2018-08-14T08:40:26-05:00 2017-09-30 476097913 SEIM JOHNSON LLP 18081 BURT STREET SUITE 200 OMAHA NE 680224722 990 2016-10-01 480561974 ATCHISON HOSPITAL ASSOCIATION ATCH 9133605584 800 RAVEN HILL DRIVE ATCHISON KS 66002 JOHN L JACOBSON CHIEF EXECUTIVE OFFICER 9133605584 2018-08-13 1 WENDY R COOLEY P01523804 4023302660 2016 2022-09-23 18:48:47Z JOHN L JACOBSON 800 RAVEN HILL DRIVE ATCHISON KS 66002 46080332 0 X WWW.ATCHISONHOSPITAL.ORG X 1912 KS TO PROVIDE EXCELLENT HEALTH CARE AND IMPROVE THE QUALITY OF LIFE IN OUR COMMUNITY. 7 7 365 125 14521 12466 693394 834539 40381657 44888769 213824 172509 2427088 83907 43715963 45979724 0 0 0 0 21299555 22584353 0 0 0 20443775 21826604 41743330 44410957 1972633 1568767 58283653 49450839 44062591 34005467 14221062 15445372 TO PROVIDE EXCELLENT HEALTH CARE AND IMPROVE THE QUALITY OF LIFE IN OUR COMMUNITY. 0 0 35433961 44861944 ATCHISON HOSPITAL PROVIDED ACUTE INPATIENT AND OUTPATIENT HEALTH SERVICES TO THE GENERAL PUBLIC. SERVICES INCLUDE BUT ARE NOT LIMITED TO: EMERGENCY SERVICES, HOME HEALTH AND HOSPICE, GENERAL INPATIENT ACUTE SERVICES, RADIOLOGY, & OBSTETRICS. THE NUMBER OF PEOPLE SERVED DURING THE FISCAL YEAR ENDING 09/30/17 WAS 125,242. 35433961 1 1 0 1 0 0 1 0 0 0 1 0 0 0 1 1 0 1 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 1 1 0 0 1 41 0 1 365 1 1 1 0 0 0 0 0 0 0 0 0 X 7 7 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 X GARY R FOLL 9133672131 800 RAVEN HILL DRIVE ATCHISON KS 66002 SUSAN MYERS CHAIRPERSON 1.00 0.00 X X 0 0 0 GUS GRIFFIN VICE CHAIRPERSON 1.00 0.00 X X 0 0 0 STEVE MINNIS SECRETARY 1.00 0.00 X X 0 0 0 TODD GIGSTAD TREASURER 1.00 0.00 X X 0 0 0 GOLDIE BOLDRIDGE-BROWN DIRECTOR 1.00 0.00 X 0 0 0 LYDIA FUNK DIRECTOR 1.00 0.00 X 0 0 0 LARRY MEARS DIRECTOR 1.00 0.00 X 0 0 0 JOHN L JACOBSON CEO 40.00 1.00 X 232720 0 17141 GARY R FOLL CFO 40.00 2.00 X 154691 0 27320 SANDRA LEGGETT CNO 40.00 0.00 X 157470 0 25829 EJ WILKINSON PHYSICIAN 40.00 0.00 X 744673 0 31417 JESSICA STONE PHYSICIAN 40.00 0.00 X 329070 0 6174 BENJAMIN STONE PHYSICIAN 40.00 0.00 X 320882 0 30876 MCGARRETT GROTH PHYSICIAN 40.00 0.00 X 318397 0 31846 NORMA GREEN PHYSICIAN 40.00 0.00 X 311893 0 27613 2569796 0 198216 22 0 1 0 CASCADE HEALTH SERVICES 1045 SWIFT AVENUE KANSAS CITY MO 64116 AGENCY STAFF 356513 THOMAS FAMILY PRACTICE 174 DEER RUN ATCHISON KS 66002 PHYSICIAN SERVICES 162191 2 600000 2112 232427 834539 NET PATIENT SERVICE REVENUE 624100 24491751 24491751 MEDICARE/MEDICAID 624100 16933255 16933255 340B DRUG PRICING PROGRAM 624100 3059177 3059177 EHR INCENTIVE PAYMENTS 624100 171867 171867 232719 232719 44888769 59681 59681 123512 123512 53843 66147 -12304 -12304 -26825 14521 23777 34461 -10684 -10684 -10684 CAFETERIA 722210 96211 96211 96211 45979724 44861944 14521 268720 615171 183299 431872 18360141 15352963 3007178 339607 289391 50216 2064610 1753992 310618 1204824 1007488 197336 165083 165083 122700 122700 2777922 1545951 1231971 168202 27458 140744 1532410 1082830 449580 479348 27089 452259 550959 35406 515553 174334 133300 41034 134478 117364 17114 2004717 1925999 78718 3250493 3001505 248988 334186 153508 180678 MEDICAL SUPPLIES 5438543 5438543 BAD DEBT 3302566 3302566 COLLECTION FEES 1033008 1033008 FOOD 167604 167604 190051 55309 134742 44410957 35433961 8976996 0 10935257 6581405 417760 506107 5943634 6104348 1041699 1167523 623526 630640 52306910 29459731 25177423 22847179 13248763 11340327 329862 273310 565729 58283653 49450839 2989232 3558602 40256225 27154365 2252007 817134 1040493 44062591 34005467 X 14077846 15302156 143216 143216 14221062 15445372 58283653 49450839 X 1568767 -62014 -282443 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 6644 6644 0 PART II-B, LINE 1: LOBBYING EXPENSES THROUGH DUES PAID TO THE KANSAS HOSPITAL ASSOCIATION AND THE AMERICAN HOSPITAL ASSOCIATION. X 1 3.00 1 0 968642 968642 35029718 16960570 18069148 13707019 11225110 2481909 2601531 1274051 1327480 22847179 DUE TO AFFILIATE 7183 DEFERRED COMPENSATION 929581 ESTIMATED THIRD-PARTY PAYOR SETTLEMENTS 103729 1040493 X PART II, LINE 9: CONSERVATION EASEMENTS ARE REPORTED AT HISTORICAL COSTS AS LAND. PART X, LINE 2: THE HOSPITAL AND FOUNDATION ARE NOT-FOR-PROFIT CORPORATIONS AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. THE HOSPITAL AND FOUNDATION HAVE RECEIVED DETERMINATION LETTERS INDICATING THAT THEY ARE EXEMPT FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE INTERNAL REVENUE CODE. THE INTERNAL REVENUE SERVICE HAS ESTABLISHED STANDARDS TO BE MET TO MAINTAIN THE HOSPITAL'S TAX EXEMPT STATUS. IN GENERAL, SUCH STANDARDS REQUIRE THE HOSPITAL TO MEET A COMMUNITY BENEFITS STANDARD AND COMPLY WITH VARIOUS LAWS AND REGULATIONS. THE HOSPITAL AND FOUNDATION ACCOUNT FOR UNCERTAINTIES IN ACCOUNTING FOR INCOME TAX ASSETS AND LIABILITIES USING GUIDANCE INCLUDED IN FASB ASC 740, INCOME TAXES. THE HOSPITAL AND FOUNDATION RECOGNIZE THE EFFECT OF INCOME TAX POSITIONS ONLY IF THOSE POSITIONS ARE MORE LIKELY THAN NOT OF BEING SUSTAINED. AT SEPTEMBER 30, 2017 AND 2016, THE HOSPITAL AND FOUNDATION HAD NO UNCERTAIN TAX POSITIONS ACCRUED. 1 1 X 1 X 1 X 1 1 1 0 1 1 98236 98236 0.00240 3893127 3482559 410568 0.01000 3991363 3482559 508804 0.01240 21404 21404 0.00050 977124 977124 0.02380 998528 998528 0.02430 4989891 3482559 1507332 0.03670 1 3302566 0 13781466 13834971 -53505 X 1 1 1 1 ATCHISON HOSPITAL ASSOCIATION 800 RAVEN HILL DRIVE ATCHISON KS 66002 WWW.ATCHISONHOSPITAL.ORG H-003-001 X X X X ATCHISON HOSPITAL ASSOCIATION 1 0 0 1 X X X X X X X X X 15 1 0 1 1 X WWW.ATCHISONHOSPITAL.ORG X 1 15 1 WWW.ATCHISONHOSPITAL.ORG 0 1 X 200.000000000000 200.000000000000 X X X X X 1 1 X X X 1 X WWW.ATCHISONHOSPITAL.ORG X WWW.ATCHISONHOSPITAL.ORG X WWW.ATCHISONHOSPITAL.ORG X X X X X 1 X 0 X X X X 1 X 0 0 ATCHISON HOSPITAL ASSOCIATION PART V, SECTION B, LINE 5: A SURVEY WAS MAILED OUT TO A REPRESENTATIVE SAMPLE OF THE COMMUNITY AND A COMMUNITY TOWN HALL MEETING WAS ADVERTISED IN THE LOCAL PAPER AND LOCAL RADIO STATION FOR THE COMMUNITY TO ATTEND. THE SURVEY RESULTS WERE DISCUSSED AT THE TOWN HALL MEETING. ATCHISON HOSPITAL ASSOCIATION PART V, SECTION B, LINE 6B: NEK MULTI-COUNTY HEALTH DEPARTMENTATCHISON COUNTY HEALTH DEPARTMENT ATCHISON HOSPITAL ASSOCIATION PART V, SECTION B, LINE 11: MOST OF THE COMMUNITY HEALTH NEEDS ARE BEING ADDRESSED BY LIVE WELL, LIVE ATCHISON. THE HOSPITAL PARTICIPATES WITH AND HAS A REPRESENTATIVE ON THEIR BOARD OF DIRECTORS. IN ADDITION, THE HOSPITAL HAS A PROGRAM ALONG WITH THE KANSAS DEPARTMENT OF HEALTH AND ENVIRONMENT (KDHE) TO PROSPECTIVELY SIGN UP ELIGIBLE RECIPIENTS FOR MEDICAID AT THE HOSPITAL. THE HOSPITAL DRASTICALLY REDUCES THE BILLS OF THOSE INDIVIDUALS BELOW 200% OF THE FEDERAL POVERTY GUIDELINES. THE HOSPITAL ALSO HAS NAVIGATORS ONSITE TO STEER PATIENTS TO, AND SIGN THEM UP FOR INSURANCE PRODUCTS ON THE MARKETPLACE. THE HOSPITAL HAS A CONTRACT WITH "HUMAN ARC" TO FIND MEDICAID OR OTHER GOVERNMENTAL PROGRAMS TO HELP WITH THE COST OF THEIR BILLS. THE HOSPITAL IS WORKING TO FIND ADDITIONAL SPECIALISTS TO COME TO THE AREA TO SERVE THE POPULATION WHO CANNOT FIND TRANSPORTATION TO VISIT THEM OUT OF TOWN. THE HOSPITAL ALSO WORKS WITH THE "GUIDANCE CENTER" TO PROVIDE MORE OPPORTUNITIES FOR PEOPLE WHO NEED MENTAL HEALTH SERVICES.ECONOMIC DEVELOPMENT AND HEALTHCARE TRANSPORTATION ARE THE TWO THINGS THAT THE HOSPITAL IS NOT ABLE TO ADDRESS AT THIS TIME BECAUSE IT IS OUT OF THEIR JURISDICTION OR FROM LACK OF FUNDING. ATCHISON HOSPITAL ASSOCIATION PART V, SECTION B, LINE 13H: THERE ARE INSTANCES WHEN A PATIENT MAY APPEAR ELIGIBLE FOR FINANCIAL DISCOUNTS, BUT THERE IS NO FINANCIAL ASSISTANCE FORM ON FILE OR LACK OF SUPPORTING DOCUMENTATION. IN THE EVENT THERE IS NO EVIDENCE TO SUPPORT A PATIENT'S ELIGIBILITY FOR FINANCIAL ASSISTANCE, ATCHISON HOSPITAL 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. 1 1 - FAMILY MEDICAL CENTER OF TROY 311 W LOCUST TROY KS 66087 RURAL HEALTH CLINIC PART I, LINE 3C: NOT APPLICABLE: FEDERAL POVERTY GUIDELINES ARE USED TO DETERMINE ELIGIBILITY FOR PROVIDING FREE AND DISCOUNTED CARE TO LOW INCOME INDIVIDUALS. PART I, LINE 6A: ATCHISON HOSPITAL'S COMMUNITY BENEFIT REPORT IS NOT PREPARED BY A RELATED ORGANIZATION. PART I, LINE 7: THE COSTING METHODOLOGY USED TO CALCULATE THE AMOUNTS CONTAINED IN THE TABLE OF PART I, LINE 7, OR SCHEDULE H, IS A COST TO CHARGE RATIO CALCULATED USING WORKSHEET 2. PART I, LINE 7G: THERE ARE NO COSTS ATTRIBUTABLE TO A PHYSICIAN CLINIC INCLUDED ON LINE 7G. PART I, LN 7 COL(F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25(A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $3,302,566. PART III, LINE 2: IN EVALUATING THE COLLECTIBILITY OF ACCOUNTS RECEIVABLE, THE HOSPITAL ANALYZES ITS PAST HISTORY AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYOR SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS AND PROVISION FOR BAD DEBTS. MANAGEMENT REGULARLY REVIEWS DATA ABOUT THESE MAJOR PAYOR SOURCES OF REVENUE IN EVALUATING THE SUFFICIENCY OF THE ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS. FOR RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRD-PARTY COVERAGE, THE HOSPITAL ANALYZES CONTRACTUALLY DUE AMOUNTS AND PROVIDES AN ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS AND A PROVISION FOR BAD DEBTS FOR THOSE ACCOUNTS OVER A CERTAIN AGE BASED ON DISCHARGE THAT MAKE THE REALIZATION OF AMOUNTS DUE UNLIKELY. 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 HOSPITAL 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 UNCOLLECTIBLE ACCOUNTS. PART III, LINE 4: THE HOSPITAL'S FINANCIAL STATMENTS DO NOT CONTAIN A SPECIFIC FOOTNOTE DESCRIBING BAD DEBT. HOWEVER, PAGES 7 AND 9 OF THE ATTACHED FINANCIAL STATEMENTS INCLUDE FOOTNOTES TITLED "PATIENT RECEIVABLES, NET," "NET PATIENT SERVICE REVENUE AND "FINANCIAL ASSISTANCE/CHARITY CARE". PART III, LINE 8: ANY MEDICARE SHORTFALL SHOULD NOT BE TREATED AS A COMMUNITY BENEFIT COST. THE COSTING METHODOLOGY CONSISTED OF INFORMATION FOR THE HOSPITAL'S ACCOUNTING SYSTEM AS WELL AS COSTS FROM THE MEDICARE COST REPORT. PART III, LINE 9B: THE HOSPITAL DOES NOT PURSUE COLLECTION ON ACCOUNTS THAT HAVE BEEN DETERMINED TO BE ELIGIBLE FOR CHARITY CARE. PART VI, LINE 2: ATCHISON HOSPITAL ASSOCIATION HAS ACCESS TO THE KANSAS HEALTH INITIATIVE SURVEY ON HEALTH INDICATORS. BASED ON THESE INDICATORS, ATCHISON HOSPITAL DETERMINES THE NEEDS OF THE COMMUNITY AND WHAT PROGRAMS TO IMPLEMENT. PART VI, LINE 3: PATIENTS ARE GIVEN A PAMPHLET DESCRIBING THE POLICY FOR FINANCIAL ASSISTANCE WHEN THEY ARE ADMITTED. THE ADMITTING OFFICE ASKS THEM TO SPEAK WITH THE HOSPITAL FINANCIAL COUNSELOR IF THEY DO NOT HAVE INSURANCE. AFTER THE PATIENT RECEIVES THEIR STATEMENT IN THE MAIL, THEY CAN CALL IN AND TALK WITH THE FINANCIAL COUNSELOR. IF THE ACCOUNT GOES TO A COLLECTION COMPANY BECAUSE THE PATIENT DID NOT PAY OR TALK WITH THE FINANCIAL COUNSELOR, THE COLLECTION COMPANY WILL GIVE THEM THE PROPER APPLICATION TO FILL OUT TO SEE IF THEY ARE ELIGIBLE FOR FINANCIAL ASSISTANCE. PART VI, LINE 4: THE HOSPITAL SERVES THE COMMUNITY OF ATCHISON, KANSAS AND THE SURROUNDING COUNTY OF ATCHISON, KANSAS. ATCHISON IS A COMMUNITY OF APPROXIMATELY 10,500 PEOPLE WHO WOULD BE DESCRIBED AS MOSTLY COMPRISED OF BLUE-COLLAR AND LOW-INCOME INDIVIDUALS. THE SURROUNDING COUNTY HAS A POPULATION OF AN ADDITIONAL 6,300 PEOPLE. THERE ARE SEVERAL LARGE FARMS WHICH PLANT ROW CROPS OF CORN AND BEANS. PART VI, LINE 5: ATCHISON HOSPITAL BELIEVES COMMUNITY BENEFIT GOES BEYOND HOSPITAL VISITS AND EMERGENCY CARE. IT MEANS GETTING INVOLVED AND WORKING TO IMPROVE THE HEALTH OF OUR COMMUNITY; IT MEANS HELPING OTHERS PURSUE GOOD HEALTH THROUGH DONATIONS, EDUCATION AND VOLUNTEERISM. THE FOLLOWING IS A SUMMARY OF THE NUMEROUS ACTIVITIES, INITATIVES AND EVENTS THAT HAVE BEEN IMPLEMENTED IN SUPPORT OF PROVIDING COMMUNITY BENEFITS TO THE RESIDENTS IN THE ATCHISON COMMUNITY AND REGION. LIVE WELL LIVE ATCHISON IS A HOSPITAL INITIATIVE THAT INVOLVES PARTNERSHIPS WITH THE KANSAS HEALTH INITIATIVE, ATCHISON COUNTY SCHOOLS, BENEDICTINE COLLEGE, CITY AND COUNTY GOVERNMENTS, STATE REPRESENTATIVES, FAITH-BASED CHURCHES, THE HEALTH DEPARTMENT, COUNTY EXTENSION OFFICE AND AREA BUSINESSES, HEALTH AND SERVICE AGENCIES, AS WELL AS COMMUNITY AND CIVIC ORGANIZATIONS. THE GROUP IS WORKING TOWARD IMPROVING THE HEALTH BEHAVIORS AND LIFESTYLE OF ATCHISON COUNTY. ATCHISON HOSPITAL'S "BEST CARE COMMUNITY HEALTH FAIR," IS AN ANNUAL EVENT BY THE HOSPITAL AND HELD AT THE ATCHISON ELEMENTARY SCHOOL. HOSPITAL EMPLOYEES AS WELL AS COMMUNITY HEALTH AGENCIES, ORGANIZATIONS, LOCAL AND REGIONAL AREA RESPONDERS AND PHYSICIAN PRACTICES, PROVIDE HEALTH SCREENINGS, INTERACTIVE EDUCATIONAL AND FITNESS ACTIVITIES. ATCHISON HOSPITAL SUPPORTS THE ATCHISON COMMUNITY HEALTH CLINIC, A FEDERAL QUALIFIED HEALTH CLINIC, BY SUBSIDIZING THE CLINIC'S FACILITIES RENT, GENERAL MAINTENANCE AND SNOW REMOVAL. THE HOSPITAL CONDUCTS AND SPONSORS SUPPORT GROUPS AND CLASSES THAT PROVIDE ONGOING EDUCATION AND COUNSELING SUCH AS GRIEF SUPPORT, BIRTHING AND CHILDCARE CLASSES. ADDITIONALLY, THE HOSPITAL OFFERS A HOSPICE VOLUNTEER PROGRAM. THE HOSPITAL ALSO PROVIDES SPONSORSHIP AND DONATIONS TO VARIOUS ORGANIZATIONS, LOCAL SCHOOLS AND NURSING HOMES, AS WELL AS COMMUNITY INITIATIVES. THEY INCLUDE: RELAY FOR LIFE, AMELIA EARHART FESTIVAL, BEAUTIFICATION OF OUR CITY, FARM SAFETY DAYS, JOGGIN'FOR THE NOGGIN', PARTICIPATION IN LOCAL AND REGIONAL HEALTH FAIRS AND PHYSICIAN SUPPORT AT LOCAL HIGH SCHOOL AND COLLEGE ATHLETIC EVENTS. ATCHISON HOSPITAL'S CARE TEAM, AN EMPLOYEE GROUP THAT GENERATES COMMUNITY INVOLVEMENT IN ACTIVITIES SUCH AS AN ANNUAL FOOD DRIVE AND ADOPT-A-FAMILY. THE HOSPITAL AS WELL AS THE ATCHISON HOSPITAL AUXILIARY, EACH HOSTS COMMUNITY BLOOD DRIVES THROUGHOUT THE YEAR. THE HOSPITAL PROVIDES COMMUNITY EDUCATION AND CAREER DEVELOPMENT TO ORGANIZATIONS, SCHOOLS AND COLLEGES THROUGHOUT THE AREA THROUGH SPEAKING ENGAGEMENTS, CAREER FAIRS, CLASS IN-SERVICES AND HOSPITAL TOURS. IN ADDITION, HOSPITAL EMPLOYEES VOLUNTEER THEIR SERVICES WITH COMMUNITY NOT-FOR-PROFIT AND CIVIC ORGANIZATIONS AND COMMITTEES, INCLUDING THE CHAMBER OF COMMERCE, WORKFORCE DEVELOPMENT, ROTARY, LIONS CLUB, YMCA, ALL FAITH COUNSELING CENTER AND THE BOY SCOUTS. THE HOSPITAL OFFERS A JOB SHADOWING PROGRAM AND PARTNERS WITH THE BOY SCOUTS OF AMERICA "VENTURING PROGRAM," PROVIDING INTERNSHIPS AND TEEN VOLUNTEER PROGRAMS. PART VI, LINE 6: ATCHISON HOSPITAL ASSOCIATION IS NOT PART OF AN AFFILIATED HEALTH CARE SYSTEM. X 1 1 X X X X 0 0 0 0 0 0 0 1 0 JOHN L JACOBSON CEO 220114 0 10000 0 2606 0 2475 0 14666 0 249861 0 0 0 GARY R FOLL CFO 146165 0 8000 0 526 0 4601 0 22719 0 182011 0 0 0 SANDRA LEGGETT CNO 149192 0 8000 0 278 0 3110 0 22719 0 183299 0 0 0 EJ WILKINSON PHYSICIAN 661024 0 83649 0 0 0 8597 0 22820 0 776090 0 0 0 JESSICA STONE PHYSICIAN 205712 0 123264 0 94 0 6174 0 0 0 335244 0 0 0 BENJAMIN STONE PHYSICIAN 264606 0 56049 0 227 0 8209 0 22667 0 351758 0 0 0 MCGARRETT GROTH PHYSICIAN 291309 0 26919 0 169 0 9026 0 22820 0 350243 0 0 0 NORMA GREEN PHYSICIAN 229985 0 81788 0 120 0 4952 0 22661 0 339506 0 0 0 PART 1, LINE 1A: SOCIAL CLUB DUES WERE PAID BY THE HOSPITAL FOR JOHN L. JACOBSON AND WERE NOT INCLUDED IN HIS W-2 AS TAXABLE COMPENSATION BECAUSE THEY WERE USED 100% FOR BUSINESS. PART 1, LINE 7: VARIOUS EMPLOYED PHYSICIANS ARE PROVIDED THE OPPORTUNITY FOR BONUS POTENTIAL. IN THEIR CONTRACT WITH THE HOSPITAL ARE TIERS BASED ON CURRENT MEDICAL GROUP MANAGEMENT ASSOCIATION REGIONAL DATA. IF THE PHYSICIANS ANNUALIZED NET QUALIFIED PATIENT CHARGES EXCEEDS THE TIER, A PERCENTAGE OF THEIR NET QUALIFIED PATIENT CHARGES ARE ELIGIBLE FOR BONUS SUBJECT TO THEIR ANNUAL BASE COMPENSATION. A CITY OF ATCHISON KS 486025033 046687CA5 2009-06-30 17550505 ACQUIRE, CONSTRUCT, AND EQUIPMENT REPLACEMENT FOR THE HOSPITAL 1 0 0 B CITY OF ATCHISON KS 486025033 046687CF4 2016-07-27 9450000 ADVANCE REFUND A PORTION OF THE 2008A, 2008B, 2009 BONDS 0 0 0 C CITY OF ATCHISON KS 486025033 046687CM9 2017-06-06 8835000 CURRENT REFUND A PORTION OF THE 2008A BONDS ORIGINALLY ISSUED 09/23/08 0 0 0 D CITY OF ATCHISON KS 486025033 046687CR8 2017-06-06 3400000 CUURENT REFUND A PORTION OF THE 2009 BONDS ORIGINALLY ISSUED 06/30/09 0 0 0 A 4320000 7850000 17551893 1137340 511389 220250 16820254 2010 0 0 1 1 B 9450000 630200 185895 9264105 2010 0 1 1 1 C 8835000 606441 79515 8755485 2010 1 0 1 1 D 3400000 235838 30600 3369400 2010 1 0 1 1 A 0 0 1 1 0 0.00000 0.00000 0.00000 0 0 1 B 0 0 1 1 0 0.00000 0.00000 0.00000 0 0 1 C 0 0 1 1 0 0.00000 0.00000 0.00000 0 0 1 D 0 0 1 1 0 0.00000 0.00000 0.00000 0 0 1 A 0 0 0 1 1 0 0 0 1 B 0 1 0 0 0 0 0 1 1 C 0 1 0 0 0 0 0 0 1 D 0 1 0 0 0 0 0 0 1 A 1 B 1 C 1 D 1 PART I, LINE A: THE ORIGINAL PAR AMOUNT OF THE 2009 BONDS WAS $17,620,000. OF THIS AMOUNT, $4,320,000 HAS MATURED, $4,450,000 WAS ADVANCE REFUNDED BY THE 2016 BONDS AND REDEEMED ON 9/1/2017, $3,400,000 WAS CURRENT REFUNDED BY THE 2017B BONDS AND REDEEMED ON 9/1/2017, AND $5,450,000 WAS ADVANCE REFUNDED BY THE 2017C BONDS AND WILL BE REDEEMED ON 8/30/2019. THE 2017C BONDS WERE ISSUED AFTER THE 2017 FISCAL YEAR END AND CONSEQUENTLY HAVE NOT BEEN REPORTED. PART II, COLUMN A, LINE 1 AND LINE 2: THE ORIGINAL PAR AMOUNT OF THE 2009 BONDS WAS $17,620,000. OF THIS AMOUNT $4,320,000 HAS MATURED, $4,450,000 WAS ADVANCE REFUNDED BY THE 2016 BONDS AND REDEEMED ON 9/1/2017, AND $3,400,000 WAS CURRENT REFUNDED BY THE 2017B BONDS AND WAS REDEEMED ON 9/1/2017. PART II, COLUMN A, LINE 3: AMOUNT DOES NOT EQUAL ISSUE PRICE DUE TO INVESTMENT EARNINGS RECEIVED IN THE PROJECT FUND. PART II, COLUMN B, LINE 11: THIS AMOUNT WAS USED TO ADVANCE REFUND A PORTION OF THE 2008A BONDS, 2008B BONDS AND 2009 BONDS. PART II, COLUMN C, LINE 11: THIS AMOUNT WAS USED TO CURRENT REFUND A PORTION OF THE 2008A BONDS. PART II, COLUMN D, LINE 11: THIS AMOUNT WAS USED TO CURRENT REFUND A PORTION OF THE 2009 BONDS. PART IV, COLUMN A, LINE 2(D): ARBITRAGE REBATE ANALYSIS DATED 9/1/2013. PART IV, COLUMN B, LINE 6: PROCEEDS WERE DEPOSITED AND HELD IN A YIELD RESTRICTED ESCROW FOR THE REFUNDED BONDS BEYOND THE AVAILABLE TEMPORARY PERIOD. 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 MANAGEMENT. ANY QUESTIONS OR CONCERNS THE ORGANIZATION'S MANAGEMENT HAVE ARE ADDRESSED AND ANY CORRECTIONS OR CLARIFICATIONS ARE MADE. THE 990 IS THEN REVIEWED BY THE HOSPITAL FINANCE COMMITTEE. ANY QUESTIONS OR CONCERNS THE FINANCE COMMITTEE HAVE ARE ADDRESSED AND ANY CORRECTIONS OR CLARIFICATIONS ARE MADE. THE 990 IS THEN REVIEWED BY THE BOARD OF DIRECTORS, ANY CORRECTIONS OR CONCERNS THE BOARD HAVE ARE ADDRESSED PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C AT THE TIME OF THE ELECTION OR HIRE AND ANNUALLY THEREAFTER, THE GOVERNING BOARD MEMBERS, OFFICERS, AND KEY EMPLOYEES SHALL PROVIDE THE APPLICABLE CONFLICT OF INTEREST DISCLOSURES WHICH SHALL BE COMPLETED TO IDENTIFY ANY RELATIONSHIPS, POSITIONS, OR CIRCUMSTANCES IN WHICH IT IS BELIEVED A CONFLICT MAY ARISE. IF A CONFLICT ARISES, THE BOARD MEMBER ABSTAINS FROM THE VOTE OF THE CONFLICTED POSITION. FORM 990, PART VI, SECTION B, LINE 15 IN 2017, THE ORGANIZATION ENGAGED ITS LEGAL COUNSEL TO PREPARE A COMPENSATION DATA STUDY. IN ADDITION TO VARIOUS DATA COLLECTED, OTHER HOSPITALS' 990'S WERE REVIEWED AND COMBINED IN THE COMPENSATION STUDY. THE HOSPITAL'S LEGAL COUNSEL REVIEWED THE STUDY WITH THE BOARD OF DIRECTORS TO ADJUST THE CEO'S COMPENSATION. ANY DECISION THAT IS MADE IN REGARDS TO THE CEO'S COMPENSATION IS DOCUMENTED BY THE BOARD OF DIRECTORS. 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. PHYSICIAN COMPENSATION IS DETERMINED BASED ON CONTRACT AND IS COMPARED TO RECENT MEDICAL GROUP MANAGEMENT ASSOCIATION INFORMATION BY REGION TO DETERMINE FAIR MARKET COMPENSATION. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE NOT MADE AVAILABLE TO THE PUBLIC. FORM 990, PART XI, LINE 9: LOSS ON EARLY EXTINGUISHMENT OF DEBT -282,443. FORM 990, PART XI, LINE 2C: AN INDEPENDENT ACCOUNTING FIRM AUDITS THE ORGANIZATION'S FINANCIAL STATEMENTS. THE ORGANIZATION HAS A COMMITTEE THAT ASSUMES RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT OF ITS FINANCIAL STATEMENTS AND SELECTION OF AN INDEPENDENT ACCOUNTANT. THIS PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. RIVERBEND REGIONAL HEALTHCARE FOUNDATION 800 RAVEN HILL DRIVE ATCHISON KS 66002 480955489 SUPPORT ATCHISON HOSPITAL ASSOCIATION KS 501(C)(3) LINE 12B, II ATCHISON HOSPITAL ASSOCIATION 1 0 0 1 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0 RIVERBEND REGIONAL HEALTHCARE FOUNDATION C 600000 FMV