2017-08-14T15:05:58-05:00 2016-09-30 390758449 Wipfli LLP PO Box 12237 Green Bay WI 543072237 990 2015-10-01 390884478 Bellin Memorial Hospital Inc BELL 9204457260 PO Box 23400 Green Bay WI 54305 JAMES DIETSCHE CFO 9204457260 2017-08-14 1 Terri Rexrode CPA MST P00096513 9206620016 2017-08-14 2015 2021-01-29 14:40:06Z JAMES DIETSCHE PO Box 23400 Green Bay WI 54305 482837642 0 X WWW.BELLIN.ORG X 1908 WI BELLIN MEMORIAL HOSPITAL, INC. (BMH) PROVIDES HEALTH CARE SERVICES AND OTHER FINANCIAL SUPPORT THROUGH VARIOUS PROGRAMS THAT ARE DESIGNED, AMONG OTHER MATTERS, TO ENHANCE THE HEALTH OF THE COMMUNITY AND IMPROVE THE HEALTH OF LOW-INCOME PATIENTS. CONSISTENT WITH THE MISSION OF BMH, CARE IS PROVIDED TO PATIENTS REGARDLESS OF THEIR ABILITY TO PAY. IN ADDITION, BMH PROVIDES SERVICES INTENDED TO BENEFIT THE POOR AND UNDERSERVED, INCLUDING THOSE PERSONS WHO CANNOT AFFORD HEALTH INSURANCE BECAUSE OF INADEQUATE RESOURCES OR ARE UNINSURED OR UNDERINSURED. HEALTH CARE SERVICES TO PATIENTS UNDER GOVERNMENT PROGRAMS, SUCH AS MEDICAID, ARE ALSO CONSIDERED PART OF THE BELLIN HEALTH BENEFITS PROVIDED TO THE COMMUNITY SINCE A SUBSTANTIAL PORTION OF SUCH SERVICES ARE REIMBURSED AT AMOUNTS LESS THAN COST. 22 15 3483 420 8224037 -790158 1097065 922507 449192956 472729864 5978466 1277875 3911513 4062031 460180000 478992277 1225882 607321 0 0 227999752 255739020 0 0 0 194357613 195052016 423583247 451398357 36596753 27593920 454995944 491466100 140678606 145530736 314317338 345935364 X Bellin Health is a community-owned not-for-profit organization responsible for improving the health and wellbeing of people living in Northeast Wisconsin and the Upper Peninsula of Michigan, and all others we serve. We carry out this responsibility through individualized care excellence, community health improvement, and equitable healthcare financing plans all designed to positively impact health and wellbeing. We are steadfast in our commitment to providing compassionate, safe, and coordinated care that is accessible and affordable for everyone. We build trusted relationships and advance true collaboration, fueling our desire to constantly improve and innovate. 0 0 370867487 606348 453799453 THE HOSPITAL PROVIDES ACUTE HOSPITAL CARE TO RESIDENTS OF NORTHEASTERN WISCONSIN. DURING FISCAL YEAR 2016 33,060 INPATIENT DAYS WERE PROVIDED (30,075 ADULTS AND PEDIATRICS), AS COMPARED TO 33,329 (30,590 ADULTS AND PEDIATRICS) IN FISCAL YEAR 2015. THE NUMBER OF OUTPATIENTS REGISTERED FOR 2016 AND 2015 WERE 241,774 AND 242,670, RESPECTIVELY. BELLIN MEMORIAL HOSPITAL ALSO PROVIDED 828,162 (AS COMPARED TO 745,126 IN 2015) PHYSICIAN CLINIC VISITS THROUGH BELLIN MEDICAL AND SPECIALTY GROUPS. 16149096 973 13350771 Northreach Healthcare is a primary care organization with service lines of family practice, ob/gyn, pediatrics, and internal medicine. NorthReach provides service to Marinette county, Menominee county, and the surrounding areas. 387016583 1 1 0 1 0 0 0 0 0 1 1 0 0 0 1 0 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 1 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 1 1 1 0 0 1 325 0 3483 1 1 1 0 0 0 0 0 0 0 0 0 X 22 15 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 1 1 WI X James Dietsche CFOVP 9204457260 744 S Webster Ave green bay WI 54301 TERRY FULWILER Chairperson 0.50 X X 0 0 0 ELL LEE DDS Vice Chairperson 0.50 X X 0 0 0 MARK MCMULLEN Secretary 0.50 X X 0 0 0 NANCY ARMBRUST Board MEMBER 0.50 X 0 0 0 G CORT CONDON Board MEMBER 0.50 X 0 0 0 Daniel Gulling Board MeMBER 0.50 X 0 0 0 FRED SCHMIDT MD BOARD MEMBER 0.50 X 0 0 0 DANIEL ARIENS Board MEMBER 0.50 X 0 0 0 WILLIAM WITTMAN MD Board Member 40.00 X 377831 0 23250 LARRY BORGARD Board MEMBER 0.50 X 0 0 0 JOHN JONES Board MEMBER 0.50 X 0 0 0 SUSAN FINCO Board MEMBER 0.50 X 0 0 0 MICHAEL HADDAD BOARD MEMBER 0.50 X 0 0 0 LOREN FUGLESTAD MD - Termed Board Member/BMG physician 40.00 X 316520 0 33047 CHRISTINE VANDENHOUTEN BOARD MEMBER 0.50 X 0 0 0 JOHN DYKEMA Treasurer 0.50 X X 0 0 0 ROBERT CLAUSEN BOARD MEMBER 0.50 X 0 0 0 GEORGE KERWIN Bellin CEO/Board Member 50.00 X X 910203 0 27477 Paul Casey MD Board Member/President Medical Staff 50.00 X 111515 0 0 Cynthia Lasecki MD Board Member/Former President Medical Staff 50.00 X 350680 0 17301 Sabina Singh MD Board Member/President Bellin Medical Group 50.00 X 263429 0 21321 Mark Ringwelski MD Board Member/FPresident Bellin Specialty Group 50.00 X 312926 0 28241 Karl Schmidt Board Member 0.50 X 0 0 0 Dennis Hogan - Termed Board Member 0.50 X 0 0 0 JAMES DIETSCHE CFO 50.00 X 385624 0 30760 PETER KNOX EXECUTIVE VP 50.00 X 376989 0 34275 CHRISTINE WOLESKE EXECUTIVE VP 50.00 X 410015 0 35558 CHRISTOPHER WOLFRAM MD Physician 40.00 X 939518 0 26211 TIMOTHY TANKE MD Physician 40.00 X 886258 0 30839 RICHARD TIMMONS MD PHYSICIAN 40.00 X 824336 0 32558 Vijaya Munagala MD Physician 40.00 X 789439 0 28985 Paul Hudson MD PHYSICIAN 40.00 X 856152 0 34228 8111435 0 404051 308 0 1 0 IEI General Contractors 1725 Midway Road De Pere WI 54115 Construction contractor services 6039255 BLR Further LLC 4841 Summer Avenue Memphis TN 38122 Advertising/marketing services 2445723 AmeriEBO LLC 1851 South Alverno Road Manitowoc WI 54220 Collections services 1709919 Miron Construction Co Inc PO Box 509 Neenah WI 54957 Construction contractor services 1216027 Bay Towel & Linen 2580 South Broadway Green Bay WI 54301 Linen services 1190559 64 554562 367945 922507 NET PATIENT SERVICE REVENUE 621500 464766967 457173783 7593184 CONTRACTED SERVICES 621110 3078643 3078643 MISCELLANEOUS 621110 2631757 2631757 CAFETERIA 621110 863578 863578 ACO INCENTIVE 621110 609812 609812 779107 91255 630853 56999 472729864 2082486 2082486 3156971 45925 2659914 45925 497057 0 497057 497057 334915 846470 293056 -846470 41859 -804611 -804611 Income FROM HEALTHCARE AFFILIATES 900099 3281597 3281597 EHR INCENTIVE 621110 283377 283377 3564974 478992277 467150224 8224037 2695509 607321 607321 4066962 1744546 2322416 203472603 185629454 17843149 9152929 8275797 877132 26272558 22934678 3337880 12773968 11442936 1331032 636232 636232 621851 621851 622909 622909 27202082 20011440 7190642 7630896 43351 7587545 4960659 2057032 2903627 7699772 3807148 3892624 11118215 10001161 1117054 1097813 676033 421780 1698577 1022850 675727 3838662 402263 3436399 18461552 13410094 5051458 871334 684816 186518 Supplies expense 77151680 76602961 548719 Equipment Rent/Maint 11726994 10084183 1642811 Dues & subscriptions 10051961 8515251 1536710 Bad Debt expense 6705765 6704616 1149 2955062 1722420 1232642 451398357 387016583 64381774 0 15994 17432 90773641 80772767 48389694 48985833 6347210 2968083 4987231 5813537 6774092 5826209 367306413 195531478 144955990 171774935 123364419 135677068 13839345 17958742 6105842 5368296 9442486 16303198 454995944 491466100 38980842 47700716 320036 230863 72367813 67651129 29009915 29948028 140678606 145530736 X 310758298 341994662 1388632 1450794 2170408 2489908 314317338 345935364 454995944 491466100 X 27593920 6374351 -2350245 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 5840 5840 0 Part II-B, Line 1: AHA and WHA Dues 2283113 319500 45890 10824 2637679 2446300 101050 -255551 8686 2283113 2417823 35966 7489 2446300 2372548 48841 3566 2417823 2239178 86124 68097 20851 2372548 0.00000 0.94400 0.05600 1 1 1 7483827 7483827 134067453 56654528 77412925 2404457 1757006 647451 200839132 137119944 63719188 22511544 22511544 171774935 Deferred compensation 8880480 Noncontrolling interest of consolidated affiliate 1206577 Capital lease obligations 9407798 Interest rate swap valuation 10453173 29948028 477809238 6374351 -9853897 -3479546 481288784 -2296507 -2296507 478992277 447214305 2913502 2913502 444300803 7097554 7097554 451398357 Part V, Line 4: ENDOWMENT FUNDS ARE INTENDED TO BE USED FOR HEALTH CARE SERVICES AND EMPLOYEE TRAINING AND DEVELOPMENT. Part XI, Line 2d - Other Adjustments: LOSS ON SWAP AGREEMENT -1,293,827. NON-CONTROLLING INTEREST -1,854,305. Provision for bad debts -6,705,765. Part XI, Line 4b - Other Adjustments: TRANSFER FROM FOUNDATION 554,562. HOSPITAL SUPPLIES 62,433. RENTAL EXPENSES -2,705,839. Loss from healthcare affiliates -207,663. Part XII, Line 2d - Other Adjustments: RENTAL EXPENSES 2,705,839. Loss from healthcare affiliates 207,663. Part XII, Line 4b - Other Adjustments: REALLOCATION OF SUPPLIES EXPENSE TO 990T 62,433. EXPENSES PAID FOR BY FOUNDATION TRANSFERS 329,356. Provision for bad debts 6,705,765. 1 1 X 1 X 220.000000000000 1 X 1 1 0 1 1 2251326 2251326 0.00510 53192139 27705329 25486810 0.05730 55443465 27705329 27738136 0.06240 4277046 4277046 0.00960 3285907 3285907 0.00740 705626 705626 0.00160 8268579 8268579 0.01860 63712044 27705329 36006715 0.08100 722593 722593 0.00160 722593 722593 0.00160 1 2649862 127704014 192605440 -64901426 X 1 1 1 Bellin Orthopedic Surgery Center LLC orthopedic surgery center 0.55000 0.45000 1 1 Bellin Memorial Hospital 744 S Webster Ave Green Bay WI 54305 147 X X X Bellin Memorial Hospital 1 0 0 1 X X X X X X X X X 14 1 1 1 1 X www.bellin.org/patients_visitors/company-information/community-health X 1 14 1 www.bellin.org/patients_visitors/company-information/community-health 0 0 1 X 220.000000000000 400.000000000000 X X 1 1 X X X 1 X X X X 1 0 X X X X 1 X 0 0 Bellin Memorial Hospital Part V, Section B, Line 5: THE BROWN COUNTY AND CITY OF DE PERE HEALTH DEPARTMENTS CONVENED A COMMUNITY HEALTH NEEDS ASSESSMENT STEERING COMMITTEE THAT INCLUDED REPRESENTATIVES OF BELLIN HEALTH, ST. MARYS ANDITS SISTER HOSPITAL ST. VINCENT, THE LOCAL UNITED WAY, AND REPRESENTATIVES OF THE REGIONAL OFFICE OF WISCONSINS DEPARTMENT OF HEALTH. THIS STEERING COMMITTEE WORKED TO IDENTIFY REPRESENTATIVES THAT COULD BROADLY REPRESENT THE COMMUNITY IN ACTUALLY CONDUCTING THE NEEDS ASSESSMENT AND SETTING PRIORITIES. THESE INDIVIDUALS WERE REFERRED TO AS COMMUNITY PARTNERS.LIST OF NAMES FOLLOWS:AGING & DISABILITY RESOURCE CENTER, SUNNY ARCHAMBAULTAURORA HEALTH SYSTEM, JULIE POMASLBAY AREA COMMUNITY COUNCIL, PAT FINDER-STONEBELLIN COLLEGE, KATHIE DEMUTHBELLIN HEALTH, JODY WILMET*BELLIN HEALTH, LINDA ROETHLEBOYS & GIRLS CLUB, JOHN BENBERGBROWN COUNTY BOARD, MIKE FLECKBROWN COUNTY BOARD OF HEALTH (BOARD MEMBER), AUDREY MURPHY**BROWN COUNTY COMMUNITY TREATMENT CENTER, MARY JOHNSONBROWN COUNTY COOPERATIVE EXTENSION, JUDY KNUDSENBROWN COUNTY HEALTH DEPARTMENT, JUDY FRIEDERICHS (DIRECTOR, BROWN COUNTYHEALTH DEPARTMENT)* **BROWN COUNTY HUMAN SERVICES, KEVIN LUNOGBROWN COUNTY PLANNING, CHUCK LAMINEBROWN COUNTY UNITED WAY, STEPHANIE FOLEY*#CENTER FOR CHILDHOOD SAFETY/ SAFE KIDS GREATER GREEN BAY, JUSTINE LODLCITY OF DE PERE BOARD OF HEALTH (BOARD MEMBER), PAT FINDER-STONE **CITY OF DE PERE HEALTH DEPARTMENT, MARY DORN, HEALTH DIRECTOR* **DE PERE AREA CHAMBER OF COMMERCE, CHERYL DETRICKDIVISION OF PUBLIC HEALTH NORTHEAST REGIONAL OFFICE, REBECCA HOVARTER,REGIONAL PUBLIC HEALTH NURSING CONSULTANT* **DIVISION OF PUBLIC HEALTH NORTHEAST REGIONAL OFFICE, LYNN HRABIK,EPIDEMIOLOGIST* **FAMILY SERVICES-CRISIS CENTER, TANA KOSS #GREATER GREEN BAY COMMUNITY FOUNDATION, MARTHA AHRENDTGREATER GREEN BAY YMCA, SANDY ATKINSGREEN BAY CHAMBER OF COMMERCE, NAN NELSON, CCEHOMELESS POPULATION REPRESENTATIVE, SETH MOORE #N.E.W. COMMUNITY CLINIC, BONNIE KUHR #NWTC HEALTH SCIENCE, KAY TUPALA, DEANONEIDA TRIBE OF INDIANS, MICHELLE MYERS #PARISH NURSE, KATIE DYKES #BROWN COUNTY SHERIFF REPRESENTATION - CHIEFS GROUP, CAPT. RANDY SCHULTZPREVEA HEALTH, DR. ASHOK RAIST. MARYS HOSPITAL MEDICAL CENTER, HEIDI SELBERG*ST. VINCENT HOSPITAL, HEIDI SELBERG*ST. WILLEBROAD CATHOLIC PARISH, MARIA PLASCENCIASCHOOL REPRESENTATION - SUPERINTENDENTS GROUP, BARB NATELLETHE SALVATION ARMY, REBECCA LESPERANCE #UNITED HMONG AND ASIAN AMERICAN COMMUNITY CENTER, STARYOUNG THAO #UWGB-ENVIRONMENTAL SCIENCES, THOMAS ERDMANUW-GREEN BAY NURSING PROGRAM, CHRIS VANDENHOUTENWOMEN, INFANT AND CHILDREN (WIC), BONNIE KUHR #* STEERING COMMITTEE MEMBER** PERSON WITH SPECIAL KNOWLEDGE OF PUBLIC HEALTH, INCLUDING PUBLIC HEALTHDEPARTMENT LEADERSHIP STAFF AND MEMBERS OF GOVERNANCE BODIES FOR PUBLICHEALTH DEPARTMENTS.# REPRESENTATIVES OF UNDERSERVED, LOW INCOME, MINORITY OR CHRONIC DISEASE Bellin Memorial Hospital Part V, Section B, Line 6a: St. Mary's and St. Vincent Hospitals (HSHS, Green Bay) Bellin Memorial Hospital Part V, Section B, Line 6b: BROWN COUNTY HEALTH DEPARTMENT, CITY OF DE PERE HEALTH DEPARTMENT, BROWN COUNTY UNITED WAY, AND WI DIVISION OF PUBLIC HEALTH NE REGIONAL OFFICE Bellin Memorial Hospital Part V, Section B, Line 11: The most recent CHNA identified community needs from 2015 through 2017. We are in the process of leading a community reassessment.The needs identified are: Oral Health, Alcohol and Other Drug Abuse, Mental Health and Physical Activity and Nutrition. Bellin representatives lead the Alcohol and Other Drug Abuse and Mental Health Community Action teams and is active on the other teams. A summary of how Bellin has been addressing the needs identified in the CHNA is as follows:Oral Health: Bellin sponsored a legislative breakfast to improve health care policy and coverage of Medicaid patients. We have standardized our ED protocols to be consistent with the other health care systems for patients with oral pain., along with conducting a oral health screening pilot with our OB patients. Bellin donates funds annually to the NEW Community Clinic which has been able to expand access for oral care for Medicaid and uninsured patients. Alcohol and Other Drug Misuse: The Alcohol and Drug Task Force has three key focus areas: Access to Care, Public Policy, and Public Awareness. This past year the group has partnered with the Mental Health Task Force in establishing a goal of four days to treatment for those who are in need of Alcohol and Drug treatment. The team has partnered with local agencies to understand barriers to access-including financial, transportation, and education. Interventions are being tested to remove barriers. Under public awareness there has been work done to provide education within the Green Bay Public schools in a presentation called "Wrecked at the Weidner". This presentation was a community effort to address impaired/inattentive driving due to alcohol and drug use and texting. Nearly 3,000 youth attended. Multiple media outlets covered the impact of binge drinking on the communitywith responses from our local representatives. Work also occurred around advancing education surrounding Opioid and Heroin use within the community. Public policy: Action has been made by local representatives towards passing the ordinance around Social Hosting. Work also being prioritized with local festivals around "evidenced based strategies to decrease alcohol misuse". Alcohol compliance checks also started back up in the city of Green Bay to address the sale of alcohol to minors.Physical Activity and Nutrition: Bellin sponsors on a Community team which has focused on increasing healthy food donations at local food pantry's. This team has met monthly from 2015 until present. This team has effectively improved the percent of healthy foods by 2% every year. The team has also worked on the ability for EBT dollars to be used at the local farmers market, the creation of the Food Drive 5 Toolkit, and a collaborative Food Drive with the Boys and Girls Scouts of America.Mental Health: Brown County Mental Health Task Force Goal: Brown County will increase access to mental health services for all populations in the county by identifying gaps and disparities and creating a common platform that mental health providers, partner agencies, and stakeholders can access 1. By December 31, 2017, with a goal of getting to 0 suicides, the number of annual suicides in Brown County will decrease from 35 to 302. By December 31, 2017, the average number of poor mental health days per 30 days, as reported by county residents, will decrease from 3.2 to 3.0OBJECTIVE #1: By December 31, 2017, the task force will create a document accessible to all stakeholders that identifies the current state of mental health care in Brown County, including all available resources and services provided, gaps and disparities in care, needed programs, and ratio of specific mental health providers to population. We have evaluated best practice screening tools that can be implemented across community and healthcare settings (help identify current state of mental health and needs) In partnership with the St. Norbert College Strategic Research Center, we have identified disparities in poor mental health days in Brown County and created initiatives to address these areas. (see below)OBJECTIVE #2: By December 31, 2017, the mental health task force will create a draft proposal for creating a community-wide "No Wrong Door" access platform for mental health treatment and connection between mental health providers. (The goal is to create the right access at the right time by having a comprehensive view and collaborative connections between all Brown County mental health service providers.) We have selected our virtual online vendor for community-wide access platform. We received a $1M grant in collaboration with Connections for Mental Wellness to reduce the number of poor mental health days by: o Improving accesso Improving community members' knowledge of mental health and mental wellnesso Creating mentally healthy workplaceso Building the workforce (psychiatrists and mental health therapists) Bellin Memorial Hospital Part V, Section B, Line 13b: A patient's liability is capped to 15% of annual income. A patient who receives any percentage of charity care based on their income, will not be responsible for more than 15% of their annual income. Bellin Memorial Hospital Part V, Section B, Line 22d: The hospital looked at the average amount collected for all payers (including medicare and medicaid). Average collection rate was 44%. Any patient receiving Financial Assistance, will not be responsible for more than 44% of charges. 48 2 - The Cancer Team of Bellin Health 1580 Commanche Ave Green Bay WI 54313 Hospital Based Site 3 - Cardiology Associates of Bellin Health 744 S Webster Ave Green Bay WI 54301 Hospital Based Site 4 - Family Medical Center Ashwaubenon 1630 Commanche Ave Green Bay WI 54313 Provider Clinic Site 5 - Bellin Health Cardiovascular & Thoracic Su 720 S Van Buren St Suite 303 Green Bay WI 54301 Provider Clinic Site 6 - Bellin Health Surgical Associates 720 S Van Buren St Suite 201 Green Bay WI 54301 Provider Clinic Site 7 - Gastroenterology Associates of Green Bay 725 S Webster Ave Green Bay WI 54301 Provider Clinic Site 8 - Family Medical Center De Pere East 555 Redbird Circle De Pere WI 54115 Provider Clinic Site 9 - Bellin Health Generations 704 S Webster Ave Suite 300 Green Bay WI 54301 Provider Clinic Site 10 - Family Medical Center Howard 2714 Riverview Green Bay WI 54313 Provider Clinic Site 11 - Family Medical Center Bellevue 3263 Eaton Rd Green Bay WI 543116830 Provider Clinic Site 12 - Family Medical Center De Pere West 1800 Lawrence Dr De Pere WI 54115 Provider Clinic Site 13 - Bellin Health Iron Mountain 440 Woodward Ave Iron Mountain MI 49801 Provider Clinic Site 14 - Neurology Consultants of Bellin Health 725 S Webster Ave Green Bay WI 54301 Provider Clinic Site 15 - Bellin Health Orthopedics 1630 Commanche Ave Green Bay WI 54313 Provider Clinic Site 16 - Bellin Health NorthReach Internal Medicine 3123 Shore Drive Suite 102 Marinette WI 54143 Provider Clinic Site 17 - Bellin Health Escanaba 610 S Lincoln Road ESCANABA MI 49829 Provider Clinic Site 18 - Family Medical Center Green Bay 704 S Webster Ave Green Bay WI 54301 Provider Clinic Site 19 - Bellin Health NorthReach Pediatrics 1106 Universtiy Drive Marinette WI 54143 Provider Clinic Site 20 - Bellin Health NorthReach Crivitz Medical C 218 S Hwy 141 Crivitz WI 54114 Provider Clinic Site 21 - Family Medical Center Kewaunee 575 - 4th Street Kewaunee WI 54216 Provider Clinic Site 22 - Bellin Health NorthReach FamilyCare Medica 3123 Shore Drive Marinette WI 54143 Provider Clinic Site 23 - Bellin Health Marinette Menominee Clinic 3200 Shore Drive Marinette MI 54143 Provider Clinic Site 24 - Family Medical Center Algoma 831 Parker Ave Algoma WI 54201 Provider Clinic Site 25 - Family Medical Center Brillion 964 W Ryan St Suite B Brillion WI 54110 Provider Clinic Site 26 - Bellin Health Oconto Falls 107 E Highland Dr Oconto Falls WI 54154 Provider Clinic Site 27 - Bellin Health Asthma & Allergy 519 S Monroe Avenue Green Bay WI 54301 Provider Clinic Site 28 - Bellin Health NorthReach OBGYN 3123 Shore Drive Suite 201 Marinette WI 54143 Provider Clinic Site 29 - Family Medical Center Denmark 595 County Road R Denmark WI 54208 Provider Clinic Site 30 - Bellin Health NorthReach Peshtigo Family M 441 French St Peshtigo WI 54143 Provider Clinic Site 31 - Family Medical Center Seymour 405 Commercial St Seymour WI 54165 Provider Clinic Site 32 - Bellin Health NorthReach Urgent Care 3200 Shore Drive Marinette WI 54143 Provider Clinic Site 33 - Family Medical Center Wrightstown 555 Quality Ct Wrightstown WI 54180 Provider Clinic Site 34 - Family Medical Center Luxemburg 140 B School Creek Trail Luxemburg WI 54217 Provider Clinic Site 35 - Family Medical Center Manitowoc 3415 Custer St Suite D Manitowoc WI 54221 Provider Clinic Site 36 - Bellin Health NorthReach Menominee Medical 1100 10th Street Menominee MI 49858 Provider Clinic Site 37 - Family Medical Center Pulaski 723 S Wisconsin St Pulaski WI 541620109 Provider Clinic Site 38 - Bellin Health NorthReach Daggett Medical C 106 S School Rd Daggett MI 49821 Provider Clinic Site 39 - Bellin Health NorthReach After Hours Marin 1106 Universtiy Drive Marinette MI 54143 Provider Clinic Site 40 - Bellin Health Asthma & Allergy - Neenah 119 E Bell St Suite B Neenah WI 54957 Provider Clinic Site 41 - BELLIN HEALTH FAST CARE ASHWAUBENON 301 BAY PARK SQUARE Green Bay WI 54304 Convenient Care Center 42 - BELLIN HEALTH FAST CARE EAST TOWNE MALL 2430 E MASON STREET Green Bay WI 54302 Convenient Care Center 43 - Bellin Health NorthReach Laboratory 3200 Shore Drive Marinette WI 54143 Provider Clinic Site 44 - Family Medical Center Bonduel 401 W Mill St Bonduel WI 54107 Provider Clinic Site 45 - Bellin Health Endocrinology 720 S Van Buren Ste 104 Green Bay WI 54301 Provider Clinic Site 46 - BELLIN HEALTH FAST CARE SUAMICO 2318 LINEVILLE ROAD Suamico WI 54173 Convenient Care Center 47 - Bellin Health NorthReach Fast Care Marinet 2741 Roosevelt Road Marinette MI 54143 Convenience Care Center 48 - Family Medical Center Suring 307 Manor Dr Suring WI 54174 Provider Clinic Site 49 - Family Medical Center Sturgeon Bay 311 N 3rd Ave Sturgeon Bay WI 43235 Provider Clinic Site Part I, Line 6a: BELLIN MEMORIAL HOSPITAL IN INCLUDED IN THE 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 $6,705,765 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: COMMUNITY BUILDING ACTIVITIES FOCUS ON SOCIAL CONDITIONS THAT CONTRIBUTE TO HEALTH PROBLEMS, SUCH AS HOMELESSNESS, POVERTY, AND OTHER LIVING CONDITIONS AFFECTING THE QUALITY OF LIFE. THESE RANGE FROM DEVELOPING COMMUNITY LEADERS, DISASTER READINESS, AND SUPPORT OF LOCAL ECONOMIC DEVELOPMENT, TO HEALTH IMPROVEMENT ADVOCACY. BELLIN MEMORIAL HOSPITAL IS ACTIVE IN THE GREEN BAY PUBLIC SCHOOLS WITH OUR THRIVE PROGRAM THAT ASSISTS IN SETTING AND MEETING HEALTH AND WELLNESS GOALS FOR STUDENTS IN THIS SCHOOL SYSTEM. BELLIN ALSO HOLDS AN ANNUAL BELLIN RUN/WALK 10K EVENT EACH YEAR WITH OVER 18,000 PARTICIPANTS OF ALL AGES LEARNING FIRST HAnD THE VALUE OF EXERCISE IN DAILY LIFE. Part III, Line 2: THE BAD DEBT EXPENSE AT COST IS CALCULATED BASED ON THE COST TO CHARGE RATIOS 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 provision for bad debt on pages 12 and 13 of the financial statements.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 a portion of the bill), Bellin Health Systems 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 allowances for doubtful accounts. 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 SERVICES 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, FOR-PROFIT HOSPITALS HAVE CARVED OUT HIGH-MARGIN SERVICES (I.E. ONCOLOGY, ORTHO, ETC) LEAVING GENERAL ACUTE CARE HOSPITALS WITH LOWER-MARGIN MEDICARE SERVICES. THIS MEANS THAT 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: If a patient is known to qualify for charity care, the amount of charity care the patient receives is based on the patients income. We have a sliding scale that looks at your income as a % of the Federal Poverty Level. Income from 0-220% gets 100% charity care. Income 401% or more than the federal poverty level gets 0%. In between 220% and 400% is the sliding scale. Once qualified for charity care, this qualification is good for 6 months going forward. Part VI, Line 2: BELLIN MEMORIAL HOSPITAL 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 MEMORIAL HOSPITAL SERVES NORTHEAST WISCONSIN AND UPPER MICHIGAN. OUR CURRENT PAYOR SUPPLEMENTAL INFORMATION MIX IS 48.7% MEDICARE AND 9.8% MEDICAID. 12% OF THE POPULATION IS BELOW THE POVERTY LEVEL AND 13.5% OF THE POPULATION IS OVER AGE 65. Part VI, Line 5: A MAJORITY OF BELLIN MEMORIAL HOSPITALS GOVERNING BODY IS COMPRISED OF PERSON WHO RESIDE IN BELLIN MEMORIAL HOSPITAL'S PRIMARY SERVICE AREA WHO ARE NEITHER EMPLOYEES NOR CONTRACTORS OF THE ORGANIZATION, NOR FAMILY MEMBERS THEROF. IN ADDITION, BELLIN MEMORIAL HOSPITAL EXTENDS MEDICAL STAFF PRIVELEGES TO ALL QUALIFIED PHYSICIANS IN ITS COMMUNITY FOR ALL OF ITS DEPARTMENTS. BELLIN MEMORIAL HOSPITAL 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 THROUGHOUT THE WORLD. Part VI, Line 7, Reports Filed With States WI 1 NEW Community Clinic 622 Bodart Street Green Bay WI 54301 391200636 501(c)3 100000 Support Free Community Health Clinic GREEN BAY PUBLIC SCHOOLS PO BOX 23387 Green Bay WI 543053387 396002329 GOVT - PUBLIC SCHOOL 63333 HEALTH & WELLNESS PROGRAM FESTIVAL FOODS TURKEY TROT 2250 W MASON ST GREEN BAY WI 54303 391814712 15000 TURKET TROT RUN FOR CHARITY DOWNTOWN GREEN BAY INC 130 E WALNUT ST STE 501 GREEN BAY WI 54301 391858389 501(c)3 8500 Winter Farmers Market KIWANIS SKI CLUB PO BOX 475 IRON MOUNTAIN MI 49801 383254313 501(c)3 25000 DONATION UW OSHKOSH 842 ALGOMA BLVD OSHKOSH WI 54901 391805963 Govt- STATE AGENCY 60000 SUPPORT ORGANIZATION'S ACTIVITIES NORTHEAST WISCONSIN TECHNICAL COLLEGE 2740 W MASON ST GREEN BAY WI 54307 391087141 GOVT- STATE AGENCY 21000 HEALTH SCIENCE SIMULATION LAB AMERICAN FOUNDATION OF COUNSELING 130 E WALNUT ST 7TH FLOOR GREEN Bay WI 54301 391047205 501(c)3 8000 ETHICS IN BUSINESS AWARDS AND MORE PROGRAM FOR MENTAL WELLNESS/TREATMENT INDIGENT POPULATION GREATER GREEN BAY COMMUNITY FOUNDATION 310 W WALNUT ST SUITE 350 GREEN Bay WI 54303 391699966 501(c)3 40200 Green Bay Neighboorhood Leadership Council, Women's Fund of Green Bay UNITED WAY OF BROWN COUNTY 112 N ADAMS ST STE 201 GREEN BAY WI 54301 390806299 501(c)3 36000 Donation ALGOMA SCHOOL DISTRICT 1715 DIVISION ST ALGOMA WI 54201 391032686 GOVT - PUBLIC SCHOOL 20400 DONATION ASHWAUBENON EDUCATION FOUNDATION 320 N BROADWAY ST SUITE 260 GREEn Bay WI 54303 396000770 GOVT - PUBLIC SCHOOL 5000 DONATION BRIAN LAVIOLETTE SCHOLARSHIP 1135 PLEASANT VALLEY DR ONEIDA WI 54155 391836591 501(c)3 5500 BELLIN COLLEGE SCHOLARSHIP NEIGHBORHOOD HOUSING SERVICES OF GREEN BAY 437 S JACKSON ST GREEN BAY WI 54301 391402851 501(c)3 10000 PROGRAM ASSISTANCE UNIVERSITY OF WISCONSIN - GREEN BAY FOUNDATION 2420 NICOLET DR GREEN BAY WI 54311 391805963 GOVT - PUBLIC SCHOOL 20000 MARK REINKE, MD MEMORIAL SCHOLARSHIP BROWN COUNTY MEDICAL SOCIETY ALLIANCE 563 CARTER CT STE B KIMBERLY WI 54136 391516026 501(c)3 5000 2015 DOCTORS IN RECITAL SPONSORSHIP BELLIN COLLEGE 3201 EATON RD GREEN BAY WI 54311 391620530 501(c)3 63938 BUILD OUT LAB AND NURSING CAMPS UNITY HOSPICE 2366 OAK RIDGE CIRCLE DE PERE WI 54115 391750729 501(c)3 5500 DONATION US VENTURE OPEN 425 BETTER WAY APPLETON WI 54915 391548450 501(c)3 25000 DONATION 20 0 Part I, Line 2: THE ORGANIZATION REQUIRES A COMPREHENSIVE REQUEST OF THE GRANTEE TO PROVIDE RATIONALE FOR THE REQUEST. REQUIRED INFORMATION TO BE PROVIDED BY THE GRANTEE INCLUDES, TAX-EXEMPT STATUS, IDENTIFICATION OF USE OF RESOURCES AND FOLLOW UP INFORMATION AS TO THE UTILIZATION OF THE RESOURCES. THE ORGANIZATION REVIEWS EACH GRANTEE REQUEST IN RELATIONSHIP TO THE MISSION OF THE ORGANIZATION AND COMMUNITY SUPPORT. ALL REQUESTS REQUIRE APPROVAL BY SENIOR LEADERSHIP OF THE ORGANIZATION. X X X X X 0 0 0 0 0 0 0 0 0 WILLIAM WITTMAN MD Board Member 231823 0 144820 0 1188 0 8673 0 14577 0 401081 0 0 0 LOREN FUGLESTAD MD - Termed Board Member/BMG physician 195487 0 120763 0 270 0 13424 0 19623 0 349567 0 0 0 GEORGE KERWIN Bellin CEO/Board Member 546445 0 348100 0 15658 0 10400 0 17077 0 937680 0 0 0 Cynthia Lasecki MD Board Member/Former President Medica 184632 0 165778 0 270 0 13742 0 3559 0 367981 0 0 0 Sabina Singh MD Board Member/President Bellin Medica 184631 0 78528 0 270 0 10460 0 10861 0 284750 0 0 0 Mark Ringwelski MD Board Member/FPresident Bellin Speci 231352 0 80800 0 774 0 10010 0 18231 0 341167 0 0 0 JAMES DIETSCHE CFO 325354 0 60000 0 270 0 10079 0 20681 0 416384 0 0 0 PETER KNOX EXECUTIVE VP 325801 0 50000 0 1188 0 17698 0 16577 0 411264 0 0 0 CHRISTINE WOLESKE EXECUTIVE VP 329653 0 79948 0 414 0 16752 0 18806 0 445573 0 0 0 CHRISTOPHER WOLFRAM MD Physician 552922 0 386416 0 180 0 7588 0 18623 0 965729 0 0 0 TIMOTHY TANKE MD Physician 552221 0 333623 0 414 0 12432 0 18407 0 917097 0 0 0 RICHARD TIMMONS MD PHYSICIAN 555930 0 267632 0 774 0 12562 0 19996 0 856894 0 0 0 Vijaya Munagala MD Physician 514087 0 275082 0 270 0 8112 0 20873 0 818424 0 0 0 Paul Hudson MD PHYSICIAN 681661 0 174311 0 180 0 13547 0 20681 0 890380 0 0 0 A WISCONSIN HEALTH AND EDUCATIONAL FACILITIES AUTHORITY 391337855 2011-11-23 12944000 REFINANCING OF 2001 BONDS 0 0 0 B Wisconsin Health and EDUCATIONAL FACILITIES AUTHORITY 391337855 97712DLH7 2015-04-09 44994006 Refund and legally defease 0 0 0 A 1040000 12944000 79844 2001 1 0 1 1 B 1355616 44994006 528236 44465770 2009 0 1 1 1 A 0 1 1 1 0 0.01000 0.00000 0.01000 0 0 1 B 0 1 1 1 0 0.01000 0.01000 1 0 1 A 1 0 0 0 0 1 B 0 1 0 0 0 0 0 0 1 A 1 B 1 Wisconsin Public Service Corp Constellation Energy Services & WE Energies Board Member Larry Borgard is President & COO - Utilities at Integrys 3226053 Integrys Energy Group provides utility services to Bellin Memorial Hospital 0 Associated Bank Board Member Denis Hogan is Market President 205229 Banking Services 0 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 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 11 The Form 990 is reviewed in detail by senior administration and is presented to the Executive Committee in its entirety for a review of the document. 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. If there is a conflict of interest, the corporate compliance officer and corporate compliance committee which is a committee of the board of directors is notified. The corporate compliance officer and corporate compliance committee addresses the issue. 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 THE ORGANIZATION 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: CHANGE IN INTEREST IN FOUNDATION 797,887. INTEREST RATE SWAP AGREEMENT -1,293,827. NON-CONTROLLING INTEREST IN CONSOLIDATED AFFILIATE -1,854,305. FORM 990, PART XI, LINE 2B-2C BELLIN MEMORIAL HOSPITAL, INC. 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. THIS PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. NORTHREACH HEALTHCARE LLC 3120 RIVERSIDE AVE GATE B BLDG 1 MARINETTE WI 54143 391999260 PRIMARY AND SPECIALTY PHYSICIAN CLINICS WI 13542838 785285 BELLIN MEMORIAL HOSPITAL LAKE MICHIGAN HEALTH SERVICES INC 744 SOUTH WEBSTER AVE GREEN BAY WI 54305 391512903 SUPPORT PURPOSES OF BELLIN MEMORIAL HOSPITAL WI 501(c)(3) Line 11b, II Bellin Health Systems Inc 1 BELLIN COLLEGE INC 3201 EATON ROAD GREEN BAY WI 54311 391620530 NURSING COLLEGE WI 501(c)(3) Line 2 Bellin Health Systems Inc 1 THE BELLIN HEALTH FOUNDATION INC PO BOX 23400 GREEN BAY WI 54305 391809171 FOUNDATION WI 501(c)(3) Line 7 Bellin Health Systems Inc 1 BELLIN PSYCHIATRIC CENTER INC PO BOX 23725 GREEN BAY WI 54305 391657627 PPSYCHIATRIC HOSPITAL WI 501(c)(3) Line 3 Bellin Health Systems Inc 1 OCONTO HOSPITAL & MEDICAL CENTER INC PO BOX 357 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 11b, II N/A 0 UNITY LIMITED PARTNERSHIP 2366 OAK RIDGE CIRCLE DE PERE WI 54115 391750729 HOSPICE, PALLIATIVE & BEREAVEMENT SERVICES WI 501(c)(3) Line 9 BELLIN MEMORIAL HOSPITAL INC 1 BELLIN ORTHOPEDIC SURGERY CENTER LLC 2223 LIME KILN RD GREEN BAY WI 54311 264677834 AMBULATORY ORTHOPEDIC SURGERY WI Bellin Memorial Hospital Inc RELATED 2277170 566118 0 0 D1 SPORTS TRAINING OF GREEN BAY LLC SOUTH SPRINGS DRIVE FRANKLIN TN 37067 454848172 SPORTS TRAINING TN 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 0 BELLIN INVESTMENTS INC PO BOX 23400 GREEN BAY WI 54305 391564939 OTHER WI N/A C 0 1 1 1 1 0 0 0 0 0 1 0 1 1 1 1 1 1 0 1 OCONTO HOSPITAL & MEDICAL CENTER D 12249995 ACTUAL OCONTO HOSPITAL & MEDICAL CENTER O 657118 ACTUAL OCONTO HOSPITAL & MEDICAL CENTER M 1233599 ACTUAL OCONTO HOSPITAL & MEDICAL CENTER Q 4250000 ACTUAL bellin college B 63938 ACTUAL Bellin Health Foundation C 554562 ActUAL Bellin Psychiatric Center L 2097955 ActUAL Bellin psychiatric Center D 3060492 ACTUAL bellin college L 329943 actual bellin college N 350014 aCTUAL bellin health Foundation Q 560294 aCTUAL bellin health Foundation O 367331 aCTUAL bellin health Foundation S 1345000 aCTUAL