2013-11-15T09:04:33-06:00 2012-12-31 363168081 SIKICH LLP 13400 BISHOPS LANE SUITE 300 BROOKFIELD WI 53005 990 2012-01-01 391500074 CHILDREN'S HOSPITAL AND HEALTH SYSTEM INC CHIL 4142665420 9000 W WISCONSIN AVE PO BOX 1997 MILWAUKEE WI 53201 WELDON GAGE 4142665420 2013-11-03 1 BRYAN L PAUTSCH CPA P00034913 2627549400 2013-11-01 2012 2016-02-25 16:41:14Z MARGARET TROY 9000 W WISCONSIN AVE PO BOX 1997 MILWAUKEE WI 53201 109100391 0 X WWW.CHW.ORG X 1985 WI INTEGRATED AND COORDINATED HEALTH SERVICES NETWORK FOR INFANTS, CHILDREN AND ADOLESCENTS. 25 17 685 3294 251155 10979 13557884 13905451 80082979 93657430 326861 301053 667238 1004312 94634962 108868246 303897 306691 0 0 48857138 49032022 0 0 0 46114465 62230458 95275500 111569171 -640538 -2700925 72842210 70835861 18966118 26320272 53876092 44515589 X CHILDREN'S HOSPITAL AND HEALTH SYSTEM, INC. ("CHHS") IS COMMITTED TO ENSURING A HEALTHIER FUTURE FOR CHILDREN BY PROVIDING AN INTEGRATED AND COORDINATED HEALTH AND SOCIAL SERVICES NETWORK FOR INFANTS, CHILDREN AND ADOLESCENTS. 0 0 70365841 298681 80353856 CHHS IS THE PARENT ORGANIZATION OF AN INTEGRATED SYSTEM OF ENTITIES PROVIDING COMPREHENSIVE MEDICAL CARE AND SOCIAL SERVICES TO CHILDREN FROM WISCONSIN AND THROUGHOUT THE MIDWEST. THE SYSTEM INCLUDES WISCONSIN'S ONLY FREESTANDING HOSPITAL DEDICATED SOLELY TO THE CARE AND TREATMENT OF CHILDREN, AS WELL AS VARIOUS OTHER FACILITIES PROVIDING INPATIENT AND OUTPATIENT CARE FOR CHILDREN WITH ALL TYPES OF ILLNESSES, INJURIES, BIRTH DEFECTS AND OTHER DISORDERS. THE SYSTEM ALSO INCLUDES EXTENSIVE RESEARCH, EDUCATION AND COMMUNITY OUTREACH PROGRAMS. ON AN AGGREGATE BASIS, THE ENTITIES WITHIN THE SYSTEM PROVIDED COMMUNITY BENEFITS OF OVER $117 MILLION.CHHS OVERSEES AND COORDINATES THE ACTIVITIES OF THE VARIOUS OPERATING ENTITIES WITHIN THE INTEGRATED SYSTEM, INCLUDING THROUGH THE PROVISION OF SUPPORTIVE AND ADMINISTRATIVE SERVICES ON A CONSOLIDATED, CENTRALIZED BASIS. 12432628 1009739 CHILDREN'S RESEARCH INSTITUTE ("CRI") IS A PROGRAM OF CHHS THAT ADVANCES PEDIATRIC MEDICAL RESEARCH IN WISCONSIN AND BEYOND. WITH A FOCUS ON TRANSLATIONAL RESEARCH, THE CRI IS TAKING DISCOVERIES FROM THE LABORATORY AND CONVERTING THEM TO NEW THERAPIES AT PATIENTS' BEDSIDES. RESEARCHERS AT THE CRI CONTINUE TO INVESTIGATE IMMUNE RESPONSES TO CANCER CELLS, POTENTIAL IMMUNE THERAPIES FOR CANCER, AND WAYS TO MAKE BONE MARROW TRANSPLANTS (BMTS) SAFER. IN 2012, A CRI RESEARCHER RECEIVED A $250,000 GRANT FROM HYUNDAI HOPE ON WHEELS FOUNDATION TO DEVELOP AN APPROACH THAT ALLOWS MORE CHILDREN TO RECEIVE BMTS FOR CANCER WITH FEWER COMPLICATIONS. CHILDREN WHO DEVELOP HIGHLY AGGRESSIVE CANCERS OFTEN REQUIRE A BMT TO CURE THEIR DISEASE. HOWEVER, BMTS CAN HAVE SERIOUS SIDE EFFECTS. IN ADDITION TO CONTINUED RESEARCH EFFORTS IN THE LABORATORY, CHILDREN'S HOSPITAL OF WISCONSIN, A CHHS AFFILIATE, CONTINUES TO PARTICIPATE IN THE CHILDREN'S ONCOLOGY GROUP CONSORTIUM, WHICH INCLUDES PARTICIPATION IN EARLY-PHASE CLINICAL RESEARCH WHEN PATIENTS NO LONGER BENEFIT FROM TRADITIONAL CANCER TREATMENTS. THE CRI ALSO CONTINUES TO FOCUS RESEARCH EFFORTS ON TYPE I DIABETES. IN 2012, RESEARCHERS AT THE CRI RECEIVED A $4.3 MILLION GRANT FROM THE NATIONAL INSTITUTES OF HEALTH'S NATIONAL INSTITUTE OF DIABETES AND DIGESTIVE AND KIDNEY DISEASES, A $400,000 GRANT FROM THE JUVENILE DIABETES RESEARCH FOUNDATION, AND A $300,000 GRANT FROM THE AMERICAN DIABETES ASSOCIATION TO STUDY A POTENTIAL PREDICTIVE MARKER OF THE DEVELOPMENT OF TYPE I DIABETES AND TO IDENTIFY PATHWAYS THAT COULD POTENTIALLY LEAD TO THERAPEUTIC INTERVENTIONS FOR PATIENTS WHO DEVELOP THE DISEASE.RESEARCHERS AT THE CRI ARE STUDYING THE USE OF A COMPOUND TO PROTECT THE LUNGS OF NEWBORNS AGAINST DAMAGE FROM EXPOSURE TO EXCESSIVE LEVELS OF OXYGEN. NEWBORN BABIES, PARTICULARLY THOSE BORN PREMATURELY, WHO ARE PUT ON BREATHING MACHINES AND RECEIVE HIGH LEVELS OF OXYGEN, ARE LIKELY TO DEVELOP A CONDITION CALLED BRONCHOPULMONARY DYSPLASIA (BPD). BPD CAN IMPAIR THE PROPER GROWTH OF BLOOD VESSELS AND CELLS IN THE LUNG. BABIES WITH BPD ARE SUSCEPTIBLE TO LUNG INFECTION AND CAN DEVELOP CHRONIC DAMAGE TO LUNG TISSUE. IN ADDITION, RESEARCHERS ARE USING TRANSLATIONAL AND BASIC SCIENCE APPROACHES TO EXAMINE THE PATHOGENESIS OF BPD. 8399770 11618081 CHHS PROVIDES VARIOUS OUTPATIENT HEALTH CARE SERVICES. IN 2012, THERE WERE 22,161 VISITS TO THE ORGANIZATION'S URGENT CARE CLINICS, AND 5,237 OUTPATIENT SURGICAL CASES PERFORMED AT THE ORGANIZATION'S AMBULATORY SURGICAL CENTER, THE SURGICENTER OF GREATER MILWAUKEE, LLC (A DISREGARDED ENTITY FOR FEDERAL TAX PURPOSES). 6049364 8010 194517 OTHER PROGRAMS OF CHHS INCLUDE THE OUTCOMES ANALYSIS SERVICES AT NATIONAL OUTCOMES CENTER ("NOC") AND HEALTH EDUCATION SERVICES AT CHILDREN'S HEALTH EDUCATION CENTER ("CHEC"). NOC PROVIDES PROFESSIONAL SERVICES ON A CONTRACTUAL BASIS FOR DATA MANAGEMENT AND ANALYSIS SERVICES AND REVIEWS OF CLINICAL OUTCOMES PURSUANT TO HEALTH RELATED STUDIES FOCUSED ON ENHANCING MORE EFFECTIVE AND EFFICIENT DELIVERY OF HEALTH CARE.CHEC OFFERS FREE AND INEXPENSIVE HEALTH EDUCATION PROGRAMS AND RESOURCES TO TEACHERS, CHILDREN AND PARENTS. PROGRAMS OFFERED INCLUDE IN-CLASSROOM PROGRAMS ON HEALTHY EATING AND EXERCISE, BULLYING AND TEEN DEPRESSION. IN ADDITION, CHEC ALSO HAS INJURY PREVENTION PROGRAMS WHICH FOCUS ON CAR SEAT AND BIKE HELMET FITTINGS, TO KEEP CHILDREN SAFE AND HEALTHY. ADDITIONALLY, CHEC OFFERS HEALTH-BASED E-LEARNING PROGRAMS THROUGH BLUEKIDS.ORG WHICH HELPS STUDENTS MAKE MORE POSITIVE HEALTH CHOICES. ADDITIONALLY, CHHS PROVIDES SCHOOL-BASED HEALTH CENTERS IN MILWAUKEE SCHOOLS. THESE CENTERS PROVIDE PREVENTIVE CARE, PHYSICALS, IMMUNIZATIONS AND TREATMENT FOR ILLNESSES TO AN AREA THAT PREVIOUSLY DID NOT HAVE PEDIATRICIAN PRACTICES AVAILABLE TO ATTEND TO THE COMMUNITY'S NEEDS. IN 2012, THERE WERE 17,476 SCHOOL-BASED NURSE ENCOUNTERS WHICH INCLUDED 2,206 VISION AND HEARING SCREENINGS. THE SCHOOL-BASED HEALTH CENTERS ALSO EDUCATE CHILDREN AND FAMILIES ABOUT PREVENTIVE CARE. 6049364 8010 194517 97247603 1 1 0 1 0 0 0 0 1 1 1 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 0 1 1 1 0 0 0 1 0 0 0 1 0 0 0 0 1 1 1 1 0 0 1 24 0 685 1 1 1 0 0 0 0 0 0 0 0 0 X 25 17 1 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 1 1 WI X MS SARAH KAFKA 4142661854 9000 W WISCONSIN AVENUE MILWAUKEE WI 53201 WILLIAM J ABRAHAM JR 1.00 1.00 X 0 0 0 MICHAEL W ALTSCHAEFL 1.00 1.00 X 0 0 0 THOMAS M BOLGER 1.00 1.00 X 0 0 0 ELIZABETH BRENNER 1.00 1.00 X 0 0 0 CURT S CULVER 1.00 1.00 X 0 0 0 BETH DALEY-ULLEM 1.00 1.00 X 0 0 0 DAVID J DRURY 1.00 1.00 X X 0 0 0 DAVID H GILBERT 1.00 1.00 X 0 0 0 SUSAN HERMA 1.00 1.00 X 0 0 0 MARK R HOGAN 1.00 1.00 X 0 0 0 PAUL W JONES 1.00 1.00 X 0 0 0 JOSEPH KERSCHNER MD 1.00 1.00 X 0 0 0 KEVIN MANSELL 1.00 1.00 X 0 0 0 LINDA T MELLOWES 1.00 1.00 X 0 0 0 C DAVID MYERS 1.00 1.00 X 0 0 0 ALBERT S ORR III 1.00 1.00 X 0 0 0 MICHAEL T PEPKE 1.00 1.00 X 0 0 0 J JOEL QUADRACCI 1.00 1.00 X 0 0 0 LARRY A RAMBO 1.00 1.00 X 0 0 0 JAY O ROTHMAN 1.00 1.00 X 0 0 0 JOHN E SCHLIFSKE 1.00 1.00 X 0 0 0 PETER M SOMMERHAUSER 1.00 1.00 X X 0 0 0 PAUL W SWEENEY 1.00 1.00 X 0 0 0 OWEN J SULLIVAN 1.00 1.00 X 0 0 0 PHOEBE W WILLIAMS 1.00 1.00 X 0 0 0 MARK C WITT 1.00 1.00 X 0 0 0 MARGARET TROY 40.00 0.00 X X 1263624 0 291068 MARC CADIEUX 40.00 0.00 X 238911 0 22520 CINTHIA S CHRISTENSEN 0.00 40.00 X 0 679101 92874 ROBERT DUNCAN 40.00 0.00 X 400496 0 64825 WELDON GAGE 40.00 0.00 X 362086 0 70172 TRICIA GERAGHTY 40.00 0.00 X 42685 0 8288 VERONICA GUNN 40.00 0.00 X 276741 0 32045 MICHELLE METTNER 40.00 0.00 X 251994 0 35439 MICHAEL NAUMAN 40.00 0.00 X 531496 0 75966 MARGARET NIEMER 40.00 0.00 X 360321 0 66813 SHEILA REYNOLDS 40.00 0.00 X 389028 0 76385 RAMESH SACHDEVA MD 40.00 0.00 X 274351 0 10232 ROBERT SANDERS 40.00 0.00 X 298169 0 57550 MARK SHIP 33.00 7.00 X 285169 33039 37576 DENISE AUGUSTIN 40.00 0.00 X 181276 0 38995 SMRITI KHARE MD 40.00 0.00 X 338148 0 66619 MARK RAKOWSKI 40.00 0.00 X 224542 0 41684 ROY JOHNSON 40.00 0.00 X 216415 0 33889 THOMAS SHANAHAN 40.00 0.00 X 200061 0 39506 STEPHANIE LENZNER 40.00 0.00 X 188064 0 20705 JAMES MILLER 0.00 40.00 X 0 524732 70286 MARTIN VOGEL 0.00 40.00 X 0 229144 38169 THOMAS DUNIGAN MD 0.00 40.00 X 0 220656 18709 TIMOTHY L BIRKENSTOCK 0.00 0.00 X 232256 0 1866 6555833 1686672 1312181 76 1 1 0 MEDICAL COLLEGE OF WISCONSIN 8701 WATERTOWN PLANK RD MILWAUKEE WI 53226 RESEARCH, EDUCATION, MEDICAL LEADERSHIP 10192102 DELOITTE CONSULTING LLP PO BOX 7247-6447 PHILADELPHIA PA 191706447 CONSULTING AND MANAGEMENT 2824322 EPIC SYSTEMS CORPORATION PO BOX 88314 MILWAUKEE WI 532880314 SOFTWARE LICENSING AND MAINTENANCE 2187064 MICROSOFT LICENSING GP 1401 ELM ST 5TH FLR DEPT 842467 DALLAS TX 75202 SOFTWARE LICENSING AND MAINTENANCE 1475641 KFORCE INC PO BOX 277997 ATLANTA GA 303847997 IT CONTRACTORS AND CONSULTING 1307146 56 13472225 335834 97392 13905451 OPER SUPPORT SERVICES 541900 80962003 79547569 251155 1163279 OUTPATIENT HEALTH CARE SERVICES 621400 11612999 11612999 RESEARCH ADMINISTRATION FEE 900099 933461 933461 DATA MANAGEMENT & ANALYSIS 541900 91176 91176 CHEC FEES 900099 57791 57791 93657430 409283 409283 71115 0 71115 71115 71115 114947 8968 0 232145 114947 -223177 -108230 -108230 EDUCATIONAL SERVICES 611430 280478 280478 652719 652719 933197 108868246 93176193 251155 1535447 X 266988 266988 39703 39703 7410308 6363182 1047126 31422075 27364156 4057919 2384001 2083911 300090 4928369 4276519 651850 2887269 2501349 385920 52171 200 51971 293834 260043 33791 288132 254997 33135 446480 395135 51345 18587909 16232007 2355902 351780 342356 9424 1123637 973387 150250 11442898 10110168 1332730 3544097 2516961 1027136 930249 840952 89297 15356 11439 3917 4295284 3661063 634221 1941931 1588262 353669 PURCHASED SERVICES 6286298 5613251 673047 RESEARCH 5778412 5778412 MEDICAL SUPPLIES 1788117 1784700 3417 5063873 3988462 1075411 111569171 97247603 14321568 0 1481883 450989 366562 385546 1606901 1742884 28000 56000 69500 77500 439776 545480 5218454 4904570 71528273 23234144 51303435 48294129 6590694 7806050 5737005 6572713 72842210 70835861 13548825 14724661 190604 281790 5226689 11313821 18966118 26320272 X 51862520 41606725 1776104 2657644 237468 251220 53876092 44515589 72842210 70835861 X -2700925 145129 -6804707 X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 16310 530968 547278 96700325 97247603 1000000 250000 0 0 1000000 1000000 1000000 1000000 4000000 6000000 374061 282225 296103 547278 1499667 250000 250000 250000 250000 1000000 1500000 16310 16310 1 217666 587042 687057 117651 0 2013572 1748443 27616 879862 905 2908864 1914287 843860 1271 745000 846 2013572 1614564 1249343 30138 978936 822 1914287 1614564 1614564 0.00000 0.08600 0.91400 0 1 1 1457978 1457978 50005077 11762426 38242651 291402 172452 118950 19413141 11229488 8183653 360675 69778 290897 48294129 DUE FROM AFFILIATES 662175 DEFERRED COMPENSATION PLAN ASSETS 1874050 BENEFICIAL INTEREST IN NET ASSETS OF CHILDREN'S HOSPITAL OF WISCONSIN FOUND. 2908865 INVESTMENT IN VIRTUAL PICU SYSTEMS, LLC 430342 INVESTMENT IN NORTH SHORE SURGERY CENTER 663713 INVESTMENT IN MED-HEALTH FINANCIAL SERVICES, INC. 9000 ORGANIZATIONAL COSTS 24568 6572713 DEFERRED COMPENSATION PLAN LIABILITY 1874051 RETIREMENT PLAN LIABILITY 3059090 DUE TO AFFILIATES 6380680 11313821 X PART IV, LINE 1B: CERTAIN EMPLOYEES OF THE ORGANIZATION HAVE SIGNING AUTHORITY FOR THE CHECKING ACCOUNT OF THE CENTER FOR INTERNATIONAL HEALTH, INC. ("CIH"). ADDITIONALLY, CERTAIN EMPLOYEES OF THE ORGANIZATION HAVE SIGNING AUTHORITY FOR THE CHECKING ACCOUNT OF THE WELFARE AUXILIARY OF CHILDREN'S HOSPITAL OF WISCONSIN, INC. ("WA"). THE ORGANIZATION ALSO PROVIDES ACCOUNTING FUNCTIONS FOR WA. THE AMOUNTS IN PART IV ARE THE COMBINED TOTALS FOR THESE TWO INDIVIDUAL ACCOUNTS. DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: CHILDREN'S HOSPITAL OF WISCONSIN FOUNDATION, INC., A RELATED ENTITY, HOLDS ENDOWMENT FUNDS ON BEHALF OF CHHS. INTENDED USES OF THE ENDOWMENT FUNDS INCLUDE VARIOUS HEALTH-EDUCATION RELATED PROJECTS. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X, LINE 2: FOOTNOTE 2 INCOME TAXES: CHHS EVALUATES ITS UNCERTAIN TAX POSITIONS ON AN ANNUAL BASIS, AND THERE HAVE BEEN NO UNCERTAIN TAX POSITIONS RECORDED FOR THE YEARS ENDED DECEMBER 31, 2012 AND 2011. 1 FAMILY & CHILDRENS CENTER 1707 MAIN STREET LA CROSSE WI 54601 390821863 501(C)(3) 49636 ANNUAL GRANT FOR A CHILD ABUSE PREVENTION PROGRAM FAMILY RESOURCE CENTER OF SHEBOYGAN 1209A EASTERN AVENUE PLYMOUTH WI 53073 391857835 501(C)(3) 68906 ANNUAL GRANT FOR A CHILD ABUSE PREVENTION PROGRAM FAMILY RESOURCE CENTER ST CROIX VALLEY INC 857 MAIN STREET PO BOX 2087 BALDWIN WI 54002 391943404 501(C)(3) 18905 ANNUAL GRANT FOR A CHILD ABUSE PREVENTION PROGRAM FAMILY SERVICES OF NORTHEAST WISCONSIN PO BOX 22308 GREEN BAY WI 54305 390827320 501(C)(3) 59000 ANNUAL GRANT FOR A CHILD ABUSE PREVENTION PROGRAM SAFE BABIES HEALTHY FAMILIES 137 WISCONSIN AVENUE WAUKESHA WI 53188 391552886 501(C)(3) 54000 ANNUAL GRANT FOR A CHILD ABUSE PREVENTION PROGRAM SEXUAL ASSAULT CRISIS CENTER 35 PARK PLACE SUITE 100 APPLETON WI 54914 391309331 501(C)(3) 14942 ANNUAL GRANT FOR A CHILD ABUSE PREVENTION PROGRAM 6 0 PROJECT MANAGEMENT FOR HOME VISITATION OUTCOMES PROJECT 2 31693 N/A SCHOLARSHIPS 11 8010 N/A PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: MONITORING PROCEDURES - THE CHILD ABUSE PREVENTION FUND IS COMMITTED TO ENSURING A SAFE ENVIRONMENT FOR CHILDREN THROUGH FINANCIAL SUPPORT OF PRIMARY PREVENTION ACTIVITIES THROUGHOUT WISCONSIN, AS WELL AS EDUCATING PROFESSIONALS AND THE PUBLIC ABOUT THE ROLE OF PREVENTION IN ELIMINATING CHILD ABUSE. THE CHILD ABUSE PREVENTION FUND IS A SPECIAL FUNDRAISING INITIATIVE OF CHHS. THE FUND'S FOCUS IS ON OUTCOMES OR RESULTS FOR FAMILIES, CHILDREN AND COMMUNITIES. AGENCIES THAT RECEIVE FUNDING MEET CRITERIA FOR EFFECTIVENESS AND ACCOUNTABILITY. EACH ORGANIZATION FUNDED IS EXPECTED TO DEMONSTRATE POSITIVE OUTCOMES THROUGH SIX-MONTH AND ANNUAL PROGRESS REPORTS. IN MANY CASES, CHHS STAFF OVERSEE AND PLAY A ROLE IN HELPING ORGANIZATIONS DEMONSTRATE POSITIVE OUTCOMES. CHHS STAFF ALSO PERFORM SITE VISITS. SCHEDULE I, PART III: SCHOLARSHIPS AWARDED TO RECIPIENTS ARE PAID DIRECTLY TO THE EDUCATIONAL INSTITUTIONS. X X X X X X 1 1 0 0 0 0 0 1 0 MARGARET TROY 759976 0 376671 0 126977 0 259150 0 31918 0 1554692 0 50833 0 MARC CADIEUX 189232 0 34000 0 15679 0 15814 0 6706 0 261431 0 0 0 CINTHIA S CHRISTENSEN 0 424640 0 152683 0 101778 0 65020 0 27854 0 771975 0 33569 ROBERT DUNCAN 267931 0 82190 0 50375 0 37420 0 27405 0 465321 0 20329 0 WELDON GAGE 336629 0 25000 0 457 0 51785 0 18387 0 432258 0 0 0 VERONICA GUNN 221257 0 55000 0 484 0 8500 0 23545 0 308786 0 0 0 MICHELLE METTNER 198189 0 41352 0 12453 0 13500 0 21939 0 287433 0 0 0 MICHAEL NAUMAN 337354 0 105020 0 89122 0 49830 0 26136 0 607462 0 25492 0 MARGARET NIEMER 236476 0 72477 0 51368 0 44670 0 22143 0 427134 0 19026 0 SHEILA REYNOLDS 259682 0 78354 0 50992 0 48690 0 27695 0 465413 0 18023 0 RAMESH SACHDEVA MD 168842 0 84377 0 21132 0 0 0 10232 0 284583 0 20257 0 ROBERT SANDERS 194515 0 59901 0 43753 0 35130 0 22420 0 355719 0 13582 0 MARK SHIP 186798 32876 77404 0 20967 163 16000 0 18028 3548 319197 36587 18414 0 DENISE AUGUSTIN 154993 0 18477 0 7806 0 15013 0 23982 0 220271 0 0 0 SMRITI KHARE MD 280997 0 54931 0 2220 0 54471 0 12148 0 404767 0 0 0 MARK RAKOWSKI 185591 0 29046 0 9905 0 17291 0 24393 0 266226 0 0 0 ROY JOHNSON 183952 0 10000 0 22463 0 17173 0 16716 0 250304 0 0 0 THOMAS SHANAHAN 176978 0 1000 0 22083 0 18698 0 20808 0 239567 0 0 0 STEPHANIE LENZNER 166558 0 10000 0 11506 0 5709 0 14996 0 208769 0 0 0 JAMES MILLER 0 315444 0 84050 0 125238 0 46300 0 23986 0 595018 0 26337 MARTIN VOGEL 0 200958 0 13927 0 14259 0 17224 0 20945 0 267313 0 13614 THOMAS DUNIGAN MD 0 200279 0 0 0 20377 0 8400 0 10309 0 239365 0 20377 TIMOTHY L BIRKENSTOCK 0 0 0 0 232256 0 0 0 1866 0 234122 0 0 0 PART I, LINES 4A-B UNTIL MARCH 2011, TIMOTHY BIRKENSTOCK SERVED AS TREASURER & CFO OF CHHS. CHHS PAID CERTAIN AMOUNTS AS SEVERANCE TO MR. BIRKENSTOCK PURSUANT TO A WRITTEN AGREEMENT. CASH PAYMENTS MADE TO MR. BIRKENSTOCK IN 2012 TOTALED $234,122. UNTIL NOVEMBER 2012, JAMES MILLER SERVED AS PRESIDENT OF CHILDREN'S HOSPITAL OF WISCONSIN FOUNDATION, INC. THE FOUNDATION PAID CERTAIN AMOUNTS AS SEVERANCE TO MR. MILLER PURSUANT TO A WRITTEN AGREEMENT. CASH PAYMENTS MADE TO MR. MILLER IN 2012 TOTALED $75,692. PART I, LINE 4B: IN 2012, THERE WAS A CHHS FLEXIBLE BENEFIT PLAN IN PLACE WHICH WAS A SUPPLEMENTAL NONQUALIFIED RETIREMENT PLAN (457(F)). THE ORGANIZATION CONTRIBUTES 7% OF EACH PARTICIPATING EXECUTIVE'S SALARY. THE AMOUNTS OF EMPLOYER CONTRIBUTIONS TO THIS PLAN FOR PARTICIPATING EXECUTIVES IN 2012 WERE AS FOLLOWS: M. TROY, $54,180; C. CHRISTENSEN, $44,020; R. DUNCAN, $28,920; W. GAGE, $43,852; T. GERAGHTY, $8,288; M. NAUMAN, $36,330; M. NEIMER, $26,170; S. REYNOLDS, $30,190; R. SANDERS, $21,630; AND S. KHARE, M.D., $35,971. AFTER A VESTING PERIOD, PARTICIPANTS MAY ELECT TO WITHDRAW AMOUNTS PREVIOUSLY CONTRIBUTED AND REPORTED. AMOUNTS WITHDRAWN BY PARTICIPANTS IN 2012 WERE: M. TROY, $50,833; C. CHRISTENSEN, $33,569; R. DUNCAN, $20,329; J. KERSTEN, $13,331; M. NAUMAN, $25,492; M. NEIMER, $19,026; S. REYNOLDS, $18,023; R. SACHDEVA, M.D., $20,257; R. SANDERS, $13,582; M. SHIP, $18,414; T. DUNIGAN, M.D., $20,377; J. MILLER, $26,337; AND M. VOGEL, $13,614. CHHS HAS REPORTED ADDITIONAL AMOUNTS SET ASIDE FOR A NONQUALIFIED RETIREMENT PLAN ON BEHALF OF ITS PRESIDENT AND CEO. THE AMOUNT SET ASIDE IN 2012 WAS $191,470. PART I, LINE 7 CERTAIN EXECUTIVES PARTICIPATE IN AN ANNUAL BONUS PLAN THAT PROVIDES COMPENSATION BASED ON ACHIEVING SPECIFIC PRE-DEFINED GOALS. BONUS CRITERIA ARE COMPRISED OF BOTH SYSTEM LEVEL AND EXECUTIVE SPECIFIC COMPONENTS. SUCH CRITERIA PERTAIN TO MATTERS WITHIN THE EXECUTIVE'S AREA OF RESPONSIBILITY, AS WELL AS ACHIEVEMENT OF OVERALL STRATEGIC OBJECTIVES OF THE ORGANIZATION AND ITS AFFILIATES IN ALIGNMENT WITH SYSTEM-WIDE BALANCED MEASURES. SUPPLEMENTAL INFORMATION PART III FORM 990, PART VII, COLUMN E AND SCHEDULE J, PART II: SALARIES PAID BY RELATED ORGANIZATIONS: 1. CINTHIA CHRISTENSEN, PRESIDENT OF CHW AND EXECUTIVE VICE PRESIDENT OF CHHS AND MARK SHIP, VP OF REVENUE CYCLE - REPORTABLE COMPENSATION FROM RELATED ORGANIZATIONS AND OTHER COMPENSATION LISTED IN PART VII AND SCHEDULE J WERE PAID FOR SERVICES PROVIDED (40 HOURS PER WEEK) TO CHW AND AFFILIATES. THESE AMOUNTS WERE PAID BY CHW. 2. JAMES MILLER, PRESIDENT AND CEO OF CHILDREN'S HOSPITAL OF WISCONSIN FOUNDATION, INC. ("CHWF") (JAN NOV 2012) - REPORTABLE COMPENSATION FROM RELATED ORGANIZATIONS AND OTHER COMPENSATION LISTED IN PART VII AND SCHEDULE J WERE PAID FOR SERVICES PROVIDED (40 HOURS PER WEEK) TO CHWF. THESE AMOUNTS WERE PAID BY CHWF. PRIOR TO 2011, MR. MILLER'S COMPENSATION FOR SERVICES AS PRESIDENT AND CEO OF CHWF WAS PAID BY CHHS AND ALLOCATED TO CHWF. AS A RESULT, MR. MILLER WAS REPORTED AS A HIGHLY COMPENSATED EMPLOYEE OF CHHS IN PREVIOUS YEARS. 3. MARTIN VOGEL, VICE PRESIDENT OF PRINCIPAL GIFTS OF CHWF - REPORTABLE COMPENSATION FROM RELATED ORGANIZATIONS AND OTHER COMPENSATION LISTED IN PART VII AND SCHEDULE J WERE PAID FOR SERVICES PROVIDED (40 HOURS PER WEEK) TO CHWF. THESE AMOUNTS WERE PAID BY CHWF. PRIOR TO 2011, MR. VOGEL'S COMPENSATION FOR SERVICES AS VICE PRESIDENT OF PRINCIPAL GIFTS OF CHWF WAS PAID BY CHHS AND ALLOCATED TO CHWF. AS A RESULT, MR. VOGEL WAS REPORTED AS A HIGHLY COMPENSATED EMPLOYEE OF CHHS IN PREVIOUS YEARS. 4. THOMAS DUNIGAN, M.D., PEDIATRIC PHYSICIAN, FORMER PRESIDENT OF CMG AND PRESIDENT AND TREASURER OF CHILDREN'S PHYSICIAN GROUP, P.C. ("CPG") - REPORTABLE COMPENSATION FROM RELATED ORGANIZATIONS AND OTHER COMPENSATION LISTED IN PART VII AND SCHEDULE J WERE PAID FOR SERVICES PROVIDED TO CMG (40 HOURS PER WEEK) AND CPG (1 HOUR PER WEEK). THESE AMOUNTS WERE PAID BY CMG. M CADIEUX OFFICER EDUCATION X 56000 56000 0 0 1 56000 HUMANA DIRECTOR (L. RAMBO) 171365 MR. RAMBO WAS THE SENIOR EXECUTIVE FOR STRATEGIC PARTNERSHIPS OF HUMANA, INC. THE ORGANIZATION PAID HUMANA FOR TPA SERVICES FOR ITS SELF-INSURED HEALTH PLAN IN THE AMOUNT OF $171,365. 0 HUMANA DIRECTOR (L. RAMBO) 830281 MR. RAMBO WAS THE SENIOR EXECUTIVE FOR STRATEGIC PARTNERSHIPS OF HUMANA, INC. THE ORGANIZATION RECEIVED APPROXIMATELY $830,281 FROM HUMANA FOR HEALTH CARE SERVICES PROVIDED TO HUMANA ENROLLEES. 0 FOLEY AND LARDNER LLP DIRECTORS (J. ROTHMAN & W. ABRAHAM, JR.) 187596 MR. ROTHMAN IS THE CHIEF EXECUTIVE OFFICER AT FOLEY AND LARDNER, LLP AND MR. ABRAHAM IS A KEY EMPLOYEE. THE ORGANIZATION PAID FOLEY AND LARDNER $187,596 FOR LEGAL SERVICES. 0 JOHNSON INSURANCE DIRECTOR (T. BOLGER) 204094 MR. BOLGER IS THE CHIEF EXECUTIVE OFFICER OF JOHNSON BANK AND ITS PARENT COMPANY JOHNSON FINANCIAL GROUP. THE ORGANIZATION PAID JOHNSON INSURANCE, A SUBSIDIARY OF JOHNSON FINANCIAL GROUP, $204,094 FOR BROKERAGE SERVICES. 0 FORM 990, PART VI, SECTION A, LINE 2 BUSINESS RELATIONSHIPS EXIST BETWEEN THE FOLLOWING BOARD MEMBERS OR OFFICERS: ORR AND PEPKE, DRURY AND SCHLIFSKE, DRURY AND SOMMERHAUSER, DRURY AND BRENNER, DRURY AND SULLIVAN, BRENNER AND SULLIVAN, ROTHMAN AND ABRAHAM, SCHLIFSKE AND SOMMERHAUSER, SCHLIFSKE AND MANSELL, PEPKE AND ALTSCHAEFL, MANSELL AND SOMMERHAUSER, ABRAHAM AND QUADRACCI, HERMA AND SOMMERHAUSER, WITT AND SOMMERHAUSER, KERSCHNER AND BRENNER, KERSCHNER AND CULVER, KERSCHNER AND MELLOWES, KERSCHNER AND SULLIVAN, BRENNER AND SACHDEVA, CULVER AND SACHDEVA, KERSCHNER AND SACHDEVA, MELLOWES AND SACHDEVA, AND SULLIVAN AND SACHDEVA. FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 WAS REVIEWED BY THE AUDIT AND COMPLIANCE COMMITTEE OF THE CHHS BOARD OF DIRECTORS, AND PRIOR TO FILING, A COPY WAS PROVIDED TO ALL DIRECTORS OF CHHS. FORM 990, PART VI, SECTION B, LINE 12C ANNUALLY, ALL MEMBERS OF THE BOARD OF DIRECTORS, OFFICERS AND KEY EMPLOYEES ARE REQUESTED TO SUBMIT A CONFLICT OF INTEREST DISCLOSURE TO THE CORPORATE VICE PRESIDENT AND GENERAL COUNSEL. A LIST OF POTENTIAL CONFLICTS IS PREPARED AND IS AVAILABLE AT EACH BOARD AND COMMITTEE MEETING. THE COMPLIANCE DEPARTMENT MONITORS AND PERIODICALLY REVIEWS TRANSACTIONS BETWEEN THE ORGANIZATION AND BOARD MEMBERS OR ENTITIES WITH WHICH THEY ARE AFFILIATED. FORM 990, PART VI, SECTION B, LINE 15 THE COMPENSATION OF THE ORGANIZATION'S CEO AND SENIOR OFFICERS, WITH THE EXCEPTION OF THE INTERIM TREASURER / CFO, THE CORPORATE VP MARKETING & PR, THE VP POPULATION HLTH MGMT, THE VP GOVERNMENT RELATIONS, THE VP REVENUE CYCLE, AND THE SURGICENTER EXECUTIVE DIRECTOR, WAS REVIEWED AND APPROVED BY THE INDEPENDENT COMPENSATION COMMITTEE OF THE ORGANIZATION'S BOARD OF DIRECTORS. WITH THE ASSISTANCE OF AN INDEPENDENT COMPENSATION CONSULTANT AND INFORMATION FROM A VARIETY OF EXTERNAL SOURCES (AS INDICATED ON SCHEDULE J), THE COMMITTEE CONFIRMED THAT TOTAL COMPENSATION AMOUNTS TO BE PAID WERE REASONABLE AND COMPARABLE TO AMOUNTS PAID BY SIMILARLY SITUATED ORGANIZATIONS. THE PROCESS FOLLOWED BY THE COMMITTEE, INCLUDING THE DATA RELIED UPON AND THE COMMITTEE'S DECISIONS, WAS THOROUGHLY AND TIMELY DOCUMENTED. COMPENSATION OF OTHER OFFICERS AND THE KEY EMPLOYEES EXCEPTED ABOVE WAS SET BY SUPERVISORY EXECUTIVES IN CONSULTATION WITH CHHS HUMAN RESOURCES LEADERS. THE PROCESS INCLUDED REVIEW BY INDEPENDENT PERSONS WHO, USING A VARIETY OF EXTERNAL SOURCES (AS INDICATED ON SCHEDULE J), CONFIRMED THAT TOTAL COMPENSATION AMOUNTS TO BE PAID WERE REASONABLE AND COMPARABLE TO AMOUNTS PAID BY SIMILARLY SITUATED ORGANIZATIONS. THE PROCESS AND DATA RELIED ON WERE THOROUGHLY AND TIMELY DOCUMENTED. FORM 990, PART VI, SECTION C, LINE 19 THE GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL INFORMATION OF CHHS ARE AVAILABLE TO THE PUBLIC UPON REQUEST TO THE CHHS PUBLIC RELATIONS DEPARTMENT. OTHER FEES FORM 990, PART IX, LINE 11G CONSULTING FEES: PROGRAM SERVICE EXPENSES 13,579,718. MANAGEMENT AND GENERAL EXPENSES 1,764,596. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 15,344,314. RESEARCH ADMINISTRATION FEES: PROGRAM SERVICE EXPENSES 1,333,349. MANAGEMENT AND GENERAL EXPENSES 291,588. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,624,937. PROFESSIONAL FEES: PROGRAM SERVICE EXPENSES 89,827. MANAGEMENT AND GENERAL EXPENSES 11,673. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 101,500. OTHER FEES: PROGRAM SERVICE EXPENSES 1,229,113. MANAGEMENT AND GENERAL EXPENSES 288,045. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,517,158. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 9: NET ASSET/CASH TRANSFER TO CHILDREN'S COMMUNITY HEALTH PLAN, INC. -7,700,000. INCREASE IN BENEF. INTEREST IN NET ASSETS OF CHILDREN'S HOSPITAL FOUNDATION 895,293. FORM 990, PART V, LINE 1A: THE ORGANIZATION DID NOT FILE ANY 1099 FORMS DURING THE TAXABLE YEAR. ALTHOUGH THE ORGANIZATION DID RETAIN INDEPENDENT CONTRACTORS, THE COMPENSATION AMOUNTS OWED TO SUCH CONTRACTORS WERE PROCESSED AND PAID BY A RELATED ENTITY, CHW, WITH APPROPRIATE INTERCOMPANY ARRANGEMENTS BETWEEN THE ORGANIZATION AND CHW. THE 1099 FORMS FOR SUCH PAYMENTS WERE ISSUED BY CHW, AS THE ENTITY THAT PROCESSED AND MADE THE PAYMENTS TO THE INDEPENDENT CONTRACTORS. THE 1099 FORMS LISTED IN PART V ARE THE FORMS FILED BY THE ORGANIZATION'S DISREGARDED ENTITY. SURGICENTER OF GREATER MILWAUKEE LLC 9000 W WISCONSIN AVENUE PO BOX 1997 MILWAUKEE WI 53201 391682308 AMBULATORY SURGERY CENTER/MEDICAL OFFICE BUILDING WI 10279408 22826279 N/A CHILDREN'S HOSPITAL OF WISCONSIN INC 9000 W WISCONSIN AVE PO BOX 1997 MILWAUKEE WI 53201 390812532 PEDIATRIC HOSPITAL WI 501(C)(3) LINE 3 N/A 1 CHILDREN'S HOSPITAL OF WISCONSIN FOUNDATION INC 9000 W WISCONSIN AVE PO BOX 1997 MILWAUKEE WI 53201 391500075 FUND DEVELOPMENT WI 501(C)(3) LINE 7 N/A 1 CHILDREN'S MEDICAL GROUP INC 9000 W WISCONSIN AVE PO BOX 1997 MILWAUKEE WI 53201 391789197 PEDIATRIC PHYSICIAN SERVICES WI 501(C)(3) LINE 3 N/A 1 CHILDREN'S PHYSICIAN GROUP PC 9000 W WISCONSIN AVE PO BOX 1997 MILWAUKEE WI 53201 364303682 PEDIATRIC PHYSICIAN SERVICES IL 501(C)(3) LINE 9 N/A 1 CHILDREN'S SERVICE SOCIETY OF WISCONSIN 9000 W WISCONSIN AVE PO BOX 1997 MILWAUKEE WI 53201 390806380 CHILD WELFARE SERVICES WI 501(C)(3) LINE 7 N/A 1 CHILDREN'S COMMUNITY HEALTH PLAN INC 9000 W WISCONSIN AVE PO BOX 1997 MILWAUKEE WI 53201 271494977 WISCONSIN MEDICAID HMO WI 501(C)(3) LINE 9 N/A 1 CHILDREN'S SPECIALTY GROUP INC 999 N 92ND ST SUITE C740 MILWAUKEE WI 53226 391990012 PEDIATRIC PHYSICIAN SERVICES WI 501(C)(3) LINE 11 N/A 0 VIRTUAL PICU SYSTEMS LLC 401 WYTHE STREET SUITE 101 ALEXANDRIA VA 22314 201414664 QUALITY/OUTCOMES ANALYSIS DE N/A RELATED 118490 608765 0 0 0.33330 MED-HEALTH FINANCIAL SERVICES INC 9000 W WISCONSIN AVE PO BOX 1997 MILWAUKEE WI 53201 391547907 COLLECTION SERVICES WI N/A C 3804033 3678563 1.00000 1 1 0 1 0 0 0 0 0 0 1 1 1 1 0 0 1 1 1 1 CHILDREN'S HOSPITAL OF WISCONSIN INC - RENT (LINE 1A (IV) ABOVE A 558388 CASH PAID/RECEIVED CHILDREN'S MEDICAL GROUP INC - RENT (LINE 1A (IV) ABOVE) A 238508 CASH PAID/RECEIVED CHILDREN'S SERVICE SOCIETY OF WISCONSIN - RENT (LINE 1A (IV) ABOVE) A 1152 CASH PAID/RECEIVED CHILDREN'S HOSPITAL OF WISCONSIN INC C 9136944 CASH PAID/RECEIVED CHILDREN'S HOSPITAL OF WISCONSIN FOUNDATION INC C 4335281 CASH PAID/RECEIVED CHILDREN'S HOSPITAL OF WISCONSIN INC K 66690 CASH PAID/RECEIVED CHILDREN'S HOSPITAL OF WISCONSIN INC L 70739388 CASH PAID/RECEIVED CHILDREN'S SERVICE SOCIETY OF WISCONSIN L 2094798 CASH PAID/RECEIVED CHILDREN'S MEDICAL GROUP INC L 3505826 CASH PAID/RECEIVED CHILDREN'S COMMUNITY HEALTH PLAN INC L 1009174 CASH PAID/RECEIVED CHILDREN'S HOSPITAL OF WISCONSIN FOUNDATION INC L 746081 CASH PAID/RECEIVED CHILDREN'S PHYSICIAN GROUP PC L 182040 CASH PAID/RECEIVED MED-HEALTH FINANCIAL SERVICES INC L 594832 CASH PAID/RECEIVED CHILDREN'S COMMUNITY HEALTH PLAN INC - PATIENT REIMBURSEMENT L 481370 CASH PAID/RECEIVED CHILDREN'S HOSPITAL OF WISCONSIN INC M 70866 CASH PAID/RECEIVED CHILDREN'S SERVICE SOCIETY OF WISCONSIN M 170909 CASH PAID/RECEIVED MED-HEALTH FINANCIAL SERVICES INC M 58482 CASH PAID/RECEIVED CHILDREN'S HOSPITAL OF WISCONSIN INC P 239681 CASH PAID/RECEIVED CHILDREN'S COMMUNITY HEALTH PLAN INC R 7700000 CASH PAID/RECEIVED