OCONTO HOSPITAL & MEDICAL CENTER INC: Form 990, tax year 2010
View the entire original 990 at ProPublica ↗
- Organization
- OCONTO HOSPITAL & MEDICAL CENTER INC (EIN 06-1745397)
- Tax period
- 2010-10-01 to 2011-09-30
- Filed
- 2012-08-15
- IRS object ID
- 201232289349300103
- Schema version
- 2010v3.4
- Source
- Download XML · Original 990 at ProPublica
Every field in the e-filed return. Faint text is the IRS element name, for citing.
- Return header
- Form 990
- Schedule A
- Schedule B
- Schedule D
- Schedule H
- Schedule J
- Schedule K
- Schedule O
- Schedule R
Return header ReturnHeader
| Field | Value | IRS element (for citing) |
|---|---|---|
| Timestamp | 2012-08-15T04:53:55-05:00 | Timestamp |
| Tax Period End Date | 2011-09-30 | TaxPeriodEndDate |
Preparer Firm PreparerFirm
Preparer Firm Business Name PreparerFirmBusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | WIPFLI LLP | BusinessNameLine1 |
Preparer Firm US Address PreparerFirmUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | PO BOX 12237 | AddressLine1 |
| City | GREEN BAY | City |
| State | WI | State |
| ZIP Code | 543072237 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return Type | 990 | ReturnType |
| Tax Period Begin Date | 2010-10-01 | TaxPeriodBeginDate |
Filer Filer
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 061745397 | EIN |
Name Name
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | OCONTO HOSPITAL & MEDICAL CENTER INC | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name Control | OCON | NameControl |
| Phone | 9208351100 | Phone |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | PO BOX 357 | AddressLine1 |
| City | OCONTO | City |
| State | WI | State |
| ZIP Code | 54153 | ZIPCode |
Officer Officer
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name | CHRISTINE WOLESKE | Name |
| Title | CEO | Title |
| Phone | 9208351100 | Phone |
| Date Signed | 2012-08-14 | DateSigned |
| Authorize Third Party | 1 | AuthorizeThirdParty |
Preparer Preparer
| Field | Value | IRS element (for citing) |
|---|---|---|
| Phone | 9206620016 | Phone |
| Date Prepared | 2012-08-14 | DatePrepared |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tax Year | 2010 | TaxYear |
| Build TS | 2016-02-24 21:20:13Z | BuildTS |
Form 990 IRS990
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name Of Principal Officer Person | CHRISTINE WOLESKE | NameOfPrincipalOfficerPerson |
Address Principal Officer US AddressPrincipalOfficerUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | PO BOX 357 | AddressLine1 |
| City | OCONTO | City |
| State | WI | State |
| ZIP Code | 54153 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Receipts | 4243964 | GrossReceipts |
| Group Return For Affiliates | 0 | GroupReturnForAffiliates |
| Organization501c3 | X | Organization501c3 |
| Web Site | WWW.OCONTOHOSPITAL.ORG | WebSite |
| Type Of Organization Corporation | X | TypeOfOrganizationCorporation |
| Year Formation | 2005 | YearFormation |
| State Legal Domicile | WI | StateLegalDomicile |
| Activity Or Mission Description | 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. | ActivityOrMissionDescription |
| Nbr Voting Members Governing Body | 8 | NbrVotingMembersGoverningBody |
| Nbr Independent Voting Members | 7 | NbrIndependentVotingMembers |
| Total Nbr Employees | 45 | TotalNbrEmployees |
| Total Nbr Volunteers | 7 | TotalNbrVolunteers |
| Total Gross UBI | 0 | TotalGrossUBI |
| Net Unrelated Business Txbl Income | 0 | NetUnrelatedBusinessTxblIncome |
| Contributions Grants Prior Year | 38655 | ContributionsGrantsPriorYear |
| Contributions Grants Current Year | 11692 | ContributionsGrantsCurrentYear |
| Program Service Revenue Prior Year | 3573104 | ProgramServiceRevenuePriorYear |
| Program Service Revenue CY | 4106964 | ProgramServiceRevenueCY |
| Investment Income Prior Year | 897 | InvestmentIncomePriorYear |
| Investment Income Current Year | 1468 | InvestmentIncomeCurrentYear |
| Other Revenue Prior Year | -4680 | OtherRevenuePriorYear |
| Other Revenue Current Year | -840 | OtherRevenueCurrentYear |
| Total Revenue Prior Year | 3607976 | TotalRevenuePriorYear |
| Total Revenue Current Year | 4119284 | TotalRevenueCurrentYear |
| Grants And Similar Amnts Prior Year | 0 | GrantsAndSimilarAmntsPriorYear |
| Grants And Similar Amnts CY | 0 | GrantsAndSimilarAmntsCY |
| Benefits Paid To Members Prior Year | 0 | BenefitsPaidToMembersPriorYear |
| Benefits Paid To Members CY | 0 | BenefitsPaidToMembersCY |
| Salaries Etc Prior Year | 2344597 | SalariesEtcPriorYear |
| Salaries Etc Current Year | 2349556 | SalariesEtcCurrentYear |
| Total Prof Fundrsng Exp Prior Year | 0 | TotalProfFundrsngExpPriorYear |
| Total Prof Fundrsng Exp CY | 0 | TotalProfFundrsngExpCY |
| Total Fundrsng Exp Current Year | 0 | TotalFundrsngExpCurrentYear |
| Other Expense Prior Year | 1846620 | OtherExpensePriorYear |
| Other Expenses Current Year | 1961943 | OtherExpensesCurrentYear |
| Total Expenses Prior Year | 4191217 | TotalExpensesPriorYear |
| Total Expenses Current Year | 4311499 | TotalExpensesCurrentYear |
| Revenues Less Expenses Prior Year | -583241 | RevenuesLessExpensesPriorYear |
| Revenues Less Expenses CY | -192215 | RevenuesLessExpensesCY |
| Total Assets BOY | 6933464 | TotalAssetsBOY |
| Total Assets EOY | 23119453 | TotalAssetsEOY |
| Total Liabilities BOY | 4922869 | TotalLiabilitiesBOY |
| Total Liabilities EOY | 19787535 | TotalLiabilitiesEOY |
| Net Assets Or Fund Balances BOY | 2010595 | NetAssetsOrFundBalancesBOY |
| Net Assets Or Fund Balances EOY | 3331918 | NetAssetsOrFundBalancesEOY |
| Info In Schedule O Part III | X | InfoInScheduleOPartIII |
| Mission Description | 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. | MissionDescription |
| Significant New Program Services | 1 | SignificantNewProgramServices |
| Significant Change | 0 | SignificantChange |
| Expense | 3565241 | Expense |
| Revenue | 4106758 | Revenue |
| Description | 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, 2010 TO SEPTEMBER 30, 2011, 34 INPATIENT DAYS WERE PROVIDED AND 105 SWING BED DAYS WERE PROVIDED. THE NUMBER OF OUTPATIENTS REGISTERED DURING THE SAME 12 MONTH PERIOD WAS 6,864. | Description |
| Total Program Service Expense | 3565241 | TotalProgramServiceExpense |
| Described In501 C3 | 1 | DescribedIn501C3 |
| Schedule B Required | 1 | ScheduleBRequired |
| Political Activities | 0 | PoliticalActivities |
| Lobbying Activities | 0 | LobbyingActivities |
| Donor Advised Funds | 0 | DonorAdvisedFunds |
| Conservation Easements | 0 | ConservationEasements |
| Collections Of Art | 0 | CollectionsOfArt |
| Credit Counseling | 0 | CreditCounseling |
| Term Or Permanent Endowments | 0 | TermOrPermanentEndowments |
| Report Land Bldg Equip | 1 | ReportLandBldgEquip |
| Report Invest Oth Securities | 0 | ReportInvestOthSecurities |
| Report Prog Rel Invest | 0 | ReportProgRelInvest |
| Report Other Assets | 0 | ReportOtherAssets |
| Report Other Liabilities | 1 | ReportOtherLiabilities |
| Report Fin48 Footnote | 1 | ReportFin48Footnote |
| Independent Audit Financial Stmt | 0 | IndependentAuditFinancialStmt |
| Consolidated Audit Financial Stmt | 1 | ConsolidatedAuditFinancialStmt |
| School | 0 | School |
| Foreign Office | 0 | ForeignOffice |
| Foreign Activities | 0 | ForeignActivities |
| More Than5000 K To Organizations | 0 | MoreThan5000KToOrganizations |
| More Than5000 K To Individuals | 0 | MoreThan5000KToIndividuals |
| Professional Fundraising | 0 | ProfessionalFundraising |
| Fundraising Activities | 0 | FundraisingActivities |
| Gaming | 0 | Gaming |
| Hospital | 1 | Hospital |
| Financial Stmt Attached | 1 | FinancialStmtAttached |
| Grants To Organizations | 0 | GrantsToOrganizations |
| Grants To Individuals | 0 | GrantsToIndividuals |
| Schedule J Required | 1 | ScheduleJRequired |
| Tax Exempt Bonds | 1 | TaxExemptBonds |
| Invest Tax Exempt Bonds | 0 | InvestTaxExemptBonds |
| Escrow Account | 0 | EscrowAccount |
| On Behalf Of Issuer | 0 | OnBehalfOfIssuer |
| Excess Benefit Transaction | 0 | ExcessBenefitTransaction |
| Prior Excess Benefit Transaction | 0 | PriorExcessBenefitTransaction |
| Loan To Officer Or DQP | 0 | LoanToOfficerOrDQP |
| Grant To Related Person | 0 | GrantToRelatedPerson |
| Bsnss Rltnshp With Organization | 0 | BsnssRltnshpWithOrganization |
| Bsnss Rltnshp Thru Family Member | 0 | BsnssRltnshpThruFamilyMember |
| Officer Entity With Bsnss Rltnshp | 0 | OfficerEntityWithBsnssRltnshp |
| Deductible Non Cash Contributions | 0 | DeductibleNonCashContributions |
| Deductible Contributions Of Art | 0 | DeductibleContributionsOfArt |
| Terminated | 0 | Terminated |
| Partial Liquidation | 0 | PartialLiquidation |
| Disregarded Entity | 0 | DisregardedEntity |
| Related Entity | 1 | RelatedEntity |
| Related Org Controlled Entity | 0 | RelatedOrgControlledEntity |
| Transaction Related Entity | 0 | TransactionRelatedEntity |
| Transfers To Exempt Non Chrtbl Org | 0 | TransfersToExemptNonChrtblOrg |
| Activities Conducted Partnership | 0 | ActivitiesConductedPartnership |
| Schedule O Required | 1 | ScheduleORequired |
| Number Forms Transmitted With1096 | 0 | NumberFormsTransmittedWith1096 |
| Number W2 G Included | 0 | NumberW2GIncluded |
| Number Of Employees | 45 | NumberOfEmployees |
| Employment Tax Returns Filed | 1 | EmploymentTaxReturnsFiled |
| Unrelated Business Income | 0 | UnrelatedBusinessIncome |
| Foreign Financial Account | 0 | ForeignFinancialAccount |
| Prohibited Tax Shelter Trans | 0 | ProhibitedTaxShelterTrans |
| Taxable Party Notification | 0 | TaxablePartyNotification |
| Non Deductible Contributions | 0 | NonDeductibleContributions |
| Quid Pro Quo Contributions | 0 | QuidProQuoContributions |
| Form8282 Property Disposed Of | 0 | Form8282PropertyDisposedOf |
| Funds To Pay Premiums | 0 | FundsToPayPremiums |
| Premiums Paid | 0 | PremiumsPaid |
| Indoor Tanning Services | 0 | IndoorTanningServices |
| Info In Schedule O Part VI | X | InfoInScheduleOPartVI |
| Nbr Voting Governing Body Members | 8 | NbrVotingGoverningBodyMembers |
| Number Independent Voting Members | 7 | NumberIndependentVotingMembers |
| Family Or Business Relationship | 0 | FamilyOrBusinessRelationship |
| Delegation Of Management Duties | 0 | DelegationOfManagementDuties |
| Changes To Organizing Docs | 1 | ChangesToOrganizingDocs |
| Material Diversion Or Misuse | 0 | MaterialDiversionOrMisuse |
| Members Or Stockholders | 1 | MembersOrStockholders |
| Election Of Board Members | 1 | ElectionOfBoardMembers |
| Decisions Subject To Approval | 1 | DecisionsSubjectToApproval |
| Minutes Of Governing Body | 1 | MinutesOfGoverningBody |
| Minutes Of Committees | 1 | MinutesOfCommittees |
| Officer Mailing Address | 0 | OfficerMailingAddress |
| Local Chapters | 0 | LocalChapters |
| Form990 Provided To Governing Body | 1 | Form990ProvidedToGoverningBody |
| Conflict Of Interest Policy | 1 | ConflictOfInterestPolicy |
| Annual Disclosure Covered Persons | 1 | AnnualDisclosureCoveredPersons |
| Regular Monitoring Enforcement | 1 | RegularMonitoringEnforcement |
| Whistleblower Policy | 1 | WhistleblowerPolicy |
| Document Retention Policy | 1 | DocumentRetentionPolicy |
| Compensation Process CEO | 1 | CompensationProcessCEO |
| Compensation Process Other | 1 | CompensationProcessOther |
| Investment In Joint Venture | 0 | InvestmentInJointVenture |
| Upon Request | X | UponRequest |
The Books Are In Care Of TheBooksAreInCareOf
Name Business NameBusiness
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | SARA ARNDT | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Telephone Number | 9204457260 | TelephoneNumber |
Address US AddressUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 2020 SOUTH WEBSTER AVE | AddressLine1 |
| City | GREEN BAY | City |
| State | WI | State |
| ZIP Code | 54301 | ZIPCode |
Form990 Part VII Section A Form990PartVIISectionA (9 entries)
| TitleTitle | Average Hours Per WeekAverageHoursPerWeek | Individual Trustee Or DirectorIndividualTrusteeOrDirector | OfficerOfficer | Reportable Comp From OrganizationReportableCompFromOrganization | Reportable Comp From Related OrgsReportableCompFromRelatedOrgs | Other CompensationOtherCompensation | Highest Compensated EmployeeHighestCompensatedEmployee |
|---|---|---|---|---|---|---|---|
| CHRISTINE WOLESKE | |||||||
| CEO | 1.00 | X | X | 0 | 0 | 0 | |
| GEORGE KERWIN | |||||||
| BOARD MEMBER | 1.00 | X | 0 | 0 | 0 | ||
| SARA ARNDT | |||||||
| BOARD MEMBER | 1.00 | X | 0 | 0 | 0 | ||
| DAVID HONISH | |||||||
| CHAIRPERSON | 1.00 | X | X | 0 | 0 | 0 | |
| RODNEY R JOHNSON | |||||||
| SECRETARY/TREASURER | 1.00 | X | X | 0 | 0 | 0 | |
| LAURA CORMIER | |||||||
| VP OF OPERATIONS | 45.00 | X | 95841 | 0 | 15571 | ||
| CHARLES HEYKA MD | |||||||
| BOARD MEMBER | 1.00 | X | 0 | 0 | 0 | ||
| JOHN HONISH | |||||||
| BOARD MEMBER | 1.00 | X | 0 | 0 | 0 | ||
| ROBERT BIVINS MD | |||||||
| PHYSICIAN | 36.00 | 273462 | 0 | 22310 | X | ||
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Reportable Comp From Org | 369303 | TotalReportableCompFromOrg |
| Total Reportable Comp Frm Rltd Orgs | 0 | TotalReportableCompFrmRltdOrgs |
| Total Other Compensation | 37881 | TotalOtherCompensation |
| Number Individuals GT100 K | 1 | NumberIndividualsGT100K |
| Formers Listed | 0 | FormersListed |
| Total Comp GT150 K | 1 | TotalCompGT150K |
| Compensation From Other Sources | 0 | CompensationFromOtherSources |
Contractor Compensation ContractorCompensation (2 entries)
| Address Line1AddressOfContractor/AddressUS/AddressLine1 | CityAddressOfContractor/AddressUS/City | StateAddressOfContractor/AddressUS/State | ZIP CodeAddressOfContractor/AddressUS/ZIPCode | Description Of ServicesDescriptionOfServices | CompensationCompensation |
|---|---|---|---|---|---|
| SOMERVILLE INC | |||||
| 2100 RIVERSIDE DR | GREEN BAY | WI | 54301 | ARCHITECT AND DESIGN SERVICES | 448620 |
| BELLIN MEMORIAL HOSPITAL INC | |||||
| PO BOX 23400 | GREEN BAY | WI | 54305 | MANAGEMENT SERVICES | 270054 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Number Of Contractors GT100 K | 2 | NumberOfContractorsGT100K |
| Government Grants | 9712 | GovernmentGrants |
| All Other Contributions | 1980 | AllOtherContributions |
| Total Contributions | 11692 | TotalContributions |
Program Service Revenue ProgramServiceRevenue (2 entries)
| DescriptionDescription | Business CodeBusinessCode | Total Revenue ColumnTotalRevenueColumn | Related Or Exempt Function IncomeRelatedOrExemptFunctionIncome | ExclusionExclusionAmount |
|---|---|---|---|---|
| NET PATIENT REVENUE | 621300 | 4106758 | 4106758 | |
| VENDING MACHINE REVENU | 900099 | 206 | $206 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Revenue | 4106964 | TotalProgramServiceRevenue |
Investment Income InvestmentIncome
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 1468 | TotalRevenueColumn |
| Exclusion | $1,468 | ExclusionAmount |
Gross Rents GrossRents
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | 123840 | Real |
Less Rental Expenses LessRentalExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | 124680 | Real |
Rental Income Or Loss RentalIncomeOrLoss
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | -840 | Real |
Net Rental Income Or Loss NetRentalIncomeOrLoss
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | -840 | TotalRevenueColumn |
| Exclusion | -$840 | ExclusionAmount |
Total Revenue TotalRevenue
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 4119284 | TotalRevenueColumn |
| Related Or Exempt Function Income | 4106758 | RelatedOrExemptFunctionIncome |
| Unrelated Business Revenue | 0 | UnrelatedBusinessRevenue |
| Exclusion | $834 | ExclusionAmount |
Comp Current Officers Directors CompCurrentOfficersDirectors
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 407183 | Total |
| Program Services | 295772 | ProgramServices |
| Management And General | 111411 | ManagementAndGeneral |
Other Salaries And Wages OtherSalariesAndWages
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 1599609 | Total |
| Program Services | 1555346 | ProgramServices |
| Management And General | 44263 | ManagementAndGeneral |
Pension Plan Contributions PensionPlanContributions
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 73137 | Total |
| Program Services | 71642 | ProgramServices |
| Management And General | 1495 | ManagementAndGeneral |
Other Employee Benefits OtherEmployeeBenefits
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 142578 | Total |
| Program Services | 140055 | ProgramServices |
| Management And General | 2523 | ManagementAndGeneral |
Payroll Taxes PayrollTaxes
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 127049 | Total |
| Program Services | 116873 | ProgramServices |
| Management And General | 10176 | ManagementAndGeneral |
Fees For Services Legal FeesForServicesLegal
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 1311 | Total |
| Management And General | 1311 | ManagementAndGeneral |
Fees For Services Other FeesForServicesOther
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 653323 | Total |
| Program Services | 415662 | ProgramServices |
| Management And General | 237661 | ManagementAndGeneral |
Advertising Advertising
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 9013 | Total |
| Management And General | 9013 | ManagementAndGeneral |
Office Expenses OfficeExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 358223 | Total |
| Program Services | 329984 | ProgramServices |
| Management And General | 28239 | ManagementAndGeneral |
Information Technology InformationTechnology
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 42851 | Total |
| Program Services | 12542 | ProgramServices |
| Management And General | 30309 | ManagementAndGeneral |
Occupancy Occupancy
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 94541 | Total |
| Program Services | 89302 | ProgramServices |
| Management And General | 5239 | ManagementAndGeneral |
Travel Travel
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 9023 | Total |
| Program Services | 4830 | ProgramServices |
| Management And General | 4193 | ManagementAndGeneral |
Conferences Meetings ConferencesMeetings
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 4031 | Total |
| Management And General | 4031 | ManagementAndGeneral |
Interest Interest
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 236045 | Total |
| Management And General | 236045 | ManagementAndGeneral |
Depreciation Depletion DepreciationDepletion
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 177234 | Total |
| Program Services | 174630 | ProgramServices |
| Management And General | 2604 | ManagementAndGeneral |
Insurance Insurance
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 20502 | Total |
| Program Services | 10731 | ProgramServices |
| Management And General | 9771 | ManagementAndGeneral |
Other Expenses OtherExpenses (3 entries)
| DescriptionDescription | TotalTotal | Program ServicesProgramServices | Management And GeneralManagementAndGeneral |
|---|---|---|---|
| BAD DEBT EXPENSE | 335034 | 335034 | |
| DUES, LICENSES AND SUBS | 14994 | 12838 | 2156 |
| MISCELLANEOUS | 5818 | 5818 |
Total Functional Expenses TotalFunctionalExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 4311499 | Total |
| Program Services | 3565241 | ProgramServices |
| Management And General | 746258 | ManagementAndGeneral |
| Fundraising | 0 | Fundraising |
Cash Non Interest Bearing CashNonInterestBearing
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 273626 | BOY |
| EOY | 320518 | EOY |
Savings And Temp Cash Investments SavingsAndTempCashInvestments
| Field | Value | IRS element (for citing) |
|---|---|---|
| EOY | 13929740 | EOY |
Accounts Receivable AccountsReceivable
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 507990 | BOY |
| EOY | 825548 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Land Buildings Equipment Basis | 9875706 | LandBuildingsEquipmentBasis |
| Land Bldg Equipment Accum Deprec | 2111592 | LandBldgEquipmentAccumDeprec |
Land Buildings Equipment Basis Net LandBuildingsEquipmentBasisNet
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 5716848 | BOY |
| EOY | 7764114 | EOY |
Other Assets Total OtherAssetsTotal
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 435000 | BOY |
| EOY | 279533 | EOY |
Total Assets TotalAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 6933464 | BOY |
| EOY | 23119453 | EOY |
Accounts Payable Accrued Expenses AccountsPayableAccruedExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 216101 | BOY |
| EOY | 227166 | EOY |
Mort Notes Pybl Secured Invest Prop MortNotesPyblSecuredInvestProp
| Field | Value | IRS element (for citing) |
|---|---|---|
| EOY | 14000000 | EOY |
Other Liabilities OtherLiabilities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 4706768 | BOY |
| EOY | 5560369 | EOY |
Total Liabilities TotalLiabilities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 4922869 | BOY |
| EOY | 19787535 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Follow SFAS117 | X | FollowSFAS117 |
Unrestricted Net Assets UnrestrictedNetAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 2010595 | BOY |
| EOY | 3331918 | EOY |
Total Net Assets Fund Balances TotalNetAssetsFundBalances
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 2010595 | BOY |
| EOY | 3331918 | EOY |
Total Liab Net Assets Fund Balances TotalLiabNetAssetsFundBalances
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 6933464 | BOY |
| EOY | 23119453 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part XI | X | InfoInScheduleOPartXI |
| Reconcilation Revenue Expenses | -192215 | ReconcilationRevenueExpenses |
| Reconcilation Other Changes | 1513538 | ReconcilationOtherChanges |
| Info In Schedule O Part XII | X | InfoInScheduleOPartXII |
| Method Of Accounting Accrual | X | MethodOfAccountingAccrual |
| Accountant Compile Or Review | 0 | AccountantCompileOrReview |
| FS Audited | 1 | FSAudited |
| Audit Committee | 1 | AuditCommittee |
| Financial Statement Consolidated | X | FinancialStatementConsolidated |
| Federal Grant Audit Required | 0 | FederalGrantAuditRequired |
Schedule A IRS990ScheduleA
| Field | Value | IRS element (for citing) |
|---|---|---|
| Hospital170b1 Aiii | X | Hospital170b1Aiii |
Schedule B IRS990ScheduleB
Contributor Info ContributorInfo
| Field | Value | IRS element (for citing) |
|---|---|---|
| Contributor Number | RESTRICTED | ContributorNumber |
Contributor Name Business ContributorNameBusiness
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | RESTRICTED | BusinessNameLine1 |
Contributor Address US ContributorAddressUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | RESTRICTED | AddressLine1 |
| Address Line2 | RESTRICTED | AddressLine2 |
| City | RESTRICTED | City |
| State | RESTRICTED | State |
| ZIP Code | RESTRICTED | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Aggregate Contributions | RESTRICTED | AggregateContributions |
Schedule D IRS990ScheduleD
Land Land
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 661050 | OtherCostOrOtherBasis |
| Book Value | 661050 | BookValue |
Buildings Buildings
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 6288814 | OtherCostOrOtherBasis |
| Depreciation | 1073284 | Depreciation |
| Book Value | 5215530 | BookValue |
Leasehold Improvements LeaseholdImprovements
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 17579 | OtherCostOrOtherBasis |
| Depreciation | 7003 | Depreciation |
| Book Value | 10576 | BookValue |
Equipment Equipment
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 2174564 | OtherCostOrOtherBasis |
| Depreciation | 1031305 | Depreciation |
| Book Value | 1143259 | BookValue |
Other Land Buildings OtherLandBuildings
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 733699 | OtherCostOrOtherBasis |
| Book Value | 733699 | BookValue |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Of Book Value Land Buildings | 7764114 | TotalOfBookValueLandBuildings |
Other Liabilities OtherLiabilities
| Field | Value | IRS element (for citing) |
|---|---|---|
| Description | DUE TO AFFILIATE | Description |
| Amount | $5,560,369 | Amount |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Of Amounts | 5560369 | TotalOfAmounts |
| Total Revenue | 4119284 | TotalRevenue |
| Total Expenses | 4311499 | TotalExpenses |
| Excess Or Deficit For Year | -192215 | ExcessOrDeficitForYear |
| Other | $1,513,538 | OtherAmount |
| Total Adjustments | 1513538 | TotalAdjustments |
| Excess Or Deficit Per FS | 1321323 | ExcessOrDeficitPerFS |
| Tot Revenue Etc Audited Fincl Stmt | 4243964 | TotRevenueEtcAuditedFinclStmt |
| Revenue Not Rptd F990 | 0 | RevenueNotRptdF990 |
| Revenue Subtotal | 4243964 | RevenueSubtotal |
| Other Revenues Not Included | -124680 | OtherRevenuesNotIncluded |
| Revenue Not Rptd On Fin Stmt | -124680 | RevenueNotRptdOnFinStmt |
| Total Revenue Per Form990 | 4119284 | TotalRevenuePerForm990 |
| Tot Expenses Etc Audited Fincl Stmt | 4436179 | TotExpensesEtcAuditedFinclStmt |
| Other Expenses Included | 124680 | OtherExpensesIncluded |
| Expenses Not Rptd F990 | 124680 | ExpensesNotRptdF990 |
| Expenses Subtotal | 4311499 | ExpensesSubtotal |
| Expenses Not Rptd On Fin Stmt | 0 | ExpensesNotRptdOnFinStmt |
| Total Expenses Per Form990 | 4311499 | TotalExpensesPerForm990 |
Form990 Schedule D Part XIV Form990ScheduleDPartXIV (4 entries)
| IdentifierIdentifier | Return ReferenceReturnReference | ExplanationExplanation |
|---|---|---|
| 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 2011 OR 2010. FEDERAL AND STATE INCOME TAX RETURNS FOR TAX YEARS 2007 AND BEYOND REMAIN SUBJECT TO EXAMINATION BY APPLICABLE TAXING AUTHORITIES. |
| PART XII, LINE 4B - OTHER ADJUSTMENTS: | RENTAL DEPRECIATION -124,680. | |
| PART XIII, LINE 2D - OTHER ADJUSTMENTS: | RENTAL DEPRECIATION 124,680. | |
| SCH D, PART XI, LINE 8; AS BELLIN HOSPITAL GAINED A CONTROLLING INTEREST IN THE ORGANIZATION, THIS TRANSACTION WAS ACCOUNTED FOR USING THE ACQUISITION METHOD OF ACCOUNTING. UNDER THE ACQUISITION METHOD OF ACCOUNTING, THE ASSETS ACQUIRED, LIABILITIES ASSUMED, AND NONCONTROLLING INTEREST WERE MEASURED AT FAIR VALUE BASED ON AN INDEPENDENT APPRAISAL. AS THE FAIR VALUE OF THE ASSETS ACQUIRED EXCEEDED THE FAIR VALUE OF THE LIABILITIES ASSUMED AND THE NONCONTROLLING INTEREST, THE TRANSACTION RESULTED IN AN INCREASE IN ASSET VALUATION OF $1,513,538. |
Schedule H IRS990ScheduleH
| Field | Value | IRS element (for citing) |
|---|---|---|
| Charity Care Policy | 1 | CharityCarePolicy |
| Written Policy | 1 | WrittenPolicy |
| FPG Reference Free Care | 1 | FPGReferenceFreeCare |
| Pcent200 | X | Pcent200 |
| FPG Reference Discounted Care | 1 | FPGReferenceDiscountedCare |
| Pcent400 | X | Pcent400 |
| Free Disc Care Medically Indigent | 1 | FreeDiscCareMedicallyIndigent |
| Amounts Budgeted For Charity Care | 1 | AmountsBudgetedForCharityCare |
| Expenses Exceeded Budget | 0 | ExpensesExceededBudget |
| Annual Community Benefit Report | 0 | AnnualCommunityBenefitReport |
Charity Care At Cost CharityCareAtCost
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 144798 | TotalCommunityBenefitExpense |
| Net Community Benefit Expense | 144798 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.03640 | PercentOfTotalExpense |
Unreimbursed Medicaid UnreimbursedMedicaid
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 1046940 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 856610 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 190330 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.04790 | PercentOfTotalExpense |
Total Charity Care TotalCharityCare
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 1191738 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 856610 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 335128 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.08430 | PercentOfTotalExpense |
Total Community Benefits TotalCommunityBenefits
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 1191738 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 856610 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 335128 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.08430 | PercentOfTotalExpense |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bad Debt Expense Reported | 1 | BadDebtExpenseReported |
| Bad Debt Expense | $286,797 | BadDebtExpenseAmount |
| Amount Reimbursed By Medicare | 757861 | AmountReimbursedByMedicare |
| Cost Of Care Reimbursed By Medicare | 819412 | CostOfCareReimbursedByMedicare |
| Medicare Surplus Or Shortfall | -61551 | MedicareSurplusOrShortfall |
Costing Methodology Used CostingMethodologyUsed
| Field | Value | IRS element (for citing) |
|---|---|---|
| Cost To Charge Ratio | X | CostToChargeRatio |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Written Debt Collection Policy | 1 | WrittenDebtCollectionPolicy |
| Provision For Charity Care | 0 | ProvisionForCharityCare |
| Number Of Hospital Facilities | 1 | NumberOfHospitalFacilities |
Form990 Schedule H Part V Section A Form990ScheduleHPartVSectionA
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility Number | 1 | FacilityNumber |
Name Name
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | OCONTO HOSPITAL & MEDICAL CENTER INC | BusinessNameLine1 |
Address Address
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 820 ARBUTUS AVE | AddressLine1 |
| City | OCONTO | City |
| State | WI | State |
| ZIP Code | 54153 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Licensed Hospital | X | LicensedHospital |
| Critical Access Hospital | X | CriticalAccessHospital |
| Er24 Hours | X | Er24Hours |
Form990 Schedule H Part V Section B Form990ScheduleHPartVSectionB
Hospital Facility Name HospitalFacilityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | OCONTO HOSPITAL & MEDICAL CENTER INC | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Hospital Facility Number | 1 | HospitalFacilityNumber |
Form990 Schedule H Part VI Form990ScheduleHPartVI (11 entries)
| ExplanationExplanation |
|---|
| 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 $335,034 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. |
| 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 6: 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 7: IN THE FISCAL YEAR 2011, BELLIN MEMORIAL HOSPITAL, INC. GAINED A CONTROLLING INTEREST IN THE ORGANIZATION. THE ORGANIZATION, IN PARTNERSHIP WITH BELLIN HEALTH SYSTEMS, INC., CONTINUES TO SERVE IT'S COMMUNITY. |
Schedule J IRS990ScheduleJ
| Field | Value | IRS element (for citing) |
|---|---|---|
| Compensation Survey | X | CompensationSurvey |
| Severance Payment | 0 | SeverancePayment |
| Supplemental Nonqual Retire Plan | 0 | SupplementalNonqualRetirePlan |
| Equity Based Comp Arrangement | 0 | EquityBasedCompArrangement |
| Comp Based On Revenue Of Filing Org | 0 | CompBasedOnRevenueOfFilingOrg |
| Comp Based On Revenue Related Orgs | 0 | CompBasedOnRevenueRelatedOrgs |
| Comp Based Net Earnings Filing Org | 0 | CompBasedNetEarningsFilingOrg |
| Comp Based Net Earnings Relate Orgs | 0 | CompBasedNetEarningsRelateOrgs |
| Any Non Fixed Payments | 0 | AnyNonFixedPayments |
| Initial Contract Exception | 0 | InitialContractException |
Form990 Schedule J Part II Form990ScheduleJPartII
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name Person | ROBERT BIVINS MD | NamePerson |
| Base Compensation Filing Org | 262838 | BaseCompensationFilingOrg |
| Comp Based On Related Orgs | 0 | CompBasedOnRelatedOrgs |
| Bonus Filing Org | 10354 | BonusFilingOrg |
| Bonus Related Orgs | 0 | BonusRelatedOrgs |
| Other Compensation Filing Org | 270 | OtherCompensationFilingOrg |
| Other Compensation Related Orgs | 0 | OtherCompensationRelatedOrgs |
| Deferred Comp Filing Org | 7098 | DeferredCompFilingOrg |
| Deferred Comp Related Orgs | 0 | DeferredCompRelatedOrgs |
| Nontaxable Benefits Filing Org | 15212 | NontaxableBenefitsFilingOrg |
| Nontaxable Benefits Related Orgs | 0 | NontaxableBenefitsRelatedOrgs |
| Total Compensation Filing Org | 295772 | TotalCompensationFilingOrg |
| Total Compensation Related Orgs | 0 | TotalCompensationRelatedOrgs |
| Comp Report Prior990 Filing Org | 0 | CompReportPrior990FilingOrg |
| Comp Report Prior990 Related Orgs | 0 | CompReportPrior990RelatedOrgs |
Schedule K IRS990ScheduleK
Form990 Schedule K Part I Form990ScheduleKPartI
Issuer Name IssuerName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | WISCONSIN HEALTH & EDUCATIONAL FACILITIES AUTHORITY | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Issuer EIN | 391337855 | IssuerEIN |
| Date Issued | 2011-08-18 | DateIssued |
| Issue Price | 14000000 | IssuePrice |
| Description Of Purpose | FACILITY AND SERVICE EXPANSION | DescriptionOfPurpose |
| Defeased | 0 | Defeased |
| On Behalf Of Issuer | 0 | OnBehalfOfIssuer |
| Pool Financing | 0 | PoolFinancing |
Form990 Schedule K Part II Form990ScheduleKPartII
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Proceeds | 14000000 | TotalProceeds |
| Issuance Costs From Proceeds | 76135 | IssuanceCostsFromProceeds |
| Amount Unspent | 13923865 | AmountUnspent |
| Year Of Subst Completion | 2012 | YearOfSubstCompletion |
| Current Refunding | 0 | CurrentRefunding |
| Advance Refunding | 0 | AdvanceRefunding |
| Final Allocation Made | 0 | FinalAllocationMade |
| Adequate Books And Recds Maintaind | 1 | AdequateBooksAndRecdsMaintaind |
Form990 Schedule K Part III Form990ScheduleKPartIII
| Field | Value | IRS element (for citing) |
|---|---|---|
| Owning Bond Financed Property | 0 | OwningBondFinancedProperty |
| Any Lease Arrangements | 0 | AnyLeaseArrangements |
| Mngment Cntrct Bond Financd Prprty | 0 | MngmentCntrctBondFinancdPrprty |
| Any Research Agreements | 0 | AnyResearchAgreements |
| Bond Counsel Routinely Engaged | 1 | BondCounselRoutinelyEngaged |
| Prcntge Prvt Business Use By Others | 0.00000 | PrcntgePrvtBusinessUseByOthers |
| Percentage Of Prvt Business Re UBI | 0.00000 | PercentageOfPrvtBusinessReUBI |
| Total Private Business Use | 0.00000 | TotalPrivateBusinessUse |
| Post Issuance Compliance Procdrs | 1 | PostIssuanceComplianceProcdrs |
Form990 Schedule K Part IV Form990ScheduleKPartIV
| Field | Value | IRS element (for citing) |
|---|---|---|
| Form8038 T Filed | 0 | Form8038TFiled |
| Variable Rate Issue | 0 | VariableRateIssue |
| Hedge Identified In Books And Recds | 0 | HedgeIdentifiedInBooksAndRecds |
| Gross Proceeds Invested In GIC | 0 | GrossProceedsInvestedInGIC |
| Gross Proceeds Invested | 0 | GrossProceedsInvested |
| Exception To Rebate | 0 | ExceptionToRebate |
Schedule O IRS990ScheduleO
General Explanation GeneralExplanation (11 entries)
| IdentifierIdentifier | Return ReferenceReturnReference | ExplanationExplanation |
|---|---|---|
| NEW PROGRAM SERVICES | FORM 990, PART III, LINE 2 | SWING BED CERTIFICATION EFFECTIVE 12/02/10. |
| FORM 990, PART VI, SECTION A, LINE 4 | BELLIN HOSPITAL AND OCONTO MEMORIAL HOSPITAL CITIZEN'S FOUNDATION, INC. ("OCONTO FOUNDATION") JOINTLY DEVELOPED A NONSTOCK, NONPROFIT CORPORATION TO OPERATE A CRITICAL ACCESS HOSPITAL IN OCONTO, WISCONSIN. PRIOR TO JUNE 30, 2011, BELLIN HOSPITAL HAD A 50% MEMBERSHIP INTEREST IN OCONTO HOSPITAL AND RECORDED ITS INVESTMENT UNDER THE EQUITY METHOD. DURING 2011, THE ORGANIZATION'S BOARD OF DIRECTORS APPROVED A PROJECT TO EXPAND THE ORGANIZATION. IN ORDER TO OBTAIN FINANCING FOR THE PROJECT, BELLIN HOSPITAL AGREED TO GUARANTEE THE ORGANIZATION'S NEW DEBT. AS CONSIDERATION FOR THIS GUARANTEE, EFFECTIVE JULY 1, 2011, BELLIN HOSPITAL ACQUIRED AN ADDITIONAL 25% MEMBERSHIP INTEREST IN THE ORGANIZATION. NO CASH CONSIDERATION WAS PAID BY BELLIN HOSPITAL RELATED TO THIS ACQUISITION. AS BELLIN HOSPITAL GAINED A CONTROLLING INTEREST IN THE ORGANIZATION, THIS TRANSACTION WAS ACCOUNTED FOR USING THE ACQUISITION METHOD OF ACCOUNTING AND, ACCORDINGLY, THE ACCOMPANYING CONSOLIDATED STATEMENTS OF OPERATIONS AND CHANGES IN NET ASSETS INCLUDE THE AMOUNTS FOR THE ORGANIZATION FROM THE DATE CONTROL WAS OBTAINED. UNDER THE ACQUISITION METHOD OF ACCOUNTING, THE ASSETS ACQUIRED, LIABILITIES ASSUMED, AND NONCONTROLLING INTEREST WERE MEASURED AT FAIR VALUE BASED ON AN INDEPENDENT APPRAISAL. AS THE FAIR VALUE OF THE ASSETS ACQUIRED EXCEEDED THE FAIR VALUE OF THE LIABILITIES ASSUMED AND THE NONCONTROLLING INTEREST, THE TRANSACTION RESULTED IN AN INHERENT CONTRIBUTION OF $1,513,000. | |
| 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 REQUEST 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. | |
| CHANGES IN NET ASSETS OR FUND BALANCES: | FORM 990, PART XI, LINE 5: | FIXED ASSET VALUATION ADJUSTMENT 1,513,538. TOTAL TO FORM 990, PART XI, LINE 5: 1,513,538. |
| 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. |
Schedule R IRS990ScheduleR
Form990 Schedule R Part II Form990ScheduleRPartII (8 entries)
| Address Line1AddressUS/AddressLine1 | CityAddressUS/City | StateAddressUS/State | ZIP CodeAddressUS/ZIPCode | EINEIN | Primary ActivitiesPrimaryActivities | Legal Domicile StateLegalDomicileState | Exempt Code SectionExemptCodeSection | Public Charity StatusPublicCharityStatus | Direct Controlling Entity NADirectControllingEntityNA | Controlled OrgControlledOrg | Business Name Line1DirectControllingEntityName/BusinessNameLine1 |
|---|---|---|---|---|---|---|---|---|---|---|---|
| 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 | 0 | BELLIN HEALTH SYSTEMS INC | |
| BELLIN COLLEGE INC | |||||||||||
| 3201 EATON ROAD | GREEN BAY | WI | 54311 | 391620530 | NURSING COLLEGE | WI | 501(C)(3) | LINE 2 | 0 | BELLIN HEALTH SYSTEMS INC | |
| THE BELLIN HEALTH FOUNDATION INC | |||||||||||
| PO BOX 23400 | GREEN BAY | WI | 54305 | 391809171 | FOUNDATION | WI | 501(C)(3) | LINE 7 | 0 | BELLIN HEALTH SYSTEMS INC | |
| BELLIN PSYCHIATRIC CENTER INC | |||||||||||
| PO BOX 23725 | GREEN BAY | WI | 54305 | 391657627 | PPSYCHIATRIC HOSPITAL | WI | 501(C)(3) | LINE 3 | 0 | BELLIN HEALTH SYSTEMS INC | |
| BELLIN MEMORIAL HOSPITAL INC | |||||||||||
| PO BOX 23400 | GREEN BAY | WI | 54305 | 390884478 | ACUTE CARE HOSPITAL | WI | 501(C)(3) | LINE 3 | 0 | BELLIN HEALTH SYSTEMS INC | |
| OCONTO HOSPITAL & MEDICAL CENTER INC | |||||||||||
| PO BOX 357 | OCONTO | WI | 54153 | 061745397 | HOSPITAL | WI | 501(C)(3) | LINE 3 | 0 | BELLIN MEMORIAL HOSPITAL INC | |
| 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 | |
Form990 Schedule R Part III Form990ScheduleRPartIII (2 entries)
| Address Line1AddressUS/AddressLine1 | CityAddressUS/City | StateAddressUS/State | ZIP CodeAddressUS/ZIPCode | EINEIN | Primary ActivityPrimaryActivity | Legal Domicile StateLegalDomicileState | Business Name Line1DirectControllingEntityName/BusinessNameLine1 | Predominant Income TypePredominantIncomeType | Share Of Total IncomeShareOfTotalIncome | Share Of EOY AssetsShareOfEOYAssets | Disproportionate AllocationsDisproportionateAllocations | General Or Managing PartnerGeneralOrManagingPartner | Percentage OwnershipPercentageOwnership |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| BELLIN ORTHOPEDIC SURGERY CENTER LLC | |||||||||||||
| 2223 LIME KILN RD | GREEN BAY | WI | 54311 | 264677834 | AMBULATORY ORTHOPEDIC SURGERY | WI | BELLIN MEMORIAL HOSPITAL INC | RELATED | -671481 | 180835 | 0 | 0 | 0.55000 |
| CT IMAGING LLC | |||||||||||||
| PO BOX 33164 | GREEN BAY | WI | 54303 | 810601297 | MEDICAL SCANNING | WI | BELLIN MEMORIAL HOSPITAL INC | RELATED | -59867 | 0 | 0 | 0.70000 | |
Form990 Schedule R Part IV Form990ScheduleRPartIV (3 entries)
| Address Line1AddressUS/AddressLine1 | CityAddressUS/City | StateAddressUS/State | ZIP CodeAddressUS/ZIPCode | EINEIN | Primary ActivityPrimaryActivity | Legal Domicile StateLegalDomicileState | Business Name Line1DirectControllingEntityName/BusinessNameLine1 | Type Of EntityTypeOfEntity | Share Of Total IncomeShareOfTotalIncome | Share Of EOY AssetsShareOfEOYAssets | Percentage OwnershipPercentageOwnership |
|---|---|---|---|---|---|---|---|---|---|---|---|
| BEL-REGIONAL HOME MEDICAL INC | |||||||||||
| 617 S ROOSEVELT | GREEN BAY | WI | 54301 | 391504766 | DURABLE MEDICAL EQUIPMENT, RETAIL PHARMACY, FITNESS | WI | LAKE MICHIGAN HEALTH SERVICES INC | C | -1591347 | 4538095 | 1.00000 |
| BELLIN INVESTMENTS INC | |||||||||||
| PO BOX 23400 | GREEN BAY | WI | 54305 | 391564939 | OTHER | WI | LAKE MICHIGAN HEALTH SERVICES INC | C | -2185 | 8692 | 1.00000 |
| UNITED PROVIDERS INC | |||||||||||
| PO BOX 23400 | GREEN BAY | WI | 54305 | 391907541 | OTHER | WI | BELLIN INVESTMENTS INC | C | -50 | 4066 | 1.00000 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Receipt Of Int Ann Rents Royalties | 0 | ReceiptOfIntAnnRentsRoyalties |
| Gift Grant Or Cap Contr To Other Org | 0 | GiftGrantOrCapContrToOtherOrg |
| Gift Grant Or Cap Contr Fr Other Org | 0 | GiftGrantOrCapContrFrOtherOrg |
| Loans Or Guarantees To Other Org | 0 | LoansOrGuaranteesToOtherOrg |
| Loans Or Guarantees From Other Org | 1 | LoansOrGuaranteesFromOtherOrg |
| Sale Of Assets To Other Org | 0 | SaleOfAssetsToOtherOrg |
| Purchase Of Assets From Other Org | 0 | PurchaseOfAssetsFromOtherOrg |
| Exchange Of Assets | 0 | ExchangeOfAssets |
| Rental Of Facilities To Other Orgs | 1 | RentalOfFacilitiesToOtherOrgs |
| Rental Of Facilities Fr Other Orgs | 0 | RentalOfFacilitiesFrOtherOrgs |
| Perform Of Services For Other Orgs | 0 | PerformOfServicesForOtherOrgs |
| Perform Of Services By Other Orgs | 0 | PerformOfServicesByOtherOrgs |
| Sharing Of Facilities | 0 | SharingOfFacilities |
| Sharing Of Paid Employees | 1 | SharingOfPaidEmployees |
| Reimbursement Paid To Other Org | 1 | ReimbursementPaidToOtherOrg |
| Reimbursement Paid By Other Org | 0 | ReimbursementPaidByOtherOrg |
| Other Transfer To Other Org | 0 | OtherTransferToOtherOrg |
| Other Transfer From Other Org | 0 | OtherTransferFromOtherOrg |
Transactions Related Orgs Table TransactionsRelatedOrgsTable (4 entries)
| Transaction TypeTransactionType | Amount InvolvedAmountInvolved | Method Of Amt DeterminationMethodOfAmtDetermination |
|---|---|---|
| BELLIN MEMORIAL HOSPITAL INC | ||
| E | 14000000 | FMV |
| BELLIN MEMORIAL HOSPITAL INC | ||
| N | 370265 | FMV |
| BELLIN MEMORIAL HOSPITAL INC | ||
| O | 1409735 | FMV |
| BEL-REGIONAL HOME MEDICAL INC | ||
| J | 123840 | FMV |
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