CHEYENNE COUNTY HOSPITAL ASSOCIATION INC: Form 990, tax year 2018

View the entire original 990 at ProPublica ↗

Organization: CHEYENNE COUNTY HOSPITAL ASSOCIATION INC (EIN 47-0408242)
Tax period: 2018-01-01 to 2018-12-31
Filed: 2019-11-13
IRS object ID: 201943179349302654
Schema version: 2018v3.1
Source: Download XML · Original 990 at ProPublica

Every field in the e-filed return. Faint text is the IRS element name, for citing.

Return header
Form 990
Schedule A
Schedule B
Schedule C
Schedule D
Schedule H
Schedule I
Schedule J
Schedule K
Schedule L
Schedule O
Schedule R

Return header ReturnHeader

Field	Value	IRS element (for citing)
Return	2019-11-13T09:55:44-06:00	ReturnTs
Tax Period End	2018-12-31	TaxPeriodEndDt

Preparer Firm PreparerFirmGrp

Field	Value	IRS element (for citing)
Preparer Firm EIN	476097913	PreparerFirmEIN

Preparer Firm Name PreparerFirmName

Field	Value	IRS element (for citing)
Business Name Line1	SEIM JOHNSON LLP	BusinessNameLine1Txt

Preparer US Address PreparerUSAddress

Field	Value	IRS element (for citing)
Address Line1	18081 BURT STREET SUITE 200	AddressLine1Txt
City	OMAHA	CityNm
State Abbreviation	NE	StateAbbreviationCd
ZIP	680224722	ZIPCd

Field	Value	IRS element (for citing)
Return Type	990	ReturnTypeCd
Tax Period Begin	2018-01-01	TaxPeriodBeginDt

Filer Filer

Field	Value	IRS element (for citing)
EIN	470408242	EIN

Business Name BusinessName

Field	Value	IRS element (for citing)
Business Name Line1	CHEYENNE COUNTY HOSPITAL	BusinessNameLine1Txt
Business Name Line2	ASSOCIATION INC	BusinessNameLine2Txt

Field	Value	IRS element (for citing)
Business Name Control	CHEY	BusinessNameControlTxt
Phone	3082545825	PhoneNum

US Address USAddress

Field	Value	IRS element (for citing)
Address Line1	1000 POLE CREEK CROSSING	AddressLine1Txt
City	SIDNEY	CityNm
State Abbreviation	NE	StateAbbreviationCd
ZIP	691620000	ZIPCd

Business Officer BusinessOfficerGrp

Field	Value	IRS element (for citing)
Person	JASON PETIK	PersonNm
Person Title	CEO	PersonTitleTxt
Phone	3082545825	PhoneNum
Signature	2019-11-05	SignatureDt
Discuss With Paid Preparer	Yes (1)	DiscussWithPaidPreparerInd

Preparer Person PreparerPersonGrp

Field	Value	IRS element (for citing)
Preparer Person	WENDY R COOLEY	PreparerPersonNm
PTIN	P01523804	PTIN
Phone	4023302660	PhoneNum

Filing Security Information FilingSecurityInformation

IP Address IPAddress

Field	Value	IRS element (for citing)
I Pv4 Address	209.34.201.180	IPv4AddressTxt

Field	Value	IRS element (for citing)
IP	2019-11-05	IPDt
IP Tm	16:10:26	IPTm
IP Timezone	CS	IPTimezoneCd
Filing License Type	P	FilingLicenseTypeCd
At Submission Creation Device Id	5D066E2939FE45487034BD10C4A0DC94BE27FEF9	AtSubmissionCreationDeviceId
At Submission Filing Device Id	5D066E2939FE45487034BD10C4A0DC94BE27FEF9	AtSubmissionFilingDeviceId

Field	Value	IRS element (for citing)
Tax	2018	TaxYr
Build TS	2020-03-31 21:24:44Z	BuildTS

Form 990 IRS990

Doing Business As Name DoingBusinessAsName

Field	Value	IRS element (for citing)
Business Name Line1	SIDNEY REGIONAL MEDICAL CENTER	BusinessNameLine1Txt

Field	Value	IRS element (for citing)
Principal Officer	JASON PETIK	PrincipalOfficerNm

US Address USAddress

Field	Value	IRS element (for citing)
Address Line1	1000 POLE CREEK CROSSING	AddressLine1Txt
City	SIDNEY	CityNm
State Abbreviation	NE	StateAbbreviationCd
ZIP	691620000	ZIPCd

Field	Value	IRS element (for citing)
Gross Receipts	$55,311,830	GrossReceiptsAmt
Group Return For Affiliates	0	GroupReturnForAffiliatesInd
Organization501c3	Yes (X)	Organization501c3Ind
Website Address	WWW.SIDNEYRMC.COM	WebsiteAddressTxt
Type Of Organization Corp	Yes (X)	TypeOfOrganizationCorpInd
Formation	1951	FormationYr
Legal Domicile State	NE	LegalDomicileStateCd
Activity Or Mission	TO REVOLUTIONIZE HEALTHCARE SERVICES IN THE REGION.	ActivityOrMissionDesc
Voting Members Governing Body	13	VotingMembersGoverningBodyCnt
Voting Members Independent	11	VotingMembersIndependentCnt
Total Employee	501	TotalEmployeeCnt
Total Volunteers	100	TotalVolunteersCnt
Total Gross UBI	$0	TotalGrossUBIAmt
Net Unrelated Bus Txbl Incm	$0	NetUnrelatedBusTxblIncmAmt
PY Contributions Grants	$16,387	PYContributionsGrantsAmt
CY Contributions Grants	$81,684	CYContributionsGrantsAmt
PY Program Service Revenue	$55,594,969	PYProgramServiceRevenueAmt
CY Program Service Revenue	$54,638,831	CYProgramServiceRevenueAmt
PY Investment Income	$82,317	PYInvestmentIncomeAmt
CY Investment Income	$448,505	CYInvestmentIncomeAmt
PY Other Revenue	$136,711	PYOtherRevenueAmt
CY Other Revenue	$131,327	CYOtherRevenueAmt
PY Total Revenue	$55,830,384	PYTotalRevenueAmt
CY Total Revenue	$55,300,347	CYTotalRevenueAmt
PY Grants And Similar Paid	$20,254	PYGrantsAndSimilarPaidAmt
CY Grants And Similar Paid	$7,500	CYGrantsAndSimilarPaidAmt
PY Benefits Paid To Members	$0	PYBenefitsPaidToMembersAmt
CY Benefits Paid To Members	$0	CYBenefitsPaidToMembersAmt
PY Salaries Comp Emp Bnft Paid	$29,376,815	PYSalariesCompEmpBnftPaidAmt
CY Salaries Comp Emp Bnft Paid	$29,870,405	CYSalariesCompEmpBnftPaidAmt
PY Total Prof Fndrsng Expns	$0	PYTotalProfFndrsngExpnsAmt
CY Total Prof Fndrsng Expns	$0	CYTotalProfFndrsngExpnsAmt
CY Total Fundraising Expense	$0	CYTotalFundraisingExpenseAmt
PY Other Expenses	$25,000,358	PYOtherExpensesAmt
CY Other Expenses	$25,926,902	CYOtherExpensesAmt
PY Total Expenses	$54,397,427	PYTotalExpensesAmt
CY Total Expenses	$55,804,807	CYTotalExpensesAmt
PY Revenues Less Expenses	$1,432,957	PYRevenuesLessExpensesAmt
CY Revenues Less Expenses	-$504,460	CYRevenuesLessExpensesAmt
Total Assets BOY	$87,596,964	TotalAssetsBOYAmt
Total Assets EOY	$85,551,950	TotalAssetsEOYAmt
Total Liabilities BOY	$45,592,963	TotalLiabilitiesBOYAmt
Total Liabilities EOY	$44,443,156	TotalLiabilitiesEOYAmt
Net Assets Or Fund Balances BOY	$42,004,001	NetAssetsOrFundBalancesBOYAmt
Net Assets Or Fund Balances EOY	$41,108,794	NetAssetsOrFundBalancesEOYAmt
Info In Schedule O Part III	Yes (X)	InfoInScheduleOPartIIIInd
Mission	TO REVOLUTIONIZE HEALTHCARE SERVICES IN THE REGION.	MissionDesc
Significant New Program Srvc	0	SignificantNewProgramSrvcInd
Significant Change	0	SignificantChangeInd
Expense	$36,407,034	ExpenseAmt
Grant	$7,500	GrantAmt
Revenue	$42,526,104	RevenueAmt
Desc	SIDNEY REGIONAL MEDICAL CENTER IS A NOT-FOR-PROFIT ACUTE CARE HOSPITAL WHICH PROVIDES INPATIENT, OUTPATIENT AND EMERGENCY ROOM CARE SERVICE TO PATIENTS IN SIDNEY, NEBRASKA. IT ALSO OPERATES LONG-TERM CARE FACILITIES, A HOME HEALTH AGENCY, AND PROVIDER-BASED RURAL HEALTH CLINICS IN SIDNEY, NEBRASKA AND CHAPPELL, NEBRASKA, AS WELL AS A STAND ALONE PRIMARY CARE CLINIC IN SIDNEY, NEBRASKA.	Desc

Prog Srvc Accom Acty2 ProgSrvcAccomActy2Grp

Field	Value	IRS element (for citing)
Expense	$5,152,744	ExpenseAmt
Revenue	$7,689,465	RevenueAmt
Desc	IN 2018, THE HOSPITAL NURSING DEPARTMENT PROVIDED 1,965 PATIENT DAYS OF CARE, INCLUDING GENERAL INPATIENT, ICU PATIENTS AND SWING BED PATIENTS, AND DELIVERED 36 NEWBORNS FOR THE SEVEN COUNTY AREA THAT SIDNEY REGIONAL MEDICAL CENTER (SRMC) SERVES. SRMC HAD 3,510 PATIENTS SEEK CARE IN THE EMERGENCY DEPARTMENT DURING 2018 AND CARED FOR 373 OBSERVATION PATIENTS.	Desc

Prog Srvc Accom Acty3 ProgSrvcAccomActy3Grp

Field	Value	IRS element (for citing)
Expense	$4,615,257	ExpenseAmt
Revenue	$4,423,262	RevenueAmt
Desc	THE EXTENDED CARE UNIT PROVIDED CARE FOR AN AVERAGE OF 48 PATIENTS DAILY DURING 2018. SRMC PROVIDED 17,960 PATIENT DAYS OF CARE FOR RESIDENTS FROM THE CHEYENNE, DEUEL, KIMBALL AND SURROUNDING AREAS.	Desc

Prog Srvc Accom Acty Other ProgSrvcAccomActyOtherGrp

Field	Value	IRS element (for citing)
Desc	THE SRMC PHARMACY DEPARTMENT HAS BEEN ACTIVELY INVOLVED WITH THE QUALITY OF CARE PROVIDED TO ALL PATIENTS BOTH IN THE ACUTE AND OUT PATIENT SETTINGS. THE PHARMACY DEPARTMENT HAS HELPED PROVIDE CARE FOR THOSE INDIVIDUALS WITH THE TREATMENT FOR RADIATION OR CHEMOTHERAPY.	Desc

Field	Value	IRS element (for citing)
Total Program Service Expenses	$46,175,035	TotalProgramServiceExpensesAmt
Described In Section501c3	Yes (1)	DescribedInSection501c3Ind
Schedule B Required	Yes (1)	ScheduleBRequiredInd
Political Campaign Acty	0	PoliticalCampaignActyInd
Lobbying Activities	Yes (1)	LobbyingActivitiesInd
Subject To Proxy Tax	0	SubjectToProxyTaxInd
Donor Advised Fund	0	DonorAdvisedFundInd
Conservation Easements	0	ConservationEasementsInd
Collections Of Art	0	CollectionsOfArtInd
Credit Counseling	0	CreditCounselingInd
Temp Or Permanent Endowments	0	TempOrPermanentEndowmentsInd
Report Land Building Equipment	Yes (1)	ReportLandBuildingEquipmentInd
Report Investments Other Sec	0	ReportInvestmentsOtherSecInd
Report Program Related Invst	0	ReportProgramRelatedInvstInd
Report Other Assets	0	ReportOtherAssetsInd
Report Other Liabilities	Yes (1)	ReportOtherLiabilitiesInd
Include FIN48 Footnote	Yes (1)	IncludeFIN48FootnoteInd
Independent Audit Fincl Stmt	0	IndependentAuditFinclStmtInd
Consolidated Audit Fincl Stmt	Yes (1)	ConsolidatedAuditFinclStmtInd
School Operating	0	SchoolOperatingInd
Foreign Office	0	ForeignOfficeInd
Foreign Activities	0	ForeignActivitiesInd
More Than5000 K To Org	0	MoreThan5000KToOrgInd
More Than5000 K To Individuals	0	MoreThan5000KToIndividualsInd
Professional Fundraising	0	ProfessionalFundraisingInd
Fundraising Activities	0	FundraisingActivitiesInd
Gaming Activities	0	GamingActivitiesInd
Operate Hospital	Yes (1)	OperateHospitalInd
Audited Financial Stmt Att	Yes (1)	AuditedFinancialStmtAttInd
Grants To Organizations	Yes (1)	GrantsToOrganizationsInd
Grants To Individuals	0	GrantsToIndividualsInd
Schedule J Required	Yes (1)	ScheduleJRequiredInd
Tax Exempt Bonds	Yes (1)	TaxExemptBondsInd
Invest Tax Exempt Bonds	0	InvestTaxExemptBondsInd
Escrow Account	0	EscrowAccountInd
On Behalf Of Issuer	0	OnBehalfOfIssuerInd
Engaged In Excess Benefit Trans	0	EngagedInExcessBenefitTransInd
PY Excess Benefit Trans	0	PYExcessBenefitTransInd
Loan Outstanding	0	LoanOutstandingInd
Grant To Related Person	0	GrantToRelatedPersonInd
Business Rln With Org Mem	0	BusinessRlnWithOrgMemInd
Business Rln With Fam Mem	Yes (1)	BusinessRlnWithFamMemInd
Business Rln With Officer Ent	0	BusinessRlnWithOfficerEntInd
Deductible Non Cash Contri	0	DeductibleNonCashContriInd
Deductible Art Contribution	0	DeductibleArtContributionInd
Terminate Operations	0	TerminateOperationsInd
Partial Liquidation	0	PartialLiquidationInd
Disregarded Entity	0	DisregardedEntityInd
Related Entity	Yes (1)	RelatedEntityInd
Related Organization Ctrl Ent	0	RelatedOrganizationCtrlEntInd
Trnsfr Exmpt Non Chrtbl Rltd Org	0	TrnsfrExmptNonChrtblRltdOrgInd
Activities Conducted Prtshp	0	ActivitiesConductedPrtshpInd
Schedule O Required	Yes (1)	ScheduleORequiredInd
IRP Document	82	IRPDocumentCnt
IRP Document W2 G	0	IRPDocumentW2GCnt
Backup Wthld Compliance	Yes (1)	BackupWthldComplianceInd
Employee	501	EmployeeCnt
Employment Tax Returns Filed	Yes (1)	EmploymentTaxReturnsFiledInd
Unrelated Bus Incm Over Limit	0	UnrelatedBusIncmOverLimitInd
Foreign Financial Account	0	ForeignFinancialAccountInd
Prohibited Tax Shelter Trans	0	ProhibitedTaxShelterTransInd
Taxable Party Notification	0	TaxablePartyNotificationInd
Nondeductible Contributions	0	NondeductibleContributionsInd
Quid Pro Quo Contributions	0	QuidProQuoContributionsInd
Form8282 Property Disposed Of	0	Form8282PropertyDisposedOfInd
Rcv Fnds To Pay Prsnl Bnft Cntrct	0	RcvFndsToPayPrsnlBnftCntrctInd
Pay Premiums Prsnl Bnft Cntrct	0	PayPremiumsPrsnlBnftCntrctInd
Indoor Tanning Services	0	IndoorTanningServicesInd
Subj To Tax Rmnrtn Ex Prcht Pymt	0	SubjToTaxRmnrtnExPrchtPymtInd
Subject To Excs Tax Net Invst Inc	0	SubjectToExcsTaxNetInvstIncInd
Info In Schedule O Part VI	Yes (X)	InfoInScheduleOPartVIInd
Governing Body Voting Members	13	GoverningBodyVotingMembersCnt
Independent Voting Member	11	IndependentVotingMemberCnt
Family Or Business Rln	0	FamilyOrBusinessRlnInd
Delegation Of Mgmt Duties	Yes (1)	DelegationOfMgmtDutiesInd
Change To Org Documents	0	ChangeToOrgDocumentsInd
Material Diversion Or Misuse	0	MaterialDiversionOrMisuseInd
Members Or Stockholders	0	MembersOrStockholdersInd
Election Of Board Members	0	ElectionOfBoardMembersInd
Decisions Subject To Approva	0	DecisionsSubjectToApprovaInd
Minutes Of Governing Body	Yes (1)	MinutesOfGoverningBodyInd
Minutes Of Committees	Yes (1)	MinutesOfCommitteesInd
Officer Mailing Address	0	OfficerMailingAddressInd
Local Chapters	0	LocalChaptersInd
Form990 Provided To Gvrn Body	0	Form990ProvidedToGvrnBodyInd
Conflict Of Interest Policy	Yes (1)	ConflictOfInterestPolicyInd
Annual Disclosure Covered Prsn	Yes (1)	AnnualDisclosureCoveredPrsnInd
Regular Monitoring Enfrc	Yes (1)	RegularMonitoringEnfrcInd
Whistleblower Policy	Yes (1)	WhistleblowerPolicyInd
Document Retention Policy	Yes (1)	DocumentRetentionPolicyInd
Compensation Process CEO	Yes (1)	CompensationProcessCEOInd
Compensation Process Other	Yes (1)	CompensationProcessOtherInd
Investment In Joint Venture	0	InvestmentInJointVentureInd
Upon Request	Yes (X)	UponRequestInd

Books In Care Of Detail BooksInCareOfDetail

Business Name BusinessName

Field	Value	IRS element (for citing)
Business Name Line1	KELLY UTLEY	BusinessNameLine1Txt

Field	Value	IRS element (for citing)
Phone	3082545825	PhoneNum

US Address USAddress

Field	Value	IRS element (for citing)
Address Line1	1000 POLE CREEK CROSSING	AddressLine1Txt
City	SIDNEY	CityNm
State Abbreviation	NE	StateAbbreviationCd
ZIP	69162	ZIPCd

Field	Value	IRS element (for citing)
Info In Schedule O Part VII	Yes (X)	InfoInScheduleOPartVIIInd

Form990 Part VII Section A Form990PartVIISectionAGrp (20 entries)

TitleTitleTxt	Average Hours Per WeekAverageHoursPerWeekRt	Average Hours Per Week Rltd OrgAverageHoursPerWeekRltdOrgRt	Individual Trustee Or DirectorIndividualTrusteeOrDirectorInd	OfficerOfficerInd	Reportable Comp From OrgReportableCompFromOrgAmt	Reportable Comp From Rltd OrgReportableCompFromRltdOrgAmt	Other CompensationOtherCompensationAmt	Highest Compensated EmployeeHighestCompensatedEmployeeInd
WILLIAM PILE
CHAIRMAN	4.00	0.00	Yes (X)	Yes (X)	$0	$0	$0
TIM MILLER
VICE CHAIRMAN	4.00	0.00	Yes (X)	Yes (X)	$0	$0	$0
JEFF ELLWANGER
TREASURER	4.00	0.00	Yes (X)	Yes (X)	$0	$0	$0
KATHY NARJES
SECRETARY	4.00	0.00	Yes (X)	Yes (X)	$0	$0	$0
STAN BELIEU
MEMBER	4.00	1.00	Yes (X)		$0	$0	$0
REBECCA L ALLARD MD
MEMBER -PHYSICIAN AT LARGE	40.00	0.00	Yes (X)		$549,668	$0	$57,938
MATTHEW JANSEN MD
MEMBER -CHIEF OF STAFF	40.00	0.00	Yes (X)		$722,516	$0	$56,017
TIM HENRY
MEMBER	4.00	0.00	Yes (X)		$0	$0	$0
JIM JONES
MEMBER	4.00	0.00	Yes (X)		$0	$0	$0
ROB ROBINSON
MEMBER	4.00	0.00	Yes (X)		$0	$0	$0
DWIGHT SMITH
MEMBER	4.00	0.00	Yes (X)		$0	$0	$0
RON SPATH
MEMBER	4.00	0.00	Yes (X)		$0	$0	$0
NANCI MCCASLIN
MEMBER	4.00	1.00	Yes (X)		$0	$0	$0
JASON PETIK
CEO	40.00	0.00		Yes (X)	$0	$0	$0
KELLY UTLEY
CFO	39.00	1.00		Yes (X)	$172,092	$0	$8,605
JAMES THAYER MD
DOCTOR	40.00	0.00			$314,482	$0	$39,388	Yes (X)
JENNIFER BROWN MD
DOCTOR (THRU 8/2018)	40.00	0.00			$347,233	$0	$0	Yes (X)
ROBERT GRAVES MD
DOCTOR	40.00	0.00			$271,859	$0	$51,128	Yes (X)
THERESA SIMMONS
CRNA	40.00	0.00			$276,167	$0	$44,188	Yes (X)
ANGELA HARTZLER
CRNA	40.00	0.00			$250,031	$0	$56,089	Yes (X)

Field	Value	IRS element (for citing)
Total Reportable Comp From Org	$2,904,048	TotalReportableCompFromOrgAmt
Tot Reportable Comp Rltd Org	$0	TotReportableCompRltdOrgAmt
Total Other Compensation	$313,353	TotalOtherCompensationAmt
Indiv Rcvd Greater Than100 K	39	IndivRcvdGreaterThan100KCnt
Former Ofcr Employees Listed	0	FormerOfcrEmployeesListedInd
Total Comp Greater Than150 K	Yes (1)	TotalCompGreaterThan150KInd
Compensation From Other Srcs	Yes (1)	CompensationFromOtherSrcsInd

Contractor Compensation ContractorCompensationGrp (5 entries)

Address Line1ContractorAddress/USAddress/AddressLine1Txt	CityContractorAddress/USAddress/CityNm	State AbbreviationContractorAddress/USAddress/StateAbbreviationCd	ZIPContractorAddress/USAddress/ZIPCd	ServicesServicesDesc	CompensationCompensationAmt
RURAL PARTNERS IN MEDICINE LLC
11880 AIRPORT WAY	BROOMFIELD	CO	80021	PHYSICIAN SERVICES	$2,190,724
PRIME TIME HEALTHCARE LLC
PO BOX 3544	OMAHA	NE	68103	TEMPORARY STAFFING	$556,123
BYTES COMPUTER & NETWORK SOLUTIONS INC
1620 BROADWAY STE D	SCOTTSBLUFF	NE	69361	IT SERVICES	$555,118
DOCS WHO CARE
800 W FRONTIER LANE	OLATHE	NE	66061	PHYSICIAN SERVICES	$417,015
POUDRE VALLEY HEALTHCARE INC
PO BOX 732033	DALLAS	TX	75373	MANAGEMENT SERVICES	$281,185

Field	Value	IRS element (for citing)
Cntrct Rcvd Greater Than100 K	16	CntrctRcvdGreaterThan100KCnt
Related Organizations	$7,970	RelatedOrganizationsAmt
All Other Contributions	$73,714	AllOtherContributionsAmt
Total Contributions	$81,684	TotalContributionsAmt

Program Service Revenue ProgramServiceRevenueGrp (4 entries)

DescDesc	BusinessBusinessCd	Total Revenue ColumnTotalRevenueColumnAmt	Related Or Exempt Func IncomeRelatedOrExemptFuncIncomeAmt
NET PATIENT SERVICE REVENUE	621110	$29,384,288	$29,384,288
MEDICARE/MEDICAID	621110	$24,108,511	$24,108,511
340B REVENUE	621110	$696,641	$696,641
SCHOOL REHAB REVENUE	621110	$89,615	$89,615

Total Oth Program Service Rev TotalOthProgramServiceRevGrp

Field	Value	IRS element (for citing)
Total Revenue Column	$359,776	TotalRevenueColumnAmt
Related Or Exempt Func Income	$359,776	RelatedOrExemptFuncIncomeAmt

Field	Value	IRS element (for citing)
Total Program Service Revenue	$54,638,831	TotalProgramServiceRevenueAmt

Investment Income InvestmentIncomeGrp

Field	Value	IRS element (for citing)
Total Revenue Column	$371,012	TotalRevenueColumnAmt
Exclusion	$371,012	ExclusionAmt

Gross Amount Sales Assets GrossAmountSalesAssetsGrp

Field	Value	IRS element (for citing)
Other	$88,976	OtherAmt

Less Cost Oth Basis Sales Expnss LessCostOthBasisSalesExpnssGrp

Field	Value	IRS element (for citing)
Other	$11,483	OtherAmt

Gain Or Loss GainOrLossGrp

Field	Value	IRS element (for citing)
Other	$77,493	OtherAmt

Net Gain Or Loss Investments NetGainOrLossInvestmentsGrp

Field	Value	IRS element (for citing)
Total Revenue Column	$77,493	TotalRevenueColumnAmt
Exclusion	$77,493	ExclusionAmt

Other Revenue Misc OtherRevenueMiscGrp (2 entries)

DescDesc	BusinessBusinessCd	Total Revenue ColumnTotalRevenueColumnAmt	ExclusionExclusionAmt
CAFETERIA	722210	$130,936	$130,936
PATRONAGE DIVIDEND	900099	$391	$391

Field	Value	IRS element (for citing)
Other Revenue Total	$131,327	OtherRevenueTotalAmt

Total Revenue TotalRevenueGrp

Field	Value	IRS element (for citing)
Total Revenue Column	$55,300,347	TotalRevenueColumnAmt
Related Or Exempt Func Income	$54,638,831	RelatedOrExemptFuncIncomeAmt
Unrelated Business Revenue	$0	UnrelatedBusinessRevenueAmt
Exclusion	$579,832	ExclusionAmt

Field	Value	IRS element (for citing)
Info In Schedule O Part IX	Yes (X)	InfoInScheduleOPartIXInd

Grants To Domestic Orgs GrantsToDomesticOrgsGrp

Field	Value	IRS element (for citing)
Total	$7,500	TotalAmt
Program Services	$7,500	ProgramServicesAmt

Comp Current Ofcr Directors CompCurrentOfcrDirectorsGrp

Field	Value	IRS element (for citing)
Total	$1,566,836	TotalAmt
Program Services	$1,386,139	ProgramServicesAmt
Management And General	$180,697	ManagementAndGeneralAmt

Comp Disqual Persons CompDisqualPersonsGrp

Field	Value	IRS element (for citing)
Total	$109,063	TotalAmt
Management And General	$109,063	ManagementAndGeneralAmt

Other Salaries And Wages OtherSalariesAndWagesGrp

Field	Value	IRS element (for citing)
Total	$21,366,712	TotalAmt
Program Services	$19,706,871	ProgramServicesAmt
Management And General	$1,659,841	ManagementAndGeneralAmt

Pension Plan Contributions PensionPlanContributionsGrp

Field	Value	IRS element (for citing)
Total	$714,029	TotalAmt
Program Services	$664,109	ProgramServicesAmt
Management And General	$49,920	ManagementAndGeneralAmt

Other Employee Benefits OtherEmployeeBenefitsGrp

Field	Value	IRS element (for citing)
Total	$4,595,512	TotalAmt
Program Services	$273,849	ProgramServicesAmt
Management And General	$4,321,663	ManagementAndGeneralAmt

Payroll Taxes PayrollTaxesGrp

Field	Value	IRS element (for citing)
Total	$1,518,253	TotalAmt
Program Services	$1,388,541	ProgramServicesAmt
Management And General	$129,712	ManagementAndGeneralAmt

Fees For Services Management FeesForServicesManagementGrp

Field	Value	IRS element (for citing)
Total	$251,393	TotalAmt
Management And General	$251,393	ManagementAndGeneralAmt

Fees For Services Legal FeesForServicesLegalGrp

Field	Value	IRS element (for citing)
Total	$64,867	TotalAmt
Management And General	$64,867	ManagementAndGeneralAmt

Fees For Services Accounting FeesForServicesAccountingGrp

Field	Value	IRS element (for citing)
Total	$40,867	TotalAmt
Management And General	$40,867	ManagementAndGeneralAmt

Fees For Srvc Invst Mgmnt Fees FeesForSrvcInvstMgmntFeesGrp

Field	Value	IRS element (for citing)
Total	$65,810	TotalAmt
Management And General	$65,810	ManagementAndGeneralAmt

Fees For Services Other FeesForServicesOtherGrp

Field	Value	IRS element (for citing)
Total	$7,527,300	TotalAmt
Program Services	$7,273,387	ProgramServicesAmt
Management And General	$253,913	ManagementAndGeneralAmt

Advertising AdvertisingGrp

Field	Value	IRS element (for citing)
Total	$301,326	TotalAmt
Management And General	$301,326	ManagementAndGeneralAmt

Office Expenses OfficeExpensesGrp

Field	Value	IRS element (for citing)
Total	$1,081,385	TotalAmt
Program Services	$883,120	ProgramServicesAmt
Management And General	$198,265	ManagementAndGeneralAmt

Information Technology InformationTechnologyGrp

Field	Value	IRS element (for citing)
Total	$1,260,629	TotalAmt
Program Services	$1,115,204	ProgramServicesAmt
Management And General	$145,425	ManagementAndGeneralAmt

Occupancy OccupancyGrp

Field	Value	IRS element (for citing)
Total	$1,022,115	TotalAmt
Program Services	$977,856	ProgramServicesAmt
Management And General	$44,259	ManagementAndGeneralAmt

Travel TravelGrp

Field	Value	IRS element (for citing)
Total	$174,787	TotalAmt
Program Services	$150,258	ProgramServicesAmt
Management And General	$24,529	ManagementAndGeneralAmt

Conferences Meetings ConferencesMeetingsGrp

Field	Value	IRS element (for citing)
Total	$16,167	TotalAmt
Management And General	$16,167	ManagementAndGeneralAmt

Interest InterestGrp

Field	Value	IRS element (for citing)
Total	$1,288,960	TotalAmt
Management And General	$1,288,960	ManagementAndGeneralAmt

Depreciation Depletion DepreciationDepletionGrp

Field	Value	IRS element (for citing)
Total	$5,020,014	TotalAmt
Program Services	$4,680,167	ProgramServicesAmt
Management And General	$339,847	ManagementAndGeneralAmt

Insurance InsuranceGrp

Field	Value	IRS element (for citing)
Total	$353,257	TotalAmt
Program Services	$337,578	ProgramServicesAmt
Management And General	$15,679	ManagementAndGeneralAmt

Other Expenses OtherExpensesGrp (4 entries)

DescDesc	TotalTotalAmt	Program ServicesProgramServicesAmt	Management And GeneralManagementAndGeneralAmt
MEDICAL SUPPLIES	$5,382,467	$5,382,467
BAD DEBTS	$1,442,254	$1,442,254
FOOD PRODUCTS	$378,178	$378,178
DUES AND SUBSCRIPTIONS	$124,109	$48,771	$75,338

All Other Expenses AllOtherExpensesGrp

Field	Value	IRS element (for citing)
Total	$131,017	TotalAmt
Program Services	$78,786	ProgramServicesAmt
Management And General	$52,231	ManagementAndGeneralAmt

Total Functional Expenses TotalFunctionalExpensesGrp

Field	Value	IRS element (for citing)
Total	$55,804,807	TotalAmt
Program Services	$46,175,035	ProgramServicesAmt
Management And General	$9,629,772	ManagementAndGeneralAmt
Fundraising	$0	FundraisingAmt

Cash Non Interest Bearing CashNonInterestBearingGrp

Field	Value	IRS element (for citing)
BOY	$3,716,862	BOYAmt
EOY	$1,737,540	EOYAmt

Savings And Temp Cash Invst SavingsAndTempCashInvstGrp

Field	Value	IRS element (for citing)
BOY	$23,770,173	BOYAmt
EOY	$27,405,327	EOYAmt

Accounts Receivable AccountsReceivableGrp

Field	Value	IRS element (for citing)
BOY	$7,379,272	BOYAmt
EOY	$6,950,969	EOYAmt

Oth Notes Loans Receivable Net OthNotesLoansReceivableNetGrp

Field	Value	IRS element (for citing)
BOY	$55,808	BOYAmt
EOY	$166,729	EOYAmt

Inventories For Sale Or Use InventoriesForSaleOrUseGrp

Field	Value	IRS element (for citing)
BOY	$1,492,041	BOYAmt
EOY	$1,324,515	EOYAmt

Prepaid Expenses Defrd Charges PrepaidExpensesDefrdChargesGrp

Field	Value	IRS element (for citing)
BOY	$523,662	BOYAmt
EOY	$616,248	EOYAmt

Field	Value	IRS element (for citing)
Land Bldg Equip Cost Or Other Bss	$69,043,493	LandBldgEquipCostOrOtherBssAmt
Land Bldg Equip Accum Deprec	$23,536,182	LandBldgEquipAccumDeprecAmt

Land Bldg Equip Basis Net LandBldgEquipBasisNetGrp

Field	Value	IRS element (for citing)
BOY	$49,935,873	BOYAmt
EOY	$45,507,311	EOYAmt

Other Assets Total OtherAssetsTotalGrp

Field	Value	IRS element (for citing)
BOY	$723,273	BOYAmt
EOY	$1,843,311	EOYAmt

Total Assets TotalAssetsGrp

Field	Value	IRS element (for citing)
BOY	$87,596,964	BOYAmt
EOY	$85,551,950	EOYAmt

Accounts Payable Accr Expnss AccountsPayableAccrExpnssGrp

Field	Value	IRS element (for citing)
BOY	$3,421,849	BOYAmt
EOY	$3,780,458	EOYAmt

Tax Exempt Bond Liabilities TaxExemptBondLiabilitiesGrp

Field	Value	IRS element (for citing)
BOY	$9,492,704	BOYAmt
EOY	$9,117,704	EOYAmt

Mortg Notes Pybl Scrd Invst Prop MortgNotesPyblScrdInvstPropGrp

Field	Value	IRS element (for citing)
BOY	$31,500,609	BOYAmt
EOY	$30,880,328	EOYAmt

Other Liabilities OtherLiabilitiesGrp

Field	Value	IRS element (for citing)
BOY	$1,177,801	BOYAmt
EOY	$664,666	EOYAmt

Total Liabilities TotalLiabilitiesGrp

Field	Value	IRS element (for citing)
BOY	$45,592,963	BOYAmt
EOY	$44,443,156	EOYAmt

Field	Value	IRS element (for citing)
Organization Follows SFAS117	Yes (X)	OrganizationFollowsSFAS117Ind

Unrestricted Net Assets UnrestrictedNetAssetsGrp

Field	Value	IRS element (for citing)
BOY	$42,004,001	BOYAmt
EOY	$41,108,794	EOYAmt

Total Net Assets Fund Balance TotalNetAssetsFundBalanceGrp

Field	Value	IRS element (for citing)
BOY	$42,004,001	BOYAmt
EOY	$41,108,794	EOYAmt

Tot Liab Net Assets Fund Balance TotLiabNetAssetsFundBalanceGrp

Field	Value	IRS element (for citing)
BOY	$87,596,964	BOYAmt
EOY	$85,551,950	EOYAmt

Field	Value	IRS element (for citing)
Reconcilation Revenue Expnss	-$504,460	ReconcilationRevenueExpnssAmt
Net Unrlzd Gains Losses Invst	-$390,747	NetUnrlzdGainsLossesInvstAmt
Other Changes In Net Assets	$0	OtherChangesInNetAssetsAmt
Info In Schedule O Part XII	Yes (X)	InfoInScheduleOPartXIIInd
Method Of Accounting Accrual	Yes (X)	MethodOfAccountingAccrualInd
Accountant Compile Or Review	0	AccountantCompileOrReviewInd
FS Audited	Yes (1)	FSAuditedInd

FS Audited Basis FSAuditedBasisGrp

Field	Value	IRS element (for citing)
Consolidated Basis Fincl Stmt	Yes (X)	ConsolidatedBasisFinclStmtInd

Field	Value	IRS element (for citing)
Audit Committee	Yes (1)	AuditCommitteeInd
Federal Grant Audit Required	0	FederalGrantAuditRequiredInd

Schedule A IRS990ScheduleA

Field	Value	IRS element (for citing)
Hospital	Yes (X)	HospitalInd

Schedule B IRS990ScheduleB

Contributor Information ContributorInformationGrp

Field	Value	IRS element (for citing)
Contributor	RESTRICTED	ContributorNum

Contributor Business Name ContributorBusinessName

Field	Value	IRS element (for citing)
Business Name Line1	RESTRICTED	BusinessNameLine1

Contributor US Address ContributorUSAddress

Field	Value	IRS element (for citing)
Address Line1	RESTRICTED	AddressLine1
Address Line2	RESTRICTED	AddressLine2
City	RESTRICTED	City
State	RESTRICTED	State
ZIP Code	RESTRICTED	ZIPCode

Field	Value	IRS element (for citing)
Total Contributions	RESTRICTED	TotalContributionsAmt

Schedule C IRS990ScheduleC

Field	Value	IRS element (for citing)
Volunteers	0	VolunteersInd
Paid Staff Or Management	0	PaidStaffOrManagementInd
Media Advertisements	0	MediaAdvertisementsInd
Mailings Members	0	MailingsMembersInd
Publications Or Broadcast	0	PublicationsOrBroadcastInd
Grants Other Organizations	0	GrantsOtherOrganizationsInd
Direct Contact Legislators	0	DirectContactLegislatorsInd
Rallies Demonstrations	0	RalliesDemonstrationsInd
Other Activities	Yes (1)	OtherActivitiesInd
Other Activities	$5,544	OtherActivitiesAmt
Total Lobbying Expenditures	$5,544	TotalLobbyingExpendituresAmt
Not Described Section501c3	0	NotDescribedSection501c3Ind

Supplemental Information Detail SupplementalInformationDetail

Field	Value	IRS element (for citing)
Form And Line Reference	PART II-B, LINE 1:	FormAndLineReferenceDesc
Explanation	A PORTION OF THE DUES PAID TO THE AMERICAN HOSPITAL ASSOCIATION (AHA) AND THE NEBRASKA HOSPITAL ASSOCIATION (NHA) ARE USED BY THOSE ORGANIZATIONS FOR LOBBYING ACTIVITIES.	ExplanationTxt

Schedule D IRS990ScheduleD

Land LandGrp

Field	Value	IRS element (for citing)
Investment Cost Or Other Basis	$92,500	InvestmentCostOrOtherBasisAmt
Other Cost Or Other Basis	$1,947,968	OtherCostOrOtherBasisAmt
Book Value	$2,040,468	BookValueAmt

Buildings BuildingsGrp

Field	Value	IRS element (for citing)
Other Cost Or Other Basis	$48,833,060	OtherCostOrOtherBasisAmt
Depreciation	$12,606,918	DepreciationAmt
Book Value	$36,226,142	BookValueAmt

Equipment EquipmentGrp

Field	Value	IRS element (for citing)
Other Cost Or Other Basis	$17,241,308	OtherCostOrOtherBasisAmt
Depreciation	$10,684,956	DepreciationAmt
Book Value	$6,556,352	BookValueAmt

Other Land Buildings OtherLandBuildingsGrp

Field	Value	IRS element (for citing)
Other Cost Or Other Basis	$928,657	OtherCostOrOtherBasisAmt
Depreciation	$244,308	DepreciationAmt
Book Value	$684,349	BookValueAmt

Field	Value	IRS element (for citing)
Total Book Value Land Buildings	$45,507,311	TotalBookValueLandBuildingsAmt

Other Liabilities Org OtherLiabilitiesOrgGrp

Field	Value	IRS element (for citing)
Desc	DEFERRED COMPENSATION PLAN LIABILITY	Desc
Amt	$664,666	Amt

Field	Value	IRS element (for citing)
Total Liability	$664,666	TotalLiabilityAmt
Footnote Text	Yes (X)	FootnoteTextInd

Supplemental Information Detail SupplementalInformationDetail

Field	Value	IRS element (for citing)
Form And Line Reference	PART X, LINE 2:	FormAndLineReferenceDesc
Explanation	SIDNEY REGIONAL MEDICAL CENTER AND CHEYENNE COUNTY HOSPITAL AND HEALTH CENTER FOUNDATION ARE EXEMPT FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE INTERNAL REVENUE CODE AND A SIMILAR PROVISION OF STATE LAW. THE INTERNAL REVENUE SERVICE HAS ESTABLISHED STANDARDS TO BE MET TO MAINTAIN TAX-EXEMPT STATUS. THE SYSTEM ACCOUNTS FOR UNCERTAINTIES IN ACCOUNTING FOR INCOME TAX ASSETS AND LIABILITIES USING GUIDANCE INCLUDED IN FASB ASC 740, INCOME TAXES. THE SYSTEM RECOGNIZES THE EFFECT OF INCOME TAX POSITIONS ONLY IF THOSE POSITIONS ARE MORE LIKELY THAN NOT OF BEING SUSTAINED. AT DECEMBER 31, 2018, THE SYSTEM HAD NO UNCERTAIN TAX POSITIONS ACCRUED.	ExplanationTxt

Schedule H IRS990ScheduleH

Field	Value	IRS element (for citing)
Financial Assistance Policy	Yes (1)	FinancialAssistancePolicyInd
Written Policy	Yes (1)	WrittenPolicyInd
All Hospitals Policy	Yes (X)	AllHospitalsPolicyInd
FPG Reference Free Care	Yes (1)	FPGReferenceFreeCareInd
Percent100	Yes (X)	Percent100Ind
FPG Reference Discounted Care	Yes (1)	FPGReferenceDiscountedCareInd
Percent300	Yes (X)	Percent300Ind
Free Care Medically Indigent	Yes (1)	FreeCareMedicallyIndigentInd
Financial Assistance Budget	Yes (1)	FinancialAssistanceBudgetInd
Expenses Exceed Budget	0	ExpensesExceedBudgetInd
Annual Community Bnft Report	0	AnnualCommunityBnftReportInd

Financial Assistance At Cost Typ FinancialAssistanceAtCostTyp

Field	Value	IRS element (for citing)
Total Community Benefit Expns	$1,054,436	TotalCommunityBenefitExpnsAmt
Direct Offsetting Revenue	$0	DirectOffsettingRevenueAmt
Net Community Benefit Expns	$1,054,436	NetCommunityBenefitExpnsAmt
Total Expense	0.01890	TotalExpensePct

Unreimbursed Medicaid UnreimbursedMedicaidGrp

Field	Value	IRS element (for citing)
Total Community Benefit Expns	$5,508,133	TotalCommunityBenefitExpnsAmt
Direct Offsetting Revenue	$4,706,265	DirectOffsettingRevenueAmt
Net Community Benefit Expns	$801,868	NetCommunityBenefitExpnsAmt
Total Expense	0.01440	TotalExpensePct

Total Financial Assistance Typ TotalFinancialAssistanceTyp

Field	Value	IRS element (for citing)
Total Community Benefit Expns	$6,562,569	TotalCommunityBenefitExpnsAmt
Direct Offsetting Revenue	$4,706,265	DirectOffsettingRevenueAmt
Net Community Benefit Expns	$1,856,304	NetCommunityBenefitExpnsAmt
Total Expense	0.03330	TotalExpensePct

Community Health Services CommunityHealthServicesGrp

Field	Value	IRS element (for citing)
Total Community Benefit Expns	$175,568	TotalCommunityBenefitExpnsAmt
Direct Offsetting Revenue	$123,325	DirectOffsettingRevenueAmt
Net Community Benefit Expns	$52,243	NetCommunityBenefitExpnsAmt
Total Expense	0.00090	TotalExpensePct

Health Professions Education HealthProfessionsEducationGrp

Field	Value	IRS element (for citing)
Total Community Benefit Expns	$19,365	TotalCommunityBenefitExpnsAmt
Direct Offsetting Revenue	$0	DirectOffsettingRevenueAmt
Net Community Benefit Expns	$19,365	NetCommunityBenefitExpnsAmt
Total Expense	0.00030	TotalExpensePct

Cash And In Kind Contributions CashAndInKindContributionsGrp

Field	Value	IRS element (for citing)
Total Community Benefit Expns	$27,006	TotalCommunityBenefitExpnsAmt
Direct Offsetting Revenue	$0	DirectOffsettingRevenueAmt
Net Community Benefit Expns	$27,006	NetCommunityBenefitExpnsAmt
Total Expense	0.00050	TotalExpensePct

Total Other Benefits TotalOtherBenefitsGrp

Field	Value	IRS element (for citing)
Total Community Benefit Expns	$221,939	TotalCommunityBenefitExpnsAmt
Direct Offsetting Revenue	$123,325	DirectOffsettingRevenueAmt
Net Community Benefit Expns	$98,614	NetCommunityBenefitExpnsAmt
Total Expense	0.00170	TotalExpensePct

Total Community Benefits TotalCommunityBenefitsGrp

Field	Value	IRS element (for citing)
Total Community Benefit Expns	$6,784,508	TotalCommunityBenefitExpnsAmt
Direct Offsetting Revenue	$4,829,590	DirectOffsettingRevenueAmt
Net Community Benefit Expns	$1,954,918	NetCommunityBenefitExpnsAmt
Total Expense	0.03500	TotalExpensePct

Community Support CommunitySupportGrp

Field	Value	IRS element (for citing)
Activities Or Programs	101	ActivitiesOrProgramsCnt
Persons Served	12	PersonsServedCnt
Total Community Benefit Expns	$16,317	TotalCommunityBenefitExpnsAmt
Net Community Benefit Expns	$16,317	NetCommunityBenefitExpnsAmt
Total Expense	0.00030	TotalExpensePct

Health Improvement Advocacy HealthImprovementAdvocacyGrp

Field	Value	IRS element (for citing)
Activities Or Programs	93	ActivitiesOrProgramsCnt
Persons Served	207	PersonsServedCnt
Total Community Benefit Expns	$18,900	TotalCommunityBenefitExpnsAmt
Net Community Benefit Expns	$18,900	NetCommunityBenefitExpnsAmt
Total Expense	0.00030	TotalExpensePct

Other Communtity Building Acty OtherCommuntityBuildingActyGrp

Field	Value	IRS element (for citing)
Activities Or Programs	152	ActivitiesOrProgramsCnt
Persons Served	152	PersonsServedCnt
Total Community Benefit Expns	$18,553	TotalCommunityBenefitExpnsAmt
Net Community Benefit Expns	$18,553	NetCommunityBenefitExpnsAmt
Total Expense	0.00030	TotalExpensePct

Total Communtity Building Acty TotalCommuntityBuildingActyGrp

Field	Value	IRS element (for citing)
Activities Or Programs	346	ActivitiesOrProgramsCnt
Persons Served	371	PersonsServedCnt
Total Community Benefit Expns	$53,770	TotalCommunityBenefitExpnsAmt
Net Community Benefit Expns	$53,770	NetCommunityBenefitExpnsAmt
Total Expense	0.00090	TotalExpensePct

Field	Value	IRS element (for citing)
Bad Debt Expense Reported	Yes (1)	BadDebtExpenseReportedInd
Bad Debt Expense	$1,442,254	BadDebtExpenseAmt
Bad Debt Expense Attributable	$288,451	BadDebtExpenseAttributableAmt
Reimbursed By Medicare	$17,982,109	ReimbursedByMedicareAmt
Cost Of Care Reimbursed By Medcr	$18,375,990	CostOfCareReimbursedByMedcrAmt
Medicare Surplus Or Shortfall	-$393,881	MedicareSurplusOrShortfallAmt

Costing Methodology Used CostingMethodologyUsedGrp

Field	Value	IRS element (for citing)
Cost To Charge Ratio	Yes (X)	CostToChargeRatioInd

Field	Value	IRS element (for citing)
Written Debt Collection Policy	Yes (1)	WrittenDebtCollectionPolicyInd
Financial Assistance Prvsn	Yes (1)	FinancialAssistancePrvsnInd
Hospital Facilities	1	HospitalFacilitiesCnt

Hospital Facilities HospitalFacilitiesGrp

Field	Value	IRS element (for citing)
Facility	1	FacilityNum

Business Name BusinessName

Field	Value	IRS element (for citing)
Business Name Line1	CHEYENNE COUNTY HOSPITAL ASSOCIATION	BusinessNameLine1Txt

US Address USAddress

Field	Value	IRS element (for citing)
Address Line1	1000 POLE CREEK CROSSING	AddressLine1Txt
City	SIDNEY	CityNm
State Abbreviation	NE	StateAbbreviationCd
ZIP	69162	ZIPCd

Field	Value	IRS element (for citing)
Website Address	WWW.SIDNEYRMC.COM	WebsiteAddressTxt
State License	150001	StateLicenseNum
Licensed Hospital	Yes (X)	LicensedHospitalInd
General Medical And Surgical	Yes (X)	GeneralMedicalAndSurgicalInd
Critical Access Hospital	Yes (X)	CriticalAccessHospitalInd
Emergency Room24 Hrs	Yes (X)	EmergencyRoom24HrsInd

Hospital Fclty Policies Prctc HospitalFcltyPoliciesPrctcGrp

Hospital Facility Name HospitalFacilityName

Field	Value	IRS element (for citing)
Business Name Line1	CHEYENNE COUNTY HOSPITAL ASSOCIATION INC	BusinessNameLine1Txt

Field	Value	IRS element (for citing)
Facility	1	FacilityNum
First Licensed CY Or PY	0	FirstLicensedCYOrPYInd
Tax Exempt Hospital CY Or PY	0	TaxExemptHospitalCYOrPYInd
CHNA Conducted	Yes (1)	CHNAConductedInd
Community Definition	Yes (X)	CommunityDefinitionInd
Community Demographics	Yes (X)	CommunityDemographicsInd
Existing Resources	Yes (X)	ExistingResourcesInd
How Data Obtained	Yes (X)	HowDataObtainedInd
Community Health Needs	Yes (X)	CommunityHealthNeedsInd
Other Health Issues	Yes (X)	OtherHealthIssuesInd
Community Hlth Needs Id Process	Yes (X)	CommunityHlthNeedsIdProcessInd
Consulting Process	Yes (X)	ConsultingProcessInd
Prior CHNA Impact	Yes (X)	PriorCHNAImpactInd
CHNA Conducted	17	CHNAConductedYr
Take Into Account Others Input	Yes (1)	TakeIntoAccountOthersInputInd
CHNA Conducted With Other Fclts	Yes (1)	CHNAConductedWithOtherFcltsInd
CHNA Conducted With Non Fclts	Yes (1)	CHNAConductedWithNonFcltsInd
CHNA Report Widely Available	Yes (1)	CHNAReportWidelyAvailableInd
Rpt Available On Own Website	Yes (X)	RptAvailableOnOwnWebsiteInd
Own Website URL	WWW.SIDNEYRMC.COM/501R	OwnWebsiteURLTxt
Other Website	Yes (X)	OtherWebsiteInd
Other Website URL	WWW.PPHD.ORG/PAGES/CHIP.HTML	OtherWebsiteURLTxt
Paper Copy Public Inspection	Yes (X)	PaperCopyPublicInspectionInd
Implementation Strategy Adopt	Yes (1)	ImplementationStrategyAdoptInd
Implementation Strategy Adpt	17	ImplementationStrategyAdptYr
Strategy Posted Website	Yes (1)	StrategyPostedWebsiteInd
Strategy Website URL	WWW.SIDNEYRMC.COM/501R	StrategyWebsiteURLTxt
Organization Incur Excise Tax	0	OrganizationIncurExciseTaxInd
Elig Criteria Explained	Yes (1)	EligCriteriaExplainedInd
FPG Family Incm Lmt Free Dscnt	Yes (X)	FPGFamilyIncmLmtFreeDscntInd
FPG Family Incm Lmt Free Care	100.000000000000	FPGFamilyIncmLmtFreeCarePct
FPG Family Incm Lmt Dscnt Care	300.000000000000	FPGFamilyIncmLmtDscntCarePct
Income Level Criteria	Yes (X)	IncomeLevelCriteriaInd
Asset Level Criteria	Yes (X)	AssetLevelCriteriaInd
Medical Indigency Criteria	Yes (X)	MedicalIndigencyCriteriaInd
Underinsurance Stat Criteria	Yes (X)	UnderinsuranceStatCriteriaInd
Residency Criteria	Yes (X)	ResidencyCriteriaInd
Explained Basis	Yes (1)	ExplainedBasisInd
App Financial Asst Expln	Yes (1)	AppFinancialAsstExplnInd
Described Info	Yes (X)	DescribedInfoInd
Described Suprt Doc	Yes (X)	DescribedSuprtDocInd
Provided Hospital Contact	Yes (X)	ProvidedHospitalContactInd
Provided Nonprofit Contact	Yes (X)	ProvidedNonprofitContactInd
Includes Publicity Measures	Yes (1)	IncludesPublicityMeasuresInd
FAP Available On Website	Yes (X)	FAPAvailableOnWebsiteInd
FAP Available On Website URL	SIDNEYRMC.COM/501R	FAPAvailableOnWebsiteURLTxt
FAP App Available On Website	Yes (X)	FAPAppAvailableOnWebsiteInd
FAP App Available On Website URL	SIDNEYRMC.COM/501R	FAPAppAvailableOnWebsiteURLTxt
FAP Summary On Website	Yes (X)	FAPSummaryOnWebsiteInd
FAP Summary On Website URL	SIDNEYRMC.COM/501R	FAPSummaryOnWebsiteURLTxt
FAP Avlbl On Request No Charge	Yes (X)	FAPAvlblOnRequestNoChargeInd
FAP App Avlbl On Request No Chrg	Yes (X)	FAPAppAvlblOnRequestNoChrgInd
FAP Sum Avlbl On Request No Chrg	Yes (X)	FAPSumAvlblOnRequestNoChrgInd
Notified FAP Copy Bill Display	Yes (X)	NotifiedFAPCopyBillDisplayInd
Communtity Notified FAP	Yes (X)	CommuntityNotifiedFAPInd
Other Publicity	Yes (X)	OtherPublicityInd
FAP Actions On Nonpayment	Yes (1)	FAPActionsOnNonpaymentInd
Permit No Actions	Yes (X)	PermitNoActionsInd
Collection Activities	0	CollectionActivitiesInd
Provided Written Notice	Yes (X)	ProvidedWrittenNoticeInd
Made Effort Orally Notify	Yes (X)	MadeEffortOrallyNotifyInd
Processed FAP Application	Yes (X)	ProcessedFAPApplicationInd
Made Presumptive Elig Determ	Yes (X)	MadePresumptiveEligDetermInd
Other Actions Taken	Yes (X)	OtherActionsTakenInd
Nondis Emergency Care Policy	Yes (1)	NondisEmergencyCarePolicyInd
Look Back Medicare Private	Yes (X)	LookBackMedicarePrivateInd
Amounts Generally Billed	0	AmountsGenerallyBilledInd
Gross Charges	0	GrossChargesInd

Supplemental Information SupplementalInformationGrp (7 entries)

Form And Line ReferenceFormAndLineReferenceDesc	ExplanationExplanationTxt
CHEYENNE COUNTY HOSPITAL ASSOCIATION INC	PART V, SECTION B, LINE 5: A PARTNERSHIP STEERING COMMITTEE WAS FORMED IN 2014, MADE UP OF REPRESENTATIVES FROM EACH OF THE EIGHT PANHANDLE HOSPITALS (SEE LIST OF MEMBERS IN LINE 6A). COMMITTEE MEMBERS PROVIDE GUIDANCE THROUGHOUT THE MAPP PROCESS AND ARE CHARGED WITH REVIEWING DATA AND PROGRESS ON THE CHOSEN PRIORITY AREAS, USING QUALITY IMPROVEMENT TO MODIFY IMPLEMENTATION PLANS AS NEEDED, AND SHARING RESULTS WITH STAKEHOLDERS. TWO NEW REPRESENTATIVES JOINED THE COMMITTEE IN 2017: A REPRESENTATIVE FROM THE PANHANDLE PARTNERSHIP, SERVING AS A REPRESENTATIVE OF A VARIETY OF COMMUNITY-BASED ORGANIZATIONS, AND A REPRESENTATIVE FROM THE LOCAL ECONOMIC DEVELOPMENT DISTRICT, PANHANDLE AREA DEVELOPMENT DISTRICT (PADD). ADDITIONALLY SRMC HELD THREE FOCUS GROUPS BETWEEN FEBRUARY AND MAY 2017. ONE GENERAL COMMUNITY FOCUS GROUP WAS HELD IN BOTH CHEYENNE AND DEUEL COUNTIES, AND AN ADDITIONAL HISPANIC FOCUS GROUP WAS HELD IN CHEYENNE COUNTY. OVERALL, 23 PEOPLE GAVE INPUT ON THE HEALTH STATUS OF THE SRMC SERVICE AREA THROUGH FOCUS GROUPS. THE FOCUS GROUP DISCUSSIONS WERE CONDUCTED TO FULFILL THE COMMUNITY THEMES AND STRENGTHS ASSESSMENT COMPONENT OF THE 2017 MOBILIZING FOR ACTION THROUGH PLANNING AND PARTNERSHIPS (MAPP) PROCESS. THE PURPOSE OF THE FOCUS GROUP IS TO GATHER INPUT FROM COMMUNITY MEMBERS IN ORDER TO DEVELOP A BETTER UNDERSTANDING OF THE ISSUES THEY FEEL ARE IMPORTANT, THEIR CONCERNS, AND THEIR OVERALL PERCEPTION OF THEIR COMMUNITY.
CHEYENNE COUNTY HOSPITAL ASSOCIATION INC	PART V, SECTION B, LINE 6A: THE FOLLOWING IS A LIST OF HOSPITALS THAT PARTICIPATED IN THE CHNA:-BOX BUTTE GENERAL HOSPITAL, ALLIANCE, NE-MORRILL COUNTY HOSPITAL, BRIDGEPORT, NE-REGIONAL WEST MEDICAL CENTER, SCOTTSBLUFF, NE-CHADRON COMMUNITY HOSPITAL, CHADRON, NE-GARDEN COUNTY HEALTH SERVICES, OSHKOSH, NE-GORDON MEMORIAL HOSPITAL, GORDON, NE-KIMBALL HEALTH SERVICES, KIMBALL, NE-SCOTTSBLUFF COUNTY HEALTH DEPARTMENT, SCOTTSBLUFF, NE-SIDNEY REGIONAL MEDICAL CENTER, SIDNEY, NE
CHEYENNE COUNTY HOSPITAL ASSOCIATION INC	PART V, SECTION B, LINE 6B: PANHANDLE PUBLIC HEALTH DEPARTMENT
CHEYENNE COUNTY HOSPITAL ASSOCIATION INC	PART V, SECTION B, LINE 11: IN MAY OF 2017, SRMC HELD A TOTAL OF THREE COMMUNITY FOCUS GROUPS, ONE WAS FOR HISPANICS, ONE IN CHAPPELL AND THE OTHER IN SIDNEY. THESE DISCUSSIONS WERE HELD TO BETTER ASSIST IN DETERMINING THE NEEDS WITHIN THOSE COMMUNITIES, EXPRESSED BY ALL IN ATTENDANCE. SRMC ALSO HAD A COMMUNITY HEALTH SURVEY DISTRIBUTED AT THE FOCUS GROUP MEETINGS, TO COMMUNITY BASED ORGANIZATIONS AND ALSO ELECTRONICALLY. THERE WERE 167 RESPONDENTS FROM WITHIN THE SRMC SERVICE AREA. WITH THIS DATA, SRMC WAS ABLE TO PUT TOGETHER SOME STRATEGIC INITIATIVES THAT THEY WOULD FOCUS ON FOR THE 2018-2020 COMMUNITY HEALTH IMPROVEMENT PLAN. THEY INCLUDE CANCER PREVENTION, BEHAVIORAL HEALTH AND ACCESS TO AFFORDABLE HEALTH CARE. - CANCER PREVENTION/ INCREASE AWARENESS TO THE BENEFIT OF EARLY DETECTION FOR PROSTATE (PSA), BREAST (EVERY WOMAN MATTERS PROGRAM), COLON (FECAL OCCULT BLOOD TESTING OR COLONOSCOPY) AND CERVICAL CANCER SCREENINGS. PROVIDE ACCESS TO RESOURCES FOR LOW COST OR FREE SCREENINGS BUILDING ON THE WELLNESS WEDNESDAY. PROMOTE THE EVERY WOMAN MATTERS PROGRAM FOR FREE MAMMOGRAPHY'S AND CERVICAL SCREENINGS TO THOSE QUALIFIED WOMEN, PARTNERING WITH PANHANDLE PUBLIC HEALTH. OFFER FREE FOBT KITS TO THOSE AGES 50 TO 74 WHOM HAVEN'T OR WILL NOT DO THE COLONOSCOPY. REDUCED COST PSA TESTING ON WELLNESS WEDNESDAYS. SRMC IS TRACKING NUMBERS FOR EACH, STARTING WITH 2018, TO DETERMINE IF OFFERING MORE EDUCATION TO THE COMMUNITY WILL INCREASE THE NUMBER OF PEOPLE BEING SCREENED FOR THE ABOVE CANCERS THROUGH 2020. - BEHAVIORAL HEALTH/DETERMINE LOCAL RESOURCES AVAILABLE TO PROVIDE FREE OR LOW COST SCREENINGS TO ASSESS MENTAL HEALTH ISSUES FOR ALL AGES. RESEARCH ADDING BEHAVIORAL HEALTH TO OUR OSAGE CAMPUS. WORKING WITH KARUNA COUNSELING TO LEARN MORE ABOUT ASSESSMENT TOOLS AVAILABLE. PROVIDER USE OF THE PHQ-9 PATIENT QUESTIONNAIRE IN THE CLINICAL SETTING. ENCOURAGE STAFF TO TAKE FIRST AID MENTAL HEALTH, A FREE EIGHT HOUR COURSE ON HELPING IDENTIFY SIGNS OF MENTAL ILLNESS AND BETTER PREPARE OUR COMMUNITY. - ACCESS TO AFFORDABLE HEALTH CARE/EDUCATE THE COMMUNITY MEMBERS ON KEY SCREENINGS THAT MAY BE FREE OR LOW COST AND AFFORDABLE. UTILIZE WELLNESS WEDNESDAYS FOR SEVERAL OPTIONS OF LOW COST BLOOD SCREENINGS THAT CAN BE OBTAINED WITHOUT A DOCTOR'S ORDER. OFFER FREE FLU VACCINATIONS IN THE COMMUNITY WHEN DIRECTED BY ADMINISTRATION. LAUNCH THE E-VISITS AT THE CLINIC IN CHAPPELL. LAUNCHING OF THE NEW PRICING REVIEW AND THE PROCEDURE PRICING TOOL ON OUR WEBSITE FOR THE COMMUNITY IN AUGUST OF 2018. OFFER AFTER HOURS FREE SPORTS PHYSICALS TO COMMUNITY SCHOOL AGE KIDS IN SPORTS.THE FOLLOWING IS A QUARTERLY RECAP OF 2018: - 1ST QTR - DIRECT ACCESS TESTING WAS INITIATED IN OUR LAB EVERY WEDNESDAY STARTING JANUARY 16TH, 2018. COMMUNITY MEMBERS CAN CHOOSE CERTAIN LOW COST BLOOD SCREENINGS OR WELLNESS LABS THEY WOULD LIKE FROM A LIMITED LIST AND PAY A REDUCED, CASH PRICE. THESE TESTS CAN BE OBTAINED WITHOUT A DOCTOR'S ORDER. IT IS THE PATIENT'S RESPONSIBILITY TO TAKE THEIR RESULTS TO THEIR PROVIDER TO DISCUSS IF NORMAL/ABNORMAL. NO INSURANCE CAN BE BILLED WITH THESE LOW COST SCREENINGS. WE ALSO HELD THREE BLOOD DRIVES WITH 101 PARTICIPANTS DONATING BLOOD. - 2ND QTR - FREE SPORTS PHYSICALS DONE BY SRMC PROVIDERS FOR SIDNEY AND THE SURROUNDING COMMUNITY'S SCHOOL AGE KIDS WITH 109 PARTICIPATING. DIRECT ACCESS TESTING HAD 240 COMMUNITY MEMBERS USE THE REDUCED COST WELLNESS LABS. ON APRIL 19TH, CEO JASON PETIK HELD A COMMUNITY FORUM IN SIDNEY AT THE COMMUNITY CENTER TO DISCUSS CHANGES AND NEW PROVIDERS COMING. WITH 40+ ATTENDING. SRMC HELD TWO BLOOD DRIVES THIS QUARTER WITH 98 PARTICIPANTS GIVING THE GIFT OF LIFE! - 3RD QTR - E-VISITS WERE LAUNCHED IN THE CHAPPELL CLINIC. AFTER HOURS FREE SPORTS PHYSICALS OFFERED BY SRMC PROVIDERS FOR SIDNEY AND SURROUNDING COMMUNITIES FOR SCHOOL AGE KIDS IN SPORTS, WITH 78 PARTICIPATING IN THIS FREE EVENT. DIRECT ACCESS TESTING NUMBERS FOR THE QUARTER WERE 164 PEOPLE CHOOSING TO RECEIVE LOW COST BLOOD SCREENINGS. ON JULY 19TH, CEO JASON PETIK, CINDY BOATNER AND EVIE PARSONS DID A F/U COMMUNITY FORUM IN CHAPPELL (AS PROMISED) WITH 5 IN ATTENDANCE. THE ANNUAL DASH FOR THE SPLASH WAS HELD ON AUGUST 4TH (HOSTED BY SRMC) FOR THE COMMUNITY WITH 128 ADULTS PARTICIPATING ALONG WITH 33 KIDS FOR THE KIDS EVENT. REGISTRATION WAS FREE THIS YEAR FOR ALL PARTICIPANTS, COMPLIMENTS OF SRMC. - 4TH QTR - SRMC OFFERED FREE FLU SHOTS TO THOSE 6 MONTHS AND OLDER, HOLDING 13 FREE FLU CLINICS IN SIDNEY AND THE SURROUNDING COMMUNITIES WITH 448 FLU SHOTS GIVEN AWAY FREE. DIRECT ACCESS TESTING ON WELLNESS WEDNESDAYS SAW 112 COMMUNITY MEMBERS USE THIS SERVICE FOR LOW COST BLOOD SCREENINGS. OCTOBERFEST 5/10 K WALK-RUN (SPONSORED BY SRMC) WAS HELD AND 137 COMMUNITY MEMBERS PARTICIPATED. ON OCTOBER 26TH, SRMC HELD A FREE KIDS EVENT "BUILDING BLOCKS TO GOOD HEALTH" FOR AREA STUDENTS FROM SIDNEY, CHAPPELL, PEETZ AND ILIFF, CO WITH THE MEGA HEART AND COLON INFLATABLES AND SEVERAL DEPARTMENTS OFFERING FUN, INTERACTIVE AND EDUCATIONAL TOPICS FOR 200 KIDS IN ATTENDANCE. THE FOLLOWING DAY, WAS THE ADULT HEALTH FAIR AND APPROXIMATELY 300 WERE IN ATTENDANCE. SRMC HOSTED A BLOOD DRIVE IN CONJUNCTION WITH THE HEALTH FAIR WITH 29 PARTICIPANTS DONATING BLOOD FOR THOSE IN NEED. SRMC ALSO OFFERED FREE FLU SHOTS AT SATURDAY'S EVENT WITH 188 KIDS/ADULTS GETTING THEIR FLU SHOT.SRMC DID NOT HAVE THE RESOURCES TO INCLUDE MENTAL AND EMOTIONAL WELL BEING INTO ITS COMMUNITY HEALTH DURING THIS TIME PERIOD.
CHEYENNE COUNTY HOSPITAL ASSOCIATION INC	PART V, SECTION B, LINE 13B: PATIENTS MAY BE CONSIDERED FOR CHARITY CARE FOR MEDICALLY NECESSARY SERVICES. WHEN IN QUESTION, MEDICALLY NECESSARY SERVICES SHALL BE DETERMINED BY THE EXAMINING PHYSICIAN. PATIENTS MUST BE RESIDENTS OF CHEYENNE OR DEUEL COUNTY AND/OR A 20 MILE RADIUS OF SIDNEY REGIONAL MEDICAL CENTER. THIS MAY BE WAIVED FOR PATIENTS ADMITTED VIA THE EMERGENCY DEPARTMENT OR AT THE DISCRETION OF ADMINISTRATION.SPECIFICALLY IDENTIFIED CASES MAY BE PRESUMED ELIGIBLE FOR CHARITABLE ASSISTANCE AND CLASSIFIED WITHOUT A COMPLETED APPLICATION OR ASSESSMENT. EXAMPLES OF THESE CASES ARE: PATIENT IS DECEASED WITH NO KNOWN ESTATE OR SPOUSE; PATIENTS WITH CURRENT ELIGIBILITY UNDER COUNTY OR STATE MEDICAL INDIGENT SERVICES ADMINISTERED BY COUNTY OR STATE FACILITIES; PATIENT IS HOMELESS OR HAS BEEN IDENTIFIED AS BEING WITHOUT RESOURCES BASED ON PREVIOUS ACCOUNT ACTION AND CONTACT WITH THE SRMC STAFF.PERCENT OF CHARITY WILL BE BASED ON HOUSEHOLD INCOME AND SIZE, REAL ESTATE, PERSONAL PROPERTY AND INVESTMENT EQUITY, WITH CREDIT TO BE GIVEN FOR ALREADY EXISTING MEDICAL LOANS, IN COMPARISON TO THE CURRENT YEAR FEDERAL POVERTY GUIDELINES. THE HHS POVERTY GUIDELINES ARE PUBLISHED EACH YEAR IN THE FEDERAL REGISTER. FREE CARE WILL BE GIVEN TO HOUSEHOLDS THAT ARE AT 100% OF THE POVERTY LEVEL. DISCOUNTED CARE WILL BE GIVEN AT UP TO 300% OF THE POVERTY LEVEL.
CHEYENNE COUNTY HOSPITAL ASSOCIATION INC	PART V, SECTION B, LINE 16J: THE POLICY IS REFERENCED IN BILLING LETTERS AND IS ORALLY COMMUNICATED DURING REGISTRATION OR ADMISSIONS AND THROUGH THE PATIENT FINANCIAL SERVICES FOLLOW UP PROCESSES, INCLUDING PATIENT ADVOCACY CONVERSATIONS. THE POLICY IS AVAILABLE IN ADMISSIONS AND WAITING AREAS AT THE HOSPITAL. SIGNAGE IS POSTED IN WAITING AREAS REFERRING PATIENTS TO THE WEBSITE TO VIEW THE POLICY. ADDITIONALLY, PLAIN LANGUAGE SUMMARY IS INCLUDED IN ALL DISCHARGE PACKETS WITH REFERENCE TO THE WEBSITE OR FINANCIAL SERVICES TO OBTAIN THE ENTIRE POLICY.
CHEYENNE COUNTY HOSPITAL ASSOCIATION INC	PART V, SECTION B, LINE 20E: SRMC ATTEMPTS OTHER NON-EXTRAORDINARY COLLECTION EFFORTS SUCH AS: SUBSEQUENT MONTHLY BILLINGS, COLLECTION LETTERS AND/OR TELEPHONE CALLS CONSTITUTING A GENUINE EFFORT TO HELP OUR PATIENTS TO ARRANGE FOR PAYMENT IF THEY CAN AFFORD IT. DOCUMENTATION OF THESE EFFORTS WILL BE MADE BY NOTATING PATIENT ACCOUNTS AND DOCUMENTING STATEMENTS AND REPORTS OF TELEPHONE CALLS AND PERSONAL CONTACTS. FOR ELECTIVE PROCEDURES, PATIENTS ARE ASKED TO MEET WITH A FINANCIAL COUNSELOR BEFORE THE PROCEDURE TO SET UP PAYMENT ARRANGEMENTS. SRMC DOES OFFER LOANS TO PATIENTS WITH NO COLLATERAL FROM THE PATIENTS. SRMC ALSO SECURES FINANCING FOR THE PATIENTS IF THEY DO NOT QUALIFY FOR CHARITY CARE. SRMC DOES NOT REQUIRE PATIENTS WHO QUALIFY FOR CHARITY CARE UNDER THE FINANCIAL ASSISTANCE POLICY TO OBTAIN A LOAN TO PAY THE ACCOUNT.

Field	Value	IRS element (for citing)
Facility	3	FacilityNum

Oth Hlth Care Fclts Not Hospital OthHlthCareFcltsNotHospitalGrp

Oth Hlth Care Fclts OthHlthCareFcltsGrp (3 entries)

Address Line1USAddress/AddressLine1Txt	CityUSAddress/CityNm	State AbbreviationUSAddress/StateAbbreviationCd	ZIPUSAddress/ZIPCd	FacilityFacilityTxt
1 - SIDNEY REG'L MEDICAL CTR EXTENDED CARE
549 KELLER DRIVE	SIDNEY	NE	69162	LONG TERM CARE FACILITY
2 - SLOAN ESTATES ASSISTED LIVING
2550 CRAIG AVENUE	SIDNEY	NE	69162	ASSISTED LIVING
3 - SIDNEY REG'L MEDICAL CTR WALK IN CLINIC
1625 DORWART DRIVE	SIDNEY	NE	69162	WALK IN CLINIC

Supplemental Information Detail SupplementalInformationDetail (16 entries)

Form And Line ReferenceFormAndLineReferenceDesc	ExplanationExplanationTxt
PART I, LINE 3C:	THE CALCULATION FOR ELIGIBILITY IS BASED ON ALL INCOME PER HOUSEHOLD WITH EXCEPTIONS MADE FOR WAGE EARNERS WHO ARE STUDENTS. OTHER MEDICAL PAYMENTS ALREADY BEING MADE ARE CONSIDERED IN THE CALCUATION. INCOME IS COMPARED TO THE NATIONAL POVERTY GUIDELINES AND A DETERMINATION OF REDUCTION IS MADE BASED ON THE ADJUSTED INCOME LEVEL. THE WRITE OFF AMOUNT MAY BE REDUCED FOR EQUITY IN ASSETS, IF ANY, ABOVE EXEMPTION THRESHOLDS FOR HOMES AND VEHICLES. THERE IS NO EXEMPTION FOR INVESTMENTS OR OTHER ASSETS HELD.
PART I, LINE 6A:	THE COMMUNITY BENEFIT REPORT IS PREPARED BY THE STAFF OF SIDNEY REGIONAL MEDICAL CENTER IN CONJUNCTION WITH PANHANDLE PUBLIC HEALTH DEPARTMENT IN ORDER TO MAINTAIN REGIONAL PARTNERSHIPS AND ASSURE COMMUNITY BENEFIT ACROSS THE REGION.
PART I, LINE 7:	THE COST TO CHARGE RATIO IS DETERMINED AS FOLLOWS: (TOTAL EXPENSES - BAD DEBT)/GROSS PATIENT SERVICE REVENUE = PERCENTAGE OF COST TO CHARGE.
PART I, LINE 7G:	THERE ARE NO SUBSIDIZED HEALTH SERVICES.
PART I, LN 7 COL(F):	BAD DEBT EXPENSE OF $1,442,254 HAS BEEN EXCLUDED FROM THE DENOMINATOR IN THE CALCULATION OF THE PERCENTAGES IN LINE 7, COLUMN F.
PART II, COMMUNITY BUILDING ACTIVITIES:	COMMUNITY SUPPORT INCLUDES ACTIVITIES SUCH AS THERAPISTS AVAILABLE AT GAMES AND AT THE COMMUNITY CENTER AND WELLNESS CAMPAIGNS IN COOPERATION WITH THE COMMUNITY CENTER. COMMUNITY HEALTH IMPROVEMENT INCLUDES COMMUNITY BLOOD DRAWS, HEALTH FAIR, BLOOD PRESSURE SCREENINGS, DIABETES PREVENTION PROGRAMS, AND MULTIPLE SMALLER COMMUNITY EDUCATION PROGRAMS THROUGH RADIO INTERVIEWS WITH HEALTH PROFESSIONALS.
PART III, LINE 2:	IN EVALUATING THE COLLECTIBILITY OF ACCOUNTS RECEIVABLE, THE SYSTEM ANALYZES ITS PAST HISTORY AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYER SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND PROVISION FOR BAD DEBTS. MANAGEMENT REGULARLY REVIEWS DATA ABOUT THESE MAJOR PAYER SOURCES OF REVENUE IN EVALUATING THE SUFFICIENCY OF THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. THE SYSTEM 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 DOUBTFUL ACCOUNTS.
PART III, LINE 3:	SIDNEY REGIONAL MEDICAL CENTER HAS ESTIMATED THE AMOUNT OF BAD DEBT EXPENSE ATTRIBUTABLE TO PATIENTS WHO MAY HAVE BEEN ELIGIBLE UNDER THE ORGANIZATION'S FINANCIAL ASSISTANCE POLICY AT 20%. THIS ESTIMATE IS BASED ON AN ANALYSIS OF PRIOR YEAR ESTIMATES VERSUS ACTUAL AND AN ANALYSIS OF THE PERCENTAGE OF CHARITY CARE VERSUS BAD DEBT IN TOTAL.
PART III, LINE 4:	THE HOSPITAL'S FINANCIAL STATMENTS DO NOT CONTAIN A SPECIFIC FOOTNOTE DESCRIBING BAD DEBT. HOWEVER, PAGES 8 AND 10 OF THE ATTACHED AUDITED FINANCIAL STATEMENTS INCLUDE FOOTNOTES TITLED "PATIENT RECEIVABLES, NET", "NET PATIENT SERVICE REVENUE AND "CHARITY CARE".
PART III, LINE 8:	THE ORGANIZATION USED THE MEDICARE COST REPORT FOR FISCAL YEAR 2018 TO REPORT THE AMOUNTS OF TOTAL REVENUE RECEIVED FROM MEDICARE AND RELATED MEDICARE ALLOWABLE COSTS. MEDICARE PAYS THE HOSPITAL'S RURAL HEALTH CLINICS (RHC) AT COST SUBJECT TO CERTAIN LIMITS. THE MEDICARE SHORTFALL IN PAYMENTS SHOULD BE CONSIDERED A COMMUNITY BENEFIT AS IT IS PART OF THE HOSPITAL'S MISSION TO PROVIDE THESE SERVICES EVEN IF MEDICARE REIMBURSEMENT IS BELOW COST.
PART III, LINE 9B:	THE CHARITY CARE POLICY ALLOWS FOR PROACTIVE WRITE OFF TO ALLOWANCE FOR CHARITY CARE OF ANY BALANCE OWED BY A PATIENT KNOWN TO QUALIFY FOR CHARITY CARE UNDER THE FINANCIAL ASSISTANCE POLICY. COLLECTION PROCEDURES DO NOT ENSUE ON ANY ACCOUNTS ELIGIBLE FOR FINANCIAL ASSISTANCE.
PART VI, LINE 2:	NEEDS ASSESSMENTS ARE DETERMINED THROUGH SCIENTIFIC, AS WELL AS UNSCIENTIFIC METHODS. EVERY 2 TO 3 YEARS A MARKET ASSESSMENT IS COMPLETED USING CLAIMS DATA WHICH REVEALS THE NEEDS OF COMMUNITY MEMBERS BEING MET ELSEWHERE DUE TO EITHER UNAVAILABILITY OF SERVICE OR PATIENT CHOICE. THIS ASSESSMENT INCLUDES THE DEMOGRAPHICS OF THE AREA WHICH SHOW AN AGING AND MODERATE INCOME POPULATION. THESE FACTS ARE THEN USED TO DETERMINE THE NEEDS OF THE COMMUNITY AS WELL AS THE FUTURE NEEDS BASED ON HISTORICAL DATA. ADDITIONALLY, COMMUNITY NEEDS ARE DETERMINED USING PUBLIC OPINION, PATIENT SATISFACTION RECOMMENDATIONS, BOARD AND LEADERSHIP EXPERIENCE, COMMUNICATIONS WITH COMMUNITY MEMBERS, AND PHYSICIAN INPUT. FUTURE MEASUREMENTS OF HEALTH DATA MINED FROM CLAIMS SUBMISSIONS WILL BE USED TO FURTHER ANALYZE THE NEEDS OF THE COMMUNITY.
PART VI, LINE 3:	AT THE POINT OF ADMISSION, A PATIENT'S INSURED STATUS IS DETERMINED. PATIENTS WHO ARE UNDERINSURED OR UNINSURED RECEIVE COUNSELING THROUGH THE HOSPITAL'S PATIENT ADVOCATE AND/OR A MEMBER OF THE FINANCIAL SERVICES STAFF SERVING AS A FINANCIAL COUNSELOR. INFORMATION IS CONVEYED TO THE PATIENT OR THE GUARANTOR REGARDING MEDICAID AND MEDICARE, AS WELL AS CHARITY CARE PROVIDED BY THE HOSPITAL. ADDITIONAL COUNSELING IS PROVIDED AFTER DISMISSAL WHEN THE PROACTIVE APPROACH WAS UNSUCCESSFUL. ADDITIONALLY, SOCIAL SERVICES PERSONNEL AND PATIENT FINANCIAL COUNSELORS MEET WITH PATIENTS INDIVIDUALLY WHEN NEEDED REGARDING THEIR COVERAGE IN AN ATTEMPT TO DETERMINE ELIGIBILITY FOR FINANCIAL ASSISTANCE AND OTHER MEANS FOR THE INDIVIDUALS.
PART VI, LINE 4:	MOST OF THE AREA THAT THE HOSPITAL SERVES IS LOCATED IN CHEYENNE COUNTY, NEBRASKA WHICH HAS A POPULATION OF APPROXIMATELY 9,310 PEOPLE. THE CITIES OF SIDNEY, LODGEPOLE, POTTER, DALTON, GURLEY, AND SUNOL ARE LOCATED WITHIN THE COUNTY AND ARE GENERALLY WITHIN APPROXIMATELY 30 MILES FROM THE HOSPITAL. ACCORDING TO THE US CENSUS BUREAU, THE 2018 DEMOGRAPHIC IS AROUND 76.5% CAUCASIAN AND THE AVERAGE HOUSEHOLD SIZE IS 2.63 PEOPLE PER HOUSEHOLD. APPROXIMATELY 10.2% OF PEOPLE ARE WITHOUT HEALTH INSURANCE OF THE TOTAL POPULATION OVER 18 YEARS OF AGE, 63.0% ARE ACTIVELY IN THE LABOR FORCE.
PART VI, LINE 5:	IN ADDITION TO ACTIVITIES ADDRESSED IN THE CHNA REPORT, THE HOSPITAL HOLDS AN ANNUAL HEALTH FAIR AND AN ANNUAL CHILDREN'S HEALTH FAIR, 10K RACES, TRIATHLON RACES, PROVIDES OUTREACH SERVICE TO LOCAL BUSINESSES TO ASSURE FLU SHOTS AND IMMUNIZATIONS ARE UP TO DATE AS WELL AS DOING BLOOD PRESSURE SCREENINGS. SRMC ALSO CONDUCTS DIABETES EDUCATION CLASSES AND A DIABETES HEALTH FAIR DURING THE YEAR. SRMC OFFERS IN-HOME FOLLOW UP VISITS TO ANY MOTHERS WITH NEW BABIES NO MATTER WHERE THEY DELIVERED THEIR BABY, AND COLLABORATES WITH THE SCHOOL TO PROVIDE FOLLOWUP THERAPY CONSULTATIONS AFTER SPORTING EVENTS. THE HOSPITAL CONTINUES TO PROVIDE OB AND DELIVERY SERVICES EVEN THOUGH MANY SMALLER HOSPITALS HAVE DISCONTINUED SUPPORT OF THEIR COMMUNITIES IN THIS ARENA. COMMUNITY EDUCATION IS PROVIDED THRU RADIO BROADCASTS EACH WEEK WITH VARYING TOPICS.
PART VI, LINE 6:	SIDNEY REGIONAL MEDICAL CENTER IS NOT PART OF AN AFFILIATED HEALTH CARE ORGANIZATION.

Schedule I IRS990ScheduleI

Field	Value	IRS element (for citing)
Grant Records Maintained	Yes (1)	GrantRecordsMaintainedInd

Recipient Table RecipientTable

Recipient Business Name RecipientBusinessName

Field	Value	IRS element (for citing)
Business Name Line1	4-H COUNCIL	BusinessNameLine1Txt

US Address USAddress

Field	Value	IRS element (for citing)
Address Line1	920 JACKSON STREET PO BOX 356	AddressLine1Txt
City	SIDNEY	CityNm
State Abbreviation	NE	StateAbbreviationCd
ZIP	69162	ZIPCd

Field	Value	IRS element (for citing)
Recipient EIN	470722021	RecipientEIN
IRC Section	501(C)(3)	IRCSectionDesc
Cash Grant	$5,000	CashGrantAmt
Purpose Of Grant	4H LIVESTOCK PROGRAM	PurposeOfGrantTxt

Field	Value	IRS element (for citing)
Total501c3 Org	1	Total501c3OrgCnt
Total Other Org	0	TotalOtherOrgCnt

Supplemental Information Detail SupplementalInformationDetail

Field	Value	IRS element (for citing)
Form And Line Reference	PART I, LINE 2:	FormAndLineReferenceDesc
Explanation	IF THE DONEE ORGANIZATION IS NOT A GOVERNMENTAL ENTITY OR IDENTIFIED AS A CHARITABLE ORGANIZATION ON GUIDESTAR, THE DONEE ORGANIZATION IS RESEARCHED TO ASSURE THEIR NOT-FOR-PROFIT STATUS. THE DONEE ORGANIZATION'S MISSION INFORMATION, THEIR FINANCIAL DATA AND THEIR FORM 990 (IF AVAILABLE) IS REVIEWED AND CONSIDERED BY THE BOARD OF DIRECTORS. THE BOARD OF DIRECTORS MUST APPROVE, BY A MAJORITY VOTE OF THE QUORUM IN ATTENDANCE, THE DONATION TO THE ORGANIZATION OR GOVERNMENTAL ENTITY. DURING THE FOLLOWING 12 TO 24 MONTHS AFTER THE DONATION IS DISTRIBUTED, CONTINUED MONITORING OF THE PROJECT OR DONATION RESTRICTIONS, IF APPLICABLE, SHALL BE REPORTED TO THE BOARD OF DIRECTORS. THE DONEE ORGANIZATION'S FORM 990 (IF AVAILABLE) FOR THE YEAR OF THE DONATION AND ANY OTHER SUBSEQUENT YEARS REQUESTED SHALL BE MADE AVAILABLE TO THE BOARD MEMBERS FOR FOLLOW UP REVIEW.	ExplanationTxt

Schedule J IRS990ScheduleJ

Field	Value	IRS element (for citing)
Compensation Committee	Yes (X)	CompensationCommitteeInd
Written Employment Contract	Yes (X)	WrittenEmploymentContractInd
Compensation Survey	Yes (X)	CompensationSurveyInd
Board Or Committee Approval	Yes (X)	BoardOrCommitteeApprovalInd
Severance Payment	0	SeverancePaymentInd
Supplemental Nonqual Rtr Plan	Yes (1)	SupplementalNonqualRtrPlanInd
Equity Based Comp Arrngm	0	EquityBasedCompArrngmInd
Comp Based On Revenue Of Flng Org	Yes (1)	CompBasedOnRevenueOfFlngOrgInd
Comp Bsd On Rev Related Orgs	0	CompBsdOnRevRelatedOrgsInd
Comp Bsd Net Earns Flng Org	0	CompBsdNetEarnsFlngOrgInd
Comp Bsd Net Earns Rltd Orgs	0	CompBsdNetEarnsRltdOrgsInd
Any Non Fixed Payments	0	AnyNonFixedPaymentsInd
Initial Contract Exception	0	InitialContractExceptionInd

Rltd Org Officer Trst Key Empl RltdOrgOfficerTrstKeyEmplGrp (8 entries)

TitleTitleTxt	Base Compensation Filing OrgBaseCompensationFilingOrgAmt	Compensation Based On Rltd OrgsCompensationBasedOnRltdOrgsAmt	Bonus Filing OrganizationBonusFilingOrganizationAmount	Bonus Related OrganizationsBonusRelatedOrganizationsAmt	Other Compensation Filing OrgOtherCompensationFilingOrgAmt	Other Compensation Rltd OrgsOtherCompensationRltdOrgsAmt	Deferred Compensation Flng OrgDeferredCompensationFlngOrgAmt	Deferred Comp Rltd OrgsDeferredCompRltdOrgsAmt	Nontaxable Benefits Filing OrgNontaxableBenefitsFilingOrgAmt	Nontaxable Benefits Rltd OrgsNontaxableBenefitsRltdOrgsAmt	Total Compensation Filing OrgTotalCompensationFilingOrgAmt	Total Compensation Rltd OrgsTotalCompensationRltdOrgsAmt	Comp Report Prior990 Filing OrgCompReportPrior990FilingOrgAmt	Comp Report Prior990 Rltd OrgsCompReportPrior990RltdOrgsAmt
REBECCA L ALLARD MD
MEMBER -PHYSICIAN AT LARGE	$549,288	$0	$0	$0	$380	$0	$13,750	$0	$44,188	$0	$607,606	$0	$0	$0
MATTHEW JANSEN MD
MEMBER -CHIEF OF STAFF	$722,138	$0	$0	$0	$378	$0	$11,829	$0	$44,188	$0	$778,533	$0	$0	$0
KELLY UTLEY
CFO	$171,468	$0	$0	$0	$624	$0	$8,605	$0	$0	$0	$180,697	$0	$0	$0
JAMES THAYER MD
DOCTOR	$276,003	$0	$36,968	$0	$1,511	$0	$8,574	$0	$30,814	$0	$353,870	$0	$0	$0
JENNIFER BROWN MD
DOCTOR (THRU 8/2018)	$346,981	$0	$0	$0	$252	$0	$0	$0	$0	$0	$347,233	$0	$0	$0
ROBERT GRAVES MD
DOCTOR	$270,077	$0	$0	$0	$1,782	$0	$13,750	$0	$37,378	$0	$322,987	$0	$0	$0
THERESA SIMMONS
CRNA	$275,637	$0	$0	$0	$530	$0	$0	$0	$44,188	$0	$320,355	$0	$0	$0
ANGELA HARTZLER
CRNA	$249,684	$0	$0	$0	$347	$0	$11,902	$0	$44,187	$0	$306,120	$0	$0	$0

Supplemental Information Detail SupplementalInformationDetail (3 entries)

Form And Line ReferenceFormAndLineReferenceDesc	ExplanationExplanationTxt
PART I, LINE 4B	JAMES THAYER M.D. AND ROBERT GRAVES M.D., BOTH HIGHLY COMPENSATED EMPLOYEES, PARTICIPATED IN A 457(B) RETIREMENT PLAN. NO PAYMENTS WERE MADE DURING THE YEAR.
PART I, LINE 5	DR. JAMES THAYER RECEIVES DRAW ON HIS SALARY BASED ON HIS GROSS CHARGES. THE DRAW IS CALCULATED BY MULTIPLYING THE GROSS CHARGES BY 33% AND SUBTRACTING OFF HIS BASE BIWEEKLY SALARY OF $10,000. ADDITIONALLY, HE HAS THE OPPORTUNITY TO EARN A BONUS BASED UPON QUALITY INDICATORS, MEDICAL RECORDS COMPLETION, ETC.
SCHEDULE J, PART III:	JASON PETIK, CEO, RECEIVES COMPENSATION FROM THE UNIVERSITY OF COLORADO HOSPITAL AUTHORITY, AN UNRELATED ENTITY. THE UNIVERSITY OF COLORADO HOSPITAL AUTHORITY PROVIDES MANAGEMENT SERVICES TO ITS CLIENTS, INCLUDING THE SIDNEY REGIONAL MEDICAL CENTER. THE SIDNEY REGIONAL MEDICAL CENTER'S BOARD OF DIRECTORS SETS THE SALARY AND BENEFITS FOR MR. PETIK. MR. PETIK RECEIVED A SALARY OF $226,266, RETIREMENT BENEFITS OF $7,961 AND NONTAXABLE BENEFITS OF $17,166. MR. PETIK'S SALARY IS REFLECTED IN PART IX, LINE 11A.

Schedule K IRS990ScheduleK

Tax Exempt Bonds Issues TaxExemptBondsIssuesGrp

Field	Value	IRS element (for citing)
Bond Reference	A	BondReferenceCd

Issuer Name IssuerName

Field	Value	IRS element (for citing)
Business Name Line1	THE COUNTY OF DEUEL NEBRASKA	BusinessNameLine1Txt

Field	Value	IRS element (for citing)
Bond Issuer EIN	476006452	BondIssuerEIN
CUSIP	251476AA5	CUSIPNum
Bond Issued	2014-10-16	BondIssuedDt
Issue Price	$10,000,000	IssuePriceAmt
Purpose	CONSTRUCT HOSPITAL	PurposeDesc
Defeased	0	DefeasedInd
On Behalf Of Issuer	0	OnBehalfOfIssuerInd
Pool Financing	0	PoolFinancingInd

Tax Exempt Bonds Proceeds TaxExemptBondsProceedsGrp

Field	Value	IRS element (for citing)
Bond Reference	A	BondReferenceCd
Retired	$375,000	RetiredAmt
Total Proceeds	$10,000,000	TotalProceedsAmt
Capital Expenditures	$10,000,000	CapitalExpendituresAmt
Substantial Completion	2015	SubstantialCompletionYr
Refunding Tax Exempt Bonds	0	RefundingTaxExemptBondsInd
Refunding Taxable Bonds	0	RefundingTaxableBondsInd
Final Allocation Made	Yes (1)	FinalAllocationMadeInd
Adequate Books And Rec Maint	Yes (1)	AdequateBooksAndRecMaintInd

Tax Exempt Bonds Private Bus Use TaxExemptBondsPrivateBusUseGrp

Field	Value	IRS element (for citing)
Bond Reference	A	BondReferenceCd
Owning Bond Financed Property	0	OwningBondFinancedPropertyInd
Any Lease Arrangements	0	AnyLeaseArrangementsInd
Mgmt Contract Bond Fincd Prop	0	MgmtContractBondFincdPropInd
Any Research Agreements	0	AnyResearchAgreementsInd
Private Bus Use By Others	0.00000	PrivateBusUseByOthersPct
Private Bus Concerning UBI	0.00000	PrivateBusConcerningUBIPct
Total Private Business Use	0.00000	TotalPrivateBusinessUsePct
Bond Iss Meet Prvt Sec Pymt Test	0	BondIssMeetPrvtSecPymtTestInd
Change In Use Bond Financed Prop	0	ChangeInUseBondFinancedPropInd
Procs Nonqualified Bond Remdtd	Yes (1)	ProcsNonqualifiedBondRemdtdInd

Tax Exempt Bonds Arbitrage TaxExemptBondsArbitrageGrp

Field	Value	IRS element (for citing)
Bond Reference	A	BondReferenceCd
Form8038 T Filed	0	Form8038TFiledInd
Rebate Not Due Yet	0	RebateNotDueYetInd
Exception To Rebate	Yes (1)	ExceptionToRebateInd
No Rebate Due	0	NoRebateDueInd
Variable Rate Issue	Yes (1)	VariableRateIssueInd
Hedge Identified In Bks And Rec	0	HedgeIdentifiedInBksAndRecInd
Gross Proceeds Invested In GIC	0	GrossProceedsInvestedInGICInd
Gross Proceeds Invested	0	GrossProceedsInvestedInd
Written Proc To Monitor Reqs	Yes (1)	WrittenProcToMonitorReqsInd

Procedures Corrective Action ProceduresCorrectiveActionGrp

Field	Value	IRS element (for citing)
Bond Reference	A	BondReferenceCd
Procedures Corrective Action	Yes (1)	ProceduresCorrectiveActionInd

Schedule L IRS990ScheduleL

Bus Tr Involve Interested Prsn BusTrInvolveInterestedPrsnGrp

Name Of Interested NameOfInterested

Field	Value	IRS element (for citing)
Person	KEVIN UTLEY	PersonNm

Field	Value	IRS element (for citing)
Relationship Description	EMPLOYEE OF ORGANIZATION AND SPOUSE OF KELLY UTLEY, CFO	RelationshipDescriptionTxt
Transaction	$109,063	TransactionAmt
Transaction	EMPLOYEE COMPENSATION	TransactionDesc
Sharing Of Revenues	0	SharingOfRevenuesInd

Schedule O IRS990ScheduleO

Supplemental Information Detail SupplementalInformationDetail (9 entries)

Form And Line ReferenceFormAndLineReferenceDesc	ExplanationExplanationTxt
FORM 990, PART VI, SECTION A, LINE 3	THE UNIVERSITY OF COLORADO HOSPITAL AUTHORITY CURRENTLY EMPLOYS THE CHIEF EXECUTIVE OFFICER FOR SIDNEY REGIONAL MEDICAL CENTER. EACH MONTH, SRMC PROVIDES THE UNIVERSITY OF COLORADO HOSPITAL AUTHORITY WITH DATA ON SERVICES PROVIDED TO THE COMMUNITY FOR COMPARISON DATA PURPOSES.
FORM 990, PART VI, SECTION B, LINE 11B	THE ORGANIZATION'S ACCOUNTING DEPARTMENT PROVIDES DOCUMENTATION TO THE INDEPENDENT ACCOUNTING FIRM FOR THE PREPARATION OF THE FORM 990. COMMUNICATIONS BETWEEN THE ACCOUNTING FIRM AND THE ACCOUNTING DEPARTMENT FINALIZE THE PREPARATION OF THE FORM 990. THE CEO AND CFO THEN REVIEW THE FORM 990 AND E-MAIL THE PUBLIC DISCLOSURE COPY TO ALL MEMBERS OF THE BOARD OF DIRECTORS FOR THEIR REVIEW. ONCE THE 990 RETURN HAS BEEN APPROVED BY ALL PARTIES IT IS SUBMITTED TO THE IRS ON OR BEFORE THE REGULAR OR EXTENDED DUE DATE.
FORM 990, PART VI, SECTION B, LINE 12C	EACH YEAR ALL BOARD MEMBERS ARE REQUIRED TO DISCLOSE ANY CONFLICTS OF INTEREST. ANY DUALITY OF INTEREST OR POTENTIAL CONFLICT OF INTEREST ON THE PART OF ANY OFFICER, DIRECTOR, COMMITTEE MEMBER, OR ANY KEY EMPLOYEE IS DISCLOSED TO THE BOARD OF DIRECTORS AND MADE A MATTER OF RECORD WHENEVER IT ARISES. WHENEVER IT INVOLVES A MATTER OF BOARD ACTION, ANY OFFICER, DIRECTOR, COMMITTEE MEMBER, OR KEY EMPLOYEE HAVING A DUALITY OF INTEREST OR A POSSIBLE CONFLICT OF INTEREST IN ANY MATTER DOES NOT VOTE OR ABSTAINS FROM THE VOTE, IF PRESENT IN THE ROOM. OFTEN THE BOARD MEMBER IS ASKED TO LEAVE THE MEETING DURING DISCUSSION PERIODS AND FOR THE VOTE ON ISSUES FOR WHICH CONFLICT EXISTS. THESE INDIVIDUALS DO NOT USE THEIR PERSONAL INFLUENCE ON THE MATTERS.
FORM 990, PART VI, SECTION B, LINE 15	THE UNIVERSITY OF COLORADO HOSPITAL AUTHORITY PROVIDES ADMINISTRATIVE SERVICES TO SIDNEY REGIONAL MEDICAL CENTER (SRMC). THIS INCLUDES PROVIDING THE HOSPITAL'S CHIEF EXECUTIVE OFFICER. SRMC'S METHOD TO DETERMINE EXECUTIVE SALARY RANGES IS TO ANNUALLY PULL SALARY RANGES FROM NO LESS THAN TWO SURVEY SOURCES (THREE WHEN POSSIBLE) TO DETERMINE THE AVERAGE SALARY RANGE FOR EACH EXECUTIVE POSITION BY GEOGRAPHICAL REGION. THESE ARE REVIEWED AND PRESENTED TO THE HUMAN RESOURCE COMMITTEE OF THE BOARD OF DIRECTORS FOR REVIEW AND APPROVAL/RECOMMENDATIONS.
FORM 990, PART VI, SECTION C, LINE 19	THE GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS ARE MADE AVAILABLE UPON REQUEST. ALSO, THE FINANCIAL STATEMENTS ARE SENT ANNUALLY TO COMMUNITY LEADERS.
FORM 990, PART VII, SECTION A, LINE 5:	JASON PETIK RECEIVES COMPENSATION FROM AN UNRELATED ORGANIZATION, THE UNIVERSITY OF COLORADO HOSPITAL AUTHORITY, WHICH PROVIDES MANAGEMENT SERVICES TO SIDNEY REGIONAL MEDICAL CENTER.
FORM 990, PART VII, SECTION A, LINE 1A:	MATTHEW JANSEN, M.D. AND REBECCA ALLARD, M.D. ARE PHYSICIANS OF SIDNEY REGIONAL MEDICAL CENTER AND ARE COMPENSATED FOR THE MEDICAL SERVICES THEY PROVIDE. NEITHER IS PAID BY THE HOSPITAL FOR THEIR SERVICE ON THE BOARD OF DIRECTORS.
FORM 990, PART IX, LINE 11G	PROFESSIONAL FEES - OTHER: PROGRAM SERVICE EXPENSES 5,429,962. MANAGEMENT AND GENERAL EXPENSES 253,913. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 5,683,875. CONTRACT SERVICES - SURGERY PROFESSIONALS: PROGRAM SERVICE EXPENSES 647,991. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 647,991. CONTRACT SERVICES - ANESTHESIA PROFESSIONALS: PROGRAM SERVICE EXPENSES 191,871. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 191,871. RECRUITING FEES: PROGRAM SERVICE EXPENSES 322,194. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 322,194. CONTRACT SERVICES - RADIOLOGY PROFESSIONALS: PROGRAM SERVICE EXPENSES 681,369. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 681,369.
FORM 990, PART XI, LINE 2C:	THE BOARD OF DIRECTORS ASSUMES THE RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT OF SRMC'S FINANCIAL STATEMENTS AND SELECTION OF AN INDEPENDENT ACCOUNTANT. THIS PROCESS HAS NOT CHANGED SINCE THE PRIOR YEAR.

Schedule R IRS990ScheduleR

Id Related Tax Exempt Org IdRelatedTaxExemptOrgGrp

Disregarded Entity Name DisregardedEntityName

Field	Value	IRS element (for citing)
Business Name Line1	CHEYENNE COUNTY HOSPITAL AND HEALTH CENTER FOUNDATION	BusinessNameLine1Txt

US Address USAddress

Field	Value	IRS element (for citing)
Address Line1	1000 POLE CREEK CROSSING	AddressLine1Txt
City	SIDNEY	CityNm
State Abbreviation	NE	StateAbbreviationCd
ZIP	69162	ZIPCd

Field	Value	IRS element (for citing)
EIN	470686476	EIN
Primary Activities	SUPPORT SIDNEY REGIONAL MEDICAL CENTER	PrimaryActivitiesTxt
Legal Domicile State	NE	LegalDomicileStateCd
Exempt Code Section	501(C)(3)	ExemptCodeSectionTxt
Public Charity Status	LINE 12C, III-FI	PublicCharityStatusTxt
Direct Controlling NA	N/A	DirectControllingNACd
Controlled Organization	0	ControlledOrganizationInd

Field	Value	IRS element (for citing)
Receipt Of Int Annts Rnts Rylts	0	ReceiptOfIntAnntsRntsRyltsInd
Gift Grnt Or Cap Contri To Oth Org	0	GiftGrntOrCapContriToOthOrgInd
Gift Grnt Cap Contri From Oth Org	Yes (1)	GiftGrntCapContriFromOthOrgInd
Loans Or Guarantees To Other Org	Yes (1)	LoansOrGuaranteesToOtherOrgInd
Loans Or Guarantees From Oth Org	0	LoansOrGuaranteesFromOthOrgInd
Div Related Organization	0	DivRelatedOrganizationInd
Asset Sale To Other Org	0	AssetSaleToOtherOrgInd
Asset Purchase From Other Org	0	AssetPurchaseFromOtherOrgInd
Asset Exchange	0	AssetExchangeInd
Rental Of Facilities To Oth Org	0	RentalOfFacilitiesToOthOrgInd
Rental Of Fclts From Oth Org	0	RentalOfFcltsFromOthOrgInd
Perform Of Services For Oth Org	0	PerformOfServicesForOthOrgInd
Perform Of Services By Other Org	Yes (1)	PerformOfServicesByOtherOrgInd
Sharing Of Facilities	Yes (1)	SharingOfFacilitiesInd
Paid Employees Sharing	Yes (1)	PaidEmployeesSharingInd
Reimbursement Paid To Other Org	Yes (1)	ReimbursementPaidToOtherOrgInd
Reimbursement Paid By Other Org	Yes (1)	ReimbursementPaidByOtherOrgInd
Transfer To Other Org	0	TransferToOtherOrgInd
Transfer From Other Org	0	TransferFromOtherOrgInd