2025-11-12T14:16:17-06:00 2024-12-31 450250958 EIDE BAILLY LLP 18081 BURT ST STE 200 OMAHA NE 680224722 990 2024-01-01 480577658 HIAWATHA HOSPITAL ASSOCIATION INC HIAW 9133605584 300 UTAH STREET HIAWATHA KS 66434 CHASE DUDZINSKI CFO 9133605584 2025-11-12 1 1 WENDY R COOLEY CPA P01523804 4023302660 2025-11-12 2024 2025-03-06 01:10:19Z AMBERWELL HIAWATHA JARED ABEL 300 UTAH STREET HIAWATHA KS 66434 35875099 0 X HTTPS://WWW.HCH-KS.ORG/ X 1945 KS PROVIDE MODERN, RELIABLE, AFFORDABLE HEALTH CARE THAT BEST MEETS THE NEEDS OF OUR COMMUNITY. 7 7 316 7 0 0 161489 177687 29299685 35491921 5298 204492 -6035 -8601 29460437 35865499 0 0 0 0 19372871 19015757 0 0 0 14531978 15124184 33904849 34139941 -4444412 1725558 20078246 20386919 8677416 7276596 11400830 13110323 X AMBERWELL HIAWATHA PROVIDES COMPASSIONATE CARE WITH CLINICAL EXCELLENCE. 0 0 28460668 35491921 HIAWATHA HOSPITAL ASSOCIATION, INC. DBA AMBERWELL HEALTH HIAWATHA IS A CRITICAL ACCESS HOSPITAL (CAH) THAT PROVIDES RELATED INPATIENT, OUTPATIENT, EMERGENCY CARE, AND PHYSICIAN SERVICES TO PATIENTS IN HIAWATHA, KANSAS AND SURROUNDING AREAS. HIAWATHA COMMUNITY HOSPITAL'S PRIMARY GOAL IS TO PROVIDE QUALITY, MODERN, AFFORDABLE HEALTHCARE TO OUR COMMUNITY. IN 2024, WE PROVIDED SERVICE FOR 2,277 INPATIENT DAYS, 71 INPATIENT SURGERIES AND 714 OUTPATIENT SURGERIES. WE DELIVERED 64 BABIES AND PROVIDED OUTPATIENT SERVICES TO 65,761 PATIENTS. (STATEMENT CONTINUED ON SCHEDULE O)BY PROVIDING SERVICES LIKE OBSTETRICS AND 24 HOUR EMERGENCY SERVICES THAT NOT ALL SMALL RURAL HOSPITALS PROVIDE, EVEN THOUGH THE PROGRAMS ARE NOT ALWAYS PROFITABLE FOR THE HOSPITAL, WE STRONGLY FEEL THAT THESE SERVICES PROVIDE NECESSARY CARE TO ADDRESS OUR COMMUNITY'S OVERALL HEALTH WHILE PROMOTING OUR MISSION AS A CHARITABLE ORGANIZATION.THE HOSPITAL MAINTAINS A FINANCIAL ASSISTANCE POLICY FOR PATIENTS WHO ARE FINANCIALLY UNABLE TO PAY FOR THE HEALTHCARE SERVICES THEY RECEIVE. IT IS THE POLICY OF THE HOSPITAL NOT TO PURSUE COLLECTION OF AMOUNTS DETERMINED TO QUALIFY AS PATIENT FINANCIAL ASSISTANCE UNDER THE POLICY. ACCORDINGLY, THE HOSPITAL DOES NOT REPORT THESE AMOUNTS IN PATIENT SERVICE REVENUE. THE HOSPITAL DETERMINES THE COSTS ASSOCIATED WITH PROVIDING CHARITY CARE BY AGGREGATING THE DIRECT AND IN DIRECT COSTS, INCLUDING SALARIES, BENEFITS, SUPPLIES, AND OTHER OPERATING EXPENSES, BASED ON AN OVERALL COST TO CHARGE RATIO. THE COSTS OF CARING FOR THESE PATIENTS FOR THE YEAR ENDED DECEMBER 31, 2024 WAS APPROXIMATELY $19,000. 28460668 1 1 0 1 0 0 0 0 0 0 1 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 40 0 1 316 1 0 0 0 0 0 0 0 0 0 0 0 0 X 7 7 0 0 0 0 0 0 1 1 0 0 0 1 1 1 1 1 1 1 0 0 X ERICA NORRIS 9133605884 300 UTAH STREET HIAWATHA KS 66434 X GREG RODVELT PRESIDENT 0.25 X X 0 0 0 DEL ELFFNER VICE PRESIDENT 0.25 X X 0 0 0 JOHN MOORE SECRETARY/TREASURER 0.25 X X 0 0 0 ERIC INGMIRE DIRECTOR 0.25 X 0 0 0 WILLIE GEISENDORF DIRECTOR 0.25 X 0 0 0 HOWARD ELLIOTT DIRECTOR 0.25 X 0 0 0 JASON SMITH DIRECTOR 0.25 X 0 0 0 JEFFREY PERRY PRESIDENT & CEO THRU 5/24 20.00 X 118476 0 0 JARED ABEL PRESIDENT & CEO AS OF 6/24 20.00 X 78826 0 0 CHASE DUDZINSKI CFO 20.00 X 83987 0 13661 JESSICA JARVIS MD CHIEF OF STAFF 40.00 X 294048 0 50274 CROSBY GERNON MD RADIOLOGIST 40.00 X 397407 0 49826 MARIAH KRIWIEL MD PHYSICIAN 40.00 X 359773 0 49167 ROBIN ALEXANDER CRNA 40.00 X 287470 0 50505 PAIGE KNUDSON CRNA 40.00 X 268443 0 10593 DUSTIN WILLIAMS NURSE PRACTITIONER 40.00 X 246080 0 50285 2134510 0 274311 28 0 1 1 GRACE ANESTHESIA SERVICES LLC PO BOX 535 CARROLL IA 51401 ANESTHESIOLOGY SERVICES 411405 AYA HEALTHCARE INC PO BOX 674907 DALLAS TX 75267 RESPIRATORY THERAPIST 309410 RESTORE 201 S 4TH STREET HIAWATHA KS 66434 THERAPY SERVICES 132480 PREMIER SPECIALTY NETWORKS 3610 BUTTONWOOD DR STE 200 COLUMBIA MO 652013721 PAIN MANAGEMENT 122473 EIDE BAILLY LLP PO BOX 88678 MILWAUKEE WI 532888678 PREPARATION OF AUDIT & COST REPORT 119768 6 82210 95477 177687 PATIENT SERVICE REVENUE 621110 32136617 32136617 PHARMACY REVENUE 456110 2725536 2725536 PHYSICAL THERAPY 621110 369994 369994 CAFETERIA 900099 89484 89484 170290 170290 35491921 2887 2887 999 9600 -8601 -8601 -8601 201605 0 201605 201605 201605 35865499 35491921 0 195891 X 639498 344321 295177 14560215 13019289 1540926 216177 204054 12123 2595002 2358990 236012 1004865 1004865 167715 28 167687 134450 8600 125850 4205 4205 3620560 2312863 1307697 124274 28410 95864 2030905 1912874 118031 1022322 946804 75518 546399 413765 132634 103362 98388 4974 238542 1859 236683 2083937 1284677 799260 305229 194587 110642 MEDICAL SUPPLIES 3301553 3301552 1 REPAIRS AND MAINTENANCE 1059993 810158 249835 DUES & SUBSCRIPTIONS 298711 203047 95664 MISCELLANEOUS 82027 11537 70490 34139941 28460668 5679273 0 858 808 1386231 4286772 4021764 4465348 389495 282644 297111 452834 28641439 19296767 11009628 9344672 678631 760944 43500 0 2251028 792897 20078246 20386919 3418802 2488572 5111959 4765074 106898 22328 39757 622 8677416 7276596 X 10781723 12507281 619107 603042 11400830 13110323 20078246 20386919 X 1725558 -16065 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 4205 4205 0 PART II-B, LINE 1: A PORTION OF THE DUES PAID TO KANSAS HOSPITAL ASSOCIATION ARE ATTRIBUTABLE TO LOBBYING. 795559 795559 17729689 11806675 5923014 8986961 6637430 2349531 1129230 852662 276568 9344672 LEASE LIABILITY 622 622 X 35875099 9600 9600 35865499 0 35865499 34149541 9600 9600 34139941 0 34139941 PART X, LINE 2: THE HOSPITAL BELIEVES THAT IS HAS APPROPRIATE SUPPORT FOR ANY TAX POSITIONS TAKEN AFFECTING ITS ANNUAL FILING REQUIREMENTS, AND AS SUCH, DOES NOT HAVE ANY UNCERTAIN TAX POSITIONS THAT ARE MATERIAL TO THE FINANCIAL STATEMENTS. THE HOSPITAL WOULD RECOGNIZE FUTURE ACCRUED INTEREST AND PENALTIES RELATED TO UNRECOGNIZED TAX BENEFITS AND LIABILITIES IN INCOME TAX EXPENSE IF SUCH INTEREST AND PENALTIES ARE INCURRED. PART XI, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSE 9,600. PART XII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSE 9,600. 1 1 X 1 X 1 X 1 1 1 0 1 1 19000 19000 0.00060 4718810 4310304 408506 0.01200 4737810 4310304 427506 0.01260 5618252 4369178 1249074 0.03660 5618252 4369178 1249074 0.03660 10356062 8679482 1676580 0.04920 1 1848080 279060 8278964 8304628 -25664 X 1 1 1 1 HIAWATHA HOSPITAL ASSOCIATION INC 300 UTAH STREET HIAWATHA KS 66434 WWW.HCH-KS.ORG H007001 X X X X 2 PROVIDER BASED RURAL HEALTH CLINICS HIAWATHA HOSPITAL ASSOCIATION INC 1 0 0 1 X X X X X X X X X 22 1 0 1 1 X PART V, PAGE 8 X 1 22 1 PART V, PAGE 8 0 1 X 200.000000000000 200.000000000000 X X X X X X 1 1 X X X 1 X HTTPS://AMBERWELLHEALTH.ORG/FINANCIAL-ASSISTANCE-AT-AMBERWELL-HIAWATHA/ X HTTPS://AMBERWELLHEALTH.ORG/FINANCIAL-ASSISTANCE-AT-AMBERWELL-HIAWATHA/ X HTTPS://AMBERWELLHEALTH.ORG/FINANCIAL-ASSISTANCE-AT-AMBERWELL-HIAWATHA/ X X X X X 1 X 0 X X X X 1 X 0 0 HIAWATHA HOSPITAL ASSOCIATION, INC. PART V, SECTION B, LINE 5: WE CHOSE INDIVIDUALS WHO WOULD HAVE UNIQUE UNDERSTANDING OF THE DIFFERENT POPULATIONS IN OUR COMMUNITY TO BE ON THE COMMITTEE. THE COMMITTEE HELPED FORMULATE THE SURVEY TO TAKE TO OUR COMMUNITY AND GAVE SIGNIFICANT FEEDBACK AND DIRECTION ABOUT WHAT SPECIFIC POPULATION NEEDS WERE.INCLUDED ON THE COMMITTEE:AMBERWELL HIAWATHAKANZA MENTAL HEALTHHORIZON THERAPYNEK AREA AGENCY ON AGINGAMBERWELL HEALTHGN BANKNEK MULTICOUNTY HEALTH DEPARTMENTSCITY OF HIAWATHAHIAWATHA FUMC HIAWATHA HOSPITAL ASSOCIATION, INC. PART V, SECTION B, LINE 6B: BROWN COUNTY HEALTH DEPARTMENT HIAWATHA HOSPITAL ASSOCIATION, INC. PART V, SECTION B, LINE 11: THE HOSPITAL COMPLETED ITS COMMUNITY HEALTH NEEDS ASSESSMENT IN 2022. THE FOLLOWING NEEDS WERE IDENTIFIED AND WILL BE ADDRESSED OVER THE NEXT 3 YEARS.PRIMARY CARE/MENTAL HEALTH CARE AND INTEGRATED DELIVERYMENTAL HEALTHCHRONIC DISEASE MANAGEMENT (DIABETIC)HOUSING FOOD INSECURITYPOVERTYTHE ORGANIZATION WILL NOT ADDRESS THE FOLLOWING NEEDS IDENTIFIED SINCE THEY ARE NOT PART OF THE HOSPITAL'S MISSION OF CRITICAL OPERATIONS. WE WILL PARTNER WITH OTHERS AS APPROPRIATE.HOUSING FOOD INSECURITYPOVERTYPRIMARY CARE / MENTAL HEALTH CARE INTEGRATED DELIVERY1. ASSESS PCP COMFORT AND INVOLVEMENT IN DIAGNOSING AND TREATING COMMON MENTAL HEALTH CONDITIONS.2. EXPLORE INTEGRATED BEHAVIORAL CARE MODELS AND EVALUATE COMMUNITY RESOURCES REQUIRED TO IMPLEMENT.3. RESEARCH GRANTS FOR PRIMARY CARE PRACTICES TO HIRE BEHAVIORAL HEALTH PROVIDERS OR OTHERWISE FACILITATE THE ADOPTION OF MODELS TO INTEGRATE BEHAVIORAL HEALTH AND PRIMARY CARE.MENTAL HEALTH1. MAINTAIN A COMMUNITY INVENTORY OF SERVICES TO DOCUMENT THE AVAILABILITY OF MENTAL HEALTH RESOURCES, INCLUDING HOURS OF SERVICE. MAKE THE INVENTORY AVAILABLE TO THE PUBLIC AS NEEDED. DOCUMENT MENTAL HEALTH SERVICES BY AGE CATEGORIES.2. INCREASE DEPRESSION SCREENINGS BY PRIMARY CARE PROVIDERS. 3. EXPAND MENTAL HEALTH TRAINING AND CREATE EDUCATION (MATERIALS / PRESENTATIONS) IN SCHOOLS AND COMMUNITY PROGRAMS TO DESTIGMATIZE MENTAL HEALTH ISSUES. EXPAND ACCESS TO MENTAL HEALTH THROUGH ADDING ADDITIONAL MENTAL HEALTH PROFESSIONALS TO SERVE THE COMMUNITY. 4. EXPAND ACCESS TO MENTAL HEALTH THROUGH ADDING ADDITIONAL MENTAL HEALTH PROFESSIONALS TO SERVE THE COMMUNITY. 5. INVESTIGATE GRANT WRITING TO FUND MENTAL HEALTH EDUCATION AND SERVICES. IF AVAILABLE, DESIGNATE COMMUNITY LEAD TO ATTAIN THE NECESSARY GRANT. 6. PROMOTE EXISTING MENTAL HEALTH SERVICES, FACILITIES, AND PROVIDERS. EDUCATE COMMUNITY ON PLACEMENT PROCESS AND OPTIONS THROUGH HOSPITAL PHYSICIANS, CLINICS, AND E.R. 7. ESTABLISH SUPPORT GROUPS (SUCH AS FAMILIES WITH MENTAL HEALTH CRISES, GRIEF GROUP) LED BY A SOCIAL WORKER.IN 2024, WE INTEGRATED BEHAVIORAL HEALTH SERVICES INTO THE PRIMARY CARE SETTING, SIGNIFICANTLY ENHANCING ACCESS TO MENTAL HEALTH RESOURCES ACROSS THE COMMUNITY.CHRONIC DISEASE MANAGEMENT (DIABETIC)1. CONTINUE DIABETES PREVENTION LIFESTYLE CHANGE PROGRAM WITH SELF-MANAGEMENT EDUCATION AND MEDICAL NUTRITION THERAPY FOR THOSE WITH DIABETES OR PRE-DIABETES.2. EXPLORE OFFERING MOBILE OR OFFSITE DIABETIC SCREENINGS IN COMMUNITY.3. OFFER EXERCISE CLASSES AND FITNESS PROGRAM SUPPORT IN COMMUNITY.4. SUPPORT TEMPORARY PROGRAMS THAT WORK TO ENERGIZE PARTICIPANTS TO LOSE WEIGHT VIA PRIZES, OFTEN COMBINED WITH EDUCATION, WEIGHT STATUS AND FOOD INTAKE TRACKING, REGULAR CHECK-INS, AND GROUP SUPPORT.5. BUILD, STRENGTHEN, AND MAINTAIN SOCIAL NETWORKS THAT PROVIDE SUPPORTIVE RELATIONSHIPS FOR BEHAVIOR CHANGE THROUGH WALKING GROUPS OR OTHER COMMUNITY-BASED INTERVENTIONS. HIAWATHA HOSPITAL ASSOCIATION, INC. PART V, SECTION B, LINE 13H: IN ADDITION TO FEDERAL POVERTY GUIDELINES, THE ORGANIZATION USES ASSET LEVEL, INSURANCE STATUS, RESIDENCY, MEDICAL INDIGENCY, HOUSEHOLD SIZE AND UNDERINSURANCE STATUS AS FACTORS IN DETERMINING ELIGIBILITY FOR FREE OR DISCOUNTED CARE.A DISCOUNT IN 10% INCREMENTS (RANGING FROM 10% TO 100%) IS GIVEN ON INCOME UP TO 200% OF FEDERAL POVERTY GUIDELINES. PRESUMPTIVE FINANCIAL ASSISTANCE ELIGIBILITY1. THERE ARE INSTANCES WHEN A PATIENT MAY APPEAR ELIGIBLE FOR FINANCIAL DISCOUNTS, BUT THERE IS NO FINANCIAL ASSISTANCE FORM ON FILE OR A LACK OF SUPPORTING DOCUMENTATION. IN THE EVENT THERE IS NO EVIDENCE TO SUPPORT A PATIENT'S ELIGIBILITY FOR FINANCIAL ASSISTANCE, AMBERWELL HIAWATHA MAY USE OUTSIDE AGENCIES OR VENDORS IN DETERMINING ELIGIBILITY AND POTENTIAL DISCOUNT AMOUNTS. THESE RESOURCES MAY USE DEMOGRAPHIC AND HOUSEHOLD INFORMATION AND/OR CREDIT SCORING TECHNOLOGY TO DETERMINE THE PERCENT OF ASSISTANCE TO APPLY TO THE PATIENT'S ACCOUNT.2. PATIENTS WHO MEET PRESUMPTIVE ELIGIBILITY CRITERIA MAY BE GRANTED FINANCIAL ASSISTANCE WITHOUT COMPLETING THE APPLICATION. SCHEDULE H, PART V, SECTION B, LINE 7A AND 10A: COMMUNITY HEALTH NEEDS ASSESSMENT AND IMPLEMENTATIONSTRATEGY WEBSITE:HTTPS://AMBERWELLHEALTH.ORG/COMMUNITY-HEALTH-NEEDS-ASSESSMENT/ PART I, LINE 3C: IN ADDITION TO FEDERAL POVERTY GUIDELINES, THE ORGANIZATION USES ASSET LEVEL, INSURANCE STATUS, RESIDENCY, MEDICAL INDIGENCY, HOUSEHOLD SIZE AND UNDERINSURANCE STATUS AS FACTORS IN DETERMINING ELIGIBILITY FOR FREE OR DISCOUNTED CARE.A DISCOUNT IN 10% INCREMENTS (RANGING FROM 10% TO 100%) IS GIVEN ON INCOME UP TO 200% OF FEDERAL POVERTY GUIDELINES. PRESUMPTIVE FINANCIAL ASSISTANCE ELIGIBILITY1. THERE ARE INSTANCES WHEN A PATIENT MAY APPEAR ELIGIBLE FOR FINANCIAL DISCOUNTS, BUT THERE IS NO FINANCIAL ASSISTANCE FORM ON FILE OR A LACK OF SUPPORTING DOCUMENTATION. IN THE EVENT THERE IS NO EVIDENCE TO SUPPORT A PATIENT'S ELIGIBILITY FOR FINANCIAL ASSISTANCE, AMBERWELL HIAWATHA MAY USE OUTSIDE AGENCIES OR VENDORS IN DETERMINING ELIGIBILITY AND POTENTIAL DISCOUNT AMOUNTS. THESE RESOURCES MAY USE DEMOGRAPHIC AND HOUSEHOLD INFORMATION AND/OR CREDIT SCORING TECHNOLOGY TO DETERMINE THE PERCENTAGE OF ASSISTANCE TO APPLY TO THE PATIENT'S ACCOUNT.2. PATIENTS WHO MEET PRESUMPTIVE ELIGIBILITY CRITERIA MAY BE GRANTED FINANCIAL ASSISTANCE WITHOUT COMPLETING THE APPLICATION. PART I, LINE 6A: THE COMMUNITY BENEFIT REPORT IS PREPARED BY VVV CONSULTING AND IS POSTED ON THE HOSPITAL'S WEBSITE. PART I, LINE 7: CHARITY CARE EXPENSE WAS CONVERTED TO COST ON AN OVERALL COST-TO-CHARGE RATIO ADDRESSING ALL PATIENT SEGMENTS. UNREIMBURSED MEDICAID ON LINE 7B WAS CALCULATED USING THE COSTING METHODS TO PREPARE THE COST REPORTS. THE COST FOR SUBSIDIZED HEALTH SERVICES WAS DETERMINED USING THE MEDICARE COST REPORT. PART III, LINE 2: THE AMOUNT REPORTED ON LINE 2 REPRESENTS IMPLICIT PRICE CONCESSIONS. THE HOSPITAL DETERMINES ITS ESTIMATE OF IMPLICIT PRICE CONCESSIONS BASED ON ITS HISTORICAL COLLECTION EXPERIENCE WITH THIS CLASS OF PATIENTS. PART III, LINE 3: THE ESTIMATED AMOUNT OF THE ORGANIZATION'S IMPLICIT PRICE CONCESSIONS ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S CHARITY CARE POLICY IS CALCULATED BASED ON AN APPROXIMATE 15.1% OF INDIVIDUALS LIVING BELOW THE POVERTY LEVEL IN THE SERVICE AREA. PART III, LINE 4: THE FOOTNOTE TO THE ORGANIZATION'S FINANCIAL STATEMENTS CAN BE FOUND ON PAGES 11 AND 12 OF THE ATTACHED AUDITED FINANCIAL STATEMENTS. PART III, LINE 8: HIAWATHA HOSPITAL ASSOCIATION, INC. PROVIDES SERVICES TO PATIENTS UNDER THE MEDICARE PROGRAM KNOWING THEY WILL NOT RECOVER ALL THE COSTS ASSOCIATED WITH PROVIDING THESE SERVICES. PROVIDING THESE SERVICES IS ESSENTIAL TO THESE PATIENTS AND THE COMMUNITY AND INCREASES THEIR ACCESS TO HEALTHCARE SERVICES. THEREFORE, THE MEDICARE SHORTFALL IS CONSIDERED A COMMUNITY BENEFIT.TOTAL REVENUE RECEIVED FROM MEDICARE IS THE GROSS REIMBURSEMENT PLUS SETTLEMENT. BOTH TOTAL REVENUE RECEIVED FROM MEDICARE AND THE MEDICARE ALLOWABLE COSTS ARE REPORTED FROM THE MEDICARE COST REPORT. THE MEDICARE COST REPORT IS COMPLETED BASED ON THE RULES AND REGULATIONS SET FORTH BY THE CENTERS FOR MEDICARE AND MEDICAID SERVICES.HOSPITAL SERVICES REIMBURSED ON A FEE SCHEDULE ARE NOT INCLUDED IN THE MEDICARE CALCULATION PER THE 990 INSTRUCTIONS. HAD THIS BEEN REPORTED THE TOTAL LOSS FROM MEDICARE SERVICES WOULD HAVE INCREASED BY $233,013.MEDICARE FEE SCHEDULE REVENUE $ 315,564MEDICARE ESTIMATED COSTS OF CARE RELATING TO PAYMENTS (548,577)NET (SHORTAGE) $ (233,013) PART III, LINE 9B: THE HOSPITAL WILL NOT PURSUE EXTRAORDINARY COLLECTION ACTIVITIES ON PATIENTS FOR AT LEAST 120 DAYS FROM THE DATE OF THE FIRST STATEMENT AND PROVIDES PATIENTS 240 DAYS TO APPLY FOR ASSISTANCE. AFTER FINANCIAL ASSISTANCE DISCOUNTS HAVE BEEN APPLIED, ANY REMAINING SELF-PAY BALANCES WILL BE THE RESPONSIBILITY OF THE PATIENT/GUARANTOR, AND SUBJECT TO THE NORMAL STATEMENT PROCESS. THE PATIENT/GUARANTOR WILL RECEIVE A STATEMENT FROM OUR BILLING COMPANY. THEY WILL CONTINUE TO RECEIVE MONTHLY STATEMENTS FROM OUR BILLING COMPANY, AS WELL AS INTERMITTENT PHONE CALLS FOR APPROXIMATELY 120 DAYS UNTIL THE BALANCE IS PAID IN FULL OR A PAYMENT PLAN HAS BEEN SET UP. IF PAYMENT PLAN ARRANGEMENTS OR PAYMENT IN FULL HAVE NOT BEEN RECEIVED, THEY WILL RECEIVE A FINAL NOTICE AND BE SUBJECT TO FURTHER COLLECTION PROCESSES. WE ENCOURAGE PAYMENT IN FULL BUT UNDERSTAND THAT IT IS NOT ALWAYS POSSIBLE AND OFFER PAYMENT PLANS.FINANCIAL ASSISTANCE MAY BE APPLIED ON ANY ACCOUNT(S) THAT HAS BEEN ASSIGNED TO AN OUTSIDE COLLECTION AGENCY. AMBERWELL HIAWATHA CAN PLACE ACCOUNTS WITH A COLLECTION AGENCY WITHIN 120 DAYS, HOWEVER, THE COLLECTION AGENCY CANNOT BEGIN ANY EXTRAORDINARY COLLECTION ACTIONS AS DEFINED BY THE PATIENT PROTECTION AND AFFORDABLE CARE ACT SUBSECTION 501(R) SUCH AS LEGAL PROCESS, SELLING DEBT, REPORTING ADVERSE INFORMATION ON CREDIT BUREAUS, COMMENCE CIVIL ACTION, GARNISH WAGES, COMPLETE A LIEN OR CAUSE AN ARREST BEFORE THE FIRST 240 DAYS FROM THE DATE OF THE FIRST STATEMENT. ACCOUNTS ASSIGNED TO AN OUTSIDE AGENCY WILL BE REVIEWED ON A CASE-BY-CASE BASIS. PART VI, LINE 2: NOT ONLY DID WE SEEK FEEDBACK FROM COMMITTEE MEMBERS REPRESENTING LESSER-HEARD VOICES FROM OUR COMMUNITY, BUT WE MADE AN ONLINE SURVEY AVAILABLE, WE PUT HARD COPIES OF THE SURVEY IN MULTIPLE PLACES INCLUDING ALL OF THE TOWNS IN OUR SERVICE AREA. WE COMBINED THAT FEEDBACK WITH STATISTICAL INFORMATION FROM RELIABLE SOURCES TO IDENTIFY PRIORITIES. PART VI, LINE 3: WE POST INFORMATION ABOUT OUR FINANCIAL ASSISTANCE POLICY IN PROMINENT LOCATIONS. WE MAKE COPIES OF THE FINANCIAL ASSISTANCE POLICY AVAILABLE DURING REGISTRATION, IN INPATIENT ROOMS, ONLINE, AND ON OUR BILLING CORRESPONDENCE. PART VI, LINE 4: THE HOSPITAL SERVES A GEOGRAPHIC AREA THAT ENCOMPASSES ATCHISON, BROWN, DONIPHAN, JACKSON AND NEMAHA COUNTIES IN KANSAS, AND RICHARDSON COUNTY IN NEBRASKA. OF THOSE PATIENTS, 85% ARE FROM BROWN AND DONIPHAN COUNTIES. THESE ARE MOSTLY RURAL COMMUNITIES. 88% OF THE POPULATION OF THE BROWN AND DONIPHAN COUNTIES THAT IS 25 YEARS OR OLDER HAS A MINIMUM OF A HIGH SCHOOL DIPLOMA, 16% HAS A BACHELORS DEGREE OR HIGHER. THE AVERAGE MEDIAN HOUSEHOLD INCOME IS $41,300 COMPARED TO THE STATE WIDE MEDIAN HOUSEHOLD INCOME OF $50,594. 15.1% OF THE POPULATION LIVES BELOW THE FEDERAL POVERTY LEVEL. 16% OF THE POPULATION IN BROWN AND DONIPHAN COUNTIES DOES NOT HAVE HEALTH INSURANCE. PART VI, LINE 5: A MAJORITY OF THE HOSPITAL'S BOARD OF DIRECTORS ARE COMPRISED OF PERSONS WHO RESIDE IN THE HOSPITAL'S PRIMARY SERVICE AREA AND ARE NEITHER EMPLOYEES NOR CONTRACTORS OF THE HOSPITAL OR FAMILY MEMBERS THEREOF. THE HOSPITAL ALLOWS OTHER COMMUNITY PHYSICIANS (NOT EMPLOYED BY HIAWATHA) TO APPLY FOR AND BE GRANTED PRIVILEGES. ANY SURPLUS FUNDS FOR THE HOSPITAL ARE USED FOR CAPITAL INITIATIVES. EACH BUDGET MANAGER SUBMITS THEIR YEARLY BUDGETS TO THE ADMIN TEAM. ONCE THE SURPLUS AMOUNT IS CALCULATED, THE ADMIN TEAM WILL DISCUSS/APPROVE WHICH CAPITAL PROJECTS ARE PRIORITY FOR THE HOSPITAL'S CURRENT SITUATION AND FUTURE GROWTH.WE SUPPORT A WIDE ARRAY OF PROGRAMS AND PROJECTS IN OUR COMMUNITY. MANY OF OUR KEY EMPLOYEES SERVE ON MULTIPLE BOARDS THAT HAVE A POSITIVE IMPACT ON VARIOUS ASPECTS OF THE COMMUNITY. WE PROVIDE DONATIONS OF BOTH TIME AND MONEY TO VARIOUS SERVICE ORGANIZATIONS. PART VI, LINE 6: THE HOSPITAL IS PART OF AN AFFILIATED HEALTH CARE SYSTEM WITH AMBERWELL ATCHISON ASSOCIATION. X X X 0 0 0 0 0 0 0 0 0 CROSBY GERNON MD RADIOLOGIST 397407 0 0 0 0 0 7763 0 42063 0 447233 0 0 0 MARIAH KRIWIEL MD PHYSICIAN 326773 0 33000 0 0 0 3072 0 46095 0 408940 0 0 0 JESSICA JARVIS MD CHIEF OF STAFF 269707 0 24341 0 0 0 6209 0 44065 0 344322 0 0 0 ROBIN ALEXANDER CRNA 287470 0 0 0 0 0 6569 0 43936 0 337975 0 0 0 DUSTIN WILLIAMS NURSE PRACTITIONER 233370 0 12710 0 0 0 5373 0 44911 0 296364 0 0 0 PAIGE KNUDSON CRNA 268443 0 0 0 0 0 3085 0 7508 0 279036 0 0 0 A CITY OF HIAWATHA KANSAS 486025665 428545CY1 2020-03-31 6295000 SEE PART VI 0 0 0 A 1405000 6295000 125900 2000000 4169100 2022 1 0 1 1 A 0 0 0 0 0.00000 0.00000 0.00000 0 0 1 A 0 0 0 0 0 0 0 0 1 A 1 SCHEDULE K, PART I, LINE A, COLUMN F: THE BONDS WERE ISSUED TO (1) REFUND THE SERIES 2014 BONDS (ISSUED 9/29/2014) AND (2) MAKE CAPITAL IMPROVEMENTS INCLUDING STRUCTURAL IMPROVEMENTS AND THE ACQUISITION OF CAPITAL ASSETS TO IMPROVE HOSPITAL SERVICES. SCHEDULE K, PART IV, LINE 2: THE CLIENT IS IN THE PROCESS OF COMPLETING THE ARBITRAGE CALCULATION. SINCE NONE OF THE PROCEEDS WERE INVESTED THERE WILL BE NO REBATE DUE. FORM 990, PART VI, SECTION A, LINE 7B THE GOVERNING BOARD SHALL HAVE RESPONSIBILITY FOR THE MANAGEMENT AND OPERATION OF THE HOSPITAL ACTIVITIES SUBJECT TO THE RATIFICATION RIGHTS OF THE HEALTH SYSTEM SET FORTH IN THE AFFILIATION AGREEMENT, WHICH INCLUDES: A. THE HEALTH SYSTEM'S RIGHT TO RATIFY THE APPOINTMENT AND RETENTION OF DIRECTORS OF THE GOVERNING BOARD, WHICH, APPROVAL MAY ONLY BE WITHHELD BY THE HEALTH SYSTEM DUE TO A CANDIDATE'S CONFLICT OF INTEREST OR FAILURE TO MEET BEST PRACTICES FOR HOSPITAL GOVERNANCE; B. THE HEALTH SYSTEM'S RIGHT TO EXERCISE REASONABLY NECESSARY MANAGEMENT AUTHORITY IN ORDER FOR THE HEALTH SYSTEM TO PROVIDE SERVICES AS A "HOME OFFICE" ON BEHALF OF THE HOSPITAL WHICH, PURSUANT TO 42 CFR PART 485 AND THE REGULATIONS PROMULGATED BY THE LICENSING AUTHORITY OF THE STATE OF KANSAS, MAY BE DELEGATED TO A MANAGEMENT COMPANY BY A STATE LICENSED CRITICAL ACCESS HOSPITAL, EXCLUDING THOSE AUTHORITIES WHICH, PURSUANT TO THE FOREGOING REGULATIONS OR THE EXPRESS TERMS OF THE AFFILIATION AGREEMENT ARE RETAINED BY THE HOSPITAL'S GOVERNING BOARD; C. THE HEALTH SYSTEM'S RIGHT TO FACILITATE THE ADOPTION OF THE ANNUAL CAPITAL AND OPERATING BUDGETS AS FOLLOWS. THE HEALTH SYSTEM SHALL HAVE AUTHORITY AND RESPONSIBILITY FOR CREATING A HOSPITAL BUDGET PROCESS WHICH WILL HAVE THE FOLLOWING CONDITIONS: I. THE HEALTH SYSTEM WILL ANNUALLY PROVIDE THE PROTOCOLS FOR THE HOSPITAL BUDGET PROCESS WHICH THE HOSPITAL MUST FOLLOW IN CREATING THE HOSPITAL BUDGET; II. THE HOSPITAL'S CHIEF EXECUTIVE OFFICER AND CHIEF FINANCIAL OFFICER WILL ANNUALLY IMPLEMENT THE HOSPITAL BUDGET PROCESS WITH THE ASSISTANCE OF THE HEALTH SYSTEM, TO INCLUDE HOSPITALS' DEPARTMENT MANAGERS; III. ANNUALLY, THE HOSPITAL'S GOVERNING BOARD WILL SUBMIT A HOSPITAL BUDGET TO THE HEALTH SYSTEM DIRECTORS WHO MAY EITHER A) APPROVE; OR, B) REJECT AND SEND BACK TO THE HOSPITAL'S GOVERNING BOARD WITH RECOMMENDED CHANGES. THE HOSPITAL'S GOVERNING BOARD WILL BE REQUIRED TO SEND A REVISED HOSPITAL BUDGET TO THE HEALTH SYSTEM DIRECTORS WHO MAY THEREAFTER EITHER APPROVE OR MODIFY THE HOSPITAL BUDGET, WHICH THE HOSPITAL'S GOVERNING BOARD SHALL ADOPT; AND IV. THE ANNUAL HOSPITAL BUDGET WILL INCLUDE PROVISIONS THAT AUTHORIZE DISCRETIONARY SPENDING BY THE HOSPITAL'S GOVERNING BOARD WITHIN THE HOSPITAL'S BUDGET AND STRATEGIC PLAN DURING THE HOSPITAL'S FISCAL YEAR. D. THE HEALTH SYSTEM'S RIGHT TO APPROVE OF ANY STRATEGIC PLANS OR MATERIAL NONCLINICAL PROGRAMING AND MARKETING PLANS, INCLUDING MATERIAL MODIFICATIONS THEREOF; E. THE HEALTH SYSTEM'S PRE-AUTHORIZATION OF DEBT INCURRED, ASSUMED, OR GUARANTEED BY THE HOSPITAL OTHER THAN AS PROVIDED FOR IN ANY APPROVED ANNUAL CAPITAL OR OPERATING BUDGET; F. THE HEALTH SYSTEM'S PRE-AUTHORIZATION OF ANY MATERIAL ACQUISITION, DISPOSITION, FORMATION, ORGANIZATION OR INVESTMENT BY THE HOSPITAL OF OR IN ANY OTHER CORPORATION, PARTNERSHIP, LIMITED LIABILITY COMPANY, OTHER ENTITY OR JOINT VENTURE; G. THE HEALTH SYSTEM'S PRE-AUTHORIZATION OF THE SALE, DISPOSITION, MORTGAGE, OR ENCUMBRANCE OF ANY ASSETS DEDICATED TO THE OPERATIONS OF THE HOSPITAL; H. THE HEALTH SYSTEM'S PRE-AUTHORIZATION OF THE HOSPITAL TO ENTER INTO ANY MERGER, CONSOLIDATION OR JOINT VENTURE; OR TO SELL OR DISPOSE OF SUBSTANTIALLY ALL OF THE ASSETS OF THE HOSPITAL OR ANY OF ITS RESPECTIVE SUBSIDIARIES; OR TO CREATE OR ACQUIRE ANY SUBSIDIARY ORGANIZATION; I. THE HEALTH SYSTEM'S PRE-AUTHORIZATION OF THE HOSPITAL TO INSTITUTE ANY BANKRUPTCY, INSOLVENCY OR REORGANIZATION PROCEEDINGS FOR ITSELF OR ANY SUBSIDIARY; J. THE HEALTH SYSTEM'S PRE-AUTHORIZATION OF A CAPITAL INVESTMENT BY THE HOSPITAL OR ANY OF ITS SUBSIDIARIES IN ANY INDIVIDUAL ENTITY OR PROJECT IN THE FORM OF CASH OR EITHER TANGIBLE OR INTANGIBLE PROPERTY, EXCEPT AS PROVIDED IN ANY APPROVED ANNUAL CAPITAL OR OPERATING BUDGET; K. THE HEALTH SYSTEM'S PRE-AUTHORIZATION TO DEVELOP, IMPLEMENT OR APPROVE THE TERMINATION OF A SERVICE LINE BY THE HOSPITAL OR ITS SUBSIDIARIES; L. THE HEALTH SYSTEM'S PRE-AUTHORIZATION OF ANY AMENDMENT OF THE ARTICLES OF INCORPORATION OR BYLAWS OF THE HOSPITAL OR ITS SUBSIDIARIES TO THE EXTENT THAT IT WOULD A) IMPACT THE RESERVED POWERS SET FORTH IN THE AFFILIATION AGREEMENT; OR B) REASONABLY BE EXPECTED TO HAVE A MATERIAL STRATEGIC, COMPETITIVE OR FINANCIAL IMPACT ON THE HEALTH SYSTEM OR ANY OF ITS AFFILIATES; AND M. THE HEALTH SYSTEM'S COLLABORATION WITH THE HOSPITAL'S GOVERNING BOARD'S APPOINTMENT OR REAPPOINTMENT OF A CHIEF EXECUTIVE OFFICER IN A PROCESS DESCRIBED IN THE AFFILIATION AGREEMENT. FORM 990, PART VI, SECTION A, LINE 8B THE HEALTH SYSTEM DOES NOT HAVE A COMMITTEE THAT ACTS ON BEHALF OF THE GOVERNING BOARD. FORM 990, PART VI, SECTION B, LINE 11B AN INDEPENDENT ACCOUNTING FIRM PREPARES AND REVIEWS THE 990. THE 990 IS THEN REVIEWED BY THE ORGANIZATION'S OFFICERS AND ACCOUNTING PERSONNEL. ANY QUESTIONS OR CONCERNS THE ORGANIZATION'S OFFICERS AND ACCOUNTING PERSONNEL HAVE ARE ADDRESSED AND ANY CORRECTIONS OR CLARIFICATIONS THAT NEED TO BE MADE ARE MADE. THE FINAL FORM 990 WITH ALL REQUIRED SCHEDULES IS THEN PROVIDED TO ALL VOTING MEMBERS OF THE BOARD PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C ALL EMPLOYEES AND DECISION MAKERS FOR THE HOSPITAL ARE COVERED UNDER THIS POLICY. CONFLICTS ARE EITHER REVIEWED BY THE CORPORATE COMPLIANCE OFFICER OR THE BOARD PRESIDENT. AT BOARD MEETINGS, THE BOARD CHAIR IS APPRAISED OF ALL CONFLICTS OF INTEREST AND THEN ASKS THE MEMBER TO ABSTAIN FROM DISCUSSING AND VOTING ON TOPICS OF CONFLICT. FORM 990, PART VI, SECTION B, LINE 15A THE ORGANIZATION ENGAGES ITS LEGAL COUNSEL TO PREPARE COMPENSATION DATA STUDIES. IN ADDITION TO VARIOUS DATA COLLECTED, OTHER HOSPITALS' 990'S ARE REVIEWED AND COMBINED IN THE COMPENSATION STUDY. THE HOSPITAL'S LEGAL COUNSEL REVIEWS THE STUDY WITH THE BOARD OF DIRECTORS TO ADJUST THE PRESIDENT & CEO'S COMPENSATION. ANY DECISION THAT IS MADE IN REGARDS TO THE PRESIDENT & CEO'S COMPENSATION IS DOCUMENTED BY THE BOARD OF DIRECTORS. THE PROCESS WAS LAST COMPLETED IN 2024. THE CEO AND HUMAN RESOURCE DIRECTOR CONDUCT AN ANNUAL REVIEW OF OTHER OFFICERS AND KEY EMPLOYEES' COMPENSATION BASED ON COMPARABLE DATA OF OTHER ORGANIZATIONS OF SIMILAR SIZE AND INDUSTRY. THIS IS DONE ON AN ANNUAL BASIS AND DOCUMENTED IN THE PERSONNEL FILES. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART VII: CHASE DUDZINSKI SERVED AS THE CFO. COMPENSATION FOR THE CFO WAS DETERMINED AND PAID BY AMBERWELL ATCHISON ASSOCIATION, AN UNRELATED ORGANIZATION, FOR SERVICES PROVIDED TO BOTH AMBERWELL ATICHISON ASSOCIATION AND HIAWATHA HOSPITAL ASSOCIATION. HIAWATHA HOSPITAL ASSOCIATION REIMBURSES AMBERWELL ATCHISON ASSOCIATION 30% OF THE CFO'S TOTAL COMPENSATION AND BENEFITS. THE AMOUNTS REPORTED ON PART VII REFLECT THE PORTION OF COMPENSATION THAT IS REIMBURSED BY HIAWATHA HOSPITAL ASSOCIATION FOR HIS SERVICES AS THE CFO. FORM 990, PART IX, LINE 11G OTHER SERVICE FEES: PROGRAM SERVICE EXPENSES 314,367. MANAGEMENT AND GENERAL EXPENSES 618,149. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 932,516. PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 462,816. MANAGEMENT AND GENERAL EXPENSES 145,404. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 608,220. LEASED EMPLOYEES: PROGRAM SERVICE EXPENSES 1,090,562. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,090,562. SHARED EMPLOYEE: PROGRAM SERVICE EXPENSES 445,118. MANAGEMENT AND GENERAL EXPENSES 544,144. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 989,262. FORM 990, PART XI, LINE 9: CHANGE IN INTEREST IN FOUNDATION -16,065. FORM 990, PAGE 12, PART XII, LINE 2C: THE BOARD OF DIRECTORS HAS THE RESPONSIBILITY OF SELECTING THE INDEPENDENT ACCOUNTANT TO COMPLETE THE AUDIT WORK. THE FINANCE COMMITTEE OF THE BOARD OF DIRECTORS HAS THE RESPONSIBILITY FOR THE OVERSIGHT OF THE AUDIT. UPON CONCLUSION OF THE AUDIT, THE AUDITING FIRM PRESENTS THE RESULTS AND FINDINGS TO THE BOARD OF DIRECTORS. THIS PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. HIAWATHA COMMUNITY HOSPITAL FOUNDATION 300 UTAH STREET HIAWATHA KS 66434 481223766 FUNDRAISING KS 501(C)(3) LINE 12D, III-O 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 0 0