2018-11-12T09:11:09-06:00 2017-12-31 476097913 SEIM JOHNSON LLP 18081 BURT STREET SUITE 200 OMAHA NE 680224722 990 2017-01-01 470408242 CHEYENNE COUNTY HOSPITAL ASSOCIATION INC CHEY 3082545825 1000 POLE CREEK CROSSING SIDNEY NE 691620000 JASON PETIK CEO 3082545825 2018-11-09 1 WENDY R COOLEY P01523804 4023302660 209.34.201.180 2018-11-09 10:11:05 CS P B319C935D5CD5DD24452FA9CD51ABCBD1A9C8C2C 5D066E2939FE45487034BD10C4A0DC94BE27FEF9 2017 2019-02-21 02:37:17Z SIDNEY REGIONAL MEDICAL CENTER JASON PETIK 1000 POLE CREEK CROSSING SIDNEY NE 691620000 55830384 0 X WWW.SIDNEYRMC.COM X 1951 NE TO REVOLUTIONIZE HEALTHCARE SERVICES IN THE REGION. 12 10 472 100 0 0 46543 16387 56805243 55594969 36996 82317 113656 136711 57002438 55830384 40033 20254 0 0 29070665 29376815 0 0 0 26572885 25000358 55683583 54397427 1318855 1432957 87055366 87596964 46484322 45592963 40571044 42004001 X TO REVOLUTIONIZE HEALTHCARE SERVICES IN THE REGION. 0 0 38376317 20254 40695257 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. 4236276 3796233 THE EXTENDED CARE UNIT PROVIDED CARE FOR AN AVERAGE OF 47 PATIENTS DAILY DURING 2017. SRMC PROVIDED 16,206 PATIENT DAYS OF CARE FOR RESIDENTS IN THE CHEYENNE, DEUEL, KIMBALL AND SURROUNDING AREAS. 3831559 7222265 IN 2017, THE HOSPITAL NURSING DEPARTMENT PROVIDED 1,913 PATIENT DAYS OF CARE, INCLUDING INPATIENT AND OBSERVATION PATIENTS, AND DELIVERED 44 NEWBORNS FOR THE SEVEN COUNTY AREA THAT SIDNEY REGIONAL MEDICAL CENTER (SRMC) SERVES. SRMC HAD 3,412 PATIENTS SEEK CARE IN THE EMERGENCY DEPARTMENT DURING 2017. 2540311 3881214 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. 2540311 3881214 48984463 1 1 0 1 0 0 0 0 0 0 1 0 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 0 0 0 1 81 0 1 472 1 0 0 0 0 0 0 0 0 0 0 X 12 10 0 1 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 X KELLY UTLEY 3082545825 1000 POLE CREEK CROSSING SIDNEY NE 69162 X WILLIAM PILE CHAIRMAN 4.00 0.00 X X 0 0 0 TIM MILLER VICE CHAIRMAN 4.00 0.00 X X 0 0 0 JEFF ELLWANGER TREASURER 4.00 0.00 X X 0 0 0 KATHY NARJES SECRETARY 4.00 0.00 X X 0 0 0 REBECCA L ALLARD MD CHIEF OF MEDICAL STAFF 40.00 0.00 X 382807 0 56643 STAN BELIEU MEMBER 4.00 1.00 X 0 0 0 SCOTT COLLIGNON MEMBER (THRU MAY 2017) 4.00 0.00 X 0 0 0 ROBERT GRAVES MD MEMBER - PHYSICIAN AT LARGE 40.00 0.00 X 296267 0 50378 TIM HENRY MEMBER 4.00 0.00 X 0 0 0 ANNE JOHNSON MEMBER (THRU DEC. 2017) 4.00 0.00 X 0 0 0 JIM JONES MEMBER 4.00 0.00 X 0 0 0 ROB ROBINSON MEMBER 4.00 0.00 X 0 0 0 DWIGHT SMITH MEMBER 4.00 0.00 X 0 0 0 RON SPATH MEMBER 4.00 0.00 X 0 0 0 JULIE WAMSLEY MEMBER (THRU DEC. 2017) 4.00 1.00 X 0 0 0 JASON PETIK CEO 40.00 0.00 X 0 0 0 KELLY UTLEY CFO 39.00 1.00 X 167119 0 8326 MATTHEW JANSEN DOCTOR 40.00 0.00 X 489588 0 54443 MANDY SHAW MD DOCTOR 40.00 0.00 X 486645 0 10164 JAMES THAYER MD DOCTOR 40.00 0.00 X 365201 0 39312 MICHAEL MATTHEWS DOCTOR 40.00 0.00 X 321554 0 12083 JENNIFER BROWN DOCTOR 40.00 0.00 X 304071 0 43143 2813252 0 274492 39 0 1 1 RURAL PARTNERS IN MEDICINE LLC PO BOX 772519 STEAMBOAT SPRINGS CO 80477 PHYSICIAN SERVICES 1871080 BYTES COMPUTER & NETWORK SOLUTIONS INC 1712 AVENUE B SCOTTSBLUFF NE 69361 IT SERVICES 609963 FUSION MEDICAL STAFFING PO BOX 82674 LINCOLN NE 68501 TEMPORARY STAFFING 264737 POUDRE VALLEY HEALTHCARE INC PO BOX 732033 DALLAS TX 75373 MANAGEMENT SERVICES 261928 PANHANDLE TRANSCRIPTION SERVICE 17200 HILLIARD ROAD LAKEWOOD OH 44107 TRANSCRIPTION SERVICES 156715 12 15803 584 16387 NET PATIENT SERVICE REVENUE 621110 31697386 31697386 MEDICARE/MEDICAID 621110 22630075 22630075 340B REVENUE 621110 896447 896447 SCHOOL REHAB REVENUE 621110 83610 83610 287451 287451 55594969 77317 77317 5000 0 5000 5000 5000 CAFETERIA 722210 135853 135853 PATRONAGE DIVIDEND 900099 858 858 136711 55830384 55594969 0 219028 X 20254 20254 961540 786095 175445 109241 109241 21719927 21172684 547243 733652 719184 14468 4343575 4218422 125153 1508880 1451841 57039 261928 261928 108972 108972 59811 59811 6851916 6768915 83001 205097 205097 909806 846592 63214 467389 467389 1053909 1053909 178080 166195 11885 28509 28509 1325820 1325820 5170322 2848320 2322002 342298 342298 MEDICAL SUPPLIES 5936190 5936190 BAD DEBTS 1376460 1376460 FOOD PRODUCTS 380958 380958 DUES AND SUBSCRIPTIONS 149321 72815 76506 193572 150845 42727 54397427 48984463 5412964 0 3487073 3716862 19412822 23770173 6235226 7379272 79808 55808 1389092 1492041 440555 523662 68660492 18724619 54132728 49935873 1878062 723273 87055366 87596964 3933611 3421849 9941008 9492704 31966973 31500609 642730 1177801 46484322 45592963 X 40571044 42004001 40571044 42004001 87055366 87596964 1432957 0 X X 0 1 X 1 0 X 0 0 0 0 0 0 0 0 1 6013 6013 0 PART II-B, LINE 1: 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. 92500 1929968 2022468 48823151 9551773 39271378 16986648 8941079 8045569 828225 231767 596458 49935873 DEFERRED COMPENSATION PLAN LIABILITY 708423 ESTIMATED THIRD-PARTY PAYOR SETTLEMENTS 469378 1177801 X PART X, LINE 2: SIDNEY REGIONAL MEDICAL CENTER AND CHEYENNE COUNTY HOSPITAL AND HEALTH CENTER FOUNDATION ARE EXEMPT FROM INCOME TAXES UNDER SECTION 501(A) OF THE 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, 2017, THE SYSTEM HAD NO UNCERTAIN TAX POSITIONS ACCRUED. 1 1 X 1 X 1 X 1 1 1 0 1 1 941143 0 941143 0.01780 3180145 3158412 21733 0.00040 4121288 3158412 962876 0.01820 214309 113541 100768 0.00190 19686 0 19686 0.00040 35505 0 35505 0.00070 269500 113541 155959 0.00300 4390788 3271953 1118835 0.02120 58 1406 44735 44735 0.00080 69 2458 2741 2741 0.00010 110 865 14780 14780 0.00030 237 4729 62256 62256 0.00120 1 1376460 275292 16569463 16997178 -427715 X 1 1 1 1 CHEYENNE COUNTY HOSPITAL ASSOCIATION 1000 POLE CREEK CROSSING SIDNEY NE 69162 WWW.SIDNEYRMC.COM 150001 X X X X CHEYENNE COUNTY HOSPITAL ASSOCIATION INC 1 0 0 1 X X X X X X X X X 17 1 1 1 1 X WWW.SIDNEYRMC.COM/501R X WWW.PPHD.ORG X 1 17 1 WWW.SIDNEYRMC.COM/501R 0 1 X 100.000000000000 300.000000000000 X X X X X 1 1 X X X X 1 X SIDNEYRMC.COM/501R X SIDNEYRMC.COM/501R X SIDNEYRMC.COM/501R X X X X X X 1 X 0 X X X X X 1 X 0 0 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: 2017 ACTIVITIES TO ADDRESS THE SIGNIFICANT NEEDS IDENTIFIED IN THE MOST RECENTLY CONDUCTED CHNA:NUTRITION AND WEIGHT STATUS:IN ORDER TO ADDRESS NUTRITION AND WEIGHT STATUS THE HOSPITAL IS PROVIDING EDUCATION TO THE COMMUNITY ON HOW TO MAKE HEALTHY FOOD CHOICES DURING 2017. PHYSICAL ACTIVITY:IN ORDER TO ADDRESS PHYSICAL ACTIVITY THE HOSPITAL IS PARTNERING WITH THE AREA COMMUNITY CENTER TO TRACK EMPLOYEE ACTIVITY THROUGH WELLNESS PROGRAMS. IN JANUARY OF 2017, DPP GROUP #6 (POST CORE) COMPLETED THEIR YEAR LONG COMMITMENT WITH 7 PARTICIPANTS LOSING A TOTAL OF 111 POUNDS OR 9% OF THEIR TOTAL BODY WEIGHT. IN MAY OF 2017, DPP GROUP #8 FINISHED ITS 16 WEEK PROGRAM FOR COMMUNITY MEMBERS WITH 7 MEMBERS LOSING A TOTAL OF 52.7 POUNDS OR 7.5% PER PERSON AVERAGE. IN JULY OF 2017, THE DIETITIAN PRESENTED TO THE PREVENT T2 POST CORE CLASS ABOUT CARBOHYDRATES, THE GOOD AND THE BAD. IN AUGUST OF 2017, THE DPP GROUP #7 (POST CORE) COMPLETED THEIR YEAR LONG COMMITMENT WITH 5 COMMUNITY PARTICIPANTS HAVING A TOTAL WEIGHT LOSS OF 106.7 POUNDS OR 8.4% WEIGHT LOSS. THEIR 2 GOALS ARE TO LOSE 5-7% OF TOTAL BODY WEIGHT AND BECOME MORE PHYSICALLY ACTIVE. IN MARCH OF 2017, THE PREVENT T2 CLASS (SRMC EMPLOYEES) WAS GIVEN A GROCERY STORE TOUR WITH HEALTHIER OPTIONS DONE BY THE DIETITIAN, MARCI ROSENBURG. THE HOSPITAL PROVIDED THREE, 16-WEEK PROGRAMS ON DPP. IN APRIL OF 2017, A GROCERY STORE TOUR WAS GIVEN FOR THE COMMUNITY MEMBERS OF PREVENT T2 CLASS BY MARCI ROSENBURG, DIETITIAN, TO PICK HEALTHIER OPTIONS AND RAISE AWARENESS OF THE HIGH SODIUM AND HIGH FAT CONTENT IN CERTAIN FOODS. IN JUNE OF 2017, THE DIETITIAN PRESENTED TO THE COOL KIDS CLUB AN INTERACTIVE NUTRITION PRESENTATION TO TWO DIFFERENT AGE GROUPS (K AND 1ST GRADE AND 2ND THROUGH 6TH GRADE). IN JUNE OF 2017, ANOTHER NUTRITION PRESENTATION WAS DONE BY THE DIETARY STAFF AT OSAGE CAMPUS CAFETERIA ON LEARNING ABOUT FARM TO TABLE AND THEY ALSO TOURED THE CAFETERIA. THIS WAS THE COOL KIDS CLUB AGAIN IN THREE SEPARATE GROUPS. PHYSICAL ACTIVITY WAS APPROACHED DURING ALL OF THE DPP PRESENTATIONS, AND TO TRACK THE MINUTES FOR INDIVIDUALS IN THE DPP. SRMC HELD ITS ANNUAL DASH FOR THE SPLASH TRIATHLON FOR OUR COMMUNITY AND SURROUNDING AREA DURING THE MONTH OF JULY, WITH 159 PARTICIPANTS (33 WERE KIDS). SUBSTANCE ABUSE EDUCATION:SUBSTANCE ABUSE EDUCATION WAS HELD ON OCTOBER 2017. SRMC PHARMACISTS EDUCATED CHILDREN AT THE PRE-HEALTH FAIR KIDS EVENT ON CANDY VERSUS MEDS AND THE IMPORTANCE OF GETTING THEIR VACCINATIONS TO PREVENT ILLNESS AND DISEASES. HAND HYGIENE:HAND HYGIENE WAS REPLACED WITH THE ANTIMICROBIAL STEWARDSHIP WITH FULL PROMOTION AND EDUCATION TO THE COMMUNITY. THE ANTIMICROBIAL STEWARDSHIP IS CONTINUED INTO THE YEAR 2018. MARCH 29TH THROUGH MARCH 31ST COMMUNITY BLOOD DRAWS WERE HELD IN CONJUNCTION WITH 9 HEALTH FAIR AND FOR THE THREE DAYS THERE WERE 578 PARTICIPANTS. ON APRIL 1, 2017, SRMC AGAIN PARTNERED WITH 9 HEALTH FAIR FOR A COMMUNITY BLOOD DRAW AND HAD A TOTAL OF 238 PARTICIPANTS. WITH APRIL BEING AUTISM AWARENESS MONTH, SRMC'S REHAB PEDIATRIC TEAM PARTNERED WITH THE LOCAL EDUCATIONAL SERVICE UNIT TO HOST A WALKING EVENT WITH A 150 PARTICIPANTS TO HELP RAISE AWARENESS FOR AUTISM. ON APRIL 18TH, SRMC'S COMMUNITY HEALTH TEAM ASSISTED THE DONOR CENTER OUT OF SCOTTSBLUFF, NEBRASKA IN AN EMPLOYEE BLOOD DRIVE HELD AT CABELA'S, KICKING OFF THEIR WELLNESS WEEK WITH 51 PARTICIPANTS. ON APRIL 19TH, SRMC'S REHAB, COMMUNITY HEALTH AND MARKETING DEPARTMENTS AND THE SRMC DIETITIAN TEAMED UP AND PARTICIPATED IN THE CABELA'S WELLNESS FAIR AT CORPORATE CABELA'S WITH OVER 300 IN ATTENDANCE. ON JUNE 15TH, SRMC HELD AN EMPLOYEE BLOOD DRIVE WITH 44 EMPLOYEES PARTICIPATING AND EACH DONATING A UNIT OF BLOOD TO THE DONOR CENTER IN SCOTTSBLUFF, NEBRASKA. ON OCTOBER 20TH, SRMC HELD A FREE PRE-HEALTH FAIR KIDS EVENT FOR AREA SCHOOL CHILDREN AND THEIR TEACHERS AND HAD OVER 350 PARTICIPANTS. THE KIDS TOOK PART IN INTERACTIVE, EDUCATIONAL HEALTH TOPICS TRYING THEIR SKILLS, AS WELL AS TOURING A 50 FOOT MEGABODY. ON OCTOBER 21ST, SRMC HOSTED THE ANNUAL FAMILY HEALTH AND WELLNESS FAIR WITH OVER 400 ATTENDING THIS FREE EVENT WHICH INCLUDED THE CHILD ID PROGRAM, CAR SEAT SAFETY, DRUG TAKEBACK PROGRAM AND ADMINISTERED FREE FLU SHOTS TO 190 ADULTS AND KIDS. THERE WERE INTERACTIVE AND EDUCATIONAL BOOTHS FOR KIDS AND ADULTS AND A 50 FOOT MEGABODY.ALSO, DURING THE FOURTH QUARTER OF 2017, SRMC LAUNCHED A NEW SIDNEYRMC APP WHICH FEATURES A SYMPTOM CHECKER THAT CAN BE DOWNLOADED FOR FREE. ON NOVEMBER 29TH, SRMC HOSTED IT'S SECOND DIABETES HEALTH FAIR IN RECOGNITION OF NATIONAL DIABETES AWARENESS MONTH. THIS WAS ATTENDED BY OVER 40 COMMUNITY MEMBERS AND FEATURED LAB DRAWS, FLU SHOTS, BLOOD PRESSURE SCREENINGS, EDUCATION AND BOTH A REGISTERED DIETITIAN AND PHARMACIST AVAILABLE FOR QUESTIONS.MENTAL AND EMOTIONAL WELL BEING: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. 3 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 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 $1,376,460 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, 9, 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 2017 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 9,700 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 2017 DEMOGRAPHIC IS AROUND 96% CAUCASIAN AND THE AVERAGE HOUSEHOLD SIZE IS 1.93 PEOPLE PER HOUSEHOLD. APPROXIMATELY 7% OF PEOPLE ARE WITHOUT HEALTH INSURANCE OF THE TOTAL POPULATION OVER 16 YEARS OF AGE, 73.1% 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. 1 4-H COUNCIL 920 JACKSON STREET PO BOX 356 SIDNEY NE 69162 470722021 501(C)(3) 5000 DONATION CHEYENNE COUNTY HOSPITAL AND HEALTH CENTER FOUNDATION 1000 POLE CREEK CROSSING SIDNEY NE 69162 470686476 501(C)(3) 15254 SPONSORSHIP OF FUNDRAISING ACTIVITIES; GENERAL OPERATIONS 2 0 PART I, LINE 2: 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. X X X X 0 0 0 1 0 0 0 0 0 REBECCA L ALLARD MD CHIEF OF MEDICAL STAFF 382539 0 0 0 268 0 13500 0 43143 0 439450 0 0 0 ROBERT GRAVES MD MEMBER - PHYSICIAN AT LARGE 294702 0 0 0 1565 0 13000 0 37378 0 346645 0 0 0 KELLY UTLEY CFO 166525 0 0 0 594 0 8326 0 0 0 175445 0 0 0 MATTHEW JANSEN DOCTOR 489252 0 0 0 336 0 10800 0 43643 0 544031 0 0 0 MANDY SHAW MD DOCTOR 486380 0 0 0 265 0 10164 0 0 0 496809 0 0 0 JAMES THAYER MD DOCTOR 327027 0 36511 0 1663 0 8940 0 30372 0 404513 0 0 0 MICHAEL MATTHEWS DOCTOR 320522 0 0 0 1032 0 12083 0 0 0 333637 0 0 0 JENNIFER BROWN DOCTOR 303786 0 0 0 285 0 0 0 43143 0 347214 0 0 0 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 $222,544, RETIREMENT BENEFITS OF $7,886 AND NONTAXABLE BENEFITS OF $10,330. MR. PETIK'S SALARY IS REFLECTED IN PART IX, LINE 11A. A THE COUNTY OF DEUEL NEBRASKA 476006452 251476AA5 2014-10-16 10000000 CONSTRUCT HOSPITAL 0 0 0 B THE COUNTY OF CHEYENNE NEBRASKA 476006443 1668ATAA7 2014-09-30 32000000 CONSTRUCT HOSPITAL 0 0 0 A 10000000 10000000 2015 0 0 1 1 B 32000056 212500 31787556 2015 0 0 1 1 A 0 0 0 0 0.00000 0.00000 0.00000 0 0 1 B 0 0 0 0 0.00000 0.00000 0.00000 0 0 1 A 0 0 1 0 1 0 0 0 1 B 0 0 1 0 0 0 0 0 1 A 1 B 1 PART II, LINE 3, COLUMN B: THE TOTAL PROCEEDS DO NOT AGREE TO THE ISSUE PRICE IN PART I, COLUMN E DUE TO INVESTMENT EARNINGS. KEVIN UTLEY EMPLOYEE OF ORGANIZATION AND SPOUSE OF KELLY UTLEY, CFO 109241 EMPLOYEE COMPENSATION 0 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 IT 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: ROBERT GRAVES, MD AND REBECCA ALLARD, MD 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 4,841,011. MANAGEMENT AND GENERAL EXPENSES 83,001. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 4,924,012. CONTRACT SERVICES - SURGERY PROFESSIONALS: PROGRAM SERVICE EXPENSES 831,293. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 831,293. CONTRACT SERVICES - ANESTHESIA PROFESSIONALS: PROGRAM SERVICE EXPENSES 318,774. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 318,774. RECRUITING FEES: PROGRAM SERVICE EXPENSES 345,723. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 345,723. CONTRACT SERVICES - RADIOLOGY PROFESSIONALS: PROGRAM SERVICE EXPENSES 432,114. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 432,114. 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. CHEYENNE COUNTY HOSPITAL AND HEALTH CENTER FOUNDATION 1000 POLE CREEK CROSSING SIDNEY NE 69162 470686476 SUPPORT SIDNEY REGIONAL MEDICAL CENTER NE 501(C)(3) LINE 12C, III-FI N/A 0 0 1 1 1 0 0 0 0 0 0 0 0 1 1 1 1 1 0 0