2022-04-21T14:52:49-05:00 2021-06-30 476097913 SEIM JOHNSON LLP 18081 BURT STREET SUITE 200 OMAHA NE 680224722 990 2020-07-01 470393176 ANTELOPE MEMORIAL HOSPITAL ANTE 4028874151 PO BOX 229 NELIGH NE 68756 DIANE CARLIN CEO 4028874151 2022-04-20 1 DIANE CARLIN 999009999 MEGAN L KOZIOL P01544037 4023302660 2 AAL1 IAL1 2020 2022-09-23 18:48:47Z DIANE CARLIN PO BOX 229 NELIGH NE 68756 21729349 0 X WWW.AMHNE.ORG X 1974 NE 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. 11 11 206 12 0 0 924853 5163770 15080766 16326052 90794 145205 64052 55489 16160465 21690516 7500 960 0 0 8659024 9515367 0 0 0 6691405 7535751 15357929 17052078 802536 4638438 30307047 29095684 14192227 8306271 16114820 20789413 MAKING A DIFFERENCE IN PEOPLE'S LIVES THROUGH EXCELLENT PATIENT CARE. 0 0 14795137 960 16326052 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. 14795137 1 1 0 1 0 0 0 0 0 0 1 0 0 1 1 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 34 0 1 206 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 PHILIP KLUTHE MEMBER THRU 9/20 2.00 X 0 0 0 DIANE CARLIN ADMINISTRATOR/CEO 40.00 X 252228 0 13845 MARTHA NELSON CFO 36.00 X 162219 0 31113 ROGER RUDLOFF MD PHYSICIAN 40.00 X 427977 0 30914 TROY DAWSON MD PHYSICIAN 40.00 X 371420 0 38214 KELLI OSBORN MD PHYSICIAN 40.00 X 285857 0 43454 PATRICIA GOOD APRN APRN 40.00 X 151584 0 17602 KAREN GALLAGHER PHARMACIST 40.00 X 140127 0 14203 1791412 0 189345 8 0 1 0 PINNACLE ANESTHESIA SERVICES 608 EAST 4TH STREET NELIGH NE 68756 NURSING SERVICES 425000 OVERLAND REHAB SERVICES 405 JAMES STREET VERDIGRE NE 68783 PHYSICAL THERAPY SERVICES 361120 PSYCHIATRIC MEDICAL SERVICES 8 CADILLAC DRIVE SUITE 230 BRENTWOOD TN 37027 PSYCHIATRIC SERVICES 322575 DOCS WHO CARE 1337 S FOUNTAIN DRIVE OLATHE KS 66061 ER COVERAGE 251506 4 5007734 156036 5163770 MEDICARE/MEDICAID PAYMENTS 621400 9569967 9569967 NET PATIENT SERVICE REVENUE 621400 6256718 6256718 340B REVENUE 611400 456087 456087 AMBULANCE 621910 6600 6600 36680 36680 16326052 121816 121816 62222 38833 23389 23389 23389 CAFETERIA 900099 55489 55489 55489 21690516 16326052 0 200694 X 960 960 459405 459405 7543395 6651276 892119 219108 178787 40321 782496 655720 126776 510963 443082 67881 9043 9043 50948 50948 2513903 2353768 160135 101391 8290 93101 725145 615231 109914 513859 413022 100837 232327 222733 9594 29411 27155 2256 28702 27426 1276 1165118 1113314 51804 171357 163738 7619 MEDICAL SUPPLIES 1339070 1339070 BAD DEBT 507737 507737 MISCELLANEOUS EXPENSE 80385 26993 53392 DUES & SUBSCRIPTIONS 67355 46835 20520 17052078 14795137 2256941 0 181407 403460 17181393 14498321 6375 5525 1791300 1317153 99193 177829 320017 341212 108110 143277 26154799 16029754 10003256 10125045 530359 584454 85637 1499408 30307047 29095684 1710342 1999146 1147808 873539 1542700 9791377 5433586 14192227 8306271 X 16099550 20777888 15270 11525 16114820 20789413 30307047 29095684 4638438 36155 0 X X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 1657 1657 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 8048290 4734672 3313618 13637055 9514375 4122680 4345225 1780707 2564518 10125045 ACCRUED INTEREST RECEIVABLE 1993 340B RECEIVABLE 59454 DEPOSIT ON RENOVATION PROJECT 1437961 1499408 ESTIMATED THIRD-PARTY PAYER SETTLEMENT 343233 REFUNDABLE ADVANCES 500000 CONTRACT LIABILITY - MEDICARE ADVANCE PAYMENTS 4590353 5433586 X 21218934 36155 36155 21182779 507737 507737 21690516 16544341 0 16544341 507737 507737 17052078 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. 1 1 1 X 125.000000000000 0 1 1 0 1 1 45330 45330 0.00270 1359649 1097330 262319 0.01590 1404979 1097330 307649 0.01860 23470 0 23470 0.00140 790486 178429 612057 0.03700 960 960 0.00010 814916 178429 636487 0.03850 2219895 1275759 944136 0.05710 550 0 550 0.00000 10500 0 10500 0.00060 11050 11050 0.00060 1 507737 0 9209407 9210446 -1039 X 1 0 1 1 ANTELOPE MEMORIAL HOSPITAL 102 WEST 9TH STREET NELIGH NE 68756 WWW.AMHNE.ORG 020001 X X X ANTELOPE MEMORIAL HOSPITAL 1 0 0 1 X X X X X X X X X 18 1 1 1 1 X WWW.AMHNE.ORG X 1 18 1 WWW.AMHNE.ORG 0 1 X 125.000000000000 X X X 1 1 X X X 1 X WWW.AMHNE.ORG X WWW.AMHNE.ORG X WWW.AMHNE.ORG 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) 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. 5 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 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. X X X 0 0 0 0 0 0 0 0 0 ROGER RUDLOFF MD PHYSICIAN 422773 0 5000 0 204 0 12969 0 17945 0 458891 0 0 0 TROY DAWSON MD PHYSICIAN 366216 0 5000 0 204 0 12969 0 25245 0 409634 0 0 0 KELLI OSBORN MD PHYSICIAN 280653 0 5000 0 204 0 12969 0 30485 0 329311 0 0 0 DIANE CARLIN ADMINISTRATOR/CEO 231776 0 20251 0 201 0 3749 0 10096 0 266073 0 0 0 MARTHA NELSON CFO 146893 0 15188 0 138 0 6407 0 24706 0 193332 0 0 0 PATRICIA GOOD APRN APRN 151470 0 0 0 114 0 5157 0 12445 0 169186 0 0 0 KAREN GALLAGHER PHARMACIST 139994 0 0 0 133 0 4337 0 9866 0 154330 0 0 0 A THE COUNTY OF ANTELOPE NEBRASKA 476006428 036654AH4 2015-10-15 2290000 REFUND PRIOR ISSUE (12/21/2010) 0 0 0 A 1395000 2290280 91500 2198780 2006 1 0 1 1 A 0 0 0 0 0.00000 0.00000 0.00000 0 0 1 A 0 0 1 1 0 0 0 0 1 A 1 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 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.