2013-08-15T11:49:13-05:00 2012-09-30 390758449 WIPFLI LLP PO BOX 12237 GREEN BAY WI 543072237 990 2011-10-01 390848401 COMMUNITY MEMORIAL HOSPITAL INCORPORATED COMM 9208463444 855 S MAIN STREET OCONTO FALLS WI 54154 MICHELE MILLER-CAMPBELL 9208463444 2013-08-14 1 TERRI REXRODE P00096513 9206620016 2013-08-14 2011 2016-02-24 21:20:13Z DANIEL DEGROOT 855 S MAIN STREET OCONTO FALLS WI 54154 37479191 0 X WWW.CMHOSPITAL.ORG X 1929 WI 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. 7 5 416 86 2389798 -143765 249389 143789 37242847 36932424 142453 213793 -82057 -65976 37552632 37224030 0 0 0 0 20737802 19861888 0 0 0 18213287 17178769 38951089 37040657 -1398457 183373 29769545 30397704 13043656 13112680 16725889 17285024 X TO PROVIDE HIGH QUALITY HEALTHCARE, CLOSE TO HOME. 0 1 28336364 34486042 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. 28336364 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 0 0 1 1 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 1 0 0 0 1 29 0 1 416 1 1 1 0 0 0 0 1 1 0 0 0 0 X 7 5 0 0 0 0 0 0 0 1 1 0 0 0 1 1 1 1 0 1 1 0 WI X MICHELE MILLER-CAMPBELL CFO 9208463444 855 SOUTH MAIN STREET OCONTO FALLS WI 54154 CRISTY KAEMPFER 2.00 X X 0 0 0 DANIEL BOETTCHER 2.00 X X 0 0 0 JAN STRANZ 2.00 X X 0 0 0 HOWARD ESLIEN JR 2.00 X 0 0 0 TOM BAYER 2.00 X 0 0 0 DR ASHOK RAI 2.00 X 0 0 0 DR ISAIAS CUPINO 42.00 X 463996 0 29754 DR GENADI MALTINSKI 42.00 X 351749 0 5189 DR JUDITH BOWERS 2.00 X 0 0 0 KARL APPLETON 2.00 X 0 0 0 JAMES VANDORNICK 42.00 X X 104624 0 0 DANIEL DEGROOT 42.00 X X 74335 0 282 MICHELE MILLER-CAMPELL 40.00 X 24972 0 75 DR JEFFREY BENTSON 40.00 X 523463 0 36326 DR R SCOTT LIEBL 40.00 X 426474 0 36654 DR KEVIN HIBBETT 40.00 X 316395 0 29425 DR LUZ BALMADRID 40.00 X 301082 0 11551 2587090 0 149256 17 0 1 0 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 8 53748 74444 15597 143789 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 30563 26021 26021 36932424 225059 225059 176919 242895 -65976 -65976 -65976 1000 12266 -11266 -11266 -11266 37224030 34486042 2389798 204401 1905664 1701376 204288 13761471 11596138 2165333 287502 236461 51041 2962271 2278465 683806 944980 771452 173528 133826 133826 669482 669482 19391 19391 2435815 1766731 669084 117202 117202 7013838 6408031 605807 145711 54871 90840 1746267 886531 859736 94134 60757 33377 3027 894 2133 541995 541995 1125542 1125542 195472 113089 82383 BAD DEBT EXPENSE 2302959 2302959 OTHER EXPENSES 634108 158609 475499 37040657 28336364 8704293 0 2006109 3464369 2652213 2588212 5276893 4673351 14203 1700933 92120 1231963 1274010 564760 532249 26815763 16905800 9151588 9909963 5366288 5949244 173766 167555 1630829 1746631 29769545 30397704 3026530 3003234 305121 0 7920236 7752375 948311 917669 843458 1439402 13043656 13112680 X 16554623 17119970 171266 165054 16725889 17285024 29769545 30397704 X 183373 375762 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 8497 8497 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: PORTION OF THE FOLLOWING DUES: WHA: $1,641; RWHC: $3,058; AND AHA: $3,798. 4171266 20000 168896 802599 417915 3139648 0.97000 0.00000 0.03000 0 0 235001 235001 14414936 6971672 7443264 11102495 9640131 1462364 1063331 293997 769334 9909963 DUE FROM WOODLANDS 130687 BOND FUNDS 982925 SECTION 457 PLAN ASSET 632727 OTHER 292 1746631 CAPITAL LEASES 96891 DUE TO THIRD PARTY PAYORS 709784 SECTION 457 PLAN LIABILITY 632727 1439402 37224030 37040657 183373 436254 -60492 375762 559135 37368619 242895 242895 37125724 19391 78915 98306 37224030 37238994 242895 242895 36996099 19391 25167 44558 37040657 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. 1 1 1 X 1 X 1 1 0 1 1 814668 0 814668 0.02350 5899745 3512354 2387391 0.06870 113404 48051 65353 0.00190 6827817 3560405 3267412 0.09410 11 60036 60036 0.00170 11 60036 60036 0.00170 11 6887853 3560405 3327448 0.09580 36870 2280 34590 0.00100 190346 190346 0.00550 227216 2280 224936 0.00650 1 649699 0 8229390 8167592 61798 X 1 1 1 1 COMMUNITY MEMORIAL HOSPITAL

855 SOUTH MAIN STREET OCONTO FALLS WI 54154

X X X X COMMUNITY MEMORIAL HOSPITAL INCORPORATED 1 0 1 1 200.000000000000 1 400.000000000000 1 X X X X X 1 1 X X X 1 0 1 X 0 0 6 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 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. COMMUNITY MEMORIAL HOSPITAL INCORPORATED 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. 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. REPORTS FILED WITH STATES PART VI, LINE 7 WI X X 0 0 0 0 0 0 0 0 0 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 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 385187 3445154 293583 46266 315020 2784783 2006 0 0 1 1 603464 5470872 465730 73469 500248 4472409 2006 0 0 1 1 0 1 0 0 0.01280 0.00300 0.01580 0 0 1 0 0 0.01280 0.00300 0.01580 0 0 0 0 0 0 0 0 0 0 0 0 0 GENADI MALTINSKI MD CONTRACT PHYSICIAN 351749 CONTRACTED PHYSCIAN 0 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. COMMUNITY HEALTHCARE FOUNDATION 855 SOUTH MAIN STREET OCONTO FALLS WI 54154 391700944 FUNDRAISING FOR LOCAL NONPROFIT ORGNAIZATIONS WI 501(C)(3) LINE 7 COMMUNITY MEMORIAL HOSPITAL 1 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 0 COMMUNITY HEALTHCARE FOUNDATION M COST COMMUNITY HEALTHCARE FOUNDATION N 41349 COST COMMUNITY HEALTHCARE FOUNDATION O 54821 COST