2012-05-15T14:24:21-05:00 2011-06-30 Wendling Noe Nelson & Johnson LLC 534 S Kansas Ave Suite 1500 Topeka KS 666033491 990 2010-07-01 481253246 Pawnee Valley Community Hospital Inc PAWN 6202853161 923 Carroll Ave Larned KS 67550 John Jeter 7856235000 2012-05-14 1 Gary D Knoll 7852334226 2012-05-14 2010 2016-02-24 21:20:13Z John Jeter 923 Carroll Ave Larned KS 67550 11004995 0 X www.pawneevalleyhospital.com X 2001 KS Pawnee Valley Community Hospital, Inc. is a tax-exempt charitable organization under Section 501(c)(3) of the Internal Revenue Code and is licensed by the State of Kansas Department of Health and Environment. The purpose of the Organization is to provide healthcare to inpatients and outpatients who are acutely ill or who otherwise require medical care and related services. The Organization is striving to be the best Critical Access Hospital in rural America. 5 0 116 90 0 0 158669 93394 4411961 10903508 1418 8093 0 0 4572048 11004995 0 0 0 0 3180486 3739930 0 0 0 4693290 6636374 7873776 10376304 -3301728 628691 2297833 4821252 2297833 4821252 0 0 X Pawnee Valley Community Hospital, Inc. is a tax-exempt charitable organization under Section 501(c)(3) of the Internal Revenue Code and is licensed by the State of Kansas Department of Health and Environment. The purpose of the Organization is to provide healthcare facitities and services for the care and treatment of inpatients and outpatients who are acutely ill or who otherwise require medical care and related services. The core purpose of the Corporation is to help people be healthy. 0 0 9180874 10790570 Patient care: Program services consist of routine and ancillary department healthcare services provided by a healthcare organization as described in 501(c)(3) of the IRS code. 9180874 1 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 0 1 0 0 0 0 0 1 0 0 0 0 1 0 0 116 1 0 0 0 0 0 0 0 0 0 0 X 5 0 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 X William Overbey Treasurer 7856235000 2220 Canterbury Hays KS 67601 John Jeter MD 4.00 X X 0 593274 142269 Bryce Young 4.00 X X 0 279750 85301 William Overbey 4.00 X X 0 277120 84847 Shae Veach 4.00 X 0 8057 3344 David Sanger MD 4.00 X 0 42577 9505 Matt Heyn 40.00 X 0 83307 15470 Ken Lindsey thru March 2011 4.00 X 0 370911 94260 Jodi Schmidt thru August 2010 4.00 X 0 164271 49582 0 1819267 484578 0 1 1 0 Docs Who Care 1337 S Fountain Dr Olathe KS 66061 ER Physician Coverage 972944 Allstaff Chartered 2000 Washington Great Bend KS 67530 Contract Nursing 541314 Quest Diagnostics PO Box 14730 St Louis MO 631504730 Lab Service 183665 Great Bend Regional Hospital 514 Cleveland Great Bend KS 67530 Lab Service 138580 Medical Solutions 9101 Western Ave Suite 101 Omaha NE 68114 Nursing & Lab Coverage 128202 11 93298 96 93394 Net patient service re 622000 10790570 10790570 Other operating revenu 900099 101896 101896 Other operating revenu 900099 11042 11042 10903508 7783 7783 310 310 310 310 11004995 10790570 0 121031 136300 136300 2804856 2514208 290648 73989 66322 7667 522276 483625 38651 202509 181524 20985 50055 50055 48602 48602 107 107 1998265 1841594 156671 79023 1777 77246 30088 22444 7644 66092 39655 26437 513202 295447 217755 46443 44531 1912 37511 37511 38997 23398 15599 Bad debts 1408450 1408450 Contract labor 854093 854093 Pharmaceuticals 511618 511618 Medical supplies 327820 325868 1952 Repairs & maintenance 175421 172682 2739 450587 356127 94460 10376304 9180874 1195430 0 210 560 171340 2678839 1960702 1879340 290 641 113446 195512 51845 66360 2297833 4821252 2297833 4192561 0 628691 2297833 4821252 X 0 0 2297833 4821252 X 628691 -628691 X X 0 1 1 X 0 X 0 Due to Pawnee County 628691 628691 11004995 10376304 628691 -628691 -628691 0 11004995 0 11004995 0 11004995 10376304 0 10376304 0 10376304 Part XI, Line 8 - Other Adjustments: Increase in amount due to Pawnee County 1 1 1 X 125.000000000000 1 X 1 1 1 0 1 0 176017 176017 0.01960 337779 337779 513796 337779 176017 0.01960 974543 883869 90674 0.01010 7452 7452 0.00080 981995 883869 98126 0.01090 1495791 1221648 274143 0.03050 0 517465 36223 6421747 6358165 63582 X 1 1 1 1 Pawnee Valley Community Hospital Inc

923 Carroll Avenue Larned KS 67550

X X X X Pawnee Valley Community Hospital Inc 1 1 1 125.000000000000 1 400.000000000000 1 X X X X 1 1 X X X X 1 X X 1 X X X X X X 1 X 0 0 Part I, Line 7: Hays Medical Center, Inc., cost accounting system was used to calculate subsidized health services, health professions education, and community health improvement services. A cost-to-charge ratio was computed and used to calculate charity care and unreimbursed Medicaid reported on line 7. Part I, L7 Col(f): Bad debt expense of $1,408,450 is included in Part IX line 25. This amount was subtracted from total expenses when computing the denominator for the percentage calculated for line 7(f). Part III, Line 4: Bad debt expense was calculated using the same cost-to-charge ratio computed for charity care and unreimbursed Medicaid. The estimate for the amount of bad debt expense attributable to patients that would qualify for charity care is based upon the experience of a related organization. The hospital's financial statements are included in a consolidated set of audited financial statements. The footnotes from these financial statements follow: Patient service revenue is recorded at HMC's established rates with contractual adjustments from third-party payors, charity allowances and other discounts deducted to arrive at net patient service revenue. Patient accounts receivable represent an estimate of net realizable amounts due from patients, third-party payors, and others for unpaid patient services, which is determined on historical payment experience. Retroactively calculated contractual adjustments arising under reimbursement agreements with Medicare and other third-party payors are accrued on an estimated basis in the periods the related services are rendered and adjusted in future periods as final settlements are determined. Medicare is HMC's most significant third-party payor. Part III, Line 8: The Medicare cost report was the costing methodology used to determine the above costs. Allowable costs of care reported on line 6 were determined using amounts from Worksheet D, Part V and Worksheet D-1 in the Pawnee Valley Community Hospital, Inc. Medicare cost report for fiscal year ended June 30, 2011. Part III, Line 9b: Whenever possible, the customer service representatives (CSR's) of Pawnee Valley Community Hospital try to determine the estimated self-pay balance prior to the patient receiving services. Charity care eligibility is first considered at this point in time. In addition, if full payment is not received or payment is not made with 30 days, the CSR contacts the patient. If it is determined that at least a two-year payment plan cannot be established with the patient, the CSR will screen for charity care and request that the charity care application be completed by the patient. Pawnee Valley Community Hospital, Inc. Part V, Section B, Line 13g: Pawnee Valley Community Hospital, Inc. (PVCH) will proactively seek out applicants who may be in need of financial assistance. PVCH will post notice of this policy to all patients/guarantors through its registration, pre-registration, and financial counseling process. This policy will also be posted in prominent areas of the hospital. Part VI, Line 3: Information regarding the Pawnee Valley Community Hospital, Inc. charity care program is located on the Hays Medical Center, Inc. website for patients and community members to view, and the financial assistance application is also on the website to print off and complete. In addition, if a customer service representative contacts a patient about a bill and in visiting with them they determine that patient could possibly qualify for the hospital's charity care policy, the CSR will send the application to the patient as well. Part VI, Line 4: Pawnee Valley Community Hospital, Inc. is located in Larned, Kansas, which has a population of approximately 4,050 people, as of the 2010 census. The median household income of Larned was $46,464. Approximately 5.9% of families were below the poverty line, and 7.4% of the total population was below the poverty line. Approximately 7.8% of the hospital's revenue is from services provided to patients eligible for Medicaid. Pawnee Valley Community Hospital, Inc. is the only hospital in Larned, Kansas. It mainly serves the community of Larned. Part VI, Line 6: Pawnee Valley Community Hospital, Inc. promotes the health of the community by extending medical privileges to most qualified, local physicians. Part VI, Line 7: Pawnee Valley Community Hospital, Inc. is not a part of an affiliated health care system. Sch J - Part VI - Line 2 Pawnee Valley Community Hospital, Inc. has begun its assessment of the health care needs of the communities it serves; however, this assessment is not yet completed. X X 0 1 0 0 0 0 1 0 0 John Jeter MD 0 400726 0 166740 0 25808 0 115727 0 26542 0 735543 0 209673 Bryce Young 0 212055 0 63120 0 4575 0 55991 0 29310 0 365051 0 105200 William Overbey 0 210672 0 63150 0 3298 0 55537 0 29310 0 361967 0 105250 Ken Lindsey thru March 2011 0 275139 0 81120 0 14652 0 67718 0 26542 0 465171 0 140930 Jodi Schmidt thru August 2010 0 109054 0 35190 0 20027 0 32390 0 17192 0 213853 0 77053 Part I, Line 4b Officers and key employees of Hays Medical Center, Inc, a related organization, are eligible to participate in Hays Medical Center, Inc.'s non-qualified retirement plan. Contributions from employer are contributed to the plan on an annual basis. Contributions to the plan for listed persons are included in Schedule J as a component of deferred compensation. Contribution amounts for listed persons for FYE 6-30-11 were: officers - $227,255. Supplemental Information Part III Schedule J, Part I, Line 6 - A portion of incentive compensation for officers and key employees of Hays Medical Center, Inc., a related organization, is determined by net earnings exceeding budget for the fiscal year. John Jeter MD Board President Pa Board President and CEO, Hays Medical Center, Inc. 0 Bryce Young Board Vice-President COO, Hays Medical Center, Inc. 0 William Overbey Board SecTreas P CFO, Hays Medical Center, Inc. 0 Shea Veach Board Member Pawnee Va Director of Regional Operations, Hays Medical Center, Inc. 0 Form 990, Part VI, Section A, line 6 The organization has one member, HaysMed Partners, Inc., which became the sole member as of March 1, 2010. HaysMed Partners, Inc. is a wholly-owned subsidiary of Hays Medical Center, Inc. Form 990, Part VI, Section A, line 7a The Board members of HaysMed Partners, Inc, the sole member of Pawnee Valley Community Hospital, appoints the Board members of Pawnee Valley Community Hospital Inc. Form 990, Part VI, Section A, line 7b HaysMed Partners, the sole member of Pawnee Valley Community Hospital, elects the Board members of Pawnee Valley Community Hospital. Form 990, Part VI, Section B, line 11 Form 990 was reviewed with the Board members prior to filing. Form 990, Part VI, Section B, line 12c Officers, directors & key employees, along with all associates, are required to complete a conflict of interest statement annually. The statements are used to monitor and enforce compliance with the policy. Form 990, Part VI, Section B, line 15 The hospital administrator, officers and key employees' salaries are reviewed annually by an independent consulting group and the Board members. Form 990, Part VI, Section C, line 19 These documents are not made available to the public. Changes in Net Assets or Fund Balances: Form 990, Part XI, line 5: Increase in amount due to Pawnee County Financial Statements and Reporting Form 990. Part XII, line 2c Hays Medical Center, Inc. has an audit committee that is responsible for the oversight of the Pawnee Valley Community Hospital, Inc. financial statement audit and the selection process of an independent accountant. HaysMed Partners Inc 2220 Canterbury Dr Hays KS 67601 270877152 Owns management contract for Pawnee Valley Community Hospital KS 501(c)(3) 170(b)(1)(A)(iii) 0 Hays Medical Center Inc 2220 Canterbury Dr Hays KS 67601 480559088 Hospital KS 501(c)(3) 170(b)(1)(A)(iii) 0 0 0 0 0 1 0 1 0 0 0 0 1 0 0 1 0 0 0 Hays Medical Center Inc E 57169 Hays Medical Center Inc L 485309 Hays Medical Center Inc N 92600 Hays Medical Center Inc G 1000 Hays Medical Center Inc I 77803