2016-08-15T11:30:39-05:00 2015-09-30 390758449 WIPFLI LLP PO BOX 12237 GREEN BAY WI 543072237 990 2014-10-01 391657627 BELLIN PSYCHIATRIC CENTER BELL 9204457260 PO BOX 23725 GREEN BAY WI 543053725 SHARLA BAENEN PRESIDENT 9204457260 2016-08-15 1 TERRI REXRODE CPA MST P00096513 9206620016 2016-08-15 2014 2016-09-27 15:27:22Z SHARLA BAENEN PO BOX 23725 GREEN BAY WI 543053725 17433178 0 X WWW.BELLIN.ORG X 1990 WI BELLIN PSYCHIATRIC CENTER, INC. (BPC) PROVIDES PSYCHIATRIC AND ALCOHOL AND OTHER DRUG ABUSE (AODA) SERVICES TO ENHANCE THE HEALTH OF THE COMMUNITY AND IMPROVE THE HEALTH OF LOW-INCOME PATIENTS. CONSISTENT WITH THE MISSION OF BPC, CARE IS PROVIDED TO PATIENTS REGARDLESS OF THEIR ABILITY TO PAY. 10 5 186 7 0 0 15819 42651 14363325 16802635 644165 587892 42200 0 15065509 17433178 0 0 0 0 12099315 13034563 0 0 0 4281250 4810323 16380565 17844886 -1315056 -411708 19542662 17972448 7982244 7348258 11560418 10624190 X BELLIN PSYCHIATRIC CENTER WILL BE RECOGNIZED AS THE PREFERRED PROVIDER FOR PSYCHIATRIC DISORDERS AND ADDICTIVE DISEASES THROUGH THE DELIVERY OF A CONTINUUM OF CARE AND PREVENTION PROGRAMS BASED ON THE QUALITY CARE DELIVERED AT A REASONABLE COST WITH A MEASURABLE OUTCOME BY:IMPROVING WORK PROCESSES AND SYSTEMSEXCEEDING CUSTOMER NEEDS AND EXPECTATIONSEMPOWERING STAFF TO EXCEL PERSONALLY AND PROFESSIONALLYIN COOPERATION WITH PSYCHIATRISTS, PSYCHOLOGISTS, PRIMARY CARE PHYSICIANS, AGENCIES AND HEALTH PROFESSIONALS, BELLIN PSYCHIATRIC CENTER IS DEDICATED TO THE MULTIDISCIPLINARY TREATMENT OF CHILDREN, ADOLESCENTS, ADULTS AND THEIR FAMILY MEMBERS THROUGHOUT OUR PRIMARY MARKET OF WISCONSIN AND THE UPPER PENINSULA OF MICHIGAN. 0 0 14972191 16650774 THE CENTER PROVIDES PSYCHIATRIC AND ALCOHOL AND OTHER DRUG ABUSE (AODA) SERVICES TO RESIDENTS OF NORTHEASTERN WISCONSIN. DURING FISCAL YEAR 2015 6,464 INPATIENT DAYS WERE PROVIDED (3,625 ADULT, 514 CHILD AND 2,325 ADOLESCENT). THE NUMBER OF OUTPATIENT THERAPY VISITS DURING FISCAL YEAR 2015 WERE 24,920. IN ADDITION THERE WERE 33,047 INPATIENT AND OUTPATIENT MD, APNP AND PHD VISITS. 14972191 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 0 186 1 0 0 0 0 0 0 0 0 0 0 X 10 5 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 X KEVIN J MCGURK 9204457260 744 S WEBSTER AVE GREEN BAY WI 54301 SHARLA BAENEN BPC PRESIDENT 45.00 X X 152310 0 28482 CHRISTINE WOLESKE MEMBER/BELLIN EXECUTIVE VP 0.50 40.00 X 0 378894 36573 CARLOS CASTILLO MD - TERMED PRESIDENT OF MEDICAL STAFF 40.00 X 426051 0 27358 MICHAEL HOFFMAN MD MEMBER/PHYSICIAN 0.50 40.00 X 0 175731 23876 TARA ROBERTSON PSYD MEMBER/CLINICAL PSYCHOLOGIST 40.00 X 123633 0 27030 WILLIAM MCKINLEY MEMBER 0.50 X 0 0 0 ROBERT FRY SECRETARY, TREASURER 0.50 X X 0 0 0 BARBARA GILLING INTERIM CHAIRPERSON 0.50 X X 0 0 0 SUE MATTISON PH D MEMBER 0.50 X 0 0 0 DAVID VANDERPLOEG MEMBER 0.50 X 0 0 0 NACIYE KALAFAT MD PRESIDENT OF MEDICAL STAFF 45.00 X 305217 0 24391 ANTHONY MARCHLEWSKI MD PSYCHIATRIST 40.00 X 270109 0 34866 JOHN CHARLES MD PSYCHIATRIST 40.00 X 437548 0 35447 DEREK CARLSON MD PSYCHIATRIST 40.00 X 276119 0 15603 KIM LASECKI PH D PSYCHOLOGIST 40.00 X 243595 0 31333 RICHARD RIDER PSY D PSYCHOLOGIST 40.00 X 185146 0 27395 2419728 554625 312354 16 0 1 0 LOCUMTENENSCOM LLC 2655 NORTHWINDS PARKWAY ALPHARETTA GA 30009 CONTRACTED SERVICES 409768 STEVEN MILJOUR W223 LUCHAY ROAD BARK RIVER MI 49807 CONTRACTED SERVICES 192825 BAY TOWEL LINEN & UNIFORM RENTAL 2580 S BROADWAY GREEN BAY WI 54304 CONTRACTED SERVICES 128708 WIPFLI LLP 469 SECURITY BOULEVARD GREEN BAY WI 54313 FINANCIAL SERVICES 128557 4 42651 42651 NET PATIENT SERVICE REVENUE 621300 16650774 16650774 MISCELLANEOUS 621300 121556 121556 MEDICAL RECORDS 621300 30305 30305 16802635 346234 346234 241658 0 241658 241658 241658 17433178 16650774 0 739753 1114475 1058749 55726 9809867 9176140 633727 483517 446616 36901 952895 813293 139602 673809 625255 48554 8596 8596 492524 376957 115567 32912 24766 8146 58919 41556 17363 31126 30346 780 354583 352261 2322 9738 4797 4941 65874 54327 11547 248954 248954 366261 366261 47342 17833 29509 SUPPLIES 2376235 1276963 1099272 BAD DEBT EXPENSE 526081 526081 EQUIPMENT RENT/MAINT 92192 81612 10580 DUES & SUBSCRIPTIONS 73091 55410 17681 25895 9229 16666 17844886 14972191 2872695 0 2154457 2121283 1174869 1662351 1185 1500 8833808 3015580 5872012 5818228 10291723 8333732 48416 35354 19542662 17972448 1337481 1560970 3341260 3291879 3303503 2495409 7982244 7348258 X 11560418 10624190 11560418 10624190 19542662 17972448 -411708 -524520 0 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 2500165 2500165 3168169 1348981 1819188 366674 193626 173048 2798800 1472973 1325827 5818228 DUE TO AFFILIATES 2495409 2495409 16899319 -524520 -524520 17423839 9339 9339 17433178 17835547 0 17835547 9339 9339 17844886 PART XI, LINE 4B - OTHER ADJUSTMENTS: TRANSFER FROM FOUNDATION 9,339. PART XII, LINE 4B - OTHER ADJUSTMENTS: TRANSFER FROM FOUNDATION 9,339. 1 1 1 X 1 X 1 1 0 1 1 102032 102032 0.00590 5189040 3929321 1259719 0.07270 5291072 3929321 1361751 0.07860 14825 3574 11251 0.00060 4598 4598 0.00030 19423 3574 15849 0.00090 5310495 3932895 1377600 0.07950 1 275363 2247557 3210594 -963037 X 1 1 1 1 BELLIN PSYCHIATRIC CENTER INC 301 E ST JOSEPH STREET GREEN BAY WI 543053725 WWW.BELLIN.ORG 263 X BELLIN PSYCHIATRIC CENTER INC 1 0 0 1 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 1 0 1 X 200.000000000000 400.000000000000 X X X X 1 1 X X X 1 X WWW.BELLIN.ORG/PATIENTS_VISITORS/PATIENT-INFORMATION/FINANCIAL-ASSISTANCE X X X X 0 0 X X X X 1 X 1 0 BELLIN PSYCHIATRIC CENTER, INC. 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 FROM BELLIN HEALTH, ST. MARYS AND ITS SISTER HOSPITAL, ST. VINCENTS, AURORA HEALTH, BROWN COUNTY UNITED WAY, AND THE REGIONAL OFFICE OF WISCONSIN'S 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 AND ARE THE FOLLOWING:ACHIEVE BROWN COUNTY: ADAM HARDYAGING AND DISABILITY RESOURCE CENTER: MEREDITH HANSEN, JANELLE WATSONAURORA BAYCARE MEDICAL CENTER: AMY HERDEE, MARK HUBER*BAY AREA COMMUNITY COUNCIL: BOB WOESSNERBC PLANNING AND LAND SERVICES DEPARTMENT: DAN TEATERSBELLIN COLLEGE: KATHIE DE MUTHBELLIN HEALTH: SHARLA BAENEN, LAURA CORMIER, CHRISTOPHER ELFNER, LAURA HIEB*, JOHN ROCHELEAU*, JODI WILMET*BROWN COUNTY EXECUTIVE OFFICE: TROY STRECKENBACHBROWN COUNTY COMMUNITY TREATMENT CENTER: TINA CAZZOLABROWN COUNTY HEALTH DEPARTMENT: DEBORAH ARMBRUSTER, JUDY FRIEDERICHS*, ROB GOLLMAN, STACY ROSS, PATTI SMEESTER, CHUA XIONGBROWN COUNTY HUMAN SERVICES: MARY MICELI-WINKBROWN COUNTY ORAL HEALTH PARTNERSHIP: CARRIE STEMPSKIBROWN COUNTY UNITED WAY: HOWARD ENDOW*, SARAH INMAN, GREG MAASS, JILL SOBIECK, ASHLEY VANDENBOOMENCATHOLIC CHARITIES: CELIA LATOURCENTER FOR CHILDHOOD SAFETY: KIMBERLY HESSCITY OF DE PERE BOARD OF HEALTH: MIKE DONOVAN, PATRICIA FINDER-STONEDE PERE HEALTH DEPARTMENT: ERIN BONGERS, CHRYSTAL WOLLER*ELIZK INSURANCE: ELIZABETH KOSTICHKAGREATER GREEN BAY CHAMBER: GRANT DVORAKGREATER GREEN BAY YMCA: SANDY ATKINSHOSPITAL SISTERS HEALTH SYSTEM: ELAINE DOXTATOR, PATTI GLASER-MARTIN, HEIDI SELBERG*LIBERTA: BARBARA CONIFFLIVE54218: JOHN DYE, MELINDA MORELLA, JEN VAN DEN ELZENN.E.W. COMMUNITY CLINIC: JAMIE CAMPBELL, BONNIE KUHR, SETH MOORE, CATHERINE THERRIENN.E.W. CURATIVE REHABILITATION: STEVE MCCARTHYNORTHEAST WISCONSIN TECHNICAL COLLEGE: SCOTT ANDERSONPREVEA HEALTH: ANGELA RALEIGHSCHNEIDER NATIONAL: CHRISTINE SCHNEIDERST. NORBERT COLLEGE:ST. NICHOLAS HOSPITAL: MARY PALUCHNIAKST. VINCENT HOSPITAL: DONNA BOEHM, CAROLINE GLANDER, KAITLIN SWANSONSTATE OF WISCONSIN-DIVISION OF PUBLIC HEALTH: ELIZABETH SCHEELKUNIFIED SCHOOL DISTRICT OF DE PERE: MARGIE HEMPELUW-GREEN BAY: THOMAS ERDMAN, SARAH HIMMELHEBER, CHRISTINE VANDENHOUTEN, LEANNE ZHUBROWN COUNTY UW-EXTENSION: KAREN EARLYWEST DE PERE SCHOOL DISTRICT: DAWN SCHAEFERWI DEPARTMENT OF HEALTH NORTHEAST REGION: CHRISTOPHER COLLETTA** STEERING COMMITTEE MEMBER BELLIN PSYCHIATRIC CENTER, INC. PART V, SECTION B, LINE 6A: AURORA BAYCARE MEDICAL CENTER (GREEN BAY) AND ST. MARY'S AND ST. VINCENT HOSPITALS (HSHS, GREEN BAY) BELLIN PSYCHIATRIC CENTER, INC. PART V, SECTION B, LINE 6B: BROWN COUNTY HEALTH DEPARTMENT, CITY OF DE PERE HEALTH DEPARTMENT, BROWN COUNTY UNITED WAY, AND WI DIVISION OF PUBLIC HEALTH NE REGIONAL OFFICE BELLIN PSYCHIATRIC CENTER, INC. PART V, SECTION B, LINE 11: THE 2012-2014 CHNA FOCUSED ON:- ORAL HEALTH- ADEQUATE AND APPROPRIATE FOOD AND NUTRITION- ALCOHOL AND OTHER DRUG ABUSE (AODA)THE 2015-2017 CHNA RECOMMENDED CONTINUED WORK IN THESE AREAS. IT ALSO IDENTIFIED ADDITIONAL AREAS OF NEED AND RECOMMENDED DEVELOPING WORK TEAMS TO FOCUS ON:- MENTAL HEALTH- PHYSICAL ACTIVITY BELLIN PSYCHIATRIC CENTER, INC. PART V, SECTION B, LINE 22D: PATIENTS CAN QUALIFY FOR COMMUNITY CARE OR A DISCOUNT DEPENDING ON LEVEL OF QUALIFICATION PRIMARILY DEPENDENT ON INCOME LEVEL AND FAMILY SIZE. THE DISCOUNT IS TAKEN FROM 80% OF GROSS CHARGES. A FAP ELIGIBLE PATIENT WILL NEVER BE RESPONSIBLE FOR MORE THAN 15% OF THEIR ANNUAL INCOME. BELLIN PSYCHIATRIC CENTER, INC. PART V, SECTION B, LINE 23: THERE IS A POSSIBILITY UNDER THE POLICY AS IT CURRENTLY EXISTS THAT THIS MAY HAPPEN; HOWEVER, THE PROBABILITY IS REMOTE. A PATIENT COULD QUALIFY UNDER THE FINANCIAL ASSISTANCE AND GET A PERCENTAGE DISCOUNT (IN ADDITION TO THE 20% SELF PAY DISCOUNT) THAT IS LESS THAN THE DISCOUNT GIVEN TO AN INDIVIDUAL WITH INSURANCE. THIS WILL BE CORRECTED BY 09/30/16 TO ELIMINATE THIS REMOTE POSSIBILITY. PART V, SECTION B, LINE 16 FINANCIAL ASSISTANCE POLICY WEBSITE AVAILABILITY BELLIN PSYCHIATRIC CENTER, INC. PART V, SECTION B, LINE 16C WEBSITE: WWW.BELLIN.ORG/PATIENTS_VISITORS/PATIENT-INFORMATION/FINANCIAL-ASSISTANCE 11 BELLIN BEHAVIORAL HEALTH CLINIC 301 E ST JOSEPH STREET GREEN BAY WI 54305 CLINIC BELLIN BEHAVIORAL HEALTH CLINIC ASHWAUBE 1630 COMMANCHE AVENUE GREEN BAY WI 54313 CLINIC BELLIN BEHAVIORAL HEALTH CLINIC NEURO CA 744 S WEBSTER AVENUE GREEN BAY WI 54301 CLINIC BELLIN BEHAVIORAL HEALTH CLINIC BELLEVUE 3263 EATON ROAD GREEN BAY WI 54311 CLINIC BELLIN BEHAVIORAL HEALTH CLINIC ESCANABA 610 S LINCOLN ROAD ESCANABA MI 49829 CLINIC BELLIN BEHAVIORAL HEALTH CLINIC MANITOWO 3415 CUSTER STREET SUITE D MANITOWOC WI 54221 CLINIC BELLIN BEHAVIORAL HEALTH CLINIC OCONTO 820 ARBUTUS AVENUE OCONTO WI 54153 CLINIC BELLIN BEHAVIORAL HEALTH CLINIC WEST DE 1800 LAWRENCE DRIVE DE PERE WI 54115 CLINIC BELLIN BEHAVIORAL HEALTH CLINIC OCONTO F 833 S MAIN STREET OCONTO FALLS WI 54154 CLINIC BELLIN BEHAVIORAL HEALTH CLINIC CANCER T 1580 COMMANCHE AVENUE ASHWAUBENON WI 54313 CLINIC BELLIN BEHAVIORAL HEALTH CLINIC KEWAUNEE 575 4TH STREET KEWAUNEE WI 54126 CLINIC PART I, LINE 6A: BELLIN PSYCHIATRIC CENTER IS INCLUDED IN THE ANNUAL BELLIN HEALTH SYSTEMS, INC. COMMUNITY BENEFIT REPORT. PART I, LINE 7: AMOUNTS ARE CALCULATED BASED ON COST TO CHARGE RATIOS AND AMOUNTS PER THE FINANCIAL STATEMENTS. PART I, LN 7 COL(F): BAD DEBT EXPENSE OF $526,081 INCLUDED ON FORM 990, PART IX, LINE 25 WAS EXCLUDED FROM THE DENOMINATOR PER INSTRUCTIONS WHEN CALCULATING THE PERCENT TOTAL EXPENSES ON SCHEDULE H. PART III, LINE 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 13 AND 14 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. ALSO, 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: PATIENTS EXPRESSING CONCERNS ABOUT THEIR ABILITY TO PAY FOR SERVICES ARE OFFERED INFORMATION ABOUT OUR COMMUNITY CARE PROGRAM AND, IF REQUESTED, CARE PROVIDED A COMMUNITY CARE APPLICATION. A COMPLETED APPLICATION WILL BE RETURNED ALONG WITH A COPY OF THE MOST RECENT FEDERAL INCOME TAX RETURN. WE MAY ALSO REQUEST THE MOST RECENT THREE MONTHS OF CHECK STUBS, AND EMPLOYER LETTER OR PROOF OF OTHER EARNINGS (SOCIAL SECURITY, PENSION, DISABILITY INCOME). IN ADDITION WE WILL REVIEW THE NET ASSETS AVAILABLE TO BE USED TOWARDS PAYMENT OF THE BILL. ONCE A COMPLETED APPLICATION AND OTHER MATERIALS ARE RECEIVED THEY WILL BE REVIEWED BY A FINANCIAL ADVISOR. THE ADJUSTED INCOME WHICH IS DETERMINED WILL BE COMPARED TO GOVERNMENT FEDERAL POVERTY GUIDELINES AND THE APPROVED DISCOUNT FROM FULL CHARGES WILL BE DETERMINED BASED ON WHERE THE PATIENT FALLS WITHIN OUR GUIDELINES. PART VI, LINE 2: BELLIN PSYCHIATRIC CENTER HAS COMPLETED A COMMUNITY NEEDS ASSESSMENT AND IT IS POSTED ON BELLIN.ORG PART VI, LINE 3: FINANCIAL COUNSELORS ADVISE PATIENTS OF ASSISTANCE PROGRAMS AS WELL AS SERVICE CALLED HRS ERASE IS USED TO REVIEW SELF PAY ACCOUNTS FOR POSSIBLE COVERAGE THROUGH GOVERNMENT PROGRAMS. PART VI, LINE 4: BELLIN PSYCHIATRIC CENTER SERVES NORTHEAST WISCONSIN INCLUDING CLINICS IN THE CITIES OF GREEN BAY, ASHWAUBENON, BELLEVUE, DE PERE, MANITOWOC, OCONTO, OCONTO FALLS, PESHTIGO AND KEWAUNEE. PART VI, LINE 5: A MAJORITY OF BELLIN PSYCHIATRIC CENTER'S GOVERNING BODY IS COMPRISED OF PERSONS WHO RESIDE IN BELLIN PSYCHIATRIC CENTER'S PRIMARY SERVICE AREA WHO ARE NEITHER EMPLOYEES NOR CONTRACTORS OF THE ORGANIZATION, NOR FAMILY MEMBERS THEREOF. IN ADDITION, BELLIN PSYCHIATRIC CENTER EXTENDS MEDICAL STAFF PRIVELEGES TO ALL QUALIFIED PHYSICIANS IN ITS COMMUNITY FOR ALL OF ITS DEPARTMENTS. BELLIN PSYCHIATRIC CENTER APPLIES SURPLUS FUNDS TO IMPROVEMENTS IN PATIENT CARE, EDUCATION AND FACILITIES. PART VI, LINE 6: BELLIN HEALTH IS A COMMUNITY-OWNED NOT-FOR-PROFIT ORGANIZATION RESPONSIBLE FOR THE PHYSICAL AND EMOTIONAL HEALTH OF PEOPLE LIVING IN NORTHEAST WISCONSIN AND THE UPPER PENINSULA OF MICHIGAN. DIRECTLY, AND IN PARTNERSHIP WITH COMMUNITIES, EMPLOYERS, SCHOOLS, AND GOVERNMENT OFFICIALS, WE GUIDE INDIVIDUALS AND FAMILIES IN THEIR LIFELONG JOURNEY TOWARD OPTIMAL HEALTH. WE ARE COMMITTED TO PROVIDING SAFE, RELIABLE, COST-EFFECTIVE TOTAL HEALTH SOLUTIONS WITH RESPECT AND COMPASSION. OUR INNOVATIVE WORK WILL IMPACT HEALTHCARE DELIVERY IN OUR REGION AS WELL AS THROUGHOUT THE WORLD. PART VI, LINE 7, REPORTS FILED WITH STATES WI X X X X 0 0 0 0 0 0 0 0 0 SHARLA BAENEN BPC PRESIDENT 137130 0 15000 0 180 0 10060 0 18422 0 180792 0 0 0 CHRISTINE WOLESKE MEMBER/BELLIN EXECUTIVE VP 0 301793 0 60000 0 17101 0 16385 0 20188 0 415467 0 0 CARLOS CASTILLO MD - TERMED PRESIDENT OF MEDICAL STAFF 197939 0 226924 0 1188 0 12504 0 14854 0 453409 0 0 0 MICHAEL HOFFMAN MD MEMBER/PHYSICIAN 0 174730 0 731 0 270 0 8968 0 14908 0 199607 0 0 TARA ROBERTSON PSYD MEMBER/CLINICAL PSYCHOLOGIST 121721 0 1750 0 162 0 6590 0 20440 0 150663 0 0 0 NACIYE KALAFAT MD PRESIDENT OF MEDICAL STAFF 252231 0 52716 0 270 0 3550 0 20841 0 329608 0 0 0 ANTHONY MARCHLEWSKI MD PSYCHIATRIST 249319 0 20376 0 414 0 14736 0 20130 0 304975 0 0 0 JOHN CHARLES MD PSYCHIATRIST 196067 0 241211 0 270 0 15806 0 19641 0 472995 0 0 0 DEREK CARLSON MD PSYCHIATRIST 265690 0 10000 0 429 0 0 0 15603 0 291722 0 0 0 KIM LASECKI PH D PSYCHOLOGIST 241575 0 1750 0 270 0 13203 0 18130 0 274928 0 0 0 RICHARD RIDER PSY D PSYCHOLOGIST 181110 0 1750 0 2286 0 9567 0 17828 0 212541 0 0 0 A WISCONSIN HEALTH AND EDUCATIONAL FACILITIES AUTHORITY 391337855 97712DLH7 2015-04-09 2468852 REFUND AND LEGALLY DEFEASE 0 0 0 A 2468852 28985 2439867 2009 0 1 1 1 A 0 1 1 1 0 0.00000 0.00000 1 0 1 A 0 1 0 0 0 0 0 0 0 A 1 FORM 990, PART VI, SECTION A, LINE 6 THE ORGANIZATION HAS ONE CORPORATE MEMBER, BELLIN HEALTH SYSTEMS, INC. FORM 990, PART VI, SECTION A, LINE 7A THE CORPORATE MEMBER, BELLIN HEALTH SYSTEMS, INC. HAS THE POWER TO APPOINT AND REMOVE BOARD MEMBERS. FORM 990, PART VI, SECTION A, LINE 7B THE CORPORATE MEMBER, BELLIN HEALTH SYSTEMS, INC., HAS THE POWER TO APPROVE MAJOR EXPENDITURES AND LONG-TERM BORROWINGS. FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 IS REVIEWED IN DETAIL BY SENIOR ADMINISTRATION AND IS PROVIDED TO THE BOARD OF DIRECTORS PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C EACH YEAR A CONFLICT OF INTEREST REQUEST DOCUMENT IS PROVIDED TO EACH BOARD MEMBER. ALL DOCUMENTS ARE PROVIDED BACK TO ADMINISTRATION AND REVIEWED. ALL EMPLOYEES ARE REQUIRED TO REVIEW THE CONFLICT OF INTEREST POLICY AS PART OF ANNUAL MANDATORY EDUCATION. AN INTERESTED PERSON MAY MAKE A PRESENTATION AT THE GOVERNING BOARD OR COMMITTEE MEETING, BUT AFTER THE PRESENTATION, HE/SHE SHALL LEAVE THE MEETING DURING THE DISCUSSION OF, AND THE VOTE ON, THE TRANSACTION OR ARRANGEMENT INVOLVING THE POSSIBLE CONFLICT OF INTEREST. SHOULD THERE BE A CONFLICT OF INTEREST WHICH ARISES AT A BOARD MEETING, THE INDIVIDUAL WITH A CONFLICT WILL BE ASKED TO LEAVE THE MEETING DURING A VOTE ON THE MATTER AND IS REQUIRED TO ABSTAIN FROM VOTING. FORM 990, PART VI, SECTION B, LINE 15 COMPENSATION FOR THE CEO AND KEY EXECUTIVES ARE SET BY THE EXECUTIVE COMMITTEE OF THE BOARD SUPPORTED BY MARKET DATA FROM SURVEYS AND AN INDEPENDENT CONSULTANTS REPORT. THE COMPENSATION IS DETERMINED BY MEMBERS OF THE EXECUTIVE COMMITTEE WITHOUT CONFLICT AND IS DOCUMENTED. CEO COMPENSATION: CEO PRESENTS RESULTS OF PERFORMANCE OBJECTIVES TO THE EXECUTIVE COMMITTEE IN JANUARY OF EACH YEAR. THE CHAIR APPLIES A FORMULA TO THE RESULTS AND COMES UP WITH A RECOMMENDATION. THE CHAIR FACILITATES GETTING APPROVAL FROM OTHER MEMBERS OF THE EXECUTIVE COMMITTEE. SENIOR LEADERS: COMPENSATION FOR THOSE WHO REPORT TO THE CEO IS TAKEN TO THE EXECUTIVE COMMITTEE FOR DISCUSSION/APPROVAL. FORM 990, PART VI, SECTION C, LINE 19 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 XII, LINE 2C: BELLIN PSYCHIATRIC CENTER IS INCLUDED IN THE CONSOLIDATED AUDIT OF BELLIN HEALTH SYSTEMS, INC. THE BELLIN HEALTH SYSTEMS, INC. BOARD OF DIRECTORS ASSUMES RESPONSIBILITY FOR THE OVERSIGHT OF THE AUDIT AND SELECTION OF THE INDEPENDENT AUDITOR. THIS PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. 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 AND RADIOLOGIC SCIENCE 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 MEMORIAL HOSPITAL INC PO BOX 23400 GREEN BAY WI 54305 390884478 ACUTE CARE 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, AND 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 N/A D1 TRAINING OF GREEN BAY LLC 7115 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 0 0 0 0 1 0 0 0 0 0 1 0 1 0 0 1 1 0 0 BELLIN MEMORIAL HOSPITAL E 3291878 ACTUAL BELLIN MEMORIAL HOSPITAL M 1926768 ACTUAL BELLIN MEMORIAL HOSPITAL K 5818 ACTUAL