2012-11-13T19:40:31-07:00 2012-06-30 202707086 TCA Partners LLP 1111 E Herndon Avenue Suite 211 Fresno CA 93720 990 2011-07-01 850442957 Clayton Health Systems Inc CLAY 5753742585 301 Harding Street Clayton NM 88415 Don Weidemann 5753742585 2012-08-31 1 Jeremy Ware P00642659 5594317708 2012-08-10 2011 2016-02-24 21:20:13Z Union County General Hospital Union County General Hospital 301 Harding Street Clayton NM 88415 12701372 0 X www.unioncountygeneral.com X 1997 NM 25-bed acute care critical access hospital service those in need in rural New Mexico. 8 7 115 0 0 0 440182 211224 11654608 12444851 10903 0 526673 45297 12632366 12701372 0 0 5100631 5240056 0 0 6614362 5817574 11714993 11057630 917373 1643742 16023794 16955856 10227804 9516124 5795990 7439732 The organization is a 25-bed acute care critical access hospital serving those in need in rural New Mexico 0 0 8846102 0 12444851 The organization is a 25 bed acute care critical access hospital serving those in need in rural New Mexico. Union County General Hospital provides services to individuals from Northern New Mexico, Southeastern Colorado, Western panhandle for Oklahoma and western panhandle of Texas. These services include inpatient, outpatient and emergency types of patient care. There were a total of 27,909 visits, including 6,954 at the Clayton Family Practice Clinic. Union County General Hospital is one of the sponsors of an annual county wide health fair where hospital personnel obtain blood samples for testing. 547 patients were drawn at the health fair, at six local businesses, and six surrounding communities. As a result of patients signing up at the Health Fair, two colonoscopies, three mammograms, one blood profile and four bone densities were done. 20 hospital personnel worked 550 hours the month of the health fair and weeks prior to and after to collect blood samples from employees at local businesses and surrounding communities during their work schedule. The Physical & Occupational Therapy departments did taping and gave samples, gaining a few patients. The Radiology Department handed out literature on the various services they provide. 0 0 0 8846102 1 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 12 0 1 115 1 0 0 0 0 0 0 X 8 7 1 1 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 NM X X Union County General Hospital 5753742585 301 Harding Street Clayton NM 88415 Claude C Austin 2 X 0 0 0 Ken Cantrell 2 X 0 0 0 Damon Brown 2 X 0 0 0 Effie Walker 2 X 0 0 0 Rosie DeHerrera 2 X 0 0 0 Della Wetzel 2 X 0 0 0 Dr Daniel Radunsky 40 X 655343 0 0 Donald Weidemann 40 X 126078 0 14500 Stacye Bradley 40 X 100821 0 5200 Jesse Jay Fluhman 40 X 123023 0 7800 Calvin Schuler 40 X 189033 0 0 1194298 0 27500 5 0 1 0 Yellowstone Insurance Exchange Nashville Nashville TN 37215 Insurance 350291 HealthTech Management Brentwood Brentwood TN 37027 Management and Billing Services 305527 Dr Patrick DeBaca Clayton Clayton NM 88415 Surgery Clinic 283543 Medical Services Network Roswell Roswell NM 88201 Anethesia Services 264885 BCBS of NM Chicago Chicago IL 60673 Health Insurance 193169 8 0 0 0 0 159293 51931 0 211224 Patient Service Revenue, net 621400 12444851 12444851 0 0 0 0 0 0 12444851 0 0 0 0 0 45297 45297 0 0 45297 12701372 12490148 0 0 4314515 3451612 862903 925541 740433 185108 730733 584586 146147 1132194 905755 226439 190200 152160 38040 324253 259402 64851 682578 546062 136516 328678 262942 65736 Purchased Services 1572798 1258238 314560 0 Repairs and Maitenance 351040 280832 70208 0 505100 404080 101020 11057630 8846102 2211528 0 1071433 3217143 76055 892118 2054829 1554893 313782 339925 67080 54696 12320605 1560348 11269122 10760257 1171493 136824 16023794 16955856 1135955 569852 8563237 8021416 528612 924856 10227804 9516124 X 5795990 7439732 0 0 0 0 5795990 7439732 16023794 16955856 1643742 0 X 0 1 1 0 X NA 0 0 0 0 11242288 1092243 10150045 0 0 0 0 0 1078317 468105 610212 0 0 0 0 10760257 0 Third Party Payor Settlements 924856 924856 12701372 11057630 1643742 0 0 0 0 0 0 1643742 13157537 0 456165 0 0 456165 12701372 0 0 0 12701372 11513795 456165 0 0 0 456165 11057630 0 0 0 11057630 1 1 X 1 X 1 X 1 1 0 0 988387 988387 0.085 300112 300112 0.026 1873264 1873264 0.162 0 0 3161763 0 3161763 0.273 0 0 0 0 0 0.000 0 0 3161763 0 3161763 0.273 1 350615 326072 3622833 3755438 -132605 X 1 1 1 1 Union County General Hospital

300 Wilson Street Clayton NM 88415

X X X Union County General Hospital 1 SchH_P01_S00_L07 Schedule H, Part I, Line 7 COST METHOD The cost method used to calculate the amounts in this table is a Cost to Charge ratio. SchH_P01_S00_L072f Schedule H, Part I, Line 7, Column f The Bad Debt Expense included on Form 990, Part IX, Line 25 Column A, subtracted for purpose of calculating the percentage in this column is 350,615. SchH_P03_S0A_L04 Schedule H, Part III, Section A, Line 4 Patient Accounts Receivable consists of amounts owed by various governmental agencies, insurance companies and private patients. The hospital manages its receivables by regularly reviewing the accounts, inquiring with respective payers as to collectiblity and providing allowances on their accounting records for estimated contractual adjustments and uncollectible accounts. SchH_P03_S0B_L08 Schedule H, Part III, Section B, Line 8 Serving patients with government health benefits, such as Medicare, is a component of the community benefit standard that tax-exempt hospitals are held to. This implies that serving Medicare patients is a community benefit and that that hospital operates to promote the health of the community. The Hospital uses Medicare cost report methodology, which apportions routine costs based on Medicaid or Medicare days to total days and apportions ancillary costs based on program charges to total charges. SchH_P03_S0C_L09b Schedule H, Part III, Section C, Line 9b When a patient has indicated or demonstrated an inability to pay, an appropriate hospital representative will provide the patient with a charity care application. Applications must be complete in their entirety before charity care can be considered. Those patients who may qualify for financial assistance from a government program should be referred to the appropriate agency prior to consideration for charity care. An application for financial assistance from an outside agency should be obtained prior to charity care approval. SchH_P06_S00_L02 Schedule H, Part VI, Line 2 Public meetings, board meetings, performance improvement and quality assurance meetings, emergency room call backs. SchH_P06_S00_L03 Schedule H, Part VI, Line 3 Patients are informed of their rights and eligibility for assistance as they go through the admissions process. SchH_P06_S00_L04 Schedule H, Part VI, Line 4 Union County is a frontier hospital with a county population of 2,700. The town of Clayton, where the hospital is located, is 45 miles from the nearest hospital. SchH_P06_S00_L05 Schedule H, Part VI, Line 5 Union County General Hospital is one of the sponsors of an annual county wide health fair where hospital personnel obtain blood samples for testing. 547 patients were drawn at the health fair, at six local businesses, and six surrounding communities. As a result of patients signing up at the Health Fair, two colonoscopies, three mammograms, one blood profile and four bone densities were done. 20 hospital personnel worked 550 hours the month of the health fair and weeks prior to and after to collect blood samples from employees at local businesses and surrounding communities during their work schedule. The Physical & Occupational Therapy departments did taping and gave samples, gaining a few patients. The Radiology Department handed out literature on the various services they provide. Quarterly mini health fairs were held at the hospital. Three of our local doctors presented information on men's health, breast cancer, prostate and colon cancer, diabetes and osteoporosis. A cardiologist from Amarillo, TX gave a very informative presentation on heart health. Hospital staff gives flu shots at local businesses once a year. We provide a nurse practitioner, LPN, and receptionist for a school based health clinic in Des Moines, NM, 60 miles from Clayton. During the school year they go twice a month. We give a nursing scholarship annually as well as two scholarships to high school seniors who are going into the healthcare field. The hospital sponsors a local baseball team, supports the 4-H youth at the county fair by purchasing livestock, and sponsors the annual arts festival by purchasing a painting. X 0 0 0 0 0 0 0 0 0 Dr Daniel Radunsky 655343 0 0 0 0 0 0 0 0 0 655343 0 0 0 Calvin Schuler 189033 0 0 0 0 0 0 0 0 0 189033 0 0 0 F990_P06_S0A_L02 Form 990, Part VI, Section A, Line 2 Claude C Austin and Rosie DeHerrera, Directors, have a business relationship. F990_P06_S0A_L03 Form 990, Part VI, Section A, Line 3 The Hospital's CEO, Don Wiedemann, is employed by a management company, Health Tech Management Services. All executive duties of the Chief Executive Officer are carried out by Mr. Wiedemann of Health Tech Management Services. F990_P06_S0B_L11b Form 990, Part VI, Section B, Line 11b Form 990 prepared and reviewed by independent accounting firm. A draft of the form 990 is then provided to hospital management and any questions or corrections are addressed. A copy of the final form 990 with all required schedules is then provided to all voting members prior to filing with the IRS. F990_P06_S0B_L12c Form 990, Part VI, Section B, Line 12c The Board of Directors, CEO and all other officers are all required to annually sign the conflict of interest policy and disclose any potential conflicts of interest. F990_P06_S0B_L15 Form 990, Part VI, Section B, Line 15 The Hospital's CEO is compensated by a management company, Health Tech management services. Annually, a representative from the management company meets with the board of directors to perform an annual evaluation of the CEO's performance, review the New Mexico Hospital services wage and salary survey as a compensation comparable. The board's approval of CEO compensation is documented in the board minutes. F990_P06_S0C_L19 Form 990, Part VI, Section C, Line 19 Available upon request