2013-04-15T15:35:08-05:00 2012-05-31 450250958 EIDE BAILLY LLP 800 NICOLLET MALL STE 1300 MINNEAPOLIS MN 554027033 990 2011-06-01 810233121 ST PETER'S HOSPITAL STPE 4064442100 2475 BROADWAY HELENA MT 59601 JOHN GREEN 4064442100 2013-04-12 1 KIM C HUNWARDSEN P00484560 6122536500 2013-04-12 2011 2016-02-25 16:41:14Z NATHAN C OLSON 2475 BROADWAY HELENA MT 59601 166937667 0 X WWW.STPETES.ORG X 1883 MT PROVIDE EXCEPTIONAL AND COMPASSIONATE HEALTH CARE. 15 13 1289 82 61468 -464968 2080000 593525 144987588 163534823 3813556 1677614 75646 61533 150956790 165867495 50458 14253 0 0 65776330 77313898 0 0 308911 73975436 82984400 139802224 160312551 11154566 5554944 233863046 232092045 75498434 82889308 158364612 149202737 X ST. PETER'S HOSPITAL PARTNERS WITH OUR PATIENTS, COMMUNITY, AND MEDICAL STAFF TO PROVIDE EXCEPTIONAL AND COMPASSIONATE HEALTH CARE. 1 0 103430351 14253 125980041 ST. PETER'S HOSPITAL IS A 122-BED ACUTE CARE HOSPITAL FACILITY SERVING RESIDENTS OF LEWIS AND CLARK COUNTY AND PORTIONS OF JEFFERSON, BROADWATER, MEAGHER AND POWELL COUNTIES. ST. PETER'S IS THE SOLE FACILITY IN THE PRIMARY SERVICE AREA. DURING THE YEAR ENDED MAY 31, 2012 THE HOSPITAL PROVIDED AT COST A TOTAL OF $16,880,442 IN COMMUNITY BENEFIT. OF THIS TOTAL $4,820,392 WAS FOR MEDICAL SERVICES TO INDIVIDUALS WHO WERE DETERMINED UNABLE TO PURCHASE SUCH SERVICES UNDER THE HOSPITAL'S CHARITY CARE POLICY. IN ADDITION TO FREE CARE AND/OR SUBSIDIZED CARE, CARE IS ALSO PROVIDED AT BELOW COST RATES TO PERSONS COVERED BY GOVERNMENTAL PROGRAMS. THE TOTAL OPERATING LOSS FOR PROVIDING CARE TO MEDICAID PATIENTS WAS $1,261,245. THE HOSPITAL PROVIDED $10,282,351 IN SUBSIDIZED HEALTH SERVICES DURING THE YEAR, INCLUDING ACUTE PATIENT CARE FOR MEDICAL, SURGICAL, PEDIATRIC AND BEHAVIORAL HEALTH PATIENTS, OUTPATIENT PHARMACY, PULMONARY REHAB, DIALYSIS, CLINICAL NUTRITION, ANTICOAGULATION, AND HOSPITALISTS SERVICES, PHYSICIAN CLINICS AND IN-HOME NURSING AND OXYGEN SERVICES. TO FULFILL ITS MISSION OF COMMUNITY SERVICE, THE ORGANIZATION 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 ORGANIZATION DOES NOT PURSUE COLLECTION OF AMOUNTS DETERMINED TO QUALIFY AS CHARITY CARE, THEY ARE NOT REPORTED AS PATIENT SERVICE REVENUE. 26930124 37554782 THE HOSPITAL OPERATES SEVERAL PHYSICIAN CLINICS, EMPLOYING 55 PHYSICIANS AND PHYSICIAN ASSISTANTS AND NURSE PRACTITIONSERS. WITHOUT THE HOSPITAL'S ASSISTANCE, LEWIS AND CLARK COUNTY WOULD BE WITHOUT MANY NEEDED MEDICAL AND SURGICAL SPECIALTIES. PHYSICIANS IN THE SPECIALTIES OF FAMILY PRACTICE, INTERNAL MEDICINE, NEUROLOGY, RHEUMATOLOGY, GASTROENTEROLOGY, ENT, CARDIOLOGY, RADIATION AND MEDICAL ONCOLOGY HAD APPROXIMATELY 93,875 PATIENT ENCOUNTERS. 130360475 1 1 0 1 0 0 0 0 0 1 1 1 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 142 0 1 1289 1 1 1 0 0 0 0 0 0 0 0 0 X 15 13 0 0 0 0 0 1 0 1 1 1 0 1 1 1 1 1 1 1 1 1 1 X JOHN GREEN CFO 4064442100 2475 BROADWAY HELENA MT 59601 X RICK HAYES 1.00 X X 0 0 0 MARIA BRAMAN 1.00 X X 0 0 0 PATTY NELSON 1.00 X X 0 0 0 JOHN FLINK 1.00 X X 0 0 0 JOHN SOLHEIM 40.00 X X 517170 0 34306 WILLIAM NORTHEY 1.00 X 0 0 0 DR THOMAS WEINER 40.00 X 1400041 0 20095 CANDACE CAIN 1.00 X 0 0 0 MARK TAYLOR 1.00 X 0 0 0 KATE MCIVOR 1.00 X 0 0 0 TOM STRIZICH 1.00 X 0 0 0 MARY SHEEHY-MOE 1.00 X 0 0 0 SHEILA HOGAN 1.00 X 0 0 0 RYAN SCRENAR 1.00 X 0 0 0 ROGER STONE 1.00 X 0 0 0 TOM GREGG 40.00 X X 206683 0 15052 JOHN GREEN 40.00 X 241899 0 18160 DR MICHAEL LEE 40.00 X 872754 0 12259 DR JOHN RIBIC 40.00 X 500981 0 10468 DR MATTHEW MCLAREN 40.00 X 563745 0 7023 DR SCOTT PARGOT 40.00 X 558426 0 13912 DR KRIS GODLEWSKI 40.00 X 502523 0 12746 DR DAVID LECHNER 40.00 X 127839 0 6207 5492061 0 150228 79 1 1 0 HORIZON MENTAL HEALTH MANAGEMENT PO BOX 840839 DALLAS TX 75284 PSYCHIATRIC SERVICES 2480186 DICK ANDERSON CONSTRUCTION 3424 HIGHWAY 12 E HELENA MT 59601 GENERAL CONTRACTOR 1204395 CAPITAL MEDICAL ANESTHESIA PO BOX 5179 HELENA MT 59601 ANESTHESIA SERVICES 705000 GE HEALTHCARE PO BOX 414-SN471 MILWAUKEE WI 53201 BIOMEDICAL SERVICES 698460 ARUP LABORATORIES 500 CHIPETA WAY SALT LAKE CITY UT 84108 LAB TESTING SERVICES 661659 44 480111 98414 15000 593525 PATIENT SERVICE REVENU 622110 114261203 114261203 PHARMACY 446110 47163005 47163005 OTHER SERVICES 900099 1001603 618982 382621 CAFETERIA 722210 634255 623950 10305 PETE'S PLACE 624410 321254 321254 153503 484961 -331458 163534823 2449465 2449465 244059 115795 239167 59154 4892 56641 61533 61533 771851 -771851 -771851 -771851 165867495 163473355 61468 1739147 14253 14253 3572375 1409180 2163195 50997 25499 25498 58563540 48631361 9692920 239259 4898410 3758205 1132695 7510 6346581 4925012 1409038 12531 3881995 2965366 900226 16403 673580 69445 604135 70169 70169 48104 48104 402592 402592 12819184 9332451 3479535 7198 341147 81478 247059 12610 1358155 611274 740400 6481 1267351 314732 952619 1964198 347640 1613790 2768 272419 116918 154628 873 269226 114477 154694 55 2014730 2014730 9062998 6277440 2785558 2101371 2080803 20568 MEDICAL SUPPLIES, OTHER 40079165 39264515 811713 2937 BAD DEBT EXPENSE 8816374 8816374 BED TAX 1234900 1234900 OTHER TAXES -66540 -103378 36838 255277 72530 182461 286 160312551 130360475 29643165 308911 18987821 16135251 16266602 22948724 3544429 3613773 2546358 2961254 171833552 74434367 98702114 97399185 69687326 64567768 23688744 24048654 439652 417436 233863046 232092045 14234992 16427015 44942031 42231476 16321411 24230817 75498434 82889308 X 147252230 138230176 3384821 3217396 7727561 7755165 158364612 149202737 233863046 232092045 X 5554944 -14716819 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 1 50 0 0 1 100 0 1 48104 48254 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: THE HOSPITAL HIRED A CONSULTANT TO PROVIDE LOBBYING SERVICES IN CONNECTION WITH GOVERNMENTAL AFFAIRS REPRESENTATION TO ENSURE HOSPITAL, COMMUNITY, AND EMPLOYEE INTERESTS AND NEEDS ARE REPRESENTED. IN ADDITION, A PORTION OF AHA/MHA DUES ARE ATTRIBUTED TO LOBBYING SERVICES. 10709927 489607 -542431 58752 10598351 9692852 127911 1052329 163165 10709927 7514363 1405761 928225 155497 9692852 9393554 630667 -2297705 212153 7514363 0.73170 0.26830 0 1 1 3745203 3745203 97116320 24494833 72621487 68550910 48678527 19872383 2421119 1261007 1160112 97399185 INVESTMENT IN JOINT VENTURES 6311132 F INTEREST IN ST. PETER'S FOUNDATION 10800250 F LTD CLASS INVESTMENTS 6937272 F 24048654 ESTIMATED THIRD-PARTY SETTLEMENTS 1922157 LIABILITY FOR PENSION BENEFITS 22308660 24230817 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: ENDOWMENT FUNDS ARE RESTRICTED FOR SUPPORT OF HOSPITAL PROGRAMS AND SERVICES AND FOR CAPITAL PURCHASES AND IMPROVEMENTS IN ACCORDANCE WITH BOARD POLICIES AND/OR DONOR RESTRICTIONS. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: THE HOSPITAL AND FOUNDATION ARE MONTANA NONPROFIT CORPORATIONS AND HAVE BEEN RECOGNIZED BY THE INTERNAL REVENUE SERVICE (IRS) AS EXEMPT FROM FEDERAL INCOME TAXES UNDER INTERNAL REVENUE CODE SECTION 501(C)(3). THE HOSPITAL AND THE FOUNDATION ARE 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 FILES AN EXEMPT ORGANIZATION BUSINESS INCOME TAX RETURN (FORM 990T) WITH THE IRS TO REPORT ITS UNRELATED BUSINESS TAXABLE INCOME. PEAK HEALTH HELENA, LLC IS A LIMITED LIABILITY COMPANY AND IS TREATED AS A CORPORATION FOR FEDERAL AND STATE INCOME TAX PURPOSES. THERE WAS NO TAXABLE INCOME IN 2012 AND 2011. THE ORGANIZATION 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 ORGANIZATION 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. THE ORGANIZATION'S FEDERAL FORM 990T FILINGS ARE NO LONGER SUBJECT TO FEDERAL TAX EXAMINATIONS BY TAX AUTHORITIES FOR YEARS BEFORE 2009. 1 1 X 1 X 1 X 1 1 1 0 1 1 8143137 3322745 4820392 0.03180 10072705 8811460 1261245 0.00830 18215842 12134205 6081637 0.04010 737409 263958 473451 0.00310 43003 43003 0.00030 43588010 33305659 10282351 0.06790 134441 134441 0.00090 44502863 33569617 10933246 0.07220 62718705 45703822 17014883 0.11230 20053 20053 0.00010 7933 7933 0.00010 27986 27986 0.00020 1 8816374 0 38387826 45200007 -6812181 X 1 1 1 HELENA SURGICENTER LLC SURGERY CENTER 0.50000 0.09150 0.05290 1 1 ST PETER'S HOSPITAL

2475 BROADWAY HELENA MT 59601

X X X PHYSICIAN CLINICS & URGENT CARE SERVICES ST PETER'S HOSPITAL 1 1 1 150.000000000000 1 250.000000000000 1 X X X X X 1 1 X X X 1 0 1 X 0 0 2 HOSPICE & HOMELINK OF ST PETER'S HOSP

201 SOUTH CALIFORNIA HELENA MT 59601

HOSPICE AND HOME HEALTH APEX OF ST PETER'S HOSPITAL

201 SOUTH CALIFORNIA HELENA MT 59601

HOME OXYGEN SERVICES PART I, LINE 6A: THE ORGANIZATION'S COMMUNITY BENEFIT REPORT CAN BE FOUND ON ITS WEBSITE AT WWW.STPETES.ORG. PART I, LINE 7: CHARITY CARE, UNREIMBURSED MEDICAID AND SUBSIDIZED HEALTH SERVICES ARE CONVERTED TO COST USING THE COST TO CHARGE RATIO DERIVED FROM THE HOSPITAL'S COST ALLOCATION SYSTEM. THE COST ALLOCATION SYSTEM ADDRESSES ALL PATIENT SEGMENTS. THE COSTS ARE ESTIMATED BY ALLOCATING DEPARTMENTAL COSTS BASED ON DIRECT COSTS LESS ANY OTHER OPERATING REVENUE THEN BY DOING AN ALLOCATION OF BENEFITS, DEPRECIATION AND OTHER OVERHEAD COSTS. COMMUNITY HEALTH IMPROVEMENT SERVICES, HEALTH PROFESSIONS EDUCATION AND CASH AND IN-KIND CONTRIBUTIONS IS DERIVED FROM THE CBISA PROGRAM. PART I, LINE 7G: SUBSIDIZED HEALTH SERVICES INCLUDES $6,175,756 OF COSTS ATTRIBUTABLE TO A PHYSICIAN CLINIC. PART I, L7 COL(F): THE AMOUNT OF BAD DEBT EXPENSE REMOVED FROM THE DENOMINATOR OF THE CALCULATIONS WAS $8,816,374. PART III, LINE 4: BAD DEBT EXPENSE IS REPORTED AT CHARGES AS RECORDED BY THE ORGANIZATION.BAD DEBT EXPENSE IS REPORTED NET OF DISCOUNTS AND CONTRACTUAL ALLOWANCES. A PAYMENT ON AN ACCOUNT PREVIOUSLY WRITTEN OFF REDUCES BAD DEBT EXPENSE IN THE CURRENT YEAR.FINANCIAL STATEMENT FOOTNOTE:PATIENT RECEIVABLES ARE UNCOLLATERALIZED PATIENT AND THIRD-PARTY PAYOR OBLIGATIONS. THE ORGANIZATION CHARGES INTEREST AT 10 PERCENT PER ANNUM ON PAST DUE ACCOUNTS AFTER 90 DAYS. PAYMENTS OF PATIENT RECEIVABLES ARE ALLOCATED TO THE SPECIFIC CLAIMS IDENTIFIED ON THE REMITTANCE ADVICE OR, IF UNSPECIFIED, ARE APPLIED TO THE EARLIEST UNPAID CLAIM. THE CARRYING AMOUNT OF PATIENT RECEIVABLES IS REDUCED BY A VALUATION ALLOWANCE THAT REFLECTS MANAGEMENT'S BEST ESTIMATE OF AMOUNTS THAT WILL NOT BE COLLECTED FROM PATIENTS AND THIRD-PARTY PAYORS. MANAGEMENT REVIEWS PATIENT RECEIVABLES BY PAYOR CLASS AND APPLIES PERCENTAGES TO DETERMINE ESTIMATED AMOUNTS THAT WILL NOT BE COLLECTED FROM THIRD PARTIES UNDER CONTRACTUAL AGREEMENTS AND AMOUNTS THAT WILL NOT BE COLLECTED FROM PATIENTS DUE TO BAD DEBTS. MANAGEMENT CONSIDERS HISTORICAL WRITE OFF AND RECOVERY INFORMATION IN DETERMINING THE ESTIMATED BAD DEBT PROVISION. PART III, LINE 8: THESE EXPENSES REPRESENT AN OVERALL SHORTFALL OF THE DIRECT MEDICARE PATIENT POPULATION. THE COSTS THEMSELVES ARE THEREFORE A COMMUNITY BENEFIT AS THE COMMUNITY WOULD NOT RECEIVE THESE SERVICES IF WE DID NOT PROVIDE THEM. TOTAL MEDICARE REVENUE AND MEDICARE ALLOWABLE COSTS OF CARE ARE CALCULATED USING A COST ALLOCATION METHOD CONSISTENT WITH THE COST REPORT. PART III, LINE 9B: ST. PETER'S HOSPITAL RECOGNIZES ITS RESPONSIBILITY TO RENDER NECESSARY HEALTH CARE SERVICES TO ALL PERSONS IN NEED OF SUCH CARE, REGARDLESS OF RACE, CREED, COLOR OR ECONOMIC CIRCUMSTANCES. ST. PETER'S HOSPITAL RECOGNIZES THAT PAYMENT FOR SERVICES RENDERED IS DUE AND PAYABLE AT THE TIME OF SERVICE. THE HOSPITAL ACCEPTS INSURANCE ASSIGNMENTS AND SOME OTHER APPROVED ARRANGEMENTS FOR DELAYED PAYMENT. FINANCIAL ASSISTANCE IS AVAILABLE FOR ALL QUALIFIED PATIENTS. PATIENTS NOT COVERED BY INSURANCE OR UNABLE TO PAY IN FULL FOR SERVICES RENDERED MUST CONTACT THE APPROPRIATE PATIENT ACCOUNT REPRESENTATIVE WHO WILL ASSIST THE PATIENT AND/OR FAMILY IN DETERMINING IF HE/SHE QUALIFIES FOR PATIENT ASSISTANCE. COLLECTION ACTIVITY WILL BE SUSPENDED WHILE A FINANCIAL ASSISTANCE APPLICATION IS UNDER REVIEW. ST. PETER'S HOSPITAL PART V, SECTION B, LINE 13G: A COPY OF THE FINANCIAL ASSISTANCE POLICY IS INCLUDED ON THE WEBSITE. ADDITIONALLY, A SUMMARY OF THE FINANCIAL ASSISTANCE POLICY IS POSTED IN THE FACILITY'S EMERGENCY ROOM AND WAITING ROOMS AND ADMISSIONS OFFICES. THE SUMMARY IS ALSO PROVIDED TO PATIENTS UPON ADMISSION TO THE HOSPITAL FACILITY. ST. PETER'S HOSPITAL PART V, SECTION B, LINE 19D: CURRENTLY UNINSURED PATIENTS ARE GIVEN A 3% DISCOUNT ON THEIR BILL PRIOR TO DETERMINATION OF QUALIFYING FOR PATIENT ASSISTANCE. UPON DETERMINATION THAT PATIENTS DO QUALIFY FOR PATIENT ASSISTANCE, A DISCOUNT IS APPLIED BASED ON THE QUALIFYING LEVEL FOR A DISCOUNT BETWEEN 15% AND 100%. THE ORGANIZATION IS WORKING TO UPDATE THEIR POLICY TO ALIGN WITH THE PROPOSED REGULATIONS. ST. PETER'S HOSPITAL PART V, SECTION B, LINE 20: CURRENTLY UNINSURED PATIENTS ARE GIVEN A 3% DISCOUNT ON THEIR BILL PRIOR TO DETERMINATION OF QUALIFYING FOR PATIENT ASSISTANCE. THE 3% DISCOUNT HAS BEEN ESTABLISHED AS A MEANS TO REDUCE GROSS CHARGES FOR SELF-PAY PATIENTS TO BE CLOSE TO THE AMOUNT CHARGED TO THOSE WITH INSURANCE. UPON DETERMINATION THAT PATIENTS DO QUALIFY FOR PATIENT ASSISTANCE, A DISCOUNT IS APPLIED BASED ON THE QUALIFYING LEVEL FOR A DISCOUNT BETWEEN 15% AND 100%. THE ORGANIZATION IS WORKING TO UPDATE THEIR POLICY TO ALIGN WITH THE PROPOSED REGULATIONS. PART VI, LINE 2: ST. PETER'S HOSPITAL CONDUCTS A COMMUNITY SURVEY EVERY THREE YEARS. THE COMMUNITY SURVEY IS PERFORMED BY AN INDEPENDENT CONTRACTOR THAT SELECTS AN ADEQUATE SAMPLE SIZE FOR THE AREA. THE HOMES OF ST. PETER'S HOSPITAL EMPLOYEES ARE EXCLUDED FROM THE SURVEY. THE SURVEY INCLUDES QUESTIONS RELATED TO EVALUATING THE COMMUNITY'S EXPERIENCE AND ABILITY TO ACCESS HEALTHCARE. THE SURVEY HELPS TO IDENTIFY SPECIALTY AREAS OF CONCERN. THE RESULTS OF THE SURVEYS ARE REVIEWED BY THE SENIOR MANAGEMENT TEAM AS WELL AS THE BOARD TO IDENTIFY THE AREAS OF FOCUS. PART VI, LINE 3: ST. PETER'S HOSPITAL (1) POSTS ITS CHARITY CARE POLICY ON ITS WEB SITE AS WELL AS AT THE ADMITTING DESK, EMERGENCY ROOM, ON THE MONTHLY STATEMENTS AND CASHIER AREAS IN WHICH ELIGIBLE PATIENTS ARE LIKELY TO BE PRESENT; (2) OFFERS A SUMMARY OF OUR POLICY AND APPLICATION TO SELF PAY PATIENTS WITH CONTACT INFORMATION TO PATIENTS AS PART OF THE INTAKE PROCESS; (3) PROVIDES A COPY OF FINANCIAL ASSISTANCE CONTACT INFORMATION TO PATIENTS WITH DISCHARGE MATERIALS; (4) FINANCIAL COUNSELORS DISCUSS WITH PATIENTS EXPECTING TO OWE MORE THAN $500 THE AVAILABILITY OF PATIENT ASSISTANCE AND VARIOUS GOVERNMENT BENEFITS, SUCH AS MEDICAID OR STATE PROGRAMS, AND ASSISTS THE PATIENT WITH QUALIFICATION FOR SUCH PROGRAMS, WHERE APPLICABLE. PART VI, LINE 4: ST. PETER'S HOSPITAL IS A 122-BED ACUTE CARE HOSPITAL FACILITY SERVING RESIDENTS OF LEWIS AND CLARK COUNTY AND PORTIONS OF JEFFERSON, BROADWATER, MEAGHER AND POWELL COUNTIES. ST. PETER'S IS THE SOLE FACILITY IN THE PRIMARY SERVICES AREA. THE HOSPITAL FINANCIAL PAYOR MIX CONSISTED OF 6.8% SELF PAY PATIENTS, 7.8% OF MEDICAID PATIENTS AND 43.4% MEDICARE PATIENTS. APPROXIMATELY 15.6% OF THE POPULATION IS AGE 65 AND OLDER. THE AVERAGE PER CAPITA INCOME IS $27,583 AND APPROXIMATELY 12.1% OF THE POPULATION IS BELOW THE FEDERAL POVERTY LEVEL. THE NEAREST HOSPITAL IN THE AREA IS APPROXIMATELY 35 MILES FROM ST. PETER'S CAMPUS. PART VI, LINE 5: THE ORGANIZATION'S GOVERNING BODY MEMBERS RESIDE IN THE COMMUNITY. MEDICAL STAFF PRIVILEGES ARE EXTENDED TO ALL QUALIFIED PHYSICIANS IN THE COMMUNITY. SURPLUS FUNDS ARE USED TO MAKE CAPITAL PURCHASES AND UPGRADES TO THE FACILITIES.ST. PETER'S HOSPITAL IS THE SOLE ACUTE CARE PROVIDER IN THE PRIMARY SERVICE AREA MADE UP OF LEWIS & CLARK COUNTY AND THE NORTHERN PORTION OF JEFFERSON COUNTY. THERE IS A POPULATION OF APPROXIMATELY 74,800. OUT-MIGRATION IS GENERALLY LIMITED TO TERTIARY SERVICES NOT AVAILABLE AT ST. PETER'S HOSPITAL INCLUDING CARDIAC SURGERY AND NEO-NATAL CARE. ST. PETER'S HOSPITAL PROVIDES CARE TO ALL PATIENTS REGARDLESS OF THEIR ABILITY TO PAY. ST. PETER'S HOSPITAL MAINTAINS CHARGES AS ONE OF THE LOWEST HOSPITALS WITHIN THE STATE DEPENDING ON THE SERVICES BEING PROVIDED. ST. PETER'S HOSPITAL SPONSORS SEVERAL WELLNESS SCREENINGS, HEALTH FAIRS AND EDUCATIONAL LECTURES, CLASSES, AND EVENTS THROUGHOUT THE YEAR TO PROMOTE BETTER LIVING, NUTRITION AND GOOD HEALTH. CONTINUING EDUCATION IS ALSO PROVIDED TO THE MEMBERS OF THE MEDICAL COMMUNITY ON AN ON-GOING BASIS. IN ADDITION, ST. PETER'S HOSPITAL HAD 14,037 VOLUNTEER HOURS FROM THE COMMUNITY ASSISTING IN A VARIETY OF ROLES WITHIN THE ORGANIZATION.ST. PETER'S HOSPITAL MADE $134,441 OF CASH AND IN-KIND DONATIONS TO A VARIETY OF ORGANIZATIONS WITHIN THE COMMUNITY. THIS INCLUDES BUT IS NOT LIMITED TO CR ANDERSON MIDDLE SCHOOL FOR ITS HONOR STUDENT PROGRAM, ANGEL FUND TO PURCHASE CLOTHING AND SCHOOL SUPPLIES FOR YOUTH, HELENA HIGH SCHOOL FOR SOCCER TENT, LEWIS AND CLARK COUNTY FOR CRISIS RESPONSE TEAM, HEALTHY MOTHER'S/HEALTHY BABIES, HOSA, FRIENDSHIP CENTER, FLORENCE CRITTENTON, YMCA, GOD'S LOVE, CARROLL COLLEGE ATHLETICS WITH EMERGENCY SERVICES AT EVENTS, CARROLL COLLEGE NURSING DEPARTMENT WITH MEDICAL SUPPLIES NEEDED FOR LEARNING LABS, EXPLORATION WORKS WITH MEDICAL SUPPLIES NEEDED FOR STUDENT SCIENCE EXPERIMENTS, UNITED WAY TO ASSIST LOW-INCOME AND HOMELESS RESIDENTS WITH BASIC NEEDS, SPIRIT OF SERVICE CAMPAIGN BY PROVIDING SUPPLIES AND VOLUNTEERS TO HELP ELDERLY RESIDENTS AND OTHERS WITH SPECIAL NEEDS IMPROVE THEIR HOMES AND YARDS, KAY MCKENNA YOUTH FOUNDATION TO PROVIDE SAFE SUMMER YOUTH ACTIVITIES, ARCHIE BRAY FOUNDATION, HELENA FOOD SHARE PROGRAM FOR BACK PACK PROGRAM IN THE SCHOOLS AND BIG BROTHERS AND SISTERS. THE DONATIONS WERE MADE TO ASSIST THESE COMMUNITY SPONSORS IN THEIR VARIOUS PROGRAMS. 1 EDUCATION ASSISTANCE 13 14253 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: AS DETERMINED BY THE PUBLIC RELATIONS DIRECTOR AND THE CEO, THE ORGANIZATION FINANCIALLY SUPPORTS COMMUNITY INDIVIDUALS PURSUING EDUCATION PROGRAMS THAT ENRICH HEALTH AND SAFETY TO THE COMMUNITY. DUE TO KNOWLEDGE OF THE RECIPIENTS AND THE PURPOSE OF THE GRANTS, FURTHER MONITORING ON THE USE OF THE FUNDS WAS NOT DEEMED NECESSARY. X X X 1 1 X X X X X 0 1 0 0 0 0 0 0 0 JOHN SOLHEIM 368754 0 130141 0 18275 0 14700 0 22392 0 554262 0 0 0 DR THOMAS WEINER 1398194 0 0 0 1847 0 13287 0 6809 0 1420137 0 0 0 TOM GREGG 160769 0 36614 0 9300 0 7057 0 8312 0 222052 0 0 0 JOHN GREEN 185821 0 45598 0 10480 0 9581 0 8579 0 260059 0 0 0 DR MICHAEL LEE 871920 0 0 0 834 0 8175 0 4084 0 885013 0 0 0 DR JOHN RIBIC 499001 0 0 0 1980 0 8175 0 2293 0 511449 0 0 0 DR MATTHEW MCLAREN 563745 0 0 0 0 0 0 0 7023 0 570768 0 0 0 DR SCOTT PARGOT 558426 0 0 0 0 0 10023 0 3889 0 572338 0 0 0 DR KRIS GODLEWSKI 501572 0 0 0 951 0 7350 0 5396 0 515269 0 0 0 DR DAVID LECHNER 121493 0 6000 0 346 0 0 0 6207 0 134046 0 0 0 PART I, LINE 1A PRESIDENT/CEO RECEIVES REIMBURSEMENT FOR MEMBERSHIP DUES PAID TO A SOCIAL CLUB, AN ANNUAL COMMUNITY SUPPORT ALLOWANCE AND A CAR ALLOWANCE. THE PRESIDENT/CEO IS TAXED ON THE PERSONAL MILEAGE THAT HE USES. THE PRESIDENT/CEO IS PROVIDED TRAVEL FOR COMPANIONS FOR BUSINESS FUNCTIONS. ALL AMOUNTS ARE REPORTED AS TAXABLE COMPENSATION. PART I, LINE 4B JOHN SOLHEIM, TOM WEINER, AND KRIS GODLEWSKI PARTICIPATE IN A NONQUALIFIED RETIREMENT PLAN UNDER 457(F). AMOUNTS FROM THEIR BASE WAGES WERE DEFERRED INTO THEIR PLAN AT THEIR DISCRETION. THE ORGANIZATION DID NOT CONTRIBUTE MONEY INTO THE PLAN ON BEHALF OF THE INDIVIDUALS NAMED ABOVE. MONTANA FACILITY FINANCE AUTHORITY 810302402 61204JBR4 2004-05-06 29748183 TO FUND EXPANSION AND RENOVATION OF EXISTING HOSPITAL FACILITY. 0 0 0 MONTANA FACILITY FINANCE AUTHORITY 810302402 61204JBY9 2007-03-22 22826511 FUND MED OFFICE BLDG & WOMEN & CHILDREN'S BED WING & REFUND BONDS 1/23/97 0 0 0 5025000 29748183 2242316 2973582 422346 27111925 2008 0 0 1 1 7100000 22826511 2509328 465447 7154609 353863 14743608 7154609 2009 1 0 1 1 0 0 0 0 0.00000 0.00000 0.00000 1 0 0 0 0 0.00000 0.04500 0.04500 1 0 0 0 0 0 0 0 0 0 0 0 0 SCHEDULE K, PART II, LINE 11(B): THE AMOUNT REPORTED AS OTHER SPENT PROCEEDS WAS USED TO REFUND A PRIOR BOND ISSUE. NEW PROGRAM SERVICES FORM 990, PART III, LINE 2 IN 2012 WE PURCHASED AN O-ARM DIGITAL IMAGING SYSTEM FOR THE OPERATING ROOM ALLOWING FOR GREATER DETAIL IN THE IMAGES DURING SURGERY AND REDUCING THE LENGTH OF SURGERY IN INTENSIVE SPINE CASES. ST. PETER'S MEDICAL GROUP RECRUITED AN ADDITIONAL SURGEON, NEPHROLOGIST AND MEDICAL ONCOLOGIST TO THE COMMUNITY EXPANDING THE AVAILABILITY OF APPOINTMENTS WITHIN THE COMMUNITY. IN 2011 WE RECRUITED TWO ORTHOPEDIC SURGEONS TO THE COMMUNITY. IN 2012 THESE INDIVIDUALS APPROACHED ST. PETER'S HOSPITAL TO JOIN ST. PETER'S MEDICAL GROUP AND BECAME EMPLOYED PHYSICIANS. FORM 990, PART VI, SECTION A, LINE 1 THE EXECUTIVE COMMITTEE CONSISTS OF THE OFFICERS OF THE BOARD OF DIRECTORS, PAST CHAIR OF THE BOARD PROVIDED HE/SHE CONTINUES TO BE A DIRECTOR, AND THE CHIEF OF STAFF. IF THE PAST CHAIR OF THE BOARD IS UNABLE TO SERVE, THE BOARD CHAIR MAY APPOINT ANOTHER MEMBER TO THE EXECUTIVE COMMITTEE. THE EXECUTIVE COMMITTEE HAS THE POWER TO TRANSACT ALL REGULAR BUSINESS OF THE HOSPITAL DURING THE INTERIM BETWEEN MEETINGS OF THE BOARD OF DIRECTORS, PROVIDED THAT ANY ACTION DOES NOT CONFLICT WITH THE POLICIES OF THE BOARD OF DIRECTORS AND ALL MATTERS OF MAJOR IMPORTANCE ARE REFERRED TO THE BOARD OF DIRECTORS. SHOULD ANY MATTER OF EXTREME URGENCY ARISE BETWEEN THE REGULAR MEETINGS OF THE BOARD OF DIRECTORS, IT IS THE DUTY OF THE EXECUTIVE COMMITTEE TO REQUEST THE PRESIDENT CALL A SPECIAL MEETING OF THE BOARD OF DIRECTORS. MINUTES OF THE EXECUTIVE COMMITTEE ARE SUBMITTED TO THE BOARD OF DIRECTORS AND ITS ACTIONS ARE SUBJECT TO APPROVAL OR DISAPPROVAL AT THE NEXT REGULAR BOARD MEETING. THE COMMITTEE IS RESPONSIBLE FOR CONDUCTING THE PRESIDENT'S EVALUATION, SETTING THE PRESIDENT'S COMPENSATION AND NEGOTIATING THE TERMS OF THE PRESIDENT'S EMPLOYMENT CONTRACT. FORM 990, PART VI, SECTION A, LINE 7A THE NOMINATING COMMITTEE SOLICITS QUALIFIED CANDIDATES FOR MEMBERSHIP ON THE BOARD OF DIRECTORS AND PRESENTS A SLATE TO THE BOARD OF DIRECTORS WITH ONE CANDIDATE FOR EACH POSITION TO BE FILLED. MEMBERS OF THE BOARD OF DIRECTORS MAY SUBMIT THE NAMES OF POTENTIAL CANDIDATES TO THE NOMINATING COMMITTEE FOR THE COMMITTEE'S CONSIDERATION. THE NOMINATING COMMITTEE'S SLATE OF POTENTIAL CANDIDATES IS SUBMITTED TO THE BOARD AT THE BOARD OF DIRECTOR'S ANNUAL MEETING. FIVE MEMBERS OF THE BOARD OF DIRECTORS SERVE BY VIRTUE OF THE OFFICES AND FOR THE DURATION OF THE TIME THEY REMAIN IN OFFICE; THE PRESIDENT AND CHIEF EXECUTIVE OFFICER OF THE HOSPITAL, THE CHIEF-OF-STAFF OF THE HOSPITAL, THE CHIEF-OF-STAFF ELECT OF THE HOSPITAL, THE ST. PETER MEDICAL GROUP PRESIDENT, AND THE ST. PETER'S FOUNDATION CHAIR. FORM 990, PART VI, SECTION B, LINE 11 A ROUGH DRAFT OF THE FORM 990 IS REVIEWED BY THE CEO AND CFO AS WELL AS THE FINANCE COMMITTEE PRIOR TO FULL BOARD APPROVAL OF THE FINAL FORM 990 PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C THE CONFLICT OF INTEREST POLICY COVERS ALL BOARD MEMBERS, OFFICERS, SENIOR ADMINISTRATION AND KEY EMPLOYEES. THE BOARD IDENTIFIES POTENTIAL CONFLICTS AND DETERMINES IF VOTING ON RELATED ITEMS WOULD BE A CONFLICT OF INTEREST IF A CONFLICT IS DETERMINED TO EXIST, THE CONFLICTED INDIVIDUAL IS EXCLUDED FROM VOTING ON THE CONFLICTED ITEM. FORM 990, PART VI, SECTION B, LINE 15 AN INDEPENDENT COMPENSATION CONSULTANT PERFORMS A REVIEW OF SALARIES AND BENEFITS USING DATA FROM COMPARABLE HEALTHCARE FACILITIES. A REPORT IS PREPARED AND PRESENTED TO THE EXECUTIVE COMMITTEE OF THE BOARD OF DIRECTORS, WHICH USES THE REPORT TO DETERMINE OFFICER AND SENIOR MANAGEMENT COMPENSATION. THE INFORMATION IS THEN REVIEWED WITH THE BOARD OF DIRECTORS. THE ANNUAL PROCESS WAS PERFORMED DURING 2012. FORM 990, PART VI, SECTION C, LINE 19 THE GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE MADE AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART VII: PERCENTAGE OF TIME SPENT BETWEEN RELATED ORGANIZATIONS: JOHN SOLHEIM, HOSPITAL AND FOUNDATION CEO, SPENDS 98% OF HIS TIME ON HOSPITAL BUSINESS AND 2% OF HIS TIME ON FOUNDATION BUSINESS. TOM GREGG, HOSPITAL AND FOUNDATION CEO, SPENDS 98% OF HIS TIME ON HOSPITAL BUSINESS AND 2% OF HIS TIME ON FOUNDATION BUSINESS. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED LOSSES ON INVESTMENTS: -6,210,353. MINIMUM PENSION LIABILITY ADJUSTMENT -8,542,940. CHANGE IN PERMANENTLY AND TEMPORARILY RESTRICTED NET ASSETS OF FOUNDATION -139,821. BOOK/TAX ADJUSTMENT FOR PARTNERSHIPS 176,295. TOTAL TO FORM 990, PART XI, LINE 5: -14,716,819. FORM 990, PART VI, SECTION A, LINE 9: JOHN SOLHEIM PO BOX 238 DEERWOOD MN 56444 LISTING OF ALL CUSIP#'S ASSOCIATED WITH BOND ISSUANCE SCHEDULE K, PART I, BOND A, CUSIP#'S FOR SERIES 2004 BOND 61204J BR4, 61204J AX2, 61204J AY0, 61204J AZ7, 61204J BA1, 61204J BB9, 61204J BC7, 61204J BD5, 61204J BE3, 61204J BF0, 61204J BG8, 61204J BH6, 612047J BL7 LISTING OF ALL CUSIP#'S ASSOCIATED WITH BOND ISSUANCE SCHEDULE K, PART I, BOND A, CUSIP#'S FOR SERIES 2007 BOND 61204J BY9, 61204J BS2, 61204J BTO, 61204J BU7, 61204J BV5, 61204J BW3 FORM 8621, PART IV: ST. PETER'S HOSPITAL IS FILING FORM 8621 AS A SHAREHOLDER IN PASSIVE FOREIGN INVESTMENT COMPANIES. ST. PETER'S HOSPITAL DISTRIBUTION IS NOT TAXABLE AND THEREFORE NOT INCLUDED ON PART IV OF FORM 8621. THE AMOUNT OF NON-TAXABLE DISTRIBUTION FROM EACH FUND IS IDENTIFIED BELOW. BR PROPERTIES S.A. $4 PSAM GLOBAL EVENT UCITS FUND $2 ST PETER'S HOSPITAL FOUNDATION 2475 BROADWAY HELENA MT 59601 810392270 RAISE FUNDS TO SUPPORT ST. PETER'S HOSPITAL MT 501(C)(3) LINE 11A, I ST PETER'S HOSPITAL 1 PEAK HEALTH LLC 2475 BROADWAY AVENUE HELENA MT 59601 271863807 HEALTH CLUB MT N/A UNRELATED 4568 1993685 0 0 0.65000 PEAK HEALTH REALTY LLC 2475 BROADWAY AVENUE HELENA MT 59601 272492966 RENTAL PROPERTY MT N/A UNRELATED -122552 -60115 0 0 0.65000 PEAK HEALTH HELENA LLC 2475 BROADWAY AVENUE HELENA MT 59601 271863807 HEALTH CLUB MT N/A UNRELATED -302004 -318046 0 0 0.65000 0 0 1 0 0 0 0 0 1 1 0 1 0 1 1 1 0 1 ST PETER'S HOSPITAL FOUNDATION C 480111 FMV ST PETER'S HOSPITAL FOUNDATION N 275703 COST PEAK HEALTH LLC N 181146 COST