2013-10-24T14:23:50-05:00 2012-12-31 390758449 WIPFLI LLP PO BOX 12237 GREEN BAY WI 543072237 990 2012-01-01 390824015 APPLETON MEDICAL CENTER INC APPL 9207355560 PO BOX 8025 APPLETON WI 54912 TIM A OLSON 9207355560 2013-10-14 1 TERRI REXRODE CPA MST P00096513 9206620016 2013-10-14 2012 2016-02-24 21:20:13Z TIM A OLSON PO BOX 8025 APPLETON WI 54912 229809299 0 X WWW.THEDACARE.ORG X 1958 WI TO IMPROVE THE HEALTH OF OUR COMMUNITY. 15 11 0 569 900487 -209199 5415 72824 226654684 229158631 189306 421053 1303493 156791 228152898 229809299 750000 8000 0 0 140942437 107238432 0 0 0 109251555 108919506 250943992 216165938 -22791094 13643361 317424671 326853142 1919036 1611587 315505635 325241555 TO PROVIDE THE HIGHEST QUALITY HEALTH CARE, DELIVERED IN THE MOST EFFICIENT AND COST-EFFECTIVE WAYS, AND ACCESSIBLE TO ALL MEMBERS OF THE COMMUNITY. 0 0 184251723 8000 226975780 160-BED ACUTE CARE HOSPITAL, HEART, CANCER, AND OUTPATIENT SURGERY CENTERS, AND WELLNESS PROGRAMS. WITH CORPORATE PARENT THEDACARE, WE OFFER PUBLIC AWARENESS CAMPAIGNS, CHARITY CARE, SUPPORT GROUPS, AND EDUCATION PROGRAMS TARGETED TO LOCAL COMMUNITY NEEDS. 184251723 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 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 0 1 1 0 0 0 0 0 0 0 0 0 X 15 11 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 X KRISTEN COGSWELL 9207386471 122 EAST COLLEGE AVENUE APPLETON WI 54911 STELLMACHERJON 1.00 2.00 X X 0 0 0 MALANOWSKIJOHN 1.00 2.00 X X 0 0 0 SWANSONJACK MD 1.00 2.00 X X 0 0 0 WELLERMIKE 1.00 2.00 X X 0 0 0 ANDERLADAVID MD 1.00 43.00 X X 0 308202 33534 ATTASSIOMAR MD 1.00 3.00 X 0 0 0 CONNOLLY-KEESLEREILEEN 1.00 2.00 X 0 0 0 DAVISJOHN 1.00 2.00 X 0 0 0 EDELMANGARY MD 1.00 42.00 X 0 414561 36509 GRUNERDEAN 7.00 36.00 X 141210 800191 202822 JONESGINGER 1.00 2.00 X 0 0 0 LARSONJIM 1.00 4.00 X 0 0 0 MEYERJIM 1.00 3.00 X 0 0 0 MOARD DOUGLAS MD 1.00 42.00 X 0 289772 37000 TIMBERLAKEKAREN 1.00 2.00 X 0 0 0 WHITESIDEJEFFREY MD 1.00 2.00 X 0 0 0 OLSONTIM 6.00 36.00 X 67336 381573 109293 BARNASKIM 10.00 30.00 X 87584 262753 115579 LIVINGSTONKEITH 6.00 34.00 X 57036 323207 96814 PISTONEMAUREEN 6.00 34.00 X 47643 269973 87634 FERRANTEROBERT MD 40.00 0.00 X 738570 0 29974 FLETCHER WILLIAM MD 40.00 0.00 X 590128 0 37445 ROSELAAR SIMON MD 40.00 0.00 X 590733 0 38295 WILSONROBERT MD 40.00 0.00 X 595834 0 36641 MIELKEDOUGLAS MD 40.00 1.00 X 590870 0 36703 CORREIAKATHRYN 0.00 0.00 X 62838 146624 0 3569782 3196856 898243 67 1 1 0 GROWTH GROUP LLC 200 E WASHINGTON ST APPLETON WI 54912 MANAGEMENT SERVICES 800000 FRESENIUS MANAGEMENT SVCS INC 16343 COLLECTION CENTER DR CHICAGO IL 60693 MANAGEMENT SERVICES 282675 FOX VALLEY PATHOLOGISTS SC 325 N COMMERCIAL STREET NEENAH WI 54956 MEDICAL SERVICES 256618 FOX VALLEY HEMATOLOGY ONCOLOGY 900 E GRANT STREET APPLETON WI 54911 MEDICAL SERVICES 193674 RADIOLOGY ASSOCIATES OF APPLETON PO BOX 117 APPLETON WI 54912 MEDICAL SERVICES 173894 5 30071 42753 72824 OUTPATIENT REVENUE 621400 124748290 124748290 INPATIENT REVENUE 621990 100959562 100959562 OTHER MISC REVENUE 900099 1267928 1267928 LAB REFERRAL REVENUE 621500 900487 900487 CAFETERIA REVENUE 900099 721900 721900 560464 560464 229158631 29237 29237 156791 0 156791 156791 156791 391816 0 391816 391816 391816 229809299 226975780 900487 1860208 X 8000 8000 3569782 3569782 80373928 66575140 13798788 3263448 3263448 14985699 11899923 3085776 5045575 5045575 800000 800000 31068828 21676852 9391976 5376 5376 39771954 38504061 1267893 6185162 6185162 94358 94358 274410 274410 6187465 6187465 16395633 16395633 484605 484605 BAD DEBT EXPENSE 4196595 4196595 EQUIPMENT MAINTENANCE 3455120 3455120 216165938 184251723 31914215 0 3299 3500 27914377 25957519 798277 1061453 218052998 110631314 114825011 107421684 173883707 192408986 317424671 326853142 1790446 1577821 128590 33766 1919036 1611587 X 315504587 325240507 1048 1048 315505635 325241555 317424671 326853142 X 13643361 2275 -3909716 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 6514 6514 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: PORTION OF WHA DUES = $6,514 2384215 2384215 142812901 57515217 85297684 598160 595430 2730 72257722 52520667 19737055 107421684 DUE FROM AFFILIATES 192408986 192408986 MORTGAGES DUE AND LOANS PAYABLE 33766 33766 X DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X, LINE 2: IN ORDER TO ACCOUNT FOR ANY UNCERTAIN TAX POSITIONS, THEDACARE 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. THEDACARE RECORDED NO ASSETS OR LIABILITIES RELATED TO UNCERTAIN TAX POSITIONS IN 2012 AND 2011. TAX RETURNS FOR THE YEARS ENDED 2009 AND BEYOND REMAIN SUBJECT TO EXAMINATION BY THE INTERNAL REVENUE SERVICE. 1 1 X 1 X 1 X 1 0 1 1 2346025 2346025 0.01110 17419718 12219983 5199735 0.02450 19765743 12219983 7545760 0.03560 24 1095094 1907710 240 1907470 0.00900 4 994 749020 4500 744520 0.00350 4 6065207 6065207 0.02860 3 2765 357377 39230 318147 0.00150 6 232542 785757 785757 0.00370 41 1331395 9865071 43970 9821101 0.04630 41 1331395 29630814 12263953 17366861 0.08190 1 3238 3238 0.00000 1 1253 1253 0.00000 1 268 2098 2098 0.00000 1 46 1639 1639 0.00000 1 325 4916 4916 0.00000 1 40000 1686 1686 0.00000 1 108066 108066 0.00050 1 18836 42958 42958 0.00020 8 59475 165854 165854 0.00070 0 3764479 2016091 36952511 38184652 -1232141 X 1 1 1 1 APPLETON MEDICAL CENTER

PO BOX 8025 APPLETON WI 54912

X X X APPLETON MEDICAL CENTER 1 0 1 1 200.000000000000 1 300.000000000000 1 X X X X X X X 1 1 X X X X X 1 0 1 X 0 0 1 GROTH SURGERY CENTER

PO BOX 8025 APPLETON WI 54912

OUTPATIENT SURGERY CENTER PART I, LINE 7: THE COSTING METHODOLOGY USED TO CALCULATE THE AMOUNTS IN THE TABLE IS A COMBINATION OF AVERAGE COSTS AND ACTUAL COSTS PERTAINING TO SUPPLIES, WAGES, AND BENEFITS. FOR SUPPLIES, THE ACTUAL COST OF ITEMS USED FOR EACH EVENT IS APPLIED. IF NO ACTUAL COST IS AVAILABLE, WE THEN USE AN ESTIMATE. WAGES ARE CALCULATED BY MULTIPLYING THE AVERAGE WAGE RATE TIMES ACTUAL HOURS WORKED. THE BENEFIT RATE USED INCLUDES A FRINGE RATIO OF ALL BENEFITS RELATED TO THE ABOVE WAGE CALCULATION. THE COST ACCOUNTING SYSTEM DOES NOT DIFFERENTIATE BETWEEN DIFFERENT PAYER TYPES AND NO COST-TO-CHARGE RATIO IS USED. PART I, LINE 7G: NO PHYSICIAN CLINICS ARE INCLUDED IN SUBSIDIZED HEALTH SERVICES. PART I, L7 COL(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 $4,196,595. PART II: THE HEALTH OF THE COMMUNITY APPLETON MEDICAL CENTER SERVES IS PROMOTED THROUGH SEVERAL COMMUNITY BUILDING ACTIVITIES AS DESCRIBED BELOW:-WELL CITY INITIATIVE: PROMOTES DEVELOPMENT OF A HEALTHY WORKPLACE THROUGH FOX CITIES.-NEW MENTAL HEALTH CONNECTION: COALITION OF MENTAL HEALTH PROVIDERS THAT MEETS TO IMPROVE ACCESS TO MENTAL HEALTH SERVICES THROUGHOUT FOX CITIES.-CHAMBER OF COMMERCE SUPPORT: ENCOURAGES ECONOMIC DEVELOPMENT WHICH IN TURN PROVIDES JOBS AND INCOME, BOTH CONTRIBUTORS TO HEALTH.-VOICES OF MEN: WORKS TO ADDRESS THE ROOT CAUSE OF VIOLENCE AGAINST WOMEN AND GIRLS WHICH INCLUDES DEVALUING AND OBJECTIFYING WOMEN AND TREATING WOMEN AS PROPERTY. -MENTAL HEALTH SUMMIT: COMMUNITY GATHERING TO IDENTIFY WHAT MENTAL HEALTH STAKEHOLDERS WANT TO DO ABOUT ACCESS TO CARE.-NO WRONG DOOR: EFFORT TO DEVELOP COMMUNITY WIDE MENTAL HEALTH SAFETY NET.-GLBT PLUNGE: DAY-LONG COMMUNITY FIELD TRIP TO CREATE UNDERSTANDING OF CHALLENGES FACED BY GLBT COMMUNITY. RELATED TO HEALTH SINCE GLBT POPULATION HAS DEPRESSION AND SUICIDE RATES MORE THAN TWICE THAT OF GENERAL POPULATION.-REBUILDING TOGETHER PROJECT DAY: ASSIST DISABLED HOMEOWNER WITH HOME REPAIR. HELPS KEEP RESIDENT INDEPENDENTLY LIVING AT HOME.DISASTER READINESS HELPS ENSURE THE ENTIRE COMMUNITY IS READY FOR POTENTIAL EMERGENCIES. -PSYCHIATRIST RECRUITMENT: IMPROVES MENTAL HEALTH OF COMMUNITY. COMMUNITY ACTION FOR HEALTHY LIVING COALITION THAT ADVOCATES FOR HEALTHY LIFESTYLE CHANGE. -THEDACARE NEIGHBORHOOD GARDEN: PROVIDES FRESH PRODUCE TO AREA FOOD PANTRIES. PART III, LINE 2 IT IS THE ORGANIZATION'S POLICY THAT NO PATIENT SHOULD BE DENIED APPROPRIATE AND NECESSARY CARE ON THE BASIS OF INCOME. IN RESPONSE TO THIS POLICY, THE CARING HEARTS FINANCIAL ASSISTANCE PROGRAM WAS SET UP TO PROVIDE SHELTER TO THOSE PATIENTS WHO ARE UNABLE TO PAY FOR THEIR MEDICAL SERVICES. MEDICAL SERVICE FEES ARE WRITTEN OFF UNDER THE FINANCIAL ASSISTANCE PROGRAM THAT WOULD OTHERWISE HAVE BEEN SENT TO A COLLECTION AGENCY. PART III, LINE 3 OVERDUE PATIENT ACCOUNTS ARE SENT THREE STATEMENTS BEGINNING THE MONTH AFTER THE ACCOUNT BECOMES OVERDUE. IF NO PAYMENT IS MADE DURING THIS PERIOD A FINAL LETTER IS SENT GIVING NOTICE OF THE OVERDUE ACCOUNT AND NOTIFYING THE INDIVIDUAL THAT THE AMOUNT WILL GO INTO COLLECTIONS. AT THIS POINT, THE AMOUNT IS MARKED AS BAD DEBT. PART III, LINE 4: A COST-TO-CHARGE RATIO WAS USED TO DETERMINE THE AMOUNTS REPORTED IN PART III LINES 2 AND 3. PATIENT PAYMENTS OR DISCOUNTS ARE APPLIED PRIOR TO DETERMINING BAD DEBT EXPENSE AND ARE NOT INCLUDED IN THE BAD DEBT WRITE-OFF REPORTED ON THE AUDITED FINANCIAL STATEMENTS. DEDUCTIBLES AND COINSURANCE AMOUNTS THAT ARE DEEMED UNCOLLECTIBLE ARE WRITTEN OFF EITHER TO BAD DEBT EXPENSE OR, IF APPLICABLE, TO CHARITY CARE IF THE PATIENT SO QUALIFIES FOR FINANCIAL ASSISTANCE. THE FINANCIAL STATEMENTS DO NOT CONTAIN A FOOTNOTE BUT THEY ACCOUNT FOR BAD DEBTS BASED ON GROSS CHARGES TO PATIENTS AFTER REFLECTING ANY PAYMENTS OR DISCOUNTS, OR AMOUNTS DETERMINED TO BE ELIGIBLE FOR CHARITY CARE/FINANCIAL ASSISTANCE. PART III, LINE 8: HOSPITALS MUST ACCEPT MEDICARE PATIENTS REGARDLESS OF WHETHER THEY MAKE A SURPLUS OR DEFICIT FROM PROVIDING SERVICES TO THOSE PATIENTS. WE DID NOT REPORT ANY SHORTFALL AS A COMMUNITY BENEFIT. THE COSTING METHODOLOGY USED TO DETERMINE THE MEDICARE ALLOWABLE COSTS REPORTED IN THE ORGANIZATIONS MEDICARE COST REPORT IS STEP DOWN. PART III, LINE 9B: OUR POLICY IS NOT TO PURSUE PATIENT ACCOUNTS TO THE EXTENT ANY CHARGES ARE ELIGIBLE AND WRITTEN OFF THROUGH OUR CHARITY CARE/FINANCIAL ASSISTANCE PROGRAM. IF ONLY A PORTION OF THE CHARGES ARE ELIGIBLE AND WRITTEN OFF THROUGH OUR CHARITY CARE/FINANCIAL ASSISTANCE PROGRAM, THE REMAINING BALANCE WILL BE BILLED TO THE PATIENT AND COLLECTED IN ACCORDANCE WITH OUR NORMAL COLLECTION POLICY. PART V, LINE 13 PATIENTS ARE SENT AN OVERVIEW LETTER EXPLAINING THE PROCESS FOR APPLYING FOR OUR ASSISTANCE PROGRAM OR OUR STAFF WALKS THEM THROUGH THE PROCESS. THEY ARE ASKED TO COMPLETE AN APPLICATION THAT INCLUDES REQUESTS FOR INFORMATION. THIS INFORMATION IS NEEDED IN ORDER TO MAKE A DECISION AS TO WHETHER THE PATIENT MEETS THE CRITERIA FOR ACCEPTANCE, AND IF ACCEPTED, WHAT LEVEL OF ASSISTANCE WILL BE PROVIDED. ONCE THE DECISION IS MADE, WE WILL NOTIFY THE PATIENT AND IF ACCEPTABLE, WRITE OFF THE BALANCE AS DETERMINED. PART VI, LINE 2: THEDACARE SERVES AN 8 COUNTY PRIMARY SERVICE AREA. FIVE THEDACARE HOSPITALS PROVIDE SERVICE IN THIS AREA. THEDACARE CONDUCTS A COMMUNITY NEEDS ASSESSMENT EVERY THREE YEARS FOR THE ENTIRE SYSTEM GATHERING DATA PERTINENT TO EACH COMMUNITY. INFORMATION COLLECTED INCLUDES DATA FROM THE WISCONSIN COUNTY HEALTH RANKINGS, FOX CITIES LIFE STUDY (LOCAL INDICATORS FOR EXCELLENCE), THE BEHAVIORAL RISK FACTOR SURVEILLANCE SURVEY, INSIGHTS FROM INTERVIEWS OF PUBLIC HEALTH OFFICIALS, INSIGHTS FROM INTERVIEWS WITH REPRESENTATIVES OF VULNERABLE POPULATIONS, EMERGENCY DEPARTMENT PATIENT DATA AND INSIGHTS GATHERED FROM MONTHLY MEETINGS OF THE THEDACARE-LED CHAT TEAM (COMMUNITY HEALTH ACTION TEAM) COMPRISED OF 25 COMMUNITY LEADERS IN BUSINESS, NON-PROFIT, CLERGY, HEALTHCARE, UNITED WAY AND THE LOCAL COMMUNITY FOUNDATION. THE WISCONSIN STATE HEALTH PLAN IS ALSO TAKEN INTO CONSIDERATION. PART VI, LINE 3: THERE ARE SEVERAL WAYS THIS OCCURS. THE MOST PROMINENT OF THOSE BEING THROUGH OUR PATIENT HANDBOOK THAT IS PROVIDED TO ALL PATIENTS, THROUGH CONVERSATION WITH OUR CARE MANAGEMENT/DISCHARGE PLANNERS AFTER ADMISSION TO OUR HOSPITALS, AND THROUGH CONVERSATION WITH OUR COLLECTIONS STAFF. PART VI, LINE 4: THEDACARE'S SERVICE AREA (WHICH MIRRORS APPLETON MEDICAL CENTER'S SERVICE AREA) CONSISTS OF 8 COUNTIES INCLUDING OUTAGAMIE, WINNEBAGO, CALUMET, SHAWANO, WAUPACA, WAUSHARA, MENOMINEE AND GREEN LAKE. HIGHLIGHTS REGARDING THE COMMUNITIES WE SERVE INCLUDE:-TOTAL POPULATION OF THE SERVICE AREA IS 534,518. (CALUMET 46,272; OUTAGAMIE 178,500; WAUPACA 53,069; WAUSHARA 25,178; SHAWANO 42,108; GREEN LAKE 19,061; WINNEBAGO 165,755; MENOMINEE 4,575.)-POPULATION OF OUR SERVICE AREA CONTINUES TO GROW BUT THE RATE OF GROWTH IS DECLINING. BY 2016, THE SERVICE AREA POPULATION IS EXPECTED TO REACH 546,860.-WHILE OVERALL DEMOGRAPHICS OF THE SERVICE AREA DO NOT INDICATE A HIGH DEGREE OF ETHNIC DIVERSITY (ONLY 7% REPORT THEIR RACE AS NON-WHITE), WE BEGIN TO SEE THE INCREASING IMPACT OF DIVERSITY IN THE SCHOOL-AGE POPULATION. FOR EXAMPLE, 25% OF APPLETON AREA SCHOOL DISTRICT STUDENTS, 30% OF MENASHA STUDENTS, AND 22% OF SHAWANO STUDENTS, REPORT THEIR RACE AS NON-WHITE.-THE AVERAGE AGE OF THE POPULATION IS INCREASING; THE WORKING-AGE POPULATION IS DECLINING.-THERE IS A TREND TOWARD SUBURBANIZATION; CORE CITIES AND TOWNS STAY FLAT WHILE CITIES SPRAWL INTO THE SUBURBS.-THE FOX CITIES WILL GROW SLIGHTLY FASTER THAN THE REST OF NORTHEAST WISCONSIN.-THE NUMBER OF UNINSURED IN OUR SERVICE AREA IS CURRENTLY 8%.-96% OF SERVICE AREA IS CAUCASIAN WITH HISPANIC POPULATION OF 2% SEEING THE FASTEST GROWTH; 2% OF POPULATION IS HMONG HAVING ARRIVED HERE AS REFUGEES. -THE POVERTY RATE RANGES FROM 5.2% IN CALUMET COUNTY TO 11.7% IN WAUSHARA COUNTY. PART VI, LINE 5: EACH YEAR, APPLETON MEDICAL CENTER'S PARENT ORGANIZATION THEDACARE SETS ASIDE A PERCENTAGE OF EXCESS TARGETED MARGIN TO FUND AN EFFORT CALLED CHAT (COMMUNITY HEALTH ACTION TEAM). CHAT IS A GROUP OF 25 COMMUNITY LEADERS WHO STUDY SYSTEMIC HEALTH ISSUES OUTSIDE THE WALLS OF OUR HOSPITALS AND CLINICS AND WORK TO IDENTIFY INNOVATIVE, COLLABORATIVE SOLUTIONS THAT DRAW UPON THE WIDE ARRAY OF RESOURCES AND STRENGTHS OF OUR COMMUNITY. THROUGH CHAT, SUCH EFFORTS AS THE SHAWANO COUNTY RURAL HEALTH INITIATIVE HAVE BEEN DEVELOPED. THIS INITIATIVE TAKES BASIC HEALTH CARE AND SCREENING SERVICES TO THE FARM. EACH YEAR HUNDREDS OF FARM FAMILIES LIVING WITHOUT INSURANCE OR ONLY CATASTROPHIC COVERAGE RECEIVE CRITICAL ASSISTANCE. ANOTHER INITIATIVE IS THE NEW MENTAL HEALTH CONNECTION WHICH IS WORKING TO IMPROVE ACCESS TO MENTAL HEALTH SERVICES IN THE AREA. HIGH LATINO TEEN PREGNANCY RATES INSPIRED CHAT TO LAUNCH CUIDATE!, A CULTURALLY BASED TEEN PREGNANCY PREVENTION PROGRAM IN PARTNERSHIP WITH THE FOX CITIES COMMUNITY HEALTH CENTER. MAKING THE RIDE HAPPEN IS ANOTHER CHAT EFFORT THAT PROVIDES TRANSPORTATION TO OLDER ADULTS WHO OTHERWISE WOULD STAY COOPED UP IN APARTMENTS AND FIGHT DEPRESSION AND ISOLATION. PROJECT PROMISE IS A POVERTY INITIATIVE DEVELOPED THROUGH CHAT THAT BROUGHT TOGETHER MANY LOCAL AGENCIES AND BUSINESSES TO WORK TO ADDRESS POVERTY IN A COLLABORATIVE FASHION. VOICES OF MEN WAS LAUNCHED WITH SUPPORT FROM CHAT TO RAISE AWARENESS OF EVERYDAY BEHAVIORS OF MEN THAT CAN LEAD TO AN ACCEPTANCE OF VIOLENCE TOWARD WOMEN. ANOTHER RECENT INITIATIVE IS INCLUDE WHICH FOCUSES ON BUILDING INCLUSIVENESS AND TOLERANCE TO PREVENT SUICIDE AMONG THE GAY, LESBIAN, BISEXUAL, TRANSGENDER POPULATION. THE PROJECTS ARISING FROM CHAT ARE MANY. THE LIVES TOUCHED ARE NUMEROUS. THEDACARE PROVIDES FUNDING AND STAFF SUPPORT TO MAKE CHAT AND THESE COMMUNITY HEALTH EFFORTS POSSIBLE. OTHER WAYS THAT THEDACARE HOSPITALS IMPROVE THE HEALTH OF THE COMMUNITY INCLUDE:-THEDACARE SHARED ITS CUTTING EDGE APPLICATION OF LEAN PRODUCTION IMPROVEMENTS WITH VISITORS ALMOST WEEKLY IN 2012. HUNDREDS OF HEALTHCARE AND NON-HEALTHCARE VISITORS CAME FROM AROUND THE COUNTRY. MOST VISITORS WERE FROM HOSPITALS AND HEALTH SYSTEMS IN THE UNITED STATES LOOKING TO IMPROVE QUALITY AND REDUCE COSTS.-THEDACARE HOSPITALS PROVIDED SUPPORT TO THE THEDACARE CENTER FOR HEALTHCARE VALUE WHICH IS COORDINATING EFFORTS ACROSS THE COUNTRY TO SHARE QUALITY IMPROVEMENT AND COST REDUCTION LEARNINGS. -THEDACARE PARTNERS WITH THE FOX CITIES/UW RESIDENCY CENTER TO PROVIDE HANDS ON EXPERIENCE FOR MEDICAL STUDENTS.-THEDACARE ALSO PARTNERS WITH AREA NURSING SCHOOLS SUCH AS UW OSHKOSH AND FOX VALLEY TECHNICAL COLLEGE TO PROVIDE TEACHERS FOR THEIR NURSING PROGRAMS AND PROVIDES VENUES FOR NURSING STUDENTS TO PRACTICE THEIR SKILLS.-THEDACARE HOSPITALS PROVIDED FINANCIAL AS WELL AS DIAGNOSTIC AND LAB SUPPORT TO TWO AREA CLINICS PROVIDING MEDICAL AND DENTAL CARE TO THE UNDERSERVED IN OUR SERVICE AREA.-THEDACARE HOSPITAL EMPLOYEES TAKE PART IN HELPING HEARTS, AN EMPLOYEE VOLUNTEERISM PROGRAM ENCOURAGING STAFF TO GIVE OF THEIR TIME IN THE COMMUNITY. THEDACARE PROVIDES PAID STAFF TO COORDINATE THE PROGRAM AND IDENTIFY AND PROMOTE VOLUNTEERISM OPPORTUNITIES. THEDACARE EMPLOYEES DONATED MORE THAN $1,434,000 IN UNPAID VOLUNTEER HOURS TO LOCAL NON-PROFITS IN 2012.-APPLETON MEDICAL CENTER AND THEDACARE PROVIDERS HOSTED AN EAT WELL PLAY WELL CHILD HEALTH SCREENING AT THE BUILDING FOR KIDS TO EDUCATE THOUSANDS OF YOUTH ON HEALTHY NUTRITION AND EXERCISE CHOICES.-ALL THEDACARE HOSPITALS PROVIDE HEALTH EDUCATION PROGRAMMING FOR THEIR RESPECTIVE COMMUNITIES FOCUSING ON SUCH CRITICAL TOPICS AS PROPER NUTRITION, SMOKING CESSATION, DIABETES IDENTIFICATION, AND CANCER PREVENTION.-THEDACARE SPONSORS PARTY AT THE PAC FOR THOUSANDS OF AREA YOUTH TO EDUCATE YOUTH ON THE PERILS OF RISKY BEHAVIOR AND DRIVING. HOSTED AT OUR PERFORMING ARTS CENTER, LIVE DRAMATIZATIONS ALONG WITH STORIES OF YOUTH DISABLED DUE TO DRIVING AND RISKY BEHAVIOR ENCOURAGE TEENS TO THINK TWICE BEFORE DRINKING OR TEXTING AND DRIVING.-APPLETON MEDICAL CENTER STAFF WORK WITH THE AREA CHAMBER OF COMMERCE AND LOCAL HIGH SCHOOLS AND COLLEGES TO INFORM YOUTH ABOUT MEDICAL CAREER OPPORTUNITIES AND TO HELP PREPARE OUR EDUCATIONAL FACILITIES TO MEET THE HEALTHCARE STAFFING NEEDS FOR THE COMMUNITIES WE SERVE.-APPLETON MEDICAL CENTER SUPPORTS THE AMERICAN CANCER SOCIETY'S SOLE BURNER RUN AND THE AMERICAN HEART ASSOCIATIONS HEART WALK EVENTS TO HELP RAISE FUNDS FOR THE NON-PROFIT ORGANIZATIONS.-APPLETON MEDICAL CENTER STAFF SUPPORT THE THEDACARE NEIGHBORHOOD GARDEN WHICH SUPPLIES PRODUCE TO THE LOCAL EMERGENCY SHELTER.-APPLETON MEDICAL CENTER SUPPLIES ATHLETIC TRAINING SERVICES TO AREA HIGH SCHOOLS AT REDUCED COST.-APPLETON MEDICAL CENTER ORGANIZES SUPPORT GROUPS FOR CANCER AND DIABETES AND PROVIDES A TELEPHONE HOTLINE FOR NUTRITION COUNSELING.-APPLETON MEDICAL CENTER MAKES FINANCIAL AND IN-KIND DONATIONS TO NON-PROFIT ORGANIZATIONS INCLUDING UNITED WAY, AREA SCHOOLS, AMERICAN HEART ASSOCIATION, AMERICAN CANCER SOCIETY AND REBUILDING TOGETHER.-THEDA CARE STAFF PARTICIPATE IN LEADERSHIP FOX CITIES TO GROOM MIDDLE MANAGERS IN THE WORKINGS OF THE ENTIRE COMMUNITY, FROM EDUCATION SYSTEMS AND RECYCLING PROGRAMS TO GOVERNMENT AND JUSTICE SYSTEMS. -APPLETON MEDICAL CENTER STAFF ARE INVOLVED IN STATEWIDE AND REGIONAL DISASTER READINESS PLANNING TO PREPARE OUR COMMUNITY FOR TIMES OF CRISIS.-APPLETON MEDICAL CENTER STAFF PARTICIPATED IN A THEDACARE-WIDE REBUILDING TOGETHER EVENT WHERE STAFF SPENT THE DAY FIXING UP THE HOME OF A LOCAL FAMILY IN NEED.-THEDACARE PRESIDENT AND CEO IS ENGAGED IN STATEWIDE WISCONSIN COLLABORATIVE FOR HEALTHCARE QUALITY MAKING QUALITY HEALTHCARE DATA TRANSPARENT. PART VI, LINE 6: THEDACARE, THE PARENT ORGANIZATION, PROVIDES DIRECTION RELATED TO COMMUNITY NEEDS ASSESSMENT FOR ALL HOSPITALS AND MARKETS WITH ITS SERVICE AREA. EACH THEDACARE HOSPITAL, ALONG WITH CHI STAFF AND COMMUNITY MEMBERS DETERMINE HOW BEST TO MEET LOCAL NEEDS. IMPLEMENTATION OF COMMUNITY PROGRAMMING OCCURS AT THE LOCAL LEVEL. REPORTS FILED WITH STATES PART VI, LINE 7 WI 0 APPLETON MEDICAL CENTER FOUNDATION INC 1818 N MEADE STREET APPLETON WI 54911 391459276 8000 GENERAL 1 X X 1 1 X X X X 0 1 0 0 0 0 0 1 0 ANDERLADAVID MD 0 305861 0 511 0 1830 0 14500 0 19034 0 341736 0 0 EDELMANGARY MD 0 355742 0 47877 0 10942 0 12000 0 24509 0 451070 0 0 GRUNERDEAN 104925 594577 34077 193101 2208 12513 27480 155720 2943 16679 171633 972590 0 0 MOARD DOUGLAS MD 0 289261 0 511 0 0 0 19500 0 17500 0 326772 0 0 OLSONTIM 54992 311621 8804 49891 3540 20061 13710 77690 2684 15209 83730 474472 0 0 BARNASKIM 79007 237021 4200 12601 4377 13131 23975 71925 4920 14759 116479 349437 0 0 LIVINGSTONKEITH 46217 261897 7727 43788 3092 17522 11925 67575 2597 14717 71558 405499 0 0 PISTONEMAUREEN 38650 219017 6210 35188 2783 15768 10479 59381 2666 15108 60788 344462 0 0 FERRANTEROBERT MD 736349 0 511 0 1710 0 9500 0 20474 0 768544 0 0 0 FLETCHER WILLIAM MD 561995 0 25511 0 2622 0 15500 0 21945 0 627573 0 0 0 ROSELAAR SIMON MD 561145 0 25511 0 4077 0 15500 0 22795 0 629028 0 0 0 WILSONROBERT MD 562799 0 25511 0 7524 0 15500 0 21141 0 632475 0 0 0 MIELKEDOUGLAS MD 562737 0 25511 0 2622 0 15500 0 21203 0 627573 0 0 0 CORREIAKATHRYN 4608 10752 30603 71408 27627 64464 0 0 0 0 62838 146624 0 0 PART I, LINE 1A EXECUTIVES RECEIVE REIMBURSEMENT FOR PERSONAL MEDICAL EXPENSES AT AN AMOUNT GROSSED-UP FOR TAXES. ALL EXECUTIVES IN THE SENIOR MANAGEMENT BENEFIT CATEGORY ARE ELIGIBLE TO HAVE HEALTH OR FITNESS CLUB FEES PAID DIRECTLY TO THE CLUB, OR REIMBURSED TO THEM ON EVIDENCE OF PAYMENT. SENIOR EXECUTIVES WHOSE DUTIES INCLUDE MEETING WITH PEOPLE OUTSIDE THE COMPANY FOR PURPOSES OF DEVELOPING BUSINESS RELATIONSHIPS HAVE COMPANY PAID MEMBERSHIPS AT A LOCAL COUNTRY CLUB. 7 EMPLOYEES RECEIVED TAXABLE MEDICAL EXPENSE REIMBURSEMENTS AND 4 EMPLOYEES RECEIVED CLUB DUES REIMBURSEMENTS. PART I, LINE 3 SENIOR LEVEL EXECUTIVES OF THE COMPANY ARE ENTITLED TO AN ANNUAL FLEXIBLE BENEFIT EQUAL TO 20% OF THE MIDPOINT OF THEIR SALARY RANGE. THIS 457(F) SUPPLEMENTAL BENEFIT PLAN COMPLIES WITH THE FINAL REGULATIONS UNDER SECTION 409A AND 457(F) OF THE INTERNAL REVENUE CODE. PARTICIPANTS MAY ELECT THE BENEFIT TO BE USED TO PURCHASE PARTICULAR INSURANCE BENEFITS, INVESTED IN A CAPITAL ACCUMULATION ACCOUNT, OR A COMBINATION OF THE TWO. BENEFITS ARE ACCRUED ON A MONTHLY BASIS AND ARE SUBJECT TO THE SUBSTANTIAL RISK OF FORFEITURE AGREEMENT SIGNED BY THE PARTICIPANTS. PLAN CONTRIBUTIONS ARE MADE ON A QUARTERLY BASIS. PART I, LINE 4B EXECUTIVE AT RISK COMPENSATION PLAN THE PLAN OBJECTIVES ARE TO ENHANCE THEDACARE INC'S ABILITY TO ACHIEVE ITS GOALS BY PROVIDING A TOOL FOR STIMULATING AND REWARDING SUPERIOR LEVELS OF PERFORMANCE AMONG KEY EXECUTIVES, IMPROVE THEDACARE INC'S ABILITY TO COMPETE WITH OTHER EMPLOYERS FOR HIGH TALENT EXECUTIVES AND TO ENCOURAGE TOP-LEVEL EXECUTIVES TO WORK TOGETHER AS A COHESIVE GROUP TOWARD COMMON GOALS. THE PRESIDENT OF THEDACARE INC. DEVELOPS A LIST OF SENIOR LEVEL EXECUTIVES WHO ARE ELIGIBLE TO PARTICIPATE IN THIS PLAN, AS WELL AS THE PERFORMANCE LEVELS THE SENIOR EXECUTIVES MUST ACHIEVE AND THE BONUS AMOUNTS THAT THE EXECUTIVES WILL RECEIVE. THE PRESIDENT THEN SUBMITS THIS LIST TO THE EXECUTIVE COMMITTEE OF THE BOARD OF TRUSTEES FOR FINAL APPROVAL. THESE EXECUTIVES MUST BE IN ACTIVE REGULAR SERVICE OF THEDACARE INC. FOR THE ENTIRE PLAN YEAR (JANUARY 1, 2011 TO DECEMBER 31, 2011) TO RECEIVE THEIR 2012 BONUSES. IF THE EMPLOYEE RETIRES, BECOMES DISABLED, MOVES TO A POSITION THAT IS ELIGIBLE UNDER THE BONUS PLAN OR MOVES TO A POSITION THAT IS NO LONGER ELIGIBLE FOR THE BONUS PLAN OR DIES, THE PLAN WILL BE PRORATED FOR THE AMOUNT OF TIME THEY SERVED THE COMPANY. IF AN ELIGIBLE EMPLOYEE IS FIRED OR LEAVES THE COMPANY FOR ANY OTHER REASON THE PLAN BONUS EARNED WILL BE FORFEITED. CARING FOR SUCCESS THE PLAN OBJECTIVES ARE TO PROVIDE INCENTIVE TO FOCUS THE ORGANIZATION'S RESOURCES, ENERGY AND ATTENTION ON THE FULFILLMENT OF THEDACARE'S MISSION. EMPLOYEE ELIGIBILITY IS BASED ON THE NUMBER OF HOURS WORKED, AND ALL ELIGIBLE EMPLOYEES SHARE IN THE PAYOUT. THE PAYOUT AMOUNT IS DETERMINED BASED ON BOTH FINANCIAL AND EMPLOYEE HEALTH AND SAFETY THRESHOLDS. THE AMOUNT PER EMPLOYEE IS DETERMINED BY DIVIDING THE TOTAL GAIN REALIZED (THE EMPLOYEE SHARE) BY HOURS PAID TO ALL ELIGIBLE EMPLOYEES. THE RESULTING DOLLAR UNIT PAYOUT IS MULTIPLIED BY AN INDIVIDUAL EMPLOYEE'S NUMBER OF HOURS PAID. THIS PLAN IS OVERSEEN BY AN ADMINISTRATIVE COMMITTEE. THE THEDACARE BOARD OF TRUSTEES MUST APPROVE THE PLAN. FORM 990, PART I, LINE 5 THEDACARE INC. CENTRALIZES PAYROLL AND TAX WITHHOLDING FUNCTIONS FOR A NUMBER OF AFFILIATED ENTITIES, WHILE ALL FILING UNDER THEDACARES FEDERAL IDENTIFICATION NUMBER. APPLETON MEDICAL CENTER (AMC) REPORTS "0" EMPLOYEES BECAUSE EMPLOYEES ARE PAID BY THEDACARE, INC., THEREFORE, AMC DOES NOT FILE ANY W-2 FORMS. THEDACARE INC. IS REIMBURSED BY AMC FOR SALARY EXPENSES FOR THE EMPLOYEES WHO ARE PERMANENTLY ASSIGNED TO AMC. FORM 990, PART VI, SECTION A, LINE 6 APPLETON MEDICAL CENTER, INC.'S SOLE MEMBER OF THE SINGLE CLASS OF VOTING MEMBERS IS THEDACARE, INC. FORM 990, PART VI, SECTION A, LINE 7A THEDACARE, INC. HAS SOLE AUTHORITY IN THE CORPORATION TO VOTE AND TAKE ANY ACTION WITH RESPECT TO THE ELECTION OF DIRECTORS AND OFFICERS. FORM 990, PART VI, SECTION A, LINE 7B THEDACARE, INC. HAS THE SOLE AUTHORITY WITH RESPECT TO THE FOLLOWING MATTERS: 1. AMENDMENT OF THE ARTICLES OF INCORPORATION 2. ADOPTION AND AMENDMENT OF BYLAWS OF THE CORPORATION 3. CONSOLIDATION, MERGER AND DISSOLUTION OF THE CORPORATION 4. MONITORING COMPLIANCE WITH LAWS AND REGULATIONS 5. SELECTION, APPOINTMENT, AND REMOVAL OF A CHIEF OPERATING OFFICER 6. PROVISION FOR LONG-RANGE FINANCIAL STABILITY OF THE HOSPITAL AND PROVISION FOR THE CONTROL AND USE OF THE PHYSICAL AND FINANCIAL RESOURCES OF THE HOSPITAL 7. ESTABLISHMENT OF A LONG-RANGE PLANNING MECHANISM 8. APPROVAL OF A HOSPITAL ORGANIZATION AND MAJOR AUTHORITY DELEGATION PATTERNS 9. APPROVAL OF FINANCIAL, CAPITAL, AND OTHER ITEMS 10. APPROVAL OF DEBT OR LEASES 11. CONSIDERATION AND ACTION UPON POLICIES CONCERNING RELATIONS WITH EXTERNAL GROUPS AND ORGANIZATIONS FORM 990, PART VI, SECTION B, LINE 11 A DRAFT OF THE FORM 990 IS PROVIDED TO THE ORGANIZATION'S DESIGNATED COMMITTEE OF THE BOARD OF DIRECTORS FOR REVIEW AND DISCUSSION AT A BOARD MEETING. THE FINAL VERSION OF THE FORM 990 IS EMAILED TO THE ENTIRE BOARD BEFORE THE RETURN IS FILED. FORM 990, PART VI, SECTION B, LINE 12C QUESTIONNAIRES ARE SENT TO ALL MANAGERS, TRUSTEES AND OFFICERS ANNUALLY. COMPLETED FORMS ARE RETURNED TO THE COMPLIANCE OFFICER. THE COMPLIANCE OFFICER REVIEWS THE QUESTIONNAIRES AND FOLLOWS UP WITH ANY QUESTIONS ABOUT THE MANAGERS' ANSWERS ON THE CONFLICT OF INTEREST FORMS. FORM 990, PART VI, SECTION B, LINE 15 THEDACARE HIRES AN OUTSIDE CONSULTING FIRM TO CONDUCT A THOROUGH MARKET REVIEW OF EXECUTIVE COMPENSATION EVERY OTHER YEAR. INTERNALLY, A COMPENSATION COMMITTEE REAFFIRMS THE COMPENSATION POLICY, REVIEWS DATA FROM CONSULTANTS, AND WITH INPUT FROM THE SR VP OF HUMAN RESOURCES, ADVISES, VALIDATES, AND APPROVES A RANGE FOR CEO COMPENSATION. THE COMMITTEE ALSO RATIFIES THE BONUS PLAN. FORM 990, PART VI, SECTION C, LINE 19 APPLETON MEDICAL CENTER INC. DOES NOT MAKE ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND INTERNAL FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC. OTHER FEES FORM 990, PART IX, LINE 11G PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 19,988,713. MANAGEMENT AND GENERAL EXPENSES 9,391,976. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 29,380,689. CONTRACT LABOR SERVICES: PROGRAM SERVICE EXPENSES 1,069,604. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,069,604. OTHER: PROGRAM SERVICE EXPENSES 618,535. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 618,535. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 9: INVESTMENT RECLASS TO THEDACARE, INC. -3,909,716. FORM 990, PART XII, LINE 2C THIS PROCESS DID NOT CHANGE DURING THE YEAR. 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