2022-11-08T15:37:04-06:00 2021-12-31 450250958 EIDE BAILLY LLP 18081 BURT ST STE 200 OMAHA NE 680224722 990 2021-01-01 470408242 CHEYENNE COUNTY HOSPITAL ASSOCIATION INC CHEY 3082545825 1000 POLE CREEK CROSSING SIDNEY NE 691620000 JASON PETIK CEO 3082545825 2022-11-07 1 JASON PETIK 999009999 MEGAN L KOZIOL CPA P01544037 4023302660 2022-11-07 3 AAL1 IAL1 2021 2022-09-23 18:48:47Z SIDNEY REGIONAL MEDICAL CENTER JASON PETIK 1000 POLE CREEK CROSSING SIDNEY NE 691620000 70779074 0 X WWW.SIDNEYRMC.COM X 1951 NE TO REVOLUTIONIZE HEALTHCARE SERVICES IN THE REGION. 12 10 479 11 0 0 5762865 6348922 55178139 63840923 481614 467466 377887 121763 61800505 70779074 10200 28700 0 0 34467219 36547289 0 0 0 25990733 25635796 60468152 62211785 1332353 8567289 98988154 103262011 57308074 52722898 41680080 50539113 TO REVOLUTIONIZE HEALTHCARE SERVICES IN THE REGION. 0 0 48159663 28700 46679616 SIDNEY REGIONAL MEDICAL CENTER IS A NOT-FOR-PROFIT ACUTE CARE HOSPITAL WHICH PROVIDES INPATIENT, OUTPATIENT AND EMERGENCY ROOM CARE SERVICE TO PATIENTS IN AND AROUND SIDNEY, NEBRASKA AND THE REGION. IT ALSO OPERATES LONG-TERM CARE FACILITIES AND TWO PROVIDER-BASED RURAL HEALTH CLINICS IN SIDNEY, NEBRASKA. 4982089 12625048 IN 2021, THE HOSPITAL NURSING DEPARTMENT PROVIDED 2,131 PATIENT DAYS OF CARE, INCLUDING GENERAL INPATIENT, ICU PATIENTS AND SWING BED PATIENTS, AND DELIVERED 83 NEWBORNS FOR THE SEVEN COUNTY AREA THAT SIDNEY REGIONAL MEDICAL CENTER (SRMC) SERVES. SRMC HAD 3,663 PATIENTS SEEK CARE IN THE EMERGENCY DEPARTMENT DURING 2021 AND CARED FOR 263 OBSERVATION PATIENTS WHO NEEDED CARE BUT DID NOT QUALIFY FOR INPATIENT SERVICES UNDER CMS RULES. 3360209 4536259 THE EXTENDED CARE UNIT PROVIDED CARE FOR AN AVERAGE OF 43 PATIENTS DAILY DURING 2021. SRMC PROVIDED 15,467 RESIDENT DAYS OF CARE FOR IT'S RESIDENTS FROM THE CHEYENNE, DEUEL, KIMBALL AND SURROUNDING AREAS. 56501961 1 1 0 1 0 0 0 0 0 0 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 1 0 0 0 1 148 0 1 479 1 0 0 0 0 0 0 0 0 0 0 0 0 X 12 10 0 1 0 0 0 0 0 1 1 0 0 0 1 1 1 1 1 1 1 0 X KELLY UTLEY 3082545825 1000 POLE CREEK CROSSING SIDNEY NE 69162 X REBECCA L ALLARD MD CHIEF OF STAFF 40.00 0.00 X 684896 0 50259 MATTHEW JANSEN MD DOCTOR 40.00 0.00 X 633007 0 50259 JAMES POPOVICH MD DOCTOR 40.00 0.00 X 565954 0 50259 SARA SHOLAR MD DOCTOR 40.00 0.00 X 566053 0 35221 KELLY CASEY MD DOCTOR 40.00 0.00 X 491236 0 40926 APRIL SMITH MD DOCTOR 40.00 0.00 X 399453 0 40646 ROBERT GRAVES MD PHYSICIAN AT LARGE 40.00 0.00 X 347827 0 51815 KELLY UTLEY CFO 39.00 1.00 X 203959 0 19470 WILLIAM PILE CHAIRMAN 4.00 0.00 X X 0 0 0 TIM MILLER VICE CHAIRMAN 4.00 0.00 X X 0 0 0 KATHY NARJES SECRETARY 4.00 0.00 X X 0 0 0 JEFF ELLWANGER TREASURER 4.00 0.00 X X 0 0 0 STAN BELIEU MEMBER 4.00 1.00 X 0 0 0 DWIGHT SMITH MEMBER 4.00 0.00 X 0 0 0 NANCI MCCASLIN MEMBER 4.00 1.00 X 0 0 0 CLEM SCHUMACHER MEMBER 4.00 0.00 X 0 0 0 JEFF HELLER MEMBER 4.00 0.00 X 0 0 0 WILLIAM ROBINSON MEMBER 4.00 0.00 X 0 0 0 JIM JONES MEMBER THRU 06/21 4.00 0.00 X 0 0 0 JASON PETIK CEO 40.00 0.00 X 0 0 0 3892385 0 338855 42 0 1 1 RURAL PARTNERS IN MEDICINE LLC 11880 AIRPORT WAY BROOMFIELD CO 80021 PHYSICIAN SERVICES 2296422 UNIVERSITY OF COLORADO HEALTH 7901 E LOWRY BLVD SUITE 350 DENVER CO 90230 SYSTEM SUPPORT 874105 GE PRECISION HEALTHCARE LLC PO BOX 96483 CHICAGO IL 60693 SERVICE CONTRACTS 748373 FUSION MEDICAL STAFFING LLC PO BOX 82674 LINCOLN NE 68501 TEMPORARY STAFFING SERVICES 704869 RURAL MEDICAL SOLUTIONS LLC 8181 ARISTA PLACE STE 100 BROOMFIELD CO 80021 IMPLANT SERVICES 625322 16 6220918 128004 6348922 NET PATIENT SERVICE REVENUE 621110 36090758 36090758 MEDICARE/MEDICAID 621110 26482603 26482603 340B REVENUE 621110 1003776 1003776 SCHOOL REHAB REVENUE 621110 144364 144364 119422 119422 63840923 467466 467466 CAFETERIA 722210 121763 121763 121763 70779074 63840923 0 589229 X 28700 28700 1358226 1134797 223429 186196 95006 91190 25512245 23514624 1997621 798683 717326 81357 8691939 8181829 510110 289740 289740 24124 24124 40673 40673 7416809 6813620 603189 1251053 1141668 109385 1246771 1113985 132786 1198634 1025172 173462 85704 82592 3112 120239 49185 71054 1213302 1100304 112998 3780846 3503003 277843 746478 746478 MEDICAL SUPPLIES 6817060 6817060 RECRUITING FEES 420640 397800 22840 FOOD PRODUCTS 329149 329149 BAD DEBTS 272535 272535 382039 183606 198433 62211785 56501961 5709824 0 843641 361790 33791429 41877043 8758247 9892268 380342 462821 1715762 1698330 671809 871738 73642467 36192320 38971017 37450147 11364478 9258356 2491429 1389518 98988154 103262011 4880207 6063295 8600000 4312837 8322558 7901171 29930604 29414730 4276950 0 1297755 5030865 57308074 52722898 X 41680080 50539113 41680080 50539113 98988154 103262011 8567289 291744 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 6880 6880 0 PART II-B, LINE 1: A PORTION OF THE DUES PAID TO THE AMERICAN HOSPITAL ASSOCIATION (AHA) AND THE NEBRASKA HOSPITAL ASSOCIATION (NHA) ARE USED BY THOSE ORGANIZATIONS FOR LOBBYING ACTIVITIES. 92500 1947968 2040468 49728330 20797812 28930518 19840368 14750010 5090358 2033301 644498 1388803 37450147 DEFERRED COMPENSATION PLAN LIABILITY 1389518 ESTIMATED THIRD-PARTY PAYOR SETTLEMENTS 3641347 5030865 X PART X, LINE 2: SRMC AND THE FOUNDATION ARE EXEMPT FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE INTERNAL REVENUE CODE AND A SIMILAR PROVISION OF STATE LAW. THE INTERNAL REVENUE SERVICE HAS ESTABLISHED STANDARDS TO BE MET TO MAINTAIN TAX-EXEMPT STATUS. THE ORGANIZATION ACCOUNTS FOR UNCERTAINTIES IN ACCOUNTING FOR INCOME TAX ASSETS AND LIABILITIES USING GUIDANCE INCLUDED IN FASB ASC 740, INCOME TAXES. THE ORGANIZATION RECOGNIZES THE EFFECT OF INCOME TAX POSITIONS ONLY IF THOSE `POSITIONS ARE MORE LIKELY THAN NOT OF BEING SUSTAINED. AT DECEMBER 31, 2021, THE SYSTEM HAD NO UNCERTAIN TAX POSITIONS ACCRUED. 1 1 X 1 X 1 X 1 1 0 0 229981 0 229981 0.00370 5563990 1397467 4166523 0.06730 5793971 1397467 4396504 0.07100 90602 43233 47369 0.00080 10657 0 10657 0.00020 1254675 1254675 0.02030 63473 0 63473 0.00100 1419407 43233 1376174 0.02230 7213378 1440700 5772678 0.09330 40 884 1847 0 1847 0.00000 93 432 8475 0 8475 0.00010 133 1316 10322 10322 0.00010 1 272535 0 20901469 20922913 -21444 X 1 1 1 1 CHEYENNE COUNTY HOSPITAL ASSOCIATION 1000 POLE CREEK CROSSING SIDNEY NE 69162 WWW.SIDNEYRMC.COM 150001 X X X X CHEYENNE COUNTY HOSPITAL ASSOCIATION INC 1 0 0 1 X X X X X X X X X 20 1 1 1 1 X WWW.SIDNEYRMC.COM/501R X WWW.PPHD.ORG/PAGES/CHIP.HTML X 1 20 1 WWW.SIDNEYRMC.COM/501R 0 1 X 100.000000000000 300.000000000000 X X X X X 1 1 X X X X 1 X SIDNEYRMC.COM/501R X SIDNEYRMC.COM/501R X SIDNEYRMC.COM/501R X X X X X X 1 X 0 X X X X X 1 X 0 0 CHEYENNE COUNTY HOSPITAL ASSOCIATION INC PART V, SECTION B, LINE 5: A MAPP STEERING COMMITTEE WAS FORMED IN 2014, MADE UP OF REPRESENTATIVES FROM EACH OF THE NINE RURAL NEBRASKA HEALTH NETWORK HOSPITALS (SEE LIST OF MEMBERS IN LINE 6A). COMMITTEE MEMBERS PROVIDE GUIDANCE THROUGHOUT THE MAPP PROCESS AND ARE CHARGED WITH REVIEWING DATA AND PROGRESS ON THE CHOSEN PRIORITY AREAS, USING QUALITY IMPROVEMENT TO MODIFY IMPLEMENTATION PLANS AS NEEDED, AND SHARING RESULTS WITH STAKEHOLDERS. TWO NEW REPRESENTATIVES JOINED THE COMMITTEE IN 2017: A REPRESENTATIVE FROM THE PANHANDLE PARTNERSHIP, SERVING AS A REPRESENTATIVE OF A VARIETY OF COMMUNITY-BASED ORGANIZATIONS, AND A REPRESENTATIVE FROM THE LOCAL ECONOMIC DEVELOPMENT DISTRICT, PANHANDLE AREA DEVELOPMENT DISTRICT (PADD). EACH HOSPITAL FACILITATED AT LEAST ONE FOCUS GROUP WITH LOCAL OR AREA RESIDENTS IN THEIR SERVICE AREA. HOSPITALS WITH A GREATER THAN 50% MINORITY POPULATION MADE A CONCERTED EFFORT TO INCLUDE PEOPLE REPRESENTATIVE OF THE MINORITY POPULATION IN THE FOCUS GROUPS. GROUPS WERE INTENDED TO BE MADE UP OF 8-10 PEOPLE, ALTHOUGH THERE MAY BE SOME VARIANCE. HOSPITAL REPRESENTATIVES IDENTIFIED POTENTIAL FOCUS GROUP PARTICIPANTS AND REACHED OUT VIA PHONE CALLS, E-MAILS AND SOCIAL MEDIA TO INVITE THEM TO ATTEND A FOCUS GROUP SESSION. A TOTAL OF 16 FOCUS GROUP SESSIONS, INVOLVING APPROXIMATELY 142 NEBRASKA PANHANDLE RESIDENTS WERE COMPLETED. FOCUS GROUPS WERE LARGELY CONDUCTED IN THE SPRING OF 2020. BECAUSE OF THE COVID-19 PANDEMIC, A HANDFUL OF FOCUS GROUPS WERE COMPLETED VIA OPEN ENDED SURVEY RATHER THAN IN PERSON. CHEYENNE COUNTY HOSPITAL ASSOCIATION INC PART V, SECTION B, LINE 6A: THE FOLLOWING IS A LIST OF HOSPITALS THAT PARTICIPATED IN THE CHNA:-BOX BUTTE GENERAL HOSPITAL, ALLIANCE, NE-MORRILL COUNTY HOSPITAL, BRIDGEPORT, NE-REGIONAL WEST MEDICAL CENTER, SCOTTSBLUFF, NE-CHADRON COMMUNITY HOSPITAL, CHADRON, NE-REGIONAL WEST GARDEN COUNTY, OSHKOSH, NE-GORDON MEMORIAL HOSPITAL, GORDON, NE-KIMBALL HEALTH SERVICES, KIMBALL, NE-PERKINS COUNTY HEALTH SERVICES, GRANT, NE-SIDNEY REGIONAL MEDICAL CENTER, SIDNEY, NE CHEYENNE COUNTY HOSPITAL ASSOCIATION INC PART V, SECTION B, LINE 6B: PANHANDLE PUBLIC HEALTH DISTRICT CHEYENNE COUNTY HOSPITAL ASSOCIATION INC PART V, SECTION B, LINE 11: FROM FOCUS GROUPS, FEED BACK FROM SURVEYS, AND OTHER REGIONAL ANALYTICS, SRMC DETERMINED THE FOLLOWING POINTS WERE TO BE ADDRESSED FOR THE CHIP 2021-2023. GOALS AND STRATEGIES FOR PRIORITY AREAS ARE AS FOLLOWS:FOCUS AREA 1: BEHAVIORAL HEALTH 1. WEEKLY VISITS TO SCHOOL COUNSELORS TO IDENTIFY INDIVIDUALS WITH NEEDS AND PROACTIVELY DESIGN PLAN OF CARE. 2. MONTHLY ARTICLES, TIPS AND TECHNIQUES ABOUT MENTAL HEALTH ISSUES IN AREA MEDIA VENDORS. 3. RAISE AWARENESS FOR BEHAVIORAL HEALTH AND SENIOR LIFE SOLUTIONS AT SRMC. 4. OFFER AN ANNUAL SURVEY TO ACCESS PROGRESS AND AREAS OF NEED.SRMC WILL HOLD A "MENTAL HEALTH IN THE WORKPLACE" FOR A GROUP OF AG WORKERS CALLED "GEEPS" IN FEBRUARY 2021.FOCUS AREA 2: CHRONIC CARE 1. PROMOTE CHRONIC CARE MANAGEMENT (CCM) "PROGRAM INSERTS" TO COMMUNITY VIA SOCIAL MEDIA/WEBSITE WITH E-MAIL SIGN-UP FOR FREE DOWNLOAD. 2. RESEARCH THE VIABILITY AND USAGE FOR THE LIVING WELL ONLINE PROGRAM AVAILABLE THROUGH PPHD. 3. DETERMINE THREE KEY AREAS FOR CURRENT CCM PARTICIPANTS TO TRACK IMPROVEMENTS. 4. PROMOTE DIRECT CCESS TESTING. CHRONIC CARE MANAGEMENT IS CURRENTLY AVAILABLE FOR THOSE WHO ARE 65 AND OLDER ON MEDICARE, WITH 2 OR MORE CHRONIC ILLNESSES. REQUIRED ELIGIBILITY THROUGH THE ACO-PROGRAM REQUIRES 65+, TWO CHRONIC DISEASES AND SEEING A PROVIDER THAT WILL ENROLL THEM IF THEY QUALIFY. FOCUS AREA 3: END OF LIFE 1. CREATE ANNUAL SENIOR LIFE HEALTH FAIR PROMOTING AREA AVAILABLE RESOURCES. 2. OFFER DOULA TRAINING TO DEVELOP AN END OF LIFE VOLUNTEER SUPPORT SYSTEM. 3. DETERMINE IF PARTNERING WITH HOSPICE OF THE PLAINS AS A HOSPICE PROVIDER IS POSSIBLE.OTHER AREA NEEDS THAT ARE NOT BEING ADDRESSED AT THIS TIME ARE: 1. NOT ENOUGH HEALTH INSURANCE/NO HEALTH INSURANCE2. POVERTY3. CHILD ABUSE/NEGLECTSRMC DOES NOT HAVE THE RESOURCES TO ADDRESS THESE NEEDS AT THIS TIME. THE FOLLOWING IS A QUARTERLY RECAP OF 2021:1ST QUARTER: WITH COVID-19 PANDEMIC, THERE HAVE BEEN NO ON-SITE BLOOD DRIVES THIS QUARTER. WE HAVE HELD 52 COVID CLINICS (JANUARY 5TH THROUGH MARCH 31ST) FOR THE COMMUNITY OFFERING THE MODERNA VACCINE. WE GAVE A TOTAL OF 3501 VACCINATIONS DURING THIS TIME FRAME, FOLLOWING THE GUIDELINES/TIMELINES OF THE CDC AND PPHD GIVEN VACCINE TO AGE GROUPS AS WERE RECOMMENDED. DIRECT ACCESS TESTING CONTINUES TO BE UTILIZED ON WEDNESDAYS BY OUR COMMUNITY. NUMBERS ARE NOT AVAILABLE TO REPORT AT THIS TIME DUE TO REPORTING TOOL NOT WORKING. OFF-SITE COMMUNITY BLOOD PRESSURE SCREENINGS HAVE ALSO BEEN ON HOLD THIS QUARTER.2ND QUARTER:NO BLOOD DRIVES HELD VIA THE DONOR CENTER OUT OF SCOTTSBLUFF THIS 2ND QUARTER DUE TO THEIR LIMITED STAFFING ISSUES, AND SOME NEW OSHA REGULATIONS FOR MOBILE DRIVES. SRMC HELD 30 FREE COVID CLINICS THIS QUARTER, ALONG WITH THE ABILITY TO SEE A PROVIDER AND GET VACCINATED AT THEIR VISIT AS WELL. WE GAVE A TOTAL OF 1803 COVID VACCINES THIS QUARTER. THE RHC OFFERED UP FREE SPORTS PHYSICALS TO SCHOOL AGE KIDS AND DID 15 OF THEM. WELLNESS WEDNESDAYS OR DIRECT ACCESS TESTING CONTINUES TO BE UTILIZED BY COMMUNITY MEMBERS. WE JUST DO NOT CURRENTLY HAVE THE TOOLS TO GATHER THE TOTAL NUMBERS DONE FOR THIS QUARTER. HOPEFULLY SOON THIS WILL BE FIXED SO WE CAN AGAIN REPORT THEM. OFF-SITE BLOOD PRESSURE SCREENINGS AT AREA BUSINESSES AND SURROUNDING COMMUNITIES WERE ON HOLD FOR THE 2ND QUARTER ALSO. SEVERAL BEHAVIOR HEALTH EVENTS TOOK PLACE SUCH AS THE NATIONAL STRESS DAY OPEN HOUSE IN APRIL WITH ABOUT 20 PARTICIPANTS, THE SPRING EXPO IN APRIL WE PROVIDED COMMUNITY EDUCATION ABOUT OUR BEHAVIORAL HEALTH SERVICES. THE AMERICAN FOUNDATION FOR SUICIDE PREVENTION ACTIVITIES WERE APRIL 19TH AND 20TH AND EDUCATION WAS PROVIDED ABOUT SUICIDE PREVENTION. IN JUNE, EDUCATION WAS PROVIDED ABOUT STRESS MANAGEMENT IN AGRICULTURAL SETTINGS FOR THE AG SAFETY MANAGERS AND SUPERVISORS OF NE. SENIOR LIFE SOLUTIONS IS NOW UP AND GOING AS OF MAY 13TH. THEY CURRENTLY HAVE 5 PATIENTS WHO MEET TOGETHER IN A GROUP SETTING THREE TIMES A WEEK FOR 3 HOURS EACH TIME. THE PROGRAM IS GOING WELL.3RD QUARTER:NO BLOOD DRIVES AGAIN IN THE 3RD QUARTER DUE TO CONTINUED STAFF SHORTAGES WITH THE DONOR CENTER OUT OF SCOTTSBLUFF. THEY ARE UNABLE TO SUPPORT MOBILE BLOOD DRIVES AT THIS TIME. SRMC, THROUGH THE RHC, ADMINISTERED A TOTAL OF 350 FREE COVID-19 VACCINATIONS DURING THE 3RD QUARTER. THE RHC OFFERED REDUCED COST SPORTS PHYSICALS TO SCHOOL AGED KIDS THIS QUARTER AND THE REPORT PULLED PER MANDI RAFFELSON SHOWS 320 SPORTS PHYSICALS WERE DONE. WELLNESS WEDNESDAYS (DIRECT ACCESS TESTING) INCREASED THEIR HOURS OF OPERATIONS THIS QUARTER FROM 7 AM TO 4 PM EVERY WEDNESDAY. THIS SERVICE CONTINUES TO BE UTILIZED BY OUR COMMUNITY MEMBERS AS WELL AS SURROUNDING COMMUNITIES. THERE WERE A TOTAL OF 350 COMMUNITY MEMBERS THAT USED THIS REDUCED COST LAB TESTING SERVICE. ON-SITE FREE BLOOD PRESSURE SCREENINGS AND EDUCATION RESUMED FOR AREA BUSINESSES AND SURROUNDING COMMUNITIES THIS 3RD QUARTER. KRISTEN ROSE, BEHAVIORAL THERAPIST, DID EDUCATION ON EATING DISORDERS IN THE MILITARY FOR THE NATIONAL ASSOCIATION OF SOCIAL WORKERS NE CHAPTER AT THEIR ANNUAL CONFERENCE. SHE ALSO HAD A BOOTH AT THE AMERICAN FOUNDATION FOR SUICIDE PREVENTION AWARENESS WALK. IN JULY OF 2021 DURING THE Q3 CHEYENNE COUNTY FAIR, THE FORMER COVID TRAILER WAS USED AS A PLACE FOR FIRST AID OR A NEED FOR WATER. IT WAS STAFFED BY A PROVIDER AND A NURSE FROM THE RHC.4TH QUARTER:THIS 4TH QUARTER WE WERE ABLE TO HOST OUR FIRST BLOOD DRIVE IN TWO YEARS. WE HAD A MIXTURE OF EMPLOYEES AND COMMUNITY MEMBERS WHO DONATED 43 UNITS. THE METHODIST CHURCH ALSO HOSTED A BLOOD DRIVE IN NOVEMBER AND COLLECTED 33 UNITS OF BLOOD. SRMC, VIA THE RHC GAVE 884 FREE COVID-19 VACCINATIONS AND BOOSTERS IN THE 4TH QUARTER 2021. THE RHC OFFERED REDUCED COST SPORTS PHYSICALS AGAIN DURING THE 4TH QUARTER AND THERE WERE 13 COMPLETED. WELLNESS WEDNESDAYS (DIRECT ACCESS TESTING) IS THE REDUCED COST LABS WITHOUT A DOCTOR'S ORDER THAT COMMUNITY MEMBERS AND EMPLOYEES UTILIZEHERE IN OUR LAB DEPARTMENT AND HAPPENS EVERY WEDNESDAY. WE HAD 211 PEOPLE USE THIS SERVICE DURING THE 4TH QUARTER, WHICH IS DOWN FROM THE PREVIOUS QUARTER. FREE BLOOD PRESSURE SCREENINGS AND EDUCATION WERE PROVIDED TO VARIOUS BUSINESSES AND COMMUNITIES ON A MONTHLY BASIS DURING THE 4TH QUARTER. REGARDING BEHAVIORAL HEALTH, KRISTIN ROSE DID A PRESENTATION ON EATING DISORDERS FOR PANHANDLE PUBLIC HEALTH DISTRICTS WORKSITE WELLNESS PROGRAM IN OCTOBER. IN NOVEMBER, KRISTIN DID THE SAME PRESENTATION, VIRTUALLY, FOR THE NE COUNSELING ASSOCIATION. CHEYENNE COUNTY HOSPITAL ASSOCIATION INC PART V, SECTION B, LINE 13B: PATIENTS MAY BE CONSIDERED FOR CHARITY CARE FOR MEDICALLY NECESSARY SERVICES. WHEN IN QUESTION, MEDICALLY NECESSARY SERVICES SHALL BE DETERMINED BY THE EXAMINING PHYSICIAN. PATIENTS MUST BE RESIDENTS OF CHEYENNE OR DEUEL COUNTY AND/OR A 20 MILE RADIUS OF SIDNEY REGIONAL MEDICAL CENTER. THIS MAY BE WAIVED FOR PATIENTS ADMITTED VIA THE EMERGENCY DEPARTMENT OR AT THE DISCRETION OF ADMINISTRATION.SPECIFICALLY IDENTIFIED CASES MAY BE PRESUMED ELIGIBLE FOR CHARITABLE ASSISTANCE AND CLASSIFIED WITHOUT A COMPLETED APPLICATION OR ASSESSMENT. EXAMPLES OF THESE CASES ARE: PATIENT IS DECEASED WITH NO KNOWN ESTATE OR SPOUSE; PATIENTS WITH CURRENT ELIGIBILITY UNDER COUNTY OR STATE MEDICAL INDIGENT SERVICES ADMINISTERED BY COUNTY OR STATE FACILITIES; PATIENT IS HOMELESS OR HAS BEEN IDENTIFIED AS BEING WITHOUT RESOURCES BASED ON PREVIOUS ACCOUNT ACTION AND CONTACT WITH THE SRMC STAFF.PERCENT OF CHARITY WILL BE BASED ON HOUSEHOLD INCOME AND SIZE, REAL ESTATE, PERSONAL PROPERTY AND INVESTMENT EQUITY, WITH CREDIT TO BE GIVEN FOR ALREADY EXISTING MEDICAL LOANS, IN COMPARISON TO THE CURRENT YEAR FEDERAL POVERTY GUIDELINES. THE HHS POVERTY GUIDELINES ARE PUBLISHED EACH YEAR IN THE FEDERAL REGISTER. FREE CARE WILL BE GIVEN TO HOUSEHOLDS THAT ARE AT 100% OF THE POVERTY LEVEL. DISCOUNTED CARE WILL BE GIVEN AT UP TO 300% OF THE POVERTY LEVEL. CHEYENNE COUNTY HOSPITAL ASSOCIATION INC PART V, SECTION B, LINE 16J: THE POLICY IS REFERENCED IN BILLING LETTERS AND IS ORALLY COMMUNICATED DURING REGISTRATION OR ADMISSIONS AND THROUGH THE PATIENT FINANCIAL SERVICES FOLLOW UP PROCESSES, INCLUDING PATIENT ADVOCACY CONVERSATIONS. THE POLICY IS AVAILABLE IN ADMISSIONS AND WAITING AREAS AT THE HOSPITAL. SIGNAGE IS POSTED IN WAITING AREAS REFERRING PATIENTS TO THE WEBSITE TO VIEW THE POLICY. ADDITIONALLY, PLAIN LANGUAGE SUMMARY IS INCLUDED IN ALL DISCHARGE PACKETS WITH REFERENCE TO THE WEBSITE OR FINANCIAL SERVICES TO OBTAIN THE ENTIRE POLICY. CHEYENNE COUNTY HOSPITAL ASSOCIATION INC PART V, SECTION B, LINE 20E: SRMC ATTEMPTS OTHER NON-EXTRAORDINARY COLLECTION EFFORTS SUCH AS: SUBSEQUENT MONTHLY BILLINGS, COLLECTION LETTERS AND/OR TELEPHONE CALLS CONSTITUTING A GENUINE EFFORT TO HELP OUR PATIENTS TO ARRANGE FOR PAYMENT IF THEY CAN AFFORD IT. DOCUMENTATION OF THESE EFFORTS WILL BE MADE BY NOTATING PATIENT ACCOUNTS AND DOCUMENTING STATEMENTS AND REPORTS OF TELEPHONE CALLS AND PERSONAL CONTACTS. FOR ELECTIVE PROCEDURES, PATIENTS ARE ASKED TO MEET WITH A FINANCIAL COUNSELOR BEFORE THE PROCEDURE TO SET UP PAYMENT ARRANGEMENTS. SRMC DOES OFFER LOANS TO PATIENTS WITH NO COLLATERAL FROM THE PATIENTS. SRMC ALSO SECURES FINANCING FOR THE PATIENTS IF THEY DO NOT QUALIFY FOR CHARITY CARE. SRMC DOES NOT REQUIRE PATIENTS WHO QUALIFY FOR CHARITY CARE UNDER THE FINANCIAL ASSISTANCE POLICY TO OBTAIN A LOAN TO PAY THE ACCOUNT. 3 1 - SIDNEY REG'L MEDICAL CTR EXTENDED CARE 549 KELLER DRIVE SIDNEY NE 69162 LONG TERM CARE FACILITY 2 - SLOAN ESTATES ASSISTED LIVING 2550 CRAIG AVENUE SIDNEY NE 69162 ASSISTED LIVING 3 - SIDNEY REG'L MEDICAL CTR WALK IN CLINIC 610 GROVER ROAD SUITE 4 SIDNEY NE 69162 WALK IN CLINIC PART I, LINE 3C: THE CALCULATION FOR ELIGIBILITY IS BASED ON ALL INCOME PER HOUSEHOLD WITH EXCEPTIONS MADE FOR WAGE EARNERS WHO ARE STUDENTS. OTHER MEDICAL PAYMENTS ALREADY BEING MADE ARE CONSIDERED IN THE CALCUATION. INCOME IS COMPARED TO THE NATIONAL POVERTY GUIDELINES AND A DETERMINATION OF REDUCTION IS MADE BASED ON THE ADJUSTED INCOME LEVEL. THE WRITE OFF AMOUNT MAY BE REDUCED FOR EQUITY IN ASSETS, IF ANY, ABOVE EXEMPTION THRESHOLDS FOR HOMES AND VEHICLES. THERE IS NO EXEMPTION FOR INVESTMENTS OR OTHER ASSETS HELD. PART I, LINE 6A: THE COMMUNITY BENEFIT REPORT WAS NOT PREPARED IN THE CURRENT YEAR. PART I, LINE 7: THE COST TO CHARGE RATIO IS DETERMINED AS FOLLOWS: (TOTAL EXPENSES - BAD DEBT)/GROSS PATIENT SERVICE REVENUE = PERCENTAGE OF COST TO CHARGE. PART I, LINE 7G: THERE ARE NO COSTS ASSOCIATED WITH PHYSICIAN CLINICS INCLUDED AS SUBSIDIZED HEALTH SERVICES. PART I, LN 7 COL(F): BAD DEBT EXPENSE OF $272,535 HAS BEEN EXCLUDED FROM THE DENOMINATOR IN THE CALCULATION OF THE PERCENTAGES IN LINE 7, COLUMN F. PART II, COMMUNITY BUILDING ACTIVITIES: COMMUNITY SUPPORT INCLUDES ACTIVITIES SUCH AS THERAPISTS AVAILABLE AT GAMES AND AT THE COMMUNITY CENTER AND WELLNESS CAMPAIGNS IN COOPERATION WITH THE COMMUNITY CENTER. OTHER ACTIVITIES INCLUDE COMMUNITY BLOOD DRAWS, HEALTH FAIR, BLOOD PRESSURE SCREENINGS, DIABETES PREVENTION PROGRAMS, AND MULTIPLE SMALLER COMMUNITY EDUCATION PROGRAMS THROUGH RADIO INTERVIEWS WITH HEALTH PROFESSIONALS. PART III, LINE 2: BAD DEBTS RESULT WHEN A PATIENT WHO HAS BEEN DETERMINED TO HAVE THE FINANCIAL CAPACITY TO PAY FOR HEALTHCARE SERVICES IS UNWILLING TO SETTLE THE CLAIM. DUE TO A COMPLIANCE WITH FASB TOPIC 606 CONCERNING REVENUE RECOGNITION, BAD DEBT EXPENSE HAS BEEN GREATLY REDUCED AS THE RECOGNITION OF BAD DEBT IS AN EXPENSE ASSOCIATED WITH SPECIFIC ACCOUNTS RATHER THAN AN ALLOWANCE FOR DOUBTFUL ACCOUNTS WHICH ARE UNSPECIFIC AND CLASSIFIED AS AN IMPLICIT PRICE CONCESSION REDUCING REVENUE ON THE OPERATING STATEMENT. PART III, LINE 3: GENERALLY, PATIENTS WHO ARE COVERED BY THIRD-PARTY PAYORS ARE RESPONSIBLE FOR RELATED DEDUCTIBLES AND COINSURANCE, WHICH VARY IN AMOUNT. THE ORGANIZATION PROVIDES SERVICES TO UNINSURED PATIENTS, AND OFFERS THOSE UNINSURED PATIENTS A DISCOUNT, EITHER BY POLICY OR LAW, FROM STANDARD CHARGES. THE ORGANIZATION 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 DECEMBER 31, 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. NONE OF THE AMOUNT IS INCLUDED AS COMMUNITY BENEFIT. PART III, LINE 4: THE HOSPITAL'S FINANCIAL STATMENTS DO NOT CONTAIN A SPECIFIC FOOTNOTE DESCRIBING BAD DEBT. HOWEVER, PAGES 8, 10, 11, AND 12 OF THE ATTACHED AUDITED FINANCIAL STATEMENTS INCLUDE FOOTNOTES TITLED "PATIENT RECEIVABLES", "PATIENT SERVICE REVENUE AND "PATIENT FINANCIAL ASSISTANCE". PART III, LINE 8: THE ORGANIZATION USED THE MEDICARE COST REPORT FOR FISCAL YEAR 2021 TO REPORT THE AMOUNTS OF TOTAL REVENUE RECEIVED FROM MEDICARE AND RELATED MEDICARE ALLOWABLE COSTS. MEDICARE PAYS THE HOSPITAL'S RURAL HEALTH CLINICS (RHC) AT COST SUBJECT TO CERTAIN LIMITS. THE MEDICARE SHORTFALL IN PAYMENTS SHOULD BE CONSIDERED A COMMUNITY BENEFIT AS IT IS PART OF THE HOSPITAL'S MISSION TO PROVIDE THESE SERVICES EVEN IF MEDICARE REIMBURSEMENT IS BELOW COST. PART III, LINE 9B: THE CHARITY CARE POLICY ALLOWS FOR PROACTIVE WRITE OFF TO ALLOWANCE FOR CHARITY CARE OF ANY BALANCE OWED BY A PATIENT KNOWN TO QUALIFY FOR CHARITY CARE UNDER THE FINANCIAL ASSISTANCE POLICY. COLLECTION PROCEDURES DO NOT ENSUE ON ANY ACCOUNTS ELIGIBLE FOR FINANCIAL ASSISTANCE. PART VI, LINE 2: NEEDS ASSESSMENTS ARE DETERMINED THROUGH SCIENTIFIC, AS WELL AS UNSCIENTIFIC METHODS. EVERY 3 YEARS A MARKET ASSESSMENT IS COMPLETED USING CLAIMS DATA WHICH REVEALS THE NEEDS OF COMMUNITY MEMBERS BEING MET ELSEWHERE DUE TO EITHER UNAVAILABILITY OF SERVICE OR PATIENT CHOICE. THIS ASSESSMENT INCLUDES THE DEMOGRAPHICS OF THE AREA WHICH SHOW AN AGING AND MODERATE INCOME POPULATION. THESE FACTS ARE THEN USED TO DETERMINE THE NEEDS OF THE COMMUNITY AS WELL AS THE FUTURE NEEDS BASED ON HISTORICAL DATA. ADDITIONALLY, COMMUNITY NEEDS ARE DETERMINED USING PUBLIC OPINION, PATIENT SATISFACTION RECOMMENDATIONS, BOARD AND LEADERSHIP EXPERIENCE, COMMUNICATIONS WITH COMMUNITY MEMBERS, AND PHYSICIAN INPUT. FUTURE MEASUREMENTS OF HEALTH DATA MINED FROM CLAIMS SUBMISSIONS WILL BE USED TO FURTHER ANALYZE THE NEEDS OF THE COMMUNITY. PART VI, LINE 3: AT THE POINT OF REGISTRATION, A PATIENT'S INSURED STATUS IS DETERMINED. PATIENTS WHO ARE UNDERINSURED OR UNINSURED RECEIVE COUNSELING THROUGH THE HOSPITAL'S PATIENT ADVOCATE AND/OR A MEMBER OF THE FINANCIAL SERVICES OR REGISTRATION STAFF SERVING AS A FINANCIAL COUNSELOR. INFORMATION IS CONVEYED TO THE PATIENT OR THE GUARANTOR REGARDING MEDICAID AND MEDICARE, AS WELL AS CHARITY CARE PROVIDED BY THE HOSPITAL. ADDITIONAL COUNSELING IS PROVIDED AFTER DISMISSAL WHEN THE PROACTIVE APPROACH WAS UNSUCCESSFUL. ADDITIONALLY, SOCIAL SERVICES PERSONNEL AND PATIENT FINANCIAL COUNSELORS MEET WITH PATIENTS INDIVIDUALLY WHEN NEEDED REGARDING THEIR COVERAGE IN AN ATTEMPT TO DETERMINE ELIGIBILITY FOR FINANCIAL ASSISTANCE AND OTHER MEANS FOR THE INDIVIDUALS. PART VI, LINE 4: MOST OF THE AREA THAT THE HOSPITAL SERVES IS LOCATED IN CHEYENNE COUNTY, NEBRASKA WHICH HAS A POPULATION OF APPROXIMATELY 9,529 PEOPLE. THE CITIES OF SIDNEY, LODGEPOLE, POTTER, DALTON, GURLEY, AND SUNOL ARE LOCATED WITHIN THE COUNTY AND ARE GENERALLY WITHIN APPROXIMATELY 30 MILES FROM THE HOSPITAL. ACCORDING TO THE US CENSUS BUREAU, THE 2021 DEMOGRAPHIC IS AROUND 94.9% CAUCASIAN. THE AVERAGE HOUSEHOLD INCOME IN CHEYENNE COUNTY IS $52,270 WITH A POVERTY RATE OF 10.0%. PART VI, LINE 5: IN ADDITION TO ACTIVITIES ADDRESSED IN THE CHNA REPORT, THE HOSPITAL NORMALLY HOLDS AN ANNUAL HEALTH FAIR AND AN ANNUAL CHILDREN'S HEALTH FAIR, 10K RACES, TRIATHLON RACES, PROVIDES OUTREACH SERVICE TO LOCAL BUSINESSES TO ASSURE FLU SHOTS AND IMMUNIZATIONS ARE UP TO DATE AS WELL AS DOING BLOOD PRESSURE SCREENINGS. THE HOSPITAL WAS UNABLE TO DO MANY THINGS IN 2021 DUE TO THE COVID-19 PANDEMIC. SRMC ALSO CONDUCTS DIABETES EDUCATION CLASSES AND A DIABETES HEALTH FAIR DURING THE YEAR. SRMC OFFERS IN-HOME FOLLOW UP VISITS TO ANY MOTHERS WITH NEW BABIES NO MATTER WHERE THEY DELIVERED THEIR BABY, AND COLLABORATES WITH THE SCHOOL TO PROVIDE FOLLOWUP THERAPY CONSULTATIONS AFTER SPORTING EVENTS. THE HOSPITAL CONTINUES TO PROVIDE OB AND DELIVERY SERVICES EVEN THOUGH MANY SMALLER HOSPITALS HAVE DISCONTINUED SUPPORT OF THEIR COMMUNITIES IN THIS ARENA. COMMUNITY EDUCATION IS PROVIDED THRU RADIO BROADCASTS EACH WEEK WITH VARYING TOPICS. PART VI, LINE 6: SIDNEY REGIONAL MEDICAL CENTER IS NOT PART OF AN AFFILIATED HEALTH CARE ORGANIZATION. 1 DICKEY AND ASSOCIATES AUCTIONEERS 1616 BIRCH STREET SIDNEY NE 69162 822544780 501(C)(3) 11200 0 YOUTH LIVESTOCK SPONSORSHIP KIDS PLUS INC PO BOX 296 SIDNEY NE 69162 470715249 501(C)(3) 12500 0 SIDNEY PARK PROJECT 2 0 PART I, LINE 2: IF THE DONEE ORGANIZATION IS NOT A GOVERNMENTAL ENTITY OR IDENTIFIED AS A CHARITABLE ORGANIZATION ON GUIDESTAR, THE DONEE ORGANIZATION IS RESEARCHED TO ASSURE THEIR NOT-FOR-PROFIT STATUS. THE DONEE ORGANIZATION'S MISSION INFORMATION, THEIR FINANCIAL DATA AND THEIR FORM 990 (IF AVAILABLE) IS REVIEWED AND CONSIDERED BY THE BOARD OF DIRECTORS. THE BOARD OF DIRECTORS MUST APPROVE, BY A MAJORITY VOTE OF THE QUORUM IN ATTENDANCE, THE DONATION TO THE ORGANIZATION OR GOVERNMENTAL ENTITY. DURING THE FOLLOWING 12 TO 24 MONTHS AFTER THE DONATION IS DISTRIBUTED, CONTINUED MONITORING OF THE PROJECT OR DONATION RESTRICTIONS, IF APPLICABLE, SHALL BE REPORTED TO THE BOARD OF DIRECTORS. THE DONEE ORGANIZATION'S FORM 990 (IF AVAILABLE) FOR THE YEAR OF THE DONATION AND ANY OTHER SUBSEQUENT YEARS REQUESTED SHALL BE MADE AVAILABLE TO THE BOARD MEMBERS FOR FOLLOW UP REVIEW. X X X X 0 0 0 0 0 0 0 0 0 REBECCA L ALLARD MD CHIEF OF STAFF 657276 0 27500 0 120 0 14500 0 35759 0 735155 0 0 0 MATTHEW JANSEN MD DOCTOR 630399 0 2500 0 108 0 14500 0 35759 0 683266 0 0 0 JAMES POPOVICH MD DOCTOR 563346 0 2500 0 108 0 14500 0 35759 0 616213 0 0 0 SARA SHOLAR MD DOCTOR 563457 0 2500 0 96 0 11307 0 23914 0 601274 0 0 0 KELLY CASEY MD DOCTOR 488460 0 2500 0 276 0 2417 0 38509 0 532162 0 0 0 APRIL SMITH MD DOCTOR 396845 0 2500 0 108 0 14500 0 26146 0 440099 0 0 0 ROBERT GRAVES MD PHYSICIAN AT LARGE 343803 0 2500 0 1524 0 14444 0 37371 0 399642 0 0 0 KELLY UTLEY CFO 200943 0 2500 0 516 0 9774 0 9696 0 223429 0 0 0 SCHEDULE J, PART III: JASON PETIK, CEO, RECEIVES COMPENSATION FROM POUDRE VALLEY MEDICAL GROUP, AN UNRELATED ENTITY. POUDRE VALLEY MEDICAL GROUP PROVIDES MANAGEMENT SERVICES TO ITS CLIENTS, INCLUDING THE SIDNEY REGIONAL MEDICAL CENTER. THE SIDNEY REGIONAL MEDICAL CENTER'S BOARD OF DIRECTORS SETS THE COMPENSATION FOR MR. PETIK. MR. PETIK RECEIVED TOTAL COMPENSATION OF $289,740. MR. PETIK'S COMPENSATION IS REFLECTED IN PART IX, LINE 11A. A THE COUNTY OF DEUEL NEBRASKA 476006452 251476AA5 2014-10-16 10000000 CONSTRUCT HOSPITAL 0 0 0 A 2098829 10000000 10000000 2015 0 0 1 1 A 0 0 0 0 0.00000 0.00000 0.00000 0 0 1 A 0 0 1 0 1 0 0 0 1 A 1 KEVIN UTLEY EMPLOYEE OF ORGANIZATION AND SPOUSE OF KELLY UTLEY, CFO 91190 EMPLOYEE COMPENSATION 0 SUSAN PETIK EMPLOYEE OF ORGANIZATION AND SPOUSE OF JASON PETIK, CEO 95006 EMPLOYEE COMPENSATION 0 FORM 990, PART VI, SECTION A, LINE 3 POUDRE VALLEY MEDICAL GROUP CURRENTLY EMPLOYS THE CHIEF EXECUTIVE OFFICER FOR SIDNEY REGIONAL MEDICAL CENTER. FORM 990, PART VI, SECTION B, LINE 11B THE ORGANIZATION'S ACCOUNTING DEPARTMENT PROVIDES DOCUMENTATION TO THE INDEPENDENT ACCOUNTING FIRM FOR THE PREPARATION OF THE FORM 990. COMMUNICATIONS BETWEEN THE ACCOUNTING FIRM AND THE ACCOUNTING DEPARTMENT FINALIZE THE PREPARATION OF THE FORM 990. THE CEO AND CFO THEN REVIEW THE FORM 990 AND E-MAIL THE PUBLIC DISCLOSURE COPY TO ALL MEMBERS OF THE BOARD OF DIRECTORS FOR THEIR REVIEW. ONCE THE 990 RETURN HAS BEEN APPROVED BY ALL PARTIES IT IS SUBMITTED TO THE IRS ON OR BEFORE THE REGULAR OR EXTENDED DUE DATE. FORM 990, PART VI, SECTION B, LINE 12C EACH YEAR ALL BOARD MEMBERS ARE REQUIRED TO DISCLOSE ANY CONFLICTS OF INTEREST. ANY DUALITY OF INTEREST OR POTENTIAL CONFLICT OF INTEREST ON THE PART OF ANY OFFICER, DIRECTOR, COMMITTEE MEMBER, OR ANY KEY EMPLOYEE IS DISCLOSED TO THE BOARD OF DIRECTORS AND MADE A MATTER OF RECORD WHENEVER IT ARISES. WHENEVER IT INVOLVES A MATTER OF BOARD ACTION, ANY OFFICER, DIRECTOR, COMMITTEE MEMBER, OR KEY EMPLOYEE HAVING A DUALITY OF INTEREST OR A POSSIBLE CONFLICT OF INTEREST IN ANY MATTER DOES NOT VOTE OR ABSTAINS FROM THE VOTE, IF PRESENT IN THE ROOM. OFTEN THE BOARD MEMBER IS ASKED TO LEAVE THE MEETING DURING DISCUSSION PERIODS AND FOR THE VOTE ON ISSUES FOR WHICH CONFLICT EXISTS. THESE INDIVIDUALS DO NOT USE THEIR PERSONAL INFLUENCE ON THE MATTERS. FORM 990, PART VI, SECTION B, LINE 15 POUDRE VALLEY MEDICAL GROUP PROVIDES ADMINISTRATIVE SERVICES TO SIDNEY REGIONAL MEDICAL CENTER (SRMC). THIS INCLUDES PROVIDING THE HOSPITAL'S CHIEF EXECUTIVE OFFICER. SRMC'S METHOD TO DETERMINE EXECUTIVE SALARY RANGES IS TO ANNUALLY PULL SALARY RANGES FROM NO LESS THAN TWO SURVEY SOURCES (THREE WHEN POSSIBLE) TO DETERMINE THE AVERAGE SALARY RANGE FOR EACH EXECUTIVE POSITION BY GEOGRAPHICAL REGION. THESE ARE REVIEWED AND PRESENTED TO THE HUMAN RESOURCE COMMITTEE OF THE BOARD OF DIRECTORS FOR REVIEW AND APPROVAL/RECOMMENDATIONS. FORM 990, PART VI, SECTION C, LINE 19 THE GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS ARE MADE AVAILABLE UPON REQUEST. ALSO, THE FINANCIAL STATEMENTS ARE SENT ANNUALLY TO COMMUNITY LEADERS. FORM 990, PART VII, SECTION A, LINE 5: JASON PETIK RECEIVES COMPENSATION FROM AN UNRELATED ORGANIZATION, POUDRE VALLEY MEDICAL GROUP, WHICH PROVIDES MANAGEMENT SERVICES TO SIDNEY REGIONAL MEDICAL CENTER. FORM 990, PART IX, LINE 11G PROFESSIONAL FEES - OTHER: PROGRAM SERVICE EXPENSES 4,148,288. MANAGEMENT AND GENERAL EXPENSES 603,189. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 4,751,477. CONTRACT SERVICES - SURGERY PROFESSIONALS: PROGRAM SERVICE EXPENSES 2,380,393. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,380,393. CONTRACT SERVICES - ANESTHESIA PROFESSIONALS: PROGRAM SERVICE EXPENSES 284,939. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 284,939. FORM 990, PART XI, LINE 2C: THE BOARD OF DIRECTORS ASSUMES THE RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT OF SRMC'S FINANCIAL STATEMENTS AND SELECTION OF AN INDEPENDENT ACCOUNTANT. THIS PROCESS HAS NOT CHANGED SINCE THE PRIOR YEAR. CHEYENNE COUNTY HOSPITAL AND HEALTH CENTER FOUNDATION 1000 POLE CREEK CROSSING SIDNEY NE 69162 470686476 SUPPORT SIDNEY REGIONAL MEDICAL CENTER NE 501(C)(3) LINE 12C, III-FI N/A 0 0 1 0 0 0 0 0 0 0 0 0 0 1 1 1 1 1 0 0