2013-12-17T16:31:09-07:00 2013-06-30 202707086 TCA Partners LLP 1111 E Herndon Avenue Suite 211 Fresno CA 93720 990 2012-07-01 850442957 Clayton Health Systems CLAY 5753742585 300 Wilson Street Clayton NM 88415 G Scott Manis 5753742585 2013-12-06 1 Jeremy Ware P00642659 5594317708 2013-12-02 2012 2016-02-25 16:41:14Z Union County General Hospital Union County General Hospital 300 Wilson Street Clayton NM 88415 11778503 0 X www.unioncountygeneral.com X 1997 NM 25-bed acute care critical access hospital service those in need in rural New Mexico. 7 7 127 0 211224 694824 12444851 10966900 0 0 45297 116779 12701372 11778503 0 0 0 0 5240056 5409348 0 0 0 5817574 6600620 11057630 12009968 1643742 -231465 16955856 16929576 9516124 9721309 7439732 7208267 The organization is a 25-bed acute care critical access hospital serving those in need in rural New Mexico. 0 0 9607975 0 12234668 The organization is a 25 bed acute care critical access hospital serving those in need in rural New Mexico. Union County General Hospital provides services to individuals from Northern New Mexico, Southeastern Colorado, and the Western Panhandle of Oklahoma and Texas. These services include inpatient, outpatient, emergency, Home Health, and DME areas of patient care. There were a total of 20,675 visits, as well as 8,615 visits at the Clayton Family Practice Clinic and 1,407 Home Health visits. Union County General Hospital is one of the sponsors of an annual county wide health fair where the hospital Lab staff obtains blood samples for testing. 336 patients were drawn at the health fair. The Physical Therapy and Occupational Therapy departments did taping and gave samples, gaining a few patients. The Radiology Department handed out literature on the various services they provide. They also arranged to have representatives from NuMed, our nuclear medicine provider, and the Harrington Cancer Center for mammograms. The Nursing Department did glucose finger sticks, blood pressure checks, Don't Text and Drive campaign, and promoted organ donation. Clinic staff and physicians handed out information on services they provide and the doctors answered general questions from the public. The Home Health department had a booth and had literature on their services. Union County General Hospital sponsors the annual Arts Festival, a local Little League team, and the 4th of July Rodeo. The Union County 2013 Relay for Life was organized and sponsored by the hospital. At the Relay for Life a Bike Rodeo was held for children, promoting bike safety and giving away free bike helmets. Union County General Hospital participates in the local parades on July 4, Clayton High School's Homecoming, and the Light Parade in early December. 0 0 0 9607975 1 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 1 0 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 0 0 0 0 1 25 0 1 127 1 0 0 0 0 0 0 X 7 7 1 1 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 CA X Union County General Hospital 5753742585 301 Harding Street Clayton NM 88415 Claude C Austin 2 0 X 0 0 0 Ken Cantrell 2 0 X 0 0 0 Damon Brown 2 0 X 0 0 0 Effie Walker 2 0 X 0 0 0 Rosie DeHerrera 2 0 X 0 0 0 Della Wetzel 2 0 X 0 0 0 Dr Daniel Radunsky 40 0 X 685031 0 15128 Jesse Jay Fluhman 40 0 X 125759 0 20165 Calvin Schuler 40 0 X 197242 0 1083 Stacye Bradley 40 0 X 101387 0 19162 1109419 0 55538 4 0 1 0 NearTerm 15915 Katy Freeway Houston TX 77094 Contract Labor 118437 HealthTech Management Brentwood Brentwood TN 37027 Management and Billing Services 177572 Dr Patrick DeBaca Clayton Clayton NM 88415 Surgery Clinic 242913 Medical Services Network Roswell Roswell NM 88201 Anethesia Services 247467 Ned Shulman 92 Fairfield Street Albans VT 05478 Medical Services 157588 5 0 0 0 0 669204 25620 0 694824 Net Patient Service Revenue 621400 10966900 10966900 0 0 0 0 0 0 10966900 0 0 0 0 0 116779 116779 0 0 116779 11778503 11083679 0 0 4430386 3544309 886077 978962 783170 195792 1472939 1178351 294588 1288092 1030474 257618 210552 168442 42110 301008 240806 60202 704171 563337 140834 410214 328171 82043 Purchased services 1160472 928378 232094 0 Equipment rental and maintenance 380003 304002 76001 0 673169 538535 134634 12009968 9607975 2401993 0 3217143 2615721 892118 1455732 1554893 1656741 339925 254930 54696 55218 13018455 2254695 10760257 10763760 136824 127474 16955856 16929576 569852 1197111 8021416 7686979 924856 837219 9516124 9721309 X 7439732 7208267 0 0 0 0 7439732 7208267 16955856 16929576 -231465 X 0 1 X 1 0 X 0 0 0 0 11384308 1578286 9806022 0 0 0 0 0 1634147 676409 957738 0 0 0 0 10763760 0 Third Party Settlements 837219 837219 12234668 0 456165 0 0 456165 11778503 0 0 0 11778503 12466133 456165 0 0 0 456165 12009968 0 0 0 12009968 1 1 X 1 X 1 X 1 1 0 1 1 1093202 489550 1382429 0 0 2965181 0 0 0 0 0 0 0 0 0 0 0 2965181 0 0 0 1 351749 351749 4064103 4203594 -139491 X 1 1 1 1 Union County General Hospital

300 Wilson Street Clayton NM 88415

X X X Union County General Hospital 1 1 X X X X X X X X X 13 1 0 1 X X X X 1 0 1 0 1 200 1 X 1 1 X X X 1 0 1 0 0 SchH_P01_S00_L07 Schedule H, Part I, Line 7 The cost method used to calculate the amounts in this table is a Cost to Charge ratio. SchH_P01_S00_L072f Schedule H, Part I, Line 7, Column f The Bad Debt Expense included on Form 990, Part IX, Line 25 Column A, subtracted for purpose of calculating the percentage in this column is 351,749. SchH_P03_S0A_L04 Schedule H, Part III, Section A, Line 4 Patient Accounts Receivable consists of amounts owed by various governmental agencies, insurance companies and private patients. The hospital manages its receivables by regularly reviewing the accounts, inquiring with respective payers as to collectiblity and providing allowances on their accounting records for estimated contractual adjustments and uncollectible accounts. SchH_P03_S0B_L08 Schedule H, Part III, Section B, Line 8 Serving patients with government health benefits, such as Medicare, is a component of the community benefit standard that tax-exempt hospitals are held to. This implies that serving Medicare patients is a community benefit and that that hospital operates to promote the health of the community. The Hospital uses Medicare cost report methodology, which apportions routine costs based on Medicaid or Medicare days to total days and apportions ancillary costs based on program charges to total charges. SchH_P03_S0C_L09b Schedule H, Part III, Section C, Line 9b When a patient has indicated or demonstrated an inability to pay, an appropriate hospital representative will provide the patient with a charity care application. Applications must be complete in their entirety before charity care can be considered. Those patients who may qualify for financial assistance from a government program should be referred to the appropriate agency prior to consideration for charity care. An application for financial assistance from an outside agency should be obtained prior to charity care approval. SchH_P06_S00_L02 Schedule H, Part VI, Line 2 Public meetings, board meetings, performance improvement and quality assurance meetings, emergency room call backs. SchH_P06_S00_L03 Schedule H, Part VI, Line 3 Patients are informed of their rights and eligibility for assistance as they go through the admissions process. SchH_P06_S00_L04 Schedule H, Part VI, Line 4 Union County is a frontier hospital with a county population of 2,700. The town of Clayton, where the hospital is located, is 45 miles from the nearest hospital. SchH_P06_S00_L05 Schedule H, Part VI, Line 5 The organization is a 25 bed acute care critical access hospital serving those in need in rural New Mexico. Union County General Hospital provides services to individuals from Northern New Mexico, Southeastern Colorado, and the Western Panhandle of Oklahoma and Texas. These services include inpatient, outpatient, emergency, Home Health, and DME areas of patient care. There were a total of 20,675 visits, as well as 8,615 visits at the Clayton Family Practice Clinic and 1,407 Home Health visits. Union County General Hospital is one of the sponsors of an annual county wide health fair where the hospital Lab staff obtains blood samples for testing. 336 patients were drawn at the health fair. The Physical Therapy and Occupational Therapy departments did taping and gave samples, gaining a few patients. The Radiology Department handed out literature on the various services they provide. They also arranged to have representatives from NuMed, our nuclear medicine provider, and the Harrington Cancer Center for mammograms. The Nursing Department did glucose finger sticks, blood pressure checks, Don't Text and Drive campaign, and promoted organ donation. Clinic staff and physicians handed out information on services they provide and the doctors answered general questions from the public. The Home Health department had a booth and had literature on their services. Union County General Hospital sponsors the annual Arts Festival, a local Little League team, and the 4th of July Rodeo. The Union County 2013 Relay for Life was organized and sponsored by the hospital. At the Relay for Life a Bike Rodeo was held for children, promoting bike safety and giving away free bike helmets. Union County General Hospital participates in the local parades on July 4, Clayton High School's Homecoming, and the Light Parade in early December. X 0 0 0 0 0 0 0 0 0 Dr Daniel Radunsky 685031 0 0 0 0 0 0 0 0 0 685031 0 0 0 Calvin Schuler 197242 0 0 0 0 0 0 0 0 0 197242 0 0 0 F990_P06_S0A_L02 Form 990, Part VI, Section A, Line 2 Claude C Austin and Rosie DeHerrera, Directors, have a business relationship. F990_P06_S0A_L03 Form 990, Part VI, Section A, Line 3 The Hospital's CEO, Don Wiedemann, is employed by a management company, Health Tech Management Services. All executive duties of the Chief Executive Officer are carried out by Mr. Wiedemann of Health Tech Management Services. F990_P06_S0B_L11b Form 990, Part VI, Section B, Line 11b Form 990 prepared and reviewed by independent accounting firm. A draft of the form 990 is then provided to hospital management and any questions or corrections are addressed. A copy of the final form 990 with all required schedules is then provided to all voting members prior to filing with the IRS. F990_P06_S0B_L12c Form 990, Part VI, Section B, Line 12c The Board of Directors, CEO and all other officers are all required to annually sign the conflict of interest policy and disclose any potential conflicts of interest. F990_P06_S0B_L15 Form 990, Part VI, Section B, Line 15 The Hospital's CEO is compensated by a management company, Health Tech management services. Annually, a representative from the management company meets with the board of directors to perform an annual evaluation of the CEO's performance, review the New Mexico Hospital services wage and salary survey as a compensation comparable. The board's approval of CEO compensation is documented in the board minutes. F990_P06_S0C_L19 Form 990, Part VI, Section C, Line 19 Available upon request.