EDGERTON HOSPITAL AND HEALTH SERVICES INC: Form 990, tax year 2012
View the entire original 990 at ProPublica ↗
- Organization
- EDGERTON HOSPITAL AND HEALTH SERVICES INC (EIN 39-0819992)
- Tax period
- 2012-01-01 to 2012-12-31
- Filed
- 2013-11-15
- IRS object ID
- 201343199349302214
- Schema version
- 2012v2.1
- 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 D
- Schedule H
- Schedule I
- Schedule J
- Schedule L
- Schedule O
- Schedule R
Return header ReturnHeader
| Field | Value | IRS element (for citing) |
|---|---|---|
| Timestamp | 2013-11-15T08:51:27-06:00 | Timestamp |
| Tax Period End Date | 2012-12-31 | TaxPeriodEndDate |
Preparer Firm PreparerFirm
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 450250958 | EIN |
Preparer Firm Business Name PreparerFirmBusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Eide Bailly LLP | BusinessNameLine1 |
Preparer Firm US Address PreparerFirmUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 800 Nicollet Mall Ste 1300 | AddressLine1 |
| City | Minneapolis | City |
| State | MN | State |
| ZIP Code | 554027033 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return Type | 990 | ReturnType |
| Tax Period Begin Date | 2012-01-01 | TaxPeriodBeginDate |
Filer Filer
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 390819992 | EIN |
Name Name
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Edgerton Hospital and Health Services Inc | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name Control | EDGE | NameControl |
| Phone | 6088843441 | Phone |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 11101 North Sherman Road | AddressLine1 |
| City | Edgerton | City |
| State | WI | State |
| ZIP Code | 53534 | ZIPCode |
Officer Officer
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name | Charles Roeder | Name |
| Title | CFO | Title |
| Phone | 6088843441 | Phone |
| Date Signed | 2013-11-13 | DateSigned |
| Authorize Third Party | 1 | AuthorizeThirdParty |
Preparer Preparer
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name | Kim Hunwardsen CPA | Name |
| PTIN | P00484560 | PTIN |
| Phone | 6122536500 | Phone |
| Date Prepared | 2013-11-13 | DatePrepared |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tax Year | 2012 | TaxYear |
| Build TS | 2016-02-25 16:41:14Z | BuildTS |
Form 990 IRS990
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name Of Principal Officer Person | James Pernau | NameOfPrincipalOfficerPerson |
Address Principal Officer US AddressPrincipalOfficerUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 11101 North Sherman Road | AddressLine1 |
| City | Edgerton | City |
| State | WI | State |
| ZIP Code | 53534 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Receipts | 19264814 | GrossReceipts |
| Group Return For Affiliates | 0 | GroupReturnForAffiliates |
| Organization501c3 | X | Organization501c3 |
| Web Site | www.edgertonhospital.com | WebSite |
| Type Of Organization Corporation | X | TypeOfOrganizationCorporation |
| Year Formation | 1968 | YearFormation |
| State Legal Domicile | WI | StateLegalDomicile |
| Activity Or Mission Description | Serve area communities with exceptional quality and innovative health services | ActivityOrMissionDescription |
| Nbr Voting Members Governing Body | 13 | NbrVotingMembersGoverningBody |
| Nbr Independent Voting Members | 12 | NbrIndependentVotingMembers |
| Total Nbr Employees | 215 | TotalNbrEmployees |
| Total Nbr Volunteers | 96 | TotalNbrVolunteers |
| Total Gross UBI | 0 | TotalGrossUBI |
| Net Unrelated Business Txbl Income | 0 | NetUnrelatedBusinessTxblIncome |
| Contributions Grants Prior Year | 163791 | ContributionsGrantsPriorYear |
| Contributions Grants Current Year | 492253 | ContributionsGrantsCurrentYear |
| Program Service Revenue Prior Year | 15545480 | ProgramServiceRevenuePriorYear |
| Program Service Revenue CY | 18729089 | ProgramServiceRevenueCY |
| Investment Income Prior Year | -251573 | InvestmentIncomePriorYear |
| Investment Income Current Year | 13397 | InvestmentIncomeCurrentYear |
| Other Revenue Prior Year | 23322 | OtherRevenuePriorYear |
| Other Revenue Current Year | -20058 | OtherRevenueCurrentYear |
| Total Revenue Prior Year | 15481020 | TotalRevenuePriorYear |
| Total Revenue Current Year | 19214681 | TotalRevenueCurrentYear |
| Grants And Similar Amnts Prior Year | 586695 | GrantsAndSimilarAmntsPriorYear |
| Grants And Similar Amnts CY | 174587 | GrantsAndSimilarAmntsCY |
| Benefits Paid To Members Prior Year | 0 | BenefitsPaidToMembersPriorYear |
| Benefits Paid To Members CY | 0 | BenefitsPaidToMembersCY |
| Salaries Etc Prior Year | 8402677 | SalariesEtcPriorYear |
| Salaries Etc Current Year | 9607677 | 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 | 8345601 | OtherExpensePriorYear |
| Other Expenses Current Year | 10629668 | OtherExpensesCurrentYear |
| Total Expenses Prior Year | 17334973 | TotalExpensesPriorYear |
| Total Expenses Current Year | 20411932 | TotalExpensesCurrentYear |
| Revenues Less Expenses Prior Year | -1853953 | RevenuesLessExpensesPriorYear |
| Revenues Less Expenses CY | -1197251 | RevenuesLessExpensesCY |
| Total Assets BOY | 32790644 | TotalAssetsBOY |
| Total Assets EOY | 32899272 | TotalAssetsEOY |
| Total Liabilities BOY | 26553319 | TotalLiabilitiesBOY |
| Total Liabilities EOY | 27855769 | TotalLiabilitiesEOY |
| Net Assets Or Fund Balances BOY | 6237325 | NetAssetsOrFundBalancesBOY |
| Net Assets Or Fund Balances EOY | 5043503 | NetAssetsOrFundBalancesEOY |
| Info In Schedule O Part III | X | InfoInScheduleOPartIII |
| Mission Description | To provide exceptional healthcare for our communities | MissionDescription |
| Significant New Program Services | 0 | SignificantNewProgramServices |
| Significant Change | 0 | SignificantChange |
| Expense | 16766874 | Expense |
| Grants | 174587 | Grants |
| Revenue | 18729089 | Revenue |
| Description | Edgerton Hospital and Health Services, Inc. is an 18-bed acute care hospital located in Edgerton, Wisconsin.There were 432 total adult admissions in 2012. Total patient days were 3,148 with an average daily census of 8.6 patients. Emergency room and urgent care visits for 2012 were 6,072.Preventive Care Services:Edgerton Hospital and Health Services (Edgerton Hospital) provides several types of free health screenings during the year. These include: blood pressure, dietary counseling and education, diabetes, and cancer screenings.Emergency Room:Edgerton Hospital's Emergency Room is fully staffed 24 hours a day, seven days a week. Edgerton Hospital is affiliated with "Life Flight," a helicopter service that delivers patients to area tertiary care centers. Edgerton Hospital's Urgent Care Center provides another level of walk-in care when appropriate.Community Outreach:Edgerton Hospital works closely with the community to provide hospital and hospital-related services responsive to the specific needs of Edgerton and surrounding farming communities. Edgerton Hospital partners with other city services (such as the police and fire departments) to provide emergency equipment and training necessary to enhance area emergency services. Edgerton Hospital also participates in cooperative emergency response training (with the county and other community services) in preparation for local or area disasters. Community Education:Events are held at the Hospital or conducted by Hospital staff several times a year. In addition, Edgerton Hospital provides targeted outreach to the transient recreational communities within the service area. Charity Care:The Hospital provides care to patients who meet certain criteria under its charity care policy without charge or at amounts less than established rates. Because the Hospital does not pursue collection of amounts determined to qualify as charity care, they are not reported as revenue. The amount of charges foregone for services provided under the Hospital's charity care policy was approximately $616,000 for the year ended December 31, 2012. The estimated costs of the charges foregone, based upon an overall cost-to-charge ratio calculation, for the year ended December 31, 2012, was $382,000. | Description |
| Total Program Service Expense | 16766874 | TotalProgramServiceExpense |
| Described In501 C3 | 1 | DescribedIn501C3 |
| Schedule B Required | 1 | ScheduleBRequired |
| Political Activities | 0 | PoliticalActivities |
| Lobbying Activities | 0 | 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 | 0 | 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 | 1 | GrantsToOrganizations |
| Grants To Individuals | 0 | GrantsToIndividuals |
| Schedule J Required | 1 | ScheduleJRequired |
| Tax Exempt Bonds | 0 | TaxExemptBonds |
| 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 | 1 | TransactionRelatedEntity |
| Transfers To Exempt Non Chrtbl Org | 0 | TransfersToExemptNonChrtblOrg |
| Activities Conducted Partnership | 0 | ActivitiesConductedPartnership |
| Schedule O Required | 1 | ScheduleORequired |
| Number Forms Transmitted With1096 | 210 | NumberFormsTransmittedWith1096 |
| Number W2 G Included | 0 | NumberW2GIncluded |
| Compliance With Backup Witholding | 1 | ComplianceWithBackupWitholding |
| Number Of Employees | 215 | NumberOfEmployees |
| Employment Tax Returns Filed | 1 | EmploymentTaxReturnsFiled |
| Unrelated Business Income | 0 | UnrelatedBusinessIncome |
| 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 | 0 | QuidProQuoContributions |
| 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 | 13 | NbrVotingGoverningBodyMembers |
| Number Independent Voting Members | 12 | 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 | 1 | 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 | 1 | 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 | 1 | DocumentRetentionPolicy |
| Compensation Process CEO | 1 | CompensationProcessCEO |
| Compensation Process Other | 0 | 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 | Charles Roeder | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Telephone Number | 6088841656 | TelephoneNumber |
Address US AddressUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 11101 North Sherman Road | AddressLine1 |
| City | Edgerton | City |
| State | WI | State |
| ZIP Code | 53534 | ZIPCode |
Form990 Part VII Section A Form990PartVIISectionA (18 entries)
| TitleTitle | Average Hours Per WeekAverageHoursPerWeek | Average Hours Per Week RelatedAverageHoursPerWeekRelated | Individual Trustee Or DirectorIndividualTrusteeOrDirector | OfficerOfficer | Reportable Comp From OrganizationReportableCompFromOrganization | Reportable Comp From Related OrgsReportableCompFromRelatedOrgs | Other CompensationOtherCompensation | Highest Compensated EmployeeHighestCompensatedEmployee |
|---|---|---|---|---|---|---|---|---|
| James Schultz | ||||||||
| Chair | 0.30 | 0.30 | X | X | 0 | 0 | 0 | |
| Jay Peterson DC | ||||||||
| Vice Chair | 0.30 | 0.00 | X | X | 0 | 0 | 0 | |
| Melva Sue Larson | ||||||||
| Treasurer | 0.30 | 0.00 | X | X | 0 | 0 | 0 | |
| Steve Thompson | ||||||||
| Secretary | 0.30 | 0.00 | X | X | 0 | 0 | 0 | |
| Kamal Muzaffar MD | ||||||||
| Chief of Staff | 0.30 | 0.00 | X | 0 | 0 | 0 | ||
| Dennis Litsheim MD | ||||||||
| Trustee | 0.30 | 0.00 | X | 0 | 0 | 0 | ||
| Lawanna Schieldt | ||||||||
| Trustee | 0.30 | 0.00 | X | 0 | 0 | 0 | ||
| Sara Karman | ||||||||
| Trustee | 0.30 | 0.00 | X | 0 | 0 | 0 | ||
| Matthew Roethe | ||||||||
| Trustee | 0.30 | 0.00 | X | 0 | 0 | 0 | ||
| Fred Falk | ||||||||
| Trustee | 0.30 | 0.30 | X | 0 | 0 | 0 | ||
| Charlie Johnson | ||||||||
| Trustee | 0.30 | 0.00 | X | 0 | 0 | 0 | ||
| Linda Taplin Statz | ||||||||
| Trustee | 0.30 | 0.00 | X | 0 | 0 | 0 | ||
| Donald Bice | ||||||||
| Trustee | 0.30 | 0.00 | X | 0 | 0 | 0 | ||
| James Pernau | ||||||||
| CEO | 40.00 | 0.30 | X | 181921 | 0 | 19314 | ||
| Charles Roeder | ||||||||
| CFO | 40.00 | 0.00 | X | 143374 | 0 | 18296 | ||
| Todd Crowley | ||||||||
| Pharmacist | 40.00 | 0.00 | 132625 | 0 | 13354 | X | ||
| Caryn Oleston | ||||||||
| Chief Clinical Officer | 40.00 | 0.00 | 131475 | 0 | 7922 | X | ||
| William West MD | ||||||||
| Family Practice Physician | 40.00 | 0.00 | 196649 | 0 | 14114 | X | ||
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Reportable Comp From Org | 786044 | TotalReportableCompFromOrg |
| Total Reportable Comp Frm Rltd Orgs | 0 | TotalReportableCompFrmRltdOrgs |
| Total Other Compensation | 73000 | TotalOtherCompensation |
| Number Individuals GT100 K | 5 | 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 |
|---|---|---|---|---|---|
| Gilbane Building Co Inc | |||||
| 101 W Pleasant Street 104 | Milwaukee | WI | 53207 | Construction management | 2170568 |
| Southern Wisconsin Emergency Physicians | |||||
| PO Box 793 | Traverse City | MI | 49685 | ER Physicians | 1477538 |
| Rock Valley Radiologists | |||||
| PO Box 2103 | Janesville | WI | 53546 | Radiology physicians | 310000 |
| Stoughton Hospital | |||||
| PO Box 78216 | Milwaukee | WI | 53278 | Certified Registered Nurse Anesthetists | 235895 |
| Aviand's | |||||
| 1751 W Cty Rd B | Roseville | MN | 55113 | Food services management | 212706 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Number Of Contractors GT100 K | 12 | NumberOfContractorsGT100K |
| Related Organizations | 374053 | RelatedOrganizations |
| Government Grants | 118200 | GovernmentGrants |
| Total Contributions | 492253 | TotalContributions |
Program Service Revenue ProgramServiceRevenue (3 entries)
| DescriptionDescription | Business CodeBusinessCode | Total Revenue ColumnTotalRevenueColumn | Related Or Exempt Function IncomeRelatedOrExemptFunctionIncome |
|---|---|---|---|
| Patient service revenue | 622110 | 18322103 | 18322103 |
| MEHR Incentive payment | 900099 | 241587 | 241587 |
| Other supporting revenue | 900099 | 165399 | 165399 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Revenue | 18729089 | TotalProgramServiceRevenue |
Investment Income InvestmentIncome
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 10300 | TotalRevenueColumn |
| Exclusion | $10,300 | ExclusionAmount |
Gross Rents GrossRents
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | 27003 | Real |
Less Rental Expenses LessRentalExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | 47061 | Real |
Rental Income Or Loss RentalIncomeOrLoss
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | -20058 | Real |
Net Rental Income Or Loss NetRentalIncomeOrLoss
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | -20058 | TotalRevenueColumn |
| Exclusion | -$20,058 | ExclusionAmount |
Gross Amount Sales Assets GrossAmountSalesAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | 6169 | Other |
Less Cost Oth Basis Sales Expenses LessCostOthBasisSalesExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | 3072 | Other |
Gain Or Loss GainOrLoss
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | 3097 | Other |
Net Gain Or Loss Investments NetGainOrLossInvestments
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 3097 | TotalRevenueColumn |
| Exclusion | $3,097 | ExclusionAmount |
Total Revenue TotalRevenue
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 19214681 | TotalRevenueColumn |
| Related Or Exempt Function Income | 18729089 | RelatedOrExemptFunctionIncome |
| Unrelated Business Revenue | 0 | UnrelatedBusinessRevenue |
| Exclusion | -$6,661 | ExclusionAmount |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part IX | X | InfoInScheduleOPartIX |
Grants To Domestic Orgs GrantsToDomesticOrgs
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 174587 | Total |
| Program Services | 174587 | ProgramServices |
Comp Current Officers Directors CompCurrentOfficersDirectors
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 365860 | Total |
| Management And General | 365860 | ManagementAndGeneral |
Other Salaries And Wages OtherSalariesAndWages
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 7343797 | Total |
| Program Services | 6177329 | ProgramServices |
| Management And General | 1166468 | ManagementAndGeneral |
Pension Plan Contributions PensionPlanContributions
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 85734 | Total |
| Program Services | 71473 | ProgramServices |
| Management And General | 14261 | ManagementAndGeneral |
Other Employee Benefits OtherEmployeeBenefits
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 1266278 | Total |
| Program Services | 848900 | ProgramServices |
| Management And General | 417378 | ManagementAndGeneral |
Payroll Taxes PayrollTaxes
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 546008 | Total |
| Program Services | 451607 | ProgramServices |
| Management And General | 94401 | ManagementAndGeneral |
Fees For Services Legal FeesForServicesLegal
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 205449 | Total |
| Management And General | 205449 | ManagementAndGeneral |
Fees For Services Accounting FeesForServicesAccounting
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 48031 | Total |
| Program Services | 9500 | ProgramServices |
| Management And General | 38531 | ManagementAndGeneral |
Fees For Services Other FeesForServicesOther
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 3967910 | Total |
| Program Services | 3365350 | ProgramServices |
| Management And General | 602560 | ManagementAndGeneral |
Advertising Advertising
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 128141 | Total |
| Program Services | 3430 | ProgramServices |
| Management And General | 124711 | ManagementAndGeneral |
Office Expenses OfficeExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 702946 | Total |
| Program Services | 455854 | ProgramServices |
| Management And General | 247092 | ManagementAndGeneral |
Occupancy Occupancy
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 230881 | Total |
| Program Services | 227704 | ProgramServices |
| Management And General | 3177 | ManagementAndGeneral |
Travel Travel
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 60833 | Total |
| Program Services | 34586 | ProgramServices |
| Management And General | 26247 | ManagementAndGeneral |
Conferences Meetings ConferencesMeetings
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 117952 | Total |
| Program Services | 51298 | ProgramServices |
| Management And General | 66654 | ManagementAndGeneral |
Interest Interest
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 1512401 | Total |
| Program Services | 1512401 | ProgramServices |
Depreciation Depletion DepreciationDepletion
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 1812413 | Total |
| Program Services | 1812413 | ProgramServices |
Insurance Insurance
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 201508 | Total |
| Program Services | 32000 | ProgramServices |
| Management And General | 169508 | ManagementAndGeneral |
Other Expenses OtherExpenses (3 entries)
| DescriptionDescription | TotalTotal | Program ServicesProgramServices | Management And GeneralManagementAndGeneral |
|---|---|---|---|
| Medical supplies | 984838 | 984838 | |
| Provision for bad debts | 524039 | 524039 | |
| Dues and subscriptions | 122493 | 23710 | 98783 |
All Other Expenses AllOtherExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 9833 | Total |
| Program Services | 5855 | ProgramServices |
| Management And General | 3978 | ManagementAndGeneral |
Total Functional Expenses TotalFunctionalExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 20411932 | Total |
| Program Services | 16766874 | ProgramServices |
| Management And General | 3645058 | ManagementAndGeneral |
| Fundraising | 0 | Fundraising |
Savings And Temp Cash Investments SavingsAndTempCashInvestments
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 1536681 | BOY |
| EOY | 2651923 | EOY |
Pledges And Grants Receivable PledgesAndGrantsReceivable
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 8124 | BOY |
| EOY | 4527 | EOY |
Accounts Receivable AccountsReceivable
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 3869810 | BOY |
| EOY | 2791041 | EOY |
Inventories For Sale Or Use InventoriesForSaleOrUse
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 278592 | BOY |
| EOY | 326426 | EOY |
Prepaid Expenses Deferred Charges PrepaidExpensesDeferredCharges
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 140577 | BOY |
| EOY | 149892 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Land Buildings Equipment Basis | 27888723 | LandBuildingsEquipmentBasis |
| Land Bldg Equipment Accum Deprec | 4339414 | LandBldgEquipmentAccumDeprec |
Land Buildings Equipment Basis Net LandBuildingsEquipmentBasisNet
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 24909080 | BOY |
| EOY | 23549309 | EOY |
Investments Pub Traded Securities InvestmentsPubTradedSecurities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 659948 | BOY |
| EOY | 1885721 | EOY |
Investments Program Related InvestmentsProgramRelated
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 10641 | BOY |
| EOY | 14069 | EOY |
Intangible Assets IntangibleAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 456577 | BOY |
| EOY | 456577 | EOY |
Other Assets Total OtherAssetsTotal
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 920614 | BOY |
| EOY | 1069787 | EOY |
Total Assets TotalAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 32790644 | BOY |
| EOY | 32899272 | EOY |
Accounts Payable Accrued Expenses AccountsPayableAccruedExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 2647922 | BOY |
| EOY | 1993747 | EOY |
Deferred Revenue DeferredRevenue
| Field | Value | IRS element (for citing) |
|---|---|---|
| EOY | 724760 | EOY |
Mort Notes Pybl Secured Invest Prop MortNotesPyblSecuredInvestProp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 20544515 | BOY |
| EOY | 24545077 | EOY |
Other Liabilities OtherLiabilities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 3360882 | BOY |
| EOY | 592185 | EOY |
Total Liabilities TotalLiabilities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 26553319 | BOY |
| EOY | 27855769 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Follow SFAS117 | X | FollowSFAS117 |
Unrestricted Net Assets UnrestrictedNetAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 6226080 | BOY |
| EOY | 5029434 | EOY |
Temporarily Restricted Net Assets TemporarilyRestrictedNetAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 11245 | BOY |
| EOY | 14069 | EOY |
Total Net Assets Fund Balances TotalNetAssetsFundBalances
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 6237325 | BOY |
| EOY | 5043503 | EOY |
Total Liab Net Assets Fund Balances TotalLiabNetAssetsFundBalances
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 32790644 | BOY |
| EOY | 32899272 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part XI | X | InfoInScheduleOPartXI |
| Reconcilation Revenue Expenses | -1197251 | ReconcilationRevenueExpenses |
| Reconcilation Other Changes | 3429 | ReconcilationOtherChanges |
| Method Of Accounting Accrual | X | MethodOfAccountingAccrual |
| Accountant Compile Or Review | 0 | AccountantCompileOrReview |
| FS Audited | 1 | FSAudited |
FS Audited Basis FSAuditedBasis
| Field | Value | IRS element (for citing) |
|---|---|---|
| Financial Statement Consolidated | X | FinancialStatementConsolidated |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Audit Committee | 1 | AuditCommittee |
| Federal Grant Audit Required | 1 | FederalGrantAuditRequired |
| Federal Grant Audit Performed | 1 | FederalGrantAuditPerformed |
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 D IRS990ScheduleD
Land Land
| Field | Value | IRS element (for citing) |
|---|---|---|
| Investment Cost Or Other Basis | 50000 | InvestmentCostOrOtherBasis |
| Other Cost Or Other Basis | 34853 | OtherCostOrOtherBasis |
| Book Value | 84853 | BookValue |
Buildings Buildings
| Field | Value | IRS element (for citing) |
|---|---|---|
| Investment Cost Or Other Basis | 507142 | InvestmentCostOrOtherBasis |
| Other Cost Or Other Basis | 21521573 | OtherCostOrOtherBasis |
| Depreciation | 1697659 | Depreciation |
| Book Value | 20331056 | BookValue |
Leasehold Improvements LeaseholdImprovements
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 97209 | OtherCostOrOtherBasis |
| Depreciation | 89699 | Depreciation |
| Book Value | 7510 | BookValue |
Equipment Equipment
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 5587122 | OtherCostOrOtherBasis |
| Depreciation | 2552056 | Depreciation |
| Book Value | 3035066 | BookValue |
Other Land Buildings OtherLandBuildings
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 90824 | OtherCostOrOtherBasis |
| Book Value | 90824 | BookValue |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Of Book Value Land Buildings | 23549309 | TotalOfBookValueLandBuildings |
Other Liabilities OtherLiabilities (2 entries)
| DescriptionDescription | AmountAmount |
|---|---|
| Estimated third party payor settlements | $483,000 |
| Construction accounts payable | $109,185 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Of Amounts | 592185 | TotalOfAmounts |
| Footnote In Part XIII | X | FootnoteInPartXIII |
Form990 Schedule D Part XIII Form990ScheduleDPartXIII
| Field | Value | IRS element (for citing) |
|---|---|---|
| Identifier | Description of Uncertain Tax Positions Under FIN 48: | Identifier |
| Return Reference | Part X, Line 2: | ReturnReference |
| Explanation | The Hospital is organized as a Wisconsin non-profit corporation and has been recognized by the Internal Revenue Service (IRS) as exempt from federal income taxes under Internal Revenue Code Section 501(c)(3). The Hospital is annually required to file a Return of Organization Exempt from Income Tax (Form 990) with the IRS. In addition, they are also subject to income tax on net income that is derived from business activities that are unrelated to its exempt purpose, if applicable. The Organization believes it has appropriate support for any tax positions taken affecting their annual filing requirments, and as such, does not have any uncertain tax positions that are material to the consolidated financial statements. The Organization would recognize future accrued interest and penalties related to unrecognized tax benefits and liabilities in income tax expense if such interest and penalties are incurred. | Explanation |
Schedule H IRS990ScheduleH
| Field | Value | IRS element (for citing) |
|---|---|---|
| Charity Care Policy | 1 | CharityCarePolicy |
| Written Policy | 1 | WrittenPolicy |
| Policy Applied To All Hospitals | X | PolicyAppliedToAllHospitals |
| FPG Reference Free Care | 1 | FPGReferenceFreeCare |
Other Percentage OtherPercentage
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | X | Other |
| Free Other Percentage | 125.000000000000 | FreeOtherPercentage |
| Field | Value | IRS element (for citing) |
|---|---|---|
| FPG Reference Discounted Care | 1 | FPGReferenceDiscountedCare |
Discounted Other DiscountedOther
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | X | Other |
| Discounted Other Percentage | 225.000000000000 | DiscountedOtherPercentage |
| Field | Value | IRS element (for citing) |
|---|---|---|
| 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 | 382000 | TotalCommunityBenefitExpense |
| Net Community Benefit Expense | 382000 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.01920 | PercentOfTotalExpense |
Total Charity Care TotalCharityCare
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 382000 | TotalCommunityBenefitExpense |
| Net Community Benefit Expense | 382000 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.01920 | PercentOfTotalExpense |
Community Health Services CommunityHealthServices
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 31739 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 7550 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 24189 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.00120 | PercentOfTotalExpense |
Health Professions Education HealthProfessionsEducation
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 71982 | TotalCommunityBenefitExpense |
| Net Community Benefit Expense | 71982 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.00360 | PercentOfTotalExpense |
Subsidized Health Services SubsidizedHealthServices
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 5284169 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 3221648 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 2062521 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.10370 | PercentOfTotalExpense |
Cash And In Kind Contributions CashAndInKindContributions
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 2639 | TotalCommunityBenefitExpense |
| Net Community Benefit Expense | 2639 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.00010 | PercentOfTotalExpense |
Total Other Benefits TotalOtherBenefits
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 5390529 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 3229198 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 2161331 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.10860 | PercentOfTotalExpense |
Total Community Benefits TotalCommunityBenefits
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 5772529 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 3229198 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 2543331 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.12780 | PercentOfTotalExpense |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bad Debt Expense Reported | 0 | BadDebtExpenseReported |
| Bad Debt Expense | $524,039 | BadDebtExpenseAmount |
| Amount Attributable To | 174662 | AmountAttributableTo |
| Amount Reimbursed By Medicare | 8131421 | AmountReimbursedByMedicare |
| Cost Of Care Reimbursed By Medicare | 8050911 | CostOfCareReimbursedByMedicare |
| Medicare Surplus Or Shortfall | 80510 | MedicareSurplusOrShortfall |
Costing Methodology Used CostingMethodologyUsed
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | X | Other |
| 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 | Edgerton Hospital and Health Services | BusinessNameLine1 |
Address Address
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 11101 North Sherman Road | AddressLine1 |
| City | Stoughton | City |
| State | WI | State |
| ZIP Code | 53534 | 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 |
| Other | Provider based clinic - Milton Clinic | Other |
Form990 Schedule H Part V Section B Form990ScheduleHPartVSectionB
Hospital Facility Name HospitalFacilityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Edgerton Hospital and Health Services | 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 | 125.000000000000 | FPGFreePercent |
| Uses FPG Discounted | 1 | UsesFPGDiscounted |
| FPG Discount Percent | 225.000000000000 | FPGDiscountPercent |
| Explains Basis | 1 | ExplainsBasis |
| Income Level | X | IncomeLevel |
| Asset Level | X | AssetLevel |
| Medical Indigency | X | MedicalIndigency |
| Insurance Status | X | InsuranceStatus |
| Uninsured Discount | X | UninsuredDiscount |
| Medicaid Medicare | X | MedicaidMedicare |
| Other Factors | X | OtherFactors |
| Explains Application Method | 1 | ExplainsApplicationMethod |
| Includes Publicity Measures | 1 | IncludesPublicityMeasures |
| Available On Request | X | AvailableOnRequest |
| Other Publicity | X | OtherPublicity |
| Actions On Nonpayment | 1 | ActionsOnNonpayment |
| Collection Activities | 0 | CollectionActivities |
| Notify Upon Admission | X | NotifyUponAdmission |
| Notified All Patients | X | NotifiedAllPatients |
| Documented Determination | X | DocumentedDetermination |
| Other Actions Taken | X | OtherActionsTaken |
| Nondiscrim Emergency Care Policy | 1 | NondiscrimEmergencyCarePolicy |
| Average Negotiated Rates | X | AverageNegotiatedRates |
| Amounts Generally Billed | 0 | AmountsGenerallyBilled |
| Gross Charges | 0 | GrossCharges |
Form990 Schedule H Part VI Form990ScheduleHPartVI (15 entries)
| ExplanationExplanation | IdentifierIdentifier | Return ReferenceReturnReference |
|---|---|---|
| Part I, Line 3c: In addition to providing free or discounted care based on Federal Poverty Guidelines, Edgerton Hospital provides certain accommodations to patients who have trouble paying their bills. These practices include offering uninsured patients a cash discount for prompt payment of the estimated or final charges for services provided. Edgerton Hospital provides interest-bearing loans through H.E.L.P. Financial Inc. Payment arrangements are also available for accounts to be paid within 6 months at no interest. | ||
| Part I, Line 6a: Edgerton Hospital and Health Services makes its community benefit report available to the public by providing it upon request. | ||
| Part I, Line 7: Charity care expense was converted to cost on line 7a based on an overall cost-to-charge ratio addressing all patient segments. Community health improvement services, line 7e, health professions education, line 7f, and cash and in-kind contributions, line 7i are reported based on actual expenses recorded in the Organization's general ledger. The cost for subsidized health services reported on line 7g was determined using the Medicare Cost Report. | ||
| Part I, L7 Col(f): The amount of bad debt expense removed from total expenses to determine the percentage was $524,039. | ||
| Part III, Line 4: All past due accounts are reviewed to determine if a patient qualifies for charity care, or federal, state, or local assistance. Before an account is written off to bad debt all discounts and payments are applied, including contractual allowances. After every attempt is made to collect the unpaid balance, the account is written off to bad debt. Payments on accounts that were written off as bad debt reduces bad debt expense.A reasonable estimate of the Organization's bad debt expense attributable to patients under the Organization's financial assistance policy is one-third of bad debt expense. Footnote to financial statements:Patient accounts receivable are reduced by an allowance for doubtful accounts. In evaluating the collectability of accounts receivable, the Hospital analyzes its past history and identifies trends for each of its major payor sources of revenue to estimate the appropriate allowance for doubtful accounts and provision for bad debts. Management regularly reviews data about these major payors sources of revenue in evaluating the sufficiency of the allowance for doubtful accounts. For receivables associated with services provided to patients who have third party coverage, the Hospital analyzes contractually due amounts and provides an allowance for doubtful accounts and a provision for bad debts, if necessary (for example, for expected uncollectible deductibles and copayments on accounts for which the third-party payor has not yet paid, or for payors who are known to be having financial difficulties that make the realization of amounts due unlikely).For receivables associated with self-pay patients (which includes both patients without insurance and patients with deductible and copayment balances due for which third-party coverage exists for part of the bill), the Hospital records a provision for bad debts in the period of service on the basis of its past experience, which indicates that many patients are unable or unwilling to pay the portion of their bill for which they are financially responsible. The difference between the standard rate (or the discounted rates, if negotiated) and the amounts actually collected after all reasonable collection efforts have been exhausted is charged off against the allowance for doubtful accounts. | ||
| Part III, Line 8: Edgerton Hospital and Health Services, Inc. is a critical access hospital and therefore did not have a Medicare shortfall in 2012. Total revenue received from Medicare is the gross reimbursement plus settlement. Both total revenue received from Medicare and the Medicare allowable costs are reported from the Medicare Cost Report. The Medicare Cost Report is completed based on the rules and regulations set forth by the Centers for Medicare and Medicaid Services. | ||
| Part III, Line 9b: Edgerton Hospital and Health Services provides a charitable program consisting of partial or total discounts for those patients who are uninsured, underinsured, and/or unable to pay for necessary healthcare services and are determined eligible to receive such care. As part of the debt collection policy patients are given a written notice after 30 days, 45 days, 60 days, and 70 days. This is followed up by a phone call and if there is no response the account is sent to a pre-collection agency and then the collection agency. For patients known to qualify for charity care or financial assistance, this process is followed for the portion they are responsible for. On accounts which have been assigned to outside collection agencies and are later approved for Community Care, the hospital will request such agencies to cancel and return accounts to the hospital, and to reverse any applicable detrimental credit information created against the patient/guarantor. | ||
| Part V, Section B, Line 12h: Other living expenses and financial obligations relative to household/family size is considered in the calculation for amounts charged to patients. | Edgerton Hospital and Health Services | |
| Part V, Section B, Line 14g: A summary of the financial assistance policy was made available to the public upon admission, included as a brochure in registration areas, emergency room, and waiting rooms of the Hospital, and is available on our website. | Edgerton Hospital and Health Services | |
| Part V, Section B, Line 18e: All accounts were reviewed for possible financial assistance prior to sending to a collection agency. | Edgerton Hospital and Health Services | |
| Part VI, Line 2: We use the following tools to assess health care needs of the communities we serve: (1) Patient exit questionnaires; (2) Involvement in community groups such as the Edgerton Coalition for a Healthy Community where we assess health needs based upon discussions and topics brought up by the Coalition members; (3) Analysis of data received from the Wisconsin Hospital Association and the Rock County Department of Health; and (4) Utilization of the Intelimed software program which allows us to analyze data from facilities comparable to ours.The data for our Community Health Needs Assessment (CHNA) is complete and we are in the process of writing our CHNA. The CHNA will be presented to the board in November. At that time the implementation strategy will be completed. The CHNA will be posted to our website before December 31, 2013. | ||
| Part VI, Line 3: A summary of our community care program is listed on our Hospital website and is contained in a brochure that is available to all patients at all registration areas, emergency room, and waiting rooms in the Hospital. The policy is also provided upon admission and upon request. The complete packet of information, along with an application, is given to any patient upon request. Posters which explain our community care program are located in the Emergency Department and inform patients to contact the Business Office for more information. Billing staff discuss the availability of various government benefits, state programs, and assist the patient on how to qualify for such programs where applicable. | ||
| Part VI, Line 4: Edgerton is located 30 miles south of Madison and 12 Miles north of Janesville on the northern edge of Rock County. Edgerton is in a rural, agricultural area. The 2010 population of Edgerton and Rock County was 5,461 and 160,331 with a projected county growth to 186,331 by 2035. Rock County is dominated by service and manufacturing sectors. The median household income for the county is $49,716, the poverty level is at 12.4% and the population aged 65+ is at 13.8%.There are multiple hospitals within 30 miles of Edgerton including three facilities in Madison, one in Janesville, one in Stoughton and one in Fort Atkinson.Madison Hospitals (30 miles distant)* St.Mary's - 440 bed acute care hospital * Meriter - 448 bed acute care hospital* University of Wisconsin Hospital - 536 bed acute care hospitalOther Hospitals (20 or less miles distant)* Mercy Hospital - Located 12 miles south - 240 bed acute care hospital* Stoughton Hospital - located 12 miles northwest - 35 bed acute care, critical access hospital* Fort Atkinson - Located 17 miles northeast - 82 bed acute care hospital | ||
| Part VI, Line 5: Edgerton Hospital is an 18-bed critical access hospital located in Edgerton, Wisconsin. Our Board of Trustees is comprised of persons who reside in our primary service area who are not employees of our Organization. The Hospital extends medical staff privileges to all qualified physicians in the community and all surplus funds are reinvested in patient care and plant upgrades. Our Organization is the fiscal agent for the Edgerton Coalition for a Healthy Community and one of our employees is the Project Director of the Coalition. We hold an annual health fair for the community and offer many health related community education classes at little or no cost to the attendees. We provide and staff a First Aid tent at our local community summer festival. Our CEO sits on the Board of Directors of the local Hope Institute of Uganda with meetings held in Janesville, Wisconsin. | ||
| WI | Reports Filed With States | Part VI, Line 7 |
Schedule I IRS990ScheduleI
| Field | Value | IRS element (for citing) |
|---|---|---|
| Records Maintained | 1 | RecordsMaintained |
Recipient Table RecipientTable
Recipient Name Business RecipientNameBusiness
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Edgerton Hospital Capital Foundation Inc | BusinessNameLine1 |
Address US AddressUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 11101 North Sherman Road | AddressLine1 |
| City | Edgerton | City |
| State | WI | State |
| ZIP Code | 53534 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN Of Recipient | 203161048 | EINOfRecipient |
| IRC Section | 501(c)(3) | IRCSection |
| Amount Of Cash Grant | 171546 | AmountOfCashGrant |
| Purpose Of Grant | Support for operating expenses | PurposeOfGrant |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Nbr Of501 C3 And Govt Grants | 1 | TotalNbrOf501C3AndGovtGrants |
| Total Nbr Of Other Organizations | 0 | TotalNbrOfOtherOrganizations |
Form990 Schedule I Part IV Form990ScheduleIPartIV
| Field | Value | IRS element (for citing) |
|---|---|---|
| Identifier | Procedure for Monitoring Grants in the U.S.: | Identifier |
| Return Reference | Part I, Line 2: | ReturnReference |
| Explanation | Schedule I, Part I, Line 2: Edgerton Hospital provides support to assist with operating expenses for Edgerton Hospital Capital Foundation, Inc. The Foundation must provide documentation of what the funding was used for. | Explanation |
Schedule J IRS990ScheduleJ
| Field | Value | IRS element (for citing) |
|---|---|---|
| Written Employment Contract | X | WrittenEmploymentContract |
| Compensation Survey | X | CompensationSurvey |
| Board Or Committee Approval | X | BoardOrCommitteeApproval |
| 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 (3 entries)
| TitleTitle | 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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| James Pernau | ||||||||||||||
| CEO | 156832 | 0 | 0 | 0 | 25089 | 0 | 3600 | 0 | 17194 | 0 | 202715 | 0 | 0 | 0 |
| Charles Roeder | ||||||||||||||
| CFO | 117017 | 0 | 0 | 0 | 26357 | 0 | 2385 | 0 | 17385 | 0 | 163144 | 0 | 0 | 0 |
| William West MD | ||||||||||||||
| Family Practice Physician | 169187 | 0 | 0 | 0 | 27462 | 0 | 900 | 0 | 14530 | 0 | 212079 | 0 | 0 | 0 |
Schedule L IRS990ScheduleL
Form990 Schedule L Part IV Form990ScheduleLPartIV
Name Of Interested Person NameOfInterestedPerson
Name Business NameBusiness
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Rock Valley Radiologists | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Relationship | Officer and 33.3% owner is a member of the Board | Relationship |
| Amount Of Transaction | 310000 | AmountOfTransaction |
| Description Of Transaction | Radiology physician services | DescriptionOfTransaction |
| Sharing Of Revenues | 0 | SharingOfRevenues |
Schedule O IRS990ScheduleO
General Explanation GeneralExplanation (8 entries)
| Return ReferenceReturnReference | ExplanationExplanation | IdentifierIdentifier |
|---|---|---|
| Form 990, Part VI, Section A, line 1 | The Executive Committee consists of the Board Chair, Vice Chair, Secretary, and Treasurer of the Corporation. The Executive Committee has power to transact all regular business of the Corporation during the interim between meetings of the Board of Trustees, except the power to: elect officers of the Corporation, fill vacancies in the Board of Trustees or in the Executive Committee, amend or repeal any provisions of these Bylaws, appropriate funds of the Corporation not included in the budget or exceeding an amount for any one purpose in any one fiscal year fixed or authorized by the Board from time to time, or adopt programs which would involve continuing activity or support by the Corporation for more than one fiscal year. Minutes of the Executive Committee summarizing its actions must be submitted to the Board at its next regularly scheduled meeting. | |
| Form 990, Part VI, Section A, line 7a | The Board of Trustees consists of two classes: Class E Trustees and Class S Trustees. SSM Health Care of Wisconsin, Inc. has the right to appoint and remove the Class S Trustees. SSM Health Care of Wisconsin, Inc. also has the right to appoint an alternate who will serve instead of a Class S Trustee with voting rights if the Class S Trustee is unable to attend a meeting of the Board of Trustees. | |
| Form 990, Part VI, Section B, line 11 | The Form 990 is provided to the Trustees of the Board before it is filed. The return is reviewed by the Accounting Manager and CFO. | |
| Form 990, Part VI, Section B, line 12c | Board members, officers, and employees complete and sign a conflict of interest policy annually. The employee handbook contains a conflict of interest policy. The Board Chair and CEO review the potential conflicts of Board members and the HR department reviews the potential conflicts of employees. Potential conflicts may include but are not limited to ownership or control of an entity that contracts with Edgerton Hospital. Board members with conflicts are restricted from voting on such matters and the conflict is made a matter of record in the minutes. | |
| Form 990, Part VI, Section B, line 15a | The Board determines compensation for the CEO. It is based on an annual performance review and comparability data. The Board provides substantiation of the deliberation and decision for the compensation process. The process is completed annually and was last completed in 2012. The CEO determines the salary of the CFO based on comparability data. | |
| Form 990, Part VI, Section C, line 19 | The Organization's governing documents, conflict of interest policy, and financials statements are available to the public upon request. The financial statements are also attached to the Form 990. | |
| Form 990, Part IX, line 11g | Equipment repair, rental and service agreements: Program service expenses 1,135,051. Management and general expenses 323,604. Fundraising expenses 0. Total expenses 1,458,655. Physician and consulting fees: Program service expenses 1,793,626. Management and general expenses 95,659. Fundraising expenses 0. Total expenses 1,889,285. Contract fees and purchased services: Program service expenses 436,673. Management and general expenses 183,297. Fundraising expenses 0. Total expenses 619,970. | Other Fees |
| Form 990, Part XI, line 9: | Decrease in net assets of Edgerton Memorial Community Hospital Auxiliary 3,429. | Changes in Net Assets or Fund Balances: |
Schedule R IRS990ScheduleR
Form990 Schedule R Part II Form990ScheduleRPartII
Name Of Disregarded Entity NameOfDisregardedEntity
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Edgerton Hospital Capital Foundation Inc | BusinessNameLine1 |
Address US AddressUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 11101 North Sherman Road | AddressLine1 |
| City | Edgerton | City |
| State | WI | State |
| ZIP Code | 53534 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 203161048 | EIN |
| Primary Activities | Provide financial support for Edgerton Hospital and Health Services, Inc. | PrimaryActivities |
| Legal Domicile State | WI | LegalDomicileState |
| Exempt Code Section | 501(c)(3) | ExemptCodeSection |
| Public Charity Status | Line 11a, I | PublicCharityStatus |
Direct Controlling Entity Name DirectControllingEntityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Edgerton Hospital and Health Services Inc | 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 | 1 | GiftGrantOrCapContrToOtherOrg |
| Gift Grant Or Cap Contr Fr Other Org | 1 | GiftGrantOrCapContrFrOtherOrg |
| Loans Or Guarantees To Other Org | 0 | LoansOrGuaranteesToOtherOrg |
| Loans Or Guarantees From Other Org | 0 | LoansOrGuaranteesFromOtherOrg |
| Dividends Related Organization | 0 | DividendsRelatedOrganization |
| 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 | 1 | 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 (2 entries)
| Transaction TypeTransactionType | Amount InvolvedAmountInvolved | Method Of Amt DeterminationMethodOfAmtDetermination |
|---|---|---|
| Edgerton Hospital Capital Foundation Inc | ||
| C | 374053 | General ledger |
| Edgerton Hospital Capital Foundation Inc | ||
| B | 171546 | General ledger |