2016-05-16T10:52:23-05:00 2015-06-30 410746749 CLIFTONLARSONALLEN LLP 220 SOUTH SIXTH STREET SUITE 300 MINNEAPOLIS MN 55402 990 2014-07-01 810233499 SIDNEY HEALTH CENTER SIDN 4064882100 216 14TH AVENUE SW SIDNEY MT 59270 RICHARD HARALDSON CEO 4064882100 2016-05-13 1 KURT BENNION P01469618 6123764500 2014 2016-08-17 19:52:53Z RICHARD HARALDSON 216 14TH AVENUE SW SIDNEY MT 59270 61804992 0 X WWW.SIDNEYHEALTH.ORG X 1946 MT TO HELP THOSE WE SERVE ACHIEVE THEIR HIGHEST LEVEL OF HEALTH BY PROVIDING QUALITY MEDICAL CARE. 8 8 605 150 5650432 0 280844 302664 50709258 54170348 849518 885455 2150213 3637822 53989833 58996289 1307 100 0 0 23683993 23786401 0 0 277863 31037451 34192602 54722751 57979103 -732918 1017186 65918520 66633712 33509373 33337312 32409147 33296400 X TO HELP THOSE WE SERVE ACHIEVE THEIR HIGHEST LEVEL OF HEALTH AND WELL-BEING. 1 0 52363761 100 54170348 SIDNEY HEALTH CENTER IS A NOT-FOR-PROFIT COMMUNITY BASED MEDICAL CENTER THAT HAS BEEN SERVING PEOPLE IN THE MONDAK REGION FOR MORE THAN 100 YEARS. OUR PASSION FOR CARING IS SHARED BY THE DOCTORS, NURSES, AND SEVERAL HUNDRED EMPLOYEES AND VOLUNTEERS. THIS COMMITMENT TO CARING IS OUR ALLEGIANCE TO THE COMMUNITY AS WE STRIVE TO PROVIDE "EXCEPTIONAL CARE FOR LIFE."LOCATED IN THE HEART OF RICHLAND COUNTY, THE ATTRACTIVE EASTERN MONTANA CAMPUS INCLUDES AN ACUTE CARE HOSPITAL, CLINIC AREA, RETAIL PHARMACY AND A 93-BED EXTENDED CARE FACILITY OFFERING A COMPLETE RANGE OF SERVICES FROM BIRTH THROUGH END-OF-LIFE, WHICH IS COMPLEMENTED BY AN ARRAY OF OUTREACH SERVICES. THIS CONTINUUM OR SUCCESSION OF SERVICES IS NOT TYPICAL OF RURAL HEALTHCARE ORGANIZATIONS, BUT SIDNEY HEALTH CENTER IS NOT TYPICAL. A STRONG COMPLEMENT OF PRIMARY CARE PHYSICIANS AND A UNIQUE SELECTION OF SURGICAL SPECIALISTS COMBINED WITH A MODERN FACILITY, AND UP-TO-DATE MEDICAL EQUIPMENT, MAKES SIDNEY HEALTH CENTER A SPECIAL PLACE TO WORK, RECEIVE CARE AND PRACTICE MEDICINE. SIDNEY HEALTH CENTER ALSO PROVIDES VARIOUS COMMUNITY BENEFIT PROGRAMS FOR THE INDIVIDUALS IN THEIR SERVICE REGION.RICHLAND COUNTY TRANSPORTATION - THIS PROGRAM GIVES OPPORTUNITIES FOR THOSE WHO CANNOT DRIVE THE OPTION OF A RIDE. SIDNEY HEALTH CENTER PROVIDES A DRIVER AND HELPS PAY FOR BUSSES. SINCE IT'S CONCEPTION WE HAVE GONE FROM ONE BUS AND ONE DRIVER FOR THE FULL PROGRAM TO 5 BUSSES AND 8 DRIVERS. WE WORK WITH THE HEALTH DEPARTMENT, RICHLAND COUNTY AND THE LODGE.MILES CITY NURSING PROGRAM - WE PROVIDE THE FACILITY AND PROGRAM COSTS TO HAVE MILES CITY COMMUNITY COLLEGE RUN A SATELLITE SCHOOL HERE IN SIDNEY. THIS PROMOTES NURSING AS A PROFESSION AND KEEPS THOSE WHO ARE INTERESTED IN OUR COMMUNITY AS POSSIBLE EMPLOYEES LATER.OUTREACH CLINIC - SOME OF THE OUTLYING COMMUNITIES DO NOT HAVE ACCESS TO AN ENT PHYSICIAN. SIDNEY HEALTH CENTER PROVIDES THE TRAVEL FOR OUR ENT TO GO TO THOSE OUTREACH AREAS.HEALTH FAIR - WORKING WITH RICHLAND COUNTY HEALTH DEPARTMENT, COALITION ON AGING, FIRE, POLICE AND MENTAL HEALTH PROFESSIONS, JUST TO NAME A FEW, SIDNEY HEALTH CENTER HOLDS A HEALTH FAIR WHERE PEOPLE CAN COME AND LEARN ABOUT DIFFERENT HEALTHCARE NEEDS OF OUR COMMUNITY. SIDNEY HEALTH CENTER PROMOTES PREVENTATIVE CARE, DIABETES EDUCATION, LAB SCREENINGS AND MANY OTHER TOPICS.LIVE-IT-UP - THIS IS A PROGRAM THAT SIDNEY HEALTH CENTER DOES TO MAKE WOMEN OF RICHLAND COUNTY AWARE OF HOW HEART DISEASE AFFECTS THEM. RICHLAND COUNTY FAIR & RODEO - SIDNEY HEALTH CENTER PROVIDES A BOOTH WHERE PEOPLE CAN GET THEIR BLOOD PRESSURE TAKEN, DO A FINGER STICK BLOOD TEST FOR DIABETS AND GET A BOTTLE OF WATER FOR FREE IN THE EXTREME HOT AUGUST DAYS OF THE FAIR.GRIEF RECOVERY SUPPORT GROUPS - SIDNEY HEALTH CENTER'S HOSPICE PROGRAMS PUT ON TWO DIFFERENT CAMPS FOR PEOPLE WHO HAVE LOST LOVED ONES. ONE IS FOR ADULTS, THE OTHER FOR KIDS. THERE ARE ALSO MEMORIAL SERVICES AND NUMEROUS GRIEF SUPPORT GROUPS THROUGHOUT THE YEAR.BIRTHDAY HEALTH FAIR - PATIENTS WHO SIGN UP CAN GET LABS DURING THEIR BIRTHDAY MONTH.VISITING NURSE SERVICE - INITIAL NURSE VISIT.MEDICATION ASSISTANCE - PROVIDES MEDS TO THOSE WHO HAVE NO INSURANCE. ALSO HELPS GET PATIENTS SIGNED UP WITH DRUG COMPANIES FOR FREE MEDICATIONSRX BOXES - PHARMACY SETS UP PILLS IN MEDICATION BOXES SO THAT GROUP HOME RESIDENTS GET THE CORRECT PILLS FOR EACH ADMINISTRATION TIME.SCHOOL AGE BASED EDUCATION ACTIVITIES - CENTRAL SCHOOL BLOOD TYPING. INTERACTIVE TOUR FOR 2ND GRADERS.AARP DRIVING - DRIVING COURSE FOR THOSE OVER 55 THROUGH AARP.CHAMBER OF COMMERCE - VARIOUS DONATIONS FOR COMMUNITY AND CHAMBER FUNCTIONS.CHILDBIRTH CLASSES - CLASSES OFFERED TO THE COMMUNITY. 52363761 1 0 0 1 0 0 0 0 1 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 1 0 0 0 0 0 0 1 1 1 0 0 1 72 0 605 1 1 1 0 0 0 0 0 0 0 0 0 X 8 8 0 0 0 0 1 1 1 1 1 0 0 0 1 1 1 1 1 1 1 0 X TINA MONTGOMERY CFO 4064882117 216 14TH AVE SW SIDNEY MT 59270 RANDY JOHNSON PRESIDENT 1.00 1.00 X X 0 0 0 GALE FRANK VICE PRESIDENT (THROUGH 8/14) 1.00 1.00 X X 0 0 0 BRIAN MCGINNIS VICE PRESIDENT 1.00 1.00 X X 0 0 0 NICOLE BEYER SECRETARY/TREASURER (THROUGH 11/14) 1.00 1.00 X X 0 0 0 MARK MARTIN SECRETARY/TREASURER 1.00 1.00 X X 0 0 0 ROBERT BURNISON TRUSTEE 1.00 1.00 X 0 0 0 SANDY CHRISTENSEN TRUSTEE 1.00 1.00 X 0 0 0 SANDRA JEPSEN TRUSTEE 1.00 1.00 X 0 0 0 DICK VANDE BOSSCHE TRUSTEE 1.00 1.00 X 0 0 0 CINDY WAGNER TRUSTEE 1.00 1.00 X 0 0 0 RICHARD HARALDSON CEO 39.00 1.00 X 225439 0 9155 TINA MONTGOMERY CFO 39.00 1.00 X 136659 0 10740 SHARI TWIGG MD PHYSICIAN 40.00 X 365543 0 9104 ANDREA BARRETT MD PHYSICIAN 40.00 X 701799 0 13680 BRADLEY STRUPP CRNA 40.00 X 332475 0 10804 BARBARA LUNDEMO CRNA 40.00 X 268398 0 8155 GEORGE SCORDALAKES MD PHYSICIAN 40.00 X 400005 0 8261 2430318 0 69899 30 0 1 0 BRETT BENNION MD 214 14TH AVE SW SIDNEY MT 59270 PHYSICIAN SERVICES 1084354 EDWARD P BERGIN MD PO BOX 1529 SIDNEY MT 59270 PHYSICIAN SERVICES 631000 JAMES SCOTT MD 3560 MASTERSON CIRCLE BILLINGS MT 59106 PHYSICIAN SERVICES 361149 ORIN P COUNCIL MD 12775 CTY RD 352 SIDNEY MT 59270 PHYSICIAN SERVICES 356900 EDWARD PIERCE MD 214 14TH AVE SW SIDNEY MT 59270 PHYSICIAN SERVICES 272823 12 302664 302664 PATIENT REVENUES 621500 47433485 47433485 CLINIC PHARMACY 446110 5650432 5650432 OTHER PATIENT CARE 621500 1086431 1086431 54170348 519065 519065 8500 0 8500 8500 8500 2979407 16700 2629717 0 349690 16700 366390 366390 370657 178986 191671 191671 OTHER PHARMACY REVENUE 900099 1674622 1674622 MISCELLANEOUS REVENUE 900099 1340290 1340290 MEAL INCOME 900099 335292 335292 87447 87447 3437651 58996289 48519916 5650432 4523277 X 100 100 345909 130939 187171 27799 19222296 17449205 1624143 148948 414158 366873 42222 5063 2450107 2207660 221990 20457 1353931 1216322 123987 13622 190 190 25607 25607 96264 95639 625 96127 96127 8491396 8357723 123357 10316 169562 3639 150808 15115 2755722 1893553 836657 25512 606087 606087 1153083 1142720 4854 5509 323480 336194 -15260 2546 1293882 1293882 4036623 4036623 595459 595459 PHARMACY/LAB EXPENSE 8153374 8148503 4871 BAD DEBT 4825547 4825547 GOOD CENTS STORE 347204 84778 262426 RECRUITING 338754 334449 3179 1126 884241 627197 255819 1225 57979103 52363761 5337479 277863 2096493 3305692 14478314 17454565 63833 61158 1836592 1519520 794870 909359 66376288 40269088 27805983 26107200 13164201 11200479 1734143 2499791 512201 642222 418971 398469 3012919 2535257 65918520 66633712 4054051 4577981 23573706 22391936 10245 13112 186994 2454889 3092735 3229488 3261548 33509373 33337312 X 31896946 32654178 512201 642222 32409147 33296400 65918520 66633712 X 1017186 -535629 405696 X 0 1 X 1 0 X 0 0 0 0 0 0 0 0 1 4624 4624 0 PART II-B, LINE 1: A PORTION OF THE MEMBERSHIP DUES PAID TO THE MONTANA HOSPITAL ASSOCIATION AND THE AMERICAN HOSPITAL ASSOCIATION ARE USED FOR LOBBYING. 0 1 X 198261 198261 42286305 23785714 18500591 23882102 16483374 7398728 9620 9620 26107200 THIRD PARTY PAYABLE 1017596 SWAP CONTRACT LIABILITY 2243952 3261548 X 53161609 178986 178986 52982623 96127 5917539 6013666 58996289 53236415 178986 178986 53057429 96127 4825547 4921674 57979103 PART IV, LINE 2B: RESIDENT TRUST ACCOUNT: THIS IS THE EXTENDED CARE RESIDENT TRUST ACCOUNT WHICH IS MADE UP OF THE RESIDENTS' MONEY THAT SIDNEY HEALTH CENTER HOLDS ON THEIR BEHALF. THESE MONIES ARE KEPT IN A SEPARATE BANK ACCOUNT FROM THE ORGANIZATION'S FUNDS AND ARE DUE BACK TO THE RESIDENTS UPON LEAVING THE FACILITY. PART X, LINE 2: THE INTERNAL REVENUE SERVICE (IRS) HAS DETERMINED THAT THE HEALTH CENTER IS A TAX-EXEMPT, NOT-FOR-PROFIT CORPORATION UNDER SECTION 501(C)(3) OF THE IRC. THE HEALTH CENTER 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 HEALTH CENTER'S FINANCIAL STATEMENTS. THE HEALTH CENTER'S INCOME TAX RETURNS ARE SUBJECT TO REVIEW AND EXAMINATION BY FEDERAL, STATE, AND LOCAL AUTHORITIES. PART XI, LINE 2D - OTHER ADJUSTMENTS: COST OF GOODS SOLD 178,986. PART XI, LINE 4B - OTHER ADJUSTMENTS: INVESTMENT INCOME 772,628. GRANTS AND CONTRIBUTIONS 302,664. GAIN ON DISPOSAL OF FIXED ASSETSE 16,700. BAD DEBT EXPENSE 4,825,547. PART XII, LINE 2D - OTHER ADJUSTMENTS: COST OF GOODS SOLD 178,986. PART XII, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT EXPENSE 4,825,547. 1 1 X 1 X 1 X 175.000000000000 1 1 0 1 1 110966 274749 -163783 0.00000 837598 639540 198058 0.00340 948564 914289 34275 0.00340 121908 121908 0.00210 17947 17947 0.00030 2477381 2064088 413293 0.00710 139855 139855 0.00240 2757091 2064088 693003 0.01190 3705655 2978377 727278 0.01530 1 4825547 0 8593295 8711144 -117849 X 1 1 1 1 SIDNEY HEALTH CENTER 216 14TH AVENUE SW SIDNEY MT 59270 WWW.SIDNEYHEALTH.ORG 12709 X X X X SIDNEY HEALTH CENTER 1 0 0 1 X X X X X X X X X 12 1 0 0 1 X SEE SCHEDULE H, PART VI, LINE 2 X 1 12 1 SEE SCHEDULE H, PART VI, LINE 2 0 0 1 X 100.000000000000 175.000000000000 X X X X X 1 1 X X 1 X WWW.SIDNEYHEALTH.ORG/BILLING X X X 1 X 0 X X X X 1 X 0 0 SIDNEY HEALTH CENTER PART V, SECTION B, LINE 5: THE COMMUNITY HEALTH NEEDS ASSESSMENT WAS OVERSEEN BY A STEERING COMMITTEE CONSISTING OF A DIVERSE GROUP OF COMMUNITY MEMBERS REPRESENTING VARIOUS ORGANIZATIONS AND POPULATIONS WITHIN THE COMMUNITY (EX. PUBLIC HEALTH, ELDERLY, UNINSURED). SURVEYS WERE SENT TO A RANDOM SAMPLE OF 724 INDIVIDUALS IN THE HOSPITAL'S COMMUNITY, 170 OF WHICH WERE RETURNED COMPLETED. THE RANDOM SELECTION PROCESS AND THE LARGE NUMBER OF RESPONSES IMPLY THAT THE SURVEY RESULTS REPRESENT THE VOICE OF THE COMMUNITY IN GENERAL. FINALLY, THREE FOCUS GROUPS WERE HELD WITH TWENTY-TWO COMMUNITY MEMBERS. SIDNEY HEALTH CENTER PART V, SECTION B, LINE 11: SIDNEY HEALTH CENTER IS NOT RESPONDING TO ALL IDENTIFIED COMMUNITY HEALTH NEEDS BECAUSE THE HOSPITAL HAS LIMITED HOSPITAL STAFF AND FINANCIAL RESOURCES, OTHER COMMUNITY RESOURCES ARE ALREADY AVAILABLE, AND SIDNEY HEALTH CENTER WANTS TO FOCUS ON HIGHER PRIORITIES THAT WE BELIEVE CAN HAVE A GREATER IMPACT ON THE LIVES OF OUR COMMUNITY MEMBERS. PART V, SECTION B, LINE 16 FINANCIAL ASSISTANCE POLICY WEBSITE AVAILABILITY SIDNEY HEALTH CENTER PART V, SECTION B, LINE 16B WEBSITE: WWW.SIDNEYHEALTH.ORG/BILLING 2 SIDNEY HEALTH CENTER EXTENDED CARE 216 14TH AVE SW SIDNEY MT 59270 NURSING HOME THE LODGE AT LONE TREE 1015 7TH AVE SW SIDNEY MT 59270 ASSISTED LIVING COMPLEX PART I, LINE 3C: ELIGIBILITY CRITERIA: 1. FINANCIAL ASSISTANCE IS SECONDARY TO ALL OTHER FINANCIAL RESOURCES AVAILABLE TO THE PATIENT. THIS INCLUDES BUT IS NOT LIMITED TO:A. GROUP OR INDIVIDUAL MEDICAL INSURANCE PLANSB. WORKERS COMPENSATION PLANSC. MEDICAID, STATE, OR COUNTY MEDICAL PROGRAMSD. OTHER STATE, FEDERAL, OR MILITARY PROGRAMSE. THIRD PARTY LIABILITY SITUATIONS (E.G., AUTO ACCIDENTS OR PERSONAL INJURY CLAIMS)F. ANY OTHER PERSONS OR ENTITIES WHO MAY HAVE A LEGAL RESPONSIBILITY TO PAY FOR THE MEDICAL SERVICESG. CRIME VICTIMS2. DETERMINATION OF ELIGIBILITY OF A PATIENT FOR ASSISTANCE SHALL BE APPLIED REGARDLESS OF THE SOURCE OF REFERRAL AND WITHOUT DISCRIMINATION AS TO RACE, COLOR, CREED, NATIONAL ORIGIN, AGE, HANDICAP STATUS, OR MARITAL STATUS.3. PATIENT CARE WHICH IS ELECTIVE (NON-EMERGENT), COSMETIC, AND/OR EXPERIMENTAL SHALL NOT BE CONSIDERED ELIGIBLE FOR ASSISTANCE. FOR EMERGENCY ROOM SERVICES, IF THE VISIT IS DEEMED NON-EMERGENT AND THE PATIENT COULD HAVE BEEN SEEN IN A PHYSICIAN'S OFFICE, THE CHARITY CARE WRITE OFF WILL BE SUBJECT TO A 50% LIMITATION.4. PATIENT SPEND DOWNS AS DETERMINED BY MEDICAID, STATE OR COUNTY MEDICAL PROGRAMS ARE NOT ELIGIBLE FOR ASSISTANCE. (THE PATIENT ACCOUNTS MANAGER CAN MAKE EXCEPTIONS ON A CASE-BY-CASE BASIS.)5. TO THE EXTENT THE HOSPITAL CHARGES RELATED TO APPROPRIATE HOSPITAL BASED MEDICAL SERVICES ARE NOT COVERED BY THIRD-PARTY COVERAGE, A 100% WRITE-OFF MAY BE PROVIDED TO PATIENTS IF THE NET AVAILABLE ASSETS ARE NO GREATER THAN TWO TIMES THE FEDERAL INCOME POVERTY GUIDELINES AS ADJUSTED FOR FAMILY SIZE AND THE FAMILY'S GROSS INCOME IS BELOW %100 OF THE FEDERAL INCOME POVERTY GUIDELINES AS ADJUSTED FOR FAMILY SIZE. 6. PARTIAL ASSISTANCE MAY BE PROVIDED TO PATIENTS IF NET AVAILABLE ASSETS ARE NO GREATER THAN TWO TIMES THE FEDERAL INCOME POVERTY GUIDELINES AS ADJUSTED FOR FAMILY SIZE AND THE GROSS FAMILY INCOME IS BETWEEN 100% AND 175% OF THE FEDERAL INCOME POVERTY GUIDELINES AS ADJUSTED FOR FAMILY SIZE. THE UNPAID BALANCE AFTER THIRD-PARTY PAYMENTS FOR PATIENTS MEETING THIS CRITERIA WILL BE DISCOUNTED ACCORDING TO THE FOLLOWING SLIDING FEE SCALE CONSIDERING INDIVIDUAL CIRCUMSTANCES SUCH AS EXTRAORDINARY NONDISCRETIONARY EXPENSES RELATIVE TO THE AMOUNT OF MEDICAL EXPENSES, THE EXISTENCE AND AVAILABILITY OF FAMILY ASSETS, THE RESPONSIBLE PARTY'S FUTURE INCOME EARNING CAPACITY, AND ABILITY TO MAKE PAYMENTS OVER AND EXTENDED PERIOD OF TIME. THE FINANCIAL OBLIGATIONS WHICH REMAIN AFTER THE APPLICATION OF THIS SLIDING SCALE MAY BE PAYABLE IN MONTHLY INSTALLMENTS OVER A REASONABLE PERIOD OF TIME WHICH SHOULD BE CONSISTENT WITH THE ESTABLISHED MONTHLY PAYMENT PLAN GUIDELINES.7. FULL FINANCIAL ASSISTANCE (LESS CO-PAY) MAY BE PROVIDED TO PATIENTS THAT DO NOT HAVE AVAILABLE ASSETS AND WITH GROSS FAMILY INCOME BETWEEN 100%-175% OF THE FEDERAL POVERTY GUIDELINES AS ADJUSTED FOR FAMILY SIZE WHEN CIRCUMSTANCES AS DETERMINED BY THE PATIENT ACCOUNTS MANAGER INDICATE THAT FULL PAYMENT MAY CAUSE SOCIAL AND FINANCIAL HARDSHIP SO AS TO SIGNIFICANTLY HARM THE PATIENT OR THE FAMILY UNIT. CO-PAY PROVISION: A PATIENT CO-PAY AMOUNT WILL BE ASSIGNED TO THOSE PATIENTS QUALIFYING FOR 100% ASSISTANCE AS FOLLOWS: A.INPATIENT SERVICES 10% OR $500, WHICHEVER IS THE LESSER AMOUNTB.OUTPATIENT SURGERY 10% OR $250, WHICHEVER IS THE LESSER AMOUNTC.OUTPATIENT ANCILLARY 10% OF BILL8. FULL OR PARTIAL ASSISTANCE MAY BE PROVIDED TO PATIENTS WITH GROSS FAMILY INCOME ABOVE 175% OF THE POVERTY GUIDELINES WHEN CIRCUMSTANCES DETERMINED BY THE PATIENT ACCOUNTS MANAGER INDICATE THAT FULL PAYMENT MAY CAUSE SOCIAL AND FINANCIAL HARDSHIPS SO AS TO SIGNIFICANTLY HARM THE PATIENT OR THE FAMILY UNIT. SHC WILL DETERMINE IF ASSETS CAN BE LIQUEFIED TO MEET THE OUTSTANDING MEDICAL EXPENSES AND/OR WHAT MONTHLY PAYMENT AMOUNT COULD BE MADE FOR A PERIOD OF UP TO 36 MONTHS AND THE REMAINING BALANCE WRITTEN OFF AS FINANCIAL ASSISTANCE. PART I, LINE 7: IN ORDER TO CALCULATE THE OVERALL HOSPITAL'S COST TO CHARGE RATIO USED FOR PART I, LINE 7, THE HOSPITAL FIRST DETERMINED A COST TO CHARGE RATIO BASED ON THE 2015 FILED MEDICARE COST REPORT SEPARATELY FOR INPATIENT SERVICES, OUTPATIENT SERVICES, AND TOTAL SERVICES. TO CALCULATE THE COST OF CHARITY CARE INCLUDED ON LINE 7A, THE HOSPITAL TOOK EACH OF THE SEPARATE COST TO CHARGE RATIOS DESCRIBED IN THE PRECEEDING PARAGRAPH AND APPLIED THEM ONLY TO THE RELATED CHARGES BY SERVICE TYPE TO COME UP WITH A WEIGHTED AVERAGE COST TO CHARGE RATIO. PART I, LINE 7G: THE FOLLOWING SUBSIDIZED HEALTH SERVICES WERE INCLUDED IN PART I, LINE 7G:EMERGENCY ROOM, CARDIAC REHAB, OBSERVATION AND AMBULANCE SERVICES. PART I, LN 7 COL(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 $4,825,547. PART III, LINE 2: IN EVALUATING THE COLLECTABILITY OF PATIENT AND RESIDENT ACCOUNTS RECEIVABLE, THE HEALTH CENTER 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 UNCOLLECTIBLE ACCOUNTS. 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 HEALTH CENTER ANALYZES CONTRACTUALLY DUE AMOUNTS AND PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS AND A PROVISION FOR UNCOLLECTIBLE ACCOUNTS, IF NECESSARY. 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 HEALTH CENTER RECORDS A PROVISION FOR UNCOLLECTIBLE ACCOUNTS IN THE PERIOD OF SERVICE ON THE BASIS OF ITS PAST EXPERIENCE. PART III, LINE 3: THE HEALTH CENTER IS UNABLE TO ESTIMATE THE AMOUNT OF ITS BAD DEBT EXPENSE THAT IS ATTRIBUTABLE TO PATIENTS WHO WOULD QUALIFY FOR FINANCIAL ASSISTANCE IF THEY WERE TO COMPLETE A FINANCIAL ASSISTANCE APPLICATION. PART III, LINE 4: SEE THE "PATIENT AND RESIDENT ACCOUNTS RECEIVABLE, NET" PARAGRAPH IN NOTE 1 (PAGE 9) OF THE ATTACHED FINANCIAL STATEMENTS. PART III, LINE 8: THE MEDICARE ALLOWABLE COSTS INCLUDED IN PART III, LINE 6 IS DERIVED FROM USING THE 2015 FILED MEDICARE COST REPORT. THE SHORTFALL OCCURS DUE TO VARIOUS EXPENSES INCURRED BY THE FACILITY WHICH ARE CONSIDERED NON-REIMBURSABLE BY MEDICARE. SINCE PART OF THE COSTS ARE NOT REIMBURSED IT IS ONLY PRUDENT TO CONSIDER THIS SHORTFALL TO BE A BENEFIT TO THE COMMUNITY. PART III, LINE 9B: IF THE PATIENT INDICATES THEIR INABILITY TO PAY ACCORDING TO THE HOSPITAL CREDIT TERMS THEY WILL BE ASKED TO FILL OUT A FINANCIAL STATEMENT. THE HOSPITAL MAY PULL A CREDIT REPORT TO CONFIRM OR SUPPLEMENT INFORMATION PROVIDED TO THE HOSPITAL ON THE FINANCIAL STATEMENT. THE PATIENT CAN THEN BE EVALUATED TO DETERMINE WHETHER THEY MAY BE ELIGIBLE FOR FINANCIAL ASSISTANCE OR AN EXTENDED PAYMENT PROGRAM.IF THE FINANCIAL STATEMENT SHOWS THAT THE PATIENT HAS ASSETS OR POTENTIAL SOURCES OF INCOME THAT WOULD ENABLE THEM TO PAY THE HOSPITAL BILL WITHIN A YEAR, THEY WILL BE DENIED THE EXTENDED PAYMENT WAIVER. IF A PATIENT REFUSES TO FURNISH A COMPLETED FINANCIAL STATEMENT, THEIR ACCOUNT WILL BE DEEMED DELINQUENT AND FURTHER COLLECTION ACTION WILL BE TAKEN. PRIOR TO ADMISSION, AT THE TIME OF ADMISSION, OR AS SOON AS POSSIBLE THEREAFTER, THE HOSPITAL WILL MAKE AN INITIAL ASSESSMENT OF POTENTIAL ELIGIBILITY BASED ON THE VERBAL APPLICATION FOR FINANCIAL ASSISTANCE. IF POTENTIAL ASSISTANCE IS INDICATED WITH INITIAL ASSESSMENT, THE HOSPITAL WILL NOT INITIATE COLLECTION EFFORTS OR REQUESTS FOR DEPOSITS PENDING THE RECEIPT OF THE COMPLETED APPLICATION AND FINAL ELIGIBILITY DETERMINATION. THE RESPONSIBLE PARTY MUST BE COOPERATIVE WITH THE HOSPITAL'S EFFORTS TO REACH A DETERMINATION OF ELIGIBILITY WITH OTHER ASSISTANCE PROGRAMS AND TO VALIDATE THE INFORMATION NEEDED.SIDNEY HEALTH CENTER WILL MAKE A CONCERTED EFFORT TO COMMUNICATE THE AVAILABILITY OF CHARITY CARE. EDUCATIONAL MATERIALS ABOUT THE PROGRAM WILL BE AVAILABLE TO PATIENTS THROUGH THE ADMISSIONS PROCESS. AS SOON AS A PATIENT EVIDENCES INABILITY TO PAY HE OR SHE WILL BE REFERRED TO THE PATIENT FINANCIAL SERVICES COUNSELOR FOR AN APPLICATION. APPLICATIONS ARE ALSO AVAILABLE AT THE ADMISSIONS AREA, AND THROUGH SOCIAL SERVICES. PART VI, LINE 2: THE HOSPITAL CONDUCTED A COMMUNITY HEALTH NEEDS ASSESSMENT IN THE YEAR ENDED JUNE 30, 2013. THE REPORT AND PLANNED RESPONSES ARE AVAILABLE ONLINE AT HTTP://WWW.SIDNEYHEALTH.ORG/ABOUTUS/COMMUNITY-HEALTH-ASSESSMENT-IMPLEMENTATION-PLAN. PART VI, LINE 3: SIDNEY HEALTH CENTER HAS NOTICES LOCATED AT THE ADMISSIONS OFFICE INFORMING PATIENTS ABOUT THEIR FINANCIAL ASSISTANCE POLICY. THE PROGRAM IS ALSO STATED ON THE ORGANIZATION'S WEBSITE AND INCLUDED IN THE PATIENT'S PACKET UPON DISCHARGE FROM THE FACILITY. PART VI, LINE 4: LOCATED IN THE HEART OF RICHLAND COUNTY, SIDNEY HEALTH CENTER SERVES PEOPLE IN ALL OF THE MONDAK REGION. PART VI, LINE 5: THE HEALTH CENTER DEFINES AND MEASURES THEIR INVESTMENT IN AND PARTNERSHIP WITH THE COMMUNITY PRIMARILY THROUGH VARIOUS COMMUNITY BASED SERVICES PROGRAMS, PROVIDING HEALTH EQUIPMENT IN AREA SCHOOLS, AND COMMUNITY PROGRAMS AND EDUCATION. A NUMBER OF HEALTH RELATED EDUCATIONAL PROGRAMS ARE PROVIDED FOR THE BENEFIT OF THE COMMUNITY, INCLUDING HEALTH ENHANCEMENTS AND WELLNESS, CLASSES ON SPECIFIC CONDITIONS, AND PROGRAMS DESIGNED TO IMPROVE THE GENERAL STANDARDS OF THE HEALTH OF THE COMMUNITY. X 1 0 X X 0 0 0 1 0 0 0 0 0 RICHARD HARALDSON CEO 225439 0 0 0 0 0 6425 0 2730 0 234594 0 0 0 SHARI TWIGG MD PHYSICIAN 365543 0 0 0 0 0 5474 0 3630 0 374647 0 0 0 ANDREA BARRETT MD PHYSICIAN 701799 0 0 0 0 0 5880 0 7800 0 715479 0 0 0 BRADLEY STRUPP CRNA 332475 0 0 0 0 0 7108 0 3696 0 343279 0 0 0 BARBARA LUNDEMO CRNA 268398 0 0 0 0 0 5037 0 3118 0 276553 0 0 0 GEORGE SCORDALAKES MD PHYSICIAN 400005 0 0 0 0 0 5031 0 3230 0 408266 0 0 0 PART I, LINE 1A RICHARD HARALDSON - HEALTH OR SOCIAL CLUB DUES OF $1,685 - NOT INCLUDED IN TAXABLE INCOME. PART I, LINE 5 PHYSICIANS RECEIVE BONUSES BASED ON PRODUCTIVITY, WHICH IS CLOSELY CONNECTED WITH REVENUES. A RICHLAND COUNTY MT 816001419 2010-12-01 2350000 MEDICAL EQUIPMENT REVENUE BOND FOR TOMOTHERAPY RADIATION ONCOLOGY UNIT 0 0 0 B RICHLAND COUNTY MT 816001419 2011-09-15 24370000 REDEEMING AND RETIRING PREVIOUSLY ISSUED DEBT (2006, 2007A AND 2007B) 0 0 0 A 1428064 2350000 20059 2329941 2011 0 0 1 1 B 2900000 24370000 233683 137747 2012 1 0 1 1 A 1 0 0 0 0 0 0 B 1 0 0 0 0 0 0 A 0 1 0 0 0 0 0 0 0 B 0 1 0 0 1 1 US BANK 7.900000000000 0 0 0 0 0 A 0 B 0 ROBERT MONTGOMERY SPOUSE OF TINA MONTGOMERY, CFO 62732 EMPLOYEE COMPENSATION 0 FORM 990, PART III, LINE 2 COMPLETED AND OPENED A NEW ON-SITE MRI SUITE AT THE HOSPITAL. FORM 990, PART VI, SECTION A, LINE 1 THE EXECUTIVE COMMITTEE CONSISTS OF THE OFFICERS AND ONE OTHER MEMEBER OF THE BOARD APPOINTED BY THE PRESIDENT. THE EXECUTIVE COMMITTEE HAS THE POWER TO TRANSACT ALL REGULAR BUSINESS OF THE CORPORATION DURING THE INTERIM BETWEEN THE MEETINGS OF THE BOARD, PROVIDED ANY ACTION TAKEN SHALL NOT CONFLICT WITH THE ARTICLES OF INCORPORATION, BYLAWS AND STATE POLICIES. ANY OFFICIAL ACTION TAKEN BY THE EXECUTIVE COMMITTEE IS SUBMITTED TO THE BOARD FOR RATIFICATION AT THE NEXT BOARD MEETING. FORM 990, PART VI, SECTION A, LINE 6 NATURAL PERSONS, CORPORATIONS, OR UNINCORPORATED ASSOCIATIONS MAY BECOME MEMBERS OF SIDNEY HEALTH CENTER BY: A. PAYMENT TO SIDNEY HEALTH CENTER A SUM OF NOT LESS THAN $100 CASH OR BY AN EQUIVALENT CONTRIBUTION OR METHOD AS APPROVED BY THE BOARD; B. RESIDING IN OR HAVING ITS PRINCIPAL PLACES OF BUSINESS IN THE SERVICE AREA OF SIDNEY HEALTH CENTER; AND C. AGREEING TO BE BOUND BY THE BYLAWS OF SIDNEY HEALTH CENTER. FORM 990, PART VI, SECTION A, LINE 7A ELECTION OF DIRECTORS IS HELD AT THE ANNUAL MEETING OF THE MEMBERS BY WRITTEN BALLOT LISTING THE CANDIDATES NOMINATED BY THE NOMINATING COMMITTEE OF THE MEMBERS. EACH MEMBER OF SIDNEY HEALTH CENTER, PRESENT IN PERSON OR BY PROXY, IS ENTITLED TO VOTE FOR ONE CANDIDATE FOR EACH DIRECTOR VACANCY TO BE FILLED. THE CANDIDATES RECEIVING THE HIGHEST NUMBER OF VOTES AT THE MEETING ARE CONSIDERED ELECTED AS DIRECTORS. FORM 990, PART VI, SECTION A, LINE 7B ANY PROPOSED AMENDMENTS APPROVED BY THE BOARD OR BY VERIFIED PETITION TO THE ARTICLES OF INCORPORATION OR BYLAWS SHALL BE SUBMITTED FOR VOTE BY THE MEMBERS AT THE NEXT SPECIAL OR ANNUAL MEMBERSHIP MEETING. FORM 990, PART VI, SECTION B, LINE 11 THE CEO AND CFO WILL REVIEW THE COMPLETED 990 WITH THE BOARD OF DIRECTORS AT THEIR NEXT SCHEDULED MEETING AFTER THE 990 IS FILED. FORM 990, PART VI, SECTION B, LINE 12C THE POLICY OF THE CORPORATION IS TO REQUIRE THAT EACH INDIVIDUAL SUBJECT TO THIS POLICY STATEMENT PROMPTLY AND FULLY DISCLOSE ANY ACTUAL, APPARENT, OR POTENTIAL CONFLICT OF INTEREST, AND THAT THE CORPORATION WILL NOT ENGAGE IN ANY CONTRACT, TRANSACTION, OR ARRANGEMENT INVOLVING A CONFLICT OF INTEREST UNLESS THE DISINTERESTED MEMBERS OF THE BOARD OF DIRECTORS (ACTING AT A DULY CONSTITUTED MEETING THEREOF) DETERMINE BY A MAJORITY VOTE THAT APPROPRIATE SAFEGUARDS TO PROTECT THE CHARITABLE MISSION OF THE CORPORATION HAVE BEEN IMPLEMENTED. A CONFLICT OF INTEREST QUESTIONNAIRE IS DISTRIBUTED ANNUALLY TO ALL INTERESTED PERSONS (BOARD MEMBERS, OFFICERS, AND COMMITTEE MEMBERS). AN INTERESTED PERSON HAS A CONTINUING OBLIGATION TO DISCLOSE THE EXISTENCE AND NATURE OF ANY ACTUAL, APPARENT, OR POTENTIAL CONFLICT OF INTEREST HE/SHE MAY HAVE. "DISCLOSURE" MEANS PROMPTLY PROVIDING A WRITTEN DESCRIPTION OF THE MATERIAL FACTS OF THE ACTUAL, APPARENT, OR POTENTIAL CONFLICT OF INTEREST TO THE EXECUTIVE COMMITTEE ON THE CONFLICTS-OF-INTEREST QUESTIONNAIRE. SUCH DISCLOSURE SHALL BE MADE PROMPTLY ANY TIME AN ACTUAL, APPARENT, OR POTENTIAL CONFLICT OF INTEREST ARISES AND BEFORE THE CONSUMMATION OF THE CONTRACT, TRANSACTION, OR ARRANGEMENT THAT IS THE SUBJECT OF THE POTENTIAL CONFLICT OF INTEREST. AT ANY TIME THAT AN ACTUAL, APPARENT, OR A POTENTIAL CONFLICT OF INTEREST IS IDENTIFIED TO THE BOARD OF DIRECTORS, WHETHER THROUGH THE VOLUNTARY SUBMISSION OF A DISCLOSURE STATEMENT BY AN INTERESTED PERSON, OR BY A DISCLOSURE BY A PERSON OTHER THAN THE SUBJECT INTERESTED PERSON, THE EXECUTIVE COMMITTEE SHALL REVIEW THE MATTER AND DETERMINE WHETHER A CONFLICT OF INTEREST EXISTS. THE SUBJECT INTERESTED PERSON SHALL NOT BE PRESENT DURING ANY MEETING IN WHICH THE EXECUTIVE COMMITTEE CONDUCTS ITS EVALUATION, EXCEPT TO ANSWER QUESTIONS AS MAY BE NECESSARY. THE EXECUTIVE COMMITTEE MAY REQUEST ADDITIONAL INFORMATION FROM ALL REASONABLE SOURCES AND MAY INVOLVE THE GENERAL COUNSEL IN ITS DELIBERATIONS. ONCE ALL NECESSARY INFORMATION HAS BEEN OBTAINED, EXECUTIVE COMMITTEE SHALL MAKE A FINDING AS TO WHETHER A CONFLICT OF INTEREST INDEED EXISTS, AND SHALL FORWARD THAT FINDING TO THE BOARD OF DIRECTORS FOR DISCUSSION AND VOTE. ONLY DISINTERESTED DIRECTORS MAY VOTE TO DETERMINE WHETHER A CONFLICT OF INTEREST EXISTS. THE SUBJECT INTERESTED PERSON MAY NOT BE PRESENT WHEN THIS VOTE IS TAKEN. ONCE THE DISINTERESTED MEMBERS OF THE BOARD OF DIRECTORS HAVE DETERMINED THAT AN ACTUAL CONFLICT OF INTEREST EXISTS WITH RESPECT TO A PARTICULAR TRANSACTION OR ARRANGEMENT: (I) THE DISINTERESTED MEMBERS OF THE BOARD OF DIRECTORS SHALL EXERCISE DUE DILIGENCE TO DETERMINE WHETHER THE CORPORATION COULD OBTAIN A MORE ADVANTAGEOUS CONTRACT, TRANSACTION, OR ARRANGEMENT WITH REASONABLE EFFORTS UNDER THE CIRCUMSTANCES AND, IF APPROPRIATE, SHALL APPOINT A NON-INTERESTED PERSON OR COMMITTEE TO INVESTIGATE ALTERNATIVES TO THE PROPOSED CONTRACT, TRANSACTION, OR ARRANGEMENT. (II) IN CONSIDERING WHETHER TO ENTER INTO THE PROPOSED CONTRACT, TRANSACTION, OR ARRANGEMENT, THE BOARD OF DIRECTORS MAY APPROVE SUCH A CONTRACT, TRANSACTION, OR ARRANGEMENT ONLY IF THE DISINTERESTED DIRECTORS DETERMINE BY A MAJORITY VOTE THAT: (A) THE PROPOSED CONTRACT, TRANSACTION, OR ARRANGEMENT IS IN THE CORPORATION'S BEST INTERESTS AND FOR THE CORPORATION'S OWN BENEFIT; AND (B) THE PROPOSED TRANSACTION IS FAIR AND REASONABLE TO THE CORPORATION, TAKING INTO ACCOUNT, AMONG OTHER RELEVANT FACTORS, WHETHER THE CORPORATION COULD OBTAIN A MORE ADVANTAGEOUS CONTRACT, TRANSACTION, OR ARRANGEMENT WITH REASONABLE EFFORTS UNDER THE CIRCUMSTANCES. (III) THE DISINTERESTED MEMBERS OF THE BOARD OF DIRECTORS MAY, IN THEIR DISCRETION, REQUIRE THE INTERESTED PERSON TO LEAVE THE ROOM WHILE THE PROPOSED CONTRACT, TRANSACTION, OR ARRANGEMENT IS DISCUSSED. THE INTERESTED PERSON SHALL LEAVE THE ROOM WHILE THE MATTER IS VOTED ON AND ONLY DISINTERESTED DIRECTORS MAY VOTE TO DETERMINE WHETHER TO APPROVE THE TRANSACTION OR ARRANGEMENT. FORM 990, PART VI, SECTION B, LINE 15 THE BOARD OF DIRECTORS DETERMINES SALARIES USING THE MHA SALARY SURVEY FOR MARKET INFORMATION AND ALSO PERFORMS A WRITTEN EVALUATION ANNUALLY. ADDITIONALLY, THE CEO USES MHA MANAGEMENT SURVEY, AS WELL AS OTHER COMPENSATION SURVEYS, TO DETERMINE ANNUAL PAY INCREASES FOR ADMINISTRATION. A WRITTEN EVALUATION IS PERFORMED. ALL ESTIMATED ANNUAL INCREASES ARE INCLUDED IN THE BUDGET, WHICH IS APPROVED BY THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE MADE AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART IX, LINE 11G OTHER PROFESSIONAL FEES: PROGRAM SERVICE EXPENSES 8,357,723. MANAGEMENT AND GENERAL EXPENSES 123,357. FUNDRAISING EXPENSES 10,316. TOTAL EXPENSES 8,491,396. FORM 990, PART XI, LINE 9: CHANGE IN BENEFICIAL INTEREST IN NET ASSETS OF FOUNDATION 130,021. CHANGE IN VALUE OF FAIR VALUE SWAP 275,675. LONE TREE SENIOR LIVING 1015 7TH AVENUE SW SIDNEY MT 59270 810518821 ASSISTED LIVING MT 501(C)(3) LINE 9 SIDNEY HEALTH CENTER 1 FOUNDATION FOR COMMUNITY CARE OF RICHLAND COUNTY 221 2ND ST NW SIDNEY MT 59270 810417465 FUNDRAISING MT 501(C)(3) LINE 11A, I SIDNEY HEALTH CENTER 1 1 0 1 1 0 0 0 0 0 0 0 1 1 1 1 0 1 0 0