THEDACARE MEDICAL CENTER-WILD ROSE INC: Form 990, tax year 2013
View the entire original 990 at ProPublica ↗
- Organization
- THEDACARE MEDICAL CENTER-WILD ROSE INC (EIN 39-6089134)
- Tax period
- 2013-10-01 to 2014-09-30
- Filed
- 2015-08-20
- IRS object ID
- 201512329349300006
- Schema version
- 2013v4.0
- 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 L
- Schedule O
- Schedule R
Return header ReturnHeader
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return | 2015-08-20T08:15:26-05:00 | ReturnTs |
| Tax Period End | 2014-09-30 | 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 | BusinessNameLine1 |
Preparer US Address PreparerUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | PO BOX 12237 | AddressLine1 |
| City | GREEN BAY | City |
| State | WI | State |
| ZIP Code | 543072237 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return Type | 990 | ReturnTypeCd |
| Tax Period Begin | 2013-10-01 | TaxPeriodBeginDt |
Filer Filer
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 396089134 | EIN |
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | WILD ROSE COMMUNITY MEMORIAL HOSPITAL INC | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Control | WILD | BusinessNameControlTxt |
| Phone | 9206223257 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | PO BOX 243 | AddressLine1 |
| City | WILD ROSE | City |
| State | WI | State |
| ZIP Code | 549840243 | ZIPCode |
Business Officer BusinessOfficerGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person | THOMAS P KRYSTOWIAK CFO | PersonNm |
| Person Title | CFO | PersonTitleTxt |
| Phone | 9206223257 | PhoneNum |
| Signature | 2015-08-20 | SignatureDt |
| Discuss With Paid Preparer | Yes (1) | DiscussWithPaidPreparerInd |
Preparer Person PreparerPersonGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Person | TERRI REXRODE CPA | PreparerPersonNm |
| PTIN | P00096513 | PTIN |
| Phone | 9206620016 | PhoneNum |
| Preparation | 2015-08-12 | PreparationDt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tax | 2013 | TaxYr |
| Build TS | 2016-03-07 17:11:31Z | BuildTS |
Form 990 IRS990
| Field | Value | IRS element (for citing) |
|---|---|---|
| Principal Officer | THOMAS P KRYSTOWIAK | PrincipalOfficerNm |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | PO BOX 243 | AddressLine1 |
| City | WILD ROSE | City |
| State | WI | State |
| ZIP Code | 549840243 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Receipts | $14,595,655 | GrossReceiptsAmt |
| Group Return For Affiliates | 0 | GroupReturnForAffiliatesInd |
| Organization501c3 | Yes (X) | Organization501c3Ind |
| Website Address | WWW.WILDROSEHOSPITAL.ORG | WebsiteAddressTxt |
| Type Of Organization Corp | Yes (X) | TypeOfOrganizationCorpInd |
| Formation | 1956 | FormationYr |
| Legal Domicile State | WI | LegalDomicileStateCd |
| Activity Or Mission | WILD ROSE HOSPITAL PROVIDES INPATIENT AND OUTPATIENT HOSPITAL AND CLINIC SERVICES TO THE WAUSHARA COUNTY AREA. | ActivityOrMissionDesc |
| Voting Members Governing Body | 10 | VotingMembersGoverningBodyCnt |
| Voting Members Independent | 8 | VotingMembersIndependentCnt |
| Total Employee | 188 | TotalEmployeeCnt |
| Total Volunteers | 62 | TotalVolunteersCnt |
| Total Gross UBI | $0 | TotalGrossUBIAmt |
| Net Unrelated Bus Txbl Incm | $0 | NetUnrelatedBusTxblIncmAmt |
| PY Contributions Grants | $67,166 | PYContributionsGrantsAmt |
| CY Contributions Grants | $119,462 | CYContributionsGrantsAmt |
| PY Program Service Revenue | $14,807,211 | PYProgramServiceRevenueAmt |
| CY Program Service Revenue | $13,926,802 | CYProgramServiceRevenueAmt |
| PY Investment Income | $7,178 | PYInvestmentIncomeAmt |
| CY Investment Income | $6,732 | CYInvestmentIncomeAmt |
| PY Other Revenue | $0 | PYOtherRevenueAmt |
| CY Other Revenue | $542,659 | CYOtherRevenueAmt |
| PY Total Revenue | $14,881,555 | PYTotalRevenueAmt |
| CY Total Revenue | $14,595,655 | 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 | $6,673,193 | PYSalariesCompEmpBnftPaidAmt |
| CY Salaries Comp Emp Bnft Paid | $7,054,154 | CYSalariesCompEmpBnftPaidAmt |
| PY Total Prof Fndrsng Expns | $0 | PYTotalProfFndrsngExpnsAmt |
| CY Total Prof Fndrsng Expns | $0 | CYTotalProfFndrsngExpnsAmt |
| CY Total Fundraising Expense | $0 | CYTotalFundraisingExpenseAmt |
| PY Other Expenses | $8,115,835 | PYOtherExpensesAmt |
| CY Other Expenses | $8,172,549 | CYOtherExpensesAmt |
| PY Total Expenses | $14,789,028 | PYTotalExpensesAmt |
| CY Total Expenses | $15,226,703 | CYTotalExpensesAmt |
| PY Revenues Less Expenses | $92,527 | PYRevenuesLessExpensesAmt |
| CY Revenues Less Expenses | -$631,048 | CYRevenuesLessExpensesAmt |
| Total Assets BOY | $6,526,843 | TotalAssetsBOYAmt |
| Total Assets EOY | $7,031,017 | TotalAssetsEOYAmt |
| Total Liabilities BOY | $7,338,444 | TotalLiabilitiesBOYAmt |
| Total Liabilities EOY | $8,488,030 | TotalLiabilitiesEOYAmt |
| Net Assets Or Fund Balances BOY | -$811,601 | NetAssetsOrFundBalancesBOYAmt |
| Net Assets Or Fund Balances EOY | -$1,457,013 | NetAssetsOrFundBalancesEOYAmt |
| Info In Schedule O Part III | Yes (X) | InfoInScheduleOPartIIIInd |
| Mission | PROVIDE SUPERIOR SERVICES TO IMPROVE THE HEALTH OF THOSE WE SERVE. | MissionDesc |
| Significant New Program Srvc | 0 | SignificantNewProgramSrvcInd |
| Significant Change | 0 | SignificantChangeInd |
| Expense | $13,107,796 | ExpenseAmt |
| Revenue | $14,359,550 | RevenueAmt |
| Desc | WILD ROSE HOSPITAL'S MISSION IS TO "PROVIDE SUPERIOR SERVICES TO IMPROVE THE HEALTH OF THOSE WE SERVE." IN PURSUIT OF ITS PRIMARY EXEMPT PURPOSE OF PROVIDING INPATIENT AND OUTPATIENT HOSPITAL AND CLINIC SERVICES TO THE WAUSHARA COUNTY AREA, WILD ROSE HOSPITAL PROVIDES MEDICAL CARE AND OTHER FINANCIAL SUPPORT THROUGH VARIOUS PROGRAMS THAT ARE DESIGNED, AMONG OTHER MATTERS, TO ENHANCE THE HEALTH OF THE COMMUNITY. WILD ROSE HOSPITAL BELIEVES IT HAS A SPECIAL DUTY TO MEET THE NEEDS OF THE POOR, INDIGENT, AND MEDICALLY UNDERSERVED IN THE COMMUNITIES AND SURROUNDING AREAS. THEY HAVE PROVIDED CARE TO ALL PATIENTS WITHOUT REGARD FOR THE ABILITY TO PAY.WILD ROSE HOSPITAL ACTIVELY PROVIDED OR PARTICIPATED IN THE FOLLOWING COMMUNITY-BASED ACTIVITIES AND PROGRAMS:GENERAL HEALTH EDUCATION SERVICES SUCH AS HEALTH FAIRS- PROVIDED HEALTH INFORMATION ON THE CORPORATION'S WEB SITE AND THROUGH HEALTH RELATED PUBLICATIONS DISTRIBUTED AT NO CHARGEDIABETES EDUCATION AND SUPPORT GROUP AND BALANCE TRAINING (PHYSICAL THERAPY)HOSTED SELF-HELP AND WELLNESS PROGRAMS SUCH AS AA, AL-ANON, DIETBLOOD PRESSURE SCREENINGS, CHOLESTEROL TESTING AND SCHOOL-BASED TESTINGGUIDANCE, REFERRAL AND ENROLLMENT ASSISTANCE FOR PUBLIC MEDICAL PROGRAMS AND OTHER FAMILY SUPPORT ASSISTANCEDISCOUNTED OR FREE MEDICAL SUPPLIES AND EQUIPMENT TO THOSE UNABLE TO PAY BASED ON FAP POLICY.HOSTED FIVE BLOOD DRIVES AND ENCOURAGED EMPLOYEE PARTICIPATIONCONTRIBUTED TO THE EDUCATION OF STUDENT NURSES AND OTHER HEALTH CARE PROFESSIONALSPROVIDED FIRST AID FOR COMMUNITY SPORTING EVENTSPARTICIPATED IN WORK HEALTH EDUCATION PROGRAMS THROUGH PRIMARY CARE INITIATIVE PROGRAM MADE CASH CONTRIBUTIONS TO SUPPORT COMMUNITY SERVICES AND EVENTSPROVIDED MEETING ROOMS TO COMMUNITY GROUPS AT NO CHARGEWILD ROSE HOSPITAL OPERATES AN EMERGENCY ROOM THAT IS OPEN TO ALL PERSONS REGARDLESS OF ABILITY TO PAY. IT HAS AN OPEN MEDICAL STAFF WITH PRIVILEGES AVAILABLE TO ALL QUALIFIED PHYSICIAN IN THE AREA. THE MAJORITY OF THE BOARD OF DIRECTORS IS COMPRISED OF INDEPENDENT INDIVIDUALS WHO ARE REPRESENTATIVE OF THE COMMUNITY. CONSISTENT WITH WILD ROSE HOSPITAL'S MISSION, CARE IS PROVIDED TO PATIENTS REGARDLESS OF THEIR ABILITY TO PAY, INCLUDING PROVIDING SERVICES TO THOSE PERSONS WHO CANNOT AFFORD HEALTH INSURANCE BECAUSE OF INADEQUATE RESOURCES OR THOSE WHO ARE UNDERINSURED. WILD ROSE HOSPITAL GIVES DISCOUNTS FROM ESTABLISHED CHARGES TO SELF-PAY PATIENTS WITHOUT REGARD TO ABILITY TO PAY AND CONSIDERS THESE DISCOUNTS A PART OF ITS COMMUNITY BENEFIT. HEALTH CARE SERVICES TO PATIENTS UNDER GOVERNMENT PROGRAMS, SUCH AS MEDICAID, ARE ALSO CONSIDERED PART OF WILD ROSE HOSPITAL'S BENEFIT PROVIDED TO THE COMMUNITY SINCE A SUBSTANTIAL PORTION OF SUCH SERVICES ARE REIMBURSED AT AMOUNTS LESS THAN THE COST OF PROVIDING CARE. PATIENTS WHO MEET CRITERIA FOR CHARITY CARE, GENERALLY BASED ON FEDERAL POVERTY GUIDELINES, ARE PROVIDED CARE WITHOUT CHARGE OR AT A REDUCED RATE. ELIGIBILITY FOR CHARITY CARE IS DETERMINED BASED ON QUALIFYING CRITERIA AS DEFINED IN WILD ROSE HOSPITAL'S CHARITY CARE POLICY AND FROM APPLICATIONS COMPLETED BY PATIENTS AND THEIR FAMILIES. IN 2014 OVER 132 ACCOUNTS RECEIVED CHARITY CARE WITH A TOTAL COST OF OVER $414,189. | Desc |
| Total Program Service Expenses | $13,107,796 | 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 | Yes (1) | 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 | Yes (1) | 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 | 0 | TaxExemptBondsInd |
| Engaged In Excess Benefit Trans | 0 | EngagedInExcessBenefitTransInd |
| PY Excess Benefit Trans | 0 | PYExcessBenefitTransInd |
| Loan Outstanding | 0 | LoanOutstandingInd |
| Grant To Related Person | 0 | GrantToRelatedPersonInd |
| Business Rln With Org Mem | 0 | BusinessRlnWithOrgMemInd |
| Business Rln With Fam Mem | Yes (1) | 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 | Yes (1) | RelatedOrganizationCtrlEntInd |
| Transaction With Control Ent | Yes (1) | TransactionWithControlEntInd |
| Trnsfr Exmpt Non Chrtbl Rltd Org | 0 | TrnsfrExmptNonChrtblRltdOrgInd |
| Activities Conducted Prtshp | 0 | ActivitiesConductedPrtshpInd |
| Schedule O Required | Yes (1) | ScheduleORequiredInd |
| IRP Document | 14 | IRPDocumentCnt |
| IRP Document W2 G | 0 | IRPDocumentW2GCnt |
| Employee | 188 | 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 | 10 | GoverningBodyVotingMembersCnt |
| Independent Voting Member | 8 | IndependentVotingMemberCnt |
| Family Or Business Rln | Yes (1) | FamilyOrBusinessRlnInd |
| Delegation Of Mgmt Duties | Yes (1) | DelegationOfMgmtDutiesInd |
| Change To Org Documents | Yes (1) | 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 | 0 | 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 | 0 | CompensationProcessCEOInd |
| Compensation Process Other | 0 | 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
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person | THOMAS P KRYSTOWIAK | PersonNm |
| Phone | 9203611313 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 225 MEMORIAL DRIVE | AddressLine1 |
| City | BERLIN | City |
| State | WI | State |
| ZIP Code | 54984 | ZIPCode |
Form990 Part VII Section A Form990PartVIISectionAGrp (17 entries)
| TitleTitleTxt | Average Hours Per WeekAverageHoursPerWeekRt | Individual Trustee Or DirectorIndividualTrusteeOrDirectorInd | Reportable Comp From OrgReportableCompFromOrgAmt | Reportable Comp From Rltd OrgReportableCompFromRltdOrgAmt | Other CompensationOtherCompensationAmt | OfficerOfficerInd | Average Hours Per Week Rltd OrgAverageHoursPerWeekRltdOrgRt | Highest Compensated EmployeeHighestCompensatedEmployeeInd |
|---|---|---|---|---|---|---|---|---|
| LYNN CREAMER | ||||||||
| BOARD MEMBER | 1.00 | Yes (X) | $0 | $0 | $0 | |||
| JAMES ERDMAN | ||||||||
| BOARD MEMBER | 1.00 | Yes (X) | $0 | $0 | $0 | |||
| PATRICK MORROW | ||||||||
| BOARD MEMBER | 1.00 | Yes (X) | $0 | $0 | $0 | |||
| MARK KJENTVET MD | ||||||||
| BOARD MEMBER | 1.00 | Yes (X) | $0 | $0 | $0 | |||
| ROGER WILLIAMS | ||||||||
| CHAIRMAN OF BOARD | 1.00 | Yes (X) | $0 | $0 | $0 | Yes (X) | ||
| FREDERICK GELLERUP | ||||||||
| SECRETARY OF BOARD | 1.00 | Yes (X) | $0 | $0 | $0 | Yes (X) | ||
| CAROL WILLIAMS | ||||||||
| TREASURER OF BOARD | 1.00 | Yes (X) | $0 | $0 | $0 | Yes (X) | ||
| ALLEN STEA | ||||||||
| VICE-CHAIRMAN OF BOARD | 1.00 | Yes (X) | $0 | $0 | $0 | Yes (X) | ||
| DONALD R CAVES | ||||||||
| CEO/BOARD MEMBER | 40.00 | Yes (X) | $91,480 | $0 | $8,075 | Yes (X) | 0.00 | |
| MICHAEL STAUDINGER MD | ||||||||
| CHIEF OF MEDICAL STAFF | 40.00 | Yes (X) | $0 | $393,423 | $26,380 | Yes (X) | ||
| THOMAS KRYSTOWIAK | ||||||||
| CFO | 1.00 | $0 | $190,631 | $30,070 | Yes (X) | 41.00 | ||
| DAWN SHUMAN | ||||||||
| CEO | 40.00 | $98,975 | $0 | $7,486 | Yes (X) | |||
| CHAD VOSKUIL MD | ||||||||
| PHYSICIAN | 40.00 | $0 | $293,221 | $34,070 | Yes (X) | |||
| REGINALDO ABOLEDA MD | ||||||||
| PHYSICIAN | 40.00 | $0 | $203,271 | $11,663 | Yes (X) | |||
| CHANDLER CAVES MD | ||||||||
| PHYSICIAN | 40.00 | $0 | $439,889 | $32,756 | Yes (X) | |||
| GILBERT STEFFANIDES MD | ||||||||
| PHYSICIAN | 40.00 | $0 | $230,067 | $30,911 | Yes (X) | |||
| CATHERINE TRUEHL | ||||||||
| DIRECTOR OF AMBULATORY SERVICES | 40.00 | $113,684 | $0 | $6,885 | Yes (X) | |||
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Reportable Comp From Org | $304,139 | TotalReportableCompFromOrgAmt |
| Tot Reportable Comp Rltd Org | $1,750,502 | TotReportableCompRltdOrgAmt |
| Total Other Compensation | $188,296 | TotalOtherCompensationAmt |
| Indiv Rcvd Greater Than100 K | 1 | IndivRcvdGreaterThan100KCnt |
| Former Ofcr Employees Listed | 0 | FormerOfcrEmployeesListedInd |
| Total Comp Greater Than150 K | Yes (1) | TotalCompGreaterThan150KInd |
| Compensation From Other Srcs | 0 | CompensationFromOtherSrcsInd |
Contractor Compensation ContractorCompensationGrp (3 entries)
| Address Line1ContractorAddress/USAddress/AddressLine1 | CityContractorAddress/USAddress/City | StateContractorAddress/USAddress/State | ZIP CodeContractorAddress/USAddress/ZIPCode | ServicesServicesDesc | CompensationCompensationAmt |
|---|---|---|---|---|---|
| COMMUNITY HEALTH NETWORK | |||||
| 225 MEMORIAL DRIVE | BERLIN | WI | 54923 | MANAGEMENT AND PHYSICIAN SERVICES | $2,679,242 |
| SHARED MEDICAL EQUIPMENT GROUP LLC | |||||
| PO BOX 330 | COTTAGE GROVE | WI | 535270330 | HOSPITAL EQUIPMENT RENTAL | $155,445 |
| SHARED MEDICAL SERVICES | |||||
| PO BOX 330 | COTTAGE GROVE | WI | 535270330 | MRI SERVICES | $146,387 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Cntrct Rcvd Greater Than100 K | 3 | CntrctRcvdGreaterThan100KCnt |
| All Other Contributions | $119,462 | AllOtherContributionsAmt |
| Total Contributions | $119,462 | TotalContributionsAmt |
Program Service Revenue ProgramServiceRevenueGrp (2 entries)
| DescDesc | BusinessBusinessCd | Total Revenue ColumnTotalRevenueColumnAmt | Related Or Exempt Func IncomeRelatedOrExemptFuncIncomeAmt | ExclusionExclusionAmt |
|---|---|---|---|---|
| NET PATIENT SERVICE REVENUE | 621990 | $13,816,891 | $13,816,891 | |
| OTHER OPERATING REVENUE | 900099 | $109,911 | $109,911 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Revenue | $13,926,802 | TotalProgramServiceRevenueAmt |
Investment Income InvestmentIncomeGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $6,732 | TotalRevenueColumnAmt |
| Exclusion | $6,732 | ExclusionAmt |
Other Revenue Misc OtherRevenueMiscGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Desc | EMR INCENTIVE REVENUE | Desc |
| Business | 900099 | BusinessCd |
| Total Revenue Column | $542,659 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $542,659 | RelatedOrExemptFuncIncomeAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Revenue Total | $542,659 | OtherRevenueTotalAmt |
Total Revenue TotalRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $14,595,655 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $14,359,550 | RelatedOrExemptFuncIncomeAmt |
| Unrelated Business Revenue | $0 | UnrelatedBusinessRevenueAmt |
| Exclusion | $116,643 | ExclusionAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part IX | Yes (X) | InfoInScheduleOPartIXInd |
Other Salaries And Wages OtherSalariesAndWagesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $5,532,894 | TotalAmt |
| Program Services | $4,314,114 | ProgramServicesAmt |
| Management And General | $1,218,780 | ManagementAndGeneralAmt |
Pension Plan Contributions PensionPlanContributionsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $202,350 | TotalAmt |
| Program Services | $161,442 | ProgramServicesAmt |
| Management And General | $40,908 | ManagementAndGeneralAmt |
Other Employee Benefits OtherEmployeeBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $930,057 | TotalAmt |
| Program Services | $922,622 | ProgramServicesAmt |
| Management And General | $7,435 | ManagementAndGeneralAmt |
Payroll Taxes PayrollTaxesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $388,853 | TotalAmt |
| Program Services | $315,357 | ProgramServicesAmt |
| Management And General | $73,496 | ManagementAndGeneralAmt |
Fees For Services Legal FeesForServicesLegalGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $50,243 | TotalAmt |
| Management And General | $50,243 | ManagementAndGeneralAmt |
Fees For Services Other FeesForServicesOtherGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $3,143,161 | TotalAmt |
| Program Services | $2,893,457 | ProgramServicesAmt |
| Management And General | $249,704 | ManagementAndGeneralAmt |
Advertising AdvertisingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $13,766 | TotalAmt |
| Program Services | $258 | ProgramServicesAmt |
| Management And General | $13,508 | ManagementAndGeneralAmt |
Office Expenses OfficeExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,586,640 | TotalAmt |
| Program Services | $1,509,552 | ProgramServicesAmt |
| Management And General | $77,088 | ManagementAndGeneralAmt |
Information Technology InformationTechnologyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $57,933 | TotalAmt |
| Program Services | $57,933 | ProgramServicesAmt |
Occupancy OccupancyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $874,825 | TotalAmt |
| Program Services | $807,600 | ProgramServicesAmt |
| Management And General | $67,225 | ManagementAndGeneralAmt |
Travel TravelGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $49,090 | TotalAmt |
| Program Services | $38,878 | ProgramServicesAmt |
| Management And General | $10,212 | ManagementAndGeneralAmt |
Conferences Meetings ConferencesMeetingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $3,757 | TotalAmt |
| Program Services | $3,757 | ProgramServicesAmt |
Interest InterestGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $183,102 | TotalAmt |
| Program Services | $148,780 | ProgramServicesAmt |
| Management And General | $34,322 | ManagementAndGeneralAmt |
Depreciation Depletion DepreciationDepletionGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $710,959 | TotalAmt |
| Program Services | $577,693 | ProgramServicesAmt |
| Management And General | $133,266 | ManagementAndGeneralAmt |
Insurance InsuranceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $28,696 | TotalAmt |
| Program Services | $28,696 | ProgramServicesAmt |
Other Expenses OtherExpensesGrp (3 entries)
| DescDesc | TotalTotalAmt | Program ServicesProgramServicesAmt | Management And GeneralManagementAndGeneralAmt |
|---|---|---|---|
| PROVISION FOR BAD DEBT | $1,243,126 | $1,243,126 | |
| LICENSE AND CERTIFICATI | $38,153 | $27,865 | $10,288 |
| ASSOCIATION DUES | $12,895 | $5,188 | $7,707 |
All Other Expenses AllOtherExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $176,203 | TotalAmt |
| Program Services | $51,478 | ProgramServicesAmt |
| Management And General | $124,725 | ManagementAndGeneralAmt |
Total Functional Expenses TotalFunctionalExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $15,226,703 | TotalAmt |
| Program Services | $13,107,796 | ProgramServicesAmt |
| Management And General | $2,118,907 | ManagementAndGeneralAmt |
| Fundraising | $0 | FundraisingAmt |
Cash Non Interest Bearing CashNonInterestBearingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $430,130 | BOYAmt |
| EOY | $448,448 | EOYAmt |
Savings And Temp Cash Invst SavingsAndTempCashInvstGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $64,728 | BOYAmt |
| EOY | $141,280 | EOYAmt |
Accounts Receivable AccountsReceivableGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $3,294,026 | BOYAmt |
| EOY | $3,150,092 | EOYAmt |
Inventories For Sale Or Use InventoriesForSaleOrUseGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $249,203 | BOYAmt |
| EOY | $254,680 | EOYAmt |
Prepaid Expenses Defrd Charges PrepaidExpensesDefrdChargesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $101,462 | BOYAmt |
| EOY | $73,960 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Land Bldg Equip Cost Or Other Bss | $6,754,653 | LandBldgEquipCostOrOtherBssAmt |
| Land Bldg Equip Accum Deprec | $3,792,096 | LandBldgEquipAccumDeprecAmt |
Land Bldg Equip Basis Net LandBldgEquipBasisNetGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $2,132,930 | BOYAmt |
| EOY | $2,962,557 | EOYAmt |
Other Assets Total OtherAssetsTotalGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $254,364 | BOYAmt |
| EOY | $0 | EOYAmt |
Total Assets TotalAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $6,526,843 | BOYAmt |
| EOY | $7,031,017 | EOYAmt |
Accounts Payable Accr Expnss AccountsPayableAccrExpnssGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,390,438 | BOYAmt |
| EOY | $3,184,145 | EOYAmt |
Mortg Notes Pybl Scrd Invst Prop MortgNotesPyblScrdInvstPropGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $555,848 | BOYAmt |
| EOY | $58,966 | EOYAmt |
Other Liabilities OtherLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $5,392,158 | BOYAmt |
| EOY | $5,244,919 | EOYAmt |
Total Liabilities TotalLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $7,338,444 | BOYAmt |
| EOY | $8,488,030 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Organization Follows SFAS117 | Yes (X) | OrganizationFollowsSFAS117Ind |
Unrestricted Net Assets UnrestrictedNetAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | -$825,965 | BOYAmt |
| EOY | -$1,457,013 | EOYAmt |
Temporarily Rstr Net Assets TemporarilyRstrNetAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $14,364 | BOYAmt |
| EOY | $0 | EOYAmt |
Total Net Assets Fund Balance TotalNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | -$811,601 | BOYAmt |
| EOY | -$1,457,013 | EOYAmt |
Tot Liab Net Assets Fund Balance TotLiabNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $6,526,843 | BOYAmt |
| EOY | $7,031,017 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part XI | Yes (X) | InfoInScheduleOPartXIInd |
| Reconcilation Revenue Expnss | -$631,048 | ReconcilationRevenueExpnssAmt |
| Other Changes In Net Assets | -$14,364 | 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 | $1,275 | OtherActivitiesAmt |
| Total Lobbying Expenditures | $1,275 | 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 | A PORTION OF THE WHA DUES REPRESENT LOBBYING PERFORMED IN REGARD TO HEALTHCARE ISSUES. THE AMOUNT FOR 2013 WAS $1,275. | ExplanationTxt |
Schedule D IRS990ScheduleD
CY Endwmt Fund CYEndwmtFundGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Beginning Year Balance | $79,092 | BeginningYearBalanceAmt |
| Contributions | $78,458 | ContributionsAmt |
| Investment Earnings Or Losses | $67,488 | InvestmentEarningsOrLossesAmt |
| Grants Or Scholarships | $32,119 | GrantsOrScholarshipsAmt |
| End Year Balance | $192,919 | EndYearBalanceAmt |
CY Minus1 Yr Endwmt Fund CYMinus1YrEndwmtFundGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Beginning Year Balance | $69,176 | BeginningYearBalanceAmt |
| Contributions | $18,060 | ContributionsAmt |
| Investment Earnings Or Losses | $17,335 | InvestmentEarningsOrLossesAmt |
| Grants Or Scholarships | $25,479 | GrantsOrScholarshipsAmt |
| End Year Balance | $79,092 | EndYearBalanceAmt |
CY Minus2 Yr Endwmt Fund CYMinus2YrEndwmtFundGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Beginning Year Balance | $71,372 | BeginningYearBalanceAmt |
| Investment Earnings Or Losses | $3,129 | InvestmentEarningsOrLossesAmt |
| Other Expenditures | $5,325 | OtherExpendituresAmt |
| End Year Balance | $69,176 | EndYearBalanceAmt |
CY Minus3 Yr Endwmt Fund CYMinus3YrEndwmtFundGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Beginning Year Balance | $63,947 | BeginningYearBalanceAmt |
| Contributions | $6,904 | ContributionsAmt |
| Investment Earnings Or Losses | $521 | InvestmentEarningsOrLossesAmt |
| End Year Balance | $71,372 | EndYearBalanceAmt |
CY Minus4 Yr Endwmt Fund CYMinus4YrEndwmtFundGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Beginning Year Balance | $162,815 | BeginningYearBalanceAmt |
| Investment Earnings Or Losses | $520 | InvestmentEarningsOrLossesAmt |
| Other Expenditures | $99,388 | OtherExpendituresAmt |
| End Year Balance | $63,947 | EndYearBalanceAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Board Designated Balance EOY | 1.00000 | BoardDesignatedBalanceEOYPct |
| Endowments Held Unrelated Org | Yes (1) | EndowmentsHeldUnrelatedOrgInd |
| Endowments Held Related Org | Yes (1) | EndowmentsHeldRelatedOrgInd |
| Related Org List Sch R | 0 | RelatedOrgListSchRInd |
Land LandGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $167,668 | OtherCostOrOtherBasisAmt |
| Book Value | $167,668 | BookValueAmt |
Buildings BuildingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $2,423,783 | OtherCostOrOtherBasisAmt |
| Depreciation | $1,480,032 | DepreciationAmt |
| Book Value | $943,751 | BookValueAmt |
Leasehold Improvements LeaseholdImprovementsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $66,340 | OtherCostOrOtherBasisAmt |
| Depreciation | $61,521 | DepreciationAmt |
| Book Value | $4,819 | BookValueAmt |
Equipment EquipmentGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $4,028,069 | OtherCostOrOtherBasisAmt |
| Depreciation | $2,250,543 | DepreciationAmt |
| Book Value | $1,777,526 | BookValueAmt |
Other Land Buildings OtherLandBuildingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $68,793 | OtherCostOrOtherBasisAmt |
| Book Value | $68,793 | BookValueAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Book Value Land Buildings | $2,962,557 | TotalBookValueLandBuildingsAmt |
Other Liabilities Org OtherLiabilitiesOrgGrp (3 entries)
| DescDesc | AmtAmt |
|---|---|
| LONG TERM NOTES PAYABLE TO RELATED PARTY | $4,000,000 |
| DUE TO THIRD-PARTY REIMBURSEMENT PROGRAM | $697,330 |
| ACCOUNTS PAYABLE DUE TO RELATED PARTY | $547,589 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Liability | $5,244,919 | TotalLiabilityAmt |
| Footnote Text | Yes (X) | FootnoteTextInd |
Supplemental Information Detail SupplementalInformationDetail (2 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| PART V, LINE 4: | ENDOWMENT EARNINGS ARE TO BE UTILIZED TO SUPPORT THE ORGANZIATIONS MISSION AND PURPOSE. |
| PART X, LINE 2: | THE CONSOLIDATED ENTITIES ARE NONPROFIT CORPORATIONS AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE (THE "CODE") AND ARE EXEMPT FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE CODE. THE CONSOLIDATED ENTITIES ARE ALSO EXEMPT FROM STATE INCOME TAXES ON RELATED INCOME. IN ORDER TO ACCOUNT FOR ANY UNCERTAIN TAX POSITIONS, THEDACARE DETERMINES WHETHER IT IS MORE LIKELY THAN NOT THAT A TAX POSITION WILL BE SUSTAINED UPON EXAMINATION OF THE TECHNICAL MERITS OF THE POSITION, ASSUMING THE TAXING AUTHORITY HAS FULL KNOWLEDGE OF ALL INFORMATION. IF THE TAX POSITION DOES NOT MEET THE MORE-LIKELY-THAN-NOT RECOGNITION THRESHOLD, THE BENEFIT OF THAT POSITION IS NOT RECOGNIZED IN THE CONSOLIDATED FINANCIAL STATEMENTS. THE HOSPITAL RECORDED NO ASSETS OR LIABILITIES RELATED TO UNCERTAIN TAX POSITIONS IN 2014 AND 2013. TAX RETURNS FOR THE YEARS ENDED 2011 AND BEYOND REMAIN SUBJECT TO EXAMINATION BY APPLICABLE TAXING AUTHORITIES. |
Schedule H IRS990ScheduleH
| Field | Value | IRS element (for citing) |
|---|---|---|
| Financial Assistance Policy | Yes (1) | FinancialAssistancePolicyInd |
| Written Policy | Yes (1) | WrittenPolicyInd |
| FPG Reference Free Care | Yes (1) | FPGReferenceFreeCareInd |
| Percent150 | Yes (X) | Percent150Ind |
| FPG Reference Discounted Care | Yes (1) | FPGReferenceDiscountedCareInd |
| Percent300 | Yes (X) | Percent300Ind |
| Free Care Medically Indigent | 0 | FreeCareMedicallyIndigentInd |
| Financial Assistance Budget | Yes (1) | FinancialAssistanceBudgetInd |
| Expenses Exceed Budget | 0 | ExpensesExceedBudgetInd |
| 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 | $261,123 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $261,123 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.01870 | TotalExpensePct |
Unreimbursed Medicaid UnreimbursedMedicaidGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $1,414,601 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $627,369 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $787,232 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.05630 | TotalExpensePct |
Total Financial Assistance Typ TotalFinancialAssistanceTyp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $1,675,724 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $627,369 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $1,048,355 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.07500 | TotalExpensePct |
Community Health Services CommunityHealthServicesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $568 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $568 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00000 | TotalExpensePct |
Health Professions Education HealthProfessionsEducationGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $9,846 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $9,846 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00070 | TotalExpensePct |
Cash And In Kind Contributions CashAndInKindContributionsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $8,190 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $8,190 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00060 | TotalExpensePct |
Total Other Benefits TotalOtherBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $18,604 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $18,604 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00130 | TotalExpensePct |
Total Community Benefits TotalCommunityBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $1,694,328 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $627,369 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $1,066,959 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.07630 | TotalExpensePct |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bad Debt Expense Reported | Yes (1) | BadDebtExpenseReportedInd |
| Bad Debt Expense | $609,132 | BadDebtExpenseAmt |
| Reimbursed By Medicare | $4,322,081 | ReimbursedByMedicareAmt |
| Cost Of Care Reimbursed By Medcr | $4,279,288 | CostOfCareReimbursedByMedcrAmt |
| Medicare Surplus Or Shortfall | $42,793 | 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 | WILD ROSE COMMUNITY MEMORIAL HOSPITAL | BusinessNameLine1 |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 601 GROVE AVE | AddressLine1 |
| City | WILD ROSE | City |
| State | WI | State |
| ZIP Code | 54984 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Website Address | HTTP://WWW.WILDROSEHOSPITAL.ORG/ | WebsiteAddressTxt |
| State License | 1004 | 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 | WILD ROSE COMMUNITY MEMORIAL HOSPITAL | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | 1 | FacilityNum |
| 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 |
| Information Gaps | Yes (X) | InformationGapsInd |
| CHNA Conducted | 12 | CHNAConductedYr |
| Take Into Account Others Input | Yes (1) | TakeIntoAccountOthersInputInd |
| CHNA Conducted With Other Fclts | Yes (1) | CHNAConductedWithOtherFcltsInd |
| CHNA Report Widely Available | Yes (1) | CHNAReportWidelyAvailableInd |
| Rpt Available On Own Website | Yes (X) | RptAvailableOnOwnWebsiteInd |
| Own Website URL | SEE WEBSITE ON 5D | OwnWebsiteURLTxt |
| Rpt Available Thru Other Method | Yes (X) | RptAvailableThruOtherMethodInd |
| Adopt Implementation Strategy | Yes (X) | AdoptImplementationStrategyInd |
| Exec Implementation Strategy | Yes (X) | ExecImplementationStrategyInd |
| Develop Community Wide Plan | Yes (X) | DevelopCommunityWidePlanInd |
| Exec Community Wide Plan | Yes (X) | ExecCommunityWidePlanInd |
| Include Operational Plan | Yes (X) | IncludeOperationalPlanInd |
| Adopt Budget | Yes (X) | AdoptBudgetInd |
| Prioritize Health Needs | Yes (X) | PrioritizeHealthNeedsInd |
| Prioritize Services | Yes (X) | PrioritizeServicesInd |
| All Needs Addressed | 0 | AllNeedsAddressedInd |
| Organization Incur Excise Tax | 0 | OrganizationIncurExciseTaxInd |
| Elig Criteria Explained | Yes (1) | EligCriteriaExplainedInd |
| FPG Used Deter Elig Free Care | Yes (1) | FPGUsedDeterEligFreeCareInd |
| FPG Family Incm Lmt Free Care | 150.000000000000 | FPGFamilyIncmLmtFreeCarePct |
| FPG Used Determ Elig Dscnt Care | Yes (1) | FPGUsedDetermEligDscntCareInd |
| FPG Family Incm Lmt Dscnt Care | 300.000000000000 | FPGFamilyIncmLmtDscntCarePct |
| Explained Basis | Yes (1) | ExplainedBasisInd |
| Income Level | Yes (X) | IncomeLevelInd |
| Asset Level | Yes (X) | AssetLevelInd |
| Medical Indigency | Yes (X) | MedicalIndigencyInd |
| Insurance Status | Yes (X) | InsuranceStatusInd |
| Uninsured Discount | Yes (X) | UninsuredDiscountInd |
| Medicaid Medicare | Yes (X) | MedicaidMedicareInd |
| State Regulation | Yes (X) | StateRegulationInd |
| Residency | Yes (X) | ResidencyInd |
| App Financial Asst Expln | Yes (1) | AppFinancialAsstExplnInd |
| Includes Publicity Measures | Yes (1) | IncludesPublicityMeasuresInd |
| Posted In Admission Office | Yes (X) | PostedInAdmissionOfficeInd |
| Provided On Admission | Yes (X) | ProvidedOnAdmissionInd |
| Other Publicity | Yes (X) | OtherPublicityInd |
| FAP Actions On Nonpayment | Yes (1) | FAPActionsOnNonpaymentInd |
| 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 |
|---|---|
| WILD ROSE COMMUNITY MEMORIAL HOSPITAL | PART V, SECTION B, LINE 3: MEMBERS OF THE COMMUNITY WERE SURVEYED AT THE WAUSHARA COUNTY FAIR, WILD ROSE HOSPITAL PERSONNEL ALSO CONSULTED WITH THE WAUSHARA COUNTY PUBLIC HEALTH OFFICE REGARDING THE NEEDS OF THE AMISH COMMUNITY AND WITH LA CLINICA FOR INPUT ON THE HISPANIC RESIDENTS OF WAUSHARA COUNTY. |
| WILD ROSE COMMUNITY MEMORIAL HOSPITAL | PART V, SECTION B, LINE 4: COMMUNITY HEALTH NETWORK |
| WILD ROSE COMMUNITY MEMORIAL HOSPITAL | PART V, SECTION B, LINE 5D: HTTP://WWW.WILDROSEHOSPITAL.ORG/SITE/INDEX .PHP/FOR-PATIENTS/COMMUNITY-HEALTH-NEEDS- ASSESSMENT-COMMUNITY-HEALTH-IMPROVEMENT-PLAN-2013-2018 |
| WILD ROSE COMMUNITY MEMORIAL HOSPITAL | PART V, SECTION B, LINE 7: THE NEEDS WERE PRIORITIZED WITH COMMUNITY PARTNERS AND THOSE THAT WOULD HAVE THE BROADEST IMPACT WERE SELECTED BY THE GROUP. COMMITTEES WERE DEVELOPED TO WORK ON THE PLAN. WHILE SOME NEEDS WERE NOT SELECTED TO ACTIVELY WORK ON, PREVENTION STRATEGIES ARE USED IN HOPE OF IMPACTING ALL AREAS OVER TIME.WE CONTINUE TO HAVE A NEED TO REDUCE THE NUMBER OF SMOKERS IN OUR COMMUNITY. HOWEVER, WE HAVE DONE A LOT OF WORK ON SMOKING CESSATION IN PREVIOUS YEARS AND HAVE MADE TREMENDOUS STRIDES THROUGH A COMMUNITY TOBACCO CESSATION COUNCIL. BECAUSE WE ARE RURAL AND CONSTRAINED BY FINANCES, WE FELT CONCENTRATING OUR EFFORTS ON THE AREAS IDENTIFIED IN OUR PLAN WOULD ADDRESS THE AREAS OF GREATEST NEED AND GIVE US THE BEST CHANCE OF SUCCESSFULLY MOVING THE NEEDLE IN A POSITIVE DIRECTION. WE BELIEVE THAT THE SMOKING CESSATION INITIATIVE WILL CONTINUE TO IMPROVE THROUGH THE CONTINUED WORK OF INDEPENDENT AGENCIES IN OUR COMMUNITY SUCH AS: PUBLIC HEALTH, THE HOSPITAL, PRIMARY CARE PRACTICES, AND SCHOOLS, ETC. SIMILARLY, IF WE REDUCE OBESITY WE WILL REDUCE THE INCIDENCE OF CHRONIC HEALTH CONDITIONS, LIKE DIABETES AND HYPERTENSION. |
| WILD ROSE COMMUNITY MEMORIAL HOSPITAL | PART V, SECTION B, LINE 14G: THE POLICY IS COMMUNICATED DIRECTLY TO PATIENTS BY BILLING STAFF WHEN THEY INDICATE THEY DO NOT HAVE THE FINANCIAL MEANS TO PAY THEIR BILL, OR BY NURSING STAFF DURING THE ADMISSION ASSESSMENT WHEN A PATIENT INDICATES THEY HAVE FINANCIAL CONCERNS. |
| WILD ROSE COMMUNITY MEMORIAL HOSPITAL | PART V, SECTION B, LINE 20D: WILD ROSE COMMUNITY MEMORIAL HOSPITAL, INC. MAINTAINS WRITTEN POLICIES TO DETERMINE PATIENTS' ABILITY TO PAY AND ELIGIBILITY FOR FINANCIAL ASSISTANCE. APPLICANTS TO THE COMMUNITY CARE ASSISTANCE PROGRAM ARE REQUIRED TO COMPLETE AN APPLICATION TO DETERMINE ELIGIBILITY AND MAY QUALIFY FOR 25%, 50% OR 100% REDUCTION IN GROSS CHARGES. ELIGIBILITY IS DETERMINED ON THE BASIS ON A PATIENTS INCOME AND ASSETS. COMMUNITY CARE WILL BE APPROVED IN A THREE (3) TIER PROGRAM.1. 100% FOR APPLICANTS AT OR BELOW 150% OF FEDERAL POVERTY GUIDELINES.2. 50% FOR APPLICANTS BETWEEN 150% AND 200% OF FEDERAL POVERTY GUIDELINES.3. 25% FOR APPLICANTS BETWEEN 200% AND 300% OF FEDERAL POVERTY GUIDELINES. |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | 4 | FacilityNum |
Oth Hlth Care Fclts Not Hospital OthHlthCareFcltsNotHospitalGrp
Oth Hlth Care Fclts OthHlthCareFcltsGrp (4 entries)
| Address Line1USAddress/AddressLine1 | CityUSAddress/City | StateUSAddress/State | ZIP CodeUSAddress/ZIPCode | FacilityFacilityTxt |
|---|---|---|---|---|
| WFP WILD ROSE | ||||
| 701 GROVE AVE | WILD ROSE | WI | 54984 | OUTPATIENT PHYSICIAN CLINIC |
| WFP PLAINFIELD | ||||
| N6493 VALLEY CIRCLE ROAD | PLAINFIELD | WI | 54966 | OUTPATIENT PHYSICIAN CLINIC |
| WFP WAUTOMA | ||||
| N2934 HWY 22 NORTH | WAUTOMA | WI | 54982 | OUTPATIENT PHYSICIAN CLINIC |
| WFP COLOMA | ||||
| 141 FRONT STREET | COLOMA | WI | 54930 | OUTPATIENT PHYSICIAN CLINIC |
Supplemental Information Detail SupplementalInformationDetail (11 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| PART I, LINE 7: | COST TO CHARGE RATIO. |
| PART I, LN 7 COL(F): | BAD DEBT EXPENSE OF $1,852,557 FROM FORM 990, PART IX, LINE 25 WAS REMOVED FOR THE PURPOSE OF CALCULATING THE PERCENTAGES IN PART 1, LINE 7, COLUMN (F). |
| PART III, LINE 4: | THE COSTING METHODOLOGY USED IN DETERMINING THE AMOUNTS ABOVE IS A COST TO CHARGE RATIO BASED ON THE TOTAL OPERATING EXPENSE NET OF COMMUNITY BENEFIT EXPENSES AND NON-PATIENT CARE OPERATIONS, AND PATIENT CHARGES NET OF COMMUNITY BENEFIT CHARGES. MANY PATIENTS WHOSE ACCOUNTS/OUT-OF-POCKET LIABILITY ARE WRITTEN OFF TO BAD DEBT ARE UNABLE TO PAY BUT DID NOT COMPLETE THE PROCESS FOR CHARITY CARE/FINANCIAL ASSISTANCE. BECAUSE THESE PATIENTS WOULD HAVE QUALIFIED FOR CHARITY CARE, BUT DIDN'T COMPLETE THE PROCESS, THESE BAD DEBT WRITE-OFFS SHOULD BE CONSIDERED COMMUNITY BENEFIT AS CHARITY CARE. IN ADDITION, WILD ROSE HOSPITAL CONTINUES TO SERVE PATIENTS WHOSE ACCOUNTS ARE WRITTEN OFF TO BAD DEBT EVEN THOUGH THERE IS A GOOD CHANCE FUTURE SERVICES MAY CONTINUE TO BE WRITTEN OFF TO BAD DEBT, WHICH DEMONSTRATES A COMMUNITY BENEFIT, SERVING PATIENTS EVEN THOUGH WE MAY NOT BE PAID. |
| PART III, LINE 8: | THE ORGANIZATION USES A COST TO CHARGE RATIO TO CALCULATE ALLOWABLE COSTS ABOVE. ANY SHORTFALL SHOULD BE TREATED AS COMMUNITY BENEFIT BECAUSE WILD ROSE HOSPITAL CONTINUES TO SERVE THE MEDICARE POPULATION REGARDLESS OF WHETHER THEY COVER THEIR COSTS. WILD ROSE HOSPITAL HAS A SURPLUS BECAUSE IT IS A CRITICAL ACCESS HOSPITAL AND AS A CRITICAL ACCESS HOSPITAL, IT RECEIVES 101% OF ITS COST PER MEDICARE. |
| PART III, LINE 9B: | PATIENTS WHO HAVE AN APPLICATION OUTSTANDING ARE NOT KNOWINGLY SENT TO COLLECTIONS. PATIENTS WHO QUALIFY FOR 100% CHARITY HAVE THE ENTIRE AMOUNT OF THE BILL WRITTEN OFF AND NO FURTHER COLLECTION PROCEDURES ARE DONE. BALANCES REMAINING AFTER CHARITY CARE PERCENTAGE HAS BEEN DETERMINED (THOSE WHO QUALIFY FOR FINANCIAL ASSITANCE/PARTIAL CHARITY CARE) ARE CONSIDERED SELF PAY AND PAYMENT ARRANGEMENTS MUST BE MADE. SHOULD THE PATIENT FAIL TO MAKE PAYMENT ARRANGEMENTS OR MAINTAIN THE PAYMENTS AGREED UPON THEY WILL BE NOTIFIED IN WRITTING THAT THE ACCOUNT BALANCE IS PAST DUE AND THE ACCOUNT WILL BE SUBJECT TO NORMAL COLLECTION PROCEDURES. |
| PART VI, LINE 2: | WILD ROSE HOSPITAL WORKS IN COLLABORATION WITH WAUSHARA COUNTY WELLNESS COALITION TO ASSESS COMMUNITY NEEDS IN ORDER TO CREATE A HEALTH IMPROVEMENT PLAN BASED ON THOSE ISSUES AND CONCERNS IDENTIFIED. THE WAUSHARA WELLNESS COALITION CONSISTS OF MULTIDISCIPLINARY TEAM THAT INCLUDES THE AGING AND DISABILITY RESOURCE CENTER AND PUBLIC HEALTH. IN THE EFFORT TO PROVIDE COMPREHENSIVE CARE, THE WAUSHARA WELLNESS COALITION ALSO STRIVES TO DECREASE INEFFICIENCIES DUE TO OVERLAP OF CARE PROVIDERS AND ORGANIZATIONS IN THE AREA. |
| PART VI, LINE 3: | SELF PAY PATIENTS ARE CONTACTED BY A MEMBER OF THE PATIENT ACCOUNTING STAFF TO INFORM THEM OF AVAILABLE GOVERNMENT PROGRAMS AND CHARITY CARE. IF APPROPRIATE THE PATIENT ACCOUNTING STAFF WILL OFFER ASSISTANCE WITH THE COMPLETION OF THE COMMUNITY CARE (CHARITY CARE) APPLICATION. |
| PART VI, LINE 4: | WILD ROSE HOSPITAL IS IN AN HPSA AREA AND IS THE ONLY HOSPITAL IN WAUSHARA COUNTY. AS OF THE CENSUS OF 2013 THERE WERE 24,441 RESIDENTS OCCUPYING 10,143 HOUSEHOLDS WITH A 75% INCREASE IN POPULATION DURING THE SUMMER. THE ELDERLY COMPRISE 21% OF THE POPULATION COMPARED WITH 14% STATEWIDE. THE AVERAGE ANNUAL WAGE IN 2012 WAS ABOUT 31% LESS THAN THE STATE AVERAGE. APPROXIMATELY 13% OF THE POPULATION LIVE BELOW THE POVERTY LEVEL . THERE ARE NO MAJOR POPULATION CENTERS IN WAUSHARA COUNTY WITH THE LARGEST COMMUNITY BEING WAUTOMA HAVING A POPULATION OF 2,218. THE POPULATION CONSISTS OF 19% UNDER THE AGE OF 18, 28% FROM 18 TO 44, 32% FROM 44 TO 64, 21% WHO WERE 65 AND OLDER. THE MEDIAN AGE WAS 46 YEARS AND THE GENDER PERCENTAGE IS 53% MALE, 47% FEMALE. |
| PART VI, LINE 5: | THE MAJORITY OF OUR ORGANIZATION'S GOVERNING BODY IS COMPRISED OF PERSONS WHO RESIDE IN THE ORGANIZATION'S PRIMARY SERVICE AREA WHO ARE NEITHER EMPLOYEES NOR CONTRACTORS OF THE ORGANIZATION, NOR FAMILY MEMBERS THEREOF. WILD ROSE HOSPITAL CONDUCTS HEALTH FAIRS AND CAREER FAIRS FOR THE COMMUNITY TO ENCOURAGE HEALTHY LIFESTYLES AND TO RAISE AWARENESS OF HEALTH ISSUES AND TRENDS AS WELL AS CAREER OPPORTUNITIES WITHIN THE LOCAL HEALTH FACILITIES.WE ALSO CONDUCT CPR AND FIRST AID CLASSES, EDUCATION AND OUTREACH FOR SENIOR CITIZENS, EDUCATIONAL OPPORTUNITIES FOR RESIDENTS AND MEDICAL STUDENTS, AS WELL AS CHOLESTEROL SCREENING. IN ADDITION, WE ADMINISTER A DIABETES SUPPORT GROUP. |
| PART VI, LINE 6: | WILD ROSE HOSPITAL IS AFFILIATED WITH COMMUNITY HEALTH NETWORK THROUGH PARTNERS HEALTH SYSTEM (PHS). THE BENEFIT IS A COORDINATED EFFORT TO PROVIDE COMPREHENSIVE HEALTH CARE TO AN EXTENDED, MULTI-COUNTY RURAL AREA. AN ADDITIONAL BENEFIT IS INCREASED EFFICIENCIES THROUGH SHARED RESOURCES, THEREFORE PROVIDING A WIDER RANGE OF HEALTH SERVICES THROUGHOUT THE ENTIRE COMBINED SERVICE AREA. |
| PART VI, LINE 7, REPORTS FILED WITH STATES | WI |
Schedule J IRS990ScheduleJ
| Field | Value | IRS element (for citing) |
|---|---|---|
| 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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| MICHAEL STAUDINGER MD | ||||||||||||||
| CHIEF OF MEDICAL STAFF | $0 | $372,510 | $0 | $0 | $0 | $20,913 | $0 | $5,000 | $0 | $21,380 | $0 | $419,803 | $0 | $0 |
| THOMAS KRYSTOWIAK | ||||||||||||||
| CFO | $0 | $176,715 | $0 | $3,459 | $0 | $10,457 | $0 | $7,491 | $0 | $22,579 | $0 | $220,701 | $0 | $0 |
| CHAD VOSKUIL MD | ||||||||||||||
| PHYSICIAN | $0 | $293,221 | $0 | $0 | $0 | $0 | $0 | $5,000 | $0 | $29,070 | $0 | $327,291 | $0 | $0 |
| REGINALDO ABOLEDA MD | ||||||||||||||
| PHYSICIAN | $0 | $173,956 | $0 | $0 | $0 | $29,315 | $0 | $6,053 | $0 | $5,610 | $0 | $214,934 | $0 | $0 |
| CHANDLER CAVES MD | ||||||||||||||
| PHYSICIAN | $0 | $410,033 | $0 | $0 | $0 | $29,856 | $0 | $5,000 | $0 | $27,756 | $0 | $472,645 | $0 | $0 |
| GILBERT STEFFANIDES MD | ||||||||||||||
| PHYSICIAN | $0 | $229,394 | $0 | $0 | $0 | $673 | $0 | $4,691 | $0 | $26,220 | $0 | $260,978 | $0 | $0 |
Schedule L IRS990ScheduleL
Bus Tr Involve Interested Prsn BusTrInvolveInterestedPrsnGrp (3 entries)
| Relationship DescriptionRelationshipDescriptionTxt | TransactionTransactionAmt | TransactionTransactionDesc | Sharing Of RevenuesSharingOfRevenuesInd |
|---|---|---|---|
| ANDREEN KJENTVET | |||
| SPOUSE OF BOARD MEMBER. | $34,231 | COMPENSATION | 0 |
| DANAE SHUMAN TIEDJE | |||
| DAUGHTER OF COO | $36,648 | COMPENSATION | 0 |
| CHANDLER CAVES MD | |||
| SON OF CEO | $472,645 | COMPENSATION | 0 |
Schedule O IRS990ScheduleO
Supplemental Information Detail SupplementalInformationDetail (13 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| FORM 990, PART VI, SECTION A, LINE 2 | MARK KJENVET HAS A FAMILY RELATIONSHIP WITH ANDREEN KJENVET, AN EMPLOYEE OF WILD ROSE HOSPITAL. DONALD CAVES HAS A FAMILY RELATIONSHIP WITH CHANDLER CAVES, MD, WHOM IS EMPLOYEED BY A RELATED PARTY. |
| FORM 990, PART VI, SECTION A, LINE 3 | PRIOR TO JUNE 30,2014, WILD ROSE COMMUNITY MEMORIAL HOSPITAL WAS AFFILIATED WITH COMMUNITY HEALTH NETWORK (CHN), A 501(C)(3) ORGANIZATION, THROUGH AN AFFILIATION AGREEMENT BETWEEN THE TWO ORGANIZATIONS. THE AFFILIATION AGREEMENT IS DATED AUGUST 19, 2009, EFFECTIVE OCTOBER 1, 2009. BOTH ORGANIZATIONS HAVE FORMED PARTNERS HEALTH SYSTEM (PHS), A 501(C)(3) ORGANIZATION, WITH THE INTENT OF CREATING AN INTEGRATED HEALTH CARE DELIVERY SYSTEM. THROUGH PHS, SOME OF WILD ROSE HOSPITAL'S MANAGEMENT DUTIES ARE DELEGATED TO PHS OR CHN SUCH AS: - CONTRACTING FOR SERVICES AND PURCHASING OF EQUIPMENT AND SUPPLIES - SETTING OF CHARGES - BILLING AND COLLECTIONS - DEVELOPMENT OF POLICIES AND PROCEDURES - PREPARATION OF BUDGETS - PREPARATION OF FINANCIAL AND COST REPORTS - CONTRACTING FOR SERVICES BY HEALTH CARE PROVIDERS - HANDLING OF MATTERS INVOLVING MEDICAL STAFF RELATIONS - PROVIDE ANESTHESIA COVERAGE |
| FORM 990, PART VI, SECTION A, LINE 4 | THE ORGANIZATION'S ARTICLES OF INCORPORATION AND BYLAWS WERE AMENDED, EFFECTIVE JUNE 30,2014, TO REFLECT THE AFFILIATION WITH THEDACARE, INC. IN ADDITION, THE FISCAL YEAR OF THE ORGANIZATION IS NOW A CALENDAR YEAR. |
| FORM 990, PART VI, SECTION A, LINE 6 | EFFECTIVE JUNE 30, 2014, WILD ROSE COMMUNITY MEMORIAL HOSPITAL, INC.'S SOLE MEMBER OF THE SINGLE CLASS OF VOTING MEMBERS IS THEDACARE, INC. |
| FORM 990, PART VI, SECTION A, LINE 7A | EFFECTIVE JUNE 30, 2014, THEDACARE, INC. HAS THE AUTHORITY IN THE CORPORATION TO VOTE AND TAKE ANY ACTION WITH RESPECT TO THE ELECTION OF DIRECTORS AND OFFICERS. A CONSULTATION WOULD OCCUR WITH WILD ROSE BEFORE SUCH ACTIONS WERE TAKEN. |
| FORM 990, PART VI, SECTION A, LINE 7B | PRIOR TO JUNE 30, 2014, WILD ROSE HOSPITAL(WRH) HAD DELEGATED TO THE PARTNERS HEALTH SYSTEM (PHS) BOARD THE FOLLOWING AUTHORITY: - PHS SHALL ESTABLISH OVERALL STRATEGIC & BUDGETARY OBJECTIVES FOR THE SYSTEM (INCLUDES WRH) - PHS SHALL REVIEW, CONSOLIDATE, MODIFY AND APPROVE OR DISAPPROVE STRATEGIC PLANS PREPARED BY THE PARTIES - PHS SHALL INITIATE AND APPROVE CAPITAL PROJECTS FOR OR ON BEHALF OF THE PARTIES - PHS SHALL INITIATE AND APPROVE THE INCURRENCE OF DEBT BY THE PARTIES - PHS MAY CONTRACT ON BEHALF OF THE PARTIES - PHS SHALL ESTABLISH CHARGE RATES FOR THE PARTIES - PHS CEO SHALL HIRE THE CEOS OF THE PARTIES SUBJECT TO APPROVAL OF THE BOARD OF DIRECTORS OF THE APPLICABLE PARTY - PHS CEO SHALL HAVE THE AUTHORITY TO TERMINATE THE CEO OF A PARTY, SUBJECT TO THE CONSENT OF THE CHAIR OF THE BOARD OF THE PARTY. - PHS SHALL MANAGE THE SYSTEMS EMPLOYED PHYSICIANS EFFECTIVE JUNE 30, 2014, THEDACARE, INE. HAS THE AUTHORITY WITH RESPECT TO THE FOLLOWING MATTERS: 1. MERGE, CONSOLIDATE, OR CHANGE CONTROL OF THE ORGANIZATION 2. SELL, LEASE, TRANSFER, OR DISPOSE OF MATERIAL ASSETS 3. ENTER JOINT VENTURES OR AFFILIATIONS 4. AMEND BYLAWS AND ARTICLES OF INCORPORATION 5. DEVELOP AND APPROVE CAPITAL AND OPERATING BUDGETS 6. AUTHORIZE AND MAKE CAPITAL EXPENDITURES 7. APPROVE STRATEGIC PLANS, WITH MANAGEMENT AND BOARD OVERSIGHT 8. APPROVE THE SAFETY AND QUALITY PLAN 9. APPROVE THE DISSOLUTION OR LIQUIDATION 10. APPOINT AUDITORS AND LEGAL COUNSEL 11. RETAIN INVESTMENT ADVISORS AND ESTABLISH INVESTMENT POLICIES 12. HIRE OR TERMINATE THE CEO 13. BORROW AND INCUR DEBT |
| FORM 990, PART VI, SECTION B, LINE 11 | THE BOD HAS DELEGATED THE DETAILED REVIEW OF THE FORM 990 TO MANAGEMENT OF THE CORPORATION. THEY COMPLETED THE REVIEW PRIOR TO SUBMISSION. |
| FORM 990, PART VI, SECTION B, LINE 12C | IT IS THE DIRECTOR, OFFICER AND/OR COMMITTEE MEMBER'S RESPONSIBILITY TO DISCLOSE TO THE BOARD OF DIRECTORS OR COMMITTEE CONSIDERING A TRANSACTION, ANY POTENTIAL FINANCIAL INTEREST. CHAIRPERSON OF THE BOARD OR COMMITTEE MAKES A DECISION WHETHER A CONFLICT OF INTEREST EXISTS. THE BOARD OF DIRECTORS OR A COMMITTEE THEREOF TO WHICH SUCH DISCLOSURE IS MADE SHALL DETERMINE, BY MAJORITY VOTE, IF SUCH PERSON SHALL NOT VOTE ON, NOR SUCH HIS PERSONAL INFLUENCE ON, NOR PARTICIPATE (OTHER THAN TO PRESENT FACTUAL INFORMATION OR TO RESPOND TO QUESTIONS) IN THE DISCUSSIONS OR DELIBERATIONS WITH RESPECT TO SUCH CONTRACT OR TRANSACTION. IN ADDITION TO THE ABOVE, DIRECTORS, OFFICERS AND COMMITTEE MEMBERS EXECUTE AND DELIVER TO THE CORPORATION A "CERTIFICATE REGARDING CONFLICTS OF INTEREST" ON AN ANNUAL BASIS. PER THE POLICY, THE BOARD IS TO CONDUCT PERIODIC REVIEWS OF ITS TRANSACTIONS AND ARRANGEMENTS. REVIEW SHALL INCLUDE: - WHETHER COMPENSATION ARRANGEMENTS AND BENEFITS ARE REASONABLE AND ARE THE RESULT OF ARM'S-LENGTH BARGAINING - WHETHER ACQUISITIONS OF PHYSICIANS PRACTICES AND OTHER PROVIDER SERVICES RESULT IN PRIVATE INUREMENT OR IMPERMISSIBLE PRIVATE BENEFIT - WHETHER PARTNERSHIPS, JOINT VENTURES, AND OTHER TYPES OF ARRANGEMENT FURTHER THE CORPORATION'S CHARITABLE PURPOSE AND DO NOT RESULT IN INUREMENT OR IMPERMISSIBLE PRIVATE BENEFIT. |
| FORM 990, PART VI, SECTION B, LINE 15 | THE COMPENSATION DETERMINATION FOR THE CEO OF COMMUNITY HEALTH NETWORK IS AS FOLLOWS: THE CEO IS UNDER AN EMPLOYMENT CONTRACT. HIS SALARY IS REVIEWED PER HIS CONTRACT BY THE EXECUTIVE COMMITTEE OF THE BOARD OF DIRECTORS (THOSE WITHOUT CONFLICT). THE EXECUTIVE COMMITTEE REVIEWS COMPENSATION BENCHMARK DATA, COMPARES THE DATA WITH THE CEO'S CURRENT SALARY AND MAKES A SALARY DETERMINATION WHICH IS THEN VOTED ON BY THE EXECUTIVE COMMITTEE. THE COMPENSATION DETERMINATION FOR THE CFO IS AS FOLLOWS: ONCE A YEAR, CHN'S CEO REVIEWS COMPENSATION BENCHMARK DATA AND COMPARES THE DATA WITH THE CFO'S CURRENT SALARY AND THE PROPOSED INCREASE. BASED ON THE DATA THE CEO, A PERSON WITHOUT CONFLICT, DETERMINES THE CFO'S SALARY FOR THE COMING YEAR. THE SALARY IS DISCUSSED AND AGREED UPON BY CHN'S CEO AND THE INDIVIDUAL. THE PROCESS WAS NOT FULLY DOCUMENTED IN THE MINUTES THUS A "NO" RESPONSE. |
| FORM 990, PART VI, SECTION C, LINE 19 | THE ORGANIZATION BELIEVES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE THE PROPERTY OF THE ORGANIZATION AND DOES NOT MAKE THEM AVAILABLE TO THE PUBLIC. |
| FORM 990, PART IX, LINE 11G | PURCHASED MEDICAL SERVICES: PROGRAM SERVICE EXPENSES 2,893,457. MANAGEMENT AND GENERAL EXPENSES 249,704. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 3,143,161. |
| FORM 990, PART XI, LINE 9: | ELIMINATION OF INTEREST IN PARTNER'S HEALTH SYSTEM FOUNDATION, INC. -14,364. |
| FORM 990, PART XI, LINE 2C | MANAGEMENT PROVIDES OVERSIGHT OF THE AUDIT. AUDIT RESULTS ARE PRESENTED TO MANAGEMENT AND THE BOARD OF DIRECTORS. THE PROCESS HAS NOT CHANGED FROM PRIOR YEAR. |
Schedule R IRS990ScheduleR
Id Related Tax Exempt Org IdRelatedTaxExemptOrgGrp (11 entries)
| Address Line1USAddress/AddressLine1 | CityUSAddress/City | StateUSAddress/State | ZIP CodeUSAddress/ZIPCode | EINEIN | Primary ActivitiesPrimaryActivitiesTxt | Legal Domicile StateLegalDomicileStateCd | Exempt Code SectionExemptCodeSectionTxt | Public Charity StatusPublicCharityStatusTxt | Business Name Line1DirectControllingEntityName/BusinessNameLine1 | Controlled OrganizationControlledOrganizationInd | Direct Controlling NADirectControllingNACd |
|---|---|---|---|---|---|---|---|---|---|---|---|
| COMMUNITY HEALTH NETWORK INC | |||||||||||
| 225 MEMORIAL DRIVE | BERLIN | WI | 54923 | 390806359 | HOSPITAL | WI | 501(C)(3) | LINE 3 | THEDACARE INC | Yes (1) | |
| PARTNERS HEALTH SYSTEM FOUNDATION | |||||||||||
| 225 MEMORIAL DRIVE | BERLIN | WI | 54923 | 731639346 | SUPPORTING ORGANIZATION | WI | 501(C)(3) | LINE 11B, II | PARTNERS HEALTH SYSTEM INC | Yes (1) | |
| THEDACARE INC | |||||||||||
| 122 EAST COLLEGE AVENUE | APPLETON | WI | 54911 | 391509362 | HEALTHCARE | WI | 501(C)(3) | LINE 11C, III-FI | Yes (1) | N/A | |
| THEDA CLARK MEDICAL CENTER INC | |||||||||||
| PO BOX 8025 | APPLETON | WI | 54912 | 390830664 | HOSPITAL | WI | 501(C)(3) | LINE 3 | THEDACARE INC | Yes (1) | |
| NEW LONDON FAMILY MEDICAL CENTER INC | |||||||||||
| 1405 MILL STREET | NEW LONDON | WI | 54961 | 390869788 | HOSPITAL | WI | 501(C)(3) | LINE 3 | THEDACARE INC | Yes (1) | |
| RIVERSIDE MEDICAL CENTER INC | |||||||||||
| 800 RIVERSIDE DRIVE | WAUPACA | WI | 54981 | 390871113 | HOSPITAL | WI | 501(C)(3) | LINE 3 | THEDACARE INC | Yes (1) | |
| APPLETON MEDICAL CENTER INC | |||||||||||
| PO BOX 8025 | APPLETON | WI | 54912 | 390824015 | HOSPITAL | WI | 501(C)(3) | LINE 3 | THEDACARE INC | Yes (1) | |
| SHAWANO MEDICAL CENTER INC | |||||||||||
| 309 N BARTLETTE STREET | SHAWANO | WI | 54166 | 390807068 | HOSPITAL | WI | 501(C)(3) | LINE 3 | THEDACARE INC | Yes (1) | |
| APPLETON MEDICAL CENTER FOUNDATION INC | |||||||||||
| 1818 NORTH MEADE STREET | APPLETON | WI | 54911 | 391459276 | FOUNDATION | WI | 501(C)(3) | LINE 7 | THEDACARE INC | Yes (1) | |
| THEDACARE FAMILY OF FOUNDATIONS INC | |||||||||||
| 1818 NORTH MEADE STREET | APPLETON | WI | 54912 | 464112255 | FOUNDATION | WI | 501(C)(3) | LINE 11A, I | THEDACARE INC | Yes (1) | |
| PARTNERS HEALTH SYSTEM INC | |||||||||||
| 225 MEMORIAL DRIVE | BERLIN | WI | 54923 | 271119447 | SUPPORTING ORGANIZATION | WI | LINE 11B, II | 0 | N/A | ||
| 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 | 0 | GiftGrntCapContriFromOthOrgInd |
| Loans Or Guarantees To Other Org | Yes (1) | 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 | Yes (1) | 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 | Yes (1) | 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 | COMMUNITY HEALTH NETWORK INC | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Transaction Type | N | TransactionTypeTxt |
| Involved | $2,679,242 | InvolvedAmt |
| Method Of Amount Determination | ACTUAL | MethodOfAmountDeterminationTxt |