2011-08-15T12:05:23-05:00 2010-09-30 WIPFLI LLP PO BOX 12237 GREEN BAY WI 543072237 990 2009-10-01 391101287 Ripon Medical Center Inc RIPO 9207483101 933 Newbury Street Ripon WI 54971 ROBERTA POLLESCH 9207489167 2011-08-08 1 Terri Rexrode CPA MST 9206620016 2011-08-08 X 2009 2016-02-24 21:20:13Z ROBERTA POLLESCH 933 NEWBURY ST Ripon WI 54971 23968383 0 X www.riponmedicalcenter.com X 1936 WI 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. 9 8 240 140 45672 -28025 49675 126268 20184681 23605829 77302 -25267 33401 -40747 20345059 23666083 0 0 10531347 12869764 0 0 10011324 11300966 20542671 24170730 -197612 -504647 17653743 16967605 4062869 3504596 13590874 13463009 CONNECTED TO YOUR COMMUNITY, WE PROVIDE QUALITY HEALTH CARE WITH A PERSONALIZED APPROACH. 0 0 20914945 23560157 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. 20914945 1 1 0 1 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 1 0 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 1 0 0 0 1 28 0 1 240 1 1 1 0 0 0 0 0 0 0 0 9 8 0 0 0 0 0 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 WI X ROBERTA POLLESCH 9207489167 933 NEWBURY STREET Ripon WI 54971 JOAN KARSTEN 1.00 X X 0 0 0 Kathryn A Schwandt 1.00 X X 0 0 0 DAVID N GRAY 1.00 X 0 0 0 Jay B McDonald 1.00 X X 0 0 0 ALLEN SCHRAEDER 1.00 X X 0 0 0 MARY LYKE 1.00 X 0 0 0 MICHELE WITTLER 1.00 X 0 0 0 J Drew Diedrich 1.00 X 0 0 0 Mary M de Regnier 1.00 X 0 0 0 ROBERTA POLLESCH 40.00 X 119818 0 21736 JAMES TAVARY 40.00 X 152000 0 45600 Jean Surguy 40.00 X 118904 0 4525 Mark Adorjan 40.00 X 124359 0 12844 Steven Pals MD 40.00 X 177181 0 5616 JON HILLIER 40.00 X 141903 0 30393 PATRICIA SIAS MD 40.00 X 181253 0 17271 DANIEL GARCIA 40.00 X 123988 0 27823 1139406 0 165808 8 0 1 0 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 19 92508 33760 126268 PATIENT SERVICE REVENU 900099 22712475 22712475 OTHER OPERATING REVENU 900099 847682 847682 Lab Revenue 621500 45672 45672 23605829 68754 68754 62432 103179 -40747 -40747 -40747 8824 96276 199121 8824 -102845 -94021 -94021 23666083 23560157 45672 -66014 390611 330516 60095 9953399 8684039 1269360 221168 192743 28425 1705747 1683298 22449 598839 521874 76965 4366254 3506890 859364 195155 7599 187556 2650944 2552325 98619 89 89 1609494 1331292 278202 26612 19337 7275 101714 81371 20343 838052 670442 167610 83017 83017 Bad debt 933131 933131 Other expenses 348356 230079 118277 dues/books/subscription 106812 45656 61156 Green Lake Clinic 41336 41336 24170730 20914945 3255785 0 492122 507148 85281 85281 2460237 2975520 640408 443171 481791 639260 272343 326268 21739158 14085486 8044670 7653672 1801671 1215001 3375220 3122284 17653743 16967605 1868244 1934075 1445000 905000 736197 665521 13428 0 4062869 3504596 X 13548420 13403649 42454 59360 13590874 13463009 17653743 16967605 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 3546 3546 0 Part II-B, Line 1i: Explanation of Other Lobbying Activities: AHA and WHA Dues 732202 732202 9404503 5024747 4379756 44855 4486 40369 11339832 8850564 2489268 217766 205689 12077 7653672 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 3122284 23666083 24170730 -504647 376782 376782 -127865 23652525 27778 27778 23624747 41336 41336 23666083 24123334 0 24123334 47396 47396 24170730 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. 1 1 1 X 1 X 1 1 0 1 1 126765 126765 0.00550 2126692 1164501 962191 0.04140 2253457 1164501 1088956 0.04690 172249 95334 76915 0.00330 162861 4945 157916 0.00680 20363 20363 0.00090 355473 100279 255194 0.01100 2608930 1264780 1344150 0.05790 1 549757 0 5447012 5393081 53931 X 1 1 Ripon Medical Center

933 Newbury St Ripon WI 54971

X X X X outpatient physicians clinic 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. 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. 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. 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. 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. 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. 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. 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. Part VI, Line 5: N/A 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. Part VI, Line 7: N/A WI X X X 1 0 0 0 0 0 0 0 0 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 Part I, Line 4a: Mark Adorjan, MD received severance pay in the amount of $5,577. Samantha Westphal Daughter of Board member Jay McDonald 54218 Compensation as an employee of Ripon Medical Center. Date of hire was 11/17/10. 0 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. 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 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 1 0 1