2012-08-13T10:13:19-05:00 2011-09-30 WIPFLI LLP PO BOX 12237 GREEN BAY WI 543072237 990 2010-10-01 390816818 ST ELIZABETH HOSPITAL INC STEL 9207382000 1506 S ONEIDA STREET APPLETON WI 549151397 JEFF BADGER 9207382000 2012-08-02 1 TERRI REXRODE CPA 9206620016 2012-08-02 2010 2016-02-24 21:20:13Z JEFF BADGER 1506 S ONEIDA STREET APPLETON WI 549151397 163846331 0 0928 X WWW.AFFINITYHEALTH.ORG X 1899 WI FOR MORE THAN 100 YEARS, WE HAVE BEEN A LEADER IN PROVIDING QUALITY HEALTH CARE TO FOX VALLEY RESIDENTS, ESPECIALLY THE MEDICALLY UNDERSERVED. THE HOSPITAL MEETS A BROAD VARIETY OF PATIENT NEEDS THROUGH GENERAL CARE, SURGICAL SERVICES AND NUMEROUS MEDICAL SPECIALTIES INCLUDING CARDIOLOGY, ONCOLOGY, PEDIATRICS, EMERGENCY, INTENSIVE CARE AND OBSTETRICS. WITH 352 LICENSED PATIENT BEDS AND MORE THAN 420 SKILLED MEDICAL STAFF, WE OFFER COMPLETE, COMPASSIONATE, QUALITY HEALTH CARE FOR THE ENTIRE FAMILY.AVAILABLE SERVICES: ALLERGY; CANCER; CARDIAC REHABILITATION; CARDIOLOGY; CARDIOVASCULAR SURGERY; DIABETES, NUTRITION AND ENDOCRINOLOGY; EMERGENCY/TRAUMA; GENERAL SURGERY; GENETIC COUNSELING; GYNECOLOGY; HOSPITALIST; HYPERBARIC OXYGEN THERAPY; LABORATORY; LIFELINE HOME MONITORING; LIFESPAN; OBSTETRICS; ORTHOPAEDICS; PAIN MANAGEMENT; PALLIATIVE CARE (END OF LIFE CARE); PEDIATRICS; PSYCHIATRY/PSYCHOLOGY; PULMONOLOGY; SPIRITUAL SERVICES; UROLOGY; VASCULAR MEDICINE; AND WOUND CARE. 18 10 1300 467 110875 -20576 335395 1523999 150372410 155146394 4739260 4770922 851529 721665 156298594 162162980 643255 547961 0 0 69353862 74256464 0 0 0 67540912 71364575 137538029 146169000 18760565 15993980 268264475 316311656 83211158 118794099 185053317 197517557 X ST. ELIZABETH HOSPITAL HAS ADOPTED THE MISSION STATEMENT OF AFFINITY HEALTH SYSTEM. THE MISSION OF AFFINITY HEALTH SYSTEM IS TO LIVE OUT THE HEALING MINISTRY OF CHRIST BY PROVIDING SERVICES THAT PROMOTE THE HEALTH AND WELL-BEING OF THE COMMUNITIES WE SERVE, ESPECIALLY THE POOR. 0 0 110799387 547961 154180896 THE ENTITY BELIEVES THERE IS A STRONG DUTY TO MEET THE NEEDS OF THE POOR, INDIGENT, AND MEDICALLY UNDERSERVED IN THE COMMUNITIES. IN KEEPING WITH THE PHILOSOPHY OF EMPOWERMENT AND TRANSFORMATION OF ALL INDIVIDUALS, CARE HAS BEEN PROVIDED TO ALL PATIENTS WITHOUT REGARDS FOR ABILITY TO PAY.OTHER SERVICES INCLUDE:-FREE MAMMOGRAPHY SCREENING AND BREAST EXAMS FOR LOW INCOME WOMEN-FREE NEWLETTERS FOCUSING ON WOMENS HEALTH ISSUES-FREE HEART DISEASE SCREENING FOR INDIVIDUALS-CHILDREN'S HEALTH AND SAFETY ISSUES-FREE SPEAKERS BUREAU-WOMENS RUN FOR HEALTH-TEEN PREGNANCY, PARENTING, AND NURTURING PROGRAMS-THROUGH PATHWAY TO PEACE, A COMPREHENSIVE SERVICE FOR PARENTS AND FAMILIES WHO HAVE EXPERIENCED A PREGNANCY LOSS OF AN INFANT-TELEVISED MASS FOR THE HOMEBOUND IN THE COMMUNITY-CHAPLAINCY AND SUPPORT SERVICES FOR THOSE WHO HAVE HAD A FAMILY MEMBER OR FRIEND DIE-FREE BLOOD PRESSURE SCREENING-FREE PROSTATE SCREENING-COMMUNITY BLOOD DRIVES-HEALTH INFORMATION SPOTS ON TELEVISION AND RADIO 110799387 1 1 0 1 0 0 0 0 0 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 0 0 0 0 0 0 0 1 0 0 0 0 0 1 0 0 0 0 1 60 0 1 1300 1 1 1 0 0 0 0 0 0 0 0 0 X 18 10 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 WI X JEFF BADGER 9207201300 1570 MIDWAY PLACE MENASHA WI 54952 X DANIEL E NEUFELDER 13.30 X X 261340 572814 65400 DAVID GITTER 0.30 X X 0 0 0 CATHERINE J TIERNEY 0.30 X X 0 0 0 JOSEPH MCCORMICK MD 0.30 X 0 1097589 41533 BARBARA STRAND MD 0.30 X 0 264298 43300 CARLA ALTEPETER 0.30 X 0 0 0 MARY HARP-JIRSCHELE 0.30 X 0 0 0 FREDERICK KLEIN MD 0.30 X 0 0 0 STEPHEN C MORTON 0.30 X X 0 0 0 JOHN RUSSO 0.30 X X 0 0 0 THOMAS SCHMIDT 0.30 X 0 0 0 WAYNE TREMBLY 0.30 X 0 0 0 SUSAN VETTE 0.30 X 0 0 0 RICHARD WELLS 0.30 X 0 0 0 STACEY SENSOR DO 0.30 X 0 482023 40878 MARK FAUSTICH MD 0.30 X 0 369720 35440 JAY MULLER MD 0.30 X 0 373057 37687 CHRISTOPHER ROCKE DO 0.30 X 0 232694 35386 NICHOLAS DESIEN 0.30 X X 0 0 0 JOHN OLIVERIO 0.30 X X 0 1813218 157725 KATHRYN SIEMAN 0.30 X 0 0 0 MONICA VOMASTIC 0.30 X 0 0 0 JEFF BADGER 13.00 X 139259 305233 62470 TRAVIS ANDERSEN 40.00 X 359125 0 47409 BRIAN HUMPHREY 40.00 X 159694 0 48234 RICHARD GOODMAN 40.00 X 162924 0 21478 JENNIE GAURKEE 40.00 X 162500 0 23781 DEBRA LASTOFKA 40.00 X 146787 0 44540 GARY MILLER 40.00 X 142042 0 21368 1533671 5510646 726629 23 0 1 0 AFFINITY HEALTH SYSTEM INC 1570 MIDWAY PLACE MENASHA WI 54952 CONSULTING/LEGAL/MISC/SALARIES/MISC SERV 14071329 THE BOLDT CO 2525 N ROEMER RD PO BOX 419 APPLETON WI 54912 PURCHASED SERVICES 11548327 HAMMEL GREEN & ABRAHAMSON INC 333 EASAT ERIE ST MILWAUKEE WI 53202 CONSULTING/DESIGN/MISC 3304392 WHEATON FRANCISCAN SERVICES INC 26W171 ROOSEVELT RD WHEATON IL 60187 MANAGEMENT 1678296 SHARED MEDICAL SERVICES PO BOX 330 COTTAGE GROVE WI 53527 MEDICAL SERVICES 1028065 29 1523999 1523999 NET PATIENT REVENUE AN 621990 154180896 154180896 CAFETERIA INCOME 722210 854623 854623 OUPATIENT LAB REVENUE 621500 110875 110875 155146394 4721919 4721919 2392917 1671252 721665 721665 721665 61102 12099 49003 49003 49003 162162980 154180896 110875 6347210 547961 547961 847195 847195 56349691 43828674 12521017 2291517 1782337 509180 11201050 8712154 2488896 3567011 2774414 792597 15361689 8171699 7189990 30018988 29026407 992581 29994 29994 3563625 2708067 855558 297844 50925 246919 2435907 1851092 584815 8325245 6534308 1790937 445470 445470 OTHER EXPENSES 6115035 161876 5953159 BAD DEBT 4589436 4589436 DUES AND LICENSES 181342 30043 151299 146169000 110799387 35369613 0 5282 5385 16584094 20116092 18088856 21057269 151829447 169736552 2693852 2887120 489624 1583593 235477780 138662830 74564231 96814950 1233710 1252757 0 2775379 2857938 268264475 316311656 27073134 26217792 44201773 75893644 11936251 16682663 83211158 118794099 X 185004941 197469181 48376 48376 185053317 197517557 268264475 316311656 X 15993980 -3529740 X X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 9331 9331 0 EXPLANATION OF OTHER LOBBYING ACTIVITIES: PART II-B, LINE 1I: AHA, WHA & CHA MEMBERSHIP DUES 1368739 1368739 101165278 50445228 50720050 2987838 2225322 762516 111031055 85947842 25083213 18924870 44438 18880432 96814950 DUE TO 3RD PARTY - RESERVE 1101172 PENSION LIABILITY 15336814 457B PLAN 244677 16682663 162162980 146169000 15993980 6017 -3535757 -3529740 12464240 162352783 0 162352783 -189803 -189803 162162980 147345209 1654170 1654170 145691039 477961 477961 146169000 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: FASB ASC SUBTOPIC 740-10, INCOME TAXES OVERALL, PRESCRIBES A RECOGNITION THRESHOLD AND MEASUREMENT ATTRIBUTE FOR THE FINANCIAL STATEMENT RECOGNITION AND MEASUREMENT OF A TAX POSITION TAKEN OR EXPECTED TO BE TAKEN IN A TAX RETURN. THE AMOUNT OF UNRECOGNIZED TAX EXPENSE RELATED TO THESE CRITERIA FOR THE CORPORATION WAS ZERO AS OF SEPTEMBER 30, 2011 AND 2010. PART XI, LINE 8 - OTHER ADJUSTMENTS: PENSION ADJUSTMENT -3,535,757. PART XII, LINE 4B - OTHER ADJUSTMENTS: RENTAL EXPENSE IN REVENUE -1,654,170. CONTRIBUTIONS IN NET ASSETS 1,464,367. PART XIII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSE IN REVENUE 1,654,170. PART XIII, LINE 4B - OTHER ADJUSTMENTS: GRANT TO SPONSOR ORGANIZATION 477,961. 1 1 1 X 1 X 662.000000000000 1 1 1 0 1 1 696 1884611 1884611 0.01330 19006 3802899 3802899 0.02690 850 136511 136511 0.00100 20552 5824021 5824021 0.04120 4 2778 127038 127038 0.00090 3 179 1082860 165730 917130 0.00650 2 1444 3939034 3467711 471323 0.00330 2 17938 1164617 1164617 0.00820 11 22339 6313549 3633441 2680108 0.01890 11 42891 12137570 3633441 8504129 0.06010 1 821 821 0.00000 1 24 122 122 0.00000 1 576 576 0.00000 1 390 390 0.00000 4 24 1909 1909 0 1759045 55784719 57875073 -2090354 X 1 1 1 1 ST ELIZABETH HOSPITAL INC

1506 S ONEIDA STREET APPLETON WI 54915

X X X X ST ELIZABETH HOSPITAL INC 1 PART I, LINE 3C: IT IS THE POLICY OF ST. ELIZABETH HOSPITAL TO PROVIDE MEDICALLY NECESSARY HEALTH CARE SERVICES TO PEOPLE IN THE COMMUNITIES IT SERVES, REGARDLESS OF THEIR ABILITY TO PAY. AFFINITY CARE FINANCIAL ASSISTANCE IS GRANTED BASED UPON THE PATIENT'S INABILITY TO PAY AND TO INDIVIDUALS WHO ARE UNINSURED, UNDERINSURED OR MEDICALLY INDIGENT. AFFINITY CARE WORKS IN COLLABORATION WITH OTHER FINANCIAL (BOTH PUBLIC AND PRIVATE) ASSISTANCE PROGRAMS. THIS IS TO ENSURE HOLISTIC WELLNESS OF PATIENTS BY FACILITATING KNOWLEDGE OF AVAILABLE SERVICES AND PROGRAMS FOR HEALTH WHILE PRACTICING GOOD STEWARDSHIP OF FUNDS. KEY CRITERIA UTILIZED TO DETERMINE ELIGIBILITY FOR AFFINITY CARE FINANCIAL ASSISTANCE INCLUDES FAMILY SIZE, FEDERAL POVERTY INCOME GUIDELINES AND AVAILABLE ASSETS. THE AVAILABLE ASSET TEST INCLUDES CONSIDERATION OF THE AMOUNT OF EQUITY IN A HOME, AUTOMOBILES, AND SAVINGS ACCOUNTS WHICH ARE CONSIDERED PART OF TOTAL ALLOWABLE INCOME WHEN ASSESSING AGAINST THE FEDERAL POVERTY INCOME GUIDELINES. PART I, LINE 7: AMOUNTS CALCULATED IN PART I, LINE 7 ARE DETERMINED BOTH ON A COST ACCOUNTING SYSTEM AND A COST-TO-CHARGE RATIO. OTHER BENEFITS ARE DETERMINED BASED ON THE DIRECT AND INDIRECT COSTS (WHERE ALLOCATED) ASSOCIATED WITH A PROGRAM NET OF EARNED REVENUE. DETAIL FOR EACH PROGRAM/ACTIVITY IS MAINTAINED AND DETERMINED AT THE DEPARTMENT LEVEL. CHARITY CARE AND MEANS-TESTED PROGRAMS ARE DETERMINED BASED ON A COST-TO-CHARGE RATIO CONSISTENT WITH WORKSHEET 2, RATIO OF PATIENT CARE COST TO CHARGES. PRIOR YEAR COST REPORT SETTLEMENTS ARE EXCLUDED FROM THE SHORTFALL CALCULATION IN ORDER TO GET A TRUE FISCAL YEAR SHORTFALL AMOUNT. PART I, L7 COL(F): BAD DEBT EXPENSE OF $4,589,436 INCLUDED ON FORM 990, PART IX, LINE 25 WAS EXCLUDED FROM THE DENOMINATOR PER INSTRUCTIONS WHEN CALCULATING THE PERCENT OF TOTAL EXPENSES ON SCHEDULE H. PART II: COMMUNITY-BUILDING ACTIVITIES INCLUDE PROGRAMS THAT, WHILE NOT DIRECTLY RELATED TO HEALTH CARE, PROVIDE OPPORTUNITIES TO ADDRESS THE ROOT CAUSES OF HEALTH PROBLEMS, SUCH AS POVERTY, HOMELESSNESS, AND ENVIRONMENTAL PROBLEMS. THESE ACTIVITIES SUPPORT COMMUNITY ASSETS BY OFFERING THE EXPERTISE AND RESOURCES OF THE ORGANIZATION. COSTS FOR THESE ACTIVITIES INCLUDE CASH, IN-KIND DONATIONS, AND EXPENDITURES FOR THE DEVELOPMENT OF A VARIETY OF COMMUNITY HEALTH PROGRAMS AND PARTNERSHIPS. SOME EXAMPLES INCLUDE: REBUILDING TOGETHER IN WHICH MANAGERS FROM ST. ELIZABETH HOSPITAL WENT OUT TO HELP LOW-INCOME ELDERLY MEMBERS OF THE COMMUNITY WITH REMODELING PROJECTS TO IMPROVE SAFETY OR CONDITION OF THEIR HOMES. ANOTHER EXAMPLE IS THE HEALTH CAREER EXPERIENCE DAY IN WHICH PROFESSIONALS FROM ST. ELIZABETH HOSPITAL HIGHLIGHT A VARIETY OF HEALTHCARE CAREERS AND TALK ABOUT THEIR PROFESSIONS (I.E. NURSING, SURGERY, LABORATORY AND RADIOLOGY) PART III, LINE 4: NO FOOTNOTE EXISTS IN ST. ELIZABETH HOSPITALS FINANCIALS STATEMENTS THAT DESCRIBE BAD DEBT EXPENSE. BAD DEBT EXPENSE IS RECORDED IN A CONSISTENT MANNER WITH THE ORGANIZATIONS COLLECTION POLICIES. BAD DEBT EXPENSE INCLUDES ACCOUNTS WHICH ARE WRITTEN OFF AND ESTIMATES MADE ON LIVE ACCOUNTS BASED ON HISTORICAL PAYMENT TRENDS AND ACCOUNT MODELING.A NUMBER OF PATIENTS ARE TRULY UNABLE TO PAY THEIR OUT-OF-POCKET LIABILITY, BUT DO NOT COMPLETE THE PROCESS REQUIRED TO APPLY FOR FINANCIAL ASSISTANCE UNDER THE HOSPITALS AFFINITY CARE POLICY. THESE PATIENTS WOULD QUALIFY FOR AFFINITY CARE IF THEY COMPLETED THE CHARITY APPLICATION, SO THE BAD DEBT EXPENSE ASSOCIATED WITH TREATING THEM SHOULD BE TREATED AS COMMUNITY BENEFIT. THE ORGANIZATION DOES HAVE A PRESUMPTIVE ELIGIBILITY PROGRAM IN PLACE TO HELP IDENTIFY INDIGENT PATIENTS AND MINIMIZE THE INSTANCES OF WHEN THEY BECOME A BAD DEBT. THE ADMINISTRATIVE REQUIREMENTS TO DETERMINE WHETHER PATIENTS WHO DO NOT COOPERATE WITH THE FINANCIAL ASSISTANCE PROCESS WOULD HAVE QUALIFIED FOR CHARITY CAN BE BURDENSOME, PARTICULARLY FOR SMALL BALANCES. PART III, LINE 8: THE SHORTFALL ASSOCIATED WITH MEDICARE SHOULD BE CONSIDERED A COMMUNITY BENEFIT FOR SEVERAL REASONS. FIRST, IRS REV. RUL. 69-545, WHICH ESTABLISHED THE COMMUNITY BENEFIT STANDARD FOR NON-PROFIT HOSPITALS, STATES THAT IF A HOSPITAL SERVES PATIENTS WITH GOVERNMENT HEALTH BENEFITS, INCLUDING MEDICARE, THEN THIS IS AN INDICATION THAT THE HOSPITAL OPERATES TO PROMOTE THE HEALTH OF THE COMMUNITY. THIS IMPLIES THAT TREATING MEDICARE PATIENTS IS A COMMUNITY BENEFIT. SECOND, FOR-PROFIT SPECIALTY HOSPITALS HAVE BEEN CARVING OUT CERTAIN HIGH-MARGIN SERVICES (I.E. CARDIAC, ORTHOPEDICS, AND ONCOLOGY), LEAVING GENERAL ACUTE CARE HOSPITALS WITH LOWER-MARGIN MEDICARE SERVICES. THIS INDICATES THAT MEDICARE LOSSES CAN BE A RESULT OF RENDERING THESE LOWER-MARGIN SERVICES (WHICH BENEFIT THE COMMUNITY) RATHER THAN INEFFICIENT OPERATIONS. LASTLY, THE COMMUNITY WHICH THE ORGANIZATION SERVES HAS MEDICARE AS THE LARGEST PAYER. THE ORGANIZATION MUST ACCEPT THESE PATIENTS REGARDLESS OF WHETHER THEY MAKE A SURPLUS OR DEFICIT FROM PROVIDING SUCH SERVICES. IF THE MEDICARE PARTICIPATION IS PREMISED ON THIS FACT, THEN PROVIDING MEDICARE SERVICES PROMOTES ACCESS TO HEALTHCARE SERVICES WHICH IS A COMMUNITY BENEFIT. THE DEMOGRAPHIC OF THE COMMUNITY IS ALSO AN AGING AND UNDERSERVED POPULATION WHO EXPERIENCE ISSUES WITH ACCESS TO HEALTHCARE SERVICES. WITHOUT TAX-EXEMPT HOSPITALS PROVIDING MEDICARE SERVICES, CMS WOULD BEAR THE BURDEN OF DIRECTLY PROVIDING SERVICES TO THE ELDERLY. PART III, LINE 9B: ST. ELIZABETH HOSPITAL HAS A DEBT COLLECTION POLICY WHICH SETS FORTH COLLECTION PRACTICES FOR PATIENTS WHO ARE KNOWN TO QUALIFY OR MAY QUALIFY FOR FINANCIAL ASSISTANCE UNDER THE CHARITY CARE PROGRAM. SUFFICIENT FINANCIAL COUNSELING SUPPORT IS MADE AVAILABLE TO PATIENTS SO THEY CAN EASILY ACCESS PATIENT FINANCIAL SERVICE REPRESENTATIVES AND HAVE THEIR QUESTIONS ANSWERED, AND GAIN AN UNDERSTANDING OF THE REASONS WHY THEY OWE A BALANCE. ACCOUNTS ARE DESIGNATED AS CHARITY CARE IN THE BUSINESS OFFICES SO NO ADDITIONAL TIME IS SPENT ON COLLECTION EFFORTS. PART VI, LINE 7: ST. ELIZABETH HOSPITAL, INC. FILES THEIR COMMUNITY BENEFIT RESULTS IN THE STATE OF WISCONSIN. THEIR DATA IS INCORPORATED INTO A REPORT FOR ALL OF AFFINITY HEALTH SYSTEM THAT ULTIMATELY IS PUBLISHED IN THE AREA NEWSPAPERS. PART VI, LINE 2: ST. ELIZABETH HOSPITAL PERFORMS COMMUNITY HEALTH NEEDS ASSESSMENTS AS NEEDED. PLANNING WORKGROUPS CONSISTING OF COMMUNITY PARTNERS ARE FORMED TO DEFINE THE COMMUNITY AND ITS HEALTH NEEDS THROUGH REVIEW OF UNITED WAY LIFE STUDY RESULTS, HEALTHY PEOPLE INITIATIVES, CENSUS DOCUMENTS, AND LOCAL GOVERNMENT HEALTH AND WELFARE AGENCIES. CONSIDERING OTHER COMMUNITY RESOURCES/ASSETS, DATA COLLECTION METHODS ARE USED TO IDENTIFY PARTICULAR PROBLEMS OR SUBGROUPS AND AREAS KNOWN TO HAVE HIGH POVERTY RATES AND TO BE UNDERSERVED. THE DATA IS ANALYZED AND PRIORITIES ARE SET BASED ON TRENDING INFORMATION WHICH MAY TARGET A SPECIFIC NEED. WHEN A NEED IS IDENTIFIED, THE HOSPITAL DEVELOPS A PLAN TO IMPLEMENT A PROGRAM EITHER THROUGH COMMUNITY COLLABORATION OR INDIVIDUALLY. OUTCOMES FROM THE PROGRAMS ARE MEASURED AND CONSIDERED IN SUBSEQUENT COMMUNITY HEALTH NEEDS ASSESSMENTS. THE LEADERSHIP AT AFFINITY TAKES THEIR COMMITMENT TO THE HEALTH AND WELL-BRING OF THE COMMUNITY IT SERVES VERY SERIOUSLY. IN FACT, IT IS CORE TO THE ORGANIZATIONS MISSION, TO LIVE OUT THE HEALING MINISTRY OF CHRIST BY PROVIDING SERVICES THAT PROMOTE THE HEALTH AND WELL-BEING OF THE COMMUNITIES WE SERVE, ESPECIALLY THE POOR. SENIOR LEADERS AND MANAGEMENT ARE ALSO HIGHLY ENCOURAGED TO PROVIDE DIRECT SERVICE TO THE POOR IN THEIR COMMUNITIES. ST. ELIZABETH AND THE LEADERSHIP ALSO SUBSCRIBE TO PUBLICATIONS LIKE THE ADVISORY BOARD TO COMPARE NATIONAL TRENDS TO LOCAL TRENDS TO ENSURE THE HOSPITAL IS RESOURCING AREAS TO MEET PATIENT NEEDS. PART VI, LINE 3: ST. ELIZABETH HOSPITAL GOES TO GREAT LENGTHS IN ORDER TO INFORM AND EDUCATE PATIENTS/PERSONS WHO MAY BE BILLED FOR PATIENT CARE ABOUT THEIR ELIGIBILITY FOR ASSISTANCE UNDER FEDERAL, STATE OR LOCAL GOVERNMENT PROGRAMS AND UNDER THE ORGANIZATIONS AFFINITY CARE POLICY. THE AFFINITY CARE POLICY AND APPLICATION IS POSTED ON THE ORGANIZATIONS WEBSITE. ADMISSIONS AND OTHER KEY AREAS CONTAIN SUMMARY INFORMATION OF THE AFFINITY CARE POLICY. AS PART OF THE INTAKE/DISCHARGE PROCESS, PATIENTS ARE PROVIDED WITH A COPY OF THE POLICY AND OTHER INFORMATION FOR FINANCIAL ASSISTANCE. IF DURING THE COURSE OF THE PATIENT REGISTRATION PROCESS, CARE ENCOUNTER, TREATMENT, OR UPON DISCHARGE IT BECOMES EVIDENT THAT A PATIENT MAY NEED FINANCIAL ASSISTANCE, THE PATIENT SHALL BE REFERRED TO THE ORGANIZATIONS AFFINITY CARE PROGRAM. PATIENTS MAY BE IDENTIFIED AS NEEDING FINANCIAL ASSISTANCE AT ANY TIME DURING THE COURSE OF AN ENCOUNTER. A REFERRAL FOR CONSIDERATION OF AFFINITY CARE FINANCIAL ASSISTANCE CAN BE INITIATED BY ANY MEMBER OF THE HOSPITALS WORKFORCE, INCLUDING MEDICAL STAFF MEMBERS, WHO BECOME AWARE OF THE PATIENTS POTENTIAL NEED FOR AFFINITY CARE FINANCIAL ASSISTANCE. THE AFFINITY CARE BROCHURE WAS ALSO TRANSLATED INTO DIALECTS PREVALENT IN THE COMMUNITY IN ORDER TO REACH OUT TO THOSE THAT MAY SPEAK ANOTHER LANGUAGE (SPANISH AND HMONG). PATIENT REGISTRATION STAFF AND FINANCIAL COUNSELORS ARE PROVIDED WITH GUIDELINES TO FOLLOW WHEN INTERACTING WITH PATIENTS. AS PART OF THE AFFINITY CARE PROCESS, PATIENTS MUST REGISTER WITH THE COUNTY PUBLIC ASSISTANCE TO SEE IF THEY MAY QUALIFY UNDER ANY OTHER FEDERAL OR STATE PROGRAMS. PART VI, LINE 4: WHILE THERE IS GROWING AGREEMENT IN THE UNITED STATES ABOUT WHAT CONSTITUTES A NON-PROFIT HOSPITALS COMMUNITY BENEFIT, THIS IS A WORK IN PROGRESS. ST. ELIZABETH HOSPITAL PROVIDED SIGNIFICANT 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 COMMUNITY HOSPITALS, WAS CREATED AND IS MAINTAINED IN ORDER TO PROVIDE CARE LOCALLY-CARE THAT WITHOUT OUR HOSPITAL, MAY NOT BE AVAILABLE LOCALLY.CERTAIN SPECIALIZED SERVICES AVAILABLE INCLUDE: I/P ADULT BEHAVIORAL HEALTH SERVICES, I/P ADOLESCENT BEHAVIORAL HEALTH SERVICES AND NEONATAL INTENSIVE CARE SERVICES PART VI, LINE 6: ST. ELIZABETH HOSPITALS GOVERNING BOARD CONSISTS PRIMARILY OF PERSONS WHO RESIDE WITHIN THE PRIMARY SERVICE AREA. THEY ARE NOT EMPLOYEES OF THE ORGANIZATION.THE ORGANIZATION STRIVES TO FURTHER ITS EXEMPT PURPOSES BY THE FOLLOWING: ST. ELIZABETH HOSPITAL PARTICIPATES IN GOVERNMENT-SPONSORED HEALTH PROGRAMS (MEDICARE, MEDICAID, CHAMPUS, GENERAL RELIEF, SPECIALIZED COUNTY PROGRAMS AND AREA PRISONS ) ST. ELIZABETH HOSPITAL DONATES FOOD TO AN AREA HALF-WAY HOUSE AND THEIR DIETARY DEPARTMENT ALSO SUBSIDIZES MOBILE MEALS PROGRAMS FOR THE ELDERLY AND LOW INCOME INDIVIDUALS. ST. ELIZABETH HOSPITAL FOUNDATION DONATED FUNDS TO SUPPORT AREA ORGANIZATIONS THAT PROVIDE SERVICES TO THE FOLLOWING SECTORS OF OUR POPULATION: LOW-INCOME, HOMELESS, PHYSICALLY AND MENTALLY CHALLENGED AND CHRONICALLY ILL. ST. ELIZABETH HOSPITAL WORKS WITH THE LOCAL PUBLIC HEALTH DEPARTMENT TO DO NEEDS ASSESSMENT FOR BEHAVIORAL HEALTH SERVICES. ST. ELIZABETH HOSPITAL PROVIDES COMMUNITY HEALTH IMPROVEMENT SERVICES THROUGH HEALTH EDUCATION LECTURES, HEALTH FAIRS AND SUPPORT GROUPS. ST. ELIZABETH HOSPITAL SUBSIDIZES YMCA INSTRUCTORS TO WORK WITH INDIVIDUALS WHO HAVE REHABILITATION NEEDS. ALSO HOLD FREE FOLLOW-UP CLINICS OF INFANTS BORN IN THE HOSPITAL NICU. DISCOUNTED CARE IS PROVIDED TO LOW INCOME FAMILIES UP TO 662% OF FEDERAL POVERTY GUIDELINES.. ST. ELIZABETH HOSPITAL IS A DISPROPORTIONATE SHARE HOSPITAL WITH A COMBINED MEDICAID AND SSI UTILIZATION OF OVER 31.53%. ST. ELIZABETH HOSPITAL PROVIDES A SUBSIDY TO UW-FAMILY PRACTICE PHYSICIAN RESIDENCY PROGRAM. ALSO SUBSIDIZE A SCHOOL OF MEDICAL TECHNOLOGY PROGRAM. ST. ELIZABETH HOSPITAL SERVES AS A SPONSOR SITE FOR CLINICAL TRAINING OF COLLEGE STUDENTS IN VARIOUS HEALTH CARE PROGRAMS. ST. ELIZABETH HOSPITAL HELPS TO SUBSIDIZE AN AREA COMMUNITY CLINIC THAT SERVES THE UNINSURED AND LOW INCOME MEMBERS OF THE COMMUNITY. SUPPORT CONSISTS OF CASH DONATIONS FOR OPERATIONS, NURSING STAFF AND LAB AND X-RAY SERVICES. PART VI, LINE 7: ST. ELIZABETH HOSPITAL, OF APPLETON, WISCONSIN IS PART OF AN AFFILIATED HEALTH CARE SYSTEM CALLED AFFINITY HEALTH SYSTEM. AFFINITY HEALTH SYSTEM ALSO HAS TWO OTHER HOSPITALS, MERCY MEDICAL CENTER, IN OSHKOSH, WI AND CALUMET MEDICAL CENTER, IN CHILTON, WI. THE LATTER HOSPITAL QUALIFIES AS A CRITICAL ACCESS HOSPITAL. IN ADDITION TO THE HOSPITALS, AFFINITY HEALTH SYSTEM ALSO HAS 25 AREA CLINICS UNDER THE CONTROL OF AFFINITY MEDICAL GROUP. THE MISSION OF AFFINITY, AS A CATHOLIC HEALTH CARE SYSTEM, IS TO LIVE OUT THE HEALING MINISTRY OF BY PROVIDING SERVICES THAT PROMOTE THE HEALTH AND WELL BEING OF THE COMMUNITIES WE SERVE, ESPECIALLY THE POOR. AFFINITY HEALTH SYSTEM IS SPONSORED EQUALLY BY TWO CATHOLIC HEALTH SYSTEMS, MINISTRY HEALTH CARE, HEADQUARTERED IN MILWAUKEE, WI AND WHEATON FRANCISCAN HEALTH CARE, ALSO HEADQUARTERED IN MILWAUKEE, WI. ST. ELIZABETH HOSPITAL AND MERCY MEDICAL CENTER BOTH SUBSIDIZE AREA COMMUNITY MEDICAL CLINICS AS WELL AS COMMUNITY DENTAL CLINICS. THE 3 HOSPITALS AND THE 25 CLINICS PROVIDE FREE OR MINIMAL COST HEALTH EDUCATION, SUPPORT AND SCREENING SERVICES FOR THE POPULATIONS THEY SERVE. ST. ELIZABETH HOSPITAL AND MERCY MEDICAL CENTER BOTH PROVIDE SUPPORT FOR EDUCATIONAL PROGRAMS TO EDUCATE FUTURE HEALTH CARE PROFESSIONALS. THERE IS ALSO AN EXPECTATION THAT ALL PEOPLE IN MANAGEMENT SERVICES AT AFFINITY HEALTH SYSTEM WILL PROVIDE DIRECT SERVICES TO THE POOR. ST. ELIZABETH HOSPITAL HAS A FOUNDATION WHICH IS NOT INCLUDED WITHIN THE OPERATIONS OF THE ORGANIZATION. THE FOUNDATION PROVIDES CASH DONATIONS WHICH HELP SUPPORT THE MISSION OF THE ORGANIZATION AND THE AFFILIATED HEALTH CARE SYSTEM. EXAMPLES OF THE DONATIONS ARE INCLUDED IN ITEM #6 ABOVE. REPORTS FILED WITH STATES PART VI, LINE 7 WI 1 WHEATON FRANSICAN SERVICES INC 26 W 171 ROOSEVELT RD WHEATON IL 601890667 363262111 501(C)(3) 477961 GRANT TO SERVE THE POOR FOX CITIES COMMUNITY HEALTH CENTER INC 1800 APPLETON RD MENASHA WI 54952 202090446 501(C)(3) 70000 PROVIDE HEALTHCARE TO THE INDIGENT AND UNDERSERVED 2 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: EACH YEAR ST. ELIZABETH HOSPITAL PROVIDES A GRANT BASED ON AN INTEGRATION AGREEMENT. THE INTEGRATION AGREEMENT SUBSTANTIATES THE AMOUNT AND THE RECIPIENT OF THE GRANT. X X 0 1 X X X X X 0 1 0 0 0 0 0 0 0 DANIEL E NEUFELDER 192588 422120 66564 145898 2188 4796 15640 34280 4850 10630 281830 617724 0 0 JOSEPH MCCORMICK MD 0 1096449 0 0 0 1140 0 18640 0 22893 0 1139122 0 0 BARBARA STRAND MD 0 262911 0 0 0 1387 0 22346 0 20954 0 307598 0 0 STACEY SENSOR DO 0 480983 0 0 0 1040 0 22374 0 18504 0 522901 0 0 MARK FAUSTICH MD 0 368541 0 0 0 1179 0 28196 0 7244 0 405160 0 0 JAY MULLER MD 0 372671 0 0 0 386 0 18692 0 18995 0 410744 0 0 CHRISTOPHER ROCKE DO 0 232298 0 0 0 396 0 17670 0 17716 0 268080 0 0 JOHN OLIVERIO 0 918033 0 527500 0 367685 0 92775 0 64950 0 1970943 0 350448 JEFF BADGER 101843 223223 30422 66681 6994 15329 13320 29195 6252 13703 158831 348131 0 0 TRAVIS ANDERSEN 263833 0 76004 0 19288 0 28086 0 19323 0 406534 0 0 0 BRIAN HUMPHREY 159209 0 0 0 485 0 36584 0 11650 0 207928 0 0 0 RICHARD GOODMAN 161878 0 0 0 1046 0 8396 0 13082 0 184402 0 0 0 JENNIE GAURKEE 162201 0 0 0 299 0 8544 0 15237 0 186281 0 0 0 DEBRA LASTOFKA 146265 0 0 0 522 0 37522 0 7018 0 191327 0 0 0 GARY MILLER 140549 0 0 0 1493 0 7178 0 14190 0 163410 0 0 0 PART I, LINE 1B BUSINESS TRAVEL EXPENSES FOR SPOUSES OF EXECUTIVES AND GOLF CLUB MEMBERSHIP FOR EXECUTIVES ARE REIMBURSED AS PART OF THEIR EXECUTIVE FLEX CREDIT ACCOUNT. RECEIPTS ARE PROVIDED TO SR. ADMINISTRATIVE ASSISTANT IN HR WHO REVIEWS FOR ACCURACY, COMPLETES A REIMBURSEMENT FORM WITH SUBSTANTIATION TO PAYROLL FOR REIMBURSEMENT. THESE REIMBURSEMENTS ARE TAXABLE AND, WHEN ADDED TO THE COMPENSATION PACKAGE TAKEN AS A WHOLE, HAVE BEEN INCLUDED WHEN COMPARED TO THE COMPENSATION STUDIES. PART I, LINE 4B JOHN OLIVERIO RECEIVED A 2010 TAXABLE PAYOUT OF $350,448 RELATED TO A SUPPLEMENTAL NONQUALIFIED RETIREMENT PLAN KNOW AS THE WHEATON FRANCISCAN SERVICES BENEFIT RESTORATION PLAN. MORTON PHARMACY STEPHEN MORTON, A DIRECTOR, IS AN OWNER OF MORTON PHARMACY 4955 PURCHASE OF PHARMACEUTICALS 0 FORM 990, PART VI, SECTION A, LINE 6 WHEATON FRANSICAN SERVICES, INC IS A CORPORATE MEMBER AND AFFINITY HEALTH SYSTEM IS A MANAGING MEMBER. FORM 990, PART VI, SECTION A, LINE 7A WHEATON FRANCISCAN SERVICES, INC. HAS THE POWER TO APPROVE AND REMOVE DIRECTORS FROM ST. ELIZABETH HOSPITAL FORM 990, PART VI, SECTION A, LINE 7B AMENDMENTS OF THE ARTICLES OF INCORPORATION AND BYLAWS MUST BE APPROVED BY WHEATON FRANCISCAN SERVICES, INC. FORM 990, PART VI, SECTION B, LINE 11 THE CONTROLLER AND CFO OF AFFINITY HEALTH SYSTEM PERFORM A DETAIL REVIEW OF THE 990. AFTER MANAGEMENT REVIEW, A COPY OF THE 990 IS PROVIDED TO THE BOARD OF DIRECTORS PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C THE BOARD OF DIRECTORS RECEIVES A CONFLICT OF INTEREST QUESTIONNAIRE EVERY YEAR. FORM 990, PART VI, SECTION B, LINE 15 EACH YEAR THE ORGANIZATION ENGAGES AN INDEPENDENT COMPENSATION FIRM TO PROVIDE MARKET DATA FOR CEO, EXECUTIVES AND KEY EMPLOYEE POSTIONS. THIS STUDY IS SHARED WITH THE COMPENSATION COMMITTEE OF THE BOARD OF DIRECTORS FOR THEIR REVIEW AND RECOMMENDATIONS REGARDING ANY COMPENSATION CHANGES. THE COMPENSATION COMMITTEE IS COMPRISED OF INDEPENDENT MEMBERS. THE CEO REVIEWS EACH EXECUTIVE AND KEY EMPLOYEE'S ANNUAL PERFORMANCE APPRAISAL RATINGS IN MAKING HIS COMPENSATION RECOMMENDATIONS TO THE COMPENSATION COMMITTEE. THE COMPENSATION COMMITTEE HAS THE FINAL AUTHORITY TO APPROVE ANY AND ALL AMOUNTS OF COMPENSATION FOR MEMBERS OF THE EXECUTIVE TEAM. THE FINAL APPROVAL OF COMPENSATION AMOUNTS ARE DOCUMENTED. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION BELIEVES THE FINANCIAL STATEMENTS, GOVERNING DOCUMENTS, AND POLICES ARE THE PROPERTY OF THE ORGANIZATION AND ARE NOT AVAILABLE FOR PUBLIC INSPECTION. HOURS WORKED FOR RELATED ORGANIZATIONS FORM 990, PART VII MARK FAUSTICH, MD WORKED AN AVERAGE OF 40 HOURS PER WEEK FOR A RELATED ORGANIZATIONS. JOSEPH MCCORMICK, MD WORKED AN AVERAGE OF 40 HOURS PER WEEK FOR A RELATED ORGANIZATION. JAY MULLER, MD WORKED AN AVERAGE OF 40 HOURS PER WEEK FOR A RELATED ORGANIZATIONS. CHRISTOPHER ROCKE, MD WORKED AN AVERAGE OF 40 HOURS PER WEEK FOR A RELATED ORGANIZATIONS. STACEY SENSOR, DO WORKED AN AVERAGE OF 40 HOURS PER WEEK FOR A RELATED ORGANIZATIONS. BARBARA STRAND, MD WORKED AN AVERAGE OF 40 HOURS PER WEEK FOR A RELATED ORGANIZATIONS. DANIEL NEUFELDER WORKED AN AVERAGE OF 27 HOURS PER WEEK FOR RELATED ORGANIZATIONS. JEFF BADGER WORKED AN AVERAGE OF 27 HOURS PER WEEK FOR RELATED ORGANIZATIONS. JOHN OLIVERIO WORKED AN AVERAGE OF 40 HOURS PER WEEK FOR A RELATED ORGANIZATIONS. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED GAINS ON INVESTMENTS: 6,017. PENSION ADJUSTMENT -3,535,757. TOTAL TO FORM 990, PART XI, LINE 5: -3,529,740. PROCESS FOR OVERSIGHT OF AUDIT AND SELECTION OF AN INDEPENDENT ACCOUNTANT FORM 990, PART XI, LINE 2B-2C ST. ELIZABETH HOSPITAL, INC. (ORGANIZATION) DOES NOT RECEIVE SEPARATELY AUDITED FINANCIAL STATEMENTS. THE ORGANIZATION IS AUDITED AND REPORTED THROUGH CONSOLIDATED FINANCIAL STATEMENTS. THE AUDIT COMMITTEE IS RESPONSIBLE FOR THE AUDITOR SELECTION. THE AUDIT STATEMENTS ARE REVIEWED BY THE CONTROLLER, CFO, AND THE AUDIT COMMITTEE. THIS PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. AFFINITY HEALTH SYSTEM 1570 MIDWAY PL MENASHA WI 54952 391568866 SUPPORT RELATED HEALTHCARE ORGRANIZATIONS IL 501(C)(3) 3 N/A 0 MERCY MEDICAL CENTER OF OSHKOSH INC 500 S OAKWOOD OSHKOSH WI 54904 390806268 HEALTH CARE SERVICES WI 501(C)(3) 3 AFFINITY HEALTH SYSTEMS INC 0 NETWORK HEALTH SYSTEM INC 1570 MIDWAY PL MENASHA WI 54952 391127163 CLINICAL HEALTHCARE SERVICES WI 501(C)(3) 3 AFFINITY HEALTH SYSTEMS INC 0 ST ELIZABETH HOSPITAL FOUNDATION 1506 SOUTH ONEIDA STREET APPLETON WI 54915 391256677 RAISE FUNDS IN SUPPORT OF ST.ELIZABETH HOSPITAL AND RELATEDENTITIES WI 501(C)(3) 7 AFFINITY HEALTH SYSTEMS INC 0 CALUMET MEDICAL CENTER INC 614 MEMORIAL DRIVE CHILTON WI 53014 390905385 HOSPITAL WI 501(C)(3) 3 AFFINITY HEALTH SYSTEMS INC 0 MERCY HEALTH FOUNDATION INC PO BOX 3370 OSHKOSH WI 54903 237140261 PUBLIC WELFARE THROUGH COMMUNITY HEALTH DEVELOPMENT WI 501(C)(3) 9 AFFINITY HEALTH SYSTEMS INC 0 WEATON FRANCISCAN SERVICES INC 26 W171 ROOSEVELT ROAD WHEATON IL 60187 363262111 SUPPORT RELATED HEALTHCARE ORGRANIZATIONS IL 501(C)(3) 11A-1 N/A 0 TWIN MED LLP PO BOX 8005 MENASHA WI 54952 391180341 RENTAL PROPERTY WI N/A NETWORK HEALTH PLAN INC 1570 MIDWAY PLACE MENASHA WI 54952 391442058 INSURANCE WI N/A C NETWORK HEALTH INSURANCE CORPORATION 1570 MIDWAY PLACE MENASHA WI 54952 392020474 INSURANCE WI N/A C 0 0 1 1 0 1 0 0 1 1 0 1 1 1 1 1 0 0