2018-05-04T08:26:10-05:00 2017-06-30 410746749 CLIFTONLARSONALLEN LLP 220 SOUTH SIXTH STREET SUITE 300 MINNEAPOLIS MN 55402 990 2016-07-01 810233499 SIDNEY HEALTH CENTER SIDN 4064882100 216 14TH AVENUE SW SIDNEY MT 59270 TINA MONTGOMERY CFO 4064882100 2018-05-03 1 KURT BENNION P01469618 6123764500 2018-05-03 2016 2022-09-23 18:48:47Z THERESA LIVERS 216 14TH AVENUE SW SIDNEY MT 59270 73050026 0 X WWW.SIDNEYHEALTH.ORG X 1946 MT TO HELP THOSE WE SERVE ACHIEVE THEIR HIGHEST LEVEL OF HEALTH BY PROVIDING QUALITY MEDICAL CARE. 10 8 581 145 958591 201002 352942 400457 57417667 61358944 507510 871763 2770181 2284589 61048300 64915753 400 43854 0 0 25967546 27797641 0 0 318582 38332808 35146992 64300754 62988487 -3252454 1927266 61758012 61740167 31715771 28620615 30042241 33119552 X TO HELP THOSE WE SERVE ACHIEVE THEIR HIGHEST LEVEL OF HEALTH AND WELL-BEING. 0 0 56340170 43854 61358944 SIDNEY HEALTH CENTER IS A NOT-FOR-PROFIT COMMUNITY BASED MEDICAL CENTER THAT HAS BEEN SERVING PEOPLE IN THE MONDAK REGION FOR MORE THAN 100 YEARS. OUR PASSION FOR CARING IS SHARED BY THE DOCTORS, NURSES, AND SEVERAL HUNDRED EMPLOYEES AND VOLUNTEERS. THIS COMMITMENT TO CARING IS OUR ALLEGIANCE TO THE COMMUNITY AS WE STRIVE TO PROVIDE "EXCEPTIONAL CARE FOR LIFE."LOCATED IN THE HEART OF RICHLAND COUNTY, THE ATTRACTIVE EASTERN MONTANA CAMPUS INCLUDES AN ACUTE CARE HOSPITAL, CLINIC AREA, RETAIL PHARMACY AND A 93-BED EXTENDED CARE FACILITY OFFERING A COMPLETE RANGE OF SERVICES FROM BIRTH THROUGH END-OF-LIFE, WHICH IS COMPLEMENTED BY AN ARRAY OF OUTREACH SERVICES. THIS CONTINUUM OR SUCCESSION OF SERVICES IS NOT TYPICAL OF RURAL HEALTHCARE ORGANIZATIONS, BUT SIDNEY HEALTH CENTER IS NOT TYPICAL. A STRONG COMPLEMENT OF PRIMARY CARE PHYSICIANS AND A UNIQUE SELECTION OF SURGICAL SPECIALISTS COMBINED WITH A MODERN FACILITY, AND UP-TO-DATE MEDICAL EQUIPMENT, MAKES SIDNEY HEALTH CENTER A SPECIAL PLACE TO WORK, RECEIVE CARE AND PRACTICE MEDICINE. SIDNEY HEALTH CENTER ALSO PROVIDES VARIOUS COMMUNITY BENEFIT PROGRAMS FOR THE INDIVIDUALS IN THEIR SERVICE REGION.RICHLAND COUNTY TRANSPORTATION - THIS PROGRAM GIVES OPPORTUNITIES FOR THOSE WHO CANNOT DRIVE THE OPTION OF A RIDE. SIDNEY HEALTH CENTER PROVIDES A DRIVER AND HELPS PAY FOR BUSSES. SINCE IT'S CONCEPTION WE HAVE GONE FROM ONE BUS AND ONE DRIVER FOR THE FULL PROGRAM TO 5 BUSSES AND 8 DRIVERS. WE WORK WITH THE HEALTH DEPARTMENT, RICHLAND COUNTY AND THE LODGE.MILES CITY NURSING PROGRAM - WE PROVIDE THE FACILITY AND PROGRAM COSTS TO HAVE MILES CITY COMMUNITY COLLEGE RUN A SATELLITE SCHOOL HERE IN SIDNEY. THIS PROMOTES NURSING AS A PROFESSION AND KEEPS THOSE WHO ARE INTERESTED IN OUR COMMUNITY AS POSSIBLE EMPLOYEES LATER.OUTREACH CLINIC - SOME OF THE OUTLYING COMMUNITIES DO NOT HAVE ACCESS TO AN ENT PHYSICIAN. SIDNEY HEALTH CENTER PROVIDES THE TRAVEL FOR OUR ENT TO GO TO THOSE OUTREACH AREAS.LIVE-IT-UP - THIS IS A PROGRAM THAT SIDNEY HEALTH CENTER DOES TO MAKE WOMEN OF RICHLAND COUNTY AWARE OF HOW HEART DISEASE AFFECTS THEM. RICHLAND COUNTY FAIR & RODEO - SIDNEY HEALTH CENTER PROVIDES A BOOTH WHERE PEOPLE CAN GET THEIR BLOOD PRESSURE TAKEN, DO A FINGER STICK BLOOD TEST FOR DIABETS AND GET A BOTTLE OF WATER FOR FREE IN THE EXTREME HOT AUGUST DAYS OF THE FAIR.GRIEF RECOVERY SUPPORT GROUPS - SIDNEY HEALTH CENTER'S HOSPICE PROGRAMS PUT ON TWO DIFFERENT CAMPS FOR PEOPLE WHO HAVE LOST LOVED ONES. ONE IS FOR ADULTS, THE OTHER FOR KIDS. THERE ARE ALSO MEMORIAL SERVICES AND NUMEROUS GRIEF SUPPORT GROUPS THROUGHOUT THE YEAR.BIRTHDAY HEALTH FAIR - PATIENTS WHO SIGN UP CAN GET LABS DURING THEIR BIRTHDAY MONTH.VISITING NURSE SERVICE - INITIAL NURSE VISIT.MEDICATION ASSISTANCE - PROVIDES MEDS TO THOSE WHO HAVE NO INSURANCE. ALSO HELPS GET PATIENTS SIGNED UP WITH DRUG COMPANIES FOR FREE MEDICATIONSRX BOXES - PHARMACY SETS UP PILLS IN MEDICATION BOXES SO THAT GROUP HOME RESIDENTS GET THE CORRECT PILLS FOR EACH ADMINISTRATION TIME.SCHOOL AGE BASED EDUCATION ACTIVITIES - CENTRAL SCHOOL BLOOD TYPING. INTERACTIVE TOUR FOR 2ND GRADERS.CHAMBER OF COMMERCE - VARIOUS DONATIONS FOR COMMUNITY AND CHAMBER FUNCTIONS.CHILDBIRTH CLASSES - CLASSES OFFERED TO THE COMMUNITY. 56340170 1 1 0 1 0 0 0 0 1 0 1 1 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 1 1 1 0 0 1 115 0 581 1 1 1 0 0 0 0 0 0 0 0 0 X 10 8 0 0 0 0 1 1 1 1 1 0 0 0 1 1 1 1 1 1 1 0 X TINA MONTGOMERY CFO 4064882117 216 14TH AVENUE SW SIDNEY MT 59270 RANDY JOHNSON PRESIDENT 1.00 1.00 X X 0 0 0 BRIAN MCGINNIS VICE PRESIDENT (THROUGH AUG 2016) 1.00 1.00 X X 0 0 0 DICK VANDE BOSSCHE TRUSTEE & VICE PRESIDENT 1.00 1.00 X X 0 0 0 MARK MARTIN SECRETARY/TREASURER (THRU AUG 2016) 1.00 1.00 X X 0 0 0 REBECCA BRADLEY TRUSTEE & SECRETARY/TREASURER 1.00 1.00 X X 0 0 0 LANCE AVERETT TRUSTEE 1.00 1.00 X 0 0 0 BRYCE BAKER TRUSTEE 1.00 1.00 X 0 0 0 ROBERT BURNISON TRUSTEE 1.00 1.00 X 0 0 0 LYLE HARRISON MD TRUSTEE 39.00 1.00 X 0 0 0 LESZEK JASZCZAK MD TRUSTEE 39.00 1.00 X 519300 0 1028 SANDRA JEPSEN TRUSTEE 1.00 1.00 X 0 0 0 CHERYL VAN EVERY TRUSTEE 1.00 1.00 X 0 0 0 RICHARD HARALDSON CEO 39.00 1.00 X 270006 0 8533 TINA MONTGOMERY CFO 39.00 1.00 X 143405 0 10561 JEROME KESSLER PHYSICIAN 40.00 X 421010 0 8978 KELLY O'NEAL GENERAL SURGEON 40.00 X 440508 0 8978 GEORGE SCORDALAKES MD PHYSICIAN 40.00 X 449380 0 8690 SHARI TWIGG MD PHYSICIAN 40.00 X 314180 0 6677 JEFFREY GILES ORTHOPEDIC SURGEON 40.00 X 618558 0 1028 3176347 0 54473 28 0 1 0 MEDIKAR PC 214 14TH AVE SUITE 110 SIDNEY MT 59270 PHYSICIAN SERVICES 1000000 BRETT BENNION MD 214 14TH AVENUE SW SIDNEY MT 59270 PHYSICIAN SERVICES 774700 O PETE COUNCIL MD 214 14TH AVENUE SW SUITE 104 SIDNEY MT 59270 PHYSICIAN SERVICES 409081 DAWN MCCARTNEY-TANNER MD 1153 BERGEN PARKWAY SUITE I-409 EVERGREEN CO 80439 PHYSICIAN SERVICES 329869 MICHAEL LAPAN MD 517 4TH STREET SE SIDNEY MT 59270 PHYSICIAN SERVICES 325000 10 16500 383957 400457 PATIENT REVENUES 621500 54673094 54673094 CLINIC PHARMACY 446110 5838056 4879465 958591 OTHER PATIENT CARE 621500 847794 847794 61358944 478437 478437 6000 0 6000 6000 6000 8331631 7927421 10884 404210 -10884 393326 393326 324787 195968 128819 128819 OTHER PHARMACY REVENUE 900099 1431359 1431359 MEAL INCOME 900099 347691 347691 MISCELLANEOUS REVENUE 900099 280717 280717 90003 90003 2149770 64915753 60400353 958591 3156352 X 43854 43854 472910 174334 259400 39176 22347199 20653005 1532241 161953 443433 406094 34614 2725 2994619 2723284 236208 35127 1539480 1402260 122701 14519 70349 70349 105326 104686 640 97763 97763 11580691 10058715 1508520 13456 166672 15236 139975 11461 2650604 2027849 598331 24424 551287 551287 1070166 1061883 3179 5104 380783 398312 -25650 8121 1110319 1110319 4211159 4211159 683027 671546 11481 UBI TAXES 77883 77883 PHARMACY/LAB EXPENSE 9227066 9225810 1256 BAD DEBT 1708729 1708729 RECRUITING 397569 391427 6081 61 1057599 615386 440398 1815 62988487 56340170 6329735 318582 5103095 7511134 13828196 10988295 41158 41158 1675187 1701733 996417 972557 68744185 48028991 23127846 20715194 11733529 13547232 2304918 3571410 672456 573085 2275210 2118369 61758012 61740167 5716354 5122161 20885206 19395087 8927 9883 2688153 2078474 2417131 2015010 31715771 28620615 X 29369785 32546467 672456 573085 30042241 33119552 61758012 61740167 X 1927266 406601 743444 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 3960 3960 0 PART II-B, LINE 1: A PORTION OF THE MEMBERSHIP DUES PAID TO THE MONTANA HOSPITAL ASSOCIATION, THE AMERICAN HOSPITAL ASSOCIATION AND LEADINGAGE ARE USED FOR LOBBYING. 0 1 X 198261 198261 43000231 27076814 15923417 25447816 20952177 4495639 97877 97877 20715194 MONEY MARKET FUNDS 1725057 F CDS AND REPURCHASE AGREEMENTS 1846353 F 3571410 ESTIMATED THIRD-PARTY PAYOR PAYABLES 639000 SWAP CONTRACT LIABILITIES 1376010 2015010 X 62130772 206852 206852 61923920 97763 2894070 2991833 64915753 61377963 195968 195968 61181995 97763 1708729 1806492 62988487 PART IV, LINE 2B: RESIDENT TRUST ACCOUNT: THIS IS THE EXTENDED CARE RESIDENT TRUST ACCOUNT, WHICH IS MADE UP OF THE RESIDENTS' MONEY THAT SIDNEY HEALTH CENTER HOLDS ON THEIR BEHALF. THESE MONIES ARE KEPT IN A SEPARATE BANK ACCOUNT FROM THE ORGANIZATION'S FUNDS AND ARE DUE BACK TO THE RESIDENTS UPON LEAVING THE FACILITY. PART X, LINE 2: THE IRS HAS DETERMINED THAT THE HEALTH CENTER IS A TAX-EXEMPT, NOT-FOR-PROFIT CORPORATION UNDER SECTION 501(C)(3) OF THE IRC. THE HEALTH CENTER FOLLOWS THE GUIDANCE IN THE ACCOUNTING STANDARDS REGARDING THE RECOGNITION AND MEASUREMENT OF UNCERTAIN TAX POSITIONS. THE GUIDANCE CLARIFIES THE ACCOUNTING FOR UNCERTAINTY IN INCOME TAXES RECOGNIZED IN AN ENTITY'S FINANCIAL STATEMENTS. THE GUIDANCE FURTHER PRESCRIBES RECOGNITION AND MEASUREMENT OF TAX PROVISIONS TAKEN OR EXPECTED TO BE TAKEN ON A TAX RETURN THAT ARE NOT CERTAIN TO BE REALIZED. THE APPLICATION OF THIS STANDARD HAS NO IMPACT ON THE HEALTH CENTER'S FINANCIAL STATEMENTS. THE HEALTH CENTER'S INCOME TAX RETURNS ARE SUBJECT TO REVIEW AND EXAMINATION BY FEDERAL, STATE, AND LOCAL AUTHORITIES. PART XI, LINE 2D - OTHER ADJUSTMENTS: COST OF GOODS SOLD 195,968. LOSS ON DISPOSAL OF FIXED ASSETS 10,884. PART XI, LINE 4B - OTHER ADJUSTMENTS: INVESTMENT INCOME 784,884. GRANTS AND CONTRIBUTIONS 400,457. BAD DEBT EXPENSE 1,708,729. PART XII, LINE 2D - OTHER ADJUSTMENTS: COST OF GOODS SOLD 195,968. PART XII, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT EXPENSE 1,708,729. 1 1 X 1 X 1 X 1 1 0 1 1 542299 542299 0.00860 542299 542299 0.00860 108474 108474 0.00170 14318 14318 0.00020 14758798 9825712 4933086 0.07830 14881590 9825712 5055878 0.08020 15423889 9825712 5598177 0.08880 1 1708729 0 12803727 12877852 -74125 X 1 1 1 1 SIDNEY HEALTH CENTER 216 14TH AVENUE SW SIDNEY MT 59270 WWW.SIDNEYHEALTH.ORG 12709 X X X X SIDNEY HEALTH CENTER 1 0 0 1 X X X X X X X X X 15 1 0 1 1 X SEE SCHEDULE H, PART VI, LINE 2 X 1 15 1 SEE SCHEDULE H, PART VI, LINE 2 0 1 X 100.000000000000 200.000000000000 1 1 X X X X 1 X WWW.SIDNEYHEALTH.ORG/BILLING X WWW.SIDNEYHEALTH.ORG/BILLING X WWW.SIDNEYHEALTH.ORG/BILLING X X X X X X 1 X 0 X X X 1 X 0 0 SIDNEY HEALTH CENTER PART V, SECTION B, LINE 5: PUBLIC INPUT WAS COLLECTED USING THE "COMMUNITY ASSESSMENT USING A PUBLIC HEALTH EMERGENCY RESPONSE" (CASPER) PROCESS. OVER A TWO-DAY PERIOD, 42 VOLUNTEERS WENT DOOR-TO-DOOR ACROSS OUR COMMUNITY AND COMPLETED 204 INTERVIEWS. IN ADDITION, SEVEN TOWN HALL MEETINGS WERE HELD IN APRIL 2016 IN VARIOUS LOCATIONS OF RICHLAND COUNTY. THESE MEETINGS WERE ADVERTISED IN LOCAL NEW MEDIA AND WERE OPEN TO THE PUBLIC. SIDNEY HEALTH CENTER PART V, SECTION B, LINE 6B: THE JUNE 30, 2016 COMMUNITY HEALTH NEEDS ASSESSMENT WAS OVERSEEN BY SIDNEY HEALTH CENTER, RICHLAND COUNTY HEALTH DEPARTMENT, AND THE PUBLIC HEALTH AND SAFETY DIVISION. SIDNEY HEALTH CENTER PART V, SECTION B, LINE 11: SIDNEY HEALTH CENTER ("SHC") IS RESPONDING TO ALL THE IDENTIFIED COMMUNITY HEALTH NEEDS, WITH THE EXCEPTION OF ONE THAT IS NOT WITHIN OUR SCOPE. SIDNEY HEALTH CENTER ADDRESSES THE NEEDS IDENTIFIED BY THE CHNA THAT ARE IN ALIGNMENT WITH OUR STRATEGIC GOALS. ONCE THESE NEEDS ARE IDENTIFIED, SHC CREATES A COMMUNITY HEALTH NEEDS IMPLEMENTATION PLAN.SHC IS ADDRESSING CHRONIC ILLNESS BY PROMOTING HEALTHY LIFESTYLES THROUGH COMMUNITY ENGAGEMENT ACTIVITIES, PROVIDING EDUCATIONAL RESOURCES AND SERVICES TO THE COMMUNITY, AND PROVIDING EDUCATIONAL SUPPORT TO THE COMMUNITY. OVERALL AWARENESS OF THE CANCER SERVICES PROVIDED BY SHC ARE BEING ADDRESSED BY IMPROVING ACCESS TO CANCER CARE SERVICES, IMPROVING QUALITY OF CARE FOR INDIVIDUALS WITH CANCER, AND PARTICIPATING IN COMMUNITY EVENTS SPECIFIC TO CANCER. SHC IS TRYING TO BETTER SERVE THE MENTAL AND BEHAVIORAL HEALTH NEEDS BY PARTICIPATING IN COMMUNITY GROUPS CONCERNED WITH MENTAL HEALTH, PROVIDING RESOURCES AND SUPPORT TO THE COMMUNITY TO ADDRESS MENTAL HEALTH, AND INCREASING ACCESS TO MENTAL AND BEHAVIORAL HEALTH SERVICES AND RESOURCES. 2 1 - SIDNEY HEALTH CENTER EXTENDED CARE 216 14TH AVE SW SIDNEY MT 59270 NURSING HOME 2 - THE LODGE AT LONE TREE 1015 7TH AVE SW SIDNEY MT 59270 ASSISTED LIVING COMPLEX PART I, LINE 3C: FINANCIAL ASSISTANCE IS BASED ON INCOME AND FAMILY SIZE ONLY. PRIOR TO QUALIFYING FOR FINANCIAL ASSISTANCE, AN INDIVIDUAL MUST (A) RECEIVE QUALIFYING MEDICAL SERVICES FROM SIDNEY HEALTH CENTER; (B) EXHAUST ALL ALTERNATIVE PAYMENT RESOURCES INCLUDING THIRD-PARTY AND FEDERAL AND STATE PROGRAMS; AND (C) SUBMIT A COMPLETED APPLICATION WITH THE REQUIRED SUPPORTING DOCUMENTATION. PART I, LINE 7: IN ORDER TO CALCULATE THE OVERALL HOSPITAL'S COST TO CHARGE RATIO USED FOR PART I, LINE 7, THE HOSPITAL FIRST DETERMINED A COST-TO-CHARGE RATIO BASED ON THE 2017 FILED MEDICARE COST REPORT SEPARATELY FOR INPATIENT SERVICES, OUTPATIENT SERVICES, AND TOTAL SERVICES. TO CALCULATE THE COST OF CHARITY CARE INCLUDED ON LINE 7A, THE HOSPITAL TOOK EACH OF THE SEPARATE COST-TO-CHARGE RATIOS DESCRIBED IN THE PRECEEDING PARAGRAPH AND APPLIED THEM ONLY TO THE RELATED CHARGES BY SERVICE TYPE TO COME UP WITH A WEIGHTED AVERAGE COST-TO-CHARGE RATIO. PART I, LINE 7G: THE FOLLOWING SUBSIDIZED HEALTH SERVICES WERE INCLUDED IN PART I, LINE 7G:OBSERVATION, NURSERY, IMPLANTS, AUDIOLOGY, CARDIAC REHAB, CLINIC FACILITY, EMERGENCY ROOM, AMBULANCE SERVICES, AND ENT/RADIOLOGY/ONCOLOGY CLINIC AND PROVIDER-BASED CLINIC. PART I, LN 7 COL(F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN A, BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $1,708,729. PART III, LINE 2: IN EVALUATING THE COLLECTABILITY OF PATIENT AND RESIDENT ACCOUNTS RECEIVABLE, THE HEALTH CENTER ANALYZES ITS PAST HISTORY AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYOR SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND PROVISION FOR UNCOLLECTIBLE ACCOUNTS. MANAGEMENT REGULARLY REVIEWS DATA ABOUT THESE MAJOR PAYOR SOURCES OF REVENUE IN EVALUATING THE SUFFICIENCY OF THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. FOR RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRD-PARTY COVERAGE, THE HEALTH CENTER ANALYZES CONTRACTUALLY DUE AMOUNTS AND PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS AND A PROVISION FOR UNCOLLECTIBLE ACCOUNTS, IF NECESSARY. FOR RECEIVABLES ASSOCIATED WITH SELF-PAY PATIENTS (WHICH INCLUDES BOTH PATIENTS WITHOUT INSURANCE AND PATIENTS WITH DEDUCTIBLE AND COPAYMENT BALANCES DUE FOR WHICH THIRD-PARTY COVERAGE EXISTS FOR PART OF THE BILL), THE HEALTH CENTER RECORDS A PROVISION FOR UNCOLLECTIBLE ACCOUNTS IN THE PERIOD OF SERVICE ON THE BASIS OF ITS PAST EXPERIENCE. PART III, LINE 3: THE HEALTH CENTER IS UNABLE TO ESTIMATE THE AMOUNT OF ITS BAD DEBT EXPENSE THAT IS ATTRIBUTABLE TO PATIENTS WHO WOULD QUALIFY FOR FINANCIAL ASSISTANCE IF THEY WERE TO COMPLETE A FINANCIAL ASSISTANCE APPLICATION. PART III, LINE 4: SEE THE "PATIENT AND RESIDENT ACCOUNTS RECEIVABLE, NET" PARAGRAPH IN NOTE 1 (PAGE 9) OF THE ATTACHED FINANCIAL STATEMENTS. PART III, LINE 8: THE MEDICARE ALLOWABLE COSTS INCLUDED IN PART III, LINE 6 IS DERIVED FROM USING THE 2017 FILED MEDICARE COST REPORT. THE SHORTFALL OCCURS DUE TO VARIOUS EXPENSES INCURRED BY THE FACILITY WHICH ARE CONSIDERED NON-REIMBURSABLE BY MEDICARE. SINCE PART OF THE COSTS ARE NOT REIMBURSED, IT IS ONLY PRUDENT TO CONSIDER THIS SHORTFALL TO BE A BENEFIT TO THE COMMUNITY. PART III, LINE 9B: IF THE PATIENT INDICATES THEIR INABILITY TO PAY ACCORDING TO THE HOSPITAL CREDIT TERMS THEY WILL BE ASKED TO FILL OUT A FINANCIAL STATEMENT. THE HOSPITAL MAY PULL A CREDIT REPORT TO CONFIRM OR SUPPLEMENT INFORMATION PROVIDED TO THE HOSPITAL ON THE FINANCIAL STATEMENT. THE PATIENT CAN THEN BE EVALUATED TO DETERMINE WHETHER THEY MAY BE ELIGIBLE FOR FINANCIAL ASSISTANCE OR AN EXTENDED PAYMENT PROGRAM.IF THE FINANCIAL STATEMENT SHOWS THAT THE PATIENT HAS ASSETS OR POTENTIAL SOURCES OF INCOME THAT WOULD ENABLE THEM TO PAY THE HOSPITAL BILL WITHIN A YEAR, THEY WILL BE DENIED THE EXTENDED PAYMENT WAIVER. IF A PATIENT REFUSES TO FURNISH A COMPLETED FINANCIAL STATEMENT, THEIR ACCOUNT WILL BE DEEMED DELINQUENT AND FURTHER COLLECTION ACTION WILL BE TAKEN. PRIOR TO ADMISSION, AT THE TIME OF ADMISSION, OR AS SOON AS POSSIBLE THEREAFTER, THE HOSPITAL WILL MAKE AN INITIAL ASSESSMENT OF POTENTIAL ELIGIBILITY BASED ON THE VERBAL APPLICATION FOR FINANCIAL ASSISTANCE. IF POTENTIAL ASSISTANCE IS INDICATED WITH INITIAL ASSESSMENT, THE HOSPITAL WILL NOT INITIATE COLLECTION EFFORTS OR REQUESTS FOR DEPOSITS PENDING THE RECEIPT OF THE COMPLETED APPLICATION AND FINAL ELIGIBILITY DETERMINATION. THE RESPONSIBLE PARTY MUST BE COOPERATIVE WITH THE HOSPITAL'S EFFORTS TO REACH A DETERMINATION OF ELIGIBILITY WITH OTHER ASSISTANCE PROGRAMS AND TO VALIDATE THE INFORMATION NEEDED.SIDNEY HEALTH CENTER WILL MAKE A CONCERTED EFFORT TO COMMUNICATE THE AVAILABILITY OF CHARITY CARE. EDUCATIONAL MATERIALS ABOUT THE PROGRAM WILL BE AVAILABLE TO PATIENTS THROUGH THE ADMISSIONS PROCESS. AS SOON AS A PATIENT EVIDENCES INABILITY TO PAY HE OR SHE WILL BE REFERRED TO THE PATIENT FINANCIAL SERVICES COUNSELOR FOR AN APPLICATION. APPLICATIONS ARE ALSO AVAILABLE AT THE ADMISSIONS AREA, AND THROUGH SOCIAL SERVICES. PART VI, LINE 2: THE HOSPITAL CONDUCTED A COMMUNITY HEALTH NEEDS ASSESSMENT IN THE YEAR ENDED JUNE 30, 2016. THE REPORT AND PLANNED RESPONSES ARE AVAILABLE ONLINE AT HTTP://WWW.SIDNEYHEALTH.ORG/ABOUTUS/COMMUNITY-HEALTH-ASSESSMENT-IMPLEMENTATION-PLAN. PART VI, LINE 3: SIDNEY HEALTH CENTER HAS NOTICES LOCATED AT THE ADMISSIONS OFFICE INFORMING PATIENTS ABOUT THEIR FINANCIAL ASSISTANCE POLICY. THE PROGRAM IS ALSO STATED ON THE ORGANIZATION'S WEBSITE AND INCLUDED IN THE PATIENT'S PACKET UPON DISCHARGE FROM THE FACILITY. PART VI, LINE 4: LOCATED IN THE HEART OF RICHLAND COUNTY, SIDNEY HEALTH CENTER SERVES PEOPLE IN ALL OF THE MONDAK REGION. PART VI, LINE 5: THE HEALTH CENTER DEFINES AND MEASURES THEIR INVESTMENT IN AND PARTNERSHIP WITH THE COMMUNITY PRIMARILY THROUGH VARIOUS COMMUNITY-BASED SERVICES PROGRAMS, PROVIDING HEALTH EQUIPMENT IN AREA SCHOOLS, AND COMMUNITY PROGRAMS AND EDUCATION. A NUMBER OF HEALTH-RELATED EDUCATIONAL PROGRAMS ARE PROVIDED FOR THE BENEFIT OF THE COMMUNITY, INCLUDING HEALTH ENHANCEMENTS AND WELLNESS, CLASSES ON SPECIFIC CONDITIONS, AND PROGRAMS DESIGNED TO IMPROVE THE GENERAL STANDARDS OF THE HEALTH OF THE COMMUNITY. 1 LONE TREE SENIOR LIVING 216 14TH AVE SW SIDNEY MT 59270 810518821 501(C)(3) 20912 CONSTUCTION OF A NEW SHED 1 0 PART I, LINE 2: SIDNEY HEALTH CENTER CONFIRMS THAT RECIPIENT ORGANIZATION ARE A QUALIFIED GOVERNMENT OR CHARITY ORGANIZATION. CONTRIBUTED FUNDS ARE INTENDED FOR GENERAL OPERATING SUPPORT, SO SIDNEY HEALTH CENTER DOES NOT CONDUCT ANY FOLLOW-UP MONITORING ACTIVITIES. X 1 1 X X 0 0 0 1 0 0 0 0 0 LESZEK JASZCZAK MD TRUSTEE 519300 0 0 0 0 0 0 0 1028 0 520328 0 0 0 RICHARD HARALDSON CEO 270006 0 0 0 0 0 7505 0 1028 0 278539 0 0 0 TINA MONTGOMERY CFO 143405 0 0 0 0 0 4302 0 6259 0 153966 0 0 0 JEROME KESSLER PHYSICIAN 421010 0 0 0 0 0 7950 0 1028 0 429988 0 0 0 KELLY O'NEAL GENERAL SURGEON 440508 0 0 0 0 0 7950 0 1028 0 449486 0 0 0 GEORGE SCORDALAKES MD PHYSICIAN 449380 0 0 0 0 0 7950 0 740 0 458070 0 0 0 SHARI TWIGG MD PHYSICIAN 314180 0 0 0 0 0 5649 0 1028 0 320857 0 0 0 JEFFREY GILES ORTHOPEDIC SURGEON 618558 0 0 0 0 0 0 0 1028 0 619586 0 0 0 PART I, LINE 1A RICHARD HARALDSON - HEALTH OR SOCIAL CLUB DUES OF $1,805 - NOT INCLUDED IN TAXABLE INCOME. PART I, LINE 5 PHYSICIANS RECEIVE BONUSES BASED ON PRODUCTIVITY, AMONG OTHER FACTORS. PRODUCTIVITY IS CLOSELY CONNECTED WITH REVENUES. A RICHLAND COUNTY MT 816001419 2010-12-01 2350000 MEDICAL EQUIPMENT REVENUE BOND FOR TOMOTHERAPY RADIATION ONCOLOGY UNIT 0 0 0 B RICHLAND COUNTY MT 816001419 2011-09-15 24370000 REDEEMING AND RETIRING PREVIOUSLY ISSUED DEBT (2006, 2007A AND 2007B) 0 0 0 A 2157559 2350000 20059 2329941 2011 0 0 1 1 B 4700000 24370000 233683 137747 2012 1 0 1 1 A 1 0 0 0 0 0 0 B 1 0 0 0 0 0 0 A 0 1 0 0 0 0 0 0 0 B 0 1 0 0 1 1 US BANK 7.900000000000 0 0 0 0 0 A 0 B 0 ROBERT MONTGOMERY SPOUSE OF TINA MONTGOMERY, CFO 68879 EMPLOYEE COMPENSATION 0 FORM 990, PART VI, SECTION A, LINE 1 THE EXECUTIVE COMMITTEE CONSISTS OF THE OFFICERS AND ONE OTHER MEMEBER OF THE BOARD APPOINTED BY THE PRESIDENT. THE EXECUTIVE COMMITTEE HAS THE POWER TO TRANSACT ALL REGULAR BUSINESS OF THE CORPORATION DURING THE INTERIM BETWEEN THE MEETINGS OF THE BOARD, PROVIDED ANY ACTION TAKEN SHALL NOT CONFLICT WITH THE ARTICLES OF INCORPORATION, BYLAWS AND STATE POLICIES. ANY OFFICIAL ACTION TAKEN BY THE EXECUTIVE COMMITTEE IS SUBMITTED TO THE BOARD FOR RATIFICATION AT THE NEXT BOARD MEETING. FORM 990, PART VI, SECTION A, LINE 6 NATURAL PERSONS, CORPORATIONS, OR UNINCORPORATED ASSOCIATIONS MAY BECOME MEMBERS OF SIDNEY HEALTH CENTER BY: A. PAYMENT TO SIDNEY HEALTH CENTER A SUM OF NOT LESS THAN $100 CASH OR BY AN EQUIVALENT CONTRIBUTION OR METHOD AS APPROVED BY THE BOARD; B. RESIDING IN OR HAVING ITS PRINCIPAL PLACES OF BUSINESS IN THE SERVICE AREA OF SIDNEY HEALTH CENTER; AND C. AGREEING TO BE BOUND BY THE BYLAWS OF SIDNEY HEALTH CENTER. FORM 990, PART VI, SECTION A, LINE 7A ELECTION OF DIRECTORS IS HELD AT THE ANNUAL MEETING OF THE MEMBERS BY WRITTEN BALLOT LISTING THE CANDIDATES NOMINATED BY THE NOMINATING COMMITTEE OF THE MEMBERS. EACH MEMBER OF SIDNEY HEALTH CENTER, PRESENT IN PERSON OR BY PROXY, IS ENTITLED TO VOTE FOR ONE CANDIDATE FOR EACH DIRECTOR VACANCY TO BE FILLED. THE CANDIDATES RECEIVING THE HIGHEST NUMBER OF VOTES AT THE MEETING ARE CONSIDERED ELECTED AS DIRECTORS. FORM 990, PART VI, SECTION A, LINE 7B ANY PROPOSED AMENDMENTS APPROVED BY THE BOARD OR BY VERIFIED PETITION TO THE ARTICLES OF INCORPORATION OR BYLAWS SHALL BE SUBMITTED FOR VOTE BY THE MEMBERS AT THE NEXT SPECIAL OR ANNUAL MEMBERSHIP MEETING. FORM 990, PART VI, SECTION B, LINE 11B THE CEO AND CFO WILL REVIEW THE COMPLETED FORM 990 WITH THE BOARD OF DIRECTORS AT THEIR NEXT SCHEDULED MEETING AFTER THE FORM 990 IS FILED. FORM 990, PART VI, SECTION B, LINE 12C THE POLICY OF THE CORPORATION IS TO REQUIRE THAT EACH INDIVIDUAL SUBJECT TO THIS POLICY STATEMENT PROMPTLY AND FULLY DISCLOSE ANY ACTUAL, APPARENT, OR POTENTIAL CONFLICT OF INTEREST, AND THAT THE CORPORATION WILL NOT ENGAGE IN ANY CONTRACT, TRANSACTION, OR ARRANGEMENT INVOLVING A CONFLICT OF INTEREST UNLESS THE DISINTERESTED MEMBERS OF THE BOARD OF DIRECTORS (ACTING AT A DULY CONSTITUTED MEETING THEREOF) DETERMINE BY A MAJORITY VOTE THAT APPROPRIATE SAFEGUARDS TO PROTECT THE CHARITABLE MISSION OF THE CORPORATION HAVE BEEN IMPLEMENTED. A CONFLICT OF INTEREST QUESTIONNAIRE IS DISTRIBUTED ANNUALLY TO ALL INTERESTED PERSONS (BOARD MEMBERS, OFFICERS, AND COMMITTEE MEMBERS). AN INTERESTED PERSON HAS A CONTINUING OBLIGATION TO DISCLOSE THE EXISTENCE AND NATURE OF ANY ACTUAL, APPARENT, OR POTENTIAL CONFLICT OF INTEREST HE/SHE MAY HAVE. "DISCLOSURE" MEANS PROMPTLY PROVIDING A WRITTEN DESCRIPTION OF THE MATERIAL FACTS OF THE ACTUAL, APPARENT, OR POTENTIAL CONFLICT OF INTEREST TO THE EXECUTIVE COMMITTEE ON THE CONFLICTS-OF-INTEREST QUESTIONNAIRE. SUCH DISCLOSURE SHALL BE MADE PROMPTLY ANY TIME AN ACTUAL, APPARENT, OR POTENTIAL CONFLICT OF INTEREST ARISES AND BEFORE THE CONSUMMATION OF THE CONTRACT, TRANSACTION, OR ARRANGEMENT THAT IS THE SUBJECT OF THE POTENTIAL CONFLICT OF INTEREST. AT ANY TIME THAT AN ACTUAL, APPARENT, OR A POTENTIAL CONFLICT OF INTEREST IS IDENTIFIED TO THE BOARD OF DIRECTORS, WHETHER THROUGH THE VOLUNTARY SUBMISSION OF A DISCLOSURE STATEMENT BY AN INTERESTED PERSON, OR BY A DISCLOSURE BY A PERSON OTHER THAN THE SUBJECT INTERESTED PERSON, THE EXECUTIVE COMMITTEE SHALL REVIEW THE MATTER AND DETERMINE WHETHER A CONFLICT OF INTEREST EXISTS. THE SUBJECT INTERESTED PERSON SHALL NOT BE PRESENT DURING ANY MEETING IN WHICH THE EXECUTIVE COMMITTEE CONDUCTS ITS EVALUATION, EXCEPT TO ANSWER QUESTIONS AS MAY BE NECESSARY. THE EXECUTIVE COMMITTEE MAY REQUEST ADDITIONAL INFORMATION FROM ALL REASONABLE SOURCES AND MAY INVOLVE THE GENERAL COUNSEL IN ITS DELIBERATIONS. ONCE ALL NECESSARY INFORMATION HAS BEEN OBTAINED, EXECUTIVE COMMITTEE SHALL MAKE A FINDING AS TO WHETHER A CONFLICT OF INTEREST INDEED EXISTS, AND SHALL FORWARD THAT FINDING TO THE BOARD OF DIRECTORS FOR DISCUSSION AND VOTE. ONLY DISINTERESTED DIRECTORS MAY VOTE TO DETERMINE WHETHER A CONFLICT OF INTEREST EXISTS. THE SUBJECT INTERESTED PERSON MAY NOT BE PRESENT WHEN THIS VOTE IS TAKEN. ONCE THE DISINTERESTED MEMBERS OF THE BOARD OF DIRECTORS HAVE DETERMINED THAT AN ACTUAL CONFLICT OF INTEREST EXISTS WITH RESPECT TO A PARTICULAR TRANSACTION OR ARRANGEMENT: (I) THE DISINTERESTED MEMBERS OF THE BOARD OF DIRECTORS SHALL EXERCISE DUE DILIGENCE TO DETERMINE WHETHER THE CORPORATION COULD OBTAIN A MORE ADVANTAGEOUS CONTRACT, TRANSACTION, OR ARRANGEMENT WITH REASONABLE EFFORTS UNDER THE CIRCUMSTANCES AND, IF APPROPRIATE, SHALL APPOINT A NON-INTERESTED PERSON OR COMMITTEE TO INVESTIGATE ALTERNATIVES TO THE PROPOSED CONTRACT, TRANSACTION, OR ARRANGEMENT. (II) IN CONSIDERING WHETHER TO ENTER INTO THE PROPOSED CONTRACT, TRANSACTION, OR ARRANGEMENT, THE BOARD OF DIRECTORS MAY APPROVE SUCH A CONTRACT, TRANSACTION, OR ARRANGEMENT ONLY IF THE DISINTERESTED DIRECTORS DETERMINE BY A MAJORITY VOTE THAT: (A) THE PROPOSED CONTRACT, TRANSACTION, OR ARRANGEMENT IS IN THE CORPORATION'S BEST INTERESTS AND FOR THE CORPORATION'S OWN BENEFIT; AND (B) THE PROPOSED TRANSACTION IS FAIR AND REASONABLE TO THE CORPORATION, TAKING INTO ACCOUNT, AMONG OTHER RELEVANT FACTORS, WHETHER THE CORPORATION COULD OBTAIN A MORE ADVANTAGEOUS CONTRACT, TRANSACTION, OR ARRANGEMENT WITH REASONABLE EFFORTS UNDER THE CIRCUMSTANCES. (III) THE DISINTERESTED MEMBERS OF THE BOARD OF DIRECTORS MAY, IN THEIR DISCRETION, REQUIRE THE INTERESTED PERSON TO LEAVE THE ROOM WHILE THE PROPOSED CONTRACT, TRANSACTION, OR ARRANGEMENT IS DISCUSSED. THE INTERESTED PERSON SHALL LEAVE THE ROOM WHILE THE MATTER IS VOTED ON AND ONLY DISINTERESTED DIRECTORS MAY VOTE TO DETERMINE WHETHER TO APPROVE THE TRANSACTION OR ARRANGEMENT. FORM 990, PART VI, SECTION B, LINE 15 THE BOARD OF DIRECTORS DETERMINES SALARIES USING THE MHA SALARY SURVEY FOR MARKET INFORMATION AND ALSO PERFORMS A WRITTEN EVALUATION ANNUALLY. ADDITIONALLY, THE CEO USES MHA MANAGEMENT SURVEY, AS WELL AS OTHER COMPENSATION SURVEYS, TO DETERMINE ANNUAL PAY INCREASES FOR ADMINISTRATION. A WRITTEN EVALUATION IS PERFORMED. ALL ESTIMATED ANNUAL INCREASES ARE INCLUDED IN THE BUDGET, WHICH IS APPROVED BY THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE MADE AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART IX, LINE 11G OTHER PROFESSIONAL FEES: PROGRAM SERVICE EXPENSES 10,058,715. MANAGEMENT AND GENERAL EXPENSES 1,508,520. FUNDRAISING EXPENSES 13,456. TOTAL EXPENSES 11,580,691. FORM 990, PART XI, LINE 9: CHANGE IN BENEFICIAL INTEREST IN NET ASSETS OF FOUNDATION -99,371. CHANGE IN VALUE OF FAIR VALUE SWAP 842,815. LONE TREE SENIOR LIVING 216 14TH AVENUE SW SIDNEY MT 59270 810518821 ASSISTED LIVING MT 501(C)(3) LINE 10 SIDNEY HEALTH CENTER 1 FOUNDATION FOR COMMUNITY CARE OF RICHLAND COUNTY 221 2ND STREET NW SIDNEY MT 59270 810417465 FUNDRAISING MT 501(C)(3) LINE 12A, I SIDNEY HEALTH CENTER 1 1 0 1 1 0 0 0 0 0 0 0 1 1 1 1 0 1 0 0 LONE TREE SENIOR LIVING A 97047 CONTRACTED INTEREST RATE LONE TREE SENIOR LIVING L 94203 FAIR MARKET VALUE