2014-05-13T13:03:22-05:00 2013-06-30 410746749 CLIFTONLARSONALLEN LLP 220 SOUTH SIXTH STREET SUITE 300 MINNEAPOLIS MN 55402 990 2012-07-01 810233499 SIDNEY HEALTH CENTER SIDN 4064882100 216 14TH AVENUE SW SIDNEY MT 59270 RICHARD HARALDSON 4064882100 2014-05-13 1 DARRYN MCGARVEY P00958683 6123764500 2012 2015-11-30 17:44:51Z RICHARD HARALDSON 216 14TH AVENUE SW SIDNEY MT 59270 53164736 0 X WWW.SIDNEYHEALTH.ORG X 1946 MT TO HELP THOSE WE SERVE ACHIEVE THEIR HIGHEST LEVEL OF HEALTH BY PROVIDING QUALITY MEDICAL CARE. 8 8 628 178 4985633 0 661649 2078985 46110885 48389436 -934522 565674 1149818 1549434 46987830 52583529 14171 807 0 0 21160749 21705953 0 0 306654 26406787 29707820 47581707 51414580 -593877 1168949 64091778 64003703 34030525 31863461 30061253 32140242 X TO HELP THOSE WE SERVE ACHIEVE THEIR HIGHEST LEVEL OF HEALTH AND WELL-BEING. 0 0 45474579 807 48389436 SIDNEY HEALTH CENTER IS A NOT-FOR-PROFIT COMMUNITY BASED MEDICAL CENTER THAT HAS BEEN SERVING PEOPLE IN THE MONDAK REGION FOR MORE THAN 100 YEARS. OUR PASSION FOR CARING IS SHARED BY THE DOCTORS, NURSES, AND SEVERAL HUNDRED EMPLOYEES AND VOLUNTEERS. THIS COMMITMENT TO CARING IS OUR ALLEGIANCE TO THE COMMUNITY AS WE STRIVE TO PROVIDE "EXCEPTIONAL CARE FOR LIFE."LOCATED IN THE HEART OF RICHLAND COUNTY, THE ATTRACTIVE EASTERN MONTANA CAMPUS INCLUDES AN ACUTE CARE HOSPITAL, CLINIC AREA, RETAIL PHARMACY AND A 93-BED EXTENDED CARE FACILITY OFFERING A COMPLETE RANGE OF SERVICES FROM BIRTH THROUGH END-OF-LIFE, WHICH IS COMPLEMENTED BY AN ARRAY OF OUTREACH SERVICES. THIS CONTINUUM OR SUCCESSION OF SERVICES IS NOT TYPICAL OF RURAL HEALTHCARE ORGANIZATIONS, BUT SIDNEY HEALTH CENTER IS NOT TYPICAL. A STRONG COMPLEMENT OF PRIMARY CARE PHYSICIANS AND A UNIQUE SELECTION OF SURGICAL SPECIALISTS COMBINED WITH A MODERN FACILITY, AND UP-TO-DATE MEDICAL EQUIPMENT, MAKES SIDNEY HEALTH CENTER A SPECIAL PLACE TO WORK, RECEIVE CARE AND PRACTICE MEDICINE. SIDNEY HEALTH CENTER ALSO PROVIDES VARIOUS COMMUNITY BENEFIT PROGRAMS FOR THE INDIVIDUALS IN THEIR SERVICE REGION.RICHLAND COUNTY TRANSPORTATION - THIS PROGRAM GIVES OPPORTUNITIES FOR THOSE WHO CANNOT DRIVE THE OPTION OF A RIDE. SIDNEY HEALTH CENTER PROVIDES A DRIVER AND HELPS PAY FOR BUSSES. SINCE IT'S CONCEPTION WE HAVE GONE FROM ONE BUS AND ONE DRIVER FOR THE FULL PROGRAM TO 5 BUSSES AND 8 DRIVERS. WE WORK WITH THE HEALTH DEPARTMENT, RICHLAND COUNTY AND THE LODGE.MILES CITY NURSING PROGRAM - WE PROVIDE THE FACILITY AND PROGRAM COSTS TO HAVE MILES CITY COMMUNITY COLLEGE RUN A SATELLITE SCHOOL HERE IN SIDNEY. THIS PROMOTES NURSING AS A PROFESSION AND KEEPS THOSE WHO ARE INTERESTED IN OUR COMMUNITY AS POSSIBLE EMPLOYEES LATER.OUTREACH CLINIC - SOME OF THE OUTLYING COMMUNITIES DO NOT HAVE ACCESS TO AN ENT PHYSICIAN. SIDNEY HEALTH CENTER PROVIDES THE TRAVEL FOR OUR ENT TO GO TO THOSE OUTREACH AREAS.HEALTH FAIR - WORKING WITH RICHLAND COUNTY HEALTH DEPARTMENT, COALITION ON AGING, FIRE, POLICE AND MENTAL HEALTH PROFESSIONS, JUST TO NAME A FEW, SIDNEY HEALTH CENTER HOLDS A HEALTH FAIR WHERE PEOPLE CAN COME AND LEARN ABOUT DIFFERENT HEALTHCARE NEEDS OF OUR COMMUNITY. SIDNEY HEALTH CENTER PROMOTES PREVENTATIVE CARE, DIABETES EDUCATION, LAB SCREENINGS AND MANY OTHER TOPICS.LIVE-IT-UP - THIS IS A PROGRAM THAT SIDNEY HEALTH CENTER DOES TO MAKE WOMEN OF RICHLAND COUNTY AWARE OF HOW HEART DISEASE AFFECTS THEM. RICHLAND COUNTY FAIR & RODEO - SIDNEY HEALTH CENTER PROVIDES A BOOTH WHERE PEOPLE CAN GET THEIR BLOOD PRESSURE TAKEN, DO A FINGER STICK BLOOD TEST FOR DIABETS AND GET A BOTTLE OF WATER FOR FREE IN THE EXTREME HOT AUGUST DAYS OF THE FAIR.GRIEF RECOVERY SUPPORT GROUPS - SIDNEY HEALTH CENTER'S HOSPICE PROGRAMS PUT ON TWO DIFFERENT CAMPS FOR PEOPLE WHO HAVE LOST LOVED ONES. ONE IS FOR ADULTS, THE OTHER FOR KIDS. THERE ARE ALSO MEMORIAL SERVICES AND NUMEROUS GRIEF SUPPORT GROUPS THROUGHOUT THE YEAR.BIRTHDAY HEALTH FAIR - PATIENTS WHO SIGN UP CAN GET LABS DURING THEIR BIRTHDAY MONTH.VISITING NURSE SERVICE - INITIAL NURSE VISIT.MEDICATION ASSISTANCE - PROVIDES MEDS TO THOSE WHO HAVE NO INSURANCE. ALSO HELPS GET PATIENTS SIGNED UP WITH DRUG COMPANIES FOR FREE MEDICATIONSRX BOXES - PHARMACY SETS UP PILLS IN MEDICATION BOXES SO THAT GROUP HOME RESIDENTS GET THE CORRECT PILLS FOR EACH ADMINISTRATION TIME.SCHOOL AGE BASED EDUCATION ACTIVITIES - CENTRAL SCHOOL BLOOD TYPING. INTERACTIVE TOUR FOR 2ND GRADERS. 45474579 1 1 0 1 0 0 0 0 0 0 1 1 0 1 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 50 0 628 1 1 1 0 0 0 0 0 0 0 0 0 X 8 8 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 X TINA MONTGOMERY CFO 4064882117 216 14TH AVE SW SIDNEY MT 59270 RANDY JOHNSON 1.00 1.00 X X 0 0 0 LAURA SCHIEBER 1.00 1.00 X X 0 0 0 GALE FRANK 1.00 1.00 X X 0 0 0 NICOLE BEYER 1.00 1.00 X 0 0 0 PAM BURMAN 1.00 1.00 X 0 0 0 SANDY CHRISTENSEN 1.00 1.00 X 0 0 0 MARK MARTIN 1.00 1.00 X 0 0 0 BRIAN MCGINNIS 1.00 1.00 X 0 0 0 JANICE NORBY 1.00 1.00 X 0 0 0 CINDY WAGNER 1.00 1.00 X 0 0 0 RICHARD HARALDSON 39.00 1.00 X 224442 0 9346 TINA MONTGOMERY 39.00 1.00 X 103750 0 9337 SHARI TWIGG MD 40.00 0.00 X 426641 0 3315 LINDA KLEIN MD 40.00 0.00 X 257074 0 1064 BRADLEY STRUPP 40.00 0.00 X 307804 0 12116 BARBARA LUNDEMO 40.00 0.00 X 283598 0 14775 GEORGE SCORDALAKES MD 40.00 0.00 X 310029 0 3230 1913338 0 53183 16 0 1 0 BRETT BENNION MD 214 14TH AVE SW SIDNEY MT 59270 PHYSICIAN SERVICES 1064905 JACOBYTREXLER ARCHITECTS 430 MAIN ST SUITE 201 JOHNSTOWN PA 159011823 ARCHITECTURE 943254 EDWARD P BERGIN MD PO BOX 1529 SIDNEY MT 59270 PHYSICIAN SERVICES 642461 NOTHERN PLAINS RADIATION ONCOLOGY PO BOX 782 SIDNEY MT 59270 ONCOLOGY SERVICES 520000 WEATHERBY LOCUMS PO BOX 972633 DALLAS TX 753972633 MEDICAL STAFFING 409308 11 1400004 678981 2078985 PATIENT REVENUES 621500 42723258 42723258 CLINIC PHARMACY 446110 3888394 3888394 OTHER PATIENT CARE 621500 1218833 1218833 MONDAK PHARMACY 446110 309084 309084 DURAMED EQUIPMENT 621500 249867 249867 48389436 536215 536215 45056 45056 58955 0 58955 58955 58955 400178 37064 407783 0 -7605 37064 29459 29459 428064 173424 254640 254640 OTHER PHARMACY REVENUE 900099 534068 534068 MEAL INCOME 900099 330603 330603 MISCELLANEOUS REVENUE 900099 175931 4220 171711 150181 150181 1190783 52583529 43942091 4985633 1576820 X 807 807 369966 135801 203371 30794 17389284 15962535 1294610 132139 361121 319046 38781 3294 2345694 2068122 257179 20393 1239888 1111126 116979 11783 92362 76841 15521 51818 51818 93115 90958 2157 89423 89423 6547330 6073718 419194 54418 220864 7741 201412 11711 2878237 2262664 584076 31497 445159 19858 425301 1139665 1020891 114370 4404 297676 277759 16498 3419 1268155 1268155 3648283 3648283 510615 506349 4266 PHARMACY/LAB EXPENSE 7774097 7773968 129 BAD DEBT 3632333 3632333 GOOD CENTS STORE 282879 61890 220989 RECRUITING 240522 218265 22257 495287 296582 198060 645 51414580 45474579 5633347 306654 6464777 5527491 8486466 10177721 243747 99911 1505487 1653803 655016 682192 65474149 38003365 29247072 27470784 10226540 10031214 2375250 3524464 1188836 407700 346357 435541 3352230 3992882 64091778 64003703 3263436 3311330 25764486 24691019 16374 12542 207460 197469 852465 497712 3926304 3153389 34030525 31863461 X 28525497 31326762 1535756 813480 30061253 32140242 64091778 64003703 X 1168949 712761 197279 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 4301 4301 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: INDIRECT: THE PERCENTAGE OF DUES PAID TO MHA & AHA IS USED FOR LOBBYING EXPENSES AT 2.1% AND 23.98% RESPECTIVELY. 0 1 X 198261 198261 41551485 20524822 21026663 656750 340372 316378 23033926 17138171 5895755 33727 33727 27470784 OTHER SECURITIES 3524464 F 3524464 THIRD PARTY RECEIVABLE 907509 DUE FROM RELATED PARTY 2657220 ACCRUED INTEREST RECEIVABLE 22373 DONOR RESTRICTED FUNDS 405780 3992882 THIRD PARTY PAYABLE 405882 SWAP CONTRACT LIABILITY 2747507 3153389 X 46434905 173424 173424 46261481 6322048 6322048 52583529 47866248 173424 173424 47692824 89423 3632333 3721756 51414580 PART IV, LINE 2B: RESIDENT TRUST ACCOUNT: THIS IS THE EXTENDED CARE RESIDENT TRUST ACCOUNT WHICH IS MADE UP OF THE RESIDENTS' MONEY THAT SIDNEY HEALTH CENTER HOLDS ON THEIR BEHALF. THESE MONIES ARE KEPT IN A SEPARATE BANK ACCOUNT FROM THE ORGANIZATION'S FUNDS AND ARE DUE BACK TO THE RESIDENTS UPON LEAVING THE FACILITY. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X, LINE 2: THE INTERNAL REVENUE SERVICE (IRS) HAS DETERMINED THAT THE HEALTH CENTER AND AFFILIATE ARE TAX-EXEMPT, NOT-FOR-PROFIT CORPORATIONS UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE (IRC). THE HEALTH CENTER FOLLOWS THE GUIDANCE IN THE ACCOUNTING STANDARDS REGARDING THE RECOGNITION AND MEASUREMENT OF UNCERTAIN TAX POSITIONS. THE GUIDANCE CLARIFIES THE ACCOUNTING FOR UNCERTAINTY IN INCOME TAXES RECOGNIZED IN AN ENTITY'S FINANCIAL STATEMENTS. THE GUIDANCE FURTHER PRESCRIBES RECOGNITION AND MEASUREMENT OF TAX PROVISIONS TAKEN OR EXPECTED TO BE TAKEN ON A TAX RETURN THAT ARE NOT CERTAIN TO BE REALIZED. THE APPLICATION OF THIS STANDARD HAS NO IMPACT ON THE HEALTH CENTER'S CONSOLIDATE FINANCIAL STATEMENTS. THE HEALTH CENTER'S INCOME TAX RETURNS ARE SUBJECT TO REVIEW AND EXAMINATION BY FEDERAL, STATE, AND LOCAL AUTHORITIES. THE INFORMATION TAX RETURNS FOR THE YEARS ENDED 2010 TO 2012 ARE OPEN TO EXAMINATION BY FEDERAL, LOCAL, AND STATE AUTHORITIES. PART XI, LINE 2D - OTHER ADJUSTMENTS: COST OF GOODS SOLD 173,424. PART XI, LINE 4B - OTHER ADJUSTMENTS: INVESTMENT INCOME NET OF FEES 528,610. UNRESTRICTED CONTRIBUTIONS 318,257. GAIN ON DISPOSAL 37,064. T/R CONTRIBUTIONS NET OF UNRESTRICTED 405,780. CONTRIBUTION FROM FOUNDATION 1,400,004. BAD DEBT EXPENSE 3,632,333. PART XII, LINE 2D - OTHER ADJUSTMENTS: COST OF GOODS SOLD 173,424. PART XII, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT EXPENSE 3,632,333. 1 1 X 1 X 1 X 175.000000000000 1 1 0 1 1 531778 531778 0.01110 4436923 4674003 -237080 0.00000 123452 133559 -10107 0.00000 5092153 4807562 284591 0.01110 214673 4700 209973 0.00440 4174272 3911674 262598 0.00550 395 395 0.00000 4389340 3916374 472966 0.00990 9481493 8723936 757557 0.02100 7423 7423 0.00020 7423 7423 0.00020 1 3632333 0 9049592 9166231 -116639 X 1 1 1 1 SIDNEY HEALTH CENTER

216 14TH AVE SW SIDNEY MT 59270

X X X X SIDNEY HEALTH CENTER 1 1 X X X X X X X X X 12 1 0 1 X X X X X X X X X X 1 0 1 1 100.000000000000 1 175.000000000000 1 X X X X X X X 1 1 X X X 1 X X X 0 X X X X 1 X 0 0 2 SIDNEY HEALTH CENTER EXTENDED CARE

216 14TH AVE SW SIDNEY MT 59270

NURSING HOME THE LODGE AT LONE TREE

1015 7TH AVE SW SIDNEY MT 59270

ASSISTED LIVING COMPLEX PART I, LINE 3C: ELIGIBILITY CRITERIA: 1. FINANCIAL ASSISTANCE IS SECONDARY TO ALL OTHER FINANCIAL RESOURCES AVAILABLE TO THE PATIENT. THIS INCLUDES BUT IS NOT LIMITED TO:A. GROUP OR INDIVIDUAL MEDICAL INSURANCE PLANSB. WORKERS COMPENSATION PLANSC. MEDICAID, STATE, OR COUNTY MEDICAL PROGRAMSD. OTHER STATE, FEDERAL, OR MILITARY PROGRAMSE. THIRD PARTY LIABILITY SITUATIONS (E.G., AUTO ACCIDENTS OR PERSONAL INJURY CLAIMS)F. ANY OTHER PERSONS OR ENTITIES WHO MAY HAVE A LEGAL RESPONSIBILITY TO PAY FOR THE MEDICAL SERVICESG. CRIME VICTIMS2. DETERMINATION OF ELIGIBILITY OF A PATIENT FOR ASSISTANCE SHALL BE APPLIED REGARDLESS OF THE SOURCE OF REFERRAL AND WITHOUT DISCRIMINATION AS TO RACE, COLOR, CREED, NATIONAL ORIGIN, AGE, HANDICAP STATUS, OR MARITAL STATUS.3. PATIENT CARE WHICH IS ELECTIVE (NON-EMERGENT), COSMETIC, AND/OR EXPERIMENTAL SHALL NOT BE CONSIDERED ELIGIBLE FOR ASSISTANCE. FOR EMERGENCY ROOM SERVICES, IF THE VISIT IS DEEMED NON-EMERGENT AND THE PATIENT COULD HAVE BEEN SEEN IN A PHYSICIAN'S OFFICE, THE CHARITY CARE WRITE OFF WILL BE SUBJECT TO A 50% LIMITATION.4. PATIENT SPEND DOWNS AS DETERMINED BY MEDICAID, STATE OR COUNTY MEDICAL PROGRAMS ARE NOT ELIGIBLE FOR ASSISTANCE. (THE PATIENT ACCOUNTS MANAGER CAN MAKE EXCEPTIONS ON A CASE-BY-CASE BASIS.)5. TO THE EXTENT THE HOSPITAL CHARGES RELATED TO APPROPRIATE HOSPITAL BASED MEDICAL SERVICES ARE NOT COVERED BY THIRD-PARTY COVERAGE, A 100% WRITE-OFF MAY BE PROVIDED TO PATIENTS IF THE NET AVAILABLE ASSETS ARE NO GREATER THAN TWO TIMES THE FEDERAL INCOME POVERTY GUIDELINES AS ADJUSTED FOR FAMILY SIZE AND THE FAMILY'S GROSS INCOME IS BELOW %100 OF THE FEDERAL INCOME POVERTY GUIDELINES AS ADJUSTED FOR FAMILY SIZE. 6. PARTIAL ASSISTANCE MAY BE PROVIDED TO PATIENTS IF NET AVAILABLE ASSETS ARE NO GREATER THAN TWO TIMES THE FEDERAL INCOME POVERTY GUIDELINES AS ADJUSTED FOR FAMILY SIZE AND THE GROSS FAMILY INCOME IS BETWEEN 100% AND 175% OF THE FEDERAL INCOME POVERTY GUIDELINES AS ADJUSTED FOR FAMILY SIZE. THE UNPAID BALANCE AFTER THIRD-PARTY PAYMENTS FOR PATIENTS MEETING THIS CRITERIA WILL BE DISCOUNTED ACCORDING TO THE FOLLOWING SLIDING FEE SCALE CONSIDERING INDIVIDUAL CIRCUMSTANCES SUCH AS EXTRAORDINARY NONDISCRETIONARY EXPENSES RELATIVE TO THE AMOUNT OF MEDICAL EXPENSES, THE EXISTENCE AND AVAILABILITY OF FAMILY ASSETS, THE RESPONSIBLE PARTY'S FUTURE INCOME EARNING CAPACITY, AND ABILITY TO MAKE PAYMENTS OVER AND EXTENDED PERIOD OF TIME. THE FINANCIAL OBLIGATIONS WHICH REMAIN AFTER THE APPLICATION OF THIS SLIDING SCALE MAY BE PAYABLE IN MONTHLY INSTALLMENTS OVER A REASONABLE PERIOD OF TIME WHICH SHOULD BE CONSISTENT WITH THE ESTABLISHED MONTHLY PAYMENT PLAN GUIDELINES.7. FULL FINANCIAL ASSISTANCE (LESS CO-PAY) MAY BE PROVIDED TO PATIENTS THAT DO NOT HAVE AVAILABLE ASSETS AND WITH GROSS FAMILY INCOME BETWEEN 100%-175% OF THE FEDERAL POVERTY GUIDELINES AS ADJUSTED FOR FAMILY SIZE WHEN CIRCUMSTANCES AS DETERMINED BY THE PATIENT ACCOUNTS MANAGER INDICATE THAT FULL PAYMENT MAY CAUSE SOCIAL AND FINANCIAL HARDSHIP SO AS TO SIGNIFICANTLY HARM THE PATIENT OR THE FAMILY UNIT. CO-PAY PROVISION: A PATIENT CO-PAY AMOUNT WILL BE ASSIGNED TO THOSE PATIENTS QUALIFYING FOR 100% ASSISTANCE AS FOLLOWS: A.INPATIENT SERVICES 10% OR $500, WHICHEVER IS THE LESSER AMOUNTB.OUTPATIENT SURGERY 10% OR $250, WHICHEVER IS THE LESSER AMOUNTC.OUTPATIENT ANCILLARY 10% OF BILL8. FULL OR PARTIAL ASSISTANCE MAY BE PROVIDED TO PATIENTS WITH GROSS FAMILY INCOME ABOVE 175% OF THE POVERTY GUIDELINES WHEN CIRCUMSTANCES DETERMINED BY THE PATIENT ACCOUNTS MANAGER INDICATE THAT FULL PAYMENT MAY CAUSE SOCIAL AND FINANCIAL HARDSHIPS SO AS TO SIGNIFICANTLY HARM THE PATIENT OR THE FAMILY UNIT. SHC WILL DETERMINE IF ASSETS CAN BE LIQUEFIED TO MEET THE OUTSTANDING MEDICAL EXPENSES AND/OR WHAT MONTHLY PAYMENT AMOUNT COULD BE MADE FOR A PERIOD OF UP TO 36 MONTHS AND THE REMAINING BALANCE WRITTEN OFF AS FINANCIAL ASSISTANCE. PART I, LINE 7: IN ORDER TO CALCULATE THE OVERALL HOSPITAL'S COST TO CHARGE RATIO USED FOR PART I, LINE 7, THE HOSPITAL FIRST DETERMINED A COST TO CHARGE RATIO BASED ON THE 2013 FILED MEDICARE COST REPORT SEPARATELY FOR INPATIENT SERVICES, OUTPATIENT SERVICES, AND TOTAL SERVICES. TO CALCULATE THE COST OF CHARITY CARE INCLUDED ON LINE 7A, THE HOSPITAL TOOK EACH OF THE SEPARATE COST TO CHARGE RATIOS DESCRIBED IN THE PRECEEDING PARAGRAPH AND APPLIED THEM ONLY TO THE RELATED CHARGES BY SERVICE TYPE TO COME UP WITH A WEIGHTED AVERAGE COST TO CHARGE RATIO. PART I, LINE 7G: THE FOLLOWING SUBSIDIZED HEALTH SERVICES WERE INCLUDED IN PART I, LINE 7G:EMERGENCY ROOM, PHYSICIAN SERVICES, CARDIAC REHAB, PHYSICAL THERAPY, OCCUPATIONAL THERAPY, SPEECH THERAPY, PATIENT/HEALTH EDUCATION, AUDIOLOGY, WOMEN & CHILDREN SERVICES, HOME HEALTH, ECF, HOSPICE, AND CCU. PART I, L7 COL(F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN A, BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $3,632,333. PART III, LINE 4: THE FOLLOWING NARRATIVE IS FROM FOOTNOTE 1 OF THE FINANCIAL STATMENTS UNDER THE HEADING "PATIENT AND RESIDENT ACCOUNTS RECEIVEABLE, NET":PATIENT AND RESIDENT ACCOUNTS RECEIVABLE ARE REDUCED BY AN ALLOWANCE FOR DOUBTFUL ACCOUNTS. IN EVALUATING THE COLLECTABILITY OF PATIENT AND RESIDENT ACCOUNTS RECEIVABLE, THE HEALTH CENTER 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 HEALTH CENTER ANALYZES CONTRACTUALLY DUE AMOUNTS AND PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS AND A PROVISION FOR BAD DEBTS, IF NECESSARY (FOR EXAMPLE, FOR EXPECTED UNCOLLECTIBLE DEDUCTIBLES AND COPAYMENTS ON ACCOUNTS FOR WHICH THE THIRD-PARTY PAYOR HAS NOT YET PAID, OR FOR PAYORS WHO ARE KNOWN TO BE HAVING FINANCIAL DIFFICULTIES 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 HEALTH CENTER RECORDS A PROVISION FOR BAD DEBTS IN THE PERIOD OF SERVICE ON THE BASIS OF ITS PAST EXPERIENCE, WHICHINDICATES 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 8: THE MEDICARE ALLOWABLE COSTS INCLUDED IN PART III, LINE 6 IS DERIVED FROM USING THE 2013 FILED MEDICARE COST REPORT. THE SHORTFALL OCCURS DUE TO VARIOUS EXPENSES 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: IF THE PATIENT INDICATES THEIR INABILITY TO PAY ACCORDING TO THE HOSPITAL CREDIT TERMS THEY WILL BE ASKED TO FILL OUT A FINANCIAL STATEMENT. THE HOSPITAL MAY PULL A CREDIT REPORT TO CONFIRM OR SUPPLEMENT INFORMATION PROVIDED TO THE HOSPITAL ON THE FINANCIAL STATEMENT. THE PATIENT CAN THEN BE EVALUATED TO DETERMINE WHETHER THEY MAY BE ELIGIBLE FOR FINANCIAL ASSISTANCE OR AN EXTENDED PAYMENT PROGRAM.IF THE FINANCIAL STATEMENT SHOWS THAT THE PATIENT HAS ASSETS OR POTENTIAL SOURCES OF INCOME THAT WOULD ENABLE THEM TO PAY THE HOSPITAL BILL WITHIN A YEAR, THEY WILL BE DENIED THE EXTENDED PAYMENT WAIVER. IF A PATIENT REFUSES TO FURNISH A COMPLETED FINANCIAL STATEMENT, THEIR ACCOUNT WILL BE DEEMED DELINQUENT AND FURTHER COLLECTION ACTION WILL BE TAKEN. PRIOR TO ADMISSION, AT THE TIME OF ADMISSION, OR AS SOON AS POSSIBLE THEREAFTER, THE HOSPITAL WILL MAKE AN INITIAL ASSESSMENT OF POTENTIAL ELIGIBILITY BASED ON THE VERBAL APPLICATION FOR FINANCIAL ASSISTANCE. IF POTENTIAL ASSISTANCE IS INDICATED WITH INITIAL ASSESSMENT, THE HOSPITAL WILL NOT INITIATE COLLECTION EFFORTS OR REQUESTS FOR DEPOSITS PENDING THE RECEIPT OF THE COMPLETED APPLICATION AND FINAL ELIGIBILITY DETERMINATION. THE RESPONSIBLE PARTY MUST BE COOPERATIVE WITH THE HOSPITAL'S EFFORTS TO REACH A DETERMINATION OF ELIGIBILITY WITH OTHER ASSISTANCE PROGRAMS AND TO VALIDATE THE INFORMATION NEEDED.SIDNEY HEALTH CENTER WILL MAKE A CONCERTED EFFORT TO COMMUNICATE THE AVAILABILITY OF CHARITY CARE. EDUCATIONAL MATERIALS ABOUT THE PROGRAM WILL BE AVAILABLE TO PATIENTS THROUGH THE ADMISSIONS PROCESS. AS SOON AS A PATIENT EVIDENCES INABILITY TO PAY HE OR SHE WILL BE REFERRED TO THE PATIENT FINANCIAL SERVICES COUNSELOR FOR AN APPLICATION. APPLICATIONS ARE ALSO AVAILABLE AT THE ADMISSIONS AREA, AND THROUGH SOCIAL SERVICES. SIDNEY HEALTH CENTER PART V, SECTION B, LINE 3: THE COMMUNITY HEALTH NEEDS ASSESSMENT WAS OVERSEEN BY A STEERING COMMITTEE CONSISTING OF A DIVERSE GROUP OF COMMUNITY MEMBERS REPRESENTING VARIOUS ORGANIZATIONS AND POPULATIONS WITHIN THE COMMUNITY (EX. PUBLIC HEALTH, ELDERLY, UNINSURED). SURVEYS WERE SENT TO A RANDOM SAMPLE OF 724 INDIVIDUALS IN THE HOSPITAL'S COMMUNITY, 170 OF WHICH WERE RETURNED COMPLETED. THE RANDOM SELECTION PROCESS AND THE LARGE NUMBER OF RESPONSES IMPLY THAT THE SURVEY RESULTS REPRESENT THE VOICE OF THE COMMUNITY IN GENERAL. FINALLY, THREE FOCUS GROUPS WERE HELD WITH TWENTY-TWO COMMUNITY MEMBERS. SIDNEY HEALTH CENTER PART V, SECTION B, LINE 5C: HTTP://WWW.SIDNEYHEALTH.ORG/ABOUTUS/COMMUNITY-HEALTH-ASSESSMENT-IMPLEMENTATION-PLAN PART VI, LINE 2: THE HOSPITAL CONDUCTED A COMMUNITY HEALTH NEEDS ASSESSMENT IN THE YEAR ENDED JUNE 30, 2013. THE REPORT AND PLANNED RESPONSES ARE AVAILABLE ONLINE AT HTTP://WWW.SIDNEYHEALTH.ORG/ABOUTUS/COMMUNITY-HEALTH-ASSESSMENT-IMPLEMENTATION-PLAN. PART VI, LINE 3: SIDNEY HEALTH CENTER HAS NOTICES LOCATED AT THE ADMISSIONS OFFICE INFORMING PATIENTS ABOUT THEIR FINANCIAL ASSISTANCE POLICY. THE PROGRAM IS ALSO STATED ON THE ORGANIZATION'S WEBSITE AND INCLUDED IN THE PATIENT'S PACKET UPON DISCHARGE FROM THE FACILITY. PART VI, LINE 4: LOCATED IN THE HEART OF RICHLAND COUNTY, SIDNEY HEALTH CENTER SERVES PEOPLE IN ALL OF THE MONDAK REGION. PART VI, LINE 5: THE HEALTH CENTER DEFINES AND MEASURES THEIR INVESTMENT IN AND PARTNERSHIP WITH THE COMMUNITY PRIMARILY THROUGH VARIOUS COMMUNITY BASED SERVICES PROGRAMS, PROVIDING HEALTH EQUIPMENT IN AREA SCHOOLS, AND COMMUNITY PROGRAMS AND EDUCATION. A NUMBER OF HEALTH RELATED EDUCATIONAL PROGRAMS ARE PROVIDED FOR THE BENEFIT OF THE COMMUNITY, INCLUDING HEALTH ENHANCEMENTS AND WELLNESS, CLASSES ON SPECIFIC CONDITIONS, AND PROGRAMS DESIGNED TO IMPROVE THE GENERAL STANDARDS OF THE HEALTH OF THE COMMUNITY. X 1 0 X X 0 0 0 0 0 0 0 0 0 RICHARD HARALDSON 224442 0 0 0 0 0 7097 0 2249 0 233788 0 0 0 SHARI TWIGG MD 426641 0 0 0 0 0 0 0 3315 0 429956 0 0 0 LINDA KLEIN MD 257074 0 0 0 0 0 0 0 1064 0 258138 0 0 0 BRADLEY STRUPP 307804 0 0 0 0 0 7621 0 4495 0 319920 0 0 0 BARBARA LUNDEMO 283598 0 0 0 0 0 10541 0 4234 0 298373 0 0 0 GEORGE SCORDALAKES MD 310029 0 0 0 0 0 0 0 3230 0 313259 0 0 0 PART I, LINE 1A RICHARD HARALDSON - HEALTH OR SOCIAL CLUB DUES OF $1,595 - NOT INCLUDED IN TAXABLE INCOME. A RICHLAND COUNTY MT 816001419 2010-12-01 2350000 MEDICAL EQUIPMENT REVENUE BOND FOR TOMOTHERAPY RADIATION ONCOLOGY UNIT 0 0 0 B RICHLAND COUNTY MT 816001419 2011-09-15 24370000 REDEEMING AND RETIRING PREVIOUSLY ISSUED DEBT (2006, 2007A AND 2007B) 0 0 0 A 758981 2350000 20059 2329941 2011 0 0 1 1 B 1270000 24370000 233683 137747 2012 1 1 1 1 A 1 0 0 0 0 0 0 B 1 0 0 0 0 0 0 A 0 1 0 0 0 0 0 0 0 B 0 1 0 0 1 1 US BANK 8.900000000000 0 0 0 0 0 A 0 B 0 FORM 990, PART VI, SECTION A, LINE 1 THE EXECUTIVE COMMITTEE CONSISTS OF THE OFFICERS AND ONE OTHER MEMEBER OF THE BOARD APPOINTED BY THE PRESIDENT. THE EXECUTIVE COMMITTEE HAS THE POWER TO TRANSACT ALL REGULAR BUSINESS OF THE CORPORATION DURING THE INTERIM BETWEEN THE MEETINGS OF THE BOARD, PROVIDED ANY ACTION TAKEN SHALL NOT CONFLICT WITH THE ARTICLES OF INCORPORATION, BYLAWS AND STATE POLICIES. ANY OFFICIAL ACTION TAKEN BY THE EXECUTIVE COMMITTEE IS SUBMITTED TO THE BOARD FOR RATIFICATION AT THE NEXT BOARD MEETING. FORM 990, PART VI, SECTION A, LINE 6 NATURAL PERSONS, CORPORATIONS, OR UNINCORPORATED ASSOCIATIONS MAY BECOME MEMBERS OF SIDNEY HEALTH CENTER BY: A. PAYMENT TO SIDNEY HEALTH CENTER A SUM OF NOT LESS THAN $100 CASH OR BY AN EQUIVALENT CONTRIBUTION OR METHOD AS APPROVED BY THE BOARD; B. RESIDING IN OR HAVING ITS PRINCIPAL PLACES OF BUSINESS IN THE SERVICE AREA OF SIDNEY HEALTH CENTER; AND C. AGREEING TO BE BOUND BY THE BYLAWS OF SIDNEY HEALTH CENTER. FORM 990, PART VI, SECTION A, LINE 7A ELECTION OF DIRECTORS IS HELD AT THE ANNUAL MEETING OF THE MEMBERS BY WRITTEN BALLOT LISTING THE CANDIDATES NOMINATED BY THE NOMINATING COMMITTEE OF THE MEMBERS. EACH MEMBER OF SIDNEY HEALTH CENTER, PRESENT IN PERSON OR BY PROXY, IS ENTITLED TO VOTE FOR ONE CANDIDATE FOR EACH DIRECTOR VACANCY TO BE FILLED. THE CANDIDATES RECEIVING THE HIGHEST NUMBER OF VOTES AT THE MEETING ARE CONSIDERED ELECTED AS DIRECTORS. FORM 990, PART VI, SECTION A, LINE 7B ANY PROPOSED AMENDMENTS APPROVED BY THE BOARD OR BY VERIFIED PETITION TO THE ARTICLES OF INCORPORATION OR BYLAWS SHALL BE SUBMITTED FOR VOTE BY THE MEMBERS AT THE NEXT SPECIAL OR ANNUAL MEMBERSHIP MEETING. FORM 990, PART VI, SECTION B, LINE 11 THE CEO AND CFO REVIEWED THE COMPLETED 990 WITH THE BOARD OF DIRECTORS AT A SCHEDULED MEETING. FORM 990, PART VI, SECTION B, LINE 12C THE POLICY OF THE CORPORATION IS TO REQUIRE THAT EACH INDIVIDUAL SUBJECT TO THIS POLICY STATEMENT PROMPTLY AND FULLY DISCLOSE ANY ACTUAL, APPARENT, OR POTENTIAL CONFLICT OF INTEREST, AND THAT THE CORPORATION WILL NOT ENGAGE IN ANY CONTRACT, TRANSACTION, OR ARRANGEMENT INVOLVING A CONFLICT OF INTEREST UNLESS THE DISINTERESTED MEMBERS OF THE BOARD OF DIRECTORS (ACTING AT A DULY CONSTITUTED MEETING THEREOF) DETERMINE BY A MAJORITY VOTE THAT APPROPRIATE SAFEGUARDS TO PROTECT THE CHARITABLE MISSION OF THE CORPORATION HAVE BEEN IMPLEMENTED. A CONFLICT OF INTEREST QUESTIONNAIRE IS DISTRIBUTED ANNUALLY TO ALL INTERESTED PERSONS (BOARD MEMBERS, OFFICERS, AND COMMITTEE MEMBERS). AN INTERESTED PERSON HAS A CONTINUING OBLIGATION TO DISCLOSE THE EXISTENCE AND NATURE OF ANY ACTUAL, APPARENT, OR POTENTIAL CONFLICT OF INTEREST HE/SHE MAY HAVE. "DISCLOSURE" MEANS PROMPTLY PROVIDING A WRITTEN DESCRIPTION OF THE MATERIAL FACTS OF THE ACTUAL, APPARENT, OR POTENTIAL CONFLICT OF INTEREST TO THE EXECUTIVE COMMITTEE ON THE CONFLICTS-OF-INTEREST QUESTIONNAIRE. SUCH DISCLOSURE SHALL BE MADE PROMPTLY ANY TIME AN ACTUAL, APPARENT, OR POTENTIAL CONFLICT OF INTEREST ARISES AND BEFORE THE CONSUMMATION OF THE CONTRACT, TRANSACTION, OR ARRANGEMENT THAT IS THE SUBJECT OF THE POTENTIAL CONFLICT OF INTEREST. AT ANY TIME THAT AN ACTUAL, APPARENT, OR A POTENTIAL CONFLICT OF INTEREST IS IDENTIFIED TO THE BOARD OF DIRECTORS, WHETHER THROUGH THE VOLUNTARY SUBMISSION OF A DISCLOSURE STATEMENT BY AN INTERESTED PERSON, OR BY A DISCLOSURE BY A PERSON OTHER THAN THE SUBJECT INTERESTED PERSON, THE EXECUTIVE COMMITTEE SHALL REVIEW THE MATTER AND DETERMINE WHETHER A CONFLICT OF INTEREST EXISTS. THE SUBJECT INTERESTED PERSON SHALL NOT BE PRESENT DURING ANY MEETING IN WHICH THE EXECUTIVE COMMITTEE CONDUCTS ITS EVALUATION, EXCEPT TO ANSWER QUESTIONS AS MAY BE NECESSARY. THE EXECUTIVE COMMITTEE MAY REQUEST ADDITIONAL INFORMATION FROM ALL REASONABLE SOURCES AND MAY INVOLVE THE GENERAL COUNSEL IN ITS DELIBERATIONS. ONCE ALL NECESSARY INFORMATION HAS BEEN OBTAINED, EXECUTIVE COMMITTEE SHALL MAKE A FINDING AS TO WHETHER A CONFLICT OF INTEREST INDEED EXISTS, AND SHALL FORWARD THAT FINDING TO THE BOARD OF DIRECTORS FOR DISCUSSION AND VOTE. ONLY DISINTERESTED DIRECTORS MAY VOTE TO DETERMINE WHETHER A CONFLICT OF INTEREST EXISTS. THE SUBJECT INTERESTED PERSON MAY NOT BE PRESENT WHEN THIS VOTE IS TAKEN. ONCE THE DISINTERESTED MEMBERS OF THE BOARD OF DIRECTORS HAVE DETERMINED THAT AN ACTUAL CONFLICT OF INTEREST EXISTS WITH RESPECT TO A PARTICULAR TRANSACTION OR ARRANGEMENT: (I) THE DISINTERESTED MEMBERS OF THE BOARD OF DIRECTORS SHALL EXERCISE DUE DILIGENCE TO DETERMINE WHETHER THE CORPORATION COULD OBTAIN A MORE ADVANTAGEOUS CONTRACT, TRANSACTION, OR ARRANGEMENT WITH REASONABLE EFFORTS UNDER THE CIRCUMSTANCES AND, IF APPROPRIATE, SHALL APPOINT A NON-INTERESTED PERSON OR COMMITTEE TO INVESTIGATE ALTERNATIVES TO THE PROPOSED CONTRACT, TRANSACTION, OR ARRANGEMENT. (II) IN CONSIDERING WHETHER TO ENTER INTO THE PROPOSED CONTRACT, TRANSACTION, OR ARRANGEMENT, THE BOARD OF DIRECTORS MAY APPROVE SUCH A CONTRACT, TRANSACTION, OR ARRANGEMENT ONLY IF THE DISINTERESTED DIRECTORS DETERMINE BY A MAJORITY VOTE THAT: (A) THE PROPOSED CONTRACT, TRANSACTION, OR ARRANGEMENT IS IN THE CORPORATION'S BEST INTERESTS AND FOR THE CORPORATION'S OWN BENEFIT; AND (B) THE PROPOSED TRANSACTION IS FAIR AND REASONABLE TO THE CORPORATION, TAKING INTO ACCOUNT, AMONG OTHER RELEVANT FACTORS, WHETHER THE CORPORATION COULD OBTAIN A MORE ADVANTAGEOUS CONTRACT, TRANSACTION, OR ARRANGEMENT WITH REASONABLE EFFORTS UNDER THE CIRCUMSTANCES. (III) THE DISINTERESTED MEMBERS OF THE BOARD OF DIRECTORS MAY, IN THEIR DISCRETION, REQUIRE THE INTERESTED PERSON TO LEAVE THE ROOM WHILE THE PROPOSED CONTRACT, TRANSACTION, OR ARRANGEMENT IS DISCUSSED. THE INTERESTED PERSON SHALL LEAVE THE ROOM WHILE THE MATTER IS VOTED ON AND ONLY DISINTERESTED DIRECTORS MAY VOTE TO DETERMINE WHETHER TO APPROVE THE TRANSACTION OR ARRANGEMENT. FORM 990, PART VI, SECTION B, LINE 15 THE BOARD OF DIRECTORS DETERMINES SALARIES USING THE MHA SALARY SURVEY FOR MARKET INFORMATION AND ALSO PERFORMS A WRITTEN EVALUATION ANNUALLY. ADDITIONALLY, THE CEO USES MHA MANAGEMENT SURVEY, AS WELL AS OTHER COMPENSATION SURVEYS, TO DETERMINE ANNUAL PAY INCREASES FOR ADMINISTRATION. A WRITTEN EVALUATION IS PERFORMED. ALL ESTIMATED ANNUAL INCREASES ARE INCLUDED IN THE BUDGET, WHICH IS APPROVED BY THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE MADE AVAILABLE TO THE PUBLIC UPON REQUEST. OTHER FEES FORM 990, PART IX, LINE 11G CONSULTING: PROGRAM SERVICE EXPENSES 6,073,718. MANAGEMENT AND GENERAL EXPENSES 419,194. FUNDRAISING EXPENSES 54,418. TOTAL EXPENSES 6,547,330. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 9: CHANGE IN BENEFICIAL INTEREST IN NET ASSETS OF FOUNDATION -722,205. CHANGE IN VALUE OF FAIR VALUE SWAP 919,484. LONE TREE SENIOR LIVING 1015 7TH AVENUE SW SIDNEY MT 59270 810518821 ASSISTED LIVING MT 501(C)(3) LINE 9 SIDNEY HEALTH CENTER 1 FOUNDATION FOR COMMUNITY CARE OF RICHLAND COUNTY 221 2ND ST NW SIDNEY MT 59270 810417465 FUNDRAISING MT 501(C)(3) LINE 11A, I SIDNEY HEALTH CENTER 1 1 0 1 1 0 0 0 0 0 0 0 1 0 0 1 0 0 0 0 LONE TREE SENIOR LIVING A 124365 ACTUAL AMOUNT LONE TREE SENIOR LIVING D 131842 ACTUAL AMOUNT FOUNDATION FOR COMMUNITY CARE OF RICHLAND COUNTY C 1400004 ACTUAL AMOUNT