2015-05-15T14:39:27-05:00 2014-06-30 461497033 EKS&H LLLP 7979 E TUFTS AVENUE SUITE 400 DENVER CO 802372521 990 2013-07-01 841262971 POUDRE VALLEY HEALTH CARE INC POUD 9702377000 2315 E HARMONY ROAD NO 200 FORT COLLINS CO 80528 STEPHANIE DOUGHTY CHIEF FINANCIAL OFFICER 9702377000 2015-05-15 1 CRAIG R CHOUN P00173718 3037409400 2013 2016-02-25 16:41:14Z KEVIN UNGER 2315 E HARMONY RD 200 FT COLLINS CO 80528 481878053 0 X WWW.UCHEALTH.ORG X 1994 CO WE IMPROVE LIVES. 11 9 4388 729 10121084 1401618 25492114 4199637 545139001 446107775 7452561 15060636 9500694 12929131 587584370 478297179 1864214 36808195 0 0 319437809 186655969 0 0 0 242119517 216747452 563421540 440211616 24162830 38085563 1036706894 1439397024 446760442 687341243 589946452 752055781 X WE IMPROVE LIVES. IN BIG WAYS THROUGH LEARNING, HEALING AND DISCOVERY. IN SMALL, PERSONAL WAYS THROUGH HUMAN CONNECTION. BUT IN ALL WAYS, WE IMPROVE LIVES. 0 1 384390680 36808195 443711093 POUDRE VALLEY HEALTH CARE INC. (PVHC) PROVIDES TERTIARY, ACUTE, INPATIENT, OUTPATIENT AS WELL AS EMERGENCY CARE. PVHC SERVICES COMMUNITIES IN NORTHERN COLORADO, SOUTHWESTERN NEBRASKA, AND SOUTHEASTERN WYOMING. DURING FISCAL YEAR 2014, PVHC RECORDED 58,001 PATIENT DAYS, 14,668 ADMISSIONS, 209,037 OUTPATIENT VISITS, 55,889 EMERGENCY VISITS, 2,388 DELIVERIES, 4,416 INPATIENT SURGERIES, AND 5,036 OUTPATIENT SURGERIES. 384390680 1 1 0 1 0 0 0 0 0 1 1 0 0 1 1 0 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 1 0 0 0 1 1 1 1 0 0 1 312 0 1 4388 1 1 1 0 0 0 0 0 0 0 0 0 X 11 9 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 1 1 X STEPHANIE DOUGHTY 9702377000 2315 E HARMONY ROAD SUITE 200 FORT COLLINS CO 80528 DANIEL G STROH BOARD CHAIR 1.00 2.00 X X 0 0 0 CHRISTINE CHIN VICE BOARD CHAIR 1.00 2.00 X X 0 0 0 RICHARD M DELLENBACH BOARD MEMBER 1.00 2.00 X 0 0 0 JOE D HENDRICKSON BOARD MEMBER 1.00 2.00 X 0 0 0 DENNIS JOHN HOUSKA BOARD MEMBER 1.00 2.00 X 0 0 0 THAINE J MICHIE BOARD MEMBER 1.00 2.00 X 0 0 0 DAVID C OSBORN BOARD MEMBER 1.00 2.00 X 0 0 0 TODD S SORENSEN BOARD MEMBER 1.00 2.00 X 0 0 0 JAMES ALAN SPROWELL BOARD MEMBER 1.00 2.00 X 0 0 0 LAURIE S STEELE BOARD MEMBER 1.00 2.00 X 0 0 0 RULON STACEY PVHS, CEO TERM END 11/13 25.00 25.00 X X 2652266 2652266 14508 KEVIN UNGER PVH PRESIDENT 25.00 25.00 X X 601261 0 69026 STEPHANIE DOUGHTY CFO 25.00 25.00 X 319094 319094 57876 DOUG FAUS VP OPERATIONS 50.00 X 308634 0 49153 DR WILLIAM NEFF CMO 50.00 X 366960 0 24345 DONNA PODUSKA CNO 50.00 X 238394 0 28041 DR MICHAEL RANDLE CMO, CHMG 25.00 25.00 X 174571 174571 19700 DAN ROBINSON CEO, CHMG 25.00 25.00 X 175649 175649 62756 STEVEN SCHWARTZ CFO, CHMG 25.00 25.00 X 93192 93192 26706 DR HANS COESTER PHYSICIAN 25.00 25.00 X 743493 743493 120974 DR MARK GUADAGNOLI PHYSICIAN 25.00 25.00 X 441706 441706 80830 DR WILLIAM MILLER PHYSICIAN 25.00 25.00 X 246693 246693 49832 DR JOSH PETIT PHYSICIAN 25.00 25.00 X 663852 663852 116340 DR LARS WIDDEL PHYSICIAN 25.00 25.00 X 472946 472946 90508 RUSS BRANZELL CEO, CHMG 50.00 X 223020 0 28182 GRACE KOWALYSHYN-TAYLOR DIR PHY RELATIONS 50.00 X 143129 0 18235 7864860 5983462 857012 71 1 1 0 NORTHERN COLORADO HOSPITALISTS 2121 E HARMONY RD STE 300 FT COLLINS CO 80528 MEDICAL 1769589 NUANCE COMMUNICATIONS ONE WAYSIDE RD BURLINGTON MA 01803 IT SUPPORT 1638304 FORT COLLINS WOMEN'S CLINIC 1107 S LEMAY AVE STE 300 FT COLLINS CO 80524 MEDICAL 1635656 LEIDOS HEALTH HOLDINGS INC PO BOX 2589 FORT WAYNE IN 46801 IT CONSULTING 1334813 HOSPITAL SHARED SERVICES 900 S BROADWAY STE 100 DENVER CO 80209 SECURITY AND MAINTENANCE 1300528 78 3626893 101733 471011 3454772 4199637 NET PATIENT SVC REV 900099 441531095 441531095 PROVIDER FEE INCOME 621400 24811245 24811245 LAB UBI 621500 2626071 2626071 DIETARY SVC INCOME 900099 1972399 1972399 RETAIL SERVICES 900099 1215537 959232 256305 -26048572 -26390792 342220 446107775 10974939 10974939 246357 246357 7688458 455166 2035638 455166 5652820 0 5652820 2549451 3103369 4181744 309584 16800 635188 4164944 -325604 3839340 3839340 687844 438082 249762 120801 128961 REIMBURSE- NON-OP DEPT 621400 4151152 4151152 MISCELLANEOUS REVENUE 621400 2537439 2493406 44033 INCOME TAX REFUND 621400 306907 306907 31051 31051 7026549 478297179 443711093 10121084 20265365 36808195 36808195 5190359 624222 4566137 60807 60807 140727709 126946159 13781550 18909415 16552262 2357153 19722390 13744743 5977647 2045289 1790333 254956 41457 16500 24957 19930 779 19151 12008 12008 514660 514660 28732365 21567292 7165073 1401135 22142 1378993 4119033 3452672 666361 8228099 6212426 2015673 4877176 4269212 607964 2144579 760031 1384548 224568 135830 88738 12885750 12885750 25093223 15269147 9824076 1931037 1792739 138298 MEDICAL SUPPLIES 71411014 71104546 306468 BAD DEBT 26221519 26221519 PROVIDER FEE EXPENSE 17414458 17414458 UBI TAXES 1188447 184 1188263 10286994 6738732 3548262 440211616 384390680 55820936 0 16706035 3709644 299523 1026320 73303366 56214512 2483125 1364113 6266869 6500134 6517958 3427999 549638934 287789700 267813924 261849234 5485130 6123945 2997063 2997063 29654266 24095655 625179635 1072088405 1036706894 1439397024 60962420 53074553 65775 69473 131119658 131401661 136284565 131854723 5116039 1379436 113211985 369561397 446760442 687341243 X 589946452 752055781 589946452 752055781 1036706894 1439397024 X 38085563 42759258 81264508 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 1 12008 0 0 12008 0 PART II-B, LINE 1: PORTION OF DUES FROM MEMBERSHIP IN CHA AND AHA THAT ARE ATTRIBUTABLE TO LOBBYING ACTIVITIES. 10692037 4841525 985793 3756845 2453518 10308992 8938992 2680308 520466 565964 881765 10692037 8589487 1202986 379517 448977 784021 8938992 8012240 3552647 -345716 1678528 712777 238379 8589487 7405708 2585645 656963 910474 1725602 8012240 0.00000 0.57410 0.42590 1 1 1 62136902 62136902 194364589 103049597 91314992 92843116 59197318 33645798 156434798 102136153 54298645 43859529 23406632 20452897 261849234 INTERCOMPANY RECEIVABLE 1065398313 DEFERRED DEBT ISSUANCE COSTS 3234708 OTHER RECEIVABLES 3330806 OTHER ASSETS 124578 1072088405 INTERCOMPANY PAYABLES 365740235 ACCRUED INTEREST PAYABLE 2248135 OTHER DEFERRED EXPENSES 1573027 369561397 521819736 42759258 3021018 45780276 476039460 514660 1743059 2257719 478297179 411422708 3021018 3021018 408401690 514660 31295266 31809926 440211616 PART V, LINE 4: ENDOWMENT FUNDS ARE USED FOR THE INTENDED PURPOSE TO FUND SCHOLARSHIPS, EDUCATION, PROGRAMS, AND COMMUNITY BENEFIT. TEMPORARILY RESTRICTED NET ASSETS ARE THOSE WHOSE USE BY THE FOUNDATION HAVE BEEN LIMITED BY THE DONOR TO A SPECIFIC TIME PERIOD OR PURPOSE. THESE NET ASSETS ARE AVAILABLE FOR VARIOUS HEALTH CARE PURPOSES AS DEFINED BY DONORS. THE ENDOWMENT FUND IS OWNED BY POUDRE VALLEY HEALTH SYSTEM FOUNDATION. PART XI, LINE 2D - OTHER ADJUSTMENTS: LOSS ON SALE OF ASSETS 325,604. RENTAL EXPENSE INCLUDED IN EXPENSE ON AFS 2,490,804. COST OF GOODS SOLD INCLUDED IN EXPENSE ON AFS 204,610. PART XI, LINE 4B - OTHER ADJUSTMENTS: PROVISION FOR BAD DEBT IN AFS INCOME 26,221,520. NON-OPERATING REIMBURSEMENTS INCLUDED IN EXPENSE ON AFS 4,151,152. AUXILIARY INCOME NOT INCLUDED IN AFS INCOME 128,962. CONTRIBUTIONS FROM PV FOUNDATION NOT IN AFS INCOME 264,373. BOOK VS. TAX ADJUSTMENT IN EQUITY EARNINGS -29,819,020. SERVICES PROVIDED TO OUTSIDE ENTITIES IN EXPENSE ON AFS 31,051. VARIOUS UBI INCOME NOT INCLUDED IN AFS INCOME 44,033. PHARMACY SALES INCLUDED IN EXPENSE ON AFS 99,732. RENTAL EXP AS INCOME ON 990 314,349. INCOME TAX REFUND REDUCED EXPENSES ON AFS 306,907. PART XII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSE INCLUDED IN EXPENSE ON AFS 2,490,804. COST OF GOODS SOLD INCLUDED IN EXPENSE ON AFS 204,610. LOSS ON SALE OF ASSETS 325,604. PART XII, LINE 4B - OTHER ADJUSTMENTS: PROVISION FOR BAD DEBT IN AFS INCOME 26,221,520. NON-OPERATING REIMBURSEMENTS INCLUDED IN EXPENSE ON AFS 4,151,152. AUXILIARY GRANTS NOT ON AFS 126,522. RENTAL EXP AS INCOME ON 990 314,349. SERVICES PROVIDED TO OUTSIDE ENTITIES IN EXPENSE ON AFS 31,051. VARIOUS UBI INCOME NOT INCLUDED IN AFS INCOME 44,033. PHARMACY SALES INCLUDED IN EXPENSE ON AFS 99,732. INCOME TAX REFUND REDUCED EXPENSES ON AFS 306,907. 1 1 X 1 X 250.000000000000 1 X 0 0 1 1 2467171 2467171 0.00600 60014650 43773400 16241250 0.03920 17517755 11912368 5605387 0.01350 79999576 55685768 24313808 0.05870 2390244 174023 2216221 0.00540 5443017 984932 4458085 0.01080 12522310 5970176 6552134 0.01580 35476648 35476648 0.08570 55832219 7129131 48703088 0.11770 135831795 62814899 73016896 0.17640 1300 1300 0.00000 104941 104941 0.00030 3000 3000 0.00000 1000 1000 0.00000 68740 68740 0.00020 178981 178981 0.00050 1 26221520 122302678 171801041 -49498363 X 1 1 1 HARMONY SURGERY CENTER LLC AMBULATORY SURGERY 0.51000 0.49000 2 PEAK SURGICAL MANAGEMENT MANAGEMENT SERVICES 0.14000 0.86000 3 HARMONY IMAGING CENTER LLC MEDICAL IMAGING 0.46000 0.54000 4 SURGERY CENTER OF FORT COLLINS AMBULATORY SURGERY 0.26000 0.49000 5 GATEWAY MEDICAL SERVICES REAL ESTATE/MEDICAL EQUIPMENT 0.50000 0.50000 6 EYE AND LASER CENTER OF NORTHERN COLO LLC LASER SURGERY 0.50000 0.50000 7 VEIN AND LASER CENTER OF N COLO LASER SURGERY 0.33000 0.67000 8 PVHS-ICM EHW LLC MEDICAL CLINIC 0.50000 0.50000 1 1 POUDRE VALLEY HOSPITAL 1024 S LEMAY FORT COLLINS CO 80524 X X X X X PHARMACY, LAB, CARDIOVASCULAR POUDRE VALLEY HEALTH CARE 1 1 X X X X X X X X X X 13 1 1 1 X SEE PART V, SECTION C X X X X X X X X 0 0 1 1 250.000000000000 1 400.000000000000 1 X X X X X X X 1 1 X X 1 X 1 X X X X X X X 1 X 0 0 POUDRE VALLEY HEALTH CARE PART V, SECTION B, LINE 1J: THE CHNA REPORT ALSO DESCRIBES CLINICAL SERVICES PROVIDED BY HOSPITAL FACILITY ADDRESSING THE FOUR LEADING CAUSES OF MORTALITY IN THE COUNTY. POUDRE VALLEY HEALTH CARE PART V, SECTION B, LINE 3: TWO COMMUNITY MEETINGS WERE HELD DURING FEBRUARY 2013 WHERE FINDINGS FROM THE CHNA WERE PRESENTED, QUESTIONS AND COMMENTS WERE RECEIVED AND RESPONSES PROVIDED. THE FOLLOWING INDIVIDUALS WERE CONSULTED:ANNETTE ALFANO, UNIVERSITY OF COLORADO HEALTHMARY ATCHISON, KAISER PERMANENTEKRISTIN BIERI, FOOD BANK FOR LARIMER COUNTYDEBORAH CAMPBELL, LARIMER COUNTY COMPASSJENNIFER CHASE, NORTHERN COLORADO AIDS PROJECTANDREA CLEMENT-JOHNSON, LARIMER COUNTY DEPARTMENT OF HEALTH & ENVIRONMENTBRUCE COOPER, HEALTH DISTRICT OF NORTHERN LARIMER COUNTYLORI DAIGLE, NORTHERN COLORADO AIDS PROJECTALISON DAWSON, DISABLED RESOURCE SERVICESEMILY DAWSON PETERSEN, TOUCHSTONE HEALTH PARTNERSTOM DONNELLY, LARIMER COUNTY COMMISSIONERSMICHELE DOYLE, COLUMBINE HEALTH CARE SYSTEMSLINDA FELLION, EARLY CHILDHOOD COUNCIL OF LARIMER COUNTYLEW GAITER, LARIMER COUNTY COMMISSIONERSCHAZZ GLAZE, SALUD FAMILY HEALTH CENTERNEIL GLUCKMAN, LARIMER COUNTY, ASSISTANT COUNTY MANAGERMARTHA HARGRAVES, COMMUNITY MEMBERBARBARA HARTMAN, THOMPSON SCHOOL DISTRICTSUE HEWITT, HEALTH DISTRICT OF NORTHERN LARIMER COUNTYJESSICA HINTERBERG, CANDO WITH UNIVERSITY OF COLORADO HEALTHERICA IVERSON, FOOD BANK FOR LARIMER COUNTYSTEVE JOHNSON, LARIMER COUNTY COMMISSIONERSASHLEY KASPRZAK, TEAM FORT COLLINSKATY KOHNEN, LEAGUE OF WOMEN VOTERSJENNY LANGNESS, ALPHA CENTERJENNIFER LEE, LARIMER COUNTY BOARD OF HEALTHDIANA LINDEN, PLANNED PARENTHOOD OF THE ROCKY MOUNTAIN'S RESPONSIBLE SEX EDUCATION INSTITUTEMARIE MACPHERSON, LARIMER COUNTY DEPT OF HEALTH AND ENVIRONMENTJOHN MCGEE, CROSSROADS SAFEHOUSEDAWN NANNINI, TEAM FORT COLLINSKAREN NICHOLSON, ESTES PARK MEDICAL CENTERTRACI ODDY, BANNER MCKEE MEDICAL CENTERCAROL PLOCK, HEALTH DISTRICT OF NORTHERN LARIMER COUNTYMARK RICHARDS, LARIMER COUNTY BOARD OF HEALTHDOUG RYAN, LARIMER COUNTY DEPARTMENT OF HEALTH & ENVIRONMENTKIM SHARPE, HEALTHIER COMMUNITIES COALITION OF LARIMER COUNTYBILL STOUT, WOMEN'S RESOURCE CENTERAVERIL STRAND, LARIMER COUNTY DEPARTMENT OF HEALTH AND ENVIRONMENTDEIRDRE SULLIVAN, CANDO WITH UNIVERSITY OF COLORADO HEALTHJILL TAYLOR, UNIVERSITY OF COLORADO HEALTHGRACE TAYLOR, UNIVERSITY OF COLORADO HEALTHMARILYN THAYER, COMMUNITY ORGANIZING TO REACH EMPOWERMENT (CORE) CENTERLEE THIELEN, THIELEN CONSULTINGCOLETTE THOMPSON, UNIVERSITY OF COLORADO HEALTHJANE VISTE, LARIMER COUNTY DEPARTMENT OF HEALTH AND ENVIRONMENTSCOTT VON BARGEN, TURNING POINT CENTER FOR YOUTH & FAMILY DEVELOPMENTMARGARET WATSON, UNITED WAY 2-1-1 OF LARIMER COUNTYNANCY WEBER, POUDRE SCHOOL DISTRICTVALERIE WENDELL, BOHEMIAN FOUNDATIONLISE YOUNGBLADE, HUMAN DEVELOPMENT AND FAMILY STUDIES/COLORADO STATE UNIVERSITYSTEVE YURASH, LARIMER COUNTY BOARD OF HEALTH POUDRE VALLEY HEALTH CARE PART V, SECTION B, LINE 4: MEDICAL CENTER OF THE ROCKIES ALSO PARTICIPATED IN THE 2013 CHNA. POUDRE VALLEY HEALTH CARE PART V, SECTION B, LINE 5D: E-MAIL DISTRIBUTION OF LINK TO CHNA REPORT ON HOSPITAL WEBSITE TO MEMBERS OF THE COUNTY HEALTH ASSESSMENT PLANNING & PARTNERSHIP TEAM.WEBSITE: HTTPS://WWW.UCHEALTH.ORG/PAGES/ABOUT-UCHEALTH/COMMUNITY-HEALTH-NEEDS-ASSESSMENT.ASPX POUDRE VALLEY HEALTH CARE PART V, SECTION B, LINE 7: AN IDENTIFIED HEALTH ISSUE RELATED TO A HIGH RATE OF UNINTENDED TEEN PREGNANCY IN WELD COUNTY IS NOT BEING ADDRESSED WITH DIRECT RESOURCES ALLOCATED FROM POUDRE VALLEY HOSPITAL OR THE MEDICAL CENTER OF THE ROCKIES. THE WELD COUNTY DEPARTMENT OF PUBLIC HEALTH & ENVIRONMENT PROVIDES REPRODUCTIVE HEALTH SERVICES FOR TEENS THROUGH A TITLE X CLINIC. ADDITIONAL EDUCATION AND OUTREACH TO WELD COUNTY TEENS IS PROVIDED BY A COMMUNITY ORGANIZATION; LUTHERAN FAMILY SERVICES. POUDRE VALLEY HOSPITAL AND MEDICAL CENTER OF THE ROCKIES PROVIDED SUPPORT TO THIS ORGANIZATION THROUGH CASH DONATIONS TOTALING $2,460.00 DURING THE 2012/13 FISCAL YEAR AND $2,500 DURING THE 2013/14 FISCAL YEAR. ANOTHER IDENTIFIED HEALTH ISSUE - MOTOR VEHICLE SAFETY FOR TEENS IN WELD COUNTY - IS ALSO NOT BEING DIRECTLY ADDRESSED DUE TO LACK OF RESOURCES. THE ISSUE IS BEING ADDRESSED BY A NON-PROFIT COMMUNITY COALITION - DRIVE SMART WELD COUNTY - WHICH HAS DEDICATED RESOURCES AND ACTION PLANS TO ADDRESS THIS ISSUE. 61 HARMONY CAMPUS MOB 2121 E HARMONY RD FORT COLLINS CO 80528 PHYSICIAN OFFICES, ONCOLOGY, HCOR, CANCER CENTER HARMONY CAMPUS AMBLUATORY CARE CENTER 2127 E HARMONY RD FORT COLLINS CO 80528 SURGERY CENTER, DIAGNOSTIC CENTER, IMAGING, URGENT CARE CHMG CLINICS 1400 E BOULDER STREET COLORADO SPRINGS CO 80909 PHYSICIAN OFFICES MCR NORTH MOB 2500 ROCKY MTN AVE LOVELAND CO 80538 PHYSICIAN OFFICES REDSTONE 2315 E HARMONY RD FORT COLLINS CO 80528 OUTPAITENT LAB, PHYSICIAN OFFICE, SSOR, UROLOGY PEAKVIEW MEDICAL CENTER 5881 W 16TH STREET GREELEY CO 80634 PHYSICIAN OFFICES CHMG THE VEIN CENTER 4110 BRIARGATE PARKWAY SUITE 140 COLORADO SPRINGS CO 80920 PHYSICIAN OFFICES GREELEY MEDICAL CLINIC 1900 16TH STREET GREELEY CO 80631 PHYSICIAN OFFICES MCR SOUTH MOB 2500 ROCKY MTN AVE LOVELAND CO 80538 PHYSICIAN OFFICES, HCOR, SSOR CENTRE AVE HEALTH AND REHAB-JV 915 CENTRE AVE FORT COLLINS CO 80526 REHAB PENNOCK PLACE 1025 PENNOCK PLACE FORT COLLINS CO 80524 PHYSICIAN OFFICES, BLOOD BANK CHMG CHEYENNE MEDICAL SPECIALISTS 5050 POWDERHOUSE RD CHEYENNE WY 82009 PHYSICIAN OFFICES PROSPECT MEDICAL PLAZA 1106 E PROSPECT SUITE 100 FORT COLLINS CO 80524 PHYSICIAN OFFICES, OUTPAITENT REHAB, NEUROLOGY, INT MEDICINE SURGERY CENTER OF FT COLLINS-JV 1100 E PROSPECT RD FORT COLLINS CO 80524 SURGERY CENTER WESTBRIDGE 1107 S LEMAY FORT COLLINS CO 80524 PHYSICIAN OFFICES, MEDICAL SPA, BLOOD DRAW SNOW MESA 4674 SNOW MESA DRIVE FORT COLLINS CO 80528 PHYSICIAN OFFICES WINDSOR MEDICAL CENTER 1455 MAIN STREET WINDSOR CO 80550 PHYSICIAN OFFICES, RAADIOLOGY, LAB CARDIOTHORACIC SURGERY 525 N FOOTE AVE SUITE 302 COLORADO SPRINGS CO 80910 PHYSICIAN OFFICES UROLOGY CENTER OF THE ROCKIES 3520 E 15TH STREET LOVELAND CO 80538 PHYSICIAN OFFICES MEMORIAL NEUROSCIENCES 1725 BOULDER STREET SUITE 101 COLORADO SPRINGS CO 80909 PHYSICIAN OFFICES EXPRESS LAB 1020 DOCTORS LANE FORT COLLINS CO 80524 LAB MOUNTAIN CREST BEHAVIORAL HEALTH 4601 CORBETT DR FORT COLLINS CO 80528 BEHAVORIAL HEALTH HEMATOLOGYONCOLOGY 525 N FOOTE AVE SUITE 202 COLORADO SPRINGS CO 80910 PHYSICIAN OFFICES CHILDREN'S THERAPY 1500 S LEMAY FORT COLLINS CO 80526 THERAPY WEST LOVELAND 3850 N GRANT AVE LOVELAND CO 80538 URGENT CARE, PHYSICIAN OFFICES BREAST SURGERY 4110 BRIARGATE PARKWAY SUITE 465 COLORADO SPRINGS CO 80920 PHYSICIAN OFFICES MEMORIAL SUNFLOWER FAMILY MEDICINE 1730 N CORONA STREET COLORADO SPRINGS CO 80907 PHYSICIAN OFFICES COLUMBINE POUDRE HOMECARE-JV 915 CENTRE AVE FORT COLLINS CO 80526 HOME HEALTHCARE HCORSCOTTSBLUFF 2 W 42ND ST 2200 SCOTTSBLUFF NE 69361 PHYSICIAN OFFICES SENIOR CLINIC 175 S UNION BLVD SUITE 300 COLORADO SPRINGS CO 80910 PHYSICIAN OFFICES PRIMARY CARE-STERLING 620 IRIS DRIVE STERLING CO 80751 PHYSICIAN OFFICES CHMG PRIMARY CARE AT BRIARGATE 8890 N UNION BLVD SUITE 100B COLORADO SPRINGS CO 80920 PHYSICIAN OFFICES TIMERLINE MEDICAL 131 STANLEY DR ESTES PARK CO 80517 PHYSICIAN OFFICES THE VEIN AND LASER CENTER-JV 2008 CARIBOU DRIVE FORT COLLINS CO 80525 PHYSICIAN OFFICES YAMPA VALLEY STEAMBOAT 940 CENTRAL PARK DR 290 STEAMBOAT SPRINGS CO 80487 PHYSICIAN OFFICES THOMPSON VALLEY TOWNE CENTER 1327 EAGLE DRIVE LOVELAND CO 80537 PHYSICIAN OFFICES CHMG PRIMARY CARE - ROCKRIMMON 6615 DELMONICO DRIVE COLORADO SPRINGS CO 80919 PHYSICIAN OFFICES POUDRE INFUSION THERAPY-JV 915 CENTRE AVE FORT COLLINS CO 80526 INFUSION WATER VALLEY 1870 MARINA PLAZA DRIVE WINDSOR CO 80550 OUTPATIENT REHAB FORT MORGAN 1000 LINCOLN STREET 207 FORT MORGAN CO 80701 PHYSICIAN OFFICES EYE LASER CENTER OF N COLORADO-JV 1725 EAST PROSPECT RD FORT COLLINS CO 80525 PHYSICIAN OFFICES CRAIG 595 RUSSELL STREET CRAIG CO 81625 PHYSICIAN OFFICES CHMG PRIMARY CARE - NO UNION 5333 N UNION BLVD SUITE 200 COLORADO SPRINGS CO 80918 PHYSICIAN OFFICES LARAMIE 3116 WILLET DRIVE LARAMIE WY 82070 PHYSICIAN OFFICES CHMG SLEEP MEDICINE CLINIC 4110 BRIARGATE PARKWAY SUITE 445 COLORADO SPRINGS CO 80920 PHYSICIAN OFFICES ESTES PARK 555 PROSPECT AVE ESTES PARK CO 80517 PHYSICIAN OFFICES SIDNEY 1625 DORWART DRIVE SIDNEY NE 69162 PHYSICIAN OFFICES ALLIANCE 2101 BOX BUTTE AVE ALLIANCE NE 69301 PHYSICIAN OFFICES KREMMLING 214 S 4TH STREET KREMMLING CO 80459 PHYSICIAN OFFICES YUMA 910 S MAIN STREET YUMA CO 80759 PHYSICIAN OFFICES CHMG HCOR CV SURGEON 2030 MOUNTAIN VIEW AVE 540 LONGMONT CO 80503 PHYSICIAN OFFICES WALDEN 350 MCKINGLEY ST WALDEN CO 80480 PHYSICIAN OFFICES GMCBRUSH 2400 EDISON STREET BRUSH CO 80723 PHYSICIAN OFFICES CHMG OB-GYN CLINIC 1715 61ST AVENUE GREELEY CO 80631 PHYSICIAN OFFICES PHLEBOTOMY STATION 1107 SOUTH LEMAY AVE FORT COLLINS CO 80526 LAB DRAWS PHLEBOTOMY STATION 1113 OAKRIDGE DRIVE FORT COLLINS CO 80525 LAB DRAWS PHLEBOTOMY STATION 2001 S SHIELDS FORT COLLINS CO 80526 LAB DRAWS PHLEBOTOMY STATION 2025 BIG HORN DRIVE FORT COLLINS CO 80525 LAB DRAWS PHLEBOTOMY STATION 3519 RICHMOND DRIVE FORT COLLINS CO 80526 LAB DRAWS LAB DRAWS 708 22ND STREET GREELEY CO 80631 LAB HAYTHORN BROTHERS 7251 W 20TH ST GREELEY CO 80631 SLEEP LAB PART I, LINE 7: THE ORGANIZATION USED A COST-TO-CHARGE RATIO FOR LINE 7B AND 7C. THE COST-TO-CHARGE RATIO WAS DERIVED FROM WORKSHEET 2, RATIO OF PATIENT CARE TO COST-TO-CHARGES.LINE 7A WAS DERIVED USING A COST-TO-CHARGE RATIO FROM THE COST REPORT.THE INFORMATION FOR LINES 7E THROUGH 7I WAS DERIVED FROM INFORMATION IN THE GENERAL LEDGER AND OTHER FINANCIAL DATA RELATED SPECIFICALLY TO THE VARIOUS TYPES OF COMMUNITY BENEFITS. PART I, LINE 7G: INCLUDES PHYSICIAN GROUPS AS A SUBSIDIZED SERVICE. THESE CLINICS PROVIDE SERVICES IN UNDERSERVED AREAS IN COLORADO, NEBRASKA AND WYOMING. PART I, LN 7 COL(F): TOTAL BAD DEBT EXPENSE REMOVED FROM THE DENOMINATOR PRIOR TO THE PERCENTAGE CALCULATION = $26,221,520. PART II, COMMUNITY BUILDING ACTIVITIES: AS MENTIONED UNDER PROMOTION OF COMMUNITY HEALTH WE HAVE A MULTITUDE OF PROGRAMS DESIGNED TO ADDRESS THE HEALTH OF OUR COMMUNITY INVOLVING ALL AGE GROUPS AND FOCUS ON WHAT AN INDIVIDUAL CAN DO TO IMPROVE HIS/HER HEALTH. MANY OF THE PROGRAMS REFLECTED IN PART II ARE DESIGNED TO PROMOTE HEALTHY OPTIONS AND CHOICES FOR OUR COMMUNITY WHICH IS AN IMPORTANT PART OF OVERALL COMMUNITY HEALTH AND THEREFORE A BENEFIT TO THE COMMUNITY.PART III, LINE 2: ACCOUNTS WITH UNRESOLVED PATIENT LIABILITY AFTER REASONABLE COLLECTION EFFORTS, SET BY POLICY AND IN CONJUNCTION WITH FEDERAL, STATE, AND PAYOR SPECIFIC REGULATIONS, WILL BE ASSIGNED TO BAD DEBT. THESE ACCOUNTS SHALL BE REFERRED TO AN OUTSIDE COLLECTION AGENCY, OR IN SELECTED INSTANCES, ATTORNEYS, FOR ADDITIONAL COLLECTION ACTIVITIES. PART III, LINE 4: PATIENT ACCOUNTS RECEIVABLE ARE REPORTED NET OF ALLOWANCES FOR DOUBTFUL ACCOUNTS, CONTRACTUAL ADJUSTMENTS, AND MEDICALLY INDIGENT ALLOWANCES.PART III, LINE 5: MEDICARE REVENUE WAS COMPUTED AS FOLLOWS:POUDRE VALLEY HEALTH CARE COST REPORT 72,782,447POUDRE VALLEY HEALTH CARE GME PAYMENT (683,147)CENTRE AVE HEALTH & REHAB COST REPORT 3,776,993COLUMBINE POUDRE HOMECARE COST REPORT 1,167,553PVHC INC. MEDICARE DISALLOWED PROGRAMS 911,223JOINT VENTURES 44,347,609TOTAL TO LINE 5 122,302,678PART III, LINE 6: ALLOWABLE COSTS AS REPORTED ON THE POUDRE VALLEY HEALTH CARE INC. 2014 COST REPORT.PART III, LINE 6: MEDICARE ALLOWABLE COSTS OF CARE RELATING TO PAYMENTS WAS COMPUTED AS FOLLOWS:POUDRE VALLEY HEALTH CARE COST REPORT 106,763,826CENTRE AVE HEALTH & REHAB COST REPORT 5,486,056COLUMBINE POUDRE HOMECARE COST REPORT 1,273,777PVHC INC. MEDICARE DISALLOWED PROGRAMS 1,019,905JOINT VENTURES 57,257,477TOTAL TO LINE 6 171,801,041 PART III, LINE 8: APPROXIMATELY 19.4% OF NET PATIENT SERVICE REVENUE IS FROM PARTICIPATION IN THE MEDICARE PROGRAM, THUS PROVIDING MEDICARE SERVICES PROMOTES ACCESS TO HEALTHCARE SERVICES TO A SIGNIFICANT PORTION OF THE COMMUNITY POPULATION. PART III, LINE 9B: PATIENT PROVIDES DOCUMENTATION BASED ON COLORADO INDIGENT CARE GUIDELINES, REVIEWED BY FINANCIAL ASSISTANCE COMMITTEE (FAC), CROSS FUNCTIONAL TEAM CHAIRED BY DIRECTOR PATIENT FINANCIAL SERVICES. UPON APPROVAL OR DENIAL OF THE REQUEST FOR CHARITABLE AID FROM THE FAC, THE PATIENT WILL BE ADVISED OF THE DECISION. THE BILL IS PARTIALLY OR TOTALLY ADJUSTED AS APPROVED BY THE FAC, NO FURTHER COLLECTION PROCESS WITH THE PATIENT. FOR ANY PORTION NOT ADJUSTED OFF, THE PROPER SEQUENCE OF ATTEMPTS TO COLLECT ARE FOLLOWED. FINAL ASSIGNMENT OF THE BILL IS TO A COLLECTION AGENCY. PART VI, LINE 2: HEALTH CARE NEEDS ARE ADDITIONALLY IDENTIFIED THROUGH COLLABORATIVE RELATIONSHIPS WITH HEALTHCARE PROVIDERS IN THE COMMUNITIES WE SERVE. AN EXAMPLE IS OUR CARE COORDINATION INITIATIVE TARGETED TO AT-RISK CHILDREN WITH SPECIAL HEALTHCARE NEEDS . PHYSICIANS IDENTIFIED THE NEED TO IMPROVE THE COORDINATION AND TIMELINESS OF CARE FOR THIS POPULATION; WE RESPONDED BY DEVELOPING AND STAFFING A CARE COORDINATION / PATIENT NAVIGATION SERVICE MODEL (HEALTHY HARBORS). PART VI, LINE 3: THERE ARE SEVERAL WAYS WE NOTIFY THE PATIENT AND ATTEMPT TO ASSIST THEM. FOR SURGERIES AND HIGH DOLLAR SCHEDULED PROCEDURES, WE PROVIDE THEM WITH AN ESTIMATE AT REGISTRATION AND GO OVER ALL FINANCIAL ASSISTANCE OPTIONS AVAILABLE IF THEY ARE INTERESTED. WE ALSO HAVE FINANCIAL COUNSELORS AVAILABLE EACH DAY THAT CAN ANSWER QUESTIONS AND HELP THEM FILL OUT CHARITY APPLICATIONS. FOR THOSE THAT ARE UNINSURED, OUR CONDITIONS OF SERVICE FORM HAS A SPOT THEY INITIAL STATING THAT WE HAVE OFFERED ASSISTANCE AND MADE THEM AWARE OF PROGRAMS AVAILABLE TO THEM. ONCE A PERSON HAS RECEIVED CARE IN THE EMERGENCY DEPARTMENT, WE ALSO HAVE EDUCATED STAFF THAT ASSISTS THEM AND EDUCATES THEM OF WHAT IS AVAILABLE FOR FINANCIAL ASSISTANCE. IN ADDITION, ONCE A PATIENT DOES RECEIVE A STATEMENT OR BILL, THERE IS INFORMATION ON THE BILL OF WHO THEY CAN CALL TO GET INFORMATION ON FINANCIAL ASSISTANCE. PART VI, LINE 4: POUDRE VALLEY HEALTH CARE INC. IS A LOCALLY OWNED, PRIVATE, NON-PROFIT ORGANIZATION WITH A STRONG VISION: FROM HEALTH CARE TO HEALTH. BASED IN NORTHERN COLORADO, PVHC PROVIDES EVIDENCE-BASED HEALTHCARE AND WELLNESS SERVICES AND PRODUCTS IN COLORADO, NEBRASKA AND WYOMING, ACROSS A SERVICE AREA COVERING MORE THAN 50,000 SQUARE MILES.PVHC IS A PART OF THE UNIVERSITY OF COLORADO HEALTH WHICH AIMS TO DELIVER THE HIGHEST QUALITY PATIENT CARE WITH THE HIGHEST QUALITY PATIENT EXPERIENCE. THE PARTNERSHIP COMBINES POUDRE VALLEY HOSPITAL, MEDICAL CENTER OF THE ROCKIES, COLORADO HEALTH MEDICAL GROUP, UNIVERSITY OF COLORADO HOSPITAL AND MEMORIAL HEALTH SYSTEM INTO AN ORGANIZATION DEDICATED TO BUILDING HEALTHIER COMMUNITIES AND PROVIDING UNMATCHED PATIENT CARE IN THE ROCKY MOUNTAIN WEST. THE ORGANIZATION'S MISSION IS AS FOLLOWS: WE IMPROVE LIVES. IN BIG WAYS THROUGH LEARNING, HEALING AND DISCOVERY. IN SMALL, PERSONAL WAYS THROUGH HUMAN CONNECTION. BUT IN ALL WAYS, WE IMPROVE LIVES. PART VI, LINE 5: WE HAVE IMPLEMENTED A MULTITUDE OF PROGRAMS AND SERVICES THAT ADDRESS THE HEALTH NEEDS OF OUR BROADER COMMUNITY TARGETING ALL AGE GROUPS WHILE MAINTAINING A SPECIAL FOCUS ON SERVING VULNERABLE POPULATIONS . WE ALSO GIVE DOLLARS TO OTHER ENTITIES THAT WORK TO IMPROVE THE HEALTH OF OUR COMMUNITY. EXAMPLES ARE: TEEN PREGNANCY PREVENTION EDUCATION; SUBSTANCE ABUSE PREVENTION EDUCATION FOR YOUTH AND YOUNG ADULTS; OBESITY PREVENTION; IMPROVED FOOD SECURITY FOR LOW INCOME RESIDENTS; AND MENTAL HEALTH SERVICES FOR THE UNDERSERVED. PART VI, LINE 6: ALL THE SERVICES WE OFFER ARE AVAILABLE TO ANYONE THAT USES ANY OF OUR FACILITIES IN THE HEALTH SYSTEM. OUR GEOGRAPHY IS NOT THAT LARGE SO WE ARE ABLE TO ACCOMMODATE THE DIFFERENT COMMUNITIES THAT UTILIZE OUR SERVICES WITH THE SAME LEVEL OF COMMUNITY HEALTH PROGRAMMING. PART VI, LINE 7, REPORTS FILED WITH STATES CO 1 PVHMCR HOSPITAL FOUNDATION 2315 E HARMONY RD 200 FORT COLLINS CO 80528 741894581 501(C)(3) 844463 SEE SCH I, PART IV UNIVERSITY OF N COLORADO 501 20TH STREET GREELEY CO 80639 846000546 GOVERNMENT 88820 SEE SCH I, PART IV IVINSON MEMORIAL HOSPITAL FOUNDATION 255 N 30TH STREET LARAMIE CO 82072 836000188 501(C)(3) 6500 SEE SCH I, PART IV GREELEY CENTENNIAL ROTARY 1035 37TH AVE CT GREELEY CO 80634 840714073 501(C)(3) 7500 SEE SCH I, PART IV ALTERNATIVES TO VIOLENCE 313 E 4TH STREET LOVELAND CO 80537 840886127 501(C)(3) 6060 SEE SCH I, PART IV UNITED WAY OF LARIMER COUNTY 424 PINE ST 102 FORT COLLINS CO 80524 846031503 501(C)(3) 81759 SEE SCH I, PART IV NORTHERN COLORADO CYCLING 5280 ARENA CIRCLE 100 LOVELAND CO 80538 462713441 501(C)(3) 13000 SEE SCH I, PART IV DOWNTOWN BUSINESS ASSOCIATION 19 OLD TOWN SQUARE 230 FORT COLLINS CO 80524 840535419 501(C)(3) 25000 SEE SCH I, PART IV UNIVERSITY OF COLORADO SCHOOL OF MEDICINE 13001 E 17TH PLACE AURORA CO 80045 846000555 501(C)(3) 1659574 SEE SCH I, PART IV POUDRE VALLEY MEDICAL GROUP LLC 2315 EAST HARMONY ROAD SUITE 200 FORT COLLINS CO 80528 800348943 N/A 33095072 SEE SCH I, PART IV 9 1 PART I, LINE 2: THE ORGANIZATION AWARDS GRANTS BASED ON THE BENEFIT TO THE COMMUNITY. THE ORGANIZATION REQUESTS INFORMATION FROM THE GRANTEES TO ENSURE THAT THE FUNDS WILL BE USED FOR THE SPECIFIED PURPOSE. QUESTION I, PART II, COLUMN H PURPOSE OF GRANT OR ASSISTANCE FOR RELATED ENTITIES, THE GRANTS ARE RELATED TO SPECIFIC REQUESTS. THE FUNDS ARE TO BE USED TO BENEFIT THE HEALTHCARE COMMUNITY OF NORTHERN COLORADO. EACH REQUEST IS EVALUATED ON AN INDIVIDUAL BASIS. FOR NON-RELATED COMMUNITY AND GOVERNMENTAL ORGANIZATIONS, THE GRANTS ARE MADE AT THE DISCRETION OF THE ORGANIZATION. THESE DISCRETIONARY GRANTS ARE TO BE USED TO BENEFIT THE HEALTHCARE COMMUNITY OF NORTHERN COLORADO. X X X 1 1 X X X X X 1 1 0 0 0 0 0 0 0 RULON STACEY PVHS, CEO TERM END 11/13 248085 248085 1014515 1014515 1389666 1389666 0 0 7254 7254 2659520 2659520 964577 964577 KEVIN UNGER PVH PRESIDENT 389433 0 198764 0 13064 0 7650 0 61376 0 670287 0 0 0 STEPHANIE DOUGHTY CFO 239996 239996 77640 77640 1458 1458 3825 3825 25113 25113 348032 348032 0 0 DOUG FAUS VP OPERATIONS 218053 0 89863 0 718 0 7650 0 41503 0 357787 0 0 0 DR WILLIAM NEFF CMO 281996 0 83647 0 1317 0 7650 0 16695 0 391305 0 0 0 DONNA PODUSKA CNO 183272 0 52730 0 2392 0 5551 0 22490 0 266435 0 0 0 DR MICHAEL RANDLE CMO, CHMG 173702 173702 0 0 869 869 3825 3825 6025 6025 184421 184421 0 0 DAN ROBINSON CEO, CHMG 130341 130341 44185 44185 1123 1123 3825 3825 27553 27553 207027 207027 0 0 STEVEN SCHWARTZ CFO, CHMG 86437 86437 6148 6148 607 607 2823 2823 10530 10530 106545 106545 0 0 DR HANS COESTER PHYSICIAN 740674 740674 0 0 2819 2819 3825 3825 56662 56662 803980 803980 0 0 DR MARK GUADAGNOLI PHYSICIAN 426467 426467 13750 13750 1489 1489 3825 3825 36590 36590 482121 482121 0 0 DR WILLIAM MILLER PHYSICIAN 245542 245542 0 0 1151 1151 3825 3825 21091 21091 271609 271609 0 0 DR JOSH PETIT PHYSICIAN 663307 663307 0 0 545 545 3825 3825 54345 54345 722022 722022 0 0 DR LARS WIDDEL PHYSICIAN 472649 472649 0 0 297 297 3825 3825 41429 41429 518200 518200 0 0 RUSS BRANZELL CEO, CHMG 116806 0 71737 0 34477 0 4609 0 23573 0 251202 0 0 0 GRACE KOWALYSHYN-TAYLOR DIR PHY RELATIONS 118396 0 24040 0 693 0 3847 0 14388 0 161364 0 0 0 PART I, LINE 1A TRAVEL FOR COMPANIONS: PER SYSTEM POLICY, TRAVEL FOR COMPANIONS IS NOT REIMBURSABLE. FOR CONVENIENCE OF TRAVEL ARRANGEMENTS FOR THE ANNUAL BOARD MEMBER RETREAT AND SELECT CONFERENCES, PVHC PAYS FOR ONE COMPANION PER BOARD MEMBER AND EMPLOYEE ATTENDING THE CONFERENCE. EACH BOARD MEMBER RECEIVES A 1099 FOR THIS INCOME. EACH EMPLOYEE HAS THIS ADDED TO THEIR FORM W-2 GROSS-UP PAYMENTS: GROSS UP PAYROLL IS CALCULATED AT YEAR END FOR SPECIAL CHECKS CREATED TO ADD SPECIFIC ITEMS TO EMPLOYEE'S FORM W-2 WAGES INCLUDING COUNTRY CLUB DUES, PERSONAL USE OF LAPTOP COMPUTERS AND IPADS, SPOUSE TRAVEL FOR ANNUAL BOARD RETREAT AND SELECT CONFERENCES AND IMPUTED INCOME ON LIFE INSURANCE POLICIES. CLUB DUES: THE HEALTH SYSTEM EXPECTS THE HOSPITAL MANAGEMENT TO PARTICIPATE IN COMMUNITY LIFE AND THEREFORE THE SYSTEM PAYS SOCIAL CLUB DUES FOR SPECIFIC MEMBERS OF THE SENIOR MANAGEMENT GROUP. THE CLUB DUES ARE ADDED TO THE SENIOR MANAGEMENT'S FORM W-2 ON AN ANNUAL BASIS. PART I, LINES 4A-B RULON STACEY RECEIVED A SEVERANCE PAYMENT IN THE AMOUNT OF $2,666,667. THE ORGANIZATION PAID $105,244 INTO A DEFERRED COMPENSATION PLAN FOR RULON STACEY AND $105,244 WAS INCLUDED IN TAXABLE WAGES. A COLORADO HEALTH FACILITIES AUTHORITY SERIES A 840752932 196474W48 2005-03-31 50000000 REFUNDING 1999A BONDS 0 0 0 B COLORADO HEALTH FACILITIES AUTHORITY SERIES B 840752932 196474W48 2005-03-31 26294807 PAYMENT OF COMMERCIAL PAPER DEBT 0 0 0 C COLORADO HEALTH FACILITIES AUTHORITY SERIES F 840752932 196474W48 2005-03-31 55000000 REFUNDING 1999A BONDS 0 0 0 A 50000000 3133031 46468713 433893 3097393 2005 0 1 1 1 B 26294807 1644630 25000000 397052 897754 2005 1 0 1 1 C 55000000 3474651 54542446 795916 2005 0 1 1 1 A 0 1 0 0 0.00310 0.00310 0 0 1 B 0 1 0 0 0.00310 0.00310 0 0 1 C 0 1 0 0 0.00310 0.00310 0 0 1 A 0 0 0 1 0 1 JP MORGAN CHASE 25.670000000000 1 0 0 0 1 B 0 0 0 1 0 1 JP MORGAN CHASE 30.830000000000 1 0 0 0 1 C 0 0 0 1 0 0 0 0 1 A 1 B 1 C 1 SCHEDULE K, PART I, COLUMN E BOND ISSUE PRICE THE BOND ISSUE PRICE FOR THE SERIES B BOND DOES NOT EQUAL THE ISSUE PRICE LISTED ON THE FILED FORM 8038 AS THIS BOND WAS SPLIT WITH A RELATED ENTITY. ISSUE PRICE AS REPORTED ON FORM 8038: $83,000,000. SCHEDULE K, PART IV, LINE 2C THE REBATE CALCULATION WAS PERFORMED IN APRIL 2015 FOR THE THREE BOND ISSUANCES. KATHLEEN MICHIE SEE PART V 60807 SEE PART V 0 SCH L, PART IV, BUSINESS TRANSACTIONS INVOLVING INTERESTED PERSONS (A) NAME OF PERSON: KATHLEEN MICHIE(B) RELATIONSHIP BETWEEN INTERESTED PERSON AND ORGANIZATION: KATHLEEN MICHIE IS A FAMILY MEMBER OF THAINE MICHIE, DIRECTOR(D) DESCRIPTION OF TRANSACTION: W-2 WAGES X MEDICAL EQUIP 1 3362520 FMV 0 0 0 PART I, LINE 6 VOLUNTEERS PVH HAS 729 ACTIVE VOLUNTEERS IN FISCAL YEAR 2014. AT POUDRE VALLEY HOSPITAL, MEDICAL CENTER OF THE ROCKIES, AND OFF-SITE LOCATIONS, VOLUNTEERS PLAY AN INTEGRAL ROLE IN PROVIDING MUCH NEEDED SUPPORT FOR PATIENTS, VISITORS, PHYSICIANS, AND STAFF. FROM ASSISTING IN SURGERY AND CARDIAC WAITING ROOMS, INFORMATION DESK, VOLUNTEER PATIENT LIASONS, BABY KNITTERS, VOLUNTEERS, AND PET THERAPY TO NAME JUST A FEW OF THE MANY PROGRAMS, EVERY VOLUNTEER CONTRIBUTES TO THE SUCCESS OF POUDRE VALLEY HEALTH SYSTEM TO ENHANCE THE COMFORT AND CARE OF THE PATIENTS AND THEIR FAMILIES. FORM 990, PART III, LINE 3 IN PRIOR YEARS, PVHC REPORTED THE OPERATIONS OF ITS PHYSICIAN NETWORKS AS A SEPARATE PROGRAM ACTIVITY. THESE PHYSICIAN NETWORKS WERE OPERATED IN SINGLE MEMBER LLCS, WHICH ARE TREATED AS DISREGARDED ENTITIES FOR TAX PURPOSES. THE LARGEST OF THE PHYSICIAN NETWORKS, POUDRE VALLEY MEDICAL GROUP, BECAME A TWO-MEMBER LLC AND HENCE IS NO LONGER A DISREGARDED ENTITY. ITS FINANCIAL ACTIVITY IS REPORTED AS PART OF PART VIII, LINE 2F. THE PROGRAM SERVICE ACCOMPLISHMENTS OF THE REMAINING PHYSICIAN NETWORKS HAVE BEEN ROLLED UP INTO THE PROGRAM SERVICE ACCOMPLISHMENTS REPORTED ON LINE 4A. FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 IS PREPARED BY INDEPENDENT CPAS. A PRELIMINARY DRAFT IS REVIEWED BY THE INTERNAL FINANCE DEPARTMENT. THE FINAL COPY OF THE FORM 990 IS PROVIDED IN AN ELECTRONIC FORMAT TO ALL BOARD OF DIRECTORS PRIOR TO FILING WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C THE ORGANIZATION'S CONFLICT OF INTEREST POLICY REQUIRES COMPLETION OF THE FORM ON AN ANNUAL BASIS BY THE BOARD MEMBERS, OFFICERS AND KEY EMPLOYEES OF THE ORGANIZATION. COMPLETED FORMS ARE SUBMITTED AND REVIEWED BY THE INTERNAL COMPLIANCE DEPARTMENT TO ENSURE COMPLIANCE WITH THE WRITTEN POLICY. ANY QUESTIONS OR ULTIMATE ENFORCEMENT WOULD BE HANDLED BY THE COMPLIANCE DEPARTMENT. FORM 990, PART VI, SECTION B, LINE 15 THE ORGANIZATION IS PART OF THE UC HEALTH SYSTEM. THE SYSTEM PRESIDENT AND CEO DETERMINES THE SALARY OF THE ENTITY CEO'S COMPENSATION ANNUALLY. THIS DETERMINATION IS ACCOMPLISHED THROUGH THE USE OF THE HAYGROUP. THESE SERVICES ANNUALLY COLLECT LIKE DATA ON LIKE JOBS FROM LIKE ORGANIZATIONS. THE DATA IS SUBMITTED TO THE CHIEF HUMAN RESOURCES OFFICER WHO ADVISES THE SYSTEM PRESIDENT AND CEO ON COMPENSATION DECISIONS FOR SENIOR EXECUTIVES. FORM 990, PART VI, SECTION C, LINE 19 GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICIES, AND FINANCIAL STATEMENTS ARE PROVIDED TO THE PUBLIC BASED ON THE BUSINESS PURPOSE FOR THE REQUEST. THESE REQUESTS ARE ADDRESSED BY THE SENIOR MANAGEMENT TEAM ON A CASE BY CASE BASIS. FORM 990, PART XI, LINE 9: MCR DISTRIBUTIONS TO PVH 28,884,981. UMA BEGINNING NET EARNINGS 925,833. INVESTMENT IN CHMG ELIMINATED IN PY 7,870,287. REMOVE CHMG BEGINNING BALANCE 14,031,200. AUXILLIARY INCOME ON 990, NOT IN AUDIT -128,962. DONATION TO FOUNDATION FROM AUXILLIARY NOT IN AUDIT EXPENSE 126,522. CONTRIBUTION FROM FOUNDATION -264,373. BOOK VS. TAX ADJUSTMENT IN EQUITY EARNINGS 29,819,020. TIMBERLINE MEDICAL CLINIC 131 STANLEY AVE ESTES PARK CO 80517 043772090 OUTPATIENT CO 727514 259460 PVHC INC LAKOTA LAKE LLC 2315 E HARMONY RD STE 200 FORT COLLINS CO 80528 841447761 OUTPATIENT CO 3331747 11345569 PVHC INC HERON LAKE LLC 2315 E HARMONY RD STE 200 FORT COLLINS CO 80528 264189163 OUTPATIENT CO 680017 866902 PVHC INC UNITED MED ALLIANCE 2021 BATTLECREEK DRIVE STE A FORT COLLINS CO 80528 820572743 OUTPATIENT CO 87263 0 PVHC INC MEDICAL CENTER OF THE ROCKIES 2315 E HARMONY RD STE 200 FORT COLLINS CO 80528 043730045 TERTIARY CARE CO 501(C)(3) LINE 3 PVHC INC 1 PVHS FOUNDATION 2315 E HARMONY RD STE 200 FORT COLLINS CO 80528 741894581 BENEFIT HEALTH CO 501(C)(3) LINE 7 PVHC INC 1 HARMONY SURGERY CENTER 2127 E HARMONY RD 200 FT COLLINS CO 80528 841479751 AMBULATORY SURG CO N/A RELATED 2097104 2974838 0 0 0.51100 CENTRE AVENUE HEALTH & REHAB FACILITY 947 WORTHINGTON CIRCLE FT COLLINS CO 80526 841560494 NURSING FACILITY CO N/A RELATED 118071 839998 0 0 0.50000 COLUMBINE POUDRE HOME CARE 947 WORTHINGTON CIRCLE FT COLLINS CO 80526 841529817 NURSING CARE CO N/A RELATED 19654 339036 0 0 0.50000 EYE LASER CENTER OF NO COLORADO 1725 E PROSPECT RD FORT COLLINS CO 80525 841518334 LASER SURGERY CO N/A UNRELATED 69802 72233 0 0 0.50000 GATEWAY MEDICAL SERVICES 2500 E PROSPECT RD FORT COLLINS CO 80525 841427970 REAL EST/MED CO N/A UNRELATED 2681931 9178946 0 0 0.50000 POUDRE INFUSION THERAPY 947 WORTHINGTON CIRCLE FORT COLLINS CO 80526 841530973 MEDICAL SERVICES CO N/A RELATED -74044 140209 0 0 0.50000 PVHS HOME MEDICAL SUPPLY 6820 N COUNTY RD 13 LOVELAND CO 80538 202034599 MEDICAL SUPPLY CO N/A UNRELATED 350972 1116658 0 1 0.50000 THE VEIN AND LASER CENTER OF NO COLORADO 2008 CARIBOU DRIVE FORT COLLINS CO 80525 204943970 MEDICAL SERVICES CO N/A UNRELATED -229 47152 0 0 0.33330 HARMONY IMAGING CENTER 1951 WILMINGTON DRIVE FORT COLLINS CO 80528 582479187 MEDICAL IMAGING CO N/A RELATED 972329 1589587 0 0 0.46000 PEAK SURGICAL MANAGEMENT 2127 E HARMONY RD STE 200 FORT COLLINS CO 80528 260899618 SURGICAL MGMT CO N/A RELATED 145094 65013 0 0 0.14290 SURGERY CENTER OF FORT COLLINS 1100 E PROSPECT ROAD FORT COLLINS CO 80525 841541559 SURGICAL PROC CO N/A UNRELATED 456641 1109052 0 0 0.26000 POUDRE VALLEY MEDICAL GROUP LLC 2315 E HARMONY RD STE 200 FORT COLLINS CO 80528 800348943 MEDICAL SERVICES CO N/A RELATED -29907356 28887868 0 1 0.99000 PVHS-ICM EHW 3702 AUTOMATION WAY 103 FORT COLLINS CO 80525 463311308 MEDICAL SERVICES CO N/A RELATED 17064 19064 0 0 0.50000 INNOVATION ENTERPRISES 2315 E HARMONY RD STE 200 FORT COLLINS CO 80528 202036774 IT CONSULTING CO N/A C 985241 3250634 1.00000 1 1 1 1 1 0 0 1 1 0 1 0 1 1 1 1 1 1 1 1 HARMONY SURGERY CENTER A 872457 TRANSACTION TOTAL HARMONY SURGERY CENTER Q 605914 TRANSACTION TOTAL HARMONY SURGERY CENTER S 1058220 TRANSACTION TOTAL UNITED MEDICAL ALLIANCE M 68003 TRANSACTION TOTAL CENTRE AVENUE HEALTH & REHAB FACILITY S 150000 TRANSACTION TOTAL COLUMBINE POUDRE HOME CARE S 125000 TRANSACTION TOTAL EYE LASER CENTER OF NO COLORADO M 102092 TRANSACTION TOTAL GATEWAY MEDICAL SERVICES S 3290000 TRANSACTION TOTAL MEDICAL CENTER OF THE ROCKIES L 6927402 TRANSACTION TOTAL MEDICAL CENTER OF THE ROCKIES M 6097437 TRANSACTION TOTAL MEDICAL CENTER OF THE ROCKIES S 28884981 TRANSACTION TOTAL PVHS FOUNDATION B 844463 TRANSACTION TOTAL PVHS FOUNDATION C 3626893 TRANSACTION TOTAL INNOVATION ENTERPRISES A 122788 TRANSACTION TOTAL INNOVATION ENTERPRISES A 290897 TRANSACTION TOTAL INNOVATION ENTERPRISES S 50530 TRANSACTION TOTAL PVHS-ICM EHW D 50621 TRANSACTION TOTAL POUDRE VALLEY MEDICAL GROUP LLC B 33095072 TRANSACTION TOTAL POUDRE VALLEY MEDICAL GROUP LLC J 3227785 TRANSACTION TOTAL POUDRE VALLEY MEDICAL GROUP LLC M 3874347 TRANSACTION TOTAL