2013-11-14T15:03:50-06:00 2012-12-31 476097913 SEIM JOHNSON LLP 18081 BURT STREET SUITE 200 OMAHA NE 680224722 990 2012-01-01 470408242 CHEYENNE COUNTY HOSPITAL ASSOCIATION INC CHEY 3082545825 645 OSAGE STREET SIDNEY NE 69162 JASON PETIK 3082545825 2013-11-13 1 BARBARA J FAJEN P00400874 4023302660 2012 2016-02-25 16:41:14Z SIDNEY REGIONAL MEDICAL CENTER KELLY UTLEY 645 OSAGE STREET SIDNEY NE 69162 38134703 0 X WWW.SIDNEYRMC.COM X 1951 NE FOCUS ON THE NEEDS OF THOSE SERVED THROUGH THE DELIVERY OF HIGH QUALITY AND COMPASSIONATE CARE. 13 11 413 109 0 0 428769 93508 29553726 37787380 63175 76507 89767 157073 30135437 38114468 0 0 0 0 15095069 19286514 0 0 0 10478230 15272166 25573299 34558680 4562138 3555788 29888648 34308543 5007660 5519538 24880988 28789005 X OUR MISSION IS TO FOCUS ON THE NEEDS OF THOSE WE SERVE THROUGH THE DELIVERY OF HIGH QUALITY AND COMPASSIONATE CARE. 0 0 2790369 5136725 THE HOSPITAL NURSING DEPARTMENT PROVIDED 2,351 PATIENTS DAYS OF CARE IN 2012, DELIVERING 60 NEWBORNS FOR THE ELEVEN COUNTY AREA THAT SIDNEY REGIONAL MEDICAL CENTER (SRMC) SERVES. SRMC HAD 3,364 PATIENTS SEEK CARE IN THE EMERGENCY DEPARTMENT DURING 2012. 2101457 3757293 THE EXTENDED CARE UNIT PROVIDED CARE FOR AN AVERAGE OF 53 PATIENTS DAILY DURING 2012. SRMC PROVIDED 19,300 PATIENT DAYS OF CARE FOR RESIDENTS IN THE CHEYENNE, DEUEL, KIMBALL AND SURROUNDING AREAS. 1770596 4224403 SRMC PHARMACY DEPARTMENT HAS BEEN ACTIVELY INVOLVED WITH THE QUALITY OF CARE PROVIDED TO ALL PATIENTS BOTH IN THE ACUTE AND OUT PATIENT SETTINGS. THE PHARMACY DEPARTMENT HAS HELPED PROVIDE CARE FOR THOSE INDIVIDUALS WITH THE TREATMENT FOR RADIATION OR CHEMOTHERAPY. 26674794 24677177 OTHER MISCELLANOUES PATIENT SERVICES. 26674794 24677177 33337216 1 1 0 1 0 0 0 0 0 0 1 0 0 0 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 1 43 0 1 413 1 0 0 0 0 0 0 0 0 0 0 X 13 11 0 1 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 X KELLY UTLEY 3082545825 645 OSAGE STREET SIDNEY NE 69162 X BILL PILE 1.00 0.00 X X 0 0 0 TIM MILLER 1.00 0.00 X X 0 0 0 TOM MILLMAN 1.00 0.00 X X 0 0 0 JEFF ELLWANGER 1.00 0.00 X X 0 0 0 MICHAEL MATTHEWS MD 40.00 0.00 X 381554 0 12250 STAN BELIEU 1.00 0.00 X 0 0 0 KATHY NARJES 1.00 0.00 X 0 0 0 JIM JONES 1.00 0.00 X 0 0 0 ROB ROBINSON 1.00 0.00 X 0 0 0 LAURIE WIDDOWSON 1.00 0.00 X 0 0 0 CALVIN CUTRIGHT MD 40.00 0.00 X 217552 0 22207 DWIGHT SMITH 1.00 0.00 X 0 0 0 JULIE WAMSLEY 1.00 0.00 X 0 0 0 JASON PETIK 40.00 0.00 X 167062 0 19399 KELLY UTLEY 39.00 1.00 X 121816 0 26510 MANDY SHAW 40.00 0.00 X 298869 0 12250 JAMES THAYER 40.00 0.00 X 358060 0 34457 DANA HLAVINKA 40.00 0.00 X 192361 0 30771 CLINTON DORWART 40.00 0.00 X 228224 0 32579 ROBERT GRAVES 40.00 0.00 X 167366 0 23069 2132864 0 213492 19 0 1 1 RURAL PARTNERS IN MEDICINE LLC PO BOX 772519 STEAMBOAT SPRINGS CO 80477 PHYSICIAN SERVICES 1162192 POUDRE VALLEY HEALTH CARE INC PO BOX 2103 FORT COLLINS CO 80522 MANAGEMENT SERVICES 238831 HEALTH CAROUSEL LLC PO BOX 44743 MIDDLETOWN OH 45044 HOME HEALTH CONTRACT SERVICES 199426 SEIM JOHNSON LLP 18081 BURT ST STE 200 OMAHA NE 68022 AUDIT & TAX SERVICES 193542 PANHANDLE TRANSCRIPTION PO BOX 407 CHADRON NE 69337 TRANSCRIPTION SERVICES 148874 6 26196 67312 93508 PATIENT SERVICE REVENUE NET OF CO 624100 27815062 27815062 MEDICARE/MEDICAID 624100 9143155 9143155 MISC. MEDICAL SERVICES 621400 389430 389430 HOME CARE 621610 268955 268955 MEDICAL SERVICES - COMMUNITY 621400 104922 104922 65856 65856 37787380 79977 79977 8358 0 8358 8358 8358 16765 20235 -3470 -3470 -3470 CAFETERIA 624100 104979 104979 PATRONAGE DIVIDEND 624100 35518 35518 MEDICAL RECORDS 624100 8218 8218 148715 38114468 37795598 0 225362 X 148326 148326 633563 633563 14736591 14507506 229085 334898 333113 1785 2351542 2317468 34074 1081594 1056677 24917 186461 186461 69358 69358 110185 110185 3923422 3793015 130407 93987 93987 2481665 2478268 3397 971912 971912 174645 165906 8739 81081 81081 1193047 1193047 446141 446141 BAD DEBTS 2541612 2541612 MEDICAL SUPPLIES 2447675 2447675 MISCELLANEOUS EXPENSE 377578 232769 144809 TAXES & LICENSES 128227 100740 27487 45170 23817 21353 34558680 33337216 1221464 0 12976872 4547176 1178213 9240879 4554336 6549084 636117 895473 225212 205422 25127247 13495810 10015823 11631437 248228 81017 53847 1158055 29888648 34308543 2479010 3105212 2229673 1926291 266585 233054 32392 254981 5007660 5519538 X 24878090 28789005 2898 0 24880988 28789005 29888648 34308543 X 3555788 352229 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 4873 4873 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: A PORTION OF THE DUES PAID TO AHA AND NHA ARE USED BY THOSE ORGANIZATIONS FOR LOBBYING ACTIVITIES. 92500 526741 619241 15125016 7586141 7538875 8614039 5579927 3034112 768951 329742 439209 11631437 DUE TO CHEYENNE COUNTY HOSP & HEALTH CARE FOUNDATION 15 DEFERRED COMPENSATION PLAN LIABILITY 254966 254981 X DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X, LINE 2: SIDNEY REGIONAL MEDICAL CENTER AND CHEYENNE COUNTY HOSPITAL AND HEALTH CENTER FOUNDATION ARE EXEMPT FROM INCOME TAXES UNDER SECTION 501(A) OF THE CODE AND A SIMILAR PROVISION OF STATE LAW. HOWEVER, THEY ARE SUBJECT TO FEDERAL INCOME TAX ON ANY UNRELATED BUSINESS TAXABLE INCOME. THE SYSTEM ACCOUNTS FOR UNCERTAINTIES IN ACCOUNTING FOR INCOME TAX ASSETS AND LIABILITIES USING GUIDANCE INCLUDED IN FASB ASC 740, INCOME TAXES. THE SYSTEM RECOGNIZES THE EFFECT OF INCOME TAX POSITIONS ONLY IF THOSE POSITIONS ARE MORE LIKELY THAN NOT OF BEING SUSTAINED. AT DECEMBER 31, 2012, THE SYSTEM HAD NO UNCERTAIN TAX POSITIONS ACCRUED. WITH FEW EXCEPTIONS, THE SYSTEM IS NO LONGER SUBJECT TO INCOME TAX EXAMINATIONS BY U.S. FEDERAL, STATE, OR LOCAL AUTHORITIES FOR YEARS BEFORE 2009. 1 1 1 X 1 X 1 1 1 0 1 1 251348 0 251348 0.00790 2916635 2917219 -584 0.00000 3167983 2917219 250764 0.00790 179060 50902 128158 0.00400 45426 0 45426 0.00140 9430 0 9430 0.00030 233916 50902 183014 0.00570 3401899 2968121 433778 0.01360 1 2541612 1078036 9910491 10047291 -136800 X 1 1 1 1 CHEYENNE COUNTY HOSPITAL ASSOCIATION DBA

645 OSAGE STREET SIDNEY NE 69162

X X X X CHEYENNE COUNTY HOSPITAL ASSOCIATION INC 1 1 1 100.000000000000 1 300.000000000000 1 X X X 1 1 X X 1 0 1 X 0 0 2 SIDNEY REG'L MEDICAL CTR EXTENDED CARE

645 OSAGE SIDNEY NE 69162

LONG TERM CARE FACILITY SLOAN ESTATES ASSISTED LIVING

2550 CRAIG AVENUE SIDNEY NE 69162

ASSISTED LIVING PART I, LINE 3C: NOT APPLICABLE. PART I, LINE 6A: THE COMMUNITY BENEFIT REPORT IS PREPARED BY THE STAFF OF SIDNEY REGIONAL MEDICAL CENTER. PART I, LINE 7: THE COST TO CHARGE RATIO IS DETERMINED AS FOLLOWS: (TOTAL EXPENSES - BAD DEBT)/GROSS PATIENT SERVICE REVENUE = PERCENTAGE OF COST TO CHARGE. PART I, LINE 7G: THERE ARE NO SUBSIDIZED HEALTH SERVICES. PART I, L7 COL(F): BAD DEBT EXPENSE OF $2,541,612 HAS BEEN EXCLUDED FROM THE DENOMINATOR IN THE CALCULATION OF THE PERCENTAGES IN LINE 7, COLUMN F. PART III, LINE 4: THE HOSPITAL'S FINANCIAL STATEMENTS DO NOT CONTAIN A SPECIFIC FOOTNOTE DESCRIBING BAD DEBT. HOWEVER, THE FOLLOWING IS THE TEXT OF THE FOOTNOTE TITLED "PATIENT RECEIVABLES, NET", "NET PATIENT SERVICE REVENUE", AND "CHARITY CARE":PATIENT RECEIVABLES, NET:THE SYSTEM REPORTS PATIENT ACCOUNTS RECEIVABLE FOR SERVICES RENDERED AT NET REALIZABLE AMOUNTS FROM THIRD-PARTY PAYORS, PATIENTS, AND OTHERS. ACCOUNTS RECEIVABLE ARE REDUCED BY AN ALLOWANCE FOR DOUBTFUL ACCOUNTS. IN EVALUATING THE COLLECTIBILITY OF ACCOUNTS RECEIVABLE, THE SYSTEM ANALYZES ITS PAST HISTORY AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYER SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND PROVISION FOR BAD DEBTS. MANAGEMENT REGULARLY REVIEWS DATA ABOUT THESE MAJOR PAYER SOURCES OF REVENUE IN EVALUATING THE SUFFICIENCY OF THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. THE SYSTEM 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 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.NET PATIENT SERVICE REVENUE:THE SYSTEM HAS AGREEMENTS WITH THIRD-PARTY PAYERS THAT PROVIDE FOR PAYMENTS TO THE SYSTEM AT AMOUNTS DIFFERENT FROM ITS ESTABLISHED RATES. PAYMENT ARRANGEMENTS INCLUDE PROSPECTIVELY DETERMINED RATES PER DISCHARGE, REIMBURSED COSTS, DISCOUNTED CHARGES, AND PER DIEM PAYMENTS. NET PATIENT SERVICE REVENUE IS REPORTED AT THE ESTIMATED NET REALIZABLE AMOUNTS FROM PATIENTS, THIRD-PARTY PAYERS, AND OTHERS FOR SERVICES RENDERED, INCLUDING ESTIMATED RETROACTIVE ADJUSTMENTS UNDER REIMBURSEMENT AGREEMENTS WITH THIRD-PARTY PAYERS. RETROACTIVE ADJUSTMENTS ARE ACCRUED ON AN ESTIMATED BASIS IN THE PERIOD THE RELATED SERVICES ARE RENDERED AND ADJUSTED IN FUTURE PERIODS AS FINAL SETTLEMENTS ARE DETERMINED.CHARITY CARE:THE HOSPITAL 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 SYSTEM DOES NOT PURSUE COLLECTION OF AMOUNTS DETERMINED TO QUALIFY AS CHARITY CARE, THEY ARE NOT REPORTED AS REVENUE IN THE COMBINED STATEMENTS OF OPERATIONS. PART III, LINE 8: THE ORGANIZATION USED THE MEDICARE COST REPORT FOR FISCAL YEAR 2012 TO REPORT THE AMOUNTS OF TOTAL REVENUE RECEIVED FROM MEDICARE AND RELATED MEDICARE ALLOWABLE COSTS. MEDICARE PAYS THE HOSPITAL'S RURAL HEALTH CLINICS (RHC) AT COST SUBJECT TO CERTAIN LIMITS. MEDICARE SHORTFALLS IN PAYMENT SHOULD BE CONSIDERED A COMMUNITY BENEFIT AS IT IS PART OF THE HOSPITAL'S MISSION TO PROVIDE THESE SERVICES EVEN IF MEDICARE REIMBURSEMENT IS BELOW COST. PART III, LINE 9B: THE CHARITY CARE POLICY ALLOWS FOR PROACTIVE WRITE OFF TO ALLOWANCE FOR CHARITY CARE OF ANY BALANCE OWED BY A PATIENT KNOWN TO QUALIFY FOR CHARITY CARE. TO ENHANCE OUR STANDARD CHARITY PROGRAM, SIDNEY REGIONAL MEDICAL CENTER (SRMC) CURRENTLY UTILIZES A PRESUMPTIVE CHARITY SCREENING PRIOR TO REFERRING ACCOUNTS TO BAD DEBT WITH AN OBJECTIVE TO WRITE OFF ACCOUNTS OF THE MOST ELIGIBLE AND IN-NEED FAMILIES OR INDIVIDUALS. CHEYENNE COUNTY HOSPITAL ASSOCIATION INC PART V, SECTION B, LINE 14G: OUR FINANCIAL ASSISTANCE POLICY IS WELL VERSED AMONGST THE PATIENT FINANCIAL SERVICES REPRESENTATIVES. THE FINANCIAL SERVICE REPRESENTATIVES ACTIVELY SCAN FOR ACCOUNTS WHICH WOULD QUALIFY FOR CHARITY CARE AND OFFER IT WITH OTHER OPTIONS FOR PAYMENT DURING THEIR CONVERSATIONS WITH PATIENTS. AS WELL, THE FINANCIAL ASSISTANCE PROGRAM IS COMMUNICATED WITH PATIENTS WHO INDICATE THAT THEY ARE HAVING TROUBLE. CHEYENNE COUNTY HOSPITAL ASSOCIATION INC PART V, SECTION B, LINE 20D: THIS IS ADJUSTED AS A PERCENT OF CHARGES BASED ON THE FEDERAL POVERTY GUIDELINES. PART VI, LINE 2: NEEDS ASSESSMENTS ARE DETERMINED THROUGH SCIENTIFIC, AS WELL AS, UNSCIENTIFIC METHODS. EVERY 2 TO 3 YEARS A MARKET ASSESSMENT IS COMPLETED USING CLAIMS DATA WHICH REVEALS THE NEEDS OF COMMUNITY MEMBERS BEING MET ELSEWHERE DUE TO EITHER UNAVAILABILITY OF SERVICE OR PATIENT CHOICE. THIS ASSESSMENT INCLUDES THE DEMOGRAPHICS OF THE AREA WHICH SHOW AN AGING AND MODERATE INCOME POPULATION. THESE FACTS ARE THEN USED TO DETERMINE THE NEEDS OF THE COMMUNITY AS WELL AS THE FUTURE NEEDS BASED ON HISTORICAL DATA. ADDITIONALLY, COMMUNITY NEEDS ARE DETERMINED USING PUBLIC OPINION, PATIENT SATISFACTION RECOMMENDATIONS, BOARD AND LEADERSHIP EXPERIENCE, COMMUNICATIONS WITH COMMUNITY MEMBERS, AND PHYSICIAN INPUT. FUTURE MEASUREMENTS OF HEALTH DATA MINED FROM CLAIMS SUBMISSIONS WILL BE USED TO FURTHER ANALYZE THE NEEDS OF THE COMMUNITY. PART VI, LINE 3: AT THE POINT OF ADMISSION, A PATIENT'S INSURED STATUS IS DETERMINED. PATIENTS WHO ARE UNINSURED OR UNDERINSURED RECEIVE COUNSELING THROUGH THE HOSPITAL'S PATIENT ADVOCATE &/OR A MEMBER OF THE FINANCIAL SERVICES STAFF SERVING AS A FINANCIAL COUNSELOR. INFORMATION IS CONVEYED TO THE PATIENT OR THE GUARANTOR REGARDING MEDICAID AND MEDICARE, AS WELL AS CHARITY CARE PROVIDED BY THE HOSPITAL. ADDITIONALLY, SOCIAL SERVICES PERSONNEL HOLD WORKSHOPS AND MEET WITH PATIENTS INDIVIDUALLY REGARDING THEIR COVERAGE IN AN ATTEMPT TO DETERMINE ELIGIBILITY, THE NEEDS OF THE INDIVIDUALS WITH RESPECT TO ABILITIES, AND THE AMOUNT OF ASSISTANCE NEEDED. PART VI, LINE 4: THE HOSPITAL'S PRIMARY SERVICE AREA (PSA) IDENTIFIES THE GEOGRAPHIC AREA THAT ACCOUNTS FOR 80-90% OF ALL PATIENT VISITS. RESIDENTS OF SRMC'S PSA IN THE PANHANDLE OF WESTERN NEBRASKA COMPRISE 90% OF THE HOSPITAL'S INPATIENT DISCHARGES AND 83% OF ITS ER VISITS. THE PSA POPULATION IS ESTIMATED AT APPROXIMATELY 12,500 WITH A NONEXISTENT GROWTH PATTERN EXPECTED BETWEEN 2009 AND 2014. MEDIAN AGE IN THE PSA IS 40.7, WHICH IS SLIGHTLY YOUNGER THAN THE STATE OF NEBRASKA AT 43.7. SIGNIFICANT GROWTH IS PROJECTED FOR THE AGE GROUP 65+ BETWEEN 2009 & 2014. MEDIAN HOUSEHOLD INCOME IN THE PSA IS COMPARABLE TO THE STATE OF NEBRASKA OVERALL, HOWEVER THERE IS WIDE VARIATION IN MEDIAN HOUSEHOLD INCOME WITHIN THE PSA. PART VI, LINE 5: SPECIFIC TO THE COMMUNITY BUILDING ACTIVITIES THE HOSPITAL CONTRIBUTES THROUGH LEADERSHIP EDUCATION, RESIDENCIES AND SCHOLARSHIPS, IMPROVEMENTS TO FACILITIES, AND COLLABORATION WITH COMMUNITY CLUBS, EMPLOYERS, LEADERS AND THE COMMUNITY CENTER. THE CFO SERVED DURING 2012 AS THE PRESIDENT OF THE FINANCE COMMITTEE FOR PANHANDLE PUBLIC HEALTH AND A BOARD MEMBER OF THE CHAMBER OF COMMERCE WHILE OTHER LEADERS IN THE HOSPITAL PARTICIPATED IN THE CHEYENNE COUNTY LEADERSHIP GROUPS. ROTARY CLUB AND CITY COUNCIL ACTIVITIES AS WELL AS OTHER VOLUNTEER ORGANIZATIONS SAW COLLABORATION FROM THE HOSPITAL AND ITS REPRESENTATIVES. SIDNEY REGIONAL MEDICAL CENTER (SRMC) HOLDS A HOSPITAL SPONSORED COMMUNITY HEALTH FAIR ANNUALLY. SRMC ALSO PROVIDES SMALLER HEALTH CLINICS AT BUSINESSES THROUGHOUT THE COMMUNITY. CHILD OUTREACH FOR NEW MOTHERS, IMMUNIZATION CLINICS, DIABETES EDUCATION, FLU SHOTS AND COMMUNITY WELLNESS ACTIVITIES ARE ACCOMPLISHED THROUGH COLLABORATION WITH SCHOOLS, THE COMMUNITY CENTER, DOCTORS' OFFICES, AND COMMUNITY BUSINESSES AS WELL AS OTHER NOT FOR PROFIT ORGANIZATIONS. SMALL HOSPITALS HAVE BEEN INCREASINGLY CHALLENGED TO MAINTAIN THEIR HISTORICAL SCOPE OF SERVICES, AND MANY HAVE RELUCTANTLY DISCONTINUED PROVIDING OBSTETRICS, CRITICAL CARE, HOME HEALTH AND OTHER SERVICES IMPORTANT TO THE COMMUNITY BUT NOT SUSTAINABLE FROM A FINANCIAL PERSPECTIVE. SRMC HAS BEEN ABLE TO CONTINUE PROVIDING THESE SERVICES AND REMAINS COMMITTED TO DOING SO IN THE FORESEEABLE FUTURE.THE HOSPITAL ORGANIZATION IS PART OF A 'HEALTH SERVICES' COLLABORATION FOCUSING ON THE INITIATIVES ABOVE IN DAILY ROUTINE. THE ORGANIZATION INCLUDES HOME HEALTH AND HOSPICE SERVICES IN COLLABORATION WITH MANY COMMUNITY VOLUNTEERS, WITHOUT WHOM THE SERVICE WOULD NOT BE SUCCESSFUL. EXTENDED CARE SERVICES AS WELL AS ASSISTED LIVING SERVICES ARE OFFERED AS DEPARTMENTAL ENTITIES OF THE HOSPITAL ORGANIZATION. THESE SERVICES ALONG WITH THE HOME HEALTH AND HOSPICE ARE NOT COST BASED REIMBURSED AND, IN FACT, ERODE THE COST BASED REIMBURSEMENT WHICH COULD BE ENJOYED AS A CRITICAL ACCESS HOSPITAL. HOWEVER, THE BOARD OF THE DIRECTORS IS COMMITTED TO PUBLIC HEALTH IN ITS ENTIRETY AND CONTINUES TO SUPPORT ALL HEALTH SERVICES IN THE COMMUNITY. PART VI, LINE 6: SIDNEY REGIONAL MEDICAL CENTER IS NOT PART OF AN AFFILIATED HEALTH CARE ORGANIZATION. REPORTS FILED WITH STATES PART VI, LINE 7 NE X X X X 0 0 0 1 0 0 0 0 0 MICHAEL MATTHEWS MD 380974 0 0 0 580 0 12250 0 0 0 393804 0 0 0 CALVIN CUTRIGHT MD 214971 0 0 0 2581 0 0 0 22207 0 239759 0 0 0 JASON PETIK 167062 0 0 0 0 0 1915 0 17484 0 186461 0 0 0 MANDY SHAW 298755 0 0 0 114 0 12250 0 0 0 311119 0 0 0 JAMES THAYER 356976 0 0 0 1084 0 12250 0 22207 0 392517 0 0 0 DANA HLAVINKA 192222 0 0 0 139 0 10120 0 20651 0 223132 0 0 0 CLINTON DORWART 226806 0 0 0 1418 0 9510 0 23069 0 260803 0 0 0 ROBERT GRAVES 166789 0 0 0 577 0 0 0 23069 0 190435 0 0 0 PART I, LINE 5 DR. JAMES THAYER RECEIVES DRAW ON HIS SALARY BASED ON HIS GROSS CHARGES. THE DRAW IS CALCULATED BY MULTIPLYING THE GROSS CHARGES BY 33% AND SUBTRACTING OFF HIS BASE BIWEEKLY SALARY OF $10,000. ADDITIONALLY, HE RECEIVES A BONUS BASED UPON QUALITY INDICATORS, MEDICAL RECORDS COMPLETION, ETC. SUPPLEMENTAL INFORMATION PART III JASON PETIK, CEO, RECEIVES COMPENSATION FROM POUDRE VALLEY HEALTH CARE, INC., AN UNRELATED ENTITY. POUDRE VALLEY HEALTH CARE, INC. PROVIDES MANAGEMENT SERVICES TO ITS CLIENTS, INCLUDING THE SIDNEY REGIONAL MEDICAL CENTER. THE SIDNEY REGIONAL MEDICAL CENTER'S BOARD OF DIRECTORS SETS THE SALARY AND BENEFITS FOR MR. PETIK. MR. PETIK RECEIVED $167,062 SALARY, $1,915 RETIREMENT BENEFITS, AND $17,484 NONTAXABLE BENEFITS. FORM 990, PART VI, SECTION A, LINE 3 POUDRE VALLEY HEALTH CARE, INC. CURRENTLY EMPLOYS THE CHIEF EXECUTIVE OFFICER FOR SIDNEY REGIONAL MEDICAL CENTER. SRMC PROVIDES POUDRE VALLEY HEALTH CARE WITH DATA ON SERVICES PROVIDED TO THE COMMUNITY MONTHLY FOR COMPARISON DATA PURPOSES. FORM 990, PART VI, SECTION B, LINE 11 THE ORGANIZATION'S ACCOUNTING DEPARTMENT PREPARES AN ORGANIZER SUPPLIED BY THE ACCOUNTING FIRM SEIM JOHNSON, LLP AND SUBMITS THE ORGANIZER TO THE ACCOUNTING FIRM FOR THE PREPARATION OF THE FORM 990. COMMUNICATIONS BETWEEN THE ACCOUNTING FIRM AND THE ACCOUNTING DEPARTMENT FINALIZE THE PREPARATION OF THE FORM 990. THE CEO AND CFO THEN REVIEW THE FORM 990 AND E-MAIL IT TO ALL MEMBERS OF THE BOARD OF DIRECTORS FOR THEIR REVIEW. ONCE THE 990 RETURN HAS BEEN APPROVED BY ALL PARTIES IT IS SUBMITTED TO THE IRS ON OR BEFORE THE REGULAR OR EXTENDED DUE DATE. FORM 990, PART VI, SECTION B, LINE 12C EACH YEAR, ALL BOARD MEMBERS ARE REQUIRED TO DISCLOSE ANY CONFLICTS OF INTEREST. ANY DUALITY OF INTEREST OR POTENTIAL CONFLICT OF INTEREST ON THE PART OF ANY OFFICER, DIRECTOR, COMMITTEE MEMBER, OR ANY KEY EMPLOYEE SHOULD BE DISCLOSED TO THE BOARD OF DIRECTORS AND MADE A MATTER OF RECORD WHENEVER IT ARISES, OR WHENEVER IT INVOLVES A MATTER OF BOARD ACTION. ANY OFFICER, DIRECTOR, COMMITTEE MEMBER, OR KEY EMPLOYEE HAVING A DUALITY OF INTEREST OR A POSSIBLE CONFLICT OF INTEREST IN ANY MATTER SHOULD NOT VOTE OR USE HIS OR HER PERSONAL INFLUENCE ON THE MATTER. FORM 990, PART VI, SECTION B, LINE 15 POUDRE VALLEY HEALTH CARE, INC. PROVIDES ADMINISTRATIVE SERVICES TO SIDNEY REGIONAL MEDICAL CENTER (SRMC). THIS INCLUDES THE HOSPITAL'S CHIEF EXECUTIVE OFFICER. SRMC USES A METHOD ANNUALLY TO DETERMINE EXECUTIVE SALARY RANGES WHEREBY SRMC PULLS RANGES FROM NO LESS THAN TWO SURVEY SOURCES (THREE WHEN POSSIBLE) TO DETERMINE THE AVERAGE SALARY RANGES FOR EACH EXECUTIVE POSITION ACCORDING TO THEIR GEOGRAPHICAL REGION. THESE ARE THEN REVIEWED AND THEN PRESENTED TO THE HUMAN RESOURCE COMMITTEE OF THE BOARD OF DIRECTORS FOR REVIEW AND APPROVAL/RECOMMENDATIONS. FORM 990, PART VI, SECTION C, LINE 19 THE GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICIES AND FINANCIAL STATEMENTS ARE MADE AVAILABLE UPON REQUEST. ALSO, THE FINANCIAL STATEMENTS ARE SENT OUT ONCE A YEAR TO COMMUNITY LEADERS. OFFICERS PAID BY UNRELATED ORGANIZATION FORM 990, PART VII, SECTION A, LINE 1A: JASON PETIK RECEIVES COMPENSATION FROM AN UNRELATED ORGANIZATION, POUDRE VALLEY HEALTH CARE INC., WHICH PROVIDES MANAGEMENT SERVICES TO SIDNEY REGIONAL MEDICAL CENTER. FORM 990, PART VII, SECTION A MICHAEL MATTHEWS, MD AND CALVIN CUTRIGHT, MD ARE PHYSICIANS OF SIDNEY REGIONAL MEDICAL CENTER AND ARE NOT BEING PAID BY THE HOSPITAL FOR THEIR SERVICE ON THE BOARD OF DIRECTORS. OTHER FEES FORM 990, PART IX, LINE 11G PROFESSIONAL FEES - OTHER: PROGRAM SERVICE EXPENSES 2,676,255. MANAGEMENT AND GENERAL EXPENSES 130,407. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,806,662. CONTRACT SERVICES - SURGERY PROFESSIONALS: PROGRAM SERVICE EXPENSES 1,116,760. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,116,760. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 9: HIGH PLAINS MEDICAL FOUNDATION D/B/A SIDNEY MEDICAL ASSOCIATES' NET ASSETS 352,229. COMMITTEE WITH OVERSIGHT OF THE AUDIT FORM 990, PART XI, LINE 2C: THERE HAVE BEEN NO CHANGES FROM THE PRIOR YEAR. THE BOARD OF DIRECTORS ASSUMES THE RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT OF ITS FINANCIAL STATEMENTS AND SELECTION OF AN INDEPENDENT ACCOUNTANT. OTHER CHANGES IN NET ASSETS: FORM 990, PART XI, LINE 9: AS OF DECEMBER 31, 2011 THE COMBINED FINANCIAL STATEMENTS INCLUDE THE ACCOUNTS OF CHEYENNE COUNTY HOSPITAL ASSOCIATION, INC. D/B/A SIDNEY REGIONAL MEDICAL CENTER, CHEYENNE COUNTY HOSPITAL AND HEALTH CENTER FOUNDATION, AND HIGH PLAINS MEDICAL FOUNDATION D/B/A SIDNEY MEDICAL ASSOCIATES. DURING 2011, THE HIGH PLAINS MEDICAL FOUNDATION D/B/A SIDNEY MEDICAL ASSOCIATES' (SMA) BOARD OF DIRECTORS APPROVED THE DISSOLUTION OF SMA EFFECTIVE JANUARY 1, 2012. UPON DISSOLUTION, SMA DISTRIBUTED ITS ASSETS AFTER PAYING ALL EXISTING LIABILITIES, TO CHEYENNE COUNTY HOSPITAL ASSOCIATION, INC. D/B/A SIDNEY REGIONAL MEDICAL CENTER. SIDNEY REGIONAL MEDICAL CENTER ASSUMED OPERATIONS AND RECEIVED APPROVAL FROM THE CENTERS FOR MEDICARE AND MEDICAID SERVICES FOR THE CLINIC TO BE DESIGNATED AS A PROVIDER-BASED RURAL HEALTH CLINIC (RHC) EFFECTIVE JANUARY 1, 2012. CHEYENNE COUNTY HOSPITAL AND HEALTH CENTER FOUNDATION 645 OSAGE SIDNEY NE 69162 470686476 SUPPORT SIDNEY REGIONAL MEDICAL CENTER NE 501(C)(3) LINE 11C, III-FI N/A 0 WESTERN NEBRASKA HEALTH SYSTEMS 645 OSAGE SIDNEY NE 69162 911774837 SUPPORT SIDNEY REGIONAL MEDICAL CENTER NE 501(C)(3) LINE 9 N/A 0 0 0 1 0 0 0 0 0 0 0 0 0 0 1 1 1 1 0 0