2012-08-13T10:13:19-05:00 2011-09-30 WIPFLI LLP PO BOX 12237 GREEN BAY WI 543072237 990 2010-10-01 391127163 NETWORK HEALTH SYSTEM INC D/B/A AFFINITY MEDICAL GROUP NETW 9207382000 PO BOX 800 1570 MIDWAY PLACE MENASHA WI 54952 JEFF BADGER 9207382000 2012-08-02 1 TERRI REXRODE CPA MST 9206620016 2012-08-02 2010 2016-02-24 21:20:13Z JEFF BADGER PO BOX 800 1570 MIDWAY PLACE MENASHA WI 54952 143517847 0 X WWW.AFFINITYHEALTH.ORG X 1969 WI NETWORK HEALTH SYSTEM INC D/B/A AFFINITY MEDICAL GROUP IS A TEAM OF ABOUT 200 HEALTH CARE PROFESSIONALS, PROVIDING MEDICAL CARE THROUGH A NETWORK OF 25 CLINICS IN 14 NORTHEAST WISCONSIN COMMUNITIES. OUR HISTORY OF PROVIDING HIGH-QUALITY HEALTH CARE TO THE COMMUNITY GOES BACK MORE THAN 50 YEARS. 18 10 1494 0 102307 0 55347 86259 130708874 142778852 169363 190440 96617 51826 131030201 143107377 0 0 0 0 117117463 127513957 0 0 0 37352212 40720685 154469675 168234642 -23439474 -25127265 129851451 149380977 130670361 160831853 -818910 -11450876 X NETWORK HEALTH SYSTEM HAS ADOPTED THE MISSION STATEMENT OF AFFINITY HEALTH SYSTEM. THE MISSION OF AFFINITY HEALTH SYSTEM IS TO LIVE OUT THE HEALING MINISTRY OF CHRIST BY PROVIDING SERVICES THAT PROMOTE THE HEALTH AND WELL-BEING OF THE COMMUNITIES WE SERVE, ESPECIALLY THE POOR. 0 0 139956560 142676545 NETWORK HEALTH SYSTEM IS A REGIONAL HEALTH CARE ORGANIZATION FOCUSED ON COMMUNITY-BASED CARE INCLUDING OUTPATIENT, INPATIENT, ANCILLARY, AND LONG-TERM CARE AS WELL AS INSURANCE SERVICES. THE 25 CLINICS IN THE 13 COMMUNITIES AROUND THE FOX CITIES AND OSHKOSH AREA PROVIDE PRIMARY AND SPECIALTY CARE CLOSE TO HOME. 139956560 1 1 0 0 0 0 0 0 0 1 1 0 1 1 1 0 1 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 1 59 0 1 1494 1 1 1 0 0 0 0 0 0 0 0 0 X 18 10 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 WI X JEFF BADGER 9207201300 1570 MIDWAY PLACE MENASHA WI 54952 CARLA ALTEPETER 0.30 X 0 0 0 NICHOLAS DESIEN 0.30 X X 0 0 0 MARK FAUSTICH MD 40.30 X 369720 0 35440 DAVID GITTER 0.30 X X 0 0 0 MARY HARP-JIRSCHELE 0.30 X 0 0 0 FRED KLEIN MD 0.30 X 0 0 0 JOSEPH MCCORMICKMD 40.30 X 1097589 0 41533 STEPHEN MORTON 0.30 X X 0 0 0 JAY MULLER MD 40.30 X 373057 0 37687 DANIEL E NEUFELDER 12.30 X X 255085 579069 65401 JOHN OLIVERIO 0.30 X X 0 1813218 157725 CHRISTOPHER ROCKE DO 40.30 X 232694 0 35386 JOHN RUSSO 0.30 X X 0 0 0 THOMAS SCHMIDT 0.30 X 0 0 0 STACEY SENSOR DO 40.30 X 482023 0 40878 KATHRYN SIEMAN 0.30 X 0 0 0 BARBARA STRAND MD 40.30 X 264298 0 43300 CATHERINE TIERNEY 0.30 X X 0 0 0 WAYNE TREMBLY 0.30 X 0 0 0 MONICA VOMASTIC 0.30 X 0 0 0 SUSAN VETTE 0.30 X 0 0 0 RICHARD WELLS 0.30 X 0 0 0 JEFF BADGER 12.00 X 135925 308566 62470 CHRISTINE GRIGER 40.00 X 192749 0 12456 TIMOTHY LOCH 40.00 X 282761 0 38248 ZENOUN ABOUZELAM MD 40.00 X 1875300 0 52990 DOUGLAS HORAN MD 40.00 X 1206497 0 52396 MICHELE HOLDER MD 40.00 X 1077960 0 45760 KHALID ALAM MD 40.00 X 1117235 0 49605 JOHN BRADFORD PRACYK MD 40.00 X 808739 0 28884 9771632 2700853 800159 198 0 1 0 WEATHERBY LOCUMS INC PO BOX 97633 DALLAS TX 75397 LOCUMS 1503262 MARSHFIELD LABORATORIES 1000 N OAK AVENUE MARSHFIELD WI 54449 LAB SERVICES 879863 COMPHEALTH PO BOX 972651 DALLAS TX 75397 LOCUMS 428607 PHYTEL INC 11511 LUNA ROAD SUITE 600 DALLAS TX 75234 APPOINTMENTS 424863 ST ELIZABETH HOSPITAL 1506 S ONEIDA ST APPLETON WI 54915 SALARIES/LAB SERVICES 418687 13 86259 86259 NET PATIENT REVENUE 621110 138613276 138613276 OTHER OPERATING REVENU 621110 4063269 4063269 COSMETIC SALES 900099 102307 102307 142778852 190440 190440 462296 410470 51826 51826 51826 143107377 142676545 102307 242266 4009932 3053605 956327 99821498 87982369 11839129 4732771 4179491 553280 14190553 12531620 1658933 4759203 4202833 556370 12963645 4060147 8903498 750 750 10746394 10550325 196069 6663125 6037531 625594 204207 160724 43483 173609 172387 1222 1343263 1205918 137345 1667929 1517815 150114 1546850 1546850 BAD DEBT EXPENSE 3496430 3496430 MISCELLANEOUS 1163678 72390 1091288 RECRUITMENT 374145 374145 GAIN SHARE EXPENSE 263438 263438 DUES & LICENSES 113222 94642 18580 168234642 139956560 28278082 0 3433010 3746617 16586882 17764739 711970 1038798 71863 833205 1349513 50673642 29863900 20958970 20809742 61959577 74312062 25367837 30287643 129851451 149380977 86957945 106785733 43712416 54046120 130670361 160831853 X -818910 -11450876 -818910 -11450876 129851451 149380977 X -25127265 14495299 X X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 1460578 1460578 22280255 6950828 15329427 26932809 22913072 4019737 20809742 INVESTMENT IN NHP 72783555 C INVESTMENT IN TWIN MEDICAL 886949 C INVESTMENT FOR UNEMPLOYMENT RESERVE 641558 C 74312062 DUE FROM AFFILIATES 24930865 DEPOSITS 42547 457B PLAN 5281856 DUE TO 3RD PARTY PAYORS 32375 30287643 RETIREMENT PLAN CONTRIBUTION 5281856 DEFERRED COMPENSATION 1631986 PENSION LIABILITY 28431929 ASSET RETIREMENT OBLIGATION 66913 LONG-TERM DEBT 18633436 54046120 143107377 168234642 -25127265 22110643 -7615344 14495299 -10631966 165623591 22110644 410470 22521114 143102477 4900 4900 143107377 168645112 410470 410470 168234642 0 168234642 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: FASB ASC SUBTOPIC 740-10, INCOME TAXES OVERALL, PRESCRIBES A RECOGNITION THRESHOLD AND MEASUREMENT ATTRIBUTE FOR THE FINANCIAL STATEMENT RECOGNITION AND MEASUREMENT OF A TAX POSITION TAKEN OR EXPECTED TO BE TAKEN IN A TAX RETURN. THE AMOUNT OF UNRECOGNIZED TAX EXPENSE RELATED TO THESE CRITERIA FOR THE CORPORATION WAS ZERO AS OF SEPTEMBER 30, 2011 AND 2010. PART XI, LINE 8 - OTHER ADJUSTMENTS: PENSION ADJUSTMENT -8,401,779. ADJUSTMENT TO INVESTMENT IN SUBSIDIARY 786,435. PART XII, LINE 2D - OTHER ADJUSTMENTS: EXPENSE ALLOCATION TO RENTAL INCOME 410,470. PART XII, LINE 4B - OTHER ADJUSTMENTS: DONATION FROM ST. ELIZABETH COMMUNITY FOUNDATION 4,900. PART XIII, LINE 2D - OTHER ADJUSTMENTS: EXPENSE ALLOCATION TO RENTAL INCOME 410,470. X X 0 1 X X X X X 0 1 0 0 0 0 0 0 0 MARK FAUSTICH MD 368541 0 0 0 1179 0 28196 0 7244 0 405160 0 0 0 JOSEPH MCCORMICKMD 1096449 0 0 0 1140 0 18640 0 22893 0 1139122 0 0 0 JAY MULLER MD 372671 0 0 0 386 0 18692 0 18995 0 410744 0 0 0 DANIEL E NEUFELDER 187978 426730 64971 147491 2136 4848 15266 34655 4734 10746 275085 624470 0 0 JOHN OLIVERIO 0 918033 0 527500 0 367685 0 92775 0 64950 0 1970943 0 350448 CHRISTOPHER ROCKE DO 232298 0 0 0 396 0 17670 0 17716 0 268080 0 0 0 STACEY SENSOR DO 480983 0 0 0 1040 0 22374 0 18504 0 522901 0 0 0 BARBARA STRAND MD 262911 0 0 0 1387 0 22346 0 20954 0 307598 0 0 0 JEFF BADGER 99405 225661 29694 67409 6826 15496 13001 29514 6102 13853 155028 351933 0 0 CHRISTINE GRIGER 162881 0 0 0 29868 0 0 0 12456 0 205205 0 0 0 TIMOTHY LOCH 229390 0 46169 0 7202 0 15941 0 22307 0 321009 0 0 0 ZENOUN ABOUZELAM MD 1870378 0 0 0 4922 0 26426 0 26564 0 1928290 0 0 0 DOUGLAS HORAN MD 1201461 0 0 0 5036 0 28141 0 24255 0 1258893 0 0 0 MICHELE HOLDER MD 1076250 0 0 0 1710 0 22785 0 22975 0 1123720 0 0 0 KHALID ALAM MD 1114778 0 0 0 2457 0 25349 0 24256 0 1166840 0 0 0 JOHN BRADFORD PRACYK MD 807375 0 0 0 1364 0 13229 0 15655 0 837623 0 0 0 PART I, LINE 1B BUSINESS TRAVEL EXPENSES FOR SPOUSES OF EXECUTIVES AND GOLF CLUB MEMBERSHIP FOR EXECUTIVES ARE REIMBURSED AS PART OF THEIR EXECUTIVE FLEX CREDIT ACCOUNT. RECEIPTS ARE PROVIDED TO SR. ADMINISTRATIVE ASSISTANT IN HR WHO REVIEWS FOR ACCURACY, COMPLETES A REIMBURSEMENT FORM WITH SUBSTANTIATION TO PAYROLL FOR REIMBURSEMENT. THESE REIMBURSEMENTS ARE TAXABLE AND, WHEN ADDED TO THE COMPENSATION PACKAGE TAKEN AS A WHOLE, HAVE BEEN INCLUDED WHEN COMPARED TO THE COMPENSATION STUDIES. SUPPLEMENTAL INFORMATION PART III SCHEDULE J PART I LINE 4B JOHN OLIVERIO RECEIVED A 2010 TAXABLE PAYOUT OF $350,448 RELATED TO A SUPPLEMENTAL NONQUALIFIED RETIREMENT PLAN KNOWN AS THE WHEATON FRANCISCAN SERVICES BENEFIT RESTORATION PLAN. FORM 990, PART VI, SECTION A, LINE 6 NETWORK HEALTH SYSTEM HAS ONE CORPORATE MEMBER, AFFINITY HEALTH SYSTEM. FORM 990, PART VI, SECTION A, LINE 7A NETWORK HEALTH SYSTEM'S CORPORATE MEMBER, AFFINITY HEALTH SYSTEM, HAS THE POWER TO ELECT AND REMOVE MEMBERS OF THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION A, LINE 7B AMENDMENTS OF THE ARTICLES OF INCORPORATION AND BYLAWS MUST BE APPROVED BY NETWORK HEALTH SYSTEM'S CORPORATE MEMBER, AFFINITY HEALTH SYSTEM. FORM 990, PART VI, SECTION B, LINE 11 THE CONTROLLER AND CFO OF AFFINITY HEALTH SYSTEM PERFORM A DETAIL REVIEW OF THE 990. AFTER MANAGEMENT REVIEW, A COPY OF THE 990 IS PROVIDED TO THE BOARD OF DIRECTORS PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C THE BOARD OF DIRECTORS RECEIVE A CONFLICT OF INTEREST QUESTIONNAIRE EVERY YEAR. FORM 990, PART VI, SECTION B, LINE 15 EACH YEAR THE ORGANIZATION ENGAGES AN INDPENDENT COMPENSATION FIRM TO PROVIDE MARKET DATA FOR CEO, EXECUTIVES AND KEY EMPLOYEE POSITIONS. THIS STUDY IS SHARED WITH THE COMPENSATION COMMITTEE OF THE BOARD OF DIRECTORS FOR THEIR REVIEW AND RECOMMENDATIONS REGARDING ANY COMPENSATION CHANGES. THE COMPENSATION COMMITTEE IS COMPRISED OF INDEPENDENT MEMBERS. THE CEO REVIEWS EACH EXECUTIVE AND KEY EMPLOYEE'S ANNUAL PERFORMANCE APPRAISAL RATINGS IN MAKING HIS COMPENSATION RECOMMENDATIONS TO THE COMPENSATION COMMITTEE. THE COMPENSATION COMMITTEE HAS THE FINAL AUTHORITY TO APPROVE ANY AND ALL AMOUNTS OF COMPENSATION FOR MEMBERS OF THE EXECUTIVE TEAM. THE FINAL APPROVAL OF COMPENSATION AMOUNTS ARE DOCUMENTED. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION BELIEVES THE FINANCIAL STATEMENTS, GOVERNING DOCUMENTS, AND POLICIES ARE THE PROPERTY OF THE ORGANIZATION AND ARE NOT AVAILABLE FOR PUBLIC INSPECTION. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED GAINS ON INVESTMENTS: 22,110,643. PENSION ADJUSTMENT -8,401,779. ADJUSTMENT TO INVESTMENT IN SUBSIDIARY 786,435. TOTAL TO FORM 990, PART XI, LINE 5: 14,495,299. AUDITED FINANCIAL STATEMENTS FORM 990 PART XI LINE 2B-2C NETWORK HEALTH SYSTEM, INC. DOES NOT RECEIVE SEPARATELY AUDITED FINANCIAL STATEMENTS. THE ORGANIZATION IS AUDITED AND REPORTED THROUGH CONSOLIDATED FINANCIAL STATEMENTS. THE AUDIT COMMITTEE IS RESPONSIBLE FOR THE AUDITOR SELECTION. THE AUDIT STATEMENTS ARE REVIEWED BY THE CONTROLLER, CFO, MINISTRY HEALTH CFO, AND THE AUDIT COMMITTEE. THIS PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. FORM 990, SCHEDULE A, PART 1, LINE 3 NETWORK HEALTH SYSTEM, INC. IS A CLINIC AND NOT A LICENSED HOSPITAL. SCHEDULE H IS NOT REQUIRED. HOURS WORKED FOR RELATED ORGANIZATIONS FORM 990, PART VII JOHN OLIVERIO WORKED AN AVERAGE OF 40 HOURS PER WEEK FOR A RELATED ORGANIZATIONS. DANIEL NEUFELDER WORKED AN AVERAGE OF 28 HOURS PER WEEK FOR RELATED ORGANIZATIONS. JEFF BADGER WORKED AN AVERAGE OF 28 HOURS PER WEEK FOR RELATED ORGANIZATIONS. AFFINITY HEALTH SYSTEM 1570 MIDWAY PLACE MENASHA WI 54952 391568866 SUPPORT RELATED HEALTHCARE ORGANIZATIONS IL 501(C)(3) 3 N/A 0 MERCY MEDICAL CENTER OF OSHKOSH INC 500 S OAKWOOD OSHKOSH WI 54904 390806268 HEALTH CARE SERVICES WI 501(C)(3) 3 AFFINITY HEALTH SYSTEM 0 ST ELIZABETH HOSPITAL INC 1506 S ONEIDA STREET APPLETON WI 54915 390816818 HEALTH CARE SERVICES WI 501(C)(3) 3 AFFINITY HEALTH SYSTEM 0 ST ELIZABETH HOSPITAL FOUNDATION 1506 S ONEIDA STREET APPLETON WI 54915 391256677 RAISE FUNDS IN SUPPORT OF ST. ELIZABETH HOSPITAL AND RELATED ENTITIES WI 501(C)(3) 7 AFFINITY HEALTH SYSTEM 0 WHEATON FRANCISCAN SERVICES INC 26 W171 ROOSEVELT ROAD WHEATON IL 60187 363262111 SUPPORT RELATED HEALTHCARE ORGANIZATIONS IL 501(C)(3) 11A-1 N/A 0 MERCY HEALTH FOUNDATION INC PO BOX 3370 OSHKOSH WI 54903 237140261 PUBLIC WELFARE THROUGH COMMUNITY HEALTH DEVELOPMENT WI 501(C)(3) 9 AFFINITY HEALTH SYSTEM 0 CALUMET MEDICAL CENTER INC 614 MEMORIAL DRIVE CHILTON WI 53014 390905385 HOSPITAL WI 501(C)(3) 3 AFFINITY HEALTH SYSTEM 0 TWIN MED LLP 22 W COLLEGE AVE SUITE 3B APPLETON WI 54911 391180341 RENTAL PROPERTY WI NETWORK HEALTH SYSTEM INC RELATED 373376 988602 0 1 0.64000 NETWORK HEALTH PLAN 1570 MIDWAY PLACE MENASHA WI 54952 391442058 INSURANCE WI NETWORK HEALTH SYSTEM INC C 30544538 103113529 1.00000 NETWORK HEALTH INSURANCE CORPORATION 1570 MIDWAY PLACE MENASHA WI 54952 392020474 INSURANCE WI NETWORK HEALTH PLAN C -4320742 51574868 1.00000 1 0 1 0 1 0 1 0 1 1 0 1 0 1 1 1 0 0 NETWORK HEALTH PLAN A 6375000 FAIR MARKET VALUE TWIN MED LLP A 407326 FAIR MARKET VALUE TWIN MED LLP J 642360 FAIR MARKET VALUE NETWORK HEALTH PLAN N 16101227 FAIR MARKET VALUE