2012-03-27T16:58:57-05:00 2011-06-30 CHMS PC 741 3RD AVE S GLASGOW MT 59230 990 2010-07-01 810233499 SIDNEY HEALTH CENTER SIDN 4064882100 216 14TH AVE SW SIDNEY MT 59270 TINA MONTGOMERY 4064882100 2012-03-20 1 RICHARD A WIENS CPA 4062289391 2010 2016-02-24 21:20:13Z TINA MONTGOMERY 216 14TH AVE SW SIDNEY MT 59270 46635829 0 X WWW.SIDNEYHEALTH.ORG X 1946 MT TO HELP THOSE WE SERVE ACHIEVE THIER HIGHEST LEVEL OF HEALTH BY PROVIDING QUALITY MEDICAL CARE. 8 8 617 149 6912948 -1170140 157967 538168 39217237 41126540 277911 1417533 61626 125867 39714741 43208108 0 0 0 0 20508024 21215049 232423 0 215909 20035933 21929138 40776380 43144187 -1061639 63921 62129772 62805020 32532080 33143407 29597692 29661613 NONE 0 0 32335177 34213592 REVENUE AND EXPENSES DIRECTLY RELATED TO PATIENT CARE. 32335177 1 1 0 1 0 0 0 0 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 53 0 617 1 1 1 0 0 0 0 0 0 0 X 8 8 0 0 0 0 0 0 1 1 1 0 1 1 1 1 1 1 1 1 1 1 0 X TINA MONTGOMERY 4064882117 2816 4TH STREET NW SIDNEY MT 59270 RANDY JOHNSON 1.00 X 0 0 0 STEVE SING 2.00 X 0 0 0 NICOLE BEYER 1.00 X 0 0 0 PAM BURMAN 1.00 X 0 0 0 GALE FRANK 1.00 X 0 0 0 MARK MARTIN 1.00 X 0 0 0 JANICE NORBY 1.00 X 0 0 0 LAURA SCHIEBER 1.00 X 0 0 0 RICK HARALDSON 40.00 X 195650 0 16992 TINA MONTGOMERY 40.00 X 102513 0 6804 BARBARA LUNDEMO 40.00 X 312002 0 16992 BRADLEY STRUPP 40.00 X 335507 0 16992 CARLOS TREVINOS 40.00 X 315421 0 16992 DR LOTFI BEN-YOUSSEF 40.00 X 467358 0 0 DR LYLE HARRISON 40.00 X 295000 0 11328 1920938 0 79296 7 0 1 0 BRETT BENNION MD 214 14TH AVE SW SUITE 105 SIDNEY MT 59270 PHYSICIAN SERVICES 846513 EDWARD L PIERCE MD PC 214 14TH AVE SW SUITE 105 SIDNEY MT 59270 PHYSICIAN SERVICES 338227 PETE COUNCIL MD 214 14TH AVE SW SUITE 105 SIDNEY MT 59270 PHYSICIAN SERVICES 251590 EDWARD P BERGIN MD 214 14TH AVE SW SUITE 105 SIDNEY MT 59270 PHYSICIAN SERVICES 140000 RAJOHN KARANJAI MD PC 214 14TH AVE SW SUITE 105 SIDNEY MT 59270 PHYSICIAN SERVICES 108793 5 94050 444118 538168 PATIENT REVENUE 900099 34213592 34213592 CLINIC PHARMACY 446110 4520925 4520925 PHYSICIAN OFFICES 621110 1903738 1903738 MONDAK PHARMACY 446110 488285 488285 41126540 1162488 1162488 119953 119953 119953 119953 3682766 3427721 255045 255045 255045 5914 5914 5914 43208108 35756992 6912948 0 17324240 12522855 4667836 133549 359958 260196 96987 2775 2205989 1594603 594380 17006 1324862 957678 356970 10214 231245 231245 4945 4945 26786 26786 3725396 3373929 351467 151084 144065 7019 8761763 8575990 179911 5862 359407 43066 316341 1354766 1337136 12091 5539 160855 112384 17812 30659 110066 89530 20536 1858102 1858102 3263537 3263537 502336 502336 BAD DEBT EXPENSE 790683 790683 TOTAL SUBSCRIPTION 211608 88884 119995 2729 RECRUITING 202624 202624 OTHER EXPENSES 198543 115389 82597 557 DONATIONS 15394 15394 -2 -2 43144187 32335177 10593101 215909 9088068 8652187 6675912 6908028 2995580 2896211 1298473 1273723 717011 577398 61784195 31084696 28968162 30699499 3380231 3768495 1294927 175633 5935148 6447096 1776260 1406750 62129772 62805020 3428190 3299632 9425000 9425000 17222219 18301778 2456671 2116997 32532080 33143407 X 29597692 29661613 29597692 29661613 62129772 62805020 63921 0 X 0 0 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 1 17500 0 1 4535 22035 0 EXPLANATION OF OTHER LOBBYING ACTIVITIES: PART II-B, LINE 1I: INDIRECT: THE PERCENTAGE OF DUES PAID TO MHA, AHA AND LEADINGAGE AKA AAHSA IS USED FOR LOBBYING EXPENSES AT 2.01%, 24.42% AND 6.20% RESPECTIVELY.TOTAL AMOUNT OF INDIRECT LOBBYING EXPENSE WAS $4,535 198261 198261 39847442 17077737 22769705 21726227 14006959 7719268 12265 12265 30699499 FUNDED DEPRECIATION 6447096 F 6447096 INTEREST RATE SWAP LIABILITY 2116997 2116997 43208108 43144187 63921 63921 UNREALIZED LOSSES ON MARKETABLE SECURITIES AND INTEREST RATE SWAP. 1 1 1 X 1 X 1 1 1 0 470123 470123 0.01110 1254531 1620676 -366145 0.00000 1724654 1620676 103978 0.01110 1724654 1620676 103978 0.01110 1 585696 6742508 6742508 X 1 1 1 1 SIDNEY HEALTH CENTER

216 14TH AVENUE SW SIDNEY MT 59270

X X X X SIDNEY HEALTH CENTER 1 0 0 0 0 0 0 0 0 0 0 0 PART I, LINE 3C: INDIVIDUAL 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 UNEMPLOYMENT 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 THRESHOLD 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 $ 790683. PART III, LINE 4: ACCOUNTS RECEIVABLE ARE CARRIED NET OF AN ESTIMATE FOR UNCOLLECTIBLES AND ALLOWANCES. ACCOUNTS WHICH ARE NOT CONSIDERED COLLECTIBLE ARE WRITTEN OFF AGAINST THE ALLOWANCE ACCOUNT. ALLOWANCES FOR UNCOLLECTIBLE ACCOUNTS ARE SET BASED ON HISTORICAL LOSS RATES APPLIED TO AGED ACCOUNTS RECEIVABLE. 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 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. 0 0 0 0 0 0 0 0 0 RICK HARALDSON 195650 0 0 0 0 0 0 0 16992 0 212642 0 187974 0 BARBARA LUNDEMO 312002 0 0 0 0 0 0 0 16992 0 328994 0 298460 0 BRADLEY STRUPP 335507 0 0 0 0 0 0 0 16992 0 352499 0 306013 0 CARLOS TREVINOS 315421 0 0 0 0 0 0 0 16992 0 332413 0 278986 0 DR LOTFI BEN-YOUSSEF 467358 0 0 0 0 0 0 0 0 0 467358 0 457272 0 DR LYLE HARRISON 295000 0 0 0 0 0 0 0 11328 0 306328 0 0 0 RICHLAND COUNTY 2008-07-03 9685000 CONSTRUCTION 0 0 0 260000 10109019 801529 2710046 6597444 2010 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 FORM 990, PART VI, SECTION A, LINE 7B THE HOSPITAL'S BOARD OF DIRECTORS APPROVES ALL MAJOR DECISIONS MADE BY MANAGEMENT. FORM 990, PART VI, SECTION B, LINE 11 A COPY OF THE 990 WAS GIVEN TO THE CFO AND MADE AVAILABLE TO THE BOARD FOR APPROVAL. FORM 990, PART VI, SECTION B, LINE 12C A CONFLICT OF INTEREST QUESTIONNAIRE IS DISTRIBUTED TO THE BOARD ANNUALLY AND IS REQUIRED TO BE FILLED OUT BY EACH MEMBER. FORM 990, PART VI, SECTION B, LINE 15 THE BOARD REVIEWS THE MONTANA HOSPITAL COMPENSATION SALARIES FOR COMPARABLE HOSPITALS ANNUALLY AND COMPARE TO THE SALARIES BEING PAID BY THE FACILITY. FORM 990, PART VI, SECTION C, LINE 19 POLICIES ARE KEPT AT THE HOSPITAL AND ARE AVAILABLE UPON REQUEST. LONE TREE SENIOR LIVING 216 14TH AVENUE SW SIDNEY MT 59270 810518821 OPERATION OF AN ASSISTED LIVING FACILITY MT 0 THE FOUNDATION FOR COMMUNITY CARE 221 2ND ST NW SIDNEY MT 59270 810417465 SUPPORT SIDNEY HEALTH CENTER MT 0 1 0 1 1 0 0 0 0 0 0 1 0 0 0 0 0 1 0 LONE TREE SENIOR LIVING D 2842883 LONE TREE SENIOR LIVING D 52508 LONE TREE SENIOR LIVING A 136218 LONE TREE SENIOR LIVING K 75756 THE FOUNDATION FOR COMMUNITY CARE Q 215909 THE FOUNDATION FOR COMMUNITY CARE C 137930 HEALTH NET LLC 11 SOUTH 7TH SUITE 241 MILES CITY MT 59301 810506005 DATA PROCESSING MT 1 0 1