2014-05-14T15:10:57-05:00 2013-06-30 390758449 WIPFLI LLP PO BOX 12237 GREEN BAY WI 543072237 990 2012-07-01 390807236 AGNESIAN HEALTHCARE INC AGNE 9209262300 430 EAST DIVISION ST FOND DU LAC WI 53935 BONNIE SCHMITZ 9209262300 2014-05-13 1 TERRI REXRODE CPA MST P00096513 9206620016 2014-05-13 2012 2015-11-30 17:44:51Z STEVEN LITTLE CEO 430 EAST DIVISION ST FOND DU LAC WI 53935 397721644 0 1 0928 X WWW.AGNESIAN.COM X 1892 WI AGNESIAN HEALTHCARE IS A LOCALLY-BASED, INTEGRATED HEALTHCARE SYSTEM WHICH BEGAN ITS MISSION IN 1892. THE SYSTEM IS COMPRISED OF SEVEN MINISTRIES - ST. AGNES HOSPITAL, WAUPUN MEMORIAL HOSPITAL, RIPON MEDICAL CENTER, ST. FRANCIS HOME, FOND DU LAC REGIONAL CLINIC, CONSULTANTS LABORATORY OF WISCONSIN, AND AGNESIAN HEALTHCARE ENTERPRISES. AGNESIAN PROVIDES A CONTINUUM OF HEALTHCARE SERVICES FROM BIRTH TO END OF LIFE, PREVENTIVE HEALTHCARE DIAGNOSIS, TREATMENT AND FOLLOWUP, ASSISTED LIVING, AND INDEPENDENT SKILL CARE SERVICES. 16 12 3230 630 5698765 598454 0 0 303846638 309916813 4671883 8489027 15415062 15364161 323933583 333770001 0 0 0 0 131086985 136508008 0 0 0 173115111 173932625 304202096 310440633 19731487 23329368 405106873 470805863 179598113 208582531 225508760 262223332 X THE MISSION OF AGNESIAN HEALTHCARE IS TO PROVIDE COMPASSIONATE CARE THAT BRINGS HOPE, HEALTH AND WHOLENESS TO THOSE WE SERVE BY HONORING THE SACREDNESS AND DIGNITY OF ALL PERSONS AT EVERY STAGE OF LIFE. WE ARE ROOTED IN THE HEALING MINISTRY OF THE CATHOLIC CHURCH AS WE CONTINUE THE MISSION OF OUR SPONSOR, THE CONGREGATION OF SISTERS OF ST AGNES. 0 0 205719455 293043925 AGNESIAN HEALTHCARE OPERATES ST. AGNES HOSPITAL, A 160-BED GENERAL/SURGICAL ACUTE CARE HOSPITAL WHICH PROVIDES INPATIENT AND OUTPATIENT SERVICES TO RESIDENTS OF FOND DU LAC AND THE SURROUNDING COUNTIES. DURING FISCAL YEAR 2013, ST. AGNES HOSPITAL HAD 6,899 INPATIENT ADMISSIONS, WITH TOTAL PATIENT DAYS OF 28,468. THERE WAS A TOTAL OF 28,016 EMERGENCY ROOM VISITS AND 12,880 SURGERIES PERFORMED IN FY13. IN ADDITION, ST. AGNES HOSPITAL PROVIDED 402,034 PHYSICIAN CLINIC VISITS, 106,379 MEDICAL IMAGING PROCEDURES, AND 1,305,390 PHYSICAL, OCCUPATIONAL AND SPEECH THERAPY UNITS. THERE WERE 1,614 CARDIAC CATH LAB VISITS AND 41,558 HOSPICE DAYS. THE HOSPITAL ALSO OPERATES SAMARITAN CLINIC, A FREE CLINIC OFFERING MEDICAL SERVICES TO QUALIFIED INDIVIDUALS. SAMARITAN CLINIC PROVIDED 5,018 VISITS TO PATIENTS, AT A COST OF $686,304 FOR FY13. THE HOSPITAL MAINTAINS RECORDS TO IDENTIFY AND MONITOR THE LEVEL OF CHARITY IT PROVIDES TO ITS PATIENTS. THE COST OF SERVICES AND SUPPLIES FURNISHED UNDER THE HOSPITAL'S CHARITY CARE POLICY WAS $3,432,216. IN ADDITION TO QUALITY HEALTH CARE SERVICES, ST. AGNES HOSPITAL PROVIDES ITS COMMUNITIES WITH EDUCATION, SUPPORT GROUPS AND OTHER COMMUNITY BENEFITS. THE NET COST OF THESE COMMUNITY BENEFITS WAS $3,562,857. 13011665 16373861 AGNESIAN HEALTHCARE OPERATES CONSULTANTS LABORATORY OF WISCONSIN, AN INDEPENDENT REFERENCE LAB SERVING FOND DU LAC, DODGE, OUTAGAMIE, WINNEBAGO AND COLUMBIA COUNTIES. CLW PROVIDED 1,142,773 TESTS DURING FISCAL YEAR 2013. THE LABORATORY ALSO PROVIDES THE COMMUNITY WITH CAREER EDUCATION, CONTRIBUTIONS AND SERVICES TO SAMARITAN CLINIC. THE NET COST OF THESE COMMUNITY BENEFITS WAS $330,846. THE COST OF SERVICES AND SUPPLIES FURNISHED UNDER THE CHARITY CARE POLICY WAS $129,221. 6775122 8978648 AGNESIAN HEALTHCARE OPERATES AGNESIAN ENTERPRISES, WHICH IS COMPRISED OF EIGHT PHARMACIES SERVING FOND DU LAC AND SURROUNDING TOWNS, AS WELL AS AGNESIAN HEALTH SHOPPE, WHICH SERVES THE POPULATION WITH HOSPITAL (INPATIENT AND OUTPATIENT), CLINIC AND HOME HEALTH EQUIPMENT. AGNESIAN ENTERPRISES FILLED 434,971 PRESCRIPTIONS DURING FY13. AGNESIAN HEALTH SHOPPE PROVIDES RETAIL SALES OF DURABLE MEDICAL EQUIPMENT, AS WELL AS TELECARE AND HOME OXYGEN SERVICES. THE COST OF SERVICES AND SUPPLIES FURNISHED UNDER AHE'S CHARITY CARE POLICY WAS $15,000. AGNESIAN HEALTHCARE ENTERPRISES CONTRIBUTES TO COMMUNITY BENEFIT WITH SEVERAL SUPPORT GROUPS. THE COST OF COMMUNITY BENEFIT WAS $3,181. 225506242 1 0 0 1 0 0 0 0 0 1 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 1 1 0 0 0 0 1 1 1 0 0 0 1 281 0 1 3230 1 1 1 1 CJ 0 0 0 0 0 0 0 0 X 16 12 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 1 1 X LESLIE STEPHANY 9209264512 430 EAST DIVISION STREET FOND DU LAC WI 54935 STEVEN N LITTLE 50.00 X X 764859 0 35201 SR MARY NOEL BROWN 1.00 X 0 0 0 JAMES R CHATTERTON 1.00 X X 0 0 0 DENISE DEVERAUX 1.00 X 0 0 0 JOAN KARSTEN 1.00 X 0 0 0 SR ANN KOERNER 1.00 X 0 0 0 SR HERTHA LONGO 1.00 X 0 0 0 STEPHEN MASSICK MD 1.00 X 0 0 0 WAYNE MATZKE 1.00 X X 0 0 0 ROBERT MIKKELSON MD 1.00 X 0 0 0 H JACK POLLEI 1.00 X 10042 0 0 JOSEPH REITEMEIER 1.00 X X 0 0 0 JAMES B SIMON 1.00 X X 4859 0 0 MICHAEL STRINGENZ MD 1.00 X 0 0 0 JEFFERY STRONG MD 1.00 X 0 0 0 DR JUDITH WESTPHAL 1.00 X 0 0 0 ALLAN MILANI MD 1.00 X 464776 0 24695 JAMES P MUGAN 50.00 X 345315 0 38946 BONNIE SCHMITZ 50.00 X 296640 0 22465 DENNIS YUNK 50.00 X 274980 0 29865 CAROL B HYLAND 50.00 X 263848 0 31734 DOUGLAS D TROST 50.00 X 220682 0 30136 SR MARY MOLLISON 50.00 X 214662 0 9271 BARBARA LKNUTZEN 50.00 X 205693 0 25899 SUSAN L EDMINSTER 50.00 X 202817 0 18660 NANCY A BIRSCHBACH 50.00 X 175189 0 31367 JILL A STENSON 50.00 X 172491 0 17170 JOHN CHOI MD 50.00 X 983914 0 31933 YASIR HATAHET MD 50.00 X 855374 0 40652 PONTUS OSTMAN MD 50.00 X 801295 0 15985 HONG C WANG MD 50.00 X 595869 0 32562 STEVEN FLURRY MD 50.00 X 588271 0 30910 ROBERT A FALE 40.00 X 478292 0 13172 7919868 0 480623 140 1 1 0 FOND DU LAC REGIONAL CLINIC 420 E DIVISION ST FOND DU LAC WI 54935 PHYSICIAN SERVICES 51442636 CERNER CORP 2800 ROCKCREEK PKWY KANSAS CITY MO 64141 COMPUTER SERVICES 8678458 IBM CORPORATION 1 NEW ORCHARD RD ARMONK NY 105041722 COMPUTER SERVICES 8534858 CD SMITH CONSTRUCTION PO BOX 1066 FOND DU LAC WI 54935 CONSTRUCTION 5686980 AMERICAN HEALTHCARE SERVICES PO BOX 945 TRAVERSE CITY MI 49685 TEMPORARY STAFFING 1304382 67 NET PATIENT SERVICE REVENUE 621400 194037946 192099590 1938356 MEDICARE/MEDICAID SERVICE REVENUE 621400 115878867 115878867 309916813 5256125 5256125 95081 95081 46130252 73305 43046860 18876 3083392 54429 3137821 3137821 30494468 20885907 9608561 5873295 3735266 WORK INJURY - SAH 592512 1324359 1324359 CAFETERIA SALES 900099 1210918 25143 1185775 CLINIC REIMBURSEMENT 621110 755420 755420 2464903 2464903 5755600 333770001 318396434 5698765 9674802 X 4095145 464776 3630369 114954178 94463873 20490305 6015311 4517887 1497424 3628363 252831 3375532 7815011 6028072 1786939 240776 1148 239628 136671 136671 617224 617224 61656928 58697102 2959826 1481765 46782 1434983 49182521 45611264 3571257 25461758 8391 25453367 5235834 1667992 3567842 630701 520703 109998 676277 459521 216756 4473513 4473513 12972000 5766957 7205043 2329696 1303959 1025737 HOSPITAL ASSESSMENT TAX 5151952 5151952 MISCELLANEOUS EXPENSES 2284053 236657 2047396 LOSS ON DEFEASANCE OF B 734929 734929 DUES, SUBSCRIPTIONS AND 666027 306375 359652 310440633 225506242 84934391 0 5837093 8477558 8935657 13801713 44502314 48131908 4857997 4643411 2612600 2771241 305678988 158229944 136806603 147449044 146174087 169914673 55380522 75616315 405106873 470805863 27123150 31020630 125173728 142479805 27301235 35082096 179598113 208582531 X 212398409 251329672 10649139 8737112 2461212 2156548 225508760 262223332 405106873 470805863 X 23329368 6047675 50848 7286681 X 0 1 X 1 0 X 0 0 0 0 0 0 0 0 1 16982 16982 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: OTHER LOBBYING ACTIVITIES: LOBBYING PORTION OF WHA AND AHA DUES. 1004976 57144 40000 2733 1019387 992140 15366 2530 1004976 996299 48126 50000 2285 992140 1020134 23156 45000 1991 996299 1014822 45000 -37548 2140 1020134 1.00000 0 1 1 6165464 6165464 145319866 59666962 85652904 2958597 1161294 1797303 137204580 97401688 39802892 14030481 14030481 147449044 DUE FROM AFFILIATED ENTITIES 1628018 LONG-TERM DEBT FROM AFFILIATED ENTITY 5000000 INVESTMENT - MERCURY CLINIC 3005130 INVESTMENT - SAH FOUNDATION 9833328 OTHER RECEIVABLES 800795 BOND DEFERRED FINANCING COSTS 1163208 ASSETS WHOSE USE IS LIMITED - BOND FUNDS 26345637 ASSETS WHOSE USE IS LIMITED - PHYSICIAN SUPPLEMENTAL BENEFIT PLAN 24936423 MISCELLANEOUS RECEIVABLES 2228137 DUE FROM FOUNDATION 675639 75616315 CAPITAL LEASE PAYABLE 7565556 PHYSICIANS SUPPLEMENTAL BENEFIT PLAN 24228143 FUND BAL SWAP MKT ADJUSTMENT 2055151 DUE TO MEDICARE/MEDICAID 310385 EXECUTIVE DEFERRED COMPENSATION PLAN 708280 LAND CONTRACT - FAMILY FOOT CLINIC 214581 35082096 X DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: AGNESIAN HEALTHCARE, INC. HOLDS AN ENDOWMENT FROM THE CONGREGATION OF THE SISTERS OF ST. AGNES. THE ORIGINAL ENDOWMENT OF $1,000,000 IS PERMANENTLY RESTRICTED. INCOME GENERATED FROM THE ENDOWMENT IS UNRESRICTED AND TO BE USED AT THE DISCRETION OF THE CHIEF EXECUTIVE OFFICER TO FUND PROGRAMS SUCH AS DOMESTIC VIOLENCE, CHARITY CARE, ETC. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X, LINE 2: IN ORDER TO ACCOUNT FOR ANY UNCERTAIN TAX POSITIONS, ASC TOPIC 740-10, ACCOUNTING FOR UNCERTAINTY IN INCOME TAXES, REQUIRES AN ORGANIZATION TO ASSESS 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 THE TAX POSITION IS NOT RECOGNIZED IN THE FINANCIAL STATEMENTS. AGNESIAN HEALTHCARE, INC. RECORDED NO ASSETS OR LIABILITIES FOR UNCERTAIN TAX POSITIONS OR UNRECOGNIZED TAX BENEFITS. FEDERAL RETURNS FOR THE YEARS ENDED 2010, 2011, AND 2012 REMAIN SUBJECT TO EXAMINATION BY THE INTERNAL REVENUE SERVICE. 1 1 X 1 X 165.000000000000 1 X 1 1 1 0 1 1 3576437 3576437 0.01150 11380592 11380592 0.03670 14957029 14957029 0.04820 1205960 74381 1131579 0.00360 465729 465729 0.00150 853790 853790 0.00280 1559 1559 0.00000 1222756 1222756 0.00390 3749794 74381 3675413 0.01180 18706823 74381 18632442 0.06000 987 987 0.00000 3988 3988 0.00000 1215 1215 0.00000 5240 5240 0.00000 20029 20029 0.00010 136 136 0.00000 152194 152194 0.00050 37682 37682 0.00010 221471 221471 0.00070 1 15298309 0 102118000 137871622 -35753622 X 1 1 1 1 ST AGNES HOSPITAL

430 E DIVISION STREET FOND DU LAC WI 54935

X X X ST AGNES HOSPITAL 1 1 X X X X X X X X X 12 1 1 1 X X X X X X X X X X X X 1 0 1 1 165.000000000000 1 300.000000000000 1 X X X X X 1 1 X X X X X 1 X X 0 X X X X 1 X 0 1 3 FOND DU LAC REGIONAL CLINIC

420 E DIVISION STREET FOND DU LAC WI 54935

OUTPATIENT PHYSICIAN CLINIC CONSULTANTS LAB OF WISCONSIN LLC

430 E DIVISION STREET FOND DU LAC WI 54935

LABORATORY AND TESTING AGNESIAN HEALTHCARE ENTERPRISES LLC

430 E DIVISION STREET FOND DU LAC WI 54935

PHARMACEUTICALS, HOME HEALTH, MEDICAL SUPPLIES PART I, LINE 6A: AN ANNUAL COMMUNITY BENEFIT REPORT IS COMPLETED BY THE FINANCE DEPARTMENT AND DISTRIBUTED TO THE PUBLIC THROUGH THE PUBLIC RELATIONS OFFICE OF AGNESIAN HEALTHCARE, INC. PART I, LINE 7: A COST-TO-CHARGE RATIO WAS USED TO COMPUTE COST OF COMMUNITY BENEFIT SERVICES. OVERALL COSTS LESS TAXES WERE DIVISIBLE BY TOTAL CHARGES. PART I, LINE 7G: SUBSIDIZED HEALTH SERVICES INCLUDES SAMARITAN CLINIC, A CLINIC OFFERING FREE MEDICAL SERVICES TO QUALIFIED INDIVIDUALS. SAMARITAN CLINIC COSTS WERE $686,304 FOR FISCAL YEAR 2013. THE SAMARITAN HEALTH CLINIC PROVIDES PATIENTS WITH IMPORTANT BASIC HEALTH SERVICES, MEDICATIONS AND URGENT DENTAL NEEDS AT NO CHARGE TO THE PATIENT. PART I, L7 COL(F): BAD DEBT EXPENSES INCLUDED ON FORM 990, PART VIII, LINE 2 WAS $15,298,309 AND WAS EXCLUDED FROM THE DENOMINATOR PER INSTRUCTIONS. PART II, LINE 8 WORKFORCE DEVELOPMENT INCLUDES JOB SHADOWING, CAREERS CAMP, AND THE HEALTHCARE YOUTH APPRENTICE PROGRAM. THESE PROGRAMS ALLOW STUDENTS AND OTHERS TO LEARN ABOUT DIFFERENT OCCUPATIONS IN THE HEALTHCARE INDUSTRY BY BECOMING CERTIFIED AND GAINING ACTUAL WORK EXPERIENCE. THE PROGRAMS ALSO PROMOTE THESE STUDENTS TO BRING VALUABLE HEALTHCARE KNOWLEDGE BACK TO THEIR FAMILIES AND THE COMMUNITY. 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 CHARGE TO CONTRACTUAL ADJUSTMENTS AND A CREDIT TO THE ALLOWANCE FOR CONTRACTUAL ADJUSTMENTS. IN ADDITION, MANAGEMENT PROVIDES FOR PROBABLE UNCOLLECTIBLE AMOUNTS, PRIMARILY FROM 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 ACCOUNTS RECEIVABLE. THE COSTING METHODOLOGY FOR DETERMINING BAD DEBTS IS A COST TO CHARGE RATIO. PART III, LINE 8: MEDICARE SHORTFALL IS NOT TREATED AS A COMMUNITY BENEFIT. TO ARRIVE AT COST OF MEDICARE SERVICES, THE TOTAL EXPENSE LESS OTHER OPERATING REVENUE IS MULTIPLIED BY THE RATIO OF MEDICARE REVENUE TO TOTAL REVENUE.ALTHOUGH MEDICARE SHORTFALL HAS NOT BEEN REPORTED AS A COMMUNITY BENEFIT, IT SHOULD BE TREATED AS A COMMUNITY BENEFIT BECAUSE IT PROMOTES ACCESS TO HEALTHCARE TO THE UNDERSERVED ELDERLY POPULATION, WHO WOULD NOT HAVE ACCESS TO LOCAL CARE IF WE WERE NOT ABLE TO SERVE THEM. ALTHOUGH OUR HOSPITAL IS EFFICIENTLY OPERATED, THE CALCULATIONS USED FOR MEDICARE REIMBURSEMENT DO NOT ALLOW FOR PAYMENTS THAT COVER COSTS OF NECESSARY SERVICES. PART III, LINE 9B: A ZERO DOLLAR AMOUNT WAS ESTIMATED FOR THE AMOUNT OF BAD DEBTS ATTRIBUTABLE TO PATIENTS WHO WOULD QUALIFY FOR FINANCIAL ASSISTANCE. IF PATIENTS QUALIFY, THEIR EXPENSES ARE RECLASSIFIED AS CHARITY CARE. PATIENTS WHO RECEIVED A COLLECTION NOTICE COULD APPLY FOR CHARITY CARE. IF THEIR APPLICATION IS APPROVED, THIS WOULD TRIGGER A TRANSFER OF EXPENSES FROM BAD DEBT TO CHARITY CARE. PART III, LINE 9A AGNESIAN HEALTHCARE, INC. HAS A WRITTEN DEBT COLLECTION POLICY. PAYMENT IS DUE WITHIN 30 DAYS OF RECEIPT OF A STATEMENT. IF PATIENTS DO NOT SET UP ACCEPTABLE PAYMENT ARRANGEMENTS, BILLS WILL BE REFERRED TO AN OUTSIDE COLLECTION AGENCY. FINANCIAL COUNSELORS WORK WITH ALL PATIENTS ON AN INDIVIDUAL BASIS AND MAY OFFER EXTENDED MONTHLY PAYMENTS WITHOUT INTEREST BASED ON DOLLAR AMOUNT, PRIVATE PAY DISCOUNTS (INDIVIDUALS WHO DO NOT HAVE INSURANCE COVERING EMERGANCY OR OTHER MEDICALLY NECESSARY CARE ARE BILLED AT A REDUCED RATE), OR GUARANTEED BANK LOANS. ST. AGNES HOSPITAL PART V, SECTION B, LINE 3: THE CHNA WAS COMMISSIONED BY THE FDL COMMUNITY HEALTH ASSESSMENT TASK FORCE, WHICH INCLUDED EXECUTIVES FROM THE FOLLOWING ORGANIZATIONS: FDL AREA BUSINESS ON HEALTH, FDL COUNTY HEALTH DEPT, FDL YMCA, AGNESIAN HEALTHCARE, FDL AREA UNITED WAY, FDL SCHOOL DISTRICT, WAUPUN MEMORIAL HOSPITAL, RIPON MEDICAL CENTER, AND AURORA HEALTHCARE. THE TASK FORCE REVIEWED COUNTY AND STATE SPECIFIC DISEASE INCIDENCE AND DEATH DATA, AS WELL AS ECONOMIC, DEMOGRAPHIC, AND HEALTH STATUS DATA. TO SUPPLEMENT THIS DATA, COMMUNITY AND STAKEHOLDER OPINION SURVEYS WERE CONDUCTED TO DETERMINE WHAT PEOPLE IN FDL COUNTY PERCEIVED AS THE MAJOR HEALTH PROBLEMS IN THE COUNTY. COMMUNITY MEMBERS WERE SCIENTIFICALLY SELECTED SO THAT THE SURVEY WOULD BE REPRESENTATIVE OF ALL ADULTS 18 YEARS OLD AND OLDER. A TOTAL OF 800 TELEPHONE INTERVIEWS WERE COMPLETED WITH COMMUNITY MEMBERS. IN ADDITION, SURVEYS WERE CONDUCTED AMONG FDL COUNTY STAKEHOLDERS. STAKEHOLDERS WERE DEFINED AS PEOPLE WHO WERE INVOLVED WITH HUMAN RESOURCE ISSUES SUCH AS BENEFITS, INSURANCE, SICK TIME OR DISABILITY ISSUES AS WELL AS PEOPLE WHO WERE INVOLVED WITH OR AWARE OF THE HEALTH ISSUES RESIDENTS AND FAMILIES FACE THROUGH THEIR PLACE OF WORK OR VOLUNTEER RELATIONSHIPS. A TOTAL OF 84 SURVEYS WERE COMPLETED AMONG STAKEHOLDERS. AFTER COMPLETION OF THE CHNA, THE FOND DU LAC COUNTY HEALTHY 2020 COALITION WAS FORMED TO ADDRESS THE NEEDS IDENTIFIED IN THE CHNA. THE HEALTHY 2020 STEERING COMMITTEE INCLUDES THE FOLLOWING MEMBERS: GREGG BREWER, AGNESIAN HEALTHCARE EMPLOYEE ASSISTANCE PROGRAM DIRECTOR JEFF BUTZ, WELLNESS DIRECTOR OF FOND DU LAC AREA BUSINESS ON HEALTH, AN EMPLOYER-OWNED BUSINESS COALITION FOCUSING ON HEALTH; DIANE CAPPOZZO, RN, FOND DU LAC COUNTY HEALTH DEPARTMENT NURSE; DR STEVE DI SALVO, PRESIDENT, MARIAN UNIVERSITY; ERIN GERRED, FDL COUNTY DIRECTOR OF ADMINISTRATION; GREG GILES, FDL FAMILY YMCA EXECUTIVE DIRECTOR; BILL LAMB, CHIEF OF POLICE, FDL CITY POLICE DEPARTMENT; STEVE LITTLE, CEO, AGNESIAN HEALTHCARE; SR. MARY MOLLISON, VP OF CARE TRANSITION, AGNESIAN HEALTHCARE; WARREN POST, MD, FDL BOARD OF HEALTH MEDICAL DIRECTOR; TINA POTTER, FDL AREA UNITED WAY EXECUTIVE DIRECTOR; SANDI ROEHRIG, FDL AREA FOUNDATION EXECUTIVE DIRECTOR; MARTY RYAN, ROTARY REPRESENTATIVE; KEVIN SHAW, ST. MARY'S SPRINGS ACADEMY PRESIDENT; MARIAN SHERIDAN, FDL SCHOOL DISTRICT HEALTH AND SAFETY COORDINATOR; MICHELLE TIDEMANN, FDL COUNTY UW-EXTENSION; DEANN THURMER, COO, WAUPUN MEMORIAL HOSPITAL; KATHERINE VERGOS, COO, RIPON MEDICAL CENTER; JENNIFER WALTERS, MANAGER OF GROWTH AND MARKET DEVELOPMENT, AURORA HEALTHCARE. THE HEALTHY 2020 COMMITTEE HAS TAKEN THE LEAD ON DISTRIBUTION OF INFORMATION TO THE PUBLIC, AS WELL AS CONTINUING COMMUNITY UPDATES AND ASSESSMENT OF PROGRESS. ST. AGNES HOSPITAL PART V, SECTION B, LINE 4: HOSPITALS INCLUDED IN THE CHNA WERE AGNESIAN HEALTHCARE (ST. AGNES HOSPITAL), WAUPUN MEMORIAL HOSPITAL AND RIPON MEDICAL CENTER. ST. AGNES HOSPITAL PART V, SECTION B, LINE 5C: IN ADDITION TO THE HOSPITAL'S WEBSITE, THE HEALTHY 2020 COALITION MADE THE RESULTS OF THE CHNA WIDELY AVAILABLE THROUGH A SERIES OF COMMUNITY MEETINGS, DISTRIBUTION OF COMMUNITY HEALTH IMPROVEMENT PLAN FLYERS, NEWSPAPER ARTICLES, AND THE HEALTHY 2020 WEBSITE, WWW.LIVINGWELLFDL.ORG. IN ADDITION, THE FULL REPORT IS AVAILABLE ON THE FOND DU LAC COUNTY WEBSITE. ST. AGNES HOSPITAL PART V, SECTION B, LINE 6I: AS A RESULT OF THE CHNA, FOUR MAJOR AREAS OF CONCERN WERE DETERMINED, AND A STRATEGIC ACTION PLAN HAS BEEN DEVELOPED FOR EACH AREA. (1) INCREASE THE NUMBER OF FDL COUNTY RESIDENTS WHO ARE AT A HEALTHY WEIGHT - AGNESIAN HEALTHCARE HAS COLLABORATED WITH THE YMCA BY HIRING AND PROVIDING FUNDING FOR A WELLNESS COORDINATOR FOR OUTREACH INTO THE COMMUNITY. THE WELLNESS COORDINATOR IS DEVELOPING AND IMPLEMENTING A COMMUNITY EDUCATION CAMPAIGN ON HEALTHY EATING AND ACTIVE LIVING, INCLUDING THE 5,2,1,0 CAMPAIGN IN THE SCHOOL DISTRICT. (2) INCREASE DENTAL CARE ACCESS FOR CHILDREN AND ADULTS WITH MEDICAID - AGNESIAN HEALTHCARE HAS PROVIDED FUNDING TO FOND DU LAC COUNTY TO EXTEND THEIR PROGRAM TO PROVIDE DENTAL CARE TO ADULTS WHO DO NOT CURRENTLY HAVE ACCESS TO DENTAL CARE. IN ADDITION, AGNESIAN HEALTHCARE HAS PROVIDED FUNDING TO THE SAVE A SMILE INITIATIVE, WHICH PROVIDES ACCESS TO DENTAL CARE FOR CHILDREN UTILIZING THE MEDICAID PROGRAM. (3) IMPROVE MENTAL HEALTH ACCESS - AGNESIAN HEALTHCARE ASSOCIATES ARE PARTICIPATING ON A COMMUNITY-WIDE TASK FORCE TO PROVIDE EDUCATIONAL PROGRAMS TO DECREASE THE STIGMA SURROUNDING MENTAL HEALTH ISSUES. AGNESIAN HEALTHCARE IS PARTNERING WITH THE YMCA TO PROVIDE CITY AND COUNTY EVENTS AND EDUCATION. FUNDING HAS ALSO BEEN PROVIDED TO SHARDS, A MENTAL HEALTH PROVIDER WHICH PROVIDES MENTAL HEALTH COUNSELING TO THOSE WITHOUT INSURANCE. (4)DECREASE BINGE DRINKING AND OVER-CONSUMPTION OF ALCOHOL AMONG YOUTH AND ADULTS - AGNESIAN HEALTHCARE HAS PARTICIPATED ON A TASK FORCE TO ASSIST THE POLICE DEPARMENT IN OBTAINING A GRANT TO INCREASE OWI PATROLS. THE TASK FORCE IS ALSO DEVELOPING A DRUG COURT, AND PARTICIPATING IN MEDIA MARKETING CAMPAIGNS TO DISCOURAGE BINGE DRINKING. ST. AGNES HOSPITAL PART V, SECTION B, LINE 7: THE HOSPITAL IS PARTICIPATING IN THE INITIATIVES NOTED IN QUESTION 6 TO ADDRESS THE NEEDS IDENTIFIED IN THE CHNA. OUR INITIATIVES ARE ALREADY SHOWING POSITIVE RESULTS. THE UNIVERSITY OF WISCONSIN POPULATION HEALTH INSTITUTE PRODUCES A WELL-KNOWN DOCUMENT TITLED "COUNTY HEALTH RANKINGS AND ROADMAPS." THE MOST CURRENT REPORT SHOWS THAT FOND DU LAC COUNTY HAS IMPROVED FROM THE RANK OF 33 TO RANK OF 22 IN THE STATE. IN ORDER TO FURTHER HELP COMMUNITY MEMBERS TAKE POSITIVE STEPS IN IMPROVING THEIR HEALTH, AGNESIAN HEALTCARE DISTRIBUTED 2014 WELLNESS CALENDARS TO 78,000 RESIDENTS. ST. AGNES HOSPITAL PART V, SECTION B, LINE 12H: UNINSURED PATIENTS ARE AUTOMATICALLY GIVEN A 15% DISCOUNT. ST. AGNES HOSPITAL PART V, SECTION B, LINE 16E: COLLECTION AGENCIES ARE ENGAGED TO COLLECT UNPAID BALANCES. THESE AGENCIES ARE AUTHORIZED TO REPORT TO CREDIT AGENCIES. COLLECTION AGENCIES ARE AUTHORIZED BY THE HOSPITAL TO ESTABLISH GARNISHMENT AGAINST WAGES ON UNPAID BALANCES THEY ARE ATTEMPTING TO COLLECT. ST. AGNES HOSPITAL PART V, SECTION B, LINE 20D: UNINSURED PATIENTS AUTOMATICALLY RECEIVE A 15% DISCOUNT OFF GROSS CHARGES. ST. AGNES HOSPITAL PART V, SECTION B, LINE 22: UNINSURED PATIENTS WOULD AUTOMATICALLY RECEIVE A 15% DISCOUNT. INSURED PATIENTS WHO ARE PART OF AN INSURANCE PLAN WITHOUT A NEGOTIATED RATE WITH THE HOSPITAL MIGHT PAY FULL CHARGES IF THE ENTIRE CHARGE WAS APPLIED TO THEIR DEDUCTIBLE. PART VI, LINE 2: IN ADDITION TO THE CHNA NOTED ABOVE, THE HOSPITAL'S SENIOR LEADERS MEET REGULARLY WITH COMMUNITY LEADERS TO GATHER INPUT FROM AND RESPOND TO PATIENT AND CUSTOMER NEEDS. SENIOR LEADERS AND MEMBERS OF THE WORKFORCE PARTICIPATE IN A VARIETY OF ORGANIZATIONS IN SUPPORT OF AGNESIAN HEALTHCARE INC.'S KEY COMMUNITIES. THROUGH THE HOSPITAL'S PARTICIPATION IN THESE ACTIVITIES, COMMUNITY MEMBERS LEARN OF THE HOSPITAL'S COMMITTMENT TO COMMUNITY-WIDE HEALTHCARE AND PROVIDE AGNESIAN HEALTHCARE WITH INSIGHTS INTO COMMMUNITY HEALTH NEEDS AND DESIRES. PART VI, LINE 3: FINANCIAL COUNSELORS AT AGNESIAN HEALTHCARE ASSIST PATIENTS WITH APPLICATION TO COMMUNITY CARE. PATIENTS CAN BE REFERRED TO COMMUNITY CARE BY CLERGY, DEPARTMENTS OF AGNESIAN HEALTHCARE, SISTERS OF ST. AGNES, AREA SOCIAL AND HEALTH AGENCIES, FAMILY OR SELF. THE APPLICATION IS COMPLETED BY THE PATIENT WITH ASSISTANCE FROM THE FINANCIAL COUNSELOR IF NEEDED. THE FINANCIAL COUNSELOR WILL COMMUNICATE TO THE PATIENT WHAT PROGRAMS THEY WILL BE ELIGIBLE FOR, AS WELL AS PROVIDE NOTIFICATION OF APPROVAL OR DENIAL OF THEIR APPLICATION IN A TIMELY MANNER. PART VI, LINE 4: COMMUNITY CARE APPLICATIONS ARE ACCEPTED ONLY FROM PATIENTS OF AGNESIAN HEALTHCARE WHO RESIDE IN THE COUNTIES OF CALUMET, COLUMBIA, DODGE, FOND DU LAC, GREEN LAKE, MARQUETTE, WASHINGTON, WAUSHARA OR WINNEBAGO. INDIVIDUALS MUST BE A RESIDENT OF ONE OF THOSE AREAS FOR A MINIMUM OF THREE MONTHS AND PROVIDE SUPPORTING DOCUMENTATION. ON OCCASION, INDIVIDUALS ARE NOT COMMUNITY MEMBERS BUT MAY NEED ASSISTANCE; THOSE APPLICATIONS ARE CONSIDERED ON A CASE-BY-CASE BASIS. THE SAMARITAN CLINIC SERVES PATIENTS FROM FOND DU LAC AND DODGE COUNTIES. PART VI, LINE 5: AGNESIAN HEALTHCARE LEADERS DEVELOP GRANT APPLICATIONS IN SUPPORT OF PROGRAMS AND SERVICES SERVING THE GREATER NEEDS OF THE COMMUNITY, INCLUDING HOSPICE HOPE, DOMESTIC VIOLENCE PROGRAMS, CARDIAC CARE, AND PREVENTIVE HEALTH SERVICES AND SCREENINGS. PROVIDING THESE SERVICES LOCALLY IS A FOCUS OF OUR COMMUNITY BENEFIT PROGRAM. AGNESIAN HEALTHCARE OFFERS PROGRAMS TO THE COMMUNITY THAT ALLOW STUDENTS AND OTHERS TO LEARN ABOUT DIFFERENT OCCUPATIONS IN THE HEALTHCARE INDUSTRY BY BECOMING CERTIFIED AND GAINING ACTUAL WORK EXPERIENCE. THE DIFFERENT PROGRAMS PROVIDE HANDS-ON OPPORTUNITIES AND ALLOW JOB SHADOWING SO THE FUTURE OF THE PROFESSION CAN GAIN CONFIDENCE AND SKILLS. IN ADDITION, AGNESIAN HEALTHCARE SHARES ITS PROFESSIONAL STAFF EXPERTISE TO OFFER HEALTH EDUCATION CLASSES, HEALTH SCREENINGS, SUPPORT GROUPS, AND OTHER HEALTH PROMOTION ACTIVITIES THROUGHOUT THE YEAR. OTHER COMMUNITY ACTIVITIES INCLUDE SUPPORT AND TRAINING FOR THE DODGE CORRECTIONAL INSTITUTIONAL HOSPICE PROGRAM, SHARPS DISPOSAL SERVICE, ADOPT-A-FAMILY, DONATIONS TO FOOD PANTRIES, AND LEADERSHIP PARTICIPATION IN COMMUNITY NONPROFIT ORGANIZATIONS. PART VI, LINE 6: AGNESIAN HEALTHCARE, INC. IS AN INTEGRATED, COMPREHENSIVE NOT-FOR-PROFIT HEALTHCARE DELIVERY SYSTEM COMPRISED OF SEVEN MINISTRIES: AGNESIAN HEALTHCARE ENTERPRISES, LLC, CONSULTANTS LAB OF WI, LLC, FOND DU LAC REGIONAL CLINIC, ST. AGNES HOSPITAL, ST. FRANCIS HOME, WAUPUN MEMORIAL HOSPITAL AND RIPON MEDICAL CENTER. AGNESIAN PROVIDES A CONTINUUM OF HEALTHCARE SERVICES FROM BIRTH TO END OF LIFE, PREVENTIVE HEALTHCARE, DIAGNOSIS, TREATMENT AND FOLLOWUP, ASSISTED LIVING, AND INDEPENDENT AND SKILL CARE SERVICES. AGNESIAN HEALTHCARE IS COMMITTED TO ENSURING THAT INDIVIDUALS NEEDING VITAL HEALTHCARE SERVICES GET THE HELP THEY NEED AND DESERVE. REPORTS FILED WITH STATES PART VI, LINE 7 WI X X 1 1 X X X X 0 1 0 1 0 0 0 0 0 STEVEN N LITTLE 518132 0 246727 0 0 0 0 0 35201 0 800060 0 0 0 ALLAN MILANI MD 464776 0 0 0 0 0 0 0 24695 0 489471 0 0 0 JAMES P MUGAN 259237 0 86078 0 0 0 0 0 38946 0 384261 0 0 0 BONNIE SCHMITZ 264048 0 32592 0 0 0 0 0 22465 0 319105 0 0 0 DENNIS YUNK 239580 0 27354 0 8046 0 0 0 29865 0 304845 0 0 0 CAROL B HYLAND 235027 0 28821 0 0 0 0 0 31734 0 295582 0 0 0 DOUGLAS D TROST 196306 0 19527 0 4849 0 0 0 30136 0 250818 0 0 0 SR MARY MOLLISON 149983 0 54324 0 10355 0 0 0 9271 0 223933 0 0 0 BARBARA LKNUTZEN 176359 0 22353 0 6981 0 0 0 25899 0 231592 0 0 0 SUSAN L EDMINSTER 189139 0 13678 0 0 0 0 0 18660 0 221477 0 0 0 NANCY A BIRSCHBACH 155508 0 19681 0 0 0 0 0 31367 0 206556 0 0 0 JILL A STENSON 152340 0 20151 0 0 0 0 0 17170 0 189661 0 0 0 JOHN CHOI MD 546794 0 437120 0 0 0 0 0 31933 0 1015847 0 0 0 YASIR HATAHET MD 527051 0 328323 0 0 0 0 0 40652 0 896026 0 0 0 PONTUS OSTMAN MD 407284 0 394011 0 0 0 0 0 15985 0 817280 0 0 0 HONG C WANG MD 595869 0 0 0 0 0 0 0 32562 0 628431 0 0 0 STEVEN FLURRY MD 588271 0 0 0 0 0 0 0 30910 0 619181 0 0 0 ROBERT A FALE 169948 0 76479 0 231865 0 0 0 13172 0 491464 0 0 0 PART I, LINE 1A ALL GROSSUP PAYMENTS AND SOCIAL CLUB DUES ARE INCLUDED ON FORM 1099. THESE PAYMENTS ARE MADE FOR TWO MEMBERS OF THE BOARD OF DIRECTORS. PART I, LINE 4B ALL EXECUTIVES EXCEPT CEO PARTICIPATE IN A 457(B) SUPPLEMENTAL NONQUALIFIED RETIREMENT PLAN. PART I, LINE 5 COMPENSATION FOR SOME EMPLOYED PHYSICIANS IS BASED ON A PERCENTAGE OF GROSS BILLINGS. A WI HEALTH AND EDUC FACILITIES AUTHORITY 391337855 97710BGG1 2008-12-11 49330000 REFUNDING OF 2001 ISSUE, PRIVATE ROOM PROJECT 0 0 0 B WI HEALTH AND EDUC FACILITIES AUTHORITY 391337855 97710BYW6 2010-12-01 57260000 REFUNDING OF 2001 ISSUE, PRIVATE ROOM PROJECT 0 0 0 C WI HEALTH AND EDUC FACILITIES AUTHORITY 391337855 NONEAVAIL 2011-12-15 10020000 PARTIAL REFUNDING OF 1998 ISSUE 0 0 0 D WI HEALTH AND EDUC FACILITIES AUTHORITY 391337855 97710B7C0 2013-03-14 5705000 CONSTRUCTION AND EXPANSION OF FACILITIES 0 0 0 A 1925000 49330000 430000 48900000 2005 1 0 1 1 B 2715000 57260000 4518399 31465565 767686 22727526 2431172 1 0 0 1 C 1862000 10020000 9930000 90000 2011 1 0 1 1 D 5705000 61653 32111 460633 5150603 0 0 0 1 A 0 0 0 0 0.01470 0.01470 1 0 1 B 0 0 0 0 1 0 1 C 0 0 0 0 1 0 1 D 0 0 0 0 1 0 1 A 1 1 1 PIPER JAFFRAY 28.000000000000 0 0 0 0 0 B 1 0 0 0 0 0 C 1 0 0 0 0 0 D 1 0 0 0 0 0 A 1 B 1 C 1 D 1 A WI HEALTH AND EDUC FACILITIES AUTHORITY 391337855 97710B7C0 2013-03-14 53273496 CONSTRUCTION AND EXPANSION OF FACILITIES 0 0 0 A 53276496 569394 296559 4254141 48156402 0 0 0 1 A 0 0 0 0 1 0 1 A 1 0 0 0 0 0 A 1 JOSEPH REITEMEIER DIRECTOR 373224 JOSEPH REITEMEIER IS PRESIDENT OF FOND DU LAC ASSOCIATION OF COMMERCE. AGNESIAN HEALTHCARE, INC. PROVIDED OCCUPATIONAL HEALTH SERVICES TO THE ASSOCIATION OF COMMERCE, BILLING $2,364 FOR THESE SERVICES IN FISCAL YEAR 2013. IN ADDITION, AGNESIAN HEALTHCARE, INC. PURCHASED SERVICES TOTALING $370,860 FROM THE ASSOCIATION OF COMMERCE DURING FISCAL YEAR 2013. 0 JOSEPH REITEMEIER DIRECTOR 45136 JOSEPH REITEMEIER IS PRESIDENT OF FOND DU LAC ASSOCIATION OF COMMERCE. HIS DAUGHTER-IN-LAW, JENNIFER REITEMEIER, IS EMPLOYED AS AN RN AT AGNESIAN HEALTHCARE, EARNING AN ANNUAL SALARY OF $45,136. 0 WAYNE MATZKE DIRECTOR 169106 WAYNE MATZKE IS CEO OF GRANDE CHEESE. AGNESIAN HEALTHCARE PROVIDED OCCUPATIONAL HEALTH SERVICES TO GRANDE CHEESE, BILLING $169,106 IN FISCAL YEAR 2013. 0 DENISE DEVERAUX DIRECTOR 482254 DENISE DEVERAUX IS VICE PRESIDENT OF HUMAN RESOURCES AT MERCURY MARINE. AGNESIAN HEALTHCARE PROVIDED OCCUPATIONAL HEALTH SERVICES TO MERCURY MARINE, BILLING $482,254 IN FISCAL YEAR 2013. 0 FORM 990, PART VI, SECTION A, LINE 6 THE ORGANIZATION HAS TWO CLASSES OF MEMBERS - CLASS A MEMBERS WHO ARE MEMBERS OF THE CONGREGATION OF THE SISTERS OF ST. AGNES AND CLASS B MEMBERS WHO CONSTITUTE THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION A, LINE 7A THE CLASS A MEMBERS, WHO ARE THE GENERAL COUNCIL OF THE CONGREGATION OF SISTERS OF ST. AGNES, HAVE THE POWER TO ELECT OR APPOINT THE CLASS B MEMBERS. THE CLASS B MEMBERS CONSTITUTE THE BOARD OF DIRECTORS. THE CLASS B MEMBERS HAVE THE POWER, UPON THE RECOMMENDATION OF THE BOARD OF DIRECTORS, TO APPOINT AND REMOVE, WITH OR WITHOUT CAUSE, THE PRESIDENT/CHIEF EXECUTIVE OFFICER OF THE CORPORATION. FORM 990, PART VI, SECTION A, LINE 7B THE CONGREGATION OF THE SISTERS OF ST. AGNES SPONSORSHIP MINISTRIES IS THE CLASS B MEMBER WHO IS RESPONSIBLE FOR APPROVING CERTAIN RESERVED POWERS OF THE CORPORATION DELIGATED TO THEM BY CLASS A. THE GENERAL COUNCIL OF THE CONGREGATION OF SISTERS OF ST. AGNES IS THE CLASS A MEMBER WHO IS RESPONSIBLE FOR APPROVING CERTAIN RESERVED POWERS OF THE CORPORATION. FORM 990, PART VI, SECTION B, LINE 11 THE FINANCE DEPARTMENT PREPARES THE FORM 990 AND THE RETURN IS REVIEWED BY THE DIRECTOR OF FINANCE AND CFO. A FINAL COPY OF THE 2012 FORM 990 IS PROVIDED TO THE BOARD EXECUTIVE COMMITTEE FOR REVIEW AND APPROVAL TO THE AGNESIAN HEALTHCARE BOARD BEFORE THE RETURN IS FILED WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C WE HAVE A WRITTEN CONFLICT OF INTEREST AND INSIDER TRANSACTION POLICY THAT REQUIRES EACH DIRECTOR, PRINCIPAL OFFICER, TRUSTEE OR COMMITTEE MEMBER TO DISCLOSE ON AN ANNUAL BASIS TO THE DESIGNATED AUTHORITY A CONFLICT OF INTEREST DISCLOSURE STATEMENT. THE DESIGNATED AUTHORITY ENSURES THAT ALL STATEMENTS ARE COMPLETED, REVIEWS THEM FOR CONFLICTS, AND SUBMITS TO THE BOARD FOR REVIEW ANY CONFLICT OF INTEREST DISCLOSURE STATEMENTS THAT DISCLOSE ACTUAL OR POTENTIAL CONFLICTS. FORM 990, PART VI, SECTION B, LINE 15 DETERMINATION OF COMPENSATION OF THE CEO AND OFFICERS INCLUDES ANALYSIS OF COMPARABLE COMPENSATION SURVEYS BY AN INDEPENDENT COMPENSATION CONSULTANT, WHO RECOMMENDS RANGES OF APPROPRIATE COMPENSATION TO THE BOARD OF DIRECTORS. THE BOARD OF DIRECTORS APPROVES THE COMPENSATION PACKAGE FOR OFFICERS, AND CONTEMPORANEOUS SUBSTANTIATION OF THE DELIBERATIONS AND DECISION IS INCLUDED IN THE BOARD MINUTES. THE FINAL AGREEMENT IS DOCUMENTED WITH A WRITTEN CONTRACT, WHICH IS SIGNED BY BOTH PARTIES. FORM 990, PART VI, SECTION C, LINE 19 AGNESIAN HEALTHCARE'S POLICY AND PROCEDURE FIN1069 DEFINES THE PROCEDURE FOR MAKING ANNUAL INFORMATION RETURNS AVAILABLE FOR PUBLIC INSPECTION. INDIVIDUALS REQUESTING INSPECTION ARE REFERRED TO THE ADMINISTRATION OFFICE, WHERE THEY ARE PROVIDED WITH THE DOCUMENTS AND A CONFERENCE ROOM FOR INSPECTING DOCUMENTS. PHOTOCOPIES WILL BE PROVIDED TO THE REQUESTOR. ANYONE MAY INSPECT THE RETURNS UPON DEMAND, WITHOUT AN APPOINTMENT OR ANY FOREWARNING, DURING AGNESIAN HEALTHCARE INC'S NORMAL BUSINESS HOURS. GOVERNING DOCUMENTS AND CONFLICT OF INTEREST STATEMENTS ARE NOT AVAILABLE FOR PUBLIC INSPECTION, BUT CAN BE MADE AVAILABLE IF THE REQUESTING PARTY HAS A BONAFIDE REASON. ALL FINANCIAL STATEMENTS ARE AVAILABLE TO THE PUBLIC THROUGH A POSTING ON A PUBLIC WEBSITE. OTHER FEES FORM 990, PART IX, LINE 11G PURCHASED SERVICES - PHYSICIANS: PROGRAM SERVICE EXPENSES 53,720,671. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 53,720,671. PURCHASED SERVICES - LABORATORY: PROGRAM SERVICE EXPENSES 181,137. MANAGEMENT AND GENERAL EXPENSES 479,088. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 660,225. PURCHASED SERVICES - LAUNDRY: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 651,231. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 651,231. PURCHASED SERVICES - ELEVATOR: PROGRAM SERVICE EXPENSES 5,812. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 5,812. PURCHASED SERVICES - MISCELLANEOUS: PROGRAM SERVICE EXPENSES 1,503,369. MANAGEMENT AND GENERAL EXPENSES 398,515. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,901,884. PURCHASED SERVICES - REFERENCE TESTS: PROGRAM SERVICE EXPENSES 866,633. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 866,633. PURCHASED SERVICES - HOUSEKEEPING: PROGRAM SERVICE EXPENSES 64,613. MANAGEMENT AND GENERAL EXPENSES 161,787. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 226,400. PURCHASED SERVICES - IT: PROGRAM SERVICE EXPENSES 1,279,183. MANAGEMENT AND GENERAL EXPENSES 15,635. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,294,818. PURCHASED SERVICES - TRANSCRIPTION: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 283,048. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 283,048. PROFESSIONAL FEES: PROGRAM SERVICE EXPENSES 846,224. MANAGEMENT AND GENERAL EXPENSES 250,459. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,096,683. PROFESSIONAL FEES - MEDICAL DIRECTOR: PROGRAM SERVICE EXPENSES 223,977. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 223,977. PROFESSIONAL FEES - COLLECTION: PROGRAM SERVICE EXPENSES 5,483. MANAGEMENT AND GENERAL EXPENSES 720,063. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 725,546. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 9: CAPITAL CONTRIBUTIONS FROM AFFILIATES 5,000,000. CHANGE IN SWAP FUND BALANCE 1,136,608. CHANGE IN FUND BALANCE - SAH FOUNDATION 1,150,073. 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