2022-04-09T10:58:45-05:00 2021-05-31 390758449 WIPFLI LLP 170 NORTH RADNOR-CHESTER ROAD SUITE 200 RADNOR PA 19087 990 2020-06-01 264321839 LAKESHORE COMMUNITY HEALTH CARE INC LAKE 9207836633 1721 SAEMANN AVENUE SHEBOYGAN WI 53081 KRISTIN BLANCHARD STEARNS CEO 9207836633 2022-04-08 1 KRISTIN BLANCHARD STEARNS 999009999 SOLOMON MARDAKHAEV P01806552 6105653930 2022-04-08 3 AAL1 IAL1 2020 2022-09-23 18:48:47Z KRISTIN BLANCHARD STEARNS 1721 SAEMANN AVENUE SHEBOYGAN WI 53081 15884458 0 X WWW.LAKESHORECHC.ORG X 2009 WI LCHC STRIVES TO CREATE COMMUNITIES WHERE ALL PEOPLE LIVE HEALTHY, ACTIVE, AND PROSPEROUS LIVES. LCHC ASPIRES TO BE A PREFERRED PROVIDER AND AN EMPLOYER OF CHOICE. 13 13 165 15 0 0 2695777 6031684 10892612 9742554 87865 79027 6304 29653 13682558 15882918 0 0 0 0 8141024 9953567 70139 53777 53777 3818600 3557000 12029763 13564344 1652795 2318574 11827632 13068357 2155699 1077850 9671933 11990507 X LAKESHORE COMMUNITY HEALTH CARE PROVIDES ACCESS TO COMPREHENSIVE, INTEGRATED HEALTH CARE, REGARDLESS OF ABILITY TO PAY, ELIMINATING HEALTH DISPARITIES AMONG THE UNDERSERVED. 0 0 9810017 0 9742554 LAKESHORE COMMUNITY HEALTH CARE, INC. PROVIDES HEALTH CARE SERVICES TO PEOPLE WHO STRUGGLE TO FIND A DOCTOR, DENTIST, OR A COUNSELOR FOR CARE. THE ORGANIZATION ALSO PROVIDES PHARMACY AND CHIROPRACTIC SERVICES. THE ORGANIZATION WORKS WITH OUR COMMUNITY PARTNERS TO REFER PATIENTS FOR ANY SERVICES THE ORGANIZATION IS UNABLE TO PROVIDE. THE ORGANIZATION WORKS VERY HARD TO MAKE SURE PATIENTS GET WHAT THEY NEED AND PROVIDES UP TO 90% DISCOUNTS FOR ANYONE WHO CANNOT AFFORD TO PAY FOR THESE SERVICES.LAKESHORE PROVIDED SERVICES TO 11,466 UNDUPLICATED PATIENTS IN OUR FY2021. THESE PATIENTS WERE SEEN FOR 20,867 DENTAL VISITS (1,218 OF THOSE THROUGH OUR SCHOOL-BASED DENTAL PROGRAM), 6,841 MEDICAL VISITS, 8,062 BEHAVIORAL HEALTH VISITS (3,547 OF THOSE THROUGH OUR SCHOOL-BASED PATH PROGRAM), AND 2,361 CHIROPRACTIC VISITS. LAKESHORE ALSO PROVIDED 27,712 PRESCRIPTIONS TO OUR PATIENTS THROUGH OUR 340B PHARMACY PROGRAM. 9810017 1 1 0 0 0 0 0 0 0 0 1 0 0 0 1 1 0 1 0 0 0 0 0 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 1 18 0 165 1 0 0 0 0 0 0 0 0 0 0 0 0 X 13 13 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 WI X CALEB JENSEMA CFO 9207836633 1721 SAEMANN AVENUE SHEBOYGAN WI 53081 RACHEL LABORDE PRESIDENT (THRU FEBRUARY) 2.00 X X 0 0 0 BRENDA SMITH PRESIDENT 2.00 X X 0 0 0 DIANE LIEBENTHAL VICE PRESIDENT 2.00 X X 0 0 0 GERALYN LEANNAH TREASURER 2.00 X X 0 0 0 JOSEPH RUPNIK TREASURER 2.00 X X 0 0 0 LEIGHANNE MATTER-JENSEN SECRETARY 2.00 X X 0 0 0 MICHELLE ELDER BOARD MEMBER (THRU MAY) 2.00 X 0 0 0 BECK GRAUMAN BOARD MEMBER (THRU MAY) 2.00 X 0 0 0 CARLY HAKALA BOARD MEMBER (THRU FEB) 2.00 X 0 0 0 SCOTT HAYES BOARD MEMBER 2.00 X 0 0 0 KELYN NETZ BOARD MEMBER 2.00 X 0 0 0 WILLIAM PFEFFERKORN BOARD MEMBER 2.00 X 0 0 0 SHENITA SALAAM BOARD MEMBER 2.00 X 0 0 0 PENNY SENKBEIL BOARD MEMBER 2.00 X 0 0 0 DENISE WITTSTOCK BOARD MEMBER 2.00 X 0 0 0 KRISTIN BLANCHARD STEARNS CEO 40.00 1.00 X 120862 0 28641 MARTIN SCHALLER CFO 40.00 1.00 X 107393 0 28227 MICHELE SCHMITT COO 40.00 X 102883 0 12949 ROBERT WENBERG MD MEDICAL DIRECTOR 40.00 X 246505 0 39702 CASEY WILSON DDS DENTAL DIRECTOR 40.00 X 148530 0 18085 JOSHUA ADAMETZ DDS DENTIST 40.00 X 136353 0 16948 IVONA CRISTI DDS DENTIST 40.00 X 151735 0 16872 SMRITI MADRECHA DDS DENTIST 40.00 X 132858 0 13592 1147119 0 175016 21 0 1 0 PLEXUS HEALTH SOLUTIONS INC PO BOX 0655 KENOSHA WI 53141 CONTRACT BILLING SERVICES 342283 BARTON ASSOCIATES PO BOX 417844 BOSTON MA 02241 PHYSICIAN STAFFING SERVICES 162755 SABERCOR LLC 2935 S FISH HATCHERY ROAD UNIT 283 FITCHBURG WI 53711 HOUSEKEEPING/JANITORIAL SERVICES 132607 3 9433 22000 5662428 337823 18214 6031684 PATIENT SERVICE REVENUE 621400 9067483 9067483 PHARMACY REVENUE 621400 654858 654858 20213 20213 9742554 79067 79067 40 -40 -40 -40 0 9433 1500 -1500 -1500 31153 31153 31153 15882918 9742554 0 108680 425158 425158 7650237 5778904 1871333 260601 200590 60011 1046327 721554 324773 571244 412242 159002 5941 1721 4220 45765 8083 37682 53777 53777 685525 324610 360915 26915 18291 8624 73905 51222 22683 185275 109647 75628 742582 606168 136414 23702 19365 4337 33710 27157 6553 4507 3715 792 177291 137500 39791 35684 22035 13649 MEDICAL SUPPLIES 923342 922317 1025 EQUIPMENT 313182 228191 84991 ELECTRONIC HEALTH RECOR 131302 131302 LICENSES & DUES 102575 54476 48099 45797 30927 14870 13564344 9810017 3700550 53777 469529 569751 4733403 4724451 61206 601187 496466 929322 4955250 4955250 48996 76643 107197 84342 2357056 1240687 944573 1116369 11012 11042 11827632 13068357 788886 1044295 49358 6205 1317455 27350 2155699 1077850 X 9007809 11275151 664124 715356 9671933 11990507 11827632 13068357 2318574 0 X 0 1 X 1 1 1 X SCHEDULE A: THE ORGANIZATION IS NOT LICENSED AS A HOSPITAL IN THE STATE OF WISCONSIN. THE ORGANIZATION HAS RECEIVED ITS IRS DETERMINATION LETTER SHOWING THAT THE ORGANIZATION'S PUBLIC CHARITY STATUS IS SECTION 170(B)(1)(A)(III). RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 272846 23044 249802 220622 82958 137664 1863588 1134685 728903 1116369 CAPITAL LEASE OBLIGATIONS 27350 27350 X PART X, LINE 2: THE ORGANIZATION RECOGNIZES THE BENEFITS OF A TAX POSITION ONLY AFTER DETERMINING WHETHER IT IS MORE LIKELY THAN NOT THAT THE TAXING AUTHORITY WOULD SUSTAIN THE TAX POSITION UPON EXAMINATION OF THE TECHNICAL MERITS OF THE TAX POSITION, ASSUMING THE TAXING AUTHORITY HAS FULL KNOWLEDGE OF ALL INFORMATION. THE ORGANIZATION RECORDED NO ASSETS OR LIABILITIES RELATED TO UNCERTAIN TAX POSITIONS. X X X X X X 1 NON-PROFIT FUNDRAISING PARTNERS 1711 VAN HISE AVENUE MADISON WI 53726 GOVERNMENT AND NON-GOVERNMENT GRANT WRITING AND FUNDRAISING 0 2520936 53777 2467159 2520936 53777 2467159 WI X X 0 0 0 0 0 0 0 0 0 ROBERT WENBERG MD MEDICAL DIRECTOR 244525 0 0 0 1980 0 10260 0 29442 0 286207 0 0 0 IVONA CRISTI DDS DENTIST 151045 0 0 0 690 0 5981 0 10891 0 168607 0 0 0 CASEY WILSON DDS DENTAL DIRECTOR 148290 0 0 0 240 0 6214 0 11871 0 166615 0 0 0 JOSHUA ADAMETZ DDS DENTIST 136173 0 0 0 180 0 5646 0 11302 0 153301 0 0 0 FORM 990, PART VI, SECTION B, LINE 11B BOARD MEMBERS ARE GIVEN COPIES OF THE FORM 990 TO REVIEW BEFORE FILING WITH THE INTERNAL REVENUE SERVICE. FORM 990, PART VI, SECTION B, LINE 12C EVERY MEMBER OF THE ORGANIZATION SIGNS A CONFLICT OF INTEREST STATEMENT ANNUALLY. ADMINISTRATION MONITORS THIS WITH THE USE OF A CHECKLIST. EACH INDIVIDUAL SHALL DISCLOSE TO THE ORGANIZATION, ANY PERSONAL INTEREST THAT HE OR SHE MAY HAVE IN ANY MATTER PENDING BEFORE THE ORGANIZATION AND SHALL REFRAIN FROM PARTICIPATION IN ANY DECISION ON SUCH MATTER. FORM 990, PART VI, SECTION B, LINE 15 THE ORGANIZATION LOOKS AT NATIONAL AND LOCAL COMPARISON DATA FROM NACHC AND MGMA TO SET SALARY RANGES FOR EACH POSITION. ACTUAL SALARIES ARE BASED ON QUALIFICATIONS AND DETERMINED BY HR AND THE CFO. THE BOARD OF DIRECTORS HAS THE POWER TO ESTABLISH AND PERIODICALLY UPDATE THE SALARY AND BENEFITS SCALES AND MOST RECENTLY APPROVED THE ENGAGEMENT WITH A CONSULTING FIRM TO CONDUCT A WAGE RANGE STUDY FOR ALL OF OUR EMPLOYEES WHICH CONCLUDED AT THE END OF 2021 AND UTILIZED DATA FROM NACHC AS WELL AS MGMA. THESE NEW SALARY RANGES FROM THIS PROPOSAL SET FORTH BY THE CONSULTING FIRM ARE ALL TO BE REVIEWED AND APPROVED BY THE BOARD OF DIRECTORS BEFORE BEING IMPLEMENTED IN ANY CAPACITY. FORM 990, PART VI, SECTION C, LINE 19 GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE MADE AVAILABLE TO THE PUBLIC UPON REQUEST. LCHC QALICB INC 1721 SAEMANN AVENUE SHEBOYGAN WI 53081 815453995 TO SUPPORT LAKESHORE COMMUNITY HEALTH CARE, INC. WI 501(C)(3) LINE 12A, I LAKESHORE COMMUNITY HEALTH CARE INC 1 0 0 1 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 LCHC QALICB INC K 108000 CASH