RIPON MEDICAL CENTER INC: Form 990, tax year 2009
View the entire original 990 at ProPublica ↗
- Organization
- RIPON MEDICAL CENTER INC (EIN 39-1101287)
- Tax period
- 2009-10-01 to 2010-09-30
- Filed
- 2011-08-15
- IRS object ID
- 201122279349302607
- Schema version
- 2009v1.7
- 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 L
- Schedule O
- Schedule R
Return header ReturnHeader
| Field | Value | IRS element (for citing) |
|---|---|---|
| Timestamp | 2011-08-15T12:05:23-05:00 | Timestamp |
| Tax Period End Date | 2010-09-30 | TaxPeriodEndDate |
Preparer Firm PreparerFirm
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 | PO BOX 12237 | AddressLine1 |
| City | GREEN BAY | City |
| State | WI | State |
| ZIP Code | 543072237 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return Type | 990 | ReturnType |
| Tax Period Begin Date | 2009-10-01 | TaxPeriodBeginDate |
Filer Filer
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 391101287 | EIN |
Name Name
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Ripon Medical Center Inc | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name Control | RIPO | NameControl |
| Phone | 9207483101 | Phone |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 933 Newbury Street | AddressLine1 |
| City | Ripon | City |
| State | WI | State |
| ZIP Code | 54971 | ZIPCode |
Officer Officer
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name | ROBERTA POLLESCH | Name |
| Title | CFO | Title |
| Phone | 9207489167 | Phone |
| Date Signed | 2011-08-08 | DateSigned |
| Authorize Third Party | 1 | AuthorizeThirdParty |
Preparer Preparer
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name | Terri Rexrode CPA MST | Name |
| Phone | 9206620016 | Phone |
| Date Prepared | 2011-08-08 | DatePrepared |
| Self Employed | X | SelfEmployed |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tax Year | 2009 | TaxYear |
| Build TS | 2016-02-24 21:20:13Z | BuildTS |
Form 990 IRS990
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name Of Principal Officer Person | ROBERTA POLLESCH | NameOfPrincipalOfficerPerson |
Address Principal Officer US AddressPrincipalOfficerUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 933 NEWBURY ST | AddressLine1 |
| City | Ripon | City |
| State | WI | State |
| ZIP Code | 54971 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Receipts | 23968383 | GrossReceipts |
| Group Return For Affiliates | 0 | GroupReturnForAffiliates |
| Organization501c | X | Organization501c |
| Web Site | www.riponmedicalcenter.com | WebSite |
| Type Of Organization Corporation | X | TypeOfOrganizationCorporation |
| Year Formation | 1936 | YearFormation |
| State Legal Domicile | WI | StateLegalDomicile |
| Activity Or Mission Description | AT RIPON MEDICAL CENTER, WE CARE FOR YOU, FOR LIFE. LOCATED IN RIPON, WISCONSIN, WE OFFER OUR PATIENTS PERSONALIZED, COMPASSIONATE CARE AT A LOCATION CLOSE TO HOME. WE ARE ALSO PROUD TO PROVIDE ADDITIONAL SERVICES THROUGH PRIMARY CARE AND SPECIALTY CLINICS TO ENSURE HEALTHY LIVING THROUGH ALL STAGES OF LIFE.OUR 24-HOUR PROFESSIONAL STAFF UTILIZES STATE-OF-THE ART MEDICAL EQUIPMENT TO SERVE OVER 25,000 PEOPLE FROM RIPON, GREEN LAKE, PRINCETON, MARKESAN, BRANDON, ROSENDALE, FAIRWATER AND OTHER AREA COMMUNITIES. | ActivityOrMissionDescription |
| Nbr Voting Members Governing Body | 9 | NbrVotingMembersGoverningBody |
| Nbr Independent Voting Members | 8 | NbrIndependentVotingMembers |
| Total Nbr Employees | 240 | TotalNbrEmployees |
| Total Nbr Volunteers | 140 | TotalNbrVolunteers |
| Total Gross UBI | 45672 | TotalGrossUBI |
| Net Unrelated Business Txbl Income | -28025 | NetUnrelatedBusinessTxblIncome |
| Contributions Grants Prior Year | 49675 | ContributionsGrantsPriorYear |
| Contributions Grants Current Year | 126268 | ContributionsGrantsCurrentYear |
| Program Service Revenue Prior Year | 20184681 | ProgramServiceRevenuePriorYear |
| Program Service Revenue CY | 23605829 | ProgramServiceRevenueCY |
| Investment Income Prior Year | 77302 | InvestmentIncomePriorYear |
| Investment Income Current Year | -25267 | InvestmentIncomeCurrentYear |
| Other Revenue Prior Year | 33401 | OtherRevenuePriorYear |
| Other Revenue Current Year | -40747 | OtherRevenueCurrentYear |
| Total Revenue Prior Year | 20345059 | TotalRevenuePriorYear |
| Total Revenue Current Year | 23666083 | TotalRevenueCurrentYear |
| Grants And Similar Amnts CY | 0 | GrantsAndSimilarAmntsCY |
| Benefits Paid To Members CY | 0 | BenefitsPaidToMembersCY |
| Salaries Etc Prior Year | 10531347 | SalariesEtcPriorYear |
| Salaries Etc Current Year | 12869764 | SalariesEtcCurrentYear |
| Total Prof Fundrsng Exp CY | 0 | TotalProfFundrsngExpCY |
| Total Fundrsng Exp Current Year | 0 | TotalFundrsngExpCurrentYear |
| Other Expense Prior Year | 10011324 | OtherExpensePriorYear |
| Other Expenses Current Year | 11300966 | OtherExpensesCurrentYear |
| Total Expenses Prior Year | 20542671 | TotalExpensesPriorYear |
| Total Expenses Current Year | 24170730 | TotalExpensesCurrentYear |
| Revenues Less Expenses Prior Year | -197612 | RevenuesLessExpensesPriorYear |
| Revenues Less Expenses CY | -504647 | RevenuesLessExpensesCY |
| Total Assets BOY | 17653743 | TotalAssetsBOY |
| Total Assets EOY | 16967605 | TotalAssetsEOY |
| Total Liabilities BOY | 4062869 | TotalLiabilitiesBOY |
| Total Liabilities EOY | 3504596 | TotalLiabilitiesEOY |
| Net Assets Or Fund Balances BOY | 13590874 | NetAssetsOrFundBalancesBOY |
| Net Assets Or Fund Balances EOY | 13463009 | NetAssetsOrFundBalancesEOY |
| Mission Description | CONNECTED TO YOUR COMMUNITY, WE PROVIDE QUALITY HEALTH CARE WITH A PERSONALIZED APPROACH. | MissionDescription |
| Significant New Program Services | 0 | SignificantNewProgramServices |
| Significant Change | 0 | SignificantChange |
| Expense | 20914945 | Expense |
| Revenue | 23560157 | Revenue |
| Description | RIPON MEDICAL CENTER PROVIDES AND PROMOTES HEALTH CARE SERVICES TO RESIDENTS OF RIPON, GREEN LAKE AND THE SURROUNDING COMMUNITIES REGARDLESS OF RACE, RELIGION, SEX, AGE OR ANY INDIVIDUAL'S ABILITY TO PAY FOR SERVICES. THE SERVICES AREA INCLUDES APPROXIMATELY 25,000 PEOPLE. RIPON MEDICAL CENTER ADMITTED 847 PATIENTS AND PROVIDED 2,699 DAYS OF INPATIENT CARE DURING FY 2010. 8,333 PATIENTS WERE SEEN IN THE EMERGENCY ROOM. 1,115 SURGERIES WERE PERFORMED. IN ADDITION, RIPON MEDICAL CENTER PROVIDED OUTPATIENT SERVICES IN LAB, IMAGING, PHYSICAL AND OCCUPATIONAL THERAPY, AND CARDIAC REHAB TOTALLING APPROXIMATELY 31,655 VISITS. THE MEDICAL CENTER MAINTAINS RECORDS TO IDENTIFY AND MONITOR THE LEVEL OF CHARITY IT PROVIDES TO ITS PATIENTS. THE COST OF SERVICES AND SUPPLIES FURNISHED UNDER THE MEDICAL CENTER'S CHARITY CARE POLICY WAS approximately $127,000 IN FY 2010. RIPON MEDICAL CENTER IS ACCREDITED BY THE JOINT COMMISSION. IN ADDITION TO QUALITY HEALTH CARE SERVICES, RIPON MEDICAL PROVIDES ITS COMMUNITIES WITH EDUCATION, SUPPORT GROUPS AND OTHER COMMUNITY BENEFITS. THE COST OF THESE COMMUNITY BENEFITS WAS APPROXIMATELY $255,000 IN FY 2010. | Description |
| Total Program Service Expense | 20914945 | TotalProgramServiceExpense |
| Described In501 C3 | 1 | DescribedIn501C3 |
| Schedule B Required | 1 | ScheduleBRequired |
| Political Activities | 0 | PoliticalActivities |
| Lobbying Activities | 1 | LobbyingActivities |
| Donor Advised Funds | 0 | DonorAdvisedFunds |
| Conservation Easements | 0 | ConservationEasements |
| Collections Of Art | 0 | CollectionsOfArt |
| Credit Counseling | 0 | CreditCounseling |
| Term Or Permanent Endowments | 0 | TermOrPermanentEndowments |
| Balance Sheet Amounts Reported | 1 | BalanceSheetAmountsReported |
| Independent Audit Financial Stmt | 1 | IndependentAuditFinancialStmt |
| Consolidated Audit Financial Stmt | 0 | 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 |
| 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 | 1 | 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 | 0 | RelatedOrgControlledEntity |
| Transfers To Exempt Non Chrtbl Org | 0 | TransfersToExemptNonChrtblOrg |
| Activities Conducted Partnership | 0 | ActivitiesConductedPartnership |
| Schedule O Required | 1 | ScheduleORequired |
| Number Forms Transmitted With1096 | 28 | NumberFormsTransmittedWith1096 |
| Number W2 G Included | 0 | NumberW2GIncluded |
| Compliance With Backup Witholding | 1 | ComplianceWithBackupWitholding |
| Number Of Employees | 240 | 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 |
| Nbr Voting Governing Body Members | 9 | NbrVotingGoverningBodyMembers |
| Number Independent Voting Members | 8 | 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 | 1 | ElectionOfBoardMembers |
| Decisions Subject To Approval | 1 | 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 | 1 | 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 | ROBERTA POLLESCH | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Telephone Number | 9207489167 | TelephoneNumber |
Address US AddressUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 933 NEWBURY STREET | AddressLine1 |
| City | Ripon | City |
| State | WI | State |
| ZIP Code | 54971 | ZIPCode |
Form990 Part VII Section A Form990PartVIISectionA (17 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 |
|---|---|---|---|---|---|---|---|
| JOAN KARSTEN | |||||||
| PRESIDENT | 1.00 | X | X | 0 | 0 | 0 | |
| Kathryn A Schwandt | |||||||
| TREASURER | 1.00 | X | X | 0 | 0 | 0 | |
| DAVID N GRAY | |||||||
| BOARD MEMBER | 1.00 | X | 0 | 0 | 0 | ||
| Jay B McDonald | |||||||
| SECRETARY | 1.00 | X | X | 0 | 0 | 0 | |
| ALLEN SCHRAEDER | |||||||
| VICE PRESIDENT | 1.00 | X | X | 0 | 0 | 0 | |
| MARY LYKE | |||||||
| BOARD MEMBER | 1.00 | X | 0 | 0 | 0 | ||
| MICHELE WITTLER | |||||||
| bOARD MEMBER | 1.00 | X | 0 | 0 | 0 | ||
| J Drew Diedrich | |||||||
| BOARD MEMBER | 1.00 | X | 0 | 0 | 0 | ||
| Mary M de Regnier | |||||||
| BOARD MEMBER | 1.00 | X | 0 | 0 | 0 | ||
| ROBERTA POLLESCH | |||||||
| CHIEF FINANCIAL OFFICER | 40.00 | X | 119818 | 0 | 21736 | ||
| JAMES TAVARY | |||||||
| CHIEF EXECUTIVE OFFICER | 40.00 | X | 152000 | 0 | 45600 | ||
| Jean Surguy | |||||||
| VP of Patient Services | 40.00 | X | 118904 | 0 | 4525 | ||
| Mark Adorjan | |||||||
| physICIAN | 40.00 | 124359 | 0 | 12844 | X | ||
| Steven Pals MD | |||||||
| PHYSICIAN | 40.00 | 177181 | 0 | 5616 | X | ||
| JON HILLIER | |||||||
| PHMCY DIR. | 40.00 | 141903 | 0 | 30393 | X | ||
| PATRICIA SIAS MD | |||||||
| PHYSICIAN | 40.00 | 181253 | 0 | 17271 | X | ||
| DANIEL GARCIA | |||||||
| REHAB. DIR. | 40.00 | 123988 | 0 | 27823 | X | ||
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Reportable Comp From Org | 1139406 | TotalReportableCompFromOrg |
| Total Reportable Comp Frm Rltd Orgs | 0 | TotalReportableCompFrmRltdOrgs |
| Total Other Compensation | 165808 | TotalOtherCompensation |
| Number Individuals GT100 K | 8 | NumberIndividualsGT100K |
| Formers Listed | 0 | FormersListed |
| Total Comp GT150 K | 1 | TotalCompGT150K |
| Compensation From Other Sources | 0 | CompensationFromOtherSources |
Contractor Compensation ContractorCompensation (5 entries)
| Address Line1AddressOfContractor/AddressUS/AddressLine1 | CityAddressOfContractor/AddressUS/City | StateAddressOfContractor/AddressUS/State | ZIP CodeAddressOfContractor/AddressUS/ZIPCode | Description Of ServicesDescriptionOfServices | CompensationCompensation |
|---|---|---|---|---|---|
| BADGER EMERGENCY PHYSICIANS SC | |||||
| PO BOX 11 | RIPON | WI | 54971 | EMERGENCY ROOM PHYSICIANS | 1070480 |
| SODEXO INC AND AFFILIATES | |||||
| 4880 PAYSPHERE CIRCLE | CHICAGO | IL | 60674 | DIETARY AND ENGINEERING SERVICES | 519695 |
| AFFINITY MEDICAL GROUP | |||||
| 222 W COLLEGE AVE | APPLETON | WI | 54911 | CARDIOLOGY SERVICE | 311322 |
| CENTRAL WISCONSIN ANESTHESIA ASSOC | |||||
| PO BOX 249 | BERLIN | WI | 54923 | ANESTHESIA SERVICE | 246313 |
| mercy medical center | |||||
| 500 s oakwood road | oshkosh | WI | 54904 | lab services | 233243 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Number Of Contractors GT100 K | 19 | NumberOfContractorsGT100K |
| Related Organizations | 92508 | RelatedOrganizations |
| Government Grants | 33760 | GovernmentGrants |
| Total Contributions | 126268 | TotalContributions |
Program Service Revenue ProgramServiceRevenue (3 entries)
| DescriptionDescription | Business CodeBusinessCode | Total Revenue ColumnTotalRevenueColumn | Related Or Exempt Function IncomeRelatedOrExemptFunctionIncome | Unrelated Business RevenueUnrelatedBusinessRevenue |
|---|---|---|---|---|
| PATIENT SERVICE REVENU | 900099 | 22712475 | 22712475 | |
| OTHER OPERATING REVENU | 900099 | 847682 | 847682 | |
| Lab Revenue | 621500 | 45672 | 45672 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Revenue | 23605829 | TotalProgramServiceRevenue |
Investment Income InvestmentIncome
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 68754 | TotalRevenueColumn |
| Exclusion | $68,754 | ExclusionAmount |
Gross Rents GrossRents
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | 62432 | Real |
Less Rental Expenses LessRentalExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | 103179 | Real |
Rental Income Or Loss RentalIncomeOrLoss
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | -40747 | Real |
Net Rental Income Or Loss NetRentalIncomeOrLoss
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | -40747 | TotalRevenueColumn |
| Exclusion | -$40,747 | ExclusionAmount |
Gross Amount Sales Assets GrossAmountSalesAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| Securities | 8824 | Securities |
| Other | 96276 | Other |
Less Cost Oth Basis Sales Expenses LessCostOthBasisSalesExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | 199121 | Other |
Gain Or Loss GainOrLoss
| Field | Value | IRS element (for citing) |
|---|---|---|
| Securities | 8824 | Securities |
| Other | -102845 | Other |
Net Gain Or Loss Investments NetGainOrLossInvestments
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | -94021 | TotalRevenueColumn |
| Exclusion | -$94,021 | ExclusionAmount |
Total Revenue TotalRevenue
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 23666083 | TotalRevenueColumn |
| Related Or Exempt Function Income | 23560157 | RelatedOrExemptFunctionIncome |
| Unrelated Business Revenue | 45672 | UnrelatedBusinessRevenue |
| Exclusion | -$66,014 | ExclusionAmount |
Comp Current Officers Directors CompCurrentOfficersDirectors
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 390611 | Total |
| Program Services | 330516 | ProgramServices |
| Management And General | 60095 | ManagementAndGeneral |
Other Salaries And Wages OtherSalariesAndWages
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 9953399 | Total |
| Program Services | 8684039 | ProgramServices |
| Management And General | 1269360 | ManagementAndGeneral |
Pension Plan Contributions PensionPlanContributions
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 221168 | Total |
| Program Services | 192743 | ProgramServices |
| Management And General | 28425 | ManagementAndGeneral |
Other Employee Benefits OtherEmployeeBenefits
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 1705747 | Total |
| Program Services | 1683298 | ProgramServices |
| Management And General | 22449 | ManagementAndGeneral |
Payroll Taxes PayrollTaxes
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 598839 | Total |
| Program Services | 521874 | ProgramServices |
| Management And General | 76965 | ManagementAndGeneral |
Fees For Services Other FeesForServicesOther
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 4366254 | Total |
| Program Services | 3506890 | ProgramServices |
| Management And General | 859364 | ManagementAndGeneral |
Advertising Advertising
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 195155 | Total |
| Program Services | 7599 | ProgramServices |
| Management And General | 187556 | ManagementAndGeneral |
Office Expenses OfficeExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 2650944 | Total |
| Program Services | 2552325 | ProgramServices |
| Management And General | 98619 | ManagementAndGeneral |
Information Technology InformationTechnology
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 89 | Total |
| Management And General | 89 | ManagementAndGeneral |
Occupancy Occupancy
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 1609494 | Total |
| Program Services | 1331292 | ProgramServices |
| Management And General | 278202 | ManagementAndGeneral |
Travel Travel
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 26612 | Total |
| Program Services | 19337 | ProgramServices |
| Management And General | 7275 | ManagementAndGeneral |
Interest Interest
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 101714 | Total |
| Program Services | 81371 | ProgramServices |
| Management And General | 20343 | ManagementAndGeneral |
Depreciation Depletion DepreciationDepletion
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 838052 | Total |
| Program Services | 670442 | ProgramServices |
| Management And General | 167610 | ManagementAndGeneral |
Insurance Insurance
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 83017 | Total |
| Program Services | 83017 | ProgramServices |
Other Expenses OtherExpenses (4 entries)
| DescriptionDescription | TotalTotal | Program ServicesProgramServices | Management And GeneralManagementAndGeneral |
|---|---|---|---|
| Bad debt | 933131 | 933131 | |
| Other expenses | 348356 | 230079 | 118277 |
| dues/books/subscription | 106812 | 45656 | 61156 |
| Green Lake Clinic | 41336 | 41336 |
Total Functional Expenses TotalFunctionalExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 24170730 | Total |
| Program Services | 20914945 | ProgramServices |
| Management And General | 3255785 | ManagementAndGeneral |
| Fundraising | 0 | Fundraising |
Cash Non Interest Bearing CashNonInterestBearing
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 492122 | BOY |
| EOY | 507148 | EOY |
Savings And Temp Cash Investments SavingsAndTempCashInvestments
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 85281 | BOY |
| EOY | 85281 | EOY |
Accounts Receivable AccountsReceivable
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 2460237 | BOY |
| EOY | 2975520 | EOY |
Other Notes Loans Receivable Net OtherNotesLoansReceivableNet
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 640408 | BOY |
| EOY | 443171 | EOY |
Inventories For Sale Or Use InventoriesForSaleOrUse
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 481791 | BOY |
| EOY | 639260 | EOY |
Prepaid Expenses Deferred Charges PrepaidExpensesDeferredCharges
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 272343 | BOY |
| EOY | 326268 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Land Buildings Equipment Basis | 21739158 | LandBuildingsEquipmentBasis |
| Land Bldg Equipment Accum Deprec | 14085486 | LandBldgEquipmentAccumDeprec |
Land Buildings Equipment Basis Net LandBuildingsEquipmentBasisNet
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 8044670 | BOY |
| EOY | 7653672 | EOY |
Investments Pub Traded Securities InvestmentsPubTradedSecurities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 1801671 | BOY |
| EOY | 1215001 | EOY |
Other Assets Total OtherAssetsTotal
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 3375220 | BOY |
| EOY | 3122284 | EOY |
Total Assets TotalAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 17653743 | BOY |
| EOY | 16967605 | EOY |
Accounts Payable Accrued Expenses AccountsPayableAccruedExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 1868244 | BOY |
| EOY | 1934075 | EOY |
Tax Exempt Bond Liabilities TaxExemptBondLiabilities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 1445000 | BOY |
| EOY | 905000 | EOY |
Mort Notes Pybl Secured Invest Prop MortNotesPyblSecuredInvestProp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 736197 | BOY |
| EOY | 665521 | EOY |
Other Liabilities OtherLiabilities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 13428 | BOY |
| EOY | 0 | EOY |
Total Liabilities TotalLiabilities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 4062869 | BOY |
| EOY | 3504596 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Follow SFAS117 | X | FollowSFAS117 |
Unrestricted Net Assets UnrestrictedNetAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 13548420 | BOY |
| EOY | 13403649 | EOY |
Temporarily Restricted Net Assets TemporarilyRestrictedNetAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 42454 | BOY |
| EOY | 59360 | EOY |
Total Net Assets Fund Balances TotalNetAssetsFundBalances
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 13590874 | BOY |
| EOY | 13463009 | EOY |
Total Liab Net Assets Fund Balances TotalLiabNetAssetsFundBalances
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 17653743 | BOY |
| EOY | 16967605 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Method Of Accounting Accrual | X | MethodOfAccountingAccrual |
| Accountant Compile Or Review | 0 | AccountantCompileOrReview |
| FS Audited | 1 | FSAudited |
| Audit Committee | 1 | AuditCommittee |
| Financial Statement Separate | X | FinancialStatementSeparate |
| Federal Grant Audit Required | 0 | FederalGrantAuditRequired |
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 | $3,546 | OtherActivitiesAmount |
| Total Lobbying Expenditures IIB | 3546 | TotalLobbyingExpendituresIIB |
| Not Described In501c3 | 0 | NotDescribedIn501c3 |
Form990 Schedule C Part IV Form990ScheduleCPartIV
| Field | Value | IRS element (for citing) |
|---|---|---|
| Identifier | Part II-B, Line 1i: | Identifier |
| Return Reference | Explanation of Other Lobbying Activities: | ReturnReference |
| Explanation | AHA and WHA Dues | Explanation |
Schedule D IRS990ScheduleD
Land Land
| Field | Value | IRS element (for citing) |
|---|---|---|
| Investment Cost Or Other Basis | 732202 | InvestmentCostOrOtherBasis |
| Book Value | 732202 | BookValue |
Buildings Buildings
| Field | Value | IRS element (for citing) |
|---|---|---|
| Investment Cost Or Other Basis | 9404503 | InvestmentCostOrOtherBasis |
| Depreciation | 5024747 | Depreciation |
| Book Value | 4379756 | BookValue |
Leasehold Improvements LeaseholdImprovements
| Field | Value | IRS element (for citing) |
|---|---|---|
| Investment Cost Or Other Basis | 44855 | InvestmentCostOrOtherBasis |
| Depreciation | 4486 | Depreciation |
| Book Value | 40369 | BookValue |
Equipment Equipment
| Field | Value | IRS element (for citing) |
|---|---|---|
| Investment Cost Or Other Basis | 11339832 | InvestmentCostOrOtherBasis |
| Depreciation | 8850564 | Depreciation |
| Book Value | 2489268 | BookValue |
Other Land Buildings OtherLandBuildings
| Field | Value | IRS element (for citing) |
|---|---|---|
| Investment Cost Or Other Basis | 217766 | InvestmentCostOrOtherBasis |
| Depreciation | 205689 | Depreciation |
| Book Value | 12077 | BookValue |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Of Book Value Land Buildings | 7653672 | TotalOfBookValueLandBuildings |
Other Assets OtherAssets (4 entries)
| DescriptionDescription | Book ValueBookValue |
|---|---|
| NET INVESTMENT IN FOUNDATION FOR RIPON MEDICAL CENTER, INC. | 2959512 |
| INVESTMENTS HELD BY TRUSTEE UNDER BOND INDENTURE AGREEMENTS | 121860 |
| INVESTMENT IN AFFILIATES | 22107 |
| DEFERRED FINANCING COSTS | 18805 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Book Value Other Assets | 3122284 | TotalBookValueOtherAssets |
| Total Revenue | 23666083 | TotalRevenue |
| Total Expenses | 24170730 | TotalExpenses |
| Excess Or Deficit For Year | -504647 | ExcessOrDeficitForYear |
| Other | $376,782 | OtherAmount |
| Total Adjustments | 376782 | TotalAdjustments |
| Excess Or Deficit Per FS | -127865 | ExcessOrDeficitPerFS |
| Tot Revenue Etc Audited Fincl Stmt | 23652525 | TotRevenueEtcAuditedFinclStmt |
| Other Revenues | 27778 | OtherRevenues |
| Revenue Not Rptd F990 | 27778 | RevenueNotRptdF990 |
| Revenue Subtotal | 23624747 | RevenueSubtotal |
| Other Revenues Not Included | 41336 | OtherRevenuesNotIncluded |
| Revenue Not Rptd On Fin Stmt | 41336 | RevenueNotRptdOnFinStmt |
| Total Revenue Per Form990 | 23666083 | TotalRevenuePerForm990 |
| Tot Expenses Etc Audited Fincl Stmt | 24123334 | TotExpensesEtcAuditedFinclStmt |
| Expenses Not Rptd F990 | 0 | ExpensesNotRptdF990 |
| Expenses Subtotal | 24123334 | ExpensesSubtotal |
| Other Expenses Not Included | 47396 | OtherExpensesNotIncluded |
| Expenses Not Rptd On Fin Stmt | 47396 | ExpensesNotRptdOnFinStmt |
| Total Expenses Per Form990 | 24170730 | TotalExpensesPerForm990 |
Form990 Schedule D Part XIV Form990ScheduleDPartXIV (5 entries)
| IdentifierIdentifier | Return ReferenceReturnReference | ExplanationExplanation |
|---|---|---|
| Part X: | Description of Uncertain Tax Positions Under FIN 48: | In order to account for any uncertain tax positions, ASC Topic 740-10, Accounting for Uncertainty in Income Taxes, requires an organization to determine whether it is more likely than not that a tax position will be sustained upon examination of the technical merits of the position, assuming the taxing authority has full knowledge of all information. If the tax position does not meet the more-likely-than-not recognition threshold, the benefit of that position is not recognized in the financial statements. The Medical Center recorded no assets or liabilities related to uncertain tax positions or unrecognized tax benefits in 2010 or 2009. Federal tax returns for the years ended September 30, 2007, 2008, and 2009, remain subject to examination by the Internal Revenue Service. |
| Part XI, Line 8 - Other Adjustments: | CHANGE IN INTEREST IN FOUNDATION FOR RIPON MEDICAL CENTER: 204215. UNREALIZED Gain IN INVESTMENTS OTHER THAN TRADING SECURITIES: 52304. change in interest in loss of LN LLC: -2427. Transfer From Foundation: 86425. Change in Interest in Gain of CMCGL: 36265. | |
| Part XII, Line 2d - Other Adjustments: | Equity in loss of LN LLC: -2427. Depreciation on vacant house: -6060. Lease for provider clinic: 36265. | |
| Part XII, Line 4b - Other Adjustments: | Green lake Clinic expenses: 41336. | |
| Part XIII, Line 4b - Other Adjustments: | Green Lake Clinic Expenses: 41336. Depreciation on vacant houses: 6060. |
Schedule H IRS990ScheduleH
| Field | Value | IRS element (for citing) |
|---|---|---|
| Charity Care Policy | 1 | CharityCarePolicy |
| Written Policy | 1 | WrittenPolicy |
| FPG Reference Free Care | 1 | FPGReferenceFreeCare |
| Pcent100 | X | Pcent100 |
| 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 | 126765 | TotalCommunityBenefitExpense |
| Net Community Benefit Expense | 126765 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.00550 | PercentOfTotalExpense |
Unreimbursed Medicaid UnreimbursedMedicaid
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 2126692 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 1164501 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 962191 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.04140 | PercentOfTotalExpense |
Total Charity Care TotalCharityCare
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 2253457 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 1164501 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 1088956 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.04690 | PercentOfTotalExpense |
Community Health Services CommunityHealthServices
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 172249 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 95334 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 76915 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.00330 | PercentOfTotalExpense |
Health Professions Education HealthProfessionsEducation
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 162861 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 4945 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 157916 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.00680 | PercentOfTotalExpense |
Cash And In Kind Contributions CashAndInKindContributions
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 20363 | TotalCommunityBenefitExpense |
| Net Community Benefit Expense | 20363 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.00090 | PercentOfTotalExpense |
Total Other Benefits TotalOtherBenefits
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 355473 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 100279 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 255194 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.01100 | PercentOfTotalExpense |
Total Community Benefits TotalCommunityBenefits
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 2608930 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 1264780 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 1344150 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.05790 | PercentOfTotalExpense |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bad Debt Expense Reported | 1 | BadDebtExpenseReported |
| Bad Debt Expense | $549,757 | BadDebtExpenseAmount |
| Amount Attributable To | 0 | AmountAttributableTo |
| Amount Reimbursed By Medicare | 5447012 | AmountReimbursedByMedicare |
| Cost Of Care Reimbursed By Medicare | 5393081 | CostOfCareReimbursedByMedicare |
| Medicare Surplus Or Shortfall | 53931 | 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 |
Form990 Schedule H Part V Form990ScheduleHPartV
Name Name
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Ripon Medical Center | BusinessNameLine1 |
Address Address
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 933 Newbury St | AddressLine1 |
| City | Ripon | City |
| State | WI | State |
| ZIP Code | 54971 | 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 |
| Other | outpatient physicians clinic | Other |
Form990 Schedule H Part VI Form990ScheduleHPartVI
| Field | Value | IRS element (for citing) |
|---|---|---|
| Costing Method Used | Part I, Line 7: a cost to charge ratio from worksheet 2 is utilized in computing the costs for charity care and unreimbursed medicaid. for the other categories (community health improvement services/community benefit operations, health professions education and cash and in-kind contributions, Direct costs of each benefit plus 17% for overhead allocation is used to report the costs. | CostingMethodUsed |
| Bad Debt Footnote | Part III, Line 4: Ratio of patient care costs to charges. As a critical access hospital, we have to offer our community essential healthcare services regardless of their ability or willingness to pay. | BadDebtFootnote |
| Shortfall As Community Benefit | Part III, Line 8: Ripon medical Center has a surplus of reimbursement from medicare because of their critical access status which allows reimbursement at a rate of 101% of allowed costs. However, Ripon Medical Center believes that if there were a shortfall, the costs should be treated as community benefit because 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. | ShortfallAsCommunityBenefit |
| Debt Collection Policy | Part III, Line 9b: Free or discounted care for essential health services will be provided to uninsured and underinsured patients who meet the established criteria and complete the required application and review process. All patients will be treated equitably, with dignity, and with respect. | DebtCollectionPolicy |
| General Explanation | Part I, line 7, column (f) - the calculation of the percentages in the table were computed by removing $933,131 of bad debt expense from the denominator, as allowed by IRS instructions. | GeneralExplanation |
| Needs Assessment | Part VI, Line 2: Ripon Medical Center uses the 2010 Healthiest Wisconsin Initiative by the population health institute at UW Health. The report identified 10 health priorities for the state and ranked them by county. both fond du lac county and green lake county initiatives were used to determine programs needed in our communities since our service area overlaps both counties. In addition, Ripon Medical Center's community outreach coordinator works closely with the fond du lac county and green lake county public health departments to identify health needs in our service area. | NeedsAssessment |
| Patient Education Assistance | Part VI, Line 3: During normal business hours, the financial counselor will meet or call all possible applicants giving or mailing them information packets pertaining to charity care. After hours patients are given the information packets including the financial counselor's contact information. financial assistance policies are also available on the website. | PatientEducationAssistance |
| Community Information | Part VI, Line 4: Ripon Medical Center is a rural community hospital serving approximately 25,000 people in its primary and secondary service areas that include Ripon, Green Lake, Princeton, Markesan, Brandon, Fairwater, Rosendale and Montello. The population has remained the same for many years with little or no growth. While the area still attracts young families, the area has a higher percentage of people in the 45-64 age groups and the 65+ age group than the State or National Averages. The economy is stable. Unemployment is below the national average. The median income is slightly below the national average, but the cost of living is also lower than the national average. | CommunityInformation |
| Community Building Activities | Part VI, Line 5: N/A | CommunityBuildingActivities |
| Other Information | Part VI, Line 6: Ripon Medical Center is a community-governed hospital. The majority of the Board of Directors is comprised of independent individuals who are representatives of the communities we serve. Ripon Medical center has an open medical staff, extending medical staff privileges to all qualified physicians in the community. In addition to providing charity care and other community benefits as defined by the IRS, Ripon Medical Center provides 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 - care that without our hospital, would not be provided locally. Beyond inpatient hospitalizations, we provide local access to many health services: Primary Care and Specialty Physician Services, Emergency Services and Urgent Care, Imaging and Lab Services, Rehabilitation Services, Surgical Services and Occupational Health. | OtherInformation |
| Affiliated Health Care System | Part VI, Line 7: N/A | AffiliatedHealthCareSystem |
| Reports Filed With States | WI | ReportsFiledWithStates |
Schedule J IRS990ScheduleJ
| Field | Value | IRS element (for citing) |
|---|---|---|
| Written Employment Contract | X | WrittenEmploymentContract |
| Compensation Survey | X | CompensationSurvey |
| Board Or Committee Approval | X | BoardOrCommitteeApproval |
| Severance Payment | 1 | SeverancePayment |
| Supplemental Nonqual Retire Plan | 0 | SupplementalNonqualRetirePlan |
| Equity Based Comp Arrangement | 0 | EquityBasedCompArrangement |
| Comp Based On Revenue Of Filing Org | 0 | 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 (5 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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| JAMES TAVARY | |||||||||||||
| 152000 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 45600 | 0 | 197600 | 0 | 0 | 0 |
| Steven Pals MD | |||||||||||||
| 177043 | 0 | 0 | 0 | 138 | 0 | 1846 | 0 | 3770 | 0 | 182797 | 0 | 0 | 0 |
| JON HILLIER | |||||||||||||
| 140871 | 0 | 0 | 0 | 1032 | 0 | 5784 | 0 | 24609 | 0 | 172296 | 0 | 0 | 0 |
| PATRICIA SIAS MD | |||||||||||||
| 180701 | 0 | 0 | 0 | 552 | 0 | 6978 | 0 | 10293 | 0 | 198524 | 0 | 0 | 0 |
| DANIEL GARCIA | |||||||||||||
| 123778 | 0 | 0 | 0 | 210 | 0 | 4722 | 0 | 23101 | 0 | 151811 | 0 | 0 | 0 |
Form990 Schedule J Part III Form990ScheduleJPartIII
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return Reference | Part I, Line 4a: | ReturnReference |
| Explanation | Mark Adorjan, MD received severance pay in the amount of $5,577. | Explanation |
Schedule L IRS990ScheduleL
Form990 Schedule L Part IV Form990ScheduleLPartIV
Name Of Interested Person NameOfInterestedPerson
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name Person | Samantha Westphal | NamePerson |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Relationship | Daughter of Board member Jay McDonald | Relationship |
| Amount Of Transaction | 54218 | AmountOfTransaction |
| Description Of Transaction | Compensation as an employee of Ripon Medical Center. Date of hire was 11/17/10. | DescriptionOfTransaction |
| Sharing Of Revenues | 0 | SharingOfRevenues |
Schedule O IRS990ScheduleO
General Explanation GeneralExplanation (7 entries)
| IdentifierIdentifier | ExplanationExplanation |
|---|---|
| Form 990, Part VI, Section A, line 7a | OF THE NINE BOARD MEMBERS, FIVE ARE APPOINTED BY THE CITY OF RIPON AND THE OTHER FOUR ARE ELECTED BY THE BOARD ITSELF. |
| Form 990, Part VI, Section A, line 7b | CHANGES TO THE ORGANIZATION'S BY-LAWS MUST BE APPROVED BY THE CITY OF RIPON. |
| Form 990, Part VI, Section B, line 11 | THE CHIEF EXECUTIVE OFFICER REVIEWS THE FORM 990 WITH THE CHIEF FINANCIAL OFFICER OF RIPON MEDICAL CENTER PRIOR TO ITS FILING. IN ADDITION, THE FORM 990 IS DISTRIBUTED VIA EMAIL TO ALL BOARD MEMBERS PRIOR TO FILING. |
| Form 990, Part VI, Section B, line 12c | BOARD MEMBERS SIGN A CONFLICT OF INTEREST STATEMENT ANNUALLY, DISCLOSING ANY CONFLICT OF INTEREST THAT MAY EXIST. |
| Form 990, Part VI, Section B, line 15 | COMPENSATION FOR THE CEO IS DETERMINED BY THE BOARD AND BRIM, WHO EMPLOYS THE CEO. IT IS BASED ON MARKET DATA AVAILABLE TO BRIM WHO EMPLOYS CEO'S AT ALL OF THEIR CONTRACT MANAGED HOSPITALS THROUGHOUT THE COUNTRY. BRIM USES UP TO THREE SALARY SURVEYS, WHICH ARE SHARED WITH THE BOARD. BRIM MAKES A RECOMMENDATION TO THE BOARD AND THE BOARD MAKES THE FINAL DECISION. COMPENSATION FOR THE OTHER KEY EMPLOYEeS IS DETERMINED FROM AT LEAST TWO SALARY SURVEYS, ALONG WITH CONSIDERATION OF EXPERIENCE AND QUALIFICATIONS. COMPENSATION IS APPROVED BY THE CEO OF RIPON MEDICAL CENTER WHO DOES NOT HAVE A CONFLICT OF INTEREST WITH THE KEY EMPLOYEES. DOCUMENTATION IS IN THE PERSONNEL FILES. |
| Form 990, Part VI, Section C, line 19 | The governing documents, conflicts of interest policy, and financial statements are made available to the public upon request. |
| Form 990, Part XI, Line 2C | The process has not changed since the prior year.Ripon Medical Center's Board approves a 3 year contract with an independent auditor. |
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 | Direct Controlling Entity NADirectControllingEntityNA |
|---|---|---|---|---|---|---|---|---|---|
| Foundation For Ripon medical center | |||||||||
| 933 Newbury St | Ripon | WI | 54971 | 391605953 | support of Ripon Medical Center | WI | 501(c)(3) | 509(a)(3), Type 1 | N/A |
| Ripon Medical Center associates | |||||||||
| 933 Newbury St | ripon | WI | 54971 | 396088384 | support of Ripon Medical Center | WI | 501(c)(3) | 509(a)(3), Type 1 | N/A |
| 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 | 1 | PerformOfServicesByOtherOrgs |
| Sharing Of Facilities | 0 | SharingOfFacilities |
| Sharing Of Paid Employees | 0 | 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 | 1 | OtherTransferFromOtherOrg |