2012-08-15T04:53:55-05:00 2011-09-30 WIPFLI LLP PO BOX 12237 GREEN BAY WI 543072237 990 2010-10-01 390806359 COMMUNITY HEALTH NETWORK INC COMM 9203611313 225 MEMORIAL DR BERLIN WI 54923 TOM KRYSTOWIAK 9203611313 2012-08-13 1 TERRI REXRODE CPA MST 9206620016 2012-08-13 2010 2016-02-24 21:20:13Z TOM KRYSTOWIAK 225 MEMORIAL DRIVE BERLIN WI 54923 77899119 0 X WWW.CHNWI.ORG X 1910 WI COMMUNITY HEALTH NETWORK, INC PROVIDES INPATIENT AND OUTPATIENT HOSPITAL AND CLINIC SERVICES, HOME CARE SERVICES AND SKILLED NURSING SERVICES TO GREEN LAKE COUNTY AND SURROUNDING COUNTIES WITH TOTAL NET PATIENT SERVICE REVENUES OF $72,535,000 (TOTAL GROSS REVENUE OF $147,885,000). 12 10 841 110 2123131 0 0 1213 74885484 77046871 512408 572275 -276931 -209407 75120961 77410952 0 0 0 0 42679208 44289157 0 0 0 31863993 32402773 74543201 76691930 577760 719022 54650324 54353488 28017060 26577162 26633264 27776326 X TO PROVIDE SUPERIOR SERVICES TO IMPROVE THE HEALTH OF THOSE WE SERVE. 1 0 66464142 74807891 COMMUNITY HEALTH NETWORK OPERATES A 25-BED ACUTE CARE FACILITY, 72 BED EXTENDED CARE FACILITY, PHYSICIAN CLINICS LOCATED IN 8 COMMUNITIES, A HOME HEALTH AGENCY, REHABILITATION SERVICES AND RETAIL PHARMACY SERVICES.IN PURSUIT OF OUR PRIMARY EXEMPT PURPOSE OF PROVIDING HEALTH CARE SERVICES, COMMUNITY HEALTH NETWORK PROVIDES MEDICAL CARE AND HEALTH INFORMATION AIMED AT IMPROVING THE HEALTH STATUS OF THE COMMUNITIES WE SERVE. WE BELIEVE THAT WE HAVE A SPECIAL DUTY TO MEET THE NEEDS OF THE POOR, INDIGENT, AND MEDICALLY UNDERSERVED IN OUR COMMUNITIES AND SURROUNDING AREAS. WE HAVE PROVIDED CARE TO ALL PATIENTS WITHOUT REGARD FOR THE ABILITY TO PAY. COMMUNITY HEALTH NETWORK 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 PHYSICIANS IN THE AREA. THE MAJORITY OF THE BOARD OF DIRECTORS IS COMPRISED OF INDEPENDENT INDIVIDUALS WHO ARE REPRESENTATIVE OF THE COMMUNITY. COMMUNITY HEALTH NETWORK ENGAGES IN TRAINING AND EDUCATION OF HEALTH CARE PROFESSIONALS THROUGH INTERNSHIP PROGRAMS. IT OPERATES A WOMAN'S HEALTH AND RESOURCE CLINIC THAT PROVIDES SERVICES TO UNINSURED AND UNDERINSURED WOMEN THROUGH A STATE OF WISCONSIN GRANT PROGRAM. COMMUNITY HEALTH NETWORK'S VISION INCLUDES A HEALTHIER COMMUNITY. TO ACHIEVE THIS VISION, IT CONTINUALLY ASSESSES THE COMMUNITIES FOR OPPORTUNITIES FOR HEALTH CARE IMPROVEMENT. DIABETES MANAGEMENT HAS BEEN IDENTIFIED AS A COMMUNITY NEED. DIABETES MANAGEMENT AND EDUCATION CONTINUES TO BE A COMMUNITY PROGRAM OFFERED TO THE COMMUNITY AT NO COST. COMMUNITY HEALTH NETWORK PARTICIPATES IN GOVERNMENT-SPONSORED HEALTH CARE PROGRAMS SUCH AS MEDICAID, MEDICARE, CHAMPUS, AND TRICARE. IN FISCAL YEAR 2011 OVER 1,900 ACCOUNTS RECEIVED CHARITY CARE WITH A TOTAL COST OF OVER $1,289,000. THE COST OF SERVICES PROVIDED TO MEDICAID PATIENTS THAT WERE NOT REIMBURSED TOTALED MORE THAN $2.6 MILLION. COMMUNITY HEALTH NETWORK'S LOSS FOR PROVIDING LONG TERM CARE SERVICES TO THE COMMUNITIES WAS $374,000 IN 2011. FINANCIAL AND IN-KIND CONTRIBUTIONS TO THE COMMUNITY TOTALED APPROXIMATELY $80,000. IN ADDITION, COMMUNITY HEALTH NETWORK ACTIVELY PROVIDED OR PARTICIPATED IN THE FOLLOWING COMMUNITY-BASED ACTIVITIES AND PROGRAMS OF WHICH APPROXIMATELY 7,000 PERSONS IN THE COMMUNITIES THAT WE SERVE PARTICIPATED AT A TOTAL COST TO COMMUNITY HEALTH NETWORK OF APPROXIMATELY $158,000. - GENERAL HEALTH EDUCATION SERVICES SUCH AS HEALTH FAIRS; CANCER EDUCATION; HEART DISEASE EDUCATION; DIABETES EDUCATION; FAMILY, PARENT, AND SIBLING EDUCATION; FAMILY PLANNING; AND WOMEN'S HEALTH EDUCATION- PROVIDED HEALTH INFORMATION ON THE CORPORATION'S WEB SITE AND THROUGH HEALTH RELATED PUBLICATIONS DISTRIBUTED AT NO CHARGE- SUPPORT GROUPS SUCH AS DIABETES, CANCER, AND BEREAVEMENT- HOSTED SELF-HELP AND WELLNESS PROGRAMS SUCH AS NUTRITION, WEIGHT MANAGEMENT AND FITNESS,- 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- DELIVERED HOT IN-HOME MEALS- PROMOTED PARTICIPATION IN BLOOD DRIVES BY EMPLOYEES- CONTRIBUTED TO THE EDUCATION OF STUDENT NURSES AND OTHER HEALTH CARE PROFESSIONALS- PROVIDED FIRST AID FOR COMMUNITY SPORTING EVENTS- PARTICIPATED IN WORK SITE HEALTH EDUCATION PROGRAMS - MADE CASH CONTRIBUTIONS TO SUPPORT COMMUNITY SERVICES AND EVENTS- PROVIDED MEETING ROOMS TO COMMUNITY GROUPS AT NO CHARGE 66464142 1 0 0 1 0 0 0 0 0 0 1 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 1 0 1 1 0 0 0 0 0 1 1 0 0 0 0 1 45 0 1 841 1 1 1 0 0 0 0 0 0 0 0 0 X 12 10 1 0 0 0 1 1 0 1 1 0 0 0 1 1 1 1 1 0 0 0 WI X THOMAS KRYSTOWIAK 9203611313 225 MEMORIAL DRIVE BERLIN WI 54923 X HENRY DERLETH 0.50 X 5600 0 0 JAMES CLARK 0.50 X X 6500 0 0 JODI TIMLER OLMEN 0.50 X 6800 0 0 KRISTIN GALATOWITSCH 0.50 X X 5300 0 0 PAT MCCONNELL 0.50 X 4600 0 0 P MICHAEL SHATTUCK MD 40.50 X 235174 0 22659 RUSSELL KUEHN 0.50 X X 4200 0 0 STEVE SORENSON 0.50 X X 8904 0 0 THOMAS WILLETT DO 0.50 X 135400 0 0 DOUGLAS GUY 32.00 X X 218774 6837 7615 LARRY WISE 0.50 X 3800 0 0 PAUL KUJAWA 0.50 X 4400 0 0 FRANK CUMBERBATCH 0.50 X 0 0 0 THOMAS RIEK 0.50 X 0 0 0 JOHN FEENEY 42.50 X X 0 0 0 THOMAS KRYSTOWIAK 42.00 X 150304 5368 28374 DONALD CAVES 31.00 X 125957 36568 22786 JOHN HORAN MD 40.00 X 643991 0 20331 DAVID JONES MD 40.00 X 788027 0 26718 DAVID KURTZ MD 40.00 X 534149 0 28712 JOSEPH LEE MD 40.00 X 570166 0 13995 URI VAISMAN MD 40.00 X 849034 0 27612 4301080 48773 198802 45 0 1 0 ZR ENTERPRISES SC 6809 MAGNOLIA CT GREENDALE WI 53129 ER PHYSICIAN SERVICE 1442538 CENTRAL WI ANESTHESIA ASSOC SC PO BOX 249 BERLIN WI 54923 ANESTHESIA SERVICES 483581 STAFF CARE INC PO BOX 281923 ATLANTA GA 30384 PHYSICIAN STAFFING 436554 SHARED MEDICAL SERVICES PO BOX 330 COTTAGE GROVE WI 53527 MRI SERVICES 411188 HALL RENDER KILLIAN HEALTH & LYMAN PC 39778 TREASURY CTR CHICAGO IL 60694 CONSULTING/LEGAL SERVICES 321042 11 1213 1213 PATIENT SERVICE REVENU 624100 70582958 70582958 OTHER OPERATING REVENU 900099 4224933 4224933 PHARMACY REVENUE 446110 2123131 2123131 CAFETERIA REVENUE 900099 115849 115849 77046871 416811 416811 275280 484687 -209407 -209407 -209407 153819 5125 3480 153819 1645 155464 155464 77410952 74807891 2123131 478717 987710 987710 33783382 29715340 4068042 758993 622668 136325 6828044 5793814 1034230 1931028 1601149 329879 368447 368447 6621416 5647189 974227 194710 11311 183399 12128120 11515341 612779 430898 51975 378923 976193 926375 49818 294284 254388 39896 76419 3140 73279 828010 822728 5282 2508569 2440071 68498 621674 413196 208478 MISCELLANEOUS 3368713 2762155 606558 PROVISION FOR BAD DEBTS 2801717 2801717 MEDICAID ASSESSMENT 585947 585947 RECRUITING 397440 346151 51289 LICENSES, DUES, AND CER 141722 99757 41965 58494 49730 8764 76691930 66464142 10227788 0 4025 4125 11487208 10357747 9529706 9739707 150000 670022 859104 1404226 1075943 51342463 32635816 18274373 18706647 9601754 9286088 0 61333 141861 3617677 4032266 54650324 54353488 5643904 4901782 184047 229882 13445000 13140000 3026493 3051867 5717616 5253631 28017060 26577162 X 26633264 26772266 1004060 26633264 27776326 54650324 54353488 X 719022 424040 X X 0 1 1 X 0 X 0 0 0 0 0 0 0 0 1 4664 4664 0 EXPLANATION OF OTHER LOBBYING ACTIVITIES: PART II-B, LINE 1I: WHA DUES OF $4,664. 919246 919246 28444608 17003893 11440715 1225658 970077 255581 19113388 14661846 4451542 1639563 1639563 18706647 RECEIVABLE FROM PHYSICIANS 72992 UNAMORTIZED BOND ISSUE COSTS 460754 INTEREST RECEIVABLE 24703 OTHER ASSETS 193111 CMC CLINIC 240228 ACCOUNTS RECEIVABLE - WILD ROSE 2036418 ASSETS HELD BY FOUNDATION 1004060 4032266 DEFERRED COMPENSATION 3601637 ACCRUED INTEREST 94630 SELF FUNDED HEALTH INSURANCE 491002 NET AMOUNTS PAYABLE FROM THIRD-PARTY REIMBURSEMENT PROGRAMS 573524 MISCELLANEOUS 40287 DEFERRED PHYSICIAN COMP 452551 5253631 77410952 76691930 719022 -322744 873273 -126489 424040 1143062 77895639 0 77895639 -484687 -484687 77410952 77176617 484687 484687 76691930 0 76691930 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: IN ORDER TO ACCOUNT FOR ANY UNCERTAIN TAX POSITIONS, COMMUNITY HEALTH NETWORK, INC. 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 CONSOLIDATED FINANCIAL STATEMENTS. THE ORGANIZATION RECORDED NO ASSETS OR LIABILITIES RELATED TO UNCERTAIN TAX POSITIONS OR UNRECOGNIZED TAX BENEFITS IN 2011, 2010, OR 2009. COMMUNITY HEALTH NETWORK INC.'S POLICY IS TO RECOGNIZE INTEREST AND ANY PENALTIES RELATED TO INCOME TAX MATTERS IN INCOME TAX EXPENSE WHEN INCURRED. AS OF AND FOR THE YEARS ENDED SEPTEMBER 30, 2011, 2010, AND 2009, THERE WAS NO INCOME TAX EXPENSE, TAX PENALTIES, OR INTEREST RELATED TO TAX PENALTIES RECORDED BY THE ORGANIZATION IN THE CONSOLIDATED FINANCIAL STATEMENTS. FEDERAL INCOME TAX RETURNS FOR THE YEAR ENDED SEPTEMBER 30, 2008, AND BEYOND REMAIN SUBJECT TO EXAMINATION BY THE INTERNAL REVENUE SERVICE. PART XI, LINE 8 - OTHER ADJUSTMENTS: TRANSFER TO PARTNERS HEALTH SYSTEM FOUNDATION, INC -143,168. NET ASSETS RELEASED FROM RESTRICTIONS USED FOR CAPITAL PURCHASES 16,679. PART XII, LINE 4B - OTHER ADJUSTMENTS: RENTAL EXPENSES -484,687. PART XIII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES 484,687. 1 1 1 X 1 X 1 1 1 0 1 0 1904 1714709 1714709 0.02320 9819066 7188267 2630799 0.03560 1904 11533775 7188267 4345508 0.05880 7647 54494 54494 0.00070 132 24360 24360 0.00030 79587 79587 0.00110 7779 158441 158441 0.00210 9683 11692216 7188267 4503949 0.06090 1 1339713 11848043 11730738 117305 X 1 1 1 1 BERLIN MEMORIAL HOSPITAL

225 MEMORIAL DRIVE BERLIN WI 54923

X X X X BERLIN MEMORIAL HOSPITAL 1 15 BERLIN MEMORIAL HOSPITAL

225 MEMORIAL DRIVE BERLIN WI 54923

OUTPATIENT PHYSICIAN CLINIC CHN MEDICAL OFFICE BUILDING

225 MEMORIAL DRIVE BERLIN WI 54923

OUTPATIENT PHYSICIAN CLINIC CHN MEDICAL CENTER - WAUTOMA

N HIGHWAY 22 WAUTOMA WI 54982

OUTPATIENT PHYSICIAN CLINIC CHN MEDICAL CENTER - MARKESAN

340 ENTERPRISE DRIVE MARKESAN WI 53946

OUTPATIENT PHYSICIAN CLINIC CHN MEDICAL CENTER - PRINCETON

502 W WATER STREET PRINCETON WI 54968

OUTPATIENT PHYSICIAN CLINIC CHN MEDICAL CENTER - MONTELLO

315 CHURCH STREET MONTELLO WI 53949

OUTPATIENT PHYSICIAN CLINIC CHN MEDICAL CENTER - RIPON

1080 FOND DU LAC STREET RIPON WI 54971

OUTPATIENT PHYSICIAN CLINIC CHN MEDICAL CENTER - REDGRANITE

402 PRESTON LANE REDGRANITE WI 54970

OUTPATIENT PHYSICIAN CLINIC CHN MEDICAL CENTER - EASTRIDGE

W832 HIGHWAY 91 BERLIN WI 54923

OUTPATIENT PHYSICIAN CLINIC CHN MEDICAL CENTER - WOMENS HEALTH

270 MARQUETTE STREET BERLIN WI 54923

OUTPATIENT PHYSICIAN CLINIC CHN ORTHOPEDICS & SPORTS MEDICINE

191 MEMORIAL DRIVE BERLIN WI 54923

OUTPATIENT PHYSICIAN CLINIC JULIETTE MANOR

169 EAST HURON STREET BERLIN WI 54923

SKILLED NURSING FACILITY CHN HOME CARE

270 MARQUETTE STREET BERLIN WI 54923

HOME HEALTH CARE COMMUNITY MEDICAL CENTER - GREEN LAKE

670 CTY HIGHWAY A GREEN LAKE WI 54941

OUTPATIENT PHYSICIAN CLINIC CHN MEDICAL CENTER - GREEN LAKE

N6205 BUSSE DR GREEN LAKE WI 54941

OUTPATIENT PHYSICIAN CLINIC PART I, LINE 7: THE NUMBERS IN THE TABLE FOR CHARITY CARE AND UNREIMBURSED MEDICAID WERE DERIVED FROM USE OF THE WORKSHEET 2 COST-TO-CHARGE RATIO. THE COST OF THE COMMUNITY HEALTH IMPROVEMENTS WERE CALCULATED BASED ON LABOR COSTS, SUPPLY COSTS AND ROOM COSTS. HEALTH PROFESSIONAL EDUCATION COSTS WERE BASED ON THE AMOUNT OF SCHOLARSHIPS AWARDED AND THE ROOM & LABOR COSTS FOR PROVIDING COMMUNITY EDUCATION FOR HEALTH PROFESSIONALS IN OUR COMMUNITIES. CASH IS THE AMOUNT OF CONTRIBUTIONS TO THE COMMUNITY AND IN-KIND DONATIONS ARE BASED ON THE COST OF THE IN-KIND DONATION. 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 $ 2801717. PART II: COMMUNITY HEALTH NETWORK 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 PROVIDE MEETING ROOMS AND SUPPORT TO OTHER NOT-FOR-PROFIT ORGANIZATIONS THAT IMPROVE THE HEALTH OF THE COMMUNITY. ALL OF THESE EFFORTS ARE FOCUSED ON MINIMIZING THE HEALTH IMPACT OF CATASTROPHES, LARGE AND SMALL, AS WELL AS SUPPORTING HEALTH ACTIVITIES AND GROUPS WITH A QUALITY OF LIFE FOCUS. PART III, LINE 4: USED COST TO CHARGE RATIO BASED ON COST BEING THE TOTAL OPERATING EXPENSE NET OF COMMUNITY BENEFIT EXPENSE AND NON-PATIENT CARE OPERATIONS AND CHARGES BEING 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, COMMUNITY HEALTH NETWORK CONTINUES TO SERVE PATIENTS WHOSE ACCOUNTS ARE WRITTEN OFF TO BAD DEBT EVEN THOUGH THERE IS A GOOD CHANGE FUTURE SERVICES MAY CONTINUE TO BE WRITTEN OFF TO BAD DEBT, WHICH DEMONSTRATES A COMMUNITY BENEFIT-SERVING PATIENTS EVEN THOUGH WE MAY NOT RECEIVE PAYMENT. PART III, LINE 8: ANY SHORTFALL SHOULD BE TREATED AS COMMUNITY BENEFIT BECAUSE COMMUNITY HEALTH NETWORK CONTINUES TO SERVE THE MEDICARE POPULATION REGARDLESS OF WHETHER THEY COVER THEIR COSTS. COMMUNITY HEALTH NETWORK HAS A SURPLUS BECUASE IT IS A CRITICAL ACCESS HOSPITAL AND AS A CRITICAL ACCESS HOSPITAL, IT RECEIVES 101% OF ITS COST PER THE MEDICARE COST REPORT PART III, LINE 9B: PATIENTS WHO HAVE AN APPLICATION OUTSTANDING FOR CHARITY CARE ARE NOT KNOWINGLY SENT TO COLLECTIONS. PATIENTS WHO QUALIFY FOR 100% CHARITY HAVE THE ENTIRE AMOUNT OF THE BILL WRITTEN OFF AND NO FURTHER COLLECTIONS PROCEDURES ARE DONE. BALANCES REMAINING AFTER CHARITY CARE PERCENTAGE HAS BEEN DETERMINED (THOSE WHO QUALIFY FOR FINANCIAL ASSISTANCE/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 WRITING THAT THE ACCOUNT BALANCE IS PAST DUE AND THE AMOUNT WILL BE SUBJECT TO NORMAL COLLECTION PROCEDURES. PART VI, LINE 8 - WISCONSIN PART VI, LINE 2: COMMUNITY HEALTH NETWORK WORKS IN COLLABORATION WITH GREEN LAKE AND WAUSHARA COUNTY PUBLIC HEALTH TO ASSESS COMMUNITY NEEDS IN ORDER TO CREATE A PLAN OF CARE BASED ON THOSE ISSUES AND CONCERNS IDENTIFIED. COMMUNITY HEALTH NETWORK ALSO PARTICIPATES WITH THE GREEN LAKE COUNTY AND WAUSHARA COUNTY WELLNESS COALITION. IN THE EFFORT TO PROVIDE COMPREHENSIVE CARE, THE WELLNESS COALITION ALSO STRIVES TO DECREASE INEFFICIENCIES DUE TO OVERLAP OF CARE PROVIDERS AND ORGANIZATIONS IN THE AREA. COMMUNITY HEALTH NETWORK ALSO ASSESSES COMMUNITY NEED BY USING UNIVERSITY OF WISCONSIN HEALTH RANKINGS WHICH PROVIDES COUNTY BY COUNTY BREAKDOWNS OF HEALTH OUTCOMES, HEALTH FACTORS, AND HEALTH ISSUES TO ASSIST IN DETERMINING COMMUNITY NEED. 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: COMMUNITY HEALTH NETWORK PRIMARILY SERVES RESIDENTS FROM GREEN LAKE, MARQUETTE, AND WAUSHARA COUNTIES. THE SERVICE AREA HAD AN ESTIMATED POPULATION OF 63,000 AND IS MOSTLY RURAL. THE POPULATION CONSISTS OF 21.3% UNDER THE AGE OF 18, 29.4% FROM 18 TO 44, 29.8% FROM 45 TO 64 AND 19.5% WHO WERE 65 AND OLDER. PORTIONS OF THE COMMUNITY HEALTH NETWORK SERVICE AREA ARE FEDERALLY QUALIFIED HPSA AREAS. COMMUNITY HEALTH NETWORK OPERATES THE ONLY HOSPITAL IN GREEN LAKE COUNTY. 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.COMMUNITY HEALTH NETWORK CONDUCTS HEALTH FAIRS FOR THE COMMUNITY TO ENCOURAGE HEALTHY LIFESTYLES AND TO RAISE AWARENESS OF HEALTH ISSUES AND TRENDS.COMMUNITY HEALTH NETWORK ALSO CONDUCTS CPR AND FIRST AID CLASSES, EDUCATION AND OUTREACH FOR SENIOR CITIZENS, AND EDUCATION OPPORTUNITIES FOR PHYSICIANS AND MEDICAL STUDENTS. IN ADDITION, WE ADMINISTER A DIABETES SUPPORT GROUP. PART VI, LINE 7: COMMUNITY HEALTH NETWORK IS AFFILIATED WITH WILD ROSE HOSPITAL 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. X X X 0 1 0 1 0 0 0 0 0 P MICHAEL SHATTUCK MD 195591 0 36483 0 3100 0 5200 0 17459 0 257833 0 0 0 DOUGLAS GUY 218774 6837 0 0 0 0 6587 206 797 25 226158 7068 0 0 THOMAS KRYSTOWIAK 138603 4950 0 0 11701 418 7832 280 19563 699 177699 6347 0 0 DONALD CAVES 111954 32503 0 0 14003 4065 5127 1489 12532 3638 143616 41695 0 0 JOHN HORAN MD 643991 0 0 0 0 0 0 0 20331 0 664322 0 0 0 DAVID JONES MD 788027 0 0 0 0 0 0 0 26718 0 814745 0 0 0 DAVID KURTZ MD 414781 0 119368 0 0 0 9800 0 18912 0 562861 0 0 0 JOSEPH LEE MD 429998 0 140168 0 0 0 7350 0 6645 0 584161 0 0 0 URI VAISMAN MD 643437 0 205597 0 0 0 7350 0 20262 0 876646 0 0 0 PART I, LINE 4B THE FIVE HIGHEST PAID EMPLOYEES, JOHN HORAN, MD, DAVID JONES, MD DAVID KURTZ, MD JOSEPH LEE MD & URI AISMAN MD ALL PARTICIPATED BUT DID NOT RECEIVE A PAYMENT FROM A NONQUALIFIED RETIREMENT PLAN. PART I, LINE 5 RADIOLOGISTS RECEIVE 50% OF REVENUE FROM PROFESSIONAL FEES OVER 2.2 MILLION. IN THE CURRENT YEAR, DR. URI VAISMAN RECEIVED $205,597, DR. JOSEPH LEE RECEIVED $140,168, AND DR. DAVID KURTZ RECEIVED $119,368 RELATED TO THIS ARRANGEMENT. WISCONSIN HEALTH AND EDUCATIONAL FACILITIES AUTHORITY 391337855 97710VUX4 2004-08-01 10060000 SEE SCHEDULE O FOR DESCRIPTION 0 0 0 WISCONSIN HEALTH AND EDUCATIONAL FACILITIES AUTHORITY 391337855 97710VVF2 2004-08-01 5000000 SEE SCHEDULE O FOR DESCRIPTION 0 0 0 10060000 756255 3745240 201200 5357305 2005 1 0 1 1 5000000 2712071 100000 85643 2102286 2005 1 0 1 1 0 1 0 0 0.00060 0.00000 0.00060 1 0 1 0 0 0.00060 0.00060 1 1 0 0 0 0 0 1 1 0 0 0 SCHEDULE K, PART I, LINE A: WISCONSIN HEALTH AND EDUCATIONAL FACILITIES BOND HAS THE ADDITIONAL CUSIP NUMBERS: 97710VUZ9 97710VUY2 97710VVA3 97710VVB1 97710VVC9 97710VVD7 97710VVE5 DR JOHN HORAN COMPENSATION ADVANCE X 225000 150000 0 1 1 150000 THOMAS WILLETT DO CHN BOARD MEMBER 108060 CHN RENTS SPACE FROM DR. WILLETT FOR MEDICAL GROUP OFFICES. 0 THOMAS WILLETT DO CHN BOARD MEMBER 132000 CHN CONTRACTS PHYSICIAN SERVICES FROM DR WILLETT 0 P MICHAEL SHATTUCK MD CHN BOARD MEMBER 138636 CHN RENTS SPACE FROM DR. SHATTUCK FOR MEDICAL GROUP OFFICES 0 RUSSELL KUEHN CHN BOARD MEMBER 1134000 BOARD MEMBER OF 1ST NATIONAL BANK WHICH IS CHN'S PRIMARY BANK & CHN HAS NOTE WITH 1ST NATIONAL BANK AT 9/30/11 0 NEW PROGRAM SERVICES FORM 990, PART III, LINE 2 COMMUNITY HEALTH NETWORK, INC PURCHASED A LOCAL GENERAL SURGICAL PRACTICE WHICH BEGAN OPERATING UNDER COMMUNITY HEALTH NETWORK, INC IN DECEMBER 2010. FORM 990, PART VI, SECTION A, LINE 2 HENRY DERLETH, RUSSELL KUEHN AND THOMAS WILLETT, DO HAVE A BUSINESS RELATIONSHIP. STEVE SORENSON HAS A BUSINESS RELATIONSHIP WITH PAT MCCONNELL AND LARRY WISE. THOMAS WILLETT, DO AND PATRICK MCCONNELL HAVE A BUSINESS RELATIONSHIP. FORM 990, PART VI, SECTION A, LINE 6 MEMBERSHIP MAY BE OBTAINED BY ANYONE EIGHTEEN OR MORE YEARS OF AGE AND EITHER: (A) RESIDE OR WORK IN THE CORPORATION'S SERVICE AREA, WHICH IS DEFINED AS THE FOLLOWING ZIP CODES: 53919, 53923, 53926, 53930, 53931, 53935, 53939, 53946, 53947, 53949, 53952, 53953, 53956, 53964, 54909, 54921, 54923, 54930, 54934, 54940, 54941, 54943, 54960, 54963, 54964, 54965, 54966, 54967, 54968, 54970, 54971, 54976, 54980, 54982, 54984, AND 54986. AN INDIVIDUAL IS DEEMED TO WORK WITHIN THE CORPORATION'S SERVICE AREA IF HIS OR HER PRIMARY SOURCE OF INCOME STEMS FROM WORK PERFORMED IN THE SERVICE AREA; OR (B) AN EMPLOYEE OF THE CORPORATION OR MEMBER OF HIS OR HER FAMILY. MAY BECOME A MEMBER OF THE CORPORATION UPON SUBMISSION OF A SIGNED APPLICATION DELIVERED TO THE PRINCIPAL OFFICE OF THE CORPORATION. THE CORPORATION'S BOARD OF DIRECTORS OR ITS DESIGNEE(S) HAS THE AUTHORITY TO, FROM TIME TO TIME, MAKE GOOD FAITH DETERMINATIONS REGARDING WHETHER AN APPLICANT OR AN EXISTING MEMBER MEETS THE QUALIFICATIONS FOR MEMBERSHIP OF THE CORPORATION. ANY PERSON WHO DOES NOT MEET THE CRITERIA AS DETERMINED BY THE BOARD OF DIRECTORS OR ITS DESIGNEE(S) WILL NOT BE A MEMBER. AN INDIVIDUAL'S MEMBERSHIP SHALL BE TERMINATED UPON DEATH, RESIGNATION OR THE FAILURE TO MEET THE QUALIFICATION. INDIVIDUALS GRANTED HONORARY MEMBERSHIP IN THE CORPORATION SHALL BE ENTITLED TO LIFELONG VOTING MEMBERSHIP IN THE CORPORATION. FORM 990, PART VI, SECTION A, LINE 7A THERE ARE TWELVE DIRECTORS ON THE BOARD OF DIRECTORS THAT ARE ELECTED ANNUALLY BY THE MEMBERS AT THE ANNUAL MEETING OR AT A SPECIAL MEETING HELD FOR SUCH PURPOSE. THE CHIEF EXECUTIVE OFFICER IS AN EX-OFFICIO MEMBER OF THE BOARD OF DIRECTORS FORM 990, PART VI, SECTION B, LINE 11 THE BOARD OF DIRECTORS (BOD) HAS DELEGATED THE DETAIL REVIEW OF THE FORM 990 TO THE MANAGEMENT OF THE CORPORATION. THEY COMPLETED THEIR REVIEW PRIOR TO SUBMISSION. FORM 990, PART VI, SECTION B, LINE 12C IT IS THE DIRECTOR, OFFICER AND/OR COMMITTEE MEMBER'S RESPONSIBILITY TO DISCLOSE TO THE BOARD OF DIRECTORS OR COMMITTEE CONSIDERING A TRANSACTION, ANY POTENTIAL FINANCIAL INTEREST. THE CHAIRPERSON OF THE BOARD OR COMMITTEE MAY THEN QUESTION THE INTERESTED PERSON FURTHER. THE BOARD OR COMMITTEE MAKES THE DECISION WHETHER A CONFLICT OF INTEREST EXISTS. IN ADDITION TO THE ABOVE, DIRECTORS, OFFICERS AND COMMITTEE MEMBERS EXECUTE AND DELIVER TO CHN A "CERTIFICATE REGARDING CONFLICTS OF INTEREST" ON AN ANNUAL BASIS. PER THE POLICY, THE BOARD IS TO CONDUCT PERIODIC REVIEWS OF ITS TRANSACTIONS AND ARRANGEMENTS. REVIEW SHALL INCLUDE: - WHETHER COMPENSATION ARRANGEMENTS AND BENEFITS ARE REASONABLE AND ARE THE RESULT OF ARM'S-LENGTH BARGAINING - WHETHER ACQUISITIONS OF PHYSICIAN PRACTICES AND OTHER PROVIDER SERVICES RESULT IN PRIVATE INUREMENT OR IMPERMISSIBLE PRIVATE BENEFIT - WHETHER PARTNERSHIPS, JOINT VENTURES, AND OTHER TYPES OF ARRANGEMENTS FURTHER CHN'S CHARITABLE PURPOSE AND DO NOT RESULT IN PRIVATE INUREMENT OR IMPERMISSIBLE PRIVATE BENEFIT THE COMPENSATION DETERMINATION FOR THE CEO OF COMMUNITY HEALTH NETWORK IS AS FOLLOWS: THE CEO IS UNDER AN EMPLOYMENT CONTRACT. HIS SALARY IS REVIEWED PER HIS CONTRACT BY THE EXECUTIVE COMMITTEE OF THE BOARD OF DIRECTORS (THOSE WITHOUT CONFLICT). THE EXECUTIVE COMMITTEE REVIEWS COMPENSATION BENCHMARK DATA, COMPARES THE DATA WITH THE CEO'S CURRENT SALARY AND MAKES A SALARY DETERMINATION WHICH IS THEN VOTED ON BY THE EXECUTIVE COMMITTEE. THE COMPENSATION DETERMINATION FOR THE CFO IS AS FOLLOWS. ONCE A YEAR, CHN'S CEO REVIEWS COMPENSATION BENCHMARK DATA AND COMPARES THE DATA WITH THE CFO'S CURRENT SALARY AND THE PROPOSED INCREASE. BASED ON THE DATA, THE CEO, A PERSON WITHOUT CONFLICT, DETERMINES THE CFO'S SALARY FOR THE COMING YEAR. THE SALARY IS DISCUSSED AND AGREED UPON BY CHN'S CEO AND THE INDIVIDUAL. THE QUESTIONS WERE MARKED "NO" AS THE PROCESS FOR 2011 WAS NOT DOCUMENTED. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION BELIEVES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE THE PROPERTY OF THE ORGANIZATION AND DOES NOT MAKE THEM AVAILABLE TO THE PUBLIC, EXCEPT FOR DISCLOSURE OF THE FINANCIAL STATEMENTS WITH FORM 990, AS REQUIRED. HOURS WORKED AT RELATED ORGANIZATION FORM 990, PART VII, SECTION A, COLUMN (B) DONALD CAVES WORKED AN AVERAGE OF 9 HOURS A WEEK AT A RELATED ORGANIZATION. THOMAS KRYSTOWIAK WORKED AN AVERAGE OF 2 HOURS A WEEK AT RELATED ORGANIZATIONS DOUGLAS GUY WORKED AN AVERAGE OF 1 HOUR A WEEK AT A RELATED ORGANIZATION. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED LOSSES ON INVESTMENTS: -322,744. PRIOR PERIOD ADJUSTMENTS: 873,273. TRANSFER TO PARTNERS HEALTH SYSTEM FOUNDATION, INC -143,168. NET ASSETS RELEASED FROM RESTRICTIONS USED FOR CAPITAL PURCHASES 16,679. TOTAL TO FORM 990, PART XI, LINE 5: 424,040. RESPONSIBLE FOR THE AUDIT FORM 990, PART XI, LINE 2C MANAGEMENT PROVIDES OVERSIGHT OF THE AUDIT. THE AUDIT IS PRESENTED TO THE FINANCE COMMITTEE OF THE BOARD OF DIRECTORS. OVERSIGHT OF AUDIT PART XI, LINE 2C THE PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. 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