ST CLARE MEMORIAL HOSPITAL INC: Form 990, tax year 2011
View the entire original 990 at ProPublica ↗
- Organization
- ST CLARE MEMORIAL HOSPITAL INC (EIN 39-0848401)
- Tax period
- 2011-10-01 to 2012-09-30
- Filed
- 2013-08-15
- IRS object ID
- 201312279349302131
- Schema version
- 2011v1.5
- Source
- Download XML · Original 990 at ProPublica
Every field in the e-filed return. Faint text is the IRS element name, for citing.
- Return header
- Form 990
- Schedule A
- Schedule B
- Schedule C
- Schedule D
- Schedule H
- Schedule J
- Schedule K
- Schedule L
- Schedule O
- Schedule R
Return header ReturnHeader
| Field | Value | IRS element (for citing) |
|---|---|---|
| Timestamp | 2013-08-15T11:49:13-05:00 | Timestamp |
| Tax Period End Date | 2012-09-30 | TaxPeriodEndDate |
Preparer Firm PreparerFirm
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 390758449 | EIN |
Preparer Firm Business Name PreparerFirmBusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | WIPFLI LLP | BusinessNameLine1 |
Preparer Firm US Address PreparerFirmUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | PO BOX 12237 | AddressLine1 |
| City | GREEN BAY | City |
| State | WI | State |
| ZIP Code | 543072237 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return Type | 990 | ReturnType |
| Tax Period Begin Date | 2011-10-01 | TaxPeriodBeginDate |
Filer Filer
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 390848401 | EIN |
Name Name
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | COMMUNITY MEMORIAL HOSPITAL INCORPORATED | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name Control | COMM | NameControl |
| Phone | 9208463444 | Phone |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 855 S MAIN STREET | AddressLine1 |
| City | OCONTO FALLS | City |
| State | WI | State |
| ZIP Code | 54154 | ZIPCode |
Officer Officer
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name | MICHELE MILLER-CAMPBELL | Name |
| Title | CFO | Title |
| Phone | 9208463444 | Phone |
| Date Signed | 2013-08-14 | DateSigned |
| Authorize Third Party | 1 | AuthorizeThirdParty |
Preparer Preparer
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name | TERRI REXRODE | Name |
| PTIN | P00096513 | PTIN |
| Phone | 9206620016 | Phone |
| Date Prepared | 2013-08-14 | DatePrepared |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tax Year | 2011 | TaxYear |
| Build TS | 2016-02-24 21:20:13Z | BuildTS |
Form 990 IRS990
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name Of Principal Officer Person | DANIEL DEGROOT | NameOfPrincipalOfficerPerson |
Address Principal Officer US AddressPrincipalOfficerUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 855 S MAIN STREET | AddressLine1 |
| City | OCONTO FALLS | City |
| State | WI | State |
| ZIP Code | 54154 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Receipts | 37479191 | GrossReceipts |
| Group Return For Affiliates | 0 | GroupReturnForAffiliates |
| Organization501c3 | X | Organization501c3 |
| Web Site | WWW.CMHOSPITAL.ORG | WebSite |
| Type Of Organization Corporation | X | TypeOfOrganizationCorporation |
| Year Formation | 1929 | YearFormation |
| State Legal Domicile | WI | StateLegalDomicile |
| Activity Or Mission Description | COMMUNITY MEMORIAL HOSPITAL, INC. OPERATES AN ACUTE CARE HOSPITAL PROVIDING COMPREHENSIVE INPATIENT MEDICAL AND SURGICAL SERVICES AS WELL AS EMERGENCY, PRIMARY CARE PHYSICIAN, AND OUTPATIENT SERVICES. THE HOSPITAL HAS BEEN DESIGNATED AS A CRITICAL ACCESS HOSPITAL UNDER MEDICARE AND MEDICAID REGULATIONS. THIS DESIGNATION, WHICH ENABLES THE HOSPITAL TO RECEIVE REIMBURSEMENT UNDER COST-BASED METHODS, LIMITS THE NUMBER OF STAFFED BEDS THE HOSPITAL MAY OPERATE TO 25. | ActivityOrMissionDescription |
| Nbr Voting Members Governing Body | 7 | NbrVotingMembersGoverningBody |
| Nbr Independent Voting Members | 5 | NbrIndependentVotingMembers |
| Total Nbr Employees | 416 | TotalNbrEmployees |
| Total Nbr Volunteers | 86 | TotalNbrVolunteers |
| Total Gross UBI | 2389798 | TotalGrossUBI |
| Net Unrelated Business Txbl Income | -143765 | NetUnrelatedBusinessTxblIncome |
| Contributions Grants Prior Year | 249389 | ContributionsGrantsPriorYear |
| Contributions Grants Current Year | 143789 | ContributionsGrantsCurrentYear |
| Program Service Revenue Prior Year | 37242847 | ProgramServiceRevenuePriorYear |
| Program Service Revenue CY | 36932424 | ProgramServiceRevenueCY |
| Investment Income Prior Year | 142453 | InvestmentIncomePriorYear |
| Investment Income Current Year | 213793 | InvestmentIncomeCurrentYear |
| Other Revenue Prior Year | -82057 | OtherRevenuePriorYear |
| Other Revenue Current Year | -65976 | OtherRevenueCurrentYear |
| Total Revenue Prior Year | 37552632 | TotalRevenuePriorYear |
| Total Revenue Current Year | 37224030 | TotalRevenueCurrentYear |
| Grants And Similar Amnts Prior Year | 0 | GrantsAndSimilarAmntsPriorYear |
| Grants And Similar Amnts CY | 0 | GrantsAndSimilarAmntsCY |
| Benefits Paid To Members Prior Year | 0 | BenefitsPaidToMembersPriorYear |
| Benefits Paid To Members CY | 0 | BenefitsPaidToMembersCY |
| Salaries Etc Prior Year | 20737802 | SalariesEtcPriorYear |
| Salaries Etc Current Year | 19861888 | SalariesEtcCurrentYear |
| Total Prof Fundrsng Exp Prior Year | 0 | TotalProfFundrsngExpPriorYear |
| Total Prof Fundrsng Exp CY | 0 | TotalProfFundrsngExpCY |
| Total Fundrsng Exp Current Year | 0 | TotalFundrsngExpCurrentYear |
| Other Expense Prior Year | 18213287 | OtherExpensePriorYear |
| Other Expenses Current Year | 17178769 | OtherExpensesCurrentYear |
| Total Expenses Prior Year | 38951089 | TotalExpensesPriorYear |
| Total Expenses Current Year | 37040657 | TotalExpensesCurrentYear |
| Revenues Less Expenses Prior Year | -1398457 | RevenuesLessExpensesPriorYear |
| Revenues Less Expenses CY | 183373 | RevenuesLessExpensesCY |
| Total Assets BOY | 29769545 | TotalAssetsBOY |
| Total Assets EOY | 30397704 | TotalAssetsEOY |
| Total Liabilities BOY | 13043656 | TotalLiabilitiesBOY |
| Total Liabilities EOY | 13112680 | TotalLiabilitiesEOY |
| Net Assets Or Fund Balances BOY | 16725889 | NetAssetsOrFundBalancesBOY |
| Net Assets Or Fund Balances EOY | 17285024 | NetAssetsOrFundBalancesEOY |
| Info In Schedule O Part III | X | InfoInScheduleOPartIII |
| Mission Description | TO PROVIDE HIGH QUALITY HEALTHCARE, CLOSE TO HOME. | MissionDescription |
| Significant New Program Services | 0 | SignificantNewProgramServices |
| Significant Change | 1 | SignificantChange |
| Expense | 28336364 | Expense |
| Revenue | 34486042 | Revenue |
| Description | COMMUNITY MEMORIAL HOSPITAL IS AN INDEPENDENT HEALTHCARE SYSTEM SERVING GREATER OCONTO COUNTY WITH A FULL-SERVICE HOSPITAL AND SIX CMH PRIMARY CARE CLINICS LOCATED THROUGHOUT OCONTO COUNTY. THE FEDERALLY DESIGNATED CRITICAL ACCESS HOSPITAL WITH 25 BEDS AND AN ADDITIONAL 3 NURSERY BEDS HAS A 24-HOUR, PHYSICIAN-STAFFED EMERGENCY DEPARTMENT, URGENT CARE, RETAIL PHARMACY, INTENSIVE CARE, INPATIENT AND OUTPATIENT SURGICAL AND DIAGNOSTIC SERVICES, REHABILITATION, ONCOLOGY OUTPATIENT CLINIC, OBSTETRICS, THE CMH CENTER FOR WOMEN'S CARE, AND THE CMH CENTER FOR ORTHOPEDIC CARE. CMH PRIMARY CARE CLINICS ARE LOCATED IN LENA, OCONTO FALLS, OCONTO, GILLETT, SURING, AND MOUNTAIN. COMMUNITY MEMORIAL HOSPITAL IS A NON-PROFIT ORGANIZATION DEDICATED TO OUR MISSION TO PROVIDE HIGH QUALITY HEALTH CARE CLOSE TO HOME. COMMUNITY MEMORIAL HOSPITAL EXTENDS THIS MISSION INTO OUR VALUES OF QUALITY, CARE, COMMUNITY, TRUST, AND RESPECT AND PROMOTES THE HEALTH OF THE COMMUNITY BY PROVIDING A VARIETY OF HEALTHCARE SERVICES. DURING THE FISCAL YEAR ENDING SEPTEMBER 30, 2012, THE HOSPITAL HAD 1051 DISCHARGES AND 95 NEWBORNS; 6,056 VISITS TO THE EMERGENCY ROOM; 2,309 SURGICAL CASES (INCLUDING AMBULATORY); AND 39,498 VISITS TO OUR HOSPITAL-BASED CLINICS.COMMUNITY MEMORIAL HOSPITAL PROVIDES HEALTHCARE SERVICES TO ALL MEMBERS OF THE COMMUNITY WITHOUT REGARD TO THEIR AGE, RACE, SEX, OR ABILITY TO PAY FOR SERVICES. DURING FISCAL YEAR 2012, COMMUNITY MEMORIAL HOSPITAL PROVIDED $1,543,333 IN CHARITY CARE, $185,594 IN PATIENT DISCOUNTS FOR GOVERNMENT PROGRAMS OUTSIDE OF TITLE 18 & TITLE 19, AND $1,482,639 IN BAD DEBT WRITE OFFS OF PATIENT ACCOUNTS AS BAD DEBT DUE TO THE PATIENTS' INABILITY TO PAY FOR SERVICES THEY RECEIVED.IN ADDITION TO ITS HOSPITAL AND CLINIC SERVICES, COMMUNITY MEMORIAL HOSPITAL PROVIDES THE COMMUNITY MANY OPPORTUNITIES TO RECEIVE FREE AND LOW-COST HEALTH SCREENINGS AND SERVICES. FOR EACH OF THESE OFFERINGS, COMMUNITY MEMORIAL HOSPITAL PROVIDED PLANNING, PUBLICITY, STAFF, EQUIPMENT, SUPPLIES, AND FACILITIES.COMMUNITY MEMORIAL HOSPITAL HOSTS COMMUNITY HEALTH INFORMATION SEMINARS ON VARIOUS TOPICS THAT ARE FREE AND OPEN TO THE PUBLIC. COMMUNITY MEMORIAL HOSPITAL ASSUMES THE ENTIRE COSTS FOR THE SPEAKER TO PRESENT THE SEMINAR, PUBLICITY, SUPPLIES, AND THE MEALS. FOUR CMH SENIOR SPECIALS DINNER SEMINARS WERE HELD IN 2012.COMMUNITY MEMORIAL HOSPITAL IS PLEASED TO PARTNER, PARTICIPATE AND COLLABORATE WITH MANY COMMUNITY PARTNERS FOR VARIOUS INITIATIVES AND EVENTS. COMMUNITY MEMORIAL HOSPITAL PLANNED AND SPONSORED THE HOT CAKE HUSTLE 5K FUN RUN/WALK, A COMMUNITY HEALTH INITIATIVE. WE ALSO PRESENTED THE OCONTO COUNTY SAFETY FAIR IN COOPERATION WITH THE OCONTO COUNTY HEALTH DEPARTMENT, OCONTO FALLS FIRE AND POLICE DEPARTMENTS AND THE OCONTO FALLS AMBULANCE SERVICE. CMH OFFERED FOUR FREE WORKSHOPS FOR CANCER PATIENTS IN 2012 THROUGH THE AMERICAN CANCER SOCIETY LOOK GOOD FEEL BETTER PROGRAM. CMH HOSTS AMERICAN RED CROSS BLOOD DRIVES MULTIPLE TIMES EACH YEAR. COMMUNITY MEMORIAL HOSPITAL IS AN ACTIVE MEMBER IN THE OCONTO FALLS CHAMBER OF COMMERCE AND ACTIVELY PARTICIPATES IN THEIR MAJOR FUNDRAISING COMMITTEE AND THE EXECUTIVE COMMITTEE. FOR EACH OF THESE INITIATIVES, COMMUNITY MEMORIAL HOSPITAL PROVIDED PLANNING, PUBLICITY, STAFF, EQUIPMENT, SUPPLIES, AND FACILITIES.CMH SUPPORTS AND PARTICIPATES IN AREA SCHOOL-RELATED ACTIVITIES. IN ADDITION TO PROVIDING COMPREHENSIVE SPORTS PHYSICAL CLINICS IN WHICH THE FEES ARE DONATED BACK TO THE SCHOOLS OF THE PARTICIPATING STUDENTS, CMH PARTICIPATED IN AREA SCHOOL HEALTH FAIRS, CAREER FAIRS, AND EARLY CHILDHOOD SCREENINGS. SCHOOL FIELD TRIP TOURS ARE ROUTINELY HOSTED AT THE HOSPITAL. THIS IS A SUMMATION OF SERVICES PROVIDED BY COMMUNITY MEMORIAL HOSPITAL IN THE FISCAL YEAR 2012. | Description |
| Total Program Service Expense | 28336364 | TotalProgramServiceExpense |
| Described In501 C3 | 1 | DescribedIn501C3 |
| Schedule B Required | 1 | ScheduleBRequired |
| Political Activities | 0 | PoliticalActivities |
| Lobbying Activities | 1 | LobbyingActivities |
| Subject To Proxy Tax | 0 | SubjectToProxyTax |
| Donor Advised Funds | 0 | DonorAdvisedFunds |
| Conservation Easements | 0 | ConservationEasements |
| Collections Of Art | 0 | CollectionsOfArt |
| Credit Counseling | 0 | CreditCounseling |
| Term Or Permanent Endowments | 0 | TermOrPermanentEndowments |
| Report Land Bldg Equip | 1 | ReportLandBldgEquip |
| Report Invest Oth Securities | 0 | ReportInvestOthSecurities |
| Report Prog Rel Invest | 0 | ReportProgRelInvest |
| Report Other Assets | 1 | ReportOtherAssets |
| Report Other Liabilities | 1 | ReportOtherLiabilities |
| Report Fin48 Footnote | 1 | ReportFin48Footnote |
| Independent Audit Financial Stmt | 0 | IndependentAuditFinancialStmt |
| Consolidated Audit Financial Stmt | 1 | ConsolidatedAuditFinancialStmt |
| School | 0 | School |
| Foreign Office | 0 | ForeignOffice |
| Foreign Activities | 0 | ForeignActivities |
| More Than5000 K To Organizations | 0 | MoreThan5000KToOrganizations |
| More Than5000 K To Individuals | 0 | MoreThan5000KToIndividuals |
| Professional Fundraising | 0 | ProfessionalFundraising |
| Fundraising Activities | 0 | FundraisingActivities |
| Gaming | 0 | Gaming |
| Hospital | 1 | Hospital |
| Financial Stmt Attached | 1 | FinancialStmtAttached |
| Grants To Organizations | 0 | GrantsToOrganizations |
| Grants To Individuals | 0 | GrantsToIndividuals |
| Schedule J Required | 1 | ScheduleJRequired |
| Tax Exempt Bonds | 1 | TaxExemptBonds |
| Invest Tax Exempt Bonds | 0 | InvestTaxExemptBonds |
| Escrow Account | 0 | EscrowAccount |
| On Behalf Of Issuer | 0 | OnBehalfOfIssuer |
| Excess Benefit Transaction | 0 | ExcessBenefitTransaction |
| Prior Excess Benefit Transaction | 0 | PriorExcessBenefitTransaction |
| Loan To Officer Or DQP | 0 | LoanToOfficerOrDQP |
| Grant To Related Person | 0 | GrantToRelatedPerson |
| Bsnss Rltnshp With Organization | 0 | BsnssRltnshpWithOrganization |
| Bsnss Rltnshp Thru Family Member | 0 | BsnssRltnshpThruFamilyMember |
| Officer Entity With Bsnss Rltnshp | 1 | OfficerEntityWithBsnssRltnshp |
| Deductible Non Cash Contributions | 0 | DeductibleNonCashContributions |
| Deductible Contributions Of Art | 0 | DeductibleContributionsOfArt |
| Terminated | 0 | Terminated |
| Partial Liquidation | 0 | PartialLiquidation |
| Disregarded Entity | 0 | DisregardedEntity |
| Related Entity | 1 | RelatedEntity |
| Related Org Controlled Entity | 1 | RelatedOrgControlledEntity |
| Transaction Related Entity | 0 | TransactionRelatedEntity |
| Transfers To Exempt Non Chrtbl Org | 0 | TransfersToExemptNonChrtblOrg |
| Activities Conducted Partnership | 0 | ActivitiesConductedPartnership |
| Schedule O Required | 1 | ScheduleORequired |
| Number Forms Transmitted With1096 | 29 | NumberFormsTransmittedWith1096 |
| Number W2 G Included | 0 | NumberW2GIncluded |
| Compliance With Backup Witholding | 1 | ComplianceWithBackupWitholding |
| Number Of Employees | 416 | NumberOfEmployees |
| Employment Tax Returns Filed | 1 | EmploymentTaxReturnsFiled |
| Unrelated Business Income | 1 | UnrelatedBusinessIncome |
| Form990-T Filed | 1 | Form990-TFiled |
| Foreign Financial Account | 0 | ForeignFinancialAccount |
| Prohibited Tax Shelter Trans | 0 | ProhibitedTaxShelterTrans |
| Taxable Party Notification | 0 | TaxablePartyNotification |
| Non Deductible Contributions | 0 | NonDeductibleContributions |
| Quid Pro Quo Contributions | 1 | QuidProQuoContributions |
| Quid Pro Quo Disclosure | 1 | QuidProQuoDisclosure |
| Form8282 Property Disposed Of | 0 | Form8282PropertyDisposedOf |
| Funds To Pay Premiums | 0 | FundsToPayPremiums |
| Premiums Paid | 0 | PremiumsPaid |
| Indoor Tanning Services | 0 | IndoorTanningServices |
| Info In Schedule O Part VI | X | InfoInScheduleOPartVI |
| Nbr Voting Governing Body Members | 7 | NbrVotingGoverningBodyMembers |
| Number Independent Voting Members | 5 | NumberIndependentVotingMembers |
| Family Or Business Relationship | 0 | FamilyOrBusinessRelationship |
| Delegation Of Management Duties | 0 | DelegationOfManagementDuties |
| Changes To Organizing Docs | 0 | ChangesToOrganizingDocs |
| Material Diversion Or Misuse | 0 | MaterialDiversionOrMisuse |
| Members Or Stockholders | 0 | MembersOrStockholders |
| Election Of Board Members | 0 | ElectionOfBoardMembers |
| Decisions Subject To Approval | 0 | DecisionsSubjectToApproval |
| Minutes Of Governing Body | 1 | MinutesOfGoverningBody |
| Minutes Of Committees | 1 | MinutesOfCommittees |
| Officer Mailing Address | 0 | OfficerMailingAddress |
| Local Chapters | 0 | LocalChapters |
| Form990 Provided To Governing Body | 0 | Form990ProvidedToGoverningBody |
| Conflict Of Interest Policy | 1 | ConflictOfInterestPolicy |
| Annual Disclosure Covered Persons | 1 | AnnualDisclosureCoveredPersons |
| Regular Monitoring Enforcement | 1 | RegularMonitoringEnforcement |
| Whistleblower Policy | 1 | WhistleblowerPolicy |
| Document Retention Policy | 0 | DocumentRetentionPolicy |
| Compensation Process CEO | 1 | CompensationProcessCEO |
| Compensation Process Other | 1 | CompensationProcessOther |
| Investment In Joint Venture | 0 | InvestmentInJointVenture |
| States Where Copy Of Return Is Filed | WI | StatesWhereCopyOfReturnIsFiled |
| Upon Request | X | UponRequest |
The Books Are In Care Of TheBooksAreInCareOf
Name Business NameBusiness
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | MICHELE MILLER-CAMPBELL CFO | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Telephone Number | 9208463444 | TelephoneNumber |
Address US AddressUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 855 SOUTH MAIN STREET | AddressLine1 |
| City | OCONTO FALLS | City |
| State | WI | State |
| ZIP Code | 54154 | ZIPCode |
Form990 Part VII Section A Form990PartVIISectionA (17 entries)
| TitleTitle | Average Hours Per WeekAverageHoursPerWeek | Individual Trustee Or DirectorIndividualTrusteeOrDirector | OfficerOfficer | Reportable Comp From OrganizationReportableCompFromOrganization | Reportable Comp From Related OrgsReportableCompFromRelatedOrgs | Other CompensationOtherCompensation | Highest Compensated EmployeeHighestCompensatedEmployee |
|---|---|---|---|---|---|---|---|
| CRISTY KAEMPFER | |||||||
| BOARD CHAIRMAN | 2.00 | X | X | 0 | 0 | 0 | |
| DANIEL BOETTCHER | |||||||
| BOARD VICE CHAIRMAN | 2.00 | X | X | 0 | 0 | 0 | |
| JAN STRANZ | |||||||
| BOARD SECRETARY/TREASURER | 2.00 | X | X | 0 | 0 | 0 | |
| HOWARD ESLIEN JR | |||||||
| BOARD MEMBER | 2.00 | X | 0 | 0 | 0 | ||
| TOM BAYER | |||||||
| BOARD MEMBER / HSHS REP | 2.00 | X | 0 | 0 | 0 | ||
| DR ASHOK RAI | |||||||
| BOARD MEMBER / HSHS REP | 2.00 | X | 0 | 0 | 0 | ||
| DR ISAIAS CUPINO | |||||||
| BOARD MEMBER / PHYSICIAN | 42.00 | X | 463996 | 0 | 29754 | ||
| DR GENADI MALTINSKI | |||||||
| BOARD MEMBER / PHYSICIAN | 42.00 | X | 351749 | 0 | 5189 | ||
| DR JUDITH BOWERS | |||||||
| BOARD MEMBER THRU 12/11 | 2.00 | X | 0 | 0 | 0 | ||
| KARL APPLETON | |||||||
| BOARD MEMBER THRU 12/11 | 2.00 | X | 0 | 0 | 0 | ||
| JAMES VANDORNICK | |||||||
| BOARD MEMBER / CEO THRU 8/11 | 42.00 | X | X | 104624 | 0 | 0 | |
| DANIEL DEGROOT | |||||||
| BOARD MEMBER / CEO | 42.00 | X | X | 74335 | 0 | 282 | |
| MICHELE MILLER-CAMPELL | |||||||
| CFO | 40.00 | X | 24972 | 0 | 75 | ||
| DR JEFFREY BENTSON | |||||||
| PHYSICIAN | 40.00 | 523463 | 0 | 36326 | X | ||
| DR R SCOTT LIEBL | |||||||
| PHYSICIAN | 40.00 | 426474 | 0 | 36654 | X | ||
| DR KEVIN HIBBETT | |||||||
| PHYSICIAN | 40.00 | 316395 | 0 | 29425 | X | ||
| DR LUZ BALMADRID | |||||||
| PHYSICIAN | 40.00 | 301082 | 0 | 11551 | X | ||
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Reportable Comp From Org | 2587090 | TotalReportableCompFromOrg |
| Total Reportable Comp Frm Rltd Orgs | 0 | TotalReportableCompFrmRltdOrgs |
| Total Other Compensation | 149256 | TotalOtherCompensation |
| Number Individuals GT100 K | 17 | NumberIndividualsGT100K |
| Formers Listed | 0 | FormersListed |
| Total Comp GT150 K | 1 | TotalCompGT150K |
| Compensation From Other Sources | 0 | CompensationFromOtherSources |
Contractor Compensation ContractorCompensation (5 entries)
| Address Line1AddressOfContractor/AddressUS/AddressLine1 | CityAddressOfContractor/AddressUS/City | StateAddressOfContractor/AddressUS/State | ZIP CodeAddressOfContractor/AddressUS/ZIPCode | Description Of ServicesDescriptionOfServices | CompensationCompensation |
|---|---|---|---|---|---|
| HEALTHTECH SOLUTIONS GROUP | |||||
| 405 DUKE DRIVE SUITE 210 | FRANKLIN | TN | 37067 | HEALTHCARE CONSULTING | 746554 |
| ST VINCENT HOSPITAL | |||||
| 835 VAN BUREN STREET | GREEN BAY | WI | 54307 | REFERENCE LAB SERVICES | 617952 |
| AMERICOLLECT | |||||
| PO BOX 1566 | MANITOWAC | WI | 54221 | COLLECTION SERVICES | 312908 |
| COPPENS INC | |||||
| 1919 HOLMGREN WAY PO BOX 12675 | GREEN BAY | WI | 543072675 | ROOFING SERVICES | 311973 |
| ST MARY'S MEDICAL CENTER | |||||
| 1726 SHAWANO AVE | GREEN BAY | WI | 54303 | REFERENCE LAB SERVICES | 288900 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Number Of Contractors GT100 K | 8 | NumberOfContractorsGT100K |
| Related Organizations | 53748 | RelatedOrganizations |
| Government Grants | 74444 | GovernmentGrants |
| All Other Contributions | 15597 | AllOtherContributions |
| Total Contributions | 143789 | TotalContributions |
Program Service Revenue ProgramServiceRevenue (5 entries)
| DescriptionDescription | Business CodeBusinessCode | Total Revenue ColumnTotalRevenueColumn | Related Or Exempt Function IncomeRelatedOrExemptFunctionIncome | Unrelated Business RevenueUnrelatedBusinessRevenue | ExclusionExclusionAmount |
|---|---|---|---|---|---|
| NET PATIENT SERVICE RE | 900099 | 33168075 | 33168075 | ||
| RETAIL PHARMACY REVENU | 446110 | 3097104 | 707306 | 2389798 | |
| OTHER REVENUE | 900099 | 447212 | 447212 | ||
| ONCOLOGY CONTRACT REVE | 621300 | 163449 | 163449 | ||
| CAFETERIA REVENUE | 900099 | 30563 | $30,563 |
Total Oth Program Service Revenue TotalOthProgramServiceRevenue
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 26021 | TotalRevenueColumn |
| Exclusion | $26,021 | ExclusionAmount |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Revenue | 36932424 | TotalProgramServiceRevenue |
Investment Income InvestmentIncome
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 225059 | TotalRevenueColumn |
| Exclusion | $225,059 | ExclusionAmount |
Gross Rents GrossRents
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | 176919 | Real |
Less Rental Expenses LessRentalExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | 242895 | Real |
Rental Income Or Loss RentalIncomeOrLoss
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | -65976 | Real |
Net Rental Income Or Loss NetRentalIncomeOrLoss
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | -65976 | TotalRevenueColumn |
| Exclusion | -$65,976 | ExclusionAmount |
Gross Amount Sales Assets GrossAmountSalesAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | 1000 | Other |
Less Cost Oth Basis Sales Expenses LessCostOthBasisSalesExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | 12266 | Other |
Gain Or Loss GainOrLoss
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | -11266 | Other |
Net Gain Or Loss Investments NetGainOrLossInvestments
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | -11266 | TotalRevenueColumn |
| Exclusion | -$11,266 | ExclusionAmount |
Total Revenue TotalRevenue
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 37224030 | TotalRevenueColumn |
| Related Or Exempt Function Income | 34486042 | RelatedOrExemptFunctionIncome |
| Unrelated Business Revenue | 2389798 | UnrelatedBusinessRevenue |
| Exclusion | $204,401 | ExclusionAmount |
Comp Current Officers Directors CompCurrentOfficersDirectors
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 1905664 | Total |
| Program Services | 1701376 | ProgramServices |
| Management And General | 204288 | ManagementAndGeneral |
Other Salaries And Wages OtherSalariesAndWages
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 13761471 | Total |
| Program Services | 11596138 | ProgramServices |
| Management And General | 2165333 | ManagementAndGeneral |
Pension Plan Contributions PensionPlanContributions
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 287502 | Total |
| Program Services | 236461 | ProgramServices |
| Management And General | 51041 | ManagementAndGeneral |
Other Employee Benefits OtherEmployeeBenefits
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 2962271 | Total |
| Program Services | 2278465 | ProgramServices |
| Management And General | 683806 | ManagementAndGeneral |
Payroll Taxes PayrollTaxes
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 944980 | Total |
| Program Services | 771452 | ProgramServices |
| Management And General | 173528 | ManagementAndGeneral |
Fees For Services Legal FeesForServicesLegal
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 133826 | Total |
| Management And General | 133826 | ManagementAndGeneral |
Fees For Services Accounting FeesForServicesAccounting
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 669482 | Total |
| Management And General | 669482 | ManagementAndGeneral |
Fees For Services Invst Mgmnt Fees FeesForServicesInvstMgmntFees
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 19391 | Total |
| Management And General | 19391 | ManagementAndGeneral |
Fees For Services Other FeesForServicesOther
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 2435815 | Total |
| Program Services | 1766731 | ProgramServices |
| Management And General | 669084 | ManagementAndGeneral |
Advertising Advertising
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 117202 | Total |
| Management And General | 117202 | ManagementAndGeneral |
Office Expenses OfficeExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 7013838 | Total |
| Program Services | 6408031 | ProgramServices |
| Management And General | 605807 | ManagementAndGeneral |
Information Technology InformationTechnology
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 145711 | Total |
| Program Services | 54871 | ProgramServices |
| Management And General | 90840 | ManagementAndGeneral |
Occupancy Occupancy
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 1746267 | Total |
| Program Services | 886531 | ProgramServices |
| Management And General | 859736 | ManagementAndGeneral |
Travel Travel
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 94134 | Total |
| Program Services | 60757 | ProgramServices |
| Management And General | 33377 | ManagementAndGeneral |
Conferences Meetings ConferencesMeetings
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 3027 | Total |
| Program Services | 894 | ProgramServices |
| Management And General | 2133 | ManagementAndGeneral |
Interest Interest
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 541995 | Total |
| Management And General | 541995 | ManagementAndGeneral |
Depreciation Depletion DepreciationDepletion
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 1125542 | Total |
| Management And General | 1125542 | ManagementAndGeneral |
Insurance Insurance
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 195472 | Total |
| Program Services | 113089 | ProgramServices |
| Management And General | 82383 | ManagementAndGeneral |
Other Expenses OtherExpenses (2 entries)
| DescriptionDescription | TotalTotal | Program ServicesProgramServices | Management And GeneralManagementAndGeneral |
|---|---|---|---|
| BAD DEBT EXPENSE | 2302959 | 2302959 | |
| OTHER EXPENSES | 634108 | 158609 | 475499 |
Total Functional Expenses TotalFunctionalExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 37040657 | Total |
| Program Services | 28336364 | ProgramServices |
| Management And General | 8704293 | ManagementAndGeneral |
| Fundraising | 0 | Fundraising |
Cash Non Interest Bearing CashNonInterestBearing
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 2006109 | BOY |
| EOY | 3464369 | EOY |
Savings And Temp Cash Investments SavingsAndTempCashInvestments
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 2652213 | BOY |
| EOY | 2588212 | EOY |
Accounts Receivable AccountsReceivable
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 5276893 | BOY |
| EOY | 4673351 | EOY |
Receivables From Officers Etc ReceivablesFromOfficersEtc
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 14203 | BOY |
Other Notes Loans Receivable Net OtherNotesLoansReceivableNet
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 1700933 | BOY |
| EOY | 92120 | EOY |
Inventories For Sale Or Use InventoriesForSaleOrUse
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 1231963 | BOY |
| EOY | 1274010 | EOY |
Prepaid Expenses Deferred Charges PrepaidExpensesDeferredCharges
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 564760 | BOY |
| EOY | 532249 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Land Buildings Equipment Basis | 26815763 | LandBuildingsEquipmentBasis |
| Land Bldg Equipment Accum Deprec | 16905800 | LandBldgEquipmentAccumDeprec |
Land Buildings Equipment Basis Net LandBuildingsEquipmentBasisNet
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 9151588 | BOY |
| EOY | 9909963 | EOY |
Investments Pub Traded Securities InvestmentsPubTradedSecurities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 5366288 | BOY |
| EOY | 5949244 | EOY |
Investments Other Securities InvestmentsOtherSecurities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 173766 | BOY |
| EOY | 167555 | EOY |
Other Assets Total OtherAssetsTotal
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 1630829 | BOY |
| EOY | 1746631 | EOY |
Total Assets TotalAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 29769545 | BOY |
| EOY | 30397704 | EOY |
Accounts Payable Accrued Expenses AccountsPayableAccruedExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 3026530 | BOY |
| EOY | 3003234 | EOY |
Deferred Revenue DeferredRevenue
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 305121 | BOY |
| EOY | 0 | EOY |
Tax Exempt Bond Liabilities TaxExemptBondLiabilities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 7920236 | BOY |
| EOY | 7752375 | EOY |
Mort Notes Pybl Secured Invest Prop MortNotesPyblSecuredInvestProp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 948311 | BOY |
| EOY | 917669 | EOY |
Other Liabilities OtherLiabilities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 843458 | BOY |
| EOY | 1439402 | EOY |
Total Liabilities TotalLiabilities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 13043656 | BOY |
| EOY | 13112680 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Follow SFAS117 | X | FollowSFAS117 |
Unrestricted Net Assets UnrestrictedNetAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 16554623 | BOY |
| EOY | 17119970 | EOY |
Temporarily Restricted Net Assets TemporarilyRestrictedNetAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 171266 | BOY |
| EOY | 165054 | EOY |
Total Net Assets Fund Balances TotalNetAssetsFundBalances
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 16725889 | BOY |
| EOY | 17285024 | EOY |
Total Liab Net Assets Fund Balances TotalLiabNetAssetsFundBalances
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 29769545 | BOY |
| EOY | 30397704 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part XI | X | InfoInScheduleOPartXI |
| Reconcilation Revenue Expenses | 183373 | ReconcilationRevenueExpenses |
| Reconcilation Other Changes | 375762 | ReconcilationOtherChanges |
| Info In Schedule O Part XII | X | InfoInScheduleOPartXII |
| Method Of Accounting Accrual | X | MethodOfAccountingAccrual |
| Accountant Compile Or Review | 0 | AccountantCompileOrReview |
| FS Audited | 1 | FSAudited |
| Audit Committee | 1 | AuditCommittee |
| Financial Statement Consolidated | X | FinancialStatementConsolidated |
| Federal Grant Audit Required | 0 | FederalGrantAuditRequired |
Schedule A IRS990ScheduleA
| Field | Value | IRS element (for citing) |
|---|---|---|
| Hospital170b1 Aiii | X | Hospital170b1Aiii |
Schedule B IRS990ScheduleB
Contributor Info ContributorInfo
| Field | Value | IRS element (for citing) |
|---|---|---|
| Contributor Number | RESTRICTED | ContributorNumber |
Contributor Name Business ContributorNameBusiness
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | RESTRICTED | BusinessNameLine1 |
Contributor Address US ContributorAddressUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | RESTRICTED | AddressLine1 |
| Address Line2 | RESTRICTED | AddressLine2 |
| City | RESTRICTED | City |
| State | RESTRICTED | State |
| ZIP Code | RESTRICTED | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Aggregate Contributions | RESTRICTED | AggregateContributions |
Schedule C IRS990ScheduleC
| Field | Value | IRS element (for citing) |
|---|---|---|
| Volunteers | 0 | Volunteers |
| Paid Staff Or Management | 0 | PaidStaffOrManagement |
| Media Advertisements | 0 | MediaAdvertisements |
| Mailings Members | 0 | MailingsMembers |
| Publications Or Broadcast | 0 | PublicationsOrBroadcast |
| Grants Other Organizations | 0 | GrantsOtherOrganizations |
| Direct Contact Legislators | 0 | DirectContactLegislators |
| Rallies Demonstrations | 0 | RalliesDemonstrations |
| Other Activities | 1 | OtherActivities |
| Other Activities | $8,497 | OtherActivitiesAmount |
| Total Lobbying Expenditures IIB | 8497 | TotalLobbyingExpendituresIIB |
| Not Described In501c3 | 0 | NotDescribedIn501c3 |
Form990 Schedule C Part IV Form990ScheduleCPartIV
| Field | Value | IRS element (for citing) |
|---|---|---|
| Identifier | EXPLANATION OF LOBBYING ACTIVITIES: | Identifier |
| Return Reference | PART II-B, LINE 1: | ReturnReference |
| Explanation | PORTION OF THE FOLLOWING DUES: WHA: $1,641; RWHC: $3,058; AND AHA: $3,798. | Explanation |
Schedule D IRS990ScheduleD
Current Year CurrentYear
| Field | Value | IRS element (for citing) |
|---|---|---|
| Beginning Of Year Balance | 4171266 | BeginningOfYearBalance |
| Contributions | 20000 | Contributions |
| Investment Earnings Or Losses | 168896 | InvestmentEarningsOrLosses |
| Grants Or Scholarships | 802599 | GrantsOrScholarships |
| Other Expenditures | 417915 | OtherExpenditures |
| End Of Year Balance | 3139648 | EndOfYearBalance |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Board Designated EOY Balance | 0.97000 | BoardDesignatedEOYBalance |
| Permanent Endowment EOY Balance | 0.00000 | PermanentEndowmentEOYBalance |
| Term Endowment EOY Balance | 0.03000 | TermEndowmentEOYBalance |
| Endowments Held By Unrelated Orgs | 0 | EndowmentsHeldByUnrelatedOrgs |
| Endowments Held By Related Orgs | 0 | EndowmentsHeldByRelatedOrgs |
Land Land
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 235001 | OtherCostOrOtherBasis |
| Book Value | 235001 | BookValue |
Buildings Buildings
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 14414936 | OtherCostOrOtherBasis |
| Depreciation | 6971672 | Depreciation |
| Book Value | 7443264 | BookValue |
Equipment Equipment
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 11102495 | OtherCostOrOtherBasis |
| Depreciation | 9640131 | Depreciation |
| Book Value | 1462364 | BookValue |
Other Land Buildings OtherLandBuildings
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 1063331 | OtherCostOrOtherBasis |
| Depreciation | 293997 | Depreciation |
| Book Value | 769334 | BookValue |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Of Book Value Land Buildings | 9909963 | TotalOfBookValueLandBuildings |
Other Assets OtherAssets (4 entries)
| DescriptionDescription | Book ValueBookValue |
|---|---|
| DUE FROM WOODLANDS | 130687 |
| BOND FUNDS | 982925 |
| SECTION 457 PLAN ASSET | 632727 |
| OTHER | 292 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Book Value Other Assets | 1746631 | TotalBookValueOtherAssets |
Other Liabilities OtherLiabilities (3 entries)
| DescriptionDescription | AmountAmount |
|---|---|
| CAPITAL LEASES | $96,891 |
| DUE TO THIRD PARTY PAYORS | $709,784 |
| SECTION 457 PLAN LIABILITY | $632,727 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Of Amounts | 1439402 | TotalOfAmounts |
| Total Revenue | 37224030 | TotalRevenue |
| Total Expenses | 37040657 | TotalExpenses |
| Excess Or Deficit For Year | 183373 | ExcessOrDeficitForYear |
| Net Unrealized GL On Investments | 436254 | NetUnrealizedGLOnInvestments |
| Other | -$60,492 | OtherAmount |
| Total Adjustments | 375762 | TotalAdjustments |
| Excess Or Deficit Per FS | 559135 | ExcessOrDeficitPerFS |
| Tot Revenue Etc Audited Fincl Stmt | 37368619 | TotRevenueEtcAuditedFinclStmt |
| Other Revenues | 242895 | OtherRevenues |
| Revenue Not Rptd F990 | 242895 | RevenueNotRptdF990 |
| Revenue Subtotal | 37125724 | RevenueSubtotal |
| Investment Expenses Not Included | 19391 | InvestmentExpensesNotIncluded |
| Other Revenues Not Included | 78915 | OtherRevenuesNotIncluded |
| Revenue Not Rptd On Fin Stmt | 98306 | RevenueNotRptdOnFinStmt |
| Total Revenue Per Form990 | 37224030 | TotalRevenuePerForm990 |
| Tot Expenses Etc Audited Fincl Stmt | 37238994 | TotExpensesEtcAuditedFinclStmt |
| Other Expenses Included | 242895 | OtherExpensesIncluded |
| Expenses Not Rptd F990 | 242895 | ExpensesNotRptdF990 |
| Expenses Subtotal | 36996099 | ExpensesSubtotal |
| Investment Expenses Not Included2 | 19391 | InvestmentExpensesNotIncluded2 |
| Other Expenses Not Included | 25167 | OtherExpensesNotIncluded |
| Expenses Not Rptd On Fin Stmt | 44558 | ExpensesNotRptdOnFinStmt |
| Total Expenses Per Form990 | 37040657 | TotalExpensesPerForm990 |
Form990 Schedule D Part XIV Form990ScheduleDPartXIV (7 entries)
| IdentifierIdentifier | Return ReferenceReturnReference | ExplanationExplanation |
|---|---|---|
| DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: | PART V, LINE 4: | THE HOSPITAL HAS ELECTED REIMBURSEMENT FINANCING UNDER PROVISIONS OF THE STATE OF WISCONSIN'S UNEMPLOYMENT COMPENSATION LAWS. AS OF SEPTEMBER 30, 2012, THE HOSPITAL HAS DESIGNATED APPROXIMATELY $175,000, AS PART OF BOARD-DESIGNATED INVESTMENTS TO MEET THE STATE OF WISCONSIN'S FUNDING REQUIREMENTS. AS OF SEPTEMBER 30, 2012, APPROXIMATELY $3,582,000 OF THE INITIAL CAPITAL CONTRIBUTION FROM HSHS HOSPITALS IS CONSIDERED BOARD-DESIGNATED FOR RENOVATION OF INPATIENTS ROOMS, DIGITAL MAMMOGRAPHY AND RADIOLOGY ROOMS, ELECTRONIC HEALTH RECORD AMBULATORY AND HOSPITAL CONVERSIONS AND OTHER TECHNOLOGY IMPROVEMENTS. THE REMAINING PORTION OF TEMPORARILY RESTRICTED FUNDS IS INTENDED FOR GRANTS AND SCHOLARSHIPS, BOARD OR DONOR RESTRICTED PURPOSES OR OTHER USES RELATED TO THE HOSPITAL'S EXEMPT PURPOSE AND MISSION. |
| DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: | PART X: | IN ORDER TO ACCOUNT FOR ANY UNCERTAIN TAX POSITIONS, THE HOSPITAL 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 COMBINED FINANCIAL STATEMENTS. THE HOSPITAL RECORDED NO ASSETS OR LIABILITIES RELATED TO UNCERTAIN TAX POSITIONS OR UNRECOGNIZED TAX BENEFITS IN 2012 OR 2011. THE HOSPITAL IS ALSO ENGAGED, TO A LIMITED EXTENT, IN ACTIVITIES WHICH THE INTERNAL REVENUE SERVICE CONSIDERS UNRELATED TO THE HOSPITAL'S EXEMPT PURPOSE AND, THEREFORE, TAXABLE. THESE ACTIVITIES, HOWEVER, ANNUALLY RESULT IN NET OPERATING LOSSES FOR INCOME TAX PURPOSES. THE HOSPITAL 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 CARRYFOWARDS IS OFFSET BY A VALUATION ALLOWANCE OF EQUAL AMOUNT. NO DEFERRED TAX ASSETS AND LIABILITIES HAVE BEEN RECOGNIZED SINCE NO OTHER DIFFERENCE EXIST BETWEEN THE FINANCIAL AND TAX BASES OF REPORTING THE HOSPITAL'S ASSETS AND LIABILITIES. THE HOSPITAL'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, 2012 AND 2011, THERE WAS NO INCOME TAX EXPENSE, TAX PENALTIES, OR INTEREST RELATED TO TAX PENALTIES RECORDED BY THE HOSPITAL IN THE COMBINED FINANCIAL STATEMENTS. FEDERAL INCOME TAX RETURNS FOR THE YEAR ENDED SEPTEMBER 30, 2009, AND BEYOND REMAIN SUBJECT TO EXAMINATION BY THE INTERNAL REVENUE SERVICE. |
| PART XI, LINE 8 - OTHER ADJUSTMENTS: | CHANGE IN INTEREST IN COMMUNITY FOUNDATION -6,211. FUNDING OF FOUNDATION EXPENSES -54,281. TOTAL TO SCHEDULE D, PART XI, LINE 8: -60,492. | |
| PART XII, LINE 2D - OTHER ADJUSTMENTS: | RENTAL EXPENSE IN INCOME 242,895. | |
| PART XII, LINE 4B - OTHER ADJUSTMENTS: | INTERCOMPANY TRANSFER 53,748. AUXILIARY EXPENSES 25,167. | |
| PART XIII, LINE 2D - OTHER ADJUSTMENTS: | RENTAL EXPENSES INCLUDED IN INCOME 242,895. | |
| PART XIII, LINE 4B - OTHER ADJUSTMENTS: | AUXILIARY EXPENSES 25,167. |
Schedule H IRS990ScheduleH
| Field | Value | IRS element (for citing) |
|---|---|---|
| Charity Care Policy | 1 | CharityCarePolicy |
| Written Policy | 1 | WrittenPolicy |
| FPG Reference Free Care | 1 | FPGReferenceFreeCare |
| Pcent200 | X | Pcent200 |
| FPG Reference Discounted Care | 1 | FPGReferenceDiscountedCare |
| Pcent400 | X | Pcent400 |
| Free Disc Care Medically Indigent | 1 | FreeDiscCareMedicallyIndigent |
| Amounts Budgeted For Charity Care | 1 | AmountsBudgetedForCharityCare |
| Expenses Exceeded Budget | 0 | ExpensesExceededBudget |
| Annual Community Benefit Report | 1 | AnnualCommunityBenefitReport |
| Report Publically Available | 1 | ReportPublicallyAvailable |
Charity Care At Cost CharityCareAtCost
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 814668 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 0 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 814668 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.02350 | PercentOfTotalExpense |
Unreimbursed Medicaid UnreimbursedMedicaid
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 5899745 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 3512354 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 2387391 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.06870 | PercentOfTotalExpense |
Unreimbursed Costs UnreimbursedCosts
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 113404 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 48051 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 65353 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.00190 | PercentOfTotalExpense |
Total Charity Care TotalCharityCare
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 6827817 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 3560405 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 3267412 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.09410 | PercentOfTotalExpense |
Community Health Services CommunityHealthServices
| Field | Value | IRS element (for citing) |
|---|---|---|
| Number Of Activities Or Programs | 11 | NumberOfActivitiesOrPrograms |
| Total Community Benefit Expense | 60036 | TotalCommunityBenefitExpense |
| Net Community Benefit Expense | 60036 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.00170 | PercentOfTotalExpense |
Total Other Benefits TotalOtherBenefits
| Field | Value | IRS element (for citing) |
|---|---|---|
| Number Of Activities Or Programs | 11 | NumberOfActivitiesOrPrograms |
| Total Community Benefit Expense | 60036 | TotalCommunityBenefitExpense |
| Net Community Benefit Expense | 60036 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.00170 | PercentOfTotalExpense |
Total Community Benefits TotalCommunityBenefits
| Field | Value | IRS element (for citing) |
|---|---|---|
| Number Of Activities Or Programs | 11 | NumberOfActivitiesOrPrograms |
| Total Community Benefit Expense | 6887853 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 3560405 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 3327448 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.09580 | PercentOfTotalExpense |
Community Support CommunitySupport
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Building Expense | 36870 | TotalCommunityBuildingExpense |
| Direct Offsetting Revenue | 2280 | DirectOffsettingRevenue |
| Net Community Building Expense | 34590 | NetCommunityBuildingExpense |
| Percent Of Total Expense | 0.00100 | PercentOfTotalExpense |
Workforce Development WorkforceDevelopment
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Building Expense | 190346 | TotalCommunityBuildingExpense |
| Net Community Building Expense | 190346 | NetCommunityBuildingExpense |
| Percent Of Total Expense | 0.00550 | PercentOfTotalExpense |
Total Total
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Building Expense | 227216 | TotalCommunityBuildingExpense |
| Direct Offsetting Revenue | 2280 | DirectOffsettingRevenue |
| Net Community Building Expense | 224936 | NetCommunityBuildingExpense |
| Percent Of Total Expense | 0.00650 | PercentOfTotalExpense |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bad Debt Expense Reported | 1 | BadDebtExpenseReported |
| Bad Debt Expense | $649,699 | BadDebtExpenseAmount |
| Amount Attributable To | 0 | AmountAttributableTo |
| Amount Reimbursed By Medicare | 8229390 | AmountReimbursedByMedicare |
| Cost Of Care Reimbursed By Medicare | 8167592 | CostOfCareReimbursedByMedicare |
| Medicare Surplus Or Shortfall | 61798 | MedicareSurplusOrShortfall |
Costing Methodology Used CostingMethodologyUsed
| Field | Value | IRS element (for citing) |
|---|---|---|
| Cost To Charge Ratio | X | CostToChargeRatio |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Written Debt Collection Policy | 1 | WrittenDebtCollectionPolicy |
| Provision For Charity Care | 1 | ProvisionForCharityCare |
| Number Of Hospital Facilities | 1 | NumberOfHospitalFacilities |
Form990 Schedule H Part V Section A Form990ScheduleHPartVSectionA
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility Number | 1 | FacilityNumber |
Name Name
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | COMMUNITY MEMORIAL HOSPITAL | BusinessNameLine1 |
Address Address
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 855 SOUTH MAIN STREET | AddressLine1 |
| City | OCONTO FALLS | City |
| State | WI | State |
| ZIP Code | 54154 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Licensed Hospital | X | LicensedHospital |
| General Medical And Surgical | X | GeneralMedicalAndSurgical |
| Critical Access Hospital | X | CriticalAccessHospital |
| Er24 Hours | X | Er24Hours |
Form990 Schedule H Part V Section B Form990ScheduleHPartVSectionB
Hospital Facility Name HospitalFacilityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | COMMUNITY MEMORIAL HOSPITAL INCORPORATED | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Hospital Facility Number | 1 | HospitalFacilityNumber |
| CHNA Conducted | 0 | CHNAConducted |
| Eligibility Criteria Explained | 1 | EligibilityCriteriaExplained |
| Uses FPG Free | 1 | UsesFPGFree |
| FPG Free Percent | 200.000000000000 | FPGFreePercent |
| Uses FPG Discounted | 1 | UsesFPGDiscounted |
| FPG Discount Percent | 400.000000000000 | FPGDiscountPercent |
| Explains Basis | 1 | ExplainsBasis |
| Income Level | X | IncomeLevel |
| Asset Level | X | AssetLevel |
| Medical Indigency | X | MedicalIndigency |
| Insurance Status | X | InsuranceStatus |
| Medicaid Medicare | X | MedicaidMedicare |
| Explains Application Method | 1 | ExplainsApplicationMethod |
| Includes Publicity Measures | 1 | IncludesPublicityMeasures |
| Attached To Invoices | X | AttachedToInvoices |
| Provided On Admission | X | ProvidedOnAdmission |
| Available On Request | X | AvailableOnRequest |
| Actions On Nonpayment | 1 | ActionsOnNonpayment |
| Collection Activities | 0 | CollectionActivities |
| Nondiscrim Emergency Care Policy | 1 | NondiscrimEmergencyCarePolicy |
| Used Other Method | X | UsedOtherMethod |
| Amounts Generally Billed | 0 | AmountsGenerallyBilled |
| Gross Charges | 0 | GrossCharges |
Form990 Schedule H Part V Section C Form990ScheduleHPartVSectionC
| Field | Value | IRS element (for citing) |
|---|---|---|
| Number Of Other Facilities | 6 | NumberOfOtherFacilities |
Other Facilities OtherFacilities (6 entries)
| Address Line1Address/AddressLine1 | CityAddress/City | StateAddress/State | ZIP CodeAddress/ZIPCode | Facility TypeFacilityType |
|---|---|---|---|---|
| CMH PRIMARY CARE CLINIC | ||||
| 340 NORTH GREEN BAY AVE | GILLETT | WI | 54124 | CLINIC |
| CMH PRIMARY CARE CLINIC | ||||
| 200 SOUTH ROSERA STREET | LENA | WI | 54139 | CLINIC |
| CMH MEDICAL CENTER | ||||
| 103 FIRST STREET | OCONTO | WI | 54153 | CLINIC |
| CMH PRIMARY CARE CLINIC | ||||
| 14353 HWY 32/64 | MOUNTAIN | WI | 54149 | CLINIC |
| CMH PRIMARY CARE CLINIC | ||||
| 913 E MAIN STREET | SURING | WI | 54174 | CLINIC |
| COMMUNITY MEMORIAL HOSPITAL | ||||
| 855 SOUTH MAIN ST | OCONTO FALLS | WI | 54154 | LICENSED HOSPITAL, GENERAL MEDICAL AND SURGICAL, CAH, ER 24 HRS |
Form990 Schedule H Part VI Form990ScheduleHPartVI (14 entries)
| ExplanationExplanation | IdentifierIdentifier | Return ReferenceReturnReference |
|---|---|---|
| PART I, LINE 6A: WISCONSIN HOSPITAL ASSOCIATION | ||
| PART I, LINE 7: THE HOSPITAL UTILIZES THE IRS WORKSHEET TWO: RATIO OF PATIENT CARE COST TO CHARGES. | ||
| 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 $ 2302959. | ||
| PART II: THE HOSPITAL PROVIDES EDUCATION TO THE COMMUNITY MEMBERS ABOUT VARIOUS HEALTH ISSUES AT THE HEALTH FAIRS DONE THROUGHOUT THE COUNTY SUCH AS SKIN CANCER SCREENING, HEART FAIR, ETC. TO KEEP THE COMMUNITY AWARE OF HEALTH ISSUES AND HELP THEM BE PROACTIVE IN SEEKING TREATMENT FOR HEALTHCARE CONCERNS. | ||
| PART III, LINE 4: BAD DEBTS WERE REPORTED ON THE FINANCIAL STATEMENTS AT GROSS CHARGES. THEN THE COST TO CHARGE RATIO WAS USED TO CONVERT THE BAD DEBT AMOUNT FROM A CHARGE BASED NUMBER TO A COST BASED NUMBER. | ||
| PART III, LINE 8: THE MEDICARE PROGRAM DOES NOT COVER ALL SERVICES PROVIDED TO THEIR PARTICIPANTS AND THE HOSPITAL IS NOT ALLOWED TO COLLECT FROM THE PARTICIPANTS FOR SOME SERVICES BASED ON THE HOSPITAL'S AGREEMENT WITH THE PROGRAM. THEREFORE, NOT ALL REVENUES ARE COVERED BY MEDICARE. IN ADDITION, MEDICARE DOES NOT ALLOW ALL BUSINESS COSTS OF THE HOSPITAL TO BE INCLUDED IN THE COST REPORT, SO THERE ARE ADDITIONAL UNCOVERED COSTS. THE SHORTFALL BY THE MEDICARE PROGRAM COULD BE AVOIDED BY NOT PROVIDING CARE TO MEDICARE PATIENTS; THEREFORE, THIS SHORTFALL SHOULD BE INCLUDED AS A BENEFIT PROVIDED BY THE HOSPITAL.PART I, LINE 7: THE COSTING METHODOLOGY USED TO DETERMINE THE MEDICARE ALLOWABLE COST REPORT IS BASED ON THE AUDITED FINANCIAL STATEMENTS OF COMMUNITY MEMORIAL HOSPITAL AND THE HOSPITAL'S EXPENSING OF COSTS TO THE APPROPRIATE COST CENTER THROUGH THE HOSPITAL'S INTERNAL COMPUTER SYSTEM. | ||
| PART III, LINE 9B: THE POLICY PROVIDES GENERAL MEANS OF DETERMINING ELIGIBILITY INCLUDING: INCOME LEVEL, ASSET LEVEL, MEDICAL INDIGENCY, INSURANCE STATUS, MEDICAID AND MEDICARE. PATIENTS ARE INFORMED OF THE CHARITY CARE PROGRAM UPON REGISTRATION. THOSE THAT THINK THEY MAY QUALIFY ARE GIVEN AN APPLICATION WHICH IS THEN REVIEWED AND DISCOUNTS ARE APPLIED TO THE ACCOUNT BASED ON FAMILY SIZE AND HOW THERE INCOME FALLS IN THE FEDERAL POVERTY GUIDELINES. | ||
| PART V, SECTION B, LINE 19D: THE INCOME & ASSET GUIDELINES ARE THE ONLY DETERMINING FACTORS IN DETERMINING THE DISCOUNT AMOUNT. IN ADDITION, A 25% DISCOUNT IS OFFERRED TO SELF PAY PATIENTS IF THEY PAY THEIR BILL IN FULL WITHIN A SPECIFIED TIME PERIOD. | COMMUNITY MEMORIAL HOSPITAL INCORPORATED | |
| PART VI, LINE 2: A COMMUNITY HEALTH ASSESSMENT PLAN IS CURRENTLY BEING DEVELOPED. | ||
| PART VI, LINE 3: WHEN A PATIENT CALLS TO REGISTER AND INDICATES ANY TYPE OF FINANCIAL HARDSHIP OR APPEARS TO REGISTER AND STATES LACK OF INSURANCE OR OTHER FINANCIAL HARDSHIP, THE PATIENT OR THEIR REPRESENTATIVE ARE GIVEN INFORMATION ABOUT THE HOSPITAL'S CHARITY CARE PROGRAM, INCLUDING AN INTRODUCTORY LETTER AND APPLICATION, AS WELL AS INFORMATION ON OTHER PUBLIC PROGRAMS THAT MAY BE AVAILABLE AND CONTACT INFORMATION FOR THOSE PROGRAMS. THE HOSPITAL IS ABLE TO EXPRESS ENROLL CHILDREN OR PREGNANT WOMEN IN STATE GOVERNMENT PROGRAMS AS WELL. THIS SAME INFORMATION IS PROVIDED AGAIN TO THE PATIENT AT THE TIME OF BILLING. | ||
| PART VI, LINE 4: COMMUNITY MEMORIAL HOSPITAL SERVES GREATER OCONTO COUNTY. OCONTO COUNTY, WISCONSIN IS A LARGE, RURAL COUNTY WHICH INCLUDES MEDICALLY UNDERSERVED AREAS AND POPULATIONS AND WHICH CONSISTENTLY FACES ECONOMIC DEVELOPMENT CHALLENGES. RURAL: THE U.S. CENSUS BUREAU ESTIMATED THE 2010 OCONTO COUNTY POPULATION AT 37,660 PERSONS. ACCORDING TO THE U.S. CENSUS BUREAU, THE LARGEST CITY IN THE COUNTY HAD A 2000 POPULATION OF 4,708 AND THE COUNTY ITSELF HAD 37.7 PERSONS PER SQUARE MILE IN 2010. UNDERSERVED: OCONTO COUNTY CONTAINS MEDICALLY UNDERSERVED AREAS AS WELL AS PRIMARY CARE HEALTH PROFESSIONAL SHORTAGE AREAS AS DESIGNATED BY THE U.S. DEPT. OF HEALTH AND HUMAN SERVICES HEALTH RESOURCES AND SERVICES ADMINISTRATION. NINETEEN MEDICALLY UNDERSERVED AREAS ARE DESIGNATED WITHIN OCONTO COUNTY ACCORDING TO HRSA.THE ONLY OTHER HOSPITAL IN THE CMH SERVICE AREA IS A 4-BED HOSPITAL LOCATED IN OCONTO, THE COUNTY'S LARGEST CITY. OTHER HOSPITALS THAT SERVE THE OCONTO COUNTY COMMUNITY INCLUDING THE NEAREST TERTIARY CARE HOSPITALS ARE LOCATED THIRTY MILES SOUTH IN GREEN BAY.IN A COMMUNITY NEEDS ASSESSMENT SURVEY OF THE CMH SERVICE AREA CONDUCTED IN AUGUST 2007 BY THE LEEDE RESEARCH GROUP, THE LARGEST BARRIERS TO HEALTHCARE CITED BY COMMUNITY MEMBERS ARE FINANCIAL CONSTRAINTS, A LACK OF AFFORDABLE MEDICAL INSURANCE COVERAGE, AND GEOGRAPHICAL/TRANSPORTATION CONSTRAINTS THAT NEGATIVELY IMPACT ACCESS TO MEDICAL FACILITIES. OF THOSE SURVEYED, 30.1% INDICATED THAT LOCATION WAS THEIR PRIMARY CONSIDERATION WHEN SELECTING A DOCTOR AND/OR CLINIC. ACCORDING TO U.S. CENSUS BUREAU 2005-2009 DATA, IN OCONTO COUNTY THE PERCENTAGE OF PERSONS AGE 25 AND OLDER WITH A BACHELOR'S DEGREE OR HIGHER WAS 13.4% COMPARED TO 25.5.% STATEWIDE. PER CAPITA MONEY INCOME FOR THE COUNTY WAS $24,397 COMPARED TO $26,447 IN WISCONSIN. MEDIAN HOUSEHOLD INCOME FOR 2009 WAS $49,037 COMPARED TO $49,994 STATEWIDE. THE FEBRUARY 2012 UNEMPLOYMENT RATE FOR THE COUNTY WAS 9.3% COMPARED TO A STATEWIDE RATE OF 7.9% AND 8.7% NATIONALLY, ACCORDING TO THE STATE OF WISCONSIN DEPARTMENT OF WORKFORCE DEVELOPMENT. THE LATEST POVERTY DATA SHOWS OCONTO COUNTY WITH A POVERTY RATE OF 11.8%. CMH IS PROUD OF ITS COMMITMENT TO PROVIDE SERVICE TO ANY PERSON SEEKING MEDICAL CARE, REGARDLESS OF ABILITY TO PAY. THIS MAKES CMH A VERY SPECIAL PLACE IN TODAY'S HEALTHCARE MARKET. IN ADDITION, THE CMH FAMILY OF HEALTHCARE PROVIDERS HAS A LONG HISTORY OF WORKING COOPERATIVELY WITH LOCAL, STATE AND FEDERAL HEALTHCARE AGENCIES, EDUCATORS, INDUSTRY, AND THE GENERAL PUBLIC TO DEVELOP AND DELIVER EFFECTIVE HEALTHCARE SERVICES TO THE RURAL NORTHEAST WISCONSIN POPULATION. CMH IS DISTINGUISHED BY ITS RELIABLE AND CONSISTENT LEVEL OF SUPERIOR SERVICE AND COMMITMENT TO CONTINUOUS IMPROVEMENT OF ITS PATIENT CARE SERVICES. CMH MEDICAL STAFF MEMBERS ARE COMMITTED PARTNERS IN ENHANCING ORGANIZATIONAL PERFORMANCE AND CONTINUALLY WORKING TO IMPROVE PATIENT CARE. | ||
| PART VI, LINE 5: THE COMMUNITY MEMORIAL HOSPITAL BOARD OF DIRECTORS CONSIST OF DEDICATED MEMBERS OF THE COMMUNITY WHO PROVIDE EXCEPTIONAL LEADERSHIP, INSIGHT AND POSITIVE DIRECTION IN THE ORGANIZATIONAL MISSION TO MEET THE HEALTHCARE NEEDS OF OUR COMMUNITY LOCALLY. A MAJORITY OF THE GOVERNING BODY IS COMPRISED OF PERSONS WHO RESIDE IN THE CMH PRIMARY SERVICE AREA. MEMBERS ARE STAKEHOLDERS IN THE COMMUNITIES SERVED BY COMMUNITY MEMORIAL HOSPITAL WHO PROVIDE DIRECTION AND SUPERVISION TO THE ORGANIZATION. A SIGNIFICANT PORTION OF THE GOVERNING BODY IS COMPRISED OF PERSONS WHO ARE NEITHER EMPLOYEES NOR CONTRACTORS OF COMMUNITY MEMORIAL HOSPITAL, NOR FAMILY MEMBERS THEREOF.AS A NON-PROFIT HEALTHCARE SYSTEM COMMUNITY MEMORIAL HOSPITAL INVESTS IN ITS SERVICES/PROGRAMS AND FACILITY/EQUIPMENT UPGRADES AND REINVESTS ANY PROFITS TO UPDATE OR ENHANCE THE HEALTHCARE SERVICE.CMH MAINTAINS AN OPEN MEDICAL STAFF, EXTENDING PRIVILEGES TO ALL QUALIFIED PHYSICIANS IN THE COMMUNITY FOR MEDICAL AND SURGICAL SERVICES PROVIDED AT THESE FACILITIES.IN ADDITION TO ITS REGULAR HOSPITAL AND CLINIC SERVICES, COMMUNITY MEMORIAL HOSPITAL PROVIDES THE COMMUNITY MANY OPPORTUNITIES TO RECEIVE LOW-COST AND FREE HEALTH SCREENINGS AND SERVICES. FOR EACH OF THESE FREE AND LOW-COST SERVICE OFFERINGS, COMMUNITY MEMORIAL HOSPITAL PROVIDED PLANNING, PUBLICITY, STAFF, EQUIPMENT, SUPPLIES, AND FACILITIES.COMMUNITY MEMORIAL HOSPITAL PROVIDES ITS COMMUNITY ROOM LARGE CONFERENCE ROOM AS WELL AS ITS OTHER MEETING AREAS FREE-OF-CHARGE TO COMMUNITY GROUPS. SOME OF THE MANY LOCAL GROUPS THAT MEET AT COMMUNITY MEMORIAL HOSPITAL INCLUDE 4H CLOVER, RELAY FOR LIFE, OVEREATERS ANONYMOUS, CEMETERY ASSOCIATION, WEIGHT WATCHERS, QUILTING GROUPS, THE COUNTY FAIR BOARD, THE COUNTY FAIREST OF THE FAIR COMMITTEE, UW EXTENSION, BREAST CANCER SUPPORT GROUP, AND THE OCONTO FALLS LIONESS CLUB.EXCESS FUNDS OF THE ORGANIZATION ARE BEING USED TO UPDATE THE TECHNOLOGY USED IN THE FACILITY TO PROVIDE UP TO DATE PATIENT CARE TO COMMUNITY MEMBERS AND TO ENHANCE THE SERVICES PROVIDED TO THE COMMUNITY. COMMUNITY MEMORIAL HOSPITAL HAS LONG BEEN A CORNERSTONE OF THE GREATER OCONTO COUNTY COMMUNITY AND PROVIDES AN ESSENTIAL SERVICE TO OCONTO COUNTY RESIDENTS. CMH IS PROUD OF ITS MISSION TO PROVIDE HIGH QUALITY HEALTH CARE CLOSE TO HOME, AND ALWAYS STRIVES TO STRENGTHEN ITS COMMUNITY PARTNERSHIPS TO PROMOTE HEALTH AND WELLNESS. | ||
| PART VI, LINE 6: CMH IS AFFILIATED WITH ST. VINCENT & ST. MARY'S HOSPITALS AND PREVEA HEALTH. THE AFFILIATION ALLOWS CMH TO EXPAND HEALTH CARE RESOURCES AVAILABLE TO THE GREATER OCONTO COUNTY COMMUNITY. MORE SPECIALTY SERVICES ARE AVAILABLE AT CMH. THE ROLE OF CMH WITHIN THE AFFILIATION IS TO PROVIDE HOSPITAL AND CLINIC FACILITIES AND PERSONNEL, AND TO COLLABORATE WITH AFFILIATION PARTNERS TO IDENTIFY OPPORTUNITIES TO BETTER AND MORE EFFICIENTLY SERVE THE HEALTH CARE NEEDS OF THE COMMUNITY. THE ROLE OF ST. VINCENT & MARY' MARY'S HOSPITALS IS TO PROVIDE MANAGEMENT COLLABORATION, ADMINISTRATIVE SUPPORT, AND CAPITAL INVESTMENT WHICH SUPPORTS EMR. THE ROLE OF PREVEA HEALTH IS TO ASSIST CMH IN EXPANDING THE AVAILABILITY OF PHYSICIAN SPECIALISTS IN THE CMH SERVICE AREA. | ||
| WI | REPORTS FILED WITH STATES | PART VI, LINE 7 |
Schedule J IRS990ScheduleJ
| Field | Value | IRS element (for citing) |
|---|---|---|
| Written Employment Contract | X | WrittenEmploymentContract |
| Compensation Survey | X | CompensationSurvey |
| Severance Payment | 0 | SeverancePayment |
| Supplemental Nonqual Retire Plan | 0 | SupplementalNonqualRetirePlan |
| Equity Based Comp Arrangement | 0 | EquityBasedCompArrangement |
| Comp Based On Revenue Of Filing Org | 0 | CompBasedOnRevenueOfFilingOrg |
| Comp Based On Revenue Related Orgs | 0 | CompBasedOnRevenueRelatedOrgs |
| Comp Based Net Earnings Filing Org | 0 | CompBasedNetEarningsFilingOrg |
| Comp Based Net Earnings Relate Orgs | 0 | CompBasedNetEarningsRelateOrgs |
| Any Non Fixed Payments | 0 | AnyNonFixedPayments |
| Initial Contract Exception | 0 | InitialContractException |
Form990 Schedule J Part II Form990ScheduleJPartII (6 entries)
| Base Compensation Filing OrgBaseCompensationFilingOrg | Comp Based On Related OrgsCompBasedOnRelatedOrgs | Bonus Filing OrgBonusFilingOrg | Bonus Related OrgsBonusRelatedOrgs | Other Compensation Filing OrgOtherCompensationFilingOrg | Other Compensation Related OrgsOtherCompensationRelatedOrgs | Deferred Comp Filing OrgDeferredCompFilingOrg | Deferred Comp Related OrgsDeferredCompRelatedOrgs | Nontaxable Benefits Filing OrgNontaxableBenefitsFilingOrg | Nontaxable Benefits Related OrgsNontaxableBenefitsRelatedOrgs | Total Compensation Filing OrgTotalCompensationFilingOrg | Total Compensation Related OrgsTotalCompensationRelatedOrgs | Comp Report Prior990 Filing OrgCompReportPrior990FilingOrg | Comp Report Prior990 Related OrgsCompReportPrior990RelatedOrgs |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| DR ISAIAS CUPINO | |||||||||||||
| 176165 | 0 | 275254 | 0 | 12577 | 0 | 7350 | 0 | 22404 | 0 | 493750 | 0 | 0 | 0 |
| DR GENADI MALTINSKI | |||||||||||||
| 351749 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 5189 | 0 | 356938 | 0 | 0 | 0 |
| DR JEFFREY BENTSON | |||||||||||||
| 511087 | 0 | 0 | 0 | 12376 | 0 | 7350 | 0 | 28976 | 0 | 559789 | 0 | 0 | 0 |
| DR R SCOTT LIEBL | |||||||||||||
| 402000 | 0 | 0 | 0 | 24474 | 0 | 7350 | 0 | 29304 | 0 | 463128 | 0 | 0 | 0 |
| DR KEVIN HIBBETT | |||||||||||||
| 156384 | 0 | 155467 | 0 | 4544 | 0 | 7350 | 0 | 22075 | 0 | 345820 | 0 | 0 | 0 |
| DR LUZ BALMADRID | |||||||||||||
| 167184 | 0 | 133106 | 0 | 792 | 0 | 7350 | 0 | 4201 | 0 | 312633 | 0 | 0 | 0 |
Schedule K IRS990ScheduleK
Form990 Schedule K Part I Form990ScheduleKPartI (2 entries)
| Issuer EINIssuerEIN | CUSIP NumberCUSIPNumber | Date IssuedDateIssued | Issue PriceIssuePrice | Description Of PurposeDescriptionOfPurpose | DefeasedDefeased | On Behalf Of IssuerOnBehalfOfIssuer | Pool FinancingPoolFinancing |
|---|---|---|---|---|---|---|---|
| WISCONSIN HEALTH AND EDUCATIONAL FACILITIES AUTHORITY | |||||||
| 391337855 | 97710VKA5 | 2003-01-15 | 3490000 | ACQUISITION, CONSTRUCTION, IMPROVEMENT, AND EQUIPING HOSPITAL FACILITIES | 0 | 0 | 0 |
| WISCONSIN HEALTH AND EDUCATIONAL FACILITIES AUTHORITY | |||||||
| 391337855 | 97710VKB3 | 2003-01-15 | 5605000 | ACQUISITION, CONSTRUCTION, IMPROVEMENT, AND EQUIPING HOSPITAL FACILITIES | 0 | 0 | 0 |
Form990 Schedule K Part II Form990ScheduleKPartII (2 entries)
| Amount RetiredAmountRetired | Total ProceedsTotalProceeds | Amount In Reserve FundAmountInReserveFund | Issuance Costs From ProceedsIssuanceCostsFromProceeds | Working Capital ExpendituresWorkingCapitalExpenditures | Capital ExpendituresCapitalExpenditures | Year Of Subst CompletionYearOfSubstCompletion | Current RefundingCurrentRefunding | Advance RefundingAdvanceRefunding | Final Allocation MadeFinalAllocationMade | Adequate Books And Recds MaintaindAdequateBooksAndRecdsMaintaind |
|---|---|---|---|---|---|---|---|---|---|---|
| 385187 | 3445154 | 293583 | 46266 | 315020 | 2784783 | 2006 | 0 | 0 | 1 | 1 |
| 603464 | 5470872 | 465730 | 73469 | 500248 | 4472409 | 2006 | 0 | 0 | 1 | 1 |
Form990 Schedule K Part III Form990ScheduleKPartIII (2 entries)
| Owning Bond Financed PropertyOwningBondFinancedProperty | Any Lease ArrangementsAnyLeaseArrangements | Mngment Cntrct Bond Financd PrprtyMngmentCntrctBondFinancdPrprty | Any Research AgreementsAnyResearchAgreements | Prcntge Prvt Business Use By OthersPrcntgePrvtBusinessUseByOthers | Percentage Of Prvt Business Re UBIPercentageOfPrvtBusinessReUBI | Total Private Business UseTotalPrivateBusinessUse | Post Issuance Compliance ProcdrsPostIssuanceComplianceProcdrs |
|---|---|---|---|---|---|---|---|
| 0 | 1 | 0 | 0 | 0.01280 | 0.00300 | 0.01580 | 0 |
| 0 | 1 | 0 | 0 | 0.01280 | 0.00300 | 0.01580 | 0 |
Form990 Schedule K Part IV Form990ScheduleKPartIV (2 entries)
| Form8038 T FiledForm8038TFiled | Variable Rate IssueVariableRateIssue | Hedge Identified In Books And RecdsHedgeIdentifiedInBooksAndRecds | Gross Proceeds Invested In GICGrossProceedsInvestedInGIC | Gross Proceeds InvestedGrossProceedsInvested | Exception To RebateExceptionToRebate |
|---|---|---|---|---|---|
| 0 | 0 | 0 | 0 | 0 | 0 |
| 0 | 0 | 0 | 0 | 0 | 0 |
Schedule L IRS990ScheduleL
Form990 Schedule L Part IV Form990ScheduleLPartIV
Name Of Interested Person NameOfInterestedPerson
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name Person | GENADI MALTINSKI MD | NamePerson |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Relationship | CONTRACT PHYSICIAN | Relationship |
| Amount Of Transaction | 351749 | AmountOfTransaction |
| Description Of Transaction | CONTRACTED PHYSCIAN | DescriptionOfTransaction |
| Sharing Of Revenues | 0 | SharingOfRevenues |
Schedule O IRS990ScheduleO
General Explanation GeneralExplanation (7 entries)
| IdentifierIdentifier | Return ReferenceReturnReference | ExplanationExplanation |
|---|---|---|
| CHANGES IN PROGRAM SERVICES | FORM 990, PART III, LINE 3 | DISCONTINUED BIRTHING CENTER IN JULY 2012. |
| FORM 990, PART VI, SECTION B, LINE 11 | BECAUSE THE DUE DATE IS GOING TO FALL BEFORE THE NEXT BOARD MEETING, THE FORM WILL BE PRESENTED TO THE BOARD AT THE MOST RECENT BOARD MEETING FOLLOWING THE DATE OF FILING BY THE CFO. | |
| FORM 990, PART VI, SECTION B, LINE 12C | AN ANNUAL STATEMENT IS DISTRIBUTED TO THE BOARD MEMBERS FOR REVIEW AND SIGNATURE. THIS PROCESS WAS LAST COMPLETED IN SEPTEMBER OF 2011 AND IS DONE ANNUALLY. | |
| FORM 990, PART VI, SECTION B, LINE 15 | MGMA SURVEY DATA AND A POSITION REVIEW PROCESS IS DONE BY THE PERSON THE INDIVIDUAL REPORTS TO. THE INFORMATION IS THEN PRESENTED TO THE BOARD OF DIRECTORS, AN INDEPENDENT PARTY, AT THEIR MONTHLY MEETING FOR THEIR FINAL APPROVAL. DECISIONS MADE AT THE BOARD OF DIRECTORS MEETINGS ARE DOCUMENTED. | |
| FORM 990, PART VI, SECTION C, LINE 19 | THE ORGANIZATION CURRENTLY DOES NOT MAKE ITS GOVERNING DOCUMENTS AND CONFLICT ON INTEREST POLICY AVAILABLE TO THE PUBLIC AT THIS TIME. | |
| CHANGES IN NET ASSETS OR FUND BALANCES: | FORM 990, PART XI, LINE 5: | NET UNREALIZED GAINS ON INVESTMENTS: 436,254. CHANGE IN INTEREST IN COMMUNITY FOUNDATION -6,211. FUNDING OF FOUNDATION EXPENSES -54,281. TOTAL TO FORM 990, PART XI, LINE 5: 375,762. |
| FORM 990, PART XII, LINE 2C: | THIS PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. |
Schedule R IRS990ScheduleR
Form990 Schedule R Part II Form990ScheduleRPartII
Name Of Disregarded Entity NameOfDisregardedEntity
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | COMMUNITY HEALTHCARE FOUNDATION | BusinessNameLine1 |
Address US AddressUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 855 SOUTH MAIN STREET | AddressLine1 |
| City | OCONTO FALLS | City |
| State | WI | State |
| ZIP Code | 54154 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 391700944 | EIN |
| Primary Activities | FUNDRAISING FOR LOCAL NONPROFIT ORGNAIZATIONS | PrimaryActivities |
| Legal Domicile State | WI | LegalDomicileState |
| Exempt Code Section | 501(C)(3) | ExemptCodeSection |
| Public Charity Status | LINE 7 | PublicCharityStatus |
Direct Controlling Entity Name DirectControllingEntityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | COMMUNITY MEMORIAL HOSPITAL | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Controlled Org | 1 | ControlledOrg |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Receipt Of Int Ann Rents Royalties | 0 | ReceiptOfIntAnnRentsRoyalties |
| Gift Grant Or Cap Contr To Other Org | 0 | GiftGrantOrCapContrToOtherOrg |
| Gift Grant Or Cap Contr Fr Other Org | 0 | GiftGrantOrCapContrFrOtherOrg |
| Loans Or Guarantees To Other Org | 0 | LoansOrGuaranteesToOtherOrg |
| Loans Or Guarantees From Other Org | 0 | LoansOrGuaranteesFromOtherOrg |
| Sale Of Assets To Other Org | 0 | SaleOfAssetsToOtherOrg |
| Purchase Of Assets From Other Org | 0 | PurchaseOfAssetsFromOtherOrg |
| Exchange Of Assets | 0 | ExchangeOfAssets |
| Rental Of Facilities To Other Orgs | 0 | RentalOfFacilitiesToOtherOrgs |
| Rental Of Facilities Fr Other Orgs | 0 | RentalOfFacilitiesFrOtherOrgs |
| Perform Of Services For Other Orgs | 0 | PerformOfServicesForOtherOrgs |
| Perform Of Services By Other Orgs | 0 | PerformOfServicesByOtherOrgs |
| Sharing Of Facilities | 1 | SharingOfFacilities |
| Sharing Of Paid Employees | 1 | SharingOfPaidEmployees |
| Reimbursement Paid To Other Org | 1 | ReimbursementPaidToOtherOrg |
| Reimbursement Paid By Other Org | 0 | ReimbursementPaidByOtherOrg |
| Other Transfer To Other Org | 0 | OtherTransferToOtherOrg |
| Other Transfer From Other Org | 0 | OtherTransferFromOtherOrg |
Transactions Related Orgs Table TransactionsRelatedOrgsTable (3 entries)
| Transaction TypeTransactionType | Method Of Amt DeterminationMethodOfAmtDetermination | Amount InvolvedAmountInvolved |
|---|---|---|
| COMMUNITY HEALTHCARE FOUNDATION | ||
| M | COST | |
| COMMUNITY HEALTHCARE FOUNDATION | ||
| N | COST | 41349 |
| COMMUNITY HEALTHCARE FOUNDATION | ||
| O | COST | 54821 |