2013-08-13T16:03:05-05:00 2012-09-30 390758449 WIPFLI LLP PO BOX 12237 GREEN BAY WI 543072237 990 2011-10-01 390905385 CALUMET MEDICAL CENTER INC CALU 9208492386 614 MEMORIAL DR CHILTON WI 53014 JEFF BADGER 9208497544 2013-08-13 1 TERRI REXRODE CPA MST P00096513 9206620016 2013-08-13 2011 2016-02-25 16:41:14Z JEFF BADGER 614 MEMORIAL DR CHILTON WI 53014 22450578 0 X WWW.AFFINITYHEALTH.ORG X 1954 WI CALUMET MEDICAL CENTER PROUDLY SERVES THE CALUMET COUNTY AREA WITH A HISTORY OF MORE THAN A HALF CENTURY OF QUALITY CARE. THE FACILITY PROVIDES TOTAL HEALTH CARE, INCLUDING EMERGENCY/TRAUMA AND SURGICAL SERVICES AS WELL AS MANY MEDICAL SPECIALTIES. WITH 25 PATIENT BEDS, CALUMET MEDICAL CENTER TREATS PATIENTS WITH DIGNITY AND COMPASSION. 9 5 243 79 0 0 244103 90313 22722680 22180155 159043 118233 31100 36483 23156926 22425184 0 0 0 0 12070945 11760748 0 0 0 9521610 9413539 21592555 21174287 1564371 1250897 23570362 24067757 3248309 2310504 20322053 21757253 X CALUMET MEDICAL CENTER HAS ADOPTED THE MISSION STATEMENT OF AFFINITY HEALTH SYSTEM. THE MISSION OF AFFINITY HEALTH SYSTEM IS TO LIVE OUT THE HEALING MINISTRY OF CHRIST BY PROVIDING SERVICES THAT PROMOTE THE HEALTH AND WELL-BEING OF THE COMMUNITIES WE SERVE, ESPECIALLY THE POOR. 1 0 16593608 22180155 CALUMET MEDICAL CENTER, INC. OPERATES A 25 BED CRITICAL ACCESS HOSPITAL FACILITY PROVIDING MEDICAL, SURGICAL, EMERGENCY, OUTPATIENT, CLINIC, HOSPICE, AND HOME HEALTH SERVICES TO RESIDENTS IN CALUMET COUNTY REGARDLESS OF ABILITY TO PAY. THE EMERGENCY DEPARTMENT INCLUDES 24 HOUR A DAY/7 DAYS A WEEK EMERGENCY PHYSICIAN COVERAGE, SERVING 4,642 PATIENTS IN 2012, WITH 6,953 PROCEDURES PERFORMED. THE EMERGENCY DEPARTMENT ALSO OFFERS WALK-IN CLINIC SERVICES FOR AFTER DOCTOR'S OFFICE HOURS. THE SURGERY DEPARTMENT PERFORMED 652 PROCEDURES IN 2012, 617 ENDOSCOPIES, AND 1,228 ONE DAY SURGERIES. THE RADIOLOGY DEPARTMENT CONDUCTED 10,204 TESTS IN 2011. THE RADIOLOGY DEPARTMENT CONDUCTED 8,868 TESTS IN 2012. RADIOLOGY DEPARTMENT SERVICES INCLUDE RADIOLOGY, MRI, DIGITAL MAMMOGRAPHY, CT SCANS, ULTRASOUNDS, DEXASCAN, AND NUCLEAR MEDICINE. 16593608 1 1 0 1 0 0 0 0 0 0 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 20 0 1 243 1 0 0 0 0 0 0 0 0 0 0 X 9 5 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 WI X TIMOTHY RICHMAN 9208497550 614 MEMORIAL DRIVE CHILTON WI 53014 WAYNE WIETING 0.30 X X 0 0 0 DANIEL NEUFELDER 2.30 X X 42186 857305 94160 JAMES BURNETT 0.30 X X 0 0 0 ALLAN UTECHT 0.30 X X 0 0 0 PETER JANU MD 0.30 X 0 505366 44954 GENE TIPLER MD 0.30 X 0 257988 46819 JANE GEHL 0.30 X 0 0 0 TRAVIS ANDERSEN 0.30 X 0 354322 52189 CRAIG OLSON MD 0.30 X 0 0 0 TIMOTHY RICHMAN 40.00 X 216634 0 41610 JEFF BADGER 2.00 X 21587 438706 69379 JENNIFER LEIGH MEDIN WEBER 40.00 X 125785 0 28707 JUDITH ARCHE STRODTHOFF 40.00 X 107947 0 22970 514139 2413687 400788 2 0 1 0 AFFINITY MEDICAL GROUP 222 W COLLEGE AVE APPLETON WI 54915 PROFESSIONAL SERVICES 1732953 ACUTE CARE INC 1609 N ANKENY BLVD SUITE 200 ANKENY IA 50023 PROFESSIONAL SERVICES 1078148 ST ELIZABETH HOSPITAL 222 W COLLEGE AVE APPLETON WI 54915 PROFESSIONAL SERVICES 549597 NXC IMAGING 2118 4TH AVE SOUTH MINNEAPOLIS MN 55404 IMAGING SERVICES 355995 MERCY MEDICAL CENTER 222 W COLLEGE AVE APPLETON WI 54915 PROFESSIONAL SERVICES 168886 9 45128 45185 90313 PATIENT SERVICE REVENU 621110 21932913 21932913 OTHER OPERATING REVENU 621110 186271 186271 MISCELLANEOUS REVENUE 621110 60971 60971 22180155 117233 117233 61877 25394 36483 36483 36483 1000 0 1000 1000 1000 22425184 22180155 0 154716 329686 329686 8726364 6846224 1880140 235239 184663 50576 1864713 1484273 380440 604746 474726 130020 20200 20200 3847324 3204723 642601 20468 20468 3340807 2797440 543367 6793 6603 190 514485 347277 167208 86030 45326 40704 870252 587420 282832 58020 58020 BAD DEBT EXPENSE 594264 594264 DUES AND LICENSES 54896 20669 34227 21174287 16593608 4580679 0 1442 1550 7516419 8083038 3384256 3896030 45229 46680 18350895 12773669 5555308 5577226 6466840 6217308 600868 245925 23570362 24067757 2960938 2012080 287371 298424 3248309 2310504 X 20322053 21757253 20322053 21757253 23570362 24067757 X 1250897 184303 X X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 1268 1268 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: THE LOBBYING PORTION OF WHA DUES 9352 9352 10271068 7116134 3154934 224588 189811 34777 7845887 5467724 2378163 5577226 ACC RETIREMENT OBLIGATION 59208 ACCUMULATED ACCRETION 239216 298424 22425184 21174287 1250897 185166 -863 184303 1435200 22388127 25394 25394 22362733 62451 62451 22425184 21199681 25394 25394 21174287 0 21174287 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: MINISTRY RECOGNIZES THE TAX BENEFIT FROM AN UNCERTAIN TAX POSITION ONLY IF IT IS MORE LIKELY THAN NOT THAT THE TAX POSITION WILL BE SUSTAINED ON EXAMINATION BY TAXING AUTHORITIES, BASED ON THE TECHNICAL MERITS OF THE POSITION. EXAMPLES OF TAX POSITIONS FOR MINISTRY'S NOT-FOR-PROFIT CORPORATIONS INCLUDE THEIR TAX-EXEMPT STATUS AND VARIOUS POSITIONS RELATED TO THE POTENTIAL SOURCES OF UNRELATED BUSINESS TAXABLE INCOME (UBIT). THE TAX BENEFITS RECOGNIZED IN THE FINANCIAL STATEMENTS FROM SUCH A POSITION ARE MEASURED BASED ON THE LARGEST BENEFIT THAT HAS A GREATER THAN 50 PERCENT LIKELIHOOD OF BEING RECOGNIZED UPON ULTIMATE SETTLEMENT. PART XI, LINE 8 - OTHER ADJUSTMENTS: RECOGNIZED DEFERRED INCOME -38,809. WORKERS COMPENSATION ADJUSTMENT 121,164. FMV ADJUSTMENT OF ASSETS -83,218. TOTAL TO SCHEDULE D, PART XI, LINE 8: -863. PART XII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSE IN REVENUE 25,394. PART XII, LINE 4B - OTHER ADJUSTMENTS: CAPITAL CONTRIBUTIONS 62,451. PART XIII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSE IN REVENUE 25,394. 1 1 1 X 1 X 662.000000000000 1 1 0 1 1 112 148094 0 148094 0.00720 1059 637103 0 637103 0.03100 0 0 0 1171 785197 785197 0.03820 4 1804 108995 1500 107495 0.00520 2 42 22895 0 22895 0.00110 0 0 0 0 0 0 0 0 2 450 15938 0 15938 0.00080 8 2296 147828 1500 146328 0.00710 8 3467 933025 1500 931525 0.04530 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 139 2875 0 2875 0.00010 0 0 0 0 0 0 0 0 0 0 0 0 1 139 2875 2875 0.00010 0 594264 11720993 11304845 416148 X 1 1 1 1 CALUMET MEDICAL CENTER INC

614 MEMORIAL DRIVE CHILTON WI 53014

X X X X CALUMET MEDICAL CENTER INC 1 1 1 200.000000000000 1 662.000000000000 1 X X X X X X X 1 1 X X 1 0 1 X 0 0 PART I, LINE 3C: IT IS THE POLICY OF THE ORGANIZATION TO PROVIDE MEDICALLY NECESSARY HEALTH CARE SERVICES TO PEOPLE IN THE COMMUNITIES IT SERVES, REGARDLESS OF THEIR ABILITY TO PAY. AFFINITY CARE FINANCIAL ASSISTANCE IS GRANTED BASED UPON THE PATIENT'S INABILITY TO PAY AND TO INDIVIDUALS WHO ARE UNINSURED, UNDERINSURED OR MEDICALLY INDIGENT. AFFINITY CARE WORKS IN COLLABORATION WITH OTHER FINANCIAL (BOTH PUBLIC AND PRIVATE) ASSISTANCE PROGRAMS. THIS IS TO ENSURE HOLISTIC WELLNESS OF PATIENTS BY FACILITATING KNOWLEDGE OF AVAILABLE SERVICES AND PROGRAMS FOR HEALTH WHILE PRACTICING GOOD STEWARDSHIP OF FUNDS. KEY CRITERIA UTILIZED TO DETERMINE ELIGIBILITY FOR AFFINITY CARE FINANCIAL ASSISTANCE INCLUDES FAMILY SIZE, FEDERAL POVERTY INCOME GUIDELINES AND AVAILABLE ASSETS. THE AVAILABLE ASSET TEST INCLUDES CONSIDERATION OF THE AMOUNT OF EQUITY IN A HOME, AUTOMOBILES, AND SAVINGS ACCOUNTS WHICH ARE CONSIDERED PART OF TOTAL ALLOWABLE INCOME WHEN ASSESSING AGAINST THE FEDERAL POVERTY INCOME GUIDELINES. PART I, LINE 7: AMOUNTS CALCULATED IN PART I, LINE 7 ARE DETERMINED BOTH ON A COST ACCOUNTING SYSTEM AND A COST-TO-CHARGE RATIO. OTHER BENEFITS ARE DETERMINED BASED ON THE DIRECT AND INDIRECT COSTS (WHERE ALLOCATED) ASSOCIATED WITH A PROGRAM NET OF EARNED REVENUE. DETAIL FOR EACH PROGRAM/ACTIVITY IS MAINTAINED AND DETERMINED AT THE DEPARTMENT LEVEL. CHARITY CARE AND MEANS-TESTED PROGRAMS ARE DETERMINED BASED ON A COST-TO-CHARGE RATIO CONSISTENT WITH WORKSHEET 2, RATIO OF PATIENT CARE COST TO CHARGES. PRIOR YEAR COST REPORT SETTLEMENTS ARE EXCLUDED FROM THE SHORTFALL CALCULATION IN ORDER TO GET A TRUE FISCAL YEAR SHORTFALL AMOUNT. PART I, L7 COL(F): BAD DEBT EXPENSE OF $594,264 INCLUDED ON FORM 990, PART IX, LINE 25 WAS EXCLUDED FROM THE DENOMINATOR PER INSTRUCTIONS WHEN CALCULATING THE PERCENT OF TOTAL EXPENSES ON SCHEDULE H. PART II: COMMUNITY-BUILDING ACTIVITIES INCLUDE PROGRAMS THAT, WHILE NOT DIRECTLY RELATED TO HEALTH CARE, PROVIDE OPPORTUNITIES TO ADDRESS THE ROOT CAUSES OF HEALTH PROBLEMS, SUCH AS POVERTY, HOMELESSNESS, AND ENVIRONMENTAL PROBLEMS. THESE ACTIVITIES SUPPORT COMMUNITY ASSETS BY OFFERING THE EXPERTISE AND RESOURCES OF THE ORGANIZATION. COSTS FOR THESE ACTIVITIES INCLUDE CASH, IN-KIND DONATIONS, AND EXPENDITURES FOR THE DEVELOPMENT OF A VARIETY OF COMMUNITY HEALTH PROGRAMS AND PARTNERSHIPS. ANOTHER EXAMPLE IS HEALTH CAREER PRESENTATIONS IN WHICH PROFESSIONALS FROM CALUMET MEDICAL CENTER GO TO CAREER CLASSES AT AREA HIGH SCHOOLS AND UNIVERSITIES TO TALK ABOUT THEIR PROFESSIONS (I.E. PHYSICAL THERAPY, OCCUPATIONAL THERAPY, SPEECH THERAPY, CARDIAC & PULMONARY REHAB) PART III, LINE 4: NO FOOTNOTE EXISTS IN THE ORGANIZATION'S FINANCIAL STATEMENTS THAT DESCRIBE BAD DEBT EXPENSE. BAD DEBT EXPENSE IS RECORDED IN A CONSISTENT MANNER WITH THE ORGANIZATION'S COLLECTION POLICIES. BAD DEBT EXPENSE INCLUDES ACCOUNTS WHICH ARE WRITTEN OFF AND ESTIMATES MADE ON LIVE ACCOUNTS BASED ON HISTORICAL PAYMENT TRENDS AND ACCOUNT MODELING.A NUMBER OF PATIENTS ARE TRULY UNABLE TO PAY THEIR OUT-OF-POCKET LIABILITY, BUT DO NOT COMPLETE THE PROCESS REQUIRED TO APPLY FOR FINANCIAL ASSISTANCE UNDER THE HOSPITAL'S AFFINITY CARE POLICY. THESE PATIENTS WOULD QUALIFY FOR AFFINITY CARE IF THEY COMPLETED THE CHARITY APPLICATION, SO THE BAD DEBT EXPENSE ASSOCIATED WITH TREATING THEM SHOULD BE TREATED AS COMMUNITY BENEFIT. THE ORGANIZATION DOES RESERVE THE RIGHT TO PRESUME ELIGIBILITY BASED ON ADMINISTRATIVE REVIEW TO HELP IDENTIFY INDIGENT PATIENTS AND MINIMIZE THE INSTANCES OF WHEN THEY BECOME A BAD DEBT. THE ADMINISTRATIVE REQUIREMENTS TO DETERMINE WHETHER PATIENTS WHO DO NOT COOPERATE WITH THE FINANCIAL ASSISTANCE PROCESS WOULD HAVE QUALIFIED FOR CHARITY CAN BE BURDENSOME, PARTICULARLY FOR SMALL BALANCES. PART III, LINE 9B: CALUMET MEDICAL CENTER HAS A DEBT COLLECTION POLICY WHICH SETS FORTH COLLECTION PRACTICES FOR PATIENTS WHO ARE KNOWN TO QUALIFY OR MAY QUALIFY FOR FINANCIAL ASSISTANCE UNDER THE CHARITY CARE PROGRAM. SUFFICIENT FINANCIAL COUNSELING SUPPORT IS MADE AVAILABLE TO PATIENTS SO THEY CAN EASILY ACCESS PATIENT FINANCIAL SERVICE REPRESENTATIVES AND HAVE THEIR QUESTIONS ANSWERED, AND GAIN AN UNDERSTANDING OF THE REASONS WHY THEY OWE A BALANCE. ACCOUNTS ARE DESIGNATED AS CHARITY CARE IN THE BUSINESS OFFICES SO NO ADDITIONAL TIME IS SPENT ON COLLECTION EFFORTS. CALUMET MEDICAL CENTER, INC. PART V, SECTION B, LINE 9: ANYONE AT 200% POVERTY GUIDELINES IS ELIGIBLE FOR FREE CARE. CALUMET MEDICAL CENTER, INC. PART V, SECTION B, LINE 10: ANYONE BETWEEN 200-662% OF POVERTY GUIDELINES AND OTHER CRITERION IS ELIGIBLE FOR DISCOUNTED CARE BASED ON A SLIDING SCALE. PART VI, LINE 2: CALUMET MEDICAL CENTER PERFORMS COMMUNITY NEEDS ASSESSMENTS AS NEEDED. WHEN A NEED IS IDENTIFIED, THE HOSPITAL DEVELOPS A PLAN TO IMPLEMENT A PROGRAM EITHER THROUGH COMMUNITY COLLABORATION OR INDIVIDUALLY. OUTCOMES FROM THE PROGRAMS ARE MEASURED AND CONSIDERED IN SUBSEQUENT COMMUNITY NEEDS ASSESSMENTS. COMMUNITY BENEFIT PLANS ARE PRESENTED TO SENIOR LEADERSHIP AND BOARD MEMBERS TO ENSURE THE FINDINGS ARE INCORPORATED INTO THE ORGANIZATION'S STRATEGY AND POLICY DEVELOPMENT. FOR EXAMPLE, SENIOR LEADERS ARE REQUIRED TO PROVIDE DIRECT SERVICE HOURS TO THE POOR AS PART OF THEIR PERFORMANCE GOALS. PART VI, LINE 3: CALUMET MEDICAL CENTER GOES TO GREAT LENGTHS IN ORDER TO INFORM AND EDUCATE PATIENTS/PERSONS WHO MAY BE BILLED FOR PATIENT CARE ABOUT THEIR ELIGIBILITY FOR ASSISTANCE UNDER FEDERAL, STATE OR LOCAL GOVERNMENT PROGRAMS AND UNDER THE ORGANIZATION'S FINANCIAL ASSISTANCE POLICY. THE FINANCIAL ASSISTANCE POLICY AND APPLICATION IS POSTED ON THE ORGANIZATION'S WEBSITE. ADMISSIONS AND OTHER KEY AREAS CONTAIN SUMMARY INFORMATION OF THE FINANCIAL ASSISTANCE POLICY. AS PART OF THE INTAKE/DISCHARGE PROCESS, PATIENTS ARE PROVIDED WITH A COPY OF THE BROCHURE AND OTHER INFORMATION FOR FINANCIAL ASSISTANCE. IF DURING THE COURSE OF THE PATIENT REGISTRATION PROCESS, CARE ENCOUNTER, TREATMENT, OR UPON DISCHARGE IT BECOMES EVIDENT THAT A PATIENT MAY NEED FINANCIAL ASSISTANCE; THE PATIENT SHALL BE REFERRED TO CALUMET MEDICAL CENTER'S FINANCIAL ASSISTANCE PROGRAM. PATIENTS MAY BE IDENTIFIED AS NEEDING FINANCIAL ASSISTANCE AT ANY TIME DURING THE COURSE OF AN ENCOUNTER. A REFERRAL FOR CONSIDERATION OF FINANCIAL ASSISTANCE CAN BE INITIATED BY ANY MEMBER OF THE HOSPITAL'S WORKFORCE, INCLUDING MEDICAL STAFF MEMBERS, WHO BECOME AWARE OF THE PATIENT'S POTENTIAL NEED FOR FINANCIAL ASSISTANCE. THE FINANCIAL ASSISTANCE POLICY WAS ALSO TRANSLATED INTO DIALECTS PREVALENT IN THE COMMUNITY IN ORDER TO REACH OUT TO THOSE THAT MAY SPEAK ANOTHER LANGUAGE (SPANISH AND HMONG). PATIENT REGISTRATION STAFF AND FINANCIAL COUNSELORS ARE PROVIDED WITH SCRIPTS TO FOLLOW WHEN INTERACTING WITH PATIENTS. AS PART OF THE FINANCIAL ASSISTANCE PROCESS, PATIENTS MUST REGISTER WITH THE COUNTY PUBLIC ASSISTANCE TO SEE IF THEY MAY QUALIFY UNDER ANY OTHER FEDERAL OR STATE PROGRAMS. PART VI, LINE 4: WHILE THERE IS GROWING AGREEMENT IN THE UNITED STATES ABOUT WHAT CONSTITUTES A NON-PROFIT HOSPITAL'S "COMMUNITY BENEFIT" THIS IS A WORK IN PROGRESS. THE ORGANIZATION PROVIDED SIGNIFICANT CHARITY CARE AND OTHER COMMUNITY BENEFITS AS DEFINED BY THE IRS. BUT IN ADDITION, WE BELIEVE THAT WE PROVIDE A CRITICALLY IMPORTANT COMMUNITY BENEFIT, WHICH IS NOT QUANTIFIED. CALUMET MEDICAL CENTER, LIKE MOST COMMUNITY HOSPITALS, WAS CREATED AND IS MAINTAINED IN ORDER TO PROVIDE CARE LOCALLY - CARE THAT WITHOUT OUR HOSPITAL, MAY NOT BE AVAILABLE LOCALLY.CERTAIN SPECIALIZED SERVICES AVAILABLE INCLUDE: I/P REHABILITATION SERVICES, I/P SUB-ACUTE (SNF) SERVICES. PART VI, LINE 5: CALUMET MEDICAL CENTER'S GOVERNING BOARD CONSISTS PRIMARILY OF PERSONS WHO RESIDE WITHIN THE PRIMARY SERVICE AREA. MOST ARE NOT EMPLOYEES OF THE ORGANIZATION. THE ORGANIZATION STRIVES TO FURTHER ITS EXEMPT PURPOSES BY THE FOLLOWING:CALUMET MEDICAL CENTER PARTICIPATES IN GOVERNMENT-SPONSORED HEALTH PROGRAMS (MEDICARE, MEDICAID, CHAMPUS, GENERAL RELIEF, AND SPECIALIZED COUNTY PROGRAMS.)CALUMET MEDICAL CENTER DONATES FOOD TO AREA SHELTERS. THEY ALSO DONATE MEDICAL SUPPLIES AND MEDICATIONS TO CLINICS IN THIRD WORLD COUNTRIES.CALUMET MEDICAL CENTER DONATED FUNDS TO SUPPORT AREA ORGANIZATIONS THAT PROVIDE SERVICES TO THE FOLLOWING SECTORS OF OUR POPULATION: LOW-INCOME, HOMELESS, PHYSICALLY AND MENTALLY CHALLENGED AND CHRONICALLY ILL. CALUMET MEDICAL CENTER OPERATES THE ONLY PARAMEDIC-LEVEL AMBULANCE SERVICE IN CALUMET COUNTY. THIS SERVICE OPERATES AT A LOSS AND IS SUBSIDIZED BY THE HOSPITAL.CALUMET MEDICAL CENTER PROVIDES COMMUNITY HEALTH IMPROVEMENT SERVICES THROUGH HEALTH EDUCATION LECTURES, HEALTH FAIRS AND SUPPORT GROUPS.CALUMET MEDICAL CENTER CONDUCTS CARDIAC REHABILITATION AND DIABETIC EDUCATION SESSIONS. THIS SERVICE IS PROVIDED AT A COST TO THE PATIENT THAT IS FAR BELOW THE COST TO OFFER THE SERVICE.DISCOUNTED CARE IS PROVIDED TO LOW INCOME FAMILIES UP TO 662% OF FEDERAL POVERTY GUIDELINES.CALUMET MEDICAL CENTER SERVES AS A SPONSOR SITE FOR CLINICAL TRAINING OF COLLEGE STUDENTS IN VARIOUS HEALTH CARE PROGRAMS.CALUMET MEDICAL CENTER OFFERS ATHLETIC TRAINING SERVICES TO LOCAL HIGH SCHOOLS THAT WOULD OTHERWISE NOT HAVE THIS SERVICE AVAILABLE TO THEIR STUDENTS. THE SERVICE IS OFFERED AT A COST TO THE SCHOOLS THAT IS FAR BELOW THE COST TO OFFER THE SERVICE. PART VI, LINE 6: CALUMET MEDICAL CENTER, OF CHILTON, WISCONSIN IS A COMMUNITY CRITICAL ACCESS HOSPITAL MANAGED BY AN AFFILIATED HEALTH CARE SYSTEM CALLED AFFINITY HEALTH SYSTEM. AFFINITY HEALTH SYSTEM ALSO HAS TWO OTHER HOSPITALS, ST. ELIZABETH HOSPITAL, IN APPLETON, WI AND MERCY MEDICAL CENTER, IN OSHKOSH, WI. IN ADDITION TO THE HOSPITALS, AFFINITY HEALTH SYSTEM ALSO HAS 25 AREA CLINICS UNDER THE CONTROL OF AFFINITY MEDICAL GROUP. THE MISSION OF AFFINITY, AS A CATHOLIC HEALTH CARE SYSTEM, IS TO LIVE OUT THE HEALING MINISTRY OF CHRIST BY PROVIDING SERVICES THAT PROMOTE THE HEALTH AND WELL BEING OF THE COMMUNITIES WE SERVE, ESPECIALLY THE POOR. AFFINITY HEALTH SYSTEM IS SPONSORED BY MINISTRY HEALTH CARE, HEADQUARTERED IN MILWAUKEE, WI. THE 3 HOSPITALS AND THE 25 CLINICS PROVIDE FREE OR MINIMAL COST HEALTH EDUCATION, SUPPORT, AND SCREENING SERVICES FOR THE POPULATIONS THEY SERVE. CALUMET MEDICAL CENTER, MERCY MEDICAL CENTER, AND ST. ELIZABETH HOSPITAL PROVIDE SUPPORT FOR EDUCATIONAL PROGRAMS TO EDUCATE FUTURE HEALTH CARE PROFESSIONALS. THERE IS ALSO AN EXPECTATION THAT ALL PEOPLE IN MANAGEMENT SERVICES AT AFFINITY HEALTH SYSTEM WILL PROVIDE DIRECT SERVICES TO THE POOR. REPORTS FILED WITH STATES PART VI, LINE 7 WI X X 0 1 X X X X X 0 0 0 0 0 0 0 0 0 DANIEL NEUFELDER 30566 621156 10617 215763 1003 20386 3369 68467 1047 21277 46602 947049 0 0 PETER JANU MD 0 503220 0 0 0 2146 0 22565 0 22389 0 550320 0 0 GENE TIPLER MD 0 256451 0 0 0 1537 0 22821 0 23998 0 304807 0 0 TRAVIS ANDERSEN 0 279091 0 54151 0 21080 0 32330 0 19859 0 406511 0 0 TIMOTHY RICHMAN 163010 0 38174 0 15450 0 20628 0 20982 0 258244 0 0 0 JEFF BADGER 16063 326438 4230 85963 1294 26305 2084 42361 1169 23765 24840 504832 0 0 JENNIFER LEIGH MEDIN WEBER 125145 0 0 0 640 0 7782 0 20925 0 154492 0 0 0 PART I, LINE 1B BUSINESS TRAVEL EXPENSES FOR SPOUSES OF EXECUTIVES AND GOLF CLUB MEMBERSHIP FOR EXECUTIVES ARE REIMBURSED AS PART OF THEIR EXECUTIVE FLEX CREDIT ACCOUNT. RECEIPTS ARE PROVIDED TO SR. ADMINISTRATIVE ASSISTANT IN HR WHO REVIEWS FOR ACCURACY, COMPLETES A REIMBURSEMENT FORM WITH SUBSTANTIATION TO PAYROLL FOR REIMBURSEMENT. THESE REIMBURSEMENTS ARE TAXABLE AND, WHEN ADDED TO THE COMPENSATION PACKAGE TAKEN AS A WHOLE, HAVE BEEN INCLUDED WHEN COMPARED TO THE COMPENSATION STUDIES. NEW PROGRAM SERVICES FORM 990, PART III, LINE 2 CALUMET MEDICAL CENTER BEGAN ORTHOPAEDICS SERVICES IN 2012 THROUGH A COLLABORATION WITH ORTHOPAEDICS ASSOCIATES OF MANITOWOC. FORM 990, PART VI, SECTION A, LINE 6 THE CORPORATE MEMBERS OF CALUMET MEDICAL CENTER, INC. ARE CALUMET AREA COMMUNITY HEALTH FOUNDATION, INC. AND AFFINITY HEALTH SYSTEM. FORM 990, PART VI, SECTION A, LINE 7A AFFINITY HEALTH SYSTEM HAS THE POWER TO APPROVE AND REMOVE THE ORGANIZATION'S BOARD OF DIRECTORS. FORM 990, PART VI, SECTION A, LINE 7B CORPORATE MEMBERS, CALUMET AREA COMMUNITY HEALTH FOUNDATION, INC. AND AFFINITY HEALTH SYSTEM, APPROVE ALL MODIFICATIONS OF THE ARTICLES OF INCORPORATION AND PROVISIONS OF THE BYLAWS AS WELL AS APPROVE THE DISSOLUTION, CONSOLIDATION OR MERGER OF THE ORGANIZATION. AFFINITY HEALTH SYSTEM ALSO HAS MANAGING POWERS OVER THE ORGANIZATION. AFFINITY HEALTH SYSTEM'S CORPORATE MEMBERS AND MINISTRY HEALTH CARE, INC. MAY ACT IN ALL RESPECTS IN THE PLACE OF AFFINITY HEALTH SYSTEM TO THE ORGANIZATION. IN FEBRUARY 2012, MINISTRY HEALTH CARE, INC. BECAME THE SOLE OWNER OF AFFINITY HEALTH SYSTEM. FORM 990, PART VI, SECTION B, LINE 11 THE CONTROLLER AND CFO OF AFFINITY HEALTH SYSTEM PERFORM A DETAIL REVIEW OF THE 990. AFTER MANAGEMENT REVIEW, A COPY OF THE 990 IS PROVIDED TO THE BOARD OF DIRECTORS PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C THE CONFLICT OF INTEREST AND DUALITY STATEMENT IS COMPLETED BY THE BOARD OF DIRECTORS ON AN ANNUAL BASIS. FORM 990, PART VI, SECTION B, LINE 15 CALUMET MEDICAL CENTER (ORGANIZATION) HAS A COMPENSATION COMMITTEE CONSISTING OF FOUR MEMBERS OF THE BOARD OF DIRECTORS, WHICH CONSIST OF TWO REPRESENTATIVES OF THE CORPORATE MEMBERS. NO MEMBER IS AN AFFINITY MEDICAL GROUP PHYSICIAN OR A MEMBER OF THE EXECUTIVE TEAM OF THE ORGANIZATION. THE COMPENSATION COMMITTEE (THOSE WITHOUT CONFLICT) HAS AUTHORITY TO APPROVE ANY AND ALL AMOUNTS OF COMPENSATION FOR MEMBERS OF THE EXECUTIVE TEAM OF THE ORGANIZATION. THE COMPENSATION COMMITTEE AT LEAST ANNUALLY INVESTIGATES, EVALUATES, REVIEWS, DETERMINES AND DOCUMENTS THE COMPENSATION OF THE SENIOR MANAGEMENT TEAM OF THE ORGANIZATION. THE COMPENSATION COMMITTEE CONSIDERS DATA FROM INDEPENDENT SOURCES PROVIDING INFORMATION AS TO AMOUNTS PAID BY COMPARABLE ORGANIZATIONS FOR COMPARABLE POSITIONS AND INSURE THE INDIVIDUALS ARE PAID NO MORE THAN FAIR MARKET, REASONABLE COMPENSATION FOR SERVICES RENDERED. FORM 990, PART VI, SECTION C, LINE 19 ONLY THE FINANCIAL STATEMENTS ARE MADE PUBLIC AS BY WAY OF FILING THE ANNUAL IRS FORM 990, WHICH BY LAW IS AVAILABLE TO THE PUBLIC. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED GAINS ON INVESTMENTS: 185,166. RECOGNIZED DEFERRED INCOME -38,809. WORKERS COMPENSATION ADJUSTMENT 121,164. FMV ADJUSTMENT OF ASSETS -83,218. TOTAL TO FORM 990, PART XI, LINE 5: 184,303. AUDITED FINANCIAL STATEMENTS FORM 990 PART XI LINE 2B-2C THE ORGANIZATION DOES NOT RECEIVE SEPARATELY AUDITED FINANCIAL STATEMENTS. THE ORGANIZATION IS AUDITED AND REPORTED THROUGH CONSOLIDATED FINANCIAL STATEMENTS OF AFFINITY HEALTH SYSTEM. THE AUDIT COMMITTEE IS RESPONSIBLE FOR THE AUDITOR SELECTION. THE AUDIT STATEMENTS ARE REVIEWED BY THE CONTROLLER, CFO, MINISTRY HEALTH CFO, AND THE AUDIT COMMITTEE. THIS PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. HOURS WORKED FOR RELATED ORGANIZATIONS FORM 990, PART VII DANIEL NEUFELDER WORKED AN AVERAGE OF 38 HOURS PER WEEK FOR RELATED ORGANIZATIONS. TRAVIS ANDERSEN WORKED AN AVERAGE OF 40 HOURS PER WEEK FOR RELATED ORGANIZATIONS. PETER JANU WORKED AN AVERAGE OF 40 HOURS PER WEEK FOR RELATED ORGANIZATIONS. GENE TIPLER WORKED AN AVERAGE OF 40 HOURS PER WEEK FOR RELATED ORGANIZATIONS. JEFF BADGER WORKED AN AVERAGE OF 38 HOURS PER WEEK FOR RELATED ORGANIZATIONS. AFFINITY HEALTH SYSTEM 1570 MIDWAY PL MENASHA WI 54952 391568866 SUPPORT RELATED HEALTHCARE ORGANIZATIONS IL 501(C)(3) 11, TYPE II MINISTRY HEALTH CARE INC 0 MERCY MEDICAL CENTER OF OSHKOSH INC 500 S OAKWOOD OSHKOSH WI 54904 390806268 HOSPITAL WI 501(C)(3) LINE 3 AFFINITY HEALTH SYSTEM 0 NETWORK HEALTH SYSTEM INC 1570 APPLETON ROAD MENASHA WI 54952 391127163 CLINICAL HEALTHCARE SERVICES WI 501(C)(3) LINE 3 AFFINITY HEALTH SYSTEM 0 MERCY HEALTH FOUNDATION INC PO BOX 3370 OSHKOSH WI 54903 237140261 PUBLIC WELFARE THROUGH COMMUNITY HEALTH DEVELOPMENT WI 501(C)(3) LINE 9 AFFINITY HEALTH SYSTEM 0 ST ELIZABETH HOSPITAL FOUNDATION INC 1506 S ONEIDA STREET APPLETON WI 54915 391256677 RAISE FUNDS IN SUPPORT OF ST. 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