2017-02-15T15:47:54-06:00 2016-06-30 480573184 REGIER CARR & MONROE LLP 4801 E BROADWAY BLVD STE 501 TUCSON AZ 857113648 990 2015-07-01 860334996 BISBEE HOSPITAL ASSOCIATIONINC D/B/A COPPER QUEEN COMMUNITY HOSPITAL BISB 5204325383 101 COLE AVENUE BISBEE AZ 856031327 JAMES DICKSON CEO 5204325383 2017-02-07 1 DAVID B BARBER CPACFE P00348638 5206248229 2015 2021-01-29 14:40:06Z COPPER QUEEN COMMUNITY HOSPITAL JAMES DICKSON 101 COLE AVENUE BISBEE AZ 856031327 35089354 0 X WWW.CQCH.ORG X 1977 AZ TO MAINTAIN AND SUPPORT ACCESS TO PRIMARY HEALTHCARE THROUGHOUT SOUTHERN COCHISE COUNTY BY PROVIDING LEADERSHIP AND VISION TO ADDRESS OPPORTUNITIES AND CHALLENGES. 11 11 308 14 0 0 424545 225924 27929835 34722239 -71148 28286 79787 69404 28363019 35045853 0 42210 0 0 14333584 16493351 0 0 0 10866082 12866121 25199666 29401682 3163353 5644171 34030434 40005000 11916841 12247199 22113593 27757801 TO MAINTAIN AND SUPPORT ACCESS TO PRIMARY HEALTHCARE THROUGHOUT SOUTHERN COCHISE COUNTY BY PROVIDING LEADERSHIP AND VISION TO ADDRESS OPPORTUNITIES AND CHALLENGES. 0 0 23041422 42210 34722239 TO PROVIDE HEALTHCARE SERVICES THROUGH IN-PATIENT, OUT-PATIENT,24-HOUR EMERGENCY SERVICES AND RURAL HEALTH CLINIC TO THE RESIDENTS OF BISBEE & SURROUNDING COMMUNITIES. 23041422 1 1 0 0 0 0 0 0 0 0 1 0 0 0 1 1 1 0 0 0 0 0 0 0 1 0 1 1 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 111 0 1 308 1 0 0 0 0 0 0 0 0 0 0 X 11 11 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 1 1 1 1 0 AZ X X THE ORGANIZATION 5204325383 101 COLE AVENUE BISBEE AZ 856031327 KATHLEEN HEARD DIRECTOR 2.00 X 0 0 0 JOHN HARRIS CHAIR 4.00 X 0 0 0 ROSALIE BUTLER SECRETARY 2.00 X 0 0 0 DENNIS GALLUS VICE CHAIR 4.00 X 0 0 0 DENNIS NELSON DIRECTOR 2.00 X 0 0 0 LAURA CHAVEZ DIRECTOR 2.00 X 0 0 0 GARY DILLARD DIRECTOR 2.00 X 0 0 0 PETER CARBERRY DIRECTOR 2.00 X 0 0 0 ROBERT HOWELL TREASURER 2.00 X 0 0 0 LAWANA DIFFLE DIRECTOR 2.00 X 0 0 0 ROSA ANEL LOPEZ DIRECTOR 2.00 X 0 0 0 JAMES DICKSON CEO 40.00 X 353893 0 96974 JAMES EHASZ CFO 40.00 X 164808 0 10355 JOSE ROMO MD SURGEON 40.00 X 359231 0 22680 HEIDI LODGE MD PHYSICIAN 40.00 X 314218 0 20866 DANIEL ROE MD ER PHYSICIAN 40.00 X 553450 0 28837 BRIAN MILES MD PHYSICIAN 40.00 X 246890 0 11053 PANAYOTIS ELLINAS MD PHYSICIAN 40.00 X 274372 0 19284 2266862 0 210049 23 0 1 0 LABORATORY CORPORATION OF AMERICA 5005 S 40TH ST PHOENIX AZ 85040 LAB SERVICE 421626 EVIDENT 6600 WALL STREET MOBILE AL 36695 COMPUTER SERVICE 347401 JOHN WAYTUK 101 COLE AVE BISBEE AZ 85603 ER PHYSICIAN 311405 CERNER 2800 ROCKCREEK PARKWAY NORTH KANSAS CITY MO 64117 COMPUTER SERVICE 250791 DEVENEY GROUP ARCHITECTS 201 W INDIAN SCHOOL RD PHOENIX AZ 85013 ARCHITECTURAL SERVICE 154211 12 37507 176017 12400 225924 PATIENT SERVICE REVENUE 900099 34722239 34722239 34722239 23036 23036 30000 24750 5250 5250 5250 0 37507 18751 -18751 -18751 CAFETERIA 900099 79257 79257 MEDICAL RECORDS 900099 8898 8898 88155 35045853 34722239 0 97690 X 12210 12210 30000 30000 667040 667040 13065627 10487843 2577784 188761 161951 26810 1673270 1277216 396054 898653 711098 187555 142145 20008 122137 90900 90900 2940951 2192808 748143 177145 177145 92995 56179 36816 256415 248598 7817 155819 105392 50427 346344 346344 1459076 1249661 209415 412843 373441 39402 PROVISION FOR UNCOLLECT 2832544 2832544 SUPPLIES 2436641 2209800 226841 REPAIRS & MAINTENANCE 349122 281936 67186 UTILITIES 305620 305620 867561 485117 382444 29401682 23041422 6360260 0 6568884 7944443 3157455 3704849 3576589 4854497 598923 718407 121113 129910 33898767 13296576 18455951 20602191 1508486 1984831 43033 40872 25000 34030434 40005000 2520001 3025157 9396840 9222042 11916841 12247199 X 22066674 27713632 46919 44169 22113593 27757801 34030434 40005000 5644171 37 0 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 1392664 1392664 21983491 6967643 15015848 8227991 6328933 1899058 2294621 2294621 20602191 LONG-TERM DEBT 9222042 9222042 X 34958188 37 37 34958151 87702 87702 35045853 29313980 0 29313980 87702 87702 29401682 PART X, LINE 2: THE HOSPITAL IS EXEMPT FROM FEDERAL INCOME TAX UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. THE HOSPITAL RECEIVED ITS LETTER OF DETERMINATION FROM THE INTERNAL REVENUE SERVICE IN 1977. CERTAIN UNRELATED BUSINESS INCOME MAY BE SUBJECT TO INCOME TAX. THE HOSPITAL FOLLOWS FASB CODIFICATION 740-10-50 FOR DISCLOSURE OF INCOME TAX RELATED MATTERS. THE STANDARD SETS A "MORE LIKELY THAN NOT" CRITERION FOR RECOGNIZING THE TAX BENEFITS OF UNCERTAIN TAX POSITIONS. THE HOSPITAL BELIEVES THAT ITS INCOME TAX FILING POSITIONS AND DEDUCTIONS WILL BE SUSTAINED UPON EXAMINATION AND, ACCORDINGLY, HAVE NOT RECORDED ANY RESERVES OR RELATED ACCRUALS FOR INTEREST AND PENALTIES IN THE ACCOMPANYING FINANCIAL STATEMENTS FOR UNCERTAIN INCOME TAX POSITIONS. INCOME TAX RELATED INTEREST AND PENALTIES ARE REPORTED IN GENERAL AND ADMINISTRATIVE EXPENSES WHEN INCURRED. NO INCOME TAX EXAMINATIONS ARE CURRENTLY UNDERWAY OR ANTICIPATED. THE STATUTE OF LIMITATIONS IS THREE YEARS FOR FEDERAL INCOME TAX PURPOSES AND FOUR YEARS FOR THE STATE OF ARIZONA. PART XI, LINE 4B - OTHER ADJUSTMENTS: DONATION INCOME INCLUDED IN EXPENSES 49,909. PROGRAM EXPENSE INCLUDED IN INCOME 56,545. FUNDRAISING EXPENSES -18,752. PART XII, LINE 4B - OTHER ADJUSTMENTS: DONATION INCOME INCLUDED IN EXPENSES 49,909. PROGRAM EXPENSES INCLUDED IN INCOME 56,545. FUNDRAISING EXPENSES -18,752. GOLF TOURNAMENT 37507 37507 18751 37507 37507 18751 18751 -18751 1 1 X 1 X 1 X 1 1 0 1 1 143000 143000 0.00540 143000 143000 0.00540 136196 136196 0.00510 136196 136196 0.00510 279196 279196 0.01050 1 35000 35000 0.00130 1 50000 50000 0.00190 5 191921 191921 0.00720 1 18000 18000 0.00070 8 294921 294921 0.01110 1 2151693 1075847 6180557 6894957 -714400 X 1 1 1 1 COPPER QUEEN COMMUNITY HOSPITAL 101 COLE AVE BISBEE AZ 85603 X X X X COPPER QUEEN COMMUNITY HOSPITAL 1 0 0 1 X X X X X X X X X 12 1 1 0 1 X HTTP://COPPERQUEENHOSPITAL.WIX.COM/CQCH#!COMMUNITY-INFO X HTTPS://WWW.COCHISE.AZ.GOV/HEALTH-AND-SOCIAL-SERVICES/C X 1 14 1 HTTP://CQCH.ORG/RESOURCES/COMMUNITY/ 0 0 1 X 200.000000000000 400.000000000000 X 1 1 1 X 1 X 1 X X X X 1 X 0 0 COPPER QUEEN COMMUNITY HOSPITAL PART V, SECTION B, LINE 6A: SOUTHEAST ARIZONA MEDICAL CENTERBENSON HOSPITALNORTHERN COCHISE COMMUNITY HOSPITAL COPPER QUEEN COMMUNITY HOSPITAL PART V, SECTION B, LINE 11: THE HOSPITAL COLLABORATED WITH THE COCHISE COUNTY TO CONDUCT THE COCHISE COUNTY CHNA IN DECEMBER 2012. CHNA IDENTIFIED HEALTH CONCERNS FOR THE COCHISE COUNTY, INCLUDING DIABETES, OBESITY, AND AGING PROBLEMS. THE HOSPITAL IMPLEMENTED HEALTH LIVING PROGRAM, ANTIMICROBIAL STEWARDSHIP PROGRAM, MOBILE EYE CLINIC, 340 B DRUG PROGRAM, AND HOSPITAL VACCINATION PROGRAM TO ADDRESS THE ISSUES IDENTIFIED IN THE CHNA. COPPER QUEEN COMMUNITY HOSPITAL PART V, SECTION B, LINE 22D: ANY PATIENT THAT DOES NOT HAVE INSURANCE IS AUTOMATICALLY GIVEN A 50% DISCOUNT ON THE COST OF THEIR MEDICAL CARE. IF THE PATIENT MAKES LESS THAN 200% OF THE FEDERAL POVERTY LEVEL THEY WILL RECEIVE AN ADDITIONAL DISCOUNT BEYOND THE INITAL 50%. THE DISCOUNT WILL BE DETERMINED USING A SLIDING FEE SCALE DISCOUNT. 3 1 - COPPER QUEEN MEDICAL ASSOCIATES-DOUGLAS 100 E 5TH ST DOUGLAS AZ 85607 RURAL HEALTH CLINIC 2 - COPPER QUEEN MEDICAL ASSOCIATES-BISBEE 101 COLE AVE BISBEE AZ 85603 RURAL HEALTH CLINIC 3 - COPPER QUEEN MEDICAL ASSOCIATES-PALOMINA 10524 HIGHWAY 92 HEREFORD AZ 85615 RURAL HEALTH CLINIC PART I, LINE 7: THE COST ACCOUNTING SYSTEM WAS USED TO REPORT THE SUBSIDIZED HEALTH SERVICES REVENUE AND EXPENSE. THE COST ACCOUNTING SYSTEM ADDRESSES ALL PATIENT SEGMENTS (INPATIENT, OUTPATIENT, EMERGENCY ROOM, PRIVATE INSURANCE, MEDICAID, MEDICARE, AND ETC.) PART I, LINE 7, COLUMN (F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $ 2,832,544. PART II, COMMUNITY BUILDING ACTIVITIES: N/A. PART III, LINE 4: FINANCIAL NOTES REGARDING BAD DEBTS, PAGE 11 OF AUDITED FINANCIAL STATEMENTSTHE HOSPITAL PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS BASED UPON A REVIEW OF OUTSTANDING RECEIVABLES, THE AGE OF ACCOUNTS, THE PAYOR MIX, HISTORICAL COLLECTION INFORMATION, AND EXISTING ECONOMIC CONDITIONS.BAD DEBTS ARE MONITORED BY MANAGEMENT AND ARE DETERMINED TO BE DELINQUENT BASED UPON REVIEW OF AGING REPORTS COUPLED WITH CORRESPONDENCE WITH PATIENTS AND THIRD-PARTY PAYORS. BAD DEBTS ARE WRITTEN OFF WHEN ALL REASONABLE ATTEMPTS TO COLLECT THE DEBT HAVE BEEN EXHAUSTED.A COST TO CHARGES RATIO IS USED TO DETERMINE THE BAD DEBT EXPENSE AT COST. SHORTFALL IS NOT INCLUDED AS PART OF COMMUNITY BENEFIT. PART VI, LINE 2: THE ORGANIZATION ASSESSES THE HEALTH CARE NEEDS OF THE COMMUNITY IT SERVES BASED UPON HISTORICAL SERVICES PROVIDED. PART VI, LINE 3: IT IS DONE UNDER ADMISSION. THE PATIENTS ARE PROVIDED A COPY OF FINANICAL ASSISTANCE POLICY UPON ADMISSION. FINANIAL ASSISTANCE CONTACT INFORMATION IS ALSO POSTED IN THE LOBBY, EMERGENCY ROOM AND OTHER PATIENT AREA. PATIENTS WITH PAST DUE BALANCES ARE SENT A LETTER ADVISING THEM OF THE AVAILABILITY OF ASSISTANCE BEFORE THEY ARE SENT TO COLLECTIONS. PART VI, LINE 4: THE HOSPITAL PROVIDES INPATIENT, OUTPATIENT, AND EMERGENCY SERVICES TO RESIDENTS WITHIN BISBEE, ARIZONA COMMUNITY AND ADJACENT AREAS. THE HOSPITAL ALSO OPERATES A HOME HEALTH AGENCY IN THE SAME GEOGRAPHIC AREA AND THREE RURAL HEALTH CLINICS LOCATED IN BISBEE, DOUGLAS AND PALOMINAS, ARIZONA. PART VI, LINE 5: N/A PART VI, LINE 6: N/A PART VI, LINE 7, REPORTS FILED WITH STATES AZ 1 ARIZONA LIONS VISION CENTER 3003 S COUNTRY CLUB RD TUCSON AZ 85713 860289608 501(C)(3) 12210 FOR SUPPORTING OF GENERAL OPERATION. SCHOLARSHIPS AND AWARDS 15 30000 0 PART I, LINE 2: THE ORGANIZATION HAS A LEADERSHIP MEETING TO REVIEW STUDENTS' SCHOLARSHIP APPLICATION. THE APPLICATIONS ARE ON FILE IN THE HUMAN RESOURCE DEPARTMENT. X X X X 0 0 0 0 0 0 0 0 0 JAMES DICKSON CEO 353893 0 0 0 0 0 35389 0 61585 0 450867 0 0 0 JAMES EHASZ CFO 164808 0 0 0 0 0 0 0 10355 0 175163 0 0 0 JOSE ROMO MD SURGEON 359231 0 0 0 0 0 10777 0 11903 0 381911 0 0 0 HEIDI LODGE MD PHYSICIAN 314218 0 0 0 0 0 9427 0 11439 0 335084 0 0 0 DANIEL ROE MD ER PHYSICIAN 553450 0 0 0 0 0 16604 0 12233 0 582287 0 0 0 BRIAN MILES MD PHYSICIAN 246890 0 0 0 0 0 0 0 11053 0 257943 0 0 0 PANAYOTIS ELLINAS MD PHYSICIAN 274372 0 0 0 0 0 8231 0 11053 0 293656 0 0 0 FORM 990, PART VI, SECTION B, LINE 11 THE DRAFT OF 990 FORM AND RELATED SCHEDULES ARE SENT TO AND REVIEWED BY BOARD MEMBERS AND MANAGEMENT BEFORE FILING. COMMENTS AND CHANGES ARE COMMUNICATED WITH THE TAX PREPARER AND ADDRESSED ACCORDINGLY. FORM 990, PART VI, SECTION B, LINE 15 EXECUTIVE COMPENSATION IS SET BY THE BOARD BASED UPON REVIEW OF AN ANNUAL SALARY SURVEY BY THE ARIZONA HOSPITAL ASSOCIATION. THE HOSPITAL ALSO CONTRACTS WITH AN OUTSIDE CONSULTANT WHO ADVISES THE BOARD REGARDING EXECUTIVE COMPENSATION. THE ABOVE MENTIONED PROCESS IS UTILIZED IN SETTING SALARIES OF ALL OF THE EXECUTIVE TEAM AT THE HOSPITAL. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICTS OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. THE FINANCIAL STATEMENTS ARE ALSO AVAILABLE TO THE PUBLIC THROUGH THE STATE UAR REPORT AND THE FEDERAL MEDICARE COST REPORT. FORM 990, PART IX, LINE 11G MEDICAL PROFESSIONAL FEES: PROGRAM SERVICE EXPENSES 1,182,180. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,182,180. OTHER: PROGRAM SERVICE EXPENSES 1,010,628. MANAGEMENT AND GENERAL EXPENSES 748,143. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,758,771. FORM 990 PART XII, LINE 2C THE ORGANIZATION DID NOT CHANGE ITS OVERSIGHT PROCESS OR SELECTION PROCESS FROM PRIOR YEAR.