2014-08-14T10:17:18-05:00 2013-09-30 390758449 WIPFLI LLP PO BOX 12237 GREEN BAY WI 543072237 990 2012-10-01 390848401 COMMUNITY MEMORIAL HOSPITAL INCORPORATED COMM 9208463444 855 S MAIN STREET OCONTO FALLS WI 54154 MICHELE MILLER-CAMPBELL 9208463444 2014-08-13 1 TERRI REXRODE P00096513 9206620016 2014-08-13 2012 2015-11-30 17:44:51Z DANIEL DEGROOT 855 S MAIN STREET OCONTO FALLS WI 54154 35626652 0 X WWW.CMHOSPITAL.ORG X 1929 WI COMMUNITY MEMORIAL HOSPITAL, INC. OPERATES AN ACUTE CARE HOSPITAL PROVIDING COMPREHENSIVE INPATIENT MEDICAL AND SURGICAL SERVICES AS WELL AS EMERGENCY, PRIMARY CARE PHYSICIAN, AND OUTPATIENT SERVICES. THE HOSPITAL HAS BEEN DESIGNATED AS A CRITICAL ACCESS HOSPITAL UNDER MEDICARE AND MEDICAID REGULATIONS. THIS DESIGNATION, WHICH ENABLES THE HOSPITAL TO RECEIVE REIMBURSEMENT UNDER COST-BASED METHODS, LIMITS THE NUMBER OF STAFFED BEDS THE HOSPITAL MAY OPERATE TO 25. 9 7 417 50 2098841 -156990 143789 121002 36932424 35112308 213793 195466 -65976 -53722 37224030 35375054 0 0 0 0 19861888 18653248 0 0 0 17178769 18095469 37040657 36748717 183373 -1373663 30397704 29636760 13112680 13578443 17285024 16058317 X TO PROVIDE HIGH QUALITY HEALTHCARE, CLOSE TO HOME. 0 0 28953090 32948912 COMMUNITY MEMORIAL HOSPITAL IS AN INDEPENDENT HEALTHCARE SYSTEM SERVING GREATER OCONTO COUNTY WITH A FULL-SERVICE HOSPITAL AND SIX CMH PRIMARY CARE CLINICS LOCATED THROUGHOUT OCONTO COUNTY. THE FEDERALLY DESIGNATED CRITICAL ACCESS HOSPITAL WITH 25 BEDS AND HAS A 24-HOUR, PHYSICIAN-STAFFED EMERGENCY DEPARTMENT, URGENT CARE, RETAIL PHARMACY, INTENSIVE CARE, INPATIENT AND OUTPATIENT SURGICAL AND DIAGNOSTIC SERVICES, REHABILITATION, ONCOLOGY OUTPATIENT CLINIC, THE CMH CENTER FOR WOMEN'S CARE, AND THE CMH CENTER FOR ORTHOPEDIC CARE. CMH PRIMARY CARE CLINICS ARE LOCATED IN LENA, OCONTO FALLS, OCONTO, GILLETT, SURING, AND MOUNTAIN. COMMUNITY MEMORIAL HOSPITAL IS A NON-PROFIT ORGANIZATION DEDICATED TO OUR MISSION TO PROVIDE HIGH QUALITY HEALTH CARE CLOSE TO HOME. COMMUNITY MEMORIAL HOSPITAL EXTENDS THIS MISSION INTO OUR VALUES OF QUALITY, CARE, COMMUNITY, TRUST, AND RESPECT AND PROMOTES THE HEALTH OF THE COMMUNITY BY PROVIDING A VARIETY OF HEALTHCARE SERVICES. DURING THE FISCAL YEAR ENDING SEPTEMBER 30, 2013, THE HOSPITAL HAD 735 DISCHARGES; 5,124 VISITS TO THE EMERGENCY ROOM; 2,172 SURGICAL CASES (INCLUDING AMBULATORY); AND 32,442 VISITS TO OUR HOSPITAL-BASED CLINICS.COMMUNITY MEMORIAL HOSPITAL PROVIDES HEALTHCARE SERVICES TO ALL MEMBERS OF THE COMMUNITY WITHOUT REGARD TO THEIR AGE, RACE, SEX, OR ABILITY TO PAY FOR SERVICES. DURING FISCAL YEAR 2013, COMMUNITY MEMORIAL HOSPITAL PROVIDED $1,470,369 IN CHARITY CARE, $215,322 IN PATIENT DISCOUNTS FOR GOVERNMENT PROGRAMS OUTSIDE OF TITLE 18 & TITLE 19, AND $2,610,558 IN BAD DEBT WRITE OFFS OF PATIENT ACCOUNTS AS BAD DEBT DUE TO THE PATIENTS' INABILITY TO PAY FOR SERVICES THEY RECEIVED.IN ADDITION TO ITS HOSPITAL AND CLINIC SERVICES, COMMUNITY MEMORIAL HOSPITAL PROVIDES THE COMMUNITY MANY OPPORTUNITIES TO RECEIVE FREE AND LOW-COST HEALTH SCREENINGS AND SERVICES. FOR EACH OF THESE OFFERINGS, COMMUNITY MEMORIAL HOSPITAL PROVIDED PLANNING, PUBLICITY, STAFF, EQUIPMENT, SUPPLIES, AND FACILITIES.COMMUNITY MEMORIAL HOSPITAL HOSTS COMMUNITY HEALTH INFORMATION SEMINARS ON VARIOUS TOPICS THAT ARE FREE AND OPEN TO THE PUBLIC. COMMUNITY MEMORIAL HOSPITAL ASSUMES THE ENTIRE COSTS FOR THE SPEAKER TO PRESENT THE SEMINAR, PUBLICITY, SUPPLIES, AND THE MEALS. FOUR CMH SENIOR SPECIALS DINNER SEMINARS WERE HELD IN 2013.COMMUNITY MEMORIAL HOSPITAL IS PLEASED TO PARTNER, PARTICIPATE AND COLLABORATE WITH MANY COMMUNITY PARTNERS FOR VARIOUS INITIATIVES AND EVENTS. COMMUNITY MEMORIAL HOSPITAL PLANNED AND SPONSORED THE HOT CAKE HUSTLE 5K FUN RUN/WALK, A COMMUNITY HEALTH INITIATIVE. WE ALSO PRESENTED THE OCONTO COUNTY SAFETY FAIR IN COOPERATION WITH THE OCONTO COUNTY HEALTH DEPARTMENT, OCONTO FALLS FIRE AND POLICE DEPARTMENTS AND THE OCONTO FALLS AMBULANCE SERVICE. CMH OFFERED FOUR FREE WORKSHOPS FOR CANCER PATIENTS IN 2013 THROUGH THE AMERICAN CANCER SOCIETY LOOK GOOD FEEL BETTER PROGRAM. CMH HOSTS AMERICAN RED CROSS BLOOD DRIVES MULTIPLE TIMES EACH YEAR. COMMUNITY MEMORIAL HOSPITAL IS AN ACTIVE MEMBER IN THE OCONTO FALLS CHAMBER OF COMMERCE AND ACTIVELY PARTICIPATES IN THEIR MAJOR FUNDRAISING COMMITTEE AND THE EXECUTIVE COMMITTEE. FOR EACH OF THESE INITIATIVES, COMMUNITY MEMORIAL HOSPITAL PROVIDED PLANNING, PUBLICITY, STAFF, EQUIPMENT, SUPPLIES, AND FACILITIES.CMH SUPPORTS AND PARTICIPATES IN AREA SCHOOL-RELATED ACTIVITIES. IN ADDITION TO PROVIDING COMPREHENSIVE SPORTS PHYSICAL CLINICS IN WHICH THE FEES ARE DONATED BACK TO THE SCHOOLS OF THE PARTICIPATING STUDENTS, CMH PARTICIPATED IN AREA SCHOOL HEALTH FAIRS, CAREER FAIRS, AND EARLY CHILDHOOD SCREENINGS. SCHOOL FIELD TRIP TOURS ARE ROUTINELY HOSTED AT THE HOSPITAL. CMH ALSO DONATED TO THE CONSTRUCTION OF NEW SOFTBALL FIELDS FOR THE OCONTO FALLS SCHOOL DISTRICT. 28953090 1 1 0 1 0 0 0 0 0 0 1 0 0 1 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 0 0 0 0 0 0 0 0 1 1 1 0 0 1 35 0 417 1 1 1 0 0 0 0 0 0 0 0 0 X 9 7 0 0 0 0 0 0 0 1 1 0 0 0 1 1 1 1 0 1 1 0 WI X MICHELE MILLER-CAMPBELL CFO 9208463444 855 SOUTH MAIN STREET OCONTO FALLS WI 54154 CHRISTY KAEMPFER 2.00 X X 0 0 0 JAMES VANDORNICK 2.00 X X 0 0 0 JAN STRANZ 2.00 X X 0 0 0 DANIEL BOETTCHER 2.00 X 0 0 0 HOWARD ESLIEN JR 2.00 X 0 0 0 TOM BAYER 2.00 X 0 0 0 DR ASHOK RAI 2.00 X 0 0 0 DR ISAIAS CUPINO 42.00 X 493825 0 22779 DR GENADI MALTINSKI 42.00 X 347950 0 0 DANIEL DEGROOT 42.00 0.50 X 175214 0 0 MICHELE MILLER-CAMPELL 40.00 0.50 X 106265 0 19451 DR KEITH ELKINS 40.00 X 396409 0 2516 DR THOMAS KNUTSON 40.00 X 179847 0 21503 DR R SCOTT LIEBL 40.00 X 429669 0 23091 DR DOUGLAS GREMBAN 40.00 X 222153 0 23091 DR LUZ BALMADRID 40.00 X 291494 0 18437 2642826 0 130868 19 0 1 0 WIPFLI LLP PO BOX 3160 MILWAUKEE WI 53201 ACCOUNTING AND CONSULTING SERVICES 537076 BREAST SURGURY EXPERTS 3048 CORNELIUS CT GREEN BAY WI 54311 CONTRACT PHYSICIANS 393839 GENALDI MALTINSKI MD W121 LAKE SANDIA DR KRAKOW WI 54137 CONTRACT PHYSICIAN 347950 ST MARY'S MEDICAL CENTER 1726 SHAWANO AVE GREEN BAY WI 54303 VARIOUS HOSPITAL SERVICES 294819 AMERIEBO LLC AMERICOLLECT PO BOX 1566 MANITOWOC WI 54221 COLLECTION SERVICES 249432 10 100000 8925 12077 121002 NET PATIENT SERVICE REVENUE 900099 26154041 26154041 PHARMACY REVENUE 446110 7602081 5503240 2098841 OTHER REVENUE 900099 1266803 1266803 CAFETERIA REVENUE 900099 37378 37378 GIFT SHOP REVENUE 452000 27177 27177 24828 24828 35112308 165316 165316 197876 251598 -53722 -53722 -53722 30150 0 30150 30150 30150 35375054 32948912 2098841 206299 2448544 2147614 300930 12561884 10096846 2465038 279259 219566 59693 2577359 1873670 703689 786202 721136 65066 223096 223096 18067 18067 3267385 2310161 957224 116762 2624 114138 7403492 6240181 1163311 63483 63483 1899854 900079 999775 198379 141673 56706 395581 395581 1335231 1207762 127469 139369 57008 82361 BAD DEBT EXPENSE 2604667 2604667 LOSS ON REFINANCING 430103 430103 36748717 28953090 7795627 0 3464369 646671 2588212 2596340 4673351 4764825 92120 702324 1274010 1624707 532249 557823 29327782 18317291 9909963 11010491 5949244 6262027 167555 124074 1746631 1347478 30397704 29636760 3003234 3827290 7752375 8910000 917669 1439402 841153 13112680 13578443 X 17119970 15934243 165054 124074 17285024 16058317 30397704 29636760 X -1373663 190437 -43481 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 9157 9157 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: PORTION OF THE FOLLOWING DUES: WHA: $1,641; RWHC: $3,124; AND AHA: $4,392. 235001 235001 14540222 7594764 6945458 14302297 10525213 3777084 250262 197314 52948 11010491 CAPITAL LEASES 96890 SECTION 457 PLAN LIABILITY 744263 841153 X 32977555 251598 251598 32725957 18067 2631030 2649097 35375054 34351218 251598 251598 34099620 18067 2631030 2649097 36748717 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X, LINE 2: IN ORDER TO ACCOUNT FOR ANY UNCERTAIN TAX POSITIONS, THE HOSPITAL 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 COMBINED FINANCIAL STATEMENTS. THE HOSPITAL RECORDED NO ASSETS OR LIABILITIES RELATED TO UNCERTAIN TAX POSITIONS OR UNRECOGNIZED TAX BENEFITS IN 2013 OR 2012. THE HOSPITAL IS ALSO ENGAGED, TO A LIMITED EXTENT, IN ACTIVITIES WHICH THE INTERNAL REVENUE SERVICE CONSIDERS UNRELATED TO THE HOSPITAL'S EXEMPT PURPOSE AND, THEREFORE, TAXABLE. THESE ACTIVITIES, HOWEVER, ANNUALLY RESULT IN NET OPERATING LOSSES FOR INCOME TAX PURPOSES. THE HOSPITAL DOES NOT PRESENTLY ANTICIPATE THAT A TAX BENEFIT FROM THESE NET OPERATING LOSSES WILL BE REALIZED IN THE FUTURE. ACCORDINGLY, ANY POTENTIAL DEFERRED TAX ASSET RESULTING FROM THE AVAILABILITY OF NET OPERATING LOSS CARRYFOWARDS IS OFFSET BY A VALUATION ALLOWANCE OF EQUAL AMOUNT. NO DEFERRED TAX ASSETS AND LIABILITIES HAVE BEEN RECOGNIZED SINCE NO OTHER DIFFERENCE EXIST BETWEEN THE FINANCIAL AND TAX BASES OF REPORTING THE HOSPITAL'S ASSETS AND LIABILITIES. THE HOSPITAL'S POLICY IS TO RECOGNIZE INTEREST AND ANY PENALTIES RELATED TO INCOME TAX MATTERS IN INCOME TAX EXPENSE WHEN INCURRED. AS OF AND FOR THE YEARS ENDED SEPTEMBER 30, 2013 AND 2012, THERE WAS NO INCOME TAX EXPENSE, TAX PENALTIES, OR INTEREST RELATED TO TAX PENALTIES RECORDED BY THE HOSPITAL IN THE COMBINED FINANCIAL STATEMENTS. FEDERAL INCOME TAX RETURNS FOR THE YEAR ENDED SEPTEMBER 30, 2011, AND BEYOND REMAIN SUBJECT TO EXAMINATION BY THE INTERNAL REVENUE SERVICE. PART XI, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES 251,598. PART XI, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT EXPENSE 2,604,667. AUXILLARY EXPENSES 26,363. PART XII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES 251,598. PART XII, LINE 4B - OTHER ADJUSTMENTS: AUXILIARY EXPENSES 26,363. BAD DEBT EXPENSE 2,604,667. 1 1 1 X 1 X 1 1 1 1 1 1 622051 622051 0.01820 4982830 2479046 2503784 0.07330 95368 41856 53512 0.00160 5700249 2520902 3179347 0.09310 6 62543 62543 0.00180 6 62543 62543 0.00180 6 5762792 2520902 3241890 0.09490 4 34709 2280 32429 0.00090 2 194136 194136 0.00570 6 228845 2280 226565 0.00660 1 1093960 0 8126573 8039184 87389 X 1 1 1 1 COMMUNITY MEMORIAL HOSPITAL

855 SOUTH MAIN STREET OCONTO FALLS WI 54154

X X X X COMMUNITY MEMORIAL HOSPITAL INCORPORATED 1 1 X X X X X X 12 0 1 1 X X X X X X X X X X 0 0 1 1 200.000000000000 1 400.000000000000 1 X X X 1 1 X X 1 0 X X X X 1 X 0 0 5 CMH PRIMARY CARE CLINIC

340 NORTH GREEN BAY AVE GILLETT WI 54124

CLINIC CMH PRIMARY CARE CLINIC

200 SOUTH ROSERA STREET LENA WI 54139

CLINIC CMH MEDICAL CENTER

103 FIRST STREET OCONTO WI 54153

CLINIC CMH PRIMARY CARE CLINIC

14353 HWY 32/64 MOUNTAIN WI 54149

CLINIC CMH PRIMARY CARE CLINIC

913 E MAIN STREET SURING WI 54174

CLINIC PART I, LINE 6A: WISCONSIN HOSPITAL ASSOCIATION PART I, LINE 7: THE HOSPITAL UTILIZES THE IRS WORKSHEET TWO: RATIO OF PATIENT CARE COST TO CHARGES. 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 $ 2604667. PART II: THE HOSPITAL PROVIDES EDUCATION TO THE COMMUNITY MEMBERS ABOUT VARIOUS HEALTH ISSUES AT THE HEALTH FAIRS DONE THROUGHOUT THE COUNTY SUCH AS SKIN CANCER SCREENING, HEART FAIR, ETC. TO KEEP THE COMMUNITY AWARE OF HEALTH ISSUES AND HELP THEM BE PROACTIVE IN SEEKING TREATMENT FOR HEALTHCARE CONCERNS. PART III, LINE 4: BAD DEBTS WERE REPORTED ON THE FINANCIAL STATEMENTS AT GROSS CHARGES. THEN THE COST TO CHARGE RATIO WAS USED TO CONVERT THE BAD DEBT AMOUNT FROM A CHARGE BASED NUMBER TO A COST BASED NUMBER. PART III, LINE 8: THE MEDICARE PROGRAM DOES NOT COVER ALL SERVICES PROVIDED TO THEIR PARTICIPANTS AND THE HOSPITAL IS NOT ALLOWED TO COLLECT FROM THE PARTICIPANTS FOR SOME SERVICES BASED ON THE HOSPITAL'S AGREEMENT WITH THE PROGRAM. THEREFORE, NOT ALL REVENUES ARE COVERED BY MEDICARE. IN ADDITION, MEDICARE DOES NOT ALLOW ALL BUSINESS COSTS OF THE HOSPITAL TO BE INCLUDED IN THE COST REPORT, SO THERE ARE ADDITIONAL UNCOVERED COSTS. THE SHORTFALL BY THE MEDICARE PROGRAM COULD BE AVOIDED BY NOT PROVIDING CARE TO MEDICARE PATIENTS; THEREFORE, THIS SHORTFALL SHOULD BE INCLUDED AS A BENEFIT PROVIDED BY THE HOSPITAL.PART I, LINE 7: THE COSTING METHODOLOGY USED TO DETERMINE THE MEDICARE ALLOWABLE COST REPORT IS BASED ON THE AUDITED FINANCIAL STATEMENTS OF COMMUNITY MEMORIAL HOSPITAL AND THE HOSPITAL'S EXPENSING OF COSTS TO THE APPROPRIATE COST CENTER THROUGH THE HOSPITAL'S INTERNAL COMPUTER SYSTEM. PART III, LINE 9B: THE POLICY PROVIDES GENERAL MEANS OF DETERMINING ELIGIBILITY INCLUDING: INCOME LEVEL, ASSET LEVEL, MEDICAL INDIGENCY, INSURANCE STATUS, MEDICAID AND MEDICARE. PATIENTS ARE INFORMED OF THE CHARITY CARE PROGRAM UPON REGISTRATION. THOSE THAT THINK THEY MAY QUALIFY ARE GIVEN AN APPLICATION WHICH IS THEN REVIEWED AND DISCOUNTS ARE APPLIED TO THE ACCOUNT BASED ON FAMILY SIZE AND HOW THERE INCOME FALLS IN THE FEDERAL POVERTY GUIDELINES. COMMUNITY MEMORIAL HOSPITAL INCORPORATED PART V, SECTION B, LINE 3: PUBLIC OPINION SURVEY WAS CONDUCTED, WHICH WAS AVAILABLE ONLINE AT WWW.HEALTHYOCONOTOCOUNTY.INFO COMMUNITY MEMORIAL HOSPITAL INCORPORATED PART V, SECTION B, LINE 4: OCONTO HOSPITAL AND MEDICAL CENTER COMMUNITY MEMORIAL HOSPITAL INCORPORATED PART V, SECTION B, LINE 5C: WWW.HEALTHYOCONTOCOUNTY.INFO COMMUNITY MEMORIAL HOSPITAL INCORPORATED PART V, SECTION B, LINE 7: AS PART OF A LARGER COALITION, WE HAVE CREATED SUBTEAMS TO ADDRESS ALL NEEDS COMMUNITY MEMORIAL HOSPITAL INCORPORATED PART V, SECTION B, LINE 14G: PATIENTS VERBALLY INFORMED ABOUT POLICY DURING INPATIENT STAYS AND BEFORE SENDING ACCOUNTS TO COLLECTIONS. PART VI, LINE 2: DURING THE FISCAL YEAR, THE ORGANIZATION DEVELOPED A COUNTY WIDE INDIVIDUAL PUBLIC OPINION SURVEY, WHICH GENERATED 600 RESPONSES. THE RESPONSES WERE GATHERED FROM A VARIETY OF SOURCES, WHICH INCLUDED BUT WERE NOT LIMITED TO SCHOOLS, LAW ENFORCEMENT, HEALTHCARE PROVIDERS, CHURCHES, COUNTY AGENCIES, THE UNITED WAY, PUBLIC OFFICIALS, AND PUBLIC HEALTH DEPARTMENTS. THE VARIETY OF ORGANIZATIONS THAT RESPONDED ALLOWED THE ORGANIZATION TO APPROPRIATELY ASSESS THE HEALTH CARE NEEDS OF THE COMMUNITY. PART VI, LINE 3: WHEN A PATIENT CALLS TO REGISTER AND INDICATES ANY TYPE OF FINANCIAL HARDSHIP OR APPEARS TO REGISTER AND STATES LACK OF INSURANCE OR OTHER FINANCIAL HARDSHIP, THE PATIENT OR THEIR REPRESENTATIVE ARE GIVEN INFORMATION ABOUT THE HOSPITAL'S CHARITY CARE PROGRAM, INCLUDING AN INTRODUCTORY LETTER AND APPLICATION, AS WELL AS INFORMATION ON OTHER PUBLIC PROGRAMS THAT MAY BE AVAILABLE AND CONTACT INFORMATION FOR THOSE PROGRAMS. THE HOSPITAL IS ABLE TO EXPRESS ENROLL CHILDREN OR PREGNANT WOMEN IN STATE GOVERNMENT PROGRAMS AS WELL. THIS SAME INFORMATION IS PROVIDED AGAIN TO THE PATIENT AT THE TIME OF BILLING. PART VI, LINE 4: COMMUNITY MEMORIAL HOSPITAL SERVES GREATER OCONTO COUNTY. OCONTO COUNTY, WISCONSIN IS A LARGE, RURAL COUNTY WHICH INCLUDES MEDICALLY UNDERSERVED AREAS AND POPULATIONS AND WHICH CONSISTENTLY FACES ECONOMIC DEVELOPMENT CHALLENGES. RURAL: THE U.S. CENSUS BUREAU ESTIMATED THE 2010 OCONTO COUNTY POPULATION AT 37,660 PERSONS. ACCORDING TO THE U.S. CENSUS BUREAU, THE LARGEST CITY IN THE COUNTY HAD A 2000 POPULATION OF 4,708 AND THE COUNTY ITSELF HAD 37.7 PERSONS PER SQUARE MILE IN 2010. UNDERSERVED: OCONTO COUNTY CONTAINS MEDICALLY UNDERSERVED AREAS AS WELL AS PRIMARY CARE HEALTH PROFESSIONAL SHORTAGE AREAS AS DESIGNATED BY THE U.S. DEPT. OF HEALTH AND HUMAN SERVICES HEALTH RESOURCES AND SERVICES ADMINISTRATION. NINETEEN MEDICALLY UNDERSERVED AREAS ARE DESIGNATED WITHIN OCONTO COUNTY ACCORDING TO HRSA.THE ONLY OTHER HOSPITAL IN THE CMH SERVICE AREA IS A 4-BED HOSPITAL LOCATED IN OCONTO, THE COUNTY'S LARGEST CITY. OTHER HOSPITALS THAT SERVE THE OCONTO COUNTY COMMUNITY INCLUDING THE NEAREST TERTIARY CARE HOSPITALS ARE LOCATED THIRTY MILES SOUTH IN GREEN BAY.IN A COMMUNITY NEEDS ASSESSMENT SURVEY OF THE CMH SERVICE AREA CONDUCTED IN AUGUST 2007 BY THE LEEDE RESEARCH GROUP, THE LARGEST BARRIERS TO HEALTHCARE CITED BY COMMUNITY MEMBERS ARE FINANCIAL CONSTRAINTS, A LACK OF AFFORDABLE MEDICAL INSURANCE COVERAGE, AND GEOGRAPHICAL/TRANSPORTATION CONSTRAINTS THAT NEGATIVELY IMPACT ACCESS TO MEDICAL FACILITIES. OF THOSE SURVEYED, 30.1% INDICATED THAT LOCATION WAS THEIR PRIMARY CONSIDERATION WHEN SELECTING A DOCTOR AND/OR CLINIC. ACCORDING TO U.S. CENSUS BUREAU 2005-2009 DATA, IN OCONTO COUNTY THE PERCENTAGE OF PERSONS AGE 25 AND OLDER WITH A BACHELOR'S DEGREE OR HIGHER WAS 13.4% COMPARED TO 25.5.% STATEWIDE. PER CAPITA MONEY INCOME FOR THE COUNTY WAS $24,397 COMPARED TO $26,447 IN WISCONSIN. MEDIAN HOUSEHOLD INCOME FOR 2009 WAS $49,037 COMPARED TO $49,994 STATEWIDE. THE FEBRUARY 2012 UNEMPLOYMENT RATE FOR THE COUNTY WAS 9.3% COMPARED TO A STATEWIDE RATE OF 7.9% AND 8.7% NATIONALLY, ACCORDING TO THE STATE OF WISCONSIN DEPARTMENT OF WORKFORCE DEVELOPMENT. THE LATEST POVERTY DATA SHOWS OCONTO COUNTY WITH A POVERTY RATE OF 11.8%. CMH IS PROUD OF ITS COMMITMENT TO PROVIDE SERVICE TO ANY PERSON SEEKING MEDICAL CARE, REGARDLESS OF ABILITY TO PAY. THIS MAKES CMH A VERY SPECIAL PLACE IN TODAY'S HEALTHCARE MARKET. IN ADDITION, THE CMH FAMILY OF HEALTHCARE PROVIDERS HAS A LONG HISTORY OF WORKING COOPERATIVELY WITH LOCAL, STATE AND FEDERAL HEALTHCARE AGENCIES, EDUCATORS, INDUSTRY, AND THE GENERAL PUBLIC TO DEVELOP AND DELIVER EFFECTIVE HEALTHCARE SERVICES TO THE RURAL NORTHEAST WISCONSIN POPULATION. CMH IS DISTINGUISHED BY ITS RELIABLE AND CONSISTENT LEVEL OF SUPERIOR SERVICE AND COMMITMENT TO CONTINUOUS IMPROVEMENT OF ITS PATIENT CARE SERVICES. CMH MEDICAL STAFF MEMBERS ARE COMMITTED PARTNERS IN ENHANCING ORGANIZATIONAL PERFORMANCE AND CONTINUALLY WORKING TO IMPROVE PATIENT CARE. PART VI, LINE 5: THE COMMUNITY MEMORIAL HOSPITAL BOARD OF DIRECTORS CONSIST OF DEDICATED MEMBERS OF THE COMMUNITY WHO PROVIDE EXCEPTIONAL LEADERSHIP, INSIGHT AND POSITIVE DIRECTION IN THE ORGANIZATIONAL MISSION TO MEET THE HEALTHCARE NEEDS OF OUR COMMUNITY LOCALLY. A MAJORITY OF THE GOVERNING BODY IS COMPRISED OF PERSONS WHO RESIDE IN THE CMH PRIMARY SERVICE AREA. MEMBERS ARE STAKEHOLDERS IN THE COMMUNITIES SERVED BY COMMUNITY MEMORIAL HOSPITAL WHO PROVIDE DIRECTION AND SUPERVISION TO THE ORGANIZATION. A SIGNIFICANT PORTION OF THE GOVERNING BODY IS COMPRISED OF PERSONS WHO ARE NEITHER EMPLOYEES NOR CONTRACTORS OF COMMUNITY MEMORIAL HOSPITAL, NOR FAMILY MEMBERS THEREOF.AS A NON-PROFIT HEALTHCARE SYSTEM COMMUNITY MEMORIAL HOSPITAL INVESTS IN ITS SERVICES/PROGRAMS AND FACILITY/EQUIPMENT UPGRADES AND REINVESTS ANY PROFITS TO UPDATE OR ENHANCE THE HEALTHCARE SERVICE.CMH MAINTAINS AN OPEN MEDICAL STAFF, EXTENDING PRIVILEGES TO ALL QUALIFIED PHYSICIANS IN THE COMMUNITY FOR MEDICAL AND SURGICAL SERVICES PROVIDED AT THESE FACILITIES.IN ADDITION TO ITS REGULAR HOSPITAL AND CLINIC SERVICES, COMMUNITY MEMORIAL HOSPITAL PROVIDES THE COMMUNITY MANY OPPORTUNITIES TO RECEIVE LOW-COST AND FREE HEALTH SCREENINGS AND SERVICES. FOR EACH OF THESE FREE AND LOW-COST SERVICE OFFERINGS, COMMUNITY MEMORIAL HOSPITAL PROVIDED PLANNING, PUBLICITY, STAFF, EQUIPMENT, SUPPLIES, AND FACILITIES.COMMUNITY MEMORIAL HOSPITAL PROVIDES ITS COMMUNITY ROOM LARGE CONFERENCE ROOM AS WELL AS ITS OTHER MEETING AREAS FREE-OF-CHARGE TO COMMUNITY GROUPS. SOME OF THE MANY LOCAL GROUPS THAT MEET AT COMMUNITY MEMORIAL HOSPITAL INCLUDE 4H CLOVER, RELAY FOR LIFE, OVEREATERS ANONYMOUS, CEMETERY ASSOCIATION, WEIGHT WATCHERS, QUILTING GROUPS, THE COUNTY FAIR BOARD, THE COUNTY FAIREST OF THE FAIR COMMITTEE, UW EXTENSION, BREAST CANCER SUPPORT GROUP, AND THE OCONTO FALLS LIONESS CLUB.EXCESS FUNDS OF THE ORGANIZATION ARE BEING USED TO UPDATE THE TECHNOLOGY USED IN THE FACILITY TO PROVIDE UP TO DATE PATIENT CARE TO COMMUNITY MEMBERS AND TO ENHANCE THE SERVICES PROVIDED TO THE COMMUNITY. COMMUNITY MEMORIAL HOSPITAL HAS LONG BEEN A CORNERSTONE OF THE GREATER OCONTO COUNTY COMMUNITY AND PROVIDES AN ESSENTIAL SERVICE TO OCONTO COUNTY RESIDENTS. CMH IS PROUD OF ITS MISSION TO PROVIDE HIGH QUALITY HEALTH CARE CLOSE TO HOME, AND ALWAYS STRIVES TO STRENGTHEN ITS COMMUNITY PARTNERSHIPS TO PROMOTE HEALTH AND WELLNESS. PART VI, LINE 6: CMH IS AFFILIATED WITH ST. VINCENT & ST. MARY'S HOSPITALS AND PREVEA HEALTH. THE AFFILIATION ALLOWS CMH TO EXPAND HEALTH CARE RESOURCES AVAILABLE TO THE GREATER OCONTO COUNTY COMMUNITY. MORE SPECIALTY SERVICES ARE AVAILABLE AT CMH. THE ROLE OF CMH WITHIN THE AFFILIATION IS TO PROVIDE HOSPITAL AND CLINIC FACILITIES AND PERSONNEL, AND TO COLLABORATE WITH AFFILIATION PARTNERS TO IDENTIFY OPPORTUNITIES TO BETTER AND MORE EFFICIENTLY SERVE THE HEALTH CARE NEEDS OF THE COMMUNITY. THE ROLE OF ST. VINCENT & MARY' MARY'S HOSPITALS IS TO PROVIDE MANAGEMENT COLLABORATION, ADMINISTRATIVE SUPPORT, AND CAPITAL INVESTMENT WHICH SUPPORTS EMR. THE ROLE OF PREVEA HEALTH IS TO ASSIST CMH IN EXPANDING THE AVAILABILITY OF PHYSICIAN SPECIALISTS IN THE CMH SERVICE AREA. REPORTS FILED WITH STATES PART VI, LINE 7 WI X X 0 0 0 0 0 0 0 0 0 DR ISAIAS CUPINO 386910 0 106639 0 276 0 0 0 22779 0 516604 0 0 0 DR GENADI MALTINSKI 347950 0 0 0 0 0 0 0 0 0 347950 0 0 0 DANIEL DEGROOT 174938 0 0 0 276 0 0 0 0 0 175214 0 0 0 DR KEITH ELKINS 341470 0 54759 0 180 0 0 0 2516 0 398925 0 0 0 DR THOMAS KNUTSON 175762 0 3293 0 792 0 0 0 21503 0 201350 0 0 0 DR R SCOTT LIEBL 386295 0 0 0 43374 0 0 0 23091 0 452760 0 0 0 DR DOUGLAS GREMBAN 193590 0 27771 0 792 0 0 0 23091 0 245244 0 0 0 DR LUZ BALMADRID 248985 0 39348 0 3161 0 0 0 18437 0 309931 0 0 0 A WISCONSIN HEALTH AND EDUCATIONAL FACILITIES AUTHORITY 391337855 NONEAVAIL 2013-04-16 9053000 REFINANCING, CONSTRUCTION, IMPORVEMENT, AND EQUIPING HOSPITAL FACILITIES 0 0 0 A 143000 9053000 30747 180472 1681913 2012 1 0 1 1 A 0 1 0 0 0 0 1 A 0 1 0 0 0 0 0 0 0 A 1 FORM 990, PART VI, SECTION B, LINE 11 AS THE FILING DATE OF THE FORM 990 IS GOING TO FALL BEFORE THE NEXT BOARD MEETING, THE FORM WILL BE PRESENTED TO THE BOARD AT THE MOST RECENT BOARD MEETING FOLLOWING THE DATE OF FILING BY THE CFO. THE FORM 990 IS REVIEWED BY MANAGEMENT PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C A CONFLICT OF INTEREST DISCLOSURE STATEMENT IS DISTRIBUTED TO BOARD MEMBERS AND OFFICERS FOR REVIEW AND SIGNATURE EACH YEAR. THIS PROCESS COMPLETED ANNUALLY IN JANUARY. UPON DISCLOSURE OF ANY CONFLICTS, THE BOARD MEMBER OR THE OFFICER MAKING SUCH DISCLOSURE SHALL LEAVE THE BOARD OR COMMITTEE MEETING WHILE THE FINANCIAL INTEREST IS DISCUSSED AND VOTED UPON. THE REMAINING BOARD OR COMMITTEE MEMBERS SHALL DECIDE IF A CONFLICT OF INTEREST EXISTS. THE CHAIRMAN OF THE BOARD WILL IF APPROPRIATE, APPOINT A DISINTERESTED PERSON OR COMMITTEE TO INVESTIGATE ALTERNATIVES TO THE PROPOSED TRANSACTION OR ARRANGEMENT. AFTER EXERCISING DUE DILIGENCE, DETERMINE WHETHER CMH CAN OBTAIN A MORE ADVANTAGEOUS TRANSACTION OR ARRANGEMENT FROM A PERSON OR ENTITY THAT WOULD NOT GIVE RISE TO A CONFLICT OF INTEREST. IF A MORE ADVANTAGEOUS TRANSACTION OR ARRANGEMENT IS NOT REASONABLY ATTAINABLE, THE BOARD OR CEO SHALL DETERMINE WHETHER THE TRANSACTION OR ARRANGEMENT IS IN CMH'S BEST INTEREST, IS FOR CMH'S OWN BENEFIT, AND IS FAIR AND REASONABLE TO CMH AND SHALL MAKE ITS DECISION AS TO WHETHER TO ENTER INTO THE TRANSACTION OR ARRANGEMENT IN CONFORMITY WITH SUCH DETERMINATION. FORM 990, PART VI, SECTION B, LINE 15 MGMA SURVEY DATA AND A POSITION REVIEW PROCESS IS DONE BY THE PERSON THE INDIVIDUAL REPORTS TO. THE INFORMATION IS THEN PRESENTED TO THE BOARD OF DIRECTORS, AN INDEPENDENT PARTY, AT THEIR MONTHLY MEETING FOR THEIR FINAL APPROVAL. DECISIONS MADE AT THE BOARD OF DIRECTORS MEETINGS ARE DOCUMENTED. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION CURRENTLY DOES NOT MAKE ITS GOVERNING DOCUMENTS AND CONFLICT ON INTEREST POLICY AVAILABLE TO THE PUBLIC AT THIS TIME. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 9: CHANGE IN INTEREST IN COMMUNITY HEALTHCARE FOUNDATION -43,481. FORM 990, PART XII, LINE 2C: THIS PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. COMMUNITY HEALTHCARE FOUNDATION 855 SOUTH MAIN STREET OCONTO FALLS WI 54154 391700944 FUNDRAISING FOR LOCAL NONPROFIT ORGNAIZATIONS WI 501(C)(3) LINE 7 COMMUNITY MEMORIAL HOSPITAL INC 1 CMH HOUSING INC 855 SOUTH MAIN STREET OCONTO FALLS WI 54154 391586706 ELDERLY AND HANDICAPPED HOUSING WI 501(C)(3) LINE 9 COMMUNITY MEMORIAL HOSPITAL INC 1 0 0 1 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 0 COMMUNITY HEALTHCARE FOUNDATION C 100000 FMV