ANTELOPE MEMORIAL HOSPITAL: Form 990, tax year 2020
View the entire original 990 at ProPublica ↗
- Organization
- ANTELOPE MEMORIAL HOSPITAL (EIN 47-0393176)
- Tax period
- 2020-07-01 to 2021-06-30
- Filed
- 2022-04-21
- IRS object ID
- 202241119349301309
- Schema version
- 2020v4.2
- Source
- Download XML · Original 990 at ProPublica
Every field in the e-filed return. Faint text is the IRS element name, for citing.
- Return header
- Form 990
- Schedule A
- Schedule B
- Schedule C
- Schedule D
- Schedule H
- Schedule J
- Schedule K
- Schedule O
Return header ReturnHeader
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return | 2022-04-21T14:52:49-05:00 | ReturnTs |
| Tax Period End | 2021-06-30 | TaxPeriodEndDt |
Preparer Firm PreparerFirmGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Firm EIN | 476097913 | PreparerFirmEIN |
Preparer Firm Name PreparerFirmName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | SEIM JOHNSON LLP | BusinessNameLine1Txt |
Preparer US Address PreparerUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 18081 BURT STREET SUITE 200 | AddressLine1Txt |
| City | OMAHA | CityNm |
| State Abbreviation | NE | StateAbbreviationCd |
| ZIP | 680224722 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return Type | 990 | ReturnTypeCd |
| Tax Period Begin | 2020-07-01 | TaxPeriodBeginDt |
Filer Filer
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 470393176 | EIN |
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | ANTELOPE MEMORIAL HOSPITAL | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Control | ANTE | BusinessNameControlTxt |
| Phone | 4028874151 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | PO BOX 229 | AddressLine1Txt |
| City | NELIGH | CityNm |
| State Abbreviation | NE | StateAbbreviationCd |
| ZIP | 68756 | ZIPCd |
Business Officer BusinessOfficerGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person | DIANE CARLIN | PersonNm |
| Person Title | CEO | PersonTitleTxt |
| Phone | 4028874151 | PhoneNum |
| Signature | 2022-04-20 | SignatureDt |
| Discuss With Paid Preparer | Yes (1) | DiscussWithPaidPreparerInd |
Signing Officer SigningOfficerGrp
Person Full Name PersonFullName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person First | DIANE | PersonFirstNm |
| Person Last | CARLIN | PersonLastNm |
| Field | Value | IRS element (for citing) |
|---|---|---|
| SSN | 999009999 | SSN |
Preparer Person PreparerPersonGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Person | MEGAN L KOZIOL | PreparerPersonNm |
| PTIN | P01544037 | PTIN |
| Phone | 4023302660 | PhoneNum |
Additional Filer Information AdditionalFilerInformation
Trusted Customer TrustedCustomerGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Trusted Customer | 2 | TrustedCustomerCd |
| Authentication Assurance Level | AAL1 | AuthenticationAssuranceLevelCd |
| Identity Assurance Level | IAL1 | IdentityAssuranceLevelCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tax | 2020 | TaxYr |
| Build TS | 2022-09-23 18:48:47Z | BuildTS |
Form 990 IRS990
| Field | Value | IRS element (for citing) |
|---|---|---|
| Principal Officer | DIANE CARLIN | PrincipalOfficerNm |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | PO BOX 229 | AddressLine1Txt |
| City | NELIGH | CityNm |
| State Abbreviation | NE | StateAbbreviationCd |
| ZIP | 68756 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Receipts | $21,729,349 | GrossReceiptsAmt |
| Group Return For Affiliates | 0 | GroupReturnForAffiliatesInd |
| Organization501c3 | Yes (X) | Organization501c3Ind |
| Website Address | WWW.AMHNE.ORG | WebsiteAddressTxt |
| Type Of Organization Corp | Yes (X) | TypeOfOrganizationCorpInd |
| Formation | 1974 | FormationYr |
| Legal Domicile State | NE | LegalDomicileStateCd |
| Activity Or Mission | TO BUILD, ERECT, MAINTAIN, EXPAND, EQUIP, MANAGE AND OPERATE A HOSPITAL AND AFFILIATED INSTITUTIONS IN THE COUNTY OF ANTELOPE, NEBRASKA FOR THE CARE AND TREATMENT OF SICK AND INFIRM PEOPLE, REGARDLESS OF RACE, CREED, COLOR AND RESIDENCE. | ActivityOrMissionDesc |
| Voting Members Governing Body | 11 | VotingMembersGoverningBodyCnt |
| Voting Members Independent | 11 | VotingMembersIndependentCnt |
| Total Employee | 206 | TotalEmployeeCnt |
| Total Volunteers | 12 | TotalVolunteersCnt |
| Total Gross UBI | $0 | TotalGrossUBIAmt |
| Net Unrelated Bus Txbl Incm | $0 | NetUnrelatedBusTxblIncmAmt |
| PY Contributions Grants | $924,853 | PYContributionsGrantsAmt |
| CY Contributions Grants | $5,163,770 | CYContributionsGrantsAmt |
| PY Program Service Revenue | $15,080,766 | PYProgramServiceRevenueAmt |
| CY Program Service Revenue | $16,326,052 | CYProgramServiceRevenueAmt |
| PY Investment Income | $90,794 | PYInvestmentIncomeAmt |
| CY Investment Income | $145,205 | CYInvestmentIncomeAmt |
| PY Other Revenue | $64,052 | PYOtherRevenueAmt |
| CY Other Revenue | $55,489 | CYOtherRevenueAmt |
| PY Total Revenue | $16,160,465 | PYTotalRevenueAmt |
| CY Total Revenue | $21,690,516 | CYTotalRevenueAmt |
| PY Grants And Similar Paid | $7,500 | PYGrantsAndSimilarPaidAmt |
| CY Grants And Similar Paid | $960 | CYGrantsAndSimilarPaidAmt |
| PY Benefits Paid To Members | $0 | PYBenefitsPaidToMembersAmt |
| CY Benefits Paid To Members | $0 | CYBenefitsPaidToMembersAmt |
| PY Salaries Comp Emp Bnft Paid | $8,659,024 | PYSalariesCompEmpBnftPaidAmt |
| CY Salaries Comp Emp Bnft Paid | $9,515,367 | CYSalariesCompEmpBnftPaidAmt |
| PY Total Prof Fndrsng Expns | $0 | PYTotalProfFndrsngExpnsAmt |
| CY Total Prof Fndrsng Expns | $0 | CYTotalProfFndrsngExpnsAmt |
| CY Total Fundraising Expense | $0 | CYTotalFundraisingExpenseAmt |
| PY Other Expenses | $6,691,405 | PYOtherExpensesAmt |
| CY Other Expenses | $7,535,751 | CYOtherExpensesAmt |
| PY Total Expenses | $15,357,929 | PYTotalExpensesAmt |
| CY Total Expenses | $17,052,078 | CYTotalExpensesAmt |
| PY Revenues Less Expenses | $802,536 | PYRevenuesLessExpensesAmt |
| CY Revenues Less Expenses | $4,638,438 | CYRevenuesLessExpensesAmt |
| Total Assets BOY | $30,307,047 | TotalAssetsBOYAmt |
| Total Assets EOY | $29,095,684 | TotalAssetsEOYAmt |
| Total Liabilities BOY | $14,192,227 | TotalLiabilitiesBOYAmt |
| Total Liabilities EOY | $8,306,271 | TotalLiabilitiesEOYAmt |
| Net Assets Or Fund Balances BOY | $16,114,820 | NetAssetsOrFundBalancesBOYAmt |
| Net Assets Or Fund Balances EOY | $20,789,413 | NetAssetsOrFundBalancesEOYAmt |
| Mission | MAKING A DIFFERENCE IN PEOPLE'S LIVES THROUGH EXCELLENT PATIENT CARE. | MissionDesc |
| Significant New Program Srvc | 0 | SignificantNewProgramSrvcInd |
| Significant Change | 0 | SignificantChangeInd |
| Expense | $14,795,137 | ExpenseAmt |
| Grant | $960 | GrantAmt |
| Revenue | $16,326,052 | RevenueAmt |
| Desc | ANTELOPE MEMORIAL HOSPITAL IS A 23-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. | Desc |
| Total Program Service Expenses | $14,795,137 | TotalProgramServiceExpensesAmt |
| Described In Section501c3 | Yes (1) | DescribedInSection501c3Ind |
| Schedule B Required | Yes (1) | ScheduleBRequiredInd |
| Political Campaign Acty | 0 | PoliticalCampaignActyInd |
| Lobbying Activities | Yes (1) | LobbyingActivitiesInd |
| Subject To Proxy Tax | 0 | SubjectToProxyTaxInd |
| Donor Advised Fund | 0 | DonorAdvisedFundInd |
| Conservation Easements | 0 | ConservationEasementsInd |
| Collections Of Art | 0 | CollectionsOfArtInd |
| Credit Counseling | 0 | CreditCounselingInd |
| Donor Rstr Or Quasi Endowments | 0 | DonorRstrOrQuasiEndowmentsInd |
| Report Land Building Equipment | Yes (1) | ReportLandBuildingEquipmentInd |
| Report Investments Other Sec | 0 | ReportInvestmentsOtherSecInd |
| Report Program Related Invst | 0 | ReportProgramRelatedInvstInd |
| Report Other Assets | Yes (1) | ReportOtherAssetsInd |
| Report Other Liabilities | Yes (1) | ReportOtherLiabilitiesInd |
| Include FIN48 Footnote | Yes (1) | IncludeFIN48FootnoteInd |
| Independent Audit Fincl Stmt | Yes (1) | IndependentAuditFinclStmtInd |
| Consolidated Audit Fincl Stmt | 0 | ConsolidatedAuditFinclStmtInd |
| School Operating | 0 | SchoolOperatingInd |
| Foreign Office | 0 | ForeignOfficeInd |
| Foreign Activities | 0 | ForeignActivitiesInd |
| More Than5000 K To Org | 0 | MoreThan5000KToOrgInd |
| More Than5000 K To Individuals | 0 | MoreThan5000KToIndividualsInd |
| Professional Fundraising | 0 | ProfessionalFundraisingInd |
| Fundraising Activities | 0 | FundraisingActivitiesInd |
| Gaming Activities | 0 | GamingActivitiesInd |
| Operate Hospital | Yes (1) | OperateHospitalInd |
| Audited Financial Stmt Att | Yes (1) | AuditedFinancialStmtAttInd |
| Grants To Organizations | 0 | GrantsToOrganizationsInd |
| Grants To Individuals | 0 | GrantsToIndividualsInd |
| Schedule J Required | Yes (1) | ScheduleJRequiredInd |
| Tax Exempt Bonds | Yes (1) | TaxExemptBondsInd |
| Invest Tax Exempt Bonds | 0 | InvestTaxExemptBondsInd |
| Escrow Account | 0 | EscrowAccountInd |
| On Behalf Of Issuer | 0 | OnBehalfOfIssuerInd |
| Engaged In Excess Benefit Trans | 0 | EngagedInExcessBenefitTransInd |
| PY Excess Benefit Trans | 0 | PYExcessBenefitTransInd |
| Loan Outstanding | 0 | LoanOutstandingInd |
| Grant To Related Person | 0 | GrantToRelatedPersonInd |
| Business Rln With Org Mem | 0 | BusinessRlnWithOrgMemInd |
| Business Rln With Fam Mem | 0 | BusinessRlnWithFamMemInd |
| Business Rln With35 Ctrl Ent | 0 | BusinessRlnWith35CtrlEntInd |
| Deductible Non Cash Contri | 0 | DeductibleNonCashContriInd |
| Deductible Art Contribution | 0 | DeductibleArtContributionInd |
| Terminate Operations | 0 | TerminateOperationsInd |
| Partial Liquidation | 0 | PartialLiquidationInd |
| Disregarded Entity | 0 | DisregardedEntityInd |
| Related Entity | 0 | RelatedEntityInd |
| Related Organization Ctrl Ent | 0 | RelatedOrganizationCtrlEntInd |
| Trnsfr Exmpt Non Chrtbl Rltd Org | 0 | TrnsfrExmptNonChrtblRltdOrgInd |
| Activities Conducted Prtshp | 0 | ActivitiesConductedPrtshpInd |
| Schedule O Required | Yes (1) | ScheduleORequiredInd |
| IRP Document | 34 | IRPDocumentCnt |
| IRP Document W2 G | 0 | IRPDocumentW2GCnt |
| Backup Wthld Compliance | Yes (1) | BackupWthldComplianceInd |
| Employee | 206 | EmployeeCnt |
| Employment Tax Returns Filed | Yes (1) | EmploymentTaxReturnsFiledInd |
| Unrelated Bus Incm Over Limit | 0 | UnrelatedBusIncmOverLimitInd |
| Foreign Financial Account | 0 | ForeignFinancialAccountInd |
| Prohibited Tax Shelter Trans | 0 | ProhibitedTaxShelterTransInd |
| Taxable Party Notification | 0 | TaxablePartyNotificationInd |
| Nondeductible Contributions | 0 | NondeductibleContributionsInd |
| Quid Pro Quo Contributions | 0 | QuidProQuoContributionsInd |
| Form8282 Property Disposed Of | 0 | Form8282PropertyDisposedOfInd |
| Rcv Fnds To Pay Prsnl Bnft Cntrct | 0 | RcvFndsToPayPrsnlBnftCntrctInd |
| Pay Premiums Prsnl Bnft Cntrct | 0 | PayPremiumsPrsnlBnftCntrctInd |
| Indoor Tanning Services | 0 | IndoorTanningServicesInd |
| Subj To Tax Rmnrtn Ex Prcht Pymt | 0 | SubjToTaxRmnrtnExPrchtPymtInd |
| Subject To Excs Tax Net Invst Inc | 0 | SubjectToExcsTaxNetInvstIncInd |
| Info In Schedule O Part VI | Yes (X) | InfoInScheduleOPartVIInd |
| Governing Body Voting Members | 11 | GoverningBodyVotingMembersCnt |
| Independent Voting Member | 11 | IndependentVotingMemberCnt |
| Family Or Business Rln | 0 | FamilyOrBusinessRlnInd |
| Delegation Of Mgmt Duties | 0 | DelegationOfMgmtDutiesInd |
| Change To Org Documents | 0 | ChangeToOrgDocumentsInd |
| Material Diversion Or Misuse | 0 | MaterialDiversionOrMisuseInd |
| Members Or Stockholders | 0 | MembersOrStockholdersInd |
| Election Of Board Members | 0 | ElectionOfBoardMembersInd |
| Decisions Subject To Approva | 0 | DecisionsSubjectToApprovaInd |
| Minutes Of Governing Body | Yes (1) | MinutesOfGoverningBodyInd |
| Minutes Of Committees | Yes (1) | MinutesOfCommitteesInd |
| Officer Mailing Address | 0 | OfficerMailingAddressInd |
| Local Chapters | 0 | LocalChaptersInd |
| Form990 Provided To Gvrn Body | Yes (1) | Form990ProvidedToGvrnBodyInd |
| Conflict Of Interest Policy | Yes (1) | ConflictOfInterestPolicyInd |
| Annual Disclosure Covered Prsn | Yes (1) | AnnualDisclosureCoveredPrsnInd |
| Regular Monitoring Enfrc | Yes (1) | RegularMonitoringEnfrcInd |
| Whistleblower Policy | Yes (1) | WhistleblowerPolicyInd |
| Document Retention Policy | Yes (1) | DocumentRetentionPolicyInd |
| Compensation Process CEO | Yes (1) | CompensationProcessCEOInd |
| Compensation Process Other | 0 | CompensationProcessOtherInd |
| Investment In Joint Venture | 0 | InvestmentInJointVentureInd |
| Upon Request | Yes (X) | UponRequestInd |
Books In Care Of Detail BooksInCareOfDetail
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person | MARTHA NELSON | PersonNm |
| Phone | 4028876282 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | PO BOX 229 | AddressLine1Txt |
| City | NELIGH | CityNm |
| State Abbreviation | NE | StateAbbreviationCd |
| ZIP | 68756 | ZIPCd |
Form990 Part VII Section A Form990PartVIISectionAGrp (19 entries)
| TitleTitleTxt | Average Hours Per WeekAverageHoursPerWeekRt | Individual Trustee Or DirectorIndividualTrusteeOrDirectorInd | OfficerOfficerInd | Reportable Comp From OrgReportableCompFromOrgAmt | Reportable Comp From Rltd OrgReportableCompFromRltdOrgAmt | Other CompensationOtherCompensationAmt | Highest Compensated EmployeeHighestCompensatedEmployeeInd |
|---|---|---|---|---|---|---|---|
| JOHN MLNARIK | |||||||
| PRESIDENT | 4.00 | Yes (X) | Yes (X) | $0 | $0 | $0 | |
| JAMES BLACKBURN | |||||||
| VICE PRESIDENT | 4.00 | Yes (X) | Yes (X) | $0 | $0 | $0 | |
| JAMES MEURET | |||||||
| SECRETARY/TREASURER | 4.00 | Yes (X) | Yes (X) | $0 | $0 | $0 | |
| JON SCHILLING | |||||||
| MEMBER | 2.00 | Yes (X) | $0 | $0 | $0 | ||
| GORDON SHRADER | |||||||
| MEMBER | 2.00 | Yes (X) | $0 | $0 | $0 | ||
| MAURY SOPER | |||||||
| MEMBER | 2.00 | Yes (X) | $0 | $0 | $0 | ||
| SAMANTHA STOLTZ | |||||||
| MEMBER | 2.00 | Yes (X) | $0 | $0 | $0 | ||
| DAVID SULLIVAN | |||||||
| MEMBER | 2.00 | Yes (X) | $0 | $0 | $0 | ||
| CHRISTOPHER TWIBELL | |||||||
| MEMBER | 2.00 | Yes (X) | $0 | $0 | $0 | ||
| DR RUSSELL VETICK | |||||||
| MEMBER | 2.00 | Yes (X) | $0 | $0 | $0 | ||
| TOM ZWINGMAN | |||||||
| MEMBER | 2.00 | Yes (X) | $0 | $0 | $0 | ||
| PHILIP KLUTHE | |||||||
| MEMBER THRU 9/20 | 2.00 | Yes (X) | $0 | $0 | $0 | ||
| DIANE CARLIN | |||||||
| ADMINISTRATOR/CEO | 40.00 | Yes (X) | $252,228 | $0 | $13,845 | ||
| MARTHA NELSON | |||||||
| CFO | 36.00 | Yes (X) | $162,219 | $0 | $31,113 | ||
| ROGER RUDLOFF MD | |||||||
| PHYSICIAN | 40.00 | $427,977 | $0 | $30,914 | Yes (X) | ||
| TROY DAWSON MD | |||||||
| PHYSICIAN | 40.00 | $371,420 | $0 | $38,214 | Yes (X) | ||
| KELLI OSBORN MD | |||||||
| PHYSICIAN | 40.00 | $285,857 | $0 | $43,454 | Yes (X) | ||
| PATRICIA GOOD APRN | |||||||
| APRN | 40.00 | $151,584 | $0 | $17,602 | Yes (X) | ||
| KAREN GALLAGHER | |||||||
| PHARMACIST | 40.00 | $140,127 | $0 | $14,203 | Yes (X) | ||
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Reportable Comp From Org | $1,791,412 | TotalReportableCompFromOrgAmt |
| Tot Reportable Comp Rltd Org | $0 | TotReportableCompRltdOrgAmt |
| Total Other Compensation | $189,345 | TotalOtherCompensationAmt |
| Indiv Rcvd Greater Than100 K | 8 | IndivRcvdGreaterThan100KCnt |
| Former Ofcr Employees Listed | 0 | FormerOfcrEmployeesListedInd |
| Total Comp Greater Than150 K | Yes (1) | TotalCompGreaterThan150KInd |
| Compensation From Other Srcs | 0 | CompensationFromOtherSrcsInd |
Contractor Compensation ContractorCompensationGrp (4 entries)
| Address Line1ContractorAddress/USAddress/AddressLine1Txt | CityContractorAddress/USAddress/CityNm | State AbbreviationContractorAddress/USAddress/StateAbbreviationCd | ZIPContractorAddress/USAddress/ZIPCd | ServicesServicesDesc | CompensationCompensationAmt |
|---|---|---|---|---|---|
| PINNACLE ANESTHESIA SERVICES | |||||
| 608 EAST 4TH STREET | NELIGH | NE | 68756 | NURSING SERVICES | $425,000 |
| OVERLAND REHAB SERVICES | |||||
| 405 JAMES STREET | VERDIGRE | NE | 68783 | PHYSICAL THERAPY SERVICES | $361,120 |
| PSYCHIATRIC MEDICAL SERVICES | |||||
| 8 CADILLAC DRIVE SUITE 230 | BRENTWOOD | TN | 37027 | PSYCHIATRIC SERVICES | $322,575 |
| DOCS WHO CARE | |||||
| 1337 S FOUNTAIN DRIVE | OLATHE | KS | 66061 | ER COVERAGE | $251,506 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Cntrct Rcvd Greater Than100 K | 4 | CntrctRcvdGreaterThan100KCnt |
| Government Grants | $5,007,734 | GovernmentGrantsAmt |
| All Other Contributions | $156,036 | AllOtherContributionsAmt |
| Total Contributions | $5,163,770 | TotalContributionsAmt |
Program Service Revenue ProgramServiceRevenueGrp (4 entries)
| DescDesc | BusinessBusinessCd | Total Revenue ColumnTotalRevenueColumnAmt | Related Or Exempt Func IncomeRelatedOrExemptFuncIncomeAmt |
|---|---|---|---|
| MEDICARE/MEDICAID PAYMENTS | 621400 | $9,569,967 | $9,569,967 |
| NET PATIENT SERVICE REVENUE | 621400 | $6,256,718 | $6,256,718 |
| 340B REVENUE | 611400 | $456,087 | $456,087 |
| AMBULANCE | 621910 | $6,600 | $6,600 |
Total Oth Program Service Rev TotalOthProgramServiceRevGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $36,680 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $36,680 | RelatedOrExemptFuncIncomeAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Revenue | $16,326,052 | TotalProgramServiceRevenueAmt |
Investment Income InvestmentIncomeGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $121,816 | TotalRevenueColumnAmt |
| Exclusion | $121,816 | ExclusionAmt |
Gross Amount Sales Assets GrossAmountSalesAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | $62,222 | OtherAmt |
Less Cost Oth Basis Sales Expnss LessCostOthBasisSalesExpnssGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | $38,833 | OtherAmt |
Gain Or Loss GainOrLossGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | $23,389 | OtherAmt |
Net Gain Or Loss Investments NetGainOrLossInvestmentsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $23,389 | TotalRevenueColumnAmt |
| Exclusion | $23,389 | ExclusionAmt |
Other Revenue Misc OtherRevenueMiscGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Desc | CAFETERIA | Desc |
| Business | 900099 | BusinessCd |
| Total Revenue Column | $55,489 | TotalRevenueColumnAmt |
| Exclusion | $55,489 | ExclusionAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Revenue Total | $55,489 | OtherRevenueTotalAmt |
Total Revenue TotalRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $21,690,516 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $16,326,052 | RelatedOrExemptFuncIncomeAmt |
| Unrelated Business Revenue | $0 | UnrelatedBusinessRevenueAmt |
| Exclusion | $200,694 | ExclusionAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part IX | Yes (X) | InfoInScheduleOPartIXInd |
Grants To Domestic Orgs GrantsToDomesticOrgsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $960 | TotalAmt |
| Program Services | $960 | ProgramServicesAmt |
Comp Current Ofcr Directors CompCurrentOfcrDirectorsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $459,405 | TotalAmt |
| Management And General | $459,405 | ManagementAndGeneralAmt |
Other Salaries And Wages OtherSalariesAndWagesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $7,543,395 | TotalAmt |
| Program Services | $6,651,276 | ProgramServicesAmt |
| Management And General | $892,119 | ManagementAndGeneralAmt |
Pension Plan Contributions PensionPlanContributionsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $219,108 | TotalAmt |
| Program Services | $178,787 | ProgramServicesAmt |
| Management And General | $40,321 | ManagementAndGeneralAmt |
Other Employee Benefits OtherEmployeeBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $782,496 | TotalAmt |
| Program Services | $655,720 | ProgramServicesAmt |
| Management And General | $126,776 | ManagementAndGeneralAmt |
Payroll Taxes PayrollTaxesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $510,963 | TotalAmt |
| Program Services | $443,082 | ProgramServicesAmt |
| Management And General | $67,881 | ManagementAndGeneralAmt |
Fees For Services Legal FeesForServicesLegalGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $9,043 | TotalAmt |
| Management And General | $9,043 | ManagementAndGeneralAmt |
Fees For Services Accounting FeesForServicesAccountingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $50,948 | TotalAmt |
| Management And General | $50,948 | ManagementAndGeneralAmt |
Fees For Services Other FeesForServicesOtherGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $2,513,903 | TotalAmt |
| Program Services | $2,353,768 | ProgramServicesAmt |
| Management And General | $160,135 | ManagementAndGeneralAmt |
Advertising AdvertisingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $101,391 | TotalAmt |
| Program Services | $8,290 | ProgramServicesAmt |
| Management And General | $93,101 | ManagementAndGeneralAmt |
Office Expenses OfficeExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $725,145 | TotalAmt |
| Program Services | $615,231 | ProgramServicesAmt |
| Management And General | $109,914 | ManagementAndGeneralAmt |
Information Technology InformationTechnologyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $513,859 | TotalAmt |
| Program Services | $413,022 | ProgramServicesAmt |
| Management And General | $100,837 | ManagementAndGeneralAmt |
Occupancy OccupancyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $232,327 | TotalAmt |
| Program Services | $222,733 | ProgramServicesAmt |
| Management And General | $9,594 | ManagementAndGeneralAmt |
Travel TravelGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $29,411 | TotalAmt |
| Program Services | $27,155 | ProgramServicesAmt |
| Management And General | $2,256 | ManagementAndGeneralAmt |
Interest InterestGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $28,702 | TotalAmt |
| Program Services | $27,426 | ProgramServicesAmt |
| Management And General | $1,276 | ManagementAndGeneralAmt |
Depreciation Depletion DepreciationDepletionGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,165,118 | TotalAmt |
| Program Services | $1,113,314 | ProgramServicesAmt |
| Management And General | $51,804 | ManagementAndGeneralAmt |
Insurance InsuranceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $171,357 | TotalAmt |
| Program Services | $163,738 | ProgramServicesAmt |
| Management And General | $7,619 | ManagementAndGeneralAmt |
Other Expenses OtherExpensesGrp (4 entries)
| DescDesc | TotalTotalAmt | Program ServicesProgramServicesAmt | Management And GeneralManagementAndGeneralAmt |
|---|---|---|---|
| MEDICAL SUPPLIES | $1,339,070 | $1,339,070 | |
| BAD DEBT | $507,737 | $507,737 | |
| MISCELLANEOUS EXPENSE | $80,385 | $26,993 | $53,392 |
| DUES & SUBSCRIPTIONS | $67,355 | $46,835 | $20,520 |
Total Functional Expenses TotalFunctionalExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $17,052,078 | TotalAmt |
| Program Services | $14,795,137 | ProgramServicesAmt |
| Management And General | $2,256,941 | ManagementAndGeneralAmt |
| Fundraising | $0 | FundraisingAmt |
Cash Non Interest Bearing CashNonInterestBearingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $181,407 | BOYAmt |
| EOY | $403,460 | EOYAmt |
Savings And Temp Cash Invst SavingsAndTempCashInvstGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $17,181,393 | BOYAmt |
| EOY | $14,498,321 | EOYAmt |
Pledges And Grants Receivable PledgesAndGrantsReceivableGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $6,375 | BOYAmt |
| EOY | $5,525 | EOYAmt |
Accounts Receivable AccountsReceivableGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,791,300 | BOYAmt |
| EOY | $1,317,153 | EOYAmt |
Oth Notes Loans Receivable Net OthNotesLoansReceivableNetGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $99,193 | BOYAmt |
| EOY | $177,829 | EOYAmt |
Inventories For Sale Or Use InventoriesForSaleOrUseGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $320,017 | BOYAmt |
| EOY | $341,212 | EOYAmt |
Prepaid Expenses Defrd Charges PrepaidExpensesDefrdChargesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $108,110 | BOYAmt |
| EOY | $143,277 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Land Bldg Equip Cost Or Other Bss | $26,154,799 | LandBldgEquipCostOrOtherBssAmt |
| Land Bldg Equip Accum Deprec | $16,029,754 | LandBldgEquipAccumDeprecAmt |
Land Bldg Equip Basis Net LandBldgEquipBasisNetGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $10,003,256 | BOYAmt |
| EOY | $10,125,045 | EOYAmt |
Investments Pub Traded Sec InvestmentsPubTradedSecGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $530,359 | BOYAmt |
| EOY | $584,454 | EOYAmt |
Other Assets Total OtherAssetsTotalGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $85,637 | BOYAmt |
| EOY | $1,499,408 | EOYAmt |
Total Assets TotalAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $30,307,047 | BOYAmt |
| EOY | $29,095,684 | EOYAmt |
Accounts Payable Accr Expnss AccountsPayableAccrExpnssGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,710,342 | BOYAmt |
| EOY | $1,999,146 | EOYAmt |
Tax Exempt Bond Liabilities TaxExemptBondLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,147,808 | BOYAmt |
| EOY | $873,539 | EOYAmt |
Unsecured Notes Loans Payable UnsecuredNotesLoansPayableGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,542,700 | BOYAmt |
Other Liabilities OtherLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $9,791,377 | BOYAmt |
| EOY | $5,433,586 | EOYAmt |
Total Liabilities TotalLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $14,192,227 | BOYAmt |
| EOY | $8,306,271 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Organization Follows FASB117 | Yes (X) | OrganizationFollowsFASB117Ind |
No Donor Restriction Net Assets NoDonorRestrictionNetAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $16,099,550 | BOYAmt |
| EOY | $20,777,888 | EOYAmt |
Donor Restriction Net Assets DonorRestrictionNetAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $15,270 | BOYAmt |
| EOY | $11,525 | EOYAmt |
Total Net Assets Fund Balance TotalNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $16,114,820 | BOYAmt |
| EOY | $20,789,413 | EOYAmt |
Tot Liab Net Assets Fund Balance TotLiabNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $30,307,047 | BOYAmt |
| EOY | $29,095,684 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Reconcilation Revenue Expnss | $4,638,438 | ReconcilationRevenueExpnssAmt |
| Net Unrlzd Gains Losses Invst | $36,155 | NetUnrlzdGainsLossesInvstAmt |
| Other Changes In Net Assets | $0 | OtherChangesInNetAssetsAmt |
| Info In Schedule O Part XII | Yes (X) | InfoInScheduleOPartXIIInd |
| Method Of Accounting Accrual | Yes (X) | MethodOfAccountingAccrualInd |
| Accountant Compile Or Review | 0 | AccountantCompileOrReviewInd |
| FS Audited | Yes (1) | FSAuditedInd |
FS Audited Basis FSAuditedBasisGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Separate Basis Fincl Stmt | Yes (X) | SeparateBasisFinclStmtInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Audit Committee | Yes (1) | AuditCommitteeInd |
| Federal Grant Audit Required | Yes (1) | FederalGrantAuditRequiredInd |
| Federal Grant Audit Performed | Yes (1) | FederalGrantAuditPerformedInd |
Schedule A IRS990ScheduleA
| Field | Value | IRS element (for citing) |
|---|---|---|
| Hospital | Yes (X) | HospitalInd |
Schedule B IRS990ScheduleB
Contributor Information ContributorInformationGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Contributor | RESTRICTED | ContributorNum |
Contributor Business Name ContributorBusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | RESTRICTED | BusinessNameLine1 |
Contributor US Address ContributorUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | RESTRICTED | AddressLine1 |
| Address Line2 | RESTRICTED | AddressLine2 |
| City | RESTRICTED | City |
| State | RESTRICTED | State |
| ZIP Code | RESTRICTED | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Contributions | RESTRICTED | TotalContributionsAmt |
Schedule C IRS990ScheduleC
| Field | Value | IRS element (for citing) |
|---|---|---|
| Volunteers | 0 | VolunteersInd |
| Paid Staff Or Management | 0 | PaidStaffOrManagementInd |
| Media Advertisements | 0 | MediaAdvertisementsInd |
| Mailings Members | 0 | MailingsMembersInd |
| Publications Or Broadcast | 0 | PublicationsOrBroadcastInd |
| Grants Other Organizations | 0 | GrantsOtherOrganizationsInd |
| Direct Contact Legislators | 0 | DirectContactLegislatorsInd |
| Rallies Demonstrations | 0 | RalliesDemonstrationsInd |
| Other Activities | Yes (1) | OtherActivitiesInd |
| Other Activities | $1,657 | OtherActivitiesAmt |
| Total Lobbying Expenditures | $1,657 | TotalLobbyingExpendituresAmt |
| Not Described Section501c3 | 0 | NotDescribedSection501c3Ind |
Supplemental Information Detail SupplementalInformationDetail
| Field | Value | IRS element (for citing) |
|---|---|---|
| Form And Line Reference | PART II-B, LINE 1: | FormAndLineReferenceDesc |
| Explanation | PORTION OF THE DUES PAID TO THE NEBRASKA HOSPITAL ASSOCIATION AND THE AMERICAN HOSPITAL ASSOCIATION ARE ALLOCABLE TO LOBBYING ACTIVITIES. | ExplanationTxt |
Schedule D IRS990ScheduleD
Land LandGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $124,229 | OtherCostOrOtherBasisAmt |
| Book Value | $124,229 | BookValueAmt |
Buildings BuildingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $8,048,290 | OtherCostOrOtherBasisAmt |
| Depreciation | $4,734,672 | DepreciationAmt |
| Book Value | $3,313,618 | BookValueAmt |
Equipment EquipmentGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $13,637,055 | OtherCostOrOtherBasisAmt |
| Depreciation | $9,514,375 | DepreciationAmt |
| Book Value | $4,122,680 | BookValueAmt |
Other Land Buildings OtherLandBuildingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $4,345,225 | OtherCostOrOtherBasisAmt |
| Depreciation | $1,780,707 | DepreciationAmt |
| Book Value | $2,564,518 | BookValueAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Book Value Land Buildings | $10,125,045 | TotalBookValueLandBuildingsAmt |
Other Assets Org OtherAssetsOrgGrp (3 entries)
| DescDesc | Book ValueBookValueAmt |
|---|---|
| ACCRUED INTEREST RECEIVABLE | $1,993 |
| 340B RECEIVABLE | $59,454 |
| DEPOSIT ON RENOVATION PROJECT | $1,437,961 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Book Value Other Assets | $1,499,408 | TotalBookValueOtherAssetsAmt |
Other Liabilities Org OtherLiabilitiesOrgGrp (3 entries)
| DescDesc | AmtAmt |
|---|---|
| ESTIMATED THIRD-PARTY PAYER SETTLEMENT | $343,233 |
| REFUNDABLE ADVANCES | $500,000 |
| CONTRACT LIABILITY - MEDICARE ADVANCE PAYMENTS | $4,590,353 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Liability | $5,433,586 | TotalLiabilityAmt |
| Footnote Text | Yes (X) | FootnoteTextInd |
| Total Rev Etc Audited Fincl Stmt | $21,218,934 | TotalRevEtcAuditedFinclStmtAmt |
| Net Unrealized Gains Invst | $36,155 | NetUnrealizedGainsInvstAmt |
| Revenue Not Reported | $36,155 | RevenueNotReportedAmt |
| Revenue Subtotal | $21,182,779 | RevenueSubtotalAmt |
| Other Revenues Not Included | $507,737 | OtherRevenuesNotIncludedAmt |
| Revenue Not Reported Fincl Stmt | $507,737 | RevenueNotReportedFinclStmtAmt |
| Total Revenue Per Form990 | $21,690,516 | TotalRevenuePerForm990Amt |
| Tot Expns Etc Audited Fincl Stmt | $16,544,341 | TotExpnsEtcAuditedFinclStmtAmt |
| Expenses Not Reported | $0 | ExpensesNotReportedAmt |
| Expenses Subtotal | $16,544,341 | ExpensesSubtotalAmt |
| Other Expenses Not Included | $507,737 | OtherExpensesNotIncludedAmt |
| Expenses Not Rpt Fincl Stmt | $507,737 | ExpensesNotRptFinclStmtAmt |
| Total Expenses Per Form990 | $17,052,078 | TotalExpensesPerForm990Amt |
Supplemental Information Detail SupplementalInformationDetail (3 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| PART X, LINE 2: | THE HOSPITAL IS A NOT-FOR-PROFIT CORPORATION AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE AND IS EXEMPT FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE CODE. THE INTERNAL REVENUE SERVICE HAS ESTABLISHED STANDARDS TO BE MET TO MAINTAIN TAX EXEMPT STATUS. THE HOSPITAL ACCOUNTS FOR UNCERTAINTIES IN ACCOUNTING FOR INCOME TAX ASSETS AND LIABILITIES USING GUIDANCE INCLUDED IN FASB 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, 2021 AND 2020, THE HOSPITAL HAD NO UNCERTAIN TAX POSITIONS ACCRUED. |
| PART XI, LINE 4B - OTHER ADJUSTMENTS: | PROVISION FOR BAD DEBTS 507,737. |
| PART XII, LINE 4B - OTHER ADJUSTMENTS: | PROVISION FOR BAD DEBTS 507,737. |
Schedule H IRS990ScheduleH
| Field | Value | IRS element (for citing) |
|---|---|---|
| Financial Assistance Policy | Yes (1) | FinancialAssistancePolicyInd |
| Written Policy | Yes (1) | WrittenPolicyInd |
| FPG Reference Free Care | Yes (1) | FPGReferenceFreeCareInd |
Free Care Oth Percentage FreeCareOthPercentageGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | Yes (X) | OtherInd |
| Free Care Other | 125.000000000000 | FreeCareOtherPct |
| Field | Value | IRS element (for citing) |
|---|---|---|
| FPG Reference Discounted Care | 0 | FPGReferenceDiscountedCareInd |
| Free Care Medically Indigent | Yes (1) | FreeCareMedicallyIndigentInd |
| Financial Assistance Budget | Yes (1) | FinancialAssistanceBudgetInd |
| Expenses Exceed Budget | 0 | ExpensesExceedBudgetInd |
| Annual Community Bnft Report | Yes (1) | AnnualCommunityBnftReportInd |
| Report Publically Available | Yes (1) | ReportPublicallyAvailableInd |
Financial Assistance At Cost Typ FinancialAssistanceAtCostTyp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $45,330 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $45,330 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00270 | TotalExpensePct |
Unreimbursed Medicaid UnreimbursedMedicaidGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $1,359,649 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $1,097,330 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $262,319 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.01590 | TotalExpensePct |
Total Financial Assistance Typ TotalFinancialAssistanceTyp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $1,404,979 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $1,097,330 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $307,649 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.01860 | TotalExpensePct |
Community Health Services CommunityHealthServicesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $23,470 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $0 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $23,470 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00140 | TotalExpensePct |
Subsidized Health Services SubsidizedHealthServicesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $790,486 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $178,429 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $612,057 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.03700 | TotalExpensePct |
Cash And In Kind Contributions CashAndInKindContributionsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $960 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $960 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00010 | TotalExpensePct |
Total Other Benefits TotalOtherBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $814,916 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $178,429 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $636,487 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.03850 | TotalExpensePct |
Total Community Benefits TotalCommunityBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $2,219,895 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $1,275,759 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $944,136 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.05710 | TotalExpensePct |
Economic Development EconomicDevelopmentGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $550 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $0 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $550 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00000 | TotalExpensePct |
Workforce Development WorkforceDevelopmentGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $10,500 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $0 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $10,500 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00060 | TotalExpensePct |
Total Communtity Building Acty TotalCommuntityBuildingActyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $11,050 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $11,050 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00060 | TotalExpensePct |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bad Debt Expense Reported | Yes (1) | BadDebtExpenseReportedInd |
| Bad Debt Expense | $507,737 | BadDebtExpenseAmt |
| Bad Debt Expense Attributable | $0 | BadDebtExpenseAttributableAmt |
| Reimbursed By Medicare | $9,209,407 | ReimbursedByMedicareAmt |
| Cost Of Care Reimbursed By Medcr | $9,210,446 | CostOfCareReimbursedByMedcrAmt |
| Medicare Surplus Or Shortfall | -$1,039 | MedicareSurplusOrShortfallAmt |
Costing Methodology Used CostingMethodologyUsedGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Cost To Charge Ratio | Yes (X) | CostToChargeRatioInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Written Debt Collection Policy | Yes (1) | WrittenDebtCollectionPolicyInd |
| Financial Assistance Prvsn | 0 | FinancialAssistancePrvsnInd |
| Hospital Facilities | 1 | HospitalFacilitiesCnt |
Hospital Facilities HospitalFacilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | 1 | FacilityNum |
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | ANTELOPE MEMORIAL HOSPITAL | BusinessNameLine1Txt |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 102 WEST 9TH STREET | AddressLine1Txt |
| City | NELIGH | CityNm |
| State Abbreviation | NE | StateAbbreviationCd |
| ZIP | 68756 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Website Address | WWW.AMHNE.ORG | WebsiteAddressTxt |
| State License | 020001 | StateLicenseNum |
| Licensed Hospital | Yes (X) | LicensedHospitalInd |
| Critical Access Hospital | Yes (X) | CriticalAccessHospitalInd |
| Emergency Room24 Hrs | Yes (X) | EmergencyRoom24HrsInd |
Hospital Fclty Policies Prctc HospitalFcltyPoliciesPrctcGrp
Hospital Facility Name HospitalFacilityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | ANTELOPE MEMORIAL HOSPITAL | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | 1 | FacilityNum |
| First Licensed CY Or PY | 0 | FirstLicensedCYOrPYInd |
| Tax Exempt Hospital CY Or PY | 0 | TaxExemptHospitalCYOrPYInd |
| CHNA Conducted | Yes (1) | CHNAConductedInd |
| Community Definition | Yes (X) | CommunityDefinitionInd |
| Community Demographics | Yes (X) | CommunityDemographicsInd |
| Existing Resources | Yes (X) | ExistingResourcesInd |
| How Data Obtained | Yes (X) | HowDataObtainedInd |
| Community Health Needs | Yes (X) | CommunityHealthNeedsInd |
| Other Health Issues | Yes (X) | OtherHealthIssuesInd |
| Community Hlth Needs Id Process | Yes (X) | CommunityHlthNeedsIdProcessInd |
| Consulting Process | Yes (X) | ConsultingProcessInd |
| Prior CHNA Impact | Yes (X) | PriorCHNAImpactInd |
| CHNA Conducted | 18 | CHNAConductedYr |
| Take Into Account Others Input | Yes (1) | TakeIntoAccountOthersInputInd |
| CHNA Conducted With Other Fclts | Yes (1) | CHNAConductedWithOtherFcltsInd |
| CHNA Conducted With Non Fclts | Yes (1) | CHNAConductedWithNonFcltsInd |
| CHNA Report Widely Available | Yes (1) | CHNAReportWidelyAvailableInd |
| Rpt Available On Own Website | Yes (X) | RptAvailableOnOwnWebsiteInd |
| Own Website URL | WWW.AMHNE.ORG | OwnWebsiteURLTxt |
| Paper Copy Public Inspection | Yes (X) | PaperCopyPublicInspectionInd |
| Implementation Strategy Adopt | Yes (1) | ImplementationStrategyAdoptInd |
| Implementation Strategy Adpt | 18 | ImplementationStrategyAdptYr |
| Strategy Posted Website | Yes (1) | StrategyPostedWebsiteInd |
| Strategy Website URL | WWW.AMHNE.ORG | StrategyWebsiteURLTxt |
| Organization Incur Excise Tax | 0 | OrganizationIncurExciseTaxInd |
| Elig Criteria Explained | Yes (1) | EligCriteriaExplainedInd |
| FPG Family Incm Lmt Free Dscnt | Yes (X) | FPGFamilyIncmLmtFreeDscntInd |
| FPG Family Incm Lmt Free Care | 125.000000000000 | FPGFamilyIncmLmtFreeCarePct |
| Asset Level Criteria | Yes (X) | AssetLevelCriteriaInd |
| Insurance Status Criteria | Yes (X) | InsuranceStatusCriteriaInd |
| Underinsurance Stat Criteria | Yes (X) | UnderinsuranceStatCriteriaInd |
| Explained Basis | Yes (1) | ExplainedBasisInd |
| App Financial Asst Expln | Yes (1) | AppFinancialAsstExplnInd |
| Described Info | Yes (X) | DescribedInfoInd |
| Described Suprt Doc | Yes (X) | DescribedSuprtDocInd |
| Provided Hospital Contact | Yes (X) | ProvidedHospitalContactInd |
| Includes Publicity Measures | Yes (1) | IncludesPublicityMeasuresInd |
| FAP Available On Website | Yes (X) | FAPAvailableOnWebsiteInd |
| FAP Available On Website URL | WWW.AMHNE.ORG | FAPAvailableOnWebsiteURLTxt |
| FAP App Available On Website | Yes (X) | FAPAppAvailableOnWebsiteInd |
| FAP App Available On Website URL | WWW.AMHNE.ORG | FAPAppAvailableOnWebsiteURLTxt |
| FAP Summary On Website | Yes (X) | FAPSummaryOnWebsiteInd |
| FAP Summary On Website URL | WWW.AMHNE.ORG | FAPSummaryOnWebsiteURLTxt |
| FAP Avlbl On Request No Charge | Yes (X) | FAPAvlblOnRequestNoChargeInd |
| FAP App Avlbl On Request No Chrg | Yes (X) | FAPAppAvlblOnRequestNoChrgInd |
| FAP Sum Avlbl On Request No Chrg | Yes (X) | FAPSumAvlblOnRequestNoChrgInd |
| Notified FAP Copy Bill Display | Yes (X) | NotifiedFAPCopyBillDisplayInd |
| Communtity Notified FAP | Yes (X) | CommuntityNotifiedFAPInd |
| FAP Translated | Yes (X) | FAPTranslatedInd |
| FAP Actions On Nonpayment | Yes (1) | FAPActionsOnNonpaymentInd |
| Permit No Actions | Yes (X) | PermitNoActionsInd |
| Collection Activities | 0 | CollectionActivitiesInd |
| Provided Written Notice | Yes (X) | ProvidedWrittenNoticeInd |
| Made Effort Orally Notify | Yes (X) | MadeEffortOrallyNotifyInd |
| Processed FAP Application | Yes (X) | ProcessedFAPApplicationInd |
| Made Presumptive Elig Determ | Yes (X) | MadePresumptiveEligDetermInd |
| Nondis Emergency Care Policy | Yes (1) | NondisEmergencyCarePolicyInd |
| Prospective Medicare Medicaid | Yes (X) | ProspectiveMedicareMedicaidInd |
| Amounts Generally Billed | 0 | AmountsGenerallyBilledInd |
| Gross Charges | 0 | GrossChargesInd |
Supplemental Information SupplementalInformationGrp (4 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| 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) CHERRY COUNTY HOSPITAL, VALENTINE, NE (CHERRY COUNTY) ROCK COUNTY HOSPITAL, BASSETT, NE (BROWN COUNTY) |
| ANTELOPE MEMORIAL HOSPITAL | PART V, SECTION B, LINE 6B: NORTH CENTRAL DISTRICT HEALTH DEPARTMENT (NCDHD) THE EVERGREEN ASSISTED LIVING FACILITY COTTONWOOD VILLA ASSISTED LIVING FACILITY GOOD SAMARITAN SOCIETY - ATKINSON PREGANCY RESOURCE CENTER FINISH LINE CHIROPRACTIC COUNSELING AND ENRICHMENT CENTER / BUILDING BLOCKS REGION 4 BEHAVIORAL HEALTH SYSTEM CENTRAL NEBRASKA COMMUNITY ACTION PARTNERSHIP NORTHEAST NEBRASKA COMMUNITY ACTION PARTNERSHIP NORTHWEST NEBRASKA COMMUNITY ACTION PARTNERSHIP NORTHSTAR SERVICES NCDHD BOARD OF HEALTH NORTH CENTRAL COMMUNITY CARE PARTNERSHIP AREA SUBSTANCE ABUSE PREVENTION COALITION O'NEILL CHAMBER OF COMMERCE CENTRAL NEBRASKA ECONOMIC DEVELOPMENT HOLT COUNTY ECONOMIC DEVELOPMENT KNOX COUNTY ECONOMIC DEVELOPMENT NELIGH ECONOMIC DEVELOPMENT PIERCE COUNTY ECONOMIC DEVELOPMENT UNIVERSITY OF NEBRASKA LINCOLN EXTENSION OFFICE, BROWN-ROCK-KEYA -PAHA COUNTY EWING PUBLIC SCHOOL LYNCH PUBLIC SCHOOL O'NEILL PUBLIC SCHOOL BOARD O'NEILL MINISTERIAL ASSOCIATION WEST HOLT HEALTH MINISTRIES O'NEILL LIONS CLUB O'NEILL ROTARY CLUB MITCHELL EQUIPMENT - O'NEILL, NE FAMILY SERVICE CHILD CARE FOOD PROGRAM |
| 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: - CHRONIC DISEASE DETECTION & MANAGEMENT - MENTAL WELLNESSGOALS DEVELOPED BY ANTELOPE MEMORIAL HOSPITAL TO ADDRESS THE FOCUS AREAS: - EFFECTIVELY SCREEN AND MANAGE CHRONIC DISEASE THROUGHOUT ANTELOPE COUNTY: ANTELOPE MEMORIAL HOSPITAL WILL CONTINUE TO SUPPORT AND ENHANCE PROGRAMS ALREADY ESTABLISHED WITH KNOWN POSITIVE IMPACTS WHILE ALSO DEVELOPING NEW STRATEGIES TO EDUCATE THE COMMUNITY ON PREVENTIVE HEALTH. WE WILL ALSO FOLLOW STANDARD PREVENTIVE GUIDELINES TO PROVIDE PREVENTIVE CARE SUCH AS SCREENINGS, TESTS, VACCINATIONS AND COUNSELING SERVICES. WE WILL CONTINUE TO OFFER HEALTH FAIRS AND INCLUDE GUIDANCE AND SUPPORT ON HEALTHY LIVING AND PREVENTIVE MEASURES. - MENTAL HEALTH WILL BE PROMOTED THROUGHOUT ANTELOPE COUNTY AS AN INTEGRAL PART OF OVERALL WELL-BEING: ANTELOPE MEMORIAL HOSPITAL WILL CONTINUE TO PROMOTE ITS MENTAL HEALTH SERVICES ALREADY AVAILABLE, AND COLLABORATE WITH LOCAL ENTITIES TO OFFER INCREASED INPUT AND HEALTH - RELATED EXPERTISE TO ENCOURAGE AND IMPROVE PARTICIPATION . WE WILL ALSO COLLABORATE WITH OUTSIDE AGENCIES TO EXPAND OUR MENTAL HEALTH SERVICES.THE IDENTIFIED NEEDS THAT ARE NOT BEING ADDRESSED INCLUDE INJURY, SUBSTANCE ABUSE, ORAL HEALTH AND DISABILITY. THESE NEEDS CANNOT BE CURRENTLY SOLVED IN A MEANINGFUL WAY DUE TO FINANCIAL LIMITATION, LACK OF RESOURCES AND/OR LACK OF EXPERTISE. |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | 5 | FacilityNum |
Oth Hlth Care Fclts Not Hospital OthHlthCareFcltsNotHospitalGrp
Oth Hlth Care Fclts OthHlthCareFcltsGrp (5 entries)
| Address Line1USAddress/AddressLine1Txt | CityUSAddress/CityNm | State AbbreviationUSAddress/StateAbbreviationCd | ZIPUSAddress/ZIPCd | FacilityFacilityTxt |
|---|---|---|---|---|
| 1 - AMH FAMILY PRACTICE | ||||
| 109 WEST 11TH STREET PO BOX 109 | NELIGH | NE | 68756 | FAMILY PRACTICE MEDICAL CLINIC |
| 2 - AMH CLEARWATER CLINIC | ||||
| 308 NEVADA STREET | CLEARWATER | NE | 68726 | FAMILY PRACTICE MEDICAL CLINIC |
| 3 - AMH ELGIN CLINIC | ||||
| 101 WEST CEDAR STREET | ELGIN | NE | 68636 | FAMILY PRACTICE MEDICAL CLINIC |
| 4 - ORCHARD MEDICAL CLINIC | ||||
| 103 WASHINGTON STREET | ORCHARD | NE | 68764 | FAMILY PRACTICE MEDICAL CLINIC |
| 5 - AMH TILDEN CLINIC | ||||
| 104 SOUTH CENTER | TILDEN | NE | 68781 | FAMILY PRACTICE MEDICAL CLINIC |
Supplemental Information Detail SupplementalInformationDetail (16 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| 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 I, LN 7 COL(F): | THE COST OF BAD DEBT THAT HAS BEEN SUBTRACTED FROM TOTAL EXPENSES TO DETERMINE THE DENOMINATOR IN THE PERCENTAGES FOR COLUMN (F) IS $507,737. |
| 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- PARTICIPATION IN THE FAMILY MEDICINE REINVESTMENT PROGRAM, WHICH HAS THE POTENTIAL TO PLACE YOUNG DOCTORS IN RURAL COMMUNITIES |
| PART III, LINE 2: | GENERALLY, PATIENTS WHO ARE COVERED BY THIRD-PARTY PAYORS ARE RESPONSIBLE FOR RELATED DEDUCTIBLES AND COINSURANCE, WHICH VARY IN AMOUNT. THE HOSPITAL PROVIDES SERVICES TO UNINSURED PATIENTS, AND OFFERS THOSE UNINSURED PATIENTS A DISCOUNT, EITHER BY POLICY OR LAW, FROM STANDARD CHARGES. THE HOSPITAL ESTIMATES THE TRANSACTION PRICE FOR PATIENTS WITH DEDUCTIBLES AND COINSURANCE AND FROM THOSE WHO ARE UNINSURED BASED ON HISTORICAL EXPERIENCE AND CURRENT MARKET CONDITIONS. THE INITIAL ESTIMATE OF THE TRANSACTION PRICE IS DETERMINED BY REDUCING THE STANDARD CHARGE BY ANY CONTRACTUAL ADJUSTMENTS, DISCOUNTS AND IMPLICIT PRICE CONCESSIONS. FOR THE YEARS ENDED JUNE 30, 2021 AND 2020, NO SIGNIFICANT ADJUSTMENTS TO REVENUE WERE RECOGNIZED DUE TO CHANGES IN ESTIMATES OF IMPLICIT PRICE CONCESSIONS FOR PERFORMANCE OBLIGATIONS SATISFIED IN PRIOR YEARS. SUBSEQUENT CHANGES TO THE ESTIMATE OF THE TRANSACTION PRICE ARE RECORDED AS ADJUSTMENTS TO PATIENT SERVICE REVENUE IN THE PERIOD OF CHANGE. SUBSEQUENT CHANGES THAT ARE DETERMINED TO BE THE RESULT OF AN ADVERSE CHANGE IN THE PATIENT'S ABILITY TO PAY ARE RECORDED AS BAD DEBT EXPENSE. |
| 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 7, 9 AND 10 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, THE SHORTFALL WOULD BE GREATER THAN THAT SHOWN ON LINE 7. THE SHORTFALL 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. |
Schedule J IRS990ScheduleJ
| Field | Value | IRS element (for citing) |
|---|---|---|
| Independent Consultant | Yes (X) | IndependentConsultantInd |
| Compensation Survey | Yes (X) | CompensationSurveyInd |
| Board Or Committee Approval | Yes (X) | BoardOrCommitteeApprovalInd |
| Severance Payment | 0 | SeverancePaymentInd |
| Supplemental Nonqual Rtr Plan | 0 | SupplementalNonqualRtrPlanInd |
| Equity Based Comp Arrngm | 0 | EquityBasedCompArrngmInd |
| Comp Based On Revenue Of Flng Org | 0 | CompBasedOnRevenueOfFlngOrgInd |
| Comp Bsd On Rev Related Orgs | 0 | CompBsdOnRevRelatedOrgsInd |
| Comp Bsd Net Earns Flng Org | 0 | CompBsdNetEarnsFlngOrgInd |
| Comp Bsd Net Earns Rltd Orgs | 0 | CompBsdNetEarnsRltdOrgsInd |
| Any Non Fixed Payments | 0 | AnyNonFixedPaymentsInd |
| Initial Contract Exception | 0 | InitialContractExceptionInd |
Rltd Org Officer Trst Key Empl RltdOrgOfficerTrstKeyEmplGrp (7 entries)
| TitleTitleTxt | Base Compensation Filing OrgBaseCompensationFilingOrgAmt | Compensation Based On Rltd OrgsCompensationBasedOnRltdOrgsAmt | Bonus Filing OrganizationBonusFilingOrganizationAmount | Bonus Related OrganizationsBonusRelatedOrganizationsAmt | Other Compensation Filing OrgOtherCompensationFilingOrgAmt | Other Compensation Rltd OrgsOtherCompensationRltdOrgsAmt | Deferred Compensation Flng OrgDeferredCompensationFlngOrgAmt | Deferred Comp Rltd OrgsDeferredCompRltdOrgsAmt | Nontaxable Benefits Filing OrgNontaxableBenefitsFilingOrgAmt | Nontaxable Benefits Rltd OrgsNontaxableBenefitsRltdOrgsAmt | Total Compensation Filing OrgTotalCompensationFilingOrgAmt | Total Compensation Rltd OrgsTotalCompensationRltdOrgsAmt | Comp Report Prior990 Filing OrgCompReportPrior990FilingOrgAmt | Comp Report Prior990 Rltd OrgsCompReportPrior990RltdOrgsAmt |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| ROGER RUDLOFF MD | ||||||||||||||
| PHYSICIAN | $422,773 | $0 | $5,000 | $0 | $204 | $0 | $12,969 | $0 | $17,945 | $0 | $458,891 | $0 | $0 | $0 |
| TROY DAWSON MD | ||||||||||||||
| PHYSICIAN | $366,216 | $0 | $5,000 | $0 | $204 | $0 | $12,969 | $0 | $25,245 | $0 | $409,634 | $0 | $0 | $0 |
| KELLI OSBORN MD | ||||||||||||||
| PHYSICIAN | $280,653 | $0 | $5,000 | $0 | $204 | $0 | $12,969 | $0 | $30,485 | $0 | $329,311 | $0 | $0 | $0 |
| DIANE CARLIN | ||||||||||||||
| ADMINISTRATOR/CEO | $231,776 | $0 | $20,251 | $0 | $201 | $0 | $3,749 | $0 | $10,096 | $0 | $266,073 | $0 | $0 | $0 |
| MARTHA NELSON | ||||||||||||||
| CFO | $146,893 | $0 | $15,188 | $0 | $138 | $0 | $6,407 | $0 | $24,706 | $0 | $193,332 | $0 | $0 | $0 |
| PATRICIA GOOD APRN | ||||||||||||||
| APRN | $151,470 | $0 | $0 | $0 | $114 | $0 | $5,157 | $0 | $12,445 | $0 | $169,186 | $0 | $0 | $0 |
| KAREN GALLAGHER | ||||||||||||||
| PHARMACIST | $139,994 | $0 | $0 | $0 | $133 | $0 | $4,337 | $0 | $9,866 | $0 | $154,330 | $0 | $0 | $0 |
Schedule K IRS990ScheduleK
Tax Exempt Bonds Issues TaxExemptBondsIssuesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bond Reference | A | BondReferenceCd |
Issuer Name IssuerName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | THE COUNTY OF ANTELOPE NEBRASKA | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bond Issuer EIN | 476006428 | BondIssuerEIN |
| CUSIP | 036654AH4 | CUSIPNum |
| Bond Issued | 2015-10-15 | BondIssuedDt |
| Issue Price | $2,290,000 | IssuePriceAmt |
| Purpose | REFUND PRIOR ISSUE (12/21/2010) | PurposeDesc |
| Defeased | 0 | DefeasedInd |
| On Behalf Of Issuer | 0 | OnBehalfOfIssuerInd |
| Pool Financing | 0 | PoolFinancingInd |
Tax Exempt Bonds Proceeds TaxExemptBondsProceedsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bond Reference | A | BondReferenceCd |
| Retired | $1,395,000 | RetiredAmt |
| Total Proceeds | $2,290,280 | TotalProceedsAmt |
| Working Capital Expenditures | $91,500 | WorkingCapitalExpendituresAmt |
| Other Spent Proceeds | $2,198,780 | OtherSpentProceedsAmt |
| Substantial Completion | 2006 | SubstantialCompletionYr |
| Refunding Tax Exempt Bonds | Yes (1) | RefundingTaxExemptBondsInd |
| Refunding Taxable Bonds | 0 | RefundingTaxableBondsInd |
| Final Allocation Made | Yes (1) | FinalAllocationMadeInd |
| Adequate Books And Rec Maint | Yes (1) | AdequateBooksAndRecMaintInd |
Tax Exempt Bonds Private Bus Use TaxExemptBondsPrivateBusUseGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bond Reference | A | BondReferenceCd |
| Owning Bond Financed Property | 0 | OwningBondFinancedPropertyInd |
| Any Lease Arrangements | 0 | AnyLeaseArrangementsInd |
| Mgmt Contract Bond Fincd Prop | 0 | MgmtContractBondFincdPropInd |
| Any Research Agreements | 0 | AnyResearchAgreementsInd |
| Private Bus Use By Others | 0.00000 | PrivateBusUseByOthersPct |
| Private Bus Concerning UBI | 0.00000 | PrivateBusConcerningUBIPct |
| Total Private Business Use | 0.00000 | TotalPrivateBusinessUsePct |
| Bond Iss Meet Prvt Sec Pymt Test | 0 | BondIssMeetPrvtSecPymtTestInd |
| Change In Use Bond Financed Prop | 0 | ChangeInUseBondFinancedPropInd |
| Procs Nonqualified Bond Remdtd | Yes (1) | ProcsNonqualifiedBondRemdtdInd |
Tax Exempt Bonds Arbitrage TaxExemptBondsArbitrageGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bond Reference | A | BondReferenceCd |
| Form8038 T Filed | 0 | Form8038TFiledInd |
| Rebate Not Due Yet | 0 | RebateNotDueYetInd |
| Exception To Rebate | Yes (1) | ExceptionToRebateInd |
| No Rebate Due | Yes (1) | NoRebateDueInd |
| Variable Rate Issue | 0 | VariableRateIssueInd |
| Hedge Identified In Bks And Rec | 0 | HedgeIdentifiedInBksAndRecInd |
| Gross Proceeds Invested In GIC | 0 | GrossProceedsInvestedInGICInd |
| Gross Proceeds Invested | 0 | GrossProceedsInvestedInd |
| Written Proc To Monitor Reqs | Yes (1) | WrittenProcToMonitorReqsInd |
Procedures Corrective Action ProceduresCorrectiveActionGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bond Reference | A | BondReferenceCd |
| Procedures Corrective Action | Yes (1) | ProceduresCorrectiveActionInd |
Supplemental Information Detail SupplementalInformationDetail (2 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| SCHEDULE K, PART II, LINE 3: | THE TOTAL PROCEEDS DO NOT AGREE TO THE ISSUE PRICE IN PART I, COLUMN (E) DUE TO INVESTMENT EARNINGS. |
| SCHEDULE K, PART IV, LINE 2C: | DATE THE REBATE COMPUTATION WAS PERFORMED: 01/01/2018 |
Schedule O IRS990ScheduleO
Supplemental Information Detail SupplementalInformationDetail (6 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| 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 1,460,215. MANAGEMENT AND GENERAL EXPENSES 100,905. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,561,120. THERAPIST FEES: PROGRAM SERVICE EXPENSES 787,730. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 787,730. MRI FEES: PROGRAM SERVICE EXPENSES 45,960. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 45,960. NUCLEAR IMAGING FEES: PROGRAM SERVICE EXPENSES 59,863. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 59,863. COLLECTION FEES: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 59,230. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 59,230. |
| 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. |
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