2022-08-18T13:56:53-05:00 2021-09-30 450250958 EIDE BAILLY LLP 18081 BURT STREET SUITE 200 OMAHA NE 680224722 990 2020-10-01 480561974 AMBERWELL ATCHISON ASSOCIATION AMBE 9133605584 800 RAVEN HILL DRIVE ATCHISON KS 66002 CHASE DUDZINSKI CHIEF FINANCIAL OFFICER 9133605584 2022-08-18 1 CHASE DUDZINSKI XXX-XX-XXXX WENDY R COOLEY P01523804 4023302660 2022-08-12 3 AAL1 IAL1 2020 2022-09-23 18:48:47Z AMBERWELL ATCHISON JEFF PERRY 800 RAVEN HILL DRIVE ATCHISON KS 66002 60213546 0 X WWW.AMBERWELLHEALTH.ORG X 1912 KS TO PROVIDE EXCELLENT HEALTH CARE AND IMPROVE THE QUALITY OF LIFE IN OUR COMMUNITY. 8 8 463 75 0 0 2094787 8244104 46844396 51585515 539006 250747 92289 79961 49570478 60160327 0 0 0 0 26163634 28726706 0 0 0 23355055 23881844 49518689 52608550 51789 7551777 57818379 55552523 38182371 28604963 19636008 26947560 TO PROVIDE EXCELLENT HEALTH CARE AND IMPROVE THE QUALITY OF LIFE IN OUR COMMUNITY. 0 0 45841280 51589843 AMBERWELL ATCHISON PROVIDED ACUTE INPATIENT AND OUTPATIENT HEALTH SERVICES TO THE GENERAL PUBLIC. SERVICES INCLUDE BUT ARE NOT LIMITED TO: EMERGENCY SERVICES, HOME HEALTH AND HOSPICE, GENERAL INPATIENT ACUTE SERVICES, RADIOLOGY, & OBSTETRICS. THE NUMBER OF PEOPLE SERVED DURING THE FISCAL YEAR ENDING 09/30/21 WAS 140,982. 45841280 1 1 0 1 0 0 1 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 1 1 0 0 1 32 0 1 463 1 0 0 0 0 0 0 0 0 0 0 0 0 X 8 8 0 0 1 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 X CHASE DUDZINSKI 9133605584 800 RAVEN HILL DRIVE ATCHISON KS 66002 RODERICK WARREN PHYSICIAN 40.00 0.00 X 684253 0 11912 EJ WILKINSON PHYSICIAN 40.00 0.00 X 638947 0 32496 JONATHAN LECK PHYSICIAN 40.00 0.00 X 636712 0 25177 DARIN ALLEN PHYSICIAN 40.00 0.00 X 449651 0 34487 MCGARRETT GROTH PHYSICIAN 40.00 0.00 X 436274 0 23908 JEFF PERRY CEO 40.00 1.00 X 296888 0 12835 GARY R FOLL FORMER CFO THRU 09/18/20 40.00 1.00 X 182676 0 17507 JIM FRASER CFO 40.00 1.00 X 47850 0 0 LYDIA FUNK CHAIRPERSON 1.00 0.00 X X 0 0 0 SUSAN MYERS CHAIRPERSON THRU 01/21 1.00 0.00 X X 0 0 0 LARRY MEARS VICE CHAIRPERSON 1.00 0.00 X X 0 0 0 MELINDA PREGONT SECRETARY 1.00 0.00 X X 0 0 0 TODD GIGSTAD TREASURER 1.00 0.00 X X 0 0 0 CHARO KELLEY DIRECTOR 1.00 0.00 X 0 0 0 JORDAN HAWK DIRECTOR 1.00 0.00 X 0 0 0 LORIN AFFIELD DIRECTOR 1.00 0.00 X 0 0 0 JERRY HENRY DIRECTOR 1.00 0.00 X 0 0 0 JIM ROWLAND DIRECTOR THRU 03/21 1.00 0.00 X 0 0 0 3373251 0 158322 45 1 1 0 MAWD LABORATORY PARTNERS PA 2750 CLAY EDWARDS DR NORTH KANSAS CITY MO 64116 LABORATORY SERVICES 408215 SPENCER FANE LLP 1000 WALNUT ST STE 1400 KANSAS CITY MO 64106 LEGAL SERVICES 384310 CASCADE HEALTH SERVICES 1045 SWIFT AVENUE KANSAS CITY MO 64116 STAFFING SERVICES 174064 LUTZ & COMPANY PC 13616 CALIFORNIA STREET OMAHA NE 68154 ACCOUNTING SERVICES 120343 MACRO HELIX LLC PO BOX 742256 ATLANTA GA 30374 340B SERVICES 109715 6 250000 7743530 250574 8244104 NET PATIENT SERVICE REVENUE 624100 31444854 31444854 MEDICARE/MEDICAID 624100 17435539 17435539 340B DRUG PRICING PROGRAM 624100 2245613 2245613 459509 459509 51585515 226810 226810 23937 23937 57547 53219 4328 4328 4328 CAFETERIA 722210 75633 75633 75633 60160327 51589843 0 326380 357573 357573 24328294 21680276 2648018 400966 360235 40731 2135527 1902777 232750 1504346 1336910 167436 429099 429099 161548 161548 3448808 2595006 853802 130096 19612 110484 2273664 2057496 216168 917457 819326 98131 665563 631672 33891 155178 140477 14701 2691 2691 879837 843393 36444 3890096 3728972 161124 333466 326498 6968 MEDICAL SUPPLIES 6937675 6937675 BAD DEBT 1668720 1668720 COLLECTION FEES 1557786 507972 1049814 DUES & SUBSCRIPTIONS 257620 109362 148258 172540 172210 330 52608550 45841280 6767270 0 12635216 7715683 5291779 8566658 5190757 6579969 1431846 1599589 703536 773006 57648601 41507356 18435212 16141245 13392517 13996892 86851 179481 650665 0 57818379 55552523 3927758 3187488 25371742 23122442 356889 213554 8525982 2081479 38182371 28604963 X 19636008 26947560 19636008 26947560 57818379 55552523 7551777 -240225 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 8197 8197 0 PART II-B, LINE 1: LOBBYING EXPENSES THROUGH DUES PAID TO THE KANSAS HOSPITAL ASSOCIATION AND THE AMERICAN HOSPITAL ASSOCIATION. X 1 3.00 1 0 964642 964642 35636051 25458248 10177803 15235834 12513862 2721972 5812074 3535246 2276828 16141245 DEFERRED COMPENSATION 758995 REFUNDABLE ADVANCES - CARES ACT FUNDS 548384 ESTIMATED THIRD PARTY PAYOR SETTLEMENTS 774100 2081479 X PART II, LINE 9: CONSERVATION EASEMENTS ARE REPORTED AT HISTORICAL COSTS AS LAND. PART X, LINE 2: THE HOSPITAL AND FOUNDATION ARE NOT-FOR-PROFIT CORPORATIONS AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. THE HOSPITAL AND FOUNDATION HAVE RECEIVED DETERMINATION LETTERS INDICATING THAT THEY ARE EXEMPT FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE INTERNAL REVENUE CODE. THE INTERNAL REVENUE SERVICE HAS ESTABLISHED STANDARDS TO BE MET TO MAINTAIN TAX EXEMPT STATUS. THE HOSPITAL AND FOUNDATION ACCOUNT FOR UNCERTAINTIES IN ACCOUNTING FOR INCOME TAX ASSETS AND LIABILITIES USING GUIDANCE INCLUDED IN FASB ASC 740, INCOME TAXES. THE HOSPITAL AND FOUNDATION RECOGNIZE THE EFFECT OF INCOME TAX POSITIONS ONLY IF THOSE POSITIONS ARE MORE LIKELY THAN NOT OF BEING SUSTAINED. AT DECEMBER 31, 2021, THE HOSPITAL AND FOUNDATION HAD NO UNCERTAIN TAX POSITIONS ACCRUED. 1 1 X 1 X 1 X 1 1 1 0 1 1 151350 151350 0.00300 5703548 4565178 1138370 0.02230 5854898 4565178 1289720 0.02530 1112192 1112192 0.02180 1112192 1112192 0.02180 6967090 4565178 2401912 0.04710 1 1668720 0 14474001 13816594 657407 X 1 1 1 1 AMBERWELL ATCHISON ASSOCIATION 800 RAVEN HILL DRIVE ATCHISON KS 66002 WWW.AMBERWELLHEALTH.ORG H-003-001 X X X X AMBERWELL ATCHISON ASSOCIATION 1 0 0 1 X X X X X X X X X 18 1 0 1 1 X WWW.AMBERWELLHEALTH.ORG X 1 18 1 WWW.AMBERWELLHEALTH.ORG 0 1 X 200.000000000000 200.000000000000 X X X X X 1 1 X X X 1 X WWW.AMBERWELLHEALTH.ORG X WWW.AMBERWELLHEALTH.ORG X WWW.AMBERWELLHEALTH.ORG X X X X X 1 X 0 X X X X 1 X 0 0 AMBERWELL ATCHISON ASSOCIATION PART V, SECTION B, LINE 5: COMMUNITY BENEFIT NEEDS WERE OBTAINED BY A WRITTEN SURVEY MAILED TO THE COMMUNITY AND BY A TOWN HALL WHERE INTERESTED PARTIES COULD COME TOGETHER IN PERSON AND DESCRIBE THEIR NEEDS. AMBERWELL ATCHISON ASSOCIATION PART V, SECTION B, LINE 6B: NEK MULTI-COUNTY HEALTH DEPARTMENTATCHISON COUNTY HEALTH DEPARTMENT AMBERWELL ATCHISON ASSOCIATION PART V, SECTION B, LINE 11: THE HOSPITAL IS AFFILIATED WITH AN ORGANIZATION NAMED LIVE WELL LIVE ATCHISON. THEIR SOLE PURPOSE IS TO ADDRESS THE HEALTHCARE NEEDS OF THE COMMUNITY. THE ORGANIZATION IS MADE UP OF CITY AND COUNTY OFFICIALS, HEALTH DEPARTMENT, THE HOSPITAL, MAJOR EMPLOYERS, THE SCHOOL DISTRICTS, BENEDICTINE COLLEGE, FAITH BASED CHURCHES, AREA BUSINESSES, HEALTH AND SERVICE AGENCIES AS WELL AS COMMUNITY AND CIVIC ORGANIZATIONS. ANY NEEDS THAT CAN BE ADDRESSED ARE ADDRESSED BY EITHER LIVE WELL LIVE ATCHISON, THE GUIDANCE CENTER ( MENTAL HEALTH PROVIDER ) OR AMBERWELL ATCHISON.ECONOMIC DEVELOPMENT AND HEALTHCARE TRANSPORTATION ARE THE TWO THINGS THAT THE HOSPITAL IS NOT ABLE TO ADDRESS EITHER BECAUSE IT IS OUT OF THEIR JURISDICTION OR FROM LACK OF FUNDING. AMBERWELL ATCHISON ASSOCIATION PART V, SECTION B, LINE 13H: THERE ARE INSTANCES WHEN A PATIENT MAY APPEAR ELIGIBLE FOR FINANCIAL DISCOUNTS, BUT THERE IS NO FINANCIAL ASSISTANCE FORM ON FILE OR LACK OF SUPPORTING DOCUMENTATION. IN THE EVENT THERE IS NO EVIDENCE TO SUPPORT A PATIENT'S ELIGIBILITY FOR FINANCIAL ASSISTANCE, AMBERWELL ATCHISON MAY USE OUTSIDE AGENCIES OR VENDORS IN DETERMINING ELIGIBILITY AND POTENTIAL DISCOUNT AMOUNTS. THESE RESOURCES MAY USE DEMOGRAPHIC AND HOUSEHOLD INFORMATION AND/OR CREDIT SCORING TECHNOLOGY TO DETERMINE THE PERCENT OF ASSISTANCE TO APPLY TO THE PATIENT'S ACCOUNT. 2 1 - ATCHISON INTERNAL MEDICINE & FAMILY PRA 800 RAVEN HILL DRIVE ATCHISON KS 66002 RURAL HEALTH CLINIC 2 - FAMILY MEDICAL CENTER OF TROY 311 W LOCUST TROY KS 66087 RURAL HEALTH CLINIC PART I, LINE 3C: NOT APPLICABLE: FEDERAL POVERTY GUIDELINES ARE USED TO DETERMINE ELIGIBILITY FOR PROVIDING FREE AND DISCOUNTED CARE TO LOW INCOME INDIVIDUALS. PART I, LINE 6A: AMBERWELL ATCHISON'S COMMUNITY BENEFIT REPORT IS NOT PREPARED BY A RELATED ORGANIZATION. PART I, LINE 7: THE COSTING METHODOLOGY USED TO CALCULATE THE AMOUNTS CONTAINED IN THE TABLE OF PART I, LINE 7, OR SCHEDULE H, IS A COST TO CHARGE RATIO CALCULATED USING WORKSHEET 2. PART I, LINE 7G: THERE ARE NO COSTS ATTRIBUTABLE TO A PHYSICIAN CLINIC INCLUDED ON LINE 7G. PART I, LN 7 COL(F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25(A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $1,668,720. PART III, LINE 2: IN EVALUATING THE COLLECTIBILITY OF ACCOUNTS RECEIVABLE, THE HOSPITAL ANALYZES ITS PAST HISTORY AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYOR SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS AND PROVISION FOR BAD DEBTS. MANAGEMENT REGULARLY REVIEWS DATA ABOUT THESE MAJOR PAYOR SOURCES OF REVENUE IN EVALUATING THE SUFFICIENCY OF THE ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS. FOR RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRD-PARTY COVERAGE, THE HOSPITAL ANALYZES CONTRACTUALLY DUE AMOUNTS AND PROVIDES AN ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS AND A PROVISION FOR BAD DEBTS FOR THOSE ACCOUNTS OVER A CERTAIN AGE BASED ON DISCHARGE THAT MAKE THE REALIZATION OF AMOUNTS DUE UNLIKELY. FOR RECEIVABLES ASSOCIATED WITH SELF-PAY PATIENTS (WHICH INCLUDES BOTH PATIENTS WITHOUT INSURANCE AND PATIENTS WITH DEDUCTIBLE AND COPAYMENT BALANCES DUE FOR WHICH THIRD-PARTY COVERAGE EXISTS FOR PART OF THE BILL), THE HOSPITAL RECORDS A SIGNIFICANT PROVISION FOR BAD DEBTS IN THE PERIOD OF SERVICE ON THE BASIS OF ITS PAST EXPERIENCE, WHICH INDICATES THAT MANY PATIENTS ARE UNABLE OR UNWILLING TO PAY THE PORTION OF THEIR BILL FOR WHICH THEY ARE FINANCIALLY RESPONSIBLE. THE DIFFERENCE BETWEEN THE STANDARD RATES (OR THE DISCOUNTED RATES IF NEGOTIATED) AND THE AMOUNTS ACTUALLY COLLECTED AFTER ALL REASONABLE COLLECTION EFFORTS HAVE BEEN EXHAUSTED IS CHARGED OFF AGAINST THE ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS. PART III, LINE 4: THE HOSPITAL'S FINANCIAL STATMENTS DO NOT CONTAIN A SPECIFIC FOOTNOTE DESCRIBING BAD DEBT. HOWEVER, PAGES 8, 10 AND 11 OF THE ATTACHED FINANCIAL STATEMENTS INCLUDE FOOTNOTES TITLED "PATIENT RECEIVABLES" "PATIENT SERVICE REVENUE AND "PATIENT FINANCIAL ASSISTANCE". PART III, LINE 9B: THE HOSPITAL DOES NOT PURSUE COLLECTION ON ACCOUNTS THAT HAVE BEEN DETERMINED TO BE ELIGIBLE FOR CHARITY CARE. PART VI, LINE 2: AMBERWELL ATCHISON ASSOCIATION HAS ACCESS TO THE KANSAS HEALTH INITIATIVE SURVEY ON HEALTH INDICATORS. BASED ON THESE INDICATORS, THE HOSPITAL DETERMINES THE NEEDS OF THE COMMUNITY AND WHAT PROGRAMS TO IMPLEMENT. PART VI, LINE 3: PATIENTS ARE GIVEN A PAMPHLET DESCRIBING THE POLICY FOR FINANCIAL ASSISTANCE WHEN THEY ARE ADMITTED. THE ADMITTING OFFICE ASKS THEM TO SPEAK WITH THE HOSPITAL FINANCIAL COUNSELOR IF THEY DO NOT HAVE INSURANCE. AFTER THE PATIENT RECEIVES THEIR STATEMENT IN THE MAIL, THEY CAN CALL IN AND TALK WITH THE FINANCIAL COUNSELOR. IF THE ACCOUNT GOES TO A COLLECTION COMPANY BECAUSE THE PATIENT DID NOT PAY OR TALK WITH THE FINANCIAL COUNSELOR, THE COLLECTION COMPANY WILL GIVE THEM THE PROPER APPLICATION TO FILL OUT TO SEE IF THEY ARE ELIGIBLE FOR FINANCIAL ASSISTANCE. PART VI, LINE 4: THE HOSPITAL SERVES THE COMMUNITY OF ATCHISON, KANSAS AND THE SURROUNDING COUNTY OF ATCHISON, KANSAS. ATCHISON IS A COMMUNITY OF APPROXIMATELY 10,500 PEOPLE WHO WOULD BE DESCRIBED AS MOSTLY COMPRISED OF BLUE-COLLAR AND LOW-INCOME INDIVIDUALS. THE SURROUNDING COUNTY HAS A POPULATION OF AN ADDITIONAL 6,300 PEOPLE. THERE ARE SEVERAL LARGE FARMS WHICH PLANT ROW CROPS OF CORN AND BEANS. PART VI, LINE 5: AMBERWELL ATCHISON BELIEVES COMMUNITY BENEFIT GOES BEYOND HOSPITAL VISITS AND EMERGENCY CARE. IT MEANS GETTING INVOLVED AND WORKING TO IMPROVE THE HEALTH OF OUR COMMUNITY; IT MEANS HELPING OTHERS PURSUE GOOD HEALTH THROUGH DONATIONS, EDUCATION AND VOLUNTEERISM. THE FOLLOWING IS A SUMMARY OF THE NUMEROUS ACTIVITIES, INITIATIVES AND EVENTS THAT HAVE BEEN IMPLEMENTED IN SUPPORT OF PROVIDING COMMUNITY BENEFITS TO THE RESIDENTS IN THE ATCHISON COMMUNITY AND REGION. LIVE WELL LIVE ATCHISON, IS A HOSPITAL INITIATIVE THAT INVOLVES PARTNERSHIPS WITH THE KANSAS HEALTH INITIATIVE, ATCHISON COUNTY SCHOOLS, BENEDICTINE COLLEGE, CITY AND COUNTY GOVERNMENTS, STATE REPRESENTATIVES, FAITH-BASED CHURCHES, THE HEALTH DEPARTMENT, COUNTY EXTENSION OFFICE AND AREA BUSINESSES, HEALTH AND SERVICE AGENCIES, AS WELL AS COMMUNITY AND CIVIC ORGANIZATIONS. THE GROUP IS WORKING TOWARD IMPROVING THE HEALTH BEHAVIORS AND LIFESTYLE OF ATCHISON COUNTY. AMBERWELL ATCHISON'S "BEST CARE COMMUNITY HEALTH FAIR," IS AN ANNUAL EVENT BY THE HOSPITAL AND HELD AT THE ATCHISON ELEMENTARY SCHOOL. HOSPITAL EMPLOYEES AS WELL AS COMMUNITY HEALTH AGENCIES, ORGANIZATIONS, LOCAL AND REGIONAL AREA RESPONDERS AND PHYSICIAN PRACTICES, PROVIDE HEALTH SCREENINGS, INTERACTIVE EDUCATIONAL, SAFETY AND FITNESS ACTIVITIES. AMBERWELL ATCHISON SUPPORTS THE ATCHISON COMMUNITY HEALTH CLINIC, A FEDERAL QUALIFIED HEALTH CLINIC, BY SUBSIDIZING THE CLINIC'S FACILITIES RENT FREE, GENERAL MAINTENANCE AND SNOW REMOVAL. THE HOSPITAL CONDUCTS AND SPONSORS SUPPORT GROUPS AND CLASSES THAT PROVIDE ONGOING EDUCATION AND COUNSELING SUCH AS GRIEF SUPPORT, BIRTHING AND CHILDCARE CLASSES. ADDITIONALLY, THE HOSPITAL OFFERS A HOSPICE VOLUNTEER PROGRAM. THE HOSPITAL ALSO PROVIDES SPONSORSHIP AND DONATIONS TO VARIOUS ORGANIZATIONS, LOCAL SCHOOLS AND NURSING HOMES, AS WELL AS COMMUNITY INITIATIVES. THEY INCLUDE: RELAY FOR LIFE, AMELIA EARHART FESTIVAL, BEAUTIFICATION OF OUR CITY, FARM SAFETY DAYS, JOGGIN' FOR THE NOGGIN', PARTICIPATION IN LOCAL AND REGIONAL HEALTH FAIRS AND PHYSICIAN SUPPORT AT LOCAL HIGH SCHOOL AND COLLEGE ATHLETIC EVENTS. AMBERWELL ATCHISON'S CARE TEAM, AN EMPLOYEE GROUP THAT GENERATES INITIATES FUNDRAISERS AND DONATES EARNED PROCEEDS TO VARIOUS LOCAL CHARITIES. THE HOSPITAL AS WELL AS THE ATCHISON HOSPITAL AUXILIARY, EACH HOSTS COMMUNITY BLOOD DRIVES THROUGHOUT THE YEAR. THE HOSPITAL PROVIDES COMMUNITY EDUCATION AND CAREER DEVELOPMENT TO ORGANIZATIONS, SCHOOLS AND COLLEGES THROUGHOUT THE AREA THROUGH SPEAKING ENGAGEMENTS, CAREER FAIRS, CLASS IN-SERVICES AND HOSPITAL TOURS. IN ADDITION, HOSPITAL EMPLOYEES VOLUNTEER THEIR SERVICE WITH COMMUNITY NOT-FOR-PROFIT AND CIVIC ORGANIZATIONS AND COMMITTEES, INCLUDING THE CHAMBER OF COMMERCE, WORKFORCE DEVELOPMENT, ROTARY, LIONS CLUB, YMCA, GUIDANCE CENTER MENTAL HEALTH CENTER AND THE MULTIDISCIPLINARY CHILD TEAM AND THE BOY SCOUTS. THE HOSPITAL OFFERS A JOB SHADOWING PROGRAM WHICH OFFERS TEENS EXPOSURE TO A VARIETY OF CAREERS WITHIN THE MEDICAL PROFESSION. PART VI, LINE 6: AMBERWELL ATCHISON ASSOCIATION IS NOT PART OF AN AFFILIATED HEALTH CARE SYSTEM. X 1 1 X X X X 1 0 0 0 0 0 0 1 0 RODERICK WARREN PHYSICIAN 528358 0 155895 0 0 0 3089 0 8823 0 696165 0 0 0 EJ WILKINSON PHYSICIAN 624297 0 14650 0 0 0 7309 0 25187 0 671443 0 0 0 JONATHAN LECK PHYSICIAN 493483 0 143229 0 0 0 8734 0 16443 0 661889 0 0 0 DARIN ALLEN PHYSICIAN 449651 0 0 0 0 0 8433 0 26054 0 484138 0 0 0 MCGARRETT GROTH PHYSICIAN 431665 0 4609 0 0 0 0 0 23908 0 460182 0 0 0 JEFF PERRY CEO 281888 0 15000 0 0 0 4385 0 8450 0 309723 0 0 0 GARY R FOLL FORMER CFO THRU 09/18/20 182576 0 100 0 0 0 3946 0 13561 0 200183 0 0 0 PART I, LINE 4A GARY R. FOLL, FORMER CFO, RECEIVED A SEVERANCE PAYMENT FOR $43,847. PART 1, LINE 1A: SOCIAL CLUB DUES WERE PAID BY THE HOSPITAL FOR JEFF PERRY AND WERE NOT INCLUDED IN HIS W-2 AS TAXABLE COMPENSATION BECAUSE THEY WERE USED 100% FOR BUSINESS. PART 1, LINE 7: VARIOUS EMPLOYED PHYSICIANS ARE PROVIDED THE OPPORTUNITY FOR BONUS POTENTIAL. IN THEIR CONTRACT WITH THE HOSPITAL ARE TIERS BASED ON CURRENT MEDICAL GROUP MANAGEMENT ASSOCIATION REGIONAL DATA. IF THE PHYSICIANS ANNUALIZED NET QUALIFIED PATIENT CHARGES EXCEEDS THE TIER, A PERCENTAGE OF THEIR NET QUALIFIED PATIENT CHARGES ARE ELIGIBLE FOR BONUS SUBJECT TO THEIR ANNUAL BASE COMPENSATION. A CITY OF ATCHISON KS 486025033 046687CV9 2017-10-19 5910000 SEE PART VI. 0 0 0 B CITY OF ATCHISON KS 486025033 046687CF4 2016-07-27 9450000 SEE PART VI. 0 0 0 C CITY OF ATCHISON KS 486025033 046687CM9 2017-06-06 8835000 SEE PART VI. 0 0 0 D CITY OF ATCHISON KS 486025033 046687CR8 2017-06-06 3400000 SEE PART VI. 0 0 0 A 95000 5910000 588475 117700 5792300 2010 0 1 1 1 B 7745000 9450000 604956 185895 9264105 2010 0 1 1 1 C 8835000 880093 79515 8755485 2010 1 0 1 1 D 75000 3400000 342246 30600 3369400 2010 1 0 1 1 A 0 0 1 1 0 0.00000 0.00000 0.00000 0 0 1 B 0 0 1 1 0 0.00000 0.00000 0.00000 0 0 1 C 0 0 1 1 0 0.00000 0.00000 0.00000 0 0 1 D 0 0 1 1 0 0.00000 0.00000 0.00000 0 0 1 A 0 1 0 0 0 0 0 1 1 B 0 0 0 1 0 0 0 1 1 C 0 1 0 0 0 0 0 0 1 D 0 1 0 0 0 0 0 0 1 A 1 B 1 C 1 D 1 PART I, LINE B, COLUMN (F): ADVANCE REFUND A PORTION OF THE 2008A, 2008B, AND 2009 BONDS. THE 2008A BONDS WERE ORIGINALLY ISSUED ON 9/23/2008; THE 2008B BONDS WERE ORIGINALLY ISSUED ON 9/23/2008; THE 2009 BONDS WERE ORIGINALLY ISSUED ON 6/30/2009. PART I, LINE C, COLUMN (F): CURRENT REFUND A PORTION OF THE 2008A BONDS. THE 2008A BONDS WERE ORIGINALLY ISSUED ON 9/23/2008. PART I, LINE D, COLUMN (F): CURRENT REFUND A PORTION OF THE 2009 BONDS. THE 2009 BONDS WERE ORIGINALLY ISSUED ON 6/30/2009. PART I, LINE A, COLUMN (F): ADVANCE REFUND REMAINING PORTION OF THE 2009 BONDS. THE 2009 BONDS WERE ORIGINALLY ISSUED ON 6/30/2009. PART II, COLUMN B, LINE 11: THIS AMOUNT WAS USED TO ADVANCE REFUND A PORTION OF THE 2008A BONDS, 2008B BONDS AND 2009 BONDS. PART II, COLUMN C, LINE 11: THIS AMOUNT WAS USED TO CURRENT REFUND A PORTION OF THE 2008A BONDS. PART II, COLUMN D, LINE 11: THIS AMOUNTS WAS USED TO CURRENT REFUND A PORTION OF THE 2009 BONDS. PART II, COLUMN A, LINE 11: THIS AMOUNT REPRESENTS $5,786,846.35 OF BOND PROCEEDS USED TO ADVANCE REFUND A PORTION OF THE 2009 BONDS AND $5,453.65 ALLOCATED TO PAY INTEREST ON THE BONDS. PART IV, COLUMN B, LINE 6: PROCEEDS WERE DEPOSITED AND HELD IN A YIELD RESTRICTED ESCROW FOR THE REFUNDED BONDS BEYOND THE AVAILABLE TEMPORARY PERIOD. ALL SUCH PROCEEDS HAVE BEEN SPENT. PART IV, COLUMN A, LINE 6: PROCEEDS WERE DEPOSITED AND HELD IN A YIELD RESTRICTED ESCROW FOR THE REFUNDED BONDS BEYOND THE AVAILABLE TEMPORARY PERIOD. ALL SUCH PROCEEDS HAVE BEEN SPENT. PART I, LINE A2, COLUMN (F): CURRENT REFUND TAXABLE BANK LOAN. THE TAXABLE BANK LOAN WAS ORIGINALLY ISSUED ON 7/21/2015. RENOVATIONS TO AND EQUIPMENT FOR HOSPITAL FACILITIES. PART II, COLUMN A2, LINE 11: $1,709,258 OF BOND PROCEEDS WAS USED TO CURRENT REFUND THE TAXABLE BANK LOAN WITH EXCHANGE BANK & TRUST ON 10/30/2019. PART II, COLUMN A2, LINE 13: THE NEW MONEY PORTION OF THE PROJECT HAS NOT BEEN COMPLETED AS OF FISCAL YEAR END. PART IV, COLUMN B, LINE 2C: ARBITRAGE COMPUTATION COMPLETED AS OF JULY 1, 2021. PART II, COLUMN A2, LINE 3: AMOUNT DOES NOT EQUAL ISSUE PRICE AS A RESULT OF INVESTMENT EARNINGS EARNED DURING THE PROJECT PERIOD. PART II, COLUMN A2, LINE 16: THE NEW MONEY PORTION OF THE PROJECT WAS NOT COMPLETED AS OF THE FISCAL YEAR END. PART III, COLUMN A2: NOT ALL OF THE PROJECT WAS PLACED-IN-SERVICE AS OF THE FISCAL YEAR END. A CITY OF ATCHISON KS 486025033 046687DG1 2019-10-30 4255000 SEE PART VI. 0 0 0 A 530000 4267638 82475 315117 1709258 2160789 0 1 0 1 A 0 0 0 0 0.00000 0.00000 0.00000 0 0 1 A 0 1 0 0 0 0 0 0 1 A 1 FORM 990, PART VI, SECTION A, LINE 4 ON APRIL 27, 2021, THE BYLAWS AND ARTICLES OF INCORPORATION WERE REVISED TO REFLECT THE NAME CHANGE FROM ATCHISON HOSPITAL ASSOCIATION TO AMBERWELL ATCHISON ASSOCIATION. FORM 990, PART VI, SECTION B, LINE 11B AN INDEPENDENT ACCOUNTING FIRM PREPARES AND REVIEWS THE FORM 990. THE FORM 990 IS THEN REVIEWED BY THE ORGANIZATION'S MANAGEMENT. ANY QUESTIONS OR CONCERNS THE ORGANIZATION'S MANAGEMENT HAS ARE ADDRESSED AND ANY CORRECTIONS OR CLARIFICATIONS ARE MADE. THE FORM 990 IS THEN PROVIDED TO THE BOARD PRIOR TO FILING WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C AT THE TIME OF THE ELECTION OR HIRE AND ANNUALLY THEREAFTER, THE GOVERNING BOARD MEMBERS, OFFICERS, AND KEY EMPLOYEES SHALL PROVIDE THE APPLICABLE CONFLICT OF INTEREST DISCLOSURES WHICH SHALL BE COMPLETED TO IDENTIFY ANY RELATIONSHIPS, POSITIONS, OR CIRCUMSTANCES IN WHICH IT IS BELIEVED A CONFLICT MAY ARISE. IF A CONFLICT ARISES, THE BOARD MEMBER ABSTAINS FROM THE VOTE OF THE CONFLICTED POSITION. FORM 990, PART VI, SECTION B, LINE 15 IN 2019, THE ORGANIZATION ENGAGED ITS LEGAL COUNSEL TO PREPARE A COMPENSATION DATA STUDY. IN ADDITION TO VARIOUS DATA COLLECTED, OTHER HOSPITALS' 990'S WERE REVIEWED AND COMBINED IN THE COMPENSATION STUDY. THE HOSPITAL'S LEGAL COUNSEL REVIEWED THE STUDY WITH THE BOARD OF DIRECTORS TO ADJUST THE CEO'S COMPENSATION. ANY DECISION THAT IS MADE IN REGARDS TO THE CEO'S COMPENSATION IS DOCUMENTED BY THE BOARD OF DIRECTORS. THE CEO AND HUMAN RESOURCE DIRECTOR CONDUCT AN ANNUAL REVIEW OF OTHER OFFICERS AND KEY EMPLOYEES' COMPENSATION BASED ON COMPARABLE DATA OF OTHER ORGANIZATIONS OF SIMILAR SIZE AND INDUSTRY. PHYSICIAN COMPENSATION IS DETERMINED BASED ON CONTRACT AND IS COMPARED TO RECENT MEDICAL GROUP MANAGEMENT ASSOCIATION INFORMATION BY REGION TO DETERMINE FAIR MARKET COMPENSATION. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE NOT MADE AVAILABLE TO THE PUBLIC. FORM 990, PART XI, LINE 2C: AN INDEPENDENT ACCOUNTING FIRM AUDITS THE ORGANIZATION'S FINANCIAL STATEMENTS. THE ORGANIZATION HAS A COMMITTEE THAT ASSUMES RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT OF ITS FINANCIAL STATEMENTS AND SELECTION OF AN INDEPENDENT ACCOUNTANT. THIS PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. RIVERBEND REGIONAL HEALTHCARE FOUNDATION 800 RAVEN HILL DRIVE ATCHISON KS 66002 480955489 SUPPORT AMBERWELL ATCHISON ASSOCIATION KS 501(C)(3) LINE 12B, II AMBERWELL ATCHISON ASSOCIATION 1 0 0 1 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0 RIVERBEND REGIONAL HEALTHCARE FOUNDATION C 250000 CASH TRANSFERRED