THEDACARE MEDICAL CENTER-BERLIN INC: Form 990, tax year 2013
View the entire original 990 at ProPublica ↗
- Organization
- THEDACARE MEDICAL CENTER-BERLIN INC (EIN 39-0806359)
- Tax period
- 2013-10-01 to 2014-09-30
- Filed
- 2015-08-20
- IRS object ID
- 201512329349300701
- 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 I
- Schedule J
- Schedule L
- Schedule O
- Schedule R
Return header ReturnHeader
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return | 2015-08-20T08:16:50-05:00 | 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 | 390806359 | EIN |
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | COMMUNITY HEALTH NETWORK INC | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Control | COMM | BusinessNameControlTxt |
| Phone | 9203611313 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 225 MEMORIAL DR | AddressLine1 |
| City | BERLIN | City |
| State | WI | State |
| ZIP Code | 54923 | ZIPCode |
Business Officer BusinessOfficerGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person | TOM KRYSTOWIAK | PersonNm |
| Person Title | CFO | PersonTitleTxt |
| Phone | 9203611313 | 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 MST | 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 | TOM KRYSTOWIAK | PrincipalOfficerNm |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 225 MEMORIAL DR | AddressLine1 |
| City | BERLIN | City |
| State | WI | State |
| ZIP Code | 54923 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Receipts | $87,840,534 | GrossReceiptsAmt |
| Group Return For Affiliates | 0 | GroupReturnForAffiliatesInd |
| Organization501c3 | Yes (X) | Organization501c3Ind |
| Website Address | WWW.CHNWI.ORG | WebsiteAddressTxt |
| Type Of Organization Corp | Yes (X) | TypeOfOrganizationCorpInd |
| Formation | 1910 | FormationYr |
| Legal Domicile State | WI | LegalDomicileStateCd |
| Activity Or Mission | COMMUNITY HEALTH NETWORK, INC PROVIDES INPATIENT AND OUTPATIENT HOSPITAL AND CLINIC SERVICES, HOME CARE SERVICES AND SKILLED NURSING SERVICES TO GREEN LAKE COUNTY AND SURROUNDING COUNTIES WITH TOTAL NET PATIENT SERVICE REVENUES OF $79,049,000 (TOTAL GROSS REVENUE OF $185,821,000). | ActivityOrMissionDesc |
| Voting Members Governing Body | 12 | VotingMembersGoverningBodyCnt |
| Voting Members Independent | 9 | VotingMembersIndependentCnt |
| Total Employee | 837 | TotalEmployeeCnt |
| Total Volunteers | 110 | TotalVolunteersCnt |
| Total Gross UBI | $1,817,749 | TotalGrossUBIAmt |
| Net Unrelated Bus Txbl Incm | -$170,160 | NetUnrelatedBusTxblIncmAmt |
| PY Contributions Grants | $51,692 | PYContributionsGrantsAmt |
| CY Contributions Grants | $9,480 | CYContributionsGrantsAmt |
| PY Program Service Revenue | $84,988,117 | PYProgramServiceRevenueAmt |
| CY Program Service Revenue | $84,662,655 | CYProgramServiceRevenueAmt |
| PY Investment Income | $591,288 | PYInvestmentIncomeAmt |
| CY Investment Income | $67,227 | CYInvestmentIncomeAmt |
| PY Other Revenue | $738,685 | PYOtherRevenueAmt |
| CY Other Revenue | $2,656,247 | CYOtherRevenueAmt |
| PY Total Revenue | $86,369,782 | PYTotalRevenueAmt |
| CY Total Revenue | $87,395,609 | CYTotalRevenueAmt |
| PY Grants And Similar Paid | $21,039 | PYGrantsAndSimilarPaidAmt |
| CY Grants And Similar Paid | $85,199 | CYGrantsAndSimilarPaidAmt |
| PY Benefits Paid To Members | $0 | PYBenefitsPaidToMembersAmt |
| CY Benefits Paid To Members | $0 | CYBenefitsPaidToMembersAmt |
| PY Salaries Comp Emp Bnft Paid | $48,085,669 | PYSalariesCompEmpBnftPaidAmt |
| CY Salaries Comp Emp Bnft Paid | $48,806,755 | CYSalariesCompEmpBnftPaidAmt |
| PY Total Prof Fndrsng Expns | $0 | PYTotalProfFndrsngExpnsAmt |
| CY Total Prof Fndrsng Expns | $0 | CYTotalProfFndrsngExpnsAmt |
| CY Total Fundraising Expense | $0 | CYTotalFundraisingExpenseAmt |
| PY Other Expenses | $37,740,787 | PYOtherExpensesAmt |
| CY Other Expenses | $39,141,447 | CYOtherExpensesAmt |
| PY Total Expenses | $85,847,495 | PYTotalExpensesAmt |
| CY Total Expenses | $88,033,401 | CYTotalExpensesAmt |
| PY Revenues Less Expenses | $522,287 | PYRevenuesLessExpensesAmt |
| CY Revenues Less Expenses | -$637,792 | CYRevenuesLessExpensesAmt |
| Total Assets BOY | $59,518,792 | TotalAssetsBOYAmt |
| Total Assets EOY | $64,384,767 | TotalAssetsEOYAmt |
| Total Liabilities BOY | $32,090,661 | TotalLiabilitiesBOYAmt |
| Total Liabilities EOY | $38,575,741 | TotalLiabilitiesEOYAmt |
| Net Assets Or Fund Balances BOY | $27,428,131 | NetAssetsOrFundBalancesBOYAmt |
| Net Assets Or Fund Balances EOY | $25,809,026 | NetAssetsOrFundBalancesEOYAmt |
| Info In Schedule O Part III | Yes (X) | InfoInScheduleOPartIIIInd |
| Mission | TO PROVIDE SUPERIOR SERVICES TO IMPROVE THE HEALTH OF THOSE WE SERVE. | MissionDesc |
| Significant New Program Srvc | 0 | SignificantNewProgramSrvcInd |
| Significant Change | 0 | SignificantChangeInd |
| Expense | $77,086,743 | ExpenseAmt |
| Grant | $85,199 | GrantAmt |
| Revenue | $79,378,332 | RevenueAmt |
| Desc | COMMUNITY HEALTH NETWORK OPERATES A 25-BED ACUTE CARE FACILITY, 50 BED EXTENDED CARE FACILITY, PHYSICIAN CLINICS LOCATED IN 8 COMMUNITIES, A HOME HEALTH AGENCY, REHABILITATION SERVICES AND RETAIL PHARMACY SERVICES. IN PURSUIT OF OUR PRIMARY EXEMPT PURPOSE OF PROVIDING HEALTH CARE SERVICES, COMMUNITY HEALTH NETWORK PROVIDES MEDICAL CARE AND HEALTH INFORMATION AIMED AT IMPROVING THE HEALTH STATUS OF THE COMMUNITIES WE SERVE. WE BELIEVE THAT WE HAVE A SPECIAL DUTY TO MEET THE NEEDS OF THE POOR, INDIGENT, AND MEDICALLY UNDERSERVED IN OUR COMMUNITIES AND SURROUNDING AREAS. WE HAVE PROVIDED CARE TO ALL PATIENTS WITHOUT REGARD FOR THE ABILITY TO PAY. COMMUNITY HEALTH NETWORK 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 PHYSICIANS IN THE AREA. THE MAJORITY OF THE BOARD OF DIRECTORS IS COMPRISED OF INDEPENDENT INDIVIDUALS WHO ARE REPRESENTATIVE OF THE COMMUNITY. COMMUNITY HEALTH NETWORK ENGAGES IN TRAINING AND EDUCATION OF HEALTH CARE PROFESSIONALS THROUGH INTERNSHIP PROGRAMS. COMMUNITY HEALTH NETWORK'S VISION INCLUDES A HEALTHIER COMMUNITY. TO ACHIEVE THIS VISION, IT CONTINUALLY ASSESSES THE COMMUNITIES FOR OPPORTUNITIES FOR HEALTH CARE IMPROVEMENT. DIABETES MANAGEMENT HAS BEEN IDENTIFIED AS A COMMUNITY NEED. DIABETES EDUCATION CONTINUES TO BE A COMMUNITY PROGRAM OFFERED TO THE COMMUNITY AT NO COST. COMMUNITY HEALTH NETWORK PARTICIPATES IN GOVERNMENT-SPONSORED HEALTH CARE PROGRAMS SUCH AS MEDICAID, MEDICARE, CHAMPUS, AND TRICARE. IN FISCAL YEAR 2013 OVER 1700 ACCOUNTS RECEIVED CHARITY CARE WITH A TOTAL COST OF OVER $1.5 MILLION. THE COST OF SERVICES PROVIDED TO MEDICAID PATIENTS THAT WERE NOT REIMBURSED TOTALED MORE THAN $3.4 MILLION. COMMUNITY HEALTH NETWORK'S LOSS FOR PROVIDING LONG TERM CARE SERVICES TO THE COMMUNITIES WAS $476,000 IN 2014. FINANCIAL AND IN-KIND CONTRIBUTIONS TO THE COMMUNITY TOTALED APPROXIMATELY $80,000. IN ADDITION, COMMUNITY HEALTH NETWORK ACTIVELY PROVIDED OR PARTICIPATED IN THE FOLLOWING COMMUNITY-BASED ACTIVITIES AND PROGRAMS OF WHICH APPROXIMATELY 7,000 PERSONS IN THE COMMUNITIES THAT WE SERVE PARTICIPATED AT A TOTAL COST TO COMMUNITY HEALTH NETWORK OF APPROXIMATELY $120,000. - GENERAL HEALTH EDUCATION SERVICES SUCH AS HEALTH FAIRS; CANCER EDUCATION; HEART DISEASE EDUCATION; DIABETES EDUCATION; FAMILY, PARENT, AND SIBLING EDUCATION; FAMILY PLANNING; AND WOMEN'S HEALTH EDUCATION- PROVIDED HEALTH INFORMATION ON THE CORPORATION'S WEB SITE AND THROUGH HEALTH RELATED PUBLICATIONS DISTRIBUTED AT NO CHARGE- SUPPORT GROUPS SUCH AS DIABETES, CANCER, AND BEREAVEMENT- HOSTED SELF-HELP AND WELLNESS PROGRAMS SUCH AS NUTRITION, WEIGHT MANAGEMENT AND FITNESS,- BLOOD PRESSURE SCREENINGS, CHOLESTEROL TESTING AND SCHOOL-BASED TESTING- GUIDANCE, REFERRAL AND ENROLLMENT ASSISTANCE FOR PUBLIC MEDICAL PROGRAMS AND OTHER FAMILY SUPPORT ASSISTANCE- DISCOUNTED OR FREE MEDICAL SUPPLIES AND EQUIPMENT TO THOSE UNABLE TO PAY BASED ON OUR FAP- DELIVERED HOT IN-HOME MEALS- PROMOTED PARTICIPATION IN BLOOD DRIVES BY EMPLOYEES- CONTRIBUTED TO THE EDUCATION OF STUDENT NURSES AND OTHER HEALTH CARE PROFESSIONALS- PROVIDED FIRST AID FOR COMMUNITY SPORTING EVENTS- PARTICIPATED IN WORK SITE HEALTH EDUCATION PROGRAMS - MADE CASH CONTRIBUTIONS TO SUPPORT COMMUNITY SERVICES AND EVENTS- PROVIDED MEETING ROOMS TO COMMUNITY GROUPS AT NO CHARGE | Desc |
| Total Program Service Expenses | $77,086,743 | 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 | Yes (1) | GrantsToOrganizationsInd |
| Grants To Individuals | Yes (1) | 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 | Yes (1) | LoanOutstandingInd |
| Grant To Related Person | 0 | GrantToRelatedPersonInd |
| Business Rln With Org Mem | Yes (1) | BusinessRlnWithOrgMemInd |
| Business Rln With Fam Mem | Yes (1) | BusinessRlnWithFamMemInd |
| Business Rln With Officer Ent | Yes (1) | BusinessRlnWithOfficerEntInd |
| Deductible Non Cash Contri | 0 | DeductibleNonCashContriInd |
| Deductible Art Contribution | 0 | DeductibleArtContributionInd |
| Terminate Operations | 0 | TerminateOperationsInd |
| Partial Liquidation | 0 | PartialLiquidationInd |
| Disregarded Entity | Yes (1) | 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 | 45 | IRPDocumentCnt |
| IRP Document W2 G | 0 | IRPDocumentW2GCnt |
| Employee | 837 | EmployeeCnt |
| Employment Tax Returns Filed | Yes (1) | EmploymentTaxReturnsFiledInd |
| Unrelated Bus Incm Over Limit | Yes (1) | UnrelatedBusIncmOverLimitInd |
| Form990 T Filed | Yes (1) | Form990TFiledInd |
| 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 | 12 | GoverningBodyVotingMembersCnt |
| Independent Voting Member | 9 | IndependentVotingMemberCnt |
| Family Or Business Rln | Yes (1) | FamilyOrBusinessRlnInd |
| Delegation Of Mgmt Duties | 0 | 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 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 | 54923 | ZIPCode |
Form990 Part VII Section A Form990PartVIISectionAGrp (20 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 |
|---|---|---|---|---|---|---|---|---|
| PAT MCCONNELL | ||||||||
| BOARD MEMBER | 1.00 | Yes (X) | $2,100 | $0 | $0 | |||
| PAUL KUJAWA | ||||||||
| BOARD MEMBER | 1.00 | Yes (X) | $2,800 | $0 | $0 | |||
| FRANK CUMBERBATCH | ||||||||
| BOARD MEMBER | 1.00 | Yes (X) | $2,700 | $0 | $0 | |||
| THOMAS RIEK | ||||||||
| BOARD MEMBER | 1.00 | Yes (X) | $2,900 | $0 | $0 | |||
| DAVID BUDDE MD | ||||||||
| BOARD MEMBER/PHYSICIAN | 40.00 | Yes (X) | $454,223 | $0 | $36,527 | |||
| JOLENE HOSTAK | ||||||||
| BOARD MEMBER | 1.00 | Yes (X) | $2,700 | $0 | $0 | |||
| P MICHAEL SHATTUCK MD | ||||||||
| BOARD MEMBER/PHYSICIAN | 40.00 | Yes (X) | $222,561 | $0 | $25,636 | |||
| KELLY WHITE DDS | ||||||||
| BOARD MEMBER | 1.00 | Yes (X) | $2,100 | $0 | $0 | |||
| KRISTIN GALATOWITSCH | ||||||||
| CHAIRMAN | 1.00 | Yes (X) | $7,404 | $0 | $0 | Yes (X) | ||
| RUSSELL KUEHN | ||||||||
| VICE CHAIRMAN | 1.00 | Yes (X) | $4,600 | $0 | $0 | Yes (X) | ||
| THOMAS WILLETT DO | ||||||||
| SECRETARY | 1.00 | Yes (X) | $88,882 | $0 | $0 | Yes (X) | ||
| LARRY WISE | ||||||||
| TREASURER | 1.00 | Yes (X) | $5,600 | $0 | $0 | Yes (X) | ||
| JOHN FEENEY | ||||||||
| PRESIDENT/CEO | 40.00 | Yes (X) | $295,243 | $0 | $22,620 | |||
| NATHAN LUEDKE | ||||||||
| BOARD MEMBER | 40.00 | Yes (X) | $70,391 | $0 | $17,461 | |||
| THOMAS KRYSTOWIAK | ||||||||
| CFO | 40.00 | $190,631 | $0 | $30,070 | Yes (X) | 2.00 | ||
| DAVID JONES MD | ||||||||
| PHYSICIAN | 40.00 | $1,300,546 | $0 | $28,870 | Yes (X) | |||
| URI VAISMAN MD | ||||||||
| PHYSICIAN | 40.00 | $740,645 | $0 | $30,079 | Yes (X) | |||
| JOHN HORAN MD | ||||||||
| PHYSICIAN | 40.00 | $733,159 | $0 | $23,355 | Yes (X) | |||
| HORACE LO MD | ||||||||
| PHYSICIAN | 40.00 | $642,577 | $0 | $34,370 | Yes (X) | |||
| ROBERT GELLER MD | ||||||||
| PHYSICIAN | 40.00 | $660,617 | $0 | $12,067 | Yes (X) | |||
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Reportable Comp From Org | $5,432,379 | TotalReportableCompFromOrgAmt |
| Tot Reportable Comp Rltd Org | $0 | TotReportableCompRltdOrgAmt |
| Total Other Compensation | $261,055 | TotalOtherCompensationAmt |
| Indiv Rcvd Greater Than100 K | 51 | IndivRcvdGreaterThan100KCnt |
| Former Ofcr Employees Listed | 0 | FormerOfcrEmployeesListedInd |
| Total Comp Greater Than150 K | Yes (1) | TotalCompGreaterThan150KInd |
| Compensation From Other Srcs | 0 | CompensationFromOtherSrcsInd |
Contractor Compensation ContractorCompensationGrp (4 entries)
| Address Line1ContractorAddress/USAddress/AddressLine1 | CityContractorAddress/USAddress/City | StateContractorAddress/USAddress/State | ZIP CodeContractorAddress/USAddress/ZIPCode | ServicesServicesDesc | CompensationCompensationAmt |
|---|---|---|---|---|---|
| ZR ENTERPRISES SC | |||||
| 6809 MAGNOLIA COURT | GREENDALE | WI | 53129 | ER PHYSICIAN SERVICE | $1,446,240 |
| CENTRAL WI ANESTHESIA | |||||
| PO BOX 249 | BERLIN | WI | 54923 | ANESTHESIA SERVICES | $712,615 |
| SHARED MEDICAL SERVICES | |||||
| PO BOX 330 | COTTAGE GROVE | WI | 53527 | MRI SERVICES | $483,500 |
| DAVID RESEN MD | |||||
| PO BOC 42 | GREEN LAKE | WI | 54941 | PATHOLOGY SERVICES | $131,250 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Cntrct Rcvd Greater Than100 K | 4 | CntrctRcvdGreaterThan100KCnt |
| Related Organizations | $6,085 | RelatedOrganizationsAmt |
| All Other Contributions | $3,395 | AllOtherContributionsAmt |
| Total Contributions | $9,480 | TotalContributionsAmt |
Program Service Revenue ProgramServiceRevenueGrp (4 entries)
| DescDesc | BusinessBusinessCd | Total Revenue ColumnTotalRevenueColumnAmt | Related Or Exempt Func IncomeRelatedOrExemptFuncIncomeAmt | ExclusionExclusionAmt | Unrelated Business RevenueUnrelatedBusinessRevenueAmt |
|---|---|---|---|---|---|
| PATIENT SERVICE REVENUE | 624100 | $64,745,214 | $59,589,303 | $5,155,911 | |
| PHARMACY REVENUE | 446110 | $19,561,769 | $17,200,041 | $543,979 | $1,817,749 |
| MOB RENTAL | 900099 | $221,772 | $221,772 | ||
| CAFETERIA REVENUE | 900099 | $133,900 | $133,900 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Revenue | $84,662,655 | TotalProgramServiceRevenueAmt |
Investment Income InvestmentIncomeGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $376,672 | TotalRevenueColumnAmt |
| Exclusion | $376,672 | ExclusionAmt |
Gross Rents GrossRentsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | $110,269 | RealAmt |
Less Rental Expenses LessRentalExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | $43,010 | RealAmt |
Rental Income Or Loss RentalIncomeOrLossGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | $67,259 | RealAmt |
Net Rental Income Or Loss NetRentalIncomeOrLossGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $67,259 | TotalRevenueColumnAmt |
| Exclusion | $67,259 | ExclusionAmt |
Gross Amount Sales Assets GrossAmountSalesAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | $92,470 | OtherAmt |
Less Cost Oth Basis Sales Expnss LessCostOthBasisSalesExpnssGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Securities | $401,915 | SecuritiesAmt |
| Other | $0 | OtherAmt |
Gain Or Loss GainOrLossGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Securities | -$401,915 | SecuritiesAmt |
| Other | $92,470 | OtherAmt |
Net Gain Or Loss Investments NetGainOrLossInvestmentsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | -$309,445 | TotalRevenueColumnAmt |
| Exclusion | -$309,445 | ExclusionAmt |
Other Revenue Misc OtherRevenueMiscGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Desc | EHR INCENTIVE INCOME | Desc |
| Business | 900099 | BusinessCd |
| Total Revenue Column | $2,588,988 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $2,588,988 | RelatedOrExemptFuncIncomeAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Revenue Total | $2,588,988 | OtherRevenueTotalAmt |
Total Revenue TotalRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $87,395,609 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $79,378,332 | RelatedOrExemptFuncIncomeAmt |
| Unrelated Business Revenue | $1,817,749 | UnrelatedBusinessRevenueAmt |
| Exclusion | $6,190,048 | ExclusionAmt |
Grants To Domestic Orgs GrantsToDomesticOrgsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $77,699 | TotalAmt |
| Program Services | $77,699 | ProgramServicesAmt |
Grants To Domestic Individuals GrantsToDomesticIndividualsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $7,500 | TotalAmt |
| Program Services | $7,500 | ProgramServicesAmt |
Comp Current Ofcr Directors CompCurrentOfcrDirectorsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $5,521,500 | TotalAmt |
| Program Services | $4,960,532 | ProgramServicesAmt |
| Management And General | $560,968 | ManagementAndGeneralAmt |
Other Salaries And Wages OtherSalariesAndWagesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $34,638,543 | TotalAmt |
| Program Services | $29,716,712 | ProgramServicesAmt |
| Management And General | $4,921,831 | ManagementAndGeneralAmt |
Pension Plan Contributions PensionPlanContributionsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $591,124 | TotalAmt |
| Program Services | $496,490 | ProgramServicesAmt |
| Management And General | $94,634 | ManagementAndGeneralAmt |
Other Employee Benefits OtherEmployeeBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $6,069,002 | TotalAmt |
| Program Services | $5,180,946 | ProgramServicesAmt |
| Management And General | $888,056 | ManagementAndGeneralAmt |
Payroll Taxes PayrollTaxesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,986,586 | TotalAmt |
| Program Services | $1,652,421 | ProgramServicesAmt |
| Management And General | $334,165 | ManagementAndGeneralAmt |
Fees For Services Legal FeesForServicesLegalGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $99,172 | TotalAmt |
| Management And General | $99,172 | ManagementAndGeneralAmt |
Fees For Services Other FeesForServicesOtherGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $6,714,385 | TotalAmt |
| Program Services | $5,617,981 | ProgramServicesAmt |
| Management And General | $1,096,404 | ManagementAndGeneralAmt |
Advertising AdvertisingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $215,509 | TotalAmt |
| Program Services | $9,049 | ProgramServicesAmt |
| Management And General | $206,460 | ManagementAndGeneralAmt |
Office Expenses OfficeExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $14,319,393 | TotalAmt |
| Program Services | $13,947,429 | ProgramServicesAmt |
| Management And General | $371,964 | ManagementAndGeneralAmt |
Information Technology InformationTechnologyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,584,757 | TotalAmt |
| Program Services | $51,799 | ProgramServicesAmt |
| Management And General | $1,532,958 | ManagementAndGeneralAmt |
Occupancy OccupancyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,484,167 | TotalAmt |
| Program Services | $1,430,122 | ProgramServicesAmt |
| Management And General | $54,045 | ManagementAndGeneralAmt |
Travel TravelGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $338,873 | TotalAmt |
| Program Services | $258,346 | ProgramServicesAmt |
| Management And General | $80,527 | ManagementAndGeneralAmt |
Conferences Meetings ConferencesMeetingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $60,411 | TotalAmt |
| Program Services | $1,805 | ProgramServicesAmt |
| Management And General | $58,606 | ManagementAndGeneralAmt |
Interest InterestGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $854,926 | TotalAmt |
| Program Services | $842,723 | ProgramServicesAmt |
| Management And General | $12,203 | ManagementAndGeneralAmt |
Depreciation Depletion DepreciationDepletionGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $4,591,038 | TotalAmt |
| Program Services | $4,580,248 | ProgramServicesAmt |
| Management And General | $10,790 | ManagementAndGeneralAmt |
Insurance InsuranceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $579,773 | TotalAmt |
| Program Services | $365,527 | ProgramServicesAmt |
| Management And General | $214,246 | ManagementAndGeneralAmt |
Other Expenses OtherExpensesGrp (4 entries)
| DescDesc | TotalTotalAmt | Program ServicesProgramServicesAmt | Management And GeneralManagementAndGeneralAmt |
|---|---|---|---|
| PROVISION FOR BAD DEBTS | $4,312,726 | $4,312,726 | |
| EQUIPMENT RENTAL AND MA | $3,094,013 | $2,824,542 | $269,471 |
| MEDICAID ASSESSMENT | $543,900 | $543,900 | |
| LICENSES, DUES, AND CER | $172,882 | $120,685 | $52,197 |
All Other Expenses AllOtherExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $175,522 | TotalAmt |
| Program Services | $87,561 | ProgramServicesAmt |
| Management And General | $87,961 | ManagementAndGeneralAmt |
Total Functional Expenses TotalFunctionalExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $88,033,401 | TotalAmt |
| Program Services | $77,086,743 | ProgramServicesAmt |
| Management And General | $10,946,658 | ManagementAndGeneralAmt |
| Fundraising | $0 | FundraisingAmt |
Cash Non Interest Bearing CashNonInterestBearingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $3,846 | BOYAmt |
| EOY | $59,034 | EOYAmt |
Savings And Temp Cash Invst SavingsAndTempCashInvstGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $4,172,746 | BOYAmt |
| EOY | $5,528,529 | EOYAmt |
Accounts Receivable AccountsReceivableGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $16,558,337 | BOYAmt |
| EOY | $16,797,233 | EOYAmt |
Receivables From Officers Etc ReceivablesFromOfficersEtcGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $118,917 | BOYAmt |
| EOY | $75,000 | EOYAmt |
Inventories For Sale Or Use InventoriesForSaleOrUseGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,111,303 | BOYAmt |
| EOY | $1,433,837 | EOYAmt |
Prepaid Expenses Defrd Charges PrepaidExpensesDefrdChargesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $736,969 | BOYAmt |
| EOY | $426,276 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Land Bldg Equip Cost Or Other Bss | $60,478,585 | LandBldgEquipCostOrOtherBssAmt |
| Land Bldg Equip Accum Deprec | $37,481,728 | LandBldgEquipAccumDeprecAmt |
Land Bldg Equip Basis Net LandBldgEquipBasisNetGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $19,565,996 | BOYAmt |
| EOY | $22,996,857 | EOYAmt |
Investments Pub Traded Sec InvestmentsPubTradedSecGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $12,356,990 | BOYAmt |
| EOY | $12,221,542 | EOYAmt |
Intangible Assets IntangibleAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $45,607 | BOYAmt |
| EOY | $15,703 | EOYAmt |
Other Assets Total OtherAssetsTotalGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $4,848,081 | BOYAmt |
| EOY | $4,830,756 | EOYAmt |
Total Assets TotalAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $59,518,792 | BOYAmt |
| EOY | $64,384,767 | EOYAmt |
Accounts Payable Accr Expnss AccountsPayableAccrExpnssGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $7,018,223 | BOYAmt |
| EOY | $5,338,090 | EOYAmt |
Deferred Revenue DeferredRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| EOY | $62,091 | EOYAmt |
Tax Exempt Bond Liabilities TaxExemptBondLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $12,490,000 | BOYAmt |
| EOY | $11,554,244 | EOYAmt |
Unsecured Notes Loans Payable UnsecuredNotesLoansPayableGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $3,335,305 | BOYAmt |
| EOY | $3,219,516 | EOYAmt |
Other Liabilities OtherLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $9,247,133 | BOYAmt |
| EOY | $18,401,800 | EOYAmt |
Total Liabilities TotalLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $32,090,661 | BOYAmt |
| EOY | $38,575,741 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Organization Follows SFAS117 | Yes (X) | OrganizationFollowsSFAS117Ind |
Unrestricted Net Assets UnrestrictedNetAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $26,268,159 | BOYAmt |
| EOY | $25,809,026 | EOYAmt |
Temporarily Rstr Net Assets TemporarilyRstrNetAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,159,972 | BOYAmt |
| EOY | $0 | EOYAmt |
Total Net Assets Fund Balance TotalNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $27,428,131 | BOYAmt |
| EOY | $25,809,026 | EOYAmt |
Tot Liab Net Assets Fund Balance TotLiabNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $59,518,792 | BOYAmt |
| EOY | $64,384,767 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part XI | Yes (X) | InfoInScheduleOPartXIInd |
| Reconcilation Revenue Expnss | -$637,792 | ReconcilationRevenueExpnssAmt |
| Net Unrlzd Gains Losses Invst | $178,659 | NetUnrlzdGainsLossesInvstAmt |
| Other Changes In Net Assets | -$1,159,972 | 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 | $4,804 | OtherActivitiesAmt |
| Total Lobbying Expenditures | $4,804 | 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 DUES OF $4,804. | ExplanationTxt |
Schedule D IRS990ScheduleD
CY Endwmt Fund CYEndwmtFundGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Beginning Year Balance | $13,316,961 | BeginningYearBalanceAmt |
| Contributions | $293,584 | ContributionsAmt |
| Investment Earnings Or Losses | $1,207,187 | InvestmentEarningsOrLossesAmt |
| Grants Or Scholarships | $1,454,548 | GrantsOrScholarshipsAmt |
| Other Expenditures | $125,345 | OtherExpendituresAmt |
| End Year Balance | $13,237,839 | EndYearBalanceAmt |
CY Minus1 Yr Endwmt Fund CYMinus1YrEndwmtFundGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Beginning Year Balance | $11,731,635 | BeginningYearBalanceAmt |
| Contributions | $1,188,523 | ContributionsAmt |
| Investment Earnings Or Losses | $1,208,164 | InvestmentEarningsOrLossesAmt |
| Other Expenditures | $811,361 | OtherExpendituresAmt |
| End Year Balance | $13,316,961 | EndYearBalanceAmt |
CY Minus2 Yr Endwmt Fund CYMinus2YrEndwmtFundGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Beginning Year Balance | $9,942,971 | BeginningYearBalanceAmt |
| Contributions | $1,110,976 | ContributionsAmt |
| Investment Earnings Or Losses | $1,431,598 | InvestmentEarningsOrLossesAmt |
| Other Expenditures | $753,910 | OtherExpendituresAmt |
| End Year Balance | $11,731,635 | EndYearBalanceAmt |
CY Minus3 Yr Endwmt Fund CYMinus3YrEndwmtFundGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Beginning Year Balance | $9,548,648 | BeginningYearBalanceAmt |
| Contributions | $1,099,960 | ContributionsAmt |
| Investment Earnings Or Losses | $46,867 | InvestmentEarningsOrLossesAmt |
| Other Expenditures | $752,504 | OtherExpendituresAmt |
| End Year Balance | $9,942,971 | EndYearBalanceAmt |
CY Minus4 Yr Endwmt Fund CYMinus4YrEndwmtFundGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Beginning Year Balance | $8,326,892 | BeginningYearBalanceAmt |
| Contributions | $1,558,801 | ContributionsAmt |
| Investment Earnings Or Losses | $644,527 | InvestmentEarningsOrLossesAmt |
| Other Expenditures | $981,572 | OtherExpendituresAmt |
| End Year Balance | $9,548,648 | EndYearBalanceAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Board Designated Balance EOY | 0.91000 | BoardDesignatedBalanceEOYPct |
| Prmnnt Endowment Balance EOY | 0.00000 | PrmnntEndowmentBalanceEOYPct |
| Term Endowment Balance EOY | 0.09000 | TermEndowmentBalanceEOYPct |
| Endowments Held Unrelated Org | 0 | EndowmentsHeldUnrelatedOrgInd |
| Endowments Held Related Org | Yes (1) | EndowmentsHeldRelatedOrgInd |
| Related Org List Sch R | Yes (1) | RelatedOrgListSchRInd |
Land LandGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $897,715 | OtherCostOrOtherBasisAmt |
| Book Value | $897,715 | BookValueAmt |
Buildings BuildingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $19,394,931 | OtherCostOrOtherBasisAmt |
| Depreciation | $11,403,254 | DepreciationAmt |
| Book Value | $7,991,677 | BookValueAmt |
Leasehold Improvements LeaseholdImprovementsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $1,208,648 | OtherCostOrOtherBasisAmt |
| Depreciation | $1,130,158 | DepreciationAmt |
| Book Value | $78,490 | BookValueAmt |
Equipment EquipmentGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $36,955,669 | OtherCostOrOtherBasisAmt |
| Depreciation | $24,311,185 | DepreciationAmt |
| Book Value | $12,644,484 | BookValueAmt |
Other Land Buildings OtherLandBuildingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $2,021,622 | OtherCostOrOtherBasisAmt |
| Depreciation | $637,131 | DepreciationAmt |
| Book Value | $1,384,491 | BookValueAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Book Value Land Buildings | $22,996,857 | TotalBookValueLandBuildingsAmt |
Other Assets Org OtherAssetsOrgGrp (5 entries)
| DescDesc | Book ValueBookValueAmt |
|---|---|
| UNAMORTIZED BOND ISSUE COSTS | $90,601 |
| INTEREST RECEIVABLE | $1,647 |
| ACCOUNTS RECEIVABLE - WILD ROSE | $4,000,000 |
| ACCOUNTS RECEIVABLE - WORKER'S COMP | $353,208 |
| EHR INCENTIVE | $385,300 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Book Value Other Assets | $4,830,756 | TotalBookValueOtherAssetsAmt |
Other Liabilities Org OtherLiabilitiesOrgGrp (7 entries)
| DescDesc | AmtAmt |
|---|---|
| DEFERRED COMPENSATION | $7,183,250 |
| ACCRUED INTEREST | $1,371 |
| SELF FUNDED HEALTH INSURANCE | $851,518 |
| NET AMOUNTS PAYABLE FROM THIRD-PARTY REIMBURSEMENT PROGRAMS | $875,186 |
| WORKERS COMPENSATION PAYABLE | $352,033 |
| ACCRUED PHARMACY TAX | -$15,750 |
| DUE TO THEDACARE, INC. | $9,154,192 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Liability | $18,401,800 | TotalLiabilityAmt |
| Footnote Text | Yes (X) | FootnoteTextInd |
Supplemental Information Detail SupplementalInformationDetail (2 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| PART V, LINE 4: | ENDOWMENT FUNDS ARE TO BE UTILIZED TO SUPPORT THE ORGANIZATION'S 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. THEDACARE RECORDED NO ASSETS OR LIABILITIES RELATED TO UNCERTAIN TAX POSITIONS OR UNRECOGNIZED TAX BENEFITS 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 | 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 | $1,783,312 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $1,783,312 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.02130 | TotalExpensePct |
Unreimbursed Medicaid UnreimbursedMedicaidGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $10,230,550 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $7,836,427 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $2,394,123 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.02860 | TotalExpensePct |
Total Financial Assistance Typ TotalFinancialAssistanceTyp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $12,013,862 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $7,836,427 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $4,177,435 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.04990 | TotalExpensePct |
Community Health Services CommunityHealthServicesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $112,393 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $112,393 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00130 | TotalExpensePct |
Health Professions Education HealthProfessionsEducationGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $6,907 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $6,907 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00010 | TotalExpensePct |
Cash And In Kind Contributions CashAndInKindContributionsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $449,184 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $449,184 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00540 | TotalExpensePct |
Total Other Benefits TotalOtherBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $568,484 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $568,484 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00680 | TotalExpensePct |
Total Community Benefits TotalCommunityBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $12,582,346 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $7,836,427 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $4,745,919 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.05670 | TotalExpensePct |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bad Debt Expense Reported | Yes (1) | BadDebtExpenseReportedInd |
| Bad Debt Expense | $1,772,983 | BadDebtExpenseAmt |
| Reimbursed By Medicare | $12,702,116 | ReimbursedByMedicareAmt |
| Cost Of Care Reimbursed By Medcr | $12,746,360 | CostOfCareReimbursedByMedcrAmt |
| Medicare Surplus Or Shortfall | -$44,244 | 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 | BERLIN MEMORIAL HOSPITAL | BusinessNameLine1 |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 225 MEMORIAL DRIVE | AddressLine1 |
| City | BERLIN | City |
| State | WI | State |
| ZIP Code | 54923 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Website Address | WWW.COMMUNITYHEALTHNETWORK.ORG | WebsiteAddressTxt |
| State License | 1060 | 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 | BERLIN 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 | 13 | 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 Upon Request | Yes (X) | RptAvailableUponRequestInd |
| 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 |
| App Financial Asst Expln | Yes (1) | AppFinancialAsstExplnInd |
| Includes Publicity Measures | Yes (1) | IncludesPublicityMeasuresInd |
| Posted On Website | Yes (X) | PostedOnWebsiteInd |
| Posted In Emergency Room | Yes (X) | PostedInEmergencyRoomInd |
| Posted In Admission Office | Yes (X) | PostedInAdmissionOfficeInd |
| Available On Request | Yes (X) | AvailableOnRequestInd |
| FAP Actions On Nonpayment | Yes (1) | FAPActionsOnNonpaymentInd |
| Collection Activities | 0 | CollectionActivitiesInd |
| 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 (5 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| BERLIN MEMORIAL HOSPITAL | PART V, SECTION B, LINE 3: IN ORDER TO ENSURE CONSIDERATION OF BROAD COMMUNITY INTERESTS, THE CREATION OF THE 2013 CHNA WAS A PARTNERSHIP BETWEEN COMMUNITY HEALTH NETWORK, INC. D/B/A BERLIN MEMORIAL HOSPITAL ("CHN") AND EACH COUNTY HEALTH DEPARTMENT THAT COMPRISES CHN'S PRIMARY SERVICE AREA: GREEN LAKE COUNTY, WAUSHARA COUNTY AND MARQUETTE COUNTY. |
| BERLIN MEMORIAL HOSPITAL | PART V, SECTION B, LINE 4: WILD ROSE COMMUNITY MEMORIAL HOSPITAL |
| BERLIN MEMORIAL HOSPITAL | PART V, SECTION B, LINE 5D: HTTPS://WWW.THEDACARE.ORG/~/ MEDIA/THEDACARE%20INTERNET%20FILES/06%20GET%20INVOLVED/2013CHNA_CHN.PDF |
| BERLIN MEMORIAL HOSPITAL | PART V, SECTION B, LINE 7: FOR EXAMPLE, ALTHOUGH WE ARE ACTIVE IN THE PREVENTION OF ALCOHOL AND DRUG ABUSE BY PARTICIPATION ON OUR COUNTY COALITIONS, WE ARE UNABLE TO ADDRESS BEYOND THAT BASED ON FINANCIAL CONSTRAINTS AND DIFFICULTY IN RECRUITING IN THIS AREA. CHN MANAGES THESE BEHAVIORS THROUGH PRIMARY CARE SERVICES. ADDITIONALLY, WE ARE ACTIVELY LOOKING FOR PARTNERSHIPS WITH LARGER HEALTH SYSTEMS TO INCREASE SPECIALTY SERVICES THAT CAN ADDRESS THESE NEEDS. WE DO NOT INTEND TO ADDRESS ENVIRONMENTAL AND OCCUPATIONAL HEALTH IN WAUSHARA COUNTY THE WAY THAT COMMUNITY HEALTH NEEDS ASSESSMENT IDENTIFIES IT AS IT IS BEYOND OUR SCOPE. |
| BERLIN MEMORIAL HOSPITAL | PART V, SECTION B, LINE 20D: COMMUNITY HEALTH NETWORK, 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 | 13 | FacilityNum |
Oth Hlth Care Fclts Not Hospital OthHlthCareFcltsNotHospitalGrp
Oth Hlth Care Fclts OthHlthCareFcltsGrp (13 entries)
| Address Line1USAddress/AddressLine1 | CityUSAddress/City | StateUSAddress/State | ZIP CodeUSAddress/ZIPCode | FacilityFacilityTxt |
|---|---|---|---|---|
| CHN MEDICAL OFFICE BUILDING | ||||
| 225 MEMORIAL DRIVE | BERLIN | WI | 54923 | OUTPATIENT PHYSICIAN CLINIC |
| CHN MEDICAL CENTER - WAUTOMA | ||||
| N HIGHWAY 22 | WAUTOMA | WI | 54982 | OUTPATIENT PHYSICIAN CLINIC |
| CHN MEDICAL CENTER - MARKESAN | ||||
| 340 ENTERPRISE DRIVE | MARKESAN | WI | 53946 | OUTPATIENT PHYSICIAN CLINIC |
| CHN MEDICAL CENTER - PRINCETON | ||||
| 502 W WATER STREET | PRINCETON | WI | 54968 | OUTPATIENT PHYSICIAN CLINIC |
| CHN MEDICAL CENTER - MONTELLO | ||||
| 315 CHURCH STREET | MONTELLO | WI | 53949 | OUTPATIENT PHYSICIAN CLINIC |
| CHN MEDICAL CENTER - RIPON | ||||
| 1080 FOND DU LAC STREET | RIPON | WI | 54971 | OUTPATIENT PHYSICIAN CLINIC |
| CHN MEDICAL CENTER - REDGRANITE | ||||
| 402 PRESTON LANE | REDGRANITE | WI | 54970 | OUTPATIENT PHYSICIAN CLINIC |
| CHN MEDICAL CENTER - EASTRIDGE | ||||
| W832 HIGHWAY 91 | BERLIN | WI | 54923 | OUTPATIENT PHYSICIAN CLINIC |
| CHN ORTHOPEDICS & SPORTS MEDICINE | ||||
| 191 MEMORIAL DRIVE | BERLIN | WI | 54923 | OUTPATIENT PHYSICIAN CLINIC |
| JULIETTE MANOR | ||||
| 169 EAST HURON STREET | BERLIN | WI | 54923 | SKILLED NURSING FACILITY |
| CHN HOME CARE | ||||
| 270 MARQUETTE STREET | BERLIN | WI | 54923 | HOME HEALTH CARE |
| COMMUNITY MEDICAL CENTER - GREEN LAKE | ||||
| 670 CTY HIGHWAY A | GREEN LAKE | WI | 54941 | OUTPATIENT PHYSICIAN CLINIC |
| CHN MEDICAL CENTER - GREEN LAKE | ||||
| N6205 BUSSE DR | GREEN LAKE | WI | 54941 | OUTPATIENT PHYSICIAN CLINIC |
Supplemental Information Detail SupplementalInformationDetail (11 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| PART I, LINE 7: | THE NUMBERS IN THE TABLE FOR CHARITY CARE AND UNREIMBURSED MEDICAID WERE DERIVED FROM USE OF IRS WORKSHEET 2 COST-TO-CHARGE RATIO. THE COST OF THE COMMUNITY HEALTH IMPROVEMENTS WERE CALCULATED BASED ON LABOR COSTS, SUPPLY COSTS AND ROOM COSTS. HEALTH PROFESSIONAL EDUCATION COSTS WERE BASED ON THE AMOUNT OF SCHOLARSHIPS AWARDED AND THE ROOM & LABOR COSTS FOR PROVIDING COMMUNITY EDUCATION FOR HEALTH PROFESSIONALS IN OUR COMMUNITIES. CASH IS THE AMOUNT OF CONTRIBUTIONS TO THE COMMUNITY AND IN-KIND DONATIONS ARE BASED ON THE COST OF THE IN-KIND DONATION. |
| PART I, LN 7 COL(F): | THE HOSPITAL BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25(A) OF $4,312,726 WAS SUBTRACTED TO CALCULATE THE PERCENTAGE IN COLUMN (F). |
| PART II, COMMUNITY BUILDING ACTIVITIES: | COMMUNITY HEALTH NETWORK ENGAGES IN SEVERAL COMMUNITY BUILDING ACTIVITIES. OUR DISASTER READINESS PROGRAMS ARE DEVELOPED TO EXCEED THE MINIMUM REQUIREMENTS IN ORDER TO PROVIDE A RESPONSIBLE LEVEL OF SERVICE TO THE COMMUNITY. WE ALSO PROVIDE MEETING ROOMS AND SUPPORT TO OTHER NOT-FOR-PROFIT ORGANIZATIONS THAT IMPROVE THE HEALTH OF THE COMMUNITY. ALL OF THESE EFFORTS ARE FOCUSED ON MINIMIZING THE HEALTH IMPACT OF CATASTROPHES, LARGE AND SMALL, AS WELL AS SUPPORTING HEALTH ACTIVITIES AND GROUPS WITH A QUALITY OF LIFE FOCUS. |
| PART III, LINE 4: | USED COST TO CHARGE RATIO BASED ON COST BEING THE TOTAL OPERATING EXPENSE NET OF COMMUNITY BENEFIT EXPENSE AND NON-PATIENT CARE OPERATIONS AND CHARGES BEING 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, COMMUNITY HEALTH NETWORK 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: | ANY SHORTFALL SHOULD BE TREATED AS COMMUNITY BENEFIT BECAUSE CHN CONTINUES TO SERVE THE MEDICARE POPULATION REGARDLESS OF WHETHER THEY COVER THEIR COSTS. COMMUNITY HEALTH NETWORK HAS A SURPLUS BECAUSE IT IS A CRITICAL ACCESS HOSPITAL AND AS A CRITICAL ACCESS HOSPITAL, IT RECEIVES 101% OF ITS COST PER THE MEDICARE COST REPORT. |
| 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 ASSISTANCE/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 WRITING THAT THE ACCOUNT BALANCE IS PAST DUE AND THE ACCOUNT WILL BE SUBJECT TO NORMAL COLLECTION PROCEDURES. |
| PART VI, LINE 2: | COMMUNITY HEALTH NETWORK WORKS IN COLLABORATION WITH GREEN LAKE AND WAUSHARA COUNTY PUBLIC HEALTH TO ASSESS COMMUNITY NEEDS IN ORDER TO CREATE A PLAN OF CARE BASED ON THOSE ISSUES AND CONCERNS IDENTIFIED. COMMUNITY HEALTH NETWORK ALSO PARTICIPATES WITH THE GREEN LAKE COUNTY AND WAUSHARA COUNTY WELLNESS COALITION. IN THE EFFORT TO PROVIDE COMPREHENSIVE CARE, THE WELLNESS COALITION ALSO STRIVES TO DECREASE INEFFICIENCIES DUE TO OVERLAP OF CARE PROVIDERS AND ORGANIZATIONS IN THE AREA. COMMUNITY HEALTH NETWORK ALSO ASSESSES COMMUNITY NEED BY USING UNIVERSITY OF WISCONSIN HEALTH RANKINGS WHICH PROVIDES COUNTY BY COUNTY BREAKDOWNS OF HEALTH OUTCOMES, HEALTH FACTORS, AND HEALTH ISSUES TO ASSIST IN DETERMINING COMMUNITY NEED. |
| 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: | COMMUNITY HEALTH NETWORK PRIMARILY SERVES RESIDENTS FROM GREEN LAKE, MARQUETTE, AND WAUSHARA COUNTIES. THE SERVICE AREA HAD AN ESTIMATED POPULATION OF 59,000 AND IS MOSTLY RURAL. THE POPULATION CONSISTS OF 19.8% UNDER THE AGE OF 18, 26.8% FROM 18 TO 44, 32.1% FROM 45 TO 64 AND 21.3% WHO WERE 65 AND OLDER. PORTIONS OF THE COMMUNITY HEALTH NETWORK SERVICE AREA ARE FEDERALLY QUALIFIED HPSA AREAS. COMMUNITY HEALTH NETWORK OPERATES THE ONLY HOSPITAL IN GREEN LAKE COUNTY. |
| 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. COMMUNITY HEALTH NETWORK CONDUCTS HEALTH FAIRS FOR THE COMMUNITY TO ENCOURAGE HEALTHY LIFESTYLES AND TO RAISE AWARENESS OF HEALTH ISSUES AND TRENDS. COMMUNITY HEALTH NETWORK ALSO CONDUCTS CPR AND FIRST AID CLASSES, EDUCATION AND OUTREACH FOR SENIOR CITIZENS, AND EDUCATION OPPORTUNITIES FOR PHYSICIANS AND MEDICAL STUDENTS. IN ADDITION, WE ADMINISTER A DIABETES SUPPORT GROUP. |
| PART VI, LINE 6: | COMMUNITY HEALTH NETWORK ENGAGES IN SEVERAL COMMUNITY BUILDING ACTIVITIES. OUR DISASTER READINESS PROGRAMS ARE DEVELOPED TO EXCEED THE MINIMUM REQUIREMENTS IN ORDER TO PROVIDE A RESPONSIBLE LEVEL OF SERVICE TO THE COMMUNITY. WE ALSO PROVIDE MEETING ROOMS AND SUPPORT TO OTHER NOT-FOR-PROFIT ORGANIZATIONS THAT IMPROVE THE HEALTH OF THE COMMUNITY. ALL OF THESE EFFORTS ARE FOCUSED ON MINIMIZING THE HEALTH IMPACT OF CATASTROPHES, LARGE AND SMALL, AS WELL AS SUPPORTING HEALTH ACTIVITIES AND GROUPS WITH A QUALITY OF LIFE FOCUS. |
Schedule I IRS990ScheduleI
| Field | Value | IRS element (for citing) |
|---|---|---|
| Grant Records Maintained | 0 | GrantRecordsMaintainedInd |
Recipient Table RecipientTable (2 entries)
| Address Line1USAddress/AddressLine1 | CityUSAddress/City | StateUSAddress/State | ZIP CodeUSAddress/ZIPCode | Recipient EINRecipientEIN | Cash GrantCashGrantAmt | Purpose Of GrantPurposeOfGrantTxt |
|---|---|---|---|---|---|---|
| PARTNERS HEALTH SYSTEM FOUNDATION INC | ||||||
| 225 MEMORIAL DRIVE | BERLIN | WI | 54923 | 731639346 | $14,107 | FOUNDATION FUNDRAISING EVENT |
| BOYS AND GIRLS CLUB | ||||||
| 501 E PARKWAY AVE PO BOX 411 | OSHKOSH | WI | 54903 | 396120658 | $51,500 | TC CAPITAL CAMPAIGN |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total501c3 Org | 2 | Total501c3OrgCnt |
| Total Other Org | 0 | TotalOtherOrgCnt |
Grants Other Asst To Indiv In US GrantsOtherAsstToIndivInUSGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Grant Type | SCHOLARSHIPS | GrantTypeTxt |
| Recipient | 10 | RecipientCnt |
| Cash Grant | $7,500 | CashGrantAmt |
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 | Yes (1) | SupplementalNonqualRtrPlanInd |
| Equity Based Comp Arrngm | 0 | EquityBasedCompArrngmInd |
| Comp Based On Revenue Of Flng Org | Yes (1) | CompBasedOnRevenueOfFlngOrgInd |
| Comp Bsd On Rev Related Orgs | Yes (1) | 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 (9 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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| DAVID BUDDE MD | ||||||||||||||
| BOARD MEMBER/PHYSICIAN | $216,510 | $0 | $219,925 | $0 | $17,788 | $0 | $9,108 | $0 | $27,419 | $0 | $490,750 | $0 | $0 | $0 |
| P MICHAEL SHATTUCK MD | ||||||||||||||
| BOARD MEMBER/PHYSICIAN | $193,100 | $0 | $29,461 | $0 | $0 | $0 | $6,120 | $0 | $19,516 | $0 | $248,197 | $0 | $0 | $0 |
| JOHN FEENEY | ||||||||||||||
| PRESIDENT/CEO | $245,243 | $0 | $50,000 | $0 | $0 | $0 | $0 | $0 | $22,620 | $0 | $317,863 | $0 | $0 | $0 |
| THOMAS KRYSTOWIAK | ||||||||||||||
| CFO | $176,715 | $0 | $3,459 | $0 | $10,457 | $0 | $7,491 | $0 | $22,579 | $0 | $220,701 | $0 | $0 | $0 |
| DAVID JONES MD | ||||||||||||||
| PHYSICIAN | $897,839 | $0 | $338,459 | $0 | $64,248 | $0 | $0 | $0 | $28,870 | $0 | $1,329,416 | $0 | $0 | $0 |
| URI VAISMAN MD | ||||||||||||||
| PHYSICIAN | $605,007 | $0 | $135,638 | $0 | $0 | $0 | $7,500 | $0 | $22,579 | $0 | $770,724 | $0 | $0 | $0 |
| JOHN HORAN MD | ||||||||||||||
| PHYSICIAN | $449,599 | $0 | $10,000 | $0 | $273,560 | $0 | $0 | $0 | $23,355 | $0 | $756,514 | $0 | $0 | $0 |
| HORACE LO MD | ||||||||||||||
| PHYSICIAN | $488,368 | $0 | $154,209 | $0 | $0 | $0 | $5,000 | $0 | $29,370 | $0 | $676,947 | $0 | $0 | $0 |
| ROBERT GELLER MD | ||||||||||||||
| PHYSICIAN | $531,153 | $0 | $129,464 | $0 | $0 | $0 | $5,000 | $0 | $7,067 | $0 | $672,684 | $0 | $0 | $0 |
Supplemental Information Detail SupplementalInformationDetail (2 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| PART I, LINE 4B | ALL HIGHLY COMPENSATED PARTICIPATE, BUT DID NOT RECEIVE PAYMENT FROM A NON-QUALIFIED PLAN. |
| PART I, LINE 5 | RADIOLOGISTS RECEIVE 60% OF REVENUE FROM PROFESSIONAL FEES OVER $2.2 MILLION. IN CALENDAR YEAR 2013, DR. KURTZ RECEIVED $104,227 AND DR. VAISMAN RECEIVED $135,638. SERVICES PROVIDED BY RADIOLOGISTS AT WILD ROSE HOSPITAL ARE INCLUDED. |
Schedule L IRS990ScheduleL
Loans Btwn Org Interested Prsn LoansBtwnOrgInterestedPrsnGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person | DR HORAN | PersonNm |
| Loan Purpose | COMPENSATION ADVANCE | LoanPurposeTxt |
| Loan From Organization | Yes (X) | LoanFromOrganizationInd |
| Original Principal | $225,000 | OriginalPrincipalAmt |
| Balance Due | $75,000 | 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 | $75,000 | TotalBalanceDueAmt |
Bus Tr Involve Interested Prsn BusTrInvolveInterestedPrsnGrp (2 entries)
| Relationship DescriptionRelationshipDescriptionTxt | TransactionTransactionAmt | TransactionTransactionDesc | Sharing Of RevenuesSharingOfRevenuesInd |
|---|---|---|---|
| P MICHAEL SHATTUCK MD | |||
| CHN BOARD MEMBER | $24,034 | CHN RENTS SPACE FROM DR. SHATTUCK FOR MEDICAL GROUP OFFICES | 0 |
| THOMAS WILLETT DO | |||
| BOARD MEMBER | $84,082 | SPACE RENTAL | 0 |
Schedule O IRS990ScheduleO
Supplemental Information Detail SupplementalInformationDetail (12 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| FORM 990, PART VI, SECTION A, LINE 2 | RUSSELL KUEHN AND THOMAS WILLETT ARE MEMBERS OF THE BOARD OF DIRECTORS OF 1ST NATIONAL BANK. PATRICK MCCONNELL IS A MEMBER OF THE BOARD OF DIRECTORS OF HORICON BANK. THOMAS WILLET HAS A BUSINESS RELATIONSHIP. |
| 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, COMMUNITY HEALTH NETWORK, INC.'S SOLE MEMBER OF THE SINGLE CLASS OF VOTING MEMBERS IS THEDACARE, INC. PRIOR TO JUNE 30, 2014, MEMBERSHIP COULD BE OBTAINED BY ANYONE EIGHTEEN OR MORE YEARS OF AGE AND EITHER: (A) RESIDE OR WORK IN THE CORPORATION'S SERVICE AREA, WHICH IS DEFINED AS THE FOLLOWING ZIP CODES: 53919, 53923, 53926, 53930, 53931, 53935, 53939, 53946, 53947, 53949, 53952, 53953, 53956, 53964, 54909, 54921, 54923, 54930, 54934, 54940, 54941, 54943, 54960, 54963, 54964, 54965, 54966, 54967, 54968, 54970, 54971, 54976, 54980, 54982, 54984, AND 54986. AN INDIVIDUAL IS DEEMED TO WORK WITHIN THE CORPORATION'S SERVICE AREA IF HIS OR HER PRIMARY SOURCE OF INCOME STEMS FROM WORK PERFORMED IN THE SERVICE AREA; OR (B) AN EMPLOYEE OF THE CORPORATION OR MEMBER OF HIS OR HER FAMILY. MAY BECOME A MEMBER OF THE CORPORATION UPON SUBMISSION OF A SIGNED APPLICATION DELIVERED TO THE PRINCIPAL OFFICE OF THE CORPORATION. THE CORPORATION'S BOARD OF DIRECTORS OR ITS DESIGNEE(S) HAS THE AUTHORITY TO, FROM TIME TO TIME, MAKE GOOD FAITH DETERMINATIONS REGARDING WHETHER AN APPLICANT OR AN EXISTING MEMBER MEETS THE QUALIFICATIONS FOR MEMBERSHIP OF THE CORPORATION. ANY PERSON WHO DOES NOT MEET THE CRITERIA AS DETERMINED BY THE BOARD OF DIRECTORS OR ITS DESIGNEE(S) WILL NOT BE A MEMBER. AN INDIVIDUAL'S MEMBERSHIP SHALL BE TERMINATED UPON DEATH, RESIGNATION OR THE FAILURE TO MEET THE QUALIFICATION. INDIVIDUALS GRANTED HONORARY MEMBERSHIP IN THE CORPORATION SHALL BE ENTITLED TO LIFELONG VOTING MEMBERSHIP IN THE CORPORATION. |
| FORM 990, PART VI, SECTION A, LINE 7A | PRIOR TO JUNE 30, 2014, THERE WERE TWELVE DIRECTORS ON THE BOARD OF DIRECTORS THAT ARE ELECTED ANNUALLY BY THE MEMBERS AT THE ANNUAL MEETING OR AT A SPECIAL MEETING HELD FOR SUCH PURPOSE. THE CHIEF EXECUTIVE OFFICER WAS AN EX-OFFICIO MEMBER OF THE BOARD OF DIRECTORS. EFFECTIVE JUNE 30, 2014, THEDACARE, INC. HAS THE AUTHORITY IN THE COPORATION TO VOTE AND TAKE ANY ACTION WITH RESPECT TO THE ELECTION OF DIRECTORS AND OFFICERS. A CONSULTATION WOULD OCCUR WITH CHN BEFORE SUCH ACTIONS WERE TAKEN. |
| FORM 990, PART VI, SECTION A, LINE 7B | PRIOR TO JUNE 30, 2014, MEMBERS HAD THE FOLLOWING RESERVED POWERS 2.2.1 TO APPROVE ALL AMENDMENTS AND RESTATEMENTS OF ARTICLES OF INCORPORATION AND BYLAWS 2.2.2 TO VOTE ON NOMINATIONS TO FILL OPEN BOD POSITIONS AT THE ANNUAL MEETING 2.2.3. TO RECEIVE AN ANNUAL REPORT ON THE CORPORATIONS BUSINESS AND OPERATIONS 2.2.4 TO VOTE ON NOMINATIONS TO FILL OPEN NON-DIRECTOR GOVERNANCE AND NOMINATIONS COMMITTEE POSITIONS PURSUANT TO THE PROCEDURES ET FORTH IN SECTION 6.6.4 OF THESE BYLAWS. 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 BOARD OF DIRECTORS HAS DELEGATED THE DETAIL REVIEW OF THE FORM 990 TO THE MANAGEMENT OF THE CORPORATION. THEY COMPLETED THEIR 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. THE CHAIRPERSON OF THE BOARD OR COMMITTEE MAY THEN QUESTION THE INTERESTED PERSON FURTHER. THE BOARD OR COMMITTEE MAKES THE DECISION WHETHER A CONFLICT OF INTEREST EXISTS. IN ADDITION TO THE ABOVE, DIRECTORS, OFFICERS AND COMMITTEE MEMBERS EXECUTE AND DELIVER TO CHN 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 PHYSICIAN PRACTICES AND OTHER PROVIDER SERVICES RESULT IN PRIVATE INUREMENT OR IMPERMISSIBLE PRIVATE BENEFIT - WHETHER PARTNERSHIPS, JOINT VENTURES, AND OTHER TYPES OF ARRANGEMENTS FURTHER CHN'S CHARITABLE PURPOSE AND DO NOT RESULT IN PRIVATE INUREMENT OR IMPERMISSIBLE PRIVATE BENEFIT IF IT IS DETERMINED A CONFLICT OF INTEREST EXISTS, THE INTERESTED PERSON IS PROHIBITED FROM PARTICIPATING IN THE TRANSACTION. |
| 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. |
| 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 XI, LINE 9: | ELIMINATION OF INTEREST IN PARTNERS HEALTH SYSTEM FOUNDATION, INC. -1,159,972. |
| FORM 990, PART XII, LINE 2C | MANAGEMENT PROVIDES OVERSIGHT OF THE AUDIT. THE AUDIT IS PRESENTED TO THE FINANCE COMMITTEE OF THE BOARD OF DIRECTORS. |
| FORM 990, PART XI, LINE 2C | THE PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. |
Schedule R IRS990ScheduleR
Id Disregarded Entities IdDisregardedEntitiesGrp
Disregarded Entity Name DisregardedEntityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | COMMUNITY MEDICAL CENTER OF GREEN LAKE LLC | BusinessNameLine1 |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 670 COUNTY HWY A | AddressLine1 |
| City | GREEN LAKE | City |
| State | WI | State |
| ZIP Code | 54941 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 261424367 | EIN |
| Primary Activities | CLINIC | PrimaryActivitiesTxt |
| Legal Domicile State | WI | LegalDomicileStateCd |
| Total Income | -$414,537 | TotalIncomeAmt |
| End Of Year Assets | $2,284,190 | EndOfYearAssetsAmt |
Direct Controlling Entity Name DirectControllingEntityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | COMMUNITY HEALTH NETWORK INC | BusinessNameLine1 |
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|
| WILD ROSE COMMUNITY HOSPITAL | |||||||||||
| PO BOX 243 | WILD ROSE | WI | 54923 | 396089134 | SUPPORTING ORGANIZATION | 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 | Yes (1) | GiftGrntOrCapContriToOthOrgInd |
| Gift Grnt Cap Contri From Oth Org | Yes (1) | 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 | Yes (1) | 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 | Yes (1) | PaidEmployeesSharingInd |
| Reimbursement Paid To Other Org | 0 | ReimbursementPaidToOtherOrgInd |
| Reimbursement Paid By Other Org | Yes (1) | 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 | WILD ROSE COMMUNITY MEMORIAL HOSPITAL INC | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Transaction Type | N | TransactionTypeTxt |
| Involved | $2,679,242 | InvolvedAmt |
| Method Of Amount Determination | ACTUAL | MethodOfAmountDeterminationTxt |