2012-04-09T17:30:42-05:00 2011-06-30 EIDE BAILLY LLP 1601 NW EXPRESSWAY SUITE 1900 OKLAHOMA CITY OK 73118 990 2010-07-01 730579295 Farmers Union Hospital Association D/B/A Great Plains Regional Medical Ctr FARM 5802252511 1801 West Third Lincoln Box 2339 Elk City OK 73648 Roy L Ikner 5802252511 2012-04-04 1 Carolyn Levings 4054783334 2012-03-29 2010 2016-02-24 21:20:13Z Great Plains Regional Medical Center Don Ikner 1801 West Third Lincoln Box 2339 Elk City OK 73648 47478139 0 X N/A X 1929 OK Provide quality healthcare. 10 8 532 42 0 0 350000 200000 50335525 46521230 393146 422971 315761 295114 51394432 47439315 52000 1225 0 0 23688810 20709914 0 0 0 28683665 29442121 52424475 50153260 -1030043 -2713945 103978055 98650598 43674673 41061161 60303382 57589437 X Great Plains Regional Medical Center will distinguish itself as the leader in western Oklahoma & eastern Texas panhandle for comprehensive, cost effective, high-quality healthcare. We will meet the healthcare needs of patients in our service area while achieving cost effective, quality outcomes. We will maintain and enhance collaborative relationships with physicians to better serve the healthcare needs of our service area. 0 0 44711787 46521230 Farmers Union Hospital Association DBA. Great Plains Regional Medical Center in Elk City, Oklahoma (hereinafter referred to as GPRMC) provides quality health care regardless of race, religion, creed, sex, national origin, handicap, age or ability to pay. Although reimbursement for services rendered is critical to the operation and stability of GPRMC, it is recognized that not all individuals possess the ability to purchase essential medical services and further that our mission is to serve the community with respect to providing health care services and health care education. Therefore, in keeping this hospital's commitment to serve all members of its community, free care and/or subsidized care, care provided to persons covered by government programs at below cost, and health care activities and programs to support the community will be considered whether the need and/or individuals inability to pay coexists. These activities included wellness programs, community education programs, special programs for the elderly, handicapped, & medically under-served, and other broad community support activities.GPRMC served over 2,859 patients with more than 9,918 patient days on an inpatient basis. We also had over 60,200 outpatient encounters with patients during the year. We treated 11,681 patients in the emergency department. Our surgical teams performed 3,966 surgeries during the year.GPRMC provides care to persons covered by governmental and other programs as part of its mission to the community. These programs may not pay full charges. To the extent reimbursement is below full charges, GPRMC recognizes these amounts as contractual adjustments in meeting its mission to the entire community. Also, in recognizing its mission to the community, GPRMC provides services for those unable to pay. Additionally, GPRMC has provided services to others who are either unwilling or unable to qualify for charity care guidelines but who are still unable to pay. Community benefit is also provided by GPRMC by its providing reduced price services, free programs offered throughout the year, and initiatives which GPRMC believes will serve a bona fide community health need. See Schedule H for more information regarding these activities. 44711787 1 1 0 0 0 0 0 0 0 1 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 1 71 0 1 532 1 0 0 0 0 0 0 0 0 0 0 X 10 8 0 0 0 0 1 1 1 1 1 0 0 0 1 1 0 1 1 1 0 1 1 OK X Janet Miller Executive Assistant 5808215302 PO Box 2339 Elk City OK 73648 Gene Smith 2.00 X X 0 0 0 Danny L Sprowls CPA 2.00 X X 0 0 0 Paul Kumpf 2.00 X X 0 0 0 Eddie Moore 2.00 X 0 0 0 Emory Thomas 2.00 X 0 0 0 Jack Morrison DDS 2.00 X 0 0 0 Edward Albert 2.00 X 0 0 0 Craig Phelps MD 2.00 X 49300 0 0 Francis Abraham MD 40.00 X 377154 0 4529 David Bank MD 2.00 X 0 0 0 Richard McBryde 40.00 X 122808 0 957 Roy Ikner 40.00 X 298704 0 8743 Laura Kurzendoerfer 40.00 X 176915 0 343 Premal A Khetia MD 40.00 X 449821 0 237 Hugh Leavens MD 40.00 X 441705 0 1901 David G Purdom MD 40.00 X 399185 0 4318 Robert Keith MD 40.00 X 296974 0 2368 Rob Lake 40.00 X 265727 0 0 2878293 0 23396 11 1 1 0 Flintco Inc PO Box 490 Tulsa OK 74101 Construction management 1721171 EMCARE Physician Services 7032 Collection Center Drive Chicago IL 60693 Physician coverage ER 782350 Hospital Care Consultants Inc 17304 Preston Rd Suite 555 Dallas TX 75252 Hospitalist 588000 Waterstone Benefit Administrators 4013 NW Expressway STE 575 Oklahoma City OK 73116 Insurance management 421357 Weatherby Locums Inc PO Box 972633 Dallas TX 75397 Physician/nurse coverage 182945 6 200000 200000 Net Patient Revenue 621990 45090847 45090847 Medicaid Incentive Pay 900099 580698 580698 Cafeteria Sales 900099 396610 396610 Other Service Revenue 900099 241086 241086 Daycare Center Revenue 900099 141752 141752 70237 70237 46521230 425713 425713 17821 17821 277293 277293 277293 277293 36082 38824 -2742 -2742 -2742 47439315 46521230 0 718085 1225 1225 1176515 334417 842098 15648443 14556575 1091868 143234 129844 13390 2606161 2340523 265638 1135561 1007179 128382 109392 109392 47587 47587 3000286 2285529 714757 82088 82088 6936665 6939242 -2577 136204 136204 1284993 1283873 1120 71042 69666 1376 129435 92304 37131 2023592 26852 1996740 5072296 5064689 7607 225710 225710 Bad Debt Expense 7033678 7033678 Cons and Pros 1313094 1169037 144057 Equipment Rental 1261097 1259821 1276 Patient Acct. Collect. 423753 423753 Miscellaneous 217842 216946 896 73367 32632 40735 50153260 44711787 5441473 0 5670034 2834447 7771865 17830740 9799043 8467650 1341576 1348231 915004 786762 82865834 21366145 64543934 61499689 10379006 3412685 873596 842662 2683997 1627732 103978055 98650598 3975008 2236103 38625000 37895000 983854 930058 90811 43674673 41061161 X 60303382 57589437 60303382 57589437 103978055 98650598 -2713945 0 X 0 1 0 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 748759 748759 59264898 8077803 51187095 1677006 422680 1254326 21078299 12865662 8212637 96872 96872 61499689 47439315 50153260 -2713945 0 -2713945 47439315 0 47439315 0 47439315 50153260 0 50153260 0 50153260 Description of Uncertain Tax Positions Under FIN 48: Part X: The Medical Center will recognize future accrued interst and penalties related to unrecognized tax benefits in income tax expense if incurred. 1 1 X 1 X 0 0 1 0 0 386000 386000 0.00900 5231717 4874079 357638 0.00830 5617717 4874079 743638 0.01730 61847 61847 0.00140 82568 82568 0.00190 1225 1225 0.00000 145640 145640 0.00330 5763357 4874079 889278 0.02060 449 449 0.00000 11006 11006 0.00030 675776 675776 0.01570 687231 687231 0.01600 0 2281728 308033 11863820 15190765 -3326945 X 1 1 1 Plains Diagnostic Imaging Radiology Services 0.77600 0.00000 0.22400 1 1 Great Plains Regional Medical Center

PO BOX 2339 1801 W Third Elk City OK 73648

X X X Not Required 1 Part I, Line 3c: The hospital provides a 15% discount to all self-pay (no insurance) patients. There is no asset test to qualify for this discount. There is an asset test to qualify for charity care. Household resources are determined by the guidelines set forth by the Department of Human Services. Part I, Line 7: Amounts on line 7a and 7b were calculated using the cost to charge ratio in IRS worksheet 2. Amounts on lines 7e, f and i are based on actual cost recorded in the general ledger and hours at average rates. Part I, L7 Col(f): The amount of bad debt expense removed from total expenses to determine the community benefit percentage was $7,033,678. Part II: GPRMC provides community building activities within the community, but has not tracked all of the expenses related to these activities. The hospital provides support to the community in the following ways:-GPRMC employees provide many hours of volunteer service to civic and other community benefit clubs in the area. We provide various donations to these clubs, local school systems, and various non-profit foundations & organizations.-Aware of the shortage of physicians in the Elk City area, GPRMC has worked diligently to attract additional physicians to the community. These physicians range from family practice to a variety of specialty areas. Patients will be able to access their healthcare needs locally instead of driving great distances to see a specialist.-GPRMC involvement in community building activities also extends through other programs such as Meals on Wheels which delivers meals to the homebound; donating atheltic trainer services to local schools; and working with the local Foodbank.-GPRMC has a shuttle service for patients without transportation to the physician's offices, clinics and the hospital. The free shuttle travels in Elk City and area communities.-GPRMC is committed to coalition building through the March of Dimes program. Part III, Line 4: The organization's bad debt expense at cost was calculated using the expense reported on the financial statements and applying an overall cost-to-charge ratio calculated from Worksheet 2. Bad debt expense is reported net of contractual allowances and discounts. All discounts and payments are applied before written off to bad debt. A payment on an account that was previously written off reduces bad debt expense in the current year.The estimated amount of the organization's bad debt expense at cost attributable to patients under the organization's financial assistance policy was calculated by applying a percentage of the population below federal poverty guidelines to bad debt at cost.Financial Statement Footnote: The carrying amount of patient receivables is reduced by a valuation allowance that reflects management's best estimate of amounts that will not be collected from patients and third-party payors. Management reviews patient receivables by payor class and applies percentages to determine estimated amounts that will not be collected from third parties under contractual agreements and amounts that will not be collected from patients due to bad debts. Management considers historical write off and recovery information in determining the estimated bad debt provision. Part III, Line 8: GPRMC provides services to Medicare patients understanding there will be write-offs and knowing the organization will not recover the costs of the services provided. Providing these services is essential to the community and therefore increases access to healthcare services, which is a community benefit.Total revenue received from Medicare (including DSH and IME) is the gross reimbursement plus settlement (including LSA). Both the total revenue received from Medicare and the Medicare allowable costs are reported from the Medicare Cost Report. Part III, Line 9b: The patients are pre-screened prior to testing for charitable services and a determination is made as to the financial ability to pay. If patients are pre-qualified for services, the collection process is ceased. Part VI, Line 2: The organization relies on input from physicians, other healthcare providers, community leaders, the Board of Directors, citizens, etc. in the community. We look at out-migration studies to determine what services people from our community are seeking and receiving from outside locations. We also consider comparisons of the volume of physician specialties in our area to nationally recognized data. These factors are all considered in addition to feedback from patients in the community to determine shortage of care areas. Part VI, Line 3: Assistance is discussed with patients as part of the intake process. They are screened at registration for need for financial assistance and then are given copies of charity care policy/financial policy upon request. We try to assist people in qualifying for some type of medical assistance whether it be Medicare, Medicaid, disability or charity care. Part VI, Line 4: Great Plains Regional Medical Center is a sixty-two licensed bed acute care hospital located in Elk City, Oklahoma in Beckham County. The Corporation provides a comprehensive range of general, acute and specialized care, as well as outpatient and ancillary services, to residents in its primary and secondary service areas covering ten counties. Estimated primary and secondary service area population exceeds 100,000 people. The median household income in Becham County is $43,642 and 16% of the county is below poverty level. Part VI, Line 6: Our Board of Directors is made up of citizens from the community, from business owners to retired individuals. This broadly based group provides us with a broad perspective on the needs of the community.GPRMC extends medical privilegs to area physicians. They must apply for privileges and then be approved by the Medical Staff and then by the Board of Directors.If GPRMC has a surplus funds, then they are used by the organization to fulfill our mission, vision, and values.As quantified in Part II, question 7 e,f and i community benefit is provided by GPRMC through free programs offered throughout the year and initiatives which GPRMC believes serve a bona fide community health need. Some of these activities are as follows: -Notices are published in area newspapers, regarding new physicians or medical services. According to estimated newspaper circulation, these ads reach from 8,000 to 10,000 homes in the area.-The hospital offers a special reduced rate for mammogram screenings each year. -GPRMC provided flu shots for the office personnel of the physicians in the community. -GPRMC provides breast self-exam, CPR and pre-natal education to community members.-Medical professionals who work for GPRMC provide mini health fairs for the local communities and businesses.-GPRMC is one of two designated donor locations for the community-wide blood drive held five times per year.-GPRMC sponsors healthcare education initiatives for the community. Some of these include diabetes self-management classes for patients with new or uncontrolled diabetes and education to local nursing home staff regarding care of patients with dementia and other types of behavioral disorders.-Due to the shortage of nurses, scholarships are awarded to students wishing to pursue degrees in the medical field. -Representatives from GPRMC present education programs at the local adult learning center relative to education needed to fulfill the requirements for employment in a hospital setting. We also participate in several career fairs for different schools in our area.-GPRMC works in cooperation with educators by providing a clinical rotation training environment for students of various fields including physician, nursing, pharmacy, lab, radiology and medical records.-We participate with area high schools in the 'Job Shadow Program'. Students interested in health careers may observe our staff in the work setting and obtain a first-hand experience.-GPRMC has developed a collaboration with western Oklahoma State College to provide distance learning classes for those in the community wishing to pursue nursing degrees. GPRMC's part of the collaborative included a donation of $ 50,000 in 2009 to operate the program and provide a classroom in the local community. Additionally, in-kind services are provided to western Oklahoma State College. This is vital to those prospective students pursuing nursing degrees that would not have been able to drive the long distance to the college.-GPRMC provides education by hosting a Health Education Fair to help educate the community on various diseases by providing presentations from Physicians, video presentations, screening exams, and pamplets. X X X X X 1 0 0 0 0 0 0 0 0 Francis Abraham MD 345473 0 27101 0 4580 0 0 0 4529 0 381683 0 0 0 Roy Ikner 261089 0 35050 0 2565 0 3893 0 4850 0 307447 0 0 0 Laura Kurzendoerfer 175867 0 50 0 998 0 0 0 343 0 177258 0 0 0 Premal A Khetia MD 449771 0 50 0 0 0 0 0 237 0 450058 0 0 0 Hugh Leavens MD 441655 0 50 0 0 0 0 0 1901 0 443606 0 0 0 David G Purdom MD 371357 0 27828 0 0 0 2406 0 1912 0 403503 0 0 0 Robert Keith MD 252705 0 44269 0 0 0 2044 0 324 0 299342 0 0 0 Rob Lake 265727 0 0 0 0 0 0 0 0 0 265727 0 0 0 Part I, Line 4a Rob Lake, CEO $265,727 severance pay based upon prior salary and service period. The Oklahoma Development Finance Authority 731083741 678910DB3 2007-06-26 39448937 Great Plains Regional Medical Center-Construct & Furnish 62 Bed Hospital 0 0 0 36232616 2653544 562777 2009 0 0 0 1 0 0 0 0 1 0 0 0 0 0 0 Form 990, Part VI, Section A, line 6 Members are individuals who have voting shares in the organization. Membership is obtained through transfers of existing memberships. Transfers normally result either through voluntary surrender of a membership from a current member who is no longer interested in retaining their membership or through the death of a member who has no immediate family interested in retaining the membership. Each individual is allowed only one membership and there is only one vote allowed per membership. Form 990, Part VI, Section A, line 7a Governing Board members are appointed through nomination and a majority vote election by the membership at annual meetings. Form 990, Part VI, Section A, line 7b Any edits to the Governing Board Bylaws, Rules & Regulations have to be approved by a majority vote of the membership. Per the organizations bylaws, the members are the supreme authority of the Association in all its affairs. Form 990, Part VI, Section B, line 11 Form 990 will be presented and reviewed at one of the Governing Board's monthly meetings. The Form 990 will also have been posted on the Governing Board's website in the days preceding the monthly meeting. Form 990, Part VI, Section B, line 12 On an annual basis, all members of the Governing Body and key employees receive a copy of the organizations conflict of interest policy. They are required to review the policy, complete a conflict of interest questionnaire and sign the questionnaire, attesting to their understanding of the policy and that their answers on the questionnaire are true and accurate. Form 990, Part VI, Section B, line 15a HR conducts a comparative analysis using state, multi-state, regional, and national compensation (by-position) data. Data is culled into bed-size, revenue, and similar area comparatives. HR submits a report to the Executive Committee of the Board of Directors annually. The Executive Committee reviews the data, confirms the data with an out of house auditor, and recommends appropriate CEO compensation to the Board of Directors as a whole. All other positions are reviewed annually by HR and approved by the CEO. Form 990, Part VI, Section C, line 19 Those documents are available to the public upon request. A copy of the requested document is provided when practical. Otherwise, an appointment for an on-site review of the requested documents is made, with the day and time of the appointment determined by the person(s) who has made the request, according to their schedule and convenience. Foundation Board of Great Plains Regional Medical Center PO BOX 2339 Elk City OK 736482339 730479295 Providing support for Healthcare OK 501(C)3 N/A 0 Plains Diagnostic Imaging LLC PO BOX 2339 Elk City OK 73648 261530951 Radiology Services OK N/A Equipment Rental -160831 1477862 0 1 0.77600 0 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 Plains Diagnostic Imaging LLC J 1089726 Book Foundation Board of Great Plains C 200000 Book