2012-08-15T04:53:55-05:00 2011-09-30 WIPFLI LLP PO BOX 12237 GREEN BAY WI 543072237 990 2010-10-01 396089134 WILD ROSE COMMUNITY MEMORIAL HOSPITAL INC WILD 9206223257 PO BOX 243 WILD ROSE WI 549840243 THOMAS KRYSTOWIAK 9203611313 2012-08-13 1 TERRI REXRODE CPA 9206620016 2012-08-13 2010 2016-02-24 21:20:13Z DONALD CAVES PO BOX 243 WILD ROSE WI 549840243 13767533 0 X WWW.WILDROSEHOSPITAL.ORG X 1956 WI WILD ROSE HOSPITAL PROVIDES INPATIENT AND OUTPATIENT HOSPITAL AND CLINIC SERVICES TO THE GREATER WAUSHARA COUNTY AREA. 10 8 171 85 0 0 138949 153539 10031819 13602051 3884 5355 0 1922 10174652 13762867 0 0 0 0 4281606 6083063 0 0 0 5884072 7524737 10165678 13607800 8974 155067 5155368 6030710 6776993 7497268 -1621625 -1466558 X PROVIDE SUPERIOR SERVICES TO IMPROVE THE HEALTH OF THOSE WE SERVE. 0 0 11621732 13499409 WILD ROSE HOSPITAL'S MISSION IS TO "PROVIDE SUPERIOR SERVICES TO IMPROVE THE HEALTH OF THOSE WE SERVE." IN PURSUIT OF ITS PRIMARY EXEMPT PURPOSE OF PROVIDING INPATIENT AND OUTPATIENT HOSPITAL AND CLINIC SERVICES TO THE WAUSHARA COUNTY AREA, WILD ROSE HOSPITAL PROVIDES MEDICAL CARE AND OTHER FINANCIAL SUPPORT THROUGH VARIOUS PROGRAMS THAT ARE DESIGNED, AMONG OTHER MATTERS, TO ENHANCE THE HEALTH OF THE COMMUNITY. WILD ROSE HOSPITAL BELIEVES IT HAS A SPECIAL DUTY TO MEET THE NEEDS OF THE POOR, INDIGENT, AND MEDICALLY UNDERSERVED IN THE COMMUNITIES AND SURROUNDING AREAS. THEY HAVE PROVIDED CARE TO ALL PATIENTS WITHOUT REGARD FOR THE ABILITY TO PAY.WILD ROSE HOSPITAL ACTIVELY PROVIDED OR PARTICIPATED IN THE FOLLOWING COMMUNITY-BASED ACTIVITIES AND PROGRAMS:- GENERAL HEALTH EDUCATION SERVICES SUCH AS HEALTH FAIRS- PROVIDED HEALTH INFORMATION ON THE CORPORATION'S WEB SITE AND THROUGH HEALTH RELATED PUBLICATIONS DISTRIBUTED AT NO CHARGE- DIABETES EDUCATION AND SUPPORT GROUP AND BALANCE TRAINING (PHYSICAL THERAPY)- HOSTED SELF-HELP AND WELLNESS PROGRAMS SUCH AS AA, AL-ANON, DIET- BLOOD PRESSURE SCREENINGS, CHOLESTEROL TESTING AND SCHOOL-BASED TESTING- GUIDANCE, REFERRAL AND ENROLLMENT ASSISTANCE FOR PUBLIC MEDICAL PROGRAMS AND OTHER FAMILY SUPPORT ASSISTANCE- DISCOUNTED OR FREE MEDICAL SUPPLIES AND EQUIPMENT TO THOSE UNABLE TO PAY- HOSTED FIVE BLOOD DRIVES AND ENCOURAGED EMPLOYEE PARTICIPATION- CONTRIBUTED TO THE EDUCATION OF STUDENT NURSES AND OTHER HEALTH CARE PROFESSIONALS- PROVIDED FIRST AID FOR COMMUNITY SPORTING EVENTS- PARTICIPATED IN WORK HEALTH EDUCATION PROGRAMS THROUGH PRIMARY CARE INITIATIVE PROGRAM- MADE CASH CONTRIBUTIONS TO SUPPORT COMMUNITY SERVICES AND EVENTS- PROVIDED MEETING ROOMS TO COMMUNITY GROUPS AT NO CHARGE WILD ROSE HOSPITAL OPERATES AN EMERGENCY ROOM THAT IS OPEN TO ALL PERSONS REGARDLESS OF ABILITY TO PAY. IT HAS AN OPEN MEDICAL STAFF WITH PRIVILEGES AVAILABLE TO ALL QUALIFIED PHYSICIAN IN THE AREA. THE MAJORITY OF THE BOARD OF DIRECTORS IS COMPRISED OF INDEPENDENT INDIVIDUALS WHO ARE REPRESENTATIVE OF THE COMMUNITY. CONSISTENT WITH WILD ROSE HOSPITAL'S MISSION, CARE IS PROVIDED TO PATIENTS REGARDLESS OF THEIR ABILITY TO PAY, INCLUDING PROVIDING SERVICES TO THOSE PERSONS WHO CANNOT AFFORD HEALTH INSURANCE BECAUSE OF INADEQUATE RESOURCES OR THOSE WHO ARE UNDERINSURED. WILD ROSE HOSPITAL GIVES DISCOUNTS FROM ESTABLISHED CHARGES TO SELF-PAY PATIENTS WITHOUT REGARD TO ABILITY TO PAY AND CONSIDERS THESE DISCOUNTS A PART OF ITS COMMUNITY BENEFIT. HEALTH CARE SERVICES TO PATIENTS UNDER GOVERNMENT PROGRAMS, SUCH AS MEDICAID, ARE ALSO CONSIDERED PART OF WILD ROSE HOSPITAL'S BENEFIT PROVIDED TO THE COMMUNITY SINCE A SUBSTANTIAL PORTION OF SUCH SERVICES ARE REIMBURSED AT AMOUNTS LESS THAN THE COST OF PROVIDING CARE. PATIENTS WHO MEET CRITERIA FOR CHARITY CARE, GENERALLY BASED ON FEDERAL POVERTY GUIDELINES, ARE PROVIDED CARE WITHOUT CHARGE OR AT A REDUCED RATE. ELIGIBILITY FOR CHARITY CARE IS DETERMINED BASED ON QUALIFYING CRITERIA AS DEFINED IN WILD ROSE HOSPITAL'S CHARITY CARE POLICY AND FROM APPLICATIONS COMPLETED BY PATIENTS AND THEIR FAMILIES. IN 2011 OVER 350 ACCOUNTS RECEIVED CHARITY CARE WITH A TOTAL COST OF OVER $207,000. 11621732 1 1 0 1 0 0 0 0 0 0 1 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 1 0 0 0 0 1 12 0 1 171 1 0 0 0 0 0 0 0 0 0 0 X 10 8 0 0 0 0 0 0 1 1 1 0 0 0 1 1 1 1 1 1 0 0 WI X THOMAS P KRYSTOWIAK 9203611313 225 MEMORIAL DRIVE BERLIN WI 54984 X LYNN CREAMER 0.50 X 0 0 0 RICHARD A HOTCHKISS 0.50 X 0 0 0 JAMES ERDMAN 0.50 X 0 0 0 PATRICK MORROW 0.50 X 0 0 0 MARK KJENTVET MD 0.50 X 0 0 0 ROGER WILLIAMS 0.50 X X 0 0 0 FREDERICK GELLERUP 0.50 X X 0 0 0 CAROL WILLIAMS 0.50 X X 0 0 0 ALLEN STEA 0.50 X X 0 0 0 DONALD CAVES 9.00 X X 36568 125957 22786 CHAD VOSKUIL MD 40.00 X 258602 0 32718 MICHAEL STAUDINGER MD 40.00 X X 259453 0 25420 THOMAS KRYSTOWIAK 1.00 X 3579 152094 28373 558202 278051 109297 1 0 1 0 COMMUNITY HEALTH NETWORK 225 MEMORIAL DRIVE BERLIN WI 54923 MANAGEMENT AND PHYSICIAN SERVICES 3559739 SHARED MEDICAL EQUIPMENT PO BOX 330 COTTAGE GROVE WI 53527 MRI SERVICES 109125 2 146139 7400 153539 NET PATIENT SERVICE RE 621990 13499409 13499409 OTHER OPERATING REVENU 900099 102642 102642 13602051 5355 5355 6588 4666 1922 1922 1922 13762867 13499409 0 109919 622119 622119 4117988 3398600 719388 102566 82069 20497 895835 888952 6883 344555 287825 56730 34679 34679 20300 20300 2855607 2758122 97485 23838 2747 21091 1669541 1625733 43808 22901 22901 865958 799929 66029 53236 46635 6601 238928 194142 44786 134456 109253 25203 BAD DEBT EXPENSE 1098750 1098750 MISCELLANEOUS 460716 284188 176528 DUES AND SUBSCRIPTIONS 18157 11495 6662 RECRUITMENT 16139 16139 CERTIFICATIONS 11531 10391 1140 13607800 11621732 1986068 0 657941 1338349 63947 71372 2549213 2633387 216248 224683 18757 35281 4730589 3002951 1649262 1727638 5155368 6030710 2193639 2817719 583354 679549 4000000 4000000 6776993 7497268 X -1621625 -1466558 -1621625 -1466558 5155368 6030710 155067 0 X X 0 1 0 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 1238 1238 0 EXPLANATION OF OTHER LOBBYING ACTIVITIES: PART II-B, LINE 1I: WHA DUES 72982 72982 1415851 745382 670469 66340 59124 7216 3175416 2198445 976971 1727638 LONG TERM NOTES PAYABLE TO RELATED PARTY 4000000 4000000 13762867 13607800 155067 0 155067 13767533 4666 4666 13762867 0 13762867 13612466 4666 4666 13607800 0 13607800 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: IN ORDER TO ACCOUNT FOR ANY UNCERTAIN TAX POSITIONS, THE HOSPITAL DETERMINES 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 RECORDED NO ASSETS OR LIABILITIES RELATED TO UNCERTAIN TAX POSITIONS OR UNRECOGNIZED TAX BENEFITS IN 2011 OR 2010. PART XII, LINE 2D - OTHER ADJUSTMENTS: EXPENSE ALLOCATION TO RENTAL INCOME 4,666. PART XIII, LINE 2D - OTHER ADJUSTMENTS: EXPENSE ALLOCATION TO RENTAL INCOME 4,666. 1 1 X 1 X 1 X 1 1 1 0 1 1 254588 254588 0.02040 1644946 585667 1059279 0.08470 1899534 585667 1313867 0.10510 3704 3704 0.00030 210 210 0.00000 23759 23759 0.00190 27673 27673 0.00220 1927207 585667 1341540 0.10730 1600 1600 0.00010 8024 8024 0.00060 1800 1800 0.00010 11424 11424 0.00080 1 469782 0 4418605 4373516 45089 X 0 1 1 WILD ROSE COMMUNITY MEMORIAL HOSPITAL

601 GROVE AVE WILD ROSE WI 54984

X X X X WILD ROSE COMMUNITY MEMORIAL HOSPITAL 1 4 WFP WILD ROSE

701 GROVE AVE WILD ROSE WI 54984

OUTPATIENT PHYSICIAN CLINIC WFP PLAINFIELD

N6493 VALLEY CIRCLE ROAD PLAINFIELD WI 54966

OUTPATIENT PHYSICIAN CLINIC WFP WAUTOMA

N2934 HWY 22 NORTH WAUTOMA WI 54982

OUTPATIENT PHYSICIAN CLINIC WFP COLOMA

141 FRONT STREET COLOMA WI 54930

OUTPATIENT PHYSICIAN CLINIC PART I, LINE 7: COST TO CHARGE RATIO. PART I, L7 COL(F): BAD DEBT EXPENSE OF $1,098,750 FROM FORM 990, PART IX, LINE 25 WAS REMOVED FOR THE PURPOSE OF CALCULATING THE PERCENTAGES IN PART 1, LINE 7, COLUMN (F). PART II: WILD ROSE HOSPITAL ENGAGES IN SEVERAL COMMUNITY BUILDING ACTIVITIES. OUR DISASTER READINESS PROGRAMS ARE DEVELOPED TO EXCEED THE MINIMUM REQUIREMENTS IN ORDER TO PROVIDE A RESPONSIBLE LEVEL OF SERVICE TO THE COMMUNITY. WE ALSO SUPPORT WATCH GROUPS, PARTICIPATE IN THE EMS ROUNDTABLE AND PROVIDE ADMINISTRATIVE AND MEETING ROOM SUPPORT FOR OTHER NOT-FOR-PROFITS. ALL OF THESE EFFORTS ARE FOCUSED ON MINIMIZING THE HEALTH IMPACT OF CATASTROPHES, LARGE AND SMALL, AS WELL AS SUPPORTING HEALTHY ACTIVITIES AND GROUPS WITH A QUALITY OF LIFE FOCUS. PART III, LINE 4: THE COSTING METHODOLOGY USED IN DETERMINING THE AMOUNTS ABOVE IS A COST TO CHARGE RATIO BASED ON THE TOTAL OPERATING EXPENSE NET OF COMMUNITY BENEFIT EXPENSES AND NON-PATIENT CARE OPERATIONS, AND PATIENT CHARGES NET OF COMMUNITY BENEFIT CHARGES. MANY PATIENTS WHOSE ACCOUNTS/OUT-OF-POCKET LIABILITY ARE WRITTEN OFF TO BAD DEBT ARE UNABLE TO PAY BUT DID NOT COMPLETE THE PROCESS FOR CHARITY CARE/FINANCIAL ASSISTANCE. BECAUSE THESE PATIENTS WOULD HAVE QUALIFIED FOR CHARITY CARE, BUT DIDN'T COMPLETE THE PROCESS, THESE BAD DEBT WRITE-OFFS SHOULD BE CONSIDERED COMMUNITY BENEFIT AS CHARITY CARE. IN ADDITION, WILD ROSE HOSPITAL CONTINUES TO SERVE PATIENTS WHOSE ACCOUNTS ARE WRITTEN OFF TO BAD DEBT EVEN THOUGH THERE IS A GOOD CHANCE FUTURE SERVICES MAY CONTINUE TO BE WRITTEN OFF TO BAD DEBT, WHICH DEMONSTRATES A COMMUNITY BENEFIT, SERVING PATIENTS EVEN THOUGH WE MAY NOT BE PAID. PART III, LINE 8: THE ORGANIZATION USES A COST TO CHARGE RATIO TO CALCULATE ALLOWABLE COSTS ABOVE. ANY SHORTFALL SHOULD BE TREATED AS COMMUNITY BENEFIT BECAUSE WILD ROSE HOSPITAL CONTINUES TO SERVE THE MEDICARE POPULATION REGARDLESS OF WHETHER THEY COVER THEIR COSTS. WILD ROSE HOSPITAL HAS A SURPLUS BECAUSE IT IS A CRITICAL ACCESS HOSPITAL AND AS A CRITICAL ACCESS HOSPITAL, IT RECEIVES 101% OF ITS COST PER MEDICARE. PART III, LINE 9B: PATIENTS WHO HAVE AN APPLICATION OUTSTANDING ARE NOT KNOWINGLY SENT TO COLLECTIONS. PATIENTS WHO QUALIFY FOR 100% CHARITY HAVE THE ENTIRE AMOUNT OF THE BILL WRITTEN OFF AND NO FURTHER COLLECTION PROCEDURES ARE DONE. BALANCES REMAINING AFTER CHARITY CARE PERCENTAGE HAS BEEN DETERMINED (THOSE WHO QUALIFY FOR FINANCIAL ASSITANCE/PARTIAL CHARITY CARE) ARE CONSIDERED SELF PAY AND PAYMENT ARRANGEMENTS MUST BE MADE. SHOULD THE PATIENT FAIL TO MAKE PAYMENT ARRANGEMENTS OR MAINTAIN THE PAYMENTS AGREED UPON THEY WILL BE NOTIFIED IN WRITTING THAT THE ACCOUNT BALANCE IS PAST DUE AND THE ACCOUNT WILL BE SUBJECT TO NORMAL COLLECTION PROCEDURES. PART VI, LINE 2: WILD ROSE HOSPITAL WORKS IN COLLABORATION WITH WAUSHARA COUNTY PUBLIC HEALTH TO ASSESS COMMUNITY NEEDS IN ORDER TO CREATE A PLAN OF CARE BASED ON THOSE ISSUES AND CONCERNS IDENTIFIED BY THE MULTIAGENCY INCLUDING PUBLIC HEALTH AGING AND DISABILITY RESOURCE CENTER. WILD ROSE HOSPITAL ALSO PARTICIPATES WITH THE WAUSHARA WELLNESS COALITION. THE WAUSHARA WELLNESS COALITION CONSISTS OF MULTIDISCIPLINARY TEAM THAT MEETS FOUR TO SIX TIMES A YEAR TO DEVELOP PLANS FOR NEEDED SERVICES. IN THE EFFORT TO PROVIDE COMPREHENSIVE CARE THE WAUSHARA WELLNESS COALITION ALSO STRIVES TO DECREASE INEFFICIENCIES DUE TO OVERLAP OF CARE PROVIDERS AND ORGANIZATIONS IN THE AREA. PART VI, LINE 3: SELF PAY PATIENTS ARE CONTACTED BY A MEMBER OF THE PATIENT ACCOUNTING STAFF TO INFORM THEM OF AVAILABLE GOVERNMENT PROGRAMS AND CHARITY CARE. IF APPROPRIATE THE PATIENT ACCOUNTING STAFF WILL OFFER ASSISTANCE WITH THE COMPLETION OF THE COMMUNITY CARE (CHARITY CARE) APPLICATION. PART VI, LINE 4: WILD ROSE HOSPITAL IS IN AN HPSA AREA AND IS THE ONLY HOSPITAL IN WAUSHARA COUNTY. AS OF THE CENSUS OF 2007 THERE WERE 25,215 RESIDENTS OCCUPYING 9,500 HOUSEHOLDS WITH A 75% INCREASE IN POPULATION DURING THE SUMMER. THE ELDERLY COMPRISE 18.3% OF THE POPULATION COMPARED WITH 15.2% STATEWIDE. THE AVERAGE ANNUAL WAGE IN 2009 WAS ABOUT 30% LESS THAN THE STATE AVERAGE. APPROXIMATELY 10.3% OF THE POPULATION LIVE BELOW THE POVERTY LEVEL . THERE ARE NO MAJOR POPULATION CENTERS IN WAUSHARA COUNTY WITH THE LARGEST COMMUNITY BEING WAUTOMA HAVING A POPULATION OF 2194. THE POPULATION CONSISTS OF 20% UNDER THE AGE OF 20, 12% FROM 20 TO 29, 33% FROM 30 TO 54, 16% FROM 55 TO 64 AND 19% WHO WERE 65 AND OLDER. THE MEDIAN AGE WAS 42 YEARS AND THE GENDER PERCENTAGE IS 50.39% MALE, 49.61% FEMALE. PART VI, LINE 6: THE MAJORITY OF OUR ORGANIZATION'S GOVERNING BODY IS COMPRISED OF PERSONS WHO RESIDE IN THE ORGANIZATION'S PRIMARY SERVICE AREA WHO ARE NEITHER EMPLOYEES NOR CONTRACTORS OF THE ORGANIZATION, NOR FAMILY MEMBERS THEREOF. WILD ROSE HOSPITAL CONDUCTS HEALTH FAIRS AND CAREER FAIRS FOR THE COMMUNITY TO ENCOURAGE HEALTHY LIFESTYLES AND TO RAISE AWARENESS OF HEALTH ISSUES AND TRENDS AS WELL AS CAREER OPPORTUNITIES WITHIN THE LOCAL HEALTH FACILITIES.WE ALSO CONDUCT CPR AND FIRST AID CLASSES, EDUCATION AND OUTREACH FOR SENIOR CITIZENS, EDICATIONAL OPPORTUNITIES FOR PHYSICIANS AND MEDICAL STUDENTS, AS WELL AS CHOLESTEROL SCREENING. IN ADDITION, WE ADMINISTER A DIABETES SUPPORT GROUP. PART VI, LINE 7: WILD ROSE HOSPITAL IS AFFILIATED WITH COMMUNITY HEALTH NETWORK THROUGH PARTNERS HEALTH SYSTEM (PHS). THE BENEFIT IS A COORDINATED EFFORT TO PROVIDE COMPREHENSIVE HEALTH CARE TO AN EXTENDED, MULTI-COUNTY RURAL AREA. AN ADDITIONAL BENEFIT IS INCREASED EFFICIENCIES THROUGH SHARED RESOURCES, THEREFORE PROVIDING A WIDER RANGE OF HEALTH SERVICES THROUGHOUT THE ENTIRE COMBINED SERVICE AREA. REPORTS FILED WITH STATES PART VI, LINE 7 WI X X 0 1 0 0 0 0 0 0 0 DONALD CAVES 32503 111954 0 0 4065 14003 1489 5127 3638 12532 41695 143616 0 0 CHAD VOSKUIL MD 258602 0 0 0 0 0 7350 0 25368 0 291320 0 0 0 MICHAEL STAUDINGER MD 259453 0 0 0 0 0 7350 0 18070 0 284873 0 0 0 THOMAS KRYSTOWIAK 3300 140253 0 0 279 11841 186 7925 466 19796 4231 179815 0 0 PART I, LINE 4B CHAD VOSKUIL, MD AND MICHAEL STAUDINGER, MD PARTICIPATED BUT DID NOT RECEIVE PAYMENT FROM A NONQUALIFIED RETIREMENT PLAN. ANDREEN KJENTVET WIFE OF BOARD MEMBER. 30569 COMPENSATION 0 CHANDLER CAVES SON OF CEO 432101 COMPENSATION - COMMON LAW EMPLOYEE. CHANDLER IS EMPLOYED BY CHN (RELATED PARTY) BUT WORKS EXCLUSIVELY AT WILD ROSE HOSPITAL. 0 FORM 990, PART VI, SECTION A, LINE 7B WILD ROSE HOSPITAL HAS DELEGATED TO THE PHS BOARD THE FOLLOWING AUTHORITY: - PHS SHALL ESTABLISH OVERALL STRATEGIC & BUDGETARY OBJECTIVES FOR THE SYSTEM (INCLUDES WRH) - PHS SHALL REVIEW, CONSOLIDATE, MODIFY AND APPROVE OR DISAPPROVE STRATEGIC PLANS PREPARED BY THE PARTIES - PHS SHALL INITIATE AND APPROVE CAPITAL PROJECTS FOR OR ON BEHALF OF THE PARTIES - PHS SHALL INITIATE AND APPROVE THE INCURRENCE OF DEBT BY THE PARTIES - PHS MAY CONTRACT ON BEHALF OF THE PARTIES - PHS SHALL ESTABLISH CHARGE RATES FOR THE PARTIES - PHS CEO SHALL HIRE THE CEOS OF THE PARTIES SUBJECT TO APPROVAL OF THE BOARD OF DIRECTORS OF THE APPLICABLE PARTY - PHS CEO SHALL HAVE THE AUTHORITY TO TERMINATE THE CEO OF A PARTY, SUBJECT TO THE CONSENT OF THE CHAIR OF THE BOARD OF THE PARTY. - PHS SHALL MANAGE THE SYSTEMS EMPLOYED PHYSICIANS FORM 990, PART VI, SECTION B, LINE 11 THE BOD HAS DELEGATED THE DETAILED REVIEW OF THE FORM 990 TO MANAGEMENT OF THE CORPORATION. THEY COMPLETED THE REVIEW PRIOR TO SUBMISSION. FORM 990, PART VI, SECTION B, LINE 12C PERIODIC REVIEWS ARE PERFORMED. FORM 990, PART VI, SECTION B, LINE 15A THE PRESIDENT OF WILD ROSE HOSPITAL WAS EMPLOYED BY COMMUNITY HEALTH NETWORK (CHN) FOR THE CALENDAR YEAR ENDING WITHIN WRH'S TAX YEAR. ONCE A YEAR, CHN'S CEO REVIEWS COMPENSATION BENCHMARK DATA AND COMPARES THE DATA WITH WILD ROSE HOSPITAL PRESIDENT'S CURRENT SALARY AND THE PROPOSED INCREASE. BASED ON THE DATA, THE CEO DETERMINES THE PRESIDENT'S SALARY FOR THE COMING YEAR. THE QUESTION IS MARKED "NO" BECAUSE THE PROCESS IS NOT DOCUMENTED. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S FINANCIAL STATEMENTS, CONFLICT OF INTEREST POLICY, AND GOVERNING DOCUMENTS ARE THE PROPERTY OF THE ORGANIZATION AND ARE NOT AVAILABLE FOR INSPECTION, EXCEPT DISCLOSURE OF THE FINANCIAL STATEMENTS WITH THE FORM 990, AS REQUIRED. MANAGEMENT AFFILIATION FORM 990, PART VI, LINE 3 WILD ROSE COMMUNITY MEMORIAL HOSPITAL IS AFFILIATED WITH COMMUNITY HEALTH NETWORK (CHN), A 501(C)(3) ORGANIZATION, THROUGH AN AFFILIATION AGREEMENT BETWEEN THE TWO ORGANIZATIONS. THE AFFILIATION AGREEMENT IS DATED AUGUST 19, 2009, EFFECTIVE OCTOBER 1, 2009. BOTH ORGANIZATIONS HAVE FORMED PARTNERS HEALTH SYSTEM (PHS), A 501(C)(3) ORGANIZATION, WITH THE INTENT OF CREATING AN INTEGRATED HEALTH CARE DELIVERY SYSTEM. THROUGH PHS, SOME OF WILD ROSE HOSPITAL'S MANAGEMENT DUTIES ARE DELEGATED TO PHS OR CHN SUCH AS: - CONTRACTING FOR SERVICES AND PURCHASING OF EQUIPMENT AND SUPPLIES - SETTING OF CHARGES - BILLING AND COLLECTIONS - DEVELOPMENT OF POLICIES AND PROCEDURES - PREPARATION OF BUDGETS - PREPARATION OF FINANCIAL AND COST REPORTS - CONTRACTING FOR SERVICES BY HEALTH CARE PROVIDERS - HANDLING OF MATTERS INVOLVING MEDICAL STAFF RELATIONS - PROVIDE ANESTHESIA COVERAGE HOURS WORKED AT RELATED ORGANIZATIONS FORM 990,PART XII, SECTION A THOMAS KRYSTOWIAK WORKED AN AVERAGE OF 43 HOURS PER WEEK AT RELATED ORGANIZATIONS. DONALD CAVES WORKED AN AVERAGE OF 32 HOURS PER WEEK AT A RELATED ORGANIZATION. OVERSIGHT OF AUDIT PART XI, LINE 2C THE PROCESS HAS NOT CHANGED FROM PRIOR YEAR. COMMUNITY HEALTH NETWORK INC 225 MEMORIAL DRIVE BERLIN WI 54923 390806359 HOSPITAL WI 501(C)(3) LINE 3 PARTNERS HEALTH SYSTEM INC 0 PARTNERS HEALTH SYSTEM INC 225 MEMORIAL DRIVE BERLIN WI 54923 271119447 SUPPORTING ORGANIZATION WI 501(C)(3) LINE 11B, II N/A 0 PARTNERS HEALTH SYSTEM FOUNDATION 225 MEMORIAL DRIVE BERLIN WI 54923 731639346 SUPPORTING ORGANIZATION WI 501(C)(3) LINE 11B, II PARTNERS HEALTH SYSTEM INC 0 0 0 0 0 1 0 0 0 0 1 0 0 1 1 1 0 0 0