2014-08-14T15:46:28-05:00 2013-09-30 390758449 WIPFLI LLP PO BOX 12237 GREEN BAY WI 543072237 990 2012-10-01 390806359 COMMUNITY HEALTH NETWORK INC COMM 9203611313 225 MEMORIAL DR BERLIN WI 54923 TOM KRYSTOWIAK 9203611313 2014-08-14 1 TERRI REXRODE CPA MST P00096513 9206620016 2014-08-14 2012 2015-11-30 17:44:51Z TOM KRYSTOWIAK 225 MEMORIAL DRIVE BERLIN WI 54923 90903872 0 X WWW.CHNWI.ORG X 1910 WI 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 $81,218,000 (TOTAL GROSS REVENUE OF $178,246,000). 12 11 841 110 1464052 -27760 19553 51692 81269090 84988117 518236 591288 -221653 738685 81585226 86369782 23599 21039 0 0 48214027 48085669 0 0 0 34669919 37740787 82907545 85847495 -1322319 522287 56315090 59518792 29406798 32090661 26908292 27428131 X TO PROVIDE SUPERIOR SERVICES TO IMPROVE THE HEALTH OF THOSE WE SERVE. 1 0 70369044 21039 80669145 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. IT OPERATES A WOMAN'S HEALTH AND RESOURCE CLINIC THAT PROVIDES SERVICES TO UNINSURED AND UNDERINSURED WOMEN THROUGH A STATE OF WISCONSIN GRANT PROGRAM. 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 MANAGEMENT AND 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 2013. 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- 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 70369044 1 1 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 1 0 1 1 0 0 0 0 0 1 0 1 1 1 0 0 0 0 1 1 1 0 0 0 1 49 0 841 1 1 1 0 0 0 0 0 0 0 0 0 X 12 11 1 0 0 0 1 1 1 1 1 0 0 0 1 1 1 1 1 0 0 0 WI X THOMAS KRYSTOWIAK 9203611313 225 MEMORIAL DRIVE BERLIN WI 54923 PAT MCCONNELL 1.00 X 2300 0 0 PAUL KUJAWA 1.00 X 3900 0 0 FRANK CUMBERBATCH 1.00 X 3400 0 0 THOMAS RIEK 1.00 X 4100 0 0 NATHAN LUEDKE 1.00 X 3300 0 0 JOLENE HOSTAK 1.00 X 2900 0 0 P MICHAEL SHATTUCK MD 41.00 X 228258 0 24391 KELLY WHITE 1.00 X 0 0 0 KRISTIN GALATOWITSCH 1.00 X X 8687 0 0 RUSSELL KUEHN 1.00 X X 4900 0 0 THOMAS WILLETT DO 1.00 X X 18200 0 0 LARRY WISE 1.00 X X 6100 0 0 JOHN FEENEY 40.00 X X 328115 0 19091 THOMAS KRYSTOWIAK 40.00 1.00 X 206172 0 31546 DONALD CAVES 31.00 9.00 X 71342 62883 19744 DAVID JONES MD 40.00 X 1469805 0 29437 URI VAISMAN MD 40.00 X 876665 0 36315 JOHN HORAN MD 40.00 X 794641 0 22276 HORZCE LO MD 40.00 X 583244 0 42925 DAVID KURTZ MD 40.00 X 674522 0 30987 5290551 62883 256712 52 0 1 0 ZR ENTERPRISES SC 5567ANGLES LANE GREENDALE WI 53129 ER PHYSICIAN SERVICE 1482744 CENTRAL WI ANESTHESIA ASSOC SC PO BOX 249 BERLIN WI 54923 ANESTHESIA SERVICES 556029 SHARED MEDICAL SERVICES PO BOX 330 COTTAGE GROVE WI 53527 MRI SERVICES 458187 DAVID RESEN 225 MEMORIAL DR BERLIN WI 54923 PHYSICIAN SERVICES 225169 HALL RENDER KILLIAN HEATH & LYMAN PC 39778 TREASURY CTR CHICAGO IL 60694 CONSULTING/LEGAL SERVICES 184219 7 38143 13549 51692 PATIENT SERVICE REVENUE 624100 69274372 65740259 3534113 PHARMACY REVENUE 446110 15592938 14128886 1464052 CAFETERIA REVENUE 900099 120807 120807 84988117 386628 386628 320741 382056 -61315 -61315 -61315 4247916 108778 4074207 77827 173709 30951 204660 204660 EHR INCENTIVE INCOME 900099 800000 800000 800000 86369782 80669145 1464052 4184893 21039 21039 4917840 730543 4187297 34705714 33861849 843865 582884 510301 72583 5839847 4959934 879913 2039384 1690812 348572 57752 57752 7082240 5917770 1164470 209687 7694 201993 14576096 14160469 415627 1500176 39071 1461105 1098079 1050855 47224 348005 304224 43781 63142 1694 61448 794796 776670 18126 2920292 2907405 12887 591938 383001 208937 PROVISION FOR BAD DEBTS 4436105 4436105 EQUIPMENT RENTAL AND MA 3138548 2846360 292188 MEDICAID ASSESSMENT 560352 560352 LICENSES, DUES, AND CER 204654 127744 76910 158925 71609 87316 85847495 70369044 15478451 0 3964 3846 7730522 4172746 10921018 16558337 112500 118917 961108 1111303 975529 736969 55688033 36122037 20813974 19565996 10986755 12356990 93734 45607 3715986 4848081 56315090 59518792 6345323 7018223 12820000 12490000 3135230 3335305 7106245 9247133 29406798 32090661 X 25787171 26268159 1121121 1159972 26908292 27428131 56315090 59518792 X 522287 -41299 38851 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 5455 5455 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: WHA DUES OF $5,455. 11731635 1188523 1208164 811361 13316961 9942971 1110976 1431598 753910 11731635 9548648 1099960 46867 752504 9942971 8326892 1558801 644527 981572 9548648 8370586 1484600 -454237 1074057 8326892 0.91000 0.00000 0.09000 0 1 1 897715 897715 19462727 10911989 8550738 1219996 1122339 97657 32304119 23269561 9034558 1803476 818148 985328 19565996 RECEIVABLE FROM PHYSICIANS 77500 UNAMORTIZED BOND ISSUE COSTS 420410 INTEREST RECEIVABLE 1748 ACCOUNTS RECEIVABLE - WILD ROSE 2388451 ASSETS HELD BY FOUNDATION 1159972 EHR INCENTIVE 800000 4848081 DEFERRED COMPENSATION 6561475 ACCRUED INTEREST 90532 SELF FUNDED HEALTH INSURANCE 18888 NET AMOUNTS PAYABLE FROM THIRD-PARTY REIMBURSEMENT PROGRAMS 1003807 MISCELLANEOUS 1192872 DEFERRED PHYSICIAN COMP 379559 9247133 X 82313285 -41299 38851 -2448 82315733 4054049 4054049 86369782 81793446 382056 382056 81411390 4436105 4436105 85847495 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: ENDOWMENT FUNDS ARE TO BE UTILIZED TO SUPPORT THE ORGANIZATION'S MISSION AND PURPOSE. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X, LINE 2: IN ORDER TO ACCOUNT FOR ANY UNCERTAIN TAX POSITIONS, COMMUNITY HEALTH NETWORK, INC. DETERMINES WHETHER IT IS MORE LIKELY THAN NOT THAT A TAX POSITION WILL BE SUSTAINED UPON EXAMINATION OF THE TECHNICAL MERITS OF THE POSITION, ASSUMING THE TAXING AUTHORITY HAS FULL KNOWLEDGE OF ALL INFORMATION. IF THE TAX POSITION DOES NOT MEET THE MORE-LIKELY-THAN-NOT RECOGNITION THRESHOLD, THE BENEFIT OF THAT POSITION IS NOT RECOGNIZED IN THE CONSOLIDATED FINANCIAL STATEMENTS. THE ORGANIZATION RECORDED NO ASSETS OR LIABILITIES RELATED TO UNCERTAIN TAX POSITIONS OR UNRECOGNIZED TAX BENEFITS IN 2013, 2012, OR 2011. COMMUNITY HEALTH NETWORK, INC. IS ALSO ENGAGED, TO A LIMITED EXTENT, IN ACTIVITIES THAT THE INTERNAL REVENUE SERVICE CONSIDERS UNRELATED TO THE ORGANIZATION'S EXEMPT PURPOSE AND, THEREFORE, TAXABLE. THESE ACTIVITIES, HOWEVER, ANNUALLY RESULT IN NET OPERATING LOSSES FOR INCOME TAX PURPOSES. COMMUNITY HEALTH NETWORK, INC. 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 CARRYFORWARDS IS OFFSET BY A VALUATION ALLOWANCE OF EQUAL AMOUNT. NO DEFERRED TAX ASSETS AND LIABILITIES HAVE BEEN RECOGNIZED, SINCE NO OTHER DIFFERENCES EXIST BETWEEN THE FINANCIAL AND TAX BASES OF REPORTING THE ORGANIZATION'S ASSETS AND LIABILITIES. COMMUNITY HEALTH NETWORK INC.'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, 2012, AND 2011, THERE WAS NO INCOME TAX EXPENSE, TAX PENALTIES, OR INTEREST RELATED TO TAX PENALTIES RECORDED BY THE ORGANIZATION IN THE CONSOLIDATED FINANCIAL STATEMENTS. FEDERAL INCOME TAX RETURNS FOR THE YEAR ENDED SEPTEMBER 30, 2010, AND BEYOND REMAIN SUBJECT TO EXAMINATION BY MAJOR TAX JURISDICTIONS. PART XI, LINE 2D - OTHER ADJUSTMENTS: CHANGE IN BENEFICIAL INTEREST OF PARTNERS HEALTH SYSTEM FOUNDATION, INC. 38,851. PART XI, LINE 4B - OTHER ADJUSTMENTS: RENTAL EXPENSES -382,056. PROVISION FOR BAD DEBT 4,436,105. PART XII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES 382,056. PART XII, LINE 4B - OTHER ADJUSTMENTS: PROVISION FOR BAD DEBT 4,436,105. 1 1 X 1 X 1 X 1 1 1 0 1 1 2186385 2186385 0.02690 9545812 5746080 3799732 0.04670 11732197 5746080 5986117 0.07360 60694 0 60694 0.00070 5243 0 5243 0.00010 478946 0 478946 0.00590 544883 544883 0.00670 12277080 5746080 6531000 0.08030 1 1951886 0 12936428 12936480 -52 X 1 1 1 1 BERLIN MEMORIAL HOSPITAL

225 MEMORIAL DRIVE BERLIN WI 54923

X X X X BERLIN MEMORIAL 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 0 0 1 1 150.000000000000 1 300.000000000000 1 X X 1 1 X X X X 1 X 0 1 X 0 0 13 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 PART I, LINE 7: THE NUMBERS IN THE TABLE FOR CHARITY CARE AND UNREIMBURSED MEDICAID WERE DERIVED FROM USE OF THE 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, 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 $ 4436105. PART II: 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. 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 5C: COMMUNITY HEALTH NETWORK, INC. PROVIDES INFORMATION REGARDING THE COMMUNITY HEALTH NEEDS ASSESSMENT AND IMPLEMENTATION PLAN ON THE HOME PAGE OF THE COMMUNITY HEALTH NETWORK, INC. WEBSITE. 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. 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 18.9% UNDER THE AGE OF 18, 26.8% FROM 18 TO 44, 32.8% FROM 45 TO 64 AND 21.5% 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. 0 PARTNERS HEALTH SYSTEM FOUNDATION INC 225 MEMORIAL DRIVE BERLIN WI 54923 731639346 21039 FOUNDATION FUNDRAISING EVENT X X X 1 1 0 1 1 0 0 0 0 P MICHAEL SHATTUCK MD 195277 0 32981 0 0 0 5325 0 19066 0 252649 0 0 0 JOHN FEENEY 278115 0 50000 0 0 0 0 0 19091 0 347206 0 0 0 THOMAS KRYSTOWIAK 175502 0 20000 0 10670 0 9166 0 22380 0 237718 0 0 0 DONALD CAVES 0 62883 0 0 71342 0 0 1464 16490 1790 87832 66137 0 0 DAVID JONES MD 898225 0 512780 0 58800 0 0 0 29437 0 1499242 0 0 0 URI VAISMAN MD 692531 0 184134 0 0 0 14185 0 22130 0 912980 0 0 0 JOHN HORAN MD 648991 0 96804 0 48846 0 0 0 22276 0 816917 0 0 0 HORZCE LO MD 513594 0 69650 0 0 0 9405 0 33520 0 626169 0 0 0 DAVID KURTZ MD 529846 0 144676 0 0 0 11057 0 19930 0 705509 0 0 0 PART I, LINES 4A-B ALL HIGHLY COMPENSATED PARTICIPATE, BUT DID NOT RECEIVE PAYMENT FROM A NON-QUALIFIED PLAN. DONALD CAVES RECEIVED $71,342 OF SEVERANCE. PART I, LINE 5 RADIOLOGISTS RECEIVE 50% OF REVENUE FROM PROFESSIONAL FEES OVER $2.2 MILLION. IN CALENDAR YEAR 2012, DR. KURTZ RECEIVED $144,676 AND DR. VAISMAN RECEIVED $184,134. SERVICES PROVIDED BY RADIOLOGISTS AT WILD ROSE HOSPITAL ARE INCLUDED. A WISCONSIN HEALTH AND EDUCATIONAL FACILITIES AUTHORITY 391337855 97710VUX4 2004-08-01 10060000 WISCONSIN HEALTH AND EDUCATIONAL FACILITIES BOND HAS THE ADDITIONAL CUSIP NU 0 0 0 B WISCONSIN HEALTH AND EDUCATIONAL FACILITIES AUTHORITY 391337855 97710VVF2 2004-08-01 5000000 WISCONSIN HEALTH AND EDUCATIONAL FACILITIES BOND HAS THE ADDITIONAL CUSIP NU 0 0 0 A 1495000 10060000 3746185 755310 201200 5357305 2005 1 0 1 1 B 1075000 5000000 2712071 100000 85643 2102286 2005 1 0 1 1 A 0 1 0 0 0.00600 0.00000 0.00600 1 0 1 B 0 1 0 0 0.00600 0.00000 0.00600 1 0 1 A 0 1 0 0 0 0 0 0 1 B 0 1 0 0 1 0 0 0 1 A 1 B 1 SCHEDULE K, PART I, LINE A: WISCONSIN HEALTH AND EDUCATIONAL FACILITIES BOND HAS THE ADDITIONAL CUSIP NUMBERS: 97710VUZ9 97710VUY2 97710VVA3 97710VVB1 97710VVC9 97710VVD7 97710VVE5 DR HORAN COMPENSATION ADVANCE X 225000 75000 0 1 1 DR JONES COMPENSATION ADVANCE X 30000 21000 0 1 1 DR CAVES COMPENSATION ADVANCE X 47917 22917 0 1 1 118917 P MICHAEL SHATTUCK MD CHN BOARD MEMBER 138636 CHN RENTS SPACE FROM DR. SHATTUCK FOR MEDICAL GROUP OFFICES 0 NEW PROGRAM SERVICES FORM 990, PART III, LINE 2 CHN IS OFFERING UROLOGY SERVICES, WHICH BEGAN OPERATIONS IN FY 2013. FORM 990, PART VI, SECTION A, LINE 2 RUSSELL KUEHN AND THOMAS WILLETT ARE MEMBERS OF THE BOARD OF DIRECTORS OF 1ST NATIONAL BANK. THOMAS WILLETT AND PATRICK MCCONNELL HAVE A BUSINESS RELATIONSHIP. FORM 990, PART VI, SECTION A, LINE 6 MEMBERSHIP MAY 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 THERE ARE 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 IS AN EX-OFFICIO MEMBER OF THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION A, LINE 7B PER BYLAWS, MEMBERS HAVE 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. 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 THE COMPENSATION DETERMINATION FOR THE CEO OF COMMUNITY HEALTH NETWORK IS AS FOLLOWS: THE CEO IS UNDER AN EMPLOYMENT CONTRACT. HIS SALARY IS REVIEWED PER HIS CONTRACT BY THE EXECUTIVE COMMITTEE OF THE BOARD OF DIRECTORS (THOSE WITHOUT CONFLICT). THE EXECUTIVE COMMITTEE REVIEWS COMPENSATION BENCHMARK DATA, COMPARES THE DATA WITH THE CEO'S CURRENT SALARY AND MAKES A SALARY DETERMINATION WHICH IS THEN VOTED ON BY THE EXECUTIVE COMMITTEE. THE COMPENSATION DETERMINATION FOR THE CFO IS AS FOLLOWS. ONCE A YEAR, CHN'S CEO REVIEWS COMPENSATION BENCHMARK DATA AND COMPARES THE DATA WITH THE CFO'S CURRENT SALARY AND THE PROPOSED INCREASE. BASED ON THE DATA, THE CEO, A PERSON WITHOUT CONFLICT, DETERMINES THE CFO'S SALARY FOR THE COMING YEAR. THE SALARY IS DISCUSSED AND AGREED UPON BY CHN'S CEO AND THE INDIVIDUAL. THE QUESTIONS WERE MARKED "NO" AS THE PROCESS FOR 2012 WAS NOT DOCUMENTED. 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. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 9: CHANGE IN BENEFICIAL INTEREST OF PARTNERS HEALTH SYSTEM FOUNDATION, INC. 38,851. RESPONSIBLE FOR THE AUDIT 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. OVERSIGHT OF AUDIT FORM 990, PART XI, LINE 2C THE PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. COMMUNITY MEDICAL CENTER OF GREEN LAKE LLC 670 COUNTY HWY A GREEN LAKE WI 54941 261424367 CLINIC WI COMMUNITY HEALTH NETWORK INC PARTNERS HEALTH SYSTEM FOUNDATION INC 225 MEMORIAL DRIVE BERLIN WI 54923 731639346 SUPPORTING ORGANIZATION WI 501(C)(3) LINE 11B, II PARTNERS HEALTH SYSTEM INC 1 WILD ROSE COMMUNITY MEMORIAL HOSPITALINC PO BOX 243 WILD ROSE WI 54984 396089134 HOSPITAL WI 501(C)(3) LINE 3 PARTNERS HEALTH SYSTEM INC 1 PARTNERS HEALTH SYSTEM INC 225 MEMORIAL DRIVE BERLIN WI 54923 271119447 SUPPORTING ORGANIZATION WI 501(C)(3) LINE 11B, II N/A 0 0 1 1 1 0 0 0 0 0 1 0 0 0 1 1 0 1 0 0