2012-08-08T16:48:59-05:00 2011-09-30 EIDE BAILLY LLP 1601 NW EXPRESSWAY SUITE 1900 OKLAHOMA CITY OK 73118 990 2010-10-01 237169376 Pawhuska Hospital Inc PAWH 9182873232 1101 East 15th Street Pawhuska OK 740561920 Karen Arrowsmith 9182873232 2012-08-07 1 Carolyn Levings 4054783334 2012-08-07 2010 2016-02-24 21:20:13Z Karen Arrowsmith 1101 East 15th Street Pawhuska OK 740561920 3949448 0 X N/A X 1972 OK HEALTH CARE SERVICES 5 5 69 25 0 0 143846 142416 2920936 3798889 9526 8143 0 0 3074308 3949448 0 0 0 0 2290633 2468521 0 0 0 962139 1332801 3252772 3801322 -178464 148126 2416007 3700829 343377 1480073 2072630 2220756 X To provide care for persons suffering from illnesses or disabilities which require in or out patient hospital care. To carry on education activities and scientific research related to the care of the sick and injured and to promote the general health of the community. 1 0 3281622 3798889 Pawhuska Hospital is a 25-bed critical access hospital that accepts patients regardless of ability to pay. Charity care for the year ended September 30, 2011 was $106,667. 3281622 1 1 0 0 0 0 0 0 0 1 0 0 0 1 1 1 0 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 0 0 0 0 0 1 4 0 1 69 1 0 0 0 0 0 0 0 0 0 0 X 5 5 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 0 1 0 OK X Karen Arrowsmith 9182873232 1101 East 15th Street PAWHUSKA OK 740561920 James Hager 1.00 X X 0 0 0 Bob Roberts 1.00 X 0 0 0 Toby Bighorse 1.00 X X 0 0 0 Francis Altaffer 1.00 X 0 0 0 Nancy Woodyard 1.00 X 0 0 0 Karen Arrowsmith 50.00 X 86306 0 0 John Ham 52.00 X 129311 0 0 215617 0 0 1 0 0 0 0 142416 142416 Net Patient Revenue 900099 3793466 3793466 Dietary Revenue 900099 5139 5139 Miscellaneous Revenue 900099 284 284 3798889 8143 8143 3949448 3798889 0 8143 89781 89781 1850821 1650375 200446 289995 210949 79046 237924 237924 455167 455167 73126 73126 2808 280 2528 498460 429545 68915 65144 61710 3434 7906 5482 2424 19308 19308 164198 164198 46374 46374 Sales & Use Tax 310 310 3801322 3281622 519700 0 1050231 1528452 374747 673445 12428 8852 109865 136334 15080 18453 3521090 2185797 853656 1335293 2416007 3700829 272832 820397 513472 70545 146204 343377 1480073 X 2072630 2220756 2072630 2220756 2416007 3700829 148126 0 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 34360 34360 973428 617692 355736 35979 28988 6991 2477323 1539117 938206 1335293 Third Party Settlements 146204 146204 3949448 3801322 148126 0 148126 3930140 -19308 -19308 3949448 0 3949448 3782014 0 3782014 19308 19308 3801322 Description of Uncertain Tax Positions Under FIN 48: Part X: The Hospital believes that it has appropriate support for any tax positions taken affecting its annual filing requirements and, as such, does not have any uncertain tax positions that are material to the financial statements. The Hospital would recognize future accrued interest and penalties related to unrecognized tax benefits and liabilities in income tax expense if such interest and penalties are incurred. Part XII, Line 2d - Other Adjustments: Interest expenses included in Revenue on financial statements -19,308. Part XIII, Line 4b - Other Adjustments: Interest expenses included in Revenue on financial statements 19,308. 1 1 X 1 X 1 X 1 0 0 1 705 95038 95038 0.02500 1 448805 184139 264666 0.06960 28471 27256 1215 0.00030 2 705 572314 211395 360919 0.09490 2 705 572314 211395 360919 0.09490 0 430586 21529 2961198 2931879 29319 X 1 1 1 1 Pawhuska Hospital Inc

1101 E 15th St Pawhuska OK 740561920

X X X X Not Required 1 Part I, Line 3c: The Medical Center provides its services without regard to a patient's ability to pay. The Medical Center provides a discount of at least 25% of billed charges to all uninsured patients. Uninsured patients also may qualify for an additional 10% prompt pay discount. In addition to these automatic discounts, patients can apply for financial assistance including free and discounted care. The determination of the patient's qualification for financial assistance is based on an objective determination of the patient's financial resources and ability to pay. In general, all uninsured patients with household incomes of less than 150% of the Federal poverty guidelines qualify for free care. Patients with household incomes less than 300% of Federal Poverty Guidelines qualify for sliding scale discounts that are in addition to the automatic discount provided to all uninsured patients. Part I, Line 7: Charity care, unreimbursed Medicaid and unreimbursed costs-other means-tested government programs were calculated at cost using the cost-to-charge ratio derived from Worksheet 2. Part II: Currently, Pawhuska Hospital, Inc. does not have a Community Building Activity in place but is working to develop one. Part III, Line 4: The organization's bad debt expense at cost was calculated using the expense reported on the financial statements and applying an overall cost-to-charge ratio calculated from Worksheet 2. The estimated amount of bad debt attributable to charity care is 5%. This is an estimation from notifications of charity care policies sent to patients and the number completed and returned to the hospital. The majority of the population served would qualify for government assistance or meet the federal poverty guidelines therefore if patients would have applied for financial assistance, the majority of the bad debt would have been classified as charity care.Pawhuska Hospital, Inc. considers care for the poor to be an essential part of its mission of service to the community.Bad debt is reported net of discounts and contractual allowances. A payment on an account previously written off reduces bad debt expense in the current year.Financial Statement Note:The carrying amount of patient receivables is reduced by a valuation allowance that reflects management's estimate of amounts that will not be collected from patients and third-party payors. Management reviews patient receivables by payor class and applies percentages to determine estimated amounts that will not be collected from third parties under contractual agreements and amounts that will not be collected from patients due to bad debts. Management considers historical write-off and recovery information in determining the estimated bad debt provision. Part III, Line 8: Medicare allowable costs of care are based on the Medicare cost report. The Medicare cost report is completed based on the rules and regulations set forth by CMS. Part III, Line 9b: The collection policy is such that all collection activity ceases for each patient's amount determined to be eligible for financial assistance. For example, if it is determined that a patient is eligible for free care, all collection efforts stop. If a patient is eligible for discounted care, normal collection efforts continue only on the portion determined to still be owed by the patient. In FY11, all uninsured patients were eligible for an upfront discount of at least 25%. In FY11, all patients with a family income less than or equal to 300% of the federal poverty guidelines were eligible to receive financial assistance of free or discounted care. Part VI, Line 2: Administration, medical staff and the Board regularly discuss the health care needs of the local community during board meetings, as well as in the bi-monthly meetings of the medical staff. Administration is currently working with the Oklahoma Office of Rural Health to develop and implement a community needs assessment. In addition, when looking at the potential of adding new services, an integral part of that research revolves around how such services will meet and address the different needs of our community. We are planning on developing future programs that will allow us the opportunity to gather a larger community audience that can inform us as to the issues that are important to the community and to gather suggestions from those involved. Programs such as the use of focus groups will enable us to be further educated to meet the needs of our community, and to develop programs to meet those needs. Part VI, Line 3: Pawhuska Hospital, Inc. provides a letter to patients upon admission that states our Hospital provides assistance to those patients who have limited income to help pay for hospital expenses. The letter indicates that Charity Care applications are available to all patients and can be picked up at the time of service or at a later date. The Charity Care application gives an overview of our Charity Care policy and notes that Medicaid and other State programs are also available to patients that meet income requirements. Our staff is available to offer patients assistance in completing the charity care and Medicaid applications if needed. Part VI, Line 4: Pawhuska Hospital, Inc. primarily serves the citizens of the community of Pawhuska, Oklahoma and the surrounding area. Pawhuska serves as the county seat of Osage County, Oklahoma and is also the capital of the Osage Nation. The Hospital is one of two facilities located in Osage County. Pawhuska is located in a rural area, with the city's population being 3,584 and the overall county population of 47,472 (2010 Census). The per capita income for the city was $13,916. About 13.7% of families and 17.5% of the population were below the poverty line, including 22.3% of those under age 18 and 14.9% of those age 65 or over. The Hospital is located within federally-designated underserved areas for primary care health professionals, mental health professionals, dental care health professionals and is located in a medically underserved area/population. The entire county falls into two medically underserved areas: Osage Service Area and West Osage Service Area. Part VI, Line 6: The organization's governing body is comprised of volunteer members who reside in the community. Medical staff privileges are extended to all qualified physicians in the community. Surplus funds are reinvested in facilities to improve patient care. The Hospital operates an emergency room that is available to all, regardless of ability to pay. The Hospital is planning an open house next January and will be offering to the community free health screenings. We plan to invite other local healthcare entities to participate in the open house with our Hospital. New Program Services Form 990, Part III, line 2 Pawhuska Hospital, as of June 2011, began offering CT's to patients. This service allows for our community to have a more comprehensive diagnostic screening to diagnose and treat patients in a timelier manner without the need to transport them to a larger facility for the same services. Form 990, Part VI, Section B, line 11 The Form 990 is presented to the Administrator for review and then presented to the Board of Directors. The Form 990 is filed after review by the Board of Directors. Form 990, Part VI, Section B, line 12c All employees, board members, and contract employees are covered in our policies. The employee and contract employee determinations are made by Administration and any board determinations are made by the Governing Board. The employee will be asked to remedy the situation and the board member will be asked to leave after presenting their conflict and the remainder of the Governing Board will discuss and then vote. Copies of both policies can be provided upon request. Form 990, Part VI, Section B, line 15b Pawhuska Hospital follows the pay guidelines per our mananaging company, Jane Phillips Medical Center. Form 990, Part VI, Section C, line 19 Documents are available upon request.