2012-11-14T15:57:12-06:00 2011-12-31 476097913 SEIM JOHNSON LLP 18081 BURT STREET SUITE 200 OMAHA NE 680224722 990 2011-01-01 470408242 CHEYENNE COUNTY HOSPITAL ASSOCIATION INC CHEY 3082545825 645 OSAGE STREET SIDNEY NE 69162 JASON PETIK 3082545825 2012-11-14 1 BARBARA J FAJEN P00400874 4023302660 2011 2016-02-24 21:20:13Z SIDNEY REGIONAL MEDICAL CENTER KELLY UTLEY 645 OSAGE STREET SIDNEY NE 69162 30175048 0 X WWW.MEMORIALHEALTHCENTER.ORG X 1951 NE FOCUS ON THE NEEDS OF THOSE SERVED THROUGH THE DELIVERY OF HIGH QUALITY AND COMPASSIONATE CARE. 12 12 365 105 0 0 48196 428769 25941028 29553726 85262 63175 79412 89767 26153898 30135437 0 0 0 0 14628927 15095069 0 0 0 9005730 10478230 23634657 25573299 2519241 4562138 25622492 29888648 5303642 5007660 20318850 24880988 X OUR MISSION IS TO FOCUS ON THE NEEDS OF THOSE WE SERVE THROUGH THE DELIVERY OF HIGH QUALITY AND COMPASSIONATE CARE. 1 0 2750411 5183819 THE HOSPITAL NURSING DEPARTMENT PROVIDED 3,060 PATIENTS DAYS OF CARE IN 2011. WE DELIVERED 65 NEWBORNS FOR THE ELEVEN COUNTY AREAS FOR WHICH SIDNEY REGIONAL MEDICAL CENTER (SRMC) SERVES. SRMC HAD 3,354 PATIENTS THAT PASSED THROUGH THE EMERGENCY DEPARTMENT. 1828625 3581923 THE EXTENDED CARE UNIT HAS PROVIDED CARE FOR 53 PATIENTS A MONTH ON THE AVERAGE FOR 2011. SRMC PROVIDED 19,513 PATIENT DAYS OF CARE FOR RESIDENTS IN THE CHEYENNE, DEUEL, KIMBALL AND SURROUNDING AREAS. 1418421 4164473 SRMC PHARMACY DEPARTMENT HAS BEEN ACTIVELY INVOLVED WITH THE QUALITY OF CARE THAT WE HAVE PROVIDED TO ALL OUR PATIENTS IN THE SURROUNDING AREAS. THE PHARMACY DEPARTMENT HAS HELPED PROVIDE CARE FOR THOSE INDIVIDUALS WITH THE TREATMENT FOR RADIATION OR CHEMOTHERAPY. 18511529 16633953 OTHER MISCELLANOUES PATIENT SERVICES. 18511529 16633953 24508986 1 1 0 1 0 0 0 0 0 0 1 0 0 0 1 1 0 1 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 1 0 0 0 0 1 26 0 1 365 1 0 0 0 0 0 0 0 0 0 0 X 12 12 0 1 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 X KELLY UTLEY 3082545825 645 OSAGE STREET SIDNEY NE 69162 X BILL PILE 1.00 X X 0 0 0 TIM MILLER 1.00 X X 0 0 0 TOM MILLMAN 1.00 X X 0 0 0 JEFF ELLWANGER 1.00 X X 0 0 0 MICHAEL MATTHEWS MD 1.00 X 0 0 0 STAN BELIEU 1.00 X 0 0 0 JEFF JOHNSON 1.00 X 0 0 0 JIM JONES 1.00 X 0 0 0 ROB ROBINSON 1.00 X 0 0 0 LAURIE WIDDOWSON 1.00 X 0 0 0 CALVIN CUTRIGHT MD 1.00 X 0 0 0 DWIGHT SMITH 1.00 X 0 0 0 DOUG FAUS 40.00 X 0 0 0 JASON PETIK 40.00 X 0 0 0 KELLY UTLEY 39.00 X 112932 0 5941 JAMES GROSSHANS 40.00 X 200421 0 12229 JAMES THAYER 40.00 X 342063 0 13334 DANNA HLAVINKA 40.00 X 189071 0 10013 TRACY RAY 40.00 X 164563 0 8618 RACHEL FORSTER 40.00 X 147729 0 7532 1156779 0 57667 11 0 1 0 BD CONSTRUCTION 209 EAST 6TH KEARNEY NE 68848 BUILDING CONSTRUCTION 570461 POUDRE VALLEY HEALTH CARE INC PO BOX 2103 FORT COLLINS CO 80522 MANAGEMENT SERVICES 233632 SIDNEY MEDICAL ASSOCIATES 1625 DORWART DR SIDNEY NE 69162 ER DOCTORS 191225 RURAL PARTNERS IN MEDICINE PO BOX 772519 STEAMBOAT SPRINGS CO 80477 DOCTOR SERVICES 159103 WESTERN MOBILE SERVICES PO BOX 6 NEW RICHMOND WI 54017 MRI SCAN SERVICES 133125 20 36104 392665 428769 PATIENT SERVICE REVENU 624100 19648185 19648185 MEDICARE/MEDICAID 624100 9158468 9158468 HOME CARE 621610 302280 302280 MEDICAL SERVICES - COM 621400 147578 147578 MISC. MEDICAL SERVICES 621400 92822 92822 204393 204393 29553726 86087 86087 8277 0 8277 8277 8277 16699 39611 -22912 -22912 -22912 CAFETERIA 624100 71048 71048 PATRONAGE DIVIDEND 624100 9310 9310 MEDICAL RECORDS 624100 1132 1132 81490 30135437 29564168 0 142500 118873 118873 11752002 11564988 187014 316957 314630 2327 2051256 1999505 51751 855981 834869 21112 338762 338762 52119 52119 90163 90163 2311299 2311299 67680 67680 1564631 1531130 33501 650808 647808 3000 131426 117992 13434 93766 93766 1038510 1038510 374926 374926 MEDICAL SUPPLIES 1956051 1956051 BAD DEBTS 1508818 1508818 MISCELLANEOUS EXPENSE 245510 220527 24983 DUES AND SUBSCRIPTIONS 42447 18589 23858 11314 1664 9650 25573299 24508986 1064313 0 9267277 12976872 3430755 1178213 3176788 4554336 563531 636117 209917 225212 22147637 12131814 8715537 10015823 242176 248228 16511 53847 25622492 29888648 1793266 2479010 2525912 2229673 203563 266585 780901 32392 5303642 5007660 X 20307952 24878090 10898 2898 20318850 24880988 25622492 29888648 4562138 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 3389 3389 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: A PORTION OF THE DUES PAID TO AHA AND NHA ARE USED BY THOSE ORGANIZATIONS FOR LOBBYING ACTIVITIES. 92500 91219 183719 14046284 7205256 6841028 7411904 4612854 2799050 505730 313704 192026 10015823 DUE TO CHEYENNE COUNTY HOSP & HEALTH CARE FOUNDATION 1083 DEFERRED COMPENSATION PLAN LIABILITY 31309 32392 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: CHEYENNE COUNTY HOSPITAL ASSOCIATION, INC. D/B/A SIDNEY REGIONAL MEDICAL CENTER, CHEYENNE COUNTY HOSPITAL AND HEALTH CENTER FOUNDATION, AND HIGH PLAINS MEDICAL FOUNDATION ARE EXEMPT FROM INCOME TAXES UNDER SECTION 501(A) OF THE CODE AND A SIMILAR PROVISION OF STATE LAW. HOWEVER, THEY ARE SUBJECT TO FEDERAL INCOME TAX ON ANY UNRELATED BUSINESS TAXABLE INCOME. THE SYSTEM ACCOUNTS FOR UNCERTAINTIES IN ACCOUNTING FOR INCOME TAX ASSETS AND LIABILITIES USING GUIDANCE INCLUDED IN FASB ASC 740, INCOME TAXES. THE SYSTEM RECOGNIZES THE EFFECT OF INCOME TAX POSITIONS ONLY IF THOSE POSITIONS ARE MORE LIKELY THAN NOT OF BEING SUSTAINED. AT DECEMBER 31, 2011, THE SYSTEM HAD NO UNCERTAIN TAX POSITIONS ACCRUED. WITH FEW EXCEPTIONS, THE SYSTEM IS NO LONGER SUBJECT TO INCOME TAX EXAMINATIONS BY U.S. FEDERAL, STATE, OR LOCAL AUTHORITIES FOR YEARS BEFORE 2007. 1 1 1 X 133.000000000000 1 X 1 1 1 0 1 1 247192 0 247192 0.01030 2837225 2650633 186592 0.00780 3084417 2650633 433784 0.01810 20 20 50875 36952 13923 0.00060 3 4 69038 35729 33309 0.00140 1 6 750 0 750 0.00000 24 30 120663 72681 47982 0.00200 24 30 3205080 2723314 481766 0.02010 1 1508818 603527 7573501 7410312 163189 X 1 1 1 1 CHEYENNE COUNTY HOSPITAL ASSOCIATION DBA

645 OSAGE STREET SIDNEY NE 69162

X X X X CHEYENNE COUNTY HOSPITAL ASSOCIATION INC 1 1 1 133.000000000000 1 300.000000000000 1 X X X 1 1 X X 1 0 1 X 0 0 2 SIDNEY REG'L MEDICAL CTR EXTENDED CARE

645 OSAGE SIDNEY NE 69162

LONG TERM CARE FACILITY SLOAN ESTATES ASSISTED LIVING

2550 CRAIG AVENUE SIDNEY NE 69162

ASSISTED LIVING PART I, LINE 3C: NOT APPLICABLE. PART I, LINE 7: THE COST TO CHARGE RATIO IS DETERMINED AS FOLLOWS: (TOTAL EXPENSES - BAD DEBT)/GROSS PATIENT SERVICE REVENUE = PERCENTAGE OF COST TO CHARGE. PART I, LINE 7G: THERE ARE NO SUBSIDIZED HEALTH SERVICES. PART I, L7 COL(F): BAD DEBT EXPENSE OF $1,508,818 HAS BEEN EXCLUDED FROM THE DENOMINATOR IN THE CALCULATION OF THE PERCENTAGES IN LINE 7, COLUMN F. PART III, LINE 4: THE HOSPITAL'S FINANCIAL STATEMENTS DO NOT CONTAIN A SPECIFIC FOOTNOTE DESCRIBING BAD DEBT. HOWEVER, THE FOLLOWING IS THE TEXT OF THE FOOTNOTE TITLED "PATIENT RECEIVABLES, NET":THE SYSTEM REPORTS PATIENT ACCOUNTS RECEIVABLE AT NET REALIZABLE AMOUNTS FROM THIRD-PARTY PAYORS, PATIENTS, AND OTHERS. AN ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS HAS BEEN ESTABLISHED FOR THESE RECEIVABLES AND IS ADJUSTED THROUGHOUT THE YEAR BASED ON THE AGING OF EACH FUNDING SOURCE'S RECEIVABLE ACCOUNT. INDIVIDUAL ACCOUNTS WITH BALANCES OVER NINETY DAYS ARE REVIEWED PERIODICALLY FOR FUNDING SOURCE DENIALS, REBILLS TO DIFFERENT FUNDING SOURCES, SUBMISSIONS TO A COLLECTION AGENCY, OR WRITE-OFF AS BAD DEBT. ACCOUNTS DEEMED UNCOLLECTABLE ARE WRITTEN-OFF.RATIONALE FOR INCLUDING BAD DEBT AMOUNTS IN COMMUNITY BENEFITS STEMS FROM THE CULTURE OF THE COMMUNITY. GENERALLY, THE PEOPLE IN THE COMMUNITY WHO CAN AFFORD TO PAY THEIR BILLS DO PAY THEM. OTHERS WHO ARE UNINSURED, UNDERINSURED, OR SIMPLY OVER EXTENDED AND ARE UNABLE TO PAY ARE EITHER PROACTIVELY CLASSIFIED AS CHARITY CARE OR END UP ON BAD DEBT GIVEN THEIR RELUCTANCE TO APPLY FOR THE HELP. PART III, LINE 8: THE INFORMATION IS DERIVED FROM THE MEDICARE COST REPORT D,E, & H. PART III, LINE 9B: THE CHARITY CARE POLICY ALLOWS FOR PROACTIVE WRITE OFF TO CHARITY CARE OF ANY BALANCE OWED BY A PATIENT KNOWN TO QUALIFY FOR CHARITY CARE. TO ENHANCE OUR STANDARD CHARITY PROGRAM, SIDNEY REGIONAL MEDICAL CENTER (SRMC) CURRENTLY UTILIZES A PRESUMPTIVE CHARITY SCORING MODEL. OUR OBJECTIVE IS TO WRITE OFF THE MOST ELIGIBLE AND IN-NEED FAMILIES OR INDIVIDUALS. CHEYENNE COUNTY HOSPITAL ASSOCIATION INC PART V, SECTION B, LINE 13G: OUR FINANCIAL ASSISTANCE POLICY IS WELL VERSED AMONGST THE PATIENT FINANCIAL SERVICES REPRESENTATIVES. THE FINANCIAL ASSISTANCE PROGRAM IS COMMUNICATED WITH PATIENTS WHO INDICATE THAT THEY ARE HAVING TROUBLE. CHEYENNE COUNTY HOSPITAL ASSOCIATION INC PART V, SECTION B, LINE 19D: THIS IS ADJUSTED AS A PERCENT OF CHARGES BASED ON THE FEDERAL POVERTY GUIDELINES. PART VI, LINE 2: NEEDS ASSESSMENTS ARE DETERMINED THROUGH SCIENTIFIC AS WELL AS UNSCIENTIFIC METHODS. EVERY 2 TO 3 YEARS A MARKET ASSESSMENT IS COMPLETED USING CLAIMS DATA WHICH REVEALS THE NEEDS OF COMMUNITY MEMBERS BEING MET ELSEWHERE DUE TO EITHER UNAVAILABILITY OF SERVICE OR PATIENT CHOICE. THIS ASSESSMENT INCLUDES THE DEMOGRAPHICS OF THE AREA WHICH SHOW AN AGING AND MODERATE INCOME POPULATION. THESE FACTS ARE THEN USED TO DETERMINE THE NEEDS OF THE COMMUNITY AS WELL AS THE FUTURE NEEDS BASED ON HISTORICAL DATA. ADDITIONALLY, COMMUNITY NEEDS ARE DETERMINED USING PUBLIC OPINION, PATIENT SATISFACTION RECOMMENDATIONS, BOARD AND LEADERSHIP EXPERIENCE, COMMUNICATIONS WITH COMMUNITY MEMBERS, AND PHYSICIAN INPUT. PART VI, LINE 3: AT THE POINT OF ADMISSION A PATIENT'S INSURED STATUS IS DETERMINED. PATIENTS WHO ARE UNINSURED OR UNDERINSURED RECEIVE COUNSELING THROUGH THE HOSPITAL SOCIAL WORKER &/OR A MEMBER OF THE FINANCIAL SERVICES STAFF SERVING AS A FINANCIAL COUNSELOR. INFORMATION IS CONVEYED TO THE PATIENT OR THE GUARANTOR REGARDING MEDICAID AND MEDICARE, AS WELL AS CHARITY CARE PROVIDED BY THE HOSPITAL. ADDITIONALLY, SOCIAL SERVICES PERSONNEL HOLD WORKSHOPS AND MEET WITH PATIENTS INDIVIDUALLY REGARDING THEIR COVERAGE IN AN ATTEMPT TO DETERMINE ELIGIBILITY, THE NEEDS OF THE INDIVIDUALS WITH RESPECT TO ABILITIES, AND THE AMOUNT OF ASSISTANCE NEEDED. PART VI, LINE 4: THE HOSPITAL'S PRIMARY SERVICE AREA (PSA) IDENTIFIES THE GEOGRAPHIC AREA THAT ACCOUNTS FOR 80-90% OF ALL PATIENT VISITS. RESIDENTS OF SRMC'S PSA IN THE PANHANDLE OF WESTERN NEBRASKA COMPRISE 90% OF THE HOSPITAL'S INPATIENT DISCHARGES AND 83% OF ITS ER VISITS. THE PSA POPULATION IS ESTIMATED AT APPROXIMATELY 12,500 WITH A NONEXISTENT GROWTH PATTERN EXPECTED BETWEEN 2009 AND 2014. MEDIAN AGE IN THE PSA IS 40.7, WHICH IS SLIGHTLY YOUNGER THAN THE STATE OF NEBRASKA AT 41.8. SIGNIFICANT GROWTH IS PROJECTED FOR THE AGE GROUP 65+ BETWEEN 2009 & 2014. MEDIAN HOUSEHOLD INCOME IN THE PSA IS COMPARABLE TO THE STATE OF NEBRASKA OVERALL, HOWEVER THERE IS WIDE VARIATION IN MEDIAN HOUSEHOLD INCOME WITHIN THE PSA. THE MEDIAN INCOME RANGES FROM A HIGH OF $47,049 IN SIDNEY TO A LOW OF $37,222 IN BIG SPRINGS. PART VI, LINE 5: SPECIFIC TO THE COMMUNITY BUILDING ACTIVITIES THE HOSPITAL CONTRIBUTES THROUGH LEADERSHIP EDUCATION, RESIDENCIES AND SCHOLARSHIPS, IMPROVEMENTS TO FACILITIES, AND COLLABORATION WITH COMMUNITY CLUBS, EMPLOYERS, LEADERS AND THE COMMUNITY CENTER. THE CFO SERVED DURING 2011 AS THE PRESIDENT OF THE FINANCE COMMITTEE FOR PANHANDLE PUBLIC HEALTH AND A BOARD MEMBER OF THE CHAMBER OF COMMERCE WHILE OTHER LEADERS IN THE HOSPITAL PARTICIPATED IN THE CHEYENNE COUNTY LEADERSHIP GROUPS. ROTARY CLUB AND CITY COUNCIL ACTIVITIES AS WELL AS OTHER VOLUNTEER ORGANIZATIONS SAW COLLABORATION FROM THE HOSPITAL AND ITS REPRESENTATIVES. SIDNEY REGIONAL MEDICAL CENTER (SRMC) HOLDS A HOSPITAL SPONSORED COMMUNITY HEALTH FAIR ANNUALLY. SRMC ALSO PROVIDES SMALLER HEALTH CLINICS AT BUSINESSES THROUGHOUT THE COMMUNITY. CHILD OUTREACH FOR NEW MOTHERS, IMMUNIZATION CLINICS, DIABETES EDUCATION, FLU SHOTS AND COMMUNITY WELLNESS ACTIVITIES ARE ACCOMPLISHED THROUGH COLLABORATION WITH SCHOOLS, THE COMMUNITY CENTER, DOCTORS' OFFICES, AND COMMUNITY BUSINESSES AS WELL AS OTHER NOT FOR PROFIT ORGANIZATIONS. SMALL HOSPITALS HAVE BEEN INCREASINGLY CHALLENGED TO MAINTAIN THEIR HISTORICAL SCOPE OF SERVICES, AND MANY HAVE RELUCTANTLY DISCONTINUED PROVIDING OBSTETRICS, CRITICAL CARE, HOME HEALTH AND OTHER SERVICES IMPORTANT TO THE COMMUNITY BUT NOT SUSTAINABLE FROM A FINANCIAL PERSPECTIVE. SRMC HAS BEEN ABLE TO CONTINUE PROVIDING THESE SERVICES AND REMAINS COMMITTED TO DOING SO IN THE FORESEEABLE FUTURE.THE HOSPITAL ORGANIZATION IS PART OF A 'HEALTH SERVICES' COLLABORATION FOCUSING ON THE INITIATIVES ABOVE IN DAILY ROUTINE. THE ORGANIZATION INCLUDES HOME HEALTH AND HOSPICE SERVICES IN COLLABORATION WITH MANY COMMUNITY VOLUNTEERS, WITHOUT WHOM THE SERVICE WOULD NOT BE SUCCESSFUL. EXTENDED CARE SERVICES AS WELL AS ASSISTED LIVING SERVICES ARE OFFERED AS DEPARTMENTAL ENTITIES OF THE HOSPITAL ORGANIZATION. THESE SERVICES ALONG WITH THE HOME HEALTH AND HOSPICE ARE NOT COST BASED REIMBURSED AND, IN FACT, ERODE THE COST BASED REIMBURSEMENT WHICH COULD BE ENJOYED AS A CRITICAL ACCESS HOSPITAL. HOWEVER, THE BOARD OF THE DIRECTORS IS COMMITTED TO PUBLIC HEALTH IN ITS ENTIRETY AND CONTINUES TO SUPPORT ALL HEALTH SERVICES IN THE COMMUNITY. PART VI, LINE 6: SIDNEY REGIONAL MEDICAL CENTER IS NOT PART OF AN AFFILIATED HEALTH CARE ORGANIZATION. REPORTS FILED WITH STATES PART VI, LINE 7 NE X X X X 0 0 0 1 0 0 0 0 0 JAMES GROSSHANS 200421 0 0 0 0 0 10263 0 1966 0 212650 0 0 0 JAMES THAYER 329563 0 12500 0 0 0 12250 0 1084 0 355397 0 0 0 DANNA HLAVINKA 189071 0 0 0 0 0 9888 0 125 0 199084 0 0 0 TRACY RAY 164563 0 0 0 0 0 8516 0 102 0 173181 0 0 0 RACHEL FORSTER 147729 0 0 0 0 0 7447 0 85 0 155261 0 0 0 PART I, LINE 3 DOUG FAUS AND JASON PETIK RECEIVE COMPENSATION FROM POUDRE VALLEY HEALTH CARE, INC., AN UNRELATED ENTITY, WHICH PROVIDES MANAGEMENT SERVICES TO ITS CLIENTS. THE SIDNEY REGIONAL MEDICAL CENTER'S BOARD OF DIRECTORS SETS THE SALARY AND BENEFITS FOR MR. FAUS AND MR. PETIK. POUDRE VALLEY HEALTH CARE, INC. CHARGES SIDNEY REGIONAL MEDICAL CENTER FOR THE SERVICES THEY PROVIDE TO THE HOSPITAL. PART I, LINE 5 DR. JAMES THAYER RECEIVES DRAW ON HIS SALARY BASED ON HIS GROSS CHARGES. THE DRAW IS CALCULATED BY MULTIPLYING THE GROSS CHARGES BY 33% AND SUBTRACTING OFF HIS BASE BIWEEKLY SALARY OF $10,000. ADDITIONALLY, HE RECEIVES A BONUS BASED UPON QUALITY INDICATORS, MEDICAL RECORDS COMPLETION, ETC. SUPPLEMENTAL INFORMATION PART III NEW PROGRAM SERVICES FORM 990, PART III, LINE 2 DURING 2011, THE HOSPITAL INCREASED THE SERVICE OFFERINGS TO PATIENTS TO INCLUDE JOINT REPLACEMENT. THIS ENABLES PATIENTS IN OUR RURAL AREA TO GET THIS SURGICAL PROCEDURE CLOSE TO HOME AND RECOVER AT HOME. FORM 990, PART VI, SECTION A, LINE 3 POUDRE VALLEY HEALTH CARE INC CURRENTLY EMPLOYS THE CHIEF EXECUTIVE OFFICER FOR SIDNEY REGIONAL MEDICAL CENTER. SRMC PROVIDES POUDRE VALLEY HEALTH CARE WITH DATA ON SERVICES PROVIDED TO THE COMMUNITY MONTHLY FOR COMPARISON DATA PURPOSES. FORM 990, PART VI, SECTION B, LINE 11 THE ORGANIZATION'S ACCOUNTING DEPARTMENT PREPARES AN ORGANIZER SUPPLIED BY THE ACCOUNTING FIRM SEIM JOHNSON, LLP AND SUBMITS THE ORGANIZER TO THE ACCOUNTING FIRM FOR THE PREPARATION OF THE FORM 990. COMMUNICATIONS BETWEEN THE ACCOUNTING FIRM AND THE ACCOUNTING DEPARTMENT FINALIZE THE PREPARATION OF THE FORM 990. THE CEO AND CFO THEN REVIEW THE FORM 990 AND E-MAIL IT TO ALL MEMBERS OF THE BOARD OF DIRECTORS FOR THEIR REVIEW. ONCE THE 990 RETURN HAS BEEN APPROVED BY ALL PARTIES IT IS SUBMITTED TO THE IRS ON OR BEFORE THE REGULAR OR EXTENDED DUE DATE. FORM 990, PART VI, SECTION B, LINE 12C ANY DUALITY OF INTEREST OR POTENTIAL CONFLICT OF INTEREST ON THE PART OF ANY OFFICER, DIRECTOR, COMMITTEE MEMBER, OR ANY KEY EMPLOYEE SHOULD BE DISCLOSED TO THE BOARD OF DIRECTORS AND MADE A MATTER OF RECORD WHENEVER IT ARISES, OR WHENEVER IT INVOLVES A MATTER OF BOARD ACTION. ANY OFFICER, DIRECTOR, COMMITTEE MEMBER, OR KEY EMPLOYEE HAVING A DUALITY OF INTEREST OR A POSSIBLE CONFLICT OF INTEREST IN ANY MATTER SHOULD NOT VOTE OR USE HIS OR HER PERSONAL INFLUENCE ON THE MATTER. FORM 990, PART VI, SECTION B, LINE 15 POUDRE VALLEY HEALTH CARE, INC. PROVIDES ADMINISTRATIVE SERVICES TO SIDNEY REGIONAL MEDICAL CENTER (SRMC). THIS INCLUDES THE HOSPITAL'S CHIEF EXECUTIVE OFFICER. SRMC USES A METHOD ANNUALLY TO DETERMINE EXECUTIVE SALARY RANGES WHEREBY SRMC PULLS RANGES FROM NO LESS THAN TWO SURVEY SOURCES (THREE WHEN POSSIBLE) TO DETERMINE THE AVERAGE SALARY RANGES FOR EACH EXECUTIVE POSITION ACCORDING TO THEIR GEOGRAPHICAL REGION. THESE ARE THEN REVIEWED AND THEN PRESENTED TO THE HUMAN RESOURCE COMMITTEE OF THE BOARD OF DIRECTORS FOR REVIEW AND APPROVAL/RECOMMENDATIONS. FORM 990, PART VI, SECTION C, LINE 19 THE GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICIES AND FINANCIAL STATEMENTS ARE MADE AVAILABLE UPON REQUEST. ALSO, THE FINANCIAL STATEMENTS ARE SENT OUT ONCE A YEAR TO COMMUNITY LEADERS. AVERAGE HOURS PER WEEK DEVOTED TO A RELATED ORGANIZATION FORM 990, PART VII, SECTION A, LINE 1A: JASON PETIK, CEO, DEVOTED AN AVERAGE OF 1.00 HOUR PER WEEK TO CHEYENNE COUNTY HOSPITAL & HEALTH CENTER FOUNDATION, A RELATED ORGANIZATION. DOUG FAUS, INTERIM CEO, DEVOTED AN AVERAGE OF 1.00 HOUR PER WEEK TO CHEYENNE COUNTY HOSPITAL & HEALTH CENTER FOUNDATION, A RELATED ORGANIZATION FROM JANUARY 1, 2011 THROUGH MAY 31, 2011. KELLY UTLEY, CFO, DEVOTES AN AVERAGE OF 1.00 HOUR PER WEEK TO CHEYENNE COUNTY HOSPITAL & HEALTH CENTER FOUNDATION, A RELATED ORGANIZATION. ROB ROBINSON, BOARD MEMBER, DEVOTES AN AVERAGE OF 1.00 HOUR PER WEEK TO CHEYENNE COUNTY HOSPITAL & HEALTH CENTER FOUNDATION, A RELATED ORGANIZATION. STAN BELIEU, BOARD MEMBER, DEVOTES AN AVERAGE OF 1.00 HOUR PER WEEK TO CHEYENNE COUNTY HOSPITAL & HEALTH CENTER FOUNDATION, A RELATED ORGANIZATION. OFFICERS PAID BY UNRELATED ORGANIZATION FORM 990, PART VII, SECTION A, LINE 1A: DOUG FAUS AND JASON PETIK RECEIVE COMPENSATION FROM AN UNRELATED ORGANIZATION, POUDRE VALLEY HEALTH CARE INC., WHICH PROVIDES MANAGEMENT SERVICES TO CHEYENNE COUNTY HOSPITAL ASSOCIATION INC. COMMITTEE WITH OVERSIGHT OF THE AUDIT FORM 990, PART XI, LINE 2C: THERE HAVE BEEN NO CHANGES FROM THE PRIOR YEAR. THE BOARD OF DIRECTORS ASSUMES THE RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT OF ITS FINANCIAL STATEMENTS AND SELECTION OF AN INDEPENDENT ACCOUNTANT. CHEYENNE COUNTY HOSPITAL AND HEALTH CENTER FOUNDATION 645 OSAGE SIDNEY NE 69162 470686476 SUPPORT SIDNEY REGIONAL MEDICAL CENTER NE 501(C)(3) LINE 11C, III-FI N/A 0 WESTERN NEBRASKA HEALTH SYSTEMS 645 OSAGE SIDNEY NE 69162 911774837 SUPPORT SIDNEY REGIONAL MEDICAL CENTER NE 501(C)(3) LINE 9 N/A 0 0 0 1 0 0 0 0 0 0 0 0 0 1 1 1 1 0 0