2013-11-13T14:40:15-06:00 2012-12-31 481026809 Wendling Noe Nelson & Johnson LLC 534 S Kansas Ave Suite 1500 Topeka KS 666033491 990 2012-01-01 480576039 Clara Barton Hospital Association Inc CLAR 6206532114 250 West 9th Street Hoisington KS 675441799 Jim Blackwell 6206532114 2013-11-12 1 Derek H Hart P01054116 7852334226 2013-11-12 2012 2016-02-25 16:41:14Z Jim Blackwell 250 West 9th Street Hoisington KS 675441799 17071164 0 X www.clarabartonhospital.org X 1946 KS Provision of inaptient and outpatient hospital services, primary care services, and surgical services to residents of our service area. 10 8 197 13 0 0 61849 63906 16004838 16490844 81422 121773 304962 337734 16453071 17014257 0 0 0 0 8587140 9414491 0 0 63581 7622684 7198005 16209824 16612496 243247 401761 12123861 12384240 5893850 5391017 6230011 6993223 X Clara Barton Hospital Association is dedicated to meeting the health care needs and improving the quality of life for the community we serve. We continually pursue clinical excellence in an atmosphere of caring and compassion. We are deeply committed to serving all in need within our resources. 0 0 13997740 16490844 Clara Barton Hospital Association provided a wide range of health care services to residents of its service area including 3,031 patient days of inpatient care, 21,452 outpatient hospital visits and 25,842 visits to our primary care and surgical clinics. 13997740 1 1 0 0 0 0 0 0 0 0 1 0 0 1 0 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 1 0 0 0 1 45 0 1 197 1 0 0 0 0 0 0 0 0 0 0 X 10 8 0 0 0 0 1 1 0 1 1 0 0 1 1 1 1 1 1 1 0 0 X Jim Blackwell 6206532114 250 West 9th Street Hoisington KS 675441799 Curt J Colson 40.00 X X 123099 0 32795 Jon Radke 1.00 X X 0 0 0 Kathy Kaiser 1.00 X 0 0 0 Troy Bailey 1.00 X X 0 0 0 Paul Woydziak 1.00 X X 0 0 0 Jean Cavanaugh 1.00 X 0 0 0 Mike Aylward 1.00 X 0 0 0 Joshua Durham 40.00 X 259710 0 33831 Marla Mooney 1.00 X X 0 0 0 Taylor Klug 1.00 X 0 0 0 James G Blackwell 40.00 X 103578 0 32205 Ann R Taylor 40.00 X 182661 0 16965 Nathaniel Knackstedt 40.00 X 221850 0 35689 Robin Durrett 40.00 X 349766 0 8154 Timothy Webb 40.00 X 199672 0 15432 Phillip Barnes 40.00 X 122136 0 29000 1562472 0 204071 13 0 1 0 Docs Who Care PA 1337 South Fountain Drive Olathe KS 66061 ER Physician Coverage 358133 Leslie M Landau DO PA PO Box 470 Kirksville MO 63501 Surgery 313200 Aramark Uniform Services 2275 Cassens Drive Fenton MO 63026 Laundry 258290 Allstaff Chtd 2000 Washington Street Great Bend KS 67530 Nursing 160791 Mobile Imaging Inc 3520 Lakin Ave Great Bend KS 67530 Sonography 156304 10 49060 11250 3596 63906 Patient service revenue 621990 16363291 16363291 Purchase discounts and rebates 621990 64877 64877 Patient account interest 621990 24141 24141 Lab fair 621990 21449 21449 Miscellaneous 621990 17086 17086 16490844 135850 135850 268150 268150 22398 3188 19210 19210 19210 3266 36376 0 53719 3266 -17343 -14077 -14077 Cafeteria 722210 47363 47363 Meals on wheels 624210 3011 3011 50374 17014257 16490844 0 459507 585218 293541 291677 7511784 6449067 1013646 49071 112957 99413 12766 778 664659 601910 58149 4600 539873 452840 83721 3312 32108 32108 1250 1250 2444099 2223275 220759 65 70125 39130 30995 709754 604729 103084 1941 155246 155246 338000 282910 54161 929 35860 30628 5231 1 199374 199374 835507 676927 155906 2674 136112 136112 Pharmacy supplies 871270 871270 Medical supplies 619164 619164 0 Repairs and maintenance 253387 240878 12304 205 Minor equipment 206725 130506 76216 3 290024 182178 107844 2 16612496 13997740 2551175 63581 167448 987 1608969 1227760 1765385 1503193 123111 1500 523689 511806 208392 210142 12575585 8566220 4511879 4009365 2173542 2947819 5002 5547 1159555 1843010 12123861 12384240 1647331 1636884 3740784 3480697 505735 273436 0 0 5893850 5391017 X 5668498 6187195 299038 536138 262475 269890 6230011 6993223 12123861 12384240 X 401761 80704 280747 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 557102 377746 179356 6526626 4180046 2346580 4455567 3515374 940193 1036290 493054 543236 4009365 Beneficial interest in net assets of CBH Foundation 777098 Deferred financing costs 114769 Accrued Interest receivable 4101 Estimated third-party payor settlements 947042 1843010 X 17094961 80704 80704 17014257 0 17014257 16612496 0 16612496 0 16612496 Description of Uncertain Tax Positions Under FIN 48: Part X, Line 2: The Hospital is a not-for-porfit corporation as described in Section 501(c)(3) of the Internal Revenue Code and is exempt from federal income taxes on related income pursuant to Sectin 501(a) of the code. Management is not aware of any uncertainties in income tax positions. Tax years ending on and before December 31, 2009, are not subject to examination by taxing authorities. 1 1 1 X 1 X 1 1 0 0 282484 282484 0.01700 857473 784571 72902 0.00440 1139957 784571 355386 0.02140 1490 1490 0.00010 7646 7646 0.00050 3971974 3061998 909976 0.05480 3703 3703 0.00020 3984813 3061998 922815 0.05560 5124770 3846569 1278201 0.07700 1 508718 50872 6173374 6112251 61123 X 1 1 1 1 Clara Barton Hospital

250 West 9th Street Hoisington KS 675441799

X X X X Physician clinics & rural health clinics Clara Barton Hospital Association Inc 1 1 1 100.000000000000 1 300.000000000000 1 X X X X X 1 1 X X X X 1 0 X X X X X 1 X 1 0 2 Russell Family Medical Care

410 N Main Street Suite C Russell KS 67665

Rural health clinic Clara Barton Hospital Surgical Clinic

1301 Jackson Street Great Bend KS 67530

Physician clinic Part I, Line 7: Financial assistance at cost was determined by utilizing departmental cost-to-charge ratios for financial assistance provided in areas that are reported as subsidized health services. An overall cost-to-charge ratio derived from Worksheet 2 was used to determine the cost of financial assistance provided for services not reported as subsidized health services.Unreimbursed Medicaid costs were also determined using a blend of cost-to-charge ratios for certain services and an overall cost-to-charge ratio derived from Worksheet 2 for all other services.The cost of providing subsidized health services was determined using a cost-to-charge ratio for each service.Actual costs and revenues were utilized for all other items reported on line 7. Part I, Line 7g: Subsidized health services are comprised of services that the Hospital provides despite a financial loss to the organization. These services include the operation of a 24-hour emergency room and the operation of two rural health clinics. Costs attributable to physician clinics included on line 7(g), column (c) were $2,352,318 and unreimbursed costs attributable to physician clinics included on line 7(g), column (e) were $346,512. Part III, Line 4: The Hospital recognizes patient service revenue associated with services provided to patients who have third-party payor coverage on the basis of contractual rates for the services rendered. For uninsured patients that do not qualify for charity care, the Hospital recognizes revenue on the basis of its standard rates for services provided. On the basis of historical experience, a significant portion of the Hospital's uninsured patients will be unable or unwilling to pay for the services provided. Thus, the Hospital records a significant provision for bad debts related to uninsured patients in the period the services are provided.Bad debt expense at cost was determined by utilizing departmental cost-to-charge ratios for financial assistance provided in areas that are reported as subsidized health services. An overall cost-to-charge ratio derived from Worksheet 2 was applied to the charges deemed uncollectible during the year for all other services.Bad debt expense attributable to patients eligible under the organization's financial assistance policy was determined using an estimated 10% of total bad debts. The Hospital takes steps to assist individuals who are believed to qualify for financial assistance prior to writing accounts off as uncollectible.All non-reimbursed costs for treatment of patients in our community provides a community benefit since patients unwilling or unable to pay have received a valuable service at no cost or at a reduced cost to them. This improves the health of our community as a whole. Part III, Line 8: Medicare allowable costs were determined by using amounts from the Hospital's Medicare cost report as filed with the Medicare Administrative Contractor. The Medicare cost report apportions actual costs to the Medicare program using charges for ancillary services and patient days for nursing services. Part III, Line 9b: The collection policy states that the patient must cooperate with the Hospital to provide the information and documentation necessary to apply for other existing financial resources that may be available to pay for health care services, such as Medicaid. Then the information is gathered and assessed in order to determine eligibility for charity care. Whenever possible, prior to admission, the Hospital will conduct a pre-admission interview with the patient, the guarantor, and/or the patient's legal representative. Those patients who may qualify for financial assistance from a governmental program will be referred to the appropriate program, prior to the consideration for charity care. Clara Barton Hospital Association, Inc. Part V, Section B, Line 18e: Clara Barton Hospital Association, Inc., notified all uninsured patients about the Hospital's charity care program by letter. Clara Barton Hospital Association, Inc. Part V, Section B, Line 20d: Discounts to billed charges were applied based on the income of FAP-eligible patients or guarantors. Clara Barton Hospital Association, Inc. Part V, Section B, Line 21: Discounts to billed charges were applied based on the income of FAP-eligible patients or guarantors. Part VI, Line 3: There is signage posted at admissions desk. Patients are referred to a financial counselor at admission if they do not have insurance. The financial counselor also works with a Medicaid helper to try and get qualified patients register for the Medicaid program. Effort is made during billing of deductible and co-payment to see if patient can qualify for charity care. Part VI, Line 4: The community being served is located in central Kansas and consists of approximately 2,800 residents. The average household income is $32,993. 15.4% of the community residents live below federal poverty level, and 4.7% of the community residents live below 50% of the federal poverty level. Neighboring hospitals include one facilities in Ellinwood and Great Bend. They are approximately 18 and 11 miles away respectively. Part VI, Line 5: The Hospital's Board of Directors is elected from the community at large. This allows independent individuals who reside in the primary service area to serve as a director. The Hospital also extends medical staff privileges to all qualified physicians in the community. Any surplus in funds is retained by the Hospital and aids in improving overall patient care and facility maintenance. X X X 0 0 0 0 0 0 0 0 0 Curt J Colson 120017 0 0 0 3082 0 3704 0 29091 0 155894 0 0 0 Joshua Durham 259710 0 0 0 0 0 6914 0 26917 0 293541 0 0 0 Ann R Taylor 182661 0 0 0 0 0 0 0 16965 0 199626 0 0 0 Nathaniel Knackstedt 221850 0 0 0 0 0 6292 0 29397 0 257539 0 0 0 Robin Durrett 349766 0 0 0 0 0 7500 0 654 0 357920 0 0 0 Timothy Webb 199672 0 0 0 0 0 1887 0 13545 0 215104 0 0 0 Phillip Barnes 122136 0 0 0 0 0 0 0 29000 0 151136 0 0 0 A Hoisington Public Building Commission Hoisington Kansas 486012386 000434661 2006-03-23 5019230 Refund outstanding bonds issued on 12/19/2000 and 2/27/2003 0 0 0 A 1470000 5019230 97212 79389 4842629 2006 1 1 1 1 A 0 0 0 0 0 0 0 A 0 0 0 0 0 0 0 0 0 A 1 Timothy Webb Highly compensated employee Recruitment X 138500 123111 0 1 1 123111 Form 990, Part VI, Section A, line 6 Members of Clara Barton Hospital Foundation, Inc., are automatically members of Clara Barton Hospital Association, Inc. Form 990, Part VI, Section A, line 7a Members of Clara Barton Hospital Association, Inc., elect members of the governing body. Form 990, Part VI, Section B, line 11 Form 990 provided to governing body and reviewed prior to filing. Form 990, Part VI, Section B, line 12c A conflict of interest disclosure form is provided to each Board Member and is reviewed annually. Form 990, Part VI, Section B, line 15a The organization uses the KHA Salary Survey as a guide for determining CEO compensation with Board of Directors approval. The KHA Salary Survey is used by the CEO when determining compensation for other officers and key employees. Form 990, Part VI, Section C, line 19 The organization makes its governing documents, conflict of interest policy, and financial statements available to the public upon written request. Changes in Net Assets or Fund Balances: Form 990, Part XI, line 9: Change in permanently restricted beneficial interest in Foundation 7,415. Change in temporarily restricted beneficial interest in Foundation 273,332. Clara Barton Hospital Foundation Inc PO Box 25 Hoisington KS 67544 481077460 Provide support to the hospital. KS 501(c)(3) 170(b)(1) 0 0 1 1 0 0 0 0 0 0 0 0 1 0 1 1 0 0 0 0