Form990
Click to see list of attachments
Department of the Treasury
Internal Revenue Service
Return of Organization Exempt From Income Tax
Under section 501(c), 527, or 4947(a)(1) of the Internal Revenue Code (except black lung benefit trust or private foundation)

MediumBullet The organization may have to use a copy of this return to satisfy state reporting requirements.
OMB No. 1545-0047
2012
Open to Public Inspection
A For the 2012 calendar year, or tax year beginning 07-01-2012 , 2012, and ending 06-30-2013
BCheck if applicable:
CName of organization
St Josephs Community Hospital
of West Bend Inc
Doing Business As
 
 
Number and street (or P.O. box if mail is not delivered to street address)
3200 Pleasant Valley Road
 
Room/suite
City or town, state or country, and ZIP + 4
West Bend, WI53095
D Employer identification number

39-0806302
E Telephone number

G Gross receipts $ 121,465,201
F Name and address of principal officer:
Jacobson Catherine
3200 Pleasant Valley Road
West Bend,WI53095
I
Tax-exempt status: (   ) LeftBullet (insert no.) or
J
Website:MediumBullet
www.froedtert.com
H(a)
Is this a group return for
affiliates?
H(b)
Are all affiliates included?
If "No," attach a list. (see instructions)
H(c)
Group exemption number MediumBullet  
K Form of organization:
 
L Year of formation: 1930
M State of legal domicile: WI
Part I
Summary
Activities & Governance 1 Briefly describe the organization’s mission or most significant activities: St. Joseph's Community Hospital of West Bend, Inc is a health care organization serving residents of West Bend and Washington County. Our mission is to advance the health of communities we serve through exceptional care enhanced by innovation and discovery.
2 Check this box MediumBullet
3 Number of voting members of the governing body (Part VI, line 1a) ........ 3 13
4 Number of independent voting members of the governing body (Part VI, line 1b) ..... 4 8
5 Total number of individuals employed in calendar year 2011 (Part V, line 2a) ...... 5 651
6 Total number of volunteers (estimate if necessary) ............. 6 169
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  
Revenues Prior Year Current Year
8 Contributions and grants (Part VIII, line 1h) ......... 14,202 0
9 Program service revenue (Part VIII, line 2g) ......... 84,875,970 92,990,948
10 Investment income (Part VIII, column (A), lines 3, 4, and 7d ) .... 987,125 1,140,406
11 Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e) 3,659,257 4,319,228
12 Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)................... 89,536,554 98,450,582
Expenses; 13 Grants and similar amounts paid (Part IX, column (A), lines 1–3 )...   0
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) 29,341,296 29,584,404
16a Professional fundraising fees (Part IX, column (A), line 11e).....   0
b Total fundraising expenses (Part IX, column (D), line 25) MediumBullet0    
17 Other expenses (Part IX, column (A), lines 11a–11d, 11f–24e).... 56,577,617 62,337,118
18 Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25) 85,918,913 91,921,522
19 Revenue less expenses. Subtract line 18 from line 12....... 3,617,641 6,529,060
Net Assets or Fund Balances; Beginning of Current Year End of Year
20 Total assets (Part X, line 16)............. 126,472,402 132,974,592
21 Total liabilities (Part X, line 26)............. 67,008,680 68,762,606
22 Net assets or fund balances. Subtract line 21 from line 20..... 59,463,722 64,211,986
Part II
Signature Block
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete. Declaration of preparer (other than officer) is based on all information of which preparer has any knowledge.
Sign Here
JumboBullet
Signature of officer Date
JumboBullet
Type or print name and title
Paid Preparer Use Only
Print/Type preparer's name
 
Preparer's signature
Date
PTIN
Firm's name MediumBullet

Firm's EIN MediumBullet
Firm's address MediumBullet



Phone no.
May the IRS discuss this return with the preparer shown above? (see instructions) ............
For Paperwork Reduction Act Notice, see the separate instructions.
Cat. No. 11282Y
Form 990 (2012)
Form 990 (2012)
Page 2
Part III
Statement of Program Service Accomplishments
Check if Schedule O contains a response to any question in this Part III ...............
1
Briefly describe the organization’s mission: St. Joseph's Community Hospital of West Bend, Inc is a health care organization serving residents of West Bend and Washington County. Our mission is to advance the health of communities we serve through exceptional care enhanced by innovation and discovery.
2
Did the organization undertake any significant program services during the year which were not listed on
the prior Form 990 or 990-EZ? ......................
If “Yes,” describe these new services on Schedule O.
3
Did the organization cease conducting, or make significant changes in how it conducts, any program services? ............................
If “Yes,” describe these changes on Schedule O.
4
Describe the organization’s program service accomplishments for each of its three largest program services, as measured by expenses. Section 501(c)(3) and 501(c)(4) organizations are required to report the amount of grants and allocations to others, the total expenses, and revenue, if any, for each program service reported.
4a (Code:   ) (Expenses $ 39,119,120 including grants of $   ) (Revenue $ 52,085,389 )
In addition to being a 70-bed hospital, St. Joseph's Hospital offers a wide variety of outpatient services to the community, including cancer care services, various diagnostic and therapeutic treatments, outpatient and ambulatory surgeries, and rehab treatments.In 2010, St. Joseph's Hospital's Alyce and Elmore Kraemer Cancer Care Center joined the Froedtert & The Medical College Cancer Network, bringing more cancer expertise to the community. The new St. Joseph's Hospital's 16,000-square-foot Kraemer Cancer Center opened July 9, 2012. Care is conveniently provided close to home, with Medical College specialists working with community physicians to provide advanced, coordinated care, and if needed, access to specialized treatment at Froedtert & The Medical College Clinical Cancer Center in Milwaukee. Cancer network physicians in West Bend include specialists in radiation oncology, urologic oncology, gynecologic oncology and plastic and reconstructive surgery. During the fiscal year, radiation oncology and medical oncology visits totaled 5,736 and 4,987, respectively.Recently, more medical specialties became locally available as the Froedtert & The Medical College Specialty Clinics at St. Joseph's Hospital expanded to include urology, urogynecology, infectious diseases, electrophysiology and cardiology, in addition to the cancer specialties, all of which provide access to leading-edge care to the residents of West Bend and Washington County. In addition to the specialty clinics and cancer care services, St. Joseph's Hospital provided a variety of outpatient treatments and procedures during the fiscal year including:Operations: 2,359CT Scans: 5,006MRIs: 1,956Radiological Diagnostic Exams: 10,534Ultrasounds: 3,484Laboratory Tests: 156,293Nuclear Medicine Scans: 1,768Rehabilitation Treatments: 12,257Ambulatory Surgery Visits: 4,191GI Visits: 695
4b (Code:   ) (Expenses $ 26,992,420 including grants of $   ) (Revenue $ 35,939,221 )
St. Joseph's Hospital is a health care organization dedicated to improving the health status of residents of West Bend and neighboring communities regardless of ability to pay. The hospital has been serving residents of Washington County for more than 80 years and today offers a wide range of inpatient services. In 2005 St. Joseph's opened a new 70-bed hospital that earned national recognition for a design emphasizing patient safety and quality. The 143-acre hospital campus also includes the Kathy Hospice, Froedtert Health West Bend Clinic-South and the Froedtert & The Medical College of Wisconsin Specialty Clinics.St. Joseph's Hospital is an acute care general hospital with 70 licensed and staffed beds, providing a wide range of inpatient services, including general and orthopedic surgery, general medicine, intensive care services, obstetrics and maternity care, and inpatient hospice care.The New Life Center at St. Joseph's Hospital is Washington County's leading birth center, with 723 deliveries and 1,883 patient days during fiscal year 2013. Convenient and comfortable, the center offers experienced nurses, tastefully appointed labor, delivery, recovery and postpartum rooms, a special care nursery and a dedicated C-section suite. The inpatient hospice care unit, the Kathy Hospice, is a separate 8-bed building located on the campus of St. Joseph's Hospital, and provides a peaceful and comfortable environment for individuals in need of end-of-life care. The home-like hospice was the first of its kind in Washington County, and experienced 151 admissions and 2,482 patient days during the fiscal year.In addition to the newborn and hospice services, St. Joseph's Hospital had 2,738 admissions and 10,871 patient days related to medical, surgical and intensive care inpatient services. In conjunction with inpatient stays, the hospital provided a variety of inpatient ancillary treatments and procedures during the fiscal year including, but not limited, to:Operations: 808CT Scans: 1,653MRIs: 233Radiological Diagnostic Exams: 7,243Ultrasounds: 1,302Laboratory Tests: 127,291Nuclear Medicine Scans: 234Rehabilitation Treatments: 24,480
4c (Code:   ) (Expenses $ 3,730,005 including grants of $   ) (Revenue $ 4,966,338 )
The Emergency Care Center at St. Joseph's Hospital provides high-quality care for all types of emergencies, 24 hours a day, augmented by its close ties to Froedtert & the Medical College Level I Trauma Center. Staffed by board-certified emergency medicine physicians and emergency certified RNs, the center served more than 16,500 patients in FY 2013. Its designation as a Level III Trauma Center means prompt availability of surgeons and on-call physicians in multiple specialties.
4d Other program services (Describe in Schedule O.)
(Expenses $   including grants of $   ) (Revenue $   )
4e Total program service expensesMediumBullet69,841,545
Form 990 (2012)
Form 990 (2012)
Page 3
Part IV
Checklist of Required Schedules
Yes
No
1
Is the organization described in section 501(c)(3) or 4947(a)(1) (other than a private foundation)? If “Yes,” complete Schedule AClick to see attachment........................
1
Yes
 
2
Is the organization required to complete Schedule B, Schedule of Contributors (see instructions)? ...
2
 
No
3
Did the organization engage in direct or indirect political campaign activities on behalf of or in opposition to candidates for public office? If “Yes,” complete Schedule C, Part I..........
3
 
No
4
Section 501(c)(3) organizations. Did the organization engage in lobbying activities, or have a section 501(h) election in effect during the tax year? If “Yes,” complete Schedule C, Part II........
4
 
No
5
Is the organization a section 501(c)(4), 501(c)(5), or 501(c)(6) organization that receives membership dues, assessments, or similar amounts as defined in Revenue Procedure 98-19? If “Yes,” complete Schedule C,
Part III............................
5
 
No
6
Did the organization maintain any donor advised funds or any similar funds or accounts for which donors have the right to provide advice on the distribution or investment of amounts in such funds or accounts? If “Yes,” complete Schedule D, Part IClick to see attachment........................
6
 
No
7
Did the organization receive or hold a conservation easement, including easements to preserve open space,
the environment, historic land areas, or historic structures? If “Yes,” complete Schedule D, Part IIClick to see attachment...
7
 
No
8
Did the organization maintain collections of works of art, historical treasures, or other similar assets? If “Yes,” complete Schedule D, Part III Click to see attachment....................
8
 
No
9
Did the organization report an amount in Part X, line 21 for escrow or custodial account liability; serve as a custodian for amounts not listed in Part X; or provide credit counseling, debt management, credit repair, or debt negotiation services? If “Yes,” complete Schedule D, Part IVClick to see attachment..............
9
 
No
10
Did the organization, directly or through a related organization, hold assets in temporarily restricted endowments, permanent endowments, or quasi-endowments? If “Yes,” complete Schedule D, Part VClick to see attachment......
10
 
No
11
If the organization’s answer to any of the following questions is "Yes," then complete Schedule D, Parts VI, VII, VIII, IX, or X as applicable.
a
Did the organization report an amount for land, buildings, and equipment in Part X, line 10?
If “Yes,” complete Schedule D, Part VI.Click to see attachment...................
11a
Yes
 
b
Did the organization report an amount for investments—other securities in Part X, line 12 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part VIIClick to see attachment.......
11b
 
No
c
Did the organization report an amount for investments—program related in Part X, line 13 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part VIIIClick to see attachment.......
11c
 
No
d
Did the organization report an amount for other assets in Part X, line 15 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part IXClick to see attachment............
11d
 
No
e
Did the organization report an amount for other liabilities in Part X, line 25? If “Yes,” complete Schedule D, Part XClick to see attachment
11e
Yes
 
f
Did the organization’s separate or consolidated financial statements for the tax year include a footnote that addresses the organization’s liability for uncertain tax positions under FIN 48 (ASC 740)? If “Yes,” complete Schedule D, Part XClick to see attachment.........................
11f
Yes
 
12a
Did the organization obtain separate, independent audited financial statements for the tax year?
If “Yes,” complete Schedule D, Parts XI and XII Click to see attachment.................
12a
 
No
b
Was the organization included in consolidated, independent audited financial statements for the tax year? If “Yes,” and if the organization answered "No" to line 12a, then completing Schedule D, Parts XI and XII is optional Click to see attachment
12b
Yes
 
13
Is the organization a school described in section 170(b)(1)(A)(ii)? If “Yes,” complete Schedule E....
13
 
No
14a
Did the organization maintain an office, employees, or agents outside of the United States?.....
14a
 
No
b
Did the organization have aggregate revenues or expenses of more than $10,000 from grantmaking, fundraising, business, investment, and program service activities outside the United States, or aggregate foreign investments valued at $100,000 or more? If “Yes,” complete Schedule F, Parts I and IV.........
14b
 
No
15
Did the organization report on Part IX, column (A), line 3, more than $5,000 of grants or assistance to any organization or entity located outside the United States? If “Yes,” complete Schedule F, Parts II and IV
15
 
No
16
Did the organization report on Part IX, column (A), line 3, more than $5,000 of aggregate grants or assistance to individuals located outside the United States? If “Yes,” complete Schedule F, Parts III and IV...
16
 
No
17
Did the organization report a total of more than $15,000 of expenses for professional fundraising services on Part IX, column (A), lines 6 and 11e? If “Yes,” complete Schedule G, Part I (see instructions)....
17
 
No
18
Did the organization report more than $15,000 total of fundraising event gross income and contributions on Part VIII, lines 1c and 8a? If “Yes,” complete Schedule G, Part II............
18
 
No
19
Did the organization report more than $15,000 of gross income from gaming activities on Part VIII, line 9a? If “Yes,” complete Schedule G, Part III...................
19
 
No
20a
Did the organization operate one or more hospital facilities? If “Yes,” complete Schedule H.... Click to see attachment
20a
Yes
 
b
If “Yes” to line 20a, did the organization attach a copy of its audited financial statements to this return? Click to see attachment
20b
Yes
 
Form 990 (2012)
Form 990 (2012)
Page 4
Part IV
Checklist of Required Schedules (continued)
21
Did the organization report more than $5,000 of grants and other assistance to any government or organization in the United States on Part IX, column (A), line 1? If “Yes,” complete Schedule I, Parts I and II...
21
 
No
22
Did the organization report more than $5,000 of grants and other assistance to individuals in the United States on Part IX, column (A), line 2? If “Yes,” complete Schedule I, Parts I and III........
22
 
No
23
Did the organization answer “Yes” to Part VII, Section A, line 3, 4, or 5 about compensation of the organization’s current and former officers, directors, trustees, key employees, and highest compensated employees? If “Yes,” complete Schedule J....................... Click to see attachment
23
Yes
 
24a
Did the organization have a tax-exempt bond issue with an outstanding principal amount of more than $100,000 as of the last day of the year, that was issued after December 31, 2002? If “Yes,” answer lines 24b through 24d and complete Schedule K. If “No,” go to line 25................
24a
 
No
b
Did the organization invest any proceeds of tax-exempt bonds beyond a temporary period exception?...
24b
 
No
c
Did the organization maintain an escrow account other than a refunding escrow at any time during the year
to defease any tax-exempt bonds?......................
24c
 
No
d
Did the organization act as an “on behalf of” issuer for bonds outstanding at any time during the year?...
24d
 
No
25a
Section 501(c)(3) and 501(c)(4) organizations. Did the organization engage in an excess benefit transaction with a disqualified person during the year? If “Yes,” complete Schedule L, Part I........
25a
 
No
b
Is the organization aware that it engaged in an excess benefit transaction with a disqualified person in a prior year, and that the transaction has not been reported on any of the organization’s prior Forms 990 or 990-EZ? If “Yes,” complete Schedule L, Part I...................
25b
 
No
26
Was a loan to or by a current or former officer, director, trustee, key employee, highest compensated employee, or disqualified person outstanding as of the end of the organization’s tax year? If “Yes,” complete Schedule L,
Part II..........................
26
 
No
27
Did the organization provide a grant or other assistance to an officer, director, trustee, key employee, substantial contributor or employee thereof, a grant selection committee member, or to a 35% controlled entity or family member of any of these persons? If “Yes,” complete Schedule L, Part III.........
27
 
No
28
Was the organization a party to a business transaction with one of the following parties (see Schedule L, Part IV instructions for applicable filing thresholds, conditions, and exceptions):
a
A current or former officer, director, trustee, or key employee? If “Yes,” complete Schedule L, Part IV ..........................
28a
 
No
b
A family member of a current or former officer, director, trustee, or key employee? If “Yes,”
complete Schedule L, Part IV.....................
28b
 
No
c
An entity of which a current or former officer, director, trustee, or key employee (or a family member thereof) was an officer, director, trustee, or direct or indirect owner? If “Yes,” complete Schedule L, Part IV...
28c
 
No
29
Did the organization receive more than $25,000 in non-cash contributions? If “Yes,” complete Schedule M..
29
 
No
30
Did the organization receive contributions of art, historical treasures, or other similar assets, or qualified conservation contributions? If “Yes,” complete Schedule M.............
30
 
No
31
Did the organization liquidate, terminate, or dissolve and cease operations? If “Yes,” complete Schedule N,
Part I...........................
31
 
No
32
Did the organization sell, exchange, dispose of, or transfer more than 25% of its net assets? If “Yes,” complete Schedule N, Part II......................
32
 
No
33
Did the organization own 100% of an entity disregarded as separate from the organization under Regulations sections 301.7701-2 and 301.7701-3? If “Yes,” complete Schedule R, Part I........ Click to see attachment
33
 
No
34
Was the organization related to any tax-exempt or taxable entity? If “Yes,” complete Schedule R, Part II, III, or IV, and Part V, line 1........................ Click to see attachment
34
Yes
 
35a
Did the organization have a controlled entity within the meaning of section 512(b)(13)?
35a
Yes
 
b
If ‘Yes’ to line 35a, did the organization receive any payment from or engage in any transaction with a controlled entity within the meaning of section 512(b)(13)? If “Yes,” complete Schedule R, Part V, line 2... Click to see attachment
35b
 
No
36
Section 501(c)(3) organizations. Did the organization make any transfers to an exempt non-charitable related organization? If “Yes,” complete Schedule R, Part V, line 2............. Click to see attachment
36
 
No
37
Did the organization conduct more than 5% of its activities through an entity that is not a related organization and that is treated as a partnership for federal income tax purposes? If “Yes,” complete Schedule R, Part VIClick to see attachment
37
 
No
38
Did the organization complete Schedule O and provide explanations in Schedule O for Part VI, lines 11b and 19? Note. All Form 990 filers are required to complete Schedule O. ............
38
Yes
 
Form 990 (2012)
Form 990 (2012)
Page 5
Part V
Statements Regarding Other IRS Filings and Tax Compliance
Check if Schedule O contains a response to any question in this Part V ...............
Yes
No
1a
Enter the number reported in Box 3 of Form 1096 Enter -0- if not applicable ..
1a
139
b
Enter the number of Forms W-2G included in line 1a. Enter -0- if not applicable .
1b
0
c
Did the organization comply with backup withholding rules for reportable payments to vendors and reportable gaming (gambling) winnings to prize winners? ..................
1c
Yes
 
2a
Enter the number of employees reported on Form W-3, Transmittal of Wage and
Tax Statements, filed for the calendar year ending with or within the year covered by this return ..................
2a
651
b
If at least one is reported on line 2a, did the organization file all required federal employment tax returns?
Note. If the sum of lines 1a and 2a is greater than 250, you may be required to e-file (see instructions)
2b
Yes
 
3a
Did the organization have unrelated business gross income of $1,000 or more during the year?...
3a
 
No
b
If “Yes,” has it filed a Form 990-T for this year? If “No,” provide an explanation in Schedule O.....
3b
 
No
4a
At any time during the calendar year, did the organization have an interest in, or a signature or other authority over, a financial account in a foreign country (such as a bank account, securities account, or other financial account)?..........................
4a
 
No
b
If "Yes," enter the name of the foreign country: MediumBullet
See instructions for filing requirements for Form TD F 90-22.1, Report of Foreign Bank and Financial Accounts.
5a
Was the organization a party to a prohibited tax shelter transaction at any time during the tax year?..
5a
 
No
b
Did any taxable party notify the organization that it was or is a party to a prohibited tax shelter transaction?
5b
 
No
c
If “Yes,” to line 5a or 5b, did the organization file Form 8886-T? ............
5c
 
 
6a
Does the organization have annual gross receipts that are normally greater than $100,000, and did the organization solicit any contributions that were not tax deductible as charitable contributions?...
6a
 
No
b
If “Yes,” did the organization include with every solicitation an express statement that such contributions or gifts were not tax deductible?........................
6b
 
 
7
Organizations that may receive deductible contributions under section 170(c).
a
Did the organization receive a payment in excess of $75 made partly as a contribution and partly for goods and services provided to the payor?....................
7a
 
No
b
If “Yes,” did the organization notify the donor of the value of the goods or services provided?.....
7b
 
 
c
Did the organization sell, exchange, or otherwise dispose of tangible personal property for which it was required to file Form 8282?...........................
7c
 
No
d
If “Yes,” indicate the number of Forms 8282 filed during the year ....
7d
0
e
Did the organization receive any funds, directly or indirectly, to pay premiums on a personal benefit contract?............................
7e
 
No
f
Did the organization, during the year, pay premiums, directly or indirectly, on a personal benefit contract?..
7f
 
No
g
If the organization received a contribution of qualified intellectual property, did the organization file Form 8899 as required?............................
7g
 
No
h
If the organization received a contribution of cars, boats, airplanes, or other vehicles, did the organization file a Form 1098-C?..........................
7h
 
No
8
Sponsoring organizations maintaining donor advised funds and section 509(a)(3) supporting organizations. Did the supporting organization, or a donor advised fund maintained by a sponsoring organization, have excess business holdings at any time during the year?............
8
 
No
9
Sponsoring organizations maintaining donor advised funds.
a
Did the organization make any taxable distributions under section 4966?..........
9a
 
No
b
Did the organization make a distribution to a donor, donor advisor, or related person?.......
9b
 
No
10
Section 501(c)(7) organizations. Enter:
a
Initiation fees and capital contributions included on Part VIII, line 12 ...
10a
 
b
Gross receipts, included on Form 990, Part VIII, line 12, for public use of club facilities
10b
 
11
Section 501(c)(12) organizations. Enter:
a
Gross income from members or shareholders .........
11a
 
b
Gross income from other sources (Do not net amounts due or paid to other sources against amounts due or received from them.) ..........
11b
 
12a
Section 4947(a)(1) non-exempt charitable trusts. Is the organization filing Form 990 in lieu of Form 1041?
12a
 
No
b
If “Yes,” enter the amount of tax-exempt interest received or accrued during the year. ....................
12b
 
13
Section 501(c)(29) qualified nonprofit health insurance issuers.
a
Is the organization licensed to issue qualified health plans in more than one state?
Note. See the instructions for additional information the organization must report on Schedule O.
13a
 
No
b
Enter the amount of reserves the organization is required to maintain by the states in which the organization is licensed to issue qualified health plans ....
13b
 
c
Enter the amount of reserves on hand ............
13c
 
14a
Did the organization receive any payments for indoor tanning services during the tax year?.....
14a
 
No
b
If "Yes," has it filed a Form 720 to report these payments? If “No,” provide an explanation in Schedule O..
14b
 
No
Form 990 (2012)
Form 990 (2012)
Page 6
Part VI
Governance, Management, and Disclosure For each “Yes” response to lines 2 through 7b below, and for a “No” response to lines 8a, 8b, or 10b below, describe the circumstances, processes, or changes in Schedule O. See instructions.
Check if Schedule O contains a response to any question in this Part VI ...............
Section A. Governing Body and Management
Yes
No
1a
Enter the number of voting members of the governing body at the end of the tax year .....................
1a
13
If there are material differences in voting rights among members of the governing body, or if the governing body delegated broad authority to an executive committee or similar committee, explain in Schedule O.
b
Enter the number of voting members included in line 1a, above, who are independent ...................
1b
8
2
Did any officer, director, trustee, or key employee have a family relationship or a business relationship with any other officer, director, trustee, or key employee? .................
2
 
No
3
Did the organization delegate control over management duties customarily performed by or under the direct supervision of officers, directors or trustees, or key employees to a management company or other person? .
3
 
No
4
Did the organization make any significant changes to its governing documents since the prior Form 990 was filed? ...........................
4
Yes
 
5
Did the organization become aware during the year of a significant diversion of the organization’s assets? .
5
 
No
6
Did the organization have members or stockholders? ................
6
Yes
 
7a
Did the organization have members, stockholders, or other persons who had the power to elect or appoint one or more members of the governing body? ....................
7a
Yes
 
b
Are any governance decisions of the organization reserved to (or subject to approval by) members, stockholders, or persons other than the governing body? ...................
7b
Yes
 
8
Did the organization contemporaneously document the meetings held or written actions undertaken during the year by the following:
a
The governing body? .........................
8a
Yes
 
b
Each committee with authority to act on behalf of the governing body? ............
8b
Yes
 
9
Is there any officer, director, trustee, or key employee listed in Part VII, Section A, who cannot be reached at the organization’s mailing address? If “Yes,” provide the names and addresses in Schedule O.......
9
 
No
Section B. Policies (This Section B requests information about policies not required by the Internal Revenue Code.)
Yes
No
10a
Did the organization have local chapters, branches, or affiliates? ............
10a
 
No
b
If “Yes,” did the organization have written policies and procedures governing the activities of such chapters, affiliates, and branches to ensure their operations are consistent with the organization's exempt purposes?
10b
 
 
11a
Has the organization provided a complete copy of this Form 990 to all members of its governing body before filing the form? ............................
11a
Yes
 
b
Describe in Schedule O the process, if any, used by the organization to review this Form 990. .....
12a
Did the organization have a written conflict of interest policy? If “No,” go to line 13.......
12a
Yes
 
b
Were officers, directors, or trustees, and key employees required to disclose annually interests that could give rise to conflicts? ..........................
12b
Yes
 
c
Did the organization regularly and consistently monitor and enforce compliance with the policy? If “Yes,” describe in Schedule O how this was done.......................
12c
Yes
 
13
Did the organization have a written whistleblower policy? ...............
13
Yes
 
14
Did the organization have a written document retention and destruction policy? .........
14
Yes
 
15
Did the process for determining compensation of the following persons include a review and approval by independent persons, comparability data, and contemporaneous substantiation of the deliberation and decision?
a
The organization’s CEO, Executive Director, or top management official ...........
15a
Yes
 
b
Other officers or key employees of the organization ................
15b
Yes
 
If "Yes" to line 15a or 15b, describe the process in Schedule O (see instructions).
16a
Did the organization invest in, contribute assets to, or participate in a joint venture or similar arrangement with a taxable entity during the year? ......................
16a
 
No
b
If “Yes,” did the organization follow a written policy or procedure requiring the organization to evaluate its participation in joint venture arrangements under applicable federal tax law, and take steps to safeguard the organization’s exempt status with respect to such arrangements? ............
16b
 
 
Section C. Disclosure
17
List the States with which a copy of this Form 990 is required to be filedMediumBullet
WI
18
Section 6104 requires an organization to make its Form 1023 (or 1024 if applicable), 990, and 990-T (501(c)(3)s only) available for public inspection. Indicate how you made these available. Check all that apply.
19
Describe in Schedule O whether (and if so, how), the organization made its governing documents, conflict of interest policy, and financial statements available to the public during the tax year.
20
State the name, physical address, and telephone number of the person who possesses the books and records of the organization:
MediumBulletDavid DirksmeyerN74 W12501 Leatherwood CtMenomonee FallsWI53051 (414) 777-0960
Form 990 (2012)
Form 990 (2012)
Page 7
Part VII
Compensation of Officers, Directors,Trustees, Key Employees, Highest Compensated Employees, and Independent Contractors
Check if Schedule O contains a response to any question in this Part VII ...............
Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees
1a Complete this table for all persons required to be listed. Report compensation for the calendar year ending with or within the organization’s tax year.
RoundBullet List all of the organization’s current officers, directors, trustees (whether individuals or organizations), regardless of amount
of compensation. Enter -0- in columns (D), (E), and (F) if no compensation was paid.

RoundBullet List all of the organization’s current key employees, if any. See instructions for definition of "key employee."
RoundBullet List the organization’s five current highest compensated employees (other than an officer, director, trustee or key employee)
who received reportable compensation (Box 5 of Form W-2 and/or Box 7 of Form 1099-MISC) of more than $100,000 from the
organization and any related organizations.

RoundBullet List all of the organization’s former officers, key employees, or highest compensated employees who received more than $100,000
of reportable compensation from the organization and any related organizations.

RoundBullet List all of the organization’s former directors or trustees that received, in the capacity as a former director or trustee of the
organization, more than $10,000 of reportable compensation from the organization and any related organizations.

List persons in the following order: individual trustees or directors; institutional trustees; officers; key employees; highest
compensated employees; and former such persons.
Check this box if neither the organization nor any related organization compensated any current officer, director, or trustee.
(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) 		(D)
Reportable compensation from the organization (W- 2/1099-MISC) 		(E)
Reportable compensation from related organizations (W- 2/1099-MISC) 		(F)
Estimated amount of other compensation from the organization and related organizations
Individual Trustee or Director; Institutional Trustee; Officer; Key Employee; Highest compensated employee; Former;
(1) Zwygart Christopher........................................................................
Dir&Chair
 1.00
.......................1.00 		X   X       0 0 0
(2) Olson David........................................................................
Dir&President
 1.00
.......................52.00 		X   X       0 360,928 66,767
(3) Komas Ron........................................................................
Dir&Secretary
 1.00
.......................1.00 		X   X       0 0 0
(4) Ericson Allen........................................................................
Dir&Pres
 45.00
.......................6.00 		X   X       109,703 0 8,147
(5) Wolter Brian MD........................................................................
Dir&Doctor
 1.00
.......................41.00 		X           0 441,516 33,717
(6) O'Meara Charles........................................................................
Director
 1.00
.......................0.00 		X           0 0 0
(7) Neitzke Ted........................................................................
Director
 1.00
.......................0.00 		X           0 0 0
(8) Martin Mary........................................................................
Dir&CNO
 1.00
.......................40.00 		X           0 143,414 9,909
(9) Lux Theresa M........................................................................
Dir&CNO
 1.00
.......................50.00 		X           0 247,668 39,985
(10) Leitheiser Richard........................................................................
Director
 1.00
.......................1.00 		X           0 0 0
(11) Johnston Brenda........................................................................
Director
 1.00
.......................0.00 		X           0 0 0
(12) Jacobson Catherine........................................................................
Dir&FH CEO
 1.00
.......................50.00 		X           0 1,001,826 179,860
(13) Herdrich Gary MD........................................................................
Dir&Chief Staff
 1.00
.......................61.00 		X           0 625,523 34,295
(14) Gardner Patrick MD........................................................................
Director
 1.00
.......................0.00 		X           0 0 0
(15) Bloedorn Michael........................................................................
Director
 1.00
.......................0.00 		X           0 0 0
(16) Bast Ronald........................................................................
Director
 1.00
.......................2.00 		X           0 0 0
(17) Knoll Thomas........................................................................
Treasurer
 1.00
.......................41.00 		    X       0 152,361 35,101
Form 990 (2012)
Form 990 (2012)
Page 8
Part VII
Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees (continued)
(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) 		(D)
Reportable compensation from the organization (W- 2/1099-MISC) 		(E)
Reportable compensation from related organizations (W- 2/1099-MISC) 		(F)
Estimated amount of other compensation from the organization and related organizations
Individual Trustee or Director; Institutional Trustee; Officer; Key Employee; Highest compensated employee; Former;
(18) Van De Kreeke Jeffrey........................................................................
FH CFO
 1.00
.......................50.00 		    X       0 428,725 85,514
(19) Hawig Scott........................................................................
FH CFO
 1.00
.......................50.00 		    X       0 229,597 10,354
(20) Bangalore Nitish S........................................................................
Pharmacy Manager
 40.00
.......................0.00 		        X   136,037 0 10,340
(21) Herdeman Charles........................................................................
Pharmacist
 40.00
.......................0.00 		        X   144,560 0 25,790
(22) Juech Thomas........................................................................
Pharmacist
 40.00
.......................0.00 		        X   136,617 0 17,251
(23) Laird Michael........................................................................
Past President
 40.00
.......................0.00 		        X   281,200 0 13,475
(24) Less Timothy........................................................................
Medical Physicist
 40.00
.......................0.00 		        X   191,889 0 28,897
(25) Malzewski Michael........................................................................
Former - Officer (AVP Finance)
 0.00
.......................0.00 		          X 0 243,040 39,534
(26) Lauenstein Debra........................................................................
Former - Key (Dir HR)
 0.00
.......................0.00 		          X 0 154,245 18,073








1b Sub-Total................MediumBullet
c Total from continuation sheets to Part VII, Section A....MediumBullet
d Total (add lines 1b and 1c)............MediumBullet 1,000,006 4,028,843 657,009
2
Total number of individuals (including but not limited to those listed above) who received more than $100,000 of reportable compensation from the organizationMediumBullet12
Yes
No
3
Did the organization list any former officer, director or trustee, key employee, or highest compensated employee on line 1a? If “Yes,” complete Schedule J for such individual ..............
3
Yes
 
4
For any individual listed on line 1a, is the sum of reportable compensation and other compensation from the organization and related organizations greater than $150,000? If “Yes,” complete Schedule J for such individual...........................
4
Yes
 
5
Did any person listed on line 1a receive or accrue compensation from any unrelated organization or individual for services rendered to the organization? If “Yes,” complete Schedule J for such person ........
5
 
No
Section B. Independent Contractors
1
Complete this table for your five highest compensated independent contractors that received more than $100,000 of compensation from the organization. Report compensation for the calendar year ending with or within the organization’s tax year.
(A)
Name and business address 		(B)
Description of services 		(C)
Compensation
Pearson Engineering LLC14 Ellis Potter CtMadisonWI53711 Engineering services 107,897
Medical Solutions Incorporated9101 Western Avenue Suite 101OmahaNE68114 Staffing services 111,324
Medical College of WI8701 Watertown Plank RdMilwaukeeWI53226 Physician Services 3,070,468
C&A IndustriesPO Box 3037OmahaNE681370037 Staffing services 105,884
Advanced HRO Solutions Inc10 E College Avenue Suite 300AppletonWI549115759 Staffing services 143,456
2
Total number of independent contractors (including but not limited to those listed above) who received more than $100,000 of compensation from the organization MediumBullet5
Form 990 (2012)
Form 990 (2012)
Page 9
Part VIII
Statement of Revenue
Check if Schedule O contains a response to any question in this Part VIII ..............
(A)
Total revenue 		(B)
Related or
exempt
function
revenue 		(C)
Unrelated
business
revenue 		(D)
Revenue
excluded from
tax under sections
512, 513, or 514
Contributions, Gifts, Grants and Other Similar Amounts 1a Federated campaigns..1a  
b Membership dues....1b  
c Fundraising events....1c  
d Related organizations...1d  
e Government grants (contributions)1e  
f All other contributions, gifts, grants, and
similar amounts not included above1f 		 
g Noncash contributions included in lines
1a-1f:$ 		 
h Total. Add lines 1a-1f.......MediumBullet 0
Program Service Revenue Business Code
2a Outpatient Revenue 621400 52,085,389 52,085,389    
b Inpatient Revenue 621990 35,939,221 35,939,221    
c Emergency Dept Revenue 621990 4,966,338 4,966,338    
d
e
f All other program service revenue .        
g Total. Add lines 2a–2f........MediumBullet 92,990,948
Other Revenue 3 Investment income (including dividends, interest, and other similar amounts).......MediumBullet 712,809     712,809
4 Income from investment of tax-exempt bond proceeds..MediumBullet 0      
5 Royalties...........MediumBullet 0      
(i) Real (ii) Personal
6a Gross rents    
b Less: rental expenses    
c Rental income or (loss)    
d Net rental income or (loss).......MediumBullet 0      
(i) Securities (ii) Other
7a Gross amount from sales of assets other than inventory 23,402,516 39,700
b Less: cost or other basis and sales expenses 22,972,647 41,972
c Gain or (loss) 429,869 -2,272
d Net gain or (loss)..........MediumBullet 427,597     427,597
8a Gross income from fundraising events (not including
$  
of contributions reported on line 1c). See Part IV, line 18 ..
a  
b Less: direct expenses ...b  
c Net income or (loss) from fundraising events..MediumBullet 0    
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...MediumBullet 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..MediumBullet 0      
Miscellaneous Revenue Business Code
11a Medical Office Building 621110 819,431 819,431    
b Corporate Allocated Rev 900099 702,002 702,002    
c Clinic Revenue 621110 1,650,421 1,650,421    
d All other revenue .... 1,147,374 1,147,374    
e Total. Add lines 11a–11d ...... MediumBullet 4,319,228
12 Total revenue. See Instructions......MediumBullet 98,450,582 97,310,176   1,140,406
Form 990 (2012)
Form 990 (2012)
Page 10
Part IX
Statement of Functional Expenses
Section 501(c)(3) and 501(c)(4) organizations must complete all columns. All other organizations must complete column (A).Check if Schedule O contains a response to any question in this Part IX ...............
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 0  
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 .... 321,594   321,594  
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 27,212,601 25,459,439 1,753,162  
8 Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) .... 67,765   67,765  
9 Other employee benefits ....... 0      
10 Payroll taxes ........... 1,982,444 1,845,062 137,382  
11 Fees for services (non-employees):        
a Management ...... 0      
b Legal ......... 90,416   90,416  
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) ........ 9,663,460 8,797,610 865,850  
12 Advertising and promotion .... 6,832   6,832  
13 Office expenses ....... 338,170 224,242 113,928  
14 Information technology ...... 67,112 65,444 1,668  
15 Royalties .. 0      
16 Occupancy ........... 2,146,162 1,246,276 899,886  
17 Travel ............ 66,115 38,736 27,379  
18 Payments of travel or entertainment expenses for any federal, state, or local public officials ...... 0      
19 Conferences, conventions, and meetings .... 51,348 29,914 21,434  
20 Interest ........... 2,855,464 1,658,168 1,197,296  
21 Payments to affiliates ....... 0      
22 Depreciation, depletion, and amortization ..... 5,445,631 3,535,062 1,910,569  
23 Insurance .............. 6,752   6,752  
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 State Hospital Assessment 2,103,276 2,103,276    
b Loss on Refinancing 3,514,453   3,514,453  
c Medical Supplies 16,973,076 16,936,184 36,892  
d Corporate Allocated Expense 18,063,706 7,659,536 10,404,170  
e All other expenses 945,145 242,596 702,549  
25 Total functional expenses. Add lines 1 through 24e 91,921,522 69,841,545 22,079,977 0
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 MediumBullet if following SOP 98-2 (ASC 958-720).        
Form 990 (2012)
Form 990 (2012)
Page 11
Part X Balance Sheet Check if Schedule O contains a response to any question in this Part X ...............
(A)
Beginning of year 		(B)
End of year
Assets 1 Cash—non-interest-bearing ............. 2,019 1 1,920
2 Savings and temporary cash investments ......... 5,237,304 2 9,909,805
3 Pledges and grants receivable, net ...........   3 0
4 Accounts receivable, net ............. 9,398,418 4 12,244,108
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 ............. 250,000 7 0
8 Inventories for sale or use .............. 1,873,009 8 2,008,435
9 Prepaid expenses and deferred charges .......... 1,386,522 9 682,113
10a Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D 10a 131,561,417
b Less: accumulated depreciation ..... 10b 52,361,126 77,327,798 10c 79,200,291
11 Investments—publicly traded securities .......... 30,780,247 11 27,426,934
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 ........... 217,085 15 1,500,986
16 Total assets. Add lines 1 through 15 (must equal line 34)...... 126,472,402 16 132,974,592
Liabilities 17 Accounts payable and accrued expenses ......... 6,476,931 17 8,532,063
18 Grants payable .................   18  
19 Deferred revenue ................ 115,000 19 115,000
20 Tax-exempt bond liabilities ............. 55,822,923 20 58,426,605
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.................... 4,593,826 25 1,688,938
26 Total liabilities. Add lines 17 through 25......... 67,008,680 26 68,762,606
Net Assets or Fund Balance Organizations that follow SFAS 117 (ASC 958), check here MediumBullet and complete lines 27 through 29, and lines 33 and 34.
27 Unrestricted net assets .............. 59,315,827 27 64,068,318
28 Temporarily restricted net assets ........... 147,895 28 143,668
29 Permanently restricted net assets ...........   29  
Organizations that do not follow SFAS 117 (ASC 958), check here MediumBullet 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 ........... 59,463,722 33 64,211,986
34 Total liabilities and net assets/fund balances ........ 126,472,402 34 132,974,592
Form 990 (2012)
Form 990 (2012)
Page 12
Part XI
Reconcilliation of Net Assets
Check if Schedule O contains a response to any question in this Part XI ...............
1
Total revenue (must equal Part VIII, column (A), line 12) ............
1
98,450,582
2
Total expenses (must equal Part IX, column (A), line 25) ............
2
91,921,522
3
Revenue less expenses. Subtract line 2 from line 1 ..............
3
6,529,060
4
Net assets or fund balances at beginning of year (must equal Part X, line 33, column (A)) ..
4
59,463,722
5
Net unrealized gains (losses) on investments ...............
5
1,059,987
6
Donated services and use of facilities .................
6
 
7
Investment expenses .....................
7
 
8
Prior period adjustments .....................
8
 
9
Other changes in net assets or fund balances (explain in Schedule O) ........
9
-2,840,783
10
Net assets or fund balances at end of year. Combine lines 3 through 9 (must equal Part X, line 33, column (B))
10
64,211,986
Part XII
Financial Statements and Reporting
Check if Schedule O contains a response to any question in this Part XII ..............
Yes
No
1
Accounting method used to prepare the Form 990:  
If the organization changed its method of accounting from a prior year or checked "Other," explain in
Schedule O.
2a
Were the organization’s financial statements compiled or reviewed by an independent accountant?
2a
 
No
If ‘Yes,’ check a box below to indicate whether the financial statements for the year were compiled or reviewed on a separate basis, consolidated basis, or both:
b
Were the organization’s financial statements audited by an independent accountant?
2b
Yes
 
If ‘Yes,’ check a box below to indicate whether the financial statements for the year were audited on a separate basis, consolidated basis, or both:
c
If “Yes,” to line 2a or 2b, does the organization have a committee that assumes responsibility for oversight of the audit, review, or compilation of its financial statements and selection of an independent accountant?
2c
Yes
 
If the organization changed either its oversight process or selection process during the tax year, explain in Schedule O.
3a
As a result of a federal award, was the organization required to undergo an audit or audits as set forth in the Single Audit Act and OMB Circular A-133?
3a
 
No
b
If “Yes,” did the organization undergo the required audit or audits? If the organization did not undergo the required audit or audits, explain why in Schedule O and describe any steps taken to undergo such audits
3b
 
 
Form 990 (2012)
Form 990, Special Condition Description:
Special Condition Description
Additional Data


Software ID: 12000229
Software Version: 2012v2.0
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.
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
St Josephs Community Hospital
of West Bend Inc
Employer identification number

39-0806302
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.)
1
2
3
4
5
section 170(b)(1)(A)(iv). (Complete Part II.)
6
7
8
9
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.)
10
11
e
f
g
(i) A person who directly or indirectly controls, either alone or together with persons described in (ii)
Yes
No
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)
 
 
h
Provide the following information about the supported organization(s).
(i) Name of supported organization (ii) EIN (iii) Type of organization (described on lines 1- 9 above or IRC section (see instructions)) (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
Yes No Yes No Yes No
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
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) right arrow (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) right arrow (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).            
12
12
 
13
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
14
14
 
15
15
 
16a
b
17a
b
18
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
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) right arrow (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) right arrow (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.)..            
14
Section C. Computation of Public Support Percentage
15
15
 
16
16
 
Section D. Computation of Investment Income Percentage
17
17
 
18
18
 
19a
b
20
Schedule A (Form 990 or 990-EZ) 2012
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
SCHEDULE D
(Form 990)
Department of the Treasury
Internal Revenue Service
Supplemental Financial Statements
SchDMd Bullet 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
St Josephs Community Hospital
of West Bend Inc
Employer identification number

39-0806302
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 ........    
5
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? ............
6
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? ...................................
Part II
Conservation Easements. Complete if the organization answered "Yes" to Form 990, Part IV, line 7.
1
Purpose(s) of conservation easements held by the organization (check all that apply).
2
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.
Held at the End of the 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  
3
Number of conservation easements modified, transferred, released, extinguished, or terminated by the organization during
the tax year SchDMd Bullet  
4
Number of states where property subject to conservation easement is located SchDMd Bullet  
5
Does the organization have a written policy regarding the periodic monitoring, inspection, handling of violations, and
enforcement of the conservation easements it holds? .............................
6
Staff and volunteer hours devoted to monitoring, inspecting, and enforcing conservation easements during the year
SchDMd Bullet  
7
Amount of expenses incurred in monitoring, inspecting, and enforcing conservation easements during the year
SchDMd Bullet $  
8
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)? .......................................
9
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.
1a
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.
b
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 $  
2
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:
a
Revenues included in Form 990, Part VIII, line 1 ..........................SchDMd Bullet $  
b
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

Schedule D (Form 990) 2012
Page 2
Part III
Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets (continued)
3
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):
a
d
b
e
 
c
4
Provide a description of the organization’s collections and explain how they further the organization’s exempt purpose in
Part XIII.
5
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?........
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.
1a
Is the organization an agent, trustee, custodian or other intermediary for contributions or other assets not
included on Form 990, Part X? ....................................
b
If "Yes," explain the arrangement in Part XIII and complete the following table:
Amount
c Beginning balance ................................. 1c  
d Additions during the year .............................. 1d  
e Distributions during the year ............................. 1e  
f Ending balance ................................... 1f  
2a
Did the organization include an amount on Form 990, Part X, line 21? .....................
b
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 ....          
b Contributions ........          
c Net investment earnings, gains, and losses          
d Grants or scholarships .....          
e Other expenditures for facilities
and programs ........ 		         
f Administrative expenses ....          
g End of year balance ......          
2
Provide the estimated percentage of the current year end balance (line 1g, column (a)) held as:
a
Board designated or quasi-endowment SchDMd Bullet  
b
Permanent endowment SchDMd Bullet  
c
Temporarily restricted endowment SchDMd Bullet  
The percentages in lines 2a, 2b, and 2c should equal 100%.
3a
Are there endowment funds not in the possession of the organization that are held and administered for the
organization by:

Yes
No
(i) unrelated organizations ........................
3a(i)
 
 
(ii) related organizations ........................
3a(ii)
 
 
b
If "Yes" to 3a(ii), are the related organizations listed as required on Schedule R? .........
3b
 
 
4
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 (a) Cost or other basis (investment) (b)Cost or other basis (other) (c) Accumulated depreciation (d) Book value
1a Land .................   4,814,698 4,814,698
b Buildings ................   59,117,315 9,681,877 49,435,438
c Leasehold improvements ............   3,204,201 1,649,144 1,555,057
d Equipment ................   61,162,222 40,560,227 20,601,995
e Other .................   3,262,981 469,878 2,793,103
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).).......SchDMdBullet 79,200,291
Schedule D (Form 990) 2012

Schedule D (Form 990) 2012
Page 3
Part VII
Investments—Other 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.)Small Bullet  
Part VIII
Investments—Program 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.)Small Bullet  
Part IX
Other Assets. See Form 990, Part X, line 15.
(a) Description (b) Book value








Total. (Column (b) must equal Form 990, Part X, col.(B) line 15.)...........Small Bullet  
Part X
Other Liabilities. See Form 990, Part X, line 25.
1.(a) Description of liability (b) Book value
Federal income taxes  
Due to Affiliates 1,688,938








Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)Small Bullet 1,688,938
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

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. 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 recogniton, derecogniton, 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, Froedtert Health does not have an asset or liability recorded for unrecognized tax positions.
Schedule D (Form 990) 2012

Additional Data


Software ID: 12000229
Software Version: 2012v2.0




SCHEDULE H (Form 990)
Department of the Treasury
Internal Revenue Service
Hospitals
MediumBullet 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
St Josephs Community Hospital
of West Bend Inc
Employer identification number

39-0806302
Part I
Financial Assistance and Certain Other Community Benefits at Cost
Yes
No
1a
Did the organization have a financial assistance policy during the tax year? If "No," skip to question 6a ...
1a
Yes
 
b
If "Yes," was it a written policy? .......................
1b
Yes
 
2
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.
3
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.
a
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:
3a
Yes
 
%
b
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: .........
3b
Yes
 
%
c
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.
4
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"? ..............

4

Yes

 
5a
Did the organization budget amounts for free or discounted care provided under its financial assistance policy during the tax year? ............................

5a

Yes

 
b
If "Yes," did the organization's financial assistance expenses exceed the budgeted amount? ......
5b
Yes
 
c
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? ..............
5c
 
No
6a
Did the organization prepare a community benefit report during the tax year? ..........
6a
Yes
 
b
If "Yes," did the organization make it available to the public? ..............
6b
Yes
 
Complete the following table using the worksheets provided in the Schedule H instructions. Do not submit these worksheets with the Schedule H.
7
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) .. 		    1,481,964   1,481,964 1.610 %
b Medicaid (from Worksheet 3,
column a) .... 		    8,724,465 10,766,471 -2,042,006  
c Costs of other means-tested
government programs (from
Worksheet 3, column b) . 		           
d Total Financial Assistance
and Means-Tested
Government Programs . 		    10,206,429 10,766,471 -560,042 1.610 %
Other Benefits
 20 6,120 141,190   141,190 0.150 %
e Community health
improvement services and
community benefit operations
(from Worksheet 4) ..
f Health professions education
(from Worksheet 5) .. 		3 277 252,091   252,091 0.270 %
g Subsidized health services
(from Worksheet 6) .. 		           
h Research (from Worksheet 7)            
i Cash and in-kind
contributions for community
benefit (from Worksheet 8) 		4 6 124,974   124,974 0.140 %
j Total. Other Benefits .. 27 6,403 518,255   518,255 0.560 %
k Total. Add lines 7d and 7j . 27 6,403 10,724,684 10,766,471 -41,787 2.170 %
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 (d) Direct offsetting
revenue 		(e) Net community building expense (f) Percent of total expense
1 Physical improvements and housing            
2 Economic development            
3 Community support 1   9,097   9,097 0.010 %
4 Environmental improvements            
5 Leadership development and training for community members            
6 Coalition building 2   8,454   8,454 0.010 %
7 Community health improvement advocacy            
8 Workforce development 1   1,338   1,338  
9 Other            
10 Total 4   18,889   18,889 0.020 %
Part III
Bad Debt, Medicare, & Collection Practices
Section A. Bad Debt Expense
Yes
No
1
Did the organization report bad debt expense in accordance with Heathcare Financial Management Association Statement No. 15? ..........................
1
 
No
2
Enter the amount of the organization's bad debt expense. Explain in Part VI the methodology used by the organization to estimate this amount. ......
2
6,117,499
3
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. ......
3
 
4
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
5
Enter total revenue received from Medicare (including DSH and IME).....
5
27,760,790
6
Enter Medicare allowable costs of care relating to payments on line 5.....
6
34,281,587
7
Subtract line 6 from line 5. This is the surplus (or shortfall)........
7
-6,520,797
8
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:
Section C. Collection Practices
9a
Did the organization have a written debt collection policy during the tax year? ..........
9a
Yes
 
b
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.......................

9b

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
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 		Licensed Hospital General-Medical-Surgical Children's Hospital Teaching Hospital Critical Hospital Research Facility ER-24Hours ER-Other Other (Describe) Facility reporting group
1 St Josephs Comm Hospital
3200 Pleasant valley Road
West Bend,WI530953868 		X X         X      
Schedule H (Form 990) 2012
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)
St Josephs Comm Hospital
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) 1
Yes No
Community Health Needs Assessment (Lines 1 through 8c are optional for tax years begining on or before March 23, 2012)
1 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.................... 1 Yes  
If “Yes,” indicate what the CHNA report describes (check all that apply):
a
b
c
d
e
f
g
h
i
j
2 Indicate the tax year the hospital facility last conducted a CHNA: 20 12
3 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 .................... 3 Yes  
4 Was the hospital facility’s CHNA conducted with one or more other hospital facilities? If “Yes,” list the other hospital facilities in Part VI................................ 4 Yes  
5 Did the hospital facility make its CHNA report widely available to the public? ............. 5 Yes  
If “Yes,” indicate how the CHNA report was made widely available (check all that apply):
a
b
c
6 If the hospital facility addressed needs identified in its most recently conducted CHNA, indicate how (check all that apply to date):
a
b
c
d
e
f
g
h
i
7 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 ........ 7   No
8a 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)? ........................... 8a   No
b If "Yes" to line 8a, did the organization file Form 4720 to report the section 4959 excise tax? ...... 8b   No
c 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
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
b
c
d
e
f
g
h
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
b
c
d
e
f
g
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
b
c
d
e
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
b
c
d
e
Schedule H (Form 990) 2012
Schedule H (Form 990) 2012
Page
Part VFacility Information (continued)

18 Indicate which efforts the hospital facility made before initiating any of the actions listed in line 17 (check all that apply):
a
b
c
d
e
Policy Relating to Emergency Medical Care
Yes No
19 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?.......... 19 Yes  
If “No,” indicate why:
a
b
c
d
Charges to Individuals Eligible for Assistance under the FAP (FAP-Eligible Individuals)
20 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.
a
b
c
d
21 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? ............................ 21   No
If “Yes,” explain in Part VI.
22 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? ......................... 22   No
If “Yes,” explain in Part VI.
Schedule H (Form 990) 2012
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
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 Part VI - States Where Community Benefit Report FiledCommunity Benefit Data is reported annually to the Wisconsin Hospital Association.
  Part V - Explanation of Number of Facility Type St. Joseph's Community Hospital of West Bend 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 Promotion of Community HealthThe Board of Directors at St. Josephs Hospital is made up of medical and business professionals, all of whom reside in the hospitals primary service area. They are dedicated to leveraging the benefits of our community through our hospitals mission. They value the unique character and needs of the patients and communities we serve and the physicians who provide specialty care. St. Josephs Hospitals community board demonstrates our commitment to quality and service. Annually, the board reviews and approves the hospitals Community Health Improvement Plan.Additionally, SJH supports the Healthy Community Fund, administered through St. Josephs Community Foundation, was created in 2008 to support community programs or projects throughout Washington County that positively affect the health and wellness of those living and working within the area. The fund awarded $220,000 in grants to nine area non-profit organizations in fiscal year 2013.SJH has an open Medical Staff with the exception of some departments having contracted exclusivity services. As a hospital, SJH does not search outside of our system, however, if a physician comes to us wishing to have privileges they are put through the credentialing process.As a not-for-profit health system, Froedtert Health reinvests its surplus funds back to the community through programs to serve the poor and uninsured, teach future healthcare professionals, develop new medical therapies, manage chronic conditions like diabetes, provide health education and promotion initiatives, and participating 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 Hospital 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:St. Josephs Hospital develops and executes community outreach programming and activities based on identified community health needs. Every needs assessment cycle, SJH Community Outreach staff along with the hospitals community partners and other leaders 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. SJH 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 annually to the SJH Board of Directors, Physician Advisory Council, Leadership Council, Foundation and Healthy Community Fund Boards. 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- Obesity and Physical ActivityFor 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.Affiliated Health Care SystemFroedtert & the Medical College of Wisconsin St. Josephs Hospital, founded in 1930 by local doctors, community leaders and the Sisters of the Divine Savior, is a full-service hospital serving residents of West Bend and Washington County. St. Josephs Hospital, specializing in birthing services, cancer care, emergency care, orthopaedics, surgical services and womens health, is part of the Froedtert & The Medical College of Wisconsin health care network, which also includes Froedtert Memorial Lutheran Hospital, Milwaukee; Community Memorial Hospital, Menomonee Falls; and more than 30 primary and specialty care health centers and clinics.For more information about Froedtert Health, visit www.froedtert.com.
  Part VI - Explanation Of How Organization Furthers Its Exempt Purpose St. Josephs Hospital provides healthy community initiatives that support the community. These initiatives include but not limited to, community education classes, complimentary fitness classes, community volunteering, speakers bureau opportunities and community health fairs.Community Health Education ProgramsSt. Josephs Hospital regularly schedules educational classes for the community. The services offered are readily accessible to the general public and are free of charge. These programs provide information on a wide variety of health concerns including chronic disease prevention / management. In addition, St. Josephs Hospital offers a speakers bureau that is a free service to the community. Our knowledgeable health professionals provide credible, up-to-date information on a variety of healthcare topics for groups and organizations. 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, St. Josephs Hospital collaborates with the Washington County Injury Prevention Coalition 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 2006, 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. United Way Employee CampaignSt. Josephs Hospital collaborates with the United Way of Washington County to address community needs in the areas of health, education and quality of life. St. Josephs Hospital hosts an annual workplace giving campaign to support United Way and its affiliated organizations. Over 200 hours were spent coordinating the FY13 campaign. In addition to an employee campaign, St. Josephs Hospital matches donations up to $8,000.Healthy People Project of Washington CountySt. Josephs Hospital, through leadership representation on the Healthy People Project of Washington County and the committees dedication, are successfully impacting the health of many in our community. These efforts are being done through collaborative partners, such as Washington County Planning and Parks, Washington County Injury Prevention Coalition, and various local municipalities. The Healthy People Project of Washington County is one of only 118 communities throughout the country (and one of five in Wisconsin) selected as a Pioneering Healthier Communities coalition. Albrecht Free ClinicThe Albrecht Free Clinic provides free medical care to uninsured and underinsured residents of Washington County. Through the support of St. Josephs Hospital, the clinic is able to serve patients for chronic illness and acute care issues. Services provided by St. Josephs Hospital at no cost to the patient would be: x-rays, labs, MRI and CT Scans. On an average, over 3,300 patients seek medical services per year. In addition to services related to the patients direct care, St. Josephs Hospital provides assistance in providing medical supplies, IT services, and rental space at a cost of $93,009 (4,896 sq ft). Sexual Assault Nurse Examiner (SANE) Available 24 Hours a Day When emergencies take on the even more traumatic element of sexual assault, the specially trained SANE program staff has created a safe haven at St. Josephs for comprehensive, compassionate care SANE staff are registered nurses with advanced training in medical-forensic examination and in the psychological and emotional trauma patients experience. They care for victims of all ages, races and populations to provide timely:- Emotional support - Physical examination and wellness check - Collection of medical-forensic evidence - Assistance with reporting the crime to police, when requested (mandatory reporting for children) - Assistance with concerns about sexually transmitted infection and pregnancy - Assistance with safety planning - Development of a medical follow-up plan SANE nurses are available to speak to groups and organizations. They are also able to serve as expert witnesses if called to testify at a trial.In Fiscal Year 2013, St. Josephs Hospital SANE program served 15 people. Subsidized Transportation Program:The Subsidized Medical Transportation Program at St. Josephs 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, St. Josephs provided over 900 subsidized rides to 500 people who needed transportation to receive their health care. Leadership Quality Indicator:As an indication of the St. Joseph's executive teams commitment to the community, 15 hospital leaders provided more than 100 hours of support to local initiatives, not-for-profit organizations and community events. Job Shadow Program:St. Josephs Hospital recognizes the value of preparing tomorrows health care providers, giving dozens of aspiring care-givers the valuable opportunity to serve as job shadows or preceptors every year. In FY 2013, 40 students participated in the program at St. Joseph's Hospital.Project Lead the WayExperts from St. Josephs Hospital partnered with teachers at Hartford Union High School this year by sharing their knowledge and passion for their professions with high school students interested in biomedical sciences.This was the third year of an ongoing, innovative program called Project Lead the Way, a national STEM (science, technology, engineering and math) education curricular program that provides hands-on classroom experiences for students, who may earn college credit for their work.A total of 4 professionals delivered 4 classroom presentations to 125 students in the 2012-2013 school year. Presenters included an advanced practice nurse with a PHD, lab technician, cardiologist and infectious disease physician. Community Health ScreeningsSt. Josephs Hospital offered free blood pressure and skin cancer 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, St. Joseoh's Hospital conducted health screenings for 125 people.For more information on St. Joseph's Hospital Community Benefit programs, please visit www.froedtert.com or see the Community Benefit report.
  Part VI - Community Building Activities To promote the health of our communities, St. Joseph's Hospital participates in numerous community building activities that are recognized in the community, which are included elsewhere on Schedule H. These activities include:1. Physical Improvements and Housing: contributions toward neighborhood housing improvement for the underserved.2. Coalition Building: collaboration with county service agencies includes work with the Washington County Injury Prevention Coalition on the Every 15 Minutes anti-drunk driving program for teens. St. Joseph's Hospital's SANE (Sexual Assault Nurse Examiner Program) works closely with volunteers from the area Women's Shelter to care for victims of sexual assault and SANE nurses collaborate with a county coalition to promote awareness, education and prevention of sexual assaults. 3. Economic Development: Leadership participates in local chamber of commerce boards focusing on economic development.4. Diversity: training that recruits health professionals in our traditionally underserved community. 5. Other: Contributions to local organization of equipment, lease space and supplies.
  Part VI - Community Information St. Josephs Hospital has been dedicated to serving residents of West Bend and Washington County since 1930 when it was established through the efforts of visionary community leaders and volunteers. As an important part of the community fabric, the hospital continues to meet the changing health and wellness of people who live in and around Washington County. To better serve those needs in a modern, accessible, safe and efficient setting, the hospital built a new replacement facility on US 45 and Hwy PV in August 2005. The area served has a large population between the ages of 18 and 34 years old. 39% of the residents are a high school graduate or less and 34% are in the bottom 40 percent of the income bracket.Aurora Hartford Hospital is the only other hospital located in Washington county. There are no FQHC's located Washington County. Albrecht Free Clinic is a free clinic serving residents throughout Washington County.
  Part VI - Patient Education of Eligibility for Assistance St. Joseph's Community Hospital of West Bend 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 Hospital website contains information regarding pricing, how to understand your hospital bill, and how to apply for Financial Assistance. The 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 December, 2011 St. Josephs Hospital West Bend collaborated with JKV Research, LLC along with Aurora Health Care, Childrens Hospital of Wisconsin, Columbia St. Marys Health System and Washington County Health Department to conduct a Community Health Needs Assessment in Washington County. The research from the needs assessment provides valuable behavioral data, lifestyle habits, and the prevalence of risk factors and disease conditions of Washington County residents. CHNA Overview/Objectives: Gather data on behavioral and lifestyle habits of the adult population and household-level data. Gather data on the prevalence of risk factors and disease conditions of the adult population. Compare health data of residents to previous health studies. Compare health data to national and state measurements.CHNA Methodology: 18 minute telephone survey of area residents 400 completions from November 29 through December 19, 2011 Two-fold sampling1) RDD landline sample of listed & unlisted #s (n=300)- Respondents randomly selected based on number of adults in household - Weighting based on number of adults and number of residential phone numbers in HH 2) Cell phone only sample (n=100) Adult answering the phone designated as the respondent - All data post-stratified by age and gender of adult residents as of 2010 Census proportions. Margin of error: 5%In addition to the Washington County Community Health Needs Assessment, St. Josephs Hospital conducted key informant interviews with 26 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 Washington County. 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 Care- Obesity/Nutrition- Lack of Physical Exercise- Chronic Disease Management- AODAWashington County Health Department Community Health Improvement Plan 2012 2016St. Josephs Hospital is a partner with Washington County Public Health Departments Community Health Improvement Plan. The plan which was adopted by the county board in 2012 focuses on the following community health needs:- Improve Dietary Quality- Increase Breastfeeding- Increase Physical Activity- Obesity (Healthy People Project of Washington County)- Enhance state and community capacity to improve population level health.St. Josephs hospital is very active in the Healthy People Project of Washington Countys strategic plan with goals to improve access to fruit and vegetable consumption and increase physical activity as a means to decrease obesity. For more information on this initiative please go to www.getmovingwashingtoncounty.com.
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 St. Josephs Hospitals community health improvement initiatives are targeted for the broad community, especially vulnerable populations (uninsured/underinsured) in the hospitals primary and secondary service areas. St. Josephs Hospitals mission is to advance the health of the communities we serve through exceptional care enhanced by innovation and discovery. The hospitals Board of Directors and Community Engagement staff 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 Obesity/Physical Activity.The following needs are not being addressed by St. Joseph's 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 May 14, 2013, St. Josephs's Hospital adopted a Community Health Improvement Plan.OverviewThis Implementation Strategy serves as the community health improvement component of St. Josephs Hospital community benefit strategy, focusing on Access to Primary/Specialty Care, Chronic Disease Management, Alcohol and Other Drug Abuse and Obesity/Physical Activity. St. Josephs Hospital 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 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 Milwaukee Health Department aligned resources to complete a shared community health needs assessment (CHNA) in 2011 - 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 400 adults, significant key informant interviews and a secondary source data analysis. This shared CHNA serves as the foundation for St. Josephs Hospitals implementation strategy to improve health outcomes and reduce disparities in Washington County.The CHNA summary and full reports can be found on St. Josephs website.Identified Community Needs in Washington County:- 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- Transportation- Health Literacy and NavigationSt. Josephs Hospitals Implementation Strategy PrioritiesReflecting St. Josephs Hospital clinical strengths and community partnerships, the CHNA identified priorities of Access, AODA, Obesity and Physical Activity and Chronic Disease as focus areas for its Implementation Strategy. Implementation Strategy 20131. Program: Subsidized TransportationHealth Need: Affordable and Accessible TransportationInternal Resources: Community Outreach; Discharge Planning and Case Management; Nursing Administration; Emergency Department Community Resources: Washington County Shared Ride TaxiObjective: Provide affordable and accessible medical transportation to SJH patients at or below 200% Federal Poverty Level2. Program: Albrecht Free ClinicHealth Need: 8% of Washington County Residents Uninsured; Unmet Medical Care; Routine Procedures; Access to Specialty Care Internal Resources: F&MCW Community Physicians; SJH Leadership and Physician Involvement on AFC Board; SJH & CP Lab and Radiology Depts; SJH Case Managers; SJH Emergency Dept Community Resources: Albrecht Free Clinic; Washington County Healthy Community Fund; Washington County Public Health DepartmentObjective: Referral process for uninsured populations from SJH Emergency Department to Albrecht Free Clinic; Provide vouchers for ancillary services for AFC patients; Provide vouchers for specialty care to clinic patients; Recruitment and support F&MCW Community physicians that donate time to AFC3. Program: Prostate Screening ProgramHealth Need: Decrease in percentage of men having prostate cancer screenings in Washington County the past two years. Internal Resources: Kraemer Cancer Center; F&MCW Community Physicians; Community Outreach; SJH Community Foundation; Marketing Community Resources: ZERO; Albrecht Free Clinic; Washington County Public Health Dept; American Cancer Society; Casa GuadalupeObjective: Increase the amount of men having PSA and Digital Exam every two years4. Program: Colorectal Screening ProgramHealth Need: Decrease in blood stool test in past year; 69% of population age 50 and older had a colonoscopy in the past 10 yearsInternal Resources: Kraemer Cancer Center; F&MCW Community Physicians; Community Outreach; SJH Community Foundation; MarketingCommunity Resources: American Cancer Society; Albrecht Free Clinic; Casa Guadalupe; Bobbie Nick Voss Charitable FundsObjective: Increase the number of populations reporting having a colonoscopy age 50 and above; Provide care navigation and facilitate access for vulnerable populations through health education and colonoscopy screenings 5. Program: Sexual Assault Nurse Examiner Program (SANE)Health Need: 4% of population reported being afraid for their safetyInternal Resources: Emergency Department; Trained SANE Nurse; St. Joesph's Community Foundation; SJH PartnersCommunity Resources: Friends of Abused Families; Washington County EMS/Police DepartmentsObjective: Provide forensic evaluations, assessments and emotional support to victims; Track and facilitate referrals to medical and other non-profit agencies6. Program: Every 15 Minutes ProgramHealth Need: Increase in binge drinking - higher than state and national average; 3% of population reported driving while under the influence or was a passengerInternal Resources: Emergency Department; Community Outreach; Emergency Preparedness Coordinator; Marketing; Nursing StaffCommunity Resources: West Bend School District; Kewaskum School District; Washington County Sheriffs Department; West Bend Fire/EMS; Flight for LifeObjective: Reduce youth underage drinking and driving; Reduce traffic related impairment accidents and deaths; Program runs approximately every three years7. Program: Health People Project of Washington CountyHealth Need: Increase in populations reporting they are overweight- higher than the national average; Decrease in the number of populations reported getting recommended moderate and vigorous physical activity; Decrease in recommended fruit and vegetable intakeInternal Resources: Community Outreach; MarketingCommunity Resources: Washington County Healthy Community Fund; Full Shelf Food Pantry; Albrecht Free Clinic; Aurora Health Care; Kettle Moraine YMCA; UW-Extension Washington County; Washington County Public Health DeptObjective: Increase the number of individuals reporting moderate to vigorous physical activity; Increase the daily amount of fruit and vegetable intake; Decrease the number of individuals reporting being overweight or obese 8. Program: Living Well with Chronic ConditionsHealth Need: Adults in Washington County with Chronic disease: 28% with high blood pressure; 21% with high cholesterol; 9% with diabetesInternal Resources: Community Education Dept; F&MCW trained facilitators; Wellness Works; Community Outreach; F&MCW Community PhysiciansCommunity Resources: Wisconsin Institute for Health Aging; Washington County ADRC; Albrecht Free Clinic; Kettle Moraine YMCA; Casa GuadalupeObjective: Increase patient engagement in self-management of chronic disease; Decrease ED utilization for chronic disease management; Increase in self-management as measured by pre and post survey
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 - http://www.froedterthealth.org/upload/docs/community-memorial/community-giving/Benefit/washington-county-community-health-survey-report.pdfAdditional Websites:Washington County Public Health Department - http://www.co.washington.wi.us/uploads/docs/washington-county-community-health-survey-report-march-2012.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 St. Josephs HospitalAurora Health CareColumbia St. Marys Health SystemChildrens Hospital of WisconsinWashington County Public Health DepartmentJKV Research was hired by the participating Health Care Systems and Washington County Public Health Department to lead the CHNA process for Washington County. The total cost of the 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, St. Josephs Hospital Community Outreach Staff conducted key informant interviews with the following non-profit health and human service agencies:Albrecht Free Clinic Hartford Jt 1 School DistrictHartford Parks and Recreation DepartmentInterfaith Caregivers of Washington CountyUniversity of Wisconsin Extension Washington CountyWashington County Mental Health DepartmentWashington County Public Health DepartmentThe Council on AODAVolunteer Center of Washington CountyEconomic Development of Washington CountySt. Gabriel ChurchSt. Marys Catholic Parish Holy HillWashington County WICKettle Moraine YMCAAging and Disability Resource CenterFriends of Abused FamiliesCasa Guadalupe Education CenterHabitat for Humanity Washington CountyWest Bend Police DepartmentWashington County Sheriffs DepartmentWest Bend Chamber of CommerceHartford Area Chamber of Commerce
  Part III, Line 9b - Provisions On Collection Practices For Qualified Patients In alignment with the Froedtert Health, Inc. financial assistance policy regarding the billing, collection and support for patients with payment obligations, St. Joseph's Community Hospital of West Bend 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 St. Joseph's Community Hospital of West Bend believes that all of the $6,520,797 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 $91,921,522. 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 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 the instructions from the IRS.
Schedule H (Form 990) 2012
Additional Data


Software ID: 12000229
Software Version: 2012v2.0
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
St Josephs Community Hospital
of West Bend Inc
Employer identification number

39-0806302
Part I
Questions Regarding Compensation
Yes
No
1a
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.
b
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....
1b
Yes
 
2
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? .......
2
Yes
 
3
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.
4
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:
a
Receive a severance payment or change-of-control payment? ................
4a
Yes
 
b
Participate in, or receive payment from, a supplemental nonqualified retirement plan? .........
4b
Yes
 
c
Participate in, or receive payment from, an equity-based compensation arrangement? .........
4c
 
No
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.
5
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:
a
The organization? ...........................
5a
 
No
b
Any related organization? .........................
5b
 
No
If "Yes," to line 5a or 5b, describe in Part III.
6
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:
a
The organization? ...........................
6a
 
No
b
Any related organization? .........................
6b
 
No
If "Yes," to line 6a or 6b, describe in Part III.
7
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 ............
7
 
No
8
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 .............................
8
 
No
9
If "Yes" to line 8, did the organization also follow the rebuttable presumption procedure described in Regulations section 53.4958-6(c)? .........................
9
 
No
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50053T
Schedule J (Form 990) 2012

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
(i) Base compensation (ii) Bonus & incentive compensation (iii) Other reportable compensation
(1)Wolter Brian MDDir&Doctor (i)
(ii)		  
433,302 		 
  		 
8,214 		 
13,475 		 
20,242 		 
475,233 		 
 
(2)Van De Kreeke JeffreyFH CFO (i)
(ii)		  
291,459 		 
110,009 		 
27,257 		 
73,475 		 
12,039 		 
514,239 		 
 
(3)Olson DavidDir&President (i)
(ii)		  
283,065 		 
75,655 		 
2,208 		 
37,333 		 
29,434 		 
427,695 		 
 
(4)Martin MaryDir&CNO (i)
(ii)		  
143,032 		 
  		 
382 		 
6,843 		 
3,066 		 
153,323 		 
 
(5)Malzewski MichaelFormer - Officer (AVP Finance) (i)
(ii)		  
240,189 		 
  		 
2,851 		 
12,945 		 
26,589 		 
282,574 		 
 
(6)Lux Theresa MDir&CNO (i)
(ii)		  
180,144 		 
50,225 		 
17,299 		 
29,901 		 
10,084 		 
287,653 		 
 
(7)Less TimothyMedical Physicist (i)
(ii)		 190,997
  		 
  		892
  		10,924
  		17,973
  		220,786
  		 
 
(8)Lauenstein DebraFormer - Key (Dir HR) (i)
(ii)		  
153,521 		 
  		 
724 		 
8,117 		 
9,956 		 
172,318 		 
 
(9)Laird MichaelPast President (i)
(ii)		 281,200
  		 
  		 
  		13,475
  		 
  		294,675
  		 
 
(10)Knoll ThomasTreasurer (i)
(ii)		  
151,668 		 
  		 
693 		 
8,310 		 
26,791 		 
187,462 		 
 
(11)Juech ThomasPharmacist (i)
(ii)		 135,467
  		 
  		1,150
  		9,365
  		7,886
  		153,868
  		 
 
(12)Jacobson CatherineDir&FH CEO (i)
(ii)		  
698,373 		 
298,671 		 
4,782 		 
150,975 		 
28,885 		 
1,181,686 		 
 
(13)Herdrich Gary MDDir&Chief Staff (i)
(ii)		  
604,933 		 
  		 
20,590 		 
17,150 		 
17,145 		 
659,818 		 
 
(14)Herdeman CharlesPharmacist (i)
(ii)		 143,961
  		 
  		599
  		9,641
  		16,149
  		170,350
  		 
 
(15)Hawig ScottFH CFO (i)
(ii)		  
214,150 		 
9,601 		 
5,846 		 
  		 
10,354 		 
239,951 		 
 
Schedule J (Form 990) 2012

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. Country 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
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
St Josephs Community Hospital
of West Bend Inc
Employer identification number

39-0806302
Identifier Return Reference Explanation
  Part IV, Line 24a Even though the liability is on the books of St. Joseph's Community Hospital of West Bend, Inc.,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 Transfer to affiliates = -$2836555
Form 990, Part XI, Line 9 Other Changes In Net Assets Or Fund Balances - Other Decreases Released from restriction = -$8997
Form 990, Part XI, Line 9 Other Changes In Net Assets Or Fund Balances - Other Increases Contributions = $4769
Form 990, Part VI, Line 19 Form 990, Part VI, Line 19: Other Organization Documents Publicly Available Froedtert Health, Inc.'s quarterly financial information, which includes St. Joseph's Community Hospital of West Bend, Inc., is made available to the public through the Digital Assurance Corporation, Inc. website. Anyone can register to receive ongoing access to and notifications regarding financial statements at the online website. St. Joseph's Community Hospital of West Bend, Inc. governing documents and conflict of interest policy is made available to the public through the corporate office upon request.
Form 990, Part VI, Line 15a Form 990, Part VI, Line 15a: Compensation Review & Approval Process - CEO, Top Management In establishing the compensation of the organization's 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 of Froedtert Health, the parent organization.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, and key employees are required to complete a conflict of interest disclosure document. The data is compiled, and the Froedtert Health Vice President-Chief Compliance Officer (CCO), the Senior Vice President-General Counsel and/or delegate review all forms and notifications to determine if any conflicts of interest exists 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 St. Joseph's 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 once 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 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 St. Joseph's Community Hospital, has certain reserved powers and authorities with respect to the operations and management of St. Joseph's Hospital, as set forth in St. Joseph's bylaws.
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 St. Joseph's Community Hospital of West Bend, Inc. 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 St. Joseph's Community Hospital of West Bend, Inc.
Form 990, Part VI, Line 4 Form 990, Part VI, Line 4: Description of Significant Changes to Organizational Documents Articles of Incorporation and Bylaws were amended and restated to reflect termination of definitive agreement that created original health care system.
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
SCHEDULE R
(Form 990)
Department of the Treasury
Internal Revenue Service
Related Organizations and Unrelated Partnerships
MediumBulletComplete if the organization answered "Yes" to Form 990, Part IV, line 33, 34, 35, 36, or 37.
MediumBulletAttach to Form 990. MediumBullet See separate instructions.

OMB No. 1545-0047
2012
Open to Public Inspection
Name of the organization
St Josephs Community Hospital
of West Bend Inc
Employer identification number

39-0806302
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?
Yes No
(1) Community Memorial Foundation of MF Inc

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 Inc
 
 
No
(2) 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
(3) Froedtert Physician Partners Inc

9200 W Wisconsin Ave

Milwaukee,WI53226
27-2042610 		Healthcare Services WI 501(c)(3) 3 Froedtert Health Inc
 
 
No
(4) Froedtert Health Inc

9200 W Wisconsin Ave

Milwaukee,WI53226
39-2014409 		Management Services WI 501(c)(3) Ln 11, type 111 NA
 
 
No
(5) 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
(6) 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 Hospital
 
Yes
 
(7) Community Memorial Hospital of MF Inc

W180 N8085 Town Hall Road

Menomonee Falls,WI53051
39-0987025 		Hospital WI 501(c)(3) 3 Froedtert Health Inc
 
 
No
(8) Froedtert Memorial Lutheran Hosp Inc

9200 W Wisconsin Ave

Milwaukee,WI53226
39-6105970 		Hospital WI 501(c)(3) 3 Froedtert Health Inc
 
 
No
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50135Y
Schedule R (Form 990) 2012
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



 		(e)
Predominant income(related, unrelated, excluded from tax under sections 512-514)

(f)
Share of total income




 		(g)
Share of end-of-year
assets



 		(h)
Disproprtionate allocations?




 		(i)
Code V—UBI
amount in box 20 of
Schedule K-1
(Form 1065)
 		(j)
General or
managing
partner?



 		(k)
Percentage
ownership
Yes No 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
 		(h)
Percentage
ownership
 		(i)
Section 512(b)(13) controlled entity?
Yes No
(1) Progressive Physician Network Inc

9200 West Wisconsin Avenue
Milwaukee,WI53226
27-0367127 		Management Services WI Froedtert Health Inc
  		C         No












Schedule R (Form 990) 2012
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
No
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 . . . . . . . . . . . . . . . . . . . . . . .
1a
 
No
b Gift, grant, or capital contribution to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1b
Yes
 
c Gift, grant, or capital contribution from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1c
 
No
d Loans or loan guarantees to or for related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1d
 
No
e Loans or loan guarantees by related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1e
 
No
f Dividends from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1f
 
No
g Sale of assets to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1g
 
No
h Purchase of assets from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1h
 
No
i Exchange of assets with related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1i
 
No
j Lease of facilities, equipment, or other assets to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1j
Yes
 
k Lease of facilities, equipment, or other assets from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . .
1k
 
No
l Performance of services or membership or fundraising solicitations for related organization(s) . . . . . . . . . . . . . . . . . . . .
1l
Yes
 
m Performance of services or membership or fundraising solicitations by related organization(s) . . . . . . . . . . . . . . . . . . . .
1m
Yes
 
n Sharing of facilities, equipment, mailing lists, or other assets with related organization(s) . . . . . . . . . . . . . . . . . . . . .
1n
Yes
 
o Sharing of paid employees with related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1o
Yes
 
p Reimbursement paid to related organization(s) for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1p
Yes
 
q Reimbursement paid by related organization(s) for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1q
Yes
 
r Other transfer of cash or property to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1r
Yes
 
s Other transfer of cash or property from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1s
 
No
2
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
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) 		(d)
Predominant income (related, unrelated, excluded from tax under section 512-514)

(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 V—UBI
amount in box 20
of Schedule K-1
(Form 1065) 		(j)
General or
managing
partner? 		(k)
Percentage
ownership
Yes No Yes No Yes No






























Schedule R (Form 990) 2012
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