MEMORIAL HOSPITAL INC: Form 990, tax year 2011
View the entire original 990 at ProPublica ↗
- Organization
- MEMORIAL HOSPITAL INC (EIN 39-0806828)
- Tax period
- 2011-01-01 to 2011-12-31
- Filed
- 2012-10-10
- IRS object ID
- 201232849349300228
- Schema version
- 2011v1.2
- 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 O
- Schedule R
Return header ReturnHeader
| Field | Value | IRS element (for citing) |
|---|---|---|
| Timestamp | 2012-10-10T12:26:21-05:00 | Timestamp |
| Tax Period End Date | 2011-12-31 | TaxPeriodEndDate |
Preparer Firm PreparerFirm
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 390758449 | EIN |
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 | 3703 OAKWOOD HILLS PARKWAY | AddressLine1 |
| City | EAU CLAIRE | City |
| State | WI | State |
| ZIP Code | 54701 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return Type | 990 | ReturnType |
| Tax Period Begin Date | 2011-01-01 | TaxPeriodBeginDate |
Filer Filer
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 390806828 | EIN |
Name Name
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | MEMORIAL HOSPITAL INC | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name Control | MEMO | NameControl |
| Phone | 7157433101 | Phone |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 216 SUNSET PLACE | AddressLine1 |
| City | NEILLSVILLE | City |
| State | WI | State |
| ZIP Code | 54456 | ZIPCode |
Officer Officer
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name | KELLY MOEN | Name |
| Title | CFO | Title |
| Phone | 7157433101 | Phone |
| Date Signed | 2012-10-09 | DateSigned |
| Authorize Third Party | 1 | AuthorizeThirdParty |
Preparer Preparer
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name | HOLLY POKRANDT CPA | Name |
| PTIN | P00449155 | PTIN |
| Phone | 7158323407 | Phone |
| Date Prepared | 2012-10-09 | DatePrepared |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tax Year | 2011 | TaxYear |
| Build TS | 2016-02-24 21:20:13Z | BuildTS |
Form 990 IRS990
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name Of Principal Officer Person | KELLY MOEN | NameOfPrincipalOfficerPerson |
Address Principal Officer US AddressPrincipalOfficerUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 216 SUNSET PLACE | AddressLine1 |
| City | NEILLSVILLE | City |
| State | WI | State |
| ZIP Code | 54456 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Receipts | 23271900 | GrossReceipts |
| Group Return For Affiliates | 0 | GroupReturnForAffiliates |
| Organization501c3 | X | Organization501c3 |
| Web Site | WWW.MEMORIALMEDCENTER.ORG | WebSite |
| Type Of Organization Corporation | X | TypeOfOrganizationCorporation |
| Year Formation | 1954 | YearFormation |
| State Legal Domicile | WI | StateLegalDomicile |
| Activity Or Mission Description | MEMORIAL HOSPITAL'S MISSION IS TO PROVIDE THE COMMUNITIES WE SERVE THE BEST EXPERIENCE IN HEALTH CARE, EDUCATION, AND PREVENTION SUPPORTED BY OUR PILLARS OF PEOPLE, SERVICE, QUALITY, AND SAFETY, FINANCE, COMMUNITY, AND GROWTH...ONE PATIENT AT A TIME. MEMORIAL HOSPITAL, INC. PROVIDES SERVICES THROUGH THE 25-BED CRITICAL ACCESS HOSPITAL, HOME HEALTH AGENCY, ASSISTED LIVING, AS WELL AS 3 RURAL HEALTH CLINICS IN NEILLSVILLE, LOYAL, AND GREENWOOD. TO FULFILL COMMUNITY NEEDS, MEMORIAL HOSPITAL, INC. FACILITATES EDUCATIONAL SEMINARS AND SUPPORT GROUPS LED BY MEDICAL AND PROFESSIONAL STAFF AT GREATLY REDUCED-RATES; PROVIDES FREE HEALTH SCREENINGS AT GIVEN TIMES THROUGHOUT THE YEAR; STAFF BOOTHS AT COMMUNITY EVENTS; SERVES AS AN EDUCATION SITE FOR STUDENTS IN HIGH SCHOOL, TECHNICAL COLLEGE, AND UNIVERSITIES; AS WELL AS OTHER NEEDS AS DETERMINED. MEMORIAL HOSPITAL, INC. ALSO ADMINISTERS A CHARITY CARE PROGRAM HELPING TO ENSURE AFFORDABLE ACCESS TO HEALTHCARE. | ActivityOrMissionDescription |
| Nbr Voting Members Governing Body | 11 | NbrVotingMembersGoverningBody |
| Nbr Independent Voting Members | 9 | NbrIndependentVotingMembers |
| Total Nbr Employees | 287 | TotalNbrEmployees |
| Total Nbr Volunteers | 78 | TotalNbrVolunteers |
| Total Gross UBI | 443461 | TotalGrossUBI |
| Net Unrelated Business Txbl Income | -221497 | NetUnrelatedBusinessTxblIncome |
| Contributions Grants Prior Year | 68077 | ContributionsGrantsPriorYear |
| Contributions Grants Current Year | 104597 | ContributionsGrantsCurrentYear |
| Program Service Revenue Prior Year | 22288934 | ProgramServiceRevenuePriorYear |
| Program Service Revenue CY | 22637768 | ProgramServiceRevenueCY |
| Investment Income Prior Year | 629306 | InvestmentIncomePriorYear |
| Investment Income Current Year | 59427 | InvestmentIncomeCurrentYear |
| Other Revenue Prior Year | 380707 | OtherRevenuePriorYear |
| Other Revenue Current Year | 458405 | OtherRevenueCurrentYear |
| Total Revenue Prior Year | 23367024 | TotalRevenuePriorYear |
| Total Revenue Current Year | 23260197 | 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 | 14673153 | SalariesEtcPriorYear |
| Salaries Etc Current Year | 14159170 | 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 | 7143353 | OtherExpensePriorYear |
| Other Expenses Current Year | 7403465 | OtherExpensesCurrentYear |
| Total Expenses Prior Year | 21816506 | TotalExpensesPriorYear |
| Total Expenses Current Year | 21562635 | TotalExpensesCurrentYear |
| Revenues Less Expenses Prior Year | 1550518 | RevenuesLessExpensesPriorYear |
| Revenues Less Expenses CY | 1697562 | RevenuesLessExpensesCY |
| Total Assets BOY | 16588627 | TotalAssetsBOY |
| Total Assets EOY | 17909273 | TotalAssetsEOY |
| Total Liabilities BOY | 4241300 | TotalLiabilitiesBOY |
| Total Liabilities EOY | 3884093 | TotalLiabilitiesEOY |
| Net Assets Or Fund Balances BOY | 12347327 | NetAssetsOrFundBalancesBOY |
| Net Assets Or Fund Balances EOY | 14025180 | NetAssetsOrFundBalancesEOY |
| Info In Schedule O Part III | X | InfoInScheduleOPartIII |
| Mission Description | TO PROVIDE THE COMMUNITIES WE SERVE THE BEST EXPERIENCE IN HEALTH CARE, EDUCATION, AND PREVENTION, SUPPORTED BY OUR PILLARS OF PEOPLE, SERVICE, QUALITY AND SAFETY, FINANCE, COMMUNITY, AND GROWTH...ONE PATIENT AT A TIME. | MissionDescription |
| Significant New Program Services | 0 | SignificantNewProgramServices |
| Significant Change | 0 | SignificantChange |
| Expense | 13057701 | Expense |
| Revenue | 18446374 | Revenue |
| Description | HOSPITAL INPATIENT SERVICES IN 2011 INCLUDED 913 ACUTE CARE PATIENT DAYS, 191 OBSERVATION DAYS, AND 861 SWING BED PATIENT DAYS.EMERGENCY ROOM VISITS TOTALLED 3,919 AND SURGERIES AND PROCEDURES TOTALLED 1,056 IN 2011.OTHER HOSPITAL SERVICES PROVIDED IN 2011 INCLUDED BUT WERE NOT LIMITED TO ATHLETIC TRAINING, DIETARY, OBSTETRICS, PAIN MANAGEMENT, PHARMACY, PHYSICAL THERAPY, RADIOLOGY, LABORATORY, CARDIAC REHABILITATION, SPEECH THERAPY, RESPIRATORY THERAPY, OCCUPATIONAL THERAPY, SOCIAL SERVICES, DIABETIC EDUCATION, AND HOME HEALTH SERVICES. | Description |
Activity2 Activity2
| Field | Value | IRS element (for citing) |
|---|---|---|
| Expense | 4582789 | Expense |
| Revenue | 3683458 | Revenue |
| Description | A TOTAL OF 24,098 CLINIC VISITS OCCURRED IN 2011 AT THE THREE CLINICS LOCATED IN NEILLSVILLE, LOYAL, AND GREENWOOD. | Description |
Activity3 Activity3
| Field | Value | IRS element (for citing) |
|---|---|---|
| Expense | 738747 | Expense |
| Revenue | 347020 | Revenue |
| Description | THE ASSISTED LIVING FACILITY IS AN ALTERNATIVE FOR SENIORS WHO CAN NO LONGER LIVE SAFELY IN THEIR OWN HOME, YET DO NOT NEED 24-HOUR MEDICAL SUPERVISION. SUNSET GARDENS IS A HOUSING AND HEALTH CARE ALTERNATIVE, COMBINING INDEPENDENCE WITH PERSONAL CARE, IN A WARM, DIGNIFIED, HOME-LIKE ATMOSPHERE. SUNSET GARDENS HAS 11 PRIVATE ROOMS AND 2 DOUBLE ROOMS, FOR A COUPLE OR SIBLINGS. MEALS, SNACKS, HOUSEKEEPING, LAUNDRY, CABLE TELEVISION, AND MAINTENANCE SERVICES ARE PROVIDED. SOCIAL AND RECREATIONAL PROGRAMS AND A CHAPEL ARE ALSO PROVIDED. HEALTH CARE SERVICES INCLUDE A REGISTERED NURSE ON-SITE OR ON-CALL 24 HOURS PER DAY, MEDICATION MANAGEMENT, PERSONAL CARE SERVICES PROVIDED BY CERTIFIED NURSING ASSISTANTS (SUCH AS ASSISTANCE WITH BATHING, DRESSING, AND GROOMING). THE ASSISTED LIVING PROVIDED 3,550 RESIDENT DAYS. | Description |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Expense | 18379237 | TotalProgramServiceExpense |
| Described In501 C3 | 1 | DescribedIn501C3 |
| Schedule B Required | 1 | ScheduleBRequired |
| Political Activities | 0 | PoliticalActivities |
| Lobbying Activities | 1 | LobbyingActivities |
| Subject To Proxy Tax | 0 | SubjectToProxyTax |
| 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 | 1 | 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 | 0 | TaxExemptBonds |
| 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 | 0 | TransactionRelatedEntity |
| Transfers To Exempt Non Chrtbl Org | 0 | TransfersToExemptNonChrtblOrg |
| Activities Conducted Partnership | 0 | ActivitiesConductedPartnership |
| Schedule O Required | 1 | ScheduleORequired |
| Number Forms Transmitted With1096 | 16 | NumberFormsTransmittedWith1096 |
| Number W2 G Included | 0 | NumberW2GIncluded |
| Compliance With Backup Witholding | 1 | ComplianceWithBackupWitholding |
| Number Of Employees | 287 | NumberOfEmployees |
| Employment Tax Returns Filed | 1 | EmploymentTaxReturnsFiled |
| Unrelated Business Income | 1 | UnrelatedBusinessIncome |
| Form990-T Filed | 1 | Form990-TFiled |
| 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 | 11 | NbrVotingGoverningBodyMembers |
| Number Independent Voting Members | 9 | 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 | 0 | MembersOrStockholders |
| Election Of Board Members | 0 | ElectionOfBoardMembers |
| Decisions Subject To Approval | 0 | 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 | 1 | 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 | KELLY MOEN MEMORIAL HOSPITAL INC | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Telephone Number | 7157433101 | TelephoneNumber |
Address US AddressUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 216 SUNSET PLACE | AddressLine1 |
| City | NEILLSVILLE | City |
| State | WI | State |
| ZIP Code | 54456 | ZIPCode |
Form990 Part VII Section A Form990PartVIISectionA (20 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 |
|---|---|---|---|---|---|---|---|
| ALLAN HOESLY | |||||||
| SECRETARY | 1.00 | X | X | 300 | 0 | 0 | |
| DR JAMES STANGA | |||||||
| DIRECTOR/PHYSICIAN | 53.00 | X | 315911 | 0 | 23567 | ||
| JEANETTE STEINER | |||||||
| BOARD MEMBER | 1.00 | X | 225 | 0 | 0 | ||
| RICK SZYMANSKI | |||||||
| VICE-PRESIDENT | 1.00 | X | X | 300 | 0 | 0 | |
| ROBERT BARTH | |||||||
| PRESIDENT | 1.00 | X | X | 300 | 0 | 0 | |
| WENDY SIGURDSON | |||||||
| BOARD MEMBER | 1.00 | X | 200 | 0 | 0 | ||
| TREVOR WUETHRICH | |||||||
| BOARD MEMBER | 1.00 | X | 150 | 0 | 0 | ||
| KEVIN GRAPP | |||||||
| BOARD MEMBER | 1.00 | X | 100 | 0 | 0 | ||
| TIM RUETH | |||||||
| BOARD MEMBER | 1.00 | X | 0 | 0 | 0 | ||
| DOROTHY WELSH | |||||||
| BOARD MEMBER | 1.00 | X | 225 | 0 | 0 | ||
| DR KENNETH WEIMER | |||||||
| DIRECTOR/PHYSICIAN | 36.00 | X | 207014 | 0 | 26028 | ||
| DR TIM MEYER | |||||||
| CHIEF OF STAFF/CMO/PHYSICI | 35.00 | X | 363067 | 0 | 11281 | ||
| SCOTT POLENZ | |||||||
| CEO | 58.00 | X | 190737 | 0 | 25067 | ||
| KELLY MOEN | |||||||
| CFO | 47.00 | X | 102778 | 0 | 22222 | ||
| SHARON LOANEY-BERGSHOLM | |||||||
| CHIEF NURSING OFFICER | 46.00 | X | 98991 | 0 | 19969 | ||
| DR GRACE CRUZ-APOLINARIO | |||||||
| PHYSICIAN | 36.00 | 467983 | 0 | 23567 | X | ||
| DRDAVID PAUSTIAN | |||||||
| PHYSICIAN | 38.00 | 833061 | 0 | 18829 | X | ||
| DR AMY COULTHARD | |||||||
| PHYSICIAN | 46.00 | 207389 | 0 | 9821 | X | ||
| DR CAROLYN HARDESTY | |||||||
| PHYSICIAN | 37.00 | 212935 | 0 | 18828 | X | ||
| DR RANDE SHORT | |||||||
| PHYSICIAN | 60.00 | 163657 | 0 | 5348 | X | ||
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Reportable Comp From Org | 3165323 | TotalReportableCompFromOrg |
| Total Reportable Comp Frm Rltd Orgs | 0 | TotalReportableCompFrmRltdOrgs |
| Total Other Compensation | 204527 | TotalOtherCompensation |
| Number Individuals GT100 K | 14 | NumberIndividualsGT100K |
| Formers Listed | 0 | FormersListed |
| Total Comp GT150 K | 1 | TotalCompGT150K |
| Compensation From Other Sources | 0 | CompensationFromOtherSources |
Contractor Compensation ContractorCompensation (4 entries)
| Address Line1AddressOfContractor/AddressUS/AddressLine1 | CityAddressOfContractor/AddressUS/City | StateAddressOfContractor/AddressUS/State | ZIP CodeAddressOfContractor/AddressUS/ZIPCode | Description Of ServicesDescriptionOfServices | CompensationCompensation |
|---|---|---|---|---|---|
| CMDI | |||||
| PO BOX 158 | MILACA | MN | 56353 | CT SERVICES | 255100 |
| WI ANESTHESIA SERVICE LLC | |||||
| W5844 ROLLING HILLS DRIVE | NEILLSVILLE | WI | 54456 | CRNA SERVICES | 234512 |
| THOMAS R SILBERNAGEL | |||||
| W5844 ROLLING HILLS DRIVE | NEILLSVILLE | WI | 54456 | CRNA SERVICES | 220875 |
| SHARED MEDICAL SERVICES INC | |||||
| PO BOX 330 | COTTAGE GROVE | WI | 53527 | MRI SERVICES | 114945 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Number Of Contractors GT100 K | 4 | NumberOfContractorsGT100K |
| Government Grants | 51296 | GovernmentGrants |
| All Other Contributions | 53301 | AllOtherContributions |
| Total Contributions | 104597 | TotalContributions |
Program Service Revenue ProgramServiceRevenue (3 entries)
| DescriptionDescription | Business CodeBusinessCode | Total Revenue ColumnTotalRevenueColumn | Related Or Exempt Function IncomeRelatedOrExemptFunctionIncome |
|---|---|---|---|
| HOSPITAL REVENUE | 621990 | 18446374 | 18446374 |
| CLINIC REVENUE | 621110 | 3683458 | 3683458 |
| ASSISTED LIVING REVENU | 623000 | 347020 | 347020 |
Total Oth Program Service Revenue TotalOthProgramServiceRevenue
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 160916 | TotalRevenueColumn |
| Exclusion | $160,916 | ExclusionAmount |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Revenue | 22637768 | TotalProgramServiceRevenue |
Investment Income InvestmentIncome
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 59300 | TotalRevenueColumn |
| Exclusion | $59,300 | ExclusionAmount |
Gross Rents GrossRents
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | 14944 | Real |
Less Rental Expenses LessRentalExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | 0 | Real |
Rental Income Or Loss RentalIncomeOrLoss
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | 14944 | Real |
Net Rental Income Or Loss NetRentalIncomeOrLoss
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 14944 | TotalRevenueColumn |
| Exclusion | $14,944 | ExclusionAmount |
Gross Amount Sales Assets GrossAmountSalesAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | 11830 | Other |
Less Cost Oth Basis Sales Expenses LessCostOthBasisSalesExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | 11703 | Other |
Gain Or Loss GainOrLoss
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | 127 | Other |
Net Gain Or Loss Investments NetGainOrLossInvestments
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 127 | TotalRevenueColumn |
| Exclusion | $127 | ExclusionAmount |
Other Revenue Misc OtherRevenueMisc
| Field | Value | IRS element (for citing) |
|---|---|---|
| Description | DIET,MAINT,HSKG,LNDRY | Description |
| Business Code | 722230 | BusinessCode |
| Total Revenue Column | 443461 | TotalRevenueColumn |
| Unrelated Business Revenue | 443461 | UnrelatedBusinessRevenue |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Other Revenue | 443461 | TotalOtherRevenue |
Total Revenue TotalRevenue
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 23260197 | TotalRevenueColumn |
| Related Or Exempt Function Income | 22476852 | RelatedOrExemptFunctionIncome |
| Unrelated Business Revenue | 443461 | UnrelatedBusinessRevenue |
| Exclusion | $235,287 | ExclusionAmount |
Comp Current Officers Directors CompCurrentOfficersDirectors
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 1408432 | Total |
| Program Services | 1065828 | ProgramServices |
| Management And General | 342604 | ManagementAndGeneral |
Other Salaries And Wages OtherSalariesAndWages
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 9755296 | Total |
| Program Services | 8258245 | ProgramServices |
| Management And General | 1497051 | ManagementAndGeneral |
Pension Plan Contributions PensionPlanContributions
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 313444 | Total |
| Program Services | 265343 | ProgramServices |
| Management And General | 48101 | ManagementAndGeneral |
Other Employee Benefits OtherEmployeeBenefits
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 2008165 | Total |
| Program Services | 1703829 | ProgramServices |
| Management And General | 304336 | ManagementAndGeneral |
Payroll Taxes PayrollTaxes
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 673833 | Total |
| Program Services | 564391 | ProgramServices |
| Management And General | 109442 | ManagementAndGeneral |
Fees For Services Legal FeesForServicesLegal
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 41509 | Total |
| Management And General | 41509 | ManagementAndGeneral |
Fees For Services Accounting FeesForServicesAccounting
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 59800 | Total |
| Management And General | 59800 | ManagementAndGeneral |
Fees For Services Other FeesForServicesOther
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 1519418 | Total |
| Program Services | 1517985 | ProgramServices |
| Management And General | 1433 | ManagementAndGeneral |
Advertising Advertising
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 83206 | Total |
| Program Services | 2790 | ProgramServices |
| Management And General | 80416 | ManagementAndGeneral |
Office Expenses OfficeExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 756581 | Total |
| Program Services | 537591 | ProgramServices |
| Management And General | 218990 | ManagementAndGeneral |
Occupancy Occupancy
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 456108 | Total |
| Program Services | 360964 | ProgramServices |
| Management And General | 95144 | ManagementAndGeneral |
Travel Travel
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 7616 | Total |
| Program Services | 7616 | ProgramServices |
Conferences Meetings ConferencesMeetings
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 107636 | Total |
| Program Services | 92676 | ProgramServices |
| Management And General | 14960 | ManagementAndGeneral |
Depreciation Depletion DepreciationDepletion
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 639742 | Total |
| Program Services | 506292 | ProgramServices |
| Management And General | 133450 | ManagementAndGeneral |
Insurance Insurance
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 248436 | Total |
| Program Services | 71211 | ProgramServices |
| Management And General | 177225 | ManagementAndGeneral |
Other Expenses OtherExpenses (4 entries)
| DescriptionDescription | TotalTotal | Program ServicesProgramServices |
|---|---|---|
| MEDICAL SUPPLIES | 1603852 | 1603852 |
| BAD DEBT | 1292507 | 1292507 |
| REPAIRS & MAINTENANCE | 308749 | 308749 |
| ADMIN HOSPITAL TAX EXPE | 132960 | 132960 |
All Other Expenses AllOtherExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 145345 | Total |
| Program Services | 86408 | ProgramServices |
| Management And General | 58937 | ManagementAndGeneral |
Total Functional Expenses TotalFunctionalExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 21562635 | Total |
| Program Services | 18379237 | ProgramServices |
| Management And General | 3183398 | ManagementAndGeneral |
| Fundraising | 0 | Fundraising |
Cash Non Interest Bearing CashNonInterestBearing
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 4469532 | BOY |
| EOY | 5142924 | EOY |
Savings And Temp Cash Investments SavingsAndTempCashInvestments
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 2350895 | BOY |
| EOY | 2361608 | EOY |
Accounts Receivable AccountsReceivable
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 2053995 | BOY |
| EOY | 2010074 | EOY |
Inventories For Sale Or Use InventoriesForSaleOrUse
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 382552 | BOY |
| EOY | 387350 | EOY |
Prepaid Expenses Deferred Charges PrepaidExpensesDeferredCharges
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 191113 | BOY |
| EOY | 242491 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Land Buildings Equipment Basis | 15245657 | LandBuildingsEquipmentBasis |
| Land Bldg Equipment Accum Deprec | 8912702 | LandBldgEquipmentAccumDeprec |
Land Buildings Equipment Basis Net LandBuildingsEquipmentBasisNet
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 5688039 | BOY |
| EOY | 6332955 | EOY |
Other Assets Total OtherAssetsTotal
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 1452501 | BOY |
| EOY | 1431871 | EOY |
Total Assets TotalAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 16588627 | BOY |
| EOY | 17909273 | EOY |
Accounts Payable Accrued Expenses AccountsPayableAccruedExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 2107087 | BOY |
| EOY | 2080208 | EOY |
Deferred Revenue DeferredRevenue
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 547 | BOY |
| EOY | 4117 | EOY |
Tax Exempt Bond Liabilities TaxExemptBondLiabilities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 1210000 | BOY |
| EOY | 935000 | EOY |
Mort Notes Pybl Secured Invest Prop MortNotesPyblSecuredInvestProp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 296737 | BOY |
| EOY | 116587 | EOY |
Other Liabilities OtherLiabilities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 626929 | BOY |
| EOY | 748181 | EOY |
Total Liabilities TotalLiabilities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 4241300 | BOY |
| EOY | 3884093 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Follow SFAS117 | X | FollowSFAS117 |
Unrestricted Net Assets UnrestrictedNetAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 12347327 | BOY |
| EOY | 14025180 | EOY |
Total Net Assets Fund Balances TotalNetAssetsFundBalances
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 12347327 | BOY |
| EOY | 14025180 | EOY |
Total Liab Net Assets Fund Balances TotalLiabNetAssetsFundBalances
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 16588627 | BOY |
| EOY | 17909273 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part XI | X | InfoInScheduleOPartXI |
| Reconcilation Revenue Expenses | 1697562 | ReconcilationRevenueExpenses |
| Reconcilation Other Changes | -19709 | 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 | 1 | FederalGrantAuditRequired |
| Federal Grant Audit Performed | 1 | FederalGrantAuditPerformed |
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 | $3,524 | OtherActivitiesAmount |
| Total Lobbying Expenditures IIB | 3524 | TotalLobbyingExpendituresIIB |
| Not Described In501c3 | 0 | NotDescribedIn501c3 |
Form990 Schedule C Part IV Form990ScheduleCPartIV
| Field | Value | IRS element (for citing) |
|---|---|---|
| Identifier | EXPLANATION OF LOBBYING ACTIVITIES: | Identifier |
| Return Reference | PART II-B, LINE 1: | ReturnReference |
| Explanation | A PORTION OF THE ANNUAL DUES ($940) PAID TO THE WISCONSIN HOSPITAL ASSOCIATION WAS USED FOR LOBBYING EXPENDITURES AND A PORTION OF ANNUAL DUES PAID TO THE RURAL WISCONSIN HEALTH COOPERATIVE ($2,584) WAS USED FOR LOBBYING EXPENDITURES. THE DUES PAID TO THESE ORGANIZATIONS ARE PRIMARILY FOR EDUCATIONAL MATERIALS, STAFF TRAINING, AND ADMINISTRATIVE SERVICES, BUT THE AMOUNTS IDENTIFIED ABOVE REPRESENT THE PORTION OF THESE DUES USED FOR LOBBYING ACTIVITIES. | Explanation |
Schedule D IRS990ScheduleD
Land Land
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 20673 | OtherCostOrOtherBasis |
| Book Value | 20673 | BookValue |
Buildings Buildings
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 10783940 | OtherCostOrOtherBasis |
| Depreciation | 6210081 | Depreciation |
| Book Value | 4573859 | BookValue |
Equipment Equipment
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 3244260 | OtherCostOrOtherBasis |
| Depreciation | 2495361 | Depreciation |
| Book Value | 748899 | BookValue |
Other Land Buildings OtherLandBuildings
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 1196784 | OtherCostOrOtherBasis |
| Depreciation | 207260 | Depreciation |
| Book Value | 989524 | BookValue |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Of Book Value Land Buildings | 6332955 | TotalOfBookValueLandBuildings |
Other Assets OtherAssets (4 entries)
| DescriptionDescription | Book ValueBookValue |
|---|---|
| UNAMORTIZED BOND ISSUE COSTS | 17039 |
| INVESTMENT IN CENTRAL MN DIAGNOSTIC, INC. | 379054 |
| DEFERRED COMPENSATION PLAN ASSETS | 752778 |
| AMOUNTS RECEIVABLE FROM THIRD-PARTY REIUMBURSEMENT PROGRAMS | 283000 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Book Value Other Assets | 1431871 | TotalBookValueOtherAssets |
Other Liabilities OtherLiabilities
| Field | Value | IRS element (for citing) |
|---|---|---|
| Description | DEFERRED COMPENSATION LIABILITY | Description |
| Amount | $748,181 | Amount |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Of Amounts | 748181 | TotalOfAmounts |
| Total Revenue | 23260197 | TotalRevenue |
| Total Expenses | 21562635 | TotalExpenses |
| Excess Or Deficit For Year | 1697562 | ExcessOrDeficitForYear |
| Net Unrealized GL On Investments | -19709 | NetUnrealizedGLOnInvestments |
| Total Adjustments | -19709 | TotalAdjustments |
| Excess Or Deficit Per FS | 1677853 | ExcessOrDeficitPerFS |
| Tot Revenue Etc Audited Fincl Stmt | 23240488 | TotRevenueEtcAuditedFinclStmt |
| Net Unrealized Gains Investments | -19709 | NetUnrealizedGainsInvestments |
| Revenue Not Rptd F990 | -19709 | RevenueNotRptdF990 |
| Revenue Subtotal | 23260197 | RevenueSubtotal |
| Revenue Not Rptd On Fin Stmt | 0 | RevenueNotRptdOnFinStmt |
| Total Revenue Per Form990 | 23260197 | TotalRevenuePerForm990 |
| Tot Expenses Etc Audited Fincl Stmt | 21562635 | TotExpensesEtcAuditedFinclStmt |
| Expenses Not Rptd F990 | 0 | ExpensesNotRptdF990 |
| Expenses Subtotal | 21562635 | ExpensesSubtotal |
| Expenses Not Rptd On Fin Stmt | 0 | ExpensesNotRptdOnFinStmt |
| Total Expenses Per Form990 | 21562635 | TotalExpensesPerForm990 |
Form990 Schedule D Part XIV Form990ScheduleDPartXIV
| Field | Value | IRS element (for citing) |
|---|---|---|
| Identifier | DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: | Identifier |
| Return Reference | PART X: | ReturnReference |
| Explanation | THE HOSPITAL IS A NONPROFIT CORPORATION AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE (THE "CODE") AND IS EXEMPT FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE CODE. THE HOSPITAL IS ALSO EXEMPT FROM STATE INCOME TAXES ON RELATED INCOME. IN ORDER TO ACCOUNT FOR ANY UNCERTAIN TAX POSITIONS, THE ORGANIZATION 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 THE TAX POSITION IS NOT RECOGNIZED IN THE FINANCIAL STATEMENTS. THE HOSPITAL IS ALSO ENGAGED, TO A LIMITED EXTENT, IN ACTIVITIES THAT THE INTERNAL REVENUE SERVICE CONSIDERS UNRELATED TO THE HOSPITAL'S EXEMPT PURPOSE AND, THEREFORE, TAXABLE. THESE ACTIVITIES, HOWEVER, ANNUALLY RESULT IN NET OPERATING LOSSES FOR INCOME TAX PURPOSES. THE HOSPITAL DOES NOT PRESENTLY ANTICIPATE THAT A TAX BENEFIT FROM THESE NET OPERATING LOSSES WILL BE REALIZED IN THE FUTURE. ACCORDINGLY, ANY POTENTIAL DEFERRED TAX ASSET RESULTING FROM THE AVAILABILITY OF NET OPERATING LOSS CARRYFORWARDS IS OFFSET BY A CALCULATION ALLOWANCE OF EQUAL AMOUNT. NO DEFERRED TAX ASSETS AND LIABILITIES HAVE BEEN RECOGNIZED SINCE NO OTHER DIFFERENCES EXIST BETWEEN THE FINANCIAL AND TAX BASIS OF REPORTING THE HOSPITAL'S ASSETS AND LIABILITIES. THE ORGANIZATION'S POLICY IS TO RECOGNIZE INTEREST AND ANY PENALTIES RELATED TO INCOME TAX MATTERS IN INCOME TAX WHEN INCURRED. AS OF AND FOR THE YEARS ENDED DECEMBER 31, 2011 AND 2010, THERE WAS NO INCOME TAX EXPENSE, TAX PENALTIES, OR INTERST RELATED TO TAX PENALTIES RECORDED BY THE ORGANIZATION IN THE FINANCIAL STATEMENTS. IN ADDITION, THE ORGANIZATION RECORDED NO ASSETS OR LIABILITIES FOR UNCERTAIN TAX POSITIONS OR UNRECOGNIZED TAX BENEFITS IN 2011 AND 2010. FEDERAL RETURNS FOR THE YEARS 2008 AND BEYOND REMAIN SUBJECT TO EXAMINATION BY THE INTERNAL REVENUE SERVICE. | Explanation |
Schedule H IRS990ScheduleH
| Field | Value | IRS element (for citing) |
|---|---|---|
| Charity Care Policy | 1 | CharityCarePolicy |
| Written Policy | 1 | WrittenPolicy |
| FPG Reference Free Care | 1 | FPGReferenceFreeCare |
Other Percentage OtherPercentage
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | X | Other |
| Free Other Percentage | 49.000000000000 | FreeOtherPercentage |
| Field | Value | IRS element (for citing) |
|---|---|---|
| FPG Reference Discounted Care | 1 | FPGReferenceDiscountedCare |
| Pcent300 | X | Pcent300 |
| Free Disc Care Medically Indigent | 1 | FreeDiscCareMedicallyIndigent |
| Amounts Budgeted For Charity Care | 1 | AmountsBudgetedForCharityCare |
| Expenses Exceeded Budget | 0 | ExpensesExceededBudget |
| 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 | 82695 | TotalCommunityBenefitExpense |
| Net Community Benefit Expense | 82695 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.00410 | PercentOfTotalExpense |
Unreimbursed Medicaid UnreimbursedMedicaid
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 4642070 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 3222959 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 1419111 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.07000 | PercentOfTotalExpense |
Total Charity Care TotalCharityCare
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 4724765 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 3222959 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 1501806 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.07410 | PercentOfTotalExpense |
Community Health Services CommunityHealthServices
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 67775 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 5630 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 62145 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.00310 | PercentOfTotalExpense |
Health Professions Education HealthProfessionsEducation
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 195725 | TotalCommunityBenefitExpense |
| Net Community Benefit Expense | 195725 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.00970 | PercentOfTotalExpense |
Subsidized Health Services SubsidizedHealthServices
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 3763589 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 1033110 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 2730479 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.13470 | PercentOfTotalExpense |
Cash And In Kind Contributions CashAndInKindContributions
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 24989 | TotalCommunityBenefitExpense |
| Net Community Benefit Expense | 24989 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.00120 | PercentOfTotalExpense |
Total Other Benefits TotalOtherBenefits
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 4052078 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 1038740 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 3013338 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.14870 | PercentOfTotalExpense |
Total Community Benefits TotalCommunityBenefits
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 8776843 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 4261699 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 4515144 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.22280 | PercentOfTotalExpense |
Economic Development EconomicDevelopment
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Building Expense | 867 | TotalCommunityBuildingExpense |
| Net Community Building Expense | 867 | NetCommunityBuildingExpense |
| Percent Of Total Expense | 0.00000 | PercentOfTotalExpense |
Environmental Improvements EnvironmentalImprovements
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Building Expense | 428 | TotalCommunityBuildingExpense |
| Net Community Building Expense | 428 | NetCommunityBuildingExpense |
| Percent Of Total Expense | 0.00000 | PercentOfTotalExpense |
Coalition Building CoalitionBuilding
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Building Expense | 4000 | TotalCommunityBuildingExpense |
| Net Community Building Expense | 4000 | NetCommunityBuildingExpense |
| Percent Of Total Expense | 0.00020 | PercentOfTotalExpense |
Health Improvement Advocacy HealthImprovementAdvocacy
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Building Expense | 18114 | TotalCommunityBuildingExpense |
| Net Community Building Expense | 18114 | NetCommunityBuildingExpense |
| Percent Of Total Expense | 0.00090 | PercentOfTotalExpense |
Total Total
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Building Expense | 23409 | TotalCommunityBuildingExpense |
| Net Community Building Expense | 23409 | NetCommunityBuildingExpense |
| Percent Of Total Expense | 0.00110 | PercentOfTotalExpense |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bad Debt Expense Reported | 0 | BadDebtExpenseReported |
| Bad Debt Expense | $688,139 | BadDebtExpenseAmount |
| Amount Attributable To | 275250 | AmountAttributableTo |
| Amount Reimbursed By Medicare | 4288331 | AmountReimbursedByMedicare |
| Cost Of Care Reimbursed By Medicare | 4333577 | CostOfCareReimbursedByMedicare |
| Medicare Surplus Or Shortfall | -45246 | 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 | MEMORIAL HOSPITAL INC | BusinessNameLine1 |
Address Address
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 216 SUNSET PLACE | AddressLine1 |
| City | NEILLSVILLE | City |
| State | WI | State |
| ZIP Code | 54456 | 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 | MEMORIAL HOSPITAL INC | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Hospital Facility Number | 1 | HospitalFacilityNumber |
| Eligibility Criteria Explained | 1 | EligibilityCriteriaExplained |
| Uses FPG Free | 1 | UsesFPGFree |
| FPG Free Percent | 49.000000000000 | FPGFreePercent |
| Uses FPG Discounted | 1 | UsesFPGDiscounted |
| FPG Discount Percent | 300.000000000000 | FPGDiscountPercent |
| Explains Basis | 1 | ExplainsBasis |
| Income Level | X | IncomeLevel |
| Asset Level | X | AssetLevel |
| Medical Indigency | X | MedicalIndigency |
| Insurance Status | X | InsuranceStatus |
| Medicaid Medicare | X | MedicaidMedicare |
| Explains Application Method | 1 | ExplainsApplicationMethod |
| Includes Publicity Measures | 1 | IncludesPublicityMeasures |
| Posted In Admission Office | X | PostedInAdmissionOffice |
| Available On Request | X | AvailableOnRequest |
| Other Publicity | X | OtherPublicity |
| Actions On Nonpayment | 1 | ActionsOnNonpayment |
| Collection Activities | 0 | CollectionActivities |
| Nondiscrim Emergency Care Policy | 1 | NondiscrimEmergencyCarePolicy |
| Used Other Method | X | UsedOtherMethod |
| Amounts Generally Billed | 0 | AmountsGenerallyBilled |
| Gross Charges | 0 | GrossCharges |
Form990 Schedule H Part V Section C Form990ScheduleHPartVSectionC
| Field | Value | IRS element (for citing) |
|---|---|---|
| Number Of Other Facilities | 5 | NumberOfOtherFacilities |
Other Facilities OtherFacilities (5 entries)
| Address Line1Address/AddressLine1 | CityAddress/City | StateAddress/State | ZIP CodeAddress/ZIPCode | Facility TypeFacilityType |
|---|---|---|---|---|
| MEMORIAL MEDICAL CENTER | ||||
| 216 SUNSET PLACE | NEILLSVILLE | WI | 54456 | PROVIDER BASED RURAL HEALTH CLINIC |
| SUNSET GARDENS | ||||
| 216 SUNSET PLACE | NEILLSVILLE | WI | 54456 | ASSISTED LIVING FACILITY |
| LOYAL CLINIC - MEMORIAL MEDICAL CENTER | ||||
| 502 EAST ELM STREET | LOYAL | WI | 54446 | PROVIDER BASED RURAL HEALTH CLINIC |
| MEMORIAL MEDICAL CENTER | ||||
| 216 SUNSET PLACE | NEILLSVILLE | WI | 54456 | HOME HEALTH AGENCY |
| GREENWOOD FAMILY MEDICAL CENTER | ||||
| 201 SOUTH MAIN | GREENWOOD | WI | 54437 | PROVIDER BASED RURAL HEALTH CLINIC |
Form990 Schedule H Part VI Form990ScheduleHPartVI (15 entries)
| ExplanationExplanation | IdentifierIdentifier | Return ReferenceReturnReference |
|---|---|---|
| PART I, LINE 3C: MEMORIAL HOSPITAL GENERALLY USES 49% OF FEDERAL POVERTY GUIDELINES FOR OFFERING FREE CARE AND A SLIDING SCALE GOING UP TO 300% OFFERING REDUCED CHARGES FOR CARE. IT SHOULD ALSO BE NOTED THAT MEMORIAL HOSPITAL, AS A PART OF ITS COMMUNITY CARE POLICY, WILL ALSO CONSIDER AN ADMINISTRATIVE REVIEW OF OTHER OUTSTANDING BALANCES OF AN INDIVIDUAL. WE WILL DETERMINE ON AN INDIVIDUAL BASIS IF ADDITIONAL DISCOUNTS CAN BE PROVIDED TO PATIENTS. A PATIENT MAY HAVE A SIGNIFICANT OR LONG TERM NEED OF MEDICAL BILLS THAT MAY REQUIRE ADDITIONAL COMMUNITY SUPPORT TO HELP A PATIENT THROUGH A DIFFICULT TIME. | ||
| PART I, LINE 7: THE CALCULATED PERCENT OF TOTAL EXPENSES EXCLUDES BAD DEBT EXPENSE. THE COSTING METHOD USED ON FORM 990 IS BASED ON A COST TO CHARGE RATIO WHICH IS DEVELOPED BASED ON THE HOSPITAL'S TOTAL OPERATING EXPENSES MINUS THE PROVISION FOR BAD DEBTS AND IT IS DIVIDED BY GROSS PATIENT SERVICE REVENUES. THIS COST TO CHARGE RATIO WAS USED TO COMPUTE THE ESTIMATED COMMUNITY BENEFIT EXPENSE UNDER THE IRS SUGGESTED COSTING METHODS FOR THE FORM 990. | ||
| PART I, LINE 7G: THE COST OF SUBSIDIZED HEALTH SERVICES IS BASED ON COST ALLOCATIONS FROM THE MEDICARE COST REPORT. ALLOWABLE COSTS ARE ASSIGNED DIRECTLY TO DEPARTMENTS THROUGHOUT THE YEAR AND THEN THE COST REPORT USES THE ALLOCATION METHODOLOGY TO ASSIGN ALL OTHER COSTS TO CALCULATE SERVICE LINE COSTS. SUBSIDIZED HEALTH SERVICES INCLUDE THE OPERATION OF THREE FAMILY PRACTICE CLINICS. IT IS THE GOAL OF MEMORIAL HOSPITAL, INC. TO PROVIDE THESE SERVICES TO THE COMMUNITY REGARDLESS OF A PATIENT'S ABILITY TO PAY. | ||
| 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 $ 1292507. | ||
| PART II: COMMUNITY BUILDING ACTIVITIES PROMOTES THE HEALTH OF THE COMMUNITY THAT OUR HOSPITAL SERVES. THROUGH COLLABORATION WITH LOCAL ORGANIZATIONS, WE PROVIDE INFORMATION TO THE COMMUNITY REGARDING VARIOUS ISSUES THAT AFFECT HEALTH SUCH AS BABYSITTING CLASSES, ELDER COMMUNITY PROGRAMS, SERVING ON PUBLIC HEALTH BOARDS, WORKING WITH DISASTER PREPAREDNESS, CPR CLASSES, DIABETIC SUPPORT GROUPS, PRESCRIPTION ASSISTANCE, STRESS MANAGEMENT, PREVENTATIVE SERVICES, AND OTHERS. | ||
| PART III, LINE 4: BAD DEBTS ARE RECORDED IN A CONSISTENT MANNER WITH THE ORGANIZATION'S COLLECTION POLICIES. THE TOTAL IS RECORDED IN GROSS CHARGES AND THEN THE COST TO CHARGE RATIO IS APPLIED TO CALCULATE THE COST OF BAD DEBTS.THERE ARE A NUMBER OF PATIENTS THAT TRULY DO NOT HAVE THE ABILITY TO PAY BUT DO NOT FILL OUT THE PAPERWORK TO RECEIVE CHARITY CARE. THE FACILITY DOES NOT HAVE A PRESUMPTIVE ELIGIBILITY PROGRAM AT THIS TIME TO IDENTIFY THOSE INDIVIDUALS. OUR FACILITY CONTINUES TO PROVIDE HEALTHCARE TO THOSE IN NEED REGARDLESS OF THEIR ABILITY TO PAY. FOR THE BAD DEBTS RECORDED THERE WERE SERVICES PROVIDED TO IMPROVE THE HEALTH OF OUR COMMUNITY. THIS CARE WAS PROVIDED WITH COMMUNITY BENEFIT MOTIVATIONS. THE AUDITED FINANCIAL STATEMENTS DO NOT INCLUDE A SEPARATE FOOTNOTE REGARDING BAD DEBT EXPENSE.PATIENT RECEIVABLES AND CREDIT POLICY FINANCIAL STATEMENT FOOTNOTEPATIENT ACCOUNTS RECEIVABLE ARE UNCOLLATERALIZED PATIENT OBLIGATIONS THAT ARE STATED AT THE AMOUNT MANAGEMENT EXPECTS TO COLLECT FROM OUTSTANDING BALANCES. THESE OBLIGATIONS ARE PRIMARILY FROM LOCAL RESIDENTS, MOST OF WHOM ARE INSURED UNDER THIRD-PARTY PAYOR AGREEMENTS. THE HOSPITAL BILLS THIRD-PARTY PAYORS ON THE PATIENTS' BEHALF, OR IF A PATIENT IS UNINSURED, THE PATIENT IS BILLED DIRECTLY. ONCE CLAIMS ARE SETTLED WITH THE PRIMARY PAYOR, ANY SECONDARY INSURANCE IS BILLED, AND PATIENTS ARE BILLED FOR COPAY AND DEDUCTIBLE AMOUNTS THAT ARE THE PATIENTS' RESPONSIBILITY. PAYMENTS ON PATIENT ACCOUNTS RECEIVABLE ARE APPLIED TO THE SPECIFIC CLAIM IDENTIFIED ON THE REMITTANCE ADVICE OR STATEMENTTHE HOSPITAL DOES HAVE A POLICY TO CHARGE INTEREST ON ACCOUNTS NEEDING EXTENDED PAYMENT BEYOND ONE YEAR. THE HOSPITAL WILL SET UP LONG-TERM PAYMENT PLANS FOR THESE TYPES OF ACCOUNTS. THESE PATIENTS SIGN AN AGREEMENT WITH THE HOSPITAL TO REPAY THE BALANCE IN APPROXIMATELY TWO YEARS AND WILL BE ASSESSED INTEREST AT A RATE OF 0.833% PER MONTH OR 10% ANNUAL INTEREST ON THE BALANCES OUTSTANDING.THE CARRYING AMOUNTS OF PATIENT ACCOUNTS RECEIVABLE ARE REDUCED BY ALLOWANCES THAT REFLECT MANAGEMENT'S BEST ESTIMATE OF THE AMOUNTS THAT WILL NOT BE COLLECTED. MANAGEMENT PROVIDES FOR CONTRACTUAL ADJUSTMENTS UNDER TERMS OF THIRD-PARTY REIMBURSEMENT AGREEMENTS THROUGH A REDUCTION TO GROSS PATIENT SERVICE REVENUE AND A CREDIT TO PATIENT ACCOUNTS RECEIVABLE. IN ADDITION, 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.PATIENT ACCOUNTS RECEIVABLE ARE RECORDED IN THE ACCOMPANYING BALANCE SHEETS NET OF CONTRACTUAL ADJUSTMENTS AND AN ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS. | ||
| PART III, LINE 8: MEMORIAL HOSPITAL IS DESIGNATED A CRITICAL ACCESS HOSPITAL AND AS SUCH A PORTION OF ITS REVENUES ARE PAID UNDER A COST REIMBURSEMENT SYSTEM. BASED ON THE INSTRUCTIONS, THE TOTAL MEDICARE REVENUE SHOWN ON THIS FORM 990 INCLUDES ONLY A PORTION OF THE GROSS MEDICARE REVENUE THAT IS ACTUALLY RECEIVED BY THE HOSPITAL FROM THE MEDICARE PROGRAM. THE AMOUNTS LISTED FOR MEDICARE DO NOT INCLUDE PHYSICIAN AND MID-LEVEL PRACTITIONER SERVICES FOR THE COVERAGE OF THE EMERGENCY DEPARTMENT AT MEMORIAL HOSPITAL OR ANESTHESIA SERVICES. PHYSICIAN COVERAGE IS REIMBURSED PRIMARILY ON A FEE SCHEDULE REIMBURSEMENT METHODOLOGY AT RATES THAT ARE OFTEN BELOW THE COSTS OF CARING FOR PATIENTS. EMERGENCY AND ANESTHESIA SERVICES PROVIDED TO MEDICARE PATIENTS ARE VITAL TO THE WELL-BEING OF THE COMMUNITY AND AS SUCH THESE COSTS AND SHORTFALLS SHOULD ALSO BE CONSIDERED AS AN ADDITIONAL BENEFIT THAT MEMORIAL HOSPITAL PROVIDES TO THE COMMUNITY AND SURROUNDING AREA OF NEILLSVILLE, WISCONSIN. THE COSTING METHOD USED ABOVE FOR IRS 990 COMPLIANCE REPORTING IS ALSO BASED ON AN OVERALL AVERAGE COST TO CHARGE RATIO AND DOES NOT CONSIDER MEDICARE NON-ALLOWABLE EXPENSES AS IT IS BASED ON TOTAL HOSPITAL PATIENT SERVICE REVENUES (IGNORING CONTRACTUAL ADJUSTMENTS ON FEE SCHEDULE REIMBURSED ITEMS AND NON-ALLOWABLE MEDICARE EXPENSES AS NOTED ABOVE) DIVIDED BY TOTAL OPERATING EXPENSES LESS THE PROVISION FOR BAD DEBT EXPENSE. THIS RATIO IS THEN MULTIPLIED BY THE TOTAL MEDICARE SERVICES WHICH ARE REIMBURSED ON A COST METHODOLOGY EXCLUDING THE FEE SCHEDULE ITEMS LIKE PHYSICIAN AND MID-LEVEL PRACTITIONER SERVICES WHICH THE HOSPITAL WOULD SHOW A LARGE LOSS ON THESE SERVICES.WHETHER THERE IS A SHORTFALL OR SURPLUS FROM SERVICES PROVIDED TO MEDICARE BENEFICIARIES, THE RECIPIENTS ARE TYPICALLY ELDERLY AND/OR DISABLED MEMBERS OF THE COMMUNITY AND ARE AN UNDERSERVED POPULATION WHO EXPERIENCE ISSUES WITH ACCESS TO HEALTHCARE SERVICES. WITHOUT TAX-EXEMPT HOSPITALS PROVIDING MEDICARE PATIENT SERVICES, THE CENTERS FOR MEDICARE AND MEDICAID (CMS) WOULD BEAR THE BURDEN OF DIRECTLY PROVIDING SERVICES TO THE ELDERLY AND DISABLED MEMBERS OF THE COMMUNITY. | ||
| PART III, LINE 9B: UNINSURED PATIENTS ARE GIVEN THE OPPORTUNITY TO FILL OUT AN APPLICATION FOR CHARITY CARE AT THE TIME OF ADMISSION AND ALL PATIENTS ARE ASKED TO FILL OUT A CHARITY CARE APPLICATION DURING THE COLLECTION PROCESS PRIOR TO SENDING TO ANY ACCOUNTS TO A COLLECTION AGENCY. IF THE PAPERWORK IS NOT RECEIVED, THE ACCOUNT IS HANDLED THROUGH THE NORMAL COLLECTION PROCESS. | ||
| PART V, SECTION B, LINE 13G: A LETTER DESCRIBING THE HOSPITAL'S FINANCIAL ASSISTANCE POLICY IS SENT TO PATIENTS FOR EVERY SERVICE PROVIDED WHERE THEY REGISTERED AS PRIVATE PAY. A LETTER IS ALSO SENT TO PATIENTS AGAIN WHEN NO PAYMENT HAS BEEN RECEIVED AFTER TWO STATEMENTS. | MEMORIAL HOSPITAL, INC. | |
| PART V, SECTION B, LINE 19D: MAXIMUM AMOUNTS THAT CAN BE CHARGED TO INDIVIDUALS ARE AS FOLLOWS:PATIENTS WHOSE INCOME IS 49% OF LESS OF THE FEDERAL POVERTY GUIDELINES RECEIVE FREE CARE.PATIENTS WHOSE INCOME IS BELOW 200% OF THE FEDERAL POVERTY GUIDELINES RECEIVE THE LOWEST NEGOTIATED COMMERCIAL RATE.PATIENTS WHOSE INCOME IS BELOW 300% OF THE FEDERAL POVERTY GUIDELINES RECEIVE A 10% DISCOUNT FROM GROSS CHARGES. | MEMORIAL HOSPITAL, INC. | |
| PART VI, LINE 2: DURING 2009 MEMORIAL HOSPITAL, INC ENTERED INTO A FORMAL COMMUNITY NEEDS ASSESSMENT WITH CLARK COUNTY IN ORDER TO SPECIFICALLY ADDRESS PUBLIC HEALTH, WIC, SCHOOLS, ORGANIZATIONS ADVOCATING FOR THE ELDERLY ETC. AND MAINTAIN MEMBERSHIPS IN OTHER COMMUNITY ORGANIZATIONS TO STAY IN TOUCH WITH THE COMMUNITY. ALSO DURING 2009 MEMORIAL HOSPITAL, INC STARTED A COMMUNITY HEALTH COUNCIL THAT MEETS QUARTERLY. THIS COUNCIL IS COMPRISED OF APPROX 30 COMMUNITY MEMBERS REPRESENTING OUR FULL SERVICE AREA. THE PURPOSE OF THIS GROUP IS TO GAIN DIRECT INPUT FROM COMMUNITY MEMBERS ON UNMET HEALTH NEEDS AND POSSIBLE SOLUTIONS TO FILL GAPS. | ||
| PART VI, LINE 3: ALL PATIENTS WHO REGISTER WITH NO INSURANCE ARE SENT A PRIVATE PAY LETTER NOTIFYING THEM TO CONTACT A FINANCIAL SERVICES REPRESENTATIVE AT MEMORIAL HOSPITAL, INC. IF THEY NEED HELP IN PAYING THEIR BILL. THE LETTER ALSO HIGHLIGHTS THE CHARITY CARE PROGRAM AND GIVES THE WEBSITE WHERE THE APPLICATION CAN BE FOUND. THE FINANCIAL SERVICES REPRESENTATIVE THEN DISCUSSES THE OPTIONS AVAILABLE TO THE PATIENT. | ||
| PART VI, LINE 4: MEMORIAL HOSPITAL, INC SERVES IN A COUNTY IN WHICH 28% OF THE POPULATION EARNS LESS THAN 200% OF THE FEDERAL POVERTY LEVEL AND 25% OF THE POPULATION ARE UNINSURED. THE COMMUNITY HAS A HIGH POPLULATION OF ELDERLY AND AMISH/MENNONITE. TRANSPORTATION IS HIGHLY UNDER-DEVELOPED AND UNAVAILABLE. THE COUNTY IS DESIGNATED AS A HEALTH PROFESSIONAL SHORTAGE AREA AND MEDICALLY UNDERSERVED AREA. MEMORIAL HOSPITAL, INC SERVES ROUGHLY A 25 MILE RADIUS WITH A POPULATION TOTAL OF 15,000. | ||
| PART VI, LINE 5: WHILE THERE IS GROWING AGREEMENT IN THE UNITED STATES ABOUT WHAT CONSTITUTES A NON-PROFIT HOSPITAL'S COMMUNITY BENEFIT, THIS IS A WORK IN PROGRESS. OUR HOSPITAL PROVIDES CHARITY CARE AND OTHER COMMUNITY BENEFITS AS DEFINED BY THE IRS. BUT IN ADDITION, WE BELIEVE THAT WE PROVIDE A CRITICALLY IMPORTANT COMMUNITY BENEFIT WHICH IS NOT QUANTIFIED. OUR HOSPITAL, LIKE MOST RURAL HOSPITALS, WAS CREATED AND IS MAINTAINED IN ORDER TO PROVIDE CARE LOCALLY. BEYOND INPATIENT HOSPITALIZATIONS, WE PROVIDE LOCAL ACCESS TO MANY HEALTH SERVICES: BIRTHING CENTER, DIAGNOSTICS, EMERGENCY SERVICES & URGENT CARE, HOME CARE, INFUSION SERVICES, LABORATORY SERVICES, OCCUPATIONAL HEALTH, REHABILITATION SERVICES, SPECIALTY MEDICINE, SLEEP CENTER, SPEECH AND AUDIOLOGY, SURGICAL SERVICES, AND WOMENS HEALTH SERVICES. | ||
| WI | REPORTS FILED WITH STATES | PART VI, LINE 7 |
Schedule J IRS990ScheduleJ
| Field | Value | IRS element (for citing) |
|---|---|---|
| Compensation Committee | X | CompensationCommittee |
| Form990 Of Other Organizations | X | Form990OfOtherOrganizations |
| Written Employment Contract | X | WrittenEmploymentContract |
| Compensation Survey | X | CompensationSurvey |
| Board Or Committee Approval | X | BoardOrCommitteeApproval |
| Severance Payment | 0 | SeverancePayment |
| Supplemental Nonqual Retire Plan | 1 | SupplementalNonqualRetirePlan |
| Equity Based Comp Arrangement | 0 | EquityBasedCompArrangement |
| Comp Based On Revenue Of Filing Org | 1 | 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 (9 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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| DR JAMES STANGA | |||||||||||||
| 129689 | 0 | 186069 | 0 | 153 | 0 | 4500 | 0 | 19067 | 0 | 339478 | 0 | 0 | 0 |
| DR KENNETH WEIMER | |||||||||||||
| 153757 | 0 | 53165 | 0 | 92 | 0 | 4500 | 0 | 21528 | 0 | 233042 | 0 | 0 | 0 |
| DR TIM MEYER | |||||||||||||
| 197208 | 0 | 165706 | 0 | 153 | 0 | 4500 | 0 | 6781 | 0 | 374348 | 0 | 0 | 0 |
| SCOTT POLENZ | |||||||||||||
| 177853 | 0 | 12731 | 0 | 153 | 0 | 4500 | 0 | 20567 | 0 | 215804 | 0 | 0 | 0 |
| DR GRACE CRUZ-APOLINARIO | |||||||||||||
| 190460 | 0 | 277370 | 0 | 153 | 0 | 4500 | 0 | 19067 | 0 | 491550 | 0 | 0 | 0 |
| DRDAVID PAUSTIAN | |||||||||||||
| 216798 | 0 | 616110 | 0 | 153 | 0 | 4500 | 0 | 14329 | 0 | 851890 | 0 | 0 | 0 |
| DR AMY COULTHARD | |||||||||||||
| 157694 | 0 | 49603 | 0 | 92 | 0 | 2412 | 0 | 7409 | 0 | 217210 | 0 | 0 | 0 |
| DR CAROLYN HARDESTY | |||||||||||||
| 144391 | 0 | 68462 | 0 | 82 | 0 | 4500 | 0 | 14328 | 0 | 231763 | 0 | 0 | 0 |
| DR RANDE SHORT | |||||||||||||
| 146941 | 0 | 16497 | 0 | 219 | 0 | 0 | 0 | 5348 | 0 | 169005 | 0 | 0 | 0 |
Form990 Schedule J Part III Form990ScheduleJPartIII (2 entries)
| Return ReferenceReturnReference | ExplanationExplanation |
|---|---|
| PART I, LINE 4B | IN 2011, THE FOLLOWING INDIVIDUALS PARTICIPATED IN A 457(F) PLAN BUT DID NOT RECEIVE ANY PAYMENTS - DR. GRACE CRUZ-APOLINARIO AND DR. TIMITHY MEYER. |
| PART I, LINE 5 | IN 2011, THE FOLLOWING PHYSICIANS RECEIVED COMPENSATION THAT WAS PARTLY BASED ON THE GROSS CHARGES RECOGNIZED FOR THEIR PROFESSIONAL SERVICES. DR. JAMES STANGA $106,320 DR. DAVID PAUSTIAN $541,446 DR. TIMOTHY MEYER $118,770 DR. GRACE CRUZ-APOLINARIO $254,993 DR. AMY COULTHARD $ 25,582 DR. CARYLYN HARDESTY $ 15,685 |
Schedule O IRS990ScheduleO
General Explanation GeneralExplanation (6 entries)
| Return ReferenceReturnReference | ExplanationExplanation | IdentifierIdentifier |
|---|---|---|
| FORM 990, PART VI, SECTION B, LINE 11 | THE CFO DETAIL REVIEWS THE FORM BEFORE SUBMISSION. ALSO, BEFORE THE RETURN WAS FILED, A PRELIMINARY COPY WAS PROVIDED TO THE BOARD OF DIRECTORS FOR REVIEW AND COMMENTS. | |
| FORM 990, PART VI, SECTION B, LINE 12C | MEMORIAL HOSPITAL RELIES ON THE ANNUAL DISCLOSURE OF KEY INDIVIDUALS TO THE BOARD OF DIRECTORS AND MONITORS PURCHASES AND ABSTENTIONS FROM NECESSARY VOTES THROUGHOUT THE YEAR. ALL MANAGERS AND MEDICAL STAFF ARE REQUIRED TO DISCLOSE AND FOLLOW THE CONFLICT OF INTEREST POLICY. | |
| FORM 990, PART VI, SECTION B, LINE 15 | A COMMITTEE OF THE BOARD OF DIRECTORS HAS BEEN DESIGNATED TO REVIEW ALL EXECUTIVE PAY CHANGES. MARKET DATA IS PROVIDED TO THE COMMITTEE IN THEIR EVALUATION OF PAY CHANGES. COMPARABILITY DATA WAS USED AND THE RESULTS OF ANY EXECUTIVE PAY CHANGES WERE DOCUMENTED. NO ONE WITH A CONFLICT OF INTEREST WAS INCLUDED IN THE DECISION MAKING OF EXECUTIVE COMPENSATION. | |
| FORM 990, PART VI, SECTION C, LINE 19 | ALL DOCUMENTS ARE AVAILABLE UPON REQUEST. DOCUMENTS ARE ALSO DISCUSSED AT COMMUNITY MEETINGS AND EMPLOYEE FORUMS. | |
| FORM 990, PART XI, LINE 5: | NET UNREALIZED LOSSES ON INVESTMENTS: -19,709. | CHANGES IN NET ASSETS OR FUND BALANCES: |
| FORM 990, PART XII, LINE 2C | THE BOARD OF DIRECTORS IS RESPONSIBLE FOR THE SELECTION OF AN INDEPENDENT AUDITOR AND MANAGEMENT OVERSEES THE AUDIT PROCESS. THIS PROCESS HAS NOT CHANGED IN 2011. |
Schedule R IRS990ScheduleR
Form990 Schedule R Part II Form990ScheduleRPartII (2 entries)
| Address Line1AddressUS/AddressLine1 | CityAddressUS/City | StateAddressUS/State | ZIP CodeAddressUS/ZIPCode | EINEIN | Primary ActivitiesPrimaryActivities | Legal Domicile StateLegalDomicileState | Exempt Code SectionExemptCodeSection | Public Charity StatusPublicCharityStatus | Business Name Line1DirectControllingEntityName/BusinessNameLine1 | Controlled OrgControlledOrg |
|---|---|---|---|---|---|---|---|---|---|---|
| COUNTRY VIEW INC | ||||||||||
| 216 SUNSET PLACE | NEILLSVILLE | WI | 54456 | 391411586 | HUD HOUSING | WI | 501(C)(3) | 9 | MEMORIAL HOSPITAL INC | 1 |
| THE FOUNDATION OF MEMORIAL HOSPITAL INC | ||||||||||
| 216 SUNSET PLACE | NEILLSVILLE | WI | 54456 | 383800811 | FUNDRAISING | WI | 501(C)(3) | 7 | MEMORIAL HOSPITAL INC | 1 |
| 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 | 0 | 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 | 1 | PerformOfServicesForOtherOrgs |
| Perform Of Services By Other Orgs | 0 | PerformOfServicesByOtherOrgs |
| Sharing Of Facilities | 0 | SharingOfFacilities |
| Sharing Of Paid Employees | 1 | SharingOfPaidEmployees |
| Reimbursement Paid To Other Org | 0 | ReimbursementPaidToOtherOrg |
| Reimbursement Paid By Other Org | 1 | ReimbursementPaidByOtherOrg |
| Other Transfer To Other Org | 0 | OtherTransferToOtherOrg |
| Other Transfer From Other Org | 0 | OtherTransferFromOtherOrg |