2016-11-14T15:59:00-06:00 2015-12-31 476097913 SEIM JOHNSON LLP 18081 BURT STREET SUITE 200 OMAHA NE 680224722 990 2015-01-01 470408242 CHEYENNE COUNTY HOSPITAL ASSOCIATION INC CHEY 3082545825 1000 POLE CREEK CROSSING SIDNEY NE 69162 JASON PETIK CEO 3082545825 2016-11-14 1 WENDY R COOLEY P01523804 4023302660 2015 2017-02-10 21:41:12Z X SIDNEY REGIONAL MEDICAL CENTER JASON PETIK 1000 POLE CREEK CROSSING SIDNEY NE 69162 52524955 0 X WWW.SIDNEYRMC.COM X 1951 NE FOCUS ON THE NEEDS OF THOSE SERVED THROUGH THE DELIVERY OF HIGH QUALITY AND COMPASSIONATE CARE. 13 10 516 64 0 0 48282 182617 46715832 52158301 54663 -142457 114328 114857 46933105 52313318 23854 76043 0 0 25090232 28499642 0 0 0 16380325 19667482 41494411 48243167 5438694 4070151 58646230 88576422 19754255 49324233 38891975 39252189 X TO REVOLUTIONIZE HEALTHCARE SERVICES IN THE REGION. 0 0 38072966 76043 35974309 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. 3472362 7197772 IN 2015, THE HOSPITAL NURSING DEPARTMENT PROVIDED 2,718 PATIENT DAYS OF CARE, INCLUDING INPATIENT AND OBSERVATION PATIENTS, AND DELIVERED 77 NEWBORNS FOR THE SEVEN COUNTY AREA THAT SIDNEY REGIONAL MEDICAL CENTER (SRMC) SERVES. SRMC HAD 3,493 PATIENTS SEEK CARE IN THE EMERGENCY DEPARTMENT DURING 2015. 2573951 3885319 THE EXTENDED CARE UNIT PROVIDED CARE FOR AN AVERAGE OF 53 PATIENTS DAILY DURING 2015. SRMC PROVIDED 19,487 PATIENT DAYS OF CARE FOR RESIDENTS IN THE CHEYENNE, DEUEL, KIMBALL AND SURROUNDING AREAS. 2455506 5100901 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. 2455506 5100901 46574785 1 1 0 1 0 0 0 0 0 0 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 1 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0 1 0 0 0 1 85 0 1 516 1 0 0 0 0 0 0 0 0 0 0 X 13 10 0 1 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 X KELLY UTLEY 3082545825 1000 POLE CREEK CROSSING SIDNEY NE 69162 X WILLIAM PILE CHAIRMAN 4.00 0.00 X X 0 0 0 TIM MILLER VICE CHAIRMAN 4.00 0.00 X X 0 0 0 TOM MILLMAN SECRETARY 4.00 0.00 X X 0 0 0 JEFF ELLWANGER TREASURER 4.00 0.00 X X 0 0 0 STAN BELIEU MEMBER 4.00 1.00 X 0 0 0 CLINTON DORWART MD MEMBER - CHIEF OF MEDICAL STAFF 40.00 0.00 X 183337 0 8521 JIM JONES MEMBER 4.00 0.00 X 0 0 0 KATHY NARJES MEMBER 4.00 0.00 X 0 0 0 ROB ROBINSON MEMBER 4.00 0.00 X 0 0 0 MANDY SHAW MD MEMBER - PHYSICIAN AT LARGE 40.00 0.00 X 334359 0 10260 DWIGHT SMITH MEMBER 4.00 0.00 X 0 0 0 JULIE WAMSLEY MEMBER 4.00 1.00 X 0 0 0 LAURIE WIDDOWSON MEMBER 4.00 0.00 X 0 0 0 JASON PETIK CEO 40.00 0.00 X 0 0 0 KELLY UTLEY CFO 39.00 1.00 X 153803 0 35718 REBECCA L ALLARD MD DOCTOR 40.00 0.00 X 357518 0 53144 JAMES THAYER MD DOCTOR 40.00 0.00 X 338586 0 36392 MICHAEL L MATTHEWS MD DOCTOR 40.00 0.00 X 304900 0 12024 DAVID MANKE CRNA 40.00 0.00 X 267507 0 46176 JENNIFER BROWN MD DOCTOR 40.00 0.00 X 254493 0 32400 2194503 0 234635 34 0 1 1 RURAL PARTNERS IN MEDICINE LLC PO BOX 772519 STEAMBOAT SPRINGS CO 80477 PHYSICIAN SERVICES 1763330 BYTES COMPUTER & NETWORK SOLUTIONS INC 1712 AVENUE B SCOTTSBLUFF NE 69361 IT SERVICES 337475 UNIVERSITY OF COLORADO HOSPITAL AUTHORIT PO BOX 733156 DALLAS TX 75373 MANAGEMENT SERVICES 290890 SHARED MEDICAL SERVICES INC 209 LIMESTONE PASS COTTAGE GROVE WI 53527 MRI LEASE 214800 FUSION MEDICAL STAFFING LLC PO BOX 82764 LINCOLN NE 68501 TEMPORARY STAFFING 188837 12 158862 20158 3597 182617 NET PATIENT SERVICE REVENUE 621110 31506911 31506911 MEDICARE/MEDICAID 621110 20120005 20120005 340B REVENUE 621110 191017 191017 SCHOOL REHAB REVENUE 621110 76382 76382 263986 263986 52158301 68680 68680 500 211637 -211137 -211137 -211137 CAFETERIA 722210 107540 107540 PATRONAGE DIVIDEND 900099 7317 7317 114857 52313318 52158301 0 -27600 X 76043 76043 725999 536477 189522 70137 70137 20166349 19927025 239324 603745 599838 3907 5534908 5439899 95009 1398504 1340319 58185 290890 290890 58339 58339 76533 76533 5757872 5670912 86960 261204 261204 905963 840900 65063 557933 557933 986520 986520 169941 150258 19683 164 164 100453 100453 2116051 1886599 229452 323045 323045 MEDICAL SUPPLIES 6590582 6590582 BAD DEBTS 805705 805705 FOOD PRODUCTS 399131 399131 DUES AND SUBSCRIPTIONS 150143 84490 65653 117013 97905 19108 48243167 46574785 1668382 0 2793700 3036482 19805948 16162753 5427622 7383901 193641 82808 1458752 1225788 597234 554981 67748914 8858045 27201664 58890869 7423 0 1160246 1238840 58646230 88576422 8946690 9251052 10100002 7192417 240361 32342914 467202 537850 19754255 49324233 X 38891975 39252189 38891975 39252189 58646230 88576422 X 4070151 -3709937 X X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 5593 5593 0 PART II-B, LINE 1: A PORTION OF THE DUES PAID TO THE AMERICAN HOSPITAL ASSOCIATION (AHA) AND THE NEBRASKA HOSPITAL ASSOCIATION (NHA) ARE USED BY THOSE ORGANIZATIONS FOR LOBBYING ACTIVITIES. 92500 1867557 1960057 48748024 3362547 45385477 21420 6200 15220 16102732 5278984 10823748 916681 210314 706367 58890869 DEFERRED COMPENSATION PLAN LIABILITY 537333 DUE TO AFFILIATES 517 537850 X PART X, LINE 2: SIDNEY REGIONAL MEDICAL CENTER AND CHEYENNE COUNTY HOSPITAL AND HEALTH CENTER FOUNDATION ARE EXEMPT FROM INCOME TAXES UNDER SECTION 501(A) OF THE CODE AND A SIMILAR PROVISION OF STATE LAW. HOWEVER, THEY ARE SUBJECT TO FEDERAL INCOME TAX ON ANY UNRELATED BUSINESS TAXABLE INCOME. 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, 2015, THE SYSTEM HAD NO UNCERTAIN TAX POSITIONS ACCRUED. 1 1 1 X 1 X 1 1 1 0 1 1 765029 0 765029 0.01610 2807072 2528404 278668 0.00590 3572101 2528404 1043697 0.02200 245720 64742 180978 0.00380 45710 45710 0.00100 86230 0 86230 0.00180 377660 64742 312918 0.00660 3949761 2593146 1356615 0.02860 84 2008 3588 0 3588 0.00010 9 560 942 0 942 0.00000 254 6153 29689 0 29689 0.00060 347 8721 34219 34219 0.00070 1 805705 281997 14118919 14497275 -378356 X 1 1 1 1 CHEYENNE COUNTY HOSPITAL ASSOCIATION 1000 POLE CREEK CROSSING SIDNEY NE 69162 WWW.SIDNEYRMC.COM 150001 X X X X CHEYENNE COUNTY HOSPITAL ASSOCIATION INC 1 0 0 1 X X X X X X X X X X 14 1 1 0 1 X WWW.SIDNEYRMC.COM X WWW.PPHD.ORG X 1 14 1 WWW.SIDNEYRMC.COM 0 0 1 X 100.000000000000 300.000000000000 X X X X X 1 1 X X X X 1 X X 1 X 0 X X 1 X 0 0 CHEYENNE COUNTY HOSPITAL ASSOCIATION INC PART V, SECTION B, LINE 3J: THE NEEDS ASSESSMENT INDICATES OVERALL LEVEL OF HEALTH, INCLUDING WEIGHT, ACTIVITY AND LIFESTYLE CONCERNS. ALTHOUGH THERE IS A GROWING CONCERN OF SUBSTANCE ABUSE AMONG THE GENERAL POPULATION; SUBSTANCE ABUSE IS CONSIDERABLY LOW DUE TO SOCIAL AND PHYSICAL LOCATION OF THE COMMUNITY. DUE TO LIMITED HEALTHY FOOD OPTIONS IN THE REGION THE AMOUNT OF OVER WEIGHT INDIVIDUALS INCREASES. INCREASED USE OF ELECTRONICS HAS INCREASED INACTIVITY IN YOUTH. OTHER DETERMINANTS INCLUDE LACK OF TIME AND AVAILABILITY FOR PHYSICAL ACTIVITY FOR WORKING POPULATION FROM THE EXCESSIVE AMOUNT OF HOURS BEING WORKED. THE GOALS THAT WE WILL TRY TO ACHIEVE ARE AS FOLLOWS: (1) NUTRITION AND WEIGHT STATUS (2) PHYSICAL ACTIVITY (3) SUBSTANCE ABUSE AND (4) HAND HYGIENE. THROUGH THESE INITIATIVES WE PLAN TO IMPROVE THE LEVEL OF HEALTHY LIVING FOR THE MEMBERS OF THE COMMUNITY BY REDUCING THE OBESITY IN ADULTS AND IMPROVING THE AMOUNT OF PHYSICAL ACTIVITY FOR ADULTS THROUGH TARGETED FITNESS GOALS. EQUALLY IMPORTANT IS THE DECREASE OF PHARMACEUTICAL, ILLEGAL AND RECREATIONAL DRUG USE. CHEYENNE COUNTY HOSPITAL ASSOCIATION INC PART V, SECTION B, LINE 5: SIDNEY REGIONAL MEDICAL CENTER HOSTED THREE FOCUS GROUPS ON JUNE 24, 2014. THERE WERE A TOTAL OF 30 PEOPLE ATTENDING ONE OF THE THREE SESSIONS. ONE GROUP REPRESENTED THE GENERAL POPULATION OF THE COMMUNITY, ONE GROUP REPRESENTED THE HISPANIC POPULATION AND THE THIRD GROUP REPRESENTED THE SMALL COMMUNITY OF CHAPPELL, NEBRASKA IN DEUEL COUNTY LOCATED APPROXIMATELY 20 MILES EAST OF SIDNEY. A STAKEHOLDER MEETING WAS HELD IN JULY TO ESTABLISH VISION FOR CHEYENNE AND DEUEL COUNTIES. PARTICIPANTS INCLUDED REPRESENTATIVES FROM THE HOSPITAL, PUBLIC SCHOOL SYSTEM, MEDIA, CHAMBER OF COMMERCE, LOCAL BUSINESSES, NON-PROFIT AND SERVICE ORGANIZATIONS, FAITH-BASED ORGANIZATIONS, LAW ENFORCEMENT AND THE CITY OF SIDNEY. OVER THE COURSE OF THE MEETING, THE PARTICIPANTS WERE PRESENTED WITH HEALTH DATA, SOCIOECONOMIC DATA, INCLUDING THE 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, FOCUS GROUPS, HEALTH DATA AND RESULTS FROM A 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 11: IN ORDER TO ADDRESS NUTRITION AND WEIGHT STATUS THE HOSPITAL IS PROVIDING EDUCATION TO THE COMMUNITY ON HOW TO MAKE HEALTHY FOOD CHOICES DURING THE CURRENT YEAR. IN ORDER TO ADDRESS PHYSICAL ACTIVITY THE HOSPITAL IS PARTNERING WITH THE AREA COMMUNITY CENTER TO TRACK EMPLOYEE ACTIVITY THROUGH WELLNESS PROGRAMS. THE HOSPITAL PROVIDED THREE, 16-WEEK PROGRAMS REGARDING PHYSICAL ACTIVITY. THEY ALSO TAUGHT COMMUNITY MEMBERS TO TRACK THE NUMBER OF MINUTES THEY EXERCISED DURING THE PROGRAM. ADDITIONAL PLANNING AND OUTDOOR ACTIVITIES ARE BEING COORDINATED. THE HOSPITAL HAS PLANS IN THE NEXT THREE YEARS TO PARTNER WITH LAW ENFORCEMENT AND MENTAL HEALTH INSTITUTIONS TO CREATE DRUG INTERACTION EVALUATION REVIEWS. EDUCATION IS ALSO BEING DEVELOPED FOR HAND HYGIENE TECHNIQUES FOR DISTRIBUTION TO CHILDREN AND ADULTS DURING FALL OF 2016.DURING THE COMMUNITY NEEDS ASSESSMENT PROCESS, SEVERAL ITEMS WERE IDENTIFIED BY COMMUNITY MEMBERS THAT WERE NOT CHOSEN BY THE HOSPITAL TO BE INCLUDED IN THEIR HEALTH PLANS. THESE ITEMS INCLUDE ANIMAL HEALTH AND WELLNESS, A DOG PARK, RETIREMENT COMMUNITY ACTIVITIES, BIKER-FRIENDLY LANES ON STREETS AND NEIGHBORHOOD INTERACTION BETWEEN COMMUNITY MEMBERS. WHILE EACH OF THESE ITEMS IN SOME WAY AFFECT HUMAN HEALTH, AND THEREFORE COMMUNITY HEALTH, THE HOSPITAL CHOSE TO FOCUS ON HEALTH ISSUES IT COULD DIRECTLY AFFECT WHEN MAKING DECISIONS ABOUT WHAT TO ADDRESS AND WHAT NOT TO ADDRESS FROM A HOSPITAL SYSTEM LEVEL. CHEYENNE COUNTY HOSPITAL ASSOCIATION INC PART V, SECTION B, LINE 13B: CHARITY CARE, KNOWN AS SRMC FINANCIAL ADJUSTMENT PROGRAM, IS GENERALLY SECONDARY TO ALL OTHER PATIENT FINANCIAL RESOURCES. SPECIFICALLY IDENTIFIED CASES MAY BE PRESUMED ELIGIBLE FOR CHARITABLE ASSISTANCE WITHOUT A COMPLETED APPLICATION OR ASSESSMENT. EXAMPLES OF THESE CASES ARE: PATIENTS WITH NO KNOWN ESTATE OR SPOUSE, PATIENTS WITH CURRENT ELIGIBILITY UNDER COUNTY OR STATE MEDICAL INDIGENT SERVICES ADMINISTERED BY COUNTY OR STATE FACILITIES, OR A PATIENT HOMELESS OR WITHOUT RESOURCES. PERCENT OF CHARITY WILL BE BASED ON HOUSEHOLD INCOME AND SIZE, REAL ESTATE, PERSONAL PROPERTY AND INVESTMENT EQUITY, WITH CREDIT GIVEN FOR ALREADY EXISTING MEDICAL LOANS IN COMPARISON TO THE CURRENT YEAR FEDERAL POVERTY GUIDELINES. FREE CARE WILL BE GIVEN TO HOUSEHOLDS THAT ARE AT 100% OF POVERTY LEVEL. DISCOUNTED CARE WILL BE PROVIDED TO HOUSEHOLDS WITH INCOMES UP TO 300% OF THE POVERTY LEVEL. SRMC'S PRACTICE FOR ADDITIONAL DISCOUNTED CARE IS THROUGH THE TRUE PRIVATE PAY POLICY. IF A PATIENT HAS NO INSURANCE THE PATIENT WILL BE OFFERED A DISCOUNT EQUIVALENT TO THAT WHICH WOULD BE DISCOUNTED ON A CONTRACTUAL BASIS WITH COMMERCIAL PAYERS IF THEIR PAYMENT IS RECEIVED IN 45 DAYS. THE PROBABILITY OF THIS HAPPENING IS HIGH DUE TO A LOAN PROGRAM THAT SRMC HAS WITH A LOCAL BANKING INSTITUTION ALLOWING IMMEDIATE PAYMENT AT THE PATIENT'S REQUEST. CHEYENNE COUNTY HOSPITAL ASSOCIATION INC PART V, SECTION B, LINE 16I: THE POLICY IS REFERENCED IN BILLING STATEMENTS AND IS VERBALLY REVIEWED THROUGH MANY AVENUES IN ADMISSIONS AND PATIENT FINANCIAL SERVICES, INCLUDING PATIENT ADVOCACY. 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. MEDICAID PATIENTS AUTOMATICALLY QUALIFY AT 100%. THE CHARITY CARE POLICY IS ALSO SENT TO EVERY BAD DEBT ACCOUNT GUARANTOR PRIOR TO THEIR ACCOUNT BEING TURNED IN TO A COLLECTION AGENCY FOR NON-PAYMENT. CHEYENNE COUNTY HOSPITAL ASSOCIATION INC PART V, SECTION B, LINE 22D: ELIGIBLE PATIENTS UNDER THE FINANCIAL ASSISTANCE POLICY RECEIVE AN ADJUSTMENT ON A PERCENTAGE BASIS. THE ADJUSTMENT IS CALCULATED USING SOFTWARE WHICH TAKES INTO ACCOUNT THEIR INCOME, HOUSEHOLD STATUS, ETC. IN COMPLIANCE WITH THE POLICY. TRUE PRIVATE PAY INDIVIDUALS (UNINSURED) RECEIVE AN IMMEDIATE REDUCTION IN CHARGES EQUIVALENT TO AN AVERAGE COMMERCIAL RATE. FAP ELIGIBLE PATIENTS MAY RECEIVE A REDUCTION UP TO 100% OF CHARGES RESULTING IN ZERO CHARGES TO THOSE INDIVIDUALS. FAP ELIGIBLE PATIENTS WHO ARE ELIGIBLE FOR THE 70% OR 100% DISCOUNTS ARE NOT BILLED MORE THAN THE LOWEST COMMERCIAL RATE OR MEDICAID RATE AS THESE RATES ARE HIGHER THAN 30% OF CHARGES. 2 1 - SIDNEY REG'L MEDICAL CTR EXTENDED CARE 1000 POLE CREEK CROSSING SIDNEY NE 69162 LONG TERM CARE FACILITY 2 - SLOAN ESTATES ASSISTED LIVING 2550 CRAIG AVENUE SIDNEY NE 69162 ASSISTED LIVING 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 $805,705 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 40%. THIS ESTIMATE IS BASED ON A RECOVERY RATE FROM THE COLLECTION AGENCY FOR 2015 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%. NONE OF THIS AMOUNT IS CONSIDERED TO BE COMMUNITY BENEFIT. 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 2015 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: THE HOSPITAL'S PRIMARY SERVICE AREA (PSA) IDENTIFIES THE GEOGRAPHIC AREA THAT ACCOUNTS FOR 80-90% OF ALL PATIENT VISITS. RESIDENTS OF SRMC'S PSA IN THE PANHANDLE OF WESTERN NEBRASKA COMPRISE 90% OF THE HOSPITAL'S INPATIENT DISCHARGES AND 83% OF ITS ER VISITS. THE PSA POPULATION IS ESTIMATED AT APPROXIMATELY 12,500 WITH A NONEXISTENT GROWTH PATTERN EXPECTED BETWEEN 2009 AND 2015. MEDIAN AGE IN THE PSA IS 40.7, WHICH IS SLIGHTLY YOUNGER THAN THE STATE OF NEBRASKA AT 43.7. SIGNIFICANT GROWTH IS PROJECTED FOR THE AGE GROUP 65+ BETWEEN 2009 & 2015. MEDIAN HOUSEHOLD INCOME IN THE PSA IS COMPARABLE TO THE STATE OF NEBRASKA OVERALL, HOWEVER THERE IS WIDE VARIATION IN MEDIAN HOUSEHOLD INCOME WITHIN THE PSA. PART VI, LINE 5: SPECIFIC TO THE COMMUNITY BUILDING ACTIVITIES THE HOSPITAL CONTRIBUTES THROUGH LEADERSHIP EDUCATION, RESIDENCIES AND SCHOLARSHIPS, IMPROVEMENTS TO FACILITIES, AND COLLABORATION WITH COMMUNITY CLUBS, EMPLOYERS, LEADERS AND THE COMMUNITY CENTER. THE CFO SERVED DURING 2015 AS A BOARD MEMBER OF THE CHAMBER OF COMMERCE WHILE OTHER LEADERS IN THE HOSPITAL PARTICIPATED IN THE CHEYENNE COUNTY LEADERSHIP GROUPS. ROTARY CLUB AND CITY COUNCIL ACTIVITIES AS WELL AS OTHER VOLUNTEER ORGANIZATIONS SAW COLLABORATION FROM THE HOSPITAL AND ITS REPRESENTATIVES. SIDNEY REGIONAL MEDICAL CENTER (SRMC) HOLDS A HOSPITAL SPONSORED COMMUNITY HEALTH FAIR ANNUALLY. SRMC ALSO PROVIDES SMALLER HEALTH CLINICS AT BUSINESSES THROUGHOUT THE COMMUNITY. CHILD OUTREACH FOR NEW MOTHERS, IMMUNIZATION CLINICS, DIABETES EDUCATION, FLU SHOTS AND COMMUNITY WELLNESS ACTIVITIES ARE ACCOMPLISHED THROUGH COLLABORATION WITH SCHOOLS, THE COMMUNITY CENTER, DOCTORS' OFFICES, AND COMMUNITY BUSINESSES AS WELL AS OTHER NOT FOR PROFIT ORGANIZATIONS. SMALL HOSPITALS HAVE BEEN INCREASINGLY CHALLENGED TO MAINTAIN THEIR HISTORICAL SCOPE OF SERVICES, AND MANY HAVE RELUCTANTLY DISCONTINUED PROVIDING OBSTETRICS, CRITICAL CARE, HOME HEALTH AND OTHER SERVICES IMPORTANT TO THE COMMUNITY BUT NOT SUSTAINABLE FROM A FINANCIAL PERSPECTIVE. SRMC HAS BEEN ABLE TO CONTINUE PROVIDING THESE SERVICES AND REMAINS COMMITTED TO DOING SO IN THE FORESEEABLE FUTURE.THE HOSPITAL ORGANIZATION IS PART OF A 'HEALTH SERVICES' COLLABORATION FOCUSING ON THE INITIATIVES ABOVE IN DAILY ROUTINE. THE ORGANIZATION INCLUDES HOME HEALTH AND HOSPICE SERVICES IN COLLABORATION WITH MANY COMMUNITY VOLUNTEERS, WITHOUT WHOM THE SERVICE WOULD NOT BE SUCCESSFUL. EXTENDED CARE SERVICES AS WELL AS ASSISTED LIVING SERVICES ARE OFFERED AS DEPARTMENTAL ENTITIES OF THE HOSPITAL ORGANIZATION. THESE SERVICES ALONG WITH THE HOME HEALTH AND HOSPICE ARE NOT COST-BASED REIMBURSED AND, IN FACT, ERODE THE COST-BASED REIMBURSEMENT WHICH COULD BE ENJOYED AS A CRITICAL ACCESS HOSPITAL. HOWEVER, THE BOARD OF DIRECTORS IS COMMITTED TO PUBLIC HEALTH IN ITS ENTIRETY AND CONTINUES TO SUPPORT ALL HEALTH SERVICES IN THE COMMUNITY. PART VI, LINE 6: SIDNEY REGIONAL MEDICAL CENTER IS NOT PART OF AN AFFILIATED HEALTH CARE ORGANIZATION. 1 CITY OF SIDNEY 1115 13TH AVENUE PO BOX 79 SIDNEY NE 69162 476006361 GOVERNMENTAL 50000 0 TO SUPPORT SWIMMING POOL PROJECT MAKE A WISH FOUNDATION NEBRASKA 8 WEST 56TH STREET STE B-2 NORTH KEARNEY NE 68847 470671096 501(C)(3) 15000 0 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) 9000 0 SPONSORSHIP OF FUNDRAISING ACTIVITIES 3 0 PART I, LINE 2: IF THE DONEE ORGANIZATION IS NOT A GOVERNMENTAL ENTITY OR IDENTIFIED AS A CHARITABLE ORGANIZATION ON GUIDESTAR, THE DONEE ORGANIZATION IS RESEARCHED TO ASSURE THEIR NOT-FOR-PROFIT STATUS. THE DONEE ORGANIZATION'S MISSION INFORMATION, THEIR FINANCIAL DATA AND THEIR FORM 990 (IF AVAILABLE) IS REVIEWED AND CONSIDERED BY THE BOARD OF DIRECTORS. THE BOARD OF DIRECTORS MUST APPROVE, BY A MAJORITY VOTE OF THE QUORUM IN ATTENDANCE, THE DONATION TO THE ORGANIZATION OR GOVERNMENTAL ENTITY. DURING THE FOLLOWING 12 TO 24 MONTHS AFTER THE DONATION IS DISTRIBUTED, CONTINUED MONITORING OF THE PROJECT OR DONATION RESTRICTIONS, IF APPLICABLE, SHALL BE REPORTED TO THE BOARD OF DIRECTORS. THE DONEE ORGANIZATION'S FORM 990 (IF AVAILABLE) FOR THE YEAR OF THE DONATION AND ANY OTHER SUBSEQUENT YEARS REQUESTED SHALL BE MADE AVAILABLE TO THE BOARD MEMBERS FOR FOLLOW UP REVIEW. X X X X 0 0 0 1 0 0 0 0 0 CLINTON DORWART MD MEMBER - CHIEF OF MEDICAL STAFF 181009 0 0 0 2328 0 8521 0 0 0 191858 0 0 0 MANDY SHAW MD MEMBER - PHYSICIAN AT LARGE 334165 0 0 0 194 0 10260 0 0 0 344619 0 0 0 KELLY UTLEY CFO 153521 0 0 0 282 0 8006 0 27712 0 189521 0 0 0 REBECCA L ALLARD MD DOCTOR 357264 0 0 0 254 0 13250 0 39894 0 410662 0 0 0 JAMES THAYER MD DOCTOR 272264 0 64659 0 1663 0 8680 0 27712 0 374978 0 0 0 MICHAEL L MATTHEWS MD DOCTOR 303979 0 0 0 921 0 12024 0 0 0 316924 0 0 0 DAVID MANKE CRNA 267369 0 0 0 138 0 6282 0 39894 0 313683 0 0 0 JENNIFER BROWN MD DOCTOR 254304 0 0 0 189 0 0 0 32400 0 286893 0 0 0 PART I, LINE 5 DR. JAMES THAYER RECEIVES DRAW ON HIS SALARY BASED ON HIS GROSS CHARGES. THE DRAW IS CALCULATED BY MULTIPLYING THE GROSS CHARGES BY 33% AND SUBTRACTING OFF HIS BASE BIWEEKLY SALARY OF $10,000. 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 $201,518, RETIREMENT BENEFITS OF $7,347, AND NONTAXABLE BENEFITS OF $10,017. MR. PETIK'S SALARY IS REFLECTED IN PART IX, LINE 11A. A THE COUNTY OF DEUEL NEBRASKA 476006452 251476AA5 2014-10-16 10000000 CONSTRUCT HOSPITAL 0 0 0 B THE COUNTY OF CHEYENNE NEBRASKA 476006443 1668ATAA7 2014-09-30 32000000 CONSTRUCT HOSPITAL 0 0 0 A 7192417 7142416 50001 2015 0 0 0 1 B 32000056 170472 31787552 42032 2015 0 0 0 1 A 0 0 0 0 0.00000 0.00000 0.00000 0 0 1 B 0 0 0 0 0.00000 0.00000 0.00000 0 0 1 A 0 1 0 0 1 0 0 0 1 B 0 1 1 0 0 0 0 0 1 A 1 B 1 FORM 990, SCHEDULE K, PART VI: PART 2, LINE 3, COLUMN A - THE TOTAL PROCEEDS DO NOT AGREE TO THE ISSUE PRICE IN PART 1, COLUMN (E) AS THIS DEBT WAS ISSUED ON A DRAW-DOWN BASIS AND THE TOTAL PRINCIPAL AVAILABLE HAS NOT YET BEEN DRAWN. PART 2, LINE 3, COLUMN B - THE TOTAL PROCEEDS DO NOT AGREE TO THE ISSUE PRICE IN PART 1, COLUMN (E) DUE TO INVESTMENT EARNINGS. KEVIN UTLEY EMPLOYEE OF ORGANIZATION AND SPOUSE OF KELLY UTLEY, CFO 70137 EMPLOYEE COMPENSATION 0 0 FORM 990, PART VI, SECTION A, LINE 3 THE UNIVERSITY OF COLORADO HOSPITAL AUTHORITY CURRENTLY EMPLOYS THE CHIEF EXECUTIVE OFFICER FOR SIDNEY REGIONAL MEDICAL CENTER. EACH MONTH, SRMC PROVIDES THE UNIVERSITY OF COLORADO HOSPITAL AUTHORITY WITH DATA ON SERVICES PROVIDED TO THE COMMUNITY FOR COMPARISON DATA PURPOSES. FORM 990, PART VI, SECTION B, LINE 11 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: MANDY SHAW, 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 2,208,749. MANAGEMENT AND GENERAL EXPENSES 86,960. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,295,709. CONTRACT SERVICES - SURGERY PROFESSIONALS: PROGRAM SERVICE EXPENSES 2,306,402. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,306,402. CONTRACT SERVICES - ANESTHESIA PROFESSIONALS: PROGRAM SERVICE EXPENSES 147,774. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 147,774. RECRUITING FEES: PROGRAM SERVICE EXPENSES 486,920. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 486,920. CONTRACT SERVICES - RADIOLOGY PROFESSIONALS: PROGRAM SERVICE EXPENSES 521,067. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 521,067. FORM 990, PART XI, LINE 9: IMPAIRMENT LOSS ON ASSETS -3,709,937. FORM 990, PART XI, LINE 2C: THE BOARD OF DIRECTORS ASSUMES THE RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT OF SRMC'S FINANCIAL STATEMENTS AND SELECTION OF AN INDEPENDENT ACCOUNTANT. THIS PROCESS HAS NOT CHANGED SINCE THE PRIOR YEAR. CHEYENNE COUNTY HOSPITAL AND HEALTH CENTER FOUNDATION 1000 POLE CREEK CROSSING SIDNEY NE 69162 470686476 SUPPORT SIDNEY REGIONAL MEDICAL CENTER NE 501(C)(3) LINE 11C, III-FI N/A 0 0 1 1 0 0 0 0 0 0 1 0 0 0 1 1 1 1 0 0