2012-11-14T14:20:32-06:00 2011-12-31 450250958 EIDE BAILLY LLP 1601 NW Expressway Oklahoma City OK 73118 990 2011-01-01 731279909 Okmulgee Memorial Hospital Inc OKMU 9187564233 1401 Morris Drive Okmulgee OK 74447 Doran Hammett 9187564233 2012-11-14 1 Carolyn Levings P01083874 4054783334 2012-11-14 2011 2016-02-24 21:20:13Z George Miller 1401 Morris Drive Okmulgee OK 74447 20339974 0 X http://www.okmulgeehospital.com X 1967 OK Health Care Services 10 10 338 117 0 0 200529 42462 20243573 20281130 883 833 0 0 20444985 20324425 0 0 0 0 10494101 10325107 0 0 0 10957572 10530185 21451673 20855292 -1006688 -530867 5373192 5921754 4461351 5540780 911841 380974 Okmulgee Memorial Hospital's mission is to put our patients and customers first and to provide quality health care in an efficient manner. 0 0 17051324 20281130 Okmulgee Hospital is a sixty-six bed hospital facility providing such services as, but not limited to, Inpatient, Outpatient, Psychiatric, Home Health and Emergency Care services to the general public regardless of ability to pay.The Hospital provided $254,722 of charity care in 2011. 17051324 1 1 0 0 0 0 0 0 0 0 1 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 1 0 0 0 0 0 0 0 1 0 0 0 0 1 12 0 1 338 1 0 0 0 0 0 0 0 0 0 0 X 10 10 1 1 0 0 0 0 0 1 0 0 0 1 1 1 1 1 1 1 1 0 OK X Doran Hammett 9187583102 1401 Morris Drive Okmulgee OK 74447 John Fidler 1.00 X X 0 0 0 Nevyle Cable 1.00 X X 0 0 0 Barbara Osborn 1.00 X X 0 0 0 Greg Marriott 1.00 X X 0 0 0 Tracy Sanford DO 1.00 X 0 0 0 Timothy Sandford DO 1.00 X 0 0 0 Linda Janzen 1.00 X 0 0 0 Walter McGown OD 1.00 X 0 0 0 Jason Winters 1.00 X 0 0 0 R Stanley White MD 1.00 X 0 0 0 Paul Ervin 40.00 X 70371 0 0 Jason Bruce 40.00 X 269804 0 16500 Benjamin Kamp DO 40.00 X 309952 0 16500 650127 0 33000 2 0 1 0 Quorum Health Resources 105 Continental Pl Brentwood TN 37027 ER Physicians 545436 Horizon Health PO Box 840839 Dallas TX 75284 Mental Health 488283 Cardinal Health Pharmacy P O BOX 847384 Dallas TX 75284 Supplies/Med & Pharmacy 416304 Cardinal Health PO Box 847384 Dallas TX 75284 Supplies/Med & Pharmacy 325524 CPSI PO Box 850309 Mobile AL 36695 Internet & Computer Serv. 305438 5 42462 42462 Net Patient Serv. Rev. 624100 19364692 19364692 Miscellaneous Revenue 900099 805464 805464 Dietary 900099 81826 81826 Maint. & Janitorial 900099 23178 23178 Security Services 900099 5970 5970 20281130 483 483 15899 15549 350 350 350 20324425 20281130 0 833 683127 612756 70371 7361715 5689934 1671781 79260 54849 24411 1579248 1235845 343403 621757 486558 135199 51049 51049 57804 57804 2152941 1875184 277757 1507378 732384 774994 10177 4167 6010 315688 304425 11263 65592 53506 12086 136565 136565 613011 459758 153253 285322 238321 47001 Bad debt expense 4013284 4013284 Supplies 1213293 1213293 Recruitment 26150 26150 81931 77060 4871 20855292 17051324 3803968 0 14718 86569 2103925 2634983 787769 715222 233876 424204 12866706 10805930 2232904 2060776 5373192 5921754 2360125 3008084 33172 2020985 2022821 80241 476703 4461351 5540780 X 911841 380974 911841 380974 5373192 5921754 -530867 0 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 22716 22716 5305423 4759423 546000 102260 102260 0 7436307 5944247 1492060 2060776 Estimated Third Party Settlements 476703 476703 20324425 20855292 -530867 -530867 20281963 0 20281963 42462 42462 20324425 20855292 0 20855292 0 20855292 Description of Uncertain Tax Positions Under FIN 48: Part X: The Hospital undergoes an annual analysis of its various tax positions assessing the likelihood of these positions being upheld upon examination with relevant tax authorities, as defined by the accounting principles generally accepted in the United States of America. (GAAP). The Hospital believes that they are compliant with all IRS tax regulations and as of December 31, 2011 have not recorded any unrecognized tax benefit or liabilities for income taxes. Part XII, Line 4b - Other Adjustments: Capital Contributions Not included in Total Revenue 1 1 X 1 X 1 X 1 1 0 0 117000 117000 0.00690 3300884 1671747 1629137 0.09670 3417884 1671747 1746137 0.10360 3417884 1671747 1746137 0.10360 0 4013284 25017 8068192 8184590 -116398 X 1 0 1 1 Okmulgee Memorial Hospital

1401 Morris Drive Okmulgee OK 74447

X X X Psych-16 Beds Okmulgee Memorial Hospital Inc 1 1 1 200.000000000000 1 250.000000000000 1 X X 1 1 X X 1 0 1 X 0 0 2 Home Health Agency

1401 Morris Drive Okmulgee OK 744476419

In-Home Care Service Benjamin A Kamp DO

1201 S Belmont Ste 207 Okmulgee OK 744476419

Clinic Part I, Line 7: Charity care was converted to cost on line 7a based on an overall cost-to-charge ratio which addresses all patient segments.Unreimbursed Medicaid was calculated using the cost-to-charge ratio derived from Worksheet 2. Part I, L7 Col(f): The amount of bad debt expense removed from total expenses to determine the percentage was $4,013,284. Part III, Line 4: Bad debt is determined by our bad debt policy considering actual patient care charges. Charges become bad debt once a reasonable opportunity has been made by the hospital to collect an open account and the responsible party has been contacted regarding the unpaid balance. After policy based collection attempts have been exhausted, the account is written off to bad debt.All payments and contractual are applied to the account before it is written off to bad debt. If any payments are received for bad debts that have been written off, they are applied to the current year bad debt expense.The estimated amount of the organization's bad debt expense attributable to patients eligible under the organization's charity care policy is calculated based on an estimate of charges foregone to gross patient charges.The carrying amount of patient receivables is reduced by a valuation allowance that reflects management's 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: 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. The Medicare Cost Report is completed based on the rules and regulations set forth by Centers for Medicare and Medicaid Services. Part III, Line 9b: The hospital has a charity care policy and patients must meet certain established criteria for charity service consistent with OHM's mission. The policy does not specifically state the collection procedures for those who qualify for other financial assistance which most would be Medicaid. The hospital does have provisions but they are not specifically written in the policy. No collections actions are filed while an application is in review, any personal portion due after a determination of assistance would follow normal collections practices. Okmulgee Memorial Hospital, Inc. Part V, Section B, Line 13g: The financial assistance policy is available to obtain from the patient Financial Counselor. Okmulgee Memorial Hospital, Inc. Part V, Section B, Line 19d: The hospital is in the process of establishing a new plan to follow to be in compliance with the new 501(r) requirements. The probable method to use for FAP-eligible individuals will be the Medicare fee-for-service plan. Part VI, Line 2: Okmulgee Memorial Hospital has a strategic plan and looks at information provided by the state, county and Medicare. The hospital looks at discharges, hospitalization and utilization of different categories of patients. The information is used to assess physician needs as well as the purchasing of capital equipment. The hospital also participates in the County Wellness Coalition. Information from surveys are used in the needs assessment for the hospital. Part VI, Line 3: The hospital uses an electronic program at admission to determine if a patient is eligible for assistance. If a patient is determined to be eligible, then the patient is referred to a financial counselor. The financial counselor works with the patient to determine if the patient is eligible for Medicaid. If the patient is not eligible for Medicaid, the hospital then works with the patient to determine if the patient is eligible for charity care. The Financial Counselor contact information is included in the patient billing statements if further assistance is needed. Part VI, Line 4: Okmulgee Memorial Hospital is an acute care hospital located in Okmulgee, which is in Okmulgee County, Oklahoma. Okmulgee County is a federally underserved area according to the Health Resources and Services Administration. Okmulgee is a small community of about 13,000 residents. There are two other hospitals in the county with one about twenty miles from Okmulgee Memorial Hospital. The median household income is $35,615 and 19.2% of families and 21.4% of individuals of the population are below the poverty line. Part VI, Line 5: The organization has a volunteer board comprised of members of the community. Medical staff privileges are extended to all qualified physicians in the community and to those who wish to render services at OMH. Any surplus funds, if available, are reinvested in the facilities to improve patient care. X X 0 0 0 0 0 0 0 0 0 Jason Bruce 269804 0 0 0 0 0 16500 0 0 0 286304 0 0 0 Benjamin Kamp DO 309952 0 0 0 0 0 16500 0 0 0 326452 0 0 0 Tracey Timothy Sanford Board Directors 41651 Leases medical office space from a related organization, Okmulgee Medical Foundation, Inc. 0 Form 990, Part VI, Section A, line 2 Tracy & Timothy Sanford (Trustees) - family relationship Form 990, Part VI, Section A, line 3 Management duties include planning and executing financial operations. Quorem Health Resources manages the hospital. Form 990, Part VI, Section A, line 8b The organization does not have a committee with authority to act on behalf of the governing body. Form 990, Part VI, Section B, line 11 The Form 990 is prepared by an outside accounting firm and is reviewed internally by the CEO and the Finance Committee prior to filing with the IRS. The Board of Directors is provided a copy. Form 990, Part VI, Section B, line 12c We also have a conflict of interest policy which is applicable to all employees of OMH. Once a potential conflict is identified, Compliance and administration determine the level and risk of the conflict. Depending on the severity of conflict an employee may be asked to refrain involvement. If there is a known conflict that is not disclosed by an employee, they will be subject to the disciplinary action policy. Form 990, Part VI, Section B, line 15 The Board of Directors reviews and approves salaries of top management positions. Salary determination is based on comparability data from industry standards. CEO compensation is recommended by Quorem Health Resources and Board approved. Form 990, Part VI, Section C, line 19 The organization makes its governing documents, conflict of interest policy, and financial statemsnts available to the public upon request. Okmulgee Medical Foundation Inc PO Box 1038 Okmulgee OK 74447 730766656 Office building and manages tax deductible contributions OK 501(c)(3) 509(a)(1) 0 0 0 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 0 Okmulgee Medical Foundation K 60804 FMV