2021-08-13T09:04:18-05:00 2020-09-30 476097913 SEIM JOHNSON LLP 18081 BURT STREET SUITE 200 OMAHA NE 680224722 990 2019-10-01 480561974 ATCHISON HOSPITAL ASSOCIATION ATCH 9133605584 800 RAVEN HILL DRIVE ATCHISON KS 66002 JIM FRASER CHIEF FINANCIAL OFFICER 9133605584 2021-08-12 1 WENDY R COOLEY P01523804 4023302660 2019 2022-09-23 18:48:47Z AMBERWELL HEALTH JEFF PERRY 800 RAVEN HILL DRIVE ATCHISON KS 66002 58716113 0 X WWW.AMBERWELLHEALTH.ORG X 1912 KS TO PROVIDE EXCELLENT HEALTH CARE AND IMPROVE THE QUALITY OF LIFE IN OUR COMMUNITY. 9 8 379 75 13500 8772 586132 2094787 45738581 46844396 282061 539006 75715 92289 46682489 49570478 0 0 0 0 23813638 26163634 0 0 0 20988102 23355055 44801740 49518689 1880749 51789 49795262 57818379 30205505 38182371 19589757 19636008 TO PROVIDE EXCELLENT HEALTH CARE AND IMPROVE THE QUALITY OF LIFE IN OUR COMMUNITY. 0 0 43490177 46829892 ATCHISON HOSPITAL PROVIDED ACUTE INPATIENT AND OUTPATIENT HEALTH SERVICES TO THE GENERAL PUBLIC. SERVICES INCLUDE BUT ARE NOT LIMITED TO: EMERGENCY SERVICES, HOME HEALTH AND HOSPICE, GENERAL INPATIENT ACUTE SERVICES, RADIOLOGY, & OBSTETRICS. THE NUMBER OF PEOPLE SERVED DURING THE FISCAL YEAR ENDING 09/30/20 WAS 168,545. 43490177 1 1 0 1 0 0 1 0 0 0 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 1 36 0 1 379 1 1 1 0 0 0 0 0 0 0 0 0 0 0 X 9 8 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 X JIM FRASER 9133672131 800 RAVEN HILL DRIVE ATCHISON KS 66002 EJ WILKINSON PHYSICIAN 40.00 0.00 X 612491 0 34988 DARIN ALLEN MEDICAL DIRECTOR OF ANESTHESIA 40.00 0.00 X 451235 0 39364 JONATHAN LECK CHIEF OF MEDICAL STAFF 40.00 0.00 X 466892 0 18197 JOHN L JACOBSON FORMER CEO 40.00 0.00 X 399400 0 8727 STEVEN ROVENSTINE PHYSICIAN 40.00 0.00 X 345587 0 35423 DONALD ABLES PHYSICIAN 40.00 0.00 X 317547 0 35931 PAM RIZZA PHYSICIAN 40.00 0.00 X 289620 0 38286 GARY R FOLL CFO 40.00 2.00 X 165614 0 23827 JEFF PERRY CEO 40.00 1.00 X 152940 0 3516 SUSAN MYERS CHAIRPERSON 1.00 0.00 X X 0 0 0 GUS GRIFFIN VICE CHAIRPERSON THRU 05/20 1.00 0.00 X X 0 0 0 LYDIA FUNK VICE CHAIRPERSON 1.00 0.00 X X 0 0 0 LARRY MEARS SECRETARY 1.00 0.00 X X 0 0 0 STEVE MINNIS SECRETARY THRU 12/19 1.00 0.00 X X 0 0 0 TODD GIGSTAD TREASURER 1.00 0.00 X X 0 0 0 MELINDA PREGONT DIRECTOR 1.00 0.00 X 0 0 0 JIM ROWLAND DIRECTOR 1.00 0.00 X 0 0 0 LORIN AFFIELD DIRECTOR 1.00 0.00 X 0 0 0 JERRY HERNY DIRECTOR 1.00 0.00 X 0 0 0 3201326 0 238259 39 1 1 0 SPENCER FANE 1000 WALNUT ST STE 1400 KANSAS CITY MO 64106 LEGAL SERVICES 268469 CASCADE HEALTH SERVICES 1045 SWIFT AVENUE KANSAS CITY MO 64116 STAFFING SERVICES 167336 THOMAS FAMILY PRACTICE 174 DEER RUN ATCHISON KS 66002 MEDICAL SERVICES 111902 SEIM JOHNSON LLP 18081 BURT STREET STE 200 OMAHA NE 68022 ACCOUNTING SERVICES 106689 4 1774662 320125 2094787 NET PATIENT SERVICE REVENUE 624100 24128143 24128143 MEDICARE/MEDICAID 624100 19396786 19396786 340B DRUG PRICING PROGRAM 624100 2992945 2992945 326522 326522 46844396 264110 264110 48479 48479 57749 58753 -1004 -1004 -14504 13500 9095403 217896 9015603 71279 79800 146617 226417 226417 CAFETERIA 722210 93293 93293 93293 49570478 46829892 13500 632299 345897 345897 485089 485089 21373339 19148448 2224891 349460 313718 35742 2177570 1954324 223246 1432279 1272864 159415 357013 357013 172828 172828 3305235 2537102 768133 177735 177735 2012137 1884563 127574 636931 570851 66080 641493 604810 36683 126049 112172 13877 118060 113627 4433 967648 927567 40081 3950631 3786992 163639 352164 343665 8499 MEDICAL SUPPLIES 6077853 6077853 BAD DEBT 2667442 2667442 COLLECTION FEES 1477880 467887 1009993 FOOD 168396 168396 145560 52807 92753 49518689 43490177 6028512 0 8099411 12635216 893926 5291779 5765434 5190757 1251351 1431846 745440 703536 56087644 37652432 20833458 18435212 12090798 13392517 115444 86851 0 650665 49795262 57818379 3623666 3927758 23508258 25371742 2087064 356889 986517 8525982 30205505 38182371 X 19396541 19636008 193216 0 19589757 19636008 49795262 57818379 51789 -5538 0 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 9073 9073 0 PART II-B, LINE 1: LOBBYING EXPENSES THROUGH DUES PAID TO THE KANSAS HOSPITAL ASSOCIATION AND THE AMERICAN HOSPITAL ASSOCIATION. X 1 3.00 1 0 964642 964642 35204236 23117129 12087107 14753686 11789164 2964522 5165080 2746139 2418941 18435212 DEFERRED COMPENSATION 758995 REFUNDABLE ADVANCES - CARES ACT FUNDS 7766987 8525982 X PART II, LINE 9: CONSERVATION EASEMENTS ARE REPORTED AT HISTORICAL COSTS AS LAND. PART X, LINE 2: THE HOSPITAL AND FOUNDATION ARE NOT-FOR-PROFIT CORPORATIONS AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. THE HOSPITAL AND FOUNDATION HAVE RECEIVED DETERMINATION LETTERS INDICATING THAT THEY ARE EXEMPT FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE INTERNAL REVENUE CODE. THE INTERNAL REVENUE SERVICE HAS ESTABLISHED STANDARDS TO BE MET TO MAINTAIN TAX EXEMPT STATUS. THE HOSPITAL AND FOUNDATION ACCOUNT FOR UNCERTAINTIES IN ACCOUNTING FOR INCOME TAX ASSETS AND LIABILITIES USING GUIDANCE INCLUDED IN FASB ASC 740, INCOME TAXES. THE HOSPITAL AND FOUNDATION RECOGNIZE THE EFFECT OF INCOME TAX POSITIONS ONLY IF THOSE POSITIONS ARE MORE LIKELY THAN NOT OF BEING SUSTAINED. AT SEPTEMBER 30, 2020 AND 2019, THE HOSPITAL AND FOUNDATION HAD NO UNCERTAIN TAX POSITIONS ACCRUED. 1 1 X 1 X 1 X 1 1 1 0 1 1 49655 49655 0.00110 4704524 2576430 2128094 0.04540 4754179 2576430 2177749 0.04650 5818 5818 0.00010 1047313 1047313 0.02240 1053131 1053131 0.02250 5807310 2576430 3230880 0.06900 1 2667442 0 14854995 14792288 62707 X 1 1 1 1 ATCHISON HOSPITAL ASSOCIATION 800 RAVEN HILL DRIVE ATCHISON KS 66002 WWW.AMBERWELLHEALTH.ORG H-003-001 X X X X ATCHISON HOSPITAL ASSOCIATION 1 0 0 1 X X X X X X X X X 18 1 0 1 1 X WWW.AMBERWELLHEALTH.ORG X 1 18 1 WWW.AMBERWELLHEALTH.ORG 0 1 X 200.000000000000 200.000000000000 X X X X X 1 1 X X X 1 X WWW.AMBERWELLHEALTH.ORG X WWW.AMBERWELLHEALTH.ORG X WWW.AMBERWELLHEALTH.ORG X X X X X 1 X 0 X X X X 1 X 0 0 ATCHISON HOSPITAL ASSOCIATION PART V, SECTION B, LINE 5: COMMUNITY BENEFIT NEEDS WERE OBTAINED BY A WRITTEN SURVEY MAILED TO THE COMMUNITY AND BY A TOWN HALL WHERE INTERESTED PARTIES COULD COME TOGETHER IN PERSON AND DESCRIBE THEIR NEEDS. ATCHISON HOSPITAL ASSOCIATION PART V, SECTION B, LINE 6B: NEK MULTI-COUNTY HEALTH DEPARTMENTATCHISON COUNTY HEALTH DEPARTMENT ATCHISON HOSPITAL ASSOCIATION PART V, SECTION B, LINE 11: THE HOSPITAL IS AFFILIATED WITH AN ORGANIZATION NAMED LIVE WELL LIVE ATCHISON. THEIR SOLE PURPOSE IS TO ADDRESS THE HEALTHCARE NEEDS OF THE COMMUNITY. THE ORGANIZATION IS MADE UP OF CITY AND COUNTY OFFICIALS, HEALTH DEPARTMENT, THE HOSPITAL, MAJOR EMPLOYERS, THE SCHOOL DISTRICTS, BENEDICTINE COLLEGE, FAITH BASED CHURCHES, AREA BUSINESSES, HEALTH AND SERVICE AGENCIES AS WELL AS COMMUNITY AND CIVIC ORGANIZATIONS. ANY NEEDS THAT CAN BE ADDRESSED ARE ADDRESSED BY EITHER LIVE WELL LIVE ATCHISON, THE GUIDANCE CENTER ( MENTAL HEALTH PROVIDER ) OR THE ATCHISON HOSPITAL.ECONOMIC DEVELOPMENT AND HEALTHCARE TRANSPORTATION ARE THE TWO THINGS THAT THE HOSPITAL IS NOT ABLE TO ADDRESS EITHER BECAUSE IT IS OUT OF THEIR JURISDICTION OR FROM LACK OF FUNDING. ATCHISON HOSPITAL ASSOCIATION PART V, SECTION B, LINE 13H: THERE ARE INSTANCES WHEN A PATIENT MAY APPEAR ELIGIBLE FOR FINANCIAL DISCOUNTS, BUT THERE IS NO FINANCIAL ASSISTANCE FORM ON FILE OR LACK OF SUPPORTING DOCUMENTATION. IN THE EVENT THERE IS NO EVIDENCE TO SUPPORT A PATIENT'S ELIGIBILITY FOR FINANCIAL ASSISTANCE, ATCHISON HOSPITAL MAY USE OUTSIDE AGENCIES OR VENDORS IN DETERMINING ELIGIBILITY AND POTENTIAL DISCOUNT AMOUNTS. THESE RESOURCES MAY USE DEMOGRAPHIC AND HOUSEHOLD INFORMATION AND/OR CREDIT SCORING TECHNOLOGY TO DETERMINE THE PERCENT OF ASSISTANCE TO APPLY TO THE PATIENT'S ACCOUNT. 2 1 - ATCHISON INTERNAL MEDICINE & FAMILY PRA 800 RAVEN HILL DRIVE ATCHISON KS 66002 RURAL HEALTH CLINIC 2 - FAMILY MEDICAL CENTER OF TROY 311 W LOCUST TROY KS 66087 RURAL HEALTH CLINIC PART I, LINE 3C: NOT APPLICABLE: FEDERAL POVERTY GUIDELINES ARE USED TO DETERMINE ELIGIBILITY FOR PROVIDING FREE AND DISCOUNTED CARE TO LOW INCOME INDIVIDUALS. PART I, LINE 6A: ATCHISON HOSPITAL'S COMMUNITY BENEFIT REPORT IS NOT PREPARED BY A RELATED ORGANIZATION. PART I, LINE 7: THE COSTING METHODOLOGY USED TO CALCULATE THE AMOUNTS CONTAINED IN THE TABLE OF PART I, LINE 7, OR SCHEDULE H, IS A COST TO CHARGE RATIO CALCULATED USING WORKSHEET 2. PART I, LINE 7G: THERE ARE NO COSTS ATTRIBUTABLE TO A PHYSICIAN CLINIC INCLUDED ON LINE 7G. PART I, LN 7 COL(F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25(A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $2,667,442. PART III, LINE 2: IN EVALUATING THE COLLECTIBILITY OF ACCOUNTS RECEIVABLE, THE HOSPITAL ANALYZES ITS PAST HISTORY AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYOR SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS AND PROVISION FOR BAD DEBTS. MANAGEMENT REGULARLY REVIEWS DATA ABOUT THESE MAJOR PAYOR SOURCES OF REVENUE IN EVALUATING THE SUFFICIENCY OF THE ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS. FOR RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRD-PARTY COVERAGE, THE HOSPITAL ANALYZES CONTRACTUALLY DUE AMOUNTS AND PROVIDES AN ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS AND A PROVISION FOR BAD DEBTS FOR THOSE ACCOUNTS OVER A CERTAIN AGE BASED ON DISCHARGE THAT MAKE THE REALIZATION OF AMOUNTS DUE UNLIKELY. FOR RECEIVABLES ASSOCIATED WITH SELF-PAY PATIENTS (WHICH INCLUDES BOTH PATIENTS WITHOUT INSURANCE AND PATIENTS WITH DEDUCTIBLE AND COPAYMENT BALANCES DUE FOR WHICH THIRD-PARTY COVERAGE EXISTS FOR PART OF THE BILL), THE HOSPITAL RECORDS A SIGNIFICANT PROVISION FOR BAD DEBTS IN THE PERIOD OF SERVICE ON THE BASIS OF ITS PAST EXPERIENCE, WHICH INDICATES THAT MANY PATIENTS ARE UNABLE OR UNWILLING TO PAY THE PORTION OF THEIR BILL FOR WHICH THEY ARE FINANCIALLY RESPONSIBLE. THE DIFFERENCE BETWEEN THE STANDARD RATES (OR THE DISCOUNTED RATES IF NEGOTIATED) AND THE AMOUNTS ACTUALLY COLLECTED AFTER ALL REASONABLE COLLECTION EFFORTS HAVE BEEN EXHAUSTED IS CHARGED OFF AGAINST THE ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS. PART III, LINE 4: THE HOSPITAL'S FINANCIAL STATMENTS DO NOT CONTAIN A SPECIFIC FOOTNOTE DESCRIBING BAD DEBT. HOWEVER, PAGES 8, 10 AND 11 OF THE ATTACHED FINANCIAL STATEMENTS INCLUDE FOOTNOTES TITLED "PATIENT RECEIVABLES" "PATIENT SERVICE REVENUE AND "PATIENT FINANCIAL ASSISTANCE". PART III, LINE 9B: THE HOSPITAL DOES NOT PURSUE COLLECTION ON ACCOUNTS THAT HAVE BEEN DETERMINED TO BE ELIGIBLE FOR CHARITY CARE. PART VI, LINE 2: ATCHISON HOSPITAL ASSOCIATION HAS ACCESS TO THE KANSAS HEALTH INITIATIVE SURVEY ON HEALTH INDICATORS. BASED ON THESE INDICATORS, ATCHISON HOSPITAL DETERMINES THE NEEDS OF THE COMMUNITY AND WHAT PROGRAMS TO IMPLEMENT. PART VI, LINE 3: PATIENTS ARE GIVEN A PAMPHLET DESCRIBING THE POLICY FOR FINANCIAL ASSISTANCE WHEN THEY ARE ADMITTED. THE ADMITTING OFFICE ASKS THEM TO SPEAK WITH THE HOSPITAL FINANCIAL COUNSELOR IF THEY DO NOT HAVE INSURANCE. AFTER THE PATIENT RECEIVES THEIR STATEMENT IN THE MAIL, THEY CAN CALL IN AND TALK WITH THE FINANCIAL COUNSELOR. IF THE ACCOUNT GOES TO A COLLECTION COMPANY BECAUSE THE PATIENT DID NOT PAY OR TALK WITH THE FINANCIAL COUNSELOR, THE COLLECTION COMPANY WILL GIVE THEM THE PROPER APPLICATION TO FILL OUT TO SEE IF THEY ARE ELIGIBLE FOR FINANCIAL ASSISTANCE. PART VI, LINE 4: THE HOSPITAL SERVES THE COMMUNITY OF ATCHISON, KANSAS AND THE SURROUNDING COUNTY OF ATCHISON, KANSAS. ATCHISON IS A COMMUNITY OF APPROXIMATELY 10,500 PEOPLE WHO WOULD BE DESCRIBED AS MOSTLY COMPRISED OF BLUE-COLLAR AND LOW-INCOME INDIVIDUALS. THE SURROUNDING COUNTY HAS A POPULATION OF AN ADDITIONAL 6,300 PEOPLE. THERE ARE SEVERAL LARGE FARMS WHICH PLANT ROW CROPS OF CORN AND BEANS. PART VI, LINE 5: ATCHISON HOSPITAL BELIEVES COMMUNITY BENEFIT GOES BEYOND HOSPITAL VISITS AND EMERGENCY CARE. IT MEANS GETTING INVOLVED AND WORKING TO IMPROVE THE HEALTH OF OUR COMMUNITY; IT MEANS HELPING OTHERS PURSUE GOOD HEALTH THROUGH DONATIONS, EDUCATION AND VOLUNTEERISM. THE FOLLOWING IS A SUMMARY OF THE NUMEROUS ACTIVITIES, INITIATIVES AND EVENTS THAT HAVE BEEN IMPLEMENTED IN SUPPORT OF PROVIDING COMMUNITY BENEFITS TO THE RESIDENTS IN THE ATCHISON COMMUNITY AND REGION. LIVE WELL LIVE ATCHISON, IS A HOSPITAL INITIATIVE THAT INVOLVES PARTNERSHIPS WITH THE KANSAS HEALTH INITIATIVE, ATCHISON COUNTY SCHOOLS, BENEDICTINE COLLEGE, CITY AND COUNTY GOVERNMENTS, STATE REPRESENTATIVES, FAITH-BASED CHURCHES, THE HEALTH DEPARTMENT, COUNTY EXTENSION OFFICE AND AREA BUSINESSES, HEALTH AND SERVICE AGENCIES, AS WELL AS COMMUNITY AND CIVIC ORGANIZATIONS. THE GROUP IS WORKING TOWARD IMPROVING THE HEALTH BEHAVIORS AND LIFESTYLE OF ATCHISON COUNTY. ATCHISON HOSPITAL'S "BEST CARE COMMUNITY HEALTH FAIR," IS AN ANNUAL EVENT BY THE HOSPITAL AND HELD AT THE ATCHISON ELEMENTARY SCHOOL. HOSPITAL EMPLOYEES AS WELL AS COMMUNITY HEALTH AGENCIES, ORGANIZATIONS, LOCAL AND REGIONAL AREA RESPONDERS AND PHYSICIAN PRACTICES, PROVIDE HEALTH SCREENINGS, INTERACTIVE EDUCATIONAL, SAFETY AND FITNESS ACTIVITIES. ATCHISON HOSPITAL SUPPORTS THE ATCHISON COMMUNITY HEALTH CLINIC, A FEDERAL QUALIFIED HEALTH CLINIC, BY SUBSIDIZING THE CLINIC'S FACILITIES RENT FREE, GENERAL MAINTENANCE AND SNOW REMOVAL. THE HOSPITAL CONDUCTS AND SPONSORS SUPPORT GROUPS AND CLASSES THAT PROVIDE ONGOING EDUCATION AND COUNSELING SUCH AS GRIEF SUPPORT, BIRTHING AND CHILDCARE CLASSES. ADDITIONALLY, THE HOSPITAL OFFERS A HOSPICE VOLUNTEER PROGRAM. THE HOSPITAL ALSO PROVIDES SPONSORSHIP AND DONATIONS TO VARIOUS ORGANIZATIONS, LOCAL SCHOOLS AND NURSING HOMES, AS WELL AS COMMUNITY INITIATIVES. THEY INCLUDE: RELAY FOR LIFE, AMELIA EARHART FESTIVAL, BEAUTIFICATION OF OUR CITY, FARM SAFETY DAYS, JOGGIN' FOR THE NOGGIN', PARTICIPATION IN LOCAL AND REGIONAL HEALTH FAIRS AND PHYSICIAN SUPPORT AT LOCAL HIGH SCHOOL AND COLLEGE ATHLETIC EVENTS. ATCHISON HOSPITAL'S CARE TEAM, AN EMPLOYEE GROUP THAT GENERATES INITIATES FUNDRAISERS AND DONATES EARNED PROCEEDS TO VARIOUS LOCAL CHARITIES. THE HOSPITAL AS WELL AS THE ATCHISON HOSPITAL AUXILIARY, EACH HOSTS COMMUNITY BLOOD DRIVES THROUGHOUT THE YEAR. THE HOSPITAL PROVIDES COMMUNITY EDUCATION AND CAREER DEVELOPMENT TO ORGANIZATIONS, SCHOOLS AND COLLEGES THROUGHOUT THE AREA THROUGH SPEAKING ENGAGEMENTS, CAREER FAIRS, CLASS IN-SERVICES AND HOSPITAL TOURS. IN ADDITION, HOSPITAL EMPLOYEES VOLUNTEER THEIR SERVICE WITH COMMUNITY NOT-FOR-PROFIT AND CIVIC ORGANIZATIONS AND COMMITTEES, INCLUDING THE CHAMBER OF COMMERCE, WORKFORCE DEVELOPMENT, ROTARY, LIONS CLUB, YMCA, GUIDANCE CENTER MENTAL HEALTH CENTER AND THE MULTIDISCIPLINARY CHILD TEAM AND THE BOY SCOUTS. THE HOSPITAL OFFERS A JOB SHADOWING PROGRAM WHICH OFFERS TEENS EXPOSURE TO A VARIETY OF CAREERS WITHIN THE MEDICAL PROFESSION. PART VI, LINE 6: ATCHISON HOSPITAL ASSOCIATION IS NOT PART OF AN AFFILIATED HEALTH CARE SYSTEM. X 1 1 X X X X 0 0 0 0 0 0 0 1 0 EJ WILKINSON PHYSICIAN 608541 0 3950 0 0 0 5781 0 29207 0 647479 0 0 0 DARIN ALLEN MEDICAL DIRECTOR OF ANESTHESIA 451127 0 0 0 108 0 13072 0 26292 0 490599 0 0 0 JONATHAN LECK CHIEF OF MEDICAL STAFF 385044 0 81752 0 96 0 9659 0 8538 0 485089 0 0 0 JOHN L JACOBSON FORMER CEO 398532 0 0 0 868 0 2885 0 5842 0 408127 0 0 0 STEVEN ROVENSTINE PHYSICIAN 325311 0 20000 0 276 0 7131 0 28292 0 381010 0 0 0 DONALD ABLES PHYSICIAN 316755 0 0 0 792 0 9929 0 26002 0 353478 0 0 0 PAM RIZZA PHYSICIAN 289512 0 0 0 108 0 9500 0 28786 0 327906 0 0 0 GARY R FOLL CFO 164822 0 0 0 792 0 4758 0 19069 0 189441 0 0 0 JEFF PERRY CEO 145350 0 7515 0 75 0 0 0 3516 0 156456 0 0 0 PART 1, LINE 1A: SOCIAL CLUB DUES WERE PAID BY THE HOSPITAL FOR JOHN L. JACOBSON AND JEFF PERRY AND WERE NOT INCLUDED IN EITHER W-2 AS TAXABLE COMPENSATION BECAUSE THEY WERE USED 100% FOR BUSINESS. PART 1, LINE 7: VARIOUS EMPLOYED PHYSICIANS ARE PROVIDED THE OPPORTUNITY FOR BONUS POTENTIAL. IN THEIR CONTRACT WITH THE HOSPITAL ARE TIERS BASED ON CURRENT MEDICAL GROUP MANAGEMENT ASSOCIATION REGIONAL DATA. IF THE PHYSICIANS ANNUALIZED NET QUALIFIED PATIENT CHARGES EXCEEDS THE TIER, A PERCENTAGE OF THEIR NET QUALIFIED PATIENT CHARGES ARE ELIGIBLE FOR BONUS SUBJECT TO THEIR ANNUAL BASE COMPENSATION. A CITY OF ATCHISON KS 486025033 046687CV9 2017-10-19 5910000 SEE PART VI. 0 0 0 B CITY OF ATCHISON KS 486025033 046687CF4 2016-07-27 9450000 SEE PART VI. 0 0 0 C CITY OF ATCHISON KS 486025033 046687CM9 2017-06-06 8835000 SEE PART VI. 0 0 0 D CITY OF ATCHISON KS 486025033 046687CR8 2017-06-06 3400000 SEE PART VI. 0 0 0 A 45000 5910000 626218 117700 5792300 2010 0 1 1 1 B 5760000 9450000 715707 185895 9264105 2010 0 1 1 1 C 8835000 932724 79515 8755485 2010 1 0 1 1 D 75000 3400000 360613 30600 3369400 2010 1 0 1 1 A 0 0 1 1 0 0.00000 0.00000 0.00000 0 0 1 B 0 0 1 1 0 0.00000 0.00000 0.00000 0 0 1 C 0 0 1 1 0 0.00000 0.00000 0.00000 0 0 1 D 0 0 1 1 0 0.00000 0.00000 0.00000 0 0 1 A 0 1 0 0 0 0 0 1 1 B 0 1 0 0 0 0 0 1 1 C 0 1 0 0 0 0 0 0 1 D 0 1 0 0 0 0 0 0 1 A 1 B 1 C 1 D 1 PART I, LINE B, COLUMN (F): ADVANCE REFUND A PORTION OF THE 2008A, 2008B, AND 2009 BONDS. THE 2008A BONDS WERE ORIGINALLY ISSUED ON 9/23/2008; THE 2008B BONDS WERE ORIGINALLY ISSUED ON 9/23/2008; THE 2009 BONDS WERE ORIGINALLY ISSUED ON 6/30/2009. PART I, LINE C, COLUMN (F): CURRENT REFUND A PORTION OF THE 2008A BONDS. THE 2008A BONDS WERE ORIGINALLY ISSUED ON 9/23/2008. PART I, LINE D, COLUMN (F): CURRENT REFUND A PORTION OF THE 2009 BONDS. THE 2009 BONDS WERE ORIGINALLY ISSUED ON 6/30/2009. PART I, LINE A, COLUMN (F): ADVANCE REFUND REMAINING PORTION OF THE 2009 BONDS. THE 2009 BONDS WERE ORIGINALLY ISSUED ON 6/30/2009. PART II, COLUMN B, LINE 11: THIS AMOUNT WAS USED TO ADVANCE REFUND A PORTION OF THE 2008A BONDS, 2008B BONDS AND 2009 BONDS. PART II, COLUMN C, LINE 11: THIS AMOUNT WAS USED TO CURRENT REFUND A PORTION OF THE 2008A BONDS. PART II, COLUMN D, LINE 11: THIS AMOUNTS WAS USED TO CURRENT REFUND A PORTION OF THE 2009 BONDS. PART II, COLUMN A, LINE 11: THIS AMOUNT REPRESENTS $5,786,846.35 OF BOND PROCEEDS USED TO ADVANCE REFUND A PORTION OF THE 2009 BONDS AND $5,453.65 ALLOCATED TO PAY INTEREST ON THE BONDS. PART IV, COLUMN B, LINE 6: PROCEEDS WERE DEPOSITED AND HELD IN A YIELD RESTRICTED ESCROW FOR THE REFUNDED BONDS BEYOND THE AVAILABLE TEMPORARY PERIOD. ALL SUCH PROCEEDS HAVE BEEN SPENT. PART IV, COLUMN A, LINE 6: PROCEEDS WERE DEPOSITED AND HELD IN A YIELD RESTRICTED ESCROW FOR THE REFUNDED BONDS BEYOND THE AVAILABLE TEMPORARY PERIOD. ALL SUCH PROCEEDS HAVE BEEN SPENT. PART I, LINE A2, COLUMN (F): CURRENT REFUND TAXABLE BANK LOAN. THE TAXABLE BANK LOAN WAS ORIGINALLY ISSUED ON 7/21/2015. RENOVATIONS TO AND EQUIPMENT FOR HOSPITAL FACILITIES. PART II, LINE 3, COLUMN A2: AMOUNT DOES NOT EQUAL ISSUE PRICE AS A RESULT OF INVESTMENT EARNINGS EARNED DURING THE PROJECT PERIOD. PART II, COLUMN A2, LINE 11: THIS AMOUNT WAS USED TO CURRENT REFUND THE TAXABLE BANK LOAN ON 10/30/2019. PART II, COLUMN A2, LINE 13: THE NEW MONEY PORTION OF THE PROJECT HAS NOT BEEN COMPLETED. A CITY OF ATCHISON KS 486025033 046687DG1 2019-10-30 4255000 SEE PART VI. 0 0 0 A 235000 4267064 82475 11696 1709258 2463636 0 1 0 1 A 0 0 0 0 0.00000 0.00000 0.00000 0 0 1 A 0 1 0 0 0 0 0 0 1 A 1 FORM 990, PART VI, SECTION B, LINE 11B AN INDEPENDENT ACCOUNTING FIRM PREPARES AND REVIEWS THE 990. THE 990 IS THEN REVIEWED BY THE ORGANIZATION'S MANAGEMENT. ANY QUESTIONS OR CONCERNS THE ORGANIZATION'S MANAGEMENT HAVE ARE ADDRESSED AND ANY CORRECTIONS OR CLARIFICATIONS ARE MADE. THE 990 IS THEN REVIEWED BY THE HOSPITAL FINANCE COMMITTEE. ANY QUESTIONS OR CONCERNS THE FINANCE COMMITTEE HAVE ARE ADDRESSED AND ANY CORRECTIONS OR CLARIFICATIONS ARE MADE. THE 990 IS THEN REVIEWED BY THE BOARD OF DIRECTORS, ANY CORRECTIONS OR CONCERNS THE BOARD HAVE ARE ADDRESSED PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C AT THE TIME OF THE ELECTION OR HIRE AND ANNUALLY THEREAFTER, THE GOVERNING BOARD MEMBERS, OFFICERS, AND KEY EMPLOYEES SHALL PROVIDE THE APPLICABLE CONFLICT OF INTEREST DISCLOSURES WHICH SHALL BE COMPLETED TO IDENTIFY ANY RELATIONSHIPS, POSITIONS, OR CIRCUMSTANCES IN WHICH IT IS BELIEVED A CONFLICT MAY ARISE. IF A CONFLICT ARISES, THE BOARD MEMBER ABSTAINS FROM THE VOTE OF THE CONFLICTED POSITION. FORM 990, PART VI, SECTION B, LINE 15 IN 2019, THE ORGANIZATION ENGAGED ITS LEGAL COUNSEL TO PREPARE A COMPENSATION DATA STUDY. IN ADDITION TO VARIOUS DATA COLLECTED, OTHER HOSPITALS' 990'S WERE REVIEWED AND COMBINED IN THE COMPENSATION STUDY. THE HOSPITAL'S LEGAL COUNSEL REVIEWED THE STUDY WITH THE BOARD OF DIRECTORS TO ADJUST THE CEO'S COMPENSATION. ANY DECISION THAT IS MADE IN REGARDS TO THE CEO'S COMPENSATION IS DOCUMENTED BY THE BOARD OF DIRECTORS. THE CEO AND HUMAN RESOURCE DIRECTOR CONDUCT AN ANNUAL REVIEW OF OTHER OFFICERS AND KEY EMPLOYEES' COMPENSATION BASED ON COMPARABLE DATA OF OTHER ORGANIZATIONS OF SIMILAR SIZE AND INDUSTRY. PHYSICIAN COMPENSATION IS DETERMINED BASED ON CONTRACT AND IS COMPARED TO RECENT MEDICAL GROUP MANAGEMENT ASSOCIATION INFORMATION BY REGION TO DETERMINE FAIR MARKET COMPENSATION. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE NOT MADE AVAILABLE TO THE PUBLIC. FORM 990, PART XI, LINE 2C: AN INDEPENDENT ACCOUNTING FIRM AUDITS THE ORGANIZATION'S FINANCIAL STATEMENTS. THE ORGANIZATION HAS A COMMITTEE THAT ASSUMES RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT OF ITS FINANCIAL STATEMENTS AND SELECTION OF AN INDEPENDENT ACCOUNTANT. THIS PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. RIVERBEND REGIONAL HEALTHCARE FOUNDATION 800 RAVEN HILL DRIVE ATCHISON KS 66002 480955489 SUPPORT ATCHISON HOSPITAL ASSOCIATION KS 501(C)(3) LINE 12B, II ATCHISON HOSPITAL ASSOCIATION 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0