ANTELOPE MEMORIAL HOSPITAL: Form 990, tax year 2013
View the entire original 990 at ProPublica ↗
- Organization
- ANTELOPE MEMORIAL HOSPITAL (EIN 47-0393176)
- Tax period
- 2013-07-01 to 2014-06-30
- Filed
- 2015-01-29
- IRS object ID
- 201520299349300732
- Schema version
- 2013v4.0
- Source
- Download XML · Original 990 at ProPublica
Every field in the e-filed return. Faint text is the IRS element name, for citing.
- Return header
- Form 990
- Schedule A
- Schedule B
- Schedule C
- Schedule D
- Schedule H
- Schedule J
- Schedule K
- Schedule L
- Schedule O
Return header ReturnHeader
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return | 2015-01-29T13:46:07-06:00 | ReturnTs |
| Tax Period End | 2014-06-30 | TaxPeriodEndDt |
Preparer Firm PreparerFirmGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Firm EIN | 476097913 | PreparerFirmEIN |
Preparer Firm Name PreparerFirmName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | SEIM JOHNSON LLP | BusinessNameLine1 |
Preparer US Address PreparerUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 18081 BURT STREET SUITE 200 | AddressLine1 |
| City | OMAHA | City |
| State | NE | State |
| ZIP Code | 680224722 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return Type | 990 | ReturnTypeCd |
| Tax Period Begin | 2013-07-01 | TaxPeriodBeginDt |
Filer Filer
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 470393176 | EIN |
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | ANTELOPE MEMORIAL HOSPITAL | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Control | ANTE | BusinessNameControlTxt |
| Phone | 4028874151 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | PO BOX 229 | AddressLine1 |
| City | NELIGH | City |
| State | NE | State |
| ZIP Code | 68756 | ZIPCode |
Business Officer BusinessOfficerGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person | JACK W GREEN | PersonNm |
| Person Title | ADMINISTRATOR | PersonTitleTxt |
| Phone | 4028874151 | PhoneNum |
| Signature | 2015-01-24 | SignatureDt |
| Discuss With Paid Preparer | Yes (1) | DiscussWithPaidPreparerInd |
Preparer Person PreparerPersonGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Person | BARBARA J FAJEN | PreparerPersonNm |
| PTIN | P00400874 | PTIN |
| Phone | 4023302660 | PhoneNum |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tax | 2013 | TaxYr |
| Build TS | 2016-02-25 16:41:14Z | BuildTS |
Form 990 IRS990
| Field | Value | IRS element (for citing) |
|---|---|---|
| Principal Officer | JACK W GREEN | PrincipalOfficerNm |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | PO BOX 229 | AddressLine1 |
| City | NELIGH | City |
| State | NE | State |
| ZIP Code | 68756 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Receipts | $15,638,101 | GrossReceiptsAmt |
| Group Return For Affiliates | 0 | GroupReturnForAffiliatesInd |
| Organization501c3 | Yes (X) | Organization501c3Ind |
| Website Address | WWW.AMHNE.ORG | WebsiteAddressTxt |
| Type Of Organization Corp | Yes (X) | TypeOfOrganizationCorpInd |
| Formation | 1974 | FormationYr |
| Legal Domicile State | NE | LegalDomicileStateCd |
| Activity Or Mission | TO BUILD, ERECT, MAINTAIN, EXPAND, EQUIP, MANAGE AND OPERATE A HOSPITAL AND AFFILIATED INSTITUTIONS IN THE COUNTY OF ANTELOPE, NEBRASKA FOR THE CARE AND TREATMENT OF SICK AND INFIRM PEOPLE, REGARDLESS OF RACE, CREED, COLOR AND RESIDENCE. | ActivityOrMissionDesc |
| Voting Members Governing Body | 8 | VotingMembersGoverningBodyCnt |
| Voting Members Independent | 8 | VotingMembersIndependentCnt |
| Total Employee | 166 | TotalEmployeeCnt |
| Total Volunteers | 12 | TotalVolunteersCnt |
| Total Gross UBI | $0 | TotalGrossUBIAmt |
| Net Unrelated Bus Txbl Incm | $0 | NetUnrelatedBusTxblIncmAmt |
| PY Contributions Grants | $141,801 | PYContributionsGrantsAmt |
| CY Contributions Grants | $129,585 | CYContributionsGrantsAmt |
| PY Program Service Revenue | $13,385,928 | PYProgramServiceRevenueAmt |
| CY Program Service Revenue | $15,435,268 | CYProgramServiceRevenueAmt |
| PY Investment Income | $40,539 | PYInvestmentIncomeAmt |
| CY Investment Income | $27,534 | CYInvestmentIncomeAmt |
| PY Other Revenue | $90,900 | PYOtherRevenueAmt |
| CY Other Revenue | $45,689 | CYOtherRevenueAmt |
| PY Total Revenue | $13,659,168 | PYTotalRevenueAmt |
| CY Total Revenue | $15,638,076 | CYTotalRevenueAmt |
| PY Grants And Similar Paid | $0 | PYGrantsAndSimilarPaidAmt |
| CY Grants And Similar Paid | $0 | CYGrantsAndSimilarPaidAmt |
| PY Benefits Paid To Members | $0 | PYBenefitsPaidToMembersAmt |
| CY Benefits Paid To Members | $0 | CYBenefitsPaidToMembersAmt |
| PY Salaries Comp Emp Bnft Paid | $7,108,413 | PYSalariesCompEmpBnftPaidAmt |
| CY Salaries Comp Emp Bnft Paid | $7,282,780 | CYSalariesCompEmpBnftPaidAmt |
| PY Total Prof Fndrsng Expns | $0 | PYTotalProfFndrsngExpnsAmt |
| CY Total Prof Fndrsng Expns | $0 | CYTotalProfFndrsngExpnsAmt |
| CY Total Fundraising Expense | $0 | CYTotalFundraisingExpenseAmt |
| PY Other Expenses | $6,374,151 | PYOtherExpensesAmt |
| CY Other Expenses | $7,202,580 | CYOtherExpensesAmt |
| PY Total Expenses | $13,482,564 | PYTotalExpensesAmt |
| CY Total Expenses | $14,485,360 | CYTotalExpensesAmt |
| PY Revenues Less Expenses | $176,604 | PYRevenuesLessExpensesAmt |
| CY Revenues Less Expenses | $1,152,716 | CYRevenuesLessExpensesAmt |
| Total Assets BOY | $17,278,259 | TotalAssetsBOYAmt |
| Total Assets EOY | $18,247,969 | TotalAssetsEOYAmt |
| Total Liabilities BOY | $5,378,654 | TotalLiabilitiesBOYAmt |
| Total Liabilities EOY | $5,238,823 | TotalLiabilitiesEOYAmt |
| Net Assets Or Fund Balances BOY | $11,899,605 | NetAssetsOrFundBalancesBOYAmt |
| Net Assets Or Fund Balances EOY | $13,009,146 | NetAssetsOrFundBalancesEOYAmt |
| Mission | MAKING A DIFFERENCE IN PEOPLE'S LIVES THROUGH EXCELLENT PATIENT CARE. | MissionDesc |
| Significant New Program Srvc | 0 | SignificantNewProgramSrvcInd |
| Significant Change | 0 | SignificantChangeInd |
| Expense | $12,813,588 | ExpenseAmt |
| Revenue | $15,435,268 | RevenueAmt |
| Desc | ANTELOPE MEMORIAL HOSPITAL IS A 25-BED CRITICAL ACCESS HOSPITAL IN NELIGH, NE. IT PROVIDES QUALITY HEALTH CARE REGARDLESS OF RACE, CREED, COLOR, NATIONAL ORIGIN, AGE, GENDER, HANDICAP, OR ABILITY TO PAY. THE HOSPITAL IS A FAMILY-CENTERED, COMMUNITY-ORIENTED HOSPITAL, OFFERING COMPREHENSIVE MEDICAL SERVICES, INCLUDING A FULL-TIME EMERGENCY ROOM. | Desc |
| Total Program Service Expenses | $12,813,588 | TotalProgramServiceExpensesAmt |
| Described In Section501c3 | Yes (1) | DescribedInSection501c3Ind |
| Schedule B Required | Yes (1) | ScheduleBRequiredInd |
| Political Campaign Acty | 0 | PoliticalCampaignActyInd |
| Lobbying Activities | Yes (1) | LobbyingActivitiesInd |
| Subject To Proxy Tax | 0 | SubjectToProxyTaxInd |
| Donor Advised Fund | 0 | DonorAdvisedFundInd |
| Conservation Easements | 0 | ConservationEasementsInd |
| Collections Of Art | 0 | CollectionsOfArtInd |
| Credit Counseling | 0 | CreditCounselingInd |
| Temp Or Permanent Endowments | 0 | TempOrPermanentEndowmentsInd |
| Report Land Building Equipment | Yes (1) | ReportLandBuildingEquipmentInd |
| Report Investments Other Sec | 0 | ReportInvestmentsOtherSecInd |
| Report Program Related Invst | 0 | ReportProgramRelatedInvstInd |
| Report Other Assets | 0 | ReportOtherAssetsInd |
| Report Other Liabilities | Yes (1) | ReportOtherLiabilitiesInd |
| Include FIN48 Footnote | Yes (1) | IncludeFIN48FootnoteInd |
| Independent Audit Fincl Stmt | Yes (1) | IndependentAuditFinclStmtInd |
| Consolidated Audit Fincl Stmt | 0 | ConsolidatedAuditFinclStmtInd |
| School Operating | 0 | SchoolOperatingInd |
| Foreign Office | 0 | ForeignOfficeInd |
| Foreign Activities | 0 | ForeignActivitiesInd |
| More Than5000 K To Org | 0 | MoreThan5000KToOrgInd |
| More Than5000 K To Individuals | 0 | MoreThan5000KToIndividualsInd |
| Professional Fundraising | 0 | ProfessionalFundraisingInd |
| Fundraising Activities | 0 | FundraisingActivitiesInd |
| Gaming Activities | 0 | GamingActivitiesInd |
| Operate Hospital | Yes (1) | OperateHospitalInd |
| Audited Financial Stmt Att | Yes (1) | AuditedFinancialStmtAttInd |
| Grants To Organizations | 0 | GrantsToOrganizationsInd |
| Grants To Individuals | 0 | GrantsToIndividualsInd |
| Schedule J Required | Yes (1) | ScheduleJRequiredInd |
| Tax Exempt Bonds | Yes (1) | TaxExemptBondsInd |
| Invest Tax Exempt Bonds | 0 | InvestTaxExemptBondsInd |
| Escrow Account | 0 | EscrowAccountInd |
| On Behalf Of Issuer | 0 | OnBehalfOfIssuerInd |
| Engaged In Excess Benefit Trans | 0 | EngagedInExcessBenefitTransInd |
| PY Excess Benefit Trans | 0 | PYExcessBenefitTransInd |
| Loan Outstanding | 0 | LoanOutstandingInd |
| Grant To Related Person | 0 | GrantToRelatedPersonInd |
| Business Rln With Org Mem | 0 | BusinessRlnWithOrgMemInd |
| Business Rln With Fam Mem | Yes (1) | BusinessRlnWithFamMemInd |
| Business Rln With Officer Ent | 0 | BusinessRlnWithOfficerEntInd |
| Deductible Non Cash Contri | 0 | DeductibleNonCashContriInd |
| Deductible Art Contribution | 0 | DeductibleArtContributionInd |
| Terminate Operations | 0 | TerminateOperationsInd |
| Partial Liquidation | 0 | PartialLiquidationInd |
| Disregarded Entity | 0 | DisregardedEntityInd |
| Related Entity | 0 | RelatedEntityInd |
| Related Organization Ctrl Ent | 0 | RelatedOrganizationCtrlEntInd |
| Trnsfr Exmpt Non Chrtbl Rltd Org | 0 | TrnsfrExmptNonChrtblRltdOrgInd |
| Activities Conducted Prtshp | 0 | ActivitiesConductedPrtshpInd |
| Schedule O Required | Yes (1) | ScheduleORequiredInd |
| IRP Document | 28 | IRPDocumentCnt |
| IRP Document W2 G | 0 | IRPDocumentW2GCnt |
| Backup Wthld Compliance | Yes (1) | BackupWthldComplianceInd |
| Employee | 166 | EmployeeCnt |
| Employment Tax Returns Filed | Yes (1) | EmploymentTaxReturnsFiledInd |
| Unrelated Bus Incm Over Limit | 0 | UnrelatedBusIncmOverLimitInd |
| Foreign Financial Account | 0 | ForeignFinancialAccountInd |
| Prohibited Tax Shelter Trans | 0 | ProhibitedTaxShelterTransInd |
| Taxable Party Notification | 0 | TaxablePartyNotificationInd |
| Nondeductible Contributions | 0 | NondeductibleContributionsInd |
| Quid Pro Quo Contributions | 0 | QuidProQuoContributionsInd |
| Form8282 Property Disposed Of | 0 | Form8282PropertyDisposedOfInd |
| Rcv Fnds To Pay Prsnl Bnft Cntrct | 0 | RcvFndsToPayPrsnlBnftCntrctInd |
| Pay Premiums Prsnl Bnft Cntrct | 0 | PayPremiumsPrsnlBnftCntrctInd |
| Indoor Tanning Services | 0 | IndoorTanningServicesInd |
| Info In Schedule O Part VI | Yes (X) | InfoInScheduleOPartVIInd |
| Governing Body Voting Members | 8 | GoverningBodyVotingMembersCnt |
| Independent Voting Member | 8 | IndependentVotingMemberCnt |
| Family Or Business Rln | 0 | FamilyOrBusinessRlnInd |
| Delegation Of Mgmt Duties | 0 | DelegationOfMgmtDutiesInd |
| Change To Org Documents | 0 | ChangeToOrgDocumentsInd |
| Material Diversion Or Misuse | 0 | MaterialDiversionOrMisuseInd |
| Members Or Stockholders | 0 | MembersOrStockholdersInd |
| Election Of Board Members | 0 | ElectionOfBoardMembersInd |
| Decisions Subject To Approva | 0 | DecisionsSubjectToApprovaInd |
| Minutes Of Governing Body | Yes (1) | MinutesOfGoverningBodyInd |
| Minutes Of Committees | Yes (1) | MinutesOfCommitteesInd |
| Officer Mailing Address | 0 | OfficerMailingAddressInd |
| Local Chapters | 0 | LocalChaptersInd |
| Form990 Provided To Gvrn Body | Yes (1) | Form990ProvidedToGvrnBodyInd |
| Conflict Of Interest Policy | Yes (1) | ConflictOfInterestPolicyInd |
| Annual Disclosure Covered Prsn | Yes (1) | AnnualDisclosureCoveredPrsnInd |
| Regular Monitoring Enfrc | Yes (1) | RegularMonitoringEnfrcInd |
| Whistleblower Policy | Yes (1) | WhistleblowerPolicyInd |
| Document Retention Policy | Yes (1) | DocumentRetentionPolicyInd |
| Compensation Process CEO | Yes (1) | CompensationProcessCEOInd |
| Compensation Process Other | 0 | CompensationProcessOtherInd |
| Investment In Joint Venture | 0 | InvestmentInJointVentureInd |
| Upon Request | Yes (X) | UponRequestInd |
Books In Care Of Detail BooksInCareOfDetail
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person | MARTHA NELSON | PersonNm |
| Phone | 4028876282 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | PO BOX 229 | AddressLine1 |
| City | NELIGH | City |
| State | NE | State |
| ZIP Code | 68756 | ZIPCode |
Form990 Part VII Section A Form990PartVIISectionAGrp (15 entries)
| TitleTitleTxt | Average Hours Per WeekAverageHoursPerWeekRt | Average Hours Per Week Rltd OrgAverageHoursPerWeekRltdOrgRt | Individual Trustee Or DirectorIndividualTrusteeOrDirectorInd | OfficerOfficerInd | Reportable Comp From OrgReportableCompFromOrgAmt | Reportable Comp From Rltd OrgReportableCompFromRltdOrgAmt | Other CompensationOtherCompensationAmt | Highest Compensated EmployeeHighestCompensatedEmployeeInd |
|---|---|---|---|---|---|---|---|---|
| JOHN MLNARIK | ||||||||
| PRESIDENT | 4.00 | 0.00 | Yes (X) | Yes (X) | $0 | $0 | $0 | |
| JAMES BLACKBURN | ||||||||
| VICE PRESIDENT | 4.00 | 0.00 | Yes (X) | Yes (X) | $0 | $0 | $0 | |
| JOE KNIGHT | ||||||||
| SECRETARY/TREASURER | 4.00 | 0.00 | Yes (X) | Yes (X) | $0 | $0 | $0 | |
| PHILIP KLUTHE | ||||||||
| MEMBER | 2.00 | 0.00 | Yes (X) | $0 | $0 | $0 | ||
| JAMES MEURET | ||||||||
| MEMBER | 2.00 | 0.00 | Yes (X) | $0 | $0 | $0 | ||
| GORDON SHRADER | ||||||||
| MEMBER | 2.00 | 0.00 | Yes (X) | $0 | $0 | $0 | ||
| DAVID SULLIVAN | ||||||||
| MEMBER | 2.00 | 0.00 | Yes (X) | $0 | $0 | $0 | ||
| CHRISTOPHER TWIBELL | ||||||||
| MEMBER | 2.00 | 0.00 | Yes (X) | $0 | $0 | $0 | ||
| JACK W GREEN | ||||||||
| CEO | 40.00 | 0.00 | Yes (X) | $148,007 | $0 | $13,365 | ||
| MARTHA NELSON | ||||||||
| CFO | 36.00 | 0.00 | Yes (X) | $75,085 | $0 | $9,951 | ||
| ROGER RUDLOFF | ||||||||
| PHYSICIAN | 40.00 | 0.00 | $296,603 | $0 | $18,789 | Yes (X) | ||
| TROY DAWSON | ||||||||
| PHYSICIAN | 40.00 | 0.00 | $284,253 | $0 | $18,789 | Yes (X) | ||
| PATRICIA GOOD | ||||||||
| APRN | 40.00 | 0.00 | $113,085 | $0 | $10,664 | Yes (X) | ||
| SHARON GOSSMAN | ||||||||
| APRN | 40.00 | 0.00 | $103,309 | $0 | $10,155 | Yes (X) | ||
| KAREN GALLAGHER | ||||||||
| PHARMACIST | 40.00 | 0.00 | $102,499 | $0 | $10,267 | Yes (X) | ||
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Reportable Comp From Org | $1,122,841 | TotalReportableCompFromOrgAmt |
| Tot Reportable Comp Rltd Org | $0 | TotReportableCompRltdOrgAmt |
| Total Other Compensation | $91,980 | TotalOtherCompensationAmt |
| Indiv Rcvd Greater Than100 K | 5 | IndivRcvdGreaterThan100KCnt |
| Former Ofcr Employees Listed | 0 | FormerOfcrEmployeesListedInd |
| Total Comp Greater Than150 K | Yes (1) | TotalCompGreaterThan150KInd |
| Compensation From Other Srcs | 0 | CompensationFromOtherSrcsInd |
Contractor Compensation ContractorCompensationGrp (5 entries)
| Address Line1ContractorAddress/USAddress/AddressLine1 | CityContractorAddress/USAddress/City | StateContractorAddress/USAddress/State | ZIP CodeContractorAddress/USAddress/ZIPCode | ServicesServicesDesc | CompensationCompensationAmt |
|---|---|---|---|---|---|
| HAUSMANN CONSTRUCTION | |||||
| 8545 EXECUTIVE WOODS DRIVE SUITE 1 | LINCOLN | NE | 68512 | CONTRACTOR | $1,550,896 |
| OVERLAND REHAB SERVICES | |||||
| 405 JAMES STREET | VERDIGRE | NE | 68783 | PHYSICAL THERAPY SERVICES | $470,050 |
| TKO | |||||
| PO BOX 385 | NELIGH | NE | 68756 | NURSING SERVICES | $425,000 |
| MEDTYPE TRANSCRIPTION INC | |||||
| 404 NORTH 28TH STREET | NORFOLK | NE | 68701 | TRANSCRIPTION | $139,750 |
| NEBRASKA LABLINC | |||||
| PO BOX 26410 | FAIRVIEW PARK | OH | 44126 | REFERENCE LAB | $114,411 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Cntrct Rcvd Greater Than100 K | 5 | CntrctRcvdGreaterThan100KCnt |
| All Other Contributions | $129,585 | AllOtherContributionsAmt |
| Total Contributions | $129,585 | TotalContributionsAmt |
Program Service Revenue ProgramServiceRevenueGrp (5 entries)
| DescDesc | BusinessBusinessCd | Total Revenue ColumnTotalRevenueColumnAmt | Related Or Exempt Func IncomeRelatedOrExemptFuncIncomeAmt |
|---|---|---|---|
| MEDICARE/MEDICAID PAYMENTS | 621400 | $7,841,181 | $7,841,181 |
| NET PATIENT SERVICE REVENUE | 621400 | $5,328,571 | $5,328,571 |
| 340B REVENUE | 611400 | $1,794,057 | $1,794,057 |
| MEANINGFUL USE REVENUE | 621400 | $451,139 | $451,139 |
| AMBULANCE | 621910 | $6,600 | $6,600 |
Total Oth Program Service Rev TotalOthProgramServiceRevGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $13,720 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $13,720 | RelatedOrExemptFuncIncomeAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Revenue | $15,435,268 | TotalProgramServiceRevenueAmt |
Investment Income InvestmentIncomeGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $23,218 | TotalRevenueColumnAmt |
| Exclusion | $23,218 | ExclusionAmt |
Gross Amount Sales Assets GrossAmountSalesAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | $4,341 | OtherAmt |
Less Cost Oth Basis Sales Expnss LessCostOthBasisSalesExpnssGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | $25 | OtherAmt |
Gain Or Loss GainOrLossGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | $4,316 | OtherAmt |
Net Gain Or Loss Investments NetGainOrLossInvestmentsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $4,316 | TotalRevenueColumnAmt |
| Exclusion | $4,316 | ExclusionAmt |
Other Revenue Misc OtherRevenueMiscGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Desc | CAFETERIA | Desc |
| Business | 900099 | BusinessCd |
| Total Revenue Column | $45,689 | TotalRevenueColumnAmt |
| Exclusion | $45,689 | ExclusionAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Revenue Total | $45,689 | OtherRevenueTotalAmt |
Total Revenue TotalRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $15,638,076 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $15,435,268 | RelatedOrExemptFuncIncomeAmt |
| Unrelated Business Revenue | $0 | UnrelatedBusinessRevenueAmt |
| Exclusion | $73,223 | ExclusionAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part IX | Yes (X) | InfoInScheduleOPartIXInd |
Comp Current Ofcr Directors CompCurrentOfcrDirectorsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $246,409 | TotalAmt |
| Management And General | $246,409 | ManagementAndGeneralAmt |
Comp Disqual Persons CompDisqualPersonsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $45,275 | TotalAmt |
| Program Services | $45,275 | ProgramServicesAmt |
Other Salaries And Wages OtherSalariesAndWagesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $5,629,943 | TotalAmt |
| Program Services | $5,001,800 | ProgramServicesAmt |
| Management And General | $628,143 | ManagementAndGeneralAmt |
Pension Plan Contributions PensionPlanContributionsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $178,697 | TotalAmt |
| Program Services | $161,050 | ProgramServicesAmt |
| Management And General | $17,647 | ManagementAndGeneralAmt |
Other Employee Benefits OtherEmployeeBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $779,276 | TotalAmt |
| Program Services | $678,620 | ProgramServicesAmt |
| Management And General | $100,656 | ManagementAndGeneralAmt |
Payroll Taxes PayrollTaxesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $403,180 | TotalAmt |
| Program Services | $344,994 | ProgramServicesAmt |
| Management And General | $58,186 | ManagementAndGeneralAmt |
Fees For Services Legal FeesForServicesLegalGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $40,853 | TotalAmt |
| Management And General | $40,853 | ManagementAndGeneralAmt |
Fees For Services Accounting FeesForServicesAccountingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $36,169 | TotalAmt |
| Management And General | $36,169 | ManagementAndGeneralAmt |
Fees For Services Other FeesForServicesOtherGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $2,321,299 | TotalAmt |
| Program Services | $1,925,708 | ProgramServicesAmt |
| Management And General | $395,591 | ManagementAndGeneralAmt |
Advertising AdvertisingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $43,705 | TotalAmt |
| Program Services | $18,711 | ProgramServicesAmt |
| Management And General | $24,994 | ManagementAndGeneralAmt |
Office Expenses OfficeExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $534,892 | TotalAmt |
| Program Services | $457,803 | ProgramServicesAmt |
| Management And General | $77,089 | ManagementAndGeneralAmt |
Occupancy OccupancyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $213,726 | TotalAmt |
| Program Services | $213,726 | ProgramServicesAmt |
Travel TravelGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $45,561 | TotalAmt |
| Program Services | $41,911 | ProgramServicesAmt |
| Management And General | $3,650 | ManagementAndGeneralAmt |
Interest InterestGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $123,780 | TotalAmt |
| Program Services | $123,780 | ProgramServicesAmt |
Depreciation Depletion DepreciationDepletionGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,201,283 | TotalAmt |
| Program Services | $1,201,283 | ProgramServicesAmt |
Insurance InsuranceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $165,232 | TotalAmt |
| Program Services | $165,232 | ProgramServicesAmt |
Other Expenses OtherExpensesGrp (4 entries)
| DescDesc | TotalTotalAmt | Program ServicesProgramServicesAmt | Management And GeneralManagementAndGeneralAmt |
|---|---|---|---|
| MEDICAL SUPPLIES | $1,959,953 | $1,959,953 | |
| BAD DEBT | $423,194 | $423,194 | |
| MISCELLANEOUS EXPENSE | $39,106 | $8,057 | $31,049 |
| DUES & SUBSCRIPTIONS | $37,461 | $37,461 |
All Other Expenses AllOtherExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $16,366 | TotalAmt |
| Program Services | $5,030 | ProgramServicesAmt |
| Management And General | $11,336 | ManagementAndGeneralAmt |
Total Functional Expenses TotalFunctionalExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $14,485,360 | TotalAmt |
| Program Services | $12,813,588 | ProgramServicesAmt |
| Management And General | $1,671,772 | ManagementAndGeneralAmt |
| Fundraising | $0 | FundraisingAmt |
Cash Non Interest Bearing CashNonInterestBearingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,132,795 | BOYAmt |
| EOY | $135,149 | EOYAmt |
Savings And Temp Cash Invst SavingsAndTempCashInvstGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,602,251 | BOYAmt |
| EOY | $3,320,411 | EOYAmt |
Pledges And Grants Receivable PledgesAndGrantsReceivableGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $37,722 | BOYAmt |
| EOY | $29,724 | EOYAmt |
Accounts Receivable AccountsReceivableGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,440,609 | BOYAmt |
| EOY | $1,565,026 | EOYAmt |
Oth Notes Loans Receivable Net OthNotesLoansReceivableNetGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $149,530 | BOYAmt |
| EOY | $23,966 | EOYAmt |
Inventories For Sale Or Use InventoriesForSaleOrUseGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $296,150 | BOYAmt |
| EOY | $307,178 | EOYAmt |
Prepaid Expenses Defrd Charges PrepaidExpensesDefrdChargesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $39,114 | BOYAmt |
| EOY | $98,787 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Land Bldg Equip Cost Or Other Bss | $21,507,171 | LandBldgEquipCostOrOtherBssAmt |
| Land Bldg Equip Accum Deprec | $9,970,702 | LandBldgEquipAccumDeprecAmt |
Land Bldg Equip Basis Net LandBldgEquipBasisNetGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $12,028,434 | BOYAmt |
| EOY | $11,536,469 | EOYAmt |
Investments Pub Traded Sec InvestmentsPubTradedSecGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $466,102 | BOYAmt |
| EOY | $483,155 | EOYAmt |
Other Assets Total OtherAssetsTotalGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $85,552 | BOYAmt |
| EOY | $748,104 | EOYAmt |
Total Assets TotalAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $17,278,259 | BOYAmt |
| EOY | $18,247,969 | EOYAmt |
Accounts Payable Accr Expnss AccountsPayableAccrExpnssGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,721,720 | BOYAmt |
| EOY | $1,448,166 | EOYAmt |
Deferred Revenue DeferredRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| EOY | $46,300 | EOYAmt |
Tax Exempt Bond Liabilities TaxExemptBondLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $3,310,000 | BOYAmt |
| EOY | $3,075,000 | EOYAmt |
Other Liabilities OtherLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $346,934 | BOYAmt |
| EOY | $669,357 | EOYAmt |
Total Liabilities TotalLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $5,378,654 | BOYAmt |
| EOY | $5,238,823 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Organization Follows SFAS117 | Yes (X) | OrganizationFollowsSFAS117Ind |
Unrestricted Net Assets UnrestrictedNetAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $11,883,880 | BOYAmt |
| EOY | $13,003,989 | EOYAmt |
Temporarily Rstr Net Assets TemporarilyRstrNetAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $15,725 | BOYAmt |
| EOY | $5,157 | EOYAmt |
Total Net Assets Fund Balance TotalNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $11,899,605 | BOYAmt |
| EOY | $13,009,146 | EOYAmt |
Tot Liab Net Assets Fund Balance TotLiabNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $17,278,259 | BOYAmt |
| EOY | $18,247,969 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part XI | Yes (X) | InfoInScheduleOPartXIInd |
| Reconcilation Revenue Expnss | $1,152,716 | ReconcilationRevenueExpnssAmt |
| Net Unrlzd Gains Losses Invst | $3,125 | NetUnrlzdGainsLossesInvstAmt |
| Other Changes In Net Assets | -$46,300 | OtherChangesInNetAssetsAmt |
| Info In Schedule O Part XII | Yes (X) | InfoInScheduleOPartXIIInd |
| Method Of Accounting Accrual | Yes (X) | MethodOfAccountingAccrualInd |
| Accountant Compile Or Review | 0 | AccountantCompileOrReviewInd |
| FS Audited | Yes (1) | FSAuditedInd |
FS Audited Basis FSAuditedBasisGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Separate Basis Fincl Stmt | Yes (X) | SeparateBasisFinclStmtInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Audit Committee | Yes (1) | AuditCommitteeInd |
| Federal Grant Audit Required | 0 | FederalGrantAuditRequiredInd |
Schedule A IRS990ScheduleA
| Field | Value | IRS element (for citing) |
|---|---|---|
| Hospital | Yes (X) | HospitalInd |
Schedule B IRS990ScheduleB
Contributor Information ContributorInformationGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Contributor | RESTRICTED | ContributorNum |
Contributor Business Name ContributorBusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | RESTRICTED | BusinessNameLine1 |
Contributor US Address ContributorUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | RESTRICTED | AddressLine1 |
| Address Line2 | RESTRICTED | AddressLine2 |
| City | RESTRICTED | City |
| State | RESTRICTED | State |
| ZIP Code | RESTRICTED | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Contributions | RESTRICTED | TotalContributionsAmt |
Schedule C IRS990ScheduleC
| Field | Value | IRS element (for citing) |
|---|---|---|
| Volunteers | 0 | VolunteersInd |
| Paid Staff Or Management | 0 | PaidStaffOrManagementInd |
| Media Advertisements | 0 | MediaAdvertisementsInd |
| Mailings Members | 0 | MailingsMembersInd |
| Publications Or Broadcast | 0 | PublicationsOrBroadcastInd |
| Grants Other Organizations | 0 | GrantsOtherOrganizationsInd |
| Direct Contact Legislators | 0 | DirectContactLegislatorsInd |
| Rallies Demonstrations | 0 | RalliesDemonstrationsInd |
| Other Activities | Yes (1) | OtherActivitiesInd |
| Other Activities | $1,441 | OtherActivitiesAmt |
| Total Lobbying Expenditures | $1,441 | TotalLobbyingExpendituresAmt |
| Not Described Section501c3 | 0 | NotDescribedSection501c3Ind |
Supplemental Information Detail SupplementalInformationDetail
| Field | Value | IRS element (for citing) |
|---|---|---|
| Form And Line Reference | PART II-B, LINE 1: | FormAndLineReferenceDesc |
| Explanation | PORTION OF THE DUES PAID TO THE NEBRASKA HOSPITAL ASSOCIATION AND THE AMERICAN HOSPITAL ASSOCIATION ARE ALLOCABLE TO LOBBYING ACTIVITIES. | ExplanationTxt |
Schedule D IRS990ScheduleD
Land LandGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $63,764 | OtherCostOrOtherBasisAmt |
| Book Value | $63,764 | BookValueAmt |
Buildings BuildingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $6,465,891 | OtherCostOrOtherBasisAmt |
| Depreciation | $2,873,340 | DepreciationAmt |
| Book Value | $3,592,551 | BookValueAmt |
Equipment EquipmentGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $11,516,889 | OtherCostOrOtherBasisAmt |
| Depreciation | $6,292,650 | DepreciationAmt |
| Book Value | $5,224,239 | BookValueAmt |
Other Land Buildings OtherLandBuildingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $3,460,627 | OtherCostOrOtherBasisAmt |
| Depreciation | $804,712 | DepreciationAmt |
| Book Value | $2,655,915 | BookValueAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Book Value Land Buildings | $11,536,469 | TotalBookValueLandBuildingsAmt |
Other Liabilities Org OtherLiabilitiesOrgGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Desc | ESTIMATED THIRD-PARTY PAYER SETTLEMENT | Desc |
| Amt | $669,357 | Amt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Liability | $669,357 | TotalLiabilityAmt |
| Footnote Text | Yes (X) | FootnoteTextInd |
| Total Rev Etc Audited Fincl Stmt | $15,169,958 | TotalRevEtcAuditedFinclStmtAmt |
| Net Unrealized Gains Invst | $3,125 | NetUnrealizedGainsInvstAmt |
| Revenue Not Reported | $3,125 | RevenueNotReportedAmt |
| Revenue Subtotal | $15,166,833 | RevenueSubtotalAmt |
| Other Revenues Not Included | $471,243 | OtherRevenuesNotIncludedAmt |
| Revenue Not Reported Fincl Stmt | $471,243 | RevenueNotReportedFinclStmtAmt |
| Total Revenue Per Form990 | $15,638,076 | TotalRevenuePerForm990Amt |
| Tot Expns Etc Audited Fincl Stmt | $14,060,417 | TotExpnsEtcAuditedFinclStmtAmt |
| Expenses Not Reported | $0 | ExpensesNotReportedAmt |
| Expenses Subtotal | $14,060,417 | ExpensesSubtotalAmt |
| Other Expenses Not Included | $424,943 | OtherExpensesNotIncludedAmt |
| Expenses Not Rpt Fincl Stmt | $424,943 | ExpensesNotRptFinclStmtAmt |
| Total Expenses Per Form990 | $14,485,360 | TotalExpensesPerForm990Amt |
Supplemental Information Detail SupplementalInformationDetail (3 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| PART X, LINE 2: | THE HOSPITAL IS A NOT-FOR-PROFIT CORPORATION AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE AND IS EXEPMT FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE CODE. THE INTERNAL REVENUE SERVICE HAS ESTABLISHED STANDARDS TO BE MET TO MAINTAIN TAX EXEPMT STATUS. IN GENERAL, SUCH STANDARDS REQUIRE THE HOSPITAL TO MEET A COMMUNITY BENEFIT STANDARD AND COMPLY WITH VARIOUS LAWS AND REGULATIONS. THE HOSPITAL ACCOUNTS FOR UNCERTAINTIES IN ACCOUNTING FOR INCOME TAX ASSETS AND LIABILITIES USING GUIDANCE INCLUDED IN FASB ASC 740, INCOME TAXES. THE HOSPITAL RECOGNIZES THE EFFECT OF INCOME TAX POSITIONS ONLY IF THOSE POSITIONS ARE MORE LIKELY THAN NOT OF BEING SUSTAINED. AT JUNE 30, 2014 AND 2013, THE HOSPITAL HAD NO UNCERTAIN TAX POSITIONS ACCRUED. WITH FEW EXCEPTIONS, THE HOSPITAL IS NO LONGER SUBJECT TO INCOME TAX EXAMINATIONS BY THE U.S. FEDERAL, STATE OR LOCAL TAX AUTHORITIES FOR YEARS ENDED PRIOR TO JUNE 30, 2011. |
| PART XI, LINE 4B - OTHER ADJUSTMENTS: | FUNDRAISING EXPENSES 1,749. PROVISION FOR BAD DEBTS 423,194. DEFERRED GRANT REVENUE 46,300. |
| PART XII, LINE 4B - OTHER ADJUSTMENTS: | FUNDRAISING EXPENSES 1,749. PROVISION FOR BAD DEBTS 423,194. |
Schedule H IRS990ScheduleH
| Field | Value | IRS element (for citing) |
|---|---|---|
| Financial Assistance Policy | Yes (1) | FinancialAssistancePolicyInd |
| Written Policy | Yes (1) | WrittenPolicyInd |
| FPG Reference Free Care | Yes (1) | FPGReferenceFreeCareInd |
| Percent100 | Yes (X) | Percent100Ind |
| FPG Reference Discounted Care | 0 | FPGReferenceDiscountedCareInd |
| Free Care Medically Indigent | Yes (1) | FreeCareMedicallyIndigentInd |
| Financial Assistance Budget | Yes (1) | FinancialAssistanceBudgetInd |
| Expenses Exceed Budget | Yes (1) | ExpensesExceedBudgetInd |
| Unable To Provide Care | 0 | UnableToProvideCareInd |
| Annual Community Bnft Report | Yes (1) | AnnualCommunityBnftReportInd |
| Report Publically Available | Yes (1) | ReportPublicallyAvailableInd |
Financial Assistance At Cost Typ FinancialAssistanceAtCostTyp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $73,658 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $73,658 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00520 | TotalExpensePct |
Unreimbursed Medicaid UnreimbursedMedicaidGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $756,879 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $583,655 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $173,224 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.01230 | TotalExpensePct |
Total Financial Assistance Typ TotalFinancialAssistanceTyp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $830,537 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $583,655 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $246,882 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.01750 | TotalExpensePct |
Community Health Services CommunityHealthServicesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $27,011 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $16,942 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $10,069 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00070 | TotalExpensePct |
Subsidized Health Services SubsidizedHealthServicesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $961,315 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $739,132 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $222,183 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.01580 | TotalExpensePct |
Total Other Benefits TotalOtherBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $988,326 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $756,074 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $232,252 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.01650 | TotalExpensePct |
Total Community Benefits TotalCommunityBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $1,818,863 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $1,339,729 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $479,134 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.03400 | TotalExpensePct |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bad Debt Expense Reported | Yes (1) | BadDebtExpenseReportedInd |
| Bad Debt Expense | $423,194 | BadDebtExpenseAmt |
| Bad Debt Expense Attributable | $0 | BadDebtExpenseAttributableAmt |
| Reimbursed By Medicare | $7,088,594 | ReimbursedByMedicareAmt |
| Cost Of Care Reimbursed By Medcr | $7,352,652 | CostOfCareReimbursedByMedcrAmt |
| Medicare Surplus Or Shortfall | -$264,058 | MedicareSurplusOrShortfallAmt |
Costing Methodology Used CostingMethodologyUsedGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Cost To Charge Ratio | Yes (X) | CostToChargeRatioInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Written Debt Collection Policy | Yes (1) | WrittenDebtCollectionPolicyInd |
| Financial Assistance Prvsn | 0 | FinancialAssistancePrvsnInd |
| Hospital Facilities | 1 | HospitalFacilitiesCnt |
Hospital Facilities HospitalFacilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | 1 | FacilityNum |
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | ANTELOPE MEMORIAL HOSPITAL | BusinessNameLine1 |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 102 WEST 9TH STREET | AddressLine1 |
| City | NELIGH | City |
| State | NE | State |
| ZIP Code | 68756 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Website Address | WWW.AMHNE.ORG | WebsiteAddressTxt |
| State License | 020001 | StateLicenseNum |
| Licensed Hospital | Yes (X) | LicensedHospitalInd |
| Critical Access Hospital | Yes (X) | CriticalAccessHospitalInd |
| Emergency Room24 Hrs | Yes (X) | EmergencyRoom24HrsInd |
Hospital Fclty Policies Prctc HospitalFcltyPoliciesPrctcGrp
Hospital Facility Name HospitalFacilityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | ANTELOPE MEMORIAL HOSPITAL | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | 1 | FacilityNum |
| CHNA Conducted | Yes (1) | CHNAConductedInd |
| Community Definition | Yes (X) | CommunityDefinitionInd |
| Community Demographics | Yes (X) | CommunityDemographicsInd |
| Existing Resources | Yes (X) | ExistingResourcesInd |
| How Data Obtained | Yes (X) | HowDataObtainedInd |
| Community Health Needs | Yes (X) | CommunityHealthNeedsInd |
| Other Health Issues | Yes (X) | OtherHealthIssuesInd |
| Community Hlth Needs Id Process | Yes (X) | CommunityHlthNeedsIdProcessInd |
| Consulting Process | Yes (X) | ConsultingProcessInd |
| Information Gaps | Yes (X) | InformationGapsInd |
| CHNA Conducted | 12 | CHNAConductedYr |
| Take Into Account Others Input | Yes (1) | TakeIntoAccountOthersInputInd |
| CHNA Conducted With Other Fclts | 0 | CHNAConductedWithOtherFcltsInd |
| CHNA Report Widely Available | Yes (1) | CHNAReportWidelyAvailableInd |
| Rpt Available On Own Website | Yes (X) | RptAvailableOnOwnWebsiteInd |
| Own Website URL | WWW.AMHNE.ORG | OwnWebsiteURLTxt |
| Rpt Available Upon Request | Yes (X) | RptAvailableUponRequestInd |
| Adopt Implementation Strategy | Yes (X) | AdoptImplementationStrategyInd |
| Exec Implementation Strategy | Yes (X) | ExecImplementationStrategyInd |
| Develop Community Wide Plan | Yes (X) | DevelopCommunityWidePlanInd |
| Exec Community Wide Plan | Yes (X) | ExecCommunityWidePlanInd |
| Adopt Budget | Yes (X) | AdoptBudgetInd |
| Prioritize Health Needs | Yes (X) | PrioritizeHealthNeedsInd |
| Prioritize Services | Yes (X) | PrioritizeServicesInd |
| All Needs Addressed | Yes (1) | AllNeedsAddressedInd |
| Organization Incur Excise Tax | 0 | OrganizationIncurExciseTaxInd |
| Elig Criteria Explained | Yes (1) | EligCriteriaExplainedInd |
| FPG Used Deter Elig Free Care | Yes (1) | FPGUsedDeterEligFreeCareInd |
| FPG Family Incm Lmt Free Care | 100.000000000000 | FPGFamilyIncmLmtFreeCarePct |
| FPG Used Determ Elig Dscnt Care | 0 | FPGUsedDetermEligDscntCareInd |
| Explained Basis | 0 | ExplainedBasisInd |
| App Financial Asst Expln | Yes (1) | AppFinancialAsstExplnInd |
| Includes Publicity Measures | Yes (1) | IncludesPublicityMeasuresInd |
| Attached To Invoice | Yes (X) | AttachedToInvoiceInd |
| Other Publicity | Yes (X) | OtherPublicityInd |
| FAP Actions On Nonpayment | Yes (1) | FAPActionsOnNonpaymentInd |
| Collection Activities | 0 | CollectionActivitiesInd |
| FAP Notified All Patients | Yes (X) | FAPNotifiedAllPatientsInd |
| Nondis Emergency Care Policy | Yes (1) | NondisEmergencyCarePolicyInd |
| Other Method Used | Yes (X) | OtherMethodUsedInd |
| Amounts Generally Billed | 0 | AmountsGenerallyBilledInd |
| Gross Charges | 0 | GrossChargesInd |
Supplemental Information SupplementalInformationGrp (5 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| PART V, SECTION A: | ANTELOPE MEMORIAL HOSPITAL OPERATES A 25-BED CRITICAL ACCESS HOSPITAL. THE HOSPITAL ALSO OFFERS PHYSICIAN CLINICS, CARDIAC REHAB, AND HOME HEALTH. |
| ANTELOPE MEMORIAL HOSPITAL | PART V, SECTION B, LINE 3: ANTELOPE MEMORIAL HOSPITAL MET WITH COMMUNITY REPRESENTATIVES OF THE SCHOOLS, LOCAL GOVERNMENT, POLICE, MINISTERIAL ASSOCIATION, CHAMBER OF COMMERCE, NURSING HOME, ASSISTED LIVING, AND OTHER INTERESTED CITIZENS. |
| ANTELOPE MEMORIAL HOSPITAL | PART V, SECTION B, LINE 11: ANTELOPE MEMORIAL HOSPITAL DOES NOT PROVIDE DISCOUNTED CARE. |
| ANTELOPE MEMORIAL HOSPITAL | PART V, SECTION B, LINE 14G: ALTHOUGH THE CHARITY CARE POLICY DOES NOT SPECIFICALLY DESCRIBE HOW IT IS TO BE PUBLICIZED WITHIN THE COMMUNITY, IT DOES CONTAIN THIS STATEMENT: "ALL PATIENTS WILL BE NOTIFIED OF PROVIDER'S CHARITY CARE POLICY AS LEGALLY REQUIRED." THE CHARITY CARE POLICY IS MAILED TO ALL PATIENTS WITH THE EXTERNAL COLLECTION POLICY AND THE PATIENT'S INVOICE FOR SERVICES. |
| ANTELOPE MEMORIAL HOSPITAL | PART V, SECTION B, LINE 20D: CHARGES FOR SERVICES ARE THE SAME FOR ALL PATIENTS, WHETHER THEY ARE ELIGIBLE OR NOT ELIGIBLE FOR FINANCIAL ASSISTANCE. |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | 5 | FacilityNum |
Oth Hlth Care Fclts Not Hospital OthHlthCareFcltsNotHospitalGrp
Oth Hlth Care Fclts OthHlthCareFcltsGrp (5 entries)
| Address Line1USAddress/AddressLine1 | CityUSAddress/City | StateUSAddress/State | ZIP CodeUSAddress/ZIPCode | FacilityFacilityTxt |
|---|---|---|---|---|
| AMH FAMILY PRACTICE | ||||
| 109 WEST 11TH STREET PO BOX 109 | NELIGH | NE | 68756 | FAMILY PRACTICE MEDICAL CLINIC |
| AMH CLEARWATER CLINIC | ||||
| HIGHWAY 275 MAIN STREET | CLEARWATER | NE | 68726 | FAMILY PRACTICE MEDICAL CLINIC |
| AMH ELGIN CLINIC | ||||
| 101 WEST CEDAR STREET | ELGIN | NE | 68636 | FAMILY PRACTICE MEDICAL CLINIC |
| ORCHARD MEDICAL CLINIC | ||||
| 103 WASHINGTON STREET | ORCHARD | NE | 68764 | FAMILY PRACTICE MEDICAL CLINIC |
| AMH TILDEN CLINIC | ||||
| 104 SOUTH CENTER | TILDEN | NE | 68781 | FAMILY PRACTICE MEDICAL CLINIC |
Supplemental Information Detail SupplementalInformationDetail (17 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| PART I, LINE 3C: | NOT APPLICABLE: FEDERAL POVERTY GUIDELINES ARE USED TO DETERMINE ELIGIBILITY FOR PROVIDING FREE CARE TO LOW INCOME INDIVIDUALS. DISCOUNTED CARE IS NOT PROVIDED. PATIENTS ARE CATEGORIZED EITHER AS BEING ELIGIBLE FOR FREE CARE OR AS RESPONSIBLE FOR REGULAR PATIENT CHARGES. |
| PART I, LINE 6A: | ANTELOPE MEMORIAL HOSPITAL'S COMMUNITY BENEFIT REPORT IS NOT PREPARED BY A RELATED ORGANIZATION. |
| PART I, LINE 7: | THE COST TO CHARGE RATIO AS FOLLOWS WAS USED TO DETERMINE CHARITY CARE AND MEANS-TESTED GOVERNMENT PROGRAMS AT COST: (TOTAL EXPENSES - BAD DEBT) / GROSS PATIENT SERVICE REVENUE = PERCENTAGE OF COST TO CHARGE. OTHER COMMUNITY BENEFIT EXPENSES ARE STATED AT COST BASED ON ANTELOPE MEMORIAL HOSPITAL'S INTERNAL ACCOUNTING RECORDS. |
| PART I, LINE 7G: | THERE ARE NO COSTS ATTRIBUTABLE TO A PHYSICIAN CLINIC INCLUDED ON LINE 7G. |
| PART I, LN 7 COL(F): | THE COST OF BAD DEBT THAT HAS BEEN SUBTRACTED FROM TOTAL EXPENSES TO DETERMINE THE DENOMINATOR IN THE PERCENTAGES FOR COLUMN (F) IS $423,194. |
| PART II, COMMUNITY BUILDING ACTIVITIES: | NOT APPLICABLE. |
| PART III, LINE 2: | IN EVALUATING THE COLLECTIBILITY OF 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 FOR THOSE ACCOUNTS OVER A CERTAIN AGE BASED ON DISCHARGE 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. |
| PART III, LINE 3: | THE HOSPITAL PROVIDES CHARITY CARE TO PATIENTS WHO ARE FINANCIALLY UNABLE TO PAY FOR THE HEALTHCARE SERVICES THEY RECEIVE. IT IS THE POLICY OF THE HOSPITAL NOT TO PURSUE COLLECTION OF AMOUNTS DETERMINED TO QUALIFY AS CHARITY CARE. ACCORDINGLY, THE HOSPITAL DOES NOT REPORT THESE AMOUNTS IN NET OPERATING REVENUE OR IN THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. THE HOSPITAL DETERMINES THE COSTS ASSOCIATED WITH PROVIDING CHARITY CARE BY AGGREGATING THE DIRECT AND INDIRECT COSTS, INCLUDING SALARIES, BENEFITS, SUPPLIES, AND OTHER OPERATING EXPENSES, BASED ON AN OVERALL COST TO CHARGE RATIO. |
| PART III, LINE 4: | THE HOSPITAL'S FINANCIAL STATMENTS DO NOT CONTAIN A SPECIFIC FOOTNOTE DESCRIBING BAD DEBT. HOWEVER, THE FOLLOWING IS THE TEXT OF THE FOOTNOTE TITLED "PATIENT RECEIVABLES, NET," "NET PATIENT SERVICE REVENUE" AND "CHARITY CARE":PATIENT RECEIVABLES, NET:THE HOSPITAL REPORTS PATIENT ACCOUNTS RECEIVABLE FOR SERVICES RENDERED AT NET REALIZABLE AMOUNTS FROM THIRD-PARTY PAYORS, PATIENTS AND OTHERS. ACCOUNTS RECEIVABLE ARE REDUCED BY AN ALLOWANCE FOR DOUBTFUL ACCOUNTS. IN EVALUATING THE COLLECTIBILITY OF 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 FOR THOSE ACCOUNTS OVER A CERTAIN AGE BASED ON DISCHARGE 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 ACCOUNTSNET PATIENT SERVICE REVENUE:THE HOSPITAL HAS AGREEMENTS WITH THIRD-PARTY PAYORS THAT PROVIDE FOR PAYMENTS TO THE HOSPITAL AT AMOUNTS DIFFERENT FROM ITS ESTABLISHED RATES. PAYMENT ARRANGEMENTS 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. RETROACTIVE ADJUSTMENTS ARE ACCRUED ON AN ESTIMATED BASIS IN THE PERIOD THE RELATED SERVICES ARE RENDERED AND ADJUSTED IN FUTURE PERIODS AS FINAL SETTLEMENTS ARE DETERMINED.CHARITY CARE:THE HOSPITAL PROVIDES CARE TO PATIENTS WHO MEET CERTAIN CRITERIA UNDER ITS CHARITY CARE POLICY WITHOUT CHARGE OR AT AMOUNTS LESS THAN ITS ESTABLISHED RATES. BECAUSE THE HOSPITAL DOES NOT PURSUE COLLECTION OF AMOUNTS DETERMINED TO QUALIFY AS CHARITY CARE, THEY ARE NOT REPORTED IN THE STATEMENTS OF OPERATIONS.THE HOSPITAL IS DEDICATED TO PROVIDING COMPREHENSIVE HEALTHCARE SERVICE TO ALL SEGMENTS OF SOCIETY, INCLUDING THE AGED AND OTHERWISE ECONOMICALLY DISADVANTAGED. IN ADDITION, THE HOSPITAL PROVIDES A VARIETY OF COMMUNITY HEALTH SERVICES AT OR BELOW COST. |
| PART III, LINE 8: | "MEDICARE ALLOWABLE COSTS OF CARE" WAS CALCULATED FROM INFORMATION IN THE MEDICARE COST REPORT D, E, H & M WORKSHEETS, OR PS&R. IT DOES NOT INCLUDE ALL OF THE MEDICARE REVENUES AND COSTS. IF ALL OF THE MEDICARE REVENUES AND COSTS WERE INCLUDED, THE SHORTFALL WOULD BE GREATER THAN THAT SHOWN ON LINE 7. THE SHORTFALL REPRESENTS ACTUAL UNREIMBURSED COSTS INCURRED BY ANTELOPE MEMORIAL HOSPITAL IN PROVIDING SERVICES TO INDIVIDUALS ELIGIBLE FOR MEDICARE. THE COMMUNITY BENEFITS BECAUSE THE HOSPITAL APPLIES OTHER REVENUES TO COVER THE COSTS OF CARING FOR MEDICARE PATIENTS. |
| PART III, LINE 9B: | THE COLLECTION POLICY INCLUDES AN EXPLANATION OF ANTELOPE MEMORIAL HOSPITAL'S CHARITY CARE PROGRAM. THE PROGRAM IS CONSIDERED A "LAST RESORT FOR PATIENTS MAKING A GENUINE EFFORT TO PAY THEIR BILLS. ALL OTHER AVENUES FOR PAYMENT MUST BE EXHAUSTED (SUCH AS MEDICAID, DISABILITY, KID'S CONNECTION) BEFORE THIS PROGRAM APPLIES." REGULAR COLLECTION EFFORTS WILL BE FOLLOWED UNTIL A DETERMINATION IS MADE FROM A COMPLETED ASSISTANCE APPLICATION THAT A PATIENT QUALIFIES FOR FINANCIAL ASSISTANCE. |
| PART VI, LINE 2: | ANTELOPE MEMORIAL HOSPITAL PERFORMED THE FOLLOWING PROCEDURES TO ASSESS THE HEALTH NEEDS OF THE COMMUNITY IT SERVES: - COMMUNITY HEALTH NEEDS ASSESSMENT (CNHA) - PLANNING MEETING AND CNHA RESULTS PRESENTATION - COMMUNITY FOCUS GROUP MEETINGS - CONFERENCE CALLS WITH DHHS PERSONNEL FOR INPUT, GUIDANCE, AND FEEDBACK - STRATEGIC PLANNING SESSIONS - CHIP DOCUMENT DRAFTING, EDITING, REVISION, AND COMPLETION - COORDINATION OF CHIP WORK GROUP MEETINGS |
| PART VI, LINE 3: | ANTELOPE MEMORIAL HOSPITAL INCLUDES ITS PAYMENT POLICY WITH ALL STATEMENTS SENT TO PATIENTS. THIS POLICY EXPLAINS THE HOSPITAL'S CHARITY CARE PROGRAM AND GIVES INSTRUCTIONS FOR THE APPLICATION PROCESS. |
| PART VI, LINE 4: | ANTELOPE MEMORIAL HOSPITAL IS THE LARGEST ACUTE CARE FACILITY SERVING THE ANTELOPE COUNTY AREA. CURRENTLY THERE ARE TWO HOSPITALS PROVIDING ACUTE CARE SERVICES WITHIN ANTELOPE COUNTY. THE HOSPITAL ALSO PROVIDES SERVICE TO THE FOLLOWING FIVE NEBRASKA COUNTIES: BOONE, HOLT, KNOX, MADISON, AND PIERCE. |
| PART VI, LINE 5: | NOT APPLICABLE. |
| PART VI, LINE 6: | ANTELOPE MEMORIAL HEALTH SYSTEM IS NOT PART OF AN AFFILIATED HEALTH CARE ORGANIZATION. |
| FORM 990, PART VI, LINE 7: | NEBRASKA DOES NOT REQUIRE THE FILING OF A COMMUNITY BENEFIT REPORT WITH THE STATE. A COMMUNITY BENEFIT REPORT IS FILED ANNUALLY WITH THE NEBRASKA HOSPITAL ASSOCIATION. ALSO, A MEDICARE COST REPORT IS FILED ANNUALLY WITH NEBRASKA. |
Schedule J IRS990ScheduleJ
| Field | Value | IRS element (for citing) |
|---|---|---|
| Independent Consultant | Yes (X) | IndependentConsultantInd |
| Compensation Survey | Yes (X) | CompensationSurveyInd |
| Board Or Committee Approval | Yes (X) | BoardOrCommitteeApprovalInd |
| Severance Payment | 0 | SeverancePaymentInd |
| Supplemental Nonqual Rtr Plan | 0 | SupplementalNonqualRtrPlanInd |
| Equity Based Comp Arrngm | 0 | EquityBasedCompArrngmInd |
| Comp Based On Revenue Of Flng Org | 0 | CompBasedOnRevenueOfFlngOrgInd |
| Comp Bsd On Rev Related Orgs | 0 | CompBsdOnRevRelatedOrgsInd |
| Comp Bsd Net Earns Flng Org | 0 | CompBsdNetEarnsFlngOrgInd |
| Comp Bsd Net Earns Rltd Orgs | 0 | CompBsdNetEarnsRltdOrgsInd |
| Any Non Fixed Payments | 0 | AnyNonFixedPaymentsInd |
| Initial Contract Exception | 0 | InitialContractExceptionInd |
Rltd Org Officer Trst Key Empl RltdOrgOfficerTrstKeyEmplGrp (3 entries)
| TitleTitleTxt | Base Compensation Filing OrgBaseCompensationFilingOrgAmt | Compensation Based On Rltd OrgsCompensationBasedOnRltdOrgsAmt | Bonus Filing OrganizationBonusFilingOrganizationAmount | Bonus Related OrganizationsBonusRelatedOrganizationsAmt | Other Compensation Filing OrgOtherCompensationFilingOrgAmt | Other Compensation Rltd OrgsOtherCompensationRltdOrgsAmt | Deferred Compensation Flng OrgDeferredCompensationFlngOrgAmt | Deferred Comp Rltd OrgsDeferredCompRltdOrgsAmt | Nontaxable Benefits Filing OrgNontaxableBenefitsFilingOrgAmt | Nontaxable Benefits Rltd OrgsNontaxableBenefitsRltdOrgsAmt | Total Compensation Filing OrgTotalCompensationFilingOrgAmt | Total Compensation Rltd OrgsTotalCompensationRltdOrgsAmt | Comp Report Prior990 Filing OrgCompReportPrior990FilingOrgAmt | Comp Report Prior990 Rltd OrgsCompReportPrior990RltdOrgsAmt |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| JACK W GREEN | ||||||||||||||
| CEO | $147,779 | $0 | $0 | $0 | $228 | $0 | $6,465 | $0 | $6,900 | $0 | $161,372 | $0 | $0 | $0 |
| ROGER RUDLOFF | ||||||||||||||
| PHYSICIAN | $296,265 | $0 | $0 | $0 | $338 | $0 | $11,889 | $0 | $6,900 | $0 | $315,392 | $0 | $0 | $0 |
| TROY DAWSON | ||||||||||||||
| PHYSICIAN | $283,925 | $0 | $0 | $0 | $328 | $0 | $11,889 | $0 | $6,900 | $0 | $303,042 | $0 | $0 | $0 |
Schedule K IRS990ScheduleK
Tax Exempt Bonds Issues TaxExemptBondsIssuesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bond Reference | A | BondReferenceCd |
Issuer Name IssuerName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | HOSPITAL AUTH NO 1 OF ANTELOPE CTY NE | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bond Issuer EIN | 900198231 | BondIssuerEIN |
| CUSIP | 03665RBB5 | CUSIPNum |
| Bond Issued | 2010-12-21 | BondIssuedDt |
| Issue Price | $3,770,000 | IssuePriceAmt |
| Purpose | REFUND PRIOR ISSUE (7/1/2004) | PurposeDesc |
| Defeased | 0 | DefeasedInd |
| On Behalf Of Issuer | 0 | OnBehalfOfIssuerInd |
| Pool Financing | 0 | PoolFinancingInd |
Tax Exempt Bonds Proceeds TaxExemptBondsProceedsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bond Reference | A | BondReferenceCd |
| Retired | $695,000 | RetiredAmt |
| Total Proceeds | $3,770,000 | TotalProceedsAmt |
| In Reserve Fund | $363,647 | InReserveFundAmt |
| Other Spent Proceeds | $3,770,000 | OtherSpentProceedsAmt |
| Substantial Completion | 2006 | SubstantialCompletionYr |
| Current Refunding | Yes (1) | CurrentRefundingInd |
| Advance Refunding | 0 | AdvanceRefundingInd |
| Final Allocation Made | Yes (1) | FinalAllocationMadeInd |
| Adequate Books And Rec Maint | Yes (1) | AdequateBooksAndRecMaintInd |
Tax Exempt Bonds Private Bus Use TaxExemptBondsPrivateBusUseGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bond Reference | A | BondReferenceCd |
| Owning Bond Financed Property | 0 | OwningBondFinancedPropertyInd |
| Any Lease Arrangements | 0 | AnyLeaseArrangementsInd |
| Mgmt Contract Bond Fincd Prop | 0 | MgmtContractBondFincdPropInd |
| Any Research Agreements | 0 | AnyResearchAgreementsInd |
| Bond Iss Meet Prvt Sec Pymt Test | 0 | BondIssMeetPrvtSecPymtTestInd |
| Change In Use Bond Financed Prop | 0 | ChangeInUseBondFinancedPropInd |
| Procs Nonqualified Bond Remdtd | Yes (1) | ProcsNonqualifiedBondRemdtdInd |
Tax Exempt Bonds Arbitrage TaxExemptBondsArbitrageGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bond Reference | A | BondReferenceCd |
| Form8038 T Filed | 0 | Form8038TFiledInd |
| Rebate Not Due Yet | Yes (1) | RebateNotDueYetInd |
| Exception To Rebate | Yes (1) | ExceptionToRebateInd |
| No Rebate Due | 0 | NoRebateDueInd |
| Variable Rate Issue | 0 | VariableRateIssueInd |
| Hedge Identified In Bks And Rec | 0 | HedgeIdentifiedInBksAndRecInd |
| Gross Proceeds Invested In GIC | 0 | GrossProceedsInvestedInGICInd |
| Gross Proceeds Invested | 0 | GrossProceedsInvestedInd |
| Written Proc To Monitor Reqs | Yes (1) | WrittenProcToMonitorReqsInd |
Procedures Corrective Action ProceduresCorrectiveActionGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bond Reference | A | BondReferenceCd |
| Procedures Corrective Action | Yes (1) | ProceduresCorrectiveActionInd |
Supplemental Information Detail SupplementalInformationDetail
| Field | Value | IRS element (for citing) |
|---|---|---|
| Form And Line Reference | FORM 990, SCHEDULE K, PART II, LINE 3: | FormAndLineReferenceDesc |
| Explanation | THE TOTAL PROCEEDS DO NOT EQUAL THE SUM OF LINES 4 THROUGH 12 DUE TO TRANSFERRED OR REPLACEMENT PROCEEDS IN LINE 4. | ExplanationTxt |
Schedule L IRS990ScheduleL
Bus Tr Involve Interested Prsn BusTrInvolveInterestedPrsnGrp
Name Of Interested NameOfInterested
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person | PEGGY GREEN | PersonNm |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Relationship Description | FAMILY MEMBER OF JACK GREEN, CEO FOR ANTELOPE MEMORIAL HOSPITAL. | RelationshipDescriptionTxt |
| Transaction | $45,275 | TransactionAmt |
| Transaction | COMPENSATION WAS PAID TO PEGGY GREEN FOR HER SERVICES AS AN EMPLOYEE OF ANTELOPE MEMORIAL HOSPTIAL. | TransactionDesc |
| Sharing Of Revenues | 0 | SharingOfRevenuesInd |
Schedule O IRS990ScheduleO
Supplemental Information Detail SupplementalInformationDetail (7 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| FORM 990, PART VI, SECTION B, LINE 11 | THE FORM 990 IS PREPARED BY A CERTIFIED PUBLIC ACCOUNTANT AND DELIVERED TO THE CHIEF FINANCIAL OFFICER. THE CFO REVIEWS FORM 990 AND PRESENTS IT AT A MONTHLY BOARD MEETING, PRIOR TO FILING. |
| FORM 990, PART VI, SECTION B, LINE 12C | ALL OFFICERS, DIRECTORS, COMMITTEE MEMBERS, AND KEY EMPLOYEES SHALL REVIEW THE CONFLICT OF INTEREST POLICY AND COMPLETE A CONFLICT OF INTEREST QUESTIONNAIRE AND CERTIFICATION UPON INITIAL AFFILIATION WITH THE CORPORATION AND ON AN ANNUAL BASIS THEREAFTER. |
| FORM 990, PART VI, SECTION B, LINE 15A | SALARY COMPARISON DATA FROM THE NEBRASKA HOSPITAL ASSOCIATION IS USED TO COMPARE ADMINISTRATOR SALARY WITH THAT OF OTHER NEBRASKA CRITICAL ACCESS HOSPITALS. THE CHIEF EXECUTIVE OFFICER AND CHIEF FINANCIAL OFFICER SALARIES ARE DETERMINED USING THE NEBRASKA HOSPITAL ASSOCIATION SALARY SURVEYS AND ARE THEN SET BY THE BOARD OF DIRECTORS. THE BOARD MINUTES DOCUMENT THE DELIBERATIONS AND SALARY DECISIONS. |
| FORM 990, PART VI, SECTION C, LINE 19 | THE ORGANIZATION DOES NOT MAKE THESE DOCUMENTS AVAILABLE TO THE PUBLIC. |
| FORM 990, PART IX, LINE 11G | OTHER FEES FOR SERVICE: PROGRAM SERVICE EXPENSES 877,539. MANAGEMENT AND GENERAL EXPENSES 95,633. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 973,172. DATA PROCESSING FEES: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 299,958. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 299,958. THERAPIST FEES: PROGRAM SERVICE EXPENSES 874,327. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 874,327. NUCLEAR IMAGING FEES: PROGRAM SERVICE EXPENSES 71,356. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 71,356. MRI FEES: PROGRAM SERVICE EXPENSES 53,300. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 53,300. COLLECTION FEES: PROGRAM SERVICE EXPENSES 47,656. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 47,656. EEG : PROGRAM SERVICE EXPENSES 1,530. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,530. |
| FORM 990, PART XI, LINE 9: | DEFERRED GRANT REVENUE -46,300. |
| FORM 990, PART XII, LINE 2C: | THE FULL BOARD OF DIRECTORS OVERSEES SELECTION OF AN INDEPENDENT ACCOUNTANT AND THE AUDIT OF THE ANTELOPE MEMORIAL HOSPITAL'S FINANCIAL STATEMENTS. |
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