TY 2012 Form 990

(A) Name and Title	(B) Average hours per week (list any hours for related organizations below dotted line)	(C) Position (do not check more than one box, unless person is both an officer and a director/trustee)	(E) Reportable compensation from related organizations (W- 2/1099-MISC)
(1) Stadelmann Douglas J........................................................................ Dir&Secretary	1.00 .......................0.00	X	X	0	0	0
(2) Pollard Dennis........................................................................ Dir&President	1.00 .......................46.00	X	X	0	553,415	111,706
(3) Pieters Robert B........................................................................ Dir&Chair	1.00 .......................1.00	X	X	0	0	0
(4) Bast Ronald R........................................................................ Dir&Vice Chair	1.00 .......................2.00	X	X	0	0	0
(5) White MD Michael G........................................................................ Director	1.00 .......................0.00	X		0	0	0
(6) Turtenwald Robyn........................................................................ Director	1.00 .......................0.00	X		0	0	0
(7) Templin Susan........................................................................ Director	1.00 .......................1.00	X		0	0	0
(8) Specht-Palmert Christine........................................................................ Director	1.00 .......................0.00	X		0	0	0
(9) Shepherd MD Dennis W........................................................................ Executive Dir.	1.00 .......................0.00	X		0	0	0
(10) Nelson Eric........................................................................ Director	1.00 .......................0.00	X		0	0	0
(11) Mays Cedric........................................................................ Director	1.00 .......................0.00	X		0	0	0
(12) Lux Theresa M........................................................................ Dir,VP Pt Care	50.00 .......................1.00	X		247,668	0	39,985
(13) Jacobson Catherine A........................................................................ Dir,FH Pres/CEO	1.00 .......................50.00	X		0	1,001,826	179,860
(14) Hart Daniel........................................................................ Dir/Treasurer	1.00 .......................1.00	X		0	0	0
(15) Hackett MD James G........................................................................ Director	1.00 .......................0.00	X		0	0	0
(16) Goldberg MD David F........................................................................ Dir,VP Med Afrs	50.00 .......................0.00	X		346,084	0	66,474
(17) Fitzgerald Mark........................................................................ Director	1.00 .......................0.00	X		0	0	0

(A) Name and Title	(B) Average hours per week (list any hours for related organizations below dotted line)	(C) Position (do not check more than one box, unless person is both an officer and a director/trustee)	(E) Reportable compensation from related organizations (W- 2/1099-MISC)
(18) Ellis Sharon Q........................................................................ Director	1.00 .......................1.00	X				0	0	0
(19) Borden Susan........................................................................ Director	1.00 .......................0.00	X				0	0	0
(20) Becker Richard C........................................................................ Director	1.00 .......................1.00	X				0	0	0
(21) Aggarwal Anil MD........................................................................ Director	1.00 .......................0.00	X				0	0	0
(22) Knoll Thomas........................................................................ Treasurer	1.00 .......................41.00		X			0	152,361	35,101
(23) Van De Kreeke Jeffrey........................................................................ FH CFO	1.00 .......................50.00		X			0	428,725	85,514
(24) Hawig Scott........................................................................ FH CFO	1.00 .......................50.00		X			0	229,597	10,354
(25) Ehn Diane........................................................................ VP Qlty & Perf Exc	40.00 .......................0.00			X		162,789	0	37,694
(26) Evenson Rock E........................................................................ VP Pln & Prg Dvlp	50.00 .......................0.00			X		209,370	0	52,682
(27) Freiberg Kerry J........................................................................ VP Extrnl Affairs	50.00 .......................1.00			X		206,356	0	40,598
(28) McClure Debra........................................................................ Nurse Anesthetist	50.00 .......................0.00			X		273,137	0	18,052
(29) Sanders Paul A........................................................................ Sr VP, Clncl Srvcs	50.00 .......................0.00			X		304,710	0	36,109
(30) Unger Michael........................................................................ Former - Officer (VP)	0.00 .......................40.00				X	0	240,775	16,131

(A) Name and business address	(B) Description of services	(C) Compensation
Von Briesen & Roper411 E Wisconsin Ave Ste 700MilwaukeeWI53201	Legal	1,086,848
United Dynacare9200 W Wisconsin AveMilwaukeeWI53226	Lab	752,803
Medical Staffing Network901 Yamato Rd Suite 110Boca RatonFL33431	Staffing	587,563
Medical College of WI8701 Watertown PlankMilwaukeeWI53206	Physicians & Medical	6,176,730
Critical Care SolutionsN74W12501 Leatherwood CtMenomonee FallsWI53051	Virtual ICU	345,518
2 Total number of independent contractors (including but not limited to those listed above) who received more than $100,000 of compensation from the organization 14

Do not include amounts reported on lines 6b, 7b, 8b, 9b, and 10b of Part VIII.	(A) Total expenses	(B) Program service expenses	(C) Management and general expenses	(D) Fundraising expenses
1	Grants and other assistance to governments and organizations in the United States. See Part IV, line 21	49,964	49,964
2	Grants and other assistance to individuals in the United States. See Part IV, line 22	0
3	Grants and other assistance to governments, organizations, and individuals outside the United States. See Part IV, lines 15 and 16	0
4	Benefits paid to or for members	0
5	Compensation of current officers, directors, trustees, and key employees ....	724,227		724,227
6	Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) ....	0
7	Other salaries and wages	62,067,835	58,030,153	3,875,712	161,970
8	Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) ....	0
9	Other employee benefits .......	119,539	110,645	8,583	311
10	Payroll taxes ...........	4,361,983	4,037,452	313,190	11,341
11	Fees for services (non-employees):
a	Management ......	293,700	293,700
b	Legal .........	-264,512	-393,373	128,861
c	Accounting ...........	0
d	Lobbying ...........	0
e	Professional fundraising services. See Part IV, line 17	0
f	Investment management fees ......	0
g	Other (If line 11g amount exceeds 10% of line 25, column (A) amount, list line 11g expenses on Schedule O) ........	11,155,858	9,488,273	1,667,585
12	Advertising and promotion ....	91,882	2,199	89,683
13	Office expenses .......	1,319,341	478,606	831,851	8,884
14	Information technology ......	492,783	136,997	355,746	40
15	Royalties ..	0
16	Occupancy ...........	3,536,417	2,903,820	627,356	5,241
17	Travel ............	89,493	41,142	48,125	226
18	Payments of travel or entertainment expenses for any federal, state, or local public officials ......	0
19	Conferences, conventions, and meetings ....	148,900	122,900	25,700	300
20	Interest ...........	2,397,435	1,968,580	425,302	3,553
21	Payments to affiliates .......	0
22	Depreciation, depletion, and amortization .....	7,852,615	6,447,934	1,393,044	11,637
23	Insurance ..............	7,477	7,477
24	Other expenses. Itemize expenses not covered above (List miscellaneous expenses in line 24e. If line 24e amount exceeds 10% of line 25, column (A) amount, list line 24e expenses on Schedule O.)
a	Miscellaneous	3,779,138	3,620,326	157,250	1,562
b	State Hospital Assessment	5,293,260	5,293,260
c	Medical Supplies	32,782,342	32,635,966	142,989	3,387
d	Corporate Allocated Expense	40,898,592	17,660,006	23,204,803	33,783
e	All other expenses	0
25	Total functional expenses. Add lines 1 through 24e	177,198,269	142,936,027	34,020,007	242,235
26	Joint costs. Complete this line only if the organization reported in column (B) joint costs from a combined educational campaign and fundraising solicitation. Check here if following SOP 98-2 (ASC 958-720).

Part X Balance Sheet Check if Schedule O contains a response to any question in this Part X ...............
	1	Cashnon-interest-bearing .............	7,295	1	7,125
2	Savings and temporary cash investments .........	21,754,257	2	26,309,775
3	Pledges and grants receivable, net ...........		3	0
4	Accounts receivable, net .............	24,095,637	4	22,202,533
5	Loans and other receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of Schedule L ..................
			5	0
6	Loans and other receivables from other disqualified persons (as defined under section 4958(f)(1)), persons described in section 4958(c)(3)(B), and contributing employers and sponsoring organizations of section 501(c)(9) voluntary employees' beneficiary organizations (see instructions) Complete Part II of Schedule L
			6	0
7	Notes and loans receivable, net .............	20,000	7	20,000
8	Inventories for sale or use ..............	4,149,959	8	3,877,301
9	Prepaid expenses and deferred charges ..........	2,126,284	9	1,630,172
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	181,038,606
b	Less: accumulated depreciation .....	10b	95,737,925	81,377,017	10c	85,300,681
11	Investments—publicly traded securities ..........	124,482,090	11	127,899,248
12	Investments—other securities. See Part IV, line 11 .....		12	0
13	Investments—program-related. See Part IV, line 11 .....		13	0
14	Intangible assets ...............		14	0
15	Other assets. See Part IV, line 11 ...........	50,278,063	15	54,477,096
16	Total assets. Add lines 1 through 15 (must equal line 34)......	308,290,602	16	321,723,931
	17	Accounts payable and accrued expenses .........	8,803,747	17	10,485,948
18	Grants payable .................		18
19	Deferred revenue ................	5,940	19	4,199
20	Tax-exempt bond liabilities .............	63,386,192	20	55,729,972
21	Escrow or custodial account liability. Complete Part IV of Schedule D..		21
22	Loans and other payables to current and former officers, directors, trustees, key employees, highest compensated employees, and disqualified
	persons. Complete Part II of Schedule L..........		22
23	Secured mortgages and notes payable to unrelated third parties ..		23
24	Unsecured notes and loans payable to unrelated third parties ....		24
25	Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17-24). Complete Part X of Schedule D....................	97,825,874	25	69,681,506
26	Total liabilities. Add lines 17 through 25.........	170,021,753	26	135,901,625
		Organizations that follow SFAS 117 (ASC 958), check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets ..............	137,302,778	27	184,547,067
28	Temporarily restricted net assets ...........	966,071	28	1,275,239
29	Permanently restricted net assets ...........		29
	Organizations that do not follow SFAS 117 (ASC 958), check here and complete lines 30 through 34.
30	Capital stock or trust principal, or current funds ........		30
31	Paid-in or capital surplus, or land, building or equipment fund .....		31
32	Retained earnings, endowment, accumulated income, or other funds		32
33	Total net assets or fund balances ...........	138,268,849	33	185,822,306
34	Total liabilities and net assets/fund balances ........	308,290,602	34	321,723,931

- TIN:

SCHEDULE A
(Form 990 or 990EZ)

Department of the Treasury
Internal Revenue Service

Public Charity Status and Public Support

Complete if the organization is a section 501(c)(3) organization or a section
4947(a)(1) nonexempt charitable trust.

Attach to Form 990 or Form 990-EZ. right arrow

See separate instructions.

OMB No. 1545-0047

2012

Open to Public
Inspection

Name of the organization

Community Memorial Hospital of Menomonee
Falls Inc

Employer identification number

39-0987025

Part I

Reason for Public Charity Status (All organizations must complete this part.) See instructions.

The organization is not a private foundation because it is: (For lines 1 through 11, check only one box.)

A church, convention of churches, or association of churches described in section 170(b)(1)(A)(i).

A school described in section 170(b)(1)(A)(ii). (Attach Schedule E.)

A hospital or a cooperative hospital service organization described in section 170(b)(1)(A)(iii).

A medical research organization operated in conjunction with a hospital described in section 170(b)(1)(A)(iii). Enter the hospital's name, city, and state:

An organization operated for the benefit of a college or university owned or operated by a governmental unit described in

section 170(b)(1)(A)(iv). (Complete Part II.)

A federal, state, or local government or governmental unit described in section 170(b)(1)(A)(v).

An organization that normally receives a substantial part of its support from a governmental unit or from the general public described in section 170(b)(1)(A)(vi). (Complete Part II.)

A community trust described in section 170(b)(1)(A)(vi). (Complete Part II.)

An organization that normally receives: (1) more than 331/3% of its support from contributions, membership fees, and gross

receipts from activities related to its exempt functions—subject to certain exceptions, and (2) no more than 331/3% of

its support from gross investment income and unrelated business taxable income (less section 511 tax) from businesses

acquired by the organization after June 30, 1975. See section 509(a)(2). (Complete Part III.)

An organization organized and operated exclusively to test for public safety. See section 509(a)(4).

An organization organized and operated exclusively for the benefit of, to perform the functions of, or to carry out the purposes of one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2). See section 509(a)(3). Check the box that describes the type of supporting organization and complete lines 11e through 11h.

Type I

Type II

Type III - Functionally integrated

Type III - Non-functionally integrated

By checking this box, I certify that the organization is not controlled directly or indirectly by one or more disqualified persons other than foundation managers and other than one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2).

If the organization received a written determination from the IRS that it is a Type I, Type II, or Type III supporting organization, check this box ..................................................

Since August 17, 2006, has the organization accepted any gift or contribution from any of the
following persons?

(i) A person who directly or indirectly controls, either alone or together with persons described in (ii)

Yes

and (iii) below, the governing body of the supported organization? ................

11g(i)

(ii) A family member of a person described in (i) above? ......................

11g(ii)

(iii) A 35% controlled entity of a person described in (i) or (ii) above? ................

11g(iii)

Provide the following information about the supported organization(s).

(i) Name of supported organization	(ii) EIN	(iv) Is the organization in col. (i) listed in your governing document?		(v) Did you notify the organization in col. (i) of your support?		(vi) Is the organization in col. (i) organized in the U.S.?		(vii) Amount of monetary support
(i) Name of supported organization	(ii) EIN	Yes	No	Yes	No	Yes	No	(vii) Amount of monetary support


Total

For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990EZ.

Cat. No. 11285F

Schedule A (Form 990 or 990-EZ) 2012

Page 2

Part II

Support Schedule for Organizations Described in Sections 170(b)(1)(A)(iv) and 170(b)(1)(A)(vi)
(Complete only if you checked the box on line 5, 7, or 8 of Part I or if the organization failed to qualify under Part III. If the organization fails to qualify under the tests listed below, please complete Part III.)

Section A. Public Support

Calendar year (or fiscal year beginning in)		(a) 2008	(b) 2009	(c) 2010	(d) 2011	(e) 2012	(f) Total
1	Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") ....
2	Tax revenues levied for the organization's benefit and either paid to or expended on its behalf.......
3	The value of services or facilities furnished by a governmental unit to the organization without charge..
4	Total. Add lines 1 through 3
5	The portion of total contributions by each person (other than a governmental unit or publicly supported organization) included on line 1 that exceeds 2% of the amount shown on line 11, column (f)..
6	Public support. Subtract line 5 from line 4.

Section B. Total Support

Calendar year (or fiscal year beginning in)		(a) 2008	(b) 2009	(c) 2010	(d) 2011	(e) 2012	(f) Total
7	Amounts from line 4..
8	Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources...
9	Net income from unrelated business activities, whether or not the business is regularly carried on..
10	Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)..
11	Total support (Add lines 7 through 10).

Gross receipts from related activities, etc. (see instructions) ..................

First five years. If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization, check this box and stop here........................................ right arrow

Section C. Computation of Public Support Percentage

Public support percentage for 2012 (line 6, column (f) divided by line 11, column (f)) .........

Public support percentage for 2011 Schedule A, Part II, line 14 ...............

16a

33 1/3% support test—2012. If the organization did not check the box on line 13, and line 14 is 33 1/3% or more, check this box
and stop here. The organization qualifies as a publicly supported organization ....................... right arrow

33 1/3% support test—2011. If the organization did not check a box on line 13 or 16a, and line 15 is 33 1/3% or more, check this
box and stop here. The organization qualifies as a publicly supported organization ..................... right arrow

17a

10%-facts-and-circumstances test—2012. If the organization did not check a box on line 13, 16a, or 16b, and line 14
is 10% or more, and if the organization meets the "facts-and-circumstances" test, check this box and stop here. Explain
in Part IV how the organization meets the "facts-and-circumstances" test. The organization qualifies as a publicly supported
organization ..................................................... right arrow

10%-facts-and-circumstances test—2011. If the organization did not check a box on line 13, 16a, 16b, or 17a, and line
15 is 10% or more, and if the organization meets the "facts-and-circumstances" test, check this box and stop here.
Explain in Part IV how the organization meets the "facts-and-circumstances" test. The organization qualifies as a publicly
supported organization ................................................ right arrow

Private foundation. If the organization did not check a box on line 13, 16a, 16b, 17a, or 17b, check this box and see
instructions ..................................................... right arrow

Schedule A (Form 990 or 990-EZ) 2012

Page 3

Part III

Support Schedule for Organizations Described in Section 509(a)(2)
(Complete only if you checked the box on line 9 of Part I or if the organization failed to qualify under Part II. If the organization fails to qualify under the tests listed below, please complete Part II.)

Section A. Public Support

Calendar year (or fiscal year beginning in)		(a) 2008	(b) 2009	(c) 2010	(d) 2011	(e) 2012	(f) Total
1	Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") .
2	Gross receipts from admissions, merchandise sold or services performed, or facilities furnished in any activity that is related to the organization's tax-exempt purpose......
3	Gross receipts from activities that are not an unrelated trade or business under section 513..
4	Tax revenues levied for the organization's benefit and either paid to or expended on its behalf...
5	The value of services or facilities furnished by a governmental unit to the organization without charge..
6	Total. Add lines 1 through 5.
7a	Amounts included on lines 1, 2, and 3 received from disqualified persons...
b	Amounts included on lines 2 and 3 received from other than disqualified persons that exceed the greater of $5,000 or 1% of the amount on line 13 for the year.
c	Add lines 7a and 7b..
8	Public support (Subtract line 7c from line 6.)

Section B. Total Support

Calendar year (or fiscal year beginning in)		(a) 2008	(b) 2009	(c) 2010	(d) 2011	(e) 2012	(f) Total
9	Amounts from line 6...
10a	Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
b	Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
c	Add lines 10a and 10b.
11	Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on.
12	Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.) ..
13	Total support. (Add lines 9, 10c, 11, and 12.)..

First five years. If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization,
check this box and stop here............................................. right arrow

Section C. Computation of Public Support Percentage

Public support percentage for 2012 (line 8, column (f) divided by line 13, column (f)) .........

Public support percentage from 2011 Schedule A, Part III, line 15 ...............

Section D. Computation of Investment Income Percentage

Investment income percentage for 2012 (line 10c, column (f) divided by line 13, column (f)) ......

Investment income percentage from 2011 Schedule A, Part III, line 17 .............

19a

33 1/3% support tests—2012. If the organization did not check the box on line 14, and line 15 is more than 33 1/3%, and line 17 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization ........ right arrow

33 1/3% support tests—2011. If the organization did not check a box on line 14 or line 19a, and line 16 is more than 33 1/3% and line 18 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization ..... right arrow

Private foundation. If the organization did not check a box on line 14, 19a, or 19b, check this box and see instructions ..... right arrow

Schedule A (Form 990 or 990-EZ) 2012

Page 4

Part IV

Supplemental Information. Complete this part to provide the explanations required by Part II, line 10; Part II, line 17a or 17b; and Part III, line 12. Also complete this part for any additional information. (See instructions).

Facts And Circumstances Test

Explanation

Schedule A (Form 990 or 990-EZ) 2012

Additional Data

Software ID:	12000229
Software Version:	2012v2.0

- TIN:

SCHEDULE D
(Form 990)

Department of the Treasury
Internal Revenue Service

Supplemental Financial Statements

Complete if the organization answered "Yes," to Form 990,
Part IV, line 6, 7, 8, 9, 10, 11a, 11b, 11c, 11d, 11e, 11f, 12a, or 12b
SchDMd Bullet

Attach to Form 990. SchDMd Bullet

See separate instructions.

OMB No. 1545-0047

2012

Open to Public Inspection

Name of the organization

Community Memorial Hospital of Menomonee
Falls Inc

Employer identification number

39-0987025

Part I

Organizations Maintaining Donor Advised Funds or Other Similar Funds or Accounts. Complete if the organization answered "Yes" to Form 990, Part IV, line 6.

		(a) Donor advised funds	(b) Funds and other accounts
1	Total number at end of year .........
2	Aggregate contributions to (during year) ...
3	Aggregate grants from (during year) .....
4	Aggregate value at end of year ........

Did the organization inform all donors and donor advisors in writing that the assets held in donor advised
funds are the organization's property, subject to the organization's exclusive legal control? ............

Yes No

Did the organization inform all grantees, donors, and donor advisors in writing that grant funds can be
used only for charitable purposes and not for the benefit of the donor or donor advisor, or for any other purpose conferring impermissible private benefit? ...................................

Yes No

Part II

Conservation Easements. Complete if the organization answered "Yes" to Form 990, Part IV, line 7.

Purpose(s) of conservation easements held by the organization (check all that apply).

Preservation of land for public use (e.g., recreation or education) Preservation of an historically important land area

Protection of natural habitat Preservation of a certified historic structure

Preservation of open space

Complete lines 2a through 2d if the organization held a qualified conservation contribution in the form of a conservation easement on the last day of the tax year.


a	Total number of conservation easements .......................	2a
b	Total acreage restricted by conservation easements ..................	2b
c	Number of conservation easements on a certified historic structure included in (a) .....	2c
d	Number of conservation easements included in (c) acquired after 8/17/06, and not on a historic structure listed in the National Register ....................	2d

Number of conservation easements modified, transferred, released, extinguished, or terminated by the organization during
the tax year SchDMd Bullet

Number of states where property subject to conservation easement is located SchDMd Bullet

Does the organization have a written policy regarding the periodic monitoring, inspection, handling of violations, and
enforcement of the conservation easements it holds? .............................

Yes No

Staff and volunteer hours devoted to monitoring, inspecting, and enforcing conservation easements during the year
SchDMd Bullet

Amount of expenses incurred in monitoring, inspecting, and enforcing conservation easements during the year
SchDMd Bullet

Does each conservation easement reported on line 2(d) above satisfy the requirements of section 170(h)(4)(B)(i) and section 170(h)(4)(B)(ii)? .......................................

Yes No

In Part XIII, describe how the organization reports conservation easements in its revenue and expense statement, and
balance sheet, and include, if applicable, the text of the footnote to the organization’s financial statements that describes
the organization’s accounting for conservation easements.

Part III

Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets.
Complete if the organization answered "Yes" to Form 990, Part IV, line 8.

If the organization elected, as permitted under SFAS 116 (ASC 958), not to report in its revenue statement and balance sheet works of art, historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service, provide, in Part XIII, the text of the footnote to its financial statements that describes these items.

If the organization elected, as permitted under SFAS 116 (ASC 958), to report in its revenue statement and balance sheet works of art, historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service, provide the following amounts relating to these items:

(i)

Revenues included in Form 990, Part VIII, line 1 ........................ SchDMd Bullet

(ii)

Assets included in Form 990, Part X .............................. SchDMd Bullet

If the organization received or held works of art, historical treasures, or other similar assets for financial gain, provide the
following amounts required to be reported under SFAS 116 (ASC 958) relating to these items:

Revenues included in Form 990, Part VIII, line 1 .......................... SchDMd Bullet

Assets included in Form 990, Part X ............................... SchDMd Bullet

For Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 52283D

Schedule D (Form 990) 2012

Page 2

Part III

Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets (continued)

Using the organization’s acquisition, accession, and other records, check any of the following that are a significant use of its collection items (check all that apply):

Public exhibition

Loan or exchange programs

Scholarly research

Other

Preservation for future generations

Provide a description of the organization’s collections and explain how they further the organization’s exempt purpose in
Part XIII.

During the year, did the organization solicit or receive donations of art, historical treasures or other similar
assets to be sold to raise funds rather than to be maintained as part of the organization’s collection?........

Yes No

Part IV

Escrow and Custodial Arrangements. Complete if the organization answered "Yes" to Form 990,
Part IV, line 9, or reported an amount on Form 990, Part X, line 21.

Is the organization an agent, trustee, custodian or other intermediary for contributions or other assets not
included on Form 990, Part X? ....................................

Yes No

If "Yes," explain the arrangement in Part XIII and complete the following table:


c	Beginning balance .................................	1c
d	Additions during the year ..............................	1d
e	Distributions during the year .............................	1e
f	Ending balance ...................................	1f

Did the organization include an amount on Form 990, Part X, line 21? .....................

Yes No

If “Yes,” explain the arrangement in Part XIII. Check here if the explanation has been provided in Part XIII ........

Part V

Endowment Funds. Complete if the organization answered "Yes" to Form 990, Part IV, line 10.

		(a)Current year	(b)Prior year	b (c)Two years back	(d)Three years back	(e)Four years back
1a	Beginning of year balance ....	4,688,829	4,674,956	4,094,065	3,166,213	3,670,185
b	Contributions ........	379,734	265,167	1,398,548	904,863	484,004
c	Net investment earnings, gains, and losses	440,545	80,003	623,704	384,524	-466,270
d	Grants or scholarships .....	397,266	321,940	374,633	304,571	353,150
e	Other expenditures for facilities and programs ........	6,595	9,357	1,066,388	56,965	168,686
f	Administrative expenses ....			340	-1	-130
g	End of year balance ......	5,105,247	4,688,829	4,674,956	4,094,065	3,166,213

Provide the estimated percentage of the current year end balance (line 1g, column (a)) held as:

Board designated or quasi-endowment SchDMd Bullet

100.000 %

Permanent endowment SchDMd Bullet

Temporarily restricted endowment SchDMd Bullet

The percentages in lines 2a, 2b, and 2c should equal 100%.

Are there endowment funds not in the possession of the organization that are held and administered for the
organization by:

Yes

(i) unrelated organizations ........................

3a(i)

(ii) related organizations ........................

3a(ii)

Yes

If "Yes" to 3a(ii), are the related organizations listed as required on Schedule R? .........

Yes

Describe in Part XIII the intended uses of the organization's endowment funds.

Part VI

Land, Buildings, and Equipment. See Form 990, Part X, line 10.

Description of property		(b)Cost or other basis (other)	(c) Accumulated depreciation	(d) Book value
1a	Land .................	80,711		80,711
b	Buildings ................	102,365,113	44,055,728	58,309,385
c	Leasehold improvements ............	1,987,540	1,686,077	301,463
d	Equipment ................	34,208,216	24,067,118	10,141,098
e	Other .................	42,397,026	25,929,002	16,468,024
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).).......				85,300,681

Schedule D (Form 990) 2012

Page 3

Part VII

InvestmentsOther Securities. See Form 990, Part X, line 12.

(a) Description of security or category (including name of security)		(b)Book value	(c) Method of valuation: Cost or end-of-year market value
(1)Financial derivatives
(2)Closely-held equity interests
Other








Total. (Column (b) must equal Form 990, Part X, col. (B) line 12.)

Part VIII

InvestmentsProgram Related. See Form 990, Part X, line 13.

(a) Description of investment type		(b) Book value	(c) Method of valuation: Cost or end-of-year market value









Total. (Column (b) must equal Form 990, Part X, col.(B) line 13.)

Part IX

Other Assets. See Form 990, Part X, line 15.

(a) Description				(b) Book value
(1) Swap Collateral				17,261
(2) Senior Management Deferred Compensation				655,183
(3) Rounding				1
(4) Froedtert Health Executive 457f				350,174
(5) Executive Deferred Compensation				90,104
(6) Due from Affiliates				3,559,210
(7) Collateral held for securties loaned				37,466,283


Total. (Column (b) must equal Form 990, Part X, col.(B) line 15.)...........				54,477,096

Part X

Other Liabilities. See Form 990, Part X, line 25.

1.(a) Description of liability		(b) Book value
Federal income taxes
Swap mark to market		4,558,617
Pension Liability		26,898,088
Payable under securities lending agreeme		37,466,283
Estimated Settlements Due to 3rd Parties		175,957
Due to Affiliates		582,561




Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)		69,681,506
2. Fin 48 (ASC 740) Footnote. In Part XIII, provide the text of the footnote to the organization's financial statements that reports the organization's liability for uncertain tax positions under FIN 48 (ASC 740). Check here if the text of the footnote has been provided in Part XIII .....................................................

Schedule D (Form 990) 2012

Page 4

Part XI Reconciliation of Revenue per Audited Financial Statements With Revenue per Return
1	Total revenue, gains, and other support per audited financial statements .......		1
2	Amounts included on line 1 but not on Form 990, Part VIII, line 12:
a	Net unrealized gains on investments ..........	2a
b	Donated services and use of facilities .........	2b
c	Recoveries of prior year grants ...........	2c
d	Other (Describe in Part XIII.) ............	2d
e	Add lines 2a through 2d .....................		2e
3	Subtract line 2e from line 1.....................		3
4	Amounts included on Form 990, Part VIII, line 12, but not on line 1:
a	Investment expenses not included on Form 990, Part VIII, line 7b .	4a
b	Other (Describe in Part XIII.) ...........	4b
c	Add lines 4a and 4b.......................		4c
5	Total revenue. Add lines 3 and 4c. (This must equal Form 990, Part I, line 12.) ......		5

Part XII Reconciliation of Expenses per Audited Financial Statements With Expenses per Return
1	Total expenses and losses per audited financial statements ...........		1
2	Amounts included on line 1 but not on Form 990, Part IX, line 25:
a	Donated services and use of facilities ..........	2a
b	Prior year adjustments ..............	2b
c	Other losses ................	2c
d	Other (Describe in Part XIII.) ............	2d
e	Add lines 2a through 2d......................		2e
3	Subtract line 2e from line 1.....................		3
4	Amounts included on Form 990, Part IX, line 25, but not on line 1:
a	Investment expenses not included on Form 990, Part VIII, line 7b ..	4a
b	Other (Describe in Part XIII.) ............	4b
c	Add lines 4a and 4b.......................		4c
5	Total expenses. Add lines 3 and 4c. (This must equal Form 990, Part I, line 18.) ......		5

Part XIII

Supplemental Information

Complete this part to provide the descriptions required for Part II, lines 3, 5, and 9; Part III, lines 1a and 4; Part lV, lines 1b and 2b;
Part V, line 4; Part X, line 2; Part XI, lines 2d and 4b; and Part XII, lines 2d and 4b. Also complete this part to provide any additional information.

Identifier	Return Reference	Explanation
Part X	Part X : FIN48 Footnote	Froedtert Health, Inc. (FH) applies ASC No. 740, Income Taxes, which clarifies the accounting for uncertainty in income taxes recognized in a company's financial statements. ASC No. 740 prescribes a more-likely-than-not recognition threshold and measurement attribute for the financial statement recognition and measurement of a tax position taken or expected to be taken. Under ASC No. 740, tax positions are evaluated for recognition, derecognition, and measurement using consistent criteria and provide more information about the uncertainty in income tax assets and liabilities. As of June 30, 2013 and 2012, FH does not have an asset or liability recorded for unrecognized tax positions.
Part V, Line 4	Part V, Line 4: Intended uses of the endowment fund.	The funds are held by Community Memorial Foundation of Menomonee Falls (CMF), a related organization. The board designated endowment was created to support long range financial needs of Community Memorial Hospital of Menomonee Falls, Inc and its programs.

Schedule D (Form 990) 2012

Additional Data

Software ID:	12000229
Software Version:	2012v2.0

- TIN:

SCHEDULE G (Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service

Supplemental Information Regarding
Fundraising or Gaming Activities

Complete if the organization answered "Yes" to Form 990, Part IV, lines 17, 18, or 19, or if the organization entered more than $15,000 on Form 990-EZ, line 6a. Form 990-EZ filers are not required to complete this part. right arrow

Attach to Form 990 or Form 990-EZ. right arrow

See separate instructions.

OMB No. 1545-0047

2012

Open to Public Inspection

Name of the organization
Community Memorial Hospital of Menomonee
Falls Inc

Employer identification number

39-0987025

Part I

Fundraising Activities. Complete if the organization answered "Yes" to Form 990, Part IV, line 17.

Indicate whether the organization raised funds through any of the following activities. Check all that apply.

a	Mail solicitations	e	Solicitation of non-government grants
b	Internet and email solicitations	f	Solicitation of government grants
c	Phone solicitations	g	Special fundraising events
d	In-person solicitations

Did the organization have a written or oral agreement with any individual (including officers, directors, trustees

or key employees listed in Form 990, Part VII) or entity in connection with professional fundraising services?

Yes

If “Yes,” list the ten highest paid individuals or entities (fundraisers) pursuant to agreements under which the fundraiser is
to be compensated at least $5,000 by the organization.

(i) Name and address of individual or entity (fundraiser)	(iii) Did fundraiser have custody or control of contributions?
	Yes	No










Total .................

List all states in which the organization is registered or licensed to solicit funds or has been notified it is exempt from registration or licensing.

For Paperwork Reduction Act Notice, see the Instructions for Form 990or 990-EZ.

Cat. No. 50083H

Schedule G (Form 990 or 990-EZ) 2012

Page 2

Part II

Fundraising Events. Complete if the organization answered "Yes" to Form 990, Part IV, line 18, or reported more than $15,000 of fundraising event contributions and gross income on Form 990-EZ, lines 1 and 6b. List events with gross receipts greater than $5,000.

		(a) Event #1 Cheery Cherry Fall Fair (event type)	(b) Event #2 Otis Spunkmeyer Cookies (event type)	(c) Other events 2 (total number)	(d) Total events (add col. (a) through col. (c))
1	Gross receipts . . .	40,517	35,045	19,706	95,268
2	Less: Contributions . .
3	Gross income (line 1 minus line 2) . . .	40,517	35,045	19,706	95,268
4	Cash prizes . . .
5	Noncash prizes . .
6	Rent/facility costs . .	4,855			4,855
7	Food and beverages .	2,892	13,541	5,026	21,459
8	Entertainment . . .	450			450
9	Other direct expenses .	10,154		9,725	19,879
10	Direct expense summary. Add lines 4 through 9 in column (d) ...........				46,643
11	Net income summary. Combine line 3, column (d), and line 10. ..........				48,625

Part III

Gaming. Complete if the organization answered "Yes" to Form 990, Part IV, line 19, or reported more than $15,000 on Form 990-EZ, line 6a.

(a) Bingo

(b) Pull tabs/Instant
bingo/progressive bingo

(c) Other gaming

(d) Total gaming (add col.(a) through col.(c))

Gross revenue . . . .

Cash prizes . . . .

Non-cash prizes . . .

Rent/facility costs . . .

Other direct expenses . .

Volunteer labor . . .

	Yes
	No

	Yes
	No

	Yes
	No

Direct expense summary. Add lines 2 through 5 in column (d) ........... right arrow

Net gaming income summary. Combine lines 1 and 7 in column (d) .......... right arrow

Enter the state(s) in which the organization operates gaming activities:

Is the organization licensed to operate gaming activities in each of these states? ............

YesNo

If "No," explain:

10a

Were any of the organization's gaming licenses revoked, suspended or terminated during the tax year? .....

YesNo

If "Yes," explain:

Schedule G (Form 990 or 990-EZ) 2012

Page 3

Does the organization operate gaming activities with nonmembers? .................

YesNo

Is the organization a grantor, beneficiary or trustee of a trust or a member of a partnership or other entity

formed to administer charitable gaming? ..........................

YesNo

Indicate the percentage of gaming activity operated in:

The organization's facility ......................

13a

An outside facility ........................

13b

Enter the name and address of the person who prepares the organization's gaming/special events books and records:

Name

Address

15a

Does the organization have a contract with a third party from whom the organization receives gaming

revenue? ......................................

YesNo

If "Yes," enter the amount of gaming revenue received by the organization right arrow

$ and the

amount of gaming revenue retained by the third party right arrow

$ .

If "Yes," enter name and address of the third party:

Name

Address

Gaming manager information:

Name

Gaming manager compensation right arrow

Description of services provided right arrow

Director/officer Employee Independent contractor

Mandatory distributions:

Is the organization required under state law to make charitable distributions from the gaming proceeds to

retain the state gaming license? ............................

YesNo

Enter the amount of distributions required under state law distributed to other exempt organizations or spent

in the organization's own exempt activities during the tax year right arrow

Part IV

Supplemental Information. Complete this part to provide the explanations required by Part I, line 2b, columns (iii) and (v), and Part III, lines 9, 9b, 10b, 15b, 15c, 16, and 17b, as applicable. Also complete this part to provide any additional information (see instructions).

Identifier	Return Reference	Explanation

Schedule G (Form 990 or 990-EZ) 2012

Additional Data

Software ID:	12000229
Software Version:	2012v2.0

- TIN:

SCHEDULE H (Form 990)

Department of the Treasury
Internal Revenue Service

Hospitals

Complete if the organization answered "Yes" to Form 990, Part IV, question 20.
MediumBullet

Attach to Form 990. MediumBullet

See separate instructions.

OMB No. 1545-0047

2012

Open to Public Inspection

Name of the organization

Community Memorial Hospital of Menomonee
Falls Inc

Employer identification number

39-0987025

Part I

Financial Assistance and Certain Other Community Benefits at Cost

Yes

Did the organization have a financial assistance policy during the tax year? If "No," skip to question 6a ...

Yes

If "Yes," was it a written policy? .......................

Yes

If the organization had multiple hospital facilities, indicate which of the following best describes application of the financial assistance policy to its various hospital facilities during the tax year.

Applied uniformly to all hospital facilities Applied uniformly to most hospital facilities Generally tailored to individual hospital facilities

Answer the following based on the financial assistance eligibility criteria that applied to the largest number of the organization's patients during the tax year.

Did the organization use Federal Poverty Guidelines (FPG) as a factor in determining eligibility for providing free care?

If "Yes," indicate which of the following was the FPG family income limit for eligibility for free care:

Yes

100% 150% 200% Other %

Did the organization use FPG as a factor in determining eligibility for providing discounted care? If "Yes," indicate

which of the following was the family income limit for eligibility for discounted care: .........

Yes

200% 250% 300% 350% 400% Other %

If the organization used factors other than FPG in determining eligibility, describe in Part VI the income based criteria for determining eligibility for free or discounted care. Include in the description whether the organization used an asset test or other threshold, regardless of income, as a factor in determining eligibility for free or discounted care.

Did the organization's financial assistance policy that applied to the largest number of its patients during the tax year provide for free or discounted care to the "medically indigent"? ..............

Yes

Did the organization budget amounts for free or discounted care provided under its financial assistance policy during the tax year? ............................

Yes

If "Yes," did the organization's financial assistance expenses exceed the budgeted amount? ......

Yes

If "Yes" to line 5b, as a result of budget considerations, was the organization unable to provide free or discountedcare to a patient who was eligibile for free or discounted care? ..............

Did the organization prepare a community benefit report during the tax year? ..........

Yes

If "Yes," did the organization make it available to the public? ..............

Yes

Complete the following table using the worksheets provided in the Schedule H instructions. Do not submit these worksheets with the Schedule H.

Financial Assistance and Certain Other Community Benefits at Cost

Financial Assistance and Means-Tested Government Programs		(a) Number of activities or programs (optional)	(b) Persons served (optional)	(c) Total community benefit expense	(d) Direct offsetting revenue	(e) Net community benefit expense	(f) Percent of total expense
a	Financial Assistance at cost (from Worksheet 1) ..			1,360,676		1,360,676	0.770 %
b	Medicaid (from Worksheet 3, column a) ....			13,775,472	6,009,737	7,765,735	4.380 %
c	Costs of other means-tested government programs (from Worksheet 3, column b) .
d	Total Financial Assistance and Means-Tested Government Programs .			15,136,148	6,009,737	9,126,411	5.150 %
Other Benefits		46	9,724	1,457,740	15,084	1,442,656	0.810 %
e	Community health improvement services and community benefit operations (from Worksheet 4) ..	46	9,724	1,457,740	15,084	1,442,656	0.810 %
f	Health professions education (from Worksheet 5) ..	4	535	598,621		598,621	0.340 %
g	Subsidized health services (from Worksheet 6) ..
h	Research (from Worksheet 7)
i	Cash and in-kind contributions for community benefit (from Worksheet 8)	15	2,131	284,068		284,068	0.160 %
j	Total. Other Benefits ..	65	12,390	2,340,429	15,084	2,325,345	1.310 %
k	Total. Add lines 7d and 7j .	65	12,390	17,476,577	6,024,821	11,451,756	6.460 %

For Paperwork Reduction Act Notice, see the Instructions for Form 990. Cat. No. 50192T Schedule H (Form 990) 2012

Schedule H (Form 990) 2012

Page

Part II

Community Building Activities Complete this table if the organization conducted any community building activities during the tax year, and describe in Part VI how its community building activities promoted the health of the communities it serves.

		(a) Number of activities or programs (optional)	(b) Persons served (optional)	(c) Total community building expense	(e) Net community building expense	(f) Percent of total expense
1	Physical improvements and housing
2	Economic development	1		3,076	3,076
3	Community support	2		10,587	10,587	0.010 %
4	Environmental improvements
5	Leadership development and training for community members
6	Coalition building	2	1,440	30,877	30,877	0.020 %
7	Community health improvement advocacy	1		11,546	11,546	0.010 %
8	Workforce development	4	178	133,932	133,932	0.080 %
9	Other
10	Total	10	1,618	190,018	190,018	0.120 %

Part III

Bad Debt, Medicare, & Collection Practices

Section A. Bad Debt Expense

Yes

Did the organization report bad debt expense in accordance with Heathcare Financial Management Association Statement No. 15? ..........................

Enter the amount of the organization's bad debt expense. Explain in Part VI the methodology used by the organization to estimate this amount. ......

8,577,230

Enter the estimated amount of the organization's bad debt expense attributable to patients eligible under the organization's financial assistance policy. Explain in Part VI the methodology used by the organization to estimate this amount and the rationale, if any, for including this portion of bad debt as community benefit. ......

Provide in Part VI the text of the footnote to the organization’s financial statements that describes bad debt expense or the page number on which this footnote is contained in the attached financial statements.

Section B. Medicare

Enter total revenue received from Medicare (including DSH and IME).....

66,262,771

Enter Medicare allowable costs of care relating to payments on line 5.....

80,093,808

Subtract line 6 from line 5. This is the surplus (or shortfall)........

-13,831,037

Describe in Part VI the extent to which any shortfall reported in line 7 should be treated as community benefit.Also describe in Part VI the costing methodology or source used to determine the amount reported on line 6.Check the box that describes the method used:

Cost accounting system Cost to charge ratio Other

Section C. Collection Practices

Did the organization have a written debt collection policy during the tax year? ..........

Yes

If "Yes," did the organization’s collection policy that applied to the largest number of its patients during the tax year contain provisions on the collection practices to be followed for patients who are known to qualify for financial assistance? Describe in Part VI.......................

Yes

Part IV

Management Companies and Joint Ventures(owned 10% or more by officers, directors, trustees, key employees, and physicians—see instructions)

(a) Name of entity	(b) Description of primary activity of entity	(c) Organization's profit % or stock ownership %	(d) Officers, directors, trustees, or key employees' profit % or stock ownership %	(e) Physicians' profit % or stock ownership %
1
2
3
4
5
6
7
8
9
10
11
12
13

Schedule H (Form 990) 2012

Page

Part VFacility Information

Section A. Hospital Facilities (list in order of size from largest to smallest—see instructions) How many hospital facilities did the organization operate during the tax year?1 Name, address, and primary website address
1	Community Memorial Hospital W180 N8085 Town Hall Road Menomonee Falls,WI53051	X	X	X

Schedule H (Form 990) 2012

Page

Part VFacility Information (continued)

Section B. Facility Policies and Practices

(Complete a separate Section B for each of the hospital facilities or facility reporting groups listed in Part V, Section A)


Name of hospital facility or facility reporting group

For single facility filers only: line Number of Hospital Facility (from Schedule H, Part V, Section A)

Yes

Community Health Needs Assessment (Lines 1 through 8c are optional for tax years begining on or before March 23, 2012)

During the tax year or either of the two immediately preceding tax years, did the hospital facility conduct a community health needs assessment (CHNA)? If "No," skip to line 9....................

Yes

If “Yes,” indicate what the CHNA report describes (check all that apply):

A definition of the community served by the hospital facility

Demographics of the community

Existing health care facilities and resources within the community that are available to respond to the health needs of the community

How data was obtained

The health needs of the community

Primary and chronic disease needs and other health issues of uninsured persons, low-income persons, and minority groups

The process for identifying and prioritizing community health needs and services to meet the community health needs

The process for consulting with persons representing the community’s interests

Information gaps that limit the hospital facility’s ability to assess the community’s health needs

Other (describe in Part VI)

Indicate the tax year the hospital facility last conducted a CHNA: 20 12

In conducting its most recent CHNA, did the hospital facility take into account input from representatives of the community served by the hospital facility, including those with special knowledge of or expertise in public health? If “Yes,” describe in Part VI how the hospital facility took into account input from persons who represent the community, and identify the persons the hospital facility consulted ....................

Yes

Was the hospital facility’s CHNA conducted with one or more other hospital facilities? If “Yes,” list the other hospital facilities in Part VI................................

Yes

Did the hospital facility make its CHNA report widely available to the public? .............

Yes

If “Yes,” indicate how the CHNA report was made widely available (check all that apply):

Hospital facility’s website

Available upon request from the hospital facility

Other (describe in Part VI)

If the hospital facility addressed needs identified in its most recently conducted CHNA, indicate how (check all that apply to date):

Adoption of an implementation strategy that addresses each of the community health needs identified through the CHNA

Execution of the implementation strategy

Participation in the development of a community-wide plan

Participation in the execution of a community-wide plan

Inclusion of a community benefit section in operational plans

Adoption of a budget for provision of services that address the needs identified in the CHNA

Prioritization of health needs in its community

Prioritization of services that the hospital facility will undertake to meet health needs in its community

Other (describe in Part VI)

Did the hospital facility address all of the needs identified in its most recently conducted CHNA? If “No,” explain in Part VI which needs it has not addressed and the reasons why it has not addressed such needs ........

Did the organization incur an excise tax under section 4959 for the hospital facility's failure to conduct a CHNA as required by section 501(r)(3)? ...........................

If "Yes" to line 8a, did the organization file Form 4720 to report the section 4959 excise tax? ......

If "Yes" to line 8b, what is the total amount of section 4959 excise tax the organization reported on Form 4720 for all of its hospital facilities? $

Schedule H (Form 990) 2012

Page

Part VFacility Information (continued)

Financial Assistance Policy			Yes	No
9	Did the hospital facility have in place during the tax year a written financial assistance policy that:
	Explained eligibility criteria for financial assistance, and whether such assistance includes free or discounted care?	9	Yes
10	Used federal poverty guidelines (FPG) to determine eligibility for providing free care?...........	10	Yes
	If "Yes," indicate the FPG family income limit for eligibility for free care: 200.0000% If "No," explain in Part VI the criteria the hospital facility used.
11	Used FPG to determine eligibility for providing discounted care?.................	11	Yes
	If “Yes,” indicate the FPG family income limit for eligibility for discounted care: 400.0000% If "No," explain in Part VI the criteria the hospital facility used.
12	Explained the basis for calculating amounts charged to patients?.................	12	Yes
	If “Yes,” indicate the factors used in determining such amounts (check all that apply):
a	Income level
b	Asset level
c	Medical indigency
d	Insurance status
e	Uninsured discount
f	Medicaid/Medicare
g	State regulation
h	Other (describe in Part VI)
13	Explained the method for applying for financial assistance?...................	13	Yes
14	Included measures to publicize the policy within the community served by the hospital facility?.......	14	Yes
	If “Yes,” indicate how the hospital facility publicized the policy (check all that apply):
a	The policy was posted on the hospital facility’s website
b	The policy was attached to billing invoices
c	The policy was posted in the hospital facility’s emergency rooms or waiting rooms
d	The policy was posted in the hospital facility’s admissions offices
e	The policy was provided, in writing, to patients on admission to the hospital facility
f	The policy was available upon request
g	Other (describe in Part VI)
Billing and Collections
15	Did the hospital facility have in place during the tax year a separate billing and collections policy, or a written financial assistance policy (FAP) that explained actions the hospital facility may take upon non-payment?.......	15	Yes
16	Check all of the following actions against an individual that were permitted under the hospital facility's policies during the tax year before making reasonable efforts to determine the patient’s eligibility under the facility’s FAP:
a	Reporting to credit agency
b	Lawsuits
c	Liens on residences
d	Body attachments
e	Other similar actions (describe in Part VI)
17	Did the hospital facility or an authorized third party perform any of the following actions during the tax year before making reasonable efforts to determine the patient’s eligibility under the facility’s FAP?..........	17		No
	If “Yes,” check all actions in which the hospital facility or a third party engaged:
a	Reporting to credit agency
b	Lawsuits
c	Liens on residences
d	Body attachments
e	Other similar actions (describe in Part VI)

Schedule H (Form 990) 2012

Page

Part VFacility Information (continued)

Indicate which efforts the hospital facility made before initiating any of the actions listed in line 17 (check all that apply):

Notified individuals of the financial assistance policy on admission

Notified individuals of the financial assistance policy prior to discharge

Notified individuals of the financial assistance policy in communications with the patients regarding the patients’ bills

Documented its determination of whether patients were eligible for financial assistance under the hospital facility’s financial assistance policy

Other (describe in Part VI)

Policy Relating to Emergency Medical Care

Yes

Did the hospital facility have in place during the tax year a written policy relating to emergency medical care that requires the hospital facility to provide, without discrimination, care for emergency medical conditions to individuals regardless of their eligibility under the hospital facility’s financial assistance policy?..........

Yes

If “No,” indicate why:

The hospital facility did not provide care for any emergency medical conditions

The hospital facility’s policy was not in writing

The hospital facility limited who was eligible to receive care for emergency medical conditions (describe in Part VI)

Other (describe in Part VI)

Charges to Individuals Eligible for Assistance under the FAP (FAP-Eligible Individuals)

Indicate how the hospital facility determined, during the tax year, the maximum amounts that can be charged to FAP-eligible individuals for emergency or other medically necessary care.

The hospital facility used its lowest negotiated commercial insurance rate when calculating the maximum amounts that can be charged

The hospital facility used the average of its three lowest negotiated commercial insurance rates when calculating the maximum amounts that can be charged

The hospital facility used the Medicare rates when calculating the maximum amounts that can be charged

Other (describe in Part VI)

During the tax year, did the hospital facility charge any FAP-eligible individuals to whom the hospital facility provided emergency or other medically necessary services, more than the amounts generally billed to individuals who had insurance covering such care? ............................

If “Yes,” explain in Part VI.

During the tax year, did the hospital facility charge any FAP-eligible individuals an amount equal to the gross charge for any service provided to that individual? .........................

If “Yes,” explain in Part VI.

Schedule H (Form 990) 2012

Page

Part VFacility Information (continued)

Section C. Other Health Care Facilities That Are Not Licensed, Registered, or Similarly Recognized as a Hospital Facility (list in order of size, from largest to smallest) How many non-hospital health care facilities did the organization operate during the tax year?
Name and address		Type of Facility (describe)
1
2
3
4
5
6
7
8
9
10

Schedule H (Form 990) 2012

Page

Part VI

Supplemental Information

Complete this part to provide the following information.

1	Required descriptions. Provide the descriptions required for Part I, lines 3c, 6a, and 7; Part II; Part III, lines 4, 8, and 9b; Part V, Section A; and Part V, Section B, lines 1j, 3, 4, 5c, 6i, 7, 10, 11, 12h, 14g, 16e, 17e, 18e, 19c, 19d, 20d, 21, and 22.
2	Needs assessment. Describe how the organization assesses the health care needs of the communities it serves, in addition to any needs assessments reported in Part V, Section B.
3	Patient education of eligibility for assistance. Describe how the organization informs and educates patients and persons who may be billed for patient care about their eligibility for assistance under federal, state, or local government programs or under the organization’s financial assistance policy.
4	Community information. Describe the community the organization serves, taking into account the geographic area and demographic constituents it serves.
5	Promotion of community health. Provide any other information important to describing how the organization’s hospital facilities or other health care facilities further its exempt purpose by promoting the health of the community (e.g., open medical staff, community board, use of surplus funds, etc.).
6	Affiliated health care system. If the organization is part of an affiliated health care system, describe the respective roles of the organization and its affiliates in promoting the health of the communities served.
7	State filing of community benefit report. If applicable, identify all states with which the organization, or a related organization, files a community benefit report.
8	Facility reporting group(s). If applicable, for each hospital facility in a facility reporting group provide the descriptions required for Part V, Section B, lines 1j, 3, 4, 5c, 6i, 7, 10, 11, 12h, 14g, 16e, 17e, 18e, 19c, 19d, 20d, 21, and 22.

Identifier	ReturnReference	Explanation
	Part VI - Additional Information	Community Benefit Data is reported annually to the Wisconsin Hospital Association.
	Part V - Explanation of Number of Facility Type	Community Memorial Hospital is the only facility listed under this reporting of the IRS Form 990, Schedule H.
	Part VI - States Where Community Benefit Report Filed	WI
	Part VI - Affilated Health Care System Roles and Promotion	Affiliated Health SystemFroedtert & the Medical College of Wisconsin Community Memorial Hospital, founded in 1964 by the citizens of Menomonee Falls and surrounding communities, is a full-service hospital that specializes in cancer care, heart and vascular care, orthopaedics, womens health and advanced surgical procedures. Community Memorial Hospital is part of the Froedtert & the Medical College of Wisconsin health care network, which also includes Froedtert Memorial Lutheran Hospital, Milwaukee; St Josephs Community Hospital of West Bend; and more than 30 primary and specialty care health centers and clinics.For more information about Froedtert Health, visit www.froedterthealth.org.Promotion of Community HealthThe Community Outreach Steering Committee (COSC) which is a subcommittee of the hospitals Board of Directors actualizes the mission of Community Memorial Hospital (CMH) through community benefit activities that improve the quality of life and enhance wellness resources which meet identified comprehensive health needs of the communities served. The Community Outreach Steering Committee is appointed annually by the hospital president and is advisory to the CMH Board and Administration. Membership appointments are made each June with members serving one year terms. The COSC meets quarterly and is composed of hospital and board representatives plus community members representing the various constituencies of the total service area. Functions include:Provide a leadership role in advocating community wide responses to health care needs in the community.Facilitate and support community and health care partnerships.Envision, assess and guide new community benefit opportunities.Identify and describe unmet health needs.Promote universal access to health care.Determine allocation of the Community Outreach Services Fund which awards $50,000 annually towards area non-profits efforts to improve health disparities focused on Access to Care, Mental Health/AODA, Chronic Disease Management and Prevention and Wellness in the communities CMH serves.Community Memorial Hospital has an open Medical Staff with the exception of some departments having contracted exclusivity services. As a not-for-profit health system, Froedtert Health reinvests its surplus funds back into the community through programs to serve the poor and uninsured, teach future healthcare professionals, develop new medical therapies, manage chronic conditions like diabetes, health education and promotion initiatives, and participate in local partnerships aimed at reducing health disparities. In Fiscal year 2013, Froedtert Memorial Lutheran Hospital, Community Memorial Hospital of Menomonee Falls and St. Josephs Community Hospital of West Bend made significant investments in the health of their communities. Patients who couldnt pay for their medical care received more than $80.3 million in uncompensated services. Beyond providing care for the poor, we contributed $74.5 million to improve access to care, teach future healthcare professionals, develop new medical therapies and participate in local partnerships aimed at reducing health disparities. Addressing Needs Through Targeted Outreach:Community Memorial Hospital develops and executes community outreach programming and activities based on identified community health needs. Since 1990, CMH conducts needs assessments every three years in order to determine priorities and strategies in addressing community health disparities. Every needs assessment cycle, CMH Community Outreach staff along with the hospitals Community Outreach Steering Committee develops a community health improvement plan which is incorporated into the hospitals overall strategic plan to address the most critical needs in the communities we serve. The plan is reviewed annually by the Community Outreach Steering Committee. CMH Community Outreach staff, leaders and external community partners work collaboratively to develop key goals and strategies to address community health needs. Progress towards community outreach programs/activities and goals are reported quarterly through the Community Outreach Steering Committee and the Board of Directors. Based on the results from the 2012 Community Health Needs Assessment, programs and activities are focused around the following identified health needs: - Access to Primary and Specialty Care - AODA - Chronic Disease Management - Prevention and WellnessFor more information on specific community outreach efforts, please refer to the 2013 Community Benefit Report by going to www.froedterthealth.org/community-memorial-benefit-report.
	Part VI - Explanation Of How Organization Furthers Its Exempt Purpose	Community Memorial Hospital provides healthy community initiatives that support the community. These initiatives include but are not limited to the following:Drug Collection:As part of our commitment to improve the quality of life in our community, Community Memorial Hospital partnered with Waukesha County Drug Free Communities Coalition to host five drug collections since October 2009. At the collections, area residents dropped off over 4,000 pounds of prescription and over-the-counter medications. Close to 3,000 area households participated in the collections. This year alone it took over 35 staff close to 300 hours to make the collections possible. Flu Clinics: Community Memorial Hospital offers flu clinics for the public as part of its commitment to keep the community healthy. During the fall of FY13, 93 people were immunized at four locations with a community benefit value of over $4,000. Each of the clinics was staffed by hospital pharmacists who were certified by the state to give immunizations.Every 15 MinutesSpeeding, recklessness and drug or alcohol use are common risk factors among children and teens killed in motor vehicle and transport crashes, according to the Wisconsin Child Death Review Council. Changes in behavior can help prevent death and injury from vehicle crashes, one of the top five causes of preventable death in Wisconsin children.To drive home a powerful message about the consequences of drinking and driving and to help prevent death from drunk driving crashes, Community Memorial Hospital collaborates with the Germantown Police Department and Germantown High School in the Every 15 Minutes program. The program involves not only a mock crash but multiple scenarios that are videotaped by high school students and presented at a moving and emotional assembly at school the next day. The hospital has been part of the Every 15 Minutes program since 2010, as the receiving hospital for mock crash victims arriving by local EMS ambulance and Flight for Life. The Emergency Care Center provides staffing to treat the mock victims in a realistic way. Physicians, nurses, EMTs, technicians and other staff are involved. Hospital staff are also involved in the planning and communications. In a safe and caring way, the program confronts high school students with the real-life consequences of drunk driving and has been positively received by students and community. Athletic Trainer:When athletes at Menomonee Falls and Germantown High Schools prepare to compete, there is a Certified Athletic Trainer with them every step of the way. This service is provided by experienced athletic trainers from Community Memorial Hospital.The trainers work at the school each day, working evenings as well as Saturdays to provide training room, practice and event coverage. They prepare the athlete for their activities, which might include stretching, taping and treatment as needed. During FY13, 1000 students were served at the two high schools with a community benefit value of over $105,000. United Way Employee Giving Campaign :Community Memorial Hospital collaborates with United Way of Waukesha County to address community needs in the areas of meeting basic needs, developing self-reliance, strengthening communities, and community support. Community Memorial Hospital hosts an annual workplace giving campaign to support all local United Ways. Over 200 hours were spent coordinating the FY13 campaign. In addition to an employee campaign, Community Memorial Hospital matches donations up to $10,000. Community Health & Wellness Initiative Community Garden:Community Memorial Hospitals on-campus garden is providing produce to members of the local community who may not readily have access to fresh vegetables.A community health survey conducted by the hospital in 2012 identified a need for affordable and healthy nutrition options for people who use Community Outreach Health Clinic and clients of area food pantries. The garden project is a great way to help those who have chronic conditions access nutritious vegetables through the hospital's community partners. This falls harvest, which included tomatoes, cucumbers, zucchini, peppers and beans, was distributed directly to patients who use the outreach clinic and Sussex, Germantown and Menomonee Falls food pantry clients. Over 1,300 pounds of produce was donated this season.Community Outreach Health Clinic:The Community Outreach Health Clinic is a facility where uninsured populations at or below 185% federal poverty level can seek free medical care. The clinic serves people who do not have medical insurance or the ability to pay for medical care. The clinic provides quality, limited medical care with dignity and confidentiality using the services of volunteer professional staff.In FY 13, the clinic served 2,300 individuals.Community Health Screenings:Community Memorial Hospital offers free blood pressure, skin cancer and sports injury screenings. With the goal to empower people and the community to make better decisions and take actions to improve and maintain their health, our community health screenings provide much needed access to services for many of our community members. In Fiscal Year 2013, Community Memorial Hospital conducted health screenings for 279 people. Bobbie Nick Voss Colonoscopy Program:Community Memorial Hospital has partnered with Bobbie Nick Voss Charitable Funds since 2008 to provide free colonoscopies to patients (age 50 and above) in the Community Outreach Health Clinic that show signs or symptoms of colorectal related health conditions. In fiscal year 2013, 21 patients received a colonoscopy at no cost. Leadership Quality Indicator:As an indication of the Community Memorial executive teams commitment to the community, 75 hospital leaders provided more than 1,000 hours of support to local initiatives, not-for-profit organizations and community events. Subsidized Transportation Program:The Subsidized Medical Transportation Program at Community Memorial Hospital provides transportation to and from the hospital service locations for eligible persons (200% federal poverty level or below) who have difficulty arranging their own transportation and lack the financial resources to purchase transportation. In 2013, Community Memorial Hospital provided 826 subsidized rides to 444 people who needed transportation to receive their health care. Community Outreach Steering Committee Grants:Community Memorial Hospitals commitment includes grants to local not-for-profit organizations that support community health improvement efforts focused on access to primary care, chronic disease management, mental health and prevention and wellness in the hospitals service area. In 2013, nine local non-profit organizations received grants totaling $49,964 from the Community Outreach Steering Committee. Health Care Career Academy:The Healthcare Career Academy provides qualified students entering their junior or senior year at Menomonee Falls High School, Germantown High School and Sussex Hamilton High School with the opportunity to expand their knowledge base as it relates to a wide array of professional healthcare career options. The three-week program allows students to shadow and learn from professionals in various clinical and ancillary departments throughout the hospital. Through observation, hands-on experience and classroom discussion, students are able to expand their awareness and interest in healthcare careers. During FY13, 24 students participated in the program with a community benefit value of over $74,000. For more information on CMH Community Benefit programs, please visit www.froedterthealth.org.
	Part VI - Community Building Activities	To promote the health of our communities, Community Memorial Hospital participates in community building activities which are not included elsewhere on Schedule H. These activities include:1. Economic Development: participation in local chamber of commerce boards focused on economic development to improve the local economy and local job opportunities.2. Community Support: participation in local emergency preparedness and youth focused coalitions to improve the communities ability to respond to an emergency and to improve the community environment for youth to set them up for greater success.3. Coalition Building: participation in local community groups and coordination of fundraising for the local United Way Agencies to support others that are addressing health issues thats out of our scope.4. Community Health Improvement Advocacy: participation in creating the community health improvement plan with the local health departments to increase collaborative work in our communities.5. Workforce Development: diversity training that recruits health professionals in our traditionally underserved communities to diversify our workforce population to better serve our communities.
	Part VI - Community Information	Since its founding in 1964 by the citizens of the community it serves, Community Memorial Hospital (CMH) has focused on the emerging healthcare and wellness needs of over 400,000 people in the three county region of Waukesha, Washington, and northwest Milwaukee Counties. The area served is generally suburban with an average income of $50,000-$99,999 and a large population on Medicare. There are three additional hospitals (ProHealth Care, Wheaton Franciscan, & Aurora) and one FQCH (Waukesha Community Health Center)serving the community.
	Part VI - Patient Education of Eligibility for Assistance	Community Memorial Hospital informs and educates patients regarding financial assistance and government program eligibility in a number of ways. Its communication efforts also address special needs of patients and their families, such as hearing or visual impairment or language interpretation.Information on hospital-based financial support policies and government programs are made available to patients during the pre-registration and registration processes through brochures, signage and direct contact with financial counselors, social workers / case managers and registration staff. Patient billing statements also inform patients that financial assistance is available. The Community Memorial Hospital website contains information regarding pricing, how to understand your hospital bill, and how to apply for Financial Assistance. Community Memorial Hospital has made financial assistance forms and information available in Spanish. Financial counselors screen uninsured patients for government program eligibility and social services staff are available to assist patients with enrollment processes. Patients who are uninsured, those covered by government programs and those with limited financial means may also be eligible for charity care or discounts through the Hospital's financial assistance program. Financial counselors make every effort to determine a patient's eligibility prior to or at the time of admission or service. However, determination for financial assistance can be made during any stage of the patient's stay after stabilization, or the collection cycle.
	Part VI - Needs Assessment	In February, 2012 Community Memorial Hospital collaborated with JKV Research, LLC along with Aurora Health Care, Childrens Hospital of Wisconsin, Columbia St. Marys Health System, ProHealth Care, Wheaton Franciscan Healthcare, Washington County Health Department and Waukesha County Health Department to conduct a Community Health Needs Assessment (CHNA) in Washington and Waukesha Counties. The research from the needs assessment provides valuable behavioral data, lifestyle habits, and the prevalence of risk factors and disease conditions of Waukesha County residents. CHNA Overview/Objectives: o Gather data on behavioral and lifestyle habits of the adult population and household-level data. o Gather data on the prevalence of risk factors and disease conditions of the adult population. o Compare health data of residents to previous health studies. o Compare health data to national and state measurements.CHNA Methodology: o 18 minute telephone survey of area residents o 400 completions from February 21 through April 3, 2012 o Two-fold sampling 1) RDD landline sample of listed & unlisted #s (n=300) o Respondents randomly selected based on number of adults in household o Weighting based on number of adults and number of residential phone numbers in household. 2) Cell phone only sample (n=100) o Adult answering the phone designated as the respondent o All data post-stratified by age and gender of adult residents as of 2010 Census proportions. o Margin of error: 5%In addition to the Washington/Waukesha County Community Health Needs Assessments, Community Memorial Hospital conducted key informant interviews with 35 individuals representing school district representatives, public health officials, non-profit health and human service professionals, churches, police/fire departments, free clinics and business professionals throughout Waukesha and Washington Counties. Following extensive interviews with key community stakeholders, findings from the assessment were categorized into eight areas: Access to Primary and Specialty Care, Chronic Disease Management, Mental Health Services, Prevention and Wellness, Alcohol, Drug, Tobacco, Abuse, Dental Services, Transportation and Other. Of those eight health needs categories, four were identified as the focus for community outreach activities in 2012 through 2016 based on select criteria: Community Health Priorities, Disproportionate Unmet Needs, Public Health Concerns and Scope of Services. The most critically documented health needs were identified: - Access to Primary and Specialty Care - AODA - Prevention and Wellness - Chronic Disease ManagementWaukesha County Health Department Community Health Improvement Plan 2012 2016In April 2011, Community Memorial Hospital Community Engagement Staff participated in the Waukesha County Public Health Departments Community Health Improvement Planning Process (CHIPP). The CHIPP consists of a steering committee representing all health systems in Waukesha County as well as representation from area non-profit health and human service agencies. The steering committees role is to determine the top health priorities in the county and create an implementation plan to address community and health needs for Waukesha County Public Health Department to execute in 2012 - 2016. Through the work of the CHIPP Steering Committee, the following priorities have been determined: - Access to Care - Mental Health - AODA
Number of Hospital Faciltiy - 1	Part V, Line 12h - Other Factors Used in Determing Amounts Charged Patients	Out of Pocket Maximum Discount
Number of Hospital Faciltiy - 1	Part V, Line 7 - Explanation of Needs Not Addressed and Reasons Why	Community Memorial Hospitals community health improvement initiatives are targeted for the broad community, especially vulnerable populations (uninsured/underinsured) in the hospitals primary and secondary service areas. Community Memorial Hospitals mission is to advance the health of the communities we serve through exceptional care enhanced by innovation and discovery. The Community Outreach Steering Committee prioritized community health improvement programs, activities and services that reflect the hospitals mission and scope of care: Access to Primary and Specialty Care, AODA, Chronic Disease Management and Health focused Prevention and Wellness programs. The following needs are not being addressed by Community Memorial Hospital:1. Oral and Dental Health ServicesExplanation: We do not have the dedicated resources. There are other local organizations dedicated to improve access to dental care.2. Teen PregnancyExplanation: United Way, Public Health, Safe Babies Healthy Families, the Hope Network and a number of other community organizations are working on this health issue.3. Health Literacy and NavigationExplanation: Other community organizations are working to increase awareness of health services and health seeking behaviors among low income individuals.4. Cigarette UseExplanation: We support the Multi-Jurisdictional Coalitions of Tobacco Free Community Partnership Dodge Jefferson Waukesha County and Washington County.5. Mental HealthExplanation: We do not have the dedicated resources. There are other local health and human service agencies and organizations dedicated to this issue.
Number of Hospital Faciltiy - 1	Part V, Line 6i - Describe Other Needs Identified	Effective December 14, 2012 Community Memorial Hospital adopted a Community Health Improvement Plan. OverviewThis Implementation Strategy serves as the community health improvement component of Community Memorial Hospitals community benefit strategy, focusing on Access to Primary/Specialty Care, Chronic Disease Management, Alcohol and Other Drug Abuse and Prevention/Wellness.Community Memorial Hospitals community benefit framework is to improve the quality of life in the communities we serve through health care programs and services that are measurable, accessible, and culturally appropriate.Community Outreach Steering CommitteeThe Community Outreach Steering Committee (COSC) which is a subcommittee of the hospitals Board of Directors actualizes the mission of Community Memorial Hospital (CMH) through community benefit activities that improve the quality of life and enhance wellness resources which meet identified comprehensive health needs of the communities served. The Community Outreach Steering Committee is appointed annually by the hospital president and is advisory to the CMH Board and Administration. Membership appointments are made each June with members serving one year terms. The COSC meets quarterly and is composed of hospital and board representatives plus community members representing the various constituencies of the total service area. Functions include:Provide a leadership role in advocating community wide responses to health care needs in the community.Facilitate and support community and health care partnerships.Envision, assess and guide new community benefit opportunities.Identify and describe unmet health needs.Promote universal access to health care.Determine allocation of the Community Outreach Services Fund which awards $50,000 annually towards area non-profits efforts to improve health disparities focused on Access to Care, Mental AODA, Chronic Disease Management and Prevention and Wellness in the communities CMH serves.Community DemographicsCommunity Memorial Hospital develops its health improvement strategies and programs to meet the needs of the communities it serves. Community Memorial Hospitals total service area map reflects the 29 zip codes within the Milwaukee five-county area. Age The CMH Total service area has a comparable age distribution as the Milwaukee five-county area. The percentage of 35-44, critical ages when people begin getting routine screenings, is 12.75% in the CMH Total service area and slightly higher at 13.28% in the five-county area. Race/Ethnicity Similar to the age distribution, the racial distribution of the CMH Total service area is comparable to the five-county area with a Caucasian majority. Payer Mix 17.6% of the patients in the CMH Total service area are Medicaid or Self Pay (uninsured) patients, compared to 21.5% in the five-county area. Household Income 59.50% of the CMH Total service area earn more than $50,000 annually whereas in the five-county area, only 52.07% of the population earns $50,000 or more. Community Health Needs AssessmentFroedtert Health is a member of the Milwaukee Health Care Partnership www.mkehcp.org, a public private consortium dedicated to improving care for underserved populations in Milwaukee County. Through the Partnership, Milwaukees five health systems and the Washington County and Washington County Health Departments aligned resources to complete a shared community health needs assessment (CHNA) in 2012. Supported by additional analysis from the Center for Urban Population Health, this robust community-wide CHNA includes findings from a community health survey of over 800 adults, significant key informant interviews and a secondary source data analysis. This shared CHNA serves as the foundation for Community Memorial Hospitals implementation strategy to improve health outcomes and reduce disparities in Washington and Waukesha Counties.The CHNA summary and full reports can be found on Community Memorial Hospitals website:Washington County CHNA Executive SummaryWashington County CHNA Community Health SurveyWaukesha County CHNA Executive SummaryWaukesha County CHNA Community Health SurveyIdentified Community Health Needs in Washington and Waukesha Counties- Access to Health Care Services: includes behavioral, oral health and prenatal services- Health Insurance Coverage- Mental Health: includes Alcohol and Other Drug Abuse (AODA)- Obesity, Nutrition and Physical Activity- Chronic Disease- Sexual Health: includes sexually transmitted infections and teen pregnancy- Health Literacy and NavigationCommunity Memorial Hospitals Implementation Strategy Prioritiesreflect Community Memorial Hospitals clinical strengths and community partnerships. The CHNA identified priorities of Access to Primary/Specialty Care, AODA, Chronic Disease Management, Prevention and Wellness and Health Care Coverage as focus areas for its Implementation Strategy. Implementation Strategy EvaluationCommunity Memorial Hospital and its Community Outreach Steering Committee regularly monitors and reports on progress towards the Implementation Strategy objectives. Those reports will include, but are not limited to: access metrics regarding primary, specialty and preventive services; participation rates and qualitative data for individuals engaging in wellness and disease management programs; and, improvement in clinical health indicators associated with chronic disease management initiatives.
Number of Hospital Faciltiy - 1	Part V, Line 5c - Description of Making Needs Assessment Widely Available	The full version of the report and other supporting documents can be found on Froedtert Healths website: Waukesha County - http://www.froedterthealth.org/upload/docs/community-memorial/community-giving/Benefit/waukesha-county-community-health-survey-report.pdf Washington County - http://www.froedterthealth.org/upload/docs/community-memorial/community-giving/Benefit/washington-county-community-health-survey-report.pdf Additional Websites:Washington County Public Health Department - http://www.co.washington.wi.us/uploads/docs/washington-county-community-health-survey-report-march-2012.pdf Waukesha County Public Health Department http://www.waukeshacounty.gov/uploadedFiles/Media/PDF/Health_and_Human_Services/Public_Health/2012%20Community%20Health%20Survey%20Report.pdf
Number of Hospital Faciltiy - 1	Part V, Line 4 - List Other Hospital Facilities that Jointly Conducted Needs Assessment	Washington County Health Needs Assessment Collaboration:JKV ResearchFroedtert Health Froedtert Health Community Memorial HospitalAurora Health CareColumbia St. Marys Health SystemChildrens Hospital of WisconsinWashington County Public Health DepartmentWaukesha County Health Needs Assessment Collaboration:JKV ResearchFroedtert Health Froedtert Health Community Memorial HospitalAurora Health CareColumbia St. Marys Health SystemProHealth CareWheaton Franciscan HealthcareWaukesha County Public Health DepartmentJKV Research was hired by the participating Health Care Systems and Health Departments to lead the CHNA process for Waukesha, Washington and Milwaukee Counties. The total cost of each CHNA conducted was divided up by each of the participating health systems and health departments. Each health system and health department was assigned to conduct key informant interviews within their service area.
Number of Hospital Faciltiy - 1	Part V, Line 3 - Account Input from Person Who Represent the Community	In fiscal year 2012, Community Memorial Hospitals Community Outreach Department and Community Outreach Steering Committee conducted key informant interviews with the following non-profit health and human service agencies:Addiction Resource Council of Waukesha CountyAlbrecht Free ClinicCommunity Outreach Health Clinic at Community Memorial Hospital Falls Area Community ServicesGermantown Area Chamber of Commerce Village of Germantown Fire Department Germantown Police Department Germantown Park & Recreation Department and Recreation Germantown School District Gloria Dei Lutheran Church Hartford Jt 1 School District Hartford Parks and Recreation DepartmentHope Network Inc.Interfaith Caregivers of Washington County Interfaith Senior Programs Waukesha County Menomonee Falls Chamber of CommerceMenomonee Falls Community Education & Recreation Department Menomonee Falls Fire DepartmentMenomonee Falls Police DepartmentMenomonee Falls School District Safe Babies Healthy Families IncSt. Boniface Food Pantry St. Pauls United Church of Christ Stillwaters Cancer Support ServicesSussex Area Chamber of CommerceSussex Area Outreach ServicesSussex Hamilton School District Tri-County YMCA in Menomonee FallsUniversity of Wisconsin Extension Washington County Washington County Mental Health DepartmentWashington County Public Health DepartmentWaukesha County Community Dental Clinic Waukesha County Mental Health DepartmentWaukesha County Public Health Department
	Part III, Line 9b - Provisions On Collection Practices For Qualified Patients	In alignment with the Froedtert Health financial assistance policy regarding the billing, collection and support for patients with payment obligations, Community Memorial Hospital makes every effort to adhere to the policy and is committed to implementing and applying the policy for assisting patients with limited means in a professional, consistent manner. Staff members who work closely with patients (including those working in patient registration and admitting, financial assistance, customer service, billing and collections) are trained regularly about these policies with an emphasis on treating all patients with dignity and respect regardless of their insurance or their ability to pay for services.
	Part III, Line 8 - Explanation Of Shortfall As Community Benefit	Community Memorial Hospital believes that all of the shortfall should be considered as community benefit. The IRS Community Benefit Standard includes the provision of care to the elderly and Medicare patients. Medicare shortfalls must be absorbed by the hospital in order to continue treating the elderly in our community. The hospital provides care regardless of this shortfall and thereby relieves the federal government of the burden of paying the full cost for Medicare beneficiaries.The costing methodology used to determine the Medicare allowable costs is based on a calculation developed by the American Hospital Association in which the data is derived from the annual filed Medicare cost report.
	Part III, Line 4 - Bad Debt Expense	Patients accounts receivable are reduced by an allowance for uncollectible accounts. In evaluating the collectability of patients accounts receivable, Froedtert Health, Inc. (FH) analyzes its past history and identifies trends for each of its major payor sources of revenue to estimate the appropriate allowance for uncollectible accounts and provision for bad debts. Management regularly reviews data about these major payor sources of revenue in evaluating the sufficiency of the allowance for doubtful accounts. For receivables associated with services provided to patients who have third-party coverage, FH analyzes contractually due amounts and provides an allowance for doubtful accounts and a provision for bad debts, if necessary (for example, for expected uncollectible deductibles and copayments on accounts for which the third-party payor has not yet paid, or for payors who are known to be having financial difficulties that make the realization of amounts due unlikely). For receivables associated with self-pay patients (which includes both patients without insurance and patients with deductible and copayment balances due for which third-party coverage exists for part of the bill), FH records a significant provision for bad debts in the period of service on the basis of its past experience, which indicates that many patients are unable or unwilling to pay the portion of their bill for which they are financially responsible. The difference between the standard rates (or the discounted rates if negotiated) and the amounts actually collected after all reasonable collection efforts have been exhausted is charged off against the allowance for doubtful accounts.FH recognizes patient service revenue associated with services provided to patients who have third-party payor coverage on the basis of contractual rates for the services rendered. For uninsured patients that do not qualify for charity care, FH recognizes revenue on the basis of its standard rates for services provided (or on the basis of discounted rates, if negotiated or provided by policy). On the basis of historical experience, a significant portion of FHs uninsured patients will be unable or unwilling to pay for the services provided. Thus, FH records a significant provision for bad debts related to uninsured patients in the period the services are provided.See also page 26 and 27 of attached financial statements.
	Part III, Line 2 - Methodology Used To Estimate Bad Debt Expense	The Hospital provides an allowance for uncollectible accounts based upon a review of outstanding receivables, historical collection information, and existing economic conditions and trends. The ratio of patient care cost to charges is applied to the bad debt attributable to patient accounts to calculate the estimated cost of bad debt attributable to patient accounts that is reported on line 2. Discounts and payments on patient accounts are recorded as an adjustment to revenue, not bad debt expense.
	Part I, Line 7, Column F - Explanation of Bad Debt Expense	Our total expense from Form 990, Part IX, line 25, column (A) was $177,198,269. Bad debt expense is included in Form 990, Part VIII, Statement of Revenue, Lines 2a-2c as required by ASU 2011-07, Presentation and Disclosure of Patient Service Revenue, Provision for Bad Debts, and the Allowance for Doubtful Accounts for Certain Health Care Entities. Therefore, bad debt expense is not included on Form 990, Part IX, Statement of Functional Expenses, Line 25, Column (A).
	Part I, Line 7 - Explanation of Costing Methodology	Charity Care and certain other community benefits costs were determined by using internal information to reduce the various activities to cost. The costing methodology follows what is laid out in the instructions from the IRS.
	Part I, Line 6a - Related Organization Community Benefit Report	Every year, Community Memorial Hospital produces an annual community benefit report highlighting community outreach programs, patient impact stories and investments in the communities we serve. The report is mailed to over 500 area non-profits, chambers of commerce, CMH Board of Directors, CMH leaders and staff, government officials, business leaders and other community members. A copy of the report can be found at Froedterthealth.org

Schedule H (Form 990) 2012

Additional Data

Software ID:	12000229
Software Version:	2012v2.0

- TIN:

Schedule I
(Form 990)

Department of the Treasury
Internal Revenue Service

Grants and Other Assistance to Organizations,
Governments and Individuals in the United States

Complete if the organization answered "Yes," to Form 990, Part IV, line 21 or 22.
lBullet

Attach to Form 990

OMB No. 1545-0047

2012

Open to Public
Inspection

Name of the organization
Community Memorial Hospital of Menomonee
Falls Inc

Employer identification number
39-0987025

Part I

General Information on Grants and Assistance

Does the organization maintain records to substantiate the amount of the grants or assistance, the grantees' eligibility for the grants or assistance, and
the selection criteria used to award the grants or assistance? ....................................

Yes No

Describe in Part IV the organization's procedures for monitoring the use of grant funds in the United States.

Part II

Grants and Other Assistance to Governments and Organizations in the United States. Complete if the organization answered "Yes" to
Form 990, Part IV, line 21, for any recipient that received more than $5,000. Part II can be duplicated if additional space is needed.

(a) Name and address of organization or government	(b) EIN	(c) IRC Code section if applicable	(d) Amount of cash grant	(e) Amount of non-cash assistance	(h) Purpose of grant or assistance
(1) Other Grants 5000 9200 W Wisconsin Avenue Milwaukee,WI53226			19,017	0	Various
(2) Community Outreach Health Clinic W180 N8085 Town Hall Road Menomonee Falls,WI53051	39-1743056	501(c)(3)	30,947	0	Support operations of clinic

Enter total number of section 501(c)(3) and government organizations listed in the line 1 table ................ Bullet Image

Enter total number of other organizations listed in the line 1 table ........................ . Bullet Image

For Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 50055P

Schedule I (Form 990) 2012

Page 2

Part III

Grants and Other Assistance to Individuals in the United States. Complete if the organization answered "Yes" to Form 990, Part IV, line 22.
Part III can be duplicated if additional space is needed.

(a)Type of grant or assistance	(b)Number of recipients	(c)Amount of cash grant	(d)Amount of non-cash assistance	(e)Method of valuation (book, FMV, appraisal, other)	(f)Description of non-cash assistance

Part IV

Supplemental Information.

Complete this part to provide the information required in Part I, line 2, Part III, column (b), and any other additional information.

Identifier	Return Reference	Explanation
Grantmaker's Description of How Grants are Used		Organizations submit grant requests to the Community Outreach Steering Committee (the Committee). On a quarterly basis the fund allocations are determined. Each organization selected for funds receives an award letter detailing the expectations and conditions of the grant money. In order to comply with applicable tax laws, regulations and the Community Outreach Services Fund policy, the Community Outreach Services Fund will provide grant support to organizations with the understanding that:1) Grant funds distributed will be used only for the purposes designated in the award letter.2) No funds will be used for any political campaign or to support attempts to influence legislation of any governmental body. 3) If the organization loses exempt status, any unexpended funds will be returned to the Community Outreach Steering Committee.4) Adequate accounting records of the expenditures of funds will be maintained by your organization.5) This is a one time grant distribution. Future funding requests will be considered on a case by case basis. In addition, the Committee includes a Final Report Form with each organizations award letter. The form requires the organization to provide a brief description of the activity and measurable outcomes/benefits, an expenditure report, follow up actions to the Committees recommendations, and future plans. The Committee requests that each organization submit the Final Report Form to the Committee within thirty days after the completion of the project for which the funds were intended or within a maximum of one year from the receipt of funds.

Schedule I (Form 990) 2012

Additional Data

Software ID:	12000229
Software Version:	2012v2.0

- TIN:

Schedule J
(Form 990)

Department of the Treasury
Internal Revenue Service

Compensation Information

For certain Officers, Directors, Trustees, Key Employees, and Highest
Compensated Employees
SchJMediumBullet

Complete if the organization answered "Yes" to Form 990,
Part IV, question 23.
SchJMediumBullet

Attach to Form 990. SchJMediumBullet

See separate instructions.

OMB No. 1545-0047

2012

Open to Public Inspection

Name of the organization

Community Memorial Hospital of Menomonee
Falls Inc

Employer identification number

39-0987025

Part I

Questions Regarding Compensation

Yes

Check the appropiate box(es) if the organization provided any of the following to or for a person listed in Form
990, Part VII, Section A, line 1a. Complete Part III to provide any relevant information regarding these items.

First-class or charter travel Housing allowance or residence for personal use

Travel for companions Payments for business use of personal residence

Tax idemnification and gross-up payments Health or social club dues or initiation fees

Discretionary spending account Personal services (e.g., maid, chauffeur, chef)

If any of the boxes in line 1a are checked, did the organization follow a written policy regarding payment or reimbursement or provision of all of the expenses described above? If "No," complete Part III to explain....

Yes

Did the organization require substantiation prior to reimbursing or allowing expenses incurred by all officers,
directors, trustees, and the CEO/Executive Director, regarding the items checked in line 1a? .......

Yes

Indicate which, if any, of the following the filing organization used to establish the compensation of the
organization's CEO/Executive Director. Check all that apply. Do not check any boxes for methods
used by a related organization to establish compensation of the CEO/Executive Director, but explain in Part III.

Compensation committee Written employment contract

Independent compensation consultant Compensation survey or study

Form 990 of other organizations Approval by the board or compensation committee

During the year, did any person listed in Form 990, Part VII, Section A, line 1a with respect to the filing organization or a related organization:

Receive a severance payment or change-of-control payment? ................

Participate in, or receive payment from, a supplemental nonqualified retirement plan? .........

Yes

Participate in, or receive payment from, an equity-based compensation arrangement? .........

If "Yes" to any of lines 4a-c, list the persons and provide the applicable amounts for each item in Part III.

Only 501(c)(3) and 501(c)(4) organizations only must complete lines 5-9.

For persons listed in Form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the revenues of:

The organization? ...........................

Any related organization? .........................

If "Yes," to line 5a or 5b, describe in Part III.

For persons listed in Form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the net earnings of:

The organization? ...........................

Any related organization? .........................

If "Yes," to line 6a or 6b, describe in Part III.

For persons listed in Form 990, Part VII, Section A, line 1a, did the organization provide any non-fixed
payments not described in lines 5 and 6? If "Yes," describe in Part III ............

Were any amounts reported in Form 990, Part VII, paid or accured pursuant to a contract that was
subject to the initial contract exception described in Regulations section 53.4958-4(a)(3)? If "Yes," describe
in Part III .............................

If "Yes" to line 8, did the organization also follow the rebuttable presumption procedure described in Regulations section 53.4958-6(c)? .........................

For Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 50053T

Schedule J (Form 990) 2012

Page 2

Part II

Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees. Use duplicate copies if additional space is needed.

For each individual whose compensation must be reported in Schedule J, report compensation from the organization on row (i) and from related organizations, described in the
instructions, on row (ii). Do not list any individuals that are not listed on Form 990, Part VII.
Note. The sum of columns (B)(i)-(iii) for each listed individual must equal the total amount of Form 990, Part VII, Section A, line 1a, applicable column (D) and (E) amounts for that individual.

(A) Name and Title		(B) Breakdown of W-2 and/or 1099-MISC compensation			(C) Retirement and other deferred compensation	(D) Nontaxable benefits	(E) Total of columns (B)(i)-(D)	(F) Compensation reported as deferred in prior Form 990
(A) Name and Title		(i) Base compensation	(ii) Bonus & incentive compensation	(iii) Other reportable compensation	(C) Retirement and other deferred compensation	(D) Nontaxable benefits	(E) Total of columns (B)(i)-(D)	(F) Compensation reported as deferred in prior Form 990
(1)Van De Kreeke JeffreyFH CFO	(i) (ii)	291,459	110,009	27,257	73,475	12,039	514,239
(2)Unger MichaelFormer - Officer (VP)	(i) (ii)	239,377		1,398		16,131	256,906
(3)Sanders Paul ASr VP, Clncl Srvcs	(i) (ii)	225,047	54,893	24,770	14,432	21,677	340,819
(4)Pollard DennisDir&President	(i) (ii)	384,853	140,997	27,565	84,473	27,233	665,121
(5)McClure DebraNurse Anesthetist	(i) (ii)	272,528		609	5,754	12,298	291,189
(6)Lux Theresa MDir,VP Pt Care	(i) (ii)	180,144	50,225	17,299	29,901	10,084	287,653
(7)Knoll ThomasTreasurer	(i) (ii)	151,668		693	8,310	26,791	187,462
(8)Jacobson Catherine ADir,FH Pres/CEO	(i) (ii)	698,373	298,671	4,782	150,975	28,885	1,181,686
(9)Hawig ScottFH CFO	(i) (ii)	214,150	9,601	5,846		10,354	239,951
(10)Goldberg MD David FDir,VP Med Afrs	(i) (ii)	249,317	75,970	20,797	40,905	25,569	412,558
(11)Freiberg Kerry JVP Extrnl Affairs	(i) (ii)	141,743	43,621	20,992	28,752	11,846	246,954
(12)Evenson Rock EVP Pln & Prg Dvlp	(i) (ii)	144,063	44,869	20,438	28,354	24,328	262,052
(13)Ehn DianeVP Qlty & Perf Exc	(i) (ii)	127,601	33,148	2,040	21,953	15,741	200,483

Schedule J (Form 990) 2012

Page 3

Part III

Supplemental Information

Complete this part to provide the information, explanation, or descriptions required for Part I, lines 1a, 1b, 3, 4a, 4b, 4c, 5a, 5b, 6a, 6b, 7, and 8, and for Part II.
Also complete this part for any additional information.

Identifier	Return Reference	Explanation
Sch J, Part III, Additional Information	Part III, Additional Information	Part II, Column (B)(ii): Bonus and incentive compensation amounts include incentive compensation and amounts paid to individuals in lieu of participation in 457(f) deferred compensation plan for the purchase of benefits.
Sch J, Part I, Line 1a	Part I, Line 1a: Relevant information in regards to selections on 1a.	Health club membership subsidy/discount is a benefits program applicable to all employees and is outlined in the benefit program documents. Dining Club memberships for Executives are for business purposes only, with all expenses substantiated by receipts and approvals. All amounts are included in taxable compensation as required.

Schedule J (Form 990) 2012

Additional Data

Software ID:	12000229
Software Version:	2012v2.0

- TIN:

SCHEDULE O
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service

Supplemental Information to Form 990 or 990-EZ

Complete to provide information for responses to specific questions on
Form 990 or to provide any additional information.
MediumBullet

Attach to Form 990 or 990-EZ.

OMB No. 1545-0047

2012

Open to Public
Inspection

Name of the organization

Community Memorial Hospital of Menomonee
Falls Inc

Employer identification number

39-0987025

Identifier	Return Reference	Explanation
	Part VII - Section A 1a Columns C-F	Individuals listed as 'former' but receiving compensation during the year is due to the fact the individual is currently, or was during the tax year, still employed by the organization, but is no longer in the role of director, officer, key employee, etc. in the current year, but was reported as such on the organization's 990 in the previous five years.
	Part IX 24a Corporate Allocations	Froedtert Health allocates its revenues and expenses to Froedtert Memorial Lutheran Hospital, Community Memorial Hospital of Menomonee Falls, St. Joseph's Community Hospital, Froedtert Physician Partners and West Bend Clinic. The allocation is calculated by applying an allocation metric to each accounting unit at Froedtert Health, including a flat percentage, percentage of gross revenue to total, percentage of supply expense to total, etc. Each entity then receives its portion of the Froedtert Health allocation on a monthly basis.
	Part IV, Line 24	Even though the liability is on the books of Community Memorial Hospital of Menemonee Falls, this question was answered no, as Schedule K will be completed on the Form 990 of the parent corporation, Froedtert Health, Inc.
Form 990, Part XI, Line 9	Other Changes In Net Assets Or Fund Balances - Other Decreases	Other = -$12276
Form 990, Part XI, Line 9	Other Changes In Net Assets Or Fund Balances - Other Increases	Change in Foundation Unrestricted Net Assets = $2
Form 990, Part XI, Line 9	Other Changes In Net Assets Or Fund Balances - Other Increases	Change in Foundation Restricted Net Assets = $309168
Form 990, Part XI, Line 9	Other Changes In Net Assets Or Fund Balances - Other Increases	Change in APBO than net periodic benefit costs = $22157186
Form 990, Part XI, Line 9	Other Changes In Net Assets Or Fund Balances - Other Decreases	Capital Contributions = -$838632
Form 990, Part VI, Line 19	Form 990, Part VI, Line 19: Other Organization Documents Publicly Available	Froedtert Health, Inc's quarterly financial information is made available to the public online through the Digital Assurance Corporation, Inc. website. Anyone can register to receive ongoing access to and notifications regarding financial statements at the online website. Additionally, Governing Documents and Conflict of Interest Policy are made available to the public through the corporate office upon request.
Form 990, Part VI, Line 15b	Form 990, Part VI, Line 15b: Compensation Review and Approval Process for Officers and Key Employees	In establishing the compensation of the organizations Top Management, independent compensation consultants are utilized, compensation studies are completed to gather comparative data, persons with a conflict of interest regarding the compensation arrangements at issue are not involved in the decision making process, and amounts are reviewed and approved by the Compensation Committee of the Board of Directors.In addition, there is contemporaneous documentation and recordkeeping for deliberations and decisions regarding the compensation arrangements.
Form 990, Part VI, Line 12c	Form 990, Part VI, Line 12c: Explanation of Monitoring and Enforcement of Conflicts	On an annual basis all officers, directors, trustees, key employees are required to complete a conflict of interest disclosure statement. The data is compiled, and the Froedtert Health Vice President-Chief Compliance Officer (CCO), the Senior Vice-President-General Counsel and/or delegate will review all forms and notifications to determine if any conflicts of interest exist in the disclosure documents. If it is determined that a conflict of interest exists, then the person making the disclosure shall be relieved of his/her obligations on behalf of Community Memorial Hospital with respect to the transaction or arrangement that creates the conflict of interest. A report of all conflicts of interest will be made by the CCO at least annually to the Froedtert Health Finance Committee of the Board of Directors.
Form 990, Part VI, Line 11b	Form 990, Part VI, Line 11b: Form 990 Review Process	Froedtert Health, Inc. accounting staff prepare Form 990 which is reviewed by the Froedtert Health's financial leaders and legal counsel. The 990 is then reviewed by KPMG, Froedtert Health's outside accounting firm. Next, the 990 is provided to the Froedtert Health Finance Committee and Board of Directors. Finally, the 990 is filed as required.
Form 990, Part VI, Line 7b	Form 990, Part VI, Line 7b: Describe Decisions of Governing Body Approval by Members or Shareholders	Froedtert Health, Inc., as the sole member of Community Memorial Hospital of Menomonee Falls, Inc., retains certain reserved powers and authorities with respect to specific governance matters, and strategic and mission-related initiatives of Community Memorial Hospital.
Form 990, Part VI, Line 7a	Form 990, Part VI, Line 7a: How Members or Shareholders Elect Governing Body	Froedtert Health, Inc., as the member of Community Memorial Hospital of Menomonee Falls, has the final approval of election of all board members.
Form 990, Part VI, Line 6	Form 990, Part VI, Line 6: Explanation of Classes of Members or Shareholder	Froedtert Health, Inc. is the sole member of Community Memorial Hospital of Menomonee Falls, Inc.
Form 990, Part VI, Line 4	Form 990, Part VI, Line 4: Description of Significant Changes to Organizational Documents	Bylaws were amended and restated to reflect various governance related provisions to reflect current practices. None of these changes effect the tax-exempt nature of the organization.

For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.

Cat. No. 51056K

Schedule O (Form 990 or 990-EZ) 2012

Additional Data

Software ID:	12000229
Software Version:	2012v2.0

- TIN:

SCHEDULE R
(Form 990)

Department of the Treasury
Internal Revenue Service

Related Organizations and Unrelated Partnerships

Complete if the organization answered "Yes" to Form 990, Part IV, line 33, 34, 35, 36, or 37.
MediumBullet

Attach to Form 990. MediumBullet

See separate instructions.

OMB No. 1545-0047

2012

Open to Public Inspection

Name of the organization

Community Memorial Hospital of Menomonee
Falls Inc

Employer identification number

39-0987025

Part I

Identification of Disregarded Entities (Complete if the organization answered "Yes" to Form 990, Part IV, line 33.)

(a) Name, address, and EIN (if applicable) of disregarded entity	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Total income	(e) End-of-year assets	(f) Direct controlling entity

Part II

Identification of Related Tax-Exempt Organizations (Complete if the organization answered "Yes" to Form 990, Part IV, line 34 because it had one or more related tax-exempt organizations during the tax year.)

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Exempt Code section	(e) Public charity status (if section 501(c)(3))	(f) Direct controlling entity	(g) Section 512(b)(13) controlled entity?
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Exempt Code section	(e) Public charity status (if section 501(c)(3))	(f) Direct controlling entity	Yes	No
(1) Froedtert Hospital Foundation Inc 9200 West Wisconsin Avenue Milwaukee,WI532263596 39-1431192	Health, welfare, research & educ promo	WI	501(c)(3)	Ln 11, Type 1	Froedtert Memorial Lutheran Hospital Inc		No
(2) St Josephs Community Foundation Inc 3200 Pleasant Valley Road West Bend,WI530953868 39-2034296	Health and welfare promotion	WI	501(c)(3)	Ln 11, Type 1	St Josephs Comm Hosp of West Bend Inc		No
(3) Froedtert Physician Partners Inc 9200 W Wisconsin Ave Milwaukee,WI53226 27-2042610	Health Care Services	WI	501(c)(3)	3	Froedtert Health Inc		No
(4) West Bend Clinic Inc 1700 W Paradise Drive West Bend,WI53095 39-2034294	Health Care Services	WI	501(c)(3)	3	Froedtert Health Inc		No
(5) St Josephs Community Hospital Inc 3200 Pleasant Valley Road West Bend,WI530953868 39-0806302	Hospital Care Services	WI	501(c)(3)	3	Froedtert Health Inc		No
(6) Froedtert Memorial Lutheran Hospital Inc 9200 West Wisconsin Avenue Milwuakee,WI532263522 39-6105970	Hospital	WI	501(c)(3)	3	Froedtert Health Inc		No
(7) Community Memorial Foundation W180 N8085 Town Hall Road Menomonee Falls,WI53051 39-1635057	Health and Welfare promotion	WI	501(c)(3)	Ln 11, Type 1	Community Memorial Hospital of MF	Yes
(8) Community Outpatient Health Services W180 N8085 Town Hall Road Menomonee Falls,WI53051 39-1743056	Outpatient Medical and Dental Services	WI	501(c)(3)	3	Community Memorial Hospital of MF	Yes
(9) Froedtert Health Inc 9200 West Wisconsin Avenue Milwaukee,WI532263596 39-2014409	Management Services	WI	501(c)(3)	Ln 11, Type 111	NA		No

For Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 50135Y

Schedule R (Form 990) 2012

Page 2

Part III

Identification of Related Organizations Taxable as a Partnership (Complete if the organization answered "Yes" to Form 990, Part IV, line 34 because it had one or more related organizations treated as a partnership during the tax year.)

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(f) Share of total income	(g) Share of end-of-year assets	(h) Disproprtionate allocations?		(i) Code VUBI amount in box 20 of Schedule K-1 (Form 1065)	(j) General or managing partner?
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(f) Share of total income	(g) Share of end-of-year assets	Yes	No	(i) Code VUBI amount in box 20 of Schedule K-1 (Form 1065)	Yes	No

Part IV

Identification of Related Organizations Taxable as a Corporation or Trust (Complete if the organization answered "Yes" to Form 990, Part IV, line 34 because it had one or more related organizations treated as a corporation or trust during the tax year.)

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(e) Type of entity (C corp, S corp, or trust)	(f) Share of total income	(g) Share of end-of-year assets	(i) Section 512(b)(13) controlled entity?
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(e) Type of entity (C corp, S corp, or trust)	(f) Share of total income	(g) Share of end-of-year assets	Yes	No
(1) Progressive Physician Network Inc 9200 West Wisconsin Avenue Milwaukee,WI53226 27-0367127	Managment Services	WI	Froedtert Health Inc	C				No

Schedule R (Form 990) 2012

Page 3

Part V

Transactions With Related Organizations (Complete if the organization answered "Yes" to Form 990, Part IV, line 34, 35b, or 36.)

Note. Complete line 1 if any entity is listed in Parts II, III, or IV of this schedule.

Yes

1 During the tax year, did the orgranization engage in any of the following transactions with one or more related organizations listed in Parts II-IV?

a Receipt of (i) interest (ii) annuities (iii) royalties or (iv) rent from a controlled entity . . . . . . . . . . . . . . . . . . . . . . .

b Gift, grant, or capital contribution to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

c Gift, grant, or capital contribution from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

d Loans or loan guarantees to or for related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

e Loans or loan guarantees by related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

f Dividends from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

g Sale of assets to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

h Purchase of assets from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

i Exchange of assets with related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

j Lease of facilities, equipment, or other assets to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . .

k Lease of facilities, equipment, or other assets from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . .

l Performance of services or membership or fundraising solicitations for related organization(s) . . . . . . . . . . . . . . . . . . . .

m Performance of services or membership or fundraising solicitations by related organization(s) . . . . . . . . . . . . . . . . . . . .

Yes

n Sharing of facilities, equipment, mailing lists, or other assets with related organization(s) . . . . . . . . . . . . . . . . . . . . .

Yes

o Sharing of paid employees with related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

p Reimbursement paid to related organization(s) for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

q Reimbursement paid by related organization(s) for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

r Other transfer of cash or property to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

s Other transfer of cash or property from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

If the answer to any of the above is "Yes," see the instructions for information on who must complete this line, including covered relationships and transaction thresholds.

(a) Name of other organization	(b) Transaction type (a-s)	(c) Amount involved	(d) Method of determining amount involved

Schedule R (Form 990) 2012

Page 4

Part VI

Unrelated Organizations Taxable as a Partnership (Complete if the organization answered "Yes" to Form 990, Part IV, line 37.)

Provide the following information for each entity taxed as a partnership through which the organization conducted more than five percent of its activities (measured by total assets or gross revenue) that was not a related organization. See instructions regarding exclusion for certain investment partnerships.

(a) Name, address, and EIN of entity	(b) Primary activity	(c) Legal domicile (state or foreign country)	(e) Are all partners section 501(c)(3) organizations?		(f) Share of total income	(g) Share of end-of-year assets	(h) Disproprtionate allocations?		(i) Code VUBI amount in box 20 of Schedule K-1 (Form 1065)	(j) General or managing partner?
(a) Name, address, and EIN of entity	(b) Primary activity	(c) Legal domicile (state or foreign country)	Yes	No	(f) Share of total income	(g) Share of end-of-year assets	Yes	No	(i) Code VUBI amount in box 20 of Schedule K-1 (Form 1065)	Yes	No

Schedule R (Form 990) 2012

Page 5

Part VII

Supplemental Information

Complete this part to provide additional information for responses to questions on Schedule R (see instructions).

Identifier	Return Reference	Explanation
Schedule R, Part V, Line 2		Any transactions listed on Schedule R, Part V, Line 1 and not on Schedule R, Part V, Line 2 are between related 501(c)(3) organizations and therefore, are not reported in this section.

Additional Data

Software ID:	12000229
Software Version:	2012v2.0

1	Briefly describe the organization’s mission or most significant activities: Community Memorial Hospital advances the health of the communities we serve through exceptional care enhanced by innovation and discovery.
2	Check this box
3	Number of voting members of the governing body (Part VI, line 1a) ........	3	20
4	Number of independent voting members of the governing body (Part VI, line 1b) .....	4	16
5	Total number of individuals employed in calendar year 2011 (Part V, line 2a) ......	5	1,478
6	Total number of volunteers (estimate if necessary) .............	6	235
7a	Total unrelated business revenue from Part VIII, column (C), line 12 ........	7a	0
b	Net unrelated business taxable income from Form 990-T, line 34 .........	7b

		Prior Year	Current Year
8	Contributions and grants (Part VIII, line 1h) .........		0
9	Program service revenue (Part VIII, line 2g) .........	177,422,513	178,272,452
10	Investment income (Part VIII, column (A), lines 3, 4, and 7d ) ....	5,935,742	6,461,842
11	Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e)	22,078,021	10,155,074
12	Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)...................	205,436,276	194,889,368
13	Grants and similar amounts paid (Part IX, column (A), lines 1–3 )...	50,000	49,964
14	Benefits paid to or for members (Part IX, column (A), line 4).....		0
15	Salaries, other compensation, employee benefits (Part IX, column (A), lines 5–10)	64,494,413	67,273,584
16a	Professional fundraising fees (Part IX, column (A), line 11e).....		0
b	Total fundraising expenses (Part IX, column (D), line 25) 242,235
17	Other expenses (Part IX, column (A), lines 11a–11d, 11f–24e)....	118,794,930	109,874,721
18	Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25)	183,339,343	177,198,269
19	Revenue less expenses. Subtract line 18 from line 12.......	22,096,933	17,691,099
		Beginning of Current Year	End of Year
20	Total assets (Part X, line 16).............	308,290,602	321,723,931
21	Total liabilities (Part X, line 26).............	170,021,753	135,901,625
22	Net assets or fund balances. Subtract line 21 from line 20.....	138,268,849	185,822,306

Sign Here

	Signature of officer	Date

	Type or print name and title


4a	(Code: ) (Expenses $ 82,718,239 including grants of $ ) (Revenue $ 103,167,715 )
	Inpatient Services:Community Memorial Hospital was founded in 1964 by citizens of the community it serves. The hospital is accredited by The Joint Commission. Combining next-generation technology with personalized care, Community Memorial Hospital strives to enhance and improve the quality of life in Waukesha, Washington, Milwaukee and Ozaukee counties. Community Memorial Hospital is approved for 237 beds of which 202 are staffed and had 8,663 patient admissions and 40,390 patient days related to a wide range of inpatient services, including hospitalist services, general surgery, internal medicine, rehabilitation services, psychiatry, obstetrics and maternity care, cardiology, and other specialty care for the twelve months ended June 30, 2013.Community Memorial Hospital's Heart and Vascular Center is nationally recognized for its excellent outcomes and superior service to patients. At the Heart and Vascular Center, dedicated physicians work as a team with cardiac nurses and other specialized staff to provide the full spectrum of heart care services, from diagnostic tests and surgical procedures to cardiac rehabilitation. Our extensive system of heart and vascular specialists collaborate to ensure that patients receive comprehensive, high-quality care. Our partnership with Froedtert & The Medical College of Wisconsin allow us to offer patients the most advanced surgical and non-surgical treatments available. During fiscal year 2013, Community Memorial had 16,555 cardiology procedures. Community Memorial Hospital's Cancer Care Center is accredited by the American College of Surgeons Commission on Cancer and the American College of Radiology. As a select location in the Froedtert & The Medical College of Wisconsin Cancer Network, Community Memorial provides the excellent care to which you are accustomed, while offering access to the specialty expertise of Froedtert Hospital, eastern Wisconsin's only academic medical center. Through a connection to Froedtert Hospital, patients at Community Memorial have access to expanded services: nationally and internationally known specialists who focus on specific cancers, advanced treatments and technologies, and clinical trials that may provide further options. Medical College of Wisconsin cancer specialists are joined by radiation therapists, oncology nurses, genetic counselors, registered dietitians, psycho-oncology specialists, and support service specialists at Community Memorial Hospital's Cancer Care Center all of whom are keenly attuned to the needs, hopes and fears of cancer patients. Each patient's care is coordinated with specialists from many areas of Community Memorial Hospital, who help and support patients and their families through the physical, emotional and economic phases of treatment. By combining clinical research methods with the most advanced treatments, our doctors are battling cancer from every angle possible giving patients a stronger reason to believe in a full recovery. During fiscal year 2013, Community Memorial had 695 cancer registry cases.At Community Memorial Hospitals Birthing Center, we are committed to relationship-centered birthing care. The Birthing Center includes 13 specialty equipped rooms and provides the full spectrum of prenatal services for both normal and high-risk pregnancies. The Level II NICU has the technology needed to provide long-term care for babies. During fiscal year 2013, Community Memorial had 1,010 births.In addition to the cardiac, cancer care and birthing services noted above, the Hospital provided a variety of inpatient ancillary treatments and procedures during the fiscal year including but not limited to the following: Surgeries: 3,480 Laboratory Tests: 377,209 CT Scans: 3,808 MRIs: 608 Nuclear Medicine Scans: 381 Ultrasounds: 1,892

4b	(Code: ) (Expenses $ 50,469,920 including grants of $ ) (Revenue $ 62,947,016 )
	Outpatient Services:Community Memorial had 95,989 outpatient visits in the twelve months ended June 30, 2013. Community offers a wide variety of ancillary, specialty and subspecialty services including but not limited to the following: - Allergy/Immunology - Cardiology - Clinical Genetics - Dermatology - Electrophysiology - Endocrinology - Family Practice - Gastroenterology - Gerontology - Gynecologic Oncology - Gynecology - Hand Surgery - Hematology - Infectious Disease - Internal Medicine - Interventional Radiology - Magnetic Resonance Imaging - Neonatology - Nephrology - Neurosurgery - Nuclear Medicine - Occupational Medicine - Oncology - Ophthalmology - Oral Surgery - Otolaryngology - Pathology - Pediatrics - Pedodontics - Perinatology - Periodontics - Physical Medicine and Rehabilitation - Plastic/Reconstructive Surgery - Podiatry - Psychiatry - Psychology - Pulmonary Medicine - Radiology - Radiation Oncology - Rheumatology - Thoracic Surgery - Urology - Vascular Surgery

4c	(Code: ) (Expenses $ 9,747,868 including grants of $ ) (Revenue $ 12,157,721 )
	Emergency Services:Community Memorials Emergency Department is a Level III Trauma Center and provides care for individuals with emergent, urgent, and non-urgent problems. During fiscal year 2013, the emergency department had 20,747 emergency visits, with patients receiving expert care from board-certified emergency physicians and nurses certified in Advanced Cardiac Life Support, stroke and trauma care. Our Emergency Department is strengthened by the availability of and access to highly trained specialists in trauma, neurosurgery, cardiology, cardiothoracic surgery including robotic surgery, orthopaedics, respiratory, obstetrics, gynecology, psychiatry and other specialties when the need arises.Community Memorial Hospital is a Certified Advanced Primary Stroke Center, the highest level of stroke care recognized by the Joint Commission, demonstrating its ability to provide care from a multi-disciplinary team of neurologists, neurosurgeons, emergency department specialists, radiologists, nurses, therapists, pharmacists, technicians and more all working in a coordinated, collaborative system. With our new telestroke technology (secure videoconferencing), our physicians are able to consult in real-time with board-certified stroke neurologists from the Froedtert & The Medical College of Wisconsin academic medical center. This technology allows for faster diagnosis and treatment of stroke patients.

4d	Other program services (Describe in Schedule O.)
	(Expenses $ including grants of $ ) (Revenue $ )
4e	Total program service expenses142,936,027

1b	Sub-Total................
c	Total from continuation sheets to Part VII, Section A....
d	Total (add lines 1b and 1c)............	1,750,114	2,606,699	730,260

				(A) Total revenue	(B) Related or exempt function revenue	(C) Unrelated business revenue	(D) Revenue excluded from tax under sections 512, 513, or 514
1a	Federated campaigns..1a
b	Membership dues....1b
c	Fundraising events....1c
d	Related organizations...1d
e	Government grants (contributions)1e

f	All other contributions, gifts, grants, and similar amounts not included above1f

g	Noncash contributions included in lines 1a-1f:$
h	Total. Add lines 1a-1f.......			0
			Business Code
2a	Outpatient Revenue		900099	62,947,016	62,947,016
b	Inpatient Revenue		900099	103,167,715	103,167,715
c	Emergency/Trauma Revenue		900099	12,157,721	12,157,721
d
e
f	All other program service revenue .
g	Total. Add lines 2a–2f........			178,272,452
3	Investment income (including dividends, interest, and other similar amounts).......			4,684,752	1,442,436		3,242,316
4	Income from investment of tax-exempt bond proceeds..			10,232			10,232
5	Royalties...........			0
		(i) Real	(ii) Personal
6a	Gross rents
b	Less: rental expenses
c	Rental income or (loss)
d	Net rental income or (loss).......			0
		(i) Securities	(ii) Other
7a	Gross amount from sales of assets other than inventory	63,774,918	3,258
b	Less: cost or other basis and sales expenses	61,885,433	125,885
c	Gain or (loss)	1,889,485	-122,627
d	Net gain or (loss)..........			1,766,858			1,766,858
8a	Gross income from fundraising events (not including $ of contributions reported on line 1c). See Part IV, line 18 ..
	a		99,203
b	Less: direct expenses ...b		53,669
c	Net income or (loss) from fundraising events..			45,534			45,534
9a	Gross income from gaming activities. See Part IV, line 19 ...
	a
b	Less: direct expenses ...b
c	Net income or (loss) from gaming activities...			0
10a	Gross sales of inventory, less returns and allowances .
	a
b	Less: cost of goods sold ..b
c	Net income or (loss) from sales of inventory..			0
Miscellaneous Revenue			Business Code
11a	Other Dept Operating Rev		561499	3,709,677	3,709,677
b	Corporate Allocated Rev		561000	3,556,243	3,556,243
c	Claims & Settlements		900099	1,725,000	1,725,000
d	All other revenue ....			1,118,620			1,118,620
e	Total. Add lines 11a–11d ......			10,109,540
12	Total revenue. See Instructions......			194,889,368	188,705,808		6,183,560


				(A) Beginning of year		(B) End of year
1	Cashnon-interest-bearing .............			7,295	1	7,125
2	Savings and temporary cash investments .........			21,754,257	2	26,309,775
3	Pledges and grants receivable, net ...........				3	0
4	Accounts receivable, net .............			24,095,637	4	22,202,533
5	Loans and other receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of Schedule L ..................
					5	0
6	Loans and other receivables from other disqualified persons (as defined under section 4958(f)(1)), persons described in section 4958(c)(3)(B), and contributing employers and sponsoring organizations of section 501(c)(9) voluntary employees' beneficiary organizations (see instructions) Complete Part II of Schedule L
					6	0
7	Notes and loans receivable, net .............			20,000	7	20,000
8	Inventories for sale or use ..............			4,149,959	8	3,877,301
9	Prepaid expenses and deferred charges ..........			2,126,284	9	1,630,172
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	181,038,606
b	Less: accumulated depreciation .....	10b	95,737,925	81,377,017	10c	85,300,681
11	Investments—publicly traded securities ..........			124,482,090	11	127,899,248
12	Investments—other securities. See Part IV, line 11 .....				12	0
13	Investments—program-related. See Part IV, line 11 .....				13	0
14	Intangible assets ...............				14	0
15	Other assets. See Part IV, line 11 ...........			50,278,063	15	54,477,096
16	Total assets. Add lines 1 through 15 (must equal line 34)......			308,290,602	16	321,723,931
17	Accounts payable and accrued expenses .........			8,803,747	17	10,485,948
18	Grants payable .................				18
19	Deferred revenue ................			5,940	19	4,199
20	Tax-exempt bond liabilities .............			63,386,192	20	55,729,972
21	Escrow or custodial account liability. Complete Part IV of Schedule D..				21
22	Loans and other payables to current and former officers, directors, trustees, key employees, highest compensated employees, and disqualified
	persons. Complete Part II of Schedule L..........				22
23	Secured mortgages and notes payable to unrelated third parties ..				23
24	Unsecured notes and loans payable to unrelated third parties ....				24
25	Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17-24). Complete Part X of Schedule D....................			97,825,874	25	69,681,506
26	Total liabilities. Add lines 17 through 25.........			170,021,753	26	135,901,625
	Organizations that follow SFAS 117 (ASC 958), check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets ..............			137,302,778	27	184,547,067
28	Temporarily restricted net assets ...........			966,071	28	1,275,239
29	Permanently restricted net assets ...........				29
	Organizations that do not follow SFAS 117 (ASC 958), check here and complete lines 30 through 34.
30	Capital stock or trust principal, or current funds ........				30
31	Paid-in or capital surplus, or land, building or equipment fund .....				31
32	Retained earnings, endowment, accumulated income, or other funds				32
33	Total net assets or fund balances ...........			138,268,849	33	185,822,306
34	Total liabilities and net assets/fund balances ........			308,290,602	34	321,723,931