2014-08-15T14:05:02-05:00 2013-09-30 390758449 WIPFLI LLP 10000 INNOVATION DRIVE SUITE 250 MILWAUKEE WI 532264837 990 2012-10-01 390286215 FORT HEALTHCARE INC FORT 8004214677 611 E SHERMAN AVENUE FORT ATKINSON WI 53538 JAMES NELSON 8004214677 2014-08-15 1 JAY ADKISSON CPA P01360892 4144319300 2014-08-15 2012 2015-11-30 17:44:51Z JAMES NELSON 611 E SHERMAN AVENUE FORT ATKINSON WI 53538 142815894 0 X WWW.FORTHEALTHCARE.COM X 1942 WI OUR MISSION AT FORT HEALTHCARE IS TO IMPROVE THE HEALTH AND WELL-BEING OF OUR COMMUNITY. 13 9 1118 235 0 0 255640 247708 126825803 123986248 2752384 2849115 1381141 630843 131214968 127713914 0 0 0 0 53960425 55560529 0 0 0 75883556 74413567 129843981 129974096 1370987 -2260182 179070478 172497721 85133939 79461059 93936539 93036662 X OUR MISSION AT FORT HEALTHCARE IS TO IMPROVE THE HEALTH AND WELL-BEING OF OUR COMMUNITY. 0 0 80916525 93790157 OPERATION OF A 72-BED ACUTE CARE FACILITY WITH AN EMERGENCY ROOM AND FULL COMPLEMENT OF ANCILLARY SERVICES. 33622484 27966493 OPERATION OF PHYSICIAN CLINICS WITH OUTREACH INTO THE SURROUNDING COMMUNITIES 2043667 2229598 OPERATION OF A HOME HEALTH AGENCY TO CARE FOR HOMEBOUND SENIORS AND OTHERS IN THE COMMUNITY 352678 RELATED RENTAL AND INVESTMENT INCOME 352678 116582676 1 1 0 1 0 0 0 0 0 0 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 1 1 1 0 0 0 0 0 1 1 1 0 0 1 155 0 1 1118 1 0 0 0 0 0 0 0 0 0 0 X 13 9 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 1 0 WI X JAMES NELSON 9205685000 611 E SHERMAN AVENUE FORT ATKINSON WI 53538 MICHAEL WALLACE 40.00 X X 376110 0 35164 JONATHAN MCLAUGHLIN MD 3.00 X X 0 592895 37436 SHARON SCHMELING 3.00 X X 0 0 0 DEAN JOHNSON 3.00 X X 0 0 0 MICHAEL ANDERSON MD 3.00 40.00 X 0 554806 36315 MICHAEL RUMPF 3.00 X 0 0 0 DONALD WILLIAMS MD 3.00 40.00 X 0 263801 33903 BARRY CASH MD 3.00 X 0 0 0 CAROL WARD KNOX 3.00 X 0 0 0 THOMAS NORDLAND MD 3.00 40.00 X 0 665395 35729 ERIC RUNEZ 3.00 X 0 0 0 ROBERT SCHRAMM PHD 3.00 X 0 0 0 GREGORY WATERS 3.00 X 0 0 0 WADE WOELFLE MD 3.00 X 0 0 0 JAMES J NELSON 40.00 X 215412 0 35200 ISIDORO ZAMBRANO MD 1.00 40.00 X 0 902006 35436 RANDALL JENNINGS MD 1.00 40.00 X 0 617934 34916 MARC ERICKSON MD 1.00 40.00 X 0 593455 36436 BILLIE KONTNY MD 1.00 40.00 X 0 593220 37563 ALAN DETWILER MD 1.00 40.00 X 0 551332 16048 591522 5334844 374146 32 0 1 0 FORT MEDICAL GROUP 611 E SHERMAN AVENUE EAST FORT ATKINSON WI 53538 PHYSICIAN SERVICES 12184570 CERNER CORPORATION PO BOX 412702 KANSAS CITY OH 64141 PROFESSIONAL SERVICES 6647626 UW MEDICAL FOUNDATION - RADIOLOGY 600 HIGHLAND AVE MADISON WI 53792 RADIOLOGY SERVICES 1484860 MEDICUS HOSPITALIST SERVICES LLC 7 INDUSTRIAL WAY UNIT 5 SALEM NH 03079 HOSPITALIST (PHYSICIAN) SERVICES 1167493 CERNER HEALTH PLAN SERVICES 2800 ROCKCREEK PARKWAY KANSAS CITY MO 64117 ADMINISTRATIVE SERVICES 980293 35 57667 190041 247708 HOSPITAL SERVICES 623000 86684079 86684079 PHYSICIAN CLINIC REVENUE 621110 27188297 27188297 OTHER OPERATING REVENUE 623990 7884274 7884274 HOME HEALTH AGENCY 621610 2229598 2229598 123986248 1264679 1264679 913733 907374 6359 6359 6359 15336261 442781 14104932 89674 1231329 353107 1584436 1584436 INVESTMENT INCOME 623000 624484 352678 271806 624484 127713914 124338926 0 3127280 X 591522 532209 59313 41528098 37363988 4164110 1475094 1327183 147911 8946176 8049124 897052 3019639 2716853 302786 445565 445565 216108 216108 27047699 25159436 1888263 838706 224189 614517 11667569 11369110 298459 4250387 4250387 5932986 4636419 1296567 127890 123593 4297 3726516 3726516 7998624 7947654 50970 244083 196458 47625 PROVISION FOR BAD DEBTS 5432761 5432761 0 DUES 2708507 109634 2598873 EQUIPMENT 756730 752728 4002 LAUNDRY/CLEANING 698521 698521 2320915 1965913 355002 129974096 116582676 13391420 0 4508519 4312285 25328684 18740001 7475 0 1969648 1957817 1379892 1720136 166098479 95621710 74404088 70476769 58156153 63066317 8874849 7796618 4441170 4427778 179070478 172497721 15620699 14190829 55276463 51484425 14236777 13785805 85133939 79461059 X 93936539 93036662 93936539 93036662 179070478 172497721 -2260182 1360305 0 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 8931 8931 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: LOBBYING PORTION OF DUES PAID TO WHA AND AHA. 636155 636155 64304867 32081918 32222949 99997161 63539792 36457369 1160296 1160296 70476769 DEFERRED COMPENSATION 482659 CAPITOL LEASE OBLIGATIONS 10080542 DEFERRED GAIN OF SALE-LEASEBACK 2677434 RELATED PARTY PAYABLE 545170 13785805 X 124548832 1360305 -4525387 -3165082 127713914 0 127713914 125448709 907374 907374 124541335 5432761 5432761 129974096 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X, LINE 2: IN ORDER TO ACCOUNT FOR ANY UNCERTAIN TAX POSITIONS, THE SYSTEM DETERMINES WHETHER IT IS MORE LIKELY THAN NOT THAT A TAX POSITION WILL BE SUSTAINED UPON EXAMINATION ON 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 FINANCIAL STATEMENTS. THE SYSTEM RECORDED NO ASSETS OR LIABILITIES RELATED TO UNCERTAIN TAX POSITIONS IN 2013 AND 2012. TAX RETURNS FOR TAX YEARS 2009 AND BEYOND REMAIN SUBJECT TO EXAMINATION BY THE APPLICABLE TAXING AUTHORITIES. PART XI, LINE 2D - OTHER ADJUSTMENTS: BAD DEBT INCLUDED IN EXPENSES -5,432,761. RENTAL EXPENSES 907,374. PART XII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES 907,374. PART XII, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT INCLUDED IN EXPENSES 5,432,761. 1 1 1 X 1 X 1 1 1 0 1 1 1925040 1925040 0.01550 14820572 3913998 10906574 0.08760 16745612 3913998 12831614 0.10310 1457132 387240 1069892 0.00860 154205 1 154204 0.00120 1611337 387241 1224096 0.00980 18356949 4301239 14055710 0.11290 0 5432761 380293 11095215 15383749 -4288534 X 1 1 1 MEDICAL HEALTH BUILDING GROUP RENTAL OF MEDICAL BUILDINGS 0.20000 0.25000 1 1 FORT HEALTHCARE INC

611 SHERMAN AVENUE EAST FORT ATKINSON WI 53538

X X X FORT HEALTHCARE INC 1 1 X X X X X X X 12 1 1 1 X X X X X X X 0 0 1 1 150.000000000000 1 300.000000000000 1 X X 1 1 X X 1 0 X X 1 X 0 0 1 FORT HEALTHCARE HOME HEALTH

715 SHERMAN AVENUE EAST FORT ATKINSON WI 53538

HOME HEALTH AGENCY PART I, LINE 7: OVERALL COST TO CHARGE RATIO PART I, LINE 7G: SUBSIDIZED HEALTH SERVICES DID NOT INCLUDE ANY PHYSICIAN CLINICS. PART I, LINE 7, COLUMN (F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $ 5432761. PART II: FORT HEALTHCARE GIVES GENEROUSLY TO AREA COMMUNITY ORGANIZATIONS. IN FY 2012, MORE THAN $60,000 WAS PROVIDED IN DIRECT SUPPORT OF COMMUNITY EVENTS. IN ADDITION, FORT HEALTHCARE RESOURCES WERE EXPENDED TO SUPPORT THOSE ACTIVITIES- INCLUDING SIGNIFICANT STAFF TIME, VOLUNTEER TIME, MEDICAL SUPPLIES, GIVEAWAY ITEMS AND MORE. APPROXIMATELY $2.15 MILLION WAS PROVIDED IN CHARITY CARE. FORT HEALTHCARE STAFF SERVE ON THE BOARD OF DIRECTORS FOR A NUMBER OF LOCAL NON-PROFIT AGENCIES. FORT HEALTHCARE IS VERY SUPPORTIVE OF UNITED WAY, TOMORROW'S HOPE, RELAY FOR LIFE AND MANY OTHER FUNDRAISING CAUSES IN THE COMMUNITY. THE COMMUNITY HEALTH & WELLNESS DEPARTMENT IS ACTIVELY ENGAGING NON-PROFIT ENTITIES IN AREA COMMUNITIES TO BUILD COLLABORATIVE RELATIONSHIPS WITH THE GOAL OF AFFECTING OBESITY, ACCESS TO CARE, DIET, FITNESS AND NUTRITION. FOR SEVERAL COMMUNITIES IN JEFFERSON COUNTY, KEY LEADERS HAVE BEEN IDENTIFIED TO REPRESENT THE HEALTHIEST COMMUNITIES COALITION IN THEIR RESPECTIVE CITIES. COALITION MEMBERSHIP INCLUDES REPRESENTATIVES FROM LOCAL SCHOOLS, CHURCHES, GOVERNMENT AGENCIES, BUSINESSES, COMMUNITY ORGANIZATIONS AND INTERESTED INDIVIDUALS. ALL ARE ENGAGED IN A CONCERTED EFFORT TO REDUCE THE OBESITY RATE IN JEFFERSON COUNTY. EACH COALITION IS ACTIVELY DEVELOPING STRATEGIES TO IMPLEMENT IN THEIR LOCAL COMMUNITIES, FOCUSING ON THE FOLLOWING PRIORITIES:-INCREASE ACCESS TO HEALTHY FOOD OPTIONS-APPLY INCENTIVES TO IMPROVE NUTRITION-INSTITUTE WORKPLACE INCENTIVES TO REWARD INCREASED PHYSICAL ACTIVITY-EDUCATE AND INFORM THE PUBLIC ABOUT SERVING SIZES AND NUTRITIONAL CONTENT OF FOOD OPTIONS AVAILABLE IN PUBLIC AREAS-IMPLEMENT COMPREHENSIVE PROGRAMS THAT PROMOTE PHYSICAL ACTIVITY AND NUTRITION-INCREASE ACCESS TO OPPORTUNITIES AND FACILITIES THAT PROMOTE PHYSICAL ACTIVITY PART III, LINE 4: THE CARRYING AMOUNTS OF ACCOUNTS RECEIVABLE ARE REDUCED BY ALLOWANCES THAT REFLECT MANAGEMENT'S BEST ESTIMATE OF THE AMOUNTS THAT WILL NOT BE COLLECTED. MANAGEMENT PROVIDES FOR CONTRACTUAL ADJUSTMENTS UNDER TERMS OF THIRD-PARTY REIMBURSEMENT AGREEMENTS THROUGH A REDUCTION OF GROSS REVENUE AND A CREDIT TO PATIENT RECEIVABLES. IN ADDITION, MANAGEMENT PROVIDES FOR PROBABLE UNCOLLECTIBLE AMOUNTS, PRIMARILY UNINSURED PATIENTS AND AMOUNTS PATIENTS ARE PERSONALLY RESPONSIBLE FOR, THROUGH A CHARGE TO OPERATIONS AND A CREDIT TO A VALUATION ALLOWANCE BASED ON ITS ASSESSMENT OF HISTORICAL COLLECTION LIKELIHOOD AND THE CURRENT STATUS OF INDIVIDUAL ACCOUNTS. BALANCES THAT ARE STILL OUTSTANDING AFTER MANAGEMENT HAS USED REASONABLE COLLECTION EFFORTS ARE WRITTEN OFF THROUGH A CHARGE TO THE VALUATION ALLOWANCE AND A CREDIT TO PATIENT ACCOUNTS RECEIVABLE.COSTING METHODOLOGY - BASED ON A PERCENTAGE OF COMMUNITY CARE WRITE-OFFS TO OVERALL SELF PAY WRITE-OFFS RATIONALE FOR INCLUDING BAD DEBT AMOUNTS IN COMMUNITY BENEFIT- WE ARE THE ONLY HOSPITAL IN OUR SERVICE AREA AND PATIENTS WOULD HAVE TO TRAVEL TO ANOTHER COMMUNITY TO RECEIVE CARE. PART III, LINE 8: WE ARE THE ONLY HOSPITAL IN OUR SERVICE AREA & PATIENTS WOULD HAVE TO TRAVEL TO ANOTHER COMMUNITY TO RECEIVE CARE.INPATIENT COSTS COME FROM WORKSHEET D-1 PART II & OUTPATIENT COSTS ARE BASED ON THE COST TO CHARGE RATIO OF THE MEDICARE CHARGES ON WORKSHEET D PART V. SUBACUTE COSTS ARE FROM WORKSHEET D-1 PART III. HOME HEALTH IS FROM WORKSHEET H-6 PART I. PART III, LINE 9B: PERSONS WHOSE INCOME IS LESS THAN 150% OF THE FEDERAL POVERTY GUIDELINES, BUT NOT MORE THAN 300% OF THE GUIDELINES, SHALL BE ELIGIBLE FOR COMMUNITY CARE ON A REDUCED CHARGE BASIS. PERSONS WHOSE INCOME IS LESS THAN 150% OF THE GUIDELINES WILL BE CONSIDERED FOR COMPLETE FORGIVENESS OF THEIR OUTSTANDING CHARGES. FORT HEALTHCARE INC. PART V, SECTION B, LINE 3: TWO FEEDBACK SESSIONS OPEN TO THE PUBLIC WERE HELD. BASED ON THE FEEDBACK THE TOP RATED ITEMS WERE DISCUSSED AND WILL BE THE FOCUS OF COMMUNITY HEALTH IMPROVEMENT PLAN AND PROCESS FORT HEALTHCARE INC. PART V, SECTION B, LINE 4: BEAVER DAM HOSPITAL AND WATERTOWN HOSPITAL FORT HEALTHCARE INC. PART V, SECTION B, LINE 7: MENTAL HEALTH - CURRENTLY RESTRUCTURING THE WAY MENTAL HEALTH SERVICES ARE PROVIDED.ALCOHOL USE - PLAN TO ADDRESS IN FUTURE.TOBACCO USE - PLAN TO ADDRESS IN FUTURE. FORT HEALTHCARE INC. PART V, SECTION B, LINE 12H: SERVICES ARE NOT ELECTIVE. FORT HEALTHCARE INC. PART V, SECTION B, LINE 20D: WE USED OUR OVERALL AVERAGE INSURANCE RATE. PART VI, LINE 2: FORT HEALTHCARE PERFORMS REGULAR MARKET RESEARCH TO ASSESS THE HEALTHCARE NEEDS AND CONCERNS OF THE COMMUNITY. FOCUS GROUPS WITH CURRENT PATIENTS AND NON-PATIENTS HAVE HELPED US IMPROVE THE QUALITY OF CLINIC BASED SERVICES. AN ANNUAL COMMUNITY HEALTH ASSESSMENT IS ALSO IMPLEMENTED. THE PRIMARY RESEARCH TOOL IS A DOOR-TO-DOOR SURVEY OF 400+ RESIDENTS IN THE SERVICE AREA. MANY QUESTIONS RELATE SPECIFICALLY TO HEALTH NEEDS, CONCERNS, BEHAVIORS AND CONCERNS. THE SURVEY IS ADMINISTERED BY AN INDEPENDENT RESEARCH COMPANY AFFILIATED WITH THE UNIVERSITY OF WISCONSIN-WHITEWATER. FURTHERMORE, FORT HEALTHCARE HAS CREATED COMMUNITY HEALTH COALITIONS THROUGHOUT THE SERVICE AREA. CONCERNED RESIDENTS AND COMMUNITY LEADERS, WITH THE ASSISTANCE OF FORT HEALTHCARE STAFF ARE DEVELOPING SPECIFIC COMMUNITY-RELEVANT STRATEGIES TO ADDRESS OBESITY, PHYSICAL ACTIVITY, NUTRITION AND INCREASED CONSUMPTION OF WATER VS. SWEETENED BEVERAGES. PART VI, LINE 3: INFORMATION IS AVAILABLE ON THE PATIENT STATEMENT, IN MONTHLY NEWSLETTERS AND ON THE ORGANIZATION'S WEBSITE. AN ANNUAL COMMUNITY BENEFIT REPORT IS FILED WITH THE WISCONSIN HOSPITAL ASSOCIATION. A PRINTED REPORT IS PREPARED AND DELIVERED TO 48,000 HOUSEHOLDS WITHIN THE PRIMARY SERVICE AREA AS AN INSERT INTO THE HEALTH365 COMMUNITY MAGAZINE. THE FORT HEALTHCARE WEBSITE CONTAINS LINKS AND INFORMATION SPECIFIC TO THE POLICY ON CHARITY CARE, FINANCIAL AID AND REDUCED PAYMENT OPTION FOR SELF-PAY PATIENTS. INFORMATION IS ALSO AVAILABLE ON THE WEBSITE AND IN ALL FORT HEALTHCARE LOCATIONS REGARDING THE ROCK RIVER FREE CLINIC, A FREE AND REDUCED CARE CLINIC FUNDED IN A SIGNIFICANT MANNER BY FORT HEALTHCARE INCLUDING FULL FUNDING FOR A 1.0 FTE PHYSICIAN AND SUBSIDIZED LAB AND RADIOLOGY SERVICES. FINANCIAL AID COUNSELOR IS AVAILABLE AT FORT MEMORIAL HOSPITAL TO ASSIST PATIENTS WITH COMPLETING PAPERWORK FOR GOVERNMENT ASSISTANCE PROGRAMS, WITH CONTACT INFORMATION ALSO AVAILABLE ON THE WEBSITE AND IN ADMISSION PACKETS. PART VI, LINE 4: FORT HEALTHCARE'S PRIMARY SERVICE AREA CONSTITUTES AN EIGHT ZIP CODE REGION COMPRISED OF THE COMMUNITIES OF FORT ATKINSON, JEFFERSON, JOHNSON CREEK, HELENVILE, WHITEWATER, CAMBRIDGE, LAKE MILLS AND PALMYRA. THERE ARE APPROXIMATELY 75,000 PERSONS LIVING IN THE REGION. FORT MEMORIAL HOSPITAL IS THE ONLY HOSPITAL WITHIN THE PRIMARY SERVICE AREA. THE REGION IS NOT CONSIDERED A MEDICALLY UNDERSERVED REGION. PART VI, LINE 5: THE FORT HEALTHCARE BOARD OF DIRECTORS IS A COMMUNITY ORIENTED BOARD, WITH REPRESENTATIVES SOLICITED DIRECTLY FROM THE MAJORITY OF COMMUNITIES IN THE PRIMARY SERVICE AREA. THE MAJORITY OF REPRESENTATIVES ARE NOT EMPLOYEES, CONTRACTORS OR RELATIVES OF FORT HEALTHCARE STAFF. THE MEMBERS ARE NOT COMPENSATED FOR THEIR SERVICE. THE FORT MEMORIAL HOSPITAL OPERATES WITH AN 'OPEN' MEDICAL STAFF. PHYSICIANS UNAFFILIATED WITH THE ORGANIZATION MAY REQUEST PRIVILEGES AT ANY TIME. THE PLANNING COMMITTEE DETERMINES NEED FOR SPECIALTY CARE ACCORDING TO A WELL ESTABLISHED MEDICAL MANPOWER PLAN THAT INCLUDES COMMUNITY NEED FOR SERVICES. PHYSICIANS ARE GRANTED MEDICAL STAFF STATUS BASED ON NEED. THE MEDICAL STAFF IS REPRESENTED BY MEMBERS OF FORT MEDICAL GROUP (OWNED BY FORT HEALTHCARE), DEAN/ST. MARY'S REGIONAL CLINICS, UW HEALTH AND OTHERS. FORT HEALTHCARE IS A NON-PROFIT ORGANIZATION AND NET REVENUES ARE USED FOR IMPROVEMENTS IN THE STATUS OF FORT HEALTHCARE. FUNDS ARE USED TO PURCHASE CAPITAL EQUIPMENT, ENHANCE PHYSICAL FACILITIES AND IMPROVE PATIENT SERVICES. PART VI, LINE 6: FORT HEALTHCARE IS AN INDEPENDENT, NON-PROFIT ORGANIZATION. THERE ARE NO AFFILIATED ORGANIZATIONS. REPORTS FILED WITH STATES PART VI, LINE 7 WI X X X X X X 0 1 0 0 1 0 0 0 0 MICHAEL WALLACE 348115 0 16353 0 11642 0 10000 0 25164 0 411274 0 60000 0 JONATHAN MCLAUGHLIN MD 0 431191 0 160462 0 1242 0 10000 0 27436 0 630331 0 0 MICHAEL ANDERSON MD 0 425000 0 129266 0 540 0 10000 0 26315 0 591121 0 0 DONALD WILLIAMS MD 0 233964 0 26666 0 3171 0 10000 0 23903 0 297704 0 0 THOMAS NORDLAND MD 0 660869 0 2204 0 2322 0 10000 0 25729 0 701124 0 0 JAMES J NELSON 207284 0 7476 0 652 0 8629 0 26571 0 250612 0 0 0 ISIDORO ZAMBRANO MD 0 849283 0 52183 0 540 0 10000 0 25436 0 937442 0 0 RANDALL JENNINGS MD 0 607108 0 10016 0 810 0 10000 0 24916 0 652850 0 0 MARC ERICKSON MD 0 432183 0 160462 0 810 0 10000 0 26436 0 629891 0 0 BILLIE KONTNY MD 0 431516 0 160462 0 1242 0 10000 0 27563 0 630783 0 0 ALAN DETWILER MD 0 548402 0 0 0 2930 0 10000 0 6048 0 567380 0 0 PART I, LINE 4B MICHAEL WALLACE WAS AWARDED A SERP RETENTION BONUS FOR FY2013 IN THE AMOUNT OF $60,000 PART I, LINE 5 PHYSICIAN COMPENSATION IS TIED TO THE NET REVENUES OF THEIR PRACTICE A WISCONSIN HEALTH & EDUCATIONAL FACILITIES AUTHORITY 391337855 97710VTU2 2004-05-18 40072037 CONSTRUCTION & EQUIPMENT 0 0 0 B WISCONSIN HEALTH & EDUCATIONAL FACILITIES AUTHORITY 391337855 97710V4Q8 2007-09-20 26000000 CONSTRUCTION & EQUIPMENT & REFUNDING PRIOR ISSUE 0 0 0 A 5372037 40072037 2926311 320000 36825725 2006 0 0 1 1 B 6955000 26000000 9548835 391832 500 16058833 2010 0 1 1 1 A 0 0 0 0 0.00000 0.00000 0.00000 0 0 0 B 0 0 0 0 0.00000 0.00000 0.00000 0 0 0 A 0 1 0 0 0 0 1 XL ASSET FUNDING COMPANY 2.500000000000 1 0 0 B 0 1 0 0 1 0 0 0 0 A 1 B 1 500 MCMILLEN GROUP LLP PARTNERSHIP OWNED BY DONALD WILLIAMS CURRENT BOARD DIRECTOR 349179 RENT FOR THE LEASE OF OFFICE SPACE 0 JULIE MOKHTAR MD WIFE OF OFFICER EDWIN FISCHER 420275 EMPLOYEE 0 MELANIE RUMPF WIFE OF BOARD MEMBER MICHAEL RUMPH 46958 EMPLOYEE 0 MEDICAL HEALTH BUILDING GROUP PARTNERSHIP OWNED BY BILLIE KONTNY, TOP 5 PAID EMPLOYEES 1876739 RENT FOR THE LEASE OF OFFICE SPACE 0 FORM 990, PART VI, SECTION B, LINE 11 A COPY OF THE 990 IS SENT TO EACH OF THE BOARD OF DIRECTORS PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C EACH BOARD MEMBER OF THE ENTITY AND RELATED ENTITIES ANNUALLY COMPLETE A CONFLICT OF INTEREST QUESTIONNAIRE DISCLOSING THEIR CONFLICTS OF INTEREST. A SUMMARY OF CONFLICTS ARE DISTRIBUTED TO THE CHAIRMAN OF THE BOARD AND TO ADMINISTRATIVE SUPPORT PERSONNEL. BOARD MEMBERS ARE COACHED ON HOW TO MANAGE THEIR CONFLICTS. FORM 990, PART VI, SECTION B, LINE 15 OTHER ORGANIZATIONS ARE USED AS BENCHMARKS TO DETERMINE COMPENSATION. INDEPENDENT REVIEWS OF COMPENSATION ARE ALSO DONE PERIODICALLY. FORM 990, PART VI, SECTION C, LINE 19 ALL DOCUMENTS ARE AVAILABLE TO THE PUBLIC UPON REQUEST. SUMMARIES OF FINANCIAL STATEMENTS ARE AVAILABLE TO THE PUBLIC VIA AN ANNUAL REPORT THAT FORT HEALTHCARE PUBLISHES. THE ANNUAL REPORT IS DIRECT MAILED TO HOUSEHOLDS AND IS ALSO AVAILABLE TO THE PUBLIC ON FORT HEALTHCARE'S WEBSITE. OTHER FEES FORM 990, PART IX, LINE 11G PHYSICIAN SERVICES: PROGRAM SERVICE EXPENSES 23,849,654. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 23,849,654. ADMINISTRATIVE PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 1,888,263. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,888,263. MEDICAL PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 1,309,782. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,309,782. FORT MEMORIAL HOSPITAL FOUNDATION 611 SHERMAN AVE EAST FORT ATKINSON WI 53538 391397028 FOUNDATION WI 501(C)(3) LINE 11A, I FORT HEALTHCARE INC 1 FORT HEALTHCARE PARTNERS 611 SHERMAN AVE EAST FORT ATKINSON WI 53538 391040145 VOLUNTEERS WI 501(C)(3) LINE 3 FORT HEALTHCARE INC 1 UW CANCER CENTER JOHNSON CREEK LLC 250 DOCTORS COURT JOHNSON CREEK WI 53038 200341996 CANCER CARE CENTER WI N/A RELATED -24048 340675 0 0 0.33300 MEDICAL HEALTH BUILDING GROUP LLC 43 SOUTH WATER STREET EAST FORT ATKINSON WI 53538 611571669 HOLD REAL ESTATE FOR MEDICAL PRACTICES WI N/A RELATED 276176 2589019 0 0 0.20000 PAIN CENTERS OF WISCONSIN - FORT ATKINSON LLC 4131 WEST LOOMIS ROAD GREENFIELD WI 53221 900777376 PROVIDE PAIN MANAGEMENT SERVICES WI N/A RELATED 361745 340675 0 0 0.49000 FORT MEDICAL EQUIPMENT LLC 306 WASHINGTON ST FORT ATKINSON WI 53538 392042387 PROVIDE DURABLE MEDICAL EQUIPMENT WI N/A RELATED -4370 33106 0 0 0.30000 FORT MEDICAL GROUP INC 611 SHERMAN AVE EAST FORT ATKINSON WI 53538 391736513 PROVIDE PHYSICIAN SERVICES WI FORT HEALTHCARE INC C 2784237 1.00000 0 FORT CARE INC 611 SHERMAN AVE EAST FORT ATKINSON WI 53538 391725831 PREFERRED PROVIDER ORGANIZATION WI FORT HEALTHCARE INC C -14981 96269 1.00000 0 0 0 1 0 0 0 0 0 0 0 0 0 0 1 1 1 1 0 0 FORT MEMORIAL HOSPITAL FOUNDATION C 121533 FAIR MARKET VALUE FORT HEALTHCARE PARTNERS C 58563 FAIR MARKET VALUE FORT MEMORIAL HOSPITAL FOUNDATION Q 15976424 FAIR MARKET VALUE