2016-03-30T11:06:55-05:00 2015-06-30 410746749 CLIFTONLARSONALLEN LLP 220 SOUTH SIXTH STREET SUITE 300 MINNEAPOLIS MN 55402 990 2014-07-01 810240726 MARCUS DALY MEMORIAL HOSPITAL MARC 4063632211 1200 WESTWOOD DRIVE HAMILTON MT 59840 JOHN M BARTOS CEO, SECRETARY AND TREASURER 4063632211 2016-03-23 1 DARRYN MCGARVEY P00958683 6123764500 2014 2016-08-17 19:52:53Z JOHN M BARTOS 1200 WESTWOOD DRIVE HAMILTON MT 59840 60193817 0 X WWW.MDMH.ORG X 1929 MT OUR COMMITMENT TO THE BITTERROOT VALLEY IS QUALITY, ACCESSIBLE, PERSONALIZED HEALTHCARE. 10 6 621 90 0 0 1086784 1609705 56277773 57609506 -17311 38637 207321 813728 57554567 60071576 25756 72240 0 0 33925556 34802931 0 0 174367 22193650 23133990 56144962 58009161 1409605 2062415 56805326 60236732 30001919 31861353 26803407 28375379 X OUR COMMITMENT TO THE BITTERROOT VALLEY IS QUALITY, ACCESSIBLE, PERSONALIZED HEALTHCARE. 0 0 48960722 72240 57609506 MARCUS DALY MEMORIAL HOSPITAL CORPORATION OWNS AND OPERATES A 25 LICENSED BED ACUTE CARE CRITICAL ACCESS HOSPITAL. THE HOSPITAL PROVIDES ACUTE CARE SERVICES TO PATIENTS IN RAVALLI COUNTY. THE SERVICES PROVIDED INCLUDE ACUTE CARE HOSPITAL, RELATED ANCILLARY SERVICES SUCH AS LABORATORY, RADIOLOGY, THERAPY, INPATIENT AND OUTPATIENT SURGERY, EMERGENCY CARE, AMBULANCE, HOME HEALTH, CLINIC, INPATIENT AND OUTPATIENT HOSPICE CARE. THE HOSPITAL PROVIDES EMS SERVICES WITH 3 CREWS PROVIDING 911 SERVICE TO THE COUNTY. THE GOAL IS TO RESPOND WITHIN 20 MINUTES OR LESS TO ANY CALL WITHIN THE COUNTY. THE HOSPITAL IS A PEDIATRIC REHABILITATION PROVIDER OF PHYSICAL THERAPY, OCCUPATIONAL THERAPY AND SPEECH THERAPY USING CERTIFIED THERAPISTS. THE HOSPITAL CLINICS SEE ALL PATIENTS REGARDLESS OF INSURANCE OR ABILITY TO PAY AND ENABLE THE COMMUNITY ACCESS TO PRIMARY CARE. 48960722 1 1 0 0 0 0 0 0 0 1 1 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 1 1 1 0 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 1 0 0 0 1 82 0 621 1 0 0 0 0 0 0 0 0 0 0 X 10 6 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 0 0 X X DONJA ERDMAN 4063754609 1200 WESTWOOD DRIVE HAMILTON MT 59840 DON LODMELL PHD CHAIRMAN 2.00 X X 0 0 0 BILL BEAN VICE CHAIR 2.00 X X 0 0 0 BARBARA ACKERMAN BOARD MEMBER 2.00 X 0 0 0 TOM ANDERSON BOARD MEMBER 2.00 X 0 0 0 WALKER ASHCRAFT MD BOARD MEMBER/PHYSICIAN THRU APRIL 2015 40.00 X 150618 0 22882 GARY BEDEY BOARD MEMBER THRU MARCH 2015 2.00 X 0 0 0 SUSANNAH BENJAMIN BOARD MEMBER 2.00 X 0 0 0 DONNA COONEY BOARD MEMBER THRU SEPT 2014 2.00 X 0 0 0 FREDERICK ILGENFRITZ MD BOARD MEMBER/PHYSICIAN 40.00 X 220971 0 17581 ALLEN W JONES MD BOARD MEMBER/PHYSICIAN 40.00 X 191671 0 37493 BRIAN KELLEHER MD BOARD MEMBER/PHYSICIAN 40.00 X 223815 0 0 JAMES OWINGS CPA BOARD MEMBER 2.00 X 0 0 0 JOHN ORMISTON BOARD MEMBER 2.00 X 0 0 0 JOHN M BARTOS CEO/SECRETARY/TREASURER 39.00 1.00 X 305754 0 31152 DONJA C ERDMAN CFO 39.00 1.00 X 134752 0 26605 JOHN MORELAND MD CHIEF MEDICAL OFFICER 40.00 X 266902 0 39012 TROY HANSON ASSISTANT ADMINISTRATOR 40.00 X 155532 0 11035 SUSAN HILL RN DIRECTOR OF NURSING 40.00 X 119836 0 7695 RICHARD DAY MD PHYSICIAN 40.00 X 812682 0 40995 JEREMIAH CLINTON MD PHYSICIAN 40.00 X 443890 0 44391 YVONNE COURCHESNE MD PHYSICIAN 40.00 X 370195 0 35319 JOHN LARAWAY MD PHYSICIAN 40.00 X 334554 0 17150 MARK CALDERWOOD MD PHYSICIAN 40.00 X 321376 0 24290 4052548 0 355600 40 0 1 0 JACKSON CONTRACTOR GROUP INC PO BOX 967 MISSOULA MT 59806 GENERAL CONTRACTOR 4513159 CERNER CORPORATION PO BOX 959156 ST LOUIS MO 63195 EHR SERVICES 632547 HEALHCARE OUTSOURCING NETWORK 617 17TH ST 1800 DENVER CO 80293 BILLING SERVICES 531871 OZ ARCHITECTS 531 NORTH HIGGINS AVE A MISSOULA MT 59802 ARCHITECTUAL FEES 250557 BITTERROOT EMERGENCY MEDICINE 675 WILD ROSE LANE VICTOR MT 59875 EMERGENCY SERVICES 223815 8 1328893 280812 1609705 NET PATIENT SERVICE REVENUE 621400 56147632 56147632 HOSPITAL UTILZTN. REV. 621400 886454 886454 OTHER OPERATING INCOME 621400 575420 575420 57609506 29611 29611 193 193 231461 122241 109220 109220 109220 8833 0 8833 8833 8833 597756 0 597756 597756 MISCELLANEOUS 900099 78007 78007 EDUCATION 900099 23539 23539 CAFETERIA/VENDING 900099 5206 5206 106752 60071576 57609506 0 852365 72240 72240 1973982 1311069 662913 26179603 22110172 3980142 89289 1073307 909809 159847 3651 3816310 3193032 610993 12285 1759729 1438082 315976 5671 106049 106049 57515 57515 3017709 1501567 1509970 6172 72357 72357 569767 196869 371274 1624 921975 783587 138388 330073 279388 50685 159519 117079 41958 482 1186640 1004033 146086 36521 3887131 3722452 150700 13979 939525 939525 PROVISION FOR BAD DEBTS 5404637 5404637 MEDICAL SUPPLIES EXPENS 3727000 3727000 PHARMACY/ LAB EXPENSES 1229603 1229603 MAINTENANCE AND REPAIRS 908807 738322 169879 606 615683 209899 401697 4087 58009161 48960722 8874072 174367 5572347 6796587 2810312 3076859 9818544 9534975 30000 25000 1468768 2151464 451378 430819 67172140 30846569 34236745 36325571 1929655 1444609 487577 450848 56805326 60236732 7046744 8163771 293755 269181 7165000 6675000 13043144 14158822 500000 287758 1953276 2306821 30001919 31861353 X 24308870 26296467 1802320 1385095 692217 693817 26803407 28375379 56805326 60236732 X 2062415 -490443 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 313190 1019 1019 313190 313190 2806 2806 313190 313190 2665 2665 313190 313190 1997 1997 313190 313190 3160 3160 313190 0.00000 1.00000 0.00000 0 0 1637827 1637827 44269546 16987974 27281572 1050665 615410 435255 18836543 13243185 5593358 1377559 1377559 36325571 THIRD PARTY SETTLEMENT 2306821 2306821 X 52940708 -5404637 -5404637 58345345 1726231 1726231 60071576 52713404 108880 108880 52604524 5404637 5404637 58009161 PART V, LINE 4: THE ENDOWMENT FUND IS DESIGNATED FOR THE PURPOSE OF BUILDING AND CARRYING ON A HOSPITAL IN HAMILTON, MONTANA. THE EVANS ENDOWMENT IS TO BE USED FOR THE CARE AND TREATMENT OF CRIPPLED CHILDREN. PART X, LINE 2: PER THE AUDITED FINANCIAL STATEMENTS, NOTE 1: THE INTERNAL REVENUE SERVICE (IRS) HAS DETERMINED THAT MARCUS DALY MEMORIAL HOSPITAL IS A TAX-EXEMPT, NOT-FOR-PROFIT CORPORATION UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE (IRC). THE HOSPITAL FOLLOWS THE GUIDANCE IN THE ACCOUNTING STANDARDS REGARDING THE RECOGNITION AND MEASUREMENT OF UNCERTAIN TAX POSITIONS. THE GUIDANCE CLARIFIES THE ACCOUNTING FOR UNCERTAINTY IN INCOME TAXES RECOGNIZED IN AN ENTITY'S FINANCIAL STATEMENTS. THE GUIDANCE FURTHER PRESCRIBES RECOGNITION AND MEASUREMENT OF TAX PROVISIONS TAKEN OR EXPECTED TO BE TAKEN ON A TAX RETURN THAT ARE NOT CERTAIN TO BE REALIZED. THE APPLICATION OF THIS STANDARD HAS NO IMPACT ON THE HOSPITAL'S FINANCIAL STATEMENTS. PART XI, LINE 2D - OTHER ADJUSTMENTS: PROVISION FOR UNCOLLECTIBLE ACCOUNTS -5,404,637. PART XI, LINE 4B - OTHER ADJUSTMENTS: TEMPORARILY RESTRICTED CONTRIBUTIONS 1,577,321. RENTAL EXPENSES -108,880. OTHER OPERATING REVENUES 257,790. PART XII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES 108,880. PART XII, LINE 4B - OTHER ADJUSTMENTS: PROVISION FOR UNCOLLECTIBLE ACCOUNTS 5,404,637. 1 1 X 1 X 1 X 1 1 0 0 195 734967 734967 0.01400 6287596 4906471 1381125 0.02630 195 7022563 4906471 2116092 0.04030 479591 479591 0.00910 117332 117332 0.00220 4351756 2514192 1837564 0.03490 79109 79109 0.00150 5027788 2514192 2513596 0.04770 195 12050351 7420663 4629688 0.08800 1160 1160 0.00000 773 773 0.00000 148886 148886 0.00280 150819 150819 0.00280 1 5404637 0 15415273 16169117 -753844 X 1 1 1 1 MARCUS DALY MEMORIAL HOSPITAL 1200 WESTWOOD DRIVE HAMILTON MT 59840 12911 X X X X MARCUS DALY MEMORIAL HOSPITAL 1 0 0 1 X X X X X X X X X 12 1 0 1 1 X HTTP://WWW.MDMH.ORG/DOCS/COMMUNITY_HEALTH_NEEDS_ASSESSMENT_REPORT_2012.PDF X 1 12 0 0 0 1 X 100.000000000000 200.000000000000 X X X X X X 1 1 X X X 1 X HTTP://WWW.MDMH.ORG/GETPAGE.PHP?NAME=FINANCIAL_ASSISTANCE_POLICY_SUMMARY X HTTP://WWW.MDMH.ORG/DOCS/FINANCIAL_ASSISTANCE_APPLICATION.PDF X HTTP://WWW.MDMH.ORG/GETPAGE.PHP?NAME=FINANCIAL_ASSISTANCE_POLICY_SUMMARY X X X X X 1 X 0 X X 1 X 0 0 MARCUS DALY MEMORIAL HOSPITAL PART V, SECTION B, LINE 5: THOSE ZIP CODES WITH THE GREATEST NUMBER OF ADMISSIONS WERE SELECTED TO BE INCLUDED IN THE SURVEY. A RANDOM LIST OF 800 RESIDENTS WERE SELECTED FROM PRIME NET DATA SOURCE. ADDITIONALLY, THREE FOCUS GROUPS WERE HELD TO IDENTIFY THE MOTIVES OF LOCAL RESIDENTS WHEN SELECTING HEALTH CARE PROVIDERS. NOTICE OF THE SURVEY WAS PLACED IN THE LOCAL NEWSPAPER. MARCUS DALY MEMORIAL HOSPITAL PART V, SECTION B, LINE 6B: MARCUS DALY MEMORIAL HOSPITAL WORKED WITH THE MONTANA STATE UNIVERSITY OFFICE OF RURAL HEALTH. MARCUS DALY MEMORIAL HOSPITAL PART V, SECTION B, LINE 11: THE TOP SIX PRIORITIES THAT MARCUS DALY MEMORIAL HOSPITAL IS FOCUSING THEIR EFFORTS ON ARE: NUMBER OF PRIMARY CARE PROVIDERS; QUALITY OF CARE; PHYSICIAN SPECIALISTS; ALCOHOL ABUSE/SUBSTANCE ABUSE; OVERWEIGHT/OBESE RATES; AND CANCER CARE. THE FOLLOWING ARE WAYS THAT MARCUS DALY MEMORIAL HOSPITAL IS RESPONDING TO THOSE NEEDS:ACCESS TO CAREWHAT IS MARCUS DALY MEMORIAL HOSPITAL DOING? 1. RECRUITING PRIMARY CARE PHYSICIANS TO RAVALLI COUNTY - RECRUITED TWO PHYSICIANS, ESTABLISHED A HOSPITALIST PROGRAM, AND RECRUITED THREE MID-LEVEL PRACTITIONERS IN THE PAST TWO YEARS 2. QUALITY OF CARE - HOSPITAL BOARD, MEDICAL STAFF, AND HOSPITAL STAFF ALL WORK DAILY TO IMPROVE THE DELIVERY OF CARE AND TO PROVIDE THE VALUE THE PATIENT EXPECTS 3. HEALTH EDUCATION SERVICES - HOSPITAL HAS EXPANDED EDUCATIONAL PROGRAMS WOMEN'S HEART HEALTH EVENT, OSTEOPOROSIS SEMINAR, DIABETES SEMINAR, ANNUAL CHOLESTEROL SCREENING 4. GENERAL AWARENESS OF SERVICES - HOSPITAL PUBLISHES A QUARTERLY NEWSLETTER WITH INFORMATION ON PRESENT AND NEW SERVICES; A RAVALLI COUNTY FAIR BOOTH IS MANNED WITH HOSPITAL EMPLOYEES PROMOTING HEALTH AND INFORMING THE PUBLIC 5. SPECIALISTS - RECRUITMENT OF A NEUROSURGEON AND ESTABLISHMENT OF A NEUROSURGERY CENTER WAS ACCOMPLISHED THIS YEAR; RECRUITMENT OF A MID-LEVEL FOR THE CENTER IS OCCURRING AS WELL AS RECRUITMENT FOR A SECOND ORTHOPEDIC SURGEON PLAN FOR FUTURE STRATEGIES THE NEXT THREE YEARS PRIMARY CARE PROVIDERS TO MEET THE COUNTY'S NEEDS: 1. RECRUITMENT OF FAMILY PRACTICE PHYSICIANS 2. RECRUITMENT OF PRIMARY CARE MID-LEVEL PROVIDERS 3. DEVELOPMENT OF A PRIMARY CARE CLINIC IN DARBY 4. SITE FOR FAMILY PRACTICE RESIDENCY PROGRAM TO FACILITATE RECRUITMENT FROM PROGRAM QUALITY OF CARE: 1. HIRE RN CASE MANAGERS TO BECOME PATIENT LIAISONS AND TO EDUCATE AND MONITOR SPECIFIC PATIENTS WITH CHRONIC DISEASES AND/OR NEWLY DIAGNOSED ACUTE MEDICAL PROBLEMS 2. IMPLEMENT A PATIENT PORTAL TO IMPROVE PATIENT ACCESS TO THE ELECTRONIC MEDICAL RECORD 3. CONTINUE THE CULTURE OF EXCELLENCE IN PROVISION OF HIGH QUALITY OF CARE TO OUR PATIENTS AND THEIR FAMILY MEMBERS HEALTH EDUCATION/AWARENESS OF SERVICES: 1. HOSPITAL WILL CONDUCT A HEALTH FAIR SEMI-ANNUALLY, FEATURING THE HOSPITAL'S SERVICES AND A SPECIFIC SCREENING SERVICE FOR THAT YEAR 2. WILL PROVIDE 2-3 HEALTH RELATED SEMINARS PER YEAR TO HELP THE COUNTY RESIDENTS IMPROVE THEIR HEALTH 3. HEALTHLINES, THE HOSPITAL'S QUARTERLY NEWSLETTER, WILL FEATURE A HOSPITAL SERVICE OR PROVIDER EACH PUBLICATION PHYSICIAN SPECIALISTS: 1. RECRUITMENT OF AN ORTHOPEDIC SURGEON, AN ENT SURGEON, AND A NON-INVASIVE CARDIOLOGIST WILL BE OCCURRING HEALTH CONCERNS FOR THE COMMUNITYALCOHOL ABUSE/SUBSTANCE ABUSEWHAT IS MARCUS DALY MEMORIAL HOSPITAL DOING? 1. WORKING WITH LOCAL PRIMARY CARE PHYSICIANS AND PAIN CLINIC PROVIDERS, REFERRING THESE PATIENTS FOR APPROPRIATE CARE 2. DONATED LAND TO THE COUNTY FOR CONSTRUCTION OF WEST HOUSE, CRISIS STABILIZATION FACILITY 3. WESTERN MONTANA MENTAL HEALTH CENTER PROVIDES SERVICES TO THE HOSPITAL WHEN REFERRALS ARE MADE TO THEM 4. PATIENTS ADMITTED TO THE HOSPITAL ARE REFERRED TO THE APPROPRIATE PROVIDER WHEN THE PATIENT IS MEDICALLY STABLE. PLAN FOR FUTURE STRATEGIES THE NEXT THREE YEARS 1. DEVELOP A PROGRAM TO EDUCATE THE PUBLIC REGARDING TOBACCO, FOCUSING ON HEALTH ISSUES, SECONDARY SMOKE, AND CHEWING TOBACCO USE 2. DEVELOP A CONSORTIUM OF SHAREHOLDERS TO ADDRESS ONGOING DRUG AND ALCOHOL ISSUES; CONSORTIUM TO INCLUDE SCHOOL DISTRICTS, LAW ENFORCEMENT AND ELECTED COUNTY OFFICIALS 3. CONSORTIUM TO DEVELOP A PLAN TO EDUCATE THE PUBLIC ON HOW TO RECOGNIZE INDIVIDUALS WHO HAVE DRUG AND/OR ALCOHOL ISSUES AND STEPS TO REFER SUCH INDIVIDUALS TO APPROPRIATE PROVIDERS 4. PROVIDE AN EDUCATIONAL SERIES ON SIDE EFFECTS RESULTING FROM DRUG AND ALCOHOL ABUSE AND THE PREVENTION OF ALCOHOL AND DRUG ABUSE 5. PROVIDE EDUCATIONAL "BROWN BAG" SEMINARS BY THE MARCUS DALY MEMORIAL HOSPITAL STAFF ON INTERVENTION AND REFERRAL FOR ALL ALCOHOL ABUSE AND CHEMICAL ABUSE DECREASE INCIDENCE OF OVERWEIGHT AND OBESE RESIDENTS WHAT IS MARCUS DALY MEMORIAL HOSPITAL DOING? 1. PROVIDES DIETITIAN CONSULTATION SERVICES TO PATIENTS FREE OF CHARGE 2. PROVIDES HEALTH INITIATIVES FOR MARCUS DALY MEMORIAL HOSPITAL EMPLOYEES PLAN FOR FUTURE STRATEGIES THE NEXT THREE YEARS 1. EXPAND DIETITIAN HOURS TO A FULL TIME POSITION AND PROVIDE ADDITIONAL OFFICE VISIT CONSULTATIONS FOR BOTH INPATIENTS AND OUTPATIENTS 2. PROVIDE PHYSICIAN OFFICES WITH WEIGHT MANAGEMENT TOOLKITS 3. ESTABLISH A WEIGHT LOSS TASK FORCE 4. INCREASE HEALTHY OPTIONS IN THE HOSPITAL'S VENDING AND FOOD SERVICES 5. PARTNER WITH FOUR GROCERY STORES TO HAVE A DIETITIAN AVAILABLE TO HELP SHOPPERS MAKE HEALTHIER CHOICES, WHICH WOULD INCLUDE TOURS 6. PARTNER WITH ELEMENTARY SCHOOLS TO DEVELOP WELLNESS COMMITTEES FOR STUDENT HEALTH IMPROVEMENT ACTIVITIES CANCER CARE WHAT IS MARCUS DALY MEMORIAL HOSPITAL DOING? 1. IN THE MONTH OF OCTOBER FOR THE PAST SEVERAL YEARS THE COMMUNITIES IN RAVALLI COUNTY PARTICIPATE IN CANCER AWARENESS MONTH - THIS YEAR IT WAS GONE PINK. LAST YEAR (SPRINKLE PINK), THE RESIDENTS OF RAVALLI COUNTY DONATED OVER $40,000 TO THE MAMMOGRAPHY FUND AT THE HOSPITAL. THE HOSPITAL THEN MATCHED THE $40,000 TO PROVIDE $80,000 FOR PATIENTS WHO COULD NOT AFFORD A SCREENING MAMMOGRAM AND, IF NECESSARY, DIAGNOSTIC STUDIES. 2. MARCUS DALY MEMORIAL HOSPITAL WAS ONE OF THE FIRST HOSPITALS TO HAVE STATE-OF-THE-ART DIGITAL MAMMOGRAPHY. THE PAST TWO YEARS, A NEW 4D ULTRASOUND STATE-OF-THE-ART UNIT WAS PURCHASED TO ENHANCE THE MAMMOGRAPHY CENTER 3. WEEKLY ONCOLOGY SERVICES ARE PROVIDED HERE AT MARCUS DALY MEMORIAL HOSPITAL PLAN FOR FUTURE STRATEGIES THE NEXT THREE YEARS 1. CONTINUE PARTNERING WITH THE RESIDENTS OF RAVALLI COUNTY IN THE MONTH OF OCTOBER FOR PINK AWARENESS - MATCHING THE DONATIONS TO PROVIDE FREE MAMMOGRAPHY STUDIES FOR THOSE LADIES WHO CANNOT AFFORD THE STUDIES 2. WORK WITH THE ONCOLOGIST PHYSICIANS TO EXPAND THE ONCOLOGY CLINICS FROM ONCE A WEEK TO SEVERAL TIMES A WEEK 3. DEVELOP A CONSORTIUM OF SHAREHOLDERS TO LOOK AT THE TOP TEN DIAGNOSES RELATING TO CANCER, FROM THAT LIST IDENTIFY THE TWO DIAGNOSES FOR THE BASIS OF PROVIDING EDUCATIONAL PROGRAMS TO THE RESIDENTS OF RAVALLI COUNTY; CONSORTIUM TO INCLUDE PHYSICIANS, PUBLIC HEALTH DEPARTMENT, HOSPITAL STAFF, AND OTHER INDIVIDUALS INVITED BY THE CONSORTIUM GOING FORWARD THE NEXT THREE YEARS, MARCUS DALY MEMORIAL HOSPITAL WILL WORK TO SET IN MOTION STRATEGIES THAT WILL IMPACT THE NEEDS AND HEALTH ISSUES IDENTIFIED IN THIS REPORT. THE GOALS ARE TARGETED AT MAKING HEALTHIER COMMUNITIES, EXPANDING CLINICAL AND COMMUNITY BASED SERVICES, AND EMPOWERING PEOPLE TO MAKE HEALTHY CHOICES. MARCUS DALY MEMORIAL HOSPITAL PART V, SECTION B, LINE 13B: ELIGIBILITY FOR PATIENT ASSISTANCE SHALL BE MADE REGARDLESS OF RACE, GENDER, AGE, SEXUAL ORIENTATION, RELIGIOUS AFFILIATION, AND SOCIAL OR IMMIGRANT STATUS. MAJOR AREAS OF CONSIDERATIONS 1: RELATIONSHIP TO FEDERAL INCOME POVERTY GUIDELINES ADJUSTED FOR FAMILY SIZE 2) FAMILY NET ASSETS 3) DEMONSTRATION OF INABILITY TO WORK 4) COMPLETED APPLICATION AND 5) RESIDENT OF RAVALLI COUNTY MONTANA WITH EXCEPTIONS. MARCUS DALY MEMORIAL HOSPITAL PART V, SECTION B, LINE 22D: MDMH DETERMINES AMOUNTS GENERALLY BILLED ("AGB") BASED ON COMMERCIAL PAYORS. THE LARGEST COMMERCIAL PAYOR DISCOUNT WAS 19% FOR THE YEAR ENDED JUNE 30, 2015. PATIENT FINANCIAL ASSISTANCE DISCOUNTS RANGE FROM 27% TO 100%, DEPENDING UPON PATIENT ELIGIBILITY. PART V, SECTION B, LINE 16 FINANCIAL ASSISTANCE POLICY WEBSITE AVAILABILITY MARCUS DALY MEMORIAL HOSPITAL PART V, SECTION B, LINE 16A WEBSITE: HTTP://WWW.MDMH.ORG/GETPAGE.PHP?NAME=FINANCIAL_ASSISTANCE_POLICY_SUMMARY MARCUS DALY MEMORIAL HOSPITAL PART V, SECTION B, LINE 16B WEBSITE: HTTP://WWW.MDMH.ORG/DOCS/FINANCIAL_ASSISTANCE_APPLICATION.PDF MARCUS DALY MEMORIAL HOSPITAL PART V, SECTION B, LINE 16C WEBSITE: HTTP://WWW.MDMH.ORG/GETPAGE.PHP?NAME=FINANCIAL_ASSISTANCE_POLICY_SUMMARY 3 CORVALLIS FAMILY MEDICINE CLINIC 1037 MAIN STREET CORVALLIS MT 59828 FAMILY PRACTICE CLINIC BITTERROOT VALLEY EYE ASSOCIATES 300 N 10TH STREET HAMILTON MT 59840 OPTICAL SPECIALTY CLINIC RAVALLI UROLOGY 1224 MAIN STREET HAMILTON MT 59840 UROLOGY SPECIALTY CLINIC PART I, LINE 3C: FULL TO PARTIAL ASSISTANCE MAY BE GRANTED TO PATIENTS WITH GROSS FAMILY INCOME BELOW 100% OF THE FPG, AS ADJUSTED FOR FAMILY SIZE. PART I, LINE 7: EXPLANATION OF COSTING METHOD:FINANCIAL ASSISTANCE AT COST AND MEDICAID AMOUNTS REPORTED IN PART I, LINE 7 ARE COMPUTED USING THE COST TO CHARGE RATIO DERIVED FROM WORKSHEET 2 OF THE IRS INSTRUCTIONS. COMMUNITY HEALTH IMPROVEMENTS SERVICES, COMMUNITY BENEFIT OPERATIONS, HEALTH PROFESSIONAL EDUCATION, AND CASH AND IN-KIND CONTRIBUTIONS TO COMMUNITY GROUPS ARE REPORTED AT COST. GENERAL SUBSIDIZED SERVICES ARE COMPUTED USING THE IRS GUIDELINES OF COST ADJUSTED NET PAYMENTS RECEIVED. THE MEDICARE COST REPORT WAS USED TO DETERMINE THE TOTAL SUBSIDY FOR THE HOME HEALTH / HOSPICE DEPARTMENTS. PART I, LINE 7G: INCLUDED IN THE SUBSIDIZED HEALTH SERVICES ARE THE FOLLOWING DEPARTMENTS:HOME HEALTH, HOSPICE CENTER AND HOSPICE OUTPATIENT, BITTERROOT GENERAL VASCULAR SURGERY CENTER, BITTERROOT VALLEY EYE ASSOCIATES, BITTERROOT ORTHOPEDIC & SPORTS MEDICINE, AMBULANCE, HAMILTON GENERAL SURGERY CENTER, SLEEP CENTER, RAVALLI UROLOGY CLINIC, AND HAMILTON OB GYN. PART I, LN 7 COL(F): THE AMOUNT OF BAD DEBT EXPENSES THAT WAS EXCLUDED FROM THE CALCULATION TO DETERMINE THE NET COMMUNITY BENEFIT EXPENSES AS A PERCENT OF TOTAL EXPENSES WAS $5,404,637. PART II, COMMUNITY BUILDING ACTIVITIES: THE HOSPITAL PROMOTES THE HEALTH OF THE COMMUNITY BY PARTICIPATION IN BOTH ECONOMIC AND COALITION BUILDING EVENTS. THE HOSPITAL PARTNERS WITH LOCAL HIGH SCHOOLS WITH A "JOB SHADOW" PROGRAM. THE GOAL IS TO EXPOSE AND PROMOTE THE HEALTH CARE PROFESSION TO AREA YOUTH. THE HOSPITAL IS ALSO ACTIVELY INVOLVED IN NUMEROUS COMMUNITY SUPPORT ORGANIZATIONS. PART III, LINE 4: THE FOLLOWING IS FROM THE "PATIENT RECEIVABLES" PARAGRAPH IN NOTE 1 TO THE HOSPITAL'S FINANCIAL STATEMENTS:"PATIENT AND RESIDENT ACCOUNTS RECEIVABLE ARE REDUCED BY AN ALLOWANCE FOR DOUBTFUL ACCOUNTS. IN EVALUATING THE COLLECTIBILITY OF PATIENT AND RESIDENT ACCOUNTS RECEIVABLE, THE HOSPITAL ANALYZES ITS PAST HISTORY AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYOR SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND PROVISION FOR BAD DEBTS. MANAGEMENT REGULARLY REVIEWS DATA ABOUT THESE MAJOR PAYOR SOURCES OF REVENUE IN EVALUATING THE SUFFICIENCY OF THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. FOR RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRD-PARTY COVERAGE, THE HOSPITAL ANALYZES CONTRACTUALLY DUE AMOUNTS AND PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS AND A PROVISION FOR BAD DEBTS, IF NECESSARY (FOR EXAMPLE, FOR EXPECTED UNCOLLECTIBLE DEDUCTIBLES AND COPAYMENTS ON ACCOUNTS FOR WHICH THE THIRD-PARTY PAYOR HAS NOT YET PAID, OR FOR PAYORS WHO ARE KNOWN TO BE HAVING FINANCIAL DIFFICULTIES THAT MAKE THE REALIZATION OF AMOUNTS DUE UNLIKELY). FOR RECEIVABLES ASSOCIATED WITH SELF-PAY PATIENTS (WHICH INCLUDES BOTH PATIENTS WITHOUT INSURANCE AND PATIENTS WITH DEDUCTIBLE AND COPAYMENT BALANCES DUE FOR WHICH THIRD-PARTY COVERAGE EXISTS FOR PART OF THE BILL), THE HOSPITAL 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."THE AMOUNT OF BAD DEBT EXPENSE REPORTED IN PART III, LINE 2 IS CALCULATED AS FOLLOWS: PAYMENT ARRANGEMENT INCLUDE PROSPECTIVELY DETERMINED RATES PER DISCHARGE, REIMBURSED COSTS, DISCOUNTED CHARGES AND PER DIEM PAYMENTS. NET PATIENT SERVICE REVENUE IS REPORTED AT THE ESTIMATED NET REALIZABLE AMOUNTS FROM PATIENTS, THIRD-PARTY PAYORS, AND OTHERS FOR SERVICES RENDERED, INCLUDING ESTIMATED RETROACTIVE ADJUSTMENTS UNDER REIMBURSEMENT AGREEMENTS WITH THIRD-PARTY PAYORS. PART III, LINE 8: MDMH HAS A MEDICARE SHORTFALL IN EXCESS OF APPROXIMATELY $753,844. THE HOSPITAL HAS CRITICAL ACCESS HOSPITAL STATUS AND IS REIMBURSED BY MEDICARE FOR INPATIENT AND OUTPATIENT SERVICES ON A COST BASIS AS DEFINED AND LIMITED BY THE MEDICARE PROGRAM. MDMH PROVIDES A SIGNIFICANT RURAL LINK FOR BOTH THE HEALTH AND WELL-BEING OF RAVALLI COUNTY RESIDENTS. WE ARE COMMITTED TO LOCAL HEALTHCARE CLOSE TO HOME AND WORK HARD TO EARN AND KEEP THE TRUST OF THE LOCAL COMMUNITY. TO ENSURE THAT A VARIETY OF CLINIC, HOSPITAL AND EMERGENCY SERVICES ARE OPEN AND AVAILABLE TO ALL THOSE WITHIN OUR SERVICE AREA WE STRIVE TO OPERATE AT THE HIGHEST LEVEL OF FISCAL RESPONSIBILITY AND TO BE A GOOD STEWARD OF OUR RESOURCES. THE MEDICARE ALLOWABLE COSTS INCLUDED IN PART III, LINE 6 WAS DERIVED USING THE 2015 FILED MEDICARE COST REPORT. PART III, LINE 9B: IF A PATIENT IS PRESUMED TO BE FINANCIALLY INDIGENT, THE PATIENT REPRESENTATIVE WILL OFFER A PATIENT FINANCIAL STATEMENT (PFS) TO BE FILLED OUT. THE PFS WILL BE FORWARDED TO THE PATIENT FINANCIAL ASSISTANCE COMMITTEE FOR REVIEW AND DETERMINATION OF PATIENT FINANCIAL ASSISTANCE STATUS. A PATIENT MAY REQUEST A MONTHLY PAYMENT ARRANGMENT. A MINIMUM PAYMENT OF $50 MUST BE PAID MONTHLY, WITH THE BALANCE PAID IN FULL WITHIN 5 YEARS. ACCOUNTS THAT CANNOT BE COLLECTED AFTER NORMAL IN-HOUSE COLLECTION PROCEDURES MAY BE REFERRED TO A COLLECTION AGENCY, MAGISTRATE OR ATTORNEY FOR FURTHER COLLECTION ACTION. PART VI, LINE 2: IN ADDITION TO CONDUCTING A COMMUNITY HEALTH NEEDS ASSESSMENT EVERY THREE YEARS, MDMH ASSESSES THE HEALTH NEEDS OF THE COMMUNITY BY LISTENING TO OUR PATIENTS, FRIENDS, FAMILY AND NEIGHBORS AS WE INTERACT WITH THEM DAILY WE HEAR THEIR CARES AND CONCERNS. WE ALWAYS ARE LOOKING FOR NEW WAY TO RESPOND TO, AND PROVICE BETTER CARE FOR THE LOCAL COMMUNITY. PART VI, LINE 3: AS OF JANUARY 1, 2014, THE HOSPITAL'S FINANCIAL ASSISTANCE PROGRAM IS POSTED ON THEIR WEBSITE AT HTTP://WWW.MDMH.ORG/GETPAGE.PHP?NAME=FINANCIAL_ASSISTANCE_POLICY_SUMMARY. IN ADDITION THE HOSPITAL INFORMS PATIENTS UNABLE TO PAY THEIR BILLS ABOUT THEIR FINANCIAL ASSISTANCE WHILE TALKING TO THEM OVER THE PHONE AND SENDS THEM A FINANCIAL ASSISTANCE PACKET. PART VI, LINE 4: THE HOSPITAL SERVES A RURAL POPULATION WHERE THE HOUSEHOLD MEDIAN INCOME IS ABOUT $32,890. THE PAYER MIX IS 52% MEDICARE, 12% MEDICAID, 9% SELF PAY, NO INSURANCE, WITH THE BALANCE AT OTHER COMMERCIAL PAYORS. THE UNEMPLOYMENT RATE IN RAVALLI COUNTY IS CURRENTLY AT 4.5% ACCORDING TO THE MONTANTA DEPARTMENT OF LABOR AND INDUSTRY. PART VI, LINE 5: THE HOSPITAL IS PROUD OF IT'S EFFORTS TO PROMOTE COMMUNITY HEALTH AND WELLNESS. "SPRINKLE PINK" PROGRAM IS A COMMUNITY WIDE PROGRAM THAT PROMOTES MAMMOGRAPHY SCREENING AND RAISES FUNDS TO PROVIDE NO-COST MAMMOGRAMS TO QUALIFIED LOW INCOME AREA RESIDENTS. THE HOSPITAL COORDINATES AND SPONSORS THE ANNUAL SPORTS PHYSICAL CLINIC TO SUPPORT AND ENCOURAGE AREA YOUTH TO PARTICIPATE IN PHYSICIAL ACTIVITIES. OTHER COMMUNITY CLINICS OR SCREENINGS INCLUDED BLOOD PRESSURE TESTING AT AREA SENIOR CENTERS, AND LIPID PROFILES AND CHOLESTEROL TESTS PROVIDED TO THE COMMUNITY FREE OF CHARGE. A VARIETY OF HEALTH EDUCATION CLASSES ARE OFFERED TO THE COMMUNITY FREE OF CHARGE THROUGH OUT THE YEAR. PART VI, LINE 6: THE ORGANIZATION IS NOT PART OF AN AFFILIATED HEALTH CARE SYSTEM. PART VI, LINE 7, REPORTS FILED WITH STATES MT 1 HAMILTON SCHOOL DISTRICT 217 DALY AVENUE HAMILTON MT 59840 816000830 GOVERNMENTAL 9525 SUPPORT FOR SCHOOL RN PROGRAM AND STUDENT ATHLETICS. CORVALLIS SCHOOL DISTRICT PO BOX 700 1045 MAIN STREET CORVALLIS MT 59828 816000828 GOVERNMENTAL 9450 SUPPORT FOR SCHOOL RN PROGRAM AND STUDENT ATHLETICS. STEVENSVILLE SCHOOL DISTRICT 300 PARK STREET STEVENSVILLE MT 59870 816000829 GOVERNMENTAL 6625 SUPPORT FOR SCHOOL RN PROGRAM AND STUDENT ATHLETICS 3 0 PART I, LINE 2: THE HOSPITAL IS COMMITTED TO SUPPORT THE HEALTH AND WELL-BEING OF AREA SCHOOL AGED CHILDREN BY PROVIDING FUNDING GRANTS RESTRICTED TO THE DISTRICT'S SCHOOL NURSE PROGRAM. THE HOSPITAL HAS ALSO COMMITTED TO SUPPORT STUDENT ATHLETICS BY PROVIDING A VOLUNTEER BASED, LOW-COST SPORTS PHYSICAL CLINIC DURING THE SUMMER. THE PROCEEDS ARE GIVEN TO THE PARTICIPATING STUDENTS' HOME DISTRICT TO SUPPORT THE DISTRICT'S ATHLETIC PROGRAMS. OTHER COMMUNITY ORGANIZATIONS MAY SUBMIT A GRANT PROPOSAL DIRECTLY TO THE HOSPITAL CEO FOR CONSIDERATION. THE REQUESTS ARE EVALUATED BASED UPON BROAD BASED COMMUNITY SUPPORT AND THE URGENCY OF NEED. X X 1 0 X X X 0 0 0 0 0 0 0 0 0 WALKER ASHCRAFT MD BOARD MEMBER/PHYSICIAN THRU APRIL 20 143426 0 6250 0 942 0 15984 0 6898 0 173500 0 0 0 FREDERICK ILGENFRITZ MD BOARD MEMBER/PHYSICIAN 214494 0 5164 0 1313 0 12000 0 5581 0 238552 0 0 0 ALLEN W JONES MD BOARD MEMBER/PHYSICIAN 190607 0 0 0 1064 0 30000 0 7493 0 229164 0 0 0 BRIAN KELLEHER MD BOARD MEMBER/PHYSICIAN 223815 0 0 0 0 0 0 0 0 0 223815 0 0 0 JOHN M BARTOS CEO/SECRETARY/TREASURER 294388 0 0 0 11366 0 23000 0 8152 0 336906 0 0 0 DONJA C ERDMAN CFO 128927 0 0 0 5825 0 24700 0 1905 0 161357 0 0 0 JOHN MORELAND MD CHIEF MEDICAL OFFICER 209299 0 56249 0 1354 0 39012 0 0 0 305914 0 0 0 TROY HANSON ASSISTANT ADMINISTRATOR 148432 0 0 0 7100 0 0 0 11035 0 166567 0 0 0 RICHARD DAY MD PHYSICIAN 810816 0 0 0 1866 0 40500 0 495 0 853677 0 0 0 JEREMIAH CLINTON MD PHYSICIAN 440609 0 1500 0 1781 0 35000 0 9391 0 488281 0 0 0 YVONNE COURCHESNE MD PHYSICIAN 216081 0 152805 0 1309 0 35000 0 319 0 405514 0 0 0 JOHN LARAWAY MD PHYSICIAN 329917 0 3000 0 1637 0 8400 0 8750 0 351704 0 0 0 MARK CALDERWOOD MD PHYSICIAN 275210 0 44663 0 1503 0 17500 0 6790 0 345666 0 0 0 PART I, LINE 1A DR RICHARD DAY RECEIVES A HOUSING ALLOWANCE OF $7,200 THAT IS NOT INCLUDED IN HIS TAXABLE INCOME. THE HOUSE IS PROVIDED TO DR DAY AS A CONVENIENCE TO MARCUS DALY MEMORIAL HOSPITAL. PART I, LINE 1B THE CEO HAS BEEN APPROVED BY THE BOARD OF DIRECTORS TO RECEIVE A MONTHLY $400 VEHICLE ALLOWANCE. A MT HEALTH FACILITY AUTHORITY 810302406 612043ED7 2007-01-31 7068924 CONSTRUCTION OF A NEW EMERGENCY DEPARTMENT 0 0 0 A 1905000 7135000 533558 155264 5973474 2008 0 0 1 1 A 0 0 0 0 0 0 0 A 0 0 0 1 0 0 0 0 0 A 1 DATE REBATE COMPUTATION PERFORMED ISSUER NAME: MT HEALTH FACILITY AUTHORITY DATE THE REBATE COMPUTATION WAS PERFORMED: 08/01/2014 PART II, LINE 3, PROCEEDS OF ISSUE THE ISSUE PRICE OF $7,068,924 (PART I, COLUMN E) DOES NOT EQUAL THE TOTAL PROCEEDS OF ISSUE OF $7,135,000 (PART II, LINE 3) BECAUSE OF A $66,076 ORIGINAL ISSUE DISCOUNT. KATHLEEN OWINGS SPOUSE OF BOARD MEMBER 137092 EMPLOYMENT 0 FORM 990, PART VI, SECTION B, LINE 11 A REPRESENTATIVE FROM CLIFTONLARSONALLEN WILL BE RESPONSIBLE TO PRESENT THE FORM 990 TO THE HOSPITAL FINANCE COMMITTEE. UPON APPROVAL THE FORM 990 WILL BE PRESENTED TO THE BOARD OF DIRECTORS FOR ACCEPTANCE AND APPROVAL. FORM 990, PART VI, SECTION B, LINE 12C ANY DIRECTOR, CORPORATE OFFICER, SENIOR MANAGER, TRUSTEE OR MEMBER OF A COMMITTEE WITH GOVERNING BOARD DELEGATED POWERS, WHO HAS A DIRECT OR INDIRECT FINANCIAL INTEREST, IS AN INTERESTED PERSON. IF A PERSON IS AN INTERESTED PERSON WITH RESPECT TO ANY ENTITY IN THE HEALTH CARE SYSTEM OF WHICH THE HOSPITAL IS A PART, HE OR SHE IS AN INTERESTED PERSON WITH RESPECT TO ALL ENTITIES IN THE HEALTH CARE SYSTEM. UPON APPOINTMENT, HIRE OR TRANSFER AND ANNUALLY THEREAFTER, EACH INTERESTED PERSON SHALL EXECUTE AND SUBMIT TO THE HOSPITAL'S CEO A STATEMENT WHICH AFFIRMS SUCH PERSON: A. HAS RECEIVED A COPY OF THE CONFLICT OF INTEREST POLICY; B. HAS READ AND UNDERSTANDS THE POLICY; C. HAS AGREED TO COMPLY WITH THE POLICY; AND D. UNDERSTANDS THAT THE HOSPITAL IS A CHARITABLE ORGANIZATION AND IN ORDER TO MAINTAIN ITS FEDERAL AND STATE TAX EXEMPTIONS IT MUST ENGAGE PRIMARILY IN ACTIVITIES WHICH ACCOMPLISH ONE OR MORE OF ITS TAX-EXEMPT PURPOSES. IN CONNECTION WITH ANY ACTUAL OR POSSIBLE CONFLICT OF INTEREST, AN INTERESTED PERSON MUST DISCLOSE THE EXISTENCE OF THE CONFLICTING FINANCIAL INTEREST AND MUST BE GIVEN THE OPPORTUNITY TO DISCLOSE ALL MATERIAL FACTS TO THE DIRECTORS AND MEMBERS OF COMMITTEES WITH GOVERNING BOARD DELEGATED POWERS CONSIDERING THE PROPOSED TRANSACTION OR ARRANGEMENT. ANY OTHER MEMBER OF THE BOARD OR COMMITTEE MAY RAISE THE QUESTION OF WHETHER A CONFLICT EXISTS, DISCLOSE FACTS RELATING TO THE CONFLICT AND REQUEST THE INTERESTED PERSON TO PROVIDE FURTHER DETAILS. THE BOARD CHAIR (OR VICE CHAIR ACTING IN THE PLACE OF THE CHAIR) OR THE HOSPITAL'S LEGAL COUNSEL MAY, BASED ON THEIR INFORMATION ABOUT THE CONFLICT, DISCLOSE THE CONFLICT AND REQUEST THE INTERESTED PERSON TO WITHDRAW FROM DISCUSSION OF THE TRANSACTION AND/OR NOT VOTE. THE INTERESTED PERSON SHALL LEAVE THE MEETING OR REQUEST A DETERMINATION BY THE BOARD OR COMMITTEE OF WHETHER A CONFLICT OF INTEREST EXISTS. AFTER DISCLOSURE OF THE CONFLICTING INTEREST AND ALL MATERIAL FACTS, AND AFTER ANY DISCUSSION WITH THE INTERESTED PERSON, HE/SHE SHALL LEAVE THE GOVERNING BOARD OR COMMITTEE MEETING WHILE THE DETERMINATION OF A CONFLICT OF INTEREST IS DISCUSSED AND VOTED UPON. THE REMAINING, DISINTERESTED BOARD OR COMMITTEE MEMBERS SHALL DECIDE IF A CONFLICT OF INTEREST EXISTS BEFORE CONSIDERING OR ACTING UPON ANY OTHER BUSINESS. AFTER EXERCISING DUE DILIGENCE, THE GOVERNING BOARD OR COMMITTEE SHALL DETERMINE WHETHER THE HOSPITAL CAN OBTAIN WITH REASONABLE EFFORTS A MORE ADVANTAGEOUS TRANSACTION OR ARRANGEMENT WITH REASONABLE EFFORTS FROM A PERSON OR ENTITY THAT WOULD NOT GIVE RISE TO A CONFLICT OF INTEREST. IF A MORE ADVANTAGEOUS TRANSACTION OR ARRANGEMENT IS NOT REASONABLY ATTAINABLE UNDER CIRCUMSTANCES NOT PRODUCING A CONFLICT OF INTEREST, THE GOVERNING BOARD OR COMMITTEE SHALL DETERMINE BY A MAJORITY VOTE OF THE DISINTERESTED DIRECTORS WHETHER THE TRANSACTION OR ARRANGEMENT IS IN THE HOSPITAL'S BEST INTEREST, FOR ITS OWN BENEFIT, AND WHETHER IT IS FAIR AND REASONABLE. IN CONFORMITY WITH THE ABOVE DETERMINATION, THE GOVERNING BOARD OR COMMITTEE SHALL MAKE ITS DECISION AS TO WHETHER TO ENTER INTO THE TRANSACTION OR ARRANGEMENT. FORM 990, PART VI, SECTION B, LINE 15A ON AN ANNUAL BASIS, THE NON-CONFLICTED HOSPITAL BOARD MEMBERS (COMPENSATION COMMITTEE) RECEIVES THE ANNUAL COMPENSATION AND BENEFIT SURVEY PREPARED BY THE MONTANA HOSPITAL ASSOCIATION (MHA). THE COMMITTEE ALSO RECEIVES A REPORT FROM THE HOSPITAL THAT INCLUDES RESEARCH OF ALL CRITICAL ACCESS HOSPITALS IN THE STATES OF MONTANA, IDAHO, AND WYOMING. USING THIS INFORMATION THE COMPENSATION COMMITTEE THEN PROVIDES A RECOMMENDATION FOR CEO COMPENSATION TO THE FULL HOSPITAL BOARD. THE CEO HAS THE AUTHORITY TO SET THE COMPENSATION OF OTHER OFFICERS AND KEY EMPLOYEES OF THE HOSPITAL. FOR PHYSICIAN COMPENSATION, THE HOSPITAL USES A THIRD PARTY CPA FIRM TO GATHER COMPENSATION DATA FROM MGMA AND NON-PHYSICAN COMPENSATION INFORMATION IS FROM THE MHA COMPENSATION SURVEY. FORM 990, PART VI, SECTION C, LINE 18 IN ADDITION TO BEING AVAILABLE UPON REQUEST, A COPY OF THE FORM 990 IS ALSO AVAILABLE AT WWW.GUIDESTAR.ORG. FORM 990, PART VI, SECTION C, LINE 19 GOVERNING DOCUMENTS AND CONFLICT OF INTEREST POLICY ARE NOT MADE AVAILABLE TO THE PUBLIC. FINANCIAL STATEMENTS ARE MADE AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART XI, LINE 9: CHANGE IN BENEFICIAL INTEREST IN NET ASSETS OF DALY HOSPITAL FOUNDATION -485,046. AUXILIARY -5,397. DALY HOSPITAL FOUNDATIONINC 1200 WESTWOOD DRIVE HAMILTON MT 59840 363766000 CHARITABLE SERVICES MT 501(C)(3) 11-TYPE 2 N/A 0 0 0 1 0 0 0 0 0 0 0 0 1 1 1 1 0 0 0 0