2013-05-14T09:57:11-05:00 2012-06-30 410746749 CLIFTONLARSONALLEN LLP 220 SOUTH SIXTH STREET SUITE 300 MINNEAPOLIS MN 55402 990 2011-07-01 810233499 SIDNEY HEALTH CENTER SIDN 4064882100 216 14TH AVE SW SIDNEY MT 59270 TINA MONTGOMERY 4064882100 2013-05-08 1 DARRYN MCGARVEY P00958683 6123764500 2011 2016-02-24 21:20:13Z RICHARD HARALDSON 216 14TH AVE SW SIDNEY MT 59270 52292622 0 X WWW.SIDNEYHEALTH.ORG X 1946 MT TO HELP THOSE WE SERVE ACHIEVE THEIR HIGHEST LEVEL OF HEALTH BY PROVIDING QUALITY MEDICAL CARE. 8 8 641 212 4824926 0 538168 661649 41126540 46110885 1417533 -934522 125867 1149818 43208108 46987830 0 14171 0 0 21215049 21160749 0 0 213759 21929138 26406787 43144187 47581707 63921 -593877 62805020 64091778 33143407 34030525 29661613 30061253 X TO HELP THOSE WE SERVE ACHIEVE THEIR HIGHEST LEVEL OF HEALTH AND WELL-BEING. 0 0 42179157 14171 46110885 SIDNEY HEALTH CENTER IS A NOT-FOR-PROFIT COMMUNITY BASED MEDICAL CENTER THAT HAS BEEN SERVING PEOPLE IN THE MONDAK REGION FOR MORE THAN 100 YEARS. OUR PASSION FOR CARING IS SHARED BY THE DOCTORS, NURSES, AND SEVERAL HUNDRED EMPLOYEES AND VOLUNTEERS. THIS COMMITMENT TO CARING IS OUR ALLEGIANCE TO THE COMMUNITY AS WE STRIVE TO PROVIDE "EXCEPTIONAL CARE FOR LIFE."LOCATED IN THE HEART OF RICHLAND COUNTY, THE ATTRACTIVE EASTERN MONTANA CAMPUS INCLUDES AN ACUTE CARE HOSPITAL, CLINIC AREA, RETAIL PHARMACY AND A 93-BED EXTENDED CARE FACILITY OFFERING A COMPLETE RANGE OF SERVICES FROM BIRTH THROUGH END-OF-LIFE, WHICH IS COMPLEMENTED BY AN ARRAY OF OUTREACH SERVICES. THIS CONTINUUM OR SUCCESSION OF SERVICES IS NOT TYPICAL OF RURAL HEALTHCARE ORGANIZATIONS, BUT SIDNEY HEALTH CENTER IS NOT TYPICAL. A STRONG COMPLEMENT OF PRIMARY CARE PHYSICIANS AND A UNIQUE SELECTION OF SURGICAL SPECIALISTS COMBINED WITH A MODERN FACILITY, AND UP-TO-DATE MEDICAL EQUIPMENT, MAKES SIDNEY HEALTH CENTER A SPECIAL PLACE TO WORK, RECEIVE CARE AND PRACTICE MEDICINE. SIDNEY HEALTH CENTER ALSO PROVIDES VARIOUS COMMUNITY BENEFIT PROGRAMS FOR THE INDIVIDUALS IN THEIR SERVICE REGION.RICHLAND COUNTY TRANSPORTATION - THIS PROGRAM GIVES OPPORTUNITIES FOR THOSE WHO CANNOT DRIVE THE OPTION OF A RIDE. SIDNEY HEALTH CENTER PROVIDES A DRIVER AND HELPS PAY FOR BUSSES. SINCE IT'S CONCEPTION WE HAVE GONE FROM ONE BUS AND ONE DRIVER FOR THE FULL PROGRAM TO 5 BUSSES AND 8 DRIVERS. WE WORK WITH THE HEALTH DEPARTMENT, RICHLAND COUNTY AND THE LODGE.MILES CITY NURSING PROGRAM - WE PROVIDE THE FACILITY AND PROGRAM COSTS TO HAVE MILES CITY COMMUNITY COLLEGE RUN A SATELLITE SCHOOL HERE IN SIDNEY. THIS PROMOTES NURSING AS A PROFESSION AND KEEPS THOSE WHO ARE INTERESTED IN OUR COMMUNITY AS POSSIBLE EMPLOYEES LATER.OUTREACH CLINIC - SOME OF THE OUTLYING COMMUNITIES DO NOT HAVE ACCESS TO AN ENT PHYSICIAN. SIDNEY HEALTH CENTER PROVIDES THE TRAVEL FOR OUR ENT TO GO TO THOSE OUTREACH AREAS.HEALTH FAIR - WORKING WITH RICHLAND COUNTY HEALTH DEPARTMENT, COALITION ON AGING, FIRE, POLICE AND MENTAL HEALTH PROFESSIONS, JUST TO NAME A FEW, SIDNEY HEALTH CENTER HOLDS A HEALTH FAIR WHERE PEOPLE CAN COME AND LEARN ABOUT DIFFERENT HEALTHCARE NEEDS OF OUR COMMUNITY. SIDNEY HEALTH CENTER PROMOTES PREVENTATIVE CARE, DIABETES EDUCATION, LAB SCREENINGS AND MANY OTHER TOPICS.LIVE-IT-UP - THIS IS A PROGRAM THAT SIDNEY HEALTH CENTER DOES TO MAKE WOMEN OF RICHLAND COUNTY AWARE OF HOW HEART DISEASE AFFECTS THEM. RICHLAND COUNTY FAIR & RODEO - SIDNEY HEALTH CENTER PROVIDES A BOOTH WHERE PEOPLE CAN GET THEIR BLOOD PRESSURE TAKEN, DO A FINGER STICK BLOOD TEST FOR DIABETS AND GET A BOTTLE OF WATER FOR FREE IN THE EXTREME HOT AUGUST DAYS OF THE FAIR.CAMP MEND A HEART - SIDNEY HEALTH CENTER'S HOSPICE PROGRAMS PUT ON TWO DIFFERENT CAMPS FOR PEOPLE WHO HAVE LOST LOVED ONES. ONE IS FOR ADULTS, THE OTHER FOR KIDS. 42179157 1 1 0 1 0 0 0 0 1 0 1 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 57 0 641 1 1 1 0 0 0 0 0 0 0 0 0 X 8 8 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 X TINA MONTGOMERY CFO 4064882117 216 14TH AVE SW SIDNEY MT 59270 X STEVE SING 1.00 X X 0 0 0 RANDY JOHNSON 1.00 X X 0 0 0 GALE FRANK 1.00 X X 0 0 0 PAM BURMAN 1.00 X 0 0 0 LAURA SCHIEBER 1.00 X 0 0 0 JANICE NORBY 1.00 X 0 0 0 MARK MARTIN 1.00 X 0 0 0 NICOLE BEYER 1.00 X 0 0 0 RICHARD HARALDSON 40.00 X 185797 0 19808 TINA MONTGOMERY 40.00 X 93628 0 10189 LOFTI BEN-YOUSSEF MD 24.00 X 370934 0 15122 TONY HAM MD 40.00 X 348388 0 0 LYLE HARRISON MD 40.00 X 333545 0 23545 LINDA KLEIN MD 40.00 X 311592 0 16505 BRADLEY STRUPP 40.00 X 285893 0 24797 1929777 0 109966 16 0 1 0 BRETT BENNION MD 214 14TH AVE SW SIDNEY MT 59270 PHYSICIAN SERVICES 1018005 JAMES E SCOTT MD 3560 MASTERSON CIRCLE BILLINGS MT 59106 PHYSICIAN SERVICES 408496 EDWARD P BERGIN MD PO BOX 1529 SIDNEY MT 59270 PHYSICIAN SERVICES 354638 HORIZON RESTORATION 34781 CNTY RD 128 SIDNEY MT 59270 CONTRACTOR SERVICES 299847 EDWARD L PIERCE MD 214 14TH AVE SW SIDNEY MT 59270 PHYSICIAN SERVICES 232968 8 633251 23398 5000 661649 PATIENT REVENUES 621500 40545292 40545292 CLINIC PHARMACY 446110 3748807 3748807 OTHER PATIENT CARE 621500 1167549 1167549 MONDAK PHARMACY 446110 406847 406847 DURAMED EQUIPMENT 621500 242390 242390 46110885 507007 507007 93175 0 93175 93175 93175 3685651 139989 5109730 157439 -1424079 -17450 -1441529 -1441529 439846 37623 402223 402223 OTHER PHARMACY REVENUE 900099 426882 426882 MEAL INCOME 900099 291990 291990 MISCELLANEOUS REVENUE 900099 156521 156521 -220973 -220973 654420 46987830 41712841 4824926 -211586 14171 14171 311661 115412 170561 25688 17135109 15814624 1206497 113988 344391 304929 36018 3444 2187549 1946027 223357 18165 1182039 1065672 106661 9706 198012 188616 9396 43560 43560 84761 84761 78753 78753 4800371 4708346 92025 209891 14248 184265 11378 2757963 2278196 455638 24129 499364 20040 479324 1149223 1042947 101419 4857 230367 214999 13489 1879 1490931 1490931 3577811 3577811 521135 517037 4098 PHARMACY/LAB EXPENSE 7421780 7421600 180 BAD DEBT 2472433 2472433 GOOD CENTS STORE 236959 41944 195015 DUES/SUBSCRIPTIONS 223227 109876 113351 410246 310229 99492 525 47581707 42179157 5188791 213759 8652187 6464777 6908028 8486466 2896211 243747 1273723 1505487 577398 655016 63766390 34519318 30699499 29247072 3768495 10226540 175633 2248437 6447096 58933 1406750 4955303 62805020 64091778 3285198 3263436 9425000 25764486 14434 16374 18301778 207460 852465 2116997 3926304 33143407 34030525 X 29661613 28525497 1535756 29661613 30061253 62805020 64091778 X -593877 993517 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 5194 5194 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: INDIRECT: THE PERCENTAGE OF DUES PAID TO MHA, AHA AND LEADINGAGE (F/K/A AAHSA) IS USED FOR LOBBYING EXPENSES AT 4.48%, 24.6% AND 5.3% RESPECTIVELY. 0 1 198261 198261 40221159 18656434 21564725 631994 291278 340716 22344995 15571606 6773389 369981 369981 29247072 THIRD PARTY RECEIVABLE 548000 DUE FROM RELATED PARTY 2783480 ACCRUED INTEREST RECEIVABLE 20750 DEFERRED FINANCING COSTS 346357 BENEFICIAL INTEREST IN FOUNDATION 1129903 YELLOWSTONE CAPITAL INVESTMENTS 126813 4955303 THIRD PARTY PAYABLE 259312 SWAP CONTRACT LIABILITY 3666992 3926304 46987830 47581707 -593877 -114259 1156044 -48268 993517 399640 45197097 -2472433 -2472433 47669530 -681700 -681700 46987830 45071394 37623 37623 45033771 2547936 2547936 47581707 PART IV, LINE 2B: RESIDENT TRUST ACCOUNT: THIS IS THE EXTENDED CARE RESIDENT TRUST ACCOUNT WHICH IS MADE UP OF THE RESIDENTS' MONEY THAT SIDNEY HEALTH CENTER HOLDS ON THEIR BEHALF. THESE MONIES ARE KEPT IN A SEPARATE BANK ACCOUNT FROM THE ORGANIZATION'S FUNDS AND ARE DUE BACK TO THE RESIDENTS UPON LEAVING THE FACILITY. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: THE INTERNAL REVENUE SERVICE (IRS) HAS DETERMINED THAT THE HEALTH CENTER AND AFFILIATE ARE TAX-EXEMPT, NOT-FOR-PROFIT CORPORATIONS UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE (IRC). THE HEALTH CENTER FOLLOWS THE GUIDANCE IN THE ACCOUNTING STANDARDS REGARDING THE RECOGNITION AND MEASUREMENT OF UNCERTAIN TAX POSITIONS. THE GUIDANCE CLARIFIES THE ACCOUNTING FOR UNCERTAINTY IN INCOME TAXES RECOGNIZED IN AN ENTITY'S FINANCIAL STATEMENTS. THE GUIDANCE FURTHER PRESCRIBES RECOGNITION AND MEASUREMENT OF TAX PROVISIONS TAKEN OR EXPECTED TO BE TAKEN ON A TAX RETURN THAT ARE NOT CERTAIN TO BE REALIZED. THE APPLICATION OF THIS STANDARD HAS NO IMPACT ON THE HEALTH CENTER'S CONSOLIDATE FINANCIAL STATEMENTS. THE HEALTH CENTER'S INCOME TAX RETURNS ARE SUBJECT TO REVIEW AND EXAMINATION BY FEDERAL, STATE, AND LOCAL AUTHORITIES. THE INFORMATION TAX RETURNS FOR THE YEARS ENDED 2009 TO 2011 ARE OPEN TO EXAMINATION BY FEDERAL, LOCAL, AND STATE AUTHORITIES. PART XI, LINE 8 - OTHER ADJUSTMENTS: T/R NET ASSETS RELEASED FROM RESTRICTIONS FOR OPERATIONS -22,129. CHANGE IN BENEFICIAL INTEREST IN NET ASSETS OF FOUNDATION -26,139. TOTAL TO SCHEDULE D, PART XI, LINE 8: -48,268. PART XII, LINE 2D - OTHER ADJUSTMENTS: BAD DEBT EXPENSE -2,472,433. PART XII, LINE 4B - OTHER ADJUSTMENTS: INVESTMENT INCOME NET OF FEES 632,923. UNRESTRICTED CONTRIBUTIONS 233,669. LOSS ON SWAP -1,549,995. LOSS ON REFINANCING -371,204. LOSS ON DISPOSALS -17,450. T/R CONTRIBUTIONS NET OF UNRESTRICTED 427,980. COST OF GOODS SOLD (GOOD CENTS STORE) -37,623. PART XIII, LINE 2D - OTHER ADJUSTMENTS: COST OF GOOD SOLD 37,623. PART XIII, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT EXPENSE 2,472,433. INVESTMENT ADMIN FEES 75,503. 1 1 X 1 X 1 X 175.000000000000 1 1 1 0 1 0 1317782 1317782 0.02920 4905380 4279194 626186 0.01390 329079 310355 18724 0.00040 6552241 4589549 1962692 0.04350 132688 67747 64941 0.00140 7416924 2381107 5035817 0.11160 14439 14439 0.00030 7564051 2448854 5115197 0.11330 14116292 7038403 7077889 0.15680 1 2472433 0 9707861 9727735 -19874 X 1 1 1 1 SIDNEY HEALTH CENTER

216 14TH AVE SW SIDNEY MT 59270

X X X X SIDNEY HEALTH CENTER 1 1 1 100.000000000000 1 175.000000000000 1 X X X X X X X 1 1 X X X X X X 1 0 1 X 0 0 2 SIDNEY HEALTH CENTER EXTENDED CARE

216 14TH AVE SW SIDNEY MT 59270

NURSING HOME THE LODGE AT LONE TREE

1015 7TH AVE SW SIDNEY MT 59270

ASSISTED LIVING COMPLEX PART I, LINE 3C: ELIGIBILITY CRITERIA: 1. FINANCIAL ASSISTANCE IS SECONDARY TO ALL OTHER FINANCIAL RESOURCES AVAILABLE TO THE PATIENT. THIS INCLUDES BUT IS NOT LIMITED TO:A. GROUP OR INDIVIDUAL MEDICAL INSURANCE PLANSB. WORKERS COMPENSATION PLANSC. MEDICAID, STATE, OR COUNTY MEDICAL PROGRAMSD. OTHER STATE, FEDERAL, OR MILITARY PROGRAMSE. THIRD PARTY LIABILITY SITUATIONS (E.G., AUTO ACCIDENTS OR PERSONAL INJURY CLAIMS)F. ANY OTHER PERSONS OR ENTITIES WHO MAY HAVE A LEGAL RESPONSIBILITY TO PAY FOR THE MEDICAL SERVICESG. CRIME VICTIMS2. DETERMINATION OF ELIGIBILITY OF A PATIENT FOR ASSISTANCE SHALL BE APPLIED REGARDLESS OF THE SOURCE OF REFERRAL AND WITHOUT DISCRIMINATION AS TO RACE, COLOR, CREED, NATIONAL ORIGIN, AGE, HANDICAP STATUS, OR MARITAL STATUS.3. PATIENT CARE WHICH IS ELECTIVE (NON-EMERGENT), COSMETIC, AND/OR EXPERIMENTAL SHALL NOT BE CONSIDERED ELIGIBLE FOR ASSISTANCE. FOR EMERGENCY ROOM SERVICES, IF THE VISIT IS DEEMED NON-EMERGENT AND THE PATIENT COULD HAVE BEEN SEEN IN A PHYSICIAN'S OFFICE, THE CHARITY CARE WRITE OFF WILL BE SUBJECT TO A 50% LIMITATION.4. PATIENT SPEND DOWNS AS DETERMINED BY MEDICAID, STATE OR COUNTY MEDICAL PROGRAMS ARE NOT ELIGIBLE FOR ASSISTANCE. (THE PATIENT ACCOUNTS MANAGER CAN MAKE EXCEPTIONS ON A CASE-BY-CASE BASIS.)5. TO THE EXTENT THE HOSPITAL CHARGES RELATED TO APPROPRIATE HOSPITAL BASED MEDICAL SERVICES ARE NOT COVERED BY THIRD-PARTY COVERAGE, A 100% WRITE-OFF MAY BE PROVIDED TO PATIENTS IF THE NET AVAILABLE ASSETS ARE NO GREATER THAN TWO TIMES THE FEDERAL INCOME POVERTY GUIDELINES AS ADJUSTED FOR FAMILY SIZE AND THE FAMILY'S GROSS INCOME IS BELOW %100 OF THE FEDERAL INCOME POVERTY GUIDELINES AS ADJUSTED FOR FAMILY SIZE. 6. PARTIAL ASSISTANCE MAY BE PROVIDED TO PATIENTS IF NET AVAILABLE ASSETS ARE NO GREATER THAN TWO TIMES THE FEDERAL INCOME POVERTY GUIDELINES AS ADJUSTED FOR FAMILY SIZE AND THE GROSS FAMILY INCOME IS BETWEEN 100% AND 175% OF THE FEDERAL INCOME POVERTY GUIDELINES AS ADJUSTED FOR FAMILY SIZE. THE UNPAID BALANCE AFTER THIRD-PARTY PAYMENTS FOR PATIENTS MEETING THIS CRITERIA WILL BE DISCOUNTED ACCORDING TO THE FOLLOWING SLIDING FEE SCALE CONSIDERING INDIVIDUAL CIRCUMSTANCES SUCH AS EXTRAORDINARY NONDISCRETIONARY EXPENSES RELATIVE TO THE AMOUNT OF MEDICAL EXPENSES, THE EXISTENCE AND AVAILABILITY OF FAMILY ASSETS, THE RESPONSIBLE PARTY'S FUTURE INCOME EARNING CAPACITY, AND ABILITY TO MAKE PAYMENTS OVER AND EXTENDED PERIOD OF TIME. THE FINANCIAL OBLIGATIONS WHICH REMAIN AFTER THE APPLICATION OF THIS SLIDING SCALE MAY BE PAYABLE IN MONTHLY INSTALLMENTS OVER A REASONABLE PERIOD OF TIME WHICH SHOULD BE CONSISTENT WITH THE ESTABLISHED MONTHLY PAYMENT PLAN GUIDELINES.7. FULL FINANCIAL ASSISTANCE (LESS CO-PAY) MAY BE PROVIDED TO PATIENTS THAT DO NOT HAVE AVAILABLE ASSETS AND WITH GROSS FAMILY INCOME BETWEEN 100%-175% OF THE FEDERAL POVERTY GUIDELINES AS ADJUSTED FOR FAMILY SIZE WHEN CIRCUMSTANCES AS DETERMINED BY THE PATIENT ACCOUNTS MANAGER INDICATE THAT FULL PAYMENT MAY CAUSE SOCIAL AND FINANCIAL HARDSHIP SO AS TO SIGNIFICANTLY HARM THE PATIENT OR THE FAMILY UNIT. CO-PAY PROVISION: A PATIENT CO-PAY AMOUNT WILL BE ASSIGNED TO THOSE PATIENTS QUALIFYING FOR 100% ASSISTANCE AS FOLLOWS: A.INPATIENT SERVICES 10% OR $500, WHICHEVER IS THE LESSER AMOUNTB.OUTPATIENT SURGERY 10% OR $250, WHICHEVER IS THE LESSER AMOUNTC.OUTPATIENT ANCILLARY 10% OF BILL8. FULL OR PARTIAL ASSISTANCE MAY BE PROVIDED TO PATIENTS WITH GROSS FAMILY INCOME ABOVE 175% OF THE POVERTY GUIDELINES WHEN CIRCUMSTANCES DETERMINED BY THE PATIENT ACCOUNTS MANAGER INDICATE THAT FULL PAYMENT MAY CAUSE SOCIAL AND FINANCIAL HARDSHIPS SO AS TO SIGNIFICANTLY HARM THE PATIENT OR THE FAMILY UNIT. SHC WILL DETERMINE IF ASSETS CAN BE LIQUEFIED TO MEET THE OUTSTANDING MEDICAL EXPENSES AND/OR WHAT MONTHLY PAYMENT AMOUNT COULD BE MADE FOR A PERIOD OF UP TO 36 MONTHS AND THE REMAINING BALANCE WRITTEN OFF AS FINANCIAL ASSISTANCE. PART I, LINE 6A: SIDNEY HEALTH CENTER HAS BEEN COLLABORATING WITH THE RICHLAND COUNTY HEALTH DEPARTMENT AND THEIR COMMUNITY NEEDS ASSESSMENT. FOR FISCAL YEAR ENDING 2013, SIDNEY HEALTH CENTER IS DOING THEIR OWN NEEDS ASSESSMENT AND WILL MAKE IT AVAILABLE TO THE PUBLIC THEN. PART I, LINE 7: IN ORDER TO CALCULATE THE OVERALL HOSPITAL'S COST TO CHARGE RATIO USED FOR PART I, LINE 7, THE HOSPITAL FIRST DETERMINED A COST TO CHARGE RATIO BASED ON THE 2012 FILED MEDICARE COST REPORT SEPARATELY FOR INPATIENT SERVICES, OUTPATIENT SERVICES, AND TOTAL SERVICES. TO CALCULATE THE COST OF CHARITY CARE INCLUDED ON LINE 7A, THE HOSPITAL TOOK EACH OF THE SEPARATE COST TO CHARGE RATIOS DESCRIBED IN THE PRECEEDING PARAGRAPH AND APPLIED THEM ONLY TO THE RELATED CHARGES BY SERVICE TYPE TO COME UP WITH A WEIGHTED AVERAGE COST TO CHARGE RATIO. PART I, LINE 7G: THE FOLLOWING SUBSIDIZED HEALTH SERVICES WERE INCLUDED IN PART I, LINE 7G:EMERGENCY ROOM, PHYSICIAN SERVICES, CARDIAC REHAB, PHYSICAL THERAPY, OCCUPATIONAL THERAPY, SPEECH THERAPY, PATIENT/HEALTH EDUCATION, AUDIOLOGY, WOMEN & CHILDREN SERVICES, HOME HEALTH, ECF, HOSPICE, AND CCU. PART I, L7 COL(F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN A, BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $2,472,433. PART III, LINE 4: THE FOLLOWING NARRATIVE IS FROM FOOTNOTE 1 OF THE FINANCIAL STATMENTS UNDER THE HEADING "PATIENT AND RESIDENT ACCOUNTS RECEIVEABLE, NET":PATIENT AND RESIDENT ACCOUNTS RECEIVABLE ARE REDUCED BY AN ALLOWANCE FOR DOUBTFUL ACCOUNTS. IN EVALUATING THE COLLECTABILITY OF PATIENT AND RESIDENT ACCOUNTS RECEIVABLE, THE HEALTH CENTER ANALYZES ITS PAST HISTORY AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYOR SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL 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 DOUBTFUL ACCOUNTS. FOR RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRD- PARTY COVERAGE, THE HEALTH CENTER ANALYZES CONTRACTUALLY DUE AMOUNTS AND PROVIDES AN ALLOWANCE FOR DOUBTFUL 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 HEALTH CENTER RECORDS A PROVISION FOR BAD DEBTS IN THE PERIOD OF SERVICE ON THE BASIS OF ITS PAST EXPERIENCE, WHICHINDICATES 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 DOUBTFUL ACCOUNTS. PART III, LINE 8: THE MEDICARE ALLOWABLE COSTS INCLUDED IN PART III, LINE 6 IS DERIVED FROM USING THE 2012 FILED MEDICARE COST REPORT. THE SHORTFALL OCCURS DUE TO VARIOUS EXPENSES INCURRED BY THE FACILITY WHICH ARE CONSIDERED NON-REIMBURSABLE BY MEDICARE. SINCE PART OF THE COSTS ARE NOT REIMBURSED IT IS ONLY PRUDENT TO CONSIDER THIS SHORTFALL TO BE A BENEFIT TO THE COMMUNITY. PART III, LINE 9B: IF THE PATIENT INDICATES THEIR INABILITY TO PAY ACCORDING TO THE HOSPITAL CREDIT TERMS THEY WILL BE ASKED TO FILL OUT A FINANCIAL STATEMENT. THE HOSPITAL MAY PULL A CREDIT REPORT TO CONFIRM OR SUPPLEMENT INFORMATION PROVIDED TO THE HOSPITAL ON THE FINANCIAL STATEMENT. THE PATIENT CAN THEN BE EVALUATED TO DETERMINE WHETHER THEY MAY BE ELIGIBLE FOR FINANCIAL ASSISTANCE OR AN EXTENDED PAYMENT PROGRAM.IF THE FINANCIAL STATEMENT SHOWS THAT THE PATIENT HAS ASSETS OR POTENTIAL SOURCES OF INCOME THAT WOULD ENABLE THEM TO PAY THE HOSPITAL BILL WITHIN A YEAR, THEY WILL BE DENIED THE EXTENDED PAYMENT WAIVER. IF A PATIENT REFUSES TO FURNISH A COMPLETED FINANCIAL STATEMENT, THEIR ACCOUNT WILL BE DEEMED DELINQUENT AND FURTHER COLLECTION ACTION WILL BE TAKEN. PRIOR TO ADMISSION, AT THE TIME OF ADMISSION, OR AS SOON AS POSSIBLE THEREAFTER, THE HOSPITAL WILL MAKE AN INITIAL ASSESSMENT OF POTENTIAL ELIGIBILITY BASED ON THE VERBAL APPLICATION FOR FINANCIAL ASSISTANCE. IF POTENTIAL ASSISTANCE IS INDICATED WITH INITIAL ASSESSMENT, THE HOSPITAL WILL NOT INITIATE COLLECTION EFFORTS OR REQUESTS FOR DEPOSITS PENDING THE RECEIPT OF THE COMPLETED APPLICATION AND FINAL ELIGIBILITY DETERMINATION. THE RESPONSIBLE PARTY MUST BE COOPERATIVE WITH THE HOSPITAL'S EFFORTS TO REACH A DETERMINATION OF ELIGIBILITY WITH OTHER ASSISTANCE PROGRAMS AND TO VALIDATE THE INFORMATION NEEDED.SIDNEY HEALTH CENTER WILL MAKE A CONCERTED EFFORT TO COMMUNICATE THE AVAILABILITY OF CHARITY CARE. EDUCATIONAL MATERIALS ABOUT THE PROGRAM WILL BE AVAILABLE TO PATIENTS THROUGH THE ADMISSIONS PROCESS. AS SOON AS A PATIENT EVIDENCES INABILITY TO PAY HE OR SHE WILL BE REFERRED TO THE PATIENT FINANCIAL SERVICES COUNSELOR FOR AN APPLICATION. APPLICATIONS ARE ALSO AVAILABLE AT THE ADMISSIONS AREA, AND THROUGH SOCIAL SERVICES. PART VI, LINE 2: SIDNEY HEALTH CENTER RECEIVED A GRANT AND WILL BE WORKING WITH MSU TO COMPLETE A COMMUNITY HEALTH NEEDS ASSESSMENT IN FISCAL YEAR 2013. PART VI, LINE 3: SIDNEY HEALTH CENTER HAS NOTICES LOCATED AT THE ADMISSIONS OFFICE INFORMING PATIENTS ABOUT THEIR FINANCIAL ASSISTANCE POLICY. THE PROGRAM IS ALSO STATED ON THE ORGANIZATION'S WEBSITE AND INCLUDED IN THE PATIENT'S PACKET UPON DISCHARGE FROM THE FACILITY. PART VI, LINE 4: LOCATED IN THE HEART OF RICHLAND COUNTY, SIDNEY HEALTH CENTER SERVES PEOPLE IN ALL OF THE MONDAK REGION. PART VI, LINE 5: THE HEALTH CENTER DEFINES AND MEASURES THEIR INVESTMENT IN AND PARTNERSHIP WITH THE COMMUNITY PRIMARILY THROUGH VARIOUS COMMUNITY BASED SERVICES PROGRAMS, PROVIDING HEALTH EQUIPMENT IN AREA SCHOOLS, AND COMMUNITY PROGRAMS AND EDUCATION. A NUMBER OF HEALTH RELATED EDUCATIONAL PROGRAMS ARE PROVIDED FOR THE BENEFIT OF THE COMMUNITY, INCLUDING HEALTHENHANCEMENTS AND WELLNESS, CLASSES ON SPECIFIC CONDITIONS, AND PROGRAMS DESIGNED TO IMPROVE THE GENERAL STANDARDS OF THE HEALTH OF THE COMMUNITY. 0 COMMUNITY HEALTH FITNESS CENTER INC DBA HEALTHWORKS INC 216 4TH AVENUE SOUTHWEST SIDNEY MT 59270 810460658 501(C)(3) 11600 DONATION FOR THE PURCHASE OF EXERCISE EQUIPMENT. 1 0 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: SIDNEY HEALTH CENTER DOES NOT MONITOR THE USE OF GRANT FUNDS. X 1 0 X X 0 0 0 0 0 0 0 0 0 RICHARD HARALDSON 185797 0 0 0 0 0 3380 0 16428 0 205605 0 0 0 LOFTI BEN-YOUSSEF MD 370934 0 0 0 0 0 13894 0 1228 0 386056 0 0 0 TONY HAM MD 348388 0 0 0 0 0 0 0 0 0 348388 0 0 0 LYLE HARRISON MD 333545 0 0 0 0 0 10805 0 12740 0 357090 0 0 0 LINDA KLEIN MD 311592 0 0 0 0 0 0 0 16505 0 328097 0 0 0 BRADLEY STRUPP 285893 0 0 0 0 0 8269 0 16528 0 310690 0 0 0 PART I, LINE 1A RICHARD HARALDSON - HEALTH OR SOCIAL CLUB DUES OF $1,280 RICHLAND COUNTY MT 816001419 2010-12-01 2350000 MEDICAL EQUIPMENT REVENUE BOND FOR TOMOTHERAPY RADIATION ONCOLOGY UNIT 0 0 0 RICHLAND COUNTY MT 816001419 2011-09-15 24370000 REDEEMING AND RETIRING PREVIOUSLY ISSUED DEBT (2006, 2007A AND 2007B) 0 0 0 445514 2350000 20059 2329941 2011 0 0 1 1 510000 24370000 23998570 233683 137747 2012 1 1 1 1 0 0 0 0 1 0 0 0 0 1 0 0 0 0 0 0 0 1 1 US BANK 8.900000000000 0 0 0 0 0 FORM 990, PART VI, SECTION A, LINE 1 THE EXECUTIVE COMMITTEE SHALL CONSIST OF THE PRESIDENT, THE VICE-PRESIDENT, THE SECRETARY/TREASURER, AND ONE OTHER MEMEBER OF THE BOARD APPOINTED BY THE PRESIDENT. THE EXECUTIVE COMMITTEE SHALL HAVE THE POWER TO TRANSACT ALL REGULAR BUSINESS OF THE CORPORATION DURING THE INTERIM BETWEEN THE MEETINGS OF THE BOARD, PROVIDED ANY ACTION TAKEN SHALL NOT CONFLICT WITH THE ARTICLES OF INCORPORATION, BYLAWS AND STATE POLICIES. ANY OFFICIAL ACTION TAKEN BY THE EXECUTIVE COMMITTEE SHALL BE SUBMITTED TO THE BOARD FOR RATIFICATION AT THE NEXT BOARD MEETING. FORM 990, PART VI, SECTION A, LINE 6 MEMBERSHIP IN THE CORPORATION SHALL BE OF TWO CLASSES. A. ANNUAL MEMBERS, BEING THOSE WHO, DURING THE PERIOD COMMENCING SIXTY DAYS BEFORE THE LAST ANNUAL MEETING OF THE CORPORATION AND ENDING SIXTY DAYS BEFORE THE TIME OF ANY ANNUAL MEETING OF THE CORPORATION, SHALL HAVE CONTRIBUTED IN CASH, MERCHANDISE, LABOR, OR AN EQUIVALENT, A SUM OF NOT LESS THAN $10.00, AND NOT MORE THAN $99.00, TO FURTHER THE OBJECTIVES OF THE CORPORATION, AND SUCH MEMBERSHIP SHALL TERMINATE AT THE TIME OF ADJOURNMENT OF THE ANNUAL MEETING OF THE CORPORATION. B. LIFE MEMBERS, BEING THOSE WHO ARE LIVING MEMBERS ON JANUARY 15, 1974, OR AT ANY TIME NOT LESS THAN SIXTY DAYS BEFORE THE TIME SET FOR ANY ANNUAL MEETING OF THE CORPORATION, HAVE CONTRIBUTED THE SUM OF $100.00 OR MORE TO FURTHER THE OBJECTIVES OF THE CORPORATION. FORM 990, PART VI, SECTION A, LINE 7A ELECTION OF DIRECTORS SHALL BE HELD AT THE ANNUAL MEETING OF THE MEMBERS BY WRITTEN BALLOT LISTING THE CANDIDATES NOMINATED BY THE NOMINATING COMMITTEE OF THE MEMBERS. EACH MEMBER OF THE CORPORATION, PRESENT IN PERSON OR BY PROXY, SHALL BE ENTITLED TO VOTE FOR ONE CANDIDATE FOR EACH DIRECTOR VACANCY TO BE FILLED. THE CANDIDATES RECEIVING THE HIGHEST NUMBER OF VOTES AT THE MEETING SHALL BE CONSIDERED ELECTED AS DIRECTORS. FORM 990, PART VI, SECTION A, LINE 7B ANY PROPOSED AMENDMENTS APPROVED BY THE BOARD OR BY VERIFIED PETITION TO THE ARTICLES OF INCORPORATION OR BYLAWS SHALL BE SUBMITTED FOR VOTE BY THE MEMBERS AT THE NEXT SPECIAL OR ANNUAL MEMBERSHIP MEETING. FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 WILL BE REVIEWED BY THE CEO AND CFO AND THEN PRESENTED TO THE BOARD OF DIRECTORS AT A BOARD MEETING PRIOR TO BEING SUBMITTED WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C THE POLICY OF THE CORPORATION IS TO REQUIRE THAT EACH INDIVIDUAL SUBJECT TO THIS POLICY STATEMENT PROMPTLY AND FULLY DISCLOSE ANY ACTUAL, APPARENT, OR POTENTIAL CONFLICT OF INTEREST, AND THAT THE CORPORATION WILL NOT ENGAGE IN ANY CONTRACT, TRANSACTION, OR ARRANGEMENT INVOLVING A CONFLICT OF INTEREST UNLESS THE DISINTERESTED MEMBERS OF THE BOARD OF DIRECTORS (ACTING AT A DULY CONSTITUTED MEETING THEREOF) DETERMINE BY A MAJORITY VOTE THAT APPROPRIATE SAFEGUARDS TO PROTECT THE CHARITABLE MISSION OF THE CORPORATION HAVE BEEN IMPLEMENTED. A CONFLICT OF INTEREST QUESTIONNAIRE IS DISTRIBUTED ANNUALLY TO ALL INTERESTED PERSONS (BOARD MEMBERS, OFFICERS, AND COMMITTEE MEMBERS). AN INTERESTED PERSON HAS A CONTINUING OBLIGATION TO DISCLOSE THE EXISTENCE AND NATURE OF ANY ACTUAL, APPARENT, OR POTENTIAL CONFLICT OF INTEREST HE/SHE MAY HAVE. "DISCLOSURE" MEANS PROMPTLY PROVIDING A WRITTEN DESCRIPTION OF THE MATERIAL FACTS OF THE ACTUAL, APPARENT, OR POTENTIAL CONFLICT OF INTEREST TO THE EXECUTIVE COMMITTEE ON THE CONFLICTS-OF-INTEREST QUESTIONNAIRE. SUCH DISCLOSURE SHALL BE MADE PROMPTLY ANY TIME AN ACTUAL, APPARENT, OR POTENTIAL CONFLICT OF INTEREST ARISES AND BEFORE THE CONSUMMATION OF THE CONTRACT, TRANSACTION, OR ARRANGEMENT THAT IS THE SUBJECT OF THE POTENTIAL CONFLICT OF INTEREST. AT ANY TIME THAT AN ACTUAL, APPARENT, OR A POTENTIAL CONFLICT OF INTEREST IS IDENTIFIED TO THE BOARD OF DIRECTORS, WHETHER THROUGH THE VOLUNTARY SUBMISSION OF A DISCLOSURE STATEMENT BY AN INTERESTED PERSON, OR BY A DISCLOSURE BY A PERSON OTHER THAN THE SUBJECT INTERESTED PERSON, THE EXECUTIVE COMMITTEE SHALL REVIEW THE MATTER AND DETERMINE WHETHER A CONFLICT OF INTEREST EXISTS. THE SUBJECT INTERESTED PERSON SHALL NOT BE PRESENT DURING ANY MEETING IN WHICH THE EXECUTIVE COMMITTEE CONDUCTS ITS EVALUATION, EXCEPT TO ANSWER QUESTIONS AS MAY BE NECESSARY. THE EXECUTIVE COMMITTEE MAY REQUEST ADDITIONAL INFORMATION FROM ALL REASONABLE SOURCES AND MAY INVOLVE THE GENERAL COUNSEL IN ITS DELIBERATIONS. ONCE ALL NECESSARY INFORMATION HAS BEEN OBTAINED, EXECUTIVE COMMITTEE SHALL MAKE A FINDING AS TO WHETHER A CONFLICT OF INTEREST INDEED EXISTS, AND SHALL FORWARD THAT FINDING TO THE BOARD OF DIRECTORS FOR DISCUSSION AND VOTE. ONLY DISINTERESTED DIRECTORS MAY VOTE TO DETERMINE WHETHER A CONFLICT OF INTEREST EXISTS. THE SUBJECT INTERESTED PERSON MAY NOT BE PRESENT WHEN THIS VOTE IS TAKEN. ONCE THE DISINTERESTED MEMBERS OF THE BOARD OF DIRECTORS HAVE DETERMINED THAT AN ACTUAL CONFLICT OF INTEREST EXISTS WITH RESPECT TO A PARTICULAR TRANSACTION OR ARRANGEMENT: (I) THE DISINTERESTED MEMBERS OF THE BOARD OF DIRECTORS SHALL EXERCISE DUE DILIGENCE TO DETERMINE WHETHER THE CORPORATION COULD OBTAIN A MORE ADVANTAGEOUS CONTRACT, TRANSACTION, OR ARRANGEMENT WITH REASONABLE EFFORTS UNDER THE CIRCUMSTANCES AND, IF APPROPRIATE, SHALL APPOINT A NON-INTERESTED PERSON OR COMMITTEE TO INVESTIGATE ALTERNATIVES TO THE PROPOSED CONTRACT, TRANSACTION, OR ARRANGEMENT. (II) IN CONSIDERING WHETHER TO ENTER INTO THE PROPOSED CONTRACT, TRANSACTION, OR ARRANGEMENT, THE BOARD OF DIRECTORS MAY APPROVE SUCH A CONTRACT, TRANSACTION, OR ARRANGEMENT ONLY IF THE DISINTERESTED DIRECTORS DETERMINE BY A MAJORITY VOTE THAT: (A) THE PROPOSED CONTRACT, TRANSACTION, OR ARRANGEMENT IS IN THE CORPORATION'S BEST INTERESTS AND FOR THE CORPORATION'S OWN BENEFIT; AND (B) THE PROPOSED TRANSACTION IS FAIR AND REASONABLE TO THE CORPORATION, TAKING INTO ACCOUNT, AMONG OTHER RELEVANT FACTORS, WHETHER THE CORPORATION COULD OBTAIN A MORE ADVANTAGEOUS CONTRACT, TRANSACTION, OR ARRANGEMENT WITH REASONABLE EFFORTS UNDER THE CIRCUMSTANCES. (III) THE DISINTERESTED MEMBERS OF THE BOARD OF DIRECTORS MAY, IN THEIR DISCRETION, REQUIRE THE INTERESTED PERSON TO LEAVE THE ROOM WHILE THE PROPOSED CONTRACT, TRANSACTION, OR ARRANGEMENT IS DISCUSSED. THE INTERESTED PERSON SHALL LEAVE THE ROOM WHILE THE MATTER IS VOTED ON AND ONLY DISINTERESTED DIRECTORS MAY VOTE TO DETERMINE WHETHER TO APPROVE THE TRANSACTION OR ARRANGEMENT. FORM 990, PART VI, SECTION B, LINE 15 THE BOARD OF DIRECTORS DETERMINES SALARIES USING THE MHA SALARY SURVEY FOR MARKET INFORMATION AND ALSO PERFORMS A WRITTEN EVALUATION ANNUALLY. ADDITIONALLY, THE CEO USES MHA MANAGEMENT SURVEY, AS WELL AS OTHER COMPENSATION SURVEYS, TO DETERMINE ANNUAL PAY INCREASES FOR ADMINISTRATION. A WRITTEN EVALUATION IS PERFORMED. ALL ESTIMATED ANNUAL INCREASES ARE INCLUDED IN THE BUDGET, WHICH IS APPROVED BY THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE MADE AVAILABLE TO THE PUBLIC UPON REQUEST. BOARD OVERLAP FORM 990, PART VII, SECTION A THE BOARD MEMBERS OF SIDNEY HEALTH CENTER (SHC) ALSO SERVE AS THE BOARD MEMBERS OF SHC'S RELATED ORGANIZATION, LONE TREE SENIOR LIVING. EACH INDIVIDUAL WORKS APPROXIMATELY ONE HOUR PER WEEK SERVING EACH OF THE ORGANIZATIONS. THE CEO AND CFO OF SHC ALSO SERVE AS THE CEO AND CFO OF LONE TREE SENIOR LIVING AND WORKS APPROXIMATELY 40 HOURS PER WEEK SERVING EACH OF THE ORGANIZATIONS. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED LOSSES ON INVESTMENTS: -114,259. PRIOR PERIOD ADJUSTMENTS: 1,156,044. T/R NET ASSETS RELEASED FROM RESTRICTIONS FOR OPERATIONS -22,129. CHANGE IN BENEFICIAL INTEREST IN NET ASSETS OF FOUNDATION -26,139. TOTAL TO FORM 990, PART XI, LINE 5: 993,517. LONE TREE SENIOR LIVING 1015 7TH AVE SW SIDNEY MT 59270 810518821 ASSISTED LIVING MT 501(C)(3) LINE 9 SHC 1 FOUNDATION FOR COMMUNITY CARE OF RICHLAND COUNTY INC 221 2ND ST NW SIDNEY MT 59270 810417465 FUNDRAISING MT 501(C)(3) LINE 11A, I N/A 0 0 0 1 1 0 0 0 0 0 0 1 0 0 1 0 1 0 0 LONE TREE SENIOR LIVING P 70114 ACTUAL AMOUNT LONE TREE SENIOR LIVING D 125919 ACTUAL AMOUNT FOUNDATION FOR COMMUNITY CARE OF RICHLAND COUNTY INC C 633251 ACTUAL AMOUNT