2014-05-15T09:12:39-05:00 2013-06-30 461497033 EKS&H LLLP 7979 E TUFTS AVENUE SUITE 400 DENVER CO 802372521 990 2012-07-01 841262971 POUDRE VALLEY HEALTH CARE INC POUD 9702377000 2315 E HARMONY ROAD NO 200 FORT COLLINS CO 80528 STEPHANIE DOUGHTY 9702377000 2014-05-14 1 CRAIG R CHOUN P00173718 3037409400 2012 2015-11-30 17:44:51Z KEVIN UNGER 2315 E HARMONY RD 200 FT COLLINS CO 80528 833047994 0 X WWW.PVHS.ORG X 1994 CO WE IMPROVE LIVES. 11 8 4869 831 11906421 2554320 15778292 25492114 245202095 545139001 2640701 7452561 4157339 9500694 267778427 587584370 690886 1864214 0 0 137371005 319437809 0 0 0 110742702 242119517 248804593 563421540 18973834 24162830 795561995 1036706894 246640221 446760442 548921774 589946452 WE IMPROVE LIVES. IN BIG WAYS THROUGH LEARNING, HEALING AND DISCOVERY. IN SMALL, PERSONAL WAYS THROUGH HUMAN CONNECTION. BUT IN ALL WAYS, WE IMPROVE LIVES. 0 0 379586920 1864214 437975871 POUDRE VALLEY HEALTH CARE INC. (PVHC) PROVIDES TERTIARY, ACUTE, INPATIENT, OUTPATIENT AS WELL AS EMERGENCY CARE. PVHC SERVICES COMMUNITIES IN NORTHERN COLORADO, SOUTHWESTERN NEBRASKA, AND SOUTHEASTERN WYOMING. DURING FISCAL YEAR 2013, PVHC RECORDED 58,844 PATIENT DAYS, 14,411 ADMISSIONS, 166,812 OUTPATIENT VISITS, 53,545 EMERGENCY VISITS, 2,394 DELIVERIES, 5,774 INPATIENT SURGERIES, AND 3,489 OUTPATIENT SURGERIES. 124363696 102483048 THE PHYSICIAN NETWORK OF POUDRE VALLEY HEALTH SYSTEM ENCOMPASSES TIMBERLINE MEDICAL LLC, HERON LAKE LLC, AND POUDRE VALLEY MEDICAL GROUP LLC. DURING FISCAL YEAR 2013, THE PHYSICIAN NETWORK HAD 676,253 OUTPATIENT VISITS. AT YEAR END, THE PHYSICIAN NETWORK WAS COMPRISED OF 207 EMPLOYED PHYSICIANS, REPRESENTING 27 SPECIALITIES AT 60 MEDICAL CLINICS IN COLORADO, NEBRASKA, AND WYOMING. 503950616 1 1 0 1 0 0 0 0 0 1 1 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 1 0 0 0 0 0 0 0 0 1 1 0 0 0 0 1 1 1 1 0 0 1 655 0 1 4869 1 1 1 0 0 0 0 0 0 0 0 0 X 11 8 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 1 1 X STEPHANIE DOUGHTY 9702377000 2315 E HARMONY ROAD SUITE 200 FORT COLLINS CO 80528 DANIEL G STROH 2.00 X X 0 0 0 CHRISTINE CHIN 2.00 X X 0 0 0 RICHARD M DELLENBACH 2.00 X 0 0 0 JOE D HENDRICKSON 2.00 X 0 0 0 DENNIS JOHN HOUSKA 2.00 X 0 0 0 THAINE J MICHIE 2.00 X 0 0 0 DAVID C OSBORN 2.00 X 0 0 0 TODD S SORENSEN 2.00 X 0 0 0 JAMES ALAN SPROWELL 2.00 X 0 0 0 LAURIE S STEELE 2.00 X 0 0 0 RULON STACEY 26.00 14.00 X X 1132627 624092 151027 STEPHANIE DOUGHTY 26.00 14.00 X 1179557 649954 68362 RUSS BRANZELL 40.00 X 953713 0 75468 DOUG FAUS 40.00 X 396542 0 31341 DR WILLIAM NEFF 40.00 X 919197 0 80023 DONNA PODUSKA 40.00 X 328439 0 43702 DR MICHAEL RANDLE 40.00 X 304749 0 17475 DAN ROBINSON 40.00 X 638738 0 50440 STEVEN SCHWARTZ 40.00 X 166746 0 15299 KEVIN UNGER 40.00 X 840875 0 131090 DR HANS COESTER 40.00 X 1620785 0 51540 DR MARK GUADAGNOLI 40.00 X 804016 0 45385 DR WILLIAM MILLER 40.00 X 740745 0 22184 DR JOSH PETIT 40.00 X 1271922 0 56767 DR LARS WIDDEL 40.00 X 708783 0 14553 GRACE KOWALYSHYN-TAYLOR 40.00 X 261118 0 69679 PATTI OAKES 40.00 X 500448 0 33028 CARL SMITH 40.00 X 539439 0 62702 13308439 1274046 1020065 165 1 1 0 N COLORADO PULMONARY CONSULTANTS 2121 E HARMONY RD 300 FT COLLINS CO 80528 MEDICAL 2753659 FORT COLLINS WOMEN'S CLINIC 1107 S LEMAY AVE STE 300 FT COLLINS CO 80524 MEDICAL 1668913 MAYO COLLABORATIVE SERVICES INC PO BOX 9146 MINNEAPOLIS MN 55480 MEDICAL 1377679 HARMONY VALLEY CONDO ASSOC 375 E HORSETOOTH RD 3-100 FT COLLINS CO 80525 PROPERTY MANAGEMENT 1374203 FORT COLLINS YOUTH CLINIC 1200 E ELIZABETH ST FT COLLINS CO 80524 MEDICAL 1319549 66 24903465 390267 198382 25492114 NET PATIENT SVC REV 900099 503872542 503872542 PROVIDER FEE INCOME 621400 29650967 29650967 JOINT VENTURE 621400 3973161 3099263 873898 LAB UBI 621500 3146999 3146999 DIETARY SVC INCOME 900099 2031979 2031979 2463353 2160270 303083 545139001 4167956 4167956 197665 197665 5154075 457336 1943857 457336 3210218 0 3210218 3126322 83896 245185375 501080 242594857 4658 2590518 496422 3086940 3086940 791279 462916 328363 169883 158480 REIMBURSE- NON-OP DEPT 621400 4260114 4260114 MISCELLANEOUS REVENUE 621400 1678532 1675877 2655 SVCS TO OUTSIDE ENTITY 621400 23467 23467 5962113 587584370 540458919 11906421 9726916 1864214 1864214 8799457 800024 7999433 512051 512051 250003143 226851598 23151545 29221499 25762974 3458525 21855411 19779271 2076140 9046248 7236623 1809625 779402 36132 743270 174277 174277 21037 21037 266573 266573 19844589 19186499 658090 3247850 156666 3091184 10107958 4699625 5408333 9341026 7453448 1887578 12873041 12318214 554827 2752814 1394781 1358033 1312803 1252960 59843 9795134 9795134 28932230 26435563 2496667 6311944 5860649 451295 MEDICAL SUPPLIES 79193498 78703408 490090 PROVIDER FEE EXPENSE 23069759 23069759 BAD DEBT 18195632 18195632 UBI TAXES 1190000 1190000 14709950 12585391 2124559 563421540 503950616 59470924 0 4407271 16706035 84924888 299523 67221191 73303366 2164004 0 2280316 2483125 5604216 6266869 6463649 6517958 525970338 258156414 233606743 267813924 323200575 5485130 3011076 2997063 40365606 29654266 22312460 625179635 795561995 1036706894 52764430 60962420 672177 65775 131338799 131119658 24870254 136284565 6925070 5116039 30069491 113211985 246640221 446760442 X 548921774 589946452 548921774 589946452 795561995 1036706894 X 24162830 17721199 -859351 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 1 21037 0 0 21037 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: PORTION OF DUES FROM MEMBERSHIP IN CHA AND AHA THAT ARE ATTRIBUTABLE TO LOBBYING ACTIVITIES. 8938992 2680308 53692 334527 1090451 10248014 8589487 1202986 379517 448977 784021 8938992 8012240 3552647 -345716 1678528 712777 238379 8589487 7405708 2585645 656963 910474 1725602 8012240 6106859 3452441 527257 393016 2287833 7405708 0.00000 0.45610 0.54390 1 1 1 62136902 62136902 184330606 91448917 92881689 94754319 54628434 40125885 161435896 97823338 63612558 23312615 14255725 9056890 267813924 INTERCOMPANY RECEIVABLE 620393339 DEFERRED DEBT ISSUANCE COSTS 3411432 OTHER RECEIVABLES 1365619 OTHER ASSETS 9245 625179635 INTERCOMPANY PAYABLES 108418007 ACCRUED INTEREST PAYABLE 2243500 OTHER DEFERRED EXPENSES 2550478 113211985 560324927 17721199 2689153 20410352 539914575 99656 47570139 47669795 587584370 518454163 2420828 2420828 516033335 99656 47288549 47388205 563421540 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: ENDOWMENT FUNDS ARE USED FOR THE INTENDED PURPOSE TO FUND SCHOLARSHIPS, EDUCATION, PROGRAMS, AND COMMUNITY BENEFIT. TEMPORARILY RESTRICTED NET ASSETS ARE THOSE WHOSE USE BY THE FOUNDATION HAVE BEEN LIMITED BY THE DONOR TO A SPECIFIC TIME PERIOD OR PURPOSE. THESE NET ASSETS ARE AVAILABLE FOR VARIOUS HEALTH CARE PURPOSES AS DEFINED BY DONORS. THE ENDOWMENT FUND IS OWNED BY POUDRE VALLEY HEALTH SYSTEM FOUNDATION. PART XI, LINE 2D - OTHER ADJUSTMENTS: BOOK VERSUS TAX ADJUSTMENT IN EQUITY EARNINGS 327,014. RENTAL EXPENSE INCLUDED IN EXPENSE ON AFS 2,089,522. COST OF GOODS SOLD INCLUDED IN EXPENSE ON AFS 272,617. PART XI, LINE 4B - OTHER ADJUSTMENTS: PROVISION FOR BAD DEBT IN AFS INCOME 18,195,632. NON-OPERATING REIMBURSEMENTS INCLUDED IN EXPENSE ON AFS 4,260,114. AUXILIARY INCOME NOT INCLUDED IN AFS INCOME 149,769. CONTRIBUTIONS FROM PV FOUNDATION NOT IN AFS INCOME 299,322. MCR PHYSICIAN NETWORK ALLOCATION IN AFS EXPENSE 24,604,144. SERVICES PROVIDED TO OUTSIDE ENTITIES IN EXPENSE ON AFS 23,467. VARIOUS UBI INCOME NOT INCLUDED IN AFS INCOME 2,655. PHARMACY SALES INCLUDED IN EXPENSE ON AFS 35,036. PART XII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSE INCLUDED IN EXPENSE ON AFS 2,089,522. COST OF GOODS SOLD INCLUDED IN EXPENSE ON AFS 272,617. TIMING DIFFERENCE ON FDN/PVH CONTRIBUTIONS 58,689. PART XII, LINE 4B - OTHER ADJUSTMENTS: PROVISION FOR BAD DEBT IN AFS INCOME 18,195,632. NON-OPERATING REIMBURSEMENTS INCLUDED IN EXPENSE ON AFS 4,260,114. AUXILIARY GRANTS NOT ON AFS 167,501. MCR PHYSICIAN NETWORK ALLOCATION IN AFS EXPENSE 24,604,144. SERVICES PROVIDED TO OUTSIDE ENTITIES IN EXPENSE ON AFS 23,467. VARIOUS UBI INCOME NOT INCLUDED IN AFS INCOME 2,655. PHARMACY SALES INCLUDED IN EXPENSE ON AFS 35,036. 1 1 X 1 X 250.000000000000 1 X 1 1 1 0 1 1 3642977 3642977 0.00640 46970769 20536773 26433996 0.04680 43021302 34330436 8690866 0.01540 93635048 54867209 38767839 0.06860 2404323 439153 1965170 0.00350 3675053 3675053 0.00650 90111463 65441994 24669469 0.04360 2264625 2264625 0.00400 98455464 65881147 32574317 0.05760 192090512 120748356 71342156 0.12620 2600 2600 0.00000 23050 23050 0.00000 152240 152240 0.00030 8080 8080 0.00000 11630 11630 0.00000 49840 49840 0.00010 247440 247440 0.00040 1 18552643 108469025 155438465 -46969440 X 1 1 1 HARMONY SURGERY CENTER LLC AMBULATORY SURGERY 0.51000 0.49000 2 PEAK SURGICAL MANAGEMENT MANAGEMENT SERVICES 0.14000 0.86000 3 HARMONY IMAGING CENTER LLC MEDICAL IMAGING 0.46000 0.54000 4 SURGERY CENTER OF FORT COLLINS AMBULATORY SURGERY 0.26000 0.49000 5 GATEWAY MEDICAL SERVICES REAL ESTATE/MEDICAL EQUIPMENT 0.50000 0.50000 6 EYE AND LASER CENTER OF NORTHERN COLO LLC LASER SURGERY 0.50000 0.50000 7 VEIN AND LASER CENTER OF N COLO LASER SURGERY 0.33000 0.00000 1 1 POUDRE VALLEY HOSPITAL

1024 S LEMAY FORT COLLINS CO 80524

X X X X X PHARMACY, LAB, CARDIOVASCULAR POUDRE VALLEY HEALTH CARE 1 1 X X X X X X X X X X 12 1 1 1 X X X X X X X X X 0 0 1 1 250.000000000000 1 400.000000000000 1 X X X X X X X 1 1 X X 1 X 1 X X X X X X X 1 X 0 0 62 HARMONY CAMPUS MOB

2121 E HARMONY RD FORT COLLINS CO 80528

PHYSICIAN OFFICES, ONCOLOGY, HCOR HARMONY CAMPUS AMBLUATORY CARE CENTER

2127 E HARMONY RD FORT COLLINS CO 80528

SURGERY CENTER, DIAGNOSTIC CENTER, IMAGING, URGENT CARE REDSTONE

2315 E HARMONY RD FORT COLLINS CO 80528

OUTPATIENT LAB, PHYSICIAN OFFICE, SSOR, UROLOGY PEAKVIEW MEDICAL CENTER

5881 W 16TH STREET GREELEY CO 80634

PHYSICIAN OFFICES MCR NORTH MOB

2500 ROCKY MTN AVE LOVELAND CO 80538

PHYSICIAN OFFICES MOUNTAIN CREST BEHAVIORAL HEALTH

4601 CORBETT DR FORT COLLINS CO 80528

BEHAVIORAL HEALTH GREELEY MEDICAL CLINIC

1900 16TH STREET GREELEY CO 80631

PHYSICIAN OFFICES CHMG MEMORIAL GENERAL & VASCULAR SURGERY

1400 E BOULDER STREET COLORADO SPRINGS CO 80909

PHYSICIAN OFFICES CHMG CARDIOLOGY

1400 E BOULDER STREET COLORADO SPRINGS CO 80909

PHYSICIAN OFFICES MCR SOUTH MOB

2500 ROCKY MTN AVE LOVELAND CO 80538

PHYSICIAN OFFICES, HCOR, SSOR CHMG CHEYENNE MEDICAL SPECIALISTS

5050 POWDERHOUSE RD CHEYENNE WY 82009

PHYSICIAN OFFICES CHMG MATERNAL-FETAL MEDICINE

1400 E BOULDER STREET COLORADO SPRINGS CO 80909

PHYSICIAN OFFICES CHMG INPATIENT MEDICINE

1400 E BOULDER STREET COLORADO SPRINGS CO 80909

PHYSICIAN OFFICES SURGERY CENTER OF FT COLLINS-JV

1100 E PROSPECT RD FORT COLLINS CO 80524

SURGERY CENTER PROSPECT MEDICAL PLAZA

1106 E PROSPECT SUITE 100 FORT COLLINS CO 80524

PHYSICIAN OFFICES, OUTPATIENT REHAB, NEUROLOGY, INT MEDICINE CENTRE AVE HEALTH AND REHAB-JV

915 CENTRE AVE FORT COLLINS CO 80526

REHAB PENNOCK PLACE

1025 PENNOCK PLACE FORT COLLINS CO 80524

PHYSICIAN OFFICES, BLOOD BANK WESTBRIDGE

1107 S LEMAY FORT COLLINS CO 80524

PHYSICIAN OFFICES, MEDICAL SPA, BLOOD DRAW UROLOGY CENTER OF THE ROCKIES

3520 E 15TH STREET LOVELAND CO 80538

PHYSICIAN OFFICES CARDIOTHORACIC SURGERY

525 N FOOTE AVE SUITE 302 COLORADO SPRINGS CO 80910

PHYSICIAN OFFICES WINDSOR MEDICAL CENTER

1455 MAIN STREET WINDSOR CO 80550

PHYSICIAN OFFICES MEMORIAL NEUROSCIENCES

1725 BOULDER STREET SUITE 101 COLORADO SPRINGS CO 80909

PHYSICIAN OFFICES SNOW MESA

4674 SNOW MESA DRIVE FORT COLLINS CO 80528

PHYSICIAN OFFICES BREAST SURGERY

4110 BRIARGATE PARKWAY SUITE 465 COLORADO SPRINGS CO 80920

PHYSICIAN OFFICES EXPRESS LAB

1020 DOCTORS LANE FORT COLLINS CO 80524

LAB MEMORIAL VEIN CENTER

4110 BRIARGATE PARKWAY SUITE 140 COLORADO SPRINGS CO 80920

PHYSICIAN OFFICES GREELEY ONCOLOGYRHEUMATOLOGY

1800 15TH STREET GREELEY CO 80631

PHYSICIAN OFFICE HEMATOLOGYONCOLOGY

525 N FOOTE AVE SUITE 202 COLORADO SPRINGS CO 80910

PHYSICIAN OFFICES TIMERLINE MEDICAL

131 STANLEY DR ESTES PARK CO 80517

PHYSICIAN OFFICES WEST LOVELAND

3850 N GRANT AVE LOVELAND CO 80538

URGENT CARE, PHYSICIAN OFFICES CHILDREN'S THERAPY

1500 S LEMAY FORT COLLINS CO 80526

THERAPY COLUMBINE POUDRE HOMECARE-JV

915 CENTRE AVE FORT COLLINS CO 80526

HOME HEALTHCARE MEMORIAL SUNFLOWER FAMILY MEDICINE

1730 N CORONA STREET COLORADO SPRINGS CO 80907

PHYSICIAN OFFICES PRIMARY CARE-STERLING

620 IRIS DRIVE STERLING CO 80751

PHYSICIAN OFFICES FOXTRAIL FAMILY MEDICINE

1625 FOXTRAIL DR LOVELAND CO 80538

PHYSICIAN OFFICES SENIOR CLINIC

175 S UNION BLVD SUITE 300 COLORADO SPRINGS CO 80910

PHYSICIAN OFFICES POUDRE INFUSION THERAPY-JV

915 CENTRE AVE FORT COLLINS CO 80526

INFUSION HCORSCOTTSBLUFF

2 W 42ND ST 2200 SCOTTSBLUFF NE 69361

PHYSICIAN OFFICES THE VEIN AND LASER CENTER-JV

2008 CARIBOU DRIVE FORT COLLINS CO 80525

PHYSICIAN OFFICES YAMPA VALLEY STEAMBOAT

940 CENTRAL PARK DR 290 STEAMBOAT SPRINGS CO 80487

PHYSICIAN OFFICES THOMPSON VALLEY TOWNE CENTER

1327 EAGLE DRIVE LOVELAND CO 80537

PHYSICIAN OFFICES CHMG OB-GYN CLINIC

1715 61ST AVENUE GREELEY CO 80631

PHYSICIAN OFFICES ESTES PARK

555 PROSPECT AVE ESTES PARK CO 80517

PHYSICIAN OFFICES EYE LASER CENTER OF N COLORADO-JV

1725 EAST PROSPECT RD FORT COLLINS CO 80525

PHYSICIAN OFFICES CRAIG

595 RUSSELL STREET CRAIG CO 81625

PHYSICIAN OFFICES WATER VALLEY

1870 MARINA PLAZA DRIVE WINDSOR CO 80550

OUTPATIENT REHAB FORT MORGAN

1000 LINCOLN STREET 207 FORT MORGAN CO 80701

PHYSICIAN OFFICES SIDNEY

1625 DORWART DRIVE SIDNEY NE 69162

PHYSICIAN OFFICES CHMG SLEEP MEDICINE CLINIC

4110 BRIARGATE PARKWAY SUITE 445 COLORADO SPRINGS CO 80920

PHYSICIAN OFFICES GMCBRUSH

2400 EDISON STREET BRUSH CO 80723

PHYSICIAN OFFICES LARAMIE

3116 WILLET DRIVE LARAMIE WY 82070

PHYSICIAN OFFICES YUMA

910 S MAIN STREET YUMA CO 80759

PHYSICIAN OFFICES KREMMLING

214 S 4TH STREET KREMMLING CO 80459

PHYSICIAN OFFICES WALDEN

350 MCKINGLEY ST WALDEN CO 80480

PHYSICIAN OFFICES CHMG HCOR CV SURGEON

7960 NIWOT ROAD NIWOT CO 80503

PHYSICIAN OFFICES ALLIANCE

2101 BOX BUTTE AVE ALLIANCE NE 69301

PHYSICIAN OFFICES HAYTHORN BROTHERS

7251 W 20TH ST GREELEY CO 80631

SLEEP LAB LAB DRAWS

708 22ND STREET GREELEY CO 80631

LAB PHLEBOTOMY STATION

1113 OAKRIDGE DRIVE FORT COLLINS CO 80525

LAB DRAWS PHLEBOTOMY STATION

2001 S SHIELDS FORT COLLINS CO 80526

LAB DRAWS PHLEBOTOMY STATION

2025 BIG HORN DRIVE FORT COLLINS CO 80525

LAB DRAWS PHLEBOTOMY STATION

3519 RICHMOND DRIVE FORT COLLINS CO 80526

LAB DRAWS PART I, LINE 7: THE ORGANIZATION USED A COST-TO-CHARGE RATIO FOR LINE 7B AND 7C. THE COST-TO-CHARGE RATION WAS DERIVED FROM WORKSHEET 2, RATIO OF PATIENT CARE TO COST-TO-CHARGES.LINE 7A WAS DERIVED USING A COST-TO-CHARGE RATIO FROM THE COST REPORT.THE INFORMATION FOR LINES 7E THROUGH 7I WAS DERIVED FROM INFORMATION IN THE GENERAL LEDGER AND OTHER FINANCIAL DATA RELATED SPECIFICALLY TO THE VARIOUS TYPES OF COMMUNITY BENEFITS. PART I, LINE 7G: INCLUDES PHYSICIAN GROUPS AS A SUBSIDIZED SERVICE. THESE CLINICS PROVIDE SERVICES IN UNDERSERVED AREAS IN COLORADO, NEBRASKA AND WYOMING. PART I, L7 COL(F): TOTAL BAD DEBT EXPENSE REMOVED FROM THE DENOMINATOR PRIOR TO THE PERCENTAGE CALCULATION = $18,552,643. PART II: AS MENTIONED UNDER PROMOTION OF COMMUNITY HEALTH WE HAVE A MULTITUDE OF PROGRAMS DESIGNED TO ADDRESS THE HEALTH OF OUR COMMUNITY INVOLVING ALL AGE GROUPS AND FOCUS ON WHAT AN INDIVIDUAL CAN DO TO IMPROVE HIS/HER HEALTH. MANY OF THE PROGRAMS REFLECTED IN PART II ARE DESIGNED TO PROMOTE HEALTHY OPTIONS AND CHOICES FOR OUR COMMUNITY WHICH IS AN IMPORTANT PART OF OVERALL COMMUNITY HEALTH AND THEREFORE A BENEFIT TO THE COMMUNITY.PART III, LINE 2: ACCOUNTS WITH UNRESOLVED PATIENT LIABILITY AFTER REASONABLE COLLECTION EFFORTS, SET BY POLICY AND IN CONJUNCTION WITH FEDERAL, STATE, AND PAYOR SPECIFIC REGULATIONS, WILL BE ASSIGNED TO BAD DEBT. THESE ACCOUNTS SHALL BE REFERRED TO AN OUTSIDE COLLECTION AGENCY, OR IN SELECTED INSTANCES, ATTORNEYS, FOR ADDITIONAL COLLECTION ACTIVITIES. PART III, LINE 4: PATIENT ACCOUNTS RECEIVABLE ARE REPORTED NET OF ALLOWANCES FOR DOUBTFUL ACCOUNTS, CONTRACTUAL ADJUSTMENTS, AND MEDICALLY INDIGENT ALLOWANCES.PART III, LINE 5: MEDICARE REVENUE WAS COMPUTED AS FOLLOWS:POUDRE VALLEY HEALTH CARE COST REPORT 70,774,223POUDRE VALLEY HEALTH CARE GME PAYMENT (648,327)CENTRE AVE HEALTH & REHAB COST REPORT 3,958,909COLUMBINE POUDRE HOMECARE COST REPORT 1,165,018PVHC INC. MEDICARE DISALLOWED PROGRAMS 717,662DISREGARDED ENTITIES 29,410,992JOINT VENTURES 3,090,548TOTAL TO LINE 5 108,469,025PART III, LINE 6: ALLOWABLE COSTS AS REPORTED ON THE POUDRE VALLEY HEALTH CARE INC. 2013 COST REPORT.PART III, LINE 6: MEDICARE ALLOWABLE COSTS OF CARE RELATING TO PAYMENTS WAS COMPUTED AS FOLLOWS:POUDRE VALLEY HEALTH CARE COST REPORT 104,661,256CENTRE AVE HEALTH & REHAB COST REPORT 3,443,138COLUMBINE POUDRE HOMECARE COST REPORT 1,165,018PVHC INC. MEDICARE DISALLOWED PROGRAMS 937,769DISREGARDED ENTITIES 41,827,682JOINT VENTURES 3,403,602TOTAL TO LINE 6 155,438,465 PART III, LINE 8: APPROXIMATELY 22.2% OF NET PATIENT SERVICE REVENUES IS FROM PARTICIPATION IN THE MEDICARE PROGRAM, THUS PROVIDING MEDICARE SERVICES PROMOTES ACCESS TO HEALTHCARE SERVICES TO A SIGNIFICANT PORTION OF THE COMMUNITY POPULATION. PART III, LINE 9B: PATIENT PROVIDES DOCUMENTATION BASED ON COLORADO INDIGENT CARE GUIDELINES, REVIEWED BY FINANCIAL ASSISTANCE COMMITTEE (FAC), CROSS FUNCTIONAL TEAM CHAIRED BY DIRECTOR PATIENT FINANCIAL SERVICES. UPON APPROVAL OR DENIAL OF THE REQUEST FOR CHARITABLE AID FROM THE FAC, THE PATIENT WILL BE ADVISED OF THE DECISION. THE BILL IS PARTIALLY OR TOTALLY ADJUSTED AS APPROVED BY THE FAC, NO FURTHER COLLECTION PROCESS WITH THE PATIENT. FOR ANY PORTION NOT ADJUSTED OFF, THE PROPER SEQUENCE OF ATTEMPTS TO COLLECT ARE FOLLOWED. FINAL ASSIGNMENT OF THE BILL IS TO A COLLECTION AGENCY. POUDRE VALLEY HEALTH CARE PART V, SECTION B, LINE 1J: THE CHNA REPORT ALSO DESCRIBES CLINICAL SERVICES PROVIDED BY HOSPITAL FACILITY ADDRESSING THE FOUR LEADING CAUSES OF MORTALITY IN THE COUNTY. POUDRE VALLEY HEALTH CARE PART V, SECTION B, LINE 3: TWO COMMUNITY MEETINGS WERE HELD DURING FEBRUARY 2013 WHERE FINDINGS FROM THE CHNA WERE PRESENTED, QUESTIONS AND COMMENTS WERE RECEIVED AND RESPONSES PROVIDED. THE FOLLOWING INDIVIDUALS WERE CONSULTED:ANNETTE ALFANO, UNIVERSITY OF COLORADO HEALTHMARY ATCHISON, KAISER PERMANENTEKRISTIN BIERI, FOOD BANK FOR LARIMER COUNTYDEBORAH CAMPBELL, LARIMER COUNTY COMPASSJENNIFER CHASE, NORTHERN COLORADO AIDS PROJECTANDREA CLEMENT-JOHNSON, LARIMER COUNTY DEPARTMENT OF HEALTH & ENVIRONMENTBRUCE COOPER, HEALTH DISTRICT OF NORTHERN LARIMER COUNTYLORI DAIGLE, NORTHERN COLORADO AIDS PROJECTALISON DAWSON, DISABLED RESOURCE SERVICESEMILY DAWSON PETERSEN, TOUCHSTONE HEALTH PARTNERSTOM DONNELLY, LARIMER COUNTY COMMISSIONERSMICHELE DOYLE, COLUMBINE HEALTH CARE SYSTEMSLINDA FELLION, EARLY CHILDHOOD COUNCIL OF LARIMER COUNTYLEW GAITER, LARIMER COUNTY COMMISSIONERSCHAZZ GLAZE, SALUD FAMILY HEALTH CENTERNEIL GLUCKMAN, LARIMER COUNTY, ASSISTANT COUNTY MANAGERMARTHA HARGRAVES, COMMUNITY MEMBERBARBARA HARTMAN, THOMPSON SCHOOL DISTRICTSUE HEWITT, HEALTH DISTRICT OF NORTHERN LARIMER COUNTYJESSICA HINTERBERG, CANDO WITH UNIVERSITY OF COLORADO HEALTHERICA IVERSON, FOOD BANK FOR LARIMER COUNTYSTEVE JOHNSON, LARIMER COUNTY COMMISSIONERSASHLEY KASPRZAK, TEAM FORT COLLINSKATY KOHNEN, LEAGUE OF WOMEN VOTERSJENNY LANGNESS, ALPHA CENTERJENNIFER LEE, LARIMER COUNTY BOARD OF HEALTHDIANA LINDEN, PLANNED PARENTHOOD OF THE ROCKY MOUNTAIN'S RESPONSIBLE SEX EDUCATION INSTITUTEMARIE MACPHERSON, LARIMER COUNTY DEPT OF HEALTH AND ENVIRONMENTJOHN MCGEE, CROSSROADS SAFEHOUSEDAWN NANNINI, TEAM FORT COLLINSKAREN NICHOLSON, ESTES PARK MEDICAL CENTERTRACI ODDY, BANNER MCKEE MEDICAL CENTERCAROL PLOCK, HEALTH DISTRICT OF NORTHERN LARIMER COUNTYMARK RICHARDS, LARIMER COUNTY BOARD OF HEALTHDOUG RYAN, LARIMER COUNTY DEPARTMENT OF HEALTH & ENVIRONMENTKIM SHARPE, HEALTHIER COMMUNITIES COALITION OF LARIMER COUNTYBILL STOUT, WOMEN'S RESOURCE CENTERAVERIL STRAND, LARIMER COUNTY DEPARTMENT OF HEALTH AND ENVIRONMENTDEIRDRE SULLIVAN, CANDO WITH UNIVERSITY OF COLORADO HEALTHJILL TAYLOR, UNIVERSITY OF COLORADO HEALTHGRACE TAYLOR, UNIVERSITY OF COLORADO HEALTHMARILYN THAYER, COMMUNITY ORGANIZING TO REACH EMPOWERMENT (CORE) CENTERLEE THIELEN, THIELEN CONSULTINGCOLETTE THOMPSON, UNIVERSITY OF COLORADO HEALTHJANE VISTE, LARIMER COUNTY DEPARTMENT OF HEALTH AND ENVIRONMENTSCOTT VON BARGEN, TURNING POINT CENTER FOR YOUTH & FAMILY DEVELOPMENTMARGARET WATSON, UNITED WAY 2-1-1 OF LARIMER COUNTYNANCY WEBER, POUDRE SCHOOL DISTRICTVALERIE WENDELL, BOHEMIAN FOUNDATIONLISE YOUNGBLADE, HUMAN DEVELOPMENT AND FAMILY STUDIES/COLORADO STATE UNIVERSITYSTEVE YURASH, LARIMER COUNTY BOARD OF HEALTH POUDRE VALLEY HEALTH CARE PART V, SECTION B, LINE 4: MEDICAL CENTER OF THE ROCKIES ALSO PARTICIPATED IN THE 2013 CHNA. POUDRE VALLEY HEALTH CARE PART V, SECTION B, LINE 5C: E-MAIL DISTRIBUTION OF LINK TO CHNA REPORT ON HOSPITAL WEBSITE TO MEMBERS OF THE COUNTY HEALTH ASSESSMENT PLANNING & PARTNERSHIP TEAM.HTTP://WWW.PVHS.ORG/DOCUMENTS/CHGENERAL/CHNA_WEB201213.PDF POUDRE VALLEY HEALTH CARE PART V, SECTION B, LINE 7: AN IDENTIFIED HEALTH ISSUE RELATED TO A HIGH RATE OF UNINTENDED TEEN PREGNANCY IN WELD COUNTY IS NOT BEING ADDRESSED WITH DIRECT RESOURCES ALLOCATED FROM POUDRE VALLEY HOSPITAL OR THE MEDICAL CENTER OF THE ROCKIES. THE WELD COUNTY DEPARTMENT OF PUBLIC HEALTH & ENVIRONMENT PROVIDES REPRODUCTIVE HEALTH SERVICES FOR TEENS THROUGH A TITLE X CLINIC. ADDITIONAL EDUCATION AND OUTREACH TO WELD COUNTY TEENS IS PROVIDED BY A COMMUNITY ORGANIZATION; LUTHERAN FAMILY SERVICES. POUDRE VALLEY HOSPITAL AND MEDICAL CENTER OF THE ROCKIES PROVIDED SUPPORT TO THIS ORGANIZATION THROUGH CASH DONATIONS TOTALING $2,460.00 DURING THE 2012/13 FISCAL YEAR. ANOTHER IDENTIFIED HEALTH ISSUE - MOTOR VEHICLE SAFETY FOR TEENS IN WELD COUNTY - IS ALSO NOT BEING DIRECTLY ADDRESSED DUE TO LACK OF RESOURCES. THE ISSUE IS BEING ADDRESSED BY A NON-PROFIT COMMUNITY COALITION - DRIVE SMART WELD COUNTY - WHICH HAS DEDICATED RESOURCES AND ACTION PLANS TO ADDRESS THIS ISSUE. PART VI, LINE 2: HEALTH CARE NEEDS ARE ADDITIONALLY IDENTIFIED THROUGH COLLABORATIVE RELATIONSHIPS WITH HEALTHCARE PROVIDERS IN THE COMMUNITIES WE SERVE. AN EXAMPLE IS OUR CARE COORDINATION INITIATIVE TARGETED TO AT-RISK CHILDREN WITH SPECIAL HEALTHCARE NEEDS . PHYSICIANS IDENTIFIED THE NEED TO IMPROVE THE COORDINATION AND TIMELINESS OF CARE FOR THIS POPULATION; WE RESPONDED BY DEVELOPING AND STAFFING A CARE COORDINATION / PATIENT NAVIGATION SERVICE MODEL (HEALTHY HARBORS). PART VI, LINE 3: THERE ARE SEVERAL WAYS WE NOTIFY THE PATIENT AND ATTEMPT TO ASSIST THEM. FOR SURGERIES AND HIGH DOLLAR SCHEDULED PROCEDURES, WE PROVIDE THEM WITH AN ESTIMATE AT REGISTRATION AND GO OVER ALL FINANCIAL ASSISTANCE OPTIONS AVAILABLE IF THEY ARE INTERESTED. WE ALSO HAVE FINANCIAL COUNSELORS AVAILABLE EACH DAY THAT CAN ANSWER QUESTIONS AND HELP THEM FILL OUT CHARITY APPLICATIONS. FOR THOSE THAT ARE UNINSURED, OUR CONDITIONS OF SERVICE FORM HAS A SPOT THEY INITIAL STATING THAT WE HAVE OFFERED ASSISTANCE AND MADE THEM AWARE OF PROGRAMS AVAILABLE TO THEM. ONCE A PERSON HAS RECEIVED CARE IN THE EMERGENCY DEPARTMENT, WE ALSO HAVE EDUCATED STAFF THAT ASSISTS THEM AND EDUCATES THEM OF WHAT IS AVAILABLE FOR FINANCIAL ASSISTANCE. IN ADDITION, ONCE A PATIENT DOES RECEIVE A STATEMENT OR BILL, THERE IS INFORMATION ON THE BILL OF WHO THEY CAN CALL TO GET INFORMATION ON FINANCIAL ASSISTANCE. PART VI, LINE 4: POUDRE VALLEY HEALTH CARE INC. IS A LOCALLY OWNED, PRIVATE, NON-PROFIT ORGANIZATION WITH A STRONG VISION: FROM HEALTH CARE TO HEALTH. BASED IN NORTHERN COLORADO, PVHC PROVIDES EVIDENCE-BASED HEALTHCARE AND WELLNESS SERVICES AND PRODUCTS IN COLORADO, NEBRASKA AND WYOMING, ACROSS A SERVICE AREA COVERING MORE THAN 50,000 SQUARE MILES.PVHC IS A PART OF THE UNIVERSITY OF COLORADO HEALTH WHICH AIMS TO DELIVER THE HIGHEST QUALITY PATIENT CARE WITH THE HIGHEST QUALITY PATIENT EXPERIENCE. THE PARTNERSHIP COMBINES POUDRE VALLEY HOSPITAL, MEDICAL CENTER OF THE ROCKIES, COLORADO HEALTH MEDICAL GROUP, UNIVERSITY OF COLORADO HOSPITAL AND MEMORIAL HEALTH SYSTEM INTO AN ORGANIZATION DEDICATED TO BUILDING HEALTHIER COMMUNITIES AND PROVIDING UNMATCHED PATIENT CARE IN THE ROCKY MOUNTAIN WEST. THE ORGANIZATION'S MISSION IS AS FOLLOWS: WE IMPROVE LIVES. IN BIG WAYS THROUGH LEARNING, HEALING AND DISCOVERY. IN SMALL, PERSONAL WAYS THROUGH HUMAN CONNECTION. BUT IN ALL WAYS, WE IMPROVE LIVES. PART VI, LINE 5: WE HAVE IMPLEMENTED A MULTITUDE OF PROGRAMS AND SERVICES THAT ADDRESS THE HEALTH NEEDS OF OUR BROADER COMMUNITY TARGETING ALL AGE GROUPS WHILE MAINTAINING A SPECIAL FOCUS ON SERVING VULNERABLE POPULATIONS . WE ALSO GIVE DOLLARS TO OTHER ENTITIES THAT WORK TO IMPROVE THE HEALTH OF OUR COMMUNITY. EXAMPLES ARE: TEEN PREGNANCY PREVENTION EDUCATION; SUBSTANCE ABUSE PREVENTION EDUCATION FOR YOUTH AND YOUNG ADULTS; OBESITY PREVENTION; IMPROVED FOOD SECURITY FOR LOW INCOME RESIDENTS; AND MENTAL HEALTH SERVICES FOR THE UNDERSERVED. PART VI, LINE 6: ALL THE SERVICES WE OFFER ARE AVAILABLE TO ANYONE THAT USES ANY OF OUR FACILITIES IN THE HEALTH SYSTEM. OUR GEOGRAPHY IS NOT THAT LARGE SO WE ARE ABLE TO ACCOMMODATE THE DIFFERENT COMMUNITIES THAT UTILIZE OUR SERVICES WITH THE SAME LEVEL OF COMMUNITY HEALTH PROGRAMMING. REPORTS FILED WITH STATES PART VI, LINE 7 CO 1 PVHMCR HOSPITAL FOUNDATION 2315 E HARMONY RD 200 FORT COLLINS CO 80528 741894581 501(C )(3) 1332421 SEE SCH I, PART IV UNIVERSITY OF N COLORADO 501 20TH STREET GREELEY CO 80639 846000546 GOVERNMENT 170640 SEE SCH I, PART IV WELD COUNTY FOOD BANK 1108 H STREET GREELEY CO 80631 742244826 501(C )(3) 75100 SEE SCH I, PART IV HEALTH DISTRICT OF N LARMIER COUNTY 120 BRISTLECONE DR FORT COLLINS CO 80524 840515919 GOVERNMENT 41000 SEE SCH I, PART IV NORTHERN COLORADO ECONOMIC DEVELOPMENT CORPORATION 3553 CLYDESDALE PARKWAY 230 LOVELAND CO 80538 841012341 501(C )(3) 20000 SEE SCH I, PART IV UNIVERSITY OF N COLORADO FOUNDATION 501 20TH STREET GREELEY CO 80639 846044833 501(C )(3) 17610 SEE SCH I, PART IV PARTNERS MENTORING YOUTH 530 S COLLEGE AVE UNIT 1 FORT COLLINS CO 80524 742486211 501(C )(3) 11000 SEE SCH I, PART IV UNITED WAY OF WELD COUNTY 814 9TH STREET GREELEY CO 80632 846011918 501(C )(3) 10000 SEE SCH I, PART IV IVINSON MEMORIAL HOSPITAL FOUNDATION 255 N 30TH STREET LARAMIE CO 82072 836000188 501(C )(3) 9268 SEE SCH I, PART IV AMERICAN CANCER SOCIETY 8221 W 20TH STREET GREELEY CO 80634 841316555 501(C )(3) 9200 SEE SCH I, PART IV GREELEY CENTENNIAL ROTARY 1035 37TH AVE CT GREELEY CO 80634 840714073 501(C )(3) 7500 SEE SCH I, PART IV ARTHRITIS FOUNDATION 2280 S ALBION STREET DENVER CO 80222 383826066 501(C )(3) 6000 SEE SCH I, PART IV ALTERNATIVES TO VIOLENCE 313 E 4TH STREET LOVELAND CO 80537 840886127 501(C )(3) 5080 SEE SCH I, PART IV 13 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: THE ORGANIZATION AWARDS GRANTS BASED ON THE BENEFIT TO THE COMMUNITY. THE ORGANIZATION REQUESTS INFORMATION FROM THE GRANTEES TO ENSURE THAT THE FUNDS WILL BE USED FOR THE SPECIFIED PURPOSE. QUESTION 1, PART II, COLUMN H PURPOSE OF GRANT OR ASSISTANCE FOR RELATED ENTITIES, THE GRANTS ARE RELATED TO SPECIFIC REQUESTS. THE FUNDS ARE TO BE USED TO BENEFIT THE HEALTHCARE COMMUNITY OF NORTHERN COLORADO. EACH REQUEST IS EVALUATED ON AN INDIVIDUAL BASIS. FOR NON-RELATED COMMUNITY AND GOVERNMENTAL ORGANIZATIONS, THE GRANTS ARE MADE AT THE DISCRETION OF THE ORGANIZATION. THESE DISCRETIONARY GRANTS ARE TO BE USED TO BENEFIT THE HEALTHCARE COMMUNITY OF NORTHERN COLORADO. X X X 1 1 X X X X X 1 1 0 0 0 0 0 0 0 RULON STACEY 632826 348694 93872 51725 405929 223673 79798 43970 17575 9684 1230000 677746 357520 196999 STEPHANIE DOUGHTY 301861 166331 35702 19672 841994 463951 39361 21689 4714 2598 1223632 674241 770858 424755 RUSS BRANZELL 393041 0 47739 0 512933 0 49274 0 26194 0 1029181 0 503279 0 DOUG FAUS 181285 0 22945 0 192312 0 6715 0 24626 0 427883 0 182795 0 DR WILLIAM NEFF 429856 0 51666 0 437675 0 54977 0 25046 0 999220 0 418354 0 DONNA PODUSKA 179855 0 21881 0 126703 0 37398 0 6304 0 372141 0 74193 0 DR MICHAEL RANDLE 49981 0 0 0 254768 0 12500 0 4975 0 322224 0 0 0 DAN ROBINSON 232269 0 29125 0 377344 0 24859 0 25581 0 689178 0 363972 0 STEVEN SCHWARTZ 151051 0 646 0 15049 0 8298 0 7001 0 182045 0 0 0 KEVIN UNGER 379697 0 45741 0 415437 0 109132 0 21958 0 971965 0 374565 0 DR HANS COESTER 674681 0 0 0 946104 0 29500 0 22040 0 1672325 0 0 0 DR MARK GUADAGNOLI 283329 0 0 0 520687 0 29500 0 15885 0 849401 0 0 0 DR WILLIAM MILLER 359641 0 0 0 381104 0 12500 0 9684 0 762929 0 0 0 DR JOSH PETIT 1230818 0 0 0 41104 0 29500 0 27267 0 1328689 0 0 0 DR LARS WIDDEL 107136 0 0 0 601647 0 11001 0 3552 0 723336 0 0 0 GRACE KOWALYSHYN-TAYLOR 210694 0 28801 0 21623 0 43765 0 25914 0 330797 0 20247 0 PATTI OAKES 255151 0 30803 0 214494 0 24889 0 8139 0 533476 0 172530 0 CARL SMITH 138323 0 686 0 400430 0 45902 0 16800 0 602141 0 108763 0 PART I, LINE 1A TRAVEL FOR COMPANIONS: PER SYSTEM POLICY, TRAVEL FOR COMPANIONS IS NOT REIMBURSABLE. FOR CONVENIENCE OF TRAVEL ARRANGEMENTS FOR THE ANNUAL BOARD MEMBER RETREAT AND SELECT CONFERENCES, PVHC PAYS FOR ONE COMPANION PER BOARD MEMBER AND EMPLOYEE ATTENDING THE CONFERENCE. EACH BOARD MEMBER RECEIVES A 1099 FOR THIS INCOME. EACH EMPLOYEE HAS THIS ADDED TO THEIR FORM W-2 GROSS-UP PAYMENTS: GROSS UP PAYROLL IS CALCULATED AT YEAR END FOR SPECIAL CHECKS CREATED TO ADD SPECIFIC ITEMS TO EMPLOYEE'S FORM W-2 WAGES INCLUDING COUNTRY CLUB DUES, PERSONAL USE OF LAPTOP COMPUTERS AND IPADS, SPOUSE TRAVEL FOR ANNUAL BOARD RETREAT AND SELECT CONFERENCES AND IMPUTED INCOME ON LIFE INSURANCE POLICIES. CLUB DUES: THE HEALTH SYSTEM EXPECTS THE HOSPITAL MANAGEMENT TO PARTICIPATE IN COMMUNITY LIFE AND THEREFORE THE SYSTEM PAYS SOCIAL CLUB DUES FOR SPECIFIC MEMBERS OF THE SENIOR MANAGEMENT GROUP. THE CLUB DUES ARE ADDED TO THE SENIOR MANAGEMENT'S FORM W-2 ON AN ANNUAL BASIS. SUPPLEMENTAL INFORMATION PART III PART I, LINE 4A: CARL SMITH RECEIVED A SEVERANCE PAYMENT IN THE AMOUNT OF $216,919. PART I, LINE 4B: THE FOLLOWING EXECUTIVES PARTICIPATED IN AN EXECUTIVE RETENTION PLAN DURING THE YEAR. THE PLAN PROVIDES THE PARTICIPANT WITH SUPPLEMENTAL DEFERRED COMPENSATION, SUBJECT TO SUBSTANTIAL RISKS OF FORFEITURE, TO ENCOURAGE CONTINUED EMPLOYMENT WITH THE ORGANIZATION FOR A SIGNIFICANT PERIOD OF TIME. THE AMOUNT LISTED IS INCLUDED IN FORM W-2 BOX 5 WAGES AND AMOUNTS INCLUDED IN DEFERRED COMP. W-2 BOX 5 UNFUNDED DEFERRED COMP. RUSS BRANZELL 503,279 - STEPHANIE DOUGHTY 833,556 106,130 DOUG FAUS 182,795 - GRACE KOWALYSHYN-TAYLOR 20,247 - WILLIAM NEFF 418,354 - PATTI OAKES 172,530 - DONNA PODUSKA 74,193 - DAN ROBINSON 363,972 - CARL SMITH 108,763 - RULON STACEY 472,582 - KEVIN UNGER 374,565 77,002 A COLORADO HEALTH FACILITIES AUTHORITY SERIES A 840752932 196474W48 2005-03-31 50000000 REFUNDING 1999A BONDS 0 0 0 B COLORADO HEALTH FACILITIES AUTHORITY SERIES B 840752932 196474W48 2005-03-31 26294807 PAYMENT OF COMMERCIAL PAPER DEBT 0 0 0 C COLORADO HEALTH FACILITIES AUTHORITY SERIES F 840752932 196474W48 2005-03-31 55000000 REFUNDING 1999A BONDS 0 0 0 A 50000000 3133031 46468713 433893 3097393 2005 0 1 1 1 B 26294807 1644630 25000000 397052 897754 2005 1 0 1 1 C 55000000 3474651 54542446 795916 2005 0 1 1 1 A 0 1 0 0 0.00610 0.00610 0 0 1 B 0 1 0 0 0.00350 0.00350 0 0 1 C 0 1 0 0 0.00610 0.00610 0 0 1 A 1 0 1 JP MORGAN CHASE 25.670000000000 1 0 0 0 1 B 1 0 1 JP MORGAN CHASE 30.830000000000 1 0 0 0 1 C 1 0 0 0 0 1 A 1 B 1 C 1 SCHEDULE K, PART I, COLUMN E BOND ISSUE PRICE THE BOND ISSUE PRICE FOR THE SERIES B BOND DOES NOT EQUAL THE ISSUE PRICE LISTED ON THE FILED FORM 8038 AS THIS BOND WAS SPLIT WITH A RELATED ENTITY. ISSUE PRICE AS REPORTED ON FORM 8038: $83,000,000. STAMPEDE PROPERTIES SEE PART V 430092 SEE PART V 0 KATHLEEN MICHIE SEE PART V 81959 SEE PART V 0 SCH L, PART IV, BUSINESS TRANSACTIONS INVOLVING INTERESTED PERSONS:(A) NAME OF PERSON: STAMPEDE PROPERTIES(B) RELATIONSHIP BETWEEN INTERESTED PERSON AND ORGANIZATION: DAN STROH, DIRECTOR, HAS AN OWNERSIP INTEREST IN STAMPEDE PROPERTIES(D) DESCRIPTION OF TRANSACTION: 1099 INCOME PAID TO ENTITY(A) NAME OF PERSON: KATHLEEN MICHIE(B) RELATIONSHIP BETWEEN INTERESTED PERSON AND ORGANIZATION: KATHLEEN MICHIE IS A FAMILY MEMBER OF THAINE MICHIE, DIRECTOR(D) DESCRIPTION OF TRANSACTION: EMPLOYMENT WAGES VOLUNTEERS FORM 990, PART I, LINE 6 PVH HAS 831 ACTIVE VOLUNTEERS IN FISCAL YEAR 2013. AT POUDRE VALLEY HOSPITAL, MEDICAL CENTER OF THE ROCKIES, AND OFF-SITE LOCATIONS, VOLUNTEERS PLAY AN INTEGRAL ROLE IN PROVIDING MUCH NEEDED SUPPORT FOR PATIENTS, VISITORS, PHYSICIANS, AND STAFF. FROM ASSISTING IN SURGERY AND CARDIAC WAITING ROOMS, INFORMATION DESK, VOLUNTEER PATIENT LIASONS, BABY KNITTERS, VOLUNTEENS, AND PET THERAPY TO NAME JUST A FEW OF THE MANY PROGRAMS, EVERY VOLUNTEER CONTRIBUTES TO THE SUCCESS OF POUDRE VALLEY HEALTH SYSTEM TO ENHANCE THE COMFORT AND CARE OF THE PATIENTS AND THEIR FAMILIES. FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 IS PREPARED BY INDEPENDENT CPAS. A PRELIMINARY DRAFT IS REVIEWED BY THE INTERNAL FINANCE DEPARTMENT. THE FINAL COPY OF THE FORM 990 IS PROVIDED IN AN ELECTRONIC FORMAT TO ALL BOARD OF DIRECTORS PRIOR TO FILING WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C THE ORGANIZATION'S CONFLICT OF INTEREST POLICY REQUIRES COMPLETION OF THE FORM ON AN ANNUAL BASIS BY THE BOARD MEMBERS, OFFICERS AND KEY EMPLOYEES OF THE ORGANIZATION. COMPLETED FORMS ARE SUBMITTED AND REVIEWED BY THE INTERNAL COMPLIANCE DEPARTMENT TO ENSURE COMPLIANCE WITH THE WRITTEN POLICY. ANY QUESTIONS OR ULTIMATE ENFORCEMENT WOULD BE HANDLED BY THE COMPLIANCE DEPARTMENT. FORM 990, PART VI, SECTION B, LINE 15 POUDRE VALLEY HEALTHCARE, INC DETERMINES CEO, EXECUTIVE DIRECTOR, TOP MANAGEMENT OFFICIALS AND OTHER OFFICERS AND KEY EMPLOYEES COMPENSATION ANNUALLY. THIS DETERMINATION IS ACCOMPLISHED THROUGH THE USE OF THE HAY GROUP. THESE SERVICES ANNUALLY COLLECT LIKE DATA ON LIKE JOBS FROM LIKE ORGANIZATIONS. THE DATA IS SUBMITTED TO THE VP OF HUMAN RESOURCES WHO TAKES THE INFORMATION TO THE COMPENSATION COMMITTEE OF THE GOVERNING BOARD OF DIRECTORS WHERE ANY NEW COMPENSATION IS THEN ADOPTED AND RECORDED APPROPRIATELY IN THE MINUTES. EMPLOYMENT AGREEMENTS ARE KEPT ON FILE FOR THE CEO AND AN ADDITIONAL DOCUMENT THAT OUTLINES THE SENIOR MANAGEMENT ANNUAL INCENTIVE PLAN IS MADE AVAILABLE. FORM 990, PART VI, SECTION C, LINE 19 GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICIES, AND FINANCIAL STATEMENTS ARE PROVIDED TO THE PUBLIC BASED ON THE BUSINESS PURPOSE FOR THE REQUEST. THESE REQUESTS ARE ADDRESSED BY THE SENIOR MANAGEMENT TEAM ON A CASE BY CASE BASIS. POLICIES FORM 990, PART VI, SECTION B ALL ANSWERS MARKED "YES" UNDER PART VI, SECTION B - POLICIES APPLY TO POUDRE VALLEY HEALTH CARE INC AND LAKOTA LAKE LLC. QUESTIONS 15A AND 15B APPLY TO TIMBERLINE MEDICAL LLC AS WELL AS POUDRE VALLEY HEALTH CARE INC, LAKOTA LAKE LLC, AND POUDRE VALLEY MEDICAL GROUP, LLC. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 9: GASB PRIOR YEAR ADJUSTMENT 67,093. REMOVE HSS INVESTMENT BEGINNING BALANCE -913,179. AUXILIARY INCOME NOT INCLUDED IN AFS -149,769. AUXILIARY GRANTS NOT INCLUDED IN AFS 167,501. CONTRIBUTIONS FROM PV FOUNDATION NOT IN AFS INCOME -299,322. TIMING DIFFERENCE ON FDN/PVH CONTRIBUTION -58,689. BOOK VERSUS TAX ADJUSTMENT IN EQUITY EARNINGS 327,014. TIMBERLINE MEDICAL CLINIC 131 STANLEY AVE ESTES PARK CO 80517 043772090 OUTPATIENT CO 1419613 370651 PVHC INC LAKOTA LAKE LLC 2315 E HARMONY RD STE 200 FORT COLLINS CO 80528 841447761 OUTPATIENT CO 3922874 8013822 PVHC INC HERON LAKE LLC 2315 E HARMONY RD STE 200 FORT COLLINS CO 80528 264189163 OUTPATIENT CO 651660 721901 PVHC INC POUDRE VALLEY MEDICAL GROUP LLC 2315 E HARMONY RD STE 200 FORT COLLINS CO 80528 800348943 OUTPATIENT CO 74372801 20415666 PVHC INC MEDICAL CENTER OF THE ROCKIES 2315 E HARMONY RD STE 200 FORT COLLINS CO 80528 043730045 TERTIARY CARE CO 501(C)(3) LINE 3 PVHC INC 1 PVHS FOUNDATION 2315 E HARMONY RD STE 200 FORT COLLINS CO 80528 741894581 BENEFIT HEALTH CO 501(C)(3) LINE 7 PVHC INC 1 CARBON VALLEY HEALTHCARE HOLDINGS 1950 MOUNTAIN VIEW AVE LONGMONT CO 80501 273769602 LAND HOLDINGS CO 501(C)(3) LINE 3 N/A 0 HARMONY SURGERY CENTER 2127 E HARMONY RD 200 FT COLLINS CO 80528 841479751 AMBULATORY SURG CO N/A RELATED 2102135 2695569 0 0 0.51100 UNITED MEDICAL ALLIANCE 2021 BATTLECREEK DRIVE STE A FT COLLINS CO 80528 820572743 HEALTH CLAIMS CO N/A RELATED 182308 516094 0 1 0.50000 CENTRE AVENUE HEALTH & REHAB FACILITY 947 WORTHINGTON CIRCLE FT COLLINS CO 80526 841560494 NURSING FACILITY CO N/A RELATED 232710 821023 0 0 0.50000 COLUMBINE POUDRE HOME CARE 947 WORTHINGTON CIRCLE FT COLLINS CO 80526 841529817 NURSING CARE CO N/A RELATED 69546 329535 0 0 0.50000 EYE LASER CENTER OF NO COLORADO 1725 E PROSPECT RD FT COLLINS CO 80525 841518334 LASER SURGERY CO N/A UNRELATED 36722 11806 0 0 0.50000 GATEWAY MEDICAL SERVICES 2500 E PROSPECT RD FT COLLINS CO 80525 841427970 REAL EST/MED CO N/A UNRELATED 3302028 7596926 0 0 0.50000 POUDRE INFUSION THERAPY 947 WORTHINGTON CIRCLE FT COLLINS CO 80526 841530973 MEDICAL SERVICES CO N/A RELATED 40648 189639 0 0 0.50000 PVHS HOME MEDICAL SUPPLY 6820 N COUNTY RD 13 LOVELAND CO 80538 202034599 MEDICAL SUPPLY CO N/A UNRELATED 245504 664429 0 1 0.50000 THE VEIN AND LASER CENTER OF NO COLORADO 2008 CARIBOU DRIVE FORT COLLINS CO 80525 204943970 MEDICAL SERVICES CO N/A UNRELATED 34208 41440 0 0 0.33330 HARMONY IMAGING CENTER 1951 WILMINGTON DRIVE FORT COLLINS CO 80528 582479187 MEDICAL IMAGING CO N/A RELATED 902350 1551838 0 0 0.46000 PEAK SURGICAL MANAGEMENT 2127 E HARMONY RD STE 200 FORT COLLINS CO 80528 260899618 SURGICAL MGMT CO N/A RELATED 65209 48241 0 0 0.14290 SURGERY CENTER OF FORT COLLINS 1100 E PROSPECT ROAD FORT COLLINS CO 80525 841541559 SURGICAL PROC CO N/A UNRELATED 839292 1151171 0 0 0.26000 INNOVATION ENTERPRISES 2315 E HARMONY RD STE 200 FORT COLLINS CO 80528 202036774 IT CONSULTING CO N/A C 1176693 3374372 1.00000 1 1 1 1 1 0 0 1 1 0 1 0 1 1 1 1 1 1 1 1 HARMONY SURGERY CENTER A 699243 TRANSACTION TOTAL HARMONY SURGERY CENTER O 3171876 TRANSACTION TOTAL HARMONY SURGERY CENTER Q 434456 TRANSACTION TOTAL HARMONY SURGERY CENTER S 2338285 TRANSACTION TOTAL UNITED MEDICAL ALLIANCE M 1425395 TRANSACTION TOTAL CENTRE AVENUE HEALTH & REHAB FACILITY S 150000 TRANSACTION TOTAL COLUMBINE POUDRE HOME CARE S 50000 TRANSACTION TOTAL EYE LASER CENTER OF NO COLORADO M 137037 TRANSACTION TOTAL GATEWAY MEDICAL SERVICES S 3240000 TRANSACTION TOTAL MEDICAL CENTER OF THE ROCKIES L 3953227 TRANSACTION TOTAL MEDICAL CENTER OF THE ROCKIES N 3605069 TRANSACTION TOTAL MEDICAL CENTER OF THE ROCKIES O 46499678 TRANSACTION TOTAL MEDICAL CENTER OF THE ROCKIES R 81975350 TRANSACTION TOTAL PVHS FOUNDATION B 1332421 TRANSACTION TOTAL PVHS FOUNDATION C 299322 TRANSACTION TOTAL PVHS FOUNDATION O 241621 TRANSACTION TOTAL INNOVATION ENTERPRISES A 123690 TRANSACTION TOTAL INNOVATION ENTERPRISES A 437013 TRANSACTION TOTAL INNOVATION ENTERPRISES O 232090 TRANSACTION TOTAL INNOVATION ENTERPRISES S 238648 TRANSACTION TOTAL