2017-10-25T12:10:37-05:00 2016-12-31 381357951 PLANTE & MORAN PLLC 250 S High St Suite 100 Columbus OH 43215 990 2016-01-01 344428205 THE BELLEVUE HOSPITAL BELL 4194834040 1400 WEST MAIN STREET BELLEVUE OH 44811 TIMOTHY BUIT EXECUTIVE VICE PRESIDENT, CFO 4194834040 2017-10-19 1 Bernie Ostrowski P00366367 6148493000 2017-10-18 67.59.56.30 2017-10-19 09:43:22 ED P DA39A3EE5E6B4B0D3255BFEF95601890AFD80709 7BCF9D38B0E592211C041BCD1ADDE56655A5E8DF 2016 2021-01-29 14:40:06Z MICHAEL K WINTHROP 1400 WEST MAIN STREET BELLEVUE OH 44811 51543795 0 X WWW.BELLEVUEHOSPITAL.COM X 1956 OH THE BELLEVUE HOSPITAL IS A COMMUNITY BASED GENERAL ACUTE CARE HOSPITAL THAT PROVIDES CARE TO THE BELLEVUE AND SURROUNDING AREA WITHOUT REGARD TO ABILITY TO PAY. 15 12 474 44 136 0 88825 47384 50187618 49583109 753937 526789 915763 844957 51946143 51002239 143213 87500 0 0 22751921 23084572 0 0 0 25440323 25050922 48335457 48222994 3610686 2779245 64108246 65248147 27523474 28365046 36584772 36883101 X WE CARE FOR PATIENTS AS MEMBERS OF OUR FAMILY. WE WORK TO HEAL THE SICK, TREAT THE INJURED, AND PREVENT ILLNESS. WE PROTECT THE TRUST OF OUR COMMUNITY AND EMPLOYEES, TO BE A PROGRESSIVE, QUALITY HEALTH CARE ORGANIZATION. OUR PRIMARY GOAL IS AND ALWAYS WILL BE TO CARE. 0 0 41676515 87500 50213073 OUR IMPACT ON THE BELLEVUE COMMUNITY: FOR THE CALENDAR YEAR ENDING DECEMBER 31, 2016, THE BELLEVUE HOSPITAL EMPLOYED A TOTAL OF 468 INDIVIDUALS AND MAINTAINED A MEDICAL STAFF MEMBERSHIP OF OVER 80 PHYSICIANS REPRESENTING 33 SPECIALTIES. THE HOSPITAL PAID A TOTAL OF OVER $17 MILLION IN WAGES AND SALARIES. OUR EMPLOYEES PAID A TOTAL OF $245,627 IN INCOME TAXES TO THE CITY OF BELLEVUE AND AN ADDITIONAL $32,682 IN BELLEVUE LOCAL SCHOOL DISTRICT TAXES TO SUPPORT THE BELLEVUE COMMUNITY INFRASTRUCTURE AND EDUCATIONAL NEEDS. OUR EMPLOYEES LIVING IN OTHER LOCAL SCHOOL DISTRICTS PAID $15,597 IN CLYDE LOCAL SCHOOL DISTRICT TAXES, $12,795 IN FREMONT LOCAL SCHOOL DISTRICT TAXES, AND $5,766 IN SENECA EAST SCHOOL DISTRICT TAXES. IN ADDITION, A TOTAL OF $3,265,872 OF THE HOSPITAL'S TOTAL GOODS AND SERVICES EXPENSED DURING 2016 WERE PURCHASED LOCALLY FROM AREA BUSINESSES.SERVING THE BELLEVUE COMMUNITY: A TOTAL OF 1,342 COMMUNITY MEMBERS WERE ADMITTED TO OUR FACILITY DURING 2016. IN ADDITION, A TOTAL OF 66,114 VISITS WERE MADE FOR OUTPATIENT CARE. OUR EMERGENCY ROOM TREATED AN ADDITIONAL 17,304 PATIENTS DURING 2016 AND WE ASSISTED IN THE DELIVERY OF 351 BABIES. WE PROVIDED OVER $1.6 MILLION IN FREE CARE TO UNINSURED OR UNDERINSURED PATIENTS.THE BELLEVUE HOSPITAL WAS RECOGNIZED FOR THE WOMEN'S CHOICE AWARD, BEST HOSPITAL FOR EMERGENCY CARE FOR 2015 AND 2016 AND IS A NICHE DESIGNATED HOSPITAL 2014-2016.THE BELLEVUE HOSPITAL OPENED A VEIN CENTER IN 2016 AND NOW OFFERS AFFORDABLE OUTPATIENT TREATMENT FOR VARIOUS CONDITIONS, SYMPTOMS AND DISEASES OF VEINS. 41676515 1 1 0 1 0 0 0 0 0 0 1 0 0 0 1 0 0 1 0 0 0 0 0 0 0 0 1 1 1 1 1 1 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 1 1 1 0 0 1 57 0 1 474 1 1 1 0 0 0 0 0 0 0 0 0 X 15 12 1 0 0 0 1 1 0 1 1 0 0 1 1 1 1 1 1 1 1 1 1 X RACHEL HERMAN 4194834040 1400 W MAIN ST BELLEVUE OH 44811 RODNEY COOK TRUSTEE 1.00 0.00 X 0 0 0 MICHAEL K WINTHROP PRESIDENT 45.00 1.00 X X 533306 0 25486 TOM BARTH SECRETARY 1.00 0.00 X X 0 0 0 NANCY BEIER 1ST VICE CHAIR 1.00 0.00 X X 0 0 0 JIMMIE FITZGERALD CHAIRMAN 1.00 0.00 X X 0 0 0 DOUG HOY MD 2ND VICE CHAIR 1.00 0.00 X X 0 0 0 DEAN MILLER TREASURER 1.00 0.00 X X 0 0 0 ALICIA CROCKETT TRUSTEE 1.00 0.00 X 0 0 0 DAVID WEST MD TRUSTEE 1.00 0.00 X 0 0 0 JAMES HART TRUSTEE 1.00 0.00 X 0 0 0 THOMAS FORSTER TRUSTEE 1.00 0.00 X 0 0 0 JAMES GERKEN TRUSTEE 1.00 0.00 X 0 0 0 JOE WILSON TRUSTEE 1.00 0.00 X 0 0 0 BEN BALL DO TRUSTEE 1.00 0.00 X 0 0 0 NICHOLAS LIBEN DO TRUSTEE 1.00 0.00 X 0 0 0 TIMOTHY BUIT EXEC VP, CFO 45.00 0.00 X 362375 0 31693 LISA SARTAIN VICE PRESIDENT, HR 40.00 0.00 X 177855 0 14891 SARA BROKAW VICE PRESIDENT, PATIENT CARE 40.00 0.00 X 214690 0 9198 PATRICIA SEMER VICE PRESIDENT, ADMINISTRATION 40.00 0.00 X 177051 0 31137 SHARI LOVE PHARMACIST 40.00 0.00 X 128077 0 20075 CARLA WILLIAMS PHARMACIST 40.00 0.00 X 112660 0 17427 1706014 0 149907 7 0 1 0 EMERGENCY PROFESSIONAL SERVICES INC PO BOX 634850 CINCINNATI OH 45263 EMERGENCY SERVICES 600000 SOUTH SHORE RADIOLOGY PO BOX 1800 SANDUSKY OH 44870 RADIOLOGY SERVICES 525402 BELLEVUE ANESTHESIA ASSOCIATES LLC 1355 W MAIN ST BELLEVUE OH 44811 ANESTHESIA SERVICES 511891 SHIFTWISE PO BOX 70870 ST PAUL MN 55170 LAB PURCHASED LABOR 199809 PHARMACY SYSTEMS INC 5050 BRADENTON AVE DUBLIN OH 43017 PHARMACY PURCHASED LABOR 170478 9 7500 39884 47384 PATIENT SERVICES 622110 49083786 49083786 Health Department 622110 259889 259889 PASS THROUGH INCOME 900003 162329 162193 136 Contract Therapy 622110 36217 36217 Community Education 622110 21761 21761 19127 19127 49583109 547792 547792 299908 444170 -144262 -144262 -144262 76383 97386 -21003 -21003 -21003 EHR INCENTIVES 900099 543659 543659 CAFETERIA/CAFE 722514 273732 273732 Gift Shop 453220 61361 61361 110467 25080 85387 989219 51002239 50213073 136 741646 X 72500 72500 15000 15000 952860 952860 16192695 14196498 1996197 683026 592921 90105 4013487 3518714 494773 1242504 1100413 142091 124649 124649 444101 444101 5264600 4615592 649008 251979 221740 30239 3256710 2931039 325671 1053842 927381 126461 3627164 3090643 536521 2325 2046 279 128968 113069 15899 3736704 3276052 460652 441561 437820 3741 UBI TAX 2000 2000 BAD DEBT EXPENSE 2842029 2842029 MEDICAL SUPPLIES 2773148 2773148 FRANCHISE FEE 691759 691759 409383 258151 151232 48222994 41676515 6546479 0 8351729 6032533 4997530 6212860 385676 649794 789900 1104603 77433370 41099451 35871324 36333919 9748587 10660627 1308739 1285183 2654761 2968628 64108246 65248147 6795554 7668168 18698283 17856148 1295257 2536350 734380 304380 27523474 28365046 X 36584772 36883101 36584772 36883101 64108246 65248147 X 2779245 -17813 -2463103 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 4073 4073 0 Part II-B, Line 1: 3.5 PERCENT OF DUES TO THE OHIO HOSPITAL ASSOCIATION AND 21.78% OF THE AMERICAN HOSPITAL ASSOCIATION DUES WERE ALLOCATED TO LOBBYING ACTIVITIES BY THAT ORGANIZATION. 2262693 2262693 38650580 12736226 25914354 28767548 22207330 6560218 7752549 6155895 1596654 36333919 Derivative Liability 390346 DUE TO MEDICAL STAFF AND AUXILIARY 34381 UNAMORTIZED FINANCING COSTS -120347 304380 1 1 X 1 X 1 X 1 1 0 1 1 665437 0 665437 0.01470 10276752 9141157 1135595 0.02500 10942189 9141157 1801032 0.03970 90748 14234 76514 0.00170 25903 0 25903 0.00060 34717 0 34717 0.00080 151368 14234 137134 0.00310 11093557 9155391 1938166 0.04280 19053 0 19053 0.00040 19091 0 19091 0.00040 33339 0 33339 0.00070 2257 0 2257 0.00000 73740 73740 0.00150 1 2963996 203288 7586039 11670839 -4084800 X 1 1 1 1 THE BELLEVUE HOSPITAL 1400 WEST MAIN STREET BELLEVUE OH 44811 WWW.BELLEVUEHOSPITAL.COM 1261 X SWING BED - SNF HOME HEALTH THE BELLEVUE HOSPITAL 1 0 0 1 X X X X X X X X X 16 1 1 1 1 X WWW.BELLEVUEHOSPITAL.COM X SEE ATTACHED LIST X X 1 16 1 WWW.BELLEVUEHOSPITAL.COM 0 1 X 100.000000000000 400.000000000000 1 1 X X X 1 X WWW.BELLEVUEHOSPITAL.COM X WWW.BELLEVUEHOSPITAL.COM X WWW.BELLEVUEHOSPITAL.COM X X X X X X 1 X 0 X X X 1 X 0 0 THE BELLEVUE HOSPITAL Part V, Section B, Line 5: THE NEEDS OF THE POPULATION, ESPECIALLY THOSE WHO ARE MEDICALLY UNDERSERVED, LOW-INCOME, MINORITY POPULATIONS AND POPULATIONS WITH CHRONIC DISEASE NEEDS, WERE TAKEN INTO ACCOUNT THROUGH THE SAMPLE METHODOLOGY THAT SURVEYED THESE POPULATIONS AND OVER-SAMPLED MINORITY POPULATIONS. IN ADDITION, THE ORGANIZATIONS THAT SERVE THESE POPULATIONS PARTICIPATED IN THE HEALTH ASSESSMENT AND COMMUNITY PLANNING PROCESS, SUCH AS MENTAL HEALTH AND RECOVERY SERVICES BOARD, WSOS, AND SANDUSKY COUNTY HEALTH PARTNERS. PARTICIPANTS INCLUDED THE FOLLOWING GROUPS AND ORGANIZATIONS: (A (PH) AFTER THEIR NAME INDICATES THEY WORK IN THE PUBLIC HEALTH FIELD.)MIKE WINTHROP, THE BELLEVUE HOSPITAL (PH); JOE LISZAK, COMMUNITY HEALTH SERVICES (PH); TIM WISE, FIRELANDS COUNSELING AND RECOVERY SERVICES (PH); TRACI MCCAUDY, FREMONT CITY SCHOOL DISTRICT; PAM JENSEN, PROMEDICA MEMORIAL HOSPITAL (PH); MIRCEA HANDRU, MENTAL HEALTH AND RECOVERY SERVICES BOARD (PH); FRANCIS AONA, M.D., PHYSICIAN; SARAH ZIMMERMAN, SANDUSKY COUNTY BOARD OF DD (PH); CATHY GLASSFORD, SANDUSKY COUNTY FAMILY & CHILDREN FIRST COUNCIL; BETHANY BROWN, SANDUSKY COUNTY HEALTH DEPARTMENT (PH); STACEY GIBSON LSW, OCPC, SANDUSKY COUNTY HEALTH DEPARTMENT (PH), ABBY SLEMMER, UNITED WAY OF SANDUSKY COUNTY; AND RUTHANN HOUSE, WSOS COMMUNITY ACTION COMMISSION. THE BELLEVUE HOSPITAL Part V, Section B, Line 6a: PROMEDICA MEMORIAL HOSPITAL, FREMONT, OHIO. THE BELLEVUE HOSPITAL Part V, Section B, Line 6b: THE BELLEVUE HOSPITAL PARTNERED WITH OTHER LOCAL AGENCIES IN THE GROUP KNOWN AS SANDUSKY COUNTY HEALTH PARTNERS INCLUDING: SANDUSKY COUNTY HEALTH DEPARTMENT, COMMUNITY HEALTH SERVICES, FIRELANDS COUNSELING & RECOVERY SERVICES, FREMONT CITY SCHOOLS, MENTAL HEALTH AND RECOVERY SERVICES BOARD OF SENECA, SANDUSKY AND WYANDOT COUNTIES, PROMEDICA MEMORIAL HOSPITAL, SANDUSKY COUNTY BOARD OF DD, SANDUSKY COUNTY FAMILY AND CHILDREN FIRST COUNCIL, UNITED WAY OF SANDUSKY COUNTY AND WSOS. HEALTH PARTNERS THEN COLLABORATED WITH THE HOSPITAL COUNCIL OF NORTHWEST OHIO DATA DIVISION AND THE UNIVERSITY OF TOLEDO HEALTH AND HUMAN SERVICES DEPARTMENT TO CONDUCT THE FORMAL COUNTY HEALTH ASSESSMENT. THE BELLEVUE HOSPITAL Part V, Section B, Line 7d: http://www.hcno.org/wp-content/uploads/2017/04/2016-2017-Sandusky-County-FINAL-CHA-4-12-17.pdf, http://www.bellevuehospital.com, www.fremontchs.com, www.firelands.com, http://www.fremontschools.net, www.mhrsb.org, www.promedica.org/memorial-hospital, www.scbdd.org, www.sanduskycountyfcfc.org, www.alwayschooshealth.com, www.uwsandco.org, www.wsos.org, www.hcno.org/community/reports.html. THE BELLEVUE HOSPITAL Part V, Section B, Line 11: THE HEALTH NEEDS LISTED IN THE CHNA ARE IMPORTANT ISSUES AND ARE BEING ADDRESSED BY NUMEROUS PROGRAMS AND INITIATIVES SUPPORTED BY THE BELLEVUE HOSPITAL AND OTHER GROUPS AND ORGANIZATIONS WITHIN THE COMMUNITY. PLEASE REFERENCE THE ONLINE CHNA AND IMPLEMENTATION STRATEGY FOR FURTHER INFORMATION ON THE ACTIONS THAT ARE BEING UNDERTAKEN TO ADDRESS THESE NEEDS. FURTHERMORE, THE BELLEVUE HOSPITAL WILL NOT SPECIFICALLY ADDRESS MENTAL HEALTH, RISKY BEHAVIOR IN YOUTH - TEEN PREGNANCY AND RX DRUG MISUSE AS PART OF OUR IMPLEMENTATION PLAN DUE TO LIMITED FINANCIAL AND HUMAN RESOURCES AND THE NEED TO ALLOCATE SIGNIFICANT RESOURCES ON THE PRIORITY HEALTH NEEDS IDENTIFIED. THE HEALTH NEEDS MAY ALSO BE ADDRESSED BY THE HEALTH DEPARTMENT OR ANOTHER AGENCY. FURTHER INFORMATION ON THE HEALTH NEEDS THAT ARE NOT BEING ADDRESSED BY THE BELLEVUE HOSPITAL CAN BE FOUND IN THE IMPLEMENTATION STRATEGY PART IX. Part I, Line 7: CHARITY CARE AND MEDICAID COSTS WERE CALCULATED USING A COST TO CHARGE RATIO USING THE WORKSHEET 2 METHOD TO CALCULATE THE COST TO CHARGE RATIO. THE REMAINING COSTS LISTED IN 7E-7I ARE DERIVED FROM ACTUAL COSTS PULLED FROM THE HOSPITAL'S ACCOUNTING SYSTEM. Part I, Ln 7 Col(f): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $2,842,029. Part II, Community Building Activities: OUR HOSPITAL PARTICIPATES IN SEVERAL COMMUNITY BUILDING ACTIVITIES WHICH ARE INCLUDED IN PART II. THESE ACTIVITIES INCLUDE: - PHYSICAL IMPROVEMENTS: USED LAND OWNED BY HOSPITAL TO GROW A LOCAL CROP FOR DONATION TO BELLEVUE FISH & LOAVES FOR DISTRIBUTION TO LOW INCOME COMMUNITY MEMBERS TO ENSURE NUTRITIOUS FOOD CHOICES; CONTRIBUTED TO THE SANDUSKY COUNTY PARK DISTRICT WITH AN ANNUAL PLEDGE TO HELP MAINTAIN THE COUNTY PARKS AND BIKE AND WALKING TRAILS TO ENCOURAGE PHYSICAL ACTIVITY. - ECONOMIC DEVELOPMENT: ACTIVE ROLE WITH SANDUSKY COUNTY ECONOMIC DEVELOPMENT ORGANIZATION AND CLYDESCOPE ECONOMIC DEVELOPMENT CORPORATION TO CREATE NEW EMPLOYMENT OPPORTUNITIES INCLUDING HEALTHCARE COVERAGE. - COMMUNITY SUPPORT: PROVIDE SUPPORT FOR LOCAL UNITED SELECTIVE FUND CAMPAIGN AND OTHER LOCAL NON-PROFIT ORGANIZATIONS; AND CONTRIBUTED TO THE BELLEVUE RECREATION DEPARTMENT TO PURCHASE JUNGLE JUNCTION, THE LARGEST INDOOR PLAY STRUCTURE IN OHIO, TO ENCOURAGE PHYSICAL ACTIVITY FOR CHILDREN AGES 12 AND UNDER. PART III, LINE 2:THE AMOUNT OF BAD DEBT EXPENSE IS REPORTED PER THE FINANCIAL STATEMENTS. Part III, Line 3: THE ESTIMATED AMOUNT OF THE ORGANIZATION'S BAD DEBT EXPENSE THAT MAY BE ATTRIBUTABLE TO PATIENTS ELIGIBLE FOR CHARITY CARE IS MADE ON A PRESUMPTIVE BASIS BASED ON BEST INFORMATION AVAILABLE. THE IDENTIFICATION OF PATIENTS ELIGIBLE FOR CHARITY CARE IS SOLELY BASED ON THE COOPERATION OF THE PATIENT TO PROVIDE THE ORGANIZATION WITH THE APPROPRIATE FAMILY AND FINANCIAL INFORMATION TO DETERMINE THEIR ELIGIBILITY. FOR 2016 NO PATIENT ACCOUNTS WERE RETURNED FROM THE STATE COLLECTION. BASED ON ESTATE AND BANKRUPTCY ACCOUNTS, IT IS ESTIMATED THAT $203,288 OF OUR ORGANIZATION'S BAD DEBT EXPENSE MAY BE ATTRIBUTABLE TO PATIENTS ELIGIBLE FOR CHARITY CARE AND SHOULD BE COUNTED AS COMMUNITY BENEFIT. AS A NOT-FOR-PROFIT HOSPITAL, PATIENT CARE IS PROVIDED TO ALL PATIENTS, REGARDLESS OF THEIR ECONOMIC MEANS, WHICH QUALIFIES BAD DEBT AS A COMMUNITY BENEFIT. THIS IS REPORTED ON PART III, LINE 3. Part III, Line 4: ACCOUNTS RECEIVABLE FROM PATIENTS, INSURANCE COMPANIES, AND GOVERNMENTAL AGENCIES ARE BASED ON GROSS CHARGES. AN ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS IS ESTABLISHED ON AN AGGREGATE BASIS BY USING HISTORICAL WRITE-OFF RATE FACTORS APPLIED TO UNPAID ACCOUNTS BASED ON AGING. LOSS RATE FACTORS ARE BASED ON HISTORICAL LOSS EXPERIENCE AND ADJUSTED FOR ECONOMIC CONDITIONS AND OTHER TRENDS AFFECTING THE HOSPITAL'S ABILITY TO COLLECT OUTSTANDING AMOUNTS. UNCOLLECTIBLE AMOUNTS ARE WRITTEN OFF AGAINST THE ALLOWANCE FOR DOUBTFUL ACCOUNTS IN THE PERIOD THEY ARE DETERMINED TO BE UNCOLLECTIBLE. AN ALLOWANCE FOR CONTRACTUAL ADJUSTMENTS AND INTERIM PAYMENT ADVANCES IS BASED ON EXPECTED PAYMENT RATES FROM PAYORS BASED ON CURRENT REIMBURSEMENT METHODOLOGIES. THIS AMOUNT ALSO INCLUDES AMOUNTS RECEIVED AS INTERIM PAYMENTS AGAINST UNPAID CLAIMS BY CERTAIN PAYORS.FOR RECEIVABLES ASSOCIATED WITH SELF-PAY PATIENTS, WHICH INCLUDES BOTH PATIENTS WITHOUT INSURANCE AND PATIENTS WITH DEDUCTIBLE AND CO-PAYMENT BALANCES DUE FOR WHICH THIRD-PARTY COVERAGE EXISTS FOR A PORTION OF THE CLAIM, THE HOSPITAL 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. Part III, Line 8: MEDICARE ALLOWABLE COSTS WERE CALCULATED USING A COST-TO-CHARGE RATIO. THE HOSPITAL BELIEVES THAT THE $4,084,800 SHORTFALL SHOULD BE CONSIDERED COMMUNITY BENEFIT. THE IRS COMMUNITY BENEFIT STANDARD INCLUDES THE PROVISION OF CARE TO THE ELDERLY AND MEDICARE PATIENTS. MEDICARE PAYMENTS THAT ARE LESS THAN COST MUST BE ABSORBED BY THE HOSPITAL IN ORDER TO CONTINUE TREATING THE ELDERLY IN OUR COMMUNITY. IN 2016, MEDICARE ACCOUNTED FOR APPROXIMATELY 36% OF HOSPITAL REVENUES. 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. Part III, Line 9b: COLLECTION POLICIES ARE THE SAME FOR ALL PATIENTS. THE HOSPITAL WILL PURSUE PAYMENT FOR CARE FROM EVERY REASONABLE SOURCE, GOVERNMENTAL AND PRIVATE. TO ENSURE THIS IS COMPLETED, INSURANCE VERIFICATION IS PERFORMED, A SYSTEM REVIEW IS MADE OF THE PATIENT'S INSURANCE HISTORY, AND TELEPHONE CALLS ARE MADE TO THE PATIENT. IF THE PATIENT IS ELIGIBLE FOR HCAP, THE COVERED CHARGES ARE WRITTEN OFF TO HCAP. IF THE PATIENT IS LATER FOUND TO BE ELIGIBLE FOR MEDICAID, THE HCAP WRITE-OFF IS REVERSED AND THE ACCOUNT BILLED TO MEDICAID. BAD DEBT ACCOUNTS ELIGIBLE FOR CHARITY ARE REINSTATED FROM BAD DEBT AND POSTED TO THE APPROPRIATE ADJUSTMENT OR CHARITY WRITE-OFF CODES. Part VI, Line 2: N/A AS THE ORGANIZATION PERFORMED ALL HEALTH CARE NEEDS ASSESSMENTS AS PART OF THE CHNA THAT WAS FILED. PLEASE REFER TO THE CHNA FOR DETAILS. Part VI, Line 3: THE HOSPITAL POSTS NOTICES IN APPROPRIATE AREAS IN THE FACILITY, INCLUDING BUT NOT LIMITED TO THE ADMISSIONS AREAS, THE PATIENT FINANCE OFFICE, AND THE EMERGENCY DEPARTMENT. THE NOTICE SPECIFIES THE RIGHTS OF PERSONS WITH INCOMES AT OR BELOW THE FEDERAL POVERTY GUIDELINES (FPG) TO RECEIVE, WITHOUT CHARGE TO THE INDIVIDUAL, BASIC, MEDICALLY NECESSARY HOSPITAL-LEVEL SERVICES AT THE HOSPITAL. THE INITIAL BILL AND AT LEAST THE FIRST FOLLOW-UP BILL HAS A WRITTEN STATEMENT THAT EXPLAINS THAT INDIVIDUALS WITH INCOME AT OR BELOW THE FPG ARE ELIGIBLE FOR SERVICE WITHOUT CHARGE, SPECIFIES THE FPG FOR INDIVIDUALS AND FAMILIES OF VARIOUS SIZES AT THE TIME THE BILL IS SENT, AND DESCRIBES THE PROCEDURE TO APPLY FOR FREE CARE. THE PATIENT FINANCE OFFICE AND PATIENT ACCESS DEPARTMENTS WILL PROVIDE APPLICATIONS FOR FINANCIAL ASSISTANCE TO PATIENTS. A DETERMINATION OF EVERY APPLICATION WILL BE COMPLETED BY THE PATIENT FINANCE OFFICE AND A COPY SENT TO THE PATIENT. THE FAP, FAP APPLICATION FORM, AND PLAIN LANGUAGE SUMMARY ARE AVAILABLE IN BOTH ENGLISH AND SPANISH. THEY ARE ALSO AVAILABLE ON THE HOSPITAL WEBSITE AT WWW.BELLEVUEHOSPITAL.COM. Part VI, Line 4: BELLEVUE, OHIO IS A CITY IN ERIE, HURON, SANDUSKY AND SENECA COUNTIES OF OHIO. IT IS THE ONLY MUNICIPALITY IN THE STATE OF OHIO TO SPAN FOUR COUNTIES. ACCORDING TO THE U.S. CENSUS BUREAU, THE FOUR COUNTY AREA HAS A TOTAL LAND AREA OF 1702.53 SQUARE MILES. THE FOUR COUNTY ESTIMATED POPULATION WAS 248,229 FOR 2016, A 2.48% DECLINE SINCE THE 2010 CENSUS, WITH A DENSITY OF 149 PEOPLE PER SQUARE MILE, PREDOMINANTLY WHITE, HIGH SCHOOL EDUCATED. THE FOUR COUNTY AREA WAS HIT EXTREMELY HARD DURING THE MOST RECENT ECONOMIC RECESSION, BUT HAS MADE A MODEST RECOVERY. THE U.S. DEPARTMENT OF LABOR, BUREAU OF LABOR STATISTICS, REPORTS THE AVERAGE UNEMPLOYMENT RATE FOR THE FOUR COUNTY AREA FOR 2016 WAS 4.8%, WHICH IS LOWER THAN OHIO'S STATEWIDE UNEMPLOYMENT RATE AND THE NATIONWIDE UNEMPLOYMENT RATE OF 4.9% FOR JUNE 2016. HURON COUNTY RANKED 20TH IN THE STATE OF OHIO IN 2016 WITH AN ANNUAL AVERAGE UNEMPLOYMENT RATE OF 6.5%. ACCORDING TO THE U.S. CENSUS BUREAU, 2016 POVERTY RATES, THE LATEST AVAILABLE, HAVE REMAINED STEADY IN ALL FOUR COUNTIES AND RANGED FROM 5.7% FROM SANDUSKY COUNTY TO 6.5% FOR ERIE COUNTY. OHIO DEPARTMENT OF JOB & FAMILY SERVICES REPORTED THAT 59,283 RESIDENTS, OR 23.88% OF RESIDENTS IN THE FOUR COUNTY AREA WERE ELIGIBLE FOR MEDICAID AT 12/31/16, AND 11.87% OF RESIDENTS IN THE FOUR COUNTY AREA RECEIVED FOOD ASSISTANCE DURING DECEMBER 2016 COMPARED TO 12.52% OF RESIDENTS DURING DECEMBER 2015. SANDUSKY AND ERIE COUNTIES ARE BOTH DESIGNATED AS MEDICALLY UNDERSERVED AREAS, AND ALL FOUR COUNTIES ARE DESIGNATED AS PRIMARY CARE HEALTH PROFESSIONAL SHORTAGE AREAS. Part VI, Line 5: MEDICAL STAFF PRIVILEGES ARE OPEN TO ALL QUALIFIED PHYSICIANS IN THE COMMUNITY. THE HOSPITAL BOARD OF DIRECTORS IS COMPRISED OF LOCAL MEDICAL AND BUSINESS PROFESSIONALS WHO VOLUNTEER COUNTLESS HOURS OF SERVICE TO THE HOSPITAL IN THEIR OVERSIGHT ROLE OF GENERAL STEWARDSHIP. THE HOSPITAL EXPANDS ACCESS POINTS OF CARE THROUGHOUT THE COMMUNITY BY PROVIDING FREE OR LOW-COST BLOOD PRESSURE, DIABETES, CHOLESTEROL, SKIN CANCER, PROSTATE CANCER AND OTHER SCREENINGS. EDUCATIONAL PROGRAMS AND SUPPORT GROUPS ARE HELD TO PROVIDE INFORMATION ON SUCH TOPICS AS TOBACCO CESSATION, WEIGHT MAINTENANCE, DIABETES, CHILDBIRTH, INFANT CARE, AND MORE. HOSPITAL EMPLOYEES SERVE ON THE BOARDS OF MANY COMMUNITY AND HEALTH-ORIENTED ORGANIZATIONS. THE HOSPITAL ALSO PARTICIPATES IN COMMUNITY-WIDE AND REGIONAL-WIDE MASS CASUALTY AND DISASTER PREPAREDNESS WITH 33 OTHER REGIONAL HOSPITALS AS A MEMBER OF THE HOSPITAL COUNCIL OF NORTHWEST OHIO, TO ASSURE THE SAFETY AND HEALTH OF COMMUNITY RESIDENTS IN THE EVENT OF A NATURAL DISASTER, INDUSTRIAL ACCIDENT, BIOTERRORISM OR OTHER LARGE SCALE EMERGENCY. MEMBERSHIP BENEFITS INCLUDE INCREASED PURCHASING POWER FOR DISASTER SUPPLIES, EMERGENCY RESPONSE TRAINING, INCIDENT COMMAND, AND INFORMATION SHARING TO KEEP COMPLIANT WITH HOMELAND SECURITY REGULATIONS. Part VI, Line 6: THE BELLEVUE HOSPITAL IS A GENERAL ACUTE CARE PROVIDER AT ONE FACILITY IN THE BELLEVUE, OHIO AREA. THE BELLEVUE HOSPITAL IS THE PARENT ORGANIZATION OF BELLEVUE PROFESSIONAL SERVICES, INC. AND THE SOLE BENEFICIARY OF THE BELLEVUE HOSPITAL FOUNDATION. THE BELLEVUE HOSPITAL ASSOCIATION IS THE PARENT ORGANIZATION OF THE BELLEVUE HOSPITAL. THE BELLEVUE HOSPITAL ASSOCIATION MEETS ANNUALLY IN FEBRUARY TO ELECT THE BELLEVUE HOSPITAL BOARD OF TRUSTEES AND TO CONDUCT ANY NECESSARY BUSINESS. BELLEVUE PROFESSIONAL SERVICES, INC. PROVIDES CLINICAL AND MEDICAL PROFESSIONAL SERVICES TO RESIDENTS OF BELLEVUE AND CLYDE, OHIO AND THE SURROUNDING AREA. THE BELLEVUE HOSPITAL FOUNDATION SUPPORTS THE BELLEVUE HOSPITAL WITH FINANCIAL TRANSFERS IN THE FORM OF BOTH CASH AND NON-CASH TRANSFERS. 1 PROMEDICA MEMORIAL HOSPITAL FOUNDATION 5217 MONROE ST SUITE A-1 TOLEDO OH 43623 341517672 501(C)(3) 25000 DOROTHY KERN CANCER CENTER PLEDGE 1 OF 2 BELLEVUE RECREATION CLUB INC 110 CHERRY BLVD BELLEVUE OH 44811 341462214 501(C)(3) 12500 JUNGLE JUNCTION INDOOR PLAYGROUND PROJECT PLEDGE 1 OF 2 BELLEVUE REDMEN ATHLETIC BOOSTERS INC PO BOX 486 BELLEVUE OH 44811 341469153 501(C)(3) 10000 PLEDGE 3 OF 5 - TURF PROJECT SANDUSKY COUNTY PARK DISTRICT 1970 COUNTRYSIDE PLACE FREMONT OH 43420 346401312 STATE 10000 PLEDGE 2 OF 5 ANNUAL PLEDGE PMTS SANDUSKY COUNTY ECONOMIC DEVELOPMENT 2511 COUNTRYSIDE DR SUITE C FREMONT OH 43420 341424666 501(C)(3) 5000 PLEDGE 1 OF 5 - "PARTNERING FOR THE FUTURE" CAPITAL CAMPAIGN BELLEVUE DEVELOPMENT CORP 110 W MAIN ST BELLEVUE OH 44811 341397769 501(C)(3) 10000 ANNUAL DONATION, ECONOMIC DEVELOPMENT 5 1 EMPLOYEE CHILDREN'S SCHOLARSHIP 10 15000 Part I, Line 2: THE HOSPITAL PRIMARILY PROVIDES GRANTS TO GOVERNMENT PROGRAMS AND CHARITABLE ORGANIZATIONS. THE GRANTS ARE ONLY MADE TO 501(C)(3) AND/OR GOVERNMENT ENTITIES. PART III:THE HOSPITAL HAS A COMMITTEE COMPOSED OF FOUR MEMBERS (AN HOURLY EMPLOYEE, A MEMBER OF THE MEDICAL STAFF, A MEMBER OF THE BOARD OF TRUSTEES AND A MEMBER OF THE COMMUNITY RELATIONS COMMITTEE OF THE FOUNDATION BOARD). ALL ELIGIBLE APPLICATIONS ARE REVIEWED BY THE COMMITTEE. EACH CANDIDATE IS SCORED BASED UPON THE INFORMATION PROVIDED IN THEIR APPLICATION. UPON THE DISCRETION OF THE COMMITTEE, INTERVIEWS OF THE APPLICANTS CAN TAKE PLACE. UP TO 10 CANDIDATES WILL BE SELECTED TO RECEIVE A $1,500.00 SCHOLARSHIP. THE HOSPITAL AWARDS THE SCHOLARSHIP PAYMENTS DIRECTLY TO THE COLLEGES TO OFFSET TUITION ONCE THE STUDENT PROVIDES THE HOSPITAL WITH PROOF OF ENROLLMENT FEES. X 1 1 X X X X 0 0 0 0 0 0 0 0 0 MICHAEL K WINTHROP PRESIDENT 428975 0 91140 0 13191 0 10600 0 14886 0 558792 0 0 0 TIMOTHY BUIT EXEC VP, CFO 287233 0 63910 0 11232 0 10600 0 21093 0 394068 0 0 0 LISA SARTAIN VICE PRESIDENT, HR 151544 0 26311 0 0 0 6828 0 8063 0 192746 0 0 0 SARA BROKAW VICE PRESIDENT, PATIENT CARE 182910 0 31780 0 0 0 8617 0 581 0 223888 0 0 0 PATRICIA SEMER VICE PRESIDENT, ADMINISTRATION 148126 0 28925 0 0 0 7510 0 23627 0 208188 0 0 0 Part I, Line 1a THE ORGANIZATION PAYS SOCIAL CLUB DUES ON THE BEHALF OF MICHAEL WINTHROP, CEO, TO CATAWBA ISLAND CLUB, AS A MEANS TO NETWORK WITH PHYSICIANS. NONE OF THE SOCIAL CLUB DUES WERE TREATED AS TAXABLE COMPENSATION TO MICHAEL WINTHROP. A VILLAGE OF PORT JEFFERSON OHIO 341175548 NONEAVAIL 2012-08-28 9992500 SEE PART VI 0 0 0 B CITY OF BELLEVUE OHIO 346400096 NONEAVAIL 2012-09-12 8500000 SEE PART VI 0 0 0 C COUNTY OF SANDUSKY OHIO 346401312 NONEAVAIL 2012-10-03 2569153 SEE PART VI 0 0 0 A 1524980 9992500 60000 12000 9920500 2005 1 0 1 1 B 1296233 8500000 43398 8456602 2004 1 0 1 1 C 391791 2569153 30573 2538580 2004 1 0 1 1 A 0 0 0 0 0.00000 0.00000 0.00000 0 0 1 B 0 0 0 0 0.00000 0.00000 0.00000 0 0 1 C 0 0 0 0 0.00000 0.00000 0.00000 0 0 1 A 0 0 1 0 1 0 0 0 1 B 0 0 1 0 1 0 0 0 1 C 0 0 1 0 1 0 0 0 1 A 1 B 1 C 1 SCHEDULE K, PART I, LINE A, COLUMN (F): Currently refund the (1) 2003 Lease Obligations issued pursuant to the Master Lease-Purchase and Sublease-Purchase Agreement, dated as of July 1, 2003, by and among Fifth Third Bank, the City of Clyde, Ohio and The Bellevue Hospital, issued July 23, 2003 and (2) City of Bellevue, Ohio Adjustable Rate Demand Hospital Facilities Revenue Bonds, Series 2003 (The Bellevue Hospital Project) issued August 26, 2003. SCHEDULE K, PART I, LINE B, COLUMN (F): Currently refund the (1) 2003 Lease Obligations issued pursuant to the Master Lease-Purchase and Sublease-Purchase Agreement, dated as of July 15, 2003, by and among Fifth Third Bank, the County of Sandusky, Ohio and The Bellevue Hospital, issued August 8, 2003 and (2) 2003 Lease Obligations issued pursuant to the Master Lease-Purchase and Sublease-Purchase Agreement, dated as of July 1, 2003, by and among Fifth Third Bank, the City of Clyde, Ohio and The Bellevue Hospital, issued July 23, 2003. SCHEDULE K, PART I, LINE C, COLUMN (F): Currently refund the 2003 Lease Obligations issued pursuant to the Master Lease-Purchase and Sublease-Purchase Agreement, dated as of July 15, 2003, by and among Fifth Third Bank, the County of Sandusky, Ohio and The Bellevue Hospital, issued August 8, 2003. SCHEDULE K, PART II, LINE 3, COLUMN C: SCHEDULE K, PART II, LINE 11, COLUMN B: HASSELBACH & PAUL AGENCY INC TOM BARTH IS OWNER OF HASSELBACH & PAUL AGENCY, INC 168330 INSURANCE: DIRECTOR AND OFFICERS; PROFESSIONAL LIABILITY 0 SOUTH SHORE RADIOLOGY DAVID WEST, M.D. IS OWNER OF SOUTH SHORE RADIOLOGY 525440 RADIOLOGY SERVICES 0 Form 990, Part VI, Section A, line 2 PRESIDENT MICHAEL WINTHROP AND TRUSTEE DEAN MILLER HAVE A BUSINESS RELATIONSHIP. Form 990, Part VI, Section A, line 6 THE BELLEVUE HOSPITAL ENTERED INTO AN AGREEMENT WITH THE BELLEVUE HOSPITAL ASSOCIATION, NORWALK AREA HEALTH SYSTEMS, AND FIRELANDS REGIONAL HEALTH SYSTEM. NAHS AND FIRELANDS EACH HAVE TWENTY PERCENT MEMBERSHIP INTEREST IN THE HOSPITAL AND REPRESENTATION ON THE BOARD OF TRUSTEES. THE BELLEVUE HOSPITAL ASSOCIATION HAS A 60% MEMBERSHIP INTEREST IN THE HOSPITAL AND REPRESENTATION ON THE BOARD OF TRUSTEES. Form 990, Part VI, Section A, line 7a NORWALK AREA HEALTH SYSTEMS AND FIRELANDS REGIONAL HEALTH SYSTEM CAN EACH APPOINT 2 MEMBERS TO THE BOARD OF DIRECTORS. THE BELLEVUE HOSPITAL ASSOCIATION APPOINTS THE REMAINING MEMBERS (UP TO 15) TO THE BOARD OF DIRECTORS. Form 990, Part VI, Section B, line 11b A COPY OF FORM 990 IS MADE AVAILABLE BY THE PRESIDENT & VP FINANCE AT THE FINANCE MEETING FOR REVIEW AS WELL AS PRESENTATION TO THE BOARD OF DIRECTORS. IN ADDITION, EACH BOARD MEMBER RECEIVES A COPY OF THE FORM 990 PRIOR TO FILING. Form 990, Part VI, Section B, line 12c ON AN ANNUAL BASIS, THE PRESIDENT SHALL SEND TO ALL EXECUTIVE STAFF AND SELECTED EMPLOYEES, A COPY OF THE BOARD OF TRUSTEES CONFLICT OF INTEREST POLICY TO BE COMPLETED AND RETURNED. IN ADDITION, NEW BOARD MEMBERS THAT JOIN DURING THE YEAR FILL OUT AND COMPLETE THE CONFLICT OF INTEREST POLICY WHEN THEY FIRST JOIN. AN APPROPRIATE REPORT SHALL BE SUBMITTED TO THE BOARD OF TRUSTEES CONCERNING ANY INTERESTS TO BE DISCLOSED. IF ANY CONFLICTS DO ARISE, THAT TRUSTEE WILL ABSTAIN FROM VOTING ON THE ISSUE. PERIODIC REVIEWS ARE ALSO CONDUCTED TO ENSURE THAT THE CORPORATION OPERATES IN A MANNER CONSISTENT WITH ITS CHARITABLE PURPOSES, AND THAT IT DOES NOT ENGAGE IN ACTIVITIES THAT COULD JEOPARDIZE ITS STATUS AS AN ORGANIZATION EXEMPT FROM FEDERAL INCOME TAX. THE BOARD OF DIRECTORS REVIEW THE COMPLETED CONFLICT OF INTEREST POLICIES INCLUDING THE PRESIDENT'S. THE BOARD OF DIRECTORS REVIEW THE PRESIDENT'S COMPLETED CONFLICT OF INTEREST POLICY ONCE THE PRESIDENT LEAVES THE ROOM. Form 990, Part VI, Section B, line 15 IN DETERMINING EXECUTIVE STAFF COMPENSATION FOR THE CEO AND VICE PRESIDENTS, THE BOARD HAS A COMPENSATION COMMITTEE COMPRISED OF INDEPENDENT DIRECTORS. THE COMMITTEE UTILIZES AN OUTSIDE HEALTHCARE COMPENSATION CONSULTING COMPANY COMPARING COMPARABLE SIZED ORGANIZATIONS CONSISTENT WITH THE BOARD OF TRUSTEE COMPENSATION PHILOSOPHY STATEMENT. RECOMMENDATIONS ARE MADE FROM THE COMPENSATION COMMITTEE TO THE BOARD OF TRUSTEES. ANY COMPENSATION DECISIONS THAT ARE MADE ARE DOCUMENTED IN THE MINUTES OF THE EXECUTIVE COMPENSATION COMMITTEE AND EXECUTIVE SESSION MINUTES. THIS PROCESS WAS LAST UNDERTAKEN IN NOVEMBER 2016. Form 990, Part VI, Section C, line 19 GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND THE FINANCIAL STATEMENTS ARE NOT CURRENTLY AVAILABLE TO THE PUBLIC. Form 990, Part IX, line 11g MEDICAL AND PLANT OPERATIONS: Program service expenses 4,615,592. Management and general expenses 649,008. Fundraising expenses 0. Total expenses 5,264,600. Form 990, Part XI, line 9: CHANGE IN FMV OF INTEREST RATE SWAP AGREEMENTS 181,746. CONTRIBUTION OF CAPITAL TO BELLEVUE PROFESSIONAL SERVICES, INC. -2,545,000. BOOK TO TAX DIFFERENCE IN FLOW THROUGH INCOME -99,849. FORM 990, PART XII, LINE 2C THE PROCESS FOR OVERSIGHT OF THE AUDIT AS WELL AS SELECTION OF THE INDEPENDENT ACCOUNTANT HAS NOT CHANGED FROM THE PRIOR YEAR. THE BELLEVUE HOSPITAL ASSOCIATION 1400 WEST MAIN STREET BELLEVUE OH 44811 753102199 ADMINISTRATIVE SUPPORT OH 501(C)(3) LINE 11A, 1 N/A 0 THE BELLEVUE HOSPITAL FOUNDATION 1400 WEST MAIN STREET BELLEVUE OH 44811 341745374 SUPPORT OH 501(C)(3) LINE 11A, 1 THE BELLEVUE HOSPITAL 1 BELLEVUE HEALTH NETWORK LLC 1400 WEST MAIN STREET BELLEVUE OH 44811 341870470 INSURANCE CONTRACTS OH THE BELLEVUE HOSPITAL RELATED -2675 2386 0 1 0.55560 BELLEVUE HOSPITAL PAIN MANAGEMENT LLC 1400 WEST MAIN STREET BELLEVUE OH 44811 464660177 HEALTH CARE OH THE BELLEVUE HOSPITAL RELATED 204172 262954 0 1 0.51000 BELLEVUE PROFESSIONAL SERVICES INC 1400 WEST MAIN STREET BELLEVUE OH 44811 341828724 PHYSICIAN SERVICES OH THE BELLEVUE HOSPITAL C 1996286 644148 1.00000 1 0 1 1 0 0 1 0 0 0 1 0 1 0 1 1 0 1 1 0 BELLEVUE PROFESSIONAL SERVICES INC J 52609 LEASE AGREEMENT PAYMENT BELLEVUE PROFESSIONAL SERVICES INC R 2545000 CASH CAPITAL CONTRIBUTION BELLEVUE PAIN MANAGEMENT Q 577708 REIMBURSEMENTS BELLEVUE PAIN MANAGEMENT F 232637 DIVIDENDS