2012-05-15T13:41:57-05:00 2011-06-30 BAKER TILLY VIRCHOW KRAUSE LLP 500 MIDLAND COURT PO BOX 8130 JANESVILLE WI 535478130 990 2010-07-01 390816848 MERCY HEALTH SYSTEM CORPORATION MERC 6087566000 PO BOX 5003 - 1000 MINERAL POINT JANESVILLE WI 535475003 JAVON BEA 6087566000 2012-05-15 1 WILLIAM T MURPHY CPA 6087525835 2012-05-14 2010 2016-02-24 21:20:13Z JAVON BEA PO BOX 5003 - 1000 MINERAL POINT JANESVILLE WI 535475003 483850130 0 X WWW.MERCYHEALTHSYSTEM.ORG X 1972 WI THE MISSION OF MERCY HEALTH SYSTEM IS TO PROVIDE EXCEPTIONAL HEALTH CARE SERVICES RESULTING IN HEALING IN THE BROADEST SENSE. 9 7 3553 0 10690442 -53158 239288 248889 419084944 448360006 658102 969845 1891518 3692206 421873852 453270946 0 0 0 0 254680596 262293640 0 0 0 150038775 165283940 404719371 427577580 17154481 25693366 342696939 387688494 243539510 252414775 99157429 135273719 THE MISSION OF MERCY HEALTH SYSTEM IS TO PROVIDE EXCEPTIONAL HEALTH CARE SERVICES RESULTING IN HEALING IN THE BROADEST SENSE. 0 0 351580812 436647657 HOSPITAL DISCHARGES 9,786, NURSING HOME ADMISSIONS 315, BIRTHS 1,152, OUTPATIENT VISITS 1,132,938 351580812 1 1 0 0 0 0 0 0 0 1 1 0 0 1 0 1 1 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 1 0 0 0 1 292 0 1 3553 1 1 1 0 0 0 0 0 0 0 0 0 X 9 7 0 0 0 0 0 0 0 1 1 0 0 0 1 1 1 1 1 1 1 0 IL WI X JOHN COOK 6087566642 1000 MINERAL POINT JANESVILLE WI 535475003 ROWLAND MCCLELLAN 1.00 X 455 0 0 THOMAS POOL 1.00 X 13500 0 0 LARRY SQUIRE 1.00 X 728 0 0 SIMA WEXLER 1.00 X 0 0 0 DAVE SYVERSON 1.00 X 13500 0 0 MARK GOELZER MD 1.00 X 0 0 0 ROBERT CONSIGNY 1.00 X 62 0 0 STEVE VAN GALDER 1.00 X 728 0 0 KATHERINE SCHACK 1.00 X 1062 0 0 BARB BORTNER 55.00 X 201251 0 21805 DAN COLBY 55.00 X 280650 0 39562 DAVID KURTZ 55.00 X 215552 0 41605 JOHN COOK 55.00 X 342847 0 37355 KATHY HARRIS 55.00 X 137935 0 16483 RUTH YARBROUGH 55.00 X 257040 0 40105 RICHARD GRUBER 55.00 X 209385 0 24078 RALPH TOPINKA 55.00 X 382714 0 39699 JOSEPH NEMETH 55.00 X 217326 0 41498 SUE RIPSCH 55.00 X 359970 0 26105 JAVON BEA 55.00 X X 2269615 0 1500328 BRADLEY FIDELER 40.00 X 2631159 0 230080 CAROL NEUMAN 40.00 X 1584033 0 96523 CHRISTOPHER STURM 40.00 X 1552218 0 50257 JAMES KIRSCHBAUM 40.00 X 1148906 0 55440 VIKRAM KHANNA 40.00 X 1065665 0 55029 12886301 0 2315952 356 1 1 0 MAGILL CONSTRUCTION COMPANY 977 KOOPMAN LANE ELKHORN WI 53121 CONSTRUCTION 3605462 WALSH CONSTRUCTION COMPANY II LLC 929 WEST ADAMS CHICAGO IL 60607 CONSTRUCTION 3078086 ELLERBE BECKET NW 8400 PO BOX 1450 MINNEAPOLIS MN 554858400 ARCHITECTUAL SERVICES 2747922 MANN BROS INC PO BOX 48 ELKHORN WI 53121 CONSTRUCTION 1285571 QUEST DIAGNOSTICS PO BOX 12989 CHICAGO IL 60693 LAB SERVICES 1271089 39 248889 248889 PATIENT SERVICE REVENU 621110 436647657 436647657 UNRELATED BUSINESS INC 561000 10690442 10690442 CAFETERIA 722210 1021907 1021907 448360006 861887 861887 30359980 327162 30122316 456868 237664 -129706 107958 107958 OTHER INVESTMENTS 900099 3458443 3458443 MISCELLANEOUS 900099 233763 233763 3692206 453270946 436647657 10690442 5683958 6474119 6474119 208697203 169814132 38883071 9519964 6980428 2539536 25125177 18663168 6462009 12477177 9529306 2947871 728812 728812 48300 48300 77388 77388 19088958 10139793 8949165 3170779 70186 3100593 76119009 72306642 3812367 1090127 383195 706932 7249665 6559497 690168 728008 302415 425593 1320457 931113 389344 5021698 4543632 478066 19596159 17712398 1883761 5464602 4509354 955248 BAD DEBTS 20416447 20416447 0 0 WI MEDICAID & OTHER TAX 6802235 6802235 0 0 EQUIPMENT REPAIRS & MAI 5688351 3939956 1748395 0 MEMBERSHIPS & DUES 1219312 791996 427316 0 INTER-ENTITY TRANSACTIO -11227652 -2873831 -8353821 0 2681285 58750 2622535 427577580 351580812 75996768 0 16320 17070 13332054 15650700 67615922 61920944 9501828 9690306 4648927 4665485 394028926 175726717 173375036 218302209 66794118 71251414 7412734 6190366 342696939 387688494 63452408 65708246 37224761 40071547 142862341 146634982 243539510 252414775 X 99157429 135273719 99157429 135273719 342696939 387688494 X 25693366 10422924 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 26460912 26460912 168928204 76886032 92042172 5207960 3272312 1935648 140844768 91232570 49612198 52587082 4335803 48251279 218302209 INVEST. - FUTURE REPLACE OF PROP, PLANT & EQUIPMENT 23840162 F ASSETS UNDER BOND INDENTURE AGREEMENT 9178249 F DEFERRED COMPENSATION 9098020 F INVESTMENT IN MERCYCARE 17641429 F INVESTMENTS - OTHER 4440610 F BOND PROJECT FUND 7052944 F 71251414 DEFERRED COMPENSATION 9098020 PENSION LIABILITY 25399000 CAPITAL LEASES PAYABLE 256135 DUE TO RELATED PARTY 111281827 DUE TO THIRD-PARTY PAYORS 600000 146634982 453270946 427577580 25693366 -71076 10494000 10422924 36116290 453270946 0 453270946 0 453270946 427577580 0 427577580 0 427577580 PART XI, LINE 8 - OTHER ADJUSTMENTS: CHANGES IN PENSION OBLIGATIONS 17,494,000. TRANSFER TO MERCY ALLIANCE, INC. -7,000,000. 1 1 X 1 X 1 X 1 1 1 0 1 1 4253924 0 4253924 0.01040 55954751 37634292 18320459 0.04500 5259927 3914793 1345134 0.00330 65468602 41549085 23919517 0.05870 1433214 190872 1242342 0.00310 4340733 890273 3450460 0.00850 11127623 7711479 3416144 0.00840 0 0 599432 0 599432 0.00150 17501002 8792624 8708378 0.02150 82969604 50341709 32627895 0.08020 50000 50000 0.00010 25000 25000 0.00010 25000 25000 0.00010 35000 35000 0.00010 135000 135000 0.00040 1 8787582 1177536 51065944 63840309 -12774365 X 1 1 2 1 MERCY HOSPITAL

1000 MINERAL POINT AVENUE JANESVILLE WI 53548

X X X X 2 MERCY WALWORTH HOSPITAL AND MEDICAL CENT

N2950 STATE ROAD 67 LAKE GENEVA WI 53147

X X X X MERCY HOSPITAL 1 1 1 150.000000000000 1 300.000000000000 1 X X X X X X 1 1 X X X 1 X 0 1 X 0 0 MERCY WALWORTH HOSPITAL AND MEDICAL CENT 2 1 1 150.000000000000 1 300.000000000000 1 X X X X X X 1 1 X X X 1 X 0 1 X 0 0 46 MERCY MANOR TRANSITION CENTER

1000 MINERAL POINT AVENUE JANESVILLE WI 53548

SKILLED NURSING/SUB-ACUTE CARE FACILITY MERCY REGIONAL CANCER CENTER

1000 MINERAL POINT AVENUE JANESVILLE WI 53548

RADIATION ONCOLOGY CLINIC/RADIATION THERAPY FACILITY HOUSE OF MERCY HOMELESS SHELTER

320 LINCOLN STREET JANESVILLE WI 53548

HOMELESS CENTER MERCY ALGONQUIN MEDICAL CENTER

2401 HARNISH DRIVE SUITE 101 ALGONQUIN WI 60102

OUTPATIENT PHYSICIAN CLINIC MERCY BARIATRIC WELLNESS CENTER

250 E CENTER DRIVE SUITE 201 VERNON HILLS WI 60061

OUTPATIENT PHYSICIAN CLINIC MERCY BARRINGTON MEDICAL CENTER

500 WEST HIGHWAY 22 BARRINGTON WI 60010

OUTPATIENT PHYSICIAN CLINIC MERCY BELOIT MEDICAL CENTER

2825 PRAIRIE AVENUE BELOIT WI 53511

OUTPATIENT PHYSICIAN CLINIC/URGENT CARE FACILITY MERCY BRODHEAD MEDICAL CENTER

2310 FIRST CENTER AVENUE BRODHEAD WI 53520

OUTPATIENT PHYSICIAN CLINIC MERCY CENTER FOR CORRECTIVE EYE SURGERY

5400 W ELM STREET SUITE 120 MCHENRY IL 60050

OUTPATIENT PHYSICIAN CLINIC MERCY CENTER FOR CORRECTIVE EYE SURGERY

8780 W GOLF ROAD STE 304 NILES IL 60714

OUTPATIENT PHYSICIAN CLINIC MERCY CLINIC EAST

3524 EAST MILWAUKEE STREET JANESVILLE WI 53546

OUTPATIENT PHYSICIAN CLINIC/URGENT CARE FACILITY MERCY CLINIC EAST PHARMACY

3524 EAST MILWAUKEE STREET JANESVILLE WI 53546

RETAIL PHARMACY MERCY CLINIC SOUTH

849 KELLOGG AVENUE JANESVILLE WI 53546

RESIDENCY PROGRAM / OUTPATIENT PHYSICIAN CLINIC MERCY CLINIC WEST

1000 MINERAL POINT AVENUE JANESVILLE WI 53548

OUTPATIENT PHYSICIAN CLINIC & MEDICAL ONCOLOGY MERCY CLINIC WEST PHARMACY

1000 MINERAL POINT AVENUE JANESVILLE WI 53548

RETAIL PHARMACY MERCY CRYSTAL LAKE CHIROPRACTIC AND REHA

330 W TERRA COTTA ROAD RTE 176 CRYSTAL LAKE IL 60014

CHIROPRACTOR MERCY CRYSTAL LAKE MEDICAL CENTER EAST

390 CONGRESS PARKWAY CRYSTAL LAKE IL 60014

OUTPATIENT PHYSICIAN CLINIC MERCY CRYSTAL LAKE MEDICAL CENTER WEST

350 CONGRESS PARKWAY CRYSTAL LAKE IL 60014

OUTPATIENT PHYSICIAN CLINIC MERCY CRYSTAL LAKE OBGYN

750 E TERRA COTTA STE B CRYSTAL LAKE IL 60014

OUTPATIENT PHYSICIAN CLINIC MERCY CRYSTAL LAKE MEDICAL CENTER SOUTH

415-A CONGRESS PARKWAY CRYSTAL LAKE IL 60014

OUTPATIENT PHYSICIAN CLINIC MERCY DELAVAN MEDICAL CENTER

1038 E GENEVA ST DELAVAN WI 53115

OUTPATIENT PHYSICIAN CLINIC MERCY EDGERTON MEDICAL CENTER

217 N MAIN STREET EDGERTON WI 53534

OUTPATIENT PHYSICIAN CLINIC MERCY EVANSVILLE MEDICAL CENTER

300 UNION STREET EVANSVILLE WI 53536

OUTPATIENT PHYSICIAN CLINIC MERCY HARVARD CLINIC SOUTH

348 S DIVISION HARVARD IL 60033

OUTPATIENT PHYSICIAN CLINIC MERCY HEALTH MALL

1010 NORTH WASHINGTON JANESVILLE WI 53548

OUTPATIENT PHYSICIAN CLINIC/URGENT CARE FACILITY MERCY HEALTH MALL PHARMACY

1010 NORTH WASHINGTON JANESVILLE WI 53548

RETAIL PHARMACY MERCY LAKE GENEVA MEDICAL CENTER

350 PELLER ROAD LAKE GENEVA WI 53147

OUTPATIENT PHYSICIAN CLINIC MERCY LAKESIDE ORTHOPAEDICS

352 PELLER ROAD LAKE GENEVA WI 53147

OUTPATIENT PHYSICIAN CLINIC MERCY MCHENRY INTERNAL MEDICINE CENTER

633 RIDGEVIEW DRIVE MCHENRY IL 60050

OUTPATIENT PHYSICIAN CLINIC MERCY MCHENRY MEDICAL CENTER

3922 MERCY DRIVE MCHENRY IL 60050

OUTPATIENT PHYSICIAN CLINIC MERCY MILTON MEDICAL CENTER

725 SOUTH JANESVILLE STREET MILTON WI 53563

OUTPATIENT PHYSICIAN CLINIC MERCY MILTON PHARMACY

725 SOUTH JANESVILLE STREET MILTON WI 53563

RETAIL PHARMACY MERCY NORTHWEST WOMEN'S GROUP

47 WEST ACORN LANE LAKE IN THE HILLS IL 601564804

OUTPATIENT PHYSICIAN CLINIC MERCY OPTIONS-COOPERATIVE CHILDCARE INST

20 EAST COURT STREET JANESVILLE WI 53548

TREATMENT FACILITY FOR ADOLESCENTS MERCY OPTIONS-JANESVILLE

903 MINERAL POINT AVENUE JANESVILLE WI 53548

PHYSICIAN & THERAPIST SERVICES: MENTAL HEALTH & ADDICTION TREATMENT MERCY REGIONAL DIALYSIS CENTER

903 MINERAL POINT AVENUE JANESVILLE WI 53548

DIALYSIS CENTER MERCY REGIONAL LUNG CENTER

903 MINERAL POINT AVENUE JANESVILLE WI 53548

PHYSICIANS CLINIC & SLEEP DISORDER CENTER MERCY RICHMOND MEDICAL CENTER

9715 PRAIRIE RIDGE RICHMOND IL 60071

OUTPATIENT PHYSICIAN CLINIC MERCY SHARON MEDICAL CENTER

118 PLAIN STREET SHARON WI 53585

OUTPATIENT PHYSICIAN CLINIC MERCY SPORTS MEDICINE AND REHABILITATION

557 NORTH WASHINGTON JANESVILLE WI 53548

OUTPATIENT PHYSICIAN CLINIC AND REHABILITATION FACILITY MERCY TERRACE

510 N TERRACE STREET JANESVILLE WI 53548

OUTPATIENT PHYSICIAN CLINIC MERCY WALWORTH PHARMACY

N2950 STATE ROAD 67 LAKE GENEVA WI 53147

RETAIL PHARMACY MERCY WHITEWATER MEDICAL CENTER

507 WEST MAIN STREET WHITEWATER WI 53190

OUTPATIENT PHYSICIAN CLINIC MERCY WHITEWATER SPORTS MEDICINE & REHAB

519 WEST MAIN STREET WHITEWATER WI 53190

OUTPATIENT PHYSICIAN CLINIC AND REHABILITATION FACILITY MERCY WOODSTOCK MEDICAL CENTER

2000 LAKE AVENUE WOODSTOCK IL 60098

OUTPATIENT PHYSICIAN CLINIC/URGENT CARE FACILITY MERCY WOODSTOCK PHARMACY

2000 LAKE AVENUE WOODSTOCK IL 60098

RETAIL PHARMACY PART I, LINE 6A: MERCY HEALTH SYSTEM, CORP. (MHS) SUBMITS AN ANNUAL COMMUNITY BENEFIT STATEMENT TO THE WISCONSIN HOSPITAL ASSOCIATION. PERIODICALLY, IT PUBLISHES A PAMPHLET EXPLAINING THE COMMUNITY BENEFITS THAT MERCY HEALTH SYSTEM CORP, AND THE RELATED ORGANIZATIONS OF MHS PROVIDE TO THE COMMUNITIES THEY SERVE. MHS HAS SUPPLIED SUPPLEMENTAL COMMUNITY BENEFIT STATEMENT INFORMATION WITH ITS 990 TAX RETURN SINCE FISCAL YEAR 2006 (TAX FORM 2005). PART I, LINE 7: A COST-TO-CHARGE RATIO METHODOLOGY WAS USED TO DETERMINE COSTS ASSOCIATED WITH CHARITY CARE, UNREIMBURSED MEDICAID, AND OTHER MEANS TESTED GOVERNMENT PROGRAMS. THE COST-TO-CHARGE RATIO WAS DERIVED FROM IRS WORKSHEET 2 RATIO OF PATIENT CARE COST-TO-CHARGE. THE COST OF THE OTHER BENEFITS REFERENCED IN THE TABLE OF LINE 7 (COMMUNITY HEALTH IMPROVEMENT SERVICES AND COMMUNITY BENEFIT OPERATIONS; HEALTH PROFESSIONS EDUCATION; SUBSIDIZED HEALTH SERVICES; CASH AND IN-KIND CONTRIBUTIONS) WERE DETERMINED USING ACTUAL DEPARTMENT/SERVICE SPECIFIC DATA AND/OR COST ACCOUNTING DERIVED DATA. PART I, LINE 7G: THE SUBSIDIZED HEALTH CARE LINE INCLUDES $2,350,436 OF EXPENSES (COLUMN C) AND $1,071,319 OF NET EXPENSES (COLUMN E) ATTRIBUTABLE TO THE COSTS OF TRAUMA SURGEONS. THESE SURGEONS STAFF THE LEVEL II TRAUMA PROGRAM OF MERCY HEALTH SYSTEM CORPORATION 24/7. PART I, L7 COL(F): BAD DEBT EXPENSE OF $20,416,447 INCLUDED ON FORM 990, PART IX, LINE 25, WAS EXCLUDED FROM EXPENSES WHEN CALCULATING THE PERCENTAGE IN THIS COLUMN. PART II: MERCY'S MANY HEALTH IMPROVEMENT AND BENEFIT SERVICES/OPERATIONS WERE THE RESULT OF MERCY FILLING A COMMUNITY NEED. MERCY'S COLLABORATIVE EFFORTS AND THE EFFORTS OF ITS RELATED ENTITIES HAVE BROUGHT ASSISTANCE TO THE AREA'S UNDERSERVED (AS DETAILED IN #2 ABOVE). PART III, LINE 4: BAD DEBT EXPENSE IS ACCOUNTED FOR IN THE FOLLOWING MANNER (AS DETAILED IN NOTE 1 OF THE AUDITED FINANCIAL STATEMENTS OF MERCY HEALTH SYSTEM CORPORATION AND SUBSIDIARIES). THE CARRYING AMOUNTS OF ACCOUNTS RECEIVABLE ARE REDUCED BY ALLOWANCES THAT REFLECT MANAGEMENT'S BEST ESTIMATE OF THE AMOUNTS THAT WILL NOT BE COLLECTED. . . .MANAGEMENT PROVIDES FOR PROBABLE UNCOLLECTIBLE AMOUNTS, PRIMARILY UNINSURED PATIENTS AND AMOUNTS PATIENTS ARE PERSONALLY RESPONSIBLE FOR, THROUGH A CHARGE TO OPERATIONS AND A CREDIT TO A VALUATION ALLOWANCE BASED ON ITS ASSESSMENT OF HISTORICAL COLLECTION LIKELIHOOD AND THE CURRENT STATUS OF INDIVIDUAL ACCOUNTS. BALANCES THAT ARE STILL OUTSTANDING AFTER MANAGEMENT HAS USED REASONABLE COLLECTION EFFORTS ARE WRITTEN OFF THROUGH A CHARGE TO THE VALUATION ALLOWANCE AND A CREDIT TO PATIENT ACCOUNTS RECEIVABLE. THE COST OF BAD DEBT ON LINE 2 PART III WAS DETERMINED BY APPLYING THE COST TO CHARGE RATIO TO THOSE CHARGES ESTIMATED AND EXPENSED AS UNCOLLECTIBLE. THE ESTIMATE OF BAD DEBT DOLLARS THAT MAY HAVE BEEN COVERED THROUGH MERCY'S FINANCIAL ASSISTANCE/CHARITY CARE POLICY (HAD THE PROPER PAPER WORK BEEN COMPLETED BY THE INDIVIDUAL NEEDING ASSISTANCE) IS ESTIMATED AT 13.4%. THIS FIGURE WAS BASED ON THE PERCENT OF BAD DEBT ACCOUNT DOLLARS THAT ARE RECLASSIFIED FOR CHARITY AND/OR BANKRUPTCY PURPOSES. PART III, LINE 8: DATA FOR LINES 5 & 6 OF PART III AND THE MEDICARE SHORTFALL IS BASED ON MERCY'S TWO HOSPITALS' MEDICARE COST REPORTS. PART III, LINE 9B: PATIENTS WHO ARE SELF-PAY, REGARDLESS OF WHETHER THEY QUALIFY FOR MERCY'S COMMUNITY CARE PROGRAM, WILL RECEIVE A 20% DISCOUNT FROM MERCY'S STANDARD FEE SCHEDULE. ALL SELF-PAY PATIENTS MEET WITH PATIENT FINANCIAL COUNSELORS AND DISCUSS PAYMENT OPTIONS INCLUDING MERCY'S COMMUNITY CARE PROGRAM. PATIENTS MUST APPLY FOR COMMUNITY CARE AND SUPPLY MERCY WITH THE NECESSARY FINANCIAL AND OTHER INFORMATION REQUIRED. PATIENTS WHO QUALIFY FOR COMMUNITY CARE BENEFITS WILL RECEIVE A REDUCTION IN THE BALANCE OWED, EXTENDED PAYMENT TERMS, OR BOTH. THE AMOUNT OF THE COMMUNITY CARE BENEFIT WILL BE BASED ON THE PATIENT'S ABILITY TO PAY AND THE SIZE OF THE OUTSTANDING BALANCE. MERCY HOSPITAL PART V, SECTION B, LINE 13G: AVAILABLE THROUGH PATIENT FINANCIAL COUNSELORS WHO DO PRE- OR POST-FOLLOW UP WITH SELF-PAY PATIENTS. MERCY WALWORTH HOSPITAL AND MEDICAL CENT PART V, SECTION B, LINE 13G: AVAILABLE THROUGH PATIENT FINANCIAL COUNSELORS WHO DO PRE- OR POST-FOLLOW UP WITH SELF-PAY PATIENTS. PART VI, LINE 2: MERCY HEALTH SYSTEM CORPORATION DOES COMMUNITY NEEDS ASSESSMENTS IN CONJUNCTION WITH THE PUBLIC HEALTH DEPARTMENTS OF WALWORTH (WI), ROCK (WI), AND MCHENRY (IL) COUNTIES EVERY 18 MONTHS. MERCY HAS DEDICATED STAFF THAT WORKS WITH VARIOUS AGENCIES/PROGRAMS OF NEARBY COMMUNITIES TO ASSESS HEALTH NEEDS. COLLABORATIVE EXAMPLES OF MERCY AND MERCY'S RELATED ENTITIES INCLUDE: I) THE COMMUNITY HEALTH CENTER AT MERCY CLINIC SOUTH: PARTNERSHIP WITH THE COMMUNITY HEALTH CENTER, INC. OF BELOIT, WI IN 2006, MERCY PARTNERED WITH COMMUNITY HEALTH CENTER, INC. TO OPEN THIS CLINIC IN JANESVILLE. IT PROVIDES FREE AND LOW-COST CARE TO LOW-INCOME, UNINSURED AND UNDERINSURED PATIENTS. THIS FIRST-OF-ITS-KIND PARTNERSHIP IS THE RESULT OF YEARS OF WORK WITH LOCAL PARTNERS AND THE FEDERAL GOVERNMENT TO DESIGN AND DEBUT A NEW MODEL OF CARE FOR THE UNDERSERVED. THE CLINIC SEES OVER 200 NEW PATIENTS EACH MONTH, HAS SIGNIFICANTLY IMPROVED PATIENT OUTCOMES, AND HAS SAVED MILLIONS IN UNNECESSARY EMERGENCY DEPARTMENT COSTS. II) HEALTHNET FREE CLINIC IN JANESVILLE: MERCY PHYSICIANS VOLUNTEER THEIR SERVICES. MERCY ALSO DONATES LAB, RADIOLOGY AND OTHER ANCILLARY SERVICES TO PATIENTS. III) COOPERATIVE CHILD CARE INSTITUTE: COLLABORATION WITH JANESVILLE PUBLIC SCHOOL DISTRICT AND ROCK COUNTY HUMAN SERVICES TO SERVE EMOTIONALLY CHALLENGED CHILDREN. IV) FAMILY HEALTH PARTNERSHIP CLINIC AND WELL CHILD CLINIC IN WOODSTOCK, IL AND HARVARD FREE CLINIC IN MCHENRY COUNTY, IL: MERCY PHYSICIANS VOLUNTEER THEIR SERVICES. V) FAMILY HEALTH PARTNERSHIP CLINIC: MCHENRY COUNTY DEPARTMENT OF HEALTH COLLABORATION TO PROVIDE MAMMOGRAMS AT MERCY FACILITIES FOR WOMEN WHO CANNOT OTHERWISE AFFORD THE SERVICE. VI) ROCK COUNTY HEALTH DEPARTMENT: BIOTERRORISM READINESS PROJECT. VII) RED CROSS: BLOOD DRIVE AND COOPERATIVE VOLUNTEER EFFORTS. VIII) UNITED WAY: FUND RAISING CAMPAIGN AND ROCK COUNTY NEEDS ASSESSMENT SURVEY CONTRIBUTOR IX) AREA POLICE AND FIRE DEPARTMENTS: PROVIDE PORTABLE DEFIBRILLATORS FOR POLICE VEHICLES AND FREE OR REDUCED-COST PARAMEDIC/EMT EDUCATIONAL OPPORTUNITIES. X) COMMUNITY ACTION, INC.: MERCY LEADERSHIP SERVES ON STRATEGIC PLANNING COMMITTEE AND COMMUNITY ACTION DEVELOPMENT BOARD. PART VI, LINE 3: ALL UNINSURED PATIENTS ARE NOTIFIED OF MERCY'S FINANCIAL AIDE POLICY UPON REGISTRATION. INFORMATION IS ALSO AVAILABLE AT THE HEALTH SYSTEM'S WEBSITE, IN OUR EMERGENCY ROOMS, FINANCIAL SERVICES OFFICES, AND WITH THE PATIENT FINANCIAL COUNSELORS. APPROPRIATE PERSONNEL HAVE BEEN TRAINED ON HOW TO INTERACT WITH PATIENTS ABOUT FINANCIAL AID AVAILABILITY, AND HOW TO DIRECT PATIENTS TO APPROPRIATE FINANCIAL AID STAFF. THE HOSPITALS HAVE TRANSLATION SERVICES AVAILABLE AS NEEDED. PART VI, LINE 4: ONE HOSPITAL OF MERCY HEALTH SYSTEM CORPORATION IS LOCATED IN JANESVILLE, WI. IT WAS THE ONLY GENERAL ACUTE CARE HOSPITAL LOCATED IN JANESVILLE, WI, DURING THIS REPORTING PERIOD AND IS THE LARGEST OF SIX HOSPITALS WITHIN A 30-MILE RADIUS. IT IS LICENSED FOR 240 BEDS AND IS LOCATED IN ROCK COUNTY, WI, WHERE APPROXIMATELY 11% OF THE POPULATION IS BELOW THE POVERTY LEVEL (BASED ON LAST YEAR'S FIGURES). MEDIAN HOUSEHOLD INCOME IN ROCK CO. IS BELOW THE STATE'S AVERAGE. ROCK COUNTY'S UNEMPLOYMENT RATE AS OF FEBRUARY, 2010 WAS AT 12.7%; DUE IN LARGE PART TO THE CLOSING OF GENERAL MOTORS ASSEMBLE PLANT IN DECEMBER 2008. GENERAL MOTORS USED TO BE THE LARGEST EMPLOYER IN THE AREA. MERCY HEALTH SYSTEM'S SECOND HOSPITAL IS IN WALWORTH COUNTY. IT IS DESIGNATED AS A CRITICAL ACCESS 6 BED HOSPITAL. WALWORTH COUNTY WAS ALSO ESTIMATED TO HAVE APPROXIMATELY 11% OF THE POPULATION BELOW THE POVERTY LEVEL (BASED ON LAST YEAR'S FIGURES). WALWORTH'S UNEMPLOYMENT RATE AS OF FEBRUARY, 2010 WAS AT 10.7%. THE TWO HOSPITALS' PAYOR DEMOGRAPHICS INCLUDED 39.8% MEDICARE, AND 14.6% MEDICAID FOR THE FISCAL YEAR OF JULY 1, 2010 - JUNE 30, 2011 (AS DETERMINED BY CHARGES BILLED). PART VI, LINE 6: THE HOSPITALS OF MERCY HEALTH SYSTEM HAVE AN OPEN MEDICAL STAFF WITH PRIVILEGES AVAILABLE TO ALL QUALIFIED PHYSICIANS IN THE AREA. MERCY HEALTH SYSTEM HAS A GOVERNING BODY IN WHICH INDEPENDENT PERSONS REPRESENTATIVE OF THE COMMUNITY COMPRISE A MAJORITY. PART VI, LINE 7: MERCY HEALTH SYSTEM CORPORATION OPERATES TWO HOSPITALS AND HAS COMMUNITY CLINICS LOCATED THROUGHOUT SIX COUNTIES OF WISCONSIN AND ILLINOIS. IT IS PART OF A LARGER INTEGRATED HEALTH SYSTEM AND AFFILIATED WITH OTHER SEPARATELY REPORTED ORGANIZATIONS. MERCY ALLIANCE INC. IS THE PARENT COMPANY OF MERCY HEALTH SYSTEM CORPORATION, MERCY ASSISTED CARE INC, AND MERCY HARVARD HOSPITAL INC. MERCY ASSISTED CARE PROVIDES HOME HEALTH SERVICES AND DME (DURABLE MEDICAL EQUIPMENT) SERVICES; THUS PROVIDING CONTINUATION OF CARE TO MERCY HEALTH SYSTEM PATIENTS AND THE COMMUNITY AS A WHOLE. MERCY HARVARD HOSPITAL PROVIDES ACUTE CARE SERVICES IN MCHENRY COUNTY ILLINOIS. MERCY HEALTH SYSTEM CORP. WORKS WITH THE MERCY FOUNDATION, INC. TO OPERATE A HOMELESS SHELTER IN JANESVILLE, WI.: THE HOUSE OF MERCY HOMELESS CENTER PROVIDES SHELTER, SUPPORT, AND TRAINING TO WOMEN, CHILDREN, AND FAMILIES TO HELP FIGHT HOMELESSNESS. IT SHELTERED OVER 4,700 INDIVIDUALS SINCE IT OPENED IN 1996. MERCY HOSPITAL ASSOCIATION OF VOLUNTEERS, INC. IS THE ORGANIZATION/TAX ENTITY OF MERCY'S VOLUNTEERS. VOLUNTEERS NUMBERED 1,223 IN CALENDAR YEAR 2010. THIS ORGANIZATION NOT ONLY SUPPORTS MERCY'S SERVICES, BUT PROVIDES BENEFITS TO THE COMMUNITY AS A WHOLE. IN CONJUNCTION WITH MERCY HEALTH SYSTEM'S MEAL PREPARATION, THE VOLUNTEERS PARTICIPATE IN AND OVERSEE A MEALS ON WHEELS PROGRAM: PARTICIPANT/NUTRITION SPECIFIC MEALS ARE PREPARED AND DELIVERED TO THE ELDERLY NEEDING ASSISTANCE IN JANESVILLE. THE VOLUNTEER ASSOCIATION RUNS A HOSPITALITY HOUSE IN WHICH FAMILY MEMBERS OF PATIENTS ARE OFFERED FREE HOUSING DURING THEIR LOVED ONES EXTENDED HOSPITAL STAY AND REHABILITATION. REPORTS FILED WITH STATES PART VI, LINE 7 WI X X X X 1 1 X X X X X X 0 1 0 0 0 0 0 0 0 BARB BORTNER 133222 0 65374 0 2655 0 0 0 21805 0 223056 0 0 0 DAN COLBY 181560 0 89884 0 9206 0 0 0 39562 0 320212 0 0 0 DAVID KURTZ 133222 0 71762 0 10568 0 0 0 41605 0 257157 0 0 0 JOHN COOK 231079 0 103500 0 8268 0 0 0 37355 0 380202 0 0 0 KATHY HARRIS 87107 0 46340 0 4488 0 0 0 16483 0 154418 0 0 0 RUTH YARBROUGH 155768 0 86880 0 14392 0 0 0 40105 0 297145 0 0 0 RICHARD GRUBER 133222 0 71889 0 4274 0 0 0 24078 0 233463 0 0 0 RALPH TOPINKA 250000 0 125884 0 6830 0 0 0 39699 0 422413 0 0 0 JOSEPH NEMETH 135784 0 72929 0 8613 0 0 0 41498 0 258824 0 0 0 SUE RIPSCH 237610 0 119314 0 3046 0 0 0 26105 0 386075 0 0 0 JAVON BEA 846616 0 772088 0 650911 0 1459323 0 41005 0 3769943 0 0 0 BRADLEY FIDELER 1188523 0 0 0 1442636 0 198950 0 31130 0 2861239 0 0 0 CAROL NEUMAN 270783 0 71477 0 1241773 0 71450 0 25073 0 1680556 0 0 0 CHRISTOPHER STURM 658345 0 877373 0 16500 0 18950 0 31307 0 1602475 0 0 0 JAMES KIRSCHBAUM 475603 0 139287 0 534016 0 18950 0 36490 0 1204346 0 0 0 VIKRAM KHANNA 468996 0 580169 0 16500 0 18950 0 36079 0 1120694 0 0 0 PART I, LINE 1A RESIDENCE FOR PERSONAL USE - THE CEO IS PROVIDED WITH A RESIDENCE. THE COST OF RENTING THE RESIDENCE IS TREATED AS TAXABLE COMPENSATION. PAYMENTS FOR BUSINESS USE OF PERSONAL RESIDENCE - THE CEO IS REIMBURSED FOR INTERNET ACCESS AND COMMUNICATION COSTS USED FOR BUSINESS PURPOSES AT HIS PERSONAL RESIDENCE. THE REIMBURSEMENT IS TREATED AS TAXABLE COMPENSATION. HEALTH CLUB DUES - THE CEO IS REIMBURSED FOR HEALTH CLUB DUES. THIS IS TREATED AS TAXABLE COMPENSATION. PERSONAL SERVICES - THE CEO IS REIMBURSED FOR INCOME TAX PREPARATION SERVICES. THIS IS TREATED AS TAXABLE COMPENSATION. KRISTEN GOELZER FAMILY MEMBER OF MARK GOELZER, DIRECTOR 291325 EMPLOYMENT - PHYSICIAN 0 JAMIE KURTZ FAMILY MEMBER OF DAVID KURTZ, OFFICER 34111 EMPLOYMENT - PATIENT ACCOUNT REPRESENTATIVE 0 JAMES NEMETH FAMILY MEMBER OF JOSEPH NEMETH, FORMER OFFICER 27830 EMPLOYMENT - FINANCE MANAGER 0 JOANNA BEA FAMILY MEMBER OF JAVON BEA, PRESIDENT & DIRECTOR 80998 EMPLOYMENT - MANAGER ARCHITECTURAL & INTERIOR DESIGN 0 MEGAN KRAUSE FAMILY MEMBER OF SUE RIPSCH, OFFICER 54599 EMPLOYMENT - REVENUE CYCLE COORDINATOR 0 FORM 990, PART VI, SECTION B, LINE 11 NO REVIEW WAS OR WILL BE CONDUCTED FORM 990, PART VI, SECTION B, LINE 12C OFFICERS, DIRECTORS, AND KEY EMPLOYEES ARE REQUIRED TO REPORT ALL CONFLICTS OF INTEREST. THE COMPLIANCE OFFICER IS RESPONSIBLE FOR INVESTIGATING ALL CONFLICTS AND REPORTING TO THE BOARD. FORM 990, PART VI, SECTION B, LINE 15 THE MERCY ALLIANCE COMPENSATION COMMITTEE IS COMPRISED OF THE BOARD CHAIRPERSON, SECRETARY, AND THE TREASURER. THE COMPENSATION COMMITTEE IS ASSISTED BY INDEPENDENT LEGAL COUNCIL AND AN INDEPENDENT COMPENSATION CONSULTANT. THE COMPENSATION COMMITTEE, LEGAL COUNCIL, AND THE COMPENSATION CONSULTANT MEET THROUGHOUT THE YEAR AND REPORT DIRECTLY TO THE BOARD OF DIRECTORS ANNUALLY. THIS PROCESS WAS COMPLETED FOR 2011. FORM 990, PART VI, SECTION C, LINE 19 GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY & FINANCIAL STATEMENTS ARE AVAILABLE UPON REQUEST. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED LOSSES ON INVESTMENTS: -71,076. CHANGES IN PENSION OBLIGATIONS 17,494,000. TRANSFER TO MERCY ALLIANCE, INC. -7,000,000. TOTAL TO FORM 990, PART XI, LINE 5: 10,422,924. TOTAL NUMBER OF VOLUNTEERS FORM 990, PART I, LINE 6 MERCY HEALTH SYSTEM CORPORATION HAS REPORTED ZERO FOR THE TOTAL NUMBER OF VOLUNTEERS. THIS IS DUE TO THE FACT THAT ALL 1,209 VOLUNTEERS FOR THE MERCY HEALTH SYSTEM CORPORATION ARE TECHNICALLY VOLUNTEERS OF THE MERCY HEALTH SYSTEM ASSOCIATION OF VOLUNTEERS AND AS SUCH HAVE BEEN REPORTED ON THEIR TAX RETURN. PLEASE SEE THE MERCY HEALTH SYSTEM ASSOCIATION OF VOLUNTEERS TAX RETURN FOR MORE INFORMATION ON MERCY VOLUNTEER ACTIVITIES. MERCY ALLIANCE INC 1000 MINERAL POINT JANESVILLE WI 535475003 391679859 MANAGEMENT OF HEALTHCARE ORGANIZATIONS WI 501(C)(3) 11A N/A 0 MERCY FOUNDATION INC 1000 MINERAL POINT JANESVILLE WI 535475003 237275336 TO SUPPORT MERCY HEALTH SYSTEM & THE HOUSE OF MERCY WI 501(C)(3) 11A MERCY HEALTH SYSTEM CORPORATION 0 MERCY HEALTH SYSTEM ASSOCIATION OF VOLUNTEERS 1000 MINERAL POINT JANESVILLE WI 535475003 390912682 TO SUPPORT MERCY HEALTH SYSTEM CORPORATION WI 501(C)(3) 11C MERCY HEALTH SYSTEM CORPORATION 0 MERCY ASSISTED CARE INC 901 MINERAL POINT JANESVILLE WI 535475003 391035110 HOME HEALTH CARE & SERVICES WI 501(C)(3) 9 MERCY ALLIANCE INC 0 MERCY ALLIANCE INC 901 GRANT STREET HARVARD IL 60033 311551871 MEDICAL HEALTHCARE IL 501(C)(3) 3 MERCY ALLIANCE INC 0 HARVARD MEMORIAL HOSPITAL FOUNDATION 901 GRANT STREET HARVARD IL 60033 364308662 TO SUPPORT MERCY HARVARD HOSPITAL, INC. IL 501(C)(3) 11A MERCY HARVARD HOSPITAL INC 0 MERCY CRYSTAL LAKE HOSPITAL AND MEDICAL CENTER 1000 MINERAL POINT JANESVILLE WI 535475003 201673011 NONE IL 501(C)(3) 3 MERCY ALLIANCE INC 0 JANESVILLE MEDICAL CENTER INC 1000 MINERAL POINT JANESVILLE WI 535475003 391520130 MANAGEMENT ENTITY OF UNION EMPLOYEES WI MERCY HEALTH SYSTEM CORPORATION C 11634 1.00000 MERCYCARE INSURANCE COMPANY 3430 PALMER DRIVE JANESVILLE WI 53545 391768192 INSURANCE COMPANY WI MERCY HEALTH SYSTEM CORPORATION C 113057915 46298632 1.00000 MERCYCARE HMO INC - CONSOLIDATED WITH MERCYCARE INSURANCE CO 3430 PALMER DRIVE JANESVILLE WI 53545 201482553 INSURANCE COMPANY WI MERCY HEALTH SYSTEM CORPORATION C 1.00000 1 0 0 0 1 0 0 0 1 1 0 0 1 1 0 1 1 0 MERCYCARE INSURANCE COMPANY P 5877834 COST OF SERVICES PROVIDED