2014-05-15T15:43:13-05:00 2013-06-30 450250958 Eide Bailly LLP 800 Nicollet Mall Ste 1300 Minneapolis MN 554027033 990 2012-07-01 810243720 Sheridan Memorial Hospital Association SHER 4067651420 440 W Laurel Avenue Plentywood MT 59254 Sandra Christensen 4067651420 2014-05-14 1 Kim Hunwardsen CPA P00484560 6122536500 2014-05-13 2012 2015-11-30 17:44:51Z Sandra Christensen 440 W Laurel Avenue Plentywood MT 59254 12058892 0 X www.sheridanmemorial.net X 1920 MT Provide quality care to improve the health and well-being of the people and community we serve. 7 7 247 84 0 0 170621 810602 9816962 11213915 7345 6037 352121 26130 10347049 12056684 0 0 0 0 6526926 6867395 0 0 54745 4541273 5012206 11068199 11879601 -721150 177083 8309478 9535442 1073135 2022611 7236343 7512831 X Providing quality care to improve the health and well-being of the people and community we serve. We are committed to the future healthcare needs of our community. We endeavor to be a leader and innovator in providing reliable, compassionate, comprehensive, high quality, cost effective healthcare services. 0 0 9623843 11213915 The Organization operates a 19-bed critical access hospital, a 78-bed long term care facility and a Provider Based Rural Health Clinic that benefits the people in the surrounding area. 9623843 1 1 0 0 0 0 0 0 0 1 1 0 1 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 8 0 1 247 1 0 0 0 0 0 0 0 0 0 0 X 7 7 0 1 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 0 0 0 X Sandra Christensen 4067651420 440 W Laurel Avenue Plentywood MT 59254 X Danette Ramussen 1.00 0.00 X X 0 0 0 Linda Nelson 1.00 0.00 X X 0 0 0 Kathy Hagan 1.00 0.00 X X 0 0 0 Robert Michels 1.00 0.00 X 0 0 0 Bill McCoy 1.00 1.00 X 0 0 0 Myrnette Miller 1.00 0.00 X 0 0 0 Jake Fladager 1.00 0.00 X 0 0 0 Sandra Christensen 40.00 1.00 X 57122 0 16654 Adam Graham 40.00 0.00 X 163285 0 16591 Susan Grenz 40.00 0.00 X 108942 0 0 Lynne Graham 40.00 0.00 X 110915 0 5993 Kristin McColly 37.00 0.00 X 101030 0 10483 Jennifer Hoversland 30.00 0.00 X 100518 0 1707 641812 0 51428 5 0 1 0 Billings Clinic 801 North 29th Street Billings MT 591077000 Management Services 759904 Cerner Corporation PO Box 412702 Kansas City MO 64141 Software Support/Implementation 431921 2 303497 503385 3720 3720 810602 Patient Service Revenue 621990 10769953 10769953 Other Revenue 900099 443962 443962 11213915 7493 7493 26130 0 26130 26130 26130 752 2208 -1456 -1456 -1456 12056684 11213915 0 32167 5237602 4874603 338829 24170 16997 16997 1193644 414140 772312 7192 419152 389785 27137 2230 530139 530139 851648 740038 111610 38483 21915 12976 3592 232942 197027 31922 3993 350825 292189 58636 38772 32757 6015 43844 35600 8210 34 24310 15590 7670 1050 690572 643608 46964 125562 125562 Medical Supplies 897842 897842 Bad Debt 572554 572554 Repairs and Maintenance 336143 307380 28763 Bed Tax 157451 157451 121119 31364 77271 12484 11879601 9623843 2201013 54745 319451 564616 1001210 116097 1158695 1231638 447043 148708 168164 84845 105299 17208241 11693498 4354768 5514743 169900 1061452 1160885 0 237406 8309478 9535442 1020375 1137493 52760 560118 0 325000 1073135 2022611 X 7056898 7120549 141915 278366 37530 113916 7236343 7512831 8309478 9535442 X 177083 -28 99433 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 37530 76386 27 27 113916 27195 10335 37530 27075 120 27195 26855 220 27075 0.00000 1.00000 0.00000 0 1 1 79341 79341 9637827 6719702 2918125 7491073 4973796 2517277 5514743 Interest in Net Assets of Foundation 1160885 C 1160885 Related Party Note Payable 325000 325000 X 11486795 -569889 -569889 12056684 0 12056684 11307047 0 11307047 572554 572554 11879601 Description of Intended Use of Endowment Funds: Part V, Line 4: The endowment, held by the Sherdian Health Care Foundation, Inc., consists of individual funds established by donors to provide annual funding for specific activities and general operations of the Hospital. Description of Uncertain Tax Positions Under FIN 48: Part X, Line 2: The Hospital is organized as a Montana nonprofit corporation and has been recognized by the Internal Revenue Service (IRS) as exempt from Federal income taxes under Internal Revenue Code Section 501(c)(3). The Hospital is 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 has determined it is not subject to unrelated business income tax and has not filed an Exempt Organization Business Income Tax Return (Form 990-T) with the IRS. The Hospital 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 consolidated financial statements. The Hospital 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. Part XI, Line 2d - Other Adjustments: Provision for Bad Debts -572,554. Equity in Income of Foundation 2,665. Part XII, Line 4b - Other Adjustments: Provision for Bad Debts 572,554. 1 1 X 1 X 1 X 1 1 1 0 1 1 56000 56000 0.00500 1393322 1610361 -217039 0.00000 1449322 1610361 -161039 0.00500 1449322 1610361 -161039 0.00500 1 572554 0 3816433 3441425 375008 X 1 1 1 1 Sheridan Memorial Hospital Association

440 W Laurel Ave Plentywood MT 59254

X X Rural Health Clinic, Long-term Care Facility Sheridan Memorial Hospital Association 1 1 X X X X X X X X X 12 1 0 1 X X X X X X X X 0 0 1 1 100.000000000000 1 200.000000000000 1 X X 1 1 X X 1 0 X X X 1 X 0 1 Part I, Line 3c: Individuals applying for charity care must provide pay stubs, their most recent tax return, forms approving or denying eligibility for Medicaid and/or state or county funded medical assistance, forms approving or denying unemployment compensation and current bank statements. The items listed above will be used to determine family income. Family income and family size are then used to determine what the poverty threshold is for the applicant and to determine if free or discounted care will be approved. Part I, Line 7: Charity care was calculated by multiplying the ratio of cost to gross charges by the gross uncompensated charges associated with providing charity care to its patients. The Medicaid calculation is based on gross charges and claims from the Medicaid Cost Report. Part I, L7 Col(f): The amount of bad debt expense removed from the denominator of the calculation was $572,554. Part III, Line 4: The Organization relies on Financial Management Association Statement 15 to determine bad debt expense and financial assistance in their audited financial statements.Footnote from organization's financial statements: The footnote that describes bad debt expense is found on page 8 of the attached audit report. Part III, Line 8: The cost to charge ratio is used to determine community benefit. This is done by applying the ratio to the total Medicare revenue. A shortfall or overage in any given year is a result of the timing of payments from Medicare on an interim basis and when final settlement is made. Management uses estimates to calculate such settlements but actual results vary from those estimates. Additionally, shortfalls can result from various expenses that are incurred by the facility which are considered non-reimbursable by Medicare. Since part of the costs are not reimbursed it is only prudent to consider this shortfall to be a benefit to the community. Part III, Line 9b: Once a financial assistance application is submitted, collection actions are suspended until it is determined if the patient is eligible for financial assistance. All applications for financial assistance are reviewed and approved by the board. If an individual submits an incomplete FAP application, a patient account representative provides a notice requesting additional information and lets the individual know what additional information is needed. In certain cases, where deemed appropriate, collection actions are reversed if an individual is determined to be eligible for financial assistance. Sheridan Memorial Hospital Association Part V, Section B, Line 3: Through the process of the Community Health Needs Assessment, the Hospital worked with focus groups and a committee including public health employees, retirement center representatives, and special needs and mental health counselors. Sheridan Memorial Hospital Association Part V, Section B, Line 5c: The community health needs assessment can be accessed at: www.sheridanmemorial.net. It is also posted in a couple places in the hospital. Sheridan Memorial Hospital Association Part V, Section B, Line 6i: The Implementation Strategy is not attached to the Form 990 due to system limitations however it is available upon request. Sheridan Memorial Hospital Association Part V, Section B, Line 7: Alcohol and substance abuse was one need identified in the Community Health Needs Assessment that is not being addressed. The organization does not have the space, staff or funding to start a program addressing this at this time. The organization will also not be addressing the need for Cancer related services. Space and financial constraints limit the organization's ability to start offering services such as chemo and radiation. Sheridan Memorial Hospital Association Part V, Section B, Line 14g: A summary of the financial assistance policy is posted on the Hospital website and also is provided to patients on admission. Sheridan Memorial Hospital Association Part V, Section B, Line 18e: Every statement the patient receives notes that financial assistance may be applied for within 30 days. Sheridan Memorial Hospital Association 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: In order to assess the healthcare needs of the community, the facility did a community health needs assessment which consisted of focus groups and mail in surveys. The facility also does satisfaction surveys and has a complaint policy for the public. Part VI, Line 3: The facility tries to make sure patients are aware of the financial assistance policy by giving it to them upon admission and with invoices. The facility also has it posted on the web site. All patients who call about their bill are educated on payment options. Part VI, Line 4: Sheridan Memorial Hospital is a private not-for-profit organization which is the only medical facility in Sheridan County with a population of approximately 4,105 residents. The facility provides acute, emergency, clinical and long term care for residents in the county and surrounding areas. Established in 1922 as primarily a hospital, Sheridan Memorial Hospital Association continued expanding throughout the years with first a relocation from our small main street location to our current location. In 2008 Sheridan Memorial Hospital added a Rehab suite including exam rooms, prep area, work out area and a hydrotherapy pool. The hospital has an active medical staff of one physician, three family nurse practitioners and two physician assistants as well as consulting medical doctors in the fields of radiology and surgery. Services provided at the hospital include: xray technology, respiratory therapy, physical, occupational and speech therapy, laboratory testing, visiting nurse and hospice care, durable medical equipment and home oxygen sales, social services and emergency services. In 2010 Sheridan Memorial became the first contracted tele-health VA clinic in the country offering area veterans primary health care via tele-video equipment. Part VI, Line 5: The Board of Directors is made up of volunteers from the community. We try to have representation on the Board from individuals throughout the county and not just of those living in Plentywood. We do extend privileges to all qualified physicians in the community. Surplus funds are applied back to patient care and education. We offer many services which are a community benefit to the communities we serve which include the following:-Alzheimer's support group offered-Grief counselor does counseling free of charge-Use of telemedicine open to other groups in the community such as mental health free of charge-ER open 24 hours regardless of ability to pay-Does participate in education of healthcare professionals-Hospital does participate in government sponsored health programs-Sole community provider of most of your service lines-Offers opportunities for volunteers from the community-Has a foundation that serves as a vehicle for attracting and effectively using donated funds-Auxillary X X X 0 0 0 0 0 0 0 0 0 Adam Graham 127191 0 33485 0 2609 0 377 0 16214 0 179876 0 0 0 Form 990, Part VI, Section A, line 3 The Hospital has a management agreement with Billings Clinic. They provide general accounting, HR, and business support services. Sandra Christensen, CEO, became an employee of Billings Clinic in June of 2012 and is compensated by Billings Clinic. She was previously employed by the Hospital. Her compensation for calendar year 2012 from Billings Clinic was $61,726. Form 990, Part VI, Section B, line 11 The board reviews an electronic copy of the Form 990 before the final copy is filed with the IRS. Form 990, Part VI, Section B, line 12c The Board of Directors, CEO, and meeting secretary are annually required to sign the conflict of interest policy. The board members review any potential conflicts to determine if a conflict exists. If there is a conflict of interest, the conflicted board member is not included in the vote on the particular matter. If the transaction is relating to a particularly sensitive topic, the conflicted board member may be asked to excuse themselves from both the discussion and the vote. Billings Clinic, along with input from the SMH Board of Directors, determines compensation for the CEO. Form 990, Part VI, Section C, line 19 The Organization's governing documents, conflict of interest policy, and financial statements are available upon request. Top Management and Financial Officer Form 990, Part VII: Sandra Christensen, CEO, covers both the role of Top Management and Top Financial Officer for the Organization with the assistance of Billings Clinic. Changes in Net Assets or Fund Balances: Form 990, Part XI, line 9: Net Change in Interest in Net Assets of Foundation 99,433. Sheridan Health Care Foundation Inc 440 W Laurel Avenue Plentywood MT 59254 810496987 Support activities of Sheridan Memorial Hospital Association MT 501(c)(3) Line 7 N/A 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0