CHEYENNE COUNTY HOSPITAL ASSOCIATION INC: Form 990, tax year 2016
View the entire original 990 at ProPublica ↗
- Organization
- CHEYENNE COUNTY HOSPITAL ASSOCIATION INC (EIN 47-0408242)
- Tax period
- 2016-01-01 to 2016-12-31
- Filed
- 2017-11-15
- IRS object ID
- 201713199349302121
- Schema version
- 2016v3.0
- Source
- Download XML · Original 990 at ProPublica
Every field in the e-filed return. Faint text is the IRS element name, for citing.
- Return header
- Form 990
- Schedule A
- Schedule B
- Schedule C
- Schedule D
- Schedule H
- Schedule I
- Schedule J
- Schedule K
- Schedule L
- Schedule O
- Schedule R
Return header ReturnHeader
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return | 2017-11-15T08:08:56-06:00 | ReturnTs |
| Tax Period End | 2016-12-31 | TaxPeriodEndDt |
Preparer Firm PreparerFirmGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Firm EIN | 476097913 | PreparerFirmEIN |
Preparer Firm Name PreparerFirmName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | SEIM JOHNSON LLP | BusinessNameLine1Txt |
Preparer US Address PreparerUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 18081 BURT STREET SUITE 200 | AddressLine1Txt |
| City | OMAHA | CityNm |
| State Abbreviation | NE | StateAbbreviationCd |
| ZIP | 680224722 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return Type | 990 | ReturnTypeCd |
| Tax Period Begin | 2016-01-01 | TaxPeriodBeginDt |
Filer Filer
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 470408242 | EIN |
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | CHEYENNE COUNTY HOSPITAL | BusinessNameLine1Txt |
| Business Name Line2 | ASSOCIATION INC | BusinessNameLine2Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Control | CHEY | BusinessNameControlTxt |
| Phone | 3082545825 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 1000 POLE CREEK CROSSING | AddressLine1Txt |
| City | SIDNEY | CityNm |
| State Abbreviation | NE | StateAbbreviationCd |
| ZIP | 69162 | ZIPCd |
Business Officer BusinessOfficerGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person | JASON PETIK | PersonNm |
| Person Title | CEO | PersonTitleTxt |
| Phone | 3082545825 | PhoneNum |
| Signature | 2017-11-14 | SignatureDt |
| Discuss With Paid Preparer | Yes (1) | DiscussWithPaidPreparerInd |
Preparer Person PreparerPersonGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Person | WENDY R COOLEY | PreparerPersonNm |
| PTIN | P01523804 | PTIN |
| Phone | 4023302660 | PhoneNum |
Filing Security Information FilingSecurityInformation
IP Address IPAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| I Pv4 Address | 209.34.201.180 | IPv4AddressTxt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| IP | 2017-11-14 | IPDt |
| IP Tm | 14:59:26 | IPTm |
| IP Timezone | CS | IPTimezoneCd |
| Filing License Type | P | FilingLicenseTypeCd |
| At Submission Creation Device Id | E174F7C75A15FCA0AF1E43F729F0FF7E9FDF9AE2 | AtSubmissionCreationDeviceId |
| At Submission Filing Device Id | FCEDDD786A52D146CD6D5AF04BB3D8B974087028 | AtSubmissionFilingDeviceId |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tax | 2016 | TaxYr |
| Build TS | 2017-02-10 21:41:12Z | BuildTS |
Form 990 IRS990
Doing Business As Name DoingBusinessAsName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | SIDNEY REGIONAL MEDICAL CENTER | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Principal Officer | JASON PETIK | PrincipalOfficerNm |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 1000 POLE CREEK CROSSING | AddressLine1Txt |
| City | SIDNEY | CityNm |
| State Abbreviation | NE | StateAbbreviationCd |
| ZIP | 69162 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Receipts | $57,136,824 | GrossReceiptsAmt |
| Group Return For Affiliates | 0 | GroupReturnForAffiliatesInd |
| Organization501c3 | Yes (X) | Organization501c3Ind |
| Website Address | WWW.SIDNEYRMC.COM | WebsiteAddressTxt |
| Type Of Organization Corp | Yes (X) | TypeOfOrganizationCorpInd |
| Formation | 1951 | FormationYr |
| Legal Domicile State | NE | LegalDomicileStateCd |
| Activity Or Mission | TO REVOLUTIONIZE HEALTHCARE SERVICES IN THE REGION. | ActivityOrMissionDesc |
| Voting Members Governing Body | 14 | VotingMembersGoverningBodyCnt |
| Voting Members Independent | 12 | VotingMembersIndependentCnt |
| Total Employee | 502 | TotalEmployeeCnt |
| Total Volunteers | 100 | TotalVolunteersCnt |
| Total Gross UBI | $0 | TotalGrossUBIAmt |
| Net Unrelated Bus Txbl Incm | $0 | NetUnrelatedBusTxblIncmAmt |
| PY Contributions Grants | $182,617 | PYContributionsGrantsAmt |
| CY Contributions Grants | $46,543 | CYContributionsGrantsAmt |
| PY Program Service Revenue | $52,158,301 | PYProgramServiceRevenueAmt |
| CY Program Service Revenue | $56,805,243 | CYProgramServiceRevenueAmt |
| PY Investment Income | -$142,457 | PYInvestmentIncomeAmt |
| CY Investment Income | $36,996 | CYInvestmentIncomeAmt |
| PY Other Revenue | $114,857 | PYOtherRevenueAmt |
| CY Other Revenue | $113,656 | CYOtherRevenueAmt |
| PY Total Revenue | $52,313,318 | PYTotalRevenueAmt |
| CY Total Revenue | $57,002,438 | CYTotalRevenueAmt |
| PY Grants And Similar Paid | $76,043 | PYGrantsAndSimilarPaidAmt |
| CY Grants And Similar Paid | $40,033 | CYGrantsAndSimilarPaidAmt |
| PY Benefits Paid To Members | $0 | PYBenefitsPaidToMembersAmt |
| CY Benefits Paid To Members | $0 | CYBenefitsPaidToMembersAmt |
| PY Salaries Comp Emp Bnft Paid | $28,499,642 | PYSalariesCompEmpBnftPaidAmt |
| CY Salaries Comp Emp Bnft Paid | $29,070,665 | CYSalariesCompEmpBnftPaidAmt |
| PY Total Prof Fndrsng Expns | $0 | PYTotalProfFndrsngExpnsAmt |
| CY Total Prof Fndrsng Expns | $0 | CYTotalProfFndrsngExpnsAmt |
| CY Total Fundraising Expense | $0 | CYTotalFundraisingExpenseAmt |
| PY Other Expenses | $19,667,482 | PYOtherExpensesAmt |
| CY Other Expenses | $26,572,885 | CYOtherExpensesAmt |
| PY Total Expenses | $48,243,167 | PYTotalExpensesAmt |
| CY Total Expenses | $55,683,583 | CYTotalExpensesAmt |
| PY Revenues Less Expenses | $4,070,151 | PYRevenuesLessExpensesAmt |
| CY Revenues Less Expenses | $1,318,855 | CYRevenuesLessExpensesAmt |
| Total Assets BOY | $88,576,422 | TotalAssetsBOYAmt |
| Total Assets EOY | $87,055,366 | TotalAssetsEOYAmt |
| Total Liabilities BOY | $49,324,233 | TotalLiabilitiesBOYAmt |
| Total Liabilities EOY | $46,484,322 | TotalLiabilitiesEOYAmt |
| Net Assets Or Fund Balances BOY | $39,252,189 | NetAssetsOrFundBalancesBOYAmt |
| Net Assets Or Fund Balances EOY | $40,571,044 | NetAssetsOrFundBalancesEOYAmt |
| Info In Schedule O Part III | Yes (X) | InfoInScheduleOPartIIIInd |
| Mission | TO REVOLUTIONIZE HEALTHCARE SERVICES IN THE REGION. | MissionDesc |
| Significant New Program Srvc | 0 | SignificantNewProgramSrvcInd |
| Significant Change | 0 | SignificantChangeInd |
| Expense | $40,631,893 | ExpenseAmt |
| Grant | $40,033 | GrantAmt |
| Revenue | $41,416,017 | RevenueAmt |
| Desc | SIDNEY REGIONAL MEDICAL CENTER IS A NOT-FOR-PROFIT ACUTE CARE HOSPITAL WHICH PROVIDES INPATIENT, OUTPATIENT AND EMERGENCY ROOM CARE SERVICE TO PATIENTS IN SIDNEY, NEBRASKA. IT ALSO OPERATES LONG-TERM CARE FACILITIES, A HOME HEALTH AGENCY, AND PROVIDER-BASED RURAL HEALTH CLINICS IN SIDNEY, NEBRASKA AND CHAPPELL, NEBRASKA, AS WELL AS A STAND ALONE PRIMARY CARE CLINIC IN SIDNEY, NEBRASKA. | Desc |
Prog Srvc Accom Acty2 ProgSrvcAccomActy2Grp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Expense | $3,667,536 | ExpenseAmt |
| Revenue | $7,028,815 | RevenueAmt |
| Desc | IN 2016, THE HOSPITAL NURSING DEPARTMENT PROVIDED 2,023 PATIENT DAYS OF CARE, INCLUDING INPATIENT AND OBSERVATION PATIENTS, AND DELIVERED 69 NEWBORNS FOR THE SEVEN COUNTY AREA THAT SIDNEY REGIONAL MEDICAL CENTER (SRMC) SERVES. SRMC HAD 3,752 PATIENTS SEEK CARE IN THE EMERGENCY DEPARTMENT DURING 2016. | Desc |
Prog Srvc Accom Acty3 ProgSrvcAccomActy3Grp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Expense | $3,177,496 | ExpenseAmt |
| Revenue | $3,934,396 | RevenueAmt |
| Desc | THE EXTENDED CARE UNIT PROVIDED CARE FOR AN AVERAGE OF 51 PATIENTS DAILY DURING 2016. SRMC PROVIDED 17,824 PATIENT DAYS OF CARE FOR RESIDENTS IN THE CHEYENNE, DEUEL, KIMBALL AND SURROUNDING AREAS. | Desc |
Prog Srvc Accom Acty Other ProgSrvcAccomActyOtherGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Expense | $2,617,320 | ExpenseAmt |
| Revenue | $4,426,015 | RevenueAmt |
| Desc | THE SRMC PHARMACY DEPARTMENT HAS BEEN ACTIVELY INVOLVED WITH THE QUALITY OF CARE PROVIDED TO ALL PATIENTS BOTH IN THE ACUTE AND OUT PATIENT SETTINGS. THE PHARMACY DEPARTMENT HAS HELPED PROVIDE CARE FOR THOSE INDIVIDUALS WITH THE TREATMENT FOR RADIATION OR CHEMOTHERAPY. | Desc |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Other Prog Srvc Expense | $2,617,320 | TotalOtherProgSrvcExpenseAmt |
| Total Other Prog Srvc Revenue | $4,426,015 | TotalOtherProgSrvcRevenueAmt |
| Total Program Service Expenses | $50,094,245 | TotalProgramServiceExpensesAmt |
| Described In Section501c3 | Yes (1) | DescribedInSection501c3Ind |
| Schedule B Required | Yes (1) | ScheduleBRequiredInd |
| Political Campaign Acty | 0 | PoliticalCampaignActyInd |
| Lobbying Activities | Yes (1) | LobbyingActivitiesInd |
| Subject To Proxy Tax | 0 | SubjectToProxyTaxInd |
| Donor Advised Fund | 0 | DonorAdvisedFundInd |
| Conservation Easements | 0 | ConservationEasementsInd |
| Collections Of Art | 0 | CollectionsOfArtInd |
| Credit Counseling | 0 | CreditCounselingInd |
| Temp Or Permanent Endowments | 0 | TempOrPermanentEndowmentsInd |
| Report Land Building Equipment | Yes (1) | ReportLandBuildingEquipmentInd |
| Report Investments Other Sec | 0 | ReportInvestmentsOtherSecInd |
| Report Program Related Invst | 0 | ReportProgramRelatedInvstInd |
| Report Other Assets | 0 | ReportOtherAssetsInd |
| Report Other Liabilities | Yes (1) | ReportOtherLiabilitiesInd |
| Include FIN48 Footnote | Yes (1) | IncludeFIN48FootnoteInd |
| Independent Audit Fincl Stmt | 0 | IndependentAuditFinclStmtInd |
| Consolidated Audit Fincl Stmt | Yes (1) | ConsolidatedAuditFinclStmtInd |
| School Operating | 0 | SchoolOperatingInd |
| Foreign Office | 0 | ForeignOfficeInd |
| Foreign Activities | 0 | ForeignActivitiesInd |
| More Than5000 K To Org | 0 | MoreThan5000KToOrgInd |
| More Than5000 K To Individuals | 0 | MoreThan5000KToIndividualsInd |
| Professional Fundraising | 0 | ProfessionalFundraisingInd |
| Fundraising Activities | 0 | FundraisingActivitiesInd |
| Gaming Activities | 0 | GamingActivitiesInd |
| Operate Hospital | Yes (1) | OperateHospitalInd |
| Audited Financial Stmt Att | Yes (1) | AuditedFinancialStmtAttInd |
| Grants To Organizations | Yes (1) | GrantsToOrganizationsInd |
| Grants To Individuals | 0 | GrantsToIndividualsInd |
| Schedule J Required | Yes (1) | ScheduleJRequiredInd |
| Tax Exempt Bonds | Yes (1) | TaxExemptBondsInd |
| Invest Tax Exempt Bonds | 0 | InvestTaxExemptBondsInd |
| Escrow Account | 0 | EscrowAccountInd |
| On Behalf Of Issuer | 0 | OnBehalfOfIssuerInd |
| Engaged In Excess Benefit Trans | 0 | EngagedInExcessBenefitTransInd |
| PY Excess Benefit Trans | 0 | PYExcessBenefitTransInd |
| Loan Outstanding | 0 | LoanOutstandingInd |
| Grant To Related Person | 0 | GrantToRelatedPersonInd |
| Business Rln With Org Mem | 0 | BusinessRlnWithOrgMemInd |
| Business Rln With Fam Mem | Yes (1) | BusinessRlnWithFamMemInd |
| Business Rln With Officer Ent | 0 | BusinessRlnWithOfficerEntInd |
| Deductible Non Cash Contri | 0 | DeductibleNonCashContriInd |
| Deductible Art Contribution | 0 | DeductibleArtContributionInd |
| Terminate Operations | 0 | TerminateOperationsInd |
| Partial Liquidation | 0 | PartialLiquidationInd |
| Disregarded Entity | 0 | DisregardedEntityInd |
| Related Entity | Yes (1) | RelatedEntityInd |
| Related Organization Ctrl Ent | 0 | RelatedOrganizationCtrlEntInd |
| Trnsfr Exmpt Non Chrtbl Rltd Org | 0 | TrnsfrExmptNonChrtblRltdOrgInd |
| Activities Conducted Prtshp | 0 | ActivitiesConductedPrtshpInd |
| Schedule O Required | Yes (1) | ScheduleORequiredInd |
| IRP Document | 86 | IRPDocumentCnt |
| IRP Document W2 G | 0 | IRPDocumentW2GCnt |
| Backup Wthld Compliance | Yes (1) | BackupWthldComplianceInd |
| Employee | 502 | EmployeeCnt |
| Employment Tax Returns Filed | Yes (1) | EmploymentTaxReturnsFiledInd |
| Unrelated Bus Incm Over Limit | 0 | UnrelatedBusIncmOverLimitInd |
| Foreign Financial Account | 0 | ForeignFinancialAccountInd |
| Prohibited Tax Shelter Trans | 0 | ProhibitedTaxShelterTransInd |
| Taxable Party Notification | 0 | TaxablePartyNotificationInd |
| Nondeductible Contributions | 0 | NondeductibleContributionsInd |
| Quid Pro Quo Contributions | 0 | QuidProQuoContributionsInd |
| Form8282 Property Disposed Of | 0 | Form8282PropertyDisposedOfInd |
| Rcv Fnds To Pay Prsnl Bnft Cntrct | 0 | RcvFndsToPayPrsnlBnftCntrctInd |
| Pay Premiums Prsnl Bnft Cntrct | 0 | PayPremiumsPrsnlBnftCntrctInd |
| Indoor Tanning Services | 0 | IndoorTanningServicesInd |
| Info In Schedule O Part VI | Yes (X) | InfoInScheduleOPartVIInd |
| Governing Body Voting Members | 14 | GoverningBodyVotingMembersCnt |
| Independent Voting Member | 12 | IndependentVotingMemberCnt |
| Family Or Business Rln | 0 | FamilyOrBusinessRlnInd |
| Delegation Of Mgmt Duties | Yes (1) | DelegationOfMgmtDutiesInd |
| Change To Org Documents | 0 | ChangeToOrgDocumentsInd |
| Material Diversion Or Misuse | 0 | MaterialDiversionOrMisuseInd |
| Members Or Stockholders | 0 | MembersOrStockholdersInd |
| Election Of Board Members | 0 | ElectionOfBoardMembersInd |
| Decisions Subject To Approva | 0 | DecisionsSubjectToApprovaInd |
| Minutes Of Governing Body | Yes (1) | MinutesOfGoverningBodyInd |
| Minutes Of Committees | Yes (1) | MinutesOfCommitteesInd |
| Officer Mailing Address | 0 | OfficerMailingAddressInd |
| Local Chapters | 0 | LocalChaptersInd |
| Form990 Provided To Gvrn Body | Yes (1) | Form990ProvidedToGvrnBodyInd |
| Conflict Of Interest Policy | Yes (1) | ConflictOfInterestPolicyInd |
| Annual Disclosure Covered Prsn | Yes (1) | AnnualDisclosureCoveredPrsnInd |
| Regular Monitoring Enfrc | Yes (1) | RegularMonitoringEnfrcInd |
| Whistleblower Policy | Yes (1) | WhistleblowerPolicyInd |
| Document Retention Policy | Yes (1) | DocumentRetentionPolicyInd |
| Compensation Process CEO | Yes (1) | CompensationProcessCEOInd |
| Compensation Process Other | Yes (1) | CompensationProcessOtherInd |
| Investment In Joint Venture | 0 | InvestmentInJointVentureInd |
| Upon Request | Yes (X) | UponRequestInd |
Books In Care Of Detail BooksInCareOfDetail
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | KELLY UTLEY | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Phone | 3082545825 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 1000 POLE CREEK CROSSING | AddressLine1Txt |
| City | SIDNEY | CityNm |
| State Abbreviation | NE | StateAbbreviationCd |
| ZIP | 69162 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part VII | Yes (X) | InfoInScheduleOPartVIIInd |
Form990 Part VII Section A Form990PartVIISectionAGrp (21 entries)
| TitleTitleTxt | Average Hours Per WeekAverageHoursPerWeekRt | Average Hours Per Week Rltd OrgAverageHoursPerWeekRltdOrgRt | Individual Trustee Or DirectorIndividualTrusteeOrDirectorInd | OfficerOfficerInd | Reportable Comp From OrgReportableCompFromOrgAmt | Reportable Comp From Rltd OrgReportableCompFromRltdOrgAmt | Other CompensationOtherCompensationAmt | Highest Compensated EmployeeHighestCompensatedEmployeeInd |
|---|---|---|---|---|---|---|---|---|
| WILLIAM PILE | ||||||||
| CHAIRMAN | 4.00 | 0.00 | Yes (X) | Yes (X) | $0 | $0 | $0 | |
| TIM MILLER | ||||||||
| VICE CHAIRMAN | 4.00 | 0.00 | Yes (X) | Yes (X) | $0 | $0 | $0 | |
| TOM MILLMAN | ||||||||
| SECRETARY | 4.00 | 0.00 | Yes (X) | Yes (X) | $0 | $0 | $0 | |
| JEFF ELLWANGER | ||||||||
| TREASURER | 4.00 | 0.00 | Yes (X) | Yes (X) | $0 | $0 | $0 | |
| STAN BELIEU | ||||||||
| MEMBER | 4.00 | 1.00 | Yes (X) | $0 | $0 | $0 | ||
| CLINTON DORWART MD | ||||||||
| MEMBER - PHYSICIAN AT LARGE | 40.00 | 0.00 | Yes (X) | $142,082 | $0 | $6,033 | ||
| ROBERT GRAVES MD | ||||||||
| MEMBER - CHIEF OF MEDICAL STAFF | 40.00 | 0.00 | Yes (X) | $185,102 | $0 | $9,241 | ||
| JIM JONES | ||||||||
| MEMBER | 4.00 | 0.00 | Yes (X) | $0 | $0 | $0 | ||
| KATHY NARJES | ||||||||
| MEMBER | 4.00 | 0.00 | Yes (X) | $0 | $0 | $0 | ||
| ROB ROBINSON | ||||||||
| MEMBER | 4.00 | 0.00 | Yes (X) | $0 | $0 | $0 | ||
| DWIGHT SMITH | ||||||||
| MEMBER | 4.00 | 0.00 | Yes (X) | $0 | $0 | $0 | ||
| JULIE WAMSLEY | ||||||||
| MEMBER | 4.00 | 1.00 | Yes (X) | $0 | $0 | $0 | ||
| LAURIE WIDDOWSON | ||||||||
| MEMBER | 4.00 | 0.00 | Yes (X) | $0 | $0 | $0 | ||
| ANNE JOHNSON | ||||||||
| MEMBER | 4.00 | 0.00 | Yes (X) | $0 | $0 | $0 | ||
| JASON PETIK | ||||||||
| CEO | 40.00 | 0.00 | Yes (X) | $0 | $0 | $0 | ||
| KELLY UTLEY | ||||||||
| CFO | 39.00 | 1.00 | Yes (X) | $167,994 | $0 | $8,475 | ||
| MATTHEW JANSEN | ||||||||
| DOCTOR | 40.00 | 0.00 | $480,279 | $0 | $41,217 | Yes (X) | ||
| MANDY SHAW MD | ||||||||
| DOCTOR | 40.00 | 0.00 | $332,080 | $0 | $10,000 | Yes (X) | ||
| REBECCA L ALLARD MD | ||||||||
| DOCTOR | 40.00 | 0.00 | $340,035 | $0 | $53,144 | Yes (X) | ||
| JAMES THAYER MD | ||||||||
| DOCTOR | 40.00 | 0.00 | $338,149 | $0 | $35,833 | Yes (X) | ||
| CRAIG SANDBERG | ||||||||
| CRNA | 40.00 | 0.00 | $285,765 | $0 | $13,250 | Yes (X) | ||
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Reportable Comp From Org | $2,271,486 | TotalReportableCompFromOrgAmt |
| Tot Reportable Comp Rltd Org | $0 | TotReportableCompRltdOrgAmt |
| Total Other Compensation | $177,193 | TotalOtherCompensationAmt |
| Indiv Rcvd Greater Than100 K | 39 | IndivRcvdGreaterThan100KCnt |
| Former Ofcr Employees Listed | 0 | FormerOfcrEmployeesListedInd |
| Total Comp Greater Than150 K | Yes (1) | TotalCompGreaterThan150KInd |
| Compensation From Other Srcs | Yes (1) | CompensationFromOtherSrcsInd |
Contractor Compensation ContractorCompensationGrp (5 entries)
| Address Line1ContractorAddress/USAddress/AddressLine1Txt | CityContractorAddress/USAddress/CityNm | State AbbreviationContractorAddress/USAddress/StateAbbreviationCd | ZIPContractorAddress/USAddress/ZIPCd | ServicesServicesDesc | CompensationCompensationAmt |
|---|---|---|---|---|---|
| RURAL PARTNERS IN MEDICINE LLC | |||||
| PO BOX 772519 | STEAMBOAT SPRINGS | CO | 80477 | PHYSICIAN SERVICES | $1,987,152 |
| BYTES COMPUTER & NETWORK SOLUTIONS INC | |||||
| 1712 AVENUE B | SCOTTSBLUFF | NE | 69361 | IT SERVICES | $394,963 |
| PRIME TIME HEALTHCARE LLC | |||||
| PO BOX 3544 | OMAHA | NE | 68103 | TEMPORARY STAFFING | $368,615 |
| SUNBELT STAFFING | |||||
| DEPT CH 14430 | PALATINE | IL | 60055 | TEMPORARY STAFFING | $261,708 |
| UNIVERSITY OF COLORADO HOSPITAL AUTHORIT | |||||
| PO BOX 733156 | DALLAS | TX | 75373 | MANAGEMENT SERVICES | $206,233 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Cntrct Rcvd Greater Than100 K | 13 | CntrctRcvdGreaterThan100KCnt |
| Related Organizations | $7,132 | RelatedOrganizationsAmt |
| Government Grants | $27,412 | GovernmentGrantsAmt |
| All Other Contributions | $11,999 | AllOtherContributionsAmt |
| Total Contributions | $46,543 | TotalContributionsAmt |
Program Service Revenue ProgramServiceRevenueGrp (4 entries)
| DescDesc | BusinessBusinessCd | Total Revenue ColumnTotalRevenueColumnAmt | Related Or Exempt Func IncomeRelatedOrExemptFuncIncomeAmt |
|---|---|---|---|
| NET PATIENT SERVICE REVENUE | 621110 | $33,199,728 | $33,199,728 |
| MEDICARE/MEDICAID | 621110 | $22,579,039 | $22,579,039 |
| 340B REVENUE | 621110 | $656,224 | $656,224 |
| SCHOOL REHAB REVENUE | 621110 | $70,476 | $70,476 |
Total Oth Program Service Rev TotalOthProgramServiceRevGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $299,776 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $299,776 | RelatedOrExemptFuncIncomeAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Revenue | $56,805,243 | TotalProgramServiceRevenueAmt |
Investment Income InvestmentIncomeGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $53,449 | TotalRevenueColumnAmt |
| Exclusion | $53,449 | ExclusionAmt |
Gross Amount Sales Assets GrossAmountSalesAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | $117,933 | OtherAmt |
Less Cost Oth Basis Sales Expnss LessCostOthBasisSalesExpnssGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | $134,386 | OtherAmt |
Gain Or Loss GainOrLossGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | -$16,453 | OtherAmt |
Net Gain Or Loss Investments NetGainOrLossInvestmentsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | -$16,453 | TotalRevenueColumnAmt |
| Exclusion | -$16,453 | ExclusionAmt |
Other Revenue Misc OtherRevenueMiscGrp (2 entries)
| DescDesc | BusinessBusinessCd | Total Revenue ColumnTotalRevenueColumnAmt | ExclusionExclusionAmt |
|---|---|---|---|
| CAFETERIA | 722210 | $106,292 | $106,292 |
| PATRONAGE DIVIDEND | 900099 | $7,364 | $7,364 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Revenue Total | $113,656 | OtherRevenueTotalAmt |
Total Revenue TotalRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $57,002,438 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $56,805,243 | RelatedOrExemptFuncIncomeAmt |
| Unrelated Business Revenue | $0 | UnrelatedBusinessRevenueAmt |
| Exclusion | $150,652 | ExclusionAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part IX | Yes (X) | InfoInScheduleOPartIXInd |
Grants To Domestic Orgs GrantsToDomesticOrgsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $40,033 | TotalAmt |
| Program Services | $40,033 | ProgramServicesAmt |
Comp Current Ofcr Directors CompCurrentOfcrDirectorsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $518,925 | TotalAmt |
| Program Services | $342,457 | ProgramServicesAmt |
| Management And General | $176,468 | ManagementAndGeneralAmt |
Comp Disqual Persons CompDisqualPersonsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $97,248 | TotalAmt |
| Management And General | $97,248 | ManagementAndGeneralAmt |
Other Salaries And Wages OtherSalariesAndWagesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $22,498,024 | TotalAmt |
| Program Services | $21,868,008 | ProgramServicesAmt |
| Management And General | $630,016 | ManagementAndGeneralAmt |
Pension Plan Contributions PensionPlanContributionsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $699,767 | TotalAmt |
| Program Services | $684,067 | ProgramServicesAmt |
| Management And General | $15,700 | ManagementAndGeneralAmt |
Other Employee Benefits OtherEmployeeBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $3,674,031 | TotalAmt |
| Program Services | $3,562,702 | ProgramServicesAmt |
| Management And General | $111,329 | ManagementAndGeneralAmt |
Payroll Taxes PayrollTaxesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,582,670 | TotalAmt |
| Program Services | $1,489,555 | ProgramServicesAmt |
| Management And General | $93,115 | ManagementAndGeneralAmt |
Fees For Services Management FeesForServicesManagementGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $206,233 | TotalAmt |
| Management And General | $206,233 | ManagementAndGeneralAmt |
Fees For Services Legal FeesForServicesLegalGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $66,783 | TotalAmt |
| Management And General | $66,783 | ManagementAndGeneralAmt |
Fees For Services Accounting FeesForServicesAccountingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $82,739 | TotalAmt |
| Management And General | $82,739 | ManagementAndGeneralAmt |
Fees For Services Other FeesForServicesOtherGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $7,046,446 | TotalAmt |
| Program Services | $6,951,898 | ProgramServicesAmt |
| Management And General | $94,548 | ManagementAndGeneralAmt |
Advertising AdvertisingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $212,212 | TotalAmt |
| Program Services | $212,212 | ProgramServicesAmt |
Office Expenses OfficeExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $767,940 | TotalAmt |
| Program Services | $690,654 | ProgramServicesAmt |
| Management And General | $77,286 | ManagementAndGeneralAmt |
Information Technology InformationTechnologyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $501,700 | TotalAmt |
| Program Services | $501,700 | ProgramServicesAmt |
Occupancy OccupancyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,161,140 | TotalAmt |
| Program Services | $1,161,140 | ProgramServicesAmt |
Travel TravelGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $176,712 | TotalAmt |
| Program Services | $157,804 | ProgramServicesAmt |
| Management And General | $18,908 | ManagementAndGeneralAmt |
Conferences Meetings ConferencesMeetingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $39,270 | TotalAmt |
| Management And General | $39,270 | ManagementAndGeneralAmt |
Interest InterestGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,309,193 | TotalAmt |
| Management And General | $1,309,193 | ManagementAndGeneralAmt |
Depreciation Depletion DepreciationDepletionGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $5,467,930 | TotalAmt |
| Program Services | $3,012,272 | ProgramServicesAmt |
| Management And General | $2,455,658 | ManagementAndGeneralAmt |
Insurance InsuranceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $338,073 | TotalAmt |
| Program Services | $338,073 | ProgramServicesAmt |
Other Expenses OtherExpensesGrp (4 entries)
| DescDesc | TotalTotalAmt | Program ServicesProgramServicesAmt | Management And GeneralManagementAndGeneralAmt |
|---|---|---|---|
| MEDICAL SUPPLIES | $6,586,311 | $6,586,311 | |
| BAD DEBTS | $1,940,282 | $1,940,282 | |
| FOOD PRODUCTS | $404,618 | $404,618 | |
| DUES AND SUBSCRIPTIONS | $145,926 | $79,806 | $66,120 |
All Other Expenses AllOtherExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $119,377 | TotalAmt |
| Program Services | $70,653 | ProgramServicesAmt |
| Management And General | $48,724 | ManagementAndGeneralAmt |
Total Functional Expenses TotalFunctionalExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $55,683,583 | TotalAmt |
| Program Services | $50,094,245 | ProgramServicesAmt |
| Management And General | $5,589,338 | ManagementAndGeneralAmt |
| Fundraising | $0 | FundraisingAmt |
Cash Non Interest Bearing CashNonInterestBearingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $3,036,482 | BOYAmt |
| EOY | $3,487,073 | EOYAmt |
Savings And Temp Cash Invst SavingsAndTempCashInvstGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $16,162,753 | BOYAmt |
| EOY | $19,412,822 | EOYAmt |
Accounts Receivable AccountsReceivableGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $7,383,901 | BOYAmt |
| EOY | $6,235,226 | EOYAmt |
Oth Notes Loans Receivable Net OthNotesLoansReceivableNetGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $82,808 | BOYAmt |
| EOY | $79,808 | EOYAmt |
Inventories For Sale Or Use InventoriesForSaleOrUseGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,225,788 | BOYAmt |
| EOY | $1,389,092 | EOYAmt |
Prepaid Expenses Defrd Charges PrepaidExpensesDefrdChargesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $554,981 | BOYAmt |
| EOY | $440,555 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Land Bldg Equip Cost Or Other Bss | $67,781,720 | LandBldgEquipCostOrOtherBssAmt |
| Land Bldg Equip Accum Deprec | $13,648,992 | LandBldgEquipAccumDeprecAmt |
Land Bldg Equip Basis Net LandBldgEquipBasisNetGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $58,890,869 | BOYAmt |
| EOY | $54,132,728 | EOYAmt |
Other Assets Total OtherAssetsTotalGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,238,840 | BOYAmt |
| EOY | $1,878,062 | EOYAmt |
Total Assets TotalAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $88,576,422 | BOYAmt |
| EOY | $87,055,366 | EOYAmt |
Accounts Payable Accr Expnss AccountsPayableAccrExpnssGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $9,251,052 | BOYAmt |
| EOY | $3,933,611 | EOYAmt |
Tax Exempt Bond Liabilities TaxExemptBondLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $7,192,417 | BOYAmt |
| EOY | $9,941,008 | EOYAmt |
Mortg Notes Pybl Scrd Invst Prop MortgNotesPyblScrdInvstPropGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $32,342,914 | BOYAmt |
| EOY | $31,966,973 | EOYAmt |
Other Liabilities OtherLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $537,850 | BOYAmt |
| EOY | $642,730 | EOYAmt |
Total Liabilities TotalLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $49,324,233 | BOYAmt |
| EOY | $46,484,322 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Organization Follows SFAS117 | Yes (X) | OrganizationFollowsSFAS117Ind |
Unrestricted Net Assets UnrestrictedNetAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $39,252,189 | BOYAmt |
| EOY | $40,571,044 | EOYAmt |
Total Net Assets Fund Balance TotalNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $39,252,189 | BOYAmt |
| EOY | $40,571,044 | EOYAmt |
Tot Liab Net Assets Fund Balance TotLiabNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $88,576,422 | BOYAmt |
| EOY | $87,055,366 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Reconcilation Revenue Expnss | $1,318,855 | ReconcilationRevenueExpnssAmt |
| Other Changes In Net Assets | $0 | OtherChangesInNetAssetsAmt |
| Info In Schedule O Part XII | Yes (X) | InfoInScheduleOPartXIIInd |
| Method Of Accounting Accrual | Yes (X) | MethodOfAccountingAccrualInd |
| Accountant Compile Or Review | 0 | AccountantCompileOrReviewInd |
| FS Audited | Yes (1) | FSAuditedInd |
FS Audited Basis FSAuditedBasisGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Consolidated Basis Fincl Stmt | Yes (X) | ConsolidatedBasisFinclStmtInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Audit Committee | Yes (1) | AuditCommitteeInd |
| Federal Grant Audit Required | Yes (1) | FederalGrantAuditRequiredInd |
| Federal Grant Audit Performed | Yes (1) | FederalGrantAuditPerformedInd |
Schedule A IRS990ScheduleA
| Field | Value | IRS element (for citing) |
|---|---|---|
| Hospital | Yes (X) | HospitalInd |
Schedule B IRS990ScheduleB
Contributor Information ContributorInformationGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Contributor | RESTRICTED | ContributorNum |
Contributor Business Name ContributorBusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | RESTRICTED | BusinessNameLine1 |
Contributor US Address ContributorUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | RESTRICTED | AddressLine1 |
| Address Line2 | RESTRICTED | AddressLine2 |
| City | RESTRICTED | City |
| State | RESTRICTED | State |
| ZIP Code | RESTRICTED | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Contributions | RESTRICTED | TotalContributionsAmt |
Schedule C IRS990ScheduleC
| Field | Value | IRS element (for citing) |
|---|---|---|
| Volunteers | 0 | VolunteersInd |
| Paid Staff Or Management | 0 | PaidStaffOrManagementInd |
| Media Advertisements | 0 | MediaAdvertisementsInd |
| Mailings Members | 0 | MailingsMembersInd |
| Publications Or Broadcast | 0 | PublicationsOrBroadcastInd |
| Grants Other Organizations | 0 | GrantsOtherOrganizationsInd |
| Direct Contact Legislators | 0 | DirectContactLegislatorsInd |
| Rallies Demonstrations | 0 | RalliesDemonstrationsInd |
| Other Activities | Yes (1) | OtherActivitiesInd |
| Other Activities | $6,013 | OtherActivitiesAmt |
| Total Lobbying Expenditures | $6,013 | TotalLobbyingExpendituresAmt |
| Not Described Section501c3 | 0 | NotDescribedSection501c3Ind |
Supplemental Information Detail SupplementalInformationDetail
| Field | Value | IRS element (for citing) |
|---|---|---|
| Form And Line Reference | PART II-B, LINE 1: | FormAndLineReferenceDesc |
| Explanation | A PORTION OF THE DUES PAID TO THE AMERICAN HOSPITAL ASSOCIATION (AHA) AND THE NEBRASKA HOSPITAL ASSOCIATION (NHA) ARE USED BY THOSE ORGANIZATIONS FOR LOBBYING ACTIVITIES. | ExplanationTxt |
Schedule D IRS990ScheduleD
Land LandGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Investment Cost Or Other Basis | $92,500 | InvestmentCostOrOtherBasisAmt |
| Other Cost Or Other Basis | $1,929,968 | OtherCostOrOtherBasisAmt |
| Book Value | $2,022,468 | BookValueAmt |
Buildings BuildingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $48,789,859 | OtherCostOrOtherBasisAmt |
| Depreciation | $6,518,525 | DepreciationAmt |
| Book Value | $42,271,334 | BookValueAmt |
Leasehold Improvements LeaseholdImprovementsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $21,420 | OtherCostOrOtherBasisAmt |
| Book Value | $21,420 | BookValueAmt |
Equipment EquipmentGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $15,916,429 | OtherCostOrOtherBasisAmt |
| Depreciation | $6,911,240 | DepreciationAmt |
| Book Value | $9,005,189 | BookValueAmt |
Other Land Buildings OtherLandBuildingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $1,031,544 | OtherCostOrOtherBasisAmt |
| Depreciation | $219,227 | DepreciationAmt |
| Book Value | $812,317 | BookValueAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Book Value Land Buildings | $54,132,728 | TotalBookValueLandBuildingsAmt |
Other Liabilities Org OtherLiabilitiesOrgGrp (2 entries)
| DescDesc | AmtAmt |
|---|---|
| DEFERRED COMPENSATION PLAN LIABILITY | $642,147 |
| DUE TO AFFILIATES | $583 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Liability | $642,730 | TotalLiabilityAmt |
| Footnote Text | Yes (X) | FootnoteTextInd |
Supplemental Information Detail SupplementalInformationDetail
| Field | Value | IRS element (for citing) |
|---|---|---|
| Form And Line Reference | PART X, LINE 2: | FormAndLineReferenceDesc |
| Explanation | SIDNEY REGIONAL MEDICAL CENTER AND CHEYENNE COUNTY HOSPITAL AND HEALTH CENTER FOUNDATION ARE EXEMPT FROM 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, 2016, THE SYSTEM HAD NO UNCERTAIN TAX POSITIONS ACCRUED. | ExplanationTxt |
Schedule H IRS990ScheduleH
| Field | Value | IRS element (for citing) |
|---|---|---|
| Financial Assistance Policy | Yes (1) | FinancialAssistancePolicyInd |
| Written Policy | Yes (1) | WrittenPolicyInd |
| FPG Reference Free Care | Yes (1) | FPGReferenceFreeCareInd |
| Percent100 | Yes (X) | Percent100Ind |
| FPG Reference Discounted Care | Yes (1) | FPGReferenceDiscountedCareInd |
| Percent300 | Yes (X) | Percent300Ind |
| Free Care Medically Indigent | Yes (1) | FreeCareMedicallyIndigentInd |
| Financial Assistance Budget | Yes (1) | FinancialAssistanceBudgetInd |
| Expenses Exceed Budget | Yes (1) | ExpensesExceedBudgetInd |
| Unable To Provide Care | 0 | UnableToProvideCareInd |
| Annual Community Bnft Report | Yes (1) | AnnualCommunityBnftReportInd |
| Report Publically Available | Yes (1) | ReportPublicallyAvailableInd |
Financial Assistance At Cost Typ FinancialAssistanceAtCostTyp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $511,569 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $0 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $511,569 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00950 | TotalExpensePct |
Unreimbursed Medicaid UnreimbursedMedicaidGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $3,238,624 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $3,158,412 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $80,212 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00150 | TotalExpensePct |
Total Financial Assistance Typ TotalFinancialAssistanceTyp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $3,750,193 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $3,158,412 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $591,781 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.01100 | TotalExpensePct |
Community Health Services CommunityHealthServicesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $211,285 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $122,809 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $88,476 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00160 | TotalExpensePct |
Health Professions Education HealthProfessionsEducationGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $15,997 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $0 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $15,997 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00030 | TotalExpensePct |
Cash And In Kind Contributions CashAndInKindContributionsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $54,548 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $0 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $54,548 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00100 | TotalExpensePct |
Total Other Benefits TotalOtherBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $281,830 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $122,809 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $159,021 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00290 | TotalExpensePct |
Total Community Benefits TotalCommunityBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $4,032,023 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $3,281,221 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $750,802 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.01390 | TotalExpensePct |
Community Support CommunitySupportGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Activities Or Programs | 96 | ActivitiesOrProgramsCnt |
| Persons Served | 2621 | PersonsServedCnt |
| Total Community Benefit Expns | $17,684 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $0 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $17,684 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00030 | TotalExpensePct |
Health Improvement Advocacy HealthImprovementAdvocacyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Activities Or Programs | 7 | ActivitiesOrProgramsCnt |
| Persons Served | 579 | PersonsServedCnt |
| Total Community Benefit Expns | $9,925 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $0 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $9,925 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00020 | TotalExpensePct |
Other Communtity Building Acty OtherCommuntityBuildingActyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Activities Or Programs | 206 | ActivitiesOrProgramsCnt |
| Persons Served | 2076 | PersonsServedCnt |
| Total Community Benefit Expns | $20,874 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $0 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $20,874 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00040 | TotalExpensePct |
Total Communtity Building Acty TotalCommuntityBuildingActyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Activities Or Programs | 309 | ActivitiesOrProgramsCnt |
| Persons Served | 5276 | PersonsServedCnt |
| Total Community Benefit Expns | $48,483 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $48,483 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00090 | TotalExpensePct |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bad Debt Expense Reported | Yes (1) | BadDebtExpenseReportedInd |
| Bad Debt Expense | $1,940,282 | BadDebtExpenseAmt |
| Bad Debt Expense Attributable | $679,099 | BadDebtExpenseAttributableAmt |
| Reimbursed By Medicare | $16,139,117 | ReimbursedByMedicareAmt |
| Cost Of Care Reimbursed By Medcr | $16,539,443 | CostOfCareReimbursedByMedcrAmt |
| Medicare Surplus Or Shortfall | -$400,326 | MedicareSurplusOrShortfallAmt |
Costing Methodology Used CostingMethodologyUsedGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Cost To Charge Ratio | Yes (X) | CostToChargeRatioInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Written Debt Collection Policy | Yes (1) | WrittenDebtCollectionPolicyInd |
| Financial Assistance Prvsn | Yes (1) | FinancialAssistancePrvsnInd |
| Hospital Facilities | 1 | HospitalFacilitiesCnt |
Hospital Facilities HospitalFacilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | 1 | FacilityNum |
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | CHEYENNE COUNTY HOSPITAL ASSOCIATION | BusinessNameLine1Txt |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 1000 POLE CREEK CROSSING | AddressLine1Txt |
| City | SIDNEY | CityNm |
| State Abbreviation | NE | StateAbbreviationCd |
| ZIP | 69162 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Website Address | WWW.SIDNEYRMC.COM | WebsiteAddressTxt |
| State License | 150001 | StateLicenseNum |
| Licensed Hospital | Yes (X) | LicensedHospitalInd |
| General Medical And Surgical | Yes (X) | GeneralMedicalAndSurgicalInd |
| Critical Access Hospital | Yes (X) | CriticalAccessHospitalInd |
| Emergency Room24 Hrs | Yes (X) | EmergencyRoom24HrsInd |
Hospital Fclty Policies Prctc HospitalFcltyPoliciesPrctcGrp
Hospital Facility Name HospitalFacilityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | CHEYENNE COUNTY HOSPITAL ASSOCIATION INC | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | 1 | FacilityNum |
| First Licensed CY Or PY | 0 | FirstLicensedCYOrPYInd |
| Tax Exempt Hospital CY Or PY | 0 | TaxExemptHospitalCYOrPYInd |
| CHNA Conducted | Yes (1) | CHNAConductedInd |
| Community Definition | Yes (X) | CommunityDefinitionInd |
| Community Demographics | Yes (X) | CommunityDemographicsInd |
| Existing Resources | Yes (X) | ExistingResourcesInd |
| How Data Obtained | Yes (X) | HowDataObtainedInd |
| Community Health Needs | Yes (X) | CommunityHealthNeedsInd |
| Other Health Issues | Yes (X) | OtherHealthIssuesInd |
| Community Hlth Needs Id Process | Yes (X) | CommunityHlthNeedsIdProcessInd |
| Consulting Process | Yes (X) | ConsultingProcessInd |
| Prior CHNA Impact | Yes (X) | PriorCHNAImpactInd |
| CHNA Conducted | 14 | CHNAConductedYr |
| Take Into Account Others Input | Yes (1) | TakeIntoAccountOthersInputInd |
| CHNA Conducted With Other Fclts | Yes (1) | CHNAConductedWithOtherFcltsInd |
| CHNA Conducted With Non Fclts | Yes (1) | CHNAConductedWithNonFcltsInd |
| CHNA Report Widely Available | Yes (1) | CHNAReportWidelyAvailableInd |
| Rpt Available On Own Website | Yes (X) | RptAvailableOnOwnWebsiteInd |
| Own Website URL | WWW.SIDNEYRMC.COM | OwnWebsiteURLTxt |
| Other Website | Yes (X) | OtherWebsiteInd |
| Other Website URL | WWW.PPHD.ORG | OtherWebsiteURLTxt |
| Paper Copy Public Inspection | Yes (X) | PaperCopyPublicInspectionInd |
| Implementation Strategy Adopt | Yes (1) | ImplementationStrategyAdoptInd |
| Implementation Strategy Adpt | 14 | ImplementationStrategyAdptYr |
| Strategy Posted Website | Yes (1) | StrategyPostedWebsiteInd |
| Strategy Website URL | WWW.SIDNEYRMC.COM | StrategyWebsiteURLTxt |
| Organization Incur Excise Tax | 0 | OrganizationIncurExciseTaxInd |
| Elig Criteria Explained | Yes (1) | EligCriteriaExplainedInd |
| FPG Family Incm Lmt Free Dscnt | Yes (X) | FPGFamilyIncmLmtFreeDscntInd |
| FPG Family Incm Lmt Free Care | 100.000000000000 | FPGFamilyIncmLmtFreeCarePct |
| FPG Family Incm Lmt Dscnt Care | 300.000000000000 | FPGFamilyIncmLmtDscntCarePct |
| Income Level Criteria | Yes (X) | IncomeLevelCriteriaInd |
| Asset Level Criteria | Yes (X) | AssetLevelCriteriaInd |
| Medical Indigency Criteria | Yes (X) | MedicalIndigencyCriteriaInd |
| Underinsurance Stat Criteria | Yes (X) | UnderinsuranceStatCriteriaInd |
| Residency Criteria | Yes (X) | ResidencyCriteriaInd |
| Explained Basis | 0 | ExplainedBasisInd |
| App Financial Asst Expln | Yes (1) | AppFinancialAsstExplnInd |
| Described Info | Yes (X) | DescribedInfoInd |
| Described Suprt Doc | Yes (X) | DescribedSuprtDocInd |
| Includes Publicity Measures | Yes (1) | IncludesPublicityMeasuresInd |
| FAP Available On Website | Yes (X) | FAPAvailableOnWebsiteInd |
| FAP Available On Website URL | SIDNEYRMC.COM | FAPAvailableOnWebsiteURLTxt |
| FAP App Available On Website | Yes (X) | FAPAppAvailableOnWebsiteInd |
| FAP App Available On Website URL | SIDNEYRMC.COM | FAPAppAvailableOnWebsiteURLTxt |
| FAP Summary On Website | Yes (X) | FAPSummaryOnWebsiteInd |
| FAP Summary On Website URL | SIDNEYRMC.COM | FAPSummaryOnWebsiteURLTxt |
| FAP Avlbl On Request No Charge | Yes (X) | FAPAvlblOnRequestNoChargeInd |
| FAP App Avlbl On Request No Chrg | Yes (X) | FAPAppAvlblOnRequestNoChrgInd |
| FAP Sum Avlbl On Request No Chrg | Yes (X) | FAPSumAvlblOnRequestNoChrgInd |
| Notified FAP Copy Bill Display | Yes (X) | NotifiedFAPCopyBillDisplayInd |
| Other Publicity | Yes (X) | OtherPublicityInd |
| FAP Actions On Nonpayment | Yes (1) | FAPActionsOnNonpaymentInd |
| Permit No Actions | Yes (X) | PermitNoActionsInd |
| Collection Activities | 0 | CollectionActivitiesInd |
| Made Effort Orally Notify | Yes (X) | MadeEffortOrallyNotifyInd |
| Processed FAP Application | Yes (X) | ProcessedFAPApplicationInd |
| Made Presumptive Elig Determ | Yes (X) | MadePresumptiveEligDetermInd |
| Other Actions Taken | Yes (X) | OtherActionsTakenInd |
| Nondis Emergency Care Policy | Yes (1) | NondisEmergencyCarePolicyInd |
| Look Back Medicare Private | Yes (X) | LookBackMedicarePrivateInd |
| Amounts Generally Billed | 0 | AmountsGenerallyBilledInd |
| Gross Charges | 0 | GrossChargesInd |
Supplemental Information SupplementalInformationGrp (7 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| CHEYENNE COUNTY HOSPITAL ASSOCIATION INC | PART V, SECTION B, LINE 5: SIDNEY REGIONAL MEDICAL CENTER HOSTED FOCUS GROUPS, COMMUNITY FORUMS AND STAKEHOLDERS MEETINGS FOR THE MEMBERS OF OUR AREA. OF THE THREE FOCUS GROUPS HELD FROM JUNE THROUGH JULY, 2014 THE FIRST GROUP REPRESENTED THE "HEALTHCARE DECISION MAKERS," THE SECOND INCLUDED CHAMBER AND COMMUNITY COLLEGE MEMBERS, AND THE THIRD INVOLVED MEMBERS FROM THE PUBLIC SCHOOLS. THERE WERE ALSO THREE COMMUNITY FORUMS THAT WERE OVERSEEN BY PANHANDLE PUBLIC HEALTH DISTRICT AND THEY INCLUDE A COMMUNITY GROUP FROM SIDNEY, SECOND SMALLER GROUP REPRESENTING THE 6% OF THE COUNTY'S HISPANIC POPULATION. THE THIRD GROUP REPRESENTED CHAPPELL, NEBRASKA IN DEUEL COUNTY LOCATED APPROXIMATELY 20 MILES EAST OF SIDNEY. A STAKEHOLDER MEETING WAS HELD TO ESTABLISH AN OUTREACH VISION FOR THE COMMUNITY/COUNTY. PARTICIPANTS INCLUDED REPRESENTATIVES FROM THE HOSPITAL, PUBLIC SCHOOL SYSTEM, MEDIA GROUPS, CHAMBER OF COMMERCE, LOCAL BUSINESSES, NON-PROFIT AND SERVICE ORGANIZATIONS, FAITH BASED ORGANIZATIONS, LAW ENFORCEMENT AND CITY OF SIDNEY. OVER THE COURSE OF THE MEETING THE PARTICIPANTS WERE PRESENTED WITH HEALTH DATA, SOCIOECONOMIC DATA, LEADING CAUSES OF DEATH FOR THE PANHANDLE COMPARED TO THE REST OF THE STATE, THE IMPACT OF ADVERSE CHILDHOOD EXPERIENCES (ACE) AND CHILD WELL BEING DATA. PRESENTERS ALSO GAVE AN OUTLINE OF THE CURRENT PRIORITY AREAS OF THE PANHANDLE HEALTH IMPROVEMENT PLAN. THE RESULTS OF THE STAKEHOLDER MEETING, THE FOCUS GROUPS AND THE HEALTH DATA AS WELL AS THE RESULTS FROM THE COMMUNITY HEALTH NEEDS ASSESSMENT SURVEY WERE PRESENTED TO A SMALLER COMMITTEE OF SRMC STAFF IN NOVEMBER 2014 TO DETERMINE PRIORITY AREAS. |
| 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: 2016 ACTIVITIES TO ADDRESS THE SIGNIFICANT NEEDS IDENTIFIED IN THE MOST RECENTLY CONDUCTED CHNA:NUTRITION AND WEIGHT STATUS: 1. THE HOSPITAL PARTNERED WITH THE LOCAL GROCERY STORE AND CONDUCTED DIETICIAN GUIDED TOURS OF THE STORE AND EDUCATION TO COMMUNITY MEMBERS ATTENDING. 2. RADIO SPOTS WERE AIRED WITH THE DIETICIAN AND RADIO HOST IN DIALOGUE REGARDING NUTRITION NEEDS AND WEIGHT MANAGEMENT. 3. SRMC DIETICIAN SPOKE AT THE WOMEN IN AG CONFERENCE ON "HEALTHY EATING AS WE AGE".4. DR. JENNIFER BROWN PRESENTED THE MONTHLY NUTRITION TALK "ALL ABOUT FOOD" FOR COMMUNITY MEMBERS AS AN OPEN FORUM/DISCUSSION ON HIGH CHOLESTEROL AND HIGH BLOOD PRESSURE/HEART HEALTHY FOOD CHOICES. 5. KIDS HEALTH ADVENTURE WAS HELD AT CCCC AND SRMC PROVIDED FREE HEIGHT, WEIGHT BMI AND BLOOD PRESSURE SCREENINGS, WITH A PROVIDER ON SITE TO ANSWER ANY QUESTIONS FROM PARENTS REGARDING THEIR CHILD AND WHERE THEY FELL IN TO THE GROWTH CHART. PHYSICAL ACTIVITY:1. SRMC PARTNERED WITH THE PANHANDLE PUBIC HEALTH DISTRICT AND OTHER LOCAL BUSINESSES TO SUPPORT THE WALKABILITY/BIKE-ABILITY PROJECT TO "ACTIVATE SIDNEY" BY PROMOTING A HEALTHY AND ACTIVE LIFESTYLE AND BIKING ON THE TRAIL, FOR ALL AGES WITHIN OUR COMMUNITY. SRMC ENCOURAGED LOCAL BUSINESSES TO SUPPORT WORKSITE WELLNESS/WALKABILITY FOR THEIR EMPLOYEES DURING THEIR BREAKS.2. SRMC PROMOTED AND COORDINATED THE TEACHING OF A 16-WEEK PROGRAM FOR WEIGHT LOSS AND BECOMING MORE PHYSICALLY ACTIVE WITH 9 MEMBERS DOING 13,320 MINUTES OF EXERCISE FOR THE FINAL 10 WEEKS.3. KYLE BROWN PA-C GAVE A LUNCH AND LEARN PRESENTATION ON BACK SAFETY/PHYSICAL ACTIVITY TO A GROUP AT CABELA'S DISTRIBUTION CENTER.4. SRMC'S DASH FOR THE SPLASH TRIATHLON WAS HELD FOR THE COMMUNITY AND SURROUNDING AREA WITH A TOTAL OF 174 PARTICIPANTS.5. SRMC HELD THE OCTOBERFEST 5K RUN/WALK AND 10K RUN FOR THE COMMUNITY FOR BOTH ADULTS AND KIDS FOR A TOTAL OF 101 PARTICIPANTS. 6. ON 12/29/2016 THE NATIONAL DIABETES PREVENTION PROGRAM (GROUP # 7) FINISHED THEIR 16-WEEK CLASS WITH 7 PARTICIPANTS LOGGING 7,255 MINUTES OF EXERCISE.SUBSTANCE ABUSE EDUCATION AND HAND HYGIENE:1. KIDS HEALTH ADVENTURE, SRMC PHARMACY STAFF PARTICIPATING WITH A KIDS ACTIVITY WHERE THE KIDS HAD TO "GUESS" CANDY OR PILLS ON A LARGE TAG BOARD.2. ANNIE MCCARTNEY RN, INFECTION CONTROL NURSE AT SRMC, DISCUSSED THE IMPORTANCE OF HAND HYGIENE AND COVERING THOSE SNEEZES AND COUGHS WITH FLU SEASON UPON US, TO THE KSID LISTENERS ON TUESDAY MORNING SEGMENT = 2000+ LISTENERS.3. ANNUAL KIDS HEALTH ADVENTURE WAS HELD AT CHEYENNE COUNTY COMMUNITY CENTER AND ANNIE MCCARTNEY RN, INFECTION CONTROL NURSE AT SRMC, DEMONSTRATED AND HAD AN ACTIVITY FOR THE KIDS AND THEIR PARENTS ON HOW GERMS ARE SPREAD USING GLITTER = 140 PARTICIPANTS.BREAST FEEDING PROMOTION AND EDUCATION:1. SRMC SPECIFICALLY BUILT A NEW BREAST FEEDING ROOM FOR EMPLOYEES AND PATIENTS OR VISITORS IN THE HOSPITAL.2. OB NURSE, MARION ABBOTT, PROVIDES EDUCATION AND ASSISTANCE AFTER DELIVERY BOTH IN THE HOSPITAL AND DURING HOME VISITS FOR MOTHERS WHO MAY HAVE DELIVERED AT A DIFFERENT HOSPITAL OR AT HOME.CANCER PREVENTION:1. THE HOSPITAL CONTINUES TO BE A NON-SMOKING CAMPUS2. THE HOSPITAL PROVIDES FREE NICOTINE PATCHES FOR EMPLOYEES WHO WOULD LIKE TO STOP USING TOBACCOMENTAL AND EMOTIONAL WELL BEING:1. SRMC DID NOT HAVE THE RESOURCES TO INCLUDE MENTAL AND EMOTIONAL WELLBEING INTO ITS COMMUNITY HEALTH DURING THIS TIME PERIOD. |
| CHEYENNE COUNTY HOSPITAL ASSOCIATION INC | PART V, SECTION B, LINE 13B: SPECIFICALLY IDENTIFIED CASES MAY BE PRESUMED ELIGIBLE FOR CHARITABLE ASSISTANCE WITHOUT A COMPLETED APPLICATION OR ASSESSMENT OF POVERTY LEVELS. EXAMPLES OF THESE CASES ARE: 1) DECEASED PATIENTS WITH NO KNOWN ESTATE OR SPOUSE, 2) PATIENTS WITH CURRENT ELIGIBILITY UNDER COUNTY OR STATE MEDICAL INDIGENT SERVICES ADMINISTERED BY COUNTY OR STATE FACILITIES, OR 3) A PATIENT HOMELESS OR WITHOUT RESOURCES. PERCENT OF CHARITY WILL BE BASED ON HOUSEHOLD INCOME AND SIZE, REAL ESTATE OWNERSHIP EQUITY, PERSONAL PROPERTY OWNERSHIP EQUITY AND INVESTMENT EQUITY, WITH CREDIT GIVEN FOR ALREADY EXISTING MEDICAL LOANS AND FOR INCOME EARNED BY FULL-TIME STUDENTS RESIDING IN THE HOUSEHOLD IN COMPARISON TO THE CURRENT YEAR FEDERAL POVERTY GUIDELINES. |
| CHEYENNE COUNTY HOSPITAL ASSOCIATION INC | PART V, SECTION B, LINE 16J: THE POLICY IS REFERENCED IN BILLING STATEMENTS 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 THE WAITING ROOMS AT THE HOSPITAL. ADDITIONALLY, FINANCIAL SERVICE REPRESENTATIVES ACTIVELY SCAN FOR ACCOUNTS WHICH COULD QUALIFY FOR CHARITY CARE AND OFFER IT WITH OTHER OPTIONS FOR PAYMENT DURING THEIR CONVERSATIONS WITH PATIENTS. A HARDCOPY OF THE POLICY IS OFFERED BY THE PATIENT ADVOCATE/FINANCIAL COUNSELOR DURING MEETINGS WITH PATIENTS. THE CHARITY CARE POLICY IS ALSO MAILED TO EVERY GUARANTOR PRIOR TO EXTRAORDINARY COLLECTION ACTIONS. |
| CHEYENNE COUNTY HOSPITAL ASSOCIATION INC | PART V, SECTION B, LINE 20E: PROVIDED WRITTEN NOTICE OF UPCOMING ECAS AND PROVIDED WRITTEN NOTIFICATION OF HOSPITAL FINANCIAL ASSISTANCE AVAILABILITY. |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | 3 | FacilityNum |
Oth Hlth Care Fclts Not Hospital OthHlthCareFcltsNotHospitalGrp
Oth Hlth Care Fclts OthHlthCareFcltsGrp (3 entries)
| Address Line1USAddress/AddressLine1Txt | CityUSAddress/CityNm | State AbbreviationUSAddress/StateAbbreviationCd | ZIPUSAddress/ZIPCd | FacilityFacilityTxt |
|---|---|---|---|---|
| 1 - SIDNEY REG'L MEDICAL CTR EXTENDED CARE | ||||
| 549 KELLER DRIVE | SIDNEY | NE | 69162 | LONG TERM CARE FACILITY |
| 2 - SLOAN ESTATES ASSISTED LIVING | ||||
| 2550 CRAIG AVENUE | SIDNEY | NE | 69162 | ASSISTED LIVING |
| 3 - SIDNEY REG'L MEDICAL CTR WALK IN CLINIC | ||||
| 1625 DORWART DRIVE | SIDNEY | NE | 69162 | WALK IN CLINIC |
Supplemental Information Detail SupplementalInformationDetail (17 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| PART I, LINE 3C: | THE CALCULATION FOR ELIGIBILITY IS BASED ON ALL INCOME PER HOUSEHOLD WITH EXCEPTIONS MADE FOR WAGE EARNERS WHO ARE STUDENTS. OTHER MEDICAL PAYMENTS ALREADY BEING MADE ARE CONSIDERED IN THE CALCUATION. INCOME IS COMPARED TO THE NATIONAL POVERTY GUIDELINES AND A DETERMINATION OF REDUCTION IS MADE BASED ON THE ADJUSTED INCOME LEVEL. THE WRITE OFF AMOUNT MAY BE REDUCED FOR EQUITY IN ASSETS, IF ANY, ABOVE EXEMPTION THRESHOLDS FOR HOMES AND VEHICLES. THERE IS NO EXEMPTION FOR INVESTMENTS OR OTHER ASSETS HELD. |
| PART I, LINE 6A: | THE COMMUNITY BENEFIT REPORT IS PREPARED BY THE STAFF OF SIDNEY REGIONAL MEDICAL CENTER. |
| 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 $1,940,282 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 35%. THIS ESTIMATE IS BASED ON A RECOVERY RATE FROM THE COLLECTION AGENCY FOR 2016 ACCOUNTS OF APPROXIMATELY 30%. THEORETICALLY, THE NEARLY 30% WHICH HAS BEEN RECOVERED IS BEING RECOVERED FROM PEOPLE WHO COULD PAY BUT DIDN'T. WHEN ESTIMATING THAT POSSIBLY HALF OF THE REMAINING 70% OF THE BAD DEBT WAS ATTRIBUTABLE TO PATIENTS WHO HAD NO MEANS OF PAYMENT RATHER THAN MEANS BUT NO INTENT, THIS ESTIMATE OF FAP AMOUNTS IN BAD DEBT WOULD TOTAL APPROXIMATELY 35%. |
| 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 2016 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 HOLD WORKSHOPS AND MEETINGS WITH PATIENTS INDIVIDUALLY 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 10,000 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 2016 DEMOGRAPHIC IS AROUND 96% CAUCASIAN AND THE AVERAGE HOUSEHOLD SIZE IS 2.27 PEOPLE PER HOUSEHOLD. LESS THAN 7% OF PEOPLE ARE WITHOUT HEALTH INSURANCE OF THE TOTAL POPULATION OVER 16 YEARS OF AGE, 73.1% ARE ACTIVELY IN THE LABOR FORCE. PERSONS UNDER 18 AND OVER 65 YEARS OLD TOTALED JUST UNDER 30%. |
| PART VI, LINE 5: | IN ADDITIONAL 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. |
| REQUIRED DISCLOSURE IN ACCORDANCE WITH SEC. 7 OF REV. PROC. 2015-21: | THE HOSPITAL'S FINANCIAL ASSISTANCE POLICY AS IT EXISTED PRIOR TO 01/01/17 DID NOT ADDRESS IN WRITING THE BASIS FOR CALCULATING AMOUNTS CHARGED TO PATIENTS WHO WERE ELIGIBLE FOR FINANCIAL ASSISTANCE. THE LACK OF THIS LANGUAGE IN THE POLICY WAS AN INADVERTENT ERROR BECAUSE THE HOSPITAL WAS NEVERTHELESS APPLYING DISCOUNTS TO THE AMOUNTS GENERALLY BILLED BY THE HOSPITAL EVEN THOUGH THE REQUIREMENT TO DO SO WAS MISSING IN THE WRITTEN POLICY. CONSEQUENTLY, THERE WERE NO ADVERSE EFFECTS AGAINST ANY INDIVIDUAL PATIENTS. THE HOSPITAL WAS IN THE PROCESS OF REVISING THE FINANCIAL ASSISTANCE POLICY DURING THE 2016 TAX YEAR AND THE ISSUE WAS CORRECTED WHEN THE HOSPITAL'S BOARD OF DIRECTORS ADOPTED ITS CURRENT FINANCIAL ASSISTANCE POLICY WITH AN OFFICIAL APPROVAL DATE OF 11/01/17. |
Schedule I IRS990ScheduleI
| Field | Value | IRS element (for citing) |
|---|---|---|
| Grant Records Maintained | Yes (1) | GrantRecordsMaintainedInd |
Recipient Table RecipientTable (2 entries)
| Address Line1USAddress/AddressLine1Txt | CityUSAddress/CityNm | State AbbreviationUSAddress/StateAbbreviationCd | ZIPUSAddress/ZIPCd | Recipient EINRecipientEIN | IRC SectionIRCSectionDesc | Cash GrantCashGrantAmt | Purpose Of GrantPurposeOfGrantTxt |
|---|---|---|---|---|---|---|---|
| MAKE A WISH FOUNDATION NEBRASKA | |||||||
| 8 WEST 56TH STREET STE B-2 NORTH | KEARNEY | NE | 68847 | 470671096 | 501(C)(3) | $10,000 | MAKE A WISH PLEDGE FOR A COMMUNITY CHILD |
| CHEYENNE COUNTY HOSPITAL AND HEALTH CENTER FOUNDATION | |||||||
| 1000 POLE CREEK CROSSING | SIDNEY | NE | 69162 | 470686476 | 501(C)(3) | $7,510 | SPONSORSHIP OF FUNDRAISING ACTIVITIES |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total501c3 Org | 2 | Total501c3OrgCnt |
| Total Other Org | 0 | TotalOtherOrgCnt |
Supplemental Information Detail SupplementalInformationDetail
| Field | Value | IRS element (for citing) |
|---|---|---|
| Form And Line Reference | PART I, LINE 2: | FormAndLineReferenceDesc |
| Explanation | IF THE DONEE ORGANIZATION IS NOT A GOVERNMENTAL ENTITY OR IDENTIFIED AS A CHARITABLE ORGANIZATION ON GUIDESTAR, THE DONEE ORGANIZATION IS RESEARCHED TO ASSURE THEIR NOT-FOR-PROFIT STATUS. THE DONEE ORGANIZATION'S MISSION INFORMATION, THEIR FINANCIAL DATA AND THEIR FORM 990 (IF AVAILABLE) IS REVIEWED AND CONSIDERED BY THE BOARD OF DIRECTORS. THE BOARD OF DIRECTORS MUST APPROVE, BY A MAJORITY VOTE OF THE QUORUM IN ATTENDANCE, THE DONATION TO THE ORGANIZATION OR GOVERNMENTAL ENTITY. DURING THE FOLLOWING 12 TO 24 MONTHS AFTER THE DONATION IS DISTRIBUTED, CONTINUED MONITORING OF THE PROJECT OR DONATION RESTRICTIONS, IF APPLICABLE, SHALL BE REPORTED TO THE BOARD OF DIRECTORS. THE DONEE ORGANIZATION'S FORM 990 (IF AVAILABLE) FOR THE YEAR OF THE DONATION AND ANY OTHER SUBSEQUENT YEARS REQUESTED SHALL BE MADE AVAILABLE TO THE BOARD MEMBERS FOR FOLLOW UP REVIEW. | ExplanationTxt |
Schedule J IRS990ScheduleJ
| Field | Value | IRS element (for citing) |
|---|---|---|
| Compensation Committee | Yes (X) | CompensationCommitteeInd |
| Written Employment Contract | Yes (X) | WrittenEmploymentContractInd |
| Compensation Survey | Yes (X) | CompensationSurveyInd |
| Board Or Committee Approval | Yes (X) | BoardOrCommitteeApprovalInd |
| Severance Payment | 0 | SeverancePaymentInd |
| Supplemental Nonqual Rtr Plan | 0 | SupplementalNonqualRtrPlanInd |
| Equity Based Comp Arrngm | 0 | EquityBasedCompArrngmInd |
| Comp Based On Revenue Of Flng Org | Yes (1) | CompBasedOnRevenueOfFlngOrgInd |
| Comp Bsd On Rev Related Orgs | 0 | CompBsdOnRevRelatedOrgsInd |
| Comp Bsd Net Earns Flng Org | 0 | CompBsdNetEarnsFlngOrgInd |
| Comp Bsd Net Earns Rltd Orgs | 0 | CompBsdNetEarnsRltdOrgsInd |
| Any Non Fixed Payments | 0 | AnyNonFixedPaymentsInd |
| Initial Contract Exception | 0 | InitialContractExceptionInd |
Rltd Org Officer Trst Key Empl RltdOrgOfficerTrstKeyEmplGrp (7 entries)
| TitleTitleTxt | Base Compensation Filing OrgBaseCompensationFilingOrgAmt | Compensation Based On Rltd OrgsCompensationBasedOnRltdOrgsAmt | Bonus Filing OrganizationBonusFilingOrganizationAmount | Bonus Related OrganizationsBonusRelatedOrganizationsAmt | Other Compensation Filing OrgOtherCompensationFilingOrgAmt | Other Compensation Rltd OrgsOtherCompensationRltdOrgsAmt | Deferred Compensation Flng OrgDeferredCompensationFlngOrgAmt | Deferred Comp Rltd OrgsDeferredCompRltdOrgsAmt | Nontaxable Benefits Filing OrgNontaxableBenefitsFilingOrgAmt | Nontaxable Benefits Rltd OrgsNontaxableBenefitsRltdOrgsAmt | Total Compensation Filing OrgTotalCompensationFilingOrgAmt | Total Compensation Rltd OrgsTotalCompensationRltdOrgsAmt | Comp Report Prior990 Filing OrgCompReportPrior990FilingOrgAmt | Comp Report Prior990 Rltd OrgsCompReportPrior990RltdOrgsAmt |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| ROBERT GRAVES MD | ||||||||||||||
| MEMBER - CHIEF OF MEDICAL STAFF | $184,262 | $0 | $0 | $0 | $840 | $0 | $9,241 | $0 | $0 | $0 | $194,343 | $0 | $0 | $0 |
| KELLY UTLEY | ||||||||||||||
| CFO | $167,689 | $0 | $0 | $0 | $305 | $0 | $8,475 | $0 | $0 | $0 | $176,469 | $0 | $0 | $0 |
| MATTHEW JANSEN | ||||||||||||||
| DOCTOR | $479,943 | $0 | $0 | $0 | $336 | $0 | $1,323 | $0 | $39,894 | $0 | $521,496 | $0 | $0 | $0 |
| MANDY SHAW MD | ||||||||||||||
| DOCTOR | $331,875 | $0 | $0 | $0 | $205 | $0 | $10,000 | $0 | $0 | $0 | $342,080 | $0 | $0 | $0 |
| REBECCA L ALLARD MD | ||||||||||||||
| DOCTOR | $339,781 | $0 | $0 | $0 | $254 | $0 | $13,250 | $0 | $39,894 | $0 | $393,179 | $0 | $0 | $0 |
| JAMES THAYER MD | ||||||||||||||
| DOCTOR | $295,803 | $0 | $40,683 | $0 | $1,663 | $0 | $8,121 | $0 | $27,712 | $0 | $373,982 | $0 | $0 | $0 |
| CRAIG SANDBERG | ||||||||||||||
| CRNA | $253,258 | $0 | $32,350 | $0 | $157 | $0 | $13,250 | $0 | $0 | $0 | $299,015 | $0 | $0 | $0 |
Supplemental Information Detail SupplementalInformationDetail (2 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| 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. ADDITIONALY, 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 $218,578, RETIREMENT BENEFITS OF $7,347, AND NONTAXABLE BENEFITS OF $9,672. MR. PETIK'S SALARY IS REFLECTED IN PART IX, LINE 11A. |
Schedule K IRS990ScheduleK
Tax Exempt Bonds Issues TaxExemptBondsIssuesGrp (2 entries)
| Bond ReferenceBondReferenceCd | Bond Issuer EINBondIssuerEIN | CUSIPCUSIPNum | Bond IssuedBondIssuedDt | Issue PriceIssuePriceAmt | PurposePurposeDesc | DefeasedDefeasedInd | On Behalf Of IssuerOnBehalfOfIssuerInd | Pool FinancingPoolFinancingInd |
|---|---|---|---|---|---|---|---|---|
| THE COUNTY OF DEUEL NEBRASKA | ||||||||
| A | 476006452 | 251476AA5 | 2014-10-16 | $10,000,000 | CONSTRUCT HOSPITAL | 0 | 0 | 0 |
| THE COUNTY OF CHEYENNE NEBRASKA | ||||||||
| B | 476006443 | 1668ATAA7 | 2014-09-30 | $32,000,000 | CONSTRUCT HOSPITAL | 0 | 0 | 0 |
Tax Exempt Bonds Proceeds TaxExemptBondsProceedsGrp (2 entries)
| Bond ReferenceBondReferenceCd | Total ProceedsTotalProceedsAmt | Capital ExpendituresCapitalExpendituresAmt | Substantial CompletionSubstantialCompletionYr | Current RefundingCurrentRefundingInd | Advance RefundingAdvanceRefundingInd | Final Allocation MadeFinalAllocationMadeInd | Adequate Books And Rec MaintAdequateBooksAndRecMaintInd | Capitalized InterestCapitalizedInterestAmt |
|---|---|---|---|---|---|---|---|---|
| A | $10,000,000 | $10,000,000 | 2015 | 0 | 0 | Yes (1) | Yes (1) | |
| B | $32,000,056 | $31,787,552 | 2015 | 0 | 0 | Yes (1) | Yes (1) | $212,500 |
Tax Exempt Bonds Private Bus Use TaxExemptBondsPrivateBusUseGrp (2 entries)
| Bond ReferenceBondReferenceCd | Owning Bond Financed PropertyOwningBondFinancedPropertyInd | Any Lease ArrangementsAnyLeaseArrangementsInd | Mgmt Contract Bond Fincd PropMgmtContractBondFincdPropInd | Any Research AgreementsAnyResearchAgreementsInd | Private Bus Use By OthersPrivateBusUseByOthersPct | Private Bus Concerning UBIPrivateBusConcerningUBIPct | Total Private Business UseTotalPrivateBusinessUsePct | Bond Iss Meet Prvt Sec Pymt TestBondIssMeetPrvtSecPymtTestInd | Change In Use Bond Financed PropChangeInUseBondFinancedPropInd | Procs Nonqualified Bond RemdtdProcsNonqualifiedBondRemdtdInd |
|---|---|---|---|---|---|---|---|---|---|---|
| A | 0 | 0 | 0 | 0 | 0.00000 | 0.00000 | 0.00000 | 0 | 0 | Yes (1) |
| B | 0 | 0 | 0 | 0 | 0.00000 | 0.00000 | 0.00000 | 0 | 0 | Yes (1) |
Tax Exempt Bonds Arbitrage TaxExemptBondsArbitrageGrp (2 entries)
| Bond ReferenceBondReferenceCd | Form8038 T FiledForm8038TFiledInd | Rebate Not Due YetRebateNotDueYetInd | Exception To RebateExceptionToRebateInd | No Rebate DueNoRebateDueInd | Variable Rate IssueVariableRateIssueInd | Hedge Identified In Bks And RecHedgeIdentifiedInBksAndRecInd | Gross Proceeds Invested In GICGrossProceedsInvestedInGICInd | Gross Proceeds InvestedGrossProceedsInvestedInd | Written Proc To Monitor ReqsWrittenProcToMonitorReqsInd |
|---|---|---|---|---|---|---|---|---|---|
| A | 0 | 0 | Yes (1) | 0 | Yes (1) | 0 | 0 | 0 | Yes (1) |
| B | 0 | 0 | Yes (1) | 0 | 0 | 0 | 0 | 0 | Yes (1) |
Procedures Corrective Action ProceduresCorrectiveActionGrp (2 entries)
| Bond ReferenceBondReferenceCd | Procedures Corrective ActionProceduresCorrectiveActionInd |
|---|---|
| A | Yes (1) |
| B | Yes (1) |
Supplemental Information Detail SupplementalInformationDetail
| Field | Value | IRS element (for citing) |
|---|---|---|
| Form And Line Reference | PART II, LINE 3, COLUMN B: | FormAndLineReferenceDesc |
| Explanation | THE TOTAL PROCEEDS DO NOT AGREE TO THE ISSUE PRICE IN PART I, COLUMN E DUE TO INVESTMENT EARNINGS. | ExplanationTxt |
Schedule L IRS990ScheduleL
Bus Tr Involve Interested Prsn BusTrInvolveInterestedPrsnGrp (2 entries)
| Relationship DescriptionRelationshipDescriptionTxt | TransactionTransactionAmt | TransactionTransactionDesc | Sharing Of RevenuesSharingOfRevenuesInd |
|---|---|---|---|
| KEVIN UTLEY | |||
| EMPLOYEE OF ORGANIZATION AND SPOUSE OF KELLY UTLEY, CFO | $97,248 | EMPLOYEE COMPENSATION | 0 |
| (no name) | |||
| 0 | |||
Schedule O IRS990ScheduleO
Supplemental Information Detail SupplementalInformationDetail (9 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| FORM 990, PART VI, SECTION A, LINE 3 | THE UNIVERSITY OF COLORADO HOSPITAL AUTHORITY CURRENTLY EMPLOYS THE CHIEF EXECUTIVE OFFICER FOR SIDNEY REGIONAL MEDICAL CENTER. EACH MONTH, SRMC PROVIDES THE UNIVERSITY OF COLORADO HOSPITAL AUTHORITY WITH DATA ON SERVICES PROVIDED TO THE COMMUNITY FOR COMPARISON DATA PURPOSES. |
| FORM 990, PART VI, SECTION B, LINE 11B | THE ORGANIZATION'S ACCOUNTING DEPARTMENT PROVIDES DOCUMENTATION TO THE INDEPENDENT ACCOUNTING FIRM FOR THE PREPARATION OF THE FORM 990. COMMUNICATIONS BETWEEN THE ACCOUNTING FIRM AND THE ACCOUNTING DEPARTMENT FINALIZE THE PREPARATION OF THE FORM 990. THE CEO AND CFO THEN REVIEW THE FORM 990 AND E-MAIL 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 CLINTON DORWART, 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 4,912,196. MANAGEMENT AND GENERAL EXPENSES 94,548. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 5,006,744. CONTRACT SERVICES - SURGERY PROFESSIONALS: PROGRAM SERVICE EXPENSES 710,713. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 710,713. CONTRACT SERVICES - ANESTHESIA PROFESSIONALS: PROGRAM SERVICE EXPENSES 412,547. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 412,547. RECRUITING FEES: PROGRAM SERVICE EXPENSES 424,145. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 424,145. CONTRACT SERVICES - RADIOLOGY PROFESSIONALS: PROGRAM SERVICE EXPENSES 492,297. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 492,297. |
| FORM 990, PART XI, LINE 2C: | THE BOARD OF DIRECTORS ASSUMES THE RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT OF SRMC'S FINANCIAL STATEMENTS AND SELECTION OF AN INDEPENDENT ACCOUNTANT. THIS PROCESS HAS NOT CHANGED SINCE THE PRIOR YEAR. |
Schedule R IRS990ScheduleR
Id Related Tax Exempt Org IdRelatedTaxExemptOrgGrp
Disregarded Entity Name DisregardedEntityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | CHEYENNE COUNTY HOSPITAL AND HEALTH CENTER FOUNDATION | BusinessNameLine1Txt |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 1000 POLE CREEK CROSSING | AddressLine1Txt |
| City | SIDNEY | CityNm |
| State Abbreviation | NE | StateAbbreviationCd |
| ZIP | 69162 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 470686476 | EIN |
| Primary Activities | SUPPORT SIDNEY REGIONAL MEDICAL CENTER | PrimaryActivitiesTxt |
| Legal Domicile State | NE | LegalDomicileStateCd |
| Exempt Code Section | 501(C)(3) | ExemptCodeSectionTxt |
| Public Charity Status | LINE 12C, III-FI | PublicCharityStatusTxt |
| Direct Controlling NA | N/A | DirectControllingNACd |
| Controlled Organization | 0 | ControlledOrganizationInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Receipt Of Int Annts Rnts Rylts | 0 | ReceiptOfIntAnntsRntsRyltsInd |
| Gift Grnt Or Cap Contri To Oth Org | Yes (1) | GiftGrntOrCapContriToOthOrgInd |
| Gift Grnt Cap Contri From Oth Org | Yes (1) | GiftGrntCapContriFromOthOrgInd |
| Loans Or Guarantees To Other Org | Yes (1) | LoansOrGuaranteesToOtherOrgInd |
| Loans Or Guarantees From Oth Org | Yes (1) | LoansOrGuaranteesFromOthOrgInd |
| Div Related Organization | 0 | DivRelatedOrganizationInd |
| Asset Sale To Other Org | 0 | AssetSaleToOtherOrgInd |
| Asset Purchase From Other Org | 0 | AssetPurchaseFromOtherOrgInd |
| Asset Exchange | 0 | AssetExchangeInd |
| Rental Of Facilities To Oth Org | Yes (1) | RentalOfFacilitiesToOthOrgInd |
| Rental Of Fclts From Oth Org | 0 | RentalOfFcltsFromOthOrgInd |
| Perform Of Services For Oth Org | 0 | PerformOfServicesForOthOrgInd |
| Perform Of Services By Other Org | 0 | PerformOfServicesByOtherOrgInd |
| Sharing Of Facilities | Yes (1) | SharingOfFacilitiesInd |
| Paid Employees Sharing | Yes (1) | PaidEmployeesSharingInd |
| Reimbursement Paid To Other Org | Yes (1) | ReimbursementPaidToOtherOrgInd |
| Reimbursement Paid By Other Org | Yes (1) | ReimbursementPaidByOtherOrgInd |
| Transfer To Other Org | 0 | TransferToOtherOrgInd |
| Transfer From Other Org | 0 | TransferFromOtherOrgInd |
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