2021-08-12T12:04:55-05:00 2020-09-30 390758449 WIPFLI LLP PO BOX 12237 GREEN BAY WI 543072237 990 2019-10-01 061745397 OCONTO HOSPITAL AND MEDICAL CENTER BELLIN HEALTH OCONTO HOSPITAL OCON 9208351100 PO BOX 357 OCONTO WI 54153 SHARLA BAENEN CEO 9208351100 2021-08-12 1 TERRI REXRODE CPA MST P00096513 9206620016 2021-08-12 2019 2022-09-23 18:48:47Z BELLIN HEALTH OCONTO HOSPITAL JULIE BIEBER PO BOX 357 OCONTO WI 54153 68391095 0 X WWW.OCONTOHOSPITAL.ORG X 2005 WI OCONTO HOSPITAL & MEDICAL CENTER, INC. (THE ORGANIZATION) IS YOUR HOME TOWN HEALTHCARE SERVICE PROVIDER, CREATED TO MAKE OUTSTANDING HEALTHCARE CONVENIENT. BACKED BY THE RESOURCES OF BELLIN HEALTH, THE ORGANIZATION OFFERS OUTSTANDING HOSPITAL-BASED, EMERGENCY AND PRIMARY CARE SERVICES. THE ORGANIZATION OFFERS THE CARE YOU NEED WHERE YOU WANT IT. 7 3 309 9 0 0 11996 1868323 56894851 66380773 1135 80 55429 87699 56963411 68336875 0 0 0 0 26980052 28229553 0 0 0 34701060 37592731 61681112 65822284 -4717701 2514591 42446099 44740555 46104123 45869243 -3658024 -1128688 X THE MISSION OF OCONTO HOSPITAL & MEDICAL CENTER IS TO PROVIDE 24-HOUR LOCAL ACCESS TO EFFECTIVE, EFFICIENT HEALTH, WELLNESS AND PREVENTATIVE SERVICES TO OCONTO AND THE SURROUNDING RURAL COMMUNITIES. TOWARD THIS PURPOSE, OCONTO HOSPITAL & MEDICAL CENTER WORKS IN PARTNERSHIP WITH THE COMMUNITY, THE CITIZENS HOSPITAL FOUNDATION AND BELLIN HEALTH. 0 0 17258974 23647902 AS A KEY REGIONAL ASSET, THE ORGANIZATION IS A NOT-FOR-PROFIT HEALTHCARE PROVIDER. THE ORGANIZATION PROVIDES ACUTE HOSPITAL, EMERGENCY AND URGENT CARE TO RESIDENTS OF OCONTO, WISCONSIN AND THE SURROUNDING COMMUNITIES. DURING THE PERIOD OF OCTOBER 1, 2019 TO SEPTEMBER 30, 2020, 356 INPATIENT DAYS WERE PROVIDED AND 295 SWING BED DAYS WERE PROVIDED. THE NUMBER OF OUTPATIENTS REGISTERED DURING THE SAME 12 MONTH PERIOD WAS 20,711. 40671826 42567413 THE OCONTO HOSPITAL & MEDICAL CENTER CORPORATION ALSO OPERATES A MULTISPECIALTY CLINIC IN MARINETTE WISCONSIN. SERVICES OFFERED AT THE MARINETTE LOCATION INCLUDE PRIMARY CARE SERVICES, RADIATION ONCOLOGY SERVICES, CHEMOTHERAPY AND INFUSION SERVICES. IN ADDITION THE ORGANIZATION HAS PRIMARY CARE CLINICS IN OCONTO, CRIVITZ, LAKEWOOD AND PESHTIGO WISCONSIN, AND DAGGETT AND MENOMINEE MICHIGAN. THESE PROGRAM SERVICES PROVIDED 13,739 URGENT CARE VISITS, 66,997 PRIMARY CARE VISITS AND 24,079 SPECIALTY PROVIDER VISITS TO THESE COMMUNITIES DURING THE PERIOD OF OCTOBER 1,2019 TO SEPTEMBER 30, 2020. 57930800 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 0 309 1 0 0 0 0 0 0 0 0 0 0 0 0 X 7 3 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 X SARA ARNDT 9204457260 2020 SOUTH WEBSTER AVENUE GREEN BAY WI 54301 JAMES DIETSCHE EVP-CFO 0.50 50.00 X X 0 518817 81453 PAWNEET SING MD PHYSICIAN 50.00 X 518296 0 22982 CHARLES HEYKA MD PRESIDENT OF MEDICAL STAFF 50.00 X 351236 0 45026 MICHAEL BRENNER MD PHYSICIAN 50.00 X 333341 0 37684 NICOLE HINIKER MD PHYSICIAN 50.00 X 328398 0 37783 JON SIMMONS MD PHYSICIAN 50.00 X 333185 0 23074 LAURA HIEB BOARD MEMBER 0.50 50.00 X 0 301065 56639 IVY VACHON MD PHYSICIAN 50.00 X 292621 0 33168 LAURA CORMIER - TERMED FORMER CEO 50.00 X X 166183 0 34505 JULIE BIEBER VP 50.00 X X 147734 0 21212 SARA ARNDT BOARD MEMBER 0.50 45.00 X 0 79350 26084 DAVID HONISH CHAIRPERSON 0.50 X X 0 0 0 RODNEY JOHNSON SECRETARY/TREASURER 0.50 X X 0 0 0 CRAIG ALWIN BOARD MEMBER 0.50 X 0 0 0 2470994 899232 419610 39 0 1 0 RADIOLOGY ASSOCIATES OF APPLETON SC 2500 E CAPITAL DR APPLETON WI 54911 RADIATION ONCOLOGY PROVIDER SERVICES 532530 THARIO BUILDING SERVICES 2936 HOLMGREN WAY GREEN BAY WI 54304 HOUSEKEEPING SERVICES 513045 SYNERGY SURGICALISTS 280 W KAGY BLVD STE D 320 BOZEMAN MT 59715 PROFESSIONAL SURGICAL SERVICES 457129 BELLIN ANESTHESIA ASSOCIATES 744 S WEBSTER AVE GREEN BAY WI 54301 PROFESSIONAL ANETHESIA SERVICES 362917 BAY TOWEL 2580 S BROADWAY GREEN BAY WI 54304 LAUNDRY SERVICES 169052 11 1868323 1868323 NET PATIENT REVENUE 621300 66041633 66041633 MISCELLANEOUS REVENUE 900099 219140 219140 RENT FROM AFFILIATES 900099 120000 120000 66380773 80 80 88237 54220 34017 34017 34017 INCENTIVE PAYMENTS 621110 53682 53682 53682 68336875 66215315 0 253237 765897 396262 369635 22751367 22110113 641254 944280 923522 20758 2367800 2342397 25403 1400209 1355174 45035 50000 50000 4700693 4602301 98392 16071 573 15498 659889 607211 52678 16764 16675 89 4444253 4444059 194 285575 271822 13753 73712 63388 10324 2149627 2149627 3619199 3206748 412451 98215 34199 64016 SUPPLIES EXPENSE 16600131 12831282 3768849 EQUIPMENT RENT/MAINTENA 2749269 2742337 6932 BAD DEBT EXPENSE 1851126 1851126 DUES & SUBSCRIPTIONS 180485 114582 65903 97722 17029 80693 65822284 57930800 7891484 0 2768980 3180625 8791418 13349396 851934 1266869 18191 10481 46923963 21015158 28755000 25908805 501881 250940 758695 773439 42446099 44740555 2316184 4324948 3001802 10782285 10328117 33005654 28214376 46104123 45869243 X -4416719 -1902126 758695 773438 -3658024 -1128688 42446099 44740555 X 2514591 14745 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 739879 739879 19194760 5541204 13653556 171971 171971 0 26817353 15301983 11515370 25908805 DUE TO AFFILIATE 28214376 28214376 66539969 -1851126 -1851126 68391095 -54220 -54220 68336875 64025378 54220 54220 63971158 1851126 1851126 65822284 PART XI, LINE 2D - OTHER ADJUSTMENTS: PROVISION FOR BAD DEBTS -1,851,126. PART XI, LINE 4B - OTHER ADJUSTMENTS: RENTAL DEPRECIATION -54,220. PART XII, LINE 2D - OTHER ADJUSTMENTS: RENTAL DEPRECIATION 54,220. PART XII, LINE 4B - OTHER ADJUSTMENTS: PROVISION FOR BAD DEBTS 1,851,126. 1 1 X 1 X 220.000000000000 1 X 1 1 1 0 1 1 641022 641022 0.01000 7808891 6998986 809905 0.01270 8449913 6998986 1450927 0.02270 8306 8306 0.00010 1285 1285 0.00000 9591 9591 0.00010 8459504 6998986 1460518 0.02280 2 4153 4153 0.00010 2 4153 4153 0.00010 1 910750 8344000 7435343 908657 X 1 1 1 1 OCONTO HOSPITAL & MEDICAL CENTER INC 820 ARBUTUS AVE OCONTO WI 54153 WWW.OCONTOHOSPITAL.ORG 1061 X X X X OCONTO HOSPITAL & MEDICAL CENTER INC 1 0 0 1 X X X X X X X X X 19 1 1 1 1 X SEE PART V, SECTION B, LINE 7D X SEE PART V, SECTION B, LINE 7D X 1 17 1 SEE PART V, SECTION B, LINE 7D 0 1 X 220.000000000000 400.000000000000 X X X 1 1 X X X X 1 X HTTPS://WWW.BELLIN.ORG/IMAGES/UPLOADS/BUSOF.001_-_FINANCIAL_ASSISTANCE.PDF X HTTPS://WWW.BELLIN.ORG/IMAGES/UPLOADS/COMMUNITY_CARE_APPLICATION.PDF X HTTPS://WWW.BELLIN.ORG/IMAGES/UPLOADS/PLAIN_LANGUAGE_SUMMARY_-_FINANCIAL_AS X X X X X X 1 X 0 X X X X 1 X 0 0 OCONTO HOSPITAL & MEDICAL CENTER, INC. PART V, SECTION B, LINE 5: THIS YEAR'S ASSESSMENT BUILT ON COLLABORATION, ACTIVELY SEEKING INPUT FROM A BROAD CROSS SECTION OF COMMUNITY STAKEHOLDERS WITH THE GOAL OF REACHING CONSENSUS ON PRIORITIES TO MUTUALLY FOCUS HUMAN, MATERIAL AND FINANCIAL RESOURCES. BELOW IS A LISTING OF PARTICIPANTS IN A CHNA SUMMIT IN WHICH HEALTH PRIORITIES WERE DETERMINED: OCONTO COUNTY PUBLIC HEALTH* HSHS ST. CLARE MEMORIAL HOSPITAL BELLIN HEALTH OCONTO HOSPITAL UW-EXTENSION OCONTO COUNTY WOLF RIVER AGING DISABILITY RESOURCE CENTER (ADRC)* GILLETT SCHOOL DISTRICT* SURING SCHOOL DISTRICT* LENA SCHOOL DISTRICT* NURSES NOOK* MARINETTE COUNTY PUBLIC HEALTH HILLSIDE ASSEMBLY CHURCH FOOD PANTRY* TRI-CITY UNITED WAY OCONTO COUNTY BOARD OF HEALTH NEWCAP* COMMUNITY MEMBERS AT LARGE*DENOTES GROUPS REPRESENTING MEDICALLY UNDERSERVED, LOW-INCOME AND MINORITY POPULATIONS. THESE ORGANIZATIONS SERVE THE UNDER-RESOURCED IN OUR COMMUNITY, INCLUDING LOW-INCOME SENIORS, CHILDREN LIVING IN POVERTY, FAMILIES WHO STRUGGLE WITH SHELTER AND FOOD INSECURITY; VETERANS AND VICTIMS OF DOMESTIC VIOLENCE. OCONTO HOSPITAL & MEDICAL CENTER, INC. PART V, SECTION B, LINE 6A: HSHS ST. CLARE MEMORIAL HOSPITAL OCONTO HOSPITAL & MEDICAL CENTER, INC. PART V, SECTION B, LINE 6B: UW-EXTENSION OCONTO COUNTY WOLF RIVER AGING DISABILITY RESOURCE CENTER (ADRC)* GILLETT SCHOOL DISTRICT* SURING SCHOOL DISTRICT* LENA SCHOOL DISTRICT* NURSES NOOK* MARINETTE COUNTY PUBLIC HEALTH HILLSIDE ASSEMBLY CHURCH FOOD PANTRY* TRI-CITY UNITED WAY OCONTO COUNTY BOARD OF HEALTH NEWCAP**DENOTES GROUPS REPRESENTING MEDICALLY UNDERSERVED, LOW-INCOME AND MINORITY POPULATIONS. THESE ORGANIZATIONS SERVE THE UNDER-RESOURCED IN OUR COMMUNITY, INCLUDING LOW-INCOME SENIORS, CHILDREN LIVING IN POVERTY, FAMILIES WHO STRUGGLE WITH SHELTER AND FOOD INSECURITY; VETERANS AND VICTIMS OF DOMESTIC VIOLENCE. OCONTO HOSPITAL & MEDICAL CENTER, INC. PART V, SECTION B, LINE 7D: FULL URL FOR PART V, SECTION B, LINE 7A:HTTPS://WWW.BELLIN.ORG/IMAGES/UPLOADS/BROWN_COUNTY-FY2018_CHNA_EDITS_04_10_FULL URL FOR PART V, SECTION B, LINE 7B:HTTPS://WWW.CO.OCONTO.WI.US/DEPARTMENTS/PAGE_7389C0128C0F/?DEPARTMENT=AE781FULL URL FOR PART V, SECTION B, LINE 10A:HTTPS://WWW.BELLIN.ORG/IMAGES/UPLOADS/BROWN_COUNTY_FY2018_IMPLEMENTATION_PL OCONTO HOSPITAL & MEDICAL CENTER, INC. PART V, SECTION B, LINE 11: THE MOST RECENT CHNA IDENTIFIED COMMUNITY NEEDS FOR FISCAL YEARS 2021 THROUGH 2023. THE NEEDS IDENTIFIED ARE: MENTAL HEALTH, ALCOHOL AND OTHER DRUG ABUSE (AODA), PHYSICAL ACTIVITY AND NUTRITION, IN ADDITION TO ORAL HEALTH. A SUMMARY OF HOW THE HOSPITAL HAS BEEN ADDRESSING SOME OF THE NEEDS IDENTIFIED IN THE CHNA IS AS FOLLOWS:1. ALCOHOL AND OTHER DRUG ABUSE (AODA) -AODA MISUSE TEAM -DARJUNE RECOVERY COACHING -DRUG DROP BOXES IN CLINICS AND PHARMACIES -INFORMATION POWERPOINT TO DECREASE UNDERAGE DRINKING AND DRUGS -EXPLORE SOBER LIVING (IN PARTNERSHIP WITH DARJUNE)2. NUTRITION AND PHYSICAL ACTIVITIES -OCONTO COUNTY FARMERS MARKET -SAFETY FAIR -DONATE HEALTH PLATE - LOCAL FOOD PANTRY SUPPORT AND EDUCATION -PLANT A SEED - GROWING AN ADDITIONAL ROW OF VEGETABLES IN YOUR GARDENS TO DONATE TO FOOD PANTRIES -BELLIN HEART RUN/WALK 5K - MARINETTE, WI -SUMMER MEAL PROGRAM OCONTO HOSPITAL & MEDICAL 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. 6 1 - BELLIN HEALTH MARINETTE 2820 ROOSEVELT ROAD MARINETTE WI 54143 RURAL HEALTH CLINIC, ASC 2 - BELLIN HEALTH CRIVITZ 218 S US HWY 141 SUITE 100 CRIVITZ WI 54114 RURAL HEALTH CLINIC 3 - BELLIN HEALTH PESHTIGO 441 FRENCH STREET PESHTIGO WI 54162 RURAL HEALTH CLINIC 4 - BELLIN HEALTH MENOMINEE 1100 10TH STREET MENOMINEE MI 49858 RURAL HEALTH CLINIC 5 - BELLIN HEALTH DAGGETT 106 S SCHOOL ROAD DAGGETT MI 49821 RURAL HEALTH CLINIC 6 - BELLIN HEALTH LAKEWOOD 15481 COMMERCIAL RD STE E LAKEWOOD WI 54138 RURAL HEALTH CLINIC PART I, LINE 6A: OCONTO HOSPITAL AND MEDICAL CENTER IS INCLUDED IN THE BELLIN HEALTH SYSTEMS, INC. COMMUNITY BENEFIT REPORT. PART I, LINE 7: AMOUNTS ARE CALCULATED BASED ON THE COST TO CHARGE RATIOS AND WORKSHEET 2 PROVIDED BY THE IRS. PART I, LN 7 COL(F): BAD DEBT EXPENSE OF $1,851,124 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 II, COMMUNITY BUILDING ACTIVITIES: OHMC SUPPORTED THE BOTH THE MARINETTE AND PESHTIGO HIGH SCHOOLS BY SPONSORING A CAREER EXPO FOR BOTH SCHOOLS. THE HOSPITAL ALSO PRESENTED AT THE EXPO TO TALK ABOUT HEALTHCARE CAREERS AND OPPORTUNITIES. PART III, LINE 2: THE BAD DEBT EXPENSE AT COST IS CALCULATED BASED ON THE COST TO CHANGE RATIOS. 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 16 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 2020 AND 2019. 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 RUL 69-545 WHICH ESTABLISHED THE COMMUNITY BENEFIT STANDARD FOR NONPROFIT HOSPITALS, STATES THAT IF A HOSPITAL SERVES PATIENTS WITH GOVERNMENT HEALTH BENEFITS, INCLUDING MEDICARE, THEN THIS IS AN INDICATION THAT THE HOSPITAL OPERATES TO PROMOTE THE HEALTH OF THE COMMUNITY. IN ADDITION, ELDERLY PATIENTS ARE OFTEN UNDERSERVED AND EXPERIENCE ISSUES WITH ACCESS TO HEALTHCARE SERVICES. WITHOUT EXEMPT HOSPITALS, CMS WOULD NEED TO PROVIDE THESE 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: THE ORGANIZATION HAS A KEY STRATEGIC OBJECTIVES OF "THE BEST CARE & HEALTHIEST COMMUNITIES" FOCUSED ON INCREASING YEARS OF QUALITY LIFE BY PROVIDING APPROPRIATE, HIGHEST QUALITY, SAFE AND COORDINATED CARE THAT IS AFFORDABLE FOR EVERYONE. WITH A RELENTLESS DESIRE TO IMPROVE HEALTH AND WELL-BEING, WE USE OUR EXPERTISE, TECHNOLOGY, RELATIONSHIPS, FINANCIAL AND OTHER RESOURCES TO ADDRESS THE SOCIAL DETERMINANTS OF HEALTH AND POSITIVELY IMPACT THE HEALTH AND WELL-BEING OF OUR COMMUNITIES. WE ANNUALLY REVIEW THE COUNTY HEALTH RANKINGS THROUGH THE UW POPULATIONS HEALTH DEPARTMENT, MINE OUR PATIENT DATA BY REGION FOR THE HEALTH AREAS MOST IN NEED OF IMPROVEMENT AND MANAGE THIS THROUGH OUR PRIMARY CARE PROVIDER RELATIONSHIPS WITH KEY QUALITY INDICATORS. PART VI, LINE 3: INFORMATION ON GOVERNMENT ASSISTANCE PROGRAMS AND THE CHARITY CARE PROGRAM IS MADE AVAILABLE TO PATIENTS IN THE EMERGENCY ROOM AND AT THE TIME OF REGISTRATION. ADDITIONALLY, THE INFORMATION IS INCLUDED IN PATIENT STATEMENTS AND LETTERS FROM THE BILLING OFFICE. PART VI, LINE 4: THE ORGANIZATION IS LOCATED IN THE CITY OF OCONTO, WISCONSIN. ITS PRIMARY SERVICE AREA IS THE CITY OF OCONTO AND ITS SECONDARY SERVICE AREA SPREADS TO THE NORTHERN PORTION OF OCONTO COUNTY AND SOUTHERN MARINETTE COUNTY. THE CITY OF OCONTO HAS A POPULATION OF 4,500. 17% OF THE POPULATION IS OVER AGE 65 AND 8.8% OF THE POPULATION IS BELOW THE POVERTY LINE. PART VI, LINE 5: THE ORGANIZATION IS A STEERING TEAM MEMBER OF THE HEALTHY OCONTO COUNTY IMPROVEMENT WORK ALONG WITH HSHS ST. CLARE HOSPITAL AND OCONTO COUNTY PUBLIC HEALTH. THE ORGANIZATION ACTIVELY PARTICIPATES IN THE OCONTO AREA CHAMBER OF COMMERCE BUSINESS EXPOR, COPPERFEST SPONSORSHIP, NEWCAP AND HUMANE SOCIETY FOOD DRIVES. IN ADDITION THE ORGANIZATION IS A SOLE COMMUNITY HOSPITAL WITH AN EMERGENCY ROOM AVAILABLE 24/7 TO ALL. PART VI, LINE 6: THE ORGANIZATION, IN PARTNERSHIP WITH BELLIN HEALTH SYSTEMS, INC., CONTINUES TO SERVE IT'S COMMUNITY. X X X X 0 1 0 0 0 0 0 0 0 JAMES DIETSCHE EVP-CFO 0 428323 0 90080 0 414 0 57862 0 23591 0 600270 0 0 PAWNEET SING MD PHYSICIAN 452579 0 65555 0 162 0 14352 0 8630 0 541278 0 0 0 CHARLES HEYKA MD PRESIDENT OF MEDICAL STAFF 349968 0 80 0 1188 0 18582 0 26444 0 396262 0 0 0 MICHAEL BRENNER MD PHYSICIAN 333081 0 80 0 180 0 13861 0 23823 0 371025 0 0 0 NICOLE HINIKER MD PHYSICIAN 87000 0 240984 0 414 0 17364 0 20419 0 366181 0 0 0 JON SIMMONS MD PHYSICIAN 187171 0 145600 0 414 0 13943 0 9131 0 356259 0 0 0 LAURA HIEB BOARD MEMBER 0 268232 0 25140 0 7693 0 45575 0 11064 0 357704 0 0 IVY VACHON MD PHYSICIAN 221564 0 40913 0 30144 0 11999 0 21169 0 325789 0 0 0 LAURA CORMIER - TERMED FORMER CEO 156831 0 5080 0 4272 0 11866 0 22639 0 200688 0 0 0 JULIE BIEBER VP 124575 0 6080 0 17079 0 10575 0 10637 0 168946 0 0 0 PART I, LINE 4B THE HOSPITAL HAS A DEFERRED COMPENSATION PLAN FOR SELECTED EXECUTIVES. THE PARTICIPANT IS LAURA HIEB. A WISCONSIN HEALTH & EDUCATIONAL FACILITIES AUTHORITY 391337855 2011-08-18 14000000 FACILITY AND SERVICE EXPANSION 0 0 0 A 466667 14000000 36149 132033 13831818 2012 0 0 1 1 A 0 0 0 0 0 0 1 A 0 1 0 0 0 0 0 0 A 1 FORM 990, PART VI, SECTION A, LINE 6 THE ORGANIZATION HAS TWO MEMBERS, BELLIN MEMORIAL HOSPITAL, INC. AND OCONTO MEMORIAL HOSPITAL CITIZENS FOUNDATION, INC. FORM 990, PART VI, SECTION A, LINE 7A THE MEMBERS OF THE ORGANIZATION HAVE THE POWER TO APPOINT/ELECT THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION A, LINE 7B THE MEMBERS ALSO HAVE THE POWER TO APPROVE, BUT NOT LIMITED TO, THE PHILOSOPHY, MISSION, AND VALUE OF THE ORGANIZATION, STRATEGIC PLANS, THE ANNUAL OPERATING AND CAPITAL BUDGET, AMENDMENTS OR RESTATEMENTS OF THE ARTICLES OF INCORPORATION AND BYLAWS. 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 THE ORGANIZATION REQUESTS AN ANNUAL UPDATE FROM ALL BOARD MEMBERS WHO SIGN THE POLICY. ALL DOCUMENTS ARE PROVIDED BACK TO ADMINISTRATION AND REVIEWED. IF THERE IS A CONFLICT OF INTERST, THE CORPORATE COMPLIANCE OFFICER IS NOTIFIED. MEMBERS OF THE BOARD WHO HAVE A CONFLICT OF INTEREST WITH A BOARD DECISION ABSTAIN FROM VOTING ON THE ISSUE. FORM 990, PART VI, SECTION B, LINE 15 COMPENSATION OF KEY EXECUTIVES ARE SET BY THE EXECUTIVE COMMITTEE OF THE BOARD WITHOUT CONFLICT OF INTEREST AND IS SUPPORTED BY MARKET DATA FROM SURVEYS AND AN INDEPENDENT CONSULTANT'S REPORT. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION CONSIDERS THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS PROPERTY OF THE ORGANIZATION AND THEREFORE ARE NOT AVAILABLE TO THE PUBLIC. FORM 990, PART XI, LINE 9: CHANGE IN INTEREST IN OCONTO MEMORIAL HOSPITAL CITIZENS' FOUNDATION, INC. 14,745. FORM 990, PART XI, 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 54305 391512903 SUPPORT PURPOSES OF BELLIN MEMORIAL HOSPITAL WI 501(C) 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) LINE 2 BELLIN HEALTH SYSTEMS INC 1 THE BELLIN HEALTH FOUNDATION INC PO BOX 23400 GREEN BAY WI 54305 391809171 FOUNDATION WI 501(C) LINE 7 BELLIN HEALTH SYSTEMS INC 1 BELLIN PSYCHIATRIC CENTER INC PO BOX 23725 GREEN BAY WI 54305 391657627 PSYCHIATRIC HOSPITAL WI 501(C) LINE 3 BELLIN HEALTH SYSTEMS INC 1 BELLIN MEMORIAL HOSPITAL INC PO BOX 23400 GREEN BAY WI 54305 391900586 ACUTE CARE HOSPITAL WI 501(C) LINE 3 BELLIN HEALTH SYSTEMS INC 1 BELLIN HEALTH SYSTEMS INC 744 SOUTH WEBSTER AVE GREEN BAY WI 54305 391512904 SUPPORT OF HEALTHCARE ORGANIZATIONS WI 501(C) LINE 12B, II N/A 0 UNITED LIMITY PARTNERSHIP 2366 OAK RIDGE CIRCLE DE PERE WI 54115 391750729 HOSPICE, PALLIATIVE & BEREAVEMENT SERVICES WI 501(C) LINE 10 N/A 0 BELLIN ORTHOPEDIC SURGERY CENTER LLC 2223 LIME KILN RD GREEN BAY WI 54311 264677834 AMBULATORY ORTHOPEDIC SURGERY WI N/A 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 PO BOX 23400 GREEN BAY WI 54305 391564939 OTHER WI N/A C 1 0 0 0 0 1 0 0 0 0 1 1 0 1 0 1 1 0 0 0 BELLIN MEMORIAL HOSPITAL INC E 10328117 FMV BEL-REGIONAL HOME MEDICAL INC J 120000 FMV BELLIN MEMORIAL HOSPITAL INC K 2760893 FMV BELLIN MEMORIAL HOSPITAL INC M 6066479 FMV BELLIN MEMORIAL HOSPITAL INC P 52800784 FMV BELLIN MEMORIAL HOSPITAL INC O 6551522 FMV BELLIN MEMORIAL HOSPITAL INC E 26300000 FMV BELLIN MEMORIAL HOSPITAL INC E 1914376 FMV BEL-REGIONAL HOME MEDICAL INC O 21809 FMV