2013-02-12T15:44:46-06:00 2012-06-30 476097913 SEIM JOHNSON LLP 18081 BURT STREET SUITE 200 OMAHA NE 680224722 990 2011-07-01 470393176 ANTELOPE MEMORIAL HOSPITAL ANTE 4028874151 PO BOX 229 NELIGH NE 68756 JACK W GREEN 4028874151 2013-02-10 1 BARBARA J FAJEN P00400874 4023302660 2011 2016-03-07 17:11:31Z JACK W GREEN PO BOX 229 NELIGH NE 68756 13291578 0 X WWW.AMHNE.ORG X 1974 NE TO BUILD, ERECT, MAINTAIN, EXPAND, EQUIP, MANAGE AND OPERATE A HOSPITAL AND AFFILIATED INSTITUTIONS IN THE COUNTY OF ANTELOPE, NEBRASKA FOR THE CARE AND TREATMENT OF SICK AND INFIRM PEOPLE, REGARDLESS OF RACE, CREED, COLOR AND RESIDENCE. 8 8 172 10 0 0 32756 599451 13346921 12587516 66769 62070 32240 34914 13478686 13283951 0 0 0 0 6613253 6716620 0 0 0 5582401 5439417 12195654 12156037 1283032 1127914 16314684 17077908 5724388 5362907 10590296 11715001 MAKING A DIFFERENCE IN PEOPLE'S LIVES THROUGH EXCELLENT PATIENT CARE. 0 0 10820050 12592527 ANTELOPE MEMORIAL HOSPITAL IS A 25-BED CRITICAL ACCESS HOSPITAL IN NELIGH, NE. IT PROVIDES QUALITY HEALTH CARE REGARDLESS OF RACE, CREED, COLOR, NATIONAL ORIGIN, AGE, GENDER, HANDICAP, OR ABILITY TO PAY. THE HOSPITAL IS A FAMILY-CENTERED, COMMUNITY-ORIENTED HOSPITAL, OFFERING COMPREHENSIVE MEDICAL SERVICES, INCLUDING A FULL-TIME EMERGENCY ROOM. 10820050 1 1 0 1 0 0 0 0 0 0 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 1 19 0 1 172 1 0 0 0 0 0 0 0 0 0 0 X 8 8 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 0 0 X MARTHA NELSON 4028876282 PO BOX 229 NELIGH NE 68756 JOHN MLNARIK 4.00 X X 0 0 0 JAMES BLACKBURN 4.00 X X 0 0 0 JOE KNIGHT 4.00 X X 0 0 0 PHILIP KLUTHE 2.00 X 0 0 0 JAMES MEURET 2.00 X 0 0 0 GORDON SHRADER 2.00 X 0 0 0 DAVID SULLIVAN 2.00 X 0 0 0 CHRISTOPHER TWIBELL 2.00 X 0 0 0 JACK W GREEN 40.00 X 155071 0 12406 MARTHA NELSON 36.00 X 89232 0 9067 ROGER RUDLOFF 40.00 X 321436 0 17818 TROY DAWSON 40.00 X 289682 0 17813 DOUGLAS DILLY 40.00 X 130658 0 10793 PATRICIA GOOD 40.00 X 113678 0 9761 KAREN GALLAGHER 39.00 X 104852 0 9331 1204609 0 86989 6 0 1 0 HAUSMANN CONSTRUCTION 8545 EXECUTIVE WOODS DRIVE SUITE 1 LINCOLN NE 68512 CONTRACTOR 1135644 TKO PO BOX 385 NELIGH NE 68756 NURSING SERVICES 425000 OVERLAND REHAB SERVICES 405 JAMES STREET VERDIGRE NE 68783 PHYSICAL THERAPY SERVICES 288979 DAVIS DESIGN INC 1221 N STREET SUITE 600 LINCOLN NE 68508 ARCHITECTURE 155969 APPLIED CONNECTIVE TECHNOLOGIES PO BOX 446 ALBION NE 68620 TECHNOLOGY SERVICES 119201 7 455500 143951 599451 MEDICARE/MEDICAID PAYM 621400 7199436 7199436 OTHER PATIENT SERVICE 621400 5345931 5345931 LIFELINE 621990 29794 29794 LABORATORY 621990 6955 6955 AMBULANCE 621910 5400 5400 12587516 54049 54049 15648 7627 8021 8021 8021 CAFETERIA 900099 29903 29903 MISCELLANEOUS REVENUE 900099 5011 5011 34914 13283951 12592527 0 91973 265775 265775 36048 36048 5067958 4582662 485296 166376 151599 14777 809209 709442 99767 371254 320609 50645 53901 53901 32320 32320 1928497 1718510 209987 40881 14311 26570 484222 423907 60315 198792 198792 39582 35147 4435 131460 131460 922560 922560 171639 171639 MEDICAL SUPPLIES 953833 953833 BAD DEBT 410817 410817 DUES & SUBSCRIPTIONS 30003 30003 LICENSES 23480 3823 19657 17430 4888 12542 12156037 10820050 1335987 0 1235354 1360605 4657818 3027043 13370 48431 1435327 1291974 23450 480262 309263 299454 48468 26770 18335412 8345458 8059697 9989954 429275 442110 102662 111305 16314684 17077908 1397175 1822907 3770000 3540000 557213 0 5724388 5362907 X 10533546 11713501 56750 1500 10590296 11715001 16314684 17077908 X 1127914 -3209 X X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 1320 1320 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: PORTION OF NEBRASKA HOSPITAL ASSOCIATION AND AMERICAN HOSPITAL ASSOCIATION DUES ALLOCABLE TO LOBBYING ACTIVITIES. 63764 63764 5224419 2494558 2729861 9153704 5293961 3859743 3893525 556939 3336586 9989954 13283951 12156037 1127914 -3209 -3209 1124705 13279838 -3209 -3209 13283047 904 904 13283951 12155133 0 12155133 904 904 12156037 PART XII, LINE 4B - OTHER ADJUSTMENTS: FUNDRAISING EXPENSES 904. PART XIII, LINE 4B - OTHER ADJUSTMENTS: FUNDRAISING EXPENSES 904. 1 1 1 X 0 1 1 0 1 1 56523 56523 0.00480 760741 601559 159182 0.01360 817264 601559 215705 0.01840 17630 9204 8426 0.00070 709815 465161 244654 0.02080 727445 474365 253080 0.02150 1544709 1075924 468785 0.03990 1 410817 0 6820799 6858855 -38056 X 1 0 1 1 ANTELOPE MEMORIAL HOSPITAL

102 WEST 9TH STREET NELIGH NE 68756

X X X ANTELOPE MEMORIAL HOSPITAL 1 1 1 100.000000000000 0 0 1 1 X X 1 0 1 X 0 0 5 AMH FAMILY PRACTICE

109 WEST 11TH STREET PO BOX 109 NELIGH NE 68756

FAMILY PRACTICE MEDICAL CLINIC AMH CLEARWATER CLINIC

HIGHWAY 275 MAIN STREET CLEARWATER NE 68726

FAMILY PRACTICE MEDICAL CLINIC AMH ELGIN CLINIC

101 WEST CEDAR STREET ELGIN NE 68636

FAMILY PRACTICE MEDICAL CLINIC ORCHARD MEDICAL CLINIC

103 WASHINGTON STREET ORCHARD NE 68764

FAMILY PRACTICE MEDICAL CLINIC AMH TILDEN CLINIC

104 SOUTH CENTER TILDEN NE 68781

FAMILY PRACTICE MEDICAL CLINIC PART I, LINE 3C: NOT APPLICABLE: FEDERAL POVERTY GUIDELINES ARE USED TO DETERMINE ELIGIBILITY FOR PROVIDING FREE CARE TO LOW INCOME INDIVIDUALS. DISCOUNTED CARE IS NOT PROVIDED. PATIENTS ARE CATEGORIZED EITHER AS BEING ELIGIBLE FOR FREE CARE OR AS RESPONSIBLE FOR REGULAR PATIENT CHARGES. PART I, LINE 6A: ANTELOPE MEMORIAL HOSPITAL'S COMMUNITY BENEFIT REPORT IS NOT PREPARED BY A RELATED ORGANIZATION. PART I, LINE 7: THE COST TO CHARGE RATIO AS FOLLOWS WAS USED TO DETERMINE CHARITY CARE AND MEANS-TESTED GOVERNMENT PROGRAMS AT COST: (TOTAL EXPENSES - BAD DEBT) / GROSS PATIENT SERVICE REVENUE = PERCENTAGE OF COST TO CHARGE. OTHER COMMUNITY BENEFIT EXPENSES ARE STATED AT COST BASED ON ANTELOPE MEMORIAL HOSPITAL'S INTERNAL ACCOUNTING RECORDS. PART I, LINE 7G: THERE ARE NO COSTS ATTRIBUTABLE TO A PHYSICIAN CLINIC INCLUDED ON LINE 7G. PART I, L7 COL(F): THE COST OF BAD DEBT THAT HAS BEEN SUBTRACTED FROM TOTAL EXPENSES TO DETERMINE THE DENOMINATOR IN THE PERCENTAGES FOR COLUMN (F) IS $410,817. PART III, LINE 4: THE COSTING METHODOLOGY USED IN DETERMINING THE BAD DEBT EXPENSE INCLUDED CALCULATING THE TOTAL ESTIMATE AMOUNTS BASED ON THE AGING TRIAL BALANCE REPORT THEN ADJUSTING FOR ALLOWANCES, RECOVERIES, OTHER CHANGES IN ACCOUNTS RECEIVABLE AND CHANGES TO REFUNDS CLEARING. WHEN CALCULATING BAD DEBT, ANY INSURANCE DISCOUNTS AND PATIENT PAYMENTS HAVE BEEN REMOVED FROM THE ACCOUNT BALANCES. THE BALANCE OF THE ACCOUNT IS USED TO CALCULATE THE BAD DEBT ESTIMATE.THE HOSPITAL'S FINANCIAL STATMENTS DO NOT CONTAIN A SPECIFIC FOOTNOTE DESCRIBING BAD DEBT. HOWEVER, THE FOLLOWING IS THE TEXT OF THE FOOTNOTE TITLED "PATIENT RECEIVABLES, NET" AND "CHARITY CARE":"PATIENT RECEIVABLES, NET" NET PATIENT RECEIVABLES CONSIST OF UNCOLLATERALIZED PATIENT AND THIRD PARTY OBLIGATIONS REDUCED BY A VALUATION ALLOWANCE FOR DOUBTFUL ACCOUNTS AND CONTRACTUAL ADJUSTMENTS FROM THIRD PARTY PAYORS. THE ALLOWANCES REFLECT MANAGEMENT'S ESTIMATE OF AMOUNTS THAT WILL NOT BE COLLECTED IN THE FUTURE AND ARE BASED ON REVIEWS OF PATIENT BALANCES BY PAYOR CLASSES. PERCENTAGES ARE APPLIED TO EACH PAYOR CLASS BASED ON CONTRACTUAL AGREEMENTS AND HISTORICAL COLLECTION AND RECOVERY INFORMATION TO DETERMINE THE NET REALIZABLE VALUE OF THE PATIENT RECEIVABLES.PAYMENT FOR SERVICES IS EXPECTED WITHIN THIRTY DAYS OF INITIAL BILLING. ACCOUNTS CONSIDERED PAST DUE ARE SENT TO COLLECTION AGENCIES WHEN INTERNAL COLLECTION EFFORTS HAVE BEEN UNSUCCESSFUL. ANY AMOUNTS DEEMED UNCOLLECTIBLE ARE WRITTEN OFF ON A MONTHLY BASIS. THE HOSPITAL DOES NOT CHARGE INTEREST ON OUTSTANDING BALANCES OWED. THE HOSPITAL ALSO MAINTAINS A CHARITY CARE POLICY."CHARITY CARE"THE HOSPITAL PROVIDES CARE TO PATIENTS WHO MEET CERTAIN CRITERIA UNDER ITS CHARITY CARE POLICY WITHOUT CHARGE OR AT AMOUNTS LESS THAN ITS ESTABLISHED RATES. BECAUSE THE HOSPITAL DOES NOT PURSUE COLLECTION OF AMOUNTS DETERMINED TO QUALIFY AS CHARITY CARE, THEY ARE NOT REPORTED IN THE STATEMENTS OF OPERATIONS.THE HOSPITAL IS DEDICATED TO PROVIDING COMPREHENSIVE HEALTHCARE SERVICE TO ALL SEGMENTS OF SOCIETY, INCLUDING THE AGED AND OTHERWISE ECONOMICALLY DISADVANTAGED. IN ADDITION, THE HOSPITAL PROVIDES A VARIETY OF COMMUNITY HEALTH SERVICES AT OR BELOW COST.THE HOSPITAL PROVIDES CHARITY CARE TO PATIENTS WHO ARE FINANCIALLY UNABLE TO PAY FOR THE HEALTHCARE SERVICES THEY RECEIVE. IT IS THE POLICY OF THE HOSPITAL NOT TO PURSUE COLLECTION OF AMOUNTS DETERMINED TO QUALIFY AS CHARITY CARE. ACCORDINGLY, THE HOSPITAL DOES NOT REPORT THESE AMOUNTS IN NET OPERATING REVENUE OR IN THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. THE HOSPITAL DETERMINES THE COSTS ASSOCIATED WITH PROVIDING CHARITY CARE BY AGGREGATING THE DIRECT AND INDIRECT COSTS, INCLUDING SALARIES, BENEFITS, SUPPLIES, AND OTHER OPERATING EXPENSES, BASED ON AN OVERALL COST TO CHARGE RATIO. THE COSTS OF CARING FOR THESE PATIENTS FOR THE YEARS ENDED JUNE 30, 2012 AND 2011 WERE APPROXIMATELY $83,000 AND $53,000, RESPECTIVELY. PART III, LINE 8: "MEDICARE ALLOWABLE COSTS OF CARE" WAS CALCULATED FROM INFORMATION IN THE MEDICARE COST REPORT D, E, H & M WORKSHEETS, OR PS&R. IT DOES NOT INCLUDE ALL OF THE MEDICARE REVENUES AND COSTS. IF ALL OF THE MEDICARE REVENUES AND COSTS WERE INCLUDED, THE SHORTFALL WOULD BE GREATER THAN THAT SHOWN ON LINE 7. THE SHORTFALL REPRESENTS ACTUAL UNREIMBURSED COSTS INCURRED BY ANTELOPE MEMORIAL HOSPITAL IN PROVIDING SERVICES TO INDIVIDUALS ELIGIBLE FOR MEDICARE. THE COMMUNITY BENEFITS BECAUSE THE HOSPITAL APPLIES OTHER REVENUES TO COVER THE COSTS OF CARING FOR MEDICARE PATIENTS. PART III, LINE 9B: THE COLLECTION POLICY INCLUDES AN EXPLANATION OF ANTELOPE MEMORIAL HOSPITAL'S CHARITY CARE PROGRAM. THE PROGRAM IS CONSIDERED A "LAST RESORT FOR PATIENTS MAKING A GENUINE EFFORT TO PAY THEIR BILLS. ALL OTHER AVENUES FOR PAYMENT MUST BE EXHAUSTED (SUCH AS MEDICAID, DISABILITY, KID'S CONNECTION) BEFORE THIS PROGRAM APPLIES." REGULAR COLLECTION EFFORTS WILL BE FOLLOWED UNTIL A DETERMINATION IS MADE FROM A COMPLETED ASSISTANCE APPLICATION THAT A PATIENT QUALIFIES FOR FINANCIAL ASSISTANCE. PART V, SECTION A: ANTELOPE MEMORIAL HOSPITAL OPERATES A 25-BED CRITICAL ACCESS HOSPITAL. THE HOSPITAL ALSO OFFERS PHYSICIAN CLINICS, CARDIAC REHAB, AND HOME HEALTH. ANTELOPE MEMORIAL HOSPITAL PART V, SECTION B, LINE 13G: ALTHOUGH THE CHARITY CARE POLICY DOES NOT SPECIFICALLY DESCRIBE HOW IT IS TO BE PUBLICIZED WITHIN THE COMMUNITY, IT DOES CONTAIN THIS STATEMENT: "ALL PATIENTS WILL BE NOTIFIED OF PROVIDER'S CHARITY CARE POLICY AS LEGALLY REQUIRED." THE CHARITY CARE POLICY IS MAILED TO ALL PATIENTS WITH THE EXTERNAL COLLECTION POLICY AND THE PATIENT'S INVOICE FOR SERVICES. ANTELOPE MEMORIAL HOSPITAL PART V, SECTION B, LINE 19D: CHARGES FOR SERVICES ARE THE SAME FOR ALL PATIENTS, WHETHER THEY ARE ELIGIBLE OR NOT ELIGIBLE FOR FINANCIAL ASSISTANCE. PART VI, LINE 7: NEBRASKA DOES NOT REQUIRE THE FILING OF A COMMUNITY BENEFIT REPORT WITH THE STATE. A COMMUNITY BENEFIT REPORT IS FILED ANNUALLY WITH THE NEBRASKA HOSPITAL ASSOCIATION. ALSO, A MEDICARE COST REPORT IS FILED ANNUALLY WITH NEBRASKA. PART VI, LINE 2: CURRENTLY, ANTELOPE MEMORIAL HOSPITAL DOES NOT PERFORM ANY PROCEDURES TO ASSESS THE HEALTH NEEDS OF THE COMMUNITY IT SERVES. PART VI, LINE 3: ANTELOPE MEMORIAL HOSPITAL INCLUDES ITS PAYMENT POLICY WITH ALL STATEMENTS SENT TO PATIENTS. THIS POLICY EXPLAINS OUR CHARITY CARE PROGRAM AND GIVES INSTRUCTIONS FOR THE APPLICATION PROCESS. PART VI, LINE 4: ANTELOPE MEMORIAL HOSPITAL IS THE LARGEST ACUTE CARE FACILITY SERVING THE ANTELOPE COUNTY AREA. CURRENTLY THERE ARE TWO HOSPITALS PROVIDING ACUTE CARE SERVICES WITHIN ANTELOPE COUNTY. THE HOSPITAL ALSO PROVIDES SERVICE TO THE FOLLOWING FIVE NEBRASKA COUNTIES: BOONE, HOLT, KNOX, MADISON, AND PIERCE. PART VI, LINE 5: NOT APPLICABLE. PART VI, LINE 6: ANTELOPE MEMORIAL HEALTH SYSTEM IS NOT PART OF AN AFFILIATED HEALTH CARE ORGANIZATION. X X X 0 0 0 1 0 0 0 0 0 JACK W GREEN 155071 0 0 0 0 0 6233 0 6173 0 167477 0 0 0 ROGER RUDLOFF 321436 0 0 0 0 0 11496 0 6322 0 339254 0 0 0 TROY DAWSON 289682 0 0 0 0 0 11496 0 6317 0 307495 0 0 0 PART I, LINE 5 PROFESSIONAL EMPLOYMENT AGREEMENTS ENTERED INTO BETWEEN THE HOSPITAL AND PHYSICIANS PROVIDE FOR ANNUAL INCENTIVE PAY. PHYSICIANS ELIGIBLE FOR INCENTIVE PAY RECEIVE A PERCENTAGE OF THE COLLECTIVE GROSS RECEIPTS IN EXCESS OF A SPECIFIED AMOUNT FOR SERVICES PERSONALLY PERFORMED BY THAT PHYSICIAN. HOSPITAL AUTH NO 1 OF ANTELOPE CTY NE 900198231 03665RBB5 2010-12-21 3770000 REFUND PRIOR ISSUE (7/1/2004) 0 0 0 230000 3770000 366759 3770000 2006 1 0 1 1 0 0 0 0 1 0 0 0 0 0 1 X FORM 990, SCHEDULE K, PART II, LINE 3: THE TOTAL PROCEEDS DO NOT EQUAL THE SUM OF LINES 4 THROUGH 12 DUE TO TRANSFERRED OR REPLACEMENT PROCEEDS IN LINE 4. FORM 990, SCHEDULE K, PART III, LINE 7: THE TAX COMPLIANCE AGREEMENT FOR THE ORGANIZATION'S 2010 BONDS SPECIFICALLY STATES THAT IT IS INTENDED TO SERVE AS PART OF ITS WRITTEN POLICIES AND PROCEDURES TO ENSURE POST-ISSUANCE COMPLIANCE RELATING TO ITS OUTSTANDING TAX-EXEMPT BOND OBLIGATIONS. THE AGREEMENT ALSO SETS FORTH POLICIES RELATING TO REMEDIAL ACTIONS RELATING TO SUCH OBLIGATIONS AS, AND TO THE EXTENT NECESSARY. THE ORGANIZATION INTENDS TO ADOPT SEPARATE GENERALLY-APPLICABLE POLICIES AND PROCEDURES ADDRESSING THESE MATTERS AT AN APPROPRIATE MEETING OF ITS BOARD OF DIRECTORS SUBSEQUENT TO THIS FILING. PEGGY GREEN FAMILY MEMBER OF JACK GREEN, CEO FOR ANTELOPE MEMORIAL HOSPITAL. 36048 COMPENSATION WAS PAID TO PEGGY GREEN FOR HER SERVICES AS AN EMPLOYEE OF ANTELOPE MEMORIAL HOSPTIAL. 0 FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 IS PREPARED BY A CERTIFIED PUBLIC ACCOUNTANT AND DELIVERED TO THE CHIEF FINANCIAL OFFICER. THE CFO REVIEWS FORM 990 AND PRESENTS IT AT A MONTHLY BOARD MEETING, PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C ALL OFFICERS, DIRECTORS, COMMITTEE MEMBERS, AND KEY EMPLOYEES SHALL REVIEW THE CONFLICT OF INTEREST POLICY AND COMPLETE A CONFLICT OF INTEREST QUESTIONNAIRE AND CERTIFICATION UPON INITIAL AFFILIATION WITH THE CORPORATION AND ON AN ANNUAL BASIS THEREAFTER. FORM 990, PART VI, SECTION B, LINE 15A SALARY COMPARISON DATA FROM THE NEBRASKA HOSPITAL ASSOCIATION IS USED TO COMPARE ADMINISTRATOR SALARY WITH THAT OF OTHER NEBRASKA CRITICAL ACCESS HOSPITALS. THE CHIEF EXECUTIVE OFFICER AND CHIEF FINANCIAL OFFICER SALARIES ARE DETERMINED USING THE NEBRASKA HOSPITAL ASSOCIATION SALARY SURVEYS AND ARE THEN SET BY THE BOARD OF DIRECTORS. THE BOARD MINUTES DOCUMENT THE DELIBERATIONS AND SALARY DECISIONS. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION DOES NOT MAKE THESE DOCUMENTS AVAILABLE TO THE PUBLIC. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED LOSSES ON INVESTMENTS: -3,209. FORM 990, PART XII, LINE 2C: THE FULL BOARD OF DIRECTORS OVERSEES SELECTION OF AN INDEPENDENT ACCOUNTANT AND THE AUDIT OF THE ANTELOPE MEMORIAL HOSPITAL'S FINANCIAL STATEMENTS.