2013-08-14T15:55:32-05:00 2012-09-30 390758449 WIPFLI LLP PO BOX 12237 GREEN BAY WI 543072237 990 2011-10-01 061745397 OCONTO HOSPITAL AND MEDICAL CENTER OCON 9208351100 PO BOX 357 OCONTO WI 54153 CHRISTINE WOLESKE 9208351100 2013-08-14 1 P00096513 9206620016 2013-08-14 2011 2016-02-24 21:20:13Z CHRISTINE WOLESKE PO BOX 357 OCONTO WI 54153 7230226 0 X WWW.BELLIN.ORG X 2005 WI OCONTO HOSPITAL & MEDICAL CENTER, INC. (THE ORGANIZATION) IS YOUR HOME TOWN HOSPITAL, CREATED TO MAKE OUTSTANDING HEALTHCARE CONVENIENT. BACKED BY THE RESOURCES OF BELLIN HEALTH SYSTEMS, INC., THE ORGANIZATION OFFERS OUTSTANDING HOSPITAL-BASED, EMERGENCY AND PRIMARY CARE SERVICES. THE ORGANIZATION OFFERS THE CARE YOU NEED WHERE YOU WANT IT. 8 3 40 9 0 0 11692 1482000 4106964 5622385 1468 2001 -840 -840 4119284 7105546 0 0 0 0 2349556 2994332 0 0 0 1961943 2800839 4311499 5795171 -192215 1310375 23119453 26383327 19787535 21159572 3331918 5223755 X THE MISSION OF THE ORGANIZATION 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, INC. WORKS IN PARTNERSHIP WITH THE COMMUNITY, THE CITIZENS HOSPITAL FOUNDATION AND BELLIN HEALTH. 1 0 4759862 5618637 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, 2011 TO SEPTEMBER 30, 2012, 82 INPATIENT DAYS WERE PROVIDED AND 103 SWING BED DAYS WERE PROVIDED. THE NUMBER OF OUTPATIENTS REGISTERED DURING THE SAME 12 MONTH PERIOD WAS 7,141. 4759862 1 1 0 0 0 0 0 0 0 0 1 0 0 0 1 1 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 0 0 0 0 1 0 0 40 1 0 0 0 0 0 0 0 0 0 0 X 8 3 1 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 AVE GREEN BAY WI 54301 X CHRISTINE WOLESKE 0.50 X X 0 376509 30610 GEORGE KERWIN 0.50 X 0 648208 27585 SARA ARNDT 0.50 X 0 44247 21754 DAVID HONISH 0.50 X X 0 0 0 RODNEY R JOHNSON 0.50 X X 0 0 0 LAURA CORMIER 45.00 X 104088 0 15975 CHARLES HEYKA MD 0.50 X 0 317109 28497 JOHN HONISH 0.50 X 0 0 0 ROBERT BIVINS MD 40.00 X 257021 0 24733 361109 1386073 149154 2 0 1 0 IEI GENERAL CONTRACTORS INC 1725 MIDWAY ROAD DE PERE WI 54155 CONTRACTOR SERVICES 521701 BELLIN MEMORIAL HOSPITAL INC PO BOX 23400 GREEN BAY WI 54305 MANAGEMENT SERVICES 260180 JIN KIM MD 2587 N FARWELL AVE MILWAUKEE WI 53211 CONTRACTED ED PHYSICIAN SERVICES 180630 SOMERVILLE INC 2100 RIVERSIDE DR GREEN BAY WI 54301 ARCHITECT AND DESIGN SERVICES 114050 4 465000 1017000 1482000 NET PATIENT REVENUE 621300 5618637 5618637 MISCELLANEOUS REVENUE 900099 3748 3748 5622385 2001 2001 123840 124680 -840 -840 -840 7105546 5618637 0 4909 401816 281754 120062 2203143 2114419 88724 95822 93415 2407 132354 117705 14649 161197 148453 12744 6002 6002 870477 633315 237162 72648 72648 629188 607456 21732 52543 4678 47865 104287 98573 5714 17177 11973 5204 622 622 311609 311609 319140 286187 32953 35368 15937 19431 BAD DEBT EXPENSE 341122 341122 DUES, LICENSES AND SUBS 26862 4875 21987 MISCELLANEOUS 13794 13794 5795171 4759862 1035309 0 320518 303291 13929740 33050 825548 2007951 146211 25237572 2542356 7764114 22695216 279533 1197608 23119453 26383327 227166 675816 14000000 14000000 5560369 6483756 19787535 21159572 X 3331918 4642293 581462 3331918 5223755 23119453 26383327 X 1310375 581462 X X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 661050 661050 14372299 1302481 13069818 171971 10789 161182 8159338 1229086 6930252 1872914 1872914 22695216 DUE TO AFFILIATE 6483756 6483756 7105546 5795171 1310375 581462 581462 1891837 5765226 0 5765226 1340320 1340320 7105546 5919851 124680 124680 5795171 0 5795171 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: IN ORDER TO ACCOUNT FOR UNCERTAIN TAX POSITIONS, BELLIN HEALTH SYSTEMS DETERMINES WHETHER IT IS MORE LIKELY THAN NOT THAT A TAX POSITION WILL BE SUSTAINED UPON EXAMINATION OF THE TECHNICAL MERITS OF THE POSITION, ASSUMING THE TAXING AUTHORITY HAS FULL KNOWLEDGE OF ALL INFORMATION. IF THE TAX POSITION DOES NOT MEET THE MORE-LIKELY-THAN-NOT RECOGNITION THRESHOLD, THE BENEFIT OF THAT POSITION IS NOT RECOGNIZED IN THE CONSOLIDATED FINANCIAL STATEMENTS. BELLIN HEALTH SYSTEMS RECORDED NO ASSETS OR LIABILITIES FOR UNCERTAIN TAX POSITIONS OR UNRECOGNIZED TAX BENEFITS IN 2012 OR 2011. FEDERAL AND STATE INCOME TAX RETURNS FOR TAX YEARS 2009 AND BEYOND REMAIN SUBJECT TO EXAMINATION BY APPLICABLE TAXING AUTHORITIES. PART XI, LINE 8 - OTHER ADJUSTMENTS: CHANGE IN INTEREST IN THE BELLIN HEALTH FOUNDATION, INC. 119,018. CHANGE IN INTEREST IN OCONTO MEMORIAL HOSPITAL CITIZENS' FOUNDATION, INC. 462,444. TOTAL TO SCHEDULE D, PART XI, LINE 8: 581,462. PART XII, LINE 4B - OTHER ADJUSTMENTS: RENTAL DEPRECIATION -124,680. STATE GRANT REVENUE 1,000,000. OCONTO MEMORIAL HOSPITAL CITIZENS FOUNDATION, INC. REVENUE 465,000. PART XIII, LINE 2D - OTHER ADJUSTMENTS: RENTAL DEPRECIATION 124,680. 1 1 1 X 1 X 1 1 0 0 168869 168869 0.03100 1201619 967329 234290 0.04300 1370488 967329 403159 0.07400 474 474 0.00010 5 1200 2390 2390 0.00040 5 1200 2864 2864 0.00050 5 1200 1373352 967329 406023 0.07450 1 303871 1374332 1360724 13608 X 1 0 1 1 OCONTO HOSPITAL & MEDICAL CENTER INC

820 ARBUTUS AVE OCONTO WI 54153

X X X OCONTO HOSPITAL & MEDICAL CENTER INC 1 0 1 1 200.000000000000 1 400.000000000000 1 X X X X 1 1 X X X X X 1 X 0 1 X 0 0 PART I, LINE 7: AMOUNTS ARE CALCULATED BASED ON THE COST TO CHARGE RATIOS AND WORKSHEET 2 PROVIDED BY THE IRS. PART I, L7 COL(F): BAD DEBT EXPENSE OF $341,122 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: THE ORGANIZATION REPORTED NO COMMUNITY BUILDING ACTIVITIES REPORTED IN PART II. PART III, LINE 4: THE COST OF BAD DEBT IS DETERMINED USING THE COST TO CHARGE RATIO. THERE MAY BE A SMALL PERCENTAGE OF THE BAD DEBT EXPENSE ATTRIBUTABLE TO PATIENTS WHO ARE ELIGIBLE FOR CHARITY CARE. THE ORGANIZATION CURRENTLY DOES NOT TRACK THESE NUMBERS AND IS UNABLE TO MAKE A SUBSTANTIATED ESTIMATE. 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: WHEN A PATIENT QUALIFIES FOR CHARITY CARE HIS/HER ACCOUNT BALANCE ARE ADJUSTED TO REFLECT THE PORTION OF THE CHARGES THAT HE/SHE ARE STILL RESPONSIBLE FOR PAYING. IF THOSE PAYMENTS ARE NOT MADE AND THE PATIENT DOES NOT QUALIFY FOR ADDITIONAL ASSISTANCE, THE COLLECTORS WILL FOLLOW THE STANDARD WRITTEN COLLECTION POLICY. OCONTO HOSPITAL & MEDICAL CENTER, INC. PART V, SECTION B, LINE 19D: PATIENTS CAN QUALIFY FOR COMMUNITY CARE OR A DISCOUNT DEPENDING ON LEVEL OF QUALIFICATION PRIMARILY DEPENDENT ON INCOME LEVEL AND FAMILY SIZE . PATIENTS WITHOUT ANY INSURANCE ARE GIVEN AN AUTOMATIC 20% DISCOUNT OFF OF GROSS CHARGE. PART VI, LINE 2: THE ORGANIZATION HAS NOT YET CONDUCTED ITS OWN ASSESSMENT OF THE HEALTHCARE NEEDS IN THE COMMUNITY. THE HOSPITAL IS BEGINNING TO DEVELOP A PROCESS FOR CONDUCTING THIS ASSESSMENT IN THE COMING YEAR. IN THE PAST, THE HOSPITAL HAS RELIED ON THE COMMUNITY HEALTHCARE NEEDS ASSESSMENT THAT WAS CONDUCTED BY THE COUNTY OF OCONTO. 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 INVOLVED IN THE OCONTO/MARINETTE WELLNESS COALITION, OCONTO AREA CHAMBER OF COMMERCE BUSINESS EXPO, COPPERFEST SPONSORSHIP, NEWCAP AND HUMANE SOCIETY FOOD DRIVES. IN ADDITION THE ORGANIZATION IS A SOLE COMMUNITY HOSPITAL WITH AN EMERGENCY ROOM AVAILABLE TO ALL. PART VI, LINE 6: THE ORGANIZATION, IN PARTNERSHIP WITH BELLIN HEALTH SYSTEMS, INC., CONTINUES TO SERVE IT'S COMMUNITY. X X 0 0 0 0 0 0 0 0 0 CHRISTINE WOLESKE 0 274210 0 100000 0 2299 0 11865 0 18745 0 407119 0 0 GEORGE KERWIN 0 397058 0 233500 0 17650 0 11752 0 15833 0 675793 0 0 CHARLES HEYKA MD 0 296109 0 21000 0 0 0 7752 0 20745 0 345606 0 0 ROBERT BIVINS MD 248861 0 7890 0 270 0 8988 0 15745 0 281754 0 0 0 WISCONSIN HEALTH & EDUCATIONAL FACILITIES AUTHORITY 391337855 2011-08-18 14000000 FACILITY AND SERVICE EXPANSION 0 0 0 14000000 36149 132033 13867967 2012 0 0 1 1 0 0 0 0 1 0 0 0 0 0 0 NEW PROGRAM SERVICES FORM 990, PART III, LINE 2 THE ORGANIZATION WAS OFFICIALLY DESIGNATED A PROVIDER-BASED RURAL HEALTH CLINIC ON 8/13/12. THIS INCREASES REIMBURSEMENT RATES FOR BOTH MEDICARE AND MEDICAID PROGRAMS. FORM 990, PART VI, SECTION A, LINE 2 JOHN HONISH AND DAVID HONISH HAVE A FAMILY RELATIONSHIP. 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 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 THE ORGANIZATION REQUESTS AN ANNUAL UPDATE FROM ALL MEMBERS WHO SIGN THE POLICY. 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 VII, LINE 1A CHRISTINE WOELKE WORKS AN AVERAGE OF 55 HOURS PER WEEK AT RELATED ORGANIZATIONS. GEORGE KERWIN WORKS AN AVERAGE OF 50 HOURS PER WEEK AT RELATED ORGANIZATIONS. SARA ARNDT WORKS AN AVERAGE OF 40 HOURS PER WEEK AT REALTED ORGANIZATIONS. CHARLES HYEKA WORKS AN AVERAGE OF 40 HOURS PER WEEK AT RELATED ORGANIZATIONS. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: CHANGE IN INTEREST IN THE BELLIN HEALTH FOUNDATION, INC. 119,018. CHANGE IN INTEREST IN OCONTO MEMORIAL HOSPITAL CITIZENS' FOUNDATION, INC. 462,444. TOTAL TO FORM 990, PART XI, LINE 5: 581,462. 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. OCONTO MEMORIAL HOSPITAL CITIZENS FOUNDATION 405 1ST STRET OCONTO WI 54153 391900586 SUPPORTING ORGANIZATION WI 501(C) 11-I N/A 0 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 0 BELLIN COLLEGE INC 3201 EATON ROAD GREEN BAY WI 54311 391620530 NURSING COLLEGE WI 501(C)(3) LINE 2 BELLIN HEALTH SYSTEMS INC 0 THE BELLIN HEALTH FOUNDATION INC PO BOX 23400 GREEN BAY WI 54305 391809171 FOUNDATION WI 501(C)(3) LINE 7 BELLIN HEALTH SYSTEMS INC 0 BELLIN PSYCHIATRIC CENTER INC PO BOX 23725 GREEN BAY WI 54305 391657627 PPSYCHIATRIC HOSPITAL WI 501(C)(3) LINE 3 BELLIN HEALTH SYSTEMS INC 0 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 0 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 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 BELLIN INVESTMENTS INC PO BOX 23400 GREEN BAY WI 54305 391564939 OTHER WI N/A C UNITED PROVIDERS INC PO BOX 23400 GREEN BAY WI 54305 391907541 OTHER WI N/A C 0 0 0 0 1 0 0 0 1 0 0 1 0 1 1 0 0 0 BELLIN MEMORIAL HOSPITAL INC E 14000000 FMV BELLIN MEMORIAL HOSPITAL INC N 378783 FMV BELLIN MEMORIAL HOSPITAL INC O 17075000 FMV BEL-REGIONAL HOME MEDICAL INC J 120000 FMV BELLIN MEMORIAL HOSPITAL INC E 6483756 FMV BELLIN MEMORIAL HOSPITAL INC L 264638 FMV