2011-08-15T12:40:43-05:00 2010-09-30 WIPFLI LLP PO BOX 12237 GREEN BAY WI 543072237 990 2009-10-01 061745397 Oconto Hospital and Medical Center OCON 9208351100 PO BOX 357 OCONTO WI 54153 CHRISTINE WOLESKE 9208351100 2011-08-15 1 9206620016 2011-08-15 2009 2016-02-24 21:20:13Z CHRISTINE WOLESKE PO BOX 357 OCONTO WI 54153 3732656 0 X www.ocontohospital.org X 2005 WI OCONTO HOSPITAL & MEDICAL CENTER, INC. IS YOUR HOME TOWN HOSPITAL, CREATED TO MAKE OUTSTANDING HEALTHCARE CONVENIENT. BACKED BY THE RESOURCES OF BELLIN HEALTH, OCONTO HOSPITAL & MEDICAL CENTER, INC. OFFERS OUTSTANDING HOSPITAL-BASED, EMERGENCY AND PRIMARY CARE SERVICES. OCONTO HOSPITAL & MEDICAL CENTER, INC. OFFERS THE CARE YOU NEED WHERE YOU WANT IT. 7 6 39 0 0 0 1000 38655 3609628 3573104 1681 897 -4680 -4680 3607629 3607976 0 0 2324646 2344597 0 0 2028332 1846620 4352978 4191217 -745349 -583241 7032961 6933464 4439125 4922869 2593836 2010595 THE MISSION OF OCONTO HOSPITAL & MEDICAL CENTER 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. 0 0 3388921 3572738 AS A KEY REGIONAL ASSET, OCONTO HOSPITAL & MEDICAL CENTER, INC. IS A NOT-FOR-PROFIT HEALTHCARE PROVIDER. THE HOSPITAL PROVIDES ACUTE HOSPITAL, EMERGENCY AND URGENT CARE TO RESIDENTS OF OCONTO WISCONSIN AND THE SURROuNDING COMMUNITIES. DURING THE PERIOD OF OCTOBER 1, 2009 TO SEPTEMBER 30, 2010, 37 INPATIENT DAYS WERE PROVIDED. THE NUMBER OF OUTPATIENTS REGISTERED DURING THE SAME 12 MONTH PERIOD WAS 6,691. 3388921 1 1 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 1 39 1 0 0 0 0 0 0 0 0 0 7 6 0 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 CHRISTINE WOLESKE 1.00 X X 0 0 0 GEORGE KERWIN 1.00 X 0 0 0 JAMES DIETSCHE 1.00 X 0 0 0 ROBERT BIVINS MD 36.00 X 270437 0 25696 MICHAEL DIECK 1.00 X X 0 0 0 DAVID HONISH 1.00 X 0 0 0 RODNEY R JOHNSON 1.00 X X 0 0 0 LAURA CORMIER 45.00 X 101216 0 15571 371653 0 41267 2 0 1 0 Bellin Memorial Hpospital Inc PO Box 23400 Green Bay WI 54305 Management Services 265167 1 38655 38655 NET PATIENT REVENUE 621300 3572738 3572738 MISCELLANEOUS 900099 366 366 3573104 897 897 120000 124680 -4680 -4680 -4680 3607976 3572738 0 -3417 412920 296133 116787 1615958 1565654 50304 64857 64446 411 122552 117869 4683 128310 117160 11150 1064 1064 530088 305236 224852 7910 7910 406571 369874 36697 31842 1717 30125 66057 63963 2094 11361 3020 8341 3353 3353 218671 218671 191611 186147 5464 23637 8066 15571 BAD DEBT EXPENSE 276648 276648 AMORTIZATION 52932 52932 MISCELLANEOUS 14439 3056 11383 DUES, LICENSES AND SUBS 10436 9932 504 4191217 3388921 802296 0 329606 273626 591436 507990 7526527 1809679 5583987 5716848 527932 435000 7032961 6933464 204152 216101 4234973 4706768 4439125 4922869 X 2593836 2010595 2593836 2010595 7032961 6933464 X 0 0 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 83000 83000 5068593 898294 4170299 15036 5461 9575 1895286 905924 989362 464612 464612 5716848 DUE FROM AFFILIATES 435000 435000 DUE TO AFFILIATE 4706768 4706768 3607976 4191217 -583241 0 -583241 3732656 0 3732656 -124680 -124680 3607976 4315897 124680 124680 4191217 0 4191217 Part X: Description of Uncertain Tax Positions Under FIN 48: This organization is not currently audited and therefore does not have a FIN 48 disclosure. Part XII, Line 4b - Other Adjustments: RENTAL DEPRECIATION: -124680. Part XIII, Line 2d - Other Adjustments: RENTAL DEPRECIATION: 124680. 1 1 1 X 1 X 225.000000000000 1 1 0 0 155121 155121 0.03960 155121 155121 0.03960 515 515 0.00010 978 978 0.00020 1493 1493 0.00030 156614 156614 0.03990 1 237138 755840 835556 -79716 X 1 0 Oconto Hospital & Medical Center Inc

820 Arbutus Ave Oconto WI 54153

X X X PRIMARY CARE CLINIC Part I, Line 7: AMOUNTS ARE CALCULATED BASED ON THE COST TO CHARGE RATIOS AND WORKSHEET 2 PROVIDED BY THE IRS. Part I, Line 7f: BAD DEBT EXPENSE OF $276,648 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 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. OCONTO HOSPITAL & MEDICAL CENTER 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: OCONTO HOSPITAL & MEDICAL CENTER, INC. 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: OCONTO HOSPITAL & MEDICAL CENTER 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: OCONTO HOSPITAL & MEDICAL CENTER, INC. REPORTED NO COMMUNITY BUILDING ACTIVITIES REPORTED IN PART II. Part VI, Line 6: OCONTO HOSPITAL AND MEDICAL CENTER, INC. 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 OCONTO HOSPITAL AND MEDICAL CENTER, INC. IS A SOLE COMMUNITY HOSPITAL WITH AN EMERGENCY ROOM AVAILABLE TO ALL. X 0 0 0 0 0 0 0 0 0 ROBERT BIVINS MD 258032 0 12135 0 270 0 9343 0 16353 0 296133 0 0 0 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 OCONTO HOSPITAL AND MEDICAL CENTER, INC. 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 (VP of Operations) IS SET BY THE EXECUTIVE COMMITTEE OF THE BOARD WITHOUT CONFLICT OF INTEREST AND IS SUPPORTED BY MARKET DATA FROM COMPENSATION SURVEYS. The VP of Operations' compensation was determined by Member, Bellin Health Sytems AND IS DOCUMENTED IN HUMAN RESOURCES. 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. Oconto Memorial Hospital Citizens Foundation 405 1st Stret Oconto WI 54153 391900586 Supporting Organization WI 501(c) 11-I N/A 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0