2016-08-12T14:34:23-05:00 2015-09-30 420714325 RSM US LLP 4801 MAIN STREET SUITE 400 KANSAS CITY MO 64112 990 2014-10-01 480561974 ATCHISON HOSPITAL ASSOCIATION ATCH 9133605584 800 RAVEN HILL DRIVE ATCHISON KS 66002 JOHN L JACOBSON CEO 9133605584 2016-08-09 1 CONNIE HENDERSON P00156688 8167533000 2014 2016-09-27 15:27:22Z JOHN L JACOBSON 800 RAVEN HILL DRIVE ATCHISON KS 66002 42317803 0 X WWW.ATCHISONHOSPITAL.ORG X 1912 KS TO PROVIDE EXCELLENT HEALTH CARE AND IMPROVE THE QUALITY OF LIFE IN OUR COMMUNITY 7 7 359 85 0 1947 603771 539824 39278916 39827294 16016 45342 2073982 1866450 41972685 42278910 0 0 0 0 21094998 20667859 0 0 0 20138415 20100908 41233413 40768767 739272 1510143 46062970 49505512 35324684 37257083 10738286 12248429 TO PROVIDE EXCELLENT HEALTH CARE AND IMPROVE THE QUALITY OF LIFE IN OUR COMMUNITY. 0 0 33749446 39827294 ATCHISON HOSPITAL PROVIDED ACUTE INPATIENT AND OUTPATIENT HEALTH SERVICES TO THE GENERAL PUBLIC. SERVICES INCLUDE BUT ARE NOT LIMITED TO EMERGENCY SERVICES, HOME HEALTH & HOSPICE, GENERAL INPATIENT ACUTE SERVICES, RADIOLOGY & OBSTETRICS. NUMBER OF PEOPLE SERVED DURING FISCAL YEAR ENDING 9/30/15 WERE 116,355. 33749446 1 1 0 1 0 0 1 0 0 0 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 33 0 1 359 1 1 1 0 0 0 0 0 0 0 0 0 X 7 7 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 X GARY R FOLL 9133672131 800 RAVEN HILL DRIVE ATCHISON KS 66002 GOLDIE BOLDRIDGE-BROWN DIRECTOR 1.00 X 0 0 0 LYDIA FUNK DIRECTOR 1.00 X 0 0 0 LARRY MEARS DIRECTOR 1.00 X 0 0 0 SUSAN MYERS DIRECTOR/CHAIRPERSON 1.00 X X 0 0 0 STEVE MINNIS DIRECTOR/SECRETARY 1.00 X X 0 0 0 TODD GIGSTAD DIRECTOR/TREASURER 1.00 X X 0 0 0 GUS GRIFFIN DIRECTOR/VICE CHAIRPERSON 1.00 X X 0 0 0 JOHN L JACOBSON CEO 40.00 1.00 X 204319 0 18510 GARY R FOLL CFO 40.00 2.00 X 140469 0 29554 BENJAMIN STONE PHYSICIAN 36.00 X 292825 0 39904 STEPHEN MEIROSE PHYSICIAN 36.00 X 263451 0 34222 MIKE JONES PHYSICIAN 36.00 X 246282 0 14104 EVERETT WILKINSON PHYSICIAN 36.00 X 667909 0 39046 MCGARRETT GROTH PHYSICIAN 36.00 X 296898 0 30727 2112153 0 206067 24 0 1 0 SILVERCREEK REIMBURSEMENT INC 2400 N BROADWAY PITTSBURG KS 66762 BILLING SERVICES 435416 PARALLON 3867 TREASURY CENTER CHICAGO IL 60694 BILLING SERVICES 384250 HBCS 118 LUKENS DR NEW CASTLE DE 19720 BILLING SERVICES 358186 LABCORP 531 S SPRING ST BURLINGTON NC 271262140 REFERENCE LABORATORY 259510 US FOODS PO BOX 501133 ST LOUIS MO 631501133 FOOD ITEMS 201236 16 510000 13490 16334 539824 NET PATIENT SERVICE REVENUE 621400 39827294 39827294 39827294 1697 1697 19524 19524 41990 33709 8281 8281 8281 27307 1998 0 5184 27307 -3186 24121 24121 ANESTHESIA SERVICES 621400 326246 326246 MISC REVENUE 900099 267473 267473 DIETARY SERVICES 722210 109276 109276 1155174 1155174 1858169 42278910 39827294 0 1911792 377430 377430 16594714 14930088 1664626 250907 215780 35127 2351751 2022506 329245 1093057 940029 153028 55663 55663 297110 297110 2469516 1926222 543294 194905 140331 54574 241984 169389 72595 738512 553884 184628 133771 105695 28076 84254 84254 1778145 1333609 444536 3382946 2537210 845736 321835 270341 51494 SUPPLIES 4561745 4333638 228107 BAD DEBT EXPENSE 4210369 4210369 COLLECTION FEES 1516276 1516276 DUES & SUBSCRIPTIONS 113877 60355 53522 40768767 33749446 7019321 0 4278835 8679347 1342611 801645 6926252 5966667 902869 941136 587509 656589 51054265 23141563 27217549 27912702 3705120 3812216 423442 334144 678783 401066 46062970 49505512 2725925 3654028 31347152 32460629 1251607 1142426 35324684 37257083 X 10595049 12105213 143237 143216 10738286 12248429 46062970 49505512 1510143 0 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 44268 44268 0 PART II-B, LINE 1: LOBBYING EXPENSES THROUGH DUES PAID TO KHA (KANSAS HOSPITAL ASSOCIATION) AND AHA (AMERICAN HOSPITAL ASSOCIATION). X 1 3.00 1 0 979525 979525 18883189 12583311 6299878 28743416 9591043 19152373 2448135 967209 1480926 27912702 DUE TO AFFILIATE 446079 DEFERRED COMPENSATION 696347 1142426 X 42315805 36895 36895 42278910 0 42278910 40805662 36895 36895 40768767 0 40768767 PART X, LINE 2: THE HOSPITAL AND FOUNDATION ARE NOT-FOR-PROFIT CORPORATIONS AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE AND ARE EXEMPT FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE CODE. THE HOSPITAL AND FOUNDATION EACH FILE A FORM 990 (RETURN OF ORGANIZATION EXEMPT FROM INCOME TAX) ANNUALLY. WHEN THIS RETURN IS FILED, IT IS HIGHLY CERTAIN THAT SOME POSITIONS TAKEN WOULD BE SUSTAINED UPON EXAMINATION BY THE TAXING AUTHORITIES, WHILE OTHERS ARE SUBJECT TO UNCERTAINTY ABOUT THE MERITS OF THE TAX POSITION TAKEN OR THE AMOUNT OF THE POSITION THAT WOULD ULTIMATELY BE SUSTAINED. EXAMPLES OF TAX POSITIONS COMMON TO HOSPITALS AND FOUNDATIONS INCLUDE SUCH MATTERS AS THE FOLLOWING: THE TAX EXEMPT STATUS OF THE ENTITY, THE CONTINUED TAX EXEMPT STATUS OF BONDS ISSUED BY THE OBLIGATED GROUP, THE NATURE, THE CHARACTERIZATION AND TAXABILITY OF JOINT VENTURE INCOME AND VARIOUS POSITIONS RELATIVE TO POTENTIAL SOURCES OF UNRELATED BUSINESS INCOME (UBI). UBI IS REPORTED ON FORM 990T, AS APPROPRIATE. THE BENEFIT OF A TAX POSITION IS RECOGNIZED IN THE FINANCIAL STATEMENTS IN THE PERIOD DURING WHICH, BASED ON ALL AVAILABLE EVIDENCE, MANAGEMENT BELIEVES THAT IT IS MORE LIKELY THAN NOT THAT THE POSITION WILL BE SUSTAINED UPON EXAMINATION, INCLUDING THE RESOLUTION OF APPEALS OR LITIGATION PROCESSES, IF ANY. TAX POSITIONS ARE NOT OFFSET OR AGGREGATED WITH OTHER POSITIONS. TAX POSITIONS THAT MEET THE "MORE LIKELY THAN NOT" RECOGNITION THRESHOLD ARE MEASURED AS THE LARGEST AMOUNT OF TAX BENEFIT THAT IS MORE THAN 50% LIKELY TO BE REALIZED ON SETTLEMENT WITH THE APPLICABLE TAXING AUTHORITY. THE PORTION OF THE BENEFITS ASSOCIATED WITH TAX POSITIONS TAKEN THAT EXCEEDS THE AMOUNT MEASURED AS DESCRIBED ABOVE IS REFLECTED AS A LIABILITY FOR UNCERTAIN TAX BENEFITS IN THE ACCOMPANYING CONSOLIDATED BALANCE SHEET ALONG WITH ANY ASSOCIATED INTEREST AND PENALTIES THAT WOULD BE PAYABLE TO THE TAXING AUTHORITIES UPON EXAMINATION. AS OF SEPTEMBER 30, 2015 AND 2014, THERE WERE NO UNCERTAIN TAX BENEFITS IDENTIFIED AND RECORDED AS A LIABILITY. FORMS 990 AND 990T FILED BY THE HOSPITAL AND FOUNDATION ARE GENERALLY SUBJECT TO EXAMINATION BY THE INTERNAL REVENUE SERVICE (IRS) UP TO THREE YEARS FROM THE EXTENDED DUE DATE OF EACH RETURN. PART XI, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES 33,709. LOSS FROM DISPOSAL OF EQUIPMENT 3,186. PART XII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES 33,709. LOSS FROM DISPOSAL OF EQUIPMENT 3,186. FORM 990, SCHEDULE D, PART II, LINE 9 CONSERVATION EASEMENTS ARE REPORTED AT HISTORICAL COSTS AND INCLUDED IN OUR FIXED ASSET LISTING AS LAND. 1 1 1 X 1 X 1 1 1 0 1 1 237673 237673 0.00650 4356659 3148470 1208189 0.03300 4594332 3148470 1445862 0.03950 148222 148222 0.00410 1541416 1541416 0.04220 1689638 1689638 0.04630 6283970 3148470 3135500 0.08580 1 1541416 14679146 12678055 2001091 X 1 1 1 1 ATCHISON HOSPITAL ASSOCIATION 800 RAVEN HILL DRIVE ATCHISON KS 66002 X X X X ATCHISON HOSPITAL ASSOCIATION 1 0 0 1 X X X X X X X X X 13 1 0 0 1 X WWW.ATCHISONHOSPITAL.ORG X 1 13 1 WWW.ATCHISONHOSPITAL.ORG 0 0 1 X 200.000000000000 200.000000000000 X X X X 1 1 X X X 1 X WWW.ATCHISONHOSPITAL.ORG X WWW.ATCHISONHOSPITAL.ORG X X X X 1 X X 0 X X X X 1 X X 0 0 ATCHISON HOSPITAL ASSOCIATION PART V, SECTION B, LINE 11: AN ORGANIZATION THAT HAS FORMED A 501 (C) 3 CALLED LIVE WELL LIVE ATCHISON WHICH IS MADE UP OF THE CITY MANAGER, A COUNTY COMMISSIONER, THE LOCAL HEALTH DEPARTMENT, A REPRESENTATIVE FROM BENEDICTINE COLLEGE (LOCAL COLLEGE) BOTH SCHOOL DISTRICTS IN THE COUNTY, MGP (LOCAL BUSINESS), A COUNSELING AND PSYCHIATRIC CENTER, AND VARIOUS LOCAL COMMUNITY MEMBERS HAS COME TOGETHER TO IMPROVE THE HEALTH OF OUR COMMUNITY. AFTER THE TOWN HALL MEETING TO DETERMINE THE NEEDS OF THE COMMUNITY THE EXECUTIVE DIRECTOR OF LIVE WELL LIVE ATCHISON, THE MARKETING DIRECTOR OF ATCHISON HOSPITAL AND IT'S CFO MEET TO DETERMINE HOW THE GOALS WILL BE MET AND A STRATEGY IS MAPPED OUT TO ACHIEVE THE NEEDS. PART V, SECTION B, LINE 5: A SURVEY WAS MAILED OUT TO A REPRESENTATIVE SAMPLE OF THE COMMUNITY AND A COMMUNITY TOWN HALL WAS ADVERTISED IN THE LOCAL PAPER AND LOCAL RADIO STATION FOR THE COMMUNITY TO ATTEND. THE SURVEY RESULTS WERE DISCUSSED AT THE TOWN HALL MEETING. PART V, SECTION B, LINE 16 FINANCIAL ASSISTANCE POLICY WEBSITE AVAILABILITY ATCHISON HOSPITAL ASSOCIATION PART V, SECTION B, LINE 16A WEBSITE: WWW.ATCHISONHOSPITAL.ORG ATCHISON HOSPITAL ASSOCIATION PART V, SECTION B, LINE 16C WEBSITE: WWW.ATCHISONHOSPITAL.ORG 1 FAMILY MEDICAL CENTER OF TROY 311 W LOCUST TROY KS 66087 RURAL HEALTH CLINIC PART I, LINE 3C: NOT APPLICABLE PART I, LINE 7: THE COSTING METHODOLOGY USED TO CALCULATE THE AMOUNTS CONTAINED IN THE TABLE OF PART I, LINE 7, OR SCHEDULE H, IS A COST TO CHARGE RATIO CALCULATED USING WORKSHEET 2. PART I, LINE 7G: NO COSTS ASSOCIATED WITH A PHYSICIAN CLINIC WERE REPORTED IN SUBSIDIZED HEALTH SERVICES. 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 $ 4,210,369. PART III, LINE 4: ACCOUNTS RECEIVABLE ARE REDUCED BY AN ALLOWANCE FOR DOUBTFUL ACCOUNTS. IN EVALUATING THE COLLECTIBILITY OF ACCOUNTS RECEIVABLE, THE ORGANIZATION 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 ORGANIZATION ANALYZES CONTRACTUALLY DUE AMOUNTS AND PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS AND A PROVISION FOR BAD DEBTS IF NECESSARY. FOR RECEIVABLES ASSOCIATED WITH SELF PAY PATIENTS, THE ORGANIZATION 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 AND THE AMOUNTS ACTUALLY COLLECTED AFTER ALL REASONABLE COLLECTION EFFORTS HAVE BEEN EXHAUSTED IS CHARGED OFF AGAINST THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. THE COSTING METHOD FOR DETERMINING THE AMOUNT ON LINE 2 IS THE ACTUAL BAD DEBT EXPENSE MULTIPLIED BY THE COST TO CHARGE RATIO FOR THE OVERALL HOSPITAL. THE MAJORITY OF THE BAD DEBT COMES FROM PATIENTS WHO HAVE VISITED THE EMERGENCY DEPARTMENT AND HAVE BEEN TREATED REGARDLESS OF THEIR ABILITY TO PAY BASED ON EMTALA GUIDELINES. PART III, LINE 8: ANY MEDICARE SHORTFALL SHOULD NOT BE TREATED AS A COMMUNITY BENEFIT COST. THE COSTING METHODOLOGY CONSISTED OF INFORMATION FOR THE HOSPITAL'S ACCOUNTING SYSTEM AS WELL AS COSTS FROM THE MEDICARE COST REPORT. PART III, LINE 9B: THE HOSPITAL DOES NOT PURSUE COLLECTION ON ACCOUNTS THAT IT HAS BEEN DETERMINED THE PATIENT IS ELIGIBLE FOR CHARITY CARE. PART VI, LINE 2: ATCHISON HOSPITAL ASSOCIATION HAS ACCESS TO THE KANSAS HEALTH INITIATIVE SURVEY ON HEALTH INDICATORS. BASED ON THESE INDICATORS, ATCHISON HOSPITAL DETERMINES THE NEEDS OF THE COMMUNITY AND WHAT PROGRAMS TO IMPLEMENT. PART VI, LINE 3: PATIENTS ARE GIVEN A PAMPHLET DESCRIBING THE POLICY FOR FINANCIAL ASSISTANCE WHEN THEY ARE ADMITTED. THE ADMITTING OFFICE ASKS THEM TO SPEAK WITH THE HOSPITAL FINANCIAL COUNSELOR IF THEY DO NOT HAVE INSURANCE. AFTER THE PATIENT RECEIVES THEIR STATEMENT IN THE MAIL, THEY CAN CALL IN AND TALK WITH THE FINANCIAL COUNSELOR. IF THE ACCOUNT GOES TO A COLLECTION COMPANY BECAUSE THE PATIENT DID NOT PAY OR TALK WITH THE FINANCIAL COUNSELOR, THE COLLECTION COMPANY WILL GIVE THEM THE PROPER APPLICATION TO FILL OUT TO SEE IF THEY ARE ELIGIBLE FOR FINANCIAL ASSISTANCE. PART VI, LINE 4: THE HOSPITAL SERVES THE COMMUNITY OF ATCHISON, KS AND THE SURROUNDING COUNTY OF ATCHISON, KS. ATCHISON IS A COMMUNITY OF APPROXIMATELY 10,500 PEOPLE WHO WOULD BE DESCRIBED AS MOSTLY COMPRISED OF BLUE COLLAR AND LOW INCOME INDIVIDUALS. THE SURROUNDING COUNTY HAS A POPULATION OF AN ADDITIONAL 6,300 PEOPLE. THERE ARE SEVERAL LARGE FARMS WHICH PLANT ROW CROPS OF CORN AND BEANS. PART VI, LINE 5: ATCHISON HOSPITAL BELIVES COMMUNITY BENEFIT GOES BEYOND HOSPITAL VISITS AND EMERGENCY CARE. IT MEANS GETTING INVOLVED AND WORKING TO IMPROVE THE HEALTH OF OUR COMMUNITY; IT MEANS HELPING OTHERS PURSUE GOOD HEALTH THROUGH DONATIONS, EDUCATION AND VOLUNTEERISM. THE FOLLOWING IS A SUMMARY OF THE NUMEROUS ACTIVITIES, INITIATIVES AND EVENTS THAT HAVE BEEN IMPLEMENTED IN SUPPORT OF PROVIDING COMMUNITY BENEFITS TO THE RESIDENTS IN THE ATCHISON COMMUNITY AND REGION. LIVE WELL LIVE ATCHISON, IS A HOSPITAL INITIATIVE THAT INVOLVES PARTNERSHIPS WITH THE KANSAS HEALTH INITIATIVE, ATCHISON COUNTY SCHOOLS, BENEDICTINE COLLEGE, CITY AND COUNTY GOVERNMENT, STATE REPRESENTATIVES, FAITH-BASED CHURCHES, THE HEALTH DEPARTMENT, COUNTY EXTENSION OFFICE AND AREA BUSINESSES, HEALTH AND SERVICE AGENCIES, AS WELL AS COMMUNITY AND CIVIC ORGANIZATIONS. THE GROUP IS WORKING TOWARD IMPROVING HEALTH BEHAVIORS AND LIFESTYLE OF ATCHISON COUNTY. ATCHISON HOSPITAL'S "BEST CARE COMMUNITY HEALTH FAIR," IS AN ANNUAL EVENT HOSTED BY THE HOSPITAL AND HELD AT THE ATCHISON ELEMENTARY SCHOOL. HOSPITAL EMPLOYEES AS WELL AS COMMUNITY HEALTH AGENCIES, ORGANIZATIONS, LOCAL AND REGIONAL AREA RESPONDERS AND PHYSICIAN PRACTICES, PROVIDE HEALTH SCREENINGS, INTERACTIVE EDUCATIONAL AND FITNESS ACTIVITIES. ATCHISON HOSPITAL SUPPORTS THE COMMUNITY HEALTH CLINIC, A FREE HEALTH CLINIC, BY SUBSIDIZING THE CLINIC'S FACULTY, SUPPLIES AND DIAGNOSTIC TESTING. ADDITIONALLY, HOSPITAL PHYSICIANS, CLINICAL STAFF AND EMPLOYEES VOLUNTEER THEIR TIME AT THE CLINIC. THE HOSPITAL CONDUCTS AND SPONSORS SUPPORT GROUPS AND CLASSES THAT PROVIDE ONGOING EDUCATION AND COUNSELING SUCH AS GRIEF SUPPORT, BIRTHING AND CHILDCARE CLASSES. ADDITIONALLY, THE HOSPITAL OFFERS A HOSPICE VOLUNTEERS PROGRAM. THE HOSPITAL ALSO PROVIDES SPONSORSHIP AND DONATIONS TO VARIOUS ORGANIZATIONS AND LOCAL SCHOOLS, AS WELL AS COMMUNITY INITIATIVES. THEY INCLUDE: RELAY FOR LIFE, AMELIA EARHEART FESTIVAL, BEAUTIFICATION OF OUR CITY, FARM SAFETY DAY, AFTER PROM SPONSORSHIPS FOR ALL COMMUNITY AND REGIONAL SCHOOLS, JOGGIN FOR THE NOGGIN, PARTICIPATION IN LOCAL AND REGIONAL HEALTH FAIRS AND PHYSICIAN SUPPORT AT LOCAL HIGH SCHOOL AND COLLEGE ATHLETIC EVENTS. ATCHISON HOSPITAL'S CARE TEAM, AN EMPLOYEE GROUP AND GENERATES EMPLOYEE AND COMMUNITY INVOLVEMENT IN ACTIVITIES SUCH AS AN ANNUAL FOOD DRIVE, ADOPT A FAMILY. THE HOSPITAL AS WELL AS THE HOSPITAL AUXILIARY, EACH HOSTS COMMUNITY BLOOD DRIVES THROUGHOUT THE YEAR. THE HOSPITAL SPONSORS A LOCAL RADIO SHOW, "THE BEST CARE ON THE AIR." IT IS A FIFTEEN MINUTE RADIO PROGRAM THAT IS AIRED TWICE A WEEK AND TACKLES SEVERAL PERTINENT HEALTH RELATED TOPICS. THE HOSPITAL PROVIDES COMMUNITY EDUCATION AND CAREER DEVELOPMENT TO ORGANIZATIONS, SCHOOLS AND COLLEGES THROUGHOUT THE AREA THROUGH SPEAKING ENGAGEMENTS, CAREER FAIRS, CLASS IN-SERVICES AND HOSPITAL TOURS. IN ADDITION, HOSPITAL EMPLOYEES VOLUNTEER THEIR SERVICE WITH COMMUNITY NOT-FOR-PROFIT AND CIVIC ORGANIZATIONS AND COMMITTEES, INCLUDING THE CHAMBER OF COMMERCE, WORKFORCE DEVELOPMENT, ROTARY, LIONS CLUB, YMCA, ALL FAITH COUNSELING CENTER AND THE BOY SCOUTS. THE HOSPITAL OFFERS A JOB SHADOWING PROGRAM AND PARTNERS WITH THE BOY SCOUTS OF AMERICA "VENTURING PROGRAM," PROVIDING INTERNSHIPS AND TEEN VOLUNTEER PROGRAMS. THE HOSPITAL HOSTED A PICNIC IN PINK PROGRAM FOR LOCAL BUSINESSES WHICH RAISED AWARENESS AND EDUCATION OF THE IMPORTANCE OF EARLY DETECTION IN THE FIGHT AGAINST BREAST CANCER. THE HOSPITAL RECEIVED A GRANT FOR "GIVE THEM A BOOST, YOU CAN SAVE A LIFE" EVENT WHICH INCLUDED A CHILD SAFETY BOOSTER SEAT PROGRAM AND A BOOSTER SEAT GIVE-AWAY, WHERE NEW BOOSTER SEATS WERE GIVEN AWAY FREE OF CHARGE TO THOSE WHO NEEDED THEM. X 1 1 X X X X 0 0 0 0 0 0 0 1 0 JOHN L JACOBSON CEO 174665 0 0 0 29654 0 3220 0 15290 0 222829 0 0 0 GARY R FOLL CFO 122547 0 5000 0 12922 0 4242 0 25312 0 170023 0 0 0 BENJAMIN STONE PHYSICIAN 216260 0 0 0 76565 0 8792 0 31112 0 332729 0 0 0 STEPHEN MEIROSE PHYSICIAN 224411 0 0 0 39040 0 8109 0 26113 0 297673 0 0 0 MIKE JONES PHYSICIAN 137810 0 39453 0 69019 0 5913 0 8191 0 260386 0 0 0 EVERETT WILKINSON PHYSICIAN 515349 0 0 0 152560 0 12333 0 26713 0 706955 0 0 0 MCGARRETT GROTH PHYSICIAN 169456 0 46882 0 80560 0 4014 0 26713 0 327625 0 0 0 PART I, LINE 1A SOCIAL CLUB DUES WERE PAID BY THE HOSPITAL FOR JOHN L. JACOBSON AND WERE NOT INCLUDED IN HIS W-2 AS TAXABLE COMPENSATION BECAUSE THEY WERE USED 100% FOR BUSINESS. PART I, LINE 7 VARIOUS EMPLOYED PHYSICIANS ARE PROVIDED THE OPPORTUNITY FOR BONUS POTENTIAL, IN THEIR CONTRACT WITH THE HOSPITAL ARE TIERS BASED ON CURRENT MEDICAL GROUP MANAGEMENT ASSOCIATION REGIONAL DATA. IF THE PHYSICIANS ANNUALIZED NET QUALIFIED PATIENT CHARGES EXCEEDS THE TIER, A PERCENTAGE OF THEIR NET QUALIFIED PATIENT CHARGES ARE ELIGIBLE FOR BONUS SUBJECT TO THEIR ANNUAL BASE COMPENSATION. A CITY OF ATCHISON 486025033 046687AW9 2008-09-23 10000000 REPLACEMENT OF FACILITIES 0 0 0 B CITY OF ATCHISON 486025033 046687AW9 2008-09-23 7500000 REDEMPTION OF SERIES 2007 BOND 0 0 0 C CITY OF ATCHISON 486025033 046687CA5 2009-06-30 17620000 REPLACEMENT OF FACILITIES 0 0 0 A 10000000 206983 9793017 2008 0 0 1 1 B 7500000 156373 7343627 2008 1 0 1 1 C 17620000 396323 17223677 2009 0 0 1 1 A 0 0 0 0 0 0 0 B 0 0 0 0 0 0 0 C 0 0 0 0 0 0 0 A 0 0 0 1 0 0 0 0 0 B 0 0 0 1 0 0 0 0 0 C 0 0 0 1 0 0 0 0 0 A 1 B 1 C 1 DATE REBATE COMPUTATION PERFORMED ISSUER NAME: CITY OF ATCHISON DATE THE REBATE COMPUTATION WAS PERFORMED: 09/01/2012 ISSUER NAME: CITY OF ATCHISON DATE THE REBATE COMPUTATION WAS PERFORMED: 09/01/2012 ISSUER NAME: CITY OF ATCHISON DATE THE REBATE COMPUTATION WAS PERFORMED: 06/01/2013 FORM 990, PART VI, SECTION B, LINE 11 AN INDEPENDENT ACCOUNTING FIRM PREPARES AND REVIEWS THE 990. THE 990 IS THEN REVIEWED BY THE ORGANIZATION'S MANAGEMENT. ANY QUESTIONS OR CONCERNS THE ORGANIZATION'S MANAGEMENT HAVE ARE ADDRESSED AND ANY CORRECTIONS OR CLARIFICATIONS ARE MADE. THE 990 IS THEN REVIEWED BY THE HOSPITAL FINANCE COMMITTEE. ANY QUESTIONS OR CONCERNS THE FINANCE COMMITTEE HAVE ARE ADDRESSED AND ANY CORRECTIONS OR CLARIFICATIONS ARE MADE. THE 990 IS THEN REVIEWED BY THE BOARD OF DIRECTORS, ANY CORRECTIONS OR CONCERNS THE BOARD HAVE ARE ADDRESSED PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C AT THE TIME OF ELECTION OR HIRE AND ANNUALLY THEREAFTER, THE GOVERNING BOARD MEMBERS, OFFICERS, AND KEY EMPLOYEES SHALL PROVIDE THE APPLICABLE CONFLICT OF INTEREST DISCLOSURES WHICH SHALL BE COMPLETED TO IDENTIFY ANY RELATIONSHIPS, POSITIONS, OR CIRCUMSTANCES IN WHICH IT IS BELIEVED A CONFLICT MAY ARISE. IF A CONFLICT ARISES, THE BOARD MEMBER ABSTAINS FROM THE VOTE OF THE CONFLICTED POSITION. FORM 990, PART VI, SECTION B, LINE 15 IN 2011, THE ORGANIZATION ENGAGED ITS LEGAL COUNSEL TO PREPARE A COMPENSATION DATA STUDY. IN ADDITION TO VARIOUS DATA COLLECTED, OTHER HOSPITALS' 990'S WERE REVIEWED AND COMBINED IN THE COMPENSATION STUDY. THE HOSPITAL'S LEGAL COUNSEL REVIEWED THE STUDY WITH THE BOARD OF DIRECTORS TO ADJUST THE CEO'S COMPENSATION. ANY DECISION THAT IS MADE IN REGARDS TO THE CEO'S COMPENSATION IS DOCUMENTED BY THE BOARD OF DIRECTORS. THE CEO AND HUMAN RESOURCE DIRECTOR CONDUCT AN ANNUAL REVIEW OF OTHER OFFICERS AND KEY EMPLOYEES' COMPENSATION BASED ON COMPARABLE DATA OF OTHER ORGANIZATIONS OF SIMILAR SIZE AND INDUSTRY. PHYSICIAN COMPENSATION IS DETERMINED BASED ON CONTRACT AND IS COMPARED TO RECENT MEDICAL GROUP MANAGEMENT ASSOCIATION INFORMATION BY REGION TO DETERMINE FAIR MARKET COMPENSATION. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE NOT MADE AVAILABLE TO THE PUBLIC. FORM 990, PART XII, LINE 2C AN INDEPENDENT ACCOUNTING FIRM AUDITS THE ORGANIZATION'S FINANCIAL STATEMENTS. THE ORGANIZATION HAS A COMMITEE THAT ASSUMES RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT OF ITS FINANCIAL STATEMENTS AND SELECTION OF AN INDEPENDENT ACCOUNTANT. THIS PROCESS HAS NOT CHANGED DURING THE TAX YEAR. RIVERBEND REGIONAL HEALTHCARE FOUNDATION 800 RAVEN HILL DRIVE ATCHISON KS 66002 480955489 SUPPORT KS 501(C)(3) LINE 11B, II ATCHISON HOSPITAL ASSOCIATION 1 0 0 1 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0 RIVERBEND REGIONAL HEALTHCARE FOUNDATION C 510000 FMV