2013-04-01T17:57:04-05:00 2012-06-30 480573184 REGIER CARR & MONROE LLP 4801 E BROADWAY BLVD STE 501 TUCSON AZ 857113648 990 2011-07-01 860334996 BISBEE HOSPITAL ASSOCIATIONINC BISB 5204325383 101 COLE AVENUE BISBEE AZ 856031327 JAMES DICKSON 5204325383 2013-03-06 1 DAVID B BARBER CPACFE P00348638 5206248229 2011 2016-02-25 16:41:14Z COPPER QUEEN COMMUNITY HOSPITAL JAMES DICKSON 101 COLE AVENUE BISBEE AZ 856031327 24698328 0 X WWW.CQCH.ORG X 1977 AZ AHSSTO PROVIDE HEALTHCARE SERVICES TO THE BISBEE ARIZONA COMMUNITY. 10 10 267 0 0 0 123533 1107741 21747190 23479236 -149491 -8408 115492 93938 21836724 24672507 74703 44789 0 0 12335164 12482967 0 0 0 7774643 8442495 20184510 20970251 1652214 3702256 19720901 21717401 8070020 6364264 11650881 15353137 TO PROVIDE HEALTHCARE SERVICES TO THE BISBEE ARIZONA COMMUNITY. 0 0 17547418 23509561 TO PROVIDE HEALTHCARE SERVICES THROUGH IN-PATIENT, OUT-PATIENT,24-HOUR EMERGENCY SERVICES AND RURAL HEALTH CLINIC TO THE RESIDENTS OF BISBEE & SURROUNDING COMMUNITIES. 17547418 1 1 0 0 0 0 0 0 0 0 1 0 0 0 1 1 1 0 0 0 0 0 0 0 1 0 1 1 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 71 0 1 267 1 0 0 0 0 0 0 0 0 0 0 X 10 10 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 1 1 1 1 0 AZ X X THE ORGANIZATION 5204325383 101 COLE AVENUE BISBEE AZ 856031327 BOB HOWELL 1.00 X 0 0 0 KATHLEEN HEARD 1.00 X 0 0 0 ROSALIE BUTLER 1.00 X 0 0 0 JOHN HARRIS 1.00 X 0 0 0 DENNIS NELSON 1.00 X 0 0 0 JOHN GOLDTHORPE 1.00 X 0 0 0 LAURA CHAVEZ 1.00 X 0 0 0 GARY DILLARD 1.00 X 0 0 0 PETER CARBERRY 1.00 X 0 0 0 DENNIS GALLUS 1.00 X 0 0 0 JAMES DICKSON 40.00 X 232705 0 24701 DIANE MOORE 40.00 X 142513 0 12003 JOSE ROMO 40.00 X 315383 0 17189 HEIDI LODGE 40.00 X 290313 0 16437 DANIEL ROE 40.00 X 512856 0 23114 BRUCE CURTIS 40.00 X 196342 0 13618 MURADI NAJIBULLAH 40.00 X 195993 0 13608 1886105 0 120670 19 0 1 0 CPSI PO BOX 850309 MOBILE AL 36685 EMR SYSTEMS 585490 LABORATORY CORP OF AMERICA PO BOX 12140 BURLINGTON NC 27216 LAB 307565 SIEMENS HEALTHCARE DIAGNOSTICS PO BOX 121102 DALLAS TX 75312 DIAGNOSTIC 224606 WAYTUK JOHN P MD 4119 E SELLS DR PHOENIX AZ 85018 MEDICAL 200650 PIATT DAVID W MD 4539 W POWELL DR PHOENIX AZ 85087 MEDICAL 147800 7 19785 1064735 23221 1107741 PATIENT SERVICE REVENU 900099 23479236 23479236 23479236 10529 10529 18937 -18937 -18937 -18937 2100 19785 6884 -4784 -4784 CAFETERIA 900099 63591 63591 MISC. REVENUE-RELATED- 900099 30325 30325 MEDICAL RECORDS 900099 4806 4806 98722 24672507 23509561 0 55205 26999 26999 17790 17790 411922 411922 9869771 8736087 1133684 224215 184662 39553 1296420 1205321 91099 680639 573508 107131 156962 156962 257155 257155 10310 10310 1925473 1566152 359321 207981 207981 88013 52026 35987 39036 19996 19040 148632 105520 43112 348883 348883 1166844 1166844 322571 322571 SUPPLIES 1719886 1717229 2657 PROVISION FOR UNCOLLECT 913843 913843 REPAIRS & MAINTENANCE 440686 383286 57400 UTILITIES 219902 219902 476318 309370 166948 20970251 17547418 3422833 0 2381873 3262309 2999800 2054465 3241055 4316882 527687 530035 72649 202473 18953224 8151501 10446162 10801723 500000 51675 49514 19720901 21717401 2472811 2795601 5597209 3568663 8070020 6364264 X 11555269 15288895 95612 64242 11650881 15353137 19720901 21717401 3702256 0 X 0 1 1 X 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 893568 893568 11394889 4757933 6636956 5705632 3393568 2312064 959135 959135 10801723 LONG-TERM DEBT 3568663 3568663 24672507 20970251 3702256 3702256 24698328 0 24698328 -25821 -25821 24672507 20996072 18937 6884 25821 20970251 0 20970251 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: THE HOSPITAL IS EXEMPT FROM FEDERAL INCOME TAX UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. THE HOSPITAL RECEIVED ITS LETTER OF DETERMINATION FROM THE INTERNAL REVENUE SERVICE IN 1977. CERTAIN UNRELATED BUSINESS INCOME MAY BE SUBJECT TO INCOME TAX. THE HOSPITAL FOLLOWS FASB CODIFICATION 740-10-50 FOR DISCLOSURE OF INCOME TAX RELATED MATTERS. THE STANDARD SETS A "MORE LIKELY THAN NOT" CRITERION FOR RECOGNIZING THE TAX BENEFITS OF UNCERTAIN TAX POSITIONS. THE HOSPITAL BELIEVES THAT ITS INCOME TAX FILING POSITIONS AND DEDUCTIONS WILL BE SUSTAINED UPON EXAMINATION AND, ACCORDINGLY, HAVE NOT RECORDED ANY RESERVES OR RELATED ACCRUALS FOR INTEREST AND PENALTIES IN THE ACCOMPANYING FINANCIAL STATEMENTS FOR UNCERTAIN INCOME TAX POSITIONS. INCOME TAX RELATED INTEREST AND PENALTIES ARE REPORTED IN GENERAL AND ADMINISTRATIVE EXPENSES WHEN INCURRED. NO INCOME TAX EXAMINATIONS ARE CURRENTLY UNDERWAY OR ANTICIPATED. THE STATUTE OF LIMITATIONS IS THREE YEARS FOR FEDERAL INCOME TAX PURPOSES AND FOUR YEARS FOR THE STATE OF ARIZONA. GOLF TOURNAMENT 21885 19785 2100 4595 1290 999 21885 19785 2100 4595 1290 999 6884 -4784 1 1 X 1 X 1 X 1 1 0 0 271000 271000 0.01350 7016745 6030476 986269 0.04920 7287745 6030476 1257269 0.06270 27199 27199 0.00140 27199 27199 0.00140 7314944 6030476 1284468 0.06410 1 778270 389135 5206870 5491201 -284331 X 1 1 1 1 COPPER QUEEN COMMUNITY HOSPITAL

101 COLE AVE BISBEE AZ 85603

X X X X COPPER QUEEN COMMUNITY HOSPITAL 1 1 1 200.000000000000 1 200.000000000000 1 X 1 1 X X 1 X 1 X X X X 1 X 0 0 3 COPPER QUEEN MEDICAL ASSOCIATES-DOUGLAS

100 E 5TH ST DOUGLAS AZ 85607

RURAL HEALTH CLINIC COPPER QUEEN MEDICAL ASSOCIATES-BISBEE

101 COLE AVE BISBEE AZ 85603

RURAL HEALTH CLINIC COPPER QUEEN MEDICAL ASSOCIATES-PALOMINA

10524 HIGHWAY 92 HEREFORD AZ 85615

RURAL HEALTH CLINIC PART I, LINE 7: THE COST ACCOUNTING SYSTEM WAS USED TO REPORT THE SUBSIDIZED HEALTH SERVICES REVENUE AND EXPENSE. THE COST ACCOUNTING SYSTEM ADDRESSES ALL PATIENT SEGMENTS (INPATIENT, OUTPATIENT, EMERGENCY ROOM, PRIVATE INSURANCE, MEDICAID, MEDICARE, AND ETC.) PART I, LINE 7, COLUMN (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 $ 913843. PART II: N/A. PART III, LINE 4: FINANCIAL NOTES REGARDING BAD DEBTS, PAGE 11 OF AUDITED FINANCIAL STATEMENTSTHE HOSPITAL PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS BASED UPON A REVIEW OF OUTSTANDING RECEIVABLES, THE AGE OF ACCOUNTS, THE PAYOR MIX, HISTORICAL COLLECTION INFORMATION, AND EXISTING ECONOMIC CONDITIONS.BAD DEBTS ARE MONITORED BY MANAGEMENT AND ARE DETERMINED TO BE DELINQUENT BASED UPON REVIEW OF AGING REPORTS COUPLED WITH CORRESPONDENCE WITH PATIENTS AND THIRD-PARTY PAYORS. BAD DEBTS ARE WRITTEN OFF WHEN ALL REASONABLE ATTEMPTS TO COLLECT THE DEBT HAVE BEEN EXHAUSTED.A COST TO CHARGES RATIO IS USED TO DETERMINE THE BAD DEBT EXPENSE AT COST. SHORTFALL IS NOT INCLUDED AS PART OF COMMUNITY BENEFIT. COPPER QUEEN COMMUNITY HOSPITAL PART V, SECTION B, LINE 19D: ANY PATIENT THAT DOES DOES HAVE INSURANCE IS AUTOMATICALLY GIVEN A 50% DISCOUNT ON THE COST OF THEIR MEDICAL CARE. IF THE PATIENT MAKES LESS THAN 200% OF THE FEDERAL POVERTY LEVEL THEY WILL RECEIVE AN ADDITIONAL DISCOUNT BEYOND THE INITAL 50%. THE DISCOUNT WILL BE DETERMINED USING A SLIDING FEE SCALE DISCOUNT. PART VI, LINE 2: THE ORGANIZATION ASSESSES THE HEALTH CARE NEEDS OF THE COMMUNITY IT SERVES BASED UPON HISTORICAL SERVICES PROVIDED. PART VI, LINE 3: IT IS DONE UNDER ADMISSION. THE PATIENTS ARE PROVIDED A COPY OF FINANICAL ASSISTANCE POLICY UPON ADMISSION. FINANIAL ASSISTANCE CONTACT INFORMATION IS ALSO POSTED IN THE LOBBY, EMERGENCY ROOM AND OTHER PATIENT AREA. PATIENTS WITH PAST DUE BALANCES ARE SENT A LETTER ADVISING THEM OF THE AVAILABILITY OF ASSISTANCE BEFORE THEY ARE SENT TO COLLECTIONS. PART VI, LINE 4: THE HOSPITAL PROVIDES INPATIENT, OUTPATIENT, AND EMERGENCY SERVICES TO RESIDENTS WITHIN BISBEE, ARIZONA COMMUNITY AND ADJACENT AREAS. THE HOSPITAL ALSO OPERATES A HOME HEALTH AGENCY IN THE SAME GEOGRAPHIC AREA AND THREE RURAL HEALTH CLINICS LOCATED IN BISBEE, DOUGLAS AND PALOMINAS, ARIZONA. PART VI, LINE 5: N/A PART VI, LINE 6: N/A REPORTS FILED WITH STATES PART VI, LINE 7 AZ 1 ARIZONA LIONS VISION CENTER 3003 S COUNTRY CLUB RD TUCSON AZ 85713 860289608 501C(3) 12060 FOR SUPPORTING OF GENERAL OPERATION. 1 SCHOLARSHIPS 8 12500 HEALTH CLUB ASSISTANCE 2 5000 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: THE ORGANIZATION HAS A LEADERSHIP MEETING TO REVIEW STUDENTS' SCHOLARSHIP APPLICATION. THE APPLICATIONS ARE ON FILE IN THE HUMAN RESOURCE DEPARTMENT. X X X X 0 0 0 0 0 0 0 0 0 JAMES DICKSON 232705 0 0 0 0 0 16973 0 7728 0 257406 0 0 0 DIANE MOORE 142513 0 0 0 0 0 4275 0 7728 0 154516 0 0 0 JOSE ROMO 315383 0 0 0 0 0 9461 0 7728 0 332572 0 0 0 HEIDI LODGE 290313 0 0 0 0 0 8709 0 7728 0 306750 0 0 0 DANIEL ROE 512856 0 0 0 0 0 15386 0 7728 0 535970 0 0 0 BRUCE CURTIS 196342 0 0 0 0 0 5890 0 7728 0 209960 0 0 0 MURADI NAJIBULLAH 195993 0 0 0 0 0 5880 0 7728 0 209601 0 0 0 FORM 990, PART VI, SECTION B, LINE 11 THE DRAFT OF 990 FORM AND RELATED SCHEDULES ARE SENT TO AND REVIEWED BY BOARD MEMBERS AND MANAGEMENT BEFORE FILING. COMMENTS AND CHANGES ARE COMMUNICATED WITH THE TAX PREPARER AND ADDRESSED ACCORDINGLY. FORM 990, PART VI, SECTION B, LINE 15 EXECUTIVE COMPENSATION IS SET BY THE BOARD BASED UPON REVIEW OF AN ANNUAL SALARY SURVEY BY THE ARIZONA HOSPITAL ASSOCIATION. THE HOSPITAL ALSO CONTRACTS WITH AN OUTSIDE CONSULTANT WHO ADVISES THE BOARD REGARDING EXECUTIVE COMPENSATION. THE ABOVE MENTIONED PROCESS IS UTILIZED IN SETTING SALARIES OF ALL OF THE EXECUTIVE TEAM AT THE HOSPITAL. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICTS OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. THE FINANCIAL STATEMENTS ARE ALSO AVAILABLE TO THE PUBLIC THROUGH THE STATE UAR REPORT AND THE FEDERAL MEDICARE COST REPORT.