2013-05-14T16:10:24-05:00 2012-06-30 481026809 Wendling Noe Nelson & Johnson LLC 534 S Kansas Ave Suite 1500 Topeka KS 666033491 990 2011-07-01 481253246 Pawnee Valley Community Hospital Inc PAWN 6202853161 923 Carroll Ave Larned KS 67550 John Jeter MD 7856235000 2013-05-14 1 Derek H Hart P01054116 7852334226 2013-05-08 2011 2016-02-24 21:20:13Z John Jeter MD 923 Carroll Ave Larned KS 67550 12502927 0 X www.pawneevalleyhospital.com X 2001 KS Pawnee Valley Community Hospital, Inc. is a tax-exempt charitable organization under Section 501(c)(3) of the Internal Revenue Code and is licensed by the State of Kansas Department of Health and Environment. The purpose of the Organization is to provide healthcare to inpatients and outpatients who are acutely ill or who otherwise require medical care and related services. The Organization is striving to be the best Critical Access Hospital in rural America. 5 0 114 87 0 0 93394 0 10903508 12491037 8093 11890 0 0 11004995 12502927 0 0 0 0 3739930 4832801 0 0 0 6636374 5963639 10376304 10796440 628691 1706487 4821252 5312244 4821252 5312244 0 0 X Pawnee Valley Community Hospital, Inc. is a tax-exempt charitable organization under Section 501(c)(3) of the Internal Revenue Code and is licensed by the State of Kansas Department of Health and Environment. The purpose of the Organization is to provide healthcare facitities and services for the care and treatment of inpatients and outpatients who are acutely ill or who otherwise require medical care and related services. The core purpose of the Corporation is to help people be healthy. 0 0 9469341 12379141 Patient care: Program services consist of routine and ancillary department healthcare services provided by a healthcare organization as described in 501(c)(3) of the IRS code. 9469341 1 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 0 0 114 1 0 0 0 0 0 0 0 0 0 0 X 5 0 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 X William Overbey Treasurer 7856235000 2220 Canterbury Hays KS 67601 John Jeter MD 4.00 X X 0 468021 122926 Bryce Young 4.00 X X 0 243392 77470 William Overbey 4.00 X X 0 247271 76966 Shae Veach 4.00 X 0 144878 48937 Matt Heyn 40.00 X X 97812 41678 29538 97812 1145240 355837 0 0 1 0 Hays Medical Center 2220 Canterbury Drive Hays KS 67601 Contract Services 2207127 Docs Who Care 1337 S Fountain Drive Olathe KS 66061 ER Physician Coverage 789013 Allstaff Chartered 2000 Washington Great Bend KS 67530 Contract Nursing 279307 Quest Diagnostics PO Box 14730 St Louis MO 63150 Lab Service 199926 Shared Med Equipment Group LLC PO Box 330 Cottage Grove WI 53527 Equipment maintenance 135000 6 Net patient service re 622000 12379141 12379141 Other operating revenu 900099 111896 111896 12491037 11589 11589 301 0 301 301 301 12502927 12379141 0 123786 174300 174300 3626868 3180625 446243 131166 116024 15142 632160 555831 76329 268307 226454 41853 23616 23616 24789 24789 321 321 1981304 1809840 171464 70198 2242 67956 36128 23849 12279 67106 40655 26451 158706 107460 51246 17647 13710 3937 4720 4720 38326 22996 15330 Bad debts 1649703 1649703 Contract labor 398006 398006 Medical supplies 320165 320045 120 Pharmaceuticals 288974 288974 883930 708207 175723 10796440 9469341 1327099 0 560 560 2678839 2764507 1879340 1263463 641 9199 195512 316765 66360 115912 0 841838 4821252 5312244 4192561 942625 628691 4369619 4821252 5312244 X 0 0 4821252 5312244 X 1706487 -1706487 X X 0 1 1 X 0 X 0 Estimated third-party payor settlements 841838 841838 Due to Pawnee County 1695113 Due to Hays Medical Center, Inc. 2625531 Estimated third-party payor settlements 48975 4369619 12502927 10796440 1706487 -1706487 -1706487 0 10853224 0 10853224 1649703 1649703 12502927 9146737 0 9146737 1649703 1649703 10796440 Description of Uncertain Tax Positions Under FIN 48: Part X: Management is not aware of any uncertainties in income tax positions. Part XI, Line 8 - Other Adjustments: Increase in amount due to Pawnee County -1,066,422. Transfers to Pawnee County -640,065. Total to Schedule D, Part XI, Line 8: -1,706,487. Part XII, Line 4b - Other Adjustments: Bad debts treated as net patient service revenue in financial statements 1,649,703. Part XIII, Line 4b - Other Adjustments: Bad debts treated as net patient service revenue in financial statements 1,649,703. 1 1 1 X 125.000000000000 1 X 1 1 0 1 0 132291 132291 0.01450 746236 607942 138294 0.01510 878527 607942 270585 0.02960 970253 567770 402483 0.04400 7600 7600 0.00080 977853 567770 410083 0.04480 1856380 1175712 680668 0.07440 0 604707 42329 6510497 6446036 64461 X 1 1 1 1 Pawnee Valley Community Hospital Inc

923 Carroll Avenue Larned KS 67550

X X X X Pawnee Valley Community Hospital Inc 1 1 1 125.000000000000 1 400.000000000000 1 X X X X 1 1 X X X X 1 0 1 X 0 0 Part I, Line 7: A cost-to-charge ratio derived from Worksheet 2 was used to determine financial assistance at cost and the cost of subsidized health services. A cost-to-charge ratio derived from Worksheet 2 was used to determine the costs of serving Medicaid managed care organization beneficiaries and costs from the Medicaid cost report filed with the state Medicaid agency were used to determine the costs of serving traditional Medicaid beneficiaries. Part I, L7 Col(f): Bad debt expense of $1,649,703 is included in Part IX line 25. This amount was subtracted from total expenses when computing the denominator for the percentage calculated for line 7(f). Part III, Line 4: Bad debt expense was calculated using a cost-to-charge ratio derived from Worksheet 2. The estimate for the amount of bad debt expense attributable to patients eligible under the FAP is based upon the experience of a related organization. The hospital's financial statements are included in a consolidated set of audited financial statements. The footnote from these financial statements follows:Accounts receivable are reduced by an allowance for uncollectible accounts. In evaluating the collectability of accounts receivable, the HaysMed Group analyzes its past history and identifies trends for each of its major payor sources of revenue to estimate the appropriate allowance for uncollectible 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 uncollectible accounts. For receivables associated with services provided to patients who have third-party coverage, the HaysMed Group analyzes contractually due amounts and provides an allowance for uncollectible 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 HaysMed Group 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 uncollectible accounts. Part III, Line 8: The Medicare cost report was the costing methodology used to determine the allowable Medicare costs pertaining to Medicare net revenue. Allowable costs of care reported on line 6 were determined using amounts from Worksheet D, Part V and Worksheet D-1 in the Pawnee Valley Community Hospital, Inc., Medicare cost report for fiscal year ended June 30, 2012. Part III, Line 9b: Whenever possible, the customer service representatives (CSR's) of Pawnee Valley Community Hospital try to determine the estimated self-pay balance prior to the patient receiving services. Charity care eligibility is first considered at this point in time. In addition, if full payment is not received or payment is not made with 30 days, the CSR contacts the patient. If it is determined that at least a two-year payment plan cannot be established with the patient, the CSR will screen for charity care and request that the charity care application be completed by the patient. Pawnee Valley Community Hospital, Inc. Part V, Section B, Line 13g: Pawnee Valley Community Hospital, Inc. (PVCH) will proactively seek out applicants who may be in need of financial assistance. PVCH will post notice of this policy to all patients/guarantors through its registration, pre-registration, and financial counseling process. This policy will also be posted in prominent areas of the hospital. Part VI, Line 3: Information regarding the Pawnee Valley Community Hospital, Inc. charity care program is located on the Hays Medical Center, Inc. website for patients and community members to view, and the financial assistance application is also on the website to print off and complete. In addition, if a customer service representative contacts a patient about a bill and in visiting with them they determine that patient could possibly qualify for the hospital's charity care policy, the CSR will send the application to the patient as well. Part VI, Line 4: Pawnee Valley Community Hospital, Inc. is located in Larned, Kansas, which has a population of approximately 4,050 people, as of the 2010 census. The median household income of Larned was $46,464. Approximately 5.9% of families were below the poverty line, and 7.4% of the total population was below the poverty line. Approximately 8.9% of the hospital's revenue is from services provided to patients eligible for Medicaid. Pawnee Valley Community Hospital, Inc. is the only hospital in Larned, Kansas. It mainly serves the community of Larned. Part VI, Line 5: Pawnee Valley Community Hospital, Inc. promotes the health of the community by extending medical privileges to most qualified, local physicians. Part VI, Line 6: Pawnee Valley Community Hospital, Inc. is not a part of an affiliated health care system. Sch H - Part VI - Line 2 Pawnee Valley Community Hospital, has completed its assessment of the health care needs of the communities it serves, and is in the process of making the study available to the public. X X 0 1 0 0 0 1 1 0 0 John Jeter MD 0 408709 0 44543 0 14769 0 97963 0 24963 0 590947 0 0 Bryce Young 0 219371 0 19388 0 4633 0 49739 0 27731 0 320862 0 0 William Overbey 0 216282 0 19119 0 11870 0 49235 0 27731 0 324237 0 0 Shae Veach 0 136257 0 5312 0 3309 0 24728 0 24209 0 193815 0 0 Matt Heyn 97812 23678 0 18000 0 0 3276 1462 20003 4797 121091 47937 0 0 Part I, Line 3 The hospital Administrator's salary is reviewed annually by an independent consulting group and the Board of Directors. Part I, Line 4b John Jeter, M.D. - $67,988 Bryce Young - $36,264 William Overbey - $35,760 Shae Veach - $21,235 Part I, Line 6 A portion of the Administrator's incentive compensation is determined by net earnings exceeding budget for the fiscal year. A portion of incentive compensation for officers and key employees of Hays Medical Center, Inc., a related organization, is determined by net earnings exceeding budget for the fiscal year. Form 990, Part VI, Section A, line 6 The organization has one member, HaysMed Partners, Inc., which became the sole member as of March 1, 2010. HaysMed Partners, Inc., is a wholly-owned subsidiary of Hays Medical Center, Inc. Form 990, Part VI, Section A, line 7a The Board members of HaysMed Partners, Inc., the sole member of Pawnee Valley Community Hospital, appoint the Board members of Pawnee Valley Community Hospital, Inc. Form 990, Part VI, Section A, line 7b HaysMed Partners, Inc., the sole member of Pawnee Valley Community Hospital, elects the Board members of Pawnee Valley Community Hospital. Form 990, Part VI, Section B, line 11 Form 990 was reviewed with the Board members prior to filing. Form 990, Part VI, Section B, line 12c Officers, directors & key employees, along with all associates, are required to complete a conflict of interest statement annually. The statements are used to monitor and enforce compliance with the policy. Form 990, Part VI, Section B, line 15 The hospital administrator and officers' salaries are reviewed annually by an independent consulting group and the Board members. Form 990, Part VI, Section C, line 19 These documents are not made available to the public. Changes in Net Assets or Fund Balances: Form 990, Part XI, line 5: Increase in amount due to Pawnee County -1,066,422. Transfers to Pawnee County -640,065. Total to Form 990, Part XI, Line 5: -1,706,487. Financial Statements and Reporting Form 990. Part XII, Line 2c Hays Medical Center, Inc., has an audit committee that is responsible for the oversight of Pawnee Valley Community Hospital, Inc's., financial statement audit and the selection process of an independent accountant. HaysMed Partners Inc 2220 Canterbury Dr Hays KS 67601 270877152 Owns management contract for Pawnee Valley Community Hospital KS 501(c)(3) 170(b)(1)(A)(iii) 0 Hays Medical Center Inc 2220 Canterbury Dr Hays KS 67601 480559088 Hospital KS 501(c)(3) 170(b)(1)(A)(iii) 0 0 0 0 0 1 0 0 0 1 0 0 1 0 1 1 0 0 0