2014-08-14T14:20:42-05:00 2013-09-30 381357951 PLANTE & MORAN PLLC PO BOX 307 SOUTHFIELD MI 480370307 990 2012-10-01 390794174 OCONOMOWOC MEMORIAL HOSPITAL INC OCON 2629282496 791 SUMMIT AVENUE OCONOMOWOC WI 530663844 RONALD FARR 2629282496 2014-08-12 1 DAVID LOWENTHAL P00378651 2483522500 2012 2015-11-30 17:44:51Z SUSAN EDWARDS 791 SUMMIT AVENUE OCONOMOWOC WI 530663844 104294600 0 X WWW.PROHEALTHCARE.ORG X 1948 WI PROVIDE GENERAL ACUTE CARE AND SUPPORT ACTIVITIES. 12 9 1013 310 2278146 -173640 271446 632715 93228981 100576030 125406 2650572 2226185 413956 95852018 104273273 3720000 2997500 0 0 28538623 29808053 0 0 0 64563166 66859381 96821789 99664934 -969771 4608339 166902475 164461358 115645132 107536660 51257343 56924698 CONTINUOUSLY IMPROVING THE HEALTH OF OUR COMMUNITY. 0 0 96365641 2997500 98297884 OCONOMOWOC MEMORIAL HOSPITAL FULFILLS ITS EXEMPT PURPOSE BY PROVIDING CARE AND SERVICES TO ALL PATIENTS REGARDLESS OF INSURANCE OR ABILITY TO PAY. OCONOMOWOC MEMORIAL HOSPITAL ALSO USES ITS RESOURCES TO ADDRESS VARIOUS COMMUNITY NEEDS. OCONOMOWOC MEMORIAL HOSPITAL PROVIDED APPROXIMATELY 9,926 DAYS OF INPATIENT CARE AND APPROXIMATELY 66,602 OUTPATIENT VISITS DURING THE FISCAL YEAR ENDED SEPTEMBER 30, 2013. 96365641 1 1 0 0 0 0 0 0 0 1 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 1 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 1 1 0 0 1 98 0 1 1013 1 1 1 0 0 0 0 0 0 0 0 0 X 12 9 0 1 0 0 1 0 1 1 1 0 0 1 1 1 1 1 1 1 1 1 0 WI X RONALD FARR 2629284740 N17 W24100 RIVERWOOD DRIVE SUITE WAUKESHA WI 53188 SUSAN EDWARDS 2.00 50.00 X X 0 1062296 748997 GARY BEYER 2.00 4.00 X X 0 24000 0 TED GARVEY 2.00 4.00 X X 0 0 0 EILEEN GILLESPIE 2.00 4.00 X X 0 0 0 EDWARD J LUMP 2.00 4.00 X X 0 0 0 JOHN ROBERTSTAD 8.00 36.00 X X 0 617785 272942 MICHAEL G BARRY 2.00 4.00 X 0 0 0 PAUL BOSTROM 2.00 4.00 X 0 0 0 CLIFF BROOKS 2.00 4.00 X 0 0 0 CHARLOTTE HALL 2.00 4.00 X 0 0 0 RICHARD NEILS MD 2.00 4.00 X 0 0 0 TIM WESTLAKE 2.00 4.00 X 0 0 0 ARCH PEQUEST 2.00 4.00 X 0 0 0 NANINE M NELSON 2.00 50.00 X 0 478402 208280 DAVID EBEL 2.00 50.00 X 0 0 0 MARK A ZWASKA 40.00 0.00 X 135012 0 28839 LORI NAVARRO 18.00 22.00 X 46081 82647 12410 GARY SIUTA 40.00 0.00 X 124202 0 24174 JOHN CHASE 40.00 0.00 X 119263 0 20566 JUDITH MOONEY 4.00 36.00 X 2251 118028 34896 426809 2383158 1351104 7 0 1 0 RILEY CONSTRUCTION CO INC 5301-99TH AVE KENOSHA WI 53144 MAINTENANCE SERVICES 468865 ADVANCED ICU CARE PO BOX 671773 DALLAS TX 75267 HEALTHCARE SERVICES 380904 HEALOGICS WOUND CARE 3087 MOMENTUM PLACE CHICAGO IL 60689 MANAGEMENT FEES 347885 HAMILTON BENCHMARK 1330 E WATERFORD AVENUE ST FRANCIS WI 53235 MAINTENANCE SERVICES 324453 MEDICAL STAFFING NETWORK PO BOX 203000 DALLAS TX 75320 STAFFING 319341 11 526858 60095 45762 632715 PATIENT SERVICES 622110 92732612 92732612 PHARMACY SALES 446110 3097201 1444500 1652701 LABORATORY REVENUE 621500 2068626 1443181 625445 MEANINGFUL USE 900099 1793769 1793769 RENTAL REVENUE - AFFILIATES 532000 165728 165728 718094 718094 100576030 2646822 2646822 42575 21327 21248 21248 21248 3750 0 3750 3750 3750 CAFETERIA SALES 722210 392236 392236 472 472 392708 104273273 98297884 2278146 3064528 X 2997500 2997500 23006094 22520149 485945 2034882 1991900 42982 3101189 3035684 65505 1665888 1644440 21448 -68 -68 26078882 24199885 1878997 18712312 18605436 106876 2880985 2838940 42045 49510 47841 1669 39228 30735 8493 5548926 5548926 7945045 7851618 93427 367533 367533 MEDICAID PROVIDER TAXES 2698958 2698958 BAD DEBT 2373404 2373404 DUES, FEES & LICENSES 137071 -24451 161522 BANK CHARGES 22919 22919 4676 4676 99664934 96365641 3299293 0 2841707 5625031 11388106 11929839 2126379 2844114 440707 421146 195617594 100961537 98034700 94656057 41266508 45631225 506022 437099 10298346 2916847 166902475 164461358 8559035 8688536 79064714 78438066 11451764 11261026 16569619 9149032 115645132 107536660 X 42732702 56038400 8189557 886298 335084 0 51257343 56924698 166902475 164461358 X 4608339 2977588 -1918572 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 394293 394293 326376 20265 47652 394293 326222 33945 -33791 326376 306912 5000 14310 326222 317404 -10492 306912 0 1 1 2030526 2030526 123642164 43075893 80566271 2156159 1086124 1070035 66218311 56296412 9921899 1570434 503108 1067326 94656057 ACCRUED MINIMUM PENSION 6367719 ACCRUED POST-RETIREMENT 26015 INTEREST RATE SWAPS 2523063 ASSET RETIREMENT OBLIGATION 232235 9149032 X DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: OCONOMOWOC MEMORIAL HOSPITAL USES FUNDS FROM THE ENDOWMENT TO FURTHER ITS CHARITABLE MISSION. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X, LINE 2: FIN48 DISCLOSURE: PHC, WMH, OMH, NATIONAL REGENCY, PHCMA, PHCF, AND PHHC ARE NOT-FOR-PROFIT CORPORATIONS AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE (THE "CODE") AND ARE EXEMPT FROM FEDERAL INCOME TAXES PURSUANT TO SECTION 501(A) OF THE CODE. ALL OF THESE ENTITIES ARE, HOWEVER, SUBJECT TO FEDERAL AND STATE INCOME TAXES ON ANY UNRELATED BUSINESS INCOME UNDER THE PROVISIONS OF SECTION 511 OF THE CODE. ACCOUNTING PRINCIPLES GENERALLY ACCEPTED IN THE UNITED STATES OF AMERICA REQUIRE MANAGEMENT TO EVALUATE TAX POSITIONS TAKEN BY THE CORPORATION AND RECOGNIZE A TAX LIABILITY IF THE CORPORATION HAS TAKEN AN UNCERTAIN POSITION THAT MORE LIKELY THAN NOT WOULD NOT BE SUSTAINED UPON EXAMINATION BY THE IRS OR OTHER APPLICABLE TAXING AUTHORITIES. MANAGEMENT HAS ANALYZED THE TAX POSITIONS TAKEN BY THE CORPORATION AND HAS CONCLUDED THAT AS OF SEPTEMBER 30, 2013, THERE ARE NO UNCERTAIN POSITIONS TAKEN OR EXPECTED TO BE TAKEN THAT WOULD REQUIRE RECOGNITION OF A LIABILITY OR DISCLOSURE IN THE FINANCIAL STATEMENTS. THE CORPORATION IS SUBJECT TO ROUTINE AUDITS BY TAXING JURISDICTIONS; HOWEVER, THERE ARE CURRENTLY NO AUDITS FOR ANY TAX PERIODS IN PROGRESS. MANAGEMENT BELIEVES IT IS NO LONGER SUBJECT TO INCOME TAX EXAMINATIONS FOR YEARS PRIOR TO SEPTEMBER 30, 2010. 1 1 X 1 X 1 X 0 1 1 0 0 1001054 1001054 0.01030 8259656 2954746 5304910 0.05460 9260710 2954746 6305964 0.06490 25 14934 478706 426 478280 0.00490 8 971 202681 202681 0.00210 1 100 107512 107512 0.00110 9 1773 307545 307545 0.00320 43 17778 1096444 426 1096018 0.01130 43 17778 10357154 2955172 7401982 0.07620 1 1500 1500 0.00000 1 18325 18325 0.00020 800 800 0.00000 1 1350 1350 0.00000 1 36 36 0.00000 4 22011 22011 0.00020 1 2373404 277041 18132259 33120115 -14987856 X 1 1 1 LAKE COUNTRY ENDOSCOPY CENTER LLC DIAGNOSTIC CENTER 0.50000 0.50000 1 1 OCONOMOWOC MEMORIAL HOSPITAL INC

791 SUMMIT AVENUE OCONOMOWOC WI 530663844

X X X OCONOMOWOC MEMORIAL HOSPITAL 1 1 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 1 200.000000000000 1 400.000000000000 1 X X X 1 1 X X X X X X 1 1 X X X X X 1 X 0 0 1 LAKE COUNTRY ENDOSCOPY CENTER LLC

1185 CORPORATE CENTER DR OCONOMOWOC WI 53066

DIAGNOSITC CENTER PART I, LINE 3C: N/A PART I, LINE 6A: N/A PART I, LINE 7: THE COST-TO-CHARGE RATIO WAS USED TO CALCULATE AMOUNTS ON LINES 7A-7D. THIS WAS CALCULATED BY USING WORKSHEET 2 OF THE SCHEDULE H INSTRUCTIONS. THE HOSPITAL'S FINANCIAL COST REPORTING SYSTEM WAS USED TO CALCULATE THE AMOUNTS ON LINES 7E-7I PART I, LINE 7G: N/A PART I, L7 COL(F): $2,373,404 OF BAD DEBT EXPENSES WAS INCLUDED ON FORM 990, PART IX, LINE 25 BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE. PART II: OCONOMOWOC/WAUKESHA MEMORIAL HOSPITALS HAVE PARTNERSHIPS WITH VARIOUS ORGANIZATIONS THROUGHOUT THE COMMUNITIES WE SERVE. ONE EXAMPLE IS THE PARTNERSHIPS WE HAVE WITH THE LOCAL CHAMBERS OF COMMERCE WITHIN OUR SERVICE AREA BY PROVIDING LEADERSHIP AND HEALTH RELATED OUTREACH TOWARDS STRENGTHENING COMMUNITY DEVELOPMENT. WE ARE THE MAJOR SPONSOR FOR "LEADERSHIP WAUKESHA", A PROGRAM THAT FOCUSES ON THE DEVELOPMENT OF EMERGING LEADERS IN OUR COUNTY. ADDITIONALLY, WE PROVIDE LAND, RESOURCES AND EXPERTISE FOR LOCAL COMMUNITY GARDENS. WE PROVIDE DELIVERY OF EMERGENCY CARE IN THE COMMUNITY AND OFFER/SUPPORT NUMEROUS SERVICES AIMED AT OUR YOUTH INCLUDING SPONSORSHIP OF SAFE "AFTER PROM" ACTIVITIES. WE SUPPORT AREA HOMELESS SHELTERS AND ARE ACTIVE MEMBERS OF THE HOUSING ACTION COALITION AND HISPANIC COLLABORATIVE NETWORK. PART III, LINE 4: BAD DEBT EXPENSE FOOTNOTE: AN ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS IS ESTABLISHED ON AN AGGREGATE BASIS BY USING HISTORICAL WRITE-OFF RATE FACTORS APPLIED TO UNPAID ACCOUNTS BASED ON AGING. LOSS RATE FACTORS ARE BASED ON HISTORICAL LOSS EXPERIENCE AND ARE ADJUSTED FOR ECONOMIC CONDITIONS AND OTHER TRENDS AFFECTING THE HOSPITAL'S ABILITY TO COLLECT OUTSTANDING AMOUNTS. UNCOLLECTIBLE AMOUNTS ARE WRITTEN OFF AGAINST THE ALLOWANCE FOR DOUBTFUL ACCOUNTS IN THE PERIOD THEY ARE DETERMINED TO BE UNCOLLECTIBLE. THE AMOUNT OF BAD DEBT EXPENSE REPORTED ON PART III LINE 2 IS THE BAD DEBT EXPENSE REPORTED ON FORM 990 PART IX.THE BAD DEBT COST WAS REVIEWED BY THE HOSPITAL'S REVENUE CYCLE TEAM AND THE AMOUNT OF BAD DEBT ESTIMATED TO BE ATTRIBUTABLE TO PATIENTS WHO WOULD HAVE QUALIFIED UNDER OUR CHARITY CARE PROGRAM IS 30% OF TOTAL BAD DEBTS. PART III, LINE 8: THE SHORTFALL ON LINE 7 SHOULD NOT BE TREATED AS COMMUNITY BENEFIT. COSTING METHODOLOGY IS THE COST TO CHARGE RATIO AS REPORTED ON THE MEDICARE COST REPORT. PART III, LINE 9B: PATIENTS THAT QUALIFY FOR FINANCIAL ASSISTANCE WILL HAVE A CHARITY DISCOUNT APPLIED TO THEIR BALANCES AT THE TIME OF BILLING. IF THIS RESULTS IN NO BALANCE DUE FORM THE PATIENT, THEN THE PATIENT WILL NOT RECEIVE A STATEMENT. IF A BALANCE REMAINS AFTER THE DISCOUNT PERCENTAGE IS APPLIED, THE PATIENT WILL RECEIVE A STATEMENT FOR THE BALANCE DUE. THE STATEMENT CYCLE IS CONSISTENT FOR ALL PATIENTS. OCONOMOWOC MEMORIAL HOSPITAL PART V, SECTION B, LINE 7: ADDITIONAL COMMUNITY NEEDS IDENTIFIED INCLUDED MENTAL HEALTH, AODA AND ACCESS TO CARE. AS THESE ARE THE NEEDS CHOSEN BY THE WAUKESHA COUNTY HHS, WE CHOSE NOT TO DUPLICATE. RATHER, WE ARE ACTIVELY PARTNERING WITH THE COUNTY TO ADDRESS THESE NEEDS IN ADDITION TO OTHER NEEDS WE IDENTIFIED AS A PART OF OUR CHNA. PART VI, LINE 2: OUR NEEDS ASSESSMENT WAS A VERY STRUCTURED, RIGOROUS PROCESS INVOLVING STATISTICAL ANALYSIS, FORMAL SURVEYS, INTERVIEWS AND COMMITTEE REVIEWS AND ASSESSMENT. WE ALSO ARE MINDFUL OF ONGOING/EMERGING COMMUNITY NEEDS THAT COME TO US IN A LESS FORMAL MATTER. KEY TO THIS ONGOING FEEDBACK IS INFORMATION RECEIVED FROM OUR COMMUNITY OUTREACH NURSES (STATIONED IN MORE THAN 70 LOCATIONS). ADDITIONALLY, WE HAVE A LEADERSHIP COMMUNITY SERVICE REQUIREMENT, WHICH PLACES LEADERS IN NOT-FOR-PROFIT AGENCIES THROUGHOUT OUR SERVICE AREA. LEADERS BRING FORWARD CONCERNS AND OBSERVATIONS WHICH ASSIST US IN FORMULATING PLANS AND RESPONSES. OUR EXPANSIVE COMMUNITY EDUCATION PROGRAMS ALSO PROVIDE FEEDBACK ON EMERGING NEEDS. PART VI, LINE 3: EVERY PATIENT WITH A SELF PAY BALANCE RECEIVES A STATEMENT WHICH CONVEYS THE AVAILABILITY OF COMMUNITY (CHARITY) CARE AND A CONTACT NUMBER FOR FURTHER INFORMATION. PATIENTS THAT ARE UNINSURED RECEIVE AN UNINSURED DISCOUNT WHICH IS LISTED ON THE FIRST STATEMENT THAT THEY RECEIVE. PATIENTS RECEIVE A TOTAL OF FOUR STATEMENTS. EACH STATEMENT CONTAINS VERBIAGE REFERENCING THE HOSPITAL'S COMMUNITY CARE PROGRAM AND A CONTACT NUMBER FOR FURTHER INFORMATION. IF SOMEONE HAS BEEN FOUND ELIGIBLE FOR SOME LEVEL OF CHARITY CARE, THE ELIGIBILITY PERIOD IS THREE MONTHS SO ANY SUBSEQUENT ACCOUNTS DURING THAT TIMEFRAME WOULD BE DISCOUNTED AT WHATEVER LEVEL OF CHARITY CARE THE PATIENT IS DEEMED ELIGIBLE. PATIENTS MAY REAPPLY FOR COMMUNITY CARE WHEN THEIR ELIGIBILITY PERIOD HAS EXPIRED. SELF PAY PATIENTS MAY ALSO BE INFORMED OF THE HOSPITAL'S COMMUNITY CARE PROGRAM WHILE THEY ARE INPATIENTS. SOCIAL WORK AND/OR THE BUSINESS OFFICE MAY MAKE CONTACT WITH THESE PATIENTS DURING THEIR STAY TO INFORM THEM OF THE COMMUNITY CARE PROGRAM AND ASSIST THEM WITH COMPLETION OF THE APPLICATION.INFORMATION IS AVAILABLE AT REGISTRATION AREAS RELATED TO OUR COMMUNITY CARE PROGRAM. THIS INFORMATION CONTAINS CONTACT INFORMATION FOR THE HOSPITAL'S CENTRAL BUSINESS OFFICE WHERE PATIENTS CAN RECEIVE ASSISTANCE IN OBTAINING AND COMPLETING APPLICATIONS. PART VI, LINE 4: PROHEALTH CARE SERVES ABOUT 285,000 PEOPLE EACH YEAR IN WAUKESHA COUNTY AND PORTIONS OF SURROUNDING COUNTIES. IN EVERY FEDERAL POPULATION CENSUS, WAUKESHA COUNTY HAS RECORDED AN INCREASE IN POPULATION. SINCE 1960, THE POPULATION OF THE COUNTY HAS MORE THAN DOUBLED. WAUKESHA COUNTY HAS AN AGING POPULATION WITH 14.7% OVER THE AGE OF 65 AND A MEDIAN AGE OF 42.0 YEARS. THE RATE OF RETIREMENT IS LIKELY TO SURPASS THE RATE OF ENTRY INTO THE WORKFORCE BETWEEN 2015 AND 2020. THE RACIAL MAKEUP OF THE WAUKESHA COUNTY COMMUNITY IS AS FOLLOWS: CAUCASIAN (NON-HISPANIC) 94.1%, HISPANIC OR LATINO 4.4%, ASIAN 3.0%, BLACK 1.4%. MEDIAN HOUSEHOLD INCOME IS $75,689, WITH 5.0% OF PEOPLE LIVING BELOW THE POVERTY LEVEL. UNEMPLOYMENT IN WAUKESHA COUNTY STOOD AT 5.4% IN AUGUST 2013. THE PRESENCE OF SOME HIGH INCOME COMMUNITIES IN WAUKESHA COUNTY OFTEN GIVES A MISTAKEN IMPRESSION. OFTEN OVERLOOKED IS A GROWING POPULATION OF LOW INCOME, NON-ENGLISH SPEAKING, VULNERABLE AND MARGINALIZED CITIZENS WHO FACE ENORMOUS ODDS IN ACCESSING HEALTH CARE. THE WAUKESHA COUNTY MEDICAID POPULATION HAS NEARLY TRIPLED IN 10 YEARS, FROM ABOUT 9,451 PEOPLE IN 2000 TO MORE THAN 30,000 IN 2011. THE HISPANIC POPULATION HAS SEEN A 42% INCREASE IN THE PAST 8 YEARS. DOWNTOWN WAUKESHA WAS DECLARED A "MEDICALLY UNDERSERVED" AREA AND A "HEALTH-PROFESSIONAL SHORTAGE AREA" BY THE FEDERAL GOVERNMENT IN 2008. AS AN UNDERSERVED AREA, MEDICAL OPTIONS FOR INDIVIDUALS, PARTICULARLY THOSE WITHOUT HEALTH INSURANCE OR WITH PUBLIC INSURANCE, ARE SEVERELY LIMITED BECAUSE PRIVATE SERVICE PROVIDERS OFTEN REFUSE TO CARE FOR THESE INDIVIDUALS. CONSEQUENTLY, PROHEALTH CARE EMBARKED ON A FUND-RAISING INITIATIVE TO SUPPORT THE FORMATION OF AN FEDERALLY QUALIFIED HEALTH CENTER (FQHC) IN DOWNTOWN WAUKESHA. PART VI, LINE 5: OCONOMOWOC/WAUKESHA MEMORIAL HOSPITAL HAS PARTNERSHIPS WITH VARIOUS NON-PROFIT ORGANIZATIONS AIMED AT IMPROVING THE HEALTH OF OUR COMMUNITY. WE ARE ACTIVELY INVOLVED WITH PROGRAMMING AND ONGOING FINANCIAL SUPPORT OF THE WAUKESHA COMMUNITY HEALTH CENTER, THE NEW AND ONLY FEDERALLY-QUALIFIED HEALTH CENTER SERVING OUR AREA. WE PROVIDE ONGOING FINANCIAL AND IN-KIND SUPPORT TO THE AREA FREE CLINICS. SEVERAL OF OUR STAFF ARE ACTIVITY INVOLVED WITH THE HEALTH DEPARTMENT'S CHIPP AND SERVE ON A VARIETY OF COMMITTEES FOR THE DEPARTMENT OF HEALTH AND HUMAN SERVICES. OUR OUTREACH NURSING PROGRAM SUPPORTS MORE THAN 70 AREA PARTNER AGENCIES. FROM COMMUNITY-WIDE HEALTH FAIRS OFFERING A WIDE VARIETY OF FREE SCREENINGS TO OUR ONGOING PROVISION OF OPERATIONAL SPACE FOR THE WAUKESHA COUNTY COMMUNITY DENTAL CLINIC AND MULTIPLE OTHER NON-PROFITS, WE PROVIDE BROAD SUPPORT TO SAFETY NET ORGANIZATIONS IN OUR AREA. WE ALSO PROVIDE OTHER, DIVERSE SUPPORT IN THE COMMUNITY SUCH AS NUMEROUS SERVICES AIMED AT OUR YOUTH INCLUDING SPONSORSHIP OF SAFE "AFTER PROM" ACTIVITIES. WE SUPPORT AREA HOMELESS SHELTERS AND ARE ACTIVE MEMBERS OF THE HOUSING ACTION COALITION AND HISPANIC COLLABORATIVE NETWORK. PART VI, LINE 6: OUR HOSPITAL IS A MEMBER OF THE PROHEALTH CARE HEALTH SYSTEM WHICH SERVES AS OUR PARENT COMPANY. WHILE COMMUNITY BENEFIT RESPONSIBILITIES RESIDE WITH OUR HOSPITAL BOARD, THE PARENT COMPANY PLAYS A KEY ROLE IN COORDINATING COMMUNITY NEEDS ASSESSMENTS, COMMUNITY BENEFIT PROGRAM PLANNING, AND EVALUATION.A DESCRIPTION OF EACH AFFILIATES ROLE IN PROMOTING HEALTH WITHIN THE COMMUNITIES SERVED IS AS FOLLOWS:PROHEALTH CARE, INC. - HELPS TO MANAGE THE HOSPITALS TO ENSURE THEY CAN PROMOTE HEALTH AND WELLNESS WITHIN THE COMMUNITY.NATIONAL REGENCY OF NEW BERLIN, INC. - OWNS AND OPERATES SENIOR LIVING CENTERS AS A MEANS TO PROMOTE HEALTH WITHIN THE COMMUNITY.PROHEALTH HOME CARE, INC. - PROVIDES HOSPICE AND HOME HEALTH CARE SERVICES AS A MEANS TO PROMOTE HEALTH WITHIN THE COMMUNITY.PROHEALTH CARE FOUNDATION, INC. - SUPPORTS THE CHARITABLE MISSION OF WAUKESHA MEMORIAL HOSPITAL AND OCONOMOWOC MEMORIAL HOSPITAL SO THAT IT MAY PROVIDE HEALTH SERVICES WITHIN THE COMMUNITY.PROHEALTH CARE MEDICAL ASSOCIATES, INC. - OPERATES 18 CLINIC AND URGENT CARE LOCATIONS THROUGHOUT WAUKESHA COUNTY AND THE SURROUNDING COMMUNITIES. PROHEALTH CARE MEDICAL ASSOCIATES FULFILLS ITS EXEMPT PURPOSE BY PROVIDING CARE AND SERVICES TO ALL PATIENTS REGARDLESS OF INSURANCE OR ABILITY TO PAY. PROHEALTH CARE MEDICAL ASSOCIATES PROVIDED 393,313 CLINIC VISITS DURING THE FISCAL YEAR ENDED SEPTEMBER 30, 2013.WAUKESHA MEMORIAL HOSPITAL, INC. - PROVIDES CARE AND SERVICES TO ALL PATIENTS REGARDLESS OF INSURANCE OR ABILITY TO PAY. WAUKESHA MEMORIAL HOSPITAL ALSO USES ITS RESOURCES TO ADDRESS VARIOUS COMMUNITY NEEDS. WAUKESHA MEMORIAL HOSPITAL PROVIDED APPROXIMATELY 58,666 DAYS OF INPATIENT CARE AND APPROXIMATELY 274,238 OUTPATIENT VISITS DURING THE FISCAL YEAR ENDED SEPTEMBER 30, 2013. REPORTS FILED WITH STATES PART VI, LINE 7 WI 0 PROHEALTH CARE INC N17 W24100 RIVERWOOD DR STE 200 WAUKESHA WI 531881131 391486873 501(C)(3) 2997500 N/A N/A TO ASSIST OCONOMOWOC MEMORIAL HOSPITAL IN ITS CHARITABLE MISSION. 1 X X X X 0 1 0 0 0 1 1 0 0 SUSAN EDWARDS 0 710875 0 348385 0 3036 0 731425 0 17572 0 1811293 0 313385 JOHN ROBERTSTAD 0 435968 0 176743 0 5074 0 241099 0 31843 0 890727 0 176743 NANINE M NELSON 0 352255 0 124984 0 1163 0 177592 0 30688 0 686682 0 124984 MARK A ZWASKA 131964 0 2354 0 694 0 18791 0 10048 0 163851 0 2354 0 JUDITH MOONEY 2032 116253 219 1775 0 0 0 16874 0 18022 2251 152924 0 0 PART I, LINE 4B NAME: NANINE NELSON SUSAN EDWARDS PROHEALTH CARE INC. (PHC) MAINTAINS A SUPPLEMENTAL RETIREMENT PLAN (SERP) FOR A SELECT GROUP OF EXECUTIVES OF PHC AND ITS AFFILIATED ENTITIES. THE SERP IS AN UNFUNDED, NONQUALIFIED DEFERRED COMPENSATION PLAN THAT IS INTENDED TO COMPLY WITH SECTION 457(F) OF THE INTERNAL REVENUE CODE. BENEFITS UNDER THE SERP ARE TAXABLE TO THE PARTICIPATING EXECUTIVES WHEN SUCH AMOUNTS ARE VESTED. PART I, LINE 6 PRO HEALTH CARE HAS A LEADERSHIP INCENTIVE PROGRAM FOR LEADERS OF THE CORPORATION AND RELATED ORGANIZATIONS (COLLECTIVELY THE "SYSTEM"). THE PLAN RELATES FINANCIAL REWARD TO THE SYSTEM'S ACHIEVEMENT OF CERTAIN FINANCIAL AND NON-FINANCIAL OBJECTIVES. THE PRIMARY PURPOSE OF THE PLAN IS TO SUPPORT THE SYSTEM'S MISSION TO ACHIEVE CONTINUED GROWTH AND DEMONSTRATE VALUE THROUGH: (1) A SEAMLESS CONTINUUM OF PATIENT CENTERED CARE; (2) NATIONALLY RECOGNIZED OUTCOMES; (3) RESPONSIBLE AND EFFICIENT USE OF HEALTH CARE RESOURCES; AND (4) A FOCUS ON THE HEALTH OF OUR COMMUNITY. SUPPLEMENTAL INFORMATION PART III SCHEDULE J, PART I THIS ENTITY RELIED ON A RELATED ORGANIZATION THAT USED THE FOLLOWING METHODS TO ESTABLISH COMPENSATION FOR OFFICERS AND DIRECTORS: 1. COMPENSATION COMMITTEE 2. COMPENSATION STUDY 3. APPROVAL OF THE BOARD ANNUALLY APPROVING COMPENSATION AMOUNTS 4. INDEPENDENT COMPENSATION CONSULTANT A WISCONSIN HEALTH & EDUCATIONAL FACILITIES 391337855 97710BDJ8 2008-08-14 14575000 CURRENT REFUND BONDS ISSUED ON 4/25/01 AND ON 6/09/04 0 0 0 B WISCONSIN HEALTH & EDUCATIONAL FACILITIES 391337855 97710BGZ9 2009-04-30 68825452 ADDITION AND RENOVATIONS TO EXISTING HOSPITAL FACILITY 0 0 0 C WISCONSIN HEALTH & EDUCATIONAL FACILITIES 391337855 97710BB50 2011-02-16 3639214 CURRENT REFUND BONDS ISSUED ON 11/14/95 AND ON 5/13/99 0 0 0 A 931178 14091525 112530 85640 13893355 2007 1 0 1 1 B 6212345 61944963 6275521 895907 61049056 2010 0 0 1 1 C 1165000 3639214 67832 3571383 2001 1 0 1 1 A 0 0 1 1 0 0.00000 0.00000 0.00000 0 0 0 B 0 0 1 1 0 0.00000 0.00000 0.00000 0 0 0 C 0 0 1 1 0 0.00000 0.00000 0.00000 0 0 0 A 0 0 1 0 1 0 0 0 0 B 0 0 1 0 0 0 0 0 0 C 0 0 1 0 0 0 0 0 0 A 0 B 0 C 0 SCH K, PART I, LINE A COLUMNS (C),(E) PART I, A (C) CUSIP #: THE CUSIP # OF 97710BDH2 ON FORM 8038 WAS NOT THE NUMBER ON THE BOND OF THE LATEST MATURITY. THE NUMBER FOR THE LATEST MATURITY IS CORRECTLY REPORTED ON SCHEDULE K. PART I, A (E) ISSUE PRICE: THE TOTAL ISSUE PRICE ON FORM 8038 IS $122,535,000. THE AMOUNT REPORTED ON SCHEDULE K IS ONLY THE AMOUNT OF THE ISSUE BENEFITING THE REPORTING ORGANIZATION. SCH K, PART I, LINE B COLUMNS (C),(E) PART I, B (C) CUSIP #: THE CUSIP # OF 97710BGW6 ON FORM 8038 WAS NOT THE NUMBER ON THE BOND OF THE LATEST MATURITY. THE NUMBER FOR THE LATEST MATURITY IS CORRECTLY REPORTED ON SCHEDULE K. PART I, B (E) ISSUE PRICE: THE TOTAL ISSUE PRICE ON FORM 8038 IS $134,951,867.50. THE AMOUNT REPORTED ON SCHEDULE K IS ONLY THE AMOUNT OF THE ISSUE BENEFITING THE REPORTING ORGANIZATION. SCH K, PART I, LINE C COLUMNS (C),(E) PART I, C (C) CUSIP #: THE CUSIP # OF 97710BB50 ON FORM 8038 WAS NOT THE NUMBER ON THE BOND OF THE LATEST MATURITY. THE NUMBER FOR THE LATEST MATURITY IS CORRECTLY REPORTED ON SCHEDULE K. PART I, C (E) ISSUE PRICE: THE TOTAL ISSUE PRICE ON FORM 8038 IS $35,678,572.65. THE AMOUNT REPORTED ON SCHEDULE K IS ONLY THE AMOUNT OF THE ISSUE BENEFITING THE REPORTING ORGANIZATION. SCH K, PART II, COLUMN A PART II, COL A, LINE 3 - TOTAL PROCEEDS OF ISSUE: SALE PROCEEDS OF ISSUE IN AMOUNT OF $14,091,525 ALLOCABLE TO REPORTING ORGANIZATION PLUS ZERO INVESTMENT PROCEEDS. PART II, COL A, LINE 6 - PROCEEDS IN REFUNDING ESCROWS: PROCEEDS IN THE AMOUNT OF $13,893,355 ALLOCABLE TO REPORTING ORGANIZATION DEPOSITED IN REFUNDING ESCROWS ON 8/14/08; BALANCE ON 9/30/13 IS ZERO. PART II, COL A, LINE 7 - ISSUANCE COSTS FROM PROCEEDS: $112,530 OF PROCEEDS ALLOCABLE TO REPORTING ORGANIZATION USED FOR ISSUANCE COSTS; $85,640 USED FOR CREDIT ENHANCEMENT. PART II, COL A, LINE 13 - YEAR OF SUBSTANTIAL COMPLETION: YEAR OF SUBSTANTIAL COMPLETION OF PROJECTS FINANCED WITH REFUNDED PRIOR BONDS ISSUED 4/25/01 WAS 2001 AND YEAR OF SUBSTANTIAL COMPLETION OF PROJECTS FINANCED WITH REFUNDED PRIOR BONDS ISSUED 6/09/04 WAS 2007. SCH K, PART II, COLUMN B PART II, COL B, LINE 3 - TOTAL PROCEEDS OF ISSUE: SALE PROCEEDS OF ISSUE IN AMOUNT OF $68,825,452 ALLOCABLE TO REPORTING ORGANIZATION PLUS $2,056 OF INVESTMENT PROCEEDS ALLOCABLE TO REPORTING ORGANIZATION LESS SALE PROCEEDS IN THE AMOUNT OF $6,882,545 DEPOSITED IN REASONABLY REQUIRED RESERVE FUND ALLOCABLE TO REPORTING ORGANIZATION. SCH K, PART II, COLUMN C PART II, COL C, LINE 3 - TOTAL PROCEEDS OF ISSUE: SALE PROCEEDS OF ISSUE IN AMOUNT OF $3,639,214.41 ALLOCABLE TO REPORTING ORGANIZATION PLUS ZERO INVESTMENT PROCEEDS. PART II, COL C, LINE 6 - PROCEEDS IN REFUNDING ESCROWS: PROCEEDS IN THE AMOUNT OF $3,571,383 ALLOCABLE TO REPORTING ORGANIZATION DEPOSITED IN REFUNDING ESCROWS ON 2/16/11; BALANCE ON 9/30/13 IS ZERO. PART II, COL C, LINE 13 - YEAR OF SUBSTANTIAL COMPLETION: YEAR OF SUBSTANTIAL COMPLETION OF PROJECTS FINANCED WITH REFUNDED PRIOR BONDS ISSUED 11/14/95 WAS 1995 AND YEAR OF SUBSTANTIAL COMPLETION OF PROJECTS FINANCED WITH REFUNDED PRIOR BONDS ISSUED 5/13/99 WAS 2001. SCH K IN 2012, PHC REFUNDED A PORTION OF THE 2009 BOND ISSUE, THE OMH PORTION IS INCLUDED IN THE BONDS RETIRED. ASSOCIATED WITH THE REFUNDING THE 2009 DEBT SERVICE RESERVE FUND WAS REDUCED BY $1,190,243.80 OF WHICH $607,024.34 IS OMH'S ALLOCATED REDUCTION. RADIOLOGY WAUKESHA BOARD MEMBER, GARY BEYER, IS A PARTNER AT RADIOLOGY WAUKESHA 154870 RADIOLOGY WAUKESHA PROVIDES IMAGING SERVICES FOR OMH. 0 LAKE COUNTRY ENDOSCOPY CENTER BOARD MEMBER JOHN ROBERTSTAD IS AN OFFICER OF LAKE COUNTRY ENDOSCOPY CENTER 569234 INVESTMENT DISTRIBUTIONS AND RENTAL EXPENSES 0 WAUKESHA HEALTH SYSTEM INC BOARD MEMBER, JOHN ROBERTSTAD, IS AN OFFICER OF WAUKESHA HEALTH SYSTEM 1117416 WAUKESHA HEALTH SYSTEM PROVIDES REIMBURSEMENT OF EXPENSES TO OMH. 0 FORM 990, PART VI, SECTION A, LINE 3 DAVID EBEL WAS COMPENSATED BY WARBIRD CONSULTING, A MANAGEMENT COMPANY, FOR SERVICES AS INTERIM CFO FOR OCONOMOWOC MEMORIAL HOSPITAL, INC. AND RELATED ORGANIZATIONS. WARBIRD CONSULTING WAS NOT PAID ANY COMPENSATION IN CALENDAR YEAR 2012, AS SERVICES DID NOT COMMENCE UNTIL 2013. BEGINNING IN MAY 2013, COMPENSATION WAS PAID TO WARBIRD CONSULTING BY PROHEALTH CARE, INC., THE PARENT ORGANIZATION. FORM 990, PART VI, SECTION A, LINE 6 PROHEALTH CARE, INC. IS THE SOLE CORPORATE MEMBER. FORM 990, PART VI, SECTION A, LINE 7B PROHEALTH CARE INC. HOLDS CERTAIN RESERVED POWERS OVER THE (NON-STOCK) CORPORATION INCLUDING APPROVAL OF STRATEGIC PLANNING, ANNUAL OPERATING AND CAPITAL BUDGETS, BORROWING, TRANSFER, LEASE, PLEDGE OR SALE OF ASSETS. FORM 990, PART VI, SECTION B, LINE 11 AFTER THE FORM 990 WAS PREPARED BY THE ORGANIZATION'S TAX PREPARERS AND PRIOR TO FILING THE FORM 990, SELECT EXECUTIVE MEMBERS OF THE ORGANIZATION AND THE AUDIT & COMPLIANCE COMMITEE PERFORMED A REVIEW. THEN THE ORGANIZATION'S TAX PREPARERS MADE A PRESENTATION TO THE AUDIT COMMITTEE, AND THE BOARD OF DIRECTORS WAS PROVIDED A COPY OF THE RETURN, WHICH WAS SUBSEQUENTLY FILED BY THE ORGANIZATION. FORM 990, PART VI, SECTION B, LINE 12C ALL OFFICERS, VICE-PRESIDENTS, MANAGERS AND ABOVE, AS WELL AS BOARD MEMBERS ARE REQUIRED TO ANNUALLY COMPLETE A CONFLICT OF INTEREST FORM. ALL REPORTED POTENTIAL CONFLICTS OF INTEREST ARE TRACKED IN THE CORPORATE COMPLIANCE DEPARTMENT. THEY ARE REVIEWED AND ANY PERSON IDENTIFIED AS HAVING A POTENTIAL CONFLICT IS GIVEN DIRECTION AS TO WHAT STEPS SHOULD BE TAKEN TO MITIGATE THE CONCERN. ALL EMPLOYEES ARE EDUCATED ANNUALLY. THE STEPS TAKEN WHEN A CONFLICT ARISES ARE AS FOLLOWS: FOR THE BOARD OF DIRECTORS, THE RESTRICTION IS NOT BEING ALLOWED TO PARTICIPATE IN DISCUSSION OR VOTING RELATED TO ANY DECISION WHERE THE BOARD MEMBER HAS BEEN DETERMINED TO HAVE A CONFLICT OF INTEREST. FOR LEADERS, RESEARCHERS, AND EMPLOYEES, RECOMMENDATIONS ARE MADE FROM COMPLIANCE MANAGER TO LEADERSHIP AND/OR HUMAN RESOURCES. RESTRICTIONS CAN RANGE FROM ANY OF THE FOLLOWING: DISCLOSING POTENTIAL CONFLICTS OF INTEREST TO PATIENTS; NOT BEING ABLE TO BE INVOLVED IN DISCUSSION OR DECISION MAKING ON SPECIFIC TOPICS; AND NOT BEING ABLE TO WORK AT PROHEALTH IN THE SPECIFIC ROLE WHERE THE REPORTED CONFLICT EXISTS. IF THE RECOMMENDATION IS CHALLENGED, THE MATTER GOES TO THE SENIOR EXECUTIVE TEAM FOR A DECISION. FORM 990, PART VI, SECTION B, LINE 15 AN INDEPENDENT, EXTERNAL COMPENSATION REVIEW IS CONDUCTED FOR THE POSITIONS OF CEO/PRESIDENT, EXECUTIVE DIRECTOR, VICE-PRESIDENT, SENIOR VICE-PRESIDENT AND ABOVE. THE RESULTS OF THE COMPENSATION REVIEW ARE PRESENTED TO THE BOARD'S EXECUTIVE COMMITTEE FOR APPROVAL. ANY MEMBER OF THE EXECUTIVE COMMITTEE WHOSE SALARY IS INCLUDED IN THE SALARY REVIEW IS RECUSED FROM THE APPROVAL PROCESS FOR HIS/HER SALARY APPROVAL. THIS PROCESS WAS LAST DONE IN 2013. FORM 990, PART VI, SECTION C, LINE 19 FINANCIAL STATEMENTS, GOVERNING DOCUMENTS & CONFLICT OF INTEREST POLICY ARE AVAILABLE UPON REQUEST. FORM 990, PART VI, SECTION B, LINE 16B: THE PROCESS IS TO HAVE ALL JOINT VENTURE ARRANGEMENTS REVIEWED BY THE LEGAL DEPARTMENT TO ENSURE IT MEETS ALL LEGAL REQUIREMENTS AND TO ENSURE THAT OCONOMOWOC MEMORIAL HOSPITAL, INC. MAY RETAIN ITS EXEMPT STATUS. OTHER FEES FORM 990, PART IX, LINE 11G PHYSICIAN FEES: PROGRAM SERVICE EXPENSES 709,420. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 709,420. PHCMA SUBSIDIES: PROGRAM SERVICE EXPENSES 2,014,980. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,014,980. AGENCY STAFFING: PROGRAM SERVICE EXPENSES 1,124,635. MANAGEMENT AND GENERAL EXPENSES 24,676. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,149,311. LINEN SERVICES: PROGRAM SERVICE EXPENSES 277,666. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 277,666. OUTSIDE SERVICES: PROGRAM SERVICE EXPENSES 2,516,585. MANAGEMENT AND GENERAL EXPENSES 363,471. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,880,056. PHC SERVICES: PROGRAM SERVICE EXPENSES 13,568,238. MANAGEMENT AND GENERAL EXPENSES 1,490,850. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 15,059,088. MAINTENANCE CONTRACTS: PROGRAM SERVICE EXPENSES 3,724,844. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 3,724,844. SEND OUT LAB WORK: PROGRAM SERVICE EXPENSES 263,517. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 263,517. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 9: TRANSFER OF NET ASSETS TO RELATED ORGANIZATION -335,084. PENSION-RELATED CHANGES 5,746,514. INTEREST IN NET ASSETS OF RELATED ORGANIZATION -7,330,002. FORM 990, PART XII, LINE 2C: THE AUDIT PROCESS HAS NOT CHANGED IN THE CURRENT YEAR. 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