2013-05-07T10:11:20-05:00 2012-06-30 410746749 CLIFTONLARSONALLEN LLP 220 SOUTH SIXTH STREET SUITE 300 MINNEAPOLIS MN 55402 990 2011-07-01 810240726 MARCUS DALY MEMORIAL HOSPITAL MARC 4063754609 1200 WESTWOOD DRIVE HAMILTON MT 59840 JOHN M BARTOS 4063754609 2013-05-06 1 DARRYN MCGARVEY P00958683 6123764500 2011 2016-03-07 17:11:31Z JOHN M BARTOS 1200 WESTWOOD DRIVE HAMILTON MT 59840 52117055 0 X WWW.MDMH.ORG X 1938 MT OUR COMMITMENT TO THE BITTERROOT VALLEY IS QUALITY, ACCESSIBLE, PERSONALIZED HEALTHCARE. 11 6 546 170 0 0 225104 115352 46893051 51546346 60140 15311 -23951 194464 47154344 51871473 2644 76726 0 0 25424585 28395994 0 0 203605 20627165 23871665 46054394 52344385 1099950 -472912 47137440 49935753 20687420 23861018 26450020 26074735 X OUR COMMITMENT TO THE BITTERROOT VALLEY IS QUALITY, ACCESSIBLE, PERSONALIZED HEALTHCARE. 0 0 43854582 76726 51546346 MARCUS DALY MEMORIAL HOSPITAL CORPORATION OWNS AND OPERATES A 48 LICENSED BED ACUTE CARE CRITICAL ACCESS HOSPITAL WITH 25 BEDS SETUP. THE HOSPITAL PROVIDES ACUTE CARE SERVICES TO PATIENTS IN RAVALLI COUNTY. THE SERVICES PROVIDED INCLUDE ACUTE CARE HOSPITAL, RELATED ANCILLARY SERVICES SUCH AS LABORATORY, RADIOLOGY AND THERAPY INPATIENT AND OUTPATIENT SURGERY, EMERGENCY CARE, AMBULANCE, HOME HEALTH, CLINIC, TRANSITIONAL CARE, INPATIENT AND OUTPATIENT HOSPICE CARE. THE HOSPITAL PROVIDES EMS SERVICES WITH 3 CREWS PROVIDING 911 SERVICE TO THE COUNTY. THE GOAL IS TO RESPOND WITHIN 20 MINUTES OR LESS TO ANY CALL WITHIN THE COUNTY. THE HOSPITAL IS THE ONLY PEDIATRIC REHABILITATION PROVIDER OF PHYSICAL THERAPY, OCCUPATIONAL THERAPY AND SPEECH THERAPY IN WESTERN MONTANA USING CERTIFIED THERAPISTS. THE HOSPITAL CLINICS SEE ALL PATIENTS REGARDLESS OF INSURANCE OR ABILITY TO PAY AND ENABLE THE COMMUNITY ACCESS TO PRIMARY CARE. 43854582 1 1 0 0 0 0 0 0 0 1 1 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 1 1 1 0 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 1 1 1 0 0 1 73 0 546 0 0 0 0 0 0 0 0 0 0 0 X 11 6 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 X DONJA ERDMAN 4063754609 1200 WESTWOOD DRIVE HAMILTON MT 59840 X SONNY LASALLE 2.00 X X 0 0 0 DON LODMELL PHD 2.00 X X 0 0 0 DONNA COONEY 2.00 X 0 0 0 STEVEN ELLIS MD 2.00 X 0 0 0 BARBARA ACKERMAN 2.00 X 0 0 0 BILL BEAN 2.00 X 0 0 0 JAMES OWINGS CPA 2.00 X 0 0 0 MICHAEL COWAN 2.00 X 0 0 0 GARY BEDEY 2.00 X 0 0 0 RANDY STEWART MD 7.00 X 51084 0 0 WALKER ASHCRAFT MD 40.00 X 152724 0 22698 FREDERIK ILGENFRITZ MD 40.00 X 219002 0 9400 JOHN M BARTOS 39.00 X 277479 0 29233 DONJA C ERDMAN 39.00 X 120169 0 19581 JOHN MORELAND MD 40.00 X 317493 0 38500 JOHN COURCHESNE MD 40.00 X 351250 0 37206 JEREMIAH CLINTON MD 40.00 X 366354 0 5185 YVONNE COURCHESNE MD 40.00 X 322413 0 31492 LUKE CHANNER MD 40.00 X 285895 0 28188 MARY CAMDEN MD 40.00 X 272432 0 7688 2736295 0 229171 25 0 1 0 CERNER CORPORATION PO BOX 412072 KANSAS CITY MO 64141 BUSINESS SERVICES PROVIDER 567444 ALLIANCE HEALTHCARE SERVICES FILE 55826 LOS ANGELES CA 90074 MRI IMAGING 552728 HEALTHCARE OUTSOURCING NETWORK LLC 621 17TH ST 1800 DENVER CO 80293 BUSINESS SERVICES PROVIDER 299899 WILLIAM DOYLE MD 447 WILCOX LANE CORVALLIS MT 59828 EMERGENCY ROOM PHYSICIAN 274312 CLINTON R ADKINS DO 387 WOMBAT CORVALLIS MT 59828 EMERGENCY ROOM PHYSICIAN 266338 15 115352 115352 NET PATIENT SERVICE RE 621400 49263153 49263153 HOSPITAL UTILZTN. REV. 621400 1410190 1410190 OTHER OPERATING INCOME 621400 873003 873003 51546346 45598 45598 146391 164870 -18479 -18479 -18479 50425 80712 -30287 -30287 -30287 MISCELLEANEOUS 900099 205078 205078 EDUCATION 900099 22100 22100 CAFETERIA/VENDING 900099 4121 4121 -18356 -18356 212943 51871473 51546346 0 209775 76726 76726 916665 463359 453306 21612862 17756510 3748726 107626 726939 599983 123295 3661 3682137 2992954 671361 17822 1457391 1168285 281136 7970 133318 133318 60868 50868 10000 3896605 2981943 912325 2337 163535 163535 4499633 4179905 317574 2154 682378 503082 179296 835556 326308 509248 148233 81824 66319 90 804657 618755 148722 37180 3785102 3490133 283918 11051 922290 922290 PROVISION FOR BAD DEBTS 6679689 6679689 MAINTENANCE AND REPAIRS 696390 551509 144881 0 MISCELLANEOUS EXPENSES 300268 43143 255420 1705 PHARMACY/ LAB EXPENSES 189185 189185 0 0 73958 65464 6485 2009 52344385 43854582 8286198 203605 3127975 7077081 2592286 2642542 11265092 9148211 108523 9261 1079757 1198333 370554 371702 52283890 24706822 26780235 27577068 1368776 1452688 444242 458867 47137440 49935753 5201791 6512071 719442 8685000 8085000 5381512 5099396 600007 2752972 819110 692137 20687420 23861018 X 24723132 24190477 743245 900075 983643 984183 26450020 26074735 47137440 49935753 X -472912 97626 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 313190 1997 1997 313190 313190 3160 3160 313190 313190 4071 4071 313190 313190 313190 0.00000 1.00000 0.00000 0 0 1462528 1462528 31234942 12866644 18368298 695752 640604 55148 16662317 11199574 5462743 2228351 2228351 27577068 THIRD PARTY SETTLEMENT 692137 692137 51871473 52344385 -472912 97626 97626 -375286 51749807 164870 164870 51584937 286536 286536 51871473 52509255 164870 164870 52344385 0 52344385 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: THE ENDOWMENT FUND IS DESIGNATED FOR THE PURPOSE OF BUILDING AND CARRYING ON A HOSPITAL IN HAMILTON, MONTANA. THE EVANS ENDOWMENT IS TO BE USED FOR THE CARE AND TREATMENT OF CRIPPLED CHILDREN. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: PER THE AUDITED FINANCIAL STATEMENTS, NOTE 1: THE INTERNAL REVENUE SERVICE (IRS) HAS DETERMINED THAT MARCUS DALY MEMORIAL HOSPITAL IS A TAX-EXEMPT, NOT-FOR-PROFIT CORPORATION UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE (IRC). THE HOSPITAL 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 HOSPITAL'S FINANCIAL STATEMENTS. THE HOSPITAL'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, STATE, AND LOCAL AUTHORITIES. PART XI, LINE 8 - OTHER ADJUSTMENTS: CHANGE IN BENEFICIAL INTEREST IN NET ASSETS OF DALY HOSPITAL FOUNDATION 83,912. AUXILIARY INCOME 13,714. TOTAL TO SCHEDULE D, PART XI, LINE 8: 97,626. PART XII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES 164,870. PART XII, LINE 4B - OTHER ADJUSTMENTS: NONOPERATING REVENUE 189,541. CONTRIBUTIONS AND GRANTS 26,424. TEMP RESTRICTED CONTRIBUTIONS 29,182. RESTRICTED CONTRIBUTIONS 59,746. LOSS FROM REFINANCING OF LONG-TERM DEBT -18,357. PART XIII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES 164,870. 1 1 X 1 X 1 X 100.000000000000 1 1 1 0 1 1 504810 504810 0.01110 3577274 3243032 334242 0.00730 4082084 3243032 839052 0.01840 346432 346432 0.00760 152471 152471 0.00330 9657292 8416923 1240369 0.02720 83600 83600 0.00180 10239795 8416923 1822872 0.03990 14321879 11659955 2661924 0.05830 3 8827 8827 0.00020 4 3115 3115 0.00010 2 133685 133685 0.00290 9 145627 145627 0.00320 1 6679689 0 14113953 15308800 -1194847 X 1 1 1 1 MARCUS DALY MEMORIAL HOSPITAL

1200 WESTWOOD DRIVE HAMILTON MT 59840

X X X X MARCUS DALY MEMORIAL HOSPITAL 1 1 1 100.000000000000 1 100.000000000000 1 X X X X X X X 1 1 X X X 1 0 1 X 0 0 5 CORVALLIS FAMILY MEDICINE CLINIC

1037 MAIN STREET CORVALLIS MT 59828

CLINIC BITTERROOT VALLEY EYE ASSOCIATES

300 N 10TH STREET HAMILTON MT 59840

CLINIC BITTERROOT CLINIC

1224 MAIN STREET HAMILTON MT 59840

CLINIC BITTERROOT VALLEY EYE ASSOCIATES

401 MAIN STREET STEVENSVILLE MT 59870

CLINIC RAVALLI UROLOGY

1224 MAIN STREET HAMILTON MT 59840

CLINIC PART I, LINE 3C: FULL TO PARTIAL ASSISTANCE MAY BE GRANTED TO PATIENTS WITH GROSS FAMILY INCOME BELOW 100% OF THE FPG, AS ADJUSTED FOR FAMILY SIZE. A FAMILY MAY NOT OWN NET ASSETS IN EXCESS OF $10,000 CURRENT VALUE. PART I, LINE 6A: A COMMUNITY BENEFIT REPORT FOR FISCAL YEAR 2011 WAS IN THE SPRING 2012 EDITION OF HEALTHLINES, THE NEWSLETTER OF MARCUS DALY MEMORIAL HOSPITAL. THE NEWSLETTER WAS DELIVERED TO EVERY MAILING ADDRESS IN RAVALLI COUNTY COVERING APPROXIMATELY 14,300 HOUSEHOLDS. AN ADDITIONAL 1,000 COPIES OF THE NEWSLETTER WERE PRINTED FOR GENERAL CIRCULATION. PART I, LINE 7: EXPLANATION OF COSTING METHOD:COMMUNITY HEALTH IMPROVEMENT SERVICES, COMMUNITY BENEFIT OPERATIONS, HEALTH PROFESSIONAL EDUCATION, AND CASH AND IN-KIND CONTRIBUTIONS TO COMMUNITY GROUPS ARE REPORTED AT COST. GENERAL SUBSIDIZED SERVICES ARE COMPUTED USING THE IRS GUIDELINES OF COST ADJUSTED NET OF PAYMENTS RECEIVED. THE MEDICARE COST REPORT WAS USED TO DETERMINE THE TOTOAL OF THE SUBSIDY FOR THE HOME HEALTH/HOSPICE DEPARTMENTS. PART I, LINE 7G: INCLUDED IN THE SUBSIDIZED HEALTH SERVICES ARE THE FOLLOWING DEPARTMENTS:EMERGENCY MEDICAL SERVICES, AMBULANCE, THE SLEEP CENTER, BITTERROOT ORTHOPEDICS AND SPORTS MEDICINE CLINIC, HOME HEALTH, HOSPICE CENTER AND HOSPICE OUTPATIENT. 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 $ 6679689. PART II: THE HOSPITAL PROMOTES THE HEALTH OF THE COMMUNITY BY PARTICIPATION IN BOTH ECONOMIC AND COALITION BUILDING EVENTS. THE HOSPITAL PARTNERS WITH LOCAL HIGH SCHOOLS WITH A "JOB SHADOW" PROGRAM. THE GOAL IS TO EXPOSE AND PROMOTE THE HEALTH CARE PROFESSION TO AREA YOUTH. THE HOSPITAL IS ALSO REPRESENTED ON THE BITTERROOT COLLEGE STEERING TEAM AND THE JOB SERVICE ECONOMIC COUNCIL. THE HOSPITAL PARTNERS WITH THE ROCKY MOUNTAIN LAB, A LEVEL 4 BIOHAZARD LAB, TO HELP ENSURE COMMUNITY SAFETY ALONG WITH OTHER COMMUNITY SUPPORT ORGANIZATIONS. PART III, LINE 4: THE FOLLOWING IS FROM THE "PATIENT RECEIVABLES" PARAGRAPH IN NOTE 1 TO THE HOSPITAL'S FINANCIAL STATEMENTS:"THE HOSPITAL MAINTAINS AN ALLOWANCE FOR UNCOLLECTIBLE SELF-PAY ACCOUNTS. PATIENTS ARE NOT REQUIRED TO PROVIDE COLLATERAL FOR SERVICES RENDERED. PAYMENT FOR SERVICES IS REQUIRED AT THE TIME OF SERVICE WHEN THE AMOUNT DUE IS KNOWN OR UPON RECEIPT OF AN INVOICE, AFTER PAYMENT BY INSURANCE, IF ANY. MANAGEMENT DETERMINES THE ALLOWANCE FOR DOUBTFUL ACCOUNTS BY IDENTIFYING TROUBLED ACCOUNTS, BY HISTORICAL EXPERIENCE APPLIED TO AN AGING OF ACCOUNTS AND BY CONSIDERING THE PATIENTS' FINANCIAL HISTORY, CREDIT HISTORY AND CURRENT ECONOMIC CONDITIONS. WHEN ALL COLLECTION EFFORTS HAVE BEEN EXHAUSTED, THE ACCOUNT IS WRITTEN OFF AGAINST THE RELATED ALLOWANCE."THE AMOUNT OF BAD DEBT EXPENSE REPORTED IN PART III, LINE 2 IS CALCULATED AS FOLLOWS: PAYMENT ARRANGEMENT 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 PAYORS, AND OTHERS FOR SERVICES RENDERED, INCLUDING ESTIMATED RETROACTIVE ADJUSTMENTS UNDER REIMBURSEMENT AGREEMENTS WITH THIRD-PARTY PAYORS. PART III, LINE 8: MDMH HAS A MEDICARE SHORTFALL IN EXCESS OF APPROXIMATELY $1.2 MILLION. THE HOSPITAL HAS CRITICAL ACCESS HOSPITAL STATUS AND IS REIMBURSED BY MEDICARE FOR INPATIENT AND OUTPATIENT SERVICES ON A COST BASIS AS DEFINED AND LIMITED BY THE MEDICARE PROGRAM. MDMH PROVIDES A SIGNIFICANT RURAL LINK FOR BOTH THE HEALTH AND WELL-BEING OF RAVALLI COUNTY RESIDENTS. WE ARE COMMITTED TO LOCAL HEALTHCARE CLOSE TO HOME AND WORK HARD TO EARN AND KEEP THE TRUST OF THE LOCAL COMMUNITY. TO ENSURE THAT A VARIETY OF CLINIC, HOSPITAL AND EMERGENCY SERVICES ARE OPEN AND AVAILABLE TO ALL THOSE WITHIN OUR SERVICE AREA WE STRIVE TO OPERATE AT THE HIGHEST LEVEL OF FISCAL RESPONSIBILITY AND TO BE A GOOD STEWARD OF OUR RESOURCES. IRS AND CLIFTONLARSONALLEN METHODOLOGY WAS USED TO COMPUTE THE MEDICARE SHORTFALL. PART III, LINE 9B: IF A PATIENT IS PRESUMED TO BE FINANCIALLY INDIGENT, THE PATIENT REPRESENTATIVE WILL OFFER A PATIENT FINANCIAL STATEMENT (PFS) TO BE FILLED OUT. THE PFS WILL BE FORWARDED TO THE CHARITY CARE COMMITTEE FOR REVIEW AND DETERMINATION OF CHARITY CARE STATUS. A PATIENT MAY REQUEST A MONTHLY PAYMENT ARRANGMENT. A MINIMUM PAYMENT OF $50 MUST BE PAID MONTHLY, WITH THE BALANCE PAID IN FULL WITHIN 5 YEARS. ACCOUNTS THAT CANNOT BE COLLECTED AFTER NORMAL IN-HOUSE COLLECTION PROCEDURES MAY BE REFERRED TO A COLLECTION AGENCY, MAGISTRATE OR ATTORNEY FOR FURTHER COLLECTION ACTION. MARCUS DALY MEMORIAL HOSPITAL PART V, SECTION B, LINE 9: ELIGIBILITY FOR PATIENT ASSISTANCE IS MADE REGARDLESS OF RACE, COLOR, CREED, OR AGE. COSMETIC OR EXPERIMENTAL PROCEDURES AND CHARGES ARE NOT ELIGIBLE FOR CHARITY ASSISTANCE. FULL TO PARTIAL PATIENT ASSISTANCE MAY BE PROVIDED TO PATIENTS WITH GROSS FAMILY INCOME BELOW 100% OF THE FPG AS ADJUSTED FOR FAMILY SIZE. THE FAMILY MAY NOT OWN NET ASSETS IN EXCESS OF $10,000 OR GROSS ASSETS OF $200,000. OTHER CONSIDERATIONS MAY BE A PATIENT'S HEALTHINESS AND THEIR ABLILTY TO SEEK OR HOLD EMPLOYEMENT. SEE CHARITY CARE POLICY FOR DETAILS. MARCUS DALY MEMORIAL HOSPITAL PART V, SECTION B, LINE 10: ELIGIBILITY FOR PATIENT ASSISTANCE IS MADE REGARDLESS OF RACE, COLOR, CREED OR AGE. COSMETIC OR EXPERIMENTAL PROCEDURES AND CHARGES ARE NOT ELIGIBLE FOR CHARITY ASSISTANCE. FULL TO PARTIAL PATIENT ASSISTANCE MAY BE PROVIDED TO PATIENTS WITH GROSS FAMILY INCOME BELOW 100% OF THE FPG AS ADJUSTED FOR FAMILY SIZE. THE FAMILY MAY NOT OWN NET ASSETS IN EXCESS OF $10,000 OR GROSS ASSETS OV $200,000. SEE CHARITY CARE POLICY FOR DETAILS. MARCUS DALY MEMORIAL HOSPITAL PART V, SECTION B, LINE 13G: THE HOSPITAL BILLING OFFICE OR ITS REPRESENTATIVE CONTACTS EACH PATIENT TO DISCUSS THEIR ACCOUNT BALANCES AND THEIR ABILITY TO MAKE PAYMENT. EACH BILLING STATEMENT CONTAINS INFORMATION ON THE CHARITY CARE PROGRAM. MARCUS DALY MEMORIAL HOSPITAL PART V, SECTION B, LINE 19D: MDMH DETERMINES AMOUNTS GENERALLY BILLED ("AGB") BASED ON COMMERCIAL PAYORS. THE LARGEST COMMERCIAL PAYOR DISCOUNT WAS 27% FOR THE YEAR ENDED JUNE 30, 2012. PATIENT FINANCIAL ASSISTANCE DISCOUNTS RANGE FROM 34% TO 100%, DEPENDING UPON PATIENT ELIGIBILITY. PART VI, LINE 2: THE ORGANIZATION HAS PARTNERED WITH THE MONTANA OFFICE OF RURAL HEALTH AT MONTANA STATE UNIVERSITIY, BOSEMAN MT BEGINNING MAY 2012. A FINAL REPORT IS EXPECTED IN DECEMBER 2012. PART VI, LINE 3: BILLING AND COLLECTION INFORMATION IS LOCATED ON THE BACK OF EACH BILLING STATEMENT SENT TO PATIENTS OR THEIR GUARANTORS. ON A MONTHLY BASIS FOLLOW-UP PHONE CALLS ARE MADE INQUIRING AS TO EXPECTED PAYMENTS. EXPLANATION AND DISCUSSION AS TO THE CHARITY CARE POLICY MAY BE HAD AT THAT TIME AS NECESSARY AND APPROPRIATE. THE MASH PROGRAM IS ALSO EMPLOYED BY THE HOSPITAL TO HELP SCREEN PRIVATE PAY PATIENTS WHO MAY QUALIFY FOR OTHER PROGRAMS SUCH AS MEDICAID AND DISABILITY. PART VI, LINE 4: THE HOSPITAL SERVES A RURAL POPULATION WHERE THE HOUSEHOLD MEDIAN INCOME IS ABOUT $28,000. THE PAYER MIX IS 52% MEDICARE, 9% MEDICAID, 12% SELF PAY, NO INSURANCE, WITH THE BALANCE AS OTHER COMMERCIAL PAYERS. THE PERIOD UNEMPLOYMENT RATE IN RAVALLI COUNTY IS BETWEEN 9 AND 10.2%. PART VI, LINE 5: THE HOSPITAL IS PROUD OF IT'S EFFORTS TO PROMOTE COMMUNITY HEALTH AND WELLNESS. THIS YEAR THE FOCUS WAS ON "SPRINKLE PINK" A PROGRAM TO WHICH PROMOTE COMMUNITY AWARENESS FOR BREAST CANCER. THE HOSPITAL SPONSORS AN ANNUAL SPORTS PHYSICAL CLINIC TO SUPPORT AND ENCOURAGE AREA YOUTH TO PARTICIPATE IN PHYSICAL ACTIVITIES. OTHER COMMUNITY CLINICS OR SCREENINGS INCLUDED BLOOD PRESSURE TESTING AT AREA SENIOR CENTERS, AND LIPID PROFILES AND CHOLESTEROL TESTS PROVIDED TO THE COMMUNITY FREE OF CHARGE. A VARIETY OF HEALTH EDUCATION CLASSES WERE CONDUCTED INCLUDING, BUT NOT LIMITED TO, A SERIES RELATING TO DIABETES AND A ONE-DAY WORKSHOP ON WOMEN HEALTH. PART VI, LINE 6: THE ORGANIZATION IS NOT PART OF AN AFFILIATED HEALTH CARE SYSTEM. REPORTS FILED WITH STATES PART VI, LINE 7 MT 1 PERFORMING ARTS COMPANY INC 610 N 1ST STREET HAMILTON MT 59840 270273010 501(C)(3) 10000 SUPPORT FOR ACTIVITIES AND PROGRAMS RAVALLI COUNTY MUSEUM 205 BEDFORD STREET HAMILTON MT 59840 810370013 501(C)(3) 10000 SUPPORT FOR ACTIVITIES AND PROGRAMS HAMILTON SCHOOL DISTRICT 217 DALY AVE HAMILTON MT 59840 816000830 GOVERNMENTAL 9800 SUPPORT FOR SCHOOL RN PROGRAM AND STUDENT ATHLETICS CORVALLIS SCHOOL DISTRICT PO BOX 700 1045 MAIN STREET CORVALLIS MT 59828 816000828 GOVERNMENTAL 8925 SUPPORT FOR SCHOOL RN PROGRAM AND STUDENT ATHLETICS STEVENSVILLE SCHOOL DISTRICT 300 PARK STREET STEVENSVILLE MT 59870 816000829 GOVERNMENTAL 6500 SUPPORT FOR SCHOOL RN PROGRAM 5 0 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: THE HOSPITAL IS COMMITTED TO SUPPORT THE HEALTH AND WELL-BEING OF AREA SCHOOL AGED CHILDREN BY PROVIDING FUNDING GRANTS RESTRICTED TO THE DISTRICT'S SCHOOL NURSE PROGRAM. THE HOSPITAL HAS ALSO COMMITTED TO SUPPORT STUDENT ATHLETICS BY PROVIDING A VOLUNTEER BASED, LOW-COST SPORTS PHYSICAL CLINIC DURING THE SUMMER. THE PROCEEDS ARE GIVEN TO THE PARTICIPATING STUDENTS' HOME DISTRICT TO SUPPORT THE DISTRICT'S ATHLETIC PROGRAMS. THESE GRANTS ARE IN DIRECT SUPPORT OF OUR COMMUNITY BENEFIT GOALS. OTHER COMMUNITY ORGANIZATIONS MAY SUBMIT A GRANT PROPOSAL DIRECTLY TO THE HOSPITAL CEO FOR CONSIDERATION. THE REQUESTS ARE EVALUATED BASED UPON BROAD BASED COMMUNITY SUPPORT AND THE URGENCY OF NEED. X X X 0 0 0 0 0 0 0 0 0 WALKER ASHCRAFT MD 132001 0 20723 0 0 0 15984 0 6714 0 175422 0 0 0 FREDERIK ILGENFRITZ MD 219002 0 0 0 0 0 8400 0 1000 0 228402 0 0 0 JOHN M BARTOS 228670 0 0 0 48809 0 20520 0 8713 0 306712 0 0 0 JOHN MORELAND MD 271844 0 45649 0 0 0 38500 0 0 0 355993 0 0 0 JOHN COURCHESNE MD 184452 0 166798 0 0 0 30492 0 6714 0 388456 0 0 0 JEREMIAH CLINTON MD 366354 0 0 0 0 0 0 0 5185 0 371539 0 0 0 YVONNE COURCHESNE MD 163708 0 158705 0 0 0 30492 0 1000 0 353905 0 0 0 LUKE CHANNER MD 249999 0 35896 0 0 0 18500 0 9688 0 314083 0 0 0 MARY CAMDEN MD 272322 0 0 0 110 0 0 0 7688 0 280120 0 0 0 MT HEALTH FACILITY AUTHORITY 810302402 612043ED7 2007-01-31 7068924 CONSTRUCTION OF A NEW EMERGENCY DEPARTMENT 0 0 0 1020000 7135000 1006262 155264 5973474 2008 1 0 1 1 0 0 0 0 1 0 0 0 0 0 0 X THE ISSUE PRICE OF $7,068,924 DOES NOT EQUAL THE TOTAL PROCEEDS OF ISSUE OF $7,135,000 BECAUSE OF A $66,076 ORIGINAL ISSUE DISCOUNT. KATHLEEN OWINGS SPOUSE OF BOARD MEMBER 90549 EMPLOYMENT 0 STEPHEN ELLIS MD BOARD MEMBER 36606 MORTGAGE AGREEMENT 0 WALKER ASHCRAFT MD BOARD MEMBER 36606 MORTGAGE AGREEMENT 0 FORM 990, PART VI, SECTION B, LINE 11 DONJA ERDMAN, CFO AND JOHN BARTOS, CEO WILL REVIEW THE FORM 990 AT THE BOARD MEETING. THIS WILL INCLUDE A DETAIL REVIEW OF THE ITEMS ON EACH PAGE. FORM 990, PART VI, SECTION B, LINE 12C THE HOSPITAL ATTORNEY ATTENDS ALL BOARD MEETINGS AND HE IS GIVEN THE AUTHORITY TO QUESTION, PRIOR TO DISCUSSION, A POTENTIAL CONFLICT OF INTEREST FOR ANY DIRECTOR. THE CEO RAISES A QUESTION REGARDING CONFLICT OF INTEREST. THE HOSPITAL BOARD ASKS THE DIRECTOR TO STEP OUT OF THE ROOM DURING DISCUSSION OF CONFLICT. THE DIRECTOR IS EXCUSED FOR THE DISCUSSION ONCE A CONFLICT HAS BEEN DETERMINED OR IS INVITED BACK INTO THE ROOM IF NO CONFLICT IS DETERMINED TO EXIST. FORM 990, PART VI, SECTION B, LINE 15 CEO - OCCURS ANNUALLY WITH ANNUAL COMPENSATION COMMITTEE OF THE BOARD. THE COMMITTEE REVIEWS SURVEYS FOR COMPARABLE PAY AND BENEFITS. THIS COMMITTEE ALSO CONDUCTS THE ANNUAL EVALUATION OF THE CFO. FORM 990, PART VI, SECTION C, LINE 19 GOVERNING DOCUMENTS AND CONFLICT OF INTEREST POLICY ARE NOT MADE AVAILABLE TO THE PUBLIC. FINANCIAL STATEMENTS ARE MADE AVAILABLE TO THE PUBLIC UPON REQUEST. OFFICER OVERLAP FORM 990, PART VII, SECTION A JOHN M. BARTOS (CEO) AND DONJA C. ERDMAN (CFO) BOTH SERVE AS OFFICERS FOR THE DALY HOSPITAL FOUNDATION. ON AVERAGE THEY WORK 40 HOURS PER WEEK SERVING EACH ORGANIZATION. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: CHANGE IN BENEFICIAL INTEREST IN NET ASSETS OF DALY HOSPITAL FOUNDATION 83,912. AUXILIARY INCOME 13,714. TOTAL TO FORM 990, PART XI, LINE 5: 97,626. DALY HOSPITAL FOUNDATIONINC 1200 WESTWOOD DRIVE HAMILTON MT 59840 363766000 CHARITABLE SERVICES MT 501(C)(3) 11-TYPE 2 N/A 0 0 0 1 0 0 0 0 0 0 0 1 0 1 1 0 0 0 0 DALY HOSPITAL FOUNDTION INC K 163402 FAIR MARKET VALUE