2013-08-13T14:47:38-05:00 2012-09-30 381357951 PLANTE & MORAN PLLC PO BOX 307 SOUTHFIELD MI 480370307 990 2011-10-01 390794174 OCONOMOWOC MEMORIAL HOSPITAL INC OCON 2629284740 791 SUMMIT AVENUE OCONOMOWOC WI 530663844 DAVID EBEL 2629284740 2013-08-07 1 SUSAN MIENCIER P00842339 2483522500 2011 2016-02-24 21:20:13Z SUSAN EDWARDS 791 SUMMIT AVENUE OCONOMOWOC WI 530663844 96209437 0 X WWW.PROHEALTHCARE.ORG X 1948 WI PROVIDE GENERAL ACUTE CARE AND SUPPORT ACTIVITIES. 14 11 944 347 2607248 0 382288 271446 90936119 93228981 1603671 125406 1008130 2226185 93930208 95852018 2947500 3720000 0 0 30386309 28538623 0 0 0 60863868 64563166 94197677 96821789 -267469 -969771 166242121 166902475 115214677 115645132 51027444 51257343 CONTINUOUSLY IMPROVING THE HEALTH OF OUR COMMUNITY. 0 0 92755843 3720000 92458094 OCONOMOWOC MEMORIAL HOSPITAL FULFILLS ITS EXEMPT PURPOSE BY PROVIDING CARE AND SERVICES TO ALL PATIENTS REGARDLESS OF INSURANCE OR ABILITY TO PAY. OCONOMOWOC MEMORIAL HOSPITAL ALSO USES ITS RESOURCES TO ADDRESS VARIOUS COMMUNITY NEEDS. OCONOMOWOC MEMORIAL HOSPITAL PROVIDED APPROXIMATELY 9,905 DAYS OF INPATIENT CARE AND APPROXIMATELY 69,125 OUTPATIENT VISITS DURING THE FISCAL YEAR ENDED SEPTEMBER 30, 2012. 92755843 1 1 0 0 0 0 0 0 0 1 1 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 1 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 1 1 0 0 1 98 0 1 944 1 1 1 0 0 0 0 0 0 0 0 0 X 14 11 0 0 0 0 1 0 1 1 1 0 0 1 1 1 1 1 1 1 1 1 0 WI X DAVID EBEL 2629284740 N17 W24100 RIVERWOOD DRIVE SUITE WAUKESHA WI 53188 X EDWARD J LUMP 2.00 X 0 0 0 GLENN ROSKILLY 2.00 X 0 0 0 MICHAEL G BARRY 2.00 X 0 0 0 PAUL BOSTROM 2.00 X 0 0 0 THOMAS R PACKEE 2.00 X 0 0 0 TED GARVEY 2.00 X 0 0 0 MATTHEW S MACLEAN 2.00 X 0 0 0 RICHARD NEILS MD 2.00 X 0 0 0 CHARLOTTE HALL 2.00 X 0 0 0 MAC DORN 2.00 X 0 0 0 HELEN FORSTER 2.00 X 0 0 0 MARY LEE RATZEL 2.00 X X 0 0 0 JOHN R ROBERTSTAD 8.00 X X 104836 513919 457965 DAVID ROELKE MD 2.00 X 0 0 0 JANET R SWANDBY 2.00 X 0 0 0 SUSAN EDWARDS 2.00 X 0 1071851 1043530 NANINE M NELSON 2.00 X 0 494847 344126 BARBARA J PINEKENSTEIN 2.00 X 63098 281867 95057 MARY JO O'MALLEY 8.00 X 43955 214752 105111 MOHAMMAD KHARBAT 8.00 X 40358 141966 43988 MARY JANE REICHART 8.00 X 20000 151461 6363 THOMAS MCELMEEL 2.00 X 8464 132452 36644 MARK A ZWASKA 40.00 X 138146 0 20982 JOHN MCGINNIS 8.00 X 26102 108219 42473 444959 3111334 2196239 10 0 1 0 HAMILTON BENCHMARK 1330 E WATERFORD AVENUE ST FRANCIS WI 53235 MAINTENANCE SERVICES 535188 GE HEALTHCARE PO BOX 640200 PITTSBURGH PA 15264 MAINTANENCE SERVICES 328812 NATIONAL WOUND CARE 3087 MOMENTUM PLACE CHICAGO IL 60689 MANAGEMENT FEES 316905 ADVANCED ICU CARE PO BOX 671773 DALLAS TX 75267 HEALTHCARE SERVICES 251938 CG SCHMIDT 11777 W LAKE PARK DRIVE MILWAUKEE WI 53224 CONSTRUCTION SERVICE 235452 8 177019 56350 38077 271446 PATIENT SERVICES 622110 89157310 89157310 PHARMACY SALES 446110 2122177 1464423 657754 LABORATORY REVENUE 621500 1949494 1949494 93228981 136872 136872 473681 294013 179668 179668 179668 51940 63406 -11466 -11466 -11466 MISCELLANEOUS REVENUE 900099 1627232 1626796 436 CAFETERIA SALES 722210 389388 389388 MASSAGE THERAPY REVENU 624310 29897 29897 2046517 95852018 92458094 2607248 515230 3720000 3720000 296062 296062 22646326 22176219 470107 1334966 1290384 44582 2561071 2475543 85528 1700198 1666364 33834 70915 70915 22187163 21856172 330991 17468665 17332395 136270 2930373 1079294 1851079 52683 48377 4306 31713 24398 7315 5709546 5709546 9118257 9015345 102912 376535 376535 BAD DEBT 3205889 3205889 MEDICAID PROVIDER TAXES 3088148 3088148 DUES, FEES & LICENSES 261217 53551 207666 PUBLIC RELATIONS 25558 361 25197 36504 13857 22647 96821789 92755843 4065946 0 3384562 2841707 9045785 11388106 2218447 2126379 464611 440707 191256802 93222102 104370332 98034700 37080977 41266508 305250 506022 9372157 10298346 166242121 166902475 9887649 8559035 8061 0 90904395 79064714 0 11451764 14414572 16569619 115214677 115645132 X 43541611 42732702 7198401 8189557 287432 335084 51027444 51257343 166242121 166902475 X -969771 1199670 X X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 326376 20265 47652 394293 326222 33945 -33791 326376 306912 5000 14310 326222 317404 -10492 306912 1.00000 0 1 1 2030526 2030526 122782678 38706622 84076056 4234456 3101661 1132795 61394923 50910711 10484212 814219 503108 311111 98034700 ACCOUNTS RECEIVABLE FOUNDATION 453295 ACCRUED INTEREST RECEIVABLE 38517 BENEFICIAL INTEREST IN PERPETUAL TRUST 335084 DEFERRED FINANCING 349181 MISCELLANEOUS RECEIVABLES 872159 INTEREST IN THE NET ASSETS OF OMHF, INC. 7330002 DUE FROM AFFILIATES 920108 10298346 ACCRUED MINIMUM PENSION 12353560 ACCRUED POST-RETIREMENT 91727 ESTIMATED THIRD PARTY PAYOR SETTLEMENT 75000 INTEREST RATE SWAPS 3713737 ASSET RETIREMENT OBLIGATION 245595 INSURANCE LIABILITY 90000 16569619 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: OCONOMOWOC MEMORIAL HOSPITAL USES FUNDS FROM THE ENDOWMENT TO FURTHER ITS CHARITABLE MISSION. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: FIN48 DISCLOSURE: FEDERAL INCOME TAX - PHC, WMH, OMH, NATIONAL REGENCY, AND PHHC ARE NOT-FOR-PROFIT CORPORATIONS AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE (THE CODE) AND ARE EXEMPT FROM FEDERAL INCOME TAXES PURSUANT TO SECTION 501(A) OF THE CODE. ALL OF THESE ENTITIES ARE, HOWEVER, SUBJECT TO FEDERAL AND STATE INCOME TAXES ON ANY UNRELATED BUSINESS INCOME UNDER THE PROVISIONS OF SECTION 511 OF THE CODE. WHS IS A FOR-PROFIT STOCK CORPORATION AND IS SUBJECT TO INCOME TAXES. WHS ACCOUNTS FOR INCOME TAXES UNDER THE ASSET AND LIABILITY METHOD. UNDER THIS METHOD, DEFERRED TAX ASSETS AND LIABILITIES ARE RECOGNIZED RELATED TO THE FUTURE TAX CONSEQUENCES ATTRIBUTABLE TO DIFFERENCES BETWEEN THE CONSOLIDATED FINANCIAL STATEMENT CARRYING AMOUNTS OF EXISTING ASSETS AND LIABILITIES AND THEIR RESPECTIVE TAX BASES AND OPERATING LOSS AND TAX CREDIT CARRYFORWARDS. DEFERRED TAX ASSETS AND LIABILITIES ARE MEASURED USING ENACTED TAX RATES EXPECTED TO APPLY TO TAXABLE INCOME IN THE YEARS IN WHICH THOSE TEMPORARY DIFFERENCES ARE EXPECTED TO BE RECOVERED OR SETTLED. THE ACCOUNTING STANDARD THAT REFERS TO ACCOUNTING FOR UNCERTAINTY IN INCOME TAXES ADDRESSES THE DETERMINATION OF HOW TAX BENEFITS CLAIMED OR EXPECTED TO BE CLAIMED ON A TAX RETURN SHOULD BE RECORDED ON THE CONSOLIDATED FINANCIAL STATEMENTS. COMPANIES MUST RECOGNIZE THE TAX BENEFIT FROM AN UNCERTAIN TAX POSITION ONLY IF IT IS MORE LIKELY THAN NOT THAT THE TAX POSITION WILL BE SUSTAINED ON EXAMINATION BY THE TAXING AUTHORITIES, BASED ON THE TECHNICAL MERITS OF THE POSITION. THE STANDARD ALSO PROVIDES GUIDANCE ON DERECOGNITION, CLASSIFICATION, INTEREST AND PENALTIES ON INCOME TAXES, AND ACCOUNTING IN INTERIM PERIODS, AND REQUIRES INCREASED DISCLOSURES. THE CORPORATION IS SUBJECT TO EXAMINATION BY TAXING AUTHORITIES. CURRENTLY THE WHS AND SUBSIDIARIES 2011 TAX RETURN IS BEING AUDITED BY THE INTERNAL REVENUE SERVICE. MANAGEMENT BELIEVES THE CORPORATION IS NOT SUBJECT TO TAX EXAMINATIONS FOR YEARS PRIOR TO SEPTEMBER 30, 2009. 1 1 X 1 X 1 X 0 1 1 0 0 920280 920280 0.00980 8614426 3828082 4786344 0.05110 9534706 3828082 5706624 0.06090 22 11008 465500 956 464544 0.00500 7 1122 249656 249656 0.00270 102819 102819 0.00110 8 12250 266038 266038 0.00280 37 24380 1084013 956 1083057 0.01160 37 24380 10618719 3829038 6789681 0.07250 1 576 576 0.00000 1 3587 3587 0.00000 1 3602 3602 0.00000 800 800 0.00000 1 671 671 0.00000 4 9236 9236 0.00010 1 3205889 961767 16882283 32253107 -15370824 X 1 1 1 LAKE COUNTRY ENDOSCOPY CENTER LLC DIAGNOSTIC CENTER 0.50000 0.50000 1 1 OCONOMOWOC MEMORIAL HOSPITAL INC

791 SUMMIT AVENUE OCONOMOWOC WI 530663844

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

1185 CORPORATE CENTER DR OCONOMOWOC WI 53066

DIAGNOSITC CENTER PART I, LINE 3C: N/A PART I, LINE 6A: N/A PART I, LINE 7: THE COST-TO-CHARGE RATIO WAS USED TO CALCULATE AMOUNTS ON LINES 7A-7D. THIS WAS CALCULATED BY USING WORKSHEET 2 OF THE SCHEDULE H INSTRUCTIONS. THE HOSPITAL'S FINANCIAL COST REPORTING SYSTEM WAS USED TO CALCULATE THE AMOUNTS ON LINES 7E-7I PART I, LINE 7G: N/A PART I, L7 COL(F): $3,205,889 OF BAD DEBT EXPENSES WAS INCLUDED ON FORM 990, PART IX, LINE 25 BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE. PART II: OCONOMOWOC MEMORIAL HOSPITAL HAS PARTNERSHIPS WITH VARIOUS ORGANIZATIONS THROUGHOUT THE COMMUNITIES WE SERVE. ONE EXAMPLE IS THE PARTNERSHIPS WE HAVE WITH THE LOCAL CHAMBERS OF COMMERCE WITHIN OUR SERVICE AREA BY PROVIDING LEADERSHIP AND HEALTH RELATED OUTREACH TOWARDS STRENGTHENING COMMUNITY DEVELOPMENT. WE ARE THE MAJOR SPONSOR FOR "LEADERSHIP WAUKESHA", A PROGRAM THAT FOCUSES ON THE DEVELOPMENT OF EMERGING LEADERS IN OUR COUNTY. ADDITIONALLY, WE PROVIDE LAND, RESOURCES AND EXPERTISE FOR LOCAL COMMUNITY GARDENS. WE PROVIDE DELIVERY OF EMERGENCY CARE IN THE COMMUNITY AND OFFER/SUPPORT NUMEROUS SERVICES AIMED AT OUR YOUTH INCLUDING SPONSORSHIP OF SAFE "AFTER PROM" ACTIVITIES. WE SUPPORT AREA HOMELESS SHELTERS AND ARE ACTIVE MEMBERS OF THE HOUSING ACTION COALITION AND HISPANIC COLLABORATIVE NETWORK. PART III, LINE 4: BAD DEBT EXPENSE FOOTNOTE: AN ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS IS ESTABLISHED ON AN AGGREGATE BASIS BY USING HISTORICAL WRITE-OFF RATE FACTORS APPLIED TO UNPAID ACCOUNTS BASED ON AGING. LOSS RATE FACTORS ARE BASED ON HISTORICAL LOSS EXPERIENCE AND ARE ADJUSTED FOR ECONOMIC CONDITIONS AND OTHER TRENDS AFFECTING THE HOSPITAL'S ABILITY TO COLLECT OUTSTANDING AMOUNTS. UNCOLLECTIBLE AMOUNTS ARE WRITTEN OFF AGAINST THE ALLOWANCE FOR DOUBTFUL ACCOUNTS IN THE PERIOD THEY ARE DETERMINED TO BE UNCOLLECTIBLE. THE AMOUNT OF BAD DEBT EXPENSE REPORTED ON PART III LINE 2 IS THE BAD DEBT EXPENSE REPORTED ON FORM 990 PART IX.THE BAD DEBT COST WAS REVIEWED BY THE HOSPITAL'S REVENUE CYCLE TEAM AND THE AMOUNT OF BAD DEBT ESTIMATED TO BE ATTRIBUTABLE TO PATIENTS WHO WOULD HAVE QUALIFIED UNDER OUR CHARITY CARE PROGRAM IS 30% OF TOTAL BAD DEBTS. PART III, LINE 8: THE SHORTFALL ON LINE 7 SHOULD NOT BE TREATED AS COMMUNITY BENEFIT. COSTING METHODOLOGY IS THE COST TO CHARGE RATIO AS REPORTED ON THE MEDICARE COST REPORT. PART III, LINE 9B: PATIENTS THAT QUALIFY FOR FINANCIAL ASSISTANCE WILL HAVE A CHARITY DISCOUNT APPLIED TO THEIR BALANCES AT THE TIME OF BILLING. IF THIS RESULTS IN NO BALANCE DUE FORM THE PATIENT, THEN THE PATIENT WILL NOT RECEIVE A STATEMENT. IF A BALANCE REMAINS AFTER THE DISCOUNT PERCENTAGE IS APPLIED, THE PATIENT WILL RECEIVE A STATEMENT FOR THE BALANCE DUE. THE STATEMENT CYCLE IS CONSISTENT FOR ALL PATIENTS. OCONOMOWOC MEMORIAL HOSPITAL PART V, SECTION B, LINE 13G: THE POLICY IS AVAILABLE UPON REQUEST OR ON OUR WEBSITE. A PHONE NUMBER IS PROVIDED ON OUR BILLING STATEMENTS, AND IN THE EMERGENCY DEPARTMENT AND ADMITTING AREAS FOR A PATIENT TO CALL IF THEY HAVE A FINANCIAL NEED. PART VI, LINE 2: COMMUNITY NEEDS ARE IDENTIFIED BASED UPON A REVIEW OF STATE, COUNTY AND COMMUNITY HEALTH DATA AND ASSESSMENTS. THIS INCLUDES SUCH DOCUMENTS AS: THE STATE HEALTH PLAN, THE COUNTY HEALTH REPORT CARD, THE WAUKESHA COMMUNITY HEALTH SURVEY, THE HEALTHY PEOPLE 2020 PLAN AND VARIOUS OTHER NEEDS ASSESSMENTS, SUCH AS THE UNITED WAY/UNIVERSITY OF WISCONSIN SURVEY OF WAUKESHA COUNTY. ADDITIONALLY, WE HAVE ACTIVELY PARTNERED WITH OUR COUNTY HEALTH DEPARTMENT IN THEIR COMMUNITY HEALTH IMPROVEMENT PLAN AND PROCESS (CHIPP) ASSESSMENT. TO COMPLEMENT ALL OF THESE DATA SOURCES, WE ALSO PERIODICALLY PERFORM A SERVICE GAP ANALYSIS WITH OUR EMPLOYED COMMUNITY OUTREACH NURSES AS WELL AS LOCAL NON-PROFIT AGENCIES WITH WHICH WE PARTNER. WE THEN ANALYZE THE DATA, IDENTIFY THE PRESSING NEEDS, AND PROACTIVELY PLAN AND IMPLEMENT COMMUNITY BENEFIT INITIATIVES TO ADDRESS THESE NEEDS. WE ARE CURRENTLY COLLECTING AND ANALYZING PRIMARY DATA FOR OUR FORMAL CHNA AS REQUIRED BY THE AFFORDABLE CARE ACT. PART VI, LINE 3: EVERY PATIENT WITH A SELF PAY BALANCE RECEIVES A STATEMENT WHICH CONVEYS THE AVAILABILITY OF COMMUNITY (CHARITY) CARE AND A CONTACT NUMBER FOR FURTHER INFORMATION. PATIENTS THAT ARE UNINSURED RECEIVE AN UNINSURED DISCOUNT WHICH IS LISTED ON THE FIRST STATEMENT THAT THEY RECEIVE. PATIENTS RECEIVE A TOTAL OF FOUR STATEMENTS. EACH STATEMENT CONTAINS VERBIAGE REFERENCING THE HOSPITAL'S COMMUNITY CARE PROGRAM AND A CONTACT NUMBER FOR FURTHER INFORMATION. IF SOMEONE HAS BEEN FOUND ELIGIBLE FOR SOME LEVEL OF CHARITY CARE, THE ELIGIBILITY PERIOD IS THREE MONTHS SO ANY SUBSEQUENT ACCOUNTS DURING THAT TIMEFRAME WOULD BE DISCOUNTED AT WHATEVER LEVEL OF CHARITY CARE THE PATIENT IS DEEMED ELIGIBLE. PATIENTS MAY REAPPLY FOR COMMUNITY CARE WHEN THEIR ELIGIBILITY PERIOD HAS EXPIRED. SELF PAY PATIENTS MAY ALSO BE INFORMED OF THE HOSPITAL'S COMMUNITY CARE PROGRAM WHILE THEY ARE INPATIENTS. SOCIAL WORK AND/OR THE BUSINESS OFFICE MAY MAKE CONTACT WITH THESE PATIENTS DURING THEIR STAY TO INFORM THEM OF THE COMMUNITY CARE PROGRAM AND ASSIST THEM WITH COMPLETION OF THE APPLICATION.INFORMATION IS AVAILABLE AT REGISTRATION AREAS RELATED TO OUR COMMUNITY CARE PROGRAM. THIS INFORMATION CONTAINS CONTACT INFORMATION FOR THE HOSPITAL'S CENTRAL BUSINESS OFFICE WHERE PATIENTS CAN RECEIVE ASSISTANCE IN OBTAINING AND COMPLETING APPLICATIONS. PART VI, LINE 4: PROHEALTH CARE SERVES ABOUT 285,000 PEOPLE EACH YEAR IN WAUKESHA COUNTY AND PORTIONS OF SURROUNDING COUNTIES. IN EVERY FEDERAL POPULATION CENSUS, WAUKESHA COUNTY HAS RECORDED AN INCREASE IN POPULATION. SINCE 1960, THE POPULATION OF THE COUNTY HAS MORE THAN DOUBLED. WAUKESHA COUNTY HAS AN AGING POPULATION WITH 14.7% OVER THE AGE OF 65 AND A MEDIAN AGE OF 42.0 YEARS. THE RATE OF RETIREMENT IS LIKELY TO SURPASS THE RATE OF ENTRY INTO THE WORKFORCE BETWEEN 2015 AND 2020. THE RACIAL MAKEUP OF THE WAUKESHA COUNTY COMMUNITY IS AS FOLLOWS: WHITE 94.2%, HISPANIC OR LATINO 4.3%, ASIAN 2.9%, BLACK 1.4%. MEDIAN HOUSEHOLD INCOME IS $75,845, WITH 4.7% OF PEOPLE LIVING BELOW THE POVERTY LEVEL. UNEMPLOYMENT IN WAUKESHA COUNTY STOOD AT 5.3% ON 12/31/12. THE PRESENCE OF SOME HIGH INCOME COMMUNITIES IN WAUKESHA COUNTY OFTEN GIVES A MISTAKEN IMPRESSION. OFTEN OVERLOOKED IS A GROWING POPULATION OF LOW INCOME, NON-ENGLISH SPEAKING, VULNERABLE AND MARGINALIZED CITIZENS WHO FACE ENORMOUS ODDS IN ACCESSING HEALTH CARE. THE WAUKESHA COUNTY MEDICAID POPULATION HAS NEARLY TRIPLED IN 10 YEARS, FROM ABOUT 9,451 PEOPLE IN 2000 TO MORE THAN 30,000 IN 2011. THE HISPANIC POPULATION HAS SEEN A 42% INCREASE IN THE PAST 8 YEARS. DOWNTOWN WAUKESHA WAS DECLARED A "MEDICALLY UNDERSERVED" AREA AND A "HEALTH-PROFESSIONAL SHORTAGE AREA" BY THE FEDERAL GOVERNMENT IN 2008. AS AN UNDERSERVED AREA, MEDICAL OPTIONS FOR INDIVIDUALS, PARTICULARLY THOSE WITHOUT HEALTH INSURANCE OR WITH PUBLIC INSURANCE, ARE SEVERELY LIMITED BECAUSE PRIVATE SERVICE PROVIDERS OFTEN REFUSE TO CARE FOR THESE INDIVIDUALS. CONSEQUENTLY, PROHEALTH CARE EMBARKED ON A FUND-RAISING INITIATIVE TO SUPPORT THE FORMATION OF AN FEDERALLY QUALIFIED HEALTH CENTER (FQHC) IN DOWNTOWN WAUKESHA. PART VI, LINE 5: BECAUSE OF THE MIXTURE OF BOTH URBAN AND RURAL AREAS IN OUR SERVICE AREA, OUR COMMUNITY BENEFIT PROGRAM MAKES A CONSCIOUS EFFORT TO REACH OUT AND FIND DISADVANTAGED, UNDERSERVED POPULATIONS. THESE TARGET POPULATIONS INCLUDE NON- ENGLISH SPEAKING, UNINSURED OR UNDERINSURED, ISOLATED AND FRAIL ELDERLY, HOMELESS, AND MENTALLY DISABLED. OUR GOVERNING AND COMMUNITY BENEFIT COMMITTEE ARE CHAIRED BY AND CONSIST PRIMARILY OF COMMUNITY MEMBERS. WE ALSO MAKE EXTENSIVE USE OF INDEPENDENT COMMUNITY PARTNER AGENCIES IN PLANNING, DESIGN AND OPERATION OF COMMUNITY BENEFIT PROGRAMS. PART VI, LINE 6: OUR HOSPITAL IS A MEMBER OF THE PROHEALTH CARE HEALTH SYSTEM WHICH SERVES AS OUR PARENT COMPANY. WHILE COMMUNITY BENEFIT RESPONSIBILITIES RESIDE WITH OUR HOSPITAL BOARD, THE PARENT COMPANY PLAYS A KEY ROLE IN COORDINATING COMMUNITY NEEDS ASSESSMENTS, COMMUNITY BENEFIT PROGRAM PLANNING, AND EVALUATION.A DESCRIPTION OF EACH AFFILIATES ROLE IN PROMOTING HEALTH WITHIN THE COMMUNITIES SERVED IS AS FOLLOWS:PROHEALTH CARE, INC. - HELPS TO MANAGE THE HOSPITALS TO ENSURE THEY CAN PROMOTE HEALTH AND WELLNESS WITHIN THE COMMUNITY.NATIONAL REGENCY OF NEW BERLIN, INC. - OWNS AND OPERATES SENIOR LIVING CENTERS AS A MEANS TO PROMOTE HEALTH WITHIN THE COMMUNITY.PROHEALTH HOME CARE, INC. - PROVIDES HOSPICE AND HOME HEALTH CARE SERVICES AS A MEANS TO PROMOTE HEALTH WITHIN THE COMMUNITY.WAUKESHA MEMORIAL HOSPITAL FOUNDATION, INC. - SUPPORTS THE CHARITABLE MISSION OF WAUKESHA MEMORIAL HOSPITAL SO THAT IT MAY PROVIDE HEALTH SERVICES WITHIN THE COMMUNITY.OCONOMOWOC MEMORIAL HOSPITAL FOUNDATION, INC. - SUPPORTS THE CHARITABLE MISSION OF OCONOMOWOC MEMORIAL HOSPITAL SO THAT IT MAY PROVIDE HEALTH SERVICES WITHIN THE COMMUNITY.WAUKESHA MEMORIAL HOSPITAL, INC. - PROVIDES CARE AND SERVICES TO ALL PATIENTS REGARDLESS OF INSURANCE OR ABILITY TO PAY. WAUKESHA MEMORIAL HOSPITAL ALSO USES ITS RESOURCES TO ADDRESS VARIOUS COMMUNITY NEEDS. WAUKESHA MEMORIAL HOSPITAL PROVIDED APPROXIMATELY 61,727 DAYS OF INPATIENT CARE AND APPROXIMATELY 267,691 OUTPATIENT VISITS DURING THE FISCAL YEAR ENDED SEPTEMBER 30, 2012. REPORTS FILED WITH STATES PART VI, LINE 7 WI 0 PROHEALTH CARE INC N17 W24100 RIVERWOOD DR STE 200 WAUKESHA WI 531881131 391486873 501(C)(3) 3720000 0 N/A N/A TO ASSIST OCONOMOWOC MEMORIAL HOSPITAL IN ITS CHARITABLE MISSION. 1 X 0 0 X X X X 1 1 0 0 0 0 0 0 0 JOHN R ROBERTSTAD 97259 292176 0 218410 7577 3333 43103 380662 8125 26075 156064 920656 0 0 SUSAN EDWARDS 0 671679 0 397496 0 2676 0 1025550 0 17980 0 2115381 0 0 NANINE M NELSON 0 334971 0 158924 0 952 0 314384 0 29742 0 838973 0 0 BARBARA J PINEKENSTEIN 62477 170233 0 100096 621 11538 1509 77904 4355 11289 68962 371060 0 0 MARY JO O'MALLEY 43125 126865 0 78131 830 9756 5039 81617 4165 14290 53159 310659 0 0 MOHAMMAD KHARBAT 40311 118363 0 23480 47 123 1123 23065 5788 14012 47269 179043 0 0 MARY JANE REICHART 20000 22976 0 0 0 128485 0 612 0 5751 20000 157824 0 0 THOMAS MCELMEEL 8464 120221 0 4642 0 7589 0 11678 0 24966 8464 169096 0 0 MARK A ZWASKA 115924 0 5106 0 17116 0 11226 0 9756 0 159128 0 0 0 JOHN MCGINNIS 26028 89731 0 18268 74 220 811 17975 6881 16806 33794 143000 0 0 PART I, LINE 1A COUNTRY CLUB MEMBERSHIPS: JOHN ROBERTSTAD - BENEFIT WAS NOT INCLUDED IN TAXABLE INCOME AS MEMBERSHIP IS FOR BUSINESS USE ONLY. PART I, LINES 4A-B MARY JANE REICHART RECEIVED SEVERANCE PAYMENTS TOTALING $125,295 DURING THE TAX YEAR. PAYMENTS WERE MADE IN BIWEEKLY INSTALLMENTS OVER A 46 WEEK PERIOD PER AGREEMENT SIGNED BY THE PARTIES ON 3/8/11. NAME MARY JANE REICHART BARBARA PINEKENSTEIN MARY JO O'MALLEY SUSAN EDWARDS NANINE NELSON JOHN ROBERTSTAD PROHEALTH CARE INC. (PHC) MAINTAINS A SUPPLEMENTAL RETIREMENT PLAN (SERP) FOR A SELECT GROUP OF EXECUTIVES OF PHC AND ITS AFFILIATED ENTITIES. THE SERP IS AN UNFUNDED, NONQUALIFIED DEFERRED COMPENSATION PLAN THAT IS INTENDED TO COMPLY WITH SECTION 457(F) OF THE INTERNAL REVENUE CODE. BENEFITS UNDER THE SERP ARE TAXABLE TO THE PARTICIPATING EXECUTIVES WHEN SUCH AMOUNTS ARE VESTED. SUPPLEMENTAL INFORMATION PART III SCHEDULE J, PART I THIS ENTITY RELIED ON A RELATED ORGANIZATION THAT USED THE FOLLOWING METHODS TO ESTABLISH COMPENSATION FOR OFFICERS AND DIRECTORS: 1. COMPENSATION COMMITTEE 2. COMPENSATION STUDY 3. APPROVAL OF THE BOARD ANNUALLY APPROVING COMPENSATION AMOUNTS 4. INDEPENDENT COMPENSATION CONSULTANT WISCONSIN HEALTH & EDUCATIONAL FACILITIES 391337855 97710BDJ8 2008-08-14 14575000 CURRENT REFUND BONDS ISSUED ON 4/25/01 AND ON 6/09/04 0 0 0 WISCONSIN HEALTH & EDUCATIONAL FACILITIES 391337855 97710BGZ9 2009-04-30 68825452 ADDITION AND RENOVATIONS TO EXISTING HOSPITAL FACILITY 0 0 0 WISCONSIN HEALTH & EDUCATIONAL FACILITIES 391337855 97710BB50 2011-02-16 3639214 CURRENT REFUND BONDS ISSUED ON 11/14/95 AND ON 5/13/99 0 0 0 659293 14091525 112530 85640 13893355 2007 1 0 1 1 6212345 61944963 6275521 895907 61049056 2010 0 0 1 1 715000 3639214 67832 3571383 2001 1 0 1 1 0 0 1 1 0 0.00000 0.00000 0.00000 1 0 0 1 1 0 0.00000 0.00000 0.00000 1 0 0 1 1 0 0.00000 0.00000 0.00000 0 0 1 0 0 0 1 0 0 0 0 0 1 0 0 0 0 0 1 SCH K, PART I, LINE A COLUMNS (C),(E) PART I, A (C) CUSIP #: THE CUSIP # OF 97710BDH2 ON FORM 8038 WAS NOT THE NUMBER ON THE BOND OF THE LATEST MATURITY. THE NUMBER FOR THE LATEST MATURITY IS CORRECTLY REPORTED ON SCHEDULE K. PART I, A (E) ISSUE PRICE: THE TOTAL ISSUE PRICE ON FORM 8038 IS $122,535,000. THE AMOUNT REPORTED ON SCHEDULE K IS ONLY THE AMOUNT OF THE ISSUE BENEFITING THE REPORTING ORGANIZATION. SCH K, PART I, LINE B COLUMNS (C),(E) PART I, B (C) CUSIP #: THE CUSIP # OF 97710BGW6 ON FORM 8038 WAS NOT THE NUMBER ON THE BOND OF THE LATEST MATURITY. THE NUMBER FOR THE LATEST MATURITY IS CORRECTLY REPORTED ON SCHEDULE K. PART I, B (E) ISSUE PRICE: THE TOTAL ISSUE PRICE ON FORM 8038 IS $134,951,867.50. THE AMOUNT REPORTED ON SCHEDULE K IS ONLY THE AMOUNT OF THE ISSUE BENEFITING THE REPORTING ORGANIZATION. SCH K, PART I, LINE C COLUMNS (C),(E) PART I, C (C) CUSIP #: THE CUSIP # OF 97710BB50 ON FORM 8038 WAS NOT THE NUMBER ON THE BOND OF THE LATEST MATURITY. THE NUMBER FOR THE LATEST MATURITY IS CORRECTLY REPORTED ON SCHEDULE K. PART I, C (E) ISSUE PRICE: THE TOTAL ISSUE PRICE ON FORM 8038 IS $35,678,572.65. THE AMOUNT REPORTED ON SCHEDULE K IS ONLY THE AMOUNT OF THE ISSUE BENEFITING THE REPORTING ORGANIZATION. SCH K, PART II, COLUMN A PART II, COL A, LINE 3 - TOTAL PROCEEDS OF ISSUE: SALE PROCEEDS OF ISSUE IN AMOUNT OF $14,091,525 ALLOCABLE TO REPORTING ORGANIZATION PLUS ZERO INVESTMENT PROCEEDS. PART II, COL A, LINE 6 - PROCEEDS IN REFUNDING ESCROWS: PROCEEDS IN THE AMOUNT OF $13,893,355 ALLOCABLE TO REPORTING ORGANIZATION DEPOSITED IN REFUNDING ESCROWS ON 8/14/08; BALANCE ON 9/30/12 IS ZERO. PART II, COL A, LINE 7 - ISSUANCE COSTS FROM PROCEEDS: $112,530 OF PROCEEDS ALLOCABLE TO REPORTING ORGANIZATION USED FOR ISSUANCE COSTS; $85,640 USED FOR CREDIT ENHANCEMENT. PART II, COL A, LINE 13 - YEAR OF SUBSTANTIAL COMPLETION: YEAR OF SUBSTANTIAL COMPLETION OF PROJECTS FINANCED WITH REFUNDED PRIOR BONDS ISSUED 4/25/01 WAS 2001 AND YEAR OF SUBSTANTIAL COMPLETION OF PROJECTS FINANCED WITH REFUNDED PRIOR BONDS ISSUED 6/09/04 WAS 2007. SCH K, PART II, COLUMN B PART II, COL B, LINE 3 - TOTAL PROCEEDS OF ISSUE: SALE PROCEEDS OF ISSUE IN AMOUNT OF $68,825,452 ALLOCABLE TO REPORTING ORGANIZATION PLUS $2,056 OF INVESTMENT PROCEEDS ALLOCABLE TO REPORTING ORGANIZATION LESS SALE PROCEEDS IN THE AMOUNT OF $6,882,545 DEPOSITED IN REASONABLY REQUIRED RESERVE FUND ALLOCABLE TO REPORTING ORGANIZATION. SCH K, PART II, COLUMN C PART II, COL C, LINE 3 - TOTAL PROCEEDS OF ISSUE: SALE PROCEEDS OF ISSUE IN AMOUNT OF $3,639,214.41 ALLOCABLE TO REPORTING ORGANIZATION PLUS ZERO INVESTMENT PROCEEDS. PART II, COL C, LINE 6 - PROCEEDS IN REFUNDING ESCROWS: PROCEEDS IN THE AMOUNT OF $3,571,383 ALLOCABLE TO REPORTING ORGANIZATION DEPOSITED IN REFUNDING ESCROWS ON 2/16/11; BALANCE ON 9/30/12 IS ZERO. PART II, COL C, LINE 13 - YEAR OF SUBSTANTIAL COMPLETION: YEAR OF SUBSTANTIAL COMPLETION OF PROJECTS FINANCED WITH REFUNDED PRIOR BONDS ISSUED 11/14/95 WAS 1995 AND YEAR OF SUBSTANTIAL COMPLETION OF PROJECTS FINANCED WITH REFUNDED PRIOR BONDS ISSUED 5/13/99 WAS 2001. SCH K IN 2012, PHC REFUNDED A PORTION OF THE 2009 BOND ISSUE, THE OMH PORTION IS INCLUDED IN THE BONDS RETIRED. ASSOCIATED WITH THE REFUNDING THE 2009 DEBT SERVICE RESERVE FUND WAS REDUCED BY $1,190,243.80 OF WHICH $607,024.34 IS OMH'S ALLOCATED REDUCTION. RADIOLOGY WAUKESHA BOARD MEMBER, DAVID ROELKE, IS AN OWNER OF RADIOLOGY WAUKESHA 181990 RADIOLOGY WAUKESHA PROVIDES IMAGING SERVICES FOR OMH. 0 WAUKESHA HEALTH SYSTEM INC BOARD MEMBER, JOHN ROBERTSTAD, IS AN OFFICER OF WAUKESHA HEALTH SYSTEM 1806191 WAUKESHA HEALTH SYSTEM PROVIDES REIMBURSEMENT OF EXPENSES TO OMH. 0 LAKE COUNTRY ENDOSCOPY CENTER BOARD MEMBER JOHN ROBERTSTAD IS AN OFFICER OF LAKE COUNTRY ENDOSCOPY CENTER 562711 INVESTMENT DISTRIBUTIONS 0 FORM 990, PART VI, SECTION A, LINE 6 PROHEALTH CARE, INC. IS THE SOLE CORPORATE MEMBER. FORM 990, PART VI, SECTION A, LINE 7B PROHEALTH CARE INC. HOLDS CERTAIN RESERVED POWERS OVER THE (NON-STOCK) CORPORATION INCLUDING APPROVAL OF STRATEGIC PLANNING, ANNUAL OPERATING AND CAPITAL BUDGETS, BORROWING, TRANSFER, LEASE, PLEDGE OR SALE OF ASSETS. FORM 990, PART VI, SECTION B, LINE 11 AFTER THE FORM 990 WAS PREPARED BY THE ORGANIZATION'S TAX PREPARERS AND PRIOR TO FILING THE FORM 990, SELECT EXECUTIVE MEMBERS OF THE ORGANIZATION, AND THE AUDIT & COMPLIANCE COMMITEE PERFORMED A REVIEW; THEN THE BOARD OF DIRECTORS WAS PROVIDED A COPY OF THE RETURN, WHICH WAS SUBSEQUENTLY FILED BY THE ORGANIZATION. FORM 990, PART VI, SECTION B, LINE 12C ALL OFFICERS, VICE-PRESIDENTS, MANAGERS AND ABOVE, AS WELL AS BOARD MEMBERS ARE REQUIRED TO ANNUALLY COMPLETE A CONFLICT OF INTEREST FORM. ALL REPORTED POTENTIAL CONFLICTS OF INTEREST ARE TRACKED IN THE CORPORATE COMPLIANCE DEPARTMENT. THEY ARE REVIEWED AND ANY PERSON IDENTIFIED AS HAVING A POTENTIAL CONFLICT IS GIVEN DIRECTION AS TO WHAT STEPS SHOULD BE TAKEN TO MITIGATE THE CONCERN. ALL EMPLOYEES ARE EDUCATED ANNUALLY. THE STEPS TAKEN WHEN A CONFLICT ARISES ARE AS FOLLOWS: FOR THE BOARD OF DIRECTORS, THE RESTRICTION IS NOT BEING ALLOWED TO PARTICIPATE IN DISCUSSION OR VOTING RELATED TO ANY DECISION WHERE THE BOARD MEMBER HAS BEEN DETERMINED TO HAVE A CONFLICT OF INTEREST. FOR LEADERS, RESEARCHERS, AND EMPLOYEES, RECOMMENDATIONS ARE MADE FROM COMPLIANCE MANAGER TO LEADERSHIP AND/OR HUMAN RESOURCES. RESTRICTIONS CAN RANGE FROM ANY OF THE FOLLOWING; DISCLOSING POTENTIAL CONFLICTS OF INTEREST TO PATIENTS, NOT BEING ABLE TO BE INVOLVED IN DISCUSSION OR DECISION MAKING ON SPECIFIC TOPICS, AND NOT BEING ABLE TO WORK AT PROHEALTH IN THE SPECIFIC ROLE WHERE THE REPORTED CONFLICT EXISTS. IF THE RECOMMENDATION IS CHALLENGED, THE MATTER GOES TO THE SENIOR EXECUTIVE TEAM FOR A DECISION. FORM 990, PART VI, SECTION B, LINE 15 AN INDEPENDENT, EXTERNAL COMPENSATION REVIEW IS CONDUCTED FOR THE POSITIONS OF CEO/PRESIDENT, EXECUTIVE DIRECTOR, VICE-PRESIDENT, SENIOR VICE-PRESIDENT AND ABOVE. THE RESULTS OF THE COMPENSATION REVIEW ARE PRESENTED TO THE BOARD'S EXECUTIVE COMMITTEE FOR APPROVAL. ANY MEMBER OF THE EXECUTIVE COMMITTEE WHOSE SALARY IS INCLUDED IN THE SALARY REVIEW IS RECUSED FROM THE APPROVAL PROCESS FOR HIS/HER SALARY APPROVAL. THIS PROCESS WAS LAST DONE IN 2012. FORM 990, PART VI, SECTION C, LINE 19 FINANCIAL STATEMENTS, GOVERNING DOCUMENTS & CONFLICT OF INTEREST POLICY ARE AVAILABLE UPON REQUEST. FORM 990, PART VI, SECTION B, LINE 16B: THE PROCESS IS TO HAVE ALL JOINT VENTURE ARRANGEMENTS REVIEWED BY THE LEGAL DEPARTMENT TO ENSURE IT MEETS ALL LEGAL REQUIREMENTS AND TO ENSURE THAT OCONOMOWOC MEMORIAL HOSPITAL, INC. MAY RETAIN ITS EXEMPT STATUS. FORM 990, PART VII, LINE 1A: FORM 990 PART VII: THE FOLLOWING OFFICERS AND DIRECTORS HAVE DEVOTED HOURS TO RELATED ORGANIZATIONS. THESE INDIVIDUALS ARE AS FOLLOWS: OFFICERS/DIRECTORS AVG. HRS. / WEEK DEVOTED TO RELATED ORGANIZATION ---------------------------------------------------------------------- JOHN ROBERTSTAD 32.00 HOURS BARBARA PINEKENSTEIN GREATER THAN 40.00 SUSAN EDWARDS GREATER THAN 40.00 NANINE NELSON GREATER THAN 40.00 MOHAMMAD S KHARBAT 32.00 HOURS MARY JO O'MALLEY 32.00 HOURS MARY JANE REICHART 32.00 HOURS THOMAS MCELMEEL GREATER THAN 40.00 JOHN MCGINNIS GREATER THAN 40.00 DAVID ROELKE, M.D. 2.00 HOURS HELEN FORSTER 2.00 HOURS JANET SWANDBY 2.00 HOURS MAC DORN 4.00 HOURS THOMAS PACKEE 2.00 HOURS CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED GAINS ON INVESTMENTS: 3,581,670. EQUITY CHANGE IN INTEREST OF NET ASSETS OF RELATED ORGANIZATION 973,000. PENSION-RELATED CHANGES -3,355,000. TOTAL TO FORM 990, PART XI, LINE 5: 1,199,670. FORM 990, PART XII, LINE 2C: THE AUDIT PROCESS HAS NOT CHANGED IN THE CURRENT YEAR. 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