2020-11-12T15:22:42-06:00 2019-12-31 621517792 PYA P C 2220 SUTHERLAND AVE KNOXVILLE TN 37919 990 2019-01-01 480581968 SUSAN B ALLEN MEMORIAL HOSPITAL SUSA 3163213300 720 WEST CENTRAL EL DORADO KS 67042 LEONARD HERNANDEZ PRESIDENT & CEO 3163213300 2020-11-12 1 DEBORAH O ERNSBERGER P00364912 8656730844 50.228.55.2 2020-11-12 15:22:37 ES P 14A939F37EE00550E3D549020679067564A57D08 AF23F2A68CFF53983216DF8908F842EE3670BFA3 2019 2021-01-29 14:40:06Z LEONARD HERNANDEZ 720 WEST CENTRAL EL DORADO KS 67042 43453191 0 X WWW.SBAMH.ORG X 1930 KS THE MISSION OF SUSAN B. ALLEN MEMORIAL HOSPITAL IS TO PROVIDE COMPASSIONATE, PROFESSIONAL HEALTH CARE TO THE PEOPLE WE SERVE. 11 11 448 87 -1862 0 188996 710790 48521808 39710099 1463115 1943944 649411 1088358 50823330 43453191 22356 15229 0 0 27443599 26334634 0 0 0 28223175 25362844 55689130 51712707 -4865800 -8259516 64575356 55463905 16927228 15453129 47648128 40010776 X TO PROVIDE COMPASSIONATE, PROFESSIONAL HEALTH CARE TO THE PEOPLE WE SERVE. 0 0 40146956 15229 40558557 SEE SCHEDULE O 40146956 1 1 0 1 0 0 0 0 0 1 1 1 0 0 1 1 0 1 0 0 1 0 0 0 0 0 1 1 0 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 101 0 1 448 1 1 1 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 0 1 1 1 1 1 1 1 0 KS X CINDI STRACK 3163224559 720 WEST CENTRAL EL DORADO KS 67042 CAMI BAKER CHAIR 1.00 X X 0 0 0 MICHAEL CLIFTON VICE CHAIR 1.00 1.00 X X 0 0 0 ED GARD FORMER CHAIR 1.00 X X 0 0 0 GLENN BUCHHOLZ TRUSTEE 1.00 X 0 0 0 VINCE HAINES TRUSTEE 1.00 X 0 0 0 GREG JOYCE OD TRUSTEE 1.00 X 0 0 0 BRANDI LANE TRUSTEE 1.00 X 0 0 0 SUZIE LOCKE TRUSTEE 1.00 X 0 0 0 RYAN MURRY TRUSTEE 1.00 X 0 0 0 AMY SEEBER MD TRUSTEE 1.00 X 0 0 0 JEREMY SUNDGREN TRUSTEE 1.00 X 0 0 0 JAMES KIRKBRIDE CHIEF EXECUTIVE OFFICER 40.00 1.00 X 328168 0 9560 MARK ROOKER CHIEF INFORMATION OFFICER 40.00 X 161298 0 21895 CECILIA GOEBEL CHIEF NURSING OFFICER 40.00 X 151094 0 20504 FRANCIA BIRD CHIEF QUALITY OFFICER 40.00 X 113032 0 18973 JONATHAN IMMORDINO CHIEF FINANCIAL OFFICER 40.00 1.00 X 72256 0 4804 DIANE DEBLON CHIEF FINANCIAL OFFICER 40.00 1.00 X 44404 0 5303 ANDREW HUDSPETH CHIEF HR OFFICER 40.00 X 58379 0 10555 JENNIFER PHARRIS PHYSICIAN 40.00 X 229672 0 9459 NICHOLAS POSGE PODIATRIST 40.00 X 235384 0 22076 CHARLES STAFFORD RADIATION ONCOLOGY PHYSICIST 40.00 X 201519 0 17316 GARRET DAHARSH VP OPERATIONS & BUS DEV 40.00 X 144306 0 18381 IRAM SIRAJUDDIN PHYSICIAN 40.00 X 162532 0 14879 1902044 0 173705 29 0 1 0 AIR CAPITAL EMERGENCY SERVICES LLC 1518 N TERHUNE ST WICHITA KS 67230 PHYSICIAN SERVICES 2902410 PHILIPS HEALTHCARE PO BOX 403831 ATLANTA GA 303843831 SERVICE CONTRACTS 579815 TRUBRIDGE 3725 AIRPORT BOULEVARD MOBILE AL 36608 REVENUE CYCLE SERVICES 498112 FRESENIUS MEDICAL CARE 920 WINTER STREET WALTHAM MA 024511457 DIALYSIS CONTRACT SERVICES 382500 FRESENIUS KIDNEY CARE 920 WINTER STREET WALTHAM MA 024511457 DIALYSIS CONTRACT SERVICES 346681 32 116669 216916 377205 710790 PATIENT SERVICE REVENUE 621110 39587815 39587815 MEALS ON WHEELS 624200 118572 118572 SCREENING PROGRAM 623990 3712 3712 39710099 1920427 1920427 198 198 618421 0 618421 618421 618421 23517 0 23517 23517 23517 CAFETERIA 722210 241564 241564 MISCELLANEOUS 900099 230037 230037 PARTNERSHIP INCOME 900099 -1862 -1862 469739 43453191 40558557 -1862 2185706 X 15229 15229 753592 753592 19415446 15530159 3885287 707093 544462 162631 4047117 3116280 930837 1411386 1086767 324619 140839 140839 292956 292956 8646 8646 49206 49206 9283990 6796542 2487448 54705 40048 14657 814112 595988 218124 253052 185252 67800 325047 243785 81262 3363168 2084549 1278619 427511 312969 114542 SUPPLIES - MEDICAL 6090774 6090774 REPAIRS AND MAINTENANCE 1725096 1262893 462203 BAD DEBT 1215522 1215522 SUPPLIES - GENERAL 559349 409483 149866 758871 616254 142617 51712707 40146956 11565751 0 163590 465334 10601741 8950776 1303202 998940 734860 694071 90041784 56979189 36107882 33062595 12333201 7700546 2487005 2967718 669531 357337 174344 266588 64575356 55463905 5508981 6681673 7143247 4396456 4275000 4375000 16927228 15453129 X 44043258 36042687 3604870 3968089 47648128 40010776 64575356 55463905 X -8259516 620299 1865 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 8646 8646 0 PART II-B, LINE 1I A PORTION OF THE KANSAS HOSPITAL ASSOCIATION AND AMERICAN HOSPITAL ASSOCIATION DUES ARE ATTRIBUTED TO LOBBYING EXPENSES. 1963579 5300 562647 2531526 2141962 9966 -178045 10304 1963579 1887242 20087 243725 9092 2141962 1568899 220239 105714 7610 1887242 1570557 94805 -15692 73371 7400 1568899 0.77900 0.17500 0.04600 0 1 1 4104215 4104215 46804735 23997615 22807120 37760424 31809081 5951343 1372410 1172493 199917 33062595 OTHER SECURITIES 2967718 C 2967718 LINE OF CREDIT 4375000 4375000 X 42859833 620299 3727 624026 42235807 1217384 1217384 43453191 50497185 0 50497185 1215522 1215522 51712707 PART X, LINE 2: THE HOSPITAL AND FOUNDATION ARE EXEMPT FROM INCOME TAXES UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE (IRC) AND A SIMILAR PROVISION OF STATE LAW. ACCORDINGLY, NO PROVISION FOR INCOME TAXES HAS BEEN INCLUDED IN THE ACCOMPANYING CONSOLIDATED FINANCIAL STATEMENTS. THE HOSPITAL AND FOUNDATION HAVE NO UNCERTAIN TAX POSITIONS AT DECEMBER 31, 2019 OR 2018. AT DECEMBER 31, 2019, TAX RETURNS FOR YEARS 2016 THROUGH 2018 ARE SUBJECT TO EXAMINATION BY THE INTERNAL REVENUE SERVICE. PART XI, LINE 2D - OTHER ADJUSTMENTS: OTHER ADJUSTMENTS 3,727. PART XI, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT EXPENSE 1,215,522. FLOW THRU PARTNERSHIP INCOME/LOSS 1,862. PART XII, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT EXPENSE 1,215,522. SCHEDULE D, PART V, LINE 4 THE ENDOWMENT FUNDS ARE HELD BY SUSAN B. ALLEN MEMORIAL HOSPITAL FOUNDATION, A RELATED TAX EXEMPT ORGANIZATION. THE EARNINGS FROM THE ENDOWMENT FUNDS ARE USED TO FUND THE PURCHASE OF EQUIPMENT AND PROGRAM SUPPORT FOR SUSAN B. ALLEN MEMORIAL HOSPITAL. CENTRAL AMERICA/CARIBBEAN 0 0 INVESTMENTS 44646 0 0 0 0 0 0 44646 0 44646 0 0 1 1 0 0 PART III ACCOUNTING METHOD: 1 1 1 X 0 1 1 1 0 1 1 1657203 1117918 539285 0.01070 6003754 3810185 2193569 0.04340 7660957 4928103 2732854 0.05410 126529 10500 116029 0.00230 126529 10500 116029 0.00230 7787486 4938603 2848883 0.05640 1 1215522 122768 10629977 14805473 -4175496 X 1 1 1 1 SUSAN B ALLEN MEMORIAL HOSPITAL 720 WEST CENTRAL EL DORADO KS 67042 WWW.SBAMH.ORG H-008-002 X X X SUSAN B ALLEN MEMORIAL HOSPITAL 0 0 1 X X X X X X X X X 19 1 0 0 1 X SEE PART V, SECTION C X 1 19 1 SEE PART V, SECTION C 0 1 X 200.000000000000 0.000000000000 X X X 1 1 X X X 1 X SEE PART V, SECTION C X SEE PART V, SECTION C X SEE PART V, SECTION C X X X X X X 1 X 0 X X X X 1 X 0 0 SUSAN. B ALLEN MEMORIAL HOSPITAL PART V, SECTION B, LINE 5: BASED ON DATA ACQUIRED FROM THE 2016 CHNA, HEALTH AND WELLNESS COMMUNITY PARTNERS WERE INVITED TO GIVE INPUT DURING THE 2019 CHNA DATA COLLECTION PROCESS AND PARTICIPATED IN THE TOWN HALL MEETING THAT FOLLOWED WHERE GAPS IN SIGNIFICANT NEEDS WERE IDENTIFIED AND PRIORITIZED. THESE PARTNERS INCLUDED BUT WERE NOT LIMITED TO: BUTLER COUNTY HEALTH DEPT, SOUTH CENTRAL KANSAS MENTAL HEALTH, LOCAL SCHOOL DISTRICTS, DEPARTMENT OF AGING, MEMBERS OF SBAMH MEDICAL STAFF, ALLIED HEALTH, BUTLER COMMUNITY COLLEGE SCHOOL OF NURSING, UNITED WAY, YMCA, LARGE BUSINESS OWNERS, CLERGY, DEPARTMENT OF HUMAN SERVICES, ETC. SUSAN. B ALLEN MEMORIAL HOSPITAL PART V, SECTION B, LINE 11: SBAMH HAS ADOPTED A "POPULATION HEALTH" PHILOSOPHY WHERE HEALTH & WELLNESS SERVICES ARE DEVELOPED AND DELIVERED TO ALL CITIZENS IN OUR SERVICE AREA. THE 2019 CHNA IDENTIFIED THREE (3) MAJOR UNDERSERVED AREAS OF SIGNIFICANT NEED; MENTAL HEALTH/ALLIED HEALTH, POVERTY, AND SUBSTANCE ABUSE. SCHEDULE H, PART V, SECTION B, LINE 7A & 10A WWW.SBAMH.ORG/ABOUT_US/COMMUNITY_HEALTH_NEEDS_ASSESSMENT SCHEDULE H, PART V, SECTION B, LINE 16 WWW.SBAMH.ORG/PATIENTS_INFO/BILLING_INFORMATION 7 1 - SBA MEMORIAL HOSPITAL HOME HEALTH 720 W CENTRAL EL DORADO KS 67042 HOME HEALTH AGENCY 2 - SBA MEMORIAL HOSPITAL DIALYSIS 720 W CENTRAL EL DORADO KS 67042 HEMODIALYSIS 3 - SBA MEMORIAL HOSPITAL MEDICAL CLINIC 720 W CENTRAL EL DORADO KS 67042 MEDICAL OFFICE BUILDING 4 - AUGUSTA IMMEDIATE CARE 401 W 7TH AVE AUGUSTA KS 67010 IMMEDIATE CARE CLINIC 5 - SUSAN B ALLEN MEMORIAL HOSPITAL DME 720 W CENTRAL EL DORADO KS 67042 DURABLE MEDICAL EQUIPMENT PROVIDER 6 - EL DORADO URGENT CARE 2710 W CENTRAL AVE SUITE A EL DORADO KS 67042 URGENT CARE CLINIC 7 - AUGUSTA FAMILY CLINIC 401 W 7TH AVE AUGUSTA KS 67010 FAMILY PRACTICE CLINIC PART I, LINE 3C: THE HOSPITAL ALSO USES MEDICAL INDIGENCY, ASSET LEVEL, AND RESIDENCY AS FACTORS TO DETERMINE ELIGIBILITY. PART I, LINE 7: THE HOSPITAL USES THE COST-TO-CHARGE RATIO. THIS METHOD WAS USED TO CALCULATE THE FIGURES IN THE TABLE AND WAS DETERMINED BY COMPARING PATIENT CARE COSTS TO PATIENT CARE CHARGES. PART I, LN 7 COL(F): THE AMOUNT OF BAD DEBT EXPENSE REMOVED FROM TOTAL EXPENSES FOR CALCULATING THE NET COMMUNITY BENEFIT EXPENSE PERCENTAGE WAS $1,215,522. PART III, LINE 2: NON-MEDICARE AND NON-MEDICAID ACCOUNTS RESERVE AT 100% AT THE POINT OF AGING OVER 180 DAYS. MEDICARE AND MEDICAID ACCOUNTS RESERVE AT 100% AFTER 365 DAYS. PART III, LINE 3: THIS AMOUNT IS ESTIMATED BASED ON THE U.S. CENSUS BUREAU RATE OF INDIVIDUALS BELOW POVERTY LEVEL - 10.1%. PART III, LINE 4: THE BAD DEBT FOOTNOTE IS ON PAGE 13 OF THE AUDITED FINANCIAL STATEMENTS. PART III, LINE 8: SERVING PATIENTS WITH GOVERNMENT HEALTH BENEFITS, SUCH AS MEDICARE, IS A COMPONENT OF THE COMMUNITY BENEFIT STANDARD THAT TAX-EXEMPT HOSPITALS ARE HELD TO. THIS IMPLIES THAT SERVING MEDICARE PATIENTS IS A COMMUNITY BENEFIT AND THAT THE HOSPITAL OPERATES TO PROMOTE THE HEALTH OF THE COMMUNITY. PART III, LINE 9B: THE FINANCIAL ASSISTANCE POLICY IS OFFERED AT TIME OF REGISTRATION. NOTIFICATION OF THE FINANCIAL ASSISTANCE POLICY IS AVAILABLE IN MULTIPLE FORMS. PART VI, LINE 2: IN ADDITION TO THE COMMUNITY HEALTH NEEDS ASSESSMENT THAT WAS COMPLETED IN 2019 AS REQUIRED BY INTERNAL REVENUE CODE SECTION 501(R), THE ORGANIZATION HAS A STRATEGIC PLANNING COMMITTEE OF THE BOARD WHO, THROUGH A CONSULTANT, CONDUCTS A NEEDS SURVEY OF OUR SERVICE AREA. PART VI, LINE 3: ON ADMISSION, PATIENTS ARE GIVEN A BROCHURE DESCRIBING INFORMATION ABOUT THE KANSAS HEALTHWAVE PROGRAM. IT ALSO INCLUDES INFORMATION ABOUT COVENTRY ONE HEALTH INSURANCE AND VALUE BLUE - BOTH ARE LOW COST OR NO COST INSURANCE PLANS. THE BROCHURE ALSO GIVES INFORMATION ABOUT OUR CHARITY CARE PROGRAM. OUR CHARITY CARE PROGRAM INFORMATION IS GIVEN TO OUR MEDICAL STAFF PHYSICIANS FOR DISTRIBUTION TO PATIENTS IN THEIR OFFICES. ALL OF THE BILLING STATEMENTS LIST THAT WE HAVE A CHARITY CARE PROGRAM AND THE WEBSITE URL FOR THE APPLICATION. THE CHARITY CARE APPLICATION WITH COVER LETTER IS MAILED ALONG WITH THE FIRST STATEMENT SENT TO SELF-PAY PATIENTS. THE GUIDELINES ARE INCLUDED WITH THE SECOND STATEMENT AFTER A REVIEW OF THE ACCOUNT INDICATES A NEED FOR FINANCIAL ASSISTANCE. PATIENT ACCOUNT REPRESENTATIVES REVIEW OUR CHARITY CARE PROGRAM WITH PATIENTS WHEN MAKING CALLS. WE ALSO REFER PATIENTS TO THE MIDLAND GROUP TO DETERMINE ELIGIBILITY FOR MEDICAID, OTHER ASSISTANCE PROGRAMS, AND OUR CHARITY CARE PROGRAM. THE MIDLAND GROUP ASSISTS PATIENTS IN THE APPLICATION PROCESS TO SEE IF THEY ARE ELIGIBLE FOR STATE ASSISTANCE PROGRAMS. KANSAS MEDICAL ASSISTANCE PROGRAM (KMAP) HEALTHWAVE BROCHURES AND APPLICATIONS ARE PROVIDED TO PATIENTS WHO MAY MEET THE FINANCIAL GUIDELINES OF THE KMAP. PART VI, LINE 4: THE HOSPITAL'S PRIMARY SERVICE AREA CONSISTS OF 6 COMMUNITIES WITHIN BUTLER COUNTY WHICH LIE WITHIN A 15 MILE RADIUS OF THE HOSPITAL. THE POPULATION OF THESE COMMUNITIES IS APPROXIMATELY 37,500 OF WHICH 26% ARE AGE 55 OR OLDER. THE HOSPITAL'S SECONDARY SERVICE AREA CONSISTS OF 13 SMALLER COMMUNITIES LOCATED IN BUTLER, GREENWOOD, ELK, MARION AND COWLEY COUNTIES WITH A COMBINED POPULATION OF JUST OVER 15,000 RESIDENTS OF WHICH 32% ARE AGE 55 OR OLDER. WHILE PART OF THE SERVICE AREA IS IN THE WICHITA METROPOLITAN STATISTICAL AREA, MUCH OF THE SERVICE AREA IS RURAL. PART VI, LINE 5: SBAMH PARTICIPATES OR PROVIDES SUPPORT TO:-THE BUTLER COUNTY SENIOR FAIR PROVIDING HEALTH INFORMATION ON VARIOUS HEALTH ISSUES,-THE FRONTIER REFINING EMPLOYEE HEALTH FAIR PROVIDING INFORMATION ABOUT VARIOUS HEALTH ISSUES AND OFFERING HEALTH TESTING AND SCREENINGS,-THE BUTLER COMMUNITY COLLEGE WOMEN'S FAIR,-THE BUTLER COMMUNITY COLLEGE-ANDOVER/SHERWIN WILLIAMS WELLNESS FAIR PROVIDING INFORMATION ABOUT VARIOUS HEALTH ISSUES AND OFFERING HEALTH TESTING AND SCREENINGS,-PROVIDING LOW COST SCREENING PROGRAMS FOR CARDIAC HEALTH, OSTEOPOROSIS, HYPERTENSION AND DIABETES, AND-PROVIDING FREE INFLUENZA VACCINATIONS TO MEMBERS OF THE COMMUNITY. SBAMH HAS A VOLUNTEER BOARD OF 11 MEMBERS THAT COME FROM THROUGHOUT OUR SERVICE AREA. 1 PUBLIC INFLUENZA VACCINATIONS 760 14593 BOOK VACCINATIONS NURSING SCHOLARSHIPS 1 636 NURSING SCHOLARSHIP SCHEDULE I, PART I, LINE 2 THE PUBLIC INFLUENZA VACCINATIONS ARE GIVEN TO ALL WHO SHOW UP AT THE TWO CLINICS. X 1 1 X X X X 0 0 0 0 0 1 0 0 0 JAMES KIRKBRIDE CHIEF EXECUTIVE OFFICER 233736 0 82833 0 11599 0 8310 0 1250 0 337728 0 0 0 MARK ROOKER CHIEF INFORMATION OFFICER 161298 0 0 0 0 0 6582 0 15313 0 183193 0 0 0 CECILIA GOEBEL CHIEF NURSING OFFICER 150694 0 400 0 0 0 6044 0 14460 0 171598 0 0 0 JENNIFER PHARRIS PHYSICIAN 229672 0 0 0 0 0 9198 0 261 0 239131 0 0 0 NICHOLAS POSGE PODIATRIST 235384 0 0 0 0 0 7785 0 14291 0 257460 0 0 0 CHARLES STAFFORD RADIATION ONCOLOGY PHYSICIST 198637 0 2882 0 0 0 8090 0 9226 0 218835 0 0 0 GARRET DAHARSH VP OPERATIONS & BUS DEV 144306 0 0 0 0 0 4824 0 13557 0 162687 0 0 0 IRAM SIRAJUDDIN PHYSICIAN 162532 0 0 0 0 0 6501 0 8378 0 177411 0 0 0 SCHEDULE J, PART I, LINE 1A JAMES KIRKBRIDE'S COMPENSATION INCLUDES SOCIAL CLUB DUES THAT ARE TREATED AS TAXABLE INCOME. SCHEDULE J, PART I, LINE 6A MANAGEMENT INCENTIVE PLAN BASED ON CRITERIA OF CONTRIBUTION MARGIN PERCENTAGE AFTER MEETING ACCREDITATION STANDARDS AND QUALITY STANDARDS. A BUTLER COUNTY KANSAS 486035405 12343PAA3 2012-04-30 14500000 SEE PART VI 0 0 0 B BUTLER COUNTY KANSAS 486035405 2014-12-16 6500000 SEE PART VI 0 0 0 A 13457998 14500655 24 3607315 10983316 2013 1 1 1 1 B 3074057 6503000 110354 6392646 2017 0 0 1 1 A 0 0 1 1 0 0 0 1 B 0 0 0 0 0 0 1 A 0 0 0 1 0 0 0 0 1 B 0 0 0 1 0 0 0 0 1 A 1 B 1 PART I, LINE A, COLUMN (F) IMPROVE AND EQUIP HOSPITAL FACILITIES; REFUND SERIES 1998Z BONDS (ISSUED 12/22/1998); REFUND SERIES 2002Q BONDS (ISSUED 12/17/2002). PART I, LINE B, COLUMN (F) RENOVATIONS TO AND EQUIPMENT FOR HOSPITAL FACILITIES. PART II, LINE 3, COLUMN A AMOUNT DOES NOT EQUAL ISSUE PRICE DUE TO INVESTMENT EARNINGS EARNED IN THE PROJECT FUND DURING THE PROJECT PERIOD. PART II, LINE 3, COLUMN B AMOUNT DOES NOT EQUAL ISSUE PRICE DUE TO INVESTMENT EARNINGS EARNED IN THE PROJECT FUND DURING THE PROJECT PERIOD. PART II, LINE 11, COLUMN A THIS AMOUNT WAS EXPENDED TO REDEEM THE REFUNDED BONDS ON MAY 1, 2012 AND DECEMBER 15, 2012. PART II, LINE 15, COLUMN A THE BOND ISSUE CONSTITUTES AN "ADVANCE REFUNDING ISSUE" UNDER U.S. TREASURY REGS 1.150-1(D), BUT NO BOND THAT IS PART OF THE BOND ISSUE IS AN "ADVANCE REFUNDING BOND" UNDER I.R.C. 149(D). THE BONDS WERE ISSUED AS A "DRAW-DOWN LOAN" WITHIN MEANING OF U.S. TREASURY REGS 1.150(1)(C)(4)(I). THE FIRST DRAW/ADVANCE ON THE BONDS WAS MADE APRIL 30, 2012 (I.E., THE ISSUE DATE OF THE BOND ISSUE), IN PART, TO REFUND AND REDEEM A PRIOR SERIES OF 1998Z BONDS ON MAY 1, 2012; THE SECOND DRAW/ADVANCE ON THE BONDS WAS MADE DECEMBER 14, 2012, IN PART, TO REFUND AND REDEEM A PRIOR SERIES 2002Q BONDS ON DECEMBER 15, 2012. THEREFORE, THERE ARE NO ADVANCE REFUNDING BONDS, BECAUSE NO BOND PROCEEDS WERE USED TO PAY DEBT SERVICE ON A PRIOR SERIES OF BONDS MORE THAN 90 DAYS AFTER THE ISSUE DATE OF THAT BOND. PART III, COLUMN A PART III HAS BEEN COMPLETED FOR THE PROJECTS ORIGINALLY FINANCED AFTER JANUARY 1, 2003. PART IV, LINE 2C, COLUMN A ARBITRAGE COMPUTATION COMPLETED AS OF 1/1/2014. PART IV, LINE 2C, COLUMN B ARBITRAGE COMPUTATION COMPLETED AS OF 8/1/2017. FORM 990, PART III, LINE 4A COMMUNITY SERVICES: SUSAN B. ALLEN MEMORIAL HOSPITAL (SBAMH) OFFERS A NUMBER OF PROGRAMS AND SERVICES IN OUR COMMUNITY AT MINIMAL OR NO COST IN ORDER TO PROMOTE HEALTH AND WELLNESS. ACTUAL COSTS FOR THESE SERVICES ARE NOT SEPARATELY IDENTIFIABLE AND ARE INCLUDED AS PART OF THE PATIENT SERVICES COST. 1. PARTICIPATED IN THE BUTLER COUNTY SENIOR FAIR, HELD IN EL DORADO, DISPLAYING AND PROVIDING INFORMATION REGARDING OUR DIABETES EDUCATION PROGRAM, HOME HEALTH SERVICES (INCLUDING BLOOD PRESSURE TESTING), HOME MEDICAL EQUIPMENT SERVICES, NUTRITION SERVICES, AND PHYSICAL REHABILITATION AT NO CHARGE. 2. PARTICIPATED IN THE FRONTIER REFINING EMPLOYEE HEALTH FAIR PROVIDING INFORMATION ON DIABETIC FOOT CARE, CARDIAC HEALTH, DIETARY EDUCATION, ORTHOPEDIC ISSUES, PHYSICAL THERAPY ISSUES, SKIN CANCER CHECKS, BONE DENSITY TESTING AND BLOOD WORK (INCLUDING LIPID, PSA AND HEMOGLOBIN A1C TESTING). 3. SERVED AS PROJECT SEARCH HOST SITE. PROJECT SEARCH IS A HIGH SCHOOL TO WORK TRANSITION PROGRAM SERVING STUDENTS WITH DISABILITIES BETWEEN THE AGES OF 18-21. 4. SUPPORTED MANY AREA SCHOOL EVENTS THROUGH SPONSORSHIPS AND PARTICIPATION, INCLUDING PARTICIPATED IN THE AUGUSTA SCHOOL DISTRICT WELLNESS FAIR, EHS DRAMA BOOSTER SPONSORSHIP, BUTLER COMMUNITY COLLEGE CAREER FAIR SPONSORSHIPS, BUTLER COMMUNITY COLLEGE SCHOLARSHIP SPONSORSHIP, AND EHS AFTER PROM DONATION. 5. PARTICIPATED IN THE EL DORADO SCHOOL DISTRICT KIDZFEST EVENT WHERE PARENTS AND CHILDREN OF THE SCHOOL DISTRICT WERE INVITED TO LEARN OF SERVICES AVAILABLE TO CHILDREN. STAFF ATTENDED AND SPOKE WITH CHILDREN AND THEIR PARENTS ABOUT THE POSITIVE EFFECTS OF EXERCISE AND GOOD NUTRITION ON HEART HEALTH. 6. PROVIDED A NUMBER OF DIRECTORS AND STAFF TO SPEAK AT LOCAL SCHOOL DISTRICT CAREER FAIR EVENTS INCLUDING PHYSICAL REHABILITATION, DIAGNOSTIC IMAGING, ATHLETIC TRAINING, FAMILY PRACTICE, ALLERGY/IMMUNOLOGY, AND ORTHOPEDIC SURGERY. 7. PROVIDED SPONSORSHIPS FOR THE WOMEN IN BUSINESS LUNCHEON AND THE EL DORADO HALF MARATHON/SBA ONE-MILE. 8. PROVIDED NURSING STATION AT LOCAL SCHOOL EVENTS, INCLUDING DAM MUSIC FESTIVAL AND LANTERN FESTIVAL. 9. PROVIDED DARI (MOTION ANALYSIS) SCREENINGS FOR HIGH SCHOOL ATHLETES. 10. MADE AVAILABLE A "SPEAKERS BUREAU" TO OUR COMMUNITY. HOSPITAL PERSONNEL SPOKE TO VARIOUS CIVIC GROUPS AND ORGANIZATION ON NUMEROUS OCCASIONS. 11. HOSPITAL EMPLOYEES DONATED OVER $15,000 IN SUPPORT OF THE EL DORADO UNITED WAY PROGRAM. 12. PROVIDED MEETING ROOM SPACE FOR OTHER ORGANIZATION SERVING THE COMMUNITY, SUCH AS THE BUTLER COMMUNITY DIABETES SUPPORT GROUP, THE AMERICAN CANCER SOCIETY, THE ARC OF BUTLER (SPECIAL NEEDS AND DISABILITIES), BUTLER COUNTY ALZHEIMER'S SUPPORT GROUP, AND THE BUTLER COUNTY MULTIPLE SCLEROSIS SUPPORT GROUP. 13. STAFF MEMBERS FROM THE EMERGENCY AND PHYSICAL REHABILITATION DEPARTMENTS TOOK PART IN THE BUTLER COUNTY EMS KIDS CAMP, WHERE KIDS LEARNED ABOUT SAFETY AND HEALTH RELATED TOPICS. 14. PROVIDE PERSONNEL AND FACILITIES FOR LOCAL EMERGENCY PLANNING COMMITTEE MEETINGS. 15. PROVIDE ONCE-A-MONTH FREE CHILDBIRTH EDUCATION CLASSES FOR NEW MOMS AND SIGNIFICANT OTHERS, REGARDLESS OF WHERE THEY WILL BE DELIVERING. OBSTETRICS STAFF PROVIDE EDUCATION AND INFORMATION ABOUT LABOR AND DELIVERY, COMFORT MEASURES, PAIN MANAGEMENT, NEWBORN CARE, RECOVERY AND DISCHARGE. 16. PROVIDE ONCE-A-MONTH FREE BREASTFEEDING EDUCATION CLASSES FOR NEW MOMS, REGARDLESS OF WHERE THEY WILL BE DELIVERING. 17. PROVIDED INFORMATION TO NEW MOMS AT THE FIRST BABY JUBILEE. FAMILY BIRTH CENTER STAFF TALKED ABOUT THE FACILITIES, AS WELL AS PROGRAMS OFFERED AT SBA. 18. PROVIDED A LOW-COST SCREENING PROGRAM FOR CARDIAC HEALTH, OSTEOPOROSIS, HYPERTENSION, AND DIABETES MONTHLY AT THE COMMUNITY CARE CENTER AT THE YMCA. 19. PROVIDE FREE HEARING SCREENINGS IN THE EL DORADO EAR, NOSE AND THROAT OFFICES ONE-HALF DAY EACH WEEK. 20. ANOTHER WELLNESS INITIATIVE THAT WE HAVE IS EWOW (EL DORADO WORKING ON WELLNESS). IN THIS PROGRAM WE ENGAGE WITH A GROUP OF TEACHERS OR SCHOOL EMPLOYEES AND WORK ON IMPLEMENTING HEALTHIER LIFESTYLE CHOICES THROUGH NUTRITIONAL EDUCATION, GROUP FITNESS TRAINING AND HEALTH SCREENINGS. WE ARE INVESTING IN OUR TEACHERS SO THAT THEY CAN TAKE THE HEALTH LIFESTYLE CHOICES BACK INTO THEIR CLASSROOMS AND SCHOOLS AND SHARE WHAT THEY HAVE LEARNED. WE ALSO SUPPORT THE SCHOOLS BY PROVIDING ATHLETIC TRAINERS FOR LOCAL AREA SCHOOLS AND SUMMER TRIPLE A BASEBALL TEAMS. IN ADDITION, SBA PROVIDED ATHLETIC TRAINERS FOR THE SHRINE BOWL. 21. PROVIDED A FREE INFLUENZA VACCINATION PROGRAM FOR MEMBERS OF OUR COMMUNITY. LARGE CLINICS WERE HELD FOR THE GENERAL PUBLIC - 1 IN EL DORADO AND 1 IN AUGUSTA. IN TOTAL, 760 DOSES WERE GIVEN TO COMMUNITY MEMBERS AT NO COST. WE ALSO CONDUCTED SEVERAL SMALL CLINICS AT THE COMMUNITY CARE CENTER AT THE YMCA. 22. ADMINISTRATIVE AND MANAGEMENT SERVE ON A VARIETY OF BOARDS AND COMMITTEES, INCLUDING THE RESPIRATORY CARE COUNCIL AT THE BOARD OF HEALING ARTS IN TOPEKA, ADVISORY COUNCIL FOR BCC NURSING, PROJECT SEARCH ADVISORY BOARD, KHHRA, UNITED WAY EL DORADO, EL DORADO YMCA, THRIVE!BUTLER, ADVISORY BOARD WSU MEDICAL LABORATORY SCIENTIST PROGRAM, ADVISORY BOARD MANHATTEN TECHNICAL SCHOOL MEDICAL LABORATORY TECHNICIAN PROGRAM, ADVISORY BOARD BARTON COMMUNITY COLLEGE MEDICAL LABORATORY TECHNICIAN PROGRAM, ADVISORY BOARD SEWARD COUNTY COMMUNITY COLLEGE LABORATORY TECHNICIAN PROGRAM, ASCLS, CLMA, STATE OF KANSAS LABORATORY COMMITTEE, PRESIDENT OF THE ELECT FOR KHELSA, EMPAC, TRINITY HEIGHTS RESPITE CARE IN NEWTON, DIRECTOR BOARD OF EDUCATION FOR ANNOOR ISLAMIC SCHOOL IN WICHITA AND COMMUNITY EDUCATION/OUTREACH COMMITTEE MEMBER FOR ISLAMIC SOCIETY OF WICHITA, PARTNERS IN EDUCATION BOARD MEMBER, SOROPTIMIST INTERNATIONAL OF EL DORADO, RELAY FOR LIFE BUTLER COUNTY BOARD MEMBER, CELEBRATION OF FREEDOM COMMITTEE, KANSAS OIL MUSEUM BOARD, OB/PEDS COMMITTEE AND TV CHANNEL COMMITTEE, AND SUNSET PTO. 23. IS A MEMBER OF THE EL DORADO AND AUGUSTA CHAMBERS OF COMMERCE, REPRESENTING THE HOSPITAL IN COMMUNITY DISCUSSIONS AND EVENTS. 24. OFFERED COMMUNITY HEALTH PRESENTATIONS AT AREA SENIOR CENTERS AND NURSING/RETIREMENT HOMES, WITH TOPICS INCLUDING FALL PREVENTION, TIPS TO A HEALTHY HEART, DIABETES PREVENTION, ALZHEIMER'S AWARENESS, FOOT HEALTH, LIVING WILLS, STROKE PREVENTION, ARTHRITIS, STRESS PREVENTION, DEHYDRATION, HEAT STROKE AND MORE. 25. ACT AS A CLINICAL SITE FOR TRAINING OF HEALTHCARE PROFESSIONALS INCLUDING MEDICAL STUDENTS, NURSING STUDENTS, RADIOLOGY, LAB, MEDICAL TECHNOLOGISTS, RESPIRATORY THERAPISTS, DIETICIANS, PHYSICAL, OCCUPATIONAL AND SPEECH THERAPISTS, ATHLETIC TRAINING STUDENTS, CRNA STUDENTS, PHYSICIAN ASSISTANT STUDENTS, APRN STUDENTS, AND PHARMACY STUDENTS. 26. MADE AVAILABLE SCHOLARSHIP MONEY FOR PATIENTS TO GO THROUGH THE SBA ADULT DIABETES EDUCATION PROGRAM. IN ADDITION TO THE ACTUAL CLASS COSTS, ADDITIONAL LAB WORK WAS ALSO WRITTEN OFF FOR THESE PATIENTS. 27. SPONSORED THE EL DORADO YMCA "STRONG KIDS" CAMPAIGN WITH A $1,000 DONATION. FORM 990, PART VI, SECTION B, LINE 11B AN INDEPENDENT ACCOUNTING FIRM PREPARES AND REVIEWS THE FORM 990. THE 990 IS THEN REVIEWED BY THE HOSPITAL'S OFFICERS AND THE ACCOUNTING DIRECTOR. ANY QUESTIONS OR CONCERNS THE HOSPITAL'S OFFICERS OR ACCOUNT DIRECTOR HAVE ARE ADDRESSED AND ANY CLARIFICATION OR CORRECTIONS THAT NEED TO BE MADE ARE MADE. FORM 990, PART VI, SECTION B, LINE 12C AT THE TIME OF HIRE OR ELECTION IN THE CASE OF BOARD MEMBERS, AND ANNUALLY THEREAFTER, THE PRESIDENT AND CEO OR THEIR DESIGNEE SHALL PROVIDE TO THE BOARD, EXECUTIVE OFFICERS AND DEPARTMENT DIRECTORS, A COPY OF THE CONFLICT OF INTEREST POLICY AND THE CONFLICT OF INTEREST DISCLOSURE STATEMENT WHICH WILL BE COMPLETED TO IDENTIFY ANY RELATIONSHIPS, POSITIONS OR CIRCUMSTANCES WITH RESPECT IT IS BELIEVED A CONFLICT MAY ARISE. THE ANNUAL REVIEW AND MONITORING IS A PART OF THE HOSPITAL'S COMPLIANCE PLAN. A REPORT SHALL BE MADE TO THE BOARD OF TRUSTEES OF ITEMS DISCLOSED. EACH MEMBER OF THE BOARD OF TRUSTEES OR MANAGEMENT SHALL DISCLOSE FULLY AND FRANKLY ANY AND ALL POTENTIAL CONFLICTS OF INTEREST WHICH MAY EXIST OR APPEAR TO EXIST. FORM 990, PART VI, SECTION B, LINE 15 THE HOSPITAL PARTICIPATES IN AN EXTERNAL SALARY SURVEY FOR ALL EXECUTIVE POSITIONS. THE PRESIDENT AND CEO AND CHIEF HUMAN RESOURCES OFFICER REVIEWS THE SURVEY RESULTS AND PRESENTS THEM TO THE COMPENSATION COMMITTEE OF THE BOARD WITH RECOMMENDATIONS FOR THE EXECUTIVE AND VICE PRESIDENT POSITIONS. THE COMPENSATION COMMITTEE OF THE BOARD MAKES RECOMMENDATIONS TO THE FULL BOARD FOR APPROVAL. IN ADDITION, THE COMPENSATION COMMITTEE MAKES A RECOMMENDATION FOR THE PRESIDENT AND CEO SALARY TO THE FULL BOARD FOR APPROVAL. THE REVIEW IS DONE ANNUALLY BY THE COMPENSATION COMMITTEE AND THE BOARD. FORM 990, PART VI, SECTION C, LINE 19 THE GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE NOT MADE AVAILABLE TO THE PUBLIC. FORM 990, PART IX, LINE 11G PROFESSIONAL FEES: PROGRAM SERVICE EXPENSES 3,628,749. MANAGEMENT AND GENERAL EXPENSES 1,328,076. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 4,956,825. PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 3,167,793. MANAGEMENT AND GENERAL EXPENSES 1,159,372. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 4,327,165. FORM 990, PART XI, LINE 9: OTHER ADJUSTMENTS 3,727. FLOW THRU PARTNERSHIP INCOME/LOSS -1,862. SUSAN B ALLEN MEMORIAL HOSPITAL FOUNDATION 720 WEST CENTRAL EL DORADO KS 67042 480862732 SUPPORT ORG KS 501(C)(3) LINE 12A, I SBA HOSPITAL 1 FS ALLEN 720 WEST CENTRAL EL DORADO KS 67042 486103710 GRANTOR TRUST KS N/A T 637391 3070520 1.00000 1 0 0 1 0 0 0 0 0 0 0 0 1 0 1 1 1 1 1 1 SUSAN B ALLEN MEMORIAL HOSPITAL FOUNDATION C 116699 CASH SUSAN B ALLEN MEMORIAL HOSPITAL FOUNDATION L 129177 FMV