2012-04-22T12:56:55-05:00 2011-06-30 EIDE BAILLY LLP 800 NICOLLET MALL STE 1300 MINNEAPOLIS MN 554027033 990 2010-07-01 237169043 CENTRAL MONTANA MEDICAL FACILITIES INC CENT 4065387711 408 WENDELL AVENUE LEWISTOWN MT 59457 ALAN R ALDRICH 4065386243 2012-04-16 1 KIM C HUNWARDSEN 6122536500 2012-04-17 2010 2016-02-24 21:20:13Z CENTRAL MONTANA MEDICAL CENTER DAVID FAULKNER 408 WENDELL AVENUE LEWISTOWN MT 59457 26768915 0 X WWW.CMMCCARES.COM X 1971 MT THE MISSION OF CMMC IS TO BE THE LEADER IN ASSURING COMMUNITY BASED QUALITY HEALTHCARE. 13 11 443 350 0 0 62928 140928 25012193 24480464 103817 21398 5130 4660 25184068 24647450 0 0 0 0 14740308 14754925 0 0 42909 10360013 10552851 25100321 25307776 83747 -660326 19912767 20642912 4917200 5536887 14995567 15106025 X THE MISSION OF CENTRAL MONTANA MEDICAL CENTER IS TO BE THE LEADER IN ASSURING COMMUNITY BASED QUALITY HEALTHCARE. 0 0 2492223 4164143 SKILLED NURSING CARE/LONG TERM CARE REHAB OR LONG TERM NURSING SERVICES:NUMBER OF BEDS: 85PROVIDED 20,929 DAYS OF CARE FOR A 67.46% OCCUPANCY RATE. 2437280 1427472 EMERGENCY SERVICES:PROVIDED FOR 5,199 EMERGENCY VISITS.24 HOUR PHYSICIAN COVERAGE AVAILABLE. 1507223 2527296 HOSPITAL INPATIENT SERVICES:NUMBER OF BEDS: 25PROVIDED 2,274 ACUTE DAYS OF CARE AND 923 SWING BED DAYS OF CARE FOR A 25% OCCUPANCY RATE. 14089493 16361553 CMMC ALSO PROVIDES OTHER PATIENT CARE SERVICES INCLUDING CLINIC, INTENSIVE AND CORONARY CARE AND NURSERY CARE. SOME OF THE LARGER ANCILLARY SERVICES INCLUDE LABORATORY, PHARMACY, OPERATING ROOM, CT SCAN AND RADIOLOGY, THERAPY SERVICES, SURGERY CLINIC, AND HOME OXYGEN CARE. COMMUNITY CARE AND SERVICES ARE ALSO PROVIDED THROUGH THE MANY REDUCED PRICE SERVICES AND FREE CLINICS, FAIRS, AND PROGRAMS OFFERED THROUGHOUT THE YEAR. THESE INCLUDE BUT ARE NOT LIMITED TO THE FOLLOWING (ALL COSTS ARE ESTIMATES): 1. TWENTY-NINE FOOT CLINICS WERE HELD IN 2010-2011 IN DENTON, HOBSON AND LEWISTOWN, MT. A TOTAL OF 393 PEOPLE WERE SERVED, ALL RECEIVED DISCOUNTED HEALTH CARE. TOTAL COMMUNITY BENEFIT EXPENSE OF $3,825.2. TWO HEALTH FAIRS WERE HELD IN 2010-2011, SERVING 4,306 PEOPLE IN FERGUS AND BASIN COUNTIES. ALL RECEIVED DISCOUNTED HEALTH CARE. TOTAL COMMUNITY BENEFIT EXPENSE OF $7,817.3. TWO SUPPORT GROUPS MET IN 2010-2011, SERVING 56 PEOPLE. SUPPORT GROUPS INCLUDED CANCER AND DIABETES EDUCATION. TOTAL COMMUNITY BENEFIT EXPENSE OF $1,076.4. CMMC EDUCATED LOCALS WITH A BABY SITTING CLASS (25 PEOPLE SERVED, 1 CLASS OFFERED, TOTAL COMMUNITY BENEFIT $751), AND SEVERAL COMMUNITY BOARDS WERE SERVED ON IN 2010-2011 FOR A TOTAL OF $5,722. THE FACILITY MAINTAINS RECORDS TO IDENTIFY AND MONITOR THE LEVEL OF CHARITY CARE IT PROVIDES. THESE RECORDS INCLUDE THE AMOUNT OF CHARGES FOREGONE FOR SERVICES AND SUPPLIES FURNISHED UNDER ITS CHARITY CARE POLICY. THE AMOUNT OF CHARGES FOREGONE, BASED ON ESTABLISHED RATES, WAS $739,596 FOR THE CURRENT YEAR. 14089493 16361553 20526219 1 1 0 0 0 0 0 0 0 1 0 0 1 1 1 1 0 0 0 0 0 0 0 1 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 1 32 0 1 443 1 0 0 0 0 0 0 0 0 0 0 X 13 11 1 1 0 0 1 1 0 1 1 0 0 1 1 1 1 1 1 0 0 0 X ALAN R ALDRICH CFO 4065357711 408 WENDELL AVENUE LEWISTOWN MT 59457 X WAYNE EDWARDS 2.00 X X 0 0 0 MIKE ZACHER 2.00 X X 0 0 0 NANCY WILSON 2.00 X X 0 0 0 JOHN JENSEN 1.00 X 0 0 0 DOUG FLAMENT 1.00 X 0 0 0 ALTA PALLETT 1.00 X 0 0 0 DAVE PHILLIPS 1.00 X 0 0 0 RUSSELL SPIKA CPA 1.00 X 0 0 0 MIKE DELANEY 1.00 X 0 0 0 FRANCIS WEINHEIMER 1.00 X 0 0 0 LAURA BENNETT MD 1.00 X 20000 0 0 CHRISTINE VOLF 1.00 X 0 0 0 ROY KOHLER MD 1.00 X 6912 0 0 CARL SEILSTAD 1.00 X 0 0 0 DAVID FAULKNER 40.00 X 155087 0 48792 ALAN R ALDRICH 40.00 X 102482 0 29600 DIANNE SCOTTEN 40.00 X 96283 0 12672 DANNY HARBOUR 40.00 X 175499 0 36172 JAMES FOX 40.00 X 203046 0 18344 BRIAN PRIEST 40.00 X 176880 0 25786 RONALD SKIPPER 40.00 X 296840 0 39924 RENE DEGUZMAN 40.00 X 177867 0 26838 1410896 0 238128 8 0 1 0 QUORUM HEALTH RESOURCES LLC 105 CONTINENTIAL PLACE BRENTWOOD TN 37027 FACILITY MANAGEMENT & CEO SERVICES 506743 GE MEDICAL SYSTEMS PO BOX 843553 DALLAS TX 75284 MRI CONTRACT SERVICES 140041 2 29108 24150 87670 140928 NET PATIENT REVENUE 622110 23455816 23455816 SPECIAL PROGRAMS 900099 901603 901603 CAFETERIA 722210 124396 124396 -1351 -1351 24480464 131477 131477 287656 295929 -8273 -8273 -8273 1690425 13747 1808177 6074 -117752 7673 -110079 -110079 11285 29108 11285 0 INTEREST INCOME 900099 12933 12933 12933 24647450 24480464 0 26058 258721 134489 124232 11831844 9465475 2347089 19280 239283 188513 50192 578 1578129 1254122 318131 5876 846948 677558 168158 1232 461751 277051 184700 58745 58745 32500 32500 746083 746083 57894 28947 19011 9936 3162479 2824612 335427 2440 973591 749041 222750 1800 47820 47820 93740 62012 31728 140848 109861 30987 1180190 888258 291623 309 621141 585934 35207 BAD DEBT ALLOWANCE 898816 898816 SERVICE CONTRACTS 582430 383660 197590 1180 EQUIPMENT RENTAL AND MA 251685 209457 42228 1243138 994510 248350 278 25307776 20526219 4738648 42909 1570599 576615 3479999 3339910 50238 442033 476943 144993 144684 29767038 20292731 8095441 9474307 3616602 4011332 251996 2512862 2367125 19912767 20642912 2125546 2052036 1147968 916227 1643686 2056795 443500 0 68329 4917200 5536887 X 13271811 13325124 931428 980947 792328 799954 14995567 15106025 19912767 20642912 X -660326 770784 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 1 6260 10833 11659 5434 103009 103009 16934704 11056508 5878196 11513383 8626610 2886773 1215942 609613 606329 9474307 LONG-TERM PREPAID EXPENSES 283501 DUE FROM FOUNDATION 1780901 OTHER RECEIVABLES 302723 2367125 ESTIMATED THIRD-PARTY PAYOR SETTLEMENTS 68329 68329 24647450 25307776 -660326 713639 57145 770784 110458 24831559 0 24831559 -184109 -184109 24647450 25603705 0 25603705 -295929 -295929 25307776 PART IV, LINE 1B: NURSING HOME TRUST ACCOUNT. THESE FUNDS BELONG TO OUR RESIDENTS. WE HAVE DEPOSITED THEM IN TRUST FOR VARIOUS SMALL EXPENSES INCURRED BY THE INDIVIDUALS. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: THE FACILITIES UNDERGO AN ANNUAL ANALYSIS OF ITS VARIOUS TAX POSITIONS, ASSESSING THE LIKELIHOOD OF THOSE POSITIONS BEING UPHELD UPON EXAMINATION WITH RELEVANT TAX AUTHORITIES. AS OF JUNE 30, 2011 AND 2010, THE UNRECOGNIZED TAX BENEFIT ACCRUAL IS ZERO. THE FACILITIES WILL RECOGNIZE FUTURE ACCRUED INTEREST AND PENALTIES RELATED TO TAX BENEFITS IN INCOME TAX EXPENSE, IF INCURRED. THE FACILITIES ARE NO LONGER SUBJECT TO FEDERAL OR STATE TAX EXAMINATIONS BY TAX AUTHORITIES FOR THE YEARS BEFORE 2007. PART XI, LINE 8 - OTHER ADJUSTMENTS: INTEREST IN CENTRAL MONTANA FOUNDATION 57,145. PART XII, LINE 4B - OTHER ADJUSTMENTS: CONTRIBUTIONS FOR SPECIFIC PURPOSES RECORDED IN FUND BALANCE FOR F/S 111,820. RENTAL EXPENSES RECORDED IN EXPENSES FOR FINANCIAL STATEMENTS -295,929. PART XIII, LINE 4B - OTHER ADJUSTMENTS: RENTAL EXPENSES RECORDED IN EXPENSES FOR FINANCIAL STATEMENTS -295,929. HOSPICE AUCTION & HOME TOURS 18493 12146 6347 4500 1847 GOLF TOURNEY 12001 7919 4082 449 3213 420 1 9899 9043 856 856 40393 29108 11285 449 7713 3123 11285 0 1 1 X 1 X 1 X 1 1 1 0 0 468 479247 479247 0.01960 2434515 2615931 -181416 0.00000 468 2913762 2615931 297831 0.01960 11 8760 18794 3991 14803 0.00060 3683298 2829173 854125 0.03500 3 1408 10665 10665 0.00040 14 10168 3712757 2833164 879593 0.03600 14 10636 6626519 5449095 1177424 0.05560 3 8641 12423 12423 0.00050 3 8641 12423 12423 0.00050 0 582420 13197 5955760 5861153 94607 X 1 1 1 1 CENTRAL MONTANA MEDICAL CENTER

408 WENDALL AVENUE LEWISTOWN MT 59457

X X X X HOME HEALTH / HOSPICE NOT REQUIRED 1 3 CENTRAL MONTANA MEDICAL CENTER - DME

202 4TH AVENUE SOUTH LEWISTOWN MT 59457

HME/DME SERVICES BASIN MEDICAL CENTER

76 CENTRAL AVENUE STANFORD MT 59479

RURAL HEALTH CLINIC CENTRAL MT MEDICAL CENTER SKILLED

NURSING CENTER 408 WENDELL AVENUE LEWISTOWN MT 59457

SKILLED NURSING FACILITY PART I, LINE 3C: ELIGIBILITY IS BASED ON PATIENT'S FAMILY SIZE, FAMILY GROSS INCOME, PERSONAL ASSETS, AND OTHER MEDICAL DEBTS. PART I, LINE 7: CHARITY CARE WAS CONVERTED TO COST USING THE COST-TO-CHARGE RATIO DERIVED FROM WORKSHEET 2. UNREIMBURSED MEDICAID WAS CONVERTED TO COST USING THE COST-TO-CHARGE RATIO DERIVED FROM WORKSHEET 2. COMMUNITY HEALTH IMPROVEMENT SERVICES AND CASH AND IN-KIND CONTRIBUTIONS WERE BASED ON EXPENSES RECORDED IN THE GENERAL LEDGER. SUBSIDIZED HEALTH SERVICES ARE REPORTED ACCORDING TO COSTS ALLOCATED TO THE RELEVANT COST CENTERS ON THE MEDICARE COST REPORT. PART I, LINE 7G: $317,978 OF COSTS ARE ATTRIBUTABLE TO A PROVIDER BASED CLINIC. PART I, L7 COL(F): THE AMOUNT OF BAD DEBT EXPENSE REMOVED FROM THE DENOMINATOR OF THE CALCULATION WAS $898,816. PART II: CMMC PROMOTES THE HEALTH OF THE COMMUNITY BY SERVING ON SEVERAL DIFFERENT COMMUNITY BOARDS AND THROUGH SEVERAL COMMUNITY EVENTS. SEVERAL OF THE ORGANIZATION'S DEPARTMENT MANAGERS SERVE ON COMMUNITY BOARDS SUCH AS RELAY FOR LIFE, KIWANIS, TRANSPORTATION ADVISORY BOARD, COMMUNITY HEALTH STEERING COMMITTEE, AND THE LOCAL EMERGENCY PLANNING COMMITTEE. BY BEING INVOLVED IN COMMUNITY GROUPS, THE ORGANIZATION HAS THE OPPORTUNITY TO ADDRESS UNDERLYING CAUSES OF HEALTH ISSUES. PART III, LINE 4: BAD DEBT EXPENSE WAS CONVERTED TO COST USING THE COST-TO-CHARGE RATIO DERIVED FROM WORKSHEET 2. THE ESTIMATED AMOUNT OF BAD DEBT EXPENSE ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S CHARITY CARE POLICY IS CALCULATED BY USING CHARITY CARE AS A % OF GROSS PATIENT SERVICES REVENUE. AS A PORTION OF REVENUE IS CONSIDERED CHARITY CARE, IT IS ASSUMED THAT A PERCENTAGE OF BAD DEBT EXPENSE WOULD ALSO BE CONSIDERED CHARITY CARE.BAD DEBT EXPENSE IS REPORTED NET OF DISCOUNTS AND CONTRACTUAL ALLOWANCES. A PAYMENT ON AN ACCOUNT PREVIOUSLY WRITTEN OFF REDUCES BAD DEBT EXPENSE IN THE CURRENT YEAR.FINANCIAL STATEMENT NOTE: THE CARRYING AMOUNT OF PATIENT AND RESIDENT RECEIVABLES IS REDUCED BY A VALUATION ALLOWANCE THAT REFLECTS MANAGEMENT'S BEST ESTIMATE OF AMOUNTS THAT WILL NOT BE COLLECTED FROM PATIENTS, RESIDENTS AND THIRD PARTY PAYORS. MANAGEMENT REVIEWS PATIENT AND RESIDENT 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 AND RESIDENTS DUE TO BAD DEBTS. MANAGEMENT CONSIDERS HISTORICAL WRITE OFF AND RECOVERY INFORMATION IN DETERMINING THE BAD DEBT PROVISION. PART III, LINE 8: MEDICARE ALLOWABLE COSTS OF CARE ARE BASED ON THE MEDICARE COST REPORT. THE MEDICARE COST REPORT IS COMPLETED BASED ON THE RULES AND REGULATIONS SET FORTH BY CMS. PART III, LINE 9B: PATIENTS DEEMED UNABLE TO PAY BY CMMC AT ANY TIME DURING THE REVENUE CYCLE MAY BE ELIGIBLE TO RECEIVE AVAILABLE FINANCIAL ASSISTANCE. PATIENTS MUST COMPLETE AN APPLICATION. OUR COLLECTION PRACTICE IS TO REFRAIN FROM COLLECTION EFFORTS UNTIL FINANCIAL ASSISTANCE IS DETERMINED. NORMAL COLLECTION EFFORTS WOULD RESUME IF THE APPLICATION IS NOT RETURNED TIMELY OR AFTER THE WRITE-OFF IS COMPLETE AND THE PATIENT OWES A BALANCE. PART VI, LINE 2: CURRENTLY, CMMC ASSESSES THE HEALTH CARE NEEDS OF THE COMMUNITY BY THE NUMBER OF RESPONSES TO ADS AND ARTICLES RELEASED THROUGH THE LOCAL MEDIA. CMMC MONITORS THE ATTENDANCE AT ANNUAL EVENTS SUCH AS HEALTH FAIRS. IN ADDITION, CMMC TRACKS THE TYPES OF SUPPORT REQUESTED TO PROVIDE SUCH AS CHILDREN'S SAFETY, WELLNESS INITIATIVES AND HEALTHCARE ASSESSMENTS. IN THE PAST, CMMC COMPLETED AN OFFICIAL COMMUNITY NEEDS ASSESSMENT WITH THE HELP OF MONTANA STATE UNIVERSITY. MAIL AND PHONE SURVEYS WERE COMPLETED AND "TOWN HALL" TYPE MEETINGS WERE HELD IN LEWISTOWN AS WELL AS MOST OF THE SURROUNDING SMALLER COMMUNITIES. CMMC WILL BE DOING ANOTHER COMMUNITY NEEDS ASSESSMENT IN THE NEAR FUTURE TO MEET 501(R) REQUIREMENTS. PART VI, LINE 3: CMMC HAS FINANCIAL ASSISTANCE SIGNAGE POSTED IN THE ADMISSIONS AREAS AND THE ER WAITING AREA. A PAMPHLET EXPLAINING OUR FINANCIAL ASSISTANCE PROGRAM, THE APPLICATION PROCESS AND CONTACT INFORMATION IS AVAILABLE AT ALL HOSPITAL REGISTRATION AREAS. THE CHARITY CARE POLICY AND APPLICATION ALONG WITH A CHECKLIST AND CONTACT INFORMATION IS POSTED ON OUR WEBSITE ON THE INTERNET. PRIOR TO DISCHARGE, SOMEONE FROM DISCHARGE PLANNING DISCUSSES WITH THE PATIENT THE AVAILABILITY OF VARIOUS GOVERNMENT BENEFITS, SUCH AS MEDICAID, AND ASSISTS THE PATIENT WITH QUALIFICATIONS FOR SUCH PROGRAMS, WHERE APPLICABLE. ASSISTANCE WITH FILLING OUT THE CHARITY CARE APPLICATION IS ALSO PROVIDED AT THIS TIME. PRIVATE PAY IN-PATIENTS ARE INFORMED OF CHARITY CARE EITHER PRIOR TO SCHEDULED ADMISSION BY PHYSICIAN REFERRAL OR PRIOR TO DISCHARGE FROM THE FACILITY. WE ALSO SEND OUT INFORMATION WITH FIRST TIME STATEMENTS. ALL OTHER PATIENTS ARE INFORMED UPON INQUIRY. PART VI, LINE 4: LEWISTOWN IS AN AGRICULTURAL COMMUNITY AND THE COUNTY SEAT FOR FERGUS COUNTY MONTANA. LEWISTOWN IS LOCATED IN THE CENTER OF MONTANA AND IS SURROUNDED BY FIVE MOUNTAIN RANGES: THE SNOWIES, THE JUDITHS, THE MOCCASINS, THE BELTS AND THE HIGHWOODS. THE CITY OF LEWISTOWN AND THE SURROUNDING RURAL TOWNS ARE SUPPORTED BY ONE HOSPITAL, CENTRAL MONTANA MEDICAL CENTER. FERGUS COUNTY HAS A PRIMARY CARE LOW INCOME HPSA DESIGNATION WITH A SCORE OF 16. FERGUS COUNTY IS LOCATED IN A FEDERALLY DESIGNATED MEDICALLY UNDERSERVED AREA. AS OF 2010, THERE WERE 5,901 PEOPLE RESIDING IN THE CITY. THE POPULATION DENSITY WAS 1,109.4 PEOPLE PER SQUARE MILE. ALSO 11.5% OF THE RESIDENTS WERE BELOW THE POVERTY LEVEL.THE RACIAL MAKEUP OF THE CITY WAS 95.40% WHITE, 0.30% AFRICAN AMERICAN, 1.7% NATIVE AMERICAN, 0.40% ASIAN, AND 2.0% FROM TWO OR MORE RACES. HISPANIC OR LANTINO OF ANY RACE WERE 2.1% OF THE POPULATION.THERE WERE 2,808 HOUSEHOLDS OUT OF WHICH 87.3% HAVE LIVED IN THE SAME HOUSE FOR 1 YEAR & OVER. LANGUAGES OTHER THAN ENGLISH SPOKEN AT HOME WERE 1.9%. THE AVERAGE HOUSEHOLD SIZE WAS 2.08. MEDIAN VALUE OF OWNER-OCCUPIED HOUSING UNITS WAS $96,900 WITH A PER CAPITA INCOME IN THE PAST 12 MONTHS OF $22,664. 84.4% OF THE RESIDENTS ARE HIGH SCHOOL GRADUATES WITH 20.0% HAVING RECEIVED A BACHELOR'S DEGREE OR HIGHER. IN THE CITY, THE POPULATION SPREAD WAS 5.9% PERSONS UNDER 5 YEARS OF AGE, 20.4% UNDER THE AGE OF 18, 21.7% PERSONS 65 YEARS AND OVER WITH 50.8% BEING OF FEMALE SEX. PART VI, LINE 6: THE CMMC GOVERNING BOARD CONSISTS OF 13 VOLUNTEER COMMUNITY MEMBERS INCLUDING RESIDENTS FROM GRASS RANGE, STANFORD, DENTON AND JUDITH GAP. CMMC EXTENDS MEDICAL STAFF PRIVILEGES TO QUALIFIED PHYSICIANS BASED UPON COMMUNITY NEEDS.SURPLUS FUNDS, WHEN AVAILABLE, ARE APPLIED TO PATIENT CARE NEEDS, EQUIPMENT AND BUILDING MAINTENANCE AND MEDICAL EDUCATION REQUIREMENTS. THE EXPENDITURE OF THESE FUNDS ARE APPROVED BY THE GOVERNING BOARD WHICH MEETS ON A MONTHLY BASIS. PART VI, LINE 7: N/A X 0 0 0 0 0 0 0 0 0 DAVID FAULKNER 155087 0 0 0 0 0 0 0 0 0 155087 0 0 0 DANNY HARBOUR 175499 0 0 0 0 0 23546 0 13699 0 212744 0 0 0 JAMES FOX 203046 0 0 0 0 0 18344 0 1073 0 222463 0 0 0 BRIAN PRIEST 176880 0 0 0 0 0 14830 0 10956 0 202666 0 0 0 RONALD SKIPPER 296840 0 0 0 0 0 24353 0 16644 0 337837 0 0 0 RENE DEGUZMAN 177867 0 0 0 0 0 11267 0 16608 0 205742 0 0 0 SUPPLEMENTAL INFORMATION PART III PART I, QUESTION 3: THE ORGANIZATION DOES NOT PAY COMPENSATION TO THE CEO DIRECTLY. THE CEO IS COMPENSATED BY AN UNRELATED MANAGEMENT COMPANY. THE BOARD OF DIRECTORS APPROVES THE CONTRACT WITH THE MANAGEMENT COMPANY. PART II: THE CEO, DAVID FAULKNER, IS COMPENSATED BY AN UNRELATED MANAGEMENT COMPANY, QUORUM HEALTH RESOURCES LLC. HE IS COMPENSATED FOR SERVICES PROVIDED TO C.M. MEDICAL FACILITIES, INC. THE MANAGEMENT COMPANY BASES THE CEO'S SALARY ON COMPENSATION SURVEYS FOR THE AREA. THE BOARD OF DIRECTORS APPROVES THE CONTRACT WITH QUORUM OR MAKES RECOMMENDATIONS BACK TO THE MANAGEMENT COMPANY. FERGUS COUNTY MONTANA 816001358 2003-07-31 1980000 REFUND OLD BONDS 0 0 0 FERGUS COUNTY MONTANA 816001358 2006-08-25 1529611 MRI SYSTEM PROJECT 0 0 0 FERGUS COUNTY MONTANA 816001358 2003-04-30 525000 CONSTRUCT/EQUIPMENT ADDITION 0 0 0 1354331 1980000 1980000 2003 1 0 1 1 1362768 1529611 29611 1500000 2006 0 0 1 1 525000 2800 522200 2003 0 0 1 1 0 0 0 0 0.00000 0.00000 0.00000 1 0 0 0 0 0.00000 0.00000 0.00000 1 0 0 0 0 0 1 0 0 0 0 0 1 0 0 0 0 0 1 ANNIE DAVIS FAMILY OF BOARD MEMBER 47926 PAYMENT OF COMPENSATION 0 YELLOWSTONE INSTURANCE CEO OF ORGANIZATION IS ALSO A DIRECTOR FOR YELLOWSTONE INSURANCE 530000 PAYMENT FOR SERVICES 0 FORM 990, PART VI, SECTION A, LINE 1 THE EXECUTIVE COMMITTEE INCLUDES THE PRESIDENT, VICE PRESIDENT, SECRETARY, AND TREASURER. THEIR AUTHORITY IS SIMILAR TO THAT OF THE FULL GOVERNING BOARD. FORM 990, PART VI, SECTION A, LINE 2 RUSSELL SPIKA AND ALAN R. ALDRICH HAVE A BUSINESS RELATIONSHIP. FORM 990, PART VI, SECTION A, LINE 3 THE ORGANIZATION DELEGATED CONTROL OVER MANAGEMENT DUTIES CUSTOMARILY PERFORMED BY OR UNDER DIRECT SUPERVISION OF OFFICERS, DIRECTORS, TRUSTEES, OR KEY EMPLOYEES TO THE CEO WHO IS EMPLOYED BY A MANAGEMENT COMPANY, QUORUM HEALTH RESOURCES LLC (QHR). QHR ASSISTS WITH THE MANAGEMENT AND SUPERVISION OF THE ORGANIZATION UNDER THE POLICIES AND DIRECTION OF THE GOVERNING BOARD. FORM 990, PART VI, SECTION A, LINE 6 THE ORGANIZATION MEMBERS CONSIST OF RESIDENTS OF THE CENTRAL MONTANA AREA WHO ARE AT LEAST 18 YEARS OF AGE AND WHO HAVE OR SHALL INDICATE THEIR INTEREST IN THE MAINTENANCE OF ADEQUATE MEDICAL FACILITIES AND HIGH STANDARDS OF MEDICAL CARE IN THE AREA. MEMBERS OF THE ORGANIZATION MUST ATTEND AND SIGN THE REGISTER AT THE ORGANIZATION'S ANNUAL MEETING. FORM 990, PART VI, SECTION A, LINE 7A MEMBERS OF THE ORGANIZATION MAY VOTE ON MATTERS BEING ADDRESSED AT THE ANNUAL MEETINGS. EACH MEMBER IS ENTITLED TO ONE VOTE ON ANY QUESTION OR ACTION WITH THE EXCEPTION OF THE ELECTION OF DIRECTORS OF THE CORPORATION. FOR THE ELECTION OF DIRECTORS, THE MEMBERS SHALL VOTE FOR ONE NOMINEE FOR EACH VACANT BOARD POSITION. FORM 990, PART VI, SECTION B, LINE 11 DRAFT COPY OF FORM 990 IS REVIEWED BY THE CFO AND BOARD OF DIRECTORS PRIOR TO ITS FILING. FORM 990, PART VI, SECTION B, LINE 12C THE ORGANIZATION REGULARLY AND CONSISTENTLY MONITORS AND ENFORCES COMPLIANCE WITH THE CONFLICT OF INTEREST POLICY BY DISCUSSING AT THE BOARD OF DIRECTOR MEETINGS AND OBTAINING SIGNED STATEMENTS FROM MEMBERS. ALL OFFICERS, BOARD MEMBERS, AND KEY EMPLOYEES ARE COVERED BY THE POLICY. THE BOARD DETERMINES WHETHER CONFLICTS EXIST AND ALL POTENTIAL CONFLICTS ARE REVIEWED BY THE BOARD. ANY PERSONS WITH A CONFLICT ARE NOT ALLOWED TO VOTE ON CONFLICTED ISSUES. FORM 990, PART VI, LINE 15: THE CEO IS EMPLOYED BY QUORUM HEALTH RESOURCES LLC (QHR), A HOSPITAL MANAGEMENT CORPORATION. QHR DETERMINES THE CEO'S COMPENSATION BASED ON INDEPENDENT DATA AND COMPARISONS. THE INFORMATION IS THEN PRESENTED TO THE BOARD OF DIRECTORS FOR REVIEW AND APPROVAL. THIS PROCESS IS COMPLETED ON AN ANNUAL BASIS AND WAS COMPLETED IN FISCAL YEAR ENDING 6/30/11. COMPENSATION OF THE CFO IS DETERMINED BY THE CEO. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. A COPY MAY BE REQUESTED BY CALLING, EMAILING, WALK-IN OR VIA MAIL. FORM 990, PART VII AND PART IX LINE 5 AND LINE 11A THE CEO IS PAID BY A MANAGEMENT COMPANY FOR SERVICES PROVIDED TO THE ORGANIZATION. THE COMPENSATION PAID TO THE MANAGEMENT COMPANY FOR HIS SERVICES IS DISCLOSED ON PART VII, SECTION A AND ALSO INCLUDED IN THE AMOUNT PAID TO THE MANAGEMENT COMPANY IN PART VII SECTION B. PART IX LINE 11A INCLUDES COMPENSATION PAID TO THE MANAGEMENT COMPANY FOR MANAGEMENT AND CEO SERVICES. LINE 5 INCLUDES COMPENSATION PAID TO THE CFO AND THE CCO FOR SERVICES AS AN EMPLOYEE. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED GAINS ON INVESTMENTS: 713,639. INTEREST IN CENTRAL MONTANA FOUNDATION 57,145. TOTAL TO FORM 990, PART XI, LINE 5: 770,784. ORGANIZATION VISION STATEMENT FORM 990, PART III, LINE 1 OUR VISION IS TO BE THE HEALTHCARE PROVIDER FOR OUR REGION; DEDICATE OURSELVES TO INNOVATIVE EXCELLENCE IN CARE; COLLABORATE CARE FOR ECONOMICAL SERVICES WITH OTHER AGENCIES; BE THE LEADER IN PROVIDING HEALTH EDUCATION, PREVENTION, AND WELLNESS SERVICES TO PROMOTE INDIVIDUAL RESPONSIBILITY FOR HEALTH OUTCOMES; PROVIDE FINANCIAL STEWARDSHIP FOR ECONOMIC HEALTH CARE; CREATE AN ENVIRONMENT IN WHICH ALL PARTICIPANTS FEEL VALUED AND RESPECTED; EMBRACE CHANGE WHILE EXPLORING TOMORROWS NEEDS TODAY. OUR VALUES ARE THE INTRINSIC FORCES BEHIND OUR MISSION AND VISION, AND DESCRIBE HOW OUR ACTIONS WILL BE GUIDED. WE BELIEVE IN COMPASSION: WE WILL BE AWARE AND RESPECTFUL OF THE LIFE SITUATION OF OTHERS AND TREAT THEM WITH COMPASSION AND CONSIDERATION, ACCOUNTABILITY: WITH INTEGRITY, KNOWLEDGE, ACTION AND TRUST, RESPECT: FOR DIGNITY, CARE, AND CONCERN FOR ALL, EXCELLENCE: AS A TEAM IN ALL WE DO.