAmt |
| Unrelated Business Revenue | $0 | UnrelatedBusinessRevenueAmt |
| Exclusion | $172,555 | ExclusionAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part IX | Yes (X) | InfoInScheduleOPartIXInd |
Comp Current Ofcr Directors CompCurrentOfcrDirectorsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $244,969 | TotalAmt |
| Management And General | $244,969 | ManagementAndGeneralAmt |
Other Salaries And Wages OtherSalariesAndWagesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $7,052,355 | TotalAmt |
| Program Services | $6,388,880 | ProgramServicesAmt |
| Management And General | $663,475 | ManagementAndGeneralAmt |
Pension Plan Contributions PensionPlanContributionsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $97,261 | TotalAmt |
| Program Services | $97,261 | ProgramServicesAmt |
Other Employee Benefits OtherEmployeeBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,123,997 | TotalAmt |
| Program Services | $988,580 | ProgramServicesAmt |
| Management And General | $135,417 | ManagementAndGeneralAmt |
Payroll Taxes PayrollTaxesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $470,197 | TotalAmt |
| Program Services | $415,230 | ProgramServicesAmt |
| Management And General | $54,967 | ManagementAndGeneralAmt |
Fees For Services Legal FeesForServicesLegalGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $55,302 | TotalAmt |
| Management And General | $55,302 | ManagementAndGeneralAmt |
Fees For Services Accounting FeesForServicesAccountingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $51,600 | TotalAmt |
| Management And General | $51,600 | ManagementAndGeneralAmt |
Fees For Services Other FeesForServicesOtherGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $3,702,203 | TotalAmt |
| Program Services | $3,477,415 | ProgramServicesAmt |
| Management And General | $224,788 | ManagementAndGeneralAmt |
Advertising AdvertisingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $40,408 | TotalAmt |
| Management And General | $40,408 | ManagementAndGeneralAmt |
Office Expenses OfficeExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $2,058,010 | TotalAmt |
| Program Services | $1,908,649 | ProgramServicesAmt |
| Management And General | $149,361 | ManagementAndGeneralAmt |
Information Technology InformationTechnologyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $7,562 | TotalAmt |
| Program Services | $5,293 | ProgramServicesAmt |
| Management And General | $2,269 | ManagementAndGeneralAmt |
Occupancy OccupancyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $233,492 | TotalAmt |
| Program Services | $212,590 | ProgramServicesAmt |
| Management And General | $20,902 | ManagementAndGeneralAmt |
Travel TravelGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $65,809 | TotalAmt |
| Program Services | $58,205 | ProgramServicesAmt |
| Management And General | $7,604 | ManagementAndGeneralAmt |
Interest InterestGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $232,873 | TotalAmt |
| Program Services | $211,962 | ProgramServicesAmt |
| Management And General | $20,911 | ManagementAndGeneralAmt |
Depreciation Depletion DepreciationDepletionGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,060,186 | TotalAmt |
| Program Services | $931,317 | ProgramServicesAmt |
| Management And General | $128,869 | ManagementAndGeneralAmt |
Insurance InsuranceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $251,276 | TotalAmt |
| Program Services | $226,481 | ProgramServicesAmt |
| Management And General | $24,795 | ManagementAndGeneralAmt |
Other Expenses OtherExpensesGrp (4 entries)
| DescDesc | TotalTotalAmt | Program ServicesProgramServicesAmt | Management And GeneralManagementAndGeneralAmt |
|---|---|---|---|
| BAD DEBT EXPENSE | $1,319,973 | $1,319,973 | |
| REPAIRS & MAINTENANCE | $603,342 | $515,231 | $88,111 |
| EQUIPMENT RENTS & LEASE | $357,306 | $324,690 | $32,616 |
| COLLECTION EXPENSE | $72,884 | $72,884 |
All Other Expenses AllOtherExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $149,011 | TotalAmt |
| Program Services | $44,876 | ProgramServicesAmt |
| Management And General | $104,135 | ManagementAndGeneralAmt |
Total Functional Expenses TotalFunctionalExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $19,250,016 | TotalAmt |
| Program Services | $17,126,633 | ProgramServicesAmt |
| Management And General | $2,123,383 | ManagementAndGeneralAmt |
| Fundraising | $0 | FundraisingAmt |
Cash Non Interest Bearing CashNonInterestBearingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $700 | BOYAmt |
| EOY | $700 | EOYAmt |
Savings And Temp Cash Invst SavingsAndTempCashInvstGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $3,162,292 | BOYAmt |
| EOY | $4,246,540 | EOYAmt |
Accounts Receivable AccountsReceivableGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $2,655,251 | BOYAmt |
| EOY | $2,802,226 | EOYAmt |
Receivables From Officers Etc ReceivablesFromOfficersEtcGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $20,000 | BOYAmt |
| EOY | $10,000 | EOYAmt |
Oth Notes Loans Receivable Net OthNotesLoansReceivableNetGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $22,000 | BOYAmt |
Inventories For Sale Or Use InventoriesForSaleOrUseGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $391,351 | BOYAmt |
| EOY | $426,002 | EOYAmt |
Prepaid Expenses Defrd Charges PrepaidExpensesDefrdChargesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $324,712 | BOYAmt |
| EOY | $258,526 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Land Bldg Equip Cost Or Other Bss | $20,056,363 | LandBldgEquipCostOrOtherBssAmt |
| Land Bldg Equip Accum Deprec | $11,447,930 | LandBldgEquipAccumDeprecAmt |
Land Bldg Equip Basis Net LandBldgEquipBasisNetGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $8,880,550 | BOYAmt |
| EOY | $8,608,433 | EOYAmt |
Other Assets Total OtherAssetsTotalGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $629,926 | BOYAmt |
| EOY | $728,438 | EOYAmt |
Total Assets TotalAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $16,086,782 | BOYAmt |
| EOY | $17,080,865 | EOYAmt |
Accounts Payable Accr Expnss AccountsPayableAccrExpnssGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $2,810,125 | BOYAmt |
| EOY | $2,241,659 | EOYAmt |
Deferred Revenue DeferredRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $622,197 | BOYAmt |
| EOY | $548,097 | EOYAmt |
Tax Exempt Bond Liabilities TaxExemptBondLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $4,011,000 | BOYAmt |
| EOY | $3,596,000 | EOYAmt |
Mortg Notes Pybl Scrd Invst Prop MortgNotesPyblScrdInvstPropGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $720,122 | BOYAmt |
| EOY | $318,312 | EOYAmt |
Other Liabilities OtherLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $0 | BOYAmt |
| EOY | $406,343 | EOYAmt |
Total Liabilities TotalLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $8,163,444 | BOYAmt |
| EOY | $7,110,411 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Organization Follows SFAS117 | Yes (X) | OrganizationFollowsSFAS117Ind |
Unrestricted Net Assets UnrestrictedNetAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $7,469,777 | BOYAmt |
| EOY | $9,572,908 | EOYAmt |
Temporarily Rstr Net Assets TemporarilyRstrNetAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $453,561 | BOYAmt |
| EOY | $397,546 | EOYAmt |
Total Net Assets Fund Balance TotalNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $7,923,338 | BOYAmt |
| EOY | $9,970,454 | EOYAmt |
Tot Liab Net Assets Fund Balance TotLiabNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $16,086,782 | BOYAmt |
| EOY | $17,080,865 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part XI | Yes (X) | InfoInScheduleOPartXIInd |
| Reconcilation Revenue Expnss | $2,053,408 | ReconcilationRevenueExpnssAmt |
| Other Changes In Net Assets | -$6,292 | OtherChangesInNetAssetsAmt |
| Info In Schedule O Part XII | Yes (X) | InfoInScheduleOPartXIIInd |
| Method Of Accounting Accrual | Yes (X) | MethodOfAccountingAccrualInd |
| Accountant Compile Or Review | 0 | AccountantCompileOrReviewInd |
| FS Audited | Yes (1) | FSAuditedInd |
FS Audited Basis FSAuditedBasisGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Consolidated Basis Fincl Stmt | Yes (X) | ConsolidatedBasisFinclStmtInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Audit Committee | Yes (1) | AuditCommitteeInd |
| Federal Grant Audit Required | 0 | FederalGrantAuditRequiredInd |
Schedule A IRS990ScheduleA
| Field | Value | IRS element (for citing) |
|---|---|---|
| Hospital | Yes (X) | HospitalInd |
Schedule B IRS990ScheduleB
Contributor Information ContributorInformationGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Contributor | RESTRICTED | ContributorNum |
Contributor Business Name ContributorBusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | RESTRICTED | BusinessNameLine1 |
Contributor US Address ContributorUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | RESTRICTED | AddressLine1 |
| Address Line2 | RESTRICTED | AddressLine2 |
| City | RESTRICTED | City |
| State | RESTRICTED | State |
| ZIP Code | RESTRICTED | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Contributions | RESTRICTED | TotalContributionsAmt |
Schedule C IRS990ScheduleC
| Field | Value | IRS element (for citing) |
|---|---|---|
| Volunteers | 0 | VolunteersInd |
| Paid Staff Or Management | 0 | PaidStaffOrManagementInd |
| Media Advertisements | 0 | MediaAdvertisementsInd |
| Mailings Members | 0 | MailingsMembersInd |
| Publications Or Broadcast | 0 | PublicationsOrBroadcastInd |
| Grants Other Organizations | 0 | GrantsOtherOrganizationsInd |
| Direct Contact Legislators | 0 | DirectContactLegislatorsInd |
| Rallies Demonstrations | 0 | RalliesDemonstrationsInd |
| Other Activities | Yes (1) | OtherActivitiesInd |
| Other Activities | $1,596 | OtherActivitiesAmt |
| Total Lobbying Expenditures | $1,596 | TotalLobbyingExpendituresAmt |
| Not Described Section501c3 | 0 | NotDescribedSection501c3Ind |
Supplemental Information Detail SupplementalInformationDetail
| Field | Value | IRS element (for citing) |
|---|---|---|
| Form And Line Reference | PART II-B, LINE 1: | FormAndLineReferenceDesc |
| Explanation | WHA MEMBERSHIP DUES | ExplanationTxt |
Schedule D IRS990ScheduleD
Land LandGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $63,641 | OtherCostOrOtherBasisAmt |
| Book Value | $63,641 | BookValueAmt |
Buildings BuildingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $12,244,179 | OtherCostOrOtherBasisAmt |
| Depreciation | $5,116,217 | DepreciationAmt |
| Book Value | $7,127,962 | BookValueAmt |
Leasehold Improvements LeaseholdImprovementsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $123,411 | OtherCostOrOtherBasisAmt |
| Depreciation | $64,323 | DepreciationAmt |
| Book Value | $59,088 | BookValueAmt |
Equipment EquipmentGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $7,625,132 | OtherCostOrOtherBasisAmt |
| Depreciation | $6,267,390 | DepreciationAmt |
| Book Value | $1,357,742 | BookValueAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Book Value Land Buildings | $8,608,433 | TotalBookValueLandBuildingsAmt |
Other Liabilities Org OtherLiabilitiesOrgGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Desc | OBLIGATIONS UNDER CAPITAL LEASES | Desc |
| Amt | $406,343 | Amt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Liability | $406,343 | TotalLiabilityAmt |
| Total Rev Etc Audited Fincl Stmt | $20,087,614 | TotalRevEtcAuditedFinclStmtAmt |
| Other Revenue | -$1,270,836 | OtherRevenueAmt |
| Revenue Not Reported | -$1,270,836 | RevenueNotReportedAmt |
| Revenue Subtotal | $21,358,450 | RevenueSubtotalAmt |
| Other Revenues Not Included | -$55,026 | OtherRevenuesNotIncludedAmt |
| Revenue Not Reported Fincl Stmt | -$55,026 | RevenueNotReportedFinclStmtAmt |
| Total Revenue Per Form990 | $21,303,424 | TotalRevenuePerForm990Amt |
| Tot Expns Etc Audited Fincl Stmt | $17,985,069 | TotExpnsEtcAuditedFinclStmtAmt |
| Other Expenses Included | $55,026 | OtherExpensesIncludedAmt |
| Expenses Not Reported | $55,026 | ExpensesNotReportedAmt |
| Expenses Subtotal | $17,930,043 | ExpensesSubtotalAmt |
| Other Expenses Not Included | $1,319,973 | OtherExpensesNotIncludedAmt |
| Expenses Not Rpt Fincl Stmt | $1,319,973 | ExpensesNotRptFinclStmtAmt |
| Total Expenses Per Form990 | $19,250,016 | TotalExpensesPerForm990Amt |
Supplemental Information Detail SupplementalInformationDetail (4 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| PART XI, LINE 2D - OTHER ADJUSTMENTS: | FOUNDATION MARKET ADJUSTMENT 49,137. BAD DEBT EXPENSE -1,319,973. |
| PART XI, LINE 4B - OTHER ADJUSTMENTS: | RENTAL EXPENSES -55,026. |
| PART XII, LINE 2D - OTHER ADJUSTMENTS: | RENTAL EXPENSES 55,026. |
| PART XII, LINE 4B - OTHER ADJUSTMENTS: | BAD DEBT EXPENSE 1,319,973. |
Schedule H IRS990ScheduleH
| Field | Value | IRS element (for citing) |
|---|---|---|
| Financial Assistance Policy | Yes (1) | FinancialAssistancePolicyInd |
| Written Policy | Yes (1) | WrittenPolicyInd |
| All Hospitals Policy | Yes (X) | AllHospitalsPolicyInd |
| FPG Reference Free Care | Yes (1) | FPGReferenceFreeCareInd |
Free Care Oth Percentage FreeCareOthPercentageGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | Yes (X) | OtherInd |
| Free Care Other | 175.000000000000 | FreeCareOtherPct |
| Field | Value | IRS element (for citing) |
|---|---|---|
| FPG Reference Discounted Care | Yes (1) | FPGReferenceDiscountedCareInd |
Discounted Care Oth Percentage DiscountedCareOthPercentageGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | Yes (X) | OtherInd |
| Discounted Care Other | 175.000000000000 | DiscountedCareOtherPct |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Free Care Medically Indigent | Yes (1) | FreeCareMedicallyIndigentInd |
| Financial Assistance Budget | Yes (1) | FinancialAssistanceBudgetInd |
| Expenses Exceed Budget | Yes (1) | ExpensesExceedBudgetInd |
| Unable To Provide Care | 0 | UnableToProvideCareInd |
| Annual Community Bnft Report | Yes (1) | AnnualCommunityBnftReportInd |
| Report Publically Available | Yes (1) | ReportPublicallyAvailableInd |
Financial Assistance At Cost Typ FinancialAssistanceAtCostTyp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $52,918 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $52,918 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00300 | TotalExpensePct |
Unreimbursed Medicaid UnreimbursedMedicaidGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $3,370,985 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $2,689,869 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $681,116 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.03800 | TotalExpensePct |
Total Financial Assistance Typ TotalFinancialAssistanceTyp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $3,423,903 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $2,689,869 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $734,034 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.04100 | TotalExpensePct |
Community Health Services CommunityHealthServicesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $210,465 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $12,497 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $197,968 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.01100 | TotalExpensePct |
Health Professions Education HealthProfessionsEducationGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $18,689 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $18,689 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00100 | TotalExpensePct |
Total Other Benefits TotalOtherBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $229,154 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $12,497 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $216,657 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.01200 | TotalExpensePct |
Total Community Benefits TotalCommunityBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $3,653,057 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $2,702,366 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $950,691 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.05300 | TotalExpensePct |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bad Debt Expense Reported | 0 | BadDebtExpenseReportedInd |
| Bad Debt Expense | $521,158 | BadDebtExpenseAmt |
| Bad Debt Expense Attributable | $57,200 | BadDebtExpenseAttributableAmt |
| Reimbursed By Medicare | $6,310,092 | ReimbursedByMedicareAmt |
| Cost Of Care Reimbursed By Medcr | $6,358,882 | CostOfCareReimbursedByMedcrAmt |
| Medicare Surplus Or Shortfall | -$48,790 | MedicareSurplusOrShortfallAmt |
Costing Methodology Used CostingMethodologyUsedGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Cost To Charge Ratio | Yes (X) | CostToChargeRatioInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Written Debt Collection Policy | Yes (1) | WrittenDebtCollectionPolicyInd |
| Financial Assistance Prvsn | Yes (1) | FinancialAssistancePrvsnInd |
| Hospital Facilities | 1 | HospitalFacilitiesCnt |
Hospital Facilities HospitalFacilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | 1 | FacilityNum |
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | MOUNDVIEW MEMORIAL HOSPITAL | BusinessNameLine1Txt |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 402 WEST LAKE STREET | AddressLine1Txt |
| City | FRIENDSHIP | CityNm |
| State Abbreviation | WI | StateAbbreviationCd |
| ZIP | 53934 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Website Address | WWW.MOUNDVIEW.ORG | WebsiteAddressTxt |
| State License | 1014 | StateLicenseNum |
| Licensed Hospital | Yes (X) | LicensedHospitalInd |
| General Medical And Surgical | Yes (X) | GeneralMedicalAndSurgicalInd |
| Critical Access Hospital | Yes (X) | CriticalAccessHospitalInd |
| Emergency Room24 Hrs | Yes (X) | EmergencyRoom24HrsInd |
Hospital Fclty Policies Prctc HospitalFcltyPoliciesPrctcGrp
Hospital Facility Name HospitalFacilityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | MOUNDVIEW MEMORIAL HOSPITAL | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | 1 | FacilityNum |
| First Licensed CY Or PY | 0 | FirstLicensedCYOrPYInd |
| Tax Exempt Hospital CY Or PY | 0 | TaxExemptHospitalCYOrPYInd |
| CHNA Conducted | Yes (1) | CHNAConductedInd |
| Community Definition | Yes (X) | CommunityDefinitionInd |
| Community Demographics | Yes (X) | CommunityDemographicsInd |
| Existing Resources | Yes (X) | ExistingResourcesInd |
| How Data Obtained | Yes (X) | HowDataObtainedInd |
| Community Health Needs | Yes (X) | CommunityHealthNeedsInd |
| Other Health Issues | Yes (X) | OtherHealthIssuesInd |
| Community Hlth Needs Id Process | Yes (X) | CommunityHlthNeedsIdProcessInd |
| Consulting Process | Yes (X) | ConsultingProcessInd |
| Other | Yes (X) | OtherInd |
| CHNA Conducted | 15 | CHNAConductedYr |
| Take Into Account Others Input | Yes (1) | TakeIntoAccountOthersInputInd |
| CHNA Conducted With Other Fclts | 0 | CHNAConductedWithOtherFcltsInd |
| CHNA Conducted With Non Fclts | Yes (1) | CHNAConductedWithNonFcltsInd |
| CHNA Report Widely Available | Yes (1) | CHNAReportWidelyAvailableInd |
| Rpt Available On Own Website | Yes (X) | RptAvailableOnOwnWebsiteInd |
| Own Website URL | HTTP://WWW.MOUNDVIEW.ORG/IMAGES/PDFS/COUNTYNEEDSASSESSMENT.PDF | OwnWebsiteURLTxt |
| Other Website | Yes (X) | OtherWebsiteInd |
| Other Website URL | HTTP://CO.ADAMS.WI.GOV/DEPARTMENTS/HEALTHHUMANSERVICES/PUBLICHEALTH/TABID/2 | OtherWebsiteURLTxt |
| Paper Copy Public Inspection | Yes (X) | PaperCopyPublicInspectionInd |
| Rpt Available Thru Other Method | Yes (X) | RptAvailableThruOtherMethodInd |
| Implementation Strategy Adopt | Yes (1) | ImplementationStrategyAdoptInd |
| Implementation Strategy Adpt | 15 | ImplementationStrategyAdptYr |
| Strategy Posted Website | Yes (1) | StrategyPostedWebsiteInd |
| Strategy Website URL | HTTP://WWW.MOUNDVIEW.ORG/IMAGES/PDFS/COUNTYNEEDSASSESSMENT.PDF | StrategyWebsiteURLTxt |
| Strategy Attached | 0 | StrategyAttachedInd |
| Organization Incur Excise Tax | 0 | OrganizationIncurExciseTaxInd |
| Elig Criteria Explained | Yes (1) | EligCriteriaExplainedInd |
| FPG Family Incm Lmt Free Dscnt | Yes (X) | FPGFamilyIncmLmtFreeDscntInd |
| FPG Family Incm Lmt Free Care | 175.000000000000 | FPGFamilyIncmLmtFreeCarePct |
| FPG Family Incm Lmt Dscnt Care | 175.000000000000 | FPGFamilyIncmLmtDscntCarePct |
| Income Level Criteria | Yes (X) | IncomeLevelCriteriaInd |
| Insurance Status Criteria | Yes (X) | InsuranceStatusCriteriaInd |
| Explained Basis | Yes (1) | ExplainedBasisInd |
| App Financial Asst Expln | Yes (1) | AppFinancialAsstExplnInd |
| Described Info | Yes (X) | DescribedInfoInd |
| Described Suprt Doc | Yes (X) | DescribedSuprtDocInd |
| Provided Hospital Contact | Yes (X) | ProvidedHospitalContactInd |
| Provided Nonprofit Contact | Yes (X) | ProvidedNonprofitContactInd |
| Includes Publicity Measures | Yes (1) | IncludesPublicityMeasuresInd |
| FAP Available On Website | Yes (X) | FAPAvailableOnWebsiteInd |
| FAP Available On Website URL | HTTP://WWW.MOUNDVIEW.ORG/PATIENTS-VISITORS/FINANCIAL-ASSISTANCE | FAPAvailableOnWebsiteURLTxt |
| FAP App Available On Website | Yes (X) | FAPAppAvailableOnWebsiteInd |
| FAP App Available On Website URL | HTTP://WWW.MOUNDVIEW.ORG/PATIENTS-VISITORS/FINANCIAL-ASSISTANCE | FAPAppAvailableOnWebsiteURLTxt |
| FAP Summary On Website | Yes (X) | FAPSummaryOnWebsiteInd |
| FAP Summary On Website URL | HTTP://WWW.MOUNDVIEW.ORG/PATIENTS-VISITORS/FINANCIAL-ASSISTANCE | FAPSummaryOnWebsiteURLTxt |
| FAP Avlbl On Request No Charge | Yes (X) | FAPAvlblOnRequestNoChargeInd |
| FAP App Avlbl On Request No Chrg | Yes (X) | FAPAppAvlblOnRequestNoChrgInd |
| FAP Sum Avlbl On Request No Chrg | Yes (X) | FAPSumAvlblOnRequestNoChrgInd |
| FAP Notice Displayed | Yes (X) | FAPNoticeDisplayedInd |
| Communtity Notified FAP | Yes (X) | CommuntityNotifiedFAPInd |
| FAP Actions On Nonpayment | Yes (1) | FAPActionsOnNonpaymentInd |
| Permit No Actions | Yes (X) | PermitNoActionsInd |
| Collection Activities | 0 | CollectionActivitiesInd |
| FAP Notified Upon Admission | Yes (X) | FAPNotifiedUponAdmissionInd |
| FAP Notified Before Discharge | Yes (X) | FAPNotifiedBeforeDischargeInd |
| FAP Notified All Patients | Yes (X) | FAPNotifiedAllPatientsInd |
| Documented Elig Determination | Yes (X) | DocumentedEligDeterminationInd |
| Nondis Emergency Care Policy | Yes (1) | NondisEmergencyCarePolicyInd |
| Other Method Used | Yes (X) | OtherMethodUsedInd |
| Amounts Generally Billed | 0 | AmountsGenerallyBilledInd |
| Gross Charges | 0 | GrossChargesInd |
Supplemental Information SupplementalInformationGrp (6 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| MOUNDVIEW MEMORIAL HOSPITAL | PART V, SECTION B, LINE 3J: A TEAM OF KEY STAKEHOLDERS AND COMMUNITY REPRESENTATIVES REPRESENTING A BROAD CROSS SECTION OF ADAMS COUNTY REVIEWED LOCAL AND STATE DATA DURING A SERIES OF MEETINGS. SINCE ADAMS COUNTY'S COUNTY HEALTH RANKING WAS SIGNIFICANTLY LOW ACROSS ALL AREAS EXCEPT PHYSICAL ENVIRONMENT, THE TEAM HELD AN INITIAL RANKING OF HEALTH ISSUES. SIX THEMES WERE RATED AND SCORED INCLUDING SOCIAL SUPPORT, PHYSICAL ACTIVITY, EMPLOYMENT, HEALTH LITERACY, AND ACCESS TO HIGH QUALITY CARE AND HEALTHY NUTRITION. LOCAL DATA WAS FURTHER RESEARCHED AND PRESENTED ON THESE SIX AREAS THROUGH A SERIES OF PRESENTATIONS TO BETTER UNDERSTAND THE ISSUES IDENTIFIED IN THE LOCAL STATISTICS. ADDITIONAL DATA WAS COLLECTED THROUGH A SURVEY AND FOCUS GROUPS CONDUCTED BY MOUNDVIEW REGARDING THE COMMUNITY'S PERCEPTION OF THE TOP COUNTY HEALTH PRIORITIES. SURVEY RESPONDENTS AND FOCUS GROUPS WERE ASKED A QUESTION ABOUT THE COMMUNITY'S GREATEST HEALTH NEEDS AND WERE ASKED TO RATE THE SERIOUSNESS OF THESE ISSUES. DATA AND VISION THEMES WERE THEN WITH THE COMMUNITY TEAM TO IDENTIFY THE TOP THREE KEY COMMUNITY HEALTH PRIORITIES FOR ADAMS COUNTY. THE THREE PRIORITIES CHOSEN WERE SOCIAL SUPPORT AND SOCIAL COHESION, EMPLOYMENT, AND ADEQUATE, APPROPRIATE AND SAFE FOOD AND NUTRITION. |
| MOUNDVIEW MEMORIAL HOSPITAL | PART V, SECTION B, LINE 5: FIRST, KEY STAKEHOLDERS AND COMMUNITY REPRESENTATIVES WERE IDENTIFIED AND INVITED TO JOIN A "COMMUNITY TEAM" TO CONDUCT THE NEEDS ASSESSMENT. THE TEAM REPRESENTED A CROSS SECTION OF THE RESIDENTS AND ORGANIZATIONS IN ADAMS COUNTY. INPUT WAS ALSO SOUGHT FROM THE GENERAL COMMUNITY THROUGH A COMMUNITY OPINION SURVEY (CONDUCTED BY TELEPHONE) AND FOCUS GROUPS CONDUCTED BY A MARKET RESEARCH GROUP ON BEHALF OF MOUNDVIEW MEMORIAL. SURVEY RESPONDENTS AND FOCUS GROUPS WERE ASKED A QUESTION ABOUT THE COMMUNITY'S GREATEST HEALTH NEEDS AND WERE ASKED TO RATE THE SERIOUSNESS OF THESE ISSUES. |
| MOUNDVIEW MEMORIAL HOSPITAL | PART V, SECTION B, LINE 6B: THE NEEDS ASSESSMENT WAS PARTNERSHIP BETWEEN ADAMS COUNTY HEALTH PUBLIC HEALTH AND MOUNDVIEW MEMORIAL HOSPITAL & CLINICS. SEVERAL OTHER ORGANIZATIONS PARTICIPATED AND/OR CONTRIBUTED INCLUDING ADAMS COUNTY HEALTH AND HUMAN SERVICES STAFF AND BOARD, ADAMS COUNTY UW EXTENSION, ADAMS-FRIENDSHIP SCHOOL DISTRICT, CENTRAL WISCONSIN COMMUNITY ACTION COUNCIL, ADAMS COUNTY RURAL AND INDUSTRIAL DEVELOPMENT COMMISSION, ADAMS COUNTY GOVERNMENT, ADAMS COUNTY DISTRICT ATTORNEY, ADAMS COUNTY SHERIFF'S DEPARTMENT, ADAMS COUNTY CHAMBER OF COMMERCE, ADAMS COUNTY PARKS AND RECREATION, RIVERVIEW HOSPITAL, WISCONSIN DELLS PARK AND RECREATION. |
| MOUNDVIEW MEMORIAL HOSPITAL | PART V, SECTION B, LINE 7D: A DISPLAY BOARD ON THE NEEDS ASSESSMENT FINDINGS WAS ALSO CREATED AND DISPLAYED AT LARGE SCALE COMMUNITY EVENTS AND AT THE ADAMS COUNTY COMMUNITY CENTER. INFORMATION IS REPORTED TO THE WISCONSIN HOSPITAL ASSOCIATION. |
| MOUNDVIEW MEMORIAL HOSPITAL | PART V, SECTION B, LINE 11: MOUNDVIEW HAS ADDRESSED THE NEEDS OF NUTRITION/PHYSICAL ACTIVITY AND SOCIAL SUPPORT/COHESION AS INDICATED IN OUR IMPLEMENTATION PLAN, ADAPTING THE PLAN AS NEEDED. ADDITIONALLY, MOUNDVIEW HAS WORKED ON ISSUES REGARDING "SUBSTANCE ABUSE" WHICH WAS NOT CHOSEN AS A NEEDS ASSESSMENT PRIORITY, BUT WAS IDENTIFIED BY MOUNDVIEW AS AN IMPORTANT HEALTH ISSUE. MOUNDVIEW IS LIMITED IN WHAT WE CAN DO TO SUPPORT THE "EMPLOYMENT" PRIORITY THAT WAS IDENTIFIED THROUGH THE NEEDS ASSESSMENT. MOUNDIVEW STAFF HAD PLANNED TO SERVE ON THE PROMISE NEIGHBORHOOD COMMUNITY WORK GROUP TASKED WITH ADDRESSING THIS ISSUE BUT THE GROUP IS NOT ACTIVE DUE TO THE PROMISE NEIGHBORHOOD GRANT ENDING. MOUNDVIEW WILL CONTINUE TO LOOK FOR OPPORTUNITIES TO WORK WITH OUR COMMUNITY PARTNERS ON THIS ISSUE. MOUNDVIEW DOES CONTINUE TO PROVIDE CAREER SHADOWING/JOB EXPLORATION OPPORTUNITIES AND CLINICAL EXPERIENCES TO HIGH SCHOOL AND COLLEGE STUDENTS, ATTEND JOB FAIRS, SPEAK TO AREA YOUTH AT HIGH SCHOOL CAREER DAYS AND ENCOURAGE THOSE PURSUING HEALTH CARE CAREERS TO CONSIDER RETURNING TO ADAMS COUNTY TO WORK. |
| MOUNDVIEW MEMORIAL HOSPITAL | PART V, SECTION B, LINE 22D: THE HOSPITAL USED THE LOOKBACK METHOD BASED ON THE LOWEST COMMERCIAL RATES |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | 1 | FacilityNum |
Oth Hlth Care Fclts Not Hospital OthHlthCareFcltsNotHospitalGrp
Oth Hlth Care Fclts OthHlthCareFcltsGrp
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | 1 - MOUNDVIEW CLINIC | BusinessNameLine1Txt |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 402 WEST LAKE STREET | AddressLine1Txt |
| City | FRIENDSHIP | CityNm |
| State Abbreviation | WI | StateAbbreviationCd |
| ZIP | 53934 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | CLINIC | FacilityTxt |
Supplemental Information Detail SupplementalInformationDetail (15 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| PART I, LINE 6A: | WI HOSPITAL ASSOCIATION |
| PART I, LINE 7: | UTILIZE THE MEDICARE COST TO CHARGE METHODOLOGY. |
| 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 $ 1,319,973. |
| PART II, COMMUNITY BUILDING ACTIVITIES: | THE HOSPITAL'S COMMUNITY BUILDING ACTIVITIES PROMOTES HEALTH OF THE COMMUNITIES IT SERVES THROUGH LOCAL ADVERTISEMENTS, INVOLVEMENT WITH CHAMBER OF COMMERCE, DEPARTMENT OF AGING AND OTHER COMMUNITY ORGANIZATIONS. THE AMOUNT OF SUPPORT IS DIFFICULT TO QUANTIFY. |
| PART III, LINE 2: | THE RATIO OF PATIENT COST TO CHARGES WAS CALCULATED BY DIVIDING HOSPITAL EXPENSES NET OF NON-PATIENT REVENUE AND IDENTIFIED COMMUNITY BENEFIT EXPENSE BY GROSS PATIENT REVENUE. THE PERCENTAGE WAS THEN MULTIPLED BY THE GROSS REVENUES ON BAD DEBT ACCOUNTS. |
| PART III, LINE 3: | IT IS CONSIDERED COMMUNITY BENEFIT AS THE HOSPITAL IS REIMBURSED ON MEDICARE ALLOWABLE COSTS. MEDICARE ALLOWABLE COSTS ARE DEFINED BY MEDICARE. THEY DO NOT NECESSARILY CAPTURE ALL COSTS OF THE HOSPITAL PROVIDING SERVICES TO THE COMMUNITY. CONSEQUENTLY, THERE ARE COSTS NOT REIMBURED BY EITHER PATIENT OR THE PROGRAM. THE COST METHODOLOGY USED TO DETERMINE MEDICARE ALLOWABLE COSTS IS A STEP-DOWN ALLOCATION OF COSTS FROM NON-REVENUE AREAS TO REVENUE AREAS. THIS ALLOCATION IS DONE FOLLOWING MEDICARE RULES AND REGULATIONS. |
| PART III, LINE 4: | PATIENT ACCOUNTS RECEIVABLE ARE RECORDED IN THE ACCOMPANYING CONSOLIDATED BALANCE SHEETS NET OF CONTRACTUAL ADJUSTMENTS AND AN ALLOWANCE FOR DOUBTFUL ACCOUNTS, WHICH REFLECT MANAGEMENT'S BEST ESTIMATE OF 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 ACCOUNTS RECEIVABLE. IN ADDITION, MANAGEMENT PROVIDES FOR PROBABLE UNCOLLECTIBLE AMOUNTS, PRIMARILY UNINSURED PATIENTS AND AMOUNTS PATIENTS ARE PERSONALLY RESPONSIBLE FOR, THROUGH A REDUCTION OF GROSS REVENUE AND A CREDIT TO THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. BALANCES STILL OUTSTANDING AFTER MANAGEMENT HAS USED REASONABLE COLLECTION EFFORTS ARE WRITTEN OFF THROUGH A CHARGE TO THE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND A CREDIT TO ACCOUNTS RECEIVABLE.IN EVALUATING THE COLLECTIBILITY OF PATIENT ACCOUNTS RECEIVABLE, THE HOSPITAL ANALYZES PAST RESULTS AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYOR SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND PROVISION FOR BAD DEBTS. MANAGEMENT REGULARLY REVIEWS DATA ABOUT THESE MAJOR PAYOR SOURCES OF REVENUE IN EVALUATING THE SUFFICIENCY OF THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. SPECIFICALLY, FOR RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRD-PARTY COVERAGE, THE HOSPITAL ANALYZES CONTRACTUALLY DUE AMOUNTS AND PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS AND A PROVISION FOR BAD DEBTS FOR EXPECTED UNCOLLECTIBLE DEDUCTIBLES AND COPAYMENTS ON ACCOUNTS FOR WHICH THE THIRD-PARTY PAYOR HAS NOT YET PAID, OR FOR PAYORS WHO ARE KNOWN TO BE HAVING FINANCIAL DIFFICULTIES THAT MAKE THE REALIZATION OF AMOUNTS DUE UNLIKELY. FOR RECEIVABLES ASSOCIATED WITH SELF-PAY PATIENTS (WHICH INCLUDES BOTH PATIENTS WITHOUT INSURANCE AND PATIENTS WITH DEDUCTIBLE AND COPAYMENT BALANCES DUE FOR WHICH THIRD-PARTY COVERAGE EXISTS FOR PART OF THE BILL), THE HOSPITAL RECORDS A SIGNIFICANT PROVISION FOR BAD DEBTS IN THE PERIOD OF SERVICE ON THE BASIS OF ITS PAST EXPERIENCE, WHICH INDICATES THAT MANY PATIENTS ARE UNABLE OR UNWILLING TO PAY THE PORTION OF THEIR BILL FOR WHICH THEY ARE FINANCIALLY RESPONSIBLE. THE DIFFERENCE BETWEEN THE STANDARD RATES (OR THE DISCOUNTED RATES IF NEGOTIATED) AND THE AMOUNTS ACTUALLY COLLECTED AFTER ALL REASONABLE COLLECTION EFFORTS HAVE BEEN EXHAUSTED IS CHARGED OFF AGAINST THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. |
| PART III, LINE 8: | IT IS CONSIDERED COMMUNITY BENEFIT AS THE HOSPITAL IS REIMBURSED ON MEDICARE ALLOWABLE COSTS. MEDICARE ALLOWABLE COSTS ARE DEFINED BY MEDICARE. THEY DO NOT NECESSARILY CAPTURE ALL COSTS OF THE HOSPITAL PROVIDING SERVICES TO THE COMMUNITY. CONSEQUENTLY, THERE ARE COSTS NOT REIMBURSED BY EITHER PATIENT OR THE PROGRAM. THE COST METHODOLOGY USED TO DETERMINE MEDICARE ALLOWABLE COSTS IS A STEP-DOWN ALLOCATION OF COSTS FROM NON-REVENUE AREAS TO REVENUE AREAS. THIS ALLOCATION IS DONE FOLLOWING MEDICARE RULES AND REGULATIONS. |
| PART III, LINE 9B: | PATIENTS UPON REGISTRATION ARE GIVEN THE POLICY AND REQUIREMENTS TO BE ELIGIBLE FOR CARITY CARE. THEY ARE ENCOURAGED BY A FINANCIAL ADVISOR TO REVIEW THEIR SITUATION FOR ELIGIBILITY. |
| PART VI, LINE 2: | THE HOSPITAL DEVELOPS COMMUNITY SURVEY WITH CONJUNCTION OF THE LOCAL PUBLIC HEALTH DEPARTMENT TO ASSESS SPECIFIC UNMET COMMUNITY NEEDS. |
| PART VI, LINE 3: | THE HOSPITAL ANNUALLY PUBLISHES IN THE LOCAL PAPER THE EXISTENCE OF ITS CHARITY PLAN AND QUALIFYING INCOME NEEDS TO QUALIFY. THE EXISTENCE OF A CHARITY PLAN IS POSTED IN THE ADMITTING AREA. UPON REGISTRATION, THE PATIENT IS INFORMED OF THE HOSPITAL'S CHARITY PLAN, ELIGIBILITY AND METHODS FOR APPLYING. ANYONE INTERESTED IN FURTHER INFORMATION IS REFERRED TO THE PATIENT ACCOUNT COORDINATOR FOR QUESTIONS AND ELIGIBILITY. THIS PERSON WORKS WITH THE PATIENT IN APPLICATION AS WELL AS EXPLORING THE POSSIBLE ELIGIBILITY OF ANY OTHER GOVERNMENT PROGRAM THAT MAY BE APPLICABLE. IE MEDICAID, BADGER CARE. |
| PART VI, LINE 4: | THE ORGANIZATION SERVES ADAMS COUNTY WISCONSIN BORDERED BY HWY 82 SOUTH, COUNTY C NORTH. |
| PART VI, LINE 5: | THE HOSPITAL WORKS WITH THE LOCAL PUBLIC HEALTH AGENCIES TO COORDINATE COMMUNITY HEALTH SERVICES TO MEET THE NEEDS OF THE LOCAL COMMUNITY. LONG-RANGE STRATEGIC AND CAPITAL BUDGET PLANNING WITH ADMINISTRATION, MEDICAL STAFF AND BOARD OF DIRECTORS. SURVEY OF OPINIONS FROM HOSPITAL ASSOCIATION. |
| PART VI, LINE 6: | N/A |
| PART VI, LINE 7, REPORTS FILED WITH STATES | WI |
Schedule J IRS990ScheduleJ
| Field | Value | IRS element (for citing) |
|---|---|---|
| Written Employment Contract | Yes (X) | WrittenEmploymentContractInd |
| Compensation Survey | Yes (X) | CompensationSurveyInd |
| Board Or Committee Approval | Yes (X) | BoardOrCommitteeApprovalInd |
| Severance Payment | 0 | SeverancePaymentInd |
| Supplemental Nonqual Rtr Plan | 0 | SupplementalNonqualRtrPlanInd |
| Equity Based Comp Arrngm | 0 | EquityBasedCompArrngmInd |
| Comp Based On Revenue Of Flng Org | 0 | CompBasedOnRevenueOfFlngOrgInd |
| Comp Bsd On Rev Related Orgs | 0 | CompBsdOnRevRelatedOrgsInd |
| Comp Bsd Net Earns Flng Org | 0 | CompBsdNetEarnsFlngOrgInd |
| Comp Bsd Net Earns Rltd Orgs | 0 | CompBsdNetEarnsRltdOrgsInd |
| Any Non Fixed Payments | 0 | AnyNonFixedPaymentsInd |
| Initial Contract Exception | 0 | InitialContractExceptionInd |
Rltd Org Officer Trst Key Empl RltdOrgOfficerTrstKeyEmplGrp (6 entries)
| TitleTitleTxt | Base Compensation Filing OrgBaseCompensationFilingOrgAmt | Compensation Based On Rltd OrgsCompensationBasedOnRltdOrgsAmt | Bonus Filing OrganizationBonusFilingOrganizationAmount | Bonus Related OrganizationsBonusRelatedOrganizationsAmt | Other Compensation Filing OrgOtherCompensationFilingOrgAmt | Other Compensation Rltd OrgsOtherCompensationRltdOrgsAmt | Deferred Compensation Flng OrgDeferredCompensationFlngOrgAmt | Deferred Comp Rltd OrgsDeferredCompRltdOrgsAmt | Nontaxable Benefits Filing OrgNontaxableBenefitsFilingOrgAmt | Nontaxable Benefits Rltd OrgsNontaxableBenefitsRltdOrgsAmt | Total Compensation Filing OrgTotalCompensationFilingOrgAmt | Total Compensation Rltd OrgsTotalCompensationRltdOrgsAmt | Comp Report Prior990 Filing OrgCompReportPrior990FilingOrgAmt | Comp Report Prior990 Rltd OrgsCompReportPrior990RltdOrgsAmt |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| DONALD HEINZ | ||||||||||||||
| CEO | $173,003 | $0 | $38,656 | $0 | $3,375 | $0 | $6,635 | $0 | $23,299 | $0 | $244,968 | $0 | $0 | $0 |
| MARK HATTON | ||||||||||||||
| PHYSICIAN | $216,676 | $0 | $13,860 | $0 | $0 | $0 | $3,433 | $0 | $23,071 | $0 | $257,040 | $0 | $0 | $0 |
| JOHN DAVID | ||||||||||||||
| PHYSICIAN | $187,476 | $0 | $6,416 | $0 | $0 | $0 | $1,041 | $0 | $26,084 | $0 | $221,017 | $0 | $0 | $0 |
| JASON BELLAK | ||||||||||||||
| PHYSICIAN | $247,106 | $0 | $0 | $0 | $20,000 | $0 | $7,414 | $0 | $17,969 | $0 | $292,489 | $0 | $0 | $0 |
| DAVID SHAPIRO | ||||||||||||||
| DIRECTOR OF ANCILLIARY SERVICES | $127,646 | $0 | $16,408 | $0 | $0 | $0 | $4,325 | $0 | $10,885 | $0 | $159,264 | $0 | $0 | $0 |
| CYNTHIA GANNON | ||||||||||||||
| PHYSICIAN | $228,638 | $0 | $1,033 | $0 | $0 | $0 | $0 | $0 | $31,175 | $0 | $260,846 | $0 | $0 | $0 |
Schedule K IRS990ScheduleK
Tax Exempt Bonds Issues TaxExemptBondsIssuesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bond Reference | A | BondReferenceCd |
Issuer Name IssuerName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | VILLAGE OF FRIENDSHIP REVENUE BONDS | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bond Issuer EIN | 396006271 | BondIssuerEIN |
| Bond Issued | 2003-11-01 | BondIssuedDt |
| Issue Price | $5,000,000 | IssuePriceAmt |
| Purpose | WI HOSPITAL DEVELOPMENT REVENUE BONDS | PurposeDesc |
| Defeased | 0 | DefeasedInd |
| On Behalf Of Issuer | 0 | OnBehalfOfIssuerInd |
| Pool Financing | 0 | PoolFinancingInd |
Tax Exempt Bonds Proceeds TaxExemptBondsProceedsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bond Reference | A | BondReferenceCd |
| Retired | $415,000 | RetiredAmt |
| Total Proceeds | $5,000,000 | TotalProceedsAmt |
| Issuance Costs From Proceeds | $110,000 | IssuanceCostsFromProceedsAmt |
| Capital Expenditures | $4,890,000 | CapitalExpendituresAmt |
| Substantial Completion | 2005 | SubstantialCompletionYr |
| Current Refunding | 0 | CurrentRefundingInd |
| Advance Refunding | 0 | AdvanceRefundingInd |
| Final Allocation Made | Yes (1) | FinalAllocationMadeInd |
| Adequate Books And Rec Maint | Yes (1) | AdequateBooksAndRecMaintInd |
Tax Exempt Bonds Private Bus Use TaxExemptBondsPrivateBusUseGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bond Reference | A | BondReferenceCd |
| Owning Bond Financed Property | 0 | OwningBondFinancedPropertyInd |
| Any Lease Arrangements | 0 | AnyLeaseArrangementsInd |
| Mgmt Contract Bond Fincd Prop | 0 | MgmtContractBondFincdPropInd |
| Any Research Agreements | 0 | AnyResearchAgreementsInd |
| Bond Iss Meet Prvt Sec Pymt Test | 0 | BondIssMeetPrvtSecPymtTestInd |
| Change In Use Bond Financed Prop | 0 | ChangeInUseBondFinancedPropInd |
| Procs Nonqualified Bond Remdtd | Yes (1) | ProcsNonqualifiedBondRemdtdInd |
Tax Exempt Bonds Arbitrage TaxExemptBondsArbitrageGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bond Reference | A | BondReferenceCd |
| Form8038 T Filed | 0 | Form8038TFiledInd |
| Rebate Not Due Yet | Yes (1) | RebateNotDueYetInd |
| Exception To Rebate | 0 | ExceptionToRebateInd |
| No Rebate Due | 0 | NoRebateDueInd |
| Variable Rate Issue | 0 | VariableRateIssueInd |
| Hedge Identified In Bks And Rec | 0 | HedgeIdentifiedInBksAndRecInd |
| Gross Proceeds Invested In GIC | 0 | GrossProceedsInvestedInGICInd |
| Gross Proceeds Invested | 0 | GrossProceedsInvestedInd |
| Written Proc To Monitor Reqs | 0 | WrittenProcToMonitorReqsInd |
Procedures Corrective Action ProceduresCorrectiveActionGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bond Reference | A | BondReferenceCd |
| Procedures Corrective Action | 0 | ProceduresCorrectiveActionInd |
Supplemental Information Detail SupplementalInformationDetail
| Field | Value | IRS element (for citing) |
|---|---|---|
| Form And Line Reference | FORM 990, SCHEDULE K, PART III, LINE 7 | FormAndLineReferenceDesc |
| Explanation | MANAGEMENT CALCULATES AND REVIEWS BOND COVENANTS ON A MONTHLY BASIS. THE BOND COVENANTS ARE REPORTED TO THE BOARD OF DIRECTORS. | ExplanationTxt |
Schedule L IRS990ScheduleL
Loans Btwn Org Interested Prsn LoansBtwnOrgInterestedPrsnGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person | DR JOHN DAVID | PersonNm |
| Relationship With Org | EMPLOYEE OF HOSPITAL | RelationshipWithOrgTxt |
| Loan Purpose | SIGNING BONUS | LoanPurposeTxt |
| Loan From Organization | Yes (X) | LoanFromOrganizationInd |
| Original Principal | $30,000 | OriginalPrincipalAmt |
| Balance Due | $10,000 | BalanceDueAmt |
| Default | 0 | DefaultInd |
| Board Or Committee Approval | Yes (1) | BoardOrCommitteeApprovalInd |
| Written Agreement | Yes (1) | WrittenAgreementInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Balance Due | $10,000 | TotalBalanceDueAmt |
Schedule O IRS990ScheduleO
Supplemental Information Detail SupplementalInformationDetail (10 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| FORM 990, PART VI, SECTION A, LINE 6 | ANY PERSON OVER THE AGE OF EIGHTEEN YEARS WHO IS A RESIDENT OF ADAMS COUNTY MAY BE A MEMBER OF THE CORPORATION. MEMBERSHIP MAY BE ATTAINED BY ANY SUCH PERSON WHO SHALL AGREE IN WRITING TO BECOME A MEMBER OF THIS CORPORATION BY SUBSCRIBING TO A MEMBERSHIP LIST OF SAID CORPORATION. ANNUAL MEMBERSHIPS WILL BE IN EFFECT FROM JULY 1ST TO JUNE 30TH OF EACH FISCAL YEAR. |
| FORM 990, PART VI, SECTION A, LINE 7A | EACH PERSON WHO WAS A MEMBER IN GOOD STANDING AS OF THE PREVIOUS JUNE 30TH IS ENTITLED TO ONE VOTE FOR EACH SEAT OF THE BOARD OF DIRECTORS. |
| FORM 990, PART VI, SECTION A, LINE 7B | MEMBERS OF THE ORGANIZATION MUST APPROVE BYLAW CHANGES. |
| FORM 990, PART VI, SECTION B, LINE 11 | THE 990 IS REVIEWED BY THE CEO PRIOR TO FILING. |
| FORM 990, PART VI, SECTION B, LINE 12C | THE CONFLICT OF INTEREST POLICY IS REVIEWED EVERY YEAR BY THE POLICY AND PROCEDURE COMMITTEE AND BY THE CEO. OFFICERS AND DIRECTORS ARE REQUIRED TO REVIEW THE POLICY AND DISCLOSE CONFLICTS. THE CEO REVIEWS THE SIGNED STATEMENTS. IF THERE IS A CONFLICT, THE CONFLICT WOULD BE DECLARED AND THE MEMBER WOULD ABSTAIN FROM VOTING. |
| FORM 990, PART VI, SECTION B, LINE 15 | CEO COMPENSATION IS BASED ON DIRECT NEGOTIATIONS BETWEEN THE BOARD MEMBERS WITHOUT CONFLICT AND THE INDIVIDUAL UTILIZING CURRENT RELEVANT MARKET SURVEYS AS A GUIDE WITH THE LANGUAGE OF CONTRACT GIVEN TO MMC ATTORNEYS FOR REVIEW AND COMMENTS. SUBSEQUENT MODIFICATIONS ARE PERFORMANCE BASED AND MARKET DRIVEN. FOR OTHER OFFICERS AND KEY EMPLOYEES THE CEO DETERMINES SALARY BASED ON THE MARKET, EXPERIENCE AND INDUSTRY SURVEY GUIDES. |
| FORM 990, PART VI, SECTION C, LINE 19 | THE ORGANIZATION BELIEVES THE GOVERNING DOCUMENTS, AND POLICIES ARE THE PROPERTY OF THE ORGANIZATION AND ARE NOT AVAILABLE FOR PUBLIC INSPECTION. THE AUDITED FINANCIAL STATEMENTS ARE NOW REQUIRED TO BE ATTACHED TO FORM 990. AUDITED FINANCIAL INFORMATION IS POSTED ANNUALLY ON THE HOSPITAL'S WEBSITE. |
| FORM 990, PART IX, LINE 11G | MEDICAL PROFESSIONAL FEES: PROGRAM SERVICE EXPENSES 2,761,015. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,761,015. HUMAN RESOURCES: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 19,418. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 19,418. FISCAL SERVICES: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 59,769. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 59,769. COMMUNITY RELATIONS: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 18,418. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 18,418. OTHER PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 716,400. MANAGEMENT AND GENERAL EXPENSES 127,183. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 843,583. |
| FORM 990, PART XI, LINE 9: | CHANGE IN ASSETS HELD IN POLIVKA TRUST -6,292. |
| FORM 990, PART XII, LINE 2C: | THIS PROCESS HAS NOT CHANGED FROM THE PRIOR YEARS. |
Schedule R IRS990ScheduleR
Id Related Tax Exempt Org IdRelatedTaxExemptOrgGrp
Disregarded Entity Name DisregardedEntityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | MEMORIAL HEALTHCARE FOUNDATION OF ADAMS CO | BusinessNameLine1Txt |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | PO BOX 40 | AddressLine1Txt |
| City | FRIENDSHIP | CityNm |
| State Abbreviation | WI | StateAbbreviationCd |
| ZIP | 53934 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 391775074 | EIN |
| Primary Activities | RAISE FUNDS FOR MOUNDVIEW MEMORIAL HOSPITAL & CLINICS | PrimaryActivitiesTxt |
| Legal Domicile State | WI | LegalDomicileStateCd |
| Exempt Code Section | 501(C)(3) | ExemptCodeSectionTxt |
| Public Charity Status | 11B, TYPE I | PublicCharityStatusTxt |
| Direct Controlling NA | N/A | DirectControllingNACd |
| Controlled Organization | Yes (1) | ControlledOrganizationInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Receipt Of Int Annts Rnts Rylts | 0 | ReceiptOfIntAnntsRntsRyltsInd |
| Gift Grnt Or Cap Contri To Oth Org | 0 | GiftGrntOrCapContriToOthOrgInd |
| Gift Grnt Cap Contri From Oth Org | Yes (1) | GiftGrntCapContriFromOthOrgInd |
| Loans Or Guarantees To Other Org | 0 | LoansOrGuaranteesToOtherOrgInd |
| Loans Or Guarantees From Oth Org | 0 | LoansOrGuaranteesFromOthOrgInd |
| Div Related Organization | 0 | DivRelatedOrganizationInd |
| Asset Sale To Other Org | 0 | AssetSaleToOtherOrgInd |
| Asset Purchase From Other Org | 0 | AssetPurchaseFromOtherOrgInd |
| Asset Exchange | 0 | AssetExchangeInd |
| Rental Of Facilities To Oth Org | 0 | RentalOfFacilitiesToOthOrgInd |
| Rental Of Fclts From Oth Org | 0 | RentalOfFcltsFromOthOrgInd |
| Perform Of Services For Oth Org | 0 | PerformOfServicesForOthOrgInd |
| Perform Of Services By Other Org | 0 | PerformOfServicesByOtherOrgInd |
| Sharing Of Facilities | Yes (1) | SharingOfFacilitiesInd |
| Paid Employees Sharing | 0 | PaidEmployeesSharingInd |
| Reimbursement Paid To Other Org | 0 | ReimbursementPaidToOtherOrgInd |
| Reimbursement Paid By Other Org | 0 | ReimbursementPaidByOtherOrgInd |
| Transfer To Other Org | 0 | TransferToOtherOrgInd |
| Transfer From Other Org | 0 | TransferFromOtherOrgInd |
Transactions Related Org TransactionsRelatedOrgGrp
Other Organization Name OtherOrganizationName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | MEMORIAL HEALTHCARE FOUNDATION OF ADAMS COUNTY | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Transaction Type | B | TransactionTypeTxt |
| Involved | $58,436 | InvolvedAmt |
| Method Of Amount Determination | ACTUAL | MethodOfAmountDeterminationTxt |