2014-04-15T10:51:05-05:00 2013-05-31 450250958 EIDE BAILLY LLP 800 NICOLLET MALL STE 1300 MINNEAPOLIS MN 554027033 990 2012-06-01 810233121 ST PETER'S HOSPITAL STPE 4064442100 2475 BROADWAY HELENA MT 59601 JOHN GREEN 4064442100 2014-04-15 1 KIM HUNWARDSEN CPA P00484560 6122536500 2014-04-15 2012 2015-11-30 17:44:51Z NATHAN C OLSON 2475 BROADWAY HELENA MT 59601 187029569 0 X WWW.STPETES.ORG X 1883 MT PROVIDE EXCEPTIONAL AND COMPASSIONATE HEALTH CARE. 15 11 1363 108 214087 -289523 593525 431149 163534823 181045731 1677614 5087195 61533 96880 165867495 186660955 14253 41566 0 0 77313898 85201123 0 0 331330 82984400 88008785 160312551 173251474 5554944 13409481 232092045 251823454 82889308 78667157 149202737 173156297 X ST. PETER'S HOSPITAL PARTNERS WITH OUR PATIENTS, COMMUNITY, AND MEDICAL STAFF TO PROVIDE EXCEPTIONAL AND COMPASSIONATE HEALTH CARE. 0 0 121233168 41566 135784298 ST. PETER'S HOSPITAL IS A 123-BED ACUTE CARE HOSPITAL FACILITY SERVING RESIDENTS OF LEWIS AND CLARK COUNTY AND PORTIONS OF JEFFERSON, BROADWATER, MEAGHER AND POWELL COUNTIES. ST. PETER'S IS THE SOLE FACILITY IN THE PRIMARY SERVICE AREA. DURING THE YEAR ENDED MAY 31, 2013 THE HOSPITAL PROVIDED AT COST A TOTAL OF $16,302,661 IN COMMUNITY BENEFIT. OF THIS TOTAL $4,249,196 WAS FOR MEDICAL SERVICES TO INDIVIDUALS WHO WERE DETERMINED UNABLE TO PURCHASE SUCH SERVICES UNDER THE HOSPITAL'S CHARITY CARE POLICY. IN ADDITION TO FREE CARE AND/OR SUBSIDIZED CARE, CARE IS ALSO PROVIDED AT BELOW COST RATES TO PERSONS COVERED BY GOVERNMENTAL PROGRAMS. THE TOTAL OPERATING LOSS FOR PROVIDING CARE TO MEDICAID PATIENTS WAS $1,834,550. THE HOSPITAL PROVIDED $9,613,801 IN SUBSIDIZED HEALTH SERVICES DURING THE YEAR, INCLUDING ACUTE PATIENT CARE FOR MEDICAL, SURGICAL, PEDIATRIC AND BEHAVIORAL HEALTH PATIENTS, OUTPATIENT PHARMACY, PULMONARY REHAB, DIALYSIS, CLINICAL NUTRITION, ANTICOAGULATION, AND HOSPITALISTS SERVICES, PHYSICIAN CLINICS AND IN-HOME NURSING AND OXYGEN SERVICES. TO FULFILL ITS MISSION OF COMMUNITY SERVICE, THE ORGANIZATION 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 ORGANIZATION DOES NOT PURSUE COLLECTION OF AMOUNTS DETERMINED TO QUALIFY AS CHARITY CARE, THEY ARE NOT REPORTED AS PATIENT SERVICE REVENUE. 21394088 45261433 THE HOSPITAL OPERATES SEVERAL PHYSICIAN CLINICS, EMPLOYING 59 PHYSICIANS AND PHYSICIAN ASSISTANTS AND NURSE PRACTITIONERS. WITHOUT THE HOSPITAL'S ASSISTANCE, LEWIS AND CLARK COUNTY WOULD BE WITHOUT MANY NEEDED MEDICAL AND SURGICAL SPECIALTIES. PHYSICIANS IN THE SPECIALTIES OF FAMILY PRACTICE, INTERNAL MEDICINE, NEUROLOGY, RHEUMATOLOGY, GASTROENTEROLOGY, ENT, CARDIOLOGY, RADIATION AND MEDICAL ONCOLOGY HAD APPROXIMATELY 199,704 PATIENT ENCOUNTERS. 142627256 1 1 0 1 0 0 0 0 0 1 1 1 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 1 1 1 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 1 1 1 0 0 1 160 0 1 1363 1 1 1 0 0 0 0 0 0 0 0 0 X 15 11 0 0 0 0 0 1 0 1 1 0 0 1 1 1 1 1 1 1 1 1 1 X JOHN GREEN CFO 4064442100 2475 BROADWAY HELENA MT 59601 PATTY NELSON 1.00 0.00 X X 0 0 0 DR MARIA BRAMAN 1.00 0.00 X X 63890 0 3559 WILLIAM NORTHEY 1.00 0.00 X X 0 0 0 GUY ALMQUIST 1.00 0.00 X X 0 0 0 JOHN FLINK 1.00 0.00 X X 0 0 0 RICK HAYS 1.00 0.00 X 0 0 0 JOHN GALT MD 1.00 0.00 X 9391 0 0 DUANE BRUCE 1.00 0.00 X 0 0 0 JAMES BURKHOLDER MD 1.00 0.00 X 319082 0 15657 TOM STRIZICH MD 1.00 0.00 X 13403 0 0 MICHAEL HAY 1.00 0.00 X 0 0 0 MICK ROBINSON 1.00 0.00 X 0 0 0 RYAN SCRENAR 1.00 1.00 X 0 0 0 ROGER STONE 1.00 0.00 X 0 0 0 MARK TAYLOR 1.00 0.00 X 0 0 0 NATHAN C OLSON 40.00 1.00 X X 50000 0 0 JOHN GREEN 40.00 0.00 X 242964 0 21395 TOM GREGG 40.00 1.00 X 355872 0 16918 DR MICHAEL LEE 40.00 0.00 X 809761 0 13096 DR THOMAS WEINER 40.00 0.00 X 1423381 0 23542 DR MATTHEW MCLAREN 40.00 0.00 X 606118 0 15160 DR SCOTT PARGOT 40.00 0.00 X 667107 0 15707 DR JEFFREY MARTIN 40.00 0.00 X 842891 0 8353 JOHN SOLHEIM 0.00 0.00 X 741353 0 21160 6145213 0 154547 79 1 1 0 HORIZON MENTAL HEALTH MANAGEMENT PO BOX 840839 DALLAS TX 75284 PSYCHIATRIC SERVICES 2954408 DICK ANDERSON CONSTRUCTION 3424 HIGHWAY 12 E HELENA MT 59601 GENERAL CONTRACTOR 1500372 CAPITAL MEDICAL ANESTHESIA PO BOX 5179 HELENA MT 59601 ANESTHESIA SERVICES 705000 GE HEALTHCARE PO BOX 414-SN471 MILWAUKEE WI 53201 BIOMEDICAL SERVICES 700693 ARUP LABORATORIES 500 CHIPETA WAY SALT LAKE CITY UT 84108 LAB TESTING SERVICES 647533 44 286584 144565 431149 PATIENT SERVICE REVENUE 622110 125000412 125000412 PHARMACY 446110 50177657 50177657 OTHER SERVICES 900099 3245817 3049584 196233 INCOME FROM JOINT VENTURES 900099 1051278 1147913 -96635 CAFETERIA 722210 667331 655140 12191 903236 800938 102298 181045731 5118144 5118144 315409 119136 284289 53376 31120 65760 96880 96880 20127 10822 -20127 -10822 -30949 -30949 186660955 180831644 214087 5184075 27520 27520 14046 14046 1383192 177304 1205888 66019500 54162073 11626119 231308 6937980 5259428 1665959 12593 6734511 5558052 1133329 43130 4125940 3223100 887900 14940 463144 9845 453299 74180 74180 50178 50178 404385 404385 13974067 11028224 2939755 6088 329001 71828 250501 6672 1652559 603574 1040456 8529 1300014 276656 1023358 1973852 334977 1635641 3234 311048 146266 162060 2722 356954 170268 186591 95 1799258 1799258 9317533 6728545 2588988 1956923 1956923 MEDICAL SUPPLIES, OTHER 41610761 40626782 981960 2019 BAD DEBT EXPENSE 10850345 10850345 BED TAX 1401500 1401500 OTHER TAXES 38089 38089 144994 144994 173251474 142627256 30292888 331330 16135251 24687067 22948724 26768453 3948805 3613773 3569726 2961254 2339570 176565145 80549370 97399185 96015775 64567768 72359338 24048654 21522128 417436 612592 232092045 251823454 16427015 18873326 42231476 37016209 24230817 22777622 82889308 78667157 X 138230176 160820583 3217396 4332327 7755165 8003387 149202737 173156297 232092045 251823454 X 13409481 4713331 5830748 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 1 50 0 0 1 100 0 1 50178 50328 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: THE HOSPITAL HIRED A CONSULTANT TO PROVIDE LOBBYING SERVICES IN CONNECTION WITH GOVERNMENTAL AFFAIRS REPRESENTATION TO ENSURE HOSPITAL, COMMUNITY, AND EMPLOYEE INTERESTS AND NEEDS ARE REPRESENTED. IN ADDITION, A PORTION OF AHA/MHA DUES ARE ATTRIBUTED TO LOBBYING SERVICES. 10598351 64337 979412 35418 11606682 10709927 489607 -542431 58752 10598351 9692852 127911 1052329 163165 10709927 7514363 1405761 928225 155497 9692852 9393554 630667 -2297705 212153 7514363 0.68950 0.31050 0 1 1 3745203 3745203 97953299 27710554 70242745 72559534 51506865 21052669 2307109 1331951 975158 96015775 INVESTMENT IN JOINT VENTURES 2434525 F INTEREST IN ST. PETER'S FOUNDATION 12473422 F LTD CLASS INVESTMENTS 6614181 F 21522128 ESTIMATED THIRD-PARTY SETTLEMENTS 1996668 LIABILITY FOR PENSION BENEFITS 20780954 22777622 X 175932285 -10850345 -10850345 186782630 404385 -526060 -121675 186660955 162334409 337665 337665 161996744 404385 10850345 11254730 173251474 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: ENDOWMENT FUNDS ARE RESTRICTED FOR SUPPORT OF HOSPITAL PROGRAMS AND SERVICES AND FOR CAPITAL PURCHASES AND IMPROVEMENTS IN ACCORDANCE WITH BOARD POLICIES AND/OR DONOR RESTRICTIONS. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X, LINE 2: THE HOSPITAL AND FOUNDATION ARE MONTANA NONPROFIT CORPORATIONS AND HAVE BEEN RECOGNIZED BY THE INTERNAL REVENUE SERVICE (IRS) AS EXEMPT FROM FEDERAL INCOME TAXES UNDER INTERNAL REVENUE CODE SECTION 501(C)(3). THE HOSPITAL AND THE FOUNDATION ARE ANNUALLY REQUIRED TO FILE A RETURN OF ORGANIZATION EXEMPT FROM INCOME TAX (FORM 990) WITH THE IRS. IN ADDITION, THE HOSPITAL IS SUBJECT TO INCOME TAX ON NET INCOME THAT IS DERIVED FROM BUSINESS ACTIVITIES THAT ARE UNRELATED TO ITS EXEMPT PURPOSE. THE HOSPITAL FILES AN EXEMPT ORGANIZATION BUSINESS INCOME TAX RETURN (FORM 990T) WITH THE IRS TO REPORT ITS UNRELATED BUSINESS TAXABLE INCOME. PEAK HEALTH HELENA, LLC IS A LIMITED LIABILITY COMPANY AND IS TREATED AS A CORPORATION FOR FEDERAL AND STATE INCOME TAX PURPOSES. THERE WAS NO TAXABLE INCOME IN 2013 AND 2012. THE ORGANIZATION BELIEVES THAT IT HAS APPROPRIATE SUPPORT FOR ANY TAX POSITIONS TAKEN AFFECTING ITS ANNUAL FILING REQUIREMENTS, AND AS SUCH, DOES NOT HAVE ANY UNCERTAIN TAX POSITIONS THAT ARE MATERIAL TO THE FINANCIAL STATEMENTS. THE ORGANIZATION WOULD RECOGNIZE FUTURE ACCRUED INTEREST AND PENALTIES RELATED TO UNRECOGNIZED TAX BENEFITS AND LIABILITIES IN INCOME TAX EXPENSE IF SUCH INTEREST AND PENALTIES ARE INCURRED. THE ORGANIZATION'S FEDERAL FORM 990T FILINGS ARE NO LONGER SUBJECT TO FEDERAL TAX EXAMINATIONS BY TAX AUTHORITIES FOR YEARS BEFORE 2010. PART XI, LINE 2D - OTHER ADJUSTMENTS: PROVISION FOR BAD DEBTS IN REVENUES ON FINANCIAL STATEMENTS -10,850,345. PART XI, LINE 4B - OTHER ADJUSTMENTS: RENTAL EXPENSES RECORDED IN EXPENSES FOR FINANCIAL STATEMENTS -337,665. BOOK/TAX ADJUSTMENT FOR PARTNERSHIPS -188,395. PART XII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES RECORDED IN EXPENSES FOR FINANCIAL STATEMENTS 337,665. PART XII, LINE 4B - OTHER ADJUSTMENTS: PROVISION FOR BAD DEBTS IN REVENUES FOR FINANCIAL STATEMENTS 10,850,345. 1 1 X 1 X 1 X 1 1 1 0 1 1 7705421 2929518 4775903 0.02940 9621893 7787343 1834550 0.01130 17327314 10716861 6610453 0.04070 799669 291572 508097 0.00310 36992 585 36407 0.00020 45204424 35590544 9613880 0.05920 60531 60531 0.00040 46101616 35882701 10218915 0.06290 63428930 46599562 16829368 0.10360 1 10850345 0 59051969 60193959 -1141990 X 1 1 1 HELENA SURGICENTER LLC SURGERY CENTER 0.50000 0.09150 0.05290 1 1 ST PETER'S HOSPITAL

2475 BROADWAY HELENA MT 59601

X X X PHYSICIAN CLINICS & URGENT CARE SERVICES ST PETER'S HOSPITAL 1 1 X X X X X X X X X 12 1 0 1 X X X X X X 0 0 1 1 150.000000000000 1 250.000000000000 1 X X X X X 1 1 X X X 1 0 X X X X X 1 X 0 1 2 HOSPICE & HOMELINK OF ST PETER'S HOSP

201 SOUTH CALIFORNIA HELENA MT 59601

HOSPICE AND HOME HEALTH APEX OF ST PETER'S HOSPITAL

201 SOUTH CALIFORNIA HELENA MT 59601

HOME OXYGEN SERVICES PART I, LINE 6A: THE ORGANIZATION'S COMMUNITY BENEFIT REPORT CAN BE FOUND ON ITS WEBSITE AT WWW.STPETES.ORG. PART I, LINE 7: CHARITY CARE, UNREIMBURSED MEDICAID AND SUBSIDIZED HEALTH SERVICES ARE CONVERTED TO COST USING THE COST TO CHARGE RATIO DERIVED FROM THE HOSPITAL'S COST ALLOCATION SYSTEM. THE COST ALLOCATION SYSTEM ADDRESSES ALL PATIENT SEGMENTS. THE COSTS ARE ESTIMATED BY ALLOCATING DEPARTMENTAL COSTS BASED ON DIRECT COSTS LESS ANY OTHER OPERATING REVENUE THEN BY DOING AN ALLOCATION OF BENEFITS, DEPRECIATION AND OTHER OVERHEAD COSTS. COMMUNITY HEALTH IMPROVEMENT SERVICES, HEALTH PROFESSIONS EDUCATION AND CASH AND IN-KIND CONTRIBUTIONS ARE EXPENSES INCURRED AND TRACKED IN THE CBISA PROGRAM. PART I, LINE 7G: SUBSIDIZED HEALTH SERVICES INCLUDES $5,958,125 OF COSTS ATTRIBUTABLE TO A PHYSICIAN CLINIC. PART I, L7 COL(F): THE AMOUNT OF BAD DEBT EXPENSE REMOVED FROM THE DENOMINATOR OF THE CALCULATIONS WAS $10,850,345. PART III, LINE 4: BAD DEBT EXPENSE IS REPORTED AT CHARGES AS RECORDED BY THE ORGANIZATION.BAD DEBT EXPENSE IS REPORTED NET OF DISCOUNTS AND CONTRACTUAL ALLOWANCES. A PAYMENT ON AN ACCOUNT PREVIOUSLY WRITTEN OFF REDUCES BAD DEBT EXPENSE IN THE CURRENT YEAR.THE FOOTNOTE TO THE ORGANIZATION'S FINANCIAL STATEMENTS THAT DESCRIBES BAD DEBT EXPENSES IS LOCATED IN FOOTNOTE 1 ON PAGE 8 OF THE ATTACHED FINANCIAL STATEMENTS. PART III, LINE 8: THESE EXPENSES REPRESENT AN OVERALL SHORTFALL OF THE DIRECT MEDICARE PATIENT POPULATION. THE COSTS THEMSELVES ARE THEREFORE A COMMUNITY BENEFIT AS THE COMMUNITY WOULD NOT RECEIVE THESE SERVICES IF WE DID NOT PROVIDE THEM. TOTAL MEDICARE REVENUE AND MEDICARE ALLOWABLE COSTS OF CARE ARE CALCULATED USING A COST ALLOCATION METHOD CONSISTENT WITH THE COST REPORT. PART III, LINE 9B: ST. PETER'S HOSPITAL RECOGNIZES ITS RESPONSIBILITY TO RENDER NECESSARY HEALTH CARE SERVICES TO ALL PERSONS IN NEED OF SUCH CARE, REGARDLESS OF RACE, CREED, COLOR OR ECONOMIC CIRCUMSTANCES. ST. PETER'S HOSPITAL RECOGNIZES THAT PAYMENT FOR SERVICES RENDERED IS DUE AND PAYABLE AT THE TIME OF SERVICE. THE HOSPITAL ACCEPTS INSURANCE ASSIGNMENTS AND SOME OTHER APPROVED ARRANGEMENTS FOR DELAYED PAYMENT. FINANCIAL ASSISTANCE IS AVAILABLE FOR ALL QUALIFIED PATIENTS. PATIENTS NOT COVERED BY INSURANCE OR UNABLE TO PAY IN FULL FOR SERVICES RENDERED MUST CONTACT THE APPROPRIATE PATIENT ACCOUNT REPRESENTATIVE WHO WILL ASSIST THE PATIENT AND/OR FAMILY IN DETERMINING IF HE/SHE QUALIFIES FOR PATIENT ASSISTANCE. COLLECTION ACTIVITY WILL BE SUSPENDED WHILE A FINANCIAL ASSISTANCE APPLICATION IS UNDER REVIEW. ST. PETER'S HOSPITAL PART V, SECTION B, LINE 3: A CONSULTANT WAS ENGAGED TO FACILITATE THE COMMUNITY NEEDS ASSESSMENT THROUGH USE OF INTERVIEWS AND FOCUS GROUPS UTILIZING REPRESENTATIVES FROM PUBLIC HEALTH, PHYSICIANS, OTHER HEALTH PROFESSIONALS, SOCIAL SERVICE PROVIDERS, AND OTHER COMMUNITY LEADERS. ST. PETER'S HOSPITAL PART V, SECTION B, LINE 5C: THE COMMUNITY HEALTH NEEDS ASSESSMENT MAY BE FOUND AT HTTP://WWW.STPETES.ORG/CHNA. ST. PETER'S HOSPITAL PART V, SECTION B, LINE 6I: THE IMPLEMENTATION STRATEGY MAY BE FOUND AT HTTP://WWW.STPETES.ORG/SPH-CHIP. ST. PETER'S HOSPITAL PART V, SECTION B, LINE 7: DUE TO THE TIMING OF THE ADOPTION OF THE IMPLEMENTATION STRATEGY, ST. PETER'S HOSPITAL HAS NOT HAD THE TIME TO EXECUTE THE IMPLEMENTATION STRATEGY. THE IMPLEMENTATION STRATEGY WAS MADE AVAILABLE UPON REQUEST. ST. PETER'S HOSPITAL PART V, SECTION B, LINE 14G: A COPY OF THE FINANCIAL ASSISTANCE POLICY IS INCLUDED ON THE WEBSITE. ADDITIONALLY, A SUMMARY OF THE FINANCIAL ASSISTANCE POLICY IS POSTED IN THE FACILITY'S EMERGENCY ROOM AND WAITING ROOMS AND ADMISSIONS OFFICES. THE SUMMARY IS ALSO PROVIDED TO PATIENTS UPON ADMISSION TO THE HOSPITAL FACILITY. ST. PETER'S HOSPITAL PART V, SECTION B, LINE 18E: THE POLICY IS PUBLISHED ON THE STPETES.ORG WEBSITE. ST. PETER'S HOSPITAL PART V, SECTION B, LINE 22: ALL INDIVIDUALS ELIGIBLE UNDER THE HOSPITAL FINANCIAL ASSISTANCE POLICY ARE PROVIDED A DISCOUNT FOR EMERGENCY AND OTHER MEDICALLY NECESSARY CARE. THE FINANCIAL ASSISTANCE POLICY DOES NOT APPLY TO ELECTIVE PROCEDURES. THEREFORE, FAP-ELIGIBLE PATIENTS WITHOUT INSURANCE MAY BE CHARGED GROSS CHARGES ON ELECTIVE PROCEDURES. PART VI, LINE 2: ST. PETER'S HOSPITAL CONDUCTS A COMMUNITY SURVEY EVERY THREE YEARS. THE COMMUNITY SURVEY IS PERFORMED BY AN INDEPENDENT CONTRACTOR THAT SELECTS AN ADEQUATE SAMPLE SIZE FOR THE AREA. THE HOMES OF ST. PETER'S HOSPITAL EMPLOYEES ARE EXCLUDED FROM THE SURVEY. THE SURVEY INCLUDES QUESTIONS RELATED TO EVALUATING THE COMMUNITY'S EXPERIENCE AND ABILITY TO ACCESS HEALTHCARE. THE SURVEY HELPS TO IDENTIFY SPECIALTY AREAS OF CONCERN. THE RESULTS OF THE SURVEYS ARE REVIEWED BY THE SENIOR MANAGEMENT TEAM AS WELL AS THE BOARD TO IDENTIFY THE AREAS OF FOCUS.IN 2013, THE ST. PETER'S BOARD OF DIRECTORS, MADE UP OF COMMUNITY MEMBERS, PHYSICIANS, AND SENIOR MANAGEMENT, WORKED WITH A CONSULTANT TO DEVELOP ST. PETER'S COMMUNITY HEALTH IMPROVEMENT PLAN (CHIP). BASED ON THE FINDINGS OF THE COMMUNITY HEALTH NEEDS ASSESSMENT (CHNA), THE BOARD AND ITS COMMUNITY RELATIONS COMMITTEE PRIORITIZED COMMUNITY HEALTH NEEDS FOR THE ORGANIZATION. THE COMMUNITY RELATIONS COMMITTEE REPRESENTS A BROAD RANGE OF COMMUNITY INTERESTS AND GIVES FINAL APPROVAL OF THE CHNA AND CHIP. THE PUBLIC RELATIONS AND MARKETING DEPARTMENT IS RESPONSIBLE FOR THE FACILITATION AND IMPLEMENTATION OF THE CHNA AND CHIP. PART VI, LINE 3: ST. PETER'S HOSPITAL (1) POSTS ITS CHARITY CARE POLICY ON ITS WEB SITE AS WELL AS AT THE ADMITTING DESK, EMERGENCY ROOM, ON THE MONTHLY STATEMENTS AND CASHIER AREAS IN WHICH ELIGIBLE PATIENTS ARE LIKELY TO BE PRESENT; (2) OFFERS A SUMMARY OF OUR POLICY AND APPLICATION TO SELF PAY PATIENTS WITH CONTACT INFORMATION TO PATIENTS AS PART OF THE INTAKE PROCESS; (3) PROVIDES A COPY OF FINANCIAL ASSISTANCE CONTACT INFORMATION TO PATIENTS WITH DISCHARGE MATERIALS; (4) FINANCIAL COUNSELORS DISCUSS WITH PATIENTS EXPECTING TO OWE MORE THAN $500 THE AVAILABILITY OF PATIENT ASSISTANCE AND VARIOUS GOVERNMENT BENEFITS, SUCH AS MEDICAID OR STATE PROGRAMS, AND ASSISTS THE PATIENT WITH QUALIFICATION FOR SUCH PROGRAMS, WHERE APPLICABLE. PART VI, LINE 4: ST. PETER'S HOSPITAL IS A 123-BED ACUTE CARE HOSPITAL FACILITY SERVING RESIDENTS OF LEWIS AND CLARK COUNTY AND PORTIONS OF JEFFERSON, BROADWATER, MEAGHER AND POWELL COUNTIES. ST. PETER'S IS THE SOLE FACILITY IN THE PRIMARY SERVICES AREA. THE HOSPITAL FINANCIAL PAYOR MIX CONSISTED OF 6.1% SELF PAY PATIENTS, 7.1% OF MEDICAID PATIENTS AND 45.1% MEDICARE PATIENTS. APPROXIMATELY 14.8% OF THE POPULATION IS AGE 65 AND OLDER. THE AVERAGE PER CAPITA INCOME IS $27,861 AND APPROXIMATELY 9.7% OF THE POPULATION IS BELOW THE FEDERAL POVERTY LEVEL. THE NEAREST HOSPITAL IN THE AREA IS APPROXIMATELY 35 MILES FROM ST. PETER'S CAMPUS. PART VI, LINE 5: THE ORGANIZATION'S GOVERNING BODY MEMBERS RESIDE IN THE COMMUNITY. MEDICAL STAFF PRIVILEGES ARE EXTENDED TO ALL QUALIFIED PHYSICIANS IN THE COMMUNITY. SURPLUS FUNDS ARE USED TO MAKE CAPITAL PURCHASES AND UPGRADES TO THE FACILITIES.ST. PETER'S HOSPITAL IS THE SOLE ACUTE CARE PROVIDER IN THE PRIMARY SERVICE AREA MADE UP OF LEWIS & CLARK COUNTY AND THE NORTHERN PORTION OF JEFFERSON COUNTY. THERE IS A POPULATION OF APPROXIMATELY 76,277. OUT-MIGRATION IS GENERALLY LIMITED TO TERTIARY SERVICES NOT AVAILABLE AT ST. PETER'S HOSPITAL INCLUDING CARDIAC SURGERY AND NEO-NATAL CARE. ST. PETER'S HOSPITAL PROVIDES CARE TO ALL PATIENTS REGARDLESS OF THEIR ABILITY TO PAY. ST. PETER'S HOSPITAL MAINTAINS CHARGES AS ONE OF THE LOWEST HOSPITALS WITHIN THE STATE DEPENDING ON THE SERVICES BEING PROVIDED. ST. PETER'S HOSPITAL SPONSORS SEVERAL WELLNESS SCREENINGS, HEALTH FAIRS AND EDUCATIONAL LECTURES, CLASSES, AND EVENTS THROUGHOUT THE YEAR TO PROMOTE BETTER LIVING, NUTRITION AND GOOD HEALTH. CONTINUING EDUCATION IS ALSO PROVIDED TO THE MEMBERS OF THE MEDICAL COMMUNITY ON AN ON-GOING BASIS. IN ADDITION, ST. PETER'S HOSPITAL HAD 15,177 VOLUNTEER HOURS FROM THE COMMUNITY ASSISTING IN A VARIETY OF ROLES WITHIN THE ORGANIZATION.ST. PETER'S HOSPITAL MADE $60,531 OF CASH AND IN-KIND DONATIONS TO A VARIETY OF ORGANIZATIONS WITHIN THE COMMUNITY. THIS INCLUDES BUT IS NOT LIMITED TO CR ANDERSON MIDDLE SCHOOL FOR ITS HONOR STUDENT PROGRAM, ANGEL FUND TO PURCHASE CLOTHING AND SCHOOL SUPPLIES FOR YOUTH, HELENA HIGH SCHOOL, LEWIS AND CLARK COUNTY FOR CRISIS RESPONSE TEAM, HEALTHY MOTHER'S/HEALTHY BABIES, HOSA, FRIENDSHIP CENTER, FLORENCE CRITTENTON, YMCA, GOD'S LOVE, CARROLL COLLEGE ATHLETICS WITH EMERGENCY SERVICES AT EVENTS, CARROLL COLLEGE NURSING DEPARTMENT WITH MEDICAL SUPPLIES NEEDED FOR LEARNING LABS, EXPLORATION WORKS WITH MEDICAL SUPPLIES NEEDED FOR STUDENT SCIENCE EXPERIMENTS, UNITED WAY TO ASSIST LOW-INCOME AND HOMELESS RESIDENTS WITH BASIC NEEDS, SPIRIT OF SERVICE CAMPAIGN BY PROVIDING SUPPLIES AND VOLUNTEERS TO HELP ELDERLY RESIDENTS AND OTHERS WITH SPECIAL NEEDS IMPROVE THEIR HOMES AND YARDS, KAY MCKENNA YOUTH FOUNDATION TO PROVIDE SAFE SUMMER YOUTH ACTIVITIES, ARCHIE BRAY FOUNDATION, HELENA FOOD SHARE PROGRAM FOR BACK PACK PROGRAM IN THE SCHOOLS AND BIG BROTHERS AND SISTERS. THE DONATIONS WERE MADE TO ASSIST THESE COMMUNITY SPONSORS IN THEIR VARIOUS PROGRAMS.ST. PETER'S HOSPITAL IS THE SOLE COMMUNITY ACUTE CARE FACILITY WITHIN THE IMMEDIATE AREA. ST. PETER'S HOSPITAL ALSO MAINTAINS A 24 BED BEHAVIORAL HEALTH INPATIENT ADULT AND GERIATRIC UNIT. THIS IS THE ONLY FACILITY WITHIN THE SERVICE AREA. ST. PETER'S HOSPITAL OPERATES AN EMERGENCY ROOM AND TWO URGENT CARE CLINICS THAT PROVIDE SERVICES TO ALL REGARDLESS OF ABILITY TO PAY. 1 EDUCATION ASSISTANCE 2 14046 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: AS DETERMINED BY THE PUBLIC RELATIONS DIRECTOR AND THE CEO, THE ORGANIZATION FINANCIALLY SUPPORTS COMMUNITY INDIVIDUALS PURSUING EDUCATION PROGRAMS THAT ENRICH HEALTH AND SAFETY TO THE COMMUNITY. DUE TO KNOWLEDGE OF THE RECIPIENTS AND THE PURPOSE OF THE GRANTS, FURTHER MONITORING ON THE USE OF THE FUNDS WAS NOT DEEMED NECESSARY. X X X X 1 1 X X X X X 1 1 0 0 0 0 0 0 0 JAMES BURKHOLDER MD 305938 0 12185 0 959 0 10328 0 5803 0 335213 0 0 0 JOHN GREEN 203567 0 17076 0 22321 0 11514 0 11217 0 265695 0 0 0 TOM GREGG 304474 0 24518 0 26880 0 9118 0 9175 0 374165 0 0 0 DR MICHAEL LEE 808927 0 0 0 834 0 9122 0 4304 0 823187 0 0 0 DR THOMAS WEINER 1421534 0 0 0 1847 0 17240 0 7982 0 1448603 0 0 0 DR MATTHEW MCLAREN 586138 0 0 0 19980 0 7500 0 7715 0 621333 0 0 0 DR SCOTT PARGOT 667107 0 0 0 0 0 12057 0 3981 0 683145 0 0 0 DR JEFFREY MARTIN 739046 0 0 0 103845 0 7500 0 2184 0 852575 0 0 0 JOHN SOLHEIM 163391 0 178883 0 399079 0 14497 0 7169 0 763019 0 0 0 PART I, LINE 1A JOHN SOLHEIM AND TOM GREGG RECEIVED REIMBURSEMENT FOR MEMBERSHIP DUES PAID TO A SOCIAL CLUB. JOHN SOLHEIM RECEIVED AN ANNUAL COMMUNITY SUPPORT ALLOWANCE AND A CAR ALLOWANCE. JOHN SOLHEIM WAS TAXED ON THE PERSONAL MILEAGE THAT HE USED. JOHN SOLHEIM AND TOM GREGG WERE PROVIDED TRAVEL FOR COMPANIONS FOR BUSINESS FUNCTIONS. ALL AMOUNTS WERE REPORTED AS TAXABLE COMPENSATION. A HIGHLY COMPENSATED PHYSICIAN RECEIVED A HOUSING ALLOWANCE PENDING HIS RELOCATION TO THE AREA. PART I, LINES 4A-B JOHN SOLHEIM RECEIVED A SEVERANCE PAYMENT IN FISCAL YEAR 2013. JOHN SOLHEIM AND TOM WEINER PARTICIPATE IN A NONQUALIFIED RETIREMENT PLAN UNDER 457(B). AMOUNTS FROM THEIR BASE WAGES WERE DEFERRED INTO THEIR PLAN AT THEIR DISCRETION. THE ORGANIZATION DID NOT CONTRIBUTE MONEY INTO THE PLAN ON BEHALF OF THE INDIVIDUALS NAMED ABOVE. A MONTANA FACILITY FINANCE AUTHORITY 810302402 61204JBR4 2004-05-06 29748183 TO FUND EXPANSION AND RENOVATION OF EXISTING HOSPITAL FACILITY. 1 0 0 B MONTANA FACILITY FINANCE AUTHORITY 810302402 61204JBY9 2007-03-22 22826511 FUND MED OFFICE BLDG & WOMEN & CHILDREN'S BED WING & REFUND BONDS 1/23/97 0 0 0 C MONTANA FACILITY FINANCE AUTHORITY 810302402 2013-03-13 21435000 TO REFINANCE 2004 BOND SERIES 0 0 0 A 5025000 24680000 29748183 422346 27111925 2008 0 0 1 1 B 7100000 23439515 1659659 465447 353863 14743608 7154609 2009 1 0 1 1 C 21435000 338736 21085703 10561 2013 0 1 1 1 A 0 0 0 0 0.00000 0.00000 0.00000 0 0 1 B 0 0 0 0 0.00000 0.00320 0.00320 0 0 1 C 0 0 0 0 0.00000 0.00420 0.00420 0 0 1 A 0 0 0 1 0 0 0 0 1 B 0 0 0 1 0 0 0 0 1 C 0 0 0 0 0 0 0 0 1 A 1 B 1 C 1 SCHEDULE K, PART I, LINE B(E): THE DIFFERENCE BETWEEN THE ISSUE PRICE REPORTED IN PART I AND THE TOTAL PROCEEDS OF ISSUES REPORTED IN PART II IS INTEREST EARNED ON THE BONDS DURING THE CONSTRUCTION PHASE. MARIA BRAMAN PARTIAL YEAR BOARD CHAIR 505997 PURCHASE OF LAB AND INVENTORY AFTER BOARD SERVICE TERMINATED; LAB SERVICES 0 FORM 990, PART VI, SECTION A, LINE 1 THE EXECUTIVE COMMITTEE CONSISTS OF THE OFFICERS OF THE BOARD OF DIRECTORS, PAST CHAIR OF THE BOARD PROVIDED HE/SHE CONTINUES TO BE A DIRECTOR, AND THE CHIEF OF STAFF. IF THE PAST CHAIR OF THE BOARD IS UNABLE TO SERVE, THE BOARD CHAIR MAY APPOINT ANOTHER MEMBER TO THE EXECUTIVE COMMITTEE. THE EXECUTIVE COMMITTEE HAS THE POWER TO TRANSACT ALL REGULAR BUSINESS OF THE HOSPITAL DURING THE INTERIM BETWEEN MEETINGS OF THE BOARD OF DIRECTORS, PROVIDED THAT ANY ACTION DOES NOT CONFLICT WITH THE POLICIES OF THE BOARD OF DIRECTORS AND ALL MATTERS OF MAJOR IMPORTANCE ARE REFERRED TO THE BOARD OF DIRECTORS. SHOULD ANY MATTER OF EXTREME URGENCY ARISE BETWEEN THE REGULAR MEETINGS OF THE BOARD OF DIRECTORS, IT IS THE DUTY OF THE EXECUTIVE COMMITTEE TO REQUEST THE PRESIDENT CALL A SPECIAL MEETING OF THE BOARD OF DIRECTORS. MINUTES OF THE EXECUTIVE COMMITTEE ARE SUBMITTED TO THE BOARD OF DIRECTORS AND ITS ACTIONS ARE SUBJECT TO APPROVAL OR DISAPPROVAL AT THE NEXT REGULAR BOARD MEETING. THE COMMITTEE IS RESPONSIBLE FOR CONDUCTING THE PRESIDENT'S EVALUATION, SETTING THE PRESIDENT'S COMPENSATION AND NEGOTIATING THE TERMS OF THE PRESIDENT'S EMPLOYMENT CONTRACT. FORM 990, PART VI, SECTION A, LINE 7A THE NOMINATING COMMITTEE SOLICITS QUALIFIED CANDIDATES FOR MEMBERSHIP ON THE BOARD OF DIRECTORS AND PRESENTS A SLATE TO THE BOARD OF DIRECTORS WITH ONE CANDIDATE FOR EACH POSITION TO BE FILLED. MEMBERS OF THE BOARD OF DIRECTORS MAY SUBMIT THE NAMES OF POTENTIAL CANDIDATES TO THE NOMINATING COMMITTEE FOR THE COMMITTEE'S CONSIDERATION. THE NOMINATING COMMITTEE'S SLATE OF POTENTIAL CANDIDATES IS SUBMITTED TO THE BOARD AT THE BOARD OF DIRECTOR'S ANNUAL MEETING. FIVE MEMBERS OF THE BOARD OF DIRECTORS SERVE BY VIRTUE OF THE OFFICES AND FOR THE DURATION OF THE TIME THEY REMAIN IN OFFICE; THE PRESIDENT AND CHIEF EXECUTIVE OFFICER OF THE HOSPITAL, THE CHIEF-OF-STAFF OF THE HOSPITAL, THE CHIEF-OF-STAFF ELECT OF THE HOSPITAL, THE ST. PETER MEDICAL GROUP PRESIDENT, AND THE ST. PETER'S FOUNDATION CHAIR. FORM 990, PART VI, SECTION B, LINE 11 A ROUGH DRAFT OF THE FORM 990 IS REVIEWED BY THE CEO AND CFO AS WELL AS THE FINANCE COMMITTEE PRIOR TO FULL BOARD APPROVAL OF THE FINAL FORM 990 PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C THE CONFLICT OF INTEREST POLICY COVERS ALL BOARD MEMBERS, OFFICERS, SENIOR ADMINISTRATION AND KEY EMPLOYEES. THE BOARD IDENTIFIES POTENTIAL CONFLICTS AND DETERMINES IF VOTING ON RELATED ITEMS WOULD BE A CONFLICT OF INTEREST IF A CONFLICT IS DETERMINED TO EXIST, THE CONFLICTED INDIVIDUAL IS EXCLUDED FROM VOTING ON THE CONFLICTED ITEM. FORM 990, PART VI, SECTION B, LINE 15 AN INDEPENDENT COMPENSATION CONSULTANT PERFORMS A REVIEW OF SALARIES AND BENEFITS USING DATA FROM COMPARABLE HEALTHCARE FACILITIES. A REPORT IS PREPARED AND PRESENTED TO THE EXECUTIVE COMMITTEE OF THE BOARD OF DIRECTORS, WHICH USES THE REPORT TO DETERMINE OFFICER AND SENIOR MANAGEMENT COMPENSATION. THE INFORMATION IS THEN REVIEWED WITH THE BOARD OF DIRECTORS. THE ANNUAL PROCESS WAS PERFORMED DURING 2012. FORM 990, PART VI, SECTION C, LINE 19 THE GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE MADE AVAILABLE TO THE PUBLIC UPON REQUEST. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 9: MINIMUM PENSION LIABILITY ADJUSTMENT 4,279,200. CHANGE IN PERMANENTLY AND TEMPORARILY RESTRICTED NET ASSETS OF FOUNDATION 1,363,153. BOOK/TAX ADJUSTMENT FOR PARTNERSHIPS 188,395. ST PETER'S HOSPITAL FOUNDATION 2475 BROADWAY HELENA MT 59601 810392270 RAISE FUNDS TO SUPPORT ST. PETER'S HOSPITAL MT 501(C)(3) LINE 11A, I ST PETER'S HOSPITAL 1 PEAK HEALTH LLC 2475 BROADWAY AVENUE HELENA MT 59601 271863807 HEALTH CLUB MT N/A UNRELATED 9531 2003216 0 0 0.65000 PEAK HEALTH REALTY LLC 2475 BROADWAY AVENUE HELENA MT 59601 272492966 RENTAL PROPERTY MT N/A UNRELATED -80863 -140978 0 0 0.65000 PEAK HEALTH HELENA LLC 2475 BROADWAY AVENUE HELENA MT 59601 271863807 HEALTH CLUB MT N/A UNRELATED 84267 -233779 0 0 0.65000 0 0 1 0 0 0 0 0 0 1 1 0 1 0 1 1 1 0 1 ST PETER'S HOSPITAL FOUNDATION C 286584 FMV ST PETER'S HOSPITAL FOUNDATION M 331330 COST