2024-05-02T16:08:14-05:00 2023-06-30 450250958 EIDE BAILLY LLP 18081 BURT ST STE 200 OMAHA NE 680224722 990 2022-07-01 470393176 ANTELOPE MEMORIAL HOSPITAL ANTE 4028874151 PO BOX 229 NELIGH NE 68756 DIANE BRUGGER CEO 4028874151 2024-04-23 1 DIANE BRUGGER 999009999 1 MEGAN L KOZIOL CPA P01544037 4023302660 2024-04-23 2 AAL1 IAL1 2022 2023-04-26 12:10:37Z DIANE BRUGGER PO BOX 229 NELIGH NE 68756 22542155 0 X WWW.AMHNE.ORG X 1974 NE TO OPERATE A HOSPITAL AND AFFILIATED INSTITUTIONS IN THE COUNTY OF ANTELOPE, NEBRASKA. 11 11 201 19 0 0 854561 1370691 20380285 19779516 117215 336281 42205 58676 21394266 21545164 6460 4360 0 0 11245803 11193715 0 0 0 8136874 8367692 19389137 19565767 2005129 1979397 28723751 27084366 5978881 2354257 22744870 24730109 MAKING A DIFFERENCE IN PEOPLE'S LIVES THROUGH EXCELLENT PATIENT CARE. 0 0 16836910 4360 19779516 ANTELOPE MEMORIAL HOSPITAL IS AN 18-BED CRITICAL ACCESS HOSPITAL IN NELIGH, NE. IT PROVIDES QUALITY HEALTH CARE REGARDLESS OF RACE, CREED, COLOR, NATIONAL ORIGIN, AGE, GENDER, HANDICAP OR ABILITY TO PAY. THE HOSPITAL IS A FAMILY-CENTERED, COMMUNITY-ORIENTED HOSPITAL, OFFERING COMPREHENSIVE MEDICAL SERVICES, INCLUDING A FULL-TIME EMERGENCY ROOM. 16836910 1 1 0 1 0 0 0 0 0 0 1 0 0 0 0 1 1 0 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 0 0 0 0 1 29 0 1 201 1 0 0 0 0 0 0 0 0 0 0 0 0 X 11 11 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 0 0 X MARTHA NELSON 4028876282 PO BOX 229 NELIGH NE 68756 JOHN MLNARIK PRESIDENT 4.00 X X 0 0 0 JAMES BLACKBURN VICE PRESIDENT 4.00 X X 0 0 0 JAMES MEURET SECRETARY/TREASURER 4.00 X X 0 0 0 JON SCHILLING MEMBER 2.00 X 0 0 0 GORDON SHRADER MEMBER 2.00 X 0 0 0 MAURY SOPER MEMBER 2.00 X 0 0 0 SAMANTHA STOLTZ MEMBER 2.00 X 0 0 0 DAVID SULLIVAN MEMBER 2.00 X 0 0 0 CHRISTOPHER TWIBELL MEMBER 2.00 X 0 0 0 DR RUSSELL VETICK MEMBER 2.00 X 0 0 0 TOM ZWINGMAN MEMBER 2.00 X 0 0 0 DIANE BRUGGER ADMINISTRATOR/CEO 40.00 X 272287 0 24599 MARTHA NELSON CFO 32.00 X 174229 0 32900 ROGER RUDLOFF MD PHYSICIAN 40.00 X 412802 0 32879 TROY DAWSON MD PHYSICIAN 40.00 X 370084 0 41796 KELLI OSBORN MD PHYSICIAN 40.00 X 287860 0 41146 PATRICIA GOOD APRN APRN 40.00 X 149246 0 7558 JOSHUA THOENDEL MD PHYSICIAN 40.00 X 338555 0 34103 2005063 0 214981 12 0 1 0 PSYCHIATRIC MEDICAL SERVICES 8 CADILLAC DRIVE SUITE 230 BRENTWOOD TN 37027 PSYCHIATRIC SERVICES 496405 PINNACLE ANESTHESIA SERVICES 608 EAST 4TH STREET NELIGH NE 68756 NURSING SERVICES 425000 OVERLAND REHAB SERVICES 405 JAMES STREET VERDIGRE NE 68783 PHYSICAL THERAPY SERVICES 350195 3 1230002 140689 1370691 MEDICARE/MEDICAID PAYMENTS 621400 11568321 11568321 NET PATIENT SERVICE REVENUE 621400 7706004 7706004 340B REVENUE 611400 306850 306850 AMBULANCE 621910 7200 7200 191141 191141 19779516 285266 285266 1002551 45455 994582 2409 7969 43046 51015 51015 CAFETERIA 900099 58676 58676 58676 21545164 19779516 0 394957 X 4360 4360 504015 504015 8519491 7424819 1094672 241357 202555 38802 1335570 1130135 205435 593282 511129 82153 2156 287 1869 48619 48619 2540716 2371531 169185 135799 5954 129845 994801 891855 102946 731271 591078 140193 282069 270552 11517 48709 46797 1912 8680 8294 386 1292911 1235425 57486 279309 266890 12419 MEDICAL SUPPLIES 1802627 1802627 DUES & SUBSCRIPTIONS 97944 56344 41600 MISCELLANEOUS 87696 11079 76617 LICENSES 14385 5199 9186 19565767 16836910 2728857 0 198137 222063 12829376 10840970 5525 5100 968626 1120009 113786 97622 438698 419058 194449 180707 31068123 17451436 12421382 13616687 552722 0 1001050 582150 28723751 27084366 2251700 2049257 594270 305000 3132911 0 5978881 2354257 X 22677090 24703304 67780 26805 22744870 24730109 28723751 27084366 1979397 5842 0 X X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 1995 1995 0 PART II-B, LINE 1: PORTION OF THE DUES PAID TO THE NEBRASKA HOSPITAL ASSOCIATION AND THE AMERICAN HOSPITAL ASSOCIATION ARE ALLOCABLE TO LOBBYING ACTIVITIES. 124229 124229 9813917 4997332 4816585 16785771 10432636 6353135 4344206 2021468 2322738 13616687 X 21551006 5842 5842 21545164 0 21545164 19565767 0 19565767 0 19565767 PART X, LINE 2: THE HOSPITAL ACCOUNTS FOR UNCERTAINTIES IN ACCOUNTING FOR INCOME TAX ASSETS AND LIABILITIES USING GUIDANCE INCLUDED IN FINANCIAL ACCOUNTING STANDARDS BOARD (FASB) ACCOUNTING STANDARDS CODIFICATION (ASC) 740, INCOME TAXES. THE HOSPITAL RECOGNIZES THE EFFECT OF INCOME TAX POSITIONS ONLY IF THOSE POSITIONS ARE MORE LIKELY THAN NOT OF BEING SUSTAINED. AT JUNE 30, 2023 AND 2022, THE HOSPITAL HAD NO UNCERTAIN TAX POSITIONS ACCRUED. 1 1 X 1 X 125.000000000000 0 1 1 0 1 1 13342 0 13342 0.00070 1858091 1396519 461572 0.02360 1871433 1396519 474914 0.02430 42765 3542 39223 0.00200 2927853 2227096 700757 0.03580 4360 0 4360 0.00020 2974978 2230638 744340 0.03800 4846411 3627157 1219254 0.06230 400 0 400 0.00000 13500 0 13500 0.00070 13900 13900 0.00070 1 666646 0 9733019 9771378 -38359 X 1 0 1 1 ANTELOPE MEMORIAL HOSPITAL 102 WEST 9TH STREET NELIGH NE 68756 WWW.AMHNE.ORG 020001 X X X ANTELOPE MEMORIAL HOSPITAL 1 0 0 1 X X X X X X X X X 21 1 1 1 1 X WWW.AMHNE.ORG X 1 21 1 WWW.AMHNE.ORG 0 1 X 125.000000000000 X X X 1 1 X X X 1 X WWW.AMHNE.ORG/GETPAGE.PHP?NAME=VISITORINFO&SUB=FOR%20PATIENTS X WWW.AMHNE.ORG/GETPAGE.PHP?NAME=VISITORINFO&SUB=FOR%20PATIENTS X WWW.AMHNE.ORG/GETPAGE.PHP?NAME=VISITORINFO&SUB=FOR%20PATIENTS X X X X X X 1 X 0 X X X X 1 X 0 0 ANTELOPE MEMORIAL HOSPITAL PART V, SECTION B, LINE 5: ANTELOPE MEMORIAL HOSPITAL RECEIVED INPUT FROM COMMUNITY MEMBERS THROUGHOUT ANTELOPE COUNTY THROUGH THE USE OF SURVEYS POSTED ON OUR WEBSITE AND SENT THROUGH SOCIAL MEDIA. ANTELOPE MEMORIAL HOSPITAL PART V, SECTION B, LINE 6A: ANTELOPE MEMORIAL HOSPITAL, NELIGH, NE (ANTELOPE COUNTY)AVERA CREIGHTON HOSPITAL, CREIGHTON, NE (KNOX COUNTY)AVERA SAINT ANTHONY'S HOSPITAL, O'NEILL, NE (HOLT COUNTY)OSMOND GENERAL HOSPITAL, OSMOND, NE (PIERCE COUNTY)CHI PLAINVIEW HOSPITAL, PLAINVIEW, NE (PIERCE COUNTY)NIOBRARA VALLEY HOSPITAL, LYNCH, NE (BOYD COUNTY)WEST HOLT MEMORIAL HOSPITAL, ATKINSON, NE (HOLT COUNTY)BROWN COUNTY HOSPITAL, AINSWORTH, NE (BROWN COUNTY) ANTELOPE MEMORIAL HOSPITAL PART V, SECTION B, LINE 6B: NORTH CENTRAL DISTRICT HEALTH DEPARTMENT (NCDHD)THE EVERGREEN ASSISTED LIVING FACILITYGOOD SAMARITAN SOCIETY - ATKINSONREGION 4 BEHAVIORAL HEALTH SYSTEMCENTRAL NEBRASKA COMMUNITY ACTION PARTNERSHIPNORTHSTAR SERVICES BLOOMFIELDNCDHD BOARD OF HEALTHCENTRAL NEBRASKA ECONOMIC DEVELOPMENTHOLT COUNTY ECONOMIC DEVELOPMENTO'NEILL PUBLIC SCHOOL BOARD ANTELOPE MEMORIAL HOSPITAL PART V, SECTION B, LINE 11: ANTELOPE MEMORIAL HOSPITAL PLANS TO ADDRESS BOTH PRIORITY AREAS IDENTIFIED BY THE COMMUNITY WORKGROUP, WHICH SHOULD ADEQUATELY COVER THE MAJOR HEALTH PROBLEMS AND HIGH-RISK BEHAVIORS IN ITS SERVICE AREA. THE TWO FOCUS AREAS SPECIFIC TO ANTELOPE MEMORIAL HOSPITAL ARE: - HEART HEALTH - MENTAL HEALTHGOALS DEVELOPED BY ANTELOPE MEMORIAL HOSPITAL TO ADDRESS THE FOCUS AREAS:HEART HEALTH: - EFFECTIVELY PROMOTE ANTELOPE MEMORIAL HOSPITAL'S SERVICES AIMED AT PREVENTING, SCREENING AND MANAGING HEART DISEASE THROUGHOUT THE COMMUNITY SERVICE AREA. - COLLABORATE WITH LOCAL ENTITIES AND MEDIA OUTLETS TO EDUCATE THE PUBLIC ON HEART DISEASE RISK FACTORS AND REDUCTION. - INCORPORATE CHOLESTEROL TESTS INTO COMMUNITY SCREENING EVENTS. - ENSURE STAFF IS TRAINED ON THE MOST UP-TO-DATE STANDARDS FOR BLOOD PRESSURE MEASUREMENT. - COLLABORATE WITH LOCAL ENTITIES AND MEDIA OUTLETS TO EDUCATE THE PUBLIC ON SERVICES COVERED BY INSURANCE BENEFITS.MENTAL HEALTH: - INCREASE THE NUMBER OF MENTAL HEALTH SERVICES OFFERED AT ANTELOPE MEMORIAL HOSPITAL BY 1%. - ADD AN ON-SITE LICENSED MENTAL HEALTH PRACTITIONER FOR PATIENTS OF ALL AGES. - EFFECTIVELY RAISE MENTAL HEALTH AWARENESS TO YOUTH, ADULTS AND SENIORS AND EDUCATE THEM ON AVAILABLE MENTAL HEALTH SERVICES. - INCREASE ANTELOPE MEMORIAL HOSPITAL'S STAFF PARTICIPATION IN THE ANTELOPE COUNTY DOES CARE (ACDC) COALITION. - COLLABORATE WITH LOCAL ENTITIES AND MEDIA OUTLETS TO EDUCATE THE PUBLIC ON MENTAL HEALTH RISK FACTORS AND AVAILABLE SERVICES. THERE WERE NO NEEDS IDENTIFIED THAT ARE NOT BEING ADDRESSED.DURING FYE 6/30/23, AMH CONTINUED WITH ITS HEALTH FAIRS AND COMMUNITY SCREENINGS. STAFF EDUCATION WAS STARTED ON THE MOST UP-TO-DATE STANDARDS FOR BLOOD PRESSURE MEASUREMENT. WE WERE UNABLE TO ADD AN ONSITE LICENSED MENTAL HEALTH PRACTITIONER FOR PATIENTS OF ALL AGES DUE TO THE PROGRAM DIRECTOR LEAVING AND INABILITY TO FIND A REPLACEMENT IN A TIMELY MANNER. AMH CONTINUES TO ADVERTISE OUR CURRENT MENTAL HEALTH SERVICES VIA FACEBOOK AND LOCAL NEWSPAPERS MOST OF THESE ADVERTISEMENTS INCLUDE MENTAL HEALTH EDUCATION. STAFF AT AMH CONTINUE TO PARTICIPATE IN ACDC. 5 1 - AMH FAMILY PRACTICE 109 WEST 11TH STREET PO BOX 109 NELIGH NE 68756 FAMILY PRACTICE MEDICAL CLINIC 2 - AMH TILDEN CLINIC 200 S ANTELOPE STREET TILDEN NE 68781 FAMILY PRACTICE MEDICAL CLINIC 3 - AMH CLEARWATER CLINIC 308 NEVADA STREET CLEARWATER NE 68726 FAMILY PRACTICE MEDICAL CLINIC 4 - AMH ELGIN CLINIC 101 WEST CEDAR STREET ELGIN NE 68636 FAMILY PRACTICE MEDICAL CLINIC 5 - ORCHARD MEDICAL CLINIC 103 WASHINGTON STREET ORCHARD NE 68764 FAMILY PRACTICE MEDICAL CLINIC PART I, LINE 3C: NOT APPLICABLE: FEDERAL POVERTY GUIDELINES ARE USED TO DETERMINE ELIGIBILITY FOR PROVIDING FREE CARE TO LOW INCOME INDIVIDUALS. DISCOUNTED CARE IS NOT PROVIDED. PATIENTS ARE CATEGORIZED EITHER AS BEING ELIGIBLE FOR FREE CARE OR AS RESPONSIBLE FOR REGULAR PATIENT CHARGES. PART I, LINE 6A: THE COMMUNITY BENEFIT REPORT WAS NOT PREPARED BY A RELATED PARTY. PART I, LINE 7G: SUBSIDIZED HEALTH SERVICES INCLUDE THREE PHYSICIAN CLINICS IN NEIGHBORING COMMUNITIES. PART II, COMMUNITY BUILDING ACTIVITIES: COMMUNITY BUILDING ACTIVITIES DURING THE YEAR INCLUDED THE FOLLOWING:- MEMBERSHIP DUES AND ATTENDANCE AT MONTHLY CHAMBER OF COMMERCE MEETINGS TO PROMOTE LOCAL BUSINESS AND WORKING FOR THE BETTERMENT OF THE COMMUNITY AS A WHOLE. PART III, LINE 2: THE HOSPITAL DETERMINES THE TRANSACTION PRICE BASED ON STANDARD CHARGES FOR GOODS AND SERVICES PROVIDED, REDUCED BY CONTRACTUAL ADJUSTMENTS PROVIDED TO THIRD-PARTY PAYORS, DISCOUNTS PROVIDED TO UNINSURED PATIENTS IN ACCORDANCE WITH THE HOSPITAL'S POLICY, AND/OR IMPLICIT PRICE CONCESSIONS PROVIDED TO UNINSURED PATIENTS. THE HOSPITAL DETERMINES ITS ESTIMATES OF CONTRACTUAL ADJUSTMENTS AND DISCOUNTS BASED ON CONTRACTUAL AGREEMENTS, ITS DISCOUNT POLICIES AND HISTORICAL EXPERIENCE. THE HOSPITAL DETERMINES ITS ESTIMATE OF IMPLICIT PRICE CONCESSIONS BASED ON HISTORICAL COLLECTION EXPERIENCE WITH VARIOUS CLASSES OF PATIENTS. PART III, LINE 3: THE HOSPITAL MAINTAINS A FINANCIAL ASSISTANCE POLICY FOR PATIENTS WHO ARE FINANCIALLY UNABLE TO PAY FOR THE HEALTHCARE SERVICES THEY RECEIVE. IT IS THE POLICY OF THE HOSPITAL NOT TO PURSUE COLLECTION OF AMOUNTS DETERMINED TO QUALIFY AS PATIENT FINANCIAL ASSISTANCE UNDER THE POLICY. ACCORDINGLY, THE HOSPITAL DOES NOT REPORT THESE AMOUNTS IN PATIENT SERVICE REVENUE. THE HOSPITAL DETERMINES THE COSTS ASSOCIATED WITH PROVIDING CHARITY CARE BY AGGREGATING THE DIRECT AND INDIRECT COSTS, INCLUDING SALARIES, BENEFITS, SUPPLIES, AND OTHER OPERATING EXPENSES, BASED ON AN OVERALL COST TO CHARGE RATIO. PART III, LINE 4: THE HOSPITAL'S FINANCIAL STATEMENTS DO NOT CONTAIN A SPECIFIC FOOTNOTE DESCRIBING BAD DEBT. HOWEVER, PAGES 11, 14 AND 15 OF THE ATTACHED FINANCIAL STATEMENTS INCLUDE FOOTNOTES TITLED "PATIENT RECEIVABLES," "PATIENT SERVICE REVENUE AND "PATIENT FINANCIAL ASSISTANCE". PART III, LINE 8: "MEDICARE ALLOWABLE COSTS OF CARE" WAS CALCULATED FROM INFORMATION IN THE MEDICARE COST REPORT D, E, H & M WORKSHEETS, OR PS&R. IT DOES NOT INCLUDE ALL OF THE MEDICARE REVENUES AND COSTS. IF ALL OF THE MEDICARE REVENUES AND COSTS WERE INCLUDED, THERE WOULD BE A LARGER SHORTFALL SHOWN ON LINE 7. THIS REPRESENTS ACTUAL UNREIMBURSED COSTS INCURRED BY ANTELOPE MEMORIAL HOSPITAL IN PROVIDING SERVICES TO INDIVIDUALS ELIGIBLE FOR MEDICARE. THIS IS A BENEFIT TO THE COMMUNITY BECAUSE THE HOSPITAL APPLIES OTHER FINANCIAL RESOURCES TO COVER THE UNREIMBURSED COSTS OF CARING FOR MEDICARE PATIENTS. MEDICARE PATIENTS WOULD HAVE TO TRAVEL INCONVENIENT DISTANCES FOR CARE IF THE HOSPITAL DID NOT HAVE THE RESOURCES TO CONTINUE TO PROVIDE MEDICAL CARE TO THEM. PART III, LINE 9B: THE COLLECTION POLICY INCLUDES AN EXPLANATION OF ANTELOPE MEMORIAL HOSPITAL'S CHARITY CARE PROGRAM. THE PROGRAM IS CONSIDERED A "LAST RESORT FOR PATIENTS MAKING A GENUINE EFFORT TO PAY THEIR BILLS. ALL OTHER AVENUES FOR PAYMENT MUST BE EXHAUSTED (SUCH AS MEDICAID, DISABILITY, KID'S CONNECTION) BEFORE THIS PROGRAM APPLIES." REGULAR COLLECTION EFFORTS WILL BE FOLLOWED UNTIL A DETERMINATION IS MADE FROM A COMPLETED ASSISTANCE APPLICATION THAT A PATIENT QUALIFIES FOR FINANCIAL ASSISTANCE. PART VI, LINE 2: ANTELOPE MEMORIAL HOSPITAL PERFORMED THE FOLLOWING PROCEDURES TO ASSESS THE HEALTH NEEDS OF THE COMMUNITY IT SERVES: - COMMUNITY HEALTH NEEDS ASSESSMENT (CNHA) - PLANNING MEETING AND CNHA RESULTS PRESENTATION - COMMUNITY FOCUS GROUP MEETINGS - CONFERENCE CALLS WITH DHHS PERSONNEL FOR INPUT, GUIDANCE, AND FEEDBACK - STRATEGIC PLANNING SESSIONS - CHIP DOCUMENT DRAFTING, EDITING, REVISION AND COMPLETION - COORDINATION OF CHIP WORK GROUP MEETINGS PART VI, LINE 3: ANTELOPE MEMORIAL HOSPITAL INCLUDES ITS PAYMENT POLICY WITH ALL STATEMENTS SENT TO PATIENTS. THIS POLICY EXPLAINS THE HOSPITAL'S FINANCIAL ASSISTANCE POLICY AND GIVES INSTRUCTIONS FOR THE APPLICATION PROCESS. PART VI, LINE 4: ANTELOPE MEMORIAL HOSPITAL IS THE ONLY ACUTE CARE FACILITY SERVING THE ANTELOPE COUNTY AREA DUE TO THE CLOSURE OF TILDEN COMMUNITY HOSPITAL. ANTELOPE MEMORIAL HOSPITAL ALSO PROVIDES SERVICE TO THE FOLLOWING FIVE NEBRASKA COUNTIES: BOONE, HOLT, KNOX, MADISON AND PIERCE. PART VI, LINE 5: ANTELOPE MEMORIAL HOSPITAL PROMOTES THE HEALTH OF ITS COMMUNITY BY PROVIDING A COMMUNITY-BASED WELLNESS PROGRAM THAT ENCOURAGES INDIVIDUALS TO LIVE A HEALTHIER LIFESTYLE. AMH OFFERS A VARIETY OF EQUIPMENT AND GUIDANCE TO ASSIST COMMUNITY MEMBERS IN REACHING THEIR INDIVIDUAL WELLNESS GOALS, SUCH AS PREVENTING DISEASES AND CREATING A HEALTHIER COMMUNITY. AMH OFFERS ITS COMMUNITY DIABETES EDUCATION CLASSES, SMOKING CESSATION EDUCATION, AND OUTPATIENT GROUP THERAPY PROGRAMS DESIGNED FOR THOSE STRUGGLING WITH SYMPTOMS OF DEPRESSION AND ANXIETY.AMH ALSO COLLABORATES WITH NORTH CENTRAL DISTRICT HEALTH DEPARTMENT AND OTHER COMMUNITY PARTNERS TO FOCUS ON SUBSTANCE ABUSE PREVENTION, MOST RECENTLY PROVIDING DRUG RECOGNITION AND AWARENESS TRAINING. PART VI, LINE 6: ANTELOPE MEMORIAL HOSPITAL IS NOT PART OF AN AFFILIATED HEALTH CARE ORGANIZATION. FORM 990, PART VI, LINE 7: NEBRASKA DOES NOT REQUIRE THE FILING OF A COMMUNITY BENEFIT REPORT WITH THE STATE. A COMMUNITY BENEFIT REPORT IS FILED ANNUALLY WITH THE NEBRASKA HOSPITAL ASSOCIATION. ALSO, A MEDICARE COST REPORT IS FILED ANNUALLY WITH NEBRASKA. X X X 0 0 0 0 0 0 0 0 0 ROGER RUDLOFF MD PHYSICIAN 407098 0 5500 0 204 0 13890 0 18989 0 445681 0 0 0 TROY DAWSON MD PHYSICIAN 364380 0 5500 0 204 0 13890 0 27906 0 411880 0 0 0 JOSHUA THOENDEL MD PHYSICIAN 332851 0 5500 0 204 0 7051 0 27052 0 372658 0 0 0 KELLI OSBORN MD PHYSICIAN 282156 0 5500 0 204 0 13890 0 27256 0 329006 0 0 0 DIANE BRUGGER ADMINISTRATOR/CEO 245486 0 26597 0 204 0 12145 0 12454 0 296886 0 0 0 MARTHA NELSON CFO 154721 0 19323 0 185 0 6850 0 26050 0 207129 0 0 0 PATRICIA GOOD APRN APRN 149125 0 0 0 121 0 4612 0 2946 0 156804 0 0 0 A THE COUNTY OF ANTELOPE NEBRASKA 476006428 036654AH4 2015-10-15 2290000 REFUND PRIOR ISSUE (12/21/2010) 0 0 0 A 1985000 2290000 91220 2198780 1 0 1 1 A 0 0 0 0 0.00000 0.00000 0.00000 0 0 1 A 0 0 0 1 0 0 0 0 1 A 1 SCHEDULE K, PART IV, LINE 2C: DATE THE REBATE COMPUTATION WAS PERFORMED: 01/01/2018 SINCE THE BOND PROCEEDS HAVE BEEN SPENT AND THE DEBT SERVICE FUND WAS OPERATED ON A BONA FIDE BASIS, NO FURTHER REBATE CALCULATIONS ARE NECESSARY. FORM 990, PART VI, SECTION A, LINE 1A THE EXECUTIVE COMMITTEE, COMPRISED OF THE PRESIDENT, VICE PRESIDENT, SECRETARY AND TREASURER, SHALL HAVE THE POWER TO TRANSACT ALL REGULAR BUSINESS OF THE HOSPITAL. FORM 990, PART VI, SECTION B, LINE 11B THE FORM 990 IS PREPARED BY A CERTIFIED PUBLIC ACCOUNTANT AND DELIVERED TO THE CHIEF FINANCIAL OFFICER. THE CFO AND CEO REVIEW THE FORM 990 AND THE ADMINISTRATOR PRESENTS IT AT A MONTHLY BOARD MEETING, PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C ALL OFFICERS, DIRECTORS, COMMITTEE MEMBERS AND KEY EMPLOYEES SHALL REVIEW THE CONFLICT OF INTEREST POLICY AND COMPLETE A CONFLICT OF INTEREST QUESTIONNAIRE AND CERTIFICATION UPON INITIAL AFFILIATION WITH THE CORPORATION AND ON AN ANNUAL BASIS THEREAFTER. ANY POTENTIAL CONFLICTS SHOULD BE DICLOSED TO THE BOARD OF DIRECTORS AND MADE A MATTER OF RECORD WHENEVER IT ARISES, OR WHENEVER IT INVOLVES A MATTER OF BOARD ACTION. ANY PERSON HAVING A CONFLICT OF INTEREST OR POSSIBLE CONFLICT IN ANY MATTER SHOULD NOT VOTE OR USE HIS OR HER INFLUENCE ON THE MATTER. FORM 990, PART VI, SECTION B, LINE 15A SALARY COMPARISON DATA FROM THE NEBRASKA HOSPITAL ASSOCIATION IS USED TO COMPARE ADMINISTRATOR SALARY WITH THAT OF OTHER NEBRASKA CRITICAL ACCESS HOSPITALS. THE CHIEF EXECUTIVE OFFICER AND CHIEF FINANCIAL OFFICER SALARIES ARE DETERMINED USING THE NEBRASKA HOSPITAL ASSOCIATION SALARY SURVEYS AND ARE THEN SET BY THE BOARD OF DIRECTORS. THE BOARD MINUTES DOCUMENT THE DELIBERATIONS AND SALARY DECISIONS. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION DOES NOT MAKE THESE DOCUMENTS AVAILABLE TO THE PUBLIC. FORM 990, PART IX, LINE 11G OTHER FEES FOR SERVICE: PROGRAM SERVICE EXPENSES 1,411,621. MANAGEMENT AND GENERAL EXPENSES 123,301. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,534,922. THERAPIST FEES: PROGRAM SERVICE EXPENSES 785,269. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 785,269. MRI FEES: PROGRAM SERVICE EXPENSES 88,480. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 88,480. NUCLEAR IMAGING FEES: PROGRAM SERVICE EXPENSES 86,161. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 86,161. COLLECTION FEES: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 45,884. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 45,884. FORM 990, PART XII, LINE 2C: THE FULL BOARD OF DIRECTORS OVERSEES SELECTION OF AN INDEPENDENT ACCOUNTANT AND THE AUDIT OF THE ANTELOPE MEMORIAL HOSPITAL'S FINANCIAL STATEMENTS. THIS PROCESS HAS NOT CHANGED FROM PRIOR YEARS.