MOUNDVIEW MEMORIAL HOSPITAL & CLINICS INC: Form 990, tax year 2010
View the entire original 990 at ProPublica ↗
- Organization
- MOUNDVIEW MEMORIAL HOSPITAL & CLINICS INC (EIN 39-0944012)
- Tax period
- 2010-07-01 to 2011-06-30
- Filed
- 2012-05-14
- IRS object ID
- 201221359349305017
- Schema version
- 2010v3.4
- 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 C
- Schedule D
- Schedule H
- Schedule J
- Schedule K
- Schedule O
- Schedule R
Return header ReturnHeader
| Field | Value | IRS element (for citing) |
|---|---|---|
| Timestamp | 2012-05-14T14:51:40-05:00 | Timestamp |
| Tax Period End Date | 2011-06-30 | TaxPeriodEndDate |
Preparer Firm PreparerFirm
Preparer Firm Business Name PreparerFirmBusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | WIPFLI LLP | BusinessNameLine1 |
Preparer Firm US Address PreparerFirmUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | PO BOX 12237 | AddressLine1 |
| City | GREEN BAY | City |
| State | WI | State |
| ZIP Code | 543072237 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return Type | 990 | ReturnType |
| Tax Period Begin Date | 2010-07-01 | TaxPeriodBeginDate |
Filer Filer
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 390944012 | EIN |
Name Name
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | MOUNDVIEW MEMORIAL HOSPITAL & CLINICS | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name Control | MOUN | NameControl |
| Phone | 6083393331 | Phone |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 402 WEST LAKE STREET | AddressLine1 |
| City | FRIENDSHIP | City |
| State | WI | State |
| ZIP Code | 53934 | ZIPCode |
Officer Officer
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name | JEREMY NORMINGTON | Name |
| Title | CEO | Title |
| Phone | 6083393331 | Phone |
| Date Signed | 2012-05-14 | DateSigned |
| Authorize Third Party | 1 | AuthorizeThirdParty |
Preparer Preparer
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name | TERRI REXRODE CPA MST | Name |
| Phone | 9206620016 | Phone |
| Date Prepared | 2012-05-14 | DatePrepared |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tax Year | 2010 | TaxYear |
| Build TS | 2016-02-24 21:20:13Z | BuildTS |
Form 990 IRS990
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name Of Principal Officer Person | JEREMY NORMINGTON | NameOfPrincipalOfficerPerson |
Address Principal Officer US AddressPrincipalOfficerUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 402 WEST LAKE STREET | AddressLine1 |
| City | FRIENDSHIP | City |
| State | WI | State |
| ZIP Code | 53934 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Receipts | 15831096 | GrossReceipts |
| Group Return For Affiliates | 0 | GroupReturnForAffiliates |
| Organization501c3 | X | Organization501c3 |
| Web Site | WWW.MOUNDVIEW.ORG | WebSite |
| Type Of Organization Corporation | X | TypeOfOrganizationCorporation |
| Year Formation | 1959 | YearFormation |
| State Legal Domicile | WI | StateLegalDomicile |
| Activity Or Mission Description | MOUNDVIEW MEMORIAL HOSPITAL & CLINICS PROVIDES INPATIENT HOSPITAL AND GENERAL HEALTH CARE SERVICES WITH THE PRIMARY MARKET OF ADAMS COUNTY WISCONSIN BY OPERATING A 25 BED CRITICAL ACCESS HOSPITAL. | ActivityOrMissionDescription |
| Nbr Voting Members Governing Body | 7 | NbrVotingMembersGoverningBody |
| Nbr Independent Voting Members | 7 | NbrIndependentVotingMembers |
| Total Nbr Employees | 155 | TotalNbrEmployees |
| Total Nbr Volunteers | 32 | TotalNbrVolunteers |
| Total Gross UBI | 0 | TotalGrossUBI |
| Net Unrelated Business Txbl Income | 0 | NetUnrelatedBusinessTxblIncome |
| Contributions Grants Prior Year | 126878 | ContributionsGrantsPriorYear |
| Contributions Grants Current Year | 99989 | ContributionsGrantsCurrentYear |
| Program Service Revenue Prior Year | 15171789 | ProgramServiceRevenuePriorYear |
| Program Service Revenue CY | 15597900 | ProgramServiceRevenueCY |
| Investment Income Prior Year | 86110 | InvestmentIncomePriorYear |
| Investment Income Current Year | 61380 | InvestmentIncomeCurrentYear |
| Other Revenue Prior Year | 54586 | OtherRevenuePriorYear |
| Other Revenue Current Year | 63513 | OtherRevenueCurrentYear |
| Total Revenue Prior Year | 15439363 | TotalRevenuePriorYear |
| Total Revenue Current Year | 15822782 | TotalRevenueCurrentYear |
| Grants And Similar Amnts Prior Year | 0 | GrantsAndSimilarAmntsPriorYear |
| Grants And Similar Amnts CY | 0 | GrantsAndSimilarAmntsCY |
| Benefits Paid To Members Prior Year | 0 | BenefitsPaidToMembersPriorYear |
| Benefits Paid To Members CY | 0 | BenefitsPaidToMembersCY |
| Salaries Etc Prior Year | 7240740 | SalariesEtcPriorYear |
| Salaries Etc Current Year | 7388932 | 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 | 7954865 | OtherExpensePriorYear |
| Other Expenses Current Year | 7654838 | OtherExpensesCurrentYear |
| Total Expenses Prior Year | 15195605 | TotalExpensesPriorYear |
| Total Expenses Current Year | 15043770 | TotalExpensesCurrentYear |
| Revenues Less Expenses Prior Year | 243758 | RevenuesLessExpensesPriorYear |
| Revenues Less Expenses CY | 779012 | RevenuesLessExpensesCY |
| Total Assets BOY | 14381585 | TotalAssetsBOY |
| Total Assets EOY | 14696929 | TotalAssetsEOY |
| Total Liabilities BOY | 9594717 | TotalLiabilitiesBOY |
| Total Liabilities EOY | 9063353 | TotalLiabilitiesEOY |
| Net Assets Or Fund Balances BOY | 4786868 | NetAssetsOrFundBalancesBOY |
| Net Assets Or Fund Balances EOY | 5633576 | NetAssetsOrFundBalancesEOY |
| Info In Schedule O Part III | X | InfoInScheduleOPartIII |
| Mission Description | MOUNDVIEW MEMORIAL HOSPITAL AND CLINICS, INCORPORATED, AS A COMMUNITY HEALTH RESOURCE WILL PROVIDE MODERN FACILITIES AND EQUIPMENT TO ENSURE THE DELIVERY OF SERVICES WITH AN EMPHASIS ON PRIMARY HEALTH CARE TO THE PEOPLE OF THE HOSPITAL SERVICE AREA. THE HOSPITAL'S LEADERSHIP, WITH ITS RESOURCES WILL RESPOND IN A TIMELY MANNER TO PHYSICAL, PSYCHOLOGICAL AND SPIRITUAL NEEDS, EMPHASIZING THE 'WHOLE PERSON.' MOUNDVIEW MEMORIAL HOSPITAL AND CLINCS, INCORPORATED WILL PROVIDE MANAGEMENT, AND WELL TRAINED STAFF TO PROVIDE COMPASSIONATE HEALTH CARE. MOUNDVIEW MEMORIAL HOSPITAL AND CLINICS, INCORPORATED SHALL EXPLORE THOSE PROPOSALS FOR NETWORKS, AFFILIATIONS, MERGERS, AND PARTICIPATE IN HMO'S AS DEEMED IN THE BEST INTEREST OF THOSE WE SERVE. | MissionDescription |
| Significant New Program Services | 0 | SignificantNewProgramServices |
| Significant Change | 0 | SignificantChange |
| Expense | 11796425 | Expense |
| Revenue | 15489002 | Revenue |
| Description | THE HOSPITAL IS A GENERAL MEDICAL CRITICAL ACCESS HOSPITAL LICENSED FOR 25 BEDS. DURING FISCAL YEAR 2011, THE HOSPITAL HAD 669 ACUTE INPATIENT DAYS AND 776 MEDICARE SKILL NURSING DAYS (SWING BED). THE HOSPITAL ALSO HAD 5,013 EMERGENCY ROOM VISITS, 1,337 URGENT CARE VISITS AND 17,489 OTHER OUTPATIENT ANCILLARY ENCOUNTERS. | Description |
| Total Program Service Expense | 11796425 | TotalProgramServiceExpense |
| Described In501 C3 | 1 | DescribedIn501C3 |
| Schedule B Required | 1 | ScheduleBRequired |
| Political Activities | 0 | PoliticalActivities |
| Lobbying Activities | 1 | LobbyingActivities |
| 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 | 0 | GrantsToOrganizations |
| Grants To Individuals | 0 | GrantsToIndividuals |
| Schedule J Required | 1 | ScheduleJRequired |
| Tax Exempt Bonds | 1 | TaxExemptBonds |
| Invest Tax Exempt Bonds | 0 | InvestTaxExemptBonds |
| Escrow Account | 0 | EscrowAccount |
| On Behalf Of Issuer | 0 | OnBehalfOfIssuer |
| 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 | 0 | 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 | 7 | NumberFormsTransmittedWith1096 |
| Number W2 G Included | 0 | NumberW2GIncluded |
| Compliance With Backup Witholding | 1 | ComplianceWithBackupWitholding |
| Number Of Employees | 155 | 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 | 7 | NbrVotingGoverningBodyMembers |
| Number Independent Voting Members | 7 | 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 | 1 | MembersOrStockholders |
| Election Of Board Members | 1 | ElectionOfBoardMembers |
| Decisions Subject To Approval | 1 | 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 | 0 | Form990ProvidedToGoverningBody |
| Conflict Of Interest Policy | 1 | ConflictOfInterestPolicy |
| Annual Disclosure Covered Persons | 1 | AnnualDisclosureCoveredPersons |
| Regular Monitoring Enforcement | 1 | RegularMonitoringEnforcement |
| Whistleblower Policy | 0 | WhistleblowerPolicy |
| Document Retention Policy | 1 | DocumentRetentionPolicy |
| Compensation Process CEO | 1 | CompensationProcessCEO |
| Compensation Process Other | 1 | 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 | JEREMY NORMINGTON | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Telephone Number | 6083393331 | TelephoneNumber |
Address US AddressUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 402 WEST LAKE STREET | AddressLine1 |
| City | FRIENDSHIP | City |
| State | WI | State |
| ZIP Code | 53934 | ZIPCode |
Form990 Part VII Section A Form990PartVIISectionA (16 entries)
| TitleTitle | Average Hours Per WeekAverageHoursPerWeek | Individual Trustee Or DirectorIndividualTrusteeOrDirector | OfficerOfficer | Reportable Comp From OrganizationReportableCompFromOrganization | Reportable Comp From Related OrgsReportableCompFromRelatedOrgs | Other CompensationOtherCompensation | Highest Compensated EmployeeHighestCompensatedEmployee |
|---|---|---|---|---|---|---|---|
| JOE PARLANTE DDS | |||||||
| PRESIDENT | 2.50 | X | X | 0 | 0 | 0 | |
| MARY POLIVKA | |||||||
| VICE PRESIDENT | 2.50 | X | X | 0 | 0 | 0 | |
| DEBRA SEGINA | |||||||
| TREASURER | 2.50 | X | X | 0 | 0 | 0 | |
| JEFF WEINKAUF | |||||||
| SECRETARY | 2.50 | X | X | 0 | 0 | 0 | |
| DENNIS GORDER | |||||||
| BOARD MEMBER | 2.50 | X | 0 | 0 | 0 | ||
| HARVEY WAGNER | |||||||
| BOARD MEMBER | 2.50 | X | 0 | 0 | 0 | ||
| LINDA MCFARLIN | |||||||
| BOARD MEMBER | 2.50 | X | 0 | 0 | 0 | ||
| TOM CROKE | |||||||
| BOARD MEMBER | 2.50 | X | 0 | 0 | 0 | ||
| DIANA BRONIEC | |||||||
| BOARD MEMBER | 2.50 | X | 0 | 0 | 0 | ||
| JEREMY NORMINGTON | |||||||
| CEO | 40.00 | X | 141857 | 0 | 24710 | ||
| DONALD HEINZ | |||||||
| CFO | 40.00 | X | 104699 | 0 | 16646 | ||
| MARK HATTON MD | |||||||
| MEDICAL DIRECTOR | 40.00 | 203154 | 0 | 21830 | X | ||
| JASON BELLAK MD | |||||||
| PHYSICIAN | 40.00 | 191585 | 0 | 18206 | X | ||
| SHERYL KUGEL FNP APNP | |||||||
| NURSE PRACTITIONER | 40.00 | 126005 | 0 | 18042 | X | ||
| DAVE SHAPIRO | |||||||
| PHARMACIST | 40.00 | 115770 | 0 | 6480 | X | ||
| ERNESTINE WAGNER PA-C | |||||||
| PHYSICIANS ASSISTANT | 40.00 | 100313 | 0 | 9734 | X | ||
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Reportable Comp From Org | 983383 | TotalReportableCompFromOrg |
| Total Reportable Comp Frm Rltd Orgs | 0 | TotalReportableCompFrmRltdOrgs |
| Total Other Compensation | 115648 | TotalOtherCompensation |
| Number Individuals GT100 K | 8 | 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 |
|---|---|---|---|---|---|
| EMCARE INC | |||||
| 7032 COLLECTION CENTER DRIVE | CHICAGO | IL | 60693 | ER PHYSICIANS/CHARGE CODING | 1126896 |
| SECURITY HEALTH PLAN | |||||
| 1515 SAINT JOSEPH AVE PO BOX 800 | MARSHFIELD | WI | 54449 | HEALTH INSURANCE CARRIER | 1094414 |
| SHARED IMAGING SVCS | |||||
| PO BOX 45686 | MADISON | WI | 53744 | ULTRASOUND, NUCLEAR MED, CARDIAC ECHO | 386463 |
| FIRST REFLECTIONS INC | |||||
| 228 N PINE ST | ADAMS | WI | 53910 | ANESTHESIOLOGIST | 300000 |
| MINISTRY HEALTH CARE | |||||
| 11925 W LAKE PARK DR SUITE 100 | MILWAUKEE | WI | 53224 | MANAGEMENT AND CONSULTING SERVICES | 194149 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Number Of Contractors GT100 K | 10 | NumberOfContractorsGT100K |
| Government Grants | 79282 | GovernmentGrants |
| All Other Contributions | 20707 | AllOtherContributions |
| Total Contributions | 99989 | TotalContributions |
Program Service Revenue ProgramServiceRevenue (3 entries)
| DescriptionDescription | Business CodeBusinessCode | Total Revenue ColumnTotalRevenueColumn | Related Or Exempt Function IncomeRelatedOrExemptFunctionIncome | ExclusionExclusionAmount |
|---|---|---|---|---|
| NET PATIENT REVENUE | 900099 | 15474818 | 15474818 | |
| MISCELLANEOUS | 900099 | 108898 | $108,898 | |
| DIETARY INCOME | 900099 | 14184 | 14184 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Revenue | 15597900 | TotalProgramServiceRevenue |
Investment Income InvestmentIncome
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 60880 | TotalRevenueColumn |
| Exclusion | $60,880 | ExclusionAmount |
Gross Rents GrossRents
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | 71827 | Real |
Less Rental Expenses LessRentalExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | 8314 | Real |
Rental Income Or Loss RentalIncomeOrLoss
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | 63513 | Real |
Net Rental Income Or Loss NetRentalIncomeOrLoss
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 63513 | TotalRevenueColumn |
| Exclusion | $63,513 | ExclusionAmount |
Gross Amount Sales Assets GrossAmountSalesAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | 500 | Other |
Gain Or Loss GainOrLoss
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | 500 | Other |
Net Gain Or Loss Investments NetGainOrLossInvestments
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 500 | TotalRevenueColumn |
| Exclusion | $500 | ExclusionAmount |
Total Revenue TotalRevenue
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 15822782 | TotalRevenueColumn |
| Related Or Exempt Function Income | 15489002 | RelatedOrExemptFunctionIncome |
| Unrelated Business Revenue | 0 | UnrelatedBusinessRevenue |
| Exclusion | $233,791 | ExclusionAmount |
Comp Current Officers Directors CompCurrentOfficersDirectors
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 287912 | Total |
| Management And General | 287912 | ManagementAndGeneral |
Other Salaries And Wages OtherSalariesAndWages
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 5701698 | Total |
| Program Services | 5079486 | ProgramServices |
| Management And General | 622212 | ManagementAndGeneral |
Other Employee Benefits OtherEmployeeBenefits
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 899538 | Total |
| Program Services | 749310 | ProgramServices |
| Management And General | 150228 | ManagementAndGeneral |
Payroll Taxes PayrollTaxes
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 499784 | Total |
| Program Services | 398018 | ProgramServices |
| Management And General | 101766 | ManagementAndGeneral |
Fees For Services Management FeesForServicesManagement
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 183804 | Total |
| Management And General | 183804 | ManagementAndGeneral |
Fees For Services Legal FeesForServicesLegal
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 52450 | Total |
| Management And General | 52450 | ManagementAndGeneral |
Fees For Services Accounting FeesForServicesAccounting
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 32000 | Total |
| Management And General | 32000 | ManagementAndGeneral |
Fees For Services Other FeesForServicesOther
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 2774569 | Total |
| Program Services | 2690479 | ProgramServices |
| Management And General | 84090 | ManagementAndGeneral |
Advertising Advertising
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 47640 | Total |
| Management And General | 47640 | ManagementAndGeneral |
Office Expenses OfficeExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 1595658 | Total |
| Program Services | 1368168 | ProgramServices |
| Management And General | 227490 | ManagementAndGeneral |
Occupancy Occupancy
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 226899 | Total |
| Program Services | 206187 | ProgramServices |
| Management And General | 20712 | ManagementAndGeneral |
Travel Travel
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 79885 | Total |
| Program Services | 61562 | ProgramServices |
| Management And General | 18323 | ManagementAndGeneral |
Conferences Meetings ConferencesMeetings
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 746 | Total |
| Management And General | 746 | ManagementAndGeneral |
Interest Interest
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 294351 | Total |
| Program Services | 267481 | ProgramServices |
| Management And General | 26870 | ManagementAndGeneral |
Depreciation Depletion DepreciationDepletion
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 457303 | Total |
| Program Services | 406694 | ProgramServices |
| Management And General | 50609 | ManagementAndGeneral |
Insurance Insurance
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 115320 | Total |
| Program Services | 29541 | ProgramServices |
| Management And General | 85779 | ManagementAndGeneral |
Other Expenses OtherExpenses (5 entries)
| DescriptionDescription | TotalTotal | Management And GeneralManagementAndGeneral | Program ServicesProgramServices |
|---|---|---|---|
| BAD DEBT EXPENSE | 947390 | 947390 | |
| EQUIPMENT RENTS & LEASE | 416180 | 64746 | 351434 |
| REPAIRS & MAINTENANCE | 251233 | 98993 | 152240 |
| COLLECTION EXPENSE | 82403 | 82403 | |
| DUES & SUBSCRIPTIONS | 58432 | 29710 | 28722 |
All Other Expenses AllOtherExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 38575 | Total |
| Program Services | 7103 | ProgramServices |
| Management And General | 31472 | ManagementAndGeneral |
Total Functional Expenses TotalFunctionalExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 15043770 | Total |
| Program Services | 11796425 | ProgramServices |
| Management And General | 3247345 | ManagementAndGeneral |
| Fundraising | 0 | Fundraising |
Cash Non Interest Bearing CashNonInterestBearing
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 588 | BOY |
| EOY | 600 | EOY |
Savings And Temp Cash Investments SavingsAndTempCashInvestments
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 2974719 | BOY |
| EOY | 3116239 | EOY |
Accounts Receivable AccountsReceivable
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 1515619 | BOY |
| EOY | 1478344 | EOY |
Other Notes Loans Receivable Net OtherNotesLoansReceivableNet
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 5291 | BOY |
| EOY | 1404 | EOY |
Inventories For Sale Or Use InventoriesForSaleOrUse
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 442525 | BOY |
| EOY | 403755 | EOY |
Prepaid Expenses Deferred Charges PrepaidExpensesDeferredCharges
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 138214 | BOY |
| EOY | 136504 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Land Buildings Equipment Basis | 16234161 | LandBuildingsEquipmentBasis |
| Land Bldg Equipment Accum Deprec | 7387924 | LandBldgEquipmentAccumDeprec |
Land Buildings Equipment Basis Net LandBuildingsEquipmentBasisNet
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 8618969 | BOY |
| EOY | 8846237 | EOY |
Other Assets Total OtherAssetsTotal
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 685660 | BOY |
| EOY | 713846 | EOY |
Total Assets TotalAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 14381585 | BOY |
| EOY | 14696929 | EOY |
Accounts Payable Accrued Expenses AccountsPayableAccruedExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 2119240 | BOY |
| EOY | 2098615 | EOY |
Tax Exempt Bond Liabilities TaxExemptBondLiabilities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 5856735 | BOY |
| EOY | 5537032 | EOY |
Mort Notes Pybl Secured Invest Prop MortNotesPyblSecuredInvestProp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 457615 | BOY |
| EOY | 582232 | EOY |
Other Liabilities OtherLiabilities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 1161127 | BOY |
| EOY | 845474 | EOY |
Total Liabilities TotalLiabilities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 9594717 | BOY |
| EOY | 9063353 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Follow SFAS117 | X | FollowSFAS117 |
Unrestricted Net Assets UnrestrictedNetAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 4231926 | BOY |
| EOY | 5050831 | EOY |
Temporarily Restricted Net Assets TemporarilyRestrictedNetAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 554942 | BOY |
| EOY | 582745 | EOY |
Total Net Assets Fund Balances TotalNetAssetsFundBalances
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 4786868 | BOY |
| EOY | 5633576 | EOY |
Total Liab Net Assets Fund Balances TotalLiabNetAssetsFundBalances
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 14381585 | BOY |
| EOY | 14696929 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part XI | X | InfoInScheduleOPartXI |
| Reconcilation Revenue Expenses | 779012 | ReconcilationRevenueExpenses |
| Reconcilation Other Changes | 67696 | ReconcilationOtherChanges |
| Info In Schedule O Part XII | X | InfoInScheduleOPartXII |
| Method Of Accounting Accrual | X | MethodOfAccountingAccrual |
| Accountant Compile Or Review | 0 | AccountantCompileOrReview |
| FS Audited | 1 | FSAudited |
| Audit Committee | 1 | AuditCommittee |
| Financial Statement Consolidated | X | FinancialStatementConsolidated |
| Federal Grant Audit Required | 0 | FederalGrantAuditRequired |
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 C IRS990ScheduleC
| Field | Value | IRS element (for citing) |
|---|---|---|
| Volunteers | 0 | Volunteers |
| Paid Staff Or Management | 0 | PaidStaffOrManagement |
| Media Advertisements | 0 | MediaAdvertisements |
| Mailings Members | 0 | MailingsMembers |
| Publications Or Broadcast | 0 | PublicationsOrBroadcast |
| Grants Other Organizations | 0 | GrantsOtherOrganizations |
| Direct Contact Legislators | 0 | DirectContactLegislators |
| Rallies Demonstrations | 0 | RalliesDemonstrations |
| Other Activities | 1 | OtherActivities |
| Other Activities | $2,836 | OtherActivitiesAmount |
| Total Lobbying Expenditures IIB | 2836 | TotalLobbyingExpendituresIIB |
| Not Described In501c3 | 0 | NotDescribedIn501c3 |
Form990 Schedule C Part IV Form990ScheduleCPartIV
| Field | Value | IRS element (for citing) |
|---|---|---|
| Identifier | EXPLANATION OF OTHER LOBBYING ACTIVITIES: | Identifier |
| Return Reference | PART II-B, LINE 1I: | ReturnReference |
| Explanation | WHA MEMBERSHIP DUES | Explanation |
Schedule D IRS990ScheduleD
Land Land
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 43973 | OtherCostOrOtherBasis |
| Book Value | 43973 | BookValue |
Buildings Buildings
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 11329464 | OtherCostOrOtherBasis |
| Depreciation | 3421758 | Depreciation |
| Book Value | 7907706 | BookValue |
Leasehold Improvements LeaseholdImprovements
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 7750 | OtherCostOrOtherBasis |
| Depreciation | 462 | Depreciation |
| Book Value | 7288 | BookValue |
Equipment Equipment
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 4429898 | OtherCostOrOtherBasis |
| Depreciation | 3965704 | Depreciation |
| Book Value | 464194 | BookValue |
Other Land Buildings OtherLandBuildings
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 423076 | OtherCostOrOtherBasis |
| Book Value | 423076 | BookValue |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Of Book Value Land Buildings | 8846237 | TotalOfBookValueLandBuildings |
Other Liabilities OtherLiabilities
| Field | Value | IRS element (for citing) |
|---|---|---|
| Description | PAYABLE TO THIRD PARTY REIMBURSEMENT PROGRAMS | Description |
| Amount | $845,474 | Amount |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Of Amounts | 845474 | TotalOfAmounts |
| Total Revenue | 15822782 | TotalRevenue |
| Total Expenses | 15043770 | TotalExpenses |
| Excess Or Deficit For Year | 779012 | ExcessOrDeficitForYear |
| Other | $67,696 | OtherAmount |
| Total Adjustments | 67696 | TotalAdjustments |
| Excess Or Deficit Per FS | 846708 | ExcessOrDeficitPerFS |
| Tot Revenue Etc Audited Fincl Stmt | 15868149 | TotRevenueEtcAuditedFinclStmt |
| Other Revenues | 37053 | OtherRevenues |
| Revenue Not Rptd F990 | 37053 | RevenueNotRptdF990 |
| Revenue Subtotal | 15831096 | RevenueSubtotal |
| Other Revenues Not Included | -8314 | OtherRevenuesNotIncluded |
| Revenue Not Rptd On Fin Stmt | -8314 | RevenueNotRptdOnFinStmt |
| Total Revenue Per Form990 | 15822782 | TotalRevenuePerForm990 |
| Tot Expenses Etc Audited Fincl Stmt | 15052084 | TotExpensesEtcAuditedFinclStmt |
| Other Expenses Included | 8314 | OtherExpensesIncluded |
| Expenses Not Rptd F990 | 8314 | ExpensesNotRptdF990 |
| Expenses Subtotal | 15043770 | ExpensesSubtotal |
| Expenses Not Rptd On Fin Stmt | 0 | ExpensesNotRptdOnFinStmt |
| Total Expenses Per Form990 | 15043770 | TotalExpensesPerForm990 |
Form990 Schedule D Part XIV Form990ScheduleDPartXIV (5 entries)
| IdentifierIdentifier | Return ReferenceReturnReference | ExplanationExplanation |
|---|---|---|
| DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: | PART X: | IN ORDER TO ACCOUNT FOR ANY UNCERTAIN TAX POSITIONS, ASC TOPIC 740-10, INCOME TAXES, REQUIRES AN ORGANIZATION TO ASSESS WHETHER IT IS MORE LIKELY THAN NOT THAT A TAX POSITION WILL BE SUSTAINED UPON EXAMINATION OF THE TECHNICAL MERITS OF THE POSITION, ASSUMING THE TAXING AUTHORITY HAS FULL KNOWLEDGE OF ALL INFORMATION. IF THE TAX POSITION DOES NOT MEET THE MORE-LIKELY-THAN-NOT RECOGNITION THRESHOLD, THE BENEFIT OF THAT POSITION IS NOT RECOGNIZED IN THE FINANCIAL STATEMENTS. THE HOSPITAL RECORDS NO ASSETS OR LIABILITIES FOR UNCERTAIN TAX POSITIONS OR UNRECOGNIZED TAX BENEFITS IN 2011 OR 201. FEDERAL INCOME TAX RETURNS FOR THE YEARS ENDED 2008 AND BEYOND REMAIN SUBJECT TO EXAMINATION BY THE INTERNAL REVENUE SERVICE. |
| PART XI, LINE 8 - OTHER ADJUSTMENTS: | CHANGE IN ASSETS HELD IN POLIVKA TRUST 67,696. | |
| PART XII, LINE 2D - OTHER ADJUSTMENTS: | FOUNDATION MARKET ADJUSTMENT 37,053. | |
| PART XII, LINE 4B - OTHER ADJUSTMENTS: | RENTAL EXPENSES -8,314. | |
| PART XIII, LINE 2D - OTHER ADJUSTMENTS: | RENTAL EXPENSES 8,314. |
Schedule H IRS990ScheduleH
| Field | Value | IRS element (for citing) |
|---|---|---|
| Charity Care Policy | 1 | CharityCarePolicy |
| Written Policy | 1 | WrittenPolicy |
| FPG Reference Free Care | 1 | FPGReferenceFreeCare |
| Pcent200 | X | Pcent200 |
| FPG Reference Discounted Care | 0 | FPGReferenceDiscountedCare |
| Free Disc Care Medically Indigent | 1 | FreeDiscCareMedicallyIndigent |
| Amounts Budgeted For Charity Care | 1 | AmountsBudgetedForCharityCare |
| Expenses Exceeded Budget | 1 | ExpensesExceededBudget |
| Unable To Provide Care | 0 | UnableToProvideCare |
| 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 | 539004 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 0 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 539004 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.03820 | PercentOfTotalExpense |
Unreimbursed Medicaid UnreimbursedMedicaid
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 3120079 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 2231672 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 888407 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.06300 | PercentOfTotalExpense |
Total Charity Care TotalCharityCare
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 3659083 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 2231672 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 1427411 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.10120 | PercentOfTotalExpense |
Community Health Services CommunityHealthServices
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 122461 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 17757 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 104704 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.00740 | PercentOfTotalExpense |
Subsidized Health Services SubsidizedHealthServices
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 2747785 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 2328311 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 419474 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.02980 | PercentOfTotalExpense |
Total Other Benefits TotalOtherBenefits
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 2870246 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 2346068 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 524178 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.03720 | PercentOfTotalExpense |
Total Community Benefits TotalCommunityBenefits
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 6529329 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 4577740 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 1951589 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.13840 | PercentOfTotalExpense |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bad Debt Expense Reported | 0 | BadDebtExpenseReported |
| Bad Debt Expense | $473,773 | BadDebtExpenseAmount |
| Amount Attributable To | 0 | AmountAttributableTo |
| Amount Reimbursed By Medicare | 5916318 | AmountReimbursedByMedicare |
| Cost Of Care Reimbursed By Medicare | 5872740 | CostOfCareReimbursedByMedicare |
| Medicare Surplus Or Shortfall | 43578 | MedicareSurplusOrShortfall |
Costing Methodology Used CostingMethodologyUsed
| Field | Value | IRS element (for citing) |
|---|---|---|
| Cost To Charge Ratio | X | CostToChargeRatio |
| 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 | MOUNDVIEW MEMORIAL HOSPITAL | BusinessNameLine1 |
Address Address
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 402 WEST LAKE STREET | AddressLine1 |
| City | FRIENDSHIP | City |
| State | WI | State |
| ZIP Code | 53934 | 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 |
Form990 Schedule H Part V Section B Form990ScheduleHPartVSectionB
Hospital Facility Name HospitalFacilityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | MOUNDVIEW MEMORIAL HOSPITAL | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Hospital Facility Number | 1 | HospitalFacilityNumber |
Form990 Schedule H Part V Section C Form990ScheduleHPartVSectionC
| Field | Value | IRS element (for citing) |
|---|---|---|
| Number Of Other Facilities | 1 | NumberOfOtherFacilities |
Other Facilities OtherFacilities
Name Name
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | MOUNDVIEW CLINIC | BusinessNameLine1 |
Address Address
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 402 WEST LAKE STREET | AddressLine1 |
| City | FRIENDSHIP | City |
| State | WI | State |
| ZIP Code | 53934 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility Type | CLINIC | FacilityType |
Form990 Schedule H Part VI Form990ScheduleHPartVI (14 entries)
| ExplanationExplanation |
|---|
| PART I, LINE 3C: THE ORGANIZAITON DOES NOT OFFER DISCOUNTED CARE. PATIENTS UPON REGISTRATION ARE GIVEN THE POLICY AND REQUIREMENTS TO BE ELIGIBLE FOR CARITY CARE. IF A PATIENT IS QUALIFIED FOR CHARITY CARE, THE ENTIRE AMOUNT IS WRITTEN OFF. |
| PART I, LINE 6A: WI HOSPITAL ASSOCIATION |
| PART I, LINE 7, COLUMN (F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $ 947390. |
| PART II: THE HOSPITAL'S COMMUNITY BUILDING ACTIVITIES PROMOTES HEALTH OF THE COMMUNITIES IT SERVES THROUGH LOCAL ADVERTISEMENTS, INVOLVEMENT WITH CHAMBER OF COMMERCE, DEPARTMENT OF AGING AND OTHER COMMUNITY ORGANIZATIONS. |
| PART III, LINE 4: THE RATIO OF PATIENT COST TO CHARGES WAS CALCULATED BY DIVIDING HOSPITAL EXPENSES NET OF NON-PATIENT REVENUES AND IDENTIFIED COMMUNITY BENEFIT EXPENSES BY GROSS PATIENT REVENUES. THIS PERCENTAGE WAS THEN MULTIPLIED BY THE GROSS REVENUES ON BAD DEBT ACCOUNTS. |
| PART III, LINE 8: IT IS CONSIDERED COMMUNITY BENEFIT AS THE HOSPITAL IS REIMBURSED ON MEDICARE ALLOWABLE COSTS. MEDICARE ALLOWABLE COSTS ARE DEFINED BY MEDICARE. THEY DO NOT NECESSARILY CAPTURE ALL COSTS OF THE HOSPITAL PROVIDING SERVICES TO THE COMMUNITY. CONSEQUENTLY, THERE ARE COSTS NOT REIMBURSED BY EITHER PATIENT OR THE PROGRAM. THE COST METHODOLOGY USED TO DETERMINE MEDICARE ALLOWABLE COSTS IS A STEP-DOWN ALLOCATION OF COSTS FROM NON-REVENUE AREAS TO REVENUE AREAS. THIS ALLOCATION IS DONE FOLLOWING MEDICARE RULES AND REGULATIONS. |
| PART III, LINE 9B: PATIENTS UPON REGISTRATION ARE GIVEN THE POLICY AND REQUIREMENTS TO BE ELIGIBLE FOR CARITY CARE. THEY ARE ENCOURAGED BY A FINANCIAL ADVISOR TO REVIEW THEIR SITUATION FOR ELIGIBILITY. |
| PART I, LINE 7, COLUMN (F)BAD DEBT EXPENSE OF $947,930 INCLUDED ON FORM 990, PART IX, LINE 25 WAS EXCLUDED FROM THE DENOMINATOR PER INSTRUCTIONS WHEN CALCULATING THE PERCENT TATAL EXPENSES ON SCHEDULE H. |
| PART I, LINE 7:AMOUNTS CALCULATED IN PART I, LINE 7 ARE DETERMINED BASED ON COST TO CHARGE RATIOS AND AMOUNTS PER THE FINANCIAL STATEMENTS. |
| PART 1, LINE 7G - THE SUBSIDIZED HEALTH CARE SERVICES WERE ATTRIBUTABLE TO HOSPITAL SERVICES. NONE OF THE SUBSIDIZED HEALTH CARE SERVICES WERE ATTRIBUTABLE TO PHYSICIAN SERVICES. |
| PART VI, LINE 2: THE HOSPITAL DEVELOPS COMMUNITY SURVEY WITH CONJUNCTION OF THE LOCAL PUBLIC HEALTH DEPARTMENT TO ASSESS SPECIFIC UNMET COMMUNITY NEEDS. |
| PART VI, LINE 3: THE HOSPITAL ANNUALLY PUBLISHES IN THE LOCAL PAPER THE EXISTENCE OF ITS CHARITY PLAN AND QUALIFYING INCOME NEEDS TO QUALIFY. THE EXISTENCE OF A CHARITY PLAN IS POSTED IN THE ADMITTING AREA. UPON REGISTRATION, THE PATIENT IS INFORMED OF THE HOSPITAL'S CHARITY PLAN, ELIGIBILITY AND METHODS FOR APPLYING. ANYONE INTERESTED IN FURTHER INFORMATION IS REFERRED TO THE PATIENT ACCOUNT COORDINATOR FOR QUESTIONS AND ELIGIBILITY. THIS PERSON WORKS WITH THE PATIENT IN APPLICATION AS WELL AS EXPLORING THE POSSIBLE ELIGIBILITY OF ANY OTHER GOVERNMENT PROGRAM THAT MAY BE APPLICABLE. IE MEDICAID, BADGER CARE. |
| PART VI, LINE 4: THE ORGANIZATION SERVES ADAMS COUNTY WISCONSIN BORDERED BY HWY 82 SOUTH, COUNTY C NORTH. |
| PART VI, LINE 6: THE HOSPITAL WORKS WITH THE LOCAL PUBLIC HEALTH AGENCIES TO COORDINATE COMMUNITY HEALTH SERVICES TO MEET THE NEEDS OF THE LOCAL COMMUNITY. LONG-RANGE STRATEGIC AND CAPITAL BUDGET PLANNING WITH ADMINISTRATION, MEDICAL STAFF AND BOARD OF DIRECTORS. SURVEY OF OPINIONS FROM HOSPITAL ASSOCIATION. |
Schedule J IRS990ScheduleJ
| Field | Value | IRS element (for citing) |
|---|---|---|
| Independent Consultant | X | IndependentConsultant |
| 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)
| 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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| JEREMY NORMINGTON | |||||||||||||
| 134609 | 0 | 7056 | 0 | 192 | 0 | 0 | 0 | 24710 | 0 | 166567 | 0 | 166567 | 0 |
| MARK HATTON MD | |||||||||||||
| 180948 | 0 | 21174 | 0 | 1032 | 0 | 0 | 0 | 21830 | 0 | 224984 | 0 | 224984 | 0 |
| JASON BELLAK MD | |||||||||||||
| 115403 | 0 | 75966 | 0 | 216 | 0 | 0 | 0 | 18206 | 0 | 209791 | 0 | 209791 | 0 |
Schedule K IRS990ScheduleK
Form990 Schedule K Part I Form990ScheduleKPartI
Issuer Name IssuerName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | VILLAGE OF FRIENDSHIP REVENUE BONDS | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Issuer EIN | 396006271 | IssuerEIN |
| Date Issued | 2003-11-01 | DateIssued |
| Issue Price | 5000000 | IssuePrice |
| Description Of Purpose | WI HOSPITAL DEVELOPMENT REVENUE BONDS | DescriptionOfPurpose |
| Defeased | 0 | Defeased |
| On Behalf Of Issuer | 0 | OnBehalfOfIssuer |
| Pool Financing | 0 | PoolFinancing |
Form990 Schedule K Part II Form990ScheduleKPartII
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Proceeds | 5000000 | TotalProceeds |
| Refunding Escrow | 133406 | RefundingEscrow |
| Capital Expenditures | 4794336 | CapitalExpenditures |
| Year Of Subst Completion | 2005 | YearOfSubstCompletion |
| Current Refunding | 0 | CurrentRefunding |
| Advance Refunding | 0 | AdvanceRefunding |
| Final Allocation Made | 1 | FinalAllocationMade |
| Adequate Books And Recds Maintaind | 1 | AdequateBooksAndRecdsMaintaind |
Form990 Schedule K Part III Form990ScheduleKPartIII
| Field | Value | IRS element (for citing) |
|---|---|---|
| Owning Bond Financed Property | 0 | OwningBondFinancedProperty |
| Any Lease Arrangements | 0 | AnyLeaseArrangements |
| Mngment Cntrct Bond Financd Prprty | 0 | MngmentCntrctBondFinancdPrprty |
| Any Research Agreements | 0 | AnyResearchAgreements |
| Bond Counsel Routinely Engaged | 0 | BondCounselRoutinelyEngaged |
| Prcntge Prvt Business Use By Others | 0.00000 | PrcntgePrvtBusinessUseByOthers |
| Percentage Of Prvt Business Re UBI | 0.00000 | PercentageOfPrvtBusinessReUBI |
| Total Private Business Use | 0.00000 | TotalPrivateBusinessUse |
| Post Issuance Compliance Procdrs | 1 | PostIssuanceComplianceProcdrs |
Form990 Schedule K Part IV Form990ScheduleKPartIV
| Field | Value | IRS element (for citing) |
|---|---|---|
| Form8038 T Filed | 0 | Form8038TFiled |
| Variable Rate Issue | 0 | VariableRateIssue |
| Hedge Identified In Books And Recds | 0 | HedgeIdentifiedInBooksAndRecds |
| Gross Proceeds Invested In GIC | 0 | GrossProceedsInvestedInGIC |
| Gross Proceeds Invested | 0 | GrossProceedsInvested |
| Exception To Rebate | 0 | ExceptionToRebate |
Form990 Schedule K Part V Form990ScheduleKPartV
| Field | Value | IRS element (for citing) |
|---|---|---|
| Identifier | FORM 990, SCHEDULE K, PART III, LINE 7 | Identifier |
| Explanation | MANAGEMENT CALCULATES AND REVIEWS BOND COVENANTS ON A MONTHLY BASIS. THE BOND COVENANTS ARE REPORTED TO THE BOARD OF DIRECTORS. | Explanation |
Schedule O IRS990ScheduleO
General Explanation GeneralExplanation (9 entries)
| IdentifierIdentifier | ExplanationExplanation | Return ReferenceReturnReference |
|---|---|---|
| FORM 990, PART VI, SECTION A, LINE 6 | ANY PERSON OVER THE AGE OF EIGHTEEN YEARS WHO IS A RESIDENT OF ADAMS COUNTY MAY BE A MEMBER OF THE CORPORATION. MEMBERSHIP MAY BE ATTRAINED BY ANY SUCH PERSON WHO SHALL AGREE IN WRITING TO BECOME A MEMBER OF THIS CORPORATION BY SUBSCRIBING TO A MEMBERSHIP LIST OF SAID CORPORATION. ANNUAL MEMBERSHIPS WILL BE IN EFFECT FROM JULY 1ST TO JUNE 30TH OF EACH FISCAL YEAR. | |
| FORM 990, PART VI, SECTION A, LINE 7A | EACH PERSON WHO WAS A MEMBER IN GOOD STANDING AS OF THE PREVIOUS JUNE 30TH IS ENTITLED TO ONE VOTE FOR EACH SEAT OF THE BOARD OF DIRECTORS. | |
| FORM 990, PART VI, SECTION A, LINE 7B | MEMBERS OF THE ORGANIZATION MUST APPROVE BYLAW CHANGES. | |
| FORM 990, PART VI, SECTION B, LINE 11 | THE 990 IS REVIEWED BY THE CEO AND CFO PRIOR TO FILING. | |
| THE CONFLICT OF INTEREST POLICY IS REVIEWED EVERY YEAR BY THE POLICY AND PROCEDURE COMMITTEE AND BY THE CEO. OFFICERS AND DIRECTORS ARE REQUIRED TO REVIEW THE POLICY AND DISCLOSE CONFLICTS. | FORM 990, PART VI, SECTION B, LINE 12C | |
| CEO COMPENSATION IS BASED ON DIRECT NEGOTIATIONS BETWEEN THE BOARD MEMBERS WITHOUT CONFLICT AND THE INDIVIDUAL UTILIZING CURRENT RELEVANT MARKET SURVEYS AS A GUIDE WITH THE LANGUAGE OF CONTRACT GIVEN TO MMC ATTORNEYS FOR REVIEW AND COMMENTS. SUBSEQUENT MODIFICATIONS ARE PERFORMANCE BASED AND MARKET DRIVEN. FOR OTHER OFFICERS AND KEY EMPLOYEES THE CEO DETERMINES SALARY BASED ON THE MARKET, EXPERIENCE AND INDUSTRY SURVEY GUIDES. | FORM 990, PART VI, SECTION B, LINE 15 | |
| THE ORGANIZATION BELIEVES THE GOVERNING DOCUMENTS, AND POLICIES ARE THE PROPERTY OF THE ORGANIZATION AND ARE NOT AVAILABLE FOR PUBLIC INSPECTION. THE FINANCIAL STATEMENTS ARE NOW REQUIRED TO BE ATTACHED TO FORM 990. | FORM 990, PART VI, SECTION C, LINE 19 | |
| CHANGES IN NET ASSETS OR FUND BALANCES: | CHANGE IN ASSETS HELD IN POLIVKA TRUST 67,696. TOTAL TO FORM 990, PART XI, LINE 5: 67,696. | FORM 990, PART XI, LINE 5: |
| OVERSIGHT OF AUDIT AND SELECTION OF INDEPENDENT AUDITOR IS THE RESPONSIBILITY OF THE AUDIT COMMITTEE. THIS PROCESS HAS NOT CHANGE FROM THE PRIOR YEAR. | FORM 990, PART XI, LINE 2C |
Schedule R IRS990ScheduleR
Form990 Schedule R Part II Form990ScheduleRPartII
Name Of Disregarded Entity NameOfDisregardedEntity
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | MEMORIAL HEALTHCARE FOUNDATION OF ADAMS CO | BusinessNameLine1 |
Address US AddressUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | PO BOX 40 | AddressLine1 |
| City | FRIENDSHIP | City |
| State | WI | State |
| ZIP Code | 53934 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 391775074 | EIN |
| Primary Activities | RAISE FUNDS FOR MOUNDVIEW MEMORIAL HOSPITAL & CLINICS | PrimaryActivities |
| Legal Domicile State | WI | LegalDomicileState |
| Exempt Code Section | 501(C)(3) | ExemptCodeSection |
| Public Charity Status | 11B, TYPE II | PublicCharityStatus |
Direct Controlling Entity Name DirectControllingEntityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | MOUNDVIEW MEMORIAL HOSPITAL & CLINICS | 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 | 0 | 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 |
| 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 | 0 | PerformOfServicesByOtherOrgs |
| Sharing Of Facilities | 0 | SharingOfFacilities |
| Sharing Of Paid Employees | 0 | SharingOfPaidEmployees |
| Reimbursement Paid To Other Org | 0 | 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
Name Of Other Organization NameOfOtherOrganization
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | MEMORIAL HOSPITAL FOUNDATION OF ADAMS CO | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Transaction Type | C | TransactionType |
| Amount Involved | 20867 | AmountInvolved |
| Method Of Amt Determination | CASH CONTRIBUTIONS | MethodOfAmtDetermination |