2013-11-13T13:32:09-06:00 2012-12-31 450250958 EIDE BAILLY LLP 1601 NW Expressway Oklahoma City OK 73118 990 2012-01-01 731279909 Okmulgee Memorial Hospital Inc OKMU 9187564233 1401 Morris Drive Okmulgee OK 74447 Doran Hammett 9187564233 2013-11-11 1 Carolyn Levings P01083874 4054783334 2013-11-11 2012 2016-03-07 17:11:31Z Roshanda Gray 1401 Morris Drive Okmulgee OK 74447 19613513 0 X http://www.okmulgeehospital.com X 1967 OK Health Care Services 9 9 291 25 0 0 42462 0 20281130 19611517 833 1996 0 0 20324425 19613513 0 0 0 0 10325107 10379723 0 0 0 10530185 10188705 20855292 20568428 -530867 -954915 5921754 5658007 5540780 6231948 380974 -573941 Okmulgee Memorial Hospital's mission is to put our patients and customers first and to provide quality health care in an efficient manner. 0 0 16424671 19611517 Okmulgee Hospital is a sixty-six bed hospital facility providing such services as, but not limited to, Inpatient, Outpatient, Psychiatric, Home Health and Emergency Care services to the general public regardless of ability to pay.The Hospital provided $97,000 of charity care in 2012. 16424671 1 0 0 0 0 0 0 0 0 0 1 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 1 0 0 0 0 0 0 0 1 0 0 0 1 7 0 1 291 1 0 0 0 0 0 0 0 0 0 0 X 9 9 1 1 0 0 0 0 0 1 0 0 0 1 1 1 1 1 1 1 1 0 OK X Doran Hammett 9187583102 1401 Morris Drive Okmulgee OK 74447 Nevyle Cable 1.00 X X 0 0 0 John Fidler 1.00 X X 0 0 0 Greg Marriott 1.00 X X 0 0 0 Barbara Osborn 1.00 X X 0 0 0 Kim Gage MD 1.00 X 0 0 0 Linda Janzen 1.00 X 0 0 0 Walter McGown OD 1.00 X 0 0 0 Timothy Sanford DO 1.00 X 0 0 0 Jason Winters 1.00 X 0 0 0 Paul D Ervin 40.00 X 77176 0 0 Doran Hammett-Mgmt Company 40.00 X 0 0 0 George Miller-Mgmt Company 40.00 X 0 0 0 Benjamin Kamp DO 40.00 X 320738 0 9969 Jason S Bruce 40.00 X 280822 0 8687 678736 0 18656 2 0 1 0 Quorum Health Resources 105 Continental Pl Brentwood TN 37027 Management Services 462749 Cardinal Health Pharmacy P O BOX 847384 Dallas TX 75284 Supplies/Med & Pharmacy 281008 Cardinal Health PO Box 847384 Dallas TX 75284 Supplies/Med & Pharmacy 212572 CPSI PO Box 850309 Mobile AL 36695 Internet & Computer Serv. 209904 Okmulgee Emergency PLCC 607 South Broadway Coweta OK 74429 Emergency Room Physician Services 185667 5 Net Patient Serv. Rev. 624100 17885490 17885490 Miscellaneous Revenue 900099 1641200 1641200 Dietary 900099 67675 67675 Maint. & Janitorial 900099 17152 17152 19611517 496 496 1500 0 1500 1500 1500 19613513 19611517 0 1996 77176 77176 7682502 5841492 1841010 112601 84766 27835 1907569 1436020 471549 599875 451586 148289 52688 52688 64948 64948 2017517 1691902 325615 1486124 699856 786268 16164 4788 11376 286790 270249 16541 76856 56679 20177 105008 105008 629121 471841 157280 262251 205792 56459 Bad debt expense 3416059 3416059 Supplies 1043847 1043847 Government Programs 551659 551659 Recruitment 80615 80615 99058 93127 5931 20568428 16424671 4143757 0 86569 16043 2634983 2811226 715222 591105 424204 529713 13144971 11435051 2060776 1709920 5921754 5658007 3008084 3317478 33172 3206 2022821 2438439 476703 472825 5540780 6231948 X 380974 -573941 380974 -573941 5921754 5658007 -954915 0 X 0 1 X 1 0 X 22716 22716 5305423 4780549 524874 102260 102260 0 7714572 6552242 1162330 1709920 Estimated Third Party Settlements 472825 472825 X 16197454 -3416059 -3416059 19613513 0 19613513 17152369 0 17152369 3416059 3416059 20568428 Description of Uncertain Tax Positions Under FIN 48: Part X, Line 2: The Hospital is organized as an Oklahoma nonprofit corporation and has been recognized by the Internal Revenue Service (IRS) as exempt from federal income taxes under Internal Revenue Code Section 501(c)(3). The Hospital is annually required to file a Return of Organization Exempt from Income Tax (Form 990) with the IRS. In addition, the Hospital is subject to income tax on net income that is derived from business activities that are unrelated to its exempt purpose. The Hospital has determined it is not subject to unrelated business income tax and has not filed an Exempt Organization Business Income Tax Return (Form 990T) with the IRS. The Hospital believes that it has appropriate support for any tax positions taken affecting its annual filing requirements, and as such, does not have any uncertain tax positions that are material to the financial statements. The Hospital would recognize future accrued interest and penalties related to unrecognized tax benefits and liabilities in income tax expense if such interest and penalties are incurred. Part XI, Line 2d - Other Adjustments: Bad Debt shown in Revenue on Financial Statements Part XII, Line 4b - Other Adjustments: Bad Debt shown in Revenue on Financial Statements 1 1 X 1 X 1 X 1 1 0 0 44219 44219 0.00260 3386091 2916772 469319 0.02740 3430310 2916772 513538 0.03000 3430310 2916772 513538 0.03000 0 3416059 8902 6646564 7348548 -701984 X 1 0 1 1 Okmulgee Memorial Hospital

1401 Morris Drive Okmulgee OK 74447

X X X Psych-16 Beds Okmulgee Memorial Hospital Inc 1 0 1 1 200.000000000000 1 250.000000000000 1 X X 1 1 X X 1 0 X X X X 1 X 0 0 1 Home Health Agency

1401 Morris Drive Okmulgee OK 744476419

In-Home Care Service Part I, Line 7: Charity care was converted to cost on line 7a based on an overall cost-to-charge ratio derived from Worksheet 2.Unreimbursed Medicaid was calculated using the cost-to-charge ratio derived from Worksheet 2. Part I, L7 Col(f): The amount of bad debt expense removed from total expenses to determine the percentage was $3,416,059. Part III, Line 4: Bad debt is determined by our bad debt policy considering actual patient care charges. Charges become bad debt once a reasonable opportunity has been made by the hospital to collect an open account and the responsible party has been contacted regarding the unpaid balance. After policy based collection attempts have been exhausted, the account is written off to bad debt.All payments and contractual are applied to the account before it is written off to bad debt. If any payments are received for bad debts that have been written off, they are applied to the current year bad debt expense.The estimated amount of the organization's bad debt expense attributable to patients eligible under the organization's charity care policy is calculated based on an estimate of charges foregone to gross patient charges.Footnote from financial statements:Patient accounts receivable are reduced by an allowance for doubtful accounts. In evaluating the collectability of accounts receivable, the Hospital 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 Hospital 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 Hospital records a significant provision for bad debts in the period of service on the basis of its past experience, which indicates 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: Okmulgee Memorial Hospital provides services to patients under the Medicare program knowing they will not recover all the costs associated with providing these services. Providing these services is essential to these patients and the community and increases their access to healthcare services. Therefore, the Medicare shortfall is considered a community benefit.The costs associated with Medicare were taken from the Medicare Cost Report. The Medicare Cost Report is completed based on the rules and regulations set forth by Centers for Medicare and Medicaid Services. Part III, Line 9b: The hospital has a charity care policy and patients must meet certain established criteria for charity service consistent with OHM's mission. The policy does not specifically state the collection procedures for those who qualify for other financial assistance which most would be Medicaid. The hospital does have provisions but they are not specifically written in the policy. No collections actions are filed while an application is in review, any personal portion due after a determination of assistance would follow normal collections practices. Okmulgee Memorial Hospital, Inc. Part V, Section B, Line 14g: The financial assistance policy is available from the patient Financial Counselor and is also included on patient billing statements. Summary of financial assistance is available in the waiting rooms, emergency rooom, and outpatient areas of the hospital. Part VI, Line 2: Okmulgee Memorial Hospital has a strategic plan and looks at information provided by the state, county and Medicare. The hospital looks at discharges, hospitalization and utilization of different categories of patients. The information is used to assess physician needs as well as the purchasing of capital equipment. The hospital also participates in the County Wellness Coalition. Information from surveys are used in the needs assessment for the hospital. Part VI, Line 3: The hospital uses an electronic program at admission to determine if a patient is eligible for assistance. If a patient is determined to be eligible, then the patient is referred to a financial counselor. The financial counselor works with the patient to determine if the patient is eligible for Medicaid. If the patient is not eligible for Medicaid, the hospital then works with the patient to determine if the patient is eligible for charity care. The Financial Counselor contact information is included in the patient billing statements if further assistance is needed. Summary of financial assistance is available in the waiting rooms, emergency rooom, and outpatient areas of the hospital. Part VI, Line 4: Okmulgee Memorial Hospital is an acute care hospital located in Okmulgee, which is in Okmulgee County, Oklahoma. Okmulgee County is a federally underserved area according to the Health Resources and Services Administration. Okmulgee is a small community of about 13,000 residents. There are two other hospitals in the county with one about twenty miles from Okmulgee Memorial Hospital. The median household income is $35,615 and 19.2% of families and 21.4% of individuals of the population are below the poverty line. Part VI, Line 5: The organization has a volunteer board comprised of members of the community. Medical staff privileges are extended to all qualified physicians in the community and to those who wish to render services at OMH. Any surplus funds, if available, are reinvested in the facilities to improve patient care. X X X 0 0 0 0 0 0 0 0 0 Benjamin Kamp DO 320738 0 0 0 0 0 9969 0 0 0 330707 0 0 0 Jason S Bruce 280822 0 0 0 0 0 8687 0 0 0 289509 0 0 0 Tracey Timothy Sanford Board Directors 63420 Leases medical office space from a related organization, Okmulgee Medical Foundation, Inc. 0 Form 990, Part VI, Section A, line 2 Tracy & Timothy Sanford (Trustees) - family relationship Form 990, Part VI, Section A, line 3 Management duties include planning and executing financial operations. Quorum Health Resources manages the hospital. Form 990, Part VI, Section A, line 8b The organization does not have a committee with authority to act on behalf of the governing body. Form 990, Part VI, Section B, line 11 The Form 990 is prepared by an outside accounting firm and is reviewed internally by the CEO and the Finance Committee prior to filing with the IRS. The Board of Directors is also provided a copy prior to filing. Form 990, Part VI, Section B, line 12c We also have a conflict of interest policy which is applicable to all employees of OMH. Once a potential conflict is identified, Compliance and administration determine the level and risk of the conflict. Depending on the severity of conflict an employee may be asked to refrain involvement. If there is a known conflict that is not disclosed by an employee, they will be subject to the disciplinary action policy. Form 990, Part VI, Section B, line 15 The Board of Directors reviews and approves salaries of top management positions. Salary determination is based on comparability data from industry standards. CEO compensation is recommended by Quorum Health Resources and Board approved. Form 990, Part VI, Section C, line 19 The organization makes its governing documents, conflict of interest policy, and financial statemsnts available to the public upon request. Okmulgee Medical Foundation Inc PO Box 1038 Okmulgee OK 74447 730766656 Office building and manages tax deductible contributions OK 501(c)(3) 509(a)(1) 0 0 0 0 1 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 Okmulgee Medical Foundation D 103215 FMV