2016-11-15T16:00:49-06:00 2015-12-31 450250958 EIDE BAILLY LLP 1601 NW EXPRESSWAY SUITE 1900 OKLAHOMA CITY OK 73118 990 2015-01-01 860171900 WHITE MOUNTAIN COMMUNITIES HOSPITAL INC WHIT 9283337142 118 SOUTH MOUNTAIN AVENUE SPRINGERVILLE AZ 85938 GREG WAS CEO 9283337142 2016-11-01 1 KIM HUNWARDSEN CPA P00484560 4054783334 2016-11-01 2015 2017-02-10 21:41:12Z WHITE MOUNTAIN REGIONAL MEDICAL CENTER GREG WAS 118 SOUTH MOUNTAIN AVENUE SPRINGERVILLE AZ 85938 18206921 0 X WWW.WMRMC.COM X 1962 AZ WHITE MOUNTAIN REGIONAL MEDICAL CENTER PROVIDES CARING SERVUCES TO MEET THE NEEDS OF PATIENTS. 8 5 233 41 0 0 729433 196537 16151934 17988473 1342 2198 156265 19713 17038974 18206921 0 6000 0 0 9190206 9445772 0 0 0 7347576 8921429 16537782 18373201 501192 -166280 8495183 9059553 2864283 4005024 5630900 5054529 X WHITE MOUNTAIN REGIONAL MEDICAL CENTER - PROVIDING AFFORDABLE, HIGH QUALITY CARE IN OUR COMMUNITY. 0 0 14887538 6000 17988473 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 $21,000 FOR THE YEAR ENDED DECEMBER 31, 2015. TOTAL DIRECT AND INDIRECT COSTS RELATED TO THESE FOREGONE CHARGES WAS APPROXIMATELY $12,000 AT DECEMBER 31, 2015, BASED ON AN AVERAGE RATIO OF COST TO GROSS CHARGES. 14887538 1 0 0 1 0 0 0 0 1 0 1 0 0 1 1 1 1 0 0 0 0 0 0 0 0 0 1 1 0 1 1 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 1 56 0 1 233 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 0.00 X X 0 0 0 RYAN PATTERSON VICE PRESIDENT 1.00 0.00 X X 0 0 0 TIM RASMUSSEN SECRETARY 1.00 0.00 X X 0 0 0 JOHN FREDERICKSEN TREASURER 1.00 0.00 X X 0 0 0 NADIA COMVALUIS MD BOARD MEMBER 1.00 0.00 X 0 0 0 GARY DAVIS BOARD MEMBER 1.00 0.00 X 0 0 0 RICHARD AYRES BOARD MEMBER 1.00 0.00 X 0 0 0 VERONICA DOWLING MD BOARD CHIEF OF STAFF 1.00 0.00 X 16000 0 0 GREG WAS CEO 40.00 0.00 X 160429 0 0 LARRY TYRELL CFO 40.00 0.00 X 96683 0 0 CARLA ROTERING MD PULMONOLOGY 40.00 0.00 X 227955 0 0 MICHAEL FOOTE MD INTERNAL MEDICINE 40.00 0.00 X 181030 0 0 CHRISTINE JACKSON MD CARDIOLOGIST 40.00 0.00 X 194387 0 0 876484 0 0 4 0 1 0 ROUND VALLEY EMERGENCY CARE 4141 W THORNTON SHOWLOW AZ 85901 ER PHYSICIANS/PA 1520640 EVIDENT PO BOX 850309 MOBILE AL 36685 INFORMATION TECHNOLOGY 589854 ENTECH 7300 W DETROIT ST CHANDLER AZ 85226 MEDICAL EQUIPMENT SERVICE 241493 MEDICAL DIAGNOSTIC IMAGING GROUP PO BOX 17049 PHOENIX AZ 85011 RADIOLOGY SERVICES 224738 LAB CORP PO BOX 12140 BURLINGTON NC 27216 LABORATORY SERVICES 106952 5 196411 126 196537 PATIENT SERVICE REVENUE 622110 16667275 16667275 EHR INCENTIVE 622110 612603 612603 DISTRICT ER SERVICES 624230 520000 520000 CHILDCARE REVENUE 624410 55537 55537 COMMUNITY WELLNESS 900099 47525 47525 85533 85533 17988473 958 958 19500 0 19500 19500 19500 1240 0 1240 1240 1240 213 0 213 213 18206921 17988473 0 21911 X 6000 6000 273112 16000 257112 242358 242358 7373702 5733647 1640055 989869 563317 426552 566731 451508 115223 84759 84759 40975 40975 3126098 3047855 78243 58707 31461 27246 469462 247126 222336 356840 52861 303979 590944 550967 39977 55460 45111 10349 54839 39686 15153 35703 35703 895824 895824 211773 24 211749 MEDICAL SUPPLIES 1253729 1253729 BAD DEBT EXPENSE 1173564 1173564 REPAIRS AND MAINTENANCE 396069 393906 2163 FOOD 87866 85806 2060 28817 21085 7732 18373201 14887538 3485663 0 1503 1600 791861 431462 132481 1955465 2938428 377643 360615 153627 120125 11884536 7271415 5079584 4613121 135500 461721 8495183 9059553 999412 1839237 685875 1419924 1123067 444947 356845 2864283 4005024 X 5630900 5054529 5630900 5054529 8495183 9059553 X -166280 -412068 1977 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 18780 10876 12853 16803 0 26067 26067 5084567 2906045 2178522 6748125 4365370 2382755 25777 25777 4613121 INCENTIVE FOR ELECTRONIC HEALTH RECORDS 461721 461721 ESTIMATED THIRD PARTY PAYOR SETTLEMENTS 356845 356845 X 17022481 -1173564 -1173564 18196045 10876 10876 18206921 17186784 0 17186784 1186417 1186417 18373201 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 -1,173,564. PART XI, LINE 4B - OTHER ADJUSTMENTS: WHITE MOUNTAIN AUXILIARY REVENUE INCLUDED IN REVENUE FOR FORM 990 10,876. PART XII, LINE 4B - OTHER ADJUSTMENTS: PROVISION FOR BAD DEBTS INCLUDED IN EXPENSES FOR FORM 990 1,173,564. WHITE MOUNTAIN AUXILIARY EXPENSES INCLUDED IN EXPENSES FOR FORM 990 12,853. 1 1 X 1 X 1 X 1 1 0 1 1 12000 12000 0.00070 3958385 1860970 2097415 0.12190 3970385 1860970 2109415 0.12260 7073 7073 0.00040 2226431 609458 1616973 0.09400 1240 1240 0.00010 2234744 609458 1625286 0.09450 6205129 2470428 3734701 0.21710 0 1173564 240581 5951329 5984139 -32810 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 0 1 X 100.000000000000 200.000000000000 X X X X X 1 1 X X X 1 X WWW.WMRMC.COM X WWW.WMRMC.COM X WWW.WMRMC.COM 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. THEY 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. PRESCRIPTION MEDICATION NEEDS UPON REVIEW OF THE CHNA DATA, 51% OF PATIENTS ARE NOT COMPLIANT IN TAKING THEIR PRESCRIPTION MEDICATION IN SOME WAY. WMRMC PLANS TO WORK WITH OUR STAFF PHARMACIST IN EDUCATING THE PUBLIC ABOUT THE IMPORTANCE OF TAKING PRESCRIBED MEDICATION. THIS OUTREACH WILL BE EXPLORED AND IMPLEMENTED THROUGH EVENTS LIKE THE HEALTH FAIR, SHARING INFORMATION WITH PATIENTS IN VARIOUS MEDIUMS LIKE SOCIAL MEDIA, PRINT, AND A PARTNERSHIP WITH THE APACHE COUNTY HEALTH DISTRICT. 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 WILL BE PARTICIPATING IN A PARTNERSHIP WITH ACPHD IN A CASPER (COMMUNITY ASSESSMENT FOR PUBLIC EMERGENCY RESPONSE TEAM). THIS TEAM WILL INVOLVE INTERVIEWING PEOPLE IN THE COMMUNITY ABOUT BEHAVIORAL HEALTH NEEDS AND PROVIDE VALID, POPULATION-BASED HEALTH INFORMATION ABOUT THE NEEDS OF OUR COMMUNITY. 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 ENGAGED 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. THOSE RESOURCES INCLUDE: ROUND VALLEY SENIOR CENTER, BEEHIVE HOUSE, ELDER, EMERGENCY MANAGEMENT AND CHRONIC DISEASE MANAGEMENT AT ACPHD, HOSPICE COMPASSUS AND HOSPICE ACCORD, AHCCCS, ALTCS, NAVAJO COUNTY LEGAL AID, AND LITTLE COLORADO BEHAVIORAL HEALTH CENTER ALONG WITH OUR OWN SWING BED PROGRAM. THE FORUMS BEGAN IN JANUARY 2016. COMMUNITY KNOWLEDGE OF RESOURCES AVAILABLE WMRMC IS IN THE PLANNING PROCESS OF CREATING A RESOURCE AREA FOR THE COMMUNITY TO ACCESS INFORMATION ABOUT LOCAL HEALTHCARE RESOURCES IN ITS MAIN RECEPTION AREA. THE RESOURCE AREA WILL INCLUDE 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, MOUNTAIN AVENUE CLINIC AND BILLY CREEK CLINIC, WILL ALSO PARTICIPATE AND SHARE THE INFORMATION ABOUT THEIR OFFERINGS. THE PURPOSE OF THE RESOURCE AREA IS TO HAVE A ONE-STOP LOCATION FOR COMMUNITY INFORMATION. THE MARKETING AND PUBLIC RELATIONS MANAGER WILL WORK WITH THE AGENCIES, CLINICS AND PROGRAMS TO KEEP THE INFORMATION CURRENT. ACPHD HAS DONATED MATERIALS TO HANG INFORMATION FOR THE RESOURCE AREA AND WMRMC LADIES' AUXILIARY PLANS TO DONATE A TELEVISION TO DISPLAY PATIENT COMMENTS AND RESOURCE INFORMATION. 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. WHITE MOUNTAIN COMMUNITIES HOSPITAL, INC. PART V, SECTION B, LINE 22D: THE AMOUNTS GENERALLY BILLED IS BASED UPON THE AVERAGE OF THE AMOUNTS THAT WOULD HAVE BEEN PAID TO THE HOSPITAL BY PRIVATE HEALTH INSURERS AND MEDICARE (AND CO-PAYS AND DEDUCTIBLES) FOR THE MEDICALLY NECESSARY SERVICES RECEIVED. 1 2 - 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 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 AND WILL BE POSTED TO OUR WEBSITE IN 2016. 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 $1,173,564. 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 20.5% OF BAD DEBT EXPENSE. THIS IS BASED ON THE PERCENTAGE OF INDIVIDUALS LIVING IN POVERTY.THE AMOUNT OF BAD DEBT EXPENSE REMOVED FROM TOTAL EXPENSES TO DETERMINE THE PERCENTAGE WAS $1,173,564. PART III, LINE 4: THE FOOTNOTE TO THE ORGANIZATION'S FINANCIAL STATEMENTS CAN BE FOUND ON PAGE 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 2015 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 1,964 IN 2014. THE ESTIMATED MEDIAN HOUSEHOLD INCOME IN 2013 WAS $36,889 COMPARED TO $48,510 IN ARIZONA. THE UNEMPLOYMENT RATE IN SEPTEMBER 2015 WAS 13.3% COMPARED TO 6.4% IN ARIZONA. THE PERCENTAGE OF RESIDENTS LIVING IN POVERTY IN 2013 WAS 20.5%. (13.7% FOR WHITE NON-HISPANIC RESIDENTS, 32.2% FOR HISPANIC OR LATINO RESIDENTS, 68.7% FOR AMERICAN INDIAN RESIDENTS, 30.2% FOR OTHER RACE RESIDENTS. 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. 1 HEALTHCARE TRAINING SCHOLARSHIPS 9 6000 PART I, LINE 2: WHITE MOUNTAIN REGIONAL MEDICAL CENTER AUXILIARY OFFERS SCHOLARSHIPS TO INDIVIDUALS ENTERING A HEALTH RELATED FIELD. THE GOAL IS TO MAKE IT POSSIBLE FOR THE PEOPLE OF THE AREA TO RECEIVE FIRST CLASS HEALTH CARE AS CLOSE TO HOME AS POSSIBLE. AN APPLICATION MUST BE COMPLETED AND AN INTERVIEW WITH MEMBERS OF THE SCHOLARSHIP COMMITTEE IS REQUIRED IN THE FINAL SELECTION PROCESS. CHECKS ARE WRITTEN TO THE SCHOLARSHIP RECIPIENT'S SCHOOL ON THEIR BEHALF TO ENSURE THE FUNDS ARE USED APPROPRIATELY. A GRADE POINT AVERAGE OF 3.0 IS REQUIRED FOR THE FIRST SEMESTER TO RECEIVE THE SECOND SEMESTER FUNDS. A COPY OF THE CREDITS FROM THE SELECTED INSTITUTION MUST BE RECEIVED TO ENSURE PAYMENT. X X 0 0 0 0 0 0 0 0 0 GREG WAS CEO 155048 0 5000 0 381 0 0 0 0 0 160429 0 0 0 CARLA ROTERING MD PULMONOLOGY 210955 0 17000 0 0 0 0 0 0 0 227955 0 0 0 MICHAEL FOOTE MD INTERNAL MEDICINE 177184 0 0 0 3846 0 0 0 0 0 181030 0 0 0 CHRISTINE JACKSON MD CARDIOLOGIST 192637 0 1750 0 0 0 0 0 0 0 194387 0 0 0 TOM HUNT FAMILY RELATIONSHIP WITH BOARD MEMBER 130529 COMPENSATION AND BENEFITS AS EMPLOYEE 0 ROBERT MARTIN FAMILY RELATIONSHIP WITH BOARD MEMBER 111829 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 11 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 300,451. MANAGEMENT AND GENERAL EXPENSES 60,229. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 360,680. CONSULTING FEES: PROGRAM SERVICE EXPENSES 5,302. MANAGEMENT AND GENERAL EXPENSES 16,734. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 22,036. CONTRACT LABOR: PROGRAM SERVICE EXPENSES 1,383,498. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,383,498. PROFESSIONAL FEES: PROGRAM SERVICE EXPENSES 1,357,586. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,357,586. RECRUITING: PROGRAM SERVICE EXPENSES 1,018. MANAGEMENT AND GENERAL EXPENSES 1,280. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,298. FORM 990, PART XI, LINE 9: CHANGE IN WHITE MOUNTAIN REGIONAL MEDICAL CENTER AUXILIARY'S ASSETS 1,977. FORM 990, PART XI, LINE 8: DURING THE YEAR, THE HOSPITAL HAS CHANGED THEIR POLICY REGARDING RECOGNIZING INCENTIVE FOR ELECTRONIC HEALTH RECORDS. THE REVENUE WILL BE DEFERRED OVER A 5 YEAR PERIOD. THE EFFECT OF THE CHANGE WAS AN INCREASE IN DEFERRED REVENUE OF $412,068 FOR THE PERIOD ENDING DECEMBER 31, 2014. THIS RESULTED IN A REDUCTION OF 2014 EHR INCENTIVE INCOME, AND THEREFORE 2014 ENDING NET ASSETS, OF $412,068.