2017-11-13T10:18:37-06:00 2016-12-31 450250958 EIDE BAILLY LLP 1601 NW EXPRESSWAY SUITE 1900 OKLAHOMA CITY OK 73118 990 2016-01-01 860171900 WHITE MOUNTAIN COMMUNITIES HOSPITAL INC WHIT 9283337142 118 SOUTH MOUNTAIN AVENUE SPRINGERVILLE AZ 85938 GREG WAS CEO 9283337142 2017-10-31 1 KIM HUNWARDSEN CPA P00484560 4054783334 2017-10-31 24.248.119.42 2017-10-31 10:39:36 CD P 6C9B1A35775087DBDB8A6D25ECA509C7F6C27838 E10085862974BF89EE8F231EB831862A8F193D10 2016 2018-03-14 21:41:22Z WHITE MOUNTAIN REGIONAL MEDICAL CENTER GREG WAS 118 SOUTH MOUNTAIN AVENUE SPRINGERVILLE AZ 85938 18404227 0 X WWW.WMRMC.COM X 1962 AZ WHITE MOUNTAIN REGIONAL MEDICAL CENTER PROVIDES CARING SERVICES TO MEET THE NEEDS OF PATIENTS. 8 5 235 42 0 0 196537 238337 17988473 18138595 2198 567 19713 20195 18206921 18397694 6000 2850 0 0 9445772 9399974 0 0 0 8921429 9649338 18373201 19052162 -166280 -654468 9059553 8250862 4005024 3853087 5054529 4397775 X WHITE MOUNTAIN REGIONAL MEDICAL CENTER - PROVIDING AFFORDABLE, HIGH QUALITY CARE IN OUR COMMUNITY. 0 0 15636090 2850 18138595 WHITE MOUNTAIN COMMUNITIES HOSPITAL, INC. DBA WHITE MOUNTAIN REGIONAL MEDICAL CENTER (HOSPITAL) IS A 25 BED CRITICAL ACCESS HOSPITAL LOCATED IN SPRINGERVILLE, ARIZONA, AND PROVIDES ACUTE CARE INPATIENT, OUTPATIENT AND EMERGENCY SERVICES TO RESIDENTS OF THE SURROUNDING COMMUNITIES IN THE SPRINGERVILLE AREA.WHITE MOUNTAIN REGIONAL MEDICAL CENTER WILL PROVIDE CARING SERVICES AND OPERATE ON A FINANCIALLY SOUND BASIS TO ENSURE ITS CONTINUING ABILITY TO MEET THE NEEDS OF PATIENTS AND THE COMMUNITIES IT SERVES. CONTINUED ON SCHEDULE O.THE BOARD OF DIRECTORS AND LEADERSHIP OF WHITE MOUNTAIN REGIONAL MEDICAL CENTER RECOGNIZE THE IMPORTANCE OF HEALTHCARE AS A SERVICE ESSENTIAL FOR THE WELL-BEING OF PEOPLE IN THE REGION AND AS AN IMPORTANT PART OF THE COMMUNITY'S ECONOMY. AS A COMMUNITY ORGANIZATION THE FACILITY PLAYS A VITAL ROLE IN PROVIDING SERVICES ESSENTIAL TO THE QUALITY OF LIFE FOR PEOPLE IN APACHE COUNTY, ARIZONA AND CATRON COUNTY, NEW MEXICO.THE HOSPITAL PROVIDES CARE TO PATIENTS WHO MEET CERTAIN CRITERIA UNDER ITS CHARITY CARE POLICY WITHOUT CHARGE OR AT AMOUNTS LESS THAN ESTABLISHED RATES. BECAUSE THE HOSPITAL DOES NOT PURSUE COLLECTION OF AMOUNTS DETERMINED TO QUALIFY AS CHARITY CARE, THEY ARE NOT REPORTED AS REVENUE. THE AMOUNT OF CHARGES FOREGONE FOR SERVICES PROVIDED UNDER THE HOSPITAL'S CHARITY CARE POLICY WAS APPROXIMATELY $41,000 FOR THE YEAR ENDED DECEMBER 31, 2016. TOTAL DIRECT AND INDIRECT COSTS RELATED TO THESE FOREGONE CHARGES WAS APPROXIMATELY $20,000 AT DECEMBER 31, 2016, BASED ON AN AVERAGE RATIO OF COST TO GROSS CHARGES. 15636090 1 0 0 1 0 0 0 0 1 0 1 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 1 66 0 1 235 1 0 0 0 0 0 0 0 0 0 0 X 8 5 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 0 0 AZ X X FINANCE DEPARTMENT 9283337142 118 SOUTH MOUNTAIN AVENUE SPRINGERVILLE AZ 85938 MARY NEDROW PRESIDENT 1.00 X X 0 0 0 RYAN PATTERSON VICE PRESIDENT 1.00 X X 0 0 0 TIM RASMUSSEN SECRETARY 1.00 X X 0 0 0 JOHN FREDERICKSEN TREASURER 1.00 X X 0 0 0 NADIA COMVALUIS MD BOARD MEMBER UNTIL 11/20/16 1.00 X 0 0 0 GARY DAVIS BOARD MEMBER 1.00 X 0 0 0 RICHARD AYRES BOARD MEMBER 1.00 X 0 0 0 PAUL DRAKE BOARD MEMBER 1.00 X 0 0 0 VERONICA DOWLING MD BOARD CHIEF OF STAFF 10.00 X 20000 0 0 GREG WAS CEO 40.00 X 155614 0 0 LARRY TYRELL CFO 40.00 X 95730 0 0 CARLA ROTERING MD PULMONOLOGY 40.00 X 211213 0 0 CHRISTINE JACKSON MD CARDIOLOGIST 40.00 X 189982 0 0 672539 0 0 3 0 1 0 CORNERSTONE 200 N NEBRASKA ST CHANDLER AZ 85225 HOME HEALTH SERVICES 1438010 ENTECH 7300 W DETROIT ST CHANDLER AZ 85226 MEDICAL EQUIPMENT SERVICE 313043 2 232309 6028 238337 PATIENT SERVICE REVENUE 622110 17086317 17086317 DISTRICT ER SERVICES 624230 546000 546000 EHR INCENTIVE 622110 293910 293910 COMMUNITY WELLNESS 900099 50591 50591 CHILDCARE REVENUE 624410 40404 40404 121373 121373 18138595 567 567 18000 0 18000 18000 18000 8728 6533 2195 2195 18397694 18138595 0 20762 X 100 100 2750 2750 271344 20000 251344 151358 151358 7192551 5666912 1525639 1240350 785187 455163 544371 442649 101722 121264 121264 42083 42083 3226200 3153218 72982 50192 21461 28731 553788 299433 254355 318838 71920 246918 544495 499430 45065 46662 34855 11807 42837 26888 15949 30147 30147 831699 831699 231565 231565 BAD DEBT EXPENSE 1656284 1656284 MEDICAL SUPPLIES 1379409 1379409 REPAIRS AND MAINTENANCE 454852 450037 4815 FOOD 99763 99306 457 19260 13047 6213 19052162 15636090 3416072 0 1600 1500 431462 343656 132481 124500 2938428 3118968 360615 333269 120125 141012 12291071 8103114 4613121 4187957 461721 0 9059553 8250862 1839237 2098612 685875 391965 1123067 686532 37500 356845 638478 4005024 3853087 X 5054529 4397775 5054529 4397775 9059553 8250862 X -654468 -2286 X 0 1 X 1 0 X 0 0 0 0 0 0 0 0 1 3679 3679 0 PART II-B, LINE 1: WHITE MOUNTAIN COMMUNITIES HOSPITAL PAID DUES TO THE ARIZONA HEALTH CARE ASSOCIATION IS THE AMOUNT OF $11,400. 32.27% OF THE DUES WAS ATTRIBUTABLE TO LOBBYING. 1 16803 13315 11029 19089 0 26067 26067 5084568 3083881 2000687 7154659 5019233 2135426 25777 25777 4187957 ESTIMATED THIRD PARTY PAYOR SETTLEMENTS 638478 638478 X 16734628 -1656284 -1656284 18390912 6782 6782 18397694 17391382 0 17391382 1660780 1660780 19052162 PART IV, LINE 1B: WHITE MOUNTAIN REGIONAL MEDICAL CENTER AUXILIARY USES THE MEDICAL CENTER'S FEIN BUT HAS ITS OWN CHECKING ACCOUNT. THE AUXILIARY ACCOUNT BALANCES WERE NOT INCLUDED IN THE FINANCIAL STATEMENTS FOR THE MEDICAL CENTER. PART X, LINE 2: THE HOSPITAL IS ORGANIZED AS AN ARIZONA NONPROFIT CORPORATION AND HAS BEEN RECOGNIZED BY THE INTERNAL REVENUE SERVICE (IRS) AS EXEMPT FROM FEDERAL INCOME TAXES UNDER INTERNAL REVENUE CODE SECTION 501(C)(3). THE HOSPITAL IS ANNUALLY REQUIRED TO FILE A RETURN OF ORGANIZATION EXEMPT FROM INCOME TAX (FORM 990) WITH THE IRS. IN ADDITION, THE HOSPITAL IS SUBJECT TO INCOME TAX ON NET INCOME THAT IS DERIVED FROM BUSINESS ACTIVITIES THAT ARE UNRELATED TO ITS EXEMPT PURPOSE. THE HOSPITAL HAS DETERMINED IT IS NOT SUBJECT TO UNRELATED BUSINESS INCOME TAX AND HAS NOT FILED AN EXEMPT ORGANIZATION BUSINESS INCOME TAX RETURN (FORM 990T) WITH THE IRS. THE HOSPITAL BELIEVES THAT IT HAS APPROPRIATE SUPPORT FOR ANY TAX POSITIONS TAKEN AFFECTING ITS ANNUAL FILING REQUIREMENTS, AND AS SUCH, DOES NOT HAVE ANY UNCERTAIN TAX POSITIONS THAT ARE MATERIAL TO THE FINANCIAL STATEMENTS. THE HOSPITAL WOULD RECOGNIZE FUTURE ACCRUED INTEREST AND PENALTIES RELATED TO UNRECOGNIZED TAX BENEFITS AND LIABILITIES IN INCOME TAX EXPENSE IF SUCH INTEREST AND PENALTIES ARE INCURRED. PART XI, LINE 2D - OTHER ADJUSTMENTS: PROVISION FOR BAD DEBTS INCLUDED IN EXPENSES FOR FORM 990 -1,656,284. PART XI, LINE 4B - OTHER ADJUSTMENTS: WHITE MOUNTAIN AUXILIARY REVENUE INCLUDED IN REVENUE FOR FORM 990 6,782. PART XII, LINE 4B - OTHER ADJUSTMENTS: PROVISION FOR BAD DEBTS INCLUDED IN EXPENSES FOR FORM 990 1,656,284. WHITE MOUNTAIN AUXILIARY EXPENSES INCLUDED IN EXPENSES FOR FORM 990 4,496. 1 1 X 1 X 1 X 1 1 0 1 1 20000 0 20000 0.00110 1990053 1792120 197933 0.01140 2010053 1792120 217933 0.01250 2098490 482608 1615882 0.09290 2098490 482608 1615882 0.09290 4108543 2274728 1833815 0.10540 0 1656284 606200 6608720 6646052 -37332 X 1 1 1 1 WHITE MOUNTAIN COMMUNITIES HOSPITAL INC 118 SOUTH MOUNTAIN AVENUE SPRINGERVILLE AZ 859355104 WWW.WMRMC.COM H2530 X X X X PROVIDER BASED - WHITE MTN REGL SPECIALTY CLINIC WHITE MOUNTAIN COMMUNITIES HOSPITAL INC 1 0 0 1 X X X X X X X X 15 1 0 0 1 X WWW.WMRMC.COM X 1 15 1 WWW.WMRMC.COM 0 1 X 100.000000000000 200.000000000000 X X X X X 1 1 X X X 1 X WWW.WMRMC.COM/GETPAGE.PHP?NAME=FINANCIAL_POLICY X WWW.WMRMC.COM/GETPAGE.PHP?NAME=FINANCIAL_POLICY X WWW.WMRMC.COM/GETPAGE.PHP?NAME=FINANCIAL_POLICY X X X X X 1 X 0 X X X 1 X 0 0 WHITE MOUNTAIN COMMUNITIES HOSPITAL, INC. PART V, SECTION B, LINE 5: THE CHNA SURVEY WAS SHARED WITH OUR COMMUNITY THROUGH SEVERAL VENUES, SOCIAL MEDIA, ELECTRONICALLY, PAPER COPIES, FLYERS AND SOCIAL MEDIA. WMRMC ALSO USED THE ANNUAL HEALTH FAIR AS AN EVENT TO GATHER MANY PAPER AND ELECTRONIC RESPONSES TO THE SURVEY. THE SURVEY WAS SHARED IN PAPER FORM AT THE FOLLOWING LOCATIONS: WMRMC HEALTH FAIR MOUNTAIN AVENUE CLINIC NORTH COUNTRY CLINIC BILLY CREEK CLINIC WMRMC SPECIALTY AND FAMILY CLINIC WMRMC OUTPATIENT CHECK IN WMRMC JEAN V. HALL WELLNESS CENTER WMRMC BOARD MEMBERS APACHE COUNTY FAIR THE SURVEY PRESENTS AN EFFORT TO SOLICIT INPUT FROM THE BROADER COMMUNITY. WHILE, THE INITIATIVE IS INFORMAL AND NON-REPRESENTATIVE, IT DOES CONTRIBUTE CONSIDERABLE INPUT FROM THE BROADER COMMUNITY. THE SURVEY TYPICALLY QUERIES RESPONDENT'S HEALTH-RELATED NEEDS AND BEHAVIORS. THIS PROVIDES BOTH AN INDICATION OF LOCAL DEMAND FOR HEALTH SERVICES AND THE LEVEL OF SATISFACTION WITHIN THE SERVICES RECEIVED. WHITE MOUNTAIN COMMUNITIES HOSPITAL, INC. PART V, SECTION B, LINE 11: UPON ANALYSIS OF THE CHNA COMPLETED BETWEEN JUNE AND SEPTEMBER OF 2015, THE FOLLOWING IS A PRIORITIZED DESCRIPTION OF SIGNIFICANT HEALTH NEEDS AND DIAGNOSES WITHIN THE DEMOGRAPHIC AREA OF WMRMC: 1. ADDITIONAL PRIMARY CARE PHYSICIAN TO ADDRESS THE TOP 5 HEALTHCARE NEEDS WHICH INCLUDE: GENERAL CHECKUPS, ALLERGIES, HIGH BLOOD PRESSURE, HIGH CHOLESTEROL, INJURY, SPORTS PHYSICALS AND DIABETES MANAGEMENT. 2. WOMEN'S HEALTH - GYNECOLOGY AND FAMILY PLANNING SERVICES. 3. DIABETES MANAGEMENT 4. ASTHMA MANAGEMENT 5. CHRONIC PAIN 6. DEPRESSION 7. IDENTIFY AND ACCESS TO COMMUNITY RESOURCES STRATEGY RURAL HEALTH CLINIC (DIABETES MANAGEMENT, ASTHMA MANAGEMENT, WOMEN'S HEALTH NEEDS) WMRMC IS IN FULLY ENGAGED IN THE PROCESS OF TURNING OUR FAMILY AND SPECIALTY CARE CLINIC INTO A RURAL HEALTH CLINIC (RHC). UNDER THIS DESIGNATION, WMRMC WILL RECEIVE ENHANCED REIMBURSEMENT RATES FROM MEDICARE AND AHCCCS. ONE OF THE REQUIREMENTS OF AN RHC IS THE EMPLOYMENT OF A MID-LEVEL PROVIDER IN ADDITION TO PRIMARY CARE PHYSICIANS. THIS WILL ASSIST WMRMC IN ADDRESSING DIABETES MANAGEMENT, ASTHMA MANAGEMENT AND WOMEN'S HEALTH NEEDS THROUGH EXAMS AND REFERRALS. AN ADDITIONAL MEASURE FOR DIABETES MANAGEMENT IS A PLAN TO HAVE OUR PHYSICIANS ENROLL IN A STATE PROGRAM FOR DIABETES MANAGEMENT CALLED, "AGENTS OF CHANGE, FOR DIABETES PREVENTION." THIS PROGRAM'S GOAL IS TO ENROLL PHYSICIAN TEAMS WHO PROMISE TO REFER PRE-DIABETIC PATIENTS TO CENTER FOR DISEASE CONTROL PROGRAMS SO PATIENTS CAN BE AWARE AND LEARN OF THE ILLNESS. IN 2016 THE APPLICATION WAS SUBMITTED BUT NOT APPROVED.PRESCRIPTION MEDICATION NEEDS UPON REVIEW OF THE CHNA DATA, 51% OF PATIENTS ARE NOT COMPLIANT IN TAKING THEIR PRESCRIPTION MEDICATION IN SOME WAY. WMRMC'S STAFF PHARMACIST HAS WORKED AT EDUCATING THE PUBLIC ABOUT THE IMPORTANCE OF TAKING PRESCRIBED MEDICATION. THIS OUTREACH HAS BEEN IMPLEMENTED THROUGH EVENTS LIKE THE HEALTH FAIR, COMMUNITY OPEN HOUSES, AND LOCAL EVENTS. ALSO, SHARING INFORMATION WITH PATIENTS IN VARIOUS MEDIUMS LIKE SOCIAL MEDIA, PRINT, AND A PARTNERSHIP WITH THE APACHE COUNTY HEALTH DISTRICT HAS BEEN UTILIZED. WMRMC HAS MEASURES IN PLACE THROUGH THE DISCHARGE PROCESS, EITHER INPATIENT OR EMERGENCY SERVICES TO MAKE SURE THE PATIENT UNDERSTANDS THE NEED FOR THEIR PRESCRIPTION MEDICATION, DOSAGE REQUIREMENTS AND DURATION OF THE PRESCRIPTION. ADDITIONALLY NURSES EDUCATE PATIENTS WITH A CURRENT LIST OF MEDICATIONS AND EDUCATION ON DISEASE PROCESSES TO ENSURE THE PATIENT UNDERSTANDS THE IMPORTANCE OF COMPLYING WITH PHYSICIAN'S ORDERS. BEHAVIORAL HEALTH NEEDS THOUGH WMRMC DOES NOT PROVIDE PSYCHIATRY/COUNSELING SERVICES, WMRMC HAS PARTNERED WITH ACPHD IN A CASPER (COMMUNITY ASSESSMENT FOR PUBLIC EMERGENCY RESPONSE TEAM). THIS TEAM HAS WORKED DILIGENTLY TO PROVIDE EDUCATION AND TRAINING TO OUR RESOURCES AND COMMUNITY TO BE BETTER EQUIPPED TO DEAL WITH BEHAVIORAL HEALTH NEEDS. TRAININGS SUCH AS PSYCHOLOGICAL FIRST AID, QPI - SUICIDE AWARENESS, AND MENTAL HEALTH FIRST AID HAVE BEEN PROVIDED TO PROGRAMS AND THE COMMUNITY. PROMOTION OF GRIEF SUPPORT, LIFE SKILLS TRAINING AND SUBSTANCE ABUSE GROUPS HAVE ALSO AIDED IN BRIDGING THE GAP IN SERVICES. IN ADDITION, ADDITIONAL PRIMARY CARE PHYSICIANS ARE ABLE TO ASSIST PATIENTS THROUGH RESOURCE SHARING AND MANAGING PRESCRIPTIONS FOR PATIENTS WITH MENTAL HEALTH CONCERNS. CARING FOR OUR ELDERLY POPULATION WMRMC HAS CONTINUED TO ENGAGE OUR ELDERLY POPULATION RESOURCES THROUGH AN ELDER CARE FORUM THAT OCCURS EVERY 3 MONTHS AT THE FACILITY. THE LOCAL RESOURCES THAT ASSIST THE ELDERLY AND CHRONICALLY ILL MEET TO DISCUSS GAPS IN CARE, AND SHARE INFORMATION TO BETTER ASSIST THE COMMUNITY. THE RESOURCES THAT ATTEND HAVE BEEN EXPANDED FROM LOCAL RESOURCES SUCH AS THE SENIOR CENTER AND THE COUNTY TO STATE AND FEDERAL RESOURCES SUCH AS VETERANS RESOURCES, NORTHERN ARIZONA COUNCIL OF GOVERNMENTS, ARIZONA CENTER FOR THE BLIND AND VISUALLY IMPAIRED, ADULT PROTECTIVE SERVICES AND MANY OTHERS. THE EXPANSE OF RESOURCES HAS REACHED OUT TO NAVAJO COUNTY AS WELL TO INCLUDE ORGANIZATIONS SUCH AS HOSPICE, SENIOR LIVING ESTABLISHMENTS, AND NAVAJO COUNTY HEALTH. THIS GROUP PLANS TO CONTINUE GROWING RESOURCES AVAILABLE TO OUR ELDERLY POPULATION BY NETWORKING AND EDUCATING ON AVAILABLE SERVICES. COMMUNITY KNOWLEDGE OF RESOURCES AVAILABLE WMRMC HAS CREATED A RESOURCE AREA FOR THE COMMUNITY TO ACCESS INFORMATION ABOUT LOCAL HEALTHCARE RESOURCES IN ITS MAIN RECEPTION AREA ALONG WITH EXPANDING TO THE LOCAL CHAMBER OF COMMERCE. THE RESOURCE AREA INCLUDES INFORMATION ABOUT ALL OF THE SERVICES OUR HOSPITAL PROVIDES, AS WELL AS INFORMATION ABOUT ACPHD PROGRAM INFORMATION. OTHER LOCAL PROVIDERS, LIKE NORTH COUNTRY HEALTH CARE, SUMMIT HEALTHCARE, AND BILLY CREEK CLINIC, WILL ALSO PARTICIPATE AND SHARE THE INFORMATION ABOUT THEIR OFFERINGS. THE MARKETING AND PUBLIC RELATIONS MANAGER IS CONTINUALLY WORKING WITH THESE AGENCIES, CLINICS, AND PROGRAMS TO KEEP INFORMATION CURRENT AND AVAILABLE TO THE COMMUNITY THROUGH EVENTS, DAY TO DAY ENCOUNTERS AND COMMUNITY MEETINGS TO EDUCATE WHAT IS AVAILABLE. WHITE MOUNTAIN COMMUNITIES HOSPITAL, INC. PART V, SECTION B, LINE 13H: UNINSURED PATIENTS HAVING ANNUAL HOUSEHOLD INCOMES OF $125,000 OR LESS MAY, DEPENDING UPON THEIR ASSETS AND LIABILITIES, QUALIFY FOR DISCOUNTED PRICING FOR COVERED SERVICES WITHOUT HAVING TO APPLY FOR MEDICAID ASSISTANCE. UNDER THE CHARITY CARE PROGRAM, UNINSURED PATIENTS HAVING HOUSEHOLD INCOMES AT OR BELOW 200% OF THE FEDERAL POVERTY LINE AND INSUFFICIENT ASSETS MAY, DEPENDINGUPON THEIR ASSETS AND LIABILITIES, QUALIFY CHARITY CARE IN THE FORM OF FREE EMERGENT SERVICES AND OTHER SERVICES REQUIRED TO BE PROVIDED BY WMRMC UNDER EMTALA, SUBJECT (IN MOST CIRCUMSTANCES) TO APPLICATION FOR MEDICAID, AND FOR DISCOUNTED PRICING FOR OTHER COVERED SERVICES. 1 1 - WHITE MOUNTAIN REGIONAL REHABWELLNESS 118 SOUTH MOUNTAIN AVENUE SPRINGERVILLE AZ 85938 REHAB/WELLNESS CENTER PART I, LINE 3C: UNINSURED PATIENTS HAVING ANNUAL HOUSEHOLD INCOMES OF $125,000 OR LESS MAY, DEPENDING UPON THEIR ASSETS AND LIABILITIES, QUALIFY FOR DISCOUNTED PRICING FOR COVERED SERVICES WITHOUT HAVING TO APPLY FOR MEDICAID ASSISTANCE. UNDER THE CHARITY CARE PROGRAM, UNINSURED PATIENTS HAVING HOUSEHOLD INCOMES AT OR BELOW 200% OF THE FEDERAL POVERTY LINE AND INSUFFICIENT ASSETS MAY, DEPENDING UPON THEIR ASSETS AND LIABILITIES, QUALIFY FOR CHARITY CARE IN THE FORM OF FREE EMERGENT SERVICES AND OTHER SERVICES REQUIRED TO BE PROVIDED BY WMRMC UNDER EMTALA, SUBJECT (IN MOST CIRCUMSTANCES) TO APPLICATION FOR MEDICAID, AND FOR DISCOUNTED PRICING FOR OTHER COVERED SERVICES. PART I, LINE 6A: THE COMMUNITY BENEFIT REPORT WAS AVAILABLE UPON REQUEST AT THE HOSPITAL. PART I, LINE 7: CHARITY CARE EXPENSE WAS CONVERTED TO COST ON LINE 7A BASED ON AN OVERALL COST-TO-CHARGE RATIO ADDRESSING ALL PATIENT SEGMENTS. UNREIMBURSED MEDICAID ON LINE 7B WAS CALCULATED USING THE COSTING METHODS TO PREPARE THE COST REPORTS. COMMUNITY HEALTH IMPROVEMENT SERVICES, LINE 7E, AND CASH AND IN-KIND CONTRIBUTIONS, LINE 7I ARE REPORTED BASED ON ACTUAL EXPENSE AND REVENUE AMOUNTS RECORDED FROM THE EVENTS IN THE GENERAL LEDGER. THE COST FOR SUBSIDIZED HEALTH SERVICES REPORTED ON LINE 7G WAS DETERMINED USING THE MEDICARE COST REPORT. PART I, LN 7 COL(F): THE AMOUNT OF BAD DEBT EXPENSE REMOVED FROM TOTAL EXPENSES TO DETERMINE THE PERCENTAGE WAS $1,656,284. PART III, LINE 2: PATIENT ACCOUNTS ARE WRITTEN OFF TO BAD DEBT AFTER EVERY EFFORT IS MADE TO COLLECT THE BALANCE AND PATIENTS ARE GIVEN OPPORTUNITIES TO COMPLETE CHARITY CARE APPLICATIONS OR SET UP PAYMENT PLANS. ALL DISCOUNTS AND CONTRACTUAL ADJUSTMENTS ARE APPLIED TO ACCOUNTS BEFORE THEY ARE WRITTEN OFF TO BAD DEBT. CURRENT PAYMENTS ON ACCOUNTS PREVIOUSLY WRITTEN OFF AS BAD DEBT REDUCES BAD DEBT EXPENSE.BAD DEBT EXPENSE ON LINE 2 IS REPORTED AT CHARGES AS PRESENTED ON THE FINANCIAL STATEMENTS. PART III, LINE 3: A REASONABLE ESTIMATE OF THE ORGANIZATION'S BAD DEBT EXPENSE ATTRIBUTABLE TO PATIENTS UNDER THE ORGANIZATION'S FINANCIAL ASSISTANCE POLICY IS 36.6% OF BAD DEBT EXPENSE. THIS IS BASED ON THE PERCENTAGE OF INDIVIDUALS LIVING IN POVERTY. PART III, LINE 4: THE FOOTNOTE TO THE ORGANIZATION'S FINANCIAL STATEMENTS CAN BE FOUND ON PAGES 6 AND 7 OF THE ATTACHED AUDITED FINANCIAL STATEMENTS. PART III, LINE 8: WHITE MOUNTAIN REGIONAL MEDICAL CENTER IS A CRITICAL ACCESS HOSPITAL. THERE WAS A MEDICARE SHORTFALL FOR 2016 DUE TO SEQUESTRATION. EVEN THOUGH MEDICARE WAS AT A LOSS, THE HOSPITAL PROVIDES SERVICES TO THESE PATIENTS BECAUSE ACCESS TO HEALTHCARE AND INDIVIDUAL'S HEALTH IS IMPORTANT TO THE HOSPITAL. THEREFORE, THE MEDICARE SHORTFALL IS CONSIDERED A COMMUNITY BENEFIT.TOTAL REVENUE RECEIVED FROM MEDICARE (INCLUDING DSH AND IME) IS THE GROSS REIMBURSEMENT PLUS SETTLEMENT (INCLUDING LSA). BOTH THE TOTAL REVENUE RECEIVED FROM MEDICARE AND THE MEDICARE ALLOWABLE COSTS ARE REPORTED FROM THE MEDICARE COST REPORT. THE MEDICARE COST REPORT IS COMPLETED BASED ON THE RULES AND REGULATIONS SET FORTH BY CENTERS FOR MEDICAID AND MEDICARE SERVICES. PART III, LINE 9B: IF A PATIENT QUALIFIES FOR FINANCIAL ASSISTANCE THE PATIENT WILL IN NO CASE BE CHARGED MORE THAN AMOUNTS GENERALLY BILLED FOR EMERGENCY SERVICES OR OTHER MEDICALLY NECESSARY SERVICES. IN ADDITION, THEY WILL NEVER BE REQUIRED TO MAKE ADVANCE PAYMENT OR OTHER PAYMENT ARRANGEMENTS IN ORDER TO RECEIVE EMERGENCY SERVICES. HOWEVER, THEY WILL BE REQUIRED IN MOST SITUATIONS TO MAKE A SUBSTANTIAL ADVANCE DEPOSIT OR OTHER PAYMENT ARRANGEMENTS BASED UPON AN ESTIMATE OF THE AMOUNTS GENERALLY BILLED IN ORDER TO RECEIVE NON-EMERGENCY SERVICES. THE ACCOUNT WILL NOT BE TURNED OVER TO A COLLECTION AGENCY WHILE AN APPLICATION IS IN PROCESS. ANY PERSONAL AMOUNT DUE WILL FOLLOW NORMAL COLLECTION PROCEDURES. PART VI, LINE 2: IN APRIL AND MAY, 2015, THE WHITE MOUNTAIN REGIONAL MEDICAL CENTER AND THE APACHE COUNTY HEALTH DISTRICT CO-SPONSORED THE WMRMC AND APACHE COUNTY COMMUNITY HEALTH NEEDS ASSESSMENT. A BROADLY REPRESENTATIVE GROUP OF 10 APACHE COUNTY LEADERS MET OVER THE COURSE OF THREE MEETINGS TO IDENTIFY PRIORITIES AND DEVISE ACTION STRATEGIES. AFTER CONSIDERATION OF A HOST OF INFORMATION, LOCAL HEALTH-RELATED PRIORITIES WERE ESTABLISHED. THE CHNA WAS APPROVED BY THE BOARD AND POSTED TO THE HOSPITAL'S WEBSITE. PART VI, LINE 3: THE FINANCIAL ASSISTANCE POLICY, APPLICATION AND PLAIN LANGUAGE SUMMARY ARE PROVIDED ON THE HOSPITAL'S WEBSITE. THE PLAIN LANGUAGE SUMMARY IS PROVIDED IN ENGLISH AND SPANISH. SPANISH TRANSLATION OF THE FINANCIAL ASSISTANCE POLICY AND APPLICATION AND BILLING POLICY IS AVAILABLE AT THE HOSPITAL. COPIES OF THESE DOCUMENTS ARE ALSO AVAILABLE IN THE ADMITTING AREA LOCATED NEAR THE MAIN ENTRANCE OF THE HOSPITAL AND BY MAIL BY CONTACTING PATIENT FINANCIAL SERVICES AT 928-333-7150. PART VI, LINE 4: WHITE MOUNTAIN REGIONAL MEDICAL CENTER IS A 25 BED CRITICAL ACCESS HOSPITAL. THE MEDICAL CENTER SERVES SOUTHERN APACHE COUNTY, ARIZONA, AS WELL AS CATRON, COUNTY, NEW MEXICO. BOTH ARE HIGH POVERTY AREAS. THE POPULATION IN SPRINGERVILLE, AZ WAS 1,995 IN 2016. THE ESTIMATED MEDIAN HOUSEHOLD INCOME IN 2015 WAS $32,517 COMPARED TO $51,492 IN ARIZONA. THE UNEMPLOYMENT RATE IN SEPTEMBER 2015 WAS 13.3% COMPARED TO 6.4% IN ARIZONA. THE PERCENTAGE OF RESIDENTS LIVING WITH INCOME BELOW THE POVERTY LEVEL IN 2015 WAS 46.6. THE MOST COMMON INDUSTRIES WERE CONSTRUCTION AND UTILITIES. DATA WAS OBTAINED FROM WWW.CITY-DATA.COM. THE NEAREST HOSPITAL IS 45 MINUTES AWAY IN SHOW LOW, ARIZONA. PART VI, LINE 5: THE GOVERNING BODY IS COMPRISED OF PERSONS WHO RESIDE IN THE MEDICAL CENTER'S PRIMARY SERVICE AREA. WHITE MOUNTAIN REGIONAL MEDICAL CENTER EXTENDS MEDICAL STAFF PRIVILEGES TO ALL QUALIFIED PHYSICIANS. ANY SURPLUS FUNDS ARE USED FOR EQUIPMENT AND FACILITY UPGRADES TO GIVE OUR PATIENTS THE LATEST IN TECHNOLOGY.WHITE MOUNTAIN REGIONAL MEDICAL CENTER IS CURRENTLY A LEVEL 4 TRAUMA CENTER. IN 2014, THE HOSPITAL ALSO RECEIVED PEDIATRIC EMERGENCY CERTIFICATION. THERE ARE SEVERAL PHYSICIANS/PROVIDERS LOCATED IN THE AREA THAT ROUTINELY USE OUR FACILITY IN SOME CAPACITY. IN ADDITION, THERE ARE MANY PHYSICIANS WITH SUB-SPECIALTIES THAT VISIT THE AREA PROVIDING OBSTETRICS AND GYNECOLOGY, OPHTHALMOLOGY, ORTHOPEDIC, PODIATRY, AND GENERAL SURGERY CLOSE TO HOME, THROUGH THE WHITE MOUNTAIN SPECIALTY CLINIC. AS IT CURRENTLY OPERATES, WHITE MOUNTAIN REGIONAL MEDICAL CENTER IS A 25 BED CRITICAL ACCESS HOSPITAL. IN ADDITION TO INPATIENT SERVICES, THE FACILITY OFFERS: GENERAL OUTPATIENT SURGICAL SERVICES;GENERAL OUTPATIENT MEDICAL SERVICES;EMERGENCY SERVICES;MEDICAL IMAGING SERVICES, WHICH INCLUDE X-RAY, MRI, C-T SCAN, BONE DENSITOMETRY, NUCLEAR MEDICINE AND ULTRA SOUND;LABORATORY SERVICES, WHICH INCLUDE BLOOD BANK, CHEMISTRY AND HEMATOLOGY;CARDIOPULMONARY SERVICES, WHICH INCLUDE RESPIRATORY SERVICES, PULMONARY FUNCTION SERVICES, SLEEP STUDY, EKG SERVICES AND CARDIAC STRESS TESTING;INPATIENT PHARMACY SERVICES;REHABILITATION SERVICES, WHICH INCLUDE INPATIENT AND OUTPATIENT PHYSICAL THERAPY, AND CHIROPRACTIC;WELLNESS CENTER;FOOD SERVICES, WHICH INCLUDE A CONSULTING REGISTERED DIETITIAN.WE PROVIDE WORKSHOPS FOR ELDERLY PEOPLE FOR SERVICES THAT THE HOSPITAL PROVIDES AND OTHER COMMUNITY SERVICES PROVIDED OUTSIDE THE HOSPITAL. ALSO, WE PROVIDE DIABETES EDUCATION ON DIET AND WAYS TO CONTROL DIABETES. THESE SERVICES ARE PROVIDED AT NO COST. X X 0 0 0 0 0 0 0 0 0 GREG WAS CEO 155218 0 0 0 396 0 0 0 0 0 155614 0 0 0 CARLA ROTERING MD PULMONOLOGY 211213 0 0 0 0 0 0 0 0 0 211213 0 0 0 CHRISTINE JACKSON MD CARDIOLOGIST 189982 0 0 0 0 0 0 0 0 0 189982 0 0 0 TOM HUNT FAMILY RELATIONSHIP WITH BOARD MEMBER 126516 COMPENSATION AND BENEFITS AS EMPLOYEE 0 ROBERT MARTIN FAMILY RELATIONSHIP WITH BOARD MEMBER 24842 COMPENSATION AND BENEFITS AS EMPLOYEE 0 FORM 990, PART VI, SECTION A, LINE 1 THE EXECUTIVE COMMITTEE IS COMPOSED OF THE OFFICERS OF PRESIDENT, VICE PRESIDENT, SECRETARY AND TREASURER. THE EXECUTIVE COMMITTEE IS EMPOWERED TO ACT ON BEHALF OF THE FULL BOARD ON ALL MATTERS REQUIRING ACTION AND ATTENTION BETWEEN REGULAR BOARD MEETINGS OR WHEN A SPECIAL MEETING WOULD NOT BE TIMELY. ALL ACTIONS OF THE EXECUTIVE COMMITTEE WILL BE PRESENTED AT THE NEXT REGULAR BOARD MEETING FOR INFORMATION AND/OR RATIFICATION. THIS COMMITTEE, BY ITS OWN POLICY, MAY ESTABLISH MEETING NOTIFICATION REQUIREMENTS. FORM 990, PART VI, SECTION B, LINE 11B THE FORM 990 IS REVIEWED BY ALL VOTING BOARD MEMBERS AT THE BOARD MEETING PRIOR TO FILING. THE CEO AND CFO REVIEW THE FORM 990. FORM 990, PART VI, SECTION B, LINE 12C A CONFLICT OF INTEREST IS COMPLETED AND SIGNED BY OFFICERS AND DIRECTORS ON AN ANNUAL BASIS. THE COMPLETED POLICIES ARE REVIEWED BY THE DIRECTORS. IT IS THE RESPONSIBILITY OF THE DIRECTORS TO MAKE FULL DISCLOSURE OF ANY INTEREST, WHICH MIGHT RESULT IN A CONFLICT ON THEIR PART, WHETHER FINANCIAL OR OTHERWISE. AT ANY MEETING OF THE DIRECTORS, ANY DIRECTOR MAY DECLARE A CONFLICT OF INTEREST PRIOR TO THE DISCUSSION OF THE ISSUE IN QUESTION. ANY DIRECTOR MAY STATE THAT HE OR SHE FEELS ANOTHER DIRECTOR HAS A CONFLICT OF INTEREST. IF A MAJORITY OF THE DIRECTORS DETERMINE THAT A CONFLICT DOES EXIST, THE DIRECTOR IN QUESTION WILL REMOVE HIMSELF/HERSELF FROM ANY DISCUSSION REGARDING THE ISSUE. FORM 990, PART VI, SECTION B, LINE 15A COMPENSATION FOR THE CEO IS DETERMINED UTILIZING A WAGE WATCH FOR COMPARISON SALARY DATA, APPROVED BY THE BOARD AND DOCUMENTED IN THE BOARD MINUTES. COMPENSATION FOR THE CFO IS DETERMINED UTILIZING A WAGE WATCH FOR COMPARISON SALARY DATA, APPROVED BY THE CEO AND DOCUMENTED IN THE PERSONNEL FILE. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS ARE AVAILABLE UPON REQUEST. FORM 990, PART IX, LINE 11G PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 304,737. MANAGEMENT AND GENERAL EXPENSES 54,926. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 359,663. CONSULTING FEES: PROGRAM SERVICE EXPENSES 32,294. MANAGEMENT AND GENERAL EXPENSES 11,881. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 44,175. CONTRACT LABOR: PROGRAM SERVICE EXPENSES 1,312,347. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,312,347. PROFESSIONAL FEES: PROGRAM SERVICE EXPENSES 1,456,070. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,456,070. RECRUITING: PROGRAM SERVICE EXPENSES 47,770. MANAGEMENT AND GENERAL EXPENSES 6,175. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 53,945. FORM 990, PART XI, LINE 9: CHANGE IN WHITE MOUNTAIN REGIONAL MEDICAL CENTER AUXILIARY'S ASSETS -2,286.