2015-01-29T13:46:07-06:00 2014-06-30 476097913 SEIM JOHNSON LLP 18081 BURT STREET SUITE 200 OMAHA NE 680224722 990 2013-07-01 470393176 ANTELOPE MEMORIAL HOSPITAL ANTE 4028874151 PO BOX 229 NELIGH NE 68756 JACK W GREEN ADMINISTRATOR 4028874151 2015-01-24 1 BARBARA J FAJEN P00400874 4023302660 2013 2016-02-25 16:41:14Z JACK W GREEN PO BOX 229 NELIGH NE 68756 15638101 0 X WWW.AMHNE.ORG X 1974 NE 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. 8 8 166 12 0 0 141801 129585 13385928 15435268 40539 27534 90900 45689 13659168 15638076 0 0 0 0 7108413 7282780 0 0 0 6374151 7202580 13482564 14485360 176604 1152716 17278259 18247969 5378654 5238823 11899605 13009146 MAKING A DIFFERENCE IN PEOPLE'S LIVES THROUGH EXCELLENT PATIENT CARE. 0 0 12813588 15435268 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. 12813588 1 1 0 1 0 0 0 0 0 0 1 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 1 28 0 1 166 1 0 0 0 0 0 0 0 0 0 0 X 8 8 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 0 0 X MARTHA NELSON 4028876282 PO BOX 229 NELIGH NE 68756 JOHN MLNARIK PRESIDENT 4.00 0.00 X X 0 0 0 JAMES BLACKBURN VICE PRESIDENT 4.00 0.00 X X 0 0 0 JOE KNIGHT SECRETARY/TREASURER 4.00 0.00 X X 0 0 0 PHILIP KLUTHE MEMBER 2.00 0.00 X 0 0 0 JAMES MEURET MEMBER 2.00 0.00 X 0 0 0 GORDON SHRADER MEMBER 2.00 0.00 X 0 0 0 DAVID SULLIVAN MEMBER 2.00 0.00 X 0 0 0 CHRISTOPHER TWIBELL MEMBER 2.00 0.00 X 0 0 0 JACK W GREEN CEO 40.00 0.00 X 148007 0 13365 MARTHA NELSON CFO 36.00 0.00 X 75085 0 9951 ROGER RUDLOFF PHYSICIAN 40.00 0.00 X 296603 0 18789 TROY DAWSON PHYSICIAN 40.00 0.00 X 284253 0 18789 PATRICIA GOOD APRN 40.00 0.00 X 113085 0 10664 SHARON GOSSMAN APRN 40.00 0.00 X 103309 0 10155 KAREN GALLAGHER PHARMACIST 40.00 0.00 X 102499 0 10267 1122841 0 91980 5 0 1 0 HAUSMANN CONSTRUCTION 8545 EXECUTIVE WOODS DRIVE SUITE 1 LINCOLN NE 68512 CONTRACTOR 1550896 OVERLAND REHAB SERVICES 405 JAMES STREET VERDIGRE NE 68783 PHYSICAL THERAPY SERVICES 470050 TKO PO BOX 385 NELIGH NE 68756 NURSING SERVICES 425000 MEDTYPE TRANSCRIPTION INC 404 NORTH 28TH STREET NORFOLK NE 68701 TRANSCRIPTION 139750 NEBRASKA LABLINC PO BOX 26410 FAIRVIEW PARK OH 44126 REFERENCE LAB 114411 5 129585 129585 MEDICARE/MEDICAID PAYMENTS 621400 7841181 7841181 NET PATIENT SERVICE REVENUE 621400 5328571 5328571 340B REVENUE 611400 1794057 1794057 MEANINGFUL USE REVENUE 621400 451139 451139 AMBULANCE 621910 6600 6600 13720 13720 15435268 23218 23218 4341 25 4316 4316 4316 CAFETERIA 900099 45689 45689 45689 15638076 15435268 0 73223 X 246409 246409 45275 45275 5629943 5001800 628143 178697 161050 17647 779276 678620 100656 403180 344994 58186 40853 40853 36169 36169 2321299 1925708 395591 43705 18711 24994 534892 457803 77089 213726 213726 45561 41911 3650 123780 123780 1201283 1201283 165232 165232 MEDICAL SUPPLIES 1959953 1959953 BAD DEBT 423194 423194 MISCELLANEOUS EXPENSE 39106 8057 31049 DUES & SUBSCRIPTIONS 37461 37461 16366 5030 11336 14485360 12813588 1671772 0 1132795 135149 1602251 3320411 37722 29724 1440609 1565026 149530 23966 296150 307178 39114 98787 21507171 9970702 12028434 11536469 466102 483155 85552 748104 17278259 18247969 1721720 1448166 46300 3310000 3075000 346934 669357 5378654 5238823 X 11883880 13003989 15725 5157 11899605 13009146 17278259 18247969 X 1152716 3125 -46300 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 1441 1441 0 PART II-B, LINE 1: PORTION OF THE DUES PAID TO THE NEBRASKA HOSPITAL ASSOCIATION AND THE AMERICAN HOSPITAL ASSOCIATION ARE ALLOCABLE TO LOBBYING ACTIVITIES. 63764 63764 6465891 2873340 3592551 11516889 6292650 5224239 3460627 804712 2655915 11536469 ESTIMATED THIRD-PARTY PAYER SETTLEMENT 669357 669357 X 15169958 3125 3125 15166833 471243 471243 15638076 14060417 0 14060417 424943 424943 14485360 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. 1 1 1 X 0 1 1 1 0 1 1 73658 73658 0.00520 756879 583655 173224 0.01230 830537 583655 246882 0.01750 27011 16942 10069 0.00070 961315 739132 222183 0.01580 988326 756074 232252 0.01650 1818863 1339729 479134 0.03400 1 423194 0 7088594 7352652 -264058 X 1 0 1 1 ANTELOPE MEMORIAL HOSPITAL 102 WEST 9TH STREET NELIGH NE 68756 WWW.AMHNE.ORG 020001 X X X ANTELOPE MEMORIAL HOSPITAL 1 1 X X X X X X X X X 12 1 0 1 X WWW.AMHNE.ORG X X X X X X X X 1 0 1 1 100.000000000000 0 0 1 1 X X 1 0 X 1 X 0 0 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. 5 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 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. X X X 0 0 0 0 0 0 0 0 0 JACK W GREEN CEO 147779 0 0 0 228 0 6465 0 6900 0 161372 0 0 0 ROGER RUDLOFF PHYSICIAN 296265 0 0 0 338 0 11889 0 6900 0 315392 0 0 0 TROY DAWSON PHYSICIAN 283925 0 0 0 328 0 11889 0 6900 0 303042 0 0 0 A HOSPITAL AUTH NO 1 OF ANTELOPE CTY NE 900198231 03665RBB5 2010-12-21 3770000 REFUND PRIOR ISSUE (7/1/2004) 0 0 0 A 695000 3770000 363647 3770000 2006 1 0 1 1 A 0 0 0 0 0 0 1 A 0 1 1 0 0 0 0 0 1 A 1 FORM 990, SCHEDULE K, PART II, LINE 3: THE TOTAL PROCEEDS DO NOT EQUAL THE SUM OF LINES 4 THROUGH 12 DUE TO TRANSFERRED OR REPLACEMENT PROCEEDS IN LINE 4. PEGGY GREEN FAMILY MEMBER OF JACK GREEN, CEO FOR ANTELOPE MEMORIAL HOSPITAL. 45275 COMPENSATION WAS PAID TO PEGGY GREEN FOR HER SERVICES AS AN EMPLOYEE OF ANTELOPE MEMORIAL HOSPTIAL. 0 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.