2012-08-15T04:53:55-05:00 2011-09-30 WIPFLI LLP PO BOX 12237 GREEN BAY WI 543072237 990 2010-10-01 061745397 OCONTO HOSPITAL & MEDICAL CENTER INC OCON 9208351100 PO BOX 357 OCONTO WI 54153 CHRISTINE WOLESKE 9208351100 2012-08-14 1 9206620016 2012-08-14 2010 2016-02-24 21:20:13Z CHRISTINE WOLESKE PO BOX 357 OCONTO WI 54153 4243964 0 X WWW.OCONTOHOSPITAL.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 7 45 7 0 0 38655 11692 3573104 4106964 897 1468 -4680 -840 3607976 4119284 0 0 0 0 2344597 2349556 0 0 0 1846620 1961943 4191217 4311499 -583241 -192215 6933464 23119453 4922869 19787535 2010595 3331918 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 3565241 4106758 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. 3565241 1 1 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 45 1 0 0 0 0 0 0 0 0 0 0 X 8 7 0 0 1 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 CHRISTINE WOLESKE 1.00 X X 0 0 0 GEORGE KERWIN 1.00 X 0 0 0 SARA ARNDT 1.00 X 0 0 0 DAVID HONISH 1.00 X X 0 0 0 RODNEY R JOHNSON 1.00 X X 0 0 0 LAURA CORMIER 45.00 X 95841 0 15571 CHARLES HEYKA MD 1.00 X 0 0 0 JOHN HONISH 1.00 X 0 0 0 ROBERT BIVINS MD 36.00 X 273462 0 22310 369303 0 37881 1 0 1 0 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 2 9712 1980 11692 NET PATIENT REVENUE 621300 4106758 4106758 VENDING MACHINE REVENU 900099 206 206 4106964 1468 1468 123840 124680 -840 -840 -840 4119284 4106758 0 834 407183 295772 111411 1599609 1555346 44263 73137 71642 1495 142578 140055 2523 127049 116873 10176 1311 1311 653323 415662 237661 9013 9013 358223 329984 28239 42851 12542 30309 94541 89302 5239 9023 4830 4193 4031 4031 236045 236045 177234 174630 2604 20502 10731 9771 BAD DEBT EXPENSE 335034 335034 DUES, LICENSES AND SUBS 14994 12838 2156 MISCELLANEOUS 5818 5818 4311499 3565241 746258 0 273626 320518 13929740 507990 825548 9875706 2111592 5716848 7764114 435000 279533 6933464 23119453 216101 227166 14000000 4706768 5560369 4922869 19787535 X 2010595 3331918 2010595 3331918 6933464 23119453 X -192215 1513538 X X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 661050 661050 6288814 1073284 5215530 17579 7003 10576 2174564 1031305 1143259 733699 733699 7764114 DUE TO AFFILIATE 5560369 5560369 4119284 4311499 -192215 1513538 1513538 1321323 4243964 0 4243964 -124680 -124680 4119284 4436179 124680 124680 4311499 0 4311499 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. 1 1 1 X 1 X 1 1 0 0 144798 144798 0.03640 1046940 856610 190330 0.04790 1191738 856610 335128 0.08430 1191738 856610 335128 0.08430 1 286797 757861 819412 -61551 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 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. X 0 0 0 0 0 0 0 0 0 ROBERT BIVINS MD 262838 0 10354 0 270 0 7098 0 15212 0 295772 0 0 0 WISCONSIN HEALTH & EDUCATIONAL FACILITIES AUTHORITY 391337855 2011-08-18 14000000 FACILITY AND SERVICE EXPANSION 0 0 0 14000000 76135 13923865 2012 0 0 0 1 0 0 0 0 1 0.00000 0.00000 0.00000 1 0 0 0 0 0 0 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. 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 OCONTO HOSPITAL & MEDICAL CENTER INC PO BOX 357 OCONTO WI 54153 061745397 HOSPITAL WI 501(C)(3) LINE 3 BELLIN MEMORIAL HOSPITAL 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 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 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 0 0 0 0 1 0 0 0 1 0 0 0 0 1 1 0 0 0 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