2023-08-11T08:08:13-05:00 2022-09-30 390758449 WIPFLI LLP PO BOX 12237 GREEN BAY WI 543072237 990 2021-10-01 391657627 BELLIN PSYCHIATRIC CENTER BELL 9204333630 PO BOX 23725 GREEN BAY WI 54305 SHARLA BAENEN PRESIDENT 9204333630 2023-08-07 1 SHARLA BAENEN 999009999 TERRI REXRODE CPA MST P00096513 9206620016 2023-07-28 3 AAL1 IAL1 2021 2023-04-26 12:10:37Z SHARLA BAENEN PO BOX 23725 GREEN BAY WI 54305 30479004 0 X WWW.BELLIN.ORG X 1990 WI BELLIN PSYCHIATRIC CENTER, INC. (BPC) PROVIDES PSYCHIATRIC AND ALCOHOL AND OTHER DRUG ABUSE (AODA) SERVICES TO ENHANCE THE HEALTH OF THE COMMUNITY AND IMPROVE THE HEALTH OF LOW-INCOME PATIENTS. CONSISTENT WITH THE MISSION OF BPC, CARE IS PROVIDED TO PATIENTS REGARDLESS OF THEIR ABILITY TO PAY. 12 6 300 12 0 0 152190 360812 29381803 28938158 634402 342834 525240 558850 30693635 30200654 0 0 0 0 22653104 23125579 0 0 0 7034573 8706051 29687677 31831630 1005958 -1630976 20172282 18725933 12672010 14044274 7500272 4681659 X BELLIN PSYCHIATRIC CENTER, INC. (BPC) PROVIDES PSYCHIATRIC AND ALCOHOL AND OTHER DRUG ABUSE (AODA) SERVICES TO ENHANCE THE HEALTH OF THE COMMUNITY AND IMPROVE THE HEALTH OF LOW-INCOME PATIENTS. CONSISTENT WITH THE MISSION OF BPC, CARE IS PROVIDED TO PATIENTS REGARDLESS OF THEIR ABILITY TO PAY. 0 0 28074827 0 29497008 THE CENTER PROVIDES PSYCHIATRIC AND ALCOHOL AND OTHER DRUG ABUSE (AODA) SERVICES TO RESIDENTS OF NORTHEASTERN WISCONSIN. DURING FISCAL YEAR 2022 9,122 INPATIENT DAYS WERE PROVIDED (5,539 ADULT, 858 CHILD AND 2,725 ADOLESCENT). THE NUMBER OF OUTPATIENT THERAPY VISITS DURING FISCAL YEAR 2022 WERE 28,826. IN ADDITION, THERE WERE 61,158 INPATIENT AND OUTPATIENT MD, APNP AND PHD VISITS. 28074827 1 1 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 0 0 300 1 0 0 0 0 0 0 0 0 0 0 0 0 X 12 6 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 X JULIE GRACEFFA 9204333630 744 S WEBSTER AVENUE GREEN BAY WI 54301 SHARLA BAENEN BPC PRESIDENT (THRU 12/21)/BMH COO 15.00 30.50 X X 24722 399149 75362 BARB GILLING CHAIRPERSON 0.50 1.00 X X 0 0 0 SUSAN GALLAGHER-LEPAK MEMBER 0.50 X 0 0 0 MICHAEL HOFFMAN MD MEMBER/PHYSICIAN 0.50 35.00 X 0 248870 41415 NACIYE KALAFAT MD MEMBER/FORMER PSYCH. DEPT. CHAIR 45.00 X 358621 0 42767 WILLIAM LAAKSO PSYD MEMBER 0.50 X 0 0 0 WILLIAM MCKINLEY MEMBER 0.50 X 0 0 0 JOHN PAUL MEMBER 0.50 X 0 0 0 EMILY RADEMACHER MD MEMBER/PRESIDENT MEDICAL STAFF 45.00 X 351833 0 48581 TARA ROBERTSON PSYD MEMBER/PSYCHIATRY DEPT. CHAIR 40.00 X 175513 0 11264 DAVID VANDERPLOEG MEMBER 0.50 X 0 0 0 CHRISTINE WOLESKE MEMBER/BMH CEO 0.50 51.05 X 0 1418528 201283 DEREK CARLSON MD PHYSICIAN 40.00 X 336583 0 22973 DHANVENDRAN RAMAR MD PHYSICIAN 40.00 X 475823 0 44971 REKHA VIJAYAN PHYSICIAN 40.00 X 412257 0 17318 KIM LASECKI PHYSICIAN 40.00 X 389453 0 42319 VICTORIA PASSOV ADAMS PHYSICIAN 40.00 X 330643 0 18606 2855448 2066547 566859 34 0 1 0 BELLIN MEMORIAL HOSPITAL INC 744 S WEBSTER AVE GREEN BAY WI 543043400 INTERCOMPANY SERVICES 2378222 COMPHEALTH ASSOCIATES INC 6440 S MILLROCK DR STE 175 SALT LAKE CITY UT 84121 CONTRACTED MDS 1406164 MEDICAL COLLEGE OF WI 8701 WATERTOWN PLANK RD MILWAUKEE WI 53226 RESIDENCY PROGRAM 243409 STEVEN R MILJOUR W223 LUCHAY RD BARK RIVER MI 49807 CONTRACTED MD 114900 4 6468 336126 18218 360812 NET PATIENT SERVICE REVENUE 621300 28906533 28906533 CONTRACTED SERVICES 621110 31625 31625 28938158 152469 152469 468715 278350 190365 190365 190365 INCENTIVE PAYMENTS 621300 558850 558850 558850 30200654 29497008 0 342834 1057526 1004649 52877 17959183 17353072 606111 892401 838271 54130 1967192 1856380 110812 1249277 1187493 61784 21165 21165 2992219 2744238 247981 515 515 226278 194365 31913 19474 17910 1564 482705 432735 49970 8069 4056 4013 88460 69176 19284 141120 141120 487580 202304 285276 62403 9414 52989 MEDICAL SUPPLIES 2742966 823939 1919027 BAD DEBT EXPENSE 915035 915035 FOOD 259704 259704 DUES & SUBSCRIPTIONS 125725 53167 72558 132633 108919 23714 31831630 28074827 3756803 0 1100800 822522 2033914 2034017 2934008 2482606 12779319 5875758 6754244 6903561 7349316 6483227 20172282 18725933 2818633 1661938 1631622 1538968 8221755 10843368 12672010 14044274 X 7500272 4681659 7500272 4681659 20172282 18725933 X -1630976 -1187633 -4 X X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 2747765 2747765 5750760 3050102 2700658 4177211 2825656 1351555 103583 103583 6903561 DUE TO AFFILIATES 10843368 10843368 1 1 X 1 X 220.000000000000 1 X 1 1 1 0 1 1 494214 494214 0.01600 10528497 7350468 3178029 0.10280 11022711 7350468 3672243 0.11880 18218 0 0.00000 166835 166835 0.00540 3910 3910 0.00010 170745 18218 170745 0.00550 11193456 7368686 3842988 0.12430 1 493115 0 2942750 4186776 -1244026 X 1 1 1 1 BELLIN PSYCHIATRIC CENTER INC 301 E ST JOSEPH STREET GREEN BAY WI 543053725 WWW.BELLIN.ORG 263 X PSYCHIATRIC BELLIN PSYCHIATRIC CENTER INC 1 0 0 1 X X X X X X X X X 20 1 1 1 1 X SEE PART V, SECTION C, LINE 7D X X 1 20 1 SEE PART V, SECTION C, LINE 7D 0 1 X 220.000000000000 400.000000000000 X X X 1 1 X X X X 1 X SEE PART V, SECTION C, LINES 16A-C X SEE PART V, SECTION C, LINES 16A-C X SEE PART V, PAGE 10 X X X X X X 1 X 0 X X X X 1 X 0 0 BELLIN PSYCHIATRIC CENTER, INC. PART V, SECTION B, LINE 5: THE PRIORITIES FROM 2021-2023 WERE MENTAL HEALTH, ALCOHOL/DRUG USE AND ABUSE, AND NUTRITION/PHYSICAL ACTIVITY. WE NOW KNOW THAT WE NEED TO LOOK AT THE REASONS WHY HEALTH GAPS EXIST. COMMUNITY FEEDBACK WAS INCLUDED IN THE COMMUNITY MEMBER CHA SUMMARY. FEEDBACK WAS SOLICITED IN THE FOLLOWING WAYS:- ONGOING CHA/CHIP SURVEY ON THE BCHP WEBSITE, WHICH ASKS FOR FEEDBACK IN ENGLISH, HMONG, OR SPANISH. SEVENTY-NINE RESPONSES WERE RECEIVED FROM THE GENERAL PUBLIC. - ORGANIZATIONAL REPRESENTATIVES WERE ALSO SURVEYED AND ASKED FOR THEIR FEEDBACK ON THE PRIORITIES, WITH TWENTY-ONE RESPONSES, WITH THOSE ORGANIZATIONS LISTED BELOW.- ADS WERE RUN IN THE NEWSPAPER AND ON SOCIAL MEDIA ASKING FOR COMMUNITY MEMBERS' FEEDBACK -BEYOND HEALTH STEERING COMMITTEE, WHICH INCLUDES REPRESENTATION FROM LOCAL PUBLIC HEALTH AGENCIES, AREA HEALTH SYSTEMS, AND COMMUNITY AGENCIES. THE FOLLOWING ARE REPRESENTED ON THE BEYOND HEALTH STEERING COMMITTEE:- BROWN COUNTY PUBLIC HEALTH- DE PERE HEALTH DEPARTMENT- WI DEPARTMENT OF HEALTH SERVICES, DIVISION OF PUBLIC HEALTH- BROWN COUNTY UNITED WAY- NEW COMMUNITY CLINIC- PREVEA HEALTH- HSHS- ADVOCATE AURORA- BELLIN HEALTHORGANIZATIONS REPRESENTED THROUGH FEEDBACK TO SURVEYS:- UNIVERSITY OF WISCONSIN-MADISON, DIVISION OF EXTENSION BROWN COUNT- BROWN COUNTY VETERANS SERVICE- WELLO- FORWARD SERVICE CORPORATION- JACKIE NITSCHKE CENTER- THE FRIENDS OF THE FOX RIVER TRAIL- OPTIONS FOR INDEPENDENT LIVING- NWTC- GREEN BAY AREA PUBLIC SCHOOLS- CONNECTIONS FOR MENTAL WELLNESS- UNIVERSITY OF WISCONSIN-MADISON, DIVISION OF EXTENSION FOODWISE- ASHWAUBENON SCHOOL DISTRICT- UW CENTER FOR TOBACCO RESEARCH AND INTERVENTION- GREEN BAY POLICE DEPT- NEW NORTH, INC.- DOWNTOWN GREEN BAY, INC.- ONEIDA COMMUNITY HEALTH SERVICES- HMONG/ASIAN COMMUNITY BELLIN PSYCHIATRIC CENTER, INC. PART V, SECTION B, LINE 6A: AURORA BAYCARE MEDICAL CENTER (GREEN BAY) AND ST. MARY'S AND ST. VINCENT HOSPITALS (HSHS, GREEN BAY) BELLIN PSYCHIATRIC CENTER, INC. PART V, SECTION B, LINE 6B: BEYOND HEALTH, A STEERING COMMITTEE COMPRISED OF LEADERS FROM BOTH THE PUBLIC AND PRIVATE SECTORS: HEALTHCARE PARTNERS, PUBLIC HEALTH AGENCIES, AND NON-PROFIT PARTNERS WHO WORK COLLABORATIVELY TO IDENTIFY ACTIONABLE PRIORITIES, MINIMIZE DISPARITIES IN HEALTH, AND ADAPT AS NEEDED TO NEW AND EMERGING HEALTH CONCERNS. BELLIN PSYCHIATRIC CENTER, INC. PART V, SECTION B, LINE 7D: FULL URL FOR PART V, SECTION B, LINE 7A:HTTPS://WWW.BELLIN.ORG/IMAGES/UPLOADS/PDF/BELLIN_FY2021-CHNA.PDFFULL URL FOR PART V, SECTION B, LINE 10A:HTTPS://WWW.BELLIN.ORG/IMAGES/UPLOADS/BELLIN_FY2021-ASSESSMENT_CHIP.PDF BELLIN PSYCHIATRIC CENTER, INC. PART V, SECTION B, LINE 11: THE MOST RECENT CHNA IDENTIFIED COMMUNITY NEEDS FOR FISCAL YEARS 2021 THROUGH 2023.AS DETAILED IN THE CHNA REPORT, BELLIN HEALTH, IN COLLABORATION WITH COMMUNITY PARTNERS, IDENTIFIED THE FOLLOWING HEALTH PRIORITIES IN BROWN COUNTY:- EQUITABLE ACCESS- SOCIAL COHESION- UNIFIED PLANNING AND POLICYUNDER THE BROAD UMBRELLAS OF THESE PRIORITIES, BASED ON THE HEALTH OUTCOME DATA AND OBSERVED COMMUNITY NEEDS, BELLIN HAS CHOSEN TO FOCUS SPECIFICALLY ON THE AREAS OUTLINED IN THE ACTION PLAN.PLANNED ACTIONS EQUITABLE ACCESSSTRATEGY: PARTNER WITH LOCAL HEALTH SYSTEMS AND THE N.E.W. COMMUNITY CLINIC ON EFFORTS TO INCREASE ACCESS TO PREVENTATIVE SCREENINGS AND EARLY INTERVENTION SERVICES FOR DIVERSE POPULATIONS. PRIORITY FOCUS WILL BE AROUND ACCESS TO DIABETES SERVICES AND EQUITABLE ACCESS TO DEPRESSION SCREENINGS.STRATEGY: INCREASE ACCESS TO SCREENINGS AND EARLY INTERVENTION SERVICES FOR INDIVIDUALS OF COLOR AND THE SOMALI AND REFUGEE COMMUNITY.STRATEGY: CONTINUE TO SUPPORT THE ORAL HEALTH PARTNERSHIP AND PROVIDE ACCESS TO ORAL CARE FOR THE LOW-INCOME CHILDREN IN OUR COMMUNITY.PLANNED ACTIONS UNIFIED POLICY AND PLANNINGSTRATEGY: CONTINUE TO SUPPORT THE ALCOHOL AND DRUG COALITION FOR CHANGE WITH COMMUNITY PARTNERS TO INCREASE POLICY CHANGES THAT CREATE SAVER COMMUNITIES AND SUPPORT CULTURAL CHANGE AROUND ALCOHOL AND DRUG USE.STRATEGY: LEAD A UNIQUE COLLABORATION WITH LOCAL NURSING HOME, HEALTH SYSTEM, COLLEGE, AND THE WISCONSIN NATIONAL GUARD TO PRODUCE MORE CERTIFIED NURSING ASSISTANTS (CNAS) AND INCREASE CAPACITY AT A LOCAL NURSING HOME.PLANNED ACTIONS SOCIAL COHESIONSTRATEGY: FACILITATION OF THE COMMUNITY-WIDE ALCOHOL AND DRUG COALITION FOR CHANGES WITH A FOCUS ON INTERVENTIONS THAT LEAD TO INCREASED SOBER AWARENESS AND CULTURAL CHANGE AT LOCAL EVENTS AND BUSINESSES.HEALTH NEEDS THAT WILL NOT BE ADDRESSED AT THIS TIMEIN ADDITION TO THE HEALTH NEEDS BELLIN SELECTED AS TOP PRIORITIES, THE CHNA IDENTIFIED OTHER SIGNIFICANT HEALTH NEEDS IN BROWN COUNTY. STRATEGY OWNERS/ORGANIZATIONS ARE ASSIGNED TO LEAD WORK WITHIN THIS SPACE AND CAPITALIZE ON COMMUNITY RESOURCES AND PARTNERS COLLABORATING TO ADDRESS THE NEEDS. BELLIN PSYCHIATRIC CENTER, INC. PART V, SECTION B, LINE 13H: PRESUMPTIVE ELIGIBILITY INCLUDES FACTORS AS: HOMELESS, DECEASED WITH NO KNOWN ESTATE, APPROVED COURT BANKRUPTCY, PAYMENT ASSISTANCE RANK ORDER SCORE, ELIGIBLE FOR STATE OF WI FOOD SHARE PROGRAM. PART V, SECTION B, LINES 16A-C: LINE 16A:HTTPS://WWW.BELLIN.ORG/IMAGES/UPLOADS/BELLIN_-_BUSOF.001_-_FINANCIAL_ASSISTANCE_POLICY.PDFLINE 16B:HTTPS://WWW.BELLIN.ORG/IMAGES/UPLOADS/COMMUNITY_CARE_APPLICATION.PDFLINE 16C:HTTPS://WWW.BELLIN.ORG/IMAGES/UPLOADS/PLAIN_LANGUAGE_SUMMARY_-_FINANCIAL_ASSISTANCE.PDF 23 1 - BELLIN BEHAVIORAL HEALTH CLINIC 301 E ST JOSEPH STREET GREEN BAY WI 54305 OUTPATIENT MENTAL HEALTH CLINIC 2 - BELLIN HEALTH RIVERSIDE PSYCHIATRIC CLIN 1325 ANGELS PATH DE PERE WI 54115 OUTPATIENT MENTAL HEALTH CLINIC 3 - BELLIN BEHAVIORAL HEALTH CLINIC THE NEUR 744 S WEBSTER AVENUE GREEN BAY WI 54301 PSYCHOLOGICAL TESTING 4 - BELLIN BEHAVIORAL HEALTH CLINIC DE PERE 555 REDBIRD CIR DE PERE WI 54115 OUTPATIENT MENTAL HEALTH CLINIC 5 - BELLIN BEHAVIORAL HEALTH CLINIC ASHWAUBE 1630 COMMANCHE AVENUE GREEN BAY WI 54313 OUTPATIENT MENTAL HEALTH CLINIC 6 - BELLIN BEHAVIORAL HEALTH CLINIC BELLEVUE 3263 EATON ROAD GREEN BAY WI 54311 OUTPATIENT MENTAL HEALTH CLINIC 7 - BELLIN BEHAVIORAL HEALTH CLINIC MARINETT 2820 ROOSEVELT RD MARINETTE WI 54143 OUTPATIENT MENTAL HEALTH CLINIC 8 - BELLIN BEHAVIORAL HEALTH CLINIC ESCANABA 610 S LINCOLN ROAD ESCANABA MI 49829 OUTPATIENT MENTAL HEALTH CLINIC 9 - BELLIN BEHAVIORAL HEALTH CLINIC IRON MOU 440 WOODWARD AVE UNIT 101 IRON MOUNTAIN MI 49801 OUTPATIENT MENTAL HEALTH CLINIC 10 - BELLIN BEHAVIORAL HEALTH CLINIC HOWARD 2714 RIVERVIEW DR GREEN BAY WI 54313 OUTPATIENT MENTAL HEALTH CLINIC 11 - BELLIN BEHAVIORAL HEALTH CLINIC PULASKI 723 N WISCONSIN ST PULASKI WI 54162 OUTPATIENT MENTAL HEALTH CLINIC 12 - BELLIN BEHAVIORAL HEALTH CLINIC OCONTO F 107 E HIGHLAND DR OCONTO FALLS WI 54154 OUTPATIENT MENTAL HEALTH CLINIC 13 - BELLIN BEHAVIORAL HEALTH CLINIC DE PERE 1800 LAWRENCE DRIVE DE PERE WI 54115 OUTPATIENT MENTAL HEALTH CLINIC 14 - BELLIN BEHAVIORAL HEALTH CLINIC LUXEMBUR 140 SCHOOL CREEK TRAIL LUXEMBURG WI 54217 OUTPATIENT MENTAL HEALTH CLINIC 15 - BELLIN BEHAVIORAL HEALTH CLINIC STURGEON 311 N 3RD AVE STURGEON BAY WI 54235 OUTPATIENT MENTAL HEALTH CLINIC 16 - BELLIN BEHAVIORAL HEALTH CLINIC WEBSTER 704 S WEBSTER AVE STE 300 GREEN BAY WI 54301 OUTPATIENT MENTAL HEALTH CLINIC 17 - BELLIN BEHAVIORAL HEALTH CLINIC BONDUEL 401 W MILL ST BONDUEL WI 54107 OUTPATIENT MENTAL HEALTH CLINIC 18 - BELLIN BEHAVIORAL HEALTH CLINIC WRIGHTSTOW 555 QUALITY CT STE 101 WRIGHTSTOWN WI 54180 OUTPATIENT MENTAL HEALTH CLINIC 19 - BELLIN BEHAVIORAL HEALTH CLINIC CANCER T 1580 COMMANCHE AVENUE ASHWAUBENON WI 54313 OUTPATIENT MENTAL HEALTH CLINIC 20 - BELLIN BEHAVIORAL HEALTH CLINIC MANITOWO 3415 CUSTER ST STE D MANITOWOC WI 54220 OUTPATIENT MENTAL HEALTH CLINIC 21 - BELLIN BEHAVIORAL HEALTH CLINIC KEWAUNEE 575 4TH ST KEWAUNEE WI 54216 OUTPATIENT MENTAL HEALTH CLINIC 22 - BELLIN BEHAVIORAL HEALTH CLINIC ALGOMA 831 PARKER AVE ALGOMA WI 54201 OUTPATIENT MENTAL HEALTH CLINIC 23 - BELLIN BEHAVIORAL HEALTH CLINIC OCONTO 820 ARBUTUS AVENUE OCONTO WI 54153 OUTPATIENT MENTAL HEALTH CLINIC PART I, LINE 6A: BELLIN PSYCHIATRIC CENTER IS INCLUDED IN THE ANNUAL BELLIN HEALTH SYSTEMS, INC. COMMUNITY BENEFIT REPORT. PART I, LINE 7: AMOUNTS ARE CALCULATED BASED ON COST TO CHARGE RATIOS AND AMOUNTS PER THE FINANCIAL STATEMENTS. PART I, LN 7 COL(F): BAD DEBT EXPENSE OF $915,035 INCLUDED ON FORM 990, PART IX, LINE 25 WAS EXCLUDED FROM THE DENOMINATOR PER INSTRUCTIONS WHEN CALCULATING THE PERCENT TOTAL EXPENSES ON SCHEDULE H. PART III, LINE 2: THE BAD DEBT EXPENSE AT COST IS CALCULATED BASED ON THE COST TO CHARGE RATIO. PART III, LINE 3: THE HOSPITAL UTILIZES HFMA #15 THEREFORE NONE OF THE BAD DEBT WOULD BE DEEMED CHARITY CARE. PART III, LINE 4: THE ATTACHED FINANCIAL STATEMENTS DO NOT CONTAIN A SPECIFIC BAD DEBT EXPENSE FOOTNOTE. HOWEVER, THE SUMMARY OF SIGNIFICANT ACCOUNTING POLICIES DESCRIBES THE HOSPITAL'S POLICY ON PAGE 21 OF THE FINANCIAL STATEMENTS. THE ATTACHED FINANCIAL STATEMENTS DO NOT CONTAIN A SPECIFIC BAD DEBT EXPENSE FOOTNOTE. HOWEVER, THE SUMMARY OF SIGNIFICANT ACCOUNTING POLICIES DESCRIBES THE HOSPITAL'S POLICY ON PAGE 19 OF THE FINANCIAL STATEMENTS. CONSISTENT WITH BELLIN HEALTH SYSTEMS' MISSION, CARE IS PROVIDED TO PATIENTS REGARDLESS OF THEIR ABILITY TO PAY. THEREFORE, BELLIN HEALTH SYSTEMS HAS DETERMINED IT HAS PROVIDED IMPLICIT PRICE CONCESSIONS TO UNINSURED PATIENTS AND PATIENTS WITH OTHER UNINSURED BALANCES (FOR EXAMPLE, COPAYS AND DEDUCTIBLES). THE IMPLICIT PRICE CONCESSIONS INCLUDED IN ESTIMATING THE TRANSACTION PRICE REPRESENT THE DIFFERENCE BETWEEN AMOUNTS BILLED TO PATIENTS AND THE AMOUNTS BELLIN HEALTH SYSTEMS EXPECTS TO COLLECT BASED ON ITS COLLECTION HISTORY WITH THOSE PATIENTS. BELLIN HEALTH SYSTEMS' POLICY IS TO PROVIDE A 35% DISCOUNT FROM ESTABLISHED CHARGES TO UNINSURED PATIENTS. THIS POLICY DID NOT CHANGE IN 2022 AND 2021. PART III, LINE 8: THE AMOUNTS REPORTED FOR MEDICARE WERE CALCULATED USING A COST TO CHARGE RATIO. THE SHORTFALL SHOULD BE TREATED AS A COMMUNITY BENEFIT FOR THE FOLLOWING REASONS. IRS REV RULE 69-545 WHICH ESTABLISHED THE COMMUNITY BENEFIT STANDARD FOR NONPROFIT HOSPITALS STATES THAT IF A HOSPITAL SERVICES PATIENTS WITH GOVERNMENT HEALTH BENEFITS, INCLUDING MEDICARE, THEN THIS IS AN INDICATION THAT THE HOSPITAL OPERATES TO PROMOTE THE HEALTH OF THE COMMUNITY. THE SHORTFALL IS NOT NECESSARILY FROM INEFFICIENT OPERATIONS. MEDICARE CAN BE THE LARGEST PAYOR AND HOSPITALS HAVE NO ABILITY TO DENY COVERAGE. THIS, IN TURN, IS A PROMOTION OF ACCESS TO HEALTHCARE SERVICES (A COMMUNITY BENEFIT). ALSO, ELDERLY PATIENTS ARE OFTEN UNDERSERVED AND EXPERIENCE ISSUES WITH ACCESS TO HEALTHCARE SERVICES. PART III, LINE 9B: FOR PATIENTS WHO CANNOT MEET THE EXPECTATIONS OF THE DEBT COLLECTION POLICY, THE ORGANIZATION OFFERS FINANCIAL ASSITANCE. THE ORGANIZATION WILL NOT ENGAGE IN EXTRAORDINARY COLLECTION ACTIONS BEFORE DETERMING WHETHER A GUARANTOR IS ELIGILBE FOR ASSISTANCE UNTER THE FINANCIAL ASSISTANCE POLICY. ALL PATIENTS ARE OFFERED A PLAIN LANGUAGE SUMMARY EXPLAINING THE FINANCIAL ASSISTANCE PROGRAM AS PART OF THE REGISTRATION PROCESS IN ADDITION, ALL STATEMENTS INCLUDE INFORMATION REGARDING FINANCIAL ASSISTANCE AVAILABILITY. PART VI, LINE 2: BELLIN PSYCHIATRIC CENTER HAS COMPLETED A COMMUNITY NEEDS ASSESSMENT AND IT IS POSTED ON BELLIN.ORG PART VI, LINE 3: FINANCIAL COUNSELORS ADVISE PATIENTS OF ASSISTANCE PROGRAMS AS WELL AS SERVICE CALLED HRS ERASE IS USED TO REVIEW SELF PAY ACCOUNTS FOR POSSIBLE COVERAGE THROUGH GOVERNMENT PROGRAMS. PART VI, LINE 4: BELLIN PSYCHIATRIC CENTER SERVES NORTHEAST WISCONSIN AND THE UPPER PENINSULA OF MICHIGAN, INCLUDING CLINICS IN THE CITIES OF GREEN BAY, ASHWAUBENON, BELLEVUE, DE PERE, LEDGEVIEW, MARINETTE, OCONTO, OCONTO FALLS, PESHTIGO, ALGOMA, ESCANABA, AND IRON MOUNTAIN. PART VI, LINE 5: A MAJORITY OF BELLIN PSYCHIATRIC CENTER'S GOVERNING BODY IS COMPRISED OF PERSONS WHO RESIDE IN BELLIN PSYCHIATRIC CENTER'S PRIMARY SERVICE AREA, WHO ARE NEITHER EMPLOYEES NOR CONTRACTORS OF THE ORGANIZATION, NOR FAMILY MEMBERS THEREOF. IN ADDITION, BELLIN PSYCHIATRIC CENTER EXTENDS MEDICAL STAFF PRIVELEGES TO ALL QUALIFIED PHYSICIANS IN ITS COMMUNITY FOR ALL OF ITS DEPARTMENTS. BELLIN PSYCHIATRIC CENTER APPLIES SURPLUS FUNDS TO IMPROVEMENTS IN PATIENT CARE, EDUCATION, AND FACILITIES. PART VI, LINE 6: BELLIN HEALTH IS A COMMUNITY-OWNED NOT-FOR-PROFIT ORGANIZATION RESPONSIBLE FOR THE PHYSICAL AND EMOTIONAL HEALTH OF PEOPLE LIVING IN NORTHEAST WISCONSIN AND THE UPPER PENINSULA OF MICHIGAN. DIRECTLY, AND IN PARTNERSHIP WITH COMMUNITIES, EMPLOYERS, SCHOOLS, AND GOVERNMENT OFFICIALS, WE GUIDE INDIVIDUALS AND FAMILIES IN THEIR LIFELONG JOURNEY TOWARD OPTIMAL HEALTH. WE ARE COMMITTED TO PROVIDING SAFE, RELIABLE, COST-EFFECTIVE TOTAL HEALTH SOLUTIONS WITH RESPECT AND COMPASSION. OUR INNOVATIVE WORK WILL IMPACT HEALTHCARE DELIVERY IN OUR REGION AS WELL AS THROUGHTOUT THE WORLD. PART VI, LINE 7, REPORTS FILED WITH STATES WI X X 0 1 0 0 0 0 0 0 0 CHRISTINE WOLESKE MEMBER/BMH CEO 0 827437 0 568087 0 23004 0 181537 0 19746 0 1619811 0 0 DHANVENDRAN RAMAR MD PHYSICIAN 436011 0 39542 0 270 0 16508 0 28463 0 520794 0 0 0 SHARLA BAENEN BPC PRESIDENT (THRU 12/21)/BMH COO 24680 299233 0 93438 42 6478 3277 48172 5280 18633 33279 465954 0 0 KIM LASECKI PHYSICIAN 385929 0 2750 0 774 0 17831 0 24488 0 431772 0 0 0 REKHA VIJAYAN PHYSICIAN 410987 0 1000 0 270 0 16038 0 1280 0 429575 0 0 0 NACIYE KALAFAT MD MEMBER/FORMER PSYCH. DEPT. CHAIR 346919 0 11288 0 414 0 16179 0 26588 0 401388 0 0 0 EMILY RADEMACHER MD MEMBER/PRESIDENT MEDICAL STAFF 340671 0 11000 0 162 0 17068 0 31513 0 400414 0 0 0 DEREK CARLSON MD PHYSICIAN 325426 0 9969 0 1188 0 15387 0 7586 0 359556 0 0 0 VICTORIA PASSOV ADAMS PHYSICIAN 329373 0 1000 0 270 0 16460 0 2146 0 349249 0 0 0 MICHAEL HOFFMAN MD MEMBER/PHYSICIAN 0 228605 0 19851 0 414 0 17799 0 23616 0 290285 0 0 TARA ROBERTSON PSYD MEMBER/PSYCHIATRY DEPT. CHAIR 162597 0 12740 0 176 0 10517 0 747 0 186777 0 0 0 PART I, LINE 4B BELLIN MEMORIAL HOSPITAL, A RELATED PARTY, HAS A DEFERRED COMPENSATION PLAN FOR SELECTED EXECUTIVES. SHARLA BAENEN AND CHRISTINE WOLESKE PARTICIPATED IN THE 457(F) PLAN. THERE WERE NO DISTRIBUTIONS DURING CALENDAR YEAR 2021. THE FOLLOWING INDIVIDUALS, LISTED ON PART VII OF FROM 990, HAD THE FOLLOWING AMOUNTS ACCRUED DURING CALENDAR YEAR 2021: CHRISTINE WOLESKE $161,537 SHARLA BAENEN $33,651 A WISCONSIN HEALTH AND EDUCATIONAL FACILITIES AUTHORITY 391337855 97712DLH7 2015-04-09 2468852 REFUND AND LEGALLY DEFEASE 0 0 0 A 14305 2468852 28985 2439867 2009 0 1 1 1 A 0 1 1 1 0 1 0 1 A 1 0 0 0 0 1 A 1 FORM 990, PART VI, SECTION A, LINE 6 THE ORGANIZATION HAS ONE CORPORATE MEMBER, BELLIN HEALTH SYSTEMS, INC. FORM 990, PART VI, SECTION A, LINE 7A THE CORPORATE MEMBER, BELLIN HEALTH SYSTEMS, INC. HAS THE POWER TO APPOINT AND REMOVE BOARD MEMBERS. FORM 990, PART VI, SECTION A, LINE 7B THE CORPORATE MEMBER, BELLIN HEALTH SYSTEMS, INC., HAS THE POWER TO APPROVE MAJOR EXPENDITURES AND LONG-TERM BORROWINGS. FORM 990, PART VI, SECTION B, LINE 11B THE FORM 990 IS REVIEWED IN DETAIL BY SENIOR ADMINISTRATION AND IS PROVIDED TO THE BOARD OF DIRECTORS PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C EACH YEAR A CONFLICT OF INTEREST REQUEST DOCUMENT IS PROVIDED TO EACH BOARD MEMBER. ALL DOCUMENTS ARE PROVIDED BACK TO ADMINISTRATION AND REVIEWED. ALL EMPLOYEES ARE REQUIRED TO REVIEW THE CONFLICT OF INTEREST POLICY AS PART OF ANNUAL MANDATORY EDUCATION. AN INTERESTED PERSON MAY MAKE A PRESENTATION AT THE GOVERNING BOARD OR COMMITTEE MEETING, BUT AFTER THE PRESENTATION, HE/SHE SHALL LEAVE THE MEETING DURING THE DISCUSSION OF, AND THE VOTE ON, THE TRANSACTION OR ARRANGEMENT INVOLVING THE POSSIBLE CONFLICT OF INTEREST. SHOULD THERE BE A CONFLICT OF INTEREST WHICH ARISES AT A BOARD MEETING, THE INDIVIDUAL WITH A CONFLICT WILL BE ASKED TO LEAVE THE MEETING DURING A VOTE ON THE MATTER AND IS REQUIRED TO ABSTAIN FROM VOTING. FORM 990, PART VI, SECTION B, LINE 15 COMPENSATION FOR THE CEO AND KEY EXECUTIVES ARE SET BY THE EXECUTIVE COMMITTEE OF THE BOARD SUPPORTED BY MARKET DATA FROM SURVEYS AND AN INDEPENDENT CONSULTANTS REPORT. THE COMPENSATION IS DETERMINED BY MEMBERS OF THE EXECUTIVE COMMITTEE WITHOUT CONFLICT AND IS DOCUMENTED. CEO COMPENSATION: CEO PRESENTS RESULTS OF PERFORMANCE OBJECTIVES TO THE EXECUTIVE COMMITTEE IN JANUARY OF EACH YEAR. THE CHAIR APPLIES A FORMULA TO THE RESULTS AND COMES UP WITH A RECOMMENDATION. THE CHAIR FACILITATES GETTING APPROVAL FROM OTHER MEMBERS OF THE EXECUTIVE COMMITTEE. SENIOR LEADERS: COMPENSATION FOR THOSE WHO REPORT TO THE CEO IS TAKEN TO THE EXECUTIVE COMMITTEE FOR DISCUSSION/APPROVAL. FORM 990, PART VI, SECTION C, LINE 19 BELLIN PSYCHIATRIC CENTER, INC. BELIEVES THE FINANCIAL STATEMENTS, GOVERNING DOCUMENTS, AND POLICIES ARE THE PROPERTY OF THE ORGANIZATION AND ARE NOT AVAILABLE FOR PUBLIC INSPECTION. FORM 990, PART XI, LINE 9: OTHER CHANGES -4. FORM 990, PART XII, LINE 2B-2C THE ORGANIZATION IS INCLUDED IN THE CONSOLIDATED AUDIT OF BELLIN HEALTH SYSTEMS, INC. THE BOARD OF DIRECTORS OF BELLIN HEALTH SYSTEMS, INC. ASSUMES RESPONSIBILITY FOR THE OVERSIGHT OF THE AUDIT AND SELECTION OF AN INDEPENDENT AUDITOR. LAKE MICHIGAN HEALTH SERVICES INC 744 SOUTH WEBSTER AVE GREEN BAY WI 54301 391512903 SUPPORT PURPOSES OF BELLIN MEMORIAL HOSPITAL WI 501(C)(3) LINE 12B, II BELLIN HEALTH SYSTEMS INC 1 BELLIN COLLEGE INC 3201 EATON ROAD GREEN BAY WI 54311 391620530 NURSING AND RADIOLOGIC SCIENCE COLLEGE WI 501(C)(3) LINE 2 BELLIN HEALTH SYSTEMS INC 1 THE BELLIN HEALTH FOUNDATION INC 744 SOUTH WEBSTER AVE GREEN BAY WI 54301 391809171 FOUNDATION WI 501(C)(3) LINE 7 BELLIN HEALTH SYSTEMS INC 1 BELLIN MEMORIAL HOSPITAL INC 744 SOUTH WEBSTER AVE GREEN BAY WI 54301 390884478 ACUTE CARE HOSPITAL WI 501(C)(3) LINE 3 BELLIN HEALTH SYSTEMS INC 1 OCONTO HOSPITAL & MEDICAL CENTER INC 820 ARBUTUS AVENUE OCONTO WI 54153 061745397 HOSPITAL WI 501(C)(3) LINE 3 BELLIN MEMORIAL HOSPITAL INC 1 BELLIN HEALTH SYSTEMS INC 744 SOUTH WEBSTER AVE GREEN BAY WI 54305 391512904 SUPPORT OF HEALTHCARE ORGANIZATIONS WI 501(C)(3) LINE 12B, II N/A 0 UNITY LIMITED PARTNERSHIP 2366 OAK RIDGE CIRCLE DE PERE WI 54115 391750729 HOSPICE, PALLIATIVE, AND BEREAVEMENT SERVICES WI 501(C)(3) LINE 10 N/A 0 BEL-REGIONAL HOME MEDICAL INC 617 S ROOSEVELT GREEN BAY WI 54301 391504766 DURABLE MEDICAL EQUIPMENT, RETAIL PHARMACY, FITNESS WI N/A C 1 BELLIN INVESTMENTS INC 744 SOUTH WEBSTER AVE GREEN BAY WI 54301 391564939 OTHER WI N/A C 1 0 0 1 0 1 0 0 0 0 0 1 0 1 0 0 1 1 0 0 BELLIN MEMORIAL HOSPITAL INC E 12382336 ACTUAL BELLIN MEMORIAL HOSPITAL INC K 57076 ACTUAL BELLIN MEMORIAL HOSPITAL INC M 2540494 ACTUAL BELLIN MEMORIAL HOSPITAL INC P 18500000 ACTUAL