2020-07-13T12:51:02-05:00 2019-06-30 381357951 PLANTE & MORAN PLLC 8181 E TUFTS AVE SUITE 600 DENVER CO 80237 990 2018-07-01 841262971 POUDRE VALLEY HEALTH CARE INC POUD 9702377000 2315 E HARMONY ROAD NO 200 FORT COLLINS CO 80528 DAVID THOMPSON CHIEF FINANCIAL OFFICER 9702377000 2020-07-09 1 DORI J EGGETT P00645252 3037409400 2020-07-09 71.218.248.222 2020-07-09 18:28:50 MD P DA39A3EE5E6B4B0D3255BFEF95601890AFD80709 321DDE24B35CC1D1467AEA03569F7C6B0A555C82 2018 2020-09-22 18:59:49Z KEVIN UNGER 2315 E HARMONY RD 200 FT COLLINS CO 80528 1895963381 0 X WWW.UCHEALTH.ORG X 1994 CO WE IMPROVE LIVES THROUGH LEARNING, HEALING, DISCOVERY, AND THROUGH HUMAN CONNECTION. 12 11 4404 476 6963666 5957763 2438879 2525135 659740233 708240921 49194013 62737119 1402448 13290404 712775573 786793579 43656988 39643462 0 0 231007789 245900138 0 0 0 276218006 285144951 550882783 570688551 161892790 216105028 5905134945 6985306171 4290573331 5067119966 1614561614 1918186205 WE IMPROVE LIVES. IN BIG WAYS THROUGH LEARNING, HEALING AND DISCOVERY. IN SMALL, PERSONAL WAYS THROUGH HUMAN CONNECTION. BUT IN ALL WAYS, WE IMPROVE LIVES. 0 0 512117995 39643462 706011343 POUDRE VALLEY HEALTH CARE INC. (PVHC) PROVIDES TERTIARY, ACUTE, INPATIENT, OUTPATIENT AS WELL AS EMERGENCY CARE. PVHC SERVICES COMMUNITIES IN NORTHERN COLORADO, SOUTHWESTERN NEBRASKA, AND SOUTHEASTERN WYOMING. DURING FISCAL YEAR 2019, PVHC RECORDED 63,478 PATIENT DAYS, 15,235 ADMISSIONS, 304,214 OUTPATIENT VISITS, 66,277 EMERGENCY VISITS, 1,897 DELIVERIES, 3,909 INPATIENT SURGERIES, AND 5,464 OUTPATIENT SURGERIES. 512117995 1 1 0 1 0 0 0 0 0 1 1 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 1 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 1 1 1 0 0 1 374 0 1 4404 1 1 1 0 0 0 0 0 0 0 0 0 0 0 X 12 11 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 1 1 X DAVID THOMPSON 9702377000 2315 E HARMONY ROAD SUITE 200 FORT COLLINS CO 80528 MIKE DELLENBACH CHAIR 1.00 2.00 X X 0 0 0 DENNIS HOUSKA VICE CHAIR 1.00 2.00 X X 391 793 0 CHRISTINE CHIN DIRECTOR 1.00 2.00 X 0 0 0 LISA CLAY DIRECTOR 1.00 2.00 X 0 0 0 DOUG ERION DIRECTOR 1.00 2.00 X 0 0 0 CHRIS OSBORN DIRECTOR 1.00 2.00 X 0 0 0 JIM PARKE DIRECTOR 1.00 2.00 X 0 0 0 JAMES SPROWELL DIRECTOR 1.00 2.00 X 0 0 0 DAN STROH DIRECTOR 1.00 2.00 X 491 998 0 KEVIN UNGER PRESIDENT/CEO 25.00 25.00 X X 652400 832417 119912 FARAZ NAQVI DIRECTOR 1.00 2.00 X 0 0 0 RICH LOWE DIRECTOR 1.00 2.00 X 0 0 0 STEPHANIE DOUGHTY CHIEF FINANCIAL OFFICER 25.00 25.00 X 280352 357711 61914 STEVE SCHWARTZ INTERIM CFO 1.00 40.00 X 0 301932 42396 DIANA BREYER CHIEF QUALITY OFFICER 17.00 33.00 X 184036 325197 39607 THOMAS DOWNES CHIEF MEDICAL OFFICER 29.00 21.00 X 290952 212422 59180 RODNEY GOOD SR DIRECTOR PHARMACY 29.00 21.00 X 122935 89754 41326 DONNA PODUSKA CHIEF NURSING OFFICER 45.00 5.00 X 291603 0 37818 GRACE KOWALYSHYN-TAYLOR VP ADMINISTRATION 25.00 25.00 X 140826 179684 54573 RYAN ROHMAN CHIEF OPERATING OFFICER 25.00 25.00 X 142388 181677 32249 ROBERT WAGNER JR SR DIRECTOR CARDIOVASCULAR SERVICES 22.00 28.00 X 91105 115271 36806 JILLIAN BUSCH PSYCHIATRIST 50.00 X 305058 0 45398 JOSEPH GOTTFRIED PSYCHIATRIST 50.00 X 272977 0 50612 HERMANN MORENO PSYCHIATRIST 50.00 X 298885 0 49093 KENNETH WATANABE MED DIRECTOR/MTN CREST 50.00 X 330655 0 48959 JANELL WOZNIAK PROGRAM DIRECTOR/FMC 50.00 X 314077 0 43608 3719131 2597856 763451 219 0 1 0 ALLIED BARTON SECURITY PO BOX 31001-2374 PASADENA CA 91110 SECURITY 3358414 NORTHERN COLORADO HOSPITALISTS 2121 E HARMONY ROAD STE 300 FORT COLLINS CO 80528 MEDICAL 2346722 FORT COLLINS WOMEN'S CLINIC 1107 S LEMAY AVENUE STE 300 FORT COLLINS CO 80524 MEDICAL 1945415 SUMMIT PATHOLOGY 5802 WRIGHT DRIVE LOVELAND CO 80538 MEDICAL 1774159 ARUP LABORATORIES PO BOX 27964 SALT LAKE CITY UT 84127 MEDICAL 1483539 45 849552 1047389 628194 533326 2525135 NET PATIENT SVC REV 900099 663291987 663291987 PROVIDER FEE INCOME 621400 39467947 39467947 JOINT VENTURE 621400 3121471 3270559 -149088 DIETARY SVC INCOME 900099 2324862 2324862 34654 -19150 53804 708240921 28709234 28709234 8967 8967 11686200 167588 1910154 167588 9776046 0 9776046 7058950 2717096 1140780305 184809 1106764066 182130 34016239 2679 34018918 34018918 403145 145864 257281 257281 MISCELLANEOUS REVENUE 621400 2227980 2227980 EHR REVENUE 624100 1029097 1029097 3257077 786793579 709268420 6963666 68036358 39643462 39643462 4203501 2544337 1659164 187504105 160952163 26551942 15853713 13436521 2417192 35883407 30412318 5471089 2455412 2081039 374373 55632 55632 48418 48418 37204 37204 2354333 2354333 26861901 20507676 6354225 3248021 3160809 87212 4163824 3745826 417998 9741786 8937251 804535 3380293 2243759 1136534 1226623 926520 300103 762037 531263 230774 5874543 5874543 24318079 21113500 3204579 1348517 948000 400517 MEDICAL SUPPLIES 131317964 130872634 445330 PROVIDER FEE EXPENSE 29398980 29398980 BAD DEBT 21725782 21725782 TAXES PAID 1963740 1963740 17317274 13061612 4255662 570688551 512117995 58570556 0 103317710 74136456 2094616 2188059 64649593 74134294 44543 38940 10047221 10670379 9552888 8976517 697470917 413937547 294373576 283533370 1217788470 1365355373 24535932 26820617 4178730396 5139452166 5905134945 6985306171 102376764 101121830 1655984 1653143 184335104 171510928 17304433 14836844 68772 59989 3984832274 4777937232 4290573331 5067119966 X 1614561614 1918186205 1614561614 1918186205 5905134945 6985306171 X 216105028 21482479 66037084 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 1 37204 0 0 37204 0 PART II-B, LINE 1: PORTION OF DUES FROM MEMBERSHIP IN CHA AND AHA THAT ARE ATTRIBUTABLE TO LOBBYING ACTIVITIES. 7528946 61289 260065 33759 234908 29587 7552046 7098243 34394 536004 4257 100183 35255 7528946 6872466 76668 163048 -6188 -12899 33026 7098243 7151577 39217 55040 19049 317893 36426 6872466 7079697 46722 95036 22644 14222 33012 7151577 0.06050 0.86740 0.07210 1 1 1 58514943 58514943 291532511 139353994 152178517 99989388 80460978 19528410 195984873 147046067 48938806 51449202 47076508 4372694 283533370 INTERCOMPANY RECEIVABLE 5117738820 DEFERRED PENSION OUTFLOW COSTS 18256147 OTHER RECEIVABLES 3457199 5139452166 INTERCOMPANY PAYABLES 4752947766 ACCRUED INTEREST PAYABLE 488554 OTHER DEFERRED EXPENSES 2549272 PENSION LIABILITIES 21951640 4777937232 783118650 21482479 2953826 24436305 758682345 2354333 25756901 28111234 786793579 544800923 2223606 2223606 542577317 2354333 25756901 28111234 570688551 PART V, LINE 4: ENDOWMENT FUNDS ARE USED FOR THE INTENDED PURPOSE TO FUND SCHOLARSHIPS, EDUCATION, PROGRAMS, AND COMMUNITY BENEFIT. TEMPORARILY RESTRICTED NET ASSETS ARE THOSE WHOSE USE BY THE FOUNDATION HAVE BEEN LIMITED BY THE DONOR TO A SPECIFIC TIME PERIOD OR PURPOSE. THESE NET ASSETS ARE AVAILABLE FOR VARIOUS HEALTH CARE PURPOSES AS DEFINED BY DONORS. THE ENDOWMENT FUND IS OWNED BY POUDRE VALLEY HEALTH SYSTEM FOUNDATION. PART XI, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSE INCLUDED IN EXPENSE ON AFS 2,077,742. COGS REPORTED AS EXPENSE ON AFS 145,864. BOOK VS. TAX ADJUSTMENT IN EQUITY EARNINGS 730,220. PART XI, LINE 4B - OTHER ADJUSTMENTS: PROVISION FOR BAD DEBT IN AFS INCOME 21,725,782. CONTRIBUTIONS FROM PV FOUNDATION NOT IN AFS INCOME 316,226. RENTAL EXP AS INCOME ON 990 8,403. PHARMACY SALES INCLUDED IN EXPENSE ON AFS 53,804. INTERCOMPANY EXPENSE ALLOCATIONS 3,652,686. PART XII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSE INCLUDED IN EXPENSE ON AFS 2,077,742. COGS REPORTED AS EXPENSE ON AFS 145,864. PART XII, LINE 4B - OTHER ADJUSTMENTS: PROVISION FOR BAD DEBT IN AFS INCOME 21,725,782. RENTAL EXP AS INCOME ON 990 8,403. PHARMACY SALES INCLUDED IN EXPENSE ON AFS 53,804. CASH CONTRIBUTIONS FROM FOUNDATION NOT IN AFS REVENUE 316,226. INTERCOMPANY EXPENSES ALLOCATION RECLASS 3,652,686. 1 1 X 1 X 250.000000000000 1 X 1 0 1 1 344053 344053 0.00060 116172714 73638509 42534205 0.07450 12472035 5373776 7098259 0.01240 128988802 79012285 49976517 0.08750 3496528 120684 3375844 0.00590 5548086 723850 4824236 0.00850 6799710 3798226 3001484 0.00530 29373 7609 21764 0.00000 39626124 39626124 0.06940 55499821 4650369 50849452 0.08910 184488623 83662654 100825969 0.17660 1 21394598 137380970 157515937 -20134967 X 1 1 1 HARMONY SURGERY CENTER LLC AMBULATORY SURG 0.50000 0.50000 2 PEAK SURGICAL MANAGEMENT MANAGEMENT SERVINCES 0.14000 0.86000 3 HARMONY IMAGING CENTER LLC MEDICAL IMAGING 0.46000 0.54000 4 SURGERY CENTER OF FORT COLLINS AMBULATORY SURG 0.26000 0.49000 5 GATEWAY MEDICAL SERVICES REAL ESTATE/MEDICAL EQUIPMENT 0.50000 0.50000 6 EYE AND LASER CENTER OF NORTHERN COLO LLC LASER SURGERY 0.50000 0.50000 7 VEIN AND LASER CENTER OF N COLO LASER SURGERY 0.33300 0.67000 8 PVHS-ICM EHW LLC MEDICAL CLINIC 0.50000 0.50000 9 OCR OF LOVELAND LLC AMBULATORY SURG 0.10000 0.90000 1 1 POUDRE VALLEY HOSPITAL 1024 S LEMAY FORT COLLINS CO 80524 X X X X X PHARMACY, LAB POUDRE VALLEY HEALTH CARE 1 0 0 1 X X X X X X X X X 18 1 1 0 1 X HTTPS://WWW.UCHEALTH.ORG/ABOUT/COMMUNITY-HEALTH-NEEDS-ASSESSMENT/ X 1 18 1 HTTPS://WWW.UCHEALTH.ORG/ABOUT/COMMUNITY-HEALTH-NEEDS-ASSESSMENT/ 0 1 X 250.000000000000 400.000000000000 X X X 1 1 X X X 1 X HTTPS://WWW.UCHEALTH.ORG/BILLING-AND-PRICING/FINANCIAL-ASSISTANCE/ X HTTPS://WWW.UCHEALTH.ORG/BILLING-AND-PRICING/FINANCIAL-ASSISTANCE/ X HTTPS://WWW.UCHEALTH.ORG/BILLING-AND-PRICING/FINANCIAL-ASSISTANCE/ X X X X X X 1 X 0 X X 1 X 0 0 POUDRE VALLEY HEALTH CARE PART V, SECTION B, LINE 5: PVH/MCR COLLABORATED WITH THE LARIMER AND WELD COUNTY HEALTH DEPARTMENTS DURING THEIR MOST RECENT COMMUNITY HEALTH IMPROVEMENT PLANNING PROCESSES. IN NOVEMBER 2017 AND JANUARY 2018, PVH/MCR PARTICIPATED IN COMMUNITY HEALTH SUMMITS DURING WHICH LOCAL HEALTH INDICATOR DATA WAS REVIEWED, AGENCY RESOURCES WERE DESCRIBED (INCLUDING A SPECIFIC PRESENTATION BY PVH/MCR) AND PRIORITY ISSUES FOR ACTION WERE IDENTIFIED. OVER 180 AGENCIES ATTENDED THESE EVENTS, MANY OF WHICH SERVE LOW-INCOME, VULNERABLE POPULATIONS. KELSEY LYON, HEALTH PLANNER AT THE LARIMER COUNTY HEALTH DEPARTMENT AND DR. MARK WALLACE FROM THE WELD COUNTY HEALTH DEPARTMENT WERE THE EVENT ORGANIZERS AND THE MAIN POINTS OF CONTACT FOR PVH/MCR. POUDRE VALLEY HEALTH CARE PART V, SECTION B, LINE 6A: POUDRE VALLEY HOSPITAL (PVH) AND MEDICAL CENTER OF THE ROCKIES (MCR) PREPARED A JOINT CHNA AS BOTH HOSPITALS SERVE RESIDENTS FROM THE SAME GEOGRAPHIC LOCATIONS. POUDRE VALLEY HEALTH CARE PART V, SECTION B, LINE 6B: IN FY19, THE CHNA PROCESS FOR MEDICAL CENTER OF THE ROCKIES (MCR) AND POUDRE VALLEY HOSPITAL (PVH) WAS PREPARED IN CONJUNCTION WITH LARIMER AND WELD COUNTY HEALTH DEPARTMENTS. COMMUNITY-WIDE SUMMITS WERE FACILITATED BY COUNTY HEALTH DEPARTMENT STAFF, WITH MCR AND PVH PROVIDING SUBSTANTIAL INPUT INTO THE PLANNING AND EXECUTION OF THE SUMMITS. THESE SUMMITS INCLUDED APPROXIMATELY 150 REPRESENTATIVES OF COMMUNITY ORGANIZATIONS IN EACH COUNTY WHO ACTIVELY PROVIDED INPUT.FOLLOWING THE COMMUNITY SUMMIT MEETINGS LEADERSHIP TEAMS WERE ESTABLISHED BY THE COUNTY HEALTH DEPARTMENTS, PVH AND MCR TO CONTINUE THE CHNA PROCESS. THIS SMALLER LEADERSHIP TEAM INCLUDED REPRESENTATION BY: CITY OF FORT COLLINS, CITY OF GREELEY, CITY OF LOVELAND, COLORADO SCHOOL OF PUBLIC HEALTH, EARLY CHILDHOOD COUNCIL OF LARIMER COUNTY, HEALTH DISTRICT OF NORTHERN LARIMER COUNTY, LARIMER COUNTY DEPARTMENT OF HEALTH AND ENVIRONMENT, NORTH COLORADO HEALTH ALLIANCE, POUDRE SCHOOL DISTRICT, THOMPSON SCHOOL DISTRICT, THE FAMILY CENTER/LA FAMILIA, LARIMER COUNTY OFFICE ON AGING, NORTH RANGE BEHAVIORAL HEALTH, SUMMITSTONE HEALTH PARTNERS, SUNRISE LOVELAND COMMUNITY HEALTH CENTER, UNITED WAY OF LARIMER AND WELD COUNTIES, WELD COUNTY AREA AGENCY ON AGING, WELD COUNTY DEPARTMENT OF PUBLIC HEALTH, WELD COUNTY SCHOOL DISTRICTS. POUDRE VALLEY HEALTH CARE PART V, SECTION B, LINE 11: EXAMPLES OF HOW PVH/MCR IS ADDRESSING ISSUES RELATED TO ACCESS TO CARE FOR VULNERABLE INDIVIDUALS INCLUDES STAFFING A RN HOME VISIT PROGRAM FOR POSTPARTUM WOMEN WHO ARE ELIGIBLE FOR OR ENROLLED IN MEDICAID. NURSES ASSESS THE NEWBORN, PROVIDE THE MOTHER WITH LACTATION COUNSELING, SELF-CARE GUIDELINES AND ACHIEVE AN INCREASE IN THE MOTHER'S CONFIDENCE TO CARE FOR HER NEWBORN. ADDITIONALLY, COMPREHENSIVE CARE COORDINATION SERVICES ASSIST FAMILIES OF CHILDREN WITH SPECIAL HEALTH CARE NEEDS AS WELL AS VULNERABLE ADULTS WITH MEDICALLY COMPLEX, CHRONIC CONDITIONS. TO IMPROVE ACCESS TO MENTAL HEALTH SERVICES, PVH/MCR IS EXPANDING THE USE OF TECHNOLOGY TO PROVIDE TELE-PSYCH SERVICES TO RESIDENTS WHO ARE NOT ABLE TO ACCESS A LOCAL MENTAL HEALTH PROVIDER OR TO BRIDGE GAPS IN PROVIDER AVAILABILITY. FOR PERSONS WITH SUBSTANCE USE DISORDERS, PVH/MCR DIRECTS RESOURCES TO PROVIDING MEDICALLY ASSISTED ADDICTION TREATMENT AS WELL AS PARTICIPATING IN THE COLORADO ALTERNATIVES TO OPIOIDS TREATMENT PROTOCOLS. INCREASED SCREENING AND REFERRAL TO TREATMENT FOR PERSONS USING ALCOHOL HAS ALSO BEEN IMPLEMENTED. THE FULL SPECTRUM OF SERVICES AND PROGRAMS ADDRESSING IDENTIFIED HEALTH ISSUES IS DESCRIBED IN THE 2020-22 IMPLEMENTATION STRATEGY REPORT POSTED TO THE UCHEALTH WEBSITE: HTTPS://WWW.UCHEALTH.ORG/ABOUT/COMMUNITY-HEALTH-NEEDS-ASSESSMENT/ 7 3 - UCHEALTH HARMONY CAMPUS AMBULATORY CARE CE 2127 E HARMONY RD FORT COLLINS CO 80528 SURGERY CENTER, IMAGING 5 - CENTRE AVE HEALTH AND REHAB - JV 915 CENTRE AVE FORT COLLINS CO 80526 REHAB 8 - SURGERY CENTER OF FT COLLINS - JV 1100 E PROSPECT FORT COLLINS CO 80524 SURGERY CENTER 13 - COLUMBINE POUDRE HOMECARE - JV 915 CENTRE AVE FORT COLLINS CO 80526 HOME HEALTHCARE 15 - THE VEIN AND LASER CENTER - JV 2008 CARIBOU DR FORT COLLINS CO 80525 PHYSICIAN OFFICES 16 - EYE LASER CENTER OF N COLO - JV 1725 E PROSPECT RD FORT COLLINS CO 80525 PHYSICIAN OFFICES 18 - UCHEALTH WATER VALLEY 1870 MARINA PLAZA DRIVE WINDSOR CO 80550 MED FITNESS, REHAB PART I, LINE 7: THE ORGANIZATION USED A COST-TO-CHARGE RATIO FOR LINE 7B AND 7C. THE COST-TO-CHARGE RATIO WAS DERIVED FROM WORKSHEET 2, RATIO OF PATIENT CARE TO COST-TO-CHARGES.LINE 7A WAS DERIVED USING A COST-TO-CHARGE RATIO FROM THE COST REPORT.THE INFORMATION FOR LINES 7E THROUGH 7I WAS DERIVED FROM INFORMATION IN THE GENERAL LEDGER AND OTHER FINANCIAL DATA RELATED SPECIFICALLY TO THE VARIOUS TYPES OF COMMUNITY BENEFITS. PART I, LINE 7G: INCLUDES PHYSICIAN GROUPS AS A SUBSIDIZED SERVICE. THESE CLINICS PROVIDE SERVICES IN UNDERSERVED AREAS IN COLORADO, NEBRASKA AND WYOMING. PART I, LN 7 COL(F): TOTAL BAD DEBT EXPENSE REMOVED FROM THE DENOMINATOR PRIOR TO THE PERCENTAGE CALCULATION = $21,394,598 PART III, LINE 2: ACCOUNTS WITH UNRESOLVED PATIENT LIABILITY AFTER REASONABLE COLLECTION EFFORTS, SET BY POLICY AND IN CONJUNCTION WITH FEDERAL, STATE, AND PAYOR SPECIFIC REGULATIONS, WILL BE ASSIGNED TO BAD DEBT. THESE ACCOUNTS SHALL BE REFERRED TO AN OUTSIDE COLLECTION AGENCY, OR IN SELECTED INSTANCES, ATTORNEYS, FOR ADDITIONAL COLLECTION ACTIVITIES. PART III, LINE 4: PATIENT ACCOUNTS RECEIVABLE ARE REPORTED NET OF ALLOWANCES FOR DOUBTFUL ACCOUNTS, CONTRACTUAL ADJUSTMENTS, AND MEDICALLY INDIGENT ALLOWANCES.PART III, LINE 5: MEDICARE REVENUE WAS COMPUTED AS FOLLOWS:PVHC COST REPORT: $124,624,093CENTER AVE COST REPORT: $3,404,392COLUMBINE HOMECARE COST REPORT: $1,429,725PVHC DISALLOWED PROGRAMS: $2,113,545JOINT VENTURES: $5,809,215TOTAL TO LINE 5: $137,380,970PART III, LINE 6: ALLOWABLE COSTS AS REPORTED ON THE POUDRE VALLEY HEALTH CARE INC. FY19 COST REPORT AGGREGATED WITH DISREGARDED ENTITIES AND OWNERSHIP PORTIONS OF JOINT VENTURES. PART III, LINE 6: MEDICARE ALLOWABLE COSTS OF CARE RELATING TO PAYMENTS WAS COMPUTED AS FOLLOWS:PVHC COST REPORT: $143,228,381CENTRE AVE COST REPORT: $6,129,476COLUMBINE HOMECARE COST REPORT: $1,848,994PVHC DISALLOWED PROGRAMS: $119,132JOINT VENTURES: $6,189,954TOTAL TO LINE 6: $157,515,937 PART III, LINE 8: APPROXIMATELY 27.29% OF NET PATIENT SERVICE REVENUE IS FROM PARTICIPATION IN THE MEDICARE PROGRAM, THUS PROVIDING MEDICARE SERVICES PROMOTES ACCESS TO HEALTHCARE SERVICES TO A SIGNIFICANT PORTION OF THE COMMUNITY POPULATION. PART III, LINE 9B: IF UCHEALTH DETERMINES THAT AN INDIVIDUAL IS ELIGIBLE FOR FINANCIAL ASSISTANCE FOLLOWING UCHEALTH'S REVIEW OF A COMPLETE APPLICATION, UCHEALTH WILL REVERSE ECAS (IF ANY) AND WILL REFUND AMOUNTS PREVIOUSLY PAID FOR CARE COVERED BY THIS POLICY IN EXCESS OF THE AMOUNT OWED, EXCEPT OVERPAYMENTS THAT ARE $5 OR LESS. IF THE GUARANTOR STILL OWES ANY AMOUNT, UCHEALTH WILL PROVIDE AN UPDATED BILLING STATEMENT SHOWING HOW THE ADJUSTED AMOUNT WAS DETERMINED. PART VI, LINE 2: SEE NARATIVES FOR PART V, SECTION B, LINES 5 AND 6B. PART VI, LINE 3: THERE ARE SEVERAL WAYS WE NOTIFY THE PATIENT AND ATTEMPT TO ASSIST THEM. FOR SURGERIES AND HIGH DOLLAR SCHEDULED PROCEDURES, WE PROVIDE THEM WITH AN ESTIMATE AT REGISTRATION AND GO OVER ALL FINANCIAL ASSISTANCE OPTIONS AVAILABLE IF THEY ARE INTERESTED. WE ALSO HAVE FINANCIAL COUNSELORS AVAILABLE EACH DAY THAT CAN ANSWER QUESTIONS AND HELP THEM FILL OUT CHARITY APPLICATIONS. FOR THOSE THAT ARE UNINSURED, OUR CONDITIONS OF SERVICE FORM HAS A SPOT THEY INITIAL STATING THAT WE HAVE OFFERED ASSISTANCE AND MADE THEM AWARE OF PROGRAMS AVAILABLE TO THEM. ONCE A PERSON HAS RECEIVED CARE IN THE ED, WE ALSO HAVE EDUCATED STAFF THAT ASSISTS THEM AND EDUCATES THEM OF WHAT IS AVAILABLE FOR FINANCIAL ASSISTANCE. IN ADDITION, ONCE A PATIENT DOES RECEIVE A STATEMENT OR BILL, THERE IS INFORMATION ON THE BILL OF WHO THEY CAN CALL TO GET INFORMATION ON FINANCIAL ASSISTANCE. PART VI, LINE 4: POUDRE VALLEY HOSPITAL IS A LOCALLY OWNED, PRIVATE, NON-PROFIT ORGANIZATION WITH A STRONG VISION: FROM HEALTHCARE TO HEALTH.BASED IN NORTHERN COLORADO, PVH PROVIDES EVIDENCE-BASED HEALTHCARE AND WELLNESS SERVICES AND PRODUCTS IN COLORADO, NEBRASKA AND WYOMING, ACROSS A SERVICE AREA COVERING MORE THAN 50,000 SQUARE MILES.PVH IS A PART OF THE UCHEALTH WHICH AIMS TO DELIVER THE HIGHEST QUALITY PATIENT CARE WITH THE HIGHEST QUALITY PATIENT EXPERIENCE. THE PARTNERSHIP COMBINES POUDRE VALLEY HOSPITAL, MEDICAL CENTER OF THE ROCKIES, UCHEALTH MEDICAL GROUP, UNIVERSITY OF COLORADO HOSPITAL AND MEMORIAL HEALTH SYSTEM INTO AN ORGANIZATION DEDICATED TO BUILDING HEALTHIER COMMUNITIES AND PROVIDING UNMATCHED PATIENT CARE IN THE ROCKY MOUNTAIN WEST. THE ORGANIZATION'S MISSION IS WE IMPROVE LIVES. IN BIG WAYS THROUGH LEARNING, HEALING AND DISCOVERY. IN SMALL, PERSONAL WAYS THROUGH HUMAN CONNECTION. BUT IN ALL WAYS WE IMPROVE LIVES. PART VI, LINE 5: WE HAVE IMPLEMENTED A MULTITUDE OF PROGRAMS AND SERVICES THAT ADDRESS THE HEALTH NEEDS OF OUR BROADER COMMUNITY TARGETING ALL AGE GROUPS WHILE MAINTAINING A SPECIAL FOCUS ON SERVING VULNERABLE POPULATIONS. WE ALSO GIVE DOLLARS TO OTHER ENTITIES THAT WORK TO IMPROVE THE HEALTH OF OUR COMMUNITY. EXAMPLES ARE: TEEN PREGNANCY PREVENTION EDUCATION; SUBSTANCE ABUSE PREVENTION EDUCATION FOR YOUTH AND YOUNG ADULTS; OBESITY PREVENTION; IMPROVED FOOD SECURITY FOR LOW INCOME RESIDENTS; AND MENTAL HEALTH SERVICES FOR THE UNDERSERVED. PART VI, LINE 6: ALL THE SERVICES WE OFFER ARE AVAILABLE TO ANYONE THAT USES ANY OF OUR FACILITIES IN THE HEALTH SYSTEM. OUR GEOGRAPHY IS NOT THAT LARGE SO WE ARE ABLE TO ACCOMMODATE THE DIFFERENT COMMUNITIES THAT UTILIZE OUR SERVICES WITH THE SAME LEVEL OF COMMUNITY HEALTH PROGRAMMING. PART VI, LINE 7, REPORTS FILED WITH STATES CO 1 CITY OF FORT COLLINS PO BOX 580 FORT COLLINS CO 80522 846000587 GOVERNMENT 30500 SEE SCH I, PART IV COLO NONPROFIT DEVELOPMENT CENTER 789 SHERMAN STREET SUITE 250 DENVER CO 80203 841493585 501(C )(3) 25000 SEE SCH I, PART IV FOOD BANK OF LARIMER COUNTY 1301 BLUE SPRUCE DRIVE FORT COLLINS CO 80524 742336171 501(C )(3) 9940 SEE SCH I, PART IV IVINSON MEMORIAL HOSPITAL FOUNDATION 255 NORTH 30TH STREET LARAMIE WY 82072 836000188 501(C )(3) 9000 SEE SCH I, PART IV LOVELAND CHAMBER OF COMMERCE 5400 STONE CREEK CIRCLE LOVELAND CO 80538 840254565 501(C )(6) 8200 SEE SCH I, PART IV UNITED WAY OF LARIMER COUNTY 424 PINE STREET STE 5 FORT COLLINS CO 80524 846031503 501(C )(3) 24473 SEE SCH I, PART IV PVH FOUNDATION 2315 E HARMONY ROAD 200 FORT COLLINS CO 80528 741894581 501(C )(3) 1304158 SEE SCH I, PART IV UNIVERSITY OF COLORADO SCHOOL OF MEDICINE 13001 E 17TH PL AURORA CO 80045 846000555 GOVERNMENT 5051521 SEE SCH I, PART IV UCHEALTH MEDICAL GROUP 2315 E HARMONY ROAD 200 FORT COLLINS CO 80528 800348943 501(C )(3) 33077455 SEE SCH I, PART IV CHEYENNE REGIONAL MEDICAL CENTER FOUNDATION 214 E 23RD STREET CHEYENNE WY 82001 830236858 501(C )(3) 9250 SEE SCH I, PART IV THE FAMILY CENTERLA FAMILIA 309 HICKORY STREET STE 5 FORT COLLINS CO 80524 841318219 501(C )(3) 5600 SEE SCH I, PART IV 10 1 PART I, LINE 2: THE ORGANIZATION AWARDS GRANTS BASED ON THE BENEFIT TO THE COMMUNITY. THE ORGANIZATION REQUESTS INFORMATION FROM THE GRANTEES TO ENSURE THAT THE FUNDS WILL BE USED FOR THE SPECIFIED PURPOSE. QUESTION I, PART II, COLUMN H PURPOSE OF GRANT OR ASSISTANCE FOR RELATED ENTITIES, THE GRANTS ARE RELATED TO SPECIFIC REQUESTS. THE FUNDS ARE TO BE USED TO BENEFIT THE HEALTHCARE COMMUNITY OF NORTHERN COLORADO. EACH REQUEST IS EVALUATED ON AN INDIVIDUAL BASIS. FOR NON-RELATED COMMUNITY AND GOVERNMENTAL ORGANIZATIONS, THE GRANTS ARE MADE AT THE DISCRETION OF THE ORGANIZATION. THESE DISCRETIONARY GRANTS ARE TO BE USED TO BENEFIT THE HEALTHCARE COMMUNITY OF NORTHERN COLORADO. X X 1 1 X X X X 0 0 0 0 0 0 0 0 0 KEVIN UNGER PRESIDENT/CEO 258350 329638 386604 493279 7446 9500 43189 55106 9498 12119 705087 899642 0 0 STEPHANIE DOUGHTY CHIEF FINANCIAL OFFICER 216991 276866 60184 76791 3177 4054 21698 27685 5506 7025 307556 392421 0 0 STEVE SCHWARTZ INTERIM CFO 0 233186 0 66507 0 2239 0 27561 0 14835 0 344328 0 0 DIANA BREYER CHIEF QUALITY OFFICER 154354 303526 28891 21093 791 578 13064 12291 4319 9933 201419 347421 0 0 THOMAS DOWNES CHIEF MEDICAL OFFICER 224107 163620 63539 46389 3306 2413 23604 17233 10602 7741 325158 237396 0 0 RODNEY GOOD SR DIRECTOR PHARMACY 109622 80035 13162 9609 151 110 10499 7665 13388 9774 146822 107193 0 0 DONNA PODUSKA CHIEF NURSING OFFICER 222381 0 63322 0 5900 0 26112 0 11706 0 329421 0 0 0 GRACE KOWALYSHYN-TAYLOR VP ADMINISTRATION 109259 139407 31321 39963 246 314 12811 16347 11167 14248 164804 210279 0 0 RYAN ROHMAN CHIEF OPERATING OFFICER 111019 141652 31142 39735 227 290 12624 16108 1545 1972 156557 199757 0 0 ROBERT WAGNER JR SR DIRECTOR CARDIOVASCULAR SERVICES 81225 102769 9806 12408 74 94 8471 10719 7777 9839 107353 135829 0 0 JILLIAN BUSCH PSYCHIATRIST 268406 0 6892 0 29760 0 25355 0 20043 0 350456 0 0 0 JOSEPH GOTTFRIED PSYCHIATRIST 264833 0 7051 0 1093 0 25229 0 25383 0 323589 0 0 0 HERMANN MORENO PSYCHIATRIST 290762 0 7516 0 607 0 25355 0 23738 0 347978 0 0 0 KENNETH WATANABE MED DIRECTOR/MTN CREST 295039 0 34933 0 683 0 25355 0 23604 0 379614 0 0 0 JANELL WOZNIAK PROGRAM DIRECTOR/FMC 281733 0 31927 0 417 0 25355 0 18253 0 357685 0 0 0 PART I, LINE 1A GROSS-UP PAYMENTS: GROSS UP PAYROLL IS CALCULATED AT YEAR END FOR SPECIAL CHECKS CREATED TO ADD SPECIFIC ITEMS TO EMPLOYEE'S FORM W-2 WAGES INCLUDING COUNTRY CLUB DUES, SPOUSE TRAVEL FOR ANNUAL BOARD RETREAT AND SELECT CONFERENCES, AND IMPUTED INCOME ON LIFE INSURANCE POLICIES. CLUB DUES: THE HEALTH SYSTEM EXPECTS THE HOSPITAL MANAGEMENT TO PARTICIPATE IN COMMUNITY LIFE AND THEREFORE THE SYSTEM PAYS SOCIAL CLUB DUES FOR SPECIFIC MEMBERS OF THE SENIOR MANAGEMENT GROUP. THE CLUB DUES ARE ADDED TO THE SENIOR MANAGEMENT'S FORM W-2 ON AN ANNUAL BASIS. A UNIVERSITY OF COLORADO HOSPITAL AUTHORITY 2018 SERIES A 841179794 914183BH0 2018-07-26 45915000 REFUNDING 2005A BONDS 0 0 0 B UNIVERSITY OF COLORADO HOSPITAL AUTHORITY 2018 SERIES B 841179794 914183BJ6 2018-07-26 24374400 REFUNDING 2005B BONDS 0 0 0 C UNIVERSITY OF COLORADO HOSPITAL AUTHORITY 2017 SERIES A 841179794 914183BB3 2017-02-16 43493450 REFUNDING 2015A BONDS 0 0 0 D UNIVERISTY OF COLORADO HOSPITAL AUTHORITY 2017 SERIES B1B2 841179794 914183BC1 2017-02-16 44630000 REFUNDING 2015BC BONDS 0 0 0 A 45915000 318692 45596308 2018 1 0 1 1 B 24374400 169360 24205040 2018 1 0 1 1 C 43493450 43493450 2017 1 0 1 1 D 44630000 85278 44544722 2017 1 0 1 1 A 0 1 0 0 0 0 1 B 0 1 0 0 0 0 1 C 0 1 0 0 0 0 1 D 0 1 0 0 0 0 1 A 0 1 0 0 1 1 CITI 21.500000000000 0 0 0 0 1 B 0 1 0 0 1 1 CITI 21.500000000000 0 0 0 0 1 C 0 1 0 0 0 1 CITI 10.000000000000 0 0 0 0 1 D 0 1 0 0 1 0 0 0 1 A 1 B 1 C 1 D 1 A UNIVERISTY OF COLORADO HOSPITAL AUTHORITY 2017 SERIES C1C2 841179794 914183AZ1 2017-02-16 13098078 NEW CONSTRUCTION ON PVH 0 0 0 A 13098078 37902 13060176 2017 0 0 1 1 A 0 1 0 0 0 0 1 A 0 1 0 0 0 0 0 0 1 A 1 X MEDICAL EQUIPMENT 31 533326 FMV 0 1 0 FORM 990, PART I, LINE 6 PVH HAS 476 ACTIVE VOLUNTEERS IN FISCAL YEAR 2019. AT POUDRE VALLEY HOSPITAL, MEDICAL CENTER OF THE ROCKIES, AND OFF-SITE LOCATIONS, VOLUNTEERS PLAY AN INTEGRAL ROLE IN PROVIDING MUCH NEEDED SUPPORT FOR PATIENTS, VISITORS, PHYSICIANS, AND STAFF. FROM ASSISTING IN SURGERY AND CARDIAC WAITING ROOMS, INFORMATION DESK, VOLUNTEER PATIENT LIASONS, BABY KNITTERS, VOLUNTEENS, AND PET THERAPY TO NAME JUST A FEW OF THE MANY PROGRAMS, EVERY VOLUNTEER CONTRIBUTES TO THE SUCCESS OF POUDRE VALLEY HEALTH SYSTEM TO ENHANCE THE COMFORT AND CARE OF THE PATIENTS AND THEIR FAMILIES. FORM 990, PART VI, SECTION B, LINE 11B THE FORM 990 IS PREPARED BY INDEPENDENT CPAS. A PRELIMINARY DRAFT IS REVIEWED BY THE INTERNAL FINANCE DEPARTMENT. THE FINAL COPY OF THE FORM 990 IS PROVIDED IN AN ELECTRONIC FORMAT TO ALL BOARD OF DIRECTORS PRIOR TO FILING WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C THE ORGANIZATION'S CONFLICT OF INTEREST POLICY REQUIRES COMPLETION OF THE FORM ON AN ANNUAL BASIS BY THE BOARD MEMBERS, OFFICERS AND KEY EMPLOYEES OF THE ORGANIZATION. COMPLETED FORMS ARE SUBMITTED AND REVIEWED BY THE INTERNAL COMPLIANCE DEPARTMENT TO ENSURE COMPLIANCE WITH THE WRITTEN POLICY. ANY QUESTIONS OR ULTIMATE ENFORCEMENT WOULD BE HANDLED BY THE COMPLIANCE DEPARTMENT. FORM 990, PART VI, SECTION B, LINE 15 UCHEALTH CONTRACTS WITH SULLIVAN COTTER FOR EXECUTIVE COMPENSATION CONSULTING SERVICES. ON OUR BEHALF, THE SULLIVAN COTTER COLLECTS AND REVIEWS COMPENSATION LEVELS FROM LIKE ORGANIZATIONS FOR LIKE JOBS AND PROVIDES UCHEALTH WITH THE COMPARATIVE MARKET DATA. THE DATA IS SUBMITTED TO THE CHIEF HUMAN RESOURCES OFFICER WHO ADVISES THE SYSTEM PRESIDENT AND CEO ON COMPENSATION DECISIONS FOR SENIOR EXECUTIVES. BASED ON THE MARKET DATA, THE SYSTEM PRESIDENT AND CEO DETERMINE THE SALARY OF THE ENTITY CEO'S COMPENSATION ANNUALLY. FORM 990, PART VI, SECTION C, LINE 19 GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICIES, AND FINANCIAL STATEMENTS ARE PROVIDED TO THE PUBLIC BASED ON THE BUSINESS PURPOSE FOR THE REQUEST. THESE REQUESTS ARE ADDRESSED BY THE SENIOR MANAGEMENT TEAM ON A CASE BY CASE BASIS. FORM 990, PART XI, LINE 9: MCR DISTRIBUTIONS TO PVH 65,778,513. BOOK VS. TAX ADJUSTMENT IN EQUITY EARNINGS 730,220. YAMPA EPIC TRANSFER -471,649. TIMBERLINE MEDICAL CLINIC 131 STANLEY AVE ESTES PARK CO 80517 043772090 OUTPATIENT CO -16785 PVHC INC LAKOTA LAKE LLC 2315 E HARMONY RD STE 200 FORT COLLINS CO 80528 841447761 OUTPATIENT CO 7240206 45798093 PVHC INC HERON LAKE LLC 2315 E HARMONY RD STE 200 FORT COLLINS CO 80528 264189163 OUTPATIENT CO 657338 PVHC INC MEDICAL CENTER OF THE ROCKIES 2315 E HARMONY RD STE 200 FORT COLLINS CO 80528 043730045 TERTIARY CARE CO 501(C)(3) LINE 3 PVHC INC 1 PVHS FOUNDATION 2315 E HARMONY RD STE 200 FORT COLLINS CO 80528 741894581 BENEFIT HEALTH CO 501(C)(3) LINE 7 PVHC INC 1 POUDRE VALLEY MEDICAL GROUP 2315 E HARMONY RD STE 200 FORT COLLINS CO 80528 800348943 MEDICAL SERVICES CO 501(C)(3) LINE 10 PVH INC 1 HARMONY SURGERY CENTER 2127 E HARMONY RD 200 FT COLLINS CO 80528 841479751 AMBULATORY SURG CO N/A RELATED 2590942 3084406 0 0 0.50000 CENTRE AVENUE HEALTH & REHAB FACILITY 947 WORTHINGTON CIRCLE FT COLLINS CO 80526 841560494 NURSING FACILITY CO N/A RELATED -532081 438768 0 0 0.50000 COLUMBINE POUDRE HOME CARE 947 WORTHINGTON CIRCLE FT COLLINS CO 80526 841529817 NURSING CARE CO N/A RELATED 303544 449672 0 0 0.50000 EYE LASER CENTER OF NO COLORADO 1725 E PROSPECT RD FT COLLINS CO 80525 841518334 LASER SURGERY CO N/A UNRELATED 94587 205652 0 0 GATEWAY MEDICAL SERVICES 2500 E PROSPECT RD FT COLLINS CO 80525 841427970 REAL EST/MED CO N/A UNRELATED 7692193 11530842 0 0 0.50000 PVHS HOME MEDICAL SUPPLY 6820 N COUNTY RD 13 LOVELAND CO 80538 202034599 MEDICAL SUPPLY CO N/A UNRELATED -303743 519445 0 1 0.50000 THE VEIN AND LASER CENTER OF NO COLORADO 2008 CARIBOU DRIVE FT COLLINS CO 80525 204943970 MEDICAL SERVICES CO N/A UNRELATED 14667 45951 0 0 0.33330 HARMONY IMAGING CENTER 1951 WILMINGTON DRIVE FT COLLINS CO 80528 582479187 MEDICAL IMAGING CO N/A RELATED 797369 1679813 0 0 0.46000 SURGERY CENTER OF FORT COLLINS 1100 E PROSPECT ROAD FT COLLINS CO 80525 841541559 SURGICAL PROC CO N/A UNRELATED 155036 953704 0 0 0.26000 OCR LOVELAND 2500 E PROSPECT RD FT COLLINS CO 80525 301069701 AMBULATORY SURG CO N/A UNRELATED 0 0 0.10000 PVHS-ICM EHW 2315 E HARMONY RD STE 200 FT COLLINS CO 80528 463311308 MEDICAL SERVICES CO N/A RELATED 97035 585462 0 0 0.50000 PEAK SURGICAL MANAGEMENT 2127 E HARMONY RD 200 FT COLLINS CO 80528 260899618 SURGICAL MGMT CO N/A UNRELATED 177604 106121 0 0 0.14290 INNOVATION ENTERPRISES 2315 E HARMONY RD STE 200 FORT COLLINS CO 80528 202036774 IT CONSULTING CO PVHC C 36007 1638940 1.00000 1 1 1 1 1 0 0 1 1 0 1 0 1 1 1 1 1 1 0 1 MEDICAL CENTER OF THE ROCKIES S 65778513 TRANSACTION TOTAL POUDRE VALLEY MEDICAL GROUP LLC B 33077455 TRANSACTION TOTAL MEDICAL CENTER OF THE ROCKIES L 9848194 TRANSACTION TOTAL GATEWAY MEDICAL SERVICES S 7836454 TRANSACTION TOTAL POUDRE VALLEY MEDICAL GROUP LLC M 5163672 TRANSACTION TOTAL POUDRE VALLEY MEDICAL GROUP LLC L 4581199 TRANSACTION TOTAL MEDICAL CENTER OF THE ROCKIES N 2790933 TRANSACTION TOTAL HARMONY SURGERY CENTER S 2375000 TRANSACTION TOTAL POUDRE VALLEY MEDICAL GROUP LLC J 2134677 TRANSACTION TOTAL POUDRE VALLEY MEDICAL GROUP LLC N 2008113 TRANSACTION TOTAL PVHS FOUNDATION B 1304158 TRANSACTION TOTAL HARMONY SURGERY CENTER A 1011365 TRANSACTION TOTAL CENTRE AVENUE HEALTH AND REHAB B 936116 TRANSACTION TOTAL UCHEALTH NORTHERN REGION FOUNDATION C 842274 TRANSACTION TOTAL HARMONY SURGERY CENTER Q 654446 TRANSACTION TOTAL MEDICAL CENTER OF THE ROCKIES H 367829 TRANSACTION TOTAL INNOVATION ENTERPRISES A 276436 TRANSACTION TOTAL COLUMBINE POUDRE HOMECARE S 200000 TRANSACTION TOTAL EYE LASER CENTER OF NO COLO S 166255 TRANSACTION TOTAL EYE LASER CENTER OF NO COLO M 141737 TRANSACTION TOTAL INNOVATION ENTERPRISES A 118042 TRANSACTION TOTAL INNOVATION ENTERPRISES S 55815 TRANSACTION TOTAL