2025-05-05T14:34:15-05:00 2024-06-30 450250958 EIDE BAILLY LLP 18081 BURT ST STE 200 OMAHA NE 680224722 990 2023-07-01 470393176 ANTELOPE MEMORIAL HOSPITAL ANTE 4028874151 PO BOX 229 NELIGH NE 68756 DIANE BRUGGER CEO 4028874151 2025-05-05 1 1 MEGAN L KOZIOL CPA P01544037 4023302660 2025-05-05 2023 2025-03-06 01:10:19Z DIANE BRUGGER PO BOX 229 NELIGH NE 68756 22453827 0 X WWW.AMHNE.ORG X 1974 NE TO OPERATE A HOSPITAL AND AFFILIATED INSTITUTIONS IN THE COUNTY OF ANTELOPE, NEBRASKA. 11 11 202 18 0 0 1370691 88214 19779516 20731714 336281 479762 58676 246212 21545164 21545902 4360 4076 0 0 11193715 12214996 0 0 0 8367692 8463803 19565767 20682875 1979397 863027 27084366 27682171 2354257 2097183 24730109 25584988 MAKING A DIFFERENCE IN PEOPLE'S LIVES THROUGH EXCELLENT PATIENT CARE. 0 0 17530481 4076 20920661 ANTELOPE MEMORIAL HOSPITAL IS A 17-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. 17530481 1 1 0 1 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 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 34 0 1 202 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 308097 0 30438 MARTHA NELSON CFO 36.00 X 221699 0 26597 ROGER RUDLOFF MD PHYSICIAN 40.00 X 437193 0 30962 TROY DAWSON MD PHYSICIAN 40.00 X 391283 0 38370 KELLI OSBORN MD PHYSICIAN 40.00 X 282134 0 37440 PATRICIA GOOD APRN APRN 40.00 X 177635 0 346 JOSHUA THOENDEL MD PHYSICIAN 40.00 X 347705 0 37440 2165746 0 201593 13 0 1 0 PSYCHIATRIC MEDICAL SERVICES 8 CADILLAC DRIVE SUITE 230 BRENTWOOD TN 37027 PSYCHIATRIC SERVICES 491148 PINNACLE ANESTHESIA SERVICES 608 EAST 4TH STREET NELIGH NE 68756 NURSING SERVICES 457406 OVERLAND REHAB SERVICES 405 JAMES STREET VERDIGRE NE 68783 PHYSICAL THERAPY SERVICES 342077 EIDE BAILLY 18081 BURT STREET SUITE 200 OMAHA NE 68022 ACCOUNTING SERVICES 145584 APPLIED CONNECTIVE TECHNOLOGIES LLC PO BOX 446 2508 SALEBARN RD ALBION NE 68620 IT SERVICES 138409 5 26323 61891 88214 MEDICARE/MEDICAID PAYMENTS 621400 11340934 11340934 NET PATIENT SERVICE REVENUE 621400 8880504 8880504 340B REVENUE 611400 323501 323501 AMBULANCE 621910 7200 7200 179575 179575 20731714 461528 461528 926159 903648 4277 22511 -4277 18234 18234 INSURANCE PROCEEDS 900099 188947 188947 CAFETERIA 900099 57265 57265 246212 21545902 20920661 0 537027 X 4076 4076 586831 586831 9241634 8185291 1056343 255578 218576 37002 1492161 1234837 257324 638792 554859 83933 45583 14142 31441 91454 91454 2616530 2371379 245151 165560 9147 156413 715659 606054 109605 855224 575106 280118 256433 245926 10507 43215 41498 1717 1504864 1437954 66910 331718 316969 14749 MEDICAL SUPPLIES 1653413 1653413 DUES & SUBSCRIPTIONS 93856 49256 44600 MISCELLANEOUS 75589 6319 69270 LICENSES 14705 5679 9026 20682875 17530481 3152394 0 222063 623392 10840970 11994332 5100 5100 1120009 1603262 97622 0 419058 419499 180707 113569 31536567 18787478 13616687 12749089 582150 173928 27084366 27682171 2049257 1863741 305000 0 0 233442 2354257 2097183 X 24703304 25561688 26805 23300 24730109 25584988 27084366 27682171 863027 -8148 0 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 2255 2255 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 9898917 5387455 4511462 17230824 11246467 5984357 4282597 2153556 2129041 12749089 ESTIMATED 3RD PARTY PAYER SETTLEMENT 233442 233442 X 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, 2024 AND 2023, THE HOSPITAL HAD NO UNCERTAIN TAX POSITIONS ACCRUED. 1 1 X 1 X 125.000000000000 0 1 1 0 1 1 25982 0 25982 0.00130 2450472 1259247 1191225 0.05760 2476454 1259247 1217207 0.05890 26124 5581 20543 0.00100 3210439 2335890 874549 0.04230 4076 0 4076 0.00020 3240639 2341471 899168 0.04350 5717093 3600718 2116375 0.10240 400 0 400 0.00000 62387 0 62387 0.00300 62787 62787 0.00300 1 290686 33429 9644136 9811970 -167834 X 1 1 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 HEALTHFOCUS AREA 1: HEART HEALTHGOAL: EFFECTIVELY PROMOTE ANTELOPE MEMORIAL HOSPITAL'S SERVICES AIMED AT PREVENTING, SCREENING AND MANAGING HEART DISEASE THROUGHOUT THE COMMUNITY SERVICE AREA. ACTION 1: COLLABORATE WITH LOCAL ENTITIES AND MEDIA OUTLETS TO EDUCATE THE PUBLIC ON HEART DISEASE RISK FACTORS AND REDUCTIONYEARLY: EVERY YEAR IN FEBRUARY WE RECOGNIZE OUR CARDIAC REHAB STAFF ON FACEBOOK AND LOCAL RADIO STATIONS AND NEWSPAPERS THAT INCLUDES EDUCATION TO THE PUBLIC ON THE REHAB PROGRAM AND SERVICES.TWICE A MONTH: AMH NURSES PROVIDE HEALTH SCREENS (BLOOD PRESSURES, HEART RATES, O2 SATS, TEMPERATURES, RESPIRATIONS, AND BLOOD GLUCOSE) AT THE NELIGH COMMUNITY CENTER. EDUCATION IS PROVIDED. TOTAL OF 69 SCREENED DURING THE CURRENT FISCAL YEAR.AMH DIABETES EDUCATION DEPARTMENT OFFERED A FREE ROAST BEEF SUPPER AT THE NELIGH COMMUNITY CENTER. AMH'S DIABETES EDUCATION DEPARTMENT EDUCATED 65 ATTENDEES ON HEALTH LIFESTYLE TIPS/DIABETES PREVENTION.ACTION 2: INCORPORATE CHOLESTEROL TESTS INTO COMMUNITY SCREENING EVENTSSEPTEMBER 20 & 22, 2023 AMH OFFERED DISCOUNTED LAB SPECIALS WITH 138 PEOPLE TESTED.OCTOBER 2023 AMH LAB ATTENDED ELKHORN RURAL PUBLIC POWER DISTRICT'S (ERPPD) HEALTH FAIR AND DREW LAB ON 50 ERPPD EMPLOYEES.DECEMBER 11, 2023 AMH REHAB SERVICES PROVIDED CHOLESTEROL, BLOOD SUGAR, AND BLOOD PRESSURE SCREENING AND EDUCATION AT NELIGH PIONEER HOMES. 5 PEOPLE ATTENDED.APRIL 24 & 26, 2024 AMH OFFERED DISCOUNTED LAB SPECIALS WITH 164 PEOPLE TESTED. ACTION 3: ENSURE STAFF IS TRAINED ON THE MOST UP-TO-DATE STANDARDS FOR BLOOD PRESSURE MEASUREMENT.JANUARY 24, 2024 AMH STAFF TOOK THE MEASURE ACCURATELY, THE FIRST STEP IN HYPERTENSION CONTROL COURSE FROM BRYAN HEALTH. ACTION 4: COLLABORATE WITH LOCAL ENTITIES AND MEDIA OUTLETS TO EDUCATE THE PUBLIC ON SERVICES COVERED BY INSURANCE BENEFITS. OCTOBER 15 DECEMBER 7, 2023 DANIELLE VAN BUREN COUNSELED 37 PEOPLE ON MEDICARE ENROLLMENT. MARCH 5-6, 2024 ANTELOPE COUNTY AG & HOME EXPO DR. THOENDEL DID A PRESENTATION ON "NAVIGATING CANCER SCREENING: WHAT YOU NEED TO KNOW" (8 ATTENDED). TAMI KESTER, CHRISTINE COUNTS, AND AMY WRIGHT OFFERED BLOOD PRESSURE CHECKS (47 CHECKED).ACTION 5: OFFER BASIC LIFE SUPPORT (BLS) TO AMH STAFF AND LIFE-SAVING CLASSES TO THE PUBLIC. JUNE 19, 2024 AMH OFFERED A FREE LIFE-SAVING CLASS TO THE PUBLIC; HOWEVER, NO RESPONSE (ADVERTISED ON FACEBOOK). FOCUS AREA 2: MENTAL HEALTHGOAL 1: INCREASE THE NUMBER OF COUNSELING SERVICES AT ANTELOPE MEMORIAL HOSPITAL BY 1%ACTION 1: ADD AN ONSITE LICENSED MENTAL HEALTH PRACTITIONER FOR PATIENTS OF ALL AGES UNABLE TO MEET DUE TO CHANGES IN PROGRAM DIRECTORS. AMH CONTINUES TO ADVERTISE OUR CURRENT MENTAL HEALTH SERVICES VIA FACEBOOK AND LOCAL NEWSPAPERS. GOAL 2: EFFECTIVELY RAISE MENTAL HEALTH AWARENESS TO YOUTH, ADULTS AND SENIORS AND EDUCATE THEM ON AVAILABLE MENTAL HEALTH SERVICESACTION 1: INCREASE ANTELOPE MEMORIAL HOSPITAL'S STAFF PARTICIPATION IN THE ANTELOPE COUNTY DOES CARE (ACDC) COALITION. AMH HOSTED AND STAFF ATTENDED 6 MEETINGS OF THE ACDC.ACTION 2: COLLABORATE WITH LOCAL ENTITIES AND MEDIA OUTLETS TO EDUCATE THE PUBLIC ON MENTAL HEALTH RISK FACTORS AND AVAILABLE SERVICES. NOVEMBER 17, 2023 2 AMH STAFF MEMBERS ATTENDED DOUG WIDOW'S EQUINE-ASSISTED THERAPY PRESENTATION. INFORMATION WAS SHARED WITH NELIGH'S CHIEF OF POLICE AND ANTELOPE COUNTY SHERIFF.WEEKLY/MONTHLY MENTAL HEALTH SERVICES OFFERED AT AMH ARE ADVERTISED IN OUR LOCAL NEWSPAPERS AND ON FACEBOOK.MAY 2024 - MENTAL HEALTH AWARENESS MONTH - SENIOR LIFE SOLUTIONS HAD PROMOTIONAL/INFORMATIONAL TABLES SET UP AT THE NELIGH AND ELGIN SENIOR CENTERS AND HOSPITAL. AMH SENIOR LIFE SOLUTIONS STAFF PROVIDE BINGO AT THE NELIGH COMMUNITY CENTER. EDUCATION IS PROVIDED. JUNE 26, 2024 FACEBOOK POST EDUCATING PUBLIC ON THE THREE-DIGIT NATIONAL LIFELINE NUMBER TO CALL FOR SUICIDE PREVENTION AND MENTAL HEALTH CRISIS (988).THERE WERE NO SIGNIFICANT NEEDS IDENTIFIED THAT ARE NOT CURRENTLY BEING ADDRESSED. 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: IN ADDITION TO FEDERAL POVERTY GUIDELINES, THE HOSPITAL ALSO USES ASSET LEVEL, INSURANCE STATUS AND UNDERINSURANCE STATUS TO DETERMINE ELIGIBILITY FOR FREE CARE. DISCOUNTED CARE IS NOT OFFERED, AS FINANCIAL ASSISTANCE IS BASED UPON AN ALL OR NOTHING POLICY. IF THE PATIENT QUALIFIES FOR FINANCIAL ASSISTANCE, THEY WILL RECEIVE A 100% DISCOUNT. PART I, LINE 7: CHARITY CARE EXPENSE WAS CONVERTED TO COST ON LINE 7A BASED ON AN OVERALL COST-TO-CHARGE RATIO ADDRESSING ALL PATIENT SEGMENTS. UNREIMBURSED MEDICAID ON LINE 7B WAS CALCULATED USING THE COSTING METHODS TO PREPARE THE COST REPORTS. COMMUNITY HEALTH IMPROVEMENT SERVICES, LINE 7E AND CONTRIBUTIONS, LINE 7I, ARE REPORTED BASED ON ACTUAL EXPENSES REPORTED IN THE GENERAL LEDGER. THE COST FOR SUBSIDIZED HEALTH SERVICES REPORTED ON LINE 7G WAS CALCULATED USING THE RATIO OF PATIENT COST TO CHARGES ON WORKSHEET 2. PART I, LINE 7G: SUBSIDIZED HEALTH SERVICES INCLUDE THREE PHYSICIAN CLINICS IN NEIGHBORING COMMUNITIES, AS WELL AS PHYSICAL THERAPY SERVICES, PATIENT TRANSPORT AND CARDIAC REHAB. 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.- DEVELOPING THE WORKFORCE BY PROVIDING SCHOLARSHIPS TO INCREASE MEDICAL EDUCATION IN THE COMMUNITY, AS WELL AS OTHER PAYMENTS FOR ENSURING THE CONTINUOUS RECRUITMENT OF PHYSICIANS AND OTHER HEALTH PROFESSIONALS TO THE AREA. PART III, LINE 2: THE HOSPITAL DETERMINES ITS ESTIMATE OF IMPLICIT PRICE CONCESSIONS BASED ON HISTORICAL COLLECTION EXPERIENCE WITH VARIOUS CLASSES OF PATIENTS. PART III, LINE 3: THE ESTIMATED AMOUNT OF THE ORGANIZATION'S IMPLICIT PRICE CONCESSIONS ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S CHARITY CARE POLICY IS CALCULATED BASED ON AN APPROXIMATE 11.5% OF INDIVIDUALS LIVING BELOW THE POVERTY LEVEL IN THE SERVICE AREA. PART III, LINE 4: THE FOOTNOTE TO THE ORGANIZATION'S FINANCIAL STATEMENTS THAT DESCRIBES IMPLICIT PRICE CONCESSIONS IS LOCATED IN FOOTNOTE 1 ON PAGES 14 AND 15 OF THE ATTACHED FINANCIAL STATEMENTS. PART III, LINE 8: THE MEDICARE SHORTFALL IS BASED ON THE INFORMATION FROM THE COST REPORT. THESE COSTS ARE MEDICARE REIMBURSABLE COSTS, NOT ALL COSTS. THESE MEDICARE REIMBURSABLE COSTS SHOULD BE TREATED AS A COMMUNITY BENEFIT TO THE EXTENT THAT MEDICARE REVENUES DO NOT COVER THE COSTS, THEREFORE THE ENTIRE SHORTFALL SHOULD BE TREATED AS A COMMUNITY BENEFIT. WE DO NOT USE ANY NEGOTIATION TOOL WITH MEDICARE FOR OUR RATES; THE RATES THAT WE ARE PAID ARE MANDATED. HENCE, THIS DOES NOT GIVE US THE ABILITY AS A PROVIDER TO RECEIVE SUFFICIENT REVENUES TO COVER THE MEDICARE COSTS. AS A FACILITY WE ARE WORKING TOWARD COSTS SAVINGS. PART III, LINE 9B: IF A PERSON APPLIES FOR FINANCIAL ASSISTANCE IN ACCORDANCE WITH THE FINANCIAL ASSISTANCE POLICY ALL COLLECTION EFFORTS WILL STOP UNTIL THE DETERMINATION OF ELIGIBILITY FOR FINANCIAL ASSISTANCE IS MADE. IF THE PERSON QUALIFIES FOR FINANCIAL ASSISTANCE, THE HOSPITAL WILL TAKE STEPS TO REVERSE COLLECTIONS ACTION, REPORTS, AND OTHER ACTIONS THAT HAVE BEEN TAKEN TO OBTAIN PAYMENT. PART VI, LINE 2: ANTELOPE MEMORIAL HOSPITAL PERFORMED THE FOLLOWING PROCEDURES TO ASSESS THE HEALTH NEEDS OF THE COMMUNITY IT SERVES: - COMMUNITY FOCUS GROUP MEETINGS - CONFERENCE CALLS WITH DHHS PERSONNEL FOR INPUT, GUIDANCE, AND FEEDBACK - STRATEGIC PLANNING SESSIONS PART VI, LINE 3: PATIENTS MAY OBTAIN A COPY OF THE FINANCIAL ASSISTANCE POLICY, A PLAIN LANGUAGE SUMMARY OF THE POLICY, AND A FINANCIAL ASSISTANCE APPLICATION FREE OF CHARGE (I) BY MAIL BY CALLING 402-887-6286, (II) BY E-MAIL (UPON PATIENT ELECTION) BY E-MAILING PATIENTFINANCIALCOUNSELOR@AMHNE.ORG, (III) BY DOWNLOAD FROM WWW.AMHNE.ORG/PAGES/FINANCIALASSISTANCE/INDEX.HTML, OR (IV) IN PERSON AT (A) THE EMERGENCY ROOM, (B) ANY ADMISSION AREAS, OR ( C) THE OFFICE OF THE PATIENT FINANCIAL COUNSELOR LOCATED NEAR THE HOSPITAL BUSINESS OFFICE. ANTELOPE MEMORIAL HOSPITAL ALSO INCLUDES ITS PAYMENT POLICY WITH ALL STATEMENTS SENT TO PATIENTS. IF A PATIENT SUBMITS A COMPLETED FINANCIAL ASSISTANCE APPLICATION DURING THE APPLICATION PERIOD AND THE HOSPITAL DETERMINES THAT THE PATIENT MAY BE ELIGIBLE FOR PARTICIPATION IN MEDICAID, THE HOSPITAL WILL NOTIFY THE PATIENT IN WRITING OF SUCH POTENTIAL ELIGIBILITY AND REQUEST THAT THE PATIENT TAKE STEPS NECESSARY TO ENROLL IN SUCH PROGRAM. IN SUCH CIRCUMSTANCES THE HOSPITAL WILL DELAY THE PROCESSING OF THE PATIENT'S FINANCIAL ASSISTANCE APPLICATION UNTIL THE PATIENT'S APPLICATION FOR MEDICAID IS COMPLETED, SUBMITTED TO THE REQUISITE GOVERNMENTAL AUTHORITY, AND A DETERMINATION HAS BEEN MADE. 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. THE NORTH CENTRAL DISTRICT HEALTH DEPARTMENT PROJECTS THE TOTAL SERVICE POPULATION TO BE AROUND 45,000 RESIDENTS, OF WHICH 11.5% ARE BELOW THE POVERTY LEVEL. THE POPULATION IS DECREASING, AND OVER 50% OF RESIDENTS ARE OVER THE AGE OF 45. 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. FORM 990, PART VI, LINE 7: NEBRASKA DOES NOT REQUIRE THE FILING OF A COMMUNITY BENEFIT REPORT WITH THE STATE, HOWEVER A COMMUNITY BENEFIT REPORT IS FILED ANNUALLY WITH THE NEBRASKA HOSPITAL ASSOCIATION. X X X 0 0 0 0 0 0 0 0 0 ROGER RUDLOFF MD PHYSICIAN 437193 0 0 0 0 0 14994 0 15968 0 468155 0 0 0 TROY DAWSON MD PHYSICIAN 391283 0 0 0 0 0 14994 0 23376 0 429653 0 0 0 JOSHUA THOENDEL MD PHYSICIAN 347705 0 0 0 0 0 14994 0 22446 0 385145 0 0 0 DIANE BRUGGER ADMINISTRATOR/CEO 308097 0 0 0 0 0 12145 0 18293 0 338535 0 0 0 KELLI OSBORN MD PHYSICIAN 282134 0 0 0 0 0 14994 0 22446 0 319574 0 0 0 MARTHA NELSON CFO 221699 0 0 0 0 0 6850 0 19747 0 248296 0 0 0 PATRICIA GOOD APRN APRN 177635 0 0 0 0 0 0 0 346 0 177981 0 0 0 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 1,458,289. MANAGEMENT AND GENERAL EXPENSES 203,956. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,662,245. THERAPIST FEES: PROGRAM SERVICE EXPENSES 786,508. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 786,508. MRI FEES: PROGRAM SERVICE EXPENSES 61,225. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 61,225. NUCLEAR IMAGING FEES: PROGRAM SERVICE EXPENSES 65,357. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 65,357. COLLECTION FEES: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 41,195. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 41,195. 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. HILLTOP COMMUNITY PHARMACY LLC 108 W 11TH ST NELIGH NE 68756 992418371 PHARMACY NE 0 186128 ANTELOPE MEMORIAL HOSPITAL