2021-11-30T11:54:56-06:00 2020-12-31 860271207 SCHMIDT WESTERGARD & COMPANY PLLC 77 WEST UNIVERSITY DRIVE MESA AZ 852015830 990 2020-01-01 860320447 SUMMIT HEALTHCARE ASSOCIATION SUMM 9285374375 2200 E SHOW LOW LAKE ROAD SHOW LOW AZ 85901 DAVID ROTHENBERGER CFO 9285374375 2021-11-29 1 DAVID ROTHENBERGER 999009999 KELLY M WHITE P00622256 4808346030 2 AAL1 IAL1 2020 2022-09-23 18:48:47Z SUMMIT HEALTHCARE REGIONAL MEDICAL CENTER DAVID ROTHENBERGER 2200 E SHOW LOW LAKE ROAD SHOW LOW AZ 85901 218289701 0 X SUMMITHEALTHCARE.NET X 1976 AZ TRUSTED TO DELIVER EXCEPTIONAL, COMPASSIONATE CARE CLOSE TO HOME. SUMMIT HEALTHCARE CONTINUES TO PROMOTE HEALTH AND WELLNESS TO THE COMMUNITIES WE SERVE. WE INVEST IN STATE-OF-THE-ART EQUIPMENT TO HELP OUR PATIENTS REACH THEIR HEALTH CARE GOALS AND RETURN TO A HEALTHY, ACTIVE LIFESTYLE. 7 3 1672 116 0 0 1710204 16266491 198249381 196560890 2737112 -500551 3331250 2470838 206027947 214797668 0 0 0 0 113859010 108162472 0 0 0 97982690 107568577 211841700 215731049 -5813753 -933381 308568197 295477019 162699032 145472082 145869165 150004937 X TRUSTED TO DELIVER EXCEPTIONAL, COMPASSIONATE CARE CLOSE TO HOME. SUMMIT HEALTHCARE CONTINUES TO PROMOTE HEALTH AND WELLNESS TO THE COMMUNITIES WE SERVE. WE INVEST IN STATE-OF-THE-ART EQUIPMENT TO HELP OUR PATIENTS REACH THEIR HEALTH CARE GOALS AND RETURN TO A HEALTHY, ACTIVE LIFESTYLE. 0 0 181214880 197481978 SUMMIT HEALTHCARE IS A LICENSED 89-BED NOT-FOR-PROFIT RURAL HOSPITAL. SUMMIT HEALTHCARE IS COMMITTED TO PROVIDE EXCEPTIONAL COMPASSIONATE CARE TO THE COMMUNITIES WE SERVE. SUMMIT HEALTHCARE'S ARRAY OF SERVICES INCLUDE A 24-EMERGENCY DEPARTMENT WHICH IS PEDIATRIC CERTIFIED, CARDIAC AND VASCULAR CATH LAB, DIAGNOSTIC IMAGING, WOMEN'S IMAGING, HOME HEALTH SERVICES, IV THERAPY, CANCER CENTER WITH MEDICAL AND RADIATION ONCOLOGY, WOMEN & INFANT SERVICES, LEVEL II NURSERY, THERAPY SERVICES WITH CHILDREN'S THERAPY - OCCUPATIONAL HEALTH- PHYSICAL THERAPY - SPEECH THERAPY, PAIN MEDICINE, SURGICAL SERVICES, TELEMEDICINE, WOUND CARE AND HYPERBARICS AND MUCH MORE. WE ARE PROUD TO OFFER TECHNOLOGY USUALLY FOUND IN LARGER CITIES - RIGHT HERE IN THE WHITE MOUNTAINS. FOR A COMPLETE LIST OF SERVICES VISIT SUMMITHEALTHCARE.NET.ACROSS THE COUNTRY, HEALTHCARE FACILITIES IN RURAL AREAS ARE COLLABORATING WITH LARGE NETWORKS TO CONTINUE TO PROVIDE A CONTINUUM OF CARE TO THEIR PATIENTS.EVENTSDUE TO THE COVID 19 PANDEMIC SUMMIT HEALTHCARE WAS UNABLE TO HOLD EVENTS IN 2020.FACILITYFOR 2020 SUMMIT HEALTHCARE'S NEW BUILDINGS, ADMINISTRATIVE SERVICES, OUTPATIENT PAVILION, AND OUTPATIENT SURGERY CENTER WERE ALL FULLY OPERATIONAL.EACH BUILDING WILL HOUSE THE FOLLOWING SERVICES WITH MORE HEALTHCARE SERVICES TO BE ADDED:ADMINISTRATIVE SERVICES BUILDING INCLUDES:ADMINISTRATION HUMAN RESOURCES MEDICAL RECORDS MATERIALS MANAGEMENT ENVIRONMENTAL SERVICES BUSINESS OFFICE FOR HOSPITAL AND PHYSICIAN CLINICS QUALITY AND PROFESSIONAL DEVELOPMENT MEDICAL STAFF SERVICES ACCOUNTING SOME INFORMATION TECHNOLOGYMEDICAL OFFICE BUILDING PRIMARY CARE SERVICESTHE URGENT CARE CLINICS IN SHOW LOW AND PINETOP WILL REMAIN OPENSPECIALTY SERVICESSUMMIT HEALTHCARE PLASTIC & RECONSTRUCTIVE SURGERYSUMMIT HEALTHCARE INTERNAL MEDICINESUMMIT HEALTHCARE NATUROPATHIC MEDICINESUMMIT HEALTHCARE PEDIATRICSSUMMIT HEALTHCARE ORTHOPEDICSSUMMIT HEALTHCARE PAIN CLINICSUMMIT HEALTHCARE HEART, LUNG AND VASCULARSUMMIT HEALTHCARE OB/GYNSUMMIT HEALTHCARE UROLOGYSUMMIT HEALTHCARE GENERAL SURGERYSUMMIT HEALTHCARE OUTPATIENT DIAGNOSTIC IMAGINGSUMMIT HEALTHCARE WOUND CARE CENTERHEALTHY STEPSSUMMIT HEALTHCARE PHARMACYAMBULATORY SURGERY CENTER PHYSICIANSSUMMIT HAS PHYSICIAN SPECIALISTS IN ONCOLOGY, RADIATION ONCOLOGY, PLASTIC SURGERY, CARDIOLOGY, PULMONARY MEDICINE, INTERNAL MEDICINE, PEDIATRICS, OBSTETRICS, PAIN MANAGEMENT, GENERAL SURGERY, ORTHOPEDICS, PODIATRY, UROLOGY, GENERAL SURGERY, VASCULAR SURGERY. WE CONTINUE TO RECRUIT NEW PHYSICIANS TO THE COMMUNITY TO MEET THE HEALTHCARE NEEDS. 181214880 1 1 0 0 0 0 0 0 0 0 1 0 0 0 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 1 1 1 1 0 0 1 200 0 1 1672 1 0 0 0 0 0 1 1 0 0 0 0 0 0 X 7 3 1 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 1 1 X X JOSH ADAMS CONTROLLER 9285376538 2200 E SHOW LOW LAKE ROAD SHOW LOW AZ 85901 NEAL THOMPSON VICE CHAIR BOARD MEMBER 4.00 X 14400 0 0 PAUL WATSON CHAIRMAN BOARD MEMBER 4.00 X 14400 0 0 DOUG WRIGHT DO BOARD MEMBER/PHYSICIAN 40.00 X 635855 0 27743 JOHN CORDER BOARD MEMBER 4.00 X 14400 0 0 BECKY THOMPSON MD SECRETARY BOARD MEMBER 4.00 X 14400 0 0 ELIZABETH BIERER MD CHIEF OF STAFF BOARD MEMBE 4.00 X 252211 0 30673 NEIL TRAVER BOARD MEMBER 4.00 X 14400 0 0 RON MCARTHUR CEO 40.00 X 450250 0 20732 DAVID ROTHENBERGER CFO 40.00 X 274825 0 26148 DOUG GILCHRIST COO 40.00 X 185962 0 7418 ANGELA FABIAN CHIEF MARKETING OFFICER 40.00 X 171157 0 9717 CONNIE KAKAVAS CHRO 40.00 X 182546 0 17197 KENNETH ALLEN CHIEF PRACTICE ADMINISTRAT 40.00 X 245713 0 10686 ALLEN DEWITT MD CHIEF MEDICAL OFFICER 40.00 X 356492 0 19486 AARON YOUNG CIO 40.00 X 210384 0 25164 CAROLYN JACOBS CQCO 40.00 X 202288 0 10149 DAVID MURRAY CCO 40.00 X 166260 0 12390 BURKE DELANGE PHYSICIAN 40.00 X 1081923 0 23221 SIMRANJIT GALHOTRA PHYSICIAN 40.00 X 894784 0 30876 DAX TRUJILLO PHYSICIAN 40.00 X 892541 0 30232 JAMES OLACK PHYSICIAN 40.00 X 734852 0 21821 FARBOD KHAKI PHYSICIAN 40.00 X 800891 0 27767 7810934 0 351420 164 0 1 0 ALLSCRIPTS 24630 NETWORK PLC CHICAGO IL 60673 SERVICES 7411977 HEALTHCARE WORKFORCE LOGISTICS PO BOX 860573 MINNEAPOLIS MN 55486 SERVICES 2876885 INTEGRATED MEDICAL SERVICES 3815 E BELL RD PHOENIX AZ 85032 SERVICES/PHYSICIAN 2693718 NX SHOW LOW MOB LLD 1550 MARKET STREEET SUITE 200 DENVER CO 80202 SERVICES/BUILDING 2508032 COKER CONSULTING LLC 2400 LAKEVIEW PRKWY SUITE 400 ALPHARETTA GA 30009 SERVICES 1800204 54 15926389 340102 16266491 NET PATIENT REVENUE 622000 196560890 196560890 196560890 254494 254494 22783 0 22783 22783 22783 2736988 2621273 870760 115715 -870760 -755045 -755045 CAFETERIA & GIFT SHOP 622000 941984 941984 OTHER PROFESSIONAL FEES 622000 889642 889642 OTHER OPERATING REVENUE 622000 222738 222738 393691 31446 362245 2448055 214797668 197481978 0 1049199 X 8170755 8170755 82906745 68633310 14273435 572127 473628 98499 10754736 8903173 1851563 5758109 4766778 991331 410052 326564 83488 90000 71676 18324 168251 168251 26395302 21579529 4815773 966211 614751 351460 11434637 9906852 1527785 210230 133759 76471 304024 193435 110589 4627964 3651559 976405 18493462 15172683 3320779 2548368 2047876 500492 SUPPLIES 30928097 29201933 1726164 EQUIPMENT RENTAL 2530673 2012812 517861 DUES & SUBCRIPTIONS 901884 573823 328061 PHYSICIAN RECRUITMENT 659661 419709 239952 6899761 4360275 2539486 215731049 181214880 34516169 0 2065319 0 9655665 5937880 59468419 57064671 3431048 3743999 3727744 3036959 310052470 122200779 199331742 187851691 30865082 37582914 23178 258905 308568197 295477019 34016286 21464610 0 10049368 61605831 57562617 67076915 55657423 0 738064 162699032 145472082 X 145195974 149356314 673191 648623 145869165 150004937 308568197 295477019 X -933381 5317041 -247888 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 5359549 5359549 175254154 50940190 124313964 24877378 10081284 14796094 100473281 61179305 39293976 4088108 4088108 187851691 INVENTORY CLEARING ACCOUNT 738064 738064 X 219946458 5317041 5317041 214629417 168251 168251 214797668 215562798 0 215562798 168251 168251 215731049 PART X, LINE 2: THE HOSPITAL IS EXEMPT FROM FEDERAL AND STATE INCOME TAXES UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE (THE "IRC") AND SIMILAR STATE PROVISIONS. HOWEVER, INCOME FROM CERTAIN ACTIVITIES NOT DIRECTLY RELATED TO THE HOSPITAL'S TAX-EXEMPT PURPOSE MAY BE SUBJECT TO TAXATION AS UNRELATED BUSINESS INCOME. IN ADDITION, THE HOSPITAL QUALIFIES FOR THE CHARITABLE CONTRIBUTION DEDUCTION UNDER SECTION 170(B)(1)(A)(III) OF THE IRC AND HAS BEEN CLASSIFIED AS AN ORGANIZATION OTHER THAN A PRIVATE FOUNDATION UNDER SECTION 509(A)(1) OF THE IRC. THE HOSPITAL HAS PROVIDED FOR INCOME TAXES ON ITS UNRELATED BUSINESS INCOME, WHICH HAVE NOT BEEN SIGNIFICANT, AS REQUIRED BY SECTION 512 OF THE CODE. WMSP HAS ELECTED TO BE TREATED AS A PARTNERSHIP FOR FEDERAL AND STATE INCOME TAX PURPOSES. MEMBERS ARE REQUIRED TO INCLUDE IN THEIR INDIVIDUAL INCOME TAX RETURNS THEIR SHARE OF INCOME OR LOSS, AS ADJUSTED TO REFLECT THE EFFECTS OF CERTAIN TRANSACTIONS WHICH ARE AFFORDED DIFFERENT ACCOUNTING TREATMENTS. WMSP INCOME DOES NOT QUALIFY AS UNRELATED BUSINESS INCOME TAXES FOR THE HOSPITAL AND IS NOT TAXABLE. THE HOSPITAL FOLLOWS THE GUIDANCE ISSUED BY ACCOUNTING PRINCIPLES GENERALLY ACCEPTED IN THE UNITED STATES OF AMERICA ("US GAAP"). UNDER THIS GUIDANCE, THE HOSPITAL ACCOUNTS FOR THE EFFECT OF ANY UNCERTAIN TAX POSITIONS BASED ON WHETHER IT IS "MORE-LIKELY-THAN-NOT" THAT THE POSITION WILL BE SUSTAINED BY THE TAXING AUTHORITY UPON EXAMINATION. THE HOSPITAL ROUTINELY EVALUATES POTENTIAL UNCERTAIN TAX POSITIONS. THE HOSPITAL HAS IDENTIFIED ITS STATUS AS AN EXEMPT ORGANIZATION AS A TAX POSITION; HOWEVER, THE ORGANIZATION HAS DETERMINED THAT SUCH TAX POSITION DOES NOT RESULT IN AN UNCERTAINTY THAT REQUIRES RECOGNITION. THE HOSPITAL FILES INFORMATIONAL AND INCOME TAX RETURNS IN THE U.S. FEDERAL JURISDICTION AND THE STATE OF ARIZONA. AS OF DECEMBER 31, 2020, U.S. FEDERAL INFORMATIONAL AND INCOME TAX RETURNS FOR YEARS ENDED PRIOR TO DECEMBER 31, 2017 AND STATE RETURNS FOR YEARS ENDED PRIOR TO DECEMBER 31, 2016 ARE CLOSED TO ASSESSMENT. INTEREST AND PENALTIES, IF ANY, ARE ACCRUED AS A COMPONENT OF MANAGEMENT AND GENERAL EXPENSES WHEN ASSESSED. 1 1 X 1 X 1 X 1 1 1 0 1 1 103876 103876 0.00050 46577723 11855330 34722393 0.16100 46681599 11855330 34826269 0.16150 2000 2000 0.00000 73736796 20714297 53022499 0.24580 73738796 20714297 53024499 0.24580 120420395 32569627 87850768 0.40730 1 24904626 332334914 109489566 222845348 X 1 0 1 1 SUMMIT HEALTHCARE ASSOCIATION 2200 E SHOW LOW LAKE RD SHOW LOW AZ 85901 WWW.SUMMITHEALTHCARE.NET H0132 X X X SUMMIT HEALTHCARE ASSOCIATION 1 0 0 1 X X X X X X X X X 18 1 0 0 1 X WWW.SUMMITHEALTHCARE.NET X X 1 18 1 WWW.SUMMITHEALTHCARE.NET 0 1 X 200.000000000000 300.000000000000 X X 1 1 X X X 0 1 X 1 X X X 1 X 0 0 SUMMIT HEALTHCARE ASSOCIATION PART V, SECTION B, LINE 5: THE HOSPITAL CREATED A COMMITTEE CALLED "COMMUNITY HEALTH NEEDS COMMITTEE AND IT CONSISTS OF: NAVAJO COUNTY PUBLIC HEALTH, COMMUNITY COUNSELING CENTERS, COMMUNITY BRIDGES AND VARIOUS RELIGIOUS GROUPS; NAVAJO COUNTY COURTS; AND NAVAJO COUNTY PUBLIC ATTORNEY. SUMMIT HEALTHCARE ASSOCIATION PART V, SECTION B, LINE 7D: OFFERED AT COMMUNITY TOWN HALL MEETINGS. SUMMIT HEALTHCARE ASSOCIATION PART V, SECTION B, LINE 13H: NUMBER OF DEPENDENTS, FAMILY SIZE. SUMMIT HEALTHCARE ASSOCIATION PART V, SECTION B, LINE 20E: PATIENTS ARE NOTIFIED WHEN NEED IS IDENTIFIED. 18 1 - SUMMIT HEALTHCARE INTERNAL MEDICINE 2450 E SHOW LOW LAKE ROAD BLDG 1 SHOW LOW AZ 85901 INTERNAL MEDICINE 2 - SUMMIT HEALTHCARE FAMILY MEDICINE 2963 W WHITE MOUNTAIN BLVD LAKESIDE AZ 85929 FAMILY MEDICINE 3 - SUMMIT HEALTHCARE PRACTICE MANAGEMENT 3401 S WHITE MOUNTAIN RD SUITE D SHOW LOW AZ 85901 FAMILY MEDICINE 4 - SUMMIT HEALTHCARE HEBER-OVERGAARD COMMUN 2931 S HWY 260 PO BOX 1013 OVERGAARD AZ 85933 FAMILY MEDICINE 5 - SUMMIT HEALTHCARE FAMILY MEDICINE SNOWFL 1121 S MAIN STREET SNOWFLAKE AZ 85937 FAMILY MEDICINE 6 - SUMMIT HEALTHCARE SNOWFLAKE MEDICAL CENT 590 S MAIN STREET SNOWFLAKE AZ 85937 FAMILY MEDICINE 7 - SUMMIT HEALTHCARE FAMILY MEDICINE SHOWLO 5171 CUB LAKE ROAD SUITE B270 SHOW LOW AZ 85901 FAMILY MEDICINE, OBSTETRICS/GYNECOLOGY 8 - SUMMIT HEALTHCARE HIGH DESERT CLINIC 100 E CODE TALKERS DRIVE HOLBROOK AZ 85025 FAMILY MEDICINE 9 - SUMMIT HEALTHCARE FAMILY MEDICINE LAKESI 218 W WHITE MOUNTAIN BLVD LAKESIDE AZ 85929 FAMILY MEDICINE 10 - MOUNTAIN FAMILY CARE & WALK-IN 320 E DEUCE OF CLUBS SHOW LOW AZ 85901 FAMILY MEDICINE 11 - SUMMIT HEALTHCARE HEART LUNG & VASCULAR 5300 S SUTTER DRIVE SUITE 1 SHOW LOW AZ 85901 CARDIOLOGY, PULMONOLOGY, NATUROPATHIC MEDICINE 12 - SUMMIT HEALTHCARE UROLOGY 2051 E EVERGREEN LANE SUITE 8 SHOW LOW AZ 85901 UROLOGY 13 - SUMMIT HEALTHCARE ORTHOPEDIC SURGERY 2051 E EVERGREEN LANE SUITE A SHOW LOW AZ 85901 ORTHOPEDIC 14 - SUMMIT HEALTHCARE GENERAL & VASCULAR SUR 5171 CUB LAKE ROAD SUITE C350 SHOW LOW AZ 85901 GENERAL/VASCULAR SURGERY 15 - SUMMIT HEALTHCARE CANCER CENTER 2500 E HUNT STREET SUITE H SHOW LOW AZ 85901 ONCOLOGY 16 - SUMMIT HEALTHCARE PAIN CLINIC 1500 S WHITE MOUNTAIN BLVD SUITE 300 SHOW LOW AZ 85901 PAIN MANAGEMENT 17 - SUMMIT HEALTHCARE ANESTHESIOLOGY 2200 E SHOW LOW LAKE RD SHOW LOW AZ 85901 ANESTHESIOLOGY 18 - SUMMIT HEALTHCARE PLASTIC SURGERY & DERM 2450 E SHOW LOW LAKE RD SUITE 2A SHOW LOW AZ 85901 DERMATOLOGY, PLASTIC SURGERY PART I, LINE 7: COST TO CHARGE RATIO PART I, LINE 7G: SUBSIDIZED HEALTH SERVICES ARE CLINICAL SERVICES PROVIDED TO PATIENTS DESPITE A FINANCIAL LOSS TO THE ORGANIZATION. THE DIFFERENCE BETWEEN THE COSTS THE HOSPITAL INCURS TO PROVIDE A SPECIFIC SERVICE AND THE AMOUNT THE HOSPITAL RECEIVES AS PAYMENT FOR THAT SERVICE, DEFINE SUBSIDIZED HEALTH SERVICES. FURTHERMORE, THEY ARE THOSE CLINICAL SERVICES THAT: IF THE HOSPITAL WERE UNABLE TO PROVIDE, WOULD RESULT IN NOT MEETING COMMUNITY NEEDS. THIS WOULD MEAN THAT PATIENTS WOULD BE REQUIRED TO GO ELSEWHERE FOR SERVICES WHICH WOULD THEN BECOME THE RESPONSIBILITY OF GOVERNMENT OR OF OTHER TAX-EXEMPT ORGANIZATIONS. PART I, LN 7 COL(F): PLEASE REFER TO THE EXPLANATION OF BAD DEBT EXPENSE PROVIDED FOR PART III, LINE 4. PART II, COMMUNITY BUILDING ACTIVITIES: N/A PART III, LINE 2: COST TO CHARGE RATIO PART III, LINE 4: CHARGES TO THE FINANCIAL ASSISTANCE PROGRAM ARE NOT APPLIED TO BAD DEBT. THEREFORE, NONE OF THE ORGANIZATION'S BAD DEBT EXPENSE IS ATTRIBUTABLE TO THE CHARITY CARE POLICY.FINANCIAL STATEMENT FOOTNOTE:THE HOSPITAL DOES NOT HAVE A FINANCIAL STATEMENT FOOTNOTE SPECIFIC TO BAD DEBT EXPENSE, BUT DOES INCLUDE A FINANCIAL FOOTNOTE RELATED TO CHARITY CARE. THE FINANCIAL STATEMENTS COMPUTE CHARITY CARE BY AGGREGATING GROSS CHARGES AND ALL DEDUCTIONS FROM REVENUE, WHILE THE SCHEDULE H COMPUTATIONS IN PARTS I AND III ARE CALCULATED USING A COST TO CHARGE APPROACH. THE FINANCIAL STATEMENT FOOTNOTE FOLLOWS:CHARITY CARE AND COMMUNITY BENEFITIN THE FURTHERANCE OF ITS CHARITABLE PURPOSES, THE HOSPITAL PROVIDES CHARITY CARE AND OTHER BENEFITS TO THE COMMUNITY IT SERVES. THE HOSPITAL'S CHARITY CARE POLICY IS DESIGNED TO PROVIDE A DISCOUNT OR WAIVER OF THE COST OF SERVICES FOR UNINSURED OR UNDERINSURED PATIENTS WITHOUT THE ABILITY TO PAY. BECAUSE THE HOSPITAL DOES NOT PURSUE COLLECTION OF AMOUNTS DETERMINED TO QUALIFY AS CHARITY CARE, THEY ARE NOT REPORTED AS PATIENT SERVICE REVENUE. IN ADDITION TO PROVIDING CHARITY CARE, THE HOSPITAL PAYS FOR THE COSTS OF MANY PUBLIC PROGRAMS, INCLUDING UNPAID MEDICARE AND AHCCCS COSTS AND DELIVERY OF COMMUNITY OUTREACH PROGRAMS THAT INCLUDE HEALTH EDUCATION, DIAGNOSTIC SCREENINGS, COMMUNITY HEALTH ASSESSMENT SURVEYS AND MOBILE SERVICES. THE HOSPITAL ESTIMATES CHARITY CARE COSTS BASED ON THE HOSPITAL'S COST TO CHARGE RATIO, WHICH INCLUDES BOTH DIRECT AND INDIRECT COSTS. TRADITIONALLY CHARITY CARE IS ESTIMATED BASED ON THE AVERAGE COST OF SERVICES PROVIDED FOR WHICH CHARGES ARE WRITTEN OFF IN ACCORDANCE WITH THE HOSPITAL'S CHARITY CARE POLICY. A SUMMARY OF THE GROSS CHARGES AND COSTS INCURRED FOR PROVIDING CHARITY CARE AND OTHER COMMUNITY BENEFITS FOR THE YEARS ENDED DECEMBER 31 ARE AS FOLLOWS: UNPAID COSTS RELATING TO THE AHCCCS PROGRAM $119,352,820TRADITIONAL CHARITIY, AT COST $307,056TOTAL CHARITY CARE $119,659,876 UNPAID COSTS RELATING TO THE MEDICARE PROGRAM $176,298,442TOTAL CHARITY CARE AND COMMUNITY BENEFIT COSTS $295,958,318 PART III, LINE 8: THE ENTIRE SHORTFALL IS ATTRIBUTED TO COMMUNITY BENEFIT. PART III, LINE 9B: PROCEDURE: CHARITY CARE IS DEFINED AS AN INABILITY TO PAY.THE PATIENT'S INDIGENCE MUST BE DETERMINED BY THE FACILITY, NOT BY THE PATIENT. THIS DETERMINATION MAY OCCUR AT ANY TIME PRIOR TO THE PATIENT'S ACCOUNT ACHIEVING ZERO BALANCE; PRIOR TO ADMISSION, AT ADMISSION, AFTER DISCHARGE OR DURING THE BILLING AND COLLECTION PROCESS.THE CHARITY DETERMINATION IS TO BE MADE BASED ON THE PATIENT/RESPONSIBLE PARTY'S NET WORTH, NET INCOME AND THE NUMBER OF MEMBERS IN THE HOUSEHOLD. SUMMIT HEALTHCARE ASSOCIATION BASES THEIR CHARITY CARE ON THE FEDERAL POVERTY INCOME GUIDELINES.THE FACILITY MUST DETERMINE THAT NO SOURCE OTHER THAN THE PATIENT/RESPONSIBLE PARTY WOULD BE LEGALLY RESPONSIBLE FOR THE PATIENT'S MEDICAL BILL. THIS INCLUDES FEDERAL, STATE OR LOCAL FINANCIAL PROGRAMS AND/OR LEGAL GUARDIANS.THE PATIENT'S BUSINESS OFFICE FILE WILL CONTAIN DOCUMENTATION OF THE METHOD BY WHICH INDIGENCE WAS DETERMINED ALONG WITH ALL SUPPORTING DOCUMENTATION TO SUBSTANTIATE THE DECISION. THE FINAL DETERMINATION WILL BE MADE BY THE CFO, WITH THE RECOMMENDATION OF THE PATIENT ACCOUNT SUPERVISOR. PART VI, LINE 2: SUMMIT HEALTHCARE ASSOCIATION DELIVERS COMMUNITY BENEFITS BASED ON THE UNIQUE HEALTH NEEDS OF THEIR RESPECTIVE SERVICE AREAS, REGARDLESS OF SOURCE OR AVAILABILITY OF PAYMENT. THESE PROGRAMS AND SERVICES ARE INTENDED TO IMPROVE ACCESS TO HEALTHCARE, HEALTH STATUS AND THE USE OF HEALTHCARE RESOURCES. SUMMIT HEALTHCARE PROVIDED CHARITY CARE AND COMMUNITY BENEFITS TO MEMBERS OF OUR COMMUNITY AS PART OF ITS VISION; "...TO BE A MODEL OF SUCCESS AS A RURAL HEALTHCARE PROVIDER BY DELIVERING EXCEPTIONAL HEALTH CARE AND PROMOTING WELLNESS FOR THE INDIVIDUAL, THE FAMILY, AND THE COMMUNITY"... PART VI, LINE 3: HOSPITAL ADMITTING STAFF MEMBERS ADVISE AND ASSIST ALL SELF-PAY PATIENTS OF THE OPTIONS FOR AVAILABLE ASSISTANCE. PART VI, LINE 4: SUMMIT HEALTHCARE ASSOCIATION (THE HOSPITAL) OPERATES SUMMIT HEALTHCARE, AN 89-BED ACUTE CARE HOSPITAL FACILITY. THE HOSPITAL PROVIDES INPATIENT AND OUTPATIENT, HOME HEALTH, IMAGING AND OTHER HEALTH CARE RELATED SERVICES TO THE RESIDENTS OF SHOW LOW, ARIZONA AND THE SURROUNDING WHITE MOUNTAIN COMMUNITIES. PART VI, LINE 5: PLEASE REFER TO INFORMATION CONTAINED IN FORM 990, PART III, LINE 4A. PART VI, LINE 6: N/A PART VI, LINE 7, REPORTS FILED WITH STATES AZ 1 X X X 0 0 0 0 0 1 1 0 1 1 BURKE DELANGE PHYSICIAN 481510 0 600413 0 0 0 8550 0 14671 0 1105144 0 0 0 SIMRANJIT GALHOTRA PHYSICIAN 434870 0 459914 0 0 0 8550 0 22326 0 925660 0 0 0 DAX TRUJILLO PHYSICIAN 362302 0 530239 0 0 0 7906 0 22326 0 922773 0 0 0 FARBOD KHAKI PHYSICIAN 403397 0 397494 0 0 0 8517 0 19250 0 828658 0 0 0 JAMES OLACK PHYSICIAN 463217 0 271635 0 0 0 8550 0 13271 0 756673 0 0 0 DOUG WRIGHT DO BOARD MEMBER/PHYSICIAN 354975 0 280880 0 0 0 5417 0 22326 0 663598 0 0 0 RON MCARTHUR CEO 450250 0 0 0 0 0 6261 0 14471 0 470982 0 0 0 ALLEN DEWITT MD CHIEF MEDICAL OFFICER 356492 0 0 0 0 0 5015 0 14471 0 375978 0 0 0 DAVID ROTHENBERGER CFO 274825 0 0 0 0 0 3822 0 22326 0 300973 0 0 0 ELIZABETH BIERER MD CHIEF OF STAFF BOARD MEMBE 252211 0 0 0 0 0 11500 0 19173 0 282884 0 0 0 KENNETH ALLEN CHIEF PRACTICE ADMINISTRAT 245713 0 0 0 0 0 3315 0 7371 0 256399 0 0 0 AARON YOUNG CIO 210384 0 0 0 0 0 2838 0 22326 0 235548 0 0 0 CAROLYN JACOBS CQCO 202288 0 0 0 0 0 2812 0 7337 0 212437 0 0 0 CONNIE KAKAVAS CHRO 182546 0 0 0 0 0 2726 0 14471 0 199743 0 0 0 DOUG GILCHRIST COO 185962 0 0 0 0 0 2635 0 4783 0 193380 0 0 0 ANGELA FABIAN CHIEF MARKETING OFFICER 171157 0 0 0 0 0 2380 0 7337 0 180874 0 0 0 DAVID MURRAY CCO 166260 0 0 0 0 0 0 0 12390 0 178650 0 0 0 PART I, LINE 6 THE PHYSICIAN'S RECEIVED INCENTIVE COMPENSATION BONUSES BASED ON RELATIVE VALUE UNITS WRUVS, AND OFFICERS RECEIVED BONUSES BASED ON BUDGET GOALS PART I, LINE 8 PHYSICIANS HAVE EMPLOYMENT AGREEMENTS. A THE INDUSTRIAL DEVELOPMENT AUTHORITY OF THE CITY OF SHOW LOW ARIZONA 860912110 2015-08-04 23549000 REFUND 2005 BOND AND PAYING COSTS OF ISSUANCE 0 0 0 B THE INDUSTRIAL DEVELOPMENT AUTHORITY OF THE CITY OF SHOW LOW ARIZONA 860912110 2017-10-31 39046000 2017A - CONSTRUCTION OF NEW FACILITIES AND LEASEHOLD IMPROVEMENTS 0 0 0 C THE INDUSTRIAL DEVELOPMENT AUTHORITY OF THE CITY OF SHOW LOW ARIZONA 860912110 2017-10-31 5460000 2017B - CONSTRUCTION OF NEW FACILITIES AND LEASEHOLD IMPROVEMENTS 0 0 0 A 23549000 23287023 261977 2015 0 1 1 1 B 39046000 550000 2017 0 0 0 1 C 5460000 2017 0 0 0 1 A 0 0 0 0 0 0 1 B 0 0 0 0 0 0 1 C 0 0 0 0 0 0 1 A 1 0 0 0 0 0 B 1 0 0 0 0 0 C 1 0 0 0 0 0 A 0 B 0 C 0 FORM 990, PART VI, SECTION A, LINE 2 ALL OF THE HOSPITAL'S GOVERNING BOARD MEMBERS RECEIVED STIPEND PAYMENTS FOR BOARD OF DIRECTOR SERVICES. THE FOLLOWING BUSINESS TRANSACTIONS/RELATIONSHIPS ARE REPORTED FOR 2020. DOUG WRIGHT, D.O. MEDICAL DIRECTOR / PHYSICIAN WOUND CARE $470,0336 BOARD MEMBER STIPEND $14,400 PINETOP FIRE BOARD MEMBER. PINETOP FIRE PROVIDES EMS SERVICES IN THE AREA AND DELIVERS PATIENTS TO SUMMIT'S EMERGENCY DEPARTMENT. BECKY THOMPSON, M.D. OFFICE RENTAL SPACE PAID TO: OLD BEAR PROPERTIES $80,465 EMPLOYS SPOUSE OF A SUMMIT EMPLOYED PHYSICIAN ON CALL PHYSICIAN GROUP $4,500 LEADERSHIP COMPENSATION BOARD MEMBER STIPEND $14,400 PERSONAL PHYSICIAN TO SEVERAL OFFICERS CHAIRMAN OF NORTHEASTERN ARIZONA REGIONAL CARE TEAM, A CLINICALLY INTEGRATED NETWORK ESTABLISHED BY SUMMIT HEALTHCARE IN PARTNERSHIP WITH NORTHEASTERN ARIZONA REGIONAL CARE TEAM. JOHN CORDER BOARD MEMBER STIPEND $14,400 TIMBER MESA FIRE DISTRICT RETIREMENT BOARD MEMBER PAUL WATSON ASSISTANT NAVAJO COUNTY MANAGER . SUMMIT CONTRACTS WITH NAVAJO COUNTY FOR VARIOUS SERVICES. SERVES ON SEVERAL COMMITTEES FOR NAVAJO COUNTY REAL ESTATE $0 BOARD MEMBER STIPEND $14,400 NEAL THOMPSON BOARD MEMBER STIPEND $14,400 NEAL THOMPSON AND PAUL WATSON OWN LLCS TOGETHER THAT ARE NOT SUMMIT RELATED REAL ESTATE $0 JEFFREY LESUEUR, M.D. CHIEF OF MEDICAL STAFF AS OF 6/1/2018 THRU 5/31/2020 LEADERSHIP COMPENSATION ON CALL PHYSICIAN PAY BOARD MEMBER STIPEND $14,400 EQUITY OWNER IN SUNRISE SURGICAL CENTER - COMPETING PHYSICIAN OWNED ASC ELIZABETH BIERER, M.D. CHIEF OF MEDICAL STAFF AS OF 6/1/2020 TO 5/31/2022 LEADERSHIP COMPENSATION PHYSICIAN PAY $403,530 BOARD MEMBER STIPEND $14,400 STEVE GARRETT (TERM ENDED 1/23/20) BOARD MEMBER OF WHITE MOUNTAIN BIBLE CHURCH NEIL TRAVER (REPLACED STEVE GARRETT - 1/23/20) ARIZONA PUBLIC SERVICE - ELECTRIC COMPANY IN SNOWFLAKE, HOLBROOK AND PARTS OF SHOW LOW SHOW LOW CHAMBER OF COMMERCE BOARD MEMBER SUMMIT FOUNDATION BOARD MEMBER REAL AZ ECONOMIC DEVELOPMENT COMMITTEE MEMBER RON MCARTHUR CHIEF EXECUTIVE OFFICER TRUSTEE FOR ARIZONA HOSPITAL AND HEALTHCARE ASSOCIATION ALAN DEWITT, M.D. CHIEF MEDICAL OFFICER PRESIDENT OF SUMMIT PHYSICIAN GROUP, SHMA HOSPICE COMPASSUS MEDICAL DIRECTOR >10% OWNER OF SNOWFLAKE MEDICAL CENTER BUILDING RENTED BY SUMMIT $93,735 CONNIE KAKAVAS CHIEF HUMAN RESOURCES OFFICER SHOW LOW CITY COUNCILWOMAN DAVID MURRAY CHIEF RISK AND COMPLIANCE OFFICER WIFE EMPLOYED BY BLUE RIDGE SCHOOL DISTRICT WHITE MOUNTAIN BUSINESS ROUND TABLE COMMITTEE MEMBER AARON YOUNG CHIEF INFORMATION OFFICER SHOW LOW CHAMBER OF COMMERCE BOARD MEMBER FORM 990, PART VI, SECTION B, LINE 11B THE 990 IS REVIEWED IN THE SCHEDULED GOVERNING BOARD MEETING FOLLOWING ITS COMPLETION. FORM 990, PART VI, SECTION B, LINE 12C DIRECTOR OF MEDICAL STAFF/BOARD SERVICES IS RESPONSIBLE FOR MONITORING AND ENSURING RECORDS ARE UPDATED IN A TIMELY MANNER. FORM 990, PART VI, SECTION B, LINE 15 INDEPENDENT CONSULTING FIRMS ARE HIRED TO REVIEW THE COMPENSATION OF DIRECTORS, OFFICERS, AND KEY EMPLOYEES. FINAL APPROVAL OF TOP MANAGEMENT COMPENSATION IS THE RESPONSIBILITY OF THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION C, LINE 19 THESE DOCUMENTS ARE MADE AVAILABLE UP REQUEST. FORM 990, PART IX, LINE 11G OTHER SERVICE FEES: PROGRAM SERVICE EXPENSES 21,579,529. MANAGEMENT AND GENERAL EXPENSES 4,815,773. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 26,395,302. FORM 990, PART XI, LINE 9: CAPITAL DISTRIBUTIONS FOR WMSP, LLC REPORTED CONSOLIDATED BASIS -247,888. PART XII, LINE 2C THE ORGANIZATION DID NOT CHANGE EITHER ITS OVERSIGHT PROCESS OR SELECTION PROCESS DURING THE TAX YEAR. SUMMIT HEALTHCARE MEDICAL ASSOCIATES LLC 2200 E SHOW LOW LAKE ROAD SHOW LOW AZ 85901 ACQUIRE, OPERATE AND MANAGE PHYSICIAN PRACTICES AZ SUMMIT HEALTHCARE ASSOCIATION NORTHEASTERN ARIZONA REGIONAL CARE TEAM LLC 2200 E SHOW LOW LAKE ROAD SHOW LOW AZ 85901 ESTABLISH CLINICALLY INTEGRATED NETWORK AZ SUMMIT HEALTHCARE ASSOCIATION WHITE MOUNTAIN SURGICAL PARTNERS LLC 2200 E SHOW LOW LAKE ROAD SHOW LOW AZ 85901 834109264 MANAGE OUTPATIENT SURGICAL DEPARTMENT AZ N/A RELATED 2136428 3238933 0 1 0.68500 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 WHITE MOUNTAIN SURGICAL PARTNERS LLC M 5879473 ACTUAL PART I, COLUMNS D AND E: THE TOTAL INCOME AND END-OF-YEAR ASSETS CANNOT BE SEPARATELY IDENTIFIED AS THEY ARE CONSOLIDATED AND INTRINSIC TO THE EXEMPT PURPOSES AND REPORTED ACTIVITIES, CONTAINED HERE-IN, OF THE HOSPITAL.