2016-08-15T11:30:03-05:00 2015-09-30 390758449 WIPFLI LLP PO BOX 12237 GREEN BAY WI 543072237 990 2014-10-01 390286215 FORT HEALTHCARE INC FORT 8004214677 611 E SHERMAN AVENUE FORT ATKINSON WI 53538 JAMES NELSON SENIOR VICE PRESIDENT 8004214677 2016-08-15 1 TERRI REXRODE CPA MST P00096513 9206620016 2016-08-15 2014 2016-09-27 15:27:22Z JAMES NELSON 611 E SHERMAN AVENUE FORT ATKINSON WI 53538 143078752 0 X WWW.FORTHEALTHCARE.COM X 1942 WI OUR MISSION AT FORT HEALTHCARE IS TO IMPROVE THE HEALTH AND WELL-BEING OF OUR COMMUNITY. 13 8 1002 180 0 0 113331 123985 125264048 127794334 4221913 3041178 -710352 1137837 128888940 132097334 0 0 0 0 48919396 47912245 0 0 0 71604817 69666358 120524213 117578603 8364727 14518731 176287857 181623495 75707940 70638012 100579917 110985483 OUR MISSION AT FORT HEALTHCARE IS TO IMPROVE THE HEALTH AND WELL-BEING OF OUR COMMUNITY. 0 0 71278369 0 97190969 OPERATION OF A 72-BED ACUTE CARE FACILITY WITH AN EMERGENCY ROOM AND FULL COMPLEMENT OF ANCILLARY SERVICES. 33772916 0 30603365 OPERATION OF PHYSICIAN CLINICS WITH OUTREACH INTO THE SURROUNDING COMMUNITIES 349067 349067 105051285 1 1 0 1 0 0 0 0 0 0 1 0 0 0 1 0 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 1 1 1 0 0 0 0 0 1 1 1 0 0 1 117 0 1002 1 0 0 0 0 0 0 0 0 0 0 X 13 8 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 1 1 WI X JAMES NELSON 9205685000 611 E SHERMAN AVENUE FORT ATKINSON WI 53538 MICHAEL ANDERSON MD BOARD MEMBER 3.00 40.00 X 0 505179 39658 MARY BEHLING BOARD MEMBER 3.00 X 0 0 0 BARRY CASH MD BOARD MEMBER 3.00 X 0 0 0 BILLIE KONTNY MD CHIEF OF STAFF 3.00 40.00 X 0 532830 40135 JONATHAN MCLAUGHLIN MD BOARD MEMBER 3.00 40.00 X 0 532110 40135 ERIC RUNEZ BOARD MEMBER 3.00 X 0 0 0 CAROL WARD KNOX BOARD MEMBER 3.00 X 0 0 0 GREGORY WATERS BOARD MEMBER 3.00 X 0 0 0 WADE WOELFLE MD CHIEF OF STAFF - THRU 12/31/14 3.00 X 0 0 0 MICHAEL WALLACE PRESIDENT/CEO 40.00 X X 358279 0 38275 SHARON SCHMELING CHAIR 3.00 X X 0 0 0 MICHAEL RUMPF VICE CHAIR 3.00 X X 0 0 0 DONALD WILLIAMS MD SECRETARY 40.00 X X 0 267559 35958 DEAN JOHNSON TREASURER 3.00 X X 0 0 0 JAMES NELSON SR. VICE PRESIDENT / CFO 40.00 X 207560 0 37591 KAY WIPPERFURTH VP ANCILLARY & SUPPORT SERVICES 40.00 X 164343 0 35383 RENEE CLARK VP NURSING SERVICES 40.00 X 134826 0 7461 THOMAS NORDLAND MD MEDICAL DIRECTOR 1.00 40.00 X 0 569905 38503 MARC ERICKSON MD PHYSICIAN 1.00 40.00 X 0 532400 40135 ISIDORO ZAMBRANO MD PHYSICIAN 1.00 40.00 X 0 981138 37635 PAUL SCHUPPNER MD PHYSICIAN 1.00 40.00 X 0 512910 21700 CHRISTOPHER MANAKAS MD PHYSICIAN 1.00 40.00 X 0 474799 37635 JULIE MOKHTAR MD PHYSICIAN 1.00 40.00 X 0 458856 25659 865008 5367686 475863 24 0 1 0 FORT MEDICAL GROUP 611 E SHERMAN AVENUE EAST FORT ATKINSON WI 53538 PHYSICIAN SERVICES 15356984 CERNER CORPORATION PO BOX 412702 KANSAS CITY OH 64141 PROFESSIONAL SERVICES 6682058 UW MEDICAL FOUNDATION - RADIOLOGY 600 HIGHLAND AVE MADISON WI 53792 RADIOLOGY SERVICES 1932316 GE MEDICAL SYSTEMS PO BOX 96483 CHICAGO IL 60693 EQUIPMENT MAINTENANCE 878423 SSM ST MARY'S LAB SERVICES 707 S MILLS ST MADISON WI 53715 LABORATORY SERVICES 483972 28 43189 80796 123985 HOSPITAL SERVICES 623000 96619842 96619842 PHYSICIAN CLINIC REVENUE 621110 20031595 20031595 OTHER OPERATING REVENUE 623990 10936203 10936203 RENTAL INCOME - SPECIALTY CLINIC 621610 206694 206694 127794334 1596754 1596754 65120 75988 -10868 -10868 -10868 11862928 486926 10734857 170573 1128071 316353 1444424 1444424 EQUITY INCOME 623000 664358 349067 315291 484347 484347 1148705 132097334 128143401 0 3829948 X 980284 980284 35799873 32790614 3009259 1405657 1253185 152472 7117089 6345098 771991 2609342 2326307 283035 1966029 1966029 141663 141663 29360144 27444221 1915923 360793 77541 283252 11657518 11486558 170960 3971768 3971768 4007933 3943400 64533 61259 61177 82 3186713 3186713 7251907 7213907 38000 233438 187890 45548 PROVISION FOR BAD DEBTS 2517202 2517202 DUES 2432686 70598 2362088 EAR PROJECT 916903 916903 LEASED EQUIPMENT 611659 536267 75392 988743 721936 266807 117578603 105051285 12527318 0 9390019 16122332 14485619 16403865 1881520 1993827 1623766 1026619 166623421 107364003 64720195 59259418 73202999 76316972 6668428 6350609 4315311 4149853 176287857 181623495 9707478 9768201 51482024 46479668 699706 413400 13818732 13976743 75707940 70638012 X 100579917 110985483 100579917 110985483 176287857 181623495 14518731 -4113165 0 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 9028 9028 0 PART II-B, LINE 1: LOBBYING PORTION OF DUES PAID TO WHA AND AHA. 636155 636155 65264449 36015251 29249198 99881343 71348752 28532591 841474 841474 59259418 DEFERRED COMPENSATION 837920 CAPITOL LEASE OBLIGATIONS 10082718 DEFERRED GAIN OF SALE-LEASEBACK 2145811 RELATED PARTY PAYABLE 910294 13976743 127159633 -4113165 -2441214 -6554379 133714012 -1616678 -1616678 132097334 116754067 75988 75988 116678079 900524 900524 117578603 PART XI, LINE 2D - OTHER ADJUSTMENTS: BAD DEBT INCLUDED IN EXPENSES -2,517,202. RENTAL EXPENSES 75,988. PART XI, LINE 4B - OTHER ADJUSTMENTS: RENTAL INCOME -1,616,678. PART XII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES 75,988. PART XII, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT INCLUDED IN EXPENSES 2,517,202. RENTAL INCOME -1,616,678. 1 1 1 X 1 X 1 1 1 0 1 1 496784 496784 0.00430 13919837 2754071 11165766 0.09700 14416621 2754071 11662550 0.10130 1461649 379567 1082082 0.00940 170351 1 170350 0.00150 1632000 379568 1252432 0.01090 16048621 3133639 12914982 0.11220 0 2517199 176204 8396291 11280371 -2884080 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 13 1 1 1 1 X SEE STATEMENT FOR LINE 7D X X 1 14 1 HTTPS://WWW.FORTHEALTHCARE.COM/WP-CONTENT/UPLOADS/2016/05/DJHCP-CHIP_2015-F 1 0 1 X 200.000000000000 400.000000000000 X X X 1 1 X X X 1 X WWW.FORTHEALTHCARE.COM/WELLNESS/COMMUNITY-CARE-INTRO/COMMUNITY-CARE X X X 1 0 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 6A: BEAVER DAM HOSPITAL AND WATERTOWN HOSPITAL FORT HEALTHCARE INC. PART V, SECTION B, LINE 6B: CITY OF WATERTOWN PUBLIC HEALTH DEPARTMENT, JEFFERSON COUNTY HEALTH DEPARTMENT. FORT HEALTHCARE INC. PART V, SECTION B, LINE 7D: HTTPS://WWW.FORTHEALTHCARE.COM/WP-CONTENT/UPLOADS/2016/05/DJHCP-CHIP_2015-FINAL-05-09-16-UPDATED-BIB-1.PDF FORT HEALTHCARE INC. PART V, SECTION B, LINE 11: FORT HEALTHCARE CONTINUES TO SUPPORT THE WORK OF THE ROCK RIVER FREE CLINIC, WHICH OFFERS FREE SERVICES TO THOSE WHO LIVE IN OUR SERVICE AREA. ADDITIONALY, WE CONTINUE TO ADDRESS OBESITY AND LACK OF PHYSICAL ACTIVITY THROUGH TARGETED COMMUNITY PROGRAMS OFFERED IN ALL OF THE COMMUNITIES WE SERVE. FORT HEALTHCARE CONTINUES TO OFFER FREE WEIGHT MANAGEMENT PROGRAMS, SUCH AS THE SLIMDOWN CHALLENGE, TO EDUCATE THE GENERAL PUBLIC ON SAFE AND EFFECTIVE LONG TERM WEIGHT LOSS MANAGEMENT STRATEGIES. WITH REGARD TO PHYSICAL ACTIVITY WE CONTINUE TO OFFER OUR ROCK THE WALK STEP CHALLENGE, FREE TO ALL COMMUNITY MEMBERS, IN AN EFFORT TO INCREASE KNOWLEDGE REGARDING THE BENEFITS OF REGULAR PHYSICAL ACTIVITY. FORT HEALTHCARE INC. PART V, SECTION B, LINE 13H: SERVICES ARE NOT ELECTIVE. FORT HEALTHCARE INC. PART V, SECTION B, LINE 16I: 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: THE POLICY IS ALSO AVAILABLE ON OUR WEBSITE. FORT HEALTHCARE INC. PART V, SECTION B, LINE 22D: WE USED OUR OVERALL AVERAGE INSURANCE RATE. PART V, SECTION B, LINE 16 FINANCIAL ASSISTANCE POLICY WEBSITE AVAILABILITY FORT HEALTHCARE INC. PART V, SECTION B, LINE 16A WEBSITE: WWW.FORTHEALTHCARE.COM/WELLNESS/COMMUNITY-CARE-INTRO/COMMUNITY-CARE 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 $ 2,517,199. PART II, COMMUNITY BUILDING ACTIVITIES: FORT HEALTHCARE GIVES GENEROUSLY TO AREA COMMUNITY ORGANIZATIONS. IN FY 2014, MORE THAN $90,000 WAS PROVIDED IN DIRECT SUPPORT OF COMMUNITY EVENTS. IN ADDITION, FORT HEALTHCARE RESOURCES WERE EXPENDED TO SUPPORT THOSE ACTIVITIES- INCLUDING SIGNIFICANT STAFF TIME, VOLUNTEER TIME, MEDICAL SUPPLIES, GIVEAWAY ITEMS AND MORE. APPROXIMATELY $3.0 MILLION WAS PROVIDED IN CHARITY CARE. FORT HEALTHCARE STAFF SERVE ON THE BOARD OF DIRECTORS FOR A NUMBER OF LOCAL NON-PROFIT AGENCIES. FORT HEALTHCARE IS VERY SUPPORTIVE OF UNITED WAY, TOMORROW'S HOPE, RELAY FOR LIFE AND MANY OTHER FUNDRAISING CAUSES IN THE COMMUNITY. THE COMMUNITY HEALTH & 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. FOR SEVERAL COMMUNITIES IN JEFFERSON COUNTY, KEY LEADERS HAVE BEEN IDENTIFIED TO REPRESENT THE HEALTHIEST COMMUNITIES COALITION IN THEIR RESPECTIVE CITIES. COALITION MEMBERSHIP INCLUDES REPRESENTATIVES FROM LOCAL SCHOOLS, CHURCHES, GOVERNMENT AGENCIES, BUSINESSES, COMMUNITY ORGANIZATIONS AND INTERESTED INDIVIDUALS. ALL 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 ON THE FOLLOWING PRIORITIES:-INCREASE ACCESS TO HEALTHY FOOD OPTIONS-APPLY INCENTIVES TO IMPROVE NUTRITION-INSTITUTE WORKPLACE INCENTIVES TO REWARD INCREASED PHYSICAL ACTIVITY-EDUCATE AND INFORM THE PUBLIC ABOUT SERVING SIZES AND NUTRITIONAL CONTENT OF FOOD OPTIONS AVAILABLE IN PUBLIC AREAS-IMPLEMENT COMPREHENSIVE PROGRAMS THAT PROMOTE PHYSICAL ACTIVITY AND NUTRITION-INCREASE ACCESS TO OPPORTUNITIES AND FACILITIES THAT PROMOTE PHYSICAL ACTIVITY 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.SUBACUTE COSTS ARE FROM WORKSHEET D-1 PART III. HOME HEALTH IS FROM WORKSHEET H-6 PART I. PART III, LINE 9B: PERSONS WHOSE INCOME IS LESS 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. THE PRIMARY RESEARCH TOOL IS A DOOR-TO-DOOR SURVEY OF 400+ RESIDENTS IN THE SERVICE AREA. MANY QUESTIONS RELATE SPECIFICALLY TO HEALTH NEEDS, CONCERNS, BEHAVIORS AND CONCERNS. THE SURVEY IS ADMINISTERED BY AN INDEPENDENT RESEARCH COMPANY AFFILIATED WITH THE UNIVERSITY OF WISCONSIN-WHITEWATER. FURTHERMORE, FORT HEALTHCARE HAS CREATED COMMUNITY HEALTH COALITIONS THROUGHOUT THE SERVICE AREA. CONCERNED RESIDENTS AND COMMUNITY LEADERS, WITH THE ASSISTANCE OF FORT HEALTHCARE STAFF ARE DEVELOPING SPECIFIC COMMUNITY-RELEVANT STRATEGIES TO ADDRESS OBESITY, PHYSICAL ACTIVITY, NUTRITION AND INCREASED CONSUMPTION OF WATER VS. SWEETENED BEVERAGES. 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, HELENVILLE, 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), DEAN/ST. MARY'S 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 X X X X X X 0 0 0 0 1 0 0 0 0 MICHAEL ANDERSON MD BOARD MEMBER 0 414269 0 90370 0 540 0 10400 0 29258 0 544837 0 0 BILLIE KONTNY MD CHIEF OF STAFF 0 528342 0 3246 0 1242 0 10400 0 29735 0 572965 0 0 JONATHAN MCLAUGHLIN MD BOARD MEMBER 0 527622 0 3246 0 1242 0 10400 0 29735 0 572245 0 0 MICHAEL WALLACE PRESIDENT/CEO 346637 0 0 0 11642 0 10400 0 27875 0 396554 0 0 0 DONALD WILLIAMS MD SECRETARY 0 229142 0 35231 0 3186 0 8692 0 27266 0 303517 0 0 JAMES NELSON SR. VICE PRESIDENT / CFO 206577 0 0 0 983 0 8326 0 29265 0 245151 0 0 0 KAY WIPPERFURTH VP ANCILLARY & SUPPORT SERVICES 162189 0 0 0 2154 0 6530 0 28853 0 199726 0 0 0 THOMAS NORDLAND MD MEDICAL DIRECTOR 0 565832 0 509 0 3564 0 10400 0 28103 0 608408 0 0 MARC ERICKSON MD PHYSICIAN 0 531158 0 0 0 1242 0 10400 0 29735 0 572535 0 0 ISIDORO ZAMBRANO MD PHYSICIAN 0 735352 0 245246 0 540 0 10400 0 27235 0 1018773 0 0 PAUL SCHUPPNER MD PHYSICIAN 0 461915 0 50509 0 486 0 10400 0 11300 0 534610 0 0 CHRISTOPHER MANAKAS MD PHYSICIAN 0 474313 0 0 0 486 0 10400 0 27235 0 512434 0 0 JULIE MOKHTAR MD PHYSICIAN 0 394058 0 63556 0 1242 0 10400 0 15259 0 484515 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 28195000 4497804 350383 23346813 2014 0 1 1 1 B 16480000 180000 16300000 2014 0 1 1 1 A 0 0 0 0 0.00000 0.00000 0.00000 0 0 0 B 0 0 0 0 0.00000 0.00000 0.00000 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 1 500 MCMILLEN GROUP LLP PARTNERSHIP OWNED BY DONALD WILLIAMS CURRENT BOARD DIRECTOR 367786 RENT FOR THE LEASE OF OFFICE SPACE 0 MELANIE RUMPF WIFE OF BOARD MEMBER MICHAEL RUMPF 43402 EMPLOYEE 0 MEDICAL HEALTH BUILDING GROUP PARTNERSHIP OWNED BY BILLIE KONTNY, A BOARD OF DIRECTOR. 1938587 RENT FOR THE LEASE OF OFFICE SPACE 0 FORM 990, PART VI, SECTION B, LINE 11 THE 990 IS REVIEWED BY THE ORGANIZATION'S ACCOUNTING MANAGER AND CFO. A COPY OF THE 990 IS PROVIDED TO THE FINANCE COMMITTEE 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 MEDICAL & PHYSICIAN SERVICES: PROGRAM SERVICE EXPENSES 27,444,221. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 27,444,221. ADMIN PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 1,915,923. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,915,923. PART XII, LINE 2C THIS PROCESS HAS NOT CHANGED FROM PRIOR YEAR. FORT MEMORIAL HOSPITAL FOUNDATION 611 SHERMAN AVE EAST FORT ATKINSON WI 53538 391397028 FOUNDATION WI 501(C)(3) LINE 11A, I FORT HEALTHCARE INC 1 FORT MEDICAL EQUIPMENT LLC 306 WASHINGTON ST FORT ATKINSON WI 53538 392042387 PROVIDE DURABLE MEDICAL EQUIPMENT WI RELATED -32991 0 0 0.30000 FORT MEDICAL GROUP INC 611 SHERMAN AVE EAST FORT ATKINSON WI 53538 391736513 PROVIDE PHYSICIAN SERVICES WI FORT HEALTHCARE INC C 2950669 1.00000 1 FORT CARE INC 611 SHERMAN AVE EAST FORT ATKINSON WI 53538 391725831 PREFERRED PROVIDER ORGANIZATION WI FORT HEALTHCARE INC C -2666 99735 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 P 162525 FAIR MARKET VALUE FORT MEDICAL GROUP O 15356984 FAIR MARKET VALUE