2012-05-15T09:41:55-05:00 2011-06-30 WIPFLI LLP 7601 FRANCE AVENUE SOUTH SUITE 400 MINNEAPOLIS MN 55435 990 2010-07-01 710276839 DELTA MEMORIAL HOSPITAL DELT 8703824303 811 HWY 65 S DUMAS AR 71639 CHRIS BOLIN 8703824303 2012-05-15 1 RICHARD RUVELSON 9525483400 2012-05-15 2010 2016-02-24 21:20:13Z CRIS BOLIN 811 HWY 65 S DUMAS AR 71639 17340476 0 X WWW.DELTAMEM.ORG X 1975 AR AT DELTA MEMORIAL HOSPITAL, WE ARE COMMITTED TO AID HEALING AND PROMOTE WELLNESS FOR SOUTHEAST ARKANSAS IN A COURTEOUS, COST-EFFECTIVE AND CARING MANNER. 6 6 215 32 0 0 84860 329934 17181214 16776240 2924 3413 90311 230889 17359309 17340476 0 0 0 0 7528112 8123428 0 0 0 9092265 8674634 16620377 16798062 738932 542414 15350822 15620689 6033483 5760936 9317339 9859753 AT DELTA MEMORIAL HOSPITAL, WE ARE COMMITTED TO AID HEALING AND PROMOTE WELLNESS FOR SOUTHEAST ARKANSAS IN A COURTEOUS, COST-EFFECTIVE AND CARING MANNER. 0 0 14783139 16776240 DELTA MEMORIAL HOSPITAL PROVIDES MEDICAL HEALTH CARE SERVICES TO PATIENTS REGARDLESS OF RACE, CREED, SEX, NATIONAL ORIGIN, HANDICAP, OR ABILITY TO PAY. DELTA MEMORIAL HOSPITAL HAD 4,248 INPATIENT DAYS DURING THE FISCAL YEAR. THE ORGANIZATION HAD 12,732 CLINIC VISITS AND HOME HEALTH SERVED 15,862 INDIVIDUALS. 14783139 1 1 0 1 0 0 0 0 0 1 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 1 0 0 0 0 1 0 0 0 0 0 0 0 0 0 1 29 0 215 1 0 0 0 0 0 0 0 0 0 0 X 6 6 0 0 0 0 0 0 0 1 0 0 0 0 1 1 1 1 1 1 1 0 X CRIS BOLIN 8703824303 811 HWY 65 S DUMAS AR 71639 JAMES BERRY 1.00 X 0 0 0 TIMOTHY JONES 1.00 X 0 0 0 GLENN CROW 1.00 X 0 0 0 BENNY ESTES 1.00 X X 0 0 0 DON LIVINGSTON 1.00 X X 0 0 0 DR THOMAS LEWELLEN 1.00 X 0 0 0 CRIS BOLIN 40.00 X 115042 0 14802 DR F DAVID CHAMBERS 40.00 X 818449 0 14802 DR PETER GO 40.00 X 482538 0 11339 1416029 0 40943 3 0 1 1 BALLARD ISHEE CORPORATION 100 RAVENWOOD PLACE HOT SPRINGS AR 71901 CRNA SERVICES 547500 THEREX INC DEPT 95270 ATLANTA GA 31192 PHYSICAL THERAPY SERVICES 515085 DELTA SURGERY PA PO BOX 399 DUMAS AR 71639 ER COVERAGE 208500 THOMAS LEWELLEN PA PO BOX 128 DUMAS AR 71639 ER COVERAGE 196600 CPP WOUND CARE 3017 N CAUSEWAY BLVD METAIRE LA 70002 WOUND CLINIC SERVICES & MGMT 190100 7 25153 304781 138000 329934 PATIENT SERVICE REVENU 621990 15998344 15998344 ARKANSAS STATE ASSESSM 621990 766699 766699 MEDICAL RECORDS REVENU 900099 11197 11197 16776240 3221 3221 192 192 192 192 IRS PENALY REFUND 900099 82126 82126 MEAL AND VENDING REVEN 900099 59366 59366 INSURANCE CASUALTY GAI 900099 43145 43145 46252 46252 230889 17340476 16776240 0 234302 129307 129307 6896982 6054353 842629 6247 5484 763 589640 517602 72038 501252 432788 68464 31900 31900 61187 61187 2644724 2306395 338329 12344 12344 851635 785685 65950 644325 544539 99786 80487 78302 2185 285492 241915 43577 820704 693587 127117 255151 215636 39515 BAD DEBT 2465038 2465038 PATIENT SERVICES 346395 346395 OTHER 155981 95420 60561 RECRUITMENT MGMT 19271 19271 16798062 14783139 2014923 0 211923 51544 273172 201477 3560835 4621448 183837 223647 55813 73508 16418458 6148649 11023986 10269809 41256 179256 15350822 15620689 2306887 2388607 2978397 2754338 476140 289705 272059 328286 6033483 5760936 X 1052031 1988813 8265308 7870940 9317339 9859753 15350822 15620689 542414 0 X X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 4372 4372 0 EXPLANATION OF OTHER LOBBYING ACTIVITIES: PART II-B, LINE 1I: A PORTION OF THE DUES PAID TO ARKANSAS HOSPITAL ASSOCIATION IS FOR LOBBYING EXPENSES. 105910 105910 12407940 3288959 9118981 3711443 2859690 851753 193165 193165 10269809 17340476 16798062 542414 0 542414 17340476 0 17340476 0 17340476 16798062 0 16798062 0 16798062 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: IN ORDER TO ACCOUNT FOR ANY UNCERTAIN TAX POSITIONS, ASC TOPIC 740-10, ACCOUNTING FOR UNCERTAINTY IN INCOME TAXES, REQUIRES AN ORGANIZATION TO ASSESS WHETHER IT IS MORE LIKELY THAN NOT THAT A TAX POSITION WILL BE SUSTAINED UPON EXAMINATION OF THE TECHNICAL MERITS OF THE POSITION, ASSUMING THE TAXING AUTHORITY HAS FULL KNOWLEDGE OF ALL INFORMATION. IF THE TAX POSITION DOES NOT MEET THE MORE-LIKELY-THAN-NOT RECOGNITION THRESHOLD, THE BENEFIT OF THE TAX POSITION IS NOT RECOGNIZED IN THE CONSOLIDATED FINANCIAL STATEMENTS. MANAGEMENT DOES NOT BELIEVE THE ORGANIZATION HAS ANY MATERIAL UNCERTAIN TAX POSITIONS OR UNRECOGNIZED TAX BENEFITS. THE ORGANIZATION'S FEDERAL INFORMATIONAL RETURNS FOR TAX YEARS 2007 AND SUBSEQUENT YEARS REMAIN SUBJECT TO EXAMINATION BY THE INTERNAL REVENUE SERVICE. 1 1 1 X 1 X 0.0 1 1 0 0 219797 219797 0.01530 4459127 3519636 939491 0.06550 4678924 3519636 1159288 0.08080 31420 31420 0.00220 31420 31420 0.00220 4710344 3519636 1190708 0.08300 0 1433162 0 5738402 6269751 -531349 X 1 1 1 1 DELTA MEMORIAL HOSPITAL

811 HWY 65 S DUMAS AR 71639

X X X X DELTA MEMORIAL HOSPITAL 1 PART I, LINE 3C: ELIGIBILITY CRITERIA FOR DISCOUNTED CARE TO LOW INCOME INDIVIDUALS IS AS FOLLOWS: 80% DISCOUNT AT 125% OF FPG, 60% DISCOUNT AT 150% OF FPG, 40% DISCOUNT AT 175% OF FPG, 20% DISCOUNT AT 200% OF FPG. PART I, LINE 7: PART I, LINE 7: THE ORGANIZATION USES A COST TO CHARGE METHODOLOGY AS DETERMINED BY WORKSHEET 2 OF THE INSTRUCTIONS. 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 $ 2465038. FORM 990, SCHEDULE H, PART I, LINE 7, COLUMN F AS ALLOWED, THE DENOMINATOR HAS BEEN REDUCED BY $2,465,038, THE AMOUNT OF BAD DEBT REPORTED IN PART IX, LINE 25 OF FORM 990. PART II: DELTA MEMORIAL HOSPITAL PROVIDES A VARIETY OF PROGRAMS THAT PROMOTE HEALTH WITHIN THE COMMUNITIES IT SERVES. DELTA PROVIDED PHYSICALS TO DUMAS PUBLIC SCHOOLS. DELTA ALSO HAD FAMILY NIGHT OUTREACH WITH 3 RNS AND 3 LPNS WENT OUT INTO THE COMMUNITY. ANOTHER PROGRAM THAT PROMOTES HEALTH IN THE COMMUNITY IS THE PRESCRIPTION ASSISTANCE PROGRAM. PART III, LINE 4: THE CARRYING AMOUNTS OF ACCOUNTS RECEIVABLE ARE REDUCED BY ALLOWANCES THAT REFLECT MANAGEMENT'S BEST ESTIMATE OF THE AMOUNTS THAT WILL NOT BE COLLECTED. MANAGEMENT PROVIDES FOR CONTRACTUAL ADJUSTMENTS UNDER TERMS OF THIRD-PARTY REIMBURSEMENT AGREEMENTS THROUGH A REDUCTION OF GROSS REVENUE AND A CREDIT TO PATIENT ACCOUNTS RECEIVABLE. IN ADDITION, MANAGEMENT PROVIDES FOR PROBABLE UNCOLLECTIBLE AMOUNTS, PRIMARILY FROM UNINSURED PATIENTS AND AMOUNTS PATIENTS ARE PERSONALLY RESPONSIBLE FOR, THROUGH A CHARGE TO OPERATIONS AND A CREDIT TO A VALUATION ALLOWANCE BASED ON ITS ASSESSMENT OF HISTORICAL COLLECTION LIKELIHOOD AND THE CURRENT STATUS OF INDIVIDUAL ACCOUNTS. BALANCES THAT ARE STILL OUTSTANDING AFTER MANAGEMENT HAS USED REASONABLE COLLECTION EFFORTS ARE WRITTEN OFF THROUGH A CHARGE TO THE VALUATION ALLOWANCE AND A CREDIT TO PATIENT ACCOUNTS RECEIVABLE. PART III, LINE 8: THE COSTING METHODOLOGY USED IS COST TO CHARGE RATIO AS REQUIRED BY MEDICARE. PART III, LINE 9B: PATIENTS THAT QUALIFY FOR CHARITY CARE ARE NOT PUT THROUGH COLLECTION PROCESS FOR THE AMOUNT THAT QUALIFIES FOR CHARITY CARE. PART VI, LINE 2: THE ORGANIZATION ASSESSES THE HEALTH CARE NEEDS OF THE COMMUNITY IT SERVES THROUGH CONTRACTED RESEARCH SERVICES. PART VI, LINE 3: AT ADMISSIONS CHARITY CARE IS OFFERED. OUR SOCIAL SERVICES COORDINATOR IS AVAILABLE TO WORK WITH OUR BUSINESS OFFICE MANAGER ON OTHER FORMS OF ASSISTANCE. PART VI, LINE 4: WE ARE A CRITICAL ACCESS HOSPITAL, AND SERVE AN UNDERSERVED POPULATION IN DUMAS, ARKANSAS. DUMAS, ARKANSAS IS LOCATED IN DESHA COUNTY. DESHA COUNTY HAS A MEDIAN INCOME OF $27,555 AS OF 2008 WITH 29% OF PERSONS BELOW THE POVERTY LEVEL. PART VI, LINE 6: THE BOARD OF DIRECTORS IS COMPRISED OF PERSONS WHO RESIDE IN THE PRIMARY SERVICE AREA. THE ORGANIZATION PROMOTES THE HEALTH OF THE COMMUNITY BY ACCOMODATING ANY FINANCIAL CONCERNS THROUGH THE CHARITY CARE PROGRAM. PART VI, LINE 7: N/A X X X X 0 0 0 0 0 0 0 1 0 DR F DAVID CHAMBERS 588449 0 57500 0 172500 0 0 0 14802 0 833251 0 0 0 DR PETER GO 435708 0 46830 0 0 0 0 0 11339 0 493877 0 0 0 SUPPLEMENTAL INFORMATION PART III DR. DAVID CHAMBERS IS PAID A CERTAIN DOLLAR AMOUNT FOR EACH PATIENT SEEN IN THE CLINIC. DR. CHAMBERS ALSO RECEIVES COMPENSATION THROUGH A CONTRACT FOR ER COVERAGE. HE RECEIVED $172,500 FOR HIS ER COVERAGE SERVICES. THE 1099 PAYMENT RECEIVED IS INCLUDED IN OTHER COMPENSATION ABOVE. MERCHANT & FARMERS BANK CLINIC AND EQUIPMENT FINANCING X 3000000 2754338 0 1 1 2754338 X 1 138000 FMV 0 0 0 FORM 990, PART VI, SECTION A, LINE 8B NO COMMITTEE OF THE GOVERNING BODY HAS AUTHORITY TO ACT WITHOUT BOARD APPROVAL. FORM 990, PART VI, SECTION B, LINE 11 A COPY OF THE FORM 990 IS PROVIDED TO THE BOARD OF DIRECTORS FOR REVIEW AND APPROVAL AFTER SUBMISSION. FORM 990, PART VI, SECTION B, LINE 12C THE ORGANIZATION REQUIRES DISCLOSURE OF ANY CONFLICTS OF INTEREST ANNUALLY AT THE EMPLOYEE COMPLIANCE MEETINGS AND AT THE ANNUAL BOARD MEETING. FORM 990, PART VI, SECTION B, LINE 15 A COMPARISON TO MARKET INFORMATION AVAILABLE THROUGH VARIOUS MEMBERSHIP ASSOCIATIONS IS USED TO DETERMINE COMPENSATION FOR THE ADMINISTRATOR AND OTHER TOP MANAGEMENT. THE COMPARATIVE INFORMATION IS REVIEWED BY THE BOARD OF DIRECTORS AND COMPENSATION IS APPROVED BY THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION C, LINE 19 THE GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE AVAILABLE TO THE PUBLIC UPON REQUEST AND AT THE MONTHLY PUBLIC BOARD MEETINGS. FORM 990, PART XII, LINE 2C THE BOARD OF DIRECTORS OF THE ORGANIZATION ASSUMES RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT AND SELECTION OF AN INDEPENDENT ACCOUNTANT. THIS PROCESS HAS NOT CHANGED FROM PRIOR YEAR.