2013-09-13T11:32:53-05:00 2012-12-31 752570395 DURBIN & COMPANY LLP 2950 50TH STREET LUBBOCK TX 79413 990 2012-01-01 750711276 CROSBYTON CLINIC HOSPITAL CROS 8066752382 710 WEST MAIN STREET CROSBYTON TX 79322 DEBRA MILLER 8066752382 2013-09-13 JONATHAN PHILLIPS P01605460 8067911591 2013-09-13 2012 2016-02-24 21:20:13Z DEBRA MILLER 710 WEST MAIN STREET CROSBYTON TX 79322 5852683 0 X WWW.CROSBYTONCLINICHOSPITAL.COM X 1945 TX TO PROVIDE HEALTHCARE TO THE CITIZENS OF CROSBY COUNTY AND THE SURROUNDING AREAS. 6 6 100 0 0 0 0 1078 0 5006428 0 2478 0 842699 0 5852683 0 0 0 0 0 2995977 0 0 0 0 2895249 0 5891226 0 -38543 7057642 7628153 4044033 4653087 3013609 2975066 X SEE SCHEDULE O 0 0 5343406 5817583 OUR HOSPITAL PROVIDES GENERAL MEDICAL SERVICES TO THE CITIZENS OF CROSBYTON AND SURROUNDING AREAS. OUR LARGEST PROGRAMS ARE INPATIENT, SWING BED, AND OUTPATIENT SERVICES. WE OPERATE 25 ACUTE CARE BEDS. HOSPITAL PATIENT DAYS WERE 725 AND SWING BED DAYS WERE 899. ON THE OUTPATIENT SIDE, WE DID 24,018 LAB PROCEDURES, 3,949 RADIOLOGY PROCEDURES, AND 10,035 RESPIRATORY THERAPY, PHYSICAL THERAPY, AND OCCUPATIONAL THERAPY PROCEDURES. OUR RURAL HEALTH CLINIC LOGGED 7,425 VISITS AND OUR EMERGENCY ROOM SAW 2,752 PATIENTS. EMS HAD 493 RUNS IN THE TAX YEAR. 5343406 1 0 0 0 0 0 0 0 0 0 1 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 1 57 0 100 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 X 6 6 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 TX X DEBRA MILLER 8066758700 710 WEST MAIN STREET CROSBYTON TX 79322 DANNY BROOKS ELLISON 1.00 X X 0 0 457 KELLY WING 1.00 X X 0 0 457 JOAN BURKE MURRAY 1.00 X X 0 0 229 BOBBY MAX HAM 1.00 X 0 0 457 LESTER BOWNDS 1.00 X 0 0 297 DEBRA MILLER 40.00 X 66044 0 2900 66044 0 4797 0 0 0 0 STEVE ALLEY MD PA 536 S AYRSHIRE CROSBYTON TX 79322 PHYSICIAN SERVICES 292860 CONCORD PO BOX 489 MULESHOE TX 79347 ER MEDICAL 279015 WAEL QUBTI MD 16002 CR 1865 LUBBOCK TX 79424 ER MEDICAL 127220 BKD LLP 7901 WOODWAY DR WACO TX 76712 ACCOUNTING SERVICES 47509 LABORATORY CORP OF AMERICA PO BOX 12140 BURLINGTON NC 27216 LAB SERVICES 39206 3 1078 1078 NET PATIENT REVENUE 623000 4994675 4994675 RENTAL INCOME 531190 9661 9661 OTHER OPERATING REVENU 900099 2092 2092 5006428 2478 2478 UPL REVENUE 621990 662213 662213 340B REVENUE 621990 148942 148942 MISCELLANEOUS REVENUE 621400 9961 9961 21583 21583 842699 5852683 5817583 0 34022 X 2439354 2246141 193213 4929 4929 372543 372543 179151 157683 21468 80158 80158 1047840 966231 81609 5102 5102 151066 118317 32749 168669 168669 8290 7685 605 918 918 39113 39113 68021 68021 BAD DEBT EXPENSE 722824 722824 MEDICAL SUPPLIES 362873 362873 340B PROGRAM EXPENSE 175480 175480 MISCELLANEOUS 64895 64895 5891226 5343406 547820 0 75207 279661 784369 1147574 674780 778203 95793 91367 22289 49113 3893710 3397565 508259 496145 4896945 4786090 7057642 7628153 391378 644129 423870 0 37225 15893 3191560 3993065 4044033 4653087 X 3013609 2975066 3013609 2975066 7057642 7628153 -38543 0 X X 0 1 X 1 0 X 25570 25570 1868241 1497840 370401 93666 119104 -25438 1879233 1780621 98612 27000 27000 496145 DUE FROM CROSBYTON HEALTH SERVICES 4738392 PATIENTS OVERPAYMENT REFUND ACCOUNT 7079 STOP LOSS RECEIVABLE 36633 OTHER RECEIVABLES 3986 4786090 DUE FROM AFFILIATES 3993065 3993065 X 5321312 340395 340395 4980917 871766 871766 5852683 5274325 254865 254865 5019460 871766 871766 5891226 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X, LINE 2: THE HOSPITAL IS A NOT-FOR-PROFIT ORGANIZATION THAT IS EXEMPT FROM INCOME TAXES UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. THE HOSPITAL EVALUATES AND ACCOUNTS FOR UNCERTAIN TAX POSITIONS IN ACCORDANCE WITH FINANCIAL ACCOUNTING STANDARDS BOARD (FASB) ACCOUNTING STANDARDS CODIFICATION (ASC) 740, INCOME TAXES (FORMERLY FASB INTERPRETATION 48 (FIN 48) ACCOUNTING FOR UNCERTAINTY IN INCOME TAXES. THIS STANDARD REQUIRES CERTAIN DISCLOSURES ABOUT UNCERTAIN INCOME TAX POSITIONS. THE HOSPITAL EVALUATES ANY UNCERTAIN TAX POSITIONS USING THE PROVISIONS OF ASC 450, CONTINGENCIES. AS A RESULT, MANAGEMENT DOES NOT BELIEVE THAT ANY UNCERTAIN TAX POSITIONS CURRENTLY EXIST AND NO LOSS CONTINGENCY HAS BEEN RECOGNIZED IN THE ACCOMPANYING FINANCIAL STATEMENTS. THE HOSPITAL HAS FILED ALL APPLICABLE TAX RETURNS. PART XI, LINE 2D - OTHER ADJUSTMENTS: CROSBYTON HEALTH SERVICES CORPORATION REVENUE 340,395. PART XI, LINE 4B - OTHER ADJUSTMENTS: 340B PROGRAM REVENUE 148,942. BAD DEBT EXPENSE 722,824. PART XII, LINE 2D - OTHER ADJUSTMENTS: CROSBYTON HEALTH SERVICES CORPORATION EXPENSES 254,865. PART XII, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT EXPENSE 722,824. 340B PROGRAM REVENUE 148,942. 1 1 X 1 X 1 1 1 0 1 1 716272 662213 54059 0.01020 457456 230827 226629 0.04300 1173728 893040 280688 0.05320 1173728 893040 280688 0.05320 1 400771 437844 2435850 3116726 -680876 X 1 0 1 1 CROSBYTON CLINIC HOSPITAL

710 WEST MAIN STREET CROSBYTON TX 79322

X X X X CROSBYTON CLINIC HOSPITAL 0 1 1 0 1 X X X X X X X 1 1 X X X 1 X 0 X X X X 1 0 0 1 REEVES RHOADES TERRACE

640 SOUTH HARRISON CROSBYTON TX 79322

ASSISTED LIVING FACILITY PART I, LINE 7, COLUMN (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 $ 722824. ORGANIZATION MISSION STATEMENT FORM 990, PART III, LINE 1 WE BELIEVE THAT LIFE IS A GIFT FROM GOD. EACH PERSON'S LIFE IS OF GREAT VALUE AND DESERVES RESPECT IN ALL STAGES, FROM CONCEPTION UNTIL DEATH. WE ARE COMMITTED TO RESPECTING EACH PERSON AS AN IRREPLACEABLE MEMBER OF THE HUMAN COMMUNITY AND AS A UNIQUE EXPRESSION OF LIFE. THE PURPOSE OF CROSBYTON CLINIC HOSPITAL IS TO PROVIDE QUALITY HEALTHCARE SERVICES, WHICH CONTRIBUTE TO THE WELL BEING OF THE HOSPITAL'S RURAL SERVICE AREA, ALL THOSE ASSOCIATED WITH THE HOSPITAL IN SERVICE ARE COMMITTED TO TREATING PATIENTS, THEIR FAMILIES, AND OTHER HOSPITAL GUESTS AND EACH OTHER WITH DIGNITY AND RESPECT. EACH PATIENT WHO ENTERS OUR HOSPITAL FACILITY IS SERVICED BY COMPETENT, CARING AND HELPFUL HEALTHCARE PROFESSIONALS. CROSBYTON CLINIC HOSPITAL SYMBOLIZES QUALITY PERSONAL CARE IN A CARING ENVIRONMENT. FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 IS PREPARED BY AN INDEPENDENT ACCOUNTING FIRM. SENIOR MANAGEMENT CONSIDERS, COMPLETES, AND FINALIZES ALL DOCUMENTATION BEFORE FILING. FORM 990, PART VI, SECTION B, LINE 12C VERBAL AND WRITTEN DOCUMENTATION CONCERNING ANY CONFLICT OF INTEREST OCCUR DURING EMPLOYEE REVIEW AND DURING FISCAL YEAR END. FORM 990, PART VI, SECTION B, LINE 15 THE CEO, BOARD COMMITTEE, AND COMPLETE BOARD OF DIRECTORS RESEARCH AND REVIEW ALL DATA PROVIDED DURING THE SEARCH PROCESS. SEVERAL REDUCTION LAYERS ARE INVOLVED WHEN MORE THAN SEVERAL CANDIDATES ARE INVOLVED. MARKET DATA IS USED TO CONSIDER COMPENSATION LEVELS. FORM 990, PART VI, SECTION C, LINE 18 THE ORGANIZATION MAKES ITS FORM 1023 AND FORM 990 AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATIONAL GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE MADE AVAILABLE TO THE PUBLIC UPON REQUEST. OTHER FEES FORM 990, PART IX, LINE 11G EMS PROFESSIONAL SERVICES: PROGRAM SERVICE EXPENSES 92,052. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 92,052. HOSPITAL PROFESSIONAL SERVICES: PROGRAM SERVICE EXPENSES 874,179. MANAGEMENT AND GENERAL EXPENSES 20,401. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 894,580. HOME OFFICE PROFESSIONAL SERVICES: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 61,208. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 61,208. THE ORGANIZATION'S BOARD OF DIRECTORS ASSUME RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT, REVIEW, OR COMPILATION OF ITS FINANCIAL STATEMENTS AND THE SELECTION OF AN INDEPENDENT ACCOUNTANT. CROSBYTON HEALTH SERVICES 710 WEST MAIN STREET CROSBYTON TX 79322 752916531 ASSISTED LIVING TX 501(C)(3) LINE 11A, I CROSBYTON CLINIC HOSPITAL 1 0 0 0 1 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 CROSBYTON HEALTH SERVICES D 745327 BOOK VALUE