2012-03-15T15:53:58-05:00 2011-06-30 CHMS PC 741 3RD AVE S GLASGOW MT 59230 990 2010-07-01 810243720 SHERIDAN MEMORIAL HOSPITAL ASSN SHER 4067651420 440 W LAUREL AVENUE PLENTYWOOD MT 59254 SANDRA CHRISTENSEN 4067651420 2012-03-13 1 RICHARD A WIENS CPA 4062289391 2010 2016-02-24 21:20:13Z SANDRA CHRISTENSEN 440 W LAUREL AVENUE PLENTYWOOD MT 59254 9841380 0 X WWW.SHERIDANMEMORIAL .NET X 1920 MT PROVIDE QUALITY CARE TO IMPROVE THE HEALTH AND WELL BEING OF THE PEOPLE AND COMMUNITY WE SERVE. 7 7 249 75 0 0 200063 130432 9733481 9396223 20442 12574 141923 302151 10095909 9841380 0 0 0 0 6294786 6449331 0 0 39058 4103493 3768877 10398279 10218208 -302370 -376828 8249011 7890130 976142 994089 7272869 6896041 X PROVIDING QUALITY CARE TO IMPROVE THE HEALTH AND WELL BEING OF THE PEOPLE AND COMMUNITY WE SERVE. WE ARE COMMITTED TO THE FUTURE HEALTHCARE NEEDS OF OUR COMMUNITY. WE ENDEAVOR TO BE A LEADER AND INNOVATOR IN PROVIDING RELIABLE, COMPASSIONATE, COMPREHENSIVE, HIGH QUALITY, COST EFFECTIVE HEALTHCARE SERVICES. 0 0 7862208 9710948 A COMMUNITY HOSPITAL AND NURSING HOME THAT BENEFITS THE PEOPLE IN SURROUNDING AREA. 7862208 1 1 0 1 0 0 0 0 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 5 0 1 249 1 0 0 0 0 0 0 0 0 X 7 7 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 X SANDRA CHRISTENSEN CFO 4067651420 440 W LAUREL AVENUE PLENTYWOOD MT 59254 DANETTE RASMUSSEN 1.00 X X 0 0 0 MYRNETTE MILLER 1.00 X 0 0 0 KATHY HAGAN 1.00 X X 0 0 0 DAVID FULKERSON 1.00 X 0 0 0 LINDA NELSON 1.00 X X 0 0 0 BILL MCCOY 1.00 X 0 0 0 ROBERT MICHELS 1.00 X 0 0 0 SANDRA CHRISTENSEN 40.00 X 97377 0 17390 LINDA HEPPNER 37.50 X 76503 0 7124 MARK HEGYES 40.00 X 120479 0 0 294359 0 24514 1 0 0 0 0 78705 51727 130432 PATIENT REVENUE 621990 9396223 9396223 9396223 12574 12574 2740 2740 2740 2740 HOSPITAL DISTRICT SUBS 621990 299411 299411 299411 9841380 9710948 0 0 197987 197987 5187053 4048755 1130974 7324 81967 56361 25606 540367 371244 169123 441957 290442 151515 3965 3965 67896 67896 210 210 343591 256259 87332 22193 16784 5409 1937190 1741711 172226 23253 15950 7570 6544 1836 348085 269174 78911 38030 32713 5317 34413 26612 7801 662967 512672 150295 142287 109075 31976 1236 PROVISION FOR BAD DEBTS 107529 107529 EDUCATION 44571 32091 12480 10218208 7862208 2316942 39058 1021015 1038413 632454 560870 1267332 1160039 401454 330129 139426 140959 34272 66608 14851226 10427565 4584412 4423661 168646 169451 8249011 7890130 844892 899024 131250 95065 976142 994089 X 7272869 6896041 7272869 6896041 8249011 7890130 -376828 0 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 177 177 0 EXPLANATION OF OTHER LOBBYING ACTIVITIES: PART II-B, LINE 1I: SHERIDAN MEMORIAL HOSPITAL IS A MEMBER OF MONTANA HEALTH CARE ASSOCIATION. A PERCENTAGE OF THE ANNUAL DUES GOES TOWARDS LOBBYING EXPENSES. 79341 79341 8758407 6073185 2685222 5836289 4354380 1481909 177189 177189 4423661 1 1 1 X 1 X 1 1 1 0 1 1 13312 13312 0.00130 259016 265619 -6603 0.00000 272328 265619 6709 0.00130 272328 265619 6709 0.00130 1 104981 2743520 2743520 X 1 1 1 1 SHERIDAN MEMORIAL HOSPITAL ASSN

440 W LAUREL AVE PLENTYWOOD MT 59254

X SHERIDAN MEMORIAL HOSPITAL ASSN 1 0 0 0 0 0 0 0 0 0 0 0 PART I, LINE 3C: INDIVIDUALS APPLYING FOR CHARITY CARE MUST PROVIDE PAY STUBS, THIER MOST RECENT TAX RETURN, FORMS APPROVING OR DENYING ELIGIBILITY FOR MEDICAID AND OR STATE OR COUNTY FUNDED MEDICAL ASSISTANCE, FORMS APPROVING OR DENYING UNEMPLOYEMENT COMPENSATION AND CURRENT BANK STATEMENTS. THE ITEMS LISTED ABOVE WILL BE USED TO DETERMINE FAMILY INCOME. FAMILY INCOME AND FAMILY SIZE ARE THEN USED TO DETERMINE WHAT THE POVERTY THRESHHOLD IS FOR THE APPLICANT AND TO DETERMINE IF FREE OR DISCOUNTED CARE WILL BE APPROVED 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 $ 107529. PART III, LINE 4: ACCOUNTS RECEIVABLE ARE CARRIED NET OF AN ESTIMATE FOR UNCOLLECTIBLES AND ALLOWANCES. ALLOWANCES FOR UNCOLLECTIBLE ACCOUNTS ARE SET BASED ON HISTORICAL LOSS RATES APPLIED TO AGED ACCOUNTS RECEIVABLE. ACCOUNTS WHICH ARE NOT CONSIDERED COLLECTIBLE ARE WRITTEN OFF AGAINST THE ALLOWANCE ACCOUNT. BAD DEBTS ARE CLASSIFIED AS AN OPERATING EXPENSE. PART III, LINE 8: THE COST TO CHARGE RATIO IS USED TO DETERMINE COMMUNITY BENEFIT. THIS IS DONE BY APPLYING THE RATIO TO THE TOTAL MEDICARE REVENUE. THE SHORTFALL OCCURRS DUE TO VARIOUS EXPENSES INCURRED BY THE FACILITY WHICH ARE CONSIDERED NON-REIMBURSABLE BY MEDICARE. SINCE PART OF THE COSTS ARE NOT REIMBURSED IT IS ONLY PRUDENT TO CONSIDER THIS SHORTFALL TO BE A BENEFIT TO THE COMMUNITY. PART III, LINE 9B: A PATIENT ACCOUNTS REP MAINTAINS A CURRENT AGING REPORT MONTHLY. AN ACCOUNT IS CONSIDERED DELINQUENT IF IT IS NOT PAID WITHIN THIRTY DAYS OF THE MAILING OF THE FIRST STATEMENT. IF PAYMENT IS NOT RECEIVED IN THE FOLLOWING BILLING CYCLE, THE PATIENT IS IS ISSUED A "PAYMENT MISSED" STICKER,ENCOURAGING PATIENTS TO MAKE PAYMENT. ALL BILLS ARE CONSIDERED PAST DUE IF NOT PAID BY THE THIRD BILLING CYCLE. A FINAL NOTICE WILL BE ISSUED IF PAYMENT IS NOT RECEIVED BY THE FOURTH BILLING CYCLE. IF PAYMENT IS NOT MADE WITHIN 5 BUSINESS DAYS AFTER THE FOURTH BILLING CYCLE THE PATIENT'S ACCOUNT WILL BE SENT TO COLLECTION. FORM 990, PART VI, SECTION B, LINE 11 THE BOARD REVIEWS FORM 990 AT A REGULARD BOARD MEETING. FORM 990, PART VI, SECTION B, LINE 12C THE BOARD IS REQUIRED TO SIGN THE CONFLICT OF INTEREST POLICY ANNUALLY. FORM 990, PART VI, SECTION B, LINE 15 THE BOARD REVIEWS AND DECIDES THE COMPENSATION FOR THE ORGANIZATION'S CEO. THE CEO DETERMINES THE COMPENSATION PACKAGES FOR KEY EMPLOYEES BASED ON A WAGE SCALE. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST AND FINANCIAL STATEMENTS, ARE AVAILABLE UPON REQUEST. SHERIDAN HEALTHCARE FOUNDATION 440 W LAUREL AVE PLENTYWOOD MT 59254 810496987 SUPPORT SHERIDAN MEMORIAL HOSPITAL ASSN MT 501(A) 170(B)(1)(A)(VI) 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 SHERIDAN HEALTHCARE FOUNDATION C 78705